KC ID Flashcards
*Compare and contrast staph vs. strep TSS
STAPH
- 15-30y
- women > men
- pain is rare
- erythroderma rash
- mortality <3%
STREP
- 20-50y
- either sex
- ++pain
- tissue necrosis
- mortality 30-70%
BOTH
- hypotension
- renal failure
- thrombocytopenia
*Treatment for TSS
- Fluid
- O2
- Source removed
- Pressors PRN
- Clindamycin 600-900 mg IV q8 + Tazo/Vanco
- Consider IVIG if poor response
*2 ways to test for botulism
- Detection of botulinum toxin in blood
- Detection of botulinum toxin or C. botulinum in gastric contents, stool, wound, or in the suspected food source
*Name of bacteria causing botulism
clostridium botulinum
*Differential diagnosis botulism
MG
GBS
Pontine infarct
Tick paralysis
Eaton-Lambert syndrome
Paralytic shellfish poisoning
*4 types of botulism. Which is the most common?
Infantile
Wound
Iatrogenic/ Inadvertent
Unclassified
Food borne
*infant is most common per Rosens
*List 2 specific treatments for botulism
Equine antitoxin
BabyBIG
What bacteria is responsible for pertussis
Bordetella pertussis
Explain the clinical progression of pertussis
Catarrhal: 1-2 weeks of URTI sx, cough, indistinguishable from other URTIs
Paroxysmal: 1-2 weeks of increasing cough with whoop +/- post tussive emesis
Convalescent: 1-6mo of a waning cough
Infants may present with apnea instead of the whooping cough
How is pertussis treated
Why do we treat it?
Azithromycin 500mg PO on day one and 250 mg PO day 2-5. Treatment does not reduce the severity of the illness but does help to reduce infectivity
Treat it because it decreases transmission from 3 weeks to 5 days
What pathogen causes tetanus
Toxin produced by Clostridium Tetani
What is the pathophysiology of tetanus
Neurotoxin binds to the motor nerve ending and irreversible blocks the presynaptic release of inhibitory GABA neurons. Without inhibition the motor neurons undergo sustained excitatory discharge, resulting in muscle spasm
What is the major cause of death in tetanus
Autonomic dysfunction: tachycardia, hypertension, hyperpyrexia, cardiac dysrhythmias, diaphoresis
List 3 complications of tetanus
Forceful tetanic muscle spasm can cause vertebral subluxation, fractures, joint dislocation, rhabdomyolysis, laryngospasms, airway edema, dysrhythmias
Think about ortho, rhabdo, dysrrhtymia
How is tetanus diagnosed? What is one clinical test?
Clinically; would cultures are of little value and positive only 30% of the time
Spatula test: touching the oropharynx with a tongue blade. +Ve test if this produces a reflex masseter muscle spasm and the patient bites down on the spatula
Spatula 94% sensitive 100 % specific
What is one differential for tetanus
Strychnine poisoning
What are the main principles of tetanus management
- Supportive care - benzos for spasm, labetalol for autonomic dysfunction, avoid unnecessary stimulation. Intubation and muscle paralysis if necessary
- Tetanus immunoglobulin 500 units IM OPPOSITE from wound to eliminate unbound and circulating toxins
- Prevention of further toxin production - Metronidazole 500mg IV Q6H5
- Vaccination - Tetanus toxoid 0.5mL IM at presentation, 6 weeks, and 6 months
When is tetanus prophylaxis indicated?
Fully vaccinated within 10 years: no vaccination or toxin
Partially or unknown vaccination with minor wound: vaccination only
Partially or unknown vaccination with minor wound: Tetanus toxoid 250mg IM + vaccination series
High risk wound: >6 hr old, >1 cm deep, contaminate, denervated, ischemic, infected
What is the difference between Tdap and DAPT? When are each used
DTP: Diphtheria, tetanus, activated pertussis. Used less now
TdAP: tetanus, diphtheria, acellular pertussis
Used in younger children and as a booster
Those younger than 7 years old should receive diphtheria-tetanus
or DTaP. Patients 7 years old or older should receive Tdap.
What are the 5 types of botulism
Food borne, baby botulism, wound botulism, unclassified botulism, inadvertent (ex. iatrogenic from cosmetic use)
What is the mechanism of paralysis in botulism
Neurotoxins bins to the presynaptic nerve membrane and inhibit the release of acetylcholine causing paralysis
What is the clinical presentation of botulism
Cranial nerve palsies: diplopia, blurred vision, dysphonia, dysphagia, ptosis, vertigo
Descending symmetric paralysis(proximal muscles are weaker than distal muscles)
Anticholinergic toxidrome (constipation, urinary retention, dry skin) and nausea, vomiting, abdominal cramps
No sensory or pain deficits. Reflexes are normal or diminished. Mental status is preserved
How is botulism diagnosed
Clinical diagnosis, confirmed with botulism toxin found in blood or wound (may need to send to special lab)
How is botulism differentiated from Guillain Barre, tick paralysis, or myasthenia gravis
Guillain Barre - ascending weakness with paraesthesia
tick paralysis - ascending weakness with limited bulbar involvement
Myasthenia gravis - pupillary response is preserved and no autonomic symptoms are present; improvement with ice or edrophonium
Name five differentials for infant botulism
Sepsis, viral illness, encephalitis, meningitis, failure to thrive, hypothyroidism, Guillain Barre, myasthenia gravis
What is the treatment for adult botulism? Baby botulism?
Adult: Horse immunoglobulin 1 vial
Baby: Human immunoglobulin
List 5 encapsulated organisms. What population is more at risk for infection?
