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Internal Medicine Boards 2018 > Infectious Disease > Flashcards

Infectious Disease Flashcards

First Aid and NEJM Knowledge +

1
Q

Location of abnormal signal for meningitis 2/2

(a) HSV-1
(b) Tb

A

(a) Temporal lobes

(b) Basilar

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2
Q

Causes of persistent CSF pleocytosis:

lymphocytic vs. neutrophilic

A

Chronic meningitis most likely to be lymphocytic: weeks duration of elevated CSF white count

Lymphocytic- 40% Tb, atypical mycobacteria, cryptococcus 7% (HIV+ pts get cryptococcus meningitis), coccidio, histo, blasto

Neutrophilic- less common- nocardia, actinomyces, aspergillus, candida, SLE

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3
Q

Causes of persistent CSF eosinophilic pleocytosis

A

Coccidio, parasites, lymphoma, chemical agents

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4
Q

Mollaret’s syndrome

A

Recurrent HSV-2 meningitis

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5
Q

Bugs responsible for aseptic meningitis

fall vs. spring

A

Aseptic meningitis- typically viral w/ benign course

Late summer/early fall: enteroviruses (coxsackie) and arboviruses (arthropod-borne = eastern/western equine, St Louis)

Spring: mumps

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6
Q

What drugs typically can cause medication-induced aseptic meningitis

A

TMP-SMX, IVIG, NSAIDs, carbamazepine

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7
Q

Most common bugs that cause bacterial meningitis

(a) 18-50 yoa
(b) Over 50 yoa
(c) HIV
(d) Post-neurosurgical

A

Bacterial meningitis

(a) Typical adults: Strep pneumo and neisseria meningitis
(b) Over 50: S. pneumo, listeria monocytogenes, GN bacilli
(c) HIV: S. pneumo, listeria, GN bacilli (pseudomonas)
(d) Post-neurosurgical: S. pneumo then staph aureus, also GN bacilli

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8
Q

Empiric abx for bacterial meningitis in

(a) Typical adult
(b) Adult over 50
(c) HIV
(d) Post neurosurgical

A

(a) CTX, vanc
(b) CTX, vanc, ampicillin
(c) Ceftazidime (pseudomonal coverage), Vanc, Ampicillin
(d) Ceftazidime and Vanc

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9
Q

When to use steroids during empiric tx of meningitis

A

IV Dex 10mg q6h for 2-4 days when bacterial meningitis suspected due to Strep pneumo

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10
Q

CSF findings of traumatic tap

A

Expect some more cells

Correction factor: expect 800 RBCs per 1 WBC, expect 1mg protein per 1000 RBCs

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11
Q

Causes of CSF studies with

(a) Low glucose
(b) PMNs vs. lymphocytes

A

CSF studies

a) Low glucose: bacterial, fungal (Tb
(b) PMNs = bacterial
lymphocytic = fungal, viral

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12
Q

Who gets meningitis prophylaxis?

A

Rifampin for roommates, cellmates, close to respiratory secretions (ET tube, kissing, sharing utensils) within the last 7 days for suspected neisseria meningitis

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13
Q

CSF of bacterial vs. fungal meningitis

A

Bacterial- neutrophils
Fungal- lymphocytes

Then both w/ low glucose, high protein, high opening pressure (above 20)

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14
Q

List causes of chronic meningitis + cranial nerve palsy

A
  • Lyme disease
  • Syphilis
  • Sarcoid (CN VII = Bell’s)
  • Tb (CN VI)
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15
Q

Encephalitis plus causes

(a) plus flaccid paralysis
(b) plus rash

A

Encephalitis (headache, fever, nucchal rigidity PLUS focal neurologic sign)

(a) encephalitis preceded by flaccid paralysis in West Nile virus b/c it infects the anterior horn cells
(b) See a rash in VZV encephalitis (zoster rash), Lyme (targetoid), RMSF

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16
Q

Most common causes of encephalitis in the US

(a) Whichcarries the highest mortality

A

HSV and arboviruses (arthropod aka mosquito-borne): West Nile

(a) HSV encephalitis- mortality of 70%

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17
Q

Typical causes of encephalitis in

(a) Summer
(b) Fall
(c) Winter

A

Encephalitis bugs

(a) Summer- think tick-borne = Lyme, RMSF, Ehrlichiosis
(b) Fall- think mosquito/arthropod borne (arboviruses) = West Nile, east equine, west equine, St. Louis virus
(c) Winter- measles, mumps

