Stillwell's Lectures Flashcards
Reiter’s syndrome
- urethritis
- conjunctivitis
- reactive inflammatory arthritis
- HLA-B27+
- often triggered by CHLAMYDIA
what do you do if sexually active person comes in with urethritis?
- work up both UTI and STI
- STI most common -> asymptomatic in females; discharge from males
diagnosis of urethritis
-urine sample best done 1st void (1st 10 mL)
- if Neisseria -> Thayer-martin, martin lewis, New York city agar in CO2
- if trichomonas -> motile on wet mount
- if non-gonococcal (chlamydia) -> WBCs w/o visible organisms
what can all STDs cause?
hematospermia
Chlamydia Trachomatis
- obligate intracellular
- most common bacterial STI
- most common cause of NGU
- NAAT/PCR tests
- co infection common -> GC, mycoplasma genitalium, trichomonas
- cervicitis in women >85% asymptomatic
- Fitz-Hugh-Curtis syndrome
- WBCs but NO bacteria on gram stain
- proceed to Reiter syndrome
- Trachoma & Trichiasis
Lymphogranuloma venereum
- PAINLESS genital ulcers that progress to inguinal lymphadenopathy
- seen w/ Chlamydia
what is associated w/ elementary & reticulate bodies?
Chlamydia
urethritis in men w/ chlamydia vs. men w/ Neisseriae gonorrhea
- chlamydia -> watery or mucoid discharge
- Neisseria gonorrhea -> copious purulent discharge
treatment of Chlamydia
- uncomplicated -> Azithromycin or Doxycycline
- coinfection w/ GC -> Ceftriazone w/ azithromycin or Doxycycline
Neisseria Gonorrheae
- gram neg diplococci
- thayer-martin, martin-lewis, New York city agars (chocolate)
- Fitz-Hugh-Curtis syndrome
- likes to disseminate -> triad: polyarthritis, tenosynovitis, dermatitis (skin lesions)
- NAATs tests of choice
men/women who get pharyngitis w/ Nisseria Gonorrhea
-ASYMPTOMATIC
sugar fermentation w/ Neisseria Gonorrhea (GC)
- Glucose = Gonorrhea
- Glucose/Maltose = Meningococcus
treatment of N. gonorrhea
uncomplicated -> Ceftriaxone IM + Azithromycin
Trichomonas Vaginalis
- MOTILE on wet mount
- STRAWBERRY CERVIX
- yellow-green discharge; malodorous
- high vaginal pH >4.5
- most common non-viral STI in world
- Hydrogenosome -> produce ATP
- males carry short term; females long term
- asymptomatic early on -> symptomatic 5-28 days
- NAATs preferred
what is most common STI in world?
HPV
3 organisms that cause symptomatic vaginal discharge
- Candida (most common)
- BV
- Trichomonas
treatment of Trichomonas Vaginalis
Metronidazole or Tinidazole
Bacterial Vaginosis
- Gardnerella vaginalis #1
- Mobiluncus #2
- white-grey discharge
- fishy odor - +whiff test
- high vaginal pH >4.5
- CLUE CELLS
treatment of BV
Metronidazole or Clindamycin
Syphilis
-Treponema Pallidum (spirochete) -> MOBILE
- Darkfield microscope
- GUMMAS *(large, caseous)
- contagious -> 1 exposure -> primary/secondary syphilis
primary syphilis
- HARD chancre, PAINLESS
- non-tender regional lymph nodes
secondary syphilis
- MUCOUS patches
- condyloma latum
- patchy alopecia
tertiary syphilis
- GUMMAS (necrotizing, caseous)
- vasculitis of vasa vasorum and thoracic aorta -> aneurysms
- coronary artery stenosis
- Tabes dorsalis
- Rhomberg test
- Argyll-Robertson pupils
congenital syphilis
- saddle nose, SABER SHINS, Clutton’s joints, frontal bossing, Higoumenakis sign
- HUTCHINSON’S teeth
- notched incisors and Moon’s molars
- perforated hard palate
- snuffles and rhagades
diagnosis of syphilis
SEROLOGY main way
-need both + nontreponemal and treponemal tests
- cardiolipin antigen
- titer -> 1:32 (high) down to 1:8 (low) w/ treatment
- Nontreponemal (initial screen)
- RPR (blood)
- VDRL (CSF)
- Treponemal -> Abs against T. pallidum
- confirms nontreponemal if +
- POS for life (even if RPR is neg)
what is the prozone phenomenon?
