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106 Cards in this Set

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32-yr-old man renal transplant patient who is immunosuppressed has a positive India ink preparation:
cryptococcal meningitis
Bilateral ophthalmia neonatorum during the first week:
N. gonorrhoeae
transmitted on the way through the cervix
Granulocyte colony stimulating factor (G-CSF):
produced by fibroblassts
simulates neutrophil development in the bone marrow
Granulocyte/macrophage colony stimulating factory (GM-CFS):
produced by macrophages and T cells
stimulates neutrophil & monocyte development in the bone marrow
T cells:
60-70% of total lymphocyte count
markers: monoclonal antibody market studies for cluster designation (CD) types; immature T cells have nuclear enzyme terminal deoxynucleotidyl transferase (tdT) on their surface
functions: type IV hypersensitivity; cytokines regulate B cells; defense against intracellular pathogens (e.g.,TB, protozoa)
testing: mitogen assays: functioning T cells are specifically activated by phytohemagglutinin and concanavalin A; skin tests to evaluate cellular immunity: Candida is the main antigen used; absence of an immune indicates ANERGY or a lack of cellular immunity (e.g., AIDS)
Positive enzyme immunoabsorbent assay (EIA) test for HIV in a newborn:
due to transplacental transmission of the IgG antibody from the infected mother
document HIV infection in newborn by detection of HIV RNA by PCR (best test) & p24 antigen capture assay
AIDS testing with enzyme immunoabsorbent assay (EIA):
initial screening test
detects anti-gp120 antibody: sensitivity 99.5-99.8%; poor specificity due to low prevalence of HIV positivity in the general population
AIDS testing with western blot:
confirmatory test for indeterminate of positive EIA
positive western blot: presence of p24 and gp41 antibodies and either gp120 or gp160 antibodies; combined positive predictive value of a positive EIA/western blot is 99.5%
AIDS tests for monitoring immune status:
CD4T helper cell count
HIV RNA by PCR: best overall test to monitor viral burden
Non-AIDS difining infections:
oral thrush
oral hairy luekoplakia (EBV glossitis)
shingles (H.zoster)
molluscum contagiosum (poxvirus)
Diagnosis of AIDS:
HIV positive plus: CD4 T helper cell count: <200 cells/uL; specific malignancies: e.g., Kaposi's sarcoma; specific infections: e.g., P.carinti pneumonia (MC AIDS-defining disease
AIDS miscellaneous infections:
bacillary angiomatosis: due to Bartonella henselae: identify with silver stains; simulates Kaposi's sarcoma,
recurrent bacterial pneumonia: Streptococcus pneumoniae; infections encountered with CD4 T helper count 100-200 cells/uL; MC COD in AIDS
infections encountered with CD4 T helper count <100 cells/uL: disseminated MAL: usually <75 cells/uL; Candida esophagitis; CMV retinitis/essophagitis; Toxoplasma encephalitis; Cryptosporidiosis: diarrhea; cryptococcal meningitis
Transplantation success requirements:
ABO blood group compatibility; most important test
absence of preformed anti-HLA cytotoxic antibodies in the recipient's serum
close matches for HLA-A, b and D loci between recipient and donor
Lymphocyte crossmatch:
screens for recipient anti-HLA antibodies against donor lymphocytes
Lymphocyte microcytotoxicity test:
identifies HLA-A and B derived class T antigen profiles on recipient and donor lymphocytes using known test sera
Mixed lymphocyte reaction:
used for class II antigen (D loci) matching,
functional lymphocytes from the recipient and previously irradiated (killed) donor lymphocytes are mixed together with iritiated thymidine to detect the degree of compatibility between their D loci- increased radioactivity indicates incompatibility
recipient's lymphocytes are irradiated (killed) and functional donor lymphocytes are reacted against the host's HLA-D loci to check for a graft versus host reaction (GVH)
Transplant donors:
siblings are best source- chance of a sibling having another sibling with a O, 1, or 2 haplotype match is 25%, 50%, and 25%, respectively