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18
Q

Compare bugs that cause infective endocarditis of

(a) native valve
(b) prosthetic valve
(c) valve in IVDU

A

Infective endocarditis

(a) Native valve- Strep viridans, other strep. Then S. aureus and enterococcus
(b) Prosthetic valve- Staph epi, Staph aureus
(c) Staph aureus

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19
Q

Bacteremia of which 2 bugs should spark workup for GI pathology (search for colon CA)

A

Strep bovis

Clostridium septicum

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20
Q

What is marantic endocarditis

A

Nonbacterial thrombotic endocarditis = Marantic endocarditis = Libman-Sacks endocarditis

  • noninfectious endocarditis due to deposition of thrombi on heart valves
  • seen mostly in cancer and SLE
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21
Q

Libman-Sacks endocarditis

A

Libman-Sacks endocarditis = specific kind of noninfectious endocarditis seen in SLE due to autoantibodies against heart valves

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22
Q

Duke’s criteria

A

For diagnosing infective carditis: 2 major, 1 major w/ 3 minor, or 5 minor

Major criteria:

  • new regurg murmur
  • new oscillating vegetation on TTE
  • BCx w/ typical organism

Minor criteria:

  1. Fever
  2. Predisposing condition: prosthetic valve, IVDU, valvular heart disease
  3. BCx w/ atypical organism
  4. Embolic phenomenon: Janeway lesion, pulm or intracranial infarcts, conjunctival hemorrhage
  5. Immunologic phenomenon: Osler nodes, glomerulonephritis, Roth spots
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23
Q

Indications for surgery in endocarditis

A
  • Vegetation causing conduction abnormality: AV dissociation, new LBBB, PR prolongation (suggestive of abscess)
  • Intractable HFrEF
  • Fungal
  • Recurrence of fever after 5 days of abx
  • Persistent bacteremia
  • Most cases of prosthetic valve
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24
Q

Empiric abx tx of

(a) native valve endocarditis
(b) prosthetic valve endocarditis

A

(a) Native valve endocarditis: cover strep viridans, other strep, then staph and enterococcus: vanc!
(then narrow to nafcillin)

(b) Prosthetic valve endocarditis: Staph epi, staph aureus: vanc, gent (used for synergy against enterococci), and cefepime (pseudomonal coverage)

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25
Q

EEG findings of

(a) Encephalitis
(b) Specifically HSV encephalitis

A

(a) Diffuse slowing of brain waves

(b) Characteristic slow wave (2-3 Hz) complexes classically localizing to temporal lobes

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26
Q

Name the HACEK organisms

A 
Haemophilus 
Actinobacillus 
Cardiobacterium 
Eikenella 
Kingella
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27
Q

Non-bacterial causes of infective endocarditis in IVDU

A

Aspergillus, candida

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28
Q

Which populations require abx ppx for dental procedures?

A

Prosthetic heart valve

H/o infective endocarditis

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29
Q

For ppl w/ history of infective endocarditis, for which procedures are prophylactic abx recommended?

A

Prosthetic heart valve or history of endocarditis: get ppx abx x1 for dental procedures, infected MSK or skin stuff (abscess I&D), incision into respiratory mucosa (tonsillectomy, transbronchial biopsy)

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30
Q

Potential UA findings in infective endocarditis

A

Immunologic sequelae = Osler nodes, kidney deposits causing glomerulonephritis

UA with microscopic hematuria and RBC casts

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31
Q

Definition of FUO

A

Fever of unknown origin: T of at or over 100.9F for 3 or more weeks
-so it’s the fever cuttoff and the duration (3 weeks)

w/ etiology not diagnosed after a certain amount of outpatient visits/hospitalizations

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32
Q

3 buckets for etiology of FUO

A
  1. Infectious- Tb, endocarditis, abscess
  2. Neoplastic- Leukemia, lymphoma
  3. Autoimmune- Adult Still’s disease, cryoglobulinemia, SLE, polyarteritis nodosa
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33
Q

Mononucleosis

(a) Name 3 indications for steroids in acute mono
(b) Serum test
(c) Characteristic lab finding

A

Mononucleosis

(a) Tonsillar obstruction of airway, thrombocytopenia, autoimmune hemolytic anemia
(b) Heterophile antibody
(c) Peripheral smear- atypical lymphocytes (reactive T-lymphocytes w/ large eccentric nuclei) seen in 70% of cases

