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142 Cards in this Set
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Give the test for the pneumonia pathogen:
Legionella Chlamydia pneumo. Mycoplasma Strep. pneumo. viral |
Legionella: urine Legionella antigen test, sputum staining with direct fluorescent antibody (DFA)
Chlamydia pneumo.: serologic testing, culture, PCR Mycoplasma: usually clinical; serum cold agglutinins and serum Mycoplasma antigen Strep. pneumo.: urine pneumococcal antigen, culture viral: nasopharyngeal aspirate, rapid tests, DFA, viral culture |
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What pathogen is/are commonly associated with atypical pneumonia?
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Mycoplasma
Legionella Chlamydia |
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What pathogen is/are commonly associated with nosocomial pneumonia?
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GNRs
Staph anaerobes |
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What pathogen is/are commonly associated with pneumonia in immunocompromised patients?
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Staph
GPRs fungi viruses Pneumocystis jiroveci mycobacteria |
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What pathogen is/are commonly associated with aspiration pneumonia?
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anaerobes
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What pathogen is/are commonly associated with pneumonia in alcoholic/IV drug user patients?
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Strep. pneumo
Klebsiella Staph |
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What pathogen is/are commonly associated with pneumonia in CF patients?
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Pseudomonas
Burkholderia Staph. aureus mycobacteria |
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What pathogen is/are commonly associated with pneumonia in COPD patients?
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H. influenzae
Moraxella catarrhalis S. pneumoniae |
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What pathogen is/are commonly associated with pneumonia in postviral patients?
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Staph
H. influenzae |
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What pathogen is/are commonly associated with pneumonia in neonates?
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GBS
E. coli |
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What features are commonly associated with recurrent pneumonia?
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obstruction
bronchogenic carcinoma lymphoma Wegener's immunodeficiency unusual organisms (Nocardia, Coxiella, Aspergillus, Pseudomonas) |
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What pneumonia patients should be admitted and treated with with IV antibiotics?
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unstable vital signs/resp. compromise
altered mental status multilobar disease >65 years of age alcoholics COPD diabetes malnutrition immunosuppression |
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Give the sputum appearance:
S. aureus S. pneumoniae |
S. aureus: clusters of Gram+ cocci
S. pneumoniae: lancet-shaped Gram+ diplococci |
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Give the empiric coverage for the following type of pneumonia:
outpatient community-acquired pneumonia |
one of:
macrolide (e.g. azithromycin) doxycycline fluoroquinolone |
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Give the empiric coverage for the following type of pneumonia:
patients >65y or with comorbidity |
macrolide or fluoroquinolone
consider adding 2nd-gen cephalosporin or beta-lactam to macrolide |
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Give the empiric coverage for the following type of pneumonia:
CAP requiring hospitalization |
one of:
extended-spectrum cephalosporin beta-lactam/beta-lactamase inhibitor fluoroquinolone add macrolide if atypical organism suspected |
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Give the empiric coverage for the following type of pneumonia:
CAP requiring ICU care |
one of:
extended-spectrum cephalosporin beta-lactam/beta-lactamase inhibitor + macrolide fluoroquinolone |
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Give the empiric coverage for the following type of pneumonia:
HAP or healthcare facility-acquired |
one of:
extended-spectrum cephalosporin beta-lactam with antipseudomonal activity carbapenem add aminoglycoside or fluoroquinolone for coverage of resistant organisms (Pseudomonas) until culture/sensitivity returned |
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Give the empiric coverage for the following type of pneumonia:
patients critically ill or worsening 24-48 hrs after initial therapy |
think MRSA
add vancomycin or linezolid broaden Gram- coverage |
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what is the stepwise workup for TB?
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1. three AM sputum samples for AFB stain
2. bronchoscopy with bronchoalveolar lavage if AFB negative but high clinical suspicion (e.g., HIV patients have high negative AFB rate) |
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what is Tx of active TB?
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RIPE x 2 months
continue with additional 4 months INH and rifampin |
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what is potential toxicity of isoniazid (INH)?
how can it be prevented? |
peripheral neuritis
give vitamin B6 |
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what is Tx of latent TB (LTBI); i.e. positive PPD without signs/Sx of active disease?
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INH x 9 months
(or INH x 6 months or rifampin x 4 months) |
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what features are typical of Strep pharyngitis?
what features are atypical of Strep pharyngitis? |
typical: fever, sore throat, pharyngeal erythema, tonsillar exudate, scarlatiniform rash
atypical: cough, coryza, hoarseness, rhinorrhea |
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what size PPD induration should be interpreted as a positive test?
