Infectious Diseases (6%) Flashcards
(50 cards)
1
Q
botulism
A
- clostridium botulinum, results from ingestion of preformed toxins produced by spores
- source: improperly stored food (home canned goods), inactivated by cooking food at high temps (212F x10mins), wound contamination
- sxs: GI sxs (abd cramps, N/V/D), hallmark is symmetric descending flaccid paralysis starting with dry mouth, double vision, ptosis, and/or dysarthria, paralysis of limb musculature (late), resp distress leading to death
- dx: c. botulinum toxin in serum, stool, gastric bioassay
- tx: admit pt and observe resp status (gastric lavage only in first few hours), if high suspicion administer antitoxin, contaminated wounds = wound cleansing and PCN
2
Q
Chlamydia etiology and sxs
A
- Most common bacterial STD
- RF: lack of condom use, lower socioeconomic status, living in an urban area, having multiple sex partners
- most common in F 15-19, then 20-24
- independent risk factor for cervical cancer
- Sxs:
- men: dysuria, purulent urethral discharge, itching, scrotal pain and swelling, fever
- women: puruelnt urethral discharge, intermenstrual or post-coital bleeding, dysuria
- mucopurulent discharge from cervical os, friable cervix
3
Q
chlamydia diagnostics and tx
A
- Tx: NAAT, wet mount (leukorrhea >10 WBC), culture, enzyme immunoassay, PCR
4
Q
Gonorrhea etiology and sxs
A
- transmitted sexually or neonatally
- 30% coinfected with chlamydia
- Sxs: asymptomatic in women, symptomatic in men
- Cervicitis or urethritis (purulent discharge, dysuria, intermenstrual bleeding)
- Disseminated: fever, arthralgias, tenosynovitis, septic arthritis, endocarditis, meningitis, skin rash (distal extremities)
5
Q
Gonorrhea dx and tx
A
- dx: NAAT, gram stain (leukocytes, gram neg intracell. diplococci), cultures (men from urethra, women from endocervix)
- tx: tx empirically because cultures take 1-2d
- Ceftriaxone x1, add Azithromycin or doxy to cover chlamydia
- if disseminated, hospitalize and IV or IM ceftriaxone
- Complications of dz: PID, infertility, epididymitis, prostatitis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome
6
Q
diphtheria
A
- corynebacterium diphtheria
- transmission: resp secretions; produces EXOTOXIN causing myocarditis and neuropathy
- sxs: nasal infxn/discharge, laryngeal infxn, pharyngeal infxn (tenacious gray membrane covering tonsils and pharynx, mild sore throat, fever, malaise, myocarditis, neuropathy involving cranial nerves
- dx: cx to confirm, but CLINICAL dx
- tx: horse serum antitoxin from CDC, if airway obst remove via laryngoscopy, PCN or erythromycin, diphtheria toxoid as vaccine (DTaP) or Td
7
Q
tetanus
A
- neurotoxins produced by spores of clostridium tetani, a gram pos anaerobic bacillus (proliferates producing exotoxin in contaminated wounds)
- RF: incomplete or no tetanus IMZ
- sxs: hypertonicity and contraction of masseter mm - trismus or lockjaw, progresses to severe, generalized muscle contractions, risus sardonicus = grin dt contraction of facial muscles, opisthotonos = arched back dt contraction of back mm, sympathetic hyperactivity
- dx: clinical, obtain wound cx but unreliable
- tx: admit to ICU, resp support, diazepam for tetany, neutralize unbound toxin with passive IMZ, give single IM dose of tetanus immune globulin (TIG)
8
Q
acute rheumatic fever
A
- supporting RF: previous (+) throat cx or RAT (66%), elevated or rising strep ab titer
- complications: mitral stenosis
- major criteria: polyarthritis, carditis, chorea, erythema marginatum (red patches with central clearing), subcutaneous nodules)
- minor criteria: fever (>39), arthralgia, elevated CRP or ESR, prolonged PR interval (mitral regurg)
- dx: throat cx or RAT, ASO titer establishes recent strep infxn
- dx criteria: 2 major or 1 major and 2 minor + supporting evidence
- exceptions: chorea or indolent carditis with normal anti strep ab levels
- tx: PO ASA QID for 2-4 wk, 1.2 million U benzathine PCN IM, prednisone,
- prophylaxis: benzathine PCN G
9
Q
Rocky Mountain Spotted Fever
A
- southeast, midwest, western US, spring and summer, intracellular bacteria rickettsia rickettsii
- transmission: vector-borne (dog ticks)
