JH IM Board Review - Infectious Disease III

Question 1

Urogenital ulcer disease - 5 main ulcerative diseases:

Answer 1

1. Genital herpes (HSV-2>HSV-1).
2. Syphilitic chancre (T.pallidum)
3. Chancroid (H.ducreyi).
4. Donovanosis or granuloma inguinale (Klebsiella granulomatis).
5. Lymphogranuloma venereum (C.trachomatis serovar L1, L2, L3).

Question 2

Genital herpes - Clinical presentation:

Answer 2

1. Cluster of vesicles on erythematous base.
2. PAINFUL and pruritic.
3. Dysuria.
4. LAN.

Question 3

Genital herpes - Dx:

Answer 3

1. Tzanck prep, multinucleated giant cells (low se).
2. Viral culture (70% se).
3. PCR.
4. Glycoprotein G-based serologies.

Question 4

Genital herpes - Tx:

Answer 4

1. Acyclovir.
2. Famciclovir.
3. Valacyclovir.

Question 5

Syphilitic chancre - Clinical presentation:

Answer 5

1. Single, PAINLESS ulcer at the site of inoculation.
2. Clean base and raised, firm border.
3. PAINLESS LAN.

Question 6

Syphilitic chancre - Dx:

Answer 6

1. Darkfield examination.
2. Serology ==> Nontreponemal (RPR, VDRL).
3. Treponemal (FTA-ABS, MHA-TP, TP-PA, EIAs).

Question 7

Syphilitic chancre - Tx:

Answer 7

PCN.

Question 8

Chancroid - CP:

Answer 8

1. PAINFUL ulcer.
2. TENDER inguinal LAN.
3. Occurs in outbreaks.

Question 9

Chancroid - Dx:

Answer 9

1. CLINICAL.

2. Culture available but NOT widely used.

Question 10

Chancroid - Tx:

Answer 10

Azithro OR ceftriaxone OR cipro.

Question 11

Donovanosis or granuloma inguinale - CP:

Answer 11

1. Painless papule or nodule erodes into beefy-red granulomatous ulcer with rolled edges.
2. ENDEMIC in Far East Asia and Southern Africa.

Question 12

Donovanosis or granuloma inguinale - Dx:

Answer 12

Donovan bodies on biopsy.

Question 13

Donovanosis or granuloma inguinale - Tx:

Answer 13

Doxycycline or TMP-SMX ==> Tx AT LEAST 3 WEEKS.

Question 14

Lymphogranuloma venereum - CP:

Answer 14

1. PAINLESS genital ulcer.
2. PAINFUL inguinal LAN (with GROOVE SIGN).
3. Proctitis.

Question 15

Lymphogranuloma venereum - Dx:

Answer 15

1. CLINICAL syndrome.
2. Serology.
3. Complement fixation titers of at least 1:64.
4. Nucleic acid amplification tests.

Question 16

Lymphogranuloma venereum - Tx:

Answer 16

Doxycycline for 3 WEEKS.

Question 17

Genital herpes - Predominant cause among young people?

Answer 17

NOW the HSV-1.

Question 18

Seroprevalence of HSV-2 and HSV-1 in adults in the United States is …?

Answer 18

17% and 60% respectively.

Question 19

Up to …% of cases of genital herpes are asymptomatic and unrecognized.

Answer 19

70%.

Question 20

Genital herpes - Incubation period:

Answer 20

2-7 days.

Question 21

Genital herpes - Viral shedding occurs EVEN …?

Answer 21

IN THE ABSENCE OF LESIONS.

==> The amount of shedding declines over time.

Question 22

Prior infection with HSV-1 does not …?

Answer 22

PROTECT against incident HSV-2 infection.

==> Although incident HSV-1 in persons infected with HSV-2 is RARE.

Question 23

Genital herpes - PRIMARY GENITAL HERPES LESIONS:

Answer 23

Primary genital herpes lesions are classically ==> PAINFUL.