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>5mm in HIV, close TB contacts, or with CXR evidence
>10mm in health care workers, homeless, residents of developing nations, IV drug use, chronic illness, healthcare/prison residents >15 in everyone else |
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What are Centor criteria?
How many required? |
diagnostic criteria for Strep. pharyngitis:
fever tonsillar exudate tender anterior lymphadenopathy lack of cough 3 of 4 required for Dx |
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what is the management of peritonsillar abscess?
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culture abscess fluid
localize via intraoral ultrasound or CT abx + surgical drainage |
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what is Lemierre's syndrome?
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thrombophlebitis of the jugular vein due to Fusobacterium (oral anaerobe)
a rare complication of suppurative pharyngitis |
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duration and causes of acute v. chronic sinusitis
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acute, Sx <1 month: viruses!; bacteria rare w/ Sx <1 week and include S. pneumo, H. flu, M. catarrhalis
chronic, Sx >3 months: inflammatory process. may be due to obstruction or drainage; consider mucormycosis in diabetics |
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how is sinusitis diagnosed?
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clinically (but "gold standard" is bacterial culture by sinus tap)
CT only indicated if Sx persist after treatment; MRI useful to distinguish soft tissue v. mucus |
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abx for acute sinusitis?
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10 days of one of:
augmentin/clavulanate TMP/SMX macrolides fluoroquinolone 2nd-gen cephalosporin |
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adjuvant therapy (in addition to abx) for chronic sinusitis?
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intranasal steroids
decongestants antihistamines surgical intervention may be necessary |
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what patients at increased risk for coccidioidomycosis?
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HIV+
Filipino African-American pregnant (from Southwest US with respiratory infection) |
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what is Tx of acute coccidioidomycosis?
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IV amphotericin B (rarely necessary, indicated for severe or protracted primary pulmonary infxn for disseminated disease)
continue Tx with PO -azole once patient is stable |
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what is common laboratory finding of influenza viral infection?
how may this disease present in elderly? |
leukopenia
with confusion only |
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when must antivirals be given to be effective in treatment of influenza viral infections?
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within 2 days of onset
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what medication should be avoided in children with viral infections?
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ASA; may lead to Reye's syndrome/fatty liver encephalopathy
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What pathogens cause meningitis in neonates?
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GBS
E. coli Listeria |
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What pathogens cause meningitis in children 6mo-6y?
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S. pneumo
Neisseria meningitidis H. influenza type B enteroviruses |
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What pathogens cause meningitis in adults to age 60?
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Neisseria meningitidis
enteroviruses S. pneumo HSV |
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What pathogens cause meningitis in the elderly (>60y)?
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S. pneumo
GNRs Listeria Neisseria meningitidis |
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What pathogens cause meningitis in HIV+ patients?
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Cryptococcus
CMV HSV VZV TB toxoplasmosis (w/ brain abscess) JC virus |
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What are significant CSF findings in bacterial meningitis?
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increased WBCs (PMNs), protein, opening pressure
decreased glucose cloudy! |
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What are significant CSF findings in viral meningitis?
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increased WBCs (monos/lymphs)
possible increased protein and opening pressure normal glucose often clear appearance |
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What are significant CSF findings in aseptic meningitis?
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increased WBCs
normal or increased protein normal glucose clear appearance |
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What are significant CSF findings in subarachnoid hemorrhage?
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increased RBCs, WBCs, protein
yellow or red appearance |
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What are significant CSF findings in Guillain-Barré syndrome?
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markedly increased protein
clear or yellow appearance (due to high protein) |
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What are significant CSF findings in multiple sclerosis?
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possibly increased RBCs
markedly increased gamma globulins clear appearance |
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What are significant CSF findings in pseudotumor cerebri?
