Infections on Post-Transtplant pts at 2-6 months s/p transplant?
Viruses (Varicella zoster, EBV, Hep C)
Infections on Post-Transtplant pts at 4 or more months s/p transplant?
In a post-transplant pt, which organisms reactivate in a person with impaired cellular immunity?
"No TB, his cry blasted Coco strongly"
What are the common Gram-positive cocci?
Stap aureus and epidermidis
Strep pneumo (Pneumococcus)
Strep pyogenes (Group A)
Strep agalactiae (Group B)
Who commonly get Staph aureus infection?
IV drug users
Toxic shock syndrome
Thing of it in a pt with istory or pneumonia and recent influenza
A pt with symptoms of septic shock and who has a positive blood culture in 24 hours is likely infected with what organism?
How about if this is a post-surgical pt with a prostheses?
Strep usually grows in blood culture
Staph will be high in differential if after surgery especially with prostheses
Define Toxic Shock Syndrome
How many organs involved?
Wha should you rule out?
Organisms in positive or negative blood cultures?
Temp > 38.9 C (102 F)
SBP < 90 mm Hg
Rash with subsequent desquamation (palms/soles especially)
Involvement of > 3 organ systems: GI, muscular, mucous membranes, renal, liver, blood, CNS
Negative serology for RMSF, leptospirosis, measlesBlood cultures likely positive in Strep, and negative in Staph
A pt with furuncles/carbuncles with MRSA isolated, but non-septic appearing can be treated with?
Outpt treatment for MRSA is with Clindamycin or Bactrim
What is the most common cause of catheter-related bacteremia and of bacteremia in patients with "foreign body" surgeries?
Staph epi is most common
This is usually resistant to IV Nafcillin, so treat with IV Vancomycin, unless MSSE
What type is the most virulent?
Treatment if "intermediate resistant" to PCN?
Treatment if "highly resistant" to PCN?
Tx if meningitis?
Type 3: most virulent -- associated with M protein (3M is bad)
If "intermediate resistant" use 3rd generation cephalosporin
If "highly resistant" to PCN, use 3rd generation cephalosporin or add Vanc to regimen
If meningitis: Use Vanc (or RIF) + 3rd generation until sensitivities on pneumo are known
Streptococcus What is the usual presentation for pyogenes? What is the usual presentation for agalactiae?
--GAS, TSS, rheumatic fever, scarlet fever
--very young, very old (Alcoholic/DM), wound infection in diabetic foot
--Major cause of newborn pneumonia and meningitis
--UTIs in pregnant women
What is scarlet fever?
It is caused by the streptococcal bacteria, which produce a toxin that leads to the hallmark red rash of the illness.
The rash usually first appears on the neck and chest, then spreads over the body. It is described as "sandpapery" in feel. The texture of the rash is more important than the appearance in confirming the diagnosis.
The rash can last for more than a week. As the rash fades, peeling (desquamation) may occur around the fingertips, toes, and groin area.
Facts about GABHS infection:
Rheumatic fever can occur from what strain?
Effect of therapy on glomerulonephritis?
Post-strep GN can occur from what strain?
How do you prevent rheumatic fever in Strep pharyngitis?
Rheumatic fever occurs only from pharyngeal strains of GAS
Post-streptococcal glomerulonephritis can occur even with appropriate therapy
Post-strep GN can occur from skin or pharyngeal strains
Treatment of Strep pharyngitis with PCN prevents rheumatic fever
What do you treat an elderly male with sepsis s/p TURP?
What else do you do?
Sepsis/infection after TURP
--Tx: Amp/PCN or Vanc are only inhibitory.
--Add aminoglycoside for synergy with serious infections
Check Sensitivities for VRE !!!
--Use daptomycin (Cubicin), quinupristin/dalfopristin (Synercid), or linezolid (Zyvox)
Who is susceptible?
Diminished cellular immunity syndromes
--AIDS, lymphoma, leukemia
--Neonates, elderly, pregnant who like goat cheese or hot dogs
Tx: IV Amp or pcn +/- aminoglycoside for synergy in severe infections
--Vanc or TMP/SMX for PCN-allergic pts
Corynebacterium What strain causes diphtheria?
What is its clinical presentation?
What strain can cause IV catheter infections?
diphtheriae -- causes diphtheria
-Gray-white pharyngeal membrane
-Hoarseness, sore throat
-Low-grade fever < 101 F !!
-Tx: Erythro or PCN + Antitoxin
jeikeium (JK) -- IV cathether infections BMT
-Vanc drug of choice
A pt presents with the following below, along with c/o hoarseness, sore throat, low grade fever < 101.
What is the diagnosis and treatment?
Tx: Erythro or PCN + Antittoxin
Bacillus S/s of B. anthracis?
What can cause GI effects? or an infecting organism with penetrating trauma to the eye?
