Infectious Disease Flashcards
MCC bacterial endocarditis
staph aureus
Native valve endocarditis
Staph aureus, strep bovix, strep gp D (enterococci) -> Vanco/gentamycin empiric
Prosthetic valve
staph epi, streptococci, G neg fungi -> vanco, rifampin (clears sticky bugs - staph epi), gentamycin
IVDU
staph aur, enteroccus, g neg strep viridans -> vanco + gentamycin
Indications for endocarditis surgery
Severe CHF - bacteremia x 6 days (if repeat bcx 48 hrs +, cont abx, repeat ctx, recurrent emboli, valve abscess, large fungal vegetation
Rt sided endocarditis with septic emboli - abx?
Daptomycin
Pt with sympt endocarditis - bctx done, vanco/gent started - 72hrs later bctx + strept sens to PCN - abx changed to PCN - gnet d/c’d - reepat bctx still + 24hrs later wtd?
continue abx, repeat bctx in 48hrs
IVDA rec with fever, cough hempotysis, pleuritis CP - II/VI SEM - 2-3 nodules on CXR - dx?
Rt sided endocarditis -> vanc/gent
Pt fever, +BCtx for clostr sept/ Strep bovis - wtd
Colonoscopy r/o malignancy
IVDA suspected for endocarditis vanc/gent started - ctx +PCN enterocci - vanc stopped - pcn started but then with prurtis swelling lip swelling - wtd?
D/C PCN start vanc
Vanc develops itching/redness
redman’s - slow IV infusion +- benadryl
Pt s/p TURP 2 wks later with fever growing enterococci
older men, AV>MV, more CHF less embolic events, more conduction defects - don’t use ceftriaxone (doesn’t kill)
Valve replacement
NOT in pt febrile on abx - mild AR EF 60% - BUN cr 25/2 -> immune complex phenomenon - see splinter hemorrhage, janeway lesion, roth spots
Pt treated for endocardtisi defervesces and WBC dec bu twith 1st deg AVB - concerned?
yes - r/o valvular abscess - TEE
Pt on imipenum/cilastatin for nosocomial infxn h/o seizure d/o - has dz - related to imipenum?
Yes - inc’d incidence of seizures at higher doses
Endocarditis ppx only for high risk procedures in high risk conditions…
High risk condition - ALL prosthetic valve, prev h/o endocarditis, congential heart dz, unrepaired CHD, repaired CHD within 6 months, post tx heart WITH valvular dz, repaired CHD with prostesis or patch (forever)
High Risk procedure - likely to cause bleeding->endocarditis - dental extraction, periodontal procedures, root canal, implants
NOT HIGH RISK - GI/GU (only if risk of mucosal damage
Low risk conidtions - ASD secundum, 6 months after repair of ASD/VSD/PDA, prev CABG/HOCM, PPM, MVP with murmur MS/AS, fxn murmur
Low risk procedures - cavity filling, endotrach intub, bronch all GI/GU, vaginal hyterectomy, D/C C section, IUD, cath, circumcision
Endocarditis ppx
Amox 2g po 1 hr prior, if no PO then amp IV, PCN all - azithro, post procedure - > NOTHING
Pt witih PDA going for cystoscopy
NO ppx
Pt with bacteremia s aur due to IV line - vanc started wtc
TTE - neg tx x 2 weeks, + tx 4-6 weeks
Pt with susp diverticulitis pw f/c/abd pain - 3 days later temp 101, catheter site clean wbc 17K - wtd
vanc/imipenum
obesity with vanc
1.5g IV q12h
Surgical site infxn ppx
IV abx 1 hr prior to surgery/24 hrs after
35yo IVDA fever/chills wit hmurmur, vegetation on TV bctx MRSA - tx?
Daptomycin
Empiric tx meningitis
Head trauma/NSx - staph aur MRSA, S pneumo, G neg bacilli - vanc + ceftazidme
60yo Listeria, S pneumo, neisseria -> Ampicicillin (listeria), CFTtx (S pneumo), Vanco (MRSA)
15yo - S.pneuo, neisseria, h flu -> Ceftriaxone
2 month - strep agalactiae, E. Coli, Listeria - Ceftx + ampilcillin (listeria)
Normal CSF
<5cells, lymph, Gluc 40-80, Protein 15-45
Bacteria CSF
10-100K cells, PMNs, dec gluc, inc protein, inc opening pressure
West nile CSF
10-1K cells, Lymph, dec gluc, inc protein, muscle wk, rash, dec DTR
TB CSF
10-1K, lymph, dec gluc, very inc protein,
Aseptic CSF
10-2K, lympoh normal gluc, inc to normal protein, enterovirus, OKT3, NSAIDS, bactrim
Early bacterial CSF
10-1K, lymphs > PMN, dec gluc, inc protein, CSDF to ser glu <0.4
Encephalitis CSDF
1-2K, lymph, normal gluc, normal to inc protein
HSV enceph CSF
1-2K, lymph, N gluc, n to inc protein, +RBC 1:1 ratio
70yo Pt with DM p.w mental status change spinal tap with many WBCs mainly PMN G stain neg ctx pending wtc
ceeftx + vanc cover resistant strep pneumo + ampicillin cover listeria
55yo post renal tx on steroids pw fever, neck stiffness with g po rods diphteroids in csf; PMN 65% and lymphs 35% - dx?
Listeria - tx ampicillin + gentamycin (bactrim if PCN all)
24yo M neck pain, h/a, neck sign + spinal tap WBC 105, lymphs no RBC gluc 50 - cause?
entero/echo virus meningitis
Causes of aseptic meningitis
OKT3 ab, NSAID, bactrim, echo/enterovirus
70yo COPD PNA twice in 1 year p/w cough, fever, chills, MS change - WBC 17 PMN, LLL consolidation, CTH no bleed - spinal tap WBC >20K, PMN, dec gluc, inc protein, gram stain cocci in pairs - wtd?
empiric thx - ceftriaxone + vancomycin + dexamethasone
37yo woman solid organ tx couple weeks later with diarrhea/low grade fever then photophobia, h/a confusion - temp 102, CSDF 250WBC 55% PMN, gluc 35 - g stain neg - empiric tx?
ceftriaxone + ampicillin (listeria)
Pt with meningitis - LP WBC 75, gluc 28, elev protein - elev OP - crypt ag neg, g stain neg - tx for?
bacterial meningitis empirically
16yo MS change, fever BP 80/60 - exam midline scar abdomen - lab leukocytosis - h/o MVA 2ya splenectomy
organism - s pneumo (capsule)
Meningitis by h&P - wtd
IV abx - do not wait!
