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CR - Systemic Infectious Disorders Flashcards

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1
Q

Which patients will most likely need the complete tetanus vaccination series with a “dirty wound”?

A

Greater than 60 years old
Immigrants
IV drug users
Patients with < 3 doses, unknown or uncertain tetanus vaccination status

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2
Q

What is the treatment for a patient with severe anemia and malaria?

A

Parenteral therapy with

  1. quinidine + doxycycline or tetracycline or clindamycin

or

  1. Artesunate
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3
Q

Pregnant women should avoid cat litter due to the risk of contracting what parasite?

A

Toxoplasma gondii

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4
Q

A 43 year old male with a history of AIDS presents with a dry, sore mouth and painful swallowing. Examination of the mouth reveals white, lacy plaques on the tongue and buccal mucosa. What is the most likely diagnosis and how would you treat this patient?

A

Oral thrush and candida esophagitis

Clotrimazole troches or miconazole nystatin + oral fluconazole for > 3 weeks

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5
Q

What are the most common vector and infecting bacteria associated with Rocky Mountain Spotted Fever?

A

Vector: Dermacentor tick
Bacteria: rickettsia rickettsii (spirochete)

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6
Q

What is the most common presenting symptom in clostridium tetani infection?

A

Trismus (“lockjaw”) is the presenting symptom in greater than 50% of cases

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7
Q

What is the first line treatment for cryptococcus neoformans?

A

Amphotericin B + flucytosine

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8
Q

What is the only universal finding in rocky mountain spotted fever?

A

Fever (typically greater than 102.2 of 39)

Patients have severe headache, chills, and muscular pains. Rash on palms and soles that extends to neck, face, and trunk. History of a tick bite in 70% of patients

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9
Q

What is the most common cause of meningitis in HIV patients?

A

Cryptococcus neoformans is a cause of meningitis commonly associated with HIV and is an AIDS defining illness

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10
Q

What is the most common cancer seen in AIDS patients?

A

Kaposi sarcoma

Seen in approximately 40% of AIDS patients, primarily male homosexuals

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11
Q

Define systemic inflammatory response syndrome (SIRS)

A

Two or more of the following:
- Temp > 100.4 (38) or < 96.8 (36)
- HR > 90 BPM
- RR > 20 or PaCO2 < 32
- WBC > 12,000, < 4,000 or >10% bands

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12
Q

What is the first line vasopressor agent in a patient that is septic that fails IV fluid resuscitation

A

Norepinephrine

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13
Q

Patients afflicted with rocky mountain spotted fever may exhibit extreme tenderness of what muscle?

A

Gastrocnemius muscle

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14
Q

Hyponatremia < 130 and diarrhea is commonly seen with what type of pneumonia?

A

Legionella pneumophila

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15
Q

What is the treatment for toxoplasmosis?

A

Combination of IV pyrimethamine plus sulfadiazine plus leucovorin (folinic acid)

Can substitute clindamycin for sulfadiazine

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16
Q

Why is folinic acid used in the treatment for toxoplasmosis

A

Prevention of bone marrow suppression

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17
Q

What is the reaction that can occur (in up to 15% of patients) within 24 hours of starting antibiotics for treatment of lyme disease?

A

Jarisch-Herxheimer Reaction

A transient clinical phenomenon occurs in patients infected by spirochetes who undergo antibiotic treatment.

Symptoms can include fever, chills, rigors, nausea, vomiting, headaches, tachycardia, hypotension, myalgia and exacerbation of skin lesions

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18
Q

Jarisch-Herxheimer Reaction is a host immune response to spirochete antigens when treatment is started.

What are the signs/symptoms of this reaction?

A

Fever, chills, headache, rigors, tachycardia, hypotension, rash, worsening of liver or kidney function, ARDS, uterinr contractions, meningitis, altered mental status, seizures, and myalgias.

This condition can mimic SIRS / sepsis

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19
Q

What is the indication to start steroids in patients with pneumocystis jiroveci pneumonia (PJP)?

