Infectious Disease ABIM-WBS

LETS TALK FUNGI! mycoses = mycelium = ____ Molds = # cells? mne? Which have hyphae? What is mycelium? Yeasts = # cells? how reproduce? pattern of chains? Dimorphics = name them, temps? Opportunistic fungal infxn: name them

mycoses = illnesses caused by fungi mycelium = tangled network of hyphae in mold Molds = Multicellular = Messy = have hyphae = Make up Mycelium Yeasts = unicellular, yeasts asexually reproduce (budding) —> daughter chains budding off that look like hyphae "pseudohyphae" (candida) Opportunistic fungal infxn: Candida (yeast - budding yeast cold, germ tubes when hot 37deg- dimorphic) - fluc Aspergillus Fumigatus (mold - hyphae)

ok to breastfeed in hiv?

no

5) Cervicitis: / PID outpatient tx? Inpatient tx? What criteria to stay inpt?

outpt: CTX + Azithro Inpt: Cefotetan plus doxycycline is preferred for Inpatient if ascending genital tract infxn - cervical motion, uterine, or adnexal tenderness makes ascending genital tract infection

What should u not give in toxic shock syndrome? what is tx mainstay?

steroids -- Remove sources of infection and toxin production and begin aggressive IV fluid resuscitation (up to 10-20 L/d). Start broad- spectrum antibiotics initially with a carbapenem or penicillin with a β-lactamase inhibitor plus clindamycin; narrow to clin- damycin plus nafcillin if MRSA is identified. IV immune globulin may be helpful. ◆ DON'T BE TRICKED Do not select glucocorticoids to treat toxic shock syndrome.``

RMSF 1.) presentation?what does rash look like? 2.) tx? 3.) diagnostic test?

rickettsia rickettsii = rmsf 1.) nonspecific febrile illness within 3 weeks of potential tick exposure; blanching erythematous macules located around wrists and ankles --- 2.) Doxycycline 3.) Convalescent serology (weil-felix?) Rocky Mountain spotted fever is a tick-borne rickettsial infection most prevalent in the *southeastern and south central states*. Look for a history of tick bite and recent travel to an endemic area; febrile illness in spring and summer months; and nonspecific symptoms such as nausea, myalgia, dyspnea, cough, and headache. *Also look for a macular rash starting on the ankles and wrists; lesions spread centripetally and become petechial. *Thrombocytopenia and elevated aminotransferase levels are charac- teristic. Immunohistochemistry or PCR of a skin biopsy specimen allows diagnosis at the time of acute infection. Therapy Select doxycycline. In patients who are pregnant, choose chloramphenicol. Failure to respond in 72 hours suggests an alternative diagnosis.

Candida and Cryptococcus are ____(class). Do they cause rhinosinusitis? would galactomannan be pos for them too?

yeasts nope and nope

___ is used to dx rabies. ___phobia is associated

*Nuchal skin biopsy for immunohistochemistry or polymerase chain reaction* may be used to diagnose rabies. Rabies often presents with localized paresthesias at the site of inoculation, with inexorable progression to coma and death over days to weeks. Autonomic instability, muscle spasm, and *hydrophobia* are commonly present.

severe CAP - dx - sputum cultures useful?

*if high likelihood of complications get sputum culture* in patients being hospitalized and particularly for those with severe disease requiring ICU admission, possible complications of CAP, or multiple underlying comorbidities, sputum cultures may yield diagnostic information useful in guiding treatment. This patient has severe CAP requiring ICU admission; therefore, blood and sputum cultures are indicated.

1.) early lyme tx & w/o complications? (med & length) 1.) early lyme tx + 3rd deg AV block or neuro dz (meningitis, radiculopathy)? (med & length) 3) Late lyme tx for arthritis + facial nerve palsy? (med & length) 4) Late lyme tx for neuro dz (med & length) -- Do u wait on the ___ (lab test type) b4 tx? Ok to use in pregnant women?

- MKSAP Board basics: 1) In patients with erythema migrans and early disease, begin doxycycline, amoxicillin, or cefuroxime for 28 days without laboratory confirmation of Borrelia burgdorferi. 2) Manage late carditis or neurologic disease with ceftriaxone x 14-28d 3) manage arthritis and facial nerve palsy with doxycycline. Late Lyme 3) Late Lyme disease: Treat arthritis with doxycycline or amoxicillin x 28 days. 4) -Treat late neurologic disease with ceftriaxone x 14-28 days; response may be slow and incomplete. ◆ DON'T BE TRICKED Do not select the diagnosis "chronic Lyme disease" (post-Lyme disease syndrome) or treat with antibiotics. -Do not rely on serologic test results to decide on the adequacy of treatment. Do not prescribe doxycycline for pregnant women

UTI tx: 1) In preggers, Choose ___ days of empiric therapy with ___(3). 2) in preggers appropriate to get urine culture after tx ?

1) 7, amoxicillin-clavulanate, nitrofurantoin, cefpodoxime, or cefixime. 2) yes Old age is not an indicator of a complicated UTI in the absence of other indicators. UTI sx In patients at high risk for complicated UTI, obtain a urine culture and initiate treatment empirically for 7 to 14 days with a fluoroquinolone. For recurrent uncomplicated UTIs, select one or more of the following: postcoital antibiotic prophylaxis, particularly if UTIs are temporally associated with coitus continuous antibiotic prophylaxis self-initiated therapy for frequent recurrent episodes

Tb drug SEs: 1) ethambutol - what testing prior to starting ripe? 2) INH? 3) pyrazinamide?