==> Multiple, grouped on erythematous base.

==> Beginning as macules and papules, evolving to vesicles and ulcers.

Question 24

Genital herpes - Local symptoms:

Answer 24

1. Pain.
2. Itching.
3. Dysuria.
4. Tender inguinal adenopathy.

Question 25

Genital herpes - Primary lesions may accompanied by:

Answer 25

1. Fever. 2. Headache. 3. Malaise. 4. Myalgias.

Question 26

Recurrent disease is less or more severe than primary?

Answer 26

LESS severe. ==> May be severe in immunocompromised.

Question 27

Genital herpes - Extragenital complications:

Answer 27

1. CNS involvement (Meningitis, encephalitis). | 2. Urinary retention.

Question 28

Genital herpes - Dx - Preferred method when NO active lesions are present?

Answer 28

SEROLOGY.

Question 29

Genital herpes - Serology may be neg in ...?

Answer 29

PRIMARY INFECTION.

Question 30

Genital herpes - Serologic false pos may occur:

Answer 30

If the pretest probability of having HSV is LOW.

Question 31

IgM serology for genital herpes?

Answer 31

Neither sensitive nor specific for primary infections. ==> There are no universal recommendations.

Question 32

Presence of IgG antibodies to HSV-2?

Answer 32

Diagnostic of genital infection. (Anti-HSV-1 may reflect either orolabial or genital infection).

Question 33

Genital herpes - Tx:

Answer 33

Systemic antiviral drugs (eg acyclovir, famciclovir, or valacyclovir) can be used as episodic or suppressive therapy. ==> They are ALL equally efficacious.

Question 34

Genital herpes - Episodic Tx does NOT ...?

Answer 34

Eradicate the virus OR reduce frequency of recurrences.

Question 35

Genital herpes - DAILY suppressive Tx:

Answer 35

For patients with 6 or more recurrences per year can reduce the frequency by up to 80%. ==> Also prevents recurrences in 25-30% of pts; freq of episodes may diminish over time.

Question 36

Genital herpes - Suppressive Tx does NOT ...?

Answer 36

ELIMINATE SUBCLINICAL VIRAL SHEDDING.

Question 37

Once-daily valacyclovir in the infected partner, in addition to consistent condom use, may help decrease transmission to an uninfected partner by approx. ...%.

Answer 37

55%.

Question 38

Primary syph - Chancre:

Answer 38

1. Quickly erodes and becomes indurated with a CLEAN base + raised, firm borders. 2. Atypical lesions occur in 60% of cases. 3. Primary lesions may be accompanied by regional painless bilateral adenopathy.

Question 39

Secondary or disseminated syph:

Answer 39

1. Begins 2-8 weeks after appearance of chancre. 2. May be associated with flu-like symptoms, generalized LAN, and temporary alopecia. 3. Characteristic rash may be macular, maculopapular, papular, or pustular ==> May involve the whole body OR palms/soles.

Question 40

Secondary or disseminated syph - Condylomata lata:

Answer 40

1. Appear as raised, painless, gray-white lesions. 2. Highly infectious. 3. Develop in intertriginous areas and on mucous membranes.

Question 41

Latent syph:

Answer 41

1. Definition = Lack of clinical manifestations with positive serology. 2. Latent syph acquired within the preceding year is EARLY LATENT SYPH. 3. LATE latent syph implies acquisition more than 1 yr before Dx.

Question 42

Tertiary syph:

Answer 42

1. Implies late manifestations of syph. 2. Gummatous syph results in skeletal, mucosal, ocular, and visceral lesions. 3. Average time of onset is 4-12yrs after infection. 4. Cardiovascular syph causes endarteritis of the aortic vasa vasorum ==> Average time of onset is 15yr (Aortic aneurysm, or Aortic valve insufficiency).

Question 43

Neurosyph:

Answer 43

Can occur AT ANY SYPHILIS STAGE (ie may be an early manifestation or a tertiary one).

