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2019 ABIM > Oct 27 2019 > Flashcards

Oct 27 2019 Flashcards

1
Q

Name and Associated condition

A

Dermatitis Herpetiformis

(found on extensor surfaces of elbows, knees, back and buttocks)

Intensely pruritic, erythematous papules, vesicles adn bullae.

Gluten-sensitive enteropathy (celiac disease)

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2
Q

What is Acanthosis nigracans and associated conditions?

A

Increased pigmentation especially in axilla

Insulin resistance and GI malignancy

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3
Q

What are multiple skin tags associated with?

A

Insulin resistance

Pregnancy

Chron disease (when found perianal)

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4
Q

Name and associated condition?

A

Porphyria cutanea tarda

Blistering lesions on skun exposed areas, can progress to hypertrichosis, hyperpigmentation and sclerodermatous thickening.

Associated with Hepatitis C

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5
Q

What skin conditions are associated with Hepatitis C

A

Porphyria cutanea tarda, Cutaneous leukocytoclastic vasculitis and Lichen planus

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6
Q

Name and associated condition?

A

Cutaneous Leukocytoclastic Vasculitis (Palpablue purpura)

Hepatitis C (Caused by secondary cryoglobulinemia)

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7
Q

Name and associated condition?

A

Molluscum contagiosum virus (benign single or multiple rounded, dome shaped, pink, waxy papules 2-5mm)

HIV

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8
Q

What skin conditions are associated with HIV?

A

Sudden-onset, severe psoriasis

Recurrent herpes zoster

Disseminated molluscum contagiosum

Severe seborrheic dermatitis

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9
Q

What skin conditions are associated with GI malignancy?

A

Explosive onset multiple, itchy sevorrheic keratoses

Acanthosis nigricans

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10
Q

Name and associated conditions?

A

Severe seborrhic dermatitis

HIV and Parkinsons

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11
Q

What is sudden onset of multiple, itchy seborrheic keratosis associated with?

A

GI malignancy

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12
Q

Name and associated condition?

A

Pyoderma gangrenosum

Inflammatory bowel disease

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13
Q

What causes anemia in celiac?

A

Iron deficiency

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14
Q

What will a biopsy of dermatitis herpetiformis show?

A

DIF of perilesional skin shows granular IgA deposits in ther dermal papillae

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15
Q

Patient with elevated MCHC, microcytosis anemia with spherocytes. Differential and w/u?

A

Most likely are AIHA or HS

DAT or Coombs can help differentiate (positive in AIHA)

eosin-5-maleimide binding (flow cytometry) or acidified glycerol lysis test can confirm HS.

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16
Q

How do you treat Hereditary Spherocytosis (HS)?

A

RBC transfusion for symptomatic anemia, folic acid supplements, splenectomy for severe cases

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17
Q

What are the common and less common causes of peripheral spherocytes?

A

AIHA, HS

Clostridial sepsis, snake bites, G6PD deficiency, MAHA

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18
Q

What are the indications for irradiated RBC transfusion?

A

BMT recipients

Acquired or congenital cellular immunodeficiency

Blood components donated by first or second degree relatives

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19
Q

What are indications for leukoreduced PRBC?

A

Chronically transfused patients

CMV seronegative at risk pt (AIDS, Transplant)

Potential transplant recipients

Previous febrile non-hemolytic transfusion reaction

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20
Q

What are indications for Washed PRBC?

A

IgA deficiency

Complement-dependent AIHA

Continued allergic reactions with PRBC despite anti-histamines

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21
Q

What is the most common form of Diffuse Parenchymal lung disease and its associated histopath?

A

IPF, Usual interstitial pneumonia (UIP)

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22
Q

Common age of onset of IPF?

A

50-70

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23
Q

HPI of IPF?

A

>6 month dry cough that disturbs daily activities

DOE

No history of potential cuases of fibrosis

~50% have a smoking history

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24
Q

Objective findings in IPF?

A

Velcro early inspiratory crackles with base predominance

~50% clubbing

Decreased lung volumes on CXR

Bibasilar septal line thickening with reticular changes and bronchiectasis when more severe

Honeycombing, cystic changes and traction bronchiectasis prominent in bases and subpleural areas on HRCT

May have s/s of Right CHF

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25
Q

What is required to diagnose IPF?

