USMLE Step 3 Review Course S PREMIER REVIEW November 30, 2008 N=)) Your Succoss is our Passion Infectious Disease N.D. Agrawal, MD Ehrlichiosis — * Patient tick endemic area comes with fever, headache, ho tick bit + Leukopenia, thrombocytopenia + Treatment: Doxy Rocky Mountain spotted fever + Patient from tick endemic region comes with c/o fever, headache, on 4 day developed macular rash on wrist, palm, ankle and feet (distal extremity) which alter one to two days becomes petechial + Treatment: Doxy Young Children with Rash + Roseola infantum Erythema infectiosum Measles Rubella Scarlet Fever Varicella Roscola Infantum (Exanthem Subitum) * Characteristic history of fever for 3-4 days when patient becomes afebrile: developed-maculopapular rash + Cause: Herpes virus 6 + Treatment: self limited ‘thema infectiosum (fifth disease) ‘= Young child with rash on cheeks has “slapped cheek appearan« pattern, lace like rash © Cause: Parvovirus B19 ‘+ Note: Patient with this disease are infectious only before the rash appears- so if'a child comes with rash diagnosed as fifth disease can go back to school oon the body rash with reticular Measles (Rubeola) + Cough, eoryza, conjunctivitis, photophobia, Koplik’s spot (small red spot with the buccal mucosa) + Fever with brick red maculopapular rash begins on face spread downward (Koplik’s spot disappear h appear) + Infectious 5 days before and 4 days after rash appears + Respiratory isolation is suggested in the hospital but there is no specitie recommendation + Post-exposure immunoglobulin can be given in susceptible person who are pregnant, immunocompromised and children under one year of age. + Complication: Subacute sclerosing panencephalitis, Pneumonia Rubella (German measles) + Mild fever *+ Posterior cervical and post-auticular lymphadenopathy 5-10 days before rash, + Maculopapular rash begins on face spread downward ital Rubella sy -ataract, congenital heart disease (PDA), mental retardation, microcephaly y oF white center on CCopyriet Premice Revi. Pease DO NOT copy. Copying this maria swolaton of copyright ay. BUSMLE Step 3 Review Course KA PREMIER REVIEW November 30, 2008 SSD your Success is our Passion Infectious Disease N.D. Agrawal, MD Scarlet Fever + Erythematous rash that blanches on pressure + Circumoral pallor + Strawberry tongue + Skin rough feel like sand paper + Cause: Group A streptococci, jeclla (Chicken Pox) Rash begins as papule-> vesicle-> pustule> scab. Rash: pruritic, centrifugal (begins on trunk spread peripherally) Rash: appear in crops so that several stages of lesion present at the same time. Incubation period: 8-21 days, usually rash appears on day 14-16 Infectious: 24-48 hours prior to the onset of rash and 5 days after in normal host but longer in immunocomromised + Highly contagious- air borne isolation tll all lesion are crusted Complication: + Pheumonia + Encephalitis- characterized by ataxia and nystagmus + Reye’s Syndrome: with aspirin, ‘Treatment: + Children <12 years old: Healthy> Supportive treatment (Acetaminophen, Antih Immunocompromised> IV acyclovir + Children >12 years old or Adult: Oral Acyclovir Post-exposure prophylaxis, taming), no acyclovir + If known (o be immuinePNothing to worry + H/o of infection or vaccination->consider immune, nothin + No history or uncertain history->Serologie test- if not inn may be protective) Immunosuppressed or Pre + If known to be immune>Nothing to worry todo. we Varicella vaccine with in 3-5 days (It wnt women + H/o of infection or vaccination serologic test->if negative Vari after 96 hours use IVIG (Note: VZIG production has been ceased) + No history of infection or vacein: ntramuscular with in 96 hours, jon: VariZ1G Intramuscular + Note: Varicella vaccine should be administered after 5 months of immunoglobulin Health care workers: + All health care workers should be screened for varicella and if seronegative, should be vaccinated before starting the work + Ifa health care worker who is seronegative gets a patient with varicella, should avoid working with this patient. * Vaccination: 2 doses are given 4-8 weeks apart, seroconversion rate is 75% 4 weeks alter first dose and 99% 4 weeks after 2"! dose. Post-immunization serology is not recommended, as commercial test available may not detect the antibody level associated with immunization compated to infection, Copyright, Premier Review. Please DO NOT copy. Copying this material i violation of copright ls 4USMLE Step 3 Review Course ws PREMIER REVIEW November 30, 2008 Your