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ID BOARD REVIEW James Hinchey MD PhD MSW MPH JD BA SOB.

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Presentation on theme: "ID BOARD REVIEW James Hinchey MD PhD MSW MPH JD BA SOB."— Presentation transcript:

1 ID BOARD REVIEW James Hinchey MD PhD MSW MPH JD BA SOB

2 What do they like to ask? HIV- opportunistic infections Rabies Diarrhea-infectious Ticks, worms, parasites Syphilis

3 Which of the following infectious agents is thought to be the most common cause of Bell Palsy? Which of the following infectious agents is thought to be the most common cause of Bell Palsy? A. Borrelia bugdorferi B. Epstein-Barr virus C. Herpes simplex virus D. Mycobacterium tuberculosis E. Varicella-zoster virus

4 Which of the following infectious agents is thought to be the most common cause of Bell Palsy? Which of the following infectious agents is thought to be the most common cause of Bell Palsy? A. Borrelia bugdorferi B. Epstein-Barr virus C. Herpes simplex virus D. Mycobacterium tuberculosis E. Varicella-zoster virus

5 Herpes simplex virus Type 1 mostly oral, Type 2 primarily genital Type 1 mostly oral, Type 2 primarily genital prodrome of pain and hyperesthesia prodrome of pain and hyperesthesia Painful vesicles on an erythematous base crust and heal in days Painful vesicles on an erythematous base crust and heal in days recurrences in immunocompromised, prolonged sunlight exposure, stress recurrences in immunocompromised, prolonged sunlight exposure, stress Bells Palsy: Ddx- HIV, Lyme disease, TB, temporal bone trauma, mumps, Mycoplasma pneumonia, leprosy, sjogren’s, sarcoidosis; HSV most frequently associated Bells Palsy: Ddx- HIV, Lyme disease, TB, temporal bone trauma, mumps, Mycoplasma pneumonia, leprosy, sjogren’s, sarcoidosis; HSV most frequently associated antivirals in primary infection to decrease viral shedding and shorten duration of symptoms NOT to prevent recurrence antivirals in primary infection to decrease viral shedding and shorten duration of symptoms NOT to prevent recurrence long term suppressive therapy in those with severe and frequent recurrences long term suppressive therapy in those with severe and frequent recurrences IV abx and admission for HSV encephalitis IV abx and admission for HSV encephalitis

6 73 yr old woman p/w nausea and vomiting that began suddenly that afternoon. She was fine in the morning and went to a church picnic. 3 hours later she developed her current symptoms. She asked a friend to take her to he hospital, but her friend had also become ill. She recalls that they ate barbecued chicken, spinach salad, potato salad and some cookies.on exam, she appears weak and dehydrarted. She has no fever, and her stool tests hem-occult negative. What organism is the most likely cause of her symptoms? A. Campylobacter jejuni B. Clostridium perfringens C. Salmonella typhimurium D. Shigella flexneri E. Staphylococcus aureus

7 73 yr old woman p/w nausea and vomiting that began suddenly that afternoon. She was fine in the morning and went to a church picnic. 3 hours later she developed her current symptoms. She asked a friend to take her to he hospital, but her friend had also become ill. She recalls that they ate barbecued chicken, spinach salad, potato salad and some cookies.on exam, she appears weak and dehydrarted. She has no fever, and her stool tests hem-occult negative. What organism is the most likely cause of her symptoms? A. Campylobacter jejuni B. Clostridium perfringens C. Salmonella typhimurium D. Shigella flexneri E. Staphylococcus aureus

8 35 yo male with 12 hour history of severe abdominal cramping, nausea and loose watery stools, no fever no vomiting no travel-12 hours earlier he had eaten turkey left out at room temperature-what is them most likely etiology A. Campylobacter jejuni B. Clostridium perfringens C. Salmonella typhimurium D. Shigella flexneri E. Staphylococcus aureus

9 35 yo male with 12 hour history of severe abdominal cramping, nausea and loose watery stools, no fever no vomiting no travel-12 hours earlier he had eaten turkey left out at room temperature-what is them most likely etiology A. Campylobacter jejuni B. Clostridium perfringens C. Salmonella typhimurium D. Shigella flexneri E. Staphylococcus aureus

