Lecture 10 (ID) Flashcards
1
Q
Stats
* ID accounted for up to how many visits to ED for children? Adults?
A
2
Q
A
3
Q
A
4
Q
A
5
Q
Skin and Soft Tissue Infections (SSTI)
* Results form what?
* What are the different types?
A
Results from microbial invasion of the skin and surrounding structures.
* Simple (uncomplicated): cellulitis or erysipelas
* Complicated (necrotizing)
* Suppurative (Purulent) vs nonsuppurative
6
Q
Skin and Soft Tissue Infections (SSTI)
* MC pathogens? (3)
* Oral antibiotics to cover MRSA?(3)
A
- Most common pathogen: MSSA/MRSA (75%) and beta hemolytic strep
- Bactrium (Causes SJS), Clinda (Not good for older ppl dt dirreha), Doxy (photosen, Pt cannot have GERD or landscaper)
7
Q
Cellulitis
* What are the sxs?
* Will usually involve what?
A
- Hot to the touch , tender, erythematous, lymphangitis, lymphadenopathy. Inflammation of SQ tissue.
- Will usually involve papules or pustules and is not well demarcated.
8
Q
What is this?
A
Lymphangitis
* Must Hospitalize
9
Q
What is this?
A
ERYSIPELAS-> Strep + type
10
Q
Abscess
* What is it?
* may be associated with what?
* usually requires what?
* What is for most?
A
- Collection of pus in subdermal space
- May be associated with cellulitis but does not have to
- Usually requires I&D with or without packing
- Oral ABX therapy for most
11
Q
Complicated cases of abcess will require parenteral ABX.
* What are reasons to switch? (4)
A
- Systemic symptoms (SIRS criteria)
- Rapid progression
- Failure of outpatient therapy >48hrs
- Proximity to indwelling device (vascular graft/artificial joint)
12
Q
Abscess
* Simple abscesses should be what?
* They are not healed with what?
* Small uncomplicated abscesses without cellulitis (<2cm) usually txt?
A
- Simple abscesses should be incised and drained.
- They are not healed with only antibiotics.
- Small uncomplicated abscesses without cellulitis (<2cm) usually do not require antibiotics
13
Q
What do you do for this?
Have an increased risk of?
A
- bactrium, penicllin+bactrim, Keflex+bactrim
- Refer to OR
- Increase risk with chron’s disease
14
Q
- Deep abscesses should be what?
- When you evaluate anal, perirectal, rectal abscesses, be confident that there is no what?
A
- Deep abscesses should be drained in the OR and the patient should be admitted for parenteral antibiotics.
- When you evaluate anal, perirectal, rectal abscesses, be confident that there is no deep-space infection (do a rectal exam, palpate for induration, fullness, tenderness). If the abscess is deep, it is NOT an out-patient or ERprocedure
15
Q
Staphylococcal Toxic Shock Syndrome (TSS)
* What organism?
* Happens in who?
* Where do have enterance?(4)
A
- Ubiquitous organism: S. aureus
- 30-50 % of healthy adults and children
- Anterior nares, skin, vagina, and rectum
16
Q
Staphylococcal Toxic Shock Syndrome (TSS)
* What causes disease?
* What does super antigens cause?
A
- Toxic shock syndrome toxin-1 (TSST-1) and Staphylococcal enterotoxin B (A,C,D,E,H less)
- Super antigens: cause an exaggerated, dysregulated hyperimmune cytokine response.
17
Q
Staphylococcal Toxic Shock Syndrome (TSS)
* usually not what?
* _ infection
A
- Usually not purulent, but desquamates
- Multisystemic infection
18
Q
Staph Toxic Shock Syndrome (TSS)
* 50% of what cases?
* Increase incidence with what?
* Can occur in children with what?
A
- 50% non-menstrual cases
- Increased incidence due to tampon (vaginal or nasal) use: higher absorbencies, used continuously for more days, and kept in longer
- Can occur in children with nonsurgical skin lesions
19
Q
Staph Toxic Shock Syndrome (TSS)
* What precedes the physcial findings?
* What are risk factors?
A
- Pain usually precedes the physical findings
- HIV, diabetes, cancer, ethanol abuse, and other chronic diseases
20
Q
What is CDC difinition of TSS?
