Week 1 - Unit 1
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"To determine the degree of immunosuppresion, the most important assay to establish current immunologic status is the determination of the CD4 count, which is reported as both absolute number of CD4 + lymphocytes of blood (normal range 500 to 1700) and the percentage of all lymphocytes that are CD4 (normal range 35% to 61%). In addition, quantifying the amount of HIV in the patient's plasma, known as the HIV viral load or viral burden, provides additional information about immune function (the higher the viral load, the more immunologically compromised the patient); but more important, it provides an estimate of the expected rate of immunologic decline (as measured by falling CD4 count). This is established at baseline because decline in viral load after starting of ART is the most important initial marker of efficacy of ART. The viral load can be measured by two technologies reverse transcriptase PCR (RT-PCR) and bDNA"
1."Fever of Unknown Origin" (FUO): (This question is intended to review how fevers arise and evaluated, and treated.)
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For congenital rubella, the provider may find:
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Nine day measles is another name for rubeola. Rubeola is described as an acute and highly contagious viral disease with rash (Hollier & Hensley, 2011). Morbillivirus is the associated etiology. The incidence has drastically decreased since 1990 and isolated outbreaks affect mostly unvaccinated persons (Hollier & Hensley, 2011). The CDC no longer considers this endemic (Hollier & Hensley, 2011, p. 146). Those at risk are: lack of immunization of; spread in waiting rooms by microaerosolized respiratory droplets; incubation is 10-12 days from exposure to onset of symptoms; and patients are contagious from 1-2 days prior to onset of symptoms until 4 days after appearance of rash (Hollier & Hensley, 2011). Rubeola consists of prodromal stage and rash phase.
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Prodromal stage - 2 to 3 days before rash:
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Those at risk are individual that lack vaccination and are exposed to viral particle by airborne transmission (Hollier & Hensley, 2011). The incubation period is 7-21 days and rubella is most contagious when rash is erupting (Hollier & Hensley, 2011). For acquired rubella, the provider may find:
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Three day measles is another name for rubella. It is described as an acute viral infection that can affect children and adults (Hollier & Hensley, 2011). Rubella can present in two different forms: a mild viral exanthema (acquired) and may induce abortion, congenital defects if exposed during pregnancy (congenital). The etiology is the rubivirus. According to Hollier and Hensley (2011), the incidence:
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e. What are common causes of FUO?
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o
...
1.
20 mg or more per day of prednisone for 14 days or longer
2.
2mg/kg or more per day of prednisone for 14 days or longer
33% of people will develop shingles (about 1 in 3 people) in their lifetime, and of those, anywhere from 5 to 20% will have postherpetic neuralgia. Latent varicella infections are dormant in nerve roots (dorsally) or nerve ganglion cells (cranially) until immunity is decreased either by normal age-related immune decline or by other stressors to the body's immune system, at which time the vericella-zoster virus reactivates. The most common times for reactivation include after a patient reaches 50 years of age, patients with medical conditions that prevent proper immune system functioning, and patients who are immunosupressed due to drugs (CDC, 2014). And while eruption of shingles is usually seen unilaterally in one dermatome, about one in five cases will present with adjacent dermatomal involvement.
o
< 1,000 cases annually are reported
A migration in the skin around the bite which occurs after 3 to 32 days through the lymphatic system causing regional adenopathy or disseminate and blood to organs or other skin sites.
A prodromal sore throat with diffuse adenopathy may suggest infectious mononucleosis rather than viral hepatitis. Alcohol induced hepatitis is suggested by a history of drinking, is more gradual in onset of symptoms, and physical assessment would reveal the presence of vascular spiders or signs of chronic alcohol use or chronic liver disease. Other differential diagnoses may include autoimmune hepatitis, Cholangitis, Hepatitis, and Viral.
i.
According to Castle, Cox, and Palefsky (2014), the malignant conditions that the HPV vaccines can be useful against are cervical cancers, anorectal cancers, oropharyngeal cancers, a significant proportion of vulvar and vaginal cancers in women, and significant proportion of penile cancer.
i.
According to Hariri, Dunne, Saraiya, Unger, and Markowitz (2014) the vaccine can protect against low-risk HPV types, such as HPV 6 or 11 (which account for 90 % of cases), that can cause benign or low-grade abnormalities of cervical cells, anogenital warts, and a disease of the respiratory tract called recurrent respiratory papillomatosis (RRP). RRP (a rare condition) is characterized by recurrent warts or papillomas in the upper respiratory tract, particularly the larynx.
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According to Moss (2013), "when ELISA generates a positive result, a confirmation test normally is performed. The ELISA methodology is generally not used to confirm a diagnosis; for this, the CDC advocates the use of the more expensive Western blot methodology. A sizable fraction of initial positive results are refuted using the Western blot test. The Western blot technique is also an antibody detection test. Unlike the ELISA method, however, viral proteins are first separated and then immobilized. The Western blot test identifies antibodies to proteins of a specific molecular weight, which helps eliminate false-positive results" (p. 255).
