Infectious Medicine

Front 1

gram+ catalase+ cocci

Back 1

coagulase+: stah aureus
caogulase-: staph epidirmidis (novobiocin sens), staph saprophyticus (novobiocin res)

Front 2

gram+ catalase- cocci

Back 2

alpha hemolytic -->
pneumococcus (optochin sens)
viridans (optochin res)

beta hemolytic -->
group A strep pyogenes (bacitracin sens)
group B stret agalactiae (bacitracin res)

Front 3

gram+ rods

Back 3

bacillus, clostridium, corynebacterium, listeria

Front 4

gram- cocci

Back 4

meningococcus (maltose fementer), neisseria gonorrheae (maltose non fermenter)

Front 5

gram- cocobacillus

Back 5

Haemophilus
brucella
pastereulla
bordetella

Front 6

gram- rods

Back 6

lactose fermenters --> e. coli, klebsiella
lactose nonfermenter oxidase- --> salmonella, shigella, proteus
lactose nonfermenter oxidase+ --> campylobacter, pseudomonas, vibrio, H. pylori

Front 7

DNA viruses

Back 7

HHAPPPPy: herpes, hepadna, adeno, parvo, papilloma polyoma, pox

Front 8

RNA+ viruses

Back 8

Calici (Norwalk), PEeCoRnA, Flavi (hepC, dengue, yellow fever, WNV), Toga (rubella), Corona, Retro. "Call Pico and Flava To Come Rap"

Front 9

RNA- viruses

Back 9

PaRaMyxo, Rhabdo, Arena, Filo, Orthomyxo (influenza), Bunya, Delta
"Para Rabiar in the Arena, Fill OR Buny"

Front 10

arbovirus

Back 10

Togavirus, flavivirus, bunyavirus

Front 11

meningitis etiology

Back 11

bacterial: pneumococcus (adults), mningococcus (children/adolescents), agalactiae (neonates)
listeria is more common in immunosupressed
staph aureus (neurosurgery)
cryptococcus (HIV)
RMSP (geographic)
Lyme (borrelia, geographic)
TB, syphilis
viral: coxackie, HIV, herpes simplex

Front 12

meningitis presentation

Back 12

photophobia, headache, nuchal rigidity
fever, nausea, vomitting
altered mental status, seizures, neurological deficits (specially CN VIII)

petechial rash (meningococcus)
writs/ankle centripetal rash (RMSF)
facial nerve palsy (Lyme)
abnormal chest x-ray (TB)

Front 13

meningitis diagnosis

Back 13

lumbar puncture is initial procedure
if papilledema, focal motor deficits, seizures, mental status changes, or HIV --> do CT of head first

CSF analysis:
↑WBCs (neutrophils) --> bacterial;
↑WBCs (lymphocytes) --> viral, ricketsia, Lyme, TB, syphilis;
↑proteins (mostly in bacterial, but any)
↓glucose (mostly bacterial)

Lyme and RMSF have specific serology
cryptococcus detect with India ink test and serum/CSF cryptococcal antigen
syphilis with VDRL or FTA-ABS
TB with culture or PCR

Front 14

meningitis treatment

Back 14

empirical: vancomycin + ceftriaxone +- ampicillin (HIV, steroids, pregnancy or malignancies)

listeria is resistant to all cephalosporins
vancomycin if resistant pneumococcus
Lyme --> ceftriaxone
cryptococcus --> amphotericin + fluconazole
neurosyphilis --> high-dose penicillin

dexamethasone as adjuvant in bacterial meningitis

Front 15

encephalitis etiology

Back 15

most commonly by HSV-1
also by VZV, CMV, coxackie and encephalitis viruses
HSV-1 has predilection for temporal lobes

Front 16

encephalitis presentation

Back 16

altered mental status with fever and headache are main clues; can also have stiff neck

Front 17

encephalitis diagnosis and treatment

Back 17

due lumbar puncture first
PCR of CSF is sensitive and specific for HSV-1
CT or MRI to exclude other diseases and may see temporal lobe involvement
IV acyclovir or gancyclovir/foscarnet for CMV

Front 18

brain abscess etiology

Back 18

organisms spread to brain from
otitis media, sinusitis, mastoiditis, dental infections, endocarditis, pneumonia, HIV

most common -->
strep pneumonia (60-70%)
bacteroides (20-40%)
enterobacteriacea (25-35%)
staph (10%)
toxoplasmosis in AIDS
can often by polymicrobial

Front 19

brain abscess presentation

Back 19

headache is most common symptom
fever
focal neurologic deficits (60%)
seizures

Front 20

brain abscess diagnosis

Back 20

initial test is contrast CT
MRI is more accurrate
precise etiology is with examination of abscess fluid
90% of HIV brain abscess is from toxoplasma or lymphoma and diagnosis is made if it responds to 10-14 days with pyrimethadine or sulfadiazine

