IDI Exam 3

HIV Disease Progression

1-3 weeks post-infection -Acute, flu-like symptoms -Viremia 3-6 weeks (beings to seroconvert the major glycoproteins) -Begin generating immune responses -Begin slow decline in CD4 cells 10 years -Large decrease in CD4 cells -Increase viral loads -Disease progression Beyond 10 years... (there are emerging new components of the syndrome since we have recently been able to extend the life of these patients)

Incubation period of brucellosis

1-6 weeks (flu like symptoms)

Steps of Tularemia

1. Entry -Conjunctival -Oral -Tick or deer fly bite -Wound 1-3 week incubation 2. Spread -Systemic Lymphatic (Local and mesenteric) 3. Disease -Septicemia -Abscesses -Diarrhea Note: disease is highly variable, difficult to diagnose -Ulceroglandular -Oculogandular -Typhoidal (septicemia) -Pneumonic

Bubonic plague

1. Entry -Flea bite 2. Spread -Via lymph and blood 3. Disease -Buboes -Pneumonia -Internal organ hemorrhage 4. Exit from Respiratory Tract (Person-to-person)

During the acute phase of IM, up to ______ B cells in the peripheral blood is infected by EBV

1 in every 100

Ara-A (Adenine Arabinoside) (Vidarabine)

Analog of adenosine Phosphorylated by cellular kinases to triphosphate Competitive inhibitor of HSV DNA polymerase Disadvantages: High toxicity, low solubility First generation Note: Effective for keratitis (eye drops) or topically on mucous membranes. Ara-A can be used intravenously for encephalitis and neonatal infections.

Aciclovir

Analog of guanosine - Phosphorylated by viral thymidine kinase, then further by cellular enzymes. Activated only in infected cells. Triphosphate form competes with dGTP and is incorporated into DNA. Because acyclovir lacks the 3'-hydroxyl group, this terminates synthesis (Chain terminator).

____ is the most common cause of heterophiles-negative mononucleosis

CMV

Neisseria meningitidis

Cause 15% of Meningitis cases - incidence 1:100,000 pop (S. pneumoniae is the most common cause of meningitis) Distinguished from GC based on Biochemical Characteristics and presence of polysaccharide capsule Also causes Sepsis- often as prelude to meningitis

necrotizing fasciitis (flesh eating disease)

Caused by invasive GAS strains- M1T1 antigenic type- -Produce SpeA -High levels of streptodornase (degrades DNA) - easily escapes NETs -High levels of streptokinase - action helps degrades fibrin -Intracellular in macrophages and neutrophils All of which facilitates dissemination through tissues

Fifth's Disease (Erythema Infectiosum)

Caused by parvovirus (commonly parvovirus 19) ss DNA non-enveloped Replicate in nucleus POE- respiratory secretions Enters lung, disseminates to the bone marrow, replicates in erythroid progenitor cells. Inhibits erythropoiesis. (Sometimes anemia)

HSV1

Causes Keratoconjunctivitis, gingivostomatitis, encephalitis Targets mucoepithelial cells Latency is in the neuron Transmission via close contact

Propionibacterium acnes

Causes Non-infectious folliculitis (ance) Gram positive rod Oil (sebum) accumulates, is metabolized, and resultant fatty acids trigger follicular inflammation

HHV-7

Causes Roseola Targets salivary, neurons Latency is in the T cells, others? Transmission via saliva

VZV

Causes chickenpox and shingles Targets mucoepithelial and T cells Latency is in the neuron Transmission via contact/respiratory

HSV2

Causes genital herpes, neonatal herpes, meningoencephalitis Targets mucoepithelial cells Latency is in the neuron Transmission via close contact (STI)

EBV

Causes infectious mononucleosis, Burkett's lymphoma, and nasopharyngeal cancer Targets B cells and epithelia Latency is in B cells Transmission via saliva

HHV-8

Causes kaposi's sarcoma Targets lymphocytes, other? Latency is in the B cell Transmission via close contact, saliva?

HHV-6

Causes roseola Targets salivary, neurons Latency is in the T cells, others? Transmission via saliva

Treatment for S. Typhi or Cholerasuis

Ceftriaxone (TMP/SMX alternative) Carrier sate- Amoxicillin or quinolone May need surgical removal of gall bladder

S. Typhi or Cholerasuis treatment

Ceftriaxone (TMP/SMX alternative) Carrier state- Amoxicillin or quinolones May need surgical removal of gall bladder

ExPEC treatment

Ceftriaxone- Meningitis, Lung infections, Septicemia Trimethoprim sulfamethoxazole (bactrim)- UTI

Acute (cytolytic) infection

Cell death due to viral replication -permissive (kill) vs. non-permissive cells (cant replicate, may have cytoplathologic effects though) Example: Influenza A infection of airway epithelial cells leading to the epithelial cell's death

Persistent (chronic) infection

Cells produce virus but don't die Disease caused by: -Immune responses affect infected cells -Infection compromises normal cell function Examples: -Human Immunodeficiency Virus (HIV) -Norwalk (Norovirus) infection of gastric mucosal cells (infection can be cleared by immune system, dont usually die on their own)

What type of immunity is most important in controlling EBV infection?

Cellular immunity is more important than humoral immunity

A 21 year old man was referred to an orthopedic unit from the ED. History of trivial injury to knee two days ago (he walked into a wall). He complained of pain the next day, which worsened overnight. ED attending suspected cellulitis or septic arthritis.

Cellulitis

Funds to establish PCP+ practices come from the _______

Centers for Medicaid and Medicare Services -CMS

12 year old girl living in Mobile Cervical lymphadenopathy CBC shows 12,000 WBCs per ml Segmented neutrophils 55% Bands 3% Lymphocytes 40% (10% atypical) Eosinophils 2% Patient has a sore throat Which of the following is the most likely etiologic agent: A. Francisella tularensis B. Staphylococcus aureus C. Yersinia pestis D. Epstein Barr virus E. Toxoplasma gondii

D. Epstein Barr virus

Pyogenic cocci

Subset of bacteria associated with he production of pus (suppuration) -Staphylococcus -Streptococcus -Neisseria Note: infections with other bacteria can also suppurate

Body lice (Pediculosis)

Lice are ectoparasites that feed on blood. Injected saliva causes pruritus. Pediculosus humanus capitus - (head lice) corporis - (body lice) Phthirus pubis (pubic lice) -sexually transmitted -Mainly pubic hair -Also eyelashes, eyebrows, axillary hair, facial hair Note: eggs are called nits, and females lay 1-2 nits per day

Infectious folliculitis (furuncles and carbuncles)

Mostly caused by Staph. a Gram positive Coagulase positive (wall of fibrin that limits antibiotic access) Catalase positive Leukocidin kills PMNs (panton valentine leukocidin- PVL)

Chickenpox (VZV)

Mostly in Children Fever (102F) 2-3 days Generalized rash; itchy, starts on head, to trunk to extremities. Rapidly progress from macules, to papules to vesicles before crusting. 1-4 mm diameter Lesions can also occur in oropharynx, vagina, respiratory tract, conjunctiva and cornea. Successive crops appear over successive days (200-500 lesions, 2-4 crops)

Can any drug treatment eliminate latent infection?

NO Most can only reduce severity and duration of outbreak

BSL-1

No Containment Defined Organisms Unlikely to cause disease Ex. E. coli Pathogen type: agents that present minimal potential hazard to personnel and the environment Autoclave not required

Some pathogens with a high rate of antibiotic resistance and are leading cases of nosocomial infections

No ESKAPE E. faecium S. aureus K. pneumoniae A. baumannii P. aeruginosa E. aerogenes

General characteristics of viruses

No endogenous metabolism No endogenous production of PMF and ATP (ENERGY) No ribosomes Replication does not involve "cell division" Obligate Intracellular Parasites

Can a virus infect any/all eukaryotic cell types?

No!

Is Cell-mediated immunity important for protection for the common cold?

No, , but is important for resolution

Is the culture of EBV from throat washings or blood is helpful in the diagnosis of acute infection?

No, since EBV commonly persists in the oropharynx and in B cells for the lifetime of the infected individual.

Measles

Paramyxovirus family: Negative sense ssRNA, enveloped; cytoplasmic replication, buds thru cytoplasmic membrane; not segmented POE-Respiratory system or eye Cell-associated viremia disseminates the virus to other organs. (if we did an RT-PCR you will find virus genome in the blood)

How can we narrow down the agent causing a patients lymphadenopathy?

Patient history CBC with differential Isolate the organism Specific test to identify antigens or antibodies

Jarisch-Herxheimer reaction

Patient may get worse before getting better (seen in one month regimen) Antigens are released by killed spirochetes and can lead to a pronounced cytokine storm Seen in Lyme disease and Syphilis

HPV treatment options

Patient or health care provider applied topical treatment (e.g.) -Podofliox (condylox) --> arrest cell cycle to decrease viral proliferation -Imiquimod --> activator of host immunity Surgical removal or cryoremoval Vaccination (gardasil) --> HPV6, 11, 16, 18 (vaccine preventable cancer!!)

Drugs that are useful in treating acyclovir- resistant HSV or ganciclovir-resistant CMV because they work by a different mechanism

For HSV-1 and HSV-2. -Adenine arabinoside (Ara-A). -Foscarnet. This drug binds directly to HSV DNA polymerase and inhibits its action. For CMV -Cidoforver. This drug is not dependent on CMV kinase for its activity. Possesses initial phosphate; cytidine analog. Inhibits CMV DNA polymerase directly. Note: might have to go back to early generation drugs where the resistance has weaned

Famciclovir

Penciclovir analog, more readily absorbed from the gut, increasing plasma levels over the parent compounds.

Treatment for actinomyces

Penicillin G and surgical debridement, if necessary May need up to 6 months of treatment

Treatment and prevention for Corynebacterium diphtheriae

Penicillin and Antitoxin Vaccine- Toxoid- part of DTaP

Corynebacterium diphtheriae

Gram positive Rod Humans are the only reservoir Transmission by aerosol or contact Pharyngitis, Pseudomembrane A:B toxin (diphtheria toxin) disseminates and affects heart, kidneys, nerves Differentiate from innocuous oral diphtheroids by demonstrating toxin (toxin gene carried by phage)

Bacillus anthracis

Gram positive rod Spore forming Peptide capsule (in vivo only)

Pertussis toxin

Pertussis toxin is an A:B toxin ADP-ribosylates and inactivates an inhibitory GTPase, leaving adenylate cyclase overactive -High levels of cAMP -Pertussis toxins can produce fever, convulsions, brain damage, death

Body lice treatment

Remove and destroy infested clothing Permethrin cream- DOC. Neurotoxin causing paralysis and death Pyrethrin - causes seizures in lice Pyrethrin and piperonyl containing shampoo

Suramin adverse effects

Renal toxicity, nausea, vomiting, diarrhea, paresthesia.

Yersinia pestis pathogenesis

Rodents constitute the natural reservior Zoonotic infection Two transmission cycles: -Sylvavtic (reservoirs such as rock squirrels, ground squirrels, prairie dogs, mice) -Urban

Yersinia

Include (Y. pestis, Y. pseudotuberculosis, and Y. entercolitica) They are Gram negative Facultative intracellular pathogens Oxidase negative Bipolar staining Antiphagocytic surface antigen called F1 All three yersiniae resist phagocytic killing All contain virulence plasmids and a pathogenicity island All have type III secretion systems Dissemination: Y. pestis > Y. pseudotuberculosis > Y. entercolitica

HIV immune avoidance

Infection of lymphocytes and macrophages leads to inactivation of immune defenses Inactivation of CD4 TH cells leads to loss of immune activation, and Delayed type hypersensitivity responses Antigenic drift of gp120 leads to evasion of humoral immunity Glycosylation of gp120 leads to evasion of humoral immunity

Herpetic whitlow

Infection of the herpes virus around the fingernail, caused in children by thumb sucking when they have a cold sore (herpes labialis) or gingivostomatitis, and in health care workers who fail to use latex gloves

Lymphadenitis

Infection of the lymph node Will have reddening, warm to touch, and suppuration

Lymphangitis

Infection of the lymph vessels Originates from a wound infection or abscess Usually caused by a Staph and/or Strep infection

Rhinosinusitis

Infection of tissues lining the sinuses and nasal mucosa Triggered by common cold, allergic rhinitis, nasal polyps, deviated septum Usually bacterial or viral causes Inflammation leads to blockage that prevents cilliary clearance of sinus secretions

A 10 month old girl was brought to the ED by her frantic parents. The baby developed a fever of 104 F and she had a brief seizure in which her muscles tightened and she fell. It was over in 10 minutes and the girl became very drowsy. She was worked up for possible causes of fever but within 2 days developed the rash seen below. Her face was spared.

Roseola (Exanthema subitum, Sixths disease) Casued by Human herpes virus 6 or 7

Eclipse phase: +ssRNA viruses

Translation: Viral genome is a mRNA --> Translation of viral polyprotein by host ribosomes Viral polyprotein --> Processed into individual viral proteins (replicase, capsid proteins, etc...) Replication: Viral RNA-dependent RNA polymerase (replicase) -this produces negative sense RNA and the replicase uses this as a template to make positive sense RNA

T/F: despite incurring the highest expenditure in healthcare, the US ranks the lower in performance among the 11 industrialized countries

True

HPV replication

Upon infection, the virus will migrate below the epithelium to the basal keratinocyte. It will begin to produce proteins that simulate the cells to replicate and make more virus the will be shed at the corneum Note: this proliferation within the epithelium causes warts

2 classes of respiratory tract infections

Upper Respiratory tract infection Lower Respiratory tract infection

Etiology of rhinosinusitis

Usually viruses -Rhinovirus -Influenza -Parainfluenza Can lead to acute bacterial sinusitis - Staphlococcus aureus - Streptococcus pneumoniae - Haemophilus influenzae - Moraxella catarrhalis - Streptococcus pyogenes Can be mixed infections

Smallpox

Variola major Poxvirus family dsDNA, enveloped, cytoplasmic replication (unusual for DNA viruses) POE-respiratory (secretions from mouth and nose are most important for person-to-person transmission) Pustules Vaccine but not used

Is there an uncoating step in viral replication?

YES, where it does this usually depends on the virus if there are proteins surrounding, they must be removed in order to undergo replication Note: if replication occurs in the cytoplasm, uncoating occurs in the cytoplasm Note: if replication occurs in the nucleus, uncoating usually occurs right at the nuclear envelope

Do complex interactions and feedback loops exist among the social determinants of health?

Yes, For example, poor health or lack of education can impact employment opportunities which in turn constrain income. Low income reduces access to healthcare and nutritious food and increases hardship. Hardship causes stress which in turn promotes unhealthy coping mechanisms such as substance abuse and overeating of unhealthy foods

Is there dead bone present in many adult patients with osteomyelitis?

Yes, and acts as a nidus for relapse after cessation of antibiotics

Leprosy treatment

Tuberculoid form --> treated with rifampicin and dapsone for a minimum of 6 months Lepromatous form --> rifampicin, dapsone and clofazimine for 12 months Treatment of leprosy has successfully reduced the overall incidence of disease

Differential Diagnosis for plague

Tularemia Hentavirus Streptococcus- lymphadenitis Staphylococcus- abscess, lymphadenitis

Salmonellosis

Two main species: -S. enterica -S. bongeri Gram negative rods Foodborne diseases

Treatment for recurrent otitis media

Tympanostomy tubes It equalizes pressure, allows drainage

Roseola (Exanthema subitum, Sixths disease) symptoms

Typical age group 6 months to 2 years [By then seropositivity is 80%] High fever (102-104F), up to 7 days. Can develop a febrile seizure Generalized macular rash (not itchy) appears after fever starts to subside. Spares the face. Resolves in 2 days Few if any signs of URI (occasional runny nose) Irritability Anorexic Cervical lymphadenitis Recurrences are uncommon

Eclipse phase: -ssRNA viruses

Transcription & Translation: ~Virus particle must carry its own RNA-dependent RNA polymerase (transcriptase) ~-RNA --> mRNA --> Translated by host ribosomes to produce viral proteins Replication: ~Viral RNA-dependent RNA polymerase (replicase/transcriptase) ~-RNA --> +RNA (template) --> many new copies of genomic -RNA

Joint warmth, pain, swelling, and restricted motion suggest septic arthritis, and mandate _______

arthrocentesis. Synovial fluid should be evaluated for cell count and differential, Gram stain, aerobic and anaerobic culture, and crystals

Prevent of tularemia

avoid infected animals

Albendazole

benzimidazole derivative; usually first line therapy for Ascaris, Hookworm or whipworm Mechanism: Similar to Mebendazole, primarily blocking glucose uptake in helminths. Degenerative changes in the intestine and tegument of the worms are seen. Also effective for the treatment of Tapeworm cysts (T. soliumand Echinococcus granulosis cysts)

Secondary stage of lyme disease

cardiac dysfunction (myopericarditis), neural damage (meningitis, encephalitis, nerve neuropathy) muscle and joint aches - often knee complaints (contain spirochetes) Lasts for days to months Note: if untreated. 80% develop late manifestations within 1 month to 2 years

Cat scratch disease (Bartonella)

cats are reservoir found in fleas, transmitted by flea bite or cat scratch G Neg rod facultative intracellular disseminate in macrophages infection Generalized lymphadenopathy. Painful nodes. Node develops 5-10 days after bite or scratch.

CMV

causes cytomegalic inclusion disease, CMV mononucleosis, pneumonia, and retinitis Targets epithelia, monocytes, lymphocytes Latency is in the monocytes, lymphocytes, others? Transmission via contact/transfusion/transplantation, congenital

The measles skin rash is mediated by___

cell-mediated immune response due to infection of dermal capillary endothelial cells and immune complex formation

Most actinomyces infections are ____

cervicofacial finding of tissue swelling with fibrosis and scarring, as well as draining sinus tracts along the angle of the jaw and neck will alert the physician to the possibility of actinomycosis

Gonococcal arthritis yields positive synovial fluid cultures in less than half of cases. Diagnosis is usually based on the combination of finding gonococcus in genitourinary, rectal, or oropharyngeal samples, and a clinical syndrome suggestive of ______

disseminated gonococcal infection

The black area on fingers seen with the bubonic plague comes from___

disseminated intravascular coagulation

Genetic instability of the virus coupled with compliance of patients issues can lead to the emergence of ____

drug resistance It can also create difficulties for vaccine design

Human papillomavirus (skin)

ds Circular DNA (non-enveloped), intranuclear replication; Can become latent; some strains produce noncancerous cauliflower-like growths on skin Cause rapid growth of outer layers of skin Common warts Plantar warts POE-direct contact with damaged mucous membranes or skin (Human reservoir; most common sexually transmitted disease); Common warts are not as contagious as genital warts

Herpes simplex virus structure

dsDNA genome Enveloped Has proteins in the tegument that is important for the virus when it initiates its replication phase Note: also has other surface glycoproteins, etc involved in their replication

HIV replication: Attachment, Fusion, Entry

gp120 interacts with CD4 and CCR5 on macrophages. This interaction induces a conformational change exposing the fusion protein gp41 and thus allows the virus to undergo the absorption and attachment phase where it is attached to that host cell noncovalently and can release its contents into the host gp120 can also interact with CD4 and CXCR4 on T cells. This interaction induces a conformational change exposing the fusion protein gp41 and thus allows the virus to undergo the absorption and attachment phase where it is attached to that host cell noncovalently and can release its contents into the host

Yersinia entercolitica infection

ingestion; penetrates intestinal mucosa G- neg rod facultative intracellular macrophages disseminate Generalized lymphadenopathy- mostly mesenteric (abdominal)

localized lymphadenopathy

local infectious process, can result from drainage of a nearby infection

EBV-associated lymphoproliferative disease

has been described in patients with congenital or acquired immunodeficiency, including those with severe combined immunodeficiency, patients with AIDS, and recipients of bone marrow or organ transplants who are receiving immunosuppressive drugs (especially cyclosporine). Proliferating EBV-infected B cells infiltrate lymph nodes and multiple organs, and patients present with fever and lymphadenopathy or gastrointestinal symptoms

and resources at global, national and local levels. The social determinants of health are mostly responsible for_______

health inequities - the unfair and avoidable differences in health status seen within and between countries

Bacterial strategies to evade the host immune response include:

include elaboration of biofilm, a hydrated matrix that establishes a physical barrier against both host defenses and antibiotics. Bacteria embedded in biofilm are also less metabolically active, making them less susceptible to antibiotics. Inflammation associated with bacterial toxins and the host immune response leads to bone lysis

Lab evaluation for osteomyelitis

includes blood cultures, white blood cell (WBC) count with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level. WBC count usually more often elevated in acute than chronic osteomyelitis ESR and CRP are elevated our to osteomyelitis and can be used to assess patient response to treatment

Trifluorothymidine (TFT)

incorporates causing error First generation Note: Effective for keratitis (eye drops) or topically on mucous membranes.

