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ICM2 > Infectious Disease, Rheumatology > Flashcards

Infectious Disease, Rheumatology Flashcards

1
Q

Most common diagnosis for sick kids and antibiotic therapy?

A

Otitis media

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2
Q

AOM risk factors?

A 
Younger than 6yo
FH, especially if American or Australian indigenous
Male
Poor
Cold season
Smoke exposure
Day care
Decreased risk with breastfeeding
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3
Q

Respiratory epithelium histology?

A

Pseudostratified ciliated columnar epithelium with goblet cells

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4
Q

Why are infants at greater risk of AOM?

A

Flatter ETs = worse drainage of middle ear

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5
Q

AOM pathogenesis

A

Inflammation (due to URI, allergy, smoke) –> ET obstruction (mass, anatomy) –> Middle ear effusion (barotrauma) –> AOM –> OME (w/effusion) –> complications/resolution

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6
Q

Most common microbial causes

A

Viruses - Adeno, Influenza, Mono, Rhino, Corona, Parainfluenza, RSV
Strep pneumonia, Haemophilus, Moraxella, GABHStrep, Staph, Anaerobes

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7
Q

Is AOM contagious?

A

No, but URIs are, which may cause AOM secondarily

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8
Q

AOM history

A

PAIN, URI, Fever, Headache, Irritability/apathy;
Anorexia, vomiting, diarrhea with Adeno
Behavior changes, communication problems, plugged/popping ears, recent URI/allergy

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9
Q

AOM presentation and DDX

A

Otalgia = otitis externa, dental problems, pharyngitis
Ottorhea = otitis externa
Hearing loss = impaction, sensorineural deficits
Vertigo, nystagmus, tinnitus = ET dysfunction, labyrinthitis
Postauricular swelling = mastoiditis
Facial paralysis = Bell’s palsy

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10
Q

AOM physical exam findings

A 
General = sepsis
Head = craniofacial abnormalities
Eyes = drainage w/H. influenzae
Nose = congestion, drainage, septal deviation
Neck = lymph nodes, meningeal signs
Throat = Bifid uvula (cleft palate), redness, drainage - SAVE FOR LAST
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11
Q

AOM TM triad on otoscopy

A

Bulging, red, immobile

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12
Q

AOM TM abnormalities

A

Bulging, bubbles, air-fluid levels, perforation w/ottorhea, bullae, tympanosclerosis, cholesteatoma

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13
Q

Fever and earache associated with … ?

A

Pneumococcal infection

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14
Q

Otitis-conjunctivitis syndrome or bilateral otitis associated with … ?

A

Haemophilus influenzae infection

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15
Q

Ways to prevent chronic OM?

A

Educate parents - don’t smoke, breastfeed, vaccines, smaller daycare
Chemoprophylaxis
Surgery

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16
Q

Retracted TM indicates?

A

Negative pressure in middle ear

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17
Q

AOM diagnosis must have what three things?

A

Acute history of URI/congestion
Evidence of middle ear effusion - drainage, bulging TM, or abnormal tympanometry
Signs/symptoms - fever, pain

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18
Q

AOM treatment

A

Observation
If over 2yo, short course of amoxicillin preferred, macrolides or erythromycin if penicillin allergy
Should respond within 2d. Recheck by 2wk.

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19
Q

Recurrent OM treatments

A

Antibiotic prophylaxis
Image adults for masses
Surgery - myringotomy w/tympanostomy tubes
Monitor hearing, speech, language development

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20
Q

OME treatment

A

Observe unless infant
Full antibiotic course if over 3m
Surgery if high risk, chronic, or bilateral effusion - tubes, may remove adenoids if obstructing ETs
Monitor hearing, speech, language development

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21
Q

When are speech and language development at risk?

A 
Infant younger than 6m
Existing hearing loss or speech/language disorder
Autism
Developmental delay
Uncorrectable visual impairment
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22
Q

Potential targets of HIV drugs

A

Integrase inhibitors
Protease inhibitors
RT inhibitors
Fusion/entry inhibitors

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23
Q

Clinical indications for HIV testing

A

TB
Syphilis
HIV-associated opportunistic diseases: Pneumocystis, Karposi’s sarcoma
Recurrent shingles
Chronic constitutional symptoms, generalized adenopathy, diarrhea, encephalopathy, thrombocytopenia

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24
Q

Symptoms of primary HIV infection

A

Non-specific flu-like symptoms w/ or w/o rash
Fever, fatigue, rash, myalgia, night sweats, low WBCs, weight loss
Mucocutaneous ulcerations, rash, abrupt onset of multiple symptoms