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markedly increased opening pressure
otherwise normal |
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give the empiric treatment of bacterial meningitis for the following age groups:
<1 months 1-3 months 3 months-adult >60 years/alcoholic/chronic illness |
<1 months: amp + cefotaxime/gent
1-3 months: IV vanco + ceftriaxone/cefotaxime 3 months-adult: IV vanco + ceftriaxone/cefotaxime >60 years/alcoholic/chronic illness: amp + vanco + cefotaxime/ceftriaxone |
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what medication may be useful if given before abx in the treatment of bacterial meningitis?
what medication may be used for prophylaxis for close contacts of patients with meningococcal meningitis? |
dexamethasone (15-20 min before abx)
rifampin |
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what is the presentation of cerebral edema complicating meningitis?
how is it treated? |
loss of vestibulo-ocular reflex
IV mannitol |
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what is the presentation of subdural effusion complicating meningitis?
how is it treated? |
found on CT scan; occurs in 50% of infants with H. flu meningitis
no Tx necessary |
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what is the presentation of ventriculitis/hydrocephalus complicating meningitis?
how is it treated? |
worsening clinical picture with improved CSF findings
ventriculostomy, may require IV abx |
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what is the treatment of seizures complicating meningitis?
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benzos
phenytoin |
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what intervention for meningitis complicated by seizures not responsive to benzos and phenytoin?
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intractable seizures indicate subdural empyema; requires surgical evacuation
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what are the most common causes of encephalitis?
what is the clinical presentation? |
HSV
arboviruses altered consciousness headache fever seizures |
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CSF showing RBCs without evidence of trauma indicates what?
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HSV encephalitis
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what MRI finding suggests HSV encephalitis?
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contrast-enhancing lesion in the temporal lobe
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what is the Tx of HSV encephalitis?
what is the Tx of CMV encephalitis? what is the Tx of Borrelia/Rickettsia encephalitis? |
immediate IV acyclovir
gancyclovir +/- foscarnet doxycycline |
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how are pathogens resulting in brain abscesses transmitted?
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direct spread from paranasal sinusitis (10%), otitis media/mastoiditis (33%), dental infection (2%)
direct inoculation (head trauma, neurosurgery) hematogenous spread (25%), often showing MCA distribution with multiple abscesses at gray-white junction |
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what cranial nerves are primarily affected by increased ICP?
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CN III
CN VI |
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what is Dx of brain abscess?
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CT showing ring-enhancing lesion
CSF not necessary! may cause herniation syndrome! labs show peripheral leukocytosis, increased ESR and CRP |
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what brain abscesses must be treated surgically?
what follow-up is required? |
those >2cm
serial imaging to demonstrate resolution |
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what immune marker initially spikes, then decreases and persists at low levels following HIV infection?
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virus p24 antigen
anti-p24 and anti-gp120 antibodies steadily rise 1-2 months following infection and persist at high levels |
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give the opportunistic infections associated with the CD4 count:
~500 <200 <50 |
~500: TB, HSV, herpes zoster, vaginal candidiasis, hairy leukoplakia, Kaposi sarcoma
<200: PCP, toxo, crypto, coccidio, cryptosporidiosis <50: disseminated MAC, histo, CMV retinitis, CNS lymphoma |
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what evaluation should be ordered for suspected acute retroviral syndrome (acute HIV infection)?
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HIV RNA PCR
Elisa may be negative |
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What are the major AIDS pathogens?
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"The Major Pathogens Concerning Complete T Cell Collapse"
Toxo MAC PCP Candida Crypto TB CMV Cryptosporidium |
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what is the peripartum treatment of HIV+ pregnant women not on antiretroviral therapy?
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AZT (avoid efavirenz in pregnant women)
infants should receive AZT for six weeks after birth |
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Give the microscopic appearance of the following:
Candida Aspergillus Cryptococcus Mucor |
Candida: pseudohyphae + budding yeasts
Aspergillus: 45 degree angle branching septate hyphae Cryptococcus: 5-10 micron yeasts with capsular wide halo; narrow-based unequal budding Mucor: irregular broad, non-septate hyphae; wide-angle branching |
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what are risk factors for Cryptococcus infection?
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AIDS
exposure to pigeon droppings |
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what are risk factors for histoplasmosis?
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AIDS
spelunking bird or bat droppings especially in Ohio and Mississippi river valleys |
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what test is used for Dx, therapeutic monitoring, and relapse Dx in histoplasmosis?
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urine and serum polysaccharide antigen test
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what are acute and maintenance treatments for severe histoplasmosis?
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acute: amphotericin B
maintenance: itraconazole itraconazole for >1 year in chronic cavitary lesions |
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what is treatment of PCP in AIDS patients?