Cytokines secreted during inflammation promote the spread of the rhinovirus by ____

increasing ICAM-1 expression

peridontitis

inflammation of region around the teeth Often caused by bacteria

Epiglottitis

inflammation of the epiglottis (rare but serious, life threatening) Often caused by bacteria

Laryngitis

inflammation of the larynx Often caused by viruses or bacteria

Rhinitis

inflammation of the nasal mucosa leads to runny nose Often caused by viruses

Sinusitis

inflammation of the sinuses Often caused by viruses or bacteria

Pharyngitis

inflammation of the throat or pharynx (sore throat) Often caused by viruses or bacteria

Tonsillitis

inflammation of the tonsils Often caused by bacteria or viruses

Tracheitis

inflammation of the trachea Often caused by bacteria (Whooping cough)

Vertebral osteomyelitis may be complicated by epidural abscess and neurologic compromise; ongoing evaluation of these patients should include_________

periodic neurologic examination of the lower extremities

Scabies treatment

permethrin, lindane, or ivermectin ointments Permethrin cream- DOC. Neurotoxin causes mite paralysis and death Pyrethrin - causes seizures in mites Lindane - causes seizures in mites Ivermectin - blocks invertebrate glutamate-gated chloride channels

Group G streptococci can cause ___

pharyngitis

Thioglycolate broth

removes oxygen from growth, allows anaerobes to grow (neisseria no grow)

Plague (Yersinia pestis)

reservoir (rodents) vector (fleas) G Neg rod facultative intracellular pathogen macrophages disseminates infection Generalized lymphadenopathy Will see Buboe

Tuberculosis (Mycobacterium tuberculosis)

reservoir is humans acid-fast bacillus spread by aerosols facultative intracellular pathogen macrophages disseminate. TB lymphadenitis is one of most frequent presentations of extrapulmonary TB

During EBV latent infection of B cells, what are the only things expressed in vitro?

only the EBV nuclear antigens (EBNAs), latent membrane proteins (LMPs), and small EBV RNAs

In chronic osteomyelitis, in which the patient or the clinical context favors a nonsurgical approach, ________

oral antibiotics can be administered to treat intermittent flares

Docosanol (abreva)

over-the-counter cream - Active ingredient is a 22 carbon alcohol that inhibits viral attachment. Reduces symptoms when applied early (prodrome).

Yeast forms of candida albicans

thrush, vaginitis, sepsis

Filamentous candida albicans

tissue invasive disease state

Otitis media is often triggered by an ____

upper respiratory tract infection

HPV cervical dysplasia and neoplasia

Common STD Cytologic changes HPV16, 18, 31, 33, 35, 42-44

Rhinitis/ Rhinorrhea

Common cold Begins with sneezing, soon followed by rhinorrhea (runny nose). Rhinorrhea increases and soon followed by symptoms of nasal obstruction along with a mild sore throat, headache, and malaise. Fever unusual. Peaks in 3-4 days, but the cough and nasal symptoms last 7-10 days.

Hennepin interprofessoinal: Community Health worker

Community health workers reach out to and establish relationships with members to help them understand their care plans, provide follow-up on missed appointments and referrals, resolve barriers to treatment, and facilitate social support

Current care delivery and payment models that unify the aims of health, care, and cost through explicit account for patients' social needs include:

Comprehensive Primary Care Plus (CPC+) Accountable Care Organizations (ACO) Accountable Health Communities (AHC)

PRAPARE

(Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) Another tool to gather information on SDOH

Ivermectin

(macrocyclic lactone, Mectizan; used for Strongyloides and Onchocercha) Mechanism: Potentiates the release and binding of gamma-amino-butyric acid (GABA) at postsynaptic sites on the neuromuscular junction and the worm becomes paralyzed. Also affects a glutamate-gaited chloride channel in nerve and muscle (pharyngeal). Not only affects nematodes but also many arthropods (mites,fleas,ticks)

Infectious disease that cause Monocytosis

(mneumonic TRMbeL) Tuberculosis Rickettsiosis (Rickettsia) Malaria (Plasmodium) Bacterial endocarditis (Streptococcus mutants, S. bovis, Staphylococcus, Enterococcus) Leishmaniasis Ulcerative colitis- no single cause Systemic lupus erythematous

Infectious disease that cause Lymphocytosis

(mneumonic WEBCHaT) Whooping cough (Bordetella pertussis) Epstein-Barr virus (B cells altered and look like monocytes) Brucellosis (Brucella) Cytomegalovirus Hepatitis A virus Tuberculosis (Mycobacterium tuberculosis) Salmonella typhi

Upstream determinants of SDOH

-Economic and social opportunities and resources -Living and working conditions in homes and communities Facing the structural drivers of inequity, a new responsibility for health care systems A Medicaid ACO, for example, may serve an urban population with high levels of food insecurity, underemployment, and lack of access to affordable housing. Although each of these social factors is known to influence an individual's health on a population level, complex and circuitous pathways exist between these upstream social determinants and downstream health outcomes While meeting individual needs may be an important aspect of holistic patient care, these efforts are likely insufficient levers to improve overall population health. For example, although individual-level screening for depression has solid evidence and is recommended, the value of depression screening depends largely on the availability of high-quality mental health services. Even in the presence of such resources, many would argue that for certain populations, this approach may not be as important as community-based initiatives to reduce the psychological sequelae or incidence of community violence.

Downstream determinants of SDOH

-Medical care -Personal behavior Addressing SDOH at the point of care, one patient at a time The objective definition of success is when the patient secures the needed resources. -Simply handing a patient a list of community resources or other "points for effort" approaches do not count or win anyone partial credit.

HIV replication

1. Attachment, Fusion, Entry 2. Reverse Transcription (Reverse Transcriptase --> cDNA (ds) synthesis). This reverse transcriptase is an RNA dependent DNA polymerase which means it can take the RNA genome and turn it into complementary DNA. It also contains an RNAase that destroys the RNA genome once it has been copied. 3. Genome integration --> Transcription within the nucleus (Viral proteins and new viral RNA genomes). This achieved by the integrase which covalently bonds the viral cDNA into the host genome and produces a provirus and is a part of the host cell genome for life 4. Viral genome encapsidation (pkg RT, INT, PRT, and more +ssRNA and release via budding) Note: this bud contains protease needed for maturation and production of an infectious virus

5 goals to better integrate social care into health care

1. Design health care delivery to integrate social care into health care -guided by the five health care system activities—awareness, adjustment, assistance, alignment, and advocacy. 2. Build a workforce to integrate social care into health care delivery. -For instance, the scope of practice of social care workers should be expanded and standardized, and they should be considered providers eligible for reimbursement by payers. 3. Develop a digital infrastructure that is interoperable between health care and social care organizations. -For instance, the federal government should establish a large-scale social care digital infrastructure and provide resources so that social care organizations and consumers can interact with each other and the health care system. 4. Finance the integration of health care and social care. -For instance, the Centers for Medicare& Medicaid Services should clearly define which aspects of social care Medicaid can pay for as covered services. 5. Fund, conduct, and translate research and evaluation on the effectiveness and implementation of social care practices in healthcare settings. -For instance, federal and state agencies, payers, providers, delivery systems, and foundations should contribute to advancing research on and evaluating the effectiveness and implementation of social care practices.

HPV ____ and HPV ____ are associated with human cervical cancer

18 and 16 They have E6 (binds p53) and E7 (binds p105RB) which that will trick nonproliferative cells to proliferate

Bacillus anthracis pathogenesis

1. Polypeptide Capsule - genes on a plasmid 2. Anthrax Toxin - genes on a second plasmid - 3 component -Protective Antigen (PA) - required for EF and LF binding to host cells (like a B subunit of AB toxins) -Edema Factor (EF) - Adenylate cyclase, activated by calmodulin -Lethal Factor (LF) - Metaloprotease Cleaves MAPK triggers apoptosis of Alveolar Macrophages- lethal shock

3 requirements of triple aim

1. Specify a population of concern 2. Be aware of policy constraints 3. Establish an integrator

Approximately half of the cases of septic arthritis result in impaired joint function, and mortality rates range from ______ in normal hosts and up to _____ in patients with comorbidities.

10 to 15% 30%

Rubella incubation

14 days

Retrovirus (HIV) structure

2 identical copies of +ssRNA (not segmented) genome each bound by a host tRNA (primer) It is an enveloped virus, so it leaves the host via budding. Therefore it has a lipid membrane from the host and will insert its glycoproteins in it Note: contains a reverse transcriptase and integrase (helps insert into the host cell genome) and protease (used to chop up own proteins in order to mediate their activation)

Chickenpox (VZV) incubation

2 weeks post exposure

Coronavirus

2nd most common cause of colds Medium-sized, enveloped viruses with single strand, plus-sense RNA genome Is resistant to GI tract conditions and so can spread via fecal - oral route or aerosol Limited to replication in upper respiratory tract (Opt. Growth temp 33 - 35 degrees C) Infects mostly children, cross protection is poor

Lifespan of louse to nit to death is about ___

35 days

Streptococcal pyrogenic exotoxins

4 Toxins, A, B, C and F. Not all present in the same strain. Have different effects Some cause cytokine release through superantigen mechanism Can produce a Toxic shock-like syndrome Septic shock Symptoms of toxic shock-like syndrome: -Fever; Hypotension, tachycardia -Cardiotoxicity -Often times a rash - caused by the toxin inducing cytokine release in skin (ex is Scarlet Fever)

Typhoid fever prevention

4 types of vaccines (as of now!) -parenteral inactivated whole-cell vaccines- not very effective -oral attenuated S. Typhi Ty21a vaccine -parenteral Vi polysaccharide vaccine (capsule) (most common now) -parenteral Vi-rEPA conjugate typhoid - 90% effective, not yet licensed (Vi polysaccharide coupled to Pseudomonas aeruginosa Exotoxin A, adjuvant) Recommended for travelers going where typhoid is endemic (some areas of Latin America and Asia) or any area where outbreak is occurring

Hand, foot, and mouth disease incubation

4-6 days

Gingivostomatitis last _____

5-7 days

A synovial fluid white blood cell count of more than ________ and neutrophil predominance is traditionally taken as indicative of infection

50,000 cells/mm

Treatment for osteomyelitis usually last ___

6 weeks

The entire course of measles last ___

7-10 days

Measles incubation

7-14 days

Incubation time for typhoid fever

7-20 days

Hand, foot, and mouth disease is most common in what age group?

<5 yr

Wasting syndrome

A combination of weight loss, fever, and muscle wasting due to increase metabolism caused by HIV during the final stage of HIV disease. Some patients may waste to the point that they no longer have enough strength to walk or breathe.

Diabetics are predisposed to foot infections because of:

A compromised vascular supply secondary to diabetes (peripheral artery disease) Local trauma and/or pressure (often in association with lack of sensation because of neuropathy)- e.g. ill fitting shoes, tying shoes too tightly, stone in shoe Microvascular disease

Comprehensive Primary Care Plus (CPC+)

A national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. CPC+ is a unique public-private partnership which gives primary care practices additional financial resources and flexibility to make investments, improve quality of care, and reduce the number of unnecessary services their patients receive. There are currently 2851 primary care practices participating in the CPC+ program, which started in 2017

Hennepin interprofessoinal: Behavior health "in-reach" staff member

A social worker specializing in behavioral health interventions is assigned to the ED to provide "in-reach"—that is, to help members with psychiatric symptoms access primary care and outpatient behavioral health services.

Hennepin Health

A successful ACO that works to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. -Emergency department visits decreased 9.1 percent between 2012 and 2013 -Outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements.

Key drives to integrate social care at the clinic, ED, hospital

A systematic screening protocol to document SDOH Referral and navigation to connect patient with resources A dedicated workforce that can identify and address SDOH Data systems to document activities and outcomes to generate performance improvement strategies Leadership and stakeholder engagement to institutionalize the practice of Social Care

What species of actinomyces is most common in human infections?

A. Israeli

Three immunological types of influenza virus

A: Antigenic instability - found in animals (pigs, birds, human) - most well-studied B: Antigenic instability but < A C: Antigenically stable (causes minor respiratory infections)

Lipodystrophy

Abnormal fat metabolism and distribution caused by HIV and antiretroviral medications. Muscles in the extremities waste, the face thins, and fat accumulates at the abdomen. Laboratory measurements of lipids and cholesterol may also be abnormal. Especially seen in PI medications

Accountable Care Organizations (ACO)

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share the savings it achieves among its constituent organizations

Ivermectin pharmacology

Absorbed orally, highest concentrations in liver and fat, very low in CNS. T 1/2 of 10 hours. It does not cross the human blood brain barrier and unable to affect host GABA receptors.

CPC+ seeks to improve quality, access, and efficiency of primary care by realizing five key Comprehensive Primary Care Functions:

Access and Continuity Care Management Comprehensiveness and Coordination Patient and Caregiver Engagement Planned Care and Population Health

In particular, surveys respondents organizations are pursuing 2 value based strategies:

Accountable care organizations, which often use captivated payments Bundled payments, which provide single payment for multiple services addressing a single condition

Valaciclovir

Aciclovir analog, more readily absorbed from the gut, increasing plasma levels over the parent compounds.

Chief complaint: Lumpy jaw. Some suppuration. Physical exam: Evidence of periodontal disease. Aspirate taken and sent to the lab for culture

Actinomyces

Streptokinase

Activates plasminogin to form plasmin, degrades fibrin Contributes to necrotizing fasciitis

Infectious disease that cause neutrophilia

Acute (pyogenic) bacterial infections- Staph/Strep, Neisseria meningitidis Gram neg bacilli, Escherichia coli, Yersinia pestis, Salmonella

Consequences of viral infection to the host cell

Acute Infection (Cell Death) Persistent (Chronic) Infection Latent Infection Transformation (Cancer)

Brucellosis symtoms

Acute Phase: Vague Muscle and Joint Pains, lymphadenopathy, Undulating fever Acute phase progresses to chronic Phase Chronic: Psychoneurotic symptoms, fatigue, dissemination can progress to CNS infection and endocarditis Blood cultures in Chronic stage are negative Included in the differential diagnosis of Fevers of Unknown Origin

Measles complications

Acute encephalitis occurs in approximately 0.1% of reported cases Subacute Sclerosing Panencephalitis or SSPE - -RARE degenerative CNS disease due to persistent measles virus infection of brain parenchyma. -Occurs 7 years (average) after measles. -Progressive degeneration of behavior and intellect -Ataxia -Monoclonic seizures Measles illness during pregnancy results in a higher risk of premature labor, spontaneous abortion, and low-birth weight infants. Birth defects are very rare. Note: antivirals may be necessary for these complications (ribovarin- IV). This is an off-label use of the drug

The GAS causing impetigo is linked to ___

Acute glomerulonephritis Staph impetigo is not

Diabetic foot ulcers and infections can also develop:

Acute osteomyelitis Leukocytosis, ESR moderately elevated Blood cultures usually negative. If + can lead to identification of organism Bone scans are useful for assessment Can lead to sepsis Chronic osteomyelitis CBC often normal range ESR very high >100 mm/h Platelet count elevated Blood cultures usually negative Bone biopsy needed for identification

Case History: A 22-year old female presents to the urgent care clinic complaining of headache, myalgia, malaise, with a cough that has progressively worsened such that she feels nauseous. She notes that several of her co-workers started exhibiting similar symptoms after attending a work Christmas party.

Acute viral infection

Shingles (VZV)

Adults (usually > 60 years old) Reactivation of latent infection (temporary immune depressed state) Prodromal sensory manifestations along a skin dermatome (pain, itching). Due to spread of virus along sensory nerves Dermatomal vesicular rash (painful) Regional lymphadenopathy Pain may remain after vesicle resolution (post herpetic neuralgia) Post Herpetic Neuralgia (PHN) more often in pts >60 and with atherosclerosis, and in pts with eye involvement. Can be constant burning pain or "Feels like ants crawling over your skin"

Viral replication cycle

Adhesion (absorption and attachment) Entry (direct fusion vs endocytosis) Replication (Eclipse phase) Assembly (luggage) and Release (lysis vs budding)

Rhinovirus pathogenesis

Aerosol and fomite transmission VP1 Attaches to ICAM-1 (expressed on endothelial, epithelial and fibroblast cells); enters via endosome. 100 serotypes Genome injected across endosome membrane through channel created at one virion vertex. Replication happens in cytoplasm.

Chronic Asymptomatic HIV infection

After three to six months, the immune system stabilizes and HIV is firmly established in the central nervous system, lymph nodes, and peripheral blood mononuclear cells. Although most patients remain free of symptoms during this stage, HIV continues to reproduce and kill CD4+ lymphocytes. In the early stages of disease CD4+ cells are rapidly replaced, but the ability of the immune system to cope with the continuous loss of CD4+ cells diminishes and CD4+ lymphocyte numbers gradually drop.

Lancefield groups of streptococci based on cell surface Ag

Ag is part of peptidoglycan- carbohydrate Most applicable to ß-hemolytic strep 21 Groups; A thru U Gr A, ß-hemolytic strep (S. pyogenes, also known as GAS) is most common pathogen in this genus Group B, G also important

S. aureus virulence factors

Alpha-Hemolysin Leucocidins - Panton Valentine Leukocidin (PVL). Contribute to abscess formation by killing WBC Enterotoxin - Food poisoning; acts on Vagus nerve Coagulase - Converts fibrinogen to fibrin -clots plasma Exfoliation Toxin- Scalded Skin Syndrome - Desmoglein protease Toxic Shock Toxin - A Type of Pyrogenic Toxin, superantigen Protein A - "Cloaking Devise" binds Fc portion of Ab

When to start HAART

Although some patients start taking antiretroviral medications when they have a high number of CD4+ lymphocytes, others wait until their CD4+ lymphocyte counts dip below 200 cells/mm3. It is important to remember that CD4+ lymphocytes are being destroyed during all stages of HIV. When the count begins to drop, it indicates that the patient's own immune system is no longer able to replace them at the same rate at which they are being destroyed. Many patients start taking antiretroviral medications if their HIV viral levels are rising, especially if their CD4+ lymphocyte counts fall below 350 cells/mm3 (DHHS Panel on Clinical Practices for Treatment of HIV Infection, 2005). This generally occurs during the Chronic Asymptomatic Phase of HIV.

Antiviral drugs used for Influenza A virus

Amantadine- targets M2, hemagglutinin Ribavirin- targets RNA polymerase Aznamivir, oseltamivir- targets sialidase

Cellulitis

An uncomplicated, non-necrotizing, inflammation of the dermis caused by infection No fascia or muscle involvement Severe cellulitis (purulence seen): -Elderly Diabetes Recurrent cellulitis: -Immunodeficiency -Peripheral artery disease

Empiric treatment for acute otitis media

Amoxicillin (broad spectrum ß lactam) (if sensitive use erythromycin-sulfisoxazole) NSAID analgesic Note: decongestants, and antihistamines provide no obvious benefits

Penciclovir

An analog of Acyclovir - Phosphorylated more efficiently - Intracellular half-life is 10-fold longer but 100X less potent in its inhibition of viral DNA polymerase.

Rheumatic fever

An autoimmune disease of heart triggered by molecular mimicry between an epitope in certain M proteins and cardiac antigens

Diagnosis of strep throat

Anterior cervical lymphadenitis. Acute onset sore throat Headache Nausea/vomiting Cough absent, fever present Major cause of bacterial tonsillitis However these are not sufficiently specific or sensitive to treat Strep throat empirically. Laboratory Findings -Rapid Strep Test -ELISA or immunochromatography -Swab throat (tonsils and pharynx) and test for Group Antigen Measure Antistreptolysin O titer if you suspect sequalae (Rheumatic fever/ AGN) Measure anti-DNAse titer if you suspect sequalae

Habitat of S. aureus

Anterior nares

Prevention of bacillus anthracis

Anthrax Vaccine Absorbed (AVA) -culture filtrates of a nonencapsulated, avirulent strain - contains PA protein Note: Used by military- effective for 2 yrs Living spore vaccine (no capsule) - cattle Sterilize animal wool, hair and hides

Treatment of diabetic foot wounds

Antibiotic penetration a problem Debridement Resolve arterial blockage Empiric treatment should cover -MRSA (Vancomycin, Linezolid, or daptomycin) -Gram negatives and anaerobes (piperacillin-tazobactam, meropenim or ceftriaxone) Amputation Even osteomyelitis can be cured (usually IV antibiotics). Amputation may not be necessary Case by case assessment.

Treatment for lymphadenitis

Antibiotics - Vary with etiology Incision and drainage: -The skin is sterilized using rubbing alcohol or an antibacterial soap. -A local anesthetic is injected into the tissues surrounding the lymph gland. -An incision is made with a scalpel. -Pus is drained from the lymph gland. -The lymph gland cavity is flushed clean. -In some cases, a rubber drain or a strip of sterile gauze is packed inside the lymph gland cavity. -The gauze or drain placed inside the cavity is usually removed 24-36 hours later.

Peritonsillar abscess treatment

Antibiotics alone may not work Aspiration and drainage

Treatment for septic arthritis

Antibiotics and joint drainage are the foundation of septic arthritis treatment In the absence of informative microbiological data, epidemiological data can assist in directing empiric antibiotic selection. Vancomycin may be used as monotherapy for otherwise healthy patients with septic arthritis. In intravenous drug users and patients with underlying illness at higher risk for infection with Gram-negative rods, vancomycin plus an antipseudomonal beta-lactam or ciprofloxacin may be used If the Gram stain is negative and the patient is hemodynamically stable, antibiotic treatment should be held pending culture data and investigation of alternative diagnoses. Drainage can be done via arthrocentesis or by arthroscopy. arthrotomy combined with joint irrigation for large joints Practice is to continue antibiotic therapy for 3-4 weeks (often parenterally initially)

_______ is important in the resolution of adenoviruses

Antibody and cell mediated immunity

Why do people get so many common colds?

Antibody-based immunity is transient. 100 serotypes.

____ leads to the develop of the rash in fifths disease

Antigen-antibody immune complexes

Why do we vaccinate annually against Influenza A virus?

Antigenic drift

What causes the drastic antigenic changes in influenza A that lead to epidemic disease?

Antigenic shift

Treatment considerations for hematogenous osteomyelitis

Antimicrobial therapy for at least 6 weeks As the vertebrae are more vascular than other bones, surgical debridement is less often necessary than in other cases of osteomyelitis Clinical exam and the inflammatory markers ESR and CRP are helpful in following response to treatment

Hematogenous osteomyelitis

Any bone can be seeded by hematogenous spread of microbes, but in adults the spine is most often affected It commonly affects the lower thoracic or lumbar spine and less frequently the cervical spine.

What is the diagnostic procedure of choice for hematogenous osteomyelitis

As blood cultures are positive in less than half of cases, CT-guided biopsy is the diagnostic procedure of choice

Severe Immune compromise HIV infection

As the number of CD4+ lymphocytes declines over years or decades, patients eventually become susceptible to opportunistic infections (OIs) and opportunistic malignancies (OMs). The length of time needed to reach this stage depends on the amount of HIV in the blood, the strain of HIV, and the patient's genetic make-up. Patients with high amounts of HIV develop OIs and OMs and die sooner than do patients with undetectable amounts of HIV.

