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 for leptospirosis
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
Chronic carriage is associated with increased risk of GB cancer
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)
If uncomplicated, supportive only
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.
Sexual partners should also given metro 2g PO (single dose)
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
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.
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
Donovanosis -PSEUDObuboes
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
Although 20 lang to dx endocervicitis
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.
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
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 and HBV
Vaccine contraindicted when px has immediate hypersensitivity rxn to latex
Contraindications: Serogroup B meningococcal, Hep A and B
Precaution only: Td, Tdap
Vaccine contraindicted when px has immediate hypersensitivity rxn to gelatin or neomycin
MMR and Varicella
If with History of Arthus-type hypersensitivity reactions after a previous dose of TD- or DT-containing vaccines (including MenACWY). Defer vaccination until at least ___ years have elapsed since the last dose.
10
In general, inactivated vaccines (e.g., inactivated influenza, pneumococcal polysaccharide, and meningococcal conjugate vaccines) are stored at _____temperature, while vials of lyophilized-powder live-virus vaccines (e.g., varicella, live zoster, and MMR vaccines) are stored at _____ temperature
refrigerator
freezer
With the exception of ______ vaccination, an interruption in the schedule does not require restarting of the entire series or the addition of extra doses
oral typhoid
The majority of reported syncope episodes after vaccination occur within _____
15 minThe ACIP recommends that vaccine providers strongly consider observing patients, particularly adolescents, with patients seated or lying down for 15 min after vaccination. If syncope develops, patients should be observed until the symptoms resolve
prototypic lesion of infective endocarditis (IE)
vegetation
Causative agents of IE that results in an acute course
β-Hemolytic streptococci, S. aureus, and pneumococci typically result in an acute course, although S. aureus occasionally causes subacute disease. IE caused by Staphylococcus lugdunensis (a coagulase-negative species) or by enterococci may present acutely.
In patients with subacute presentations, fever is typically low-grade rarely exceeding 39.4°C (103°F); in contrast, temperatures of 39.4°– 40°C (103°–104°F) are often noted in acute IE.
Causative agents of IE that results in a subacute course
Subacute IE is typically caused by viridans streptococci, enterococci, CoNS, and the HACEK group.
In patients with subacute presentations, fever is typically low-grade rarely exceeding 39.4°C (103°F); in contrast, temperatures of 39.4°– 40°C (103°–104°F) are often noted in acute IE.
Causative agents of IE that results in a indolent course
IE caused by Bartonella species, T. whipplei, C. burnetii, or M. chimaera is exceptionally indolent.
Most common symptom of IE
fever
Risk factors associated with an increased risk of embolization
S. aureus IE, mobile vegetations >10 mm in diameter, and infection involving the mitral valve anterior leaflet are independently associated with an increased risk of embolization.
Arterial emboli, one-half of which precede the diagnosis of IE, are clinically apparent in up to 50% of patients.
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.
T/F
Electrocardiographic-gated multislice cardiac CT angiogram (CTA), which is comparable to TEE in detection of vegetations and possibly superior in defining paravalvular infection, may be definitive.
True
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^
33/M is being managed for hypotensive shock
from dengue. Initial resuscitation done with 20
mL/Kg of normal saline IV. Patient remained
hypotensive and serial CBC showed decreasing
hematocrit. What is the next best step in
management?
Transfuse pRBC since with decreasing hct. Look for signs of bleeding. May also consider whole blood for unstable px
Most bacterial pneumonias can be treated for ___ days
5-7
Treatment duration for MRSA pneumonia with bacteremia
up to 28 days
if MSSA up to 21 days
Treatment duration for pneumonia caused by Mycoplasma and Chlamydophila
10-14 days
Treatment duration for pneumonia caused by Legionella
14-21 days
T/F
NGT increases risk for HAP
True by aspiration of oropharyngeal contents in the lower respiratory tract
most common site of Pseudomonas aeruginosa infections?
lungs
Level of lactate that portends a poor prognosis in severe falciparum malaria
> 5 mmol/L
Which is more resistant? E. faecium or E. faecalis?
E. faecium
Treatment for IE caused by streptococci and enterococci
T/F
Daptomycin is only FDA approved for right sided IE and not left sided IE
Although it is FDA approved only for right-sided IE at a dose of 6 mg/kg daily, most recommend doses of 8–10 mg/kg daily for treatment of left-sided IE.
Treatment for IE caused by CONS and HACEK
Treatment for IE caused by Bartonella and Coxiella
Tx for culture negative IE
Pending the availability of diagnostic data, blood culture–negative subacute NVE is treated with vancomycin plus ampicillin-sulbactam (12 g every 24 h) or ceftriaxone; doxycycline (100 mg twice daily) is added for enhanced Bartonella coverage.
If cultures are negative because of prior antibiotic administration, pathogens likely to be inhibited by the specific prior therapy should be considered.
Generator pocket infection without bacteremia is treated with a ____-day course, some of which can be given orally
10- to 14
Defervescence can be expected __ hours after percutaneous drainage of intraabdominal abscesses.
48
recommended duration of antibiotic therapy for foot osteomyelitis in which the removal of dead bone cannot be achieved
12wks
Amount > ____ mL of retained urine for it to qualify for complicated UTI
100
T/F
Blood cultures are NOT routinely recommended in px with acute uncomplicated pyelonephritis except in patients with sepsis
True
When should you repeat Blood CS for px with IE
Control of peripheral sites of infection—source control—should be addressed promptly. Blood cultures should be repeated daily until sterile in patients with IE due to S. aureus or difficult-to-treat organisms, rechecked if there is recrudescent fever, and performed again 4–6 weeks after therapy to document cure.
Expected duration before blood CS become sterile in IE tx with appropriate abx
Blood cultures become sterile after 2 days of appropriate therapy when infection is caused by viridans streptococci, E. faecalis, or HACEK organisms.
In MSSA IE, β-lactam therapy results in sterile cultures in 3–5 days, whereas in MRSA IE, the duration of bacteremia is often longer with vancomycin or daptomycin treatment.
When fever persists for ___ days despite appropriate antibiotic therapy for IE, patients should be evaluated further for paravalvular abscess, extracardiac abscesses (spleen, kidney), or complications (embolic events).
7
Indications for surgery in IE
Indications for emergent surgical indication in patients with IE
septal perforation is urgent only
Indications for urgent surgical indication in patients with IE
Indications for elective surgical indication in patients with IE
test of choice to detect paravalvular abscesses
TEE with color Doppler is the test of choice to detect paravalvular abscesses (sensitivity, ≥85%).
Nonurgent cardiac surgery should be delayed for _____ after a large nonhemorrhagic embolic infarction and for _______ after a significant cerebral hemorrhage.
2–3 weeks
4 weeks
Antibiotic prophylaxis of IE in px with High risk cardiac lesions
High risk cardiac lesions that would require dental prophylaxis
Definition of recurrent UTI
> =2 episodes in 6 mos; >=3 in 12 mos
Definition of presumptive TB
SSx + chext xray suggestive of PTB
How do you screen HCW for PTB
Symptom screening + CXR
How many sputum samples do you need for Gene Xpert and sputum microscopy
1 for Gene Xpert:on the spot
2 for sputum microscopy: on the spot + 1 hr after or early AM the following day
Usual location of post primary TB
apical and posterior segment of the upper lobe, superior segment of the lower lobe
APU
SS
Most common site of involvement of spinal TB
Adult: lower thoracic and upper lumbar
Childern: Upper thoracic
A TB patient whose tx was interrupted for __ consecutive months is classified as lost to follow up
2
Role of glucocorticoids in typhoid fever
In px with shock/ Obtundation
Severe dengue is commonly associated with what type of serovar
2
Females are more commonly affected than males
Blood transfusion is necessary for what level of hematocrit in severe malaria
< 20
T/F Leptospires can enter intact mucous memberane
True
T/F Severe hepatocellular necrosis is not uncommon in leptospiross
False
Severe hepatocellular necrosis is not a feature of leptospirosis
In Weil’s disease, renal failure develops in __ week of illness
2nd
most common cause of death: pulmo complications
A- a gradient of ___ or Pao2 of <= ___ mmHg in PCP pneumonia warrant steroids
> 35 and 70
T/F Acyclovir is also used for routine prophylaxis for HIV
False
Rabies immunoglobulin can be given until Day __ from D0 of vaccine
7
Complication of severe malaria that is common in children but relatively infrequent in non pregnant adults
hypoglycemia
T/F Malnutrition and female sex are risk factors for severe dengue
False
malnutrition - protective
female sex- risk factor
Recommended protocol for anti malaria prophylaxis with chloroquine in adults
1-2 weeks before travelling, once a week on the same day of the week and for 4 weeks upon return
Same with other -quine except primaquine (1-2 days , daily, 7 days after return)
T/F Immune active E. coli fractions can be used to prevent recurrent UTI
True
When do you expect reduncion in sputum production in CAP
4 weeks
Phase of pneumonia that corresponds to successful containment of infection and improvement of gas exchange
Gray hepatization
Rationale for repeating CXR 4-6 weeks after CAP
Exclude possibility of malignancy after CAP
Recommended treatment for Salmonella that are MDRO and quinolone resistant
CRO 2g IV OD
Duration of tx for chronic carriers of Salmonella typhi
28 days of Cipro
Earliest CBC abnormality in dengue
Leukopenia
T/F Visible AFB on microscopy correlates directly with likelihood of transmission
True
Most potent risk factor for development of TB
HIV
T/F
False negative reactions are common among those with overwhelming TB
True
Which of HRZE needs renal dose adjustment?
Ethambutol
E for adjustment based on EGFR
Electrolyte urinary loss associated with leptospiral nephropathy
Magnesium
How many mL of specimen is needed for MTB gene xpert
1-4 mL for all specimen except CSF 0.5-4 mL
Primary mode of transmission of PTB
Droplet
T/F Clinical criteria alone should be used to diagnose HAP/VAP
True as per IDSA guidelines
In px suspected to have VAP, abx should cover which organisms
S. aureus
P. aeruginosa
G- bacilli
VAP–> SPG
Recommended duration of tx for HAP
7 days
Additional diagnostic test to clinical criteria to guide discontinuation of abx for px with HAP/VAP
Procalcitonin
CPIS not suggested
What could be given as an alternative tx for septic shock px who are allergic to beta lactams
Aztreonam + FQ
Schedule of tetanus vaccine if no primary course of vaccination in childhood
three doses 1 month apart then 2 boosters 6 months apart
if with primary course, 2 doses only 1 month apart
After recovering from tetanus how many doses of vaccines should be given?
3 doses of full primary course of immunization since natural infection is poorly immunogenic
T/F
Both remdesivir and glucocorticoids were shown to be effective in improving mortality rate in px with severe COVID-19 infection
False. Only glucocorticoids
Remdeivir- no improvement in 30-day survival rate
Recommended specimen type for lab confirmatory diagnosis of Monkey Pox
Skin lesion fluid or crusts
treatment for Clostridial infections
T/F Falsely neg TST are common among both immunosuppressed px and those with overwhelming TB infection
True
When do you send DSSM samples for clinically diagnosed TB for monitoring?
2nd month. If positive by end of 2nd month, test also 5th and 6th
bacteriologically confirmed automatic 2,5,6
Most common cause of purpura fulminans
N. meningitides
Most commonly involved encapsulated organism in asplenic patients
S. pneumoniae
Common cause of ecthyma gangrenosum in neutropenic px
P. aeruginosa
Type of meningitis with normal opening pressure
Parasitic
Most common pattern of pneumonia in nosocomial infections
bronchopneumonia
Major risk factor for primary lung abscess
Aspiration
most common etiology: polymicrobial
Symptoms of gas gangrene
The first symptom of spontaneous gas gangrene may be confusion followed by the abrupt onset of excruciating pain in the absence of trauma. These findings, along with fever, should heighten suspicion of spontaneous gas gangrene. However, because of the lack of an obvious portal of entry, the correct diagnosis is frequently delayed or missed.
trauma must be sufficient to interrupt the blood supply and thereby to establish an optimal anaerobic environment for growth of these species.
It is important to recognize that, for C. perfringens and C. novyi, trauma must be sufficient to interrupt the blood supply and thereby to establish an optimal anaerobic environment for growth of these species.
These conditions are not strictly required for the more aerotolerant species such as C. septicum and C. tertium, which can seed normal tissues from gastrointestinal lesions.
Major virulence factor of C. perfringens
Alpha toxin
T/F
When spontaneous gas gangrene is suspected by Clostridia species, blood should be cultured since bacteremia usually precedes cutaneous manifestations by several hours
True
Mortality rates are relatively high among patients with spontaneous gas gangrene, especially that due to C. septicum
Treatment for spontaneous or taumatic gas gangrene
Except for infection caused by C. tertium (see below), antibiotic treatment of traumatic or spontaneous gas gangrene consists of the administration of penicillin and clindamycin for 10–14 days.
C. tertium is resistant to penicillin, cephalosporins, and clindamycin. Appropriate antibiotic therapy for C. tertium infection is vancomycin (1 g every 12 h IV) or metronidazole (500 mg every 8 h IV).
The incubation period of rabies is usually ____days
20-90
Rabies virus spreads centripetally vs centrifugally? along peripheral nerves toward the spinal cord or brainstem via retrograde fast axonal transport (rate, up to ~250 mm/d), with delays at intervals of ~12 h at each synapse.
centripetally toward CNS
Centrifugal spread along nerves to salivary glands, skin, cornea, and other organs
T/F
There is no well-documented evidence for hematogenous spread of rabies virus.
True
Pathologic studies show mild inflammatory changes in the CNS in rabies, with mononuclear inflammatory infiltration in the leptomeninges, perivascular regions, and parenchyma, including microglial nodules called ____ nodules.
Babes
earliest specific neurologic symptoms of rabies
The earliest specific neurologic symptoms of rabies include paresthesias, pain, or pruritus near the site of the exposure, one or more of which occur in 50–80% of patients and strongly suggest rabies.
Difference between encephalitic vs paralytic stage or rabies
Diagnostically useful specimens for rabies
Diagnostically useful specimens include serum, CSF, fresh saliva, skin biopsy samples from the neck, and brain tissue (rarely obtained before death).
Corneal impression smears are of low diagnostic yield and are generally not performed
Treatment for rabies
There is no established treatment for rabies. Aggressive management with supportive care in critical care units has resulted in the survival of at least 30 patients with rabies. Many of these survivors have recently been reported from India.
There have been many recent treatment failures (more than 55) with the combination of antiviral drugs, ketamine, and therapeutic (induced) coma—measures that were used in a healthy survivor in whom neutralizing antibodies to rabies virus were detected at presentation. Expert opinion is recommended before a course of experimental therapy is embarked upon. A palliative approach may be appropriate for many patients who are not considered candidates for aggressive management
T/F
PEP is not necessary if the animal remains healthy.
True
T/F
For rabies Wound care should not be delayed, even if the initiation of immunization is postponed pending the results of the 10-day observation period
True
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.
Where do you inject rabies vaccine?
Four 1-mL doses of rabies vaccine should be given IM in the deltoid area. (The anterolateral aspect of the thigh also is acceptable in children.) Gluteal injections, which may not always reach muscle, should not be given and have been associated with rare vaccine failures
Schedule for rabies vaccination
0,3,7,14
Ideally, the first dose should be given as soon as possible after exposure; failing that, it should be given without further delay. The three additional doses should be given on days 3, 7, and 14; a fifth dose on day 28 is no longer recommended
What could be given if human RIG is unavailable
If human RIG is unavailable, purified equine RIG can be used in the same manner at a dose of 40 IU/kg
Dose of human RIG (rabies Ig)
If anatomically feasible, the entire dose of RIG (20 IU/kg) should be infiltrated at the site of the bite, and any RIG remaining after infiltration of the bite site should be administered IM at a distant site.
Only given for previously UNvaccinated
Schedule for preexposure prophylaxis
Preexposure rabies prophylaxis should be considered for people with an occupational or recreational risk of rabies exposures and also for certain travelers to rabies-endemic areas. The primary schedule consists of three doses of rabies vaccine given on days 0, 7, and 21 or 28. Serum neutralizing antibody tests help determine the need for subsequent booster doses. When a previously immunized individual is exposed to rabies, two booster doses of vaccine should be administered on days 0 and 3. Wound care remains essential. As stated above, RIG should not be administered to previously vaccinated persons.
most common manifestation of UTI
Acute cystitis
Cystitis is temporally related to recent sexual intercourse in a dose–response manner
True
increased relative risk ranging from 1.4 with one episode of intercourse in the preceding week to 4.8 with five episodes.
Early recurrence (within __weeks) is usually regarded as relapse rather than reinfection and may indicate the need to evaluate the patient for a sequestered focus.
2
The only consistently documented behavioral risk factors for recurrent UTI
frequent sexual intercourse and spermicide use.
Most common organism causing UTI
E. coli
E. coli accounts for 75–90% of isolates; Staphylococcus saprophyticus for 5–15% (with particularly frequent isolation from younger women); and Klebsiella, Proteus, Enterococcus, and Citrobacter species, along with other organisms, for 5–10%
T/F
Bacteria can gain access to the urinary tract through the bloodstream.
True
However, hematogenous spread accounts for <2% of documented UTIs and usually results from bacteremia caused by relatively virulent organisms, such as Salmonella and S. aureus
The pathogenesis of candiduria is distinct in that the hematogenous route is common. The presence of Candida in the urine of a non-instrumented immunocompetent patient implies either genital contamination or potentially widespread visceral dissemination.
critical initial step in the pathogenesis of UTI
Colonization of the vaginal introitus and periurethral area with organisms from the intestinal flora (usually E. coli) is the critical initial step in the pathogenesis of UTI
main feature distinguishing cystitis from pyelonephritis
Fever is the main feature distinguishing cystitis from pyelonephritis. The fever of pyelonephritis typically exhibits a high spiking “picket-fence” pattern and resolves over 72 h of therapy.
Emphysematous pyelonephritis is a particularly severe form of the disease that is associated with the production of gas in renal and perinephric tissues and occurs almost exclusively in ____ patients
diabetic
Based from Harrisons Studies of women with symptoms of cystitis have found that a colony count threshold of ≥ ___ bacteria/mL is more sensitive (95%) and specific (85%) than a threshold of 105/mL for the diagnosis of acute cystitis in women. In men, the minimal level indicating infection appears to be ___/mL.
10^2
10^3
The diagnosis of ASB involves both microbiologic and clinical criteria. The microbiologic criterion (including in urinary catheter–associated asymptomatic bacteriuria) is ≥___ bacterial CFU/mL of urine. The clinical criterion is an absence of signs or symptoms referable to UTI.
10^5
Most fluoroquinolones are highly effective as short-course therapy for cystitis when the causative organism is susceptible to them; the exception is _______ , which may not reach adequate urinary levels.
moxifloxacin
Treatment for acute uncomplicated cystitis from Harrisons
First line tx for acute uncomplicated pyelonephritis
High rates of TMP-SMX-resistant E. coli in patients with pyelonephritis have made fluoroquinolones the first-line therapy for acute uncomplicated pyelonephritis.
Antibiotics for UTI that are safe in pregnancy
Nitrofurantoin, ampicillin, and the cephalosporins are considered
relatively safe in early pregnancy
Ampicillin and the cephalosporins have been used extensively in pregnancy and are the drugs of choice for the treatment of asymptomatic or symptomatic UTI in this group of patients.
ASB are treated for 4–7 days in the absence of evidence to support single-dose therapy.
Treatment duration for acute bacterial prostatitis vs chronic bacterial prostatitis
If acute bacterial prostatitis is suspected, antimicrobial therapy should be initiated after urine and blood are obtained for cultures. Therapy can be tailored to urine culture results and should be continued for 2–4 weeks. For documented chronic bacterial prostatitis, a 4- to 6-week course of antibiotics is often necessary.
Treatment for xanthogranulomatous pyelonephritis
Xanthogranulomatous pyelonephritis is treated with nephrectomy. .
Treatment for emphysematous pyelonephritis
Percutaneous drainage can be used as the initial therapy in emphysematous pyelonephritis and can be followed by elective nephrectomy as needed.