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According to Ness, Price, Currie & Reilly (2014), anti-microbial resistance (AMR) is an "urgent public health concern" and a result of "high consumption, increased frequency and imprudent use of antimicrobial" (p. 248). In addition, 80% of antimicrobials are prescribed in the primary care setting meaning FNP's and family provider can greatly influence and play a key role in AMR (Ness, Price, Currie & Reilly ,2014).
According to The Centers for Disease Control & Prevention (2014), Haemophilus influenzae type b (Hib) bacteria commonly causes pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis media, purulent pericarditis, and other less common infections such as endocarditis and osteomyelitis. Nontypeable Haemophilus influenzae bacteria commonly causes ear infections in children and bronchitis in adults, but may also cause invasive disease, such as bacteremia and pneumonia.
a.
According to the CDC (2014), as a result of the vaccine, polio has been eliminated in the US for over than 30 years. The disease does still exist in certain parts of the world so it is crucial to maintain the success rate of U.S. vaccination efforts (CDC, 2014). Health care providers must continue to educate that those most at risk are the unvaccinated, those who have not received all the recommended vaccine doses, and people traveling to areas where there is a risk of infection (CDC, 2014). Health travel notices to locate these areas can be found at http://wwwnc.cdc.gov/travel/notices.
According to the CDC (2014), the shingles vaccine should be administered to people 60 years of age old or older to decrease the risk of shingles and its associated pain.
According to the United States Advisory Committee on Immunization Practices (ACIP), the influenza vaccine is recommended for all individuals of six months of age and older (Zachary et al., 2014).
b.
According to the World Health Organization (2014) only three countries remain polio-endemic: Afghanistan, Nigeria, and Pakistan. This is down from 125 in 1988
o
Acute HBV infection: 6 weeks to 6 months
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Acute HCV infection: 2 weeks to 6 months (Viral Hepatitis, 2013)
Additional history should be directed towards causative identification. The history of exposure can possibly provide the only clue of drug-induced or toxic hepatitis. The majority of acute HBV and HCV infections are asymptomatic. For this reason, the time periods for the collection of data should correspond to the time between exposure and the time in which symptoms or positive serological laboratory markers for disease may appear. Time periods are typically:
Additional patient history - Acute hepatitis C:
After 65 but with a minimum interval of five years between PPSV23 doses.
a.
Against which benign illness(es) does it protect?
b.
Against which malignant conditions in 2014 is the Advisory Committee on Immunization Practices (ACIP) recommending the vaccine be given?
1.
Alkylating agents
Anti-- HBc (also written as HBcAb), which is antibody to hepatitis B core antigen: if (positive) or (reactive,) it may suggest the person has had contact with hepatitis B. This test is very complicated to explain because the (anti--HBc) can be a "false positive" test result. A blood bank usually runs the "anti-- HBc" on donated blood a positive test depends on the results of the other two blood test previously described.
Anti-- HBs (also written as HBsAb), which is anti-body to hepatitis Be surface antigen: if this is (positive) or (reactive, post parentheses this means the person is immune to hepatitis B infection, it can be from vaccination or from past infection. This type of test is not done routinely by most blood banks on donated blood.
Antibody to HCV (anti-HCV)
2.
Antimetabolites
a.
As a child you may have received DTaP which protected against pertussis but overtime these vaccines wear off putting the adult susceptible to the infection again. TDAP is different than TD. While TDAP a vaccine for tetanus, diphtheria and pertussis (whooping cough), TD only protects against tetanus and diphtheria (CDC, 2013). Adults are the most common source of whooping cough in infants which is a highly infectious respiratory infection that can be very serious in infants and other immunocompromised persons. The Advisory Committee on Immunizations Practices (ACIP) recommends that adults 19 years and older receive a one-time vaccination of TDAP as a booster if they have never had one before regardless of last interval of TD (CDC, 2011). It is also important to inform the patient that even if you have been fully vaccinated you can still get pertussis and the best way to prevent the infection to infants, teens, and adults is to get vaccinated (CDC, 2013).
As an expansion to your post, Johnstone & Lueb state that, in general, the direct effects of vaccination refer to the direct protection of the vaccinated individual, which results in a reduced chance of infection and possibly complications. The indirect benefits of vaccination refer to protective effects observed in unvaccinated populations. This indirect effect of vaccination is known as the herd effect or 'herd immunity', defined as the indirect protection of unvaccinated persons. An increase in the amount of vaccine- immunity prevents circulation of infectious agents in unvaccinated susceptible populations. The importance of herd immunity was first recognized with smallpox, where the initial goal was to immunize 80% of the population in order to achieve such a herd effect.
i.
As like any other medication, vaccinations have side effects that can range from a mild rash to serious adverse effects. The most common side effects associated with vaccinations are mild redness and slight swelling lasting for a couple of days (Vaccine Side Effects/ Risk, 2012). However, "serious side effects following vaccination, such as severe allergic reaction, are very rare and doctors and clinic staff are trained to deal with them" (Vaccine Side Effects/ Risk, 2012). One of the most controversial vaccinations currently is the association and possible cause of Autism linked to childhood immunizations. At present, research does not prove or disprove the relationship between vaccinations and autism and is an ongoing research topic (Drutz, 2014).
