MMD Exam II
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Inflammation that can develop around the meninges
Inflammation taht can develop around the meninges and the brain parenchyma
Meningitis caused by a viral or fungal or noninfectious eitiology
Bacterial meningitis pathogen that is more common in elderly
What are the most common bacterial that cause acute bacterial meningitis?
- Strep pneumo
- neisseria meningitides
- listeria monocytogenes
What are some risk factors for developing bacterial meningtitis?
- Less than 50 y.o.
- Otitis media
- head trauma
- recent neurosurgery
- crowded living conditions
- lack of immunization
Pts with asplenia are more suseptible to what type of organism
What is the "classic" triad of meningitis symptoms?
Fever, Headache, neck stiffness
AMS in a pt with meningitis suggests what about the disease?
it indicates elevated ICP secondary to meningoencephalitic inflammation and cerebral edema or possibly delerium secondary to fever
Pt presents with HA that is accompanied by NV and photophobia. What two diagnoses are top on your differential? How does it change if the pt has Fever and nuchal ridgity?
- Meningitis and Migrains
- Meningitis is more likely with fever and or nuchal ridgidity
In a pt with meningitis, seizures are pathopneumonic for what?
Which meningitis causing bacteria is associated with a petechial rash?
What two PE tests can you use to test for nuchal ridgidity?
Kernig and Burdzinski
Anisocoria is a deficit of cranial nerve __ found in some cases of ___
- Cranial nerve 3
decerebrate posturing associated with a worse prognosis than decorticate
decorticate, more common posturing in unconcious patients and associated with a better prognosis
- Kernig (Above)
- Brudzinki (below)
- specific but non-sensitive tests for meningitis
18 y.o. pt presents with HA, diffuse HA and photophobia. He is an exchange student who recently came to the U.S. and is living in a frat house with 10 other guys. You note moderate fever, no nuchal ridgidity and anisocoria on exam however no other findings. What does your pt have?
Meningitis. It could be a migraine from the first part, but the fact that he is foreign means he possibly has not been vaccinated, and he lives in a crowded living condition. He does not have nuchal ridgidity but the anisocoria is a focal neurologic defect suggesting it is more than an a headache. The fever suggests infective eitiology.
You believe your pt may have bacterial meningitis IN ORDER! what exams/treatments will you initiate next?
- Draw blood cultures
- IMMEDIATLY start IV emperic ABX
- SIMULTANEOUSLY! administer dexamethasone
- Labs: CBC, Chem 7, lactate, ESR/CRP
- If they have a contraindication to LP do a CT if not proceed directly to LP
What are 3 signs you would see on PE that suggest elevated ICP?
- Dolls eyes
- Posturing: decerebrate and decorticate
In a meningitis patient what does their lactate level tell you?
- predictor of mortality in pts with infection as a sourrogate marker for tissue perfusion
- >4 is associated with a 22% mortality in 3 days
Name the conditions where you would do a CT before an LP in a case of meningitis (7)
- Abnormal mental status
- Seizure within 1 wk of presentation
- known CNS lesion/disease
- focal neuro findings on exam
CSF finding of WBCs 100-5,000, decreased glucose and increased protein is suggestive of ___ meningitis
CSF finding of WBCs 10-500, lymphocytic, glucose normal and protein elevated is suggestive of ___ meningitis
CSF findings of WBCs 0-500, lymphocytic, glucose normal or decreased, and protein elevated is suggestive of __ or __ meningtitis
Fungal or Tuberculous
What two conditions will elevate RBCs in the CSF?
encephalitits and sub arachnoid hem.
After you give IV abx to a pt with acute bacterial meningtitis you have a _-_ hour time window to get an LP because...
- 2-4 hour
- because the antibiotics will cause CSF steriliztion and will affect the gram stain and culture
Is LP opening pressure increased, decreased or the same in pts with meningitis?
What two sites do you perform and LP at ?
What are 4 findings on head CT that would contraindicate LP??
- Lateral shift in midline structures (unequal supratentorial ICP)
- Loss of suprachiasmatic and basilar cisterns (supratentorial pressure greater than infratentorial pressure)
- Obliteriation/shift of the 4th ventricle (increase posterior fossa pressure)
- obliteration of the superior cerebellar systerns (upward cerebellar transtentorial herniation)
What would you add to an empiric antibiotic regimine for a pt who also had elevated ICP?
