Lecture 4 (ID)-Exam 2 Flashcards

Question

MRSA * Outbreaks occurs in where? * Occurs how? * What is prevention? * What is the diagnosis? * What is the treatment?

Answer 1

* Outbreaks occur in crowded places – locker rooms, etc. * Occurs in waves * Prevention – thorough cleansing of public areas, locker rooms, hand-washing * Diagnosis – culture * Treatment – Use antibiogram (local/regional etc.) to decide on sensitivity * Clindamycin, Trimethoprim-sulfamethoxazole (Bactrim), doxycycline

Answer 2

Clindamycin, Trimethoprim-sulfamethoxazole (Bactrim), doxycycline

Answer 3

* Acute inflammatory condition of skin caused either by endogenous flora colonizing skin or by a wide variety of exogenous bacteria * Distinguish from folliculitis, furuncle and carbuncle

Answer 4

* Organisms inoculated through small breaks in skin (S. pyogenes) or via bites (Bartonella - cats, Pastuerella - dogs, Eikenella - humans, anaerobes) * Originate in wounds, ulcers or abscesses (S. aureus) * Be associated with sinusitis( H. flu) * Gain entry during immersion in water (Aeromonas, Vibrio vulnificus)

Answer 5

* Shaking chills often occur but bacteremia infrequently documented * Regional LN enlargement & tenderness common * Linear streaks of erythema & tenderness indicate lymphatic spread * Characterized by localized pain, erythema, swelling & heat * Lymphangitis vs erysipelas

Answer 6

Right: Strep Left: Staph

Answer 7

* Painful regional lymphadenopathy that persists for several weeks or months after a cat scratch. * Since scratches most often occur on the hand or face in children, youngsters account for 60% of cases, so expect LAD in the same regions. * Systemic symptoms and even severe manifestations such as encephalitis, seizures, & coma may occur. * Trench fever (B. quintana) – fever, headaches, aseptic meningitis in a homeless person or soldier

Answer 8

fever, headaches, aseptic meningitis in a homeless person or soldier * Altered mental status with negative spinal tap

Answer 9

Dx: LN biopsy or PCR serology tests for B. henselae * Warthin-Starry silver stain Tx: Azithromycin + doxycycline * Azithromycin has been noted to be successful to reduce Lymph node size * Ciprofloxacin in AIDS patients with bacteremia * Alternatives: Sulfamethoxazole/trimethoprim, rifampin or clarithromycin

Answer 10

* Vibrio parahaemolyticus, V. mimicus, V. alginolyticus, V. hollisae, and V. vulnificus * Cousins of organism causing cholera (Vibrio cholerae) * Typically inhabit **warm salt water** or mixed salt and fresh water * V. vulnificus

Answer 11

* Dx: noncholera Vibrio grow in cultures * Tx: Doxycycline + Cephalosporin (1st Gen) * Prophylax all high risk wounds * Think CD vid(brio) | Some sources say Ciprofloxacin + Cephalosporin

Answer 12

Vibrio Cellulitis (Non-cholera vibrio species) * Vibrio parahaemolyticus, V. mimicus, V. alginolyticus, V. hollisae, and V. vulnificus

Answer 13

* Group A B-hemolytic streptococci * S.aureus

Answer 14

* Gram – bacilli * Always think Pseudomonas in DM (Also mc with pneumonia in CF pts)

Answer 15

* Anaerobic bacteria * Gram-

Answer 16

Radiologic studies should be performed on patients with ulcers to R/O osteomyelitis * Use MRI or Nuclear Med scan to see cellulitis or OM

Answer 17

* Moist heat * Avoidance of irritating factors * Antibacterial soaps * Topical antibiotics * Systemic antibiotics, if more extensive * Dicloxacillin * Cephalexin

Answer 18

Localized pyogenic infection, most frequently by Staphylococcus aureus, originating deep in a hair follicle. AKA furunculus, boil. * involves sweat gland or hair follicle * Larger than follicultitis

Answer 19

Furuncle-S.aureus

Answer 20

* Deep-seated pyogenic infection of skin & subcutaneous tissues, usually arising in several contiguous hair follicles, with formation of connecting sinuses * Culture is usually not necessary unless patient has predisposing factors such as diabetes, IV drug use or HIV, or if there are systemic symptoms

Answer 21

Carbuncle * Deep-seated pyogenic infection of skin & subcutaneous tissues, usually arising in several contiguous hair follicles, with formation of connecting sinuses

Answer 22

* Moist heat * Systemic antibiotics with staph and G- coverage * PCN or Cephalosporin (Keflex or augmentin ) + MRSA coverage: Bactrim, Doxycycline or clindamycin *BCD) * Incision and drainage * Use an antibiotic such as ciprofloxacin (Cipro) if a gram negative organism is suspected.

Answer 23

* Can be present with or without cellulitis * Only effective treatment for an abscess is incision & drainage! * Use moist heat to help abscess localize or “come to a head” * Avoid aggressive manipulation

Answer 24

Abscess * If near rectum, then general surgeron needed because of a fisula

Answer 25

* Hospitalize toxic appearing patients & those with underlying diseases impairing immunity * In extremities look for circumferential coverage or joint involvement * C/S blood & any abscess, open wound, or drainage * If etiologic agent is suggested by patient’s Hx, Rx. is directed at a specific pathogen or group of pathogens * In absence of specific etiology Rx. directed at gram + * IV oxacillin(2 g q 6h) or cefazolin(2 g q8h) until signs of systemic toxicity have resolved; PO Rx. is then given to complete a 2-week course * Nafcillin or Vancomycin if MRSA high possibility * Agents active against anaerobes & gram-negative rods in diabetics with foot ulcers complicated by cellulitis

Answer 26

* IV oxacillin(2 g q 6h) or cefazolin(2 g q8h) until signs of systemic toxicity have resolved; PO Rx. is then given to complete a 2-week course * Nafcillin or Vancomycin if MRSA high possibility * Agents active against anaerobes & gram-negative rods in diabetics with foot ulcers complicated by cellulitis

Answer 27

* Gassy crepitant infection involving necrotic tissue with intact, healthy muscle spared (unlike in clostridial myonecrosis) * Local extension along fascial planes * Marked toxemia absent; Systemic effects mild

Answer 28

* Gradual onset; incubation period 3 to 5 days * Skin rarely discolored * Little or no edema distinguishes from gas gangrene * Predominant organisms proteolytic & nontoxigenic clostridia, such as Clostridial sporogenes & Clostridium tertium

Answer 29

Dry gangrene of toes showing areas of total tissue death, appearing as black & lighter shades of discoloration of skin demarcating areas of impending gangrene

Answer 30

Dry Gangrene- no drainage * deeper-> death of bone and muscle * Diabetes * PAD-> smoking

Answer 31

* Result of vascular disease * Obtain radiographs to help R/O clostridial myonecrosis & osteomyelitis-> x-ray or MRI, CT angiogram with runoff to see constriction * Soft-tissue infection may complicate this condition

