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Flashcards in Infectious Disease Deck (313):
1

MCC bacterial endocarditis

staph aureus

2

Native valve endocarditis

Staph aureus, strep bovix, strep gp D (enterococci) -> Vanco/gentamycin empiric

3

Prosthetic valve

staph epi, streptococci, G neg fungi -> vanco, rifampin (clears sticky bugs - staph epi), gentamycin

4

IVDU

staph aur, enteroccus, g neg strep viridans -> vanco + gentamycin

5

Indications for endocarditis surgery

Severe CHF - bacteremia x 6 days (if repeat bcx 48 hrs +, cont abx, repeat ctx, recurrent emboli, valve abscess, large fungal vegetation

6

Rt sided endocarditis with septic emboli - abx?

Daptomycin

7

Pt with sympt endocarditis - bctx done, vanco/gent started - 72hrs later bctx + strept sens to PCN - abx changed to PCN - gnet d/c'd - reepat bctx still + 24hrs later wtd?

continue abx, repeat bctx in 48hrs

8

IVDA rec with fever, cough hempotysis, pleuritis CP - II/VI SEM - 2-3 nodules on CXR - dx?

Rt sided endocarditis -> vanc/gent

9

Pt fever, +BCtx for clostr sept/ Strep bovis - wtd

Colonoscopy r/o malignancy

10

IVDA suspected for endocarditis vanc/gent started - ctx +PCN enterocci - vanc stopped - pcn started but then with prurtis swelling lip swelling - wtd?

D/C PCN start vanc

11

Vanc develops itching/redness

redman's - slow IV infusion +- benadryl

12

Pt s/p TURP 2 wks later with fever growing enterococci

older men, AV>MV, more CHF less embolic events, more conduction defects - don't use ceftriaxone (doesn't kill)

13

Valve replacement

NOT in pt febrile on abx - mild AR EF 60% - BUN cr 25/2 -> immune complex phenomenon - see splinter hemorrhage, janeway lesion, roth spots

14

Pt treated for endocardtisi defervesces and WBC dec bu twith 1st deg AVB - concerned?

yes - r/o valvular abscess - TEE

15

Pt on imipenum/cilastatin for nosocomial infxn h/o seizure d/o - has dz - related to imipenum?

Yes - inc'd incidence of seizures at higher doses

16

Endocarditis ppx only for high risk procedures in high risk conditions...

High risk condition - ALL prosthetic valve, prev h/o endocarditis, congential heart dz, unrepaired CHD, repaired CHD within 6 months, post tx heart WITH valvular dz, repaired CHD with prostesis or patch (forever)
High Risk procedure - likely to cause bleeding->endocarditis - dental extraction, periodontal procedures, root canal, implants
NOT HIGH RISK - GI/GU (only if risk of mucosal damage
Low risk conidtions - ASD secundum, 6 months after repair of ASD/VSD/PDA, prev CABG/HOCM, PPM, MVP with murmur MS/AS, fxn murmur
Low risk procedures - cavity filling, endotrach intub, bronch all GI/GU, vaginal hyterectomy, D/C C section, IUD, cath, circumcision

17

Endocarditis ppx

Amox 2g po 1 hr prior, if no PO then amp IV, PCN all - azithro, post procedure - > NOTHING

18

Pt witih PDA going for cystoscopy

NO ppx

19

Pt with bacteremia s aur due to IV line - vanc started wtc

TTE - neg tx x 2 weeks, + tx 4-6 weeks

20

Pt with susp diverticulitis pw f/c/abd pain - 3 days later temp 101, catheter site clean wbc 17K - wtd

vanc/imipenum

21

obesity with vanc

1.5g IV q12h

22

Surgical site infxn ppx

IV abx 1 hr prior to surgery/24 hrs after

23

35yo IVDA fever/chills wit hmurmur, vegetation on TV bctx MRSA - tx?

Daptomycin

24

Empiric tx meningitis

Head trauma/NSx - staph aur MRSA, S pneumo, G neg bacilli - vanc + ceftazidme
60yo Listeria, S pneumo, neisseria -> Ampicicillin (listeria), CFTtx (S pneumo), Vanco (MRSA)
15yo - S.pneuo, neisseria, h flu -> Ceftriaxone
2 month - strep agalactiae, E. Coli, Listeria - Ceftx + ampilcillin (listeria)

25

Normal CSF

<5cells, lymph, Gluc 40-80, Protein 15-45

26

Bacteria CSF

10-100K cells, PMNs, dec gluc, inc protein, inc opening pressure

27

West nile CSF

10-1K cells, Lymph, dec gluc, inc protein, muscle wk, rash, dec DTR

28

TB CSF

10-1K, lymph, dec gluc, very inc protein,

29

Aseptic CSF

10-2K, lympoh normal gluc, inc to normal protein, enterovirus, OKT3, NSAIDS, bactrim

30

Early bacterial CSF

10-1K, lymphs > PMN, dec gluc, inc protein, CSDF to ser glu <0.4

31

Encephalitis CSDF

1-2K, lymph, normal gluc, normal to inc protein

32

HSV enceph CSF

1-2K, lymph, N gluc, n to inc protein, +RBC 1:1 ratio

33

70yo Pt with DM p.w mental status change spinal tap with many WBCs mainly PMN G stain neg ctx pending wtc

ceeftx + vanc cover resistant strep pneumo + ampicillin cover listeria

34

55yo post renal tx on steroids pw fever, neck stiffness with g po rods diphteroids in csf; PMN 65% and lymphs 35% - dx?

Listeria - tx ampicillin + gentamycin (bactrim if PCN all)

35

24yo M neck pain, h/a, neck sign + spinal tap WBC 105, lymphs no RBC gluc 50 - cause?

entero/echo virus meningitis

36

Causes of aseptic meningitis

OKT3 ab, NSAID, bactrim, echo/enterovirus

37

70yo COPD PNA twice in 1 year p/w cough, fever, chills, MS change - WBC 17 PMN, LLL consolidation, CTH no bleed - spinal tap WBC >20K, PMN, dec gluc, inc protein, gram stain cocci in pairs - wtd?

empiric thx - ceftriaxone + vancomycin + dexamethasone

38

37yo woman solid organ tx couple weeks later with diarrhea/low grade fever then photophobia, h/a confusion - temp 102, CSDF 250WBC 55% PMN, gluc 35 - g stain neg - empiric tx?

ceftriaxone + ampicillin (listeria)

39

Pt with meningitis - LP WBC 75, gluc 28, elev protein - elev OP - crypt ag neg, g stain neg - tx for?

bacterial meningitis empirically

40

16yo MS change, fever BP 80/60 - exam midline scar abdomen - lab leukocytosis - h/o MVA 2ya splenectomy

organism - s pneumo (capsule)

41

Meningitis by h&P - wtd

IV abx - do not wait!