parents are automatically a 1 haplotype match
Graft types:
autograft: transfer of tissue from self to self: best survival
syngeneic graft (isograft)- graft between identical twins
allograft- graft between unrelated individuals
xenograft: transplant of tissue from one species to another; e.g., pig heart transplant
Corneal transplants:
best overall allograft survival rate
HLA haplotypes and disease:
familial predisposition to disease: weak penetrance; disease is not invariable; usually requires exposure to an environmental factor (e.g., virus),
HLA-A3: hemochromatosis
HLA-B8/DR3: celiac disease
HLA-B27: ankylosing spondylitis
HLA-DR2: multiple sclerosis
HLA-DR3/DR4: type I insulin-dependent diabeties mellitus
HAL-DR4: rheumatoid arthritis
Examples of type I hypersensitivity reactions:
atopy: familial predisposition (multifactorial inheritance) to develop an allergic reaction
examples: eczema (face, flexor/extensor surfaces); hives; seasonal conjunctivitis; seasonal rhinitis; asthma; hypersensitivity to bee/wasp/hornet stings
Rx of anaphylactic reactions- sc. administration of aqueous epinephrine 1:1000 dilution
Examples of type II cytotoxic hypersensitivity reactions:
involves antibody reactions with or without complement
warm autoimmune hemolytic anemias and cytopenias
Rh/ABO hemolytic disease of newborn
cells/helminths coated by specific IgG/IgE antibodies, respectively (without complement) are destroyed by cells (e.g., NK cells/eosinophils, respectively) with low affinity IgG/Ige Fe receptors
myasthenia gravis: anti-acetylcholine receptor antibodies
Grave's disease: igG thyroid-simulating Ig directed against TSH receptor
Examples of type III immunocomplex (IC) hypersensitivity reactions:
circulating ICs (antigen + IgG/IgM) deposit in target tissue (e.g., glomerulus, small vessel)--> activate complement system--> chemotactic agents recruit neutrophils/macrophages that damage the tissue
pathogenesis of localized IC reactions (Arthus reactions)- first antigen exposure results in antibody production --> second exposure to antigen deposited in tissue leads to antigen-antibody ICs --> complement system activation --> neutrophil/magrophage damage of tissue
examples: serum sickness: Rx of rattlesnake envenomations with use of horse serum antitoxins; SLE glomerulonephritis (GN): anti-DNA + DNA ICs; post-streptococcal GN: anti-bacterial antigen antibodies + bacterial antigen ICs; Henoch-Schonlein purpura: anti IgA antibodies against IgA; rheumatoid arthritis: IgM antibodies against IgG (rheumatoid factor),
clinical example of an Arthus reaction: Farmer's lung: antigen is thermophilic actinomycetes
Examples of type IV T cell-mediated hypersensitivity reactions:
antibody-independent cellular immune reations involving CD4 helper T cells (DRH reactions) and CD8 cytotoxic T cells
types of DHR reactions: allergic contact dermatitis: poison ivy, nichel; skin tests: tuberculin sensitivity, patch test in contact dermatitis; granulomas,
pathogenesis of cytotoxic T cell reactions: cytotoxic T cells normally interact with class I antigens on nucleated cells --> alteration of class I antigens on target cells activates cytotoxic T cessl to release perforins that destroy the cell; examples: neoplastic/virally infected cell, foreign antigens in a transplant cell
Parasitology terms:
definitive host: host that harbors the adult, or sexual stage of the parasite
intermediate host: host that harbors the larval, or asexual stage of the parasite
protozoa: amebae; ciliates; flagellates; sporozoa
helminths include: nematodes: roundworms, cestodes: tapeworms, trematodes: flukes
inhibits xanthine oxidase
causes pyridoxine deficiency leading to peripheral neuropathy and sideroblastic anemia
MOA - INH is nicotinic acid derivative that inhibits synthesis of mycolic acid in mycobacteria cell wall
Effect of aspirin on kidney:
decrease PGE2 synthesis (vasodilator) leading to unopposed AT II effect
renal pappillary necrosis
blocks dihydrofolate reductase - macrocytic anemia due to folate dificiency