A
- Fever: temperature greater than or equal to 102.0°F ( 38.9°C) AND
- Rash: diffuse macular erythroderma AND
- Hypotension: systolic blood pressure ≤90 mm Hg for adults or less than 5th percentile by age less than16 years; orthostatic drop in diastolic blood pressure ≥15 mm Hg from lying to sitting, orthostatic syncope, or orthostatic dizziness AND
- Desquamation: 3-7 days after onset of illness, particularly on the palms and soles
ALL NEEDS TO BE THERE
Can have only some, and still treat-> should not wait for txt
21
Q
Staph TSS- DDX
* Streptococcal TSS -
* Scarlet fever-
* Staph scalded skin syndrome-
* Meningococcal:
* Rocky Mountain Spotted Fever (RMSF):
A
- Streptococcal TSS - identical or pain, necrotizing fasciitis
- Scarlet fever- strawberry tongue, “sand paper rash”, pharyngitis
- Staph scalded skin syndrome- bullae, sheet like desquamation acutely, more common in peds
- Meningococcal: petechiae/ purpura
- Rocky Mountain Spotted Fever (RMSF): rash is petechial, begins on extremities first, and occurs~ three days after fever begins
22
Q
Staph TSS DDX
* Kawasaki disease-
* Dengue fever-
* Leptospirosis-
* Toxic epidermal necrolysis/ Stevens-Johnson syndrome-
* _ Syndrome
* _ exanthem
A
- Kawasaki disease- more common in children
- Dengue fever- endemic area, mosquito exposure
- Leptospirosis- uncommon, work with soil and animals, no rash
- Toxic epidermal necrolysis/ Stevens-Johnson syndrome- more diffuse, more mucus membrane involvement, history of medication use
- Reyes Syndrome
- Viral exanthem
23
Q
What is this?
A
24
Q
What is this?
A
Sunburn type rash that blanches; fades in 3 days with full-thickness desquamation especially palms and soles
25
Staph Toxic Shock Syndrome evaluation
* What do you need to order? (8)
26
Diagnosis/Treatment of Staph TSS
* What is not necessary but useful?
* Exploration of what?
* Admit?
* Call who?
* Isolation of bacteria not necessary, but useful
* Exploration of vagina, wounds
* Admit ICU and treat for sepsis
* Call ID
27
Diagnosis/Treatment of Staph TSS
* What is the aggressive management of shock?
* 10-20 liters/ day
* Anasarca possible (diffuse edema due to capillary leakage)-> this is due to the fluids so might need loop
* Vasopressors if needed: norepinephrine DOC
* Central venous monitoring
28
Treatment of Staph TSS
* What is the txt for empirical txt?
* What is the DOC if known culture?
## Footnote
4th gen-> nursing home+DM to cover pseduo
29
# Streptococcus TSS
30
Streptococcus TSS
* MC organism?
* Emerging organism?
* Bacteria releases what?
* What are the portals of entry?
* Etiology: S. pyogenes= Group A Streptococcus (GAS)
* Emerging: S. suis
* Bacteria releases superantigens
* Skin, vagina, throat entry portals
31
Streptococcus TSS
* Isolation of what?
* Presents with what?
* No portal site found in 45% of cases
* Isolation of GAS (Group A Strep) from normally sterile site
* Presents with usually Abrupt Pain
## Footnote
* Staph – fever and desquamation
* Strep – more of necrotizing fasciitis (mc from surgery and natural vag birth)
32
What is the Criteria for Strep TSS CDC?
33
What are the Strep TSS (GAS) risk factors? (6)
* All ages, majority healthy
* Surgery
* Use of NSAIDs (marker of severe trauma or masking of symptoms)
* Recent Varicella infection
* Can cause symptoms indistinguishable from Staphylococcus TSS
* Immunocompromised
34
Strep TSS with Necrotizing Fasciitis
* What is present?
* Widespread what?
* What is larger?
* What happens along fascial planes?
* Pain
* Widespread necrosis
* Underlying area much larger than skin
* Mushy, devitalized, necrotic tissue along fascial planes
35
Strep TSS Treatment
* What is the txt?
* Initial antibiotics: same as for Staph TSS/ sepsis
* Early surgical intervention with debridement
* ICU
* IV ABX
## Footnote
* vancomycin and [ceftriaxone OR piperacillin/ tazobactam (Zosyn®) OR meropenem (Merrem®)or fluoroquinolone for pseudomonas]
* For MRSA patients, vancomycin + clindamycin OR Linezolid *(Zyvox®) alone
36
Explain the difference?
