ID MSKAP Board Review

1. ID MSKAP Board Review Henry Fraimow MD

2. Some General Comments Lots of Public Health related Guidelines (TB, STD’s, vaccines, etc…) Areas where you may need additional focus specifically Transplant Infections Travel related Infections Prion Diseases Less focus on Specific HIV treatment regimens (change quickly) and more on general concepts of treatment

3. Item 1 Clues Rapid onset pain, swelling, erythema, fever, delerium, hemorrhagic bullae and necrosis Gulf Coast, seafood handler

4. Item 1 Disease or Syndrome: Necrotizing Fasciitis Pathogens Common: Gp A strep, other strep, S. aureus (CAMRSA), Clostridia, mixed gram negs and anaerobes Uncommon with specific associations Vibrio, Clostridium sordellii Vibrio infections (monsters of the deep): Warmer coastal waters, water/seafood contact or ingestion Wound infections: V. vulnificans but also others Ingestion especially in cirrhosis and liver disease Sepsis with hemorrhagic necrotic bullae

5. Item 2 Clues Malaise, myalgias, coyza, cough, fever, “ill” No influenza vaccination, Normal CXR Bronchodilators, ACE inhibitor

6. Item 2 Syndrome: Influenza Treatment options Amantadine, rimantidine: resistance, active only vs. Influenza A Oseltamivir: oral Zanamivir: inhaled (bronchospasm) Prophylaxis or therapy

7. Item 3 Clues Renal transplant Subacute onset of mental status changes, focal seizure, no fever, speech and word difficulties, increased reflexes MRI finding: white matter lesions

8. Item 3 Syndrome: Subacute CNS process in immunocompromised with white matter lesions JC virus infection: PML Non-enhancing white matter lesions (AIDS, transplant) Dx by PCR on CSF BK infection: renal loss in transplant pts HSV More acute onset, encephalitis, temporal lobe changes on MRI, can see hemorrhage in CSF, Dx by CSF PCR, Rx with acyclovir

9. Item 4 Clues Brief Hx of fever and papular-vesicular rash Rash on trunk, sparing palms and soles, lesions in varied stages of evolution Day care center, bioterrorism alert

10. Item 4 Syndrome: fever and vesicular rash DDx includes pox viruses, herpes viruses, enteroviruses (hand, foot, mouth) Differentiation of Varicella and smallpox: Smallpox face and extremities; lesions in single stage of development

11. Item 5 Clues: otherwise healthy, pregnant with spontaneous abortion, blood transfusions, few days later presents with HA, fever, obtundation Low peripheral WBC, Low CSF cell count (96) with normal protein and glucose, few RBC, high OP, normal imaging

12. Item 5 Clinical Syndrome: Encephalitis DDx of “aseptic” meningitis and encephalitis Peri and Postpartum infections: Listeria, group B strep, other genital flora HSV? West Nile Infections Mosquito born, summer-fall, middle age and older CNS syndromes: aseptic meningits, meningoenephalitis, “polio-like” flaccid paralysis, G-B like syndrome Transfusion Associated illnesses West Nile, malaria, Chaga’s

13. Item 6 Clues Sepsis syndrome in a nursing home patient Chronic Foley, pyuria, flank pain Recent ciprofloxacin, no response to ceftriaxone Klebsiella

14. Item 6 Syndrome: Urosepsis with septic shock Key Points: Antibiotic resistance in a nursing home pt ESBL’s in Klebsiella and E.coli Resistant to all 3rd and 4th Gen Cephalosporins Often resistant to simpler agents (TMS, FQ), risks include prior antibiotic Rx Most reliable: carbapenem Moxi not useful for urine Other gram negative resistance issues: Carbapenemases (Klebsiella) Chromosomal beta lactamases (Enterobacter)

15. Item 7 Clues Newly Diagnosed asymptomatic HIV infection CD4 184, vl 13043 Chronic Hepatitis B infection

16. Item 7 Key Points When to Start HAART (DHHS Guidelines) CD4 < 350 or vl > 55k or symptoms What Regimens? 3 drugs Generally 2 nucleosides and a non-nucleoside (Efaverenz) or a PI (Kaletra or boosted Atazanavir) Choice of specific agents from prefered and alternate regimens based on co-morbidities and risks of toxicity How to diagnose and treat chronic Hepatitis B HIV drugs with Hep B activity: lamuvidine, tenofovi

17. Item 8 Clues 52 yo with increasing non-productive cough and SOB Normal CXR, PFTs with decreased DLC0 Hot Tub

18. Item 8 Syndrome: ?Interstitial pneumonitis Significance of Mycobacterium in sputum MTB infection- abnormal CXR, productive cough, systemic Sx, does not generally affect DLCO Atypical Pulmonary Mycobacteria: Contaminant Infection: chronic cough, sputum, middle aged women, bronchiectasis/infiltrates on CXR Mycobacterial Pulmonary Hypersensitivity syndromes: Hot tub lung, metal workers lung, etc Rhodococcus and Nocardia can stain acid fast but are not mycobacteria