42

Pt with h/a x 2 days - now dizzy, lethargic - meningieal + sign - 7th episode in 6 years dx - CSDF granular cells?

beningn recurrent lymphocytic meningitis - HSV-2 - supportive care only (antivirals no benefit) - Mollarett's meningitis

43

Fever, h/a, vom/seizure - smelling fishy odor/burning rubber, auditory hallucination - MR brian hyper intensity temporal lobe -> EEG sharp and slow waves temporal lobe - LP WBC 200 lymphs, gluc 45, protein 75 RBC 65! dx?

Herpes encelphalitis - IV acyclovir

44

70yo h/a, fever x 5 days, confused, ocular pain, diplopia - hiking partner similar sx which resolved - mild neck signs + or focal wk one side body DTR absent - LP WBC 55, 100% lymph, protein 90 gluc 50 wtd

WNV IgM ab check - prognostic factor is age - >75 is bad
Reservoir - birds, transmitting agent=mosquitos

45

Pt fever h/a x 2 days - neck stiffness WBC 8800 68% PMNs - 8% bands - spinal tap WBC 85 54% PMN 33 lymph RBC 0 - gluc 26, protein 68

early bacterial meningitis

46

20yo F college with tonic clonic sz - h/a and strange behavior x 1 week with anxiety/paranoid behavior, no psych/drug abuse hx - orthostatic hypotension, choreform movements difficulty choosing words - CSF 40WBC 96% lymph, 3 RBC, gluc 62, protein 30 CTH normal - tx'd for HSV enceph no improvement HSV PCR neg - dx?

NMDA rct encephalitis

47

H/A confusion, petechial maculopapular rash - CT neg, LP WBC >2K - PMN and low gluc - G stain G neg diplococci - meningiococcal meningitis - tx with ceftx 3 days later hypotensive shock

b/l adrenal hemorrhage -> IV hydrocortisone

48

Who to PPX for meningitis

prophylax day care/nursery school contacts, household contacts

49

How to PPX meningitis

rifampin 600po BID x 2 days
If no rifampin cipro x 1 dose
If on OCP - change contraception while on rifampin
If preg ceftx 250mg IM x 1
Droplet precautions

50

Pt tx'd for meningiococcal meningitis since yesterday - how long continue isolation

D/C isolation now

51

52yo M p/w h/a - fever/neck signs - spinal tap elev open press, WBC 45 lymphs, protein 52, gluc 65, abx coverage for strep pneumo and hsv - 2 days later ctx neg, HSV pcr neg

d/c all meds and d/c home

52

HSV-2 causes...

aseptic meningitis - and can be accomopanied by gential ulcers and HSV-1 encephalitis

53

UTI

cystitis -> mostly ecoli - young women, staph saprophyticus, epi
Pyelonephritis
Catheter relted
Prostatis

54

Uncomplicated cystitis

3 days nitrofurantoin/bactrim/cipro - if sx persist >3 days c/s tx x 7 days

55

Cystitis in pregnancy

nitrofunatoin or amoxicillin x 7 days

56

Asx bacteruria in pregnancy

TREAT

57

Asx bacteriuria in DM

DO NOT TX

58

Asx bacteriuria post transplant

TREAT

59

Asx funguria with foley

DO NOT TREAT

60

asx bacteriria in foley

DO NOT TREAT

61

Recurrent cystitis

c/s and tx then suppressive regimen (bactrim/cipro)

62

Pyelonephritis

chills, fever, flank pain, tenderness, inc WBC urine

63

24yo F fever, chills, flank pain dysuria inc freq urin - +flank tenderness, +u/a 40WBC

tx cipro 7-10 days (quinolong)
if preg - admit and start ceftriaxone or amp + gent
If still temp in 3 days - renal US r/o structural abn
PCN allergy - aztreonam

64

32yo flnak pain, UA WBC >20 with many bacteria temp 102, HR 110 - started on amp-sulbactam - 3 days later pt eating/ambulating temp 99 HR 86 - grows ESBL E.coli and BCtx g neg rod -

still ok to d/c change to amox-clavulanate (augmentin)

65

Elderly male dysuria inc freq, tender prostate

Acute prostatitis - E.Coli
Tx: bactrim or quinalone (cipro) 4-6 wks

66

NH pt with foley and recurrent UTI - ppx?

nothing effective

67

Pt with foley - urosepsis -

change foley, start abx

68

NH pt with stroke, chronic foley with urosepsis several times/year - minimize risk of UTI?

close drainage catheter system

69

When is foley justified in elderly pt to promote healing

Stage IV sacral ulcer

70

STD - Gonnococcus, Chlamydia

no ulcer, no adenopathy, +discharge

71

Gonococcus

tx ceftriaxone

72

Chlamydia

Tx doxycycline or azithro

73

GC & Chlamydia

ceftriaxone + azithro 1gm or Azithro 2g one dose

74

Presentation GC/Chylamydia

urethritis, epidiymitis, mucopurulent cervicitis, dysuria, pyuria without bacteriuira, PID, diss gonococcal infxn (DIG)

75

24yo F college student sexually active with fever, chills.n,v x 3 days no vaginal d/c, tmep 102, HR 106, MM dry, left flank tenderness, mild suprapubic tenderness - no cervical motion tenderness - preg test neg

Admit - bctx, tx with IV cipro or bactrim

76

Vaginitis - Trichomonas

yellow d/c, strawberry cervix, pH>5
tx - metroniidazole 2g x 1 dose -> TX PARTNER

77

Bacterial vaginosis (gardnerella)

think d/c, clue cells, fishy odor pH>5
Tx Metronidazole x 7 days (whole garden - tx many days) - or metronid gel x 5 days, or clinda cream x 7 days - DO NOT TX PARTNER

78

Candidiasis

not smelling, thick white d/c
Tx - fluconazole 150 x1, topical clomazole x 3-7 days
tx partner only if balantitis present

79

pt with scanty foul smelling dc OTC vag azole and oral fluconazole don't work - wtd?

