Infectious Disease Flashcards
Leptospires have this type of flagella
2 periplasmic flagella
Most impt reservoir of leptospires
rodents
T/F
The vast majority of infections with Leptospira cause no or only mild disease in humans.
True
T/F
During the immune phase, the appearance of antibodies coincides with the disappearance of leptospires from the blood.
True
However, the bacteria persist in various organs, including liver, lung, kidney, heart, and brain
During the immune phase, resolution of symptoms may coincide with the appearance of antibodies, and leptospires can be cultured from the urine
Usual incubation period of leptospirosis
2-30
The incubation period is usually 1–2 weeks but ranges from 2 to 30 days.
2 phases of leptospirosis
The acute leptospiremic phase is characterized by fever of 3–10 days’ duration, during which time the organism can be cultured from blood and detected by (PCR).
During the immune phase, resolution of symptoms may coincide with the appearance of antibodies, and leptospires can be cultured from the urine.
Weil’s syndrome triad
Weil’s syndrome, encompasses the triad of hemorrhage, jaundice, and acute kidney injury.
Typical electrolyte abnormality in leptospirosis
Typical electrolyte abnormalities include hypokalemia and hyponatremia
Common ECG finding in leptospirosis
Cardiac involvement is commonly reflected on the electrocardiogram as nonspecific ST- and T-wave changes. Repolarization abnormalities and arrhythmias are considered poor prognostic factors
Most common radiologic finding in severe leptospirosis
The most common radiographic finding is a patchy bilateral alveolar pattern that corresponds to scattered alveolar hemorrhage.
Based on Harrisons , how is leptospirosis confirmed
A definitive diagnosis of leptospirosis is based on isolation of the organism from the patient, on a positive result in the PCR, or on seroconversion or a rise in antibody titer.
In cases with strong clinical evidence of infection, a single antibody titer of 1:200–1:800 (depending on whether the case occurs in a low- or high-endemic area) in the microscopic agglutination test (MAT) is required.
** In CPG At least 1:1600 is enough for diagnosis
Preferably, a fourfold or greater rise in titer is detected between acute- and convalescent-phase serum specimens.
In rare instances, a ______ reaction
develops within hours after the initiation of antimicrobial therapy for leptospirosis
Jarisch-Herxheimer
Treatment for leptospirosis
Based on CPG when do you suspect leptospirosis?
Based on CPG what are the lab results that may indicate severe leptospirosis?
Based on CPG what are the recommended tests for AKI in leptospirosis?
Based on CPG what is the IVF of choice for px with leptospirosis presenting with shock?
Plain NSS with K incorporation
Based on CPG, what are the indications for HD
Almost same values as severe lepto but K should be > 5
HD should be done DAILY in critically ill px
Based on CPG how do you manage oliguria in leptospirosis
Based on CPG, what is the 1st sign of pulmonary involvement in leptospirosis?
tachypnea >30
Based on CPG, what are the 2 most common pulmonary complications of leptospirosis?
Pulmonary hemorrhage and ARDS
Based on CPG, how do you treat the pulmonary complications of leptospirosis?
Methylprednisolone should be given as 1gm IV for 3 days then should be continued as oral prednisolone 1mg/kg/day for 7 more days
Based on CPG, recommended PRE exposure prophy for leptospirosis
Based on CPG, duration of POST exposure prophylaxis for leptospirosis
Which of the Plasmodium species can cause relapse
What stage of the Plasmodium species invade the RBCs?
Merozoites invade RBCs to become trophozoites
Phenotype resistant to P. vivax
Most West Africans and people with origins in that region are the Duffy-negative FyFy phenotype and are generally resistant to P. vivax malaria
The most effective mosquito vectors of malaria are those
Anopheles gambiae species complex in Africa, that are long-lived, occur in high densities in tropical climates, breed readily, and bite humans in preference to other animals.
P. ___ and P. ___ show a marked predilection for young RBCs and P. ____for old cells;
vivax and ovale - young
malariae- old
Genetic abnormalities/ conditions with reduced risk of dying from severe P. falciparum malaria
The geographic distributions of the thalassemias, sickle cell disease, hemoglobins C and E, hereditary ovalocytosis, and (G6PD) deficiency closely resemble that of falciparum malaria before the introduction of control measures. This similarity suggests that these genetic disorders confer protection against death from falciparum malaria
Hemoglobin S–containing RBCs impair parasite growth at low oxygen tensions, and P. falciparum– infected RBCs containing hemoglobin S or C exhibit reduced cytoadherence because of reduced surface presentation of the adhesin PfEMP1
T/F
In malaria, the corneal reflexes are
preserved even when patients are in deep coma
False
preserved except in deep coma
Pathophysiology of hypoglycemia in severe malaria
Hypoglycemia, an important and common complication of severe malaria, is associated with a poor prognosis and is particularly problematic in children and pregnant women. Hypoglycemia in malaria results from both a failure of hepatic gluconeogenesis and an increase in the consumption of glucose by the host and, to a much lesser extent, the malaria parasites.
Manifestations of severe malaria
Features indicating poor prognosis in severe malaria
T/F
Transfusion associated malaria may still have relapses from P. vivax and ovale
False
there is no preerythrocytic stage of development, and thus there are no relapses of P. vivax and P. ovale infections
Plasmodium species associated with Quartan malaria
P. malariae
Identify the stages of P. falciparum
A. Young trophozoite. B. Old trophozoite. C. Trophozoites in erythrocytes and pigment in polymorphonuclear cells. D. Mature schizont. E. Female gametocyte. F. Male gametocyte
A. Young trophozoite. B. Old trophozoite. C. Mature schizont. D. Female gametocyte. E. Male gametocyte
disadvantage of RDTs for diagnosis of P. falciparum
A disadvantage of RDTs is that they do not quantify parasitemia
In severe malaria, a poor prognosis is indicated by a predominance of more mature P. falciparum parasites (i.e., >___% of parasites with visible pigment) in the peripheral-blood film or by the presence of phagocytosed malarial pigment in >__% of neutrophils (an indicator of recent schizogony)
20%
5%
What are the diagnostic tests used for malaria
First line tx for uncomplicated P. falciparum malaria
The World Health Organization (WHO) recommends artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated P. falciparum malaria in malaria-endemic areas
Tx for severe falciparum malaria
Artesunate therefore is now the drug of choice for all patients with severe malaria everywhere
Severe falciparum malaria constitutes a medical emergency requiring intensive nursing care and careful management. Adjunctive treatments such as high-dose glucocorticoids, urea, heparin, dextran, desferrioxamine, antibody to tumor necrosis factor α, high-dose phenobarbital (20 mg/kg), mannitol, or large-volume fluid or albumin boluses have proved either ineffective or harmful in clinical trials and should not be used. In acute renal failure or severe metabolic acidosis, hemofiltration or hemodialysis should be started as early as possible
Tx to prevent relapse for P. vivax and P. ovale
Need to add primaquine in addition to chloroquine or amodiaquine
Primaquine eradicates hepatic forms of P. vivax and P. ovale;
Note: primaquine should NOT be given in severe G6PD deficiency
When a patient with severe malaria is unconscious, what lab test/s should you request for?
When the patient is unconscious, the blood glucose level should be measured every 4–6 h. All patients should receive a continuous infusion of dextrose, and blood concentrations ideally should be maintained above 4 mmol/L. Hypoglycemia (<2.2 mmol/L or 40 mg/dL) should be treated immediately with bolus glucose.