Front 21

brain abscess treatment

Back 21

stereotactic aspiration (preferred) or surgical excision

antibiotics are also given in combination depending on etiology
if toxoplasmosis --> pyrimethadine and sulfadiazine
else give combo; example: penicillin for strep, metronidazole for anaerobes and third-gen ceph for gram-

Front 22

otitis media etiology

Back 22

preceeded by viral upper respiratory infection with edema of eustachian tube
strep pneumo (35-40%)
H. influenzae (25-30%)
moraxella (15-20%)
rest is viral etiology
same breakdown as sinusitis and bronchitis

Front 23

otitis media presentation

Back 23

ear pain
fever
decreased hearing
red bulging tympanic membrane on physical

Front 24

otitis media diagnosis

Back 24

physical exam of ear

Front 25

otitis media treatment

Back 25

amoxicillin is DOC
can also use second-gen ceph
penicillin allergies --> azi/clarithromycin
quinolones have broader spectrum than required

Front 26

sinusitis etiology

Back 26

strep pneumo (35-40%)
H. influenzae (25-30%)
moraxella (15-20%)
rest is viral etiology
same breakdown as otitis media and bronchitis

Front 27

sinusitis presentation

Back 27

facial pain, headache, postnasal, purulent drainage; fever in 50%

Front 28

sinusitis diagnosis

Back 28

clinical diagnosis
routine imaging is not recommended
if in doubt or no response to treatment --> CT
sinus puncture may be necessary

Front 29

sinusitis treatment

Back 29

if mild or uncomplicated --> oral pseudoephedrine, oxymetazoline
if severe --> amoxicillin is DOC
can also use second-gen ceph
penicillin allergies --> azi/clarithromycin
viral sinusitis resolves within 10 days with symptomatic treatment (antihistamines, NSAIDs, decongestants)

Front 30

pharyngitis etiology

Back 30

majority are viral
S. pyogenes is only 15-20% but is most important due to complications

Front 31

pharyngitis presentation

Back 31

sore throat
cervical adenopathy
fever
pharynx inflammation and exudate are suggestive of S. pyogenes (or EBV)
horaseness and cough are not suggestive of pharyngitis

Front 32

pharyngitis diagnosis

Back 32

rapid strep antigen test are unsensitive but specific and diagnostic but absence doesn't exclude

Front 33

pharyngitis treatment

Back 33

penicillin; macrolides if allergic

Front 34

influenza

Back 34

influenza A or B virus leads to coryza, nonproductive cough, sore throat, conjunctival injection and systemic symptoms as fever, myalgia, headache and fatigue

diagnosis confirmation is with rapid antigen detection

treat symptoms with acetaminophen and antitussives
specific treatment is oseltamivir and zanamivir
vaccination is recommended in older than 50, lung or cardiac diasease, immunosupressed, diabetics

Front 35

bronchitis etiology

Back 35

vast majority are caused by viruses
then strep pneumo, nontypable Haemophilus, moraxella, mycoplasma
cigarette smoke is predisposing factor

Front 36

bronchitis presentation and diagnosis

Back 36

cough and sputum production with normal x-ray confirms diagnosis
lungs are clear to auscultation
fever may occur
bacterial etiology is suggested by discolored sputum

Front 37

bronchitis treatment

Back 37

mild cases require no treatment
acute exacerbations of chronic bronchitis are treated with amoxicillin, doxycycline or TMP-SMX
repeated infections: amoxicillin/clavulanate, clarithromycin, azithromycin, 2nd or 3rd-gen cephs or quinolones

Front 38

lung abscess etiology

Back 38

90% have oral anaerobes peptostrep, prevotella and fusobacterium
45% only anaerobic, 45% mixed, 10% aerobes
aerobics found are staph, e. coli, klebsiella, pseudomonas
associated oral periodontal disease or predisposition to aspiration

Front 39

lung abscess presentation

Back 39

fever, cough, sputum, chest pain, putrid odor, chronic course with weight loss, anemia, fatigue

Front 40

lung abscess diagnosis

Back 40

sputum Gram stain will not show anaerobes
chest x-ray may show cavitary lesion most commonly in lower lobes or posterior segmenet of right upper lobe
aspiration and analysis of abscess fluid confirms

Front 41

lung abscess treatment

Back 41

empiric drug is clindamycin; drainage is not required

Front 42

pneumonia etiology

Back 42

in children <5 viruses are most common
older than 5, pneumococcus is leading cause
typical agents (40-60%) S. pneumoniae, Haemophilus, moraxella
atypicals: legionella, mycoplasma, chlamydia

Front 43

pneumonia predisposing factors

Back 43

cigarette smoking, diabetes, alcoholism, malnutrition, obstruction from tumors, immunosupression

