Clinical Lab Test 4

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  1. What are the 3 main reasons for ordering a lab test?
    • Diagnosis (rule out/confirm disease)
    • Monitor therapy (repeating tests for TDM/side effects)
    • Screening (early detection of disease)
  2. What type of a test should you use to rule OUT a disease? Why?
    • High sensitivity test
    • To rule out a disease you want a test with a low chance of giving a false negative (a negative result most likely means the patient is truly negative for the disease).
  3. What type of a test should you use to CONFIRM a disease? Why?
    • High specificity test
    • To confirm a disease you want a test with a low chance of giving a false positive (a positive result most likely means the patient does have the disease).
  4. In order to ensure correct diagnostic results, what do screening and confirmatory tests need to be? What are some examples?
    • Initial tests (screening) need to be very sensitive while secondary (confirmatory) tests are very specific.
    • Syphilis (RPR (screening) -> MHA-TP or TP-PA(confirmatory))
    • Hepatitis C (HCV Ab (screening) -> RIBA (confirmatory))
    • HIV (EIA (screening) -> Western Blot (confirmatory))
  5. What must a specimen for lab testing represent?
    Location of active disease (throat swab for strep, urine for UTI, etc)
  6. What specimen can you submit in a non-sterile container?
  7. What are some considerations for transporting specimens in the following conditions?
    -Delays at room temperature
    -Use of transport media
    • Placed in a biohazard bag
    • Transported to the laboratory as soon as possible
    • Delays – stored in refrigerator/room temp
    • Use transport media
  8. Why is it important to notify the lab if you suspect specific agents?
    • Sometimes organisms require specific culture media/testing techniques or extra time to grow (fastidious).
    • More importantly, notification protects lab personnel from acquiring infections from highly contagious/biothreat agents.
  9. Name the contagious threat agents mentioned in lecture.
    • Bacillus anthracis
    • Brucella spp.
    • Francisella tularensis
    • Burkholderia pseudomallei
    • Yersinia pestis
    • Blastomyces
    • Coccidioides
    • Histoplasma
    • Paracoccidioides
  10. What are the agents that require special culture media?
    • Bordetella pertussis
    • Corynebacterium diphtheriae
    • Vibrio cholerae
    • Clostridium spp.
    • Legionella pneumophila
    • Escherichia coli O157:H7
    • Yersinia enterocolitica
  11. When should a specimen be collected and how much?
    • Collected during greatest likelihood of recovering the suspected agent. (virus->acute phase, bacteria->before antibiotic, parasite/fungi->no special guidance)
    • Adequate volume for all the micro studies requested.
  12. What specimen is superior to a swab for pathogen recovery?
    Tissue or fluid aspirate.
  13. Why are specimens placed in a biohazard bag for transport to the lab?
    Specimens have potentials for leakage.
  14. When should specimens be transported to the lab after collecting them?
    As soon as possible.
  15. How should urine, sputum, respiratory specimens and stool be kept if there is a delay in transport to the lab?
    Specimens should be refrigerated.
  16. How should cerebrospinal fluid (CSF), body fluids, and blood be kept if there is a delay in transport to the lab?
    Specimens should be at room temperature.
  17. What specimens require the use of transport media? What are the medias?
    • Viruses: viral transport media (VTM)
    • Stool: Cary-Blair media
    • Stool parasites: formalin and polyvinyl alcohol (PVA)
  18. Name the specimen rejection criteria.
    • Improper labeling
    • Prolonged transport
    • Leakage
    • Unsuitable specimen for request
    • Duplicate/repeated specimens (except for blood cultures when suspecting endocarditis)
    • Sterile body fluid not submitted immediately
  19. What are general examples for rejection criteria of microbiology samples?
    • Specimen for culture received in formalin
    • Foley catheter tip
    • Improper, non-sterile, leaking containers
    • Dry swab
    • Multiple specimen on the same day from same source (except blood)
    • Single swab for multiple tests
  20. What are the rejection criteria for anaerobes?
    • Inappropriate container
    • Inappropriate source (surface vs deep wound)
  21. What are the rejection criteria for aerobes?
    • Respiratory culture (spit vs sputum)
    • Stool culture from inpatients >3 days
    • More than 2 stools from single patient
  22. What are the rejection criteria for mycobacteriology/mycology samples?
    • 24 hr urine
    • Sputum for AFB/fungal culture
    • Sputum swabs
  23. What is the rejection criteria for virology/parasitology specimens?
    Specimen submitted in wrong format.
  24. What are examples of panic values (critical values) for patients, meaning the lab will call and contact you directly?
    • Organism in CSF or joint fluid
    • Positive cryptococcal antigen detection
    • Postive acid fast bacillus smear
    • Positive blood cultures
    • Positive CSF culture
    • Isolation of M. tuberculosis
    • Positive eye cultures for P. aeruginosa or Bacillus spp
    • Isolation of E. coli O157:H7, pathogenic Neisseria, Group B strep from pregnant women
  25. Name agents that need to be reported to public health officials (panic values for public health).
    • Malaria
    • Meningitis
    • Mumps
    • Pertussis
    • Polio
    • Rocky Mtn Spotted Fever
    • Salmonella
    • Shigella
    • Syphilis
    • Tetanus
  26. Name the agents that need to be reported to government agencies as well as public health officials (panic values for public health).
    • Anthrax
    • Botulism
    • Brucellosis
    • Tularemia
    • Plague
    • Rabies
  27. What is the importance of reporting certain diseases if isolated (reportable diseases)?
    Reporting them helps stem a potential outbreak.
  28. Name examples of specimen collection sources.
    • Blood
    • Body fluids
    • Tissues
    • Eye
    • Respiratory tract
    • Genital tract
    • Feces
    • Skin and subcutaneous lesions
  29. What are common symptoms of bacteremia, endocarditis, or sepsis?
    • Fever
    • Hypthermia
    • Leukocytosis
    • Granulocytopenia
    • Hypotension
  30. How should blood culture sets be drawn and submitted?
    • Collect before antibiotic therapy
    • 2 or more bottles per episode (1 "set"=1 aerobic, 1 anaerobic)
    • Different sites/time
    • No more than 4 total sets within 24 hrs
    • Pediatric patient sets=1 bottle
  31. What does growth of the same organism in repeated blood cultures likely indicate?
    A true positive.
  32. What does growth of different organisms in different culture bottles likely indicate?
    Probable contamination, bowel spillage.
  33. What does growth of normal skin flora indicate? What are some of these organisms?
    • Likely contamination.
    • Coagulase negative Staph, Corynebacterium, Bacillus, Propionibacterium, etc.
  34. What organisms that grow in blood cultures indicate possible endocarditis (associated with low grade fevers)?
    Organisms like viridans streptococci or enterococci.
  35. What is the turn around time for a STAT test?
    1 hour (gram stain, bacterial antigen)
  36. All body fluids are considered ____?
  37. Why would you give the lab advance notice on a throat swab if you suspect Bordetella, Corynebacterium, or Neisseria?
    Culture requires specialized media.
  38. What is the first thing the lab will do to a sputum specimen before culturing it?
    Grade the quality.
  39. What is an example of an intermediate result for body fluid testing? When is the result given? When is a final result given?
    • Gram stain
    • Same day
    • 72 hours
  40. Name examples of bronchoscopy specimens. What patients is bronchoscopy performed on and what are the specimens used for?
    • Bronchoalveolar lavage fluid, protected brush specimens.
    • Ventilated patients for diagnosis of bacterial pneumonia.
    • Immunocompromised patients with pneumonia to detect opportunistic pathogens.
  41. How are UTIs generally diagnosed from a microbiology culture?
    Quantitated colony counts
  42. What type of testing has replaced traditional culture of genital tract specimens (swab, aspirate, urine)?
    Molecular assays
  43. What organisms are being searched for in a wet mount?
    • Bacterial vaginosis
    • Trichomonas
    • Candida (fungal)
  44. Who would a gram stain be performed on if a gonorrhea infection is suspected?
    Symptomatic male
  45. Which patients are stool cultures most beneficial for? What specimens are used for culture?
    • Those with lengthy unresolved issues (diarrhea >3 days).
    • Feces/rectal swab
  46. Name the three big organisms responsible for bacterial diarrhea.
    • Salmonella
    • Shigella
    • Campylobacter
  47. Specimens for stool culture are not collected for inpatients >3 days, instead what would be suspected? What test would be performed? What kind of stool specimen is used for this testing?
    • C. difficile antibiotic associated diarrhea (CDAD)
    • Toxin assay for C. diff
    • "Loose and free flowing" specimen
  48. If a stool culture comes back negative for a patient with unresolved diarrhea (lasting >3 days), what else can the lab look for? What is the name of the test?
    • Parasites
    • Ova and parasites (O&P)
  49. What are the specimens that can be submitted for culture of skin and subcutaneous lesions (vesicles, bullae, pustules, ulcers, wound infection/abscess)? What is the preferred specimen?
    • 2 swabs
    • Aspirate fluid/tissue (preferred)
  50. What should be done with a skin/subcutaneous lesion sample in which a viral infection is suspected?
    Place in viral transport medium (VTM)
  51. If anaerobes are suspected as the cause of infection how should the specimen(s) be submitted?
    • Fluids should be kept in a capped syringe to minimize exposure to oxygen.
    • Or place a 3rd swab (in addition to the normal 2 swabs for culture) into an anaerobic environment.
  52. Why is it important to submit specimens (swabs, fluid, tissue) for viral culture in viral transport medium (VTM)?
    VTM contains antibiotics and antifungals to help enrich growth of viruses.
  53. What kind of media is used when culturing mycology specimens? What does this media do? How long are mycology specimens incubated for?
    • Specialized media that inhibits bacteria and fast fungal growers.
    • 4 weeks
  54. Why does the lab need to be alerted if a dimorphic fungus is suspected?
    These organisms are hazardous to everyone, including lab staff.
  55. Name some examples of dimorphic fungi.
    • Histoplasma capsulatum
    • Blastomyces dermatitidis
    • Coccidioides immitis
    • Paracoccidioides brasiliensis
    • Sporothrix schenckii
    • Penicillium marneffei
  56. What type of specimen is the best for detecting mycobacteria infections?
    First morning sputum.
  57. What are mycobacteria also known as? What is the best recognized mycobacterial disease?
    • Acid fast organisms
    • Tuberculosis
  58. How long do mycobacteriology specimens need to be incubated?
    8 weeks
  59. What is the biological safety level of mycobacteria?
  60. How are stool specimens for O&P submitted in order to maintain structural integrity of the organisms?
    In a preservative.
  61. Name examples of provider performed microscopy (PPM). What level of complexity are these tests?
    • Urine sediment exam
    • Wet mounts (detects bacteria, fungi, parasites, cellular elements).
    • Potassium hydroxide prep (KOH) for fungal elements
    • Pinworm exam
    • Fern test
    • Postcoital direct qualitative exam of vaginal/cervical mucus
    • Nasal smears (granulocytes)
    • Fecal leukocyte
    • Qualitative semen analysis
    • Remember PPM is considered moderate complexity.
  62. What does the predictive value of tests depend on?
  63. A disease with a low prevalence will have what kind of predictive value when tested for?
    High negative predictive value.
  64. A disease with a high prevalence will have what kind of predictive value when tested for?
    High positive predictive value.
  65. What are important things to do when performing quality control?
    • Ensure QC sheet is correct and up to date.
    • DO NOT report result without ensure controls are within expected range.
    • DO NOT use expired reagents.
  66. What helps in the determination of optimal therapy?
    • Organism type
    • Location of infection
  67. The limiting of inappropriate antibiotic use while optimizing the selection, dose, duration, and route of therapy with the most appropriate drug refers to what term? What percentage of antibiotic use is unnecessary?
    • Antimicrobial stewardship
    • ˜50% of antibiotic use in unnecessary
  68. Name some examples of susceptibility tests.
    • Disk diffusion (Kirby Bauer), S-I-R
    • Broth/agar dilution (MIC)
    • Urine culture result
  69. Will all drug resistances be reported all the time? Why/why not?
    No, sometimes there is no point for certain organism susceptibility to be reported because they are either inherently susceptible or known to be susceptible, or no guidelines for reporting susceptibility exist.
  70. What are the organisms which have no guidelines available for susceptibility testing?
    • Haemophilus aphrophilus
    • Actinobacillus actinomycetemcomitans
    • Cardiobacterium hominis
    • Eikenella corrodens
    • Kingella kingae
    • "HACEK" organisms
  71. What are the three things to take into consideration before choosing the right drug to treat a patient?
    • Highest susceptibility
    • Lowest cost
    • Availability
  72. What is the screening test that looks for non-specific antibodies that may indicate syphilis? What is the confirmation test?
    • Rapid Plasma Reagin (RPR)
    • MHA-TP (microhemagglutination T. pallidum) or FTA-ABS (fluorescent treponemal antibody)
  73. If the screening test for syphilis (RPR) is positive and the confirmation is negative what is the result? If the screening test is positive and the confirmation is positive what is the result?
    • False positive RPR (negative for syphilis)
    • Active disease (syphilis)
  74. What is the confirmatory test for positive HIV EIA results?
    Western Blot (WB)
  75. What Western Blot test is used to detect HCV and Borrelia burgdorferii (Lyme disease)?
    Recombinant immunoblot assay (RIBA)
  76. What do the immunoglobulin classes IgM and IgG indicate?
    • IgM: current infection
    • IgG: current infection (acute & convalescent); previous exposure (vaccinated/old infection)
  77. What is a titer? What technique does it employ? What does the titer correspond to?
    • A way of expressing concentration.
    • Employs serial dilution to get approx. quantitative info.
    • Titer corresponds to the highest dilution factor that still yields a positive reading.
  78. When determining a titer, what two things are often compared? What indicates an acute infection?
    • Often compare acute vs convalescent sera.
    • A four fold increase in the titer=acute infection.
  79. What happens when only an acute sample is submitted for determining antibody titer?
    A cut-off value is required and may vary by organism and geographic location.
  80. In determining titers what is an example of what a primary response would look like? What is an example of a secondary response (re-exposure)?
