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152 Cards in this Set
- Front
- Back
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6 "Do-Not-Miss" Diagnoses of Infection that present with Fever and Rash
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1 Meningococcemia
2 Bacterial Sepsis (eg, Staphylococcus) 3 Endocarditis 4 Gonococcemia 5 Rocky Mountain Spotted Fever (RMSF) 6 Typhoid Fever |
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Criteria for Fever of Unknown Origin (FUO)
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1 Temperature >38.3C (101F) for >3 weeks with failure to diagnose despite 1 week of inpatient investigation or several outpatient visits
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3 Common Infectious Causes of FUO
30-40% of cases |
1 Endocarditis
2 TB 3 Occult Abscess (usually abdominal) |
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3 Common Neoplastic Causes of FUO
20-30% of cases |
1 Leukemia
2 Lymphoma 3 Renal Cell Carcinoma |
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3 Common Autoimmune Causes of FUO
15-20% of cases |
1 Giant Cell Arteritis
2 Polymyalgia Rheumatica 3 Juvenile Rheumatoid Arthritis (RA) |
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4 Risk Factors for Sinusitis
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1 Smoking
2 Viral Infection 3 Allergies 4 Barotrauma |
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3 Most Common Bacterial Pathogens causing Acute Sinusitis
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1 Streptococcus pneumoniae
2 Haemophilus influenzae 3 Moraxella catarrhalis |
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Sinuses Most Commonly Involved in Acute Sinusitis
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Maxillary Sinuses
drain superiorly against gravity |
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3 Key Clinical Findings of Acute Sinusitis
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1 Purulent Rhinorrhea
2 Facial Pain 3 Maxillary Tooth Pain |
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Treatment of Acute Sinusitis Lasting >2 Weeks
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1 Bactrim + Amoxicillin + Doxycycline x 10 Days PO
2 Decongestants |
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What condition results from obstruction of sinus drainage and ongoing anaerobic infection?
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Chronic Sinusitis
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Treatment of Chronic Sinusitis
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6-12 Weeks PO Antibiotics
Surgical Correction of Obstruction for Refractory Cases |
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Diabetics are at increased risk for developing what typeof severe sinusitis?
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Mucormycosis
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4 Potential Complications of Sinusitis
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1 Meningitis
2 Frontal Bone Osteomyelitis 3 Abscess Formation 4 Cavernous Sinus Thrombosis |
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Where do the majority of bleeds from epistaxis occur?
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Kiesselbach Plexus
Anterior Nasal Septum |
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Most Common Cause of Epistaxis in Kids
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Exploration with Digits
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2 Most Common Pathogens causing Otitis Externa (Swimmer's Ear)
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1 Pseudomonas
2 Enterobacteriaceae |
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What PE finding is virtually pathognomonic for Otitis Externa?
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Pulling on pinna or pushing tragus causes pain
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Treatment of Choice for Otitis Externa
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Antibiotic Eardrops
(Dicloxacillin for Acute Disease) |
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Group of Patients at Increased Risk for Complications from Otitis Externa
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Diabetics
increased risk of Malignant Otitis Externa and Osteomyelitis of Temporal Bone/Skull Base |
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Organism:
Fever, sore throat and red eye |
Adenovirus
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Organism:
Oral thrush, seen in AIDS and small kids |
Candida
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Organism:
Pathognomonic gray membranes on tonsils |
Diphtheria
(Membranous Pharyngitis) |
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Organism:
High fever, sore throat with exudative tonsillitis and cervical lymphadenopathy Cough usually absent |
Group A Streptococcus (GAS)
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Organism:
Tonsillitis, splenomegaly, palatal petechiae and posterior auricular lymphadenopathy |
Epstein-Barr Virus (EBV)
(Mononucleosis) |
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Primary or Secondary Tuberculosis:
Classically affects lower lobes of the lung |
Primary TB
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Primary or Secondary Tuberculosis:
Associated with reactivation |
Secondary TB
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Primary or Secondary Tuberculosis:
Fibrocaseous cavitary lung lesion |
Secondary TB
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Primary or Secondary Tuberculosis:
Ghon complex on CXR |
Primary TB
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Primary or Secondary Tuberculosis:
Affects apical lungs (Increased affinity for higher O2 environment) |
Secondary TB
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Primary or Secondary Tuberculosis:
Presents with cough/hemoptysis, fever, night sweats, weight loss |
Secondary TB
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Primary Mode of Transmission of Mycobacterium tuberculosis
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Respiratory Droplets
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Term used to describe the lymphatic and hematogenous spread of TB, causing numerous small foci of infection in extrapulmonary sites
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Miliary TB
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5 Most Common Sites of Extrapulmonary TB
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1 Central Nervous System (CNS)
- Tuberous Meningitis 2 Vertebral Bodies - Pott Disease 3 Psoas Major Muscle --> Abscess 4 Liver 5 Cervical Lymph Nodes --> Scrofuloderma (massive lymphadenopathy) |
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How is Active TB diagnosed?