As mentioned above infectious disease spread is about contact. By increasing the numbers of immunized people, there is a decreased probability of contagion spread, the rate of contagion spread and the overall percentage of morbidity of the contagion. Herd immunity provides indirect protection from disease of unvaccinated populations because of their proximity to vaccinated/disease resistant portions of the populations. Epidemiologist have worked out mathematic formulas to determine coverage, but they are restricted by factors such as imperfect immunity, homogenous populations, nonrandom vaccinations and what they describe as "freeloaders" (Fine, Eames, & Heymann, 2011).
d. Should aspirin be used as an antipyretic agent in children with fever that is probably due to a common viral illness, irrespective of the exact viral agent?
Aspirin should not be used in treating children with acute febrile forms of viral illnesses due to the fact that this medication is stated to have the potential to cause children to develop Reye's Syndrome. Thus, since "1986 the U.S. Food and Drug Administration (FDA) required that aspirin labels state that children and teenagers should not use the product" (Beutler, Chesnut, & Mattingly, 2009).
B. burgdorferi is introduced from a bite of a tick (Lyme disease)
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Bacteria - Acinetobacter, Antrax, Campylobacter, Carbapenem-resistant Enterobacteriacae, Gonorrhea, Group B Streptococcus, Methicillin-resistant Staphylococcus aureaus (MRSA), Escherichia Coli (E.coli) Neisseria meningitides, Salmonella, non-typhoidal serotypes, shigella, streptococcus pneumonia, Tuberculosis (Mycobacterium), Typhoid Fever, Vancomycin-resistant Enterocci (VRE), Vancomycin-Intermediate/Resistant Staphylococcus aureus (VISA, VRSA) (AAR, 2013)
9.
Both Lyme Disease and Rocky Mountain Spotted Fever are spread by deer ticks. Explain the pathophysiology about how this transmission occurs using a list format.
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Campylobacterosis
iii.
Chemotherapy
Cigarette smokers, chronic heart disease including cardiomyopathy and CHF, asthma, COPD, chronic lung disease, DM, chronic liver disease, cerebrospinal fluid leak, cochlear implant, congenital or acquired asplenia, sickle cell disease, congenital or acquired immunodeficiency, including B or T lymphocyte deficiency, complement phagocytic disorders, HIV infection, Chronic renal failure, Nephrotic syndrome, Leukemia, Lymphoma, Hodgkin disease, Multiple myeloma, generalized malignancy, Iatrogenic immunosuppression, including glucocorticoids or radiation, and solid organ transplant are all conditions that warrant pneumococcal vaccination before age 60 (Musher, 2014).
22.
Comment on the risk of developing autism from vaccines, citing evidence for your statements.
12.
Complications of vaccines: There are many myths about side effects of vaccines such as "I always get the flu when I get the flu vaccination."
1.
Congenital immunodeficiency
Contraindications for the annual influenza vaccine, include those who have had a previous allergy to the influenza vaccine or those who have developed Guillain-Barre after six weeks of an influenza vaccine administration (Zachary et al., 2014). Caution and precautionary measures need to be taken in those who have an allergy to eggs (Zachary et al., 2014). The live attenuated intranasal vaccine (LAIV) should not be given to immunocompromised patients (HIV and drug induced immunosuppression), patients with chronic illnesses (cardiovascular, pulmonary, renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic), influenza vaccine induced Guillain-Barre, pregnant women, adults ≥ 50, and persons with allergy to eggs (Zachary et al., 2014).
iv.
Corticosteroids
o
Diagnostic studies the provider may perform are: measles specific IgM titiers (detectable 3 days after onset of rash), there is a 4-fold substantial rise in IgG titers between acute and convalescent phase (7 days after onset of rash) (Hollier & Hensley, 2011, p. 146). Just like rubella, rubeola must be reported to public health department. Routine vaccination of MMR given at 12-15 months and then again at 4-6 years.. Respiratory isolation is needed until 4 days after rash appears and keep immunocompromised patients away entirely (Hollier & Hensley, 2011). The live virus vaccination can provide protection even if given 72 hours after exposure and immunoglobulin if given within 6 days after exposure (Hollier & Hensley, 2011).
o
Diagnostic study options are viral cultures from throat or urine, but are not usually needed, and rubella antibodies (Hollier & Hensley, 2011). A titer of 1:10 of the rubella antibodies or higher usually considered immune (Hollier & Hensley, 2011). Prevention is key and routine immunization at 12-15 months and then again at age 4-6 years is indicated. It is important to remember not to immunize patients during pregnancy and rubella is communicable in breast milk (Hollier & Hensley, 2011). All cases are reported to local public health authorities and educate women to avoid pregnancy for one month after vaccination (Hollier & Hensley, 2011).
18.
Differentiate between "nontypable and type B Hemophilus influenzae infections in terms of severity.
ii.
Disease
Disseminated intravascular quite elation (DIC) disease often occurs in the severely ill patients
c.