A

Use in patients with moderate to severe PJP and in all children and in adults with SpO2 < 92%, a pO2 < 70 mmHg and or a P(A-a) O2 gradient > 35

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20
Q

What is the most common tick/vector borne disease in the United States

A

Lyme disease

Tick/vector - ixodes
Organism - borrelia brugdorferi (spirochete)

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21
Q

A 78 year old ill appearing male presents to the ED with diffuse sweating, chills, fever, abdominal pain, and “yellowing” of his skin

8 days ago returned from Sub-Saharan Africa. Prior to departure deneis vaccination or chemoprophylaxis.

Vitals: BP 125/70, HR 130, RR 25, temp 40.2 (104.4) and O2 sat 96%.

Exam shows lethargy, bilateral scleral icterus, hepatomegaly and bilateral lower extremity edema.

Labs show total bilirubin 5.1 mg/dL, ALT 266, AST 244.

What does he likley have and how do you treat it?

A

Malaria

Treatment of uncomplicated P. falciparum malaria (except for pregnant women in their first trimester)

Artemether + lumefantrine

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22
Q

A 21 year old female college student presents to the ED with a rash on the back of her lower legs and mild joint pain after returning from a hiking trip in New Jersey. She states it appeared 8 days after her hike. 4 hours ago went to urgent care, prescribed penicillin for suspected early lyme disease. Shortly after first dose of antibiotic, developed a fever, headache, and rapidly progressive rash.

On physical examination multiple targetoid, erythematous lesions are present to the bialteral lower extremities with skin flushing. Vitals: BP 90/50, HR 130, RR 22, Temp 38.3 (100.9), O2 99% on room air.

What is the most likely diagnosis?

A

Jarishch-Herxheimer Reaction

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23
Q

What is the appropriate approach for sepsis?

A

Early treatment strategies for sepsis

  • reversing end organ hypoperfusion / hypoxia by fluid administration (initial bolus of 30 ml/kg)
  • early broad spectrum antibiotics (within 60 minutes)
  • vasopressor support (if BP does not correct with fluid resuscitation)
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24
Q

Which patients require tetanus immune globulin administration?

A

Patients with tetanus prone (dirty) wounds who:

