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Internal Medicine > JH IM Board Review - Infectious Disease III > Flashcards

JH IM Board Review - Infectious Disease III Flashcards

1
Q

Urogenital ulcer disease - 5 main ulcerative diseases:

A
  1. Genital herpes (HSV-2>HSV-1).
  2. Syphilitic chancre (T.pallidum)
  3. Chancroid (H.ducreyi).
  4. Donovanosis or granuloma inguinale (Klebsiella granulomatis).
  5. Lymphogranuloma venereum (C.trachomatis serovar L1, L2, L3).
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2
Q

Genital herpes - Clinical presentation:

A
  1. Cluster of vesicles on erythematous base.
  2. PAINFUL and pruritic.
  3. Dysuria.
  4. LAN.
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3
Q

Genital herpes - Dx:

A
  1. Tzanck prep, multinucleated giant cells (low se).
  2. Viral culture (70% se).
  3. PCR.
  4. Glycoprotein G-based serologies.
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4
Q

Genital herpes - Tx:

A
  1. Acyclovir.
  2. Famciclovir.
  3. Valacyclovir.
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5
Q

Syphilitic chancre - Clinical presentation:

A
  1. Single, PAINLESS ulcer at the site of inoculation.
  2. Clean base and raised, firm border.
  3. PAINLESS LAN.
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6
Q

Syphilitic chancre - Dx:

A
  1. Darkfield examination.
  2. Serology ==> Nontreponemal (RPR, VDRL).
  3. Treponemal (FTA-ABS, MHA-TP, TP-PA, EIAs).
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7
Q

Syphilitic chancre - Tx:

A

PCN.

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8
Q

Chancroid - CP:

A
  1. PAINFUL ulcer.
  2. TENDER inguinal LAN.
  3. Occurs in outbreaks.
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9
Q

Chancroid - Dx:

A
  1. CLINICAL.

2. Culture available but NOT widely used.

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10
Q

Chancroid - Tx:

A

Azithro OR ceftriaxone OR cipro.

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11
Q

Donovanosis or granuloma inguinale - CP:

A
  1. Painless papule or nodule erodes into beefy-red granulomatous ulcer with rolled edges.
  2. ENDEMIC in Far East Asia and Southern Africa.
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12
Q

Donovanosis or granuloma inguinale - Dx:

A

Donovan bodies on biopsy.

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13
Q

Donovanosis or granuloma inguinale - Tx:

A

Doxycycline or TMP-SMX ==> Tx AT LEAST 3 WEEKS.

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14
Q

Lymphogranuloma venereum - CP:

A
  1. PAINLESS genital ulcer.
  2. PAINFUL inguinal LAN (with GROOVE SIGN).
  3. Proctitis.
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15
Q

Lymphogranuloma venereum - Dx:

A
  1. CLINICAL syndrome.
  2. Serology.
  3. Complement fixation titers of at least 1:64.
  4. Nucleic acid amplification tests.
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16
Q

Lymphogranuloma venereum - Tx:

A

Doxycycline for 3 WEEKS.

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17
Q

Genital herpes - Predominant cause among young people?

A

NOW the HSV-1.

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18
Q

Seroprevalence of HSV-2 and HSV-1 in adults in the United States is …?

A

17% and 60% respectively.

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19
Q

Up to …% of cases of genital herpes are asymptomatic and unrecognized.

A

70%.

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20
Q

Genital herpes - Incubation period:

A

2-7 days.

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21
Q

Genital herpes - Viral shedding occurs EVEN …?

A

IN THE ABSENCE OF LESIONS.

==> The amount of shedding declines over time.

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22
Q

Prior infection with HSV-1 does not …?

A

PROTECT against incident HSV-2 infection.

==> Although incident HSV-1 in persons infected with HSV-2 is RARE.

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23
Q

Genital herpes - PRIMARY GENITAL HERPES LESIONS:

A

Primary genital herpes lesions are classically ==> PAINFUL.

==> Multiple, grouped on erythematous base.

==> Beginning as macules and papules, evolving to vesicles and ulcers.

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24
Q

Genital herpes - Local symptoms:

A
  1. Pain.
  2. Itching.
  3. Dysuria.
  4. Tender inguinal adenopathy.
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25
Q

Genital herpes - Primary lesions may accompanied by:

A
  1. Fever.
  2. Headache.
  3. Malaise.
  4. Myalgias.
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26
Q

Recurrent disease is less or more severe than primary?

A

LESS severe.

==> May be severe in immunocompromised.

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27
Q

Genital herpes - Extragenital complications:

A
  1. CNS involvement (Meningitis, encephalitis).

2. Urinary retention.

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28
Q

Genital herpes - Dx - Preferred method when NO active lesions are present?

A

SEROLOGY.