-Cutaneous (95%) and pulmonic (5%)
-Inoculation from handling hides, wool
-Painless papule -- painless ulcer -- painless black eschar -- with nonpitting, induration/swelling
-Tx: Pen G is sensitive (erhtyro/tetracycline)
-toxin strains produce GI effects
-trauma to eye, IV catheters
-Tx: Vanc (or clindamycin) for the trauma/cathether infection
What organism can be an infecting organism in a pt with penetrating trauma to the eye?
Tx: Vanc ( or clindamycin)
Facts about Bacillus anthracis (Bioterrorism)
Is isolation precaution required?
Pneumonia on CXR will have what characteristic?
Not spread from person to person (unlike pneumonic plague and smallpox)
Pneumonia -- widened mediastinum
Skin lesions, as in ranchers, etc.
--Cipro until sensitivities known
--PCN/Tetracycline also usually effective
When do you give TIG + vaccine?
When do you give Td (Tdap)?
When is treatment not required?
Wound is dirty and either:
1. < 3 immunizations, OR
2. Immunization history inknown
--The give TIG + vaccine
Wond is clean and
--Immunozations are up to date (<10 years since last) then no treatment
--Immunizations > 10 years, give Td (Tdap)
Wound is dirty and
--Immunizations are up to dare, with most recent < 5 years, then no treatment
--Immunizations > 5 years, then give Td (Tdap)
Tdap = booster
What clostridium species are associated with GI malignancy?
What is a safe prophylaxis for a pregnant pt who had exposure to Neisseria meningitidis meningitis?
Neisseria meningitidis Who is at risk?
Who gets prophylaxis?
Is a vaccine recommended? To whom?
Risk population: Humoral/complement deficiencies, College students
Prophylaxis: All household contacts, daycare, "significant others," health care workers with intimate oral contact (intubate, mouth-mouth)
Meds for prophylaxis: Rifampin, ciprofloxacin (type A), ceftriaxone (pregnant)
Conjugate vaccine recommended for college freshmen living in dorms and all previously unvaccinated adolescents
What is the differential diagnosis for a pt with fever, hypotension, diffuse purpuric lesions, petechiae, DIC?
Nesseria meningitis vs. Rocky Mountain Spotted Fever
-- if they give you geography, it is probably RMSF
Treatment for N. meningitiditis meningitis?
Neisseria meningitidis vaccine
What are the 2 vaccines available?
A patient with right lower quadrant pain (nurse thinks it might be appendicitis) whose blood cultures are growing gram-negative bacilli. What is the organism?
Y. enterocolitica or Y. psedotuberculosis
Y. enterocolitica has been diagnosed as the cause of bacteremia in sickle cell patients with iron overload
A pt from Arkansas presents with a large lymph node presents with the ff c/o:
What is the diagnosis, how diagnosed, and treatment?
This is ulcer-glandular disease
Found mainly in Arkansas, Missouri, Oklahoma
Dx by serology -- don't aspirate!
Tx: Streptomycin, gentamicin, tetracyclines
Give the cause in the following scenarios in this pt from Arkansas:
1. with lymph node
2. with pneumonia and skin lesions
Rickettsia -- RMSF
What differentiates this?
What is pertinent in the HPI?
How is this diagnosed?
Where are most cases found?
R. rickettsii -- RMSF
Differential diagnosis is meningococcus
Rash, fever, arthralgias
Report of tick exposure
Rash on distal palms, soles; rash maculo-papules to petechiae
Hyponatremiadifferentiates this from meningococcus
Dx: seology, IF staining on bx of petechial lesion
Tx: Doxycycline, chloramphenicol
Most cases in N. Carolina, S. Carolina, Georgia, Virginia, New Mexico
Pt with flu-like illness, pancytopenia, and report of tick-bite.
1. What is the organism if from Southeast, South Central, or Midwest?
2. How about if the the pt is from California, Northeast, or North Central US?
1. Ehrlichia chaffeensis
2. Anaplasma phagocytophila
Ehrlichia / Anaplasma
Distinguishing lab picture?
Southeast, South Central, Midwest
Dx: Serology, morula on smear
Human granulocytic ehrlichiosis
Same disease but live in neutrophils, not macrophages
Northeast, North Central, California
Gardnerella vaginalis Gram stain report?
Tx: Metronidazole (Flagyl)
Responsible for vaginosis
This is from a pt's pap smear
Gram stain characteristics?
Beaded, branching, filamentous, and weakly acid-fast
Lung infection usually first -- cavity
Progresses to brain abscess
Tx: bactrim or high-dose sulfas
--Amikacin + imipenem
Outbreak of diarrhea in the community. Stool gram-stain shows acid-fast organism, small and round
What is the organism?
Who do you treat?