Antibiotic of choice for prophylaxis for UTI
Continuous prophylaxis and postcoital prophylaxis usually entail low doses of TMP-SMX or nitrofurantoin. These regimens are all highly effective during the period of active
Based on Harrisons, Treatment of ASB does not decrease the frequency of symptomatic infections or complications except in pregnant women, persons undergoing urologic surgery, and perhaps ______ and _______
neutropenic patients and renal transplant recipients.
Infective stage of Schistosoma
cercaria
the only stage of the shcistosoma life cycle that can be detected in humans, either in excreta or in tissue biopsies
schistosome egg
In px infected with Schistosoma, egg-induced granulomatous responses lead to severe periportal fibrosis ( AKA as ______ ), with deposition of collagen around the portal vein, occlusion of the smaller portal branches, and severe, often irreversible, pathology
Symmers clay pipestem fibrosis
What causes Katayama fever?
Antigen excess from eggs results in the formation of soluble immune complexes, which may be deposited in several tissues and initiate a serum sickness–like illness.
. The onset occurs between 2 weeks and 3 months after exposure to the parasite
Cercarial invasion may be associated with dermatitis arising from dermal and subdermal inflammatory reactions in response to _______
dying cercariae that trigger innate immune responses
A particularly severe form of cercarial dermatitis is commonly seen after exposure to cercariae from avian schistosomes. These cercariae cannot complete their development in humans and die in the skin, causing an inflammatory allergic reaction. This form of cercarial dermatitis can occur in people who have been in contact with water from lakes (e.g., in Europe or the United States) where various species of water birds, such as ducks, geese, and swans, are found
In which veins to adult schistosome worms reside in intestinal schistosomiasis
mesenteric veins
Characteristic sign in the active stage of urogenital schistosomiasis
A characteristic sign in the active stage is painless, terminal hematuria.
Dysuria and suprapubic discomfort or pain are associated with active urogenital schistosomiasis and may persist throughout the course of active infection. Eggs deposited in the bladder mucosa may give rise to an intense inflammatory response of the bladder wall, which may cause ureteric obstruction and lead to hydroureter and hydronephrosis. These early inflammatory lesions, including obstructive uropathy, can be visualized by ultrasonography
Cystoscopy findings in urogenital schistosomiasis
As the infection progresses, the inflammatory component decreases and fibrosis becomes more prominent. The symptoms at this stage are nocturia, urine retention, dribbling, and incontinence. Cystoscopy reveals “sandy patches” composed of large numbers of calcified eggs surrounded by fibrous tissue and an atrophic mucosal surface. The ureters are less commonly involved, but ureteral fibrosis can cause irreversible obstructive uropathy that can progress to uremia
Chronic S. haematobium infection is associated with what cancer
squamous cell carcinoma of the urinary bladder
Samples where Schistosoma eggs can be detected
stool, rectal biopsy, pap smear (S. mansoni and S. hematobium) and semen samples (S. hematobium)
Schistosoma DNA can be detected in cerebrospinal fluid samples for diagnosis of neuroschistosomiasis
Treatment for schistosomiasis
see pic
Blood type that inc risk for cholera
O
VibriOOOO
39/F with no co-morbids presented at the ER due to fever, nausea, anorexia, abdominal pain and hematochezia. She travelled to Samar a month ago. Initial CBC showed elevated eosinophils. You are suspecting Schistosomiasis. When do you expect to see schistosome eggs in the feces of this patient after exposure to schistosome cercariae?
A. 1-3 weeks
B. 2-4 weeks
C. 5-7 weeks
D. 8-12 weeks
C. 5-7 weeks
how long can you be protected from dengue infection of a different serotype after primary infection?
2-3m
Which among the following factors is associated with highest risk of mortality among patients with Leptospirosis?
A. Baseline Leukocytosis >10 000
B. Elderly
C. Female
D. Constant exposure with rats
B. Elderly
most common type of amebic infection?
asymptomatic carriage
most common presenting sign of liver abscess?
fever
Fever of unknown origin may be the only manifestation of liver abscess, especially in the elderly
incubation period of measles
The incubation period for measles is ~10 days to fever onset and 14 days to rash onset
During the first 2–4 days after infection, measles virus proliferates locally in the respiratory mucosa, primarily in dendritic cells and lymphocytes, and spreads to draining lymph nodes. Virus then enters the bloodstream in infected lymphocytes, producing the primary viremia that disseminates infection throughout the reticuloendothelial system. Further replication results in secondary viremia that begins ____ days after infection and disseminates measles virus throughout the body
5–7
Koplik’s spots develop on the buccal mucosa ~_ days before the rash of measles appears.
2
The characteristic rash of measles begins 2 weeks after infection, when the clinical manifestations are most severe, and signal the host’s immune response to the replicating virus. Headache, abdominal pain, vomiting, diarrhea, and myalgia may be present
The rash of measles begins as erythematous macules behind the ears and on the neck and hairline. The rash progresses to involve the face, trunk, and arms, with involvement of the legs and feet by the end of the second day. Areas of confluent rash appear on the trunk and extremities, and petechiae may be present. The rash fades slowly in the same order of progression as it appeared, usually beginning on the _______ day after onset.
third or fourth
The CDC case definition for measles requires
(1) a generalized maculopapular rash of at least 3 days’ duration
(2) fever of at least 38.3°C (101°F); and
(3) cough, coryza, or conjunctivitis.
a slowly progressive disease characterized by seizures and progressive deterioration of cognitive and motor functions, with death occurring 5–15 years after measles virus infection
subacute sclerosing panencephalitis (SSPE)
In immunocompetent persons, administration of immunoglobulin within __ h of exposure usually prevents measles virus infection and almost always prevents clinical measles. Administered up to __ days after exposure, immunoglobulin will still prevent or modify the disease.
72
6days
In measles, Antibodies first appear _____ days after vaccination, and titers peak at months. M
12–15
1–3
When is a person with mumps most infectious?
A person is most infectious from 2 days before until 5 days after onset of parotitis or other salivary gland swelling.
However, mumps virus has been detected in saliva as early as 7 days before onset and as late as 9 days after onset of these manifestations. Mumps virus has been isolated from urine and seminal fluid up to 14 days after onset of parotitis, although no studies have assessed transmissibility of the virus through these fluids
in mumps, Parotitis typically lasts for ___ days ; most cases resolve within __ days.
5 (range, 3–7 days)
10
Parotitis is generally bilateral and may not occur synchronously on both sides
Most frequent complications of mumps
The most frequent complications of mumps include orchitis, oophoritis, mastitis, pancreatitis, hearing loss, meningitis, and encephalitis
Orchitis -most common; 30% of unvaccinated and 6% of vaccinated
T/F Mumps is the only cause of parotitis outbreak
True
although an increase in parotitis cases may also result from increased influenza activity— specifically, infection with influenza A virus subtype H3N2.
Best specimen for virus detection of mumps
Mumps virus and viral RNA can be detected in blood, saliva, urine, and CSF.
Buccal or oral swabs provide the best specimens for virus detection
As maximal viral shedding occurs within 5 days after symptom onset, specimens for mumps virologic testing ideally should be collected as close to parotitis onset as possible. The diagnostic yield of urine specimens increases over time up to 10 days after parotitis onset, but buccal specimens are more likely than urine specimens to result in virus detection at any time point.
T/F Mumps immune globulin is not recommended for postexposure prophylaxis or treatment.
True
All close contacts of a mumps patient should be advised to self-monitor for mumps symptoms for __ days after their last exposure.
25
There is no known immune correlate of protection for mumps; a positive IgG titer indicates only that a person has been exposed to mumps virus through either vaccination or natural infection and does not predict protection against infection.
Predisposing factors to hematogenously disseminated candidiasis
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Innate immunity is the most important defense mechanism against hematogenously disseminated candidiasis, and the neutrophil is the most potent component of this defense
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Organs most commonly affected by deeply invasive candidiasis
The brain, chorioretina, heart, and kidneys are most commonly infected and the liver and spleen are less commonly affected in nonneutropenic hosts (but most often involved in neutropenic patients)
Features such as budding yeast morphology, absence of hyphal growth or germ tubes, and growth at 40–42°C (unlike other Candida species) on CHROMagar that may appear white, pink, red, or purple could raise suspicion for which species of Candida
C. auris
Treatment of choice for
Cutaneous candidiasis?
Vulvovaginal candidiasis?
Oral thrush?
Esophageal candidiasis?
first choice of treatment if there is concern for resistance in px with candidemia
Echinocandin
Candida species less sensitive to fluconazole
Isolates of C. glabrata and C. krusei are less sensitive to fluconazole and more sensitive to polyenes and echinocandins
C. parapsilosis is less sensitive to echinocandins in vitro; however, this lesser sensitivity is considered clinically insignificant.
Agents for disseminated candidiasis
T/F Recovery of Candida from sputum is almost never indicative of underlying pulmonary candidiasis and does not by itself warrant antifungal treatment.
True
Similarly, Candida in the urine of a patient with an indwelling bladder catheter may represent colonization only, rather than bladder or kidney infection. However, the threshold for systemic treatment is lower in general in severely ill patients in this category since it is impossible to distinguish colonization from lower or upper urinary tract infection.
Treatment of choice for Hematogenous Candida endophthalmitis
Hematogenous Candida endophthalmitis is a special problem requiring ophthalmologic consultation. When lesions are expanding or are threatening the macula, an IV polyene combined with flucytosine (25 mg/kg four times daily) has been the regimen of choice, although comparative studies with other regimens have not yet been reported.
T/F All patients with candidemia should undergo ophthalmologic examination
True
All patients with candidemia should undergo ophthalmologic examination because of the relatively high frequency of this ocular complication Hematogenous Candida endophthalmitis(up to 15–20% in some case series)
synovial fluid culture is positive in >__% of nongonococcal bacterial arthritis cases.
60
the most common route of infectious arthritis in all age groups
hematogenous
Most common etiologic organisms implicated in infectious arthritis
Among young adults and adolescents, N. gonorrhoeae is the most commonly implicated organism. S. aureus accounts for most nongonococcal isolates in adults of all ages
Infections after surgical procedures or penetrating injuries are due most often to S. aureus and occasionally to other gram-positive bacteria or gram-negative bacilli
Patients with ______ have the highest incidence of infective arthritis
Patients with rheumatoid arthritis have the highest incidence of infective arthritis
(most often secondary to S. aureus) because of chronically inflamed joints; glucocorticoid therapy; and frequent breakdown of rheumatoid nodules, vasculitic ulcers, and skin overlying deformed joints
Polyarticular infection is most common among patients with rheumatoid arthritis and may resemble a flare of the underlying disease
In px with infectious arthritis Blood cultures are positive in up to 50–70% of ________ infections but are less frequently positive in infections due to other organisms
S. aureus
Cultures of synovial fluid are positive in >90% of cases of infectious arthritis
Empiric tx if infectious arthritis px has G+ cocci on smear
e. If there are gram-positive cocci on the smear, IV vancomycin (15−20 mg/kg/dose) every 8–12 h should be started empirically.
If methicillin-resistant S. aureus is an unlikely pathogen (e.g., when it is not widespread in the community), cefazolin (2 g every 8 h), oxacillin (2 g every 4 h), or nafcillin (2 g every 4 h) should be given.
Empiric tx if infectious arthritis px has G- bacilli on smear
If initial Gram’s stain shows gram-negative bacilli, an IV thirdgeneration cephalosporin such as cefotaxime (1 g every 8 h) or ceftriaxone (1–2 g every 24 h) provides adequate empirical coverage for most community-acquired infections. In addition, cefepime (2 g every 8−12 h) or ceftazidime (2 g every 8 h) should be given to IV drug users and to other patients in whom P. aeruginosa may be the responsible agent. Double coverage of Pseudomonas with cephalosporin and ciprofloxacin or aminoglycoside can be considered in severely ill patients
Duration of therapy for nongonococcal infectious arthritis
Staphylococcal-4 weeks
Pneumococcal and Strep and Hib- 2 weeks
G- bacilli - 3 to4 weeks
Management for hip arthritis
Septic arthritis of the hip is best managed with arthrotomy, particularly in young children, in whom infection threatens the viability of the femoral head.
Septic joints do not require immobilization except for pain control before symptoms are alleviated by treatment. Weight bearing should be avoided until signs of inflammation have subsided, but frequent passive motion of the joint is indicated to maintain full mobility
T/F
In gonococcal arthritis secondary to disseminated gonococcal infection cultures of synovial fluid are consistently negative
True and blood cultures are positive in <45% of patients
A single joint such as the hip, knee, ankle, or wrist is usually involved. Synovial fluid, which contains >50,000 leukocytes/μL, can be obtained with ease
Treatment for gonococcal arthritis
Initial treatment consists of ceftriaxone (1 g IV or IM every 24 h) to cover possible penicillin-resistant organisms. Once local and systemic signs are clearly resolving, a 7-day course of antibiotics may be completed with daily IM ceftriaxone given at 250 mg daily. An oral fluoroquinolone such as ciprofloxacin (500 mg twice daily) may be used if the organism is known to be susceptible. If penicillinsusceptible organisms are isolated, amoxicillin (500 mg three times daily) may be used
The most common presentation of TB arthriti
The most common presentation is chronic granulomatous monoarthritis
An unusual syndrome, _________ , is a reactive symmetric form of polyarthritis that affects persons with visceral or disseminated tuberculosis
Poncet’s disease
Reactive arthritis is most common among young men (except after Yersinia infection) and has been linked to the ______ locus as a potential genetic predisposing factor
HLA-B27
Treatment duration for prosthetic joint infection
Treatment includes surgery and high doses of parenteral antibiotics, which are given for 4–6 weeks because bone is usually involved
In most cases, the prosthesis must be removed and replaced to cure the infection
Definition of FUO
- Fever ≥38.3°C (≥101°F) on at least two occasions
- Illness duration of ≥3 weeks
- No known immunocompromised state
- Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations: determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST) or interferon γ release assay (IGRA).
Most common cause of infectious cause of FUO
Up to half of all infections in patients with FUO outside Western nations are caused by Mycobacterium tuberculosis, which is a less common cause in Western Europe and probably also in the United States
Sterile endocarditis is also seen in the context of
systemic lupus erythematosus and antiphospholipid syndrome
Most common cause of FUO caused by malignancy
Although most tumors can present with fever, malignant lymphoma is by far the most common diagnosis of FUO among the neoplasms. Sometimes the fever even precedes lymphadenopathy detectable by physical examination.
Common causes of drug induced fever
More common causes of drug-induced fever are allopurinol, carbamazepine, lamotrigine, phenytoin, sulfasalazine, furosemide, antimicrobial drugs (especially sulfonamides, minocycline, vancomycin, β-lactam antibiotics, and isoniazid), some cardiovascular drugs (e.g., quinidine), and some antiretroviral drugs (e.g., nevirapine)
Factitious fever is common in which subset of population?
Factitious fever (fever artificially induced by the patient—for example, by IV injection of contaminated water) should be considered in all patients but is more common among young women in health-care professions.
How do you rule out fraudulent fever?
In fraudulent fever, the patient is normothermic but manipulates the thermometer.
Simultaneous measurements at different body sites (rectum, ear, mouth) should rapidly identify this diagnosis.
Another clue to fraudulent fever is dissociation between pulse rate and temperature
T/F
Abdominal CT scan is included in the obligatory tests for FUO
False
Abdominal ultrasound is preferred to abdominal CT as an obligatory test because of relatively low cost, lack of radiation burden, and absence of side effects.
How many blood cultures and urine culture are needed for diagnosing FUO?
Blood culture –> 3
Urine CS –> 1
Performing more than three blood cultures or more than one urine culture is useless in patients with FUO in the absence of PDCs (e.g., a high level of clinical suspicion of endocarditis)
Repeat cultures useful only when previously cultured samples were collected during abx tx or within 1 week after its discontinuation f
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
How long should you discontinue the drug to rule out drug fever?
All medications, including nonprescription drugs and nutritional supplements, should be discontinued early in the evaluation to exclude drug fever. If fever persists beyond 72 h after discontinuation of the suspected drug, it is unlikely that this drug is the cause
In patients with recurrent fever lasting >___ years, it is very unlikely that the fever is caused by infection or malignancy
2
Effect of glucocorticoids on FDG result
Pathologic FDG uptake is quickly eradicated by treatment with glucocorticoids in many diseases, including vasculitis and lymphoma; therefore, glucocorticoid use should be stopped or postponed until after FDGPET/CT is performed
What are the instances when you should perform liver biopsy in px with FUO?
Liver biopsy is an invasive procedure that carries the possibility of complications and even death. Therefore, it should not be used for screening purposes in patients with FUO except in those with PDCs for liver disease or miliary tuberculosis
Therapeutic trial for the ff:
Familial Mediterranean Fever
Still’s dse
Giant cell arteritis
Polymyalgia rheumatica
Familial Mediterranean Fever –> colchicine
Still’s dse –> NSAIDs
Giant cell arteritis –> glucocorticoids
Polymyalgia rheumatica –> glucocorticoids
Commonly used antibiotic regimens for the treatment of febrile patients in whom prolonged neutropenia (>7 days) is anticipated
Commonly used antibiotic regimens for the treatment of febrile patients in whom prolonged neutropenia (>7 days) is anticipated include (1) ceftazidime or cefepime, (2) piperacillin/tazobactam, or (3) imipenem/cilastatin or meropenem. All three regimens have shown equal efficacy in large trials. All three are active against P. aeruginosa and a broad spectrum of aerobic gram-positive and gram-negative organisms.
Despite the frequent involvement of coagulase-negative staphylococci, the initial use of vancomycin or its automatic addition to the initial regimen has not resulted in improved outcomes, and the antibiotic does exert toxic effects. For these reasons, only judicious use of vancomycin is recommended
When do you add antifungal for px with febrile neutropenia
neutropenic patient remains febrile despite 4–7 days of treatment with antibacterial agents
Before the introduction of newer azoles into clinical practice, amphotericin B was the mainstay of antifungal therapy.
Echinocandins (e.g., caspofungin) are useful in the treatment of infections caused by azole-resistant Candida strains as well as in therapy for aspergillosis and have been shown to be equivalent to liposomal amphotericin B for the empirical treatment of patients with prolonged fever and neutropenia
T/F
those with ALL should receive TMP SMX for prophylaxis for PCP for the duration of chemotherapy
Any patient receiving more than a maintenance dose of glucocorticoids (e.g., in many treatment regimens for diffuse lymphoma) should also receive prophylactic TMPSMX because of the risk of Pneumocystis infection; those with ALL should receive such prophylaxis for the duration of chemotherapy
In adults, primary bacterial peritonitis (PBP) occurs most commonly in conjunction what dse entity
In adults, primary bacterial peritonitis (PBP) occurs most commonly in conjunction with cirrhosis of the liver (frequently the result of alcoholism).
Most common manifestation of primary bacterial peritonitis
The presentation of PBP differs from that of secondary peritonitis. The most common manifestation is fever, which is reported in up to 80% of patients. Ascites is found but virtually always predates infection.
T/F
finding of >250 PMNs/μL is diagnostic for secondary bacterial peritonitis
False
For primary/spontaenous only
The finding of >250 PMNs/μL is diagnostic for PBP, according to Conn. This criterion does not apply to secondary peritonitis
When do you give albumin in px with primary bacterial peritonitis
A mortality benefit from albumin (1.5 g/kg of body weight within 6 h of detection and 1.0 g/kg on day 3) has been demonstrated for patients who present with serum creatinine levels ≥1 mg/dL, blood urea nitrogen levels ≥30 mg/dL, or total bilirubin levels ≥4 mg/dL but not for patients who do not meet these criteria
Empiric treatment for primary bacterial peritonitis
Third-generation cephalosporins such as cefotaxime (2 g q8h, administered IV) provide reasonable initial coverage in moderately ill patients. Broad-spectrum antibiotics, such as β-lactam/βlactamase inhibitor combinations (e.g., piperacillin/tazobactam, 3.375 g q6h IV for adults with normal renal function) or ceftriaxone (2 g q24h IV), also are options. Broader empirical coverage aimed at resistant hospital-acquired gram-negative bacteria (e.g., treatment with a carbapenem or newer agents, such as ceftolozanetazobactam or ceftazidime-avibactam) may be appropriate for nosocomially acquired PBP until culture results become available.