37
Erythema multiforme
* What are these?
* What is the cause?
* You may see this rash in who?
* These are typical target lesions with a bulls-eye appearance.
* There are a variety of causes including infection, malignancy and drugs.
* You may see this rash in pediatric viral illnesses.
38
“Staph” Scalded Skin Syndrome
* What age?
* How does it exist like a continuum?
* Children less than 5 years old
* Exists on a continuum – they may have just a few bullous lesions or they can have generalized exfoliation of all their skin
## Footnote
The mortality is about 5%
39
Staph Scalded Skin Syndrome
* Treat staph with that?
* Skin is treated as what?
* What should you do if this is drug induced?
* Treat Staph with penicillinase-resistant penicillin.
* Skin is treated as though it is a burn
* If this is "drug induced," the drug should be discontinued, and steroids may be helpful and antibiotics would not be given.
40
Nikolsky’s Sign
* What are common causes?
* Allergic reaction (Toxic epidermal necrolysis)
* Autoimmune condition (Pemphigus vulgaris)
* Bacterial infection ( Scalded skin syndrome)
## Footnote
Separating tissue with pressure
41
Steven-Johnson Syndrome/Toxic Epidermal Necrolysis
* Both are typically triggered by what?
* Not separte, but what? Explain?
Both are typically triggered by medication reactions
Not separate -> both are continuum
* SJS is less severe (10% mortality) and less than 10% of skin involved
* TEN (50% mortality) – Lyell Syndrome - >30% of skin involvement
42
Steven-Johnson Syndrome/Toxic Epidermal Necrolysis
* Starts as what? Then what happens/
* Affects who?
* Pathophysiolgy similar to what?
* Starts as fever and flu-like and then forms erosions (spread from face down involving mucus membranes/eyes/genitalia, but not always in this distribution)
* Affects immunocompromised (HIV/SLE) and those with genetic mutation of HLA-B gene
* Pathophysiology similar to a burn – no protective barrier, loss of fluids, infection possibility -> so treatment is essentially the same
43
SJS/TEN
* What are drugs that can cause this?(4)
## Footnote
Have walking pneum then have oral, genital lesions-> SJS
44
What is this?
45
SJS/TEN MANAGEMENT
* Withdrawl what?
* Admit to where?
* manage via what?
* What do you give?
* Debride what?
* tx what?
46
What are the 3 Types of Necrotizing Fasciitis?
47
Necrotizing Fasciitis
* Widespread what?
* What is the common organism? What is seen on x-ray?
* Usually direct what?
48
Necrotizing Fasciitis
* What are sxs?
* Brawny edema, crepitance, brownish discoloration, malodorous serosanguinous discharge; bullae; air gangrene
* Fever, tachycardia, multiple laboratory & metabolic abnormalities
49
What is going on here?
Left upper extremity necrotizing fasciitis in an IVDA. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.
50
What is going on here?
Left lower extremity in a 56-year-old patient with alcoholism found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis.
51
Management of necrotizing fasciitis
* _
* What do you need to update?
* Abx?
* Surgical what?
* what type of situation?
52
West Nile (WN) Virus
* What is it caused by?
* What type of vector?
* Japanese encephalitis virus antigenic complex, member of the family Flaviviridae
* Mosquito vector with WN Virus incidence
53
West Nile (WN) Virus
* What are the sxs?
* Flu- like syndrome: headache, body aches, fever
* Meningitis, flaccid paralysis, muscle weakness
* Rash in 25-30% of patients-> Indicative of less severe disease
54
What is West Nile (WN) Virus Differential Diagnosis ?
* Dengue fever in endemic areas
* St Louis Encephalitis->Less common cause of illness
55
West Nile (WN) Virus Diagnosis
* What do you get for dx?
* What does the CBC show?
* What do you get for neuro sxs?
* IgM for WN Virus in serum or spinal fluid->Can be negative first 3 days
* CBC with Diff: leukocyte counts mostly normal or elevated.
* Spinal tap: for neuro symptoms
56
West Nile (WN) Virus Diagnosis
* What does the spinal tap show?