- mild hyperventilation
- neurosurgical consult
- hypertonic saline especially with kids
What can you use to lower ICP in kids
ABM in pts who are age 16-50 the 3 most common organisms are
N. meningitides, S. pneumoniae, and H. influenza
For pts with ABM who are over age 50 the most common organiams are
S. pneumonia, N. meningitides, Listeria monocytogenes, and aerobid GN bacilli
For Immunocompromised pts the most common pathogens of ABM are
Listeria monocytogenes, aerobid GN bacilli, S. pneumoniae and N. meningitides
For pts with recent neurosurgery the most common ABM pathogens are...
stalphylococci, aerobid GN bacilli and S. pneumoniae
The Tx for ABM pts age 16-50 is...
- Vancomycin, AND a 3rd generation cephalosporin
- and dexamethazone
Tx for ABM pts age 50+ is ..
- Vancomycin AND a 3rd generation cephalosporin and ampicillin
- (and dexamethazone)
Tx for ABM pts with immunocompromise is...
Vancomycin and a 3rd generation cephalosporin and ampicililn
Tx for an ABM in a pt with Hx of recent neurosurgery or brain trauma is...
Vancomycin, 3rd generation cephalosporin with antipseudomonal or meropenem
What is the most common cause of viral meningitis?
How is enterovirus spread?
contact of respiratory secretions or fecal oral contact as with those who change baby diapers
What time of the year are most viral meningitis cases?
early fall or summer
What are some medications that can cause aseptic meningitis?
What are some systemic disease that can lead to aseptic meningitis?
- Wegener granulomatosis
- Multiple sclerosis
What is your treatment plan for a pt whom you supect has viral meningitis?
- Admit and treat with IV ABX with CSF culture
- If cultures show aseptic eitiology at 24 hrs pts can be discharged home IF they do not live alone
- pt should have a follow up in 24 -48 hours
inflammation of the parenchyma of the brain resulting from direct viral invasion or a hypersensitivity reaction to a virus or another foreign protein several weeks after exposure
Inflammation of the brain and nerve roots
Describe the mechanism of secondary encephalitis
- post infectious hypersensitivity reaction.
- immunologic complication of a viral infection or vaccine
- usually 1-3 wks post illness
- Dx with CSF PCR to rule out active illness
The most common anteceedent illness for secondary encephalitis is
- Measles is number 1 worldwide
What is the most common viral cause of encephalitis?
HSV 1 and 2
What is the most severe herpetic cause of encephalitis?
HSV 1 and 2
What are the herpetic viruses that cause encephalitis? (4)
HSV, VZV, EBV, CMV
What are the enteroviruses that can cause encephalitis?
group of viruses transmitted by bloodsucking vector usually and insect. The group includes, La Crosse, St. Louis, Easter Equine, Japanese, West nile and western equine
Toxoplasmosis can cause encephalitis in what two pt groups?
immunocompromised and pregnant
Cysticerosi is spread by...
pork tapeworm eggs
Toxoplasmosis is transmitted by
cat fecal matter
The only tick borne encephalopathy is...
Powassan virus found in the US and Canada
"Ice pick headache"
"Throbbing" or "pulsating" headache
"worst headache of my life"
What are some warning signs that a headache may need neuroimaging?
- Worst headache ever
- worsening over days
- wakes from sleep
- aggravated by exertion or valsalva
- Age >50 first time onset
- abnormal neurologic exam
- cluter type headache that is unilateral
What are 4 causes of subacute headache
- giant cell arteritis
- brain tumor
- pseudomotor cerebri
- trigeminal neuralgia (post herpetic neuralgia)
A ___ headache occurs over a period of months to years and is more likely a benign cause
Name some of the pain sensitive structures in the head
- periosteum of the skull
- subcutaneous tissue
- muscles and arteries
- neck muscles
- 2nd and 3rd cranial nerves
- ears, eyes, teeth, sinuses
- oropharynx and mucous membranes of the nasal cavity
76 y.o. F presents with headach x4 wks. She states that she notices the headache most with her morning cup of tea. She states it usually has an aura type component and that she has never had headaches except occasional "little ones" her whole life. She is presenting to you today because she says the headache got alot worse this morning while she was having a BM. Her PMH is significant for HTN, Malignant melanoma 2 yrs ago, and being prediabetic. What do you suspect is causing your pts headache? what is your next step?
