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Infectious Disease Board Review Stephen Barone MD Pediatric Program Director Steven and Alexandra Cohen Children’s Medical Center of New York Associate.

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Presentation on theme: "Infectious Disease Board Review Stephen Barone MD Pediatric Program Director Steven and Alexandra Cohen Children’s Medical Center of New York Associate."— Presentation transcript:

1 Infectious Disease Board Review Stephen Barone MD Pediatric Program Director Steven and Alexandra Cohen Children’s Medical Center of New York Associate Professor Hofstra North Shore – LIJ School of Medicine Hofstra North Shore – LIJ School of Medicine Michael Lamacchia, MD Chairman St. Joseph’s Children’s Hospital Associate Professor Mount Sinai School of Medicine

2 A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a 3 –day history of a “bark-like” cough, low grade fever and URI symptoms. She became acutely worse today and appears “toxic”. The most likely diagnosis is? A. Viral laryngotracheitis B. Epiglottis C. Retropharyngeal abscess D. Foreign body E. Bacterial tracheitis Question 1 10

3 Key Points # 1 Key Points # 1 Bacterial tracheitis Bacterial tracheitis –Fever, toxic, stridor, secretions, S aureus Epiglottis Epiglottis –Older, unimmunized, drooling, toxic, no cough, H. Influenza Viral laryngotrachitis Viral laryngotrachitis –Cough, stridor, non-toxic, parainfluenza Retropharyngeal abscess Retropharyngeal abscess –Young, drooling, stiff neck Foreign body Foreign body –Acute onset, afebrile, historical clues

4 A 2 month old infant presents with a 2 -week history of a cough, perioral cyanosis and posttussive vomiting. The treatment of choice is? A. High dose Amoxicillin B. Azithromycin C. Clindamycin D. Steroids E. Trimethroprim - sulfamethoxazole Question 2 10

5 Key Point #2 Pertussis Pertussis –Infants or Adolescents –Macrolide - limit spread Differential Diagnosis Differential Diagnosis –Chlamydia trachomatis Staccato cough, tachypnea afebrile, Staccato cough, tachypnea afebrile, –PCP Hypoxic, toxic, immunodeficiency Hypoxic, toxic, immunodeficiency

6 A 5 year-old presents with migratory arthritis and this rapidly changing rash. The most likely diagnosis is? A. Fifth disease B. Juvenile rheumatoid arthritis C. Rheumatic fever D. Systemic Lupus E. Lyme Disease Question 3 10

7 Key Points #3 Group A Streptococcus infections Group A Streptococcus infections –Exudative pharyngitis, fever, anterior nodes –Treatment – Penicillin –Rheumatic fever Arthritis, chorea, carditis, nodules, erythema marginatum Arthritis, chorea, carditis, nodules, erythema marginatum Prophylaxis Prophylaxis Scarlet fever – no prophylaxis Scarlet fever – no prophylaxis –PSGN Skin infections, not preventable with antibiotics Skin infections, not preventable with antibiotics

8 An afebrile 12 year boy with nephrotic syndrome presents with a headache, vomiting and 6 th nerve palsy. His sensorium is intact. The most likely diagnosis is? 1. Meningitis 2. Sinus venous thrombus 3. Brain abscess 4. Sinusitis 5. Lyme Disease Question 4 10

9 Key Points #4 Sinus Venous Thrombosis Sinus Venous Thrombosis –Symptoms Headache Headache Weakness Weakness Seizures Seizures –Predisposing conditions Nephrotic syndrome Nephrotic syndrome Thrombophilia Thrombophilia Meningitis Meningitis Dehydration Dehydration

10 A child entering kindergarten has had multiple episodes of otitis media and a second episode of radiographically documented pneumonia. What is the most appropriate initial test for a possible immunodeficiency? A. Serum complement levels B. Serum immunoglobulin levels C. CD4/CD8 ratio D. Serum IgE levels E. Serial complete blood counts for 6 weeks Question 5 10

11 Key Points #5 AOM and Pneumonia AOM and Pneumonia –Encapsulated organisms Immunoglobulin Deficiency Immunoglobulin Deficiency –X – Linked Agammaglobulinemia –Common Variable Immunodeficiency –IgA immunodeficiency Screening Tests Screening Tests –Immunoglobulins –Response to vaccines

12 A 3 year old presents with a 1 month history of unilateral cervical adenitis. The child has been well appearing, afebrile and has had not traveled. A PPD measures 6 mm. The next step in the management is? A. Isoniazid and Rifampin for 6 months B. A repeat PPD in 3 months C. A CT of the neck D. Excisional biopsy E. Azithromycin for 4 weeks Question 6 10