Front 44

pneumonia associations: haemophilus

Back 44

smokers and COPD patients

Front 45

pneumonia associations: mycoplasma

Back 45

atypical presentation in young otherwise healthy patients

Front 46

pneumonia associations: legionella

Back 46

epidemic; older smokers
associated with infected water sources and air conditioning systems

Front 47

pneumonia associations: pneumocystis jiroveci

Back 47

HIV+ <200 CD4

Front 48

pneumonia associations: coxiella

Back 48

Q fever; exposure to animals specially specially when they are giving birth

Front 49

pneumonia associations: klebsiella

Back 49

alcoholics

Front 50

pneumonia associations: staph aureus

Back 50

following viruses or viral bronchitis, specially influenza

Front 51

pneumonia associations: coccidioidomycosis

Back 51

southwestern deserts

Front 52

pneumonia associations: chlamydia psittaci

Back 52

birds

Front 53

pneumonia associations: histoplasma

Back 53

bird droppings and spelunking

Front 54

pneumonia associations: bordetella

Back 54

cough with inspiratory whoop and post-tusive vomitting

Front 55

pneumonia associations: francisella

Back 55

hunters or exposure to rabbits

Front 56

pneumonia associations: SARS/avian flu

Back 56

travel to south east asia

Front 57

pneumonia associations: anthrax, yersinia, francisella

Back 57

bioterrorism

Front 58

pneumonia presentation

Back 58

cough, fever, sputum production, pleuritic chest pain, tachypnea
viral and atypicals produce a non-productive dry cough

on physical: rales, ronchi, dullness to percusion, bronchial breath sounds, increased fremitus, egophony

bacterial sputum is purulent and can be mixed with blood (rusty, pneumococcus) or blood and mucous (currant-jelly, klebsiella)

Front 59

pneumonia diagnosis

Back 59

chest x-ray is first --> localized or diffuse infiltrates and alveolar or interstitial pattern
next --> sputum Gram stain and culture (most specific for lobar pneumonia)
atypicals don't show in Gram stain or culture

mycoplasma --> cold agglutinins
legionella --> antigen tests and charcoal yeast culture
pneumocystis --> increased LDH in bronchoalveolar lavage
chlamydia pneumonia, coxiella, coccidiodes all have specific antibody titers

Front 60

pneumonia major severity signs

Back 60

hypoxia (PO2<60mmHg)
O2 saturation <94%
respiratory rate >30/min
confusion, uremia, hypotension

Front 61

pneumonia minor severity signs

Back 61

high fever
hypothermia
leukopenia
pulse >125/min
hyponatremia
dehydration determined by high BUN

Front 62

empiric treatment for pneumonia outpatients

Back 62

azithromycin or clarithromycin are DOC
alternative are levofloxacin, moxifloxacin, gatifloxacin

Front 63

empiric treatment for pneumonia inpatients

Back 63

new quinolones OR 2nd/3rd gen ceph with macrolide or doxyclycline

Front 64

empiric treatment for hospital-acquired pneumonia

Back 64

3rd gen ceph with antipseudomonal activity OR imipenem OR piperacillin/tazobactam
should also cover MRSA with vancomycin or linezolid

Front 65

haemophilus pneumonia specific treatment

Back 65

2nd or 3rd gen ceph

Front 66

mycoplasma pneumonia specific treatment

Back 66

macrolides, doxycycline or new quinolone

Front 67

legionella pneumonia specific treatment

Back 67

macrolides, doxycyline or new quinolone

Front 68

pneumocystis pneumonia specific treatment

Back 68

TMP-SMX
add steroids if PO2<70mmHg or A-a >35mmHg
if allergic to sulfa use IV pentamidine or atovoquone
prophylaxis with dapsone or atovoquone

Front 69

coxiella pneumonia specific treatment

Back 69

doxycycline

Front 70

staph pneumonia specific therapy

Back 70

oxacillin, nafcillin, etc… if MRSA --> vacomycin or linezolid

Front 71

coccidioides pneumonia specific therapy

Back 71

only need treatment if diseminated disease
mild diseasse --> fluconazole or itraconazole
severe disease --> ampB

Front 72

pneumococcal vaccine indications

Back 72

older than 65
serious lung, cardiac, liver or renal disease
steroid patients
HIV+
splenectomized patients
diabetics
leukemia/lymphoma patients

Front 73

tuberculosis etiology

Back 73

25% of world population is exposed; higher risk of exposure in alcoholics, healthcare workers, prisoners, homeless shelters, nursing homes, HIV, steroids, organ transplant, leukemia, lymphoma

Front 74

tuberculosis presenation

Back 74

cough, sputum, fever, weight loss, night sweats and abnormal lung exam
may also involve any organ specially lymph nodes, meninges, GI and GU