- sxs: onset sxs within 1 wk after bite, sudden onset F, chills, HA, photophobia, N/V, malaise, myalgias, papular rash (begins peripherally - wrists, forearms, ankles - and spreads centrally to rest of limbs, trunk, and face), becomes maculopapular - (nonblanching petechial rash
- may lead to interstitial pneumonitis, resp failure, and/or CNS involvement
- dx: elevated LFTs, thrombocytopenia, acute and convalescent serology, immunofluorescent staining of skin bx
- tx: doxy x7d, if preg or CNS manifestations tx with chloramphenicol
10
Q
Salmonella
A
- Duration: 1wk
- Transmission: food, water, fecal-oral
- Incubation: 5d-2wk (typhoid)
- sxs: inflamm D, N/V, sxs appear 24-48h after ingesting food (Salmonella typhi presents as C), possible fever
- dx: fecal leuks +, C. diff toxin and cx, 3 stool sample for ova and parasites, bact. stool cx, hypokalemia and met acidosis
- tx: cipro
11
Q
Cholera
A
- acute diarrheal dz, profound rapidly progressive dehydration and death
- protein enterotoxin produced by orgs as it colonizes
- consumption of contaminated shellfish
- Onset: 24-48h after consumption
- sxs: watery diarrhea “rice water stool” dt action of cholera toxin
- signs: fishy odor
- tx: tetracycline, FQs, or macrolide, oral rehydration
12
Q
Shigella
A
- Duration: 1wk
- Transmisison: fecal-oral, MC in developing countries, children <5
- sxs: abd pain, inflamm D, mucoid and bloody stool, N/V (less common), tenesmus (feeling like u need to constantly poop), poss fever
- dx: fecal leuks +, C diff toxin, 3 stool samps for ova and parasites, bact. stool cx, hypokalmeia and met acidosis, produces largest quantity of fecal leuks than any other gastroenteritis
- tx: TMP/SMX (bactrim)
13
Q
candidiasis
A
- 2nd MCC vaginitis
- RF: high dose OCP, diaphragm use, DM, abx, pregnant, immune suppression, tight clothes
- signs, sxs: vulvar or vag itching, burning, external dysuria, dyspareunia, odorless thick cottage cheese curd-like d/c
- erythema of vulva, excoriations from scratching
- dx: wet mount - budding yeast
- gram stain - pseudohyphae
- vaginal culture (+) for yeast
- pH <4.7 (acidic)
- tx: fluconazole 150 PO once
- tx uncircumcised partners
- short-course topical azole
- recurrent: weekly topical /PO
- resistant: boric acid TID x7d
14
Q
primary, secondary, latent, and tertiary syphilis
A
- TREPONEMA PALLIDUM
- Primary:
- chancre - painless, clean base, 3-4wk after exposure, heals in 14wk w/o light tx, HIGHLY INFXS
- inguinal lymphadenopathy
- Secondary:
- flu-like (HA, fever, sore throat, malaise)
- 4-8 wks after chancre heals, maculopapular rash
- aseptic meningitis
- 1/3 develop latent syphilis
- Latent:
- serological test in absence of clinical sxs
- 2/3 remain asymptomatic
- “early latent” = if serology + for <1 y, may relapse to secondary
- “late latent” = if serology + for >1y, patients are contagious
- Tertiary:
- years after primary infxn
- neurosyphilis, CV syphilis, gummas
- neurosyph: dementia, personality changes, tabes dorsalis (post column degen, loss of corrdination of mvmt)
- rare d/t tx with PCN
15
Q
Syphilis dx and tx
A
- Dark field microscopy (GOLD STANDARD)
- Serologic tests (MC)
- Non-treponemal tests: RPR, VDRL
- Treponemal tests: FTA-ABS, MHA-TP
- if FTA-ABS +, check for CSF-FTA-ABS
- test all pts for HIV
- Tx: PCN G (one dse IM)
- doxy and tetra x2wks if PCN allergy
- latent or tertiary: PCN x3 doses IM (1 wk apart)
- neurosyph: IV PCN x 10-14d
- repeat nontreponemal tests q3 mos
- Jarisch-Herxheimer rxn can occur w/ sudden massive destruction of spirochetes - prevent by administering antipyretics during first 24h of tx
- Report to public health agency
16
Q
cryptococcosis (PNA)
A
- MCC: cryptococcus neoformans serotype A (AIDS), cryptococcus gattii; encapsulated budding yeast found in soil contaminated with dried pigeon dung, cockroaches, or bird droppings
- transmission: inhalation, common in immunocompromised and solid organ transplant hosts, MC areas for infxn = lungs and CNS; CD4 <100 if AIDS
- sxs: hx pulm dz if COPD, steroid use, posttransplant, fever (low grade - MC in HIV), productive cough, dyspnea, HA, wt loss, pleuritic chest pain, malaise