Answer 32

* Rare, rapidly progressive, life-threatening infection * Characterized by severe systemic toxicity * Necrosis of skin, subcutaneous tissue & deep & superficial fascia with sparing of underlying muscle

Answer 33

* Disease is a clinical entity & not a specific bacterial infection * One of a group of clinical entities presenting as gangrenous or crepitant cellulitis * Previously described as hemolytic or acute streptococcal gangrene, gangrenous or necrotizing erysipelas, suppurative fasciitis & hospital gangrene

Answer 34

* Majority of cases have occurred outside hospital following minor trauma such as abrasions, cuts, bruises, boils, & insect bites on extremities * May occur following surgical procedures * Rarely no apparent inciting injury

Answer 35

* Following an insult, bacteria seed SC tissue & spread rapidly to adjacent tissue. * Massive necrosis of SC fat & fascia quickly follow due to elaboration of enzymatic toxins * Pyrogenic exotoxin induces mononuclear cells to synthesize TNF, interleukin-1 & interleukin-6 producing fever, shock, tissue injury, cytotoxicity & immunosuppression of B-lymphocyte function.

Answer 36

* With destruction of vascular supply, overlying skin becomes necrotic & bulla form. * Destruction of cutaneous nerves results in total anesthesia over affected area * Involved skin is pale red without distinct borders & with blisters or bullae (pale to red) * Clue to Dx is pain & presence of SC swelling, particularly in absence of cellulitis

Answer 37

* Minimal erythema & swelling * Involved skin is pale red without distinct borders & with blisters or bullae * Pale red areas progress to a distinct purple * Rapid progression of tenderness out of proportion to clinical appearance of wound * Systemic manifestation frequently out of proportion to local findings | Amputation

Answer 38

Necrotizing Fasciitis -Late Clinical Findings * Non blenching sign * Bulla formation

Answer 39

Scrotal Necrotizing Fasciitis -Late Clinical Findings * Note the gas formation

Answer 40

* ARF (acute renal failure) * HF * Respiratory failure * Hypocalcemia * Hypotension * Toxic shock-like syndrome * Patients rapidly deteriorate

Answer 41

* Initially target typical etiology with broad-spectrum coverage * Vancomycin + Pipercacillin/tazobactam + Metronidazole * For group A streptococci & clostridia, data suggest clindamycin may be superior * When polymicrobial infection suspected, therapy consists of metronidazole +ampicillin + gentamicin

Answer 42

* Aggressive management of septic shock & early surgical debridement essential to improved clinical outcome * Hyperbaric oxygen therapy may be useful in clostridial disease

Answer 43

* 20 to 50 % mortality rate * 3 or more risk factors increases mortality to 50%. * Survival related to timing of surgical intervention * Older the patient is & more coexisting diseases there are, higher mortality * Best outcomes associated with surgery in first 24 to 48 hours of the illness

Answer 44

* Deep infection of muscle usually caused by S. aureus & occasionally by group A Beta-hemolytic streptococci or enteric bacilli * Most cases occur in warm or tropical regions, & most occur among children * Nonpenetrating trauma may antedate the onset of symptoms

Answer 45

* Patients present with fever & tender swelling of muscle * Skin is uninvolved or minimally involved * In older patients, myositis may mimic phlebitis * Dx. made by needle aspiration, US or CT scan

Answer 46

* Rapid spreading infection known as Gas Gangrene * Occurs in association with severe wounds of large muscle masses that have become contaminated with C.perfringens * Wounds commonly caused by high-velocity missiles of modern warfare & by accidental trauma * Most likely to develop in wounds in which there has been extensive laceration or devitalization of thick muscle masses, such as buttock, thigh, & shoulder * by soil, clothing, & other foreign bodie ## Footnote Arterual involvement =rapid tissue death

Answer 47

* Within 1 or 2 days of injury ,involved extremity becomes painful & begins to swell * Patient toxic & often delirious * Skin may appear uninvolved at first but eventually may develop a bronze-blue discoloration (sweet smell of discharge) * Hypotension, hemolytic anemia, & ARF complications

Answer 48

* Emergency surgery with wide debridement * Large doses of penicillin plus clindamycin may prevent further spread of bacilli | MY PC

Answer 49

* GBS-sepsis, bacteremia, meningitis (in neonates) * Requires antepartum screening to identify carriers * Peripartum antimicrobial prophylaxis is recommended in pregnancy * GBS is part of normal vaginal flora, may cause septic abortion, endometritis, or peripartum infections and, less commonly, cellulitis, bacteremia, and endocarditis in adults

Answer 50

* Treatment: PCN or Vancomycin +/- gentamicin (2/2 in vitro synergism) * Viridans streptococci are part of the normal oral flora. Although these strains may produce focal pyogenic infection, they are most notable as the 2nd most common cause of native valve endocarditis. * Group D streptococci include Streptococcus gallolyticus (bovis) and the enterococci. S gallolyticus (bovis) is a cause of endocarditis in association with bowel neoplasia or cirrhosis and is treated like viridans streptococci.->Tx: PCN G or Ceftriaxone or Vanc alone

Answer 51

* Inflammatory disease, multi-systemic * Group A strep infection precedes onset by 2-6 weeks * Causes inflammation in the heart, joints, skin and central nervous system * Up to 60% of patients with Acute rheumatic fever progress to rheumatoid heart disease * Migratory joint pain, fatigue, fever, heart murmur, flat rash, chorea (Sydenham) and unusual behavior

Answer 52

* Prevention – treat strep correctly * Complications - heart valve disease * Treatment – PCN-G x 1 or oral PCNs (pen+ amox but allergic use zpack) * ASA (fever, arthralgias, arthritis)

Answer 53

Hand does not relax * Childhood complication of group A strep pharyngitis * Usually self-limited * One of the major Jones criteria for dx of acute rheumatic fever

Answer 54

PCN G 1.2 million units (THIS IS IV) * Alt: Amoxicillin or PCN VK (THIS IS ORAL) or Cephalosporins or Macrolides or Clindamycin * Chose based on allergy profile

Answer 55

* Arthritis management with NSAIDs * Carditis Management with conventional management of heart failure * Weak evidence of usefulness of IVIG, NSAIDs or glucocorticoids (does not prevent HF) * Chore management:Carbamazepine or valproic acid (this is seizure meds)

Answer 56

* Endocarditis is a bacterial or fungal infection of the valvular or endocardial surface of the heart. * Etiology * Underlying valve disease (~50% of cases) * IVDA * Prosthetic valve

Answer 57

Etiology (typical): * MCC=S. aureus (was previously streptococcal species) * Strep viridans * Enterococci * HACEK organisms (1.4-3.0% of cases) * Males > females * Most: Age > 50; not common in kids