Front 75

tuberculosis diagnosis

Back 75

chest x-ray is best initial test in symptomatic patients, PPD in asymptomatic
x-ray shows apical infiltrates and sometimes cavitations, adenopathy and calcifications (Ghon complex)

acid-fast stain of sputum (3 smears >90% sensitive)
culture is specific and needed for bug sensitivity testing

if acid-fast is unrevealing can do thoracentesis, gastric aspirate in children, biopsy or needle aspiration of organ involved or lumbar puncture in meningitis

pleural biopsy is most sensitive
look for casseating granulomas

Front 76

tuberculosis treatment

Back 76

empiric treatment is combo of INH/pyridoxine, rifampin, pyrazinamide, ethambutol for first 2 months or until sensitivty testing; then INH + rifampin for another 4 months

if sensitivity is not known give also ethambutol
TB meningitis add steroids + 12 months
TB in pregnancy 9 months

Front 77

tuberculosis drugs side effects

Back 77

all cause liver toxicty except streptomycin
INH --> peripheral neuropathy (give pyridoxine)
ethambutol --> optic neuritis
rifampin --> red/orange metabolites
pyrazinemide --> benign hyperuricemia

Front 78

PPD test generalities

Back 78

used to screen asymptomatic populations at risk of TB to see if they have been exposed; consits of intradermal injection of the PPD with induration of the skin 48-72 hours after

if test is <10mm, do a second test to rule out false negative
if positive do chest x-ray and acid-fast stain

positive PPD with no evidence of active disease receive prophylaxis with INH+pyridoxine for 9 months

Front 79

PPD test > 5mm induration

Back 79

considered positive if
close contacts of active TB cases
HIV+
abnormal chest x-ray
steroids or organ transplant

Front 80

PPD test > 10mm induration

Back 80

considered positive if
children < 4
leukemia or lymphoma
injection drug users
prisoners
homeless
healthcare worker
immigrants (recent)
nursing home residents
diabetics
dialysis

CLIP HINDuration

Front 81

PPD test > 15mm induration

Back 81

considered positive for people with no risk factors for TB

Front 82

food poisoning/infectious diarrhea etiology

Back 82

campylobacter is most common
salmonella (raw eggs and poultry)
e. coli (traveler's diarrhea, undercooked hamburger meat)
B. cereus (reheated fried rice)
giardia, cryptosporidia (contaminated water)
V. parahemolyticus (contaminated shellfish)
V. fulnificus (raw shellfish)
rotavirus, Norwalk agent (children)
C. difficile (antibiotics)
C. botulinum (canned food)
C. perfringes (unrefrigerated meats)

Front 83

food poisoning/infectious diarrhea presentation

Back 83

most importantly is presence of blood and specific symptoms
bloody diarrhea --> salmonella, shigela, yersinia, invasive e. coli, campylobacter
watery diarrhea --> protozoans except entamoeba, clostridium, vibrio, viruses, B. cereus, staph
predominantly nausea/vomitting --> B. cereus, staph

Front 84

food poisoning/infectious diarrhea diagnosis

Back 84

if there's no blood in stool then check for leukocytes in stools with methylene blue test
then do culture for specific etiology
for protozoans direct stool examination for parasites or ova

Front 85

food poisoning/infectious diarrhea treatment

Back 85

empiric antibiotics until stool culture and if there's abdominal pain, bloody stools and fever or hypotension; high-volume stools and dehydration don't justify antibiotics

empirical treatment is ciprofloxacin or fluoroquinolone+metronidazole

scombroid is treated with antihistamines
giardia with metronidazole
isospora with TMP/SMX
doxycycline for vibrio

Front 86

acute viral hepatitis presentation

Back 86

jaundice, dark urine, light-colored stools, fatigue, malaise, weight loss, tender liver, hepatomegaly
indistiguishable from drug-induced hepatitis; hep b and C can also have serum sickness, arthritis, rash; PAN is associated with hep B

Front 87

acute viral hepatitis diagnosis

Back 87

all hepatitis gives ↑total and ↑direct bilirubin
ALT > AST in viral
AST>ALT in drug-induced
alkaline phosphatase and GGTP may not be elevated unless canalicular damage

Front 88

viral hepatitis serology

Back 88

IgM indicates acute infection with A, C, D or E viruses
IgG antibody to A, C, D or E indicates old, resolved disease
hep C activity is followed with PCR viral load

hep B acute diagnosis: ↑HbsAg, ↑IgM-HbcAb and HbeAg (infectivity)
resolution is indicated by ↓HbsAg, ↑HbsAb, ↑HbcAb-IgG (only marker in window-period), ↑HbeAb-IgG