- signs: pleural effusions, LAD
- complications: meningitis, meningoencephalitis
- dx: CXR (solitary or mult nodules, granulomas, patchy pneumonitis), india ink (confirms, CSF - variable pleocytosis mostly lymphocytes, inc opening pressure, inc protein, dec gluc), cx of BAL; cx = budding, encapsulated fungus; CSF = crypt antigen; CT or MRI
- tx: obs only if CSR nl, CSF cx or other tests (-), urine cx (-), lesion small, stable, or shrinking, no predisp conditions for dissem
- PO fluconazole, if severe = amphotericin B, +/- flucytosine
17
Q
histoplasmosis etiology, RF, and sxs
A
- fungal infxn MC associated with spelunkers, bat droppings, chicken coops - infxn of lung leading to granuloma formation
- histoplasma capsulatum (dimorph fungus with septate hyphae), Ohio and Mississippi river valleys
- RF: AIDS CD4 <150, use of steroids, hematologic malig, solid organ transplant
- sxs: 90% asxatic, flu-like sxs, F, HA, malaise, myalgia, abd pain, chills, severe SOB, worsening cough, hemoptysis, CP, jnt pain, skin lesions, wt loss, D, abd pain, periph edema, angina, confusion, szs, AMS
- signs: erythema nodosum, erythema multiforme, arthritis, HSM, hilar and mediastinal nodes, rales/wheezes, hypoxemia, pericardial rubs, abd mass, intestinal ulcers, CN deficits, meningismus, mm weakness, ataxia
18
Q
histoplasmosis dx and tx
A
- dx: urine and serum ag testing (cross reactivity with blastomyces and coccidiodes = false +), BAL ag testing, pancytopenia, AST/ALT elevated, LDH elevated, sputum cxs, blood cxs, abx (anti-H = active, anti-M = chronic), complement fixing Ab
- Imaging: CXR (hilar and mediastinal nodes (coin lesions), cavitation in upper lobes, CT look for adrenal involvement, echo TEE or TTE if valvular involvment suspected, LB
- tx: acute asxatic = no tx; acute sxatic = PO itraconazole x 3mo, amphotericin B for severe or immunocompromised host
19
Q
pneumocystis PNA
A
- pneumocystis jiroveci - caused by fungus found in lungs of mammals, MC opportunistic infxn in HIV/AIDS
- sxs: F, SOB, nonproductive cough, exam findings disproportunate to imaging, showing diffuse interstitial infiltrates, fatigue, weakness, wt loss
- dx: CXR (definitive - diffuse or perihilar infiltrates, reticular interstitial PNA or airspace dz that mimics pulm edema), sputum wright-giemsa stain or DFA, BAL, CD4 <200 if AIDS, ABG hypoxia, hypocapnia, reduced DLCO, LDH inc but nonspecific, serum B-glucan, WBC low
- tx: BACTRIM, add roids if PaO2 <70, dapsone if sulfa allergy
- all pts with CD4 <200 should undergo prophylaxis (bactrim)
20
Q
atypical mycobacterial disease
A
- etiology: mycobacterium avium complex (MAC), M. fortuitum complex, M. kansassi
- no airbonrne contact, noncontagious
- sxs: indolent or subacute course
- MC sx = fever, cough, SOB, fatigue, weight loss, hemoptysis
- unilateral cervical, submandibular, or preauricular lymphadenitis - painless and firm, no warmth and well circumscribed
- but fever and systemic sxs are minimal or absent
- dx: Runyon criteria: nonchromogens (MAC) - produce no pigment, rapid growers; produce visible growth on standard agar in 1 wk, which usually takes 2
- Ziehl-Neelsen: AFB +
- PPD: + or -
- AFB smear and cx
- tx: surgical excision - if excision is not possible or there is a recurrence of dz, antimycobacterial drugs may be used = clarithromycin, azithromycin, rifampin and rifabutin, ethambutol
21
Q
Tuberculosis
A
- can present as acute or latent infxn
- only active TB is contagious (cough, sneezing), PRIMARY TB IS NOT CONTAGIOUS
- difficult to dx in HIV, PPD will be neg, atypical CXR findings, sputum likely neg, granuloma may not be present
- RF: HIV, immigrants, prisoners, health care workers, close contact, alcoholics, DM, steroids, blood malig, IVDU
- MC: mycobacterium tuberculosis, slow growing
- Transmission: inhalation of aerosolized droplets
- sxs: fatigue, weight loss, fever, night sweats, productive cough
- dx: sputum stain (acid fast bacilli), sputume culture + for M. tuberculosis, PPD, CXR (caseating granuloma formation (pulm opacitis, most often atypical)
- tx: RIPE tx, dc tx if transaminases >3-5x ULN, can spread to vertebral column
22
Q
