Usmle World Infectious Disease

Front 1

What is the most common cause of endocarditis following dental procedures?

Back 1

Viridans group streptococci (most commonly Strep mutans - other members of the group are Strep mitis, Strep sanguis, Strep salivarius). Strep mutans also causes dental caries

Front 2

What is a predisposing risk for infective endocarditis?

Back 2

Pre-existing mitral valve disease, IVDA, dental surgery causing bacteremia

Front 3

What are risk factors for Group B strep endocarditis?

Back 3

DM, carcinoma, alcoholism, hepatic failure, elective abortion, IVDA

Front 4

What is Strep bovis bacteremia assoc wtih?

Back 4

Colon cancer --> if organism isolated from blood cultures, need colonoscopy

Front 5

What does Staph epidermidis cause?

Back 5

Endocarditis in prosthetic valves, endocarditis in infants secondary to umbilical venous catheter infection in NICU

Front 6

Where are enterococci normal inhabitants and when does enterococcal endocadritis usually occur?

Back 6

Normally in GI tract and occasionally anterior urethra. Enterococcal endocarditis generally affects older men after GU manipulation or younger women after obstetric procedures

Front 7

Whnen should suspect babesiosis?

Back 7

Endemic area (northeast USA) who presents with tick bite, esp if there is evidence of hemolysis (ex:jaundice) and pt is splenectomized. Caused by parasite Babesia and transmitted by Ixodes tick. Following tick bite, parasite enters pts RBC and causes hemolysis

Front 8

What are the clinical manifestations of babesiosis?

Back 8

Vary from asymptomatic infection to hemoltyic anemia assoc with jaundice, Hburia, renal failure, and death. Rash is NOT a feature (unlike other tick-borne illnesses), except in severe infection where thrombocytopenia may cause a secondary petechial or purpuric rash

Front 9

Which tick-borne disease doens't cause a rash?

Back 9

Babesiosis

Front 10

When does clinically significant disease from Babesiosis occur?

Back 10

>40yo, pts without a spleen, immunocompromised

Front 11

How is the diagnosis of Babesiosis made?

Back 11

Giemsa-stained thick and thin blood smear -> intravascular hemolysis, anemia, thrombocytopenia, mild leukopenia, atypical lymphocytes. inc ESR, abnL LFTs, inc serum complement levels

Front 12

What are the 2 most common drug regimens for babesiosis?

Back 12

quinine-clindamycin and atoaquone-azithromycin

Front 13

What causes malaria and how is it transmitted?

Back 13

Plasmodium species. Transmitted by mosquitoes

Front 14

What are the s/s of Ehrlichosis and what is its other name?

Back 14

Spotless Rocky Mountain spotted fever. Fever, malaise, HA, N/V. Labs: leukopenia, thrombocytopenia

Front 15

What is Q fever, what is it caused by, and what are s/s?

Back 15

Zoonosis caused by Coxiella burnetii. Main source of human infection: infected cattle, goat, sheep. Inc people: meat processing workers, vets. S/s: flu-like syndrome, hepatitis, PNA

Front 16

What are the 3 stages of lyme disease?

Back 16

Early localized, early disseminated, late Lyme disease. Erythema chronicum migrans is a charactersitic feature of early disease

Front 17

What can use for PCP prophylaxis in transplant pts?

Back 17

Oral TMP-SMX (also prevents toxoplasmosis, nocardiosis, UTIs, PNA infections)

Front 18

What abx should all post-transplant pts get?

Back 18

TMP-SMX to prevent PCP (should also be vaccinated against influenza, pneumococcus, and hep B)

Front 19

What abx are used to prevent CMV infections?

Back 19

Ganciclovir or valganciclovir

Front 20

What is Azithromycin used for prophylaxis for in pts with HIV and when?

Back 20

MAC prophyaxis in HIV pts when CD4 < 50

Front 21

What is bloody diarrhea with abd tenderness and absence of fever suggestive of?

Back 21

EHEC (Shigella, Salmonella, and Campylobacter can cause bloody diarrhea but often result in fever and lack of abd pain)

Front 22

How is EHEC different from other strains of bloody diarrhea?

Back 22

Produces Shiga toxin that causes the bloody diarrhe.a MC serotype of EHEC is O157:H7

Front 23

What causes most EHEC?

Back 23

O157:H7. Most caused by undercooked ground beef, although not uncommon for pts to not remember a particular exposure

Front 24

What are complications of EHEC?

Back 24

HUS or TTP

Front 25

How diagnose EHEC?

Back 25

Stool culture

Front 26

When to suspect C. diff?

Back 26

Recent hospitalization or antibiotic use

Front 27

What are protozoal causes of diarrhea and when do you suspect

Back 27

Giardia, Cryptosporidium, Entamoeba histolytica. More rare causes. Suspect with recetn travel or immunocompromise

Front 28

When suspect Virbrio infection?

Back 28

People living in Gulf coast or with recent travel history. Watery, non-bloody diarrhea

Front 29

What is required for dx of gastroenteritis?

Back 29

Vomiting and diarrhea

Front 30

Does Yersinia cause fever?

Back 30

Yes

Front 31

What is Nocardia asteroides, who is susceptible, what are s/s and how do you treat?

Back 31

Gram+, partially acid-fast, filametous aerobe found in soil. Don't confuse with TB or Actinomyces. Suspectible ptople are immunocompromised pts. S/S: wt loss, fever, night sweats; pulmonary invovlement: productive cough with purulent sputum, CXR shows alveolar infiltrates and nodules often with cavitation. May have chest wall invasion.Treatment: TMP-SMX.

Front 32

Where does Norcardia asteroides disseminate to?

Back 32

Can involve any organ but most likely subcutaneous or brain abscesses

Front 33

What is Aztreonam used for?

Back 33

(monobactam abx) - treats Gram neg bacterial infections including Pseudomonas. Not effective against gram +

Front 34

What is the treatment of choice for Actinomyces?

Back 34

Penicillin G

Front 35

What distinguishes Atinomyces from Norcardia?

Back 35

Both are filamentous gram+ bacteria, but actinomycs is anaerobic and more likely to cause cervicofacial disease and sinus tracts. Also, can see sulfur granules with actinomyces

Front 36

What distinguishes Norcardia from TB?

Back 36

TB is acid-fast rods (not branching) and TB doens't gram stain (Norcardia is gram+, partially acid-fast rods)

Front 37

What is the most effective measure to reduce risk of UTI in pts with neurogenic bladder?

Back 37

Intermittent catheterization (as opposed to indwelling catheters). THis is bc bacteria can form a biofilm along the catheter wall that can reach the bladder within 24hrs of insertion. In general, the longer the catheterization, the greater the risk of bacteriuria

Front 38

What abx should start in febrile neutropenic patients? WHat is the definition of neutropenia?

Back 38

Neutropenia: ANC <1500. Suspectibility to infection when ANC <1000, inability to control endogenous flora and high risk of death when ANC <500. Fever with neutropenia: single reading >100.9 or sustained >100.4 over 1 hr. Bacterial causes most common. it is considered an emergency and need empiric abx that are broad-spectrum and cover Pseudomonas. Mono or combo therapy ok: Monotherapy with either Ceftazidime (3rd gen) or Cefepime (4th gen), imipenem, or meropenem or combo with aminoglycoside + anti-pseudomonal beta-lactam

Front 39

What is Tobramycin

Back 39

Aminoglycoside

Front 40

When is vancomycin added to empiric therapy for neutropenic fever?

Back 40

When pt hypotensive, has severe mucositis, has evidence of skin or line infection, has history of colonization with resistent strains of staph aureus or pneumococcus, or has recent prophylaxis with fluoroquinolones

Front 41

What generation is cefazolin?

Back 41

1st gen

Front 42

When should add antifungals (ampho B) to neutropenic fever regimen?

Back 42

When fever persists despite empiric antibiotic therapy

Front 43

What type of gastroenteritis does staph aureus cause? What is the time frame? What causes it? What are symptoms?

Back 43

Toxin-induced gastroenteritis - due to preformed toxin -> emesis within 6 hrs. Causes: mayonnaise-contining products, poultry, eggs, meat and meat products, cream-filled pastries, milk and dairy products. Symptoms: vomiting!!

Front 44

How can differentiate B. cereus from Staph aureus food poisoning?

Back 44

Both are preformed toxins with similar picture of rapid-onset N/V, abd cramping, retching. B. cerus comes from starchy foods (classically, reheated rice) whereas staph aureus is poultry, milk products, mayo, cream-filled paistries, eggs, meat and meat products

Front 45

What is C. perfringens and what does it cause?

Back 45

Spore-forming, spores germinate in foods such as meats, poultry, gravy. S/S: watery diarreha (due to production of toxin in the gut)

Front 46

What does ETEC cause:

Back 46

Traveler's diarrhea

Front 47

What are the early localized (days-1mo) manifestations of Lyme disease?

Back 47

Erythema migrans (80% of pts), fatigue, malaise, lethargy, mild HA, neck stiffness, myalgias and arthralgias

Front 48

What are the early disseminated (weeks-mo after bite) manifestations of Lyme disease?

Back 48

Carditis (5% of untreated; AV block, CM), Neurologic (15% untreated; unilateral or bilatl CN defects - usually VII, meningitis, encephalitis), Muscular (60% untreated; migratory arthralgias), Conjunctivitis (10% untreated), skin (multiple erythema migrans), regional or generalized LAD

Front 49

WHat are the late or chronic (mo-yrs after tick bite) manifestations of lyme disease?

Back 49

Muscular (60% untreated; arthritis), Neurologic (encehpalomyelitis, peripheral neuropathy)

Front 50

What symptoms is pathognomonic for lyme disease?

Back 50

Erythema migrans

Front 51

What is Lyme disease do to?

Back 51

Infection by Borrelia burgdorferi transmitted by bite of Ixodes tick

Front 52

When is IV ceftriaxone used for Lyme disease?

Back 52

Reserved for early disseminated and late diseases

Front 53

What do you use to treat early localized Lyme disease? What about if child or pregnant?

Back 53

Oral doxycycline (Amoxicillin if <8yo and pregnant women)

Front 54

What are the SE of doxycycline in children and unborn fetuses?

Back 54

Permanent tooth discoloration and skeletal problems

Front 55

Is serology for lyme disease recommended?

Back 55

Not in early localized disease bc too insensitive and many pts seroneg. After onset of erythema migrans, IgM antibodies to B. burgdorferi usually appear in 1-2 weeks and IgG in 2-6 weeks. Should get serology in pts with signs of early disseminated or late Lyme disease

Front 56

What is the classic presentation of cervicofacial actinomycosis? How do you treat?

Back 56

Slowly progressive, non-tender, indurated mass which evolves into multiple abscesses, fistulae, and draining sinus tracts with sulfur granules which appear yellow. Tx: high-dose penicillin for 6-12 weeks.

Front 57

What is an Actinomyces israelii infection?

Back 57

Anaerobic, Gram+ branching bacteria with infection in cervicofacial, thoracic, or abdominal region.

Front 58

What is the TB draining cervicofacial lesion called?

Back 58

Scrofula

Front 59

When is Amphotericin used?

Back 59

Systemic fungal infections in severely ill. Several serious SE

Front 60

When is hyperbaric oxygen therapy used/

Back 60

To treat the "bends" from deep sea diving, CO poisoning, and slow-healing ulcers

Front 61

What is the treatment of choice for primary (early) syphilis? What if allergic?

Back 61

A single IM injection of benzathine penicillin. If allergic to penicillin, get single dose of oral azithromycin or 2 weeks of doxy

Front 62

What is treatment of choice for neurosyphliis?

Back 62

IV aqueous craystaline penicillin or IM procaine penicillin

Front 63

What organism is responsible for most nosocoimal PNA in intubated pts? How treat?

Back 63

Pseudomonas. Treat with Cefepime (4th generation) or piperacillin-tazobactam. Can also use aztreonam, cipro, imipenem/cilastatin, tobramycin, gentamicin, amikacin

Front 64

What should think of in Gram neg bacilli in sputum of intubated ICU pt with fever and leukocytosis?

Back 64

Pseudomonas

Front 65

What are common sources of nosocomial Pseudomonas infections?

Back 65

Contaminated water faucets, respiratory therapy equipment, therapy pools, plant products (flowers, vegetables)

Front 66

What is clindaymcin effective against?

Back 66

Anaerobic and gram+ infections

Front 67

If an abx is being used and pt is deteriorating, should should continue that abx when start a new one?

Back 67

No - it isn't working, no reason to continue it

Front 68

What is used to prevent toxoplasmosis in HIV pts? What about PCP?

Back 68

Both can be prevented with TMP-SMX

Front 69

What are s/s of reactivation of toxoplasmosis in brain in immunocompromised pt?

Back 69

Fever, HA, confusion, ataxia, ring-enhancing lesion on brain MRI; can have seizure/focal neuro deficits due to mass effect of intracerebral lesion.

Front 70

When does toxoplasmosis risk inc in HIV pts?

Back 70

CD4 <100

Front 71

When is Isoniazid indicated for TB prophylaxis in HIV pts?

Back 71

Positive tuberculin skin test (>5mm) and those who have had contact with individual with active TB

Front 72

What finding of TB can look like toxo in brain in terms of symptoms?

Back 72

Tuberculoma but far less common than toxo

Front 73

When should give Azithro to HIV pts and what is it preventing?

Back 73

MAC prophyaxis in HIV pts when CD4 < 50

Front 74

What does Fluconazole protect against in HIV pts and when do use it?

Back 74

Prophylaxis against Cryptococcus neoformans and Coccidiodes immitis in HIV pts who have had these diseases in the past. Also used in pts with frequent Candida infections

Front 75

Do you need to prophylax against CMV in HIV pts?

Back 75

No - although ganciclovir has been shown to prevent CMV in HIV pts with CD4 <50, prophylaxis isn't generally recommended

Front 76

What is the MCC of UTI with alkaline urine (pH>7)?

Back 76

Proteus - secretes urease (an enzyme that hydrolyzes urea to ammonia and CO2. Ammonia then combines with H+ to form ammonium, which decreases the free H+ ion concentration). Alkaline pH promotes struvite stones, which contain a mixture of bacteria and proteinaceous matrix adn luekocytes. THe stone becomes a permanent source of bacteria to perpetuate the cycle.

Front 77

How do you treat Proteus UTI with staghorn (struvite) stones?

Back 77

Very difficult - abx alone won't cure bc the bacteria grow within the stone matrix and are not eradicated until teh entire stone and its fragments are removed

Front 78

What are the urease-producing bacteria?

Back 78

Klebsiella, Morganella morganii, Pseudomonas, Providencia, Stpah, Ureaplasma urealyticum, and Proteus.

Front 79

Which catheters have an inc risk of being infected by urease-producing bacteria?

Back 79

Chronic indwelling catheters

Front 80

What is the MC UTI pathogen?

Back 80

E. coli

Front 81

What is the abx regimen of choice for CNS cryptococcal infection in AIDS pts?

Back 81

IV Amphotericin + flucystoine. (then when there is clincal improvement with induciton therapy, those are discontinued and oral fluconazole is started as mainenance therapy)

Front 82

What is cryptococcus and who does it infect and what does it cause?

Back 82

Encapsulated yeast that commonly causes meningitis in HIV pts.

Front 83

What is an important cause of subacute meningitis in HIV pts?

Back 83

TB

Front 84

What can you treat Histoplasma capsulatum meningitis with?

Back 84

Itraconazole or Amphotericin

Front 85

What is used to treat toxoplasmosis and how does it usually present in HIV pts?

Back 85

Tx with oral sulfadiazine-pyrimethamine. Usually manifests as encephalitis in HIV pts - CT with contrast will show multiple hypodense, ring-enhancing lesions

Front 86

What should any HIV+ pt with blood diarrhea and normal stool exam have and what are you looking for?

Back 86

Colonoscopy looking for CMV colitis

Front 87

How does CMV colitis present? What does colonoscopy and bx present?

Back 87

Bloody diarrhea with abd pain. Colonoscopy - multiple ulcers and mucosal erosions. Bx: cytomegalic cells with inclusion bodies (eosinophilic intranuclear and basophilic intracytoplasmic ("owls eye" effect))

Front 88

What are causes of diarrhea in HIV pts (opportunitistic, non-opportunistic, and non-infectious)?

Back 88

Non-opportunitistic: Salmonella, Campylobacter, Entamoeba, Chlamydia, Shigella, Giardia lamblia. Opportunitistic: CMV, Cryptosporidium, Isopora belli, Blastocystis, MAC, HSV, Adenovirus, HIV itself. Non-infectious: Kaposi sarcoma, Lymphoma of the GI tract (hematochezia and lower abd cramps are usually due to colonic infection with CMV, C diff, Shigella, E. histolytica, or Campylobacter)

Front 89

What is CMV and what can it cause?

Back 89

Common opportunitistic pathogen in HIV pts, can cause esophagitis, gastritis, colitis, proctitis, or small bowel disease.

Front 90

What is the typical presentation of CMV colitis?

Back 90

Chronic bloody diarrhea, abd pain, CD4 <50.

Front 91

How do you treat CMV colitis?

Back 91

Ganciclovir (or Foscarnet in cases of ganciclovir failure or intolerance)

Front 92

What would you suspect in pt with facial nerve palsy and erythema migrans following outdoor activities in Lyme-endemic area?

Back 92

Lyme disease - Borrelia burgdorferi infection

Front 93

What is the most common tick-borne illness in the USA?

Back 93

Lyme disease - Borrelia burgdorferi infection

Front 94

What kind of infection is Lyme disease?

Back 94

Spirochete (Borrelia burgdorferi from Ixodes tick)

Front 95

What stage of Lyme disease is bell's palsy?

Back 95

Early disseminated

Front 96

What is the most common neurologic complication of Lyme disease?

Back 96

Unilateral or bilateral palsy of CN VII - usually lasts <2mo

Front 97

How should treat pts with Bell's palsy?

Back 97

In addition to treating the cause, if facial palsy is severe, corena may be at risk of dryness and abrasions due ot poor eyelid closure and reduced tearing --> artifiical tears during the day and eye patching at night

Front 98

What are the s/s of bell's palsy?

Back 98

Inability to close eye, dec forehead movement, absence of nasolabial fold

Front 99

How do you treat non-pregnant, >8yo pts with Bells palsy from Lyme?

Back 99

Doxycycline

Front 100

What is the classic presentation of Guillain-Barre?

Back 100

Ascending flaccid paralysis

Front 101

What are the MCC of idiopathic CN VII palsy?

Back 101

HSV and VZV.

Front 102

What is unique about idiopathic (VZV/HSV) Bells Palsy?

Back 102

Idiopathic: reactivation of HSV or VZV usually causes peripheral mononeuropathy without an associated vesicular rash

Front 103

What is Ramsay Hunt syndrome?

Back 103

(herpes zoster oticus) - mainfestation of VZV reactivation characterized by the triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and external auricle

Front 104

What do pts with disseminated gonococcal infection present with?

Back 104

Vesiculopustular dermatitis but not neurologic symptoms.

Front 105

What is the classic rash of syphilis?

Back 105

Diffuse maculopapular eruption of palms and soles

Front 106

What should pts started on anti-TB therapy also be started on ?

Back 106

VItamin supplements, esp pyridoxine to avoid peripheral neuropathy and other neurologic complications. 10mg/day to start, 100mg/day if already have peripheral neuropathy

Front 107

What is a known SE of isoniazid that can be prevented with pyridoxine supplements?

Back 107

Peripheral neuropathy (tingling in extremities, numbness, ataxia)

Front 108

What is the Jarisch-Herxhemier reaction?

Back 108

May develop in the treatment of syphilis - when primary or secondary syphilis is treated with penicilin, the spirochetes die rapidly, thereby leading to release of Ag-Ab complexes in the blood and consequently an immunologic reaction, which seems like an acute flare-up of syphilis

Front 109

What are signs/symptoms of a drug reaction?

Back 109

Skin eruptions, fever, angioedema, urticaria

Front 110

What must you need to suspect TB meningitis?

Back 110

Meningeal signs or CN involvement

Front 111

What is the MC pathogen causing PNA in nursing home pts?

Back 111

Strep pneumo

Front 112

What is the leading cause of death in nursing homes?

Back 112

PNA

Front 113

What is the MCC of CAP in adults?

Back 113

Strep pneumo

Front 114

What are common causes of PNA in adults?

Back 114

STrep pneumo, Staph aureus, H flu, Gram neg rods

Front 115

What are pts with neurologic disorders at inc risk for in terms of PNA?

Back 115

Aspiration PNA caused by anaerobes

Front 116

What causes N/V after eating rice? How quickly do these symptoms present?

Back 116

B. cereus. 1-6 hours before symptom onset. B. cereus is a heat stable toxin in inadequately refrigerated cooked rice.

Front 117

What 2 things can cause abrupt onset nausea and severe vomiting?

Back 117

Preformed toxins (B cereus, Staph auresu), chemical irritants

Front 118

How does Clostridium perfringens present?

Back 118

Watery diarrhea due to production of toxin in the gut. Symptom onset later than preformed toxins (8-14 hrs after ingestion). Diarrhea occurs with ingestion of a large number of organisms. Spore-forming, spores germinate in foods such as meats, poultry, or gravy

Front 119

What is mucormycosis? What can it lead to and how do you treat?

