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ORAL EXAM CASES > Fungal and Parasitic infections > Flashcards

Fungal and Parasitic infections Flashcards

1
Q

What is Candida infection?

A

CH 234: CANDIDIASIS
- Candida albicans
- 3rd most common cause of blood stream infection in preterms
- Most common cause of invasive candidiasis among
immunocompromised pedia pxs
Patho:
- immunologic immaturity, devices, exposure to broad
spectrum abx –> decrease physiologic barriers that
protect against invasive infection

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2
Q

What are the clinical manifestations of Candida infection?

A

CM:
1. Oral candidiasis
- “Thrush”: pseudomembranous candidiasis
- Usually among infants or in older children treated with
abx
- White to gray plaques on a red base in buccal mucosa,
tongue or palate; “cheesy” looking colonies that form
pseudomembranes
- Gentle removal reveals a raw red base
- Pain, fussiness, decreased feeding
- Usually as early as 7th-10th DOL
2. Diaper dermatitis
- Most common infection caused by Candida
- Confluent, erythematous, well demarcated rash with
peripheral scales and satellite pustules
- Involves inguinal creases
- May be “beefy red”
3. Vulvovaginitis
- Pubertal and postpubertal females
- Pain or itching, dysuria, vulvar or vaginal erythema,
opaque white or cheesy exudate
4. Systemic/Invasive candidiasis – in PT: T instability,
lethargy, apnea, hypotension, RD, abdominal
distention, thrombocytopenia, meningoencephalitis

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3
Q

How is Candida infection diagnosed?

A

Dx:
1. GS or KOH smear
2. Candida C/S – definitive diagnosis from normal sterile
body fluids; BCS very low sn
3. CBC – thrombocytopenia (80%)

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4
Q

what is the management of Candida infection?

A

Mgt
1. Oral nystatin 1ml to each side of the mouth qid x5d
2. Topical nystatin, Miconazole, Clotrimazole – In the
absence of systemic sx, topical tx is the treatment of
choice
- Presumptively treat any diaper rash >3d
- Add hydrocortisone 1% for 1st 1-2d if with significant
inflammation
3. Oral mycostatin or fluconazole – if recurrent, extensive
x 21d
Fluconazole 12mg/kg LD then 6-12mg/kg OD
4. Amphotericin B 1mkd OD - mainstay tx for systemic
candidiasis

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5
Q

Case
9 year-old female from Tondo, consulted for blood in stool
HISTORY
14 days PTC, complained of 4-5 episodes of watery diarrhea, and
dull, hypogastric pain, with decreased appetite. Brought to the
nearby health center and was given ORS.
In the interim, patient would pass scant, watery stools sometimes
with streaks of mucous. There are times when patient would feel
the urge to defecate, but pass no stool.
Note of blood-streaked stool that morning prompted consult.
PAST MEDICAL HISTORY
Admitted for vomiting and diarrhea at 2 y/o, no known allergies
FAMILY MEDICAL HISTORY
Younger sibling was hospitalized for typhoid fever
BIRTH AND MATERNAL HISTORY
Unremarkable birth and maternal history.
IMMUNIZATIONS
Completed EPI, given 1 dose of MMR; Hep B, DTap and Hib
boosters as a toddler
NUTRITION
Exclusively breastfed until 6 mos
Started complementary feeding at 6 mos
Eats 3 meals a day, 1-2 snacks
DEVELOPMENTAL
At par with age, average academic performance
PHYSICAL EXAM
Awake, ambulatory, drinks eagerly
BP 90/60, HR 82, RR 18, T 37.5C
Wt 25 kg (z -1), Ht 130 cm (z 0)
Pink conjunctivae, anicteric sclerae, sunken eyes, no
tonsillopharyngeal congestion, no cervical lymphadenopathy
Equal chest expansion, clear breath sounds, no retractions
Adynamic precordium, loud S1 S2, PMI not displaced, regular
rhythm, no murmurs
Soft and flat abdomen, normoactive bowel sounds, no
hepatosplenomegaly, non-tender
Pink nail beds, full pulses, fair skin turgor
LABORATORY EXAMS
CBC: Hgb 125, Hct 0.335, WBC 13.0, N 70%, L 24%, M 3%, E 3%, Plt
358
ESR: 6 mm/hr, AST 37, ALT 44
Urinalysis: Yellow, clear, pH 6.8, SG 1.030, WBC 0/hpf, RBC 0/hpf,
glucose none, nitrite negative, protein none, EC none, hyaline
casts 3-5/lpf
Stool exam: Brown, mucoid, PMN 0, RBC many, no ova/parasite
seen
FOBT: positive
FECT: Negative for parasites
Stool culture: negative
Stool PCR: Positive for Entamoeba histolytica
Blood culture: negative