Pt with h/a x 2 days - now dizzy, lethargic - meningieal + sign - 7th episode in 6 years dx - CSDF granular cells?
beningn recurrent lymphocytic meningitis - HSV-2 - supportive care only (antivirals no benefit) - Mollarett’s meningitis
Fever, h/a, vom/seizure - smelling fishy odor/burning rubber, auditory hallucination - MR brian hyper intensity temporal lobe -> EEG sharp and slow waves temporal lobe - LP WBC 200 lymphs, gluc 45, protein 75 RBC 65! dx?
Herpes encelphalitis - IV acyclovir
70yo h/a, fever x 5 days, confused, ocular pain, diplopia - hiking partner similar sx which resolved - mild neck signs + or focal wk one side body DTR absent - LP WBC 55, 100% lymph, protein 90 gluc 50 wtd
WNV IgM ab check - prognostic factor is age - >75 is bad
Reservoir - birds, transmitting agent=mosquitos
Pt fever h/a x 2 days - neck stiffness WBC 8800 68% PMNs - 8% bands - spinal tap WBC 85 54% PMN 33 lymph RBC 0 - gluc 26, protein 68
early bacterial meningitis
20yo F college with tonic clonic sz - h/a and strange behavior x 1 week with anxiety/paranoid behavior, no psych/drug abuse hx - orthostatic hypotension, choreform movements difficulty choosing words - CSF 40WBC 96% lymph, 3 RBC, gluc 62, protein 30 CTH normal - tx’d for HSV enceph no improvement HSV PCR neg - dx?
NMDA rct encephalitis
H/A confusion, petechial maculopapular rash - CT neg, LP WBC >2K - PMN and low gluc - G stain G neg diplococci - meningiococcal meningitis - tx with ceftx 3 days later hypotensive shock
b/l adrenal hemorrhage -> IV hydrocortisone
Who to PPX for meningitis
prophylax day care/nursery school contacts, household contacts
How to PPX meningitis
rifampin 600po BID x 2 days If no rifampin cipro x 1 dose If on OCP - change contraception while on rifampin If preg ceftx 250mg IM x 1 Droplet precautions
Pt tx’d for meningiococcal meningitis since yesterday - how long continue isolation
D/C isolation now
52yo M p/w h/a - fever/neck signs - spinal tap elev open press, WBC 45 lymphs, protein 52, gluc 65, abx coverage for strep pneumo and hsv - 2 days later ctx neg, HSV pcr neg
d/c all meds and d/c home
HSV-2 causes…
aseptic meningitis - and can be accomopanied by gential ulcers and HSV-1 encephalitis
UTI
cystitis -> mostly ecoli - young women, staph saprophyticus, epi
Pyelonephritis
Catheter relted
Prostatis
Uncomplicated cystitis
3 days nitrofurantoin/bactrim/cipro - if sx persist >3 days c/s tx x 7 days
Cystitis in pregnancy
nitrofunatoin or amoxicillin x 7 days
Asx bacteruria in pregnancy
TREAT
Asx bacteriuria in DM
DO NOT TX
Asx bacteriuria post transplant
TREAT
Asx funguria with foley
DO NOT TREAT
asx bacteriria in foley
DO NOT TREAT
Recurrent cystitis
c/s and tx then suppressive regimen (bactrim/cipro)
Pyelonephritis
chills, fever, flank pain, tenderness, inc WBC urine
24yo F fever, chills, flank pain dysuria inc freq urin - +flank tenderness, +u/a 40WBC
tx cipro 7-10 days (quinolong)
if preg - admit and start ceftriaxone or amp + gent
If still temp in 3 days - renal US r/o structural abn
PCN allergy - aztreonam
32yo flnak pain, UA WBC >20 with many bacteria temp 102, HR 110 - started on amp-sulbactam - 3 days later pt eating/ambulating temp 99 HR 86 - grows ESBL E.coli and BCtx g neg rod -
still ok to d/c change to amox-clavulanate (augmentin)
Elderly male dysuria inc freq, tender prostate
Acute prostatitis - E.Coli
Tx: bactrim or quinalone (cipro) 4-6 wks
NH pt with foley and recurrent UTI - ppx?
nothing effective
Pt with foley - urosepsis -
change foley, start abx
NH pt with stroke, chronic foley with urosepsis several times/year - minimize risk of UTI?
close drainage catheter system
When is foley justified in elderly pt to promote healing
Stage IV sacral ulcer
STD - Gonnococcus, Chlamydia
no ulcer, no adenopathy, +discharge
Gonococcus
tx ceftriaxone
Chlamydia
Tx doxycycline or azithro
GC & Chlamydia
ceftriaxone + azithro 1gm or Azithro 2g one dose
Presentation GC/Chylamydia
urethritis, epidiymitis, mucopurulent cervicitis, dysuria, pyuria without bacteriuira, PID, diss gonococcal infxn (DIG)
24yo F college student sexually active with fever, chills.n,v x 3 days no vaginal d/c, tmep 102, HR 106, MM dry, left flank tenderness, mild suprapubic tenderness - no cervical motion tenderness - preg test neg
Admit - bctx, tx with IV cipro or bactrim
Vaginitis - Trichomonas
yellow d/c, strawberry cervix, pH>5
tx - metroniidazole 2g x 1 dose -> TX PARTNER
Bacterial vaginosis (gardnerella)
think d/c, clue cells, fishy odor pH>5
Tx Metronidazole x 7 days (whole garden - tx many days) - or metronid gel x 5 days, or clinda cream x 7 days - DO NOT TX PARTNER
Candidiasis
not smelling, thick white d/c
Tx - fluconazole 150 x1, topical clomazole x 3-7 days
tx partner only if balantitis present
pt with scanty foul smelling dc OTC vag azole and oral fluconazole don’t work - wtd?