Awareness ex.

Ask people about their access to transportation

Awareness

Asking about SDOH and recording the data Including a concise panel of standard measures of social and behavioral determinants in every patient's EHR will increase clinical awareness of the patient's health status and enable clinical, public health, and community resources to work in concert. With more accurate information on a patient's situation, such as his or her financial strain, clinicians can better partner with the patient to make informed and realistic medication choices. PRAPAThe information can prompt the clinical team to refer a patient to a public health department or a community agency that helps to address problems such as financial strain or intimate- partner violence.

Source of GAS infection

Asymptomatic carriers have nasal carriage 5% carrier rate during epidemics Transmission: sneeze produces droplet nuclei also pharyngeal formites

Vaccines needed for HIV patients

At any CD4+ lymphocyte count: -Influenza virus (vaccine) -Hepatitis A virus (HA V) (vaccine) -Hepatitis B virus (HBV) (vaccine) -Mycobacterium tuberculosis (TB) (With positive skin tests) CD4+ lymphocyte count < 200 (add): -Streptococcus pneumoniae (vaccine) -Pneumocystis cariini pneumonia (PCP) -Toxoplasma gondii CD4+ lymphocyte count < 100 (add): -Mycobacterium avium complex (MAC)

Bortella pertussis pathogenesis

Attachment: Bordetella pertussis adheres specifically to ciliated respiratory epithelial cells. -Inhibits mucocilliary escalator -Tracheitis Replication in trachea, nasopharynx (Catarrhal Phase) -Secretion of several toxins -Tracheal cytotoxin paralyzes cilia (piece of peptidoglycan) -Bacterial adenylyl cyclase and pertussis toxin increase respiratory secretions- leads to paroxysmal cough followed by inspiratory gasp or "whoop" Paroxysmal stage Endotoxin release -activates complement, and binds TLR4- cytokine release, Immunopathology.

Hyaluronidase

Attacks connective tissue, aids in spread of disease

IM autoimune hemolytic anemia

Autoimmune hemolytic anemia occurs in 2% of cases during the first 2 weeks. In most cases, the anemia is Coombs-positive

Hennepin interprofessoinal: Vocational services counselor

Available through a referral, these counselors work on employment goals with members who have a recent history of behavioral health hospitalization or residential treatment

5 complementary activates can facilitate the integration of social care into health care:

Awareness Adjustment Assistance Alignment Advocacy While all of the activities will ultimately benefit patients, adjustment and assistance focus on improving care delivery provided specifically to individual patients based on information about their social needs: they operate downstream. Alignment and advocacy relate to roles that the health care sector can play in influencing and investing in social care resources at the community level; they operate upstream

Treatment and prevention of pertussis

Azithromycin (a Macrolide) in catarrhal stage Almost useless in paroxysmal stage Pertussis Vaccine -Acellular, comprised of inactivated pertussis toxin, an attachment protein (FHA) and other components -a part of DTaP Multivalent vaccine; Diphtheria, Tetanus, acellular Pertussis 5 doses Note: increasing cases because of decreased vaccination and immunity wanes

22 year old man living in NYC Cervical lymphadenitis CBC shows 15,000 WBCs per ml Segmented neutrophils 60% Bands 15% Abscess noted on back of neck Which of the following is the most likely etiologic agent: A. Francisella tularensis B. Staphylococcus aureus C. Yersinia pestis D. Epstein Barr virus E. Toxoplasma gondii

B. Staphylococcus aureus

Pathophysiology of septic arthritis

Bacteria enter the joint space primarily through hematogenous spread, as well as direct inoculation and spread from a contiguous infection in soft tissue or bone The resulting inflammatory response of the synovium is intensely neutrophilic Bacterial toxins and neutrophil proteases break down cartilage, and the increased intraarticular pressure leads to ischemic injury through vascular thrombosis and obstruction

HSV replication Overview

Binding (attachment) Fusion (entry) mRNA Synthesis Protein Synthesis DNA Replication Glycoprotein Synthesis Assembly Release Note: replication occurs in the nucleus

Accountable Health Communities (AHC)

Based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. This model will promote clinical-community collaboration through: -Screening of community-dwelling Medicaid and Medicare beneficiaries to identify certain unmet health-related social needs -Referral to increase awareness of community services; -Provision of navigation services to assist high-risk Medicaid and Medicare beneficiaries with accessing community services -Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of Medicaid and Medicare beneficiaries. The AHC Model will test the effectiveness of the "Integrator" organization

Biosafety level

Based on the preventative measures we have and rather or not it is transmitted via aerosols

Roseola diagnosis

Because of high fever do the following: -CBC Blood cultures (these will be negative) -Urine analysis (this will be negative) -Serology for anti HHV6 or HHV7 IgM (will be positive after a few days) -PCR from blood monocytes -Histology - ballooning monocyte cells in blood -If child had a febrile seizure, do a seizure work up

Most lymphadenopathy in children is due to ____

Benign self-limited disease (viral infections) Due to increase in normal lymphocytes and macrophages in response to an antigen usually not tender, hot, or red

HPV warts

Benign, self-limiting, regresses with time Dome-shaped, flat, plantar (cutaneous) Infection occurs in childhood/early adolescence HPV1, 2, 3, & 4

Marine injuries associated with Vibrio vulnificus (necrotizing fasciitis)

Brackish water Rapidly progressing, potentially deadly infection Sepsis Multisystem organ failure in 24 h

Why doesnt brucella cause abortion in humans?

Brucella spp. prefer Erythritol over glucose as carbon source. Erythritol is present at high concentrations in breast, uterus, placenta, and fetal membranes of goats, pigs, cattle, sheep. The organism has a predilection for these tissues. Thus, Brucella can be passed through milk and causes abortions in animals. Humans do not have erythritol, so the organism distributes to more tissues. Does not cause abortions.

Organisms that cause lymphadenitis/lymphadenopathy

Brucellosis (Brucella) Cat Scratch Disease (Bartonella) Plague (Yersinia pestis) Salmonella Infection (salmonella typhye) Tularemia (Francisella tularensis) Yersinia enterocolitica infection Staphylococcus aureus Infection Streptococcal Infection, Group A Tuberculosis (Mycobacterium tuberculosis) Cytomegalovirus Infection Mononucleosis and Epstein-Barr Virus Infection Toxoplasmosis "Tis hardly vague, but Bruce and Bart have Toxic Plague. And after he toils, Francis eats Salmon with Tubers and Boils Mona thinks Colitica is cyto megalo-monitical."

A 24 year old man presented to the emergency room with a 17 day history of high fevers, night sweats, and complained of backaches. The man returned from Honduras about six weeks ago, where he was visiting his family at their farm. He recalled eating goat cheese prepared at the farm. His temperature varied in daily cycles ranging from 100 to 103 F. Blood cultures revealed a Gram negative, coccobacillary microbe.

Brucellosis (undulant fever)

A male patient presented to the ER with fever, chills, headache, nausea, and weakness. On examination he is found to have an enlarged lymph node in his armpit (bubo), which is tender. He told the physician that he just returned from a vacation in the Four Corners area of New Mexico with his wife. When asked about encounters with wildlife, he reported contact with some prairie dogs. A sample of blood taken from the patient shows a capsulated, bipolar-staining, non-enteric bacillus organism. The physician immediately begins treating the patient with streptomycin and tetracycline.

Bubonic plaque caused by yersinia pestis

EBV antigens expressed on several human tumors

Burkitt's Lymphoma -A B-cell tumor of face and jaw expressing EBNA-1. Hodgkin lymphomas -Many of these tumors express EBNA-1 and LMP-1. Nasopharyngeal Cancer -A tumor of epithelial cell origin expressing EBNA-1 and LMP-1.

Pentamidine adverse effects

Burning throat pain, dryness or sensation of lump in throat; cough, chest pain; skin rash, pancreatitis

Peritonsillar abscess

Collection of pus or fluid around the tonsil Gr A Strep Fusobacterium necrophorum (G- rod, anaerobe) Worry about organism spreading to deep neck structures. Imaging by X ray or CT scan may be warranted

Prolonged antibiotic treatment risks ________

C. diff infection

A 54 yo male collapsed with rigors and was taken to a local hospital. 3 day history of high fever, shortness of breath, dry cough, and malaise. Chest radiograph revealed bilateral lung infiltrates. Four blood culture bottles grew Gram positive rods.

CDC identified the isolate as Bacillus anthracis.

EBV receptor on the surface of B cells

CD21; which is also the receptor for the C3d component of complement. EBV infection of epithelial cells results in viral replication and production of virions. When B cells are infected by EBV in vitro, they become transformed and can proliferate indefinitely.

HIV receptor

CD4 (immunoglobulin superfamily) and the co receptor CXCR4 and CCR5 (chemokine receptors)

What is often used to track the progression of HIV infection?

CD4+ Lymphocyte counts

What is used to determine when to start antiretroviral treatment or initiate prophylactic medications to prevent opportunistic infections

CD4+ lymphocytes counts in combination with an evaluation of clinical symptoms Clinicians also review laboratory test results measuring HIV viral loads to help determine when to start antiretroviral treatment and to evaluate whether current treatment is effective.

Herpes virus latency is usually stopped by _____

CD8 T cell response Note: exists as a minichromosome associated with histones but not inserted into host chromosome

How do you keep abreast of emerging infectious diseases

CDC (MMWR and emerging infectious diseases), WHO, etc Note: the CDC often requires physicans to report infections of certain pathogens they are tracking

Epstein barr virus receptor

CR2 /CD21 (complement receptor)

Neonatal herpes

Can be caused by both HSV-1 and HSV-2 Most cases caused by contact with herpes lesions in the birth canal or from relatives and hospital workers with orolabial infections. Enters newborn through break in skin. Mortality rate exceeds 65% due to herpes encephalitis or meningoencephalitis (disseminated disease) No vaccine; treat with antivirals (acyclovir, valacyclovir, etc.)

Treatment of enterococci

Can be difficult- resistant to penicillins, BUT effective synergy occurs when a pen (ampicillin) and an aminoglycoside are combined. Vancomycin can be used. If resistant (VRE) -Synercid- for E. faecium (streptogramins- Quinupristin and Dalfopristin) -Oxazolidinone (linezolid)- for E. faecalis Note: Streptogramins and Oxazolidinone are protein synthesis inhibitors

Outcomes of pregnancies with Zika Virus

Can cause defects such as microcephaly (seemed to be localized though) Some have pregnancy loss

S. aureus pathogenesis

Can enter by hair follicles, cuts, wounds Coagulase helps wall off the organism from immune system Organisms can disseminate to other sites or secrete toxins that disseminate. Causes boils, septicemia, abscesses (internal or external) Primarily an extracellular pathogen but evidence mounting that it can persist, if not grow, intracellularly in some instances.

Brucella epidemiology

Can get from: lab accident Raw milk, slaughter, vet care of cows or goats and sheep Vet care from dogs Slaughter and vet car of pigs Note: person to person transmission is rare!

Oral Candidiasis (Thrush)

Candida albicans "Dimorphic" yeast Normal Microbiota Opportunistic pathogen Overgrowth can lead to disease Thrush typically develops when immune systems become compromised Pseudomembrane can form that includes necrotic tissue, bacteria and keratin (White coating in mouth)

as we prolong the life of HIV affected individuals, what new components of the syndrome are emerging?

Cardiovascular problems

Hennepin interprofessoinal: Care coordination

Care coordinators (generally registered nurses) are embedded in primary care clinics. They oversee care needs and identify gaps in care for members with the most medically complex conditions.

3 stages of Pertussis

Catarrhal stage -Nasal congestion, sneezing, low grade fever. -Highly contagious - lasts 1 to 2 weeks -Antibiotics will be curative Paroxysmal stage -Paroxysmal coughing followed by whoop -vomiting -Lasts 1- 6 weeks. -15 attacks per day -Antibiotics do NOT work in paroxysmal stage Convalescent stage -Chronic cough -Lasts 2-3 weeks -Possibility of secondary infections with other pathogens

Croup (laryngotracheitis)

Children 6 mos- 3 yrs Fever and runny nose for a few days Swelling of the larynx Seal-like barking cough at night; wake up because of the respiratory distress Called Stridor; partially obstructed airflow Caused by multiple viruses and bacteria Usually a mild disease Transmitted by inhalation Spreads to larynx and trachea Fibrinous exudates

Many parasitic infections are ______ infections

Chronic The parasites are well adapted to their host and have devised incredible ways to survive in a hostile environment Some are self-limiting infections but may be transmitted to others and in the US are usually but not always treated

Skin abscess treatment

Cleaning and disinfection of affected areas followed by Drainage and debridement Antibiotics Minor skin infections: -Treat topically with mupiricin (bactroban) Moderate infection: -Empiric --> Bactrim, or Doxycycline -S. aureus --> ~MSSA- use cephalosporin (cephalexin) ~MRSA- use Bactrim (IF SENSITIVE) Serious Infection (Empiric): -If immunocompromised (e.g. diabetes) or signs of systemic infection --> Vancomycin OR Daptomycin Linezolid -If MSSA --> Nafcillin (oxacillin), cephalosporin, or clindamycin

Measles diagnosis

Clinical diagnosis: -Koplick's spots are pathognomonic -Leukopenia with relative lymphocytosis -ELISA looking for IgM anti-measles virus is best -If you look for IgG, you need acute vs convalescent sera -Can do viral RT-PCR -Samples sent to CDC for epidemiologic purposes

Lyme disease diagnosis

Clinical presentation Darkfield examination of synovial fluid Some serology- not very useful for early Lyme, better for late Lyme

Chickenpox diagnosis

Clinical presentation Tzanck smear- Giemsa stain multinucleated giant cells (not done often) Latex bead agglutination for antibody titer

Hennepin interprofessoinal: Clinical social worker

Clinical social workers address behavioral health needs of patients that have often been unmet. The social workers are co-located with medical clinics at Hennepin County Medical Center and North Point Health and Wellness Center to facilitate access for patients.

Conjunctivitis and Epidemic Keratoconjuncivitis

Clinical syndrome associated with adenovirus Both palpebral and bulbar conjunctivae become inflammed Outbreaks can be traced to a common source (e.g. poorly chlorinated pool) EK is occupational hazard for industrial workers

Gastroenteritis and diarrhea

Clinical syndrome associated with adenovirus Enteric serotypes 40, 41, 42 (Group F)

Acute respiratory distress

Clinical syndrome associated with adenovirus Fever, cough, pharyngitis High incidence in military trainees Vaccine for serotypes 4&7 (not used)

Acute febrile pharyngitis and pharyngoconjunctival fever

Clinical syndrome associated with adenovirus Pharyngitis accompanied by pinkeye Mild flu-like symptoms (3-5 days) Common in children

Myocarditis

Clinical syndrome associated with adenovirus Rare consequence of these other diseases

Carbuncle

Cluster of boils

Herpes virus lesions

Cold sores at the margins of lips Erythema multiforme ("target" lesions caused by HSV-1) Herpetic whitlow Herpes corneal infection

HPV anogenital warts

Condylomata acuminata HPV6 & 11 Rarely become malignant

Rubella prodrome in adults

Conjunctivitis, sore throat, headache, myalgia, low grade fever, tender lymph nodes. Adults can develop joint pain

BSL-2

Containment Moderate risk Disease of varying severity Ex. Influenza, HIV, Lyme disease Pathogen type: agents associated with human disease and post moderate hazard to personnel and the environment Auotclave not required

Herpesvirus beta

Cytomegalovirus (CMV) Herpesvirus 6 (exanthem subitum or roseola) Herpesvirus 7 (exanthem subitum or roseola)

What is the receptor for the adenovirus?

Coxsackie/ adenovirus receptor

____commonly causes synovial white blood cell counts in this range, while immunosuppressed patients may not be able to mount synovial leukocytosis in response to infection

Crystalline arthropathy

RNA viruses types

Double-Stranded (dsRNA) -segmented Single-Stranded (ssRNA) -circular, linear or segmented Polarity of ssRNA Genomes -Positive-sense (+ssRNA) works just like mRNA -Negative-sense (-ssRNA) requires 'transcription' to make viral mRNA

Brucella treatment

Doxycycline + rifampin for six weeks Note: Rifampin is lipid soluble and penetrates WBCs

HPV structure

DNA virus that is a naked capsid virus Contains capsid proteins to protect the DNA and act as the VAP to mediate entry Contains histones that wrap genomic DNA

Epstein barr virus

DNA virus which is the causative agent of Infectious Mononucleosis. Causally associated with Burkitt's lymphoma, Hodgkin lymphomas, and nasal pharyngeal carcinoma. Virus infects a small number of cell types that express the receptor for complement C3d component (CD21). These include certain epithelial cells (oro-and naso-pharynx) and B lymphocytes (exhibits cellular tropism). Replicates in B cells or permissive epithelial cells Causes latent infection of B cells Stimulates and immortalizes B cells

Herpesvirus

DNA viruses Double stranded Enveloped Belongs in the Herpesviridae family Includes 3 groups: alpha, beta, gamma (note all have a common virion structure and mode of replication) Note: infections result in a LATENT state (differ in location (cell type) of latency)

Important HSV enzymes targets for selective toxicity

DNA-dependent DNA polymerase Thymidine kinase Ribonucleotide reductase

Streptodornase

DNAse - decreases viscosity of pus caused by DNA released from dead cells Releases strep from neutrophil extracellular traps-

Treatment for gas gangrene

Debridement Antibiotics --> penicillin and Clindamycin Hyperbaric oxygen (if anaerobe, such as Clostridium perfringens) Amputation

Cellulitis treatment

Debridement not usually necessary unless signs of myonecrosis or necrotizing fasciitis For mild cellulitis --> Amoxicillin or cephalexin Penicillin-sensitive patient--> Clindamycin or a macrolide Severe cellulitis requires parenteral administration (IV) Cover for MRSA until labs back -if mild case use TMP-SMX or doxycycline -if severe case use vancomycin or linezolid Patients with recurrent cellulitis (two or more episodes): Preventative low dose penicillin (1 year)

Albendazole adverse effects

Diarrhea and epigastric abdominal pain occasionally. Rarely leukopenia and hepatotoxicity are observed.

Dengue Hemorrhagic fever

Dengue fever can develop into Dengue Hemorrhagic Fever (headache, fever, rash, petechiae, bleeding from nose, gums, eyes, skin, vomiting blood, or passing blood in stool. Cytokines alter endothelial junctions. In severe cases, sever hypotension leads to dengue shock syndrome.

Dengue Fever

Dengue fever is a sudden onset disease. Following the bite of an infected mosquito (5-8 d), a person will develop fever, headache, intense and severe muscle and joint pains (called bonebreak fever), distinctive retro-orbital pain, a maculopapular rash, and red, swollen palms of hands and soles of feet. Symptoms are caused by cytokines released from infected lymphocytes. Symptoms last 2 to 4 days and then there is a rapid return to normal temperature with profuse sweating (defervescence). After a day, the fever and rash may return for ~2 more days.

Hennepin interprofessoinal: Dentist, Hygienist, Dental assistant

Dental care providers are employed at North Point Health and Wellness Center and Hennepin County Medical Center. Coordination between the two centers allows patients to be granted same-day access and in some cases to be escorted to an on-site dental clinic, saving costs and possibly removing the need for a pain medicine prescription

A 62-year-old Asian woman was admitted with cellulitis of the left foot. She had noticed a ticking sound while walking on a tiled floor and found an embedded thumb tack at the base of the 2d toe. There was swelling, redness, and pus. She has been diabetic for 15 years. At presentation, she had no pain sensation and could not feel crude touch bilaterally up to the mid leg. Foot pulses were easily palpable. She had only received informal instructions about foot care from her practitioner. She wore footwear outside, but walked barefoot indoors at her home. This patient had an injury that could have gone unrecognized but for the ticking thumb tack.

Diabetic foot ulcers and infections Foot infection sore the most common problems in persons with diabetes

Adenovirus

Double stranded DNA, Non enveloped; Replicate in nucleus 52 serotypes Fiber contains viral attachment proteins Primarily upper respiratory tract infections Latent infections (persistence in tonsils, adenoid, Peyer's patches) Establishes a pharyngeal infection. Fingers can spread virus to eyes. Virus infects mucoepithelial cells in the respiratory tract, gastrointestinal tract, and conjunctiva or cornea, causing cell damage directly.

E. coli good vs. bad stains

Diarrheagenic strains ExPEC strains Note: diarrheagenic strains of E. coli generally do not produce sepsis

Bacteria infect bone through____

Direct contamination during trauma or surgery, spread of infection from adjacent soft tissue, or hematogenous seeding of microbes

Viral replication cycle: penetration

Direct fusion- Requires the activity of G and F proteins -G protein is the VAP which allows the virus to attach to the host cell and trigger the next stage -F protein allows the viral envelop to fuse with the host envelope and release its contents in the cell Receptor mediated endocytosis- tricks the host cells to envelope the virus and ingest it as a endosome - There is a VAP which allows the virus to attach to the host cell and trigger the next stage -Virus enters the host cell as an endosome -pH drops and there is a conformation change which allows the exposure of the fusion domains allowing viral envelop to fuse with the host endosome envelope and release its contents in the cell

Leprosy (Hansen's disease) (Mycobacterium leprae)

Discovered in 1873 by Armauer Hansen Acid Fast bacillus; waxy coat, no Gram Stain Chronic granulomatous disease of the peripheral nerves and superficial tissues, particularly the nasal mucosa (produces inflammatory nodules (granulomas) in the skin and nerves over time) Disease ranges from slowly resolving anesthetic skin lesions to disfiguring facial lesions Tuberculoid form milder- hypopigmented lesions. Loss of sensation. Lepromatous form - most infectious. Retain sensation Social stigma and ostracism of afflicted individuals (lepers)

DNA viruses types

Double-Stranded (dsDNA) -circular or linear Single-Stranded (ssDNA) -circular or linear

Septicemic plague

Dissemination, no buboe

Herpes simplex

Double stranded DNA virus, enveloped. Replicate in the nucleus, envelope comes from budding through ER membrane HSV1 - (oral lesions) HSV2 - (genital lesions) Actually they have equal chance of causing genital herpes POE oral or genital They can become latent in neural ganglia, stress can lead to recurrence.

