Step 2 Infectious Diseases

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First and most important step in managing septic shock:

Back 1

IV NS

Front 2

PMN count for dx of spontaneous bacterial peritonitis

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>250

Front 3

Follicular occlusion tetrad:

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suppurative hiradenitis, pilonidal dz, dissecting folliculitis of the scalp, acne conglobata
multiple painful nodules and pusltes of axillae & groin --> sinus formation 7 fibrosis

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tick bite: thrombocytopenia, leukopenia, elevated LFTs

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ehrlichiosis
spotless RMSF
tx: Doxy
Gram Negative Tickborne

Front 5

Pt with Anti-HBsAg is stuck with HepB Tx:

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Reassure; HBV and HBIG only for those with unknown immunity

Front 6

most common cause of otitis externa in diabetics

+ Tx

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psuedomonas is the most common cause of otitis externa even in diabetics
tx: cipro

Front 7

Undiagonsed plueral effusions
workup

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always tapped unless there is clear evidence of heart failure.

Front 8

Looks like streptococci but is branching instead of just straight

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--> Nocardia --> Bactrim
Risk by deficient Cell Mediated Immunity
"weakly acid fast branching filamentous rods"

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"weakly acid fast branching filamentous rods"
in sputum

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Looks like streptococci but is branching instead of just straight
--> Nocardia --> Bactrim
Risk by deficient Cell Mediated Immunity
"weakly acid fast branching filamentous rods"

Front 10

skin infection: eryspelias vs impetigo

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erysipelas = strep, sharp raised, advancing
impetigo = strep or staph

Front 11

HepA vaccine in HIV?

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yes if:
-have hepB or C
-IV drug use, sex with men or preexisting liver dz
---> so not everybody
BCG is live may casue dissmeinated TB in HIV pt

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vaccines in HIV pts

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HIV pts w/ CD4+>200 get Pneumococcal vaccine
they do not all get meningococcal vaccine unless splenectomy or high risk travel
HIV pts s immunity & >200CD4+ get MMR even though live -exception is because Measles is so deadly to HIV pts

HepA vaccine in HIV:
yes if:
-have hepB or C
-IV drug use, sex with men or preexisting liver dz
---> so not everybody
BCG is live may casue dissmeinated TB in HIV pt

Front 13

Chronic Granulomatous Dz: subject to which infxs?

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Catalase positives:
staph aureaus, serratia mascerens, burkholderia cepacia, kleb & aspergillus

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Numberous umbilicated vesicles over area of healing atopic dermatitis

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Eczema herpeticum: herpes superimposed on atopic dermatitis
life threatening in infnats

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All newly dx'd HIV pts receive:

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2x HIV [RNA] levels
CD4 count
VDRL, PPD tests
anti-toxoplasma antibody titers
HepA & B serology, vaccines prn
Mini MSE
pneumococcal vaccine unless CD4<400

additionally (but not at diagnosis) before starting retroviral tx:
1. CBC, Chem, LFTs, Lipids, CD4 count & HIV load titer

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EBV DNA + CSF in HIV pt -->

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1* CNS lymphoma
weakly ring-enhancing mass; solitary & periventricular.

Front 17

HIV & Toxoplasmosis Tx

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Bactrim used for toxoplasmosis prophyulxis in HIV, sulfadiazine + pyrimethamine used for treatment.

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Esophagitis in HIV pt
MCC, Course of Action

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MCC: Candida.
First Step: 2 weeks of oral fluconazole
Persistent: Scope & Bx
large shallow superficial ulcerations --> CMV --> Ganciclovir
multple small well circumscribed deep ulcers "volcano like" --> HSV --> Acyclovir

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Tx: HepC vs HepB

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HepC: Inferferon + Ribavirin
HepB: Interferon + Lamivudine

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Adult pneumococcal vaccine

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given to all adults >65
given once to all adults <65 with chronic immunocomprimzing dzs

Front 21

Pneumonia in immunocompromised pt
CXR shows halos

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Aspergillosis

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Pneumonia with GI Sx

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Legionella, also hyponatremia

Legionella pneumonia features: GI sx, hyponatremia, elevated LFTs
Dx: Urine antigen, Tx: Quinolone or Macrolide

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Pneumonia with Hyponatremia

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Legionella, also GI Sx
Legionella pneumonia features: GI sx, hyponatremia, elevated LFTs
Dx: Urine antigen, Tx: Quinolone or Macrolide

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MCC: subacute endocarditis in non-drug users

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mitral valve prolabse/mitral regurge