SHiNE SKiS: Strep pneumo, Hemophilus influenzae, Neisseria meningitidis, E coli, Salmonella, Klebsiella, Streptococcus (group b)
Asplenia patients
What prophylaxis is recommended for meningococcemia
Close patient contact should receive antibiotics: rifampin 10 mg/kg q 12 h for 4 doses or 250 mg IM ceftriaxone + vaccination if available for the particular serotype
Define toxic shock syndrome
Clinical: fever >38.9, rash (diffuse macular erythroderma with desquamation), hypotension, multisystem involvement with three of: GI, muscular myalgias or elevated CK, mucous membrane hyperemia, renal, hepatic doubled liver enzymes, hematologic plt <100, CNS confusion
Lab: -ve cultures for anything other than staph, rise in titer to RMSK, leptospirosis, or rubeola
Probably if lab criteria + 4/5 clinical. Confirmed if lab + 5/5 clinical
Define strep toxic shock syndrome
Clinical: hypotension + two of: generalized rash, soft tissue necrosis, ARDS, renal cr >177, heme plt <100 or DIC, hepatic enzymes doubled
Lab: isolation of group A strep
Probably if clinical + group A strep from non sterile site. Confirmed if clinical + group A strep from sterile site (CSF, joint, pleural, pericardial)
List 5 risk factors for toxic shock syndrome
Foreign bodies: superabsorbent tampons, nasal packing
Wounds: post op wounds, postpartum
Co infection: bacterial infections, influenza, varicella
Co morbidities: cancer, ethanol, diabetes, HIV, chronic cardiac disease, chronic pulmonary disease
List 5 differentiating features between staph and strep toxic shock
Rash: more common in staph, less common in strep
Bacteremia: less common in staph (non invasive), more common in strep
Mortality: <3% for staph, 30-70% for strep
Age: 15-30 staph, 20-50 strep
Predisposing factors: tampons, packing in staph; cuts and burns in strep
List 5 differentials for a desquamating rash
Staph TS, strep TS, staph scalded skin, Kawasaki, Stevens-Johnson, TEN
What antibiotic is important to add in toxic shock
Clindamycin; prevents toxin formation
List 4 gram +ve bacilli
CLAN:Clostridium,Corynebacterium, Listeria, Actinomyces, Anthrax, Nocardia
Examples of clostridium: (C.diff,Tetani, Botulinum, Perfringens)
List 2 gram +ve cocci
Staph, strep, enterococcus
List 4 gram -ve bacilli
UTI bugs (Klebsiella, E.Coli, Enterobacter, Pseudomonas, Proteus,Serratia) + GI bugs (Shigella, Salmonella, Campylobacter, E coli, Yersinia)
List 2 gram -ve cocci
Gonorrhea, meningitides, catarrhalis
*5 diagnostic signs of measles
cough, coryza, and conjunctivitis
Koplik spots
nonpruritic maculopapular rash that begins on the head and face and spreads down the entire body
*5 ddx measles
rubella, roseola, dengue, Kawasaki disease, and drug rash.
acute respiratory viral illnesses with rash or even noninfectious illnesses that present with fever and rash
*2 lab tests for measles
The most common methods of confirmation are serologic testing for measles specific IgM antibody and detection of measles RNA by RT-PCR.
*3 infectious disease precautions to take
It is important, however, to observe appropriate isolation precautions in the hospital setting.
Infected individuals should have airborne isolation for 4 days after they develop the rash.
Negative pressure.
Family isolation
Consider post exposure prophylaxis for contacts with incomplete immunization
*When is the patient contagious
Patients are contagious 4 days before and 4 days after onset of the rash.
*3 things that are risks for contraction as a health care worker through airbourne means
TB, measles, covid
*What is the incubation time of ebola and how is it transmitted?
o 2-21days
o Droplet (Direct contact with blood, saliva, vomit, stool or semen
*3 signs and symptoms of chikungunya and how is it transmitted?
o Fever, Myalgias, Polyarthralgias
o Mosquito
*Three phases of dengue
- Febrile phase: Sudden high grade fever (>38.5 Celsius), headache, vomiting, myalgia, arthralgia, transient macular rash
- Critical phase: Systemic vascular leak syndrome, characterized by plasma leakage, bleeding, shock, and organ impairment
- Convalescent phase: Resolution of features of critical phase, an additional rash may appear
*Complications of acute varicella in children
- Secondary bacterial infection of skin lesions
- Disseminated disease and visceral organ involvement, if immunocompromised
- Pneumonia
- Encephalitis
- Aseptic meningitis
- Transverse myelitis
- Reye syndrome
*What treatment and why for varicella
Acyclovir if over 12, immunocomp, preggo, long term salicylate tx, chronic cutaneous or resp disorders
*Who needs varicella prophylaxis and how
Not in new Rosen’s but pregnant, immunosuppressed and neonates
*How long is varicella contagious?
Until all lesions scabbed over
*Risk factors for complications from varicella
Pregnancy, advanced age
*2 ways to differentiate the rash of varicella from from Smallpox
ZOSTER
- Lesions at different stages of healing
- fever and rash same time
SMALLPOX
- lesions at same stage
- fever before rash
*Stem describes secondary infection of VZV, what is the serious complication of this?
group A streptococcal infections and necrotizing fasciitis
*Pathogen for herpangina
Coxsackie A virus
*Vesicular rash anterior to ear: What cranial nerve could be affected, what is the syndrome called, what is the causative organism, 2 treatments, how long contagious?
- Cranial nerve VII
- Ramsay Hunt
- Herpes Zoster
- Acyclovir or valacyclovir
- non-infectious after crusting
F*ourteen days after coming in contact with another child (who two days later developed a rash), a 4 year old kid develops a papulovesicular rash on trunk and extremities after URTI symptoms. He now presents to the ED as now he is febrile, increasingly lethargic, and 3 of the lesions on his trunk are surrounded by 3 cm of erythema. These spots are tender. The patient looks toxic. On exam he is calm, and as described above. No other focus of infection is found.
a) What is the etiologic agent of this child’s primary condition?
b) What complication is the patient now demonstrating?
c) What OTC drug has been implicated in this complication?
d) If not treated aggressively with IV abx - what serious complications can result?
a) Varicella
b) Strep toxic shock syndrom
c) Ibuprofen
d) Nec fasc and death
*Precautions for specific conditions
C diff
NH in diaper
Infulenzae
VZV
TB
Pertussis
a) C diff - contact
b) NH in diaper?? - contact
c) Influenza - droplet
d) VZV - airborne
e) Tb - airborne
f) Pertussis - droplet
*Fever in returning traveler. What are incubation times (short <10 d, intermediate 10-14 d, long < 21 d, or very long – wks to mos)?
