Infectious & Dermatology Flashcards
(86 cards)
Historical and physical “red flags” in a patient with an unknown rash
<ul><li>Fever</li><li>Toxic appearance</li><li>Hypotension</li><li>Mucosal lesions</li><li>Severe pain</li><li>Very old or young age</li><li>Immunosuppressed</li><li>New medication</li></ul>
DDX of Petichiae
Palpable:<br></br> Vasculitis<br></br> Infection<br></br>Non-palpable:<br></br> Low plt (ITP, DIC)
DDx of petichiae in a febrile patient:
<b>Palpable:</b><br></br> Meningococcemia<br></br> Disseminated GC<br></br> Endicarditis<br></br> RMSF<br></br> HSP<br></br><br></br><b>Non-palpable:</b><br></br> Purpura fulminans<br></br> DIC<br></br> TTP
DDx of erythematous Rash
Staphylococcal scalded skin syndrome<br></br>Toxic epidermal necrolysis<br></br>Toxic shock syndrome<br></br>Kawasaki dis<br></br>Anaphylaxis<br></br><br></br>Other DDx:<br></br>Scarlet fever<br></br>Alcohol flush<br></br><br></br>
<strong>Approach to the maculopapular rash</strong>
<b>Febrile/Toxic & Central:</b><br></br>Erythema migrans (Lyme dis)<br></br>Viral exanthem (measles, rubella)<br></br><br></br><strong>Febrile/Toxic & Peripheral:<br></br></strong>Erythema multiforme<br></br>Stevens-Johnson Syndrome<br></br>TEN<br></br><br></br><strong>Afebrile/Nontoxic:<br></br></strong>non life threatening<br></br>Drug reaction<br></br>Pitryasis<br></br>Scabies<br></br>Eczema<br></br>Psoriasis
<strong>Approach to the vesiculobullous rash</strong>
<b>Febrile and Diffuse:</b><br></br>Varicella<br></br>Smallpox<br></br>Disseminated GC<br></br>DIC<br></br><br></br><strong>Febrile and localized</strong>:<br></br>Necrotizing fasciitis<br></br>Hand foot mouth dis (Coxackie A)<br></br><br></br><strong>Afebrile and Diffuse:<br></br></strong>Bollous pemphigoid<br></br>Pemphigus vulgaris<br></br><br></br><strong>Afebrile and localized</strong>:<br></br>HZV<br></br>Contact dematitis
Malaria classic triad
Fever<br></br>Splenomegaly<br></br>TCP
Risk factors for TSS
Current menstruation (using tempones)<br></br>Postpartum/post abortion<br></br>Recent surgical procedure<br></br>Burns<br></br>Deep abscess<br></br><br></br><i>Sinusitis<br></br>IUD<br></br>Peritonsillar abscess<br></br>Nasal packing for epistaxis</i>
Commonly missed topics in Hx regarding infectious diseases
Immunocompromized<br></br>Age<br></br>Comorbidities<br></br>Travel Hx<br></br>ETOH<br></br>Substance abuse esp IVDU<br></br>Men sex with men<br></br>Endocarditis<br></br>Asplenia<br></br>Immunization status
Atypical causes of PUO
Meningitis<br></br>Endocarditis<br></br>TB<br></br>Malaria<br></br>HIV<br></br>Malignancy
DDx of Fever + ALOC (Hot and Altered)
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Features favoring encephalitis over meningitis
AMS<br></br>Focal signs<br></br>Altered behaviour and personality change<br></br>Speech changes<br></br>Seizures<br></br>CN palsies<br></br>Exaggerated DTRs
Meningitis Rx
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<div><b>Contraindications to lumbar puncture include:</b></div>
<div>1. Cellulitis over the proposed site of puncture, </div>
<div>2. Cardiopulmonary instability, </div>
<div>3. Bleeding diathesis, or platelet count below 50,000/μl, </div>
<div>4. Focal neurologic deficits, and </div>
<div>5. Signs of increased intracranial pressure, including papilledema</div>
<div><b>Pediatrics sepsis by age groups:</b></div>
<div>< 28 days</div>
<div>GBS, Listeria, E. Coli</div>
<div>1-3 months</div> <div>H.flu; pneumococcus, meningococcus, e coli</div> <div>3-36 months</div> <div>Same as above, less Hflu</div> <div>> 3 yr</div> <div>Same as above, but add in Group A Strep</div>
<div><b>CSF analysis is composed of:</b></div>
<div>1. Cell count and differential</div>
<div>2. Gram stain and Culture</div>
<div>3. Protein</div>
<div>4. Glucose</div>
<div>5. HSV PCR</div>
<div><b>What are risk factors for UTI in infants?</b></div>
<ul> <li>Age < 12 months</li> <li>Fever >24hours (boys) or >2 days (girls)</li> <li>Fever >39 degrees</li> <li>Absence of another source of infection</li> <li>Non-black race (boys) or white race (girls)</li> <li>Uncircumcised</li> </ul>
Dose of dexamethasone in meningitis
0.6 mg/kg/day in qid or<br></br>0.8 mg/kg/day in bid for 2-4 days
Who are the close contacts for meningitis?