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Histoplasmosis vs Blatomycosis

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Blastomycosis: 1* pulm infx is asx/flu like; cutaneous lesions (ulcerative or warty, violacious hue); source: soil, rotting wood; not an immunocompromised pt
Histoplasmosis: manifests as acute pneumonia, palatal ulcers, but no cutaneous lesions; occurs in immunocompromised pt; pancytopenic;

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Fist Bite Antibiotic Prophylaxisis

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Augmentin

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Febrile neutropenia:

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colon flora taking over, must cover pseudomonas & gram postiives
Monotherapies: ceftazidine, cefepime (4th gen, full spectrum), imipenem or meropenem
combo = aminoglycoside + anti-pseudobetalactam

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2* syphillis

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palms & soles & mucosa

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Tx: chronic HepB

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lamivudine & interferon are only two drugs approved
these drugs are unlikely to be useful in pts with normal ALT
ALT 2x ULN will respond well
lamivudine is oral & has less side effects

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Asymptomatic Isolated Thrombocytopenia

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Often an early presentation of HIV

Front 31

anti-smooth muscle and anti-LKM antiboides

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are associated with acute & chornic hepatitis; higher titers = chronic active heptatiis.

Front 32

TB test readings: postivie if

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>15mm in normal individual, no risk factors
>10mm in people with risk factors (exosure, youth, other dzs)
>5 mm in immunocompromised

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Pt on INH with elevated LFTs

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20% of pts on INH will have sublcinical hepatic injury, transaminases willl stay <100, excellent prognosis, self limited;

Front 34

suspected HSV encephalitis
course of action

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Do not delay acyclovir for suspected HSV encephalitis; diagnosis is PCR not cx!

Front 35

Cat bite infection

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DOC: 5 days of Augmentin vs Pasturella multocida (anaerobe)

Front 36

anaerobic lung infection doc

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clindamycin

Front 37

where do aspiration anaerobes go

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recumbant: posterior segment of upper lobe
standing: superior & basilar segments of lowe lobe

Front 38

FU: pt has chronic HepB

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evalute chornic HepB with liver Bx

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lytic bone lesions, ulcerated skin lesions + upper lobe lesions

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Balstomycosis:

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infx from salad

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are aureus not bacillus, because they think of salad as containing mayonase for some reason

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what constitutes an acceptible specimine for sputum culture of pneumonia

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>25 PMN & <10 epithelial cells per low powered field
rarely ordered for CAP

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MCC: COPD exacerbations

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S pneumo, H flu, M catarrhalis

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Post-exposure prophylaxis vs Varicella:

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Vaccine within 5 days to healthy individuals
VZIG within 4 days to pregnant, immunocompromised indiividuals --monoitor as the vaccine could just delay onset
healthy unvaccinated individual >5d from expose --> going to get chickenpox
acyclovir for pts >12 yo or immunocompr
nothing for healthy pts <12 yo

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Tx: pertussus

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Bordetella pertussis is treated with erythromycin - given at any stage of dz
hospitalize infants <3 mo or <6 mo with seere paroxysms

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HIV pt with bloody diarrhea & normal stool sample

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MCC: CMV
bx confirms with erosions &
eosinophilic nuclear inclusions + basophilic intracytoplasmic inclusions ("Owls eye")

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Unvaccinated pt with HepB needlestick:

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IVIG now + Vaccine

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Vaccines for Chronic Hepatitisers:

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Tdap as with normal pop, annual influ as with normal pop
HepA: 2 doses 6 mo apart for seronegative
HepB: 3 doses at: 0, 1 & 4 mo for negative
PPSV: 1 dose q 5 years

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MCC: viral meningitis

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non-polio echoviruses (echo, coxsackie)

Front 49

Acne step up ladder

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: topical Retinoids for mild, topical antibiotics for moderate, oral antibiotics for papular/pinflmmatory acne, oral isotretinoin for nodulocystic and scarring acne.

Front 50

MCC: endocarditis c prosthetic valve:

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staph epi

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MCC: mucopurlent cervicitis

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= Chlamydira

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confirm the dx of babesiosis

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: giemsa stained thick & thin blood smear

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chronic diarrhea with weightloss, non-tender LAD

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HIV pts can present as chronic diarrhea with weightloss, non-tender LAD

Front 54

Joint WBC cellularity

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<200 = normal
200 - 2k = OA
2-5k = Inflammatory A
>50k = septic

Front 55

MCC: osteomyelitis in adults with Hx nail pnx

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Pseudomonas aeruginosa
Tx: quinolones & aggressive surgical debridement.