Answer 58

* MCC=S. aureus * Enterococci * Streptococci * Fungi * Multiple organisms common * MC valve affected = Tricuspid (80-90%) * Septic pulmonary emboli w/ tricuspid infection * Young males common

Answer 59

Bartonella quintana

Answer 60

If early infection (w/in 2 mo. post-implantation) * MCC-Staph (Gram + and Gram -) or fungi If late infection (>2 mo. Post-implantation) * MCC-Strep viridans

Answer 61

* Right side: pneumonia * Left: air/fluid lvl * From endocarditis that spread pass the heart

Answer 62

Patients with IE should receive multidisciplinary care by infectious disease, cardiology, and cardiac surgery

Answer 63

* Blood cultures x 3 BEFORE starting antibiotics * CBC * CMP

Answer 64

* Hospitalization, ID consult * Most get Vancomycin and Cefazolin and then adjust based on culture * Native Valve IE-> Vancomycin for 4-6 weeks * Typically left-sided unless caused by IVDA * Prosthetic Valve IE-> Surgical replacement +/- abx for 6 weeks

Answer 65

HACEK organisms — A number of fastidious gram-negative bacilli are grouped by the acronym "HACEK" – these include: * Haemophilus aphrophilus (subsequently called Aggregatibacter aphrophilus and Aggregatibacter paraphrophilus) * Actinobacillus actinomycetemcomitans (subsequently called Aggregatibacter actinomycetemcomitans) * Cardiobacterium hominis * Eikenella corrodens * Kingella kingae

Answer 66

* Somewhat controversial b/c prophylaxis now recommended for fewer patients * Abx solely for GI or GU procedures are NOT recommended

Answer 67

Streptococcus pneumoniae (~50%)-MCC

Answer 68

* Pneumococcal PNA * Sinusitis * Otitis media * Alcoholism * Diabetes * Splenectomy * Hypogammaglobulinemia * Complement deficiency * Head trauma w/ basilar skull fracture & CSF rhinorrhea

Answer 69

* Acute fulminant illness vs. subacute infection * Most present within 24hrs of symptoms onset * Class clinical triad: fever, headache and nuchal rigidity (“Stiff neck”) -> Pathognomonic, but is a late sign * Triad not always present BUT fever, and either headache, stiff neck, or AMS will be present in nearly 100% of pts w/ bacterial meningitis

Answer 70

* Blood cultures * CT/MRI before LP -> not everyone needs imaging before LP. Only of GCS is reduced (<12) or there is evidence of brain “shift” on physical exam * LP with CSF analysis * Other labs to consider: * CBC * CRP * Lactic acid * Lactate dehydrogenase * HIV * Procalcitonin

Answer 71

* Dexamethasone + 3rd or 4th cephalosporin (Ceftriaxone, Cefotaxime) * And Vancomycin PLUS Acyclovir

Answer 72

* The efficacy of **dexamethasone** therapy in preventing neurologic sequelae is different between high- and low-income countries. * Three large randomized trials in low-income countries (sub-Saharan Africa, Southeast Asia) failed to show benefit in subgroups of patients. * The lack of efficacy of **dexamethasone** in these trials has been attributed to late presentation to the hospital with more advanced disease, antibiotic pretreatment, malnutrition, infection with HIV, and treatment of patients with probable, but not microbiologically proven, bacterial meningitis. * The results of these clinical trials suggest that patients in sub-Saharan Africa and those in low-income countries with negative CSF Gram’s stain and culture should not be treated with **dexamethasone**.

Answer 73

* S. pneumoniae (mortality) * H. influenzae (hearing loss) * N. meningitidis (arthritis) * M. tuberculosis (mortality)

Answer 74

* Steroids are detrimental in Listeria or Cryptococcus * Use in viral encephalitis is unclear (limited studies)

Answer 75

(1) Decreased level of consciousness on admission (2) Onset of seizures within 24h of admission (33%) * 3% remain with seizure d/o after recovery (3) Signs of increased ICP (4) Young age (infancy) and age >50 (5) Presence of comorbid conditions including shock and/or the need for mechanical ventilation (6) Delay in the initiation of treatment (esp with imaging prior to LP)

Answer 76

* CSF: Normal glucose, normal or elevated opening pressure, normal or slightly elevated protein * CBC w/ diff * CMP * CRP * CK * Lipase * HIV

Answer 77

Rads: MRI preferable to CT; neither absolutely necessary if uncomplicated viral meningitis * Unless there are risk factors * HSV-1 prefers temporal lobe involvement

Answer 78

## Footnote NEED A CT BECAUSE VIRAL

Answer 79

The combination of unrelenting headache, stiff neck, fatigue, night sweats, & fever with a CSF lymphocytic pleocytosis and a mildly decreased glucose concentration is highly suspicious for tuberculous meningitis.

Answer 80

* Fever, headache, vomiting, delirium, convulsions. * Petechial rash on skin and mucous membranes in many. * Neck and back stiffness and positive Kernig and Brudzinski signs are characteristic, but are usually late signs. * Purulent spinal fluid with gram-negative intracellular and extracellular diplococci. * Culture of cerebrospinal fluid, blood, or petechial aspiration confirms the diagnosis. * Bacterial meningitis CSF: High neutrophils, Low glucose, High protein, Increased opening pressure (>180mmH20)

Answer 81

* Viral CSF Profile: Normal glucose, lymphocytic pleocytosis, negative Gram stain * Red blood cells predominance in the absence of traumatic tap is suggestive of HSV (or other necrotizing encephalitides) * Subacute/fungal: Glucose is usually lower than in acute bacterial meningitis (which is already low) * PCR is required for confirmation ## Footnote Pleocytosis: It is often defined specifically as an increased white blood cell count in cerebrospinal fluid.

Answer 82

* Occurs during hospitalization after first 72 hours * MC bacterial pathogens are gram-negative rods (E. coli, Pseudomonas) and Staphylococcus aureus * MDR Pathogens

Answer 83

* Influenza vaccine (yearly) * Pneumococcal vaccine (>65 years and any high-risk any patients) High risk: [heart disease, sickle cell, pulmonary disease, diabetes, alcoholic cirrhosis or asplenic individuals]

Answer 84

* Pulse oximetry (RA with rest & activity) ⭐️ * CBC * CMP * ABGs * Sputum gram stain/cultures * Blood cultures * Urine for Legionella antigen * Procalcitonin ## Footnote ⭐️ admit or go home based on this: over 88 on 6 min walk test then they are good

Answer 85

* Incubation period 2-14 days * Acute onset of high fever, chills, headache, nausea, and vomiting, myalgias, restlessness, insomnia, irritability * The rash appears between day 2 and 6 of the fever – initially wrists, ankles and spreads centrally to arms, legs and trunk over next few days (~10% have no rash) * Involves palms and soles * Hard palate lesions, facial flushing, conjunctival injection may occur * Splenomegaly, hepatomegaly, jaundice, ARDS and necrotizing vasculitis may occur