* Pleocytosis (increased WBCs) and predominance of lymphocytes
* Normal or elevated protein
* Normal glucose
* Normal or elevated opening pressure
57
West Nile (WN) Virus Diagnosis
* What type of treatment?
* Admit for what?
* Supportive Treatment
* Admit if toxic or unsure/ neurologic symptoms
58
Can confirm dx with Tzank prep and viral culture. Acyclovir should be started within 72 hours. May shorten course and may mitigate against post-herpetic neuralgia.
59
Herpes Zoster
* What is it?
* Rash is usually what?
* Complicated by what?
* Pain may appear when?
* Often in who?
* Shingles-Reactivation of latent varicella virus
* rash is (usually) in dermatomal distribution
* complicated by post-herpetic neuralgia
* Pain may appear before the rash and last months after rash clears -> post herpetic neuralgia – tx gabapentin, pregablin
* Often immunocompromised: older, DM, HIV, stress, cancer
60
Herpes Zoster
* What sign can present?
* When and what do we do for disseminated disease?
* How do we dx it?
* Hutchinson Sign: lesion on tip of nose (SIGNALS EYE INVOLVEMENT AS WELL)
* Disseminated disease: immunocompromised→admit
* Diagnosis via Viral Culture
61
How do you txt herpes zoster?
Treatment: oral acyclovir 800 mg po 5x/day x 7 days (within 72hrs of onset) or IV and admit if immunocompromised
* Valacyclovir/Famcyclovir: dosed once or twice daily, depending on type
* May require ABX to prevent secondary infection
* Will also need steroids
62
Disseminated Herpes Zoster
* Does not follow what?
* What is the txt?
63
Infective Endocarditis
* Causes?
* What is the organism for IVDA? What can it cause?
64
Infective Endocarditis
* What happens to the heart?
* Valve leaflets destruction
* Walls of the heart cavities
* Tissue surrounding prosthetic heart valves
## Footnote
Reason why murmur shows up
65
Endocarditis
* What are the two types?
* What are the sxs?
* What can happen to the body?
* What is common in young patients?
## Footnote
*CVA, ARTERIAL EMBOLI IN EXTREMITIES
66
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What are the Sign and symptoms of Infective endocarditis?
69
Circulating Immune Complexes of infective FROM JANE
endo
* Petechiae
* Splinter hemorrhages
* Osler’s nodes
* Janeway lesions-septic emboli:
* _ _ in eye
70
Petechiae
* What is it?
71
What are these?
Osler Nodes & Janeway Lesions
72
What is this?
Splinter hemorrhage
73
What is this?
74
Endocarditis Treatment
* What is the initial management?
* What do you need to collect?
* What dx tests? (2)
* Admit and call who?
* Look for what?
* Initial Management: ABCs
* Blood cultures x 3 in 24 hours
* EKG and Echocardiogram
* Admit and call cardiology
* Look for distal emboli-> neck/back or lungs
75
Endocarditis Treatment
* What are the abx?
* Vancomycin, gentamicin and cephalosporin (4th gen) for empiric
* Vancomycin alone if MRSA likely
* Vancomycin DOC for suspected community or hospital-acquired ( G-) infections + gentamycin
* For all above and prosthetic valves: add Rifampin
76
Botulism
* What is it?
* What is going on with the spores?
* Irreversibly does what?
* What are the neurotoxins?
77
Botulism
* Bacterium will not grow in what?
* HOWEVER, Toxin is resistant to what?
* Toxin can be what?
* Common in what?
Bacterium will not grow in pH<4.6 and will not generate toxin in acidic foods
* HOWEVER, Toxin is resistant to pH degradation
* Can be ingested, inhaled, injected
* Usually low acid content food, green beans, asparagus, tomatoes
78
Botulism
* What are the 3 types of botulism?
* Infant botulism (most common) - <14 days due to umbilical stump exposure
* Adult enteric botulism
* Wound botulism
79
Botulism
* What type is most commonly ingested by humans? How? (4)
Type E most commonly ingested by humans
* Home canned foods
* Seafood
* Honey
* IVDA (black tar heroin)
80
Botulism
* What are the sxs?
* Early: Dry mouth, blurred vision, drooping eyelids, slurred speech, dysphagia, loss of pupillary reflexes, GI symptoms
* Late: Respiratory failure, paralysis
* No sensory disturbance or AMS, and usually no fever
* Incubation: 4hrs-8 days
81
Botulism
* how do you dx?