Success is our Passion Infectious Disease N.D. Agrawal, MD. Post-exposure prophylaxis in health care workers: Hio infection: Immune H/o Vaccination Serology negative->Monitor between 10-21 days daily through employee health program, No hilo infection or vaccination->serologic test if not immune->sick leave or vacation between 8-21 days of exposure Ifa health care worker develops varicella and was working with immunocompromised patients, who are susceptible, patients should get immunoglobulin. Herpes Zoster (Shingles) Parvoy) ‘Copsriaht, Premier Review, Please DO NOT copy. Copying his Reactivation of Varicella Usually start with pain in affected nerve, a single unilateral dermatome is involved ( on right or eft side ‘of trunk it will not cross the midline: “band like”). In the face only one side of face. After pain vesicular lesion appear on same dermatome Tzanek Test: Scraping from base of the vesicle demonstrate- multinucleated giant cell with intranuclear inclusion.( +ve in varicella and Herpes simplex also) Ramsay Hunt S} I Palsy, zoster Lesion of external car, vertigo, tinnitus and deafness Isolation: Healthy patient->Contaet precaution Immunocompromised-> Airborne isolation Tit: Acyclovir, Fameiclovir, Valacyclovir- decreases severity and duration of lesion and incidence of post herpetic neuralgia, Ifeye involved refer immediately to the ophthalmologist. Recurrence: Rare in immunocompetent, but do oceur in immunocompromised Patients who have not had varicella, get exposed to a patient with herpes zoster are at risk to develop varicella, not zoster Zoster vaccine is recommended atter 60 years of age. It decreases risk of zoster and post herpetic neuralgia (Avoid in patients with immunodeficiency. h/o anaphylaxis to gelatin or neomycin) Post herpetic neuralgia: severe pain at the site of shingles after healing tment: Amitriptyline, 1 capsaicin, gabapentine, nplex Type ‘Type I: herpes labialis- group of vesicle around mouth usually recurrent- precipitated by stress, fever. infection, chemotherapy Complications: Bell’s palsy, encephalitis, ocular lesion ‘Treatment: Acyclovir ‘us BI9 and Pregnaney Pregnant patient exposed to patient with Parvovirus B19 infection have risk of fetal loss or hydrops fetalis Patient exposed should be tested for B19 IgG and IgM level. Those with IgG are immune but if gM present suggest acute infection, It takes 10 days after exposure for IgM to be positive Patient with IgM positive and less than 20 weeks of pregnaney should be told about the risk of fetal loss and fetal hydrops, No action needs to be taken prior to 20 week. From 24 weeks onward, weekly ultrasound is recommended to look for fetal hydrops (Ascites, scalp edema, polyhydramonios, cardiomegaly) and if develops refer to tertiary care center for the management Pregnant patient with high-risk employment like schoolteacher or day care center worker have no recommendation to leave the job. 2: involved rs Wilton of copsght aw 15USMLE Step 3 Review Course sy PREMIER REVIEW November 30, 2008 Your Success is our Passion Infectious Disease N.D. Agrawal, MD Infectious mononucleosis — Caused by Epstein Barr virus C/F: Fever, sore throat, lymphadenopathy, splenomegaly, Palatal petechiae, Labs: Lymphoeytic leukocytosis, Atypical Iymphoeyte (Large basophilic cells with vacuolated appearance), Heterophil antibody (Monospot) test ve ‘Avoid Physical activity: esp contact sports for one month till splenomeg examination or by ultrasound, to avoid splenie rupture, If misdiagnosed and treated with ampicillin-> Rash. (another way to diagnose Infectious mononucleosis) ‘Treatment: supportive ly resolves either on Sore throat Cyst Pyel Strep. Infection Infectious mononucleosis, Diphtheria Peritonsillar abscess Viral illness Epiglottitis (Urinary Traet Infections) Usually young sexually active female with increased frequency of urine, dysuria, may have lower abdominal discomfort-> No further testis required. Start treatment empirically for 3 days with either Bactrim (Trimethoprim-Sulfamethoxazole) or Ciprofloxacin. If patient is still symptomatic after 3 days requires urine culture If patient is Pregnant or Male patient, requires urin days, In pregnant patient use Amoxicillin, if allergic to Penicillin use Nitrofurantoin Pregnant patient requires follow up urine culture afier 1-2 week of treatment, There is risk of Preterm, delivery and increased neonatal mortality Male patients should always be worked up for eause of UTI Most common organism is E.coli but if urine pH is