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34
Q

Etiology of osteomyelitis

(a) sternoclavicular joint of an IVDU
(b) HIV pt
(c) Sickle cell disease
(d) Human bite
(e) prosthetic joint

A

Bug causing osteo- overall most common is staph aureus

(a) in sternoclavicular joint of IVDU- pseudomonas for some reason
(b) HIV pt- Tb, Bartonella
(c) SCD- salmonella
(d) Human bite- eikenella
(e) Prosthetic joint or post-op infection: coagulase negative staph = staph epi and staph saprophyticus

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35
Q

Key ways to distinguish cystitis and pyelo

A

Fever and WBC casts present in pyelo

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36
Q

Lab descriptors to differentiate staph species

A

Gram positive cocci

Catalase positive = staph (vs catalase negative strep)

  • GPCs, catalase positive, coagulase positive = Staph aureus (errrrything positive)
  • GPCs, catalase positive, coagulase negative (‘coag-negative staph’) = staph epi, staph saprophyticus
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37
Q

Plain film findings of osteomyelitis

A

Osteo on Xray: can initially be normal then developing about 2 weeks after infection: bony erosions or periosteal elevation

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38
Q

What kind of UTI is proteus known for?

A

Proteus = urase-producing (so is pseudomonas) so it causes struvite stone obstruction causing pyelo

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39
Q

Management of intrarenal abscess vs. perinephric abscess

A

Intrarenal abscesses comes from infection of a renal cyst- typically are small (below 5cm) and can be management w/ abx alone

while perinephric abscesses require perc or surgical drainage

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40
Q

Lab descriptors to differentiate strep species

A

Gram positive cocci

Catalase negative = strep (vs. catalase positive staph)

  • Beta-hemolytic = GAS (strep pyogenes) and GBS (Strep agalactiae)
  • Alpha-hemolytic = Strep pneumo (optochin pos) and Strep viridians (optochin neg)
  • Non-hemolytic, catalase negative GPCs = E. fecalis, E fecium
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41
Q

24 y/oF returned 2 weeks ago from Thailand, now has fever and night sweats x4 days. No GI complaints, rashes, freshwater exposure

Most likely diagnosis

A

(a) Malaria! Most dangerous species is plasmodium falciparum- most likely here b/c of rapid onset (about 1 week after travel, while other plasmodium species have dormant liver stages
- Ddx given fast onset also includes dengue but would expect prominent myalgias/arthralgias

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42
Q

Malaria

(a) Lab results that support the diagnosis
(b) Lab test to confirm

A

(a) Low H/H b/c of RBC lysis

(b) Thick and thin smear showing P falciparum “banana shaped gametocytes” inside RBCs

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43
Q

Malaria treatment

A

Malaria tx depends on species

  • P. malariae: chloroquine only
  • P. vivax and P. Ovale are “very old”: have dormant liver stage (hypnozoites) that can present months of years after exposure: tx with chloroquine then also primaquine to eradicate chronic liver stage

-Plasmodium falciparum is the most dangerous- assume chloroquine resistance and tx w/ quinine plus doxy (or atovaquone/proguanil)

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44
Q

Places that travelers should get malaria ppx for travel to

A

SE Asia (Thai-Cambodia), sub-Saharan Africa

Central America, Haiti, parts of Middle East

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45
Q

Primaquine

(a) Main use
(b) Main contraindication

A

(a) Antimalarial
Primaquine- add to chloroquine for eradication of dormant liver stage of Plasmodium vivax and ovale

(b) G6PD deficiency- b/c can lead to severe hemolytic anemia

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46
Q

Primaquine

(a) Main use
(b) Main contraindication

A

(a) Antimalarial
Primaquine- add to chloroquine for eradication of dormant liver stage of Plasmodium vivax and ovale

(b) G6PD deficiency- b/c can lead to severe hemolytic anemia

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47
Q

Drug ppx for malaria

A

Chloroquine for central America, Haiti, parts of Middle East

SE Asia (Thai/Cambodia border): doxy or atorvaquone/proguanil b/c resistance is common

Mefloquine or atovaquone/proguanil for everywhere else

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48
Q

Why bactrim alone is sufficient for an abscess post I&D but isn’t sufficient for cellulitis