Wet gangrene

Due to an infection, crushed limb, bacteria invade dead tissue

Streptococcus pyogenes pathogenesis and Virulence factors

Epithelial cell attachment -M protein, Multiple antigenic types, reinfection -Protein F - surface protein that binds fibronectin -Lipoteichoic Acid (G+ organisms) - binds fibronectin Hemolysins -Streptolysin O- oxygen labile, hemolyzes blood, but only anaerobically. -Antistreptolysin O titers (ASO) diagnostically useful -Streptolysin S - oxygen stable, responsible for agar surface hemolysis Not antigenic so no serum test

Streptococci

Gram positive Catalase negative Reservoir - Human Classification Schemes -Hemolysis ß- hemolysis alpha- hemolysis - not a toxin non hemolytic

TSST indiscriminately crosslinks ____

MHC receptors on macrophages to TCR on T cells

Praziquantel Adverse effects

Headache, dizziness and nausea are frequent but usually not limiting.

Typhoidal (septicemia)

High fever Extreme exhaustion Vomiting and diarrhea Enlarged spleen (splenomegaly) Enlarged liver (hepatomegaly) Pneumonia

Probe to bone test

Evaluate osteomyelitis from adjacent soft tissue infection If the probe reaches bone, then the bone is almost certainly infected. In patients with diabetic foot ulcers, an ulcer that measures more than 2 cm^2 is strongly suggestive of osteomyelitis

HIV Transmission

Exposure to open wound, mucous membranes Intravenous drug use Tattoo needles Sexual transmission Perinatal transmission Breast milk Blood transfusions and Factor VIII therapies (hemophilia) are no longer a major problem because of screening Note: Casual contact (kissing, handshake, close quarters, etc...) DOES NOT MEDIATE TRANSMISSION!

What is the reservoir for EBV?

Memory B cells

HPV encoded proteins

E1- binds DNA at ori and promtoes viral DNA replication and has helicase activity E2- binds DNA, helps E1 and activates viral mRNA synthesis E5 oncoprotein- activates EGF receptor to promote growth E4- disrupts cytokeratins to promote release E6 and E7- of HPV-16 and HPV-18 can become immortalizing genes L2 and L1 gene products are late structural (capsid) proteins

Virtually all CNS lymphomas in AIDS patients are associated with ___

EBV

Measles Prodrome

High fever (>104F), malaise, anorexia, myalgia Classic triad of conjunctivitis, coryza, cough Enathem Koplick's spots appear

Organisms commonly associated with septicemia and septic shock

Enterobacteriaceae (Gram negative rods) -E. coli, Klebsiella -Yersinia enterocolitica -Salmonella typhi Pyogenic cocci -Staphylococcus aureus, Streptococcus pneumoniae, (Gram positives) -Neisseria meningitidis (Gram negative) Enterococci (Gram positive) Francisella tularensis (Gram negative rod) Bacillus anthracis (Gram positive rod) Anaerobes that are normal inhabitants of the intestine for example, Bacteroides fragilis, Gram negative rod

Hand, foot, and mouth disease

Enteroviruses [RNA viruses] e.g. Coxackieviruses A16, others ssRNA positive sense (non-enveloped), cytoplasmic replication Fecal-oral or oral-oral transmission Virus infects buccal mucosa and ileum Viremia infects lymph nodes

Treatment for Lyme disease

Early Lyme -Doxycycline or amoxicillin (pregnant women) for 2 week regimen Secondary Lyme -Arthritis -Doxycycline or Amoxicillin- oral 1 month -Neuro/cardiac - Cephalosporins - one month regimen Tertiary Lyme -IV or oral Doxycycline -1 month -Very severe symptoms - 3d gen cephalosporins for 1 month

HSV replication Step 1

Early events The virus will undergo process of fusion and entry and the virion will travel to the nucleus where the viral DNA will be injected into the nucleus The tegument also has TIF (trans-inducing factor) which serves as a transcription factor to initiate its own transcription of the immediate early genes (makes alpha and beta proteins) Alpha proteins are immediate early proteins which serve as transcription regulation Beta proteins are early proteins (e.g. DNA polymerase)

Ecosystem Dynamics and Exposure Risks

Economic Globalization: -Habitat expansion and migration (HIV and Ebola) -Air travel (SARS, MERS, Zika, Dengue) -Global food distribution (E. coli O104:H4) -Climate change and introduction of new vectors (Zika, Chikungunya) This plays a risk in pathogen emergence! (ex. when aral sea was drained, it allows for more dust, etc and there was an emergence of TB)

What drives pathogen emergence?

Ecosystem Dynamics and Exposure Risks (links to transmission) Evolution of virulence (pathogens are new and/or improved)

has the triple aim improved the health care framework?

Eight years later, the Triple Aim has become the health care sector's dominant framework and has led to notable improvements: the cost curve is bending and the safety of care is better. Yet, the basic paradigm — which focuses on traditional health care delivery, rather than health itself — has not shifted.

Diagnosis of plague

Elevated WBC count Isolate organism (culturing not advisable, except in a reference lab) Four-fold rise in antibody titer to F1 (F1 capsule is actually proteinacious, not carbohydrate. It is a tangle of thin hair-like pili) Single titer > 1:128 - F1 capsule

Treatment for necrotizing fasciitis

Empiric treatment: Vancomycin PLUS Piperacillin/Tazobactam or Clindamycin, Vancomycin, and Ceftazidine

Herpesvirus gamma

Epstein-Barr (EBV) Herpesvirus 8 (Karposi's sarcoma- associated)

Necrotizing fasciitis symptoms

Erythema Pain Warmth Edema Induration (hardened area of skin) Fluctuance (indication of pus; soft, boggy feel of a skin infection) Crepitus [crackling sounds (crepitus) as a result of gas bubbles accumulating under the skin. The gas may be felt beneath the skin (palpable)] Skin necrosis Bullae Bubble-like cavity filled with fluid Abscess Fever Hypotension

Primary stage of lyme disease

Erythema migrans 30% of patients lack the rash. musculoskeletal pain myalgia fever chills fatigue

What bacterial virulence factors play a role in necrotizing fasciitis?

Exotoxins and endotoxins (LPS) are usually involved, and Exotoxins are usually superantigens Group A Strep produces Streptococcal pyogenic exotoxins (SPEs) Clostridium perfringens produce a number of toxins (e.g., lecithinase) Tissue ischemia prevents PMN entry to infection site and prevents adequate delivery of antibiotics.

What approach has enabled Hennepin Health's success?

Expansion of the traditional care service model:

Symptoms of rhinosinusitis

Facial pain Fever Pus like nasal drainage Persistent cough Sore throat Earache Decreased sense of smell

Brucella pathogenesis

Facultative intracellular pathogens Survives in Parasitophorous vacuole in Macrophage Immunity is primarily cell-mediated (CD8+ Cytotoxic T- cells) Disseminates: Lymph nodes Bone Spleen Liver

Etiology of croup

Parainfluenza > RSV and Influenza B >> Adenovirus, Enterovirus, Rhinovirus, Mycoplasma pneumoniae

Scabies (mites)

Female mite burrows and forms intraepidermal tunnel as the mite moves The burrows are a pathognomonic sign Webs of hands Elbows Axillae Feet Scrotum Belt line Transfer by skin to skin contact- Not only sexually transmitted

Plague symptoms

Fever, chills, myalgias, malaise, cough, dyspnea (shortness of breath), chest pain, hemoptysis (blood in sputum), regional lymphadenopathy Septic Shock lymph node involvement - groin, axilla, neck Tachypnea (rapid breathing), dyspnea, cyanosis Purpuric skin lesions - (endotoxin) Patient history is important for diagnosis

A three year old girl is brought to her pediatrician. She has the reddened checks of someone who had been slapped and an odd rash that looks like lace on her arm. She has a mild fever but no other symptoms. Lab work shows a low reticulocyte count. Her family just returned from a trip to Egypt and her mother is worried about some parasitic disease. You assure her this is not the case.

Fifth's disease Erythema infectiosum caused by parvovirus B19

Ebola and Marbug Viruses

Filoviridae - Filovirus Negative-sense ssRNA Enveloped, Filamentous Select Agent - Tier 1 Replicate efficiently in monocytes, macrophage, dendritic cells and others. Elicit a cytokine storm of pro-inflammatory cytokines. Common in Africa

Toxic shock syndrome

First seen in Menstruating Women, originally associated with tampon use. Vaginal colonization by S. aureus But Staph can cause a focal lesion anywhere and then secrete: Toxic Shock syndrome toxin (TSST) -gene is phage-encoded -Superantigen- binds class II MHC receptors and TCR; -Causes release of large amounts of IL1 and IL6- acts on hypothalamus to increase fever; IL 2 - rash; TNF a and b - leads tocapillary leak (hypotension) Fever, rash, hypotension leading to irreversible shock Diarrhea Desquamation of palms and foot soles

Macule

Flat lesion that cannot be palpated (e.g. freckle) Note: tend to be red in a lot of the exanthems

How are humans infected with Yersinia pestis

Flea drinks rat blood that carries Y. pestis Bacteria multiply in flea gut Gut is clogged with bacteria Still hungry, so feel bites human, regurgitates blood into open wound and we become infected

Clinical syndromes of Ebola and Marburg

Flu-like symptoms: fever, headache, myalgia Nausea, vomiting, diarrhea Hemorrhage from multiple sites - bleeding into skin, mucous membranes, visceral organs, and gastrointestinal tract. Death (50-90%)

Diabetic foot ulcers and infections

Foot infections are the most common problems in persons with diabetes Diabetic foot infections run the spectrum from simple, superficial cellulitis to chronic osteomyelitis Foot infections in diabetics become more severe and take longer to cure than do equivalent infections in persons without diabetes They are the major cause of lower limb amputations in these patients

Plague epidemiology

Four Corners -Colorado -New Mexico -Arizona -Utah Prairie dogs, Carnivors (puma), and domestic cats Travel History Important

Dengue Virus

From the family, Flaviviridae; West nile, Japanese encephalitis, and Yellow fever are all in this family 4 serotypes (produce different immunological responses) Enveloped, icosahedral, positive-sense ssRNA Located in tropical and subtropical climates (including Puerto Rico and the Caribbean). 40% of the world's population lives where dengue virus is endemic — 400 million infected 50 million cases of dengue fever/year globally. Starting in 2009, local endemic infections with dengue virus occurred in Florida. CDC determined that 5% of Key West population had anti-Dengue virus IgM in their blood. Infection more often than disease. The mosquito species that can be infected by Dengue virus lives all along the Gulf Coast (Aedes aegypti and albopictus). In 2009 and 2010 there were 85 cases of dengue fever in southern FL that were not due to travel. There were 233 cases in 2012 (MMWR), scattered around the country (travel may be involved). (All cases were with serotype 3)

syncytia

Fusion proteins, since they are a glycoprotein trafficked to the membrane, can cause indiscriminate fusion of host cell membranes to adjacent cells form a single large cell with multiple nuclei Note: can make cell fragile and prone to lysis

GAS subtypes

GAS further subdivided into 100 serological types - M protein (pilus-like) Binds factor H - accelerates decay of C3b Anti-M Ab is protective but no cross protection

Bortella pertussis

Gram negative rods Human reservoir- Respiratory transmission route

Treatment of CMV

Ganciclovir - Chemically slightly different from acyclovir (additional hydroxymethyl group). Effective against CMV even though virus lacks the thymidine kinase of other herpes viruses. -CMV encodes a different kinase to phosphorylate ganciclovir. -Cellular enzymes convert ganciclovir monophosphate to triphosphate. -Triphosphate form of ganciclovir inhibits CMV DNA polymerase more efficiently than it inhibits host cell DNA polymerase. Note: Acyclovir and analogues are not effective because CMV lacks TK gene

A 35-year-old man with a history of chronic intravenous drug use presented to the ED department with right upper limb pain and swelling lasting 24 hours. Vital signs: 102°F RR 25 bpm (12-20) HR 120 bpm (60-100) BP 141/76 mmHg. (Normal range) He had severe edema of the upper limb, erythema, blistering of the arm and crepitus over the shoulder and arm. At this time, motor and sensory function of the limb was not impaired and pulses of the radial and ulna artery could be palpated. He had increased WBC, Creatine phosphokinase, and AST/ALT transaminases were 2X higher then normal Empirical broad spectrum antibiotic treatment was started (piperacillin/tazobactam, clindamycin and vancomycin) Within one hour swelling of soft tissues expanded to the forearm and neck. The general condition of the patient was worsening with severe pain and hoarseness and he was intubated due to threatened airway. Within two hours since admission, he underwent arm and forearm fasciotomy due to threatening compartment syndrome (insufficient blood supply to compartment), and underwent broad surgical debridement and drainage of the infected areas. Foul smelling areas of necrosis in most of biceps brachii and the flexors of the forearm.

Gas Gangrene (Type III Necrotizing fasciitis)

Yersinia pseudotuberculosis

Gastroenteritis also wounds, joints, urinary tract

Roseola exanthem

Generalized macular rash (not itchy) appears after fever starts to subside. Spares the face. Resolves in 2 days

HPV associated diseases

Genital warts -Incidence may be as high as 100/100,000. -An estimated 1.4 million are affected at any one time. Cervical cancer -Rates of cervical cancer have fallen by approximately 75% since the introduction of Pap screening programs. -Incidence is estimated at 8.3/100,000. Note: can also cause warts and benign head and neck tumors

Impetigo treatment

Gentle cleansing (chlorhexidine or sodium hypochlorite baths) Topical Mupirocin (Bactroban) For more severe disease, use oral b-lactamase-resistant penicillin (Cloxacillin) UNLESS MRSA- then use vancomycin, Bactrim or clindamycin 7 day treatment

Mycobacterium leprae epidemiology

Global prevalence of leprosy has fallen dramatically with the widespread use of effective therapy -5 million cases in 1985 and <300,000 cases 20 years later approximately 100 cases reported annually in the US -most in California, Texas, Louisiana -immigrants from endemic areas -leprosy is endemic in armadillos found in Texas and Louisiana (15% of nine-banded armadillos are infected). It is thought that M. leprae is usually spread from person-to-person in respiratory droplets -a sneeze from an untreated lepromatous patient may contain >10^10 AFB (acid fast bacilli) -Armadillos can transmit the organism to humans.

Examples of viral encoded membrane proteins

Glycoproteins (G-proteins are VAPs) Fusion Proteins (F-proteins promote membrane fusion required for penetration/uncoating) Matrix Proteins (M-proteins act as scaffolds required for viral assembly)

What are some other notable determinants of health besides SDOH

Govt policies Availability of health care Individual behavioral choices Biological and genetic factors

Group A ß hemolytic Streptococcus pyogenes

Gram Positive chains of cocci Beta hemolytic on Blood agar Catalase negative Reservoir - Asymptomatic carriers, spread by droplet nuclei No vaccine

ExPEC strains

Gram negative rods Lactose fermentors Oxidase negative

Clostridium perfringens

Gram positive, spore forming, anaerobic growth Habitat- ubiquitous in soil; GI tract Spores last for decades Highly fermentative- much gas formed

Impetigo

Gram potive infection of superficial layers of the epidermis Most commonly seen in children Include non bullous and bullous form

Neisseria gonorrhoeae and N. meningitidis

Gram-Neg, diplococci - kidney bean shaped Oxidase Positive - cytochrome oxidase C Aerobic metabolism - and require CO2 Very susceptible to drying and cold Humans are the only Reservoir

Areas where enlarged lymph nodes can be palpated

Groin Armpit Neck (there is a chain of lymph nodes on either side of the front of the neck, both sides of the neck, and down each side of the back of the neck) Under the jaw and chin Behind the ears On the back of the head

scarlet fever

Group A Strep Infection with SPE toxigenic strain and no protective Antibodies (Streptococcal pyogenic exotoxin -->Superantigen) Organism stays in throat- toxin disseminates. Incubation - 1 to 5 days "Strawberry" tongue Diffuse skin rash -Punctate erythema Rash is like sandpaper.

What are some causes of cellulitis?

Group A Strep (most common, G +ve, b-hemolytic, catalase -ve) S. aureus (often community-acquired MRSA) Vibrio vulnificus (a G -ve curved rod, marine organism) Finding of purple bullae (fluid-filled blisters) are suggestive of infection Streptococcus pneumoniae can also cause purple bullae (via hematogenous spread of pathogen)

Etiology of diabetic foot wounds

Group A Strep, Staphylococcus aureus most common Bacteroides fragilis (anaerobic Gram -ve rod) Escherichia coli (Gram -ve rod) Proteus mirabilis (Gram -ve rod) Klebsiella pneumoniae (Gram -ve rod)

Major bacterial causes of pharyngitis

Group A Streptococci (Streptococcus pyogenes) Neisseria meningitidis Corynebacterium diphtheriae Bordetella pertussis

Oral hairy leukoplakia is an early manifestation of infection with ______in adults

HIV it often presents as white plaques on the lateral surface of the tongue and is associated with EBV infections

In adults, ____ causes more tonsillitis and pharyngitis than gingivostomatitis

HSV-1

Genesis of a burn infection

Immediately following a burn, surface has no bacteria. Deeper surviving structures (sweat glands, hair follicles) will have staphylococci that colonize surface within 2 days Over the next week other microbes colonize. Fungal infections develop later after broad spectrum antibiotics are used.

Hennepin interprofessoinal: medical care

Half time physician and full time advanced practice professional (Nurse Practitioner or Physician Assistant)

A 3 year-old girl was brought to her pediatrician with a 3 day history of fever and now sores inside her mouth. She also had a macular rash on her hands and the bottoms of her feet. The girl has not been drinking because of the herpangina.

Hand, foot, and mouth disease

Scarlet fever

Happens if infected with an SPE toxigenic strain and no protective ABs Organism stays in throat- toxin disseminates. Incubation period - 1 to 5 days "Strawberry" tongue Diffuse skin rash - 10% of patients; punctate erythema Rash is like sandpaper Note: streptococcal sequele

Dry gangrene

Happens when blood flow is cut off- ischemia, not infection

Oculoglandular disease

Have swollen glands and granulomas in the eye

Hennepin interprofessoinal: Data analytics professionals

Health care data analysts serve as a bridge between the technical world of data and the operational world of providing health care, sorting through complexities in the data, putting data together, and looking for patterns to help improve the care process. Data architects and developers create frameworks for bringing diverse data sources together, automate the integration processes, and set up tools to allow access to the data. Electronic health record (EHR) analysts build the technology interfaces within the EHR to support the work flow and patient care. Health care privacy officers work together with Hennepin Health leaders to find ways to share data to improve care within the accountable care organization while complying with changing laws and regulations.

Herpesvirus alpha

Herpes simplex virus type 1 (HSV1) Herpes simplex virus type 2 (HSV2) Varicella-zooster virus (VZV)

Varicella Zoster virus

Herpes virus family Linear ds DNA enveloped capsid nuclear replication Envelop donned while budding from cytoplasmic membrane. POE- Respiratory tract, infected particles from skin lesions Fluid in vesicles full of virus

BSL-3

High containment Aerosol transmission Serious/potentially lethal disease Ex. Tuberculosis Pathogen types: Indigenous or exotic agents, agents that present a potential for aerosol transmission & agents causing serous or potentially lethal disease Pass-thru autoclave with bioseal required in the lab room

Lab diagnosis of CMV

Histologic hallmark of CMV infection is the cytomegalic cell - An enlarged cell that contains a dense, central "owls eye" intranuclear inclusion body Also, antigen detection using immunofluorescence or ELISA Diagnostic PCR Note: also lack of hetrophile antibodies

S. enterica serotype Typhi; Paratyphi

Host adapted to humans; reservoir animals Typhoid Fever Gram negative rods Lactose Nonfermentor Hydrogen sulfide positive Oxidase negative Possesses a Capsule called Vi Ag

Influenza A virus: Resolution/ Prevention

Host-mediated defenses: Secretory IgA and CD8+ Cytotoxic T cells help resolve infection (IgG is produced but thought to be minimally protective) Antiviral drugs: Primary drugs are Oseltamivir (Tamiflu) taken orally and zanamivir (Relenza) inhaled into the nose inhibit action of NA (preventing enzyme from cleaving sugar groups from proteins prevents them from leaving host cells) Vaccination: Killed vaccines and live attenuated vaccines (2 most prevalent A strains and 1 or 2 most prevalent B strains)

Knowing ____ and ____ a patient gets infected with parasites helps establish risk of infection and may facilitate diagnosis, helps ID the stage of the parasite, etc.

How and Where

If Typhi and Typhimurium both invade cells, why don't they both disseminate?