  • have not completed primary immunizations series
  • HIV patients
  • Severely immunocompromised patients
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25
What are the three major criteria for a patient who has been diagnosed with small pox?
- febrile prodrome - classic "belly-button" lesions - All lesions in the same stage of evolution
26
What is the major electrolyte abnormality most commonly associated with the diagnosis of legionella pneumophila?
Hyponatremia (<130)
27
What are the criteria needed to be met to have a diagnosis of sepsis and what are the certain risk factors to increase the likelihood of becoming septic?
SIRS + suspected source of infection = sepsis SIRS - 2 + of the following - temp > 100.4 or < 96.8 - HR > 90 - RR > 20 or PaCO2 < 32 - WBC > 12,000, < 4,000, or > 10% bands Risk factors for becoming septic - infants and age > 65 - immunosuppression (AIDS, chemotherapy, chronic steroid use, diabetes, transplant patients) - lung disease - bacteremia - chronic indwelling lines and tubes (foleys, central lines)
28
What is the characteristic constellation of symptoms in Rocky Mountain Spotted Fever (RMSF)? What is the only universal clinical finding in RMSF?
Fever and myalgia followed by severe headache and GI symptoms precede the appearance of the rash (which usually develops 2-6 days after the onset of fever) The rash is erythematous, blanching macules 2-3 mm in diameter, starting on flexor surfaces of wrist and ankles, moving first to palms and soles, then moving proximally to cover the trunk. Extreme tenderness in the gastrocnemius muscle is a characteristic finding. Fever is the only universal finding and is usually high (>102.2 / 39)
29
What is the most common cardiovascular abnormality associated with lyme's disease?
Myocarditis It occurs transiently and is associated with varying degrees of AV block
30
What treatment is indicated for a nurse in your ED who is accidentally stuck with a PPED needle used on your patient that was just diagnosed with pneumocystis jiroveci pneumonia?
Recommend expanded 3 drug post exposure prophylaxis (PEP). As this patient has been diagnosed with an AIDS related pneumonia they are considered high risk with a presumed high viral load, and low CD4 count which classifies this patient as HIV-positive, class 2, symptomatic. Despite this being a "low risk" needle stick with no visible blood on the needle that wasn't used in the patients vessels, the patients advanced HIV disease warrants the highest level of PEP
31
What is the treatment for a patient who presents to your ED for new onset seizures and is noted ot have ring enhancing lesions and mass effect on CT scan with contrast?
Pyrimethamine, and sulfadiazine with folinic acid. Treatment for CNS toxoplasmosis
32
How does severe malaria caused by plasmodium falciparum present?
- severe anemia - cerebral malaria: confusion, coma, seizures, permanent neurologic deficits (deaf, blind, palsies) - pulmonary edema, ARDS - thrombocytopenia - shock - acute renal failure - hypoglycemia - abnormal bleeding - disseminated intravascular coagulation (DIC)
33
What are the treatments for generalized tetanus?
- human tetanus immune globulin IM to neutralize any unbound toxin - IV metronidazole - quiet room and benzodiazepines for muscle spasms - surgical debridement of wound
34
What are the most common rabies reservoirs in the united states?
- raccoons (most common in eastern US) - skunk (most common in central and western US) - bats - foxes - coyotes - bobcats
35
Describe the rabies immunization process
Active immunization with HDCV (human diploid cell vaccine) 1ml IM on day 0, 3, 7, and 14 Immunosuppressed patients need additional 1ml IM on day 28 Passive immunization with HRIG (human rabies immune globulin) - use if animal is or may be rabid - dose 20 IU/kg - administer as much as possible at the site of exposure - administer the remaining dose IM at siges near the wound
36
A 47 year old, previously healthy male presents to the ED with fever, dry cough, diarrhea, altered mental status, and difficulty walking. Laboratory studies are remarkable for hyponatremia and elevated LFTs. What is the antibiotic for this condition?
Azithromycin The patient has CAP caused by legionella pneumophia Alternative treatment is TMP/SMX, tetracyclines, or quinolones
37
What features differentiate chickenpox (varicella) from smallpox
Varicella tends to be more superficial, appears in crops, and are in different stages of development (papules, vesicles, scabs) and tend to be located on the abdomen and torso > extremities Smallpox lesions are all in the same stages of development
38
What biological agents can be easily transmitted from person to person?
- francisella tularensis - yersinia pestis - smallpox - ebola - coronavirus
39
What is the definition of AIDS?
HIV infection with CD4 count < 200 cells/mL or presence of an AIDs defining illness
40
What is the most common cause of opportunistic infection and leading cause of death in HIV patients?
