Michael Kulczycki, DO- Infectious Disease Board Review 2014- ARMC Emergency Medicine
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Michael Kulczycki, DO- Infectious Disease Board Review 2014- ARMC Emergency Medicine
- 1. BOARD REVIEW MICHAEL KULCZYCKI DECEMBER 18 2013
- 3. ENDOCARDITIS Subacute Acute ⢠⢠⢠⢠RISK FACTORS ⢠STRUCTURE ⢠⢠⢠PROSTHETIC HEART VALVES ⢠Normal Valves Younger Patients Sick Abnormal Valves Older patients Non-specific constitutional symptoms HEART DISEASE ⢠RHEUMATOID HEART DISEASE ⢠MITRAL VALVE PROLAPSE ⢠BICUSPID AORTIC VALVE ⢠IV DRUG ABUSE ⢠CARDIAC PROCEDURES ⢠INDWELLING VENOUS CATHETERS Left Heart ⢠⢠⢠⢠⢠⢠More Common S. Viridans S. Aureus Enterococcus CHF, CVA, AV block Systemic infarcts from septic emboli S. Aureus = Single most common cause Right Heart ⢠⢠⢠⢠⢠IVDA S. Aureus S. Pneumonia Respiratory Symptoms Misdiagnosed as PNA
- 6. ENDOCARDITIS JONES CRITERIA â 2 MAJOR, 1 MAJOR + 3 MINOR, 5 MINOR Major ⢠⢠2 Positive Blood Cultures ⢠3 sets 1 hour apart ⢠Cultures of typical bugs ⢠Persistance of cultures > 12 hrs Abnormal Echo ⢠Prosthetic valve dihiscence ⢠New valvular regurg ⢠Myocardial abscess ⢠Visible vegetation Minor ⢠⢠⢠⢠⢠Predisposition/IVDA Fever Vasular Events/Septic Emboli Immunologic Events Positive Echo or Blood cultures not meeting major criteria
- 7. ENDOCARDITIS Indications: ⢠Prosthetic Valve ⢠Congenital Defect repaired ⢠Prior Infectious Endocarditis ⢠Cardiac transplant with abnormal valves Manipulation of gingiva/mucosa or apical area of tooth
- 8. MENINGOCOCCEMIA â NEISSERIA MENINGITIDES Nuts and Bolts⌠⢠Military Recruits, College Dorms ⢠Children < 5 ⢠Gram (-) diplococcus ⢠Nasopharynx = portal of entry ⢠Septicemia without meningitis (>20% mortality)
- 9. MENINGOCOCCEMIA Rash ⢠⢠Petechia ⢠50-60% Cases ⢠Can involve mucous membranes ⢠Trunk/Extremites Purpura Fulminans ⢠Rapidly spreading ecchymosis ⢠Gangrene ⢠DIC
- 10. MENINGOCOCCEMIA Meningococcemia + Bilateral Adrenal Hemorrhage = Waterhouse-Friderichsen Sndrome Fulminant Meningococcemia
- 11. MENINGOCOCCEMIA ⢠Lumbar Puncture ⢠Early Antibiotics ⢠Prophylaxis for close contacts ⢠Ciprofloxacin ⢠Rifampin ⢠Ceftriaxone
- 12. PERTUSSIS Nuts and Bolts⌠⢠⢠⢠⢠⢠⢠Whooping Cough Summer and Fall months Cough > 2 weeks Respiratory Droplets Vaccination does not equal lifelong immunity Misdiagnosed as bronchitis
- 13. PERTUSSIS Catarrhal Phase Paroxysmal Phase URI like symptoms Cough increases, Cough, low grade fever fever subsides Highest infectivity Paroxysms of coughing (>50 times/day) Convalescent Phase Residual cough (weeks to months)
- 14. PERTUSSIS ⢠High index of suspition ⢠Lymphocytosis â correlates with severity of disease ⢠CXR: peribronchial thickening ⢠Nasopharyngeal culture ⢠Macrolide (erythromycin) ⢠Prophylactic antibiotics for close contacts ⢠Acellular pertussis vaccination for high risk exposures