1) Before starting ethambutol, patients should be evaluated for color discrimination and visual acuity because an adverse effect of the drug is a retrobulbar neuritis manifesting as decreased green-red color discrimination or decreased visual acuity. 2) INH - peripheral neuropathy, hepatitis, rash, and a lupus-like syndrome. (give b6) 3) Pyrazinamide can cause hepatitis, rash, gastrointestinal upset, and hyperuricemia. 4) Rifampin can cause hepatitis, gastrointestinal upset, rash, and orange coloring of body fluids.

Headache, fever, and altered mental status are present + elevated opening pressure CD4 cell counts are usually <100/μL dx? dx test? WHAT STAIN? tx?

1) CSF culture for Cryptococcus or cryptococcal antigen tests on CSF and serum are diagnostic; elevated CSF opening pressure is characteristic Select IgM and IgG serologic testing in patients with suspected toxoplasmosis and brain MRI or head CT for neurologic signs and symptoms. Typical findings on imaging include multiple ring-enhancing lesions. IF YOU SEE IT ON A STAIN IT'S INDIA INK!

C. Diff: 1) worst is called _______ c. diff - tx & criteria 2) mod is called ____ - tx & criteria 3) mild tx

1) Complicated CDI hypotension, ileus, or megacolon -Patients with ileus may have limited transit of oral antibiotics to distal sites of infection in the colon. Therefore, in this critically ill group, the recommendation is to give vancomycin orally or through a rectal tube in addition to intravenous metronidazole. 2) Severe CDI Leuks >15K, Cr >1.5x po vanc 3) mild/mod = flagyl po

UTI: 1) what is complicated UTI? 2) when do u culture?

1) Complicated UTI is defined as infection occurring in a patient with comorbid conditions or anatomic abnormalities of the urinary tract, including diabetes, pregnancy, male gender, advanced age, kidney transplantation, anatomic or func- tional abnormalities of the urinary tract, urinary catheterization or manipulation, recent antibiotic exposure, and recent hospitalization. *(U Tract issue including anatomy, stone or txplnt, DM, M, advanced age, urinary cath, abx exposure, recent hosp)*

1) 2 similar organisms infecting leukocytes that are like rickettsia = __ and ___. The 2 syndromes are __ and __. 2) the sx are ___ 3) on smear w one of them u see ___. What LFT changes? 4) tx =

1) Ehrlichia chaffeensis and Anaplasma phagocytophilum are rickettsia-like organisms that infect leukocytes. Ehrlichia causes human monocytic ehrlichiosis (HME) and Anaplasma phag = human granulocytic anaplasmosis (HGA). Ehrlichiosis and anaplasmosis (ixodes) are spread by ticks (same as lyme) sx = fever, headache, and myalgia multiorgan failure (AKI, ARDS, meningoencephalitis) fever of unknown origin (symptoms can persist for months) Labs: * elevated aminotransferases with NL ALP and Bili* leukopenia and thrombocytopenia presence of morulae (clumps of organisms in the cytoplasm of the appropriate leukocyte) Whole blood PCR is the most sensitive test for diagnosis of acute infection. tx = doxy po or iv for either

OBGYN Infections: 1) candidal infxn tx? 2) pH in BV? 3) tx for BV? 4) findings for trichomonas? tx?

1) Fluconazole 2) elevated pH for BV 3) Metronidazole = BV or Trich -pH of vaginal secretions would be elevated, clue cells would be visible on the wet mount (rather than numerous leukocytes), and the whiff test would have a positive result in bacterial vaginosis. 4) Metronidazole Trichomonas would result in numerous leukocytes on the wet mount, but motile organisms would also be visible; the clinical findings should include vulvar and vaginal mucosal erythema.

1) Dx? ___ 35-year-old man is evaluated for a 2-month history of abrupt left knee swelling. No overlying erythema, effusion present, STIFF BUT is pain present? 2) Best way to dx? ___ w ___ screen confirmed by ___ 3) MC joint? how many joints? 4) usually painful or not painful?

1) Lyme dz -Ixodes ticks are the vector for Borrelia burgdorferi. - STIFF JOINT BUT NO PAIN 2) serology for BB usually via ELISA screen confirmed by western blot 3) knee, usually mono or oligo Demographics: lives in Vermont and goes hiking during the summer. He has not had any episodes of diarrhea or abdominal pain and reports no trauma to the knee, fever, rash, or known insect bites.

1) ______ furunculosis is a well-described skin infection in patients who obtain pedicures at nail salons that use contaminated whirlpool footbaths. (say grows in < 7 days on agar) 2) what other mycobacteria grow <7d on agar 3) ___ (but) cause trauma-associated skin infection after exposure to fresh or salt water, including fish tanks and swimming pools. Initially papular before ulcerating, skin lesions are sometimes referred to as "fish tank granuloma." The rapid growth of the culture from this patient's lesions (<7 days) makes ____ unlikely.

1) Mycobacterium fortuitum furunculosis is a well-described skin infection in patients who obtain pedicures at nail salons that use contaminated whirlpool footbaths. -Initially papular, these progress to a boil before ulcerating. The fast growth of the organism in culture (<7 days) is consistent with rapidly growing mycobacteria, such as M. fortuitum, Mycobacterium chelonae, or Mycobacterium abscessus. 2) Mycobacterium gordonae, Mycobacterium kansasii, and Mycobacterium marinum are slowly growing bacteria (that is, growth on solid media requires more than 7 days and usually 2 to 4 weeks). 3/4: M. marinum can cause trauma-associated skin infection after exposure to fresh or salt water, including fish tanks and swimming pools. Initially papular before ulcerating, skin lesions are sometimes referred to as "fish tank granuloma." The rapid growth of the culture from this patient's lesions (<7 days) makes M. marinum unlikely.