Self-limited in normal host
Lasts 1-2 weeks
Chronic in AIDS patients, may persist indefinitely
Tx: Nitazoxanide or paromomycin +/- azithromycin
Small and round (compared to Isospora belli which is big and oval
Diarrhea caused by aeid-fast organism that is large and oval shaped.
What is the organism?
Sulfur granules = clusters of organisms
Cervicofacial swelling from dental source
Causes PID if IUD present
Can cause (rare) chronic neutrophilic meningitis
Tx: PCN/amp or tetracycline
Differential diagnosis for pt with pneumonia and splenomegaly?
Sign and symptoms?
Pt with exposure to birds, esp. poultry
Pneumonia + splenomegaly
Myalgia, rigors, fever to 105
Chlamydia pneumonia Who is commonly infected?
What illness is associated with it?
Common in adolescents
Person-person spread (not birds)
Tx: e-mycin or tetracyclines
Primary Syphilis What is the incubation period?
Is the RPR/VDRL always positive?
Chancres develop at the site of inoculation, on average, 21 days after exposure
Incubation period can range from 10-90 days
Skin lesions are painless
20-30% will be RPR/VRDL negative at this stage
Hematogenous dissemination of T. palladium
Fever, malaise, generalized lymphadenopathy are often present
Rash--macular, papular, annular, or follicular
Alopecia, condylomata lata, mucous patches
Young man or woman who presents with acute onset hearing loss. What is the possible diagnosis?
This is a symptom of neurosyphilis
How is Syphilis diagnosed?
VDRL or RPR for initial screen
Confirm + test with either:
Darkfield microscopy showing T. palladium from a clinical specimen
A sexually active old (or young person) who come in with stroke. What is your differential diagnosis?
A pt with remote history of lesions on her hand and foot who come in today c/o sensory ataxia, "lightning" pains, autonomic dysfunction. What is you diagnosis?
Treatment for Neurosyphilis?
Early (primary, secondary, or latent <1 year): Pen G benzathine 2.4 million units IM X 1
--doxycycline 100 mg PO bid X 14 days
Late (> 1 year's duration, CV, gumma, late-latent): Pen G benzathine 2.4 million U IM q week X 3
--doxycycline 100 mg PO bid X 4 weeks
Neurosyphilis: PCN G 2-4 million U IV q 4 X 10-14 days
Contact with infected animals
"Swimming with your dog," but may also be from rat feces or urine
Mild to severe disease
--Early disease: BC (+) (first week, then it's late after)
--Late disease: Urine (+)
Treatment: PCN or doxycycline
Transmitted by the Ixodes scapulars tick or Ixodes pacificus
Think Martha's Vineyard or Connecticut, Wisconsin, California
Dx: Erythema migrans is pathognomonic
Don't do serology
Presentation of Lyme Disease?
Early: Rash with fever, HA, lymph nodes
Weeks to months later:
--Meningitis and/or neuritis. Peripheral neuropathy or Bell's Palsy, or foot drop
--Cardiac--> heart block
This pt was in Connecticut recently, present to you with this rash. What is the diagnosis?
The rash is erythema migraines. This rash is pathognomonic.
No serology indicated.
--Early: Doxycycline (amoxicillin also) but doxy is 1st choice)
--Meningitis or carditis: Ceftriaxone
--Arthritis or isolated Bell's palsy: Doxycycline
Treat for at least 2 weeks
Prophylaxis for hikers/campers: not indicated
This neutropenic pt presents with the following lesions. He is currently treated broad-spectrum antibiotics. What is the diagnosis?
Treatment of Onychomycosis?
--for fingernails -- 250 mg daily by mouth for 6 weeks
--for toenails -- 250 mg daily by mouth for 12 weeks
Clinical trials show terbinafine is superior to itraconazole and griseofulvin
What is the treatment for allergic bronchopulmonary aspergillosis?
prednisone and itraconazole
Aspergillosis -- Aspergilloma
What is the characteristic radiographic picture?
What is the hallmark sign?
Characteristic radiographic picture with the fungus ball changing position in an epithelial-lined cavity or in an air-fluid level
Cavities are secondary to previous or concomitant tuberculosis, histoplasma, or bronchiectasis
Hemoptysis -- sometimes life-threatening-- is the hallmark
Tx: In cases complicated by severe hemoptysis, surgery may be required to remove the aspergilloma and stop the bleeding. Observation only if asymptomatic.
Aspergillosis -- Allergic Bronchopulmonary Aspergillosis
What is the role of serology in diagnosis of invasive disease?