- 16. PNEUMOCOCCEMIA ⢠⢠Lancet shaped G (+) diplococcus Most common cause of bacterial pneumonia Pneumonia ⢠Severe rigors ⢠Rusty colored sputum Meningitis Septicemia Endocarditis Adult vaccination for: ⢠Adults with chronic illness ⢠Age > 65 ⢠Immunocomprimised / HIV ⢠Anatomic or functional Asplenia
- 17. TETANUS Found in soil, dust, feces >70 % from wounds (post-operative) Bacteria produce neurotoxins â Tetanolysin/Tetanospasmin ⢠No mental status changes ⢠Weakness, myalgias, dysphagia, hydrophobia, drooling ⢠Trismus â âLock Jawâ ⢠Risus Sardonicus - facial muscle involved ⢠Opisthotonos â Generalized tetanus, arching of back/ neck ⢠Laryngeal Spasm and Respiratory Failure ⢠Autonomic Dysfunction
- 19. TETANUS Strychnine Poisoning Pesticide Muscle spasms, trismus, risus sardonicus, seizures
- 20. TETANUS Benzodiazepines/Narcotics Paralysis (non-depolarizing) Eliminate the toxin â Tetanus Immunoglobilin (TIG) Administer opposite arm of tetanus booster Eliminate the Bug â Flagyl Immunization ⢠⢠⢠TIG if < 3 Td and dirty wound Clean wounds â Td if > 10 years Dirty wounds â Td if > 5 years
- 21. TUBERCULOSIS ⢠⢠⢠⢠Humans sole reservoir Leading cause of infectious death worldwide Leading cause of adrenal insufficiency worldwide One third of world population infected with TB Risk Factors ⢠Immunocompromised / HIV ⢠Close contact / Occupational exposure ⢠Foreign born ⢠Low socioeconomic status ⢠IVDA ⢠Homeless ⢠Prison / shelter
- 22. TUBERCULOSIS Pulmonary Tuberculosis ⢠⢠⢠⢠⢠⢠⢠Cough â most common symptom Fever Night sweats Weight loss Pleuritic Chest pain Hemoptysis â mild to severe Erosion into pulmonary artery = Rasmussen aneurysm Chest x-ray ⢠Primary TB â difficult to differentiate from PNA ⢠Hilar / Midiastinal LAD common in primary TB ⢠Miliary (disseminated) TB â multiple nodules bilaterally ⢠Reactivation TB â Cavitation without lymphadenopathy
- 23. TUBERCULOSIS Extrapulmonary TB Lymphadenitis â Scrofula ⢠Enlarged / painful mass near cervical nodes ⢠Most common extrapulmonary manifestation ⢠Do Not I&D Bone and Joints â Pottâs Disease (spine) Acute Dissemination ⢠Typically elderly and AIDS ⢠Associated with SIADH CNS â Tuberculous Meningitis ⢠Subependymal tubercle ruptures into subarachnoid space ⢠Lowest CSF glucose of any meningitis
- 24. TUBERCULOSIS AFB sputum smear â hours, many false negatives/positives AFB culture â weeks, Gold standard, 87% sensitive Isoniazid â seizures (pyridoxine) Latent TB ⢠Isoniazid - 9 months Active TB ⢠4 drug regimen â 6 months Extrapulmonary TB ⢠4 drug regimen â 6 months Rifampin â orange urine. OCP failure Pyrazinamide - hepatotoxic Ethambutal â red-green color blindness Pregnancy â INH, RIF, ETH cross placenta and are safe
- 25. THE PLAGUE â YERSENIA PESTIS Nuts and bolts⌠⢠Vector â rat flea â xenopsylla cheopis ⢠Traditionally from rats, now squirrels and cats ⢠Potential biologic weapon ⢠Transmission â bites, close contact, direct inhalation ⢠Veterinarians, animal handlers ⢠Non-specific symptoms â Fever and myalgias