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25
Q

DDx for HIV

A

EBV mono, CMV, HSV, flu, hepatitis, organisms causing rash

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26
Q

Cryptococcus neoformans

A

HIV OI
Subacute meningitis w/fever, headache, malaise, occasionally encephalopathy
Treat w/ amphotericin B, then fluconazole
Consider CSF shunt if hydrocephalus does not resolve

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27
Q

Advanced HIV OIs (CD4 less than 50/mL)

A

CMV - now causes CNS disease when CD4 below 50/mL
TB - all HIV+ patients should be tested for latent TB at diagnosis, rifampin/isoniazid is well-tolerated; Systemic TB common in advanced HIV disease –> Fever, weight loss, sweats, diarrhea
Primary CNS lymphoma

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28
Q

Toxoplasma gondii

A

May reactivate when CD4 below 200/mL
Present in white matter, CSF
Headache, fever, behavioral change, lethargy, gait change, seizures

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29
Q

JC Virus

A

Asymptomatic latent infection reactivates causing CNS involvement

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30
Q

Potential complications of HIV treatment

A

Lipodystrophy - body morphology changes and metabolic complications
Premature osteopenia/-porosis
Peripheral neuropathy

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31
Q

Best time to start HIV treatment?

A

As early as possible if the patient is functional, esp. if pregnant
Give vaccines early to maximize benefits, but avoid live vaccines

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32
Q

Pneumocystis jirovecii

A

HIV OI
Gradual onset fever, dry cough, dyspnea, tachypnea
CXR may show indicative infiltrate
Bronchoscopy diagnostic
Treat w/ IV SxT; patient will typically worsen after 2-3d as fungus begins to die, IR begins

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33
Q

Normal stool volume and frequency

A

Less than 1L/d

Less than 7 BM/d

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34
Q

Dysentery-causing organisms

Which bowel?

A

Small bowel:
Salmonella
E. coli (all strains besides 0157)

Large bowel:
Campylobacter
Shigella
Entamoeba histolytica

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35
Q

Define pseudodiarrhea, fecal incontinence, and overflow incontinence

A

Rectal urgency due to anal inflammation/infection
Neuromuscular loss of anal sphincter control
Constipation in sigmoid colon causes watery stool to leak around blockage

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36
Q

Causes of acute diarrhea

A

Viral - most common, least complicated
Bacteria - severe
Protozoa - least common

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37
Q

Diarrhea-causing organisms with preformed toxin

Which bowel?

A

C. perfringens
Staph
Bacillus cereus
All small bowel

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38
Q

Diarrhea-causing organisms with enterotoxin

Which bowel?

A

Vibrio cholerae

Small bowel

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39
Q

Diarrhea-causing organisms with cytotoxin

Which bowel?

A

E. coli 0157:H7
C. diff
Large bowel

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40
Q

Diarrhea-causing organisms with enteroadherance

Which bowel?

A

Giardia lamblia

Small bowel

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41
Q

Diarrhea soon after cream pie/salad?

A

Staph

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42
Q

Diarrhea after rice that was left out?

A

Bacillus cereus

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43
Q

Diarrhea within enclosed space (cruise ship)?

A

Norovirus

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44
Q

Diarrhea/dysentery 1-3 days after undercooked meat?

A

Salmonella

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45
Q

Diarrhea a few days after raw vegetables or undercooked meat?

A

E coli 0157:H7

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46
Q

Diarrhea after sushi?

A

V. parahemolyticus

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47
Q

Diarrhea in child in daycare?

A

Rotavirus

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48
Q

Diarrhea associated with unsanitary conditions?

A

HepA

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49
Q

Infantile diarrhea?

A

Adenovirus

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50
Q

Diarrhea associated with unclean surface water?

A

Giardia

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51
Q

Travelers diarrhea?

A

ETEC

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52
Q

Diarrhea after antibiotic therapy?

A

C. diff

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53
Q

Diarrhea pertinent history questions

A 
Onset
Frequency
Presence of blood or mucus
BMs at night?
Associated symptoms
Exposures?
Recent antibiotics?
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54
Q

Diarrhea pertinent physical exam findings

A

Vital signs/General - patient sick and near shock?
Abdominal exam - Surgical abdomen? (Rigidity, guarding, rebounding, no sounds)
Musculoskeletal - accompanying arthritis
Skin - vasculitis?
Rectal exam - blood, masses

55
Q

Anal fissure may be indicative of?

A

Minor cause of hematochezia

56
Q

Anal fistula may be indicative of?

A

More severe disease such as IBD

57
Q

When to culture stool?

When to look for parasites/ova?

