Infectious Disease, Rheumatology Flashcards
(133 cards)
1
Q
Most common diagnosis for sick kids and antibiotic therapy?
A
Otitis media
2
Q
AOM risk factors?
A
Younger than 6yo FH, especially if American or Australian indigenous Male Poor Cold season Smoke exposure Day care Decreased risk with breastfeeding
3
Q
Respiratory epithelium histology?
A
Pseudostratified ciliated columnar epithelium with goblet cells
4
Q
Why are infants at greater risk of AOM?
A
Flatter ETs = worse drainage of middle ear
5
Q
AOM pathogenesis
A
Inflammation (due to URI, allergy, smoke) –> ET obstruction (mass, anatomy) –> Middle ear effusion (barotrauma) –> AOM –> OME (w/effusion) –> complications/resolution
6
Q
Most common microbial causes
A
Viruses - Adeno, Influenza, Mono, Rhino, Corona, Parainfluenza, RSV
Strep pneumonia, Haemophilus, Moraxella, GABHStrep, Staph, Anaerobes
7
Q
Is AOM contagious?
A
No, but URIs are, which may cause AOM secondarily
8
Q
AOM history
A
PAIN, URI, Fever, Headache, Irritability/apathy;
Anorexia, vomiting, diarrhea with Adeno
Behavior changes, communication problems, plugged/popping ears, recent URI/allergy
9
Q
AOM presentation and DDX
A
Otalgia = otitis externa, dental problems, pharyngitis
Ottorhea = otitis externa
Hearing loss = impaction, sensorineural deficits
Vertigo, nystagmus, tinnitus = ET dysfunction, labyrinthitis
Postauricular swelling = mastoiditis
Facial paralysis = Bell’s palsy
10
Q
AOM physical exam findings
A
General = sepsis Head = craniofacial abnormalities Eyes = drainage w/H. influenzae Nose = congestion, drainage, septal deviation Neck = lymph nodes, meningeal signs Throat = Bifid uvula (cleft palate), redness, drainage - SAVE FOR LAST
11
Q
AOM TM triad on otoscopy
A
Bulging, red, immobile
12
Q
AOM TM abnormalities
A
Bulging, bubbles, air-fluid levels, perforation w/ottorhea, bullae, tympanosclerosis, cholesteatoma
13
Q
Fever and earache associated with … ?
A
Pneumococcal infection
14
Q
Otitis-conjunctivitis syndrome or bilateral otitis associated with … ?
A
Haemophilus influenzae infection
15
Q
Ways to prevent chronic OM?
A
Educate parents - don’t smoke, breastfeed, vaccines, smaller daycare
Chemoprophylaxis
Surgery
16
Q
Retracted TM indicates?
A
Negative pressure in middle ear
17
Q
AOM diagnosis must have what three things?
A
Acute history of URI/congestion
Evidence of middle ear effusion - drainage, bulging TM, or abnormal tympanometry
Signs/symptoms - fever, pain
18
Q
AOM treatment
A
Observation
If over 2yo, short course of amoxicillin preferred, macrolides or erythromycin if penicillin allergy
Should respond within 2d. Recheck by 2wk.
19
Q
Recurrent OM treatments
A
Antibiotic prophylaxis
Image adults for masses
Surgery - myringotomy w/tympanostomy tubes
Monitor hearing, speech, language development
20
Q
OME treatment
A
Observe unless infant
Full antibiotic course if over 3m
Surgery if high risk, chronic, or bilateral effusion - tubes, may remove adenoids if obstructing ETs
Monitor hearing, speech, language development
21
Q
When are speech and language development at risk?