Front 89

acute viral hepatitis treatment

Back 89

ne effective treatment for acute viral hepatitis
chronic hep B --> either interferon, entecavir, adefovir, lamiduvine
chronic hep C --> combo of interferon and ribavirin
treatment for cirrhosis is transplant
after needlestick with hep B and if no adequate levels from vaccine --> HBIg + hep B vaccine;
no post-exposure prophylaxis for hep C

Front 90

urethritis

Back 90

by gonococcus or chlamydia, ureaplasma, mycoplasma, trichomona or HSV
purulent urethral disharge, dysuria, urgency, frequency

diagnose with gram stain showing coffee bean-shaped diplococci or fluorescent antibodies for chlamydia (on urethral swab or urine)

treat with single-dose ceftriaxone IM and single-dose azithromycin orally

Front 91

pelvic inflammatory disease

Back 91

gonococcus, chlamydia, mycoplasma, enterobacteria
lower abdominal pain on palpation of cervix, uterus or adnexa
cervical motion tenderness is key
fever, leukocytosis and discharge also

do gram stain of discharge and culture on Thayer-Martin
do pregnancy test
diagnosis is clinical; laparoscopy is definitive
may do culdocentesis or sonography

treat with doxycycline and cefoxitin (inpatient) or single-dose ceftriaxone and doxycyline for two weeks for outpatient

Front 92

syphilis presentation

Back 92

primary --> chancre (1-3 weeks) and regional nontender lymphadenopathy

secondary --> cutaneous rashes (6-12 weeks) on flexor areas, lympahdenopathy and condylomata lata (papules at mucocutaneous junctions)

latent stage --> may persist for life

tertiary --> 1/3 of patients, gummas lead to tabes dorsalis and Argyll-Robertson pupil

Front 93

syphilis diagnosis

Back 93

screening: VDRL, RPR
specific: FTA-ABS, MHA-TP, darkfield exam
false positive VDRL in EBV, collagen vascular disease, TB, subacute bacterial endocarditis

Front 94

syphilis treatment

Back 94

2.4 million units if IM benzathine penicilline given once for primary and secondary and once a week 2 weeks for latent (VDRL >1:8 without symptoms); tertiary is treated with 10-20 million units/day IV for 10 days; if allergic give doxycycline but desensitize for tertiary and pregnancy

Front 95

chancroid

Back 95

caused by Haemophilus ducreyi
small, soft, painful papules that coalesce and become ulcers with ragged edges
tender and enlarged inguinal nodes
diagnosis is clinical
Gram stain and culture to confirm
treat with single-dose azithromycin or ceftriaxone OR erythromycin for 7 days OR cipro for 3 days

Front 96

lymphogranuloma venereum presentation

Back 96

small, transient, nonindurated lesion that ulcerates and heals quickly producing unilateral inguinal node enlargement, multiple drainning sinuses that persist or recur; also fever, malaise, joint pains, headaches

Front 97

lymphogranuloma venereum diagnosis and treatment

Back 97

clinical diagnosis
high or rising titer of complement fixing antibodies
isolate chlamydia trachomatis from pus in buboes
treat with doxycycline

Front 98

granuloma inguinale

Back 98

painless red nodule that turns into elevated granulomatous mass by donovantia granulomatis
looks like conylomata lata or carcinoma
diagnose with Giemsa or Wright stain, punch biopsy
treat with doxycyline or ceftriaxone

Front 99

gential herpes

Back 99

vesicles on genital area or mucous membranes that become eroded ulcers with red areola; itching and soreness; can have inguinal lymphadenopathy; diagnose with Tzanck test and culture; treat with acyclovir, famcyclovir, valacyclovir or foscarnet; explain relapsing nature

Front 100

genital warts

Back 100

papilloma virus causes condylomata acuminata which are warm, moist, pink pedunculated swellings with cauliflower appearance

clinical diagnosis

treatment: destruction (curettage, sclerotherapy, trichloroacetic acid), cryotherapy, podophyllin, imiquimod, laser removal

Front 101

painless papules and pustules that ulcerate near genital areas

Back 101

condylomata lata; syphilis

Front 102

painful small soft papules that become ulcers with ragged edges and coalesce

Back 102

chancroid; H. ducreyi

Front 103

painless small transient nonindurated lesion that ulcerates and heals quickly leaving scar

Back 103

lymphogranuloma venereum; C. trachomatis

Front 104

painless red nodule develops into elevated granulomatous mass

Back 104

granuloma inguinale; donovania granulomatis, calymmatobacterium granulomatis

Front 105

painful vesicles on skin or mucous membranes that become ulcers with red areola

Back 105

genital herpes; HSV

Front 106

painless soft moist redish swellings that grow rapidly into pedunculated masses with califlower appearance

Back 106

genital warts
condylomata acuminata
papilloma virus

Front 107

painful genital lesions

Back 107

chancroid
genital herpes

Front 108

painless genital lessions

Back 108

condylomata lata
lymphogranuloma venereum
granuloma inguinale
condylomata acuminata