10 Staphylococcus Aureus Staphylococcus Aureus 2 or more persons with same illness and common food exposure- foodborne infection 2 or more persons with same illness and common food exposure- foodborne infection Staph aureus (primarily upper GI symptoms), short incubation period (1-6 hrs), preformed enterotoxin, unrefrigerated meats, potato/egg salad, cream pastries, severe sudden vomiting, Staph aureus (primarily upper GI symptoms), short incubation period (1-6 hrs), preformed enterotoxin, unrefrigerated meats, potato/egg salad, cream pastries, severe sudden vomiting, Campylobacter, Salmonella, Shigella - clinically indistinguishable, diarrheal illness 1-3 days after exposure (multiply in stomach), self-limited but usually treated with fluoroquinolone Campylobacter, Salmonella, Shigella - clinically indistinguishable, diarrheal illness 1-3 days after exposure (multiply in stomach), self-limited but usually treated with fluoroquinolone Clostridium perfringens- watery diarrhea, symptoms within 24 hrs, precooked meats allowed to thaw before cooking, self-limited Clostridium perfringens- watery diarrhea, symptoms within 24 hrs, precooked meats allowed to thaw before cooking, self-limited

11 Diarrhea...which is mucoid bloody + high fever + febrile seizure in infant  shigella...which is mucoid bloody + high fever + febrile seizure in infant  shigella …in patient with pet turtle or iguana  salmonella …in patient with pet turtle or iguana  salmonella …in patient without spleen or with sickle cell  salmonella …in patient without spleen or with sickle cell  salmonella …and pseudoappendicitis presentation  yersinia …and pseudoappendicitis presentation  yersinia …& fecal WBCs after poultry or eggs  salmonella, campylobacter …& fecal WBCs after poultry or eggs  salmonella, campylobacter …after poultry or meat, no fecal WBCs  Clostridium perfringes …after poultry or meat, no fecal WBCs  Clostridium perfringes …profuse and watery after antibiotic  Clostridium difficile …profuse and watery after antibiotic  Clostridium difficile …after potato salad or mayonnaise  Staphylococcus aureus …after potato salad or mayonnaise  Staphylococcus aureus …after fried rice  Bacillus cereus …after fried rice  Bacillus cereus …after raw oysters  Vibrio cholera …after raw oysters  Vibrio cholera …after drinking from mountain stream  Giardia lamblia …after drinking from mountain stream  Giardia lamblia …in AIDS patient  isospora or cryptosporidium …in AIDS patient  isospora or cryptosporidium …and hemolytic-uremic syndrome or TTP  E. coli 0157:H7 …and hemolytic-uremic syndrome or TTP  E. coli 0157:H7

12 Assuming the patient is a resident of North America and has never been immunized against rabies, in which of the following situations are rabies immune globulin and rabies vaccine series clearly indicated? A. Patient bitten by a chipmunk that escapes B. Patient bitten by a neighborhood dog that has been captured and quarantined C. Patient bitten by the family dog D. Patient scratched by a bat that was in his home, and the bat escapes E. Patient who sees a bat in her backyard and is not aware of any contact

13 Assuming the patient is a resident of North America and has never been immunized against rabies, in which of the following situations are rabies immune globulin and rabies vaccine series clearly indicated? A. Patient bitten by a chipmunk that escapes B. Patient bitten by a neighborhood dog that has been captured and quarantined C. Patient bitten by the family dog D. Patient scratched by a bat that was in his home, and the bat escapes E. Patient who sees a bat in her backyard and is not aware of any contact

14 Rabies Bat main vector in US; most without documented bite, so any exposure to saliva or mucous membranes indication for treatment, unless captured, sacrificed (Negri bodies) Bat main vector in US; most without documented bite, so any exposure to saliva or mucous membranes indication for treatment, unless captured, sacrificed (Negri bodies) Dog main vector in world Dog main vector in world Prodrome: excitement, opithotonus, hydrophobia, salivation, lacrimation, ataxia Prodrome: excitement, opithotonus, hydrophobia, salivation, lacrimation, ataxia In US rabies rare in canines In US rabies rare in canines Bites from rodents (chipmunks, squirrels, hamsters, guinea pigs, etc) not indication for vaccine Bites from rodents (chipmunks, squirrels, hamsters, guinea pigs, etc) not indication for vaccine Rabies postesposure prophylaxis: human rabies immune globulin (HRIG) + human diploid cell vaccine (HDCV) in deltoid days 0, 3, 7, 14, and 28 Rabies postesposure prophylaxis: human rabies immune globulin (HRIG) + human diploid cell vaccine (HDCV) in deltoid days 0, 3, 7, 14, and 28

15 Which of the following is the most common initial neurologic manifestation of diphtheria? A. Bells palsy B. Lower extremety weakness C. Diplopia, blurred vision and photophobia D. Paralysis of palate muscles E. trismus

