1. IgA deficiency
    What is the function of IgA?
    Pts with IgA deficiency has what typical c/o?
    What would you not give this pt?
    • IgA blocks viral attachment to mucosal survaces
    • Pts with deficiency typically c/o atopic diseases such as asthma, rhinitis, and are Giardia-prone, they can't get rid of Giardia infection
    • Do not give IgG immunoglobulin because of anaphylaxis risk due to possible traces of IgA in the immunoglobulin
  2. Complement deficiencies (C1, C2, C4)
    What is the most common in N. America?
    What do you think about with early onset SLE?
    • C2 is most common in N. American caucasians
    • C2 deficiency is suspect if with early onset SLE
    • Classical pathway messed up
    • Recurrent sinopulmonary infections--encapsulated organisms
  3. What do you look for in a pt with recurrent Neisseria infection?
    • Look for terminal complement deficiency
    • Test with CH50 or CH100 to eval function of terminal complement (C5-C9)
  4. Hereditary angioedema
    What is this due to?
    Presenting symptoms?
    • Due to lack of C1 inhibitor
    • Present with localized angioedema or abdominal pain with extremity swelling
    • Familial pattern
  5. Neutropenia
    What do yo do if with fever?
    Antibiotics for monotherapy?
    Antibiotics for combo therapy?
    What do you NEVER give for neutropenic fever?
    • Less hatn 500 granulocytes
    • If with fever -- antibiotics ASAP after cultures done
    • Monotherapy: Cefepime, Ceftazidime, imipenem, or meropenem
    • Combo therapy: Amingoglycoside + antipseudomonal beta lactam (Ticar/Pip, ceftazidime, cefepime or imipenem/meropenem)
    • NEVER ceftriaxone!
  6. In a pt with neutropenia, when is vancomycin for initial treatment indicated?
    • Hypotension/cardiovascular compromise
    • Suspected IV catheter-related infection
    • Known colonization with MRSA or resistant pneumococcus
    • Mucositis
    • Recent quinolone prophylaxis
  7. If a neutropenic patient,on broad-spectrum antibiotics, continue to be febrile for 5-7 days, what is your next intervention?
    Add Caspofungin or liposomal amphotericin B
  8. Infections on Post-Transtplant pts at 0 to 1 months after transplant?
    Usual post-op nosocomial pneumonias and infections (gram-)
  9. Infections on Post-Transtplant pts at 1.5 months
    Herpes reactivation
  10. Infections on Post-Transtplant pts at 1-4 months s/p transplant?
    Protozoa (PCP, toxo, Strongyloides), fungi, CMV, Mycobacterium, Listeria, Hepatitis B, Nocardia
  11. Infections on Post-Transtplant pts at 2-6 months s/p transplant?
    Viruses (Varicella zoster, EBV, Hep C)
  12. Infections on Post-Transtplant pts at 4 or more months s/p transplant?
    Cryptococcus neoformans
  13. In a post-transplant pt, which organisms reactivate in a person with impaired cellular immunity?
    • "No TB, his cry blasted Coco strongly"
    • Nocardia
    • TB
    • Histoplasmosis
    • Cryptococcus
    • Blastomycosis
    • Coccidiodomycosis
    • Strongyloides
  14. What are the common Gram-positive cocci?
    • Stap aureus and epidermidis
    • Strep pneumo (Pneumococcus)
    • Strep pyogenes (Group A)
    • Strep agalactiae (Group B)
    • Enterococcus
  15. Who commonly get Staph aureus infection?
    • IV drug users
    • Dialysis patients
    • Toxic shock syndrome
    • Thing of it in a pt with istory or pneumonia and recent influenza
  16. A pt with symptoms of septic shock and who has a positive blood culture in 24 hours is likely infected with what organism?
    How about if this is a post-surgical pt with a prostheses?
    • Strep usually grows in blood culture
    • Staph will be high in differential if after surgery especially with prostheses
  17. Define Toxic Shock Syndrome
    How many organs involved?
    Wha should you rule out?
    Organisms in positive or negative blood cultures?
    • Temp > 38.9 C (102 F)
    • SBP < 90 mm Hg
    • Rash with subsequent desquamation (palms/soles especially)
    • Involvement of > 3 organ systems: GI, muscular, mucous membranes, renal, liver, blood, CNS
    • Negative serology for RMSF, leptospirosis, measles
    • Blood cultures likely positive in Strep, and negative in Staph
  18. A pt with furuncles/carbuncles with MRSA isolated, but non-septic appearing can be treated with?
    Outpt treatment for MRSA is with Clindamycin or Bactrim
  19. What is the most common cause of catheter-related bacteremia and of bacteremia in patients with "foreign body" surgeries?
    • Staph epi is most common
    • This is usually resistant to IV Nafcillin, so treat with IV Vancomycin, unless MSSE
  20. Streptococcus pneumoniae
    What type is the most virulent?
    Treatment if "intermediate resistant" to PCN?
    Treatment if "highly resistant" to PCN?
    Tx if meningitis?
    • Type 3: most virulent -- associated with M protein (3M is bad)
    • If "intermediate resistant" use 3rd generation cephalosporin
    • If "highly resistant" to PCN, use 3rd generation cephalosporin or add Vanc to regimen
    • If meningitis: Use Vanc (or RIF) + 3rd generation until sensitivities on pneumo are known
  21. Streptococcus
    What is the usual presentation for pyogenes?
    What is the usual presentation for agalactiae?
    • pyogenes (A)
    • --GAS, TSS, rheumatic fever, scarlet fever
    • agalactiae (B)
    • --very young, very old (Alcoholic/DM), wound infection in diabetic foot
    • --Major cause of newborn pneumonia and meningitis
    • --UTIs in pregnant women
    • --Post-partum endometritis/bacteremia
  22. What is scarlet fever?
    • It is caused by the streptococcal bacteria, which produce a toxin that leads to the hallmark red rash of the illness.
    • The rash usually first appears on the neck and chest, then spreads over the body. It is described as "sandpapery" in feel. The texture of the rash is more important than the appearance in confirming the diagnosis.
    • The rash can last for more than a week. As the rash fades, peeling (desquamation) may occur around the fingertips, toes, and groin area.
  23. Facts about GABHS infection:
    Rheumatic fever can occur from what strain?
    Effect of therapy on glomerulonephritis?
    Post-strep GN can occur from what strain?
    How do you prevent rheumatic fever in Strep pharyngitis?
    • Rheumatic fever occurs only from pharyngeal strains of GAS
    • Post-streptococcal glomerulonephritis can occur even with appropriate therapy
    • Post-strep GN can occur from skin or pharyngeal strains
    • Treatment of Strep pharyngitis with PCN prevents rheumatic fever
  24. Enterococcus
    What do you treat an elderly male with sepsis s/p TURP?
    What else do you do?
    • Sepsis/infection after TURP
    • --Tx: Amp/PCN or Vanc are only inhibitory.
    • --Add aminoglycoside for synergy with serious infections
    • Check Sensitivities for VRE !!!
    • --Use daptomycin (Cubicin), quinupristin/dalfopristin (Synercid), or linezolid (Zyvox)
  25. Listeria monocytogenes
    Who is susceptible?
    • Diminished cellular immunity syndromes
    • --AIDS, lymphoma, leukemia
    • --Neonates, elderly, pregnant who like goat cheese or hot dogs
    • Tx: IV Amp or pcn +/- aminoglycoside for synergy in severe infections
    • --Vanc or TMP/SMX for PCN-allergic pts
  26. Corynebacterium
    What strain causes diphtheria?
    What is its clinical presentation?
    What strain can cause IV catheter infections?
    • diphtheriae -- causes diphtheria
    • -URI
    • -Gray-white pharyngeal membrane
    • -Hoarseness, sore throat
    • -Low-grade fever < 101 F !!
    • -Myocarditis/polyneuritis
    • -Tx: Erythro or PCN + Antitoxin