NOT Candidasis - treat for gardenerella/trichomonas with flagyl or clinda po or cream - check vaginal pH - if scraping bleeding - chlamydia

80

Pt with dysuria - d/c on exam - UA WBC and clue cells - tx?

metronidazole (bacterial vaginosis)

81

PID

lower abd pain, CMT, adnexal tenderness, mucopurulent d/c, uterine tenderness
Etiolgoy - Neiseria gonorrhea, chlamydia, vaginal anaeroboes

82

Complications of PID

infertility, ectopic preg, perihepatitis, tuboovarian abscess

83

Tx of PID

Outpt - Ceftx 250 IM, dox 100 bid x 2 weeks (PCN ofloxacin +clinda/flagyl)
Inpt - vomiting/sev pain - cefoxitin/cefotetan + doxy 100mg bid x 2 weeks (PCN allergy - clinda/flagyl + genta + doxy)

84

25yo F p/w progressie lower abd pain for past 4 days with nausea, vomiting, fever - denies dysuria or flank pain - temp 101, HR 100 lower abd tenderness - cervical d/c and CMT on exam - WBC 17, 70% pmn - ctx P

Admit and tx with IV cefoxitin iv doxy for PID (not tolerating PO)

85

24 yo sexually active man with uretheral d/c - given ceftx 250 x 1 and d/c 10 days later with uretheral d/c - wtc?

chlymida (gonnorrhea treated) - doxy 100 bid x 7 days or aithro 1g x 1 - always tx for both gonorrhea and chylamydia
Gonorreha (2-6 day incubation)
Chlymydia (1-4 wk incubation)

86

Young woman on OCP, sexually active with yellow mucoid dc - exam non-tender but bleeding and cervix erythematous swollen - smear with wbc bacteria no hypahe - organism?

Chlamydia

87

20 yo F dysuria x 1 week - no fever or flank pain - pelvic exam no CMT no bacteriuria, wbc 20/hpf pyuria

dx chlamydia - check urine nucleic acid
tx doxycycline or azithro

88

Repeat chylmydia test

false + (test neg after 3 weeks)
>3 weeks - true positive retreat pt and partner

89

Student on spring break - p.w tenderness in posterior testes 1 week later - striping of urethra with d/c

chlamydia epidiymitis - tx azithro

90

24yo F sexually active pain on movement of wrist joint - single pustular lesion on dorsum of hang, swollen right knee - greatest yield of culture from...

cervical culture or history
do not need parents permission to tx STD

91

Gay pt c/o constipation, pain on defication and generlized wk - ulcer in perieal area - ulcer in anal canal on anoscopy - dx?

HSV

92

Pt with acute testicular pain - h/o several sexual encounters - no truam - US normal - dx of epidiymitis - organism?

35yo E.Coli, entero

93

Uncircumcised pt wit pearly penile papules wtd?

do nothing

94

Genital ulcers

HSV, syphilis, H ducreyi, Lymphogranuloma venerium, granuloma inguinale

95

Pt with painful ulcers - started as grouped vesicles - lymph nodes +- -> fever, h/a, myalgias

HSV (DNA virus)
Tx - 1st episoe - acyclovir x 10 days
2nd -> acyclovir x 5 days
recurrent >6/year - acyclovir ppx
severe dz - iv acyclovir - reduces duration of sx and asympt viral shedding

96

Pt w/ painful genital ulcers, irreg borders initially started as tenderpapules painful adenopathy fluctulant -> rupture - schools of fish/boxcar - GRAM NEG Bacillus

H. ducrey -
tx - ceftrx 250 IM x1 or azithro 1gm x1 or erythro 500 x 7 days

97

Pt with PAINLESS gential ulcer - disappears in 1 week - 2-6 weeks later LAD - buboes, fistulae rectal scaring

Lymphogranulum venerum (LGV) - Chylymia tracho
tx - Doxy 100mg bid x 21 days

98

Pt with terrible looking PAINLESS ulcers on penis + LAD looks like penile CA

Granuluoma Infuinale - klebsiella granulomatis
Micro: Donovan bodies - bipolar safety pin intracytoplasmic inclusions
Tx - Doxy x 21 days or bactrim/erythro

99

Young woman 4 montsh ago with PAINLESS genital ulcer - dark field +, RPR neg at time - tx'd with PCN now p/w sever small ulcer - tender RPR 1:8 -

has herpes infxn - acyclovir

100

Asx pt RPR screening 1:8 postive FTA +

If pt RPR neg last year->early latent syphilis-> benz PCN 2.4 mu x1
If Pt RPR neg >1 yr ago -> late latent syphilis - 2.4 mill units wk x 3

101

Pt with painless genital ulcer raised with indurated margin and clean base wtd?

Dark field microscopy
tx - benz PCN 2.4 units x1 or doxy x 14 days

102

Pt with fever h/a generalized adenopathy, maculopap rash palms/soles, ele ast/alt alk phos, hereophile Ag neg, elisa neg, HIV RNA <50 wtd

VDRL/RPR to r/o 2ndary syphilus - FTA+ for life
tx - Benz PCN 2.4 mu x 1
if repeat VDRL titer dec 4 fold tx sucess
If repeat VDRL inc/stay same -> LP to r/o neural sypilis

103

40yo for regular checkup - pupils 4mm when figer to nose, eyes converge and pupils 3mm, flashing light left pupil doesn't constrict - Arygl robertson pupil

Spinal tap VDRL r/o neuro syphilus

104

Spinal tap WBC 410 lymph VDRL +, high protein, gluc 60 - wtd?