S phase inhibitor
leucovorin rescue
interstitial fibrosis in lungs
Peripheral neuropathy and cancer drug:
sulfone that inhibits synthesis of folic acid by M. Ieprae
may precipitate hemolytic anemic in G6PD deficiency
may produce methemoglobinemia
nephrotic syndrome
peripheral neuropathy
MCC of thrombocytopenia in hospital: type II hypersensitivity reaction
Acute Rx for coumarin overdose when bleeding is life-threatening:
fresh frozen plasma best choice
use IM vitamin K for less serious bleeds
hemorrhagic cystitis
transitional cell carcinoma
activated (not metabolized) in the liver
bradykinin side-effects include cough and angioedema - ACE normally degrades bradykinin
cough not seen with losartan
Drug used to climinate calcium in patient with hypercalcemia:
loop diureetic
Drug used to remove calcium from urine in a calcium stone former:
S-phase drug used in treatmente of acute lymphoblastic leukemia:
ACE inhibitors:
block in AT II (works as vasoconstrictor of efferent arteriole in glomerulus) by ACE inhibitor removes important control for maintaining intrarenal blood flow causing potential for renal failure (particularly with bilateral renal artery stenosis)
Nephron site of action of thiazides:
Na +/C1* pump in cortical thick ascending limb
Vitamin given in Rx of TB:
pyridoxine (B6) - used up when using isoniazid,
risk of peripheral neuropathy & sideroblastic anemia
Antihypertensives increasing blood lipids:
H. pylori:
Rx - amoxicillin + clarithromycin + proton pump blocker
prevention - proton pump blocker + bismuth
HMG-CoA reductase inhibitors:
statin drugs block CH synthesis
hepatocytes compensate by up-regulation of LDL receptor synthesis leading to increased clearance of IDL and LDL remnants derived from VLDL
ACE inhibitor effect of plasma renin activity:
increases due to decrease in AT II and aldosterone
Drugs affecting tubulin in mitotic phase:
vinca alkaloids
Use of aqueous epinephrine in shock:
1:1000 dilution subcutaneously
Treatment of acetaminophen overdose:
acetylcysteine to replace used up GSH - neutralizes acetaminophen free radicals formed in the liver cytochrome system
MOA of loop diuretic:
blocks Na+-K-2C1* cotransport pump in the thick ascending limb in the renal medulla
also blocks calcium reabsorption - used in the Rx of hypercalcemia
always order a pregnancy test in females
put patients on BCP
Hair loss in a woman - ? drug:
oral contraceptives - predictable side effect
estrogen causes hair to be at same stage of development
may also occur after delivery
Group of drugs has the highest association with urticarial and maculopapular lesions:
rashes are the MC adverse reaction to drugs, with maculopapular rashes leading the list
most drug reactions involving skin are not type I hypersensitivity hisstamine-related, however, those involving penicillin are usually type I hypersensitivity
CD4 helper T cell count for prophylaxis against PCP:
<200 cells/uL-Rx with TMP/SMX
CD4 helper T cell count for prophylaxis against toxoplasmosis:
<100 cells/uL- Rx with TMP/SMX
CD4 helper T cell count for prophylaxis against MAI:
<50-100 cells/uL-Rx with clarithromycin
Drugs involved in folate metabolism:
phenytoini blocks intestinal conjugase - polyglutamate to monoglutamate
BCP & alcohol block uptake of monoglutamate in the jejunum
methotrexate / TMP-SMX block dihydrofolate reductase
Drug induced SLE:
Ace inhibitors:
increase in renin & ATI, but a decrease in ATII and aldosterone
aldosterone eventually increases, hence the addition of spironolactone to keep aldostrerone suppressed --> increases longevity in CHF
Botulism toxin:
blocks the release of acetylcholine - diagram may be given of neurotransmitter synthesis & must locate the block
used to treat LES spasm in achalasia
A child who ingests 30 adult aspirins will most likely develop:
an increased anion gap metabolic acidosis
children, unlike adults, do not commonly develop a mixed metabolic acidosis and respiratory alkalosis
