board review ID Flashcards
AML induction, neuutropenic, shock
on ppx with moxi, vori. what org?
ecthyma gangrenosum - pseudomonas
febrile neutropenia
single temp of 38.3, sustained 38 for 1 hr
ANC >500 or expected within next 48h
tx
blood cx, empiric abx - cover pseudomonas
most common organisms:
1. enteric enterobacteriaceae
2. viridans group strep - severe sepsis in neuropenia
3. staph (staph aureus or coNS) - esp if central line
4. pseudomonas - less common but most severe
add vanc?
-hemodynamic instability
-suspected catheter or skin/soft tissue infection
-pna
-+/- on hx of MRSA
typhilitis
ie, neutropenic colitis
ileocecal region so RLQ pain
sx :
abd pain
fever
diarrhea
w/u CT AP, blood cx
tx: broad-spectrum abx, bowel rest, surgery if perf or necrosis
if FN persists without definite cause after 3-5 days of broad spectrum abx what should you consider?
fungal infection
–candida – if on azole ppx,, would consider C, glabrata
–aspergillis»_space; mucor
need further workup
-CT chest, sinus
serologic
-galactomannan – positive in aspergillus, not sensitive
-fungitell – 1,3 beta D glucan or fungitell – can be postive if candida, PJP,, endermics, and molds. Except mucor.
consider empiric therapy.
halo sign - invasive pulmonary fungal infection
antifungal tx:
azoles +penetration into CSF and urine, watch out drug interactions
-fluconazole” no mold, treat/prevent candida
- vori/itra: asp (vori), candida and histo (itra). does not cover mucor.
-posaconazole/isavuconazole: all of above plus covers mucor.
ambisome: nephrotoxic+penetrates csf
echinocandin: does not penetrate into csf, urine, eyes
-covers candida, aspergillis (2nd line)
-does not cover mucor, histo, crypto
-mica, caspo, andilafungin are examples.
mucor
very high mortality rate
look for necrosis on hard palate
path: pauci-septate, ribbon-like right angle branching
most commonly see sinusitis»_space; pna
risk factors: neutropenia so AML, MDS
poorly controlled DM
iron overload
high dose steroids
tx: surgical debridement, amphotericin B derivatives, reversal of immunocompromising condition
47yo F, severe RA on infliximab, miliary CT, nebraska, decreasing WBC
Histo
dx: serum and urine antigen, and BAL if done
serology(immunodiffusion and complement fixation)? may increase senstivity but may be negative initially
histo: dimorphic
tx
mild-consider if persists
severe: amphotericin B followed by itra
mild to moderate: itra
will cross react with other dimorphic (cocci, blasto)
endemic/dimorphic fungi
grows as yeast in bodies (ie, body temp)
mold in lab (room temp)
virus associated with Natalizumab
JC virus – PML
reverse IS
PJP
induced sputum or BAL with silver stain
if cannot do BAL, send fungitell
does not grow in cx
tx:
high dose bactrim (15-20mg/kg TMP)
if sulfa allergy –> desensitize better alternatives
mild to mod: atovaquone or clinda/primaquine or TMP+dapsone (check G6PD)
severe: clinda=primaquine or IV pentamidine
-steroids if A-a gradient >35 or paO2 <70
risk: hiv
impaired cellular immunity
steroids
solid organ transplant
lymphocyte depleting agents (ATg, alemtuzuman)
ppx: bactrim best
otherwise: pentamide, dapsone, atovaquone – breakthrough
crypto
control increased iCP
subacute or chronic meningitis(ha, cranial nerve palsy, ams)
meningeal sx rare
dx: csf and crypto antigen very sensitive
will typically grow from routine cx within 3-5 d
CSF opening pressure – if>25 poorer outcome and needs taps v shunt
other bad prognostic findings:
-CSF cell count <20 WBC
- CSF crypto ag >1:1024
- AMS or seizures on presentation
tx: amphotericin plus flucytosinex2 weeks (until clinical improves and csf cx sterilize)
-consolidation with fluconazole 400mg daily x8 weeks
-maintenance: fluconazole 200mg daily xat least 1 year
control of elevated ICP essential
in newly diagnosed HIV – delay ART initiation for minimum of 2 weeks given risk of IRIS (can raise ICP)
other risk factors:
SOT or ESLD
CLL
chronic high dose steroids
pregnant, fever, confusion , hypotension
household contacts with diarrhea
ate foor from relatives in mexico
listeria
–cold cuts, unpasteruzied cheese
pregnant, very young and old, immunocompromised (SOT recipients)
immunosupressed with meningitis or pregnant with bacteremia
must add amp if >50, immunocompromised
Gent used for synergy in confirmed listeria for at least 1 week until clinical improved***
IV TMP/SMX is alternative for amph or gent.
nocardia
delicate branching beaded gram stain positive
modifed AFB positive, strict aerobe
risk: SOT, HSCT and prolonged steroids
pulm: 90%
hematogenous dissemination to brain in ~50% so always need CNS imaging as may be asx
skin, softtissue, bone involement
tx: bactrim***, minocycline, imipenem, linezolid, ctx
–need 2 agents if cns and longer
nocardia
delicate branching beaded gram stain positive
modifed AFB positive, strict aerobe
risk: SOT, HSCT and prolonged steroids
pulm: 90%
hematogenous dissemination to brain in ~50% so always need CNS imaging as may be asx
skin, softtissue, bone involvement
tx: bactrim***, minocycline, imipenem, linezolid, ctx
–need 2 agents if cns and longer
dx P falciparum by smear