A
  • Bacteria suspected

- Persistent diarrhea w/risk factors, dysentery, but no fecal leukocytes

58
Q

Typical antibiotics for diarrhea

A 
Flouroquinolone = G- coverage
Metronidazole = C. diff coverage
59
Q

When to not use anti-motility agents?

A

Bacterial or amoebal dysentery, inflammatory response that needs to be cleared
Prevent C. diff establishment

60
Q

Influenza types

A 
A = humans, animals, pandemics
B = humans, no pandemics
C = mild disease
61
Q

Influenza surface proteins

A

Hemaglutinin and neuraminidase

62
Q

Antigen drift and antigen shift

A 
Drift = mutation causes small changes in H, N from year to year
Shift = Reassortment of genes in cells co-infected with different strains causes acquisition of new H, N genes
63
Q

Influenza transmission path

A

Need large respiratory droplets (sneezing, coughing)
Need close contact for these to be transmitted
Can’t get from contaminated surfaces, meat

64
Q

Clinical influenza disease

A

Fever, headache, myalgia, fatigue
Followed by cough, sore throat, nasal discharge
GI symptoms NOT typical

65
Q

Flu complications

A

Pneumonia (viral, strep, or staph)
Rhabdomyolysis
MI
Encephalitis and Reye’s syndrome (from too much aspirin) rare

66
Q

Spanish flu unique features

A

Bacterial pneumonia most common cause of death

67
Q

H5N1 bird flu unique features

A

Primarily children and young adults most affected with little person-to-person transmission

68
Q

H3N2 swine flu

A

Close contact with pigs at IN state fair, with genes from H1N1 and H3N2 strain

69
Q

Diagnosing flu

A

In season, typical symptoms usually enough

Otherwise viral culture (gold standard) or RT-PCR (higher cost)

70
Q

Flu treatment

A

No antiviral works well, but may reduce mortality
Old rimantidine and amantidine are ineffective
Current neuraminidase inhibitors only moderately shorten course

71
Q

Why must flu vaccines be changed every year?

A

Must anticipate antigenic drift with educated guess

72
Q

Flu vaccine features

A

Grown in eggs
Inactivated with formaldehyde
Current is a subunit containing only H and N proteins with few side-effects
Tri- or quadrivalent
GBS now rare
Most effective in children, least effective in elderly

73
Q

Lyme disease organism and vector

A

Borrelia burgdorferi

Deer tick

74
Q

Rocky Mountain Spotted Fever organism and vector

A

Rickettsia rickettsii

Dog tick

75
Q

Ehrlichiosis organism and vector

A

Ehrlichia chaffeensis

Lone star tick

76
Q

Lyme disease stages

A
  1. Localized - Erythema migrans (blanching)
  2. Disseminated - multiple annular skin lesions, meningitis, CN7 neuritis, carditis/AV block, arthralgia
  3. Persistent - Oligoarticular arthritis (knee), encephalopathy, axonal (distal) polyneuropathy, acrodermatitis
77
Q

DDx of CN7 palsy

A

Idiopathic Bell’s Palsy
HSV usually w/o rash
Herpes Zoster - vesicles in external auditory canal
Lyme disease

78
Q

Testing for Lyme disease

A

Serologic IgM/IgG at presentation and 2-4w later
ELISA w/ Western blot verification
PCR of joint fluid in patients w/ arthritis

79
Q

Treatment for Lyme disease

A

Doxycycline

80
Q

Rickettsia rickettsii trophism

A

Vascular endothelial cells –> Vasculitis (increased vascular permeability, non-blanching petechial rash w/palms and soles, edema, hypovolemia, hyponatremia from disproportionate ADH response, thrombocytopenia)

81
Q

Classic presentation of RMSF

A

Fever, rash, history of tick exposure

Flu-like symptoms

82
Q

Serious RMSF symptoms

A 
Shock from hypovolemia/-tension
Respiratory failure
CNS involvement
Acute tubular necrosis
Acute hepatitis/liver failure
83
Q

RMSF labs will show what?