A

Abscess- really staph
But when cellulitic (surrounding erythema): need to also cover for strep pyogenes => need a beta-lactam (PCN or cephalosporin) => add keflex

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49
Q

Illness script for pertussis

(a) Treatment

A

Pertussis: severe and persistent paroxysmal coughing episodes after initial fever and nasal congestion
-can be prolonged cough in vaccinated

(a) Azithro

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50
Q

2 MC pathogens causing post-influenzal PNA

A

Strep pneumo and staph aureus

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51
Q

Centor criteria

A

For diagnosing strep throat

4 things: 3 or more means should test

  1. fever
  2. tender cervical lymphadenopathy
  3. tonsillar exudate
  4. absence of cough
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52
Q

34 y/o w/
atypical PNA
targetoid lesion rash
mild hemolytic anemia

(a) Dx
(b) Tx

A

(a) Mycoplasma PNA
causes IgM cold agglutinin hemolytic anemia
Targetoid lesion rash- erythema migrans that can even involve hands and feet

(b) Tx w/ azithro

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53
Q

49 y/o w/ chlamydial urethritis

Tx

A

Tx for nongonococcal urethritis = azithro (1g PO x1)

While if have gonorrohea: that’s when treat for co-existing: so if have gonorrhea give CTX x1 and azithro x1

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54
Q

What degree of induration is considered positive for a TST?

A

Tuberculin skin test

5mm or more in immunocompromised (HIV) or recently exposed
10mm or more if recently (within 5 yrs) immigrated from Tb endemic area
15mm or more positive for everyone else

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55
Q

Ways to reduce risk of C. Diff recurrence

A

No antacids

Take probiotics if need another course of non-C. Diff abx

56
Q

Tx regimens for first recurrence of C. Diff

A

If treated w/ flagyl- give PO vanc

If first one treated w/ vanc- give prolonged and tapered course of pulsed PO vanc or fidoxomicin

57
Q

Presentation of strongyloides

(a) Normal
(b) Immunocompromised

A

Strongyloides = parasitic worm

(a) In immunocompetent: vague epigastric pain, nausea, bloating, diarrhea (vague GI complaints)

(b) HIV, chronic steroids, organ transplant: hyperinfection (autoinfection) = dissemination
worms leave GI tract and invade lungs (=> cough/hemoptysis) etc

58
Q

Places where strongyloides is endemic

A

Warm climates

SE US
Africa, Asia
Carribean
Central America

59
Q

Explain mechanisms of complications of strongyloides

(a) SBO/ileus
(b) bacteremia/meningitis
(c) hemoptysis

A

Strongyloides = parasitic worm

(a) Can reproduce in the small intestines => high worm burden which can lead to SBO/ileus
(b) Tracking of enteric bacteria (gram negative rods, enterococci) => bacteremia/meningitis
(c) Disseminated/hyperinfection (in immunocompromised): worms leave GI tract to lungs

60
Q

How to diagnose strongyloides?

(a) Who to expect eosinophilia in?

A

Strongyloides = parasitic worm that reproduces in small intestines and can spread to lungs
Diagnose with stool O&P
Serology if needed

(a) See eosinophilia in immunocompetent (not in the immunocompromised who get the hyperinfection)

61
Q

Tx for strongyloides

A

Strongyloides = parasitic worm that replicates in small intestines and can spread to lungs

Treat with anti-helmiths = thiabendazole, albendazole, ivermectin

62
Q

Lab tests for evaluation of traveler w/ eosinophilia

A
  • Thick and thin blood smear for malaria
  • BCx for typhoid fever (salmonella typhi) and meningococcus
  • Stool culture and O&P
63
Q

Entameoba histolytica

(a) Clinical presentation
(b) Dx
(c) Tx

A

Entameoba histolytica = amebiasis

(a) Presents w/ bloody diarrhea
(b) Diagnose w/ stool microscopy
(c) Tx flagyl then paromomycin to eradicate stool cysts
- Don’t need to drain liver abscess!!!

