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Rotation 2: IM Outpatient > ID > Flashcards

ID Flashcards

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1
Q

what bacteria cause the most TB in the US? what are 4 other bacteria that can cause it?

A

mycobacterium tuberculosis

mycobacterium bovis

mycobacterium africanum

mycobacterium microti

mycobacterium canetti

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2
Q

what are the two populations of people that TB can be divided by?

A

hight risk for becoming INFECTED with TB

high risk for DEVELOPING TB DISEASE

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3
Q

what are 7 things that can put someone at high risk for TB INFECTION (not disease)

A
  1. close contact
  2. foreign born
  3. low income and homeless
  4. health care workers in high risk groups
  5. racial and ethnic minorities
  6. infants, children and adolescents
  7. IV drug users
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4
Q

name five areas of the world where TB is common?

A
  1. asia
  2. africa
  3. russia
  4. eastern europe
  5. latin america
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5
Q

what groups of people are at risk for developing TB disease!? (7)

A
  1. people with HIV (thats why prevalence increased in the 80s)
  2. infection of TB within last two years (5% risk, and 10% lifetime)
  3. infants and children

4. prolonged therapy with corticosteroids

  1. IV drug use
  2. diabetes
  3. silicosis
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6
Q

what is the greatest risk factor for devloping TB?

A

HIV!!! 7-10% risk for devloping TB disease each year when infected with both TB and HIV

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7
Q

are people with LTBI infectious? what percent of these people will go on to develope the disease?

A

no they aren’t infectious!!

10% will go on to develope disease!

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8
Q

Explain the pathogenisis steps for TB (5 steps)

A
  1. tubercle bacilli are inhaled and travel to alveoli
  2. multiple in alveoli, infection begins
  3. small number of tubercle bacilli enter bloodstream and spread throughout body
  4. within 2-4 weeks macrophages survive bacilli, form a barrier shell that keeps the bacilli contained and under control know as LBTI
  5. if the immune system can’t keep tubercle bacilli under control, they multiple rapidly and cause TB DISEASE *it can occur in other places in the body too*
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9
Q

Is LTBI treated with medication?

A

YES IT IS

you want to prevent these patients from getting it in the future!!!

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10
Q

who is high priority treatment for LTBI with a TST >5 mm or postitive IGRA? (5 things)

A
  1. close contacts of those with infectious TB disease
  2. HIV
  3. chest xrays indicating previous TB
  4. organ donor transplants
  5. immunocomprimised patients
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11
Q

who is high priority for LTBI treatment >10 mm or positive IGRA test? (5 things)

A
  1. people who came to US within last 5 years where TB is common
  2. IV drug users
  3. live or work in high risk facilities
  4. micro labatories
  5. children
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12
Q

what are the two ways HIV can influence the path of TB?

A
  1. person with LTBI becomes infected with HIV and then developes TB disease as the immune system is weakened
  2. a person with HIV becomes infected with TB and rapidly developes the disease
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13
Q

multi-drug resistant TB is resistant to which drugs?

A

isoniazid and rifampin (2 first line drugs avaliable)

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14
Q

extensively drug resistant (XDR-TB), what drugs are they resistant to?

A

isoniazid and rifampin, PLUS fluoroquinolones and at least 1 of the 3 second line drugs

**this is a major issue around the world**

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15
Q

how long should a patient be treated for TB?

what if this person has pos sputum after 2 months of treatment?

A

at least 6 months

if cavities on chest xray and postitive sputum cultures at 2 motnhs then treatment should be extended for 9 months

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16
Q

what are the three phases of TB infection treatment?

A

1.initial phase: first 8 weeks of treatment, four drugs are used

isoniazid, rifampin, pyrazinamide, ethambutol

2. continuation phase: after first 8 weeks of treatment, bacilli remaining after initial phase are treated with at least two drugs

3. relapse phase: occurs when treatment is not continued for long enough, surviving bacilli may cause TB disease at a later time

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17
Q

in order to prevent drug resistance, TB disease must be treated with at least how many drugs?