Can be due to hyphen colonization of bronchopulmonary tree
Inhalation associated with dyspnea, wheezing, cough, rales
X-ray: diffuse nodular infiltrates
Treatment is steroids + itraconazole
Diagnosis: sputum exam or BAL maybe + but view with caution. Correlate with x-ray and clinical history. Conversely, in a severely immunocompromised pt, finding the hyphae in nasal mucous membranes could be very serious
Most recommended histology or microscopy
-- Galactomannan antigen detection is promising. Released during growth of hyphae
Serology: + in 90% of aspergillomas and 70% of ABPA --- DO NOT USE in invasive disease diagnosis
Treatment of Cryptococcosis
Acute pulmonary cryptococcosis in immune-competent: Not treatment
Acute pulmonary cryptococcosis in immune-compromised: Ampho B +/- flucytosine for 1 month
Meningitis: Ampho B 0.7 mg/kg/d for 2 weeks + flucytosine 100 mg/kg (levels needed) in 4 divided doses, followed by oral fluconazole for 6 weeks (levels needed)
HIV pts need maintenance tx with fluconazole
Dx: Culturing the organism
--SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
--Treat 4 weeks after lesions healed
--Itraconazole is better than SSKI
A gardener who pricked his finger with a thorn several days ago present with the following complaint. What is the diagnosis and what is the treatment?
SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
--Treat 4 weeks after lesions healed
--Itraconazole is better than SSKI
An AIDS patient with disseminated disease, lesions resemble histoplasmosis, but not getting better despite several days treatment with Ampho B.
What is the diagnosis?
What is the treatment?
Pseudallescheria boydii, like aspergillus but resistant to Ampho B
Treat with miconazole
What are the four types?
Cat is definitive host
Dx: Acute IgM antibody +
--Asymptomatic or mild symptoms: self-limited
--Pregnancy-acquired: Congenital infection > later in pregnancy
--CNS disease: Multiple lesions (MRI > CT)
--Ocular toxo: Yellow-white cotton patches
What do you see on the smear?
What foods is this usually seen?
Acid-fast positive on smears
Raspberries, basil seasoning, snow peas
What population of patients are high risk for mortality?
What part of the world has chloroquine resistant malaria?
- P. vivax
- P. ovale
- P. malariae
- P. falciparum
Big trouble in asplenic patients
Asia and Africa have chloroquine resistance
What makes it hard to treat?
What do you see on the blood smear?
Most fatal of the 4 types
Widespread chloroquine resistance
Blood smear: Banana gametocyte
-More than one infected RBC on slide
-Multiple parasites in one RBC
-Other forms: few parasites and hard to find
-Schizonts NOT seen on smear --- if so, it is a non-falciparum form of malaria
How about if pt is too sick to take PO?
What is the role of steroids for cerebral malaria?
--Quinine sulfate + doxycycline X 7 days
--Atovaquone/proganil (Malarone) X 3 days
--Mefloquine (Lariam) X 2 doses
Treatment (IV if too sick to take oral)
--IV quinidine until pt can take oral
If in chloroquine-sensitive area -- use chloroquine
No steroids for cerebral malaria!
Which malaria use the "Duffy RBC antigen" for its site of attachment?
Which malaria is commonly associated with nephrotic syndrome?
Which malaria form hypnozoites in the liver?
What is the treatment?
P. vivax and ovale (VOdka goes into the liver)
Give Primaquine to avoid relapse
Chloroquine is the general treatment for what type of malaria?
P. vivax, ovale, malariae
1. Prophylaxis for ALL types of malaria?
2. What do you give to traveler who came from area with known P. vivax and ovale malaria, and when do you start it?
3. What do you need to do before starting the medication in #2?
4. What malaria medication is associated with Stevens Johnson syndrome?
Mefloquine (or chloroquine if in sensitive area) 1/week for 1-2 weeks before arrival and continue 4 weeks after leaving area, or
Doxycycline q day for 1 day before until 4 weeks after travel, or
Atovaquone/proguanil (Malarone) q day 1 day before until 7 days after travel
Primaquine given last 2 weeks of prophylaxis after travel to P. vivax or ovale area
Pyrimethamine-sulfadoxine (Fansidar) associated with Stevens Johnson syndrome
Primaquine induced hemolytic anemia in G-6-PD deficiency (SCREEN)
What is the peripheral smear report?
How would the patient present?
What is the usual transmission mode?
What geography does it commonly occur?
How would the patient act?
Treatment for mild disease?
Treatment for severe disease?
Intra-RBC protozoan: Maltese cross pattern
Febrile hemolytic anemia
Ixodes tick from rodents, deer
Nantucket in summer/fall
Fever, sweats, myalgias, chills
Hemoglobinuria: predominant sign
Emotional lability is common
Mild: Clindamycin + quinine or atovaqoune + Azithromycin
Severe: Exchange transfusion, then antibiotics
What is the organism?
Where found mostly?
Mode of transmission?
Usual patient population?
How do you diagnose?