- Cancer metastasis of malignant melanoma
- neuroimaging to confirm tumor
What proceedure should you avoid on a pt who you suspect has a brain tumor?
LP, the tumor leads to increased CSF and pressure. LP can cause herniatin which will lead to irreversible damage or death from the change in CSF
What might you find on the PE of a pt with a brain tumor?
- Neurological deficits
What is the other name for pseudomotor cerebri
Idiopathic intracranial hypertension
Headache that is caused by idiopathic incresae in ICP that can compress cranial nerves making focal neurological deficits
Idiopathic intracranial Hypertension
45 y.o. F presents with diffuse generalized headache that is worse with straining. She states that the also has nausea and ringing/swooshing sound in her ears. She became concerned and came to see you because she noticed a facial droop and strange eye movements in the mirror this morning. Her PMH is unremarkable except for obesity and prediabetes. On PE you note CN 7 deficit and CN 3 deficit. You suspect her headache is....
Idiopathic intracranial hypertension
CN deficit where the eye pulls outward to the side causing horizontal double vision which is worse on the affected side
Cranial nerve lesion that causes strange eye movements
CN3 and CN4 oculomotor and abducens
CN lesion that causes total or partial weakness of the muscles of the facial expression on one or both sides of the face
CN 7 facial
Papilledema is a sign of what?
Sx of Idiopathic intracranial hypertension include...
diffuse generalized headache that is worse with straining, nausea is common, pulsatile tinnitus, incoordination and neurological deficits.
What diagnostic tests should you perform for a pt whom you suspect has idiopathic intracranial hypertension?
- MRI or CT to rule out mass
- elevated CSF pressure tx with LP drainage
What is the treatment for Idiopathic intracranial hypertension?
- LP drainage
- Acetazolamide or Lasix to diurese the extra fluid out of the brain
pt has pain along the nose cheek and eye. It is exacerbated by any type of touch or change in temperature. pt has a positive PMH of shingles. pt describes the pain as a pinprick sensation and has a decreased ability to blink on corneal reflex test. What do you suspect and how do you treat?
- Post herpetic neuralgia
- Lidocaine, capsaicin
- prevention of herpetic outbreak with acyclovir
- Sx usually subside 6-12 months later
How long before post herpetic neuralgia symptoms subside?
What is the treatment for post herpetic neuralgia?
- prevention of disease by treating herpetic outbreaks with acyclovir
"tic douloruex" is more commonly called...
Who gets trigeminal neuralgia more men or women?
What is the pathogenesis/eitiology of trigeminal neuralgia?
- microvascular compression of the CN V
- loop of artery or vein typically is pressing on the trigeminal nerve and causes demyelination of teh trigeminal which is felt as severe pain in this nerve distribution
Excruciationg "lancinating" pain over the lower 2/3 of the face... dx?
T or F the physical exam of a pt with Trigeminal neuralgia is normal except for pain
What is the treatment/prognosis for Trigeminal neuralgia?
- Most cases spontaneously recover on their own
Who is more likely to get migrains men or women?
T or F migraines tend to run in families
What are some migraine triggers?
- visual stimuli
- weather changes
What does the acronym POUND stand for?
- Migraine symptoms
- P: pulsitile
- O: onset/duration of 4-72 hours
- U: unilateral in location
- N: nausea and vomiting
- D: diabling in intensity heachache is severe
Pt is a 30 y.o. F who presents with pulsitile, unilateral headache that has nausea and vomiting. She states that it happens once or twice a month and is usually around the beginning or end of her period. She cannot tolerate loud noises or light when she has the headache. She has no papilledema on exam and no focal neurological or visual defects, she denies and aura, or use of caffine or analgesics other than her morning cup of tea. What do you think she has?
Is imaging nessisary with typical migraine symptoms?
no especially if it has been a chronic problem at the time they are seen.
What is the treatment for migraines?