64
Q

Management of amebiasis w/ liver abscess

A

Don’t need to drain! good enough to treat entameoba histolytica with flagyl then paromomycin to eradicate stool cysts

65
Q

Illness script for Dengue fever

A

Dengue fever = “break-bone” fever: acute onset (5-7 days within travel) fever, myalgias, arthralgias, retroorbital ehadache followed by several weeks of fatigue

66
Q

Illness script for Typhoid fever

A

Typhoid fever = enteric fever
step wise onset of high fever (over 3 weeks) and fatigue, vague abd pain
typical rose spot rash

67
Q

Typhoid fever

(a) How to diagnose
(b) Tx

A

Typhoid fever

(a) Diagnose with blood cultures growing salmonella typhi, but often empirically treated
- high suspicion in traveler returning 5-21 days ago w/ fever for more than 3 days and GI symptoms

(b) Floroquinolones- Cipro, levofloxacin

68
Q

Feared complication of typhoid fever

A

Intestinal perf => secondary bacteremia => overwhelming bacteremia causing death

69
Q

Swimmer’s Itch

A

Swimmer’s itch = itchy/pruritic rash at site of acute schistosomiasis infection where fluke entered the body

hypersensitivity rxn to blood fluke at site of entry

itchy rash after swimming in fresh water

70
Q

What is Katayama fever?

A

Katayama fever = acute schistosomiasis syndrome
immunologic rxn to the organism occurring 4-8 weeks after exposure
fever, myalgias, dry cough, diarrhea, diffuse lymphadenopathy and HSM

71
Q

Infectious diseases to consider for fever after

a) Travel within 21 days
(b) Longer incubation periods (fever onset after 21 days from travel

A

Fever in traveler

(a) Short incubation period: typhoid fever, plasmodium falciparum (worst species of malaria), dengue fever
Leptospirosis, rickettsial illness, meningococcemia

(b) Longer incubation period: non-falciparum malaria, Tb, hepatitis, amebic liver abscess, acute HIV, brucellosis

72
Q

Tx of

(a) Dengue fever
(b) Typhoid fever

A

Tx of

(a) Dengue fever- acute onset fever few days after travel with myalgias/arthralgias and headache (break-bone fever)
supportive tx

(b) Typhoid fever due to salmonella typhi => treat with floroquinolones (cipro, levaquin)

73
Q

Asplenic pateints

(a) What vaccines do they need?
(b) When to give these vaccines

A

Asplenia- at risk for infection w/ encapsulated organisms = S. pneumo, N. meningitis, H. influenza B

(a) S. pneumo, meningitis, and HIB vaccines
(b) Either 2 weeks before elective splenectomy or 2 weeks after procedure

74
Q

Who gets abx ppx post-splenectomy?

(a) With what?

A

Children post-splenectomy get ppx PCN or amoxicilin until age 5 or for at least one year post-splenectomy

75
Q

When does acute HIV present?

(a) When do Ab turn positive?

A

Acute HIV presents 2-6 weeks after exposure

(a) Takes 1-3 months (really 3 months to be sure) for Ab to be positive

76
Q

2 approved tests for diagnosis of acute HIV

A

Diagnosing acute HIV (before 3 months where antibodies aren’t reliably positive)

  1. HIV viral load
  2. p24 antigen
77
Q

Name all ppx drugs someone with HIV and CD4 under 50 should be on

A

HIV pt ppx:

bactrim under 200 for PCP ppx, also bactrim when under 100 and +toxo IgG for toxoplasma encephalitis ppx (but should already be on it)

then add azithro when under 50 for MAC ppx

78
Q

Describe the three drug regimen for HAART

A

3 drug regimen: 2 nucleoside analogs (AZT, abacavir, tenofovir, emtricitabine) then plus one of the following

  • non-nucleoside analog: nevirapine, efavirenz
  • protease inhibitor = fosamprenavir
  • integrase inhibitor = raltegravir
79
Q

Clinical manifestations of MAC

(a) Expected CT findings of disseminated MAC

A

MAC: fevers, weight loss, lymphadenopathy
can have diarrhea/abd pain, splenomegaly

(a) See mesenteric lymph node enlargement

80
Q

First line antimicrobial regimen for MAC infection in HIV+ pt

A

MAC tx: macrolide (clarithromycin or azithro) plus ethambutol

then also plus rifambutin if failing ART

81
Q

Diagnostic tests for MAC infection

A

Diagnosing MAC- need to get biopsy, typically negative in blood in non-disseminated infection, get lymph node biopsy or BAL wash

82
Q

HIV+ pt with CD4 count 82 p/w fever, headache, AMS

(a) Suspected diagnosis
(b) What further testing?