* What is the txt?
* What is key?
82
Tetanus
* What is the organism? What are the characterisitcs?
* What are the exotoxins? What does it cause?
* Clostridium tetani->Obligate Anaerobic, spore survives boiling temps
* Exotoxins: tetanolysin and tetanospasmin
* prevents release of inhibitory neurotransmitters: neuromuscular irritability and generalized spasms
* spreads to peripheral and CNS
83
Tetanus
* What makes it less sereve?
Less severe if previously vaccinated -> 2,4,6, 18 months then 5 yo-> every 10 years after that
84
Tetanus
* how can you get it?(4)
Wounds, surgical procedures, abortion, neonates (umbilical stump), IVDA
85
Tetanus
* What are the four types+sxs?
86
Generalized Tetanus
* What happens to jaw?
* What happens to mouth?
* What are some resp issues?
* Anutomonic?
87
Diagnosis of Tetanus
* What type of sx?
* What test can you do?
* _ dx
* Clinical symptoms
* Gag reflex test instead causes patient to bite tongue depressor
* Clinical Diagnosis
88
Tetanus
* What is the txt?
* ABC’s
* TIG
* Muscle Relaxants (benzodiazepines)
* ICU
89
Treatment of severe tetanus (5 steps)
90
91
Rabies
* What is the organism?
* Endemic in who? list them
* Bullet/rod shaped, single stranded –sense, unsegmented, enveloped RNA virus belonging to the Rhabdoviridae family.
* Endemic in many wild animals
* Major wildlife vectors: foxes, raccoons, skunks, coyotes, mongoose, bats, dogs, cats, sheep, horses
92
Rabies
* What vectors are very rarely rabid or never rabid?
* Targets CNS by means of what?
* Very rarely rabid or never rabid: squirrels, hamsters, guinea pigs, rabbits, gerbils, chipmunks, rats, mice, domesticated rabbits, small rodents
* Targets CNS by means of peripheral nervous system through inflammatory response-> encephalomyelitis
93
Rabies
* What are the sxs?
94
Rabies
* how do you dx it?
Based on known animal bite and high level of suspicion; dx of exclusion
* PCR testing in CSF, blood, saliva, tears, tissues bx.
95
Rabies
* how do you tx it?
Txt: Wound care- cleanse/irrigate (povidone, alcohol and soap solution <3hrs) followed by benzalkonium chloride or povidone-iodine
* Rabies Immune globulin ASAP along with rabies vaccine (4 in 14 d)
* Prophylactic measures for bats
96
97
Postexposure Prophylactic Therapy of rabies? (3)
* Vigorous cleaning of wound with soap
* Tetanus toxoid & antibiotics (Augmentin®) if they meet criteria
* Rabies vaccine and IVIG if they meet criteria
98
Human Bites
* Same txt applies to what?
* What is the organism?
* Present where?
* Same treatment applies to saliva exposures to wound (trauma to face and oral cavity, licking of the wounds).
* Eikenella corrodens – fastidious anaerobe
* Present in majority of human mouths
## Footnote
* See it frequently in the ER
99
Human Bites
* What is the DOC?
* Eikenella is inherently resistant to what?
* DOC – Augmentin – or any cephalosporin or tetracycline
* Eikenella is inherently resistant to clindamycin and penicillins are not effective
100
Stingray stings
* Typical for what?
* Remove what if present?
* Place extremity where and why?
* Cover for what?
101
Malaria
* Transmitted by what?
* _ sporozoites
* Reproduction?
* Transmitted by infected mosquito found in tropical and subtropical regions
* Plasmodium sporozoites
* Cyclic, complex reproduction inside liver, serum, RBCs
102
Malaria
* Cyclic what?
* What are sxs?
* Unlikely what?
* Cyclic chills and fever and sweating every 48-72 hours
* Fever, malaise, myalgia, headache, chills; may have chest pain, cough, abdominal pain, diarrhea
* Unlikely rash and lymphadenopathy
103
104
Make the Malaria Diagnosis
* Ask about what?
* What are the labs?
* Ask about foreign travel
* Labs: normochromic, normocytic anemia, hemolysis
105
Make the Malaria Diagnosis
* What is on the peripheral blood smear? How do you collect the smears?