13 Key Points #6 Unilateral adenitis Unilateral adenitis –Acute S. aureus, Group A Streptococcus S. aureus, Group A Streptococcus –Antibiotics –Sub acute Atypical Mycobacterium Atypical Mycobacterium –History, PPD, excisional biopsy Cat Scratch Cat Scratch –History, serology, no treatment Kawasaki Disease Kawasaki Disease –IVIG –Chronic Malignancy Malignancy

14 A 15 year old boy develops a fever to 101 o F, headache and bilateral swelling of his parotid glands. The most likely complication of this illness is? A. Acute airway obstruction B. Sensorineural hearing loss C. Orchitis D. Myocarditis E. Arthritis Question 7 10

15 Key Points #7 Parotitis Parotitis –Bacterial – ill appearing –Viral Mumps Mumps –Viral syndrome with swelling of parotid glands –Complication Orchitis Orchitis CSF pleocytosis – most asymptomatic CSF pleocytosis – most asymptomatic Rare – myocarditis, arthritis etc. Rare – myocarditis, arthritis etc. Vaccine Vaccine –Live vaccine

16 A 15 year old complains of a sore throat, fever and a muffled voice. On examination the adolescent is found to have trismus. The most likely diagnosis is? 1. Tetanus 2. Retropharyngeal abscess 3. Infectious mononucleosis 4. Peritonsillar abscess 5. Herpangia Question 8 10

17 Key Points #8 Peritonsillar abscesses Peritonsillar abscesses –Adolescent, sore throat, hot potato voice, trismus Dx – exam Dx – exam Organisms –S. aureus. Group A Streptococcus, Anaerobes Organisms –S. aureus. Group A Streptococcus, Anaerobes Retropharyngeal abscess Retropharyngeal abscess –Toddler, stridor, stiff neck, dysphagia, torticollis Dx – CT scan Dx – CT scan Infectious Mononucleosis Infectious Mononucleosis –Adolescent, sore throat, lymphadepathy, fatigue, fever Tetanus Tetanus –Trismus and muscle spasm –C. tetani –Treatment Tdap, TIG Tdap, TIG Penicillin Penicillin Herpangina Herpangina –Peritonsillar ulcers/vesicles –Enteroviral infection

18 A 9 month old presents with vesicular lesions on his lips and bleeding gums. He is drooling and unable to eat. There is a “target lesion rash” In addition to hydration, Which therapeutic regime will be most effective? A. IV acyclovir B. IV nafcillin C. Topical nystatin D. Topical mupirocin E. IV steroids Question 9 10

19 Key Points #9 Herpes gingivostomatitis Herpes gingivostomatitis –Young child, anterior vesicles, swollen gums –Treatment – supportive, Acyclovir –Complication – erythema multiforme –Dx – Culture, DFA Herpangina Herpangina –Posterior vesicles Candida Candida –Cottage cheese plaques on buccal mucosa Impetigo Impetigo –Honey crust lesions on the skin –Group A Streptococcus, S. aureus

20 A 3 year old presents with a three day history of fever and cough. Today he developed respiratory distress. In addition to supportive care what is the most appropriate treatment plan? A. CT Scan of chest B. Ceftriaxone C. PPD D. Bronchoscopy E. Amphotericin Question 10 10

21 Key Points #10 Pneumococcal pneumonia Pneumococcal pneumonia –Most common bacterial pneumonia –Acute, fever, tachypnea, cough, focal infiltrate Round pneumonia Round pneumonia –Treatment Inpatient – Ceftriaxone Inpatient – Ceftriaxone Outpatient – High dose Amoxicillin Outpatient – High dose Amoxicillin Resistance – Lack of PCP’s Resistance – Lack of PCP’s

22 A 5 year old presents with a month history of cough, fever and weigh loss. His CXR demonstrates a focal infiltrate with hilar lymphadenopathy. A PPD measures 7 mm. The most appropriate treatment plan is? A. Repeat PPD in 3 months B. Bronchoscopy C. Gastric lavage D. Isoniazid for nine months E. Isoniazid, Rifampin and Ethambutal for 6 months Question 11 10

23 Key Points # 11 Mycobacterium tuberculosis Mycobacterium tuberculosis –History Immigrant, insidious, weight loss, hilar nodes Immigrant, insidious, weight loss, hilar nodes –PPD 5 mm – high risk – symptoms, HIV 5 mm – high risk – symptoms, HIV 10 mm – medium – age less than 6, immigrant, travel 10 mm – medium – age less than 6, immigrant, travel 15 mm – low 15 mm – low Diagnosis – gastric lavage Diagnosis – gastric lavage –Treatment Four drugs then based on sensitivities Four drugs then based on sensitivities –Side-effects Prophylaxis Prophylaxis –INH – 9 months