A

(a) Toxoplasma gondii encephalitis

(b) LP and send for toxo antibodies
Then also NCHCT for multiple ring-enhancing lesions

83
Q

Imaging findings of toxoplasma gondii encephalitis

A

Multiple ring enhancing lesions

84
Q

2 clinical presentations of cryptococcus neoformans in HIV+ pts

A

Cryptococcus neoformans =>

  1. meningitis: often subacute
  2. pneumonia
85
Q

First line treatment regimen for cryptococcus meningitis

A

Cryptococcus neoformans tx:
induction w/ amphotericin B and flucytosine
consolidation w/ fluconazole
maintenance w/ fluconazole

86
Q

HIV+ with CD count 60 w/ persistent watery diarrhea

First line diagnosis?

A

Persist watery diarrhea in immunocompromised (typically CD4 under 100) = cryptosporidiosis

87
Q

3 main clinical syndromes that CMV causes in HIV+ pts

A
  1. Retinitis
  2. Esophagitis
  3. Colitis
88
Q

Tx of CMV

(a) Side effects of tx

A

Ganciclovir

(a) Risk of bone marrow suppression

89
Q

MC bugs causing catheter-related infections

(a) Empiric tx

A

Catheter related infections: MC is coag negative staph (staph epi), then staph aureus, enterococcus, candida

(a) Empiric tx w/ vanc

90
Q

Complications of catheter-related infections

A

Complications:
septic thrombophlebitis
septic emboli (ex: pulmonary)
infective endocarditis

91
Q

Do you have to remove all devices when there is concern for device related infection?

A

No- if uncomplicated infection of tunneled catheter or implantable device can first try to get away with just abx

Unless there’s candidemia- then need to remove

92
Q

What do we use to test for C. Diff?

A

Don’t test the stool for the bacteria itself, but for the toxin it produces

93
Q

82 y/oF on CTX for UTI who develops diarrhea

Why likely not C. Diff?

A

C. diff diarrhea typically develops about 1 week after abx exposure

94
Q

Distinguish airborne from droplet precautions

A

Airborne = negative-pressure room with N-95 respirators for staff
protects against droplet (tiny) nuclei
Tb, measles, SARS, vesicular rashes (VZV, chicken pox)

vs.

Droplet = private room, facemask for staph
protects against large particles that can suspend in air for 3 feet
Meningococcus and H. influenza meningitis, influenza, pertussis

95
Q

What diseases warrant the following

(a) airborne precautions
(b) droplet precautions
(c) contact precautions

A

Everyone gets standard- duh wash your hands, wear PPE for splashes duh

(a) Airborne (negative pressure room and N-95 respirators) for Tb, VSV, chicken pox, measles, SARS
(b) Droplet (private room, wear mask) for meningococcal/H. influenza meningitis, influenza, pertussis
(c) Contact precautions (wear gown and gloves always) for C. Diff, vesicular rash (VSV, chicken pox), SARS

96
Q

Describe shape of staph vs. strep

A

Staph like grapes come in clusters
‘Gram positive cocci in clusters’ = staph

Strep- in chains and pairs

97
Q

Buzzwords

(a) lancet-shaped pairs
(b) coagulase negative GPC
(c) GPCs

A

(a) lancet-shaped pairs of GPCs = strep pneumo (ex: as seen in pneumococcal pneumonia sputum Cx)
(b) coag negative staph = staph epidermidis and staph saprophyticus
(c) gram positive cocci = staph and strep

98
Q

How to differentiate the two gram positive branching rods

A

Abnormal gram positive bacteria shaped in branching rods = actinomyces and nocardia

Nocardia- partially/weakly AFB positive, can grow under aerobic conditions (neither of which actinomyces are)

99
Q

Lumpy jaw or draining fistula with sulfur granules on pathology

A

Actinomyces- gram positive bracing rod that presents as draining fistula/sinus in the mandible, lung, or abdomen/pelvis

100
Q

How does nocardia present clinically?

