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258 Cards in this Set
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Meningitis in 0-6 mos |
GBS
E.coli/Gram neg rods Listeria |
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Meningitis in 6 mo - 6 yo
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S. pneumonie
H. influenza B Neisseria meningitis Enterovirus |
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Meningitis in 6 -60yo
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S. pneumonie
N. meningitis Enterovirus HSV |
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Meningitis in elderly >60yo
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S. pneumonie
N. meningitis Listeria Gram neg rods |
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Diagnostic test for legionella
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urine legionella antigen
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diagnostic test for mycoplasma
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serum cold agglutinins and serum mycoplasma antigen
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diagnostic test for strep pneumo
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urine pneumococcal antigen
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UTI
(Main organism and empirical Abx to tx) |
E. coli
TMP-SMZ, nitrofurantoin, amoxicillin, quinolones |
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Bronchitis
(Main organism and empirical Abx to tx) |
Virus: no abx
Haemophilus influenza: Azithromycin/Erythromycin (macrolides "-mycin") Moraxella: either watchful waiting, quinolone (ciprofoxacin, "-floxacin"), erythromycin |
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Classic pneumonia
(Main organism and empirical Abx to tx) |
Strep pneumo, H.influenza
azithromycin, 3rd gen cephalosporin (ceftriaxone,etc) |
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Atypical pneumonia
(Main organism and empirical Abx to tx) |
Mycoplasma, Chlamydia
Macrolide (azithromycin, "-mycin"), doxycycline |
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Osteomyelitis
(Main organism and empirical Abx to tx) |
Staph aureus, Salmonella
Oxacillin, cefazlin, vancomycin |
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Cellulitis
(Main organism and empirical Abx to tx) |
Stretococci, staphyloccoci
Cephalexin, dicloxacillin If suspect MRSA: clindamycin or TMP-SMZ |
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Meningitis in neonate
(Main organism and empirical Abx to tx) |
Group B Strep, E.coli, Listeria
Ampicillin + aminoglycoside (streptomycin/amikacin/gentamicin/tobramicin), cefotaxime |
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Meningitis in child/adult
(Main organism and empirical Abx to tx) |
Strep pneumoniae, Neisseria meningitidis
*H. influenza if the child is NOT VACCINATED Cefotaxine or ceftriaxone + vancomycin |
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Endocarditis
(Main organism and empirical Abx to tx) |
Staphylcocci and streptococci
Dicloxacillin/methicillin (antistaph penicillin) or vancomycin + aminoglycoside (strepomycin/amikacin/gentamicin/tobramicin) |
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Sepsis
(Main organism and empirical Abx to tx) |
Gram-negative organisms, streptococci, staphylococci
3rd gen cephalosporin (ceftriaxone) or 3rd gen penicillin (ticarcillin/carbicillen) + aminoglycoside (strepomycin/amikacin/gentamicin/tobramicin), or imipenam |
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Septic arthritis (monogamous/nonsex vs sexually active young pt)
(Main organism and empirical Abx to tx) |
monogamous pt: staph aureus
sexually active pt: n. gonorrhea Vancomycin Ceftazidime/ceftriaxone: for gram neg Gonococci: ceftrixone, ciprofloxacin, or spectinomycin |
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Empiric abx for:
Strep A or B |
Penicillin, cefazolin
Alt: Erythromycin |
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Empiric abx for:
S. pneumoniae |
3rd gen cephalosporin + vancomycin
Alt: Fluoroquinolone |
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Empiric abx for:
Enterococcus |
Penicillin/ampicillin + aminoglycoside (amikacin/strepomycin/gentamicin/tobramicin)
Alt: Vancomycin + aminoglycoside |
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Empiric abx for:
Staph Aureus |
Methicillin
Alt: Vancomycin if MRSA |
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Empiric abx for:
Gonococcus +Additional step? |
Ceftriaxone or cefixime
Alt: Spectinomycin ADDITIONALLY, tx for chlamydia: doxycycline |
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Empiric abx for:
Meningococcus |
Ceftriaxone or cefotaxime
Alt: Pencillin G (if susceptible to pencillin) or chloramphenicol |
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Empiric abx for:
Haemophilus |
2nd gen cephalosporin (cefoxitin, ceflaclor) or 3rd gen (ceftriaxone/cefixime)
Alt: ampicillin |
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Empiric abx for:
Pseudomonas |
Ticarcillin/pipercillin + clavulanate/tazobactam (beta lactamase inhibitor)
Alt: ceftazidime, cefepime (4th gen), imipenemm, cipro |
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Empiric abx for:
Bacteroides |
Metronidazole
Alt: Clindamycin |
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Empiric abx for:
Mycoplasma |
Erythromycin, azithromycin
Alt: doxycycline |
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Empiric abx for:
Treponema pallidum |
Penicillin
Alt: Doxycycline |
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Empiric abx for:
Chlamydia |
Doxycycline, azithromycin
Alt: erythromycin, ofloxacin |
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Empiric abx for:
Lyme disease/Borrelia burgdorfei |
Doxycycline, amoxicillin, cefuroxime (2nd gen)
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Gram stain blue/purple = ?
Gram stain red = ? |
Blue/purple = gram positive
Red = gram neg |
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Gram + cocci in chains
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Streptococci
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Gram + cocci in clusters
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Staphyloccoci
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Gram + cocci in pairs (diplococci)
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Strep pneumoniae
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Gram neg coccobacilli (small rods)
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Haemophilus
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Gram neg diplococci
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Neisseria (STD, septic arthritis, meningitis)
Moraxella (lungs, sinusitis) |
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Gram neg rod with thick capsule (mucoid appearance)
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Klebsiella
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Gram + rods that form spores
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Clostridium
Bacillus |
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Pseudohyphae
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Candida
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Acid fast organism
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Mycobacterium (usually M. tuberculosis)
Nocardia (weakly acid fast) |
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Gram + with sulfur granules
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Actinomyces (PID in IUD users, rarely case neck mass or cervical adenitis)
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Silver staining
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Pneumocystis jirovecii
Cat scratch dz (bartonella henselae) |
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Positive India ink (thick capsule)
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Cryptococcus neoformans
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Spirochete
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Treponema (syphilis)
Leptospira [above 2 seen on dark field microscopy] Borrelia (seen on regular light microscope) |
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Stuck with thorn/gardening
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Sporothrix schenckii
Tx with ketoconazole or oral potassium (K) iodide |
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Aplastic crisis in sickle cell dz
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Parvovirus B19
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Sepsis after splenectomy
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SHiN
S. pneumoniae H. influenzae N. meningitis (encapsulated bugs) |
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Pneumonia in southwest (CA, arizona)
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Coccidioides immits
Tx: itraconazole or fluconazole Amphotericin B if severe |
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Pneumonia in Ohio/mississippi river
Or after cave exploring/bird droppings |
Histoplasma capsulatum
Tx: Mild pulm dz: itraconazole or supportive Chronic pulm dz (cavitation on CXR): itraconazole x >1yr Disseminated dz (HSM, palatal ulcers, pancytopenia): Liposomal amphotericin B x 2 yrs, then itraconazole x life |
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Pneumonia after exposure to parrot/exotic bird
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Chlamydia psittaci
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Fungus ball/hemopytsis after TB or cavitary lung dz
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Aspergillus sp
Tx: voriconazole |
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Pneumonia in miner/sandblaster (silicosis)
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TB
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Diarrhea after hiking/drinking from a stream
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Giarda lamblia
Dx: stool cysts Tx: metronidazole |
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Pregnant woman with cats
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Toxoplasma gondii
Dx: peripheral blood smear shows trophozoites Tx: spiramycin |
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B12 deficiency and abd sx
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Diphyllobothrium latum
Could tx with praziquantal |
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Seizures with ring-enhancing brain lesions on CT
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Taenia solium (cysticercosis)
Tx: albendazole or praziquantel + steroids Also toxoplasmosis; tx with pyrimethamine or clindamycin Tx: anticonvulsants |
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Squamous cell bladder cancer in Middle east or Africa
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Schistosoma haematobium
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Worm infxn in children
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Enterobius
Dx: positive tape test; pt complains of perianal itching Tx: mebendazole or albendazole |
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Fever + muscle pain + eosinophilia + periorbital edema after eating raw meat
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Trichinella spiralis (pork worm)
Dx: muscle bx Tx: mebendazole or albendazole if serious, usually self-resolves |
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Gastroenteritis in young kids
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Rotavirus
Norwalk virus |
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Food poisoning after eating reheated rice
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Bacillus cereus
self-limited |
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Food poisoning after eating seafood
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Vibrio parahaemolyticus
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Diarrhea after travel to Mexico
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E.coli
Tx: ciprofloxacin (entertoxic e.coli is the usual cause of traveler's diarrhea) |
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Tx for clostridium difficle
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Metronidazole or vancomycin
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Baby paralyzed after eating honey
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Clostridium botulinum
Tx: antitoxin |
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Genital lesions on kid without sexual abuse/activity
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Molluscum contagiosum (spread from hand to peepee bc they touch it)
(By DNA poxvirus); warts, self-resolves |
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Cellulitis after cat/dog bites
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Pasteurella multicoda
Ppx tx: amoxicillin-clavulanate |
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Slaughterhouse worker with fever
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Brucellosis
Tx: streptomycin and doxycycline |
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Pneumonia after being in hotel/cruise ship/air conditioner/water tower
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Legionella pneumophilia
Tx: azithromycin or levofloxacin |
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Burn wound infxn with blue/green color
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Pseudomonas
(S. aureus also in burn but not blue/green) |
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Tx for acute pharyngitis with 3/4 Centor criteria
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Center criteria for group A beta-hemolytic strep pyogenes:
1. fever 2. tonsillar exudate 3. tender anterior cervical LAD 4. lack of cough Tx with penicillin x 10 days |
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Lemierre's syndrome
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complication of group A strep pharyngitis
thrombophlebitis of the jugular vein |
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Sinusitis dx and tx
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Dx: CT scan
Tx: - usually self-limited if viral - acute bacterial: amoxicillin/clavulanate or TMP-SMZ |
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Postviral/influenza pneumonia organism
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Staph aureus
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Meningitis vs encephalitis sx
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meningitis: fever, HA, neck stiffness, photophobia
encephalitis: fever, HA, seizures, AMS |
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ppx for close contacts of pt with meningococcal meningitis
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rifampin
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pt with encephalitis sx with RBCs in CSF with h/o trauma
what will be on MRI? |
HSV encephalitis
increased temporal lobe signaling start IV acyclovir asap |
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CMV encephalitis tx
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IV ganciclovir +/- foscarnet
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young male pt with paranasal sinusitis, then with brain abscess, what is the organism?