PCN G 2m units Q4h x 2 weeks
If PCN allergic - desensitize in ICU
repeat spinal tap q6m till WBC normal

105

Pt dx with syphilis started on PCN couple hours later with HA/fever, myalgias - BP 90/70, HR 104

Jarisch Herxheimer rxn - wtd?
Bed rest, ASA, continue PCN (NOT ANAPHYLAXIS)

106

45yo M h/a, difficulty walking, imbalance, fever double vision - HIV CD4 395, VL<24 dx?

neurospyphilis - spinal tap VDRL

107

Tick borne

RMSF, Lyme, Erlichia (anaplasma), babesia, Tularemia, STARI (southern tick associated rash illness)
ONLY ONE WITHOUT RASH COMMON IS ERLICHIA**

108

22yo N carolina camp c/o h/a, fever, myalgia 3 days later macular rash extremities - next day petechial

NMSF - doxycycline/tetracycline

109

57yo M cramping p/w complaint of h/a, fever, myalgias can't recall tick bite - exam low grade temp, mild confusion no rash - WBC 2.5, Hg 13, plt 60 AST/ALT eleve 150/120 - cause?

Erlichia - anaplasma - only one without common rash!

110

Pt vacationing nantucket/long island p.w fever, shaking chills, drenching sweats NO RASH - blood smear ring forms, maltese cross, tetrads - Hg dec inc retic (hemolysis) dx?

Babesia
Tx - mild form - Azithro + atoquone
Severe - Quinine + clindamycin

111

Pt at MD office in NJ with skin lesionon thigh, erythematous lesion w/ central clearing - lesion smaller few days ago dx?

erythema migrans - secondary lyme (serology not reliable - clinical dx)
Tx - doxy, if preg then amox (fever, h/a LAD, arthralgia)

112

Pt fishing onnantucket - rash on leg which disappeared few days later - 2 wks later pt with dizziness - ii/iii heart block

Lyme secondary - cardiac
Tx: PCN/Ceftx (NO DOXY)
Cardiac I/II/III heart block
Neuro: aseptic meningitis, bell's palsy, foot drop

113

Pt with disseminated or late stage lyme usually has...

western blot IgG banding+ > 5 bands

114

22yo wk left foot, no trauma - hiking several weeks ago with as rash cleared in few days doesn't recall tick bite - dec power L foot, dec reflexes L foot dx?

Foot drop 2/2 lyme dz stage II
Stage II months to years later - presents as monoarticular arthritis or chronic neuro sx

115

Pt hiking in NE on friday, found tick monday - no rash no sx

>24hr with tick - doxycycline even if asx
(if < 24 hrs with tick can observe if asx)

116

Pt hiking NE for bird watching - p/w facial palsy - cluster of vesicular eruption over auditory canal - dx?

Herpes zoster - DNA virus
tx - acyclovir

117

40yo F refereed with rash, central clearing - tx'd with doxy x 3 weeks - rath better but then malaise - to urgent care center repeat doxy x 2 week - f/u at MD office - 7/10 IgG bands _ and all bands + IgM

Post lyme syndrome - takes 6 months for sx to resolve
Tx - reassure do not retreat

118

Pt p.w tick attached - wtd?

place forceps at base of tick and lift gently

119

22yo Pt hiking in wisconsin - to ED with new onset weakness, DTR absent, denies tick bite - wtd?

search scalp for tick - tick paralysis better in hours once tick removed

120

Elderly pt with fiery red, well demarcated cellulits on face

Erysipelas - strep - cocci in chains
Tx - PCN
Complication - endocarditis

121

Female from singapore, honey crusted lesions mouth and chin - dx?

Staph infxn - impetigo

122

Strep throat complication

Acute glomerular nephritis

123

Pt with cellulits of leg, started on cephalosporin 1st gen - 72hr later cellulitis worse no brawny edema or bullous lesions, no DM wtd?

D/C cephaloporin and start bactrim, vanc or clinda

124

32yo cellulits on left leg wtd?

bactrim and cephalexin (cover MRSA and strep)

125

Invasive MRSA commonlypresents as ?

Bacteremia

126

Daptomycin used for G pos organisms including MRSA (not for PNA) - what to follow in pt on dapto?

CPK weekly

127

Pt with venacaval filter placed - 48hrs later p/w erythema at inciision site diffuse rash hypocalcemia, hyponatremia, inc Cr dec BP, fever - wound gram stain neg

Toxic shock syndrome
Strep - early onset 24hrs - culture usually neg
Tx - surgical debridement - PCN+clindamycin

128

Pt slipped and hit leg on bed railing in hospital, or Pt fishing and scraped arm 2 days later BRAWNY edema and severe tenderness with erythema - next day BULLOUS lesions - aspiration of bullae -> G+ cocci - started on IV abx - Pt hypotensive - on clinda and 1st gen cephalosporin

dx? Group A strep necrotizing fascitis
WTD?
Surgical consult!
MRI scan to confirm (best for soft tissues)

129

Least likely cause of toxic shock syndrome

nursing home pt wearing diapers
(caused by tampons, post op wound, breast implants, nasal packing)

130

Pt Gulf coast/florida (warm waters) p.w cellulitis with hemorrhagic bullae and necrosis +LN dx?

Vibrio vulnificurous (loves iron) - liver tx patients at inc risk with raw shell fish
tx - aggressive debridement
3rd gen ceph or tetracyclin/gentamycin

131

Pt (fish tank clenaer/swimming instructor) - p.w non-healing skin ulceration - started as single lesion on hand now multiple lesions forearm - bx AFB + dx?

Mycobacterium Marinum
Tx - Clarithromycin+ethambutol +- rifabutin

132

Pt with cut while in fresh water now leg swollen, septic and has h/o ETOH LIVER DZ - what is bacteria?

Aeropronas hyophillia

133

Florist/gardener p/w multiple nodules on hand and formarm - lymphatic channels - dx?

Sporotrichosis - sporothrix schenkii
Tx: local dz - itraconazole
Disseminated - amphot B (DM transplant pts)

134

Pt p/w folliculitic rash - h/o Jacuzzi/bath tub - dx?

hot tub rash - pseduomonas - improperly chlorinated hot tub
Tx - self limited no tx needed

135

Pt with cough, CXR infiltrated with thin walled cavity - indoor hot tub 3 days/wk dx?

MAI - Hot tub lung - avoid hot tubs

136

Pt on chemo becomes neutropnic - develops cellulitis black lesion with central ulceration - dx?

Ecythema gangrenosum 2/2 pseduomonas
Tx - anti pseduomonal b lactam + aminoglycoside/cipro or imipenum (collistin/polymysin)

137

Least likely about pseudomonas

CANNOT BE TREATED WITH AMP-sulbactam
(can cause malig otitis externa in DM, osteomyelitis in nail pct, endocarditis in IVDA, sepsis in neutropenic, ecthema gangrenosum, hot tub folliculitis)

138

50yo HIV p.w vesicular lesions on one side of face including ext aud cana with burnign pain - scrapings with multinucleate giant cells wtd?