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29
Q

Genital herpes - Serology may be neg in …?

A

PRIMARY INFECTION.

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30
Q

Genital herpes - Serologic false pos may occur:

A

If the pretest probability of having HSV is LOW.

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31
Q

IgM serology for genital herpes?

A

Neither sensitive nor specific for primary infections.

==> There are no universal recommendations.

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32
Q

Presence of IgG antibodies to HSV-2?

A

Diagnostic of genital infection. (Anti-HSV-1 may reflect either orolabial or genital infection).

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33
Q

Genital herpes - Tx:

A

Systemic antiviral drugs (eg acyclovir, famciclovir, or valacyclovir) can be used as episodic or suppressive therapy.

==> They are ALL equally efficacious.

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34
Q

Genital herpes - Episodic Tx does NOT …?

A

Eradicate the virus OR reduce frequency of recurrences.

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35
Q

Genital herpes - DAILY suppressive Tx:

A

For patients with 6 or more recurrences per year can reduce the frequency by up to 80%.

==> Also prevents recurrences in 25-30% of pts; freq of episodes may diminish over time.

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36
Q

Genital herpes - Suppressive Tx does NOT …?

A

ELIMINATE SUBCLINICAL VIRAL SHEDDING.

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37
Q

Once-daily valacyclovir in the infected partner, in addition to consistent condom use, may help decrease transmission to an uninfected partner by approx. …%.

A

55%.

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38
Q

Primary syph - Chancre:

A
  1. Quickly erodes and becomes indurated with a CLEAN base + raised, firm borders.
  2. Atypical lesions occur in 60% of cases.
  3. Primary lesions may be accompanied by regional painless bilateral adenopathy.
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39
Q

Secondary or disseminated syph:

A
  1. Begins 2-8 weeks after appearance of chancre.
  2. May be associated with flu-like symptoms, generalized LAN, and temporary alopecia.
  3. Characteristic rash may be macular, maculopapular, papular, or pustular ==> May involve the whole body OR palms/soles.
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40
Q

Secondary or disseminated syph - Condylomata lata:

A
  1. Appear as raised, painless, gray-white lesions.
  2. Highly infectious.
  3. Develop in intertriginous areas and on mucous membranes.
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41
Q

Latent syph:

A
  1. Definition = Lack of clinical manifestations with positive serology.
  2. Latent syph acquired within the preceding year is EARLY LATENT SYPH.
  3. LATE latent syph implies acquisition more than 1 yr before Dx.
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42
Q

Tertiary syph:

A
  1. Implies late manifestations of syph.
  2. Gummatous syph results in skeletal, mucosal, ocular, and visceral lesions.
  3. Average time of onset is 4-12yrs after infection.
  4. Cardiovascular syph causes endarteritis of the aortic vasa vasorum ==> Average time of onset is 15yr (Aortic aneurysm, or Aortic valve insufficiency).
43
Q

Neurosyph:

A

Can occur AT ANY SYPHILIS STAGE (ie may be an early manifestation or a tertiary one).

44
Q

Neurosyph - Early:

A

MENINGOVASCULAR syph.

==> During the 1st yr after infection as meningitis (often, a basilar meningitis involving cranial nerves) particularly among HIV-infected persons.

45
Q

Neurosyph - Late:

A

Occurring many years after primary infection:

  1. May be meningovascular (presenting as stroke).
  2. Parenchymatous (manifesting as tabes dorsalis, electrical pains shooting down the legs).
  3. General paresis (personality changes, hallucinations).
46
Q

Auditory manifestations in syph:

A

May also occur during any stage of syph.

47
Q

Ophthalmic syph:

A

May occur at ANY STAGE + includes:

  1. Iritis.
  2. Uveitis.
  3. Neuroretinitis.
  4. Optic neuritis.
48
Q

Syph - Dx:

A

Darkfield exam of genital lesions + direct fluorescent antibody tests of lesion exudates or tissue ==> DEFINITIVE EVIDENCE.

49
Q

Syph - Dx - 2 types of serologic tests are used for presumptive Dx:

A
  1. Non treponemal tests (RPR + VDRL).

2. Treponemal tests (FTA-ABS, TP-PA, EIA and CIA).

50
Q

Nontreponemal tests:

A
  1. Often used as screening tests.
  2. Because of LOW SP, must be confirmed by a treponemal test.
  3. May revert to NEGATIVE, EVEN IN THE ABSENCE OF THERAPY.
51
Q

Syph - Dx - Treponemal tests:

A
  1. CIA or EIA now being used as screening tests instead of non treponemal tests.
  2. A positive test should reflex to a nontreponemal test; if the nontreponemal test is negative, a 2nd different treponemal test (usually the TP-PA) should be done to confirm the first positive treponemal test.
52
Q

Syph - Dx - Serologic tests may be NEGATIVE in approx. …?

