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X Clin Med Exam 2 > L11 Upper Respiratory Infections > Flashcards

L11 Upper Respiratory Infections Flashcards

1
Q

Virology of Common Cold

A

Mostly rhinovirus (parainfluenza virus and respiratory syncytial virus seen in peds)

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2
Q

Main presentation of Common Cold

A

Rhinorrhea, nasal congestion

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3
Q

Other symptoms of Common Cold

A

Sore throat, non-productive cough, malaise/mild headache, low-grade fever (all usually resolving in 3-10 days), nasal mucosal swelling, nasal discharge (clear, watery, purulent), +/- conjunctival infection, no pulmonary findings or adenopathy

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4
Q

What is not useful in the treatment of common cold?

A

Antibiotics will not help

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5
Q

Treatment of common cold

A

Fluids/rest etc, analgesics (acetominophen, NSAIDs), topical analgesics for sore throat (chloraseptic/sucrets), antihistamine/decongestant combo, expectorants/antitussives (guaifenesin separate or with dextromethorphan for cough)

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6
Q

Specific drugs for common cold

A

Acetominophen, NSAIDs, Chloraseptic, Sucrets, Guaifenesin (Robitussin), Guaifenesin with dextromethorphan (Robitussin DM)

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7
Q

Main presentation of Influenza

A

Abrupt onset, fever (can be very high), myalgia, sore throat (can be severe)

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8
Q

Other symptoms of influenza

A

Chills, malaise, headache, cough (usually non-productive), nasal discharge +/-, flushing, hot/dry skin, unremarkable posterior pharynx, mild cervical LAD, negative chest exam

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9
Q

High risk groups for Influenza

A

Adults >65, children <5 (mostly <2), chronic illnesses/asthma/cardiac/DM/renal or liver disease, immunosuppression (glucocorticoids, HIV/AIDS), pregnant women or post partum (within 2 wks), healthcare workers, residents of nursing homes, Native Americans, BMI >40

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10
Q

Outpatients who should be tested for Influenza during the season

A
  1. Immunocompetent with fever/respiratory symptoms after hospital admission regardless of onset
  2. Immunocompetent but high risk patients presenting within 5 days of illness onset
  3. Immunocompromised patients with acute febrile respiratory illness or community acquired pneumonia regardless of of onset
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11
Q

Inpatients who should be tested for Influenza during the season

A

Any patient with acute febrile respiratory illness, regardless of time of illness onset

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12
Q

When should diagnostic testing be done for Influenza

A

Within first 3-4 days of illness

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13
Q

Rapid Antigen Tests (RAT)

A

Nasal pharyngeal aspirate/swab and wait 15 minutes for results, some can distinguish type A/B, screening test

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14
Q

Immunofluorescence

A

Nasal swab/washing, 1-4 hours for results, can differentiate types A/B, screening test

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15
Q

Rapid Molecular Assay

A

NP swab and 15-30 minutes for results, higher sensitivity and specificity because distinguishes type A/B, currently limited availability

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16
Q

RT-PCR

A

NP swab/sputum and 1-8 hours for results, MOST sensitive and specific, used when you want an influenza type and subtype

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17
Q

Viral cultures

A

Viral tissue cell cultures come back in about 3-10 days, GOLD standard for lab diagnosis, not for initial clinical management but for confirming a screening

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18
Q

Reasons to order RT-PCR or viral culture for Influenza

A
  1. Negative RAT or immunoflorescent antibody staining screening test but community influenza rates are high
  2. Positive RAT or immunoflorescent antibody staining screening test but community influenza rates are low (test if vaccine is right in the first cases)
  3. Patient has recent exposure to pigs/poultry and there is worry for novel influenza A virus
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19
Q

Indications for antiviral treatment of Influenza

A

Illness requiring hospitalization, progressive/severe/ complicated illness, high risk for complications

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20
Q

What is the timeline for antiviral treatment of influenza?