IV Acyclovir

139

Pt p/w burning sensation over R forehead x 36hr - hyperesthesia over R forehead and single vesicular lesion on erythematous base on tip of R nose - what is WORST complication

Zoster ophtalmicus - Optho referral
slit lamp no corneal invovlment - started on valacyclovir - continues to have pain -> start prednsone

140

Post herpetic neuralgia tx

Desipramine>gabapentin

141

Isolation for herpes zoster?

Single dermatome - contact isolation
2 or > then contact and airborne

142

Herpes zoster with single rash

72hrs supportive care
>72hr and HIV treat
>72 hr Age>50 if new lesions appearing only then tx

143

65yo M herpes zoster vaccine - precautions for caregivers that never had chicken pox?

None

144

Non-Tb mycobacteria

MAC/Kansasii - common lung infx - hot tub lung
Abscessu/chelonae.fortuitum - water use, cutaneous/implnat infxn osteomylelits
Marinum - fresh and salt water

145

Non-healing cellulitis or infxn post breast implant -

M. Absessus

146

Non-healing cellulitis in pt with pedicure

Marinum, Fortuitum

147

Small Pox

Pharynx/face->extremities and trunk
Rash-> Vesicles-> pustules evolve CONcurrently
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available

148

Chicken pox

Chest and back
Rash->vesicles-> pustules evolve in crops, diff stages
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available

149

24yo brings 5yo daughter with small pox - she is worried about 20yo son who si scheduled for chemo for leukemia - new PA can't remember if he had small pox as child - wtd?

Child with immune def -> VZIG (highest risk)
Pregnant mother-> check titer if VZIG low - tx for symptoms
PA - check titer and vaccine if neg

150

Pt with lesions on extremities in diff stages (vesicle, pustule, escar) MC complication

PNA

151

Nurse/resp therapist with vesicular lesions on finger with erythema.tenderness - pet kitten at home

Herpetic whitlow - HSV -> tx with acyclovir

152

Young pt fever, malise sore throat followed by vsicular lesion on tongue, buccal mucosa -> later with painful vesicle lesions on dorsum of hand and foot

hand foot mouth dz -> coxsaxie virus

153

Pustules on palms after petting at fair or wild dog - dx?

Monkey pox

154

Week after hiking and staying at high elevation cabin NW - recurrent feverwith h/a, myalgia, arthralgia, chills, vom, abd pain - dx?

Borrelia hermsii (tick born illness in W US)

155

SW pt p.w sudden resp failure, pulm edema and inc'd HCT

Hanta virus - yosemete

156

Pt bit by cat - wtd?

Augmentin (Amox/clav) - pasterella multiloci + anaerobies (also for human and dog bites)

157

Pt h/o splenectomy for ITP plays with pet dog sustains scratch/ac - hypotensive next AM dx?

Septic shock 2/2 CAPNOCYTOPHAGA CARNIMORSUS

158

Pt with tooth ace, +submandicbular LN PCN allergic wtd?

Clindamycin

159

Pt with cat pw pustular lesion on hand and tender LN in axilla dx?

Cat scratch dz -> Bartonella Hansleae
Tx Doxy/erythro

160

HIV pt with multiple nodular lesions on extremities - ASTinc ALT inc, bx -> modifed silver stain +, warthin starry organisms+ - liver peliosis hepatis (cystic spaces with blood)

Dx bacillary angiomatosis -> bartonella henslae
Tx - doxy/erythro

161

Pt with HIV, T cells 150/cm homeless - lives in shelters and streets - with itching and excoriations of skin - pt disheveled - AST/ALT ELEVATED, spiking temp - holosystolic murmur at apex dx?

Bartonellosis endocarditis - trench fever 2/2 bartonalla quintana

162

Rabies vaccin/immune globulin for...

dog bite
bat bite/scratch
fox bite
racoon bite
NOT rat bite

163

Pt with dog bite in mexico - rabies vaccine 1 year ago

Vaccine x 2 doses (no HRIG)

164

Malaria - P. Falciparum

resistant almost everywhere

165

Malaria P. falciparum sensitive and others

caribbean, central america, near east

166

Malaria ppx

1 wk prior and 4 weeks after return arrival - mefloquine, atovaquine, chloroquine

167

Malaria tx

Quinine + doxy
Atovaquone/proguanil or cloroquine + primaquine
quinine gluconate+clinda
or arteminiin-amodiquine

168

Look at red book pg 239

Malaria endemic areas and other endemic dz

169

PT returns from nigeria trip - 2 wks later c/o shaking chills/fever, drenchign sweats then comatosed - retic 4% - gametocytes and dx cerebral malaria

Quinidine gluconate and doxy

170

Pt fever chills after nigeria 4 weeks ago - most sensitive test fo rmalaria

Ag base malaria rapid dx test
Best tx - artemether-lumefantrine (less s/e)

171

Pt did not take mefloquine for ppx now with malaria - wtd?

malarone (atovaquone/Proguanil)
mefloquone can't be used with cardiac conduction dz

172

Pt ER in NY with fever, rash mylagias retro orb h/a - vacation in florida keys, temp 101, HR 95 - faint MORBILLIFORM rash on trunck, few petechiea - plt 55K, WBC 4.5 - dx?

Dengue (bone breaking fever - hemorrhagic fever, mosquito borne, low plts, plasma leakage, low BP - n/v/f/diarrhea/GIB

173

Pt with lower abd pain, pelvic exam adnexal tenderness, cervical motion tenderness retained IUD wtd?

remove iud, ampilcillin/PCN

174

Actinomyces

sulfur granules, branching filaments

175

Pt with extensive dental caries p/w tenderness over mandible - diff opening mough, brawn edema over upper neck with tenderness dx?

