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235 Cards in this Set
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Infective Endocarditis - |
Infection of endocardium
secondary to infectious causes MC affects heart valves - esp. mitral valve Risk Factors - dental procedures that cause bleeding oral & upper respiratory surgery certain GI procedures GU surgery prosthetic heart valves valvular heart disease alimentation caths in rt. heart pressure monitoring caths IVDU MCC - acute - S. aureus subacute - S. viridans IVDU - S. aureus prosthetic valve - coag-neg. Staph coexisting GI malignancy - Strep. bovis fungal - Candida Aspergillus predisposing factors - long-term indwelling IV catheter immunosup from malignancy AIDS organ transplant IVDU |
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Infective Endocarditis -
Hx |
Fever
chills weakness dyspnea sweats anorexia skin lesions IVDU in pts. with h/o valve disease or IVDU - fever alone should be red flag |
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Infective Endocarditis -
PE |
Fever
heart murmur Osler's nodes Janeway lesions splinter hemorrhages Roth's spots |
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Infective Endocarditis -
Dx |
Fulfill Duke's criteria:
major criteria - • pos. BC - 2+ sets • abnormal echo - vegetations paravalvular abscess new regurg new partial dehiscence of prosthetic valve • TTE - very specific • TEE - very sensitive or 1 major and 3 minor minor criteria - PE findings emboli glomerulonephritis pos. Rh factor Other findings - leukocytosis left shift inc. ESR inc. C-reactive protein mild anemia microscopic hematuria EKG |
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Infective Endocarditis -
Tx |
Tx based on org. & sensitivity
if very ill - empiric empiric - antistaph, antistrep & gentamicin change as soon as know org. surgery if - severe CHF from valve incomp paravalvular leak around prosthetic valve fungal endocarditis persistent bacteremia despite ABx extravalvular infection ABx prophylaxis before: • dental work - amoxicillin if PCN allergy - clindamycin or azithromycin, clarithromycin or cephalexin • urinary or GI procedures - ampicillin and gentamicin if PCN allergy - vancomycin and gentamicin |
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Candidal Thrush -
What is it |
Infection of C. albicans
risk factors - xerostomia corticosteroid inhaler use immune def. immunosuppressive Tx leukemia lymphoma cancer diabetes obesity pregnancy can cause skin infections in noncompromised (diaper rash) |
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Candidal Thrush -
Hx/PE |
White, cream-colored
or yellow plaques can be scraped off leaves bleeding surface freq. complaint of mucosal burning oral candidiasis intertriginous candidal paronychia vulvovaginitis - pregnancy, DM |
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Candidal Thrush -
Dx |
Clinical Dx
KOH Cx - definitive |
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Candidal Thrush -
Tx |
• Hair & nails involved -
can't use topical must use systemic • not involved - topical nystatin clotrimazole fluconazole, miconazole amphotericin oral nystatin - 4x/day "swish and swallow" use for 5-7 days after lesions disappear |
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Pneumocystis Carinii Pneumonia
What is it |
Org. of low virulence
found in lung of humans predisposing factor in dev. of PCP - impaired cell-mediated immunity |
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Pneumocystis Carinii Pneumonia
Hx/PE |
Pneumonia
DOE dry cough fever chest pain impaired oxygenation SOB tachypnea tachycardia |
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Pneumocystis Carinii Pneumonia
Dx |
• Principle diagnostic test -
bronchoscopy with bronchoalveolar lavage • CXR - b/l diffuse perihilar infiltrates • silver stain and immunofluorescence of sputum samples |
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Pneumocystis Carinii Pneumonia
Tx |
TMP-SMX
pentamidine steroids - adjunct if severe severe - PaO2 <70 A-a gradient >35 prophylaxis - TMP-SMX - oral, #1 dapsone - #2 atovaquone - #3 aerolized pentamidine prophylaxis can be stopped - if antiretrovirals raise CD4 > 200 for >6 mos. |
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Chlamydia -
What is it |
MC bacterial STD in US
Chlamydia trachomatis can infect genital tract, urethra, anus and eye in newborns - conjunctivitis, pneumonia coexists or mimics gonorrhea test for both |
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Chlamydia -
Hx/PE |
Hx -
often asymp . urethritis - dysuria urgency . mucopurulent cervicitis vaginal discharge bleeding dyspareunia . salpingitis . PID - abdom pain fever . nongonocc urethritis - men PE - mucopurulent discharge cervical or adnexal tenderness penile discharge testicular tenderness |
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Chlamydia -
Dx |
• Ligase chain reaction test -
of voided urine • serology- fluorescent Ab (swab of male urethra) (gram stain of discharge - may show PMNs, but no bact.) |
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Chlamydia -
Tx |
Doxycycline
or azithromycin pregnant - erythromycin |
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Chlamydia -
Complications |
Chronic infection
pelvic pain Reiter's syndrome Fitz-Hugh-Curtis syndrome PID => infertility epididymitis |
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Gonorrhea -
What is it |
Gram-neg diplococcus
can infect almost any site in female repro tract men - usu limited to urethra |
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Gonorrhea -
Hx/PE |
Greenish-yellow discharge
pelvic or adnexal pain swollen Bartholin's glands purulent urethral discharge dysuria erythema of urethral meatus |
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Gonorrhea -
Dx |
Swab & culture on
Thayer-Martin medum gram stain cervical discharge Cx - most specific test |
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Gonorrhea -
Tx |
single-dose ceftriaxone 250 IM
and doxycycline for 7 days or single-dose ceftriaxone 250 IM and single-dose azithromycin or single-dose oral cipro or cefixime (also treating for chlamydia - doxycycline or macrolide) condoms for prophylaxis |
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Gonorrhea -
Complications |
Urethritis
epididymitis cervicitis PID tubo-ovarian abscess & rupture Fitz-Hugh-Curtis DGI (Disseminated Gonoc Infec) persistent infection with pain |
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Syphilis -
What causes it |
Treponema pallidum
spirochete |
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Syphilis -
Hx/PE |
Primary -