NOT Candidasis - treat for gardenerella/trichomonas with flagyl or clinda po or cream - check vaginal pH - if scraping bleeding - chlamydia
Pt with dysuria - d/c on exam - UA WBC and clue cells - tx?
metronidazole (bacterial vaginosis)
PID
lower abd pain, CMT, adnexal tenderness, mucopurulent d/c, uterine tenderness
Etiolgoy - Neiseria gonorrhea, chlamydia, vaginal anaeroboes
Complications of PID
infertility, ectopic preg, perihepatitis, tuboovarian abscess
Tx of PID
Outpt - Ceftx 250 IM, dox 100 bid x 2 weeks (PCN ofloxacin +clinda/flagyl)
Inpt - vomiting/sev pain - cefoxitin/cefotetan + doxy 100mg bid x 2 weeks (PCN allergy - clinda/flagyl + genta + doxy)
25yo F p/w progressie lower abd pain for past 4 days with nausea, vomiting, fever - denies dysuria or flank pain - temp 101, HR 100 lower abd tenderness - cervical d/c and CMT on exam - WBC 17, 70% pmn - ctx P
Admit and tx with IV cefoxitin iv doxy for PID (not tolerating PO)
24 yo sexually active man with uretheral d/c - given ceftx 250 x 1 and d/c 10 days later with uretheral d/c - wtc?
chlymida (gonnorrhea treated) - doxy 100 bid x 7 days or aithro 1g x 1 - always tx for both gonorrhea and chylamydia
Gonorreha (2-6 day incubation)
Chlymydia (1-4 wk incubation)
Young woman on OCP, sexually active with yellow mucoid dc - exam non-tender but bleeding and cervix erythematous swollen - smear with wbc bacteria no hypahe - organism?
Chlamydia
20 yo F dysuria x 1 week - no fever or flank pain - pelvic exam no CMT no bacteriuria, wbc 20/hpf pyuria
dx chlamydia - check urine nucleic acid
tx doxycycline or azithro
Repeat chylmydia test
false + (test neg after 3 weeks)
>3 weeks - true positive retreat pt and partner
Student on spring break - p.w tenderness in posterior testes 1 week later - striping of urethra with d/c
chlamydia epidiymitis - tx azithro
24yo F sexually active pain on movement of wrist joint - single pustular lesion on dorsum of hang, swollen right knee - greatest yield of culture from…
cervical culture or history
do not need parents permission to tx STD
Gay pt c/o constipation, pain on defication and generlized wk - ulcer in perieal area - ulcer in anal canal on anoscopy - dx?
HSV
Pt with acute testicular pain - h/o several sexual encounters - no truam - US normal - dx of epidiymitis - organism?
35yo E.Coli, entero
Uncircumcised pt wit pearly penile papules wtd?
do nothing
Genital ulcers
HSV, syphilis, H ducreyi, Lymphogranuloma venerium, granuloma inguinale
Pt with painful ulcers - started as grouped vesicles - lymph nodes +- -> fever, h/a, myalgias
HSV (DNA virus) Tx - 1st episoe - acyclovir x 10 days 2nd -> acyclovir x 5 days recurrent >6/year - acyclovir ppx severe dz - iv acyclovir - reduces duration of sx and asympt viral shedding
Pt w/ painful genital ulcers, irreg borders initially started as tenderpapules painful adenopathy fluctulant -> rupture - schools of fish/boxcar - GRAM NEG Bacillus
H. ducrey -
tx - ceftrx 250 IM x1 or azithro 1gm x1 or erythro 500 x 7 days
Pt with PAINLESS gential ulcer - disappears in 1 week - 2-6 weeks later LAD - buboes, fistulae rectal scaring
Lymphogranulum venerum (LGV) - Chylymia tracho tx - Doxy 100mg bid x 21 days
Pt with terrible looking PAINLESS ulcers on penis + LAD looks like penile CA
Granuluoma Infuinale - klebsiella granulomatis
Micro: Donovan bodies - bipolar safety pin intracytoplasmic inclusions
Tx - Doxy x 21 days or bactrim/erythro
Young woman 4 montsh ago with PAINLESS genital ulcer - dark field +, RPR neg at time - tx’d with PCN now p/w sever small ulcer - tender RPR 1:8 -
has herpes infxn - acyclovir
Asx pt RPR screening 1:8 postive FTA +
If pt RPR neg last year->early latent syphilis-> benz PCN 2.4 mu x1
If Pt RPR neg >1 yr ago -> late latent syphilis - 2.4 mill units wk x 3
Pt with painless genital ulcer raised with indurated margin and clean base wtd?
Dark field microscopy
tx - benz PCN 2.4 units x1 or doxy x 14 days
Pt with fever h/a generalized adenopathy, maculopap rash palms/soles, ele ast/alt alk phos, hereophile Ag neg, elisa neg, HIV RNA <50 wtd
VDRL/RPR to r/o 2ndary syphilus - FTA+ for life
tx - Benz PCN 2.4 mu x 1
if repeat VDRL titer dec 4 fold tx sucess
If repeat VDRL inc/stay same -> LP to r/o neural sypilis
40yo for regular checkup - pupils 4mm when figer to nose, eyes converge and pupils 3mm, flashing light left pupil doesn’t constrict - Arygl robertson pupil
Spinal tap VDRL r/o neuro syphilus
Spinal tap WBC 410 lymph VDRL +, high protein, gluc 60 - wtd?
PCN G 2m units Q4h x 2 weeks
If PCN allergic - desensitize in ICU
repeat spinal tap q6m till WBC normal
Pt dx with syphilis started on PCN couple hours later with HA/fever, myalgias - BP 90/70, HR 104
Jarisch Herxheimer rxn - wtd?