16 Which of the following is the most common initial neurologic manifestation of diphtheria? A. Bells palsy B. Lower extremety weakness C. Diplopia, blurred vision and photophobia D. Paralysis of palate muscles E. trismus

17 Diphtheria disrupts protein synthesis causes demylination- producing a peripheral neuropthy Palate muscles are most commonly affected- usually does not cause bells palsy Trismus- tetanus Diplopia, blurred vision, photophobia think botulism

18 A 75 yr old man p/w fever and ear pain. He has had the earache for several weeks and has been treating it at home with warm mineral oil. On further questioning, he says that he is diabetic and that his sugars are running higher than normal. Exam is normal except for the ear which has granualation tissue on the floor of the external auditory canal. The most likely pathogen causing this infection is: A. Aspergillus sp. B. Candida species C. Pseudomonas aeruginosa D. Staphylococcus epidermidis E. Streptococcus pneumoniae

19 A 75 yr old man p/w fever and ear pain. He has had the earache for several weeks and has been treating it at home with warm mineral oil. On further questioning, he says that he is diabetic and that his sugars are running higher than normal. Exam is normal except for the ear which has granualation tissue on the floor of the external auditory canal. The most likely pathogen causing this infection is: A. Aspergillus sp. B. Candida species C. Pseudomonas aeruginosa D. Staphylococcus epidermidis E. Streptococcus pneumoniae

20 Malignant otitis externa Seen in elderly, diabetics, HIV, immunocompromised, persistent otitis externa (failing 2-3 weeks of Abx) Seen in elderly, diabetics, HIV, immunocompromised, persistent otitis externa (failing 2-3 weeks of Abx) Pseudomonas, aspergillus, Staph, Strep Pseudomonas, aspergillus, Staph, Strep Otalgia/otorrhea, cranial nerve involvement with progression, HA, neck pain, fever, AMS Otalgia/otorrhea, cranial nerve involvement with progression, HA, neck pain, fever, AMS Management: Radiographic imaging, admission parenteral antibiotics, possibly surgical debridement Management: Radiographic imaging, admission parenteral antibiotics, possibly surgical debridement

21 24 year old man with no PMH p/w 5 days of nonprod cough, fever, sob, and DOE, the patient is thin has multiple enlarged cervical lymph nodes, bilateral ronchi on pulmonary exam, a temperature of 40.1 and O2 sat of 83% on room air. He is admitted to the hospital. Which of the following is the most appropriate choice for empiric antibiotics? A. Ceftriaxone and azithromycin B. Levofloxacin C. Levofloxacin and bactrim D. Metronidrazole E. Bactrim

22 24 year old man with no PMH p/w 5 days of nonprod cough, fever, sob, and DOE, the patient is thin has multiple enlarged cervical lymph nodes, bilateral ronchi on pulmonary exam, a temperature of 40.1 and O2 sat of 83% on room air. He is admitted to the hospital. Which of the following is the most appropriate choice for empiric antibiotics? A. Ceftriaxone and azithromycin B. Levofloxacin C. Levofloxacin and bactrim D. Metronidrazole E. Bactrim

23 PCP PneumoCystis Pneumonia caused by pneumocystis jiroveci PneumoCystis Pneumonia caused by pneumocystis jiroveci Chest pain, cough, dyspnea, scant sputum, high fever, hypoxia, A-a gradient, CXR- bilat interstitial infiltrates Chest pain, cough, dyspnea, scant sputum, high fever, hypoxia, A-a gradient, CXR- bilat interstitial infiltrates Most common opportunistic infxn in those with HIV Most common opportunistic infxn in those with HIV Rx: CAP coverage + PCP coverage: bactrim, pentamidine, clindamycin + primaquine Rx: CAP coverage + PCP coverage: bactrim, pentamidine, clindamycin + primaquine

24 In adults with suspected meningitis which of the following clinical features at presentation is most likely to predict abnormal findings on head CT scan? A. Fever B. Headache C. Immunocompromised state D. Photophobia E. Stiff neck

25 In adults with suspected meningitis which of the following clinical features at presentation is most likely to predict abnormal findings on head CT scan? A. Fever B. Headache C. Immunocompromised state D. Photophobia E. Stiff neck

26 Study of 235 patients CT before LP Study of 235 patients CT before LP Clinical features assoc with abnormal CT: age>60, immunocompromised state, h/o CNS disease, h/o seizure within 1 wk of presentation Clinical features assoc with abnormal CT: age>60, immunocompromised state, h/o CNS disease, h/o seizure within 1 wk of presentation Neuro signs associated with abnormal CT: abnormal level of consciousness, inability to answer 2 consecutive commands, gaze palsy, abnl visual fields, facial palsy, arm drift, leg drift, abnl language Neuro signs associated with abnormal CT: abnormal level of consciousness, inability to answer 2 consecutive commands, gaze palsy, abnl visual fields, facial palsy, arm drift, leg drift, abnl language