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strep miller
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empiric tx for bacterial meningitis in <1 mo
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ampicillin + cefotaxime/gentamicin
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empiric tx for bacterial meningitis in 1-3 mo
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IV vancomycin + ceftriaxone /cefotaxime
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empiric tx for bacterial meningitis in 3 mos - adulthood
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IV vancomycin + ceftriaxone/cefotaxime
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empiric tx for bacterial meningitis >60 yo/alcoholism/chronic illness
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Ampicillin + vancomycin + ceftriaxone/cefotaxime
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HIV ppx levels
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<200, against PCP; 1x TMP-SMZ
<100, against MAC; weekly azithromycin <50, against toxoplasma; 2x TMP-SMZ |
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AIDS pathogens
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The Major Pathogens Concerning Complete T-Cell Collapse
(Toxic MAC PCP Canada Crypt neo, TB CMV, crypt parvo) Toxoplasma gondii MAC PCP Cryptococcus neo CMV TB Candidasis Crypt parvum |
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Tx for candida
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Esophagitis: fluconazole
Oral: nystatin swish and swallow |
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S. pneumoniae ppx in AIDS pt
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Pneumovax q5yrs when CD4>200
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Pseudohyphae + budding yeast
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Candida
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45 angle branching septae hyphae + rare fruiting bodies
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Aspergillus
fruity ass at a cute (45) angle |
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Yeasts with wide capular halo, narrow-based unequal budding
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Cryptococcus
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Irregular broad, nonseptate, hyphae, wide-angle branching
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Mucor
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AIDS + pigeon droppings; HA/fever without meningitis signs
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Dx: CSF cryptococcal antigen, or India stain
Tx: IV amphotericin B + flucytosine x2 wk, fluconazole for life |
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HIV pt with nonproductive cough + dyspnea
also check what else? |
Pneumocystis carinii pneumonia (PCP)
check for PaO2 (it will be very low) Tx: high dose TMP-SMZ x 3 wks + predisone taper if PaO2 <70 |
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Disseminated dz in HIV pts CD4<50; fever weight loss and HSM/LAD in pts not on HAART therapy
clinical lab findings |
MAC
Lady windermere syndrome: the pulmonary form in healthy nonsmokers Lab: increased alk phos and LDH foamy macrophages with acid-fast bacilli Tx: clarithromycin if not in HAART |
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Lyme dz vs Rocky Mt Spotted Fever
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Lyme: target ("bull's eye"; erythema migrans); can get Bell's palsy and arthritis and encephalitis
- mostly in Wisconsin and the northeast states near Maine Rocky mt (by Rickettsia rickettsii): macular (spotty) rash at wrists and ankles and become itchy and spread centrally - midsouth states like Alabama/OK Tx both with doxycycline |
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CXR finding for inhaling anthrax
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Widened mediastinum
tx: ciprofloxacin |
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Pathogen in swimmer's ear (otitis externa)
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Pseudomonas
Ear drops of strepmycin/amikacin/tobramicin (aminoglycosides) |
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Osteomyelitis in pt with no risk factors
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S. aureus
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Osteomyelitis in IV drug user
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Pseudomonas or S. aureus
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Osteomyelitis in sickle cell dz
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Salmonella
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Osteomyelitis in hip replacement
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Staph epidermis
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Osteomyelitis in foot puncture wound
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Pseudnomonas
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Chronic osteomyelitis
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S. aureus, pseudomonas, Enterbacteriaecae
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Diabetic with osteomyelitis
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Polymicrobial, pseudomonas, S. aureus, streptococci, anaerobes
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TX FOR LEPROSY
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DAPSONE, RIFABUTIN FOR 5 MO IN TUBERCULOID FORMDAPSONE, RIFABUTIN AND CLOFAZAMINE FOR LEPROMATOUS FORM
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tetanus mgmt for a pt w/ unknown hx of vx and dog wound.
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toxoid + ig
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TETANUS TX FOR PT BITTEN BY A DOG AND UNKNOWN HX OF VX
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TXD + IMG (DOG WOUND HAS SALIVA SO IT'S A DIRTY WOUND
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PT WITH NAIL PUNCTURE HAD TETANUS VX 6 Y/A. TX?
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TXD ONLY: DIRTY WOUND + >5 YRS SINCE LAST VX
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WHEN DO YOU GIVE TIG IN TETANUS TX?
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< 3 DOSESDIRTY WOUND (DIRT,FECES OR SALIVA) W/ UNKNOWN STATUS
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PT DEVELOPS HIGH WBC COUNT W/ NEUTROPHILIA AFTER BEING TX'D FOR ASTHMA ATTACK. WHAT IS THE CAUSE?
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STEROID TX CAUSES DEMARGINATION OF NEUTROPHILS
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APPROACH TO PCP DX:
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1- CXR OR ABG2- SPUTUM STAIN (IF + TX)3-BRONCHO-ALVEOLAR LAVAGE (MOST ACCURATE)
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best initial tx for PID.
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CEFOTETAN/CEFOXITIN (2ND) + DOXY
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BETA-LACTAMS THAT INCREASE BLEEDING AND CAUSE DISULFRAM RX
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CEFOXITINCEFOTETAN
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ANBX TO TX NEUTROPENIC FEVER AND VENTILATOR A/S PNA (2)
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BROAD SPECT PNC (PIP/TAZO...)4TH CEFALOS CEFEPIME
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FIRST LINE TX FOR OTITIS MEDIA/SINUSITIS
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AMOXICILLIN/DOXYCYCLINE/BACTRIM
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ONLY TWO CEPHALOSPORINS W ANAEROBIC COVERAGE
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CEFOXITIN (2ND)CEFOTETAN (2ND)
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TX FOR SXTIC TB
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RIPE FOR 2 MOS OR UNTIL CX RESULTS ARE BACK.INH + RIFAMPIN FOR 4 MOS
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SIDE EFFECT OF PIRAZINAMIDE. WHATS THE TX?
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HYPERURICEMIA. DO NOTHING AS THE DRUG WILL BE D/C SOON AND ASXTIC HYPERURICEMIA HAS NO TX
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WHAT TYPE OF TB GETS LONGER TX? (4)
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BRAIN, BONE, MILIARY, PREGO
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WHEN STEROIDS ARE ADDED TO TB TX? (2)
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TB MENINGITISTB PERICARDITIS
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WHEN SHOULD THE PPD TEST BE REPEATED?
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ONLY IF FIRST TEST WAS (-). REPEAT IN TWO WEEKS AFTER FIRST ONE TO ELIMINATE POSSIBILITY OF FALSE (-)
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HIV PT PRESENTS W/ NONBLOODY DIARRHEA. MLDX? BEST DX TEST?
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CRYPTOSPORIDIUM.MODIFIED ACID FAST STAIN
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BEST TEST FOR GIARDIASIS DX?
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ELISA
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TX FOR CHRONIC HEP C?
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INF + RIBAVIRIN
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SE EFFECT OF INF?
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FLU-LIKE SX
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PT W ALLG TO PNC (ANAPX), WHAT TX IS BEST FOR GONORRHEA?