A
Infant younger than 6m Existing hearing loss or speech/language disorder Autism Developmental delay Uncorrectable visual impairment
22
Q
Potential targets of HIV drugs
A
Integrase inhibitors
Protease inhibitors
RT inhibitors
Fusion/entry inhibitors
23
Q
Clinical indications for HIV testing
A
TB
Syphilis
HIV-associated opportunistic diseases: Pneumocystis, Karposi’s sarcoma
Recurrent shingles
Chronic constitutional symptoms, generalized adenopathy, diarrhea, encephalopathy, thrombocytopenia
24
Q
Symptoms of primary HIV infection
A
Non-specific flu-like symptoms w/ or w/o rash
Fever, fatigue, rash, myalgia, night sweats, low WBCs, weight loss
Mucocutaneous ulcerations, rash, abrupt onset of multiple symptoms
25
DDx for HIV
EBV mono, CMV, HSV, flu, hepatitis, organisms causing rash
26
Cryptococcus neoformans
HIV OI
Subacute meningitis w/fever, headache, malaise, occasionally encephalopathy
Treat w/ amphotericin B, then fluconazole
Consider CSF shunt if hydrocephalus does not resolve
27
Advanced HIV OIs (CD4 less than 50/mL)
CMV - now causes CNS disease when CD4 below 50/mL
TB - all HIV+ patients should be tested for latent TB at diagnosis, rifampin/isoniazid is well-tolerated; Systemic TB common in advanced HIV disease --> Fever, weight loss, sweats, diarrhea
Primary CNS lymphoma
28
Toxoplasma gondii
May reactivate when CD4 below 200/mL
Present in white matter, CSF
Headache, fever, behavioral change, lethargy, gait change, seizures
29
JC Virus
Asymptomatic latent infection reactivates causing CNS involvement
30
Potential complications of HIV treatment
Lipodystrophy - body morphology changes and metabolic complications
Premature osteopenia/-porosis
Peripheral neuropathy
31
Best time to start HIV treatment?
As early as possible if the patient is functional, esp. if pregnant
Give vaccines early to maximize benefits, but avoid live vaccines
32
Pneumocystis jirovecii
HIV OI
Gradual onset fever, dry cough, dyspnea, tachypnea
CXR may show indicative infiltrate
Bronchoscopy diagnostic
Treat w/ IV SxT; patient will typically worsen after 2-3d as fungus begins to die, IR begins
33
Normal stool volume and frequency
Less than 1L/d
| Less than 7 BM/d
34
Dysentery-causing organisms
| Which bowel?
Small bowel:
Salmonella
E. coli (all strains besides 0157)
Large bowel:
Campylobacter
Shigella
Entamoeba histolytica
35
Define pseudodiarrhea, fecal incontinence, and overflow incontinence
Rectal urgency due to anal inflammation/infection
Neuromuscular loss of anal sphincter control
Constipation in sigmoid colon causes watery stool to leak around blockage
36
Causes of acute diarrhea
Viral - most common, least complicated
Bacteria - severe
Protozoa - least common
37
Diarrhea-causing organisms with preformed toxin
| Which bowel?
C. perfringens
Staph
Bacillus cereus
All small bowel
38
Diarrhea-causing organisms with enterotoxin
| Which bowel?
Vibrio cholerae
| Small bowel
39
Diarrhea-causing organisms with cytotoxin
| Which bowel?
E. coli 0157:H7
C. diff
Large bowel
40
Diarrhea-causing organisms with enteroadherance
| Which bowel?
Giardia lamblia
| Small bowel
41
Diarrhea soon after cream pie/salad?
Staph
42
Diarrhea after rice that was left out?
Bacillus cereus
43
Diarrhea within enclosed space (cruise ship)?
Norovirus
44
Diarrhea/dysentery 1-3 days after undercooked meat?
Salmonella
45
Diarrhea a few days after raw vegetables or undercooked meat?
E coli 0157:H7
46
Diarrhea after sushi?
V. parahemolyticus
47
Diarrhea in child in daycare?
Rotavirus
48
Diarrhea associated with unsanitary conditions?
HepA
49
Infantile diarrhea?
Adenovirus
50
Diarrhea associated with unclean surface water?
Giardia
51
Travelers diarrhea?
ETEC
52
Diarrhea after antibiotic therapy?
C. diff
53
Diarrhea pertinent history questions
```
Onset
Frequency
Presence of blood or mucus
BMs at night?
Associated symptoms
Exposures?
Recent antibiotics?
```
54
Diarrhea pertinent physical exam findings
Vital signs/General - patient sick and near shock?
Abdominal exam - Surgical abdomen? (Rigidity, guarding, rebounding, no sounds)
Musculoskeletal - accompanying arthritis
Skin - vasculitis?
Rectal exam - blood, masses
55
Anal fissure may be indicative of?
Minor cause of hematochezia
56
Anal fistula may be indicative of?
More severe disease such as IBD
57
When to culture stool?
| When to look for parasites/ova?