Human PMNs better able to kill S. enterica serovar Typhimurium S. typhi has a Vi Ag (capsule) that may prevent Phagocyt. by PMNs Note: for S. typhimurium diarrhea, the immune response to invasion contributes to blood found in the watery diarrhea

Roseola (Exanthema subitum, Sixths disease)

Human herpes virus 6 or 7 (HHV6 or HHV7) -ds DNA, enveloped, nuclear replication -Transmission is likely from oral secretions -Replication in salivary glands, T-lymphocytes, endothelial cells, epithelial cells and neurons -Can become latent in lymphocytes and monocytes -Reactivation can occur when immune compromised

Dengue virus reservoir

Humans Therefore, patients can transmit the virus to mosquitos when febrile

In contrast, up to 75% of EBV infections in adolescents present as ___

IM

___ can be used to treat HSV-1 encephalitis

IV acyclovir

Treatment of tularemia

IV gentamicin or IM streptomycin Note: gentamicin can cause hearing loss and kidney damage, must monitor blood levels

Treatment for croup

IV or oral corticosteroids (dexamethasone) to reduce inflammation When severe disease- hospitalization Antibiotics- No (unless mycoplasma)

Staph infections

Impetigo - superficial, begins around nose - 80% due to staph Furuncle - Boil ; Multiple Boils equal Carbuncle (surgical drainage) Pneumonia -Infrequent (follows lung damage; e.g. flu) Septicemia - Metastatic lesions are a sign (can arise from any abscess; high fever, chills -Sepsis) Osteomyelitis - S. aureus is most common cause (can follow septicemia) Food Poisoning - Toxin works on Vagus Nerve - activates vomit center (pt. ingests preformed toxin in contaminated food; e.g. church picnic; 4 hours post ingestion vomiting and diarrhea. Enterocolitis - Overgrowth in GI tract post Antibiotic (If enterotoxin-producing strain the result is watery diarrhea) Scalded Skin Syndrome caused by Exfoliation toxin (Epodermolytic) -organism stays in nose, toxin disseminates

Epstein barr virus infection

If the virus comes in contact with B cell (or some permissive epithelial cells) it causes their proliferation and will spit out antibodies This antibody is called a heterophile antibody which react with horse RBCs The infection eventually causes the lysis of these cells

Triple aim

In 2008, Berwick proposed that improving the performance of the US Health Care system required the pursuit of three broad goals: -Improving the individual experience of care -Improving the health of populations -Reducing the per capita costs of care for populations.

Reactivation of herpes simplex virus

In a small percentage of latently infected neurons, the virus genome spontaneously reactivates by synthesizing the early genes needed to start the replicative cycle and inhibition of LATs. Note: can be caused by stress, UV damage, etc. Note: coldsores will appear in the same place!

Viral replication cycle: Assembly and Release

In envelope viruses The G and F proteins travel to the cell membrane and the matrix protein effectively forms a scaffolding at the host cell membrane that coordinates assembly of the virus. Nucleocapsid then allows for budding Note: the alternative is lysis of the cell and release of the virus that way Note: the F and G protein are usually found on the membrane where budding is going to occur

Leukocytosis

Increase in WBC count due to any cause. Sub classified by the type of WBC: -Neutrophilia -Neutorpenia (a decrease) -Lymphocytosis (an increase) -Monocytosis (an increase) -Eosinophilia (an incase)

Lyme disease symptoms

Incubation 3-30 days Rash called Erythema migrans (may disappear before they see you, so ask history!) Classic bull's eye rash (70-80% of patients have this) Few Organisms present Has 3 stages

What population is at highest risk for developing osteomyelitis from adjacent soft tissue infection?

Individuals with diabetes and peripheral vascular disease, especially in the foot Peripheral neuropathy predisposes to soft tissue ulceration in the feet, and vascular disease impairs proper immune response and wound healing. Note: these patients may have no fever and few signs of inflammation

Influenza A virus life cycle

Induces endocytosis via VAPs Endosomes pH decreases causing a conformational change in the HA protein exposing the fusion domain allowing the virus to uncoat. The M2 protein allows the inside of the virus to acidify which allows those viral nuclear proteins that coat the RNA and protect it to be removed It will replicate in the nucleus and package and it begins to bud (It is a cap stealer (5' cap) from host mRNA and uses it to stimulate its own replication ) Note: there are sailic acid residues on the the surface of the host cell and holds on to the bud. Therefore the neuroamidase (NA) enzyme cleaves those residues and allows their release

What cells do the measle virus infect?

Infect lung epithelial cells via nectin-4 receptor; Replicates in trachea and bronchial cells. Macrophages carry virus to lymph nodes Infect B and T cells, dendritic cells, (CD150 is entry receptor)

Pathogenesis of EBV

Infection -Saliva with EBV infects epithelial cells and B cell lymphocytes in submucosa Immune response -EBV specific CD4, CD8, and B cells stimulated (hetrophile positive!) Recovery -Cell mediated and humoral immunity induced -Oropharyngeal replication suppressed

Septicemia

Infection including replication of bacteria in blood (positive blood culture)

Is lyme disease fatal?

It is rarely fatal, but can be debilitating

two primary co-morbidities to consider when treating an HIV infected patient

Infectious agents acquired in conjunction with HIV (either co-infection or behavior-associated risk) (STI or Hep) Opportunistic infections (OIs) and malignancies (OMs).

A 19-year-old male college student presents at the student health clinic complaining of malaise and fatigue. He has a fever of 100ºF, pharyngitis and marked enlargement of the cervical lymph nodes. He was treated empirically with ampicillin for his pharyngitis. A day later he returns to the clinic with a rash. Splenomegaly was also observed. Blood cell count revealed a marked hyperplasia and the appearance of atypical lymphocytes. IgM antibody to the Paul-Bunnell antigen of horse erythrocytes was detected.

Infectious mononucleosis (mono) caused by Epstein-Barr virus

Periodonitis

Inflammation and infection of ligaments and bones that support teeth. Gum recedes. the inner layer of the gum and bone pull away from the teeth and form pockets that become infected. Risk factors: -Smoking. (most important) -Diabetes. -Other illnesses. Diseases like cancer or AIDS and their treatments

Gingivitis

Inflammation limited to gums around teeth Most common form is induced by plaque. Gingival fluid accumulates, neutrophils infiltrate. Followed by lymphocyte infiltration Lesions become chronic Pockets develop where gingiva separates from tooth. May bleed with brushing As inflammation progresses can become periodontitis.

Which lymph nodes are usually enlarged with bubonic plague infection?

Inguinal

Bacillus anthracis symptoms

Inhalation Anthrax -Usually from contaminated animal hides (Woolsorters disease) -Starts with non-specific symptoms (low grade fever, non productive cough) -Then; high fever, tachypnea, chest pain, hematemesis, cyanosis -Can become Septicemic anthrax -organisms outnumber RBCs- Death Cutaneous (most common form) -Inoculation through laceration -Papule develops then blackens (not purulent)- Eschar -Fever, malaise, and lymphadenopathy -5% of cases become septicemic Intestinal -Severe abdominal pain -Hematemesis, and/or bloody diarrhea. -Shock and death may occur 2-5 days after onset

Pneumonic disease

Inhalation transmission- in elderly or those with typhoidal tularemia

HIV pathogenesis

Initial infection of Macrophages since these are the first line cells the virus usually contacts (R-5 variants, can also cause infection of Dendritic cells) Antigenic drift in gp120 leads to tropism change and infection of CD4+ T-cells in lymphatics (X-4 variants) Virus infection can lead to formation of syncytia (which makes cell fragile and prone to lysis) Loss of TH function leads to decrease CD8 T cell function (recall that CD4 T cells help maintain viability of other cell types)

Recurring themes for processes that increase value

Interprofessional care Technology to support patient engagement Attention to mental health Attention to social determinants of health

Alignment ex.

Invest in community ride-sharing or time-bank programs

What is the gold standard for the diagnosis of osteomyelitis

Isolation of a microbial pathogen via bone biopsy, along with histologic findings of inflammation and osteonecrosis The biopsy should be performed through healthy tissue under direct imaging guidance microbes cultured from superficial samples are often nonpathogenic, and correlate poorly with those responsible for the deep osteomyelitic infection

Measles Exanthem

Itchy maculopapular rash; appears two days after Koplick's spots Starts at the scalp and moves toward trunk, then extremities The rash can become confluent Note: immuocompromsied may not develop rash

Prevention of plague

Killed whole cell (not in US anymore) New vaccine in trials, contains F1 (The F1 vaccine is actually an attenuated Salmonella Typhi strain carrying the genes to make F1 antigen)

Diagnosis of bacillus anthracis

Knowledge of Patient's Occupation is VERY IMPORTANT for diagnosis Smears from cutaneous lesions- Gram Stain Culture from cutaneous or pulmonary secretions Blood culture- tangled masses of G positive cells Detect anti-PA antibody PCR tests detect spores

Hand, foot, and mouth disease diagnosis

Lab studies unnecessary

LRINEC

Laboratory Risk Indicator for Necrotizing Fasciitis used to distinguish cellulitis from necrotizing fasciitis

Herpesvirus common characteristics

Large dsDNA genome Common structure (enveloped virus) Infections often asymptomatic Establish latency - persist for life Can reactivate from latency Most reactivations are asymptomatic Re-infections can occur Most herpesviruses cause more than one disease Interfere with immune responses

Gram negative rods that can cause septicemia or sepsis

Large group of species - Enterobacteriaceae Natural habitat- intestinal tract of humans and animals- and found in lakes, streams, soil In humans - some are natural gut microbiota (E. coli) others are pathogenic when present (Salmonella) All can potentially cause disease (certain strains) 50% of nosocomial infections are caused by Enterics and Pseudomonas ID of organism important for treatment and epidemiology

Ulceroglandular disease

Lesion at site of infection and swollen lymph nodes A skin ulcer that forms at the site of infection — usually an insect or animal bite Swollen and painful lymph glands Fever Chills Headache Exhaustion

Is persistent EBV infection a cause of chronic fatigue syndrome?

NO

87 yo man from southeast LA has a complaint of unusual "rash" on back, chest, arms, legs. Present for several months. Non puritic, not painful (numb, in fact), no fever/chills, not improved with hydrocortisone, clortrimazole, zinc oxide. Denies alcohol, tobacco, or drug use. Twenty years ago he shot and buried Armadillos as a hobby. Work up: WBC 5000, HCT 45, Plt 175,000 (these are OK) Liver panel normal Punch biopsy of lesions

Leprosy (casued by mycobacterium leprae)

Is there a vaccine for Hand, foot, and mouth disease

NO

Is there a vaccine for Lyme?

NO

Is there a vaccine for fifths disease?

NO

Viral envelope features

Lipid membranes (bilayers) acquired from the host cell Contains Virus-encoded membrane proteins

Neisseria meningitidis endotoxins

Lipooligosaccharide (LOS; essentially LPS without side chains) Recall that LPS (or LOS) binds TLR4 -Interaction releases TNFa, which activates clotting factors, clots deposit in tissues- decreased platelet count (sign of sepsis) -Iron transport issues- Transferrin and lactoferrin-binding proteins -Lipoprotein in outer membrane- binds factor H (inhibits complement cascade)

Shingle and Chickenpox prevention

Live attenuated vaccine Chickenpox -schedule is 1 yr and booster at 4-5 years (same as MMR) Shingles -More concentrated (helps boost memory cells) -Recommended at age 60 -Helps prevent reactivation

Rubella prevention

Live attenuated vaccine, MMR trivalent Vaccine contraindicated in pregnant women It is administered to children with HIV (if CD4 counts >200) but not recommended for immunocompromised patients

Measles vaccine

Live, attenuated strain of virus; part of MMR (Measles, Mumps and Rubella) (dont give to newborn, pregnant mother, or immunocompromised) (prepared in chick embryo fibroblast culture) Two doses given at 1 year and 4-5 years old Maternal antibodies are protective for about 6 months Low vaccination coverage has caused a resurgence in cases Only ca. 50 cases per year, most originating from outside the country 650 CASES IN 2014, 188 in 2015

Rhinovirus replication

Looks like an mRNA molecule Get formation of polyprotein that is cleaved by viral protease to give rise to the viral components It then uses viral RNA polymerase to create negative strand RNA, then the RNA polymerase to create more positive sense strand RNAs These positive sense strand RNAs are coved with capsid protein and leads to cell lysis

Hand, foot, and mouth disease prodrome

Low grade fever, malaise, anorexia, abdominal pain, sore mouth

A 27 year-old male Connecticut resident developed joint and muscle pains and an expanding erythematous bull's-eye skin lesion on his leg in July. Three days later, he experienced severe headache, neck stiffness, photophobia, and mild thought disturbances. Soon thereafter, multiple secondary annular skin lesions appeared. Symptoms resolved within several weeks. One month later, he had severe neuritic pain (continuous or episodic pain in nerves) on the skin of his abdomen, followed by arthralgias. He was treated with IV ceftriaxone for 30 days - his symptoms improved and he completely recovered.

Lyme disease caused by Borrelia burgdorferi

How to examine lymph nodes

Lymph nodes are usually small and firm. Upon examination you look for: Swelling Firmness (fluctuant=moveable and compressible) Pain Temperature Color

HIV clinical syndromes

Lymphadenopathy and fever --> AIDS-Related Complex (ARC) with presence of 2 or more of fever, fatigue, diarrhea (persistent), weight loss, and night sweats. (note we can limit these if we catch it early enough) Opportunistic Malignancies --> human herpes virus 8-associated Kaposi sarcoma, non-Hodgkin lymphoma, EBV-related lymphomas (note: theses are rarely seen in normal patients) AIDS-related Dementia

Diagnosis of Pertussis

Lymphocytosis Collect Nasopharyngeal swab NAAT- PCR (results in a few hours) (best because it is rapid) Smeared on slide; fluorescent antibody stain (Poor Sensitivity) Culture - Reagan-Lowe medium (charcoal/horseblood/cephalexin; may take a week to grow)

____ is responsible for post infection consequences of rheumatic fever and acute glomerulonephritis

M protein

Leprosy diagnosis

M. leprae cannot grow in cell-free cultures Laboratory confirmation requires histopathologic findings consistent with the clinical disease and either skin test reactivity to lepromin (inactivated M. leprae) or observation of acid-fast bacteria in the lesions PCR tests better for detecting lepromatous than tuberculoid (paucibacillary) leprosy.

Mycobacterium leprae pathogenesis

M. leprae is an obligately intracellular bacterial species that persists in host cells (Macrophages, epithelial, and nerve cells) Bacteria multiply very slowly, the incubation period is prolonged, with symptoms developing as long as 20 years after infection Disease severity depend on cell-mediated immunocompetence of host Patients with tuberculoid leprosy (paucibacillary Hansen disease) have a strong cellular immune reaction, with many lymphocytes and granulomas present in the tissues and relatively few bacteria (Less severe) Patients with lepromatous leprosy (multibacillary Hansen disease) have a strong antibody response but a specific defect in the cellular response to M. leprae antigens (More severe)

What is the next radiologic study to diagnosis osteomyelitis?

MRI MRI is not helpful in assessing the response to therapy, as bone marrow edema persists for months after microbiological cure

Diagnosis of dengue fever

Made clinically by symptoms in combination with recent travel history. "Dengue triad" is high fever, rash, headache and other intense pains. Retro-orbital pain is distinctive.

Pentamidine

Mainly used to treat African trypanosomiasis Mechanism: Not well understood. Cross-links A:T rich regions of kinetoplast DNA in trypanosome mitochondria and/or inhibits Type II topoisomerase in trypanosome mitochondria.

Suramin

Mainly used to treat African trypanosomiasis Mechanism: Not well understood. Thought to bind trypanosomal glycolytic proteins to inhibit energy metabolism.

Treatment considerations for osteomyelitis from direct inoculation

Management of open fracture with a short course of antimicrobial prophylaxis to prevent osteomyelitis microbe identification, surgical debridement, and tailored antibiotic therapy The presence of foreign objects, such as fixation devices, requires long term oral antimicrobial therapy until fracture healing and removal of the fixation devices

BSL-4

Max Containment Exotic, High risk agents Life threatening disease Ex. Ebola virus Pathogen type: Dangerous and exotic agents that pose a high risk of aerosol transmitted lab infections and life threatening disease with no treatments Pass-thru autoclave with bioseal required in the lab room

Classic Childhood Exanthems

Measles (First Disease, Rubeola) Scarlet Fever (Second disease; Streptococcus pyogenes) Rubella (Third disease; German measles) Fourth disease (not accepted today, may be related to a Staph infection) Erythema infectiosum (Fifth disease; Parvovirus B19) Roseola infantum (Sixth disease; HHV6 and HHV-7, also called Exanthem subitum)

Three year old girl visited the ED with her grandmother. The girl has had a fever for three days (currently 105 F), conjunctivitis, cough, and coryza. She also complained of "hurting all over" (myalgia). When you examine her mouth you notice white spots on her inner cheeks and roof of her mouth (Koplick's spots). Patient history was significant for a recent trip to England two weeks ago. Grandmother was not sure of her grand-daughter's vaccination history. You send her home with orders of bed rest, plenty of fluids, tylenol, A day later the child has a maculopapular rash that started on her face and is now spreading to the extremities.

Measles aka: Rubeola Note: Koplick's spots are pathonumonic

In osteomyelitis, cure often requires a combination of _________, with debridement of infected and necrotic bone and surrounding soft tissue, as well as accompanying prolonged courses of antibiotics

Medical and surgical intervention

Neisseria meningitidis treatment

Medical emergency -Ceftriaxone (3d Gen. cephalosporin) -Intravenous -Prophylactic treatment to family, heath care workers Ciprofloxacin or rifampin Note: Rif will turn urine and milk reddish orange

Lab test for oral thrush

Microscopy will show large ovoid cells, or filamentous forms Culture usually not needed.

Otitis media

Middle ear infection Often caused by bacteria

Cellulitis signs/symptoms

Mild/moderate pain, tenderness Swelling Erythema (redness) Warmth No extreme toxicity (no systemic signs) Production of gas (fermentation) is possible

What can we do in the case of new pathogens or organisms that are difficult/impossible to grow in pure culture?

Molecular Diagnostics: -High-throughput Genome Sequencing (NextGen Sequencing) (this is an unbiased approach) -Polymerase Chain Reaction (PCR)-based Diagnostics (these are more specific) Note: Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by the SARS-associated coronavirus which was identified using these methods

Type II Necrotizing fasciitis

Monomicrobial, occurs in otherwise healthy people Usually caused by Streptococcus pyogenes (GrA strep: GAS)

Acute Otitis media

More common in toddlers (Peak age 6-18 months) Can be recurrent. Because: -Changing angle of Eustachian tube. -Infants and toddlers, short and horizontal.Poor drainage, organisms trapped (often comes from nose) -Adults longer and angled upward. Babies will tug their ear.

Treatment and immunity of S. aureus or S. epidermiditis

Most all strains are Penicillin-resistant - ß-lactamase Methicillin (Oxacillin is what is tested) -Many of the ß-lactamase-producing strains remain susceptible to methicillin, cloxacillin and cephalosporins Problem: a majority of strains are now methicillin-resistant S. aureus (MRSA) due to mutation PBP2- mecA -Backup treatment- Vancomycin -Zyvox (Oxazolidinones) Immunity is poor. Recurrent infections possible No Vaccine

EBV complications

Most cases of IM are self limited Deaths are very rare

HPV

Most common STI --> estimated annual incidence of sexually transmitted HPV infection in the U.S. is >10 million About 70 million pope currently have a detectable genital HPV infection

Pharyngitis etiology

Most common cause is viral (70-80%). Can be symptom of upper respiratory tract infections Viral pharyngitis seen in all age groups but most common in children.

Non-bullous impetigo

Most common form. Lesions begin as vesicles that rupture. Contents dry to form a honey-colored plaque. Commonly found on the face. Industrialized countries --> S. aureus Developing countries --> Group A Strep

MAC

Mycobacterium avium complex, an AIDS-defining opportunistic infection caused by a group of bacteria during the last stage of severe immune compromise of HIV infection. Symptoms include fever, wasting, and fatigue. MAC is one of the leading causes of death among people infected with HIV. When CD4+ lymphocytes fall below a certain count, patients start to take medications to prevent MAC.

Gas Gangrene

Myonecrosis with gas in tissues caused by Clostridium species (Clostridium perfringens, Clostridium septicum, Clostridium novyi, Clostridium welchii)

Does roseola have a vaccine?

NO

Are most adult bones highly vascular?

NO, except for vertebrae. Therefore, may antibiotics have marginal bone penetration Note: the problem of antibiotic delivery may often be exacerbated by peripheral vascular disease

Is there evidence of immunity for actinomyces?

NO, most infections involving actinomyces are polymicrobic

Should synovial protein and glucose studies be checked?

NO, they are neither specific nor sensitive

Shingle treatment

NSAIDS Aluminum acetate dressings (Burrow's solution) Calamine lotion Acyclovir and Famciclovir (Accelerates healing and reduces severity and duration of pain) Maybe corticosteroids

3 general structures of viruses

Naked capsid virus (genome wrapped in protein) Enveloped virus (pick up lipid bilayer from host) Hybrid (genome is packed by protein with a lipid bilayer)

Although almost any drug may be involved in a drug interaction, the most dangerous or clinically significant interactions involve drugs with these attributes:

Narrow therapeutic index. Side effects that worsen with increasing doses. Side effects that are disabling, permanent, or life threatening. Drugs extensively metabolized in the liver by the CYP450 system of enzymes.

Tularemia pathogenesis

Natural Reservoirs are small to medium size mammals Zoonotic Disease Ticks and deerflies -Hard ticks (Ixodes), also transmit vertically Contact with infected animals -Through a wound, or eye Inadequately cooked game meats- oral Ingestion of contaminated water - oral 1-3 week incubation.......

Pentavalent antimonials adverse effects

Nausea, myalgia, arthralgia, flattening of T-waves on EKG and increases in hepatic transaminases are frequent.

Diagnosis of Staph infections

Neutrophilia Aspirate material from boil Collect Blood culture- Positive in least three out of four bottles Culture on Blood agar, MacConkey, Hektoen, Chocolate ß-hemolytic on blood agar Staph aureus Gram positive cocci, catalase positive, coagulase positive Because toxic shock mimics sepsis, blood cultures may be negative. Must find source of infection.

sequestrum

Necrotic bone which has separated from the healthy bone and distinguishes chronic from acute osteomyelitis Note: new bone can surround the old bone and this walled off sequestrum may be functionally similar to an abscess

Necrotizing fasciitis

Necrotizing Fasciitis (NF) and Gas Gangrene are subtypes of necrotizing soft tissue infections (NSTI). Main difference; NF can start with minimal trauma. Bacteria gain entrance through micro-abrasion of skin (e.g. insect bites). Organism spreads through subcutaneous tissue and deep fascial planes causing death and destruction of fascia and fat without harming skin. Life threatening. Extremely Painful Toxicity Skin can show erythema and tenderness (can start as cellulitis) Can lead to sepsis Myonecrosis (muscle tissue necrosis) can develop. May or may not be gas from fermentation in necrotic muscle.