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CIPROFLOXACIN
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TEST TO DX CHLAMIDIA URETHRITIS
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DNA PROBE
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30 YO F P/W LOWER ABD PAIN, CERVICAL MOTION TENDER AND HIGH WBCS. WHATS THE NEXT BEST STEP? WHATS THE MOST ACCURATE TEST?
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- BHCG LAPAROSCOPY
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PT P/W A PAINLESS CHANCRE. WHATS THE BEST INITIAL DX TEST?
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DARK FIELD MICROSCOPY(RPR HAS ONLY 75% SE IN 1RY SYPHYLIS
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BEST INITIAL TEST FOR SYPHYLIS WO A CHANCRE?
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RPR (100% SE IN SECONDARY SYPHYLIS, CHANCRE MIGHT HAVE HEALED ON ITS OWN)
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MALE PT W UNCOMPLICATED UTI GETS WHAT TX?
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TMP/SMX FOR 2 WEEKS
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TX FOR A DM2 PT W UNCOMPLICATED UTI
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TMP/SMX OR CIPRO FOR A WEEK (IN DM2 PTS, PMNS DONT WORK AS WELL SO TX DURATION INCREASES)
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TX FOR UNCOMPLICATED UTI IN PREGOS
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NITROFURANTOIN/AMOXICILLIN/MACRODANTIN FOR 2 WEEKS
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25YO M PT P/W PAIN IN MORE THAN ONE JOINT, A PUSTULAR RASH AND TENOSYNOVITIS. DX? NEXT STEP IN MNT?
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GONORRHEA.CULTURE HOLES. (DON'T TAP JOINT ONLY 50% SE)
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EMPIRIC TX FOR ENDOCARDITIS
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VANCO + GENTAMYCIN
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PRFX FOR ENDOCARDITIS IN PTS UNDERGOING DENTAL AND GI PROCEDURES
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DENTAL: AMOXICILLIN, ALLG GET CLINDAMYCINGI: AMPICILLIN, ALLG GET VANCOMYCIN
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PT P/W FEVER AND A NEW MURMUR. WHATS THE BEST INITIAL TEST FOR DX?
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BLOOD CX. (ECHO IS FOR - CX W/ EMBOLIC PHENOMENA)
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PT P/W A TARGET LESION AFTER BEING IN LYME, CONNETICUT. NEXT BEST STEP IN MNT?
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TX W/ DOXY OR AMOXI (RASH DOESNT NEED SEROLOGY TO DX)
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PT P/W LYME ASSOC JOINT/CN7-PALSY/RASH. TX?
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DOXYCYCLINE
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PT P/W LYME ASSOC NEUROLOGIC/CARDIAC SX. TX?
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IV CEFTRIAXONE
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PT P/W TICK BITE BUT NO SX. TX?
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REASSURANCE
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HIV DRUG CONTRAINDICATED IN PREGNANCY. WHAT U REPLACE WITH?
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EFAVIRENZ.GIVE OTHER NNRTI (NEVIRAPINE, DELAVIRDINE ETC..)
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MNT OF DELIVERY IN PREGO HIV+ W >1000 VIRAL LOAD?
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C-SECTION W VL > 1000
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WHEN ARE STEROIDS ADDED TO PCP TX?
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IF SEVERE (PO2 < 70 AND Aa GRADIENT > 35)
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PT P/W ACTIVE PCP PNA AND ALLG TO SULFA. TX?
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IV PENTAMIDINE
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PT W PMHX/O G6PD N NEEDS PCP PNA PRFX. HE IS ALLG TO SULFA. WHATS THE BEST TX?
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ATOVAQUONE (DAPSONE CAN CAUSE HEMOLYSIS)
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COMMON CAUSE OF OSTEOMYELITIS IN AN ADULT W/ A NAIL PUNCTURE THROUGH A SHOE
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P. AERUGINOSA
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PT VISITS NORTHEAST AND PRESENTS A WEEK AFTER W/ FLU S/S AND SPLENOMEGALY. HE DOESNT RECALL ANY BITES AND THERE IS NO RASH. DX? LIKELY PRESENTATION IF PT WOULD HAVE BEEN ASPLENIC?
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BABEIOSISASPLENIC PTS P/W JAUNDICE
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PT P/W EAR PAIN, D/C AND GRANULATION TISSUE OF EAR CANAL. DX? WHAT FINDING SUGGESTS OSTEOMYELITIS?
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MALIGNANT OTITIS EXTERNAFACIAL PALSY SUGGESTS TEMPORAL BONE INVOLVEMENT
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PT P/W BLOODY DIARRHEA AND ABDOMINAL PAIN FOR 3 DAYS. NO FEVER OR TRAVEL HISTORY. DX?
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EHEC
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20 YO M PRESENTS W/ LESIONS SUGGESTIVE OF MOLLUSCUM CONTAGIOSUM. WHATS THE NEXT STEP?
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HIV TEST OR OTHER FORMS OF IMMUNOSUPPRESION
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HIV PT DEVELOPS STEVEN-JOHNSON SYNDROME AFTER BEGINNING HAART TX. WHAT DRUG CLASS IS RESPONSIBLE?
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NNRTIs
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HIV PT DEVELOPS LIVER FAILURE S/P STARTING HAART TX. WHAT DRUG IS RESPONSIBLE?
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NEVIRAPINE
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SIDE EFFECT AS/W NRTI TX?
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LACTIC ACIDOSIS
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FIRST LINE CHOICES FOR TX OF IMPETIGO?
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MUPIROCIN AND ERYTHROMYCIN PO
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WHAT CONDITIONS MUST BE MET TO GIVE AN HIV + PT MMR VX?
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CD4 COUNT > 200NO AIDS
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DRUG OF CHOICE FOR ANTHRAX?
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CIPROFLOXACIN.*DOXYCYCLINE IS ALTERNATE FIRST LINE AGENT.
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PT P/W SEVERE EAR PAIN AS/W MILD UPPER RESPIRATORY SX. OTOSCOPY REVEALS THE FOLLOWING. DX?
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BULLOUS MYRINGITIS PROB 2/2 MYCOPLASMA PNA
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55 YO F P/W W/ JOINT PAIN ON WRISTS AND ANKLES. NO OTHER SX PRESENT. SHE BABY-SITS TWO CHILDREN. DX?
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PARVOVIRUS B-19
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MENTION 4 NEUROLOGIC MANIFESTATIONS OF LYME'S
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- POLYNEUROPATHIES - BELL'S PALSY- MENINGITIS- ENCEPHALOPATHY
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TX OF CHOICE FOR NEUROCYSTERCOSIS
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CORTICOSTEROIDS + ALBENDAZOLE
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DRUG OF CHOICE FOR SALMONELLOSIS
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CIPRO
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HIV PT W/ A CD4 COUNT OF 99 P/W FEVER, MALAISE AND ANOREXIA. PE SHOWS THE FOLLOWING IMAGE. DX? TX?
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BACILLARY ANGIOMATOSIS.MACROLIDES/DOXYCYCLINEAVOID CATS
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PT P/W H/O LOOSE STOOLS, ANOREXIA, ABDOMINAL BLOATING AND CRAMPS. PT WENT TO MEXICO ON VACATION LAST MONTH. NO FEVER, VOMITING OR BLOODY DIARRHEA NOTED. DX? WHATS THE DIFFERENCE FROM ROTAVIRUS?
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GIARDIASIS.ROTAVIRUS P/W VOMITING AND LOW GRADE FEVER. MORE COMMON IN CHILDREN
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LIVER CYST WITH EGG-SHELL CALCIFICATIONS?
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HYDATID CYST.* BEWARE OF DOG CONTACT IN VIGNETTE
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PT W HO OF TB IS TAKING THE APPROPIATE ABX AND HAS A ROUTINE ABNORMAL LIVER PANEL. SHE FEELS FINE AND THERE'S NO HYPERBILIRUBINEMIA. WHAT DRUG IS CAUSING THIS? WHATS THE MG?
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INH.REASSURE. *INH TRANSAMINITIS IS SELF LIMITED
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PT P/W PHOTOPHOBIA, FOREIGN BODY SENSATION AND DECREASED VISION. SLIT LAMP REVEALS KERATITIS. DX? MAIN DDX?
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HSV KERATITIS.CMV RETINITIS *USUALLY ASYMPTOMATIC
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MGT OF ESOPHAGITIS IN HIV PT?
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TX W/ FLUCONAZOLE. FAILURE TO TX WARRANTS ENDOSCOPY TO LOOK FOR OTHER ETIOLOGY.
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TX FOR ERYSIPELAS?
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PNC OR KEFLEX IF STAPH SUSPECTED*INPT VANCO OR DAPTOMYCIN
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FIRST LINE TX FOR ANTHRAX?
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CIPRO
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EMPIRIC TX FOR BRAIN ABSCESS? MOST COMMON PATHOGENS?
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- FLAGYL + CEFTRIAXONE.STREP#1, ANAEROBES#2
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INITIAL DTOC TO DX PID?