Do different vaccines have the same level of herd immunity?
o
Does the patient have or receive a tattoo? Where the tattooing was performed? (Commercial parlor/shop, correctional facility, other)
a. (con't)
Dr. M - Thanks, Eduy, for the added posting material. Drug fever is something to "remember." Your listing is nice, because it points to the diversity among drug classes that could be the cause of fever: antimicrobials, antihistamines (allergy/GI), antiseizure meds, NSAIDs (remember, these drugs are very helpful, with distinct potentials for harm), and the CV drugs. You can see that I am a "grouper" (and not the fishy kind!).
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Dr.M - Quite comprehensive, Cassie. I remind all that Gardasil and Cervarix both cover types 16 and 18 of the HPV, the ones associated with malignancies as listed. Gardasil is the only one of the vaccines that also covers types 6 and 11
o
During the 2 weeks - 6 months prior to onset of symptoms was the patient in contact of a person with confirmed or suspected acute or chronic hepatitis C virus infection? Sexual, household (nonsexual), other?
o
During the 2 weeks - was six months prior to onset of symptoms, did the patient undergo hemodialysis? Have accidental stick or puncture with a needle or other object contaminated with blood? Receive blood or blood products (transfusion)? If yes, when?
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E. Coli
Erythema Migrans occurs (hallmark sign and the best clinical indicator of Lyme disease)
a. How is this defined clinically?
Fever of unknown origin (FUO) is distinguished and established differently from fever without clear etiology. In primary care setting, classic FUO is most prevalent. It is defined as temperature greater than 38.3 C (101 F), fever spanning greater than three weeks duration, and comprehensive examination does not result in a diagnosis (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Comprehensive examination is based on three days of hospitalization, three outpatient visits, or one week of thorough outpatient examination (Buttaro et al., 2013). The elimination of hospitalization from the above mentioned has been proposed due to the sufficiency of outpatient setting evaluation and the inclusion of nosocomial, neutropenic, and HIV associated fevers to the defined syndromes (Bor, 2014).
Followed by serologic conversion (antibiotic response to infection) ("Lyme," 2013)
For immunocompromised patients and individuals with functional or anatomic asplenia who are <65 years of age, the ACIP recommends only one single revaccination with PPSV23 ≥5 years after the first dose .All adults aged ≥65 years should receive a dose of PPSV23 even if they were vaccinated when they were <65 years of age; however, a minimum interval of five years between PPSV23 doses should be maintained The ACIP does not recommend routine revaccination of immunocompetent adults with PPSV23. At the present time, revaccination of adults with PCV13 is not recommended.
d.
From a serological standpoint, hepatitis B requires more than a single serological test (antigen and antibody) to determine if a person, like Randy, is also infected with this virus. What are those tests? How could you tell if a patient had only been immunized against hepatitis B? Was chronically infected by hepatitis B?
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Fungi - Candida (AAR, 2013).
3.
Generalized malignancy
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Geographic tounge - A local loss of filiform papillae lead to ulcers with reddened centers and white borders which can change size and shape rapidly (Goldstein, B., & Goldstein, A., 2014).
HBsAg
HBsAg (hepatitis B surface antigen): when this test is (positive) or (reactive) it means the person is currently infected with hepatitis B and is able to pass infection onto others.
HCV genotyping as an aid for guiding treatment ("Viral," 2014)
2.
HIV Infection:
5.
Helen is 23 years old, and single. She is sexually active, but "always" uses "protection" against pregnancy. She complains that her mouth is very sore, and you find white cheesy material on her palate, gums, and tongue surface, compatible with oral candidiasis.
Herd Immunity can be defined in numerous ways. It can indicate a particular threshold proportion of immune individuals that should lead to a decline in incidence of infection (Fine, Eames, & Heymann, 2011). Also, it can indicate a pattern of immunity that should protect a population from invasion of new infection (Fine, Eames, & Heymann, 2011). Lastly, the term Herd Immunity is described as the risk of infection among susceptible individuals in a population is reduced by the presence and proximity of immune individuals (Fine, Eames, & Heymann, 2011).
Herd immunity is when "a critical portion of a community is immunized against contagious disease" ("Community Immunity ('Herd Immunity')", 2013, n.p.). The idea is to have enough of the population immunized to prevent the spread of the infections disease to others the sick person may come into contact with. There are problems with this formula, in that it assumes a heterogenous community, not a homogenous community, where refusal rates may be much higher (Fine, Eames, & Heymann, 2011).
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Here is a list of medications with a potential for inducing fever which includes "Allopurinol, Azathioprine, Captopril, Carbamazepine, Cephalosporins, Cimetidine, Clofibrate, Erythromycin, Heparin, Hydralazine, Ibuprofen, Hydrochlorothiazide, Isoniazid, Meperidine, Methyldopa, Nifedipine, Nitrofurantoin, Penicillin, Phenytoin, Procainamide, Quinidine, Sulfonamides, Triamterene and Vancomycin" (Domino, Baldor, Grimes & Golding, 2013, p. 452).
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Herpes simplex - In oral mucosa appear as clusters of open, painful, ulcerated lesions (Domino et. al, 2013).
b.
