Infectious Diseases HighYield and Frequently tested concepts on USMLE Step 3. These slides are samples from Archer USMLE Step 3 Review Lectures. Couple it with Archer Step 3 Question bank and Step 3 CCS to easily pass your final part of USMLE licensing exams
This document summarizes information on allergic rhinitis and sinusitis. It discusses the pathophysiology, symptoms, diagnosis and management of allergic rhinitis. Intranasal corticosteroids are identified as the most effective treatment. It also covers the diagnosis and treatment of acute and chronic sinusitis, including complications. Imaging such as CT is recommended for complicated cases or recurrent sinusitis.
The document provides an overview of esophageal disorders, including their symptoms, diagnosis, and management. Key points include:
- Dysphagia can be caused by obstructive lesions like cancer/strictures or motility disorders. Diagnosis involves barium swallow, endoscopy, and manometry.
- Odynophagia can be due to conditions like GERD, infections, pill esophagitis, or radiation esophagitis.
- Barrett's esophagus develops in some with longstanding GERD and requires surveillance due to cancer risk.
- H. pylori testing is recommended if treating, for persistent dyspepsia, or lymphoma risk. Endoscopy is considered
Archer USMLE step 3 Endocrinology lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at http://www.ccsworkshop.com/Pay_Per_View.html
This document discusses hypochondriasis (excessive worry about having a serious illness despite medical evaluation finding no evidence of physical disease), including its diagnostic criteria, associations, and differential diagnoses. It also provides guidance on evaluating and managing patients with hypochondriasis, including the use of cognitive behavioral therapy and antidepressants.
Archer Review is the most widely used Step 3 lecture and CCS course and has led to an extremely high pass rate even for repeaters. By focusing on what is tested frequently exam and mastering it from one single resource, reduce your prep-time by cutting back on referring to multiple sources! An Archer strategy that has worked time and again over a decade!
1) A 5-month-old male child presented with 5 days of fever followed by seizures and was intubated due to poor condition and raised intracranial pressure. Infectious etiologies like dengue and autoimmune encephalitis were considered.
2) Investigations like MRI, LP, and metabolic workup were normal or negative. The child had refractory seizures and raised ICP and died.
3) Causes of acute encephalopathy like infection, autoimmune, metabolic and epileptic encephalopathy were discussed. Management involves stabilization, empiric antibiotics, supportive care, preventing complications, and identifying specific causes.
This document summarizes information on allergic rhinitis and sinusitis. It discusses the pathophysiology, symptoms, diagnosis and management of allergic rhinitis. Intranasal corticosteroids are identified as the most effective treatment. It also covers the diagnosis and treatment of acute and chronic sinusitis, including complications. Imaging such as CT is recommended for complicated cases or recurrent sinusitis.
The document provides an overview of esophageal disorders, including their symptoms, diagnosis, and management. Key points include:
- Dysphagia can be caused by obstructive lesions like cancer/strictures or motility disorders. Diagnosis involves barium swallow, endoscopy, and manometry.
- Odynophagia can be due to conditions like GERD, infections, pill esophagitis, or radiation esophagitis.
- Barrett's esophagus develops in some with longstanding GERD and requires surveillance due to cancer risk.
- H. pylori testing is recommended if treating, for persistent dyspepsia, or lymphoma risk. Endoscopy is considered
Archer USMLE step 3 Endocrinology lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at http://www.ccsworkshop.com/Pay_Per_View.html
This document discusses hypochondriasis (excessive worry about having a serious illness despite medical evaluation finding no evidence of physical disease), including its diagnostic criteria, associations, and differential diagnoses. It also provides guidance on evaluating and managing patients with hypochondriasis, including the use of cognitive behavioral therapy and antidepressants.
Archer Review is the most widely used Step 3 lecture and CCS course and has led to an extremely high pass rate even for repeaters. By focusing on what is tested frequently exam and mastering it from one single resource, reduce your prep-time by cutting back on referring to multiple sources! An Archer strategy that has worked time and again over a decade!
