Parasitic, spirochete, tick

Question 1

What characterizes an early, primary syphilis infection?

Answer 1

primary lesions of painless chancres and lymphadenopathy
“punched out” lesion

Question 2

What characterizes an early, secondary syphilis infection?

Answer 2

• few weeks - 6 months after chancre:
• systemic symptoms - fever, lymphadenopathy, lesions distant from site of inoculation (skin and mucosal lesions - NOT vesicular) and common on palms and soles and maybe on face
• condylomata lata, dark annular lesions, mucous patches of mucous membranes

Question 3

What characterizes an early, latent syphilis infection?

Answer 3

symptom-free period that lasts up to a year after initial infection, lesions may reoccur
** can convert to 2ndary syphilis if not treated**
highly infectious

Question 4

What characterizes a late, latent syphilis infection?

Answer 4

after 1st year – non-infectious except transplacental
can only diagnosis this w/o evidence of tertiary disease/neurosyphilis

Question 5

What characterizes late, tertiary, neurosyphilis?

Answer 5

1) gummas infiltrate tumor (localized and rapid onset)
2) neuro: HA, meningitis, dementia, vision/hearing loss, incontinence, psychosis, Argyll-Robertson pupils
3) Heart: aortis, aneurysms, aortic regurg

Question 6

In who should you be aware of syphilis risk?

Answer 6

MSM

Question 7

What is the cause and transmission of syphilis?

Answer 7

sex!
Treponema pallidum - spirochete!

Question 8

How can you prevent syphilis?

Answer 8

avoid infectious contact, condoms, MSM screening every 3-6 months, check in pregnancy at 1st visit and in 3rd trimester AND at birth if high risk

Question 9

What makes risk of congenital spread of syphilis?

Answer 9

rash, condylomas, mucous membrane patches, nasal discharge

Question 10

What happens if syphillis remains untreated congenitally?

Answer 10

Hutchinson teeth, saddle nose, TORCH syndrome

Question 11

How can you diagnose syphilis?

Answer 11

Screening –> diagnosis
* INITIAL: nontreponemal tests (VDRL and RPR 4-6 weeks post infection or 1-3 weeks after lesion, correlated w/ other labs)
* CONFIRM: treponemal tests to confirm diagnosis; TBBA or FTA-ABS absorption test to measure antibodies
* EIA-enzyme immunoassay or CIA chemiluminescene = positive
* CNS signs = CSF study

Question 12

How do you treat syphilis?

Answer 12

IM penicillin G

abstain from sex for 7-10 days after treatment
test for HIV!!
report to health department

Question 13

What reaction is common in syphilis treatment?

Answer 13

Jarisch-Herxheimer reaction w/ spirochetes being treated with abx
pink maculopapular rash

Question 14

What is syphilis associated with prenatally?

Answer 14

IGR, hepatosplenomegaly, hydrops fetalis, fetal demise, late abortion

Question 15

What is syphillis associated with neonatally?

Answer 15

prematurity, low birth weight, jaundice, necrotizing funisitis

Question 16

What is syphilis associated with in early onset babies <2 years old?

Answer 16

2-8 weeks old: persistent clear, purulent, or bloody rhinitis, maculopapular rash
+ hepatosplenomegaly, lymphadenopathy, skeletal abnormalities, joint pain, pseudoparalysis

Question 17

What is syphilis associated with in late onset kids >2 years old?

Answer 17

similar to early onset but also could have visual changes, tabes dorsalis, nystagmus, headache, hearing loss, Hutchinson’s teeth, Clutton’s joints, saddle nose deformity
risk of intellectual disability and failure to thrive :(

Question 18

What indicates early and localized lyme disease?

Answer 18

erythema migrans, bulls eye rash w/ viral like illness (myalgias, arthralgias, fatigue, HA, may/may not have fever)

Question 19

How many stages does lyme disease have?

Answer 19

3

Question 20

What characterizes early disseminated lyme disease?

Answer 20

days/weeks later, hematogenous spread, viral-like illness, fatigue

may have myopericarditis, arrhythmias, heart block

Question 21

What’s the most common neuro issue in lyme disease?

Answer 21

aseptic meningitis

Question 22

What’s the most common peripheral nerve issue in lyme disease?

Answer 22

CN7 palsy

Question 23

What characterizes late persistent lyme disease?

Answer 23

MSK, neurologic, skin
may have joint pain/swelling, rarely w/ AMS, mood changes, sleep disturbance

Question 24

What characterizes post-lyme disease?

Answer 24

fatigue, myalgia, cognitive difficulty

retreatment is NOT effective! consider co-infection or misdiagnosis

Question 25

Where is lyme disease common?

Answer 25

Midwest and Northeast

Question 26

What causes lyme disease?

Answer 26

Borrelia burgdorferi

Question 27

How long does a Borrelia tick have to be attached in order to transmit lyme disease?

Answer 27

24-36 hours

Question 28

What should you always order with a tick bite w/ symptoms?

Answer 28

Tick panel should be ordered

Question 29

How do you diagnose lyme disease based on Hx and PE?