- high Ab titers can give you FALSE NEGATIVE syphilis test
- recheck RPR on DILUTED serum
False-Pos nontreponemal test
- common
- should have NEG treponemal test
- due to SLE or autoimmune
False-Pos treponemal test
-rare
what do you do if you suspect neurosyphilis?
spinal tap
treatment of syphilis
- PENICILLIN
- 1,2,early latent -> Benzathine penicillin (IM 1 dose)
- late latent -> Benzathine penicillin (IM weekly 3x doses)
- Neurosyphilis -> Penicillin IV
Jarisch-Herxheimer Rxn
-spiked fevers with early syphilis after receiving therapy
Chancroid
-Haemophilus Ducreyi (gram neg rod)
- “school of fish”, “railroad tracks”
- PAINFUL, SOFT chancre
- PAINFUL inguinal lymph nodes
Granuloma inguinale/Donovanosis
- Klebsiella Granulomatis (encapsulated gram neg rod)
- aka Calymmatobacterium granulomatis
-DONAVAN BODIES “safety pins”
PID
- due to GC and Chlamydia
- POLYMICROBIAL
Mycoplasma/Ureaplasma
- Mollicutes
- diagnosis of exclusion
- Myc. Genitalium -> #2 cause of NGU, prostatitis, cervicitis, PID
- Ureaplasma -> urinary calculi, etc.; produces IgA protease
- NAATs main
- treat w/ Moxifloxacin > macrolide > tetracycline
highest risk groups for HIV
-blood exposure -> transfusions #1
- unprotected sex in heterosexuals #1 worldwide -> passed easier from male to female
- MSM #1 in US
risk of transmission in HIV
- related to VIRAL LOAD
- high load -> high risk
- low load -> low risk
anal>vaginal>oral>receptive>insertive
acute phase of HIV
- high viral load, low CD4
- communicable
- viral load decreases to set point
late phase of HIV
- declining CD4
- more symptoms
- still communicable
chronic phase of HIV
-IMMUNE ACTIVATION (even if on therapy)
when do you develop AIDS defining illness?
-8-10 years after HIV infection w/o HAART
HIV diagnosis testing
- 4th generation ELISA Ab/p24 antigen (initial)
- Immunoblot assay Ab (differentiate b/w HIV-1,2) to confirm
- viral load (quantitative RNA PCR)
Acute HIV syndrome
-RASH w/ MONO like syndrome w/ SORE THROAT
- rash on upper thorax, neck, face -> palms/soles
- mucocutaneous ulcers
- anorexia
- retro-orbital headache
- Leukopenia w/ atypical lymphocytes
- heterophile Ab monospot test sometimes False Pos
HIV-2
- West Africa
- long asymptomatic stage (slow CD4 decline)
- RESISTANT to all NNRTIs, fusion inhibitors, PIs
what test do you use to differentiate HIV-1 and HIV-2?
immunoblot assay
-confirms if ELISA screens are +
Medical issues in HIV ptxs
- crystalluria & kidney stones -> Atazanavir and Indinavir
- cervical lesions/carcinoma from HPV
- increased fractures, osteopenia, osteoporosis -> TDF
- lipodystrophy w/ PIs and NRTIs -> abdomen, BUFFALO HUMP, breasts, nasolabial folds
- jaundice w/ Atazanavir
HAART
1 integrase inhibitor (dolutegravir, raltegravir) + 2 NRTIs***
- Abacavir -> HLA-B5701 allele -> HYPERSENSITIVITY rxn
- Maraviroc (CCR5 antagonist) -> TROPISM test
HIV viral blips
- temporary increase in viral load after HAART
- NOT virologic failure
Virologic failure
- larger increase in viral load
- assess for non-compliance
HIV controllers
- immune system prevents replication -> no need for ART
- elite -> viral load <50 for 15-20 years
- nonprogressors -> viral load <2,000-5,000 for 15-20 years
IRIS syndrome
- worsening of disease if given HAART w/o treating opportunistic infection 1st
- get opportunistic under control 1st -> start ART 2-3 weeks after
- DO NOT STOP ART IF ALREADY ON IT
AIDS
-HIV+ plus CD4 <200 or lymphocyte <14% or AIDS defining illness
mucocutaneous candida
- Candida albicans most common in HIV+
- Pseudohyphae on KOH
- pseudomembranes SCRAPE OFF
- oral and vulvovaginal NOT AIDS defining -> esophageal/tracheal/bronchial/pulmonary IS if CD4 <200
what do you treat C. auris with?