Answer 86

* Thrombocytopenia, hyponatremia, elevated aminotransferases, hyperbilirubinemia – common * Diagnosis during acute phase can be made by immuno-histology or PCR demonstration

Answer 87

* Challenging – rarely is the triad of fever, rash and tick bite present – most patients will not know they were bit by a tick * Must rule out meningococcemia

Answer 88

* Borrelia burgdorferi, a fastidious spirochete * Principal vector in these regions is deer tick (Ixodes scapularis) & > 20% of these ticks are infected with B. burgdorferi * Major areas of disease NE, Wisconsin & Minnesota in Midwest * Incidence of disease peaks during summer

Answer 89

## Footnote An expanding erythematous rash not associated with scaling is characteristic of erythema chronicum migrans. Disease first appears weeks to months after a tick bite. Lesion begins as a red macule at the site of the bite;

Answer 90

* Paralytic disease caused by botulinum toxin produced by Clostridium botulinum * Pathophysiology – blocks release of neurotransmitter acetylcholine at neuromuscular junction * Extremely potent, feared as a possible bioterrorism agent

Answer 91

* Food borne – home canned foods, smoked meats, vacuum packed fish * Infant – ingestion of honey * Wound – injection drug use

Answer 92

* Clostridium tetani is anaerobe ubiquitous in soil, but can exist intact for years on other surfaces * Infection in humans; causes syndrome of muscle spasms and pain in trunk, jaw, and neck, respiratory distress or arrest * Initial Sxs: Trismus (lockjaw), muscle pain and stiffness, back pain, and difficulty swallowing, then risus sardonicus * Diagnosis: Clinical, Culture of C. tetani from a wound provides supportive evidence

Answer 93

DTaP * diphtheria, tetanus, and pertussis vaccine for kids under age 7 (2mo, 4mo, 6mo, 15-18 mo, 4-6 years, DT for those with pertussis susceptibility Tdap * for ages 11 thru 64 who have never yet had a dose, but Td should be use if Tdap is not available or if they have already had one dose of Tdap Td (Adacel)-> in emergency room * pts over age 7, preferable than just tetanus alone as many adults susceptible to diphtheria, booster every 10 years TIG (human or equine) human preferred to eliminate potential for hypersensitivity reaction to equine

Answer 94

* patient is unknown or less than 3 doses: give TdaP * If Patient has 3 or more doses: do not give TdaP if less than 10 years * If patient is unknown or under 3 doses and does not have 3 or more doses: do not give TIG with +/- TdAP

Answer 95

* Unknown or less than 3 doses: give Tdap * 3 or more doses: do not give TdaP if less than 5 years * If unknown or less than 3 doses: give TIG with -/+ TdaP * If has 3 or more doses: then do not give TIG

Answer 96

* Clean and debride wound of necrotic material in order to remove anaerobic foci of infection and prevent further toxin production * **Metronidazole** (400 mg rectally or 500 mg IV every 6 h for 7 days) is preferred-> Alt: PCN G or Doxycyline * Penicillin (100,000–200,000 IU/kg per day) may exacerbate spasms and in one study was associated with increased mortality. * Administer Antitoxin (early): Human tetanus immune globulin (TIG)-PREFERRED OR equine antitoxin * TIG is the preparation of choice, A single IM dose (3000–5000 IU) is given, with a portion injected around the wound.

Answer 97

* Corynebacterium Diphtheriae * Spread via respiratory secretions, produces an exotoxin responsible for myocarditis and neuropathy * Most common form – pharyngeal, but rare in the US thanks to DTaP/Tdap. * Classic physical exam finding – pseudomembrane covering tonsils and pharynx

Answer 98

* Symptoms – mild sore throat, fever, malaise * Pericarditis and neuropathy are the most common serious complications. Neuropathy usually involved the cranial nerves * Diagnosis – typically clinical, may culture

Answer 99

* Rule out other etiologies for pharyngitis, neuropathy – but do not withhold treatment * Requires admission with emergent treatment – removal of membrane if causing airway obstruction, antitoxin and PCN G or erythromycin (to prevent transmission to susceptible contacts) * Isolate until 3 consecutive cultures are negative

Answer 100

Treat contacts with Erythromycin

Answer 101

* Cause – Mycobacterium tuberculosis, a small, slow growing aerobic bacilli * The most common mycobacterial infection * The leading infectious cause of morbidity and mortality in adults worldwide * In areas of world where both TB and HIV are prevalent, HIV/AIDS is the highest risk factor ## Footnote * One of the most widespread and deadly illnesses globally * ~10 million cases annually * 1.7 mil deaths in 2016

Answer 102

Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. A global total of 206 030 people with multidrug- or rifampicin-resistant TB (MDR/RR-TB) were detected and notified in 2019, a 10% increase from 186 883 in 2018

Answer 103

* Rarely causes acute illness, 95% asymptomatic. * Pathophysiology – M. tuberculosis bacilli must be ingested by alveolar macrophage, those not killed by macrophage, replicate and kill macrophage with help from CD8 * **possible risk threshold of 250 hours**-> to actually get disease * Spread – usually not transmissible in primary stage * Rarely develops into acute illness with pneumonia, marked lymph node enlargement (mediastinal or hilar), pleural effusions. * People infected with TB bacteria have a 5–15% lifetime risk of falling ill with TB * Those with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a higher risk of falling ill

Answer 104

* Tuberculin skin test is becoming a thing of the past, although still used * **TB T-Spot test (most sensitive) or Quantiferon Gold TB test** (blood test that detects memory t cells that produce IFN-γ in response to M. tuberculosis antigens, using the enzyme-linked immunospot technique. * Chest x-ray * Acid-fast stain and culture * Test all +TB patients for HIV, obtain baseline liver and renal function tests. * Must culture sputum for definitive diagnosis and to isolate bacteria for drug sensitivity

Answer 105

* Isoniazid INH +Rifampin +Pyrazinamide +Ethambutol (RIPE) * Daily dosing for the first 2 months (intensive phase) * Daily dosing or three times per week (continuation phase)

Answer 106

* Three months of once weekly Isoniazid + rifapentine * Four months of daily rifampin * Three months of daily isoniazid + rifampin

Answer 107

* Approximately 200 NTM species * Found in fresh and salt water, soil, household dust * Typically cause chronic lung infections * 4 clinical syndromes – lung, lymphadenitis, cutaneous, disseminated

Answer 108

* Elderly and immunocompromised primary * Is AIDS defining illness, typically see CD4 counts <50 * No known person to person transmission * Typically present as lung disease * May be cutaneous, lymphadenitis (children) * Scrofula means outside of the lung presentation * Disseminated infections in patients with HIV * Diagnoses – acid-fast stain and sample culture

Answer 109

Treatment – typically Azithromycin or Clarithromycin * Alt: clarithromycin, ethambutol, rifabutin | MAC-AC for txt