48 year old female. Fever of 104OF. Lethargic; altered mental status; Heart rate 105 (tachycardic); Respiration 30 (tachypnic); WBC count 15,000/ml (Leukocytosis) BP 85/50 with fluids. (Hypotensive) Petichial rash seen on leg. Blood culture- Gram negative cocci.

Neisseria infection

CMV associated diseases

Normal -Asymptomatic carrier -Mononucleosis (Heterophile Ab negative) Baby of seronegative mother -Cytomegalic inclusion disease AIDS, Immunosuppressed -Multisite symptomatic disease

Transformation (virus infection)

Non-productive infection -Viral proteins cause uncontrolled host cell growth -Virus often integrates into host cell genome (viral oncogenes) Example: Papilloma virus infection of epidermal cells (HPV, Gardasil vaccine, cervical cancer, Michael Douglas)

Suramin pharmacology

Not orally bioavailable. Administered IV or subQ. Serum half-life 40-70 days

Clinical course of infectious mononucleosis

Note: There is a window post infection for atypical lymphocytes and heterophile antibody titer. If the person is latently infected, you will not see these hallmarks Note: can still see IgG using serology though

HIV Treatment

Nucleoside analogue reverse transcriptase inhibitors (NRTI) ex. Azidothymidine (AZT) (Zidovudine/Retrovir) (most of these nucleoside analogues act as a chain terminator by having a 3' H) (not have to be careful on dosing to prevent T cell immune suppression) Non-nucleoside Reverse transcriptase inhibitors (NNRTI) (the usually bind to another portion of the reverse transcriptase and inhibit its activity) Protease inhibitors (PI) (prevents the maturation and formation of functional proteins in the bud) Binding and Fusion inhibitors (small list due to antigenic drift) Integrase Inhibitors (no insertion in the host genome and therefore a provirus is not formed) Highly active antiretroviral therapy (HAART) (uses at least 3 drugs (2 NRTIs and 1 other active) to help prevent the emergence of resistance)

Oral thrush treatment

Nystatin locally is usually effective with an immune-competent host. Fluconazole orally in the other cases

Iodoquinol adverse effects

Occasional rash and GI intolerance. Rarely, optic atrophy, vision loss and peripheral neuropathy with prolonged use ( subacute myelo-optic neuropathy ).

Nucleoprotein (NP)

On the surface of the influenza virus, important in protecting viral RNA

Proton channel (H2)

On the surface of the influenza virus, important in viral uncoating

Human retroviruses subfamily

Oncovirinae (assoicated with cancerasn and neruo disorders) -B ~ Eccentric nucleocapsid core (ex. murine tumor virus) -C~ Central nucleocapsid core (ex. HTLV 1,2,3; can transform T cells) -D~ Cylindrical nucleocapsid core (ex. monkey virus) Lentivirinae (slow disease onset, neuro and immunological disorders, Cylindrical nucleocapsid core) (ex. HIV 1, 2) Spumavirinae (no clinical disease but form foamy cells) (ex. human foamy virus) Endogenous (integrated, inactive inserted in human genome) (makes a lot of the "junk" DNA and has some regulatory capacity)

Inhibition

One drug slows the metabolism of another ex. a drug can be metabolised by cyp450 and prevent the other drug from being metabolised by the same cyp450 St John's wort, for example, should not be used by people taking antiretroviral protease inhibitors because St. John's wort induces metabolism of protease inhibitors, which reduces protease inhibitor blood levels, and makes protease inhibitors ineffective

Induction

One drug speeds the metabolism of another ex. a drug can enhance the activity of cyp450

Hemagglutinin (HA)

One of the enzymes found on the surface of the Influenza virus. It is responsible for binding the virus to the cell that is being infected. Contains VAP and Fusion domains

Neuraminidase (NA)

One of the enzymes found on the surface of the Influenza virus. It promotes the release of progeny viruses from infected cells. Cleaves silica acid to mediate viral release

Albendazole pharmacology

Only 5% absorbed orally, rapidly metabolized in the liver, metabolites are excreted by the kidneys. T1/2=8hr

Typhoid fever symptoms

Onset - Insidious Fever - Gradual rise to high plateau Duration - Several Weeks GI symptoms - Constipation early, watery diarrhea later Lymphocytosis Blood cultures - Positive 1st & 2nd week (Hektoen, MacConkey agars) Stool culture - Positive >2nd week; negative early Rose spots Hepatosplenomegally Elevated liver transaminases

Otoscope findings of otitis media

Opacity Bulging Erythema Middle ear effusion (MEE) Decreased mobility of tympanic membrane with pneumatic otoscope

_____ are effective for treatment of oral mucosal lesions, genital lesions, and keratitis

Oral acyclovir, valacyclovir, famciclovir

Hand, foot, and mouth disease disease stage

Oral lesions (enanthem)- yellow ulcer with red halos Skin lesions (exanthem) on hands, feet, and buttocks Macular to vesicular Note: rash last 3-6 days

HPV benign head and neck tumors

Oral papilloma Not age-specific Laryngeal papilloma (HPV6 & 11) can be obstructive of the airway --> infection usually occurs at birth

Oral thrush

Oral yeast infection Often caused by Candida

Treatment for rhinosinusitis

Oral α adrenergic vasoconstrictors (pseudoephedrine, phenylephrine) Antibiotics for 14 days -Amoxicillin -Clarithromycin -Azithromycin

Streptococcal pyrogenic toxins (SPEs; superantigens)

Organism stays in the pharynx, toxins disseminate Cause: -Fever -Hypotension -Cardiotoxicity -Sometimes a rash - caused by an SPE toxin inducing cytokine release in skin -Scarlet Fever Note: do not require antigen presentation or antibodies to trigger T cell and macrophage crosslinking and activation and causes cytokine release

Transmission of CMV infections

Oropharyngeal Secretions Breast Milk Cervical & Vaginal Secretions Tears Spermatic Fluids Blood Urine Feces

Influenza A structure

Orthomyxovirus -ssRNA genome 8 individual segments (packages 8 individual -ssRNA virions) Note: There are component of the RNA transcriptase/replicase (PB1, PB2, PA) that is necessary to initiate infection

5 month old Michele was brought to her pediatrician because she had been fussy for the past few days. She was not sleeping properly and it seemed like she was trying to tug at her right ear (otalgia). She also had a mild fever of 100.5 OF. The clinician examined Michele's throat, lymph nodes, and eardrums

Otitis media

Oral microbiota

Over 700 Species Many are anaerobes. Found in gingival crevices Affix to teeth- Biofilms called plaque Acid produced by fermentation can demineralize teeth- cavities (caries) Ex: -Streptococcus mutans - highly cariogenic, also found in endocarditis -Streptococcus mitior - less cariogenic, more commonly found in endocarditis

Treatment and prevention for common cold

Over the counter medication for the symptoms The best method of control is washing hands and disinfecting contaminated objects (wipe shopping cart handles)

Ivermectin adverse effects

Overall, well tolerated and adverse effects limited and rare (except for the treatment of onchocerciasis).

fifths disease diagnosis

PCR Serology. IgG and IgM titers CBC will show low reticulocyte count Hemoglobin levels can drop (transient aplastic crisis)

Lab test for Dengue virus

PCR test for dengue virus NS1 gene in blood or rapid solid state ELISA assay for dengue virus NS1 protein in blood can be done within first 5 days of infection. Rapid immunochromatographic tests for anti-dengue virus IgM and IgG can be done after day 10 to day 30 from onset of symptoms. (note: can help to stage the disease)

Ebola and Marburg prevention

PPE! Want to protect eyes and respiratory

Pentavalent antimonials pharmacology

Parenteral administration only, cleared by the kidney, 2 phase elimination with a long T 1/2.

Symptoms of fifths disease in adults

Pericarditis Polyarthropathy (arthritis, usually women) Papular puritic gloves and socks syndrome (PGSS)- adults or children

Disseminated intravascular coagulation

Petichiae are one manifestation Multisystem organ failure Waterhos-Friderichsen syndrome is a catastrophic manifestation: -adrenal hemorrhage -death within hours (often before developing symptoms of meningitis) Seen in fatal meningococcimia

Hennepin interprofessoinal: pharmacists

Pharmacists fill prescriptions and perform medication reconciliation to increase patient understanding and compliance and to reduce medication interactions and duplication.

Jason (7 year old boy) over the past 12 hours has complained of pain when he swallows, has a headache, and has vomited twice. He has no cough. When examined by his pediatrician, Jason's pharynx, tonsils, and uvula are swollen and erythematous (red) and his tonsils are studded with white areas of exudate. He has a fever of 102F and exhibits tender, bilateral cervical lymphadenopathy. CBC reveals leukocytosis. A throat swab was taken.

Pharyngitis

Rubella exanthema

Pinpoint maculopapular rash (less red than measles and less likely to be confluent) thought to be due to cell mediated immune reaction (like measles)

Initial radiographic study for osteomyelitis

Plain film These may show soft-tissue swelling, narrowing or widening of joint spaces, bone destruction, and periosteal reaction

Type I Necrotizing Fasciitis

Polymicrobial, usually seen in immunocompromised patients 55-75% of NF cases Staphylococci Streptococci Enterococci G -ve Enterobacteriaceae (E. coli, Klebsiella, Acinetobacter) Pseudomonas aeruginosa Bacteroides (anaerobic G -ve rod)

Pentamidine pharmacology

Poorly absorbed through intestine, usually given parenterally. Half-life is about 6 hours. Metabolized in liver, secreted by kidneys.

Rubella diagnosis

Post natal infections -Rubella-specific IgM -Rise in IgG (acute vs convalescent sera) -Formerly considered a childhood disease, today 71 % of all cases occur in 15-39 year old patients Congenital Rubella -Diagnosed via positive RT-PCR, anti rubella IgM detection Cases of Postnatal or congenital rubella should be reported to CDC

Bactermia

Presence of bacteria in blood (positive blood culture)

Ebola and Marburg treatment

Previously - No specific treatment: Convalescent serum, interferon, supportive care Now - Monoclonal antibodies (Investigational - New legislation), Vaccines

Shingle diagnosis

Primarily based on history and symptoms Lab test not very helpful Tzanck smear, PCR Direct fluorescent assay

VZV viremia

Primary viremia disseminates virus to liver, spleen, and sensory ganglia. Second viremia leads to infections of capillary endothelial cells and deep dermal epithelia.

Arthrocentesis should be performed _____ to the administration of antibiotics, unless the patient's clinical status does not allow a delay in empiric treatment

Prior

gp160

Proprotein produced by ENV genes of retroviruses and is clipped to produce: -gp120 (Attachment- VAP) -gp41 (Fusion) Note: antibodies will be produced against both of these and can be used diagnostically

p55

Proprotein produced by GAG genes of retroviruses and is clipped to produce: -p17 (Matrix- core) -p24 (Capsid- core) -p15 Note: antibodies will be produced against p24 and can be used diagnostically

p150

Proprotein produced by POL genes of retroviruses and is clipped to produce: -p66 (Reverse transcriptase) -p31 (Integrase)

Viral capsid features

Protect viral genome(nucleic acid) Some viruses are 'naked' Mediate binding to the host cell (Virus Adsorption Proteins - VAPs) note: if the virus has spike proteins, those usually serve as the VAPs

Opportunistic infections of HIV

Protozoan: Pneumocystis carinii (a.k.a. jirovecii) pneumonia [PCP], Toxoplasmosis, Cryptosporidiosis Fungal: Cryptococcus, Candidiasis, Histoplasmosis Mycobacterial: disseminated TB, M. avium [MAC] Latent viral re-activation: HSV, CMV, VZV, JC virus [a polyomavirus that causes Progressive Multifocal Leukoencephalopathy] (immune competent individuals immune system usually are able to keep these in check) Recurrent bacteremia: Salmonella Note: immune competent individual are usually not affected by these!

Assistance ex.

Provide transportation vouchers so that patients can treacle to health care appointments. Vouchers can be used for ride sharing services or public transit

Pustule

Pus-filled raised lesion on the skin, which is usually a result of build up of cellular debris of inflammatory cells, with or without microorganisms, under the epidermis

Once infected and beginning to make virus, it can be detected in the blood by_____

RT-PCR

Francisella tularensis

Rabbit fever (tularemia) Tiny, pleomorphic, poorly staining, slow growing Gram-negative coccobacillus Not motile Needs CYSTEINE to grow Has a LIPID capsule (unique); antiphagocytic Facultative intracellular pathogen of macrophages One of the most infectious agents known -infectious dose 10 to 50 organisms through skin. -oral infectious dose, however, is much higher. Potential bioterrorism agent -considered a select agent by NIH/CDC -Death rate untreated is 10%

Nifurtimox pharmacology

Rapidly absorbed from GI tract. ½ life 3 hours. Metabolized in liver excreted in urine.

Antigenic shift

Re-assortment of RNAs in a cell infected with two (or more) viral subtypes (thanks to segment property of the viruses) Causes the virus to have VERY different HA or NA Major epidemics correspond to re-assortment between human and animal subtypes Note: this usually occurrs within animal reservoirs (these animal viruses can pick up human viral subtypes and allows for the infection of humans that can be deadly because the immune system has never seen it before by MHC molecules)

Praziquantel pharmacology

Readily absorbed orally and rapidly metabolized by the liver. T 1/2 of 1.5 hours, metabolites are excreted by the kidney.

Adjustment ex.

Reduce the need for in person health care appointments by using other options such as tele-health appointments

How do we monitor emerging infectious diseases (surveillance and epidemiology)

Regulatory agencies (e.g. CDC, WHO)

Treatment of Dengue fever

Relief of symptoms — rest, fluids to prevent dehydration, acetaminophen or codeine for pain. Aspirin and NSAIDs (Nonsteroidal anti-inflammatory drugs) should only be given under a physician's supervision because of hemorrhagic complications.

EBV replication

Replication. EBV infects epithelial cells and B cells. Fusion of the viral membrane with host membrane allows entry. Viral capsid dissolves and the viral genome is transported to the nucleus. EBV DNA circularizes in the nucleus and is replicated by host DNA polymerases. This is the latent form of the virus. No virus particles are produced. However, reactivation of the virus triggers lytic replication during which virion particles are produced. Reactivation in vivo probably takes place when latently infected B cells respond to unrelated antigens or infections.]

Transmission of Lyme disease

Reservoir = White-footed mouse, Deer Vector = Ixodes tick (Deer tick) Hard tick Tick vector feeds on infected animal Transmission usually late spring and Summer months No Transmission by Blood Transfusion documented Note: borellia grows in tick digestive tract; after bite the microbe migrates to salivary gland; take 1 to 2 days before ti completes the trop and is deposited into the bite; if tick is properly removed before this the organism is not transmitted)

Streptococcus pyogenes M protein

Responsible for post-streptococcal sequalae: -Rheumatic fever (CVR) -Acute Glomerulonephritis -Autoimmune neurological complications

Integrator

Responsible for realizing the triple aim (reduce cost, improve care, deliver population health) Responsible for linking together health care, public health and social service organizations to promote synchrony and reduce duplication of services

Etiology of rhinitis

Rhinovirus Coronavirus

Rhinovirus

Rhinovirus is most common cause of the common cold. Most common in early fall and late spring in temperate climates. Rhinoviruses are Picornaviruses Small, single strand RNA (plus strand), Non-enveloped viruses (environmentally stable) Rhinovirus is labile to acid pH (exception among picornaviruses, non enveloped viruses are typically resistant to stomach acidity) ... and replicates best at 33 C (92F), so limited to the upper respiratory tract.

Congenital rubella

Rubella virus is one of the few microbes that can cross the placenta to directly infect a fetus for Transplacental transmission. Cataract Heart disease Deafness Infection of mother during first trimester leads to fetal infection 50% of the time. Decreases the later during gestation that a mother is infected. Note: will see blueberry muffin spots

Scalded skin syndrome

S. aureus Exfoliation toxin Organism is present in nose, secretes toxin which disseminates, no organism in the lesions (no pus)

Staphylococci

S. aureus S. epidermidis S. saprophyticus Note: all are catalase positive and exit high salt tolerance

Common causes of septic arthritis

S. aureus is most common pathogen overall Animal bites, particularly from cats, are associated with Pasteurella infection, and human bites with Eikenella corrodens and other human oral flora

Does S. aureus and S. epidermidis have hemolysis?

S. aureus- yes S. epidermidis- no

Yersinia pestis causes____

Select agent Bubonic plague Septicemic Plague Pneumonic Plague

Sepsis

SIRS with a microbial source (bacteria or bacterial toxin)

Patient is a 7 year old male from the gulf coast transported to the ER by ambulance with his distraught mother. The resident notes the boy is extremely exhausted and experiencing chills. Temp was 105F, BP 110/70. pulse 80. History revealed family recently returned from a 3 week stay in Mexico. Child complained of sore throat and headaches for a week. He also complained of mild diarrhea and abdominal tenderness. A rash on the boys stomach was noted (small pink papules). Stool samples revealed lactose fermentors (MacConkey agar). Blood culture revealed a lactose nonfermenting, Gram negative rod.

Salmonellosis

How do you track the source of S. aureus nosocomial infection?

Sample many sources/people and S. aureus typing

Complications of chickenpox

Secondary bacterial infections (impetigo, cellulitis, erysipelas) Disseminated primary varicella infection - immunocompromised; varicella pneumonia (adults) There are more rare secondary complications such as thrombocytopenia, Encephalitis, Reyes syndrome, Guillan-Barre (neuropathy)

GAS treatment

Sensitive to Penicillin 10 day treatment will prevent Rheumatic fever or Single shot, long acting, Penicillin (benzathine penicillin) Rheumatic fever Pts. need lifetime prophylatic Treatment (until 45-50 years old)

Strep throat treatment and prevention

Sensitive to Penicillin (NO resistant strains) 10 day treatment will prevent Rheumatic fever, or Single shot, long acting, Penicillin (benzathine penicillin) Rheumatic fever Pts. need lifetime prophylatic antibiotic treatment (until 45-50 years old) No vaccine

Severe sepsis

Sepsis plus another sign (e.g. decreased urine output, altered mental status, decreased platelets, others)

Toxic shock

Septic shock caused by bacterial exotoxins

Multi-Organ Dysfunction Syndrome (MODS)

Septic shock plus organ failure

Enteric fever

Septicemia caused by S. enterica Cholerasuis (can also infect animals) Incubation - Variable Onset - Abrupt Fever - rapid rise, spike Duration - variable GI symptoms - Often None Blood cultures - Positive during high fever Stool culture - Usually negative Metastatic Infections - bones, joints, meninges, lung, heart

Neisseria meningitidis virulence factors

Serological Groups - Carbohydrate Capsule - NOT IN GC -Types A, B, C, Y, W135- epidemic meningitis; -Capsule prevents phagocytosis and C' mediated bactericidal activity of serum. -We can detect A,C,Y, W135 in CSF -We can also detect B but it's poorly immunogenic and resembles K1 capsule of E. coli N. meningitidis contain pili (attachment) and IgA1 protease (destroys some secretory IgA) Note: we have capsular vaccine for types A, C, Y, and W135

Diagnosis of adenovirus

Serology not useful Indirect immunofluorescence to direct antigens PCR is very good

SIRS

Severe inflammatory response syndrome (may or may not involve infection) 1. temperature above 38C (100.4F) or below 36 (96.8C) 2. heart rate > 90 beats/minute 3. respiration > 20/min or PaCO2 < 32mm Hg 4. leukocyte count > 12,000/mm3, < 4,000/mm3 or > 10% immature (band) cells.

Septic shock

Severe sepsis plus refractory arterial hypotension (doesn't respond to IV fluids)

Tonsillitis symptoms

Severe throat Fever Dysphagia May or may not include an exudate

A 55 year old man visited his physician complaining of fever, not wanting to eat and feeling tired. He has had muscle pain along his back on the right side for the past two days. Upon physical exam, the patient has a swath of tender redness along his ribcage, which contains several painful vesicular lesions. He also had tender, swollen axillary lymph nodes.

Shingles caused by reactivation of the latent VZV

Empiric therapy for osteomyelitis

Should be targeted to the most common pathogens in the clinical scenario. Empiric regimens typically include vancomycin for gram-positive coverage, with a second drug, such as ciprofloxacin, ceftazidime, or cefepime, with activity against Pseudomonas and other gram-negative bacilli. Once culture and susceptibility data are available, empiric therapy should be narrowed as much as possible

Influenza A receptor

Sialic acid (coats glycoproteins)

The clues used to diagnose infectious diseases

Signs Symptoms Lab Test (Tests for specific organisms and serological test) CBC with differential (can be quick and narrow the differential)

Simple vs complex retroviruses

Simple retroviruses encode gag, pol, and env genes. Complex viruses also encode accessory genes (e.g., tat, rev, nef, vif, and vpu for HIV).

Physical findings of osteomyelitis

Sinus tracts, nonhealing wounds and ulcers that probe to bone, and evidence of associated peripheral vascular disease or diabetes. Exam is often unrevealing, especially in hematogenous osteomyelitis of deep sites.