A

>6month cough

Imaging findings consistent with UIP

No known cause

Lung biopsy not necessary if imaging is consistent

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26
Q

Natural progression of IPF?

A

Progressive

Median survivial of 3-5 years post diagnosis

Stepwise decline, periods of stability with acute declines (may be triggered or idiopathic)

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27
Q

Treatment of IPF?

A

Manage comorbidities (obesity, CHF, deconditioning, OSA, Pulmonary HTN)

Supplemental oxygen

Pulmonary rehab for those with deconditioning

Nintedanib and pirfenidone

Lung transplant - early referral appropriate

If not a transplant candidate recommend against mechanical ventilation and referr to palliative

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28
Q

How do nintedanib and pirfenidone work? Common side effects?

A

Target fibroblasts (considered central in progression of IPF)

Not curative, delay progression

Diarrhea, elevated liver associated enzymes, increased risk of MI for Nintedanib

Diarrhea, nausea, headache, dyspepsia/GERD, anorexia, weight loss for pirfenidone

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29
Q

What did the trials show for nintedanib?

A

INPULSIS 1 trial (2014) -Decreased FVC decline (114 vs 239) did not reduce time to first exacerbation

INPULSIS 2 trial (2014) -Decreased FVC decline (113 vs 207) did not reduce time to first exacerbation

TOMORROW trial (2011) -reduced decline in FVC and acute exacerbations

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30
Q

What did the trail for pirfenidone show?

A

ASCEND trial (2014) - Reduced risk of progression by 30%, lower progression of FVC >10% 16.5% vs 31.8%.

SP3 trial (2010), CAPACITY 1 & 2 (2010) reduce the FVC decline and progression-free survival (no survival benefit).

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31
Q

Risk factors for AAA?

Risk factors for expansion and rupture?

A

Age >60

Male gender 6:1

HTN

Cigarettes

White

Atherosclerosis

FH of AAA

===================================

>5.5 cm

rate of expansion >= 0.5 cm every 6 mo or 1cm/yr

Active cigarette smoking (highest rate of AAA rupture)

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32
Q

Diagnosis of AAA?

A

AP diameter >3.0cm

75% asymptomatic

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33
Q

Screening guidelines for AAA?

A

Men 65-75 who have smoked at least 100 cigs

select screening in Men who have never smoked

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34
Q

Surveillance for AAA?

A

<=4cm every 2-3 years (rupture risk <0.5%/yr)

4.1-5.4cm 6-12 months (rupture risk 0.5-10%)

>5.5cm repair (rupture risk >10%) should have CTA or MRA for surgical planning.

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35
Q

Treatment for AAA?

A

>=5.5 cm, expansion >0.5cm/yr or symptoms (abd/back pain) - Aortic repair

Suprarenal/juxtarenal - usually open surgical repair

EVAR more sutable to infrarenal

Risk factor modification for non-surgical AAA

36
Q

What are the differences between AAA repair options?

A

EVAR - decreased short term morbidity/mortality, no difference in long term M/M

increased need for repeat intervention, higher endoleak, device failure, postimplantation syndrome (fever, leukocytosis, elevated CRP)

37
Q

When are aldosterone antagonists recommended post MI?

A

STEMI

LVEF <= 40% while on ACE and BB

diabetes or symptomatic CHF

38
Q

What are the two options for cardiac rehab?

A

Office based or Home based

Consider home based for low risk pt who desires home based (<=75, NYHA <iii></iii>

39
Q

Recommended CAP therapies (class)?

A

Outpatient

Healthy (Macrolide or Doxy)

Healthy >25% macrolide resistance of S. Pneumoniae (Fluoroquniolone or beta-lactam + macrolide)

Comorbidities or Ab use in last 3 months (Fluoroqunilone or beta-lactam + macrolide)

Inpatient (non-ICU)

Fluoroquniolone or beta-lactam + macrolide

Inpatient (ICU)

Beta-lactam + azithromycin or beta-lactam + fluoroqinolone

If PCN allergy, Fluoroquinolone + aztreonam

Risk factor for Pseudomonas

Anti-pseudomonal beta-lactam, fluoroquniolone or addition of aztreonam

Risk factor for CA-MRSA

Add Vanc or linezolid

40
Q

For inpatient treatment of CAP when can you consider transition to oral therapy?

A

clinically improving within 48-72hrs

tolerate oral diet

41
Q

Therapy duration for CAP?