Question 44

Neurosyph - Early:

Answer 44

MENINGOVASCULAR syph. ==> During the 1st yr after infection as meningitis (often, a basilar meningitis involving cranial nerves) particularly among HIV-infected persons.

Question 45

Neurosyph - Late:

Answer 45

Occurring many years after primary infection: 1. May be meningovascular (presenting as stroke). 2. Parenchymatous (manifesting as tabes dorsalis, electrical pains shooting down the legs). 3. General paresis (personality changes, hallucinations).

Question 46

Auditory manifestations in syph:

Answer 46

May also occur during any stage of syph.

Question 47

Ophthalmic syph:

Answer 47

May occur at ANY STAGE + includes: 1. Iritis. 2. Uveitis. 3. Neuroretinitis. 4. Optic neuritis.

Question 48

Syph - Dx:

Answer 48

Darkfield exam of genital lesions + direct fluorescent antibody tests of lesion exudates or tissue ==> DEFINITIVE EVIDENCE.

Question 49

Syph - Dx - 2 types of serologic tests are used for presumptive Dx:

Answer 49

1. Non treponemal tests (RPR + VDRL). | 2. Treponemal tests (FTA-ABS, TP-PA, EIA and CIA).

Question 50

Nontreponemal tests:

Answer 50

1. Often used as screening tests. 2. Because of LOW SP, must be confirmed by a treponemal test. 3. May revert to NEGATIVE, EVEN IN THE ABSENCE OF THERAPY.

Question 51

Syph - Dx - Treponemal tests:

Answer 51

1. CIA or EIA now being used as screening tests instead of non treponemal tests. 2. A positive test should reflex to a nontreponemal test; if the nontreponemal test is negative, a 2nd different treponemal test (usually the TP-PA) should be done to confirm the first positive treponemal test.

Question 52

Syph - Dx - Serologic tests may be NEGATIVE in approx. ...?

Answer 52

1. 30% of primary syph cases. 2. 100% sens in secondary syph. ==> A negative RPR essentially rules out the diagnosis of SECONDARY SYPH in the absence of a prozone reaction.

Question 53

A confirmed positive treponemal test and a NEGATIVE non treponemal test may be seen with:

Answer 53

1. Old treated syph. 2. Old UNtreated syph. 3. Prozone reaction. 4. Early syph ==> Where the treponemal tests became reaction before the non treponemal ones.

Question 54

Neurosyph - Dx:

Answer 54

1. Combination of serologic tests. 2. CSF abnormalities (greater than 5 WBC/mm^3 +/- abnormal protein). 3. Reactive CSF VDRL.

Question 55

CSF VDRL:

Answer 55

Highly specific but insensitive (50%). ==> Negative study does NOT exclude the diagnosis.

Question 56

CSF FTA-ABS:

Answer 56

Less specific but VERY SENSITIVE. ==> Negative study probably excludes neurosyph if the pretest probability is moderate to low.

Question 57

CSF exam is indicated in cases of ...?

Answer 57

1. NEUROLOGIC or OPHTHALMOLOGIC abnormalities. 2. Evidence of active tertiary syph. 3. Evidence of serologic treatment failure.

Question 58

Asymptomatic neurosyph?

Answer 58

HIV infection with a CD4 count less than or equal to 350 cells/mm3, or an RPR greater than or equal to 1/32, is associated with incr. risk of ASYMPTOMATIC neurosyph. ==> CSF exam may be considered.

Question 59

Syph - Tx:

Answer 59

Parenteral PCN G is the drug of choice. ==> Only accepted therapy with documented efficacy for neurosyph + syph during pregnancy is DESENSITIZATION followed by PCN therapy.

Question 60

The Jarisch-Herxheimer reaction:

Answer 60

Acute febrile reaction associated with headache and myalgias. ==> Thought to be activation of inflammatory cascade associated with lysis of spirochetes. ==> Can occur within the first 24h after Tx (particularly in early syph). ==> Tx = supportive.