Primary, Secondary, and Extrapulmonary TB
A
- Primary: bacilli inhaled and deposited into lung - ingested by alveolar macrophages
- surviving orgs multiply and disseminate via lymphatics and blood
- granulomas form and “wall off” mycobacteria - remains dormant
- insults on immune syst reactivates (5-10%)
- Asymptomatic: pleural effusion, can be progressive with pulm and constitutional sxs, usually clinically and radiographically silent
- Secondary: Host’s immunity weakened (HIV, malignancy, steroids, substance abuse, poor nutrition), gastrectomy, silicosis, DM)
- most oxygenated parts of lung: apical/posterior segments
-
Symptomatic: fever, night sweats, weight loss, malaise, chronic cough, progressive (dry to purulent, blood streaked)
- signs: chronically ill appearing, malnourished, posttussive apical rales
- Extrapulmonary TB: impaired immunity cannot contain bacteria - disseminates (HIV)
- any organ
- Miliary TB: hematogenous spread - can be due to reactivation or new infxn, HIV pts, organomegaly, reticulonodular infiltrates, choroidal tubercles in eye
23
Q
TB diagnostics
A
- high index of suspicion depending on RF and presentation
-
CXR - unilateral apical infiltrates with cavitations, hilar and paratracheal lymph node enlargement, pleural effusions, Ghon complex, Ranke complex
- HIV may show lower lung zone, diffuse, or miliary infiltrates
- Sputum studies: definitive dx by sputum culture, obtain 3 morning sputum speciments, takes 4-8wks, PCR can detect specifics
-
PPD (Mantoux test): screening to detect previous TB exposure, not for active TB dx; if + use CXR to r/o active TB
- if sxatic or abnl CXR, order AFB
- >15mm if no risk factors; >10 if high risk (homeless, imigrants, health care workers, DM); >5 if very high risk (HIV, organ transplant, contact with active TB)
- Interferon gamma release assay: measures interferon gamma release in response to MTB antigens, helps exclude false + TST
- blood cultures
- NAAT-R
24
Q
signs of healed primary TB:
A
- Ghon complex: calcified focus with associated lymph node
- Ranke complex: Ghon complex undergoes fibrosis and calcification
- CXR: fibrocavitary apical dz, discrete nodules, pneumonic infiltrates usually in apical or posterior segments of upper lobes or in superior segments of lower lobes
25
TB treatment: active TB, Pregnant women, Latent TB, Immunnocompetent, HIV pos
* Active TB: droplet precautions; isolation until sputum neg for AFB
* **2 months of tx with 4 drug RIPE, then 4 months with INH and Rifampin**
* once isolate determined to be isoniazid sensitive, ethambutold can be DCed; if susceptible to isoniazid and rif, may continue on 2-drug regimens
* tx \>/= 3 mos past neg cxs for MTB
* Pregnant: DONT TAKE PYRAZINAMIDE: RIE x 2mo, then isoniazid and rif for 7 mo; B6 (pyridoxine) daily to prevent periph neuropathy; breastfeeding NOT contraindicated
* Latent (+ PPD): 9mo INH AFTER active TB excluded via CXR, sputum, or both; NOT infxous, no active dz
* Immunocompetent: INH x9mo; adverse effect = drug induced hepatitis
* HIV pos: **9mo INH** _OR_ 2mo rif and pyrazinamide _OR_ rif x 4mo
* Other: 9 mo tx when miliary, meninegal or bone/jnt dz; surgical drainage and debridement of necrotic bone in skeletal dz; steroid tx to prevent constrictive pericarditis and neuro complications
26
tapeworm, schistosomiasis
* tapeworm (*taenia saginata, T. solium, Diphyllobothrium latum)*
* trans: raw or undercooked meat
* sxs: asx, if sx - N, abd pain, wt loss, B12 def
* dx: tape test or stool sample (**eggs)**
* tx: praziquantel, vitamin B12 if def
* Schistosomiasis (*Schistosoma mansoni, S. haematobium, S. japonicum*)
* trans: penetration of skin → lungs → portal vein → venules of mesenteric, bladder, ureters
* sxs: dermatitis, local erythema, pruritic maculopap rash, fever, myalgias, malaise, abd pain, HSM, HA, cough, +/- bloody D
* dx: **eggs** in urine or feces
* tx: praziquantel
27
Roundworm, Hookworm, Pinworm
* Roundworm (ascariasis; nematode)
* trans: fecal-oral
* sxs: asx, if sx - PP abd pain, V (associated = bowel, panc duct, or CBD obstruction if heavy worm burden)
* dx: stool sample (**eggs or adult worms)**