19. Item 9 Clues Post operative diarrhea Marked leukocytosis, systemic toxicity Dilated colon with distention Positive C.diff toxin

20. Item 9 Syndrome: Severe C.difficile infection with colonic dilitation and ileus Key Points Risks for c. difficile infection Complications of C.difficile infection Treatment options Primary infection; MTZ or oral vancomycin Treatment of MTZ failure Treatment of relapse Options where oral Rx can not be used

21. Item 10 Clues: Renal Transplant Patient Severe Back pain without neurologic compromise Abnormal films L1-L-2 7 mm PPD

22. Item 10 Syndrome: ? Vertebral Osteomyelitis in a transplant Patient Key Points: DDx broad: typical and atypical pathogens Significance of a 7 mm PPD Positive in HIV, transplant, contact of active case, pts on TNF agents/ immunosuppressants DDx of TB vs pyogenic osteomyelitis No completely diagnostic features Usually no extrapulmonary disease

23. Item 11 Clues Returned Traveler from Puerto Rico Rapid onset of Severe HA, fever, myalgias, leg muscle tenderness Low WBC, elevated LFTs, mild CSF pleocytosis, low normal plts Normal BP, no signs of hemorrhage

24. Item 11 Syndrome: Fever in a returned traveler Key Points Puerto Rico- Central America-Caribbean Vector born infections: Mosquito born: Malaria, Dengue (DDX includes typhoid) Dengue: World wide distribution, “Break-back” fever, HA, severe muscle aches, leukopenia, thrombocytopenia, epidemic in Puerto Rico Complications: Shock, Hemorrhagic Fever More common with prior exposure

25. Item 12 Clues Fever, cough, sputum production, leukocytosis, RLL infiltrate, non-smoker Chronic daily cough, exaccerbations 1-2 x/year, chronic changes at RLL

26. Item 12 Syndrome: Exaccerbation of Pulmonary infection in pt with chronic Pulm Process ? Bronchiectasis Key Points: Pathogens in bronchiectasis with multiple exacerbations: S. aureus, Pseudomonas (similar to CF patients)

27. Item 13 Clues 4 mos post heart transplant with abdominal pain, bloating and melena Prior neutropenia, off TMS and ganciclovir Anemia, leukocytosis, renal insuff Prepyloric ulcers

28. Item 13 Syndrome: Gastric ulcers in a recent transplant recipient Key Points Risk of CMV disease post transplant esp in CMV+: disseminated infection, pneumonitis, gastrointestinal: esophagus, stomach and small bowel, colon Prophylaxis with valganciclovir Diagnosis by endoscopy and Bx Treatment: IV Ganciclovir For esophageal disease only: HSV or CMV

29. Item 14 Syndrome: meningococcal meningitis Meningitis with purpuric rash, respiratory distress, CSF with gram negative diplococci Key Points: Isolation and Prophylaxis for Meningococcal meningitis Droplet precautions 1st 24 hours (vs. respiratory) Prophylaxis: Ciprofloxacin, Rifampin, Single dose Ceftriaxone (pregnancy) Household contacts and direct contact with respiratory secretions

30. Item 15 Clues Dehiscence of wound at site of prior laceration 1 week previously Purulent drainage, no fever

31. Item 15 Syndrome: wound infection, R/O osteomyelitis Key Point: Plain films will not show bony changes in 1 week MRI and CT optimal radiographic modes for assessing for underlying osteomyelitis, will also better define underlying soft tissue infection Wounds that probe to bone also highly suggestive of osteomyelitis

32. Item 16 Clues 3 day Hx earache, fever, unresponsive, meningismus, hypotensive, leukocytosis LP : PMNs, low glucose, high protein, GP diplos in prs.

33. Item 16 Syndrome: Fulminant bacterial meningitis, pneumococcal Key Points: Initial Rx includes: Antibacterial Rx; Vanco + CTX targeted at Resistant S. pneumoniae and meningococcus Adjuctive Steroids concurrent with antibiotics- decreased morbidity and mortality in adults in western countries Risks for Listeria- add Ampicillin Age > 50, immunosuppressed

34. Item 17 Clues Fever, malaise immediately after trip to Africa, was on hunting safari in bush Swelling in axilla, rash Vesicles on chest wall and cheek, eschar on clavicle

35. Item 17 Syndrome: Fever in returning traveler to S. africa, lymphadenopathy rash and eschar and bush exposure Key Points: Travelers to South Africa Tick born fevers (Rickettsial diseases) Mostly mild except RMSF Short incubation, often eschar at site of initial bite Rx with doxycycline

36. Item 18 Clues Subacute encephalopathy in a 76 y.o. with initially normal imaging, very elevated CSF protein progressing over 6 weeks Cortical white matter and basal ganglia Bright spots on MRI