A
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6
Q

EXAMINER’S GUIDE
1. Listed down salient features of case

A
  1. Listed down salient features of case
    [ ] Chronic diarrhea, hematochezia
    [ ] Tenesmus
    [ ] Signs of dehydration
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7
Q
  1. Systematic approach to diagnosis, discussed differentials
A

Infection
Bacterial (Typhoid, Shigellosis, Campylobacter, Yersinia, E.
coli)
Parasitic (Amebiasis, Giardiasis, Cryptosporidium)
Gastrointestinal
Bleeding peptic ulcer
Inflammatory bowel disease
Intestinal polyp/Polyposis
Hemorrhoids
Anal fissure
Hematologic abnormalities
Platelet dysfunction (ITP, von Willebrand disease)

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8
Q
  1. Order diagnostic tests
A

[ ] CBC
[ ] Stool PCR and/or ELISA
[ ] Stool exam and culture
[ ] Serum electrolytes
[ ] Tests for differentials (blood culture, FECT)

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9
Q
  1. Diagnosis and Pathophysiology
A
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10
Q
  1. Management
A
  1. Management
    [ ] Emergency measures
    [ ] Hydration, monitor status
    [ ] Metronidazole 35-50 mkd q8 x 10d
    [ ] Correct electrolyte abnormalities
    [ ] Preventive measures (handwashing, food preparation, boiling of drinking water, etc)
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11
Q
  1. Complications
A
  1. Complications
    [ ] Amebic liver abscess
    [ ] Toxic megacolon, perforation
    [ ] Perianal ulcers
    [ ] Pulmonary, brain abscess
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12
Q
  1. Preventive Pediatrics
A
  1. Preventive Pediatrics
    [ ] Developmental surveillance
    [ ] Atopy screen
    [ ] Monitor weight, height
    [ ] Blood pressure
    [ ] Eye exam
    [ ] Immunizations
    [ ] Deworming (albendazole 400 mg q6mos, mebendazole 500
    mg q6mos)
    [ ] Dental care
    [ ] Nutrition counseling
    [ ] Physical activity
    [ ] Injury and poisoning prevention
    [ ] Child maltreatment prevention
    [ ] Counseling on lead and toxicant exposure
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13
Q

What is Giardia lamblia? how is it transmitted?

A

CH 282: GIARDIA LAMBLIA
- No extraintestinal spread, no tissue invasion
- Cysts passed in stools –> viable in water for 2 mos
- Frequently associated with outbreaks of drinking water
IP: 1-2 wks
Patho:
- Ingestion of cysts –> trophozoites colonize lumen of
small intestines (duodenum, prox. Jejunum) –> attach
to brush

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14
Q

What are the clinical manifestations of Giardiasis?

A

CM
1. Asymptomatic excretion
2. LG fever, nausea, anorexia,
3. Diarrhea: watery to greasy and foul-smelling
alternating with constipation
4. Malabsorption – sugars, fats, fat-soluble vitamins
5. IDA
6. Abdominal distention, bloating, flatulence

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15
Q

Give diagnosis, management and prevention of giardiasis

A

Dx
1. Stool exam, Stool CS - (3x) to achieve Sn of >90%
2. EIA, direct fluorescent Ab test - DxOC
Mgt
1. Metronidazole 15mkd tid x 5-7d
2. Tinidazole 50mkd SD
Prevention:
1. Chlorination, boiling of drinking water
2. Strict handwashing

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16
Q

What is Toxoplasmosis?

A

CH 290: TOXOPLASMA GONDII
- Toxoplasmosis
- Persist throughout life: CNS, skeletal, heart, muscle
- Necrosis and calcification
- Protozoa, multiplies only intracellularly
- One of most common latent infection worldwide
Transmission
- Ingestion of undercooked/raw meat cysts from
infected cats > flies, cockroaches, dog fur
- Transplacental
Patho
- Ingestion of food contaminated by cysts or infected cat
oocysts à bradyzoites/sporozoites enter GIT to blood
à humoral and cell mediated immunity à little sx
during latent infection à recrudescent ds in
immunocompromised state

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17
Q

What are the clinical manifestations of toxoplasmosis?