Ludwigs angina
etio - peptostreptococcus, mixed anarobes
Tx - Amoxicillin-clavulante/amp-sulbactam

176

Neutropenic fever
bugs - staph au
Pseudomonas
aspergillus

absolue PMN<500 sp.p chemo p/w fever,
start on GCSF - cover G neg/pseudomonas - B lactam (ceftazidime or cefepime with amionglycoside
OR imipenum -
Add Vanc
Spikes on 7th day still - Amphotericin B - if renal failure voriconazole

177

Which antifungal improve mortality for ppx post chemo neutropenia

Posaconazole (noxafil)

178

Tx infections

4 month - fungal - cryptococcus

179

complication of BK virus

BK virus nephropathy

180

Pt s/p chemo - neutropenia and fever - pt started on vanc, primaxin 5 days later still fever - LLL infiltrate dense core gg appearaance with halo sign - dx?

Aspergilllosis - amphotericin B
if Cr elev - voriconazole

181

what is + in aspergillosis infxn pt

Serum galactomannan (aspergillous antigen - can be tested for as screen)

182

55yo renal tx - rejection 2 weeks later on immunosupp drugs - tacrolimus added - several months after - GG intranuclear inclusions in urine

BK virus - ground glass intranuclear inclusions urine

183

2 months post tx pt with fever, cough not responding to levofloxacin x 1 week - PO2 65, CXR b/l infiltrates - CMV+ b4 tx - lung bx - intracytoplasmic inlusions - dx/tx?

Ganciclovir, CMV immuneglobulin

184

Norcardia

lung skin, brain lesions - branchig/filiment, gram +, weakly acid fast
tx: sulfonamides - TMP-SMZ - if Cr increases this is NOT RENAL COMPROMISE

185

HIV pt 25 t cells VL 22K p/w fever/cough CXR thin walled cavity in RLL - BAL grows CMW, candida, HSV, norcardia - tx pt with...

Bactrim for norcardia

186

Pt with liver tx on high dose steroids and immunosuppresves - or SLE pt on steroids cough, fever, n/v - skin with nodular lesion - CXR nodular lesion - CT brain ring enhancing lesion

Nocardia

187

Osteomyelitis

hematogenous - long bones (children), vertebrae (adults)-tx with nafcillin
Contiguuous spread/DM foot - polymicrobial - broad spec abx
Prothetic implants - staph epi -> vanc, gent, refampin (sticky)
Necrotic bone (sequestrum)->chronic osteo->debridement (will return with just abx)
Sickle cell witih osteo -> salmonella>staph

188

MCC osteomyelitis in US

Staph aureus

189

Older adult with bacteremia p/w fever, lower back ache, point tenderness on spine

verebral osteomyelitis
tx - bctx, imagaing ct/mri, abx for 4-6 weeks

190

How to dx infection prosthetic hip 3 months post op

CT guided asp and culture

191

Pt with UTI, BCtx pos - Tx with IV abx, on TLC, 3 days later spiking temp, confused - hyper-reflexia in lower extrem and hyporeflexia in UE - CSF gluc 80, protein 295, WBC 75 60% pmn - dx?

Spinal epidural abscess

192

pt s/p chemo, no hs mets, recovering from neurtropenia with high fever - nodules on liver in CT dx?

hepatosphere candidiasis

193

Pt poorly controlled DM with bloodly nasal d/c - BLACK NECROTIC SPOT ON NOSE - rednes one ye - bx of lesion - FILAMENTS BRANCHING right angles

Murcormycosis
Tx: surgical debridement + amphotericin B

194

Pt with CRF on HD with recurrent staph aureus infxn - MRSA infxn from infected catheters - sucessfully treated with vancomycin IV in past - recent infection with staph not responding to vanc x 3 days

do epsilon e test measure MIC - if >2 then GISA or Vanc insensitive staph ->
tx Linezolid or quinupristin/dalfoprisitn

195

Pt started on abx for pos bctx enterobacter - pt defervesces, feels better on 6th day spiking - pt ctx positive for enterobacter now resistant to abx

what abx? cephalosporin

196

Pt with enterobacter infxn sensitive to cephalosporins - few days later enterobacter now resistant - what happened?

Plasma mediated resistance - ESBL mutans
tx - meropenum>imipenum>ertapenum (low threshold for resistance)

197

Pt growing ESBL klebsiella resitant to impipenum - wtc

polymyxin (elev cr)

198

Pt with UTI with ESBL sensitive only to colisint and tigecycline wtd?

Colistin only - tigecycline does NOT penetrate GU tract

199

Best management for stenotrophonas (xanthomonas) maltophilia

bactrim

200

What organism can be treated with abx without d/c central line?

staph epi (only remove for g neg rods)

201

Best way to do BCx on pt with central line

timed pair BCtx from both peripheral blood and catheter

202

Pt in ICU starts spiking temp of 102F, abx started, TLC changed over guide wire and tip sent for ctx - next day tip ctx grows Gram neg rods sensitive to Abx - pt better temp 100.5 wtd

REPLACE central line with fresh stick - continue abx

203

Pt in ICU with central line > 3 days ago with high fever and sepsis

dx - nosocomial line sepsis - d/c line and start vancomycin and amionglycoside

204

Best way to prevent central line infection

maximum barrier protection while insertion

205

Best way to prevent nosocomial infection outbreaks

hand washing

206

best way to prevent vent associated PNA

elevation of bed 45 deg,

207

15yo pw low fever, sore throat fatigue myalgia and cervical LAD - petetchiae on palate no phalangial lesions - monospot neg for heterphile abs - wtc

check EBV viral caspid antigen (VCA IgM)

208

Ampilcillin taken -> gets morbilliform rash - organism?

EBV - hypersensitivity rxn to abx - only occurs in presense of EBV infxn though...false neg monospot

209

pt withi +LN, monospot +, inc SOB, large tonsils - wtd

steroids...

210

Pt with infectious mono and LUQ pain wtd?

CT scan stat - splentic rupture
splenectomy

211

Pt in MICU on IV TPN x days with fever, chills opthalmitis - etology?

candida - chromium deficiency

212

Candida in BAL

DO NOT TX

213

Asymptomatic Cadiduria

DO NOT TX

214

Asymptomatic candida in blood

TREAT THIS!!

215

Pt grows candida in blood, fluconazole d/c'd 2 weeks ago wtd?

start caspofungin

216

Anthrax

Skin form - necrotizing form rare - animal hides
GI - ingestion with sever diarrhea
Inhalational - non-sp sx, h/a, chills vomm, sob, hemorrhagic meningitis pre-terminal - CXR with widened mediastinum (spores taken up by lymphocytes) - preterminal

217

Anthrax tx

Flouroquiniolone or PCN

218

Anthrax other characteristics

NO person to person tx
Isolation NOT required -
BCtx - gram + bacilli
PPX effective one day after exposure
Vaccine available for military

219

Farmer goes hunting for raabits and gets tick bites, p/w ulcers, fever, chills, myalgias and PNAA - tender inguinal and fem LN and cojuncitvitis - g neg pleomorphic organisms - dx?