- simple analgesics: acetaminophen, NSAIDs, ASA with caffine, midrin, etc
- 5HT agonists: triptans nasal spray or PO, work best if initatied early on
- Ergot Preparations
- Prophylaxis for those who have recurrent attacks
What are some contraindications to perscribing 5HT agonists for migraines
avoid in pts with ischemic stroke, CAD, uncontrolled HTN, pregnancy, and prinzmetals agina
Why are 5 HT agonists superior to NSAIDs for the treatment of migraines?
- they are specific to headache
- they block the pain pathways in teh brainstem and inhibit dural nocioception
How should you start 5HT therapy for a pt with migraines?
Administer the first dose in practice to men over 40 and women past menopaus or those with HTN or diabetes
How do Ergot preparations work?
they bind to the 5HT receptor 1b and 1d just like the 5HTs do
What are some contraindications to using Ergot preparations?
cardiac disease and pregnancy
What are some SEs of Ergot preparations?
NV, and rebound HA so don't exceed recommended dose
Name an anitemetic you might use to help treat a migraine
- IV metoclopramide
- IV or IM chlorpromazine or prochlorperazine
What can you use to prophylax a pt who has frequent recurrant migraines?
- Antihypertensive: propanalol especially
- avoid triggers
What are some contraindications for using a Beta blocker for Headache prophylaxis?
pts over 60 who smoke, have PAD, ED, raynolds, baseline bradycardia or low BP, asthma, diabetes, SA node dysfunction
a 24 y.o. F PA student presents during her spring break with cc headache. She looks and feels very ill. She is completely healthy and her Hx is only remarkable for the fact that she does not sleep well because she studies all the time. She reports drinking 7-8 energy drinks a day to stay awake in class and study. Since she has been on break she has switched to a green tea 2-3 times a day. What kind of headache is this? what will you give her for the transition?
- Drug rebound headache
- sumatriptan or dihydroergotamine IV or IM for immediate headache then cessation of Caffine
What two drugs are notorious for drug rebound headaches?
Analgesics and Caffine
What can you treat a drug reboung headache with acutely?
Sumatriptan or dihydroergotamine IV or IM
A 27 y.o. M presents with headache that is unilateral and starts as a buring/aching sensation behind the right eye. He states it occasionally wakes him from sleep and that he notices that he can't help but cry but that is only from one side. He says they typically last about 30 mins. What is it?
Who gets cluster headaches more males or females?
What is the theoretical pathogenesis of a cluster headache?
hypothalamic activation with secondary activation of the trigeminal autonomic reflex probably via a trigeminal hypothalamic pathway
28 y.o. M presents with unilateral HA that starts as a buring sensation over the nose and he reports that his nose runs on that side. He has about 5 of these per day and they each last around 15 mins. Notices his eye freqently gets red on the same side of the pain and he has trouble keeping that eyelid open.
What is the treatment for acute relief from a cluster headache?
- Acute relief
- 100% O2
- sumatriptan 4-6 mg SC (2 doses in 24 hrs)
- dihydroergotamine 1mg IV
What can you perscribe for prophylaxis of a cluster type headache?
- Verapamil (DOC)
HA that feels " like a tight band around my head"
Which type of headache begins before age 10y.o in some pts?
chronic headache of unapparent cause that lack features of migrain or cluster headaches
This headache type is thought to be caused by contraction of the neck and scalp msucles and is probably a secondary phenomena
What is the treatment for acute tension headache?
- simple analgesics
What is the prophylaxis for pts who have chronic tension HAs?
- TCAs (amitryptyline)
- Serotonin-norepinephrine reuptake inhibitiors (mirtazapine, venlafaxine)
- Anticonvulsants gabapentin and topiramate
__ is caused by the spirochete borrelia burgdorfi
The vector for lyme is the __ tick
____ is when a tick attaches to the end of a blade of grass with their hind legs and grab animals with their other limbs
T or F ticks can jump onto a host from up to a foot away.
False Ticks cannot fly or jump
The bullseye rash also known as _______ is pathopneumonic for Lyme
Erythema migrans rash
Some early symptoms of Lyme include...
- Localized lymphadenopathy
- Fever, chills, arthralgias/myalgias
An avid New England runner presents to you with fatigue malaise, localized lymphadenopathy in the right groin, with a slight fever and arthralgias. What should you look for on the skin of his right lower leg?