37. Item 18 Syndrome: Subacute encephalopathy/ encephalitis? Key Points: HSV: course much more rapid, temporal lobe findings on MRI (after 3 days) and abnormalities on EEG West Nile: course more rapid, CSF pleocytosis Prion Diseases: CJD: Suggestive Hx (cerebellar, extrapyramidal, myoclonus, mutism), MRI, EEG findings, CSF studies, 14-3-3 protein in CSF or brain Bx Variant CJD: (Mad Cow) epidemic in U.K, younger onset and more fulminant neuropsychiatric symptoms, tonsilar Bx for Dx, pulvinar sign Other Prion diseases

38. Item 19 Clues 12 Mos post renal transplant on steroids and azathiaprine PCN allergy but tolerates cephalosporins Fever, HA, confusion, loose stools CSF pleocytosis: 50% PMNS, low glucose, high protein

39. Item 19 Syndrome: Meningitis in a post transplant recipient, PCN allergy Key Points: 50% PMNS c/w bacterial but also fungal Listeria meningitis CSF usually mostly PMNs Gram stain more likely to be negative Immunosuppressed, older, pregnant, often GI Sx Ampicillin; TMS if PCN allergic

40. Item 20 Clues Recently incarcerated, former IVDU, subacute hx of cough fever, cough, sputum, sweats, wt loss CXR upper lobe infiltrate/cavity HIV negative, PPD negative 10 mos ago Smear + AFB

41. Item 20 Syndrome: Probable pulmonary TB in an HIV negative Key Points: Negative PPD does not exclude Dx of TB Initial Therapy in US: 4 drug regimen INH, Rif, PZA, ETH (4th drug for possible INH R) If pan Sensitive PZA x 2 mos, D/C ETH when Sens available Duration: 6 mos (2 + 4) or 9 mos (2 + 7) Cavitation and culture + at 2 mos? 9 mo regimen

42. Item 21 Clues 72 yo, DM, renal insufficiency, smoking, COPD Cough, sputum, fever, hypoxia, left shift on CBC, pulmonary infiltrate

43. Item 21 Syndrome: Community acquired pneumonia in pt with co-morbidities Key Points: Management of CAP Decision to Hospitalize Need for ICU Pseudomonas Risk Initial Antibiotic Regimen: Typical plus Atypical Pathogens Non ICU; CTX + Azithro or FQ monoRx ICU: CTX plus Azithro or CTX plus FQ

44. Item 22 Clues Pregnant woman with + 1st and 2nd stage syphilis tests PCN allergy: hives with amoxicillin when had a sore throat, fatigue and LN

45. Item 22 Syndrome: Syphilis in a PCN allergic woman Key Points Know your syphilis serology! Syphilis in pregnancy must be treated to prevent congenital syphilis PCN is treatment of choice, Tetracycline contraindicated in pregnancy Penicillin allergy evaluation: skin test? if +, desensitize, if negative safe to use High incidence of rash with amoxicillin with acute EBV

46. Item 23 Clues 5 days post renal transplant on mutiple immunosuppresives Local findings at operative site Leukocytosis

47. Item 23 Syndrome: Early post op fever in post renal transplant patient Key Points Early (ist month) post transplant infections are most commonly infections that are usually related to the surgical procedure itself Later (1-6 mos) fungal and CMV disease

48. Item 24 Clues Draining foot ulcer that probes to bone in a diabetic Cultures growing E. faecalis and e. coli

49. Item 24 Syndrome: Chronic osteomyelitis, diabetic foot infection Key Points: Probe to bone high probability of osteomyelitis (sensitivity 90%) Poor correlation of sinus tract cultures and bone pathogens (exception: S. aureus) Bx and culture preferred before starting long term Rx

50. Item 25 Problem: risks for central venous catheter infection Key points: Factors than decrease incidence include: Education/training of the operator Site selection (SC better than IJ or femoral) Handwashing Skin cleansing: chlorhexidine preps better than PI Drape, gown, glove and mask

51. Item 26 Clues Prisoner with fever, arm swelling, decreased BP Hx of ? Spider bite Debrided material with GPC in clusters

52. Item 26 Syndrome: CAMRSA Necrotizing fasciitis in a prisoner Key Points Rx of severe suspected MRSA soft tissue infections Vancomycin or Linezolid Less severe infections: TMS or Clindamycin (local rate of resistance, D-test)

53. Item 27 Clues Dx of AIDS with PCP pneumonia, CD4 92 On HAART with good response Now with non-adherence, rising viral load but preserved CD4 cell count at 300

54. Item 27 Syndrome: Management of treatment “failure” in HIV + patient Key points: Rising viral load (confirmed x 2) reflects treatment failure Adherence, Resistance or Both Resistance testing is key to diagnosis and management Never add single agents to failing regimens Cross resistance and low resistance barriers for non-nucleoside agents (efaverenz, nevaripine)

55. Item 28 Clues Positive PPD 22 mm Immigrant from India, prior BCG No symptoms, normal CXR

56. Item 28 Syndrome: Probable Latent TB infection with Hx of prior BCG Key Points: Ignore BCG history in management of + PPD Exclude Active TB (symptoms, CXR) prior to treating LTBI Treatment options: INH x 9 mos, Rif x 4 mos, not Rif + PZA x 2 mos Quantiferon-Gold TB test can Differentiate BCG associated + PPD from LTBI

57. Item 29 Clues 15 y.o. with penetrating injury thru sneaker Pain, fever, sinus tract, MRI with osteomyelitis

58. Item 29 Syndrome: Osteomyelitis from penetrating injury thru sneaker Key Points: Need to include empiric Pseudomonas coverage in addition to common osteomyelitis pathogens (staph, strep, anaerobes-rusty nail, other gnrs) Pseudomonas active agents: Pip-Tazo, Cefepime and Ceftazidime, Imipenem, Ciprofloxacin (not in kids) Tetanus for rusty nail injury- know your tetanus prophylaxis regimens!