alkaline about 8.0 likely organisms would be Proteus (Produces Urease) analysis, urine culture and antibiotics are used for 7 ephriti Clinical Features: Fever, polyuria, dysuria, flank pain, on exam costovertebral angle tenclerness present Investigation: UA, Urine culture Treatment: Ciprofloxacin for 10-14 days Every patient with pyelonephritis does not need to be admitted as IV fluoroquinolones have same bioavailability as oral. If patient has systemic signs and symptoms like nausea, vomiting, high fever, hypotension, increased BUNICr or if patient is pregnant or h/o non-compliance we should admit the patient send U/A, urine culture, blood culture use IV antibiotic Ciprofloxacin or levofloxacin or Cetitiaxone (In pregnant patient antibiotic of choice is Ampicillin + Gentamicin IV ifallergic to penicillin use Aztreonam or Imipenem) Once patient develop pyelonephritis during pregnancy should be on prophylaxis with Nitrofurantoin or Cephalaxin throughout the pregnancy. [patient with pyelonephritis does not improve in 48-72 hours, has persistently high fe ultrasound to rule out renal abscess, er order renal Copyright, Premier Review. Please DO NOT copy. Copying his mera i violation of epyright tw 16USMLE Step 3 Review Course \& PREMIER REVIEW ‘November 30, 2008 SSP) Your Success is our Passion Infectious Disease N.D. Agrawal, MD Recurrent UTI: >3 infections/year + Advise patient to urinate pre and post coitus + Bactrim or Nitrofurantoin can be used daily Asymptomatic Bateriuria: Positive urine culture in an as} + Treatment: No treatment unless 1: pregnant 2: Young children with vesicoureteral reflux, 3: before urological procedure 4: After the removal of a bladder catheter that had been in place for less than one week nptomatie patient Patient with long term foley’s catheter: + Asymptomatic bacteriuria: No treatment + Symptomatic: Treat CCS: 1 + Location: office + Co: Increased frequency and burning in urination + History of Present Illness (HPI): 26 years old female came with complain of increased frequeney and burning of urine. She also feels mild lower abdominal pain for last 2 days. Denied nausea, vomiting, flank pain. She felt feverish but denied high fever. Denied any vaginal discharge. She is 20 week pregnant sith her first child and sexually active only with her boy friend. She denied smoking, aleohol or drug abuse Allergy: No known drug allergy Examine: Can do full physical in off Positive findings: Mild suprapubie tenderne: Onder: CBC-Routine, Chem8-Routine, Urine Analysis—Routine, Urine Culture-Routine, Amoxicillin. oral- continuous + Change location for home + Schedule to come back in two week + Note: Before patient comes you will have all the result and ifthe urine culture is growing a bacteria not sensitive to amoxicillin you can always call the patient back to clinic. discontinue the amoxicillin and ive other appropriate antibiotic: Patient has arrived for the appointment. She feels better. her symptoms have resolved. ‘You can do some focal exam at this point. Order: Urine analysis, Urine culture Change location Home Schedule to come back in one month, End of the ease. Diagnosis: Urinary tract infection in a pregnant patient ces: 2 + Location: Emergency Room + Vital signs: B.P. 100/60 mm Hg, Pulse- 94/minute, Temperature- 101.6"F, RR- 18/minute, weight- 150 Ib, + Ce: Left flank pain, increased frequency and burning in urination, nausea, vomiting, Copytiel, Premier Reviow, Please DO NOT copy. Copying his material is vilation af copyright fe 7ep 3 Reiew Course PREMIER REVIEW vember 30, SER) our success is our Passion Tneetous Disewe AD Aue MD + History of Present Iliness (HPI): 30-year-old female presented with the complaint of increased frequency, burning in the urine, for last 2 days. Since this morning feeling left flank pain, nausea and vomited three times. Denied any blood in vomitus. She also felt fever with chills but has not measured temperature. Flank pain is dull aching type but no radiation. She is sexually active with her husband uses oral contraceptive. She denied any vaginal discharge. Her menstruation is regular, + Past Medical History: Urinary tract infection 2 years ago. + Allergy: No known drug allergy + Examination: Focal examination, since the patient is in the emergency room + General, HEENT, Heart, Lung, Abdomen, Genitalia, Extremity + Only positive finding on examination is mild suprapubic tenderness, left costovertebral angle tendemess. + Order: CBC-stat, Chem8-stat, Blood culture-stat, Pregnancy