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Clinical and Radiologic Signs of Secondary TB
Acid-Fast Bacilli in Sputum |
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What is an effective screening tool for latent TB?
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Purified Protein Derivative (PPD) Test
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What constitutes a positive PPD test?
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>5 mm induration for HIV+ or Immunocompromised individuals
>10 mm induration for high risk individuals >15 mm induration for anyone else |
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What condition causes a false negative PPD?
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Immunosuppression
Check Anergy Panel |
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What is the management of PPD+ latent TB?
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Isoniazid (INH) for 9 months
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Management for Active TB
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1 Respiratory Isolation
2 "RIPE" Therapy Rifampin INH Pyrizinamide Ethambutol Narrowed when sensitivities determined (treat for >6 months) Give Vitamin B6 with INH |
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Major Toxicity of many TB Drugs
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Hepatotoxicity
Check LFTs if symptomatic or h/o Liver Disease |
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Test used to Rule Out HIV because of its High Sensitivity
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Enzyme-Linked Immunosorbent Assay (ELISA)
to detect antibodies to viral proteins |
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Test used to confirm positive HIV test because of its high specificity
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Western Blot Assay
high false negative within 2 months of infection |
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Common presenting signs of the viral prodrome of HIV (Acute Retroviral Syndrome)
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1 Fever (97%)
2 Fatigue (90%) 3 Lymphadenopathy (50-70%) 4 Pharyngitis (73%) 5 Transient Rash (40-70%) 6 Headache (30-60%) |
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How is AIDS defined?
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CD4+ <200 cells/mL
Serologic evidence of AIDS-defining illness |
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What mutation may confer resistance to infection with HIV?
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Homozygous deletion of CCR5
or other viral receptors |
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AIDS Opportunistic Fungal Infections (5)
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1 Candida - thrush
2 Cryptococcus - meningitis 3 Pneumocystis jeroveci Pneumonia 4 Histoplasmosis 5 Coccidioidosis |
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AIDS Opportunistic Bacterial Infections
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1 Mycobacterium tuberculosis (TB)
2 Staphylococcus 3 Encapsulated Organisms 4 Mycobacterium avium-intracellulare (MAC complex) |
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AIDS Opportunistic Viral Infections
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1 Herpes Simplex Virus (HSV)
2 Varicella Zoster Virus (VZV) - shingles 3 Cytomegalovirus (CMV) Retinitis 4 JC Virus - PML 4 Epstein-Barr Virus (EBV) - B-cell Lymphoma 5 Human Herpesvirus 8 (HHV-8) - Kaposi Sarcoma |
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AIDS Opportunistic Protozoal Infection
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1 Toxoplasma - Encephalopathy
2 Cryptosporidium - severe watery diarrhea |
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CD4+ Count:
TB becomes more common |
CD4+ <400 cells/mL
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CD4+ Count:
Serious opportunists are first seen |
CD4+ <200 cells/mL
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CD4+ Count:
Toxoplasmosis, Cryptococcosis |
CD4+ <100 cells/mL
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CD4+ Count:
MAC, CMV, Cryptosporidiosis |
CD4+ <50 cells/mL
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Highly Active Antiretroviral Therapy (HAART)
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2 Nucleoside RT Inhibitors
+ Protease Inhibitor or Nonnucleoside RT Inhibitor No patient should be on monotherapy due to risk of resistance |
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What test should be used to monitor the effectiveness of antiretroviral therapy?