Empirical coverage for anaerobes is NOT necessary.
Duration of treatment for primary bacterial peritonitus
Patients with PBP usually respond within 72 h to appropriate antibiotic therapy. Antimicrobial treatment can be administered for as little as 5 days if rapid improvement occurs and blood cultures are negative, but a course of up to 2 weeks may be required for patients with bacteremia and for those whose improvement is slow
A __-day course of antibiotic prophylaxis is recommended for patients with cirrhosis and gastrointestinal bleeding.
7
Prophylaxtic abx regimen for primary bacterial peritonitis
Prophylactic regimens for adults with normal renal function include fluoroquinolones (ciprofloxacin, 500 mg weekly; or norfloxacin, 400 mg/d) or trimethoprim-sulfamethoxazole (one double-strength tablet daily).
However, long-term administration of broad-spectrum antibiotics in this setting has been shown to increase the risk of severe staphylococcal infections.
There is increased interest in using rifaximin, a broad-spectrum antibiotic that is used already for hepatic encephalopathy and is not absorbed, for PBP prophylaxis (1200 mg daily).
Usual organisms in secondary bacterial peritonitis
The organisms found almost always constitute a mixed flora in which facultative gram-negative bacilli and anaerobes predominate, especially when the contaminating source is colonic.
While recovery of organisms from peritoneal fluid is easier in secondary than in primary peritonitis, a tap of the abdomen is rarely the procedure of choice in secondary peritonitis. An exception is in cases involving
trauma, where the possibility of a hemoperitoneum may need to be excluded early
Antibiotics for secondary bacterial peritonitis
Community acquired infections associated with mild to moderate disease can be treated with β-lactam/β-lactamase inhibitor combinations (e.g., ticarcillin/clavulanate, 3.1 g q4–6h IV; or piperacillin/tazobactam, 3.375 g q6h IV) or a combination of either a fluoroquinolone (e.g., levofloxacin, 750 mg q24h IV) or a third-generation cephalosporin (e.g., ceftriaxone, 2 g q24h IV) plus metronidazole (500 mg q8h IV). Eravacycline is a newer antibiotic in the tetracycline class that has been approved by the U.S. FDA for treatment of complicated intraabdominal infections (1 mg/kg q12h IV).
Patients in ICU and/or those with health care–associated infections should receive antibiotics targeting more resistant gram-negative organisms such as Pseudomonas aeruginosa—e.g., imipenem (500 mg q6h IV), meropenem (1 g q8h IV), higher-dose piperacillin/tazobactam (4.5 g IV q6h), or drug combinations such as cefepime (2 g IV q8h) or ceftazidime (2 g IV q8h) plus metronidazole
For patients known to be colonized with (VRE), linezolid or daptomycin, should be included. Antifungal coverage is warranted if there is growth of Candida species from a sterile site. Patients who are known to be colonized with highly resistant gram-negative organisms may require treatment with a newer agent such as ceftazidime/ avibactam or ceftolozane/tazobactam.
Organisms usually involved in continuous ambulatory peritoneal dialysis
Unlike PBP and secondary peritonitis, which are caused by endogenous bacteria, CAPDassociated peritonitis usually involves skin organisms.
The most common organisms are Staphylococcus species, which accounted for ~45% of cases in one series.
Like PBP, CAPD-associated peritonitis is usually caused by a single organism. Peritonitis is, in fact, the most common reason for discontinuation of CAPD.
How do you diagnose continuous ambulatory peritoneal dialysis associated peritonitis
the clinician should use the percentage of PMNs rather than the absolute number of WBCs to diagnose peritonitis. As the normal peritoneum has very few PMNs, a proportion above 50% is strong evidence of peritonitis even if the absolute WBC count does not reach 100/μL.
Treatment for continuous ambulatory peritoneal dialysis associated peritonitis
first-generation cephalosporin such as cefazolin and a fluoroquinolone or a third-generation cephalosporin such as ceftazidime may be reasonable; in areas with high rates of MRSA, vancomycin should be used and gram-negative coverage may need to be broadened—e.g., with an aminoglycoside, ceftazidime, cefepime, or a carbapenem.
Broad coverage including vancomycin should be particularly considered for patients with septic physiology or exit-site infections.
Treatment duration for continuous ambulatory peritoneal dialysis associated peritonitis
The clinical response to an empirical treatment regimen should be rapid; if the patient has not responded after 48–96 h of treatment, new samples should be collected for cell counts and cultures, and catheter removal should be considered. For patients who lack exit-site or tunnel infection, the typical duration of antibiotic treatment is 14 days
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.
Duration of tx for intraperitoneal abscess
The appropriate duration of antibiotic treatment for abdominal abscesses depends on whether the presumptive source of the intraabdominal infection has been controlled. With adequate source control, antibiotic treatment may be limited to 4 or 5 days
Most commonly involved organ in intraabdominal abscess
The liver is the organ most subject to the development of abscesses
The single most reliable laboratory finding for intraabdominal abscess
. The single most reliable laboratory finding is an elevated serum concentration of alkaline phosphatase, which is documented in 70% of patients with liver abscesses.
Other tests of liver function may yield normal results, but 50% of patients have elevated serum levels of bilirubin, and 48% have elevated concentrations of aspartate aminotransferase.
With hematogenous spread of infection for liver abscess, usually only a single organism is encountered; this species may be _______
With hematogenous spread of infection, usually only a single organism is encountered; this species may be S. aureus or a streptococcal species such as one in the Streptococcus milleri group
mainstay of therapy for intraabdominal abscesses
Drainage is the mainstay of therapy for intraabdominal abscesses, including liver abscesses; the approach can be either percutaneous (with a pigtail catheter kept in place or possibly with a device that can perform pulse lavage to fragment and evacuate the semisolid contents of a liver abscess), transluminal (with endoscopic ultrasound guidance), or surgical.
Treatment of candidal liver abscesses
Treatment of candidal liver abscesses often entails initial administration of liposomal amphotericin B (3–5 mg/kg IV daily) or an echinocandin, with subsequent fluconazole therapy. In some cases, therapy with fluconazole alone (6 mg/kg daily) may be used—e.g., in clinically stable patients whose infecting isolate is susceptible to this drug.
Most common associated infection with splenic abscess from hematogenous spread
Although splenic abscesses may arise occasionally from contiguous spread of infection or from direct trauma to the spleen, hematogenous spread of infection is more common. Bacterial endocarditis is the most common associated infection
Most common bacterial isolates from splenic abscess
Streptococcal species are the most common bacterial isolates from splenic abscesses, followed by S. aureus—presumably reflecting the associated endocarditis
Salmonella species are seen fairly commonly, especially in patients with sickle cell hemoglobinopathy
Treatment for splenic abscess
Because of the high mortality figures reported for splenic abscesses, splenectomy with adjunctive antibiotics has traditionally been considered standard treatment and remains the best approach for complex, multilocular abscesses or multiple abscesses. However, percutaneous drainage has worked well for single, small (<3-cm) abscesses in some studies and may also be useful for patients with high surgical risk. Patients undergoing splenectomy should be vaccinated against encapsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis).
The most important factor in successful treatment of splenic abscesses is early diagnosis.
Most common route of infection of perinephric and perirenal abscess
Now, in contrast, >75% of perinephric and renal abscesses arise from a urinary tract infection. Infection ascends from the bladder to the kidney, with pyelonephritis preceding abscess development
organisms most frequently encountered in perinephric and renal abscesses
The organisms most frequently encountered in perinephric and renal abscesses are E. coli, Proteus species, and Klebsiella species. E. coli, the aerobic species most commonly found in the colonic flora, seems to have unique virulence properties in the urinary tract, including factors promoting adherence to uroepithelial cells
When should you consider the diagnosis of perinephric or renal abscess?
Perinephric or renal abscess should be most seriously considered when a patient presents with symptoms and signs of pyelonephritis and remains febrile after 4 or 5 days of treatment. Moreover, when a urine culture yields a polymicrobial flora, when a patient is known to have renal stones, or when fever and pyuria coexist with a sterile urine culture, these diagnoses should be entertained.
If a renal or perinephric abscess is diagnosed, nephrolithiasis should be excluded, especially when a high urinary pH suggests the presence of a urea-splitting organism
Isolated organisims in psoas abscess
S. aureus is most likely to be isolated when a psoas abscess arises from hematogenous spread or a contiguous focus of osteomyelitis; a mixed enteric flora is the most likely etiology when the abscess has an intraabdominal or pelvic source.
incubation period of chickenpox
The incubation period of chickenpox ranges from 10 to 21 days but is usually 14–17 days
The most common infectious complication of varicella is
secondary bacterial superinfection of the skin, which is usually caused by Streptococcus pyogenes or Staphylococcus aureus, including strains that are methicillin-resistant
the most serious complication following chickenpox,
Varicella pneumonia
develops more often in adults (up to 20% of cases) than in children and is particularly severe in pregnant women.
Most commonly involved dermatome in herpes zoster
The dermatomes from T3 to L3 are most frequently involved
The onset of disease is heralded by pain within the dermatome, which may precede lesions by ____
The onset of disease is heralded by pain within the dermatome, which may precede lesions by 48–72 h; an erythematous maculopapular rash evolves rapidly into vesicular lesions
may remain few in number and continue to form for only 3–5 days. The total duration of disease is generally 7–10 days; however, it may take as long as 2–4 weeks for the skin to return to normal
Nerve involved in Ramsay Hunt syndrome
In Ramsay Hunt syndrome, pain and vesicles appear in the external auditory canal, and patients lose their sense of taste in the anterior two-thirds of the tongue while developing ipsilateral facial palsy. The geniculate ganglion of the sensory branch of the facial nerve is involved
Lesions of herpers zoster continue to form for >__ week, and scabbing is not complete in most cases until __weeks into the illness.
1
3
Specimens for detection of VZV DNA by PCR include
Specimens for detection of VZV DNA by PCR include lesions, blood, and saliva
. Administration of aspirin to children with chickenpox should be avoided because of the association of aspirin derivatives with the development of ____ syndrome
Reye’s
Treatment for VZV
Acyclovir (800 mg by mouth five times daily), valacyclovir (1 g three times daily), or famciclovir (250 mg three times daily) for 5–7 days is recommended for adolescents and adults with chickenpox of ≤24 h duration
In severely immunocompromised hosts (e.g., transplant recipients, patients with lymphoproliferative malignancies), both chickenpox and herpes zoster (including disseminated disease) should be treated, at least at the outset, with IV acyclovir, which reduces the occurrence of visceral complications but has no effect on healing of skin lesions or pain. The dose is 10 mg/kg every 8 h for 7 days. For low-risk immunocompromised hosts, oral therapy with valacyclovir or famciclovir appears beneficial
VZV Ig should be given within how many hours
This product should be given within 96 h (preferably within 72 h) of the exposure but may be administered up to 10 days with similar efficacy
Indications for VZV ig ?
second most common cause of death related to parasitic infection (after malaria
E. histolytica
T/F Both trophozoites and cysts are found in the intestinal lumen, but only trophozoites of E. histolytica invade tissue
True
Standard of therapy for amebiasis
Metronidazole
earliest intestinal lesions in E. histolyticaa
The earliest intestinal lesions are micro-ulcerations of the mucosa of the cecum, sigmoid colon, or rectum that release erythrocytes, inflammatory cells, and epithelial cells
Symptomatic amebic colitis develops ___ weeks after the ingestion of infectious cysts
2–6
Extraintestinal infection by E. histolytica most often involves the ____
liver
Most patients are febrile and have right-upper quadrant pain, which may be dull or pleuritic in nature and may radiate to the shoulder. Point tenderness over the liver and right-sided pleural effusion are common
Which of the ff carries the gravest prognosis in px with amebic liver abscess? Hepatobronchial fistula vs rupture into the peritoneum vs rupture into the pericardium
A hepatobronchial fistula may cause cough productive of large amounts of necrotic material that may contain amebae. This dramatic complication carries a good prognosis. Abscesses that rupture into the peritoneum may present as an indolent leak or an acute abdomen and require both percutaneous catheter drainage and medical therapy. Rupture into the pericardium, usually from abscesses of the left lobe of the liver, carries the gravest prognosis; it can occur during medical therapy and requires surgical drainage.
Fecal findings suggestive of amebic colitis
Fecal findings suggestive of amebic colitis include a positive test for heme, a paucity of neutrophils, and amebic cysts or trophozoites. The definitive diagnosis of amebic colitis is made by the demonstration of hematophagous trophozoites of E. histolytica.
Because trophozoites are killed rapidly by water, drying, or barium, it is important to examine at least three fresh stool specimens
In px with amebic liver abscess, More than 80% of patients who have had symptoms for >___days have a single abscess of the right lobe of the live
10
Drug therapy for amebiasis
More than 90% of patients respond dramatically to metronidazole therapy with decreases in both pain and fever within 72 h.
Indications for aspiration of liver abscesses
Indications for aspiration of liver abscesses are
(1) the need to rule out a pyogenic abscess, particularly in patients with multiple lesions;
(2) the lack of a clinical response in 3–5 days
(3) the threat of imminent rupture; and
(4) the need to prevent rupture of left-lobe abscesses into the pericardium.
There is no evidence that aspiration, even of large abscesses (up to 10 cm), accelerates healing. Percutaneous drainage may be successful even if the liver abscess has already ruptured.
Surgery should be reserved for instances of bowel perforation and rupture into the pericardium
. If there was a negative HIV test within 6 months of the first HIV infection diagnosis, the stage is 0 and remains 0 until __ months after diagnosis
6
The AIDS pandemic is primarily caused by the HIV-1 __ group viruses
M, N, O or P?
M
Reported infections with group N and group P viruses are rare and confined almost entirely to residents of Cameroon or travelers from Cameroon
HIV-1 subtypes A, B, C, D, F, G and three of the CRFs, CRF01_AE, CRF02_AG, and CRF07_BC. Subtype __ viruses (of the M group) are by far the most common form worldwide, likely accounting for ~50% of prevalent infections worldwide.
C
In sub-Saharan Africa, home to approximately two-thirds of all individuals living with HIV/AIDS, most infections are caused by subtype C
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
In addition to blood, semen and vaginal secretions, what bodily fluids are considered potentially infectious for HIV?
The following fluids also are considered potentially infectious: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid
Hallmark of HIV dse
It is this establishment of a chronic, persistent infection that is the hallmark of HIV disease.
The principal targets of neutralizing antibodies against HIV are the envelope proteins ______
The principal targets of neutralizing antibodies against HIV are the envelope proteins gp120 and gp41.
HIV employs at least three mechanisms to evade neutralizing antibody responses: hypervariability in the primary sequence of the envelope, extensive glycosylation of the envelope, and conformational masking of neutralizing epitopes
Stage of HIV when patient is asymptomatic but with declining CD4 count
Most patients are relatively asymptomatic while this progressive decline is taking place and are often described as being in a state of clinical latency
What stage of HIV is AIDS?
the CDC case definition of stage 3 (AIDS) includes all HIV-infected individuals >5 years of age with CD4+ T-cell counts below this level
major anatomic sites for the establishment and propagation of HIV infection
Regardless of the portal of entry of HIV, lymphoid tissues are the major anatomic sites for the establishment and propagation of HIV infection
Conditions associated with Persistent Immune
Activation and Inflammation in Patients with HIV Infection
most common opportunistic infection in HIV-infected individuals
Mycobacterium tuberculosis is the most common opportunistic infection in HIV-infected individuals
autoimmune-like phenomenon characterized by a paradoxical deterioration of clinical condition, which is usually compartmentalized to a particular organ system, in individuals in whom ART has recently been initiated.
immune reconstitution inflammatory syndrome (IRIS)
The immunopathogenesis of this syndrome is felt to be related to an increase in immune response against the presence of residual antigens that are usually microbial and is most commonly seen with underlying mycobacterial (Mycobacterium tuberculosis [TB] or avium complex [MAC]), fungal (cryptococcal) and viral (CMV, HHV) infections.
T/F A relative CD8+ T lymphocytosis is generally associated with high levels of HIV plasma viremia
True
A relative CD8+ T lymphocytosis is generally associated with high levels of HIV plasma viremia and likely reflects an immune response to the virus as well as dysregulated homeostasis associated with generalized immune activation
T/F
Circulating monocytes are generally normal in number in HIV-infected individuals
True
Circulating monocytes are generally normal in number in HIV-infected individuals; however, there is evidence of increased activation within this lineage
Tissue macrophages are an important source of HIV during the inflammatory response associated with opportunistic infections and can serve as persistent reservoirs of HIV infection, thus representing an obstacle to the eradication of HIV by antiretroviral drugs
T cells and B cells –> decreased
form of focal sclerosing glomerulonephritis caused by direct infection of kidney epithelial cells with HIV
HIV-1–associated nephropathy (HIVAN) is a form of focal sclerosing glomerulonephritis caused by direct infection of kidney epithelial cells with HIV. HIVAN is more common in persons of African descent
Antibodies to HIV usually appear within ___ weeks and almost invariably within ___ weeks of primary infection
3–6
12
Detection of these antibodies forms the basis of many diagnostic screening tests for HIV infection
first antibodies detected against HIV
The first antibodies detected are those directed against the immunodominant region of the envelope gp41, followed by the appearance of antibodies to the structural or gag protein p24 and the gag precursor p55. Antibodies to p24 gag are followed by the appearance of antibodies to the outer envelope glycoprotein (gp120), the gag protein p17, and the products of the pol gene (p31 and p66)
gp 41 –> 24 –> 55 –> 120 –> 17 –> 31 and 66
In patients in whom HIV infection is suspected, the appropriate initial test is a _______________-
Fourth-generation HIV-1/2 antigen antibody immunoassay
If the result is negative, unless there is strong reason to suspect early HIV infection (as in a patient exposed within the previous 3 months), the diagnosis is ruled out and retesting should be performed only as clinically indicated.
If the repeat is negative on two occasions, one can assume that the initial positive reading was due to a technical error in the performance of the assay and that the patient is negative
When should you repeat HIV 1 Westernblot if the initial result is indeterminate?
4-6 weeks
laboratory test generally accepted as the best indicator of the immediate state of immunologic competence
The CD4+ T-cell count is the laboratory test generally accepted as the best indicator of the immediate state of immunologic competence of the patient with HIV infection.
Patients with CD4+ T-cell counts <200/μL are at high risk of disease from P. jirovecii, while patients with CD4+ T-cell counts <50/ μL are also at high risk of disease from _______ (3)
CMV, mycobacteria of the M. avium complex (MAC), and/or T. gondi
primary risk factors for invasive aspergillosis
profound neutropenia, glucocorticoid use, and underlying respiratory disease
Duration of subacute invasive aspergillosis
1-3months
80% involve the lungs and are community acquired
In the most severely immunocompromised patients, Aspergillus disseminates from the lungs to multiple organs—most often to the
brain but also to the skin, thyroid, bone, kidney, liver, gastrointestinal tract, eye endophthalmitis), and heart valve.
In acute disease, hemorrhagic infarction is most typical, and cerebral abscess is common
Most cases of Aspergillus endocarditis are due to
Most cases of Aspergillus endocarditis are prostheticvalve infections resulting from contamination during surgery.
The hallmark of chronic cavitary pulmonary aspergillosis is
one or more pulmonary cavities expanding over a period of months or years in association with pulmonary symptoms and systemic manifestations such as fatigue and weight loss.
An irregular internal cavity surface and thickened cavity walls are typical and indicative of disease activity.
Pleural thickening and pericavitary infiltrates are typical and most obvious if a positron emission tomography scan has been done as part of the workup.
In almost all cases, ABPA represents a hypersensitivity reaction to A. _____
fumigatus
The cardinal diagnostic test for ABPA is
The cardinal diagnostic test is detection of Aspergillus-specific IgE (or a positive skin-prick test in response to A. fumigatus extract) together with an elevated serum level of total IgE (usually >1000 IU/mL).