Front 109

cystitis etiology

Back 109

infection of bladder by E. coli, proteus, klebsiella
predisposed by urinary stasis, tumors, stones, strictures, prostatic hypertrophy, neurogenic bladder, sexual intercourse

Front 110

cystitis presentation

Back 110

dysuria, frequency, urgency and suprapubic (but not flank) tenderness
may also have hematuria, low fever

Front 111

cystitis diagnosis and treatment

Back 111

screening test is urinalysis looking for WBCs, RBCs, protein or bacteria
nitrites indicate gram- bacteria
urine culture with >100,000 colonies per mL of urine is confirmation
treat with 3 days of TMP/SMX or any quinolone (not pregnancy)
7 days for diabetics

Front 112

acute bacterial pyelonephritis etiology

Back 112

ascension of E. coli, klebsiella, proteus
predisposed by female sex, obstruction due to strictures, tumors, calculi, prostatic hypertrophy, neurogenic bladder, vesicouretheral reflux, catheter; catherterized immunocompromised patients are predisposed to candida

Front 113

acute bacterial pyelonephritis presentation

Back 113

fever, chills
frequeny, dysuria
flank pain, costovertebral angle tenderness
nausea/vomitting

Front 114

acute bacterial pyelonephritis diagnosis

Back 114

clinical diagnosis with confirmation by clean-catch urinalysis and culture >100,000 bacteria/mL
if patient does not improve in 3 days or complications are suspected --> ultrasound or CT is indicated

Front 115

acute bacterial pyelonephritis treatment

Back 115

10-14 days with fluoroquinolone OR
ampicillin + gentamycin OR
third-gen ceph
if can't tolerate medication --> hospitalization

Front 116

perinephric abscess etiology

Back 116

abscess from kidney cortex to surrounding areas due to E. coli, klebsiella, proteus
predisposed by kidney stones (20-60%)
strictures
prostatic hypertrophy
neurogenic bladder
trauma
diabetes

Front 117

perinephric abscess presentation

Back 117

insidious onset (2-3 weeks) of fever, flank pain, palpable flank mass, abdominal pain, and persistence of symptoms after pyelonephritis treatment

Front 118

perinephric abscess diagnosis and treatment

Back 118

urinalysis and culture of urine
then ultrasound and aspiration of abscess for definitive etiology and sensitivity
quinolone, ampicillin/gentamycin, third-gen ceph
drainage is necessary

Front 119

impetigo etiology

Back 119

superficial pustular infection with due mainly to staph aureus and group A strep

Front 120

impetigo presentation

Back 120

maculopapules that progress to vesicles, pustules and bullae with golden crusts
can lead to lymphangitis, furunculosis or cellulitis
more common on limbs and face, may follow trauma to skin

Front 121

impetigo diagnosis and treatment

Back 121

clinical diagnosis
treat with first-gen ceph OR oxacillin, cloxacillin, dicloxacillin
can also use topical mupirocin or bacitracin in mild cases
if allergic use macrolides

Front 122

erysipelas

Back 122

superficial cellulitis due to group A strep
tender, demarcated, shiny red, indurated, edematous lesions on limbs or face
treat with semisynthetic penicillin or first-gen ceph if undistinguishable with cellulits, else penicillin for Group A strep

Front 123

tinea etiology

Back 123

dermatophytes: microsporum, trichophyton, epidermophyton

Front 124

tinea presentation

Back 124

corporis: papulosquamous lesions with riased border in the body; pedis: macerated and scaling borders; unguium: thickened nails; capitis: small scaly semibold graysish patched on head; cruris: ringed lesions on crural folds and inner thighs; barbae: on face

Front 125

tinea diagnosis and treatment

Back 125

potassium hydroxide preparation; culture as definitive test; treat with terbinafine or itraconazole orally for capitis, corporis and unguium; topical clotrimazole/ketoconazole for cruris, pedis and mild corporis

Front 126

candidiasis etiology

Back 126

candida infection more frequently in:
systemic antibacterial therapy
obesity
diabetes
corticosteroid or antimetabolites
pregnancy
malignancies
blood dyscrasias
HIV

Front 127

intertriginous candidiasis presentation

Back 127

intertriginous: well-demarcated, erythematous, itchy, exudative patches rimmed with red small pustules; in groin, gluteal folds (diper rash), axilla, umbillicus, inframmary areas

Front 128

vulvovaginitis presentation

Back 128

candidiasis with white or yelloish discharge with inflammation of the vaginal wall and vulva; common in pregnancy and diabetes