    • jeikeium (JK) -- IV cathether infections BMT
    • -Vanc drug of choice
  27. A pt presents with the following below, along with c/o hoarseness, sore throat, low grade fever < 101.
    What is the diagnosis and treatment?
    Image Upload 1
    • Corynebacterium diphtheria
    • Tx: Erythro or PCN + Antittoxin
  28. Bacillus
    S/s of B. anthracis?
    What can cause GI effects? or an infecting organism with penetrating trauma to the eye?
    • B. anthracis
    • -Cutaneous (95%) and pulmonic (5%)
    • -Inoculation from handling hides, wool
    • -Painless papule -- painless ulcer -- painless black eschar -- with nonpitting, induration/swelling
    • -Tx: Pen G is sensitive (erhtyro/tetracycline)

    • B. cereus
    • -toxin strains produce GI effects
    • -trauma to eye, IV catheters
    • -Tx: Vanc (or clindamycin) for the trauma/cathether infection
  29. What organism can be an infecting organism in a pt with penetrating trauma to the eye?
    • B. cereus
    • Tx: Vanc ( or clindamycin)
  30. Facts about Bacillus anthracis (Bioterrorism)
    Is isolation precaution required?
    Pneumonia on CXR will have what characteristic?
    • Not spread from person to person (unlike pneumonic plague and smallpox)
    • Pneumonia -- widened mediastinum
    • Skin lesions, as in ranchers, etc.
    • Treatment:
    • --Cipro until sensitivities known
    • --PCN/Tetracycline also usually effective
  31. Tetanus
    When do you give TIG + vaccine?
    When do you give Td (Tdap)?
    When is treatment not required?
    • Wound is dirty and either:
    • 1. < 3 immunizations, OR
    • 2. Immunization history inknown
    • --The give TIG + vaccine

    • Wond is clean and
    • --Immunozations are up to date (<10 years since last) then no treatment
    • --Immunizations > 10 years, give Td (Tdap)

    • Wound is dirty and
    • --Immunizations are up to dare, with most recent < 5 years, then no treatment
    • --Immunizations > 5 years, then give Td (Tdap)

    Tdap = booster
  32. What clostridium species are associated with GI malignancy?
    • C. septicum
    • C. bovis
  33. What is a safe prophylaxis for a pregnant pt who had exposure to Neisseria meningitidis meningitis?
  34. Neisseria meningitidis
    Who is at risk?
    Who gets prophylaxis?
    Is a vaccine recommended? To whom?
    • Risk population: Humoral/complement deficiencies, College students
    • Prophylaxis: All household contacts, daycare, "significant others," health care workers with intimate oral contact (intubate, mouth-mouth)
    • Meds for prophylaxis: Rifampin, ciprofloxacin (type A), ceftriaxone (pregnant)
    • Conjugate vaccine recommended for college freshmen living in dorms and all previously unvaccinated adolescents
  35. What is the differential diagnosis for a pt with fever, hypotension, diffuse purpuric lesions, petechiae, DIC?
    • Nesseria meningitis vs. Rocky Mountain Spotted Fever
    • -- if they give you geography, it is probably RMSF
  36. Treatment for N. meningitiditis meningitis?
  37. Neisseria meningitidis vaccine
    What are the 2 vaccines available?
    • 2 Vaccines
    • 1. Polysaccharide
    • --Only for those > 2 years of age, and
    • --High risk (functional/anatomic asplenia, terminal complement deficiencies)
    • 2. Conjugated, MCV4
    • (licensed only for those 11-55 years of age)
    • --11-12 year visit, or entry to high school, or 15 years, whichever comes first
    • --Students entering college who plan to live in dormitories
    • --High risk individuals as above
  38. Moraxella catarrhalis
    What kind of infection and who is infected?
    What other characteristic on the culture report?
    Gram stain report?
    • Respiratory infections --COPD and Immunodeficient
    • Tx: Erythro, tetracycline, Bactrim, amox/clavulanate
    • Beta-lactamase producers usually
    • Gram-negative, aerobic, oxidase-positive diplococcus
  39. Infections caused by Pseudomonas?
    • Nail puncture wound: througha a tennis shoe
    • IV drug users: endocarditis/ osteomyelitis
    • Diabetics: chronic otitis externa
    • Echthyma gangrenosum: round, black, indurated lesion wiht central ulceration = Pseudomonal bacteremia
    • Hot tub rash: due to Pseudomonas; self-limited
  40. This lesion appears on a pt who is neutropenic due to chemo. What is the diagnosis?
    Image Upload 2
    Image Upload 3
    • Echthyma gangrenosus due to Pseudomonas
    • --round, black, indurated lesion with central ulceration
  41. E. coli
    Symptom of ETEC?
    What is the drug of choice?
    • ETEC: Enterotoxigenic
    • Watery diarrhea and "traveler's diarrhea."
    • Tx: Bactrim is drug of choice
  42. What causes "traveler's diarrhea?"
    E. coli
  43. E. coli EHEC
    Sources of EHEC?
    • EHEC: Enterohemorrhagic or STEC (Shiga toxin producing E. coli)
    • --O157:H7 induces hemolytic uremic syndrome

    • Sources:
    • Undercooked beef, unpasteurized mild, apple sause
    • Sorbitol-enhanced agar
    • Triad: renal faulre, thrombocytopenia with purpura, and hemolytic anemia
    • No antibiotics
  44. What is a side effect of high dose Erythromycin?
    hearing loss
  45. What is the drug of choice for Legionella?
  46. A pt with a cat presents with the c/o below:
    Image Upload 4
    What is the diagnosis?
    How do you confirm the diagnosis?
    • Cat scratch disease
    • Caused by Bartonella henselae
    • Classic sx in young adults
    • Don't aspirate
    • Serology is diagnostic
    • Tx: none or azithromycin
  47. An AIDS patient who recently was scratched by his cat presents with the c/o below.
    Image Upload 5
    Image Upload 6
    What is the diagnosis and treatment?
    • Bacillary angiomatosis
    • Tx: erythromycin
  48. Gram-negative coccobacilli?
    • Brucella
    • Yersinia (plague, enterocolitica)
    • Francisella
  49. What is the presentation of "plague?"
    • Caused by Yersinia pestis
    • Pneumonia is biggest concern
    • Will present in young people with hemorrhagic pneumonia, high fever
    • Is contagious to others, unlike anthrax pneumonia
  50. What is "pseudoappendicitis?"
    What organisms cause it?
    • a syndrome with Y. enteroclitica or Y. pseudotuberculosis
    • Bacteremia in those with sickle cell disease (iron overload states)
  51. Francisella tularensis
    What are the reservoirs?
    Mode of transmission?
    How diagnosed?
    • Tularemia
    • Reservoirs: Rabbits, deer, ticks
    • Mode: Tick bite, eating infected animals, inhalation, self-inoculation
    • Ulcero-glandular disease
    • Dx: Serology -- don't aspirate
    • Tx: Streptomycin, gentamicin, tetracyclines
  52. A patient with right lower quadrant pain (nurse thinks it might be appendicitis) whose blood cultures are growing gram-negative bacilli. What is the organism?
    Y. enterocolitica or Y. psedotuberculosis

