Part 2 Flashcards
(143 cards)
1
Q
% of vertical transmission in untreated HIV infection?
A
25-35 %
< 1% with effective tx
2
Q
After exposure to trans;issible TB with infection, which % develop primary disease vs latent TB ?
A
5% primary TB
95% latent TB
3
Q
Antimicrobial prophylaxis in oncology : cipro ?
A
Recommended in those at high risk of FN or prolonged profound neutropenia (>7d and ANC < 0.1)
4
Q
Candida parapsilosis and Candida lustianiae sensibility ?
A
C parapsilosis
- Variable sensibility to echinocandins
C lusitaniae
- R to ampho B
5
Q
Can TST and IGRA exclude active TB ?
A
No neither can separate LTBI from active TB
They can be both negative in active TB
6
Q
Candidemia tx if CNS infection ?
A
Ampho B +/- flucytosine
7
Q
Candidemia tx if pregnancy ?
A
Ampho B
8
Q
CD4 count and TB in HIV patients?
A
Can occur at any CD4 counts
9
Q
CD4 count if oral hairy leukoplakia ? (associated with EBV)
A
200-500
10
Q
CD4 count in non invasive candidiasis ?
A
CD4 200-500
11
Q
Chikungunya incubation ?
A
< 2w
12
Q
Clinical presentation of dengue ?
A
Fever, maculopapular rash, retro-orbital pain, myalgias, thrombocytopenia
13
Q
CMV retinitis / colitis and HIV patient : CD4 count ?
A
< 50
14
Q
Consideration in the diagnosis of latent TB if patient is immunosupressed ?
A
TST and IGRA may be negative if immunosuppressed
15
Q
Cutaneous KS seen with what CD4 count ?
A
200-500
Caused by HHV8
16
Q
Dengue : incubation ?
A
< 2 weeks
17
Q
Does this patient have early HIV infection ? Best LR ?
A
- Genital ulcers LR 5
- Weight loss, vomiting, swollen LNs LR 4
- Fever LR 3
18
Q
Duration of tx for staph aureus bacteremia ?
A
Uncomplicated 14 days IV
Complicated 4-6 weeks IV
19
Q
Endemic and non endemic fungi in HIV patients : which CD4 ?
A
< 200
Coccidiosis, histoplasmosis, blastomycosis, aspergillosis, cryptococcus
20
Q
Fever in returned traveler : biphasic fever ddx ?
A
dengue
21
Q
HHV8 infection complication in HIV patients ?
A
Cutaneous KS
22
Q
HIV and MAC infection : treatment ?
A
Clarithromycin + ethambutol or azithro + ethambutol x 12 mos
23
Q
HIV and PJP : how do you TREAT if proved infection ?
A
- TMP SMX 15-20 mg/kg IV x 21 days
Other alternatives for moderate to severe : primaquine and clinda IV or pendamidine IV
+ for severe only:
- Prednisone 40 PO BID x 5d then
20 PO BID x 5d
then 20 OD x 11d
24
Q
HIV and toxoplasma infection tx?
A
Sulfadiazine/Septra + primethamine x 6 wk +/- chronic maintenance if ongoing clinical or radiographic disease
25
How do you diagnose lyme disease if early disseminated or late manifestations ?
Serology for dx rather than PCR
26
How do you diagnose Lyme disease if erythema migrans ?
Typical lesions are sufficient for clinical diagnosis
27
How do you diagnose malaria ?
-Thick and thin blood smear x 2 separated by at least 6 hours over 24 hour period
- Rapid detection test (RDT)
28
How do you treat active TB in HIV patients ?
Tx is the same as for HIV negative patients
29
How do you treat complicated malaria ?
IV artesunate x 48h then PO
- atovaquone proguanil OR
- doxycycline OR
- clindamycin
If artesunate not available : IV quinine
Should admit to ICU
30
How do you treat latent TB ? What is the first and second line regimen ?
First line
- Rifampin daily x 4 months
Second line
- Isoniazid daily x 9 months
31
How do you treat latent TB and HIV ?
Preferred regimens :
- 3HP : weekly INH + rifapentine for 3 months
- 3HR : daily INH + rifampin for 3 months
- Alternative INH x 6-9 months
32
How do you treat lyme disease ?
Usually doxycycline x 10 days
If neurological x 14-21 days
If carditis : ceftri first
If arthritis : doxy x 28 days
33
How long should you do PJP prophylaxis ?