The parasite count and hematocrit should be measured every 6–12 h. It has been recommended that if the hematocrit falls to <20%, whole blood (preferably fresh) or packed cells should be transfused slowly, with careful attention to circulatory status.
What antimalarial drug is associated with hypoglycemia
Quinine
What antimalarial drug is associated with Hypotension
Chloroquine
What anti malarial drug is associated with Agranulocytosis and should not be used with efavirenz
Amodiaquine
What antimalarial drug is associated with Megaloblastic anemia
Pyrimethamine
Artemisinin and derivatives (artemether, artesunate) do not have action on these stages of Plasmodium
kills all but fully mature gametocytes of P. falciparum. No action on liver stages
Treatment for acute pulmonary edema in malaria
This syndrome is caused by increased pulmonary capillary permeability. Patients should be positioned with the head of the bed at a 45° elevation and should be given oxygen and IV diuretics. Positive-pressure ventilation should be started early if the immediate measures fail
Treatment for hypoglycemia in malaria
An initial slow injection of 20% dextrose (2 mL/kg over 10 min) should be followed by an infusion of 10% dextrose (0.10 g/kg per hour). The blood glucose level should be checked regularly thereafter as recurrent hypoglycemia is common, particularly among patients receiving quinine
Treatment for spontaneous bleeding in malaria
Patients who develop spontaneous bleeding should be given fresh blood and IV vitamin K.
Treatment for convulsions in malaria
Convulsions should be treated with IV or rectal benzodiazepines and, if necessary, respiratory support.
the only drug advised for pregnant women traveling to areas with drug-resistant malaria;
Mefloquine
this drug is generally considered safe in the second and third trimesters of pregnancy;
When should pre exposure prophylaxis be taken when visiting a malaria endemic region
Travelers to a malaria endemic region should start taking antimalarial drugs 2 days to 2 weeks before departure so that any untoward reactions can be detected before travel and so that therapeutic antimalarial blood concentrations will be present if and when any infections develop
Antimalarial prophylaxis should continue for 4 weeks after the traveler has left the endemic area, except if atovaquone-proguanil or primaquine has been taken; these drugs have significant activities against the liver stage of the infection (causal prophylaxis) and can be discontinued 1 week after departure from the endemic area
Atovaquone-proguanil is contraindicated in persons with _______
severe renal impairment (creatinine clearance rate, <30 mL/min).
T/F
Serotypes of Salmonella that are only restricted to human hosts
The growth of serotypes Salmonella Typhi and Salmonella Paratyphi is restricted to human hosts, in whom these organisms cause enteric (typhoid) fever.
T/F
All Salmonella infections begin with ingesting organisms, most commonly in contaminated food or water.
True
The infectious dose ranges from 200 colony-forming units (CFU) to 106 CFU, and the ingested dose is an important determinant of incubation period and disease severity
Mean incubation period for S. typhi
The mean incubation period for S. Typhi is 10–14 days but ranges from 5 to 21 days, depending on the inoculum size and the host’s health and vaccination status.
The most prominent symptom is prolonged fever (38.8°–40.5°C [101.8°–104.9°F]), which can continue for up to 4 weeks if untreated
When do yo usually see rose spots in typhoid fever
Rose spots make up a faint, salmon-colored, blanching, maculopapular rash located primarily on the trunk and chest. The rash is evident in ~30% of patients at the end of the first week and resolves without a trace after 2–5 days.
When do you expect to see GI complications of typhoid fever?
Gastrointestinal bleeding (6%) and intestinal perforation (1%) most commonly occur in the third and fourth weeks of illness and result from hyperplasia, ulceration, and necrosis of the ileocecal Peyer’s patches at the initial site of Salmonella infiltration
What are the neurologic manifestations associated with Typhoid fever
meningitis, Guillain-Barré syndrome, neuritis, and neuropsychiatric symptoms (described as “muttering delirium” or “coma vigil”), with picking at bedclothes or imaginary objects
Chronic carriage of Salmonella is common among which subsets of patients
Chronic carriage is more common among women, infants, and persons who have biliary abnormalities or concurrent bladder infection with Schistosoma haematobium
Definitive diagnostic test for typhoid fever
The definitive diagnosis of enteric fever requires the isolation of S. Typhi or S. Paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions.
The diagnostic sensitivity of blood culture is only ~60% and is lower with low blood sample volume and among patients with prior antimicrobial use or in the first week of illness, reflecting the small number of S. Typhi organisms (i.e., <15/mL) typically present in the blood
Bone marrow culture is >80% sensitive, and, unlike that of blood culture, its yield is NOT reduced by up to 5 days of prior antibiotic therapy
Stool cultures, although negative in 60–70% of cases during the first week, can become positive during the third week of infection in untreated patients.
If blood, bone marrow, and intestinal secretions are all cultured, the yield is >___ for Salmonella
90%
Antimicrobial tx for Typhoid fever
If drug susceptible, use FQ
How do you prevent typhoid fever?
Two typhoid vaccines are commercially available in the United States:
(1) Ty21a, an oral live attenuated S. Typhi vaccine (given on days 1, 3, 5, and 7, with revaccination with a full four-dose series every 5 years); and
(2) Vi CPS, a parenteral vaccine consisting of purified Vi polysaccharide from the bacterial capsule (given in a single dose, with a booster every 2 years)
S. Enteritidis infection associated with what food?
chicken eggs
Treatment of choice for non typhoidal salmonellosis (NTS)
Because of increased resistance to conventional antibiotics such as ampicillin and TMP-SMX, extended-spectrum cephalosporins and fluoroquinolones have emerged as the agents of choice for the treatment of MDR NTS infections
Bacteremia and metastatic infection are most common with which non typhoidal salmonellosis (NTS) species?
Salmonella Choleraesuis and Salmonella Dublin
Endovascular infection should be suspected if there is high-grade bacteremia (>___% of three or more blood cultures positive) of non typhoidal salmonellosis (NTS) species
50%
Echocardiography, CT, and indium-labeled white cell scanning are used to identify localized infection
Antimicrobial tx for NTS
Preemptive antibiotic treatment should be considered for patients at increased risk for invasive NTS infection, including neonates (probably up to 3 months of age); persons >50 years of age with known or suspected atherosclerosis; and patients with immunosuppression, cardiac valvular or endovascular abnormalities, or significant joint disease
Duration of tx for NTS with endocarditis, arteritis
If the patient has endocarditis or arteritis, treatment for 6 weeks with an IV β-lactam antibiotic (such as ceftriaxone or ampicillin) is indicated
Vectors of dengue viruses
Mosquitoes (predominantly Aedes aegypti, A. albopictus)
Dengue virus is under flaviviruses
Pathogenesis of encephalitis in arthropod borne viruses
Viremia leads to multifocal entry into the CNS, presumably through infection of olfactory neuroepithelium, with passage through the cribriform plate, “Trojan horse” entry with infected macrophages, or infection of brain capillaries
the most nonspecific of the disease syndromes caused by arthropod-borne and rodent-borne viruses
Fever and myalgia syndrome
Treatment is supportive, but acetylsalicylic acid is avoided because of the potential for exacerbated bleeding or Reye’s syndrome
The most clinically significant flaviviruses that cause the fever and myalgia syndrome are
dengue viruses 1–4
Duration of incubation of dengue
After dengue virus infection and an incubation period averaging 4–7 days, three evolving phases are described: a febrile phase, a critical phase, and a recovery phase.