    • Primary: Day 5 (1:4 titer), Day 12 (1:64 titer)
    • Secondary: 1:256 titer or higher
  81. The TORCH test (serodiagnostic) is an acronym for what diseases?
    • Toxoplasma
    • Rubella
    • Cytomegalovirus
    • Herpes Simplex
  82. What results would indicate that a patient is susceptible to infection with hepatitis B?
    • HBsAg: negative
    • anti-HBc: negative
    • anti-HBs: negative
  83. What results indicate that a patient is immune due to natural infection to hepatitis B?
    • HBsAg: negative
    • anti-HBc: positive
    • anti-HBs: positive
  84. What results would indicate that a patient is immune to infection with hepatitis B due to the hep B vaccination?
    • HBsAg: negative
    • anti-HBc: negative
    • anti-HBs: positive
  85. What results would indicate that a patient is undergoing an acute hepatitis B infection?
    • HBsAg: positive
    • anti-HBc: positive
    • IgM anti-HBc: positive
    • anti-HBs: negative
  86. What results would indicate that a patient is undergoing a chronic hepatitis B infection?
    • HBsAg: positive
    • anti-HBc: positive
    • IgM anti-HBc: negative
    • anti-HBs: negative
  87. Describe the four possible ways a hepatitis B test can be interpreted if the results came back as...

    HBsAg: negative
    anti-HBc: positive
    anti-HBs: negative
    • 1. resolved infection (most common)
    • 2. false-positive anti-HBc, thus patient is susceptible
    • 3. "low level" chronic infection
    • 4. resolving acute infection
  88. What are the Five recognized hepatitis viruses?
    Hepatitis viruses A-E
  89. What hepatitis virus causes an acute form of infection only?
    Hepatitis A
  90. What hepatitis virus causes acute and chronic forms of infection?
    • Hepatitis B
    • Hepatitis C
  91. Name the symptoms associated with viral hepatitis.
    • Abdominal pain/distention
    • Breast development in males
    • Dark urine & pale/clay-colored stools
    • Fatigue
    • Fever (low grade)
    • Generalized itching
    • Jaundice
    • Loss of appetite
    • Nausea, vomiting
    • Weight loss
  92. What specific lab testing is performed for determination of hepatitis infection?
    • Acute hepatitis panel (IgM anti-HAV, IgM anti-HBc, HBsAg, anti-HCV)
    • Liver function tests
    • Individual workup based on screening
  93. How is hepatitis B spread?
    Contact with blood, semen, vaginal fluids.
  94. What does a positive hepatitis B e antigen (HBeAg) mean? Is it found in all patients?
    • Positive means active hepatitis B infection with a possibility of spreading the infection through sex or needle sharing.
    • This is NOT found in all patients with the infection.
  95. What does a positive result for antibody to HBeAg (anti-HBeAg) mean?
    Positive means inactivity of the hepatitis B virus from an existing infection and low infectivity towards others.
  96. What is the concentration of antibody compared to detected antigens for hepatitis B?
    When antigen is detected the corresponding antibody is in lower concentration.
  97. How is hepatitis C typically spread?
    Contact with blood.
  98. What is the screening test for hepatitis C? What is the confirmation test? What testing is used to monitor therapeutic response to treatment?
    • EIA assay (screens)
    • RIBA (confirms)
    • HCV viral load
  99. What test results would indicate an acute infection of hepatitis C?
    • anti-HCV EIA: negative
    • anti-HCV RIBA: negative
    • qualitative HCV RNA: positive
  100. What test results would indicate an active infection of hepatitis C?
    • anti-HCV EIA: positive
    • anti-HCV RIBA: positive
    • qualitative HCV RNA: positive
  101. What test results would indicate a resolved infection or intermittent viremia of hepatitis C?
    • anti-HCV EIA: positive
    • anti-HCV RIBA: positive
    • qualitative HCV RNA: negative
  102. What test results would indicate a false positive screening for hepatitis C?
    • anti-HCV EIA: positive
    • anti-HCV RIBA: negative
    • qualitative HCV RNA: negative
  103. What is determination of viral load useful for?
    Monitoring therapy for HBC, HCV, HIV.
  104. What are signs and symptoms of an upper UTI (kidneys/acute pyelonephritis)?
    • upper back & side (flank) pain
    • high fever
    • shaking and chills
    • nausea
    • vomiting
  105. What are signs and symptoms of a lower UTI (cystitis, urethritis)?
    • pelvic pressure
    • lower abdomen discomfort
    • frequent, painful urination
    • blood in urine
    • burning with urination (urethra)
  106. What is indicative of uncomplicated UTIs?
    • Normal anatomy
    • Upper and lower tract disease
  107. What is indicative of complicated UTIs?
    • Immune depression
    • Structural/functional abnormalities
    • Obstruction, reflux
    • Mainly upper tract disease
  108. What is the most common causative agent of UTI in females? What is the prevalence of UTI in females? What is another agent that can cause UTI in young sexually active females?
    • E. coli (85%)
    • Approx. 50% of women will have at least 1 UTI
    • S. saprophyticus (young sexually active "honeymoon disease")
  109. What are the three main clinical manifestations of UTI in females? What agents besides E. coli can cause reinfection?
    • Cystitis
    • Pyelonephritis
    • Recurring infection (Proteus, Pseudomonas, Klebsiella, Enterobacter, Enterococcus, Staphylococcus)
  110. What is the main causative agent of UTI in males? What is the prevalence of UTI in males?
    • Enterobacteriaceae
    • Prevalence very low (MSM=men sleeping w/ men)
  111. What are the signs and symptoms of UTI in a male? What can these symptoms mimic?
    • Urethritis (discharge, dysuria, frequency)
    • Prostatitis (obstructed urine flow/"complicated UTI")
    • Can be confused with STIs
  112. What are clinical indications of UTI in catheterized patients?
    • Usually polymicrobial infection
    • Multi-drug resistant strains
    • Mostly asymptomatic, but can be indicated with atypical presentation of symptoms.
  113. When can UTIs be considered as recurring?
    Minimum of 2 UTIs in 6 months or ≥3 in 1 year.
  114. How is UTI diagnosed?
    • Patient history (duration, signs, symptoms)
    • Medical history (previous UTIs, abnormality, other illness)
    • Physical exam (fever, lesions, discharge, pain)
    • Specimen (if necessary)
    • Positive screening tests/cultures
  115. What must be done with urine that is delayed in getting to the lab up to 24 hours?
    Put a minimum of 3 ml in a transport device.
  116. What are the testing methods used in urinalysis to detect a UTI?
    • Nitrite: indicates bacteria that reduce urinary nitrate to nitrite
    • Leukocyte esterase: released by lysed neutrophils and acute inflammation
  117. How is it possible for a nitrite result to be negative if there is a UTI present?
    False negatives occur due to the fact that some organisms cannot convert nitrate to nitrite (S. saprophyticus, Enterococcus spp).
  118. If both nitrite and leukocyte esterase are positive on the urinalysis, the urine culture will be...?
  119. What urine sediment may also indicate kidney involvement?
  120. What does the quantitative value/amount of colony forming units (CFU) present in a urine culture need to be in order for that organism to be considered a potential pathogen?
    Anything >10^5 CFU/ml
  121. Describe the Golden rules for taking a sexual history.
    • Assume NOTHING.
    • Demonstrate you've heard it all.
    • Try NOT to look shocked/surprised if you haven't.
    • Do NOT appear judgemental.
  122. What are the general characteristics/importance of urethritis?
    • Inflammation of urethra
    • Dysuria
    • Discharge
    • Symptomatic vs asymptomatic (male/female)
    • Devastating consequences if untreated
    • Dual infection (gonococcal + nongonococcal)
  123. What is the causative agent of gonococcal urethritis?
    Neisseria gonorrhea (GC)
  124. What are the signs and symptoms of Neisseria gonorrhea?
    • Male: burning urination, purulent discharge, painful swollen testes (rare), often symptomatic
    • Female: often asymptomatic, mild non-specific, suspect UTI, later on similar symptoms to males, vaginal bleeding between periods, dyspareunia
  125. What are examples of extragenital gonococcal infections?
    • Oropharyngeal infection
    • Disseminated (arthritic)
  126. What are the causative agents of non-gonococcal urethritis?
    • Chlamydia trachomatis
    • Mycoplasma
    • Ureaplasma
    • (adenovirus, trichomonas, herpes simplex)
  127. What are the signs and symptoms of non-gonococcal urethritis?
    • Male: cloudy/watery discharge, burning urination, fever, swollen/tender testes
    • Female: often asymptomatic, suspect UTI, later unusual vaginal bleeding or discharge, abdominal pain, dyspareunia, fever, painful urination, urinary urgency
  128. How should specimens be collected for Urethritis/Cervicitis?
    • Urethral/cervical swab (may be self-collected)
    • Urethral discharge
    • Urine (first void) at least 3 ml
    • Other specimens based on sexual history (Rectal swab, Pharyngeal swab)
  129. What are the causative agents of cervicitis? What are the common symptoms? What is the clinical importance/significance of cervicitis?
    • Chlamydia trachomatis, Neisseria gonorrhea, other urethritis causes.
    • Purulent vaginal discharge, intermenstrual/postcoital bleeding.
    • Endometritis, PID, HIV
  130. What are the 5 laboratory tests for Urethritis/Cervicitis?
    • Rapid tests (swab)
    • Fluorescent (swab)
    • Culture (discharge, swab) 100% specific
    • Serology (serum)
    • Nucleic acid amplification (swab, urine)
  131. What test can detect both GC (gonorrhea) and Ct (Chlamydia) simultaneously, and is a very sensitive and specific test?
    • Nucleic acid amplification (on swab, urine)
    • This is the best answer for testing unless pt doesn't respond to therapy, then use the culture.
  132. All patients with confirmed or suspected urethritis should be tested for what?
    • Gonorrhea and Chlamydia
    • However, look for any other STI especially HIV.
  133. What are the general characteristics of vulvovaginitis?
    • Affect women of all ages
    • Vaginal itching & irritation
    • Vaginal discharge
    • Foul odor
    • Dysuria
    • Dyspareunia
    • Erythema
    • Spotting
  134. What is the causative agent of Candidiasis? What are the symptoms?
    • Candida albicans
    • Intense perivaginal itching or burning
    • Thick white cottage cheese texture, odorless & adherent to vaginal walls.
    • Dysuria
    • Normal vaginal pH
  135. What is the causative agent of bacterial vaginosis? What are the symptoms?
    • Gardenerella vaginalis
    • Slightly malodorous gray white discharge.
    • Often asymptomatic, possible UTI.
    • Increased vaginal pH >4.5
  136. What type of cell can be used to diagnose bacterial vaginosis?
    Clue cells (Gardenerella covers epithelial cells)
  137. What is the causative agent of Trichomoniasis? What are the symptoms?
    • Trichomonas vaginalis
    • Copious amounts of frothy green/yellow/gray discharge (motile organism).
    • Increased vaginal pH
    • "Strawberry cervix" (swollen and red)
    • Vaginal soreness & dyspareunia
    • Often asymptomatic
  138. What are the laboratory tests used for vulvovaginitis?
    • Vaginal pH (narrow range pH paper)
    • Amine AKA "whiff" test (KOH, increased pH, "fishy smell")
    • Gram stain, saline wet prep (within 20 mins)
    • Increased vaginal pH indicates bacterial vaginosis or trichomoniasis.
  139. How are Clue Cells identified?
    Gram stain and microscopy.
  140. What are the microscopy procedures performed for vulvovaginitis?
    • Saline wet prep (within 20 minutes) to detect "jerky" motility of Trichomonas (motility required).
    • KOH prep (KOH destroys bacterial cells but not fungi, yeast)
  141. Name examples of genital ulcer disease.
    • Syphilis (painless ulcer)
    • Chancroid (painful ulcers)
    • Herpes simplex (vesicles, painful ulcers)
    • Lymphogranuloma venereum ("groove sign", fluctuant bubos)
    • Donovanosis (painless ulcers, scar formation)
  142. What STI agent is considered "the great imitator" because its signs and symptoms are indistinguishable from other diseases?
    Treponema pallidum (syphilis)
  143. Briefly describe the stages of disease for syphilis (Treponema).
    • Primary (contagious): painless chancre, lymphadenopathy
    • Secondary (contagious): rash on palms and soles, condylomata lata
    • Latent (not contagious): silent phase with positive serologies, no major symptoms
    • Late/tertiary (not contagious): neurosyphilis, gummas
  144. What are the direct testing methods used to identify syphilis?
    Dark field microscopy (skin lesions, placenta, umbilicus). This is a definitive diagnosis.
  145. What are the non-treponemal (screening) tests used to detect syphilis? What is the specimen used?
    • RPR, VDRL (CSF)- perform titer. These are sensitive but NOT specific.
    • Serum
  146. What are the treponemal (confirmation) tests used to detect syphilis? What is the specimen used?
    • FTA-ABS, MHA-TP, TP-PA (positive results for life).
    • Serum
  147. Positive screen and positive confirmatory test for syphilis means??
    Congratulations its syphilis!
  148. How is the non-treponemal test reported? What does the magnitude of the result reflect?
    • Reported as a titer of antibody.
    • Generally reflects the activity of disease.
  149. At what intervals after treatment should serological monitoring be performed? What is an important safety tip when doing follow up testing?
    • Monitoring is critically important during the follow up of treated syphilis and should be performed at 3, 6, and 12 month intervals after treatment.
    • Tip: use the same testing assay from the same lab for follow-up exams.
  150. What does the term seroreversion refer to?
    Loss of antibodies over time.
  151. What does the term serofast refer to?
    Antibody titers remain reactive after treatment. (Serofast patients should be tested for HIV infection).
  152. What is the causative agent of chancroid? What are the symptoms?
    • Haemophilus ducreyi
    • Painful ulcers in genital region ("you do cry with ducreyi")
    • Tender inguinal lymphadenopathy
    • Necrotic, purulent base w/ ragged borders
    • School of fish/rail road track morphology
    • Diagnosed by clinical manifestation and culture (negative for HSV)
  153. What are the types of herpes simplex virus that cause disease?
    Type 1 or Type 2
  154. What are the symptoms of primary, nonprimary, and recurrent infections of herpes simplex virus? When is it infectious?