Diphtheria Short (1-8 days)
Rabies very long
Meningococcus Short
Amebic liver cysts Very Long (6 wks)
Malaria short to very long (not helpful)
*List 4 reportable conditions
Varicella
AIDS
Gono/Chlam
Syphilis
Rabies
Polio
Tetanus
List 4 DNA and 4 RNA viruses
DNA: Herpes viruses (HSV 1, HSV 2, EBV, VZV, CMV), Adenovirus, Papillomavirus, Hepatitis B, Parvovirus
RNA: Rotavirus, Coronavirus, SARS, Rabies, Ebola, Influenza, HIV, Rhinovirus, Norwalk virus, Yellow Fever, Dengue
List 3 live vaccines
smallpox, polio, measles, mumps, rubella, yellow fever, rotavirus, varicella, zoster
List 3 inactivated vaccines
hepatitis A (travelers), hepatitis B, influenza, rabies (post or pre exposure prophylaxis)
What is the clinical presentation of mumps?
Swelling of the parotid gland, 20-30% association with epididymitis/orchitis
What is 1 serious complication of measles
Subacute sclerosing panencephalitis - neurologic change (ataxia, behaviour change) that occurs years after the initial infection
What is the post exposure prophylaxis for measure for measles
MMR vaccine within 72 hours OR measles Ig IM for healthy infants or immunocompromised
What are features of congenital rubella syndrome
5s in birth defects: cochlear defect/hearing loss, cardiac defects, cataracts, microCephaly, cognitive delay
List 5 herpes viruses
HSV 1, HSV 2, CMV, VZV, HHV 6, EBV
List 5 clinical presentations of HSV
Gingivostomatitis and oral ulcers (HSV 1), genital lesions (HSV 2), encephalitis, herpetic whitlow, herpes encephalitis, herpes keratitis, herpes gladiatorum
List two clinical presentations of Varicella
Chicken pox, shingles
What medication should be avoided in Varicella? Why?
Aspirin; can precipitate Reye’s syndrome
What is Herpes Zoster
Latent reactivation of the varicella virus in a dorsal roll along a dermatome
What is Ramsay hunt syndrome
Pain + vesicular rash at the external auditory canal + facial nerve palsy
What is Hutchinson’s sign
Vesicle at the tip of the nose associated with ocular involvement
When is a patient with chicken pox no longer contagious
When all lesions have crusted over and scabbed
List 5 indications for antivirals in a patient with chicken pox
Patients older than 12, pregnant, immunocompromised, long term ASA therapy, patients who are on steroids or immunocompromised
Think >12 immunocompromised pregnant then 2 drugs steroids and ASA
Patient presents with fever, fatigue, and lymphadenopathy. What is the most likely viral pathogen and what counselling should be given to the family on discharge
Epstein- barr virus
Need to avoid contact sports to reduce the risk of splenic rupture
List 2 populations at particular risk for CMV
Pregnancy: can cause congenital CMV infection with teratogenic effects: microcephaly, growth retardation, hepatosplenomegaly, hearing loss
Immunocompromised: can cause fever, malaise, myalgias, leukopenia, pneumonia, hepatitis, encephalitis, retinitis
What is the treatment for CMV
Ganciclovir
What are enteroviruses? List 3 examples
RNA viruses that are able to multiply within the GI tract ex. poliovirus, coxsackie virus, enterovirus, echovirus
CEEPS
List 5 factors that increase the risk of contracting severe influenza
age <2 or >65, comorbidities (asthma, COPD, cardiac disease, renal insufficiency, hepatic disorders, hematologic conditions), immunosuppression, pregnancy or postpartum, obesity, residency in nursing home [Box 122.1]
Thought of a different way - people who really need a flu shot
What medication can be used in the treatment of influenza? When is it indicated?
Tamiflu 75 mg PO BID x 5 days
As early as possible (ideally within 48 hours of sx onset) but in everyone who is hospitalized, has severe illness, or at risk of complications
List 2 forms of coronavirus OTHER than COVID-19
SARS, MERS
What medication has demonstrated mortality benefit in COVID 19
Dexamethasone 6 mg PO or IV for 10 days
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, et al. Dexamethasone in Hospitalized Patients with COVID-19 – Preliminary Report. N Engl J Med. 2020.
Population: Hospitalized patients 176 sites in the UK
Intervention: Dexamethasone 6 mg PO or IV for 10 days
Control: Standard of care. This was an open label, randomized control trial
Outcome: Primary outcome 28 day mortality: lower in the dexamethasone group with RR 0.83. Subgroup analysis showed benefit only in those requiring supplemental oxygen or mechanical ventilation. Secondary outcomes showed lower hospital stay and risk of progressing to mechanical ventilation in the dexamethasone group
List 3 viruses that can gastroenteritis
Norovirus, rotavirus, adenovirus
RAN (adeno is weird think snotty kid with diarrhea I guess)
List 5 viral causes of encephalitis
HSV, Epstein-Barr, Cytomegalovirus, Rabies, West Nile, Japanese encephalitis, Eastern Equine Encephalitis, St. Louis Encephalitis, Varicella (esp in immunocompromised)
What vector is responsible for Dengue fever? For Chikungunya?
Aedes Aegypti and Aedes Albopictus mosquito (same for Dengue and Chikungunya)
Describe the clinical features of Dengue fever
Fever, headache, myalgias (break bone fever)
Hemorrhagic complications require: (Hemorrhagic Fever Virus Test): Hemorrhagic tendency, Fever, Vascular permeability (pleural effusion, ascites, etc), Thrombocytopenia low PLT
Describe the clinical features of Yellow Fever
Fever + jaundice + black emesis + albuminuria. May present with bradycardia
Visually I think of this as a sick bumblebee - fever, jaundice, black emesis “B” for bradycardia
Then also low albumin
List 5 causes of viral hemorrhagic fever
Dengue, Chikungunya, Yellow fever, Ebola, Malaria, Marburg, Lassa fever
How is Ebola transmitted? Someone in Brampton emerg saw their aunt who had Ebola 2 weeks ago - are they in the clear?