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TRANSVAGINAL U/S*LAPAROSCOPY MOST ACCURATE
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HAART DRUG THAT CAUSES PSYCH SE LIKE ANXIETY, COLORFUL DREAMS, ETC?
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EFAVIRENZ (NNRTI)
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PT W/ TRAVEL HX TO SOUTH AMERICA P/W RUQ PAIN AND BLOODY DIARRHEA. DX? WEEKS AFTER TX HE HAS FEVER, CHILLS AND RECURRENT RUQ PAIN. DX? DX TESTING OF CHOICE?
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1- AMEBIASIS *STOOL O/P REVEALS DX.2- LIVER ABCESS: SEROLOGY/SONO TO DX.**HYDATID CYST WOULD HAVE CNS AND LUNG SX SUCH AS HEMOPTISIS AND FOCAL DEFICITS.
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PTS FOR WHICH PNEUMOVX IS INDICATED? 5
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1- CHILDREN 2 MO OLD2- IMMUNOSUPRESSED3- CHRONIC DZ OF LUNGS, HEART, LIVER AND KIDNEYS4- DM5- ASPLENIC
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ABX OF CHOICE FOR PREG W/ GONORRHEA?
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AZYTHROMYCIN
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HOW TO TELL BETWEEN: BRUTON'S, SCID AND CVID?
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1- BRUTON AND SCID ONSET EARLY IN CHILDHOOD WHILE CVID ONSETS LATER IN LIFE (10-30 YO)2- BRUTON AND SCID LACK LAD WHILE CVID DOESNT3- BRUTON P/W BACTERIAL INFECTIONS (OM, PNA...) WHILE SCID P/W VIRAL/FUNGAL/PARASITIC JUST LIKE CVID**SCID LOOK FOR ABSENT THYMUS AND HEARING DEFECT!
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CT before LP when? (mnemonic)
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"Please See Ct First"PapilledemaSeizuresConfusionFocal neuro deficit
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Empiric Bacterial Meningitis Tx? (mnemonic)
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"go to CVS"CeftriaxoneVancSteroids (dexamethasone)add Amp if immunocompromised (covers listeria)
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Centor Criteria for Strep Pharyngitis?
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1 pt each:FeverExudatesTender cervical LADNo coughModified: <15ya (+1), >44ya (-1)0-1: no abx or cx, 2-3: cx, abx if +, 4-5: abx
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Best initial tx for Strep Pharyngitis? Pen allergic?
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Pen or AmoxicillinPen allergy: rash -> cephalexinanaphylaxis -> clinda or macrolide
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Labs in Acute Hepatitis?
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increased direct bili, ALT:AST, AlkPincreased PT = poor prognosis
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Serology in Acute/Chronic Hepatitis?
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+surface Ag +eAg +Core Ab (IgM or IgG)-surface Ab
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Serology in Resolved, old, or past hepatitis?
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-surface Ag -eAg +Core Ab (IgG)+surface Ab
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Serology in Vaccinated against Hepatitis?
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-surface Ag -eAg -Core Ab (IgM or IgG)+surface Ab
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Serology in Hepatitis window period?
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-surface Ag -eAg +Core Ab (IgM -> IgG)-surface Ab
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Drugs that Tx for Cervicitis or Urethritis? (mnemonic)
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"Do Coccus And Chlamydia"Gonococcus (start with C) - Cefixime or CeftriaxoneChlamydia (A&D) - Azithromycin or Doxycycline
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First step if suspect urethritis or cervicitis?
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swab and gram stain
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most accurate tests for urethritis or cervicitis?
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CxDNA probeNAT
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PID tx? pen allergy?
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outpatient - ceftriaxone + doxy (+/- metro)inpatient - cefoxitin/cefotetan + doxyPen allergy:outpatient - levofloxacin + metroinpatient - clinda, gent, + doxy*treating for gonococcus and chlamydia
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First step before you tx PID?
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r/o pg!then cervical swab for cx, DNA probe, or NATthen abx
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most accurate test for PID? When to do it?
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laparoscopy - but rarely donedo when: recurrent, dx unclear, retractable
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painless solitary genital ulcer?
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Syphilis
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painful solitary genital ulcer?
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chancroid (haemophilus ducreyi)
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Genital Ulcer with suppurative and tender LN?
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Lymphogranuloma venerum
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Vesicles followed by genital ulcer that's painful?
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Herpes simplex
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Dx steps for syphilis chancre?
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Darkfield microscopyVDRL or RPRFTA-ABS or MHA-TP (confirm)
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syphilis chancre tx?
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single dose IM Benzathine PenPen allergic: doxy
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Dx steps for genital chancroid (haemophilus ducreyi)?
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stain and cx on special media
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genital chancroid (haemophilus ducreyi) tx?
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single dose azithromycin
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Dx steps for Lymphogranuloma venerum?
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complement fixation titers in blood or NAT on swab
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Lymphogranuloma venerum tx?
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doxy
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Dx steps for Herpes genital lesions? (best initial test and most accurate test)
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Tzanck prep is best initial test (can tx if obvious clinically though)Viral cx is the most accurate test
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Herpes genital lesion tx?
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AcyclovirValacyclovirFamciclovir
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Tx for genital herpes resistant to acyclovir? |
Foscarnet
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_x0001_ SymptomsFever, chills, hypotension, hypothermia, shock. Rash (ecthyma gan-grenosum, with Pseudomonas and others).
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Bacteremia and Septicemia_x0001_ Description/DiagnosisSpread of infection to the bloodstream (bacteremia); septicemia in-cludes symptoms and infections by fungi and microbes other than bacteria. Diagnosis based on clinical scenarios._x0001_ PathologyComplex. Endotoxin or other microbial elements may cause symptoms/shock.
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_x0001_ Treatment StepsAntibiotics, supportive (fluids, pressors).
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_x0001_ SymptomsFever, rash, hypotension, dermal peeling of palms and soles (skindesquamation).
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Toxic Shock Syndrome_x0001_ DescriptionToxin-producing staphylococcal (or occasionally streptococcal) in-fection.
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_x0001_ DiagnosisHistory and physical, tampon use, culture (vagina/blood)._x0001_ Treatment StepsAntibiotics (β-lactamase resistant, antistaphylococcal), remove tampon, supportive care for shock.
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_x0001_ Description/SymptomsPurulent conjunctivitis before 1 week old.
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Ophthalmia Neonatorum PathologyEtiology in Neisseria gonorrhoeae, Chlamydia, Haemophilus.
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_x0001_ Treatment StepsAntibiotics. Prevent by 1% silver nitrate or erythromycin topically
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_x0001_ Description/SymptomsConjunctival inflammation, causing exudate, itching, eyelid edema.
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Bacterial Conjunctivitis
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_x0001_ DiagnosisClinical diagnosis, conjunctival scraping and culture used rarely._x0001_ Treatment StepsAntibiotics. Topical and/or systemic
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_x0001_ Description/SymptomsCorneal infection/inflammation, causing red, painful eye, especially in children. Clinical diagnosis.
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Viral Keratoconjunctivitis_x0001_ PathologyHerpes simplex most common in children, also other viruses including adenovirus (common with adult infections).
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_x0001_ Treatment StepsTrifluridine or acyclovir
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_x0001_ Symptoms/DiagnosisPain, drainage, itching. Clinical diagnosis.
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External Otitis_x0001_ DescriptionExternal auditory canal inflammation; swimmer’s ear_x0001_ Pathology• Staphylococcus epidermidis, other bacteria, fungal. If chronic, suspectPseudomonas.• Malignant otitis (severe infection with temporal bone invasion),suspect Pseudomonas (or occasionally Proteus).
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_x0001_ Treatment StepsTopical and (if necessary) systemic antibiotics. Systemic needed formalignant otitis.
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_x0001_ Description/SymptomsMiddle ear inflammation, causing fever, hearing loss, pain
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Otitis Media_x0001_ PathologyStreptococcus pneumoniae common. Multiple other agents possible.Common in children with eustachian tube dysfunction as possible etiology
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_x0001_ DiagnosisHistory and physical shows loss of light reflex, possible fluid behind tympanic membrane._x0001_ Treatment StepsAntibiotics (amoxicillin). If failure, use second-line antibiotic (e.g.,oral cephalosporin or clarithromycin). If fails frequently, considerear, nose, and throat (ENT) evaluation for tubes
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_x0001_ Description/SymptomsMastoid air cell inflammation, causing fever, pain, hearing loss,postauricular swelling/erythema, displaced pinna. Cause is usuallybacterial infection that started as otitis media.
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Mastoiditis
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_x0001_ DiagnosisHistory and physical, x-ray studies (computed tomography [CT])._x0001_ Treatment Steps1. Antibiotics.2. Myringotomy.3. Mastoidectomy.
