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45 Cards in this Set

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Synovitis
inflammation of the synovium
Enthesitis
Inflammation of the ligament as it inserts into the bone
Serositis
Inflammation of the serosal linings
Myositis
Inflammation of the muscles
Vasculitis
Inflammation of the blood vessels, small vessels deep in the dermis will present as pupura or petechiae
What does SLE (Systemic Lupus Erythematosus) present like?
Females 8X more than males, with an onset age 10-45 (5% presents in childhood.
May have rash (discoid or malar). Autoimmune induced inflammation in organs, tissues or joints. May have uveitis or retinitis.
fatigue, malaise, low-0grade fever weight loss, photosensitivity, Reynaud's syndrome, mouth or nasal sores Nonerosive arthritis in >2 joints, Pleuritis or pericarditis(serositis)
Seizures or psychosis.
Treatment for SLE (Systemic Lupus Erythematosus)
NSAIDs, steroids, hydroxychloroquine, immunosuppressive agents.
What do SLE (Systemic Lupus Erythematosus) laboratory findings present like?
Proteinuria (>500 mg/24 hr) or Cellular casts (RBC,Granular or tubular.
Hemolytic anemia with reticuloscytosis. OR
Leukopenia (<4k on 2 occasions) OR
Lymphopenia(<1.5k on 2 occasions) OR
Evidence of antiphospholipidd Ab of Lupus anticoagulant or false-positive VDRL for >6mo.
Positive ANA in presence of drugs known to induce Lupus. Unlikely to have SLE if negative ANA!
What is Henock-Schonlein Purpura
Vasculitis of unkown origin. Mayh be allergy mediated. May associated with group A streptococcal infection.
It is a rash of palpable purpura.
Criteria for Henoch0Schonlein Purpura?
Palpable purpura (w/o thrombocytopenia)
Bowel angina
Diagnostic biopsy will show granulocytes in small vessels.
Pediatric age group
(2 of the above is diagnostic)
Elevated ESR, CRP, WBC counts
How to treat Henoch-Schonlein Purpura
Supportive (often self resolving)
NSAIDs
Corticosteroids if GI or nephritis (elevated BUN a/o proteinuria) is involved
What is Kawasaki Disease
Vasculitis of unknown origin with multisystem involvement and inflammation of small to medium sized arteries with resulting aneurisms. Most common in asian children, rare over age 7
What are the phases of Kawasaki Disease
PHASES
Acute 1-2 weeks, hectic fever, conjuntival erythema (non suppurative), mucosal changes, strawberry tongue, cervical lymphadenopathy, Variable rash (80% of cases). May have giant coronary artery aneurysms, rare.
Subacute - inot 4th week. Desquamination of skin, high elevation of platelets, coronary artery aneurisms HIGH RISK if fever prolonged.
Convalescent - out to 6-8 weeeks after onst. ESR returns to normal
What are the criteria for diagnosing Kawasaki Disease?
Fever of at least 5 days duration + at least 4 of the following 5:
1) Billateral, nonsuppurative conjunctivitis
2) Changes to the mucus membranes, one or more (pharyngeal injection, dry fissured lips, strawberry tongue)
3) 1 or more, peripheral erythema or edema, periungual desquamination, general desquamination.
4) Polymorphous rash (primary truncal)
5) Disease that can't be explained by other causes
* If fever+3+coronary artery disease
How to treat Kawasaki Disease
IVIG (IV immunoglobulin) therapy is the mainstay for KD
Aspirin at anti-inflammatory doses (80-100 mg/kg QD div 6hr) till fever resolves for 48hrs then reduced to antithrombotic doses (3-5 mg/kg QD, one dose)
Common manifestations of infection
often SxS at respiratory or GI mucosa
Virus in the respiratory, rarely at one site (pharyngitis with coryza).
Same symptoms with respiratory distress and crackles, viral/bacterial pneumoia likely.
Site of infection will indicate symptoms.
* Fever does not always indicate infection, absence of one is not diagnostic either!

Any symptoms accompanied by mental status changes=Emergency
Screening tests for infections
PPD: skin test - TB
ESR: erythrocyte sedimentation rate (non specific).
CRP: C-reactive protein (non specific)
CBC: leukocytosis. (viral~transient neutorphils, characteristic mononuclear response)(bacterial~sustained neutrophils, with left-shift.) (atypical lymphocytes~EBV, CMV, toxoplasmosis, viral hepatitis, rubella, roseola, mumps) (Eosinophilia~tissue invasive multicellular parasites)
UA: urine analysis, UTIs,
ALT/AST: transaminase liver function tests
LP: lumbar punture for viral/bacterial menigitis, encephalitis
Cultures: mainstay of diagnosis blood, urine, stool, cdf, tissue
ELISA: enzyme linked immunosorbent assay, Ig profile
PCR: polymerase chain reaction, DNA/RNA
DIagnostic imaging:
Virus or bacteria SxS
SxS Viral Bacterial
Petechiae present present
Purpura rare if severe
Leukocytosis* uncommon common
Left shift uncommon common
(^ bands)
Neutropenia possible overwhelming infection
^ESR ** unusual common
^CRP unusual common
^TNF,IL-1,PAF unusual common
Meningitis lkymphocytic neutrophilic
(Pleocytosis)
Meningeal signs + Present for both