Droplets with infected blood or body fluids (including saliva, vomit, feces), contaminated needles
Highly contagious and high mortality 25-90% -> needs proper PPE and isolation
Incubation period is 3 weeks
What is Marburg?
Viral hemorrhagic fever clinically similar to Ebola
What is Lassa fever
Mild hemorrhagic fever caused by the African rodent Mastery natalensis. Ribavirin has been shown to decrease mortality
*How to give rabies Ig
• Rabies vaccine, intramuscular injection on days 0, 3, 7 and 14 (0, 3, 7, 14 and 28 if immunosuppressed)
• Human rabies immunoglobulin 20 U/kg should per administered soon after the bite occurs, with much of the RIG injected into and around the site of the wound, with the remainder injected intramuscularly at a distance from the vaccine administration site
*What are three methods to reduce the risk of rabies after being bitten by a raccoon
o Wound cleansing
o Injection of rabies Ig into and around site of wound, with remaining IG injected at IM site distant from vaccine site
o Injection of rabies vaccine at days 0, 3, 7, and 14 (add day 28 if immunosuppressed)
o If previously immunized, rabies IG not indicated and vaccine should be given at days 0 and 3
*Of the following animals, which are at risk of carrying rabies?
Dog Y
Cat Y
Rat N
Skunk Y
Raccoon Y
Rabbit N
Bat Y
What are the two clinical presentations of rabies
Prodrome: viral symptoms (fever, malaise, sore throat)
Encephalitic/furious: rapid progression of anxiety, confusion, cerebellar dysfunction, delirium, hallucinations, hydrophobia, aerophobia, hypersalivation, inability to handle secretions
Paralytic/dumb: ascending limb weakness with hyporeflexia, usually asymmetric
Eventually both end in coma and death
What is the incubation period of rabies
20-90 days
What is the rabies PrEP schedule
3 vaccines at day 0,7, 21 or 28
Which animals are considered high risk for rabies
Bat, raccoons, skunks, foxes, coyotes
Which animals are considered low risk for rabies
Rabbits/hares, squirrels, chipmunk, hamsters, guinea pigs, gerbils, rats, mice, small rodents
Patient is bitten by a domestic animal. Should they get rabies vaccination?
If animal available for observation -> no vaccination, start PEP at the first sign of rabies
If animal is unavailable or considered high risk -> vaccination
Patient is bitten by a wild racoon. What treatment should they get?
4 vaccines at days 0, 3, 7, 14 + additional day 28 if immunocompromised
Rabies immunoglobulin 20 IU/kg around the infected wound
Patient with previous PrEP is bitten by a wild racoon. What treatment should they get?
Two IM doses of vaccine on days 0 and 3. No IG is required
*List 8 AIDS defining illnesses
Too many to list here (see box 124.1)
Remember (CML)
C:
Candidiasis,
CMV,
CMV retinitis,
Cryptococcus extra pulmonary (remember cryptococcus meningitis) (Fungal),
cryptosporidiosis (Parasite)=
M:
Mycobacterium avium complex
Mycobacterium tuberculosis
L:
Lymphoma
Lymphoma (Burkitt’s)
Lymphoma CNS
Leukoencephalopathy (progressive multifocal leuckoencephalopathy)
Leukoplakia (Oral hairy leukoplakia)
And also remember the others that we already know
Kaposi
Herpes simplex
Toxoplasmosis
*3 illnesses with CD4 less than 50 and prophylaxis
If CD4 is less than 50, prophylaxis changes from Septra to Azithro (for disseminated MAC). 3 illnesses listed below but also:
CMV encephalitis
Primary CNS lymphoma
*Ddx for cough and fever in patient with CD4 = 50
Bacterial pneumonia
PCP
Toxoplasma gondii pneumonia
Pulmonary Kaposi’s sarcoma
Histoplasma capsulatum or Coccidioides immitis pneumonia
Mycobacterium avium complex pneumonia
*Chance of needle stick transmission with bloody needle
I assume this is the 0.33% referenced in Rosens if they are looking for a number, but if this was a super bloody hollow needle it’s considered high risk
*Chance of transmission intact skin
ZERO
C*hance with Pleural fluid in eye
Unless a mucocutaneous exposure involves large volumes of blood from a source patient with a plasma HIV viral load more than 1500 copies/µL, mucocutaneous exposures are considered to be low risk. Transmission is estimated to be as low as 0.09% (1/1000) for a splash of infectious body fluid to mucous membranes or broken skin.
*When would you want to initiate PEP by hours
If the exposed person is to receive PEP, the goal is to initiate therapy within 1 to 2 hours after exposure; the efficacy of PEP greatly decreases after 24 to 36 hours. PEP should be continued for 28 days or until the source patient tests negative for HIV. (In short, within 72h for 28d)
*When would you retest for HIV
Follow-up HIV testing should occur at 6 weeks, 3 months, and 6 months.