What is a positive tourniquet test in dengue
A positive tourniquet test—i.e., the detection of 10 or more new petechiae in one square inch of the upper arm after a 5-min blood pressure cuff inflation to midway between systolic and diastolic pressure—may demonstrate microvascular fragility associated with dengue but is more likely to be associated with severe disease.
When do rashes appear in dengue?
Near the time of defervescence on days 3–5, a maculopapular rash begins on the trunk and spreads to the extremities and the face.
The most significant flaviviruses that cause VHF are the mosquito-borne _____ and ____
dengue viruses 1–4 and yellow fever virus
Subset of people that may be given Dengvaxia
A tetravalent live attenuated dengue vaccine based on the attenuated yellow fever virus 17D platform (CYD-TDV, or Dengvaxia) was licensed in 2015 and registered in 20 countries for individuals 9–45 years of age. However, retrospective analysis of phase 3 trials in Latin America and Asia suggested protection from severe dengue only in previously seropositive individuals; indeed, the risk of severe dengue was actually increased in seronegative vaccine recipients over that in nonvaccinated seronegative individuals, a result suggesting that a “first serologic hit” from the vaccine predisposes naïve recipients to more severe natural dengue infection.
The clinical manifestations of tetanus occur only after tetanus toxin has reached _________
presynaptic inhibitory nerves
. Serum anti-tetanus immunoglobulin G also may be measured in a sample taken before the administration of antitoxin or immunoglobulin; levels >_____ (measured by standard enzyme-linked immunosorbent assay) are deemed protective and do not support the diagnosis of tetanus
0.1 IU/mL
Antimicrobial therapy for tetanus
Metronidazole (400 mg rectally or 500 mg IV every 6 h for 7 days) is preferred for antibiotic therapy. An alternative is penicillin (100,000–200,000 IU/ kg per day), although this drug theoretically may exacerbate spasms and in one study was associated with increased mortality
Two types of antitoxin preparations available for tetanus
Antitoxin should be given early in an attempt to deactivate any circulating tetanus toxin and prevent its uptake into the nervous system.
Two preparations are available: human tetanus immune globulin (TIG) and equine antitoxin.
TIG is the preparation of choice, as it is less likely to be associated with anaphylactoid reactions. A single IM dose (500–5000 IU) is given, with a portion injected around the wound.
Equine-derived antitoxin is available widely and is used in low-income countries; after hypersensitivity testing, 10,000–20,000 U is administered IM as a single dose or as divided doses.
Factors associated with poor prognosis in tetanus
Schedule for tetanus vaccination
0,1,6 months
followed by one dose in subsequent pregnancies (or intervals of at least 1 year), to a total of five doses to provide long-term immunity.
Individuals sustaining tetanus-prone wounds should be immunized if their vaccination status is incomplete or unknown or if their last booster was given >__ years earlier
10
T/F
Giardia remains a pathogen of the proximal large bowel and does not disseminate hematogenously
proximal SMALL bowel
How is giardiasis diagnosed?
Giardiasis is diagnosed by detection of parasite antigens in the feces, by identification of cysts in the feces or of trophozoites in the feces or small intestines, or by nucleic acid amplification tests (NAATs).
Cysts are oval, measure 8–12 μm × 7–10 μm, and characteristically contain four nuclei. Trophozoites are pear-shaped, dorsally convex, flattened parasites with two nuclei and four pairs of flagella
Treatment for giardiasis
Cure rates with metronidazole (250 mg thrice daily for 5 days) are usually >90%.
Tinidazole (2 g once by mouth) may be more effective than metronidazole.
Nitazoxanide (500 mg twice daily for 3 days) is an alternative agent for treatment of giardiasis.
Paromomycin, an oral aminoglycoside that is not well absorbed, can be given to symptomatic PREGNANT patients, although information is limited on how effectively this agent eradicates infection.
T/F
T. vaginalis can also infect men
Many men infected with T. vaginalis are asymptomatic, although some develop urethritis and a few have epididymitis or prostatitis.
How is trichomoniasis diagnosed?
Detection of motile trichomonads by microscopic examination of wet mounts of vaginal or prostatic secretions has been the conventional means of diagnosis. Although this approach provides an immediate diagnosis, its sensitivity for the detection of T. vaginalis is only ~50–60% in routine evaluations of vaginal secretions.
Direct immunofluorescent antibody staining is more sensitive (70–90%) than wet-mount examinations. T. vaginalis can be recovered from the urethra of both males and females and is detectable in males after prostatic massage.
NAATs are FDA approved and are highly sensitive and specific for urine and for endocervical and vaginal swabs from women
Treatment for trichomoniasis
Metronidazole (either a single 2-g dose or 500-mg doses twice daily for 7 days) or tinidazole (a single 2-g dose) is effective.
Reinfection often accounts for apparent treatment failures, but strains of T. vaginalis exhibiting high-level resistance to metronidazole have been encountered. Treatment of these resistant infections with higher oral doses, parenteral doses, or concurrent oral and vaginal doses of metronidazole or with tinidazole has been successful.
T/F
There is only one antigenic type of rubella virus, and humans are its only known reservoir.
True
Duration of shedding period of rubella
Individuals with acquired rubella may shed virus from 7 days before rash onset to ~5–7 days thereafter.
Lymphadenopathy, particularly occipital and postauricular, may be noted during the ___week after exposure to Rubella
second
What are the transient and permanent manifestation of congenital rubella syndrome?
Diagnostic test for rubella
Laboratory assessment of rubella virus infection is conducted by serologic and virologic methods. For acquired rubella, serologic diagnosis is most common and depends on the demonstration of IgM antibodies in an acute-phase serum specimen or a fourfold rise in IgG antibody titer between acute- and convalescent-phase specimens. To detect a rise in IgG antibody titer indicative of acute disease, the acute phase serum specimen should be collected within 7–10 days after onset of illness and the convalescent-phase specimen ~14–21 days after the first specimen. The enzyme-linked immunosorbent assay IgM capture technique is considered most accurate for serologic diagnosis, but the indirect IgM assays also are acceptable. After rubella virus infection, IgM antibody may be detectable for up to 6 weeks. In case of a negative result for IgM in specimens taken earlier than day 5 after rash onset, serologic testing should be repeated.
Classic triad of congenital rubella syndrome
The classic triad of CRS—clinical manifestations of cataracts, hearing impairment, and heart defects—is seen in ~10% of infants with CRS
Hearing impairment is the most common single defect of CRS.
Among women infected with rubella virus during the first 10 weeks of gestation, the risk of delivering an infant with Congenital Rubella syndrome is __%.
90%
When should administration of Ig for Rubella be considered?
Administration of immunoglobulin should be considered only if a pregnant woman who has been exposed to a person with rubella will not consider termination of the pregnancy under any circumstances. In such cases, IM administration of 20 mL of immunoglobulin within 72 h of rubella exposure may reduce—but does not eliminate—the risk of rubella
The most effective method of preventing acquired rubella and CRS is through ____
vaccination with an RCV (Rubella containing Vaccine)
One dose induces seroconversion in ≥95% of persons ≥1 year of age. Immunity is considered long-term and is probably lifelong. The most commonly used vaccine globally is the RA27/3 virus strain.
Contraindications for rubella containing vaccines
Because of the theoretical risk of transmission of live attenuated rubella vaccine virus to the developing fetus, women known to be pregnant should not receive RCV.
