Lecture 23: Clinical Considerations in Fever Flashcards
What is bacteremia and what kind of treatment does it require?
What can bacteremia cause if not treated properly?
- abnormal presence of bacteria in the blood stream
- requires empiric antibiotic treatment
- can become early SEPSIS –> Sepsis –> Septic Shock
What is qSOFA and what three things is its scoring system based on?
- easy bedside scoring system that helps predicts that chance of SEPSIS for pts. admitted to medical floor
scoring: RR > 22/min, altered mentation, systolic blood pressure < 100 mmHg
What are these risk factors for?
ICU admission, bacteremia, age of 65
SEPSIS RISK FACTORS
What are four clinical manifestations of Sepsis?
- arterial HYPOtension (SBP < 90, MAP < 70)
- temperature > 38.3
- HR > 90 bpm
- RR > 20 breaths/min (tachypnea)
How does Septic Shock manifest clinically? (End-Organ manifestations)
- skin starts out warm and flush but can cool (redirect blood flow to core organs)
- leads to dec. capillary refill and cyanosis with altered mental state
- ileus or absent bowel sounds are often end-stage signs of HYPOperfusion
What is a common lab finding in patients who are dealing with Sepsis?
- HYPERLACTATEMIA
- elevated serum lactate > 2 mmol/L can be a manifestation of organ hypoperfusion
- elevated lactate lvls associated with POOR prognosis
MSSA and MRSA
What are they associated with clinically?
- Staphylococcal Bacteremia (Methicillin Sensitive vs Resistant Staph Aureus)
- associated with bone/joint pain, protracted fever, LUQ pain (splenic infact), costovertebral angle tenderness
Where is MRSA normally acquired and what does it look like?
What 3 things should be focused on if a culture is positive for S. aureus bacteremia?
- often HOSPITAL acquired (affects multiple systems)
- erythema with purulent drainage (ABSCESS FORMS)
- pus has Gram (+) cocci in clusters
- focus on: endocarditis, osteomyelitis, systemic infections
MRSA Erysipelas and Cellulitis
E: superficial skin infection, well-defined borders
C: deeper skin infection, edema/lymphangitis
E and C: painful, warm, nonlocalized, erythematous
- STAPH has more PUS than strep usually
What four community activities can increase the risk of community-acquired MRSA?
What is MRSA commonly implicated in?
contact sports, military service, incarceration, injection drug use
- MRSA is commonly associated with DIABETIC FOOT INFECTIONS
What is Streptococcus Pyrogens (Group A) the most common cause of in children/adolescents and what test can detect it?
- most common cause of TONSILLOPHARYNGITIS (bacterial pharyngitis)
- causes pharyngitis in adults
- use ELISA to test; if negative and you still believe infection, GET A THROAT CULTURE!
What does Streptococcus Agalactiae (Group B) cause in pregnant women and what is it the most common cause of in nonpregnant adults?
Pregnant: UTI, postpartum endometritis, bacteremia, chorioamnionitis
Nonpregnant: most common strep pathogen for ADULTS (bacteremia without a focus)
How is Tuberculosis commonly spread and what are 4 community risk factors for infection?
- infection via airborne droplet inhalation
risk factors: household exposure, incarceration, drug use, travel to endemic area
What are they symptoms of?
Productive cough, hemoptysis, fatigue, weight loss, fever, night sweats?
What is the most common symptom of this infection?
Mycobacterium Tuberculosis
- most common symptom is COUGH (patients also appear chronically ill –> occurs more in elderly and HIV (+) pts)
- blood-streaked sputum also common
What are 5 risk factors for TB reactivation?
What can cause drug-resistant TB? (4)
gastrectomy, silicosis, diabetes mellitus, HIV, immunosuppressive drugs
DR: immigration from region with DRTB, close contact with patients with DRTB, unsuccessful anti-TB therapy, treatment noncompliance
What is Influenza, when is it most likely to infect, and what subtype is most common?
- orthomyxovirus transmitted via respiratory droplet
usually occurs during the fall and winter seasons (hard to diagnose without epidemic)
- Type A infections commonly cause pandemics (larger genetic reassortment; Type B is similar and Type C is milder)
How is Acute Acquired CMV different than Infectious Mononucleosis?