Question 61

Syph - Tx - Response to Tx is monitored by ...?

Answer 61

Change in titer of a non treponemal test (eg RPR) 12 (for primary, secondary, and early latent stages of syph) to 24 (for late syph) MONTHS after therapy.

Question 62

Syph - Tx - Response to Tx:

Answer 62

A 4-fold (or 2-dilution) decrease in RPR or VDRL tite (eg from 1:64 to 1:16) indicates CURE. ==> No change or increase in titer indicates failure of therapy. ==> Documentation of a titer response followed by a 4-fold increase indicates reinfection.

Question 63

Treponemal test (eg FTA-ABS) titers correlate with disease activity?

Answer 63

DO NOT correlate with disease activity or therapy and usually remain positive for life.

Question 64

In neurosyph - Quantitative non treponemal serologic tests should be repeated at ...?

Answer 64

6-12-24 months. ==> CSF exam should be repeated 6 months after Tx.

Question 65

Recommended Tx regimens for syph - Primary, secondary, and early latent syph:

Answer 65

Benzathine PCN G - 2.4 million units IM in a single dose. ==> if PCN allergic - Doxy 100mg PO bid for 2 weeks, except pregnant patients, who should be desensitized and treated with PCN.

Question 66

Recommended Tx regimens for syph - Late latent syph, syph of unknown duration, or tertiary syph (gummatous and CVS syph):

Answer 66

Benzathine PCN G: 7.2 million units, administered as 3 doses of 2.4 million units IM each at 1-week intervals.

Question 67

Recommended Tx regimens for syph - Neurosyph:

Answer 67

Aqueous crystalline PCN G: 18-24 million units per day for 10-14 days.

Question 68

Urethritis and cervicitis - Basic info:

Answer 68

Discharge of mucopurulent or purulent material. ==> Principal etiologic agents are: 1. N.gonorrhoeae. 2. C.trachomatis. 3. M.genitalium. 4. T.vaginalis.

Question 69

Gonorrhea - Can involve:

Answer 69

1. Genital tract. 2. Rectum. 3. Oropharynx. or be DISSEMINATED.

Question 70

Gonorrhea - Incubation period is ...?

Answer 70

3-7 DAYS.

Question 71

Gonorrhea - Symptoms manifest within:

Answer 71

10-14 days after exposure.

Question 72

Disseminated gonococcal infection (DGI) occurs in ...?

Answer 72

1-3% of cases.

Question 73

Gonorrhea in men:

Answer 73

1. Symptomatic in approx. 50%, with purulent urethral discharge or dysuria. 2. Causes 30% of epididymitis cases in young men.

Question 74

Gonorrhea in women:

Answer 74

Women with cervicitis may have vaginal discharge or bleeding. ==> 50% may be asymptomatic. ==> Other syndromes in women: Urethritis, Bartholin gland abscesses, PID.

Question 75

DGI may present as triad of:

Answer 75

1. Dermatitis with petechial or pustular acral skin lesions. 2. Tenosynovitis. 3. Asymmetrical migratory polyarthralgias, or as purulent arthritis without skin lesions. ==> Perihepatitis, endocarditis, meningitis, and osteomyelitis occur less commonly.

Question 76

Gonorrhea - Dx:

Answer 76

NAA tests are the tests of choice for genital and extragenital sites. ==> Extragenital testing is NOT FDA cleared but is routinely performed.

Question 77

Gonorrhea - Dx - Gram stain?

Answer 77

May show gram(-) intracellular diplococci. ==> Low sens in asymptomatic persosn and women.

Question 78

Dx of gonorrhea - Culture:

Answer 78

Thayer-Martin modified medium, Se approx. 85-90%.

Question 79

Gonorrhea - Retest?

Answer 79

Retest all patients 3 MONTHS after completing Tx because REINFECTION rates are HIGH.