Syphilis Don't be tricked 1) how are preg pts treated for syphilis? 2) what if pt getting the PCN gets acute fever while being tx for syphilis? allergy?

1) Pregnant patients who are allergic to penicillin must be desensitized and treated with penicillin. 2) Jarisch-Herxheimer reaction is an acute febrile illness occurring within 24 hours of treatment for any stage of syphilis and is not an allergic reaction to penicillin.

toxo tx: 1) __ __ AND ___ COMBO. 2) when indicated? 3) what if no response in 2 weeks?

1) Select empiric treatment with sulfadiazine, pyrimethamine, and folic acid in patients with 2) multiple ring-enhancing lesions, positive T. gondii serologic test results (IgG), and immune suppression (CD4 cell count <200/μL). Treat patients with persistent immunosuppression indefinitely. 3) Biopsy lesions that fail to respond to 2 weeks of empiric therapy.

Human bites v animal bites (also see onenote chart) dog bite immunocompromised?

1) animal bite = amp/sulb (unasyn iv) or amox/clav po 2) human bite = amp/sulb (unasyn iv) dog bite + immunocompromised = 3-5d abx ppx This patient has experienced a dog bite and should receive treatment with amoxicillin-clavulanate. A 3- to 5-day course of prophylaxis (early preemptive therapy) with amoxicillin-clavulanate is recommended for patients who are immunosuppressed (including those with asplenia or significant liver disease); have moderate to severe wounds (particularly on the face or hand); have wounds near a joint or bone; or have wounds associated with significant crush injury or edema. Amoxicillin-clavulanate, an oral β-lactam/β-lactamase inhibitor, is a good choice because it has a broad spectrum of activity against the aerobic and anaerobic bacteria that constitute a dog's oral flora. Prompt wound irrigation and debridement, if appropriate, are also indicated. Each patient should also be evaluated for the need for tetanus and rabies prophylaxis.

Ophtho: 1) visual loss, photophobia, and ocular pain and discharge after cataract surgery - dx = _____ 2) recent dental or sinus infxn, + eyelid swelling, ophthalmoplegia, pain with eye movement, and occasionally proptosis

1) endophthalmitis which is inflamm of aqueous and vitreous humors 2) orbital cellulitis

Post-Transplant ID: 1) when are these pts most vulnerable? 2) how does CMV present? melena? hematochezia? 3) say pt is She is cytomegalovirus seropositive and received an organ from a cytomegalovirus-seronegative donor; she should receive ___ ppx med for ___ (length).

1) first few months when on lots of suppression 2) see all below - no melena or hematochezia 3) valganciclovir for 3 months after transplantation Cytomegalovirus is a common complication of transplantation, especially in the first few months after transplantation when immunosuppression is typically highest, and patients who have just finished prophylaxis against cytomegalovirus are at risk for reactivation. Unless donor and recipient are CMV seronegative and the risk is low, prophylaxis with valganciclovir is often used during this time period. This patient recently finished the prophylaxis period and is at risk for CMV reactivation. She has symptoms typical for colitis; the colon and esophagus are common sites for CMV disease after transplantation. Hepatitis, gastritis, and small bowel enteritis may also occur, although less often. Quantitative polymerase chain reaction testing in serum for CMV can be suggestive, but colonoscopy with biopsy for characteristic histopathology and viral tissue culture provide a definitive diagnosis.

Induration in Tb test: 1) What's the deal if pt has hx of BCG vacc? 2) Typical Board question is a nursing home resident without clinical disease, but 13 mm diameter induration on PPD. (Here, the risk fac- tor is nursing home residence.)

1) makes no diff 2) never order both - neither can tell active v latent - Interferon-Gamma Release Assays (IGRAs) are whole-blood tests that can aid in diagnosing Mycobacterium tuberculosis infection. They do not help differentiate latent tuberculosis infection (LTBI) from tuberculosis disease TST = A tuberculin skin test (also called a Mantoux tuberculin test) is done to see if you have ever been exposed to tuberculosis (TB).

Pharyngitis: 1.) mne for CENTOR criteria? 2.) who do u test? (how?) can u tx w/o dx? 3.) who do u tx? 4.) 1st line? 2nd line? 5.) complications?

1) mne = CLEF (think of palate --- no cough, tender LAD, exudate tonsillar, fever 2) *-Test in pts w > 2 criteria. Can't tx w/o dx now. -Don't use abx unless confirmed by rapid antigen and/or throat culture* - No dx or tx in 2 or less (<3% GAS) 3) + test: tx = PCN V Tx 2 = Macrolide (mne = ACE) alternatives = cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin are alternatives in patients who are allergic to penicillin. CC: 5.) *Complications* of GAS pharyngitis include rheumatic fever and peritonsillar abscess.