A

CM
1. Acquired
- No sx in immunocompetent
- Enlargement of >1 CLN –> recover spontaneously
2. Ocular: chorioretinitis
3. Disseminated: immunocompromised
4. Congenital Toxoplasmosis
- TRIAD: chorioretinitis, Hydrocephalus, and cerebral
calcification
- Vertical transmission from infected mom
transplacentally/during SVD
- LNE – most common
- Inc AOG: the less severe ds, the more likely fetus
infected
- Hydrops fetalis, perinatal death, SGA, prematurity
- Persistent jaundice
- Mild thrombocytopenia, CSF pleocytosis
- CNS: sz, setting sun sign with downward gaze, MR,
paralysis
- Skin: rash – fine, punctate, diffuse MP, lenticular, deep
blue-red, sharply defined macular, or diffuse blue and
papular generalized (incl. palms and soles) exfoliative
dermatitis, cutaneous calcifications, jaundice,
petechiae, ecchymoses
- Endo: hypothalamic/pituitary: myxedema, persistent
hyperNa, DI
- Ears: SNHL

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18
Q

Give the diagnostics for giardiasis

A

Dx:
1. Biopsy – gold standard. Tissue, CSF, BG, BMA
2. BCS, UCS
3. CT scan: calcification of caudate and Basal Ganglia
4. IgG, IgM indirect fluorescent Ab
5. IgM ELISA PCR
6. Rectal UTZ q2wks (???)
7. Cranial CT scan – multiple hypodense regions in the
basal ganglia and corticomedullary junction, may be
associated with mass effect
8. fetal UTZ q2wks – brain hydrocephalus, intracranial
calcification

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19
Q

Give the management and prevention

A

Mgt
1. Acquired: only in severe (4-6wks)
2. Congenital: pyrimethamine 2mkd BID x2d +
sulfadiazine 100mkd q12 + leucovorin 5-10mgx 1 yr:
infant
- to mom to prevent fetal sx
3. Spiramycin 1g q8
4. Prednisone
Prevention
1. Pregnant woman should eat only well cooked meat
2. Cats should be fed clean, cooked meat, kept indoors, avoid litter

20
Q

What is trichomonas vaginalis? how is it transmitted?

A

CH 284: TRICHOMONAS VAGINALIS
- Trichomoniasis
- Most common non-viral STD
- Males asymptomatic
IP: 5-28d
Patho
- Anaerobic, flagellated protozoan parasite
- Adhesion molecules allow attachment of trichomonas
to host cells, and hydrolases, proteases, and cytotoxic
molecules act to destroy or impair the integrity of host
cells

21
Q

Give the clinical manifestations, diagnostics and management of trichomoniasis

A

CM
1. Vulvovaginitis – frothy, malodorous gray vaginal dc
- Vulvovaginal irritation
- Dysuria, dyspareunia
- Cervical hemorrhage: strawberry cervix
2. Males: occasionally epididymitis, prostatic
involvement, superficial penile ulceration, resolve
spontaneously
Dx:
1. Wet mount: twitching motility; mainstay of dx
2. Culture – gold standard
3. EIA, direct fluorescent testing of vaginal secretions,
PCR
Complic
1. PID, tubal infertility, vaginal cuff cellulitis
2. PT, LBW
Mgt
Metronidazole 2g SD (adult), 15mkd tid x7d
Tinidazole 2g SD
Sexual partners should be treated simultaneously to prevent
reinfection
Advise on safe sexual practices

22
Q

What is visceral larva migrans? How is it transmitted?

A

CH 298: VISCERAL LARVA MIGRANS
- Toxocara canis: dog roundworm
- Toxocariasis
- Eggs in dog’s feces à ingestion of eggs contaminating
soil or hands
- Eosinophilia & granulomas
- Children are at highest risk because of unsanitary play
habits and tendency to place fingers in mouth
Patho
- Toxocara secrete proteins (Ag) that induce immune
responses that lead to eosinophilia and polyclonal and
Ag-specific IgE production

23
Q

What is the classic manifestations of visceral larva migrans?