Answer 110

Cutanous MAC

Answer 111

Lymphadenitis (scrofula) MAC

Answer 112

* Found in fresh and salt water * Enters via break in skin * Causes cutaneous lesions – begins as an erythematous blue/purple papule that typically ulcerates * DX – culture * TX – opinions vary – Clarithromycin * In superficial cutaneous infections minocycline, clarithromycin, doxycycline and trimethoprim-sulfamethoxazole as monotherapy are effective treatment options

Answer 113

Mycobacterium marinum * TX – opinions vary – Clarithromycin * In superficial cutaneous infections **minocycline, clarithromycin, doxycycline and trimethoprim-sulfamethoxazole** as monotherapy are effective treatment options

Answer 114

* Mycobacterium leprae * Now rare - ~150 cases a year in US and 250,000 globally (CDC) * Passed by Armadillos * 95% of people have a natural immunity, risk highest in Africa, Asia

Answer 115

Attacks nerves, skin, mucous membranes - causes loss of sensation, can result in paralysis of hands and feet, body may reabsorb affected digits, causes corneal ulcers and blindness, “saddle-nose deformity” – due to nasal septum damage.

Answer 116

* DX – skin biopsy * FITE stain (acid fast) * Lepromin Skin test is alternative * May be negative in Lepromatous leprosy which carries high infectivity and neurological damage * TX – Dapsone, rifampicin, clofazimine

Answer 117

Leprosy * Dapsone, rifampicin, clofazimine

Answer 118

* G- bacilli colonizing water supply (infects amoebas and resists Cl and temperature) * Older age, COPD and smoking have higher incidence of occurrence * Sxs – high fever and nonproductive cough with GI Sxs, also HypoNa. Confusion is common. Bradycardia is profound. CXR shows consolidations. * Commonly occurs with diarrhea | air conditioner worker, fountain worker, cruise worker

Answer 119

Legionella pneumophilia * Pontiac Fever - headaches, fever, myalgias without pneumonia * In epidemic regions via airborne transmission * Less serious

Answer 120

* Will not show on gram stain, order urine antigen test or sputum culture * Tx: Azithromycin or Levaquin or doxy * don’t respond to PCN and like or aminoglycosides

Answer 121

* Brucella melitensis * Most common in people handling meat or those ingesting contaminated milk or meat (cattle, goats, sheep, camels, dogs) * Typical viral symptoms: fever, chills, weakness, body aches * Rare symptoms: lumbar osteomyelitis, spondylitis, endocarditis, epidydimoorchitis

Answer 122

* Dx: titer for Brucella agglutinins or Culture, but culture may take 6 weeks * Tx – Doxycycline + Rifampin for 6 weeks. Repeat cultures should be made every 3-6 months for 2 years.

Answer 123

* Francisella tularensis * Transmitted from rabbits (rabbit brains)/ticks/or deerfly. Most common in AR/OK/Missouri. * Sxs – fever, chills, myalgias, headaches * Dx based on serologic agglutination tests (>1:160 is +)-> Doesn’t gram stain * Ulceroglandular tularemia (80%) – follows skin inoculation forming papule that develops into punched-out ulcer with necrosing base.

Answer 124

Tx – DOC is streptomycin

Answer 125

* Yersinia pestis * Transmitted by bite of rodent flea or pigs mostly in Southwest US * Sxs – rapid onset of fever, myalgias and arthralgias, painful LAD – buboes (large lymphoditis). Can cause pneumonia * Dx – stains reveal bipolar safety-pins (CSF or blood or aspirated bubo) * Tx – DOC is streptomycin (Alt: tetracycline for pneumonia)->If not treated – death within 10 days due to DIC.

Answer 126

* Common cause of FUO in chronic disease pattern * Due to Coxiella burnetti, which naturally infects goats, sheep and cattle. The bacteria is inhaled. * Sxs: typical viral – fever, chill, sweats, headache, muscle aches, vomiting, cough. May cause endocarditis and hepatitis * Dx: PCR or serology * Vaccine is available

Answer 127

* Tx: Doxycycline for 2-3 weeks * Add hydroxychloroquine in endocarditis

Answer 128

* HHV 1/2 - Herpes simplex virus (HSV) type 1, HSV type 2 * HHV 3 - Varicella zoster virus (VZV) type 3 * HHV 4 - Epstein-Barr virus (EBV), infectious mononucleosis – type 4 * HHV 5 - Cytomegalovirus (CMV) – type 5 * HHV 6/7 – Roseola or 6th disease and several syndromes * HHV 8 – Kaposi sarcoma (HIV), lymphoma

Answer 129

* Virus must come in direct contact with either mucosal surface or abraded skin * Makes its way to the ganglion (nerve) via neural transmission * Latency – will be dormant until a stressor occurs * The more severe the primary infection (size and # of lesions) the more likely recurrences will occur

Answer 130

* Chicken pox * Pruritic rash – starts on face and body – moves to extremities * Papules-vesicles-honey colored crust * Typically occurs in childhood * Very contagious – droplet or contact * Classic “dew drop on rose petal”

Answer 131

* Shingles * Painful rash * Tingling and pain first, erythematous based rash along a dermatome * Half of pts >60 * 25% of adults in lifetime * Annual incidence – 1 mil in US

Answer 132

* HSV covered previously * HZ is a reactivation of varicella * Eruption of grouped vesicles on an erythematous base usually limited to a single dermatome (“shingles”) * Incubation period of 10-16 days; initial viremia w/i 4-6 days disseminating to other organs (liver, spleen, sensory ganglia), second viremia 10-21 days with presentation of rash * **Prodrome**: coryza, myalgia, nausea, decreased appetite, HA -> rash, low grade fever, malaise, oral sores

Answer 133

* Virus “hides” in a dorsal spinal root until reactivated. * Most common in ages > 50 * Postherpetic neuralgia, lasting months to years may occur, especially in elderly

Answer 134

Method of choice: RT-PCR – swab fluid-filled vesicle, or may use crust Tzank smear of both roof & floor of a herpetic vesicle demonstrating a multinucleated giant cell. * Direct fluorescent antibody (DFA) – replaced Tzank smear (use Giemsa stain -> multinucleated giant cells) * Serologic – weak, tests IgG (must be high); ELISA used for screening * In utero: VZV DNA or presence of IgM in fetal blood/cord or amniotic fluid; US – limb deformities, microcephaly, hydrocephaly, IUGR

Answer 135

herpes zoster * Tzank smear of both roof & floor of a herpetic vesicle demonstrating a multinucleated giant cell.

Answer 136

Herpes Zoster * This eruption consists of a dermatomal distribution of umbilicated vesicles on an erythematous base. * Note occasional cluster of hemorrhagic vesicles. | Unilateral: do not cross midline

Answer 137

* Erythema or tingling * Vesicles appear in a dermatomal pattern * Vesicles progress to pustules * Crusting occurs * Lesion disappear in 3 - 4 weeks * Much less contagious than chickenpox.