24 A ten year old boy presents with a four day history of cough, fever and myalgia. A rapid influenza test was positive two days ago in his physician’s office. Today he became acutely worse and is in respiratory distress. The most appropriate therapy is? A. Oseltamivir B. Ribavirin C. Clindamycin D. Aztreonam E. Azithromycin Question 12 10

25 Key Points #12 Influenza Influenza –Fever, cough, myalgia –Oseltamivir – within 48 hours –Influenza vaccine – 2A, 1B –Antigenic shift vs. antigenic drift Complications Complications –S. aureus pneumonia MRSA MRSA –Clindamycin, Vancomycin

26 A febrile irritable 20 month old male presents with a two day history of a “crusty” excoriation under his nose This was followed by a diffuse erythematous painful rash. The most likely diagnosis is? A. Kawasaki disease B. Staphylococcal scalded skin syndrome C. Toxic shock syndrome D. Roseola E. Enteroviral infection Question 13 10

27 Key Points #13 1. Staphylococcal Scalded Skin Syndrome 1. Symptoms 1.Non-toxic, impetigo, painful, sunburn rash, skin peels readily. 2. Toxic Shock Syndrome 1. Hypotension 2. Fever 3. Rash 4. Desquamation 1.Plus three or more organ systems involved

28 A 10 year boy while on summer vacation presents to a Maryland ED with a 3 day history of shaking chills, myalgia, and abdominal pain. He is noted to have this rash on his feet and splenomegaly. The most likely diagnosis is? A. Meningococcemia B. HSP C. Rocky Mountain Spotted Fever D. Lyme disease E. EBV Question 14 10

29 Key Points # 14 Rocky Mountain Spotted Fever Rocky Mountain Spotted Fever –Epidemiology, distal petiechiae, headache, increased LFT’s, hyponatremia Treatment – doxycycline Treatment – doxycycline Lyme Disease Lyme Disease –Northeast, Wisconsin, Northern CA Rash, arthritis (mono), meningitis Rash, arthritis (mono), meningitis –Treatment  Amoxicillin, Doxycycline  Ceftriaxone

30 A year old child presents with a four day history of irritability and recurrent fevers. Today he is afebrile and had a diffuse erythematous rash on his trunk. You diagnosis the child with roseola. Which of the following is a common complication of this disease? A. Arthritis B. Febrile seizures C. Aseptic meningitis D. Thrombocytopenia E. Hepatitis Question 15 10

31 Key Points # 15 Roseola Roseola –Fever followed by rash HHV6 infection HHV6 infection –Complications Febrile seizures Febrile seizures Complications Complications –Parvovirus – arthritis –EBV – hepatitis –Aseptic meningitis – Kawasaki –Thrombocytopenia - RMSF

32 A premature 11 month old infant receives a dose of palvizumab for prophylaxis against RSV infection. When should the next dose of MMR vaccine be administered? A. 1 month B. 3 months C. 6 months D. 9 months E. One year Question 16 10

33 Key Point #16 MMR Vaccine – Live vaccine MMR Vaccine – Live vaccine –Intervals Palivizumab- None Palivizumab- None PRBC – 5 months PRBC – 5 months IVIG – 11 months IVIG – 11 months Fun facts Fun facts –Not contraindicated with egg allergy –PPD suppressed for 6 weeks –If greater then 2/kg steroids – wait one month –No effect of inadvertent MMR on pregnancy

34 Which vaccine(s) is (are) not routinely recommended for catch up vaccination for healthy children greater than 5 years of age? A. Varicella B. Hib C. Pneumococcal D. Hib & Pneumococcal E. DTaP Question 17 10

35 Key Point #17 Hib and Pneumococcal vaccines Hib and Pneumococcal vaccines –No catch up greater than 5 DTaP DTaP –4 doses Varicella Varicella –Always catch -up

36 A fourteen year old male presents to the ED after sustaining a laceration with a lawn motor blade. He has not received any vaccinations in the past 5 years. Although his mother reports he received all recommended immunizations as a child. He should receive? A. Td and TIG B. TdaP C. DT D. TdaP and TIG E. TIG Question 18 10