A

Classic: Fever + hepatosplenomegaly + eosinophilia

CM
1. Classic: Fever + hepatosplenomegaly + eosinophilia
2. Hx of toddlers with hx of pica and exposure to puppies
3. Cough, wheezing, bronchoPN, anemia, hepatomegaly,
leukocytosis
4. Skin: pruritus, eczema, urticaria
5. Covert toxocariasis: chronic weakness, abdominal pain,
allergic signs, eosinophilia, inc IgE
6. Ocular toxocariasis – retinal granuloma with
characteristic fibrous stalk

24
Q

How is visceral larva migrans diagnosed, managed and prevented?

A

Dx
1. CBC – eosinophilia (>20%), leukocytosis
2. Serologic test Ig G and IgM
3. Hypergammaglobulinemia, elev isohemagglutinin titers
to A and B blood group Ag
4. ELISA 1:32 - highly sn and sp
5. Biopsy – confirms dx. Characteristic lesions are
granulomas containing eosinophils, multinucleated
giant cells (histiocytes), and collagen
Mgt
1. Most don’t require tx
2. If sx’c: CS 1mkd x 2-4wks + Mebendazole 100-200mg PO BID x 5d
Albendazole 400mg po BID x 5d

Prevention
1. Prevent dog feces from contaminating envt
2. Hand hygiene, avoid putting fingers in mouth/pica

25
Q

What is Ascariasis?

A

CH 291: ASCARIS LUMBRICOIDES

  • Ascariasis
  • Roundworms
  • Most prevalent human helminthiasis in the world,
    topical areas
  • Highest rate in preschool/school-age children
    Transmission
  • Hand to mouth and ingestion of contaminated fruits
    and veggies
26
Q

What is the pathophysio of Ascariasis?

A

Patho
- After ingestion, Ova hatch in the SI à larvae penetrate
intestinal wall and migrate to the lungs
hematogenously –> pulmonary ascariasis entering
alveoli, bronchi and trachea –> swallowed and
returned to SI as adult worms

27
Q

How is Ascariasis diagnosed?

A

Dx:
1. Stool exam + Kato-Katz thick smears – combination
produces best diagnostic yield. Eggs in stool
2. Micro exam of fecal smears
3. Cbc – eosinophilia
4. Sputum analysis – larvae or Charcot-Leyden crystals
(collections of crystalloid composed of eosinophilic
proteins)
5. Abdominal UTZ – mechanical bowel obstruction
depicting hypoechoic tubular structures with welldefined
echogenic walls (worms)

28
Q

Management and prevention of Ascariasis

A

Mgt
1. Mebendazole 500mg SD po
2. Albendazole 400mg SD po
3. Ivermectin 150-200 ug/kg po SD
4. Nitazoxanide 100mg po BID x 3d for 1-3yo; 200mg BID
for 4-11yo; 500mg BID for adolescents
5. Piperazine citrate 75mkd x 2 d – DOC for intestinal/
biliary obstruction. Causes NM paralysis of the parasite
and rapid expulsion of the worms
6. Surgery – for severe obstruction
Prevention
1. Deworming programs
2. Improving sanitation and sewage facilities

29
Q

What is Enterobius vermicularis? How is it transmitted?

A
  • Pinworm
  • White threadlike worm
  • Perianal area
  • Humans are the only known host
  • Highest in 5-14yo, crowded living conditions
    IP: eggs embryonate within 6h and remain viable for 20d, matures
    to adult in 36-53d

Transmission
- Fecal-oral or ingestion
- autoinoculation

30
Q

What is pathophysiology

A

Patho
- Gravid female –> migrate to perianal area at night
- Sx caused by mechanical stimulation and irritation,
allergic reactions, and migration of the worms to
anatomic sites where they can become pathogenic

31
Q

Give the clinical manifestations, diagnostics and management of enterobius vermicularis

A

CM
1. Nocturnal perianal pruritus
2. No eosinophilia
3. Complications: appendicitis, chronic salphingitis, PID,
peritonitis, hepatitis, ulcerative GI lesions

Dx:
1. Scotch tape swab: early AM to look for eggs

Mgt:
1. Mebendazole 100mg SD, then repeat after 2 wks
2. Albendazole 400mg po SD then repeated after 2 wks -
DOC
3. Pyrantel pamoate 11mg/kg tid x1d then repeat after 2
wks
4. Morning bathing, freq changing of bed sheets

Prevention:
1. Repeat tx every 3-4mos if with repeated exposure
2. Good hand hygiene

32
Q

What is entamoeba hystolitica?