1) Can Edentulous patients get anaerobic pnas? 2) cavities w/o air fluid levels suggest ___ type of infxn

1) no 2) fungal. or tb without air-fluid levels suggests TB or fungal infection. air-fluid levels suggests abscess formation (staphylococci, anaerobes, or gram-negative bacilli),

ChronicOsteomyelitis: 1) do u need MRI here? - need MRI? 2) any other dx test? 1) presence of chronic or intermittent drainage from a demonstrable sinus tract overlying an area of previous trauma, along with consistent clinical findings and radiographic evidence of a bone sequestra (dead bone) or involucrum (new bone formation), are hallmarks of chronic osteomyelitis. Other than local signs of ongoing infection, patients with chronic osteomyelitis rarely manifest systemic symptoms. 2)

1) no MRI needed here 2) need Bone biopsy and culture dx osteomyelitis, excluding other entities (such as neoplasm), and isolating the causative pathogen(s). MRI is the most sensitive and specific imaging modality for diagnosing osteomyelitis but is unnecessary in the presence of a chronic draining sinus. The demonstration of microorganisms coupled with characteristic features of osteomyelitis eliminates the need for MRI confirmation of the diagnosis.

endocarditis: 1) when is prosthetic valve ppx required? 2) ppx options? 3) tx for Community-acquired native valve IE Nosocomial-associated IE Prosthetic valve IE

1) only pre dental procedures (not general surgery) indications include previous endocarditis, a history of cardiac transplantation, a prosthetic valve, and specific forms of complex congenital heart disease 2) options = amox (pcn products), For patients allergic to penicillin or amoxicillin, alternatives include clindamycin, 600 mg orally; azithromycin, 500 mg orally; or cefazolin/ceftriaxone, 1 g intramuscularly or intravenously. 3) *Community-acquired native valve IE * Consider vancomycin + gentamicin *Nosocomial-associated IE * Consider vancomycin + gentamicin + rifampin or vancomycin + gentamicin + a carbapenem OR cefepime *Prosthetic valve IE * Consider vancomycin + gentamicin + rifampin

Posttransplant Issues: 1) if donor EBV seroPOS w receipient seroNEG - at risk for? what tips u off to dx? 2) CMV 3) dissem candida aka __, + on BCX? 4) Tb?

1) posttransplant lymphoproliferative dz (PTLD) - B-cell proliferation induced by infection with EBV in the setting of chronic immunosuppression and resulting decreased T-cell immune surveillance. -single big LN tips u off to PTLD 2) Cytomegalovirus infection is common after transplantation, especially in seronegative recipients with seropositive donors, and can manifest as a nonspecific febrile syndrome. 3) yup aka candidemia bro 4) Tuberculosis reactivation increases in incidence after solid organ transplantation and is more likely to have extrapulmonary findings. It could present with lymphadenopathy and fever but clear lungs, as in this patient. However, she had a negative result on a test for latent tuberculosis before transplantation, which makes reactivation of tuberculosis unlikely.

Aspergillosis: 1) tx abpa? 2) for invasive infxn? 3) what about a fungus ball? asx vs sx

1) steroid oral 2) voriconazole Voriconazole is the therapy of choice for most patients with invasive aspergillosis because of its potent fungicidal activity against Aspergillus species. Culture confirmation is important to distinguish Aspergillus from other filamentous fungal infections 3) asx = nothing + surveillance, sx e.g. hemoptysis = Surgical resection is indicated for aspergilloma and hemoptysis and is considered definitive therapy.

standard active tb tx = ? 1.) if positive TST (PPD), then you order a _____ (test). 2.) If CXR negative, then give ___ 3.) but if CXR positive, then treat for ___ w ___. (active Tb) 4.) given u treat them, then test sputum in ___ months, to determine whether they need an additional 4 or 7 months (You D/C which 2?)

1.) chest radiograph 2.) If radiographic results are negative, treatment for latent tuberculosis infection (LTBI): INH w with vitamin B6 (pyridoxine) x 9 months!!! (or Rifampin x 4 months) -- Active Tb: 3.) RIPE x 6 mos (pyrazinamide, ethambutol) 4.) @ 2 months (D/C pyrazinamide, and ethambutol at 2 months given negative radiograph?) --- considered no longer Contagious When all three met : negative sputum, Improvement in symptoms, & tx x2 weeks

What are the macrolide Abx? mne?

3 (ACE) Azithromycin Clarithromycin Erythromycin

7mm TST induration in 1) IVDU? 2) prisoner? 3) Tb lab tech? 4) HIV? 5) suspicious cxr? 6) chronic pred?

>/=15 everybody else Threshold = >/=10mm in <5 yrs from prevalent country, ivdu, high risk settings (nursing home, jail, hospital), Tb lab tech >/=5mm = HIV+, contact w Tb+ person, cxr consistent, >4 weeks pred or on immunosuppressive

What are the 3 dz caused by aspergillus infxn? when do u see invasive infxn? what cell line down? dx? what do u trend for response in inasive? mold or yeast?

ABPA Aspergilloma (mold) Invasive Sinopulmonary Aspergillosis --> invasive = immunocompromised --- e.g. rhinosinusitis acute Aspergillus rhinosinusitis. Invasive fungal infections, such as sinusitis, are uncommon except in PROLONGED NEUTROPENIA. , such as this patient who has an underlying hematologic malignancy and is undergoing chemotherapy. His clinical symptoms (sinus pain), examination and radiographic findings (sinusitis and exophthalmos), and laboratory studies (positive result on *galactomannan antigen immunoassay *and characteristic histopathologic findings) support the diagnosis of Aspergillus rhinosinusitis. Galactomannan is useful in early detection and in therapeutic monitoring. Direct invasion into the palate can occur from infection of the maxillary sinus. Infection of the ethmoid sinus may extend into the cavernous sinuses and cause cranial nerve deficits and internal carotid artery thrombosis. . Central nervous system (CNS) involvement may also occur as a complication. Additionally, periorbital infection with subsequent loss of vision may occur. The mortality rate of Aspergillus rhinosinusitis is high. .