10-60 days after infection chancre (painless ulcer) near area of contact spontan heals in 3-9 weeks Secondary - 1-2 mos. after see chancre maculopap rash on soles, palms low-grade fever headache malaise lymphadenopathy can see alopecia meningitis, hepatitis & nephritis may also be seen very infective 2o eruptions coalesce => condylomata lata spontan heals in 2-6 weeks Early latent - no symptoms pos serology first yr of infection Late latent - no symptoms pos or neg serology > 1 yr of infection 1/3 will progress to tertiary Tertiary - 3-20 yrs after init infection not contagious gummas Tabes dorsalis Argyll Robertson pupil CV - aortitis aortic root aneurysms aortic regurg |
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Syphilis -
Dx |
• Best diagnostic in primary -
dark-field microscopy • secondary - RPR/VDRL |
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Syphilis -
Tx |
• primary & secondary -
IM PCN 2.4 million units/wk primary - 1 wk secondary - 3 wks • tertiary - IV PCN 10-20 million units/day x 10D • PCN allergic - primary & secondary - doxy tertiary or pregnant - desensitize Jarisch-Herxheimer - > 50% of pts. fever headache sweating rigors temp exacerbations of lesions 6-12 hrs post Tx |
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Histoplasmosis -
What is it |
Dimorphic fungus
environment - mold (mycelial) yeast in body endemic - MS River, OH self-limited flu-like Sxs mediastinal fibrosis residual scar tissue chronic cavitary disease - if obstructive lung dis. disseminated histoplasmosis - esp. in immune compromised infants fatal if untreated risk factors - AIDS spelunking bird and bat feces |
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Histoplasmosis -
Hx/PE |
Acute infection -
arthralgia erythema nodosum erythema multiforme chronic infection - low-grade fever anorexia weight loss night sweats productive cough |
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Histoplasmosis -
Dx |
. polysaccharide Ag detection
fast test for Dx and monitoring relapse . complement fixation Ab of 1:8 of 1:16 . silver stain on Bx bone marrow, l. node, liver . bronchoalveolar lavage . CXR . chest CT |
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Histoplasmosis -
Tx |
amphotericin B
ketoconazole |
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Coccidioidomycosis -
What is it |
Dimorphic fungi
environment - breaks up into arthroconidia spherules in tissue endemic - SW, S. CA can present as flu-like or acute pneumonia if disseminates, can involve - bone, meninges, skin the "great imitator" incubation period is 1-4 weeks after exposure |
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Coccidioidomycosis -
Hx/PE |
Fever
headache anorexia chest pain cough dyspnea night sweats arthralgias |
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Coccidioidomycosis -
Dx |
. Precipitin Ab -
rise within 2 weeks disappear after 2 mos. . complement fixation Ab - rise at 1-3 mos. . culture - sputum wound exudate joint aspirate . CXR . consider - bronchoscopy fine-needle Bx open lung Bx pleural Bx |
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Coccidioidomycosis -
Tx |
Ketoconazole or
fluconazole amphotericin B |
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Cryptococcosis -
What is it |
C. neoformans
encapsulated yeast in soil with pigeon droppings can cause asymp pulmon infect affects meninges defining opportunistic infection for AIDS |
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Cryptococcosis -
Hx/PE |
Meningitis -
frontal or temporal headache fever impaired mentation no meningismus pneumonia - nonproductive cough SOB fever |
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Cryptococcosis -
Dx |
. LP with init eval by india ink
. then cryptococcal Ag testing . worse prognosis - high opening pressure high Ag titer low CSF cell count . fungal culture . latex agglutination test . CT - if neuro deficits . fungal meningitis - CSF glucose dec. protein inc. leukocyte count high lymphocytes predominate |
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Cryptococcosis -
Tx |
IV Amphotericin - 2 wks.
then oral fluconazole for life prophylaxis - fluconazole not recommended effective, but incidence of meningitis too low |
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Anthrax -
What is it |
B. anthracis
forms spores gram positive rods occupational hazard for veterinarians & farmers animal wool/hair, hides, bone meal products biological weapon MC - cutaneous inhalational - most deadly intestinal |
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Anthrax -
Hx/PE |
Cutaneous -
1-7 days after skin exposure and penetration of spores MC - exposed upper ext pruritic papule in 24-48 hrs forms ulcer with edematous halo in 7-10 days => black eschar regional lymphadenopathy |
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Anthrax -
Dx |
Aerobic culture
gram stain of ulcer exudate |
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Anthrax -
Tx |
Meningeal anthrax -
PCN - meningeal dose doxycycline chloramphenicol quinolone 1-2 wks (PCN allerg) ciprofloxacin prophylaxis - postexposure prophylaxis 60 days to prevent inhalational anthrax |
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Lyme Disease -
What is it |
Borrelia spirochete
Ixodes tick usu seen in summer months endemic - NE, Pacific, NmidW MC vector-borne dis. in NA |
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Lyme Disease -
Hx/PE |
Rash
fever malaise headache myalgias joint pain often recent h/o camping, hiking in endemic areas tick needs 24 hours of attachment to transfer Borrelia primary - Erythema migrans eryth macule or papule at tick-feeding site slowly expands central clearing "bull's eye" secondary - migratory polyarthropathy neuro - Bell's palsy - MC meningitis myocarditis MC - AV heart block tertiary - arthritis subacute encephalitis severe arthritis - HLA-DR2 |
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Lyme Disease -
Dx |
rash
1 late manifestation lab confirms org. ELISA - pos = exposure, not active dis Western Blot - to confirm |
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Lyme Disease -
Tx |
Doxycycline - minor Sxs
IV ceftriaxone - major Sxs |
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Rocky Mt Spotted Fever -
What is it |
Rickettsia rickettsii
dermacentor tick invades endothel lining of cap => small-vessel vasculitis rapidly fatal if untreated |
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Rocky Mt Spotted Fever -
Hx/PE |
Headache
fever rash - before 6th day macular pink rash starts at wrists, ankles maculopapular and darker petechial/purpuric as spreads spreads centripetally (in) => palms & soles in severe cases - altered mental status DIC |
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Rocky Mt Spotted Fever -
Dx |
Clinical
confirm - complement fixation test Weil-Felix test |
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Rocky Mt Spotted Fever -
Tx |
Doxycycline
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UTIs -
What is it Causes |
Cystitis
