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Internal Medicine > Infectious Disease > Flashcards

Infectious Disease Flashcards

1
Q

Define fever

A
  • body temperature >37.8 oral or >38.2 rectal
  • acute if less than 4 days
    Fever of Unknown Origin
  • fever >38.3 lasting >3 weeks with unknown diagnosis after 1 week of workup investigations
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2
Q

List the differential for a fever in a returning traveller

A 
Unique for Returning Traveller
- Malaria
- Dengue fever
- Typhoid
- Chikungunya
- Mononucleosis
- Rickettsial infection
- Ameobiasis
Other Common
- Pneumonia
- TB
- C diff
- Hepatitis
- STI
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3
Q

Discuss the epidemiology, presentation, investigations and management for malaria

A 
- falciparum malaris
Epidemiology
- Southern America
- Sub-Saharan Africa
- South Asia
Presentation
- present within 1 month
- flu-like prodrome of fever, chills, myalgia, cough, diarrhea
- jaundice
- hepatosplenomegaly
Investigations
- Blood thick and thin same with pathogen visualized within erythrocyte
- Hemolytic anemia
- thrombocytopenia
Management
- Artemisinin combination therapy
         - artesunate with doxycyline or clindamycin
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4
Q

Discuss the epidemiology, presentation, investigations and management for dengue fever

A 
Epidemiology
- Central and South America
- Sub-Saharan Africa
- Southern Asia
- viral infection spread by mosquito bite
- ssRNA flavivirus
Presentation
- most asymptomatic
- incubation 4-7d
- Fever, retro-orbital pain
- systemic maculopapular rash/petechial rash
Management
- symptomatic
- fluids
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5
Q

Discuss the epidemiology, presentation, investigations and management for thyphoid fever

A 
Epidemiology
- Worldwide but endemic to Africa, Asia and Central and South America
Pathophysiology
- bacteria salmonella typhi that infect GI, liver, gallbladder
- fecal-oral transmission
Presentation
- incubation for 1-3 weeks
Management
- clean food and water
- oral rehydration
- Ceftriaxone IV
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6
Q

Discuss the epidemiology, presentation, investigations and management for chikungunya

A

Epidemiology
- Sub-Saharan Africa
- South Asia
- viral infection spread by mosquito bites
Presentation
- incubation <2 weeks, usually 2-3d
- abrupt onset of fever and malaise
- maculopapular or petechial rash on trunks and limbs
- arthralgia, joint swelling and stiffness
- polyarthralgia 2-5d after onset
- resolve after 1 week but arthralgia may persist
Investigation
- CBC for leukocytopenia, neutropenia and thrombocytopenia
- ESR and CRP
- serology IgM (5d-3mon), IgG (2 weeks after)
Management
- NSAID and hydration

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7
Q

Discuss the epidemiology, presentation, investigations and management for Rickettsia

A 
- Typhus
Epidemiology
- Southern Africa
- Mediterranean
- Asia
- infection by bacteria Rickettsia (gram negative)
- transmitted by flea or tick bite
Presentation
- high fever
- dull red rash
- photophobia, arthralgia
Investigation
- serology
Treatment
- Doxycycline PO
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8
Q

Discuss the contraindications to a lumbar puncture

A
  • papilledema
  • focal neurological deficit
  • abnormal LOC
  • new onset seizure
  • immunocompromised
  • recent head trauma
  • known cancer
  • known sinusitis
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9
Q

Discuss the findings of bacterial, viral and TB/fungal meningitis

A 
Opening Pressure
- high in bacterial
- normal in viral (10-20cm H20)
- variable in TB
Protein
- high in bacterial
- normal in viral (<0.45g/L)
- high in fungal
Glucose
- low (<40%) in bacterial
- normal (>60%) in viral
- low in TB
WBC
- >1000 with neutrophils in bacterial
- <100 with lymphocytes in viral
- variable in TB
RBC
- normal (0-5) in bacterial
- high in HSV encephalitis
Gram Stain
- positive in bacterial
- negative in viral and TB
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10
Q