70M +DM2 + a severe left earache x1d . +fever tachy -- external ear canal is swollen. --- Moist white debris and granulation tissue are visible. - dx, dx and tx, most common bug?

ANSWER: Diagnose malignant external otitis and select hospitalization and IV ciprofloxacin. Malignant external otitis is characterized by systemic tox- icity and evidence of infection spread beyond the ear canal (mastoid bone, cellulitis) and is typically found in elderly patients with type 2 diabetes or patients who are immunocompromised. Most commonly caused by Pseudomonas aeruginosa.

Aminoglycosides mne? SEs? mne?

Aminoglycosides: 1.) name them - mnemonic? (for name and SEs) "mean GNATS canNOT kill anaerobes" GNATS = Gentamycin, Neomycin, Amikacin, Tobramycin, Streptomycin NOT = Nephrotoxicity (esp w/ cephalosporins) - ATN, Ototoxicity (esp w/ loop diuretics), Teratogen Aminoglycosides: 1.) toxicity 2.) incd with which other drugs (2 but each increases a diff SE)? NOT Nephrotoxicity (especially when used with cephalosporins) O = ototoxicity (esp when used with loop diuretics). CN8. irreversible vestibular damage, hearing loss and tinnitus are DOSE DEPENDENT and are mainly driven by excessively high peak plasma levels and excessive duration of treatment T = teratogen

mne for palm and sole rashes:

CARS: Coxsackie A, Rickettsia, and Syphilis

___ encephalitis should be considered in the differential diagnosis of patients with psychiatric symptoms, seizures, autonomic instability, and choreoathetoid movements.

Anti-N-methyl-D-aspartate receptor

Lyme Stages: - identify the stage and tx & length a/w these sx: arthritis, erythema migrans (groin, axilla etc), q Clinical: fever, lymphadenopathy, myalgias, or myalgias, arthralgias, facial nerve palsy meningitis?

BAKE = Bell's, Arthritis, Kardiac block, Erythema Migrans 1) stage 1 - Early localized (up to 30d out) 1st month arthritis, erythema migrans (groin, axilla etc), q Clinical: fever, lymphadenopathy, myalgias, q Treat with doxycycline. 2) stage 2- Early disseminated Stage 2 - days to weeks later Migratory myalgias, arthralgias, fatigue, and malaise are common during this phase. + neurological and cardiac manifestations -Facial nerve palsy is a clinical clue. -May cause meningitis, encephalitis, or peripheral neuropathy. -Can also cause carditis and dilated cardiomyopathy. q Treat with ceftriaxone. 3) Late Lyme dz - Stage 3 Occurs months to years after infection. q Rarely, can cause progressive, chronic encephalitis; option to treat -Attacks last weeks to months with complete remission between recurrences and become less frequent over time. • Chronic *neurologic* findings include subacute encephalopathy (mem- ory, sleep, or mood disbnbances) and *peripheral sensory polyneuropathy (pain or paresthesias; abnormal EMG).* Tx (variable response - ctx x 2-4 weeks No benefit to retreatment for recurrent sx

patient who has traveled to Cape Cod, nonspecific febrile illness, sweats, myalgia, arthralgia, nausea, vomiting, or fatigue PE: fever, splenomegaly, hepatomegaly, +/- jaundice *tx???*

Babesiosis Mild = atovaquone + Azithro x 7-10d Severe = clinda + quinine Asx = no tx

Candida: how does it present in HIV versus neutropenia and diff tx for each

Candidal infection usually does not disseminate in HIV infection (compared with the risk in neutropenia) but rather causes mucocutaneous disease (such as esophagitis), which is not clinically present in this patient. Candidal infection also should not cause systemic symptoms or this patient's CT findings. Oropharyngeal candidiasis is treated w fluconazole (or itraconazole) Disseminated candidiasis w low pmn tx'd w an echinocandin e.g. caspofungin --- Candidemia = dissem Echinocandins first line --> then switch to fluc if sensitive in 7d or so if bcx neg and better (basically replaced by echinos b/c resistance) --- Liposomal AmphoB is good too but nephrotoxicity that the echinos don't have.

Dimorphic Fungal meningitis w csf lymphocytic pleocytosis + eos (70% of cases), dx? tx?

Coccidiomycosis meningitis Fluconazole (best studied of azoles) 2nd line = ampho dx complement fixing Abs in CSF > culture -- immunodeficiency (such as HIV/AIDS infection), diabetes mellitus, alcohol abuse, and pregnancy. Headache, vomiting, and change in mental status are the most common presenting findings. Cerebrospinal fluid (CSF) demonstrates a lymphocytic pleocytosis with elevated protein and low glucose. Eosinophils in the CSF are seen in up to 70% of patients with coccidioidal meningitis. Detection of complement-fixing antibodies in the CSF is more sensitive than is culture in diagnosing coccidioidal meningitis. Complement-fixing IgG is present in up to 90% of patients. -- Fluconazole is the treatment of choice. It offers a good response rate and a favorable safety profile; therefore, it has replaced intrathecal amphotericin B as the therapy of choice. Intrathecal amphotericin B is now used only in those who have not responded to fluconazole. can't use echinocandins e.g. caspo