A

Must be within 24-30 hours of onset of symptoms

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21
Q

Antiviral medication for influenza

A

Prophylaxis for at risk groups within 30 hours can reduce symptoms, tends to shorten course by 1-2 days

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22
Q

Type of antiviral drug used for influenza A/B

A

Neuraminidase inhibitors

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23
Q

Types of neuraminidase inhibitors used for influenza

A
  1. Oseltamivir (Tamiflu)- 75 mg po bid x 5 days
  2. Zanamivir (Relenza)- 10 mg (2 inhalations) bid x 5 days
  3. Peramivir (Rapivab)- 600 mg IV x 1
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24
Q

When would you use neuraminidase inhibitors in a pregnant patient?

A

They are Category C but if confirmed, probable or suspected influenza A during the pregnancy

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25
Q

Contraindications of Zanamivir

A

Patients with asthma/chronic respiratory conditions

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26
Q

Complications of influenza

A

Pneumonia, rhinosinusitis, otitis media, myositis/rhabdomyolysis, CNS involvement, cardiac complications

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27
Q

Influenza vaccines

A
  1. Trivalent inactivated vaccine (A H1N1, A H3N2 and influenza B) given IM
  2. Quadrivalent (protections against additional influenza B virus) given IM
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28
Q

What influenza vaccine do you use in people 18-49?

A

Standard dose inactivated influenza vaccine (trivalent or quadrivalent), injectible

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29
Q

What influenza vaccine do you use in people >65?

A

High dose trivalent inactivated influenza vaccine, injectable

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30
Q

LAIV4

A

Live attenuated vaccine reintroduced this year, intranasal, recommended ages 2-49

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31
Q

Contraindications of influenza vaccine

A

Current moderate to severe illness (fever), hx of guillain-barre syndrome within 6 wks of previous vaccine, hx of allergic rxn

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32
Q

What is seen in the flu but not the common cold?

A

Fever with acute onset, headache, myalgias, fatigue/weakness, severe sore throat, cough that is more than moderate (hacking seen in cold)

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33
Q

Common viral causes of pharyngitis

A

Rhinovirus, adenovirus (not usually with pharyngeal exudate), parainfluenza, influenza

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34
Q

Presentation of pharyngitis caused by HSV

A

Vesicles on an erythematous base, culture it with Tzanck prep

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35
Q

Presentation of mononucleosis (viral pharyngitis)

A

Sore throat, pharyngeal erythema, tonsillar exudates, enlarged cervical lymph nodes of diffuse LAD, splenomegaly (50%), duration 2-4 wks (contagious up to 3 months)

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36
Q

Diagnostic studies for mononucleosis

A

Monospot, CBC with diff (see increased atypical lymphocytes)

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37
Q

Presentation of acute retroviral syndrome (viral pharyngitis)

A

Acute gingivitis, painful oropharyngeal ulceration (sharply demarcated), febrile illness like mononucleosis with painless, generalized LAD, no tonsillar enlargement or pharyngeal exudates, generalized maculopapular rash, fatigue

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38
Q

What can often be the first manifestation of an HIV infection?

A

Acute retroviral syndrome

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39
Q

Tx of viral pharyngitis

A

Hydration, antipyretics/analgesics, “magic mouthwash”

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40
Q

Tx for HSV

A

Acyclovir, famciclovir

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41
Q

Bacteria associated with pharyngitis

A

Group A streptococcus (GAS), C. trachomatis, N. gonorrhea, M. pneumoniae, H. influenza, C. diphtheriae

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42
Q

Presentation of diphtheria

A

Gray exudate tight adherent to throat and nasal passageway

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43
Q

Symptoms of streptococcal pharyngitis

A

Sore throat, odynophagia, fever/malaise/anorexia, arthralgias/myalgias, nausea/vomiting, neck discomfort from swollen glands

44
Q

Signs of streptococcal pharyngitis

A

Pharyngeal erythema, tonsillar hypertrophy, purulent exudate, tender/enlarged anterior cervical lymphnodes, palatal petechiae (CLASSIC SIGN)