Mainly Texas, Mexico, Oklahoma
Water and food sources
Institutionalized, immigrants, gay men
Liver aspirate: No ameba or WBCs; "anchovy paste"
-Diarrhea -- check stool antigen
-Liver abscess: check serology; stool usually negative
Metronidazole or Tinidazole
*Paromomycin or iodoquinol for intraluminal treatment is also given at the end of therapy for invasive disease
Who is mostly affected?
Campers, travelers, children in daycare, gay, IgA deficiency, hypogammaglobulinemia
What are the manifestations in an immigrant from Africa vs. South America?
African: Sleeping sickness
American: Chagas disease due to T. cruzi
-Self limited usually but can affect:
1. Cardiac (heart block--CHF)
2. GI (achalasia, megaesophagus, megacolon)
A recent immigrant from Latin America present with fever, malaise and the complaint below. What is your diagnosis?
What are the symptoms for cuteness form?
What are the visceral sx?
Sand fly is the vector
Cutaneous (L. major / L. tropica, military in Iraq)
-Occurs on exposed areas of skin
-Begins as a red papule that enlarges to form a PAINLESS ulcer with granulomatous tissue at the base and raised, heaped-up margins
-No surrounding induration
-Localized adenopathy can occur
Visceral leishmaniasis = kala-azar
-GI symptoms: Big liver and spleen
Treatment: Sodium stibogluconate (antimony), meglumine, or Amphotericin B
A soldier who recently came back from Iraq on a 16-month deployment comes to the ED with the lesion below. Physical exam showed liver margin a two finger widths below costal margin and a large spleen. What is the diagnosis and treatment?
Sodium stibogluconate (antimony)
Amphotericin B - now the drug of choice
Cause of citywide outbreak of diarrhea?
Rectal itching in a nursing home patient. What is the etiology?
A pt with serpeginous lesions on the foot. What is the diagnosis?
What is the treatment?
The only helminthic organism that replicates in the human body
Persists for decades
Think about this in old pt with neutropenia, now with abdominal pain and diarrhea
Typical scenario: Veteran from WWII gets neutropenic from chemo, and becomes will with recurrent severe Strongyloides
Treatment: Ivermectin or thiabendazole
Symptoms of acute schistosomiasis?
Physical exam findings?
Prophylaxis: azithromycin q week or clarithromycin once daily for CD4 < 50
An HIV pt with MAC and CD4 = 5, has been on treatment for MAC. She was started on HAART recently and was doing well. She now present with fever, malaise, weight loss, increasing SOB, and worsening adenopathy. What is the diagnosis?
Clinical criteria for initiation of Antiretroviral therapy
1. AIDS-defining opportunistic infection
2. CD4 count < 350 cells
3. Pregnant women
4. Persons with HIV-associated nephropathy
5. Persons co-infected with hep B
Side-effects of Zidovudine (ZDV, AZT)?
Anemia: reduce dose and/or epos
Neutropenia: reduce dose and/or G-CSF
Myositis: gait disturbance/loss of mm mass
--"rugged red fibers" w/ increase CPK: Stop ZDV
Didanosine (ddI) side effects?
Painful peripheral neuropathy: reduce dose
Pancreatitis: discontinue drug if occurs
Retinal depigmentation with ddI
Lamivudine (3TC) side effects?
3TC acts as reverse transcriptase inhibitor
Is incorporated in viral DNA and acts as chain terminator
An extremely potent antiviral agent
Pancreatitis is biggest concern
Emtricitabine (FTC) -- similar agent
Abacavir (Ziagen) side-effect?
1. Fever, chills
3. Flu-like illness
-If any of these occur on therapy, you must STOP
-Now screen for HLA-B*5701
-And never re-challenge pt: causes death
A pt with HIV on HAART, comes to you with report that she is pregnant. What medication do you need to stop (or at least make sure she is not on it) due to teratogenicity?
When to switch HIV therapy?
HIV RNA > 400 copies after 24 weeks of therapy or
HIV RNA > 50 copies after 48 weeks or
Repeatedly detectable HIV RNA level after prior suppression or
Post-exposure prophylaxis for HIV:
When to give it ?
What meds to give for prophylaxis?
If the answer is YES to these 2 questions, then give postexposure prophylaxis
--Is the fluid bloody?
--Is the skin integrity compromised?
Give prophylaxis if yes to both, and no prophylaxis if yes to only 1 of 2.
If urine exposure: NO
If intact skin exposure: NO
: ZDV, 3TC, +/- lopinavir / ritonavir for 4 weeks
What HIV meds should not be given to pregnant pts?
1. A pt with HIV now comes you pregnant. She is not on HAART. What is your next intervention?
2. A pt with HIV, not on HAART, comes to the ED in labor. What is your intervention?
3. What would you recommend for the infant above?
ZDV to mothers starting between 14 and 34 weeks gestation 100 mg PO 5x daily
Intrapartum ZDV IV loading dose 2 mg/kg starting in labor and continued at 1 mg/gk/hour until delivery
Oral ZDV in infants beginning 8-12 hours after birth to age 6 weeks at 2 mg/kg/dose q 6 hours
Treat the mother as though she is not pregnant; Give her 3-drug or more therapy!