A

Thrombocytopenia, hyponatremia, azotemia (high BUN, high Cr if ATN occurs)

84
Q

Fever, petechial rash on palms and soles, potential tick exposure DDx

A 
Meningococcal disease
RMSF
^^^Most important, both treated w/doxycycline, cephtriaxone^^^
Enterovirus
Secondary syphilis
85
Q

RMSF treatment for pregnant women

A

Chloramphenicol

86
Q

Reasons for RMSF treatment delay

A

Absence of skin rash
Early presentation before severe symptoms
Presentation outside of summer months

87
Q

Ehrlichiosis symptoms

A

Flu-like symptoms
Rash is rare
Fewer long-term complications

88
Q

Ehrlichiosis lab findings

A

Leukopenia
Thrombocytopenia
Elevated transaminases

89
Q

Ehrlichiosis treatment

A

Doxycycline

90
Q

Malaria physical exam findings

A 
Fever
Mild hepatomegaly
Palpable spleen
Jaundice
Rash is very unusual
91
Q

Malaria lab findings

A

Nonspecific
Normocytic normochromic anemia
Increased ESR, CRP

92
Q

Malaria drugs

A

Chloroquine - if in sensitive area
Doxycycline
Malarone
Mefloquine - avoid because of CNS side effects

93
Q

Staphylococci (aureus, epidermidis) pathogenic proteins

A

S. aureus: G+, catalase- and coagulase-positive = hemolytic

S. epidermidis: Coagulase-negative, less virulent, but affects prosthetics

94
Q

Risk factors for S. aureus colonization

A

Diabetics
HIV
Dialysis patients
Patients with skin damage (wounds, psoriasis, etc.)
PMN defects (neutropenia, chronic granulomatous disease, Chediak-Higashi syndrome)

95
Q

Staph pathogenesis

A

Pyogenic, causes abscesses at primary and/or distant sites

Inflammatory response -> PMN infiltrate -> Macrophage and fibroblast infiltration -> Contained infection OR spread

96
Q

Toxin-mediated Staph diseases

A

Cytotoxins
Pyrogenic toxin superantigens: Food-borne illness (enterotoxin), Staph toxic shock syndrome (produced at infection site, causes clinical toxin - USE CLINDAMYCIN to stop toxin production most effectively)
Exfoliative toxin: Staph scalded skin syndrome

97
Q

Protective value of anti-Staph Abs?

A

None in clinical trials

PMNs are main control

98
Q

Staph clinical manifestations

A

Skin, soft tissue infection (cellulitis, fasciitis more likely w/GABHStrep)
Bacteremia
CV infection
Sepsis, toxic shock syndrome
Bone, joint infection - osteomyelitis, septic arthritis
Pulmonary infection
Renal infarction, psoas abscess -> CVA tenderness

Rare:
Splenic abscess
Meningitis
Bacteruria - indwelling catheter

99
Q

Staph bacteremia, sepsis risk factors

A

Intravascular catheters
MRSA colonization
Implanted prosthetics
Injection drug use

100
Q

Physical exam and diagnostic evaluation of Staph in adults

A

Careful cardiac exam to detect new murmurs, heart failure, endocarditis
Blood cultures daily, ECG

101
Q

Staph aureus bacteremia treatment in adults

A

Remove infection source (catheters, prosthetic)
Empiric antibiotics until sensitivity determined - vancomycin
MSSA - nafcillin q 4h/oxacillin, cefazolin more common
Follow up blood cultures daily
Therapy duration - 14d IV abx w/o complications

102
Q

Enterococcus treatments

A

Penicillins if sensitive
Vancomycin if sensitive
MRSA drugs
Cephalosporins, fluoroquinolones, macrolides = NO EFFECT

103
Q

ESBL-producing E. coli treatment

A

Carbapenem

104
Q

Sepsis risk factors

A 
ICU, nosocomial infection, esp. pneumonia
Bacteremia
Older than 65y, immunosuppression
Diabetes
Cancer
Genetic factors
105
Q

How to manage sepsis

A

Control airway - supplemental O2, intubation, ventilation
Establish venous access - central line
Maintain perfusion - IV fluids, vasopressors
Empiric, then targeted antibiotics
Possible surgical debridement

106
Q

MRSA risk factors

A 
Recent stay in care facility or hospital
Recent antibiotic therapy
HIV
IV drug use
Dialysis
Diabetes
Shared sports equipment
107
Q

Septic shock progression

A

Systemic inflammatory response syndrome (SIRS) -> Sepsis -> Severe sepsis -> Septic shock

108
Q

Common causes of antibiotic resistance spread

A

Antibiotic use in livestock causes spread in meat
Stay in long-term care facilities w/other sick people
NOT WASHING HANDS

109
Q

Key interventions to prevent MRSA spread

A

Hand hygiene
Decontamination of environment, equipment
Contact precautions for infected/colonized patients
Active surveillance cultures of all people working/housed in facility

110
Q

Precautions for C. diff

A

Gown and gloves

Hand washing

111
Q

Vancomycin side effects

A

Renal failure, ototoxicity

112
Q

Strep throat history and physical

A

H: Contact, sore throat, headache, fever, adenopathy
P: Exudative tonsillitis, petechiae on palate (strawberry tongue), fever, cervical adenopathy, circumoral pallor (pale around mouth)