A

CH 281: ENTAMOEBA HISTOLYTICA
- Amebiasis
- 2nd leading cause of parasitic death
Transmission
- Fecal oral route, oral-anogenital sex
- Cysts are resistant to harsh environmental condition,
chlorination, gastric acidity and digestive enzymes
- Can be killed by heating water to 55C

Patho
- Ingestion of cysts à trophozoites (intestines) à tissue
invasive and kill epithelial cells, neutrophils,
monocytes, and macrophages
- Trophozoite form causes intestinal and tissue invasion
- Flask shaped ulcers
- in the liver, causes abscesses

33
Q

What are the clinical manifestations of entamoeba?

A

CM
1. 90% asx’c
2. Loose stools and fever, tenesmus, blood streaked
stools, HABS
3. Amoebic colitis: (-) constitutional sx, colicky abd pain,
freq bowel movt (6-8x), tenesmus
4. Liver abscess: rare, fever + tender hepatomegaly, abd
distention
- Fever is hallmark of amebic liver abscess

CM
1. 90% asx’c
2. Loose stools and fever, tenesmus, blood streaked
stools, HABS
3. Amoebic colitis: (-) constitutional sx, colicky abd pain,freq bowel movt (6-8x), tenesmus
4. Liver abscess: rare, fever + tender hepatomegaly, abd distention

**Fever is hallmark of amebic liver abscess

34
Q

What are the diagnostics of entamoeba?

A

Dx
1. Clinical + E.histolytica in stool microscopy
(trophozoites)
- Confirm cure, repeat stool exam 2 weeks after tx
- heme(+)
2. CBC – moderate anemia, leukocytosis without
eosinophilia
3. ESR high, elev ALP and transaminases, bilirubin
4. Low albumin
5. UTZ, CT or MRI – single abscess in the R hepatic lobe
6. Indirect hemmaglutination – most sn serologic test

35
Q

Give management, prevention of entamoeba hystolitica

A

Mgt:
1. Metronidazole 35-50 mkd TID x 7-10d
2. Tinidazole 50mkd OD x 3d (3-5d if liver abscess)
Followed by:
3. Paromomycin – DOC. 25-35 mkd TID x7d
4. diloxanide furoate 20mkd TID x 7d
- Diloxanide better because amebicidal vs trophozoite
and cyst forms, even in asymptomatic carriers. Failure
to administer this Rx will not eradicate infection
5. Iodoquinol 30-40 mkd TID x20d
For asx’c intestinal colonization
6. Paromomycin, diloxanide furoate, iodoquinol
7. Surgery – for intestinal perforation or toxic megacolon
8. Liver abscess – metronidazole, tinidazole
Prognosis:
- Asymptomatic carrier state in most
- Extraintestinal infection 5% mortality rate
Prevention
1. Proper sanitation
2. Regular examination of food handlers

36
Q

What is Malaria and its cause?

A
  • Malaria
  • Predominant in SE Asia: P.vivax & falciparum
  • Incomplete immunity, allows reinfection
    1. P. falciparum = fever variable = mature & immature
    RBC
    2. P. vivax & ovale = 48h = immature RBC. Persists in liver -> relapse
    3. P. malaria = 72h = mature RBC

Patho
- Anopheles female mosquito

37
Q

What are the phases of malaria? and give pathologic process of Malaria

A

2 phases:
1. Exoerythrocytic – hepatic cells, 1st phase
2. Erythrocytic – RBC; 2nd phase

4 Pathologic process in malaria:
1. Fever: RBC rupture –> parasitemia
2. Anemia: hemolysis, splenic sequestration, BM
suppression
3. Immunopathologic events –> excessive proinflamm
cytokines –> tissue anoxia, hypergammaglobulinemia,
immunosuppression
4. Tissue anoxia –> obstruction to blood flow (adherence of infected RBC to endothelium) –> vascular leakage of blood, protein and fluid
– > cumulatively, these lead to cerebral, cardiac, pulmo, intestinal, renal and hepatic failure.