pyelonephritis perinephric abscess cystitis - very common affects women > men E. coli - 80% • due to - urinary stasis foreign body tumor stones stricture BPH neurogenic bladder honeymoon cystitis • major cause - catheters risk related to length (time) of catheterization |
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UTIs -
UTI bugs |
SEEKS PP
S. saprophyticus E. coli Enterobacter Klebsiella Serratia Proteus Pseudomonas |
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UTIs -
Cystitis Hx/PE |
Dysuria
urgency frequency hematuria low-grade fever suprapubic pain PE - suprapubic tenderness kids - bedwetting infants - poor feeding recurrent febrile episodes foul-smelling urine |
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UTIs -
Dx |
Best init. test - UA
look for: WBC = #1 RBC protein bacteria if nitrites - gram neg. inc. urine pH - Proteus WBC < 5 is normal UC > 100,000 colonies confirmatory not always necessary if - have Sxs and pos. UA |
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UTIs -
Tx |
Uncomplicated cystitis -
TMP-SMX or any quinolone for 3 days DM - 7 days pregnant - no quinolones elderly, comorbid dis. or acute toxicity - admit IV ciprofloxacin or ampicillin & gentamicin recurrent UTIs - prophylaxis ABx |
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Pyelonephritis -
What is it |
Ascending UTI that has
reached renal parenchyma More common in - women pregnancy childhood after catheterization or instrumentation if immunosuppressed - prone to Candida due to obstruction from - strictures tumor stones bph neurogenic bladder vesicoureteral reflux |
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Pyelonephritis -
Hx/PE |
Costovertebral angle tenderness
flank pain fever/chills n/v dysuria frequency urgency |
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Pyelonephritis -
Dx |
Clean-catch urine for -
UA, UC, sensitivity >100,000 colonies suggestive US - to r/o obstruction WBC casts leukocytosis UC radiology if - pregnancy h/o urolithiasis prior GU surgery recurrent pyelonephritis prepubescent age fever > 5-7 days without appropriate med eval elderly IVP - #1 choice (if not pregn) US - safe in pregnancy CT - if nondiagnostic IVP & US if don't respond to therapy after 3 days of Tx |
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Pyelonephritis -
Tx |
Any ABx or gram neg rods
10-14 days (fluoroquinolone TMP-SMX ampicillin gentamicin 3rd gen cephalosporin) |
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Sepsis -
What is it |
Systemic infection plus
a reaction called Systemic Inflammatory Response Syndrome (SIRS) |
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Sepsis -
What causes SIRS |
A release of many mediators
into the blood that activate inflammatory and coag pathways |
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Sepsis -
What is severe sepsis |
Sepsis and signs of failure
of at least 1 organ |
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Sepsis -
What is septic shock |
Sepsis-induced
severe sepsis organ hypoperfusion hypotension (systolic BP < 90) poor response to init fluid resus most cases - hosp.-acq. gram neg bacilli or gram pos cocci gram-pos shock - secondary to fluid loss caused by exotoxins gram-neg shock - caused by vasodilation due to endotoxin (LPS) |
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Sepsis -
What causes septic shock in neonates |
Group B strep
E. coli Klebsiella |
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Sepsis -
What causes septic shock in kids |
H. influenzae
pneumococcus meningococcus |
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Sepsis -
What causes septic shock in adults |
Gram-pos cocci
aerobic bacilli anaerobes |
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Sepsis -
What causes septic shock in IV drug users |
S. aureus
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Sepsis -
What causes septic shock in asplenic pts. |
Pneumococcus
H. influenzae meningococcus (in other words, encapsulated organisms) |
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Sepsis -
Hx/PE |
Hx -
abrupt onset of fever & chills often hyperventilation altered mental status PE - fever tachy tachypnea in septic shock - may start as warm shock warm skin and extremities => cold shock cool skin and extremities petechiae or ecchymoses - DIC elderly pt. with altered mental status - consider urosepsis |
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Sepsis -
Dx |
WBCs initially dec.
WBCs inc. in 1-4 hrs. with inc. PMNs - esp. bands thrombocytopenia BC UC sputum CXR coag studies DIC panel |
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Sepsis -
Tx |
May need ICU admission
treat aggressively maintain BP IV fluids pressors ABx treat underlying cause |
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Pneumonia -
What is it |
Infection of lung parenchyma/alveoli
has inflammatory exudate • only cause of death in top 10 from infectious disease • not nec. to have predisposing condition • but predisposed if - cigarettes DM alcoholism malnutrition immunosuppression bronchial obstruction (tumor) neutropenia, steroids => aspergillosis |
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Pneumonia -
Categories of "typical" and "atypical" |
Typical -
bacteria from nasopharynx Atypical - from org. inhaled from envi hard to see on gram stain not susceptible to ABx that act on cell wall (B-lactams) RSV adenovirus mycoplasma legionella chlamydia |
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Pneumonia -
What is aspiration pneumonia |
Secondary to inhaling
a large amount of oropharyngeal secretions into larynx and lwr resp tract aspiration of small amount in pts with impaired pulmonary defenses MCC of death in pts. with dysphagia due to neurologic d/o |
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Pneumonia -
What is chemical pneumonitis |
Secondary to inhaling
gastric contents causes chemical injury to lung |
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Pneumonia -
Hx Mycoplasma Hx Legionella Hx PCP Hx |
Productive cough -
green or yellow sputum rust-colored = pneumococcus currant jelly = klebsiella hemoptysis dyspnea fever/chills night sweats pleuritic chest pain atypical organisms present - more gradual onset dry cough headaches myalgias sore throat pharyngitis • Mycoplasma - dry cough sore chest bullous myringitis anemia (from hemolysis from cold agglutinins) rare to be inpatient/need to admit • Legionella - confusion headache lethargy diarrhea abdom pain • PCP - marked dyspnea DOE chest soreness cough HIV+ |
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Pneumonia -
PE |
Decreased or
bronchial breath sounds crackles (rales) wheezing dullness to percussion egophony tactile fremitus elderly, COPD or DM - may have minimal signs on PE |
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Pneumonia -
Dx |
• CXR - initial test