1) A 5-month-old male child presented with 5 days of fever followed by seizures and was intubated due to poor condition and raised intracranial pressure. Infectious etiologies like dengue and autoimmune encephalitis were considered.
2) Investigations like MRI, LP, and metabolic workup were normal or negative. The child had refractory seizures and raised ICP and died.
3) Causes of acute encephalopathy like infection, autoimmune, metabolic and epileptic encephalopathy were discussed. Management involves stabilization, empiric antibiotics, supportive care, preventing complications, and identifying specific causes.
This document contains a list of 50 clinical cases with brief descriptions that are recommended for the USMLE Step 3 exam. Some examples included are femur neck fracture, advanced maternal age, snake bite, hepatic encephalopathy, and post-operative atelectasis. For each case, key history findings, physical exam points, testing, treatment, and follow up are outlined to help students prepare and practice clinical reasoning.
This document summarizes the pathophysiology, clinical presentation, management, and prognosis of kerosene poisoning in children. Kerosene easily penetrates the lungs due to its low viscosity and surface tension, causing chemical pneumonitis that can lead to respiratory failure. Symptoms include cough, tachypnea, hypoxemia, and neurological effects. Management involves supportive care, with intubation and ventilation for severe cases. Gastric decontamination methods are not recommended due to risk of aspiration. Outcomes are generally good with supportive care alone, though extracorporeal membrane oxygenation or high frequency ventilation may be life-saving in severe cases unresponsive to conventional ventilation.
This document provides an overview of several toxin-induced toxidromes:
- Anticholinergic toxidrome results from drugs that block muscarinic receptors causing signs like delirium, mydriasis, tachycardia and dry mouth.
- Cholinergic toxidrome is caused by increased acetylcholine and includes salivation, lacrimation, bronchorrhea and bronchospasm.
- Opiate toxidrome presents with CNS depression, respiratory depression and miosis. Naloxone is used as an antidote.
- Hypnosedative toxidrome mimics alcohol intoxication with respiratory depression, hypotension and impaired coordination.
- Sympath
The document discusses acetaminophen poisoning in children. It describes acetaminophen as a drug with analgesic and antipyretic properties that can cause toxicity when too much is ingested. The toxicity results from a reactive metabolite that depletes glutathione stores in the liver. It outlines the stages of acetaminophen toxicity and emphasizes the importance of rapid treatment with N-acetylcysteine to prevent liver damage. Diagnosis involves measuring acetaminophen levels in conjunction with liver enzymes and coagulation factors.
Tetanus is explained in very simple wording and style by the help of a scenario. Easy to memorize and present due to related pictures. Helpful for medical students, and knowledge seekers.
This document provides guidance on evaluating a child presenting with fever and rash. It describes the key characteristics of fever and rash, important aspects of history and physical exam, and the differential diagnosis for common infectious and inflammatory causes of fever and rash in children. These include viral illnesses like measles, chickenpox, rubella, scarlet fever, dengue fever, and typhoid fever, as well as bacterial infections like Kawasaki disease, systemic lupus erythematosus, and infectious mononucleosis. Diagnosis and treatment options are outlined for each condition. A thorough history, physical exam focusing on rash characteristics, and diagnostic testing can help identify the underlying cause.
This document summarizes information about animal and insect bites, including rabies, snake bites, and arthropod bites. It describes the epidemiology, transmission, clinical manifestations, diagnosis, and management of rabies. It also discusses the toxicology, clinical manifestations, laboratory examination, and hospital and field management of snake bites. Finally, it provides information on hymenoptera (bee) bites, black widow spider bites, including their venom effects, manifestations, and treatment approaches.
Pediatric Acute Liver Failure (PALF) is defined as evidence of liver dysfunction within 8 weeks of symptoms onset in children, with uncorrectable coagulopathy and no evidence of chronic liver disease. Common etiologies include viral hepatitis, drugs, and other metabolic causes. Diagnostic workup involves general and etiology-specific tests. Key parameters to monitor include encephalopathy grade, coagulopathy, electrolytes, and complications. Treatment focuses on supportive care, complication management, and liver transplantation if indicated based on severity scores. Prognosis depends on etiology and degree of encephalopathy.