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_x0001_ Symptoms of Bacterial MeningitisFever/nuchal rigidity/headache/vomiting.Brudzinski’s sign: Cervicalmotion elicits pain.Kernig’s sign: Painfulhamstring stretch.
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MeningitisSee also Chapter 11, section VII.A._x0001_ DescriptionBrain/spinal cord membrane inflammation. Much more serious and fatal if caused by bacteria rather than virus._x0001_ PathologySpread of germs to the central nervous system (CNS) via the blood.Common germs: up to 1 month of age, Escherichia coli, and group Bstrep; 1 month to age 6, H. influenzae type b, S. pneumoniae, and N.meningitidis; older than 6, S. pneumoniae and N. meningitidis
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_x0001_ DiagnosisHistory and physical. Examination of cerebrospinal fluid (CSF)(bacteria: low glucose, elevated protein, high white blood count[WBC] with predominant neutrophils, positive Gram stain; viral:normal glucose, slightly elevated protein, low WBC [< 100] with pre-dominant lymphs)._x0001_ Prevention of Bacterial MeningitisImmunization (Haemophilus influenzae, S. pneumoniae, and Neisseria meningitidis) and treatment/prophylaxis of exposed close contacts._x0001_ Treatment StepsAntibiotics given parenterally (at high doses). (See Chapter 11, sec-tion VII.A.)
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_x0001_ SymptomsHeadache, mental changes, nausea/vomiting, focal neurologic find-ings, seizures.
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Brain Abscess_x0001_ PathologyAnaerobic bacteria and oral Streptococcus common. May extend from ear/sinuses, follow injury, or be bloodborne from other areas (lung).
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_x0001_ DiagnosisHistory and physical examination, CT scan._x0001_ Treatment Steps1. Antibiotics IV.2. Surgical drainage.
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_x0001_ SymptomsLocal severe back pain changing to radicular pain, then weakness.Fever and local tenderness also.
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Spinal Epidural Abscess_x0001_ DescriptionInfrequent disease. Early intervention needed to prevent paraplegia._x0001_ PathologyBloodborne spread from skin and IV catheters, usually by Staphylococcus aureus.
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_x0001_ DiagnosisHistory and physical examination, x-rays, CT, lumbar puncture_x0001_ Treatment Steps1. Surgical drainage.2. Antibiotics.
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_x0001_ SymptomsFever, headache, weakness, sore throat. Muscle wasting, lower motor neuron lesion, vomiting
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Poliomyelitis_x0001_ DescriptionPoliomyelitis virus can be transmitted by fecal–oral route. Threeclasses of polio exist:1. Abortive polio––a febrile illness without CNS involvement.2. Nonparalytic polio––aseptic meningitis with complete recovery.3. Paralytic polio––aseptic meningitis followed by development ofmotor weakness.
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_x0001_ DiagnosisHistory and physical examination. Examination of CSF. Stool/throat/fecal culture. Serologic testing to confirm (polio virus is atype of enterovirus)._x0001_ Treatment StepsSupportive treatment. Polio is rare due to vaccination.
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_x0001_ SymptomsClinically, a prodrome of fever, myalgias, followed by encephalitiswith confusion and agitation. Hydrophobia (laryngeal spasm withdrinking or just sight of water), paresthesia/pain at bite site. Hyper-activity, ascending paralysis. Excessive salivation can cause classic “foaming at the mouth.”
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Rabies_x0001_ DescriptionViral encephalitis caused by rabies virus. Very rare in the United States. Only several cases on record of human survival in documented rabies.
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_x0001_ DiagnosisHistory and physical, animal bite. Check animal’s brain for rabies.Also via state lab: search for rabies virus/antigen by neck skin/cornea biopsy, and serologic screening (for antirabies antibody)._x0001_ PreventionImmunize high-risk individuals (veterinarians, cave explorers, animal handlers)._x0001_ Treatment StepsFor exposure: Local wound cleaning and postexposure prophylaxiswith human rabies immune globulin (HRIG), rabies vaccine. For confirmed rabies: Supportive
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_x0001_ SymptomsTonic muscle spasms (jaw, trismus/lockjaw), rictus sardonicus: tris-mus-induced facial sneer. Opisthotonos, tetanospasm.
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Tetanus_x0001_ DescriptionNeurotoxin-induced muscle spasm disorder_x0001_ PathologyClostridium tetani produces neurotoxin. Several days’ to 3 weeks’ incubation, after germ entry via wound.
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_x0001_ DiagnosisHistory and physical examination._x0001_ Treatment StepsSupportive, tetanus immune globulin, and penicillin G.
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_x0001_ SymptomsSevere headache, fever, photophobia
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Viral Encephalitis_x0001_ DescriptionCNS inflammation/infection caused by a virus (see Cram Facts)
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_x0001_ DiagnosisLumbar puncture with cell count < 100, protein < 100._x0001_ Treatment StepsSupportive.
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_x0001_ SymptomsSevere headache, fever, photophobia• CT scan of head mayshow hypodense areasin temporal lobe(s).
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HERPES ENCEPHALITIS
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CSF can be tested forherpes simplex usingpolymerase chainreaction (PCR).• Acyclovir is often startedempirically while resultsare pending.
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_x0001_ SymptomsUsually asymptomatic; fever, headache, myalgia, adenopathy. Congenital infection (microcephaly, seizures, retinochoroiditis)
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Toxoplasmosis_x0001_ DescriptionInfection with Toxoplasma gondii usually by cyst ingestion (cat litter/soil/undercooked meat, pregnant women must avoid all three). Also, transplacental transmission is possible.
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_x0001_ DiagnosisBiopsy is definitive for cysts/trophozoites. Serologic testing. Found in people with impaired cell-mediated immunity or children ofmothers who acquired toxoplasmosis during pregnancy._x0001_ Treatment StepsPyrimethamine plus sulfadiazine.
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_x0001_ SymptomsPurulent nasal discharge, tonsillar membrane, fever, cervical adenopathy, nausea/vomiting.
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Diphtheria_x0001_ DescriptionUpper respiratory tract infection caused by Corynebacterium diphtheriae. Prevent via immunization
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_x0001_ DiagnosisClinical, sore throat with green/gray pharyngeal membrane._x0001_ Treatment Steps1. Diphtheria antitoxin (DAT) and penicillin or erythromycin.2. Penicillin or erythromycin for carrier state.
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_x0001_ SymptomsFever, murmur, anemia. Multiple other symptoms possible includingsplinter hemorrhages, Osler nodes (red fingertip bumps), Janewaylesions (red macules on palms/soles), Roth spots on fundoscopic exam, weight loss, petechiae.
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Endocarditis_x0001_ DescriptionEndocardial infection._x0001_ PathologyAcute often S. aureus (drug use typical). Subacute, often α-hemolyticStreptococcus viridans (oral pathology or surgery). Mitral valve mostcommon site, pulmonic least common (in drug users, tricuspid valvemore common). Platelets/fibrin form on abnormal area, then bacte-ria attach
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_x0001_ DiagnosisHistory and physical, blood culture, echocardiogram._x0001_ Treatment Steps1. Consult current literature.2. Streptococcus—penicillin G and gentamicin (or streptomycin).3. Staphylococcus—nafcillin (watch for methicillin-resistant S. aureus[MRSA] for which vancomycin is indicated). Also, note association of Streptococcus bovis or Clostridium septicum and colon cancer.
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_x0001_ SymptomsAfter 2-week incubation, fever, headache, enlarging parotid (bilat-eral in 75%)
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Mumps_x0001_ DescriptionContagious mumps virus (a paramyxovirus) infection, only in hu-mans. Prevented with vaccination. Most commonly causes parotidi-tis, but complications can include pancreatitis, orchitis, meningitis, encephalitis, nephritis, or deafness.
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_x0001_ DiagnosisHistory and physical, serologic testing/viral isolation._x0001_ Treatment StepsNo treatment is needed. Prednisone has been used in cases of orchitis.
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Description/SymptomsCommon oral infection, usually with herpes simplex type I. Infection may be asymptomatic, or fever, vesicles and ulcers, adenopathy
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Herpetic Gingivostomatitis
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Diagnosis/TreatmentClinical diagnosis. Can culture if unsure of herpes vs. bacterial in-volvement. Often resolves spontaneously. Can use toical pencyclovir or systemic acyclovir.
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Description/SymptomsOvergrowth of Candida species, which is normally found in the body.Can cause vaginitis (vaginal itch/white thick discharge); diaper ery-thema and satellite lesions; balanitis; or oral thrush with mucosal disease and esophageal symptoms common.
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Candidiasis_x0001_ PathologySuperficial fungal infection, severe mucosal infection (rule out hu-man immunodeficiency virus [HIV]) or fungemia/disseminated disease (rule out neutropenia or intravenous [IV] catheter related).