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Extra-Hepatic Complixns of Hep C

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Cryoglobulinemia
B cell lymphomas
Plasmacytomas
Autoimmune diseases
Lichen planus
Porphyrea cutanea tarda
ITP
Membranoproliferative glomerulonephritis

Front 57

extreme tenderness to gentle percussion on spine

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: osteomyelitis, most likely staph aureus
elevations of ESR and platelets are better indicators of infection than fever & WBC count
Diagnostic Confirmation: MRI
Tx: Long ter IV antibiotics

Front 58

confirm the Dx of Lyme Dz with:

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Serum ELISA and Western blot

Front 59

toxoplasmosis in HIV prevention

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you can prevent toxoplasmosis with Bactrim
occurs at <100
screen for toxoplasma gondii at time of dx, those who havge antibodies against get prophylactic Bactrim to prevent reactivation

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Critera of Lyme Prophylaxis:

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Must Meet all 5
1. Ixodes "Deer" Tick
2. Tick attached >36 hours or engorged
3. <72h since tick removed
4. Endemic burden >20% of ticks (i.e New England)
5. No traonads to doxycycline (lactating/pregnant/<8)

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Long term neurologic sequelae of bacteiral meningitis:

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1. hearing loss
2. neuronal loss of dentate gyrus in hippocampus --> loss of cognitive fnx
3. szs
4. mental rettardation
5 spacticity/paresis

Front 62

Recurrent mucopurulent sputum
course of action

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think bronchiectasis (non purulsent chronic bornchitis)
Dx: High Res CT

Front 63

C dif colitis suspected
course of action

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empiric metronidazole & stool Cx

Front 64

Most common organisms of orbital cellulitis:

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Staph aureus, Strep pneumo, other Strep

Front 65

Orbital Celluitis vs Preseptal celluitis:

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Pain with extraocular movements or Opthalmoplegia (inability to move eye) indicates ORBITAL;
Proptosis and Visiual Impairment may not be present, but if present are ORBITAL;
Again, red flags are: decreased visual acuity, diplopia, ophthalmoplegia and proptosis.
Preseptal: outpt oral abx
Orbital: IV abx
Complixns: blindness, subperiosteal abscess, cavernous sinus thrombosis, intracranial infection, death

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breastfeeding mastitits:
tx

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dicloxaciillin or cephalosporins vs S aurus ( which is coming from the baby's nose)
abx + analgesics + continue breast feeding

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lyme dz treatment:

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oral doxycycline
preggers & <8 yo --> oral amoxicillin or cefuroxime
azith reserved for allergies to PCNs

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osteomyelitis s nail pnx

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Staph aureus is MCC in children & adults without nail punx.
In gneral CoNStaph & Streptococci don't cause osteomyelitis

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Empyema vs CAP antibiotics

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Emypema is poorly responsive to CAP antibiotics because it progresses to mixed aerobe/anaerobe environment

Front 70

bartonella henselae & Bartonella quintana

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bacillary angiomatosis in immunocompromised. angioma like blood vessel growth both visceral and cutanous. prone to hemorrhage. dx with bx with extreme acuation. Tx: erythromycin;

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Child with pertussus:

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tx with macrolide, respiratory isolation x5d of erythromycin,
provide macrolide to household x14d
pertussus is highly contageious dispute immunizations;

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HIV pts with CD4<50 should receive

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azithromycin prophylaxis vs Mycobacterium avium complex.
&
Ganciclovir prophylaxis vs CMV
Clarithrymycin + Ethambutol = Tx for MAC not prophylaxis

Front 73

Immunosuppressed pt looks like they have TB

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include Nocardiosis in DDX: unlike Mtb is partialy acid fast gram positive, filamentous branching. AEROBIC DOC: Bactrim
include Actinomyces: filamentous gram positive bacterium. ANAEROBIC. More likely to cause cervicofacial than pneumonia. Assoc w/ sulfur granules. DOC: Pen G
drains serous fluid
"gram positive branching" = actinomyces

Front 74

Bone Marrow Transplant Receipient with lung & intestinal complaints 2 months out;

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CMV

Front 75

MCC: orbital cellulitis

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extension from bacterial sinusitis

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Tx: S aureus cellulitis

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mild: oral dicloxacillin
moderate-severe: IV nafcillin

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HIV Rx Toxicities

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indinavir: crystal nephropathy
didanosine: pancreatitis
any NRTI's: lactic acidosis
NNRTI's: JSJ
Nevirapine- liver failure

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antibiotics of infective endocarditis

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oral antibiotics are not used as monotherapy for pts with endocarditis.
Strep viridans susceptible to PCN is treated with IV PenG or IV Ceftriaxone
vancomycin is most commonly used empiric (staph = most commonf)

Front 79

The most sensative test for diagnosing histoplasmosis is

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antigen in urine or serum

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Tx: Histoplasmosis in HIV pt

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Itraconazole alone for mild case
Amphotericin B for 2 weeks followed by year of itraconazole for severe case.