* adenovirus/herpes simplecx may ^leukocytosis + ESR
** EBV may cause petechiae + ^ESR
What are the common childhood vaccines
live attenuated: MMR(MeaselsMumpsRubella), Varicella.
Inactivated/killed: Polio, HAV(Hep-A); influenza
Components: HBV(Hep-B), pertussis, Hib (haemophilus influenza b), S. pneumoniae
Toxoids: diptheria, tetanus
Prophylaxis for meningococcus

Primary - prevent infection
Secondary - prevent reinfection
Agents - antibiotics, Ig, monoclonal Ab, vaccine, combinations
Administer to all contacts of index case in prior 7 days
Agents: Rifampin, ceftriaxone, sulfadiazine, if > 18y/o ciprofloxacin
Prophylaxis for Tetanus

Primary - prevent infection
Secondary - prevent reinfection
Agents - antibiotics, Ig, monoclonal Ab, vaccine, combinations
Thorough cleansing of wounds

Agent:Tetanus Ig
Prophylaxis for Rabies

Primary - prevent infection
Secondary - prevent reinfection
Agents - antibiotics, Ig, monoclonal Ab, vaccine, combinations
Thorough cleansing of wounds

Agent: RIG (Rabies Immunoglobulin) - prior to presentation of symptoms
What is behind a fever?
Pryogens act on anterior hypothalamus liberating arachidonic acid which is metabolized into prostaglandin E2, rasing the thermostat.

Exogenous microbes and toxins or endogenous ones(IL-1, IL-6, TNF and interferons)
How do antipyretics lower temperature?
Antipyretics (acetaminophen, ibuprofin, aspirin) inhibit hypothalmic cyclooxygenase, thus inhibiting prostaglandin E2 which controls elevation to the body thermostat.
differentiate bacteremia and sepsis
Bacteremia is a positive blood culture that may be primary or secondary to a focal infection.
Spepsis is the systemic response ot infection and may include: hyperthermia, hypothermia, tachycardia, tachypnea, shock. CNS involvement will include irritability+lethargy. Cardiovascular impairment can be seen in cyanosis, poor perfusion, and DIC (disseminated intravascular coagulation(petechiae, eccymosis))
Define a FUO - Fever of unknown origin
fever for > 14 days without defined etiology despinte Hx,PE, routine labs or after 1 week of hospitalization
Fever in infants < 3 month old
temperature instability in an ill-appearing baby, < 3 mo/o is associated with high risk of serious bacterial infections.
bacteremia, pneumonia, UTI, meningitis, bacterial diarrhea, osteomyelitis, septic arthritis.
CULTURE,CULTURE,CULTURE

Well appearing baby? w/ okay labs? =observe.
Fever in a child 3-36 months?
If well appearing usually self-limited viral infection, but beware the occult bacteremia (1.5% cases)
What tests to order for FUO (Fever of Unkown Origin)
Screening tests:
CBC with WBC and differential and platelet count.
ESR.
Hepatic transaminase levels.
Cultures
Urine analysis
Chest radiograph
Evaluate rheumatic: ANA, Rf and serum complement.
TST tuberculin skin test
EBV antibody profile
HIV test
B. henelae profile
CSF
CT
MRI
What about lymphadenopathy
disease or enlargement of lymph nodes. Lymphadenitis is acute or chronic.
Regional lymphadenopathy involves one nod group, Generalized is 2 or more non-contiguous groups.
Many infectious (viral/bacterial/fungal/protozoal) causes and many noninfectious as well.

Complete Hx and PE for associated findings will guide Tx. and labs. Serologic testing for EBV or B. henselae, or whatever if indicated.

Aspiration for acutely inflamed, fluctuant cervical nodes.
US or CT can determine extent.
We don't treat the nodes, we identify and treat the cause.
What about meningitis
Inflammation of the leptomeninges caused by bacteria, virus, or rarely fungus.
Aseptic meningitis (viral, chemical, autoimmune, certain parameningeal infections)
Most common:
neonatal- Group B streptococci, E. coli, klebsiella, enertobacter.
>1 mo. S. pneumoniae, Neisseria meningitis, H. influenza type-b.

clinical picture: preceding URI, may be rapid onset, Triad of (headache, nuchal rigidity, photophobia), irritability, nausea, lethargy, vomiting. SxS of ICP, intracranial pressure. *look out for bulging fontanel in infants!
Kernig's sign (extension of fully bent knee/hip causes spasm.
Brudzinski's sign - involuntary lifting of legs when lifting head off table.