• sputum Cx - most specific diag. for lobar (atypicals don't show up on gram stain or regular Cx) • invasive tests sometimes to confirm • open lung Bx - most specific • Mycoplasma - Ab titers cold agglutinins - limited • Legionella - special Cx media: charcoal yeast extract urine Ag tests direct fluorescent Ab Ab titers • PCP - bronchoalveolar lavage increased LDH • Chlamydias, Coxiella, Coccidio - Ab titers . CBC - leukocytosis left shift . sputum gram stain & culture- ID org. ID ABx susceptibility good sputum sample - many PMNs (> 25 cells/hpf) few epith cells (< 25/hpf) . BC . ABG . for recurrent pneumonias - consider underlying dis. |
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Pneumonia -
Outpt community-acq < 65 y/o otherwise healthy What are pathogens |
S. pneumoniae
M. pneumoniae Chlamydia H. flu viral |
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Pneumonia -
Outpt community-acq < 65 y/o otherwise healthy What is init coverage |
In uncomplicated cases,
tx on outpt basis erythromycin tetracycline smokers with H. flu - clarithromycin azithromycin |
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Pneumonia -
Outpt community-acq > 65 y/o or with comorbidity What are pathogens |
S. pneumoniae
H. flu E. coli Enterobacter Klebsiella S. aureus Legionella viruses |
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Pneumonia -
Outpt community-acq > 65 y/o or with comorbidity What is init coverage |
Require admission
cefuroxime (2nd gen cephalo) TMP-SMX amoxicillin if atypicals suspected - add erythromycin if pt has obstructive dis. - add pseudomonal coverage |
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Pneumonia -
Community-acq req. admission What are pathogens |
S. pneumoniae
H. flu anaerobes aerobic GNRs Legionella Chlamydia |
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Pneumonia -
Community-acq req. admission What is init coverage |
Cefotaxime or
ceftriaxone (2nd or 3rd gen) or B-lactam with B-lactam inhib if atypicals suspected - add erythomycin |
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Pneumonia -
Severe community-acq req. ICU What are pathogens |
S. pneumoniae
H. flu anaerobes aerobic GNRs Mycoplasma Legionella Pseudomonas |
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Pneumonia -
Severe community-acq req. ICU What is init coverage |
Erythromycin
macrolide and antipseudomonal agent and aminoglycoside |
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Nosocomial pneumonia -
(hospitalized > 48 hrs or in long-term care fac. > 14 days) What are pathogens |
E. coli
Enterobacter Klebsiella Pseudomonas S. aureus Legionella mixed flora |
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Nosocomial pneumonia -
(hospitalized > 48 hrs or in long-term care fac. > 14 days) What is init coverage |
3rd gen cephalosporin with
anti-pseudomonal activity and gentamicin |
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Pneumonia -
Who gets pneumococcal vaccine |
> 65 y/o
any serious lung, cardiac, liver, renal disease immunocompromised splenectomized sickle cell DM leukemia lymphoma 60-70% effective redose in 5 years if - severe immunocompromised original vaccine at < 65 y/o |
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Tuberculosis -
What is it |
Mycobacterium tuberculosis
most cases of symptomatic TB - reactivation of old infection remain confined to lung common cause of FUO MC site of extrapulmonary infection - lymph nodes (adenitis) most significant defect associated with reactivation - impaired T cell-mediated cellular immunity risk factors - immunosuppression alcoholism preexisting lung dis. immigrants from developing nations DM advancing age homelessness manourishment crowded living conditions prisoners nursing home residents health care workers sick contacts |
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Tuberculosis -
Hx/PE |
Cough
hemoptysis weight loss night sweats dyspnea fever cachexia hypoxia tachy lymphadenopathy abnormal lung sounds (positive Babinski - when affects spine) |
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Tuberculosis -
Dx |
• CXR - best init test
• AFB stain - allows for specific Dx need 3 neg. for >90% sensitivity • Cx - the most specific need for sensitivity testing • pleural Bx - most sensitive test • if AFB stain unrevealing - thoracentesis gastric aspirate (kids) Bx (extrapulmonary organ) needle aspiration (extrapul) LP (if meningitis) |
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Tuberculosis -
PPD test |
Length of induration measured
at 48-72 hrs. BCG vaccine- PPD pos. for 1 yr 2-stage testing - no recent PPD test have reactivity < 10mm 2nd test within 2 weeks Pos. results indicated by - 5 mm - HIV close TB contacts steroid use organ transplant recipient abnorm CXR - old, healed TB 10 mm - homeless recent immigrant IVDU chronic illness residents of health & correctional institutions healthcare workers immunocompromised other than in "5mm" group 15 mm - everybody else if pos. PPD - get CXR abnormal CXR - get 3 AFB if pos. AFB - Tx if neg. AFB - latent TB INH and B6 for 9 mos. ("prophylaxis") if pos. PPD - get CXR normal CXR - latent TB INH and B6 for 9 mos. ("prophylaxis") |
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Tuberculosis -
Tx |
• All cases reported to local
& state health depts. • respiratory isolation Directly Observed Therapy - • rifampin (RIF) ethambutol (ETB) pyrazinamide (PZA) INH & B6 for 2 months (until know sensitivity) • ETB & PZA discontinued cont. RIF & INH for 4 more mos. • if sensitivity not known - give ETB • TB meningitis - Tx 12 mos. TB meds and steroids • TB pericarditis - TB meds and steroids • TB in pregnancy - Tx 9 mos. • TB in osteomyelitis & HIV - Tx 6-9 mos. • pregnant - no pyrazinamide no streptomycin • all but streptomycin => liver toxicity RIF - stains contacts and underwear ETB - optic neuritis => color blind PZA - benign hyperuricemia don't Tx unless gout Sxs |
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Fever of Unknown Origin (FUO)-
What is it MCC Risk factors |
Temp > 38.3 for 3 weeks
undx after 3 outpt visits or 3 days of hospitalization MCC - infections & cancer autoimmune dis. (15%) Risk factors - recent travel immune deficiency drug abuse |
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Fever of Unknown Origin (FUO)-
Hx/PE |
Fever
headache myalgia malaise |
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Fever of Unknown Origin (FUO)-
Dx |
CBC with diff
BC ESR CXR PPD CT & MRI - if malig or abscess suspected specific tests if infectious or autoimmune suspected |
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Fever of Unknown Origin (FUO)-
Tx |
If severely ill -
empiric broad-spectrum ABx stop if no response |
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Neutropenic Fever -
What is it |
One oral temp of 38.3
or 38.0 > 1 hr. in neutropenic pt. 38.3 C = 101 F 38.0 C = 100.4 F |
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Neutropenic Fever -