Echinocandins bc it is amph. B and voriconazole resistant
what do you treat esophageal candidiasis w/?
Fluconazole
PCP/PJP
- high mortality before HAART
- normal Xray, bad presentation
- hypoxic
- HIGH LDH >500**
- SPONTANEOUS pneumothorax
- ping pong balls and tea cups on GMS stain
- treat: TMP-SMX
treatment for PCP
- high dose TMP-SMX for 21 days
- IV Pentamide 2nd choice -> hypoglycemia, pancreatitis, azotemia, hypotension
- Dapsone + TMP -> methemoglobinemia
-if pO2 <70 or alveolar-arterial O2 gradient >/= 35 -> give CORTICOSTEROIDS -> prevents IRIS
is it common to see deterioration in PCP?
- YES
- ptxs gets worse before gets better
- do NOT think respiratory distress is treatment failure until 4-8 days*** - change therapy after that
Cryptococcus Neoformans
- LOVES TO GO TO BRAIN
- meningitis or cryptocomma in brain
- Pigeons in cities
- HEADACHE
- skin lesions
- NARROW based budding
- MUCICARMINE stain
- HIGH OPENING PRESSURE (OP >25) -> confusion, blurred vision, papilledema -> REPEATED lumbar puncture
- associated w/ IRIS syndrome
induction treatment w/ crypto - 2 weeks
liposomal amphotericin B 1st (combo w/ 5-FC)
- amph. B side effects -> nephrotoxic, low K+ and Mg2+, shake and bake
- 5FC side effects -> BONE MARROW SUPPRESSION
consolidation treatment w/ crypto - 8 weeks
Fluconazole
- can cross blood brain barrier
- side effects -> teratogen
maintenance treatment w/ crypto - 1 year
Itraconazole
-no penetration of blood-brain
Histoplasma Capsulatum
- Ohio and MS river valley
- problem in AIDS ptxs in AR -> AIDS defining illness
- ULCERS in GI tract
- skin lesions
- diagnose w/ blood or urine antigens
- histo in MACS, histo in WBCs
- treat w/ liposomal amph. B (severe) -> Itraconazole if not severe
Blastomyces Dermatitidis
- NW Ar
- NOT an AIDS defining
- plaque like verrucous skin lesions
- LIKES TO GO TO BONE -> lytic bone lesions
- WIDE based budding
Coccidioidomyces Immitis
- SW US
- SPHERULES
- THIN WALLED CAVIITIES (upper lobe)
- skin lesions, meningitis, pneumonia
- Eosinophila
- treat: liposomal amph. B -> itraconazole or fluconazole
Mycobacteria
- TB at any site is AIDS defining***
- atypical mycobacterium is NOT unless extra pulmonary or disseminated
Mycobacterium Avium
WASTING SYNDROME if disseminated
-CD4 <100
Toxoplasma Gondii
- raw meat
- brain lesions, necrotizing RETINITIS
- Tachzoites
how do you distinguish b/w Toxo and CNS lymphoma?
treat for toxo for 3 weeks
- if improvement -> think toxo and keep treating
- brain biopsy if no improvement
Toxo -> MULTIPLE ring enhancing lesions
CNS lymphoma -> FEWER ring enhancing lesions (periventricular, corpus callosum)
CMV
- necrotizing RETINITIS w/ yellow-white lesions
- reactivation from latent
- CNS POLYRADICULOPATHY -> paraplegia
- OWLS EYE
- diagnosis: quantitative DNA PCR***
- treat: Ganciclovir or Foscarnet
what is a common presentation of HIV-1,2?
-ulcerative esophagitis
Recurrent Pneumonia
Strep Pneumonia and H. influenza***
-MULTI-LOBAR pneumonia
Kaposi’s Sarcoma
- HHV-8
- primary effusion lymphoma (PEL)
- multicentric Castleman’s disease (MCD)
- purple skin lesions -> NOSE and ROOF OF MOUTH
what lymphomas are HIV most associated with?
B cell lymphoma
- NHL
- Hodgkin’s lymphoma (NOT AIDS defining) -> EBV associated
Cowdry type A nuclear inclusions
HSV-1, HSV-2
SLE
- Asians, Latinos, African Americans
- high females
- heart -> Libman-Sacks endocarditis and fibrinous or exudative pericarditis and myocarditis
- lymph nodes -> hematoxylin/LE bodies
if fever resolves w/ acetaminophen, NSAIDs, or steroids
think AUTOIMMUNE or malignancy
if fever does NOT resolve w/ acetominophen, NSAIDs, or steroids
think infection or drug related
what can SLE cause in the mucosal region?