    Y. enterocolitica
    has been diagnosed as the cause of bacteremia in sickle cell patients with iron overload
  53. A pt from Arkansas presents with a large lymph node presents with the ff c/o:
    What is the diagnosis, how diagnosed, and treatment?
    Image Upload 7
    • Tularemia
    • This is ulcer-glandular disease
    • Found mainly in Arkansas, Missouri, Oklahoma
    • Dx by serology -- don't aspirate!
    • Tx: Streptomycin, gentamicin, tetracyclines
  54. Give the cause in the following scenarios in this pt from Arkansas:
    1. with lymph node
    2. with pneumonia and skin lesions
    • 1. Tularemia
    • 2. blastomycosis
  55. Rickettsia -- RMSF
    Differential diagnosis?
    What differentiates this?
    Presenting symptoms?
    What is pertinent in the HPI?
    How is this diagnosed?
    Where are most cases found?
    • R. rickettsii -- RMSF
    • Differential diagnosis is meningococcus
    • Rash, fever, arthralgias
    • Report of tick exposure
    • Rash on distal palms, soles; rash maculo-papules to petechiae
    • Hyponatremia differentiates this from meningococcus
    • Dx: seology, IF staining on bx of petechial lesion
    • Tx: Doxycycline, chloramphenicol
    • Most cases in N. Carolina, S. Carolina, Georgia, Virginia, New Mexico
  56. Pt with flu-like illness, pancytopenia, and report of tick-bite.
    1. What is the organism if from Southeast, South Central, or Midwest?
    2. How about if the the pt is from California, Northeast, or North Central US?
    • 1. Ehrlichia chaffeensis
    • 2. Anaplasma phagocytophila
  57. Ehrlichia / Anaplasma
    How transmitted?
    Presenting symptoms?
    Distinguishing lab picture?
    How diagnosed?
    • Ehrlichia chaffeensis
    • Tick borne
    • Southeast, South Central, Midwest
    • Flu-like illness
    • Pancytopenia
    • Dx: Serology, morula on smear
    • Tx: Doxycycline
    • Image Upload 8

    • Anaplasma phagocytophila
    • Human granulocytic ehrlichiosis
    • Same disease but live in neutrophils, not macrophages
    • Northeast, North Central, California
  58. Gardnerella vaginalis
    Gram stain report?
    • Gram variable
    • Tx: Metronidazole (Flagyl)
    • Responsible for vaginosis
    • Clue cells
    • Image Upload 9
    • This is from a pt's pap smear
  59. Nocardia asteroides
    Gram stain characteristics?
    • Beaded, branching, filamentous, and weakly acid-fast
    • Lung infection usually first -- cavity
    • Progresses to brain abscess
    • Tx: bactrim or high-dose sulfas
    • --Minocycline
    • --Amikacin + imipenem
  60. Outbreak of diarrhea in the community. Stool gram-stain shows acid-fast organism, small and round

    What is the organism?
    Who do you treat?
    • Cryptosporidium
    • Self-limited in normal host
    • Lasts 1-2 weeks
    • Chronic in AIDS patients, may persist indefinitely
    • Tx: Nitazoxanide or paromomycin +/- azithromycin
    • Small and round (compared to Isospora belli which is big and oval
  61. Diarrhea caused by aeid-fast organism that is large and oval shaped.

    What is the organism?
    Isospora belli
  62. Actinomyces
    Gram stain?
    • Gram-positive bacilli
    • Anaerobic infection
    • Sulfur granules = clusters of organisms
    • Cervicofacial swelling from dental source
    • Causes PID if IUD present
    • Can cause (rare) chronic neutrophilic meningitis
    • Tx: PCN/amp or tetracycline
  63. Differential diagnosis for pt with pneumonia and splenomegaly?
    • Chlamydia psittaci
    • Q fever
  64. Chlamydia psittacci
    Presenting complaint?
    Sign and symptoms?
    • Pt with exposure to birds, esp. poultry
    • Pneumonia + splenomegaly
    • Myalgia, rigors, fever to 105
  65. Chlamydia pneumonia
    Who is commonly infected?
    What illness is associated with it?
    Presenting symptom?
    • Common in adolescents
    • Community-acquired pneumonia
    • Person-person spread (not birds)
    • Wheezing prevalent
    • Tx: e-mycin or tetracyclines
  66. Primary Syphilis
    What is the incubation period?
    Is the RPR/VDRL always positive?
    • Chancres develop at the site of inoculation, on average, 21 days after exposure
    • Incubation period can range from 10-90 days
    • Skin lesions are painless
    • 20-30% will be RPR/VRDL negative at this stage
  67. Secondary syphilis
    Presenting symptom?
    • Hematogenous dissemination of T. palladium
    • Fever, malaise, generalized lymphadenopathy are often present
    • Rash--macular, papular, annular, or follicular
    • Alopecia, condylomata lata, mucous patches
  68. Young man or woman who presents with acute onset hearing loss. What is the possible diagnosis?
    • Syphilis
    • This is a symptom of neurosyphilis
  69. How is Syphilis diagnosed?
    • VDRL or RPR for initial screen
    • Confirm + test with either:
    • --FTA-ABS or
    • --MHA-TP
    • Darkfield microscopy showing T. palladium from a clinical specimen
  70. A sexually active old (or young person) who come in with stroke. What is your differential diagnosis?
    Meningovascular syphilis
  71. A pt with remote history of lesions on her hand and foot who come in today c/o sensory ataxia, "lightning" pains, autonomic dysfunction. What is you diagnosis?
    Parenchymatous syphilis
  72. Syphilis
    Early treatment?
    Late treatment?
    Treatment for Neurosyphilis?
    • Early (primary, secondary, or latent <1 year): Pen G benzathine 2.4 million units IM X 1
    • --doxycycline 100 mg PO bid X 14 days

    • Late (> 1 year's duration, CV, gumma, late-latent): Pen G benzathine 2.4 million U IM q week X 3
    • --doxycycline 100 mg PO bid X 4 weeks

    Neurosyphilis: PCN G 2-4 million U IV q 4 X 10-14 days
  73. Leptospirosis
    How diagnosed?
    • Contact with infected animals
    • "Swimming with your dog," but may also be from rat feces or urine
    • Mild to severe disease

    • Biphasic:
    • --Early disease: BC (+) (first week, then it's late after)
    • --Late disease : Urine (+)
    • Treatment: PCN or doxycycline
  74. Lyme Disease
    How diagnosed?
    • Borrelia burgdorferi
    • Transmitted by the Ixodes scapulars tick or Ixodes pacificus
    • Think Martha's Vineyard or Connecticut, Wisconsin, California
    • Dx: Erythema migrans is pathognomonic
    • Don't do serology
    • Image Upload 10
  75. Presentation of Lyme Disease?
    • Early: Rash with fever, HA, lymph nodes
    • Weeks to months later:
    • --Meningitis and/or neuritis. Peripheral neuropathy or Bell's Palsy, or foot drop
    • --Cardiac--> heart block
    • --Arthritis
  76. This pt was in Connecticut recently, present to you with this rash. What is the diagnosis?
    Image Upload 11
    • Lyme disease
    • The rash is erythema migraines. This rash is pathognomonic.
    • No serology indicated.
    • Treatment:
    • --Early: Doxycycline (amoxicillin also) but doxy is 1st choice)
    • --Meningitis or carditis: Ceftriaxone
    • --Arthritis or isolated Bell's palsy: Doxycycline
    • Treat for at least 2 weeks
    • Prophylaxis for hikers/campers: not indicated
  77. This neutropenic pt presents with the following lesions. He is currently treated broad-spectrum antibiotics. What is the diagnosis?
    Image Upload 12
  78. Treatment of Onychomycosis?
    • Terbinafine
    • --for fingernails -- 250 mg daily by mouth for 6 weeks
    • --for toenails -- 250 mg daily by mouth for 12 weeks