Discuss the presentation and management of meningitis

A 
Etiology
- strep pneumonia
- neisseria meningitidis
- hemophilus influenza
Presentation
- triad of headache, fever, stiff neck
- photophobia
- seizure
- petechial rash in meningitis
- cranial nerve abnormality if involve brainstem
- nuchal rigidity
- positive Kernig (thigh and knee at 90 and pain with resisted knee extension)
- positive Brudzinski (flexion of neck elicits flexion at hips)
Investigation
- Lumbar puncture demonstrating
    - High WBC with neutrophils
    - low glucose, high protein, high lactate
    - Gram stain and culture
Management
- <50 IV ceftriaxone with vancomycin
- >50 and immunocompromised IV ceftriaxone, vancomycin, ampicillin
- Dexamethasone 
- Intracranial pressure control
     - Elevate head of bed
     - control BP
     - Glycerol/Mannitol if ICP >20
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11
Q

List the risk factors and pathogenesis of infective endocarditis

A 
Risk Factors
- pre-existing heart disease (prosthetic valve, valvular disease, congenital heart defect)
- IV drug use
Pathogenesis
- endocardium injury from turbulent flow due to valvular structural abnormality form thrombus -> bacteria from bacteremia infect thrombus and adhere to endocardium -> proliferate and form vegetation
Microbiology
- Staphylococcus aurea or epidermidis
- Streptococcus viridins or bovis
- Enterococcus
- Gram Negative
     - HACEK: Hemophilus, Aggregatibactor, Cardiobacterium, Eikennela corrodens, Kingella
- Fungi
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12
Q

Discuss the presentation and investigation for infective endocarditis

A 
Presentation
- fever, chills
- dyspnea and chest pain
- SOB
- joint pain
- Roth spots in eyes
- new murmur
- petechiae
- Janeway lesion (non-tender, small erythematous macular lesion) 
- Osler nodes (tender, red, raised lesions on hands or feet)
- splinter hemorrhages
Investigation
- CBC, electrolytes, creatinine/BUN
- ECG
- urine analysis
- blood culture
- Echocardiogram
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13
Q

List the Duke criteria for diagnosis of infective endocarditis

A 
Major Criteria
- Positive blood cultures
       - typical microorganism from 2 seperate cultures
       - OR persistently positive culture (>12h apart or all 3
       - OR single positive for Coxiella burnetii or antiphase I IgG titer >1:800
- Evidence of endocardial involvement
       - positive echocardiogram
- New valvular regurgitation
Minor Criteria
- Predisposing condition
- Fever
- Vascular phenomenom
       - major arterial emboli
       - septic pulmonary infarct
       - conjunctival hemorrhage
       - Janeway lesion
- Immunologic phenomenom
       - glomerulonephritis
       - Rheumatoid factor
       - Osler nodes
       - Roth's spots
- Positive blood culture but not meeting major criteria
Diagnosis
- 2 major OR 1 major + 3 minor OR 5 minor then diagnosis
- 1 major + 1 minor OR 3 minor then possible
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14
Q

Discuss the management of infective endocarditis

A 
Antibiotic
- Vancomycin 1g IV Q12H
- Gentamicin 1mg/kg IV Q8H
- Ceftriaxone 2g IV Q24H
Surgical Indications
- refractory CHF
- valve ring abscess
- fungal infective endocarditis
- valve perforation
- unstable prothesis
- >2 major emboli
- antimicrobial failure
- mycotic aneurysm
- Staph on prosthetic valve
Prophylaxis
- Amoxicillin 2g PO or Clindamycin 600mg PO before
       - dental
       - respiratory
       - skin
       - MSK
       - GU procedure
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15
Q

List the diagnosis of HIV

A
  • enzyme linked immunosorbent assay (ELISA) to detect serum antibody to HIV
  • if positive ELISA, western blot detect antibodies to 2 different HIV protein bands
  • PCR to detect HIV DNA and HIV RNA to monitor viral load
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16
Q