What is the basic HIV regimen accepted today (pattern)

Consider initiating therapy in all patients motivated to start life-long medication, regardless of CD4 cell count. Current recommendations for initial HIV treatment, if the patient is not pregnant, include use of tenofovir and emtricitabine as the dual nucleoside reverse transcriptase inhibitor (RTI) "backbone." Options for a third agent to complete the regimen include: ritonavir-boosted protease inhibitors atazanavir or darunavir integrase inhibitors raltegravir, dolutegravir, or cobicistat-boosted elvitegravir nonnucleoside RTI efavirenz Do resistance testing on all patients before starting ART. Check the viral load 4 weeks after ART is initiated or changed. Viral load should fall quickly and progressively and reach undetectable levels within a few months. Viral loads should remain undetectable while the patient is receiving ART. Persistent detectable levels of virus should be considered as treatment failure and resistance testing should be repeated.

Cryptococcosis tx? (serious infxns vs long-term maintenance) -

Cryptococcosis q Causes opportunistic infection in patients with AIDS, Hodgkins, etc. q From lungs, may disseminate to CNS. q Treat with* amphoteracin B for serious infections.* q In AIDS, use maintenance treatment with long-term fluconazole. (In this case it is impossible to eradicate it completely.)

Dx? tx? A 40-year-old asymptomatic female hospital employee has a 10-mm TST reaction following routine screening. The employee was born in India and has lived in the United States for 10 years. She was vaccinated with bacillus Calmette-Guérin as a child. Her chest x-ray is normal.

Diagnose latent TB and treat with isoniazid. see one-note table - bcg doesn't affect tst but lasts about 10 yrs for igra

HIV Dx - lymphadenopathy, hepatosplenomegaly, anemia, leukopenia, *and elevated alkaline phosphatase level are typical signs. RP LAD cd4<50* tx?

Dissem MAC (DMAC) is usually seen in patients whose CD4 cell count is, or recently was, less than 50/µL. dx = culture of the blood or other normally sterile site, such as bone marrow, lymph node, or liver. tx = macrolide (ACE) usually clarithromycin and ethambutol, and continued ART are the recommended treatment. DMAC IRIS

What are indications for urgent surgery in infective endocarditis

Early surgery is indicated for patients with acute infective endocarditis presenting with 1. valve stenosis or regurgitation resulting in heart failure; 2. left-sided infective endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms; 3. infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesion; and 4. infective endocarditis with persistent ba cteremia or fever lasting longer than 5 to 7 days after starting antibiotic therapy.

fungal ppx in neutropenic pt = ___

Fluconazole is effective in preventing Candida infections in neutropenic oncology patients, and tx of esophageal candidiasis, but it has limited effectiveness for preventing other fungal infections. ---- ◆ DON'T BE TRICKED Treatment is not indicated for Candida in the sputum of patients receiving mechanical ventilation. Do not treat asymptomatic candiduria except in neutropenic patients or those undergoing invasive urologic procedures. Catheter removal and antifungal therapy has been associated with a shorter duration of infection and improved patient outcomes in nonneutropenic patients with candidemia, but not in neutropenic patients.

Uncomplicated cutaneous anthrax should be treated w _____

FQ or doxy + report to authorities

pcp pna tx? sulfa allerg?

IV pentamidine or IV clindamycin plus oral primaquine for patients with sulfa allergy

Treat a patient with malignancy-associated hypercalcemia.

Immediate hydration with large-volume normal saline infusion, forced diuresis with furosemide, glucocorticoid therapy for glucocorticoid-responsive malignancies such as multiple myeloma (and some lymphomas), and a bisphosphonate is appropriate treatment of malignancy-related hypercalcemia. Bisphosphonates are powerful inhibitors of osteoclast-mediated bone resorption with an onset of effect occurring several days after administration and a duration of up to several weeks depending on the specific agent used, which allows longer-term control of calcium levels.