Continue prophylaxis until CD4 count stabilizes > 200 for at least 3 months
34
How long should you treat candidemia ?
2 weeks from first negative blood culture (if no metastatic focus)
35
Indications for admission for lyme disease ?
PR > 300, other arrhythmias, myopericarditis
36
Interferon gamma release assay : affected by BCG ?
Not affected by BCG
37
Intrapartum care for HIV pregnant patient ?
- Always continue ARV
- If VL > 1000 copies/mL near delivery : IV zidovudine and scheduled C/S
- Zidovudive for everyone in Ontario
38
Leptospirosis incubation and transmission?
2-26 days, around 10 days
Transmitted by animal waste
39
MAC in HIV patient : CD4 count ?
< 50
40
NHL > HL, MM, leukemia in HIV patients : CD4 count ?
< 200
41
PJP infection in HIV patient : CD4 count ?
< 200
42
PJP prophylaxis in pregnancy?
Prophylaxis with TMP SMX recommended during pregnancy
Supplement with folic acid during first trimester (NT defects)
43
PJP prophylaxis with which CD4 count ?
If CD4 < 200
44
PML caused by JC virus and HIV patient : CD4 count ?
< 100
45
Post partum for HIV pregnant patients ?
- If maternal VL suppressed within 4w of delivery : infant given AZT (zidovudine) x 4wks
- If maternal VL not suppressed at birth, infant given presumptive 3 drug ART
- Breastfeeding NOT recommended for mothers living with HIV in US/Canada
46
Post travel fever with longer incubation periods > 2 weeks : ddx?
Malaria, TB, hepatitis, HIV, enteric fever due to salmonella spp
47
Post travel fever with short incubation period < 2 weeks : ddx ?
Malaria, dengue, chikungunya, traveller’s diarrhea, viral URTI, influenza
48
Sensibility C albicans / dubliniensis / tropicalis ?
SENSITIVE to all azoles
49
Sensibility of C krusei ?
Resitant to fluconazole
S to echinocandins
S to ampho B
50
Sensitivity of C glabrata ?
VARIABLE to fluconazole
S echinocandins
S ampho B
51
Should you treat pregnant woman with latent TB ?
Not until after delivery unless high risk of TB reactivation, and use 4R regimen
52
Should you treat pregnant women with active TB ?
YES as elevated risk of TB disease and significant associated morbidity to both woman and fetus
Risk of untreated < adverse effects drugs
53
Side effects of rifampin ?
Drug interaction, rash, hepatitis
54
Side effects of ethambutol ?
Eye toxicity, rash
55
Side effects of isoniazid ?
Rash, hepatitis, neuropathy
56
Side effects of pyrazinamide ?
Hepatitis, rash, arthalgia
57
Toxoplasmosis in HIV patients : CD4 count ?
< 100
58
Treatment for candidemia : stable, no recent azole exposure ?
vs unstable, neutropenic or recent azole exposure ?
- Fluconazole if stable and no recent azolel exposure
- Otherwise echinocandin also if neutropenic
59
TST criteria for planned biologic use or immunosuppressive drug ?
5 mm
60
TST criteria for presence of fibronodular disease on CXR or contact with infectious TB case within past 2 years ?
5mm
61
TST criteria if hematologic malignancies?
≥ 10 mm
62
TST in latent TB : when is the reaction considered positive ?
- 5 mm if much higher pre test probability (cf criteria)
- ≥ 10 mm other risk factors
- > 15 mm for patients without risk factors
Considered negative if 0-4mm
63
TST positive for HIV patient ?
5 mm
64
TST positive for stage 4 or 5 CKD ?
5 mm
65
Tuberculin skin test : affected by BCG ?
Yes may be affected by BCG after infancy
66
Tx for strongyloides stercoralis ?
Ivermectin
67
Typhoid clinical presentation ?
Fever, flu like illness, salmon coloured spots, constipation, abdo pain, relative brady
68
Typhoid incubation?
5-21 days
69
Vaccines that needs caution if immunocompromise ?
Live attenuated : MMR, varicella, rotavirus, immavune
70
Visceral KS and CD4 count ?
< 200
71
What are the two main types of malaria ?
- Plasmodium falciparum
can be severe, presents within 3 months
- P ovale and P vivax
less severe, may present years later due to hypnozoites in liver
72
What has the best LR+ to know if this returned traveler have malaria ?