Bed rest, ASA, continue PCN (NOT ANAPHYLAXIS)
45yo M h/a, difficulty walking, imbalance, fever double vision - HIV CD4 395, VL<24 dx?
neurospyphilis - spinal tap VDRL
Tick borne
RMSF, Lyme, Erlichia (anaplasma), babesia, Tularemia, STARI (southern tick associated rash illness)
ONLY ONE WITHOUT RASH COMMON IS ERLICHIA**
22yo N carolina camp c/o h/a, fever, myalgia 3 days later macular rash extremities - next day petechial
NMSF - doxycycline/tetracycline
57yo M cramping p/w complaint of h/a, fever, myalgias can’t recall tick bite - exam low grade temp, mild confusion no rash - WBC 2.5, Hg 13, plt 60 AST/ALT eleve 150/120 - cause?
Erlichia - anaplasma - only one without common rash!
Pt vacationing nantucket/long island p.w fever, shaking chills, drenching sweats NO RASH - blood smear ring forms, maltese cross, tetrads - Hg dec inc retic (hemolysis) dx?
Babesia
Tx - mild form - Azithro + atoquone
Severe - Quinine + clindamycin
Pt at MD office in NJ with skin lesionon thigh, erythematous lesion w/ central clearing - lesion smaller few days ago dx?
erythema migrans - secondary lyme (serology not reliable - clinical dx)
Tx - doxy, if preg then amox (fever, h/a LAD, arthralgia)
Pt fishing onnantucket - rash on leg which disappeared few days later - 2 wks later pt with dizziness - ii/iii heart block
Lyme secondary - cardiac
Tx: PCN/Ceftx (NO DOXY)
Cardiac I/II/III heart block
Neuro: aseptic meningitis, bell’s palsy, foot drop
Pt with disseminated or late stage lyme usually has…
western blot IgG banding+ > 5 bands
22yo wk left foot, no trauma - hiking several weeks ago with as rash cleared in few days doesn’t recall tick bite - dec power L foot, dec reflexes L foot dx?
Foot drop 2/2 lyme dz stage II
Stage II months to years later - presents as monoarticular arthritis or chronic neuro sx
Pt hiking in NE on friday, found tick monday - no rash no sx
> 24hr with tick - doxycycline even if asx
if < 24 hrs with tick can observe if asx
Pt hiking NE for bird watching - p/w facial palsy - cluster of vesicular eruption over auditory canal - dx?
Herpes zoster - DNA virus
tx - acyclovir
40yo F refereed with rash, central clearing - tx’d with doxy x 3 weeks - rath better but then malaise - to urgent care center repeat doxy x 2 week - f/u at MD office - 7/10 IgG bands _ and all bands + IgM
Post lyme syndrome - takes 6 months for sx to resolve
Tx - reassure do not retreat
Pt p.w tick attached - wtd?
place forceps at base of tick and lift gently
22yo Pt hiking in wisconsin - to ED with new onset weakness, DTR absent, denies tick bite - wtd?
search scalp for tick - tick paralysis better in hours once tick removed
Elderly pt with fiery red, well demarcated cellulits on face
Erysipelas - strep - cocci in chains
Tx - PCN
Complication - endocarditis
Female from singapore, honey crusted lesions mouth and chin - dx?
Staph infxn - impetigo
Strep throat complication
Acute glomerular nephritis
Pt with cellulits of leg, started on cephalosporin 1st gen - 72hr later cellulitis worse no brawny edema or bullous lesions, no DM wtd?
D/C cephaloporin and start bactrim, vanc or clinda
32yo cellulits on left leg wtd?
bactrim and cephalexin (cover MRSA and strep)
Invasive MRSA commonlypresents as ?
Bacteremia
Daptomycin used for G pos organisms including MRSA (not for PNA) - what to follow in pt on dapto?
CPK weekly
Pt with venacaval filter placed - 48hrs later p/w erythema at inciision site diffuse rash hypocalcemia, hyponatremia, inc Cr dec BP, fever - wound gram stain neg
Toxic shock syndrome
Strep - early onset 24hrs - culture usually neg
Tx - surgical debridement - PCN+clindamycin
Pt slipped and hit leg on bed railing in hospital, or Pt fishing and scraped arm 2 days later BRAWNY edema and severe tenderness with erythema - next day BULLOUS lesions - aspiration of bullae -> G+ cocci - started on IV abx - Pt hypotensive - on clinda and 1st gen cephalosporin
dx? Group A strep necrotizing fascitis
WTD?
Surgical consult!
MRI scan to confirm (best for soft tissues)
Least likely cause of toxic shock syndrome
nursing home pt wearing diapers
caused by tampons, post op wound, breast implants, nasal packing
Pt Gulf coast/florida (warm waters) p.w cellulitis with hemorrhagic bullae and necrosis +LN dx?
Vibrio vulnificurous (loves iron) - liver tx patients at inc risk with raw shell fish
tx - aggressive debridement
3rd gen ceph or tetracyclin/gentamycin
Pt (fish tank clenaer/swimming instructor) - p.w non-healing skin ulceration - started as single lesion on hand now multiple lesions forearm - bx AFB + dx?
Mycobacterium Marinum
Tx - Clarithromycin+ethambutol +- rifabutin
Pt with cut while in fresh water now leg swollen, septic and has h/o ETOH LIVER DZ - what is bacteria?
Aeropronas hyophillia
Florist/gardener p/w multiple nodules on hand and formarm - lymphatic channels - dx?
Sporotrichosis - sporothrix schenkii
Tx: local dz - itraconazole
Disseminated - amphot B (DM transplant pts)
Pt p/w folliculitic rash - h/o Jacuzzi/bath tub - dx?
hot tub rash - pseduomonas - improperly chlorinated hot tub
Tx - self limited no tx needed
Pt with cough, CXR infiltrated with thin walled cavity - indoor hot tub 3 days/wk dx?
MAI - Hot tub lung - avoid hot tubs
Pt on chemo becomes neutropnic - develops cellulitis black lesion with central ulceration - dx?