    • Multiple vesicles on erythematous base.
    • Vesicles rupture and make shallow, painful ulcers that become crusted lesions.
    • Specimens include fluid from lesion or a swab of the base of lesion.
    • Infectious when person has lesions (not always seen).
  155. Describe symptoms of 1˚ genital herpes (initial infection).
    • Low grade fever
    • Chills
    • Headache
    • Malaise
    • Myalgia
    • Encephalitis
    • Recurs often (latency)
  156. What are the direct detection (low sensitivity) methods of testing for herpes simplex virus?
    • Tzanck prep
    • Rapid antigen
  157. What are the semi-direct detection (high sensitivity) methods of testing for herpes simplex virus?
    • DFA (direct fluorescent antibody)- 24 hrs
    • Must first be inoculated into cells, incubated, then stained.
  158. What is the Gold Standard for herpes simplex virus testing?
    • Viral culture (held for 2-3 days if positive, 10 days if negative).
    • Rounding up of cells (CPE)
  159. Viral PCR for herpes simplex virus is best used on what specimen for which patients?
    CSF testing on neonates presenting with encephalitis.
  160. What is the causative agent of donovanosis (granuloma inguinale)?
    Klebsiella (Calymmatobacterium) granulomatis
  161. What are the characteristics of Donovanosis that help diagnose the disease?
    • Painless, beefy, granulomatous ulcers
    • Mononuclear cells with intro cytoplasmic vacuoles packed with bacteria aka Donovan bodies.
  162. Name the genital ulcer disease that exhibits:

    21 day incubation
    Single lesion
    Sharp demarcated border
    Red smooth, shiny/crusty base
    Firm induration
    Unilateral lymph nodes (swelling)
    Rare constitution
  163. Name the genital ulcer disease that exhibits:

    2-7 day incubation
    1-3 lesions
    Erythematous border
    Yellow gray base
    Rare, soft induration
    Common occurrence of pain
    Unilateral lymph nodes (swelling)
    Rare constitution
  164. Name the genital ulcer disease that exhibits:

    2-7 day incubation
    Multiple, vesicular lesions
    Erythematous border
    Red smooth base
    No induration
    Common occurrence of pain
    Bilateral lymph nodes (swelling)
    Common constitution
  165. Name the genital ulcer disease that exhibits:

    10-14 day incubation
    Single lesion
    Variable border
    Variable base
    No induration
    Variable occurrence of pain
    Either lymph node affected (swelling)
    Frequent constitution
    Lymphogranuloma venereum (LGV)
  166. Name the genital ulcer disease that exhibits:

    Variable period of incubation
    Either single or multiple lesions
    Rolled and elevated border
    Red rough, friable base
    Firm induration
    Rare occurrence of pain
    Inguinal lymph node swelling
    Rare constitution
  167. How many different HPV genotypes are there?
    Over 70
  168. What disease states does human papillomavirus cause (types 6, 11)?
    • Warts (normal, plantar, genital)
    • Anogenital ("condyloma acuminatum")
    • Genital warts is the most common viral STD in the U.S.
  169. What are the types of human papillomavirus that are responsible for causing epithelial carcinoma (cervical cancer)?
    • Types 6, 11 (low risk)
    • Types 16, 18, 31, 33, 35 (high risk)
  170. What is molluscum contagiosum?
    A benign disease caused by a pox virus.
  171. What is the clinical presentation of molluscum contagiosum?
    • 2-10 mm dome shaped papules with central depression (umbilicated)
    • Can occur anywhere on the body (grouped)
    • Clinical diagnosis/histopathologic exam
    • Treatment involves curettage/cryotherapy
  172. What is the causative agent of pubic lice?
    Phthiris pubis "crabs"
  173. What are the general characteristics of pubic lice?
    • They live on pubic (genital) hair.
    • Requires close contact for transmission, not necessarily pull penetrative sex.
    • Itching of the hair in pubic region, especially at night, "dandruff", blood in underwear.
  174. What is pelvic inflammatory disease?
    • Grouping of syndromes affecting female reproductive organs (endometriosis, salpingitis, tuboovarian abscess, pelvic peritonitis).
    • Is usually a complication of cervicitis due to N gonorrhea or C trachomatis.
  175. What are some of the consequences of pelvic inflammatory disease?
    • Infertility
    • Ectopic pregnancy
    • Abscess formation
    • Chronic pelvic pain
  176. What population is most at risk for pelvic inflammatory disease?
    Sexually active women of childbearing age who have/do multiple partners, douching, IUDs, early age beginning sexual activity, previous STI, gynecological procedure (abortion, birth, miscarriage).
  177. What are the signs and symptoms of pelvic inflammatory disease (PID)?
    • Vague
    • Persistent cramps
    • Dyspareunia
    • Abnormal, foul smelling discharge
    • Abdominal tenderness
    • Fever
    • Adnexal and lower abdominal tenderness
  178. How is a PID diagnosis confirmed?
    Confirmed by Nucleic Acid Test (NAT)
  179. What is the causative agent of scabies?
    Scabies sarcoptei
  180. What are the general characteristics of scabies?
    • Transmitted by close contact.
    • Burrow into skin to lay eggs under skin surface (lumpy).
    • Intense itching (allergic reaction to mites) worse at night, especially after a hot bath.
    • Scratching damages skin that allows bacterial infections to develop (alters appearance making diagnosis more difficult).
  181. What are the essential results for diagnosis of HIV?
    • HIV RNA detected/quantitated by PCR or bDNA methods.
    • Low CD4 count
    • Unexplained opportunistic infections.
    • Review of patient history (illnesses, risk factors, screening).
  182. When can HIV be detected after exposure to the virus (average)?
    Within 25 days (Positive status within 3 months)
  183. Explain force HIV screening for the military.
    • AR 600-110
    • ELISA based assay on patient blood
    • Detects HIV specific Ags or Abs
    • Negative qualitative result --> good to go!
    • Positive qualitative test --> Western Blot confirmation
  184. Explain what happens when a patient's sample Western Blot confirmation test is positive.
    • Original specimen positive: individual is notified of initial HIV + status
    • Second specimen positive: individual notified of confirmed HIV + status
    • Second specimen negative: request 3rd specimen
    • Third specimen positive: individual notified of confirmed HIV + status
    • Third specimen negative: individual is considered NOT INFECTED
  185. Explain what makes HIV results indeterminate. How is this situation handled?
    • EIA screen is reactive.
    • Western Blot indeterminate (1 band vs multiple).
    • At risk individuals may still be seroconverting, repeat WB and HIV viral load.
    • Low risk individuals are probably not infected, repeat EIA and HIV viral load.
  186. Name the forms of infectious endocarditis and give a brief description of each.
    • Acute ABE (rapid): occurs during serious septicemic episode on healthy cardiac valves (catheter), very aggressive.
    • Subacute SBE (gradual): occurs in damaged cardiac valves.
  187. What are the risk factors for developing infectious endocarditis?
    • Congenital heart disease
    • Atherosclerotic plaques
    • Prosthetic valve replacement
    • Mitral valve prolapse
    • IV drug usage
    • Intravascular device infections
  188. What is the causative agent of acute ABE infectious endocarditis?
    • Skin flora: Staphylococcus aureus (MRSA)
    • IV drug use: MRSA affecting tricuspid valve (right sided)
  189. What is the causative agent of subacute SBE infectious endocarditis?
    • Endogenous flora: Streptococcus viridans group
    • Skin flora: Staph aureus
  190. What are the symptoms of endocarditis?
    • Abnormal urine color
    • Chills and fever (common)
    • Excessive sweating (common)
    • Fatigue
    • Joint pain, myalgia
    • Night sweats
    • Paleness
    • Shortness of breath with activity
    • Swollen feet, legs, abdomen
    • Weakness
    • Weight loss
  191. What are the signs of endocarditis?
    Splinter hemorrhages, Roth spots, Osler's nodes, Clubbing (fingers), Janeway lesions
  192. Briefly describe splinter hemorrhage (endocarditis sign).
    Hemorrhaged capillaries under nail bed.
  193. Briefly describe roth spots (endocarditis sign).
    Retinal hemorrhages
  194. Briefly describe osler nodes (endocarditis sign).
    Painful red-purple, slightly raised, tender lumps
  195. Briefly describe clubbing (endocarditis sign).
    Bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit.
  196. Briefly describe Janeway lesions (endocarditis sign).
    Non- tender, often hemorrhagic (bleeding into skin), and occur mostly on the palms and soles.
  197. What is the lab workup/testing used for diagnosing endocarditis?
    • Blood culture (ID causative agent)
    • Complete blood count (CBC)- elevated WBCs
    • C-reactive protein (CRP)- elevated
    • Erythrocyte sedimentation rate (ESR)- elevated
    • Optional: serology or PCR (suspected specific agent such as Q fever)
  198. Describe how to tell if a positive blood culture is significant.
    • 1) Significance of positive culture correlates with the type of organism.
    • 2) Clinical setting (coagulase negative staph (CNS) are significant in patients with prosthetic valves, not in those with native valves).
    • 3) Multiple blood culture positive for same organism.
    • 4) Shorter incubation time for recovery.
    • 5) Degree of severity of clinical illness.
  199. How many sets of blood culture bottles would you draw over a 24 hour period of time? Where would you draw them from?
    • Draw 3-4 over 24 hours
    • Draw from different sites at different times.
  200. What should you always match blood culture results with?
    Patient's symptoms
  201. What are the common organisms of endocarditis that give a positive blood culture result?
    • Staphylococcus aureus (ACUTE)
    • Streptococcus viridans group (SUBACUTE)
    • Staphylococcus epidermidis (PVE-prosthetic valve)
    • Enterococci
    • Gram negative bacilli
  202. What are the less common organisms of endocarditis that would result in a negative blood culture because they are fastidious or require specific growth factors?
    • Aspergillus spp
    • Brucella spp
    • Coxiella burnetii
    • Chlamydia spp
    • HACEK group
  203. What are the three types of upper respiratory specimens submitted to the lab?
    • Throat specimens
    • External nare specimen
    • Nasopharyngeal specimen (swab or wash)
  204. What is the preferred specimen type for B. pertussis?
    Nasopharyngeal swab
  205. What is the preferred specimen type for the culture of upper respiratory viruses?
    Nasopharyngeal wash
  206. What is an external nare specimen cultured for?
    To identify carriers of Staph aureus (MRSA screening)
  207. What are the viruses responsible for the "common cold"?
    • Rhinoviruses
    • Coronaviruses
    • Adenoviruses (pharyngitis, epidemics of lower respiratory infection in military recruits)
  208. How is the common cold transmitted?
    Contact with infectious mucoid secretions.
  209. What are characteristics of the common cold that aid in clinical diagnosis?
    • Variable sneezing
    • Watery eyes
    • Nasal congestion & discharge (rhinorrhea)
    • Sore throat
    • Cough
    • Low grade fever
    • Headache
    • Malaise
  210. What complications can occur from the common cold?
    • Otitis media
    • Sinusitis
    • Lower resp tract infection
  211. What are the symptoms of influenza?
    • Rapid onset
    • High Fever
    • Headache
    • Fatigue
    • Dry cough
    • Sore throat
    • Runny/stuffy nose
    • Muscle aches
  212. How does the influenza virus cause infection?
    Viruses bind the surfaces of epithelial cells; typically in the nose, throat and lungs.
  213. What are the most common types of influenza? What conditions cause the mortality attributed to the flu?
    • Influenza A and B
    • Bacterial pneumonia, viral superinfection.
  214. Who should be tested for influenza?
    • Patients at high risk for complications.
    • Hospitalized patients with acute febrile respiratory illness, severe respiratory illness, or neurologic issues.
    • Immunocompromised patients.
  215. When should testing be done for influenza?
    • When results could influence clinical management.
    • Confirm a diagnosis (seasonal)- low prevalence (high NPV) positive rapid Ag test should be confirmed by viral culture.
    • Test in conjunction with other diagnostic tests.
    • Infection control (prophylaxis of contacts)
    • Community surveillance
  216. What could cause a FALSE POSITIVE rapid antigen result for influenza?
    FluMist (live attenuated flu vaccine)
  217. What diagnostic testing method for influenza gives a result in about 30 minutes, cheap, 40-75% sensitive, and is CLIA waived?
    Rapid antigen test
  218. What diagnostic testing method for influenza gives a result in 2-3 days, is considered the Gold Standard, and is a high complexity test?
    Viral culture
  219. What diagnostic testing method for influenza gives a result in 2-4 hours, is relatively expensive, 80-95% sensitive, and is a high complexity test?
    DFA (direct fluorescent antibody)
  220. What diagnostic testing method for influenza gives a result in 2-4 hours, is very expensive, >95% sensitive, is a high complexity test, and is recommended test to perform?
    PCR (polymerase chain reaction)
  221. When should collected specimens be transported to the lab for children and adults?
    • Children: within 72 hrs
    • Adults: within 24-48 hrs
  222. Is viral culture for influenza helpful in clinical decision making? Why or why not?
    No, because results are not available for 48-72 hours. It is mainly used to confirm a positive screening test and for public health surveillance.
  223. What are the most common agents of pharyngitis? What is the acronym for the main (big) three agents that cause this?
    • Adenovirus (pharyngoconjunctival fever)
    • Coxsackievirus (whitish, nodular vesicles in oropharynx)
    • Epstein Barr Virus (looks like GAS)
    • Herpes Simplex
    • Cytomegalovirus
    • HIV (mimics EBV infection)
    • Biggest: Adenovirus, Coxsackievirus, Epstein Barr "ACE"
  224. What are the differences in bacterial and viral pharyngitis clinical presentation?
    • Bacterial: younger kids (age), sudden onset, headache, vomiting, high fever
    • Viral: young adults (age), slow progression, coughing, rhinorrhea, low grade fever, conjunctivitis (adenovirus)
  225. What is the causative agent of streptococcal pharyngitis? Describe the disease characteristics. What other types of infections can occur?
    • Streptococcus pyogenes (GAS- group A strep)
    • Has abrupt onset of sore throat, high fever, malaise, and headache; pharynx and tonsils appear erythematous with exudate and swollen tender cervical lymph nodes.