P. jirovecii (formerly known as P. carinii) May see "bat-wing" pattern on CXR Tuberculosis has significant mortality in HIV patients worldwide
41
What is the treatment of PJP (p. jirovecii pneumonia)
TMP/SMX IV or PO for 14-21 days IV pentamidine is an alternative for patients with sulfa allergies. Glucocorticoids for hypoxia
42
Percutaneous inoculation with HIV is more severe when it occurs by what means?
Hollow bore needle that was used in HIV patient's artery or vein, deep puncture, visible blood on device
43
An emergency medicine resident is punctured by an 18 gauge needle that was contaminated with blood from a patient who is known to be HIV positive. What are the recommendations for post exposure prophylaxis in this situation?
- Wash the wound thoroughly and as soon as possible - start the expanded three drug post exposure prophylaxis regiment (two NRTI drugs and a protease inhibitor as recommended by the CDC) - update tetanus status - Test source patient and exposed person for HIV, HCV, and HBV
44
Do bites from rabbits or squirrels typically require rabies PEP (post-exposure prophylaxis)?
No, they are not reservoirs for rabies
45
Your patient presents to the ED with mild flu-like symptoms that has rapidly progressed to respiratory distress and shock. You suspect B anthracis to be the cause of the illness. What are the classic CXR findings for this disease? What is the treatment of choice?
Diffuse hemorrhagic lymphadenitis, widespread edema and mediastinal widening IV ciprofloxacin and clindamycin therapy, antitoxin (raxibacumab or antrax immunoglobulin), drainage of pleural effusions, supportive care, and consideration of adjunctive glucocorticoids
46
In an adult with sepsis, what is the vasopressor of choice and what is the target mean arterial pressure (MAP)
Norepinephrine MAP > 65
47
Which form of clinical tetanus can occur in a fully immunized individual
Cephalic
48
In the patient with tetanus needing aggressive airway management, what neuromuscular blockade should be utilized?
Vecuronium or rocuronium Avoid depolarizing neuromuscular blocker drugs (such as succinylcholine) should be used cautiously as it may trigger hyperkalemic arrest
49
Fluctuating meningoencephalitis is the most common neurologic abnormality of which infectious disease?
Lyme disease
50
What are the 3 predominant forms of anthrax?
Cutaneous Inhalational Gastrointestinal
51
Can HIV be transmitted through breast milk
Yes
52
What is the most common cause of focal encephalitis and the leading cause of intracranial mass lesions in AIDS patients?
CNS toxoplasmosis
53
What is the most common ocular complication seen in AIDS patients?
Cytomegalovirus retinitis
54
What is the antibiotic of choice for post-tick exposure to Lyme Disease and in what setting would therapy be required?
The tick must be attached greater than 36 hours abefore lyme disease can be transmitted and the antibiotic of choice is doxycycline 200 mg for one dose or 4 mg/kg for children > 8 years old. Treatment must be initiated within 72 hours of tick removal
55
A 36 year old patient who recently immigrated to the US from croatia presents with a clean linear 2cm laceration to the arm he sustained subsequent to a mechanical fall at work. He states that the "slipped on some liquid" and fell, causing his hand and arm to break through a glass window. His immunization status is uncertain. What tetanus intervention is indicated?
Vaccination only Tetanus immune globulin is not indicated for minor wounds, even with an uncertain immunization status
56
Among the several etiologies of malaria, which pathogen is the only one capable of causing severe disease
Plsamodium falciparum Symptoms include - severe anemia - cerebral malaria (confusion, coma, seizures, deafness, blindness) - pulmonary edema, ARDS - thrombocytopenia - shock - ARF
57
A previously healthy 62 year old male presents from home with sudden onset of fever (39.6), headache, nuchal rigidity, and whole body myalgias. He recently visited upstate New York, where he forgot to apply bug repellant during a short hike. A thorough physical exam reveals multiple small, papular lesions. No other rash or embedded ticks are visualized. CSF studies reveal elevated protein and pleocytosis, but no bacterial pathogens. CT of the brain shows no signs of CNS inflammation. what is the correct initial treatment for this patient?
Empiric treatment for bacterial meningitis and/or treatment for herpes simplex viral encephalitis are appropriate. Although there is no specific treatment, West Nile Virus is the most likely diagnosis.
58
Which patient populations are at high risk for contracting tetanus infection?
- elderly - IV drug abusers - patients with decubitus and diabetic ulcers - patients who are not up to date on their vaccinations - HIV patients - severly immunocompromised patients
59
What is the most common type of tetanus and what are its initial symptoms?
Generalized tetanus Symptoms: pain and stiffness in the jaw and trunk, facial rigidity (trismus and risus sardonicus), glottal spasm, (can lead to respiratory arrest), arms flexed, fists clenched, legs extended