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_x0001_ DiagnosisClinical picture, potassium hydroxide (KOH) preparation_x0001_ Treatment Steps1. Antifungal.2. Topical and/or oral medication for mild disease.3. Oral or IV fluconazole or IV amphotericin for moderate to severe disease
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_x0001_ Description/SymptomsOral fungal infection, usually caused by Candida albicans. Removablewhite mouth patches, plaque, halitosis. Can progress to esophagitis and cause dysphagia.
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Thrush
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_x0001_ DiagnosisHistory and physical exam, KOH preparation._x0001_ Treatment StepsNystatin mouth rinse and/or oral antifungal (fluconazole)
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_x0001_ Symptoms/DiagnosisFever, neck extension. Diagnose clinically. May culture abscess
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Retropharyngeal Abscess_x0001_ DescriptionRetropharyngeal infection caused by spread of infection from local area (sinus, tooth, etc.).
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_x0001_ Treatment StepsIncision and drainage, antibiotics. Monitor for airway compromise.
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_x0001_ SymptomsNausea, vomiting, diarrhea, after food ingestion.
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Food Poisoning_x0001_ DescriptionIllness from ingestion of contaminated food. Can be due to many bacteria, viruses, or toxins
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_x0001_ DiagnosisFood/stool culture and toxicologic studies. History and physical exam._x0001_ Treatment StepsSymptomatic, may treat specific bacterial isolate (Clostridium difficile metronidazole or vancomycin by mouth)
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_x0001_ SymptomsNausea, vomiting, dysphagia, diplopia, progressive paralysis hours todays after ingesting bad fish/meat or canned product. Both myas-thenia gravis and Guillain–Barré are usually considered in the differential, as they can all have ascending paralysis.
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Botulism_x0001_ DescriptionFoodborne botulism is caused by ingestion of food containing pre-formed toxin, most commonly via home-canned food. Infant botu-lism arises from ingesting spores of Clostridium botulinum, which pro-duces toxin in the GI tract. Wound botulism develops in woundscontaminated by C. botulinum (can be wounds contaminated by soil, such as in chronic IV drug users)_x0001_ PathologyC. botulinum produces neurotoxin. In infants, the clostridial spores can germinate in the intestine and produce toxin there
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_x0001_ DiagnosisHistory and physical, toxin in serum/stool/food. Differs from myas-thenia gravis by negative edrophonium (Tensilon) test. Must have strong clinical suspicion, usually from a thorough history._x0001_ Treatment Steps1. Trivalent antitoxin (A, B, E) should be given as soon as possible.2. Supportive treatment including close monitoring of airway, as respiratory failure can develop.3. Wound botulism––exploration and debridement also needed.
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Vomiting, diarrhea, fever,
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Viral Gastroenteritisoften due to rotavirus or Norwalk virus.
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Supportive care
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_x0001_ SymptomsMalaise, delirium, headache, constipation or diarrhea, lethargy, andfever, which could last 4–8 weeks. Exam findings incllude relative bradycardia, hepatosplenomegaly, and rose spots.
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Typhoid_x0001_ DescriptionEnteric fever, caused by Salmonella typhi (a pathogen in humansonly). Organism is ingested via contaminated food, water, or milk and is more common in travelers or patients with HIV.
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_x0001_ DiagnosisClinical picture, positive diagnosis by blood culture, presumptive by stool/urine culture, agglutinin titer._x0001_ Treatment StepsChloramphenicol, ciprofloxacin, amoxicillin. Dexamethasone maybe used for severe typhoid
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SymptomsNausea, fever, cramps, bloody diarrhea (gastroenteritis, S. enteritidis), bacteremia, or asymptomatic carrier.
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Salmonella_x0001_ DescriptionSalmonella species are found in contaminated food or drink, com-monly eggs or poultry. Can cause mild gastroenteritis or, more seri-ously, typhoid fever (see above). Immunosuppressed patients are athighest risk.
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_x0001_ DiagnosisHistory and physical, stool culture, negative blood culture with en-teritis, may be positive with enteric fever._x0001_ Treatment StepsNo treatment needed for mild disease.
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_x0001_ SymptomsRange from mild watery diarrhea to more severe abdominal pain,tenesmus, bloody stool, cramping, fever.
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Shigella_x0001_ DescriptionBacillary dysentery, caused by Shigella species. Fecal–oral and person-to-person transmission exist. At high risk are children and homosexual men, and low socioeconomic status.
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_x0001_ DiagnosisHistory and physical, stool for WBC and culture._x0001_ Treatment StepsResistance to ampicillin now becoming more common. Other antibi-otics include ciprofloxacin, trimethoprimsulfamethoxazole, or ceftriaxone
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_x0001_ SymptomsWatery diarrhea, abdominal pain. Enteroinvasive strains present likeShigella
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Toxicogenic E. coli (including O157) Infection_x0001_ DescriptionDiarrheal illness (with blood for O157)._x0001_ PathologyE. coli producing exotoxin resulting in colon mucosa fluid secretion.
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_x0001_ DiagnosisCulture, serologic testing_x0001_ Treatment StepsHydration; try tetracycline or quinolone (no treatment known to beeffective for O157). Antibiotics may increase the risk of developing hemolytic–uremic syndrome (HUS)_x0001_ SequelaeHUS in children with O157.
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_x0001_ SymptomsGas gangrene: pain at wound infection, bullae, tissue gas, hypotension
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Clostridial Infection_x0001_ DescriptionToxin-producing germs_x0001_ PathologyClostridium tetani, see Tetanus section; C. perfringens, see Gas gan-grene; C. botulinum, see Botulism section; C. difficile, see Pseudomembranous colitis.
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_x0001_ DiagnosisHistory and physical exam, Gram stain, culture_x0001_ Treatment StepsGas gangrene: debridement, penicillin G
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_x0001_ SymptomsProfuse watery diarrhea (rice-water stools), with vomiting, causing dehydration.
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Cholera_x0001_ DescriptionInfectious diarrhea caused by a curved gram-negative rod, Vibriocholerae. More common in Asia, Africa. Has occurred sporadically in the United States (Texas, Louisiana).
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_x0001_ DiagnosisCulture of stool on special medium._x0001_ Treatment Steps1. Fluid replacement (lactated Ringer’s or other crystalloid).2. In adults, single-dose tetracyline or ciprofloxacin.3. Children––erythromycin
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_x0001_ SymptomsWatery diarrhea, tenesmus, cramps. Diarrhea may have a “characteristic” smell
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Pseudomembranous Enterocolitis_x0001_ DescriptionAntibiotic-induced colitis, caused by C. difficile, which produces a toxin causing diarrhea and a pseudomembrane in the colon
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_x0001_ DiagnosisClinical scenario, stool for C. difficile toxin._x0001_ Treatment StepsStop antibiotic; give oral metronidazole, or vancomycin if metronidazole fails.
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_x0001_ SymptomsAlthough asymptomatic passage of cysts can occur, symptomaticamebic colitis develops from 2 to 6 weeks after ingestion. Mild diar-rhea, lower abdominal pain, weight loss. Cecal involvement mimicsappendicitis. Full-blown dysentery may occur. Stool is almost alwaysheme positive. With fever and right upper quadrant pain, suspect liver abscess.
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Amebiasis_x0001_ DescriptionInfection with Entamoeba histolytica, an intestinal protozoan. Highest-risk groups are travelers, recent immigrants, homosexual men, poorsocioeconomic status, and residents of institutions. Infection acquired by ingestion of cysts from fecally contaminated water, food, or hands
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_x0001_ DiagnosisDemonstration of trophozoites or cyst of E. histolytica on wet mount, iodine stain of stool, or trichrome stains of stool. Repeated stool exams are needed. Also, differentiate from other types of Entamoeba that do not cause disease. Serology may be used._x0001_ PreventionWater purification, treatment of asymptomatic carrier_x0001_ Treatment Steps1. Carriers—use one of the following three luminal agents:iodoquinol, diloxanide, and paromomycin.2. Colitis or liver abscess––a luminal agent plus and metronidazole Before startingmetronidazole, warnpatients about severereaction if taken withalcohol (Antabuse-likereaction).
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_x0001_ SymptomsRange from asymptomatic to more fulminant diarrhea and malab-sorption. Incubation period 1–3 weeks. Early diarrhea, bloating, andabdominal pain. Also increased flatus and weight loss if infection ischronic. Fever, blood, or mucus in stool is rare.
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Giardiasis_x0001_ DescriptionA common parasitic infection caused by digestion of the cyst form ofGiardia lamblia. Person-to-person transmission can occur, and there-fore risks include residents of institutions, children in day care centers, and homosexual men as well as poor socioeconomic status.
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_x0001_ PreventionHygiene, avoiding water while traveling, treatment of carriers._x0001_ Diagnosis/Treatment StepsFinding cysts or trophozoites in the feces or small intestine. Repeatexams may be needed. Can also test for parasitic antigen in the stool. Treatment: Metronidazole
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_x0001_ SymptomsCough, anemia, pruritus, weight loss.