Name the opportunistic mycoses Name the systemic mycoses which are dimorphic

Opportunistic Mycoses: Candida: Dimorphic; forms pseudohyphae and budding yeasts at 20°C A , germ tubes at37°C B. Tx = fluconazole Aspergillus Fumigatus (mold - hyphae) Causes invasive aspergillosis in immunocompromised, patients with chronic granulomatous disease. -Can cause aspergillomas in pre-existing lung cavities, especially after TB infection. Some species of Aspergillus produce Aflatoxins (associated with hepatocellular carcinoma). Allergic bronchopulmonary aspergillosis (ABPA): hypersensitivity response associated withasthma and cystic brosis; may cause bronchiectasis and eosinophilia. Tx = see subsequent slide. Invasive = voriconazole Mucor and Rhizopus Irregular, broad, nonseptate hyphae branching at wide angles H . Mucormycosis. Causes disease mostly in ketoacidotic diabetic and/or neutropenic patients (eg,leukemia). Fungi proliferate in blood vessel walls, penetrate cribriform plate, and enter brain.Rhinocerebral, frontal lobe abscess; cavernous sinus thrombosis. Headache, facial pain, black necrotic eschar on face; may have cranial nerve involvement. Treatment: surgical debridement, amphotericin B. Cryptococcus neoformans: = YEAST = narrow budding. Heavily encapsulated yeast. Not dimorphic. Found in soil, pigeon droppings. Acquired through inhalation with hematogenous dissemination to meninges. Latex agglutination test detects polysaccharide capsularantigen and is more speci c. Causes cryptococcosis, cryptococcal meningitis, cryptococcal encephalitis ("soap bubble" lesionsin brain), primarily in immunocompromised. Treatment: amphotericin B + flucytosine followed by fluconazole for cryptococcal meningitis. Pneumocystis pneumonia (PCP) = Yeast-like diffuse interstitial pneumonia A fungus (originally classi ed as protozoan). tx TMP-SMX, pentamidine, atovaquone. dapsone (prophylaxis only) CD4 < 200 ppx * Whenever possible, patients should be tested for glucose-6-phosphate dehydrogenase deficiency (G6PD) deficiency before primaquine or dapsone is administered (mod-sev dz tx) Sporothrix schenckii - yeast - rose gardner local pustule or ulcer A with nodules along draining lymphatics (ascending lymphangitis). Disseminated disease possible in immunocompromised host. Treatment: itraconazole or potassium iodide. DiMorphics = cause SYSTEMIC MYCOSES -All of the following can cause pneumonia and can disseminate. -All are caused by dimorphic fungi: cold (20°C) = mold; heat (37°C) = yeast. Only exception is Coccidioides, which is a spherule (not yeast) in tissue. -Systemic mycoses can form granulomas (like TB); cannot be transmitted person-to-person (unlike TB). Treatment: fluconazole or itraconazole for local infection; amphotericin B for systemic infection Histo: Palatal/tongue ulcers, splenomegaly MS river , OH river valley Blasto: east & central US Verrucous skin lesions can simulate SCC Forms granulomatous nodules Cocci: Southwestern US,California Spherule not a yeast (but does exist as mold) = HUGE - bigger than RBCs Disseminates to skin/bone Erythema nodosum(desert bumps) or multiforme Arthralgias (desert rheumatism) meningitis para-coccidiomycosis = similar

UTI tx - uncomplicated -can u reuse bactrim w/in 3 mos? -what is drug that is single dose?

Patients with uncomplicated cystitis do not require a urine culture but can be diagnosed with a urinalysis: urine dipsticks positive for leukocyte esterase and nitrites ≥10 WBCs/μL of unspun urine or 5-10 WBCs/hpf on a centrifuged specimen of urine Obtain a culture for suspected cystitis only if: suspected pyelonephritis complicated UTI recurrent UTI suspected unusual or antimicrobial-resistant microorganism patient is pregnant Therapy For women with symptoms of uncomplicated cystitis, prescribing antibiotics over the telephone without seeing the patients or obtaining a urinalysis is acceptable. For empiric treatment of nonpregnant women with uncomplicated cystitis, select one of the following: 3 days of oral trimethoprim-sulfamethoxazole 5 days of oral nitrofurantoin single 3-g oral dose of fosfomycin DON'T BE TRICKED Trimethoprim-sulfamethoxazole should not be used if it was taken in the preceding 3 months.

syphilis stages and mne

Primary vs. Secondary vs. Tertiary syphilis tx? Primary = painless chancre (localized) Secondary = Disseminated - constiTWOtional sx: - weeks to months after primary onset -generalized maculopapular rash involving palms & soles), Condylomata lata (has lots of treponemes) Tertiary = Gummas (chronic granulomas), Aortitis (vasa vasorum destruction), Neurosyphilis (tabes dorsalis - touch, proprioception, shooting pain, late incontinence), Argyll-Robinson pupil ---- broad-based ataxia, Charcot joints, stroke w/o HTN tx = Penicillin G (iv)

Tx for pregnant pt w tb? hiv?

Pulmonary tuberculosis (TB) treatment q "R.I.P.E." - All six-month regimens contain rifampin, isoniazid, and first two months of pyrazinamide. q Ethambutol is most often the fourth drug (added for the first two months). q This is also the treatment for TB in HIV-infected patients. q In pregnant patients, leave out pyrazinamide, and instead treat with three drugs for nine months. --

southeast US tickborn, febrile, cough, HA, rash pattern?? dx? tx? preg?

Rocky Mountain spotted fever is a tick-borne rickettsial infection most prevalent in the southeastern and south central states. Look for a history of tick bite and recent travel to an endemic area; febrile illness in spring and summer months; and nonspecific symptoms such as nausea, myalgia, dyspnea, cough, and headache. *Also look for a macular rash starting on the ankles and wrists; lesions spread centripetally and become petechial. * Thrombocytopenia and elevated aminotransferase levels are charac- teristic. Immunohistochemistry or PCR of a skin biopsy specimen allows diagnosis at the time of acute infection. Therapy Tx Select doxycycline. In patients who are pregnant, choose chloramphenicol. Failure to respond in 72 hours suggests an alternative diagnosis.

Side Effects: * Efavirenz --- * Abacavir --- * Tenofovir --- * Atazanavir ---

Side Effects: * Efavirenz (NNRTI) --- GI upset, bad dreams (that go away), and depression with suicidality * Abacavir NRTI--- HLDB5701 hypersensitivity * Tenofovir NRTI--- can cause acute or chronic kidney injury, decd bone mineral density * Atazanavir protease inhibitor--- elevated bilirubin (not necessarily a contraindication * NRTIs * Tenofovir, Entricitabine * Abacavir, Lamivudine * NNRTIs * Efavirinz * Integrase inhibitors (newest and fastest growing class) * Raltegravir (bid dosing and lower barrier to resistance) * Dolutegravir * Elvitegravir * Protease Inhibitors * r/Atazanavir * r/Darunavir Regimens * Back bone of either: * Truvada (Tenofovir/Entracitabine) * Abacavir/Lamivudine * Combos: (2 classes + NRTI back bone) * (Efavirinz or r/DrV, or r/ATZ or Dolutegravir or Raltegravir or Stribild) + Truvada(Tenofovir/Emtricitabine) * Abacavir/Lamivudine + Dolutegravir * Stribild - (is a quad pill - stribild -- EVG/cobristate/tenofovir/entricitabine) https://www.evernote.com/shard/s62/nl/1740428855/7054e947-0a62-488f-b718-76eba01e56ff/

What vaccine do u give women b/w 27-___ weeks preganncy, every pregnancy?