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HIV Polymerase Chain Reaction (PCR)
measures viral load |
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Medical Management for HIV+ Patients:
CD4+ <500 or detectable viral load |
Initiate HAART
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Medical Management for HIV+ Patients:
CD4+ <200 |
Bactrim Prophylaxis for PCP
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Medical Management for HIV+ Patients:
CD4+ <75 |
Azithromycin Prophylaxis for MAC
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Medical Management for HIV+ Patients:
CD4+ <50 |
Fluconazole Prophylaxis for Fungi
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Medical Management for HIV+ Patients:
Pregnant HIV+ Patient |
Zidovudine (Azidothymidine [AZT])
decrease vertical transmission |
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Treatment of Choice:
Immunocompromised Patient with Influenza |
Prevention:
- Trivalent Inactivated Influenza Vaccine Post-Exposure Prophylaxis: - Zanamivir or - Oseltamivir |
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Why is Oseltamivir preferred in asthmatics in the treatment of influenza?
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Zanamivir is associated with bronchospasm in 5-10% of patients with asthma
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6 Risk Factors for Urinary Tract Infections (UTIs)
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1 Foley Catheter
2 Diabetes Mellitus 3 Anatomic Anomaly 4 Pregnancy 5 Increased Sexual Activity 6 H/o UTI or Pyelonephritis |
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3 Common presenting Symptoms in UTI
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1 Frequency
2 Dysuria 3 Urgency |
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What 2 clinical findings suggest Pyelonephritis?
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1 Fever
2 Back/Flank Pain |
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What is the most common presenting symptom in a child with a UTI?
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Bedwetting
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Why are women at ten times the risk of men for developing a UTI?
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The urethra is shorter in women and more likely to be colonized with fecal flora
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Urinary Finding with UTI:
Microscopic analysis |
>5 WBC/high-power field
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Urinary Finding with UTI:
Urine dipstick |
Increased Leukocyte esterase
Increased Nitrites (specific for Gram negatives) |
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Urinary Finding with UTI:
Clean-catch urine culture |
>100,000 CFU/mL of bacteria
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Urinary Finding with UTI:
Characteristic urinalysis (UA) finding in Proteus infection |
Increased Urine pH
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Urinary Finding with UTI:
Characteristic UA finding in cystitis |
Hematuria
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Urinary Finding with UTI:
Characteristic UA finding in acute pyelonephritis |
WBC Casts
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Most Common UTI Organisms
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"SEEKS PP"
Serratia marcescens Escherichia coli Enterobacter cloacae Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa |
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Which UTI-causing bug is frequently nosocomial, drug-resistant and may produce a red pigment?
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Serratia marcescens
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What is the first-line antibiotic for lower UTIs?