A

Immunocompromised (HIV, chronic steroids, leukemia) pt w/ lung, CNS, or ski abscesses

101
Q

Two clinical presentations of bartonella

A
  1. cat-scratch disease = fever, regional lymphadenopathy around catch bite
  2. bacillary angiomatosis = FUO in AIDS pt w/ purple lesions
102
Q

Bacillary angiomatosis clinical presentation

A

AIDS pt w/ purple skin lesions that resemble (but are not…) Caposis sarcoma
Fever- cause of FUO in AIDS pt
Blood filled cystic lesions in liver and spleen

103
Q

Tx for cat-scratch disease

A

Cat-scratch disease = fever, regional lymphadenopathy around cat bite 2/2 bartonella hensilae

Tx = macrocodes (azithro)

104
Q

Next step for any pt with

(a) Candidemia
(b) Candiduria

A

(a) Any candida in blood: need optho exam to r/o candida endopthalmitis

(b) Candida in urine can be a frequent colonizer => look for WBCs and symptoms
No oral antifungals needed if asymptomatic

105
Q

Clinical hint to candida vs. CMV esophagitis

A

CMV esophagitis typically CD4 under 50

So candida higher CD4

106
Q

Lab findings seen in ABPA

A

Allergic bronchopulmonary aspergillosis

-galactomannan positive

107
Q

Allergic bronchopulmonary aspergillosis

(a) Imaging findings
(b) Tx

A

ABPA

(a) CXR: patchy, fleeting infiltrates and lobar consolidation
Late finding/complication of bronchiectasis

(b) Tx = prednisone (systemic ‘roids) + fluconazole

108
Q

Clinical features of ABPA

A

Pt w/ known asthma or CF p/w episodic bronchospasm, fever, brown-flecked sputum

109
Q

Risk factors for aspergilloma

A

Fungus ball needs an existing pulmonary cavity to grow in => RF include prior Tb, sarcoid, emphysema, or PCP

110
Q

When to be clinically suspicious for invasive aspergillosis

A

New pulmonary nodules or persistent fever w/ dry cough despite broad spectrum abx

Severely ill/septic despite broad abx

111
Q

Invasive aspergillosis

(a) Imaging findings
(b) Serum tests
(c) Tx

A

Invasive aspergillosis

(a) Air-cresent sign (cavitation of a necrotic nodule) and halo sign (necrotic nodule w/ surrounding hemorrhage)
(b) Galactomannan positive
(c) Tx- surgically remove any fungal balls. Meds- voriconazole, amphotericin, or caspofungin

112
Q

42 y/oM w/ AIDS (CD4 55) p/w headache and fever, opening pressure of 25 mmHg on LP

Dx?

A 
Cyptococcus neoformans (encapsulated budding yeast) 
- RF is immunocompromised (vs. coccidioidomycosis which is endemic to SW US and central cali and in immunocompetent)
113
Q

Buzzword: India ink prep of CSF w/ budding yeast

A

India ink prep- think cryptococcus neoformans (immunocompromised)

114
Q

Elderly non-smoker F p/w cough, malaise
CXR w/ middling nodular bronchiectasis

Dx?

A

Lady Windermere syndrome seen in MAC (mycobacterium avium)

115
Q

42 y/oF s/p lung transplant 1 yer ago p/w new lung nodule. Biopsy of nodule grows weakly acid-fast bacteria in branching rod pattern

(a) Dx
(b) Tx

A

(a) Nocardia = gram positive branching rod, weakly acid fast

(b) Tx = TMP-SMX

116
Q

35 y/oF who immigrated from India 10 yrs ago has routine PPD at 20mm induration.
Denies fever, cough, wt loss, had BCG vaccine as a child

Next step?

A

BCG vaccine does not affect decision to treat so r/o active disease w/ CXR, then treat for LTBI

**do not consider previous BCG vaccination status when interpreting reactive PPD b/c persistent reactivity is unlikely after 10 yrs

117
Q

What percent of LTBI develop active disease?

A

10% total

5% in the first 2 years of infection, then 5% over the rest of their lifetime

118
Q

Type of isolation required for MTb

A

Respiratory isolation = negative pressure room, N-95 masks

vs. droplet which is for flu and is just private room w/ face mask

119
Q

What changes in the 4 drug regimen for Tb are required for its on methadone?

A

Rifampin is a cyt p450 inducer => use rifaxamin instead when have another cyt p450 med (methadone, protease inhibitor, NNRTI, OCPs)

120
Q

Name medications that should be taken in caution w/ rifampin

A

Meds metabolized by cyt p450

Methadone, OCPs, itraconazole, NNRTIs, protease inhibitors
(hence why difficult to treat ppl on HAART for LTBI- so use rifabutin instead of rifampin)

121
Q

How to distinguish dermatologic manifestations of chickenpox from

(a) Smallpox
(b) HSV
(c) Meningococcemia

A

(a) Smallpox- all the same stage (while chickenpox are present at multiple stages simultaneously). Also chickenpox relatively spares the extremities
(b) HZV- similar appearing, need to differentiate by Tzank smear
(c) Meningococcus- petechiae, purpura, sepsis

122
Q

Tzank smear used to diagnose what?