59. Item 30 Clue Nurse with symptoms 3 days post exposure to smallpox, no prior vaccination Key Points: Vaccine effective up to 4 days post exposure Incubation typically 7-14 days (max 17) Risk of vaccination: systemic Sx, risk of dissemination exp pregnancy, eczema, etc Isolation for exposed/ at risk with fevers Immune globulin only if cannot get vaccine

60. Item 31 Clue 28 yo Post allogenic bone marrow transplant, Hodgkins, on tacrolimus, mycophenolate, prednisone Rash with vesicles and pustules on trunk to midline Vaccinations “up to date”

61. Item 31 Syndrome: Post marrow transplant pt with localized Zoster Key Points: Zoster (local or disseminated) common post allogenic BMT Prophylaxis with acyclovir or valaciclovir Even localized zoster in a marrow transplant patient is an indication for parenteral Rx Other indications for parenteral Rx of Zoster Varicella Vaccination; Primary varicella vaccine Vaccination for varicella zoster in adults

62. Item 32 Clues Bilateral axillary rash, erythema, vesicles, exudate, no fever, nl WBC Syndrome: Cellulitis vs non-infectious process Key points: Bilateral, no systemic toxicity Unrevealing microbiology (no Gp A strep, S. aureus (DDx impetigo) Superficial process

63. Item 33 Clues Fever, HA, confusion post craniotomy CSF with 300 WBC, low glucose, high protein

64. Item 33 Syndrome: Suspected post neurosurgical meningitis Key Points: Management differs from suspected community bacterial meningitis Dx by CSF fluid, cultures Pathogens include staph (CNS and S. aureus) and gram negatives including Pseudomonas

65. Item 34

66. Item 34 Clues 48 yo physician with subacute change in personality, ataxic gait, tremor, myoclonus, bright cortical signal on MRI, mild elevated protein on CSF studies

67. Item 34 Syndrome: Suspected sporadic CJ Disease Key Points See previous. In this context 14-3-3 protein studies are fairly specific in support of other studies (clinical picture, MRI)

68. Item 35 Question: Prophylaxis for Influenza in a Heart Transplant Recipient on immunosuppresives Key Points Live vaccines should be avoided Vaccine responses may be attenuated No passive immunity for Influenza Oseltamivir active against A and B and approved for prophylaxis

69. Item 36 Question: Post exposure prophylaxis for Lyme in a Lyme endemic area with probable deer tick exposure Key Point Single dose (Doxy 200 mg) prophylaxis for tic > 24 hours in Lyme endemic area may decrease risk of Lyme (90%)

70. Item 37 Question: Appropriate isolation for C. difficile infection Key Point: Spread thru infected feces (spores)onto environmental surfaces- transmission via contact with patient or environment Contact precations Soap and water preferrable to hand gel for killing c. diff spores Know your precautions: contact, droplet, respiratory

71. Item 38 Clues 38 yo with malaise, chills, fever, HA, abd pain, myalgias Splenectomized; Cape Cod Anemic with evidence of hemolysis, CHF Intraerythrocytic parasites on smear

72. Item 38 Syndrome: Intra-erythrocytic parasites and hemolytic anemia in splenectomized pt from Cape Cod Key Points Post splenectomy infections: Encapsulated organisms: pneumococcus, H.flu, meningococcus Parasites: malaria, babesiosis Erythrocytic parasites: malaria and babesia Babesiosis: Tick born, Endemic in New England Coast but foci in NJ Usually minimal symptoms, more severe disease in splenectomized and liver disease Treatment: Azithromycin and Atavoquone

73. Item 39 Question: Management of a positive HIV ELISA and indeterminant Western Blot Key Points: Indeterminant serologies must be interpreted in context of patient risk + ELISA, + WB? HIV + ELISA, neg WB? no HIV or very recent infection + ELISA, indeterminant WB? most commonly recent infection or biologic false + due to cross reacting antibodies, repeat testing indicated, no Rx

74. Item 40 Question: Differential Diagnosis of vaginal discharge Clues: Cheesy, malodorous, Ph 6.0, single sexual partner, hyphae and clue cells on smear Key Points DDX of D/C includes Candida, Bacterial vaginosis, trichomonas, less commonly GC or Chlamydia Mixed infections common Normal cervical exam excludes GC and Chlamydia

75. Item 41 Hodgkins Disease being treated for chemo related N and V, on prophylactic fluconazole and ciprofloxacin Febrile, mildly confused, started on broad spectrum antibiotics BC with yeast