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complications of mononucleosis:

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2-3 weeks after onset: autoimmune hemolytic anemia & thrombocytopenia from cold agglutinin "anti-i antibodies" --> complement mediated destruction

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all post-transplatn pts should recieve

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TMP-SMX just like HIV
& ganciclovir

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when can mono pts return to sports

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when you can't palpate their spleen anymore

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HIV pt: Kaposi Sarcoma vs Bacillary Angiomatosis

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Kaposi sarcoma becomes dark
BA stays bright red

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stye vs chalazon vs hordeolum

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chalazon: chronic sterile granulomatous inflammation of meiboian glands
hordeolum: purulent infection of eyelid
stye: small hexternal hordeolum involving zeis or molls glands

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Tx: reactive arthritis

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= NSAIDs
arthritis + urethritis, conjunctivitis, mouth ulcers

Front 87

Iron overload predisposes pt to infx with iron lovers:

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Hematochromatosis most vulnerable to Listeria monocytogenes

Listeria monocytogenes, Vibrio vulnificus, and Yersinia entercolitica

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New Diabetic Admit to Hospital for Pneumonia

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--> New Diabetic Admit for anything, check for renal failure, hold metformin

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Pt bit by known dog s signs of rabides:

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Think Rabies
Give post-exposure prophylaxis if bit in head or neck
Keep Dog 10 days for observation: any signs, start prophylaxis

Front 90

Tx: Molluscum COntagiosum

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= Curetage or Liquid N2
self limited but treat to prevent spread

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diagnostic features of BACTERIAL rhinosinusitis:

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>10d or >5d after initially improving viral URI, >39C
Viral URI's are the most common predisposing factor for Acute Bacterial Rhinosinusitis.
Treat with Oral Augmentin/Amox.

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MCC: septic arthritis

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Staph aurus & Streps - including sp joint replacement
IV Vanc

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Empiric Tx: Cystic Fibrosis Pt with Pneumonia

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antipseudomonal PCN + an aminoglycoside:
Piperacillin + Tobramycin
IV Ceftazidime + Gent

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Non-toxic child with unilateral cervical lypmhadenitits:

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MCC: Staph aureus

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MAC prophylaxis

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HIV with <50 get azithromycin or clarithromycin vs as prophylaxis vs MAC; rifabutin if allergic to macorlides.

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what organisms cause brain abscesses via contiguous spread for the sinuses

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anaerobes esp aeorbic & anaerobic streptococci & bacteroides

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Periodicity of malarial fevers:

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malariae: q72h
vivax/ovale q48
falicparum: non-perioricity

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Treating the flu:

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acetaminophen & bed rest
amantadin/rimantadine: given for type A (only work on type A)
zanamivir/oseltamivir: given for type B (work on either)
--> these are only effective if given within the first 24h of presentation of sx --> really not worth it.

Front 99

Hyperthyroid pt being treated with antithyroid drugs has a sore throat

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both PTU and MMI can cause granulocytosis
stop the drug and measure the WBC's
if <1k, do not continue drug
if >1.5 drug is okay
NOT useful to monitor, just tell pts to stop drug & come in if sore thraot & fever

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MCC: bacterial pneumonia 2/2 influenza:

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S aureus

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Listeria vs Legionella

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Listeria is a gram positive rod, legionella is a gram negative rod

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Trichomonas: oral vs vaginal metronidazole

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oral- higher cure rate

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epiglottitis: MCCs:

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H flu & S pyo

Front 104

sporadic yersiniosis:

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undercooked pork

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daycare hemorrhagic diarrhea

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shigella =

Front 106

Tx: HIV pt with cyptococcus meningitis:

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Amphotericin + Flucytosine; once stabalized --> oral fluconazole for maintenance

Front 107

Timeline of LP/CT vs Abx:

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Children: Pnx then Abx
Adults: Abx then Pnx
--> fontenelles mean less chance of herniation in children
dexamethasone will prevent hearing loss if administered <1h of abx