37 Key Points # 18 No Contraindication DTaP – under 7 TdaP – Adolescents Contraindication Td – greater than 7 DT – less than 7 VaccineClean V/TIG Dirty V/TIG Unknown or < 3 doses Y / NY / Y 3+ doses Y / N If > 10 yrs Y / N If > 5 yrs V = vaccine

38 Which of these two vaccine pairs, if not given simultaneously (at the same visit) should be separated by at four least weeks? A. Hepatitis A and Hepatitis B B. IPV and Pneumococcal C. DTaP and Hib D. MMR and Varicella E. MMR and Hepatitis B Question 19 10

39 Key Points #19 Live vaccines if not given simultaneously need to be separated by 4 weeks Live vaccines if not given simultaneously need to be separated by 4 weeks –Learn contraindications of live vaccines “egg based” vaccines “egg based” vaccines –Influenza (injectable) –Yellow fever –Measles and mumps (chick embryo)

40 A 5 year old presents with fever, jaundice and vomiting. A hepatitis profile reveals: Hepatitis A IgM – negative. Hepatitis A IgG- positive. Hepatitis BsAg –negative. Hepatitis BsAb – positive. Hepatitis BcAb – negative. Interpretation? A. Acute hepatitis A and B infections B. Chronic hepatitis A and B infections C. Previous vaccination against hepatitis A and B D. Chronic hepatitis B infection and acute hepatitis B infection E. Past hepatitis B infection and acute hepatitis B infections Question 20 10

41 Key Points #20 Hepatitis A Hepatitis A IgM – Acute IgG – Acute, past, vaccine TestsResultsInterpretation BsAg BcAb BsAb Negative Positive Vaccine BsAg BcAb BsAb Negative Positive Past infection BsAg BcAb BsAb Positive Negative Acute infection BsAg BcAb BsAb Positive Negative Chronic infection

42 A 14 year old boy returns from summer camp. He complains of a 10 day history of foul smelling watery diarrhea and abdominal pain. What is the most likely cause of his symptoms? A. Norwalk virus B. Giardia C. Campylobacter D. Yesinia E. Helicobacter Question 21 10

43 Key Points # 21 Small intestine Small intestine –Watery, high volume, frequent Rotavirus. Norwalk, Adenoviurs, Giardia Rotavirus. Norwalk, Adenoviurs, Giardia Large Intestine Large Intestine –Blood, small volume, mucus, travel Salmonella – food, turtles Salmonella – food, turtles Campylocbacter – unpasteurized milk, GBS Campylocbacter – unpasteurized milk, GBS Yersina – “chittlings” Yersina – “chittlings” Shigella – food, neurotoxin Shigella – food, neurotoxin E-coli O157H7- food, HUS E-coli O157H7- food, HUS E-coli – travel associated – watery E-coli – travel associated – watery C. difficle - antibiotics C. difficle - antibiotics

44 An 12 year old returns from a three month trip to India. She complains of a 10 day history of fever, chills, abdominal pain and myalgia. Her examination is unremarkable Lab results WBC – 6,000 Hb – 13.6 Plt – 400,000 AST – 120 Her most likely diagnosis is? A. Malaria B. Typhoid fever C. TB D. Hepatitis B E. Yellow fever Question 22 10

45 Key Points #22 Malaria Malaria –Fever, splenomegaly, hemolytic anemia Typhoid Typhoid –Flu- like illness, normal WBC TB TB –Longer incubation period Hepatitis B Hepatitis B –No risk factor for traveling adolescents Yellow fever Yellow fever –Africa, South America

46 Which is the preferred diagnostic test to confirm an HIV infection in one month old infant born to an HIV positive mother? A. HIV p24 antigen assay B. HIV DNA PCR C. HIV culture D. HIV serology E. CD4/CD8 ratio Question 23 10

47 Key Points #23 –HIV serology can be falsely positive for up to 18 months after birth –HIV p24 antigen test – false positives and negatives Not recommended Not recommended –HIV culture – requires 4 weeks, not readily available Not recommended Not recommended –HIV DNA PCR Highly sensitive and specific Highly sensitive and specific Considered infected if two separate positive tests Considered infected if two separate positive tests –CD4/CD8 ratio Not useful in the neonatal period Not useful in the neonatal period

48 A full-term normal-appearing infant was born to a 26-year old female with a history of syphilis during the first trimester of pregnancy, as evidenced by the seroconversion of her VDRL result (titer 1:4, previously nonreactive). The woman received one injection of 2.4 million units of benzathine penicillin. At delivery, her VDRL had a titer of 1:64. In evaluating this infant the appropriate conclusion is that - A. The mother has been adequately treated, and the infant requires no further therapy B. The infant has a high probability of having congenital syphilis and requires evaluation and treatment C. If the infant’s long bone radiographs show no abnormality, no treatment is indicated D. This child may be given a shot of benzathine penicillin, and no further serologic evaluation is necessary Question 24 10