In addition, pregnancy should be avoided for 28 days after receipt of RCV. In follow-up studies of ~3000 unknowingly pregnant women who received rubella vaccine, no infant was born with CRS. Receipt of RCV during pregnancy is not ordinarily a reason to consider termination of the pregnancy
Incubation period of syphilis
2-6 weeks
The only known natural host for T. pallidum subsp. pallidum
human
The generalized parenchymal, constitutional, mucosal, and cutaneous manifestations of secondary syphilis usually appear ~___ weeks after infection, although primary and secondary manifestations may occasionally overlap.
6-12
Most commonly involves vessel in cardiovascular syphillis
usually involving the vasa vasorum of
the ascending aorta and resulting in aneurysm);
Description of typical primary chancre
single painless papule that rapidly erodes and becomes indurated, with a characteristic cartilaginous consistency on palpation of the edge and base of the ulcer.
Location of primary chancre in syphillis
usually located on the penis, where it is readily seen , but in MSM, it may also be found in the anal canal, rectum, or mouth.
In women, common primary sites are the cervix, vaginal wall, and labia, as well as anal canal and mouth.
Consequently, primary syphilis goes unrecognized in women and MSM more often than in heterosexual men.
The classical manifestations of the secondary stage of syphillis include ___________
mucocutaneous or cutaneous lesions and generalized nontender lymphadenopathy
Rarely, severe necrotic lesions (lues maligna) may appear and are more commonly reported in HIV-infected individuals.
Definition of latent syphilis
Positive serologic tests for syphilis, together with a normal CSF examination and the absence of clinical manifestations of syphilis, indicate a diagnosis of latent syphilis in an untreated person.
Definition of early latent syphillis
Early latent syphilis is limited to the first year after infection, whereas late latent syphilis is defined as that of ≥1 year’s (or unknown) duration.
The classical definition of early latent syphilis would include a person whose secondary rash has resolved, as well as a person whose chancre has healed but who has not yet developed secondary manifestations.
In several large studies, neurosyphilis was associated with an RPR titer of ≥____, regardless of clinical stage or HIV infection status.
1:32
While most experts agree that neurosyphilis is more common among persons with untreated HIV infection, the immune reconstitution seen with effective ART may have a protective effect against development of clinical neurosyphilis in HIV-infected persons with syphilis
Most common presentation of meningovascular syphilis
The most common presentation is a strokes yndrome involving the middle cerebral artery of a relatively young adult.
late manifestation of syphilis that presents as symptoms and signs of demyelination of the posterior columns, dorsal roots, and dorsal root ganglia, including ataxia, foot drop, paresthesia, bladder disturbances, impotence, areflexia, and loss of positional, deep-pain, and temperature sensations.
Tabes dorsalis
the test of choice for rapid serologic diagnosis in a clinical setting for syphilis
The RPR test is easier to perform and uses unheated serum or plasma; it is the test of choice for rapid serologic diagnosis in a clinical setting.
Standard test of choice for examining CSF for neurosyphilis
The VDRL test remains the standard for examining CSF and is superior to the RPR for this purpose.
The CSF VDRL test is highly specific and, when reactive, is considered diagnostic of neurosyphilis; however, this test is insensitive and may be nonreactive even in cases of symptomatic neurosyphilis.
VDRL -Very good for the Vrain
Expected result of CSF exam of a patient with neurosyphilis
Involvement of the CNS is detected by examination of CSF for mononuclear
pleocytosis (>5 white blood cells/μL), increased protein concentration (>45 mg/dL), or CSF VDRL reactivity
Treatment of choice for all stages of syphilis
Penicillin G
Alternative drug for primary, early and latent syphilis is allergic to penicillin
For penicillin-allergic patients with syphilis, a 2-week (early syphilis) or 4-week (late or late latent syphilis) course of therapy with doxycycline or tetracycline is recommended
Doxycycline (100 mg PO bid) or tetracycline HCl (500 mg PO qid) for 2 weeks
Alternative drug for neurosyphilis is allergic to penicillin
NONE
Desensitize and treat with penicillin
Form of Pen G used for neurosyphilis to ensure treponemicidal concentrations of penicillin G in CSF
Administration of either IV aqueous crystalline penicillin G or of IM aqueous procaine penicillin G plus oral probenecid in recommended doses is thought to ensure treponemicidal concentrations of penicillin G in CSF
Alternative drug for syphilis in pregnant patients if patient is allergic to penicillin
Penicillin is the only recommended agent for the treatment of syphilis in pregnancy. If the patient has a documented penicillin allergy, desensitization and penicillin therapy should be undertaken
A dramatic although self-limited reaction consisting of fever, chills, myalgia, headache, tachycardia, increased respiratory rate, increased circulating neutrophil count, and vasodilation with mild hypotension may follow the initiation of treatment for syphilis.
JARISCH-HERXHEIMER REACTION
The Jarisch-Herxheimer reaction occurs in ~50% of patients with primary syphilis, 90% of those with secondary syphilis, and a lower proportion of persons with later-stage disease.
When should patients treated for syphilis be monitored for response to treatment
Patients with primary or secondary syphilis should be examined 6 and 12 months after treatment, and persons with latent or late syphilis at 6, 12, and 24 months.
More frequent clinical and serologic examination (3, 6, 9, 12, and 24 months) is recommended for patients concurrently infected with HIV, regardless of the stage of syphilis
What test should be used for monitoring response to treatment of patients with syphilis
Efficacy of treatment should be assessed by clinical evaluation and monitoring of the quantitative VDRL or RPR titer for a fourfold decline (e.g., from 1:32 to 1:8).
Because treponemal tests may remain reactive despite treatment for seropositive syphilis, these tests are not useful in following the response to therapy.
N. gonorrhea is oxidase positive or negative
positive
T/F
Gonorrhea is transmitted from males to females more efficiently than in the opposite direction.
True
most abundant gonococcal surface protein
Porin
most common clinical manifestation of gonorrhea in male patients
Acute urethritis is the most common clinical manifestation of gonorrhea in male patients. The usual incubation period after exposure is 2–7 days, although the interval can be longer and most men remain asymptomatic.
Pyuria in the absence of bacteriuria visible on Gram’s stain of unspun urine, accompanied by urine cultures that fail to yield >102 colonies of bacteria usually associated with urinary tract infection, signifies the possibility of urethritis usually due to __________
C. trachomatis
Urethral infection with N. gonorrhoeae also may occur in this context, but in this instance, urethral cultures are usually positive
Description of skin lesions seen in disseminated gonococcal infection
Skin lesions are seen in ~75% of patients and include papules and pustules, often with a hemorrhagic component
Most commonly involved joint in gonococcal arthritis
Suppurative arthritis involves one or two joints, most often the knees, wrists, ankles, and elbows (in decreasing order of frequency); other joints occasionally are involved.
T/F gonococcal urethritis in men and gonococcal cervicitis in women may be diagnosed via gram stain
No. Only in men
The detection of gram-negative intracellular monococci and diplococci is usually highly specific and sensitive in diagnosing gonococcal urethritis in symptomatic males but is only ~50% sensitive in diagnosing gonococcal cervicitis.
Blood should be cultured in suspected cases of Disseminated Gonococcal Infection. The probability of positive blood cultures decreases after ____ of illness.