Hx/PE |
Cmn in pts. undergoing chemo
ANC nadir 7-10 days post chemo if severely neutropenic - inflammation may be min. or 0 pain at MC infected sites - skin eye peridontium pharynx lungs lwr esoph abdomen perineum anus |
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Neutropenic Fever -
Dx |
Thorough PE
NEVER do rectal exam CBC with diff BC BUN/Cr transaminases CXR - if resp signs CT - to check for abscess |
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Neutropenic Fever -
Tx |
Empiric ABx
Tx algorithm |
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Congenital Infections -
Common sequelae |
Can occur at any time during
pregnancy, labor, delivery common sequelae - premature delivery CNS abnorm jaundice anemia hepatosplenomegaly growth retardation |
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Congenital Infections -
What are they (mnemonic) |
TORCHeS
Toxoplasmosis Other Rubella CMV Herpes Syphilis |
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Congenital Infections -
Toxoplasmosis How transmitted Specific findings |
Transplacental - rare
primary infection - consumption of raw meat - undercooked pork & lamb contact with cat feces Specific findings - intracranial calcifications chorioretinitis hydrocephalus ring-enhancing lesions on Head CT immunocompetent - usu asymp best diag. test - visualize parasite in tissue or fluid MC - serology |
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Congenital Infections -
Other (TORCHeS) What are they |
HIV
parvovirus Varicella Listeria TB malaria fungi |
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Congenital Infections -
Rubella How transmitted specific findings |
Transplacental transmission
in 1st trimester Specific findings - rubella r - r p b - c d l - m m purpuric blueberry muffin Rash PDA Cataracts Deafness Mental retardation Microcephaly |
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Congenital Infections -
CMV How transmitted specific findings |
CMv is MC congenital infection
transplacental transmission Specific findings - petechial rash periventricular calcifications |
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Congenital Infections -
Herpes How transmitted specific findings |
Intrapartum transmission if
mom has active lesions Specific findings - skin, eye and mouth infections life-threatening CNS/systemic infection |
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Congenital Infections -
Syphilis How transmitted specific findings |
Intrapartum transmission
Specific findings - maculopapular skin rash lymphadenopathy hepatomegaly "snuffles" - mucopur rhinitis osteitis In childhood, late congen - saber shins saddle nose CNS involvement Hutchinson's triad - peg-shape upr central incisors deafness interstitial keratitis (photophobia, lacrimation) |
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Congenital Infections -
Dx |
Serologic testing -
rubella toxoplasmosis HSV UC - CMV syphilis - dark field exam - skin lesions material serum test cord blood for inc. IgM viral isolation amniocentesis - PCR for CMV antigen detection all ill newborns - BC LP empiric ABx |
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Congenital Infections -
Toxoplasmosis Tx |
Pyrimethamine
sulfadiazine spiramycin (if 3rd trimester) |
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Congenital Infections -
Syphilis Tx |
PCN
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Congenital Infections -
HSV Tx |
Acyclovir
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Congenital Infections -
CMV Tx |
Ganciclovir
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Congenital Infections -
Toxoplasmosis Prevention |
Avoid exposure to cats &
cat feces during pregnancy women with primary infection - pyrimethamine and sulfadiazine in third trimester - spiramycin |
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Congenital Infections -
Rubella Prevention |
Immunize before pregnancy
consider abortion if infected or exposed vaccinate mom after delivery if titers remain negative |
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Congenital Infections -
Syphilis Prevention |
PCN in pregnant women who
test pos. |
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Congenital Infections -
CMV Prevention |
Avoid exposure
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Congenital Infections -
HSV Prevention |
C-section if lesions present
at delivery |
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Congenital Infections -
HIV Prevention |
AZT - pregnant with HIV
C-section AZT prophylaxis - infant no breast-feeding |
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Osteomyelitis -
What is it |
Three types:
• acute hematogenous - kids long bones of lwr ext MC - staph • secondary to contig infection - recent trauma placement of prosthesis MC - polymicrobial MC single org. - staph • vascular insufficiency - >50 y/o DM or PVD repeated minor trauma not noticed cuz of neuropathy small bones of lwr ext MC - polymicrobial MC single org. - staph |
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Osteomyelitis -
Common Pathogens |
Most people - staph
IVDU - staph or pseudomonas SCD - salmonella hip replaced - s. epidermidis foot puncture wound - pseudomonas chronic - staph, pseudomonas, enterobacter |
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Osteomyelitis -
Hx/PE |
Fever
localized bone pain localized warmth, tenderness, swelling, erythema limited ROM |
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Osteomyelitis -
Dx |
• XR - initial test
periosteal elevation - 1st abnorm • technetium bone scan MRI - better differentiation • ESR - nonspecific can follow during Tx • Bx and Cx - best diagnostic most invasive |
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Osteomyelitis -
Tx |
Depends on isolate
oxacillin/nafcillin and aminoglycoside or 3rd gen ceph until specific Dx chronic - 12 wks of IV therapy then 8-12 wks orally |
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Osteomyelitis -
Complications |
Chronic osteomyelitis
soft tissue infection sepsis septic arthritis chronic osteomyelitis with draining sinus tract => squamous cell ca (Marjolin's ulcer) |
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HIV -
What is it Risk factors |
Retrovirus
targets and destroys CD4+ CD4+ count = marker for extent of disease progression viral load = indicates rate Risk factors - MC risk - IVDU 2nd MC risk - homosexuality unprotected sex maternal HIV infection needle sticks mucocutaneous exposure receipt of blood products |
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HIV -
Hx/PE |
Primary infection often asymp
may present with flu-like Sxs Later - night sweats weight loss thrush cachexia complications correlate with CD4+ count |
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HIV -
Dx |
ELISA -