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high-dose TMP/SMX x 21 days
clindamycin + primaquine if sulfa allergy prednisone taper in patients with PaO2 <70 mmHg or A-a gradient >35 |
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modes of transmission for CMV
what % of US adults have been infected with CMV? |
sexual contact
breast milk respiratory droplets blood transfusions ~70%, reactivation generally in immunocompromised patients |
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what features suggest CMV encephalitis?
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CD4 count <50
periventricular calficiations |
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what patients develop the following Mycobacterium avium complex (MAC) infections:
primary secondary disseminated |
primary: apparently healthy non-smokers (Lady Windermere syndrome)
secondary: patients with pre-existing pulmonary disease e.g. COPD, TB, CF disseminated: AIDS patients with CD4 count <50 |
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what are lab findings in MAC infection?
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+ blood cultures in 2-3 weeks post-infection
increased serum alk phos and LDH! anemia hypoalbuminemia |
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what does BM, intestine, or liver biopsy reveal in MAC infection?
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foamy macrophages with acid-fast bacilli
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what is the treatment of MAC infection?
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clarithromycin and ethambutol
+/- rifabutin and HAART |
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risk factors for toxoplasmosis
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raw or undercooked meat
changing cat litter exposure is highest in France |
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what neural structures are commonly affected in toxoplasmosis?
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basal ganglia
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how is toxoplasmosis diagnosed?
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serology, PCR, histology
if CNS involvement CT scan showing multiple iso-/hypodense ring-enhancing mass lesions MRI may show basal ganglia involvement |
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what is the treatment for toxoplasmosis?
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PO pyrimethamine, sulfadiazine, leukovorin
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how does sexually transmitted Chlamydia infection present?
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often asymptomatic; may present with urethritis, mucopurulent cervicitis, or PID
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what is lymhogranuloma venereum?
how does it present? |
an emerging cause of proctocolitis and Chlamydia serovar
primary: painless, transient papule or shallow ulcer secondary: painful swelling of inguinal nodes tertiary: "anogenital syndrome" of anal pruritus with discharge, rectal strictures, rectovaginal fistula, elephantiasis |
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what does Gram stain of urethral or genital discharge show in Chlamydia?
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PMNs but no bacteria (since Chlamydia is intracellular)
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what is Tx of sexually-acquired Chlamydia infection?
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doxy x 7 days or azithromycin x 1 day
erythromycin in pregnant patients treat sexual partners and maintain low threshold to treat for N. gonorrhoeae! |
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what are potential complications of Chlamydia STI?
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PID (with potential ectopic pregnancy/infertility in women)
Reiter's syndrome (urethritis, conjunctivitis, arthritis) Fitz-Hugh-Curtis syndrome (perihepatic inflammation and fibrosis) epididymitis in men |
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what is the treatment of gonorrhea?
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1 dose of ceftriaxone IM or cefepime PO
disseminated disease requires at least 24 hours of IV ceftriaxone |
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what is the presentation of syphilis?
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primary (up to 3 months post-infection): painless ulcer (chancre)
secondary (1-2 months post-chancre): generalized illness with diffuse, symmetric, non-pruritic maculopapular rash on palms and soles; mucous patches or condylomata lata are highly infectious serology may become negative in the late latent period, which is beyond the first year of infection tertiary (1-20 years after infection): gummas, tabes dorsalis (posterior column degeneration), meningitis, Argyll Robertson pupils (constrict with accommodation but don't react to light); aortic pathology including aortic root aneurysms |
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what can cause a false positive VDRL result?
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"VDRL"
Viruses Drugs (IV drug use) Rheumatic fever/Rheumatoid arthritis Lupus/Leprosy |
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diagnostic tests for syphilis
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dark-field microscopy (motile spirochetes in primary and secondary disease)
VDRL/RPR (rapid, inexpensive, ~70% sensitive in primary disease; many false positives) FTA-ABS (secondary Dx test) T. pallidum particle agglutination test (TPPA): easier than FTA-ABS; becoming secondary test of choice |
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what is the time course of syphilis progression in AIDS patients?
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may be greatly accelerated; rule out neurosyphilis in any AIDS patient with neurologic Sx and +RPR
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which STIs have painful genital lesions?
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chancroid (Haemophilus ducreyi)
herpes (HSV1 or HSV2) Klebsiella granulomatis, HPV, and syphilis have painless lesions |
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what is the treatment for uncomplicated UTI?
for complicated UTI? in pregnancy? |
uncomplicated: 3 days of TMP-SMX or fluoroquinolone OR 7 days of nitrofurantoin
complicated: same as above, but longer duration (7-14 days) pregnancy: avoid fluoroquinolones! use nitrofurantoin or cephalosporin x3-7 days |
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what UA finding differentiates pyelonephritis from cystitis/lower UTI?