45
Q

Centor criteria for streptococcal pharyngitis

A

Patients with 3 of 4 should undergo testing for GAS
1. Tonsillar exudates
2. Tender anterior cervical adenopathy
3. Fever by history
4. Absence of cough
If patient meets criteria but negative RADT, treat empirically while waiting for culture

46
Q

Gold standard for diagnosis of pharyngitis

A

Throat culture (can be bacterial or viral)

47
Q

First line therapy for adult GAS pharyngitis

A
  1. Penicillin V 500 mg po TID x 10 days
  2. Amoxicillin 500 mg BID x 10 days
  3. Penicillin G benzathine (Bicillin L-A) 1.2 million units IM single dose (if think ppl wont follow up)
  4. Cephalexin 500 mg PO BID x 10 days
48
Q

Tx for streptococcal pharyngitis when the patient has a penicillin allergy

A
  1. Azithromycin 500 mg po day 1 followed by 250 mg po days 2-5 (Z pack)
  2. Clindamycin 300 mg po tid x 10 days
  3. Clarithromycin 250 mg bid x 10 days
    * don’t forget supportive care (lozenges, NSAIDs, acetaminophen)
49
Q

Complications of streptococcal pharyngitis

A

Acute rheumatic fever (in immunosuppressed patients), post-streptococcal glomerulonephritis, peritonsillar abscess, otitis media, rhinosinusitis, bacteremia, pneumonia, strep toxic shock syndrome, scarlet fever

50
Q

Symptoms of scarlet fever

A

Maculopapular rash (feels like sand paper-starts on trunk), desquamation, Pastia’s lines, facial flushing with circumoral pallor and strawberry tongue (***scarlet fever can predispose for acute rheumatic fever)

51
Q

Pastia’s lines

A

Scarlet lines in the antecubital fossa

52
Q

Cause of scarlet fever

A

Reaction to pyrogenic toxin of bacteria

53
Q

Etiology of peritonsillar abscess

A

Polymicrobial, mostly S pyogenes (GAS), S aureus (including MRSA), mixed respiratory anaerobes and sometimes H. influenzae

54
Q

Cellulitis in the oral cavity

A

Infection and inflammation of tissue between palatine tonsil capsule and pharyngeal muscles, no discrete pus collection

55
Q

Description of peritonsillar abscess

A

Collection of pus between capsule of tonsil and pharyngeal muscles, usually progression of cellulitis

56
Q

Symptoms of peritonsillar abscess

A

Severe sore throat (unilateral), drooling, trismus, fever, ipsilateral neck or ear pain, fatigue, irritability

57
Q

Trismus

A

Spasm of internal pterygoid muscle in peritonsillar abscess, causing lock jaw

58
Q

Signs of peritonsillar abscess

A

Swelling pushing tonsil with deviation of uvula to opposite side, fullness of posterior soft palate with palpable fluctuance, cervical LAD, “hot potato voice”

59
Q

How to distinguish cellulitis from abscess

A

CT with IV contrast (spread of infection to parapharyngeal space, or if PE is limited due to trismus)

60
Q

Labs for peritonsillar abscess

A

CBC, electrolytes, throat culture, culture and gram stain of abscess fluid if aspirated

61
Q

Antimicrobial therapy for peritonsillar abscess

A

Parenteral: ampicillin-sulbactam (Unasyn) or clindamycin (vancomycin if MRSA)
Oral: amoxicillin-clavulanate (Augmentin) or clindamycin x 14 days

62
Q

Etiology of epiglottitis

A

H. influenzae

63
Q

Symptoms of epiglottitis

A

Drooling, stridor, severe sore throat, no cough, toxic appearance (no URI symptoms)

64
Q

Imaging for epiglottitis

A

Lateral neck x-ray with “Thumb sign”, CT/MRI

65
Q

Etiology of severe tonsillopharyngitis

A

EBV, HSV 1 or 2, coxsackie virus, adenovirus, c. diphtheria, N. gonorrhea

66
Q

Presentation of severe tonsillopharyngitis

A

Pharyngeal edema, exudates, tonsillar hypertrophy

67
Q

How to diagnose severe tonsillopharyngitis

A

Monospot, viral/bacterial cultures, CT or MRI with contrast

68
Q

Causes of retropharyngeal abscess or cellulitis

A

Trauma (like chicken bone), recent instrumentation with secondary bacterial infection (Ex. tonsillectomy)