high sensitivity moderate specificity detects anti-HIV ab can take up to 6 mos. to appear after exposure Western blot - confirmatory low sensitivity high specificity viral load PPD with anergy panel VDRL CMV serology toxoplasmosis serology |
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HIV -
Tx Tx During Pregnancy Tx for Needlesticks |
• Start when -
CD4+ <350 or viral load >55,000 (PCR-RNA) 2 rev. trans. + prot. inhib or 2 rev. trans. + 2 prot. inhib or 2 rev. trans. + efavirenz • adequate Tx - viral load dec. 50% in 1st mo. • viral sensitivity/resistance monitoring - meds failing/not suppressing PREGNANCY - • if low CD4+ or high load - 3x's antiretrovirals as nonpregnant pt. • C-section - only if CD4+ & viral load not controlled • all get AZT • start AZT by 14th week • AZT => transient anemia • no efavirenz - teratogen Postexposure Prophylaxis (Needlestick) - AZT + lamivudine + nelfinavir for 4 weeks |
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HIV -
PCP CD4+ Level at Presentation Tx |
CD4+ <200
TMP-SMX pentamidine steroids - if severe prophylaxis - TMP-SMX - orally, #1 dapsone - #2 atovaquone -#3 pyrimethamine - aerolized, #4 prophylaxis may be discontinued if antivirals raise CD4 >200 for more than 6 mos. |
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HIV -
Mycobacterium Avium Complex CD4+ Level at Presentation Tx |
CD4+ <50
clarithromycin and ethambutol prophylaxis - azithromycin - orally once a week or clarithromycin BID rifabutin - alternative prophylaxis can be stopped if antiretrovirals raise CD4 >100 for several months |
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HIV -
Toxoplasma CD4+ Level at Presentation Tx |
CD4+ <100
pyrimethamine and sulfadiazine (clindamycin is substitute for sulfadiazine if sulfa-allergy) prophylaxis - TMP-SMX dapsone/pyrimethamine |
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HIV -
TB Indication for prophylaxis Medication |
PPD > 5mm
INH x 9 mos. or rifampin + pyrazinamide or rifabutin + pyrazinamide |
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HIV -
Candida Indication for prophylaxis Medication |
Multiple recurrences
Fluconazole or itraconazole |
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HIV -
HSV Indication for prophylaxis Medication |
Multiple recurrences
Acyclovir or famciclovir or valacyclovir |
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HIV -
Pneumococcus Indication for prophylaxis Medication |
All patients
Pneumovax |
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HIV -
Influenza Indication for prophylaxis Medication |
All patients
Influenza vaccine |
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Otitis Externa -
What is it Common etiologic agents |
"Swimmer's ear"
inflammation of skin lining ear canal and surrounding soft tissue from moisture - => maceration of skin breeding ground for bacteria from trauma - usu from objects for cleaning Pseudomonas Enterobacteriaceae |
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Otitis Externa -
Hx/PE |
Pain
pruritus possible purulent discharge pain with movement of tragus/pinna edematous, eryth ear canal |
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Otitis Externa -
Dx |
Clinical
gram stain & culture if suspect fungal CT if pt. looks toxic |
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Otitis Externa -
Tx |
Eardrops -
polymyxin B neomycin hydrocortisone acute - dicloxacillin DM - at risk for malignant OE at risk for osteomyelitis of skull bone admit IV ABx |
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Encephalitis -
What is it |
Inflammation of the brain
meninges and parenchyma MCC - viral infection MC virus - HSV |
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Encephalitis -
Hx |
Can have any level of neuro deficit
any level of focal deficit 1st clue - altered mental status, fever, headache nuchal rigidity mild lethargy confusion stupor coma |
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Encephalitis -
PE |
Focal neuro signs -
hemiparesis focal seizures autonomic dysfunction inc. ICP SIADH |
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Encephalitis -
Dx |
CT or MRI
HSV affects temporal lobe LP - key to Dx PCR - eliminates need for Bx |
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Encephalitis -
Tx |
HSV - immediate IV acyclovir
CMV - ganciclovir or foscarnet HIV - if suspect resistant HSV foscarnet |
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Meningitis -
What is it Risk factors |
Infection of leptomeninges
most cases - sporadic • contiguous local spread - otitis media mastoiditis sinusitis dental infections • spreads hematogenously - endocarditis pneumonia • S. aureus - surgery cryptococcus - <100 T cells RMSF Lyme TB syphillis • Listeria - immune defects, esp. T cell HIV steroids leukemia lymphoma chemo neonates & elderly - they have dec. T cell function |
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Meningitis -
Hx/PE |
Fever
malaise headache neck stiffness photophobia altered mental status seizures MC focal neuro deficits - visual fields CN MC long-term damage - CN8 signs of meningeal irritation- Kernig and Brudzinski often absent in < 2 y/o |
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Meningitis -
Dx |
LP - to establish Dx
CSF Cx - most accurate test cell count & differential - most useful CT best init test if - papilledema focal motor deficits severe abnorm in mental status give ceftriaxone prior if 20-30 min. delay in LP - best init step - ceftriaxone or cefotaxime add ampicillin if suspect Listeria |
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Meningitis -
Tx |
Empiric - ceftriaxone or cefotaxime
Listeria - add ampicillin Staph after surgery - vanco PCN resistant - vanco Lyme - ceftriaxone Syphllis - PCN TB - steroids (adults) viral - no proven useful Tx cryptococcus - amphotericin, then lifelong fluconazole if also HIV pos. contacts of pts. with meningococcal meningitis - rifampin prophylaxis |
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Meningitis -
Complications Tx |
Hyponatremia -
admin fluids monitor sodium concentration Seizures - benzos phenytoin Subdural effusions - may be seen on CT 50% of infants with H. influenzae meningitis no Tx necessary Cerebral edema - presents with loss of oculocephalic reflex IV mannitol Subdural empyema - presents as intractable Szs surgical evacuation Brain abscess - surgical drainage Ventriculitis - presents as: worsening clinical pic yet improved CSF findings need ventriculostomy, possibly intraventricular ABxs |
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Sinusitis -
What is it Risk factors |
Infection of sinuses due to
undrained collection of pus MC infected - maxillary Risk factors - barotrauma allergic rhinitis viral infection asthma smoking nasal decongestant overuse |
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Sinusitis -
Acute sinusitis Definition MC associations |
Sxs last < 1 mo.