A
  1. 30% of primary syph cases.
  2. 100% sens in secondary syph.

==> A negative RPR essentially rules out the diagnosis of SECONDARY SYPH in the absence of a prozone reaction.

53
Q

A confirmed positive treponemal test and a NEGATIVE non treponemal test may be seen with:

A
  1. Old treated syph.
  2. Old UNtreated syph.
  3. Prozone reaction.
  4. Early syph ==> Where the treponemal tests became reaction before the non treponemal ones.
54
Q

Neurosyph - Dx:

A
  1. Combination of serologic tests.
  2. CSF abnormalities (greater than 5 WBC/mm^3 +/- abnormal protein).
  3. Reactive CSF VDRL.
55
Q

CSF VDRL:

A

Highly specific but insensitive (50%).

==> Negative study does NOT exclude the diagnosis.

56
Q

CSF FTA-ABS:

A

Less specific but VERY SENSITIVE.

==> Negative study probably excludes neurosyph if the pretest probability is moderate to low.

57
Q

CSF exam is indicated in cases of …?

A
  1. NEUROLOGIC or OPHTHALMOLOGIC abnormalities.
  2. Evidence of active tertiary syph.
  3. Evidence of serologic treatment failure.
58
Q

Asymptomatic neurosyph?

A

HIV infection with a CD4 count less than or equal to 350 cells/mm3, or an RPR greater than or equal to 1/32, is associated with incr. risk of ASYMPTOMATIC neurosyph.

==> CSF exam may be considered.

59
Q

Syph - Tx:

A

Parenteral PCN G is the drug of choice.

==> Only accepted therapy with documented efficacy for neurosyph + syph during pregnancy is DESENSITIZATION followed by PCN therapy.

60
Q

The Jarisch-Herxheimer reaction:

A

Acute febrile reaction associated with headache and myalgias.

==> Thought to be activation of inflammatory cascade associated with lysis of spirochetes.

==> Can occur within the first 24h after Tx (particularly in early syph).

==> Tx = supportive.

61
Q

Syph - Tx - Response to Tx is monitored by …?

A

Change in titer of a non treponemal test (eg RPR) 12 (for primary, secondary, and early latent stages of syph) to 24 (for late syph) MONTHS after therapy.

62
Q

Syph - Tx - Response to Tx:

A

A 4-fold (or 2-dilution) decrease in RPR or VDRL tite (eg from 1:64 to 1:16) indicates CURE.

==> No change or increase in titer indicates failure of therapy.

==> Documentation of a titer response followed by a 4-fold increase indicates reinfection.

63
Q

Treponemal test (eg FTA-ABS) titers correlate with disease activity?

A

DO NOT correlate with disease activity or therapy and usually remain positive for life.

64
Q

In neurosyph - Quantitative non treponemal serologic tests should be repeated at …?

A

6-12-24 months.

==> CSF exam should be repeated 6 months after Tx.

65
Q

Recommended Tx regimens for syph - Primary, secondary, and early latent syph:

A

Benzathine PCN G - 2.4 million units IM in a single dose.

==> if PCN allergic - Doxy 100mg PO bid for 2 weeks, except pregnant patients, who should be desensitized and treated with PCN.

66
Q

Recommended Tx regimens for syph - Late latent syph, syph of unknown duration, or tertiary syph (gummatous and CVS syph):

A

Benzathine PCN G: 7.2 million units, administered as 3 doses of 2.4 million units IM each at 1-week intervals.

67
Q

Recommended Tx regimens for syph - Neurosyph:

A

Aqueous crystalline PCN G: 18-24 million units per day for 10-14 days.

68
Q

Urethritis and cervicitis - Basic info:

A

Discharge of mucopurulent or purulent material.

==> Principal etiologic agents are:

  1. N.gonorrhoeae.
  2. C.trachomatis.
  3. M.genitalium.
  4. T.vaginalis.
69
Q

Gonorrhea - Can involve:

A
  1. Genital tract.
  2. Rectum.
  3. Oropharynx.

or be DISSEMINATED.

70
Q

Gonorrhea - Incubation period is …?

A

3-7 DAYS.

71
Q

Gonorrhea - Symptoms manifest within:

A

10-14 days after exposure.

72
Q

Disseminated gonococcal infection (DGI) occurs in …?

A

1-3% of cases.

73
Q

Gonorrhea in men:

A
  1. Symptomatic in approx. 50%, with purulent urethral discharge or dysuria.
  2. Causes 30% of epididymitis cases in young men.
74
Q

Gonorrhea in women:

A

Women with cervicitis may have vaginal discharge or bleeding.

==> 50% may be asymptomatic.