49 Key Points #24 Evaluate infants for congenital syphilis if: Fourfold increase in maternal titer Infant has clinical manifestations of syphilis Syphilis is untreated, inadequately treated, or treatment not documented Mother treated with non-penicillin regimen Mother treated <1 month before delivery Treated before pregnancy but with insufficient serologic follow-up Evaluation for syphilis in an infant: Quantitative nontreponemal serologic test of serum from infant VDRL test of CSF, cell count, protein concentration Long-bone Xrays CBC w/platelets Other clinically indicated tests (C Xray, LFT’s, US, eye exam, auditory brain stem) Pathologic examination of placenta or umbilical cord using FTA staining if possible

50 A 10-year-old child develops ascending paralysis with peripheral neuropathy (cranial nerves are normal); the CSF is normal except for an elevated protein level. The likely infectious agent precipitating this syndrome is - A. Corynebacterium diphtheriae B. Clostridium botulinum C. S. dysenteriae serotype 1 D. Campylobacter jejuni E. Clostridium tetani Question 25 10

51 Keypoints #25 Guillain-Barre Syndrome Motor polyradiculoneuropathy Muscle pain, symmetric, ascending paresis with minor sensory abnormality Diagnostic criteria: Required – Progressive muscle weakness of more than 1 limb Areflexia Strongly supportive – Relative symmetry Mild or no sensory Cranial nerve involvement Autonomic dysfunction Absence of fever Disease progression halts by 4 weeks Recovery

52 Keypoint #25 - continued CSF features – Elevated protein after first week Fewer than 10 mononuclear cells Electrodiagnostic features – Nerve conduction slowing Etiology: Campylobacter jejuni CMV EBV M. pneumoniae Vaccine ie., swine flu, Menactra, rabies, tetanus toxoid, Hep. B, influenza, enteroviruses, west nile Food borne diseases (Shighella, Enteroinvasive E. coli, Yersinia enterocolitica, vibrio parahaemolyticus)

53 Congenital rubella syndrome is associated with which of the following? A. Patent ductus arteriosus (PDA) and branch pulmonary artery stenosis B. Ventricular septal defect (VSD) and PDA C. Atrial septal defect (ASD) and PDA D. VSD and ASD E. VSD and pulmonary artery stenosis Question 26 10

54 Keypoint #26 Congenital Rubella Syndrome Manifestations – Ophthalmologic Cataracts, pigmentary retinopathy, micro phthalmos congenital glaucoma Cardiac Patent ductus arteriosus, peripheral pulmonary artery stenosis Auditory Sensorineural hearing impairment Neurologic Behavioral disorders, meningoencephalitis, mental retardation Neonatal Growth retardation, interstitial pneumonitis, radiolucent bone disease, hepatosplenomegaly, thrombacytopenis, dermal erythropoiesis Occurrence of Congenital Defects – 85% if mother has rash in first 12 weeks 34% 13-16 weeks 25% during end of second trimester

55 A 4-year-old male is brought to your office because of a circular reddish rash under his armpit. The child has been afebrile and has had no other systemic symptoms. The rash is not pruritic. The child’s parents state that they have recently returned from a vacation in Massachusetts on Cape Cod and that a small tick had been removed from the same area where the rash is now. The only abnormality on the examination is the circular, flat, erythematous rash that is about 6 cm in diameter and is not tender. The appropriate next step in treating this patient is to - A. Order a test for serum antibodies against Borrelia burgdorferi to confirm that the child has Lyme disease B. Begin treatment with doxycycline C. Begin treatment with amoxicillin D. Begin treatment with ceftriaxone E. Perform a lumbar puncture to be certain that the child’s central nervous system (CNS) is not involved. Question 27 10

56 Keypoint # 27 Clinical – –Early localized Erythema migrans – –Early disseminated Multiple erythemamigrans Cranial nerve palsies Lymphocytic meningitis Arthritis Carditis – –Late Recurrent Arthritis CNS Diagnosis –Clinical (EM) during early stages –Clinical and serologic in early disseminated or late –Serology EIA or IFA for screening Western Immunoblot 1 gG 5 bands 1 gM 2 bands

57 Primary pulmonary histoplasmosis in normal children is usually? A. Asymptomatic B. Associated with severe flu-like symptoms C. Treated with assisted ventilation and steroid therapy D. Associated with sarcoid- like disease E. Complicated by mediastinal fibrosis Question 28 10