- Hyperbilirubinemia LR 7.3
- Splenomegaly LR 6.5
- Thrombocytopenia LR 5.6
- Fever LR 5.1
- Jaundice icterus LR 4.5
73
What has the best LR- to know if returned traveler has malaria ?
Cough LR- 1.3
Hepatomegaly LR- 0.95
74
What is early disseminated lyme disease ?
- Multiple erythema migrans (multiple target lesions)
- Early neuroborreliosis
- Carditis
75
What is late lyme disease ?
Arthritis
Late neuroborreliosis
76
What is malaria chemoprophylaxis for pregnant patients ?
- Chloroquine/hydroxychloroquine
- Mefloquine
77
What is the criteria for severe malaria ?
Essentially any end organ dysfunction
Hyperparasitemia
≥ 5% for non immune adults
≥ 10% for semi immune adults
78
What is the definition of moderate-severe PJP infection ?
PaO2 < 70% or Aa gradient > 35
79
What is the regimen (duration of tx) for TB disease ?
= ACTIVE TB
Here for suspected drug susceptible TB
- Intensive phase with 3-4 active drugs x 2 months
- Continuation phase with 2 active drugs x min 4 months
80
What is the regimen (which agent) for TB disease tx ?
If known susceptible : INH/RMP/PZA x 2 months then INH/RMP for 4 months
If suspect susceptible but no susceptibility results : add EMB « RIPE »
81
What is the synonym for latent / active TB?
Latent = TB infection
Active = TB disease
82
What is the tx for typhoid fever ?
IV ceftri or cipro or azithro
Careful more resistance to FQ in SE Asia
If Cambodia for ex : ceftri
83
What is the tx for uncomplicated malaria ?
P falciparum :
- Generally chloroquine resistant
- Atovaquone-proguanil
Non falciparum spp :
- Generally chloroquine sensitive
- Chloroquine
If P vivax or P ovale : add primaquine to treat hypnozoite stage
84
What is the tx of dengue ?
Supportive care, avoid NSAIDs
85
What PJP prophylaxis if sulfa allergy ?
Dapsone OK for sulga allergy, NOT OK for SJS/TEN to TMP SMX
Atovaquone for SJS/TEN
86
What should you add while using pyrimethamine ?
Add leucovorin
87
When is PJP prophylaxis recommended in oncology patients ?
if chemotherapy risk of PJP > 3.5% eg : those with ≥ 20 pred daily for > 1 month
88
When is steroids indicated in TB disease treatment ?
Add steroids for TB meningitis or pericardial disease
89
When should you add primaquine in malaria management ?
Add if P vivax or P ovale to treat hypnozoite stage
Check G6PD first
90
When should you consider PJP prophylaxis in immunomodulating therapy ?
TMP SMX for PJP if pred > 20mg/d for > 4-8 weeks
91
When should you defer ART therapy in HIV patients ?
If TB meningitis : defer for 8 weeks given high risk of ART, especially if low CD4 count i
92
When should you do G6PD testing ?
Prior to using dapsone or primaquine
93
When should you initiate ARV for HIV ?
ARV recommended for all individuals with HIV, regardless of CD4 count to reduce morbidity and mortality associated with HIV infection
94
When should you NOT prescribe echinocandins?
NOT for CNS/eyes
NOT for C parapsilosis
95
When should you screen for latent TB infection when initiating immunomodulating therapy ?
TST/IGRA if > 1 TB risk factor amd either TNF-a or Pred > 15mg per day for > 4 weeks or equivqlent
RF : close contact w TB, recent immigration high risk country, high risk work/life exposure
96
Which infection if HIV patient with CD4 > 500 and : fever, night sweats, lymphadenopathy, headache, weight loss ?
TB !
Can occur at any CD4 count
97
Which prophylaxis for HIV with CD4 < 200 ?
PJP PROPHYLAXIS
- TMP SMX 1 DS PO DAILY
98
Which prophylaxis if CD4 < 100 ?
TOXOPLASMA if toxo IgG positive
- TMP SMX 1 DS PO daily
99
Which prophylaxis if CD4 < 50 ?
MAC propjylaxis no longer recommended unless pts are not starting ART ot not fully suppressive ART
- Azithro 1200 PO weekly
- Clarithro 500 PO BID
100
Which regimen for pregnant women with active TB ?