    Clinical trials show terbinafine is superior to itraconazole and griseofulvin
  79. What is the treatment for allergic bronchopulmonary aspergillosis?
    prednisone and itraconazole
  80. Aspergillosis -- Aspergilloma
    What is the characteristic radiographic picture?
    What is the hallmark sign?
    • Characteristic radiographic picture with the fungus ball changing position in an epithelial-lined cavity or in an air-fluid level
    • Cavities are secondary to previous or concomitant tuberculosis, histoplasma, or bronchiectasis
    • Hemoptysis -- sometimes life-threatening-- is the hallmark
    • Tx: In cases complicated by severe hemoptysis, surgery may be required to remove the aspergilloma and stop the bleeding. Observation only if asymptomatic.
  81. Aspergillosis -- Allergic Bronchopulmonary Aspergillosis
    How diagnosed?
    What is the role of serology in diagnosis of invasive disease?
    • Can be due to hyphen colonization of bronchopulmonary tree
    • Inhalation associated with dyspnea, wheezing, cough, rales
    • X-ray: diffuse nodular infiltrates
    • Treatment is steroids + itraconazole
    • Diagnosis: sputum exam or BAL maybe + but view with caution. Correlate with x-ray and clinical history. Conversely, in a severely immunocompromised pt, finding the hyphae in nasal mucous membranes could be very serious
    • Most recommended histology or microscopy
    • -- Galactomannan antigen detection is promising. Released during growth of hyphae
    • Serology: + in 90% of aspergillomas and 70% of ABPA --- DO NOT USE in invasive disease diagnosis
  82. Treatment of Cryptococcosis
    • Acute pulmonary cryptococcosis in immune-competent: Not treatment
    • Acute pulmonary cryptococcosis in immune-compromised: Ampho B +/- flucytosine for 1 month
    • Meningitis: Ampho B 0.7 mg/kg/d for 2 weeks + flucytosine 100 mg/kg (levels needed) in 4 divided doses, followed by oral fluconazole for 6 weeks (levels needed)
    • HIV pts need maintenance tx with fluconazole
  83. Sporotrichosis
    How diagnosed?
    • Dx: Culturing the organism
    • Tx: Lymphocutaneous
    • --SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
    • --Treat 4 weeks after lesions healed
    • --Itraconazole is better than SSKI
  84. A gardener who pricked his finger with a thorn several days ago present with the following complaint. What is the diagnosis and what is the treatment?
    Image Upload 13
    • Sporotrichosis
    • SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
    • --Treat 4 weeks after lesions healed
    • --Itraconazole is better than SSKI
  85. An AIDS patient with disseminated disease, lesions resemble histoplasmosis, but not getting better despite several days treatment with Ampho B.

    What is the diagnosis?
    What is the treatment?
    • Pseudallescheria boydii, like aspergillus but resistant to Ampho B
    • Treat with miconazole
  86. Toxoplasma gondii
    How diagnosed?
    What are the four types?
    • Cat is definitive host
    • Dx: Acute IgM antibody +
    • 4 types:
    • --Asymptomatic or mild symptoms: self-limited
    • --Pregnancy-acquired: Congenital infection > later in pregnancy
    • --CNS disease: Multiple lesions (MRI > CT)
    • --Ocular toxo: Yellow-white cotton patches
  87. Cyclospora
    What do you see on the smear?
    What foods is this usually seen?
    • Acid-fast positive on smears
    • Raspberries, basil seasoning, snow peas
    • Tx: Bactrim
  88. Plasmodia
    What population of patients are high risk for mortality?
    What part of the world has chloroquine resistant malaria?
    • Affects RBCs
    • 4 types:
    • - P. vivax
    • - P. ovale
    • - P. malariae
    • - P. falciparum
    • Big trouble in asplenic patients
    • Asia and Africa have chloroquine resistance
  89. P. falciparum
    What makes it hard to treat?
    What do you see on the blood smear?
    • Most fatal of the 4 types
    • Widespread chloroquine resistance
    • Blood smear: Banana gametocyte
    • -More than one infected RBC on slide
    • -Multiple parasites in one RBC
    • -Other forms: few parasites and hard to find
    • -Schizonts NOT seen on smear --- if so, it is a non-falciparum form of malaria
    • Image Upload 14
    • Image Upload 15
  90. P. falciparum
    How about if pt is too sick to take PO?
    What is the role of steroids for cerebral malaria?
    • Treatment(oral):
    • --Quinine sulfate + doxycycline X 7 days
    • --Atovaquone/proganil (Malarone) X 3 days
    • --Mefloquine (Lariam) X 2 doses

    • Treatment (IV if too sick to take oral)
    • --IV quinidine until pt can take oral

    • If in chloroquine-sensitive area -- use chloroquine
    • No steroids for cerebral malaria!
  91. Which malaria use the "Duffy RBC antigen" for its site of attachment?
    P. vivax
  92. Which malaria is commonly associated with nephrotic syndrome?
    P. malariae
  93. Which malaria form hypnozoites in the liver?
    What is the treatment?
    • P. vivax and ovale (VOdka goes into the liver)
    • Give Primaquine to avoid relapse
  94. Chloroquine is the general treatment for what type of malaria?
    P. vivax, ovale, malariae
  95. 1. Prophylaxis for ALL types of malaria?
    2. What do you give to traveler who came from area with known P. vivax and ovale malaria, and when do you start it?
    3. What do you need to do before starting the medication in #2?
    4. What malaria medication is associated with Stevens Johnson syndrome?
    • Mefloquine (or chloroquine if in sensitive area) 1/week for 1-2 weeks before arrival and continue 4 weeks after leaving area, or
    • Doxycycline q day for 1 day before until 4 weeks after travel, or
    • Atovaquone/proguanil (Malarone) q day 1 day before until 7 days after travel

    • Primaquine given last 2 weeks of prophylaxis after travel to P. vivax or ovale area
    • Pyrimethamine-sulfadoxine (Fansidar) associated with Stevens Johnson syndrome
    • Primaquine induced hemolytic anemia in G-6-PD deficiency (SCREEN)
  96. Babesia microti
    What is the peripheral smear report?
    How would the patient present?
    What is the usual transmission mode?
    What geography does it commonly occur?
    How would the patient act?
    Treatment for mild disease?
    Treatment for severe disease?
    • Intra-RBC protozoan: Maltese cross pattern
    • Febrile hemolytic anemia
    • Ixodes tick from rodents, deer
    • Nantucket in summer/fall
    • Fever, sweats, myalgias, chills
    • Hemoglobinuria: predominant sign
    • Emotional lability is common
    • Mild: Clindamycin + quinine or atovaqoune + Azithromycin
    • Severe: Exchange transfusion, then antibiotics
    • Image Upload 16
  97. Amoeba
    What is the organism?
    Where found mostly?
    Mode of transmission?
    Usual patient population?
    How do you diagnose?
    • Entamoeba histolytica
    • Mainly Texas, Mexico, Oklahoma
    • Fecal-oral transmission
    • Water and food sources
    • Institutionalized, immigrants, gay men
    • Liver aspirate: No ameba or WBCs; "anchovy paste"
    • Diagnosis:
    • -Diarrhea -- check stool antigen
    • -Liver abscess: check serology; stool usually negative
    • Treatment:
    • Metronidazole or Tinidazole
    • *Paromomycin or iodoquinol for intraluminal treatment is also given at the end of therapy for invasive disease
    • Image Upload 17
  98. Giardia
    Who is mostly affected?
    Acute presentation?
    Chronic symptom?
    How diagnosed?
    • Campers, travelers, children in daycare, gay, IgA deficiency, hypogammaglobulinemia
    • Infects the duodenum but 75% asymptomatic
    • Acute: watery, smelly diarrhea, flatulence
    • Chronic: Flatulence, sulfurinc belching, soft stools
    • Dx: Fresh stool O&P, Giardia-specific antigen on stool, string test
    • Treatment: Metronidazole, tinidazole, albendazole, furazolidone
    • Image Upload 18
  99. Trypanosomiasis
    What are the manifestations in an immigrant from Africa vs. South America?
    • African: Sleeping sickness
    • --Trypanosoma brucei
    • --Tsetse fly

    • American: Chagas disease due to T. cruzi
    • -Self limited usually but can affect:
    • 1. Cardiac (heart block--CHF)
    • 2. GI (achalasia, megaesophagus, megacolon)
    • 3. CNS
  100. A recent immigrant from Latin America present with fever, malaise and the complaint below. What is your diagnosis?
    Image Upload 19
    Chagas disease
  101. Leishmaniasis
    What are the symptoms for cuteness form?
    What are the visceral sx?
    • Sand fly is the vector
    • Cutaneous (L. major / L. tropica, military in Iraq)
    • -Occurs on exposed areas of skin
    • -Begins as a red papule that enlarges to form a PAINLESS ulcer with granulomatous tissue at the base and raised, heaped-up margins
    • -No surrounding induration
    • -Localized adenopathy can occur
    • Visceral leishmaniasis = kala-azar
    • -GI symptoms: Big liver and spleen