How is it evaluated?
b.
How many doses of the vaccine be given across the lifespan?
c.
How would you re-hydrate Jimmy?
1.
IV drug users, Men who have sex with men, Persons who have sex for money or drugs, Sex partners of persons who are HIV-infected, bisexual, or inject drugs, Persons who have sex with partners whose HIV status is unknown, Pregnant women even if they have been screened during previous pregnancies
c.
If a patient has the vaccine before the age of 65, under what circumstances should the patient again receive the vaccine?
c.
If a screening enzyme-linked immunosorbent assay (ELISA) test is repeatedly reactive, which confirmatory test should be done?
d.
If both the ELISA and confirmatory test for HIV infection are positive, which additional blood tests are indicated to "stage" the degree of immunodeficiency and the number of viral particles in the blood?
IgM ant-HBc (IgM class antibody to hepatitis B core antigen: when "positive" or "reactive," the person has had hepatitis B infection in the past six months which would indicate or suggest an acute or recently acquired hepatitis B infection (Immunize action coalition website, 2014)
IgM antibody to hepatitis B core (IgM anti-HBc)
Igm antibody to HAV (IgM anti-HAV)
i.
Immunosuppression/immunodeficient states are when the body has a weakened immune system with a lessened ability to fight infection. Reasons for this state include (CDC, n.d, p. 20):
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In children, infections causes, such as viral illness and cat-scratch, are more common than malignant causes (Buttaro et al., 2013). Some bacterial causes of FUO are bacterial endocarditis, abscesses, chronic mastoiditis, bartonella henselae, pyelonephritis, salmonellosis, sinusitis, and TB. Among viral, adenovirus, cytomegalovirus, hepatitis viruses, and Epstein-Barr virus (UpToDate, 2014). Some noninfectious causes of FUO in children are systemic onset juvenile rheumatoid arthritis and Takayasu's arteritis. Also, familial Mediterranean fever or hyperimmunoglobulin D syndrome can cause fever in adults and children (Buttaro et al., 2013).
b.
In reviewing published information on vaccines, which vaccines have been associated with serious adverse complications of childhood vaccines?
11.
Influenza:
4.
Jimmy is three years old, and lives on a small ranch. His parents raise chickens and pigs on their ranch. He presents with a history of fever, loss of appetite, and recurrent bouts of diarrhea. This has been going on for three days. His abdomen is soft, but slightly tender. Bowel sounds are active.
7.
Jon's ELISA test for HIV infection is positive. What test should be done next to confirm that he has HIV infection?
b.
Laboratory screening for HIV infection is now routine among women attending an obstetrical clinic pre-partum. Which screening test(s) are routinely done in this situation for HIV infection?
2.
Leukemia or lymphoma
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Leukoplakia - Precancerous lesions that look like white patches on the oral mucosa. These white patches cannot be scraped off as mentioned in the scenario (Domino, Baldor, Grimes, & Golding, 2013).
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Lichen planus - Described as shiny, flat topped, papules of the skin, commonly seen as milky white lines with a lacy net like pattern which often occur both on the oral mucosa as well as the skin (Domino et. al, 2013).
a.
List one or two microbes as an example of having developed antimicrobial resistance among each of the following classes of microbes:
i.
Live vaccines should generally be avoided while patients are immunocompromised due to uncontrolled replication of the vaccine virus. Inactivated vaccines are recommended for this population and for those they live with (CDC, n.d).
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Measles (Rubeola) is a highly contagious respiratory disease caused by a virus. The symptoms of (9-10 day) Measles are fever, runny nose, cough and a rash all over the body. About 1out of 10 children with measles will also present with an ear infection, and 1 out of 20 will contract pneumonia (CDC, 2014). The symptoms of measles generally begin about 7-14 days after a person is infected, and include: blotchy rash, fever, cough, runny nose, red, watery eyes , feeling run down and achy, tiny white spots with bluish-white centers found inside the mouth (Koplik's spots).The typical case of measles begins with a mild to moderate fever, cough, runny nose, red eyes, and sore throat then two or three days after symptoms begin, tiny white spots (Koplik's spots) may appear inside the mouth (CDC, 2014). Three to five days after the start of symptoms, a red or reddish-brown rash will appear. The rash will usually begin on the face at the hairline and spreads downward to the neck, trunk, toward the arms, legs, and feet. When the rash appears, a person's fever may spike to more than 104 deg (CDC, 2014). After a few days, the fever should subside and the rash will fade.
3.
NOT aerosols, alternate-day, short courses, topical
Oral antiviral medications that are universally accepted as agents to which type A and B influenza viruses are still susceptible include neuraminidase inhibitors (oseltamivir and zanamivir) (Zachary et al., 2014). Adamantanes (amantadine and rimantadine) are only active against influenza type A and are generally not used in the United States due to resistance (Zachary et al., 2014). According to Zachary et al, when influenza treatment is warranted, a neuraminidase inhibitor such as oseltamivir or zanamivir are used. Both drugs are effective as long as the influenza type being treated is not an oseltamivir resistant influenza (Zachary et al., 2014). The dose for oseltamivir is 75 mg twice daily and 10 mg ( 2 inhalations) of zanamivir twice daily (Zachary et al., 2014). The duration of therapy is five days when using either drug (Zachary et al., 2014).