Front 129

oral candidiasis

Back 129

also known as thrush; white patches of exudates on tongue or bucal mucosa

Front 130

candidal paronychia

Back 130

painful red swelling around the nail

Front 131

candidiasis diagnosis and treatment

Back 131

potassium chloride on slide, culture is definitive
treat with topical nystatin or azoles
if serious infection or paronychia use amphotericin and fluconazole

Front 132

tinea versicolor

Back 132

pityrosporum orbiculare (malassezia furfur) leads to tan/brownish scaling macules that coalesce on neck, face and abdomen; diagnose with KOH showing spaghetti and meatballs; treat with topical selenium sulfide or azoles

Front 133

scabies

Back 133

due to itch mite or sarcoptes scabiei; pruritus, burrows and papules on skin folds; immunocompromised and Down patients can have malodorous discharge; diagnose by showing parasites in scrapings with mienral oil; treat with permethrin, lindane or ivermectin

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pediculosis

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due to pediculus humanus capitis, pediculus humanus corporis, phthirus pubis; itching, excoriations, erythematous macules and papules may have secondary bacterial infection; diagnose with direct analysis of hair-bearing surfaces; treat with permethrin, lindane

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molluscum contagiosum

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small waxy papules with central umbilication due to poxvirus
specially in children and HIV
clinical diagnosis
treat by cryotherapy, curettage, electrocautery

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osteomyelitis etiology

Back 136

most common organism is staph

acute hematogenous: in children occurs mostly in metaphysis of tibia and femur, in adults in the vertebral bodies

secondary to contiguous infection: recent trauma or prosthetic (could be polymicrobial)

vascular insufficiency: diabetics over 50, small bones of lower limb and majority are polymicrobial

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osteomyelitis presentation

Back 137

pain, erythema, swelling and tenderness over affected bone; in vascular insuf. May have ulcer; sometimes also drainning tract

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osteomyelitis diagnosis

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plain x-ray is usually first test but takes at least 2 weeks to show periosteal elevation
technetium scan and MRI detect it much earlier
a normal ESR strongly excludes osteomyelitis
bone biopsy and culture is best diagnostic test and its needed

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osteomyelitis treatment

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empiric: semisynthetic penicillin or vancomycin + aminoglycoside or third-gen ceph
then specific treatment
total is 6-12 weeks
adults also need drainage and debridment

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septic arthritis etiology

Back 140

joint infection mostly by gonococcus but also by gram+ (85%, staph 60%)
other gram- (10-15%) or polymicrobial (5%)
main risk factor for gonococcal is sexual activity
nongonococcal is mostly hematogenous spread by bites, direct inoculation by surgery or trauma, RA, OA, prothesis, gout, sickle cell, IV drug use, diabetes, HIV

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septic arthritis presentation

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gonococcal: polyarticular (50%) swollen, tender, erythematous joint with decreased range of motion also with tenosynovitis, migratory polyarthralgia, and petechiae or purpura

non-gonococcal is mostly monoarticular and doesn't have systemic involvement

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septic arthritis management

Back 142

joint aspiration along with empiric nafcillin combined with aminoglycoside or third-gen ceph
for gonococcal: ceftriaxone

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gas gangrene etiology

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80% C. perfringens associated with trauma, war and motor vehicle accidents; the wound must be deep, necrotic and without exit to surface

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gas gangrene presentation

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pain, swelling and edema 1-4 days after incubation
later hypotension, tachycardia, fever, crepitation and renal failure

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gas gangrene diagnosis

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gram+ rods on stain without white cells, culture and gas bubble on x-ray are suggestive
direct visualization of pale, dead muscle with sweet-smelling discharge is definitive diagnosis

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gas gangrene management

Back 146

24 million units of penicillin/day or clindamycin if allergic + debridment or amputation
hyperbaric oxygen might be of benefit

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infective endocarditis predisposing factors

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dental procedures
oral and upper respiratory surgery
some GI procedures
GU surgery
prosthetic heart valves
valvular heart disease
catheters to heart
IV drug abuse

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top 5 organisms of endocarditis in native valves

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strep viridans (50-60%)
staph aureus (20-30%)
other strep (15-20%
enterococci (5-15%)
staph epidermidis (1-3%)

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top 3 organisms of endocarditis in narcotic addicts

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staph aureus (60-95%), streptococci (10-20%), staph epidermidis (5-10%)

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top 3 organisms of endocarditis in prosthetic valves

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staph epidermidis (40-50%, 10-20 days later)
staph aureus (15-20%, 40-60 days later)
strep viridans (5-20%, 20-30 days later)

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acute endocarditis etiology

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bactermia with staph aureus seeds previously healthy valves and produces large vegetations, fever, spesis, splenomegaly

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subacute endocarditis etiology

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strep viridans is most common
low virulence seeding of abnormal valves with small vegetations made of fibrin, platelets, debris and bacteria

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infective endocarditis presentation