Household contacts<br></br>HCW<br></br>Day care<br></br>Direct nose or mouth contamination (shared bottles,,,)
<p>Indications for primary closure of mammalian bite wounds</p>
<p>–Face or scalp</p>
<p>–Within 12 hours of injury (<24 hrs face)</p>
<p>–Simple wound, appropriate for single closure, no devitalized tissue</p>
<p>–Lack of underlying injury</p>
<p>–No systemic immunocompromising conditions</p>
<p>Indications for prophylactic antibiotics in bites</p>
<p>–Cat or human bite</p>
<p>–Livestock</p>
<p>–Monkey bites</p>
<p>–Deep puncture wounds</p>
<p>–Hand, foot, face, genital wounds</p>
<p>–Bites in immunosuppressed patients</p>
<p>–Wounds requiring surgical repair</p>
ABs for bites
Clavulin 875 mg bid x 3-5 days<br></br>in PCN allergy:<br></br>Doxy/septra/cipro/levo + flagyl/clinda<br></br>or<br></br>Moxifloxacin alone
<p>Tetanus prophylaxiss</p>
<ul> <li>Clean minor wounds</li> </ul>
<p>–< 3 or uncertain doses: Td</p>
<p>–Last dose within 5 years: None</p>
<p>–Last dose within 5 – 10 years: None</p>
<p>–Last dose > 10 years: Td</p>
<p></p>
<ul> <li>All other wounds (> 6 hours, > 1 cm deep, gross contamination, saliva/feces, ischemic, infected, avulsions, crush)</li> </ul>
<p>–< 3 or uncertain: Td, TIG</p>
<p>–Last dose within 5 years: None</p>
<p>–Last dose within 5 – 10 years: Td</p>
<p>–Last dose > 10 years: Td</p>
Rabies vaccine
0,3,7,14<br></br>Post exp proph Human Rabies Ig day 0:<br></br>20 IU/kg around the wound, the remainder given im distal to vaccination site<br></br><br></br>Captured animal==> examine the brain<br></br>Pet==> quarantine<br></br><br></br>Previously vaccinated pt==> vaccines only 0 and 3
- Eikenella
- Strep viridans
- S. aureus
- Bacterioides
- Corynebacterium
Vector= Ixodes deer tick (black legged tick)
Encephalitis
Migraines
Heart block
Arthritis
Myopericarditis
Ataxia
B/L facial palsy
Encephalitis/meningitios
Hepatitis
Severe sepsis
Death
- List five risk factors which increase your risk of severe HSV disease
- Patients 12 years or over
- Those with chronic skin disease (ie. Atopic dermatitis)
- Those with underlying pulmonary disease
- Patients receiving salicylate therapy
- Those receiving oral or inhaled corticosteroids
- Patients who are immunocompromised
- Neonates
- Pregnant
Indications for VZIG
- Exposed while Pregnant
- Exposed while Immunosuppressed
- Neonates born to women who have chicken pox 5 days prebirth to 2 days after delivery
- Timing?