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Bactrim
(Trimethoprim [TMP]-Sulfamethoxazole [SMX]) - for 3 days Amoxicillin for Enterococcus |
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Treatment for Pyelonephritis
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Levofloxacin PO x 7 days
IV, if the patient has n/v |
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Sexually-Transmitted Disease & Treatment:
Clue cells in Pap smear Positive "whiff test" |
Bacterial Vaginosis
- Gardnerella vaginitis Tx: Flagyl (Metronidazole) |
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Sexually-Transmitted Disease & Treatment:
Soft, painful sexually transmitted ulcer associated with inguinal lymphadenopathy |
Chancroid
- Haemophilus ducreyi Tx: Ceftriaxone, Ciprofloxacin or Erythromycin |
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Sexually-Transmitted Disease & Treatment:
Raised, red papules Biopsy shows Donovan bodies |
Granuloma Inguinale
- Klebsiella (Calymmatobacterium) granulomatis Tx: Doxycycline 100mg bid x 3 weeks |
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Sexually-Transmitted Disease & Treatment:
Firm, painless chancre caused by a spirochete |
Syphilis
- Treponema pallidum Tx: Penicillin G |
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Sexually-Transmitted Disease & Treatment:
Most common STD Frequent cause of pelvic inflammatory disease (PID) in women and urethritis in men Associated with Reiter Syndrome |
Chlamydial Cervicitis (Types D-K)
Tx: Azithromycin Erythromycin in pregnancy Treat presumptive gonorrhea coinfection with Ceftriaxone |
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Sexually-Transmitted Disease & Treatment:
Small papule/ulcer that leads to enlargment of lymph nodes Caused by Chlamydia trachomatis serotypes L1, L2, L3 |
Lymphogranuloma Venereum
Tx: Azithromycin Erythromycin in pregnancy Treat presumptive gonorrhea coinfection with Ceftriaxone |
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Sexually-Transmitted Disease & Treatment:
STD that can result in extragenital infections (eg, pharyngitis, proctitis, arthritis and neonatal conjunctivitis) |
Gonorrhea
- Neisseria gonorrhoeae Tx: Ceftriaxone Treat presumptive chlamydial coinfection with Azithromycin |
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Sexually-Transmitted Disease & Treatment:
STD resulting in benign venereal warts caused by human papillomavirus (HPV) types 6 and 11 |
Condyloma Acuminatum
Tx: Cryotherapy or Topical Podophyllin |
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Sexually-Transmitted Disease & Treatment:
Painful vesicals/ulcers Cytology shows multinuclear giant cells Diagnose with Tzanck prep |
Herpes Genitalis
- most often HSV-2 Tx: Acyclovir for primary infection or suppression |
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Sexually-Transmitted Disease & Treatment:
STD caused by flagellated, motile protozoan #2 cause of vaginitis |
Trichomoniasis
Tx: Flagyl (Metronidazole) |
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Stage of Syphilis:
Rash on palms and soles with lymphadenopathy |
Secondary Syphilis
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Stage of Syphilis:
Firm, painless chancre |
Primary Syphilis
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Stage of Syphilis:
After 1 year of infection Can progress to tertiary syphilis |
Late Latent Syphilis
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Stage of Syphilis:
First year of infection No symptoms, but positive serology |
Early Latent Syphilis
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Stage of Syphilis:
Tabes dorsalis Aortitis Argyll-Robertson Pupil Gummas |
Tertiary Syphilis
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3 Tests for Diagnosing Syphilis
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1 Dark-field Microscopy - visible spirochetes
2 VDRL/RPR - fast, cheap, non-specific 3 Fluorescent Treponemal Antibody-Absorbed (FTA-ABS) - sensitive, specific, positive for life |
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Treatment for Syphilis
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Penicillin
- IV for neurosyphilis - Increase dose 3x if undiagnosed for >1 year |
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Complication of syphilis treatment resulting in fever and flu-like symptoms caused by massive destruction of spirochetes
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Jarisch-Herxheimer Reaction
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2 Main Routes of Infection for Osteomyelitis
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1 Direct Spread (80%)
2 Hematogenous Seeding (20%) |
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Where does hematogenous osteomyelitis typically occur?
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Metaphyses of long bones in children
- increased vascularity of growth plates Vertebral bodies of IV drug abusers |
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Organism Causing Osteomyelitis:
Newborn |
Streptococci spp
E. coli |
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Organism Causing Osteomyelitis:
Child |
Staphylococcus aureus
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Organism Causing Osteomyelitis:
Otherwise Healthy Adult |
Staphylococcus aureus
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Organism Causing Osteomyelitis:
Foot Puncture Wound |
Pseudomonas spp.