27 The organism most commonly occurring in puerperal mastitis is: A. Bacteroides fragilis B. Candida Albicans C. Escherichia coli D. Staphylococcus aureus E. Streptococci

28 8. The organism most commonly occurring in puerperal mastitis is: A. Bacteroides fragilis B. Candida Albicans C. Escherichia coli D. Staphylococcus aureus E. Streptococci

29 Puerperal Mastitis Inflammation of breast typically in immediate postpartum period but also with teeth eruption in infants Inflammation of breast typically in immediate postpartum period but also with teeth eruption in infants Blockage of ducts by overgrowth of bacteria in nutirent-rich breast milk Blockage of ducts by overgrowth of bacteria in nutirent-rich breast milk Staph, E coli, Strep Staph, E coli, Strep Vague symptoms: myalgia, fevers, chills, flu-like sx Vague symptoms: myalgia, fevers, chills, flu-like sx Rx: breast emptying, skin cleansing, analgesia, abx, breastfeeding can continue Rx: breast emptying, skin cleansing, analgesia, abx, breastfeeding can continue If fails therapy, consider abscess/polymicrobial infxn/carcinoma, do ultrasound If fails therapy, consider abscess/polymicrobial infxn/carcinoma, do ultrasound

30 Which of the following statements regarding anthrax is correct? A. Aerobic blood culture growth of gram - cocci suggests systemic anthrax B. Cutaneous anthrax, although uncomfortable, is usually self-limited and does not require therapy C. Inhalational anthrax is initially a flu-like illness that deteriorates into septic shock within hrs of symptom onset D. Only known samples are in repositories in Russia and US E. Treatment of choice for all types is ceftriaxone

31 Which of the following statements regarding anthrax is correct? A. Aerobic blood culture growth of gram - cocci suggests systemic anthrax B. Cutaneous anthrax, although uncomfortable, is usually self-limited and does not require therapy C. Inhalational anthrax is initially a flu-like illness that deteriorates into septic shock within hrs of symptom onset D. Only known samples are in repositories in Russia and US E. Treatment of choice for all types is ceftriaxone

32 Anthrax Woolsorter’s disease Woolsorter’s disease Manifestation depends on how spores enter body: Skin, GI, Inhalational (most lethal) Manifestation depends on how spores enter body: Skin, GI, Inhalational (most lethal) Cutaneous(1-5days) papule->vesicle->eschar Cutaneous(1-5days) papule->vesicle->eschar GI(2-5days) n/v, mesenteric adenitis-> hematemesis, ascites, abd. pain-> shock GI(2-5days) n/v, mesenteric adenitis-> hematemesis, ascites, abd. pain-> shock Inhalation(1-6days) ->Flu like illness ->within hours sepsis, shock, hemorrhagic mediastinitis, resp failure Inhalation(1-6days) ->Flu like illness ->within hours sepsis, shock, hemorrhagic mediastinitis, resp failure CXR: mediastinal widening, hilar adenopathy CXR: mediastinal widening, hilar adenopathy Gm + bacilli, serology, cipro or doxy, vaccine Gm + bacilli, serology, cipro or doxy, vaccine

33 Anthrax

34 Cutaneous Anthrax

35 A 22 year old man p/w headache, stiff neck, and fever. An immediate LP reveals cloudy CSF. What is the appropriate treatment? A. Dexamethasone only until gram stain of fluid is available B. Intrathecal antibiotics C. Intravenous antibiotics D. Intravenous dexamethasone followed by antibiotics E. IVIG followed by antibiotics

36 A 22 year old man p/w headache, stiff neck, and fever. An immediate LP reveals cloudy CSF. What is the appropriate treatment? A. Dexamethasone only until gram stain of fluid is available B. Intrathecal antibiotics C. Intravenous antibiotics D. Intravenous dexamethasone followed by antibiotics E. IVIG followed by antibiotics

37 Meningitis high mortality rate, survivors may have long- term neurological sequelae high mortality rate, survivors may have long- term neurological sequelae 10 mg of dexamethasone min before antibiotic reduces morbidity and mortality (steroids cont. Q6 x 4 days) 10 mg of dexamethasone min before antibiotic reduces morbidity and mortality (steroids cont. Q6 x 4 days) Gans study: dex reduced mortality rate in pneumococcal meningitis by 50% Gans study: dex reduced mortality rate in pneumococcal meningitis by 50% Not shown to reduce neurologic sequelae Not shown to reduce neurologic sequelae Not shown to provide benefit in meningococcal meningitis Not shown to provide benefit in meningococcal meningitis