*What Hx/clinical/lab findings are suggestive of PCP (list 5)
Clinical:
- Gradual onset (>2 weeks)
- Non-productive cough
- Shortness of breath
- Fever
- Exercise-induced hypoxia
Diagnostic:
- CD4+ < 200 cells/mcL
- Elevated serum lactate dehydrogenase
- Bat wing appearance on CXR
*First line abx for PCP`
TMP-SMX x21days
*List 2 indications for steroids in PCP
Hypoxic patients (partial pressure of oxygen ≤ 70 mm Hg or an alveolar-arterial oxygen gradient ≥ 35 mm Hg)
*4 causes of ring-enhancing lesions on CT
- Toxoplasmosis
- Lymphoma (primary CNS lymphoma)
- Brain abscess
- Tuberculoma
- Brain mets
- Glioblastoma
- Subacute infarct/hemorrhage/contusion
*Which is higher transmission
• Receptive anal vs percutaneous needlestick
• Transfusion vs sharing IV drugs
*Transmission risk:
• receptive anal intercourse:
• receptive vaginal:
• insertive anal intercourse:
• insertive vaginal intercourse:
• receptive anal intercourse: 1 - 30%
• receptive vaginal: 0.1 - 10%
• insertive anal intercourse: 0.1 - 10%
• insertive vaginal intercourse: 0.1 - 1%
*List five organisms causing altered LOC and fever specific to immunocompromised patients
• Primary CNS lymphoma
• Toxoplasma
• Cytomegalovirus
• Cryptococcus neoformans
• TB
• HSV encephalitis
• VZV encephalitis
*List five organisms that can cause SOB, fever, and cough in HIV
Strep pneumoniae
H. flu
Pneumocystis jiroveci
Mycobacterium tuberculosis
Cryptococcus neoformans
Mycobacterium avium complex
*List 4 factors that determine the risk of HIV seroconversion after needle stick injury
- Deep injury
- Device contaminated with patient’s blood
- Injury into vein/artery
- Terminal injury in source patient
- Hollow bore needle
*Risk of HIV seroconversion after needle stick
< 0.33%
*What are the quoted transmission rates by needlestick of these pathogens?
1) 0.3% for HIV
2) 1-40 % for Hep B
3) 3-10% for Hep C
*CD4 count for toxoplasma encephalitis
< 100
What type of virus is HIV?
RNA reverse transcriptase
Describe the timeline and clinical presentation of HIV infection
Initial infection; asymptomatic
2-4 weeks: non specific virus symptoms with fever, fatigue, lymphadenopathy. BW often negative
3-8 weeks: seroconversion
Clinical latency with no physical findings on exam
3-10 years: development of AIDs
What is the definition of AIDS
HIV + CD4 count <200 or the presence of an aids defining illness
List 2 cardiac manifestations of AIDS
Endocarditis, myocarditis
Cardiovascular disease is higher risk in ART, but benefits still outweigh risks
List 4 GI manifestations of AIDS
Oral thrush, oral hairy leukoplakia (caused by EBV), aphthous ulcers
Esophageal candidiasis
Comorbid hepatitis
List 2 renal manifestations of AIDS
HIV associated nephropathy, HIV immune complex disease
ART related kidney damage
List 2 heme manifestations of AIDs
Leukopenia, thrombocytopenia
List 2 dermatologic manifestations of HIV
Kaposi sarcoma, molluscum in an adult, HPV, HSV, Varicella, scabies, fungal infections, seborrheic dermatitis
List 2 opportunistic infections that present when CD4 counts are <200
PJP pneumonia, Kaposi sarcoma, oral thrush, local or disseminated fungal infections ex. cryptococcus, histoplasma
List 1 opportunistic infection that present when CD4 counts are <100
CNS toxoplasmosis
List 1 opportunistic infection that presents when CD4 counts are <50
CMV infection, Mycobacterium avium complex
How is HIV diagnosed
p24 antigen screen and PCR for confirmation
(Western blot and ELISA are also appropriate confirmatory tests; just not as done frequently)
List three medications that can be used for PEP
Truvada (tenofovir, emtricitabine) + dolutegravir
What prophylaxis is recommended for opportunistic infections in HIV
CD4 <200 Septra for PCP
CD4 <100 Septra for toxoplasmosis
CD4 <50 Azithro for MAC
*What is the vector for malaria?
Anopheles mosquito female
*Name the 5 malaria organisms
Plasmodium Vivax
Plasmodium Ovale
Plasmodium Malaria
Plasmodium Knowlesi
Plasmodium Falciparum
FUCK falciparum
OFF ovale
KNOWING knowlesi
MALARIA malaria
VARIANTS vivax
*What level of parasitemia defines a severe falciparum infection?
> 5%* (Public Health Agency Canada)
*What are the 5 symptoms/findings of a severe falciparum infection?
Clinical:
GCS <11
Multiple seizures
Prostration (laying face down on ground)
Shock
Spontaneous bleeding
Jaundice
Lab:
Lactate >5
Hgb <70
Cr >300
DIC
Parasitemia>2%
*What is the first-line IV treatment for severe falciparum malaria?
Artesunate (as per CDC and uptodate) but often unavailable, interim:
Quinine and doxy (or clinda)
Atovaquone-proguanil (Malarone)
Artemether-lumefantrine
Chloroquine is no longer first line due to resistance
*8 yr old, febrile, recent travel to Cambodia, maculopapular rash on torso and extremities, blanchable
a. What are 6 diagnoses that must be considered?
- Malaria
- Dengue fever
- Chikungunya
- Typhoid fever
- Measles
- Leptospirosis
- Sepsis/bacteremia
*5 specific questions on history you need to ask?
- Immunization history
- Sick contacts
- Timeline
*Besides a CBC, differential, electrolytes, BUN, creatinine, and liver enzymes, what 4 other investigations would you order?
- Thick/thin blood smears
- Antigen detection/rapid diagnostic test
- Blood cultures
- LDH
Patient stable after Tylenol for fever, what are 2 discharge instructions you would give?
- Return if worsening symptoms
- Arrange follow-up for repeat testing
*What is the gold standard diagnosis for malaria?
Light microscopic examination of thick and thin blood films
*Malaria
- What is the “gold standard” test for diagnosis of Malaria?
- The rapid screening test is negative. What test would you like to perform to ensure a negative result?
- You order an abdominal ultrasound? What two findings are you looking for with P. Falciparum infection?
- What are two causes of anemia in the patient infected with p. Falciparum?
- List 6 severe complications of p. Falciparum malaria?
- List 3 common medications used to treat malaria?
- What is the vector that carries malaria?
- Light microscopic examination of thick and thin blood films
- Light microscopic examination of thick and thin blood films (repeat q12h total of 3). PCR is another option.