- Bacteria suspected
| - Persistent diarrhea w/risk factors, dysentery, but no fecal leukocytes
58
Typical antibiotics for diarrhea
```
Flouroquinolone = G- coverage
Metronidazole = C. diff coverage
```
59
When to not use anti-motility agents?
Bacterial or amoebal dysentery, inflammatory response that needs to be cleared
Prevent C. diff establishment
60
Influenza types
```
A = humans, animals, pandemics
B = humans, no pandemics
C = mild disease
```
61
Influenza surface proteins
Hemaglutinin and neuraminidase
62
Antigen drift and antigen shift
```
Drift = mutation causes small changes in H, N from year to year
Shift = Reassortment of genes in cells co-infected with different strains causes acquisition of new H, N genes
```
63
Influenza transmission path
Need large respiratory droplets (sneezing, coughing)
Need close contact for these to be transmitted
Can't get from contaminated surfaces, meat
64
Clinical influenza disease
Fever, headache, myalgia, fatigue
Followed by cough, sore throat, nasal discharge
GI symptoms NOT typical
65
Flu complications
Pneumonia (viral, strep, or staph)
Rhabdomyolysis
MI
Encephalitis and Reye's syndrome (from too much aspirin) rare
66
Spanish flu unique features
Bacterial pneumonia most common cause of death
67
H5N1 bird flu unique features
Primarily children and young adults most affected with little person-to-person transmission
68
H3N2 swine flu
Close contact with pigs at IN state fair, with genes from H1N1 and H3N2 strain
69
Diagnosing flu
In season, typical symptoms usually enough
| Otherwise viral culture (gold standard) or RT-PCR (higher cost)
70
Flu treatment
No antiviral works well, but may reduce mortality
Old rimantidine and amantidine are ineffective
Current neuraminidase inhibitors only moderately shorten course
71
Why must flu vaccines be changed every year?
Must anticipate antigenic drift with educated guess
72
Flu vaccine features
Grown in eggs
Inactivated with formaldehyde
Current is a subunit containing only H and N proteins with few side-effects
Tri- or quadrivalent
GBS now rare
Most effective in children, least effective in elderly
73
Lyme disease organism and vector
Borrelia burgdorferi
| Deer tick
74
Rocky Mountain Spotted Fever organism and vector
Rickettsia rickettsii
| Dog tick
75
Ehrlichiosis organism and vector
Ehrlichia chaffeensis
| Lone star tick
76
Lyme disease stages
1. Localized - Erythema migrans (blanching)
2. Disseminated - multiple annular skin lesions, meningitis, CN7 neuritis, carditis/AV block, arthralgia
3. Persistent - Oligoarticular arthritis (knee), encephalopathy, axonal (distal) polyneuropathy, acrodermatitis
77
DDx of CN7 palsy
Idiopathic Bell's Palsy
HSV usually w/o rash
Herpes Zoster - vesicles in external auditory canal
Lyme disease
78
Testing for Lyme disease
Serologic IgM/IgG at presentation and 2-4w later
ELISA w/ Western blot verification
PCR of joint fluid in patients w/ arthritis
79
Treatment for Lyme disease
Doxycycline
80
Rickettsia rickettsii trophism
Vascular endothelial cells --> Vasculitis (increased vascular permeability, non-blanching petechial rash w/palms and soles, edema, hypovolemia, hyponatremia from disproportionate ADH response, thrombocytopenia)
81
Classic presentation of RMSF
Fever, rash, history of tick exposure
| Flu-like symptoms
82
Serious RMSF symptoms
```
Shock from hypovolemia/-tension
Respiratory failure
CNS involvement
Acute tubular necrosis
Acute hepatitis/liver failure
```
83
RMSF labs will show what?