38 Which of the following statements regarding bite wounds is correct? A. Cat bites are most commonly polymicrobial B. Cat bites do not require prophylactic unless there is a foreign body in the wound C. Mammal bites are not tetanus-prone wounds D. Only 5-6% of dog bites ultimately become infected without treatment E. Pasturella multocida is frequently the sole pathogen in infected dog bites

39 Which of the following statements regarding bite wounds is correct? A. Cat bites are most commonly polymicrobial B. Cat bites do not require prophylactic unless there is a foreign body in the wound C. Mammal bites are not tetanus-prone wounds D. Only 5-6% of dog bites ultimately become infected without treatment E. Pasturella multocida is frequently the sole pathogen in infected dog bites

40 Mammalian Bites / DOG Least infective Least infective Most commonly polymicrobial Most commonly polymicrobial Pasteurella multocida Pasteurella multocida RX: prophylactic antibiotics not routinely recommended except for immunocompromised or bites to hand: PCN, augmentin, doxy RX: prophylactic antibiotics not routinely recommended except for immunocompromised or bites to hand: PCN, augmentin, doxy

41 Mammalian Bites / Cat More infective (30-80%) More infective (30-80%) Pasteurella Pasteurella Same Abx Same Abx

42 Human Bite Clenched fist Clenched fist Consider in genital wounds Consider in genital wounds Most infective Most infective Eichenella corrodens Eichenella corrodens PCN, Augmentin PCN, Augmentin

43 Which of the following statements regarding Rocky Mountain Spotted Fever in children is correct? A. CSF pleocytosis is commonly present B. IV Clindamycin is the treatment of choice C. Most cases are diagnosed in the western US D. Most commonly seen in adolescents E. Rash is initially petechial and becomes purpuric

44 Which of the following statements regarding Rocky Mountain Spotted Fever in children is correct? A. CSF pleocytosis is commonly present B. IV Clindamycin is the treatment of choice C. Most cases are diagnosed in the western US D. Most commonly seen in adolescents E. Rash is initially petechial and becomes purpuric

45 Rocky Mountain Spotted Fever most common rickettsial disease in US most common rickettsial disease in US Endemic in southeast US Endemic in southeast US Most common age 5-9, least common Most common age 5-9, least common fever, rash, tick exposure (~50% don’t recall)  malaise, headache, fever, myalgias, abdominal pain, fever, rash, tick exposure (~50% don’t recall)  malaise, headache, fever, myalgias, abdominal pain, rash initially blanching becomes petechial starts on ankles and wrists, spreads inwards rash initially blanching becomes petechial starts on ankles and wrists, spreads inwards Lab: nml WBC, left shift, mild anemia, moderate thrombocytopenia, CSF pleocytosis Lab: nml WBC, left shift, mild anemia, moderate thrombocytopenia, CSF pleocytosis Clue = clinically no URI sx’s, no N/V, prodrome and labs Clue = clinically no URI sx’s, no N/V, prodrome and labs –Also seen in Erlichiosis Dx: Clinical! Don’t wait for serologies Dx: Clinical! Don’t wait for serologies Rx: Tetracycline, chloramphenicol Rx: Tetracycline, chloramphenicol

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47 Lyme Disease Borrelia burgdorferi (spirochete) Borrelia burgdorferi (spirochete) Txmitted by bites of Ixodes ticks Txmitted by bites of Ixodes ticks Tick reservoir = rodents, rabbit, deer Tick reservoir = rodents, rabbit, deer Less than 30% of pts recall tick bite Less than 30% of pts recall tick bite Fever, myalgias, arthralgias, HA, Bells Palsy Fever, myalgias, arthralgias, HA, Bells Palsy Erythema chronicum migrans – annular, erythematous lesion with central clearing as it spreads (spares palm and sole) Erythema chronicum migrans – annular, erythematous lesion with central clearing as it spreads (spares palm and sole) 3 stages: 3 stages:  キ Stage I: ECM (60 – 80%), viral symptoms  キ Stage II: neurologic (neuritis, Bell’s palsy), cardiac (nodal heart block)  キ Stage III: chronic arthritis, myocarditis, encephalopathy ELISA (screening – sensitive, not specific), Western Blot (dx) ELISA (screening – sensitive, not specific), Western Blot (dx) Rx: doxy, erythro, amox, ceftriaxone Rx: doxy, erythro, amox, ceftriaxone