Back 119

Caused by fungus Rhizopus, causes infection of sinuses, brain, or lungs in immunocompromised, KOH staining shows hyphae. Can lead to serious complications or death if left untreated. Tx: aggressive surgical debridement + early systemic amphotericin B treatment (the only effective drug against this fungus)

Front 120

What is cutaneous larva migrans? Who is at risk? How does it present?

Back 120

aka creeping eruption. Helminthic disease caused by the infective-stage larvae of Ancylostoma braziliense (the dog and cat hookworm). Infection occurs after skin contact with soil contaminated with dog or cat feces containing infective larvae. Prevalent in tropical and subtropical regsions including southeastern US. People involved in activities on sandy beaches or in sandboxes are particualry inc risk. S/S: initially, multiple pruritic erythematous papules develop at the site of larval entry, followed by severely pruritic, elevated, serpiginous reddish brown lesions on the skin, which elongate at a rate of several mm per day as the larvae migrate in teh epidermis. Most commonly seen in lower extremities but upper extremities can become involved.

Front 121

What causes cat scratch disease? How does it present?

Back 121

Bartonella henselae. Characterized by self-limiting LAD. History of exposure to cast often present

Front 122

What is Sporotrichosis and how does it present?

Back 122

Fungal infection cause dby SPorothrix schenckii (dimorphic fungus). S/S: papule at the site of inoculation, followed by ulceration and LAD. Seen in gardeners

Front 123

What do brown recluse spider bites look like?

Back 123

Papule with erythema at the site of the bite, followed by severe ulceration

Front 124

What caues scabes and how does it present? How is it transmitted?

Back 124

Parasitic infection caused by Sarcoptes scabeie. Presents as pruritic skin infection in volar wrist, interdigital web spaces, elbows, or penis. Burrows made by the parasite appear as short, wavy lines in these regions and may be accompanied by papules, vesicles, pustules, or eczemtaous plaques. Transmitted by close contact with another infected individual.

Front 125

When and how should ticks be removed?

Back 125

ASAP to dec risk of illness. Best removed with tweezers as close to teh skin as possible, pulling straight up with steady pressure

Front 126

What is the criteria for Lyme disease prophylaxis (must meet all 5). What is prophlyaxis?

Back 126

Attached tick is adult or numphal Ixodes scapularis (deer tick), tick attached for >36hrs or engorged, prophylaxis started wtihin 72hrs of tick removal, local B. burgdorferi infection rate >20% (ex: New england), no contraindicates to doxycycline (ex: <8yo, pregnant, lactating). Prophylaxis: 1 dose of doxycycline

Front 127

What is the pathogenic mechanism of osteomyelitis adjacent to a foot ulcer in DM?

Back 127

Contiguous spread of the infection

Front 128

Why are DM pts prone to developing foot ulcers?

Back 128

Arterial insufficiency and peripheral neuropathy. Bc of poor tissue perfusion, immune system has difficulty combating infection in the region surrounding the ulcer -> thus, an open ulcer is an ideal site for entry of bacteria and infection of the soft tissue can easily spread to include neighbroing bone -> osteomyelitis

Front 129

Who does hematogenous osteomyelitis occur in?

Back 129

Typically children

Front 130

What is the pathologic mechanism of post-traumatic osteomyelitis?

Back 130

Direct inoculation

Front 131

How does osteomyelitis occur after operative procedures?

Back 131

Due to nosocomial contamination

Front 132

What should HIV pts with dysphagia be treated empiricaly with? What if symptoms persist?

Back 132

1-2 weeks of oral fluconazole since candidal esophagitis is the most likely diagnosis. If symptoms persist, go to EGD

Front 133

How to distinguish esophagitis cause in HIV pts via EGD with bx?

Back 133

HSV: multiple, well circumscribed, "volcano-like" (small and deep) ulcers, cells show ballooning degeneration and eosinophilic intranuclear inclusions. CMV: Large, shallow, superficial ulcers, intranuclear and intracytoplasmic inclusions.

Front 134

What do pts with CMV esophagitis complain of?

Back 134

Focal substernal burning with odynophagia

Front 135

How do you treat CMV esophagitis? HSV esophagitis?

Back 135

IV Ganciclovir for CMV, Acyclovir for HSV

Front 136

When infective endocarditis is suspected, what is the next step?

Back 136

Empiric abx after drawing blood cultures (then can do TEE after (or TTE if suspect tricuspid endocarditis - esp in IVDA))

Front 137

What are major risk factors for infective endocarditis?

Back 137

Valvular disease, IVDA

Front 138

When have splinter hemorrhages and microscopic hematuria without migratory polyarthritis in valvular disease pt, what shoudl suspect?

Back 138

Infective endocarditis

Front 139

What is the Duke criteria used for?

Back 139

Infective endocarditis

Front 140

What are the common acute life-threatening reactions assoc with HIV therapy? (know!)

Back 140

1. Didanosine-induced pancreatitis 2. Abacavir-related hypersensitivity syndrome 3. Lactic acidosis secondary to any of NRTIs 4. Stevens-Johnson syndrome secondary to use of any of the NNRTIs 5. Nevirapine-assoc liver failure

Front 141

Which HAART therapy causes crystal-induced nephropathy?

Back 141

Indinavir (protease inhibitor) - caused by precipitation of the drug in the urine and obstruction of the urine flow. Can occur even with good hydration and complications can occur early. Therefore, monitor UA and serum Cr every 3-4mo

Front 142

**When can antiviral meds be used in influenza and how do they help?

Back 142

Must be given within 48hrs of onset of symptoms. Can reduce duration of symptoms by 2-3 days. Otherwise, tx with bed rest and simple analgesia (ex: acetaminophen)

Front 143

What are amantadine and rimantadine effective against? What are zanamivir and oseltamivir effective against? **

Back 143

Amantadine and Rimantadine - Influenza A. Neuraminidase inhibitors (zanamivir, oseltamivir) - both influenza A and B. Note: Zanamivir only approved for the treatment, but not the prevention of influenza. Use the neuraminidase inhibitors when influenza B strains are circulating in the community

Front 144

What are the symptoms of influenza?

Back 144

Abrupt onset of fever, chills, malaise, HA, coryza, non-productive cough, sore throat, muscle aches, occasionally nausea. Influenza A and B give these symptoms, C is usually minor. Self-limiting if healthy, typicla suration 1-7d

Front 145

What is the abx of choice in prophlyaxis/treatment of fite bites?

Back 145

Augmentin (amoxicillin-clavulanate) bc often polymicrobial with Gram+, Gram-, anaerobes

Front 146

What is the abx of choice in dog bites?

Back 146

Augmentin

Front 147

What is Clindamycin used for?

Back 147

Gram+, anaerobes - typically used for lung abscesses and infections of female genital tract.

Front 148

What is the drug of choice for Legionnaire disease?

Back 148

Erythromcyin

Front 149

What is Erythromycin used for?

Back 149

Legionnarie disease (DOC), treatment of CAP. No good anaerobic coverage

Front 150

What test is both sensitive and specific for diagnostic infectious mono and should be used for dx? What test should be used in suspectied mono with neg initial test?

Back 150

Heterophile Ab test (monospot) - appear within 1 week of onset of symptoms, may persist in low levels ofr up to 1 year. But may not appear until later in course of illness -> neg heterophile Ab test in first few weeks of illness doesn't rule out diagnosis of mono. If neg and suspect IM, get EBV-specific Ab test. Atypical lymphocytes on peripheral smear are seen, but aren't specific - may be present in toxo, rubella, roseola, viral hepatitis, mumps, CMV, acute HIV, some drug reactions

Front 151

What is the triad of high fever, LAD, pharyngitis highly suggestive of?

Back 151

Infectious mononucleosis

Front 152

What is the etiologic agent of mono?

Back 152

EBV (herpesvirus family).

Front 153

Who is mono most common in and how does it spread? What are s/s?

Back 153

Most common in adolescents and young adults, spread by intimate contacts. S/S: LAD involvement (typically posterior), tender HSM, mild leukocyosis with lymphocytic predominance, high fever, pharyngitis

Front 154

What is the preferred screening test for HIV infection?

Back 154

ELISA (99.9% sensitivity)

Front 155

What is the confirmatory test for HIV?

Back 155

Western blot (99.9% specificity)

Front 156

How high do viral loads need to be to be assoc with poor prognosis?

Back 156

>100,000 copies/mL

Front 157

At what CD4 count should pts be started on antiretroviral therapy?

Back 157

CD4 <200

Front 158

What do you use for antimalarial prophylaxis in Sub-Saharan Africa and India subcontinent (India, Pakistan, Bangladesh)?

Back 158

Mefloquine bc of chloroquine-resistant Plasmodium falciparum (chloroquine is DOC if in sensitive area). Need to start 1 week before travel and continue until 4 weeks after get back

Front 159

When do you use primaquine for antimalaria?

Back 159

For both prophylaxis and treatment in areas where malaria is due to P. vivax or P. ovale. These organisms cause persistent infection in the liver.

Front 160

What is Norcardia? What presentation can it have? How is at risk? Tx?

Back 160

Crooked, branching, beaded Gram+, partially acid-fast bacteria on microscpy, aerobic. Present in soil. Can present as pulmonary, CNS, or cutaneous lesiosn. Pts with cell-mediated deficiencies in immunie system (lymphoma, AIDs, transplant pts) are at inc risk for pulmonary or disseminated disease. Pulmonary occurs after inhalation of bacteria, typically manifests as subacute PNA that develops over days-weeks; empyema in 1/3; 50% have extrapulmonary dissemnaiton - brain most common site. Tx: TMP-SMX is TOC, Minocycline is best oral alternative. Can dec risk in AIDS and transplant pts with prophylaxis with TMP-SMX

Front 161

Adults and children - what are most common causes of community-acquired bacterial meningitis and what should use empirically to treat?

Back 161

Strep pneumo, H flu, Neisseria. Use Vanco + ceftriaxone (many pneumococcal strains are resistant to penicillin and cephalosporins, so need to add vanco - but note that vanco alone doesn't penetrate BBB, need with ceftriaxone)

Front 162

What do you need to add to meningitis treatment regimen in pts >55yo and what are you covering for?

Back 162

Listeria - need to add Ampicillin

Front 163

What do you use to treat immunocompromised pts with meningitis and what are you covering?

Back 163

Basic is ceftriaxone + vanco to cover the usual strep pneumo, H flu, Neisseria but add Ampicillin to cover Listeria bc of inc risk in immunocompromised, pts with malignancy (esp lymphoma), corticosteroids

Front 164

What do you use for meningitis in pts <3mo and what are you covering?

Back 164

IV cefotaxime + ampicillin - covers common CA-meningitis (strep pneumo, H flu, Neisseria) + Listeria (ampicillin). Although ceftriaxone can be used in neonates, cefotaxime is generally preferred bc ceftriaxone is assoc with biliary sludging

Front 165

What should you use in meningitis for pts after neurosurgery and why?

Back 165

IV ceftazidime (for Pseudomonas) + vanco (for staph aureus)

Front 166

How do condylomata acuminata present and how do you treat?

Back 166

(anogenital warts) Verrucous, skin colored, papilliform lesions around anogenital lesions (contrast to condyloma lata which are flat or velvety). Uusually no systemic lesions. 3 options for tx: 1. chemical or physical agents (trichloroacetic acid, 5-FU epi gel, and podophylllin). 2. Immune therapy (imiquimod, IFNalpha), 3. Surgery (cryosurgery, excisional procedures, laser tx). Choice of tx depends on number and extent of lesions - podophyllin is a topical antimitotic agent that leads to cell death - it is teratogenic and thus contraindicated in pregnancy; its other adverse effcts are local irritation and ulceration

Front 167

How do you treat condyloma lata and what are they from?

Back 167

Secondary syphillis - tx with penicillin. If allergic, give tetracycline or doxy

Front 168

What are bacillary angiomatosis? What causes it, who is at risk, and how do you treat?

Back 168

Bright red, firable, firm, exophytic nodules. Caued by Bartonella (Gram neg bacillus). HIV infected pts are at risk. TOC: oral erythromycin

Front 169

What does Kaposi sarcoma skin lesions look like?

Back 169

Papules taht become plaqures or nodules; color changes from light brown to pink to dark violet. Skin lesions occur on trunk, face, and extremities.

Front 170

What does Pneumocystis cutaneous lesions look like?

Back 170

Nodular and papular cuaneous lesions of external auditory meatus. Unlikely if pt on TMP-SMX

Front 171

What does molluscum contagiosum look like?

Back 171

Poxvirus. Centrally-umbiliated, dome-shaped papules that are non-pruritic

Front 172

Are HSV lesions painful?

Back 172

Yes

Front 173

When can pt with uncomplicated pyleonephritis be changed to oral suspecitble agent?

Back 173

After 48-72 hours; oral therapy more convenient and less expensive. Then continue for total of 2 weeks

Front 174

What is the typical presentation of Trichinosis/Trichinellosis?

Back 174

GI complaints followed by characteristic triad of periorbital edema, myositis, eosinophilia. Other clues: subungal splinter hemorrhages and conjunctival or retinal hemorrhages.

Front 175

What is Trichinosis/Trichinellosis?

Back 175

Parasitic infection cause dby the roundworm Trichinella. It is acquired by eating undercooked pork that ocntains encysted Trichinella larvae. The disease occurs in 3 phases - initially when larvae invade intestinal wall - get abdominal pain, N/V/D. Then in second week, local and systmic hypersensitivy reaction caused by larval migration causes "splinter" hemorrhages, conjunctival and retinal hemorrhages, periorbital edema, and chemosis. Then as the larvae enter the patient's skeletal muscle, get muscle pain, tenderness, swelling, weakness. High eosinophil count

Front 176

What is Ascariasis?

Back 176

Often presents as a lung phase with non-productive cough followed by asymptomatic intestinal phase. Symptoms often result from obstruction caused by the organisms themselves, such as small bowel or biliary obstruction. Will have eosinophilia

Front 177

What are s/s of botulism?

Back 177

Constipation, descending paralysis, resp failure.

Front 178

How does Guillian-Barre syndrome present?

Back 178

Usually after mild upper respiratory or GI infection. Initial symptoms include tingling of toes and fingers followed by ascending paralysis. Pts also complain of back pain. Late in course CN are affected

Front 179

What is usually assoc with angioedema?

Back 179

C1 inhibitor deficiency or ACEI

Front 180

What causes Ascariasis?

Back 180

The worm Ascaris (sp?) Lumburcoides (sp?)

Front 181

WHat is the msot common parasitic infection of the brain?

Back 181

Neurocysticoercosis

Front 182

Where do you find Neurocysticercosis (who is at risk) and what organism causes it and what is the pathogenesis? What are the s/s and what is the prognosis?

Back 182

Most prevalent in rural areas with poorer sanitary conditions and where PIGS are raised. It is a parasitic disease caused by the larval stage of the pork tapeworm Taenia solium. It is contracted when a person consumes T. solium eggs excreted by another person. Humans are the only definitive host for T. solium (they are the only ones that can be infeected). The adult tapeworm lives in the upper jejunum and excretes its eggs into the person's feces (intestinal infection). If an animal consumes these eggs, it becomes an intermediate host, with larvae encysting in its tissues. The most common intermediate host is a pig. Then, when human consumes larvae in meat that is infected (ex: infected undercooked pork), then can again develop intestinal infection with adult tapeworm. However, if a person (rather than a pig) consumes T. solium eggs excreted in human feces, cysticercosis results. After ingestion, the embryos are released in the intestine and the larvae invade the intestinal wall. After ingestion, the embryos are released in the intestine and the larvae invade the intestinal wall. They disseminate hematogenously to encyst the human brain, skeletal muscle, subcutaneous tissue, or eye (note that cysticercosis is not contracted by eating infected pork, so people who do not eat pork can still be affected. The most common manifestation of cysticerosis are neurologic. Neurocysticercosis (NCC) is characterized by multiple small (<1cm) fluid-filled cysts in the brain parenchyma. These cysticerci have a membranous wall and often demonstrate characteristic invaginated scolex on neuroimaging. Most prevalent in the rural areas of Latin America, sub-Saharan Africa, China, south and Southeast Asia and Eastern Europe, esp where pigs are raised and sanitary conditions are poor. Most common parasitic infection of the brain. Humans with cysticerci are dead-end hosts. 80% of neurocysticercal infections are asymptomatic and found accidnetally on brain autopsy

Front 183

What do CJD and Kuru look like on microscopy of brain?

Back 183

They are both prion diseases that cause spongiform encephalopathy in which intracytoplasmic vacuoles are evident diffusely throughout gray matter on microscopy

Front 184

How does lymphoma/tumors present in neuroimaging?

Back 184

Solid lesions

Front 185

What are Hydatid cysts caused by and where do you find them? Who is at risk?

Back 185

Echinococcus sp - found in liver, lungs. More common in sheep breeders

Front 186

WHere is Norcardia asteroides found and who does it commonly infect. How can it manifest and how diagnose? Tx?

Back 186

FOund in soil and water (G+, weakly acid-fast, filamentous branching rod). Infects immunocompromised (HIV, transplant). Lung is most commonly involved - can manifest as nodules, a reticulonodular pattern, diffuse pulmonary infiltrate, abscess, or cavitary formation. Dx is hard - presumptive dx can be made if partially acid-fast, filamentous branching rods are seen on clinical specimens. Tx: TMP-SMX

Front 187

Where is Coccidiodomycosis found?

Back 187

Southwestern USA

Front 188

What is the MCC of CAP?

Back 188

Pneumococcus

Front 189

What CSF findings are suggestive of bacterial meningitis?

Back 189

Inc WBC, Inc protein, Dec glucose

Front 190

What are the typical s/s of meningococcal infection?

Back 190

Skin: petechiae and purpura. Myalgias (more intense than in the flu), sudden onset fever, stiff neck, HA, nausea, hypotesnion, tachycardia. Typically otehrwise healthy pt (viral meningitis can prsent similarly but not with purpura)

Front 191

What is characteristic of syphilitic meningitis?

Back 191

Usually assoc with peripheral rash of secondary syphilis (palms, soles) with generalized LAD and usually not sudden onset

Front 192

Where does rash of RMSF start?

Back 192

ankles adn wrists and spreads centrally to palms and soles

Front 193

What are the arboviruses and what is its neurologic manifestaion and how does it present?

Back 193

Eastern equine, Western equine, St Louis, and West Nile virus. Typically causes encephalitis -> AMS, fever, focal neuro deficits without nuchal rigidity or signs of meningitis

Front 194

What causes bacillary angiomatosis, who is at risk, and what does it cause? How can dx and what should be careful for? How tx?

Back 194

Casued by Bartonella henselae and Bartonella quintana. Usually affects immunocompromised (AIDS, hematologic malignancies, chemo pts, transplant pts). Causes nonspecific constitutional symptoms (fever, wt loss, malaise, abd pain) in addition to characteristic lesions of skin and viscera - large, pedunculated exophytic papule with a collarete of scale - resembles a large pyogenic granuloma or cherry angionma. Dx: tissue bx and microscopic identification of organsms and the characteristic angioatmous histology. Use extreme caution in biopsying these lesions bc they are prone to hemorrhage. Can tx with a variety of abx which lead to involution of the diseases

Front 195

What bug/disease affecting nose and maxillary sinuses is assoc with DM? ***

Back 195

Mucormycosis most commonly caused by Rhizopus. Poorly controlled DM predisposes

Front 196

What are the s/s of mucormycosis?

Back 196

Low-grade fever, bloody nasal d/c, nasal congestion, involvement of eye with chemosis, proptosis, diploplia. Involved nasal turbinates can become necrtoic. Invasion of local tissues can lead to blindness, cavernous sinus thrombosis, coma. Typically affects nose and maxillary sinus. Can lead to death in days-weeks if not treated

Front 197

What causes malignant otitis externa commonly?

Back 197

Pseudomonas - can cause black necrotic lesions in the ear

Front 198

What does cryptococcus neoformas cause in immunocompromised pts?

Back 198

Meningitis

Front 199

What can candida caause in DM pts?

Back 199

Thrush, Vaginitis

Front 200

Who is secondary bacterial PNA common in and what are the common organisms?

Back 200

Elderly (usually viral is the primary infection). Strep pneumo, Staph aureus, H flu

Front 201

Which pathogens known to cause secondary PNA can cause necrotizing bronchopneumonia with secondary pneumatoceles (multiple nodular infiltrates that can cavitiate to cause small abscesses)

Back 201

??

Front 202

How is Legionnaires disease transmitted and what does it look like on CXR?

Back 202

Aerosol transmission from an environmental water source. CXR: multiple small pulmonary abscesses

Front 203

If a PE were to cause CXR findings, what would they look like?

Back 203

Single wedge-shaped parietal pleural-based infarct

Front 204

What does reactivation of pulmonary TB cause?

Back 204

Upper lobe fibrocaseous cavitations

Front 205

What does bronchoiectasis cause?

Back 205

Dilated bronchi, can cause blood tinged purulent sputum

Front 206

What does atypical PNA look like on CR?

Back 206

Diffuse interstital infiltrates on CXR

Front 207

When is pneumococcal vaccine recommended for HIV pts?

Back 207

All children and adults with HIV with CD4 >200

Front 208

When is Hep A vaccine recommended for HIV pts?