    • Sequelae can occur: Scarlet fever, rheumatic fever (heart), glomerulonephritis (kidney)
  226. When should a patient get tested for Strep pyogenes?
    • If they exhibit 3 or more of the typical symptoms. 
    • No treatment needed if 2 or less symptoms are present.
  227. What are other bacteria besides Group A Strep that can cause pharyngitis?
    • Mycoplasma pneumoniae
    • Chlamydia pneumoniae
    • Neisseria gonorrhoeae
    • Corynebacterium diphtheriae
    • Arcanobacterium haemolyticum
  228. What are the ONLY viral agents that can give a clinical presentation similar to Group A Strep (pharyngitis)?
    • Epstein Barr Virus (mononucleosis) exudate is prominent.
    • HIV (acute retroviral syndrome which mimics EBV infection).
  229. Describe diagnostic testing for streptococcal pharyngitis.
    • Rapid antigen test (screening): 70-90% sensitive, done in 30 mins
    • Throat culture (gold standard-confirmatory): available in 24 hrs, performed as follow up to a negative rapid Ag test result
    • Serology (>24 hrs): antistreptolysin O (ASO) and anti-deoxyribonuclease B (Dnase B) to diagnose acute rheumatic fever (ARF)
  230. Describe diagnostic testing for EBV pharyngitis (typically presents with more symptoms than GAS).
    • Monospot
    • Heterophile antibody
  231. What is the virus that causes laryngotracheobronchitis (Croup)?
    Parainfluenza virus (common illness in young children 3 months-5 yrs, usually <2 yrs)
  232. What are the signs and symptoms of Croup?
    • Variable fever
    • Inspiratory stridor
    • Barking non productive cough
    • Symptoms worse at night (5-6 nights)
    • Increased/persistent breathing difficulty, fatigue, bluish coloration of skin, dehydration indicates need for medical attention.
  233. How is Croup typically diagnosed? What specimen is submitted for viral testing?
    • Clinically diagnosed (typically)
    • Nasal wash for viral culture or PCR
  234. What condition obstructs the airway, and shows the "thumb" sign in an xray?
  235. What are the 3 "D"s of epiglottitis?
    • Dysphagia
    • Drooling
    • Distress
  236. What are the clinical signs and symptoms of epiglottitis?
    • Notable choking sensation
    • Distressed during inspiration
    • Anxiousness, restlessness, irritability
    • Muffled speech ("hot potato" voice)
    • "Tripod" posture to improve breathing
    • Potentially life threatening
  237. When should laboratory studies be performed when treating a child with suspected epiglottitis?
    Not until the airway is secured.
  238. What is the causative agent of epiglottitis?
    Haemophilus influenzae type B (notify requires special growth media)
  239. What is the causative agent of diphtheria?
    Corynebacterium diphtheriae (toxin producing strain)
  240. What is the hallmark feature of diphtheria?
    Thick pseudo-membrane covering tonsils, uvula, and palate.
  241. What are the signs and symptoms of diphtheria?
    • Sudden onset with malaise
    • Sore throat
    • Exudative pharyngitis
    • Low grade fever
    • Swollen cervical lymph nodes (bull-neck)
  242. What are possible complications of severe diphtheria disease?
    • Breathing obstruction
    • Cardiac arrhythmia
    • Coma (paroxysmal stage)
    • May also produce skin lesions
  243. How is diphtheria tested for/diagnosed, and how is it treated?
    • Positive culture + toxin assay.
    • Treated with antitoxin before confirmation.
  244. What is the causative agent of pertussis?
    • Bordetella pertussis
    • Bordetella parapertussis
  245. What is the incubation period for pertussis? How do the symptoms start?
    • 7-10 days
    • Symptoms start out like a cold with development of severe coughing bouts (paroxysms), with coughs that end with a "whoop" noise (Whooping cough).
  246. How often can paroxysms occur in patient with pertussis (whooping cough)?
    40 to 50 times daily, frequently terminated with vomiting and exhaustion
  247. Name the 3 stages of pertussis infection and briefly describe them.
    • Catarrhal stage: resembles common cold (rhinorrhea, sneezing, malaise, anorexia, low fever).
    • Paroxysmal stage: whooping cough paroxysms; mucus production common.
    • Convalescent stage: paroxysms diminish in number and severity, but secondary complications can occur.
  248. At what stage is pertussis most infectious? Who are the main carriers of the disease?
    • Catarrhal stage
    • Adults (chronic cough)
  249. What is the specimen used for lower respiratory tract infections?
    • Expectorated sputum (1st morning)/Induced sputum (1st morning)
    • Gastric aspirate
  250. How is production of a sputum sample induced?
    Patient breathes aerosol (15% sodium chloride, 10% glycerin) for 10 min or until strong cough is initiated.
  251. What specimen for lower respiratory tract infection is used exclusively for acid fast bacilli isolation, and is collected from patients who are unable to produce sputum (young children)?
    Gastric aspirate (1st morning)
  252. What is bronchitis generally proceeded by?
    Upper respiratory tract infection (flu, common cold)
  253. What are the common symptoms of bronchitis?
    • Chest discomfort
    • Cough with mucus
    • Fever
    • Fatigue
    • Shortness of breath
    • Wheezing
  254. What are chronic symptoms of bronchitis?
    • Ankle, feet, leg swelling.
    • Blue lips (decreased O2 levels)
    • Frequent respiratory infections
  255. What are the infectious causes of bronchitis (acute)?
    • Viruses
    • Bacteria (secondary infection)
  256. What are the non infectious causes of bronchitis?
    • Smoke
    • Smog
    • Food particles
    • Chemical fumes
    • Vomit
    • Dust
  257. What is bronchiectasis? What causes it? When does this disease usually begin?
    • Destruction and widening of airways
    • Recurrent inflammation/infection
    • Childhood after infection or inhaling a foreign object.
  258. What is the classic example of congenital bronchiectasis? What are the 3 main organisms that are difficult to eradicate once they develop an infection?
    • Patient with cystic fibrosis.
    • Burkholderia cepacia, Staph aureus, Pseudomonas aeruginosa (mucoid)
  259. What is an acquired form of bronchiectasis and what causes it?
    COPD, smoking
  260. What is bronchiolitis? What is the main causative agent and who does it mainly affect?
    • Swelling and mucus buildup in the bronchioles.
    • Respiratory syncitial virus (RSV)- seasonal disease (fall & winter)
    • Mainly affects children <2 yrs old (also seen in elderly in long term care)
  261. What is the specimen of choice when testing a patient who has bronchiolitis?
    Nasal wash (rapid Ag, culture, PCR)
  262. What are the symptoms of bronchiolitis?
    • Bluish skin (cyanosis)
    • Cough, wheezing, shortness of breath, difficulty breathing
    • Fever
    • Intercostal retractions
    • Nasal flaring (infants)
    • Rapid breathing (tachypnea)
  263. What are the 3 types of pneumonia?
    • Community acquired
    • Nosocomial acquired
    • Immunocompromised
  264. What are the causative agents of community acquired pneumonia in children?
    • RSV
    • Metapneumovirus
    • Parainfluenza
    • Influenza
    • Adenovirus
    • H influenzae
    • S pneumoniae
    • S aureus
    • (Mainly caused by viral agents--80%)
  265. What are the causative agents of community acquired pneumonia in young adults?
    • Influenza
    • M. pneumoniae
    • C. pneumoniae
  266. What are the causative agents of community acquired pneumonia in adults?
    • S pneumoniae
    • S aureus (follows flu virus)
    • K pneumoniae (alcoholics - aspiration)
    • A baumannii (wounded SM)
    • L pneumophila
    • Mycobacterium tuberculosis
    • Anaerobes
    • Influenza
    • Histoplasma capsulatum, C immitis, C neoformans
    • (Mainly bacterial in this population)
  267. What else besides a sputum culture should be performed on a hospitalized patient with acute pneumonia?
    • Blood cultures
    • Viral culture
  268. What are the causative agents of Nosocomial Acquired Pneumonia?
    • Bacterial: E coli, multidrug resistant Acinetobacter baumannii and Pseudomonas aeruginosa, methicillin resistant S aureus (MRSA), Legionella pneumophila, and Mycobacterium tuberculosis
    • Fungi: Candida and Aspergillus species
    • Viruses: influenza and RSV
  269. What are common organisms that can pneumonia in immunocompromised patients? What is diagnosis based on for these patients?
    • HIV patients: pneumocystis carinii, S pneumoniae, MDR M. tuberculosis, Aspergillus, Cryptococcus, Capnocytophaga
    • Solid organ transplant ptCMV, HSV, L pneumophila, P carinii, Nocardia spp.
    • Diagnosis based on known patient features and manifestation.
  270. Describe the signs/symptoms of typical (bacterial) pneumonia.
    • Abrupt onset
    • High fever, shaking chills
    • Yellow/brown sputum when coughing
    • Chest pain (worse with breathing/coughing)
    • Shortness of breath (esp. w/ chronic condition like asthma/emphysema)
  271. Describe the signs/symptoms of atypical (bacterial, viral, fungal, parasitic) pneumonia.
    • Gradual onset
    • Usually follows other illness
    • Lower fever, chills and shaking less likely
    • Headache, body ache, joint pain
    • Dry cough or very little sputum production
    • Slight/no chest pain
    • Possible abdominal pain
    • Malaise & myalgia
    • Mycoplasma pneumoniae
  272. What is the typical laboratory workup for patients with pneumonia?
    • Blood culture (hospitalized pt)
    • Sputum gram stain & culture (hospitalized pt)
    • Urinary Ag test (S pneumoniae/ L pneumophila)
    • Endotracheal aspirate culture (intubated pt)
    • Pleural fluid culture (effusion present)
    • Chemistry panels
    • Arterial blood gas determination (ABG)
    • Complete blood cell count (CBC)
  273. What is the latest "big thing" in biomarkers? Why is it useful in guiding antibiotic therapy?
    • Procalcitonin
    • Elevated levels have a high sensitivity and specificity for detecting/diagnosing bacterial infection.
  274. Describe Fungal Pneumonia.
    • Clinical Manifestations: Fever, dry cough, pleuritic chest pain, dyspnea, obstructive symptoms, hemoptysis, history of travel to or exposure
    • CBC count with differential: Elevated WBC count with endemic mycoses, Eosinophilia may denote Coccidioides, Neutropenic or leukopenic pts may be infected with Candida or Aspergillus
  275. What are endemic fungal pathogen that can cause fungal pneumonia?
    • Histoplasma capsulatum
    • Coccidioides immitis
    • Blastomyces dermatitidis
    • (these agents cause infection in both healthy and immunocompromised hosts)
  276. What are opportunistic fungal organisms that cause pneumonia in patients with congenital/acquired defects in host defenses?
    • Candida spp
    • Aspergillus spp
    • Mucor spp
    • Cryptococcus neoformans
  277. What microscopic exam allows you to look for fungal hyphae or yeasts?
    KOH prep
  278. What is defined as necrosis of the pulmonary tissues caused by microbial infection (creates cavities)?
    Lung abscess
  279. What is most common cause of lung abscess? What are the agents responsible of developing infection?
    • Aspiration (alcoholics)
    • Mainly anaerobes, Klebsiella pneumoniae, S aureus, S pneumoniae
  280. What are the signs/symptoms of lung abscess?
    • Cough
    • Fever
    • Night sweats
    • Foul smelling purulent sputum
    • Hemoptysis
    • Chest pain
    • SOB
    • Lethargy
  281. What is a collection of pus in the pleural space referred to as? How much infected fluid can build up?
    • Empyema
    • A pint or more.
  282. What are the most common causes of viral pneumonia?
    • Influenza virus
    • Respiratory syncytial virus (RSV)
    • Adenovirus
    • Parainfluenza virus (PIV)
  283. What are the lesser common causes of viral pneumonia?
    • Human metapneumovirus
    • Coronavirus (SARS)
  284. What agents cause pneumonia and rash?
    • Measles
    • Varicella zoster (chicken pox)
  285. What are the agents that commonly cause viral pneumonia in immunocompromised patients?
    • Cytomegalovirus (CMV)
    • Herpes simplex
  286. What are the zoonotic agents that cause viral pneumonia in humans?
    • Hantavirus
    • Avian influenza
    • Swine flu
  287. What is the causative agent of tuberculosis? How is TB usually transmitted? What organs are affected? What does TB combined with HIV cause?
    • Mycobacterium tuberculosis
    • Through air (infected person coughs, sneezes, talks)
    • Usually infects lungs (increasing drug resistance)
    • TB combined with HIV makes a syndemic (2 pandemics combined)
  288. What are the typical symptoms of TB?
    • Fever
    • Night sweats
    • Weight loss
    • Hemoptysis
    • (Some infected persons may not show symptoms).
  289. Name the bacterial agents that cause rare opportunistic pulmonary infections (pneumonia).
    • Klebsiella pneumoniae
    • Staphylococcus aureus
    • Coxiella burnetii (Q fever)
    • Legionella pneumophila (Legionellosis)
    • Bacillus anthracis (inhalation anthrax)
  290. What organism is aerobic, capable of causing aspiration pneumonia, is a gram negative encapsulated bacillus, and is most likely to affect alcoholics?
    Klebsiella pneumoniae
  291. What organism causes an opportunistic pulmonary infection following an influenza infection, has a high mortality rate, is common in immunocompromised pts, and is usually acquired in a hospital or institution?
    Staphylococcus aureus (pneumonia)
  292. What organism is a zoonotic gram positive spore forming coccobacillus, is found globally, can be excreted in the milk, urine or feces of affected animals, and can cause opportunistic pulmonary infection in humans?
    Coxiella burnetii (Q fever)
  293. What organism is a gram negative bacillus found in water sources, is acquired by inhalation of contaminated water mist, and causes atypical pneumonia in which affected pts present with watery secretions?
    Legionella pneumophila (Legionellosis)
  294. What organism is a gram positive spore forming facultative anaerobe, causes opportunistic infection through contact with skin, inhalation or ingestion, releases toxins that cause internal bleeding, swelling and tissue necrosis, and has a hallmark presentation of a widened mediastinum?