MC associated with - S. pneumonia H. influenza Moraxella catarrhalis viral infection |
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Sinusitis -
Chronic sinusitis Definition |
Sxs persist > 3 mos.
often ongoing low-grade anaerobic infections DM - mucormycosis can start in nose and maxillary sinuses |
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Sinusitis -
Hx/PE |
Fever
facial pain can radiate to upper teeth nasal congestion headache headache worse when lean forward tenderness erythema swelling over affected area purulent discharge in chronic - pain may be absent febrile ICU pts. - may have occult sinusitis esp. if intubated or have NGT |
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Sinusitis -
Dx |
• Obvious cases -
no XR before Tx • maxillary sinus XR - best init test air-fluid levels opacification • coronal CT - greater detail • sinus puncture - if don't respond to Tx freq. recurrences confirms bacteria |
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Sinusitis -
Tx |
Mild or acute uncomplicated -
decongestant (oral pseudoephedrine or ozymetazoline spray) severe pain & discolored discharge - amoxicillin - best initial amoxicillin-clavulanate - if recent amoxicillin use or don't respond or 2nd or 3rd ceph OK to use |
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Sinusitis -
Complications |
Osteomyelitis of frontal bone
meningitis orbital cellulitis cavernous sinus thrombosis abscess of epidural or subdural spaces |
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Acute Pharyngitis -
What is it Etiologies |
Usu self-limited
must differentiate strep from other causes MC - viral causes Grp A B-hemolytic strep Grp C B-hemolytic strep N. gonorrhoeae C. diphtheria M. pneumonia rhinovirus coronavirus adenovirus HSV EBV CMV influenza coxsackie |
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Acute Pharyngitis -
Hx/PE |
Typical of strep -
sudden-onset sore throat pharyngeal erythema fever ant. cervical lymphadenopathy soft palate petechiae headache vomiting scarlatiniform rash tonsillar exudate - EBV can give exudate mild S. pyogenes may not |
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Acute Pharyngitis -
Dx |
Clinical
rapid group A strep Ag detect throat culture pos. rapid group A strep Ag - equivalent to pos. Cx neg. test - confirm with Cx |
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Acute Pharyngitis -
Tx |
Reduce symptoms -
fluids rest antipyretics salt-water gargles PCN V po x 10 days or PCN G benzathine M x 1 dose if allergic to PCN - macrolides oral, 2nd gen cephalosporins |
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Acute Pharyngitis -
Complications |
Nonsuppurative -
acute rheumatic fever poststrep glomerulonephritis suppurative - cervical lymphadenitis mastoiditis sinusitis otitis media retropharyngeal or peritonsillar abscess peritonsillar abscess - odynophagia trismus (lockjaw) muffled voice u/l tonsil enlargement, erythema uvula & soft palate deviate away Tx - intraoral US or CT Cx abscess fluid drain PCN or erythromycin elective tonsillectomy later |
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Lymphogranuloma Venereum -
What is it |
Contagious STD
Chlamydia trachomatis |
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Lymphogranuloma Venereum -
Hx/PE |
Lesion ulcerates & heals
u/l inguinal lymph nodes enlarge => draining buboes scar formation fever joint pains headache |
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Lymphogranuloma Venereum -
Dx |
Clinical exam and Hx
high or inc. Ab titer isolate Chlamydia from bubo pus |
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Lymphogranuloma Venereum -
Tx |
Doxycycline
erythromycin - alternative |
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Chancroid -
What is it |
Haemophilus ducreyi
gram neg rod |
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Chancroid -
Hx/PE |
Small, soft, painful papules
become shallow ulcers have ragged edges vary in size & coalesce inguinal lymph nodes enlarge |
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Chancroid -
Dx |
Clinical
gram stain with Cx to confirm PCR |
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Chancroid -
Tx |
Azithromycin single dose
or ceftriaxone 250 IM one dose erythromycin x7D (alternative) cipro x3D (alternative) |
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Genital Herpes -
What is it |
HSV-2 (85%)
HSV-1 can be seen |
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Genital Herpes -
Hx/PE |
Vesicles erode
painful, circular with red areola can have inguinal lymphadenopathy relapses |
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Genital Herpes -
Dx |
Tzanck smear and Cx
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Genital Herpes -
Tx |
Acyclovir
famciclovir or valacyclovir |
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Granuloma Inguinale -
What is it |
Chronic granulomas
spread by sexual contact Donovania granulomatis Calymmatobacterium granulomatis |
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Granuloma Inguinale -
Hx/PE |
Painless, red nodule
develops into elevated granuloma heals slow scars form |
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Granuloma Inguinale -
Dx |
Giemsa or Wright stain
Donovan bodies - confirm punch Bx |
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Granuloma Inguinale -
Tx |
Doxycycline or TMP/SMZ
erythromycin (alternative) |
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Genital Warts -
What are they |
HPV 6 & 11
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Genital Warts -
Hx/PE |
Soft, moist, pink or red
grow fast cauliflower appearance condylomata acuminata |
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Genital Warts -
Dx |
Clinical
must differentiate between - warts and c. lata of syphilis |
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Genital Warts -
Tx |
Remove -
curettage sclerotherapy trichloroacetic acid cryotherapy podophyllin laser imiquimod (immune stimulant) |
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Perinephric Abscess -
What is it Causes |
Not common
• pyelonephritis => abscess rupture into perinephric space • caused by - any factor predisposing to pyelonephritis stones - #1 structural abnorm trauma recent surgery DM • "SEEKS PP" pathogens MC - E. coli then Klebsiella, Proteus S. aureus - hematogenous |
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Perinephric Abscess -
Hx/PE |
Insidious
2-3 wks of Sxs before 1st visit fever flank pain abdom pain palpable abdom mass persistence of pyelonephritic Sxs even tho Tx for pyelonephritis |
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Perinephric Abscess -
Dx |
UA/UC - init. tests
fever, pyuria & neg. UC or polymicrobial UC - suggestive US - best init. scan CT or MRI - better imaging Bx - nec. for definitive bacterial Dx |
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Perinephric Abscess -
Tx |
Abx for gram neg rods
drainage (usu percutaneous) ex. - 3rd gen ceph antipseudomonal PCN ticarcillin/clavulanate often with aminoglycoside |
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Brain Abscess -
What is it |
• Bacteria spread from contiguous infections -
dental infections otitis media mastoiditis sinusitis • spread hematogenously - endocarditis pneumonia • Toxoplasmosis can reactivate if CD4 <100 MC have Strep then Bacteroides, Enterobacteriae, Staph, polymicrobial |
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Brain Abscess -
Hx/PE |
MC Sx - headache
fever focal neuro seizures |
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Brain Abscess -
Dx |
CT with contrast - init test
MRI - more accurate bacteria - Bx for gram stain and Cx |
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Brain Abscess -
Tx |
HIV -
90% Toxo or lymphoma empiric Tx to establish Dx if respond to sulfadiazine and pyrimethamine, continue Tx Other Tx - based on etiology |