The histologic hallmarks of allergic fungal sinusitis are
The histologic hallmarks of allergic fungal sinusitis are local eosinophilia and Charcot-Leyden crystals.
Definitive confirmation of a diagnosis of invasive aspergillosis requires
(1) a positive culture of a sample taken directly from an ordinarily sterile site (e.g., a brain abscess) or (2) positive results of both histologic testing and culture (or molecular confirmation of Aspergillus spp.) of a sample taken from an affected organ (e.g., sinuses or skin).
preferred agents for invasive aspergillosis
Voriconazole, isavuconazole and posaconazole are the preferred agents for invasive aspergillosis; caspofungin, micafungin, and lipidassociated AmB are second-line agents. AmB is not active against A. terreus or A. nidulans;
currently the preferred oral agent for chronic aspergillosis
Voriconazole is currently the preferred oral agent for chronic aspergillosis with itraconazole or posaconazole as substitutes when failure, emergence of resistance, or adverse events occur.
Treatment for aspergillosis
P-osaconazole
P-rophylaxis
Indications for surgery in aspergillosis
Surgical treatment is important in several forms of aspergillosis, including fungal ball of the sinus and single aspergillomas, in which surgery is curative; invasive aspergillosis involving bone, heart valve, sinuses, and proximal areas of the lung (to avoid catastrophic hemoptysis); brain abscess; keratitis; and endophthalmitis.
In allergic fungal sinusitis, removal of abnormal mucus and polyps, with local and occasionally systemic glucocorticoid treatment, usually leads to resolution. Persistent or recurrent signs and symptoms may require more extensive surgery (ethmoidectomy) and possibly antifungal therapy.
Surgery is problematic in chronic cavitary pulmonary aspergillosis, usually resulting in serious complications. Bronchial artery embolization is preferred for problematic hemoptysis.
T/F PCP can occur at CD4+ T-cell counts >200/μL in any immunosuppressed population including persons with HIV infection.
Clinicians must recognize that PCP can occur at CD4+ T-cell counts >200/μL in any immunosuppressed population including persons with HIV infection. Such occurrences are especially common in patients who are immunosuppressed due to causes other than HIV infection, especially among patients who have undergone solid-organ transplantation, since CD4+ T-cell counts are not as sensitive and specific indicators of PCP as they are in PLWH.
T/F A normal chest CT essentially rules out the diagnosis of PCP
True
High-resolution chest CT shows diffuse ground-glass opacities in virtually all patients with PCP, often before a routine chest radiograph becomes abnormal.A normal chest CT essentially rules out the diagnosis of PCP
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
Indications for glucocorticoid therapy in PCP
A major advance in therapy for PCP was the recognition that glucocorticoids could improve survival rates among PLWH with moderate to severe disease (room air PO2 <70 mmHg or alveolar–arterial oxygen gradient ≥35 mmHg).
For patients with HIV infection who present with PCP before the initiation of ART, ART should be started within _______
the first 2 weeks of therapy for PCP in most situations.
The glucocorticoid exposure threshold that warrants chemoprophylaxis is controversial, but such preventive therapy should be strongly considered for any patient who is receiving more than the equivalent of___ mg of prednisone daily for 30 days or who is receiving glucocorticoids in conjunction with other immunosuppressive agents.
20
Prophylaxis for PCP pneumonia
type of influenza virus that affects humans almost exclusively
B
A and C affects multiple species
T/F There is only one serotype of RSV
There is only one serotype of RSV, but antigenic variability does occur in circulating field strains.
most common viral infective agents in humans and the most frequent cause of the common cold
Rhinovirus
Intermediate host of MERS-CoV
MERS-CoV is a zoonotic virus (transmitted between animals and people). The virus likely emerged from bats in the Middle East, although studies have shown that humans are infected through direct or indirect contact with an intermediate host—infected dromedary camels.
The basic reproduction number (R0) (the expected number of cases generated directly by one case in a population in which all individuals are susceptible to infection) of SARS-CoV-2 has been estimated to be between ____, which is substantially higher than that of seasonal influenza (typically 1–2).
5 and 6
principal risk factor for severe illness from COVID-19
Advanced age is the principal risk factor for severe illness from COVID-19 (marked by need for hospitalization, intensive care, and mechanical ventilation). Over 95% of COVID-19 deaths occur in people over age 45, and >80% of deaths occur in people over age 65.
Male sex is associated with higher risk of severe disease (odds ratio, ~1.8). Most individuals who die have preexisting comorbidities.
The risk of severe COVID-19 illness increases markedly with elevated body mass index (BMI).
preferred antipyretic agent for COVID-19
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as antipyretic agents, but questions have been raised about a possible association between NSAID use and worse outcomes with COVID-19; when possible, the preferred antipyretic agent is acetaminophen.
Airborne transmission occurs through the dissemination of airborne droplet nuclei (particles of ≤__ μm) or evaporated droplets containing viruses that can remain suspended in the air for long periods.
5
Patients with HIV infection should have CD4+ T-cell measurements performed at the time of diagnosis and every ____ months thereafter.
3–6
Following the initiation of therapy or any change in therapy, plasma HIV RNA levels should be monitored approximately every 4 weeks until the effectiveness of the therapeutic regimen is determined by the development of a new steady-state level of HIV RNA.
During the asymptomatic period of HIV infection, the average rate of CD4+ T-cell decline is ~____ per year in an untreated patient
50/μL
When can you stop prophylaxis against PCP pneumonia in PLHIV?
May stop prophylaxis if CD4+ T-cell count >200/μL for ≥3 months
Same with T. Gondii
Prophylaxis for MAC
May stop prophylaxis once ART initiated
Prophylaxis or C. neoformans and when to stop
most common finding on chest x-ray in PCP pneumonia
The most common finding on chest x-ray is either a normal film, if the disease is suspected early, or a faint bilateral interstitial infiltrate.
In px with HIV and PTB, which should be started first ART or anti kochs?
it is recommended that initiation of ART be delayed in antiretroviral-naïve patients with CD4 counts >50 cells/μL until 2–4 weeks following the initiation of treatment for TB.
In PLHIV, The finding of ___ consecutive sputum samples positive for MAC is highly suggestive of pulmonary infection.
The finding of two consecutive sputum samples positive for MAC is highly suggestive of pulmonary infection. Cultures may take 2 weeks to turn positive.
The most common form of heart disease in PLHIC
The most common form of heart disease is coronary heart disease.
Clinical picture of oral hairy leukoplakia
Oral hairy leukoplakia presents as white, frondlike lesions, generally along the lateral borders of the tongue and sometimes on the adjacent buccal mucosa
Work ups needed for HIV enteropathy
Note 3 samples for stool ova and parasites
ART that has been associated with at times fatal fulminant and cholestatic hepatitis, hepatic necrosis, and hepatic failure
Nevirapine has been associated with at times fatal fulminant and cholestatic hepatitis, hepatic necrosis, and hepatic failure
Hallmark of HIVAN
Proteinuria is the hallmark of this disorder
A definitive diagnosis is obtained through renal biopsy
most common presentation of syphilis in the HIV-infected patient
The most common presentation of syphilis in the HIV-infected patient is that of condylomata lata, a form of secondary syphilis
T/F
In px with PLHIV, any patient with a positive serum VDRL test, neurologic findings, and an abnormal spinal fluid examination should be considered to have neurosyphilis and treated accordingly, REGARDLESS of the CSF VDRL result
TRUE
Characteristics of IRIS
most common hematologic abnormality in HIV-infected patients
Anemia is the most common hematologic abnormality in HIV-infected patients and, in the absence of a specific treatable cause, is independently associated with a poor prognosis
In terms of CBC, . A characteristic feature of zidovudine therapy is
. A characteristic feature of zidovudine therapy is an elevated mean corpuscular volume (MCV)
Also associated with lengthening of eyelashes
leading infectious cause of meningitis in patients with AIDS
Fungal meningitis is the leading infectious cause of meningitis in patients with AIDS . While the vast majority of these are due to C. neoformans, up to 12% may be due to C. gattii
For HSV-1 infection, _____ ganglia are most commonly infected
Trigeminal
although extension to the inferior and superior cervical ganglia also occurs. With genital infection, sacral nerve root ganglia (S2–S5) are most commonly affected. Autonomic ganglia, pelvic nerves, and vaginal nerve roots are commonly infected
most common clinical manifestation of reactivation HSV-1 infection
recurrent herpes labialis
T/F Glucocorticoids are the mainstay of tx for HSV keratitis
False
Use of topical glucocorticoids may exacerbate symptoms and lead to involvement of deep structures of the eye
most common cause of acute retinal necropsy
VZV
The clinical hallmark of HSV encephalitis has been the
acute onset of fever and focal neurologic symptoms and signs, especially in the temporal lobe
While brain biopsy has been the gold standard for defining HSV encephalitis, a highly sensitive and specific PCR for detection of HSV DNA in CSF has largely replaced biopsy for defining CNS infection
Treatment for HSV encephalitis
Most authorities recommend the administration of IV acyclovir to patients with presumed HSV encephalitis until the diagnosis is confirmed or an alternative diagnosis is made. All confirmed cases should be treated with IV acyclovir (30 mg/kg per day in three divided doses for 14–21 days).
Neurologic sequelae of HSV meningitis are rare. HSV is the most commonly identified cause of recurrent lymphocytic meningitis AKA _______
Neurologic sequelae of HSV meningitis are rare. HSV is the most commonly identified cause of recurrent lymphocytic meningitis (Mollaret’s meningitis).
Most commonly involved part of HSV esophagitis
The predominant symptoms of HSV esophagitis are odynophagia, dysphagia, substernal pain, and weight loss. Multiple oval ulcerations appear on an erythematous base with or without a patchy white pseudomembrane. The distal esophagus is most commonly involved.
risk of mother-to-child transmission of HSV in the perinatal period is highest when ______
risk of mother-to-child transmission of HSV in the perinatal period is highest when the infection is acquired near the time of labor—that is, in previously HSV-seronegative women
Isolation of HSV by cervicovaginal swab at the time of delivery is the greatest risk factor for intrapartum HSV transmission
Treatment for HSV inpregnancy
For newly acquired genital HSV infection during pregnancy, most authorities recommend treatment with acyclovir (400 mg three times daily) or valacyclovir (500–1000 mg twice daily) for 7–10 days
Confirmatory test for HSV infection
HSV infection is best confirmed in the laboratory by detection of virus, viral antigen, or viral DNA in scrapings from lesions.
HSV DNA detection by PCR is the most sensitive laboratory technique for detecting mucosal or visceral HSV infections and is the recommended test for laboratory confirmation of a diagnosis.
Culture is indicated when antiviral sensitivity testing is required
Antiviral drug that demonstrated reduced transmission of HSV-2 infection between sexual partners
Only valacyclovir has been subjected to clinical trials that demonstrated reduced transmission of HSV-2 infection between sexual partners
Once-daily valacyclovir (500 mg)
major side effect associated with IV acyclovir
The major side effect associated with IV acyclovir is transient renal insufficiency, usually due to crystallization of the compound in the renal parenchyma. This adverse reaction can be avoided if the medication is given slowly over 1 h and the patient is well hydrated.
Tx for acyclovir resistant HSV infection
Therapy with the antiviral drug foscarnet (40–80 mg/kg IV every 8 h until clinical resolution) is the only clinically demonstrated approach
Because of its toxicity and cost, this drug is usually reserved for patients with extensive mucocutaneous infections
Diagnosis of cryptococcal meningitis
The diagnosis of cryptococcal meningitis is made by identification of organisms in spinal fluid with india ink examination or by the detection of cryptococcal antigen. Blood cultures for fungus are often positive. A biopsy may be needed to make a diagnosis of CNS cryptococcoma and to distinguish inadequately treated infection from immune reconstitution syndrome.
Treatment for cryptococcal meningitis
Initial treatment is with IV amphotericin B 0.7 mg/kg daily, or liposomal amphotericin 4–6 mg/kg daily, with flucytosine 25 mg/kg qid for at least 2 weeks if possible. Decreases in renal function in association with amphotericin can lead to increases in flucytosine levels and subsequent bone marrow suppression.
Therapy continues with amphotericin alone until the CSF culture turns negative followed by fluconazole 400 mg/d PO for 8 weeks, and then fluconazole 200 mg/d until the CD4+ T-cell count has increased to >200 cells/μL for 6 months in response to ART
Most common causes of focal neurologic deficits in px with PLHIV
The most common causes are toxoplasmosis, progressive multifocal leukoencephalopathy, and CNS lymphoma
The most common clinical presentation of cerebral toxoplasmosis in patients with HIV infection is
The most common clinical presentation of cerebral toxoplasmosis in patients with HIV infection is fever, headache, and focal neurologic deficits
d by confusion, dementia, and lethargy, which can progress to coma. The diagnosis is usually suspected on the basis of MRI findings of multiple lesions in multiple locations, although in some cases only a single lesion is seen
Definitive diagnosis if toxoplasmosis
The definitive diagnostic procedure is brain biopsy. However, given the morbidity rate that can accompany this procedure, it is usually reserved for the patient who has failed 2–4 weeks of empiric therapy for toxoplasmosis
Standard tx for toxoplasmosis
Standard treatment is sulfadiazine and pyrimethamine with leucovorin as needed for a minimum of 4–6 weeks.
human polyomavirus that is the etiologic agent of progressive multifocal leukoencephalopathy (PML)
JC virus
PML is the only known clinical manifestation of JC virus infection
Treatment for Trypanosomiasis
Treatment consists of benzimidazole (2.5 mg/kg bid) or nifurtimox (2 mg/kg qid) for at least 60 days, followed by maintenance therapy for the duration of immunodeficiency with either drug at a dose of 5 mg/kg three times a week.
most common peripheral neuropathy in patients with HIV infection
The most common peripheral neuropathy in patients with HIV infection is a distal sensory polyneuropathy (DSPN) also referred to as painful sensory neuropathy (HIV-SN),
The most common abnormal findings on funduscopic examination in px with HIV.
The most common abnormal findings on funduscopic examination are cotton-wool spots.
One of the most devastating consequences of HIV infection is CMV retinitis. Patients at high risk of CMV retinitis (CD4+ T-cell count <100/μL) should undergo an ophthalmologic examination every 3–6 months. The majority of cases of CMV retinitis occur in patients with a CD4+ T-cell count <50/μL.
characteristic retinal appearance of CMV retinitis
CMV retinitis usually presents as a painless, progressive loss of vision. Patients may also complain of blurred vision, “floaters,” and scintillations. The disease is usually bilateral, although typically it affects one eye more than the other. The diagnosis is made on clinical grounds by an experienced ophthalmologist. The characteristic retinal appearance is that of perivascular hemorrhage and exudate.
Treatment for CMV retinitis
Therapy for CMV retinitis consists of oral valganciclovir, IV ganciclovir, or IV foscarnet, with cidofovir as an alternative. Combination therapy with ganciclovir and foscarnet has been shown to be slightly more effective than either ganciclovir or foscarnet alone in the patient with relapsed CMV retinitis. A 3-week induction course is followed by maintenance therapy with oral valganciclovir. If CMV disease is limited to the eye, intravitreal injections of ganciclovir or foscarnet may be considered.
Maintenance therapy is continued until the CD4+ T-cell count remains >100 μL for >6 months
T/F
Generalized wasting is an AIDS-defining condition
True
Generalized wasting is an AIDS-defining condition; it is defined as involuntary weight loss of >10% associated with intermittent or constant fever and chronic diarrhea or fatigue lasting >30 days in the absence of a defined cause other than HIV infection.
Initial lesion of Kaposi Sarcoma
The initial lesion may be a small, raised, reddish-purple nodule on the skin a discoloration on the oral mucosa, or a swollen lymph node.
Lesions often appear in sun-exposed areas, particularly the tip of the nose, and have a propensity to occur in areas of trauma (Koebner phenomenon)
Three main categories of lymphoma are seen in patients with HIV infection:
Three main categories of lymphoma are seen in patients with HIV infection: grade III or IV immunoblastic lymphoma, Burkitt’s lymphoma, and primary CNS lymphoma.
Immunoblastic lymphomas account for ~60% of the cases of lymphoma in patients with AIDS. The majority of these are diffuse large B-cell lymphomas (DLBCL). T
Management for Kaposi Sarcoma
most common extranodal site involvement in HIV px with lymphoma
At least 80% of patients present with extranodal disease, and a similar percentage have B-type symptoms of fever, night sweats, and/ or weight loss. Virtually any site in the body may be involved. The most common extranodal site is the CNS, which is involved in approximately one-third of all patients with lymphoma.
Additional testing prior to starting Efavirenz and Abacavir
A pregnancy test should be done in women in whom the drug efavirenz is being considered, and HLA-B5701 testing should be done in all patients in whom the drug abacavir is being considered.
Hypersensitivity reaction In HLA-B5701+ individuals (can be fatal) in px taking Abacavir
Initial evaluation for px with HIV
Usual initial regimen for PLHIV
initial regimen will include two nucleoside/nucleotide reverse transcriptase inhibitors (usually a tenofovir-based drug or abacavir + 3TC or FTC) plus a nonnucleoside reverse transcriptase inhibitor, an integrase inhibitor, or a protease inhibitor boosted with a pharmacokinetic enhancer (ritonavir or cobicistat).
Given its renal toxicity, tenofovir disoproxil should be limited to use in patients with creatinine clearance (CrCl) >__ while tenofovir alafenamide should generally be limited to use in patients with CrCl >___
TDF = greater than 70
TAF = greater than 30
rilpivirine is approved for treatment only in ARTnaïve patients with HIV RNA levels < ___copies/mL and is contraindicated in patients taking proton pump inhibitors.
100,000
intergrase inhibitor associated with rhabdomyolysis
Raltegravir
protese inhibitor associated with renal stone
Atazanavir
NNRTI associated with abnormal dreams
Efavirenz
Elvitegravir is always given in combination with _____ , which acts to boost the concentrations of elvitegravir
cobicistat
Following the initiation of therapy, one should expect a rapid, at least 1-log (tenfold) reduction in plasma HIV RNA levels within 1–2 months and then a slower decline in plasma HIV RNA levels to <__ copies/mL within 6 months.
50
During this same time there should be a rise in the CD4+ T-cell count of 100–150/cells μL that is also particularly brisk during the first month of therapy. Subsequently, one should anticipate a CD4+ T-cell count increase of 50–100 cells/year until numbers approach normal
Principles of therapy of HIV infection
When should you repeat HIV RNA levels following initiation of ART
Plasma HIV RNA levels should be monitored within 2–4 weeks after initiation of ART or following a change in regimen, every 4–8 weeks until HIV RNA levels are suppressed to <200 copies/mL, and then every 3–6 months during therapy.
Indications for changing ART
Adult male circumcision, which has been shown to result in a ___% reduction in HIV acquisition in the circumcised subject, is currently being pursued, particularly in developing nations, as a component of HIV prevention
50–65
Conditions in which surgery should be done first before dx/ tx
Necrotizing fascitis
Clostridial myonecrosis
Vaccines that should be delayed after pregnancy
HPV
Recombinant Zoster
T/F Breastfeeding and Pregnancy are contraindication for live vaccine
False
Pregnancy only
Most live vaccines are not secreted in the breast milk
TAVR PVE has same causative organisms to PVE except for increased frequency of ________
Enterococci
Most frequent clinical feature of Infective endocarditis
Fever
In what instances can you opt to withold abx in IE
Subacute IE + stable especially if with prior abx within precedig 2 weeks
Rationale: delay allows obtaining blood for additional cultures unconfounded by empirical tx
What should be considered if a px with IE still has fever despite >7 days of appropriate abx tx
Paravalvular abscess
Extracardiac abscess
Complications (embolic)
Most commonly affected valve in perivalvular infection
AV
Dx test of choice: TEE
Tx: Pacemaker
Most common cause of spontaneous non traumatic gangrene
C. septicum –> anaerobe but o2 tolerant
Most common symptom of splenic abscess
Abdominal pain
Most common: Streptococcus species
Most common isolates reflect associated endocarditis
If with sickle cell: Salmonella
Most common etiologic agent associated with outbreaks of AGE
Norovirus
A 42 year old male, recently diagnosed with HIV, comes to the clinic for advise regarding pneumococcal vaccinations. He recalls having completed all vaccinations during childhood and has received hepatitis A and B vaccinations 3 years ago when he travelled to Africa. He has also been regularly receiving his yearly inactivated trivalent influenza virus vaccine as per company policy. Your best advise is:
A. PCV 13 should be given at least 8 weeks before PPSV 23
B. PCV 13 should be given at least 1 year before PPSV 23
C. PPSV 23 should be given at least 8 weeks before PCV 13
D. PPSV 23 should be given at least 1 year before PCV 13
A. PCV 13 should be given at least 8 weeks before PPSV 23
Giving PCV13 first allows for a strong immune response that enhances the efficacy of PPSV23 when administered later.