Ecythema gangrenosum 2/2 pseduomonas
Tx - anti pseduomonal b lactam + aminoglycoside/cipro or imipenum (collistin/polymysin)
Least likely about pseudomonas
CANNOT BE TREATED WITH AMP-sulbactam
(can cause malig otitis externa in DM, osteomyelitis in nail pct, endocarditis in IVDA, sepsis in neutropenic, ecthema gangrenosum, hot tub folliculitis)
50yo HIV p.w vesicular lesions on one side of face including ext aud cana with burnign pain - scrapings with multinucleate giant cells wtd?
IV Acyclovir
Pt p/w burning sensation over R forehead x 36hr - hyperesthesia over R forehead and single vesicular lesion on erythematous base on tip of R nose - what is WORST complication
Zoster ophtalmicus - Optho referral
slit lamp no corneal invovlment - started on valacyclovir - continues to have pain -> start prednsone
Post herpetic neuralgia tx
Desipramine>gabapentin
Isolation for herpes zoster?
Single dermatome - contact isolation
2 or > then contact and airborne
Herpes zoster with single rash
72hrs supportive care
>72hr and HIV treat
>72 hr Age>50 if new lesions appearing only then tx
65yo M herpes zoster vaccine - precautions for caregivers that never had chicken pox?
None
Non-Tb mycobacteria
MAC/Kansasii - common lung infx - hot tub lung
Abscessu/chelonae.fortuitum - water use, cutaneous/implnat infxn osteomylelits
Marinum - fresh and salt water
Non-healing cellulitis or infxn post breast implant -
M. Absessus
Non-healing cellulitis in pt with pedicure
Marinum, Fortuitum
Small Pox
Pharynx/face->extremities and trunk
Rash-> Vesicles-> pustules evolve CONcurrently
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available
Chicken pox
Chest and back
Rash->vesicles-> pustules evolve in crops, diff stages
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available
24yo brings 5yo daughter with small pox - she is worried about 20yo son who si scheduled for chemo for leukemia - new PA can’t remember if he had small pox as child - wtd?
Child with immune def -> VZIG (highest risk)
Pregnant mother-> check titer if VZIG low - tx for symptoms
PA - check titer and vaccine if neg
Pt with lesions on extremities in diff stages (vesicle, pustule, escar) MC complication
PNA
Nurse/resp therapist with vesicular lesions on finger with erythema.tenderness - pet kitten at home
Herpetic whitlow - HSV -> tx with acyclovir
Young pt fever, malise sore throat followed by vsicular lesion on tongue, buccal mucosa -> later with painful vesicle lesions on dorsum of hand and foot
hand foot mouth dz -> coxsaxie virus
Pustules on palms after petting at fair or wild dog - dx?
Monkey pox
Week after hiking and staying at high elevation cabin NW - recurrent feverwith h/a, myalgia, arthralgia, chills, vom, abd pain - dx?
Borrelia hermsii (tick born illness in W US)
SW pt p.w sudden resp failure, pulm edema and inc’d HCT
Hanta virus - yosemete
Pt bit by cat - wtd?
Augmentin (Amox/clav) - pasterella multiloci + anaerobies (also for human and dog bites)
Pt h/o splenectomy for ITP plays with pet dog sustains scratch/ac - hypotensive next AM dx?
Septic shock 2/2 CAPNOCYTOPHAGA CARNIMORSUS
Pt with tooth ace, +submandicbular LN PCN allergic wtd?
Clindamycin
Pt with cat pw pustular lesion on hand and tender LN in axilla dx?
Cat scratch dz -> Bartonella Hansleae
Tx Doxy/erythro
HIV pt with multiple nodular lesions on extremities - ASTinc ALT inc, bx -> modifed silver stain +, warthin starry organisms+ - liver peliosis hepatis (cystic spaces with blood)
Dx bacillary angiomatosis -> bartonella henslae
Tx - doxy/erythro
Pt with HIV, T cells 150/cm homeless - lives in shelters and streets - with itching and excoriations of skin - pt disheveled - AST/ALT ELEVATED, spiking temp - holosystolic murmur at apex dx?
Bartonellosis endocarditis - trench fever 2/2 bartonalla quintana
Rabies vaccin/immune globulin for…
dog bite bat bite/scratch fox bite racoon bite NOT rat bite
Pt with dog bite in mexico - rabies vaccine 1 year ago
Vaccine x 2 doses (no HRIG)
Malaria - P. Falciparum
resistant almost everywhere
Malaria P. falciparum sensitive and others
caribbean, central america, near east
Malaria ppx
1 wk prior and 4 weeks after return arrival - mefloquine, atovaquine, chloroquine
Malaria tx
Quinine + doxy
Atovaquone/proguanil or cloroquine + primaquine
quinine gluconate+clinda
or arteminiin-amodiquine
Look at red book pg 239
Malaria endemic areas and other endemic dz
PT returns from nigeria trip - 2 wks later c/o shaking chills/fever, drenchign sweats then comatosed - retic 4% - gametocytes and dx cerebral malaria
Quinidine gluconate and doxy
Pt fever chills after nigeria 4 weeks ago - most sensitive test fo rmalaria
Ag base malaria rapid dx test
Best tx - artemether-lumefantrine (less s/e)
Pt did not take mefloquine for ppx now with malaria - wtd?
malarone (atovaquone/Proguanil)
mefloquone can’t be used with cardiac conduction dz
Pt ER in NY with fever, rash mylagias retro orb h/a - vacation in florida keys, temp 101, HR 95 - faint MORBILLIFORM rash on trunck, few petechiea - plt 55K, WBC 4.5 - dx?
Dengue (bone breaking fever - hemorrhagic fever, mosquito borne, low plts, plasma leakage, low BP - n/v/f/diarrhea/GIB
Pt with lower abd pain, pelvic exam adnexal tenderness, cervical motion tenderness retained IUD wtd?
remove iud, ampilcillin/PCN
Actinomyces
sulfur granules, branching filaments
Pt with extensive dental caries p/w tenderness over mandible - diff opening mough, brawn edema over upper neck with tenderness dx?