    Bacillus anthracis (anthrax)
  295. Name the virus that may/may not present with keratoconjunctivitis and diarrhea depending on the serotype. Name the serotype that was associated with AF recruit mortality at Lackland AFB.
    • Adenovirus
    • Serotype 14 pneumonia
  296. What is the causative agent of mononucleosis? What lab tests would be performed, and what would be some of the findings?
    • Epstein Barr Virus (EBV)
    • Monospot, elevated WBC (atypical lymphs on blood smear)
  297. What virus is transmitted person to person by respiratory droplets, can be life threatening, is followed by pneumonia after initial infection, and is the causative agent of severe acute respiratory syndrome (SARS)?
  298. What virus causes a deadly disease that fills the lungs with fluid (adult respiratory stress syndrome), is carried by rodents, transmitted by contact with infected animal droppings, and is fatal is 30-40% of cases?
    Hantavirus (Hantavirus pulmonary syndrome)
  299. What is the causative agent of Histoplasmosis? What are the reservoirs?
    • Histoplasma capsulatum
    • Soil around chicken coops, starling bird roosts, bat caves (guano).
  300. What is the causative agent of Blastomycosis? What are the reservoirs?
    • Blastomyces dermatitidis
    • Primarily wood and soil.
  301. What is the causative agent of coccidioidomycosis? What are the reservoirs/where is it found?
    • Coccidioides immitis
    • Desert soil, rodent burrows in southwestern United States.
  302. What is the most commonly encountered infection in primary care?
    Foodborne illness, diarrhea (GI infections)
  303. What are things to look for when trying to diagnose a GI problem?
    • Presenting symptoms
    • Exposure to particular food associated with foodborne disease
    • Time interval between exposure to suspect food and onset of symptoms
  304. What are the 4 methods of food borne illnesses?
    • Ingestion of pre-formed toxin.
    • Toxin production following ingestion of organism.
    • Tissue invasion by microorganism.
    • Toxin production and/or tissue invasion (combination).
  305. Name the organisms that cause foodborne illness due to ingestion of a pre-formed toxin.
    • Staph aureus
    • Bacillis cereus
    • Clostridium botulinum
  306. Name the organisms that cause foodborne illness due to toxin production after ingesting the organism?
    • Bacillus cereus
    • Clostridium botulinum
    • Clostridium perfingens
    • ETEC, STEC
    • Vibrio cholerae
  307. Name the organisms that cause foodborne illness by way of tissue invasion.
    • Salmonella
    • Shigella
    • Campylobacter jejuni
    • EIEC, EHEC
  308. Name the organisms that cause foodborne illness by way of toxin production and/or tissue invasion (combination).
    • Vibrio parahemolyticus
    • Yersinia enterocolitica
  309. What is the timing in onset of symptoms of a foodborne illness that would suggest ingestion of a chemical?
    0-1 hour
  310. What is the timing in onset of symptoms of a foodborne illness that suggests ingestion of a preformed toxin? What organisms are specific to those time frames?
    • 1-6 hrs: Staph aureus, B cereus
    • 8-16 hrs: C perfringens, enterotoxin producing B cereus
    • >16 hrs: various bacteria & viruses (may overlap with diarrhea)
  311. What are the two types of diarrhea? What changes in stool may indicate disease?
    • Acute (<4 wks- generally infectious), Chronic (>4 wks- infectious/non infectious)
    • Frequency, consistency, volume, composition.
  312. What are some basic mechanisms of diarrhea?
    • Increased osmotic load (laxative, lactose intolerance).
    • Increased secretions (water, salts, minerals) from infection, unabsorbed fat, certain drugs.
    • Decreased contact time/surface area (hypermotility) from conditions like gastric bypass, inflammatory bowel, sprue.
  313. What are the types of infectious diarrhea? What are some key characteristics?
    • Secretory: non-inflammatory, watery diarrhea, affects small bowel, usually self limited, high volume
    • Inflammatory: feature mucus and PMN in diarrhea, affects large bowel, positive for fecal WBC, lasts longer than self limiting, low volume
    • Hemorrhagic: same as inflammatory with addition of blood in stool, lasts longer than self limited and causes complications, low volume
  314. What are relevant clinical questions to ask patients that present with diarrhea to help determine the need for fluid replacement and/or hospitalization?
    • Timing of disease presentation (abrupt/gradual onset, duration)
    • Stool characteristics (watery=sm bowel, bloody/mucoid/purulent= large bowel, greasy, etc)
    • Frequency of BM and quantity
    • Signs/symptoms of dysentery (fever, tenesmus, blood/pus in stool; potentially infectious)
    • Volume depletion/hydration status (thirst, tachycardia, orthostasis, decreased urine output, lethargy, decreased skin turgor)
    • Additional symptoms and their intensity (nausea, vomiting, cramps, abd. pain, HA, etc)
  315. What are the relative risk factors in helping diagnose GI infections?
    • Travel to 3rd world country (ETEC, Hep A/E)
    • Day care (child/employee)- commonly Giardia
    • Visits to petting zoo/household pets (E. coli O157:H7, Salmonella from reptiles)
    • Other ill people in area (barracks, dorm, office)
    • Recent/regular medication (antibiotics, antacids, antimotility agents)
    • Underlying medical condition (immunosuppression)
    • Anal intercourse/oral-anal sex (Hep A, HIV)
    • Occupation as a food handler/caregiver
  316. What GI infections are patients with sickle cell disease mostly predisposed to?
    Salmonella spp (Salmonellosis)
  317. What are the main pathogens the lab looks for when performing a stool culture for GI infection?
    • Salmonella
    • Campylobacter
    • Shigella
  318. A child presenting as febrile with non-bloody diarrhea will most likely have what type of infection?
    Viral enteritis (infection)
  319. A child presenting as afrebrile with non-bloody diarrhea will most likely have what type of infection?
    Viral enteritis (infection)
  320. A child presenting as febrile with bloody/mucousy diarrhea will most likely have what type of infection?
    Infectious bacterial enteritis (infection)
  321. A child presenting as afebrile with bloody diarrhea will most likely have what type of infection?
    • Bacterial infection with complications (intussusception, hemolytic uremic syndrome (HUS), pseudomembranous colitis)
    • Most worrisome category.
  322. What are the IDSA guidelines used to assist in diagnosis and test performance of GI infection?
    • Do selective testing: stool cultures have a very low yield, 2% positive rate of isolating pathogens, and are expensive.
    • Screen for inflammatory or invasive diarrhea (Salmonella, Shigella, Campylobacter): any inflammatory diarrhea needs to be cultured (test for fecal WBC or lactoferrin). 
    • Diagnose based on history and symptoms: all non inflammatory diarrheas typically do not require additional workup.
    • 3 day rule: hospitalized >3 days look for C diff
  323. Describe the interpretation of the level of seriousness for diarrhea.
    • Acute, watery: self limiting
    • Acute bloody: invasive infection
    • Recurrent bouts of bloody: inflammatory bowel disease
    • Fatty stool + weight loss: malabsorption
    • Diarrhea after eating certain foods: food intolerance
    • Recent antibiotic use: abx associated diarrhea
  324. What does a regular stool culture look for?
    Big 3: Salmonella, Shigella, Campylobacter
  325. What does an extended stool culture look for?
    Little 3: Vibrio, Yersinia, E coli O157:H7
  326. What are tests that can be performed on stool that require a special request?
    • Shiga toxin assay (Shigella & E coli O157:H7)
    • C difficile, C botulinum, L monocytogenes
    • Fungal/viral culture (Candida, CMV)
  327. What does the triage parasite panel (rapid assay) look for?
    • Giardia
    • Cryptosporidium
    • E. histolytica
  328. What is the rapid assay that looks for fecal occult blood?
    Guaiac test
  329. What rapid assay checks for the presence of Shiga toxin (Shigella & E coli O157:H7), and C. difficile?
    EIA (independent of organism presence)
  330. What diarrheal agents can be present without causing fecal WBCs to appear?
    • Viral diarrhea
    • Cholera
    • Parasites (Giardia, Entamoeba)
    • Toxic diarrheas (Staph, Clostridium)
  331. What diarrheal diseases cause a large number of fecal WBCs?
    • Chronic bacillary dysentery
    • Chronic ulcerative colitis
    • Colonic abscess
  332. What type of fecal WBCs are seen in Typhoid fever?
  333. What type of fecal WBCs are seen in ulcerative colitis, invasive E coli diarrhea, Salmonella, and Shigellosis?
  334. What tests require fresh stools?
    • Fecal leukocyte – fresh, C-B
    • Fecal fat – fresh, C-B
    • Macroscopic, pH - fresh
  335. Explain the different types of stool according to the Bristol stool chart.
    • Type 1: separate hard lumps, like nuts
    • Type 2: sausage shaped and lumpy
    • Type 3: like sausage but with crack on surface
    • Type 4: like sausage or snake, smooth and soft
    • Type 5: soft blobs with clear-cut edges
    • Type 6: fluffy pieces with ragged edges, mushy
    • Type 7: watery, no solid pieces (entirely liquid)
    • Type 8: mucous-like consistency w/ bubbles and foul odor
  336. When should you NEVER use antibiotics when treating diarrhea?
    E coli O157 because release of toxin from dying bacteria increases chances of HUS.
  337. When would you NOT want to use antidiarrheals when treating diarrhea?
    Shigella (predisposed to toxic dilation of colon)
  338. What are the symptoms, sources and diagnosis for Bacillus cereus diarrhea?
    • Symptoms (toxins): emetic form (nausea, vomiting), diarrheal form (diarrhea, abdominal pain)
    • Source: fried rice (chinese restaurant)
    • Diagnosis: clinical, outbreak (epidemiology)
  339. What are the symptoms, sources and diagnosis for Clostridium botulinum diarrhea?
    • Symptoms: flaccid paralysis, intoxication, rapid onset and decline
    • Source: raw honey (infants), home canned food
    • Diagnosis: culture (slow), toxin detection (serum, stool, food)
  340. What are the symptoms, sources and diagnosis for Staphylococcus aureus diarrhea?
    • Symptoms: food poisoning (1-6 hrs), nausea, vomiting, cramps, ingestion of enterotoxin
    • Source: casseroles, mayonnaise dishes (potato salad), food preparer's fingers
    • Diagnosis: not performed, resolves quickly
  341. What are the symptoms, sources and diagnosis for Clostridium perfringens diarrhea?
    • Symptoms: food poisoning (8-12 hrs), cramps and watery diarrhea
    • Source: high protein foods (gravies, meat dishes)
    • Diagnosis: clinical, outbreak (epidemiology)
  342. What are the symptoms, sources and diagnosis for E. coli (ETEC)?
    • Symptoms: enterotoxigenic, cramps and watery diarrhea, "Traveler's diarrhea"
    • Source: contaminated food/water
    • Diagnosis: clinical, culture usually not performed, culture on special patients
  343. What are the symptoms, sources and diagnosis for E. coli (EHEC)?
    • Symptoms: cramping and bloody diarrhea (dysentery like), hemorrhagic colitis, hemolytic uremic syndrome (HUS)
    • Source: improperly cooked hamburger, juice, petting zoos
    • Diagnosis: extended stool culture (sorbitol MAC plate + typing kit), Shiga toxin assay (faster, and recommended for ALL bloody diarrhea cases)
  344. What are the symptoms, sources and diagnosis for Campylobacter jejuni?
    • Symptoms: fever, cramping, bloody diarrhea
    • Source: undercooked poultry, unpasteurized milk
    • Diagnosis: stool culture, fecal leukocyte, EIA
  345. What are the symptoms, sources and diagnosis for Clostridium difficile?
    • Symptoms: watery diarrhea with low grade fever and abd pain, pseudomembranous colitis
    • Source: prolonged antibiotic use
    • Diagnosis: cell culture (cytotoxins), EIA (toxin assay), PCR
  346. What are the symptoms, sources and diagnosis for Listeria monocytogenes?
    • Symptoms: fever, nausea, diarrhea, muscle aches, headache (meningitis), flu-like symptoms, stillbirth
    • Source: unpasteurized cheese, lunch meats, ice cream, chocolate milk, hot dogs
    • Diagnosis: special request stool culture
  347. What are the symptoms, sources and diagnosis for Salmonella enteritidis?
    • Symptoms: nausea, vomiting, abd pain, bloody diarrhea, fever, chills, headache
    • Source: raw/undercooked meat, poultry, or eggs (also reptiles)
    • Diagnosis: stool culture, serotyping of culture
  348. What are the symptoms, sources and diagnosis for Salmonella typhi?
    • Symptoms (typhoid fever): diarrhea/constipation, high fever, rose spots, cough, mental confusion, slow heartbeat, hepatosplenomegaly
    • Source: contaminated food/water, fecal-oral route, developing country
    • Diagnosis: stool culture, agglutination assay (Vi Ag)
  349. What are the symptoms, sources and diagnosis for Shigella spp?
    • Symptoms: bloody diarrhea + mucus (dysentery), abd cramps, fever, rectal spasms
    • Source: fecal-oral route, contaminated food or water
    • Diagnosis: stool culture, fecal leukocyte, Shiga toxin assay (faster, and recommended in ALL bloody diarrhea cases)
  350. What are the symptoms, sources and diagnosis for Vibrio cholerae?
    • Symptoms: voluminous water diarrhea, rice water stools, fishy odor
    • Source: contaminated water
    • Diagnosis: extended stool culture, serotyping of isolate, PCR
  351. What are the symptoms, sources and diagnosis for Yersinia enterocolitica diarrhea?
    • Symptoms: bloody diarrhea, fever, abd pain and cramps, pseudoappendicitis
    • Source: improperly cooked pork products (chitterlings, menudo)
    • Diagnosis: extended stool culture, fecal leukocytes
  352. What are the symptoms, sources and diagnosis for Giardia lamblia?
    • Symptoms: foul-smelling bulky diarrhea, flatus, and fatty yellow stools
    • Source: contaminated water
    • Diagnosis: ova and parasite exam, rapid EIA
  353. What are the symptoms, sources and diagnosis for Cryptosporidium parvum?
    • Symptoms: watery diarrhea, dehydration, weight loss, stomach cramps, fever, nausea, vomiting
    • Source: contaminated water
    • Diagnosis: ova and parasite exam, acid fast cell wall, rapid EIA
  354. What are the symptoms, sources and diagnosis for Entamoeba histolytica diarrhea?
    • Symptoms (amoebic dysentery): dysentery, liver abscess, pain, intestinal blockage
    • Source: contaminated food and water
    • Diagnosis: ova and parasite exam (trophozoite ingested RBCs), rapid EIA
  355. What are the symptoms, sources and diagnosis for Hepatitis A virus?
    • Symptoms: nausea, vomiting, diarrhea, low fever, anorexia, rash, fatigue, jaundice, dark urine, liver pain
    • Source: contaminated food, water, undercooked shellfish
    • Diagnosis: liver function tests, acute hepatitis panel (HAV IgM, HBc IgM, HBsAg, HCV)
  356. What are the symptoms, sources and diagnosis for rotavirus?
    • Symptoms: watery diarrhea (can become bloody), vomiting, high fever
    • Source: fecal oral route, day care, diapers
    • Diagnosis: clinical, rapid EIA
    • *Also known as winter vomiting disease and mainly affects children.