What are indications for surgery?
What is the most common cause of death?
How many embolic events need to occur before surgery is indicated?
-CHF = most common cause of death
-Recurrent embolic phenomenon (2 strokes)
What is the most common cause for Native valve SBE?
A young female with 3 weeks of weakness, fatigue, and arthralgias. The following is seen on fundoscopic exam. What is the diagnosis, and what is your next intervention?
A 55-year old pt (or a pregnant pt) presents with meningitis symptoms. What antibiotic would you start?
CSF findings in bacterial meningitis?
> 90% neutrophils
< 40 mg/dL glucose
> 150 mg/dL protein
What is the organism if CSF gram stain shows gram (+) diplococci?
What is the treatment?
Gram-positive diplococci = S. pneumoniae
-Ceftriaxone or cefotaxime + vancomycin until sensitivities known
-If PCN-sensitive, switch to IV PCN
-Data now support dexamethasone
What is the organism if CSF gram stain shows gram-negative diplococci?
What is the treatment?
Treat with IV PCN or ceftriaxone/cefotaxime
CSF gram stain shows Gram (+) rods. What is the organism and what is the treatment?
Treat with Ampicillin and gentamicin
CSF gram stain shows "pleomorphic" rods. What is the organism and what is the treatment?
Dexamethasone followed by or concomitantly with ceftriaxone or cefotaxime
CSF gram stain shows gram-negative rods. What is the organism and what is the treatment?
Ceftriaxone, ceftazidime, or cefepime (if pseudomonas a concern, use the latter 2)
What is the most common sequelae of bacterial meningitis?
What is the prophylaxis for meningococcus?
Rifampin for children < 18 years of age
Ceftriaxone for pregnant women
Ciprofloxacin is an acceptable alternative to rifampin in non-pregnant adults
What is the drug of choice for prophylaxis of contacts for H. influenza?
A pt with aseptic meningitis (based on CSF result) who has a pet hamster. What is the cause of meningitis?
Lymphocytic choriomeningitis virus
Cause of meningitis in a pt who was swimming in a cow pond?
Cause of chronic neutrophilic meningitis?
What CN deficit do you see in TB meningitis?
6th nerve palsies
Lyme meningitis can present with what symptoms?
Bell's palsy or foot drop
What is the best way to diagnose?
What is the empiric treatment?
Diagnose with CT scan
Stereotactic biopsy is indicated today
Most common empiric treatment: 3rd generation cephalosporin + metronidazole and surgical drainage if possible
Diarrhea with fecal WBCs. What organisms?
What organism causes diarrhea from unpasteurized milk?
What organism causes diarrhea from holiday turkey (or chitlins)?
Gram stain result will show what?
What is the culture medium you will use?
Etiology: Neisseria gonorrhea
Small, non-motile, Gram-negative diplococci
Thayer-Martin or chocolate agar
Virulence factor involved in pathogenesis
Disseminated Gonococcal Infection
What can trigger dissemination?
1-3% of patients
Leading cause of acute septic arthritis in young adults
Local infection 7-30 days before dissemination
Menstruation may trigger dissemination
Terminal complement deficiencies at increased risk
Symptoms of early DGI (Disseminated Gonococcal Infection)?
Subacute in onset
Pustular skin lesions
Symptoms of late DGI?
A young woman, sexually active, who presents with acute onset, RUQ abd pain and tenderness, aggravated by breathing, coughing, or chest movement. What is the possible diagnosis?
Fitz-Hugh-Curtis syndrome occurs almost exclusively in women.
Usually caused by gonorrhoea (acute gonococcal perihepatitis) or chlamydia bacteria, which cause a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, causing infection and inflammation.
Occasionally, this inflammation can cause scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver.
Sx: acute onset, upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder following an episode of PID
Doxycycline 100 mg bid x 14 days +/- metronidazole 500 mg bid x 14 days
What are the suggested guidelines for hospitalization in PID?
Surgical emergencies (appendicitis, etc.) cannot be excluded
Suspected pelvic/tubo-ovarian abscess
N/V precluding oral therapy
Failure to respond to oral agents in 24-48 hours
Genital Chlamydia Infections
Chlamydia cause 2/3 of epididymitis in young women
Chlamydia in 30-60% of women co-infected with GC
Chlamydia in 1/3 of cervix and/or fallopian tubes of laparoscopically verified PID
Non-gonocococcal Urethritis (NGU):
How would this present?