    Treatment: Sodium stibogluconate (antimony), meglumine, or Amphotericin B
  102. A soldier who recently came back from Iraq on a 16-month deployment comes to the ED with the lesion below. Physical exam showed liver margin a two finger widths below costal margin and a large spleen. What is the diagnosis and treatment?
    Image Upload 20

    • Treatment:
    • Sodium stibogluconate (antimony)
    • meglumine
    • Amphotericin B - now the drug of choice
  103. Cause of citywide outbreak of diarrhea?
  104. Rectal itching in a nursing home patient. What is the etiology?
    Pinworm (Enterobius)
  105. A pt with serpeginous lesions on the foot. What is the diagnosis?
    Image Upload 21
    Hookworm (Necator)
  106. Strongyloides
    What is the treatment?
    • The only helminthic organism that replicates in the human body
    • Persists for decades
    • Think about this in old pt with neutropenia, now with abdominal pain and diarrhea
    • Typical scenario: Veteran from WWII gets neutropenic from chemo, and becomes will with recurrent severe Strongyloides
    • Treatment: Ivermectin or thiabendazole
  107. Trematodes (Flukes)
    Symptoms of acute schistosomiasis?
    How diagnosed?
    Physical exam findings?
    • Clonorchis sinensis: Chinese Liver Fluke
    • -Far East, raw fish, biliary obstruction
    • Schistosoma haematobium: Bladder
    • Schistosoma mansoni: Africa, Mid East, S. America
    • S. japonicum: Asia

    • Acute schistosomiasis: Katayama fever
    • -2 months after inoculation
    • -Fever, lymphadenopathy, diarrhea, eosinophilia, HSM
    • -complications: cirrhosis/esophageal varices
    • Dx: eggs in stool (or bladder -- S. haematobium)
    • No stigmata of alcoholic cirrhosis
    • Tx: Praziquantel is DOC for any schistosoma infection
  108. A pt with "ulcerative dendritic" keratitis presents to you. What is the appropriate intervention?
    • Stat ophthalmology consult. Start IV acyclovir stat
    • Image Upload 22
  109. Herpes simplex
    How do you treat?
    • Primary infection
    • --Fever, HA, myalgias, and lymphadenopathy can occur with initial genital infection
    • Clinical course shortened with acyclovir

    • Treatment:
    • Primary: Acyclovir 400 mg tid X 10 days
    • Recurrent: Acyclovir 400 mg tid X 5 days
    • Immunocompromised host: IV acyclovir 5-10 mg/kg q 8 h x 7 days
    • Encephalitis: IV acyclovir 10 mg/kg q8h X 14-21 days
    • If resistant HSV: Foscarnet recommended
  110. What is you intervention on a pregnancy pt who is about to deliver, and who is currently has active genital herpes?
    • Most serious neonatal infections occur in infants whose mothers acquired asymptomatic primary infection with HSV-2 late in their pregnancy
    • Women with active genital herpes at the end of pregnancy should have C-section
  111. How do you treat an immunocompromised pt who has chicken pox?
    Give IV acyclovir
  112. Treatment for Chickenpox?

    Who do you give the vaccine to?
    • Normal adolescent/adult, pregnant, pneumonia:
    • -Acyclovir 800 mg PO 5X/day for 7 days
    • ==> decreases new lesions, pain
    • -Acyclovir 10 mg/kg IV q8h X 5 days
    • ==> better healing, reduced postherpetic neuralgia from 119 days to 63 days compared to placebo
    • -Valacyclovir 1000 mg 3x/day x 5 days
    • ==> Reduces posherpetic neuralgia

    Immunocompromised: 10 mg/kg IV q8h

    Zoster vaccine (Zovirax) now approved for those > 60 years of age
  113. A patient with variscella zoster lesions on his trunk is asking if they can go to work. What is you response?
    Okay to go to work as long as they can cover the lesions
  114. Pt with HIV, now c/o visual change, floaters in the eye. What is you recommendation?
    This is CMV and they need to see an ophthalmologist ASAP
  115. What organism is associated with hairy leukoplakia lesions of the tongue in AIDS patients?
    Image Upload 23
  116. A Japanese pt who presents with gait disturbancem urinary frequency and leg weakness/stiffness. What is the cause of this presentation?
  117. What are the "three C's" of measles?
    Cough, coryza, conjunctivitis
  118. What is the cause of Kaposi's sarcoma in AIDS patients?
  119. What causes a red rash, postauricular-suboccipital lymph nodes and fever?
  120. A young male presents with swollen salivary glands. What is the diagnosis?
    • Mumps.
    • Watch out for orchitis if occur after puberty
  121. A pt was diagnosed with influenza Type A H1N1. What is your treatment?
    • Type A H1N1 is resistant to oseltamivir (Tamiflu-oral)
    • Zanamivir (Relelenza - inhalation powder) is still effective for both A and B
  122. Pneumocystis jiroveci
    When do you start prednisone?
    • Formerly known as PCP
    • Treatment for 21 days
    • DOC: Bactrim 2 DS tabs PO q8h, use IV if can't tolerate oral
    • --Pentamidine is 2nd choice
    • --Others: atovaquone, trimetrexate, clinda + primaquine
    • Prednisone: if PaO2 is less than 70 mmHg. Start at 40 mg PO bid and taper after 5-7 days
  123. 1. When do you order prophylaxis for PCP?
    2. What do you use?
    3. What other medications would you use if pt can't tolerate the drug of choice?
    • Any prior hx of PCP
    • Adult, HIV-infected: CD4 < 200 or < 15%

    • Use Bactrim DS 1 tab PO daily (preferred), or 3X per week.
    • --If can't tolerate Bactrim, use Dapsone 100 mg once daily.
    • --Check for G6PD deficiency if using dapsone
    • -- Aerosolized pentamidine 300 mg via Respirgard II inhaler monthly
  124. If you have a pt with HIV who cannot tolerate Bactrim for prophylaxis, what is one test you need to order before initiating Dapsone?
    Test for G6PD deficiency
  125. When do you discontinue PCP prophylaxis?
    When do you restart it?
    • Can discontinue PCP prophylaxis if:
    • -On antiretroviral therapy, the pt has had a rise in CD4 cell cont to > 200 cells/uL for more than 3 months

    Prophylaxis should be restarted if the CD4 cell count fall below 200 cells/uL or if PCP occurs while on anti-retroviral therapy at a CD4 cell count > 200 cells/uL
  126. In an HIV pt, what induration should you be concern about?
    • 5 mm induration is considered a +PPD
    • However, due to altered immune response, a neg. PPD never rules out infection
  127. How do you treat active TB?
    How about if positive PPD only?
    What do you add to the prophylaxis regimen if you think the pt was exposed to INH-resistant Mycobacterium?
    • Active disease: 4 drugs unless in MDR area
    • --4 drugs (INH, RIF, PZA, ETH) for 8 weeks
    • --then 2 drugs (INH/RIF) for 18 weeks

    • Positive PPD only:
    • --INH for 9 months or
    • --RIF for 4 months (use this only in the case where you think the patient was exposed to INH-resistant Mycobacterium)
  128. MAC/MAI
    At what CD4 count do you start to worry about this?
    How diagnosed?
    • Become prevalent when CD4 , 50 mm
    • Fever, night sweats, wt loss, diarrhea, abode pain
    • HSM, LFT abnormal, low WBC or pancytopenia
    • Dx: Blood culture +, BM, tissue

    • Tx: Clarithromycin (or azithromycin) + ethambutol + rifabutin (reduce dose if on PI) x 12 months
    • --Start anti-HIV therapy as well 1-2 weeks into therapy (if naive).
    • --Watch out for immune reconstitution inflammatory syndrome (IRIS)
    • ==>fever, malaise, weight loss, worsening respiratory symptoms, increase in lymph node size

