Oct 27 2019 Flashcards
Name and Associated condition
Dermatitis Herpetiformis
(found on extensor surfaces of elbows, knees, back and buttocks)
Intensely pruritic, erythematous papules, vesicles adn bullae.
Gluten-sensitive enteropathy (celiac disease)
What is Acanthosis nigracans and associated conditions?
Increased pigmentation especially in axilla
Insulin resistance and GI malignancy
What are multiple skin tags associated with?
Insulin resistance
Pregnancy
Chron disease (when found perianal)
Name and associated condition?
Porphyria cutanea tarda
Blistering lesions on skun exposed areas, can progress to hypertrichosis, hyperpigmentation and sclerodermatous thickening.
Associated with Hepatitis C
What skin conditions are associated with Hepatitis C
Porphyria cutanea tarda, Cutaneous leukocytoclastic vasculitis and Lichen planus
Name and associated condition?
Cutaneous Leukocytoclastic Vasculitis (Palpablue purpura)
Hepatitis C (Caused by secondary cryoglobulinemia)
Name and associated condition?
Molluscum contagiosum virus (benign single or multiple rounded, dome shaped, pink, waxy papules 2-5mm)
HIV
What skin conditions are associated with HIV?
Sudden-onset, severe psoriasis
Recurrent herpes zoster
Disseminated molluscum contagiosum
Severe seborrheic dermatitis
What skin conditions are associated with GI malignancy?
Explosive onset multiple, itchy sevorrheic keratoses
Acanthosis nigricans
Name and associated conditions?
Severe seborrhic dermatitis
HIV and Parkinsons
What is sudden onset of multiple, itchy seborrheic keratosis associated with?
GI malignancy
Name and associated condition?
Pyoderma gangrenosum
Inflammatory bowel disease
What causes anemia in celiac?
Iron deficiency
What will a biopsy of dermatitis herpetiformis show?
DIF of perilesional skin shows granular IgA deposits in ther dermal papillae
Patient with elevated MCHC, microcytosis anemia with spherocytes. Differential and w/u?
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.
How do you treat Hereditary Spherocytosis (HS)?
RBC transfusion for symptomatic anemia, folic acid supplements, splenectomy for severe cases
What are the common and less common causes of peripheral spherocytes?
AIHA, HS
Clostridial sepsis, snake bites, G6PD deficiency, MAHA
What are the indications for irradiated RBC transfusion?
BMT recipients
Acquired or congenital cellular immunodeficiency
Blood components donated by first or second degree relatives
What are indications for leukoreduced PRBC?
Chronically transfused patients
CMV seronegative at risk pt (AIDS, Transplant)
Potential transplant recipients
Previous febrile non-hemolytic transfusion reaction
What are indications for Washed PRBC?
IgA deficiency
Complement-dependent AIHA
Continued allergic reactions with PRBC despite anti-histamines
What is the most common form of Diffuse Parenchymal lung disease and its associated histopath?
IPF, Usual interstitial pneumonia (UIP)
Common age of onset of IPF?
50-70
HPI of IPF?
>6 month dry cough that disturbs daily activities
DOE
No history of potential cuases of fibrosis
~50% have a smoking history
Objective findings in IPF?
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
What is required to diagnose IPF?
>6month cough
Imaging findings consistent with UIP
No known cause
Lung biopsy not necessary if imaging is consistent
Natural progression of IPF?
Progressive
Median survivial of 3-5 years post diagnosis
Stepwise decline, periods of stability with acute declines (may be triggered or idiopathic)
Treatment of IPF?
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
How do nintedanib and pirfenidone work? Common side effects?
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
What did the trials show for nintedanib?
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
What did the trail for pirfenidone show?
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).
Risk factors for AAA?
Risk factors for expansion and rupture?
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)
Diagnosis of AAA?
AP diameter >3.0cm
75% asymptomatic
Screening guidelines for AAA?
Men 65-75 who have smoked at least 100 cigs
select screening in Men who have never smoked
Surveillance for AAA?
<=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.
Treatment for AAA?
>=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
What are the differences between AAA repair options?
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)
When are aldosterone antagonists recommended post MI?
STEMI
LVEF <= 40% while on ACE and BB
diabetes or symptomatic CHF
What are the two options for cardiac rehab?
Office based or Home based
Consider home based for low risk pt who desires home based (<=75, NYHA <iii></iii>
Recommended CAP therapies (class)?
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
For inpatient treatment of CAP when can you consider transition to oral therapy?
clinically improving within 48-72hrs
tolerate oral diet
Therapy duration for CAP?
5-7 days unless:
resistant organism
extrapulmonary infection
less common organisms (P. aeruginosa, S. aureus, Legionella)
Complicated PNA (empyema, lung abscess, necrotizing PNA)
CAP organsisms associated with heavy EtOH use?
S. pneumoniae, oral flora, Klebsiella pneumoniae
CAP organisms associated with COPD?
H. influenzae
S. pneumoniae
Moraxella catarrhalis
Legionella pneumophilia
P. aeruginosa
CAP organisms associated with structural lung disease?