58 Keypoint #28 Histoplasmosis Causes symptoms in fewer than 5% of infected people Site (pulmonary, extrapulmonary, disseminated) Duration (acute, chronic) Pattern (primary vs. reactivation) Mississippi, Ohio, Missouri River Valley Coccidiomycosis Asymptomatic or self-limited 60% May resemble influenza, diffuse erythematous maculopapular rash, erythema multiforme, erythema nodosum dissemination to skin, bones, joints, CNS is rare California, Arizona, New Mexico, Texas, Utah, northern New Mexico, certain areas of Central and South America Blastomycosis May be asymptomatic or acute, chronic or fulminant disease Pulmonary and cutaneous lesions Can disseminate to bones, CNS, abdominal viscera, kidneys Southeastern and central states and those bordering Great Lakes

59 All of the following are consistent with the diagnosis of congenital toxoplasmosis in an infant EXCEPT - A. An infant with normal findings on newborn evaluation B. An infant who is small for gestational age C. A CSF protein level of 3 g/dL D. An infant whose mother has no serologic evidence of Toxoplasma gondii infection E. An infant who mother has AIDS and is chronically infected with T. gondii Question 29 10

60 Key Points # 29 Congenital Toxoplasmosis – –Asymptomatic at birth 70-90% – –Many will go on to have visual impairment, learning disabilities, mental retardation – –At birth, may have maculopapular rash, generalized lymphadenopathy, hepatomegaly, splenomegaly, jaundice, thrombocytopenia – –CNS manifestations: hydrocephalus, microcephaly, chorioretinitis, seizures, deafness – –Cerebral calcifications are diffuse – –Members of cat family are definitive hosts

61 A 5-month-old previously healthy female is brought to her pediatrician because of fever, irritability, and poor feeding. She is the second child in her daycare center to be diagnosed with meningitis within a week. She has received all recommended immunizations. The most likely cause of her meningitis is - A. Haemophilus influenzae B. Neisseria meningitidis C. Group B streptococci D. Herpes simplex virus E. Listeria monocytogenes Question 30 10

62 Key Points # 30 Neisseria Meningitidis – –Children younger than 5, greatest attack rate in less than 1 year – –Adolescents 15-18 years – –Freshmen college students who live in dormitories – –Close contacts of patients with meningococcal disease Deficiency of terminal complement, properdin, or anatomic or functional asplenia Meningococcemia, meningitis – –Waterhouse-Friderichsen-purpura, DIC, shock, coma, death Vaccine – –A, C, Y, W135 – no B

63 Of the following drugs, the one most commonly associated with acute interstitial nephritis is - A. Sulfisoxazole B. Methicillin C. Nafcillin D. Penicillin E. Phenytoin Question 31 10

64 Keypoint #31 Antibiotic Complications Aminoglycosides Amikacin, gentamicin, kanamycin, tobramycin, streptomycin Ototoxicity and nephrotoxicity Ototoxicity: destruction of cochlear hair cells in the organ of Corti producing a high-frequency irreversible hearing loss (amikacin, kanamycin) Vestibular dysfunction: damage to vestibular hair cells (streptomycin, gentamicin) Can occur early or after cessation of antibiotic Tetracyclines Nausea and vomiting are most common Hepatotoxicity following high doses, intravenous usage, or in pregnancy Nephrotoxicity in pre-existing renal disease Tetracycline-calcium orthophosphate complex that inhibits bone growth in neonates and produces teeth staining Photosensitivity Decreased prothrombin activity Overgrowth of resistant bacterial organisms Esophageal ulcers Intravenous administration: pain, phlebitis, tissue injury if extravasation occurs

65 Keypoint #31 - continued Antibiotic Complications Chloramphenicol Bone marrow suppression 1. Dose, duration related and reversible (>7 days) elevated serum iron, low reticulocyte count, and low hemoglobin 2. Severe, irreversible, idiosyncratic aplastic anemia (occurs anytime during therapy or weeks after) Mechanism: thought to be direct toxicity of nitrosochloramphenicol on DNA Rifamycins Rifampin, rifabutin Contraindicated in pregnancy Orange colored urine, tears and all biologic secretions in 80% of patients Rapid and potent inducers of CYP3A4, the most abundant human cytochrome P450 found predominately in the liver and small intestine