60
What is the appropriate antibiotic therapy for sepsis per type of infection (community acquired pneumonia, hospital acquired pneumonia, UTI, unknown source)?
Community acquired pneumonia - ceftriaxone + macrolide (e.g. azithromycin) Hospital acquired pneumonia - pipercillin/tazobactam + vancomycin or - 4th generation cephalosporin (e.g. cefepime) UTI - 3rd generation cephalosporin (e.g. ceftriaxone) or - fluoroquinolone (e.g. ciprofloxacin), cephalexin Unknown source - broad spectrum coverage for gram positive, gram-negative and anaerobic organisms Special. consideration for MRSA
61
What are seven differential diagnoses for tetanus?
- strychnine poisoning (strychnine detectable in urine) - dystonic reactions to phenothiazines (improves with diphenhydramine) - hypocalcemic tetany - trismus due to dental infection - malignant neuroleptic syndrome - early rabies (trismus is uncommon) - stiff person syndrome (SPS) - a rare neurologic disorder
62
A patient presents with chief complaint of cough that is productive of purulent sputum. Associated symptoms of dyspnea and pleuritic chest pain are also present. Diagnostic testing shows WBC count of 16.2, increased sedimentation rate, elevated LFTs, and hyponatremia. CXR reveals unilateral patchy infiltrates in right lower lobe with small pleural effusion. What is the most likely diagnosis?
Legionella pneumophila
63
What are the most frequent modes of HIV transmission
Sexual intercourse Parenteral transmission (includes IV drug abuse, needle sticks, or exposure to mucous membranes or breaks in the skin) Breast milk
64
What are the appropriate prophylactic measures after a deer tick bite?
If the tick has been embedded for > 36 hours: One dose of doxycycline 200 mg orally and removal of ticks embedded in the skin (using fine-tipped tweezers as close to the skin as possible)
65
What is the characteristic rash of early lyme disease called and what are its visual features?
Erythema migrans The rash begins as a circular lesion at the site of the tick bite and enlarges. Classically it has a red border with a pale interior
66
What clinical signs may be seen during the excitement phase of rabies infection?
Thought disturbances with lucid intervals, hypersensitivity to light / sound / touch, agitation, confusion, hallucinations, restlessness, or seizures. Presentation is variable
67
What plasmodium species cause a cyclical fever of two days duration?
Plasmodium falciparum, plasmodium vivax, and plasmodium ovale
68
What are the major and minor criteria for the clinical diagnosis of smallpox?
Major criteria - febrile prodrome, "belly-button" lesions, which are typically firm round vesicles or pustules, and all lesions are in the same stage of evolution Minor criteria - centrifugal distribution of rash on the face and distal extremities; lesions that first appeared on the oral mucosa and/or palate, face or arms; a toxic-appearing patient; slow evolution of lesions (from macules ot papules to pustules) over a period of 1-2 days; lesions on the palms and soles
69
What is the complete tetanus immunization protocol for non-immunized adults and what is the dose administered?
Intramuscular Td 0.5 ml, repeat 6 weeks after first dose, and again 6 months later. Td boosters every 10 years thereafter
70
A 24 year old amish male presents to the ED by ambulance complaining of a 2 days history of generalized weakness, difficulty opening his mouth, diffuse myalgia, painful muscle spasms and sweating. 5 days ago he reports falling into a saw blade and cutting his left forearm. The father reports he received no vaccinations as a child. Vital signs are BP 195/90, HR 140, RR 24, temp 37 (98.6) and O2 100% on RA. An EKG is obtained which is unremarkable Physical examination revels a 5cm laceration to the lateral aspect of the right deltoid and diffuse, spontaneous muscle spasms with touch. What is considered the preferred antibiotic for the likely diagnosis?
IV metronidazole This is given in conjunction with wound debridement, tetanus immune globulin, and tetanus vaccine, followed by complete adult vaccination as scheduled
71
A 43 year old male presents for a refill of his metoprolol. You discover that he has not received a tetanus vaccination in 23 years. He has no open wounds. Should you administer Td to this patient?
Yes The CDC recommends that emergency physicians offer tetanus prophylaxis routinely to all patients (regardless of the presenting complaint) who have not been immunized within the last 10 years
72
What is the most common pathogen in sepsis?
Gram positive bacteria
73
Hypnozoites of plasmodium can cause reactivation of malaria months to years after initial disease without the proper treatment. Which types of plasmodium sp are these?
Plasmodium vivax and plasmodium ovale
74
What is the antibiotic of choice for a young, non-smoker, non-immunosuppressed patient with community acquired pneumonia?
Amoxicillin

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