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50 Infection with which of the following helminths is known to cause a fatal hyperinfection in immunocompromised pts? A. Ascarsis lumbricoides B. Enterobius vermicularis C. Necator americanus D. Strongyloides stercoralis E. Trichuris trichiura F. Sridhar Basarvaju

51 Infection with which of the following helminths is known to cause a fatal hyperinfection in immunocompromised pts? A. Ascarsis lumbricoides B. Enterobius vermicularis C. Necator americanus D. Strongyloides stercoralis E. Trichuris trichiura F. Sridhar Basarvaju

52 Strongyloides stercoralis Nematode resides in small intestine Nematode resides in small intestine Skin (pruritis, erythematous rash)- > lungs (cough, dyspnea, pna) -> intestinal (most asymptomatic, diarrhea) Skin (pruritis, erythematous rash)- > lungs (cough, dyspnea, pna) -> intestinal (most asymptomatic, diarrhea) Can produce infective larva internally and cause autoinfection Can produce infective larva internally and cause autoinfection Hyperinfection syndrome in pts who already have established Strongyloides infxn who become immunocompromised -> septicemia, pneumonia, meinigitis, ileus Hyperinfection syndrome in pts who already have established Strongyloides infxn who become immunocompromised -> septicemia, pneumonia, meinigitis, ileus Eosinophilia may be lost in immunocompromised Eosinophilia may be lost in immunocompromised

53 Ascarsis lumbricoides- acquired by egg ingestion, Loeffler- eosinophilic pneumonitis, intestinal obstruction Ascarsis lumbricoides- acquired by egg ingestion, Loeffler- eosinophilic pneumonitis, intestinal obstruction Enterobius vermicularis- pinworms, perianal pruritis Enterobius vermicularis- pinworms, perianal pruritis Necator americanus- hookworm, intestinal mucosa- > blood loss, anemia -> eggs in stool, larvae in soil hook onto barefoot Necator americanus- hookworm, intestinal mucosa- > blood loss, anemia -> eggs in stool, larvae in soil hook onto barefoot Trichuris trichiura- whipworm, ingestion of contaminated food/water, massive infestation-> blood loss, anemia Trichuris trichiura- whipworm, ingestion of contaminated food/water, massive infestation-> blood loss, anemia

54 Which of the following is TRUE of the majority of Toxic Shock Syndrome (TSS) cases? A. They are all unrelated to menses and cross all segments of society B. They have gram positive rods on blood culture C. They have a diffuse, painful, sunburn like rash that results in bullae D. They are associated with hyperkalemia and hypercalcemia

55 Which of the following is TRUE of the majority of Toxic Shock Syndrome (TSS) cases? Which of the following is TRUE of the majority of Toxic Shock Syndrome (TSS) cases? A. They are all unrelated to menses and cross all segments of society B. They have gram positive rods on blood culture C. They have a diffuse, painful, sunburn like rash that results in bullae D. They are associated with hyperkalemia and hypercalcemia

56 Toxic Shock syndrome Acute onset multisystem disease (Involvement of at least three:Renal, hepatic, heme, GI, musculoskeletal, CNS) Acute onset multisystem disease (Involvement of at least three:Renal, hepatic, heme, GI, musculoskeletal, CNS) Staph aureus exotoxin Staph aureus exotoxin Prolonged tampon use, packed surgical wounds, nasal packing Prolonged tampon use, packed surgical wounds, nasal packing Menstruating females, post partum, 1/3 males Menstruating females, post partum, 1/3 males Fever, hypotension Fever, hypotension Rash: diffuse erythroderma (“painless” sunburn), blanching, nonpruritic --> desquamation Rash: diffuse erythroderma (“painless” sunburn), blanching, nonpruritic --> desquamation Rx: fluids, remove source, abx Rx: fluids, remove source, abx

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58 Which of the following tick-bourne illnesses requires only symptomatic therapy A. Babesiosis B. Colorado Tick fever C. Relapsing fever D. Rocky Mountain spotted fever E. Lyme disease

59 Which of the following tick-bourne illnesses requires only symptomatic therapy A. Babesiosis B. Colorado Tick fever C. Relapsing fever D. Rocky Mountain spotted fever E. Lyme disease

60 Colorado Tick fever- Viral infection- HA photophobia- supportive care-self limited resolves 2-3 weeks Babesiosis- protazoan parasite- clinda and quinine-exchange transfusion for severe case Lyme Dz- treat with doxycyline or tetracycline Rocky mountain spotted fever-Rickettsia – tetracycline or chloramphenicol