- 26. THE PLAGUE Three Clinical Syndromes Bubonic Plague ⢠Bubos on the skin, invasion of lymphatics and vasculature ⢠Generalized painful LAD Septicemic Plague ⢠Direct invation of vasculature without bubos Pneumonic Plague ⢠Most aggressive ⢠Severe pneumonas, sepsis, death Black Plague â deep cyanosis and gangrene with disseminated disease âRing around the rosyâ âAshes, ashes we all fall downâ
- 27. THE PLAGUE ⢠Gram stain of bubo aspirate ⢠CXR â infiltrate or hilar lymphadenopathy ⢠Respiratory Isolation ⢠Streptomycin or Doxycycline ⢠Supportive care
- 28. HERPESVIRIDAE Herpes Simplex Virus HSV-1 - oropharyngeal HSV-2 â genital Multiple, painful shallow ulcers which may coalesce Shedding lasts up to 3 weeks Herpetic Whitlow ⢠Herpetic finger infection ⢠Do not I&D Neonatal Herpes ⢠Transmission at deliver ⢠High mortality if untreated Herpes Encephilitis ⢠Most common cause of encephalitis in U.S. ⢠Fever and bizarre behavior
- 29. HERPESVIRIDAE Varicella-Zoster Virus Chickenpox ⢠Acute generalized viral illness ⢠Lesions everywhere on skin and mucous membranes (palms/soles spared) ⢠Maculopapular then vesiculated Herpes Zoster ⢠Reactivation in DRG â dermatomal ⢠Multiple vesicles on erythematous base Zoster Opthalmacus ⢠Lesions on cornea / tip of nose (Hutchinson sign) ⢠Nasociliary branch of V1 - opthalamic branch of trigeminal nerve Ramsy Hunt Sydrome ⢠Bells palsy with herpetic blisters in the auditory canal or pinna
- 30. HERPESVIRIDAE Epstein Barr Virus Fever Exudative tonsillitis Posterior cervical LAD Hepatomegally in 50% Lymphocytosis with atypical lymphocytes Splenic Rupture â no contact sports Characteristic rash with antibiotics (ampicillin) Supportive treatment Steroids for severe tonsilar edeam
- 31. HIV Nuts and bolts⌠Retrovirus HIV-1 (most common), HIV-2 (western Africa) Semen, vaginal secretions, blood, breastmilk Attacks CD4 Helper T cells Acute HIV infection ⢠Follows exposure by 2-6 weeks ⢠Usually missed
- 32. HIV AIDS - CD4 < 200 CD4 < 500 ⢠TB, Zoster, HSV CD4 < 200 ⢠Pneumocysti Jiroveci Pneumonia, Candidiasis, AIDS Dementia, NonHodgekin B-cell lymphoma CD4 < 100 ⢠Toxoplasmosis, isospora, microsporidia, histoplasmosis, cryptococcus CD4 < 50 ⢠CMV, progressive multifocal leukocencephalopathy (PML), MAC
- 33. HIV Pneumonia Most common reason for ER visit CD4 > 500 â encapsulated bacteria, TB, malignancy CD4 < 500 â Think PJP, Fungal, CMV Pneumocystis Jiroveci Pneumonia ⢠Diffuse interstitial infiltrate â âbat wingâ ⢠Bactrim DS ⢠Steroids of PaO2 < 70 or Aa gradient > 35 ⢠Prophylaxis with Bactrim if CD4 <200 ⢠Pentamidine 2nd line agent if sulfa allergy
- 34. HIV Buzz words Diarrhea - cryptosporidium, isospora Esophagitis â CMV, candidiasis, HSV Retinitis â CMV Ring enhancing lesions â Toxoplasmosis, CNS lymphoma Fever and headache â Cryptococcus Plaques on Tongue â oral candidiasis vs hairy leukoplakia Purple papules/plaques â Kaposiâs sarcoma