Thrombocytopenia, hyponatremia, azotemia (high BUN, high Cr if ATN occurs)
84
Fever, petechial rash on palms and soles, potential tick exposure DDx
```
Meningococcal disease
RMSF
^^^Most important, both treated w/doxycycline, cephtriaxone^^^
Enterovirus
Secondary syphilis
```
85
RMSF treatment for pregnant women
Chloramphenicol
86
Reasons for RMSF treatment delay
Absence of skin rash
Early presentation before severe symptoms
Presentation outside of summer months
87
Ehrlichiosis symptoms
Flu-like symptoms
Rash is rare
Fewer long-term complications
88
Ehrlichiosis lab findings
Leukopenia
Thrombocytopenia
Elevated transaminases
89
Ehrlichiosis treatment
Doxycycline
90
Malaria physical exam findings
```
Fever
Mild hepatomegaly
Palpable spleen
Jaundice
Rash is very unusual
```
91
Malaria lab findings
Nonspecific
Normocytic normochromic anemia
Increased ESR, CRP
92
Malaria drugs
Chloroquine - if in sensitive area
Doxycycline
Malarone
Mefloquine - avoid because of CNS side effects
93
Staphylococci (aureus, epidermidis) pathogenic proteins
S. aureus: G+, catalase- and coagulase-positive = hemolytic
| S. epidermidis: Coagulase-negative, less virulent, but affects prosthetics
94
Risk factors for S. aureus colonization
Diabetics
HIV
Dialysis patients
Patients with skin damage (wounds, psoriasis, etc.)
PMN defects (neutropenia, chronic granulomatous disease, Chediak-Higashi syndrome)
95
Staph pathogenesis
Pyogenic, causes abscesses at primary and/or distant sites
| Inflammatory response -> PMN infiltrate -> Macrophage and fibroblast infiltration -> Contained infection OR spread
96
Toxin-mediated Staph diseases
Cytotoxins
Pyrogenic toxin superantigens: Food-borne illness (enterotoxin), Staph toxic shock syndrome (produced at infection site, causes clinical toxin - USE CLINDAMYCIN to stop toxin production most effectively)
Exfoliative toxin: Staph scalded skin syndrome
97
Protective value of anti-Staph Abs?
None in clinical trials
| PMNs are main control
98
Staph clinical manifestations
Skin, soft tissue infection (cellulitis, fasciitis more likely w/GABHStrep)
Bacteremia
CV infection
Sepsis, toxic shock syndrome
Bone, joint infection - osteomyelitis, septic arthritis
Pulmonary infection
Renal infarction, psoas abscess -> CVA tenderness
Rare:
Splenic abscess
Meningitis
Bacteruria - indwelling catheter
99
Staph bacteremia, sepsis risk factors
Intravascular catheters
MRSA colonization
Implanted prosthetics
Injection drug use
100
Physical exam and diagnostic evaluation of Staph in adults
Careful cardiac exam to detect new murmurs, heart failure, endocarditis
Blood cultures daily, ECG
101
Staph aureus bacteremia treatment in adults
Remove infection source (catheters, prosthetic)
Empiric antibiotics until sensitivity determined - vancomycin
MSSA - nafcillin q 4h/oxacillin, cefazolin more common
Follow up blood cultures daily
Therapy duration - 14d IV abx w/o complications
102
Enterococcus treatments
Penicillins if sensitive
Vancomycin if sensitive
MRSA drugs
Cephalosporins, fluoroquinolones, macrolides = NO EFFECT
103
ESBL-producing E. coli treatment
Carbapenem
104
Sepsis risk factors
```
ICU, nosocomial infection, esp. pneumonia
Bacteremia
Older than 65y, immunosuppression
Diabetes
Cancer
Genetic factors
```
105
How to manage sepsis
Control airway - supplemental O2, intubation, ventilation
Establish venous access - central line
Maintain perfusion - IV fluids, vasopressors
Empiric, then targeted antibiotics
Possible surgical debridement
106
MRSA risk factors
```
Recent stay in care facility or hospital
Recent antibiotic therapy
HIV
IV drug use
Dialysis
Diabetes
Shared sports equipment
```
107
Septic shock progression
Systemic inflammatory response syndrome (SIRS) -> Sepsis -> Severe sepsis -> Septic shock
108
Common causes of antibiotic resistance spread
Antibiotic use in livestock causes spread in meat
Stay in long-term care facilities w/other sick people
NOT WASHING HANDS
109
Key interventions to prevent MRSA spread
Hand hygiene
Decontamination of environment, equipment
Contact precautions for infected/colonized patients