Tularemia - wound bx or serology - ulceroglandular fever
tx - streptomycin x 7 to 10 days

220

Good saritan removes dead deer from highway i ARK/Oklahoma - couple days later with tender erythemaous papule, ulcerated with black eschar - organism?

Francisilla Turaemus (tularemia)

221

45yo h/a, cough, myalgias - temp 101.5 - cxr with RL infiltrate - watching US open in NYC - two other ppl had similar sx

Tularemia (infiltrate)

222

2 days after superbowl - inc'd pts a/w fever, cough, chest pain hemosptysi and prostaration - several died 24hrs after admission - dx?

Plague
Yersenia Persisitis
Bubonic (LN), Septicemic(causes DIC), Pneumonic (lungs)
Speads airborn droplets, close contact (also sexual)
Tx - doxycylcine, erythro, streptomycin (also for exposed close contacts)
Droplet isolation

223

Which most commonly aeorsolized

Coxiella burnetii (Q fever)

224

Rancher with fever, culture neg endocarditis - cryolobulins pos and HCV neg - dx?

Brucella - musc pain, sweating, fever, cryoglob +, endocarditis (neg ctx)
brucellosis - from unpaturized mild - ranchers infected animals
Tx tetracyclines, rifampin, streptomycin, aminoglycosides

225

Q fever infected most likely by...

Vets, abattoir workers in queensland (Q fever), farmers handling infected goat, sheep, cattle
Q fever - coxiella burnetti (ricksettia)
URI, fever, myalgias, headache
Tx - doxycycline, tetracycline, cipro

226

Young male with fever, myalgias, petechial rash after rafting trip PR, costa rica - icteric, mildly elev LFT with high T bili dx?

Leptospirosis - mildly elev transaminases and D bili 5-10x normal

227

Most likely inhaled with atypical PNA/h/a, fever

Q fever

228

MC with contaminated soil and animal products

Q fever

229

Caused by rikettsia

Q-fever

230

Skin contact or aerosolized -> RE system - splenomegaly, hepatitis, LN+ fever and drnching sweat - dx?

Brucellosis

231

Gram neg coccobacilli

Brucellosis

232

Sewage worker contact - fever hep, jaundice, liver hemorrhage, CONJUNCTIVAL SUFFUSION

Leptospirosis

233

Vet with fever - mental status change, jaunce renal failure, ecchymosis

Leptospirosis

234

Doxycycline

Q fever, burcellosis, leptospriosis, erysipelothrix

235

Buchter with fever, palpable spleen tip

brucellosis

236

Fisherman or fish handler with burnign or throbbing pain with erythem lesion on finger

erysipelothrix

237

Pt walks on beach in west florida pw red eyes, SOB, no wheeze or rohonci - dead fish on beach - dx?

Redtide bloom - Karenia brevis (algae)

238

Pt p/w diarrhea, fever, non-productive cough with HYPONATREMIA - drinks from TAP water

Legioniella -
tx quinolones - levoflox, azithro

239

sewage worker who hunts deer adn squirrel p/w fever, fatigue, abd pain and gen aches - CONJUNCTIVAL SUFFUSION - scrapes on hands, no ulers - CPK 765, mild ast alt elev, Bili 6.8 (elev), BUN/Cr 110/8

Dx? Leptospirosis
Tx: Doxycycline

240

21yo Iraq or afghan vet p/w 3cm lesion on arm, ulcerated with irrreg margins, eschar, surr erythema

Cutaneous Leismeniasis
Tx: fluconazole

241

40yo immigrant rural turkey/middle east with enlarged liver - dx?

Hydratid cyst (echinnococcus)

242

CMV colits isolation

none

243

MRSA isolation

contact

244

VRSA,VRE isolation

contact

245

HZV 1 dermatome isolation

contact

246

HZV >2 derm isolation

contact AND airborne

247

C diff isolation

contact

248

scabies isolation

contact

249

Measles isolation

airborne

250

Varicella isolation

contact AND airborne

251

MTB isolation

airborne

252

Neisseria isolation

dropelt

253

Influenza isolation

droplet

254

Plague isolation

droplet

255

HIV mother to child transmission

mainly during deliver
Post partum breast feeding
<2% with ART

256

Occupation risk exposure - high risk

1 protease inhibitor + 2NRTIs

257

Pt with HIV on ART undetctable VL now preg - WTD

continue ART to term - NO efavinanz

258

If HIV pt wants to breast feed

continue ART maintain undetect VL to prevent baby transission

259

Pt p/w fever sore throat rash 3 wks after high risk sex encounter - LAD (cervical , SM with apthous ulcers - atypical lymphs on smear - HIV neg - monospot/heterophiel Ab neg - wtd?

HIV RNA PCR r/o acute retroviral syndrome

260

Nurse with needle stick pt with HIV or high risk for HIV

baseline HIV elsia - start 1 protease inhib + 2 NRTI x 4 weeks - repeat HIV test if neg d/c meds

261

Sexual assult victim by IVDA unknown HIV status 24 hrs ago

offer 1 protease inhib + 2 NRTI

262

Opp infxn >200 T cells

CAP - S pneumon
PP+ Tx PPD > 5mm with INH x 9 months
Kaposi's sarcoma - dark bronish plaues on legs, pulm inviltrate - pulm nodules - purple red on bronch
HHSV8
Lymphoma

263

Opp Infxn < 200 T cells

Pneumocystis Jirovechi PNA - dry cough > 1 wk, grad onset progresssive - ABG with hypoxiemia
ele LDH, CXR b/l intersitial infiltrate or PTX
Dx - sputum silver methanamine +
BAL with stain
Tx - Bactrim (allergy - IV pentamidine or clina + primaquin)
If PaO2<70 add STEROIDS

264

Best test for suspected mild to mod dz PJP

check serum B D glucan

265

Bactrim effect on Cr

goes up, does not dec renal clearance - continue bactrim if Cr increases (dec'd tubular clearance of Cr by trimethopram)