A

2 ones the organism is suseptible to

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18
Q

Tuberculosis

what are the classic symptoms assosicated with TB (clinical and xray)?

A

clinical symptoms:

coughing >3 weeks

pleuritic chest pain

hemoptysis

positive rales

infiltrates (collection of fluid and cells in lung tissues)

cavities (hollow spaces within lung usually in the upper lobe)

caseating granuloms on biopsy (necrotizing granulomas)

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19
Q

what tests do you use to diagnose TB?

A
  1. tuberculin skin test (TST)

2. interferon gamma assays (IGRAS)-measures immune response to m. tuberculosis, less likely to be incorrect compared to TST

3. culture with AFB staining

-need 3 specimens, 8-24 hour collection intervals, can induce with inhaling saline mist spray

4. chest x-ray (infiltrates and cavities)

5. nucleic acid amplification test

6. bronchoscopy or gastric wash if having hard time getting sample

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20
Q

explain the tuberculin skin test? what can’t this test do? what are positive test results for the three groups of people?

A

in lastent infection positive 2-4 weeks after infection

-injected with inactive tubercle bacilli, read within 48-72 hours

**this test can’t differentiate between latent and active TB, just that a person has been infected at some point**

Positive test results:

15 mm in normal patients

10 mm in immigrants, children

5 mm in HIV, immunsuppressed, positive chest xray, primary TB exposure

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21
Q

explain the difference on chest xray between primary and reactivated TB?

A

primary: homogeous infiltrates, hilar/paratracheal lymph node englargement, middle/lower lobe consolidation

reactivation: fibrocavity apical disease, nodules, infiltrates **TB reactivation presents at the top of the lungs instead of wher eit happened originally**

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22
Q

what is the gold standard for TB testing?

A

acid fast bacilli tests

3 negative tests are considered negative!!

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23
Q

how long should a person be isolated and on treatment before being allowed in public when they have TB?

A

need to be isolated for a minimum of 2 weeks

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24
Q

what are the four drugs you use during the initial treatment phase for TB? what are their side effects? how do you treat someone if they have been exposed to someone with active TB? what is the treatment regiment for LBTI?

A

“RIPE acronym

  1. rifampin (hepatitis, flu, orange body secretions)
  2. isoniazid (hepatitis, periphreal neuropathy, give B6 to prevent risk)
  3. Pyrazinamide
  4. ethambutol (optic neuritis)

**for LBTI: treat with isoniazid and pyrazinamide for 9 months, or 12 months if HIV pos or granulomas present on CXR**

**if someone is exposed to patient with active TB, then treat them emipircally for 12 weeks until negative TB can be obtained**