Active surveillance cultures of all people working/housed in facility
110
Precautions for C. diff
Gown and gloves
| Hand washing
111
Vancomycin side effects
Renal failure, ototoxicity
112
Strep throat history and physical
H: Contact, sore throat, headache, fever, adenopathy
P: Exudative tonsillitis, petechiae on palate (strawberry tongue), fever, cervical adenopathy, circumoral pallor (pale around mouth)
113
Strep throat DDx
Viral pharyngitis
Coxsackie
Herpes
GABHStrep pyogenes
114
Strep throat labs
Rapid (Strep antigen - GA carb Ag) and routine throat culture
115
Strep throat treatment
Routine - Penicillin V (250 or 500mg b./t.i.d. for 10d) or G (1 IM dose), 10d erythromycin for patients with penicillin allergy, or 10d cephalosporins
Carrier - Pen G, clindamycin, cephalosporins, or amoxicillin; 10d penicillin w/ rifampin last 4d
116
Strep throat complications (5) w/cause, course, symptoms, treatment
Scarlet fever - from erythrogenic Strep exotoxin w/1-7d incubation: Fever, vomiting, headache, strep pharyngitis, chills, abdominal pain, rash first appearing in axilla/groin/neck, then generalized in 1d, followed by desquamation - Treat w/Pen 10d
Rheumatic fever - M type GABHS extracellular toxin: Carditis, migratory polyarthritis, erythema marginatum (almost looks like 2o Lyme disease), chorea, subcutaneous nodules, fever, arthralgia, high ESR/CRP, prolonged PR on EKG - Treat Strep, aspirin, steroids, bed rest, chorea w/anticonvulsants, heart failure w/bed rest, digitalis, diuretics; prevent relapse w/penicillin prophylaxis
Glomerulonephritis - GABHS infxn 1-2w prior: Hematuria (RBC casts), malaise, lethargy, abdominal/flank pain, fever, edema, oliguria, hypertension; check w/culture, serum C3, streptolysin O Abs; Treat w/Pen and for complications
Peritonsillar abscess
TSS - rare
117
Rheumatologic diseases
Musculoskeletal conditions, pain syndromes, autoimmune syndromes w/o musculoskeletal components
"Pain about, but not in joints"
118
What provides nutrients to cartilage
Synovial fluid made by the membrane (cartilage is avascular)
119
Cartilage molecular structure
Hyaluronic acid backbone w/ proteoglycan attached
| MW may reach 300m
120
Synovial membrane thickness
1-3 cells thick
121
Pathophysiology at cartilage causes ... ?
Osteoarthritis
122
Pathophysiology at bony end-plate causes ... ?
Avascular necrosis
123
Pathophysiology at synovial membrane causes ... ?
RA
124
Pathophysiology at joint space causes ... ?
Gout
125
Pathophysiology at enthesis causes ... ?
Ankylosing spondylitis
126
Rheumatologic history should include what?
Complete history
Time and rapidity of onset (Gout = rapid, RA = w/m, Fibromyalgia = slow)
Number of joints
Constitutional symptoms - systemic or local?
Response to therapy (Gout w/NSAIDs, FM w/exercise)
Functional status - define therapeutic end goals
127
Rheumatologic physical should include what?
Complete physical and joints
Palpate joints
Evaluate swelling, tenderness, limited ROM
Function
128
Rheumatologic labs
Useful for supporting Dx, not determining disease
CBC - assess systemic involvement, therapy contraindications
ESR, CRP - systemic inflammation?
RF, ANA - for classifying systemic polyarticular inflammatory arthritis, not diagnostic
Joint aspiration - diagnostic for crystal-induced, septic arthritis
X-ray - diagnostic in ankylosing spondylitis, osteoarthritis; follow RA progress
129
Rheumatologic treatments
Exercise - CV conditioning for FM, ease pain in osteoarthritis
PT, OT
NSAIDs - risks of renal insufficiency, GI bleeds, CV risk
Corticosteroids - for flares, intraarticular injections useful for non-/inflammatory arthritis, systemic for inflammatory, autoimmune
DMARDs - treat underlying immune defect
130
Articular symptoms shorter than 6w DDx
Crystal-induced (pseudo-/gout), septic, infectious arthritis, initial chronic presentation
131
Noninflammatory arthritis longer than 6w DDx
Osteoarthritis
132
Polyarticular arthritis DDx
RA, SLE, PsA
133
Pauciarticular arthritis DDx
```
Ankylosing spondylitis, Reiter's, PsA
Juvenile RA
Pseudo-/gout
Septic arthritis
Early polyarthritis symptoms
```