266

Pt with PJP on bactrim with rash and spikign tmep - wtd

change bactrim to IV pentamidin or clinda + primaquine

267

Pt on bactrim with rxn

change to dapsone or atoquaone

268

Which drug covers both PJP ppx and sec ppx for toxo

dapsone + pymethamine

269

Candidasis

oropharyngeal - white patchs
Tx Fluconazole
recurrent on fluconazole - use itraconazole

270

HIV with T cell 55 - severe heart burn

empiric fluconazole for susp esoph candidasis - if no response upper endscopy - r/o CV or HSV or candidial esophagitsi

271

<100 t cells - h/a copel weeks not relleived with analgesics - CTH neg - wtz

SP to r/o crytococal meningitis - spinal fluid - india ink + = crypt Ag +
Tx: Amphotericine 5 + 5FC -> fluconazole long term

272

< 50 t cells - MAI

fevers, hepatomeg, LAD - elev alk phos (vit D def), bctx + AFB
Tx: clarithro/ethamburol +- rifabuin

273

<25 tcells

CMV retinitis - blurring vision
Tx Gancyclovir, cidofovir, foscarnet

274

<25 cells

progressive MF leukoencephalopathy - JC virus, use of natalizumab or efalizumab, rituximab, infliximab

275

PPx vs OI's

<50 cells - MAI - azithro or clarithro

276

Pt with T cells 25 started on HAART - 6 months later T cells 150

d/c azithro for MAI ppx (not < 50)

277

Pt 4 motnsh later t cells 250

d/c bactrim for PJP ppx

278

Which finding r/o crypto meningitis

neg crypt antigen in CSF

279

Ring enhancing lesions

Toxo
brian abscess
lymphoma

280

Pt with HIV T cells 25 h/a and one sided WK - CT scan ring enhancing lesion wtd?

tx for presumptive TOXO - sulfadiazine/pyrimethamine - repeat CT 2-3 weeks if no change bx lesion

281

CNS lymptoma

T cells < 50 - EBV ag +,

282

HIV pt T cell < 45 - VL 150K wk left leg - CT scan ring enhancing lesion, CMV +

NOT CMV (biventricular enhancement should be there)
could be
toxo, lymphoma, brain abscess

283

Middle ages latin american immigarant living in US recent onset Seizures - CT multiple cystic lesions with calcifications mild hydroceph

Neurocystercircosis - Taenea soliens
Tx: Phenytoin (cyerco serolody)

284

Hog farmer with fever, myalgia - periorobital edema, spinter/conjuntival hemorrhages - muslce tenderness no murmur - EOS 8%, LDH 400, CPK 7000

Dx tes t- Muscle bx, trichinella Ab (bear meat)

285

MCC PNA HIV CD4 150

Strep Pneumo

286

Pt dx HIV VL 105K asx started on regimennelfinavir, lamivudine, stavudine and bactrim - what else to start

Azithro or clarithro for MAI ppx

287

Indications for ART therapy for HIV

VL>100K
T Cell <500
Acute retroviral syndrome
Opportunistic Infections
Pregnancy

288

Protease Inhib - main s/e Lipodystrophy

Darunavir
Lopinavir
Atazanavir - in indir bili
Indiavir - kidney stones
Ritonavir - boosting agent, inc TGA, chol

289

NRTI - lactic acidosis, CAD, nypersensitiv rxn, neuropathy

Tenofovir - renal insuffiency
Emtricitabine
Zidovudine AZT - anemia, inc MCV, neutropenia
Abacavir
Lamivudine

290

NNRTI

Efavirenz
Nevirapine - steven johnsons, liver tox
Entravirine - CNS effuects, conf, abn dreams, agitiation

291

Integrase Inhibitors

Raltegravir

292

Combinations of HIV drugs

2 NRTI + PI/Integ Inhib
2 NRTI + NNRTI

293

PI S/E

HLD, insulin resistance, lipodystrophy, liver tox

294

What drug causes bone marrow suppression?

Zidovudine (AZT)

295

Best statin for HLD with HIV

Pravastatin, or atorvastatin

296

What statin to NEVER use

Simvastatin (inc levels HIV drugs)

297

Best drug for insulin resistance

Glitazones

298

Best inh steroid for HIV asthma

Beclamethasone

299

Best HIV med with HCV therapy

Raltegravir

300

What drug causes renal insuff (HIV drug)

Tenofovir

301

HIV pt on ART with indinavir, Zidovudine, lamivudine x 3 years - noted bufalo hump - pt obeese - all may be abn except

cortisol (lipds, glucose adn weight abn)

302

HIV pt with anorexia, wt loss, lethargy dizziness - hyperpig of skin, BP low, HR orthostatic, Na 135, K 5 dx?

Addison's dz (Ag/ab HIV)

303

33 yo F HIV p/w nausea and back pain - started o stavudine, lamivudine indinavir - left flank tenderness - elev cr, K, RBC in urine - wtd?

Indinavir - kidney stones

304

Immune reconstitution syndrome -

pt with adv HIV low t cells high VL - start on ART - react to latent pathogens - inflamation - continue ART

305

Pt with T cells 25, VL 250K, start ed on ART - 3 weeks later with cervical LAD

immune reconstitution to MAI/TB

306

HIV survelilence

VL q month till VL <50 within 6 months

307

HIV VL note dropping

Reason?
Non-adherence
or Resistant virus - check HIV genotyping

308

Earliest change to see in HIV therapy failure

rise in VL

309

Earliest OI in AIDS (not aids def lesion)

Oral thrush

310

Pt dx with HIV started on Norvir, Indinavir, AZT, epivir 4 months later VL <50, T cell 500 - pulm TV dv and started on rifampin, ethambutol and PZA - VL 2 months later 15K - explanation?

pt adherance - rifampin dec level of PI - change rifampin to rifabutin or change PI to NNRTI + NRTI

311

Pt dx with TB start on 4 anti TB - found to be HIV + - when to start ART?

within 2 to 4 weeks

312

Labs/onitorsing

HIV VL, T cells, RPR, Hep panel, PPD, Tox, LFTs
Vacc - HAV, HBC, flu, pnumovax, inactiv poli, Tdt
NO LIVE VACCines

313

Live vaccines

Oral polio
MMR
Varicella
Yellow fever