Back 208

When suffering from Hep B, Hep C, or both.

Front 209

Who is Hep A vaccine recommended or?

Back 209

HIV pts with Hep B or C; IVDA; men who have sex with men; pts with preexisting liver disease

Front 210

What is seen on serology to indicate either previous Hep B vaccination or exposure to the disease?

Back 210

anti-HBsAg antiboies

Front 211

When is meningococcal vaccination indicated?

Back 211

Splenectomy or functional asplenia or for pts travelling to high risk countries. The response to vaccine has been suboptimal in HIV pts and so isn't routine

Front 212

Should HIV pts get annual flu vaccine?

Back 212

yes

Front 213

Should give HIV pts BCG vaccine?

Back 213

No - role is unproven and may cuase disseminated TB in HIV-infected pts

Front 214

What is Echinococcosis and what causes it? Who is at risk and what is the pathogenesis? What does it cause?

Back 214

Parasitic infection caused by the tapeworm echinoccocus - 4 species of Echinococcus can produce infection in humans -the 2 msot common are E. granulosis causing cystic echinococcosis and E. multilocularis causing alveolar echinococcosis. Most human infecitons are caused by the SHEEP strain of E. granulosis - dogs and other canines are definitive hosts and sheep are intermediate hosts. Humans are dead-end accidental intermediate hosts. Most common in areas where sheep are rasied and transmission is seen when dogs living in close proximity of humans are fed the viscera of home-slaughtered animals. The infectious eggs excreted by dogs in the feces are passed on to other animals and humans; after ingestion of eggs by humans, the oncospheres are hatched and penetrate the bowel wall disseminating hematogenously to various visceral organs, leading to formation of hydatid cysts. THe liver, followed by the lung, are the most common viscus invovled, but any viscera can be involved. Hydatid cysts are fluid-filled cysts with an innter germinal layer and outer acellular laminated membrane. The Germinal layer gives rise to numberous secondary daughter cysts

Front 215

Who is at risk for neurcysticercosis?

Back 215

Pig farmers

Front 216

What can gonorrhea cause in the liver?

Back 216

Perihepatitis

Front 217

What does post-exposure prophylaxis for rabies involve?

Back 217

Both active and passive immunization

Front 218

What should you do if bit by a dog and it is not captured and assumed to be rabid?

Back 218

Post-exposure prophylaxis (active + passive immunization)

Front 219

What should do if bit by a dog and it is captured but doesn't show signs of rabies?

Back 219

Keep dog in observation for 10 days to llok for features of rabies - if shows them, start post-exposure prophylaxis. The dog's diagnosis is confirmed by fluorescent AB exam of the brain

Front 220

In dog bites on what part of the body require post-expsoure prophylaxis immediately?

Back 220

Head and neck

Front 221

What is a serious pulmonary complicaiton of influenza pneumonia in both children and adults? How treat?

Back 221

Staph aureus pneumonia. Treat with anti-staph abx.

Front 222

Who is susceptible to Staph aureus PNA?

Back 222

Relatively UNcommon cause of CAP. Most often affects hospitalized pts, nursing home pts, IVDA, pts with CF, or pts with recent influenza vaccination.

Front 223

Who do you usually see PCP PNA in?

Back 223

HIV pts with Hep B or C; IVDA; men who have sex with men; pts with preexisting liver disease

Front 224

WHo do you usualy see Klebsiella PNA in? What will see on gram stain? What are the characteristic features?

Back 224

DM, alcoholics, nosocomial setting. Gram neg encapsulated rods. "Currant jelly sputum", cavitatin, empyema

Front 225

What does Pseudomonas aeroginosa cause and what kind of bug is it?

Back 225

Gram neg rod -> nosocomial PNA in pts with CF and bronchiectasis

Front 226

What is the leading cause of atypical PNA? What are teh s/s? What will see on gram stain and CXR?

Back 226

Mycoplasma pneumoniae. Non-productive cough, HA, rash. Gram stain: no organisms seen, but cold agglutinins may be present in blood. CXR: interstitial pattern

Front 227

What are the leading cause of lung abscesses and who is at risk. What is the presentation? CXR?

Back 227

Anaerobes. Pts who aspirate and have poor dentition are at risk. Presentation may be subacute. If lung abscess is present, CXR will reveal fluid-filled cavity

Front 228

Where is histoplasmosis endemic?

Back 228

Ohio rivier valley

Front 229

Who does histoplasmosis occur in and how does it present?

Back 229

Self-limited in immunocompetent but cna caouse significant pulmonary and disseminated disease in pts with CD4 <100 - these ppl present with fever, wt loss, night sweats, N/V, cough with SOB, diffuse LAD, HSM. Labs: pancytopenia (if BM invovled), elevated LFTs, elevated ferritin

Front 230

What is the most sensitive test to diagnose disseminated histoplasmosis?

Back 230

Ag detection in urine or serum (fungal blood cultures are more sensitive for chronic pulmonary histoplasmosis and can take up to 6 weeks to become positive; serologic tests for histo include complement fixation titers and immmunodiffusion tests - can initially be neg in acute disease and can take up to 4 wks to be come more positive for histo; no longer doing skin testing)

Front 231

What is the preferred TOC for histoplasmosis?

Back 231

Mild-moderate disease: Itraconazole alone. If more severe disease (high fever >103.1, lab abnormalities, or fungemia) should initially be treated with IV liposomal Ampho B for 2 weeks then Itraconazole for 1 year.

Front 232

What is caspofungin?

Back 232

An echinocandin anti-fungal

Front 233

What is Flucytosine used to treat?

Back 233

Cryptococcus and Candida

Front 234

When is induration of >5mm considered positive for PPD?

Back 234

HIV+, recent contact with TB-positive person, signs of TB on CXR, organ transplant pts, pts on immunosuppressive therapy

Front 235

When is induration of >10mm considered positive for PPD?

Back 235

Recent emigration from endemic TB area, IVDA, residents/employees of high-risk settings (prisons, homeless shelters), DM, CKD, hematologic malignancies, fibrotic lung disease, <4yo, teends exposed to high risk adults

Front 236

What induration # is considered positive for healthy individuals with no risk factors for TB?

Back 236

>15mm

Front 237

What is the next step for a pt with positive PPD?

Back 237

CXR to evaluate for pulmonary TB. If Positive PPD but no active TB signs on CXR, should be treated for latent TB infection

Front 238

What med should you use for latent TB infection?

Back 238

many - INH+pyridoxine for 6-9mo

Front 239

Who is more prone to tricupsid endocarditis caused by staph aureus?

Back 239

IVDA

Front 240

What are some of the characteristics of infective endocarditis in IVDA?

Back 240

1. HIV infection increases infective endocarditis risk in IVDU. 2. S. aureus is MC organism. 3. Tricupsid valve (right-sided) mroe common than aortic valve --> lacks audible heart mumur, septic pulmonary emboli common, fewer peripheral infectious endocarditis manifestations (splinter hemorrhages, Janeway lesions), heart failure more common in aortic valve involvement, but rare with TV involvement

Front 241

How do septic emboli appear on CT?

Back 241

pulmonary infiltrates, abscesses, infarction, pulmonary gangrene, or cavities. Usually in lung periphery. UPto 75% of pts with tricuspid IE will have septic emboli

Front 242

Where does H flu colonize? What does it cause?

Back 242

URT. URT infections, bronchitis (esp in COPD pts), and PNA.

Front 243

Who is more susceptible to Legionella infection?

Back 243

Chronic lung disease, smokers, immunosuppressed. Transmitted thru contaminated aerosolized water such as cooling symptoms.

Front 244

How do septic emboli and TB cavitary lesions differ?

Back 244

TB is SLOWER progressing with symptoms of malaise, anorexia, wt loss, fever, night sweats along with pulmonary findings. Also, chronic cough (not dyspnea) is most common pulmonary symptom

Front 245

When do you see PCP pneumona and how does it present?

Back 245

HIV pts with CD4 <200. SUBACUTE resp symptoms with diffuse infiltrates on CXR and inc alveolar-areterial gradient

Front 246

What does Staph epidermidis affect?

Back 246

Coag-neg staph - infections in prosthetic valves, IV shunts, prosthetic joints. Normally present in skin and can contaminate blood cultures

Front 247

Why is infectious endocarditis in IVDA more suspectible to septic emboli to lungs?

Back 247

Bc in IVDA, IE usually occurs in tricuspid valve (R-sided) so fragments of vegetation can embolize to the lungs -> characteristic nodular infiltrate with cavitation

Front 248

What should suspect in DM pt with severe ear pain, otorrhea, and evidence of granulation tissue in ear canal?

Back 248

Malignant otitis externa caused by Pseudomonas. Often have ear discharge and pain radiating to TMJ and exacerbated by chewing. Inc risk in DM and immunosuppressive conditions.

Front 249

What is the classic presentation of Sporotrichosis?

Back 249

aka Gardener's disease. Initial lesion is a reddish nodule that later ulcerates (painless), appears at the site of the thorn prick or other skin injury. From the site of inoculation, the fungus spreads along the lymphatics forming subcutaneous nodules and ulcers. (sporothrix schenckii is a dimorphic fungus found in the natural environment in the form of mold (hyphae); it resides on the bark of tress, shrubs, and garden plants and on plant debris in soil. Common in gardeners. Uusally no LAD or systemic signs of infection

Front 250

Is there adenopathy usually in cellulitis?

Back 250

Yes, tender LAD with systemic signs of infection

Front 251

What bugs are pts with hemochromatosis more susceptible to?

Back 251

Listeria, Yersinia, and Vibrio sepsis (all are iron-loving)

Front 252

HSV encephalitis - symptoms, exam, Labs/imaging, Tx?

Back 252

Symptoms: fever, AMS with confusion and agitation, risk of seizures and coma. Exam: hemiparesis, CN palsies (signs of focal neuro deficits), hyperreflexia. Labs/imaging: CSF: inc WBC (L's predomin), normal glucose, inc protein. Brain MRI: temporal lobe abnormalities, Dx: CSF shows presence of viral DNA on PCR. Tx: IV acyclovir - start immediately after getting CSF fluid

Front 253

What do you use to treat cryptococcal meningoencephalitis?

Back 253

IV Amph + flucystosine.

Front 254

How do pts with cryptococcal meningitis usually present and who is it common in?

Back 254

Usually cause subacute meningitis and pts commonly present weeks after symptoms. MC in immunocompromised. Symptoms are due to inc intracranial pressures (headache) from capsular swelling). Almost all pts have INC OPENING PRESSURE on spital tap.

Front 255

What is the basic empiric tx for bacterial meningitis?

Back 255

IV ceftriaxone + vanco (+ ampicillin in aduts >50yo)

Front 256

What is chlordiazepoxide used to treat?

Back 256

Alcohol withdrawal in hospitalized pts. Withdrawal can begin in 1-2 days after stopping alcohol and can present with tremulousness, anxiety, HA, and palpitations. Can progress to fever, HTN, and delirium tremnes.

Front 257

What should pts with PID also be screened for?

Back 257

HIV, syphilis, Hep B, cervical cancer pap smear), and Hep C if history of IVDA

Front 258

How should you treat gonorrhea?

Back 258

Ceftriaxone (+Azithro for Chlamydia coverage)

Front 259

How do you screen for syphilia?

Back 259

RPR

Front 260

How do you screen for HSV?

Back 260

Tzank smear on active genital lesions

Front 261

What does Hep A cause?

Back 261

Food poisoning

Front 262

How is Hep C primarily transmitted?

Back 262

IVDA or blood transfusions. Very rarely through sex

Front 263

Where is coccidiodomycosis found? What are the s/s?

Back 263

Southwestern US as well as Central and South America. Primary pulmonary infection has nonspecific features, such as fever, fatigue, dry cough, wt loss, and pleuritic CP. Cutaneous fidnings such as erythema multiforme and erythema nodosum, as well as arthralgias, are common

Front 264

Where is histoplasmosis endemic and what are the symptoms?

Back 264

Southeastern, mid-atlantic, and central US. Can cause acute PNA which presents as cough, fever, malaise

Front 265

WHere is Blastomycosis endemic and what does it cause?

Back 265

South-central and north-central US. Usually affects the lungs, skin, bones, joints and prostate. Usually in an immunocompromised host does it cause these problems. Primary pulmonary infection is asymptomatic or presents with flu-like symptoms

Front 266

What does invasive aspergillosis present as and who does it occur in? What does imagingin show?

Back 266

Immunocompromised (neutropenia, cyclosporine, high dose steroid pts). Invasive pulmonary disease presents with fever, cough, dyspnea, or hemoptysis. CXR may show cavitary lesions. CT: pulmonary noduels with halo sign or lesions with an air crescent

Front 267

When does cryptococcus typically cause meningoencephalitis in HIV pts? How is it transmitted?

Back 267

CD4 <200. Organism gains entry thru inhalation, which results in pulmonary phase - often asymtomatic but can cause CP or cough. Rare in healthy.

Front 268

When should HIV pts get prophlyaxis against MAC and with what?

Back 268

CD4 <50 with Azithromycin or Clarithromycin (or Rifabutin as an alternative to macrolides)

Front 269

What HIV pts should get prophylaxis from histoplasmosis and with what?

Back 269

CD4 <100 and living in endemic area. Get Itraconazole

Front 270

What is an alternative PCP prophlyaxis for HIV other than TMP-SMX?

Back 270

Pentamidine

Front 271

Is CMV prophylaxis for HIV recommended?

Back 271

Not currently

Front 272

What is the treatment of choice for pregnant and lactating women with early localized Lyme disease?

Back 272

Amoxicillin

Front 273

Where is Lyme disease endemic?

Back 273

NE and upper midwestern USA

Front 274

Can you diagnose early localized Lyme disease soley on erythema migrans?

Back 274

Yes

Front 275

Why is doxycycline so good for lyme disease?

Back 275

Bc it workes for Lyme but also can prevent/treat coexisting human granulocytic anaplasmosis, an infection also carreid by Ixodes scapularis.

Front 276

What is the treatment of choice for Lyme disease in children < 8yo?

Back 276

Amoxicillin

Front 277

When should expect rash and constitutional symptoms of Lyme disease to go away?

Back 277

Within 3 weeks of treatment

Front 278

When should use IV 3rd gen cephalosprins in treating lyme disease?

Back 278

Reserved for meningitis, encephalopathy, or carditis bc of need for hospitalization and exposure to broader-spectrum abx (but would work for the earlier phases ofLyme disease)

Front 279

What are the complications of lyme disease that you aim to prevent with treatment?

Back 279

Facial palsy, aseptic meningitis, heart block, or arthritis

Front 280

How does erysipelas typically present? What is the most common organism?

Back 280

Sharply-demarcated, erythematous, edematous, tender skin lesion with raised borders in a febrile pt. MCC: Group A beta-hemolytic strep. Abrupt onset, legs most common site (it is a specific type of cellulitis).

Front 281

When should consider Pseudomonas in cellulitis?

Back 281

Puncture wound

Front 282

When shoudl consider H flu in cellulitis?

Back 282

Face of a child

Front 283

What is the causative organism of gas gangrene?

Back 283

Clostridium perfringens

Front 284

What should suspect in AIDS pt with multiple ring-enhancing lesions on CT?

Back 284

Toxoplasmosis

Front 285

What should use for prophylaxis of toxoplasmosis and what should use for treatment?

Back 285

Prophylaxis with TMP-SMX and sulfadiazine and pyrimethamine for treatment

Front 286

How does primary CNS lymphoma usually present?

Back 286

Afebrile, lesiosn are weakly enhancing and usulaly single (but can be multiple)

Front 287

Where does reactivation of TB in HIV pts usually occur?

Back 287

Lungs

Front 288

What is albendazole used to treat?

Back 288

Neurocysticerosis. Very uncommon in US (but most common parasite to infect the brain worldwide) and usually not seen in AIDS pts

Front 289

In a pt with a nail puncture would resulting in osteomyelitis, what is the most likely pathogen? Tx?

Back 289

Pseudomonas (esp where puncture occurs thru rubber-soled footwear). Tx with oral or parenteral quinolones and aggressive surgical debridement

Front 290

What is the most common cause of osteomyelitis in children and adults?

Back 290

Staph aureus

Front 291

How long does it take for plain x-rays to show osteomyelitis?

Back 291

2+ weeks

Front 292

What is a common cause of osteo in DM pts?

Back 292

Staph aureus (coag positive)

Front 293

What is the presentation of candida osteomyelitis and who can it occur in?

Back 293

IVDA. Presentation usually subacute unlike bacterial osteo

Front 294

Where does TB osteo usually occur?

Back 294

Spine (Pott's disease)

Front 295

Where is blastomycosis endemic and what does it usually affect? What i the presentation?

Back 295

South-central and north-central US. Usually affects the lungs, skin, bones, joints and prostate. Usually in an immunocompromised host does it cause these problems. Primary pulmonary infection is asymptomatic or presents with flu-like symptoms. Cutaneous disease is either verrucous or ulcerative. Verrucous lesions are initially papulopustular, then progressively become crusted, heaped up and warty, with a violaceous hue. These lesions have sharp borders and may be surrounded by microabscesses. Wet preps shows broad-budding yeast

Front 296

Where is histoplasmosis endemic and how does it present?

Back 296

Southeastern, midatlantic, and central US. Can manifest as acute PNA which presents as cough, fever, and malaise. Other posible manifestations include chronic pulmonary histo and disseminated histo (most common in HIV pts)

Front 297

Where is coccidiodes endema dnw aht does it commonly cause?

Back 297

Southwestern US and central and south america. Causes pulmonary infection. Cutaneous findings such as erythema multiforme and erythema nodosum are common

Front 298

Where does invasive aspergillosis often infect?

Back 298

Multiple organ systems including pulmonary and cutaneous fndings. Affects severely immunocompromised pts - esp transplant and those taking cytotoxic meds

Front 299

What are the differences in presenation of Norcardia and Actinomyces infections?

Back 299

Both are gram neg rods (Nocardia is also weakly acid fast). Norcardia - subacute PNA that mimics TB; most pt are immunocompromised. Actinomyces: absecess near head and neck that drain sulfur granules; can cause indolent pulmonary disease

Front 300

What is the ddx in HIV pt with unexplained fever and cough and on TMP-SMX? How can differentiate?

Back 300

MAC, TB, disseminated CMV, non-Hodgkins lymphoma. MAC most likely if CD4 <50 and no reason to suspect TB.

Front 301

What is the use of dapsone in HIV?

Back 301

Alternative for PCP prophylaxis

Front 302

WHen do you start tx for TB in HIV pts?

Back 302

induration of PPD >5mm

Front 303

What is used for both prophylaxis and treatment of CMV infection?

Back 303

Ganciclovir (prophlyaxis when CD4 <50 and serum CMV IgG positive or when there is positive bx for CMV)

Front 304

Is BCG vaccine live?

Back 304

yes -> don't give to HIV pts

Front 305

What is Kaposi sarcoma in HIV pts caused by? What is presentation?

Back 305

HHV 8. Cutaneous lesions are asymptomatic, elliptical, and arranged linearly. Commonly involved regions: legs, face, oral cavity, genitalia. Lesions begin as papules and later evelop into plaques or nodules. Color typically cahnges from light brown to violet. No associated necrosis of skin or underlying structures. In US, most commonly seen in homosexual HIV pts

Front 306

What are HSV lesions like?

Back 306

Vesicular and painful

Front 307

What should do when a healthcare worker is exposed to blood or blood products of HIV-infected pt?

Back 307

Test for HIV immediately to establish pts baseline serologic status. Repeat testing after 6 weeks, 3mo, and 6mo. ONce blood is drawn for baseline, HIV post-expsoure prophylaxis should be started without delay - this is a combo of 2 or 3 drugs. 2 NRTIs are typically used - if use a third, it is usually a proteiase inhibitor (inc efficacy). 3 drug usually used, and esp indicated for exposure that post an inc risk for transmission (ex: very low CD4 count, high viral load, high risk type of injury such as deep percutaneous injury with hollow-bore needle)

Front 308

What should suspect in Asian pt with insensate, hypopigmented patch of skin?

Back 308

Leprosy (chronic garnulatomous disease that primarily affects the peripheral nerves and skin) - caused by mycobacterium leprae.

Front 309

How does leprosy usually present?

Back 309

Erarly on, may present with insensate, hypopigmented plaque. Progressive peripheral nerve damage results in muscle atrophy with consequent crippling deformities of the hands. MC affected sites: face, ears, wrists, butt, knees, eyebrows.

Front 310

How do you diagnose Leprosy?

Back 310

Skin biopsy will show acid-fast bacilli (blood cultures are negative; EMG sutdies are normally done to identify nerve pathology, esp at the lesion site and affected nerve segment but in leprosy, there is patchy, segmental nerve involvement so no strict pattern of nerve involvement is identified)

Front 311

What is the most common cause of PNA in HIV pts?

Back 311

Pneumococcus. Due to impaired humoral immunity, HIV pts are susceptibel to infection by encapsulated organisms in gneeral.

Front 312

How does TB infection present?

Back 312

Chronic cough, fever, wt loss

Front 313

What does disseminated fungal infection look like on CXR?

Back 313

Miliary or nodular infiltrate

Front 314

How does PCP pneumonia usually present?