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WBC casts
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what is first-line therapy for pyelonephritis?
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fluoroquinolones
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sepsis v. severe sepsis v. septic shock
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sepsis: SIRS + documented infection
severe sepsis: sepsis with end-organ dysfxn due to poor perfusion septic shock: sepsis with HoTN and organ dysfxn from vasodilation |
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SIRS criteria
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1. <36 or >38 degrees C
2. tachypnea >20 bpm or PaCO2 <32 mmHg 3. tachycardia (actually, HR >90) 4. leukocytosis or leukopenia: WBCs <4000/mm3 or >12000/mm3 |
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clinical presentation of malaria
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periodic chills, fever, diaphoresis every 2-3 days
asymptomatic between attacks |
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Dx of malaria
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Giemsa- or Wright-stained thick and thin blood films
determines Plasmodium strain and degree of parasitemia |
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Tx of malaria
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chloroquine
quinine with clindamycin or doxycycline for resistant strains primaquine must be added for P. vivax and P. ovale to eradicate hepatic hypnozoites |
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potential complications of malaria
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cerebral involvement --> coma
severe hemolytic anemia ATN --> renal failure ("blackwater fever" of massive hemoglobinuria) noncardiogenic pulmonary edema dysrhythmias,diarrhea, DIC |
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presentation of infectious mononucleosis
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fever, pharyngitis, fatigue
lymphadenopathy (esp. posterior cervical) bilateral upper eyelid edema |
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consequence of ampicillin administration during acute EBV infection
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prolonged, pruritic, drug-related maculopapular rash
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Dx of infectious mononucleosis
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heterophil antibody (Monospot test)
may be negative in first weeks after Sx onset |
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CBC of infectious mononucleosis
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mild thrombocytopenia
lymphocytosis >10% atypical T lymphocytes |
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Tx of infectious mononucleosis
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supportive
corticosteroids for: airway obstruction due to tonsillar enlargement severe thrombocytopenia severe AIHA |
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complications of infectious mononucleosis
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CNS infection
splenic rupture upper airway obstruction bacterial superinfection (Strep. pharyngitis) fulminant hepatic necrosis (MCC of death in affected males) AIHA (Coombs+) |
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fever of unknown origin: major etiologies
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infections and cancer (>60%)
autoimmune (15%; rheumatic disease is 1/3 of cases in the elderly) |
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presentation of neutropenic fever
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38.3C or above in patient with ANC <500/mm3
common in cancer patients 7-10 days post-chemotherapy |
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physical exam maneuver to avoid in neutropenic fever
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digital rectal exam (bleeding risk if patient is thrombocytopenic)
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DDx of fever and rash
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"Tiny GERMS"
Typhoid fever Gonococcemia Endocarditis Rocky mountain spotted fever Meningococcemia Sepsis (bacterial) |
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Tx of Lyme disease
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primary (early localized): doxycycline
secondary (Bell's palsy, heart block) and tertiary (arthritis, subacute encephalitis): ceftriaxone |
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name the vector:
Lyme disease Rocky Mountain spotted fever |
Ixodes (deer, mice)
Dermacentor (dogs) |
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presentation of Rocky Mountain spotted fever
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headache, fever, malaise
peripheral macular rash that becomes petechial, purpuric, and central |
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Tx of Rocky Mountain spotted fever
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doxycycline
chloramphenicol for resistant organisms |
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common anatomic origin of microbe/infection causing orbital cellulitis
|
paranasal sinuses
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usual microbes of orbital cellulitis
microbes in diabetic and immunocompromised patients |
Strep
Staph (including MRSA) H. influenzae Mucor Rhizopus |
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presentation of orbital cellulitis
what findings suggestive of Mucor or Rhizopus? |
Hx of ocular trauma or sinusitis
acute-onset fever proptosis decreased EOM palatal/nasal mucosal ulceration with coexisting maxillary/ethmoid sinusitis |
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Dx of orbital cellulitis
management of orbital cellulitis |
blood/tissue fluid culture
CT to r/o orbital abscess and intracranial involvement admission --> IV abx amphotericin B and debridement if Mucor or Rhizopus Dx'd (diabetics, immunocompromised) |
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potential complication of surgical debridement of orbital cellulitis in diabetic and immunocompromised patients?