48h
Treatment of choice for gonorrhea
The third-generation cephalosporin ceftriaxone is now recommended as the first-line regimen for use at twice the previous dose (now, 500 mg IM, single dose) based on doubling of mean inhibitory concentrations (MICs) of current strains compared with MICs 20 years ago
Azithromycin, which had been recommended to provide additional treatment of gonorrhea (also to include treatment of chlamydial infection) is NO longer recommended as part of a first line regimen
If chlamydial infection with gonorrhea cannot be excluded, what must be added to the first line treatment for gonorrhea
If chlamydial infection cannot be excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended
Test of cure for uncomplicated genital gonorrheal infection
None
Persons with uncomplicated genital or rectal infections who receive ceftriaxone or an alternative regimen do not need a test of cure; however, cultures for N. gonorrhoeae should be performed if symptoms persist after therapy with an established regimen, and any gonococci isolated should be tested for antimicrobial susceptibility.
Treatment for gonococcal meningitis and endocarditis
Gonococcal meningitis and endocarditis should be treated in the hospital with high-dose IV ceftriaxone (1–2 g IV every 12–24 h); therapy should continue for 10–14 days for meningitis and for at least 4 weeks for endocarditis
All persons who experience more than one episode of disseminated gonococcal infection should be evaluated for _____
complement deficiency.
All sex partners of persons with gonorrhea should be evaluated and treated for N. gonorrhoeae and C. trachomatis infections if their last contact with the patient took place within ______ before the onset of symptoms or the diagnosis of infection in the patient
60 days
If the patient’s last potential sexual exposure to infection was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated
T/F
An absence of typical gram-negative diplococci on Gram’s-stained smear of urethral exudate containing inflammatory cells warrants a preliminary diagnosis of non gonococcal urethritis
True as this test is 98% sensitive for the diagnosis of gonococcal urethral infection.
In sexually active men under age 35, acute epididymitis is caused most frequently by _______
C. trachomatis and less commonly by N. gonorrhoeae and is usually associated with overt or subclinical urethritis.
In developing countries, where clinics or pharmacies often dispense treatment based on symptoms alone without examination or testing, oral treatment with _________ —particularly with a 7-day regimen—provides reasonable coverage against both trichomoniasis and BV, the usual causes of symptoms of vaginal discharge.
metronidazole
T/F
Culture is the most sensitive test for T. vaginalis
NAAT for T. vaginalis is more sensitive than culture.
STD that may present with vaginal fluid of pH>=5
Trichomoniasis
STD that may present with vaginal discharge with fishy odor
bacterial vaginosis
assoc with Gardnerella vaginalis
Treatment for vulvovaginal candidiasis
Azole cream, tablet, or suppository—e.g., miconazole (100-mg vaginal suppository) or clotrimazole (100-mg vaginal tablet) once daily for 7 days OR
Fluconazole, 150 mg orally (single dose)
Treatment for partners of patients with Trichomonas
Examination for sexually transmitted infection; treatment with metronidazole, 2 g PO (single dose)
Clue cells are seen in what STD
Bacterial vaginosis
Amsel criteria for diagnosing bacterial vaginosis
BV is conventionally diagnosed clinically with the Amsel criteria, which include any three of the following four clinical abnormalities:
(1) objective signs of increased white homogeneous vaginal discharge;
(2) a vaginal discharge pH of >4.5;
(3) liberation of a distinct fishy odor (attributable to volatile amines such as trimethylamine) immediately after vaginal secretions are mixed with a 10% solution of KOH; and
(4) microscopic demonstration of “clue cells”
Treatment for bacterial vaginosis
> Metronidazole, 500 mg PO bid for 7 days >Metronidazole gel, 0.75%, one applicator (5 g) intravaginally once daily for 5 days
Clindamycin, 2% cream, one full applicator vaginally each night for 7 days
The presence of ≥__ PMNs per 1000× microscopic field within strands of cervical mucus not contaminated by vaginal squamous epithelial cells or vaginal bacteria indicates endocervicitis
20
Treatment and alternative tx for M. genitalium
Although the antimicrobial susceptibility of M. genitalium is not yet well defined, the organism frequently persists after doxycycline therapy, and it currently seems reasonable to use azithromycin to treat possible M. genitalium infection in such cases.
With resistance of M. genitalium to azithromycin now recognized, moxifloxacin may be a reasonable alternative.
Etiology of PID that causes greatest degree of tissue inflammation and damage
C. trachomatis
What will you consider if a patient with PID presents with RUQ pain
Perihepatitis/ Fitz-Hugh–Curtis syndrome
Pleuritic upper abdominal pain and tenderness, usually localized to the right upper quadrant (RUQ), develop in 3–10% of women with acute PID
Treatment for PID
When do you expect clinical improvement in PID
Hospitalized patients should show substantial clinical improvement within 3–5 days. Women treated as outpatients should be clinically reevaluated within 72 h.
Surgical indication for PID
Surgery is necessary for the treatment of salpingitis only in the face of life-threatening infection (such as rupture or threatened rupture of a tuboovarian abscess) or for drainage of an abscess. Conservative surgical procedures are usually sufficient. Pelvic abscesses can often be drained by posterior colpotomy, and peritoneal lavage can be used for generalized peritonitis.
Most common cause of genital ulcers
PCR testing of genital ulcers now clearly implicates genital herpes as by far the most common cause of genital ulceration in most developing countries.
T/F
All cases of genital ulcers should be tested for syphilis using rapid serologic test
True
Clinicians should order a rapid serologic test for syphilis in all cases of genital ulcer and treat presumptively while awaiting serology in a patient at high risk (especially MSM)
Typical vesicles or pustules or a cluster of painful ulcers preceded by vesiculopustular lesions suggest genital _____
herpes
These typical clinical manifestations make detection of the virus optional; however, many patients want confirmation of the diagnosis, and differentiation of HSV-1 from HSV-2 has prognostic implications, because the latter causes more frequent genital recurrences and is more infectious to vulnerable sex partners.
Painless, nontender, indurated genital ulcers with firm, nontender inguinal adenopathy suggest
primary syphilis.
Demonstration of H. ducreyi by culture (or by PCR, where available) is most useful when ________
ulcers are painful and purulent, especially if inguinal lymphadenopathy with fluctuance or overlying erythema is noted;
What should you consider when genital ulcers persist beyond the natural history of initial episodes of herpes (2–3 weeks) or of chancroid or syphilis (up to 6 weeks) and do not resolve with syndrome-based antimicrobial therapy
in addition to the usual tests for herpes, syphilis, and chancroid—biopsy is indicated to exclude donovanosis as well as carcinoma and other nonvenereal dermatoses.
Causative agent of genital ulcers that are frequently tender
Herpes and Chancroid
Causative agent of genital ulcers that is associated with pseudobuboes
Donovanosis
Causative agent of genital ulcers that presents with elevated ulcer
Donovanosis
Causative agent of genital ulcers that bleeds easily
Chancroid and Donovanosis
B-C-D
Bleed-chancroid-donovanosis
Treatment for confirmed/suspected chancroid
causes of the most cases of infectious proctitis in women and MSM
Acquisition of HSV, N. gonorrhoeae, or C. trachomatis (including LGV strains of C. trachomatis) during receptive anorectal intercourse causes most cases of infectious proctitis in women and MSM.