Back 314

Dry cough and dyspnea. CXR: bilateral diffuse infiltrates

Front 315

How does secondary syphillis present?

Back 315

Rash, LAD, constitutional symptoms (fever, malaise, sore throat). Rash typically start on the trunk and extends to the periphery including the palms.

Front 316

How does primary syphillis present?

Back 316

painless chancre that resolves in 3-6 weeks

Front 317

How is testing for syphillis done?

Back 317

Initial testing with non-treponemal test (RPR or VDRL) with positive results confirmed with a specific treponema test (FTA-ABS test).

Front 318

How is secondary syphillis treated and what is a comlcation of treatment?

Back 318

3 doses of benzathine penicillin (each given weekly). Pts occasionally develop Jarisch-Herxheimer reaction (acute febrile reaction with headaches and myalgias) in the first 24hrs of therapy. Alternative regimens include doxycycline or azithromycin if penicillin allergy

Front 319

What do drug eruption rashes look like?

Back 319

Morbilliform, urticarial, papulosquamous, pustular, and/or bullous lesions.

Front 320

How does pityriasis rosea usualy present?

Back 320

Follows a viral illness. Rash is pruritic in 75%, described as papulosquamous with initial "herald" lesion followed by general exanthem

Front 321

How does psoriasis present?

Back 321

Involves elbows and knees

Front 322

What is rash of RMSF like?

Back 322

Usually begins as maculopapular eruption on wrists and ankles that spreads to trunk, extremities, palms, soles around day 5. Often have a severe headache and diffuse myalgias.

Front 323

What is the mot common rash in children?

Back 323

Viral exathem (much less common in adults)

Front 324

How does invasive aspergillosis present with s/s and imaging?

Back 324

Immunocompromised hosts (neutropenia, steroids, cytotoxic drugs). Invasive pulmonary disease with fever, cough, dyspnea, or hemotpysis. CXR: rapidly progressing, dense consolidation. CT: pulmonary noduels with halo sign or lesions with air crescent.

Front 325

Where is aspergillus endemic?

Back 325

Nowhere specifically

Front 326

What does CXR of histoplasomsis look like?

Back 326

Hilar adenopathy and may have areas of pneumonitis

Front 327

How does sporotrichosis spread?

Back 327

Through lymphatic flow

Front 328

What is the most common cause of traveler's diarrhea? How does it present?

Back 328

Enterotoxigenic E. coli. Abd cramps, diarrhea, malaise. Usually due to contaminated water.

Front 329

What is Nepal specific for in tmers of parasites?

Back 329

Giardia, Cyclospora

Front 330

Where is Giardia more common in US?

Back 330

Northern and Western USA

Front 331

What do you think of with diarrhea transmitted by seafood (including shrimp, crab, and raw oysters)?

Back 331

Vibrio parahaemolyticus. Can cause either watery or bloody diarrhea

Front 332

What is the msot common cause of dysentery in the USA?

Back 332

Shigella - also 2nd MCC of food-borne illness

Front 333

Where is Shigella common?

Back 333

Daycare settings or other institutional settings

Front 334

When can get EHEC?

Back 334

Improperly cooked ground beef

Front 335

What increases risk of Yersinia infection?

Back 335

Undercooked pork

Front 336

What is the MCC of acute infectious diarrhea in the US? Where find it?

Back 336

Campylobacter. Undercooked infected poultry. Can have watery or bloody diarrhea, severe abd pain

Front 337

What are the s/s of campylobacter infection?

Back 337

Watery or bloody diarrhea with severe abd pain

Front 338

What is cat scratch disease caued by? What are s/s? How do you treat?

Back 338

Bartonella henselae. Can be transmitted by cat scratch/bite or flea bite. Seen in young, healthy pts. Typically presents as localized cutaneous and LN disorder near site of inoculation with rare other organ invovlement. Local skin lesion evolves through vesicular, erythematous, papular phases but can be pustular or nodular. Hallmark is localized, regional LAD which is tender and may be suppurative. Dx is clinical but positive B, henselae Ab test or tissue specifim demonstrating positive arthin-Starry stain supports dx. Short (5d) course of Azithromycin for tx

Front 339

When should you suspect Ehrichiosis?

Back 339

Pt from endemic region (southeatern, south-central, mid-atlantic, upper medwest regions, + Cali) with history of tick bite, systemic symptoms, leukopenia and/or thrombocytopenia, and inc LFTs.

Front 340

What is Ehrlichosis?

Back 340

Tick-borne illness cause dby one of 3 diff Gram neg species, each witha different tick vector. Incubation period 1-3 weeks. Fever, malaise, myalgia, HA, N/V, usually NO RASH. "Spotless RMSF".

Front 341

What is DOC for Ehrlicosis?

Back 341

Doxycycline (start whenever suspect)

Front 342

What do you use to treat RMSF in pregnant pts?

Back 342

Chloramphenicol

Front 343

What is the DOC for Legionnaire's disease?

Back 343

Erythromycin

Front 344

What would peripheral blood smear look like in Ehrlichiosis?

Back 344

Intracellular inculsions (morulae) in WBC but not required before starting treatment

Front 345

How do you treat PCP pneumonia?

Back 345

TMP-SMX (irrespective of severity of PNA. Consider adding steroids bc they have been shown to dec mortality in severe PCP cases - indications include PaO2 <70 or A-a gradient <35.

Front 346

What does PCP PNA present like?

Back 346

Dry cough, exertional dysnpea, fever, severe hypoxia (out of proportion to CXR), CXR with bilateral interstitial infiltrates, normal WBC

Front 347

What are the clinical features of infectious mono?

Back 347

Fever, sore throat, toxic symptoms, mild HSM, symmetric LAD invovling posterior cervical chian more commonly than anterior, can have inguinal and axillary LAD, also often have pharyngitis, tonsilitis, tonsillar exudates. Can also have mild palatal petechiae, but this is non-specific bc can also be seen in strep pharyngitis. Tonsillar enlargement can cause airway compression. Hepattis and jaundice are present in a small percent of cases. Things that differentiate from strep pharyngitis include HSM, malaise and fatigue, and generalized LAD

Front 348

What is a hematologic complication of infectious mono?

Back 348

Autoimmune hemolytic anemia and thrombocytopenia due to cross reactivity of the EBV-induced Ab against RBC and platelets. THese Ab are IgM cold-agglutinin Ab known as Anti-i antibodies, which lead to complete mediated destruction of RBC (usually Coombs'-test positive). The onset of hemolytic anemia can be 2-3 weeks after the onset of symptoms, even though the inital lab studies may not show anemia or thrombocytopenia (as in this patient).

Front 349

What is the spleen complication from infectious mono?

Back 349

splenic rupture (mainly caused by truauma) -> should avoid contact sports such as foodball for 3-4 weeks

Front 350

WHat is a heart complication fo Corynebacterium infection and what is the throat presentation?

Back 350

Sore throat with pseudomembrane formation. Dilated CM is a possible complication of Corynebacterium.

Front 351

What is a kidney complication of strep pharyngitis?

Back 351

Glomerulonephritis

Front 352

When is IV pentamidine used in HIV?

Back 352

For PCP treatment when can't tolerate TMP-SMX (can use inhaled pentamidine for prophylaxis)

Front 353

How do you treat Legionella or Chlamydia pneumonia?

Back 353

Macrolide abx

Front 354

What should suspect in pt with fever rash (erythematous and maculopapular that starts on face and progresses to trunk and extremities), occipital or posterior cervical LAD, and arthritis?

Back 354

Rubella. Prodrome of fever, LAD, malaise. Occipital and posterior LAD are suggestive. Adult women usually have associated arthritis. Some pts have mild coryza and conjunctivitis

Front 355

What is the characteristic rash of measles?

Back 355

Erythematous and maculopapular progressing from head to trunk and extremities (like Rubella). Koplik's spots are highly suggestive. Prodrome of fever, cough, coryza, conjuncitivitis

Front 356

What is the rash of chicken pox?

Back 356

Pruritic and usually develops after a prodrome of fever and malaise. lesions appear in consecutive crops, so lesions of several different stages are often visible on exam (papular, vesicular, crusted, etc)

Front 357

When can see rash in mono?

Back 357

After administration of ampicillin

Front 358

What infection should be part of ddx for BMT recipient with both lung and intestinal involvement? What is average time to infection?

Back 358

CMV pneumonitis - median time to development of CMV pneumonitis after BMT is about 45d (2 weeks-4mo)

Front 359

What are the risk factors for CMV pneumonitis? What do you see in CXR and CT scan. How dx?

Back 359

Immunosuppressive therapy, older age, seropositivity before transplant. CXR: multifocal diffuse patchy infiltrates. CT: parenchymal opacification or multiple small nodules. Bronchoalveolar lavage is diagnostic in most cases.

Front 360

What are the possible manifestations of CMV in bone marrow transplant pts?

Back 360

CMV pneumonitis, upper and lower gastric ulcers, bone marrow suppresion, arthralgias, myalgias, esophagitis

Front 361

What reduces incidence of PCP PNA in BMT pts? When does it occur after BMT if it does?

Back 361

Pre-transplantation TMP-SMX. Usually seen in immediate post-transplant period

Front 362

What is the most common organ for GVHD?

Back 362

Skin - skin rash is almost always seen with GVHD. Other organs include intestine, liver, lung (in lung, involvement is seen in chronic GVHD and manifests as bronchiolitis obliterans)

Front 363

Does candida cause PNA?

Back 363

Not usually

Front 364

What does Cryptosporidium cause in immunocompromised pts?

Back 364

Diarrhea

Front 365

What cancer is strep bovis endocarditis assoc with? What is next step in management?

Back 365

Colon cancer or upper GI cancer --> give abx for endocarditis and then colonoscopy looking for GI malignancy

Front 366

Is there a useful tool to screen for lung cancer?

Back 366

No - neither CXR nor bronchoscopy is indicated unless have s/s of suggestive of lung cancer

Front 367

What should you consider in a pt with mono-like symptoms, atypical L's on peripheral smear, but negative monospot test?

Back 367

CMV infection - will also have lack of pharyngitis/sore throat and cervical LAD on exam

Front 368

What do the atypical L's of CMV look like?

Back 368

Large basopihlic cells with vacuolated appearance

Front 369

What time length of symptoms is required for diagnosis of chronic fatigue syndrome?

Back 369

6+months

Front 370

What is the usual age and cell description of CLL?

Back 370

Median age 61yo (older), see mature-appearing small L's and "smudge" cells

Front 371

What are the potential causes of diarrhea in HIV pts? What is first step in management?

Back 371

Many - Shigella, Salmonella, Campylobacer, C diff, Giardia, Cryptosporidium, MAC, CMV. Should test stool for culture, ova and parasites, and C. diff before starting treatment

Front 372

Who is colonoscopy and biopsy in diarrhea pts reserved for?

Back 372

Pts with persistent diarrhea and negative stool exam

Front 373

Why do you not want to give an antidiarrheal agent in a pt whose diarrhea is likely infectious?

Back 373

More organisms or toxin would remain in the intestine, which could lead ot toxic megacolon

Front 374

What should suspect in pt with history of IV drug use and new murmur?

Back 374

Right sided endocarditis (tricuspid valve)

Front 375

How should treat IV drug users who have endocarditis?

Back 375

Empiric abx treatment geared towards MRSA, strep, and enterococci - most appropriate is vancomycin (native-valve)

Front 376

What is the murmur of tricuspid regurg?

Back 376

Holosystolic murmur at lower sternum which increases with intensity on inspiration

Front 377

What are some s/s of right-sided endocarditis?

Back 377

fever, generalized weakness, TR, IVDA

Front 378

What si the most common organism in R-sided endocarditis (IVDA)?

Back 378

Staph aureus accounts for >50%

Front 379

When is ampicillin-sulbactam recommended in infectious endocarditis?

Back 379

If cultures come back with penicillin resistant enterococcus or HACEK organisms

Front 380

What is the drug of choice for native-valve endocarditis due to penicillin-suspcetible Viridans strep?

Back 380

Aqueous penicillin G

Front 381

What is special about HIV pts and TB?

Back 381

Their TB carries a very high risk of progression to active disease

Front 382

What should be the treatment of PPD-positive HIV+ pts with neg CXR? What is a positive PPD in HIV+?

Back 382

Prophylactic treatment - Isoniazid is drug of choice and is given for 9 months; add pyridoxine to prevent possible neuropathy; but, pyridoxine doens't prevent isoniazid-induced hpetatitis, so have to monitor LFTs. Alternatives include pyrazinamide + rifampin or rifabutin for 2 months or rifampin alone for 4mo if intolerant to pyrazinamide >5mm induration.

Front 383

What blood test do you have to monitor in pts on Isoniazid?

Back 383

LFTs (Isoniazid-induced hepatitis)

Front 384

When do you use the 3 or 4 drug combos to treat TB?

Back 384

If it is an active TB infection

Front 385

When must antivirals for influenza be started to dec disease duration and severity?

Back 385

Within 48hrs of onset of symptoms

Front 386

What lung findings can you find on PE of pt with influenza? What about labs? CR?

Back 386

Fever, wheezes, crackles, coarse breath sounds, leukopenia, proteinuria. CXR normal or interstitial or alveolar pattern

Front 387

What is the fastest way to confirm the diagnosis of influenza?

Back 387

Nasal swabs

Front 388

What are the antivirals for influenza?

Back 388

Neuraminidase inhibitors: oseltamivir and zanamivir. Rimantadine and amantadine are only effective agianst influenza A

Front 389

WHat is Ganciclovir used to treat?

Back 389

CMV infections (CMV PNA is a serious infection that infectes severely immunocompromised pts)

Front 390

What is Tenofovir?

Back 390

Nucleotide analog used to treat HIV

Front 391

What is Ritonavir?

Back 391

A protease inhibitor used to treat HIV

Front 392

What is Valacyclovir?

Back 392

A valine analog of the antiviral acyclovir. Used to treat HSV and VZV infections

Front 393

What is Nevirapine?

Back 393

A nonnucleotide reverse transcriptase inhibitor used to treat HIV

Front 394

What is clindamycin used to treat?

Back 394

Anaerobic infections, particularly lung abscesses and bacterial infections of the mouth and neck

Front 395

What should always consider in pts from endemic areas with high-grade periodic fever and chills? What are other clinical clues?

Back 395

Malaria. Other clinical clues: anemia, splenomegaly, hypotension and tachycardia, N/V, headache, anorexia, malaise, myalgias

Front 396

What is malaria and how is it transmitted?

Back 396

Protozoal disease caused by the genus plasmodium, which is a RBC parasite that is transmitted by the bite of infected Anopheles mosquitoes. Endemic in most of developing countires of Asia and Africa. 4 species, most deaths are due to falciparum malarias whereas vivax and ovale are responsible for several relapses

Front 397

What is the hallmark of malaria?

Back 397

Cyclical fever - it coincides with the RBC lysis by the parasites. Fever occurs every 48hrs with P vivax and P ovale and every 72 hrs with P malariae, whereas periodicity is not generally seen with P falciparum. The typical episode consists of a chold phase of chills and shivering followed by a hot phase of high fever, followe dby 2-6hrs later by sweating stage with diaphoresis and resolution of fever

Front 398

What is Babesiosis? What are the clinical features? Who is it most common in?

Back 398

A protozoal disease caused by Babesia microti, which is a RBC parasite transmitted by a tick. FClinical features range from asymptomatic infeciton to severe hemolytic anemia with jaundice and renal failure. More common in pts with functional asplenia or splenomegaly

Front 399

What else should you screen for in pts with newly diagnosed syphilis?

Back 399

HIV

Front 400

What are VDRL and FTA-ABS tests for?

Back 400

Syphilis exposure

Front 401

When do you start screening for prostate cancer?

Back 401

Usually start at age 50

Front 402

What is the treatment of choice for herpes zoster? How can you treat postherpetic neuralgia?

Back 402

Valacyclovier is DOC, Acyclovir is an alternative. Can treat post-herpetic neuralgia (or prevent it) with tricyclic antidepressants such as amitriptyline or nortriptyline along with the acute antiviral therapy. Can combine oral steroids with acyclovir (not with valacyclovir) if the initial symptoms are sever and no contraindications

Front 403

How does shingles occur?

Back 403

Caused by reactivation of VZV virus. Following the primary infection (chicken pox), the virus remains latent in the dorsal root ganglia. A dec in cell-mediate immunity (ex: older age, stressful situation, HIV, lymphoma) can allow the virus to reactivate and spread along the sensory nerve - this accounts for the typical unilateral, dermatomal distribution of the pain and rash. T3-L3 are the most frequently involved dermatomes. Pts often develop pain or discomfort in the affected area before the onset of rash.

Front 404

How can you treat/prevent postherpetic neuralgia in herpes zoster pts?

Back 404

TCAs

Front 405

What is different between drug-induced rashes and rash from herpes zoster?

Back 405

Drug induced rashes don't usually run along dermatomes

Front 406

What is the most common cuase of pts with subacute bacterial endocarditis with preexisting valvular disease?

Back 406

Viridans group strep

Front 407

What is the mcc cause of infective endocarditis in pts with prosthetic valves?

Back 407

Staph epidermidis

Front 408

What does staph saprophyticus usually cause?

Back 408

UTIs in young women

Front 409

What should you do if pt becomes pregnant earlier than 3mo after rubella immunization?

Back 409

Reassure - previously, women of childbearing age were advised to avoid conception for at leaest 3 months after rubella immunization, but there have been no case reports to date of congenital rubella syndorme in women inadvertnetly vaccinated during pregnancy. Infact, it has been recommended to reduce the waiting time for conception from 3mo to 28 days.

Front 410

What is the protocol for treatment of HIV pts who develop esophagitis?

Back 410

Esophagitis with advanced HIV usually occurs with CD4 <50. MCC is candida, therefore should first start with fluconazole - if don't respond to 3-5d course, further investigation is warranted with EGD with cytology, bx, and culture to determine other etiology - HSV< CMV

Front 411

What do you use to treat esophagitis from HSV and CMV?

Back 411

Acyclovir and Ganciclovir respectively

Front 412

What valve is most often affected in endocarditis not related to IVDA?

Back 412

Mitral valve causing mitral regurg

Front 413

What is the MC predispsoing factor to native endocartidis in the US?

Back 413

MVP - previously, rheumatic valvular damage but not bc rheumatic heart disease is decreasing

Front 414

When can pts with mono start playing sports again?

Back 414

When splenomegaly gone and no longer palpable spleen (usually 1-3mo)

Front 415

What are the s/s of disseminated histoplasmosis?

Back 415

Paltal ulcers, HSM, pancytopenia. Also nonspecific findings such as low-grade fever, malaise, anorexia, wt loss. Bc fungus targets histiocytes and reticuloendothelial system, can cause LAD, pancytopenia, HSM. CR: hilar LAD with or without areas of pneumonitis

Front 416

Where do you find Histoplasomisi?

Back 416

Dimorphic fungi found in mold in soil. Also present in bird and bat dropping and is endemic to Mississippi and Ohio River basins. Pts may report history of exploring caves (with assoc exposure to bats) or cleaning bird cages or coops.

Front 417

What is Blastomycosis assoc with? What does CXR look like adn what are s/s? Who is it common in?

Back 417

Blastomycosis assoc with contact with soil or rotting wood. CXR: multiple nodules or dense consolidations on CXR. Spreads hematogenously to cause skin ulcerative or verrucous skin lesions, plaque-like lesions on mucous membranes, osteolytic bone lesions, and prostate involvement. Infection in immunocompromised is rare

Front 418

Where is Coccidioides found? What do you see on CXR? What does disseminated disease look like?

Back 418

Southwestern US. CXR: localized pulmonary infiltrate, hilar adenopathy, and/or pleural effusion. Disseminated disease: more likely in pts with advanced HIV - in these pts, can present with fever, maculopapular skin lesions, bone liesions. Primary lung compalints may be absent

Front 419

When dose aspergillus affect HIV pts? What are s/s?

Back 419

<50 CD4 count. Fever, cough, dyspnea

Front 420

What does pulmonary sporotrichosis look like on CXR?

Back 420

Chronic, upper lobe cavitary lesion. Less common than subcutaneous skin infeciton

Front 421

What is the key distinction between primary HIV infection and infectious mono (can look similar)

Back 421

The rash (unless abx administered) and diarrhea are much LESS common in fectionus mono and the finding of tonsillar exudate is uncommon in primary HIV

Front 422

What is the classic presentation of mono?

Back 422

Mild-mod fever, pharyngitis, LAD (symmetric, posterior>anterior cervical LN), rarely splenic rutpure.

Front 423

How dx mono?

Back 423

Heterophile Ab test - typically arises within 1 week and persists up to 1 year, both sensitive and specific. Can also test for anti-EBV ab if heterophile Ab test neg and have high clinical suspicion

Front 424

What kind of LAD is secondary syphilis assoc with?

Back 424

Generalized LAD, not isoalted

Front 425

What are the s/s of pts with acute HIV?

Back 425

fever, malaise, generalized LAD, sore throat, HA, rash,GI symptoms

Front 426

When is a LN biopsy indicated?

Back 426

When there is high degree of suspicion for neoplastic disease - if LN are tender, means less likely neoplastic

Front 427

What are some of the common s/s of SLE?