- Splenomegaly and optic nerve sheath diameter
- Hemolysis, decreased epo production, cross reactivity with unaffected RBCs
- cerebral malaria, massive hemolysis, ARDS, ATN, DIC, blackwater fever, hypoglycemia, acidosis
- chloroquine, quinine, quinidine, doxycycline, artesunate
- anopheles mosquito
What is the incubation period of malaria
7-9 days (i.e. you can’t have malaria 3 days into your trip)
Can present several months after infection as the disease sequesters in the liver
Which malaria variant is associated with the most morbidity
Falciparum
List three parasites that can cause neurologic symptoms
Cerebral malaria, cysticercosis (larva from undercooked pork), echinococcosis (tapeworm), African trypanosomiasis (sleeping sickness)
List three parasites that can cause anemia
Malaria, hookworm, ringworm
*Organism that causes lyme
Borrelia burgdorferi
*5 acute manifestations of lyme
examples from TABLE 126.2
1. myalgias
2. fever
3. Fatigue / malaise
4. arthralgias
5. Adenopathy
*3 PO abx for lyme and duration
- Doxycycline
- Amoxicillin
- Cefuroxime
21 days
*What is the name of the rash associated with lyme disease?
Erythema migrans
*Lyme neurosequelae
- Fluctuating meningoencephalitis (headache, lethargy, irritability, sleep disturbances, poor concentration, memory loss)
- Cranial neuropathy (usually Bell’s palsy, sometimes bilateral)
- Peripheral neuropathy
- Radiculopathy
- Transverse Myelitis
*2 EKG changes from lyme
- AV block
- tachydysrhythmias
- myopericarditis signs
*3 cardiac manifestations of lyme
AV block
Myopericarditis
Tachydysrhythmias
Ventricular impairment
*What is the vector for lyme?
Ixodes scapularis
*Indications for lyme prophylaxis
1 - Tick is an adult or nymphal Ixodes scapularis
2 - Tick has been attached for 36 hours or more, as indicated by certainty of the time of exposure or degree of engorgement
3 - Prophylaxis can be started within 72 hours of tick removal
4 - Local rate of infection of these ticks with Borrelia burgdorferi is 20% or greater
5 - Doxycycline is not contraindicated
*What is lyme prophylaxis
single 200-mg dose of doxycycline
*Most common early finding of lyme disease
Erythema migrans, recognized in 90% or more of patients
*4 long term manifestations that may arise from lyme
include one long term derm manifestation
Chronic encephalopathy
Psychiatric disturbances
Sensory polyradiculoneuropathy
acrodermatitis chronica atrophicans
List the 3 clinical stages of lyme disease
Early localized (days-week): erythema migrans, flu-like illness, hepatitis, conjunctivitis, pharyngitis
Early disseminated (>1mo): neurologic (encephalitis, CN palsy, meningitis), cardiac (AVB, carditis), arthritis (monoarticular)
Late (>1 yr): arthritis, chronic encephalopathy, radiculopathy, fatigue
What is the treatment for lyme disease
Doxycycline 100mg PO BID for 21 days (consider shorter duration in children, consider longer duration if neurologic or cardiac symptoms)
In what population should doxycycline be avoided
Pregnancy patient; these patient should get amoxicillin
A patient is treated with lyme but returns 2 days later with a fever and worsening symptoms. What happened?
Jarisch-herxheimer; due to the release of endotoxins
What organisms is responsible for Rocky Mountain Spotted Fever
Rickettsia Rickettsi
List clinical and laboratory features of RMSF
Clinical: fever + one of: rash, eschar, headache, myalgias, anemia, thrombocytopenia, elevated liver enzymes
Laboratory: change in titres reactive to Rickettsia Rickettsia
Besides lyme disease, name 5 tick borne illnesses and their defining characteristics
Relapsing fever: Borrelia Burgdorferi - febrile illness with 3 days of fever then relapsing cycles of viral illness. Rx with tetracycline
Tularemia: Francisella tularemia - ulcerative lymphadenopathy, similar to the bubonic plague. Also transmitted by deer, rabbit, rodents. Rx with streptomycin
Rocky Mountain Spotter Fever: Rickettsia rickettsia - fever + petechial rash
Q fever: Coxiella burnettii - fever + CHF/respiratory symptoms in farmers exposed to sheep/cattle
Ehrlichiosis: Erlichia chaffeeniss - fever + viral symptoms + cytopenia. Rx with tetracycline
Babesiosis: Babesia - fever + malarial-like illness. Rx with Atovaquone + azithromycin
Colorado tick fever - Orbinirus virus - fever + tick bite in Rocky Mountains (more common than RMSF). Self limited, no treatment necessary
*Ddx cavitating lesions
Fungal infection ( histoplasmosis, blastomyces)
Malignancy
Septic emboli
Wegener’s disease
Staph aureus
Sarcoidosis
Klebsiella
Upper lobe bullous disease / Pneumatocele
Infected PE
Neurofibromatosis
MAC
*What are three infection control mechanisms will you institute with a patient with active TB in the ED?
Notify infection control
N95 mask - airborne precaution
negative pressure room
*5 risk factors for tuberculosis
1) HIV
2) close quarters (military, native american, LTC)
3) travel to endemic area
4) homeless
5) IVDU
6) Close contact with patient with TB
7) Occupational exposure
8) Foreign born
*What are 4 LUNG complications of TB other than hemoptysis?