* tx: albendazole, **mebendazole,** pyrantel pamoate
* Hookworm (*Necator americanus)*
* trans: larvae enter skin → lungs → cough, swallow → reside in intestine
* sxs: asx, if sx - cough
* signs: malabs/wt loss, eosinophilia, anemia
* dx: stool sample (**adult worms)**
* tx: **mebendazole** or pyrantel pamoate
* Pinworm (***Enterobius vermicularis)***
* trans: fecal-oral (children)
* sxs: perianal pruritus, worse at night
* dx: "tape test" on anus (**eggs on tape)**
* tx: **mebendazole** or pyrantel pamoate
28
toxoplasmosis etiology, RF, sxs
* organism: toxoplasma gondii (obligate intracellular)
* active infxn in immunocomp hosts are dt the release of encysted parasites that undergo rapid transformation into tachyzoites within CNS and are not contained by the immune system
* definitive host: **cat (feces) -** infects birds, rodents, grazing animals (lamb, pork), humans
* transmission: oral (ingestion of **contaminated soil, food, water),** by blood or organs, transplacental, lamb, beef, pork, cat litter box
* MC space occupying lesion in HIV-infected pts
* sxs: **cervical LAD (MC -** nontender, discrete, firm), **HA,** malaise, fatigure, fever, myalgia, sore throat, abd pain, maculopap rash, **meningoencephalitis,** confusion, **encephalitis (AMS, F, szs, HA, focal neuro findings**, motor def, CN palsies, mvmt disorders, dysmetria, visual-field loss, and aphasia
* complications: PNA, myocarditis, encheph, pericarditis, polymyositis
29
toxoplasmosis dx and tx
* clinical dx in AIDS pt, serum IgG and **IgM** (acute) abs to toxoplasma (IgG detected 2-3wks, IgG levels precede encephalopathy), double dose contrast CT head (multiple peripheral **ring-enhancing lesions** usually in basal ganglia), MRI w/ contrast, brain bx to ro primary CNS lymphoma, labs
* **CD4 \<100** if AIDS, lymphocytosis, ESR high, AST/ALT high, CSF elevated ICP, mononuc pleuocytosis, inc protein and gamma globulin level
* tx: recheck serum IgM in 3wk, enceph treat = **pyrimethamine AND sulfadiazine** OR clinda, spiramycin
* **bactrim DS** daily is PROPHYLAXIS
30
trichomoniasis
* signs, sxs: increased d/c and odor, dysuria, frequency, dyspareunia, itching, irritation
* thin yellow-green to gray, adherent frothy discharge in vagina
* malodorous, musty (amine)
* hyperemic mucosa, friable cervix, strawberry cervix (petechiae)
* dx: wet mount, ph 5-6.5 (basic)
* tx: 2 g metronidazole PO x1, no ETOH 48h, TREAT PARTNER
31
Herpes simplex virus (herpes labialis), HSV-1
* transmission: kissing, resides in trigeminal ganglion
* signs and sxs: fever, malaise, vesiculopustular oral lesions in groups
* herpes labialis (cold sores): most common on lips, painful, heal in 2-6 wks
* bell palsy
* herpetic whitlow
* dx: clinical dx with lesions **dewdrop on a rose petal**
* tzanck smear - multinucleated giant cells
* culture of HSV
* ELISA
* PCR
* tx: acyclovir
* complications: herpes encephalitis, HSV keratitis
32
Genital herpes, HSV-2
* resides in sacral ganglion
* prior HSV-1 infxn confers partial immunty to HSV2
* signs and sxs: severe, prolonged sxs
* fever, HA, malaise
* painful vesicles on genitals (itching, dysuria, multiple, bilateral)
* tender inguinal lymph nodes
* dx: HSV1 and HSV2 Ab negative
* PCR, culture if active lesion present
* tx: acyclovir, sitz baths, topical xylocaine
* complications: aseptic meningitis, keratitis, blepharitis, keratoconjunctivitis
* C section recommended for pregnant women with active infxn
33
varicella infxn
* chickenpox
* incubation: 14d
* sxs: fever, rash on face/scalp, moves to trunk/extremities
* signs: papules and vesicles, crusts "dew drop on a rose petal"
* dx: tzanch smear to confirm herpes simplex, varicella, and zoster infxn
* tx: valacyclovir decreases incidence of varicella PNA
34
cytomegalovirus
* **human herpesvirus type 5,** dsDNA virus, HIV or posttransplant, CD4 \<50, asxatic - latent - reactivates
* RF: daycare, blood transfusions, mult sex partners, CMV mismatched organs or BMT
* transmission: person-person, placenta, blood trans, organ trans, breast milk, sex
* sxs: most asxatic, flu-like, F, malaise, myalgias, arthralgias (appears like mono)
* signs: fine crackles, LAD, +/- pharyngitis, HSM