==> Other syndromes in women: Urethritis, Bartholin gland abscesses, PID.

75
Q

DGI may present as triad of:

A
  1. Dermatitis with petechial or pustular acral skin lesions.
  2. Tenosynovitis.
  3. Asymmetrical migratory polyarthralgias, or as purulent arthritis without skin lesions.

==> Perihepatitis, endocarditis, meningitis, and osteomyelitis occur less commonly.

76
Q

Gonorrhea - Dx:

A

NAA tests are the tests of choice for genital and extragenital sites.

==> Extragenital testing is NOT FDA cleared but is routinely performed.

77
Q

Gonorrhea - Dx - Gram stain?

A

May show gram(-) intracellular diplococci.

==> Low sens in asymptomatic persosn and women.

78
Q

Dx of gonorrhea - Culture:

A

Thayer-Martin modified medium, Se approx. 85-90%.

79
Q

Gonorrhea - Retest?

A

Retest all patients 3 MONTHS after completing Tx because REINFECTION rates are HIGH.

80
Q

Gonorrhea - Tx:

A

Ceftiaxone 250mg IM x 1 PLUS 1g or oral azithromycin is first-line therapy.

==> ORAL cephalosporins are approved alternate agents but they may have lower activity against pharyngeal gonorrhea.

81
Q

Patients with pharyngeal gonorrhea require a …?

A

Test-of-cure 2 WEEKS after Tx to verify response if treated with oral cephalosporins.

82
Q

Gonorrhea Tx - Monotherapy?

A

NOT recommended due to incr. resistance.

83
Q

Azithro for gonorrhea?

A

Azithro monotherapy (2g) effective for BOTH gonorrheal infections + Chlamydial infections, but use is limited by GI distress and emerging resistance.

84
Q

DGI - Tx:

A

Should be hospitalized and treated parenterally with ceftiaxone and a single 2g oral dose of azithro.

==> May be discharged 24hours after clinical response to complete a 7-day course of ORAL cephalosporin.

85
Q

C.trachomatis - Basic info:

A
  1. D-K serotypes are the MC bacterial STD in the USA (C.trachomatis L1-L3 serotypes cause lymphogranuloma venereum (LGV)).
  2. Single biggest risk factor for D through K serotypes is YOUNG AGE.
86
Q

C.trachomatis - CP in women:

A

May present as cervicitis or urethritis.

==> May also have vaginal discharge + Lower abdominal pain + Dysuria.

==> Most cases are asymptomatic.

87
Q

C.trachomatis - CP in men:

A

May develop urethritis with dysuria and mucopurulent discharge ==> Most are asymptomatic.

88
Q

C.trachomatis - Epididymitis:

A

Manifests as unilateral testicular pain and tenderness, edema, and/or hydrocele.

89
Q

C.trachomatis - Dx:

A

Because asymptomatic infection is MC, annual screening of all sexually active women aged 25yrs or younger + older at-risk women is recommended to prevent sequelae.

90
Q

Untreated chlamydial infection in women is a major cause of …?

A
  1. PID.
  2. Ectopic pregnancy.
  3. Infertility.
91
Q

C.trachomatis - In men, untreated infection may result in …?

A

Prostatitis.

92
Q

C.trachomatis - Dx method of choice is:

A

NAA test.

93
Q

C.trachomatis - Tx:

A

Azithromycin or doxycycline are 1st-line agents.

==> Doxycycline is preferred for rectal infections.

94
Q

C.trachomatis - Tx - Alternatives:

A

FQ and erythromycin.

95
Q

C.trachomatis - Tx - In pregnancy:

A

Doxy and FQ ==> CONTRA.

96
Q

C.trachomatis - Tx - Test for cure:

A

Recommended after Tx with amoxicillin or erythromycin because these regimens may NOT be as efficacious, and side effects may discourage compliance.

97
Q

C.trachomatis - Reinfection:

A

COMMON - Increases PID risk - Repeat testing is warranted 3 months after therapy.

98
Q

C.trachomatis - Sexual partners in the preceding …?

A

60 DAYS (or the last sexual partner) should be referred for evaluation and Tx.

99
Q

Mycoplasma genitalium:

A

Causes acute and chronic urethritis.

==> Moderate to strong association with cervicitis and PID.

100
Q

Mycoplasma genitalium is the MCC of …?

A

Persistent urethritis in men.

101
Q

M.genitalium - Dx:

A

NAA tests are sensitive but NONE ARE FDA cleared.

102
Q

M.genitalium - Tx:

A

1g azithro orally is effective ==> BUT associated with emergence of resistance.

==> Longer azithro courses are probably better.

103
Q

M.genitalium - If resistant to azithro?

A

Moxiflox 500mg orally for 7-14 days.

Internal Medicine (106 decks)

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