List the opportunistic infections associated with specific CD4 count

A 
>500
- normal immune function
<500
- recurrent HSV
- VZV reactivation leading to shingles
- oral hairy leukoplakia due to EBV
- Oral or vaginal candidiasis
- Sinusitis
- Recurrent pneumonia
- Lymphima
- Pulmonary and extra-pulmonary tuberculosis
<200 (AIDS)
- Pneumocystis jiroveci pneumonia
- Kaposi's sarcoma
- Cryptococcosis meningitis or lung
- Histoplasmosis lung
- Cerebral toxoplasmosis
<100
- progressive multifocal leukoencephalopathy (PML) by PJ
- Cerebral toxoplasmosis
<50
- CMV 
- Mycobacterium avium complex (MAC)
- CNS lymphoma
- Bacillary angiomatosis
- Dementia
- Wasting
17
Q

Discuss the pathophysiology, presentation, investigation and management of CNS opportunistic infections with HIV

A

Cryptococcus Meningitis
- respiratory inhalation of fungus to brain
- fever, fatigue, headache, blurred vision
- crypotococcal antigen on CSF or sputum
- fluconazole PO
Cerebral Toxoplasmosis
- infection by toxoplasmosis
- fever, headache, focal neurological deficit, seizure
- ring enhancing lesion on head CT
- Septra PO
Progressive Multifocal Leukoencephalopathy
- lymphoma in CNS
- headache, confusion, hemiparesis, seizure
- characteristic lesion on CT with brain biopsy
- Palliative radiation
Cytomegalovirus Retinitis
- eye pain, photophobia, red eye
- Ganciclovir PO

18
Q

Discuss the pathophysiology, presentation, investigation and management of pulmonary opportunistic infections with HIV

A 
Pneumocystic Pneumonia
- parasite pneumocystis jirovecii
- progressive SOB, dramatic decline in O2 sat with walking
- bilateral interstitial pneumonia, broncho-alveolar lavage for diagnosis
- Prednisone with Septra
Bacterial Pneumoni
Tuberculosis
- Primary or reactivation 
- fever, weight loss, cough, hemoptysis
- 4 for 2 months including Rifampicin PO + Isoniazid PO + Pyrazinamide PO + Ethambutol PO then 2 for 4 months of Rifampicin PO + Isoniazid PO
Histoplasmosis
- fever, cough
- nodule on X-ray, antigen in blood or urine
- Amphotericin B IV
Coccidiodomycosis
- Fever, joint pain, erythema nodusum
- nodule on X-ray, detection of cells in body fluid
- Amphotericin B
Mycobacteria Avian Complex
- fever, weight loss, night sweats
- positive blood culture
- Azithromycin PO + Ethambutol PO
19
Q

Discuss the pathophysiology, presentation, investigation and management of GI opportunistic infections with HIV

A 
Candidiasis
- infection of mouth or esophagus
- oral thrush with inflamed mucosa underneath
- Nystatin PO
Gastroenteritis
- infection by Salmonella, Shigella, E coli
- diarrhea, bloody
- Ciprofloxain + Flagyl
20
Q

Discuss the pathophysiology, presentation, investigation and management of dermatologic opportunistic infections with HIV

A 
Kaposi Sarcoma
- HHV-8
- cutaneous or visceral lesions of black macules that are non-pruritic and non-tender
- anti-retroviral treatment
Bacillary Angiomatosis
- red papullar skin lesions
- Doxycyline PO
Shingles
- reactivation of VZV
- painful papulae and vesicle along dermatome
- Acyclovir PO
21
Q

Discuss primary prevention in HIV

A
  • CD4 100-200 then Septra PO to prevent PCP

- CD4 <100 Septra PO to prevent PCP and toxoplasmosis and Azithromycin to prevent MAC