Question 80

Gonorrhea - Tx:

Answer 80

Ceftiaxone 250mg IM x 1 PLUS 1g or oral azithromycin is first-line therapy. ==> ORAL cephalosporins are approved alternate agents but they may have lower activity against pharyngeal gonorrhea.

Question 81

Patients with pharyngeal gonorrhea require a ...?

Answer 81

Test-of-cure 2 WEEKS after Tx to verify response if treated with oral cephalosporins.

Question 82

Gonorrhea Tx - Monotherapy?

Answer 82

NOT recommended due to incr. resistance.

Question 83

Azithro for gonorrhea?

Answer 83

Azithro monotherapy (2g) effective for BOTH gonorrheal infections + Chlamydial infections, but use is limited by GI distress and emerging resistance.

Question 84

DGI - Tx:

Answer 84

Should be hospitalized and treated parenterally with ceftiaxone and a single 2g oral dose of azithro. ==> May be discharged 24hours after clinical response to complete a 7-day course of ORAL cephalosporin.

Question 85

C.trachomatis - Basic info:

Answer 85

1. D-K serotypes are the MC bacterial STD in the USA (C.trachomatis L1-L3 serotypes cause lymphogranuloma venereum (LGV)). 2. Single biggest risk factor for D through K serotypes is YOUNG AGE.

Question 86

C.trachomatis - CP in women:

Answer 86

May present as cervicitis or urethritis. ==> May also have vaginal discharge + Lower abdominal pain + Dysuria. ==> Most cases are asymptomatic.

Question 87

C.trachomatis - CP in men:

Answer 87

May develop urethritis with dysuria and mucopurulent discharge ==> Most are asymptomatic.

Question 88

C.trachomatis - Epididymitis:

Answer 88

Manifests as unilateral testicular pain and tenderness, edema, and/or hydrocele.

Question 89

C.trachomatis - Dx:

Answer 89

Because asymptomatic infection is MC, annual screening of all sexually active women aged 25yrs or younger + older at-risk women is recommended to prevent sequelae.

Question 90

Untreated chlamydial infection in women is a major cause of ...?

Answer 90

1. PID. 2. Ectopic pregnancy. 3. Infertility.

Question 91

C.trachomatis - In men, untreated infection may result in ...?

Answer 91

Prostatitis.

Question 92

C.trachomatis - Dx method of choice is:

Answer 92

NAA test.

Question 93

C.trachomatis - Tx:

Answer 93

Azithromycin or doxycycline are 1st-line agents. ==> Doxycycline is preferred for rectal infections.

Question 94

C.trachomatis - Tx - Alternatives:

Answer 94

FQ and erythromycin.

Question 95

C.trachomatis - Tx - In pregnancy:

Answer 95

Doxy and FQ ==> CONTRA.

Question 96

C.trachomatis - Tx - Test for cure:

Answer 96

Recommended after Tx with amoxicillin or erythromycin because these regimens may NOT be as efficacious, and side effects may discourage compliance.

Question 97

C.trachomatis - Reinfection:

Answer 97

COMMON - Increases PID risk - Repeat testing is warranted 3 months after therapy.

Question 98

C.trachomatis - Sexual partners in the preceding ...?

Answer 98

60 DAYS (or the last sexual partner) should be referred for evaluation and Tx.

Question 99

Mycoplasma genitalium:

Answer 99

Causes acute and chronic urethritis. ==> Moderate to strong association with cervicitis and PID.

Question 100

Mycoplasma genitalium is the MCC of ...?

Answer 100

Persistent urethritis in men.

Question 101

M.genitalium - Dx:

Answer 101

NAA tests are sensitive but NONE ARE FDA cleared.

Question 102

M.genitalium - Tx:

Answer 102

1g azithro orally is effective ==> BUT associated with emergence of resistance. ==> Longer azithro courses are probably better.

Question 103

M.genitalium - If resistant to azithro?

Answer 103

Moxiflox 500mg orally for 7-14 days.