Gonococcal or chlamydial proctitis typically involves the __________ and is clinically mild, without systemic manifestations.
most distal rectal mucosa and the anal crypts
Causative agents of proctitis that usually produce severe anorectal pain and often cause fever
In contrast, primary proctitis due to HSV and proctocolitis due to the strains of C. trachomatis that cause LGV usually produce severe anorectal pain and often cause fever
In MSM without HIV infection, enteritis is often attributable to __________
In MSM without HIV infection, enteritis is often attributable to Giardia lamblia.
Sexually acquired proctocolitis is most often due to ________
Sexually acquired proctocolitis is most often due to Campylobacter or Shigella species.
Treatment for proctitis
Pending test results, patients with proctitis should receive empirical syndromic treatment—e.g., with ceftriaxone (a single IM dose of 500 mg for gonorrhea) plus doxycycline (100 mg by mouth twice daily for 7 days for possible chlamydial infection) plus treatment for herpes or syphilis if indicated.
If LGV proctitis is proven or suspected, the recommended treatment is doxycycline (100 mg by mouth twice daily for 21 days); alternatively, 1 g of azithromycin once a week for 3 weeks is likely to be effective but is little studied.
consistent condom use is associated with significant protection of both males and females against all STIs. The only exceptions are probably sexually transmitted are _________
Pthirus pubis and Sarcoptes scabiei infestations
Screening sexually active female patients ≤___ years of age for C. trachomatis whenever they present for health care (at least once a year)
25
In women 25–29 years of age, chlamydial infection is uncommon but still may reach a prevalence of 3–5% in some settings;
Optimal age for recommended vaccination for HPV
The optimal age for recommended vaccination is 11–12 years because of the very high risk of HPV infection after sexual debut.
Serovars associated with
Trachoma
Oculogenital Chlamydia
LGV
Trachoma serovars A, B, Ba, and C
the oculogenital serovars D–K
and the LGV serovars L1–L3.
two highly specialized morphologic forms of Chlamydia
Elementary body, which is the infectious form and is specifically adapted for Extracellular survival, and the metabolically active and
Replicating Reticulate body, which is not infectious, is adapted for an intracellular environment, and does not survive well outside the host cell.
E-E-nfectious
R- Replicating
Because the duration of the chlamydial growth cycle is ~48–72 h, the incubation period of sexually transmitted chlamydial infections is relatively long—generally ___ weeks.
1-3
an invasive STD characterized by acute lymphadenitis with bubo formation and/or acute hemorrhagic proctitis
LGV
Definition of post gonococcal urethritis (PGU)
The designation PGU refers to NGU developing in men 2–3 weeks after treatment of gonococcal urethritis with single doses of agents such as penicillin or cephalosporins, which lack antimicrobial activity against chlamydiae.
What constitutes reactive arthritis
Reactive arthritis consists of conjunctivitis, urethritis (or, in female patients, cervicitis), arthritis, and characteristic mucocutaneous lesions.
NGU is the initial manifestation of reactive arthritis in 80% of patients, typically occurring within __ days after sexual exposure.
14
Arthritis usually begins ~4 weeks after the onset of urethritis but may develop sooner or, in a small percentage of cases, may actually precede urethritis
Clinical experience and collaborative studies indicate that a cutoff of >__ polymorphonuclear leukocytes (PMNs)/1000× field in a Gram-stained smear of cervical mucus correlates best with chlamydial or gonococcal cervicitis.
30
In the absence of infection with uropathogens such as coliforms or Staphylococcus saprophyticus, _______ is the pathogen most commonly isolated from college women with dysuria, frequency, and pyuria
C. trachomatis
Diagnostic assay of choice for Chlamydia
The first nonculture assays, such as direct fluorescent antibody staining of clinical material and enzyme immunoassay (EIA), have been replaced by NAATs, which are currently recommended by the CDC as the diagnostic assays of choice.
Recommended screening test sample for Chlamydia in asymptomatic women
For screening of asymptomatic women, the CDC now recommends that self-collected or clinician-collected vaginal swabs, which are slightly more sensitive than urine, be used.
Recommended screening test sample for Chlamydia in symptomatic women and male patients
For symptomatic women undergoing a pelvic examination, cervical swab samples are desirable because they have slightly higher chlamydial counts.
For male patients, a urine specimen is the sample of choice, but self-collected penile-meatal swabs have been shown to be very effective.
Presumptive diagnosis for NGU/PGU and epididymitis, reactive arthritis
LGV titer for confirming diagnosis of LGV
LGV CF titer, ≥1:64; MIF titer, ≥1:512
Until when should you not use NAAT as a test for cure for Chlamydia
Residual nucleic acid from cells rendered noninfective by antibiotics may continue to yield a positive result in NAATs for as long as 3 weeks after therapy when viable organisms have actually been eradicated. Therefore, clinicians should not use NAATs for test of cure until after 3 weeks.
When should you do test of cure after treatment for infection with C. trachomatis?
The CDC currently does not recommend a test of cure after treatment for infection with C. trachomatis. However, because incidence studies have demonstrated that previous chlamydial infection increases the probability of becoming reinfected, the CDC does recommend that previously infected individuals be rescreened 3 months after treatment.
Serologic test of choice for LGV
The serologic test of choice is the microimmunofluorescence (MIF) test
Treatment for Chlamydia
A 7-day course of oral doxycycline (100 mg twice daily) or a single 1-g oral dose of azithromycin are the primary recommended regimens of treatment for uncomplicated chlamydial infections.
Alternative 7-day oral regimens include erythromycin (500 mg four times daily), or a fluoroquinolone (ofloxacin, 300 mg twice daily; or levofloxacin, 500 mg/d) can be used.
The single 1-g oral dose of azithromycin is as effective as a 7-day course of doxycycline for the treatment of uncomplicated genital C. trachomatis infections in adults
How can trachoma be diagnosed clinically?
The clinical diagnosis of classic trachoma can be made if two of the following signs are present: (1) lymphoid follicles on the upper tarsal conjunctiva; (2) typical conjunctival scarring; (3) vascular pannus; or (4) limbal follicles or their sequelae, Herbert pits.
What are lepra cells?
On slit-skin smear examination at the lepromatous end of the disease spectrum, M. leprae is predominantly found in clumps or globi within macrophages (lepra cells).
Temperature required for survival and proliferation of M. leprae
The temperature required for survival and proliferation—between 27°C and 30°C—explains the greater impact of the disease on surface areas such as the skin, peripheral nerves, testicles, and upper airways, with less inner visceral involvement.
Main reservoir of infection for M. leprae.
It is assumed that humans are the main reservoir of infection for M. leprae. The armadillo is also a reservoir for human infection.
The incubation period of leprosy is estimated to range from _____ to ______
2 to ≥10 years.
Risk factos for leprosy
Poverty-associated factors such as low level of education, poor hygiene, and food shortages have been identified as risk factors for leprosy, but the most important risk factors are associated with intimacy and duration of contact with a leprosy patient, in particular with an index case with multibacillary leprosy, and the intensity of contact with and physical distance from the index patient.
often, but not always, the first clinical
sign of leprosy; manifests as one or a few hypopigmented or faintly erythematous, ill-defined to well-defined macular lesions measuring 1–5 cm in diameter. There is no thickening of the corresponding cutaneous and peripheral nerves.
Indeterminate Leprosy (IL)
Type of leprosy that presents either as a well-defined, hypopigmented macule or as a raised, erythematous/ brown/copper-colored plaque with a well-defined edge. The lesions may be found on any part of the skin and are characterized by complete loss of fine touch and temperature sensations over their surface.