Erythema migrans rash from a tick bite. your pt has Lyme
One of your pts presents with nuchal ridgitity and fever with mild headache. You are worried because they presented in July after a camping trip with a flu-like syndrome. You are confident that they have meningitis but are unsure what it is from so you do a lumbar puncture. The CSF shows moderate CSF pleocytosis and moderate protein elevation with normal glucose. You suspect a diagnosis of...
CSF from Lyme meningitis typically has what findings?
mild to moderate CSF pleocytosis and moderate protein elevation and NORMAL glucose
Lyme carditis typically manifests as
- AV nodal block
what are some Sx of Lyme carditis?
lightheadedness, palpitations, chest pain, syncope
What are some eye manifestations of Lyme disease?
If you have hepatitis with Lyme disease you should look for what co-infection?
anaplasma or ehrlichia
Musculoskeletal manifestions of Lyme include...
Migratory arthritis, arthralgias, myalgias, may also have pain in tendons bursae and bones
Positive C6 antibody
How do you test for lyme?
- Lyme antibody test
- ELISA followed by confirmation western blot test may be negative in the first 2 wks of illness
- detects C6 antibody
- PCR- may be used on tissues CSF and joint fluid
Lyme that occurs months to years after initial infection and includes neurologic and joint symptoms incluidng arthritis, and mild cognitive deficits is called ____ lyme
hookworm migration of larvae throught the lungs causing nausea vomiting pharyngeal irritation, cough, dyspnea and hoarsness
How do you treat Lyme in adults?
How do you treat Lyme in children?
How do you treat lyme in an amoxcillin allergic pt
How do you treat disseminated lyme with meningitis or cardiac involvement
- Ceftriaxone with a PICC line
- with cardiac involvement give a temporary pacemaker
when do you give post tick bite exposure prophylaxis?
- if the tick was attached for more than 36 hours
- the person was bit in an endemic lyme area
- single dose of doxy (not for pregnant women or children)
Human granulocytic anaplasma is carried by the ___ tick
80y.o. Pt presents with fever, chills, headache, myalgias, and malaise. They state that they had an engorged tick on them but did not develop a bulls eye rash. You order labs and find, CBC is positive for Leukopenia, thrombocytopenia and they also have elevated liver enzymes. The peripheral smear shows a morula (mulberry like inclusion in the white cells) What does your patient have?
- Human granulocytic anaplasma
- (all the same thing)
What two groups of people are at risk of death from anaplasma?
Elderly and immunocompromised
How does anaplasma kill?
Pts who are suseptible (elderly and immunocompromised) develope advanced disease, they may have heart failure, liver failure, respiratory failure, DIC leading to coma and eventually death
Triad of Fever, thrombocytopenia, and leukopenia
"morula" (black berry nucleus in white cells from an infected vacuole)
What two lab tests can you do to confirm a clincal diagnosis of anaplasmosis?
- Blood PCR
- peripheral smear for a morula
What do you treat anaplasmosis with?
Babesia is transmitted by the __ tick
Erhlichia is tranmitted by the __ tick
lone star tick
Which tick borne disease can also be transmitted by blood transfusion?
Which tick borne disease is associated with a hemolytic anemia?
Who is at risk for severe disease with Babesia infection? (5 risk factors)
- immunocompromise (especially due to malignancy)
- chronic medical illnes- chronic kidney disease, liver disease, diabetes
- age >50
A father 76y.o. and son 34 y.o. come in to the clinic after a hiking trip they think that they may have encountered something on their hike that made them ill. The son has fever, chills, myalgias, malaise, nausea, andorexia, and some jaundice. The father has SOB, fever, chills, myalgias, malaise, nausea, anorexia, headache and jaundice as well as bruising and purpura. On peripheral smear they both have cirucular staining organisms that look similar to malaria. and the both have elevated liver enzymes, thrombocytopenia and hemolysis/anemia. What do they have (hint: it is the same disease) ? why is dad presenting differently? What is your biggest concern?
- Dad is over 50 which is a risk factor for severe disease
- You are not as worried about the son because the disease is usually self limited in young healthy individuals however the father is over 50 so he is at higher risk of severe disease including: severe hemolytic anemia, severe thrombocytopenia, end organ failure, ARDS, and renal failure, DIC, hypotension shock and death
How do you treat severe Babesia infection?