66 Keypoint #31 - continued Antibiotic Complications Sulfonamides Rashes are the most common problem Acute lgE-medicated hypersensitivity reactions and drug-induced lupus erythematosus reactions Self-resolving granulocytopenia, megaloblastic anemia, thrombocytopenia have been described Renal failure with crystalluria and reversible hepatocellular dysfunction with jaundice have been described with sulfamethoxazole Aseptic meningitis Quinolones Rare adverse reactions: arthralgia, crystalluria, acute renal failure, antibiotic associated colitis, serum sickness like reactions, eosinophilia, leukopenia, thrombocytopenia Not approved for children <18 years of age Interference with cartilage growth in beagle puppies Human studies in cystic fibrosis patients and other infants have failed to show these problems

67 Keypoint #31 - continued Antibiotic Complications Natural Penicillins Nonfatal anaphylaxis in adults (1/1000 exposures) Fatal anaphylaxis is rare Other hypersensitivity reactions: serum sickness, cutaneous rashes, contact dermatitis Allergic reactions seem to be most prominent with procaine penicillin (up to 90%) Other reactions: hemolytic anemia, interstitial nephritis, seizures, hyperkalemia associated with high doses or prolonged exposure Cephalosporins Anaphylaxis Hypersensitivity reactions may be compound specific (e.g., cefaclor) Hypersensitivity reactions include interstitial nephritis, autoimmune thrombo- cytopenia, pulmonary eosinophilia, serum sickness like reaction, drug fever Seizures and nephrotoxicity associated with high doses and poor renal function Gastrointestinal upset is most common with oral agents Ceftriaxone: reversible biliary pseudolithiasis and rapidly fatal immune-mediated hemolytic anemia

68 Keypoint #31 - continued Antibiotic Complications Macrolides Generalized pruritus, maculopapular rash, serum sickness like reactions, erythema multiforme major associated with large doses or in patients with renal failure Intravenous administration has been associated with cardiac toxicity (prolonged QT interval, ventricular tachycardia, premature ventricular contractions, nodal bradycardia, sinus arrest), hepatotoxicity, and venous venous irritation (rate associated)

69 A gravida 1, para 0 woman is at 38 weeks’ gestation. A vaginal culture taken 48 hours ago is now reported positive for herpes simplex, type II. Her obstetrician asks your advice concerning immediate management of delivery for obstetric reasons. You should advise - A. Vaginal delivery after the spontaneous onset of labor B. Cesarean delivery before the onset of labor C. Topical treatment with tetramethyl acridine followed by phototherapy and vaginal delivery D. Immediate induction of labor and vaginal delivery E. Oral administration of acyclovir to the mother and induction of labor and vaginal delivery Question 32 10

70 Key Points # 32 Neonatal Herpes Infections – –Delivery by C-Section prior to rupture of membranes – –Risk of HSV infection at delivery in an infant born vaginally to a mother with primary infection of 33-50% – –If born to a mother with reactivated infection of less than 5% – –Neonatal HSV may be – 1) disseminated 2) localized to CNS 3) localized to skin, eyes, mouth

71 A 5 year old child presents to the emergency department 12 hours after receiving a dog bite to his hand. The hand is swollen, red and painful. The intravenous antibiotic of choice is? A. Ceftriaxone B. Doxycycline C. Clindamycin D. Ampicillin – Sulbactam E. Erythromycin Question 33 10

72 Key Points # 33 Animal Bites Animal Bites –Pasteurella multicida – rapid < 24h hours –Staphylococcus aureus –Mixed Infections P. multicida P. multicida –Drug of choice - penicillin –Resistant to many cephlosporins

73 An 17 year old sexually active female presents to the ED complaining of malodorous, frothy vaginal discharge. A wet mount is as shown. The drug of choice is? A. Ceftriaxone B. Clindamycin C. Metronidazole D. Fluconazole E. Azthromycin Question 34 10

74 Key Points # 34 Trichomonas Vaginalis – –Asymptomatic in 90% of men and 50% of women – –Frothy vaginal discharge and mild vulvovaginal itching and burning, pale-yellow to green-gray DC, musty odor – –Deeply erythematous vaginal mucousa, friable cervix – –Wet-mount prep – –Metronidazole or Tinidazole

75 A 15 year old girl had sexual intercourse for the first time a week ago. She has received 3 doses of the quadrivalent HPV vaccine. Which of the following statements are true? A. Secondary to “cross protection” she is protected from all strains of HPV B. She is fully protected against HPV related cervical cancer C. She has a decreased risk of developing genital warts D. She should receive a booster dose now. E. If her partner used a condom her risk for HPV is reduced by 95% Question 35 10