    Prophylaxis: azithromycin q week or clarithromycin once daily for CD4 < 50
  129. An HIV pt with MAC and CD4 = 5, has been on treatment for MAC. She was started on HAART recently and was doing well. She now present with fever, malaise, weight loss, increasing SOB, and worsening adenopathy. What is the diagnosis?
    IRIS (immune reconstitution inflammatory syndrome)
  130. Clinical criteria for initiation of Antiretroviral therapy
    • 1. AIDS-defining opportunistic infection
    • 2. CD4 count < 350 cells
    • 3. Pregnant women
    • 4. Persons with HIV-associated nephropathy
    • 5. Persons co-infected with hep B
  131. Side-effects of Zidovudine (ZDV, AZT)?
    • Anemia: reduce dose and/or epos
    • Neutropenia: reduce dose and/or G-CSF
    • Myositis: gait disturbance/loss of mm mass
    • --"rugged red fibers" w/ increase CPK: Stop ZDV
  132. Didanosine (ddI) side effects?
    • Painful peripheral neuropathy: reduce dose
    • Pancreatitis: discontinue drug if occurs
    • Retinal depigmentation with ddI
  133. Lamivudine (3TC) side effects?
    • 3TC acts as reverse transcriptase inhibitor
    • Is incorporated in viral DNA and acts as chain terminator
    • An extremely potent antiviral agent
    • Pancreatitis is biggest concern
    • Emtricitabine (FTC) -- similar agent
  134. Abacavir (Ziagen) side-effect?
    • Biggest concern:
    • -Hypersensitivity reaction:
    • 1. Fever, chills
    • 2. Rash
    • 3. Flu-like illness
    • -If any of these occur on therapy, you must STOP
    • -Now screen for HLA-B*5701
    • -And never re-challenge pt: causes death
  135. A pt with HIV on HAART, comes to you with report that she is pregnant. What medication do you need to stop (or at least make sure she is not on it) due to teratogenicity?
    Efivarenz (Sustiva)
  136. When to switch HIV therapy?
    • HIV RNA > 400 copies after 24 weeks of therapy or
    • HIV RNA > 50 copies after 48 weeks or
    • Repeatedly detectable HIV RNA level after prior suppression or
    • Drug toxicity
  137. Post-exposure prophylaxis for HIV:
    When to give it ?
    What meds to give for prophylaxis?
    • If the answer is YES to these 2 questions, then give postexposure prophylaxis
    • --Is the fluid bloody?
    • --Is the skin integrity compromised?
    • Give prophylaxis if yes to both, and no prophylaxis if yes to only 1 of 2.

    • If urine exposure: NO
    • If intact skin exposure: NO
    • Prophylaxis: ZDV, 3TC, +/- lopinavir / ritonavir for 4 weeks
  138. What HIV meds should not be given to pregnant pts?
    • D4T/ddI
    • efavirenz
  139. 1. A pt with HIV now comes you pregnant. She is not on HAART. What is your next intervention?
    2. A pt with HIV, not on HAART, comes to the ED in labor. What is your intervention?
    3. What would you recommend for the infant above?
    • ZDV to mothers starting between 14 and 34 weeks gestation 100 mg PO 5x daily
    • Intrapartum ZDV IV loading dose 2 mg/kg starting in labor and continued at 1 mg/gk/hour until delivery
    • Oral ZDV in infants beginning 8-12 hours after birth to age 6 weeks at 2 mg/kg/dose q 6 hours
    • Treat the mother as though she is not pregnant; Give her 3-drug or more therapy!
  140. Bacterial endocarditis
    What are indications for surgery?
    What is the most common cause of death?
    How many embolic events need to occur before surgery is indicated?
    • Surgery indications:
    • -Fistulas
    • -Abscess
    • -Pericarditis
    • -Persistent fever
    • -CHF = most common cause of death
    • -Recurrent embolic phenomenon (2 strokes)
    • -Conduction disturbances
  141. What is the most common cause for Native valve SBE?
    Viridans streptococci
  142. A young female with 3 weeks of weakness, fatigue, and arthralgias. The following is seen on fundoscopic exam. What is the diagnosis, and what is your next intervention?
    Image Upload 24
    • Bacterial endocarditis
    • Order blood cultures
  143. Encephalitis
    What is it?
    • Inflammation of the brain
    • Sx: Fever, HA, stiff neck, confusion, bizarre behavior, focal signs, seizures
  144. Acute meningitis
    If the pt is non-focal on exam, what is the next step?
    • Acute
    • -Usually symptoms less than 1 day (within hours frequently)
    • -Fever, HA, lethargy, stiff neck
    • -If non-focal exam, go directly to LP (no need for CT head)
    • -Immediate lumbar puncture
    • -Empiric antibiotics if LP abnormal
  145. Chronic Meningitis presentation
    Initial intervention?
    • Usually 7 days to 2 months in duration
    • Unilateral HA frequently
    • Focal neurologic signs and/or seizures
    • CT/MRI
    • Lumbar puncture if imaging study OK
    • Empiric therapy based on findings
  146. A 55-year old pt (or a pregnant pt) presents with meningitis symptoms. What antibiotic would you start?
  147. CSF findings in bacterial meningitis?
    • 500-10,000 WBC/uL
    • > 90% neutrophils
    • < 40 mg/dL glucose
    • > 150 mg/dL protein
  148. What is the organism if CSF gram stain shows gram (+) diplococci?
    What is the treatment?
    • Gram-positive diplococci = S. pneumoniae
    • -Ceftriaxone or cefotaxime + vancomycin until sensitivities known
    • -If PCN-sensitive, switch to IV PCN
    • -Data now support dexamethasone
  149. What is the organism if CSF gram stain shows gram-negative diplococci?
    What is the treatment?
    • N. meningitidis
    • Treat with IV PCN or ceftriaxone/cefotaxime
  150. CSF gram stain shows Gram (+) rods. What is the organism and what is the treatment?
    • Listeria
    • Treat with Ampicillin and gentamicin
  151. CSF gram stain shows "pleomorphic" rods. What is the organism and what is the treatment?
    • H. influenzae
    • Dexamethasone followed by or concomitantly with ceftriaxone or cefotaxime
  152. CSF gram stain shows gram-negative rods. What is the organism and what is the treatment?
    Ceftriaxone, ceftazidime, or cefepime (if pseudomonas a concern, use the latter 2)
  153. What is the most common sequelae of bacterial meningitis?
  154. What is the prophylaxis for meningococcus?
    • Rifampin for children < 18 years of age
    • Ceftriaxone for pregnant women
    • Ciprofloxacin is an acceptable alternative to rifampin in non-pregnant adults
  155. What is the drug of choice for prophylaxis of contacts for H. influenza?
  156. A pt with aseptic meningitis (based on CSF result) who has a pet hamster. What is the cause of meningitis?
    Lymphocytic choriomeningitis virus
  157. Cause of meningitis in a pt who was swimming in a cow pond?
    amebic meningitis
  158. Cause of chronic neutrophilic meningitis?
    • nocardia
    • actinomyces
    • fungi
  159. What CN deficit do you see in TB meningitis?
    6th nerve palsies
  160. Lyme meningitis can present with what symptoms?
    Bell's palsy or foot drop
  161. Brain abscess
    What is the best way to diagnose?
    What is the empiric treatment?
    • Diagnose with CT scan
    • Stereotactic biopsy is indicated today
    • No LP!
    • Most common empiric treatment: 3rd generation cephalosporin + metronidazole and surgical drainage if possible
  162. Diarrhea with fecal WBCs. What organisms?
    • Shigella
    • Salmonella
    • Campylobacter jejuni
    • Yersinia enterocolitica
    • Amebic
  163. What organism causes diarrhea from unpasteurized milk?
    Campylobacter jejuni
  164. What organism causes diarrhea from holiday turkey (or chitlins)?
    Yersinia enterocolitica
  165. Gonorrhea
    Gram stain result will show what?
    What is the culture medium you will use?
    • Etiology: Neisseria gonorrhea
    • Small, non-motile, Gram-negative diplococci
    • Thayer-Martin or chocolate agar
    • Virulence factor involved in pathogenesis
  166. Disseminated Gonococcal Infection
    What can trigger dissemination?
    • 1-3% of patients
    • Leading cause of acute septic arthritis in young adults
    • Local infection 7-30 days before dissemination
    • Menstruation may trigger dissemination
    • Terminal complement deficiencies at increased risk
  167. Symptoms of early DGI (Disseminated Gonococcal Infection)?
    • Subacute in onset
    • Migrating polyarthralgia
    • Pustular skin lesions
    • Tenosynovitis
  168. Symptoms of late DGI?
    • Septic arthritis
    • endocarditis
    • meningitis
    • pneumonitis
    • osteomyelitis
  169. A young woman, sexually active, who presents with acute onset, RUQ abd pain and tenderness, aggravated by breathing, coughing, or chest movement. What is the possible diagnosis?
    • Fitz-Hugh-Curtis syndrome occurs almost exclusively in women.
    • Usually caused by gonorrhoea (acute gonococcal perihepatitis) or chlamydia bacteria, which cause a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, causing infection and inflammation.
    • Occasionally, this inflammation can cause scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver.
    • Sx: acute onset, upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder following an episode of PID
  170. How do you diagnose gonorrhea?
    • Gram stain showing typical intracellular Gram (-) diplococci
    • Women have to be diagnosed through culture
    • Image Upload 25
  171. Treatment of Gonorrhea: Urethral, Cervical, Rectal
    • Ceftriaxone 125 mg IM x 1 dose (only one approved for pharyngeal gonorrhea)
    • Cefixime 400 mg PO x 1 dose