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Organism Causing Osteomyelitis:
Intravenous Drug User |
Pseudomonas spp.
Staphylococcus aureus |
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Organism Causing Osteomyelitis:
Sickle Cell Disease |
Salmonella spp.
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Organism Causing Osteomyelitis:
Hip Replacement or Other Prosthesis |
Staphylococcus epidermidis
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Organism Causing Chronic Osteomyelitis
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1 Staphylococcus aureus
2 Pseudomonas spp. 3 Enterobacteriaceae |
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Organism Causing Osteomyelitis:
Asplenic Patient |
Salmonella spp.
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Classic Radiographic Finding in Osteomyelitis
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Periosteal Elevation
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Gold Standard for Evaluation of Osteomyelitis
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MRI
can confirm with Bone Aspiration and Culture |
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Treatment for Pyogenic Osteomyelitis
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1 6-8 weeks of Antibiotics
2 Fluoroquinolones empirically, narrow as cultures come back 3 Surgical debridement if necessary |
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4 Complications of Osteomyelitis
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1 Chronic Osteomyelitis
2 Septic Arthritis 3 Systemic Sepsis 4 Draining Sinus Tract leading to Squamous Cell Carcinoma |
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Most Common Vector-Borne Disease in the US
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Lyme Disease
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Organism and Vector in Lyme Disease
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Lyme Disease
Borrelia burgdorferi Ixodes Ticks |
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Treatment for Lyme Disease
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Ceftriaxone
High-dose Penicillin, or Doxycycline |
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Stage of Lyme Disease:
Migratory polyarthropathy/arthralgias, meningitis, mycocarditis (with conduction defects), neurologic problems |
Secondary Lyme Disease
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Stage of Lyme Disease:
Erythema Chronicum Migrans |
Primary Lyme Disease
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Stage of Lyme Disease:
Encephalitis and arthritis |
Tertiary Lyme Disease
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Which tick-borne disease can lead to small vessel vasculitis?
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RMSF
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Organism and Vector in RMSF
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Rickettsia rickettsii
Dermacentor Tick |
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4 Common PE Findings in RMSF
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1 Fever
2 Headache 3 Myalgias 4 Classic Maculopapular Rash - begins on palms/soles and spreads centrally |
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Differential Diagnosis:
Rash on palms and soles |
"CARS and Kawasaki's"
Coxsackie A (Hand-Foot-Mouth Disease) RMSF Syphilis Kawasaki Syndrome |
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Treatment for RMSF
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Doxycycline
Chloramphenicol in pregnant women and kids |
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Definition of Sepsis
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Sepsis
An infection that causes Systemic Inflammatory Response Syndrome (SIRS) |
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Definition of Systemic Inflammatory Response Syndrome (SIRS)
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Two or more:
1 T >38.0C (100.4F) or <36.0C (96.8F) 2 HR >90 3 RR >20 or PCO2 <32 mmHg 4 WBC >12,000 or <4,000 or >10% band forms |
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What type of bacteria cause shock through endotoxin-mediated vasodilation?