38
Q

How is Malaria transmitted?

A

Transmission:
- Blood transfusion, contaminated needles,
transplacental

39
Q

Give the incubation period of Malaria

A

IP:
P.falciparum=9-14d
P.vivax=12-17d
P.ovale=16-18d
P.malariae=18-40d

40
Q

What are the clinical manifestations of Malaria?

A

CM:
1. Prodromal sx (2-3d): headache, fatigue, anorexia,
myalgia, LG fever, chest pain, abd pain, arthralgia
2. Paroxysms of fever alternating with periods of fatigue,
but otherwise relative wellness, chills, anemia, and
splenomegaly
3. Uncomplicated malaria – fever with alternating fatigue
but otherwise relatively well
- HG fever, severe headache, sweats, myalgia
- Nausea & vomiting, abdominal pain, diarrhea
- Hepatosplenomegaly, pallor
4. Severe malaria – sz, impaired consciousness,
prostration/weakness, poor UO, signs of pulmonary
edema, abN spontaneous bleeding, signs of organ
dysfunction, jaundice, hyperparasitemia (>2%
parasitized RBC), severe anemia, metabolic abN
(acidosis, hypoglycemia), hemoglobinuria
5. Congenital malaria – abortion, miscarriage, stillbirth,
PT, IUGR, fever, restlessness, drowsiness, pallor,
jaundice, poor feeding, v/d, cyanosis,
hepatosplenomegaly

41
Q

How is Malaria diagnosed?

A

Dx
1. Always ask for travel hx (Malaysia, Indonesia,
Singapore, PH: Palawan & Mindanao)
2. Microscopy – gold standard
a. Thick smear: scan large # of RBC
b. Thin smear: ID species, % infected RBC, tx
response
3. CBC: anemia, thrombocytopenia, N or low leukocyte
count
4. Elev ESR
5. PCR
6. Rapid diagnostic test kits – for: no microscopy center,

42
Q

How is Malaria managed?

A

Mgt (DOH)
1. P. falciparum/malariae: medical emergency
- Uncomplicated 1st line: 4 days tx as follows: Coartem
(arthemeter 20mg-lumefantrine 120mg) on days 1-3 à
primaquine 0.5 mg base/kg qd on day 4
- 2nd line tx/ Severe malaria: 7d quinine 10 mg base/kg
q8 + Clindamycin 10 mg/kg BID x 7d
Alt: Tetracycline 25 mkd po QID or
Doxycycline 2.2mg/kg BID or
3d clindamycin 20mkd TID
- Return visit at d14, 21, 28: monitor tx and failure
- Iv tx until parasitemia <1%
- Severe:
1st line: Artesunate 3mkdose in NaHCO3
2nd line: quinine 10 mg salt/kg LD then 10mg q12 MD +
Clindamycin 10mkd BID x 7d

  1. P. ovale/vivax
    1st line: Uncomplicated: chloroquine 10 mg base/kg po
    on days 1-2 then 5 mg base/kg on day 3 + Primaquine
    0.25 mkd SD x 1-14d
    - 2nd line: AL 20mg/120mg in 6 doses in 65h +
    Primaquine 0.25 mgbse/kg on D1
  2. Artesunate : DOC for severe malaria
43
Q

Give the complications of Malaria

A

Complic
P.falciparum is the most severe, most complications
P.malariae is the mildest, most chronic
1. Severe anemia – most common
2. Cerebral malaria
3. Hypoglycemia
4. Circulatory collapse (algid malaria)
5. Sz
6. Thrombocytopenia
7. Renal failure, RD, algid malaria, bleeding diatheses
8. Splenic rupture – from P.vivax
9. Nephrotic syndrome – from P.malariae

44
Q

Give prevention for Malaria

A

Prevention
1. Chemoprophylaxis
- Doxycycline 2mg/kg 100mg daily 2-3 days before à 4
weeks after
- Mefloquine 250mg weekly, 1 wk before travel à 4
weeks after
- Chloroquine 5mkdose po q7d (start 1 wk prior and
continue 4 wks after exposure)
2. Avoid outdoors from dusk to dawn, permethrintreated
mosquito netting, mosquito repellent (DEET
>2mos old)

45
Q
A

ORAL EXAM CASES (51 decks)

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