Back 427

Young woman with rash, arthritis, or serositis

Front 428

What is the most common cause of endocarditis following dental procedures?

Back 428

Viridans group streptococci (most commonly Strep mutans - other members of the group are Strep mitis, Strep sanguis, Strep salivarius). Strep mutans also causes dental caries

Front 429

What is a predisposing risk for infective endocarditis?

Back 429

Pre-existing mitral valve disease, IVDA, dental surgery causing bacteremia

Front 430

What are risk factors for Group B strep endocarditis?

Back 430

DM, carcinoma, alcoholism, hepatic failure, elective abortion, IVDA

Front 431

What is Strep bovis bacteremia assoc wtih?

Back 431

Colon cancer --> if organism isolated from blood cultures, need colonoscopy

Front 432

What does Staph epidermidis cause?

Back 432

Endocarditis in prosthetic valves, endocarditis in infants secondary to umbilical venous catheter infection in NICU

Front 433

Where are enterococci normal inhabitants and when does enterococcal endocadritis usually occur?

Back 433

Normally in GI tract and occasionally anterior urethra. Enterococcal endocarditis generally affects older men after GU manipulation or younger women after obstetric procedures

Front 434

Whnen should suspect babesiosis?

Back 434

Endemic area (northeast USA) who presents with tick bite, esp if there is evidence of hemolysis (ex:jaundice) and pt is splenectomized. Caused by parasite Babesia and transmitted by Ixodes tick. Following tick bite, parasite enters pts RBC and causes hemolysis

Front 435

What are the clinical manifestations of babesiosis?

Back 435

Vary from asymptomatic infection to hemoltyic anemia assoc with jaundice, Hburia, renal failure, and death. Rash is NOT a feature (unlike other tick-borne illnesses), except in severe infection where thrombocytopenia may cause a secondary petechial or purpuric rash

Front 436

Which tick-borne disease doens't cause a rash?

Back 436

Babesiosis

Front 437

When does clinically significant disease from Babesiosis occur?

Back 437

>40yo, pts without a spleen, immunocompromised

Front 438

How is the diagnosis of Babesiosis made?

Back 438

Giemsa-stained thick and thin blood smear -> intravascular hemolysis, anemia, thrombocytopenia, mild leukopenia, atypical lymphocytes. inc ESR, abnL LFTs, inc serum complement levels

Front 439

What are the 2 most common drug regimens for babesiosis?

Back 439

quinine-clindamycin and atoaquone-azithromycin

Front 440

What causes malaria and how is it transmitted?

Back 440

Plasmodium species. Transmitted by mosquitoes

Front 441

What are the s/s of Ehrlichosis and what is its other name?

Back 441

Spotless Rocky Mountain spotted fever. Fever, malaise, HA, N/V. Labs: leukopenia, thrombocytopenia

Front 442

What is Q fever, what is it caused by, and what are s/s?

Back 442

Zoonosis caused by Coxiella burnetii. Main source of human infection: infected cattle, goat, sheep. Inc people: meat processing workers, vets. S/s: flu-like syndrome, hepatitis, PNA

Front 443

What are the 3 stages of lyme disease?

Back 443

Early localized, early disseminated, late Lyme disease. Erythema chronicum migrans is a charactersitic feature of early disease

Front 444

What can use for PCP prophylaxis in transplant pts?

Back 444

Oral TMP-SMX (also prevents toxoplasmosis, nocardiosis, UTIs, PNA infections)

Front 445

What abx should all post-transplant pts get?

Back 445

TMP-SMX to prevent PCP (should also be vaccinated against influenza, pneumococcus, and hep B)

Front 446

What abx are used to prevent CMV infections?

Back 446

Ganciclovir or valganciclovir

Front 447

What is Azithromycin used for prophylaxis for in pts with HIV and when?

Back 447

MAC prophyaxis in HIV pts when CD4 < 50

Front 448

What is bloody diarrhea with abd tenderness and absence of fever suggestive of?

Back 448

EHEC (Shigella, Salmonella, and Campylobacter can cause bloody diarrhea but often result in fever and lack of abd pain)

Front 449

How is EHEC different from other strains of bloody diarrhea?

Back 449

Produces Shiga toxin that causes the bloody diarrhe.a MC serotype of EHEC is O157:H7

Front 450

What causes most EHEC?

Back 450

O157:H7. Most caused by undercooked ground beef, although not uncommon for pts to not remember a particular exposure

Front 451

What are complications of EHEC?

Back 451

HUS or TTP

Front 452

How diagnose EHEC?

Back 452

Stool culture

Front 453

When to suspect C. diff?

Back 453

Recent hospitalization or antibiotic use

Front 454

What are protozoal causes of diarrhea and when do you suspect

Back 454

Giardia, Cryptosporidium, Entamoeba histolytica. More rare causes. Suspect with recetn travel or immunocompromise

Front 455

When suspect Virbrio infection?

Back 455

People living in Gulf coast or with recent travel history. Watery, non-bloody diarrhea

Front 456

What is required for dx of gastroenteritis?

Back 456

Vomiting and diarrhea

Front 457

Does Yersinia cause fever?

Back 457

Yes

Front 458

What is Nocardia asteroides, who is susceptible, what are s/s and how do you treat?

Back 458

Gram+, partially acid-fast, filametous aerobe found in soil. Don't confuse with TB or Actinomyces. Suspectible ptople are immunocompromised pts. S/S: wt loss, fever, night sweats; pulmonary invovlement: productive cough with purulent sputum, CXR shows alveolar infiltrates and nodules often with cavitation. May have chest wall invasion.Treatment: TMP-SMX.

Front 459

Where does Norcardia asteroides disseminate to?

Back 459

Can involve any organ but most likely subcutaneous or brain abscesses

Front 460

What is Aztreonam used for?

Back 460

(monobactam abx) - treats Gram neg bacterial infections including Pseudomonas. Not effective against gram +

Front 461

What is the treatment of choice for Actinomyces?

Back 461

Penicillin G

Front 462

What distinguishes Atinomyces from Norcardia?

Back 462

Both are filamentous gram+ bacteria, but actinomycs is anaerobic and more likely to cause cervicofacial disease and sinus tracts. Also, can see sulfur granules with actinomyces

Front 463

What distinguishes Norcardia from TB?

Back 463

TB is acid-fast rods (not branching) and TB doens't gram stain (Norcardia is gram+, partially acid-fast rods)

Front 464

What is the most effective measure to reduce risk of UTI in pts with neurogenic bladder?

Back 464

Intermittent catheterization (as opposed to indwelling catheters). THis is bc bacteria can form a biofilm along the catheter wall that can reach the bladder within 24hrs of insertion. In general, the longer the catheterization, the greater the risk of bacteriuria

Front 465

What abx should start in febrile neutropenic patients? WHat is the definition of neutropenia?

Back 465

Neutropenia: ANC <1500. Suspectibility to infection when ANC <1000, inability to control endogenous flora and high risk of death when ANC <500. Fever with neutropenia: single reading >100.9 or sustained >100.4 over 1 hr. Bacterial causes most common. it is considered an emergency and need empiric abx that are broad-spectrum and cover Pseudomonas. Mono or combo therapy ok: Monotherapy with either Ceftazidime (3rd gen) or Cefepime (4th gen), imipenem, or meropenem or combo with aminoglycoside + anti-pseudomonal beta-lactam

Front 466

What is Tobramycin

Back 466

Aminoglycoside

Front 467

When is vancomycin added to empiric therapy for neutropenic fever?

Back 467

When pt hypotensive, has severe mucositis, has evidence of skin or line infection, has history of colonization with resistent strains of staph aureus or pneumococcus, or has recent prophylaxis with fluoroquinolones

Front 468

What generation is cefazolin?

Back 468

1st gen

Front 469

When should add antifungals (ampho B) to neutropenic fever regimen?

Back 469

When fever persists despite empiric antibiotic therapy

Front 470

What type of gastroenteritis does staph aureus cause? What is the time frame? What causes it? What are symptoms?

Back 470

Toxin-induced gastroenteritis - due to preformed toxin -> emesis within 6 hrs. Causes: mayonnaise-contining products, poultry, eggs, meat and meat products, cream-filled pastries, milk and dairy products. Symptoms: vomiting!!

Front 471

How can differentiate B. cereus from Staph aureus food poisoning?

Back 471

Both are preformed toxins with similar picture of rapid-onset N/V, abd cramping, retching. B. cerus comes from starchy foods (classically, reheated rice) whereas staph aureus is poultry, milk products, mayo, cream-filled paistries, eggs, meat and meat products

Front 472

What is C. perfringens and what does it cause?

Back 472

Spore-forming, spores germinate in foods such as meats, poultry, gravy. S/S: watery diarreha (due to production of toxin in the gut)

Front 473

What does ETEC cause:

Back 473

Traveler's diarrhea

Front 474

What are the early localized (days-1mo) manifestations of Lyme disease?

Back 474

Erythema migrans (80% of pts), fatigue, malaise, lethargy, mild HA, neck stiffness, myalgias and arthralgias

Front 475

What are the early disseminated (weeks-mo after bite) manifestations of Lyme disease?

Back 475

Carditis (5% of untreated; AV block, CM), Neurologic (15% untreated; unilateral or bilatl CN defects - usually VII, meningitis, encephalitis), Muscular (60% untreated; migratory arthralgias), Conjunctivitis (10% untreated), skin (multiple erythema migrans), regional or generalized LAD

Front 476

WHat are the late or chronic (mo-yrs after tick bite) manifestations of lyme disease?

Back 476

Muscular (60% untreated; arthritis), Neurologic (encehpalomyelitis, peripheral neuropathy)

Front 477

What symptoms is pathognomonic for lyme disease?

Back 477

Erythema migrans

Front 478

What is Lyme disease do to?

Back 478

Infection by Borrelia burgdorferi transmitted by bite of Ixodes tick

Front 479

When is IV ceftriaxone used for Lyme disease?

Back 479

Reserved for early disseminated and late diseases

Front 480

What do you use to treat early localized Lyme disease? What about if child or pregnant?

Back 480

Oral doxycycline (Amoxicillin if <8yo and pregnant women)

Front 481

What are the SE of doxycycline in children and unborn fetuses?

Back 481

Permanent tooth discoloration and skeletal problems

Front 482

Is serology for lyme disease recommended?

Back 482

Not in early localized disease bc too insensitive and many pts seroneg. After onset of erythema migrans, IgM antibodies to B. burgdorferi usually appear in 1-2 weeks and IgG in 2-6 weeks. Should get serology in pts with signs of early disseminated or late Lyme disease

Front 483

What is the classic presentation of cervicofacial actinomycosis? How do you treat?

Back 483

Slowly progressive, non-tender, indurated mass which evolves into multiple abscesses, fistulae, and draining sinus tracts with sulfur granules which appear yellow. Tx: high-dose penicillin for 6-12 weeks.

Front 484

What is an Actinomyces israelii infection?

Back 484

Anaerobic, Gram+ branching bacteria with infection in cervicofacial, thoracic, or abdominal region.

Front 485

What is the TB draining cervicofacial lesion called?

Back 485

Scrofula

Front 486

When is Amphotericin used?

Back 486

Systemic fungal infections in severely ill. Several serious SE

Front 487

When is hyperbaric oxygen therapy used/

Back 487

To treat the "bends" from deep sea diving, CO poisoning, and slow-healing ulcers

Front 488

What is the treatment of choice for primary (early) syphilis? What if allergic?

Back 488

A single IM injection of benzathine penicillin. If allergic to penicillin, get single dose of oral azithromycin or 2 weeks of doxy

Front 489

What is treatment of choice for neurosyphliis?

Back 489

IV aqueous craystaline penicillin or IM procaine penicillin

Front 490

What organism is responsible for most nosocoimal PNA in intubated pts? How treat?

Back 490

Pseudomonas. Treat with Cefepime (4th generation) or piperacillin-tazobactam. Can also use aztreonam, cipro, imipenem/cilastatin, tobramycin, gentamicin, amikacin

Front 491

What should think of in Gram neg bacilli in sputum of intubated ICU pt with fever and leukocytosis?

Back 491

Pseudomonas

Front 492

What are common sources of nosocomial Pseudomonas infections?

Back 492

Contaminated water faucets, respiratory therapy equipment, therapy pools, plant products (flowers, vegetables)

Front 493

What is clindaymcin effective against?

Back 493

Anaerobic and gram+ infections

Front 494

If an abx is being used and pt is deteriorating, should should continue that abx when start a new one?

Back 494

No - it isn't working, no reason to continue it

Front 495

What is used to prevent toxoplasmosis in HIV pts? What about PCP?

Back 495

Both can be prevented with TMP-SMX

Front 496

What are s/s of reactivation of toxoplasmosis in brain in immunocompromised pt?

Back 496

Fever, HA, confusion, ataxia, ring-enhancing lesion on brain MRI; can have seizure/focal neuro deficits due to mass effect of intracerebral lesion.

Front 497

When does toxoplasmosis risk inc in HIV pts?

Back 497

CD4 <100

Front 498

When is Isoniazid indicated for TB prophylaxis in HIV pts?

Back 498

Positive tuberculin skin test (>5mm) and those who have had contact with individual with active TB

Front 499

What finding of TB can look like toxo in brain in terms of symptoms?

Back 499

Tuberculoma but far less common than toxo

Front 500

When should give Azithro to HIV pts and what is it preventing?

Back 500

MAC prophyaxis in HIV pts when CD4 < 50

Front 501

What does Fluconazole protect against in HIV pts and when do use it?

Back 501

Prophylaxis against Cryptococcus neoformans and Coccidiodes immitis in HIV pts who have had these diseases in the past. Also used in pts with frequent Candida infections

Front 502

Do you need to prophylax against CMV in HIV pts?

Back 502

No - although ganciclovir has been shown to prevent CMV in HIV pts with CD4 <50, prophylaxis isn't generally recommended

Front 503

What is the MCC of UTI with alkaline urine (pH>7)?

Back 503

Proteus - secretes urease (an enzyme that hydrolyzes urea to ammonia and CO2. Ammonia then combines with H+ to form ammonium, which decreases the free H+ ion concentration). Alkaline pH promotes struvite stones, which contain a mixture of bacteria and proteinaceous matrix adn luekocytes. THe stone becomes a permanent source of bacteria to perpetuate the cycle.

Front 504

How do you treat Proteus UTI with staghorn (struvite) stones?

Back 504

Very difficult - abx alone won't cure bc the bacteria grow within the stone matrix and are not eradicated until teh entire stone and its fragments are removed

Front 505

What are the urease-producing bacteria?

Back 505

Klebsiella, Morganella morganii, Pseudomonas, Providencia, Stpah, Ureaplasma urealyticum, and Proteus.

Front 506

Which catheters have an inc risk of being infected by urease-producing bacteria?

Back 506

Chronic indwelling catheters

Front 507

What is the MC UTI pathogen?

Back 507

E. coli

Front 508

What is the abx regimen of choice for CNS cryptococcal infection in AIDS pts?

Back 508

IV Amphotericin + flucystoine. (then when there is clincal improvement with induciton therapy, those are discontinued and oral fluconazole is started as mainenance therapy)

Front 509

What is cryptococcus and who does it infect and what does it cause?

Back 509

Encapsulated yeast that commonly causes meningitis in HIV pts.

Front 510

What is an important cause of subacute meningitis in HIV pts?

Back 510

TB

Front 511

What can you treat Histoplasma capsulatum meningitis with?

Back 511

Itraconazole or Amphotericin

Front 512

What is used to treat toxoplasmosis and how does it usually present in HIV pts?

Back 512

Tx with oral sulfadiazine-pyrimethamine. Usually manifests as encephalitis in HIV pts - CT with contrast will show multiple hypodense, ring-enhancing lesions

Front 513

What should any HIV+ pt with blood diarrhea and normal stool exam have and what are you looking for?

Back 513

Colonoscopy looking for CMV colitis

Front 514

How does CMV colitis present? What does colonoscopy and bx present?

Back 514

Bloody diarrhea with abd pain. Colonoscopy - multiple ulcers and mucosal erosions. Bx: cytomegalic cells with inclusion bodies (eosinophilic intranuclear and basophilic intracytoplasmic ("owls eye" effect))

Front 515

What are causes of diarrhea in HIV pts (opportunitistic, non-opportunistic, and non-infectious)?

Back 515

Non-opportunitistic: Salmonella, Campylobacter, Entamoeba, Chlamydia, Shigella, Giardia lamblia. Opportunitistic: CMV, Cryptosporidium, Isopora belli, Blastocystis, MAC, HSV, Adenovirus, HIV itself. Non-infectious: Kaposi sarcoma, Lymphoma of the GI tract (hematochezia and lower abd cramps are usually due to colonic infection with CMV, C diff, Shigella, E. histolytica, or Campylobacter)

Front 516

What is CMV and what can it cause?

Back 516

Common opportunitistic pathogen in HIV pts, can cause esophagitis, gastritis, colitis, proctitis, or small bowel disease.

Front 517

What is the typical presentation of CMV colitis?

Back 517

Chronic bloody diarrhea, abd pain, CD4 <50.

Front 518

How do you treat CMV colitis?

Back 518

Ganciclovir (or Foscarnet in cases of ganciclovir failure or intolerance)

Front 519

What would you suspect in pt with facial nerve palsy and erythema migrans following outdoor activities in Lyme-endemic area?

Back 519

Lyme disease - Borrelia burgdorferi infection

Front 520

What is the most common tick-borne illness in the USA?

Back 520

Lyme disease - Borrelia burgdorferi infection

Front 521

What kind of infection is Lyme disease?

Back 521

Spirochete (Borrelia burgdorferi from Ixodes tick)

Front 522

What stage of Lyme disease is bell's palsy?

Back 522

Early disseminated

Front 523

What is the most common neurologic complication of Lyme disease?

Back 523

Unilateral or bilateral palsy of CN VII - usually lasts <2mo

Front 524

How should treat pts with Bell's palsy?

Back 524

In addition to treating the cause, if facial palsy is severe, corena may be at risk of dryness and abrasions due ot poor eyelid closure and reduced tearing --> artifiical tears during the day and eye patching at night

Front 525

What are the s/s of bell's palsy?

Back 525

Inability to close eye, dec forehead movement, absence of nasolabial fold

Front 526

How do you treat non-pregnant, >8yo pts with Bells palsy from Lyme?

Back 526

Doxycycline

Front 527

What is the classic presentation of Guillain-Barre?

Back 527

Ascending flaccid paralysis

Front 528

What are the MCC of idiopathic CN VII palsy?

Back 528

HSV and VZV.

Front 529

What is unique about idiopathic (VZV/HSV) Bells Palsy?

Back 529

Idiopathic: reactivation of HSV or VZV usually causes peripheral mononeuropathy without an associated vesicular rash

Front 530

What is Ramsay Hunt syndrome?

Back 530

(herpes zoster oticus) - mainfestation of VZV reactivation characterized by the triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and external auricle

Front 531

What do pts with disseminated gonococcal infection present with?

Back 531

Vesiculopustular dermatitis but not neurologic symptoms.

Front 532

What is the classic rash of syphilis?

Back 532

Diffuse maculopapular eruption of palms and soles

Front 533

What should pts started on anti-TB therapy also be started on ?

Back 533

VItamin supplements, esp pyridoxine to avoid peripheral neuropathy and other neurologic complications. 10mg/day to start, 100mg/day if already have peripheral neuropathy

Front 534

What is a known SE of isoniazid that can be prevented with pyridoxine supplements?

Back 534

Peripheral neuropathy (tingling in extremities, numbness, ataxia)

Front 535

What is the Jarisch-Herxhemier reaction?

Back 535

May develop in the treatment of syphilis - when primary or secondary syphilis is treated with penicilin, the spirochetes die rapidly, thereby leading to release of Ag-Ab complexes in the blood and consequently an immunologic reaction, which seems like an acute flare-up of syphilis

Front 536

What are signs/symptoms of a drug reaction?

Back 536

Skin eruptions, fever, angioedema, urticaria

Front 537

What must you need to suspect TB meningitis?

Back 537

Meningeal signs or CN involvement

Front 538

What is the MC pathogen causing PNA in nursing home pts?

Back 538

Strep pneumo

Front 539

What is the leading cause of death in nursing homes?

Back 539

PNA

Front 540

What is the MCC of CAP in adults?

Back 540

Strep pneumo

Front 541

What are common causes of PNA in adults?

Back 541

STrep pneumo, Staph aureus, H flu, Gram neg rods

Front 542

What are pts with neurologic disorders at inc risk for in terms of PNA?

Back 542

Aspiration PNA caused by anaerobes

Front 543

What causes N/V after eating rice? How quickly do these symptoms present?

Back 543

B. cereus. 1-6 hours before symptom onset. B. cereus is a heat stable toxin in inadequately refrigerated cooked rice.

Front 544

What 2 things can cause abrupt onset nausea and severe vomiting?

Back 544

Preformed toxins (B cereus, Staph auresu), chemical irritants

Front 545

How does Clostridium perfringens present?

Back 545

Watery diarrhea due to production of toxin in the gut. Symptom onset later than preformed toxins (8-14 hrs after ingestion). Diarrhea occurs with ingestion of a large number of organisms. Spore-forming, spores germinate in foods such as meats, poultry, or gravy

Front 546

What is mucormycosis? What can it lead to and how do you treat?