Burn infections

Skin is a major barrier to bacteria. When skin is damaged bacteria can infect underlying tissues. Primary burn wound colonizers: -MRSA (Gram Positive) -Gram negative bacilli ~Acinetobacter baumanni ~Pseudomonas aeruginosa ~Klebsiella pneumoniae All show increasing resistance to antibiotics (remember the ESKAPE pathogens) Fungal pathogens

Actinomyces

Slow growing, Gram positive rods that branch at acute angles Filamentous, resemble fungi in some ways NOT acid-fast Microaerophilic or strictly anaerobic Form characteristic 'molar tooth' colonies on blood agar Endogenous source; are normal inhabitants of the oral cavity, upper respiratory, GI and female genital tracts of humans. Conditions for disease in humans requires displacement into tissues. minor trauma (Dental), surgery, or infection Produce chronic, slowly developing infections

Antigenic drift

Small changes, mutation within one viral subtype This allows for immune response avoidance Note: this mutation occurs during replication

Factor H

Soluble regulator of complement activation, to prevent complement from attacking host cells Has decay accelerating activity on alternative pathway C3 convertase, and cofactor activity for Factor I-mediated C3b cleavage. It normally binds only to host membranes.

Typhoid fever pathogenesis

Source - Contaminated food or water (fecal contamination) Not as resistant to stomach acidity as E. coli or Shigella (Infectious dose is higher) Intestine -Salmonella attaches to M cells in small intestine Peyer's patches, -Injects bacterial proteins into host via Type III secretion

Staphylococcus aureus Infection

Source: Environment, skin, anterior nares G pos cocci direct infection of lymph node Extracellular pathogen Node large, warm, tender with surrounding edema and erythema; localized

Streptococcal Infection, Group A strep

Source: Human throat, skin G pos cocci direct infection of lymph node Extracellular pathogen Node large, warm, tender with surrounding edema and erythema, localized

Borrelia burgdorferi (Lyme disease)

Spirochete (no Gram Reaction) Can be cultured - but very difficult Virulence Factors -Antigenic variation of outer membrane proteins outer surface proteins A, B, C (OspA, -B, -C)- As soon as immune response generated to one type, the organism switches to avoid immune response. Vaccine development unsuccessful

Pneumonic plague

Spread by aerosol (no need for fleas) Pneumonia Dissemination 1-3 days to develop DIC- blackening of skin Nearly 100% fatal Most common person-to-person transmission Note: will hear egophany (say "e" hear "a")

Ebola and Marbug Viruses Transmission

Spread by contact with reservoir or direct contact with patient blood or secretions.

Mononucleosis (Epstein-Barr Virus Infection)

Spread by saliva (Kissing disease) Herpesvirus family (Enveloped DNA virus) infects B cells produce atypical looking lymphocytes Generalized lymphadenopathy- most prominent cervical

Erysipelas

Spreading infection of dermis Group A strep is the usual cause Prondromal symptoms, such as malaise, chills, and high fever about 48h before rash Pruritus, burning, and tenderness are typical complaints Note: lupus butterfly rash is not itchy or tender

Streptococci important species

Streptococcus pyogenes Viridans streptococci- S. mutans Enterococcus faecalis Streptococcus pneumoniae Note: generally considered extracellular pathogens (S. pyogenes can be a facultative intracellular pathogen in macrophages and neutrophils during nectroizing fasciitis)

45 y old pastry chef cut her right forearm with a knife during work. Over the week her right arm became red, swollen and warm at site. 4 days later, developed fever with shaking chills. Presented to emergency room with severe low back pain. Physical exam found temp of 39.4 C (102F), left forearm swollen with area of central softness indicating abscess. Also tenderness to pressure over lower spine. Lab reported high white cell count Gram stain of pus revealed Gram pos. cocci in clusters. X rays of lower spine showed erosion of 3d lumbar vertebra suggesting osteomyelitis. Antibiotic resistance tests showed org. was penicillin-resistant but oxacillin-sensitive.

Staphylocci infection

Neisseria meningitidis pathogenesis

Starts in Nasopharynx- -Asymptomatic most common, 20 % of healthy pop -Transmission- droplet nuclei -Closed populations - military, family, college dorms -Infection usually starts as a sore throat Facultative intracellular pathogens- -Pili attach to columnar epithelial cells in throat -Bacteria enter host cell in a membrane-bound vesicle -Vacuole transcytoses to submucosa. -Occasionally makes it past the epithelium to bloodstream -Meningococcemia

Etiologic agents of otitis media

Streptococcus pneumoniae (there is a vaccine) Haemophilus influenzae type b (there is a vaccine) Non-typeable Haemophilus influenzae - most common cause in vaccinated children Staphylococcus aureus Moraxella catarrhalis (Gram negative coccobacillus) GAS - Group A streptococci (S. pyogenes) Virus -RSV (more of a factor for precipitating bacterial otitis media)

Group D Streptococcus and Enterococcus

Streptococcus bovis (α hemolytic) Enterococcus faecalis (α or non hemolytic) Enterococcus faecium (α or non hemolytic) Normal GI flora Enterococci grow in 6.5% NaCl - S. bovis does not Enterococci are associated with infections of urinary tract, bile tract, sepsis, abdominal abscesses, endocarditis in pts with damaged heart valves.

Treatment for plague

Streptomycin Kanamycin Doxycycline

_________ is a critical element to healing, and revascularization procedures may be necessary as well.

Sufficient vascular supply

Treatment for Hand, foot, and mouth disease

Supportive Check hydration status (capillary refills, urine output. Anorexia and mouth sores can lead to diminished fluid uptake) Can give acetaminophen and topical anesthetics

Chickenpox treatment

Supportive VZ immune globulin (IM) to prevent disease in immune compromised If > 12 years old, you can use acyclovir

Tonsillitis treatment

Supportive (hydration, calorie intact, analgesics) Antibiotics if bacterial (penicillin - 10 days) Possibly Corticosteroids If more than 6 episodes- tonsillectomy

Rubella symptoms

Symptoms mild 1 week before rash, lymphadenopathy of head and neck nodes can develop, LOW GRADE FEVER Rash is Maculopapular; PINPOINT, does not become confluent Lasts 3 days ("3-day measles") Starts on face and progresses quickly from head to foot Rash not as prominent as Measles NO KOPLICK SPOTS

Rubella treatment

Supportive therapy

Treatment and prevention of adenovirus

Supportive therapy In immunocompromised- possibly ribovarin, acyclovir, or IVIG Vaccines have been developed; most disease is due to types 4 and 7; however, risk benefit assessment precludes vaccine use Hand washing and isolation procedures in hospitals can contain spread

Measles treatment

Supportive treatment

Roseola treatment

Supportive treatment Antiseizures mediations not recommended for infants Ganciclovir in bone marrow transplant patients

Treatment and prevention of enteroviruses

Supportive, check hydration status Acetaminophen, topical anesthetics No vaccine

Goal of HIV treatment

Suppress the level of HIV detectible in the blood. Preserve or restore immune function, usually measured by the number of CD4+ lymphocytes. Improve the quality of life. Reduce the number or severity HIV-related illnesses and prolong life.

Latent infection

Suppression of viral replication -Viral genome is present -No virus production, no damage to the host -Virus may re-activate to become productive Example: Herpes virus latent infection of sensory neurons of trigeminal ganglia

Treatment for burn infections

Surgery, antibiotics, and constant monitoring

Cellulitis diagnaosis

Symptomology (mainly) CBC --> Leukocytosis if severe infection C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) --> elevated if severe (inflammation causes high levels of fibrinogen in blood, binds to RB, which aggregate and increase sedimentation rate) Assume GAS unless certain signs are seen - e.g., bullae Bacteriologic labs usually NOT necessary unless purulent material present (severe cellulitis) Blood culture usually NOT necessary unless there are signs of toxicity.

Diagnosis of Gas gangrene

Symptomology plus Labs gives you Necrotizing fasciitis diagnosis Bacteriology -Gram stain of deep wound material -On Blood agar- Double zone of hemolysis -alpha and theta toxins (need anaerobic culture) Fermentation reactions to determine species Early diagnosis of Gas Gangrene critical

Diagnosis of rhinosinusitis

Symptomology, patient history Culture if immunocompromised or unresponsive to therapy CT scan to rule out tumors

Hand, foot, and mouth disease symptoms

Symptoms Most common in children < 5 years old Incubation 4-6 days Prodrome: Low grade fever; malaise; anorexia; abdominal pain; sore mouth Disease stage: Oral lesions (enanthem)- yellow ulcer with red halos Skin lesions (exanthem) on hands, feet and buttocks. Macular to vesicular Rash lasts 3-6 days

Neisseria meningitidis diagnosis

Symptoms plus Neutrophilia Types of samples: -Blood, nasopharyngeal or CSF Cultures Types of Tests: -Culture on BAP, Chocolate agar, Thioglycolate broth -Gram stain, if CSF sediment- Gram Neg diplo in PMNs (also look for Strep pneumo or Haemophilus) -Oxidase Pos colonies - Distinguish Biochemically N. meningitidis and N. gonorrhoeae Group Specific Capsular Antisera - A, C, Y, W135, B Tests are usually done at a Reference Lab - Too dangerous to lab personnel PCR has replaced cultures in many labs

S. Typhi or Cholerasuis diagnosis

Symptoms plus Rose spots for Typhi WBC ranges from leukopenia to leukocytosis (lymphocytosis) ID organism from blood or stool and plate on Hektoen, MacConkey Gram negative rod, lactose negative, H2S positive ELISA - look for antibodies >4 fold rise between acute and convalescent sera

EBV diagnosis

Symptoms: -Mild headache, fatigue, fever -Triad: Lymphadenopathy, splenomegaly, exudative pharyngitis -Other: Hepatitis, ampicillin-induced rash Complete Blood Cell Count -Hyperplasia -Atypical lymphocytes (Downey cells) Heterophile antibody (transient, beings to decrease as virus goes latent) EBV-antigen specific antibody

Clinical syndromes seen in Immunocompromised patients with a adenovirus

Systemic infections Pneumonia and hepatitis

Immunity to M. leprae is _____ mediated

T cell

_____ contributes to the symptoms produced by mononucleosis

T cell response (lymphocytosis)

HIV Lab diagnosis

Test for HIV infection is performed in order to: 1) Identify infection to initiate therapy 2) Identify carriers to limit spread 3) Follow progression of disease 4) Evaluate treatment efficacy Genomic-based Testing -Detecting viral genome load in blood by PCR/RT-PCR Serology -Detection of antibodies to p24, gp41, gp120 -ELISA , Western Blot, and Agglutination tests for antibody titres Immunological Studies -Assess CD4 and CD8 T cell levels

Brucella diagnosis

Take history, lab, course of disease Physical exam revels: fatigue, headache, undulating fever, sweats, joint, muscle, back pains, enlarged spleen or liver Note: for lab, might have normal or low WBC, 4X increase, also PCR 16sRNA can be used to ID

Epstein barr virus latency

The B cells stops proliferating and becomes a LMP-2a-positive memory B cell Virus factor, EBNA-1, is associated with this transition to latency Viral protein, LMP-2a, is now on the surface of the latent cell

Herpes corneal infection

The blood vessels penetrate the infected corner in order to deliver neutrophils to the area, which is normally devoid of blood vessels Major cause of blindness

Actinomycosis

The development of chronic granulomatous lesions that become suppurative and form abscesses connected by sinus tracts Macroscopic colonies called sulfur granules can frequently be seen in the abscesses and sinus tracts Granules appear yellow or orange and are masses of filamentous bacteria

Differential for septic arthritis

The differential diagnosis of septic bacterial arthritis includes rheumatoid arthritis, crystal-induced joint diseases, reactive arthritis, osteoarthritis, trauma, viral arthritis, Lyme disease, and other systemic diseases.

HSV replication step 2

The cell begins to round and there will be nuclear inclusions They will begin making virus gamma proteins are involved in structure and actually generating the virions and packaging

Problems with treating parasitic infections

The drugs are mostly needed for the 3rd World. The drugs are expensive but the target patient population is the least able to afford it. Reinfection with a parasitic disease occurs in endemic areas. Drug resistance is developing in endemic areas. The drugs can have serious side effects. The drugs must be stable, not need refrigeration, and must be given orally.

Primary (acute) HIV infection

The first stage lasts for several months, and most newly infected people have flu-like symptoms within the first month due to a burst of HIV viremia. Destruction of CD4+ lymphocytes begins and continues throughout all future stages.

EBV Serologic testing

The heterophile test is used for the diagnosis of IM in children and adults. In the test for this antibody, human serum is absorbed with guinea pig kidney, and the heterophile titer is defined as the greatest serum dilution that agglutinates sheep, horse, or cow erythrocytes. The heterophile antibody does not interact with EBV proteins. An increase in titer of ≥ four-fold (acute vs convalescent) is diagnostic of acute EBV infection in a patient who has symptoms compatible with IM and atypical lymphocytes. The commercially available monospot test for heterophile antibodies is somewhat more sensitive than the classic heterophile test. The monospot test is 75% sensitive and 90% specific compared with EBV-specific serologies

Shifting the paradigm: from Volume-based to Value-based health care reimbursement

The long standing fee for service paradigm for health care reimbursement rewarded volume of health care (more services = more reimbursement) rather than quality of health care In contrast, value-based reimbursement models incentivize positive results (outcomes) rather than individual procedures and treatments Value = Quality / Cost

_______ has to be addressed in order to realize the final aim of improving population health

The major determinants of health: social and societal characteristics

Cytomegalovirus (CMV)

The most common viral cause of congenital defects Important as a opportunistic pathogen in immunocompromised patients. Suppression of cell-mediated immunity allows recurrence and severe presentation. Many cell types are permissive (e.g. fibroblasts, epithelial cells, macrophages, and others). The virus can establish latency in mononuclear lymphocytes, stromal cells of the bone marrow, and other cells.

Social determinants of health

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

Might there be splenic rupture in IM infections?

The spleen ruptures in <0.5% of cases. Splenic rupture is more common among male than female patients and may manifest as abdominal pain, referred shoulder pain, or hemodynamic compromise.

Smallpox vaccine

The term vaccine came from vaccinia virus, the cause of cowpox Edward Jenner in 1796 noticed that milk maidens never contracted smallpox. But they did contract the milder cowpox disease from the cows. He used scrapings of cowpox pustules to infect others, who were then protected against smallpox. The vaccinia vaccine was used until smallpox was declared eradicated in 1980.

Ebola vaccine

The vaccine contains segments of Ebola virus genetic material from 2 species, Sudan and Zaire. It is delivered by a carrier virus (chimpanzee-derived adenovirus 3) that causes a common cold in chimpanzees but no illness in humans. All volunteers developed antibodies and T-cell responses.

EBV treatment

There is no effective treatment or vaccine Virus is ubiquitous Best to be infected early in life- more benign

Viral replication cycle: Attachment and absorption

These are kind of like two different steps (the virus lingers and attaches, then finds its receptor and is absorbed) The viruses contain VAPs which bind to host receptors and mediate their absorption

Treatment considerations for osteomyelitis from adjacent soft tissue infection

These infections are often polymicrobial Treatment usually requires a combination of broad spectrum antimicrobial treatment and surgical intervention, such as debridement or amputation. Often, revascularization [may be] a critical part of the treatment plan Antimicrobial treatment should be at least 6 weeks

Hennepin interprofessoinal: Housing or Social service navigator

These navigators arrange preferred placement for members with medically complex conditions who are seeking housing. Navigators also function as the interdisciplinary care coordination team's liaison to a variety of social service needs and work directly with members in the community

Viral replication cycle: eclipse phase

This is the stage at which replication, transcription, and translation occurs The host cell is infected but it doesnt look like it! This is because the viral proteins need time to replicate

HSV replication step 3

This is the virus release stage and will see Cowdry Type A inclusion bodies Is released by exocytosis (takes advantage of host exocytotic pathways; will be in an exosomal vesicle that fuses with the cell membrane and is released) Note: if a virion accidentally escapes the nucleus, it can mediate its return to the exocytotic pathway

Emerging Infectious Disease

Those whose incidence in humans has increased in the past 2 decades or threaten to increase in the near future. Control recommendations may not be immediately available

HIV epidemiology

Though to be derived from a simian virus that made the jump into the human population in the 1930s Most prevalent in Africa

What is the reservoir of measles?

Though to be human, there is no animal reservoir

Oral thrush epidemiology

Thrush may be an early sign of HIV infection Children on inhaled steroids also susceptible Can be triggered by recent antibiotic use

2 mechanisms of resistance to second generation antivirals

Thymidine kinase, or in the case of CMV the CMV viral kinase, undergoes mutation so that it no longer phosphorylates the drug. This is the most common resistance mechanism. The DNA polymerase gene undergoes mutation so that the polymerase no longer recognizes the phosphorylated analogs.

EBV specific antibody testing

Titers of IgM and IgG antibodies to viral capsid antigen (VCA) are elevated in the serum of more than 90% of patients at the onset of disease. IgM antibody to VCA is most useful for the diagnosis of acute IM because it is present at elevated titers only during the first 2-3 months of the disease; in contrast, IgG antibody to VCA is usually not useful for diagnosis of IM but is often used to assess past exposure to EBV because it persists for life.

Rubella (german measles)

Togaviridae family Single stranded positive sense RNA, enveloped; cytoplasmic replication; buds through cytoplasmic membrane. POE respiratory Replicates in nasopharyx and neighboring lymph nodes A viremia infects other tissues (not much known)

Eclipse phase: dsDNA viruses

Transcription & Translation: -Viral DNA is transcribed by host RNA polymerase II(in nucleus) dsDNA --> mRNA --> Translated by host ribosomes to produce viral proteins Replication: -Viral DNA replication is dependent upon host cell factors dsDNA--> many new copies of genomic dsDNA

Prevention of burn infections

Topical treatment --> Silver sulfadiazide, Silver nitrate, Mafenide (topical sulfonamide) The clinical diagnosis of wound infection is difficult because symptoms are seen in burn patients with or without infection (fever, leukocytosis, tachycardia, and intermittent temperature spikes) Wound purulence is a reliable indicator of infection only if the purulence is in the subeschar space

Nifurtimox adverse effects

Toxicity is common. Contraindicated in people with severe liver or kidney disease.

HPV pathogenesis

Transmission is mediated by contact with infected surface (towel, sexual contact, etc...) Most genital infections are transient, asymptomatic, and have no clinical consequences (asymptomatic shedding) Note: they are still infectious though! Innate and cell-mediated immunity important for control and resolution Patients will often see resolution followed by reoccurrence (re-activated infection or re-acquired?) Incubation period is unclear (can take 3-4 months for a wart to develop) Note: typically if infected once, you dont have lifelong immunity since there are over 100 different and distinct genomes

Latent herpes simplex virus infection

Travels to the neuron via retrograde transport In sensory neurons microRNA precursors called Latency-associated transcripts (LATs) are produced. These are processed into microRNAs that bind early transcripts and prevent their expression. Note: genes needed for virus replication are not expressed Note: will see viral genome, but no active viruses!

acute necrotizing ulcerative gingivitis

Trench mouth Caused by Fusobacterium, Prevotella and Treponema vincentii

Which ganglion is involved with shingles involving the eye

Trigeminal ganglion

Impetigo diagnsois

Typically done based on clinical appearance and history Culture lesions to identify potential MRSA Acute glomerulonephritis (AGN) is an important post-streptococcal sequellae

CMV pathogenesis

Typically infects monocytes Immunity mediated by T cells. NK cells, and antibody participate in clearing active infection and in maintaining virus in latent state. Thus, impairment of immunity can result in reactivation. In immunosuppressed hosts (AIDS, cancer, transplants), CMV can reactivate from latently infected monocytes at higher frequencies. Virus is then carried by the blood to cause a disseminated infection that can lead to death.

Current structural and policy constraints dictate that the ______ assume responsibility for addressing patients' unmet social needs as a standard component of care.

US health care system

Rubella complications

Uncommon Arthritis (mostly women) Thrombocytopenia Encephalitis

Brucellosis

Undulant fever Zoonotic disease Types: -Brucella abortis (cattle) -Brucella suis (pigs) -Brucella melitensis (goats, sheep) Causes spontaneous abortions Gram negative coccobaccilus Oxidase positive Urease positive Notifiable disease (report to CDC)

Post exposure measle prophylaxis

Uninfected, non-immunized people given vaccine within 72 h of exposure Pregnant or immunocompromised given immune serum globulin

__________may increase the risk of developing chronic conditions, reduce an individual's ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.

Unmet health-related social needs, such as food insecurity and inadequate or unstable housing

How long do heterophile antibodies last?

Up to a year

Paromomycin

Used for Cryptosporidia Mechanism: An aminoglycoside with poor oral absorption. Luminal amoebicide, anticryptosporidiosis and activity against tissue leishmaniasis (? visceral and cutaneous). Unclear mechanism of action. May inhibit parasite protein synthesis.

Pentavalent antimonials

Used for Leishmania Mechanism: Pentavalent antimonials interfere with parasite glycolysis and energy production by blocking phosphorylation of fructose-6-phosphate dehydrogenase in amastigotes. There is a net reduction of ATP and GTP.

Praziquantel (pyranzinoisoquinoline, Biltricide)

Used for Taenia and Schistosoma Mechanism: Exposure to praziquantel increases membrane permeability to mono- and divalent cations, particularly calcium, into the worm tegument, causing small holes and blebs (and makes it susceptible to immune attack). Also causes prolonged parasite muscle contraction and spastic paralysis.

Nifurtimox (nitrofuran)

Used in chronic Chagas Disease (American trypanosomiasis) Mechanism: Efficacy is limited. The drug is reduced to reactive radicals that produce oxygen-free radicals that injure many parasite cellular processes. Mammalian cells are protected by catalase, peroxidases and superoxide dismutase.