76. Item 41 Syndrome; probable candidemia in pt with Hodgkins, port, on prophylactic fluconazole Key Points: Initiation of Candida therapy should not be delayed Intravascular focus should be removed if possible Echinocandin more rapidly fungicidal, also preferred if higher risk for fluconazole resistant species: C. kruzeii, C. glabrata If fluconazole used: Higher doses Other options: Voriconazole, Ampho B Yeast in blood: most likely candida (but cryptococcus is a yeast)

77. Item 42 Question: When to discontinue respiratory isolation for smear + Pulmonary TB Key Point Respiratory Isolation for Pulm TB (not for extrapulmonary TB) Discontinue isolation if: 3 negative sputum specimens and clinical response If it’s not TB Sputum smear +/- does not equal culture +/- Can take weeks to months for smears to become negative

78. Item 43 Question: What is appropriate empiric treatment for otogenic bacterial brain abscess? Clues: prior amoxicillin therapy, chronic otitis media Key Points: Treatment includes ear flora including pneumococcus, viridans streptococci, anaerobes, Enterobacteraciae

79. Item 44 Clues Fevr, pain in thigh 2 days post metalic splinter injury Development of shock syndrome with renal and liver enzyme abnormalities

80. Item 44 Syndrome: shock syndrome following a fairly superficial splinter injury to thigh without significant local damage Key Points: Staphylococcal and streptococcal toxic shock Shock Rash Renal, hepatic abnormalities With/ without necrotizing fasciitis Role for MRSA active agent Role of cell wall drug and protein synthesis inhibitor for streptococcal toxic shock ? Role of immunoglobulin for Streptococcal TS

81. Item 45 Question: What is the most common pathogen in septic arthritis in patients with underlying RA? Key Point Septic arthritis in RA is predominantly S. aureus Most common causes of septic arthritis in native joints depend on context S. aureus GC (especially in sexually active) Streptococci Other organisms if prior associated bactemias

82. Item 46 Question: Which influenza drugs require dosage adjustment in renal insufficiency? Key Points Know your influenza prophylaxis and treatment drugs and indications!

83. Item 47 Clues Recent travel to rural India, took mefloquine prophylaxis Onset of HA, nausea, malaise Enlarged liver, RUQ tenderness Sky high transaminases and high bilirubin

84. Item 47 Syndrome: Fulminant hepatitis in a returning traveler to rural india Key Points Fulminant hepatitis in India likely A or E (esp pregnant women) , B more likely to be subacute Hepatitis A short incubation period Hepatitis A vaccination available Administer up to 2 weeks before travel Hep A alone Hep A plus Hep B vaccine Passive immunization with pooled gamma globulin

85. Item 48 Question: Screening for infection prior to starting TNF inhibitor agents Key Point Pts on TNF agents at higher risk for progression from LTBI to active TB (error in syllabus) TB may be extrapulmonary or disseminated, presents within the 1st year of Rx (infliximab earliest) Screening for LTBI mandated for all starting these agents and treatment recommended Criteria for a + in this population is 5 mm

86. Item 49 Clue Post stem cell transplant on cyclosporine, sirolimus and prednisone Cough, low grade fever, pulmonary nodule

87. Item 49 Post stem cell transplant with pulmonary nodule Key Points Impaired Cell mediated immunity increases risk for a variety of pathogens DDX is broad and includes fungal, mycobacterial, atypical pathogens (nocardia) and septic pulmonary emboli Establishing a Dx critical to be able to target therapy CT more sensitive than CXR for presence of multiple lesions c/w septic pulmonary emboli

88. Item 50 Former Peace Corps worker in Central Africa, Multiple episodes of diarrhea Now with fever, RUQ pain, cough, leukocytosis, elevated LFT’s and AlkPhos CT s with two lesions with brown-red fluid

89. Item 50 Syndrome: Liver abscesses (R. lobe) in recent returnee from Central Africa- ? Amoebic liver abscess Key Points Stool studies often negative, serology confirms Dx DDx is pyogenic liver abscess, location (R lobe) and “anchovy Paste” fluid supportive of Dx Treatment: Metronidazole

90. Item 51 Question: What is most appropriate empiric Rx for osteomyelitis in Sickle cell disease? Key Points: Hematogenous Osteo common in SS Disease Increased prevalence of salmonella, but S. aureus remains most common pathogen Empiric Rx includes treatment for S.aureus (including MRSA) and other usual pathogens and Salmonella: 3rd Gen Ceph or FQ

91. Item 52 Clues AIDS, HA, Mental Status Changes Positive CSF VDRL and lymphocytic pleocytosis Recent Hx of angioedema to PCN

92. Item 52 Syndrome: AIDS with neurosyphilis and probable immediate type hypersensitivity Key Points: Parenteral PCN is treatment of choice for symptomatic neurosyphilis; Ceftriaxone with 20% failure rate; Doxycycline of ? benefit Hx of angioedema is suggestive of IgE mediated hypersensitivity Rxn and requires desensitization Oral desensitization protocols for PCN