Less dysuris, less d/c than GC in general
Urinary frequency, irritation can be present
Leukocyte urethral exudate with > 4 PMNs on Gram stain of urethral swab without organism is correlated with chlamydial NGU
-Yellow or creamy d/c from cervix
-Gram stain + for WBCs
-Similar symptoms to GC
- > 10 PMNs/HPF on Gram stain smear of cervical mucous correlates with Chlamydia if GC if ruled out
PID -- probably as common as GC as cause
Genital Chlamydia infections: Lymphogranuloma venereum
Describe the clinical course
3 days to 3 weeks after exposure, get a small painless vesicle or papule/ulcer at the site of initial contact (1/3 of patients only)
2-6 weeks after exposure, regional lymphadenopathydevelops. Painful periadenitis occurs with matted nodes and inflamed overlying skin. Suppuration occurs with fistula formation (heals after several months).
LGV 2nd stage:
-Fever, chills, HA, myalgias
-Can get aseptic meningitis, meningoencephalitis, conjunctivitis, hepatitis, arthritis
LGV 3rd stage:
Chronic ulcerative/infiltrative local structures, fibrosis, strictures, impaired lymphatic flow with resulting genial elephatiasis
-Detection of elementary bodies by Giemsa, etc. or
-IF staining with monoclonal antibody: Most sensitive
-Chlamydiazyme and MicroTrak: rapid assays for detection of Chlamydia in clinical specimens
-Serologic 4-fold rise in antibody titer or +IgM
Treatment of Genital Chlamydia Infections:
For Urethritis, cervicitis, conjunctivitis, proctitis?
How about for a pregnant patient?
For pt with LGV?
Urethritis, cervicitis, conjunctivitis, proctitis
--Azithromycin 1 gm x 1 dose or doxycycline 100 mg PO bid x 7 days
----Ofloxacin 300 mg bid x 7 days or e-mycin 500 mg qid x 7 days or levofloxacin 500 mg x 7 days
Pregnant: Azithromycin 1 gm x 1 or amoxicillin 500 mg tid x 7 days
--Erythromycin 500 mg PO qid x 7 daus (not estolate form)
LGV: Doxycyline 100 mg PO bid x 21 days
--Erythromycin 500 mg qid x 21 days
Describe clinical course
Incubation period: median 5-7 days
Begins as small tender papule with surrounding erythema at site of contact
Evolves to pustule which erodes and ulcerates
Ulcers are painful
Tender regional lymphadenopathy in 50%
Azithromycin 1 gm PO x 1
Ceftriaxone 250 mg IM x 1
Ciprofloxacin 500 mg PO bid x 3 days
Erythromycin 500 mg PO tid x 7 days
Treat sexual partners also
The pt below present with the tender lesion in his groin. Gram stain is shown below. What is the diagnosis?
Azithromycin 1 gm PO x 1
Ceftriaxone 250 mg IM x 1
Ciprofloxacin 500 mg PO bid x 3 days
E-mycin 500 mg PO tid x 7 days
A young female presents with mucopurulemt cervicitis. Gram stain is (+) for WBCs, > 10 PMNs/HPF. Symptoms are similar to a friend of hers who had gonorrhea. GC was ruled out. What is the diagnosis?
How do you diagnose it?
What is the differential dx?
Diagnosis: Culture of ulcer base with swab or aspirated from inguinal nodes or buboes
--Gram stain shows gram (-) coccobacilli ("school of fish")
Treatment: Metronidazole 2 gm x 1 or 500 mg bid x 7 days
Treat sexual partners
What is the treatment?
Do you treat sex partners?
No treatment of sex partners necessary
Clindamycin cream or PO
Metronidazole 500 mg bid x 7 days
Who gets treated for asymptomatic bacteriuria?
What is the most common cause of acute osteo?
Common cause in IV drug abuser?
Common cause in SS patient?
What can exclude osteomyelitis?
Does sinus drainage correlate with organism in wound?
Acute: S. aureus
-IV drug abuser: Pseudomonas, MRSA
-SS patient: Salmonella, S. aureus
-Negative bone scan excludes osteomyelitis
-Sinus drainage does not correlate with organism in wound (except S. aureus)
Prosthetic joint - Staph epi, chronic, do joint aspiration
What is the most common nosocomial infection?
What is it?
What are the most distinguishing characteristics?
This organism is found throughout the world and is endemic in the United States. Wound infection with RGM is uncommon but can be catastrophic if not recognized and treated appropriately. The most distinguishing characteristics of the infections are nodules, often purple in color, and chronic abscess or sinuses.Skin and subcutaneous infections with RGM should be strongly considered in clinical situations demonstrating chronic purulent drainage, a lack of a convincing pathogen on routine culture, and association with implanted prosthetic devices. A lack of response to treatment and the failure to isolate a convincing pathogen should prompt further diagnostic evaluation consisting of staining and special culturing for mycobacteria followed by sensitivity testing to determine the appropriate antimicrobial therapy.
What is the gram stain result for Klebsiella granulomatosis?