Osteomyelitis in children is caused by bacterial infection, most commonly Hemophilus influenzae or Kingella kingae. It presents with pain, fever, and swelling near the infected bone. Diagnosis involves blood tests showing elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Imaging like x-ray, bone scan, MRI can identify bone changes. Treatment is usually intravenous antibiotics for 2-6 weeks, sometimes with surgery to remove dead bone if the infection is not improving. Complications can include recurrence, bone damage affecting growth, or pathological fractures.
Severe hypertension that is a potentially life-threatening condition refers to a hypertensive crisis.
Severe hypertension is further classified into hypertensive emergencies or hypertensive urgencies.
Hypertensive emergency refers to a severe hypertension that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure should be reduced immediately to prevent or minimize organ dysfunction.
Hypertensive urgency refers to severe hypertension without evidence of new or worsening end-organ injury.
A hypertensive emergency is hypertension with acute impairment of one or more
organ systems that can result in irreversible organ damage. Especially:-
Central nervous system
Cardiovascular system
Renal system.
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120mmHg and/or systolic blood pressure greater than or equal to 180mmHg.
Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.
Cerebral malaria is a life-threatening complication caused by the Plasmodium parasite transmitted through the bites of infected female Anopheles mosquitoes. It primarily affects children and is characterized by impaired consciousness. The document outlines the criteria for diagnosing cerebral malaria, including unrousable coma, exclusion of other causes, and confirmation of P. falciparum infection. Proper management requires urgent antimalarial treatment as well as intensive care for complications, but the prognosis is often poor.
This document provides an overview of key aspects of pediatric trauma. It begins with the epidemiology, noting that trauma is a leading cause of death above infancy. The primary causes of injury-related death are discussed. The document then covers the primary and secondary survey, focusing on the ABCDE approach. Specific types of injuries are addressed, including head trauma, chest trauma, abdominal trauma, burns, and submersion injuries. Diagnostic tools and management strategies are outlined for each. The importance of early specialty involvement is emphasized.
This document discusses special situations and adverse events following immunization. It provides guidance on vaccinating preterm/low birth weight infants, those receiving corticosteroids or immunosuppressive therapy, children with malignancies, congenital immunodeficiencies, chronic diseases, allergies, bleeding disorders, or acute illness. It recommends that most vaccines can be administered according to chronological age for preterm/low birth weight infants. It also provides specific guidance on contraindications and precautions for different groups.
Fat embolism syndrome is caused by fat globules entering the bloodstream after trauma like long bone fractures. It can cause respiratory failure, neurological symptoms, and a rash. Diagnosis is based on clinical criteria like hypoxemia, thrombocytopenia, and petechial rash appearing 1-4 days after injury. Treatment focuses on respiratory support, fluid resuscitation, steroids to reduce lung inflammation, and early fracture fixation to prevent worsening.
This document discusses febrile neutropenia in children undergoing cancer treatment. It defines febrile neutropenia and describes its causes and risk factors. Potential sites of infection are outlined. Evaluation involves history, exam, and initial tests like blood cultures and chest x-ray. Patients are stratified as low or high risk. High risk patients require hospitalization and intravenous antibiotics. Management focuses on early antibiotic treatment and supportive care measures. Outcomes depend on identification and treatment of infection foci.
This document discusses principles of damage control resuscitation for traumatic hemorrhage. It describes how hemorrhage can lead to hypovolemic shock and coagulopathy, exacerbating blood loss. Damage control resuscitation aims to rapidly restore blood volume while limiting blood pressure increases to prevent further bleeding. It emphasizes early use of blood products rather than crystalloids to avoid dilutional coagulopathy, and maintaining hemostasis through permissive hypotension, tranexamic acid, and ratio-based blood component resuscitation. While controversial, this approach may improve outcomes compared to aggressive crystalloid resuscitation in severely bleeding trauma patients.