Peripheral blood smear to look for plasmodium organism: thick/ thin prep
* Smears every 6 to 12 hours for 48- 72 hours
* The first smear is positive in 95% of cases
* Ring forms" of Plasmodium trophozoites
* P. falciparum and P. vivax (2 most common ones)
106
Malaria
* see the parasite in the red blood cells and identify the parasite: P. falciparum, P. vivax, P. ovale or P.malariae
107
Malaria Treatment
* For severe?
* Self txt?
* Preg?
* Prophylaxis?
* other one?
108
History
* What do you need to get with dirreaha?
109
110
What is AGE Physical ?
* Hypotension or postural hypotension
* Rebound
* Melena, blood by history/ PE
* High fever
* Signs of dehydration
* Altered mental status -> late sign
* Consider hypovolemic shock (hemorrhagic and non-hemorrhagic
111
AGE work up
* What is the work up?
* WHen do you get imaging?
* R/O what?
112
113
Treatment AGE
* What do you give for fever?
* What is diet?
* What do you give for pain?
* Acetaminophen for fever
* Clear liquids until symptoms better, BRAT diet
* Pain: Ketorolac IM
114
Treatment AGE
* What antiemetics?
* What fluids do you give?
* If abnormal, then order what?
* Anti-emetics:
* ondansetron (Zofran®)
* Prochlorperazine (Compazine®)
* Metoclopramide (Reglan®)
* Fluids- 1 liter NS if healthy/ normal renal function
* If abnormal labs, stabilize/ admit
115
Lyme Borreliosis
* What is the organism?
Borrelia burgdorferi, a fastidious (cannot culture) spirochete
116
Lyme Borreliosis
* Vector?
* Endemic where?
* Incidence peaks when?
* MC what?
* Need how long of exposure?
117
Stage 1(Localized Infection)
* What are the sxs? When do they occur?
118
Stage 2 (Disseminated Infection)
* What happens to skin?
* What happens systemic?
Hematogenous Spread
* Skin: Secondary annular skin lesions like primary lesion
* Systemic:fever, chills, arthralgias, malaise & fatigue
119
Stage 2 (Disseminated Infection)
* Neuro?
* Cardiac?
* MSK?
* Neurologic abnormalities: Bells’ palsy, headache, mild neck stiffness, meningitis
* Cardiac abnormalities: Bradycardia, AV block
* Musculoskeletal: pain, migratory in joints, tendons, bursae, muscles, or bones & without joint swelling
120
Lyme Dz
* What is stage 3 sxs?
121
Lyme Disease: Lab
* What are the lab dx for stage 1,2,3
122
123
Rocky Mountain Spotted Fever (RMFS)
* What is the organism?
* Second MC what?
* Hist of what?
* Transmitted by what? Spreads where?
* Rickettsia rickettsii
* Second most common tick borne-illness
* History of tick bite, travel or outdoor activity
* Transmitted by a tick & spread through lymphatics to pulmonary circulation then attaches & attack vascular endothelium
124
RMSF
* Incubation period?
* What sxs?
125
RMSF
* What happens during the first 3 days?
* What happens by day 3?
* First 3 days, HA, fever, malaise, myalgias, nausea, vomiting, & anorexia
* By day 3, develop rash on wrists & ankles, later on palms and soles, then spread over legs & trunk.
126
RMSF
* look for what?
* What happens secondary to vascular damage?
* What are the focal neuro defects?
Look for tick, it is still likely present if Hx does not state removal
* Hypotensive, noncardiogenic PE, renal & hepatic injury & bleeding secondary to vascular damage
* Focal neurological defects: photophobia, confusion, lethargy, & encephalitis progressing to coma
127
Skin Findings in RMSF
* Where does it start?
* later becomes what?
* Rash spreads where?
* How do you dx?
* Blanching macules develop initially on wrists & ankles & then spread over palms and soles, then to legs and trunk.
* Later becomes hemorrhagic & frequently petechial.
* Rash spreads to palms & soles later
* Diagnosis: Skin biopsy of rash or IFA 7- 14 days
128
RMSF
* What tests can be done?
* Indirect immunofluorescence antibody (IFA) assay for immunoglobulin G (IgG) or a PCR test
* Not apparently evident on blood smear
129
RMSF
* What is the txt?
* Doxycycline 100 mg BID x 7 days or 2 days after fever normal – DOC even in pregnancy or lactation and <8yo.