Answer 138

Ophthalmic Herpes Zoster * This patient has vesicles in ophthalmic division of CN V bilaterally

Answer 139

Disseminated Herpes Zoster Infection * Vesicles are seen over entire face, representing disseminated HZV infection (multiple dermatomal distributions)

Answer 140

* Acyclovir (Zovirax) * Higher doses required * 800 mg. 5 times a day for 7 - 10 days * Famciclovir (Famvir) 500mg. TID * Valacyclovir (Valtrex) 1g TID X 7 * Zovirax cream ineffective for VZV

Answer 141

* Domeboro soaks * Analgesics * Post herpetic neuralgia * Nerve blocks (lidocaine) * Capsaicin (Zostirx) * Antidepressants (pain and wellbeing) * VZV IVIG (immunoglobulin) for immunocompromised * Vaccination

Answer 142

* Adults: more severe disease, Pneumonia * In utero: Varicella congenital syndrome- hypoplasia of GI/GU tract and extremities, cortical atrophy, chorioretinitis, microcephaly, low birth weight. Chickenpox at birth * Secondary bacterial infections, CNS involvement, myelitis, GBS, meningitis

Answer 143

* HHV4 infection – Causes Mononucleosis * Maybe asymptomatic * Systemic manifestations: FATIGUE, fever, malaise, HA, sore throat with exudates, LAD?, splenomegaly, lymphocytosis, abnormal LFTs * Fatigue and pharyngitis can linger for 6+ months and may recur with compromised immune system

Answer 144

Dx: Serologic testing * Atypical lymphocytosis on peripheral smear * Heterophile Ab testing (Rapid Mono-Spot test-> blood test) * (kids may not produce so low sensitivity) * Viral capsid Ag for confirmation : IgM = acute infection, IgG = chronic or prior infection * In absence of testing ability, prophylactic amoxicillin may serve as diagnostic tool Tx: Supportive * Avoid contact sports dt splenomeganly * Recent studies show 40 fold increased risk of MS development

Answer 145

* HSV 5 – reactivates in compromised immune system * Maybe asymptomatic in immunocompetent host * Reactivation 2◦ immunosuppression: fatigue, low grade fever, chills, sweats, myalgia, decreased appetite, LAD, sore throat, HA, rash, leukocytosis, anemia, abnormal LFTs, +Rf, +ANA (CD4<50) * In severe immunocompromised hosts: hepatitis, pneumonitis, colitis, retinitis, encephalitis, myelitis

Answer 146

Dx: Gold standard – Inclusions on Histology with + immunochemistry * Preferred – Quantitative PCR – detects viral DNA in sample OR * Serology – detects CMV IgM antibodies - indicates acute infection Tx: Immunocompromised only (ganciclovir, foscarnet, cidofovir, valganciclovir) * Seronegative transplant patients should receive prophylactically

Answer 147

HHV 6 (6th Disease, Exanthema subitum) * Replicates in leukocytes and salivary glands Sxs: High Fever (104) for 3-5 days, febrile seizures, malaise, conjunctivitis, orbital edema, TM inflammation, LAD, irritability, anorexia, bulging fontanelle, diarrhea, cough, and URI symptoms * Nagayama spots (Uvulopalatoglossal spots )- erythematous papules on soft palate and uvula. Dx: Clinical and to r/o others Tx: supportive, high risk of febrile seizures. Risk of recurrence in immunocompromised states (cancer/transplant etc.) | there is blenching in mouth

Answer 148

After fever dissipates [day 5-6] rash develops [1-2days] * 2-5mm rose-pink/red maculopapular appearance with halos, starting on trunk spreading to neck, face, and extremities.

Answer 149

* Dx: Serology to detect Parvovirus B19 IgM (detectable within 7 days, may be positive for months) * Can cause “Glove and Sock” distribution of rash as well * Tx: Self-limiting ## Footnote Be careful: sypillis, HFM, and 5th disease all cause glove and sock distribution

Answer 150

Aplastic crisis- inability to produce RBC leading to sudden and severe anemia * In utero can cause fetal hydrops and CHF

Answer 151

Single stranded RNA virus (many subtypes, 2 most prevalent) * A (Severe) – H1N1 Swine; H1N5 Avian; * B (mild) – more seasonal * C (rare) – not a typical test in clinical practice Transmitted directly or indirectly via droplets or inanimate objects Sxs: Typical respiratory (High fever, chills, headache, coryza, myalgia, flushed, hyperemic oropharynx, decreased appetite) * Severe symptoms in immunocompromised patients Dx: Clinical suspicion, Antigen vs PCR test

Answer 152

* RIDTs (Rapid Influenza Diagnostic tests) – nasal swab antigen detection w/i 3 days of onset, specific not sensitive, 15-30min results; good for outpatient use [false -], costly * Rapid molecular assay/ RT-PCR – detects viral RNA, can be used as a rapid for hospitalized patients or confirmatory with symptomatic false – RIDTs, detect nucleic acid with high sens/spec, 45 min – 2hr * EIA (Enzyme immunoassay) – detects A and B but not subtypes, 2 hours * Serology – not recommended, takes two + weeks * Viral culture – 4-10 days, used for characterization and identification for surveillance

Answer 153

Self-limiting in stable patient. Consider Tx in pregnant, elderly, abnormal vital signs, presence of abnormality on work-up (i.e. pneumonia). **72hr treatment window** * Antiviral medications for A and B: Oseltamivir (can be used as a prophylactic measure in high-risk areas or individuals), zanamivir, and peramivir * Flu A: Amantadine, Rimantidine * Flu vaccine yearly, educate on hand washing, hydration, symptom control

Answer 154

Multiple strains, cause various upper vs lower respiratory symptoms * Common cold, Croup, Tracheobronchitis, Bronchiolitis, Pneumonia * Triggers Asthma, COPD, CHF Community acquired for children < 5years old, immunocompromised, elderly, with predisposing factors: * Malnutrition, overcrowding, Vitamin A def, environmental smoke or toxin

Answer 155

Dx: Clinically, high level of suspicion during times of outbreak * Molecular/PCR testing – most accurate * Flocked swabs of nasopharynx during early illness and later on nasal aspiration/washes, sputum, lavage * Viral Culture – rarely used, time consuming * EIA – no rapid available Tx: Depending on associated illness, supportive measures * Croup – corticosteroids (PO/IM), nebulized epinephrine * Humidifier, Hand hygiene, fluids * Abx (only if have bacterial infection or pneumonia present)

Answer 156

* Incubation 7-18 days * Penetrates into host cells (pharynx/lung), where the virus and cell create a matrix, thus regulating/suppressing host cell immune response, thus increasing viremia * Can be transmitted 4 days before and after 4 rash presence * Typical host – child 4-5yo (esp. those with Vit. A deficiency or malnutrition); pregnant or immunosuppressed.