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25
In TB, explain the differences between LTBI and TB disease in these characteristic: 1. active/inactive bacilli 2. chest xray findings 3. sputum smears 4. symptoms 5. infectivity 6. a case of TB or not
26
what should you connect Ghon complexes and Ranke complexes? what are they?
**TB** ghon complexes: calcified primary focus ranke complexes: calcified primary focus and hilar lymph nodes \*\*these represent healed primary infection\*\*
27
\*\*what is the highest risk group for HIV infection\*\*\*
men having sex with men
28
what are the two receptors HIV uses to get into the cell?
CCR5 and CXCR4
29
explain the structure of the HIV virus? why does it mutate quickly?
1. RNA virus 2. glycoprotein 120 and stem gp14 3. viral protein _p24 core antigen_ 4. CCR5 or CXCR4 receptors \*\*\*\*MUTATIONS OCCUR QUICKLY SINCE THE RNA POLYMERASE USED TO MAKE THE DNA TO INSERT INTO THE HUMAN DNA ISN'T GOOD AT ITS JOB AND OFTEN THERE ARE COPYING ERROS LEADING TO MUTATIONS\*\*\*
30
what are the two strains of HIV and where are they found?
HIV1: most common in the US "M strain" HIV2: Africa, less aggressive
31
what cells does HIV infection?
CD4 Helper T cells also monocytes and macrophages because they have the CD4 receptor
32
briefly explain the differences between HIV and AIDS?
HIV is in the infection ## Footnote patient is usually asymptomatic or minimally symptomatic and the infection hasn't yet effected the persons immune system yet **_HAVING HIV DOESN"T MEAN YOU HAVE AIDS_** AIDS when the persons immune system has become compromised and the CD4 cells have become significantly diminished
33
\*\*\*Acquired immunodeficiency syndrome (AIDS)\*\*\* ## Footnote what are the 3 options the CDC defines this?
1. clinically: **_opprtunistic infections effect patient_** that wouldn't otherwise if the pt wasn't immunocomprimised ## Footnote 2. biomedically: **_CD4 count less than 200_** 3. historically: at some potin in the past **_ever had opportunistic infections or a CD4 count lower than 200_** \*\*must have one of these qualifications but you don' thave to have all of them\*\*\*
34
what is the percent chance of contracting HIV from a needle stick?
0.3%
35
how is HIV transmitted? (4)
**_sexual_** **_vertical- mother to child_** **_parenteral- injection drug users_** transfusion **_Body fluids_** 1. blood 2. seme 3. vaginal fluids
36
what racial group have the highest burden of HIV/AIDS?
african americans
37
what are the four stages of HIV infection?
**stage 1 primary** **stage 2 asymptomatic** **stage 3 symptomatic with viral replication** **stage 4 AIDS**
38
stage 1 HIV ## Footnote when does this occur? length? sxs?
**_short_** **_flu-like illness_** **_6 weeks after infection_** **_infectious_**
39
stage 2 asymptomatic ## Footnote how llong does this last? what might they have? HIV levels? antibodies?
lasts 10 years ## Footnote _free of symptoms_ possible swollen glands _levels of HIV in blood drop to low levels_ HIV antibodies are detectable in the blood
40
stage 3 HIV symptomatic with viral replication when odes this occur? what happens? what are theu suspectible to? **_at what CD4 level are HIV patients susceptible to opportunistic infection_**??
after 10 years viral replication is triggered at a high rate ## Footnote **_CD4 cells destroyed_** in the process and the **_loss is significant_** cause increase symptoms of HIV and increased **susceptibility to opportunistic infections, disease and malignancy** \*\*CD4 below 500 HIV infected pt is at risk for opportunistic infection\*\*
41
in stage 3 HIV what are 4 diseases that can suggest the patient may progress to AIDS?
1. persistent herpes-zoster infection (shingles) ## Footnote 2. oral candidiasis 3. oral hairy leukoplakia 4. kaposi sarcoma
43
stage 4 HIV/AIDs ## Footnote what is this characterzied by? what 2 CD4 levels suggest progression to stage 4? what are disease that a person can be susceptible for both? 7 5
immune system significantly weakened ## Footnote **_1. CD4 less than 500_** **bacterial infection** TB Herpes simplex **herpes zoster** vaginal candidiasis **karposi sarcoma** **hairy leukoplakia** **_2. CD4 less than 200_** **toxoplasmosis** **crytococcois** coccidiodomycosis crytospooriosis non-hodgkin’s lymphoma