- quinine/clindamycin (quinine causes QT prolongation so caution in pts with heart disease)
- Exchange transfusion: for disease with parasitemia more than 10%, severe anemia/thrombocytopenia/ end organ failure, refractory to treatment
How do you treat mild babesia infection
Tick borne illness caused by rickettsia reckettsii
Rocky mountain spotten fever
The vector for rocky mountain spotted fever (RMSF) is
- dermatocenter variabilis (american dog tick)
- D. andersoni (rocky mountain wood tick)
how long does a tick have to be attached in order to transimit RMSF?
6 hours or more
What is the incubation period of RMSF?
Which tick borne disease has a pathopneumonic rash on the wrists ankles palms and soles?
Rocky Mountain Spotted Fever
A 26 y.o. Black male with history of G6PD deficency presents to his primary care with an engorged tick. The tick is sent for processing and he is told to come back if he has symptoms of Lyme. Pt returns to his PCM 7 days later with confusion, lethargy, cough, flu like sx and a strange rash that is hard to identify because of his dark skin the rash is on his wrists and legs. His lungs have rales on auscultation and he is lethargic with decreased mental function. His labs show elevated liver enzymes, anemia, elevated bun/creatinine, and thrombocytopenia. Where should the pt be referred to? what is his diagnosis?
This pt has Rocky Mountain spotted fever. As a black male with G6PD deficiency he is at a higher risk for fulminant disease that presents early. He is in Renal failure, has pulmonary edema and CNS invovment as well as hepatic injury he needs to go to the ED and be admitted to the ICU
What do you use to treat pregnant women with rocky mountain spotted fever?
Who is at high risk for developing fulminant rocky mountain spotted fever?
black males iwth glucose-6-phosphate deficency
What do you give moderate or sever cases of RMSF?
Doxycycline (even if it is a child)
What serology test can you do for RMSF?
What are some complications of RMSF?
- Multiorgan failure and death
- Infection of pulmonary vasculature leasds to noncardioenic pulmonary edema
- cardiac arrhythmias
- CNS encepathilitis
- Renal failure
- Hepatic injury
Meningoencephalitis due to RMSF is associated with what findings on LP?
pleocytosis usually 10-100 cells/uL with a mononuclear predominance
Untreated cases of RMSF usually die within ___ days of onset
_____ is the infectious agent of malaria that not only causes the majority of malarial infections, but is also the most virulent
What is the vector for Lyme?
explain the pathology of Malaria
travels to the liver then infects the blood cells, falciparum sx develope 12-14 days after exposure, other species may infect the liver and cause relase over several months later
What are risk factors for severe Malarial disease?
Pregnant women, young children, travelers from non-endemic areas
23 y.o. M pt presents with fatigue malaise, fever, chills, N,V, D and abdominal pain. He recently returned from a trip to India. what do you suspect?
What should you order on your peripheral smear if you suspect malaria?
Name a few drugs used to treat malaria
chloroquine, malarone, coartem, fefloquin, quinine, quinidien, doxycycline, slindamycin, artesunate
You just diagnosed a pt with malaria, what are some signs of serious disease that you want to be vigulant of?
- respiratory failure
- hemodynamic instability
- renal failure
- liver failure
- metabolic acidosis
- severe hemolysis
- Cerebral malaria
What are the two human infecting hookworms?
- ancylostoma duaodenale
- necator americanus
How is hookworm aquired?
fecal contamination of soil in a warm climate with favorable growth conditions. A human then must walk across the soil or come into contact with the soil allowing the worm to penetrate the host's skin and infect the body
How does hookworm cause infection?
- once the larvae penetrate the skin they travel through the blood vessels to the alveoli and the bronchial tree
- from here they are coughted up into the pharynx and swallowed
- finally in teh small intestine they live and grow to become adults attached to the intestinal lumen
While you are on a clincal rotation in the carribean, a young woman on her honeymoon presents to you with a serpigenous rash on her foot along with GI upset and a cough. Her labs show anemia and eosinophila. What is the next diagnostic test you order? What is the disease?
- Stool Ova and parasite
What will lab studies of a pt with hookworm show?
- Unexplained anemia
- O and P for worms and eggs is positive
What is the treatment for hookworm?
- albendazole, mebendazole, pyrantel pamoate (Al, Me and Pam all bend over from the abdominal pain from our hookworms)
- iron supplementation
Who is at high risk of pinworm
- children aged 5-10
- institutionalized children
- caregivers of children
What is the organism that causes pinworm?