|
cavernous sinus thrombosis
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most common pathogen in infectious conjunctivitis
other pathogens |
adenovirus
Staph Strep Haemophilus Pseudomonas Moraxella N. gonorrhoeae C. trachomatis |
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management of infectious conjunctivitis
|
depends on pathogen
adenovirus: self-limited; topical corticosteroids with ophthalmologist if needed Staph, Strep, etc.: abx drops/ointment N. gonorrhoeae: emergency! IM ceftriaxone, PO cipro or ofloxacin (admit if complicated!) Chlamydia: azithromycin, tetracycline, erythromycin x3-4 weeks |
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most common agents of otitis externa
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Pseudomonas
Enterobacteriaceae |
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distinguishing exam finding in otitis externa v. otitis media?
|
otitis externa: pain with movement of tragus/pinna; edematous and erythematous ear canal
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Tx of otitis externa
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abx and steroid ear drops
systemic abx if severe disease; diabetics at risk for osteomyelitis of skull base (admit --> IV abx) |
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presentation of endocarditis
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"JR = NO FAME"
Janeway lesions Roth's spots Nail-bed (splinter) hemorrhage Osler's nodes Fever Anemia Murmur Emboli |
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infective endocarditis: give correlated clinical setting for below pathogens
S. aureus Viridans strep coag-neg Staph Strep bovis Candida, Aspergillus |
S. aureus: acute bacterial endocarditis in IV drug users
Viridans strep: L-sided subacute bacterial endocarditis coag-neg Staph: prosthetic valve endocarditis Strep bovis: endocarditis with coexisting GI malignancy Candida, Aspergillus: AIDS, malignancy, indwelling catheters, organ transplantation, IV drug use |
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describe each:
Janeway lesions splinter hemorrhages Roth's spots Osler's nodes |
small peripheral hemorrhages
subungual petechiae retinal hemorrhages small, tender nodules on finger and toe pads |
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Tx of suspected infective endocarditis
|
early empiric IV abx: vancomycin or nafcillin+gentamicin
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indications for surgery in endocarditis
|
"PUS RIVER"
Prosthetic valve endocarditis Uncontrolled Infxn Suppurative complications w/ conduction abnormalities Resection of mycotic aneurysm Ineffective antimicrobial therapy (fungi) Valvular damage (significant) Embolization (repeated systemic) Refractory CHF (or sudden onset) |
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sources of B. anthracis
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hazard for vets and farmers:
animal wool, hair, hides, or bone meal products |
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forms and presentation of anthrax
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cutaneous: pruritic papule enlarging to form ulcer with round, regular, raised edge --> black eschar within 10 days; regional lymphadenopathy
inhalational: pneumonia Sx due to hemorrhagic mediastinitis GI (poorly cooked, contaminated meat!): dysphagia, n/v, bloody diarrhea, abd pain |
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Tx of anthrax
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inhalational: cipro or doxy + 1-2 additional for 14 days
cutaneous: same, with 60 days of post-exposure cipro prophylaxis to prevent inhalation |
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anatomic origin of bug in osteomyelitis
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direct spread from soft tissue infection (80%)
hematogenous seeding (20%) hematogenous seeding more common in children at metaphyses of long bones; IV drug users in vertebral bodies |
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labs in osteomyelitis
imaging in osteomyelitis |
increased WBCs, ESR, CRP
X-ray initially negative but shows periosteal elevation within 10-14 days; MRI shows increased signal in BM and associated soft tissue infxn |
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give causative pathogen for osteomyelitis in following groups:
most people: IV drug users: sickle cell dz: hip replacement: foot puncture wound: chronic: diabetic: |
most people: S. aureus
IV drug users: S. aureus, Pseudomonas sickle cell dz: Salmonella hip replacement: Staph epidermidis foot puncture wound: Pseudomonas chronic: S. aureus, Pseudomonas, Enterobacteriaceae diabetic: polymicrobial, Pseudomonas, S. aureus, Strep, anaerobes |
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Tx of osteomyelitis
|
surgical debridement of necrotic, infected bone followed by 4-6 weeks of IV abx
diabetics should receive abx for Gram+ and anaerobes |
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complications of osteomyelitis
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chronic infection, sepsis, septic arthritis
long-standing dz with draining tract may lead to squamous cell carcinoma (Marjolin's ulcer) |