NASAL PERFORATION
-mucosal and nasal septal ulcers
what cutaneous lesions are associated w/ SLE
- butterfly rash (spare nasolabial)
- skin photosensitivity
- discoid lupus
what kind of lung disease is seen in SLE?
interstitial lung disease -> ground glass pattern
2 most common hematologic diseases in SLE?
- anemia of chronic disease
- leukopenia
labs for SLE
- ANA (95%) -> homogenous pattern of ANA
- anti-dsDNA
- anti-Smith
- high ESR and CRP
- hematoxylin/LE bodies
does pos ANA alone mean you have SLE?
NO!!
lupus like syndrome - drug induced lupus
- rarely affects CNS or kidneys, unlike SLE
- male = female
the high risk drugs for drug induced lupus
- hydralazine (HTN)
- Procainamide (restore rhythm)
- Quinidine (restore rhythm)
labs for drug induced lupus
- ANA pos 95% -> homogenous pattern
- anti-dsDNA neg
- anti-histone Ab*** pos
Sjogren’s Syndrome (SS)
- xeropthlamia, xerostomia, xerosis, vaginal dryness -> SICCA SYNDROME
- DRY MUCOUS MEMBRANES
- high females
- Schirmer’s test is decreased
labs for Sjogren’s syndrome
- ANA 1:320 -> speckled pattern
- anti-Ro/SSA and anti-La/SSB Abs***
MCTD
- high females
- RAYNAUD’S PHENOMENON -> vasospasm of digital arteries
- swollen hands or digits
- deforming like RA
MCTD labs
- ANA pos -> speckled pattern
- anti-RNP Abs***
CREST syndrome
- C -> calcinosis cutis
- R -> raynauds
- E -> esophageal dysmotility
- S -> sclerodactyly
- T -> telangiectasia
CREST labs
- pos ant-centromere Ab**
- Anti-Scl-70 Neg** (for scleroderma)
Antiphospholipid syndrome
- autoimmune hyper coagulable state
- Abs bind/inhibit protein C and S
- high in females
- mixing study for cardiolipin Abs or lupus anticoagulant
what MHC is associated w/ ankylosing spondylitis & other spondyloarthropathies?
HLA-B27
- MHC class I
- > /=90% in AS
- lower in others
Ankylosing Spondylitis (AS)
- > /= 90% w/ HLA-B27
- male: female is 3:1**
- low back pain -> improves w/ exercise, NOT rest
- spine and sacroiliac joints
- bamboo spine -> marginal syndesmophytes**
- uveitis or aoritis
- NO response to DMARDs
Psoriatic Arthritis (PA)
- males = females
- psoriasis precedes PA by 7-10 years*** -> plaque psoriasis most common
- NAIL PITTING, onycholysis, ridging/cracking, hyperkeratosis, leukonychia
- oligoarthritis (DIP > PIP, MCP)
- HLA-B27 +
- can treat w/ DMARDs
Classic Reactive Arthritis
- microbes can’t be recovered
- Reiter’s syndrome -> post-infectious arthritis, urethritis, conjunctivitis
- oligoarthritis (spine and sacroiliac joints)
- KERATODERMA BLENNORRHAGICUM
- CIRCINATE BALANITIS
- HLA-B27+
- can use DMARDs
the most common infectious cause of reactive arthritis?
-Chlamydia trachomatis
Post-strep reactive arthritis
- immune rxn after GAS > GCS, GGS
- 1-10 days after pharyngitis
- NON-MIGRATORY
- minimal response to NSAIDs
- HLA-B27+
- only treat for >/= 1 year -> monitor closely
- doesn’t tend to relapse
Enteropathic Reactive Arthritis
- ulcerative colitis and Chron’s disease most common
- type 1 -> oligoarticular -> LARGE joints -> HAS IBD flares
- type 2 -> polyarticular -> MCPs -> NOT associated w/ IBD flares
- HLA-B27+
- responds to DMARDs
Celiac disease arthritis
- rxn to gluten in small intestine
- women > men
- DERMATITIS HERPETIFORMIS
- improves and Abs resolve w/ gluten free diet
- if IgA deficiency -> rely on IgG tests