Enterobius vermicularis (the vermin that lives in the enteric system)
T or F pinworm can be spread via a fomite
Anal pruritis that is worse at night and may migrate to the peritoneum, nasal and vaginal openings
What test do you do to confirm pinworm diagnosis?
scotch tape test
How do you treat Pinworm?
- Supportive measures: clean everything including the child, reinfection is common
This AIDS associated disese occurs at a CD4 count less than 100 and is characterized by a focal ring or nodular enhancing mass or lesion with surrounding edema in teh brain on CT or MRI. It can consist of a single (usually but may be multiple) lesions in the basal ganglia, thalamus and corpus callosum, and less commonly the cerebellum, midbrain and pons
Primary Central Nervous system lymphoma
___ is the most common cause of an intracranial mass lesion in AIDs and is spread by handling kitty litter, undercooked or raw meat handling or eating, and gardening.
This AIDS associated intracranial lesion occurs at a CD4 less than 200, has Sx of fever, HA, focal neurological defects and seizures. It is characterized by MRI/CT findings which include: encephalitis
focal or multiple ring and or nodular enhanding lesins surroudned by variable degrees of edema
rings that primarily occur where gray and white matter meet
Lesions that tend to be located superficially or deeply the basal gangila or thalamus
Toxoplasmosis of the Brain.
AIDs related encephalopathy that begins with viral infection of the oligodendrocytes and leads to demyelination that affects the white matter and tends to be asymetric. It typically occurs in pts with a CD4 of less than 100
Progressive multifocal leukoencephalopathy
This pathogen is the most common OI in AIDs pts. Especially prevalent with CD 4 counts less than 200, It causes a pneumonia with fever, dry cough and progressive SOB, often clear lung sounds are heard on auscultation, but 6 min walk of life shows O2 desat, and CT reveals ground glass opacities.
Pneumocystis Jiroveci Pneumonia
Is chest X-ray and auscultation enough to rule out PCP in an AIDs pt?
No, 50% are clear to auscultation and 25% have a negative chest x-ray. TEST of choice is CT
These two labs are typically elevated in a pneumocystic jirovechi pneumonia
Serum beta-D-glucan and LDH
What is seen on Chest CT of a pt with PCP?
ground glass opacities
This acid fast bacilli is a common OI in AIDs pts with a CD4 count of less than 100. It causes disseminated infection to the bone marrow, liver, spleen, lymph nodes, and lungs. Typically pts have Fever, night sweats, abdominal pain, diarrhea and wt loss
Mycobacterium avium complex
A 26 y.o. M presents with fever, night sweats, abdominal pain, diarrhea, and wt loss. A complete pannel is done on him including blood cultures. The labs are significant for Anemia, alk phos elevation and LDH elevation. A few days later the blood cultures grow out MAC. What co-infection should be considered in this patient? What test should he have done?
HIV infection test him for HIV/AIDs run an HIV titer, and western blot to confirm as well as a CD4 count
Pt presents with dark brown plaque like lesions on the torso and limbs. Biopsy and stain of the lesions reveals a spindle shaped cell that stains positively for human herpes virus. Pt is a known AIDs pt and so his CD4 count is drawn and is less than 200 what are the lesions most likely to be.
This virus in AIDs pts can lead to Retinitis that leads to blindness, Esophatitis that leads to wt loss, colitis, and nurological symptoms that are similar to guillian barre syndrome with an ascending myelitis. It occurs in pts with a CD4 of less than 100
This disease causes a chronic life threatening cholera type diarrhea in AIDs pts with a CD4 less than 100. It causes wasting and chronic diarrhea that can lead to death. It is contracted from contaminated water or contact with animals or farms.
This AIDs pathogen likes to hang out in the lungs (reservoir) the optic nerve, CSF, brain, liver and prostate. It reactivates upon a CD4 count of less than 200 and causes meningoencephalitis that has Sx of progressive confusion, fever, somnolence, thrus, wasting. India ink prep will show an encapsulated bacteria
What are some early infections that may occur at a CD4 of less than 350 that may be indicators of HIV infection?
Esophageal candidiasis, Herpes Zoster, Oral candidiasis
What is the primary way that women aquire HIV?