Bullous impetigo

Usually caused by S. aureus. Characterized by larger fluid-filled blisters that rupture less easily than non bullous vesicles. Systemic signs of infection such as fever and lymphadenopathy are more likely to occur. The torso is more likely to be affected. Organisms typically present in bullae. Note: the bullae is due to the epidermolytic, or exfoliative, toxin that also causes SSS

Oral thrush diagnosis

Usually clinical. The typical presentation (white plaques) and the context (age) are sufficient to make the diagnosis. Suspicion: -In infant, this is a normal finding not indicative of immunocompromised state unless the disease recurs or if the context is relevant (i.e. a mother with +HIV, inhaled steroid use) -In adult: prior antibiotic use or immunocompromised state is likely

Meningococcemia

Usually in children. Two outcomes: Gradual disease; -Sepsis: fever, petechial rash -joint lesions -Pneumonia -Can progress to meningitis. Fulminating Disease; -highly serum resistant strains, high #s of meningococci in blood, -Endotoxin leads to blood clots due to LOS- TLR4 interaction; -Release of TNFa, which activates clotting factors, clots deposit in tissues (decreased platelet count)

Diagnosis and treatment of Gingivitis/periodontitis

Usually in the dentist domain Cleanse Deep cleaning Topical or oral antibiotics: Penicillin, Clindamycin, Metronidazole Surgery

What are the leukocyte counts for tularemia, bartonella, toxoplasma?

Usually normal or near normal

Treatment for gingivostomatisit

Usually supportive therapy Acyclovir or other antivirals for immunocompromised patients or HSV encephalitis No vaccine

Neisseria meningitidis prevention

Vaccine (Capsule antigen) - Recommended for 11-18 year old kids Targets A,C,Y, W135 - B also available but not a capsule vaccine

Brucella prevention

Vaccine for cattle (live attenuated) Pasteurization Cook meat

___ can be given to people orally when they have frequent genital occurrences for one year or longer.

Valacyclovir Suppresses recurrences by 50%

Symptoms of fifths disease

Very common infection. 50% of children aged 15 are seropositive Outbreaks in late winter or early spring Mild prodrome starts 1 weeks after infection Fever (30% of pts), malaise, headache, myalgia, rhinorrhea 1 week later, bright red rash on cheeks Diffuse maculopapular rash develops, fades to lacy erythematous rash [patients with an aplastic crisis do not have rash] Usually resolves after a week

Tonsillitis etiology

Viral causes: -Herpes -EBV -Cytomegalovirus -Adenovirus -Measles virus Bacterial causes: -Group A Strep Recurrent or chronic tonsillitis is usually a mixed infection that includes anaerobes

Influenza A virus pathogenesis

Virus enters the upper respiratory tract (NA thought to be important to breach protective mucus layer) Kills-off mucus-secreting and ciliated lung epithelial cells to establish infection → promotes bacterial adhesion and secondary infections (pneumonia) Infection leads to inflammatory cell response of mucosal membrane → monocytes and lymphocytes Production of pro-inflammatory cytokines lead to immunopathology (cytokine storm) → Flu-like symptoms (fever, malaise, headache, myalgia, cough, nausea)

Why are old people with shingles dangerous?

Virus is present in the lesions, therefore they can pass it to their unvaccinated children or others (they will present as chickenpox)

Diagnosis of HSV infections

Virus isolation -Cytopathic effect (see lysis of the cells) Direct analysis of a clinical sample -Tzanck smear (a scraping of the base of a lesion will see Cowdry Type A inclusions and smaller more dense nuclei or syncytia) Immunofluoresence staining

HPV cervical cancer diagnosis

Visual inspection Pap-smear -Papanicolaou-stained cervical smears looking for Poikilocytosis (Koilcytosis) Detection of capsid protein Detection of viral nucleic acid

Diagnosis of tularemia

WBC ranges from Normal to high. Isolation from blood is rare. Did they visit endemic areas? Culture difficult; biosafety level 3 Serological -4X increase -single >1:160 DNA techniques

Are there some emerging bacteria?

YES Due to bacterial antibiotic resistance, virulence factors, horizontal gene transfer (accessory shopping), and pathogenesis

How does HPV cause cancer?

We have enzymes that are capable of recombination events between pieces of DNA. This causes the illegitimate integration of HPV viral DNA into the host genome. This can disrupt the normal viral lifecycle and end up with a piece of viral genomic DNA that can make virus anymore This allows for the host cell to not die and produce those E6 and E7 proteins which cause uncontrolled proliferation. This growth can become invasive or even metastatic Note: normally causes lytic infections but recombination of viral DNA into host chromosome can lead to cellular immortalization (transformation) which leads to cancer)

Symptoms

What a patient experiences -Pain -Nausea -Vision

Signs

What you can see or measures -Fever -Sweating -Chills -Rash -Swollen lymph nodes

Lab finds for EBV infection

White blood cell count is usually elevated and peaks at 10,000-20,000/uL during the second or third week of illness. Lymphocytosis is usually demonstrable, with >10% atypical lymphocytes CD8+ T cells predominate among the atypical lymphocytes

Paromomycin adverse effects

With prolonged treatment blood levels can be achieved and with associated nephrotoxicity, ototoxicity and vestibular toxicity. May cause nausea, cramping and diarrhea.

Advocacy ex.

Work to promote policies that fundamentally change the transportation infrastructure within the community

Hennepin interprofessoinal: Emergency medical services (EMS) staff member

Working at the front desk of a homeless shelter, EMS staff assess cases and distinguish those that can be handled through an outpatient appointment or urgent care visit from those that require urgent attention

___________is a recessive disorder of young boys who have a normal response to childhood infections but develop fatal lymphoproliferative disorders after infection with EBV

X-linked lymphoproliferative disease (XLPD)

Are antibody necessary to clear fifths disease

YES

Are most EBV infections in infants and young children either asymptomatic or present as mild pharyngitis with or without tonsillitis?

YES

Can EBV be responsible for lymphoma in immunosuppressed persons and African children in malarial regions (African Burkett's lymphoma) and with nasopharyngeal carcinoma in China?

YES

Can cigarette some cause recurrent otitis media

YES

Can many of the organisms that cause lymphoctyosis or monocytosis also develop into neutropenia?

YES

Can skin HPV strains produce cancerous lesions in immunocompromised individuals?

YES

Can you have glandular disease without cutaneous lesion?

YES

Do adenoviruses resists drying, detergents, mild chlorine treatment (swimming pools)

YES

Does HIV cause lymphadenitis?

YES

Does HPV have a small icosahedral capsid virion?

YES

Does sporotrichosis (Sporothrix schenkii) cause lymphadenitis?

YES

During Epstein barr virus infection, do T cells kill and limit B cell outgrowth?

YES

Is HIV an enviromently unstable virus?

YES

Is an early symptom of EBV severe sore throat?

YES

When B cells are infected by EBV in vitro, can they become transformed and can proliferate indefinitely?

YES

Can fifths disease lead to hydrops fetalis?

YES Accumulation of fluid in fetal extravascular compartments Condition stems from fetal anemia High output cardiac failure leads to fluid accumulation. Treat with blood transfusions in womb

Will tonsillitis may or may not include pharyngitis?

YES And pharyngitis may or may not include tonsillitis

Can acute trauma associated osteomyelitis often go undiagnosed?

YES As untreated acute osteomyelitis progresses to chronic osteomyelitis, signs and symptoms indicative of chronic osteomyelitis, such as fracture nonunion, poor wound healing, and sinus tract formation, may appear. Plain radiographs are often unhelpful

Do viruses cover a wide range of sizes and structural diversity?

YES Note: they are much smaller than bacteria and are filterable

Is pus with strep more fluid than with staph

YES Staph coagulase increases viscosity

Does the US have a high mortality from diseases amendable to health care?

YES They showed the least decrease in mortality from diseases amenable to health care in the decade from 2004 to 2014

Do warts spontaneously regress?

YES Though they may be removed or treated because of pain, discomfort, or cosmetic reasons

Do many viral diseases have a prodromal phase (prodrome) that mimics pharyngitis or a cold?

YES e.x. measles, mumps, chickenpox, EBV, CMV, coxsackievirus

Does measles infection cause immunosuppression?

Yes Secondary infectious possible (bronchopneumonia)

Does VZV go latent?

Yes, becomes latent in the dorsal root ganglia

Should lyme disease be considered for when thinking of septic arthritis?

Yes, in patients from endemic areas with evidence of inflammatory arthritis but negative Gram stain and culture.

Can HSV interfere with MHC I presentation of antigen?

Yes, it can interfere with TAP transporter

Is Variola major a bioterrism agent

Yes, it could be. US and Russia are the only places with it

Do most EBV patients treated with ampicillin develop a macular rash?

Yes, it is not predictive of future adverse reactions to penicillins

Are children lymph nodes more active than those of adults?

Yes, they easily swell They often feel like "buckshot" in children following viral infection- "shotty" nodes

Zika virus

Zika is spread mostly by the bite of an infected Aedes species mosquito (A. aegypti and A. albopictus). These mosquitoes bite during the day and night. Zika can be passed from a pregnant woman to the fetus (Vertical Transmission). Infection during pregnancy can cause certain birth defects such as microcephaly. Also transmitted by sexual contact There is no vaccine for Zika. Local mosquito-borne Zika virus transmission has been reported in the continental United States. Suspected to be due to sexual transmission.

Bacillus anthracis transmission

Zoonotic disease- dead infected animal contaminate soil -infected cut -inhale spores -ingest spores Note: potential bioterrosim agent

Reservoir of Ebola and Marburg viruses

Zoonotic- Non human primates; bats

Koch's postulates

a sequence of experimental steps for directly relating a specific microbe to a specific disease 1.Identify a specific organism associated with all diseases cases 2.Obtain a pure culture of that organism (clonal isolation) 3. Reproduce the disease in experimental animals using pure culture and look at symptoms, etc. 4. Recover the organism from the infected animals.

Swollen nodes also may be caused by___

accumulation of inflammatory cells in response to an infection in the node (lymphadenitis) Neoplastic lymphocyte or macrophages (lymphoma) Metabolite-laden macrophages in storage disease (Gaucher disease)

Social care

activities that address health-related social risk factors and social needs, should be integrated into health care delivery

Pneumocystis carinii pneumonia (PCP)

an AIDS-defining opportunistic infection caused by a protozoan during the last stage of severe immune compromise of HIV infection. Symptoms include fever, shortness of breath, and a dry cough. When CD4+ lymphocytes fall below a certain count, patients start to take medications to prevent PCP.

replicase

an enzyme that catalyzes the synthesis of a complementary RNA molecule using an RNA template.

Hetrophile antibodies

antibodies that react across species lines. B cells infected with EBV start making high levels of the antibody they were programmed to make. Because many different B cells with diverse Ag specificities are indiscriminately infected by EBV, the antibodies to many different antigens are over produced. Some of those antibodies react with horse red blood cell antigens. These are the heterophile antigens screened by the monospot test.

For remote sequellae of S. pyogenes infections, like Rheumatic fever (cardiac) or Acute glomerulonephritis (kidney), the organism is no longer present in the throat. However, a high ________ provides evidence of previous strep infection and supports a diagnosis of RF or AGN

antistreptolysin O titer

Expenditures in the US healthcare system mostly address ______

biological and medical care factors, but those account for only 24% of the determinants of health

Rapid Plasma Reagin (RPR)

blood test for syphilis

Furuncle

boil (presence of pus and raised red surface)

Treatment of bacillus anthracis

ciprofloxcin or doxycycline Could use antiserum against toxin for septic anthrax

EBV is spread via____

contact with oral secretions The virus is frequently transmitted form asymptomatic adults to infants and among young adults by transfer of saliva during kissing Note: transmission by less intimate contact is rare More than 90% of asymptomatic seropositive individuals shed the virus in oropharyngeal secretions

Tertiary stage of lyme disease

crippling arthritis chronic neurologic complications. Few organisms isolated- May be due to overactive immune response (Persistent infection or autoimmunity?) Lasts for months to years

_____ is a major predisposing factor for necrotizing fasciitis

diabetes

risk factor for osteomyelitis

diabetes, vascular disease, intravenous drug use, and recent trauma or surgery

EBV infections are most common in ___

early childhood By adulthood, more than 90% of individuals have been infected and have antibodies to the virus Infectious mononucleosis is usually a disease of young adults (in areas with higher standards of hygiene)

Physical exam for osteomyelitis from adjacent soft tissue infection

evaluation of pulses and Doppler ultrasound measurement of vascular flow, as well as characterization of neuropathy. If necessary, a more detailed evaluation including arteriography and nerve conduction studies could be considered

Vesicle

forms via accumulation of fluid under the epidermis

What is the receptor for parvovirus 19?

globoside, which is also on endothelium, lung, heart, kidney, gut.

S. enterica serotype Typhimurium causes __

gastroenteritis

Brucellosis (Brucella)

get through ingestion G Neg rod facultative intracellular macrophages disseminate infection lymph nodes enlarge; Generalized lymphadenopathy

Salmonella typhi infection

get through ingestion G Neg rod facultative intracellular macrophages disseminate infection lymph nodes enlarge; Generalized lymphadenopathy

For genital HSV infections, treatment is beneficial in first out break if ___

given early Self-initiate: Give patients prescriptions so they can treat themselves at the first "tingle" of new outbreak

Cytomegalovirus Infection

human herpevirus family (Enveloped DNA virus) spread by contact with body fluids (saliva, blood, milk etc.) can cause a mononucleosis type disease, Generalized lymphadenopathy

Rubella reservoir

humans, no animal reservoir

sensitivity

if a patient has the disease, how often will the test be postive

specificity

if the patient doesnt have the diseases, how often will the test be negative

Where does EBV replicate

in the nucleus (dsDNA virus)

Necrotizing fasciitis is most often caused by ___

invasive Group A Strep- M1T1 antigenic type They produce: -SpeA --> superantigen toxin -High levels of stretodornase --> Easily escape NETs -High levels of streptokinase--> action helps degrade fibrin All of these facilities dissemination through tissues

What geen is responsible for methicillin resistance?

mecA Can be ID with PCR

Leukocytosis is mediated by ___

molecules realsed or unregulated in response to stimulatory events (ex. growth or survival factors, adhesion molecules, and various cytokines) Note: cells are related form bone marrow into circulation

Most cases of vertebral osteomyelitis are _____

mono microbial, with the most common pathogen being S. aureus

Acute bacterial septic arthritis results in _______

most rapid joint destruction, and it is primarily for this reason that the joint must undergo prompt evaluation

EBV is associated with several human tumors, including____

nasopharyngeal carcinoma (common in china) Burkitts lymphoma (About 15% of cases of Burkitt's lymphoma in the United States and 90% of those in Africa are associated with EBV) Hodgkins disease (The risk of EBV-positive Hodgkin's disease is significantly increased in young adults after EBV-seropositive IM. About 50% of non-Hodgkin's lymphomas in patients with AIDS are EBV-positive.) In immunodeficient patients, B cell lymphoma

Where does VZV replicate

nasopharyx and regional lymph nodes.

A woman camping with her children suffered a minor cut on her finger and injured the left side of her body while playing sports. Two days later, she had vomiting, diarrhea, and a fever. Her side had started to bruise (the skin did not look broken) and was severely painful. The next day she was breathing with difficulty and could not see. Her side began to leak fluid and blood. She was admitted with septic shock and no detectable blood pressure. Administered vasopressors to increase blood pressure. An ID doc diagnosed necrotizing fasciitis, and she was rushed into surgery. 7% of her body surface was removed. Continued use of vasopressors caused gangrene in her fingers and lower extremities. After nearly three months and several operations, including amputation. The patient recovered.

necrotizing fasciitis

____ protein is associated with progression to "full blown aids"

nef

Group B strepococcus causes____

neonatal sepsis and meningitis (S. agalactiae)

Social determinants of health are an underlying cause of today's major societal health dilemmas including:

obesity, heart disease, diabetes, and depression.

Proproteins produced in most retroviruses

p55 p150 gp160

Wuchereria bancrofti

parasite that blocks lymphatics and causes elephantiasis

Infectious disease that cause Eosinophilia

parasitic infections asthma/allergic drug reactions malignancies autoimmune

Toxoplasmosis (Toxoplasma gondii)

protozoan; ingestion Source: cat feces; improperly cooked meats; mothers can transmit the protozoan to their fetus form tissue cysts that can lie dormant in brains for years immunocompromised can exhibit serious reactivation infection such as encephalitis Most immunocompetent humans are infected without symptoms. Some get a lymphadenopathy with primary infections. Usually cervical but can be generalized. Note: also liked to schizophrenia

The most important risk factor for the development of septic arthritis is

preexisting joint disease Systemic illness and other conditions, such as immunosuppression, diabetes mellitus, renal and liver insufficiency, and intravenous drug abuse, also predispose to septic arthritis a history of skin lesions should be noted. Rheumatoid arthritis places individuals at particularly high risk through the combination of joint damage, immunosuppressive medications, and poor skin quality.

Folliculitis

presence of inflammatory cells within the hair follicle

The evolution of dengue fever into dengue hemorrhagic fever is potentiated by ______

previous infection with a different serotype of dengue virus because of cross-reactive antibodies induced by the first infection. The non-neutralizing antibodies will opsonize the virus and potentiate its uptake by macrophages, thus promoting infection. This phenomenon has hindered vaccine development.

What causes enlarged lymphoid tissue in EBV during IM?

proliferation and expansion

FInal morphogenesis of mature HIV requires___

protease cleavage of gag and gag-pol polypeptides after envelopment

Tularemia (Francisella tularensis)

rabbit fever Wound, ingestion, ocular; G neg rod facultative intracellular Macrophages disseminate Generalized lymphadenopathy

Papule

raised because of the accumulation of material, infectious or otherwise, in the dermis (no fluid)

Exanthems

rash

S. enterica serotype Choleraesuis

septicemia (enteric fever)

Rigors

shaking because of high fever Due to cytokine and prostaglandin release

Serum studies for septic arthritis

should include blood cultures, peripheral white blood cell count with differential, and inflammatory markers ESR and CRP These can help track response to treatment

The source of bacteremia causing hematogenous osteomyelitis may include:

skin and soft tissue infections, urinary tract infections, dental abscesses, and central venous catheter-associated infections, but it is often unidentified.

The viral capsid is make up of:

specific proteins encoded by the viral genome Note: some know how to make higher order structures and can make geometrical shapes

How is adenovirus transmitted

spread by aerosol, close contact, or fecal-oral means

Enterovirus (eg. Coxackievirus a Picornavirus (small RNA))

ss (+) sense RNA virus, Non-Enveloped; replicates in cytoplasm Transmitted by fecal-oral, aerosol routes Group A infects skin and mucous membranes (herpangina; hand, foot and mouth disease) and can cause severe pharyngitis. -Herpangina: high fever, coryza, anorexia, sometime headache, enathem, exanthem -Hand, foot and mouth disease: low grade fever, malaise and rash on hands and feet Group B infects heart (Myocarditis), pleura (pleurodynia), and liver (hepatitis). Seen more in children Lab test unnecessary

Common organisms involved in osteomyelitis from direct inoculation

staphylococci, gram-negative bacilli, and other skin flora and soil organisms If they have multiple surgeries, they may be at risk for nosocomial pathogens as well

About 10% of patients with IM develop _______ after their initial sore throat resolves.

streptococcal pharyngitis

S. bovis causes ____

subacute bacterial endocarditis - Amp/Pen treatment

Therapy for IM consists of ___

supportive measures, with rest and analgesia

fifths disease treatment

supportive treatment Patients with anemia: -uses IVIG -transfusion

Clinical presentation of septic arthritis

swollen, painful joint with limited range of motion. Typical features of infection, including fever and leukocytosis, are frequently absent Monoarticular arthritis involvement of the joints of the feet usually arises with progression of contiguous soft tissue infection or osteomyelitis, as commonly observed in patients with diabetes and vascular insufficiency Polyarticular arthritis is more common among patients with impaired immunity, and with gonococcal, pneumococcal, group B streptococcal, and Gram-negative infection.

Chronic diseases and obesity are on the rise, As well as ________

the cost of health care

Population health

the health outcomes of a group of individuals, including the distribution of such outcomes within the group (emphasizes health outcomes rather than processes of care) Note: the US health care system doesn't fare well when evaluated from a population health perspective

The transcription of the genome of human retroviruses is regulated by___

the interaction of host transcription factors with promoter and enhancer elements in the long terminal repeat (LRT) portion of the genome

Viral Tropism

the spectrum of cells of a host that a virus may infect Most have defined host ranges and defined cell types Note: most of these are mediated by VAP and receptor interactions Note: can also include tropism at the level of if there are factors needed for replication are present

Factors that influence the establishment and progression of osteomyelitis include______

virulence of the pathogen, inoculum size, characteristics of the involved bone, presence of foreign objects, host immune system, and duration of infection.

While health care organizations may not be equipped to address each of the root causes of their patients' conditions, they need to broaden their perspective on how to address social determinants of health and___________.

use their expertise to influence initiatives on education, housing, employment, and other important health related social issues that take place beyond their immediate clinical purview. Health systems need to look at underwriting community efforts to improve health, looking creatively at what the health system can do. Can a health care system have hiring programs, for example, that are part of the solution for underemployment in the community?

Iodoquinol

used for Giardia Mechanism: Luminal amoebicide and unknown mechanism of action. Intracellular accumulation may intercalate DNA and disrupt synthesis.

Over time, as bone infection becomes chronic, suppuration leads to:

vascular congestion, raised intraosseous pressure, and ischemia of infected bone

The rash of smallpox starts at ______

vesicular rash and processes to a pustular rash

How is the measles virus shed

via nasopharynx (respiratory droplets)

Rubella transmission

via respiratory secretions

A 25 year old presents with ill feeling, painful gums and mouth for 2 days and getting worse. The Physical examination shows: 1.Short onset, some systemic signs 2. Worsening 3. Ulcers on the lips and base of the tongue

viral etiology, most likely

The persistence of soft tissue inflammation and ulceration for a ______ should raise suspicion

week or longer

International disease

• Entamoeba histolytica • Malaria • Toxoplasma gondii • Leishmania • Trypanosoma cruzi • Ascaris lumbricoides • Hookworm • Trichuris trichiura • Strongyloides • Enterobius vermicularis Note: international travel has increased dramatically

Common exposure risk to parasitic infections

• Travel to endemic areas • Military/paramilitary • High risk travel: rural travel, off-the beaten path, camping or roughing it, indulging in local cuisine. • Eating undercooked foods and contaminated water • Day care exposure • Immunocompromised