Rx is to preform gastric lavage & add activated charcoal & to produce an alkaline urine for increased excretion of the acid
weak estrogen that acts as an antagonist in breast tissue (estrogen competes with tamoxifen for binding to the receptor, and partial agonist in uterus (can produce endometrial hyperplasia)
also protects against osteoporosis & can be used in women who have ERA positive tumors
can be used in treating progestin-resistant endometrial cancer
complications: flushing (menopausal symptoms), vaginal bleeding, potential for endometrial hyperplasia/cancer
analgesic & antipyretic but not an anti-inflammatory agent
inhibits prostaglandia synthesis in the CNS
very week cyclooxygenase inhibitor
MC drug causing acute fulminant hepatitis
converted into free radicals in the liver - * glutathione inactivates the FRs, * acetylcysteine treatment replaces GSH
Drug for bacterial carrier states (S.aureus, N.meningitidis, H.influenzae):
Single dose drug for GC and Chlamydia:
Rx of malignant hypertension:
Estrogen effects:
Lipid effects
prevents osteoporosis
increases liver synthesis of transcortin & thyroid binding globulin
increases liver synthesis of sex hormone (testosterone or androgen) binding globulin
cancer risk
Iron toxicity:
clinical setting - accidental overdose of ferrous sulfate in children
S/S of iron
Organophosphate poisoning:
MOA: irreversible block of acetylcholine esterase (non competitive inhibitor); accuulation of acetylcholine at synapsis/myoneural junctions
source: pesticides
Initial autonomic system overactivity: excessive lacrimation/salivation, fecal incontinence, constrited pupils
Nicotinic effects later in toxicity: muscle weakness/paralysis; muscle fasciculations,
Low serum & RBC cholinesterase (pseudocholinesterase)
Rx: atropine Rx of choice; pralidoxime (2-PAM) also may be used
Rx of hypertension (HTN):
weight reduction is the most important factor in lowering BP
Antidotes used in unconscious patients:
dextrose - R/O possible hypoglycemia from insulin overdose
naloxone - possible opiate overdose
intravenous thiamine - glucose may precipitate Wernicke's encephalopathy in alcoholics with thiamine deficiency
Intravenous drug abuse (IVDA):
MC localized infection is skin abscesses due to Staphylococcus aureus
HBV MC systemic infection
infective endocarditis: MC tricuspid and aortic valve; S. aureus MCC,
tetanus: complication of "skin popping"
derived from poppy plant
usually "cut" with some agent (e.g., quinine, talc) - granulomatous reactions occur in skin / lungs from the cutting agents,
non-cardiogenic pulmonary edema: frothing from the mouth is common
focal segmental glomerulosclerosis: hypertension + nephrotic syndrome
Rs: naloxone, a morphone derivative with a high affinity for opioid binding sites of the mu receptor type
MC DOA in health professionals, 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydro-pyridine (MPTP): by-product of attempted synthesis of meperidine; produces irreversible Parkinson's: cytotoxic to neurons in nigrostriatal dopaminergic pathways
MC COD from DOA in United States,
MOA: blocks uptake of neurotransmitters dopamine/NOR by presynaptic axon,
predisposes to: sudden death; acute myocardial infarction (AMI); stoke; pulmonary edema; ventricular arrhythmias; myocarditis,
S/S: hypertension/sinus tachycardia, psychosis/seizure activity, mydriasis
MOA: release catecholamines from presynptic terminals,
examples of amphetamines: dextroamphetamine; Rx obesity; methylphenidate: Rx ADHD and narcolepsy; methamphetamine; "ice" is street form of the drug,
hallucinations: drug that most simulates schizophrenia
MC illegal DOA used in United States,
MOA: contains the psychoactive stimulant TRIANGLE9-tetrahydrocannabinol (THC); THC binds to receptors in substantia nigra, globus pallidus, hippocampus, cerebellum; derives from leaves/flowering tops of hemp plants (Cannibis sativa); hashish is extracted resin of marijuana that has 5-10 times the potency of the parent compound; high lipid solubility: THC is present in urine for more than a week,