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Hookworm _x0001_ DescriptionIntestinal nematode infection. Hookworm is rare in the UnitedStates, while pinworm is common. Pathology• Hookworm: Ancylostoma duodenale or Necator americanus. Cycle:eggs in feces reach soil; larvae form; larvae enter skin/blood/then lungs; larvae swallowed reach intestine.
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_x0001_ Treatment Stepsmild infection, none; severe, mebendazole (Vermox), or pyrantel pamoate.
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_x0001_ SymptomsPruritus ani at night
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Pinworm_x0001_ DescriptionIntestinal nematode infection. Hookworm is rare in the UnitedStates, while pinworm is common._x0001_ Pathology• Pinworm: Enterobius vermicularis. Most frequent worm infection inthe United States.
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_x0001_ Treatment Stepsmild infection, none; severe, mebendazole (Vermox), or pyrantel pamoate.
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_x0001_ SymptomsLeft lower quadrant (LLQ) pain and/or mass, constipation,chills/fever.
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Diverticulitis_x0001_ DescriptionDiverticular inflammation and perforation.
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_x0001_ Treatment StepsIf mild, medical (nothing by mouth [NPO], antibiotics), otherwisesurgical resection.
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_x0001_ SymptomsHepatic abscess: fever, right upper quadrant (RUQ) pain, jaundice. Intra-abdominal abscess: fever, elevated diaphragm, leukocytosis, pain
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Intra-abdominal Abscess, Hepatic/ Subphrenic_x0001_ DescriptionHepatic abscess: local collection of pus in liver. Intra-abdominal abscess includes subphrenic abscess._x0001_ PathologyE. coli common. Amebic liver abscess in high-risk individual (due to Entamoeba histolytica).
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_x0001_ DiagnosisHistory and physical, ultrasound, CT, gallium scan, positive Hoover’ssign (x-ray sternochondral widening)._x0001_ Treatment StepsSurgery and antibiotics.
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_x0001_ SymptomsCan cause cutaneous symptoms (usually pruritus and a mild rash) atthe area where the organism penetrated the skin, usually the feet.Pulmonary involvement can cause cough, fever, dyspnea. GI disease can cause nausea, vomiting, and diarrhea.
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Strongyloidiasis_x0001_ DescriptionA relatively uncommon condition in the United States, caused by in-fection with Strongyloides stercoralis. Endemic areas––tropics. Can be serious infection in an immunocompromised patient
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_x0001_ DiagnosisFinding worm in feces or other body specimens; serology._x0001_ Treatment StepsThiabendazole; ivermectin. Prevention: wearing shoes
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Nonspecific symptoms such as back, flank, or abdominal pain and fever.
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• Renal and perinephric abscess––often sequela from a urinary tract infection or nephrolithiasis.Organisms include S. aureusand E. coli.
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Abscess usually seen on ultrasound or CT scan. Systemic antibiotics and drainage needed
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Pelvic abscess
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–in females often related to reproductive tract, in-cluding septic abortion, endometritis, postoperative infection af-ter hysterectomy, or with pelvic inflammatory disease (tubo-ovarian abscess). A multitude of organisms can cause the abscess.
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Antibiotics with potent anaerobic coverage should be used w/ possible surgical exploration/drainage
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_x0001_ Description/SymptomsBacterial infection spread into lymph nodes. Exam reveals red streak extending from wound; fever, adenopathy.
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Lymphangitis_x0001_ Diagnosis/PathologyClinical diagnosis. Common cause hemolytic strep; rule out cat scratch fever.
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_x0001_ Treatment StepsAntibiotics.
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_x0001_ Symptoms• Stage I––early infection. Classic erythema chronicum migransrash: a flat to slightly raised erythematous rash with central clear-ing. Usually occurs at area of tick bite, but many persons do notrecall the bite or the tick. • Stage II––disseminated infection. Secondary skin lesions can appear.Complaints include headache, stiff neck, fever, myalgias, arthralgias,and fatigue. Neurologic complaints can include cranial neuritis (par-ticularly cranial nerve VII), myelitis, or subtle encephalitis. CSF mayshow lymphocytes, elevated protein, and normal to low protein. Car-diac abnormalities can include arteriovenus (AV) block.• Stage III––persistent infection. Intermittent oligoarticular arthri-tis in large joints, particularly knees.
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Lyme Disease_x0001_ DescriptionMultisystem disorder caused by the spirochete Borrelia burgdorferi.Usually transmitted by the deer tick Ixodes dammini. Three stages ofthe disease exist
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_x0001_ DiagnosisClinical setting, but it can be difficult to diagnose. If the rash isnoted in a patient who lives in or has visited an area with a high inci-dence of Lyme disease (particularly the Northeast United States),empiric treatment should be started. Serologic testing not needed,as it may come back as a false negative early in the infection. Later inthe disease course, serologies can confirm infection. PCR of the CSFor joint fluid can be done to look for presence of the organism._x0001_ Treatment StepsDepends on the stage and the clinical manifestations. Skin lesions: • Doxycycline 100 mg bid for 14–21 days.• Amoxicillin (used in pregnant women and children) for 14–21days.• Arthritis.• Doxycycline or amoxicillin for 30–60 days.Neurologic or cardiac involvement:• Often requires intravenous treatment (with ceftriaxone or cefotaxime). Total duration of treatment usually at least 30 days
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_x0001_ SymptomsInitially nonspecific: Malaise, headache, fatigue, myalgias, abdomi-nal pain, followed by fevers. Classic malaria paroxysms where feverspikes and chills occur at regular intervals suggests infection with P.vivax or P. ovale.
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Malaria_x0001_ DescriptionThe most important parasitic infection in humans, causing up to 3million deaths per year worldwide. Infection with one of the follow-ing four Plasmodium species: P. vivax, P. ovale, P. malariae, and P. falci-parum. Disease found in the tropics and transmitted via mosquitoes.Prevention with antimalarial drugs is of utmost importance in travel-ers, and is guided by the resistance patterns of the Plasmodium species in the particular area they are visiting.
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_x0001_ DiagnosisThick and thin smears of the blood should be done. The parasitecan be visualized on these smears. Repeated smears should be exam-ined on successive days before the diagnosis is excluded. Infectionwith P. falciparum versus other species should be defined._x0001_ Treatment Steps1. Antimalarials include chloroquine, sulfadoxin/pyrimethamine,mefloquine, quinine, quinidine.2. Prophylactic medications include chloroquine (where resistance is not a problem), mefloquine, doxycycline.
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_x0001_ SymptomsVariable depending on stage of disease and OIs. Primary infectionwith HIV is often asymptomatic; but a viral illness occurring withacute HIV infection has been described. Symptoms are nonspecific(fever, fatigue, rash, lymphadenopathy, night sweats) but if sus-pected clinically, HIV can be diagnosed if blood is sent for HIV RNAvia PCR.
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HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome)_x0001_ Description(See Chapter 7, section I.B, for epidemiology, impact, and screen-ing.) Infection with the retrovirus HIV is the cause of AIDS. The pri-mary target for HIV is the CD4 T lymphocyte. HIV infection causesCD4 counts to decrease, resulting in a strong inverse relationship be-tween CD4 count and the risk of opportunistic infections (OIs). Pa-tients can be infected with HIV but not have AIDS. AIDS occurs inan HIV-positive patient whose CD4 count is < 200, has had one ofmany AIDS-defining illnesses (including Pneumocystis carinii pneu-monia [PCP], disseminated or Kaposi’s sarcoma, extrapulmonaryhistoplasmosis, cerebral toxoplasmosis, esophageal candidiasis)._x0001_ DiagnosisPatient consent must be obtained prior to testing for HIV. Screen-ing for HIV antibody is done first with enzyme-linked immunosor-bent assay (ELISA). If the first ELISA screen is positive, the test is re-peated. If positive a second time, confirmatory testing is done withWestern blot. If HIV diagnosed, patient’s total CD4 count and viralload (using PCR for HIV RNA) should be obtained.