(ie. bronchiectasis, CF)
P. aeruginosa
Burkholderia cepacia
Stenotrophomonas maltophilia
S. aureus
CAP organsisms associated with aspiration and causes?
(seizures, neurologic impairment, LOC, GERD, EtOH or Drugs, stroke, poor dentition, vomiting)
Oral anaerobes
Enterobacteriacae
CAP organsisms associated with age >65
Influenza virus
S. pneumoniae
rhinovirus
CAP organisms associated with post viral illness?
S. aureus
Streptococcus pyogenes
S. pneumoniae
CAP organsism associated with bird exposure?
Chlamydophila psittaci
Histoplasma capsulatum
Cryptococcus neoformans
CAP organisms associated with dog exposure?
Bordetella bronchiseptica
CAP organism associated with cat exposure?
Pasteurella multocida
CAP organsism associated with fam animals or domesticated pregnant animals?
Coxiella burnetii
Brucella spp
CAP organism associated with horses?
Rhodococcus equi
CAP organism associated with rodent droppings?
Hantavirus
CAP organism associated with rabbits?
Francisella tularensis
CAP organism associated with Hot Tubs?
Legionella pneumoniae
Atypical mycobacteria (causing a hypersensitivity pneumonitis)
CAP organism considerations by geography?
Eastern US
Histoplasma capsulatum
Blastomyces dermatitidis
Southwest US
Coccidiodies
Southeast Asia
Burkholderia pseudomallei
SARS
Avian influenza
Middle East
MERS
CAP organisms by time of year?
Late fall, winter early spring:
Influenza virus
Parainfluenza virus
Rhinovirus
Most common organisms by treatment environment?
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
When should negative CXR prompt further imaging in suspected CAP?
If high suspicion with negative initial imaging can repeat in 24 hours
High risk patients (febrile neutropenia, risk for anthrax, ARDS) perform chest CT
Radiographic patterns and associated organism in CAP?
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
When should microbiologic studies be obtained in CAP?
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
How sensitive are blood cultures in pneumococcal PNA?
20-25%
How sensitive is pneumococcal urinary antigen?
70%, not affected by antimicrobial administration
What does legionella urinary antigen test for?
L. pneumophilia serotype 1
Can remain positive for prolonged period post infection
When should thoracentesis be performed in CAP?
Unknown cause or effusions >1cm
To exclude concomitant empyema that requires drainage
When should bronchoscopy with transbronchial biopsy be performed in CAP?
unrevealing non-invasive evaluation who do not respond to empiric therapy.
When should you consider MRSA coverage in CAP?
Suspicious gram stain (G+ cocci in clusters
Conventional therapy failure
Pleural-based lung nodules (suggest septic pulm emboli)
Cavitary lung lesions
IVDU
Of MRSA options, which cannot be used in PNA?
Daptomycin binds to surfactant resulting in negligible alveolar levels and is not effective in PNA
When should you consider coverage for P. aeruginosa?
Immunocompromised patients
Structural lung disease (Bronchiectasis, CF)
Repeated Ab due to medical condition
What conditions would allow a 5 day course of Ab in CAP vs longer course?
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
What are pulmonary complications of CAP?
Non-resolving PNA (resistant infection, non-infectious causes)
Lung Abscess (prolonged Ab)
Empyema (Chest tube drainage)
ARDS (Ventilation, steroids)
What are neurologic complications of PNA?
Delirium (may be 2/2 hypoxemia, hypercarbia, ICU)
What are hematologic complications of PNA?
Leukopenia (2/2 Sepsis, medications)
Thrombocytopenia (2/2 sepsis, medications)
What are cardiac complications of PNA?
ACS (5-10% of hospitalized patients)
Arrhythmias (most common a-fib)
What are renal complications of PNA?
AKI (hypotensive, medication)
What are endocrine complications of PNA?
Adrenal insufficiency (Waterhouse-Friderichsen in setting of overwhelming bacterial infection or septic shock)
Based on a recent study, what adjunctive therapy MAY help reduce morbidity in PNA?
In high risk patient’s for ARDS glucocorticoids may help reduce mortality, mechanical ventilation needs and shorten hospitalization.
What is the primary reason for repeat chest imaging in PNA?
r/o Postobstructive PNA (Bronchial carcinoma most commonly)
Imaging in 2-3 months especially in age >50 or smoking history
What additional medicaion can provide symptom and mortality benefit in AA with CHF?
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
What are levels concerning for hereditary hemochromatosis?
Ferritin >1000 ng/mL or transferrin saturation >45-50%
What are the typical levels and ratio of transaminases in NAFLD?
2-5 times upper limit of normal and AST to ALT <1
What is the presentation of Acute Eosinophilic PNA?
Idiopathic, more common in new onset/resumption of smoking
High fever <3wk
Non-prod cough, dyspnea
Bibasilar inspiratory crackles
Hypoxemic resp failure
What is the presentation of chronic eosinophilic PNA?
More common in women, non-smokers, asthmatics, post radiation (breast CA)
Fever, cough, progressive dyspnea
Wt loss, night sweats
Resp failure rare
Diagnosis of acute eosinophilic PNA?
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
Diagnosing Chronic Eosinophilic PNA?
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