Front 108

Confirm the Dx: Amebic Liver Abscess

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NB: Entamoeba Histolytica
Single abscess, right lobe
Confirm with Stool for Trophozoites, Serology & Imaging
Tx: metronidazole
If serology is negative, alternative tests (aspiration)

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Hydatid Cyst

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Caused by Echinococcus granulosus
Aqd via intimate contact with Dogs
"Egg shell" calcifications in liver.
Do not aspirate --> anyphylactic shock from spillage
Tx: Albendazole + Surgery

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most vestibulotoxic antibiotic

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Gentamycin is the most vestibulotoxic of the amicoglycosides
(a class known for nephro/vestibulo toxicity)
toxicity may be transient or permenant

Front 111

Productive Cough, Hemopytsis, intermittent fevers

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-->TB suspect

Front 112

Clinical Presentation: 1* HIV vs CMV

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CMV: Tonsillar Exudate + Rash IF Abx
HIV: Diarrhea + Rash without Abx

Front 113

"purified protein derivative" testing

Back 113

is a sneaky way of saying TB test

Front 114

SIRS:

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2/4 of the following
- T >38.5 or <35
- P >90
- R >20
WBC >12k or <4k or >10% bands

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Most Common Cause of Adult Viral Encephalitis:

Back 115

HSV-1
Confirm with PCR
Treat with Acyclovir

Front 116

Slow ascending paralysis over severla days

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: tick borne paralysis.

Front 117

Tx: local impetigo

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= topical mupirocin (binds tRNA synthase in Gram +'s) or oral erythromycin

Front 118

HIV pt has >5mm induration on ppd

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if aSx then only need prophlyaxis: INH & B6 for 9 mo
don't need to treat with full regimen if aSx

Front 119

chronic/subacute couch followup URI

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--> 3 week trial of oral antihistamine

Front 120

periorbital edema, myositis, eosinophilia

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= trichinellosis
starts as stomach pain, on eweek later systemic hypersensitivity tolarval migration "splinter hemorrhages, periorbital edema, chemosis", 3rd week starts myositis.

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rash + slow blinking

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most common neurologic involvement of lyme is CN7

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Tx: HIV + PCP

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Bactrim/Bactrim + Steroids in severe PCP
indications for Steroids: PaO2 <70 or A-a gradient >35 mmHg
--> steroids significantly reduce mortality

Front 123

Which malaria regions get which prophylaxis?

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Plasmodium falciparum is in Subsaharan Africa & India = chloroquin resistant
--> mefloquin chemoprophylaxis started one week before travle & continued 4 weeks after

Plasmodium Vivax & Plasmodium ovale = primaquin

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pt has rheumatic fever
course of action

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Almost 100% of MS is 2/2 Rheumatic fever from GABHS
These pts are at high risk for recurrence & progression
--> All pts should recived continuous antibiotic prophylaxis to prevent recurrence
Rheumatic fever s carditis --> until age 21 or 5 years (whichever is longer)
Rheumatic fever c carditis s valvular dz --> until age 21 or 10 yrs (longer)
Rheumatic fever c carditis --> valvular dz --> until age 40 or 10 years (longer)

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erysipelas vs imepetigo

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erysipelas = strep, sharp raised, advancing
impetigo = strep or staph

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photosensitizing antibiotics

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tetracyclines are photosensitizing, macrolides are not

Front 127

Best Testing for acute Heptatis B

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HBsAg + anti-HBc
HBsAg is present early in the infection then dissapears for a "window period" before Anti-HBs appears & confirms immunity
anti-HBc appears shortly after appearnce of HBsAg and is present during the window period
NB: persistence of HBeAg indicates chronic infx but is not best means of screening for HB infx

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Echinococcus:

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granulosus = sheep = cystic
multilocalaris =

Front 129

Kleb pneumo hot words:

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alcohol, currant jelly, "mucoid colonies", upper lobes, encapsulated, Fridlander's pneumonia
early abscess formation & fulminant course

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C dif colitis doesn't start for

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5-10d after Clindamycin is initiated

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asymmetric polyarthritis

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--> gonorrhea

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Reactive arthritis

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: arthritis, conjunctivitis + urethritis = chalmydia

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post-viral URI with hemoptsysis & abscessant nodularity

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= S aureaus

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Tb antibiotic therapy --> aquired sideroblastic anemia

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--> Pyridixone deficiency --> defective heme synth -->

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HIV diarrhea:

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many organisms, sample & attempt to ID [Salmonella, capmylobacter, Cdif, Giardia, Crypto, MAC]
Most common @CD4 <180 = Cryptosporidium parvum, will have oocysts.