INH, RIF, EMB SAFE in pregnancy so give all three
PZA added if extensive disease, smear positive pulmonary disease, disseminated TB
101
Which species are resistant to ampho B ?
C lusitaniae
102
Which species are resistant to echinocandis ?
C parapsilosis variable
103
Which species are resitant to fluconazole ?
C krusei R
C glabrata variable
104
Which test to use for latent TB if patient unlikely to be compliant to visits ?
Interferon Gamma Release Assay as TST takes 2 patient visits
105
Which test to use for latent TB if prior BCG ?
Interferon Gamma Release Assay
106
Which tests can NOT separate LTBI from active TB ?
- Tuberculin Skin test
- IGRA interferon gamma release assay
107
Which tests should you use to diagnose latent TB ?
- Tuberculin Skin Test
- IGRA : interferon gamma release assay
108
Which vitamin should you prescribe when treating TB disease ?
Add B6 (pyridoxine) to prevent peripheral neuropathy
109
Zika virus incubation ?
< 2 w
110
Fever after travelling to South East Asia like Cambodia ?
Typhoid fever in SE Asia prevalent
Increased FQ resistance in SE Asia so use ceftriaxone
111
Rash in typhoid fever ?
Rose / salmon colored spots
112
HIV and PJP active infection : tx ?
TMP SMX 15-20mg/kg IV x 21 days for any severity
+ prednisone if severe only
113
HIV and PJP infection if sulfa allergic ?
If moderate to severe
- Clindamycin IV and primaquine (G6PD to check)
- Pentamidine IV
IF FROM SAUDI ARABIA : higher risk of G6PD deficiency so give pentamidine
114
68 y M from Saudi Arabia living with HIV admitted with PJP pneumonia confirmed by bronchoscopy. ABG shows PaO2 62. He has a severe allergy to sulfa reported. In addition to prednisone, management should include:
a. TMP-SMX 15mg/kg IV
b. IV foscarnet
c. IV pentamidine
d. PO dapsone
e. Clindamycin and Primaquine
C - He is Sulfa Allergic so TMP-SMX is off the table. For second line – clinda/primaquine usually preferred but being from Saudi Arabia higher chance this man has G6PD deficiency so would recommend PENTAMIDINE instead.
115
You are seeing a 25yo MSM for HIV pre-exposure prophylaxis. As part of routine screening, you diagnose pharyngeal gonorrhea by NAAT testing. He weighs 52kg. How do you treat?
A. Ceftriaxone 250 mg IM x1 and doxycycline 100mg PO BID x 10d
B. Ceftriaxone 250 mg IM x1 and Azithromycin 1 g PO x1 and test of cure
C. Ceftriaxone 500 mg IM x1 and test of cure
D. Ceftriaxone 250 mg IM x1, Azithromycin 1 g PO x1 and Pen G 2.4MU IM x 1
B - Depending on whether you read PHAC or CDC guidelines. Would follow PHAC guidelines for exam, but would not likely be faulted for saying C in the oral exam.
Increasing CFTx resistance is the reason for dosing increase from CDC, whereas PHAC chose dual coverage to overcome resistance. Note: Pharyngeal gonorrhea requires test of cure in both guidelines.
116
You have been referred a 78M patient for positive syphilis serology (RPR 1:32), ordered in the context of work-up for dementia. They do not have a previous history of syphilis have never been previously tested, and are asymptomatic aside from some intermittent ringing in their ears. They have already been given one dose of benzathine pen G by their family physician last week. The remainder of screening of STIs is negative. What further work-up do you recommend?
A. No further work-up or treatment.
B. Continue benzathine pen G 2.4 million units IM x 2 more doses 1 week apart, for total 3 doses
C. Repeat syphilis serology now to assess RPR titre for decrease to further guide treatment
D. Follow-up in 3 months with repeat serology at that point. Repeat penicillin dose then if titre has not decreased 3-fold
E. Lumbar puncture
E – at minimum this is late latent syphilis of unknown origin, but sx of dementia, + ringing in ears could be findings of neurosypihilis/otic syphilis. This requires LP, and treatment with IV penicillin x 14d. If this was negative, then continue treatment for late latent as in option B but need to rule out neuro first. Repeating serology now is too early, but goal is 4-fold drop within 6 months (if latent) or 1 year (if neur
117
Nova scotia and Lyme disease ?
+++ prevalent
118
What is the presentation of hepatosplenic candidiasis ?