PPSV23 should not be administered before PCV13 because it may blunt the immune response to PCV13 if given later
A 35 year old female, known RHD, with severe MR, MS s/p MV repair with prosthesis, consults your clinic for medical clearance prior to dental extraction under local anesthesia. Patient has a known allergy to ibuprofen and penicillin. She is alert and oriented. What is your best recommendation prior to dental procedure?
A. Amoxicillin: 2g P.O. 1 hour before procedure
B. Ampicillin: 2 gm IM within 1 hour before procedure
C. Azithromycin 500mg P.O. 1 hour before procedure
D. Clindamycin 600mg IM 1 hour before procedure
C. Azithromycin 500mg P.O. 1 hour before procedure
A 55-year old male has been having intermittent fever for the past 6 weeks. He has no co-morbid condition and is not on any medications. Obligatory work ups and imaging tests were non-specific. He is otherwise in stable condition. What therapeutic option may be considered at this point?
A. NSAID
B. Glucocorticoid trial therapy
C. Anti-TB drugs
D. Broad spectrum antibiotics
A. NSAID
Withold abx and steroids if stable and no PDCs since may interfere with work ups
A 36/M presents with symmetric multiple xanthoma-like nodules on his extremities and torso. He also complains of blurring of vision and nasal congestion. On PE, he is afebrile with stable vital signs. He is noted to have leonine facies with clawing of the 4th and 5th fingers of both hands. Skin biopsy showed Bacterial Index (BI) >2 with 4+ AFB, no lymphocytic infiltration with absent Langerhans giant cells and foamy macrophages. Based on WHO, what is the recommended treatment for this patient?
A. Dapsone 100mg/day x 5 years
B. Dapsone 100mg/day (unsupervised) + Rifampin 600mg/month (supervised) x 6months
C. Dapsone 100mg/day + Clofazimine 50mg/day (unsupervised) and Rifampin 600mg/month + Clofazimine 300mg/month (supervised) x 1-2 years
D. Rifampin 600mg/day x 3 years + Dapsone 100mg/day indefinitely
C. Dapsone 100mg/day + Clofazimine 50mg/day (unsupervised) and Rifampin 600mg/month + Clofazimine 300mg/month (supervised) x 1-2 years
The clinical presentation of this patient, including multiple xanthoma-like nodules, leonine facies, clawing of fingers, and positive acid-fast bacilli (AFB) on skin biopsy, is consistent with multibacillary (MB) leprosy (lepromatous leprosy). The absence of lymphocytic infiltration and Langerhans giant cells with foamy macrophages on biopsy further supports the diagnosis.
A healthy Canadian newlywed couple consults your clinic as advised by their travel agent. The husband is 34 years old while the wife is 31 years old. They just arrived in Manila to meet with some friends and is scheduled to travel to Palawan in 2 days for their extended honeymoon. The travel agent advised them to consult you for “vaccinations” to prevent infections endemic in the area of destination. Your best advise is: A. Start chloroquine 500mg PO now then once weekly until 4 weeks after leaving Palawan
B. Start hydroxychloroquine 400mg PO now then once weekly until 4 weeks after leaving Palawan
C. Start doxycycline 100mg PO now then once daily until 4 weeks after leaving Palawan
D. Start mefloquine 250mg PO now then once daily until 4 weeks after leaving Palawan
C. Start doxycycline 100mg PO now then once daily until 4 weeks after leaving Palawan
Doxy
Dose: 100 mg orally once daily, starting 1–2 days before travel, continued during the stay, and for 4 weeks after leaving the malaria-endemic area
Chloroquine and Mefloquine should be started 1-2 weeks before hence not ideal for this couple
Which is TRUE regarding fever?
A. DRESS is usually accompanied by multiple lymphadenopathies and neutrophilia
B. Furosemide is one of the common causes of drug fever
C. Factitious fever is more common among old men working in the pharmaceutical industry
D. Measurement of temperature at different points in time will help diagnose fraudulent fever
B. Furosemide is one of the common causes of drug fever
A - DRESS (drug reaction with eosinophilia and systemic symptoms), is often accompanied by eosinophilia and also by lymphadenopathy, which can be extensive
C - Factitious fever (fever artificially induced by the patient—for example, by IV injection of contaminated water) should be considered in all patients but is more common among young women in health-care professions.
D - In fraudulent fever, the patient is normothermic but manipulates the thermometer. Simultaneous measurements at different body sites (rectum, ear, mouth) should rapidly identify this diagnosis. Another clue to fraudulent fever is dissociation between pulse rate and temperature.
In working up for fever of unknown origin, if the potential diagnostic clues seem absent and misleading, what is the next BEST approach?
A. Do a fundoscopic examination
B. Request for whole body FDG PET CT scan
C. Repeat Complete Blood Count and Procalcitonin
D. Give empiric Prednisone to address the fever
A. Do a fundoscopic examination
Which of the following statements accurately describes COVID infection?
A. The basic reproduction number is higher than that of influenza A
B. Airborne transmission over long distances is highly likely
C. Transmission in schools has been considered a primary driver of population transmission
D. Sex is the principal risk factor for developing a severe illness
A. The basic reproduction number is higher than that of influenza A
A - The basic reproduction number (R0 ) (the expected number of cases generated directly by one case in a population in which all individuals are susceptible to infection) of SARS-CoV-2 has been estimated to be between 5 and 6, which is substantially higher than that of seasonal influenza (typically 1–2).
B - Airborne transmission by small particle from person-to-person may occur, but airborne transmission over long distances is unlikely.
C - Densely populated settings such as prisons, cruise ships, nursing homes, airplanes, and large indoor gatherings facilitate even higher transmission efficiency.
D - Advanced age is the principal risk factor for severe illness from COVID-19 (marked by need for hospitalization, intensive care, and mechanical ventilation)
A 62 year old female came to your clinic for swelling on her face. She mentioned that it started as minimal erythema with defined margins along the nasolabial fold associated intense pain. Now on its 3rd day, you noticed flaccid bullae formation on the same area surrounded by intense erythema. What is the BEST antibiotic regimen?
A. Vancomycin
B. Penicillin G
C. Piperacillin Tazobactam
D. Linezolid
B. Penicillin G
Erysipelas is due to S. pyogenes and is characterized by an abrupt onset of fiery-red swelling of the face or extremities. The distinctive features of erysipelas are well-defined indurated margins, particularly along the nasolabial fold; rapid progression; and intense pain. Flaccid bullae may develop during the second or third day of illness, but extension to deeper soft tissues is rare. Treatment with penicillin is effective; swelling may progress despite appropriate treatment, although fever, pain, and the intense red color diminish.
A 63 years old female came in for swelling of right leg. She underwent incision and drainage of abscess which revealed Streptococcus agalactiae. What should have been asked in the history that will correlate the isolated organism?
A. History of endocarditis
B. History of Type 2 Diabetes Mellitus
C. Inquire regarding swimming activities especially on salt water
D. Inquire if patient could recall any insect bite
B. History of Type 2 Diabetes Mellitus
Given the clinical vignette, the patient seems to have cellulitis. Cellulitis caused by Streptococcus agalactiae (group B Streptococcus) occurs primarily in elderly patients and those with diabetes mellitus or peripheral vascular disease
A 72 year old male, hypertensive, with mitral valve prolapse and previous stroke 2 years ago, had 5 days of watery diarrhea, abdominal pain and fever. He was admitted for hydration and work up that revealed 2 sites Blood culture positive for Salmonella choleraesuis that was sensitive to all antibiotics tested. After 1 week of Ceftriaxone, patient is still having high grade fever and chills but no more abdominal pain and diarrhea. Physical examination was unremarkable aside from the fever. Repeat Blood culture showed the same organism and sensitivity. What is the BEST treatment approach to the case?
A. Extend Ceftriaxone to 42 days of treatment
B. Shift Ceftriaxone to Piperacillin Tazobactam
C. Send the patient home with Co trimoxazole to complete 21 days
D. Add Ciprofloxacin to Ceftriaxone for dual coverage
A. Extend Ceftriaxone to 42 days of treatment
Given the clinical vignette, the patient seems to have nontyphoidal salmonellosis. 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. If the patient has endocarditis or arteritis, treatment for 6 weeks with an IV β-lactam antibiotic (such as ceftriaxone or ampicillin) is indicated.
What is the treatment of choice for uncomplicated cervical gonorrhea?
A. Ceftriaxone plus Doxycycline
B. Azithromycin plus Ertapenem
C. Penicillin G
D. Amoxicillin Clavulanic acid
A. Ceftriaxone plus Doxycycline
What is the most common infectious complication of varicella zoster?
A. Acute Neuritis
B. Pneumonia
C. Meningoencephilitis
D. Staphylococcal superinfection
D. Staphylococcal superinfection
The most common infectious complication of varicella is secondary bacterial superinfection of the skin, which is usually caused by Streptococcus pyogenes or Staphylococcus aureus, including strains that are methicillin-resistant. Pneumonia is the most serious complication
A 45-year-old female patient with a history of chronic anemia and autoimmune disease received intravenous immunoglobulin (IVIg) therapy and a blood transfusion two weeks ago. She comes to your clinic asking about receiving the vaccines, as she was recently exposed to a child with chickenpox. Which of the following would be the BEST advice regarding the timing of her vaccination?
A. Administer both the MMR and varicella vaccines today to ensure immediate protection.
B. Delay the MMR and varicella vaccines for at least 3 months after the blood transfusion and IVIg.
C. Administer only the varicella vaccine today, and delay the MMR vaccine for 1 month.
D. Delay the MMR and varicella vaccines for 2 weeks, then administer both vaccines.
B. Delay the MMR and varicella vaccines for at least 3 months after the blood transfusion and IVIg.
After receiving IVIg, the passive immunity provided by the IgG antibodies can interfere with the effectiveness of live vaccines. The usual recommendation is to wait at least 3 months after receiving IVIg before administering a live vaccine. This is because IVIg can provide temporary immunity that might suppress the immune response to the live vaccine.
A 28-year-old male patient, who is HIV-positive and on antiretroviral therapy (ART), comes to your clinic for a consultation about receiving the HPV vaccine. He has had multiple sexual partners and is concerned about his risk for HPV-related cancers. He has never been vaccinated for HPV before and asks whether it is still beneficial for him to receive the vaccine. Which of the following is the most appropriate recommendation?
A. He should not receive the HPV vaccine because he is over 26 years old and has already had multiple sexual partners.
B. The HPV vaccine is contraindicated for HIV-positive individuals due to their immunocompromised status.
C. He should receive the HPV vaccine, as it is recommended for immunocompromised individuals, including those with HIV.
D. He should only receive the HPV vaccine if his CD4 count is greater than 500 cells/μL.
C. He should receive the HPV vaccine, as it is recommended for immunocompromised individuals, including those with HIV.
The CDC recommends that HIV-positive individuals aged 9–26 years receive the HPV vaccine. For those aged 27–45, the vaccine may still be considered if they are at risk for new HPV infections, which includes those with multiple sexual partners, as in this patient’s case
A 62-year-old male with poorly controlled diabetes mellitus was referred to you by ENT service for further management. He presents with fever, nasal congestion, and facial pain. Physical examination reveals black necrotic tissue in the nasal cavity. A CT scan of the sinuses shows invasive destruction of the nasal septum and surrounding tissue. KOH smear revealed hyphal elements. What is the most likely pathogen, and what is the appropriate initial treatment?
A. Aspergillus species; initiate voriconazole.
B. Candida species; initiate fluconazole.
C. Mucorales; initiate amphotericin B and consider surgical debridement.
D. Cryptococcus neoformans; initiate fluconazole and consider lumbar puncture.
C. Mucorales; initiate amphotericin B and consider surgical debridement.
A 28-year-old HIV-positive male with a CD4 count of 150 cells/μL presents to the emergency department with fever, dry cough, and progressive shortness of breath over the past week. Oxygen saturation is 88% at room air. His chest X-ray reveals bilateral interstitial infiltrates but no consolidation. He reports no history of prophylaxis for opportunistic infections. What is the most appropriate next step in the management of his condition?
A. Perform a bronchoalveolar lavage with staining for Pneumocystis organisms.
B. Start trimethoprim-sulfamethoxazole and wait for clinical improvement.
C. Obtain a sputum culture and blood cultures to identify the causative organism.
D. Perform a lung biopsy for definitive diagnosis
A. Perform a bronchoalveolar lavage with staining for Pneumocystis organisms.
Given the clinical vignette, the patient seems to have Pneumocystis pneumonia. Pneumocystis is an opportunistic pathogen that is an important cause of pneumonia in immunocompromised hosts, particularly those with HIV infection. The demonstration of organisms in bronchoalveolar lavage (BAL) fluid is almost 100% sensitive and specific for PCP in patients with HIV infection and is almost as sensitive in patients with immunosuppression due to other processes.
A 30-year-old female with no known co-morbids consulted due to 10-day history of diarrhea, abdominal pain, bloating, nausea and fatigue. She returned from a hiking trip where she consumed untreated stream water. She also showed her fecalysis results revealing cysts consistent with Giardia lamblia. Which of the following is consistent with its clinical manifestations?
A. Lower gastrointestinal symptoms predominate
B. Symptoms of colitis are common
C. Symptoms tend to be acute and disabling like other enteric bacterial infections
D. Most infected persons are asymptomatic except in epidemics
D. Most infected persons are asymptomatic except in epidemics
A - Although diarrhea is common, upper intestinal manifestations such as nausea, vomiting, bloating, and abdominal pain may predominate
B - Fever, the presence of blood and/or mucus in the stools, and other signs and symptoms of colitis are uncommon and suggest a different diagnosis or a concomitant illness.
C - Symptoms tend to be intermittent yet recurring and gradually debilitating, in contrast with the acute disabling symptoms associated with many enteric bacterial infections.
D - Most infected persons are asymptomatic, but in epidemics, the proportion of symptomatic cases may be higher
A 28-year-old female photographer went to a trip in Samar where she swam in lakes. She consulted the clinic due to an intensely itchy, red rash on her legs and arms. The rash appeared within hours after she swam in a freshwater lake during a weekend trip. She reports that the area became raised and swollen before developing into small blisters. She has no other co-morbids. What is the most likely cause of her condition?
A. Direct infection by adult Schistosoma
B. Larval penetration of avian schistosomes
C. Allergic reaction to contaminated water
D. Ingestion of Schistosoma eggs in contaminated water
B. Larval penetration of avian schistosomes
Given the clinical vignette, the patient seems to have cercarial dermatitis. Cercarial penetration of the skin may result in a maculopapular rash called cercarial dermatitis or “swimmer’s itch.” A particularly severe form of cercarial dermatitis is commonly seen after exposure to cercariae from avian schistosomes. These cercariae cannot complete their development in humans and die in the skin, causing an inflammatory allergic reaction.
A veterinarian from Manila is planning to travel to a remote region in the Philippines for a wildlife conservation project where he will be in close contact with wild animals and bats. He already received a full pre-exposure rabies vaccination series 5 years ago. He consulted your clinic to seek advice on rabies prevention before his trip. He has no known comorbids. What is the BEST recommendation for him?
A. No further vaccination is necessary; he remains fully protected by his prior vaccination series.
B. Administer a single booster dose of rabies vaccine to maintain protection before his trip.
C. Administer a full three-dose rabies vaccine series again due to the high-risk nature of his work and the time
D. Provide both rabies booster vaccine and rabies immunoglobulin (RIG) immediately to boost his protection.
B. Administer a single booster dose of rabies vaccine to maintain protection before his trip.
Individuals who previously completed a full pre-exposure rabies vaccine series retain long-term memory immunity. However, antibody titers may wane over time, particularly in those with high-risk exposure. The World Health Organization (WHO) and the Advisory Committee on Immunization Practices (ACIP) recommend a single booster dose for individuals with continued or re-established high-risk exposure
Preexposure rabies prophylaxis should be considered for people with an occupational or recreational risk of rabies exposures and also for certain travelers to rabies-endemic areas. The primary schedule consists of three doses of rabies vaccine given on days 0, 7, and 21 or 28. Serum neutralizing antibody tests help determine the need for subsequent booster doses. When a previously immunized individual is exposed to rabies, two booster doses of vaccine should be administered on days 0 and 3.
RIG should not be administered to previously vaccinated persons.
A 45-year-old driver from Davao consulted due to 6-month history of progressive numbness in his hands and feet, along with several hypopigmented skin lesions on his arms and back. He reports no pain associated with the lesions but has noticed muscle weakness in his hands. Physical examination reveals multiple, well-defined hypopigmented macules and plaques with loss of sensation. There is palpable thickening of the ulnar and peroneal nerves. A skin biopsy from one of the lesions shows numerous acid-fast bacilli. Based on his clinical presentation, what is the most appropriate next step in management?
A. Initiate treatment with dapsone and rifampin for 6 months.
B. Initiate treatment with dapsone and rifampin for 12 months.
C. Initiate treatment with multidrug therapy (MDT) for 6 months.
D. Initiate treatment with multidrug therapy (MDT) for 12 months.
D. Initiate treatment with multidrug therapy (MDT) for 12 months.
Only one multidrug regimen is recommended by the WHO for the treatment of leprosy. This regimen consists of a combination of two or three of the following drugs: rifampin, dapsone, and clofazimine. The keystone of WHO-recommended multidrug therapy for multibacillary leprosy is a monthly dose of rifampin together with daily doses of dapsone and daily and monthly doses of clofazimine. Patients with paucibacillary leprosy are treated with two drugs, receiving monthly doses of rifampin and daily doses of dapsone. The treatment duration is 12 months for multibacillary disease and 6 months for paucibacillary disease
A 40-year-old female with lepromatous leprosy has been on multidrug therapy for 3 months with good compliance. She presents with new painful, erythematous skin nodules and swelling of the face and extremities, associated with fever and joint pains. On examination, she has tender nodules on the arms and legs. Which of the following is TRUE in her case?
A. Characterized by reversal reactions
B. Delayed type of hypersensitivity reaction
C. Can become Tuberculoid histologically
D. An immune complex-mediated syndrome
D. An immune complex-mediated syndrome
Type 2 Leprosy Reaction (T2R), also known as ENL (erythema nodosum leprosum), is an immune complex–mediated syndrome (i.e., an antigen–antibody reaction involving complement) that causes inflammation of the skin, nerves, and other organs as well as general malaise.
A - Applicable for type 1 leprosy reaction (T1R)
B - ENL is an example of a type III hypersensitivity reaction (Coombs and Gell classification) or Arthus phenomenon
A 25-year-old woman experienced a sudden undocumented fever lasting five days, along with epigastric pain and vomiting. On the sixth day of her illness, she was afebrile but had increased abdominal pain and noticed gum bleeding after brushing her teeth, prompting her immediate consult to the emergency room. A physical examination revealed she was conscious and oriented, with vital signs showing BP 80/50, HR 115, RR 23, and T 36.8. She had pinkish conjunctiva and anicteric sclera, no CLADS, minimal gum bleeding, and tenderness in the right upper quadrant, with liver span of 12 cm. The rest were unremarkable. A complete blood count indicated: WBC 2.3 (70% seg, 30% lymph), hematocrit 0.58, hemoglobin 14, and platelet count of 55,000. What could explain the pathogenesis of her condition?