A

5-7 days unless:

resistant organism

extrapulmonary infection

less common organisms (P. aeruginosa, S. aureus, Legionella)

Complicated PNA (empyema, lung abscess, necrotizing PNA)

42
Q

CAP organsisms associated with heavy EtOH use?

A

S. pneumoniae, oral flora, Klebsiella pneumoniae

43
Q

CAP organisms associated with COPD?

A

H. influenzae

S. pneumoniae

Moraxella catarrhalis

Legionella pneumophilia

P. aeruginosa

44
Q

CAP organisms associated with structural lung disease?

A

(ie. bronchiectasis, CF)

P. aeruginosa

Burkholderia cepacia

Stenotrophomonas maltophilia

S. aureus

45
Q

CAP organsisms associated with aspiration and causes?

A

(seizures, neurologic impairment, LOC, GERD, EtOH or Drugs, stroke, poor dentition, vomiting)

Oral anaerobes

Enterobacteriacae

46
Q

CAP organsisms associated with age >65

A

Influenza virus

S. pneumoniae

rhinovirus

47
Q

CAP organisms associated with post viral illness?

A

S. aureus

Streptococcus pyogenes

S. pneumoniae

48
Q

CAP organsism associated with bird exposure?

A

Chlamydophila psittaci

Histoplasma capsulatum

Cryptococcus neoformans

49
Q

CAP organisms associated with dog exposure?

A

Bordetella bronchiseptica

50
Q

CAP organism associated with cat exposure?

A

Pasteurella multocida

51
Q

CAP organsism associated with fam animals or domesticated pregnant animals?

A

Coxiella burnetii

Brucella spp

52
Q

CAP organism associated with horses?

A

Rhodococcus equi

53
Q

CAP organism associated with rodent droppings?

A

Hantavirus

54
Q

CAP organism associated with rabbits?

A

Francisella tularensis

55
Q

CAP organism associated with Hot Tubs?

A

Legionella pneumoniae

Atypical mycobacteria (causing a hypersensitivity pneumonitis)

56
Q

CAP organism considerations by geography?

A

Eastern US

Histoplasma capsulatum

Blastomyces dermatitidis

Southwest US

Coccidiodies

Southeast Asia

Burkholderia pseudomallei

SARS

Avian influenza

Middle East

MERS

57
Q

CAP organisms by time of year?

A

Late fall, winter early spring:

Influenza virus

Parainfluenza virus

Rhinovirus

58
Q

Most common organisms by treatment environment?

A

Outpatient

S. pneumoniae

Mycoplasma

Chlamydophilia

Respiratory viruses

Inpatient (non-ICU)

S. pneumoniae

Mycoplasma

Chlamydophilia

H. influenzae

Legionella

Oral anaerobes

Respiratory Viruses

Inpatient (ICU)

S. pneumoniae

S. aureus

H. influenzae

Legionella

Gram-negative bacilli

59
Q

When should negative CXR prompt further imaging in suspected CAP?

A

If high suspicion with negative initial imaging can repeat in 24 hours

High risk patients (febrile neutropenia, risk for anthrax, ARDS) perform chest CT

60
Q

Radiographic patterns and associated organism in CAP?

A

Lobar PNA

S. pneumoniae

RLL PNA

Oral anerobes (aspiration)

Lung Abscess/cavitary lesion

Oral anaerobes

S. aureus

Klebsiella pneumoniae

Nocardia

Actinomyces

Rhodococcus

Mycobacteria

Endemic fungi

Interstitial infiltrate

Atypical pathogens

Legionella

Mycoplasma

Chlamydophilia

Viruses

Pleural effusion/empyema

Oral anaerobes

Anginosus-constellatus group streptococci

S. aureus

S. pneumoniae

61
Q

When should microbiologic studies be obtained in CAP?

A

In the ICU

If it would change care in non-ICU hospitalized patients

Non-response to outpatient therapy

Cavitary lung lesions

Underlying structural lung disease

62
Q

How sensitive are blood cultures in pneumococcal PNA?

A

20-25%

63
Q

How sensitive is pneumococcal urinary antigen?

A

70%, not affected by antimicrobial administration

64
Q

What does legionella urinary antigen test for?

A

L. pneumophilia serotype 1

Can remain positive for prolonged period post infection

65
Q

When should thoracentesis be performed in CAP?