* In clinically mild or special cases such as pregnancy and lactation and <8yo, use chloramphenicol or cefuroxime or amoxicillin, but only with ID input
* Treat before cultures are back
130
Difference between RMSF and TSS?
RMSF starts in wrist and ankles
131
STDs
* May be what?
* General course of care is what?
* What is the txt?
132
STDs
* What test is there?
* What can you use for trich/yeast and BV?
* Must keep it in the ddx for who?
* Counsel who?
* Disseminated disease/PID will require what?
* DNA/NAAT tests for GC and Chlamydia
* Wet Prep for Trichomonas/Yeast/BV (clue cells)
* Must keep it in differentials for infants and pharyngitis and conjunctivitis if patient has oral sex
* Counsel sex partners to be treated as well
* Disseminated disease/PID will require ID consult and admission for IV antibiotics
133
Syphilis
* Think of it when see what?
* What is txt?
* Think of it when see palmar/plantar rash and patient has painless lesion, typically 2-3 weeks after exposure.
* Penicillin G 2.4mU single dose is not typically used
* Current recommendation is oral amoxicillin for 10 days
134
Disseminated GC
* Can be the cause of what?
* Petechial rash =
* GC can also cause a septic arthritis in adolescents and young adults.
* Petechial rash = meningococcemia
135
Reiter Syndrome Reactive Arthritis
* What is the triad?
* Arthritis
* Urethritis
* Conjunctivitis
## Footnote
cannot see, cannot pee, cannot climb up a tree
136
Reiter Syndrome Reactive Arthritis
* Can be precipitated by what?
* Can be precipitated by what?
* Can be precipitated by infection (Chlamydia, Salmonella, Shigella, Campylobacter)
* Differentiate from GC (migratory arthritis
137
Petechial Rashes/”Fever”(SERIOUS)
* If you see the patient early, there may be what?
* Patients with petechial rashes can what?
* Examine the skin of who?
* If you see the patient early, there may be only one or two areas of small petechiae
* “Patients with petechial rashes can die within hours”
* Examine the skin of a febrile patient
138
Henoch Schoenlein Purpura
* What is it?
* What is the triad?
139
Henoch Schoenlein Purpura
* When/who?
* What is present
140
Pemphigus Vulgaris
* What is this?
* What type of blistering?
* Bullous pemphigoid is similar but what?
* What is the txt?
* Generalized, mucocutaneous, auto-immune, blistering eruption
* Intraepidermal blistering
* Bullous pemphigoid is similar but tends to occur in the elderly and has a better prognosis
* Immunosuppressant/steroids
141
What is the txt of anthrax?
Cipro + MRSA coverage
142
Tinea
* Capitis – _ and txt with what?
* Dermatophyte infection (_ culture)
* Corporis –
* Cruris -
* Pedis –
* Manuum –
* Capitis – head (scalp)-treated with oral griseofulvin
* Dermatophyte infection (fungal culture)
* Corporis – body
* Cruris - crotch
* Pedis – foot – “athlete’s foot”
* Manuum – hand
143
Tinea
* txt ?
Treated with anti-fungal agents such as clotrimazole, miconazole, ketoconazole
144
Cutaneous larvae migrans
* What is it?
* What is the presentaiton?
* What is the txt?
145
Candida
* What is the organism?
* See what?
* may see what?
* Oral candidias=
* txt with what?
146
Infestations-Scabies
* What is the organism?
* Extrememly what?
* Comonly where?
* Scabies-mites: Sarcoptes scabiei
* Extremely itchy
* Commonly hands, feet, flexor creases, umbilicus, groin, genitals
147
Infestations-Scabies-mites
* What do you see?
* Tx with what?
* Fine, erythematous, linear burrow, often seen best between the fingers
* Treat with topical scabicides – permethrin (Nix)
148
Pediculosis (Lice, Nits)
* Capitis?
* Pubis? Usually what?
* Corporis?
* Capitis – head lice.
* Pubis – usually sexually transmitted – affects pubic hair of the groin.
* Corporis – body lice.
149
Pediculosis (Lice, Nits)
* tx with what?
* Treat who?
* Wash what?
* Treat with permethrin (nix) and again in 10 days (larvae hatch).
* Treat all family contacts.
* Wash all clothing, bed linen, etc.