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fever + new heart murmur + anemia
chills, sweats, weakness, dyspnea, anorexia, cough, embolic events (petechiae, splinter hemorrhages, Janeway lesions), skin manifestation, splenomegaly, FROM JANE

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infective endocarditis major diagnostic criteria

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positive blood culture and abnormal echo; need both or 1 major/3minor for diagnosis

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infective endocarditis minor criteria

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cardiac lesion from IV drug use
vascular events (arterial emboli, septic lung infarcts, Janeway)
immunologic events (Osler, Roth, GN, rheumatoid factor)
microbiologic evidence (active infection consistent with endocarditis)
need 3 minor and 1 major or 2 major for diagnosis

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infective endocarditis empiric treatment

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antistaph (nafcillin) + antistrep (penicillin/ampicillin) + gentamicin
change as soon as specific agent is known by blood culture

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infective endocarditis specific treatment for strep viridans

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4 weeks penicillin OR if allergic, 4 weeks of ceftriaxone or vancomycin OR 2 weeks of penicillin or ceftriaxone + gentamicin

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infective endocarditis specific treatment for native valve/staph aureus

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if methicillin sensitive:
4-6 weeks of nafcillin + 5 days gentamicin
OR cefazolin or vancomycin + 5 days of gentamicin if allergic

for methicillin resistant:
4-6 weeks of vancomycin

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infective endocarditis specific treatment for enterococcus

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4-6 weeks of penicillin/ampicillin + gentamicin OR vacomycin + gentamicin

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major criteria for infective endocarditis surgery

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progressive or unresponsive CHF
recurrent systemic emboli
persistent bacteremia despite antibiotics
fungal etiology
extravalvular infection
prosthetic valve dehiscence or obstruction
recurrence despite therapy

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minor criteria for infective endocarditis surgery

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resolved CHF with therapy
single systemic embolic event
large aortic or mitral vegetations on echo
prosthetic valve infection other than penicillin sensitive strep
gram- tricuspid endocarditis
persistent fever
new regurgitation

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indications of prophylaxis for infective endocarditis

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when there's serious cardiac defect and procedure causing bacteremia; for dental procedures give amoxicillin or clindamycin/macrolide if allergic

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cardiac conditions that indicate infective endocarditis prophylaxis

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prosthetic heart valves
previous bacterial endocarditis
most congenital cardiac malformations

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conditions that don’t require infective endocarditis prophylaxis

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surgically corrected systemic pulmonary shunts, rheumatic valve dysfunction, hypertrophy cardiomyopathy, mitral valve prolapse with regurgitation, surgical repaired intracardiac defects

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acute pericarditis etiology

Back 165

any infectious agent
coxsackie and ECHO viruses are most common viruses
vascular --> SLE, RA, scleroderma
1/3 of uremic patients
neoplasia adjacent to heart
hypothyroidism
mediastinal irradiation
rheumatic fever
injury to heart

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acute pericarditis presentation

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sharp pleuritic chest pain improved by leaning forward; friction rub heard at apex; low fever

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pericardial tamponade presentation

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signs and symptoms of perdicarditis plus pulsus paradoxus, distended neck veins, tachycardia, hypotension

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acute pericarditis diagnosis

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diffuse ST elevation and maybe PR depression
echo normal in viral but used to detect effusion
pericardiocentesis for microbiology

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acute pericarditis therapy

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treat underlying cause; if viral give indomethacin or ibuprofen or prednisone if no response or if TB; pericardiocentesis for large effusions

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myocarditis etiology

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any infectious agent but coxackie B is very common
also radiotherapy, drugs, vascular disease, hyperthyroidism

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myocarditis presentation

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asymptomatic or any presentation
signs of myocardial dysfunction (dyspnea, fatigue) or rapid progression to chest pain and arrhythmia
may have S3 and murmurs

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myocarditis diagnosis

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any EKG alteration like ST-T wave changes, heart blocks
elevated cardiac enzymes may be found
may have left ventricular systolic dysfunction on echo
viruses may be isolated from body fluids or titers of serum antibodies are found

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myocarditis treatment

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supportive for viral (resolves spontaneously); steroids can be damaging

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Lyme disease presentation

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80% develop erythema migrans rash 3-30 days after bite
flulike illness occurs in 50%
neurologic symptoms develop weeks later in 10-20%
(facial paralysis, meningitis, encephalitis or headaches)
heart block, arrhythmia, myocarditis or pericarditis in <10%
migratory polyarthritis develops months to years later in 60%;

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Lyme disease diagnosis

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diagnostic criteria are presence of rash with at least one late manifestation + ELISA and western blot looking for anti borrelia antibodies (serum studies may not false negative early when rash is still present)

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Lyme disease treatment

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rash, facial palsy and joint pain with doxycyline
if serious neurologic or cardiac --> IV ceftriaxone