A

Unknown cause or effusions >1cm

To exclude concomitant empyema that requires drainage

66
Q

When should bronchoscopy with transbronchial biopsy be performed in CAP?

A

unrevealing non-invasive evaluation who do not respond to empiric therapy.

67
Q

When should you consider MRSA coverage in CAP?

A

Suspicious gram stain (G+ cocci in clusters

Conventional therapy failure

Pleural-based lung nodules (suggest septic pulm emboli)

Cavitary lung lesions

IVDU

68
Q

Of MRSA options, which cannot be used in PNA?

A

Daptomycin binds to surfactant resulting in negligible alveolar levels and is not effective in PNA

69
Q

When should you consider coverage for P. aeruginosa?

A

Immunocompromised patients

Structural lung disease (Bronchiectasis, CF)

Repeated Ab due to medical condition

70
Q

What conditions would allow a 5 day course of Ab in CAP vs longer course?

A

5 Day

Clinical improvement and defervescence in 48-72 hours

7 Day or longer

Cavitary disease

Lung abscess

empyema

concomitant bacteremia

extrapulmonary infection

ongoing instability (fever, abnormal VS, hypoxia)

>14 Days

S. aureus

Enterobacteriaceae

Fungal

Mycobacteria

71
Q

What are pulmonary complications of CAP?

A

Non-resolving PNA (resistant infection, non-infectious causes)

Lung Abscess (prolonged Ab)

Empyema (Chest tube drainage)

ARDS (Ventilation, steroids)

72
Q

What are neurologic complications of PNA?

A

Delirium (may be 2/2 hypoxemia, hypercarbia, ICU)

73
Q

What are hematologic complications of PNA?

A

Leukopenia (2/2 Sepsis, medications)

Thrombocytopenia (2/2 sepsis, medications)

74
Q

What are cardiac complications of PNA?

A

ACS (5-10% of hospitalized patients)

Arrhythmias (most common a-fib)

75
Q

What are renal complications of PNA?

A

AKI (hypotensive, medication)

76
Q

What are endocrine complications of PNA?

A

Adrenal insufficiency (Waterhouse-Friderichsen in setting of overwhelming bacterial infection or septic shock)

77
Q

Based on a recent study, what adjunctive therapy MAY help reduce morbidity in PNA?

A

In high risk patient’s for ARDS glucocorticoids may help reduce mortality, mechanical ventilation needs and shorten hospitalization.

78
Q

What is the primary reason for repeat chest imaging in PNA?

A

r/o Postobstructive PNA (Bronchial carcinoma most commonly)

Imaging in 2-3 months especially in age >50 or smoking history

79
Q

What additional medicaion can provide symptom and mortality benefit in AA with CHF?

A

In NYHA class III or IV

AA patients with LV failure (EF <40%), when on appropriate GDMT

Addition of hydralazine + long acting nitrate therapy can provide symptom and mortality benefit

80
Q

What are levels concerning for hereditary hemochromatosis?

A

Ferritin >1000 ng/mL or transferrin saturation >45-50%

81
Q

What are the typical levels and ratio of transaminases in NAFLD?

A

2-5 times upper limit of normal and AST to ALT <1

82
Q

What is the presentation of Acute Eosinophilic PNA?

A

Idiopathic, more common in new onset/resumption of smoking

High fever <3wk

Non-prod cough, dyspnea

Bibasilar inspiratory crackles

Hypoxemic resp failure

83
Q

What is the presentation of chronic eosinophilic PNA?

A

More common in women, non-smokers, asthmatics, post radiation (breast CA)

Fever, cough, progressive dyspnea

Wt loss, night sweats

Resp failure rare

84
Q

Diagnosis of acute eosinophilic PNA?

A

Neutrophil predominant leukocytosis that progresses to eosinophilia

Chest imaging: b/l diffuse ground glass and reticular opacities

BAL >25% eosinophils

Lung biopsy: diffuse alveolar damage, increased interstitial eosinophils

85
Q

Diagnosing Chronic Eosinophilic PNA?

A

Peripheral eosinophilia

Elevated ESR/CRP

Iron deficiency anemia with elevated Plt

Imaging: b/l peripheral/pleural based infiltrates, sparing of the perihilar and central lung

BAL >25% eosinophils

Lung biopsy: interstitial & alveolar eosinophils, multi-nucleated giant cells

86
Q
A

2019 ABIM (5 decks)

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