Ludwigs angina
etio - peptostreptococcus, mixed anarobes
Tx - Amoxicillin-clavulante/amp-sulbactam
Neutropenic fever
bugs - staph au
Pseudomonas
aspergillus
absolue PMN<500 sp.p chemo p/w fever,
start on GCSF - cover G neg/pseudomonas - B lactam (ceftazidime or cefepime with amionglycoside
OR imipenum -
Add Vanc
Spikes on 7th day still - Amphotericin B - if renal failure voriconazole
Which antifungal improve mortality for ppx post chemo neutropenia
Posaconazole (noxafil)
Tx infections
4 month - fungal - cryptococcus
complication of BK virus
BK virus nephropathy
Pt s/p chemo - neutropenia and fever - pt started on vanc, primaxin 5 days later still fever - LLL infiltrate dense core gg appearaance with halo sign - dx?
Aspergilllosis - amphotericin B
if Cr elev - voriconazole
what is + in aspergillosis infxn pt
Serum galactomannan (aspergillous antigen - can be tested for as screen)
55yo renal tx - rejection 2 weeks later on immunosupp drugs - tacrolimus added - several months after - GG intranuclear inclusions in urine
BK virus - ground glass intranuclear inclusions urine
2 months post tx pt with fever, cough not responding to levofloxacin x 1 week - PO2 65, CXR b/l infiltrates - CMV+ b4 tx - lung bx - intracytoplasmic inlusions - dx/tx?
Ganciclovir, CMV immuneglobulin
Norcardia
lung skin, brain lesions - branchig/filiment, gram +, weakly acid fast
tx: sulfonamides - TMP-SMZ - if Cr increases this is NOT RENAL COMPROMISE
HIV pt 25 t cells VL 22K p/w fever/cough CXR thin walled cavity in RLL - BAL grows CMW, candida, HSV, norcardia - tx pt with…
Bactrim for norcardia
Pt with liver tx on high dose steroids and immunosuppresves - or SLE pt on steroids cough, fever, n/v - skin with nodular lesion - CXR nodular lesion - CT brain ring enhancing lesion
Nocardia
Osteomyelitis
hematogenous - long bones (children), vertebrae (adults)-tx with nafcillin
Contiguuous spread/DM foot - polymicrobial - broad spec abx
Prothetic implants - staph epi -> vanc, gent, refampin (sticky)
Necrotic bone (sequestrum)->chronic osteo->debridement (will return with just abx)
Sickle cell witih osteo -> salmonella>staph
MCC osteomyelitis in US
Staph aureus
Older adult with bacteremia p/w fever, lower back ache, point tenderness on spine
verebral osteomyelitis
tx - bctx, imagaing ct/mri, abx for 4-6 weeks
How to dx infection prosthetic hip 3 months post op
CT guided asp and culture
Pt with UTI, BCtx pos - Tx with IV abx, on TLC, 3 days later spiking temp, confused - hyper-reflexia in lower extrem and hyporeflexia in UE - CSF gluc 80, protein 295, WBC 75 60% pmn - dx?
Spinal epidural abscess
pt s/p chemo, no hs mets, recovering from neurtropenia with high fever - nodules on liver in CT dx?
hepatosphere candidiasis
Pt poorly controlled DM with bloodly nasal d/c - BLACK NECROTIC SPOT ON NOSE - rednes one ye - bx of lesion - FILAMENTS BRANCHING right angles
Murcormycosis
Tx: surgical debridement + amphotericin B
Pt with CRF on HD with recurrent staph aureus infxn - MRSA infxn from infected catheters - sucessfully treated with vancomycin IV in past - recent infection with staph not responding to vanc x 3 days
do epsilon e test measure MIC - if >2 then GISA or Vanc insensitive staph ->
tx Linezolid or quinupristin/dalfoprisitn
Pt started on abx for pos bctx enterobacter - pt defervesces, feels better on 6th day spiking - pt ctx positive for enterobacter now resistant to abx
what abx? cephalosporin
Pt with enterobacter infxn sensitive to cephalosporins - few days later enterobacter now resistant - what happened?
Plasma mediated resistance - ESBL mutans
tx - meropenum>imipenum>ertapenum (low threshold for resistance)
Pt growing ESBL klebsiella resitant to impipenum - wtc
polymyxin (elev cr)
Pt with UTI with ESBL sensitive only to colisint and tigecycline wtd?
Colistin only - tigecycline does NOT penetrate GU tract
Best management for stenotrophonas (xanthomonas) maltophilia
bactrim
What organism can be treated with abx without d/c central line?
staph epi (only remove for g neg rods)
Best way to do BCx on pt with central line
timed pair BCtx from both peripheral blood and catheter
Pt in ICU starts spiking temp of 102F, abx started, TLC changed over guide wire and tip sent for ctx - next day tip ctx grows Gram neg rods sensitive to Abx - pt better temp 100.5 wtd
REPLACE central line with fresh stick - continue abx
Pt in ICU with central line > 3 days ago with high fever and sepsis
dx - nosocomial line sepsis - d/c line and start vancomycin and amionglycoside
Best way to prevent central line infection
maximum barrier protection while insertion
Best way to prevent nosocomial infection outbreaks
hand washing
best way to prevent vent associated PNA
elevation of bed 45 deg,
15yo pw low fever, sore throat fatigue myalgia and cervical LAD - petetchiae on palate no phalangial lesions - monospot neg for heterphile abs - wtc
check EBV viral caspid antigen (VCA IgM)
Ampilcillin taken -> gets morbilliform rash - organism?
EBV - hypersensitivity rxn to abx - only occurs in presense of EBV infxn though…false neg monospot
pt withi +LN, monospot +, inc SOB, large tonsils - wtd
steroids…
Pt with infectious mono and LUQ pain wtd?
CT scan stat - splentic rupture
splenectomy
Pt in MICU on IV TPN x days with fever, chills opthalmitis - etology?
candida - chromium deficiency
Candida in BAL
DO NOT TX
Asymptomatic Cadiduria
DO NOT TX
Asymptomatic candida in blood
TREAT THIS!!