76 Key Points # 35 Human Papilloma Virus – –Condylomata Acuminata – skin colored warts with a cauliflower-like surface – –HPV the cause of cervical, vulvar, vaginal cancers – –HPV Vaccine 16, 18 cervical cancer – 67% decrease 6,11 cervical warts – 98% decrease

77 Abdominal pain and bloody diarrhea develop in a 2- year-old boy two days after completion of therapy for otitis media. The child is febrile and has abdominal distention. An assay for C. difficile toxin in positive. The most appropriate next step in the management of this child is? A. Confirmatory stool culture for C. difficile B. A colonoscopy to determine the extent of the disease C. Initiation of oral metronidazole D. Initiation of oral Vancomycin E. Initiation of IV Vancomycin Question 36 10

78 Key Points # 36 C. Difficile – –Pseudomembranous colitis – diarrhea, abdominal cramps, fever, systemic toxicity, abdominal tenderness, stools with blood and mucous – –At risk groups for severe or fatal disease are: leukemics with fever and neutropenia, Hirschsprung, IBD – –Diagnosis C. Difficle toxin Infants have greater than 50% positivity – –Treatment Discontinue antibiotics Oral metronidazole, In severe disease, if diarrhea persists –vancomycin

79 A 10 day old infant presents with fever and irritability. The infant’s mother was ill with fever, malaise and abdominal pain 7 days prior to delivery. She reports her Group B strep status as negative. A lumbar puncture revealed a RBC count of 50 and a WBC count of 2,500. The most likely organism causing this child’s meningitis is? A. Group B streptococcus B. Escherichia coli C. Listeria monocytogenes D. Enterviral E. Herpes Simplex Question 37 10

80 Key Points # 37 Listeria monocytogenes – –Infections associated with maternal flu like illness, fever, malaise, GI symptoms – –Early or late onset Early – preterm, pneumonia, sepsis Late - Meningitis

81 A nurse reports 2 week old infant born at a gestational age of 33 weeks is no longer moving his right leg. An x-ray of the child’s leg reveals a lytic lesion in his femur and tibia. The most likely etiologic agent is? A. Group B streptococcus B. S. aureus C. S. epidermidis D. Pseudomonas aeruginosa E. Kingella kingae Question 38 10

82 Key Points # 38 Neonatal Osteomylitis – –Most likely – Group B streptococcus Multifocal Pseudo-paralysis Afebrile

83 An adolescent patient with ALL is being treated for prolonged fever and neutropenia. On a routine set of electrolytes it is noted that her serum potassium is 2.0. Which of the following drugs is most likely the cause of this patient’s hypokalemia? A. Vancomycin B. Amphotericin C. Cefepine D. Acyclovir E. Gentamicin Question 39 10

84 Key Points # 39 Complications of Amphotericin – –Systemic Fever, Chills – –Renal Azotemia Hypokalemia – –Essentially any other system as some potential side - effects

85 A 6 month old is admitted to the hospital for elective tonsillectomy. During your history and physical examination the mother reports he was expose to varicella at day care 48 hours ago. At this time you should? A. Place the baby on respiratory isolation B. Place the baby on respiratory isolation and administer VZIG C. Place the baby on respiratory isolation and administer both the varicella vaccine and VZIG D. Administer VZIG only and reschedule the surgery E. No special precautions Question 40 10

86 Key Points # 40 Varicella – –Incubation 7 to 21 days Indications for VZIG – –Immunocompromised – –Newborn- mothers onset 5 days before to 2 days afterward – –Preterm infant < 28 weeks Exposure – –Household – –Face to face play – –Hospital – same room, face to face contact

87 Answers 1 - e 1 - e 2 - b 2 - b 3 - c 3 - c 4 - b 4 - b 5 - b 5 - b 6 - d 6 - d 7 - c 7 - c 8 - d 8 - d 9 - a 9 - a 10 - b 10 - b 11 - e 11 - e 12 - c 12 - c 13 - b 13 - b 14 - c 14 - c 15 - b 15 - b 16 - a 16 - a 17 - d 17 - d 18 - b 18 - b 19 - d 19 - d 20 - c 20 - c 21 - b 21 - b 22 - b 22 - b 23 - b 23 - b 24 - b 24 - b 25 - d 25 - d 26 - a 26 - a 27 - c 27 - c 28 - a 28 - a 29 - d 29 - d 30 - b 30 - b 31 - b 31 - b 32 - b 32 - b 33 - d 33 - d 34 - c 34 - c 35 - c 35 - c 36 - c 36 - c 37 - c 37 - c 38 - a 38 - a 39 - b 39 - b 40 - e 40 - e

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