A. The extravasation of plasma into extravascular sites heralding DSS occurs during the febrile phase.
B. The increase in vascular permeability is associated with immune activation and cytokine response.
C. The shock state occurs commonly among individuals infected with primary DF infection
D. The degree and duration of fever is proportional to the propensity for DSS
B. The increase in vascular permeability is associated with immune activation and cytokine response.
Given the clinical vignette, the patient seems to have severe dengue (previously called dengue hemorrhagic fever and dengue shock syndrome). Severe dengue is associated with a transient increase in vascular permeability due to endothelial dysfunction in the critical phase. The induction of vascular permeability and shock depends on multiple factors, such as the presence or absence of enhancing and non-neutralizing antibodies, age (susceptibility to severe dengue drops considerably after 12 years of age), sex (females are more often affected than males), race (whites are more often affected than Black people), nutritional status, and timing and sequence of infections (e.g., dengue virus 1 infection followed by dengue virus 2 infection seems to be more dangerous than dengue virus 4 infection followed by dengue virus 2 infection).
A - The extravasation of plasma into extravascular sites heralding DSS occurs during the critical phase
C - The shock state occurs commonly among individuals infected with secondary DF infection
D - There is no correlation between the degree and duration of fever to the propensity for DSS
A 48-year-old male with a history of diabetes presented to the emergency room with right upper quadrant pain and fever lasting three days. He appeared lethargic and restless and was subsequently admitted. In the ward, he experienced three episodes of loose, watery stools. His vital signs showed awake but lethargic with blood pressure 100/70, heart rate 108, respiratory rate 23, and temperature 36.7. He has sunken eyeballs and no cervical lymphadenopathy. His abdomen was soft with tenderness in the right upper quadrant, and liver span measured 2.5 cm. No easy bruisability and capillary refill time is 2.5 seconds. A complete blood count showed WBC 2.1, hemoglobin 13, hematocrit 0.53, and platelet count 78,000. What would be the BEST initial management for his condition?
A. Give PNSS at 5-7ml/kg/hour for 1-2 hours, then reassess
B. Transfer patient to ICU for close monitoring and observe for any signs of bleeding
C. Monitor CBC every four hours and fluids should be adjusted accordingly
D. Insert IFC and monitor urine output hourly to know if the patient is properly hydrated
A. Give PNSS at 5-7ml/kg/hour for 1-2 hours, then reassess
Patient is already tachycardic despite being afebrile –> could be a sign of hemodynamic instability
Initial IVF rate: 5-7mL/kg/hr for 2-4 hrs
● If improving, decrease to 3-5mL/kg/hr for 2-4 hrs
● If improving, decrease to 2-4mL/kg/hr Most patients with shock respond promptly to close monitoring, oxygen administration, and infusion of crystalloid or—in severe cases—colloid.
A 45-year-old construction worker, had history of high-grade fever for more than 12 days with associated retroorbital headache, with noted intense myalgia with noticeable pain on the calves and back. He self-medicated with Paracetamol 500 mg tablet as needed for fever but afforded temporary relief. Important physical examination showed: Lethargic, weak looking with the following vital signs: BP 110/80, HR 115 RR:24 Temp 39 C, 02 sat 94% at RA. Positive subconjunctival suffusion, no CLAD, with tonsillopharyngeal exudates. (+) calf tenderness with noted erythematous rashes diffusely distributed on both forearms. No neurologic symptoms. Current labs requested: Crea: 0.54 mg/dl (EGFR :92), CBC: WBC (9.2) PMN 89 Lymphocytes (18) Platelet (100). What is the BEST diagnostic test to be done?
A. Blood Culture
B. Antibody titers on week three (3) of illness
C. Spinal tap should be done
D. Urine PCR and Urine Culture
D. Urine PCR and Urine Culture
Given the clinical vignette, the patient seems to have leptospirosis and is on the 2nd week of illness. 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.
A and C - usually used in the 1st week of illness
B - Preferably, a fourfold or greater rise in titer is detected between acute- and convalescent-phase serum specimens
Which is TRUE in Acute Kidney injury (AKI) in Severe Leptospirosis?
A. Typical electrolyte abnormalities observed are hyperkalemia and hypomagnesemia which can be associated with nephropathy
B. This is mostly non oliguric type AKI which is present several days after the initial illness.
C. Hypotension is the initial manifestation of ATN and can be managed by fluid resuscitation.
D. Hemodialysis is prescribed only if patient is hemodynamically compromised.
C. Hypotension is the initial manifestation of ATN and can be managed by fluid resuscitation.
Hypotension is associated with acute tubular necrosis, oliguria, or anuria, requiring fluid resuscitation and sometimes vasopressor therapy.
A - Typical electrolyte abnormalities include hypokalemia and hyponatremia. Loss of magnesium in the urine is uniquely associated with leptospiral nephropathy.
B - Acute kidney injury is common in severe disease, presenting after several days of illness, and can be either nonoliguric or oliguric
D - Hemodialysis can be lifesaving, with renal function typically returning to normal in survivors.
A 40-year-old male diabetic, with indwelling foley catheter due to spinal cord injury was referred due to pyuria (WBC 10/HPF) on urinalysis. He has no fever, flank pain and dysuria. What is your management?
A. Repeat urinalysis
B. Request for Urine CS and treat based on sensitivity result
C. Start empiric antibiotic treatment
D. No treatment necessary, remove IFC
D. No treatment necessary, remove IFC
A 71/M diabetic came in for more than 2 weeks fever associated with chills, anorexia, weight loss, right upper quadrant pain. On PE, there is note of jaundice and right upper quadrant tenderness. What is the most common laboratory finding among patients with this condition?
A. Elevated serum levels of bilirubin
B. Elevated concentrations of aspartate transaminases
C. Elevated serum alkaline phosphatase
D. Decreased serum albumin
C. Elevated serum alkaline phosphatase
Given the clinical vignette, the patient seems to have a liver abscess. Fever is the most common presenting sign of liver abscess.
The single most reliable laboratory finding is an elevated serum concentration of alkaline phosphatase, which is documented in 70% of patients with liver abscesses.
Other tests of liver function may yield normal results, but 50% of patients have elevated serum levels of bilirubin, and 48% have elevated concentrations of AST. Other laboratory findings include leukocytosis in 77% of patients, anemia (usually normochromic, normocytic) in 50%, & hypoalbuminemia in 33%
A 32 year old health worker came to you for advise regarding vaccination update. He recalls having completed all vaccinations during childhood and has received Hepatitis B vaccination 3 years ago prior to employment. He has also been regularly receiving his yearly inactivated trivalent in[uenza virus vaccine as per company policy. Your best advise is:
a. One dose of Tetanus diphtheria booster every 10 years
b. One dose of Varicella vaccine
c. Two doses of Measles-Mumps-Rubella
d. Three doses of Human papillomavirus vaccine
a. One dose of Tetanus diphtheria booster every 10 years
B and C = already part of immunization during childhood
D= px is > 26yo
A 50-year old diabetic with end-stage renal disease, on hemodialysis, developed S. aureus infective endocarditis. Which among the following strategies in monitoring treatment response is most appropriate for her?
a. Blood cultures taken upon admission and repeated after 3-5 days of antibiotic therapy
b. Blood cultures taken upon admission and repeated 4-6 weeks after antibiotic therapy
c. Blood cultures taken upon admission and repeated daily until sterile
d. Blood cultures taken upon admission and repeated if no significant decrease in size of vegetation after 7 days of treatment
c. Blood cultures taken upon admission and repeated daily until sterile
Since organism is S. aureus, blood cs must be repeated daily until sterile then 4-6 weeks after
In this type of malarial infection, membrane protuberances appear on the erythrocyte’s surface 12-15 hours after the cell’s invasion…
a. Plasmodium falcifarum
b. Plasmodium vivax
c. Plasmodium ovale
d. Plasmodium malariae
a. Plasmodium falcifarum
A 38 year old woman was bitten by a stray cat. After 1 month, she presented with lower extremity weakness. Which of the following is true regarding this type of rabies?
a. Incidence is less than 5% of cases
b. This is an aggressive type with early mortality
c. Hydrophobia and aerophobia are also present
d. GBS should be considered as a differential diagnosis
d. GBS should be considered as a differential diagnosis
The patient presents with lower extremity weakness following a cat bite 1 month prior. This presentation is consistent with paralytic (dumb) rabies, a less common form of rabies that mimics neurological conditions like Guillain-Barré Syndrome (GBS).
Which of the following is true about Coronaviridae?
a. Middle East respiratory syndrome may cause tropical hemorrhagic fever
b. Currently, only three representative strains are known to cause disease
c. Middle East respiratory syndrome has a 15% mortality
d. SARS typically presents with upper respiratory symptoms
a. Middle East respiratory syndrome may cause tropical hemorrhagic fever
Mr Nud , 58 y.o diabetic was admitted to the hospital complaining of left thigh pain. He is treated empirically with Oxacillin IV for Cellulitis. As his admitting physician, you note that the degree of pain appears disproportionate to the amount of overlying cellulitis. After 24 hours the patient developed hypotension, acute kidney injury and evidence of DIC. You requested a CT scan of his left leg which showed a collection of fluid with gas in the deep fascia of his left leg. What changes to the patient’s antibiotic will you make?
a. Discontinue Oxacillin and start Piperacillin/Tazobactam
b. Discontinue Oxacillin and start Piperacillin/Tazobactam and vancomycin
c. Discontinue Oxacillin and start Clindamycin, Ampicillin and Ciprofloxacin
d. Continue Oxacillin and add Clindamycin and Gentamicin
c. Discontinue Oxacillin and start Clindamycin, Ampicillin and Ciprofloxacin
Pain out of proportion –> necrotizing fascitis
A 58 year-old man, known diabetic with poor control, was seen at the ER due to 5 days high grade fever, chills and swelling of the right knee. He denied trauma or any manipulation of the involved knee, but he mentioned that he was taking Methylprednisolone 16mg once daily for his arthritis. Upon examination of the right knee, there was severe pain around the swollen joint with limitation of range of motion. An arthrocentesis was performed and synovial fluid was sent for examination. Which of the following findings will be most consistent with his synovial fluid analysis?
a. Elevated lactate dehydrogenase and total protein
b. 40,000 cell/uL with 70% neutrophils; Negative staining and culture studies
c. Mixed mononuclear and neutrophilic synovial-fluid pleocytosis
d. Granulomatous inflammation
a. Elevated lactate dehydrogenase and total protein
Patients with rheumatoid arthritis have the highest incidence of infective arthritis (most often secondary to S. aureus) because of chronically inflamed joints; glucocorticoid therapy
Specimens of peripheral blood and synovial fluid should be obtained before antibiotics are administered. Blood cultures are positive in up to 50–70% of S. aureus infections but are less frequently positive in infections due to other organisms. The synovial fluid is turbid, serosanguineous, or frankly purulent. Gram-stained smears confirm the presence of large numbers of neutrophils.
Levels of total protein and lactate dehydrogenase in synovial fluid are elevated, and the glucose level is depressed; however, these findings are not specific for infection, and measurement of these levels is not necessary for diagnosis.
48 year old female, is admitted with a 10 day history of moderate to high grade fever with associated RUQ abdominal pain, body malaise, and nausea/vomiting. At the ER, the patient is conscious, coherent, with BP of 110/70, HR 110, RR 22, Temp 38.5 C. Sclerae are anicteric. Abdomen is kat with normoactive bowel sounds with liver edge palpable about 2 cm below the right subcostal area. There is a palpable mass with direct tenderness at the area of the liver. Work up done showed the following: Hgb 148 d/dL, Hct 0.45, WBC 20 x 10 /uL, Platelets 253 x 10 /L INR 0.9/80% activity Albumin 40g/L (nv 35-50), ALT 40 IU/L (nv 5-40) AST 32 (nv 5-40), ALP 250 IU/L (nv 35-130) Ultrasound of the abdomen showed a 9 x 10 cm complex mass on the right lobe of the liver. What is the most common underlying cause of this disease? 3
a. Pelvic infections
b. Pylephlebitis
c. Biliary tract infection
d. Ruptured appendicitis
c. Biliary tract infection
Case is liver abscess which is commonly from an underlying biliary tract infection
70/M currently in the ICU due to severe pneumonia was referred to you due to growth of Candida glabrata in urine CS. What is the treatment of choice?
A. Fluconazole
B. Itraconazole
C. Amphotericin B
D. Anidulafungin
C. Amphotericin B
28/M had 1 week history of fever (Tmax 39C), anorexia and abdominal pain, with the following vital signs – BP 110/70 mmHg, HR 60 bpm, RR 22 cpm, T 38.6C. On PE, he has abdominal tenderness and salmon-colored, blanching, maculopapular rashes on the trunk. Which of the following is TRUE in the diagnosis of his condition?
A. The causative agent can be cultured from punch biopsies of skin lesions
B. Blood culture has a higher diagnostic yield than bone marrow culture
C. Widal test can be used as a screening tool
D. Typhidot can be used to confirm diagnosis
A. The causative agent can be cultured from punch biopsies of skin lesions
28/M construction worker came in due to trismus, myalgia, back pain and dysphagia. He also had an open wound on the left foot after stepping on a rusty nail 1 week ago. Vaccination history is unrecalled. Which of the following is TRUE in the pathogenesis of his condition?
A. The toxin responsible for the disease undergoes retrograde transport to the autonomic nervous system
B. The toxin responsible for the disease is intra-axonally transported to the motor nuclei of the cranial nerves
C. Clinical manifestations only occur after the toxin has reached the postsynaptic inhibitory nerves
D. The toxin responsible for the disease enters the vascular system and is transported at the neuromuscular junction
B. The toxin responsible for the disease is intra-axonally transported to the motor nuclei of the cranial nerves
65/M farmer, with unknown vaccination status, sustained lacerations on his arm 6 days ago. He presented at the ER due to severe muscle spasms, fever, sweating and difficulty breathing. At the ER, he has the following VS: BP 130/90 mmHg, HR 130 bpm, RR 30 cpm, T 38.5C. You are suspecting Tetanus infection. Which of the following factors is associated with poor prognosis?
A. Age of 65 yrs
B. Incubation period of 6 days
C. HR 130
D. RR 30
B. Incubation period of 6 days
Since <7 days
Age >70
HR >140
No RR in poor prognosticators
21/F came in due to 3-day history of fever, headache, retro-orbital pain, myalgia and rashes. Dengue NS1 is positive. Which of the following best describes the rash of dengue?
A. Rash is maculopapular and appears after day 7 of illness
B. Rash begins on the trunk and spreads to extremities and face
C. Rash usually appears before the onset of fever
D. Rash signifies microvascular fragility
B. Rash begins on the trunk and spreads to extremities and face
89/M consulted due to sudden onset red swelling of the face with well-defined margins, accompanied with fever and pain. You are suspecting possible Erysipelas infection. Which of the following describes its presentation and pathogenesis?
A. Flaccid bullae may develop during the first week of illness
B. Desquamation of the involved skin occurs 5-10 days into the illness
C. Onset of symptoms is rapid and commonly extends to deeper tissues
D. Etiologic agent is S. pyogenes and is commonly resistant to Penicillin
B. Desquamation of the involved skin occurs 5-10 days into the illness
19/F underwent spontaneous vaginal delivery at a lying-in clinic 1 week ago. She was rushed to the emergency room due to severe hypogastric pain, fever and vomiting. Her vital signs were: BP 70/40 mmHg, HR 138 bpm, RR 32 cpm, T 37.5C. On physical examination, she has decreased breath sounds on both lung bases, tender abdomen, and bipedal edema. There is no vaginal discharge. Initial CBC showed marked leukocytosis. What is the most likely causative agent in her case?
A. Staphylococcus aureus
B. Streptococcus pyogenes
C. Streptococcus agalactiae
D. Clostridium sordellii
D. Clostridium sordellii
This postpartum patient presents with severe hypogastric pain, fever, vomiting, hypotension, tachycardia, and leukocytosis. The constellation of symptoms, particularly the absence of vaginal discharge and marked systemic signs, strongly suggests Clostridium sordellii toxic shock syndrome (CSTSS), a rare but life-threatening condition associated with postpartum or post-abortion sepsis.
22/M IV drug user presents with sudden onset fever and lower neck pain. On examination, you noted the right sternoclavicular joint to be swollen, warm to touch, erythematous and tender. In the management of his condition, you should also start antimicrobials that will cover for what organism?
A. P. aeruginosa
B. N. gonorrhea
C. S. pyogenes
D. Candida spp
A. P. aeruginosa
This patient presents with sternoclavicular joint septic arthritis, a condition that is rare but more common in intravenous (IV) drug users. The key to effective management is identifying and treating the likely causative pathogens.
25/F with rheumatoid arthritis presents with sudden onset fever, left knee and left ankle pain and swelling. On physical examination, the left knee and left ankle are both swollen, warm to touch and have limitation of motion. Synovial fluid smear showed gram positive cocci in clusters. What empiric antimicrobial therapy should you give?
A. Penicillin
B. Ceftriaxone
C. Cefepime
D. Vancomycin
D. Vancomycin
Cover for mrsa
You are reading a clinical practice guideline stating that ZVL vaccine should be given in precaution in the context of severe illness. As an internist, how would you interpret this?
A. The condition poses a serious adverse reaction to the condition
B. ZVL vaccination is an absolute contraindication to the condition
C. The vaccine may compromise the ability to evoke immune response
D. Paracetamol should be given prior the vaccination to lessen the adverse reaction
C. The vaccine may compromise the ability to evoke immune response
The Zoster Vaccine Live (ZVL) is a live attenuated vaccine used to prevent shingles (herpes zoster) in older adults. In the context of severe illness, the precaution regarding its administration reflects concerns about the immune system’s ability to respond effectively to the vaccine, rather than the risk of a severe adverse reaction.
KL, 30 years old male is currently being managed as MRSA native valve endocarditis. He is being given Vancomcyin at 1gram IV every 12hrs for 5 days now. You requested for Vancomycin trough and peak levels with resultant AUC:MIC of 410. What is the next best step?
A. Increase dose of Vancomycin to 1gram IV every 8hrs and repeat levels prior to 4th new adjusted dose
B. Maintain the current dose of Vancomycin
C. Shift to Daptomycin
D. Repeat Vancomycin trough and peak as the levels are not congruent with the current dose
B. Maintain the current dose of Vancomycin
AUC : MIC of >400 is adequate
RM, 56 years old female breast cancer patient recently received Doxorubicin 1 week ago. She consulted at the ER presenting as fever and chills for 2 days. She had no previous antibiotic use in the last 3 months. Pertinent PE: BP 130/90 HR 108 RR 21 Temp 39C; No cervical adenopathy; Vesicular breath sounds; No murmur; No wound; Pertinent laboratory: CBC Hb 12.1 WBC 1500 Neutrophil 8 Stab 2 Lymphocyte 90 Platelet 161k. What is the next best step?
A. Obtain Blood cultures 2 sites and wait for the result since the fever is likely chemotherapy induced
B. Start Ciprofloxacin plus Vancomycin to cover for both Gram negative and Gram positive organisms
C. Start Ceftazidime for empiric Pseudomonal coverage
D. Start Meropenem for a broader coverage including ESBL producing organism given her comorbidity
C. Start Ceftazidime for empiric Pseudomonal coverage
Which among the following antifungals is recommended for initial empirical treatment coverage for Candida among patients with prolonged fever and neutropenia?
A. Caspofungin
B. Fluconazole
C. Amphotericin B deoxycholate
D. Flucytosine
A. Caspofungin
DA, 45 years old female consulted at your clinic for low grade intermittent fever for 2 months. She was seen by another doctor and was treated as TB lymphadenitis (biopsy granulomatous disease, negative for TB PCR, negative for AFB) with HRZE for 7 weeks now, however her fever is has been present in almost daily despite compliance. Pertinent PE revealed 2x2cm lymphadenopathy on the cervical area. How will you advise the patient?