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Oral candidiasis - Also known as thrush, presents as cottage cheese like lesions usually covering large areas of the mouth (Munsell, 2013).
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Oral candidiasis can typically be suspected based on clinical presentation of a white cheesy substance coating the mouth, but can be confirmed by performing a gram stain or KOH preparation on a scraping of the substance.(Kauffman, 2014). Testing of the scraping would be preformed to confirm the diagnosis.
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Parasitic - Malaria (AAR, 2013).
Persons who should not receive the shingles vaccine is anyone who has an allergy to gelatin or neomycin, have a primary or acquired immunodeficiencies (leukemia, lymphoma, or other cancers affecting bone marrow or lymphatic system), receiving cancer or radiation, had a solid organ transplant, receive high dose steroids, HIV, or pregnant or may become.
15.
Pneumococcal vaccines
3.
Prevention of Antimicrobial Resistance: (This is a review topic, now applied to the clinical setting.)
10.
QUESTIONS ON HERD IMMUNITY:
Quantitative HCV RNA assay
RMSF is caused by Rickettsia rickettsii and is transmitted by ixodid ticks.
3.
Radiation
8.
Randy's a "former" injecting drug user who presents for follow up of his recent routine health assessment and checkup. He "feels fine." His examination is unremarkable. His new laboratory reports reveal that his liver enzymes (AST, ALT) are elevated to 6 times the normal values and his screen for hepatitis C is now "reactive."
o
Rash phase - characterized by the more severe the rash, the more severe the illness:
o
Receive any IV infusions and/or injections in the outpatient setting?
Rickettsiae proliferates within the damaged endothelial cells
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Routine screening for HIV is recommended for adolescents and adults between the ages of 13-75 years of age (Bartlett, 2014). For patients who are considered low risk, a one time HIV screening is reasonable. According to Bartlett (2014), patients considered high risk would be candidates for annual or more frequent HIV testing which include the following high risk groups:
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Rubella or 3 day measles is highly contagious. It is a viral disease characterized by slight fever, mild rash and swollen glands. Most cases are mild but if rubella is contracted early in pregnancy, it can spread from the infected mother to her developing resulting in birth defects or fetal death. As a result of widespread immunization in the United States rubella is rare and usually related to foreign travel (Mayo Clinic, 2014). People infected with rubella are contagious from 10 days before the onset of the rash and up to t one to two weeks after the rash disappears. People infected can spread the illness before they realizes they have it (Mayo Clinic, 2014). Rubella usually causes the following symptoms in children: rash that starts on the face and spreads to the rest of the body, low fever (less than 101 degrees). Symptoms usually last 2 or 3 days. Older children or adults may also have swollen glands and symptoms of a cold before the rash appears. Aching joints may occur, especially among young women. Half of the people who get rubella do not have symptoms (CDC, 2014).
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Salmonella - non typhoidal
a.
Should every patient undergo laboratory screening for HIV infection?
Small blood vessels on the sites of the characteristic pathological lesion
So, Dr. Miller, your statistical chances of getting shingles is 33%. If you are the one in three that is unlucky enough to have your VZV reactivate, then you have up to a 20% chance of having pain for (up to) years after the eruption. Unless you enjoy pain ("described as stabbing, burning, aching, or excruciating" in Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013, pg. 271), or feel that a 66% chance of not having viral reactivation is worth taking, I would recommend the Zoster vaccine.
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Stool culture to rule in or out bacterial etiology; CBC to assess leukocytosis, leukopenia or anemia if diarrheal blood loss.
The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for many years in the United States for all adults ≥65 years of age and in younger patients who have a condition that increases the risk of invasive pneumococcal disease or pneumococcal pneumonia. Conditions that increase the risk are smoking, chronic heart disease, chronic lung disease, diabetes mellitus, alcoholism, and chronic liver disease. The ACIP recommends that both PCV13 and PPSV23 be given sequentially to adults ≥50 years of age who have the underlying conditions such as cerebrospinal fluid leak, cochlear implant, functional or anatomic asplenia, and immunocompromised patiens. PCV13 is not recommended for healthy adults of any age.
f.
The CDC has reported numerous instances where the rotavirus vaccine has been given intramuscularly. How would you handle this situation if you were in charge of the clinic?
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The ELISA test for HIV screening has a sensitivity and specificity of > greater than 98% but is confirmed byWestern blot or immunofluorescence assay (IFA).
The first question to address is the distribution of vaccine. Fine, Eames and Heymann (2011) state that, " early theoretical work ...assumed that vaccines induce solid immunity against infection....more recent research has addressed the complexities of imperfect immunity, heterogeneous populations, nonrandom vaccination and 'freeloaders'" (2011, p. 913).
The second question is the affect of the vaccines themselves. Vaccinations are not uniform in their ability to give immunity. Many require multiple doses (such as MMR, HBV, HAV) and many have differing formulations (monovalent v. trivalent polio vaccines).