A

Thank smear of base of vesicle to differentiate VZV (chicken pox/shingles) from HSV

123
Q

Ramsay Hunt Syndrome

(a) Cause
(b) Clinical triad

A

Ramsay Hunt syndrome = (a) Herpes zoster opticus (VZV)

(b) Thought to be a polycranial neuropathy from VZV reactivation
1. ipsilateral facial paralysis
2. ear pain
3. vesicles in ear
- can also see hearing problems, lacrimation issues

124
Q

Ramsay Hunt Syndrome

(a) Cause
(b) Clinical triad

A

Ramsay Hunt syndrome = (a) Herpes zoster opticus (VZV)

(b) Thought to be a polycranial neuropathy from VZV reactivation
1. ipsilateral facial paralysis
2. ear pain
3. vesicles in ear
- can also see hearing problems, lacrimation issues

125
Q

Meds to continue when CSF gram stain grows strep pneumo

A

Continue vanc/CTX until sensitivities return given risk of CTX-resistant strep pneuma

Then of course IV dex x4 days

126
Q

Tx for 65 y/oM w/ indwelling foley, no urinary symptoms.

UCx growing >100,000 CFU pan-sensitive E. Coli

A

No tx

Only treat asymptomatic bacteuria in pregnant F

127
Q

Abx therapy for culture proven listeria meningitis

A

Ampicillin (or PCN) w/ aminoglycoside (gentamicin) for synergy

Amp + gent

128
Q

68 y/oF w/ dysuria, foamy vaginal discharge, and punctate-appearing cervix

(a) Dx
(b) Diagnostic test

A

(a) vaginitis, foamy vaginal discharge, ‘strawberry’ cervix = trichomonads
(b) Vaginal fluid microscopy for motile trichomonads

129
Q

Prosthetic joint infection bugs

Early vs. late

A

Early (within 3 months of surgery): MC is staph aureus

After 3 months: MC is coag. negative staph (staph epi)

130
Q

Bactrim ppx use in AIDs its for PCP vs. toxo ppx

A

PCP- can be one DS or SS tab daily

Toxo with positive toxo IgG - one DS tab daily once CD4 reaches under 100

131
Q

When to start HAART on HIV+ pt w/ CD4 350-500

A

NOT once drops below 350, new guidelines say start HAART on everyone, regardless of cd4 count

Starting it despite CD4 count decreased sexual transmission and HIV-related complications (ex: extra pulmonary Tb)

132
Q

Odynophagia and dysphagia

(a) immunocompromised
(b) immunocompetent

A

(a) Candida esophagitis- empiric tx w/ fluconazole, can proceed to endoscopy if inadequate response
(b) Immuncompetent- these are warning signs! straight to endoscopy w/ biopsy and test for HIV

133
Q

Empiric abx for community-acquired diverticulitis complicated by abcess

A

Zosyn (pip-tazo) given good coverage for gram negative aerobes, gram positive strep species, and anaerobes

Don’t need vanc (MRSA) or fluconazole (candida) for community acquired

134
Q

Herpes zoster ophthalmicus

(a) Etiology
(b) Treatment

A

(a) Reactivation of VZV in the ophthalmic division of the trigeminal nerve- vesicles on tip of nose, periorbital

(b) Tx: oral valacyclovir or famcyclovir, better absorbed and not 5x daily like acyclovir
but IV acyclovir if immunocompromised

135
Q

Abx of choice for dental procedure ppx

(a) If PCN allergy

A

First line- PO amoxicillin (strep coverage)

(a) PCN allergy- use clinda

136
Q

Vaccine/immune globulin choice for 18 y/o w/ dirty wound and unknown immunization history

A
  1. TDap (preferred over TD)

2. tetanus immune globulin given dirty wound

137
Q

Abx ppx to offer adult F victims of sexual assault

A

CTX, flagyl, azithro cover gonorrhea, trichomonas, and chlamydia respectively

And then HIV PEP

  • CTX can cover syphilis, benzaprine/PCN not indicated given low prevalence syphilis
  • no acyclovir

Internal Medicine Boards 2018 (13 decks)

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