113
Q

Strep throat DDx

A

Viral pharyngitis
Coxsackie
Herpes
GABHStrep pyogenes

114
Q

Strep throat labs

A

Rapid (Strep antigen - GA carb Ag) and routine throat culture

115
Q

Strep throat treatment

A

Routine - Penicillin V (250 or 500mg b./t.i.d. for 10d) or G (1 IM dose), 10d erythromycin for patients with penicillin allergy, or 10d cephalosporins
Carrier - Pen G, clindamycin, cephalosporins, or amoxicillin; 10d penicillin w/ rifampin last 4d

116
Q

Strep throat complications (5) w/cause, course, symptoms, treatment

A

Scarlet fever - from erythrogenic Strep exotoxin w/1-7d incubation: Fever, vomiting, headache, strep pharyngitis, chills, abdominal pain, rash first appearing in axilla/groin/neck, then generalized in 1d, followed by desquamation - Treat w/Pen 10d
Rheumatic fever - M type GABHS extracellular toxin: Carditis, migratory polyarthritis, erythema marginatum (almost looks like 2o Lyme disease), chorea, subcutaneous nodules, fever, arthralgia, high ESR/CRP, prolonged PR on EKG - Treat Strep, aspirin, steroids, bed rest, chorea w/anticonvulsants, heart failure w/bed rest, digitalis, diuretics; prevent relapse w/penicillin prophylaxis
Glomerulonephritis - GABHS infxn 1-2w prior: Hematuria (RBC casts), malaise, lethargy, abdominal/flank pain, fever, edema, oliguria, hypertension; check w/culture, serum C3, streptolysin O Abs; Treat w/Pen and for complications
Peritonsillar abscess
TSS - rare

117
Q

Rheumatologic diseases

A

Musculoskeletal conditions, pain syndromes, autoimmune syndromes w/o musculoskeletal components
“Pain about, but not in joints”

118
Q

What provides nutrients to cartilage

A

Synovial fluid made by the membrane (cartilage is avascular)

119
Q

Cartilage molecular structure

A

Hyaluronic acid backbone w/ proteoglycan attached

MW may reach 300m

120
Q

Synovial membrane thickness

A

1-3 cells thick

121
Q

Pathophysiology at cartilage causes … ?

A

Osteoarthritis

122
Q

Pathophysiology at bony end-plate causes … ?

A

Avascular necrosis

123
Q

Pathophysiology at synovial membrane causes … ?

A

RA

124
Q

Pathophysiology at joint space causes … ?

A

Gout

125
Q

Pathophysiology at enthesis causes … ?

A

Ankylosing spondylitis

126
Q

Rheumatologic history should include what?

A

Complete history
Time and rapidity of onset (Gout = rapid, RA = w/m, Fibromyalgia = slow)
Number of joints
Constitutional symptoms - systemic or local?
Response to therapy (Gout w/NSAIDs, FM w/exercise)
Functional status - define therapeutic end goals

127
Q

Rheumatologic physical should include what?

A

Complete physical and joints
Palpate joints
Evaluate swelling, tenderness, limited ROM
Function

128
Q

Rheumatologic labs

A

Useful for supporting Dx, not determining disease
CBC - assess systemic involvement, therapy contraindications
ESR, CRP - systemic inflammation?
RF, ANA - for classifying systemic polyarticular inflammatory arthritis, not diagnostic
Joint aspiration - diagnostic for crystal-induced, septic arthritis
X-ray - diagnostic in ankylosing spondylitis, osteoarthritis; follow RA progress

129
Q

Rheumatologic treatments

A

Exercise - CV conditioning for FM, ease pain in osteoarthritis
PT, OT
NSAIDs - risks of renal insufficiency, GI bleeds, CV risk
Corticosteroids - for flares, intraarticular injections useful for non-/inflammatory arthritis, systemic for inflammatory, autoimmune
DMARDs - treat underlying immune defect

130
Q

Articular symptoms shorter than 6w DDx

A

Crystal-induced (pseudo-/gout), septic, infectious arthritis, initial chronic presentation

131
Q

Noninflammatory arthritis longer than 6w DDx

A

Osteoarthritis

132
Q

Polyarticular arthritis DDx

A

RA, SLE, PsA

133
Q

Pauciarticular arthritis DDx

A 
Ankylosing spondylitis, Reiter's, PsA
Juvenile RA
Pseudo-/gout
Septic arthritis
Early polyarthritis symptoms

ICM2 (5 decks)

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