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There are several different syndromes of fever of unknown origin (FUO) that include classic FUO, nosocomial FUO, neutropenic FUO, and FUO related to HIV infection; however, classic FUO is the most seen in primary care settings (Buttaro, Trybulski, Polgar Bailey, & Sandberg-Cook, 2013). The most common causes of classic FUO in adults are infections, noninfectious inflammatory diseases, and malignancies. Among infections, tuberculosis (TB), abscess, osteomyelitis, and bacterial endocarditis are the most common etiologies. In noninfectious inflammatory diseases, Adult Still's disease and giant cell arteritis are the most common rheumatologic diseases presenting as FUO. The most common malignancies to present with FUO are lymphoma, leukemia, renal cell carcinoma, and hepatocellular carcinoma (UpToDate, 2014).
c. Should a patient receive antipyretic medication during the evaluation? Please explain your answer in detail.
There is no evidence to support the treatment of fever; hence, antipyretic administration may not be a necessary component during evaluation (Domino, Baldor, Golding, & Grimes, 2014). Ideal situation warrants the treatment of the cause of fever because suppressing fever itself may actually delay recovery from infection (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). When fever is present and identification of infection has been done, administration of antipyretic provides symptomatic relief. Nonetheless, certain circumstances require treatment of the fever itself such as when fever is greater than 41 C (105.8 F) to avoid brain damage, younger children ages 3 months to 5 years to prevent manifestation of seizure, and those with cardiovascular disease who may not be able to tolerate the metabolic demands (Buttaro et al., 2013).
This suggests that there is no blanket coverage, but varying degrees of reduced risk. I was one of those "college students" who had to receive catch up vaccines because it was discovered that the MMR provided as a child really needed two doses for coverage. As our understanding of diseases and immunogenicity improves, so will our ability to produce high quality vaccinations.
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Three different antiretroviral medications are recommended during ART therapy in order to improve effectiveness and decrease drug resistance. Drugs should be selected from two different classes. The base of the regimen should either be a NNRTI or a PI, and the backbone should consist of two different NRTIs. No more than 3 drugs are recommended due to no shown evidence of increased effectiveness and the risk of toxicity. The goals of ART therapy include: viral load <50, immune restoration, prevention of HIV transmission and resistance, and increased quality of life (Bartlett, 2014).
Thrombus may obstructe vessels producing a vasculitis in the skin, subcutaneous tissues, CMS, lungs, heart, kidneys, liver, and spleen
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To answer your question on what to do next while waiting for the stool cultures to come back, I would focus on rehydrating Jimmy to help replenish his electrolytes. According to Chiocca (2011) Jimmy has both a hot (fever/diarrhea) and cold (stomach pains) condition where barely water and bottled milk could be uses as well as cheese and chocolate can help entice him to start eating. Of course three year olds are picky eaters and this may not work, but I would encourage the mother to attempt to feed him and supplement with Pedialyte to help with dehydration. In an article written by Stanton, Evans, and Batra (2012), oral rehydration therapy (ORT) is the preferred first line treatment of fluid and electrolyte losses caused by diarrhea and are used independently from the age of the child, the causative agent, or initial sodium levels. They also state that if the ORT is started early enough and the parents are taught when to initiate it then this can help reduce the need for IV therapy, amounts to lower costs, and reduce the amount of emergency room/doctor visits (Stanton, Evans, & Batra, 2012).
a. (con't)
Treatment of fever of unknown origin may prove difficult. The attempt should be to determine the etiology prior to initializing any type of medical therapy. Using "shotgun approaches" is frowned upon because they may cloud the true clinical picture and not solve the problem. Treatment during these episodes will include fluid replacement and increased calories in the diet due to the temperature elevations. Initial labs that should be considered are: CBC, LFTs, peripheral blood smear, CRP, ESR, HIV, Blood cultures, UA and urine culture. Continued fever after an extended time may warrant additional labs to include: RA, ANA, Epstein Barr, hepatitis, syphilis, Lyme disease, CMV, serum ferritin, sputum culture (possible TB) and a TB skin test. Initial imaging of a CXR and a CT of the abdomen and pelvis may be needed. Follow up includes a full history and physical with repeat labs (Domino et al., 2012).
13.
Vaccination against the human papilloma virus protects against both benign and malignant illness. The vaccine is also now approved for use in males.
Vaccinations are one of the most effective means of decrease and at times eliminating death causing diseases in the world; however the discussion on risk verses benefits has been brought to the fore front due to media creating a very bias opinion to an extremely large population. "The mainstream media has a limited ability (or perhaps preference) to adequately communicate scientific data on vaccines, and Internet sites are not subject to constraints regarding scientific accuracy or fairness of their reporting. The resulting misinformation leads to unnecessary parental concerns" (Boom &Healy, 2014).
14.
Vaccine delivery:
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Viruses - Influenza (Antibiotic/Antimicrobial Resistance [AAR], 2013).
a.
What additional health history needs to be reviewed with Randy?
b.
What are the most common reasons for the development of antimicrobial resistance?
e.