- Up to 96 hours of exposure (can be given up to 10 days later)
Ramsy Hunt Syndrome
HZ ophthamicus
Pneumonitis
Meningitis
Hepatitis
Encephalitis
Sepsis
In HIV patients, list 3 causes of neurologic symptoms
- Toxoplasmosis (multiple ring enhancing lesions)
- CNS lymphoma (solitary lesion)
- TB
- Progressive multifocal leukoencephalopathy
- Cryptococcus
- Bacterial abscess
- Benign brain tumours
- Malignant brain tumours
- Kaposi's sarcoma
- Neurosyphilis
- HSV
- CMV
List two other investigations to confirm a diagnosis of Toxoplasmosis
- CD4 count (<100 highly suggestive)
- Toxoplasmosis IgG serology (positive, but negative does not exclude it)
- LP
What is the most common cause of pneumonia in HIV-infected patients?
Pneumonia in HIV, List five investigations aside from basic bloodwork
- ABG
- Sputum culture with Gram and acid fast staining
- Blood cultures for mycobacteria
- NAAT(nucleic acid amplification)/PCR for Mycobacterium
- CXR/CT
- Biopsy
What CD4 levels is prophylaxis started for:
Aside from infections, what illnesses would make you suspicious for AIDs
- HIV encephalopathy
- Kaposi’s sarcoma
- Burkitt’s lymphoma
- Brain lymphoma
- Progressive multifocal leukoencephalopathy
- Wasting syndrome due to HIV
PEP for HIV (triple therapy using Truvada+Dolutegravir)
LABS: creat, CBC, LFT
HIV titre at 3 months
Counsell to reduce transmission for 4 months (blood donation, unprotected sex, razors...)
Mycoplasma pn
HSV
HIV
Drugs:
Anticonvulsants
ABs (septra, PCN, Cephalo)
NSAIDS
Allopurinol
Steroids
Auto immune:
SLE
HLA type (chinese/japanese)
Small pox vaccination
Myocarditis
Pericarditis
Peric.effusion
Vantr.dysfunction
Valv.dysfunction
Arrhythmias
2-4 wks:
Coronary a aneurysm
Kawasaki Disease
Treatment
- IV Ig 2 g/kg as single dose
–Expect rapid resolution of fever
–Decrease coronary artery aneurysms from 20% to < 5%
- ASA - low dose vs high dose
–80-100 mg/kg/day until day 14
–3-5 mg/kg/day for 6 weeks
- Repeat echocardiogram at 6 weeks
-Gonococcemia
-Bacterial Endocarditis
-Rocky Mountain Spotted fever
-TSS
-Q Fever
-Vasculitis
-DIC
-TTP
-HUS
-Leukemia
-Vancomycin 1g IV OR 15 mg/kg IV
Metronidazole 500 mg IV (sinusitis is the likely source here)
Notes:
(given she has the meningococcemia rash, she is unlikely to benefit from dexamethasone administration as this is more effective with S. pneumonia)
(Acyclovir 10mg/kg would be appropriate to give this patient to cover for herpes encephalitis, but would NOT be accepted here as it is not, a “treatment for this condition”)
Osler nodes
Splinter hge
Petechiae
New murmur
Cong heart dis
Immunocompromized
prosthetic valve
Prior Hx of IE
-Viral infection (EBV, adenovirus, etc)
-Neisseria/Chlamydophila infection
-Mycoplasma pneumonia
-Uvula deviation
-Trismus
-Unilateral swollen tonsil
-Free fluid collection on bedside ultrasound
-Shigella
-Ecoli
-Campylobacter
-Yersinia
-Entomoeba
-Vibrio
-Bloody diarrhea
-Fever
-Severe pain
-Recent antibiotic use
-Elderly
-Immunocompromised
-Symptoms >1 week
-Signs of sepsis
-syphilis
-tinea versicolor
-contact dermatitis
-seborrheic dermatitis
-lichen planus
-scabies
-eczema
- Fever (Temp > 38.8)
- Rash – diffuse macular erythroderma
- Desquamation (1 – 2 weeks after onset of illness) - Particularly of the palm and soles
- Hypotension: Systolic BP <90 for adults and <5th percentile for age in <16
- Multisystem involvement (3 or more):
- GI, muscular (CK >2x upper limit),
- mucous memberane (vaginal, oral, conjuctival) hyperemia,
- renal (>2x Creat), hepatic )>2x LFT rise),
- hematologic (plt < 100,000),
- CNS (disorientation and no focal)
- Negative Blood, throat, or CSF cultures (other than Staph aureus in Blood) and Negative Serology for RMSF or Measles
What are the suggestions for obtaining a Head CT prior to LP?