TT leprosy
On slit-skin smear examination, no acid-fast
bacilli (AFB) are normally found. The lepromin skin test is strongly positive, signifying good host CMI status.
One of the most striking features of this type of leprosy is susceptibility to a type 1 leprosy reaction that exacerbates skin lesions and/or peripheral nerves. If not diagnosed and treated early, disease in these patients tends to downgrade across the spectrum
Borderline Tuberculoid (BT) Leprosy
This form of leprosy is unstable. Many cases downgrade toward BL and LLs disease, especially if not treated. There are multiple plaque lesions and, not infrequently, macular lesions; the lesions are of various shapes and sizes, are bilateral, and usually occur in a more or less symmetrical distribution. In annular lesions, the inner edge is well demarcated and “punched out,” and the outer edge is ill defined and merges with normal-looking skin.
Mid-Borderline (BB) Leprosy
In this type of leprosy, there are numerous bilateral, round or oval, macular, diffusely infiltrated, erythematous or hypopigmented lesions with moderately defined borders. The lesions are usually 2–3 cm in diameter, may have a coppery hue, and tend to become symmetrical. Some loss of sensation may be detected, particularly over older lesions; however, no loss of sensation is observed over fresh lesions.
Borderline Lepromatous Leprosy
This type of leprosy presents with innumerable bilateral, symmetrically distributed, diffusely indurated, erythematous, copper-colored or skin-colored patches or plaques. There is no loss of sensation over these lesions, which have a smooth, shiny surface. The lesions spread over the face, earlobes, ears, extensor aspects of the upper and lower extremities, back, and buttocks.
Coarse induration on the face sometimes results in gross skin folds that lead to an appearance referred to as “lion face”
Lepromatous leprosy
clue: symmetric lesions, lion face
portal of entry for M. leprae and is the earliest site of involvement in LL leprosy.
The nose is the portal of entry for M. leprae and is the earliest site of involvement in LL leprosy.
rare form of LL leprosy in which waxy, shiny, firm, symmetrical or asymmetrical nodules and plaques are observed over normal-looking skin
Histoid leprosy
rare form of non-nodular LL leprosy occurring in Mexico and Central America is characterized by diffuse shiny infiltration of the skin and widespread sensory loss. The skin looks waxy and has a shiny appearance (“lepra bonita,” or beautiful leprosy), with obvious diffuse induration of the earlobes and forehead as well as loss of eyebrows, sometimes eyelashes, and not infrequently all body hair. This form of leprosy can be complicated by an unusual reaction known as Lucio’s phenomenon
Diffuse leprosy of Lucio and Latapi
Type of lepra reaction that is considered as a delayed hypersensitivity reaction associated with sudden alteration of CMI status and leading to a shift in the patient’s position on the leprosy spectrum. Skin lesions are characterized by acute swelling and redness
Type 1
Type of lepra reaction also known as ENL (erythema nodosum leprosum) that is an immune complex–mediated syndrome that causes inflammation of the skin, nerves, and other organs as well as general malaise.
Type 2
Type of lepra reaction that is observed in diffuse leprosy of Lucio and Latapí and may be a variant of erythema nodosum necroticans. It is characterized by marked vasculitis and thrombosis of the superficial and deep vessels result in hemorrhage and infarction of the skin.
Lucio phenomenon
Three cardinal signs indicate a diagnosis of leprosy.
Three cardinal signs indicate a diagnosis of leprosy. The diagnosis can be established when two of these three signs are present:
1. Hypopigmented or erythematous skin lesion(s) with definite loss or impairment of sensation
2. Involvement of the peripheral nerves, as demonstrated by definite thickening with sensory impairment
peripheral nerves commonly palpated in a leprosy patient are the greater auricular, ulnar, radial, radial cutaneous, median, lateral popliteal, posterior tibial, sural, and superficial peroneal nerves.
3. A positive result for AFB in slit-skin smears, establishment of the presence of AFB in a skin smear or biopsy sample, or a positive result in a biopsy PCR.
Normally a slit-skin smear is taken from four sites which include
the right earlobe, the forehead above the eyebrows, the chin, and the left buttock in men or the left upper thigh in women.
a specific lipid on the M. leprae cell wall that has been used for serologic diagnosis of leprosy, yielding positive results in 90–95% of multibacillary cases and 25–60% of paucibacillary cases
PGL-1 ELISA
A negative lepromin test is generally seen in patients with which types of leprosy
LL or BL leprosy, indicating the lack of a protective cellular response.
Nerves that are usually tested for touch sensation in leprosy
The ulnar and median nerves and the posterior tibial nerve are usually tested for touch sensation.
The most reliable test is the Semmes-Weinstein monofilament (SWM) test.
Treatment for leprosy
Syndrome associated with dapsone severe adverse event that is not uncommon in some countries.
“DDS syndrome” (also called the dapsone hypersensitivity syndrome) is a severe adverse event that is not uncommon in some countries.
It usually develops 6 weeks after the commencement of dapsone administration and manifests as fever, skin rash, eosinophilia, lymphadenopathy, hepatitis, and encephalopathy.
The most noticeable adverse event of Clofazimine
The most noticeable adverse event is skin discoloration ranging from red to purple or black, with the degree of discoloration depending on the dosage
The abnormal pigmentation usually fades within 6–12 months of clofazimine discontinuation, although traces of discoloration may remain for up to 4 years.
The cure rate for leprosy with multidrug therapy is ___%, but relapse is possible.
99%
Treatment for rifampicin resistant leprosy
For rifampin-resistant leprosy, the WHO guidelines recommend daily treatment with at least two second-line drugs—clarithromycin, minocycline, or a quinolone (ofloxacin, levofloxacin, or moxifloxacin)—plus clofazimine for 6 months, followed by clofazimine plus one of the second-line drugs daily for an additional 18 months.
Leprosy patients infected with M. leprae resistant to both rifampin and ofloxacin may be treated daily with the following regimen: clarithromycin, minocycline, and clofazimine for 6 months, followed by clarithromycin or minocycline plus clofazimine for an additional 18 months.
Post exposure prophylxis for leprosy
A large randomized controlled trial has shown that single-dose rifampin, given once to household contacts, neighbors, and social contacts, reduces the recipients’ risk of leprosy by ~60%.
Treatment of choice for T1 Leprosy reaction
Oral, short-acting glucocorticoids are the treatment of choice for T1R.
Prednisolone is used most often in an initial dose of 1 mg/kg of body weight once a day, usually with a maximum of 60–80 mg
The dose is tapered slowly, usually by 5 mg every 2 weeks over a period of 20 weeks—a schedule that results in better outcomes and lower reaction relapse rates than the previously recommended 12-week glucocorticoid regimen.
Patients should be examined every 2 weeks, and the examination should include a quick nerve function assessment.
Treatment for Type 2 Leprosy reaction
Mild first-time T2R (or ENL) reactions with localized skin nodules may be treated with aspirin and pentoxifylline.
If a rapid effect is needed, the most effective drug to date is thalidomide, which rapidly suppresses clinical signs, including nerve impairment and iritis. A dose of 100–200 mg is given either once or twice daily. In patients with severe recurrent ENL, a daily thalidomide maintenance dose of 50 mg may be effective in suppressing new episodes.
High-dose clofazimine also is effective in preventing recurrent ENL, but attainment of a maximal effect takes several weeks.
Treatment of neuropathic pain for Leprosy
Generally, for the treatment of neuropathic pain, three classes of medication are available: tricyclic antidepressants, phenothiazines, and anticonvulsants (carbamazepine, oxcarbazepine, gabapentin, and pregabalin).