  357. What are the symptoms, sources and diagnosis for norovirus?
    • Symptoms: sever diarrhea, projectile vomiting, abd pain, cramping, malaise, low fever
    • Source: highly contagious, fecal oral route, confined spaces
    • Diagnosis: clinical, PCR, EM
  358. What are the symptoms, sources and diagnosis for Helicobacter pylori?
    • Symptoms: abd pain, bloating and fullness, dyspepsia, mild nausea, acid reflux, flatulence, chronic gastritis, ulcer
    • Source: poor sanitary conditions, fecal-oral route
    • Diagnosis: stool Ag assay, urea breath test, serolgoy
  359. Describe acute septic arthritis.
    • Evolves over hours or days in synovial or periarticular tissues
    • Mainly affects children or young adults
    • Multiple agents – aerobes, anaerobes, viruses
    • Common agent – Neisseria gonorrhoeae – disseminated infection (DGI)
  360. Described chronic septic arthritis.
    • Slow onset, gradual swelling, warmth (slow growing organisms)
    • Mainly affects patients with underlying illness (rheumatoid arthritis, immunosuppression, or prosthetic joints)
    • Typical agents – Mycobacterium, fungi, B burgdorferii (Lyme)
  361. What are the symptoms of Non-Gonococcal Septic Arthritis?
    • Common Symptoms: Redness, warmth, swelling; Limitation of movement
    • Newborns and Infants Symptoms: Cries when infected joint is moved, Fever, Irritability
    • Children and Adults Symptoms: Intense joint pain, Low fever
  362. What are the symptoms of Gonococcal Septic Arthritis?
    • Common symptoms: purulent arthritis without skin lesions, triade of tenosynovitis, deratitis, polyarthralgias without purulent arthritis
    • Young adults: mainly women (asymptomatic for primary infection; dissemination)
  363. What is the most common form of septic arthritis?
  364. Describe the basic Arthritis Lab Workup.
    • Aspiration of joint fluid for synovial fluid analysis includes: cell count + diff, polarizing microscopy, gram stain + culture.
    • Blood culture
    • CBC
    • Gonococcal infections: Cultures of blood, endocervix, and urethra are essential; cultures of the pharynx and rectum may be very helpful.
  365. What are the causative agents of Osteomyelitis?
    • Acute - S. aureus or Streptococcus species
    • Chronic – (diabetic ulcers) Enterobacteriaceae
    • Prosthetics – S. epidermidis
  366. What are the 3 routes of infection for Osteomyelitis?
    • Hematogenous spread (metaphysis of growing bones-children, spine-adults)
    • Direct inoculation (direct trauma)
    • Contiguous spread (poor blood supply, recent trauma; spread from adjacent site infection)
  367. What is the appropriate Lab workup for osteomyelitis?
    • Blood cultures
    • Bone biopsy (which is then cultured)
    • Needle aspirate for culture
    • Complete blood count (CBC)
    • C-reactive protein (CRP)
    • Erythrocyte sedimentation rate (ESR)
    • Needle aspiration of the area around affected bones
  368. What are the symptoms of osteomyelitis?
    • Bone pain
    • Fever
    • General discomfort, uneasiness, ill-feeling
    • Drainage, sinus tracts, ulceration
    • Local swelling, redness, warmth
    • Reduction in extremity use
  369. What does a Wood’s Lamp detect?
    Fluorescence that helps diagnose dermatological disease – mostly caused by fungi.
  370. What part of the skin should be excised deeply for histologic evaluation of depth in a punch biopsy?
    All pigmented lesions.
  371. What is a Tzanck Smear used for?
    • Diagnose herpes virus infections (HSV or VZV)
    • Uses Wright or Giemsa stain. Multinucleated giant cells are a sign of herpes infection.
    • Very poor sensitivity
  372. What is diascopy used for?
    • Determines lesion type by testing for blanchability.
    • Hemorrhagic lesions, nonvascular lesions do not blanch; inflammatory lesions do blanch.
  373. What is the agent, symptoms and diagnosis of Scarlet Fever?
    • Strep pyogenes (SPE A exotoxin)
    • Symptoms - Begins with fever and sore throat; might also exhibit chills, vomiting, abdominal pain, fine “sandpaper” rash, diffuse, blanching, desquamation afterwards, “Strawberry tongue
    • Diagnosis- clinical, throat culture
  374. Define Erysipelas and the causative agent.
    • Type of superficial cellulitis with dermal lymphatic involvement.
    • Strep pyogenes (GAS)
  375. What are the symptoms and diagnostic tests of Erysipelas?
    • Symptoms: shiny, raised, indurated, and tender plaque-like lesions with distinct margins; “peau d’orange” appearance.
    • Diagnostic tests: routine CBC, CRP, ESR, blood culture in toxic pts
  376. What are the symptoms of impetigo?
    • Infects superficial layers of the skin (nonfollicular).
    • Progresses from macule to honey colored crusty vesicle/pustule, pruritis, fragile vesicles rupture and can spread with scratching, poorly healing wound.
    • More serious form found in pts with pre-existing skin disease (eczema, chickenpox)
  377. What are the types of impetigo?
    • Bullous (fluid filled)
    • Non-bullous (more common)
    • Occurs frequently in children around nose and lips.
  378. What are the agents of impetigo?
    • Staph aureus
    • MRSA
    • Strep pyogenes
    • May be dual infection.
  379. What are the causative agent, symptoms and source of Folliculitis?
    • Staph aureus
    • Symptoms: rash, itching, pimples/pustules near a hair follicle in the neck, groin, or genital area. Pimples may crust over. Rash is thicker under swimsuit areas (hot tub folliculitis).
    • Source: hair follicles damaged by friction from clothing, blockage, shaving, hot tubbing (wooden)
  380. What is Ecthyma?
    Ulcerative form of impetigo ("deep impetigo").
  381. What are the symptoms of Ecthyma?
    • Small blister w/ red border that may be filled with pus (main symptom).
    • Blister similar to those found in pts with impetigo but infection spreads deeper into skin.
    • After blister goes away a crusty ulcer appears.
  382. What are the agents, routes of infection, diagnosis techniques and risky behaviors for Cellulitis?
    • GAS, Staph aureus, MRSA
    • Occurs where skin is compromised by spider bite, blister, animal bite, rash, athlete's foot, dry skin, etc.
    • Diagnosed clinically and with blood and tissue culture from immunocompromised pt (bacteria common).
    • IV drug users are at increased risk for severe Streptococcal cellulitis.
  383. What are the symptoms of Cellulitis?
    • Pain
    • Rapidly spreading erythema & edema
    • Fever may occur
    • Region lymph nodes by enlarge
  384. What are the causes and symptoms of Halophilic Vibrio Infection?
    • Caused by V. vulnificus in those who eat contaminated seafood/have an open wound that is exposed to seawater.
    • Symptoms include vomiting, diarrhea, abd pain.
    • In immunocompromised pts (esp. w/ chronic liver disease), organism can infect the bloodstream causing septic shock, gangrenous cellulitis and blistering skin lesions.
  385. What are the agents, sources, symptoms and diagnosis of skin Clostridial Infections (necrotizing fasciitis)?
    • Clostridium botulinum/perfringens/tetani
    • Symptoms include cellulitis, lymphangitis, lymphadenopathy at wound site, rapid destruction of muscle (gangrene), contaminated devitalized tissue.
    • Source is from a penetrating wound.
    • Diagnosed clinically, culture comes after (gram stain shows GPR, no PMNs)
  386. Where does Rocky Mountain Spotted Fever come from?
    Typically found in Eastern US- NC, SC, OK
  387. What are the symptoms of Rocky Mountain Spotted Fever?
    • Fever
    • Headache
    • Abdominal pain
    • Vomiting
    • Muscle pain
    • Rash comes later (not everyone gets one!)
  388. What is the causative agent of Rocky Mountain Spotted Fever?
    Rickettsia rickettsii
  389. What is the Gold standard testing used to detect rocky mountain spotted fever?
    Serology (indirect immunofluorescence assy)
  390. What is the causative agent of Lyme disease?
    Borrelia burgdorferi
  391. What are the symptoms of Lyme disease?
    • Fatigue
    • Malaise
    • Fever
    • Chills
    • Myalgia
    • Headache
    • Erythema migrans (bullseye rash)
    • Meningitis (complication if untreated)
    • Late stage manifestation: arthritis, other neurological complaints
  392. How is Lyme disease diagnosed?
    Clinical diagnosis + lab confirmation (serology like HIV--EIA followed by Western Blot)
  393. What is the causative agent of Tularemia?
    Francisella tularensis (rabbit fever)
  394. What are the symptoms of Tularemia? How is it diagnosed?
    • Ulceroglandular form (most common)
    • Diagnosis difficult, based on symptoms and patient history (wildlife exposure).
    • Is a biothreat agent (Category A="Uh oh" disease)
  395. What infection does Tineas cause? How is it transmitted, etc.?
    • Ringworm (dermatophyte infection) by Trichophyton, Epidermophyton or Microsporum.
    • Transmitted by direct contact.
    • Location of infection determines the name of disease.
    • Diagnosis is mainly clinical, Wood's lamp, KOH microscopy, culture.
  396. What is the agent of Sporotrichosis? What are its symptoms?
    • Sporothrix schenckii (dimorphic fungi) "Rose handler's" disease
    • Poorly healing skin wounds (red, nodular lesions of the skin, along with secondary lesions of lymphatic vessels).
  397. Define herpes, what the agent is, and the symptoms.
    • HSV infection, cold sores, genital herpes, gingivostomatitis.
    • Caused by herpes simplex virus.
    • Symptoms- vesicles at source of contact with virus.
  398. What are the sources of contracting herpes virus?
    • Transmitted by direct contact with a lesion or body fluid of an infected individual.
    • Virus becomes laten in ganglion (recurring).
  399. How is herpes diagnosed?
    Clinically, PCR, cell culture, tzanck prep
  400. What presentation of herpes do nurses and wrestlers typically get?
    • Nurses: Herpetic whitlow (fingers)
    • Wrestlers: Herpes gladiatorum (face)
  401. Describe the agent, source and diagnosis of chicken pox. What is a secondary infection (in adults) caused by this same virus?
    • Varicella zoster virus (VZV)
    • Spread by coughing & sneezingdirect contact, and aerosolization of virus from skin lesions (on trunk).
    • Diagnosed clinically, with PCR or tzanck prep
    • Adults who have had chicken pox may develop shingles (latency) on a dermatome.
  402. What are the symptoms of chicken pox?
    • Fever
    • Itchy rash
    • Skin rash (blister like lesions)
    • Rash covering body but more concentrated on the face, scalp.
    • Rash development is asynchronous.
  403. Describe the agent, source and diagnosis of small pox.
    • Variola virus (major and minor)
    • Spreads by saliva droplets/contact with infected materials (sheets, clothing, etc); patient is contagious during the first weekk of the infection until scabs from the rash fall off.
    • Diagnosed clinically, with PCR or viral culture
  404. What are the symptoms of small pox?
    • Backache
    • Delirium
    • Diarrhea
    • Excessive bleeding
    • Fatigue
    • High fever
    • Malaise
    • Headache Vomiting
    • Raised pink rash progressing simultaneously from macules to papules to pustules then scabs (synchronous growth).
  405. What are the differences between smallpox and chicken pox?
    • Severity and location of lesions (VZV- trunk; SP- extremities)
    • Types of lesions (VZV- combination scabs, vesicles, pustules; SP- synchronous lesions)
    • Timing of transmission (VZV- contagious before pox appear; SP- contagious after pox appear)
  406. Which Viral infections produce rashes?
    • Measles (rubeola)
    • German measles (rubella)
    • Shingles (VZV)
    • 5th disease (erythema infectiosum, parvovirus)
    • Roseola (erythema subitum, human herpes virus 6)
    • Echovirus & adenovirus
    • EBV
    • Primary HIV infection
  407. Describe the agent, source, and diagnosis of Rubeola.
    • Rubeloa virus
    • Spread by contact with droplets from the nose, mouth, or throat of infected person.
    • Diagnosed clinically, with PCR or viral culture (serology- measles IgM, Measles IgG=4 fold increase), can be cultured from throat, urine, nasal specimens
  408. What are the symptoms of Rubeola?
    • Rash
    • Koplik spots
    • Red eyes
    • Photophobia
    • Coughing
    • Fever
    • Runny nose
    • Sore throat
  409. Describe the agent, source and diagnosis of Rubella.
    • Rubella virus (German measles "3 day measles")
    • Spread through the air or by close contact.
    • Diagnosed clinically, with PCR or viral culture (serology- Rubella IgM, Rubella IgG=4 fold increase) can be isolated from nasal, throat, urine, CSF, and blood specimens
  410. Differentiate Rubeola or Rubella with respect to time of disease, fever, and other symptoms.
    • Measles (rubeola), German measles (rubella)
    • M- generalized maculopapular rash for >3 days; GM- acute onset of maculopapular rash for <3 days
    • M- fever >101˚F (38.3˚C); GM- fever >99˚F (>37.2˚C)
    • M- cough, coryza/conjunctivitis; GM- arthralgia, arthritis, lymphadenopathy/conjunctivitis
    • M- Koplik spots
  411. Describe the agent, source and diagnosis of 5th disease.
    • Parvovirus B19
    • Spread through air or close contact.