44
what is the order of tests you order if suspecting HIV in patient?? what do they tell us? what test don't we use anymore?
1. **_TOC #1: 4th Gen_** ## Footnote **_HIV-1 and HIV-2 IgG_** **_and IgM plus HIV-1 p24 Antigen_** \*\*tests antigen so can be detected earlier, 2-3 weeks after infection\*\* \*if postitive then move onto next!!!! TOC #2 if previous postivie: **_Multispot Or RNA PCR_** \*\*distinguishes between presence of HIV1 or HIV2\*\* \*\*\*this testing algorithm is more accurate, faster, and less expensive than previous so not longer use western blot\*\*
45
are there at home HIV tests?
yes!!! oraquick (mouth) or HIV-1 test system (prick finger, mail it in..wait a week)
46
what should you do if someones at home screening test is positive?
1. order 4th gen HIV1/2 IgG/IgM/p24Ag if postivie..... 2. multispot HIV1 if postiive..... 3. order **_quantitative HIV-1 PCR to get viral load!!!_**
47
what should you continue to monitor in HIV/Aids patients every 3-6 months?
1. viral load 2. CD4 levels
48
what are the 5 tx options reccomended to HIV?
4 integrase strand transfer inhibitor (INSTI)-based regimens 1 ritonavir-boosted protease inhibitor-based regiment
49
Years ago, some patients and providers made the decision to delay initiation of HIV therapy with the thought that later treatment would reduce total medication exposure and decrease adverse effects. Do we still follow these guidlines or suggestions?
NOPE!!!!! ## Footnote data suggesting tha**_t earlier therapy improves long-term immune function_**
50
what is the HAART tx for HIV? 4 drug classes
highly active anti-retroviral tx ## Footnote 1. Fusion inhibitors 2. nucleoside/nucleotide reverse transcriptase inhibitors 3. non-nucleoside reverse transcriptase inhibitors 4. protease inhibitors \*\*\*\*\*combination of 3 active anti-retrovirals\*\*\*\*
52
what are the goals of HIV treatment? (4)
1. supress HIV viral load 2. reconstitiute the immune system and get CD4 levels back 3. prevent reistance 4. prevent future infections
54
what is the post-exposure DOC for HIV? when do you give it? goal?
**_truvada plus raltegravir_** _started ideally 1-2 hours after exposure but_ **must be within a minimum of 72 hours for best results** tx for _28 days, but **high risk groups can start up to 2 weeks post exposure**_ \*\*\*goal: prevent initial infection with antivirals!!!\*\*\*
55
\*\*\*pre-exposure HIV prophlaxsis\*\*\* ## Footnote who is this given in? what does it do? name of the drug? how many times must you take it for it to be effective?
given to someone with partner who has HIV or someone who plans to participate in sexual activity with someone with HIV and wants to protec thtemself PrEP is generally well-tolerated and can be dramatically successful that early HIV treatment **_can reduce the risk of transmitting HIV to the uninfected partner by 96%.1_** TRUVADA can prevent transmission!!!! must be take _more than or equal to 4 times a week_!!!!!
56
\*\*\*who does the CDC reccomend get tested for HIV\*\*\*
CDC reccomends everyone age **_13-64 to be tested at least once_** ## Footnote and!!!... **1. everyone who presents with symptoms of STD should be tested at that visit** **2. testing anyone that starts new relationship**
57
\*\*\*\*what is the reccomendations for HIV testing in gay or bisexual testing for HIV?\*\*\*\*
For individuals who identify as gay or bisexual testing every **_3-6 months may be beneficial._** ## Footnote but _AT LEAST ANNUALLY_
58
\*\*\*explain the life expectancy of someone living with HIV?\*\*\*
life expectancy for those living with HIV has increased to approximately the same as that for HIV negative individuals
59
\*\*\*what does HIV treatment regimen consist of?\*\*\*
regimens must **_consist of 3 or more active agents from multiple medication classes_** ## Footnote many pills have a combination of multiple drugs in them to increase compliance
60
\*\*when should post exposure prophylaxsis be started\*\*\*
within a minimum of 72 hours for best results!!!
61