69
Q

Cause of submandibular space infection (Ludwig’s angina)

A

Often due to odontogenic infection (from a tooth)

70
Q

Distinctive sign of submandibular space infection (Ludwig’s angina)

A

“Woody” indurated submandibular area with possible crepitus

71
Q

Most common infectious etiology of laryngitis

A

Viruses associated w/ URI (bacteria can be streptococci, moraxella catarrhalis or H. influenzae)

72
Q

Key symptom of laryngitis

A

Hoarseness (can also have dysphonia (variation in vocal quality) or URI symptoms

73
Q

Rhinosinusitis (ARS) (sinus infection)

A

Purulent nasal drainage AND nasal obstruction and/or facial pain, pressure or fullness

74
Q

Acute vs subacute vs chronic rhinosinusitis

A

Acute: symptoms less than 4 weeks
Subacute: symptoms for 4-12 weeks
Chronic: symptoms longer than 12 weeks

75
Q

Recurrent acute rhinosinusitis

A

4 or more episodes or ARS per year

76
Q

Most common etiology for acute viral rhinosinusitis

A

rhinovirus, influenza or parainfluenza

77
Q

Symptoms of acute viral rhinosinusitis

A

Low grade fever, nasal congestion/discharge, facial pain/pressure, fatigue, cough, maxillary tooth discomfort, ear pressure/fullness, headache

78
Q

Signs of acute viral rhinosinusitis

A

Purulent drainage in nose or posterior pharynx, nasal mucosal edema, edema in facial area, tenderness ot percussion of upper teeth, sinus tenderness, may be able to use transillumination to see opacity

79
Q

Acute viral sinusitis dx

A

Clinical, less than 10 days of symptoms consistent with ARS that are not worsening and progressively getting better

80
Q

What are plain sinus films used for?

A

Acute viral sinusitis

May show sinus fluid levels/poor detecting mucosal thickening, inability to distinguish polyps/masses from fluid/edema

81
Q

Treatment during days 1-9 of acute viral sinusitis

A

Analgesics, saline irrigation, mucolytics, intranasal decongestants, intranasal glucocorticoids

82
Q

Pathophysiology of acute bacterial sinusitis

A

Prior history of a URI and AVRS (secondary bacterial infection to viral infection), decreased drainage of thick secretions leads to obstruction of sinus ostia and entrapment of bacteria leads to infection

83
Q

Guidelines for diagnosis of acute bacterial sinusitis

A

Persistent symptoms lasting longer than 10 days with no clinical improvement
OR
Onset with severe symptoms (fever over 102, purulent nasal discharge, facial pain at least 3-4 consecutive says at onset
OR
viral URI lasted 5-6 days and was improving followed by double worsening and severe symptoms

84
Q

Patients at high risk for antibiotic resistance

A 
Over 65 years
Severe infection with fever over 102
Recent hospitalization
Immunocompromised
Comorbidities
Recent antimicrobial use in last month
85
Q

First line antimicrobial treatment of ABRS that is not at high risk for resistance

A
  1. Amoxicillin-clavulanate (Augmentin) 500/125 mg TID or 875/125 mg BID
  2. Penicillin allergy:
    Doxyxycline 100 mg BID
    Levofloxacin (Levaquin) 500 mg qd
    Moxifloxacin (Avelox) 400 mg qd

5-7 days!

86
Q

When do you move to second-line antimicrobial meds for ABRS?

A

If no response or worsening symptoms after 7 days of empiric antibiotic tx or high risk of antibiotic resistance

87
Q

Second line antimicrobial treatment of ABRS

A
  1. Amoxicillin-clavulanate (Augmentin) 2000 mg/ 125 mg BID
  2. Penicillin allergy:
    Levofloxacin (Levaquin) 500 mg qd
    Moxifloxacin (Avelox) 400 mg qd
    Doxyxycline 100 mg BID

7-10 days!