93. Item 53 Question: DDX of penile ulcers Key Points: Herpes Simplex (usually HSV-2): small # of lesions, inguinal Lymphadenopathy 1st episodes may be more severe- fever, HA, etc; some protection from prior HSV-1 antibodies; recurrent episodes milder or asymptomatic Syphilis: solitary non painful ulcer (chancre) Chancroid: painful ulcer with raised border

94. Item 54 Clues 18 yo with fever, obtundation, meningismus recent sinusitis Increased BP, decreased HR, dilated pupils CT with enhancing subdural fluid and midline shift

95. Item 55 Syndrome: Subdural empyema Key Points; Management requires drainage of pus in (closed or open) addition to antimicrobials Antibiotics similar to those for bacterial meningitis but S. aureus also a concern Midline Shift and increased ICP contraindications to LP

96. Item 55 Question: What is optimal surgical prophylaxis regimen for CABG? Key Points Antimicrobial prophylaxis now a major Quality indicator (SCIP Project); CT, ortho, GI surgery Choice of Rx: 1st Gen Cephalosporin; If MRSA risk: Vancomycin ( + gram – agent?) Timing: Dose within 1 hr of incision- goal is tissue levels at time of incision (decrease infection rate) Redose intraop after 1 half-life of drug (3-4 hrs) No indication for Rx beyond 24 hrs Recommendations for Joint replacement parallel those for CT Surgery

97. Item 56 Clues Fever, HA, malaise, dry cough after trip to rural Mexico doing construction, multiple others with similar symptoms Labs normal except mild transaminases CXR with reticulonodular infiltrates and LN Granulomatous inflammation on Bx

98. Item 56 Syndrome: Granulomatous pneumonitis and lymphadenopathy post travel to Mexico Key Points: Broad DDx of granulomatous inflammation including infectious and non-infectious; infectious includes mycobacterial and fungal Infiltrates and Hilar LN c/w endemic fungi: Histoplasmosis, Coccidiomycosis Histo belt extends down into Mexico Can see similar picture with TB but more subacute and unlikely multiple exposures; Interstitial disease with LN more common in HIV

99. Item 57 Clues Fever, confusion, HA, jaundice 4 weeks post lung transplant Mycophenolate, tacrolimus, prednisone Tachycardic, tachypenic, low WBC and plts, increased LFT’s

100. Item 57 Syndrome: multisystem illness 1 month following lung transplantation Key Points: Systemic illnesses include disseminated viruses- most commonly latent Herpes group DNA viruses: CMV but also HSV, VZV and reactivation of HHV6 HHV-6: Childhood illness; Most adults are seropositive, reactivation in immunodeficient with multisystem involvement ? Treatment with Ganciclovir or Foscarnet

101. Item 58 Clues Hx of untreated positive PPD (conversion test) Fever, cough, sputum, LUL infiltrate with cavity

102. Item 58 Syndrome: Suspected Primary Pulmonary TB Key Points: Documented PPD conversion: up to 5% risk of symptomatic disease in first few years after conversion; High priority for treatment of LTBI Can initiate therapy, but always preferable to get sputum smears/cultures at onset of Rx; + cultures will help guide subsequent treatment decisions Do not require + smears to initiate Rx

103. Item 59 Clues 83 yo with fever, redness, swelling of leg, tenderness Hypotensive, nausea, vomitting, renal insufficiency, leukocytosis

104. Item 59 Syndrome: leg cellulitis with hypotension, nausea, vomitting, renal insufficency: Toxic shock? Key Points: Most common pathogens would be Gp A strep and S. aureus

105. Item 60 Clues Man with Wrist pain erythema and swelling, fever, papules on legs From Hawaii, recent sexual contact with men in the Philipines

106. Item 60 Syndrome: Disseminated Gonococcal infection with tenosinovitis acquired in Hawaii/ Philippines Key Points: Increasing FQ resistance in GC (highest in Pacific rim) no longer recommended as front line Rx Culture of throat, urethra, rectum important adjuncts to Dx (yield on BC low) Treatment duration shorter than for other forms of septic arthritis

107. Item 61 Question: Infection control measures for patient with suspected varicella or Smallpox Key Points DDx of primary varicella and smallpox may be difficult (see earlier question) Primary varicella and smallpox have contact and airborne transmission and require contact and respiratory isolation: gown, gloves, use of respirator (N-95 mask or other)

108. Item 62 Clues HIV positive with CD4 449, vl 12k, no symptoms Hepatitis C positive

109. Item 62 Syndrome: Hepatitis C antibody positive with HIV infection Key Points: Diagnosis of Hepatitis C includes diagnosis of virus, not just antibody (most but not all Ab + have chronic infection) HIV + with low CD4 can have chronic infection (viremia) and low Ab Hepatitis C infection with stable HIV disease may be treated with interferon and ribaviran, response rates lower than for HIV negative (other evaluation includes genotype, ? Liver Bx)

110. Item 63 Question: Optimal Rx of bacteremic pneumococcal pneumonia with PCN MIC of 1 Key Points Susceptible vs Intermediate vs Resistant to PCN (recent change for non-meningeal isolates) Breakpoints different for meningeal isolates