    • Diagnosed clinically, with serology or PCR
  412. What are the symptoms of 5th disease?
    • Rash
    • Fever
    • Headache
    • Slapped cheek appearance of face
    • "Lacy" rash on extremities
    • Severe congenital infection
  413. Describe the agent, source, and diagnosis of Roseola.
    • HHV6 or HHV7
    • Spread between children 6-15 months via transfer of oral secretions.
    • Diagnosed clinically (rash, swollen lymph nodes, serology)
  414. What are the symptoms of Roseola?
    • Higher fever followed by rash on trunk, limbs, neck and face (starts on trunk).
    • Rash is pink/rose-colored, and has fairly small sores that are slightly raised.
  415. What is the definition of Roseola?
    Acute disease of infants & young children that causes rash and high fever (6th disease).
  416. Describe the agent, source, and diagnosis of infectious mononucleosis.
    • Epstein Barr Virus
    • Spread by intimate contact with saliva of infected person (can look like strep throat!)
    • Diagnosed with blood smear, monospot, heterophile antibody test
  417. What are the symptoms of EBV?
    • Fever
    • Sore throat
    • Swollen lymph glands
    • Swollen spleen
    • Liver involvement
  418. Describe the symptoms and diagnosis of Primary HIV infection.
    • Symptoms are similar to common illnesses like the flu or mono. Most common body-wide S&S include fever, sore throat, headache, muscle and joint pain (last about 2 weeks).
    • Infected ppl are highly contagious at this stage (do not realize they have it). Can look like strep throat!
    • Many ppl also develop a rash 2-3 days after fever on face, neck, upper chest (may be more widespread), that lasts about 5-8 days.
    • Diagnosis includes a positive screening and confirmation test.
  419. What is the cause of Cutaneous larva migrans?
    • Hookworm larvae (Acylostoma duodenale, Necator americanus)
    • AKA "creeping eruption"
  420. What are the forms of Leishmaniasis?
    • Cutaneous (sores on skin, volcanic appearance with raised edge and central crater)
    • Visceral form (fever, weight loss, hepatosplenomegaly, anemia, kala-azar)
  421. How is Leishmania spread?
    Phlebotomine sandfly
  422. How do Meningeal pathogens enter the CNS?
    The respiratory route- pathogen evades host immune response and enter submucosa, eventually cross the blood-brain barrier and access CSF.
  423. What are the cell, glucose, protein, and opening pressure of normal CSF?
    • Cells per L: 0-5 lymphs
    • Glucose: 45-85 mg/dL
    • Protein: 15-45 mg/dL
    • Pressure: 70-180 mm H2O
  424. What are the cell, glucose, protein, and opening pressure of CSF with bacteria?
    • Cells per L: 200-20,000 PMNs
    • Glucose: Low (<45 mg/dL)
    • Protein: High (>50 mg/dL)
    • Pressure: greatly increased
  425. What are the cell, glucose, protein, and opening pressure of CSF with viral infection?
    • Cells per L: 100-1000, mostly lymph
    • Glucose: Normal (45-85 mg/dL)
    • Protein: Moderately high (>50 mg/dL)
    • Pressure: Normal to increased
  426. What are the cell, glucose, protein, and opening pressure of CSF with fungal infection?
    • Cells per L: 100-1000, mostly lymphs
    • Glucose: Low (<45 mg/dL)
    • Protein: High (>50 mg/dL)
    • Pressure: Moderately increased
  427. What are the cell, glucose, protein, and opening pressure of CSF with parasitic infection?
    • Cells per L: 100-1000 eosinophils
    • Glucose: Normal or Low (≤45-85 mg/dL)
    • Protein: High (>50 mg/dL)
    • Pressure: Increased
  428. Name 4 CNS infections.
    • Meningitis (rapidly fatal, early symptoms resemble flu/cold)
    • Encephalitis
    • Brain abscess
    • Subdural empyema
  429. What is the Classic triad of meningitis?
    • Fever
    • Headache
    • Stiff neck
  430. What are the "big 3" agents of bacterial meningitis?
    • Strep pneumoniae
    • Neisseria meningitidis (petchiae)
    • Haemophilus influenzae type B
  431. What are the signs and symptoms of bacterial meningitis?
    • Headache
    • High fever
    • Stiff painful neck
    • Photophobia
    • Nausea
    • Vomiting
    • Deteriorating level consciousness
    • Generalized purpura
    • Edematous eyelids (swollen shut)
    • DIC
    • Neutrophils with intracellular bacteria
    • Waterhouse-Friedrichsen Syndrome
  432. What are the agents of Viral Meningitis?
    Enterovirus (spring-summer), Arbovirus- warm months (West Nile, St Louis encephalitis virus), HSV, HIV, Adenovirus, Measles (winter)
  433. Describe the Bacterial Meningitis Age Distribution.
    • ElderlyStrep pneumoniae, E coli, Kleb pneumo, Strep agalactiae, L monocytogenes
    • AdultsStrep pneumoniae, N meningitis, Staph, H influenzae, G bacilli, Strep, L monocytogenes
    • ChildrenStrep pneumoniae, N meningitidis, H influenzae
    • Neonates: Strep agalactiae (Grp B strep), E coli, L monocytogenes, Strep
  434. What are the signs and symptoms of viral meningitis?
    • Mild, self limiting (7-10 days, seasonal)
    • Headache
    • Fever
    • Viral syndrome
    • Gastroenteritis (enterovirus)
  435. Describe HSV meningitis.
    • Associated with primary HSV infection (resolves over time, treat with ribavirin).
    • Note vesicular regions in genital area or around mouth.
    • Can recur w/out accompanying manifestations- latent reactivation (Mollaret's Syndrome)
    • Need to rule out bacterial meningitis in infants/newborns.
  436. Describe Enterovirus meningitis.
    • Aseptic
    • Hx of flue-like URT infection prior to meningitis symptoms.
    • Occasionally nondescript, non-blanching maculo-papulo-vesicular rash.
    • Self limiting (symptoms last 7-10 days)
    • Seasonal (summer, fall)
    • Usually affects infants and children
  437. What are the agents of fungal meningitis?
    • Cryptococcus
    • Candida
    • Aspergillus
    • Dimorphics (Histoplasma, Bastomyces, Coccidioides)
  438. What are the signs and symptoms of fungal meningitis?
    • Gradual onset headache
    • Fever
    • Stiff painful neck
    • Drowsiness
    • Seizures
  439. In what patients is fungal meningitis usually found?
    • Immunocompromised pts 
    • Also consider geography, travel history to endemic areas/recreational activities (raising pigeons)
  440. What is the agent of primary amebic meningoencephalitis (PAM) and other parasitic meningitis?
    • Naegleria fowleri (PAM)- swim in warm fresh water
    • Acanthamoeba- ate parasite eggs
    • Taenia- ate parasite eggs
    • Toxoplasma- ate improperly cook food/clean litter box
  441. What is the main sign/symptom of parasitic meningitis?
    Eosinophilia with meningitis symptoms.
  442. What are the signs and symptoms or chronic meningitis?
    • Headache
    • Fever
    • Meningismus
    • Confusion
    • Hydrocephalus
  443. How is chronic meningitis diagnosed?
    • Signs/symptoms are non-specific.
    • MRI/CT of head by show hydrocephalus/contrast enhancement of basal meninges.
    • Lumbar puncture.
  444. What are the agents that cause chronic meningitis?
    • Slow growing organisms
    • Cryptococcus neoformans (common)
    • HIV
    • M. tuberculosis
    • M. avium
    • T. pallidum
    • Nocardia spp
    • Candida
    • Aspergillus
    • Taenia solium
    • Brucellosis (cysticercosis)
    • Toxoplasma gondii
  445. What are the signs and symptoms of encephalitis?
    • Confusion
    • Personality change
    • Altered mental status
    • Fever
    • Seizures
    • Aphasia, ataxia, myoclonic jerks, cranial nerve deficits
  446. How is encephalitis diagnosed?
    • History & physical
    • Brain imaging
    • Lumbar puncture
    • CSF culture
    • Acute & convalescent antibody titers
    • PCR of CSF for herpes
    • Mainly caused by virus (type)
  447. What is the method of transmission for rabies and what are reservoirs for the virus?
    • Requires contact with rabid animal and exposure to it's saliva.
    • Animals that carry rabies are raccoons (most common), skunks, foxes, bats, coyotes.
  448. What is the incubation period of rabies after exposure?
    30-60 days
  449. What are the symptoms of rabies?
    • Anxiety, stress, tension
    • Drooling
    • Convulsions
    • Exaggerated sensation at bite site
    • Excitability
    • Loss of feeling in an area of the body
    • Loss of muscle funtion
    • Low grade fever (102˚ or lower)
    • Muscle spasms (twitching)
    • Numbness & tingling
    • Restlessness
    • Swallowing difficulty (hydrophobia)
  450. How is rabies tested for?
    • Several tests required for ante-mortem isolation (no single test is sufficient)
    • Saliva (PCR), Serum & CSF (rabies Ab test), Skin biopsy (rabies Ag test)
    • ID of Negri bodies from brain post-mortem/Babes nodules
  451. What are the signs and symptoms of brain abscess?
    • Expanding intracranial mass lesion
    • Headache + focal neurologic deficits
    • Fever, chills, other signs usually don't occur
    • Papilledema, nausea, vomiting (increased ICP)
  452. How is a brain abscess diagnosed?
    • Focal neurologic deficit/seizure
    • CT with contrast showing lesions and edema
    • Brain biopsy NO lumbar puncture because it can cause brain stem herniation
  453. What is the usual cause/type of infection that causes brain abscesses?
    • Bacterial often polymicrobial (aerobic/anaerobic mix)
    • Staph aureus may cause it in association with endocarditis.
  454. When is lumbar puncture mandatory? When should it be avoided?
    • If bacterial meningitis is suspected.
    • Should be avoided in cases of increased intracranial pressure, coagulopathy, brain abscess (potential for herniation).
  455. What is a subdural empyema?
    • Collection of pus between the dura and arachnoid membrane.
    • Typically follows sinus infection/surger, aerobic and anaerobic strep, staph, enterobacteriaceae.
  456. What are the symptoms of subdural empyema? How is it diagnosed?
    • Fever, progressively worse headache after known sinus infection.
    • Diagnosed with imagining studies, NO lumbar puncture, blood culture.
  457. What lab tests are run on CSF?
    • CSF exam (visual inspection, chemical analysis, cell count)
    • CSF microscopy (gram stain, india ink, CFW)
    • CSF culture
    • PCR
    • Bacterial Ag test (correlates with gram stain)
    • Serology (IgM capture assay)
    • Immunoblot
  458. What is the "gold standard" for identifying agents in CSF?
    • Cultures (blood and CSF)
    • Adjust therapy based on ID and susceptibility.
  459. Briefly explain meningitis signs during PE.
    • Nuchal rigidity: inability to flex head forward
    • Kernig's sign: positive when leg is bent at hip and knee at 90˚ angles and subsequent extension in knee is painful (resistance)
    • Brudzinski's neck sign: appearance of involuntary lifting of legs when lifting patient's head off the exam couch (pt is supine)
  460. Describe the virulence factors, source, transmission, and risk characteristics of Streptococcus pneumoniae.
    • Virulence: polysaccharide capsule
    • Source: nasopharynx colonization
    • Transmission: person to person through droplets/local extension from infected sinus/middle ear
    • Risk factors: splenectomy, diabetes mellitus, liver disease, alcoholism, CSF leak, terminal complement deficiency, pneumococcal pneumonia, cochlear implant
  461. Describe the virulence factors, source, transmission, and risk characteristics of Neisseria meningitidis.
    • Virulence: capsule, fimbriae, IgA protease
    • Source: colonizes nasopharynx
    • Transmission: person to person through respiratory droplets
    • Risk factors: close quarters, unvaccinated, college kids, military (purple spots)
  462. Describe the virulence factors, source, transmission, and risk characteristics of Haemophilus influenzae.
    • Virulence: polysaccharide capsule
    • Source: colonizes the URT of humans
    • Transmission: respiratory droplets/direct contact with respiratory secretions
    • Risk factors: lower since there is a vaccine (head trauma, neurosurgery, paranasal sinusitis, otitis media, CSF leak)
  463. Describe the virulence factors, source, transmission, and risk characteristics of Listeria monocytogenes.
    • Virulence: intracellular survival in phagocytic cells
    • Source: human feces, unpasteurized milk/cheeses, contaminated food
    • Transmission: ingestion/vaginal delivery
    • Risk factors: pregnancy, advanced age, immunosuppression
  464. Describe the virulence factors, source, transmission, and risk characteristics of Streptococcus agalactiae.
    • Virulence: beta hemolysin + hyaluronidase (cytotoxic and invasive)
    • Source: GI flora
    • Transmission: transmission to neonate occurs from mother colonized by group B strep
    • Risk factors: pregnant women and newborns
  465. Describe the virulence factors, source, transmission, and risk characteristics of Mycobacterium tuberculosis.
    • Virulence: survival in lung tissue (granuloma), reactivation during immunosuppression