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_x0001_ Treatment Steps1. Antiretroviral treatment. There are multiple drugs used in thetreatment of HIV/AIDS, and their management should be by aninfectious disease/HIV specialist. Drugs are given in combina-tion. Drug resistance patterns can be identified. Goals of therapyare to raise the CD4 count and suppress the HIV viral load (toundetectable levels, if possible).• Nucleoside analog reverse transcriptase inhibitors:• AZT (zidovudine, Retrovir). Not used with d4T. Side effects:Headaches, stomach upset, anemia, neutropenia, myopathy. • ddI (didanosine, Videx). Side effects: Pancreatitis, fat redis-tribution, peripheral neuropathy.• ddC (zalcitabine Hivid). Side effects: Pancreatitis and periph-eral neuropathy.• d4T (stavudine, Zerit). Side effects: Pancreatitis, fat redistri-bution, peripheral neuropathy. Not be used with AZT. • 3TC (lamivudine, Epivir). Side effects: Headaches and insom-nia; pancreatitis, particularly in pediatric patients.• Abacavir (Ziagen, Epzicom). A potentially serious hypersensi-tivity reaction occurs in about 3% of patients; begins days to 4weeks after starting the drug, and resolves without furtherproblem if the drug is stopped and not restarted. Symptomsinclude fever, nausea, malaise, and possibly rash. If hypersen-sitivity is suspected, Abacavir should never be restarted, sincerestarting can cause a more serious and possibly fatal reac-tion.• Emtricitabine (Truvada). Side effects: Gastrointestinal (GI)upset, hyperpigmentation of palms or soles.• Tenofovir (Viread). Bioavailability enhanced by a high-fatmeal. Side effects: GI upset, fat redistribution, lactic acidosis.• Non-nucleoside reverse transcriptase inhibitors:• Nevirapine (Viramune). Side effects: Severe hepatotoxicity orStevens–Johnson syndrome.• Delavirdine (Rescriptor). Side effects: Rash, GI upset, abnor-mal liver function tests.• Efavirenz (Sustiva). Side effects: CNS and psychiatric side ef-fects, fat redistribution.• Protease inhibitors:• Saquinavir (Fortovase, Invirase). Works well with ritonavir,lowering doses of both drugs. Side effects: stomach upset, ele-vated liver enzymes.INFECTIOUS AND PARASITIC DISEASES Infectious Diseases by System242• Ritonavir (Norvir). Multiple drug interactions. Side effects:GI upset, generalized discomfort, tingling or numbnessaround the mouth.• Indinavir (Crixivan). Avoid dehydration, as drug can precipi-tate and cause nephrolithiasis.• Nelfinavir (Viracept). Side effects: Fat redistribution, stom-ach upset, diarrhea.• Atazanavir (Reyataz). Side effects: GI upset, hyperglycemia,fat redistribution.• Fusion inhibitor:• Enfuvirtide (Fuzeon). Subcutaneous injection. Side effects:Peripheral neuropathy, pancreatitis, elevated liver enzymes.• Combination pills:• Combivir––AZT and 3TC• Kaletra––lopinavir and ritonavir • Trizivir––abacavir, zidovudine, lamivudine2. Prevention of opportunistic infections. Prophylaxis for certainconditions is based on CD4 count.• CD4 < 200:• P. carinii pneumonia––regimen of choice is trimethoprim–sulfamethoxazole (alternative regimens include dapsone,pentamidine).• CD4 < 100:• Toxoplasma gondii––in patients with serum anti-Toxoplasma an-tibodies, regimen of choice is trimethoprim–sulfamethoxazole(alternative regimens include dapsone/pyramethamine/leukovorin, atovaquone).• CD4 < 50:• M. avium complex––azithromycin weekly or clarithromycindaily.• Other considerations:• M. tuberculosis––primary prophylaxis indicated for patientswith a positive purified protein derivative (PPD) (induration> 5 mm) who have never been treated for tuberculosis, andpatients with recent exposure to someone with active tuber-culosis, regardless of CD4 count. Depending on drug resis-tance patterns, regimens vary.• Primary prophylaxis is not routinely recommended againstherpesviruses (cytomegalovirus [CMV], herpes simplex virus,and varicella–zoster virus) or fungi (Candida species, Cryptococ-cus neoformans, Histoplasma capsulatum, and Coccidioides immitis).3. Treatment of opportunistic infections as appropriate. Examples:• Bactrim/pentamidine for PCP• Pyrimethamine for toxoplasmosis• Amphotericin for cryptococcal meningitis• Ganciclovir for CMV
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_x0001_ SymptomsPainless chancre generally appears within 2–6weeks of infection, most commonly on the penis, vulva, or vagina,but can develop on the cervix, tongue, lips, or other parts of thebody. Associated with lymphadenopathy. Chancre heals within 4–6weeks even without treatment, but lymphadenopathy can be per-sistent. If not treated during the primary stage, about one-third ofpeople will go on to the chronic stages.
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• Primary syphilis: _x0001_ Description Infection with the spirochete Treponema pallidum, transmitted sexu- ally (or from mother to fetus). Four stages of disease––primary, sec- ondary, latent, and tertiary. An infected, untreated person is contagious during the first two stages, which usually last 1–2 years |
_x0001_ Treatment Steps_x0001_ DiagnosisSerologic testing most often used for diagnosis. Nontreponemal tests(Venereal Disease Research Laboratory [VDRL] and rapid plasmareagin [RPR]) are used as initial screening test and become negativewith treatment. Specific treponemal tests (fluorescent treponemalantibody absorption test [FTA-ABS]) are more specific and confirmsyphilis when positive, and remain positive even after therapy. Dark-field examination can be used to evaluate suspicious moist cutaneous lesions. All patients with syphilis should undergo HIV testing.1. Primary, secondary, or early latent––penicillin G (2.4 millionunits IM, once).
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_x0001_ SymptomsIncludes rash, lymphadenopathy, and constitu-tional symptoms. A skin rash begins as pale, pink to red maculeswhich can progress to papules or pustules. Rash can occur any-where, but almost always on the palms and soles. Papules can en-large, usually in intertriginous areas, to form moist pint-gray le-sions called condylomata lata, which are highly infectious. Rashusually heals within several weeks or months. Constitutional symp-toms can occur (mild fever, fatigue, headache, sore throat), maybe very mild,
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Secondary syphilis_x0001_ DescriptionInfection with the spirochete Treponema pallidum, transmitted sexu-ally (or from mother to fetus). Four stages of disease––primary, sec-ondary, latent, and tertiary. An infected, untreated person is contagious during the first two stages, which usually last 1–2 yearsConstitutional symp-toms can occur (mild fever, fatigue, headache, sore throat), maybe very mild, and, like primary syphilis, will disappear withouttreatment. The signs of secondary syphilis may come and go overthe next 1–2 years of the disease.
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_x0001_ Treatment Steps1. Primary, secondary, or early latent––penicillin G (2.4 millionunits IM, once).
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Positive lab testing for syphilis in a patient with noclinical manifestations of syphilis and a normal CSF exam indicatelatent syphilis.
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Latent syphilis• Early latent––latency within the first year after infection• Late latent––latency after 1 year of infection_x0001_ DescriptionInfection with the spirochete Treponema pallidum, transmitted sexu-ally (or from mother to fetus). Four stages of disease––primary, sec-ondary, latent, and tertiary. An infected, untreated person is contagious during the first two stages, which usually last 1–2 yearsConstitutional symp-toms can occur (mild fever, fatigue, headache, sore throat), maybe very mild, and, like primary syphilis, will disappear withouttreatment. The signs of secondary syphilis may come and go overthe next 1–2 years of the disease.
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_x0001_ Treatment Steps1. Primary, secondary, or early latent––penicillin G (2.4 millionunits IM, once).2. Late latent (or latent of uncertain duration), cardiovascular, orbenign tertiary)––penicillin G (2.4 million units IM weekly for 3weeks) (lumbar puncture should be done in these cases, and ifabnormal, treat as neurosyphilis even if asymptomatic).
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One-third of people who have had secondarysyphilis develop tertiary syphilis (includes neurosyphilis, cardiovas-cular syphilis, and gummas).• Neurosyphilis––meningeal involvement (usually within the firstyear of infection), general paresis (after about 20 years), andtabes dorsalis (after 25–30 years).• Cardiovascular syphilis––includes aortitis, aortic regurgitation,saccular aneurysm.• Gummas––granulomatous inflammatory lesions; involves skin, bones, mouth, upper respiratory tract, larynx, liver, stomach
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Tertiary syphilis_x0001_ DescriptionInfection with the spirochete Treponema pallidum, transmitted sexu-ally (or from mother to fetus). Four stages of disease––primary, sec-ondary, latent, and tertiary. An infected, untreated person is contagious during the first two stages, which usually last 1–2 years._x0001_ DiagnosisSerologic testing most often used for diagnosis. Nontreponemal tests(Venereal Disease Research Laboratory [VDRL] and rapid plasmareagin [RPR]) are used as initial screening test and become negativewith treatment. Specific treponemal tests (fluorescent treponemal antibody absorption test [FTA-ABS]) are more specific and confirm syphilis when positive, and remain positive even after therapy. Dark-field examination can be used to evaluate suspicious moist cutaneous lesions. All patients with syphilis should undergo HIV testing.
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_x0001_ Treatment Steps1. Primary, secondary, or early latent––penicillin G (2.4 millionunits IM, once).2. Late latent (or latent of uncertain duration), cardiovascular, orbenign tertiary)––penicillin G (2.4 million units IM weekly for 3weeks) (lumbar puncture should be done in these cases, and ifabnormal, treat as neurosyphilis even if asymptomatic).3. Neurosyphilis––penicillin G 12–24 million units daily given intra-venously in divided doses q4h for 10–14 days
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PUPIL Reacts toaccommodation but notto light
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ARGYLL–ROBERSTON PUPIL • Occurs in general paresis and tabes dorsalis |
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