* complications: esophageal ulcers (CD4 \<100), encephalitis (AMS), peripheral polyradiculopathy, retinitis (CD4 \<50)
* dx: ag test (CMV pp65 in WBCs), qualitative PCR in blood and tissue, labs (lymphocytosis or leukopenia, LFTs elevated)
* cx: difficult, antigens in blood, urine, CSF via PCR
* **BAL** positive for CMV, tissue bx (owl's eyes, **intracytoplasmic inclusions)**, CXR consistent with pneumonia
* tx: healthy without sxs = no tx; immunocompromised = CMV immunoglobulin and IV **ganciclovir**
* AE = fever, rash, D, heme effects
* prophylaxis: bactrim if CD4 \<50
35
rabies
* devastating, deadly viral encephalitis, contracted from a bit or scratch by infected animal; infxn from corneal transplant as well; more prominent in developing countries where rabies vaccination is not widespread
* sxs: once sxs present can be fatal - pain at site of bite, **prodromal sxs** of sore throat, fatigue, HA, N/V, **encephalitis** (confusion, combativeness, hyperactivity, fever, seizures), **hydrophobia**, **ascending paralysis**
* dx: virus or viral ag form infxed tissue or saliva, 4x inc in serum ab titers, **negri bodies**, PCR detection of viral RNA
* tx: clean wound thoroughly, wild animal bits - send animal for immunofluorescence of brain tissue; if healthy animal - capture, place in observation x10d
* known rabies: **passive IMZ** (human rabies IG 40units into wound and gluteal region), **active IMZ** (human diploid cell rabies (HDCV) vaccine in 3 IM doses into deltoid or thigh over 28d
36
varicella (herpes zoster)
* age \>50yo, caused by reactivation of variceclla-zoster virus, which is dormant in the dorsal root ganglia and reactivated during stress, infxn, or illness; occurs only in pts who have had chickenpox, contagious when open vesicles present and immunocompromised
* sxs: **severe pain and rash** in dermatomal distrib (pain before rash - **thorax MC** and trigeminal distrib), vesicles = pustular on d3-4, crust over by 7-10d
* signs: grouped vesicles on erythematous base
* complications: **postherpetic neuralgia,** excruciating pain persisting after lesions have cleared and does not respond to analgesics, uveitis, meningoencephalitis, deafness
* dx: tzanch smear, **cx of vesicular fluid**, varivax indicated for indiv \>1yo, zostavax for prevention of zoster in pts who have no CIs
* tx: keep lesions dry/clean, **analgesics for pain**, local triam in lidocaine, **antivirals** (acyc, famcic, valavyc reduce incidence of PHN, reduce pain, dec length of illness), roids to dec incidenc of PHN, **live vaccine** (varizig) to reduce severity and duration
37
mononucleosis (what do you not give)
* caused by epstein-barr virus (rarely CMV), adolescents, college students, or military recruit
* transmisison: saliva, 90% adults infected previously are carriers, lifelong immunity w/ 1 infxn
* sxs: fever, LAD, pharyngitis → fever resolves in 2 wks, sore throat, malaise, myalgias, weakness
* signs: **LAD,** posterior cervical, tonsillar, enlarged, painful, tender; pharyngeal erythema and/or exudate, **splenomegaly,** maculopapular rash, hepatomeg, palatal petechiae and periorbital edema
* dx: **monospot, WBC count with diff, transaminitis,** EBV specific Ab, peripheral smear shows lymphocytic leukocytoisis with large, atypical lymphocytes
* tx: supportive, short course steroids, avoid sports 3-4wks (SPLENIC RUPTURE)
* complicaitons: hep, meningoencephalitis, Guillain Barre, splenic rupture, thrombocytopenia, URTI
* DONT GIVE AMOX or AMP → can cause maculopap rash
38
influenza
* orthomyxovirus
* transmission: resp droplets, winter months
* sxs: rapid onset of fever, chills, malaise, myalgia (legs or lumbosacral area), **fever, HA (**generalized or frontal), **nonproductive cough** (may last more than 1 wk), ocular signs/sxs (pain w/ motion of eyes, photophob, bruning of eyes), sore throat, +/-N
* signs: cervical LAD, rhonchi, wheezes, scattered rales
* dx: RT-PCR = most sensitive and specific (can differentiate subtypes and detect avian flu
* tx: supportive care (tylenol or NSAIDs . for HA, myalgias, fever; no cough suppressants, **neruaminidase inhib:** zanamivir or oseltamivir for flu type A and B → reduces sxs by 1-1.5d if started w/in 2 days of onset