Pt grows candida in blood, fluconazole d/c’d 2 weeks ago wtd?
start caspofungin
Anthrax
Skin form - necrotizing form rare - animal hides
GI - ingestion with sever diarrhea
Inhalational - non-sp sx, h/a, chills vomm, sob, hemorrhagic meningitis pre-terminal - CXR with widened mediastinum (spores taken up by lymphocytes) - preterminal
Anthrax tx
Flouroquiniolone or PCN
Anthrax other characteristics
NO person to person tx Isolation NOT required - BCtx - gram + bacilli PPX effective one day after exposure Vaccine available for military
Farmer goes hunting for raabits and gets tick bites, p/w ulcers, fever, chills, myalgias and PNAA - tender inguinal and fem LN and cojuncitvitis - g neg pleomorphic organisms - dx?
Tularemia - wound bx or serology - ulceroglandular fever
tx - streptomycin x 7 to 10 days
Good saritan removes dead deer from highway i ARK/Oklahoma - couple days later with tender erythemaous papule, ulcerated with black eschar - organism?
Francisilla Turaemus (tularemia)
45yo h/a, cough, myalgias - temp 101.5 - cxr with RL infiltrate - watching US open in NYC - two other ppl had similar sx
Tularemia (infiltrate)
2 days after superbowl - inc’d pts a/w fever, cough, chest pain hemosptysi and prostaration - several died 24hrs after admission - dx?
Plague
Yersenia Persisitis
Bubonic (LN), Septicemic(causes DIC), Pneumonic (lungs)
Speads airborn droplets, close contact (also sexual)
Tx - doxycylcine, erythro, streptomycin (also for exposed close contacts)
Droplet isolation
Which most commonly aeorsolized
Coxiella burnetii (Q fever)
Rancher with fever, culture neg endocarditis - cryolobulins pos and HCV neg - dx?
Brucella - musc pain, sweating, fever, cryoglob +, endocarditis (neg ctx)
brucellosis - from unpaturized mild - ranchers infected animals
Tx tetracyclines, rifampin, streptomycin, aminoglycosides
Q fever infected most likely by…
Vets, abattoir workers in queensland (Q fever), farmers handling infected goat, sheep, cattle
Q fever - coxiella burnetti (ricksettia)
URI, fever, myalgias, headache
Tx - doxycycline, tetracycline, cipro
Young male with fever, myalgias, petechial rash after rafting trip PR, costa rica - icteric, mildly elev LFT with high T bili dx?
Leptospirosis - mildly elev transaminases and D bili 5-10x normal
Most likely inhaled with atypical PNA/h/a, fever
Q fever
MC with contaminated soil and animal products
Q fever
Caused by rikettsia
Q-fever
Skin contact or aerosolized -> RE system - splenomegaly, hepatitis, LN+ fever and drnching sweat - dx?
Brucellosis
Gram neg coccobacilli
Brucellosis
Sewage worker contact - fever hep, jaundice, liver hemorrhage, CONJUNCTIVAL SUFFUSION
Leptospirosis
Vet with fever - mental status change, jaunce renal failure, ecchymosis
Leptospirosis
Doxycycline
Q fever, burcellosis, leptospriosis, erysipelothrix
Buchter with fever, palpable spleen tip
brucellosis
Fisherman or fish handler with burnign or throbbing pain with erythem lesion on finger
erysipelothrix
Pt walks on beach in west florida pw red eyes, SOB, no wheeze or rohonci - dead fish on beach - dx?
Redtide bloom - Karenia brevis (algae)
Pt p/w diarrhea, fever, non-productive cough with HYPONATREMIA - drinks from TAP water
Legioniella -
tx quinolones - levoflox, azithro
sewage worker who hunts deer adn squirrel p/w fever, fatigue, abd pain and gen aches - CONJUNCTIVAL SUFFUSION - scrapes on hands, no ulers - CPK 765, mild ast alt elev, Bili 6.8 (elev), BUN/Cr 110/8
Dx? Leptospirosis
Tx: Doxycycline
21yo Iraq or afghan vet p/w 3cm lesion on arm, ulcerated with irrreg margins, eschar, surr erythema
Cutaneous Leismeniasis
Tx: fluconazole
40yo immigrant rural turkey/middle east with enlarged liver - dx?
Hydratid cyst (echinnococcus)
CMV colits isolation
none
MRSA isolation
contact
VRSA,VRE isolation
contact
HZV 1 dermatome isolation
contact
HZV >2 derm isolation
contact AND airborne
C diff isolation
contact
scabies isolation
contact
Measles isolation
airborne
Varicella isolation
contact AND airborne
MTB isolation
airborne
Neisseria isolation
dropelt
Influenza isolation
droplet
Plague isolation
droplet
HIV mother to child transmission
mainly during deliver
Post partum breast feeding
<2% with ART
Occupation risk exposure - high risk
1 protease inhibitor + 2NRTIs
Pt with HIV on ART undetctable VL now preg - WTD
continue ART to term - NO efavinanz
If HIV pt wants to breast feed
continue ART maintain undetect VL to prevent baby transission
Pt p/w fever sore throat rash 3 wks after high risk sex encounter - LAD (cervical , SM with apthous ulcers - atypical lymphs on smear - HIV neg - monospot/heterophiel Ab neg - wtd?