Answer 157

Sxs: 3 C’s = Cough, coryza, conjunctivitis; depletes vitamin A (epithelial cell damage); 4 D’s = rash starts on day 4 * **Prodromal stage** - fever, malaise, coryza, cough, conjunctivitis/photophobia, palpebral edema, dry cough; Koplik spots (white spots on buccal mucosa) * **Eruptive stage** – high fever spikes with onset of maculopapular rash (fine ->coarse becoming confluent) which starts behind the auricle/hair line towards the face, trunk and extremities; fever disappears 2-3 days after rash starts * **Convalescent stage** – 3-4 days after rash disappears, all symptoms dissipate in the way they appeared * **Atypical** – high fever, HA, abdo pain, myalgia; pneumonia, otitis media, myocarditis, pericarditis, encephalitis | RASH IS LATER

Answer 158

Clinically * Serology IgM (day 3 of rash - ~60days) and IgG (4 fold increase in Ab from acute to convalescent stage) * RT-PCR – pharyngeal or nasopharyngeal swabs, urine; allows for genotyping * Viral isolation

Answer 159

* Vitamin A (100-200k iu) * Symptom control, hydration, nutritional support, prevention of secondary infections * Routine Immunization (1st dose 12-15 mo, 2nd dose 4-6 y/o or 1 month after first dose if >12 mo)

Answer 160

* For infants 0 to 5 months of age, it is recommended that they receive immune globulin within 6 days of exposure. * For infants 6 to 11 months of age, it is recommended that they receive either a measles vaccination within 72 hours of exposure or immune globulin within 6 days of exposure. * For children greater than 12 months of age, who are unvaccinated, it is recommended that they receive measles vaccination within 72 hours of exposure (preferred over immune globulin). If the exposure occurred more than 72 hours, but within 6 days, the patient should receive immune globulin if they have not received at least one dose of the measles vaccine (unless the child is severely immunocompromised, see below).

Answer 161

Pregnancy * It is recommended that they receive immune globulin. * Measles vaccination, in conjunction with mumps and rubella, is contraindicated. For immunocompromised patients: * Immune globulin should be administered regardless of immunologic or vaccination status.

Answer 162

* Two doses of measles vaccine at the routine intervals should be administered for unvaccinated healthcare personnel regardless of the birth year who lack laboratory evidence of measles immunity or laboratory confirmation of disease. * Health care workers that lack evidence of immunity who were exposed to a patient with measles should be excluded from the workplace from day 5 through day 21 after exposure.

Answer 163

Incubation period of 17-23 days; low grade fever, malaise, HA, sore throat, LAD, rash * **Rash begins, after fever**, on face as pinpoint pink macules and papules (scarlatiniform or purpuric) and rapidly spread to trunk and extremities. [3 days] * Forchheimer spots –petechiae on soft palate | RASH AFTER FEVER

Answer 164

* Serologic testing, EIA for IgM seen w/i 4 days of rash. IgG maybe used during acute exposure and convalescent phase * In utero: IgM in fetal blood or detection of rubella RNA via RT-PCR in amniotic fluid, fetal blood, chorionic villus bx

Answer 165

Symptom control with use of NSAIDS * In utero < 18 weeks – discuss pregnancy termination; >18 weeks – serial monitoring, US * Children born with CRS need multidisciplinary approach * Prevention through Vaccination

Answer 166

* Caused by Rubulavirus via respiratory droplets * Incubates 7-21 days; Highly contagious 1-2 days before symptoms, then highly contagious * Infects mononuclear cells ->systemic inflammation in salivary glands, testes, ovaries, pancreas, mammary glands, CNS

Answer 167

* Prodrome – HA, fatigue, fever, anorexia, malaise * Followed by parotitis, orchitis; mild flat red rash; meningitis, encephalitis, myelitis, Guillan-Bare syndrome, cerebellar ataxia, facial palsy, hydrocephalus * Parotitis – MC manifestation 70%; Bilateral, painful inflammation between the earlobe and angle of the mandible * Stenson’s duct red, swollen, and involves the submaxillary and submandibular glands; Recurrent sialadenitis * Orchitis – bilateral painful swelling, enlargement, and tenderness of the testes -> testicular atrophy. Sterility is rare

Answer 168

Dx: Clinically, plus labs * RT-PCR serum or oral secretions, and for viral cultures * Oral swab must be within 3-8 days of parotitis * Serology for IgM and IgG – timing is everything. Vaccinated pt may result in false -; reportable CDC

Answer 169

Self resolving, Symptom control * Cold compresses, pain management. * Prevention through vaccination; live vaccine not for pregnant women, * 5 day isolation

Answer 170

* Arthropod-borne flavivirus * Transmitted by mosquito, sex, transfusion, maternal/fetal * Central, South America, Caribbean & Pacific * Clinical Presentation – most asymptomatic, about 20% have mild illness with low grade fever, rash, arthralgias, conjunctivitis. * Congenital Zika is devastating – microcephaly, cerebral malformation, ocular lesions, congenital contractures and hypertonia

Answer 171

Dx: * Serum or urine Zika virus IgM, screen pregnant women with reverse-transcriptase PCR, NAAT Txt: * Supportive care, hydration * Prevention –Avoiding mosquito bites, avoiding unprotected sex with a partner at risk of having Zika virus infection, and, for pregnant women, avoiding travel to areas with ongoing transmission.

Answer 172

* Congenital toxoplasmosis is caused by transplacental acquisition of Toxoplasma gondii * Manifestations (if present): Prematurity, intrauterine growth restriction, jaundice, hepatosplenomegaly, myocarditis, pneumonitis, rash, chorioretinitis, hydrocephalus, intracranial calcifications, microcephaly, and seizures

Answer 173

* Diagnosis is by serologic or PCR testing. * For fetal infection, PCR analysis of amniotic fluid is emerging as the diagnostic method of choice * Serial IgG measurement (maternal infection) * Treatment is with pyrimethamine, sulfadiazine, and leucovorin.->PLS do not have tox while preg

Answer 174

* Overall risk of transplacental infection of the fetus is about 60 to 80% * Likelihood is increased during the 2nd half of the pregnancy * Untreated primary or secondary syphilis in the mother usually is transmitted, but latent or tertiary syphilis is transmitted in only about 20% of cases * Untreated syphilis in pregnancy is also associated with a significant risk of stillbirth and neonatal death.