What defines an "immunodeficient state" in a patient?
a.
What does the literature support related to serious complications of childhood vaccines?
a.
What is herd immunity?
19.
What is the "3 day measles"? Differentiate it from the "9 or 10 day measles."
a.
What is the differential diagnosis of his problem?
c.
What is your differential diagnosis at this point for Randy's health problem?
a.
What is your differential diagnosis?
6.
What studies would you order, if any? Why would you order each study if you feel some are necessary?
b.
What studies would you order, if any? Why would you order each study if you feel some are necessary?
b.
When is it appropriate to delay vaccinating a child?
f.
Which drugs can be the primary cause of FUO?
17.
Which medical conditions provide an indication for pneumococcal vaccine before the age of 60?
a.
Which oral antiviral medications are still universally accepted as agents to which type A and B influenza viruses are still susceptible? Cite current evidence.
a.
Which vaccines can be given simultaneously?
c.
Which vaccines contain live viruses?
d.
Which vaccines should be avoided among immunodeficient patients?
20.
Which viral illness that is vaccine-preventable has nearly been eliminated globally, like smallpox?
16.
Who should receive the vaccine to prevent occurrence of herpes zoster?
a.
Who should receive the vaccine?
b.
Who should, and who should not, receive the annual influenza vaccine?
b.
Why is herd immunity important?
e.
Why is treatment with more than one class of antiretroviral medications recommended for persons with symptomatic HIV infection with CD4 T lymphocyte counts of 350/mm3?
Without immunization, children are at risk of infection of some vaccine preventable diseases and can then serve as a reservoir for the infection to spread to other age groups, such as infants and the elderly (Mameli, Fabiano, & Zuccotti, 2011). When addressing the immunization of adolescents, it is not only essential for protecting the individual but also for protecting the community as a whole because achieving and maintaining high immunization rates in the general population is critical for disease prevention (Mameli, Fabiano, & Zuccotti, 2011). Some parents refuse to get their children vaccinated or at a rate they feel is necessary. Those parents are not only putting their children at risk for infection, but the community as well.
b.
Would you recommend any other testing? If so, what would these be, and how would you justify ordering them to his insurance carrier?
21.
You are seeing a 56 year old woman who has never had the acellular form of the pertussis vaccine. Explain how you will tell her she should have the vaccine, TDaP, at this time.
o
after 3 to 4 days the rash begin to clear and may leave a brownish discoloration and scaling (Hollier & Hensley, 2011, p. 146)
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cardiac defects: patent ductaus arteriosus (PDA), atrial and ventricular septal defects, coarctation of the aorta, pulmonic stenosis
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congenital rubella syndrome occurs rarely
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conjunctivitis
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endocrine defects: thyroid disorders, diabetes mellitus, precocious puberty
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eye defects: cataracts, glaucoma, retinopathy
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fetal demise
o
fetal infection if exposed during the first trimester is 50-80%
o
fetal infection if exposed during the second trimester 10-205
o
fetal infection if exposed during the third trimester is > 60% (p. 144)
o
fever up to 104 degrees F
o
hematological defect: splenomegaly, thrombocytopenia, hepatitis (Hollier & Hensley, 2011, p. 145)
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in adults and adolescents, arthralgia and arthritis common (Hollier & Hensley, 2011, p. 145)
o
infection rates are highest for person 5-9 years of age, but may affect any age
o
late winter and spring likely for outbreaks
o
low birth weight
o
low-grade fever
o
lymphadenopathy: postauricular, posterior cervical
o
maculopapular rash 1-4mm) which starts on the face and spreads to chest, usually lasts about 3 days
o
maculopapular rash and elevation of temperature up to 104.7 degrees F occur at the same time
o
malaise (Hollier & Hensley, 2011, p. 146)
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nervous system defects: mental retardation, psychomotor retardation, encephalitis, autism, deafness
o
next 24 hours rash spreads to trunk, thighs, and hips
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occipital lymph nodes are most commonly involved and are essentially diagnostic
o
over the first 24 hours the rash spreads to face, neck, and arms
o
pharyngitis, cervical lymphadenopathy and splenomegaly often accompany rash
o
possible desquamation
o
possible splenomegaly
o
premature delivery
o
presence of Koplik's spots - 2 to 3 mm gray/white raised lesions on buccal mucosa, is pathognomonic
o
rarely rash can become hemorrhagic leading to fatality
o
rash starts on forehead and behind the ears
o
the 3 C's: croupy cough, coryza, conjunctivitis
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the Western Blot is considered the Gold Standard for validation of prior positive HIV testing. While there may be variations of number of positve bands and the intensity of the bands, the CDC considers a positive reactivity when bands are noted in at least 2 antigens, p24, gp41, gp120/140. No bands is considered a negative result. There are however possible scenarios that may lead to indeterminate result which requires retesting in 3-6 months. Reasons for indeterminate results are positives in certain antigens but not the ones for true positive criteria as seen in early or new exposure, patients who have not seroconverted and also certain patients who may show some reactivity but are truly noninfected.
o
upper respiratory infection symptoms