Typically occurs in patients with heme malignancy and prolonged neutropenia. Candida gets into the bloodstream and seeds the liver/spleen.
Lesions are often not visible while neutropenic, but emerge once the neutrophil count recovers.
May be accompanied by an elevated ALP.
Suspect in someone who either is not improving on antifungals or improves then worsens again especially after neutrophil recovery.
119
You have just diagnosed active pulmonary TB. In which patient would the likelihood of MDR-TB be lowest?
A. Patient with thoracotomy 20 years ago for TB
B. Patient with well controlled HIV
C. Patient from a northern First Nations community with recent contact with MDR TB patient
D. PatientfromSouthAfrica
B is the best answer based on the guidelines as known risk factors for MDR include previously treated TB (anti-TB medications would have been used 20 years ago), known contact with an MDR case and being born in an endemic country .
120
Known risk factors for MDR - TB ?
- Previously treated TB
- Known contact with MDR case
- Being born in endemic country
121
Infection precautions if suspected case of H5N1 ?
Contact/droplet precautions
Some hospital will request airbone precautions
122
Treatment of H5 N1 ?
Oseltamivir or zanamivir
123
How do you treat Kaposi sarcoma in HIV patients ?
Usual treatment is initiation of ART, and follow up as this generally regresses with treatment. Intralesional chemotherapy can be considered for large lesions, especially if not improved on ART.
124
If traveller returned from travel 22 days ago, which infection is least likely ?
DENGUE
125
Which ameboe causes liver abscesses ?
Entamoeba Histolytica.
Entamoeba Dispar is a non-pathogenic species that resembles E. Histolytica on microscopy.
Naegleria and Acanthamoeba primarily cause CNS related disease.
126
Which amoebae causes SNC disease?
Naegleria
Acanthamoeba
Naegleria is also not found in Canada. The incubation period is 5 days and death usually follows 5 days after symptom onset, so it is unlikely that
a case even in a traveller would occur be seen in Canada.
127
Giardia transmission and epidemiology ?
Fecal oral transmission
Day care, drinking swimming in lake or river, MSM
128
Giardia treatment ?
Metronidazole x 14 days
129
Leishmania presentation ?
Cutaneous ulcers, mucocutaneous and visceral forms
130
How do you treat entamoeba histolytica liver abscess ?
Paromonycin for luminal
Metronidazole for systemic
131
Which helminths/worm after eating undercooked wild animal meat (bear/pork) ?
Trichinella spiralis (trichinosis)
GI sx, muscle pain, cysts
Tx : albendazole/mebendazole
132
Trichinella spiralis / trichinosis epidemiology and tx ?
Undercooked wild meat animal meat
Tx albendazole / mebendazole
133
When should we initiate ART therapy in ART naive HIV patients with active TB ?
• IfCD4<50→within2weeks
• IfCD4>50→within8weeks
• Pregnancy → ASAP regardless of CD4
• If TB meningitis → defer for ~8 weeks given ↑ risk of IRIS (especially if low CD4 count
134
Can you distinguish active pulmonary TB from inactive disease on the basis of radiography alone ?
No
135
Tree in bud pattern on chest CT : dx ?
First decribed in cases of endobronchial spread of m. tuberculosis
But seen in various entities, not specific at all
136
Comment couvrir le Streptocoque R pénicilline avec les céphalos ?
On choisit une C3G car non couvert par C2G (cefuroxime)
Ex : ceftriaxone, cefotaxime similaire et interchangeable
137
Quelle céphalos pour traiter une pneumonie ?
C2G OK pour un patient traité un externe (ex cefuroxime)
C3G pour couvrir strep R PNC : cefotaxime, ceftriaxone
Ceftazidime aussi dans la même famille mais couvre + les gram négatif
138
Différence entre ceftriaxone et cefotaxime?
Both C3G
Ceftri a une excrétion biliaire donc risque de cholestase
Cefotaxime a une excrétion rénale donc bien pour la PBS
139
Tropical disease with thrombocytopenia particularly ?
Dengue
140
TST cut off if smoking ?
10 mm
141
TST cutoff if DM ?
10 mm even if well controlled
142
What is the next step once PPD + ?
R/O active TB
Then tx
143
Outpatient management for febrile neutropenia ?
Cipro + clav (or clinda if pen allergic)
Inpatient if anticipated neutropenia > 7 days, heme malignancy or SCT