What region of the US has the highest number of AIDs cases?
Minorities are (overrepresented or underrepresented) in AIDs case statistics
What are some risk factors for transmission of AIDs?
- Viral load
- lack of circumcision
- Sexual partner number and sex practices
What are 2 ways STDs improve HIV transmission?
- transmission is higher in the presence of active genital ulcer disease because more fluid contact
- other infections distract the immune system from attempting to control the HIV infection leading to a higher viral load
What type of intercourse carries the highest transmission risk for HIV
Receptive anal sex
What are the 3 primary modes of HIV transmission
Sex Blood Birth
What are some symptoms of primary AIDs infection?
- Oral ulcers
- Genital ulcers
What are some stage B HIV/AIDs associated illnesses?
- Vaginal candidiasis
- Oral hairy leukoplakia
- Herpes Zoster
- Peripheral neuropathy
- Bacillary angiomatosis
- Cervical dysplasia
- cervical carcinoma in situ
- constitutional symptoms such as fever or prolonged diarrhea
What are some AIDs definding illnesses (Stage C)
- Candidiasis of bronchi trachea or lungs or esophagus
- coccidiomycosis disseminated or extrapulmonary
- cryptococcosis extrapulmonary
- cryptosporidiosis other than liver spleen or lymph nodes
- Herpes simplex; with chronic ulcers for more than 1 mo or bronchitis, pneumonitis, esophagitis
- histoplasmosis disseminated or extrapulmonary
- Isosporiasis chronic infestation
- Kaposi's sarcoma
- Mycobacterium kansasii
- mycobacterium species or TB
- pneumocystic jiroveci pneumonia
- progressive multifocal leukoencephalopathy
- salmonella septisemia
- toxoplasmosis of the brain
- wasting syndrome of HIV
A person recently infected with HIV who has acute seroconversion syndrome with an EBV or viral type symptoms is what stage of HIV infection?
Stage A or primary HIV infection
A person who may be asymptomatic or have only generalized lymphadenopathy with recen HIV infection is at what stage of infection?
Stage A or the clinical latent period
Formerly known as AIDs related complex this stage of HIV infection has signs of troublesome but common infections that appear more frequently
Stage B also called the Early symptomatic HIV infection
Stage __ also called ___ is an HIV infectoin plus either a CD4 count less than 200 reguardless of symptoms or an ___ defining condition at any CD4 count
Stage C, AIDs
The _____ test for HIV tests for antibodies to different surface antigens on the HIV virus. it requires seroconversion which is approximatly 2 wks post exposure. becomes positve 2 wks at the earliest and months at the latest and must be confirmed with western blot
ELISA antibody test
This test for HIV becomes positive 5-20 days after infection onset and is ALWAYS positive at high levels when the patient has symptoms.
The ___ antigen test for HIV becomes positve earlier than the antibody test but can be negative in up to 10% of cases of primary HIV
P24 antigen test
If you suspect acute HIV infection what tests should you order?
- HIV viral load (PCR)
- HIV andibody test (ELISA)
- Western blot to confirm
What medication is used for HIV post exposure prophylaxis?
What two situations would you perscribe post exposure prophylaxis for HIV?
- Sexual contact as with a rape victim
- Blood stick with a large bore needle
What are the 5 classes of Drugs used to treat HIV/AIDs?
- nRTIs: Nucleotide Reverse Transcriptase Inhibitors
- NNRTIs: non-nukes
- PIs: protease inhibitors
- Entry Inhibitors
- Integrase Inhibitors
Name an integrase inhibitor
What entry inhibitor can you only use for CCR5 viruses?
Name a Protease inhibitor
name a non-nuke (nnRTI)
Name a nRTI
What must you check before perscribing a HIV pt Abacavir?
genotyping for HLAB5701 because if they have it it can clead to a severe hypersensitivity reaction
Tenofovir should be perscribed with water and calcium why?
it causes renal damage and bone demineralization
___ is an HIV drug that causes asymptomatic rise in unconjugated bilirubin so it won't hurt the patient but they will turn yellow
___ is the PI of choice in HIV tx
What are some of the SEs associated with Efavirenz for HIV?
transient rash, vivid dreams, CNS effects
Which non-nuke can induce non-nuke resistance in HIV strains?
What would you like to do?
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