Gram stain for Listeria?
What is the treatment for Cryptospirodiosis?
Treatment depends on the immune status of the host. Immunocompetent patients generally require no specific therapy because the disease is self-limited. If symptoms persist beyond several weeks, a course of nitazoxanide can be tried because it has been shown to hasten symptom resolution and clear oocysts from the stool. Immunocompromised patients, such as those with HIV infection, respond poorly to nitazoxanide, paromomycin, trimethoprim-sulfamethoxazole, and metronidazole. For these patients, initiation of highly active antiretroviral therapy to induce immune reconstitution is critical for controlling the cysts.
Proper hygiene is essential to decrease person-to-person spread of Cryptosporidium. Boiling or filtering of tap water may decrease the incidence of infection in immunocompromised hosts but is not routinely recommended. Persons who are immunocompromised should also limit time in public swimming pools, water parks, and lakes.
How do you manage close ontacts of a pt with smallpox (variola)?
Immediate vaccination of close contacts (ring vaccination) is the appropriate response to a community outbreak of smallpox.
Acyclovir has no effect against variola, and cidofovir has not been tested as a prophylactic agent for this infection. Passive immunization with hyperimmune globulin is an effective prophylaxis for smallpox, but supplies are too limited to be of practical use in epidemic-control efforts.
Explain how you manage a needlestick injury from a source who is HIV and hepatitis C virus-positive
After needlestick injury, injured persons should immediately wash the area with soap and water and report to the employee health department or specified area for needlestick evaluation. Baseline serologies and postexposure HIV prophylaxis should be done immediately, with follow-up serologies done as indicated.
Recommendations for postexposure HIV prophylaxis are based on severity of exposure and the source HIV class. Severity is divided into two categories: less severe is defined as exposure to a solid needle with superficial injury; and more severe is defined as exposure to a large-bore hollow needle, deep puncture, visible blood on device, or needle used in a patient’s artery or vein. An HIV class 1 exposure is defined as exposure to an asymptomatic source or to a source in whom the viral load is low (for example, <1500 HIV RNA copies/mL). An HIV class 2 exposure is defined as exposure to a source with symptomatic HIV infection, AIDS, acute seroconversion, or a known high viral load.
For low-risk exposure, prophylaxis with two nucleosides is recommended.
Severe exposure and the source’s class is 2; therefore, the recipient of the needlestick should be offered postexposure prophylaxis with three or more antiretroviral agents.
What are the clinical features of West Nile virus encephalitis?
Clinical features include tremores, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.
What are the clinical feaures of herpes simplex encephailitis?
language and vehavioral abnormalities
cranial nerve deficits
How do you treat disseminated herpes zoster infection?
Intravenous acyclovir is the treatment of choice for immunocompromised patients with disseminated herpes zoster infection.
What are clues to the diagnosis of Plasmodium falciparum?
If malaria is acquired in Africa, the likelihood that it is Plasmodium falciparum is at least 3:1
P. falciparum infections have a clinical onset beyond 2 months after exposure in only 5% of cases; therefore, patients with symptoms lasting beyond 2 months after return from travel are unlikely to have P. falciparum infection
Peripheral Blood Smear Findings Likely for P. falciparum Infection
Level of parasitemia is >2%
Only ring forms are present
Banana-shaped gametocytes are seen
Erythrocytes of all sizes are infected
Numerous multiply infected erythrocytes are seen
Erythrocytes contain no Schüffner granules
How do you manage a pt with suspected variant Creutzfeldt-Jakob disease?
What is variant CJD?
How is it diagnosed?
Variant Creutzfeldt-Jakob disease (vCJD) is characterized by early-onset psychiatric symptoms suggestive of depression, an earlier age of onset than CJD, an absence of periodic sharp waves on electroencephalogram, and presumptive diagnosis by tonsillar biopsy.
How do you obtain a diagnosis of Creutzfeldt-Jakob disease?
How do you evaluate a patiend with West Nile virus encephalopathy?
In patients with encephalitis caused by flaviviruses (such as West Nile virus), the detection of cerebrospinal fluid (CSF) IgM antibodies is considered diagnostic of neuroinvasive disease.
What are the clinical features of West Nile virus infection?
Clinical features of neurologic infection with West Nile virus include tremors, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.
How do you treat acyclovir-resistant genital herpes simplex virus infection?
Foscarnet is the drug of choice for treating acyclovir-resistant genital herpes simplex virus infection.
Resistance should be suspected if herpetic lesions do not resolve within 7 to 10 days after the initiation of adequate antiviral therapy. Resistance is most commonly reported for acyclovir, but this may simply be because acyclovir has been available for clinical use longer than the other drugs in this family. If resistance is suspected, a viral culture should be obtainedand the specimen submitted for in vitro susceptibility testing; the correlation between in vitro resistance and clinical response is good.