Clinical uses: cancer: decreased N/V in cancer patients; lower intraocular pressure in glaucoma; analgesia,
S/S of marijuana use: reddening of conjunctiva; euphoria; delayed reastion time: engineer driving a train involved in a crash with an oncoming train was found to have THC metabolites in his urine
LSD (lysergic acid diethylamide):
MOA: erot alkaloid that binds to D2 dopamine receptors in the brain; also blocks 5-HT2 serotonin receptor in peripheral tissue,
Predisposis to chromosomal breakage leading to congenital defects,
S/S of LSD toxicity: hallucinations; flashbacks
PCP (phencyclidine):
Angel dust,
MOA: reacts with opioid-like sigma receptors & subtypes of glutamate receptors (antagonist); initially introduced as a dissociative anesthetic: separates bodily functions from the mind without a loss of consciousness,
S/S of PCP toxicity; agitation/violent behavior; coma with the eyes open; impervious to pain
Use of Beta-blocker in Rx of Grave's disease:
Thyroid hormones normally upregulate synthesis of beta-receptors that interact with catecholamines & produce many of the symptoms of thyrotoxicosis,
Giving beta-blockers, blocks the beta-receptors, hence blocking the adrenergic symptoms of thyrotoxicosis
Electrolyte changes when giving insulin:
drives glucose into the cell along with potassium & phosphate
Central & neophrogenic DI:
Both have low UOsm & increased POsm,
Central DI shows > 50% increase in UOsm with administration of vasopressin,
Nephrogenic DI shows <50% increase in UOsm with vasopressin
Respiration changes with increasing altitude:
Respiratory alkaloisis, hypoxemia due to decreased atmospheric pressure not a decrease in % oxygen in air,
Increase in 2,3 BPG right shifts the ODC
Synthesized in Sertoli cells in seminiferous tubules,
Negative feedback with FSH,
Increased if seminiferous tubules are destroyed,
Normal if Leydig cells are destroyed, since testosterone has a negative feedback with LH
Alveolar ventilation - PAOx = PiO2 - PACO2/R, where PiO2 equals % oxygen x 713) and R is the respiratory quotient that normally equals o.8, subtract PaO2 from PAO2 and you have the A-a gradient,
Fick's equation for cardiac output - cardiac output mL/min = oxygen consumption divided by oxygen in pulmonary vein - oxygen in pulmonary artery
Placental anatomy/physiology:
Maternal surface has slightly bulging areas called cotyledons, which are covered by a layer of deciua basalis,
Fetal surface is entirely covered by the chorionic plate - chorionic vessels converge with the umbilical cord, which is composed of 2 umbilical arteries (venous blood returning from the fetal heart) and 1 umbilical vein (carries ocygenated blood from the placenta),
Chorionic villus / umbilical cord - * chorionic villi project in the intervillous space, which contains maternal blood from which oxygen is extracted: spiral arteries from the uterus empty into the space, * chorionic villi are lined by trophoblastic tissue: outside layer is composed of syncytiotrophoblast; synthesized bCG and human placental lactogen (growth hormone of preganccy) and inside layer is composed of cytotrophoblast: clear cells, the interior of the chorionic villus has fetal blood vessels, which coalesce to form the chorionic vessels that converge with the umbilical cord,
The umbilical cord contains 2 umbilical arteries (contains deoxygenated blood exiting the fetal heart & returning to the placenta) and 1 umbilical vein (contains oxygenated blood)
Has luteinizing hormone activity,
Keeps corpus luteum of pregnancy synthesizing progesterone until 8-10 wks and then placenta takes over that function
Atrial natriuretic peptide:
mediated by guanylate cyclase, increased if left or right atrium is volume overloaded
Most effective nephron site for acid excretion:
proximal tubule of the kidney
Nephron site for DH effect:
collecting tubule
Nephron site for greatest of free water/most susceptible to ischemia:
thick ascending limb in the medulla
Constriction of the efferent arteriole:
increases the GFR & decreases renal plasma flow
Causes of metabolic acidosis