61 Which is the most accurate way to diagnosis PCP in Pt with HIV? A. ABG B. CXR C. VQ scan D. Gallium scan of chest E. Indirect Immunoflorescent stain of sputum

62 Which is the most accurate way to diagnosis PCP in Pt with HIV? A. ABG B. CXR C. VQ scan D. Gallium scan of chest E. Indirect Immunoflorescent stain of sputum

63 PCP Most common OI in pts with AIDS CXR may be normal ABG normally high A-a gradient but not specific for PCP Gallium and VQ scans are not specific Bronchoscopy is effective but invasive – sputum is highly specific and non invasive

64 Which of the following statements best describes rabies? A. Acute Rickettsial disease of the CNS spread centripetally through peripheral nerves B. Acute Rickettsial disease of the CNS with an incubation period of 10 days to 1 year C. Acute viral illness of the CNS that affects all mammals D. Acute viral illness of the CNS that affects all mammals except rodents E. Acute Rickettsial disease of the CNS spread centripetally through lymphatics

65 18. Which of the following statements best describes rabies? A. Acute Rickettsial disease of the CNS spread centripetally through peripheral nerves B. Acute Rickettsial disease of the CNS with an incubation period of 10 days to 1 year C. Acute viral illness of the CNS that affects all mammals D. Acute viral illness of the CNS that affects all mammals except rodents E. Acute Rickettsial disease of the CNS spread centripetally through lymphatics

66 Rabies Acute viral illness- affects all mammals -spread through saliva -spreads through peripheral nerves- centrally Average incubation days

67 35 yo male with painless hematuria after returning from North Africa has what A. Entamoeba histolytica B. Leishmania donovani C. Plasmodium malariae D. Schistosoma haematobium E. Trympanosoma brucei rhodesiense

68 35 yo male with painless hematuria after returning from North Africa has what A. Entamoeba histolytica B. Leishmania donovani C. Plasmodium malariae D. Schistosoma haematobium E. Trympanosoma brucei rhodesiense

69 Schistasoma-Africa, India, Portugal- Can migrate to venules in bladder Causes hematuria dx with eggs in urine Trichamonas- vaginitis, urithritis prostatitis Entomoeba-bloody diarrhea- liver abscess Leishmania-hepatomegaly splenomegaly Trypanosoma- african sleeping sickness

70 62 yo male BIB EMS- wife says confused- hypothermic 35.5, Bp 77/30- lungs clear abdomen normal non focal neuro exam-extremity exam shows-see pic-with crepitance halfway up leg- which antibiotic should be ordered 62 yo male BIB EMS- wife says confused- hypothermic 35.5, Bp 77/30- lungs clear abdomen normal non focal neuro exam-extremity exam shows-see pic-with crepitance halfway up leg- which antibiotic should be ordered A. Cefazolin and PCN B. Cipro C. Clinda and PCN D. Metronidazole E. Vanco

71 62 yo male BIB EMS- wife says confused- hypothermic 35.5, Bp 77/30- lungs clear abdomen normal non focal neuro exam-extremity exam shows-see pic-with crepitance halfway up leg- which antibiotic should be ordered A. Cefazolin and PCN B. Cipro C. Clinda and PCN D. Metronidazole E. Vanco

72 Gas Gangrene Surgical debridement critical-Fluid resusitation Usually Polymicrobial infection-can be group A strep along- needs broad coverage Cefazolin with PCN does not cover Gm negatives, nor does vancomycin Clindamycin is believed to decrease toxin production as well

73 Which organism causes a characteristic rash with a “slapped cheek” appearance Which organism causes a characteristic rash with a “slapped cheek” appearance A. Coxasackie virus B. Group A beta hemolytic strep C. Human herpes virus C D. Parvovirus B19 E. Varicella Virus

74 Which organism causes a characteristic rash with a “slapped cheek” appearance A. Coxasackie virus B. Group A beta hemolytic strep C. Human herpes virus C D. Parvovirus B19 E. Varicella Virus

75 Infectious rash descriptions Slapped Cheek= Parvovirus B19 Dew drop on rose petal= varicella Circumoral pallor and sandpaper rash=scarlet fever with Group A strep Oral and palmar vesicles Coxasackie- Hand foot and mouth disease HHV6 = roseola-

76 21 yo female presents with red hot painful right ankle- had similar pain in left wrist 2 days earlier- a pustular lesion is noted in the web spaces on her hand. A culture from which of the following sites is likely to reveal the causative organism A. Ankle synovial fluid B. blood C. genitalia D. Leading edge of the cellulitis E. Pustule