A. Let’s just continue HRZE for 1 more month
B. Let’s revisit other possible diagnosis aside from TB
C. Let’s discontinue HRZE since TB PCR is negative
D. Let’s start Prednisone on top of HRZE
B. Let’s revisit other possible diagnosis aside from TB
If fever still persists after 6 weeks of anti TB tx , consider other dx
Which among the following modes of transmission of HIV has the highest risk of acquiring the virus per act probability?
A. Receptive anal intercourse
B. Receptive penile vaginal intercourse
C. Blood transfusion
D. Needle sharing during injection drug use
C. Blood transfusion
Which among the following factors is associated with highest risk of mortality among patients with Leptospirosis?
A. Baseline Leukocytosis >10 000
B. Elderly
C. Female
D. Constant exposure with rats
B. Elderly
. JJ, 31 years old male is diagnosed of multiple myeloma on treatment. He came to your clinic complaining of 1 year history chronic cough, fatigue and weight loss. He recently completed a 6 months course treatment for PTB with HRZE/HR with good compliance. On review of his laboratory tests, baseline Sputum TB CS showed Mycobacterium tuberculosis susceptible to isoniazid, rifampin, ethambutol and pyrazinamide; TB PCR was also positive for MTB but no rpo gene detected. Chest CT scan revealed a localized ground glass opacity on the right upper lobe and multiple cavitary lesions on the left upper lobe. What is the most likely differential diagnosis?
A. COVID 19 Pulmonary Infection
B. Pulmonary Cryptococcosis
C. Pulmonary Aspergillosis
D. Drug Resistant Pulmonary Tuberculosis
C. Pulmonary Aspergillosis
This patient, with multiple myeloma, has a history of pulmonary tuberculosis (PTB) successfully treated with a susceptible regimen. His persistent symptoms of chronic cough, fatigue, and weight loss, coupled with CT findings of cavitary lesions and ground-glass opacities, raise suspicion for a secondary fungal infection, particularly chronic pulmonary aspergillosis (CPA).
What is the most common type of amebic infection?
A. Colitis
B. Liver Abscess
C. Genital ulcer
D. Asymptomatic cyst carriage
D. Asymptomatic cyst carriage
RT, 31 years old male is an MSM with recent sexual partner in the last 3 months. He came to your clinic complaining of pink, nonpruritic, discrete macules on the trunk and forearms that later progressed to papular lesions involving the palms and soles in a span of 5 days. He denies any urethral or anal discharge nor any lesions on his penis nor the inguinal area. What serologic test of choice would you request to strengthen your likely clinical diagnosis?
A. NAAT
B. RPR
C. VDRL
D. HSV IgM
B. RPR
RPR (Rapid Plasma Reagin):
A non-treponemal test, it is used for initial screening of syphilis due to its high sensitivity during secondary syphilis (90–100%).
It detects antibodies against cardiolipin-lecithin-cholesterol antigens, which are elevated during active infection.
Positive results should be confirmed with a treponemal-specific test (e.g., FTA-ABS or TP-PA).
Similar to RPR, VDRL is a non-treponemal test. While it can also detect syphilis, RPR is more commonly used for screening due to its ease of performance and rapid turnaround time.
Which statement is true regarding primary bacterial peritonitis?
A. Cause has not been established but hematogenous spread of organisms in a patient with diseased liver is suggested
B. Abdominal pain is the most common clinical manifestation
C. A finding of ascitic fluid WBC >250/uL is diagnostic
D. Carbapenem is a drug of choice for antibiotic naïve individuals
A. Cause has not been established but hematogenous spread of organisms in a patient with diseased liver is suggested
Why other options are wrong
B. Abdominal pain is the most common clinical manifestation –> FEVER
C. A finding of ascitic fluid WBC >250/uL is diagnostic –> PMN
D. Carbapenem is a drug of choice for antibiotic naïve individuals –> 3rd gen cephalosporin
LV, 54 years old male came to the ER complaining of 3 days left upper quadrant abdominal pain. It was associated with nausea, vomiting and fever. BP 150/100 CR 112 RR 24 Temp 39.8C. Whole abdominal CT scan revealed hypodense lesion on the spleen. What additional diagnostic test would you request that would help you rule out a concomitant infection commonly associated with the condition?
A. Spinal MRI
B. 2D Echo
C. Plain Cranial CT scan
D. Urine Culture and Sensitivity
B. 2D Echo
Splenic abscess is associated with endocarditis
Cassandra, a 22-year-old female, presents to the clinic with a two-week history of persistent fever, headache, abdominal pain, and constipation. On further inquiry, she mentions recent travel to Benguet and Mountain Province. Her vital signs include a temperature of 102.5°F (39.2°C). Laboratory investigations reveal a positive Widal test. What is the most effective antibiotic for fully susceptible individual in this case?
A. Ceftriaxone
B. Ciprofloxacin
C. Chloramphenicol
D. TMP-SMX
B. Ciprofloxacin
Fully susceptible –> FQ
A 55-year-old female, presents to the urology clinic with a history of recurrent urinary tract infections and persistent flank pain on the right side. Imaging studies reveal a large, irregular mass involving the right kidney, and a subsequent biopsy confirms the diagnosis of xanthogranulomatous pyelonephritis. What is the next best step in management of xanthogranulomatous pyelonephritis?
A. Nephrectomy
B. High-dose IV antibiotics
C. Percutaneous drainage
D. Intravenous antifungal therapy
A. Nephrectomy
A 37-year-old pregnant patient on 28 weeks AOG came to ER due to fever Tmax 38.3C, chills, dysuria and right flank pain. You decided to request for urinalysis and urine GS/CS. What laboratory findings will likely support your diagnosis?
a. ≥5 WBC/LPF on urinalysis and 105 CFU/mL on urine culture
b. ≥5 WBC/HPF on urinalysis and 104 CFU/mL on urine culture
c. ≥5 WBC/LPF on urinalysis and 104 CFU/mL on urine culture
d. ≥5 WBC/HPF on urinalysis and 105 CFU/mL on urine culture
d. ≥5 WBC/HPF on urinalysis and 105 CFU/mL on urine culture
A 28-year-old female on her 2nd trimester of pregnancy consulted regarding tetanus vaccination during pregnancy. What will you advise her?
a. Tetanus vaccination is contraindicated during pregnancy
b. 2 doses of tetanus toxoid 4 weeks apart
c. 2 doses of tetanus toxoid on third trimester, 6 weeks apart
d. 1 dose of tetanus vaccination now and another dose on or after giving birth
b. 2 doses of tetanus toxoid 4 weeks apart
A 35-year-old pregnant patient on 28 weeks AOG came to ER due to dog bite on her right foot. The wound was deep and bled spontaneously. Based on DOH AO 2018-0013 on the Guidelines on the management of Rabies Exposures, you should give the following intramuscularly as post-exposure prophylaxis.
a. Rabies vaccine and rabies Ig are contraindicated in pregnancy
b. Rabies vaccine until Day 28; Rabies Ig is contraindicated
c. 1 dose rabies Ig and post rabies vaccine until Day 7
d. 1 dose rabies Ig and post rabies vaccine until Day 28
c. 1 dose rabies Ig and post rabies vaccine until Day 7
Both rabies vaccine and Rabies Ig are safe during pregnancy and do not harm the fetus
A 45/M, who was bitten by a dog 2 weeks ago, presented at the ER due to hydrophobia and aerophobia. Primary consideration was rabies infection. Which of the following best describes the pathogenesis of rabies virus in the nervous system?
a. Rabies virus spreads centrifugally along the peripheral nerves via antegrade axonal transport
b. Rabies virus spreads centripetally along the autonomic nerves via antegrade axonal transport
c. Rabies virus spreads centripetally along the autonomic nerves via retrograde axonal transport
d. Rabies virus spreads centripetally along the peripheral nerves via retrograde axonal transport
d. Rabies virus spreads centripetally along the peripheral nerves via retrograde axonal transport
A 20-year-old male who received Rabies Ig and rabies vaccine one month ago went to your clinic inquiring on timing of MMR vaccine. What will you advise regarding the interval of vaccination?
a. 4 weeks after rabies Ig
b. 4 months after rabies Ig
c. 6 weeks after rabies Ig
d. 6 months after rabies Ig
b. 4 months after rabies Ig
A 45-year-old female with history of travel to Sudan consulted due to fever spikes, chills and rigors occurring every 2 days, associated with headache, fatigue and myalgia. Peripheral blood smear was done showing infected young RBCs with black pigment. 22. What is the likely organism involved?
a. Plasmodium falciparum
b. Plasmodium vivax
c. Plasmodium ovale
d. Plasmodium malariae
a. Plasmodium falciparum
Infected young RBCs with black pigment are characteristic of P. falciparum. The black pigment is hemozoin, a byproduct of hemoglobin digestion by the parasite.
An 80/M known with severe aortic stenosis underwent valve replacement surgery. 8 months after, he developed intermittent fever, shortness of breath, easy fatigability, bipedal edema and a new onset 3/6 systolic murmur. What is the most likely etiologic agent?
a. viridans Strep
b. S. aureus
c. Cardiobacterium hominis
d. Coagulase-negative staphylococci
d. Coagulase-negative staphylococci
This patient presents with symptoms suggestive of prosthetic valve endocarditis (PVE), including intermittent fever, shortness of breath, easy fatigability, bipedal edema, and a new systolic murmur, 8 months after valve replacement surgery. The likely etiologic agent depends on the timing of presentation following surgery.
Classification of Prosthetic Valve Endocarditis:
Early PVE:
Occurs within 60 days post-surgery.
Caused primarily by Staphylococcus aureus, coagulase-negative staphylococci, and Gram-negative bacilli due to surgical contamination.
Late PVE:
Occurs >60 days post-surgery (as in this case, 8 months after surgery).
Typically caused by low-virulence organisms like:
Coagulase-negative staphylococci (e.g., Staphylococcus epidermidis): A common cause of late PVE, particularly in prosthetic valves.
Viridans streptococci and HACEK organisms.
A 20/F with history of congenital heart disease underwent repair of ASD when she was a child, with no complications. She consulted for prophylaxis prior to dental tooth extraction. What will you advise her?
a. No need for prophylaxis
b. Take Amoxicillin 2g 1 hour prior to dental procedure c. Take Clindamycin 600mg 1 hour prior to dental procedure
d. Ceftriaxone 1gm IM prior to dental procedure
a. No need for prophylaxis
A 53/M consulted due to right trunk pain along the distribution of T6-T8 dermatome, with no other symptoms. He has unrecalled history of varicella infection. You are still considering herpes-zoster infection. In how many days are rashes expected to appear from onset of pain?
a. in 24 hours
b. in 1-2 days
c. in 2-3 days
d. in 3-5 days
c. in 2-3 days
The onset of disease is heralded by pain within the dermatome, which may precede lesions by 48–72 h; an erythematous maculopapular rash evolves rapidly into vesicular lesions. In the normal host, these lesions may remain few in number and continue to form for only 3–5 days
A 40/M farmer admitted at the Orthopedic unit was referred to you due to fever, severe right leg pain and hypotension. He sustained a right leg fracture due to vehicular accident and underwent ORIF. On physicalexamination, he is in severe pain, and you noted a foul-smelling serosanguineous wound discharge. The right leg also appeared mottled, with brawny color, edematous and with bullous lesions. What is the likely diagnosis?
a. Pyomyositis
b. Clostridial Myonecrosis
c. Acute Osteomyelitis
d. Necrotizing Fasciitis
b. Clostridial Myonecrosis
A 22-year-old commercial sex worker with history of untreated gonorrhea had 10-day history of intermittent fever, chills, and joint pains involving her right elbow, right wrist, left knee and left ankle. Arthrocentesis and synovial fluid aspirate gram stain were done revealing a gram negative intracellular monococci and diplococci. Which of the following is TRUE of this case?
a. Men are at greater risk of acquiring gonococcal arthritis
b. True gonococcal septic arthritis is less common than disseminated gonococcal infection (DGI) and always follows DGI
c. Gonococcal septic arthritis usually involves multiple joints such as hip, ankle, knee or wrist
d. Blood cultures are almost always positive in most cases of gonococcal septic arthritis
b. True gonococcal septic arthritis is less common than disseminated gonococcal infection (DGI) and always follows DGI
A 55/M diabetic with history of nephrolithiasis consulted due to progressive and worsening right flank pain of 3 months duration, now associated with fever, chills, nausea and vomiting. Diagnostics were done including urine CS, blood CS and KUB imaging. Ultrasound showed subcapsular abscess in the right kidney. What is the most likely organism involved?
a. E. coli
b. S. aureus
c. Anaerobes
d. Mixed flora
a. E. coli
Which of the following is NOT part of obligatory tests in management of FUO?
a. Procalcitonin
b. IGRA
c. ESR
d. LDH
a. Procalcitonin
Organisms that are intrinsically resistant to nitrofurantoin
Proteus, Pseudomonas, Serratia, Enterobacter, yeast
PCR for leptospira can confirm dx within __ days of illness
5
What is the diagnostic test that should be requested during immune phase of Leptospirosis
Urine CS
Acute leptospiremic phase 3-10 days
Immune phas coincides with disappearance oof leptospires in the blood
The most frequently encountered organisms in perinephric and renal abscesses are
a. Klebsiella species
b. Escherichia coli
c. Proteus species
d. A and B
e. All of the above
e. All of the above
A patient diagnosed with lepromatous leprosy, started on multibacillary treatment 6 months ago, developed
generalized painful erythematous subcutaneous nodules, some of which are ulcerated with purulent discharge.
There was also note of associated fever, myalgia, arthritis of the knees, and anorexia. Which of the following is
correct about the case?
a. It is characterized by downgrading or reversal reactions
b. Biopsy of the skin lesions will show vasculitis with many lymphocytes and PMNs
c. Foot drop is the most severe complication
d. Histologically becomes tuberculoid as these appeared after initiation of therapy
e. Inflammation of nerves complicates the clinical course
b. Biopsy of the skin lesions will show vasculitis with many lymphocytes and PMNs
Type 2 Lepra reaction
A and C: describes Type 1
The most commonly affected nerves in tuberculoid leprosy include
a. Ulnar
b. Posterior auricular
c. Radial
d. A and B
e. All of the above
d. A and B
ulnar, posterior auricular, peroneal, posterior tibial
A 21-year old college student is brought to the ER with history of high grade fever (39.5-40OC) with chills, headache, body malaise and muscle pains for the last 4 days. He also complains of intermittent abdominal pain and constipation. He has no other co-morbid conditions, no family history of diabetes or hypertension. He has no vices but is fond of eating street foods. Initial PE findings are as follows: BP=110/70, HR=86, RR=24, T=39.8OC Pink conjunctivase, anicteric sclerae, no TPC, no CLAD (+) faint salmon-colored maculopapular rash with blanching over the chest Clear breath sounds, no rales; Good heart sounds, no murmurs Liver edge palpable 5 cms below the right subcostal margin, obliterated Traube’s space, (+) direct abdominal tenderness, no rebound tenderness; full pulses, no edema What laboratory findings is/are consistent with the most likely clinical impression?
a. WBC = 2,500/mm3
b. Negative stool culture
c. Positive culture of punch biopsy of rashes
d. A and B
e. All of the above
e. All of the above
Typhoid fever typically causes leukopenia (low WBC count), unlike most bacterial infections that present with leukocytosis.
While Salmonella typhi is shed in the stool, stool cultures may be negative early in the disease (during the first week). The organism is more reliably detected in blood culture in the first week and in bone marrow culture (which has the highest yield).
“Rose spots” are caused by S. typhi invading capillaries in the skin. A punch biopsy of these lesions can yield a positive culture for the organism.
What is the next appropriate step for the management of typhoid fever in a 28 year old female patient with “fully susceptible” positive culture of Salmonella typhi, initially given azithromyicn as empiric therapy if pregnancy test is positive?
a. Maintain Azithromycin 1 g/d IV for a total of 7 days
b. Shift to Cotrimozaxole 800/160mg BID for 14 days
c. Shift to Ciprofloxacin 500mg BID for 7 days
d. Shift to Amoxicillin 1 g q6h for 14 days
e. Shift to Ceftriaxone 2-3 g IV q24h for 7 days
e. Shift to Ceftriaxone 2-3 g IV q24h for 7 days
Ceftriaxone is the safest and most effective option in pregnancy.
48-year old female patient with prior history of gallstones is admitted for 3 day history of high grade fever and chills. She had complained of nausea, vomiting, and abdominal pain but no diarrhea. She noted appearance of a faint salmon-colored maculopapular rash a day earlier. There were no coughs or urinary symptoms. No history of HTN or DM. VS: BP=130/70; HR=72; RR=20; T=39.8OC No jaundice, clear breath sounds, no murmur (+) crops of salmon-colored blanching maculopapular rashes over the anterior chest. No noted organomegaly. What is the proper approach to the management of this patient after confirming your initial diagnosis?
a. Single course of 1st line IV or PO antibiotic therapy for 7 days will be sufficient
b. Single course of 1st line IV or PO antibiotic therapy for 7 days followed by 4-6 weeks of cotrimoxazole
c. Single course of 1st line IV or PO antibiotic therapy for 7 days followed by 6-12 weeks of cotrimoxazole, schedule for surgery
d. None of these
c. Single course of 1st line IV or PO antibiotic therapy for 7 days followed by 6-12 weeks of cotrimoxazole, schedule for surgery
1st line (CIP) then TMP SMX (6-12 weeks; gallstone is risk for chronic carrier state)
if with anatomic abnormality (biliary / kidney stone): abx + surgery
Which of the following statements is correct regarding the pathogenesis of Severe Dengue
a. Most commonly associated with type 4 serovar
b. Central to the pathogenesis is neutrophil infection
c. Malnutrition increases the risk
d. Females are more commonly affected than males
e. Most patients with shock require platelet transfusion
d. Females are more commonly affected than males
Severe Dengue
- Monocyte infection
- Risk factors: enhancing nonneutralizing antibodies (mother to baby) age (< 12 yo), females, caucasans, type 1 –> 2 > type 4 –> 2, TYPE 2 (most dangerous)
!!!! malnutrition is protective
Which of the following statements is correct about Chikungunya infection
a. Vectors are Anopheline mosquitoes
b. It is caused by a Flaviviridae virus
c. It is a common cause of Hemorrhagic Fever
d. It generally presents with arthritis and rash
e. Thrombocytopenia is generally severe
d. It generally presents with arthritis and rash
Chikungunya
- SS + RNA
- Vector: Aedes aegypti and albopticus
- Similar to dengue but no hemorrhagic fever
- migratory polyarthritis and maculopapular rash (does nodesquamate)
- MILD THROMBOCYTOPENIA
True about the pathogenesis of rabies, EXCEPT
a. Initial viral replication happens within striated muscles at the site of inoculation
b. Virus spreads centripetally to the CNS via the peripheral nerve axoplasm
c. In the CNS the virus replicates almost exclusively at the white matter
d. From the CNS the virus passes centrifugally along the autonomic nerves to other tissues
e. Virus entering the salivary glands replicate in mucinogenic acinar cells
c. In the CNS the virus replicates almost exclusively at the white matter
should be grey matter
Favor a diagnosis of GBS over paralytic rabies
a Lower extremity paralysis
b Fever
c Normal sensory examination
d Bladder dysfunction
e CSF pleocytosis
a Lower extremity paralysis
Paralytic rabies presents with quadriplegia
What is the utility of RDT?
a. Diagnosis of P. vivax and P. malariae in Falciparum-endemic regions
b. Diagnosis of P. malariae in patients who have taken anti-malarial drugs
c. Diagnosis of Falciparum malaria in patients who have taken anti-malarial drugs
d. Risk prognostication of cerebral malaria
e. Risk prognostication of elderly patients with falciparum malaria
c. Diagnosis of Falciparum malaria in patients who have taken anti-malarial drugs
Complications of chronic malaria include which of the following
a. Tropical splenomegaly
b. Nephropathy
c. Burkitt’s lymphoma
d. A and B
e. All of the above
e. All of the above
Which laboratory findings in a patient diagnosed with falciparum malaria indicates poor prognosis?