Answer 29

exposure in endemic area WITH: 1) physician documented erythema migrans w/n 30 days 2) OR 1 late manifestation of disease 3) AND lab confirmation

Question 30

What labs do you do to diagnose lyme disease?

Answer 30

-elevated ESR and liver enzymes 2 test diagnostic approach: ELISA antibody AND confirm w/ western blot note: may have negative antibody in first few weeks **false positives are common, patients w/ non specific symptoms w/o objective signs should NOT have this done**

Question 31

When is lyme prophylaxis recommended?

Answer 31

1) tick identified and attached 36+ hours 2) prophylaxis can be started w/n 72 hours of time tick was removed 3) more than 20% of ticks are known to be infected w/ B 4) no contraindications DOXYCYCLINE!

Question 32

How can you treat lyme disease?

Answer 32

doxycycline OR amoxicillin and cefuroxime

Question 33

How can you treat lyme-based cardiac disease?

Answer 33

outpatient: doxycycline, amoxicillin, cefuroxime inpatient: IV ceftriaxone

Question 34

How can you treat lyme-based neurologic lyme disease?

Answer 34

CNS: IV cephalosporin or PO doxycycline Peripheral: ceftriaxone, cefotaxime, PEN G (IV), PO doxy Isolated 7th nerve palsy: PO doxy or cefuroxime

Question 35

What indicates relapsing fever?

Answer 35

abrupt onset of fever, chills, tachycardia, N/V, arhtralgia, severe HA, hepatomegaly, splenomegaly various rashes high fever and delirum 3-10 day termination --> relapse 1-2 weeks later, with risk of 3-10 relapses before recovery

Question 36

Where is relapsing fever common?

Answer 36

mountainous west

Question 37

What causes relapsing fever?

Answer 37

tick borne or louse-borne mostly rodent-based

Question 38

What signifies relapsing fever in labs?

Answer 38

CBC - mild anemia and thrombocytopenia Blood smear - large spirochetes w/ Wright-Giemsa stain, dark field microscopy Consider PCR hematuria anti-borrelia antibodies **CSF abnormalities w/ meningitis involvement**

Question 39

How do you treat relapsing fever?

Answer 39

post exposure prophylaxis = doxycycline tick borne withOUT nervous system involvement: - IV PCN G or IV ceftriaxone - followed by tetracycline or erythromycin for 10 days WITH CNS involvement: - IV PCN or ceftriaxone for 10-14 days also Jarish-Herxheimer reaction in about 50% of patients

Question 40

What indicates RMSF?

Answer 40

2-14 days after tick bite: abrupt onset of fever, HA, rash, chills, malaise, restlessness, insomnia, irritability, anorexia, N/V, facial flushing, conjunctival injection, hard palatal lesions, cough pneumonitis KEY: **triad of fever, HA, rash w/ history, involvement of palms/soles**

Question 41

Where is RMSF common?

Answer 41

NC, TN, OK, AR, MO

Question 42

What causes RMSF?

Answer 42

ricketta rickettsi

Question 43

How long does a Ricketta tick have to remain attached to transmit illness?

Answer 43

6-10 hours

Question 44

How can you diagnose RMSF?

Answer 44

hyponatremia, elevated liver eynzymes, elevated bilirubin, thrombocytopenia skin biopsy or PCR, cutaneous swab OR ELISA , complement function, latex agglutination check CSF for CNS involvement 2nd week - utilize Ab serologic studies

Question 45

How do you treat RMSF?

Answer 45

doxycycline or chloramphenicol

Question 46

are prophylatic abx recommended for RMSF?

Answer 46

NO

Question 47

What's the incubation period of ehrlichiosis?

Answer 47

1-2 weeks

Question 48

What are the key symptoms of ehrlichiosis?

Answer 48

malaise, rigors, nausea --> high fever & HA may have pleomorphic rash that affects up to 30% of patients

Question 49

Where is ehrlichiosis common?

Answer 49

Missouri, Arkansas, Oklahoma from lone star ticks like from white tail deer

Question 50

What has rare, serious complications like acute respiratory failure, ARDs, neuro symptoms, acute kidney disease, hemophagocytic syndrome, and multi-organ failure?

Answer 50

erlichiosis

Question 51

How do you diagnose ehrlichiosis?

Answer 51

Hx & characteristics Labs: leukopenia, lymphopenia, thrombocytopenia, transaminitis Peripheral smear w/ stain: intraleukocytic vacuoles Confirm w/ PCR, indirect fluorescnet antibody assay

Question 52

How do you treat ehrlichiosis?

Answer 52

doxycycline, or rifampin for pregnant women

Question 53

What does lack of improvement in treatment for ehrlichiosis mean?

Answer 53

not ehrlichiosis...different diagnosis. Note: may have weakness or malaise for several weeks despite treatment

Question 54

What is the first test you will do to test for syphilis?

Answer 54

nontreponemal: VDRL And RPR

Question 55

What's the confirmatory test you will do for syphilis?

Answer 55

treponemal: TBBA or FTA-ABS