77 21 yo female presents with red hot painful right ankle- had similar pain in left wrist 2 days earlier- a pustular lesion is noted in the web spaces on her hand. A culture from which of the following sites is likely to reveal the causative organism A. Ankle synovial fluid B. blood C. genitalia D. Leading edge of the cellulitis E. Pustule

78 Arthritis-Dermititis syndrome from dissemintaed GC More common in women- migratory arthritis- tenosynovitis with pustules lesion son extremeties Synovial fluid cx + 50% of the time- Cervical Cx % of time

79 Which of the following reguarding Pneumonia in HIV + patients is correct? A. Haemophilus is an uncommon cause B. Opportunistic infections are common with CD4 less than 1000 C. Pt with HIV and bacterial PNA have a higher mortality rate D. Pt with HIV and bacterial PNA typically present with sign and symptoms similar to seronegative patients E. PCP occurs more commonly than bacterial PNA

80 Which of the following regarding Pneumonia in HIV + patients is correct? A. Haemophilus is an uncommon cause B. Opportunistic infections are common with CD4 less than 1000 C. Pt with HIV and bacterial PNA have a higher mortality rate D. Pt with HIV and bacterial PNA typically present with sign and symptoms similar to seronegative patients E. PCP occurs more commonly than bacterial PNA

81 HIV and PNA HIV pt have higher rates of bacterial pna but same mortality Bacterial pneumonia is more common than PCP Pt with CD4 count greater than 800 rarely get opportunistic infections Usually present in similar manner to seronegative pts

82 Which of the following manifestation of syphilis appears only after 20 yes of infection? A. Aortic dz B. Aseptic menigitis C. chancre D. Menigovascualar syphilis E. neurosyphilis

83 Which of the following manifestation of syphilis appears only after 20 yes of infection? Which of the following manifestation of syphilis appears only after 20 yes of infection? A. Aortic dz B. Aseptic menigitis C. chancre D. Menigovascualar syphilis E. neurosyphilis

84 Syphilis Chancre- painless papule- hallmark of primary syphilis 2ndary syphilis 4-10 weeks- macular rash- trunk  extremities- palms + soles oral lesions grey painless ulcers Tertiary syphilis-untreated for years- 2 types- neurosyphilis after 10 yrs-meningovascualar vasculitis of vertebral or spinal vessels or tabetic syphilis-demylination and ataxia Cardiovascular only after yrs usually thoracic aorta- aortiv valve insufficiency

85 Which of the following animals is least likely to transmit rabies A. chipmunk B. cow C. Groundhog D. racoon E. skunk

86 Which of the following animals is least likely to transmit rabies A. chipmunk B. cow C. Groundhog D. racoon E. skunk

87 More rabies Can affect all mammals including cows Very rare in rabbits and small rodents (rats, mice, chipmunks) considered safe Larger Rodents beavers, groundhogs do carry rabies

88 Which of the following is true of acute rheumatic fever? A. Caused by group B strep B. Fever is a major diagnostic criteria C. Occurs during the coarse of acute strep infection D. Affect primarily lower socioeconomic groups E. Steroids my be useful in treating carditis

89 Which of the following is true of acute rheumatic fever? A. Caused by group B strep B. Fever is a major diagnostic criteria C. Occurs during the coarse of acute strep infection D. Affect primarily lower socioeconomic groups E. Steroids my be useful in treating carditis

90 Rheumatic Fever 3-4 weeks after Group A strep infection Jones criteria-major- Joints-polyrthritis, Carditis, Nodules- subcutaneous, erythema marginatum, chorea Fever is one of the minor criteria Tx PCN, aspirin for arthritis and steroids for carditis

91 41 yo female presents with 2 large fleshy, flat, painless, moist, pearly grey, pale lesions on either side of her anus the most likely diagnosis is? A. Chancroid B. Condyloma acuminata C. Gonococcal proctitis D. Granuloma inguinale E. Secondary syphilis

92 41 yo female presents with 2 large fleshy, flat, painless, moist, pearly grey, pale lesions on either side of her anus the most likely diagnosis is? A. Chancroid B. Condyloma acuminata C. Gonococcal proctitis D. Granuloma inguinale E. Secondary syphilis

93 STD’s Condyloma lata-secondary syphilis- typically-large painless flat topped lesions-typically in anogenital region Condyloma acuminata- genital warts – HPV – pink to grey keritanized with papilliform growths Gonococcal proctitis- tenismus, anal itching and yellow discharge Granuloma inguinale- bacterial infection with Calymmatobacterium granulomatis-painless papules  beefy red ulcers with rolled edges Chancroid- Heomophilus Ducreyi- painful genital ulcer-


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