Up to what age may you give HPV vaccine (quadrivalent) in males
26
Most common cause of community acquired abscess
K. pneumoniae
Most common cause of community acquired endocarditis
Viridans streptococci
if hospital acquired: S. aureus
Duration of tx for febrile neutropenia
Until neutropenia resolves (>500)
First line tx for streptococcal pharyngitis
Benzathine Pen G 1.2 mU or Pen V 250 mg TID or 500 mg BID x 10 days
Main species of Schistosoma in PH
S. japonicum
Treatment of choice for filariasis
Diethylcarbamazine
Drug of choice for asymptomatic carriage of Entamoeba
Iodoquinol or Paromomycin
Most common form of botulism
foodborne botulism
Most common source of sepsis
pulmonary infection
5 moments of hand hygiene
Before touching a patient
Before clean or aseptic procedures
After exposure to bodily fluids or risk of exposure
After touching a patient
After touching a patient’s surrounding
Precaution for aspergillosis
Standard
Precaution for Avian Influenza
Airborne
but if Influenza A and B –> droplet
Precaution for Coxsackie
Droplet
2nd line TB drug that can cause hypothyroidism
Ethionamide
Vibrio vulnificus is highly susceptible to what drug
tetracycline
Impetigo contagiosa is caused by ______, and bullous impetigo is due to ______
Impetigo contagiosa is caused by S. pyogenes, and bullous impetigo is due to S. aureus.
T/F Rheumatic fever is not a complication of skin infection caused by S. pyogenes.
True
PSGN is a complication but not rheumatic fever (molecular mimicry)
most common cause of localized folliculitis
S. aureus
Hot-tub folliculitis is caused by _______ in waters that are insufficiently chlorinated and maintained at temperatures of 37–40°C.
Pseudomonas aeruginosa
Verruga peruana is caused by _________ , which is transmitted to humans by the sandfly Phlebotomus.
Bartonella bacilliformis
Erysipelas is due to ________ and is characterized by an abrupt onset of fiery-red swelling of the face or extremities.
S. pyogenes
Flaccid bullae may develop during the second or third day of illness, but extension to deeper soft tissues is rare.
The gram-positive aerobic rod _______ is most often associated with fish and domestic swine and causes cellulitis primarily in bone renderers and fishmongers.
Erysipelothrix rhusiopathiae
remains susceptible to most β-lactam antibiotics (including penicillin), erythromycin, clindamycin, tetracycline, and cephalosporins but is resistant to sulfonamides, chloramphenicol, and vancomycin.
Its resistance to vancomycin, which is unusual among gram-positive bacteria, is of potential clinical significance since this agent is sometimes used in empirical therapy for skin infection.
Strains of MRSA that produce the ____ toxin have been reported to cause necrotizing fasciitis.
Panton-Valentine leukocidin (PVL) toxin
Treatment of choice for animal bites
>prophylaxis
>established infection
Treatment of choice for gas gangrene and necrotizing fasciitis (caused by GAS)
Same Pen G + Clinda
but if necrotizing fascitis is caused by mixed aerobes and anaeroebs = Ampisul+ clinda + cipro
Treatment of choice for bacillary angiomatosis
Which of the 3 types of polio has not been eradicated?
Type 1
T/F
breast-feeding is not a contraindication for live-virus or other vaccines.
True
Vaccine/s contraindicated when px has immediate hypersensitivity rxn to yeast
HPV
Vaccine contraindicted when px has immediate hypersensitivity rxn to latex
Td, Tdap, Serogroup B meningococcal
Diagnosis of infective endocarditis
A clinical diagnosis of definite IE requires documentation of two major criteria, of one major and three minor criteria, or of five minor criteria.
Features Guiding the Need for Echocardiographic Assessment in Patients with Selected Monomicrobial Bacteremia
Next step when patient is high risk for developing IE and has undergone 2 negative TEE and still highly suspected to have IE
Consider CTA or FDG-PET/CT^
Treatment for IE caused by streptococci and enterococci
Treatment for IE caused by CONS and HACEK
Treatment for IE caused by Bartonella and Coxiella
Indications for surgery in IE
Indications for emergent surgical indication in patients with IE
Indications for urgent surgical indication in patients with IE
Indications for elective surgical indication in patients with IE
Antibiotic prophylaxis of IE in px with High risk cardiac lesions
High risk cardiac lesions that would require dental prophylaxis
treatment for Clostridial infections
Difference between encephalitic vs paralytic stage or rabies
If patient has category III dog bite and the animal was not captured, what is/are the recommended medications for post exposure trophy?
RIG and vaccine
If RIG is not immediately available, it should be administered no later than 7 days after the first vaccine dose.
After day 7, endogenous antibodies are being produced, and passive immunization may actually be counterproductive.
Treatment for acute uncomplicated cystitis from Harrisons
Treatment for schistosomiasis
see pic
Treatment of choice for
Cutaneous candidiasis?
Vulvovaginal candidiasis?
Oral thrush?
Esophageal candidiasis?
Agents for disseminated candidiasis
Next step for FUO when PDC is misleading
Cryoglobulin, fundoscopy (r/o retinal vasculitis)
If all the tests for FUO (obligatory and non obligatory) all turned out to be negative and patient has stable condition, what is the next step?
Ff up new PDCs
Consider NSAID
If all the tests for FUO (obligatory and non obligatory) all turned out to be negative and patient is deteriorating, what is the next step?
Further dx test
Do therapeutic trial
Empirical therapeutic trials with antibiotics, glucocorticoids, or antituberculous agents should be avoided in FUO except when a patient’s condition is rapidly deteriorating after the aforementioned diagnostic tests have failed to provide a definite diagnosis
Treatment for intraperitoneal abscess
Treatment of intraabdominal infections involves determination of the initial focus of infection, administration of broad-spectrum antibiotics targeting the organisms involved, and performance of a drainage procedure if one or more definitive abscesses have formed.
Indications for VZV ig ?
Drug therapy for amebiasis
More than 90% of patients respond dramatically to metronidazole therapy with decreases in both pain and fever within 72 h.
Most common mode of transmission of HIV
Blood transfusion
The quantity of HIV-1 in plasma (viral load) is a primary determinant of the risk of HIV-1 transmission
Conditions associated with Persistent Immune
Activation and Inflammation in Patients with HIV Infection
When should you repeat HIV 1 Westernblot if the initial result is indeterminate?
4-6 weeks
Treatment for aspergillosis
P-osaconazole
P-rophylaxis
The treatment of choice for PCP
The treatment of choice for PCP is trimethoprim-sulfamethoxazole (TMP-SMX), given either IV or PO for 14 days to non-HIVinfected patients with mild disease and for 21 days to all other patients
Intravenous pentamidine or the combination of clindamycin plus primaquine is an option for patients who cannot tolerate TMP-SMX and for patients in whose treatment TMP-SMX appears to be failing
Prophylaxis for PCP pneumonia
Prophylaxis for MAC
May stop prophylaxis once ART initiated
Prophylaxis or C. neoformans and when to stop
Work ups needed for HIV enteropathy
Noted 3 samples for stool ova and parasites
Characteristics of IRIS
TIS staging for Kaposi Sarcoma
Management for Kaposi Sarcoma
Initial evaluation for px with HIV
Principles of therapy of HIV infection
Indications for changing ART