    • Source: lungs, dissemination to other organs
    • Transmission: aerosol inhalation, respiratory droplets
    • Risk factors: immunosuppressed, previously infected
  466. Describe the virulence factors, source, transmission, and risk characteristics of Treponema pallidum.
    • Virulence: untreated infection
    • Source: STD laden partner
    • Transmission: unprotected sex
    • Risk factors: untreated syphilis, predilection for HIV
  467. Describe the virulence factors, source, transmission, and risk characteristics of Arboviruses.
    • Virulence: vertical transmission
    • Source: mosquitos
    • Transmission: infected mosquito taking blood meal
    • Risk factors: outdoors in endemic areas without covering or defense
    • Examples: West Nile, Eastern equine encephalitis
  468. Describe the virulence factors, source, transmission, and risk characteristics of Cryptococcus neoformans.
    • Virulence: capsule
    • Source: pigeon droppings
    • Transmission: aerosol inhalation, respiratory droplets
    • Risk factors: HIV infected patients
  469. Describe the virulence factors, source, transmission, and risk characteristics of Naegleria fowleri.
    • Virulence: 99.999% fatal, free living amoeba (migratory)
    • Source: warm bodies of fresh water
    • Transmission: penetrate olfactory mucosa and cribiform plate, migrates to brain
    • Risk factors: swimmers getting "dunked"
  470. Describe the virulence factors, source, transmission, and risk characteristics of Toxoplasma gondii.
    • Virulence: modulate immune response
    • Source: cat feces, raw meat
    • Transmission: carelessly handling cat litter, eating contaminated soil/raw or undercooked meat
    • Risk factors: pregnant mother, newborns
  471. Describe the virulence factors, source, transmission, and risk characteristics of Borrelia burgdorferi.
    • Virulence: changes outer surface proteins, evades innate immune response
    • Source: deer tick
    • Transmission: attachment and feeding of tick
    • Risk factors: outdoors, endemic areas, uncovered skin
  472. Describe the virulence factors, source, transmission, and risk characteristics of Aspergillus spp.
    • Virulence: necrotizing vasculitis, invasive
    • Source: indoor and outdoor environment
    • Transmission: aerosol inhalation
    • Risk factors: immunocompromised pts (neutropenic and corticosteroid use)
  473. Describe the virulence factors, source, transmission, and risk characteristics of Coccidioides immitis.
    • Virulence: dimorphic fungi
    • Source: location dependent
    • Transmission: aerosol inhalation, respiratory droplets
    • Risk factors: HIV infected pts/immunosuppressed
  474. Describe the virulence factors, source, transmission, and risk characteristics of Cryptococcus neoformans.
    • Virulence: capsule
    • Source: pigeon droppings
    • Transmission: aerosol inhalation, respiratory droplets
    • Risk factors: HIV infected pts
  475. Describe the virulence factors, source, transmission, and risk characteristics of Taenia solium.
    • Virulence: hatched larvae can migrate
    • Source: pork meat
    • Transmission: ingestion of T solium eggs
    • Risk factors: eating improperly cooked pork, neurocysticercosis
  476. What demographic does TB usually have fatal effects in?
    TB is a major cause of death among people living with HIV.
  477. What are TB pulmonary Clinical Manifestations?
    • Productive prolonged cough, chest pain, hemoptysis
    • Fever, chills, night sweats, fatigue, appetite and weight loss
  478. What will the TB TST test results show for latent and active infections?
    Positive for both
  479. Describe PPD and IGRA testing for TB (latent TB).
    • Purified protein derivative (PPD) screening for TB exposure: red and raised response, zone size varies by patient (5mm- HIV, 10mm- HCW, 15mm- no known risk)
    • Interferon gamma release assay: more specific than PPD, but unable to distinguish LTBI and active TB
  480. What test is run for suspected active TB?
    • Early morning sputum specimens on 3 consecutive days for smear and culture (now 3 within 24 hr period).
    • Bronchial washes, gastric lavage, urine specimens.
    • Blood and stool for AIDS patients.
    • Culture results in 6-8 weeks
    • Positive AFB smear suspect TB, positive culture confirms TB
    • Susceptibility results (multidrug resistant (MDR))
  481. What are the differences between TST and IGRA?
    • TST: detects antibody against M tb, can give false positive for BCG vaccinated pts or environmental non-tb mycobacteria, results available in 48-72 hrs (requires 2nd visit), 2 step testing useful for initial skin test, very cheap
    • IGRA: measures T cell release of gamma interferon of cells exposed to TB, not affected by Bacille Calmette-Guerin (BCG) vaccination or environmental non-tb mycobacteria, results available in 24-48 hrs (requires 1 visit), 2 step testing is not required, is very costly
  482. When is IGRA recommended?
    • Contacts of active TB
    • Immunocompromised
    • Low risk people who are TST positive
  483. When is IGRA not recommended?
    • Serial testing
    • Children
    • Immigrant screening
    • Diagnosing active TB
  484. Which malaria is most common? Which is most deadly? What two factors are important in diagnosis?
    • Common: P vivax
    • Deadly: P falciparum
    • Important items: travel history, periodicity of fever spikes
  485. What are the Clinical Manifestations of P. falciparum?
    • Continual fevers, irregular spikes, often misdiagnosed
    • Cerebral malaria – CNS changes, respiratory distress, bleeding, circulatory collapse
    • Fatigue, malaise
    • Hepatic malaria – hyperbilirubinemia, jaundice, blackwater fever
    • Medical emergency
    • High mortality with low parasitemia
    • Fatality, microvascular obstruction, hemolysis, multiorgan system failure
  486. What are the clinical manifestations of P vivax/P ovale (simple tertian malaria)?
    • Cyclic episodes of chills
    • Fever
    • Defervescence
    • Diaphoresis (ever 48 hrs)
  487. What are the clinical manifestations of P malariae (simple quartan malaria)?
    • Cyclic episodes of chills
    • Followed by fever
    • Defervescence
    • Diaphoresis (every 72 hrs)
    • Glomerulonephritis
  488. What are the clinical manifestations of P falciparum (malignant tertian malaria)?
    • Continuous fevers
    • Irregular spikes
    • Some hyperparasitemia w/ microvascular damage and compromise leading to CNS damage
    • Renal and pulmonary failure
    • Death
  489. Describe diagnostic methods for malaria. What are the different blood film exams?
    • Specimen collection: STAT, prepare smears w/in 1 hr of collection, finger prick/draw blood.
    • Thick smear: gold standard (detection)
    • Thin smear: gold standard (speciation)
    • Single set of negatives does NOT exclude malaria
    • Collect additional specimens at 12 hr intervals for 36 hrs
  490. What are the AIDS defining illnesses?
    • Brain: Cryptococcal meningitis, Toxoplasmosis
    • Eyes: CMV 
    • Mouth and throat: cold sores & ulcers, thrush (candidiasis)
    • Lungs: Histoplasmosis, pneumocystis carinii pneumonia (PCP), tuberculosis (TB)
    • Stomach: CMV, Cryptosporidosis, mycobacterium avium complex (MAC)
    • Liver: HCV
    • Reproductive: genital ulcers, HPV, cervical cancer, menstrual problems, PID, UTI, vaginal yeast infections (candidiasis)
  491. What tests should be utilized to manage HIV patients?
    • CD4 count (assesses stage of disease)
    • Viral load (monitor response to therapy)
    • HIV resistance testing (drug resistance)
    • CBC and metabolic panel (chemistries)
  492. What other agents should HIV patients be tested for?
    • Hep A, B and C
    • Syphilis, chlamydia, gonorrhea, HSV, other STIs
    • CMV, VZV, EBV, HPV
    • Annually screened for TB and chest X-ray
  493. What treatment should be given extra consideration before administration?
    Immunizations especially live attenuated vaccines.
  494. How does TB differ in early and late stage HIV infection?
    • PPD: early- usually positive; late- usually negative
    • Adenopathy: early- unusual; late- common
    • Pulmonary distribution: early- upper lobe; late- lower + middle lobes
    • Cavitation: early- often present; late- typically absent
    • Extrapulmonary disease: early- 10-15% of cases; late- 50% of cases
  495. What is the definitive confirmatory test for Hep C?
    Qualitative HCV RNA
  496. What environmental conditions put people at risk for Hep C?
    • Have been on long-term kidney dialysis
    • Have regular contact with blood at work
    • Risks include: unprotected sexual contact, IV drug use, blood transfusion before
    • July 1992, tattoo or acupuncture with contaminated instruments, received blood, blood products, or solid organs from an HCV + donor
    • Share personal items such as toothbrushes and razors with someone who has hepatitis C (less common)
    • Were born to a hepatitis C-infected mother
    • Most people who are infected develop chronic disease
  497. Describe the agent, sources, and routes of anthrax infection.
    • Bacillus anthracis (spore former)
    • Infection in humans from hoofed animal, affects the skin, GI tract or lungs. Persons at risk are farm workers, vets, tannery & wool workers ("wool sorter's disease").
    • Routes: anthrax touches cut or scrape on skin (cutaneous), inhalation of anthrax spores (lungs) potential biothreat, ingestion of anthrax tainted meat (GI)
  498. What are the symptoms of anthrax?
    • Cutaneous: blister/ulcer that later forms a black scab (eschar), surrounded by lots of swelling
    • Lungs (inhalation): begins with fever, malaise, headache, cough, SOB, chest pain, shock, widened mediastinum
    • GI: nausea, vomiting (may include blood), anemia, bloody diarrhea
  499. What causes the plague? How is it spread? Where is it found?
    • Yersinia pestis
    • Rodents (rats) spread disease to humans, pneumonic plague is high contagious human to human by microscopic droplet inhalation from infected coughing person.
    • Localized in U.S. mainly in parts of CA, UT, AZ, NV, NM
  500. What are the risk factors for contracting plague?
    • Flea bite
    • Exposure to rodents (rabbits, squirrels, prairie dogs) scratches or bites from infected domesticated cats.
  501. What is the lab workup for suspected plague?
    • Blood culture
    • Culture of lymph node aspirate
    • Sputum culture
    • Patients with suspected plague are strictly isolated.
  502. How is brucellosis contracted? Who is most as risk?
    • Contact with animals carrying bacteria called Brucella (cattle, goats, camels, dogs, pigs), or ingestion of unpasteurized milk/cheese.
    • Occupational hazard for slaughterhouse workers, farmers and veterinarians.
  503. What are the agents of Brucellosis? Which is the most virulent?
    • B abortus
    • B melitensis (most virulent)
    • B canis
    • B suis
  504. What are the symptoms of Brucellosis?
    • Flu like (chills, fever)
    • Undulant up and down fever (Bang's disease, Malta fever)
    • Abdominal pain
    • Back pain
    • Excessive sweating
    • Fatigue
    • Headache
    • Loss of appetite
    • Joint pain
    • Weakness
    • Weight loss
  505. What is the lab workup for suspected Brucellosis?
    • Blood culture
    • Clean catch urine culture
    • CSF culture
    • Bone marrow culture
    • Serology detecting brucellosis antigen
  506. What are the common symptoms of viral hemorrhagic fevers?
    • Marked fever
    • Fatigue
    • Dizziness
    • Muscle aches
    • Weakness
    • Exhaustion
  507. What are some issues patients with severe cases of viral hemorrhagic fever face?
    • May bleed under skin, in internal organs, or from orifices.
    • May also show shock, nervous system malfunction, coma, delirium, seizures.
    • Renal failure.
  508. What is the incubation period after ingestion of Salmonella typhi (typhoid fever) and what are the symptoms?
    • 7-14 days (stepwise fever)
    • GI manifestations, diffuse abd pain & tenderness, colicky right upper quadrant pain
    • Inflamed Peyer patches, narrowed bowel lumen causing constipation for duration of illness
    • Dry cough, frontal headache, delirium, increasingly stuporous malasie
    • 2nd week of illness symptoms get progressively worse, fever plateaus at 103-104˚F
    • Rose spots (salmon colored)
    • 3rd week febrile, more toxic, anorexic, infected conjunctiva, patient is tachypneic, severe abdominal distension, foul green-yellow liquid diarrhea (pea soup)
    • Typhoid state, apathy, confusion, psychosis
    • Toxemia, mycarditis, intestinal hemorrhage may cause death
  509. What is the lab workout for typhoid fever?
    • Clinical diagnosis
    • Culture
    • Blood culture (positive in first week)
    • Stool culture (positive in 2nd week)
    • Culture punch biopsy of rose spots
  510. What are the symptoms of cutaneous leshmaniasis (most common)?
    One or more painless ulcers, lymphadenopathy, disfiguring, self limiting.
  511. What is the agent of yellow fever? How is it transmitted?
    • Flavivirus (mainly in West Africa and South America)
    • Transmitted between humans by Aedes aegypti mosquito.
  512. What are the symptoms of yellow fever?
    • Some are asymptomatic or develop mild febrile illness (fever, headache, chills, back pain, loss of appetite, nausea, vomiting)
    • After 3-4 days more severely ill patients develop bradycardia (Faget's sign), jaundice, hemorrhagic manifestations (bleeding in mouth, eyes, GI tract-"black vomit/coffee grounds")
  513. How is yellow fever diagnosed and treated?
    • Serology (IgM, IgG= 4 fold increase is confirmatory)
    • No specific antiviral treatment exists.
    • Affective live attenuated vaccine is available.
  514. What kind of virus causes Dengue fever?
    • Arbovirus (arthropod borne)
    • Virus is in the flavivirus family, has 4 serotypes (transmitted by Aedes mosquito)
  515. What are symptoms of Dengue fever?
    • High fever
    • Lymphadenopathy
    • Myalgia
    • Sever bone & joint pain
    • Headache
    • Maculopapular rash
    • "Breakbone fever"
    • **severe cases may present with hemorrhagic fever and shock (mortality 5-10%)
  516. How is Dengue fever diagnosed?
  517. What type of a virus causes West Nile? When does it normally occur?
    • Flavivirus spread by mosquito that has bitten an infected bird and then a human.
    • Summer and fall seasons (in cluster/outbreak)
  518. What are the symptoms of West Nile?
    • Immune competent: abd pain, diarrhea, fever, headache, loss of appetite, myalgias, nausea, sore throat, vomiting, rash
    • Immune compromised: confusion, loss of consciousness, muscle weakness, stiff neck
  519. What lab tests are performed to determine West Nile infection?
    • CBC, CSF testing, IgM assy, PCR
    • Lymphocytic pleocytosis in CSF with normal glucose and protein (viral meningitis)
  520. Where is the "meningitis belt"? What is the agent? Is there a vaccine available?
    • Sub-Saharan Africa and Asia
    • Neisseria meningitidis
    • Yes, meningococcal vaccine (A,C, Y, W-135)
Card Set:
Clinical Lab Test 4
2013-04-11 23:26:14
Clinical Lab Test

Clinical Lab Test 4
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