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Gram-Negative Bacteria
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Organism Causing Sepsis:
IV Drug Abusers |
Staphylococcus aureus
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Organism Causing Sepsis:
Asplenic/Sickle Cell Patients |
Encapsulated Bacteria
Haemophilus influenzae Meninogococcus Pneumococcus |
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Organism Causing Sepsis:
Neonates |
Group B Streptococcus (GBS)
Klebsiella E. coli |
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Organism Causing Sepsis:
Children |
Haemophilus influenzae
Meningococcus Pneumococcus |
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Organism Causing Sepsis:
Adults |
Gram-Positive Cocci
Anaerobes Aerobic Bacilli |
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Affected in Septic Shock:
Temperature |
Increased
though 15% present with hypothermia |
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Affected in Septic Shock:
Respirations |
Increased
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Affected in Septic Shock:
Heart Rate |
Increased
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Affected in Septic Shock:
Blood Pressure or Total Peripheral Resistance (TPR) |
Decreased
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Affected in Septic Shock:
Cardiac Output |
Increased
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Affected in Septic Shock:
Pulmonary Capillary Wedge Pressure |
Increased
or sometimes normal |
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First-line Management of Septic Shock
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1 Aggressive IV Fluids
2 Vasopressors 3 IV Empiric Antibiotics 4 Removal of Potential Source - eg, catheter, IV line |
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18 yo student returns to clinic with a rash after being treated with Ampicillin for fever and sore throat
PE: tonsillar exudates and enlarged posterior cervical lymph nodes LABS: Increased lymphocytes, + Heterophil Ab Test |
Infectious Mononucleosis
EBV |
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17 yo swimmer presents with pain and discharge from the left ear
PE: movement of tragus is extremely painful |
Otitis Externa
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2 mo with maternal h/o rash and flu in first trimester presents with failure to attain milestones
PE: microcephaly, cataracts, jaundice, continuous machinery-like murmur at left upper sternal border (LUSB), and hepatosplenomegaly (HSM) |
Congenital Rubella
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8 yo from Connecticut presents with fever, rash, headache, and joint pain after playing in the woods
PE: distinctive macule with surrounding 6 cm target-shaped lesion |
Lyme Disease
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Newborn with h/o intrauterine growth retardation (IUGR) presents with rash and maternal h/o "flu" during first trimester
PE: petechial rash, chorioretinitis, microcephaly, decreased hearing, HSM CBC: thrombocytopenia Head CT: periventricular calcifications |
Congenital CMV
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25 yo West Virginian male presents with fever, headache, myalgia, and a petechial rash that began peripherally but now involves his whole body, even his palms and soles
+ OX19 and OX2 Weil-Felix Reaction (antigenic cross-reactivity between Rickettsia spp. and certain serotypes of non-motile Proteus spp.) |
Rocky Mountain Spotted Fever (RMSF)
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28 yo male with h/o syphilis treatment (5 h ago) with IM penicillin presents with fever, chills, muscle pain, and headache
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Jarisch-Herxheimer Reaction
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26 yo sexually active, native-Caribbean presents with painless, beefy-red ulcers of the genitalia and inguinal swelling
Peripheral Blood Smear: Donovan bodies on Giemsa-stained smear |
Granuloma Inguinale
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31 yo obese female presents with pruritis in her skin fold beneath her pannus
PE: whitish-curd-like concretions beneath the abdominal pannus W/U: budding yeast on 10% KOH prep |
Cutaneous Candidiasis
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35 yo male presents with recurrent Giardia infection and respiratory infections
LABS: decreased serum IgG |
Common Variable Immunodeficiency
(Hypogammaglobulinemia) |
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25 yo female presents with homogenous white vaginal discharge with fishy odor
PE: no vaginal erythema, vaginal pH >4.5, wet mount "clue cells" |
Bacterial Vaginosis
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25 yo female presents with "cottage-cheese," non-odorous vaginal discharge with significant vaginal irritation
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Candidal Vaginitis
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25 yo female presents with yellow-green, pruritic, "frothy" vaginal discharge
PE: erythematous cervix |
Trichomonas vaginalis
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30 yo HIV+ male presents with new erythematous and violaceous macules and large nodules throughout his body
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Kaposi Sarcoma
- HHV-8 |
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65 yo male who lives in a nursing home presents with headache, lethargy, confusion, nausea, vomiting, diarrhea and abdominal pain
PE: high fever and relative bradycardia LABS: hyponatremia, increased liver enzymes, decreased phosphate, azotemia, increased creatinine kinase |
Legionella Pneumophila Pneumonia
azotemia - high levels of nitrogen-containing compounds, such as urea, creatinine |