Back 546

Caused by fungus Rhizopus, causes infection of sinuses, brain, or lungs in immunocompromised, KOH staining shows hyphae. Can lead to serious complications or death if left untreated. Tx: aggressive surgical debridement + early systemic amphotericin B treatment (the only effective drug against this fungus)

Front 547

What is cutaneous larva migrans? Who is at risk? How does it present?

Back 547

aka creeping eruption. Helminthic disease caused by the infective-stage larvae of Ancylostoma braziliense (the dog and cat hookworm). Infection occurs after skin contact with soil contaminated with dog or cat feces containing infective larvae. Prevalent in tropical and subtropical regsions including southeastern US. People involved in activities on sandy beaches or in sandboxes are particualry inc risk. S/S: initially, multiple pruritic erythematous papules develop at the site of larval entry, followed by severely pruritic, elevated, serpiginous reddish brown lesions on the skin, which elongate at a rate of several mm per day as the larvae migrate in teh epidermis. Most commonly seen in lower extremities but upper extremities can become involved.

Front 548

What causes cat scratch disease? How does it present?

Back 548

Bartonella henselae. Characterized by self-limiting LAD. History of exposure to cast often present

Front 549

What is Sporotrichosis and how does it present?

Back 549

Fungal infection cause dby SPorothrix schenckii (dimorphic fungus). S/S: papule at the site of inoculation, followed by ulceration and LAD. Seen in gardeners

Front 550

What do brown recluse spider bites look like?

Back 550

Papule with erythema at the site of the bite, followed by severe ulceration

Front 551

What caues scabes and how does it present? How is it transmitted?

Back 551

Parasitic infection caused by Sarcoptes scabeie. Presents as pruritic skin infection in volar wrist, interdigital web spaces, elbows, or penis. Burrows made by the parasite appear as short, wavy lines in these regions and may be accompanied by papules, vesicles, pustules, or eczemtaous plaques. Transmitted by close contact with another infected individual.

Front 552

When and how should ticks be removed?

Back 552

ASAP to dec risk of illness. Best removed with tweezers as close to teh skin as possible, pulling straight up with steady pressure

Front 553

What is the criteria for Lyme disease prophylaxis (must meet all 5). What is prophlyaxis?

Back 553

Attached tick is adult or numphal Ixodes scapularis (deer tick), tick attached for >36hrs or engorged, prophylaxis started wtihin 72hrs of tick removal, local B. burgdorferi infection rate >20% (ex: New england), no contraindicates to doxycycline (ex: <8yo, pregnant, lactating). Prophylaxis: 1 dose of doxycycline

Front 554

What is the pathogenic mechanism of osteomyelitis adjacent to a foot ulcer in DM?

Back 554

Contiguous spread of the infection

Front 555

Why are DM pts prone to developing foot ulcers?

Back 555

Arterial insufficiency and peripheral neuropathy. Bc of poor tissue perfusion, immune system has difficulty combating infection in the region surrounding the ulcer -> thus, an open ulcer is an ideal site for entry of bacteria and infection of the soft tissue can easily spread to include neighbroing bone -> osteomyelitis

Front 556

Who does hematogenous osteomyelitis occur in?

Back 556

Typically children

Front 557

What is the pathologic mechanism of post-traumatic osteomyelitis?

Back 557

Direct inoculation

Front 558

How does osteomyelitis occur after operative procedures?

Back 558

Due to nosocomial contamination

Front 559

What should HIV pts with dysphagia be treated empiricaly with? What if symptoms persist?

Back 559

1-2 weeks of oral fluconazole since candidal esophagitis is the most likely diagnosis. If symptoms persist, go to EGD

Front 560

How to distinguish esophagitis cause in HIV pts via EGD with bx?

Back 560

HSV: multiple, well circumscribed, "volcano-like" (small and deep) ulcers, cells show ballooning degeneration and eosinophilic intranuclear inclusions. CMV: Large, shallow, superficial ulcers, intranuclear and intracytoplasmic inclusions.

Front 561

What do pts with CMV esophagitis complain of?

Back 561

Focal substernal burning with odynophagia

Front 562

How do you treat CMV esophagitis? HSV esophagitis?

Back 562

IV Ganciclovir for CMV, Acyclovir for HSV

Front 563

When infective endocarditis is suspected, what is the next step?

Back 563

Empiric abx after drawing blood cultures (then can do TEE after (or TTE if suspect tricuspid endocarditis - esp in IVDA))

Front 564

What are major risk factors for infective endocarditis?

Back 564

Valvular disease, IVDA

Front 565

When have splinter hemorrhages and microscopic hematuria without migratory polyarthritis in valvular disease pt, what shoudl suspect?

Back 565

Infective endocarditis

Front 566

What is the Duke criteria used for?

Back 566

Infective endocarditis

Front 567

What are the common acute life-threatening reactions assoc with HIV therapy? (know!)

Back 567

1. Didanosine-induced pancreatitis 2. Abacavir-related hypersensitivity syndrome 3. Lactic acidosis secondary to any of NRTIs 4. Stevens-Johnson syndrome secondary to use of any of the NNRTIs 5. Nevirapine-assoc liver failure

Front 568

Which HAART therapy causes crystal-induced nephropathy?

Back 568

Indinavir (protease inhibitor) - caused by precipitation of the drug in the urine and obstruction of the urine flow. Can occur even with good hydration and complications can occur early. Therefore, monitor UA and serum Cr every 3-4mo

Front 569

**When can antiviral meds be used in influenza and how do they help?

Back 569

Must be given within 48hrs of onset of symptoms. Can reduce duration of symptoms by 2-3 days. Otherwise, tx with bed rest and simple analgesia (ex: acetaminophen)

Front 570

What are amantadine and rimantadine effective against? What are zanamivir and oseltamivir effective against? **

Back 570

Amantadine and Rimantadine - Influenza A. Neuraminidase inhibitors (zanamivir, oseltamivir) - both influenza A and B. Note: Zanamivir only approved for the treatment, but not the prevention of influenza. Use the neuraminidase inhibitors when influenza B strains are circulating in the community

Front 571

What are the symptoms of influenza?

Back 571

Abrupt onset of fever, chills, malaise, HA, coryza, non-productive cough, sore throat, muscle aches, occasionally nausea. Influenza A and B give these symptoms, C is usually minor. Self-limiting if healthy, typicla suration 1-7d

Front 572

What is the abx of choice in prophlyaxis/treatment of fite bites?

Back 572

Augmentin (amoxicillin-clavulanate) bc often polymicrobial with Gram+, Gram-, anaerobes

Front 573

What is the abx of choice in dog bites?

Back 573

Augmentin

Front 574

What is Clindamycin used for?

Back 574

Gram+, anaerobes - typically used for lung abscesses and infections of female genital tract.

Front 575

What is the drug of choice for Legionnaire disease?

Back 575

Erythromcyin

Front 576

What is Erythromycin used for?

Back 576

Legionnarie disease (DOC), treatment of CAP. No good anaerobic coverage

Front 577

What test is both sensitive and specific for diagnostic infectious mono and should be used for dx? What test should be used in suspectied mono with neg initial test?

Back 577

Heterophile Ab test (monospot) - appear within 1 week of onset of symptoms, may persist in low levels ofr up to 1 year. But may not appear until later in course of illness -> neg heterophile Ab test in first few weeks of illness doesn't rule out diagnosis of mono. If neg and suspect IM, get EBV-specific Ab test. Atypical lymphocytes on peripheral smear are seen, but aren't specific - may be present in toxo, rubella, roseola, viral hepatitis, mumps, CMV, acute HIV, some drug reactions

Front 578

What is the triad of high fever, LAD, pharyngitis highly suggestive of?

Back 578

Infectious mononucleosis

Front 579

What is the etiologic agent of mono?

Back 579

EBV (herpesvirus family).

Front 580

Who is mono most common in and how does it spread? What are s/s?

Back 580

Most common in adolescents and young adults, spread by intimate contacts. S/S: LAD involvement (typically posterior), tender HSM, mild leukocyosis with lymphocytic predominance, high fever, pharyngitis

Front 581

What is the preferred screening test for HIV infection?

Back 581

ELISA (99.9% sensitivity)

Front 582

What is the confirmatory test for HIV?

Back 582

Western blot (99.9% specificity)

Front 583

How high do viral loads need to be to be assoc with poor prognosis?

Back 583

>100,000 copies/mL

Front 584

At what CD4 count should pts be started on antiretroviral therapy?

Back 584

CD4 <200

Front 585

What do you use for antimalarial prophylaxis in Sub-Saharan Africa and India subcontinent (India, Pakistan, Bangladesh)?

Back 585

Mefloquine bc of chloroquine-resistant Plasmodium falciparum (chloroquine is DOC if in sensitive area). Need to start 1 week before travel and continue until 4 weeks after get back

Front 586

When do you use primaquine for antimalaria?

Back 586

For both prophylaxis and treatment in areas where malaria is due to P. vivax or P. ovale. These organisms cause persistent infection in the liver.

Front 587

What is Norcardia? What presentation can it have? How is at risk? Tx?

Back 587

Crooked, branching, beaded Gram+, partially acid-fast bacteria on microscpy, aerobic. Present in soil. Can present as pulmonary, CNS, or cutaneous lesiosn. Pts with cell-mediated deficiencies in immunie system (lymphoma, AIDs, transplant pts) are at inc risk for pulmonary or disseminated disease. Pulmonary occurs after inhalation of bacteria, typically manifests as subacute PNA that develops over days-weeks; empyema in 1/3; 50% have extrapulmonary dissemnaiton - brain most common site. Tx: TMP-SMX is TOC, Minocycline is best oral alternative. Can dec risk in AIDS and transplant pts with prophylaxis with TMP-SMX

Front 588

Adults and children - what are most common causes of community-acquired bacterial meningitis and what should use empirically to treat?

Back 588

Strep pneumo, H flu, Neisseria. Use Vanco + ceftriaxone (many pneumococcal strains are resistant to penicillin and cephalosporins, so need to add vanco - but note that vanco alone doesn't penetrate BBB, need with ceftriaxone)

Front 589

What do you need to add to meningitis treatment regimen in pts >55yo and what are you covering for?

Back 589

Listeria - need to add Ampicillin

Front 590

What do you use to treat immunocompromised pts with meningitis and what are you covering?

Back 590

Basic is ceftriaxone + vanco to cover the usual strep pneumo, H flu, Neisseria but add Ampicillin to cover Listeria bc of inc risk in immunocompromised, pts with malignancy (esp lymphoma), corticosteroids

Front 591

What do you use for meningitis in pts <3mo and what are you covering?

Back 591

IV cefotaxime + ampicillin - covers common CA-meningitis (strep pneumo, H flu, Neisseria) + Listeria (ampicillin). Although ceftriaxone can be used in neonates, cefotaxime is generally preferred bc ceftriaxone is assoc with biliary sludging

Front 592

What should you use in meningitis for pts after neurosurgery and why?

Back 592

IV ceftazidime (for Pseudomonas) + vanco (for staph aureus)

Front 593

How do condylomata acuminata present and how do you treat?

Back 593

(anogenital warts) Verrucous, skin colored, papilliform lesions around anogenital lesions (contrast to condyloma lata which are flat or velvety). Uusually no systemic lesions. 3 options for tx: 1. chemical or physical agents (trichloroacetic acid, 5-FU epi gel, and podophylllin). 2. Immune therapy (imiquimod, IFNalpha), 3. Surgery (cryosurgery, excisional procedures, laser tx). Choice of tx depends on number and extent of lesions - podophyllin is a topical antimitotic agent that leads to cell death - it is teratogenic and thus contraindicated in pregnancy; its other adverse effcts are local irritation and ulceration

Front 594

How do you treat condyloma lata and what are they from?

Back 594

Secondary syphillis - tx with penicillin. If allergic, give tetracycline or doxy

Front 595

What are bacillary angiomatosis? What causes it, who is at risk, and how do you treat?

Back 595

Bright red, firable, firm, exophytic nodules. Caued by Bartonella (Gram neg bacillus). HIV infected pts are at risk. TOC: oral erythromycin

Front 596

What does Kaposi sarcoma skin lesions look like?

Back 596

Papules taht become plaqures or nodules; color changes from light brown to pink to dark violet. Skin lesions occur on trunk, face, and extremities.

Front 597

What does Pneumocystis cutaneous lesions look like?

Back 597

Nodular and papular cuaneous lesions of external auditory meatus. Unlikely if pt on TMP-SMX

Front 598

What does molluscum contagiosum look like?

Back 598

Poxvirus. Centrally-umbiliated, dome-shaped papules that are non-pruritic

Front 599

Are HSV lesions painful?

Back 599

Yes

Front 600

When can pt with uncomplicated pyleonephritis be changed to oral suspecitble agent?

Back 600

After 48-72 hours; oral therapy more convenient and less expensive. Then continue for total of 2 weeks

Front 601

What is the typical presentation of Trichinosis/Trichinellosis?

Back 601

GI complaints followed by characteristic triad of periorbital edema, myositis, eosinophilia. Other clues: subungal splinter hemorrhages and conjunctival or retinal hemorrhages.

Front 602

What is Trichinosis/Trichinellosis?

Back 602

Parasitic infection cause dby the roundworm Trichinella. It is acquired by eating undercooked pork that ocntains encysted Trichinella larvae. The disease occurs in 3 phases - initially when larvae invade intestinal wall - get abdominal pain, N/V/D. Then in second week, local and systmic hypersensitivy reaction caused by larval migration causes "splinter" hemorrhages, conjunctival and retinal hemorrhages, periorbital edema, and chemosis. Then as the larvae enter the patient's skeletal muscle, get muscle pain, tenderness, swelling, weakness. High eosinophil count

Front 603

What is Ascariasis?

Back 603

Often presents as a lung phase with non-productive cough followed by asymptomatic intestinal phase. Symptoms often result from obstruction caused by the organisms themselves, such as small bowel or biliary obstruction. Will have eosinophilia

Front 604

What are s/s of botulism?

Back 604

Constipation, descending paralysis, resp failure.

Front 605

How does Guillian-Barre syndrome present?

Back 605

Usually after mild upper respiratory or GI infection. Initial symptoms include tingling of toes and fingers followed by ascending paralysis. Pts also complain of back pain. Late in course CN are affected

Front 606

What is usually assoc with angioedema?

Back 606

C1 inhibitor deficiency or ACEI

Front 607

What causes Ascariasis?

Back 607

The worm Ascaris (sp?) Lumburcoides (sp?)

Front 608

WHat is the msot common parasitic infection of the brain?

Back 608

Neurocysticoercosis

Front 609

Where do you find Neurocysticercosis (who is at risk) and what organism causes it and what is the pathogenesis? What are the s/s and what is the prognosis?

Back 609

Most prevalent in rural areas with poorer sanitary conditions and where PIGS are raised. It is a parasitic disease caused by the larval stage of the pork tapeworm Taenia solium. It is contracted when a person consumes T. solium eggs excreted by another person. Humans are the only definitive host for T. solium (they are the only ones that can be infeected). The adult tapeworm lives in the upper jejunum and excretes its eggs into the person's feces (intestinal infection). If an animal consumes these eggs, it becomes an intermediate host, with larvae encysting in its tissues. The most common intermediate host is a pig. Then, when human consumes larvae in meat that is infected (ex: infected undercooked pork), then can again develop intestinal infection with adult tapeworm. However, if a person (rather than a pig) consumes T. solium eggs excreted in human feces, cysticercosis results. After ingestion, the embryos are released in the intestine and the larvae invade the intestinal wall. After ingestion, the embryos are released in the intestine and the larvae invade the intestinal wall. They disseminate hematogenously to encyst the human brain, skeletal muscle, subcutaneous tissue, or eye (note that cysticercosis is not contracted by eating infected pork, so people who do not eat pork can still be affected. The most common manifestation of cysticerosis are neurologic. Neurocysticercosis (NCC) is characterized by multiple small (<1cm) fluid-filled cysts in the brain parenchyma. These cysticerci have a membranous wall and often demonstrate characteristic invaginated scolex on neuroimaging. Most prevalent in the rural areas of Latin America, sub-Saharan Africa, China, south and Southeast Asia and Eastern Europe, esp where pigs are raised and sanitary conditions are poor. Most common parasitic infection of the brain. Humans with cysticerci are dead-end hosts. 80% of neurocysticercal infections are asymptomatic and found accidnetally on brain autopsy

Front 610

What do CJD and Kuru look like on microscopy of brain?

Back 610

They are both prion diseases that cause spongiform encephalopathy in which intracytoplasmic vacuoles are evident diffusely throughout gray matter on microscopy

Front 611

How does lymphoma/tumors present in neuroimaging?

Back 611

Solid lesions

Front 612

What are Hydatid cysts caused by and where do you find them? Who is at risk?

Back 612

Echinococcus sp - found in liver, lungs. More common in sheep breeders

Front 613

WHere is Norcardia asteroides found and who does it commonly infect. How can it manifest and how diagnose? Tx?

Back 613

FOund in soil and water (G+, weakly acid-fast, filamentous branching rod). Infects immunocompromised (HIV, transplant). Lung is most commonly involved - can manifest as nodules, a reticulonodular pattern, diffuse pulmonary infiltrate, abscess, or cavitary formation. Dx is hard - presumptive dx can be made if partially acid-fast, filamentous branching rods are seen on clinical specimens. Tx: TMP-SMX

Front 614

Where is Coccidiodomycosis found?

Back 614

Southwestern USA

Front 615

What is the MCC of CAP?

Back 615

Pneumococcus

Front 616

What CSF findings are suggestive of bacterial meningitis?

Back 616

Inc WBC, Inc protein, Dec glucose

Front 617

What are the typical s/s of meningococcal infection?

Back 617

Skin: petechiae and purpura. Myalgias (more intense than in the flu), sudden onset fever, stiff neck, HA, nausea, hypotesnion, tachycardia. Typically otehrwise healthy pt (viral meningitis can prsent similarly but not with purpura)

Front 618

What is characteristic of syphilitic meningitis?

Back 618

Usually assoc with peripheral rash of secondary syphilis (palms, soles) with generalized LAD and usually not sudden onset

Front 619

Where does rash of RMSF start?

Back 619

ankles adn wrists and spreads centrally to palms and soles

Front 620

What are the arboviruses and what is its neurologic manifestaion and how does it present?

Back 620

Eastern equine, Western equine, St Louis, and West Nile virus. Typically causes encephalitis -> AMS, fever, focal neuro deficits without nuchal rigidity or signs of meningitis

Front 621

What causes bacillary angiomatosis, who is at risk, and what does it cause? How can dx and what should be careful for? How tx?

Back 621

Casued by Bartonella henselae and Bartonella quintana. Usually affects immunocompromised (AIDS, hematologic malignancies, chemo pts, transplant pts). Causes nonspecific constitutional symptoms (fever, wt loss, malaise, abd pain) in addition to characteristic lesions of skin and viscera - large, pedunculated exophytic papule with a collarete of scale - resembles a large pyogenic granuloma or cherry angionma. Dx: tissue bx and microscopic identification of organsms and the characteristic angioatmous histology. Use extreme caution in biopsying these lesions bc they are prone to hemorrhage. Can tx with a variety of abx which lead to involution of the diseases

Front 622

What bug/disease affecting nose and maxillary sinuses is assoc with DM? ***

Back 622

Mucormycosis most commonly caused by Rhizopus. Poorly controlled DM predisposes

Front 623

What are the s/s of mucormycosis?

Back 623

Low-grade fever, bloody nasal d/c, nasal congestion, involvement of eye with chemosis, proptosis, diploplia. Involved nasal turbinates can become necrtoic. Invasion of local tissues can lead to blindness, cavernous sinus thrombosis, coma. Typically affects nose and maxillary sinus. Can lead to death in days-weeks if not treated

Front 624

What causes malignant otitis externa commonly?

Back 624

Pseudomonas - can cause black necrotic lesions in the ear

Front 625

What does cryptococcus neoformas cause in immunocompromised pts?

Back 625

Meningitis

Front 626

What can candida caause in DM pts?

Back 626

Thrush, Vaginitis

Front 627

Who is secondary bacterial PNA common in and what are the common organisms?

Back 627

Elderly (usually viral is the primary infection). Strep pneumo, Staph aureus, H flu

Front 628

Which pathogens known to cause secondary PNA can cause necrotizing bronchopneumonia with secondary pneumatoceles (multiple nodular infiltrates that can cavitiate to cause small abscesses)

Back 628

?

Front 629

How is Legionnaires disease transmitted and what does it look like on CXR?

Back 629

Aerosol transmission from an environmental water source. CXR: multiple small pulmonary abscesses

Front 630

If a PE were to cause CXR findings, what would they look like?

Back 630

Single wedge-shaped parietal pleural-based infarct

Front 631

What does reactivation of pulmonary TB cause?

Back 631

Upper lobe fibrocaseous cavitations

Front 632

What does bronchoiectasis cause?

Back 632

Dilated bronchi, can cause blood tinged purulent sputum

Front 633

What does atypical PNA look like on CR?

Back 633

Diffuse interstital infiltrates on CXR

Front 634

When is pneumococcal vaccine recommended for HIV pts?

Back 634

All children and adults with HIV with CD4 >200

Front 635

When is Hep A vaccine recommended for HIV pts?