Increased AG Lactic acidosis
End-product anaerobic glycolysis.
Overproduction: alcoholism; shock; phenformin-like drugs.
Decreased metabolism: chronic liver disease
Causes of metabolic acidosis

Liver conversion excess acetyl CoA into AcAc and Beta-OHB.
Overproduction: diabetic ketoacidosis: alcoholism; starvation
Causes of metabolic acidosis

Renal failure
Retention phosphoric & sulfuric acid
Causes of metabolic acidosis

Salicylate poisoning
Excess salicylic acid.
Overstimulation respiratory center may produce primary respiratory alkalosis as well.
Causes of metabolic acidosis

Ethylene glycol (antifreeze)
Converted into glycolic & oxalic acid by alcohol dehydrogenase.
Calcium oxalate crystals in renal tubules produce renal failure.
Rx with IV alcohol (competes with ethylene glycol for metabolism by alcohol dehydrogenase).
Causes of metabolic acidosis

Methyl alcohol (solvent)
Converted into formic acid by alcohol dehydrogenase.
Damage to optic nerve with potential for blindness.
Rx same as ethylene glycol.
Causes of metabolic acidosis

Normal AG Diarrhea
Lose HCO3 in stool.
Isotonic loss Na+ and loss in K+.
Causes of metabolic acidosis

Type I distal RTA
Dysfunctional aldonsterone-mediated H+/K+ ATPase pump in collecting ducts.
HCO3 not regenerated, Excess H+ combines with C1 to form HC1, Urine pH>5.5 (decrease acid in urine).
Causes: drugs (e.g., amphotericin); BJ protein, RX: increase HCO3 intake.
Causes of metabolic acidosis

Type II proximal RTA
Low threshold for HCO3 reclamation in proximal tubule (e.g., 15 mEq/L vs 24 mEq/L).
Urine pH>5.5 (lost HCO3).
Causes: acetazolamide (blocks carbonic anhydrase); heavy metals (Pb and Hg).
Rx: thiazide (produces volume depletion, which increases renal threshold for reclaiming HCO3).
Examples of Acid-Base Disorders

Patient: 24-yr-old woman with barbiturate overdose
uncompensated acute respiratory acidosis (HCO3 <30 mEq/L)
Examples of Acid-Base Disorders

Patient: 55-yr-old smoker with chronic bronchitis
partially compensated chronic respiratory acidosis
HCO3 >30 mEqL)
Examples of Acid-Base Disorders

Patient: 35-yr-old woman with a pulmonary embolus
acute respiratory alkalosis
(HCO3 > 18mEq/L)
Examples of Acid-Base Disorders

Patient: 29-yr-old man with acute gastritis and vomiting
partially compensated metabolic alkalosis
Examples of Acid-Base Disorders

Patient: 32-yr-old man drank antifreeze
partially compensated metabolic acidosis
Examples of Acid-Base Disorders

Patient: 4-yr-old child with salicylate intoxication
mixed blood gas disorder with primary metabolic acidosis & primary respiratory alkalosis.
NOTE: pH is normal because both conditions are primary disorders; this is not full compensation