39
First disease: **measles**
* AKA rubeola
* incubation: 2wk
* sxs: prodromal (malaise and anorexia), then **high fever and lethargy** (4-7d), 3 Cs Triad (**cough, coryza (runny nose, congestion), conjunctivitis)**, rash on day 3
* signs: **Koplik spots** (blue/gray spots on buccal mucosa), blanching erythematous macules and papules on face at hairline, sides of neck, and behind ears (coalesce into patches and plaques on trunk and extrems (palms/soles) lasts 5-7d
* dx: clinical, IgM titer, IgG, viral cx from throat and nasal swab, RT-PCR
* tx: ibuprofen, fluids, vitA
* complications: PNA, OM, endcephalitis
40
third disease: Rubella
* **blueberry muffin baby, german measles**
* Rubella virus (RNA virus rubivirus), 2-3wk incubation, prodromal phase absent in children
* transmission: droplet
* incubation period: 14-19d
* sxs: mild URI, low grade fever, macular rash day 1, face → trunk → limbs, **arthralgia**
* signs: **postauricular,** postcervical, and **occipital nodes** (tender, generalized), **forscheimer sign (enanthem of soft palate)**
* clinical dx
* tx: ibuprofen, fluids, contageious for 7d after rash onset
* complications: **PDA,** pulm art stenosis, aortic sten, ventricular defects, thrombocytopenic purpura w/ purple macular lesions, cataracts, retinopathy, sensorineural deafness
41
sixth disease: Roseola
* HHV 6B or 7, 5-15d, MC in 9-12mo olds
* sxs: **high fever** x3-4d +/- febrile seizure, after 3d fever dissapates and **rash occurs** (small pink blanchable rash - morbilliform, nagayama spots (red papules on soft palate and base of uvula))
* dx: CBC, UA, blood cx, CSF exam, roseola IgM
* tx: ibuprofen, fluids
* complications: febril seizures
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Ebstein-Barr dz
* caused by epstein-barr virus (rarely CMV), adolescents, college students, or military recruit
* caused by human herpes virus 4
* transmisison: saliva, 90% adults infected previously are carriers, lifelong immunity w/ 1 infxn
* sxs: fever, LAD, pharyngitis → fever resolves in 2 wks, sore throat, malaise, myalgias, weakness
* signs: LAD, posterior cervical, tonsillar, enlarged, painful, tender; pharyngeal erythema and/or exudate, splenomegaly, maculopapular rash, hepatomeg, palatal petechiae and periorbital edema
* dx: monospot, WBC count with diff, transaminitis, EBV specific Ab, peripheral smear shows lymphocytic leukocytoisis with large, atypical lymphocytes
* tx: supportive, short course steroids, avoid sports 3-4wks (SPLENIC RUPTURE)
* complicaitons: hep, meningoencephalitis, Guillain Barre, splenic rupture, thrombocytopenia, URTI
* DONT GIVE AMOX or AMP → can cause maculopap rash
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Fifth disease: erythema infectiosum
* slapped cheek syndrome
* parvovirus B19, 4-14d incubation
* transmission: aerosolized resp droplets, mother to fetus
* sxs: mild URI, HA, pharyngitis, itching, coryza, abd pain, arthralgias, low fever, 1wk later **slapped cheek (nasal perioral, and periorbital sparing)**, **lacy reticular rash** on prox extrems and trunk, palms and soles spared
* complications: arthritis, anemia, fetal hydrops
* clinical dx
* tx: ibuprofen, fluids
* **NOT INFECTIOUS when rash occurs, may attend school or childcare** (only infxous in mild URI phase (2-3d))
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Mumps parotitis
* Develops in 70-90% sxatic infxns w/in 24hrs of prodromal sx onset but can begin as long as a week after
* First most common complication/manifestation of mumps
* MCC: paramyxovirus, but also caused by influenza, parainfluenza, coxsackie, echovirus, HIV
* MC: children \<15
* transmission: airborne droplets
* sxs: lo fever, malaise, myalgia, arthralgias, HA, anorexia, acute onset unilat or bilat swelling of parotid or salivary glands lasting \>2d, tenderness and obliteration of space between earlobe and angle of mandible, earache and difficulty swallowing, eating, or talking
* signs: gland is tense, painful, erythema and warmth absent, no pus expressed from stensen duct
* dx: clinical, CT
* tx: supportive (self-limiting)