- very similar but PHARYNGEAL symptoms are UNUSUAL in Acute CMV
- most CMV infections are asymptomatic
How does CMV affect infants and neonates?
- HEARING LOSS in > 50% who are symptomatic at birth, but most are asymptomatic (mental retardation and hearing loss can occur later in life)
- jaundice, periventricular CNS calcifications, mental retardation, and motor disability are possible symptoms
What test is negative in an immunocompetent person with CMV infection?
- negative HETEROPHIL ANTIBODIES
- usually occurs with mononucleosis-like syndrome
Where is Histoplasmosis infection commonly acquired, what is its most common clinical problem, and who is it commonly seen in?
- exposure to bird/bat droppings along river valleys
- respiratory illness is MOST COMMON problem, but most pts. are asymptomatic (looks like INFLUENZA)
- disseminated infection common in pts. with underlying HIV infection (CD4 < 100)
What problems does Coccidioidomycosis cause, what does it look like on chest radiograph, and where is it commonly acquired?
- acute infection is INFLUENZA-like but can disseminate causing meningitis, bone lesions, soft tissue abscesses
- Chest X-Ray varies from pneumonitis to cavitation
- usually from molds in soil of Southwest US, Mexico and Central/South America
What are two main symptoms of Primary Coccidioidomycosis? (A/EN)
- arthralgia with periarticular swelling of knees/ankles
- erythema nodosum (2-20 days after symptoms)
What does Disseminated Coccidioidomycosis look like in HIV patients?
- often shows PULMONARY MILIARY (seed infiltrates) on chest radiograph
- also has lymphadenopathy, meningitis, but SKIN LESIONS ARE UNCOMMON
How is Malaria spread, what is the most severe strain, and how does it present acutely?
- transmitted by bite from infected anopheline mosquito (see on thick or thin blood smears)
- P. falciparum is responsible for nearly all severe disease (vivax, ovale, malariae aren’t as severe)
- usually headaches/fatigue/irregular fever
- (vivax/ovale - 48 hr cycle, malariae - 72 hour cycle)
What infection are these symptoms of?
Anemia, jaundice, splenomegaly, mild hepatomegaly, hypotension, seizure?
ACUTE MALARIA
What is Multiple Myeloma and what are its 4 main clinical manifestations?
What other disease is it similar to?
- clonal plasma cells that infiltrate the bone marrow, cause bone destruction, and produce monoclonal immunoglobulins (occurs in adults 65+)
- anemia, lytic bone lesions, kidney failure, soft tissue masses
- similar to Waldenstrom’s Macroglobulinemia but WM does NOT have lytic bone lesions
How does Multiple Myeloma cause renal failure and what infections does it put a patient at an increased risk for?
- produces light chains that deposit in tissue as amyloid
- more prone to ENCAPSULATED infections, like Strep Pneumoniae and H. influenzae
What is Kaposi Sarcoma and what does it look like?
- MOST COMMON HIV-related MALIGNANCY (associated with HHV-8)
- red/purple/dark plaques or nodules on cutaneous or mucosal surface
- melanoma is in the DDx of Kaposi Sarcoma
Who does Systemic Lupus Erythematous occur in, what are common symptoms of it, and what serological findings are associated with it?
- occurs in young women usually
Symptoms: malar rash, Raynauds, alopecia, Joint issues (often earliest manifestation - Swan Neck deformities but erosion almost NEVER seen)
Serological: ANA (+), anti DS Ab (+), dec. serum complement
How does Sjogren’s usually present and what is Secondary Sjogren’s associated with?
- dryness of eyes/mouth (SICCA components) due to immune-mediated dysfunction of lacrimal/salivary glands
- ropy secretions from eye, enlarged parotid, loss of taste and smell
Secondary Sjogrens - dryness AND rheumatoid arthritis
What pulmonary and kidney manifestations can be seen in Sjogren’s Syndrome?
P: obstructive airway disease/interstitial lung disease IN ABSENCE of smoking
K: renal tubular acidosis and chronic interstitial nephritis