Focal symptoms/signs
Seizure
Papilledema
Immuncompromised
Hx of malignancy
Hx suspicious of CNS dis (CVA, SOL)
Age > 60
List four infectious causes and three potential drug causes for Erythema Nodosum
- Infection:
- Bacterial:
- Streptococcal
- TB
- Leprosy
- Mycoplasma pneumoniae
- Fungal:
- Coccidomycosis
- histoplasmosis
- Blastomycosis
- Viral:
- IMN
- Cat scratch dis
- HBV
- Bacterial:
- Drugs:
- Sulfonamides
- OCP
- PCN
- Ulcerative disease of GIT (UC)
- Malignancy
- Idiopathic
Nickel
Neomycin
Bacitracin
Perfumes
Sodium gold thiosulfate
Formaldehyde
PVD
Lymphedema
Skin breakdown
Venous insufficiency
Obesity
?DM
Ischemia
Torsion
Malingering
What patients are at risk of developing complications from this condition?"
Immunocompromised patients
Patients with iron deficiency anemia, HIV, sickle cell disease, spherocytosis, thalassemia
Due to risk of aplastic crisis: Parvo b19 can stop erythrocyte production
-Positional headache
-Fever, immunocompromised
-Dizziness, focal weakness or other neurological complaints
-Clotting disorder/ anticoagulation
-Trauma
-Neck, facial pain, cervical manipulation
-Eye pain/ vision change
-Jaw claudication, muscle aches, temporal artery pain
-Multiple patients with headache
Rabies: most concerning animals, incubation period, how you can get it, mortality, S/Sx
- Most concerning animals:
Bats, raccoons, foxes, skunks, unknown/wild dogs
- Incubation period: 5 d – 1 yr (avg 20 -90 days)
- Risk: 5 – 80%
- You can get it with a bite, scratch, lick over an open wound or mucus membrane or exposure to brain tissue or CSF
- Mortality: once symptoms develop it is considered to be 100% fatal
- S/Sx:
Prodrome: Pain/parasthesias at site of bite/scratch, fever, h/a, anorexia
Neurologic stage (2 – 7d) Aphasia, incoordination, Increased lacrimation, increased salivation, paresis, paralysis, MS changes, hyperactivity
Late symptoms: decreased BP, coma, DIC, arrhythmia, cardiac arrest, DEATH
Outline the PEP for Rabies & the immunization schedule
Animal Type
Evaluation & Disposition of Animal
Recommendation for Prophylaxis
Dogs, Cats, Ferrets
Healthy & avail for 10 days obs
Don’t start unless animal develops symptoms then immediately HRIG + HDCV
Rabid or Suspected Rabid
Immediate HRIG + HDCV
Unknown
Contact local PH
Skunks, Raccoons, Bats, Foxes, Coyotes & most carnivores
Regard as Rabid
Immediate HRIG + HDCV
Livestock, rodents, rabbits (incl hares, squirrels, guinea pigs, hamsters, gerbils, chipmunks, rats, mice, woodchuks
Almost never require anti-rabies
HRIG (Human Rabies IG) 20U/kg infiltrate as much as poss around the wound and then the rest IM in the gluteal area
HDCV (Human Diploid cell vaccine) 1.0mL IM (deltoid) on days 0, 3, 7, 14 & 28
If previous vaccination then HDCV on 1.0mL IM on days 0 & 3
"Histoplasmosis
Primary CNS lymphoma
Cryptococcus Neoforms (CD4<100)
Cerebral malaria (encephalitis, seizure, edema)
GN
Splenic rupture
Hypoglycemia
Rheumatic fever
Peritonsillar/retropharyngeal abscess
Suppurative lymphadenitis
Also to hasten recovery
Electrolytes disturbances
Pulm edema
ARDS
Renal failure
Death
Burkitt lymphoma, and
EBV can affect nearly all organ systems. Neurologic complications such as encephalitis, meningitis, and Guillain-Barré