* children shouldnt return to school for 9 days after onset of swelling
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HPV
* etiology: MC - condylomata acuminatum
* Low-risk types: 6, 11
* anogenital warts - most common viral STD in US
* Causes nearly 100% of cervical cancers - most significant RF for cervical CA
* sxs and signs: most asymptomatic
* flesh-colored papillary exophytic lesions on genitalia
* dx: RPR/VDRL - r/o syphilis
* HIV, HPV viral typing not recommended daily
* Shave or punch bx confirms - hyperplastic prickle cells, koilocytotic or vacuolated squamous epithelial cells in clumps on pap (cervical warts)
* tx: most resolve spontaneously
* podophyllin or trichloroacetic acid
* surgery (cryotherapy, excision, electrocautery, intralesional interferon
* guarasil
* 6, 11 = warts
* 16, 18 = cervical CA
* condoms reduce transmission of warts
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HIV
* women infected younger than men, 76% men (exposed via MSM, IVDU, heterosexual contact, MSM + IVDU)
* transmission: blood-blood
* RF: sex w/ infected person, IV exposure to infected blood by transfusion or needle sharing, perinatal exposure
* sxs: asx (mean 10y); primary HIV infxn → fever, night sweats, wt loss, skin lesions, pharyngitis, swollen lymph nodes → lasts days-weeks)
* signs: hair leukoplakia, dissem kaposi sarcoma, cutaneous bacillary angiomatosis, gen LAD
* dx: **HIV ELISA, western blot (confirmatory), HIV rapid Ab test,** CBC (anem, neutropen, thrombocytopen), **absolute CD4** (monitor q3-6mos), CD4 %, viral load, CXR, blood cx if fever, crytococcal Ag, sinus CT or XR
* tx: start tx regardless of CD4 and perform resistance testing prior to ART initiation; primary goal is complete suppression of replication; combo tx w/ at least 3 meds
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AIDS
* coccidioidomycosis, enceph, histoplasmosis, isosporiasis with D \>1mo, kaposi, lymphoma of brain, non-hodgkin lymphoma of B cell, MAC, extrapulm TB, salmonella septicemia, HIV wasting syndrome, pulm TB, recurrent PNA, invasive cervical CA
* dx: HIV serology +, CD4 count \<200cells or \<14%
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lyme disease
* northeastern (main-maryland), midwest, west coast; incubation = 3-32d
* transmission: **ticks,** mice, **deer;** caused by **Borrelia burgdorferi**
* stage 1: **erythema chronicum migrans (hallmark)** → large, painless, well-demarcated target shaped lesion on **trunk,** thigh, groin, axilla
* stage 2: disseminated, **flu like sxs (**HA, stiff neck, fever/chills, fatigue, malaise, myalgias); after a few weeks → meningitis, encephalitis, cranial neruitis, peripheral radiculoneruopathy, **bell palsy**; within wks to mos → **AV block,** pericarditis, **carditis**
* stage 3: late, persistent; **arthritis** large jnts, chronic CNS dz, mild enceph, transverse myelitis, axonal polyneuropathy, acrodermatitis chronica atrophicans (reddish-purple plaques and nodules on extensor surfaces of legs)
* clinical dx: **ELISA** in 1st mo, **western blot to confirm**
* tx: early disease, localized → 10d abx; if beyond skin, **PO doxy x21d** (amox and ceguroxime are alternatives)
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Malaria
* Anopheles mosquito - bite leads to sporozoites invading hepatocytes where they mature into schizonts. Schizonts invade red blood cells and cause rupture
* sxs: shaking chills (cold stage), fever (hot stage), diaphoresis (sweating stage)
* infection is usually with P. falciparum.
* dx: blood films with Giemsa or Wright stain - looking for infected blood cells
* Abs appear 8-10d later which is too late for dx benefit
* Abs persist for 10y which makes it difficult to
* tx: chloroquine is DOC for **both prophylaxis and tx**
* **It is SAFE in pregnancy**
* can also treat with quinine, quinidine, or add doxy, clinda, or tetra to chloroquine
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campylobacter jejuni
* from undercooked poultry, onset 2-5d
* sxs: N/V, purulent, bloody, cramping diarrhea, fever
* tx: supportive, but dz duration can be shortened with azithromycin or ciprofloxacin