a. LDH 3-fold elevated from upper limit of normal
b. Serum blood glucose of 70mg/dL
c. Serum creatinine of 200 umoL/L
d. WBC of 15,000/uL
e. Arterial pH of 7.35
d. WBC of 15,000/uL
Since > 12k
a. LDH 3-fold elevated from upper limit of normal –> AST/ALT
b. Serum blood glucose of 70mg/dL –> <40
c. Serum creatinine of 200 umoL/L –> >265
e. Arterial pH of 7.35 –> <7.25
True about schistosoma infections, EXCEPT
a. Most infected individuals have low worm burden
b. Worms generally multiply within human hosts
c. Associated with moderate to high degree of peripheral eosinophilia
d. Granulomatous response to ova is a form of cell-mediated immunity
e. Morbidity and death are primarily associated with intensity of infection and host reactions, and genetics of the parasite and human host
b. Worms generally multiply within human hosts
Maturation only
True about Katayama fever
a. Acute schistosomiasis
b. Serum sickness-like
c. Peripheral blood eosinophilia, lymphadenopathy, hepatosplenomegaly
d. Generally benign
e. All of the above
e. All of the above
What pathologic liver changes can be directly attributed to Schistosomiasis?
a. Presinusoidal portal obstruction
b. Periportal fibrosis
c. Liver cirrhosis
d. A and B
e. All of the above
d. A and B
No cirrhosis in Schistosoma
Early change: hepatomegaly –> correlates with intensity of infection
Due to granumalatous lesions
Presinusoidal obstruction –> portal HTN and splenomegaly
Periportal fibrosis–> Symmers clay pipe stem fibrosis
In which culture specimen/s can Leptospires be isolated earliest within the first week of illness?
a. CSF
b. Blood
c. Urine
d. Nasal secretions
e. Bone marrow
b. Blood
1st week: blood
latter 1st week: CSF
2nd week and beyond: urine
After 10 days –> immune phase –> urine
Which of the following can be reservoir sites of leptospires?
a. Liver
b. Lung
c. Proximal renal tubules
d. Spleen
e. Testes
c. Proximal renal tubules
reservoir: brain, kidney, eyes
Pathogenesis of organ involvement in leptopirosis
a. Interstitial nephritis and tubular necrosis with renal failure contributed by dehydration and altered capillary permeability
b. Severe hepatocellular necrosis
c. Pulmonary inflammation
d. All of the above
a. Interstitial nephritis and tubular necrosis with renal failure contributed by dehydration and altered capillary permeability
B–> focal necrosis only
C–> pulmo hemorrhage
Which of the following statements is true of Weil’s syndrome
a. Onset of illness is similar to anicteric leptospirosis but with earlier occurrence of jaundice, renal and vascular complications
b. Profound jaundice is usually associated with severe hepatic necrosis
c. Most common cause of death is liver failure
d. Renal failure often develops early and within the 1st week of illness
e. Common hemorrhagic complications include GI bleeding and adrenal hemorrhage
a. Onset of illness is similar to anicteric leptospirosis but with earlier occurrence of jaundice, renal and vascular complications
Profound jaundice but no severe necrosis
Renal failure 2nd week of illness
MC death: pulmonary hemorrhage
A 67 year old male retired teacher who has been taking clindamycin for the past 6 days due to a dental infection develops loose watery, non-bloody profuse diarrhea. Sigmoidoscopy revealed rectal mucosa that was hyperemic and friable with multiple discrete yellowish plaques. What is the most appropriate initial management?
a. Stop clindamycin
b. Give loperamide or antispasmodic agents
c. Hydrate
d. A and C
e. ALL
d. A and C
Dont give loperamide since infetious
C diff infection
Tx: stop abx; hydrate
Give oral vanco or MTR
Among patients who develop nephrotoxicity from anti-TB drugs, which of the following medications should be discontinued?
A. Rifampicin and Streptomycin
B. Ethambutol and Pyrazinamide
C. Isoniazid and Rifampicin
D. Rifampicin and Ethambutol
A. Rifampicin and Streptomycin
Which of the following laboratory tests can be used to confirm the diagnosis of leptospirosis with the advantage of early conrmation during the acute leptospiremic phase (first week of illness) before the appearance of antibodies
A. Culture and isolation
B. PCR
C. LeptoMAT
D. LeptoDipstick
B. PCR
Which of the following portends poor prognosis in patients with leptospirosis?
A. High grade fever
B. Non-oliguric acute renal failure
C. Abdominal pain
D. Atrial fibrillation
D. Atrial fibrillation
Altered mental status
Respiratory insuiciency (rales, inltrates)
Hemoptysis
Oliguric hyperkalemic acute renal failure
Cardiac involvement (myocarditis, complete or incomplete heart block, AF)
Which of the following patients with leptospirosis would need acute renal replacement therapy?
A. 34/F with acidosis, pH of 7.31 on ABG
B. 40/M with hyperkalemia, K of 5.3 mEq/L and non-oliguric AKI
C. 30/M with hemoptysis and hypoxemia
D. 28/M, asymptomatic, with creatinine of 2.8 mg/dL
C. 30/M with hemoptysis and hypoxemia
This is an indirect test recommended to confirm the diagnosis of typhoid fever
A. Culture and isolation
B. Polymerase chain reaction
C. Typhidot
D. Widal test
Typhidot
35/M presenting with prolonged fever, headache, diarrhea, and severe dehydration. Thypidot turned out to be positive. Which of the following is the most appropriate antibiotic regimen
A. Amoxicillin 1000 mg PO Q6H x 14 days
B. Cexime 200 mg PO Q12H x 7 days
C. Ceftriaxone 2 g IV Q24H x 14 days
D. Ciprofloxacin 500 mg PO Q12H x 7 days
C. Ceftriaxone 2 g IV Q24H x 14 days
Which of the following is true regarding multidrug resistant typhoid fever?
A. It is defined as strains of Salmonella typhi which are resistant to chloramphenicol, ampicillin, and cephalosporins
B. MDRTF should be suspected if a patient fails to respond after 5 days of appropriate first line therapy
C. Empiric treatment with cefixime is not recommended D. Duration of treatment of 7 days is insufficient for MDRTF.
B. MDRTF should be suspected if a patient fails to respond after 5 days of appropriate first line therapy
Which of the following statements regarding the clinical course of Dengue?
A. Leukopenia is the earliest abnormality in CBC starts in the critical phase
B. Thrombocytopenia is a consequence of plasma leakage
C. Critical phase coincides with defervescence and rise in hematocrit
D. Platelet count generally recovers earlier than WBC count.
C. Critical phase coincides with defervescence and rise in hematocrit
Leukopenia is the earliest abnormality in CBC starts in the febrile phase
Thrombocytopenia precedes signs of plasma leakage
Viremia coincides with the peak of fever and critical phase coincides with defervescence and rise of hematocrit.
Platelet count generally recovers later than WBC count.
33/M is being managed for hypotensive shock from dengue. Initial resuscitation done with 20 mL/Kg of normal saline IV. Patient remained hypotensive and serial CBC showed decreasing hematocrit. What is the next best step in management?
A. Increase rate of IV hydration
B. Start norepinephrine drip
C. Start IV colloid infusion
D. Transfuse packed RBCs
D. Transfuse packed RBCs
What should patients with dengue without warning signs be advised regarding home care?
A. Drink distilled water for hydration
B. Take ibuprofen as needed for arthralgia
C. Take aspirin as needed for fever
D. Watch out for heavy menstrual bleeding
D. Watch out for heavy menstrual bleeding
Which of the following is true regarding the duration of treatment of pneumonia?
A. Most bacterial pneumonias can be treated for 7 to 10 days
B. Pneumonia from MRSA without bacteremia can require up to 21 days of treatment
C. Mycoplasma pneumonia is treated for 10 to 14 days
D. Legionella pneumonia is treated for 10 to 14 days
C. Mycoplasma pneumonia is treated for 10 to 14 days
Which of the following is a risk factor for HAP?
A. Lower abdominal surgery
B. Decreased gastric pH
C. Elevation of head at 30 degrees
D. Nasogastric tube without active drainage
D. Nasogastric tube without active drainage
What Plasmodium species is known to cause quartan malarial nephropathy
A. Plasmodium vivax
B. Plasmodium falciparum
C. Plasmodium ovale
D. Plasmodium malariae
D. Plasmodium malariae
P. falciparum is the predominant species in the Philippines and is responsible for almost all deaths and neurologic
complications from malaria
P. vivax causes benign tertian malaria
The correct answer is:
Plasmodium malariae
Which of the following portends a poor prognosis in severe falciparum malaria
A. 35/M with glucose level of 60 mg/dL
B. 32/F with serum lactate of 5.2 mmol/L
C. 75/F with mild agitation
D. 27/M with platelet count of 75,000/microliter
B. 32/F with serum lactate of 5.2 mmol/L
67/M with known alcoholic liver cirrhosis is admied for a 5-day history of fever, abdominal pain and increasing jaundice and abdominal girth. He is febrile, tachycardic and tachypneic. He has icteric sclerae, decreased breath sounds on bilateral lung elds with crackles. His abdomen is warm and mildly tender abdomen. He has Gr 3 bipedal edema. Diagnostic paracentesis was performed. Ascitic fluid PMN = 350/uL. Other diagnostics revealed Crea 120 micromol/L, BUN 28 mg/dL, Na 123 mmol/L, INR 1.8, Bilirubin 3 mg/dL. What is the most appropriate management for the patient?
A. Empiric anaerobic coverage
B. Empiric coverage for Gram positive cocci and Gram negative aerobic bacilli
C. Albumin infusion after 6 hours of diagnosis to prevent complications
D. Renal replacement therapy
B. Empiric coverage for Gram positive cocci and Gram negative aerobic bacilli
Which of the following is true regarding intraabdominal abscess?
A. Medical management is the mainstay therapy for intraabdominal abscesses
B. Splenic abscesses are much more common than liver abscesses.
C. Defervescence can be expected 48 hours after percutaneous drainage of intraabdominal abscesses.
D. The most important risk factor for developing perinephric abscess is diabetes mellitus
C. Defervescence can be expected 48 hours after percutaneous drainage of intraabdominal abscesses.
Drainage is the mainstay therapy for intraabdominal abscesses
Splenic abscesses are much lesscommon than liver abscesses.
Defervescence can be expected 48 hours after percutaneous drainage of intraabdominal abscesses.
The most important risk factor for developing perinephric abscess is obstructing urolithiasis.
What is the recommended duration of antibiotic therapy for foot osteomyelitis in which the removal of dead bone cannot beachieved?
A. 4 weeks
B. 6 weeks
C. 8 weeks
D. 12 weeks
D. 12 weeks
20/M went to the ED because of a dog bite. Patient has stable vital signs and the bite wound has no signs of infection. Patient has a documented penicillin allergy. He was given anti-rabies vaccine. Which of the following is an appropriate antibiotic regimen for the patient?
A. Ampicillin-Sulbactam 1.5 g IV Q6H
B. Doxycycline 100 mg PO BID
C. Clindamycin 600 mg IV Q8H plus Ciprofloxacin 400 mg IV Q12H
D. Co-amoxiclav 1 g PO BID
B. Doxycycline 100 mg PO BID
This is the primary treatment for necrotizing fasciitis caused by mixed aerobes and anaerobes
A. Clindamycin + Penicillin G
B. Clindamycin + 1 generation cephalosporin
st
C. Clindamycin + Ampicillin + Ciprofloxacin
D. Vancomycin + Metronidazole + Ciprofloxacin
C. Clindamycin + Ampicillin + Ciprofloxacin
Clindamycin + Penicillin G is the primary treatment for necrotizing fasciitis caused by group A streptococci. Clindamycin + 1 generation cephalosporin is the alternative.
Vancomycin + Metronidazole + Ciprofloxacin is the alternative treatment for necrotizing fasciitis from mixed aerobes and anaerobes.
Which of the following are true regarding laboratory diagnosis of acute uncomplicated pyelonephritis?
A. Urinalysis shows pyuria of >5 WBC/lpf
B. Urine culture shows at least 100,000 cfu/mL of any bacteria
C. Blood cultures are not routinely recommended except in patients with sepsis
D. Procalcitonin, mid-regional pro-ANP, or CRP have adjunctive roles in determining need for admission and predicting adverse outcomes
C. Blood cultures are not routinely recommended except in patients with sepsis
Urinalysis shows pyuria of >5 WBC/hpf
Urine culture shows at least 100,000 cfu/mL of uropathogens.
Blood cultures are not routinely recommended except in patients with sepsis
Procalcitonin, mid-regional pro-ANP, or CRP are not useful in determining need for admission and predicting adverse
outcomes
Which of the following regimens is appropriate for complicated UTI
A. Ciprofloxacin 500 mg BID x 7-14 days
B. Co-amoxiclave 625 mg TID x 7-14 days
C. Both A and B are appropriate
D. Neither A nor B are appropriate. Treat complicated UTI only with parenteral regimens
C. Both A and B are appropriate
36/M presented with painless nontender indurated penile ulcer with bilateral inguinal lymph node enlargement. Rapid serologic test for syphilis was negative. What is the most appropriate next step?
A. Retest and treat for syphilis if positive
B. Consider alternative diagnoses
C. CSF testing for neurosyphilis
D. HIV testing and counseling
D. HIV testing and counseling
Presumptive therapy must be initiated based on risk prole even without diagnostic results
CSF analysis for neurosyphilis is recommended for PLHIV with any stage of syphilis
HIV testing and counseling is recommended for all patients with genital ulcers.
This is the most common manifestation of pulmonary disease among PLHIVs
A. Bacterial pneumonia
B. Pulmonary tuberculosis
C. Pneumocystis pneumonia
D. Influenza pneumonia
A. Bacterial pneumonia
Which of the following is true regarding Immune reconstitution inflammatory syndrome (IRIS)?
A. Unmasking IRIS involves worsening of a known preexisting infection or neoplasm
B. It occurs days to weeks following initiation of antiretroviral therapy
C. It is more common among PLHIVs with CD4 counts above 50 per microliter who experience a precipitous drop in viral load
D. It is frequently seen in the seing of tuberculosis, when ART is started soon after TB therapy
D. It is frequently seen in the seing of tuberculosis, when ART is started soon after TB therapy
ParadoxicalIRIS involves worsening of a known preexisting infection or neoplasm
It occurs weeks to months following initiation of antiretroviral therapy
It is more common among PLHIVs with CD4 counts below 50 per microliter who experience a precipitous drop in viral load
65/M admied for trismus, myalgia, stiness and back pain. His wife recalls that less than a week ago he sustained a deep laceration on his left leg after falling. He aempted to clean the wound site but did not seek consult due to nancial constraints. At the ED, vitals are as follows: BP 130/80, HR 118, RR 20, afebrile. He is awake and not in distress, notable on examination is trismus and spastic tone on all extremities. Which of the following is recommended for diagnosis?
A. Clinical findings
B. C. tetani culture
C. PCR
D. Anti-tetanus IgG titer
A. Clinical findings
Diagnosis of tetanus is clinical.
Treatment should not be delayed while laboratory tests are conducted
Culture of C. tetani from a wound provides supportive evidence
Serum anti-tetanus immunoglobulin G also may be measured in a sample taken before the administration of antitoxin or immunoglobulin
Polymerase chain reaction also has been used for detection of tetanus toxin, but its sensitivity is unknown
A 28/M came to the ED after sustaining multiple injuries after a car crash. He is unable to recall when he was last vaccinated for tetanus. How should this patient be managed best?
A. TIG only
B. Tetanus toxoid only
C. TIG + Tetanus toxoid
D. Thorough wound cleaning only
C. TIG + Tetanus toxoid
Which of the following is a bundled intervention to prevent surgical site infections?
A. Remove hair around the surgical site ahead of the procedure
B. Prepare the surgical site with povidone-iodine solution
C. Prophylactic antibiotics an hour prior to surgery, discontinue within 24 hours
D. Treat latent infections preoperatively
C. Prophylactic antibiotics an hour prior to surgery, discontinue within 24 hours
HPV vaccine is contraindicated in patients with immediate hypersensitivity to what substance?
A. Gelatin
B. Yeast
C. Neomycin
D. Latex
B. Yeast
Same goes with HBV
Which of the following is true regarding the influenza vaccine
A. It is available as the bivalent inactivated and quadrivalent inactivated vaccines
B. Single 0.5 mL dose is given subcutaneously
C. The recombinant vaccine is not recommended in PLHIV with CD4 count <200
D. The Southern hemisphere strain is recommended in the Philippines
D. The Southern hemisphere strain is recommended in the Philippines
Available as trivalent and quadrivalent
Given intramuscularly
Recommended for PLHIV regardless of CD4 count
Which of the following organisms is the most common cause of monomicrobial community-acquired pyogenic liver abscess?
A. Bacteroides fragilis
B. Enterobacter cloacae
C. Escherichia coli
D. Klebsiella pneumoniae
D. Klebsiella pneumoniae
Which of the following is a well-recognized factor/condition predisposing to hematogenously disseminated candidiasis
A. Thoracic surgery
B. Thrombocytopenia
C. External urinary catheter
D. Oral glucocorticoids
A. Thoracic surgery
33/F from Samar is admitted for abdominal enlargement, noted to have hepatosplenomegaly and ascites. Stool microscopy showed ova with a terminal spine. What is an appropriate drug treatment for this patient?
A. Praziquantel 40 mg/Kg PO in 2 divided doses x 1 day
B. Praziquantel 60 mg/Kg PO in 3 divided doses x 1 day C. Praziquantel 25 mg/Kg PO TID x 3 days
D. Triclabendazole 10 mg/g PO single dose
A. Praziquantel 40 mg/Kg PO in 2 divided doses x 1 day
S. haematobium
B is for S. japonicum and mekongi
Which of the following is true regarding filariasis?
A. Lymphedema is caused by obstruction of afferent lymphatics, sinuses, and nodes by live adult worms
B. Diethylcarbamazine is recommended for treatment
C. Culex mosquitoes serve as the vector for Brugia malayi
D. Adult Wuchereria bancrofti worms are found in subcutaneous tissue
B. Diethylcarbamazine is recommended for treatment
Lymphedema is caused by granulomatous host response to non-viable adult worms
Mansonia and Anopheles mosquitoes serve as the vector for Brugia malayi
Adult Wuchereria bancrofti worms are found in lymphatic tissue
What is required to make the diagnosis of amebic colitis?
A. Sigmoidoscopy with biopsy
B. Serologic tests
C. Demonstration of Entamoeba histolytica cysts
C. Demonstration of Entamoeba histolytica cysts
What is the drug of choice for asymptomatic carriage of Entamoeba?
A. Iodoquinol
B. Metronidazole
C. Tinidazole
D. Albendazole
A. Iodoquinol
Which of the following is true regarding the diagnosis of rabies?
A. Patients present with acute atypical encephalitis or spastic paralysis.
B. Hydrophobia is usually present
C. Skin biopsy samples from the bite site is diagnostically useful
D. Tests may need to be repeated after an interval for diagnostic confirmation
D. Tests may need to be repeated after an interval for diagnostic confirmation
Patients present with acute atypical encephalitis or flaccid paralysis
Hydrophobia is not usually present
Skin biopsy samples from the neck is diagnostically useful
Tests may need to be repeated after an interval for diagnostic confimation
This is the most common form of botulism reported in many countries
A. Foodborne botulism
B. Wound botulism
C. Infant botulism
D. Adult intestinal botulism
A. Foodborne botulism
A patient with sepsis is given crystalloid IV but the blood pressure remains low, which of the following is the next best management?
A. Norepinephrine drip
B. Passive leg raids to assess volume status
C. Give more crystalloid fluid
D. Measure serum lactate
B. Passive leg raids to assess volume status
The 1-hour bundle of care for sepsis includes:
A. Crystalloid bolus at 20 mL/Kg
B. Measure serum lactate and remeasure if initial is >4 mmol/L
C. Blood culture before antibiotic administration
D. Early vasopressors for first episode of hypotension
C. Blood culture before antibiotic administration
Which of the following is not particularly used in the treatment of Mycobacterium avium complex infections?
A. Isoniazid
B. Rifampicin
C. Azithromycin
D. Ethambutol
A. Isoniazid