    Spectinomycin 2 g IM x 1 dose (if has anaphylactic reaction to cephalosporin). This is no longer available except on Board exams
  172. Treatment for gonorrhea with Bacteremia, Arthritis, or Disseminated?
    • Ceftriaxone 1 g IV q day x 7-10 days or for 2-3 days followed by either:
    • -Cefixime 400 mg PO bid or
    • -Cefpodoxime 400 mg PO bid
    • ==> complete 7-10 day total therapy

    Ceftizoxime or Cefotaxime may also be used for IV therapy followed by same drugs above.
  173. Inpatient treatment for Pelvic Inflammatory Disease?
    • Choose 1 of these 2 regimens:
    • 1. Cefoxitin 2 gm IV q 6 or cefotetan 2 gm IV q 12 + doxycycline 100 mg IV q 12 until improved followed by doxycycline 100 mg PO bid to complete 14 days


    2) Clindamycin 900 mg IV q 8 + gentamicin 2 mg/kg IV x 1 followed by gent 1.5 mg/kg IV q 8 until improved followed by doxycycline 100 mg PO bid to complete 14 days

    (Alternative: Ampicillin/sulbactam 3 gm IV q 6 + doxycycline 100 mg q 12)
  174. Outpatient treatment for PID?
    Ceftriaxone 250 mg IM x 1


    Cefoxitin 2 gm IM + probenecid 1 gm x 1 dose


    Doxycycline 100 mg bid x 14 days +/- metronidazole 500 mg bid x 14 days
  175. What are the suggested guidelines for hospitalization in PID?
    • Surgical emergencies (appendicitis, etc.) cannot be excluded
    • Suspected pelvic/tubo-ovarian abscess
    • Pregnancy
    • Uncertain diagnosis
    • N/V precluding oral therapy
    • Failure to respond to oral agents in 24-48 hours
  176. Genital Chlamydia Infections
    • Chlamydia cause 2/3 of epididymitis in young women
    • Chlamydia in 30-60% of women co-infected with GC
    • Chlamydia in 1/3 of cervix and/or fallopian tubes of laparoscopically verified PID
  177. Non-gonocococcal Urethritis (NGU):
    How would this present?
    • Less dysuris, less d/c than GC in general
    • Urinary frequency, irritation can be present
    • Leukocyte urethral exudate with > 4 PMNs on Gram stain of urethral swab without organism is correlated with chlamydial NGU

    • Mucopurulent cervicitis
    • -Yellow or creamy d/c from cervix
    • -Gram stain + for WBCs
    • -Similar symptoms to GC
    • - > 10 PMNs/HPF on Gram stain smear of cervical mucous correlates with Chlamydia if GC if ruled out
    • PID -- probably as common as GC as cause
  178. Genital Chlamydia infections: Lymphogranuloma venereum
    Describe the clinical course
    How diagnosed?
    • 3 days to 3 weeks after exposure, get a small painless vesicle or papule/ulcer at the site of initial contact (1/3 of patients only)
    • 2-6 weeks after exposure, regional lymphadenopathy develops. Painful periadenitis occurs with matted nodes and inflamed overlying skin. Suppuration occurs with fistula formation (heals after several months).
    • LGV 2nd stage:
    • -Fever, chills, HA, myalgias
    • -Can get aseptic meningitis, meningoencephalitis, conjunctivitis, hepatitis, arthritis
    • LGV 3rd stage:
    • Chronic ulcerative/infiltrative local structures, fibrosis, strictures, impaired lymphatic flow with resulting genial elephatiasis

    • Diagnosis:
    • -Culture
    • -Detection of elementary bodies by Giemsa, etc. or
    • -IF staining with monoclonal antibody: Most sensitive
    • -Chlamydiazyme and MicroTrak: rapid assays for detection of Chlamydia in clinical specimens
    • -Serologic 4-fold rise in antibody titer or +IgM
  179. Treatment of Genital Chlamydia Infections:
    For Urethritis, cervicitis, conjunctivitis, proctitis?
    How about for a pregnant patient?
    For pt with LGV?
    • Urethritis, cervicitis, conjunctivitis, proctitis
    • --Azithromycin 1 gm x 1 dose or doxycycline 100 mg PO bid x 7 days
    • ----Ofloxacin 300 mg bid x 7 days or e-mycin 500 mg qid x 7 days or levofloxacin 500 mg x 7 days

    • Pregnant: Azithromycin 1 gm x 1 or amoxicillin 500 mg tid x 7 days
    • --Erythromycin 500 mg PO qid x 7 daus (not estolate form)

    • LGV: Doxycyline 100 mg PO bid x 21 days
    • --Erythromycin 500 mg qid x 21 days
  180. Chancroid
    Describe clinical course
    • Incubation period: median 5-7 days
    • Begins as small tender papule with surrounding erythema at site of contact
    • Evolves to pustule which erodes and ulcerates
    • Ulcers are painful
    • Tender regional lymphadenopathy in 50%

    • Treatment:
    • Azithromycin 1 gm PO x 1
    • Ceftriaxone 250 mg IM x 1
    • Ciprofloxacin 500 mg PO bid x 3 days
    • Erythromycin 500 mg PO tid x 7 days

    Treat sexual partners also
  181. The pt below present with the tender lesion in his groin. Gram stain is shown below. What is the diagnosis?
    Image Upload 26
    Image Upload 27