88
Q

What is complicated acute bacterial sinusitis?

A

Spread of the infection to the CNS, orbits or surrounding tissues

89
Q

Symptoms of complicated ABRS

A

Osteomyelitis (frontal, doughy edema; sever HA), meningitis/brain abscess/epidural abscess (severe HA, altered mental status, +/- nuchal rigidity), periorbital and/or preseptal or orbital cellulitis (periorbtal edema/erythema, abnormal EOM, proptosis, vision changes), may have high fever >102

90
Q

Studies used to diagnose complicated ABRS

A

CT scan with contrast, MRI if suspected extra sinus involvement, sinus aspirate culture; ADMIT TO HOSPITAL; URGENT ENT/ID CONSULT

91
Q

Gold standard for diagnosis of complicated ABRS

A

Sinus aspirate culture

92
Q

Chronic rhinosinusitis risk factors

A

Allergic rhinitis, chronic exposure to environmental irritants, defects in mucociliary clearance, immune deficiency, anatomical abnormalities predisposing to sinus obstruction, latrogenic (multiple sinus surgeries)

93
Q

4 cardinal symptoms of CRS in adults (what is the 4th symptom in children?)

A

Mucopurulent nasal drainage
Nasal obstruction and congestion
Facial pain, pressure and fullness
Reduction/loss of sense of smell (ethmoid sinuses)
* in kids is is cough instead of disturbance of smell

94
Q

Diagnostic criteria of CRS

A

Presence or at least 2 of 4 cardinal symptoms
AND
Infection lasting longer than 12 weeks with medical management
PLUS
Sinus mucosal disease with imaging (CT) with mucosal thickening or partial/complete opacification of paranasal sinuses
OR
Direct visualization (nasal endoscopy) of mucosal inflammation, polyps and/or purulent mucus and edema

95
Q

Diagnosis of CRS

A

Non-contrast CT (because want to see anatomical abnormalities); refer to ENT (nasal endoscopy and sinus aspirate culture)

96
Q

Treatment of CRS

A

Nasal saline lavage, intranasal corticosteroids, oral corticosteroids, oral antimicrobials, antihistamines, topical/systemic antifungals, endoscopic sinus surgery

97
Q

Sx of retropharyngeal abscess or cellulitis

A

neck stiffness, minimal peritonsilar findings; trismus uncommon; VERY SERIOUS- can extend to mediastinum

98
Q

Dx/tx for retropharyngeal abscess

A

CT/MRI w/ contrast, airway management, abx, image guided aspiration of abscess

99
Q

Sx. of submandibular space infection

A

swelling, stiff neck, drooling, often unable to talk, “woody” sign w/ possible crepitus (indurated)

100
Q

Tx for submandibular space infection

A

CT/MRI w/ contrast, airway management, abscess drainage, abx

101
Q

Non-infectious causes of laryngitis

A

vocal abuse, intubation, toxic exposure (smoke inhalation, radiation), GERD, vocal cord nodules or polyps, carcinoma of vocal cords, neuro dysfunciton

102
Q

Dx of laryngitis

A

Hx and PE; hoarseness >2 weeks w/o URI sx requires ENT referral for laryngoscopy (especially w/ hx of tobacco or alcohol use); hoarseness from URI can last 2-3 weeks

103
Q

Signs of laryngitis

A

erythem, edema, vascular engorgement, nodules or ulcerations of vocal cords

104
Q

Tx of laryngitis

A

remove offending agent, voice rest, humidification, increase fluids, stop smoking, refer to ENT prn, no need for abx unless bacterial infection

105
Q

Who is at increased risk for rhinosinusitis

A

females; ages 45-64

106
Q

Etiology of Acute bacterial rhinosinusitis (ABRS) (only 0.5-2%)

A

strep pneumoniae, H. influenzae, moraxella catarrhalis

X Clin Med Exam 2 (6 decks)

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