travels diareahh ## Footnote what does this come from? who is it common in? what is the 4 most common causes? what is the most common? what are 3 symptoms? what are 4 tx considerations?
**fecally contaminated water and food** more common in _younger_ people **_MOST COMON BACTERIA, then parasites_** **_MOST COMMON: E.coli_**, shigella/salmonella, campylobacter, viral symptoms: 1. abrupt onset of loose stools 2. abdominal cramping 3. rectal urgency tx: 1. typically self limited 2. REHYDRATION 3. **_fluoroquinolones, short 3 day course_** - rifaximin - azithromycin 4. immodium
62
is prophylaxsis reccomended for travelers diarreah?
nope it is not... ## Footnote but you can consider prophylaxsis in special situations with fluorquinolones/refaxamin
63
what are 5 preventative measures you can take to prevent travelers diarreah?
1. avoid street vendors 2. buffets 3. raw or undercooked meats/seafoods 4. avoid raw fruits, vegetables 5. avoid tap water, ice and dairy products
64
what is the most common E.coli for what we think of as e. coli?
shigella toxin-producing (STEC) also called "enterohemmorrhagic" ## Footnote E. COLI0157 is the one that we usually think of when taking about e.coli outbreak!!
65
what is the most common cause of travelers diarreah? 3 sxs? and duration? tx?
e.coli ## Footnote diarreah is: 1. purlulent 2. bloody 3. assocaited with abdominal cramping 4. 5-10 duration tx: supportive unless severe
66
salmonellosis ## Footnote what is the main bacteria that causes this? what is it most common in? what does it break out across states? what are the _3 types_?
_salmonella typhimurium MC_ ## Footnote **_POULTRY MC!!! c_**an also include leafy greens, beef, dairy, nuts \*\*\*\*MULTISTATE OUTBREAKS COMMON since found in animal flocks and herds\*\*\* 1. enteric fever, TYPHOID FEVER 2. gastroenteritis 3. bacteremia
67
enteric fever salmonellosis "enteric fever/typhoid fever" where are the 3 places this replicates? is there a prodrome? what happens as fever develops? (5) DX (what to keep in mind)? Tx: 2 abx and for how long?
replicate in _peyer patches, mesenteric lymph nodes, spleen_ ## Footnote prodrome: malaise, headache, cough, sore throat **as fever developes:** (peaks 7-10 days) **1. abdominal pain/distension** **2. _pea soup poop_** **3. splenomegaly** **4. bradycardia** **5. _rash pink papules primarily on trunk during 2nd week_** DX: **1. _blood sample_** **+ during first week** **- after first week** TX: 1. **ceftriazone** 2. **fluoroquinolines** **TWO WEEKS!!!!**
68
salmonellosis "gastroenteritis" what is the incubration? what are the 5 sxs and msot important? DX? tx?
most common form of salmonella infection!! ## Footnote incubation **_​8-48_** hours after ingestion of infected food or water SXS: fever nausea vomiting **_bloody diarreah 3-5 days!!!!_** DX: STOOL CULTURE Tx: selflimited symptomatic
69
shigellosis ## Footnote what does this cause? what are 5 sxs associated with this? what are the 2 ways to dx this and what do you see? what are 2 tx options?
dysentery ## Footnote SXS: 1. starts abruptly with diarrhea 2. lower abdominal cramps 3. tenesmus with fever chills 4. _l**oose stools with mixed blood and mucous**_ 5. tender abdomen **DX:** 1. stool 2. sigmoidoscopy with _punctate lesions, ulcers and inflammed mucose_ TX: 1. _FLUIDS!!!!!!!_ 2. TMP-SMX
70
cholera ## Footnote what is the bacterial that causes this? what does it cause in the body? what does the pt present with? transmission? what are the 2 tx options?
**_vibrio cholera_** ## Footnote toxin activates adenylyl cylase in the intestinal epithelial cells in the small intesting causes _hyper secretion of water and chloride ions with **massive diarreah**_ "rice water stool" grey turbid diarreah and causes _hypovolemia_ transmission: fecal-oral Dx: 1. stool culture for vibrio cholerae TX: `1. **replace fluids and electrolytes** _sugar/salt water_, severe use IV replacement 2. **abx in severe cases**
71
what are the 3 things you can do to prevent cholera?
1. clean water and food 2. proper waste disposal 3. vaccine but protection is temporary and **booster is needed every 6 months**

Rotation 2: IM Outpatient (12 decks)

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