PTX
Pleural eff
Empyema
Superinfection with fungi
Abscess
*List in correct order 6 methods to don PPE prior to an airway assessment with TB
1 - Perform hand hygiene
2 - Put on gown
3 - Put on N95 respiratory
4 - Put on eye protection
5 - Put on gloves
*3 reasons, specific to TB, to cause massive hemoptysis
- Destruction of lung parenchyma
- Erosion into pulmonary artery/pseudoaneurysm formation
- Superinfection of cavities by invasive organisms/tumor development causes erosion of bronchial/pulmonary vessels (esp. aspergilloma)
*3 different image modalities that can be used for massive hemoptysis in TB
- Chest X-ray (portable)
- POCUS
- CT angiography
- Bronchoscopy
*3 temporizing measures you can do in the emerge until definite management
- Reverse coagulopathy (PCC, TXA, DDAVP as indicated)
- Intubation with large diameter 8.0 ETT
- Bleeding lung down position
- Main-stem intubation if no improvement
- TXA Nabs
- MTP
List 5 extra pulmonary manifestations of TB
Painless lymphadenopathy (scrofula), hepatosplenomegaly, peritoneal tubercles, prostatitis, epididymitis or orchitis, adrenal insufficiency, bone pain, spinal TB (Pott’s disease), renal failure, pericarditis, tuberculous meningitis
List 3 x ray findings of TB
Parenchymal infiltrates, hilar and mediastinal adenopathy, effusions, healed lesion creating a calcified scar
Describe a Ghon, Simon, and Ranke focus, and a Rassmussen aneurysm
Ghon focus: healed lesion creating a calcified scar
Simon focus: calcified secondary foci of infection
Ranke complex: Ghon focus + calcified hilar nodes
Rasmussen aneurysm: erosion of the cavitary TB into the pulmonary artery, causing pseudoaneurysm formation and massive/fatal hemoptysis
List 4 potential first line treatments for TB
rifampin, isoniazid, pyrazinamide, ethambutol RIPE
*2 bugs per age group in septic arthritis (listed above in arthritis as well)
Neonate to <3 mo - Staphylococcus aureus, GBS
3mo - 14y - Staphylococcus aureus, GAS
14y - adult - Staphylococcus aureus, strep spp, GNR
Sickle cell - Staphylococcus aureus, Salmonella
IVDU - Staphylococcus aureus, Pseudomonas
*5 risk factors for septic arthritis
DM
Sickle cell (Salmonella)
AIDS
Alcoholism
IVDU (Pseudomonas)
Chronic corticosteroids
Preexisting joint disease
Other immunosuppressed state
Post-surgical patients
Prosthetic devices
*5 causes of monoarticular arthritis
o Septic arthritis
o Gonococcal arthritis
o Gouty arthritis - Pseudogout
o Osteoarthritis
o Trauma/hemarthrosis
List 4 etiologies for osteomyelitis
Open fractures, hematogenous spread, surgery, trauma (ex. bites, puncture wounds)
List 3 microbes responsible for osteomyelitis in neonates
Group B strep, Ecoli (gram -ve rods), Staph aureus
List a bacteria likely associated with 1) fresh water exposure, salt water exposure 2) dog or cat bite 3) human bites (2) 4) puncture wounds through rubber shoes 5) risky sexual behaviours 6) sickle cell
1) Aeromonas hydrophilia (fresh), vibrio (salty)
2) Pasteurella
3) strep, fusobacterium, eikenella
4) pseudomonas
5) gonorrhea
6) salmonella
List 4 risk factors for the development of osteomyelitis
diabetes, sickle cell, AIDs, alcoholism, IVDU, steroid use, immunocompromised, joint disease, recent surgery, indwelling lines
List 5 x ray findings of osteomyelitis
soft tissue swelling, air in the soft tissue, periosteal reaction, bony destruction with lytic lesions (black), cyst formation, non union, heterotopic bone formation (white), collapsed joint lines
List 3 antibiotics that can be used in the treatment of osteomyelitis
1st generation cephalosporin ex. ancef, 3rd generation cephalosporin in concern for gram negative bacteria ex. ceftriaxone, fluoroquinolone if concern for pseudomonas ex. ciprofloxacin
List 6 complications of osteomyelitis
Chronic osteomyelitis, septic arthritis, bacteremia, sepsis, local spread (meningitis, brain abscess, epidural abscess), pathologic fracture, growth alteration in children
List 4 diagnostic modalities that can be used to image osteomyelitis. Which is the best
X ray (findings lag), CT, bone scan, MRI (gold standard)
What is the gold standard diagnosis of osteomyelitis
Direct tissue or needle aspiration
List 4 antibiotics that have ESBL coverage
FatCAT: fosfomycin, carbapenems (meropenem), aminoglycosides (gentamycin), tigecycline
List 5 antibiotics that have VRE coverage
Linezolid, daptomycin, tigecycline, chloramphenicol, high dose ampicillin, nitrofurantoin
List 5 antibiotics that have MRSA coverage
Septra, doxycycline, clindamycin, linezolid, vancomycin, tigecycline, daptomycin
List 4 antibiotics that have pseudomonal coverage
Ceftazidime, cefepime, piptazo, ciprofloxacin, meropenem, tobramycin, colistin
What is reactive arthritis
Sterile secondary inflammation of a joint with no infecting microorganisms on the synovial fluid
What triad is associated with gonococcal septic arthritis
Migratory polyarthralgias, tenosynovitis, dermatitis
What is the Kocher criteria
Fever >38.5, inability to weight bear, ESR >40 (or CRP >20), WBC >12
What should you include on synovial analysis
Gram stain, culture, cell count and differential, crystals, glucose, protein, lactate
What findings on synovial fluid analysis indicate gout? pseudogout?