Back 635

When suffering from Hep B, Hep C, or both.

Front 636

Who is Hep A vaccine recommended or?

Back 636

HIV pts with Hep B or C; IVDA; men who have sex with men; pts with preexisting liver disease

Front 637

What is seen on serology to indicate either previous Hep B vaccination or exposure to the disease?

Back 637

anti-HBsAg antiboies

Front 638

When is meningococcal vaccination indicated?

Back 638

Splenectomy or functional asplenia or for pts travelling to high risk countries. The response to vaccine has been suboptimal in HIV pts and so isn't routine

Front 639

Should HIV pts get annual flu vaccine?

Back 639

yes

Front 640

Should give HIV pts BCG vaccine?

Back 640

No - role is unproven and may cuase disseminated TB in HIV-infected pts

Front 641

What is Echinococcosis and what causes it? Who is at risk and what is the pathogenesis? What does it cause?

Back 641

Parasitic infection caused by the tapeworm echinoccocus - 4 species of Echinococcus can produce infection in humans -the 2 msot common are E. granulosis causing cystic echinococcosis and E. multilocularis causing alveolar echinococcosis. Most human infecitons are caused by the SHEEP strain of E. granulosis - dogs and other canines are definitive hosts and sheep are intermediate hosts. Humans are dead-end accidental intermediate hosts. Most common in areas where sheep are rasied and transmission is seen when dogs living in close proximity of humans are fed the viscera of home-slaughtered animals. The infectious eggs excreted by dogs in the feces are passed on to other animals and humans; after ingestion of eggs by humans, the oncospheres are hatched and penetrate the bowel wall disseminating hematogenously to various visceral organs, leading to formation of hydatid cysts. THe liver, followed by the lung, are the most common viscus invovled, but any viscera can be involved. Hydatid cysts are fluid-filled cysts with an innter germinal layer and outer acellular laminated membrane. The Germinal layer gives rise to numberous secondary daughter cysts

Front 642

Who is at risk for neurcysticercosis?

Back 642

Pig farmers

Front 643

What can gonorrhea cause in the liver?

Back 643

Perihepatitis

Front 644

What does post-exposure prophylaxis for rabies involve?

Back 644

Both active and passive immunization

Front 645

What should you do if bit by a dog and it is not captured and assumed to be rabid?

Back 645

Post-exposure prophylaxis (active + passive immunization)

Front 646

What should do if bit by a dog and it is captured but doesn't show signs of rabies?

Back 646

Keep dog in observation for 10 days to llok for features of rabies - if shows them, start post-exposure prophylaxis. The dog's diagnosis is confirmed by fluorescent AB exam of the brain

Front 647

In dog bites on what part of the body require post-expsoure prophylaxis immediately?

Back 647

Head and neck

Front 648

What is a serious pulmonary complicaiton of influenza pneumonia in both children and adults? How treat?

Back 648

Staph aureus pneumonia. Treat with anti-staph abx.

Front 649

Who is susceptible to Staph aureus PNA?

Back 649

Relatively UNcommon cause of CAP. Most often affects hospitalized pts, nursing home pts, IVDA, pts with CF, or pts with recent influenza vaccination.

Front 650

Who do you usually see PCP PNA in?

Back 650

HIV pts with Hep B or C; IVDA; men who have sex with men; pts with preexisting liver disease

Front 651

WHo do you usualy see Klebsiella PNA in? What will see on gram stain? What are the characteristic features?

Back 651

DM, alcoholics, nosocomial setting. Gram neg encapsulated rods. "Currant jelly sputum", cavitatin, empyema

Front 652

What does Pseudomonas aeroginosa cause and what kind of bug is it?

Back 652

Gram neg rod -> nosocomial PNA in pts with CF and bronchiectasis

Front 653

What is the leading cause of atypical PNA? What are teh s/s? What will see on gram stain and CXR?

Back 653

Mycoplasma pneumoniae. Non-productive cough, HA, rash. Gram stain: no organisms seen, but cold agglutinins may be present in blood. CXR: interstitial pattern

Front 654

What are the leading cause of lung abscesses and who is at risk. What is the presentation? CXR?

Back 654

Anaerobes. Pts who aspirate and have poor dentition are at risk. Presentation may be subacute. If lung abscess is present, CXR will reveal fluid-filled cavity

Front 655

Where is histoplasmosis endemic?

Back 655

Ohio rivier valley

Front 656

Who does histoplasmosis occur in and how does it present?

Back 656

Self-limited in immunocompetent but cna caouse significant pulmonary and disseminated disease in pts with CD4 <100 - these ppl present with fever, wt loss, night sweats, N/V, cough with SOB, diffuse LAD, HSM. Labs: pancytopenia (if BM invovled), elevated LFTs, elevated ferritin

Front 657

What is the most sensitive test to diagnose disseminated histoplasmosis?

Back 657

Ag detection in urine or serum (fungal blood cultures are more sensitive for chronic pulmonary histoplasmosis and can take up to 6 weeks to become positive; serologic tests for histo include complement fixation titers and immmunodiffusion tests - can initially be neg in acute disease and can take up to 4 wks to be come more positive for histo; no longer doing skin testing)

Front 658

What is the preferred TOC for histoplasmosis?

Back 658

Mild-moderate disease: Itraconazole alone. If more severe disease (high fever >103.1, lab abnormalities, or fungemia) should initially be treated with IV liposomal Ampho B for 2 weeks then Itraconazole for 1 year.

Front 659

What is caspofungin?

Back 659

An echinocandin anti-fungal

Front 660

What is Flucytosine used to treat?

Back 660

Cryptococcus and Candida

Front 661

When is induration of >5mm considered positive for PPD?

Back 661

HIV+, recent contact with TB-positive person, signs of TB on CXR, organ transplant pts, pts on immunosuppressive therapy

Front 662

When is induration of >10mm considered positive for PPD?

Back 662

Recent emigration from endemic TB area, IVDA, residents/employees of high-risk settings (prisons, homeless shelters), DM, CKD, hematologic malignancies, fibrotic lung disease, <4yo, teends exposed to high risk adults

Front 663

What induration # is considered positive for healthy individuals with no risk factors for TB?

Back 663

>15mm

Front 664

What is the next step for a pt with positive PPD?

Back 664

CXR to evaluate for pulmonary TB. If Positive PPD but no active TB signs on CXR, should be treated for latent TB infection

Front 665

What med should you use for latent TB infection?

Back 665

many - INH+pyridoxine for 6-9mo

Front 666

Who is more prone to tricupsid endocarditis caused by staph aureus?

Back 666

IVDA

Front 667

What are some of the characteristics of infective endocarditis in IVDA?

Back 667

1. HIV infection increases infective endocarditis risk in IVDU. 2. S. aureus is MC organism. 3. Tricupsid valve (right-sided) mroe common than aortic valve --> lacks audible heart mumur, septic pulmonary emboli common, fewer peripheral infectious endocarditis manifestations (splinter hemorrhages, Janeway lesions), heart failure more common in aortic valve involvement, but rare with TV involvement

Front 668

How do septic emboli appear on CT?

Back 668

pulmonary infiltrates, abscesses, infarction, pulmonary gangrene, or cavities. Usually in lung periphery. UPto 75% of pts with tricuspid IE will have septic emboli

Front 669

Where does H flu colonize? What does it cause?

Back 669

URT. URT infections, bronchitis (esp in COPD pts), and PNA.

Front 670

Who is more susceptible to Legionella infection?

Back 670

Chronic lung disease, smokers, immunosuppressed. Transmitted thru contaminated aerosolized water such as cooling symptoms.

Front 671

How do septic emboli and TB cavitary lesions differ?

Back 671

TB is SLOWER progressing with symptoms of malaise, anorexia, wt loss, fever, night sweats along with pulmonary findings. Also, chronic cough (not dyspnea) is most common pulmonary symptom

Front 672

When do you see PCP pneumona and how does it present?

Back 672

HIV pts with CD4 <200. SUBACUTE resp symptoms with diffuse infiltrates on CXR and inc alveolar-areterial gradient

Front 673

What does Staph epidermidis affect?

Back 673

Coag-neg staph - infections in prosthetic valves, IV shunts, prosthetic joints. Normally present in skin and can contaminate blood cultures

Front 674

Why is infectious endocarditis in IVDA more suspectible to septic emboli to lungs?

Back 674

Bc in IVDA, IE usually occurs in tricuspid valve (R-sided) so fragments of vegetation can embolize to the lungs -> characteristic nodular infiltrate with cavitation

Front 675

What should suspect in DM pt with severe ear pain, otorrhea, and evidence of granulation tissue in ear canal?

Back 675

Malignant otitis externa caused by Pseudomonas. Often have ear discharge and pain radiating to TMJ and exacerbated by chewing. Inc risk in DM and immunosuppressive conditions.

Front 676

What is the classic presentation of Sporotrichosis?

Back 676

aka Gardener's disease. Initial lesion is a reddish nodule that later ulcerates (painless), appears at the site of the thorn prick or other skin injury. From the site of inoculation, the fungus spreads along the lymphatics forming subcutaneous nodules and ulcers. (sporothrix schenckii is a dimorphic fungus found in the natural environment in the form of mold (hyphae); it resides on the bark of tress, shrubs, and garden plants and on plant debris in soil. Common in gardeners. Uusally no LAD or systemic signs of infection

Front 677

Is there adenopathy usually in cellulitis?

Back 677

Yes, tender LAD with systemic signs of infection

Front 678

What bugs are pts with hemochromatosis more susceptible to?

Back 678

Listeria, Yersinia, and Vibrio sepsis (all are iron-loving)

Front 679

HSV encephalitis - symptoms, exam, Labs/imaging, Tx?

Back 679

Symptoms: fever, AMS with confusion and agitation, risk of seizures and coma. Exam: hemiparesis, CN palsies (signs of focal neuro deficits), hyperreflexia. Labs/imaging: CSF: inc WBC (L's predomin), normal glucose, inc protein. Brain MRI: temporal lobe abnormalities, Dx: CSF shows presence of viral DNA on PCR. Tx: IV acyclovir - start immediately after getting CSF fluid

Front 680

What do you use to treat cryptococcal meningoencephalitis?

Back 680

IV Amph + flucystosine.

Front 681

How do pts with cryptococcal meningitis usually present and who is it common in?

Back 681

Usually cause subacute meningitis and pts commonly present weeks after symptoms. MC in immunocompromised. Symptoms are due to inc intracranial pressures (headache) from capsular swelling). Almost all pts have INC OPENING PRESSURE on spital tap.

Front 682

What is the basic empiric tx for bacterial meningitis?

Back 682

IV ceftriaxone + vanco (+ ampicillin in aduts >50yo)

Front 683

What is chlordiazepoxide used to treat?

Back 683

Alcohol withdrawal in hospitalized pts. Withdrawal can begin in 1-2 days after stopping alcohol and can present with tremulousness, anxiety, HA, and palpitations. Can progress to fever, HTN, and delirium tremnes.

Front 684

What should pts with PID also be screened for?

Back 684

HIV, syphilis, Hep B, cervical cancer pap smear), and Hep C if history of IVDA

Front 685

How should you treat gonorrhea?

Back 685

Ceftriaxone (+Azithro for Chlamydia coverage)

Front 686

How do you screen for syphilia?

Back 686

RPR

Front 687

How do you screen for HSV?

Back 687

Tzank smear on active genital lesions

Front 688

What does Hep A cause?

Back 688

Food poisoning

Front 689

How is Hep C primarily transmitted?

Back 689

IVDA or blood transfusions. Very rarely through sex

Front 690

Where is coccidiodomycosis found? What are the s/s?

Back 690

Southwestern US as well as Central and South America. Primary pulmonary infection has nonspecific features, such as fever, fatigue, dry cough, wt loss, and pleuritic CP. Cutaneous fidnings such as erythema multiforme and erythema nodosum, as well as arthralgias, are common

Front 691

Where is histoplasmosis endemic and what are the symptoms?

Back 691

Southeastern, mid-atlantic, and central US. Can cause acute PNA which presents as cough, fever, malaise

Front 692

WHere is Blastomycosis endemic and what does it cause?

Back 692

South-central and north-central US. Usually affects the lungs, skin, bones, joints and prostate. Usually in an immunocompromised host does it cause these problems. Primary pulmonary infection is asymptomatic or presents with flu-like symptoms

Front 693

What does invasive aspergillosis present as and who does it occur in? What does imagingin show?

Back 693

Immunocompromised (neutropenia, cyclosporine, high dose steroid pts). Invasive pulmonary disease presents with fever, cough, dyspnea, or hemoptysis. CXR may show cavitary lesions. CT: pulmonary noduels with halo sign or lesions with an air crescent

Front 694

When does cryptococcus typically cause meningoencephalitis in HIV pts? How is it transmitted?

Back 694

CD4 <200. Organism gains entry thru inhalation, which results in pulmonary phase - often asymtomatic but can cause CP or cough. Rare in healthy.

Front 695

When should HIV pts get prophlyaxis against MAC and with what?

Back 695

CD4 <50 with Azithromycin or Clarithromycin (or Rifabutin as an alternative to macrolides)

Front 696

What HIV pts should get prophylaxis from histoplasmosis and with what?

Back 696

CD4 <100 and living in endemic area. Get Itraconazole

Front 697

What is an alternative PCP prophlyaxis for HIV other than TMP-SMX?

Back 697

Pentamidine

Front 698

Is CMV prophylaxis for HIV recommended?

Back 698

Not currently

Front 699

What is the treatment of choice for pregnant and lactating women with early localized Lyme disease?

Back 699

Amoxicillin

Front 700

Where is Lyme disease endemic?

Back 700

NE and upper midwestern USA

Front 701

Can you diagnose early localized Lyme disease soley on erythema migrans?

Back 701

Yes

Front 702

Why is doxycycline so good for lyme disease?

Back 702

Bc it workes for Lyme but also can prevent/treat coexisting human granulocytic anaplasmosis, an infection also carreid by Ixodes scapularis.

Front 703

What is the treatment of choice for Lyme disease in children < 8yo?

Back 703

Amoxicillin

Front 704

When should expect rash and constitutional symptoms of Lyme disease to go away?

Back 704

Within 3 weeks of treatment

Front 705

When should use IV 3rd gen cephalosprins in treating lyme disease?

Back 705

Reserved for meningitis, encephalopathy, or carditis bc of need for hospitalization and exposure to broader-spectrum abx (but would work for the earlier phases ofLyme disease)

Front 706

What are the complications of lyme disease that you aim to prevent with treatment?

Back 706

Facial palsy, aseptic meningitis, heart block, or arthritis

Front 707

How does erysipelas typically present? What is the most common organism?

Back 707

Sharply-demarcated, erythematous, edematous, tender skin lesion with raised borders in a febrile pt. MCC: Group A beta-hemolytic strep. Abrupt onset, legs most common site (it is a specific type of cellulitis).

Front 708

When should consider Pseudomonas in cellulitis?

Back 708

Puncture wound

Front 709

When shoudl consider H flu in cellulitis?

Back 709

Face of a child

Front 710

What is the causative organism of gas gangrene?

Back 710

Clostridium perfringens

Front 711

What should suspect in AIDS pt with multiple ring-enhancing lesions on CT?

Back 711

Toxoplasmosis

Front 712

What should use for prophylaxis of toxoplasmosis and what should use for treatment?

Back 712

Prophylaxis with TMP-SMX and sulfadiazine and pyrimethamine for treatment

Front 713

How does primary CNS lymphoma usually present?

Back 713

Afebrile, lesiosn are weakly enhancing and usulaly single (but can be multiple)

Front 714

Where does reactivation of TB in HIV pts usually occur?

Back 714

Lungs

Front 715

What is albendazole used to treat?

Back 715

Neurocysticerosis. Very uncommon in US (but most common parasite to infect the brain worldwide) and usually not seen in AIDS pts

Front 716

In a pt with a nail puncture would resulting in osteomyelitis, what is the most likely pathogen? Tx?

Back 716

Pseudomonas (esp where puncture occurs thru rubber-soled footwear). Tx with oral or parenteral quinolones and aggressive surgical debridement

Front 717

What is the most common cause of osteomyelitis in children and adults?

Back 717

Staph aureus

Front 718

How long does it take for plain x-rays to show osteomyelitis?

Back 718

2+ weeks

Front 719

What is a common cause of osteo in DM pts?

Back 719

Staph aureus (coag positive)

Front 720

What is the presentation of candida osteomyelitis and who can it occur in?

Back 720

IVDA. Presentation usually subacute unlike bacterial osteo

Front 721

Where does TB osteo usually occur?

Back 721

Spine (Pott's disease)

Front 722

Where is blastomycosis endemic and what does it usually affect? What i the presentation?

Back 722

South-central and north-central US. Usually affects the lungs, skin, bones, joints and prostate. Usually in an immunocompromised host does it cause these problems. Primary pulmonary infection is asymptomatic or presents with flu-like symptoms. Cutaneous disease is either verrucous or ulcerative. Verrucous lesions are initially papulopustular, then progressively become crusted, heaped up and warty, with a violaceous hue. These lesions have sharp borders and may be surrounded by microabscesses. Wet preps shows broad-budding yeast

Front 723

Where is histoplasmosis endemic and how does it present?

Back 723

Southeastern, midatlantic, and central US. Can manifest as acute PNA which presents as cough, fever, and malaise. Other posible manifestations include chronic pulmonary histo and disseminated histo (most common in HIV pts)

Front 724

Where is coccidiodes endema dnw aht does it commonly cause?

Back 724

Southwestern US and central and south america. Causes pulmonary infection. Cutaneous findings such as erythema multiforme and erythema nodosum are common

Front 725

Where does invasive aspergillosis often infect?

Back 725

Multiple organ systems including pulmonary and cutaneous fndings. Affects severely immunocompromised pts - esp transplant and those taking cytotoxic meds

Front 726

What are the differences in presenation of Norcardia and Actinomyces infections?

Back 726

Both are gram neg rods (Nocardia is also weakly acid fast). Norcardia - subacute PNA that mimics TB; most pt are immunocompromised. Actinomyces: absecess near head and neck that drain sulfur granules; can cause indolent pulmonary disease

Front 727

What is the ddx in HIV pt with unexplained fever and cough and on TMP-SMX? How can differentiate?

Back 727

MAC, TB, disseminated CMV, non-Hodgkins lymphoma. MAC most likely if CD4 <50 and no reason to suspect TB.

Front 728

What is the use of dapsone in HIV?

Back 728

Alternative for PCP prophylaxis

Front 729

WHen do you start tx for TB in HIV pts?

Back 729

induration of PPD >5mm

Front 730

What is used for both prophylaxis and treatment of CMV infection?

Back 730

Ganciclovir (prophlyaxis when CD4 <50 and serum CMV IgG positive or when there is positive bx for CMV)

Front 731

Is BCG vaccine live?

Back 731

yes -> don't give to HIV pts

Front 732

What is Kaposi sarcoma in HIV pts caused by? What is presentation?

Back 732

HHV 8. Cutaneous lesions are asymptomatic, elliptical, and arranged linearly. Commonly involved regions: legs, face, oral cavity, genitalia. Lesions begin as papules and later evelop into plaques or nodules. Color typically cahnges from light brown to violet. No associated necrosis of skin or underlying structures. In US, most commonly seen in homosexual HIV pts

Front 733

What are HSV lesions like?

Back 733

Vesicular and painful

Front 734

What should do when a healthcare worker is exposed to blood or blood products of HIV-infected pt?

Back 734

Test for HIV immediately to establish pts baseline serologic status. Repeat testing after 6 weeks, 3mo, and 6mo. ONce blood is drawn for baseline, HIV post-expsoure prophylaxis should be started without delay - this is a combo of 2 or 3 drugs. 2 NRTIs are typically used - if use a third, it is usually a proteiase inhibitor (inc efficacy). 3 drug usually used, and esp indicated for exposure that post an inc risk for transmission (ex: very low CD4 count, high viral load, high risk type of injury such as deep percutaneous injury with hollow-bore needle)

Front 735

What should suspect in Asian pt with insensate, hypopigmented patch of skin?

Back 735

Leprosy (chronic garnulatomous disease that primarily affects the peripheral nerves and skin) - caused by mycobacterium leprae.

Front 736

How does leprosy usually present?

Back 736

Erarly on, may present with insensate, hypopigmented plaque. Progressive peripheral nerve damage results in muscle atrophy with consequent crippling deformities of the hands. MC affected sites: face, ears, wrists, butt, knees, eyebrows.

Front 737

How do you diagnose Leprosy?

Back 737

Skin biopsy will show acid-fast bacilli (blood cultures are negative; EMG sutdies are normally done to identify nerve pathology, esp at the lesion site and affected nerve segment but in leprosy, there is patchy, segmental nerve involvement so no strict pattern of nerve involvement is identified)

Front 738

What is the most common cause of PNA in HIV pts?

Back 738

Pneumococcus. Due to impaired humoral immunity, HIV pts are susceptibel to infection by encapsulated organisms in gneeral.

Front 739

How does TB infection present?

Back 739

Chronic cough, fever, wt loss

Front 740

What does disseminated fungal infection look like on CXR?

Back 740

Miliary or nodular infiltrate

Front 741

How does PCP pneumonia usually present?