Answer 175

* There is no single recommended way to monitor pregnant women with parvovirus B19 infection. * Can get blood test to screen for disease or immunity * Avoid exposures in endemic areas or during outbreaks (workplace)

Answer 176

* Primary – anti-viral – Acyclovir most common * Secondary Prophylaxis for recurrent infections – anti-viral initiated by patient at time of first sign/symptom * Secondary pharmaceutical therapies based on primary manifestation – Bells Palsy - Prednisolone

Answer 177

* Condom barrier protection during intercourse * Isolation, hand washing, gloves and gowns for care providers of patients with open lesions * Counseling patients to notify all partners and potential partners of status

Answer 178

* CRS in pregnancy can lead to miscarriage or stillbirth, and increase risk of severe birth defects. * Although specific symptoms can be treated, there is no cure for CRS. Since there is no cure, it is important for women to get vaccinated before they get pregnant

Answer 179

* Because MMR vaccine is an attenuated (weakened) live virus vaccine, pregnant women who are not vaccinated should wait to get MMR vaccine until after they have given birth * Adult women of childbearing age should avoid getting pregnant for at least four weeks after receiving MMR vaccine. * **Pregnant women should NOT get MMR vaccine, or rotavirus, chickenpox, small pox or yellow fever**

Answer 180

* Cytomegalovirus infection may be acquired prenatally or perinatally * Most common congenital viral infection * Signs at birth (if present: Intrauterine growth restriction, prematurity, microcephaly, jaundice, petechiae, hepatosplenomegaly, periventricular calcifications, chorioretinitis, pneumonitis, hepatitis, and sensorineural hearing loss * If acquired later in infancy, signs may include pneumonia, hepatosplenomegaly, hepatitis, thrombocytopenia, sepsis-like syndrome, and atypical lymphocytosis. * Diagnosis of neonatal infection is best made by viral detection via culture or PCR testing

Answer 181

Mainly supportive * **Parenteral ganciclovir or oral valganciclovir** may prevent hearing deterioration and improve developmental outcomes and is given to infants with symptomatic disease identified in the neonatal period

Answer 182

* Nonimmune pregnant women should attempt to limit exposure to the virus. For instance, because CMV infection is common among children attending day care centers, pregnant women should always wash their hands thoroughly after exposure to urine and oral or respiratory secretions from children. * Transfusion-associated perinatal CMV disease can be avoided by giving preterm neonates blood products from CMV-seronegative donors or leukoreduced products.

Answer 183

* A patient can get genital warts or develop abnormal cell changes on cervix during pregnancy * Abnormal cell changes can be found with routine cervical cancer screening, which should continue during pregnancy * And a mother can transmit HPV to her baby during birth, but this is also uncommon-> for a female newborn, it will increase the risk of cervical cancer (16/18/35)

Answer 184

* Normal flora becomes an opportunistic pathogen * Can be cultured from the mouth, vagina, and feces of most people * Risk factors – neutropenia, recent abd sx, broad spectrum abx, renal disease, IV catheters, cellular immunodeficiency * Scraping usually causes bleeding

Answer 185

* Esophageal involvement is the most frequent type of significant mucosal disease * Clinical presentation – painful swallowing (substernal), gastroesophageal reflux, nausea without substernal pain. * Diagnosis – endoscopy with biopsy and culture * KOH prep will reveal budding yeast * Treatment – fluconazole daily for 10-14d

Answer 186

* Vulvovaginal candidiasis occurs in an ~75% of women. * Clinical presentation – acute vulvar pruritus, burning vaginal discharge, and painful sexual intercourse * Diagnosis –** Wet prep with KOH** visualize budding filaments and mycelia * Treatment – topical azole preparations –miconazole 200mg vaginal suppository for 3 days, or Fluconazole

Answer 187

* Bloodstream * Candidemia with deep-seated infection * Deep seated candidiasis in absence of bloodstream infection * Clinical presentation – varies from minimal fever to septic shock and can mimic a severe bacterial infection * Expect in immunocompromised patients * Requires ID consult * Note: Posaconazole has been approved for prophylaxis of Candida in neutropenic patients

Answer 188

Beta D-Glucan is the test of choice – indicates invasive fungal infection

Answer 189

History of headache and neurologic symptoms in a patient with an underlying immunosuppressive disorder (HIV, organ transplant)

Answer 190

* Most are asymptomatic, go unrecognized * Past infection leaves pulmonary and splenic calcification * May involve soft tissues * May have a mild flu-like-illness * Moderately severe infections have a clinical picture of pneumonia with fever, cough and mild central chest pain lasting 5-15 days

Answer 191

* Pancytopenia on CBC * Increased alkaline phosphatase and LDH * **Antigen test – sputum or urine** * Blood or Sputum Cultures * CXR – pulmonary infiltrates, hilar or mediastinal lymphadenopathy

Answer 192

* In most cases Itraconazole OR AmB + Itraconazole (for severe disease) * AIDS related histoplasmosis requires life long suppressive therapy.

Answer 193

* Fever with non-productive cough * Progressive dyspnea on exertion * Physical signs may be minor; nonspecific * Bibasilar crackles (may develop later) * Extrapulmonary manifestations: Rare, most notably include lymph nodes, hepatosplenomegaly

Answer 194

to start empiric therapy * Oral trimethoprim-sulfamethoxazole x 14 days is the preferred agent for mild-moderate disease

Answer 195

* Enterobius vermicularis * Cardinal sign – perianal pruritis, typically nocturnal * Diagnosis – identification of eggs or adult worms on perianal skin * Scotch tape test

Answer 196

* Treatment – Albendazole 400mg or Pyrantel pamoate 11mg/kg to max of 1 gram (caution <2yo), mebendazole 100mg – all single doses * Repeat dose in two weeks due to frequent reinfection * Wash all cloths and bedding * Treatment of household members is advocated to eliminate asymptomatic reservoirs of potential reinfection

Answer 197

* Cause – T. gondii * Hosts – cats * Humans infected by ingestion, food or water contaminated by cats, transplacental, transfusion or organ transplant * ~1.1 million in US, vision loss in 4800

Answer 198

* Confirmed by isolation of Toxoplasma gondii or identification of tachyzoites in tissue or body fluids * Multiple serologic methods – IgM and IgG most sensitive * Medications do not eradicate disease and immunocompetent persons infected do not typically require tx * If severe sxs: Generally treat for 1 month with pyrimethamine plus either sulfadiazine or clindamycin and sometimes with prednisone

Answer 199

* Treatment required in Pregnancy * Pyrimethamine and sulfadiazine, plus folinic acid (Leucovorin) * Alternatives are available, but are inferior to pyr-sulf * Prevention – avoid cats, avoid undercooked meat, pregnant women should not empty litter boxes

Answer 200

* Due to fecal/oral transmission of Entamoeba histolytica * Consider in recent travelers or immigrants * See diarrhea, abdominal pain, weight loss, hepatomegaly/RUQ pain. * On CT will see oval lesions in the liver – if aspirate see “anchovy paste” appearance.

Answer 201

* Dx by Stool O&P, antigen tests or FNA if cysts on skin. * Tx Metronidazole or tinidazole and Paromomycin. * If asymptomatic liver cysts order PO ABX – iodoquinol or paromomycin

Lecture 4 (ID)-Exam 2 Flashcards

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