111. Item 64 Clue 3 mos post cadaveric Renal transplant on tacrolimus, mycophenolate, prednisone Asymptomatic but increased creatinine UA with protein, Leukocytes with transitional cell inclusions, RBC

112. Item 64 Syndrome: Renal transplant pt with deteriorating renal function and transitional cells with inclusions on UA Key Points Polyoma viruses: BK, JC BK associated with nephropathy and graft failure Finding of inclusions highly specific CMV can also cause graft failure

113. Item 65 Clues Visual changes in pt with HIV infection, CD4 355, viral load 15 k, suboptimal adherence Area of hemorrhagic necrosis in fovea

114. Item 65 Syndrome: Acute retinal disease in patient with HIV and CD4 355 Key Points: CMV retinitis unlikely with good CD4- typically less than 50; exception: in setting of immune reconstitution disease Toxo rarely causes retinal disease in HIV infection, CD4 < 150 ARN is caused by Herpes viruses (VAV, HSV) Syphilis can cause multiple eye processes but not retinal necrosis

115. Item 66 Clues 6 month Hx of neuropsychiatric sx, leg and arm parasthesias, ataxic gait, memory loss Lived in France, England, Argentina Increased CSF protein and pulvinar signal

116. Item 66 Syndrome: subacute encephalopathy Key points Variant CJD: younger, more prominent Neuropsychiatric symptoms, pulvinar sign Potential exposure risk as lived in England and France

117. Item 67 Question: How to prevent catheter associated UTI’s Key Points UTI most common HC associated infection; 90% related to catheters No strategy other than removal of catheters clearly decreases risk Condom catheter, intermittent catheterization and Suprapubic lower risk than indwelling

118. Item 68 Question: Empiric Rx of probable vertebral osteomyelitis and epidural abscess in IVDU Key Points Most common pathogen is S. aureus followed by strep and other GPC, GNRS (including pseudomonas) can occur

119. Item 69 Clues HIV + from Dominican Republic, baseline CD4 240, started on HAART with increased CD4 Development of R cervical LN with AFB

120. Item 69 Syndrome: Mycobacterial cervical lymphadenitis in pt with HIV and CD4 > 240 Key Points Atypical cervical mycobacterial infections in HIV rare with CD4 > 200 (exception: immune reconstitution disease) TB most common infection in HIV + in countries where TB is endemic; Africa, Asia, Central and South America and can present at any CD4 count Prevalence of Extrapulmonary TB higher in HIV + All HIV+ should be screened for LTBI (5 mm PPD)

121. Item 70 Clues 8 mos post heart transplant, on prednisone, sirolimus, mycophenolate Fever and mild confusion, supple neck Blood culture with yeast

122. Item 70 Syndrome: CNS syndrome in post solid organ transplant patient; yeast in blood culture Key Points: Listeria and cryptococcus can both present as febrile syndromes with subtle CNS symptoms Yeast in blood can be cryptococcus in addition to candida; echinocandins will not treat cryptococcus Diagnosis includes CSF findings (OP, cells, culture, india ink, CrAG) Treatment: Ampho B plus 5FC

123. Item 71 Question; What is optimal antibiotic Rx for clenched fist injury to mouth (human bite wound) Key Points: Human bite wounds: oral flora: strep, anerobes, Eikenella Closed space hand injuries require aggressive antibiotic Rx and surgicl management HIV and bloodborn pathogen exposure evaluation for human bite wounds

124. Item 72 Question: What is the treatment for primary genital HSV Infection Key Points Primary HSV infection: more systemic symptoms and local LN Transmission can occur in absence of symptoms or apparent lesions Treatment: an oral acyclovir agent: acyclovir, famciclovir or valaciclovir

125. Item 73 Clues 2 day Hx of bulbar symptoms and descending flaccid paralysis Husband with similar symptoms Bioterrorism alert

126. Item 73 Syndrome: Botulism Key Points: Remember Agents of bioterrorism! Smallpox, Anthrax, Botulism, Tularemia, Yersinia, viral hemorrhagic fevers Botulism: rapid onset bulbar symptoms and descending paralysis, absence of sensory symptoms; respiratory failure Risks for botulism: Ingestion of preformed toxin; inoculation of wound with spores and in situ toxin production; bioterrorism? aerosolization Treatment: supportive and antitoxin

127. Item 74 Clues 50 year old with 1 year Hx of difficulty falling asleep, personality changes, autonomic dysfunction Myoclonic jerks, clonus, hyperactive reflexes Normal CSF, increased signal cerebral cortx and basal ganglia

128. Item 74 Syndrome: Subacute encephalopathy with predominant sleep disturbance Key Points DDx of prion diseases Diagnosis of prion diseases

129. Item 75 Clues Recent Hiking/fishing Trip to Virginia 3 day Hx fever, leg pains, leg weakness, abdominal tenderness Leukopenia, thrombocytopenia, elevated liver enzymes Cytoplasmic inclusions in leukocytes