Back 741

Dry cough and dyspnea. CXR: bilateral diffuse infiltrates

Front 742

How does secondary syphillis present?

Back 742

Rash, LAD, constitutional symptoms (fever, malaise, sore throat). Rash typically start on the trunk and extends to the periphery including the palms.

Front 743

How does primary syphillis present?

Back 743

painless chancre that resolves in 3-6 weeks

Front 744

How is testing for syphillis done?

Back 744

Initial testing with non-treponemal test (RPR or VDRL) with positive results confirmed with a specific treponema test (FTA-ABS test).

Front 745

How is secondary syphillis treated and what is a comlcation of treatment?

Back 745

3 doses of benzathine penicillin (each given weekly). Pts occasionally develop Jarisch-Herxheimer reaction (acute febrile reaction with headaches and myalgias) in the first 24hrs of therapy. Alternative regimens include doxycycline or azithromycin if penicillin allergy

Front 746

What do drug eruption rashes look like?

Back 746

Morbilliform, urticarial, papulosquamous, pustular, and/or bullous lesions.

Front 747

How does pityriasis rosea usualy present?

Back 747

Follows a viral illness. Rash is pruritic in 75%, described as papulosquamous with initial "herald" lesion followed by general exanthem

Front 748

How does psoriasis present?

Back 748

Involves elbows and knees

Front 749

What is rash of RMSF like?

Back 749

Usually begins as maculopapular eruption on wrists and ankles that spreads to trunk, extremities, palms, soles around day 5. Often have a severe headache and diffuse myalgias.

Front 750

What is the mot common rash in children?

Back 750

Viral exathem (much less common in adults)

Front 751

How does invasive aspergillosis present with s/s and imaging?

Back 751

Immunocompromised hosts (neutropenia, steroids, cytotoxic drugs). Invasive pulmonary disease with fever, cough, dyspnea, or hemotpysis. CXR: rapidly progressing, dense consolidation. CT: pulmonary noduels with halo sign or lesions with air crescent.

Front 752

Where is aspergillus endemic?

Back 752

Nowhere specifically

Front 753

What does CXR of histoplasomsis look like?

Back 753

Hilar adenopathy and may have areas of pneumonitis

Front 754

How does sporotrichosis spread?

Back 754

Through lymphatic flow

Front 755

What is the most common cause of traveler's diarrhea? How does it present?

Back 755

Enterotoxigenic E. coli. Abd cramps, diarrhea, malaise. Usually due to contaminated water.

Front 756

What is Nepal specific for in tmers of parasites?

Back 756

Giardia, Cyclospora

Front 757

Where is Giardia more common in US?

Back 757

Northern and Western USA

Front 758

What do you think of with diarrhea transmitted by seafood (including shrimp, crab, and raw oysters)?

Back 758

Vibrio parahaemolyticus. Can cause either watery or bloody diarrhea

Front 759

What is the msot common cause of dysentery in the USA?

Back 759

Shigella - also 2nd MCC of food-borne illness

Front 760

Where is Shigella common?

Back 760

Daycare settings or other institutional settings

Front 761

When can get EHEC?

Back 761

Improperly cooked ground beef

Front 762

What increases risk of Yersinia infection?

Back 762

Undercooked pork

Front 763

What is the MCC of acute infectious diarrhea in the US? Where find it?

Back 763

Campylobacter. Undercooked infected poultry. Can have watery or bloody diarrhea, severe abd pain

Front 764

What are the s/s of campylobacter infection?

Back 764

Watery or bloody diarrhea with severe abd pain

Front 765

What is cat scratch disease caued by? What are s/s? How do you treat?

Back 765

Bartonella henselae. Can be transmitted by cat scratch/bite or flea bite. Seen in young, healthy pts. Typically presents as localized cutaneous and LN disorder near site of inoculation with rare other organ invovlement. Local skin lesion evolves through vesicular, erythematous, papular phases but can be pustular or nodular. Hallmark is localized, regional LAD which is tender and may be suppurative. Dx is clinical but positive B, henselae Ab test or tissue specifim demonstrating positive arthin-Starry stain supports dx. Short (5d) course of Azithromycin for tx

Front 766

When should you suspect Ehrichiosis?

Back 766

Pt from endemic region (southeatern, south-central, mid-atlantic, upper medwest regions, + Cali) with history of tick bite, systemic symptoms, leukopenia and/or thrombocytopenia, and inc LFTs.

Front 767

What is Ehrlichosis?

Back 767

Tick-borne illness cause dby one of 3 diff Gram neg species, each witha different tick vector. Incubation period 1-3 weeks. Fever, malaise, myalgia, HA, N/V, usually NO RASH. "Spotless RMSF".

Front 768

What is DOC for Ehrlicosis?

Back 768

Doxycycline (start whenever suspect)

Front 769

What do you use to treat RMSF in pregnant pts?

Back 769

Chloramphenicol

Front 770

What is the DOC for Legionnaire's disease?

Back 770

Erythromycin

Front 771

What would peripheral blood smear look like in Ehrlichiosis?

Back 771

Intracellular inculsions (morulae) in WBC but not required before starting treatment

Front 772

How do you treat PCP pneumonia?

Back 772

TMP-SMX (irrespective of severity of PNA. Consider adding steroids bc they have been shown to dec mortality in severe PCP cases - indications include PaO2 <70 or A-a gradient <35.

Front 773

What does PCP PNA present like?

Back 773

Dry cough, exertional dysnpea, fever, severe hypoxia (out of proportion to CXR), CXR with bilateral interstitial infiltrates, normal WBC

Front 774

What are the clinical features of infectious mono?

Back 774

Fever, sore throat, toxic symptoms, mild HSM, symmetric LAD invovling posterior cervical chian more commonly than anterior, can have inguinal and axillary LAD, also often have pharyngitis, tonsilitis, tonsillar exudates. Can also have mild palatal petechiae, but this is non-specific bc can also be seen in strep pharyngitis. Tonsillar enlargement can cause airway compression. Hepattis and jaundice are present in a small percent of cases. Things that differentiate from strep pharyngitis include HSM, malaise and fatigue, and generalized LAD

Front 775

What is a hematologic complication of infectious mono?

Back 775

Autoimmune hemolytic anemia and thrombocytopenia due to cross reactivity of the EBV-induced Ab against RBC and platelets. THese Ab are IgM cold-agglutinin Ab known as Anti-i antibodies, which lead to complete mediated destruction of RBC (usually Coombs'-test positive). The onset of hemolytic anemia can be 2-3 weeks after the onset of symptoms, even though the inital lab studies may not show anemia or thrombocytopenia (as in this patient).

Front 776

What is the spleen complication from infectious mono?

Back 776

splenic rupture (mainly caused by truauma) -> should avoid contact sports such as foodball for 3-4 weeks

Front 777

WHat is a heart complication fo Corynebacterium infection and what is the throat presentation?

Back 777

Sore throat with pseudomembrane formation. Dilated CM is a possible complication of Corynebacterium.

Front 778

What is a kidney complication of strep pharyngitis?

Back 778

Glomerulonephritis

Front 779

When is IV pentamidine used in HIV?

Back 779

For PCP treatment when can't tolerate TMP-SMX (can use inhaled pentamidine for prophylaxis)

Front 780

How do you treat Legionella or Chlamydia pneumonia?

Back 780

Macrolide abx

Front 781

What should suspect in pt with fever rash (erythematous and maculopapular that starts on face and progresses to trunk and extremities), occipital or posterior cervical LAD, and arthritis?

Back 781

Rubella. Prodrome of fever, LAD, malaise. Occipital and posterior LAD are suggestive. Adult women usually have associated arthritis. Some pts have mild coryza and conjunctivitis

Front 782

What is the characteristic rash of measles?

Back 782

Erythematous and maculopapular progressing from head to trunk and extremities (like Rubella). Koplik's spots are highly suggestive. Prodrome of fever, cough, coryza, conjuncitivitis

Front 783

What is the rash of chicken pox?

Back 783

Pruritic and usually develops after a prodrome of fever and malaise. lesions appear in consecutive crops, so lesions of several different stages are often visible on exam (papular, vesicular, crusted, etc)

Front 784

When can see rash in mono?

Back 784

After administration of ampicillin

Front 785

What infection should be part of ddx for BMT recipient with both lung and intestinal involvement? What is average time to infection?

Back 785

CMV pneumonitis - median time to development of CMV pneumonitis after BMT is about 45d (2 weeks-4mo)

Front 786

What are the risk factors for CMV pneumonitis? What do you see in CXR and CT scan. How dx?

Back 786

Immunosuppressive therapy, older age, seropositivity before transplant. CXR: multifocal diffuse patchy infiltrates. CT: parenchymal opacification or multiple small nodules. Bronchoalveolar lavage is diagnostic in most cases.

Front 787

What are the possible manifestations of CMV in bone marrow transplant pts?

Back 787

CMV pneumonitis, upper and lower gastric ulcers, bone marrow suppresion, arthralgias, myalgias, esophagitis

Front 788

What reduces incidence of PCP PNA in BMT pts? When does it occur after BMT if it does?

Back 788

Pre-transplantation TMP-SMX. Usually seen in immediate post-transplant period

Front 789

What is the most common organ for GVHD?

Back 789

Skin - skin rash is almost always seen with GVHD. Other organs include intestine, liver, lung (in lung, involvement is seen in chronic GVHD and manifests as bronchiolitis obliterans)

Front 790

Does candida cause PNA?

Back 790

Not usually

Front 791

What does Cryptosporidium cause in immunocompromised pts?

Back 791

Diarrhea

Front 792

What cancer is strep bovis endocarditis assoc with? What is next step in management?

Back 792

Colon cancer or upper GI cancer --> give abx for endocarditis and then colonoscopy looking for GI malignancy

Front 793

Is there a useful tool to screen for lung cancer?

Back 793

No - neither CXR nor bronchoscopy is indicated unless have s/s of suggestive of lung cancer

Front 794

What should you consider in a pt with mono-like symptoms, atypical L's on peripheral smear, but negative monospot test?

Back 794

CMV infection - will also have lack of pharyngitis/sore throat and cervical LAD on exam

Front 795

What do the atypical L's of CMV look like?

Back 795

Large basopihlic cells with vacuolated appearance

Front 796

What time length of symptoms is required for diagnosis of chronic fatigue syndrome?

Back 796

6+months

Front 797

What is the usual age and cell description of CLL?

Back 797

Median age 61yo (older), see mature-appearing small L's and "smudge" cells

Front 798

What are the potential causes of diarrhea in HIV pts? What is first step in management?

Back 798

Many - Shigella, Salmonella, Campylobacer, C diff, Giardia, Cryptosporidium, MAC, CMV. Should test stool for culture, ova and parasites, and C. diff before starting treatment

Front 799

Who is colonoscopy and biopsy in diarrhea pts reserved for?

Back 799

Pts with persistent diarrhea and negative stool exam

Front 800

Why do you not want to give an antidiarrheal agent in a pt whose diarrhea is likely infectious?

Back 800

More organisms or toxin would remain in the intestine, which could lead ot toxic megacolon

Front 801

What should suspect in pt with history of IV drug use and new murmur?

Back 801

Right sided endocarditis (tricuspid valve)

Front 802

How should treat IV drug users who have endocarditis?

Back 802

Empiric abx treatment geared towards MRSA, strep, and enterococci - most appropriate is vancomycin (native-valve)

Front 803

What is the murmur of tricuspid regurg?

Back 803

Holosystolic murmur at lower sternum which increases with intensity on inspiration

Front 804

What are some s/s of right-sided endocarditis?

Back 804

fever, generalized weakness, TR, IVDA

Front 805

What si the most common organism in R-sided endocarditis (IVDA)?

Back 805

Staph aureus accounts for >50%

Front 806

When is ampicillin-sulbactam recommended in infectious endocarditis?

Back 806

If cultures come back with penicillin resistant enterococcus or HACEK organisms

Front 807

What is the drug of choice for native-valve endocarditis due to penicillin-suspcetible Viridans strep?

Back 807

Aqueous penicillin G

Front 808

What is special about HIV pts and TB?

Back 808

Their TB carries a very high risk of progression to active disease

Front 809

What should be the treatment of PPD-positive HIV+ pts with neg CXR? What is a positive PPD in HIV+?

Back 809

Prophylactic treatment - Isoniazid is drug of choice and is given for 9 months; add pyridoxine to prevent possible neuropathy; but, pyridoxine doens't prevent isoniazid-induced hpetatitis, so have to monitor LFTs. Alternatives include pyrazinamide + rifampin or rifabutin for 2 months or rifampin alone for 4mo if intolerant to pyrazinamide >5mm induration.

Front 810

What blood test do you have to monitor in pts on Isoniazid?

Back 810

LFTs (Isoniazid-induced hepatitis)

Front 811

When do you use the 3 or 4 drug combos to treat TB?

Back 811

If it is an active TB infection

Front 812

When must antivirals for influenza be started to dec disease duration and severity?

Back 812

Within 48hrs of onset of symptoms

Front 813

What lung findings can you find on PE of pt with influenza? What about labs? CR?

Back 813

Fever, wheezes, crackles, coarse breath sounds, leukopenia, proteinuria. CXR normal or interstitial or alveolar pattern

Front 814

What is the fastest way to confirm the diagnosis of influenza?

Back 814

Nasal swabs

Front 815

What are the antivirals for influenza?

Back 815

Neuraminidase inhibitors: oseltamivir and zanamivir. Rimantadine and amantadine are only effective agianst influenza A

Front 816

WHat is Ganciclovir used to treat?

Back 816

CMV infections (CMV PNA is a serious infection that infectes severely immunocompromised pts)

Front 817

What is Tenofovir?

Back 817

Nucleotide analog used to treat HIV

Front 818

What is Ritonavir?

Back 818

A protease inhibitor used to treat HIV

Front 819

What is Valacyclovir?

Back 819

A valine analog of the antiviral acyclovir. Used to treat HSV and VZV infections

Front 820

What is Nevirapine?

Back 820

A nonnucleotide reverse transcriptase inhibitor used to treat HIV

Front 821

What is clindamycin used to treat?

Back 821

Anaerobic infections, particularly lung abscesses and bacterial infections of the mouth and neck

Front 822

What should always consider in pts from endemic areas with high-grade periodic fever and chills? What are other clinical clues?

Back 822

Malaria. Other clinical clues: anemia, splenomegaly, hypotension and tachycardia, N/V, headache, anorexia, malaise, myalgias

Front 823

What is malaria and how is it transmitted?

Back 823

Protozoal disease caused by the genus plasmodium, which is a RBC parasite that is transmitted by the bite of infected Anopheles mosquitoes. Endemic in most of developing countires of Asia and Africa. 4 species, most deaths are due to falciparum malarias whereas vivax and ovale are responsible for several relapses

Front 824

What is the hallmark of malaria?

Back 824

Cyclical fever - it coincides with the RBC lysis by the parasites. Fever occurs every 48hrs with P vivax and P ovale and every 72 hrs with P malariae, whereas periodicity is not generally seen with P falciparum. The typical episode consists of a chold phase of chills and shivering followed by a hot phase of high fever, followe dby 2-6hrs later by sweating stage with diaphoresis and resolution of fever

Front 825

What is Babesiosis? What are the clinical features? Who is it most common in?

Back 825

A protozoal disease caused by Babesia microti, which is a RBC parasite transmitted by a tick. FClinical features range from asymptomatic infeciton to severe hemolytic anemia with jaundice and renal failure. More common in pts with functional asplenia or splenomegaly

Front 826

What else should you screen for in pts with newly diagnosed syphilis?

Back 826

HIV

Front 827

What are VDRL and FTA-ABS tests for?

Back 827

Syphilis exposure

Front 828

When do you start screening for prostate cancer?

Back 828

Usually start at age 50

Front 829

What is the treatment of choice for herpes zoster? How can you treat postherpetic neuralgia?

Back 829

Valacyclovier is DOC, Acyclovir is an alternative. Can treat post-herpetic neuralgia (or prevent it) with tricyclic antidepressants such as amitriptyline or nortriptyline along with the acute antiviral therapy. Can combine oral steroids with acyclovir (not with valacyclovir) if the initial symptoms are sever and no contraindications

Front 830

How does shingles occur?

Back 830

Caused by reactivation of VZV virus. Following the primary infection (chicken pox), the virus remains latent in the dorsal root ganglia. A dec in cell-mediate immunity (ex: older age, stressful situation, HIV, lymphoma) can allow the virus to reactivate and spread along the sensory nerve - this accounts for the typical unilateral, dermatomal distribution of the pain and rash. T3-L3 are the most frequently involved dermatomes. Pts often develop pain or discomfort in the affected area before the onset of rash.

Front 831

How can you treat/prevent postherpetic neuralgia in herpes zoster pts?

Back 831

TCAs

Front 832

What is different between drug-induced rashes and rash from herpes zoster?

Back 832

Drug induced rashes don't usually run along dermatomes

Front 833

What is the most common cuase of pts with subacute bacterial endocarditis with preexisting valvular disease?

Back 833

Viridans group strep

Front 834

What is the mcc cause of infective endocarditis in pts with prosthetic valves?

Back 834

Staph epidermidis

Front 835

What does staph saprophyticus usually cause?

Back 835

UTIs in young women

Front 836

What should you do if pt becomes pregnant earlier than 3mo after rubella immunization?

Back 836

Reassure - previously, women of childbearing age were advised to avoid conception for at leaest 3 months after rubella immunization, but there have been no case reports to date of congenital rubella syndorme in women inadvertnetly vaccinated during pregnancy. Infact, it has been recommended to reduce the waiting time for conception from 3mo to 28 days.

Front 837

What is the protocol for treatment of HIV pts who develop esophagitis?

Back 837

Esophagitis with advanced HIV usually occurs with CD4 <50. MCC is candida, therefore should first start with fluconazole - if don't respond to 3-5d course, further investigation is warranted with EGD with cytology, bx, and culture to determine other etiology - HSV< CMV

Front 838

What do you use to treat esophagitis from HSV and CMV?

Back 838

Acyclovir and Ganciclovir respectively

Front 839

What valve is most often affected in endocarditis not related to IVDA?

Back 839

Mitral valve causing mitral regurg

Front 840

What is the MC predispsoing factor to native endocartidis in the US?

Back 840

MVP - previously, rheumatic valvular damage but not bc rheumatic heart disease is decreasing

Front 841

When can pts with mono start playing sports again?

Back 841

When splenomegaly gone and no longer palpable spleen (usually 1-3mo)

Front 842

What are the s/s of disseminated histoplasmosis?

Back 842

Paltal ulcers, HSM, pancytopenia. Also nonspecific findings such as low-grade fever, malaise, anorexia, wt loss. Bc fungus targets histiocytes and reticuloendothelial system, can cause LAD, pancytopenia, HSM. CR: hilar LAD with or without areas of pneumonitis

Front 843

Where do you find Histoplasomisi?

Back 843

Dimorphic fungi found in mold in soil. Also present in bird and bat dropping and is endemic to Mississippi and Ohio River basins. Pts may report history of exploring caves (with assoc exposure to bats) or cleaning bird cages or coops.

Front 844

What is Blastomycosis assoc with? What does CXR look like adn what are s/s? Who is it common in?

Back 844

Blastomycosis assoc with contact with soil or rotting wood. CXR: multiple nodules or dense consolidations on CXR. Spreads hematogenously to cause skin ulcerative or verrucous skin lesions, plaque-like lesions on mucous membranes, osteolytic bone lesions, and prostate involvement. Infection in immunocompromised is rare

Front 845

Where is Coccidioides found? What do you see on CXR? What does disseminated disease look like?

Back 845

Southwestern US. CXR: localized pulmonary infiltrate, hilar adenopathy, and/or pleural effusion. Disseminated disease: more likely in pts with advanced HIV - in these pts, can present with fever, maculopapular skin lesions, bone liesions. Primary lung compalints may be absent

Front 846

When dose aspergillus affect HIV pts? What are s/s?

Back 846

<50 CD4 count. Fever, cough, dyspnea

Front 847

What does pulmonary sporotrichosis look like on CXR?

Back 847

Chronic, upper lobe cavitary lesion. Less common than subcutaneous skin infeciton

Front 848

What is the key distinction between primary HIV infection and infectious mono (can look similar)

Back 848

The rash (unless abx administered) and diarrhea are much LESS common in fectionus mono and the finding of tonsillar exudate is uncommon in primary HIV

Front 849

What is the classic presentation of mono?

Back 849

Mild-mod fever, pharyngitis, LAD (symmetric, posterior>anterior cervical LN), rarely splenic rutpure.

Front 850

How dx mono?

Back 850

Heterophile Ab test - typically arises within 1 week and persists up to 1 year, both sensitive and specific. Can also test for anti-EBV ab if heterophile Ab test neg and have high clinical suspicion

Front 851

What kind of LAD is secondary syphilis assoc with?

Back 851

Generalized LAD, not isoalted

Front 852

What are the s/s of pts with acute HIV?

Back 852

fever, malaise, generalized LAD, sore throat, HA, rash,GI symptoms

Front 853

When is a LN biopsy indicated?

Back 853

When there is high degree of suspicion for neoplastic disease - if LN are tender, means less likely neoplastic

Front 854

What are some of the common s/s of SLE?

Back 854

Young woman with rash, arthritis, or serositis