22
Q

List the indications and types of anti-retroviral medication

A
  • suppress viral load <40 and restore CD4 count
    Indications
  • CD4 <350
  • HIV patient that is pregnant
  • HIV patient with opportunistic infection
  • HIV patient being treated for hepatitis
  • HIV patient with nephropathy or thrombocytopenia due to HIV
    Classes (6)
  • Nucleoside Reverse transcriptase inhibitors
    - inhibit HIV reverse transcriptase by binding to active site
  • Non-nucleoside reverse transcriptase inhibitor
    - bind outside of active site
  • Protease inhibitor
    - inhibit HIV protease activity to prevent viral maturation and release
  • Integrase inhibitor
    - inhibit HIV integrase block integration of provirus to cellular genome
  • Fusion inhibitor
    - prevent HIV-cell membrane fusion
  • CCR5 inhibitor
    - bind CCR5 co-receptor prevent HIV binding`
23
Q

List the common HIV formulation

A
  • usually 2 NRTI with 1 NNRTI or 2 NRTI with 1 protease
    Atriplia
  • Tenoforvir (NRTI) + Emtricitabine (NRTI) + Efavirenz (NNRTI)
24
Q

Discuss the different infectious disease precautions

A

Contact Precaution
- Indications: acute diarrhea/vomiting, abscess, undiagnosed rash without fever
- gloves required with possible gown
Droplet Precaution
- indications: meningitis, sepsis with petechial rash, acute respiratory infection
- mask with visor, gloves, with possible gown
Airborne Precautions
- indications: suspected measles, TB, VZV
- negative pressure room with N95, gloves and possible gown

25
Q

Discuss factors leading to increasing antibiotic resistance

A
  • over use of unnecessary prescription
  • improper antimicrobial use
  • lack of proper infection control
  • lack of resistance tracking
26
Q

Discuss the risk factors for tuberculosis

A
  • Aboriginal
  • Foreign born individuals from Asia, Sub-Saharan Africa
  • Urban, poor homeless population
  • High risk occupation
  • Travel to TB endemic area
  • contact with high risk population
27
Q

Discuss the presentation, investigation and management of tuberculosis

A

Presentation
- latent is asymptomatic
- active TB: fever, chills, anorexia, night sweats, weight loss
- pulmonary: productive cough, hemoptysis
- extra-pulmonary: pleurisy, pericarditis, osteomyelitis, adrenal or renal infection
Investigation
- Pulmonary TB: nodular/alverolar infiltrate with cavitation in upper lobe
- Miliary TB: scattered discrete nodules
- Latent TB: pulmonary nodule, hilar adenopathy
- Resolved: calcified hilar node, pleural thickening
Management
- 4 for 2
- Isozianid + Rifampin + Pyrazinamide + Ethambutol
- 2 for 4 months
- Isozianid + Rifampin
- extra-pulmonary require 12 months of treatment

28
Q

Discuss the diagnosis of TB

A
  • Mantoux skin test for latent
    - >5mm induration for immunosuppresed, active
    - >10mm
  • 3 consecutive sputum culture staining for acid fast bacilli, culture and AMTD
  • biopsy of infected site
29
Q

Discuss the risk factors and pathophysiology of clostridium difficile

A
  • gram positive anaerobic bacillus
  • secrete enterotoxin A, B
  • spread by fecal-oral
    Risk Factors
  • antimicrobial therapy in last 3 months
  • hospitalization
  • immunodeficiency
  • IBD
  • chronic renal failure and chemotherapy
    Pathophysiology
  • Hos acquires and experience dysbiosis -> spore survive gastric acid and germinate in small bowel -> anaerobic environment allow to colonize -> secrete toxins leading to waterry diarrhea
30
Q

Discuss the presentation, investigation and treatment for c difficile

A 
Presentation
- watery diarrhea
Investigation
- stool test for C diff
- direct examination of colon show pseudomembrane and histology
Management
- Isolation
- Address underlying cause
- Stabilize patient
- Antibiotic
     - Flagyl 500mg PO/IV Q6-8H for 2 weeks
     - Vancomycin 125-500 PO Q6H for 2 weeks

Internal Medicine (12 decks)

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