Td booster every 10 y for all adults (replace one time with Tdap); primary series for unvaccinated adults; *all pregnant women between 27-36 weeks' gestation, every pregnancy*

Syphilis Tx: don't b tricked - alternative drugs in non-preg pts?

The preferred therapy for syphilis at all stages is parenteral penicillin, which is the only acceptable therapy for pregnant patients. --- *Treat primary or secondary or early latent syphilis with one dose of IM benzathine penicillin.* -- *Treat late latent or asymptomatic syphilis of unknown duration with 3 weekly doses of IM benzathine penicillin.* -- Treat late (tertiary) nonneurosyphilis with three weekly doses of IM benzathine penicillin. -- *Treat neurosyphilis with continuous penicillin infusion (or IM benzathine penicillin every 4 hours) for 10 to 14 days.* -- Doxycycline and tetracycline are alternatives for penicillin- allergic nonpregnant patients. Failure of nontreponemal serologic test results to decrease fourfold in the 6 to 12 months after treatment indicates treatment failure or reacquisition.

tx for systemic mycoses - local v dissem

Treatment: fluconazole or itraconazole for local infection; amphotericin B for systemic infection

dx? ___= 30M, aseptic meningitis, fever, lymphadenopathy, pharyngitis, myalgias and arthralgias, and a generalized maculopapular rash. He indicates that he had a reddish skin rash located across his chest and upper abdomen that first appeared several days after onset of his fevers and other symptoms and began to fade several days ago; the rash was present for approximately 1 week.

acute hiv aka acute retroviral syndrome

AML pt after induction chemo - neutropenic x 12d - on abx, cavitation in lung w 3 small densities in lungs - dx? tx?

aspergillus fumigatus MOLD Diagnose angioinvasive aspergillosis in neutropenic leukemia patients on prolonged antibiotic therapy. chest shows cavitation and three other small densities in the right middle and lower lobes. -Bronchoscopy with bronchoalveolar lavage* yields washings with lymphocytes and macrophages and* no organisms on Gram stain, acid-fast bacilli testing, and fungal stains*. *Empiric therapy with voriconazole* is initiated. After several days, the fungal cultures are growing a mold.

pertussis tx =

azithromycin or clarithromycin Macrolide = first line not a lot of benefit > 3 weeks out can use bactrim if need to

pseudohyphae = code for what bug

candida

Treat suspected methicillin-resistant Staphylococcus aureus cellulitis and bacteremia in a patient who is intolerant of vancomycin.

daptomycin

What class of antifungals don't penetrate CSF?

echinocandins - e.g. caspofungin

vesicular lesions on the butt? (sacrum)

hsv2

mac and pcp ppx thresholds? (and toxo?)

mac = azithro = < 50 pcp = <200 you're already doing it w ur pcp ppx bactrim but at risk < 100 w +IgG

Bacillary angiomatosis - tx?

q A vascular proliferation of Bartonella species, often in advanced HIV. q Clinically, resembles Kaposi sarcoma. q However, cutaneous lesions can be painful and rapidly progressive. q Also, can have constitutional symptoms such as fever, chills, abdomi- nal pain, depression, and psychosis. q Treat with erythromycin or tetracycline (doxy) for 8-12 weeks.

IE tx: Electrocardiogram shows normal sinus rhythm, a PR interval of 230 ms, and nonspecific T-wave changes. Except for the increased PR interval, there are no changes compared with a prior tracing. A transthoracic echocardiogram shows a 6-mm vegetation on the aortic valve with mild to moderate aortic regurgitation

urgent aortic valve replacement (b/c has affected conduction system When this occurs, the effectiveness of cure with antibiotics alone is decreased significantly, and early surgical intervention is indicated. Other indications for early surgery in native valve infective endocarditis include valve stenosis or regurgitation resulting in heart failure; left-sided endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms; endocarditis complicated by annular or aortic abscess; and endocarditis with persistent bacteremia or fever lasting longer than 5 to 7 days after starting antibiotic therapy. Additionally, early surgery is reasonable in patients with infective endocarditis who have recurrent emboli and persistent vegetations on antibiotic therapy, and may be considered in patients with native valve endocarditis who have mobile vegetations greater than 10 mm in length.

What is Pott dz?

xJoint infections with M. tuberculosis present as an indolent process, often in the hip, knee, or spine (Pott disease). Constitutional symptoms are frequently absent, and imaging may reveal nonspecific erosions that may be interpreted as osteoarthritis. Moderate elevation of the erythrocyte sedimentation rate is common. The diagnosis is made by joint aspiration with fluid sent for mycobacterial cultures. This patient is at increased risk due to origination from and travel to an endemic area (India) and the recent initiation of the tumor necrosis factor (TNF)-α inhibitor etanercept for treatment of rheumatoid arthritis. Isolated inflammation of a single joint out of proportion to other joints is a clue to infection.