    • Treatment:
    • Azithromycin 1 gm PO x 1
    • Ceftriaxone 250 mg IM x 1
    • Ciprofloxacin 500 mg PO bid x 3 days
    • E-mycin 500 mg PO tid x 7 days
  182. A young female presents with mucopurulemt cervicitis. Gram stain is (+) for WBCs, > 10 PMNs/HPF. Symptoms are similar to a friend of hers who had gonorrhea. GC was ruled out. What is the diagnosis?
  183. Chancroid
    How do you diagnose it?
    What is the differential dx?
    • Diagnosis: Culture of ulcer base with swab or aspirated from inguinal nodes or buboes
    • --Gram stain shows gram (-) coccobacilli ("school of fish")
    • Differential: LGV, HSV, syphilis, granuloma inguinale
    • Image Upload 28
  184. Granuloma Inguinale
    What is the etiology?
    How contagious is it?
    • Etiology: Klebsiella granulomatosis
    • --gram-negative bacillus
    • Mildly contagious, requires repeated exposures
    • Tx: Doxycycline
  185. A female pt comes to you for advise regarding an abnormal pap smear. What would you recommend?
  186. HPV vaccine
    Who is it recommended to?
    What HPV types does it cover?
    How is the vaccine given?
    • For females ages 9-26 years
    • Works for HPV types 6, 11, 16, 18
    • Series of 3 shots over 6 months
  187. Trichomoniasis
    What is the usual presenting complaint?
    How do men frequently present?
    How is this diagnosed?
    What is the treatment?
    Who else is treated?
    • Etiology: Trichomonas vaginalis
    • 50% are asymptomatic
    • Accounts for 25% of symptomatic vulvovaginitis in U.S.
    • Found in 13-58% of male partners, no symptoms
    • Copious, malodorous, yellow-green vaginal d/c most commonly seen
    • Intense vaginal pruritus in 25-50%
    • Vulvar, labial, vaginal mucosal edema and erythema may be seen
    • Men: asymptomatic
    • Diagnosis: Wet mount 75% sensitive.
    • --PAP, Giemsa, acridine orange stains also
    • --Culture available; 48 hours anaerobic incubation
    • Treatment: Metronidazole 2 gm x 1 or 500 mg bid x 7 days
    • Treat sexual partners
  188. Bacterial Vaginosis
    What is the treatment?
    Do you treat sex partners?
    • No treatment of sex partners necessary
    • Treatment:
    • Metronidazole cream
    • Clindamycin cream or PO
    • Metronidazole 500 mg bid x 7 days
  189. Who gets treated for asymptomatic bacteriuria?
    • Pregnant
    • Neutropenic
    • Transplant patients
  190. Osteomyelitis
    What is the most common cause of acute osteo?
    Common cause in IV drug abuser?
    Common cause in SS patient?
    What can exclude osteomyelitis?
    Does sinus drainage correlate with organism in wound?
    • Acute: S. aureus
    • -IV drug abuser: Pseudomonas, MRSA
    • -SS patient: Salmonella, S. aureus
    • -Negative bone scan excludes osteomyelitis
    • -Sinus drainage does not correlate with organism in wound (except S. aureus)
    • Prosthetic joint - Staph epi, chronic, do joint aspiration
  191. What is the most common nosocomial infection?
  192. Mycobacterium abscessus

    What is it?
    What are the most distinguishing characteristics?
    This organism is found throughout the world and is endemic in the United States. Wound infection with RGM is uncommon but can be catastrophic if not recognized and treated appropriately. The most distinguishing characteristics of the infections are nodules, often purple in color, and chronic abscess or sinuses. Skin and subcutaneous infections with RGM should be strongly considered in clinical situations demonstrating chronic purulent drainage, a lack of a convincing pathogen on routine culture, and association with implanted prosthetic devices. A lack of response to treatment and the failure to isolate a convincing pathogen should prompt further diagnostic evaluation consisting of staining and special culturing for mycobacteria followed by sensitivity testing to determine the appropriate antimicrobial therapy.
  193. What is the gram stain result for Klebsiella granulomatosis?
    gram-negative bacillus
  194. Gram stain for Listeria?
    Gram-positive rods
  195. What is the treatment for Cryptospirodiosis?
    • Treatment depends on the immune status of the host. Immunocompetent patients generally require no specific therapy because the disease is self-limited. If symptoms persist beyond several weeks, a course of nitazoxanide can be tried because it has been shown to hasten symptom resolution and clear oocysts from the stool. Immunocompromised patients, such as those with HIV infection, respond poorly to nitazoxanide, paromomycin, trimethoprim-sulfamethoxazole, and metronidazole. For these patients, initiation of highly active antiretroviral therapy to induce immune reconstitution is critical for controlling the cysts.
    • Proper hygiene is essential to decrease person-to-person spread of Cryptosporidium. Boiling or filtering of tap water may decrease the incidence of infection in immunocompromised hosts but is not routinely recommended. Persons who are immunocompromised should also limit time in public swimming pools, water parks, and lakes.
  196. How do you manage close ontacts of a pt with smallpox (variola)?
    • Immediate vaccination of close contacts (ring vaccination) is the appropriate response to a community outbreak of smallpox.
    • Acyclovir has no effect against variola, and cidofovir has not been tested as a prophylactic agent for this infection. Passive immunization with hyperimmune globulin is an effective prophylaxis for smallpox, but supplies are too limited to be of practical use in epidemic-control efforts.
  197. Explain how you manage a needlestick injury from a source who is HIV and hepatitis C virus-positive
    • After needlestick injury, injured persons should immediately wash the area with soap and water and report to the employee health department or specified area for needlestick evaluation. Baseline serologies and postexposure HIV prophylaxis should be done immediately, with follow-up serologies done as indicated.
    • Recommendations for postexposure HIV prophylaxis are based on severity of exposure and the source HIV class. Severity is divided into two categories: less severe is defined as exposure to a solid needle with superficial injury; and more severe is defined as exposure to a large-bore hollow needle, deep puncture, visible blood on device, or needle used in a patient’s artery or vein. An HIV class 1 exposure is defined as exposure to an asymptomatic source or to a source in whom the viral load is low (for example, <1500 HIV RNA copies/mL). An HIV class 2 exposure is defined as exposure to a source with symptomatic HIV infection, AIDS, acute seroconversion, or a known high viral load.
    • For low-risk exposure, prophylaxis with two nucleosides is recommended.
    • Severe exposure and the source’s class is 2; therefore, the recipient of the needlestick should be offered postexposure prophylaxis with three or more antiretroviral agents.
  198. What are the clinical features of West Nile virus encephalitis?
    Clinical features include tremores, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.
  199. What are the clinical feaures of herpes simplex encephailitis?
    • fever
    • hemicranial headache
    • language and vehavioral abnormalities
    • memory impairment
    • cranial nerve deficits
    • seizures
  200. How do you treat disseminated herpes zoster infection?
    Intravenous acyclovir is the treatment of choice for immunocompromised patients with disseminated herpes zoster infection.
  201. What are clues to the diagnosis of Plasmodium falciparum?
    • If malaria is acquired in Africa, the likelihood that it is Plasmodium falciparum is at least 3:1
    • P. falciparum infections have a clinical onset beyond 2 months after exposure in only 5% of cases; therefore, patients with symptoms lasting beyond 2 months after return from travel are unlikely to have P. falciparum infection
    • Peripheral Blood Smear Findings Likely for P. falciparum Infection
    • Level of parasitemia is >2%
    • Only ring forms are present
    • Banana-shaped gametocytes are seen
    • Erythrocytes of all sizes are infected
    • Numerous multiply infected erythrocytes are seen
    • Erythrocytes contain no Schüffner granules
  202. How do you manage a pt with suspected variant Creutzfeldt-Jakob disease?

    What is variant CJD?

    How is it diagnosed?
    Variant Creutzfeldt-Jakob disease (vCJD) is characterized by early-onset psychiatric symptoms suggestive of depression, an earlier age of onset than CJD, an absence of periodic sharp waves on electroencephalogram, and presumptive diagnosis by tonsillar biopsy.
  203. How do you obtain a diagnosis of Creutzfeldt-Jakob disease?
    Brain biopsy
  204. How do you evaluate a patiend with West Nile virus encephalopathy?
    In patients with encephalitis caused by flaviviruses (such as West Nile virus), the detection of cerebrospinal fluid (CSF) IgM antibodies is considered diagnostic of neuroinvasive disease.
  205. What are the clinical features of West Nile virus infection?
    Clinical features of neurologic infection with West Nile virus include tremors, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.
  206. How do you treat acyclovir-resistant genital herpes simplex virus infection?
    • Foscarnet is the drug of choice for treating acyclovir-resistant genital herpes simplex virus infection.
    • Resistance should be suspected if herpetic lesions do not resolve within 7 to 10 days after the initiation of adequate antiviral therapy. Resistance is most commonly reported for acyclovir, but this may simply be because acyclovir has been available for clinical use longer than the other drugs in this family. If resistance is suspected, a viral culture should be obtainedand the specimen submitted for in vitro susceptibility testing; the correlation between in vitro resistance and clinical response is good.
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