test, urine-stat, Urine analysis-stat, Urine Gram stain-stat, Urine culture-stat, IV line-stat, Normal saline 0.9%-continuous + Move the clock to get the result of pregnancy test result (Usually available in minutes) + Pregnancy test- Negative + Order again: Ciprofloxacin- TV-continuous + Move the clock to get the result of other labs ordered. + CBC will have inereased WBC, CHEM 8 normal, UA has increased WBC, nitrite positive + Urine Gram stain-Gram negative bacilli *+ Urine Culture: Pending (result comes in 24 hour), Blood culture: Pending + Change location- ward + Move the clock for next day round at 10 AM or whatever time the urine culture result is coming back + [twill be end of the case. Diagnosis: Pyelonephritis Neutropenia: + Mild: Absolute neutrophil eount 1000-1500 eellsmm3 + Moderate: Absolute neutrophil eount 500-1000 cells/mm’ + Severe: Absolute neutrophil count <500 eellsimm3 + When neutropenia is secondary to chemotherapy use Granulocyte-colony stimulating f or Granulocyte maerophage-colony stinrulating factor (argramostny) Febrile Neutropenic Patient: + Use antibiotic empiric: c ctor (Filgrastim) whieh covers Pseudomonas + Ceftazidime or Cefepime or Imipenem (As monotherapy) + Antipseudomonal penicillin*Aminoglyeoside + Celiazidime or Cefepime + Aminoglycoside If patient has hypotension, Mucositis, skin or catheter site infection--> Vancomycin+ Ceftazidime If patient continue to be febrile after $ days Add antifungal therapy (Amphotericin B, lot of centers use Voriconazole or Caspofungin these days as they are better tolerated) Meningocoecemia + Pever, stiff neck, headache with +ve Kernig’s sign (signs and symptoms of meningitis) + Petechial rash + Treatment: Penicillin is DOC. IFallergie Chloramphenicol (s/e-Bone marrow suppression) + Prevention: Droplet Isolation for 24 hour afier starting therapy *+ Meningococcal infection is more common in patients with terminal complement deficiency (C5-C9) + Meningocoecemia patients suddenly developed hypotensio hemorrhage (Waterhouse Friderichsen syndrome) + TAELV Corticosteroid + treat meningococcal infection, shock- most likely diagnosis adrenal Copyright, Premier Review. Please DO NOT copy. Copying this material is violation of copyright I. 18USMLE Step 3 Review Course fey PREMIER REVIEW ‘November 30, 2008 SN) Your Success is our Passion Infectious Disease N.D. Agrawal, MD Meningococeal Prophylaxis ‘+ Population exposed who need prophylaxis: House hold contact, Day care center contact + Population exposed does not need prophylaxis: School and work contact, hospital contact + Drugs used for prophylaxis: + Rifampin 600mg BID x 2 days + Ciprotiox- S00mg PO x 1 dose + Ceftriaxone. 250mg IM x1dose. Whooping Cough + Caused by Bordetella pertussis + Young child with fever, cough which is paroxysmal and end with a high pitched inspiratory whoop with lymphocytosis (80%lymphocytes) + Treatment: Erythromycin + Prevention: Infant and susceptible adults with significant exposure should receive prophylaxis with Erythromycin for 10 days + Note: 5% of infants getting Erythromycin can develop Infantile hypertrophic pyloric stenosis. Cat Scratch Disease + Caused by Bartonella Henselae + Usually in patient who work with animals (Veterinarian) comes with fever, malaise tender regional lymphadenopathy. occasionally hvo scratch by cat is there + Confirmed by aspiration or biopsy of Iymph node + In children one of the causes of lever of unknown or hepatosplenom + Treatment: Adult self timited or Azithromycin Children: Rifampin + Azithromycin nand usually associated with Rat Bite Fever + Cause: Streptobacillus moniliformis, spirillum minor . sing or intermittent, rash, asymmetrical polyarthritis, and history of rat-infested sI + Te Penicillin G. it all bite oF patient is from > Tetracyelin Vibrio Vulnificus Infection Injury in sea water or alter cleaning fish patient develops cellulitis with hemorrhagic bullae and necrosis. * History could be hand injury white opening oyster or leg injury while launching boats. + Treatment: Doxyeyeline Complement deficiency + CI, C2, Cd def: Recurrent Infection with encapsulated bacteria ( Strep, H.AnfTuenzae) + C5-9 def: Recurrent meningococcal and gonococcal infection + Best single test to screen complement def CH50 Reye's Syndrome Rapidly progressive hepatic failure and encephalopathy (TAST/ ALTIP' + Cause: Aspirin in patients with influenza or varicella /Bilirubin/Ammonia level) Copysigh, Premise Review: Pee DO NOT copy. 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