HIV RNA PCR r/o acute retroviral syndrome
Nurse with needle stick pt with HIV or high risk for HIV
baseline HIV elsia - start 1 protease inhib + 2 NRTI x 4 weeks - repeat HIV test if neg d/c meds
Sexual assult victim by IVDA unknown HIV status 24 hrs ago
offer 1 protease inhib + 2 NRTI
Opp infxn >200 T cells
CAP - S pneumon PP+ Tx PPD > 5mm with INH x 9 months Kaposi's sarcoma - dark bronish plaues on legs, pulm inviltrate - pulm nodules - purple red on bronch HHSV8 Lymphoma
Opp Infxn < 200 T cells
Pneumocystis Jirovechi PNA - dry cough > 1 wk, grad onset progresssive - ABG with hypoxiemia
ele LDH, CXR b/l intersitial infiltrate or PTX
Dx - sputum silver methanamine +
BAL with stain
Tx - Bactrim (allergy - IV pentamidine or clina + primaquin)
If PaO2<70 add STEROIDS
Best test for suspected mild to mod dz PJP
check serum B D glucan
Bactrim effect on Cr
goes up, does not dec renal clearance - continue bactrim if Cr increases (dec’d tubular clearance of Cr by trimethopram)
Pt with PJP on bactrim with rash and spikign tmep - wtd
change bactrim to IV pentamidin or clinda + primaquine
Pt on bactrim with rxn
change to dapsone or atoquaone
Which drug covers both PJP ppx and sec ppx for toxo
dapsone + pymethamine
Candidasis
oropharyngeal - white patchs
Tx Fluconazole
recurrent on fluconazole - use itraconazole
HIV with T cell 55 - severe heart burn
empiric fluconazole for susp esoph candidasis - if no response upper endscopy - r/o CV or HSV or candidial esophagitsi
<100 t cells - h/a copel weeks not relleived with analgesics - CTH neg - wtz
SP to r/o crytococal meningitis - spinal fluid - india ink + = crypt Ag +
Tx: Amphotericine 5 + 5FC -> fluconazole long term
< 50 t cells - MAI
fevers, hepatomeg, LAD - elev alk phos (vit D def), bctx + AFB
Tx: clarithro/ethamburol +- rifabuin
<25 tcells
CMV retinitis - blurring vision
Tx Gancyclovir, cidofovir, foscarnet
<25 cells
progressive MF leukoencephalopathy - JC virus, use of natalizumab or efalizumab, rituximab, infliximab
PPx vs OI’s
<50 cells - MAI - azithro or clarithro
Pt with T cells 25 started on HAART - 6 months later T cells 150
d/c azithro for MAI ppx (not < 50)
Pt 4 motnsh later t cells 250
d/c bactrim for PJP ppx
Which finding r/o crypto meningitis
neg crypt antigen in CSF
Ring enhancing lesions
Toxo
brian abscess
lymphoma
Pt with HIV T cells 25 h/a and one sided WK - CT scan ring enhancing lesion wtd?
tx for presumptive TOXO - sulfadiazine/pyrimethamine - repeat CT 2-3 weeks if no change bx lesion
CNS lymptoma
T cells < 50 - EBV ag +,
HIV pt T cell < 45 - VL 150K wk left leg - CT scan ring enhancing lesion, CMV +
NOT CMV (biventricular enhancement should be there)
could be
toxo, lymphoma, brain abscess
Middle ages latin american immigarant living in US recent onset Seizures - CT multiple cystic lesions with calcifications mild hydroceph
Neurocystercircosis - Taenea soliens
Tx: Phenytoin (cyerco serolody)
Hog farmer with fever, myalgia - periorobital edema, spinter/conjuntival hemorrhages - muslce tenderness no murmur - EOS 8%, LDH 400, CPK 7000
Dx tes t- Muscle bx, trichinella Ab (bear meat)
MCC PNA HIV CD4 150
Strep Pneumo
Pt dx HIV VL 105K asx started on regimennelfinavir, lamivudine, stavudine and bactrim - what else to start
Azithro or clarithro for MAI ppx
Indications for ART therapy for HIV
VL>100K T Cell <500 Acute retroviral syndrome Opportunistic Infections Pregnancy
Protease Inhib - main s/e Lipodystrophy
Darunavir Lopinavir Atazanavir - in indir bili Indiavir - kidney stones Ritonavir - boosting agent, inc TGA, chol
NRTI - lactic acidosis, CAD, nypersensitiv rxn, neuropathy
Tenofovir - renal insuffiency Emtricitabine Zidovudine AZT - anemia, inc MCV, neutropenia Abacavir Lamivudine
NNRTI
Efavirenz
Nevirapine - steven johnsons, liver tox
Entravirine - CNS effuects, conf, abn dreams, agitiation
Integrase Inhibitors
Raltegravir
Combinations of HIV drugs
2 NRTI + PI/Integ Inhib
2 NRTI + NNRTI
PI S/E
HLD, insulin resistance, lipodystrophy, liver tox
What drug causes bone marrow suppression?
Zidovudine (AZT)
Best statin for HLD with HIV
Pravastatin, or atorvastatin
What statin to NEVER use
Simvastatin (inc levels HIV drugs)
Best drug for insulin resistance
Glitazones
Best inh steroid for HIV asthma
Beclamethasone
Best HIV med with HCV therapy
Raltegravir
What drug causes renal insuff (HIV drug)
Tenofovir
HIV pt on ART with indinavir, Zidovudine, lamivudine x 3 years - noted bufalo hump - pt obeese - all may be abn except
cortisol (lipds, glucose adn weight abn)
HIV pt with anorexia, wt loss, lethargy dizziness - hyperpig of skin, BP low, HR orthostatic, Na 135, K 5 dx?
Addison’s dz (Ag/ab HIV)
33 yo F HIV p/w nausea and back pain - started o stavudine, lamivudine indinavir - left flank tenderness - elev cr, K, RBC in urine - wtd?
Indinavir - kidney stones
Immune reconstitution syndrome -
pt with adv HIV low t cells high VL - start on ART - react to latent pathogens - inflamation - continue ART
Pt with T cells 25, VL 250K, start ed on ART - 3 weeks later with cervical LAD
immune reconstitution to MAI/TB
HIV survelilence
VL q month till VL <50 within 6 months
HIV VL note dropping
Reason?
Non-adherence
or Resistant virus - check HIV genotyping
Earliest change to see in HIV therapy failure
rise in VL
Earliest OI in AIDS (not aids def lesion)
Oral thrush
Pt dx with HIV started on Norvir, Indinavir, AZT, epivir 4 months later VL <50, T cell 500 - pulm TV dv and started on rifampin, ethambutol and PZA - VL 2 months later 15K - explanation?
pt adherance - rifampin dec level of PI - change rifampin to rifabutin or change PI to NNRTI + NRTI
Pt dx with TB start on 4 anti TB - found to be HIV + - when to start ART?
within 2 to 4 weeks
Labs/onitorsing
HIV VL, T cells, RPR, Hep panel, PPD, Tox, LFTs
Vacc - HAV, HBC, flu, pnumovax, inactiv poli, Tdt
NO LIVE VACCines
Live vaccines
Oral polio
MMR
Varicella
Yellow fever