MoNosodium urate crystals = gout, Needle shape, Normal gout
Calcium Pyrophosphate crystals = Pseudogout
What finding on synovial fluid analysis indicate septic arthritis
WBC >50x 10e9 (traditional cutoff, but only 61% sensitive)
What empiric antibiotics would you start in someone with a clinical suspicion of septic arthritis
Ceftriaxone + vancomycin
(Ancef appropriate in peds)
*4 Non-Pharmacological management for cat bites (copied from mammalian bites)
• Wound cleansing
• Water Irrigation
• Wound exploration
• Splint/elevation
• Plastic surgery/Hand surgeon consultation
*Bacteria to be concerned about in cat bites
Pasteurella species
*Antibiotic for cat bites (and human bites and sutured dog bites)
AmoxiClav
*THREE complications of a cat bite
Abscess
Cellulitis
Tenosynovitis
Septic joint
Osteomyelitis
Mycotic aneurysm
*5 clinical signs and symptoms of NEC fasc
- Rapid spread
- Pain out of proportion
- Violaceous/ecchymotic skin changes
- Crepitus
- Anesthesia over involved tissue (due to infarction of superficial nerves)
- Wooden-hard subcutaneous tissue
- Ill-appearing/hemodynamically unstable
*What is the gold standard for Dx for nec fasc
“characteristic appearance of the tissue by direct visualization in the operating room”
*5 management steps for nec fasc (including specific abx)
- Critical care resuscitation (IV crystalloid, vasopressors as indicated)
- Broad-spectrum antibiotics (Piperacillin- tazobactam, vancomycin, clindamycin)
- Surgical consultation/source control
- Blood culture
- Group and screen
- Airway management as indicated
*True/false - hyperbaric therapy useful in nec fasc
True but should not delay surgery
*5 risk factors for necrotizing infection
Type I (polymicrobial):
Diabetes
IV drug use
Obesity
Immunosuppression
recent surgery
traumatic wounds
peripheral vascular disease
Type II (single organism - often GAS):
any age group, especially without any medical history
history of skin injury (eg laceration or burn)
blunt trauma
recent surgery
Childbirth
injection drug use
varicella infection (chickenpox)
*Fight bite pathogens
Streptococcus
Staphylococcus
Eikenella corrodens
Bacteroides
*Fight bite antibiotic if pen allergic
Clindamycin + Septra
*Management plan for signs of rapidly advancing infection after fight bite
Irrigate
IV Abx
TD immunization
xray look for FB
plastic surgery consult
What bacteria is associated with puncture wounds through the sole of a shoe
Pseudomonas
What bacteria is associated with saltwater exposure? Freshwater? Fishtank?
Vibrio vulnificus, Aeromonas, Mycobacterium marinum
What bacteria responsible for the formation of a black eschar with raised border
Bacillus anthracis (anthrax)
List 5 antibiotics that can be used in the treatment of cellulitis, and specific indications for each
Cephalexin: uncomplicated cellulitis
Septra: MRSA concern
Doxycycline: tick bite, fresh or salt water exposure
Clindamycin: pen-allergic, nec fas
Ciprofloxacin: diabetic foot, pseudomonal concern
What is erysipelas
Superficial skin infection with clear demarcations and prominent lymphatic involvement
What is hidradenitis suppitiva
Inflammation of apocrine bearing skin caused by occlusion of follicles - non infectious
What is the clinical presentation of staph scalded skin
Infant with fever and a tender, bullous rash with +ve Nikolsky. Does not involve mucus membrane. Endotoxin
List 5 causes of a desquamating rash
SJS, SSS, toxic shock, bullous pemphigoid, TENS, pemphigus vulgaris
List 6 risk factors for MRSA
Hospital acquired: recent hospitalization, resident of long term care facility, healthcare worker, invasive procedures (indwelling lines), hemodialysis, recent antibiotics
Community acquired: crowding (dorms, prisons), contact, homeless, IVDU, immunocompromised
*5 “strong” recommendations from 2021 surviving sepsis guidelines
- start IV antimicrobials ASAP and within 1h
- choose broad spectrum antimicrobials to cover all possible microbes
-Crystalloid for fluid resuscitation - Target MAP >65
- Nor-epi is first choice pressor
Tidal volume 6cc per kilo
Keep platueau pressure <30
*What inotrope is used for fluid and vasopressor refractory shock?
Dobutamine
*TV and Pplat for ARDS
TV: 6cc/kg
Plateau pressure: 30 cm/H20
*4 interventions for low Sv02
- Fluid resuscitation
- Use of vasoactive agents: norepinephrine, dobutamine
- Reduce work of breathing by mechanical ventilation
- Transfusion of packed RBCs (goal: hematocrit >= 30)
*3 goals other than SvO2 (> 70%) in fluid resuscitation
MAP > 65 mmHg
CVP > 8-12 mmHg ** not followed anymore
Urine output (goal: >0.5 ml/kg/hr)
Lactate clearance
*How to calculate MAP
[1 SBP + 2 x DBP] / 3
What are the components of qSOFA
Hypotension <100, Altered mental status, Tachypnea
What is the definition of sepsis
Life threatening organ dysfunction caused by a dysregulated response to an infection
*6 causes of hyperthermia
Infection
Malignancy
Pancreatitis
Trauma
Transfusion reaction
Kawasaki
JRA
ICH
Connective tissue disorder
Hyperthyroidism
Serotonin syndrome
NMS
Malignant hyperthermia
Environmental Hyperthermia
*5 non-infectious causes of fever in an oncology patient
Transfusion reaction
Drug reaction
Tumor burden
Tumor lysis
PE
Invasive procedure
List 7 non infectious cases of fever
Structural: ACS, PE, ICH, pulmonary edema
Tox: NMS, serotonin syndrome, anticholinergic toxidrome, sympathomimetic toxidrome, recent seizure, malignant hyperthermia
Endocrine: Thyroid storm, adrenal insufficiency
Immune: transfusion reaction, drug reaction, lupus, pancreatitis, malignancy
Environmental: heat stroke
Differentiate between fever and hyperthermia
Fever is an increase in the body’s set point, rarely above 41 degrees
Hyperthermia is caused by an inability to dissipate enough heat
5 complications of pertussis
Case defintion of pertussis
The possible cases are also who we test in
3 Risk factors for tetanus
unvacicnate (number 1 RF), >65, IVDU
4 types of tetanus?
Generalized - classic form with masseter spasms or lockjaw, opisthonosis, sardonic smile, autonimic changes. 4 weeks to recover patients lucid.
Localized - muscle spasm near site of wound, better mortality. Might be from partial immunity
Cephalic - isolated CN spasm - most common 7 (Bells). 1/3 go to generalized and 1/3 get better. think OM or trauma as source.
Neonatal - generalized tetanus of newborn. Dirty instruments to cut cord. 100% mortality
What is some relevent pathophysiology of tetanus?
Not invasive needs a portal to get in (why we think of wounds)
Hard to test for because only mature forms create toxin, takes a long time to grow, might not even see puncture no cellulitis
The toxin itself is actually everywhere in soil ect but needs to get into the right host to duplicate