Cleansing of the offending agent with antibiotics and supportive therapies in imperative. Mortality for bacterial meningitis is significant!
What about encephalitis
Inflamed parenchyma of the brain. usually an acute viral infection (mostly seasonal arboviral, enteroviral) a/o subsequent immune response in the days after appearance of other infectious symptoms

Beware Acute disseminated encephalomyelitis (ADEM); appears post measles, chicken pox or vaccination.
Exam of CSF via PCR is diagnostic in most cases, EEG, CT/MRI help.
Tx with IV acyclovir and for ADEM corticosteroids.
5% mortality and 33%morbidity
What about the common cold
a viral infection with rhinorrhea and nasal obstruction causedd by rhinoviruses and some by coronaviruses. Symptoms are caused by the immune/inflammatory response.
Kids can have from 6-12 colds a year with occurrence decreasing with age into adulthood.
Labs are not helpful unless screening for eosinophils in allergic rxn.
Can have rare causes, atresia, stenosis, CSF fistula...
Tx, there is no effective treatment, first generation (sedating) antihistamines reduce rhinorrhea, 2nd generation do nothing.
Vit. C, guaifensin and warm humidifed are do little/nothing. Zinc lozenges may help/inconsistnent. Prophylactic vitamin c has good evidence.
What is rhinitis medicamentosa
Prolonged use of nasal sprays or drops (xylometzoline, oxymetazoline, phenylphrine) may cause a rebound effect of the sensation that the nares are blocked when the drug is discontinued.
What is behind pharyngitis
Bacterial: Group A (and C) streptococcus
Viral with intensity varying by bug, adenoviruses, rhino and coronaviruses, HSV Influeenza, EBV.
40% are of unknown cause!
Strep throat?
Streptococcal pharyngitis, rapid onset with prominent sore throat mild to moderate fever, Headache, nausea, vomiting, abdominal pain. In typical florid cases tonsils are enlarged and covered with exudate., petechiae on the soft palate and posterior pharynx and the uvual may be red and tippled. Cervicle nodes are swollen and tender.
May be accompanied by scarlet fever and strawberry tongue (white or red)
Bacterial onset sudden
Viral onset slow with more rhinorrhea and diarrhea. Gingivomatitis is characteristic of HSV-1
Lab work: differentiate group a strep from other cause --> rapid streptococcal antigen test, confirm with culture.
Most episodes will resolve in a few days even without Tx. Antimicrobial therapy will accelerate healing (penicillin or erythromycin). Good prognosis, beware the middle ear infection.
What is RSV
Respiratory Syncytial Virus, one of the leading causes of croup(laryngotracheobronchitis
Differential for laryngotracheal respiratory tract infections
Viral laryngotracheobronchitis (croup)
Epiglotitis
Brachial tracheitis
Spasmodic croup
Epiglottitis
children 1-5, usually Hib caused
Sudden onset of high fever, stridor muffled rather than hoarse voice, dysphagia, drooling, refusal to eat drink or sleep, sitting in the "sniff" position.
Pediatric emergency requiring intubation and antibiotic therapy.
Causes of acute conjunctivitis
Bacterial: H influenzae, S. pneumoniae, M. cartarrhalis

Viral: Adenoviruses (8, 19), Enteroviruses, HSV
Conjunctivitis
Warm compresses,
If bacterial is confirmed: topical
If gonococcal: ceftrazone
If chlamydia: erythromycin
If HSV: Acyclovir - IV
What is the most important sign of infection in immunocompromised patients
Fever! Most common and sometimes only sign of infection in cancer and transplant patients.
Leading causal organisms in catheter related infections
systemic local
Gram-positive cocci 71% 52%
Gram-negative bacilli 20 4
Fungi 6 2
Uncommon bacteria 3 6
Common Zoonoses in New Mexico

There are over 150 different (human - animal - arthropod) diseases
Rocky mountain spotted fever(Rickettsia rickettsia)
Plague (Yersinia pestis)
Hanta virus
Cat scratch fever (bartonella henselae)
Lyme disease (if pt was travelling)
Rocky Mountain Spotted Fever
Tick bite: Rickettsia rickettsii - gram negative coccobacillary organisms that resemble bacteria, but have incomplete walls and require an intracellular site for replication.

incubae 2-14 days, headache malaise fever, pale rose-red macular /macularpapular rash. Early rash blanches on pressure. Progresses to petechial - purpuritic eruption, hands+feet, myalgias and intractable headaches. In severe cases, splenomegaly, myocarditis, renal impairment, pneumonitis, shock.
Tx, Doxycycline or fluoroquinolones