130. Item 75 Syndrome: Human Granulocytic Ehrlichiosis ( Anaplasmosis) Key Points Febrile Tick born illness Exposure risks same as for Lyme and Babesiosis Unlike Lyme, no chronic disease state Dx: Leukocyte inclusions, serology Rx: Doxycycline

131. Item 76 Clues Short duration of Fever, expressive aphasia, RLE weakness January in Minnesota Mild lymphocytic CSF pleocytosis, elevated protein, no RBC

132. Item 76 Syndrome: Febrile Encephalitis with focality in January in Minnesota Key Points: Enteroviral infections and vector-born arbovirus infections rare in Winter CMV, EBV extremely rare in non-immunocompromised HSV most common diagnosed cause of encephalitis Initiate Rx with IV Acyclovir 10 mg/kg/q8 as soon as diagnosis suspected Dx by CSF PCR; supportive data MRI, EEG Absence of blood in CSF does not exclude Dx

133. Item 77 Question: What strategies can help prevent VAP? Key Points: Modifiable Risks for VAP include: Mechanical ventillation Use of H2 blockers, recumbent position, not using subglottic suctioning Malnutrition, chest and abdominal surgery

134. Item 78 Clues Post liver transplant with bacterial abscess On linezolid and Pip-Tazobactam Platelets 28K

135. Item 78 Thrombocytopenia 3 weeks post OLT in patient on Linezolid and Pip-Tazobactam Key Points Linezolid associated thrombocytopenia usually after > 2 weeks Rx Incidence ? 5% Other linezolid toxicities: anemia (marrow supression); optic neuritis and lactic acidosis syndrome

136. Item 79 Clues 62 year old with underlying cardiac disease with fever, cough, tachypnea, low BP, PO2 82%, admitted to ICU

137. Item 79 Syndrome: Severe CAP requiring ICU admission Key Points: Guidelines for management of CAP: indications for ICU admission Adjunctive diagnostic testing: blood culture, sputum (if available), urinary Legionella Ag Antibiotic choice for severe CAP requiring ICU admission

138. Item 80 Question: Outpatient antimicrobial therapy for diverticular abscess growing Klebsiella and anaerobes Key Points QDay parenteral broad spectrum antibiotics Ertapenem: no Rx for MRSA, VRE, Pseudomonas and Acinetobacter Ceftrixone: suboptimal anaerobic coverage FQ: suboptimal anaerobic coverage ( except Moxifloxacin)

139. Item 81 Clues HIV + on no RX CD4 402, vl 14335 Solitary KS lesion

140. Item 81 Syndrome: HIV infection with good CD4 and solitary cutaneous KS lesion Key Points KS can occur at any CD4 count May respond to HAART and is an indication for HAART Due to HHV-8 Indications for systemic Rx: visceral involvement: Pulmonary, GI Local cutaneous disease can be treated locally; need for Bx for Dx

141. Item 82 Clues 27 year old with pyelonephritis, WBC 20K No nausea/vomitting Recent treatment with TMS

142. Item 82 Syndrome: acute pyelonephritis in a healthy young woman Key Points: Cystitis vs. Pyelonephritis Indications for oral vs. IV Rx Complicated vs Uncomplicated pyelonephritis Abnormal urinary tract, pregnancy, DM or other immune deficits Quinolones and TMS can be used orally but increasing TMS resistance in E. coli- the predominant organism

143. Item 83 Cat bite (puncture wound) followed by fever, local erythema and swelling and leukocytosis Hives to PCN

144. Item 83 Syndrome: Cat bite infection in woman with PCN allergy Key Points: Cat bites: high rate of infection Pasteurella and oral flora:Gp A strep, staph, (increasing rates of MRSA) Rx of Pasteurella (gram neg coccobacillus): PCN, if allergic: TMS or a quinolone Animal bite wounds: rabies and tetanus prophylaxis!

145. Item 84 Retired miner with chronic fatigue and dry cough, now bloody sputum and fever CXR with upper lobe masses and cavitary lesion, old Hilar calcification

146. Item 84 Syndrome; Cavitary pulmonary nodules in miner with silicosis Key Points: Risks for higher rates of progression from LTBI to active TB Recent infection (converters, contacts, infants), HIV, old untreated disease on CXR, Immune suppression (TNF, prednisone), malnutrition, CRF, prior gastrectomy Silicosis DDx of Prgressive massive fibrosis vs. TB

147. Item 85 Clues IVDU with fever, cardiac murmur and pain at left Sternoclavicular joint

148. Item 85 Syndrome: Sternoclavicular joint infection in IVDU, possible endocarditis Key Points: Impossible to include/exclude Dx of endocarditis in febrile IVDU Suppurative arthritis in IVDU most commonly S. aureus (MRSA) but also Pseudomonas, especially sternoclavicular and sacroiliac

149. Item 86 Question: What is the most common etiology of uncomplicated traveler’s diarrhea in Mexico? Key Points: Most common: E. coli- generally self limited disease, treatment symptomatically Treatment regimens for travelers’ diarrhea Salmonella, Shigella