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Bronchitis -
What is it |
Infection limited to bronchial tree
Caused by - S. pneumonia H. influenza Moraxella viruses MC causative factor - cigarettes acute and chronic form chronic can => COPD |
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Bronchitis -
Hx/PE |
Cough
sputum discolored sputum = bacteria may have low-grade fever most are afebrile |
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Bronchitis -
Dx |
Clinical
CXR - 1st test normal CXR confirms! |
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Bronchitis -
Tx |
Mild -
no Tx needed usually from virus resolves spontaneously severe - amoxicillin, doxycycline or TMP-SMZ repeated infection or not responding - amoxicillin/clavulanate, clarithromycin, azithromycin, oral 2nd or 3rd gen cephalo or new fluoroquinolones |
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Lung Abscess -
What is it |
Necrosis of pulmonary parenchyma
caused by bacterial infection 90% - anaerobes involved Staph E. coli Klebsiella periodontal disease predisposition to aspiration noninfectious causes - pulmonary infarction cancer vasculitis (Wegener's) |
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Lung Abscess -
Hx/PE |
Fever
cough chest pain foul-smelling sputum chronic course |
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Lung Abscess -
Dx |
CXR
CT Bx - for specific bact. Dx sputum for gram stain & Cx - will NOT show causative org. common sites of aspiration - lower lobes - if upright post. segment of rt. upr lobe - if supine |
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Lung Abscess -
Tx |
Clindamycin - empiric
PCN - alternate empiric |
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Impetigo -
What is it |
Skin infection
mainly kids S. pyogenes S. aureus (bullous) untreated => lymphangitis a. glomerulonephritis cellulitis furunculosis |
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Impetigo -
Hx/PE |
Superficial
pustular oozing, crusting, draining of lesions • common on - arms, legs, face • may follow trauma to skin • maculopapular => vesicles |
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Impetigo -
Tx |
Oral 1st gen ceph or
ox-, clox-, or dicloxacillin mild - topical mupirocin or bacitracin PCN-allergy - macrolide |
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Erysipelas -
What is it |
Superficial cellulitis
S. pyogenes |
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Erysipelas -
Hx/PE |
B/L
shiny, red, edematous face, arms, legs |
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Erysipelas -
Tx |
If can't tell from cellulitis-
1st gen cephalosporin oxa-, cloxa, dicloxacillin if sure Strep - PCN |
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Tinea Versicolor -
What is it |
Skin infection
Malassezia furfur (Pityrosporum orbiculare) |
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Tinea Versicolor -
Hx/PE |
Tan, brown, white lesions
coalesce chest, neck, abdomen, face lesions do not tan |
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Tinea Versicolor -
Tx |
Topical selenium sulfide,
ketoconazole, oral itraconazole |
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Scabies -
What is it |
Parasitic skin infection
Sarcoptes scabiei (itch mite) transmitted skin-to-skin contact |
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Scabies -
Hx/PE |
Digs into skin at skin folds
burrows pruritis flexor surfaces of - wrists finger webs axillary folds areola (women) genitals (men) |
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Scabies -
Dx |
See in scrapings (mineral oil)
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Scabies -
Tx |
Permethrin
lindane (Kwell) |
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Pediculosis -
What is it |
Skin infestation by lice
• Head - pediculus humanus capitis • Body - pediculus humanus corporis |
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Pediculosis -
Hx/PE |
Itching
excoriation secondary bacterial infections |
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Pediculosis -
Dx |
Direct exam of hair-bearing surfaces
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Pediculosis -
Tx |
Permethrin
lindane (Kwell) |
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Molluscum Contagiosum -
What is it |
Skin-colored, waxy,
umbilicated papule poxvirus |
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Molluscum Contagiosum -
Hx/PE |
Small papules
central umbilication anywhere on skin asymptomatic adults - usually by venereal contact genitals, pubic area |
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Molluscum Contagiosum -
Dx |
Appearance
giemsa stain - large cells with inclusion bodies |
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Molluscum Contagiosum -
Tx |
Freezing
curettage electrocautery cantharidin |
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Gas Gangrene
(Clostridial Myonecrosis) - What is it |
Wounds contaminated by
Clostridium perfringens not common inc. in wartime trauma (50%) shrapnel MVA postop nontraumatic uterine gangrene - was complication of improper abortion |
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Gas Gangrene
(Clostridial Myonecrosis) - Hx/PE |
<1-4 days of incubation -
pain, edema => hypotension tachycardia fever crepitation renal failure |
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Gas Gangrene
(Clostridial Myonecrosis) - Dx |
Gram stain -
pos. rods, no WBC Cx - not diagnostic gas bubbles on XR - not diag. diagnostic - direct visualization pale, dead muscle brown, sweet-smelling discharge |
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Gas Gangrene
(Clostridial Myonecrosis) - Tx |
High-dose PCN
PCN-allergy - clindamycin surgical debridement or amputation hyperbaric O2 - controversial |
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Septic Arthritis -
What is it |
Infection due to any agent
MC - bacterial rickettsia, virus, spirochete may also cause gonococcal and nongonococcal • nongonococcal - any previous damage to joint OA, RA previous surgery prosthesis placement IVDU gout sickle cell gram pos - S. aureus (60%) Strep (15%) gram neg (15%) polymicrobial |
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Septic Arthritis -
Hx/PE |
• Gonococcal -
polyarticular 50% tenosynovitis migratory polyarthralgia petechiae & purpura • nongonococcal - monoarticular swollen, tender erythematous dec. ROM usually knee |
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Septic Arthritis -
Dx |
• gonococcal -
hard to Cx Cx sites other than knee - greater yield • nongonococcal - synovial fluid aspiration: Cx gram stain cell count - high mainly PMN low glucose |
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Septic Arthritis -
Tx |
• gonococcal -
ceftriaxone • nongonoccocal - good empiric - staph/strep & gram-neg. drug nafcillin or oxacillin & aminoglycoside or 3rd gen ceph |
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Myocarditis -
What is it |
Associated with every group of
infectious agent MC - Coxsackie B also noninfectious - radiation drugs collagen vascular dis. hyperthyroidism |
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Myocarditis -
Hx/PE |
Any presentation possible
MC - dyspnea & fatigue can be asymp, subclinical, or rapid progression to death PE - normal or S3 and murmurs |
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Myocarditis -
Dx |
Any EKG abnormality
MC - ST-T changes any type of heart block possible cardiac enzymes may be inc. Ab titers may be inc. viruses may be isolated - stool saliva NPA endomyocardial Bx - best diag. test |
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Myocarditis -
Tx |
Viral -
supportive most spontan resolve no steroids (damaging) other Tx depends on agent |