The document discusses the diagnosis of syphilis through various testing methods. Dark field microscopy can detect Treponema pallidum in lesions during primary or secondary syphilis. Non-treponemal tests like VDRL and RPR are screening tests but have low sensitivity in early and late syphilis. Treponemal specific tests like FTA-Abs are used to confirm syphilis diagnosis when non-treponemal tests are reactive. Both types of tests are used at different stages of syphilis to make or confirm the diagnosis.
This document provides information on puncture wounds and their management. It discusses the pathophysiology, risk factors, clinical features, diagnosis, and treatment of various types of puncture wounds including those from high pressure injection injuries, animal bites, needle sticks, and more. Complications are outlined along with prevention and management recommendations. Imaging, wound care, debridement, antibiotics, and tetanus prophylaxis are frequently recommended depending on the wound type and risk of infection.
This document contains a list of 50 clinical cases with brief descriptions that are recommended for the USMLE Step 3 exam. Some examples included are femur neck fracture, advanced maternal age, snake bite, hepatic encephalopathy, and post-operative atelectasis. For each case, key history findings, physical exam points, testing, treatment, and follow up are outlined to help students prepare and practice clinical reasoning.
This document summarizes the pathophysiology, clinical presentation, management, and prognosis of kerosene poisoning in children. Kerosene easily penetrates the lungs due to its low viscosity and surface tension, causing chemical pneumonitis that can lead to respiratory failure. Symptoms include cough, tachypnea, hypoxemia, and neurological effects. Management involves supportive care, with intubation and ventilation for severe cases. Gastric decontamination methods are not recommended due to risk of aspiration. Outcomes are generally good with supportive care alone, though extracorporeal membrane oxygenation or high frequency ventilation may be life-saving in severe cases unresponsive to conventional ventilation.
This document provides an overview of several toxin-induced toxidromes:
- Anticholinergic toxidrome results from drugs that block muscarinic receptors causing signs like delirium, mydriasis, tachycardia and dry mouth.
- Cholinergic toxidrome is caused by increased acetylcholine and includes salivation, lacrimation, bronchorrhea and bronchospasm.
- Opiate toxidrome presents with CNS depression, respiratory depression and miosis. Naloxone is used as an antidote.
- Hypnosedative toxidrome mimics alcohol intoxication with respiratory depression, hypotension and impaired coordination.
- Sympath
The document discusses acetaminophen poisoning in children. It describes acetaminophen as a drug with analgesic and antipyretic properties that can cause toxicity when too much is ingested. The toxicity results from a reactive metabolite that depletes glutathione stores in the liver. It outlines the stages of acetaminophen toxicity and emphasizes the importance of rapid treatment with N-acetylcysteine to prevent liver damage. Diagnosis involves measuring acetaminophen levels in conjunction with liver enzymes and coagulation factors.
Tetanus is explained in very simple wording and style by the help of a scenario. Easy to memorize and present due to related pictures. Helpful for medical students, and knowledge seekers.
This document provides guidance on evaluating a child presenting with fever and rash. It describes the key characteristics of fever and rash, important aspects of history and physical exam, and the differential diagnosis for common infectious and inflammatory causes of fever and rash in children. These include viral illnesses like measles, chickenpox, rubella, scarlet fever, dengue fever, and typhoid fever, as well as bacterial infections like Kawasaki disease, systemic lupus erythematosus, and infectious mononucleosis. Diagnosis and treatment options are outlined for each condition. A thorough history, physical exam focusing on rash characteristics, and diagnostic testing can help identify the underlying cause.
This document summarizes information about animal and insect bites, including rabies, snake bites, and arthropod bites. It describes the epidemiology, transmission, clinical manifestations, diagnosis, and management of rabies. It also discusses the toxicology, clinical manifestations, laboratory examination, and hospital and field management of snake bites. Finally, it provides information on hymenoptera (bee) bites, black widow spider bites, including their venom effects, manifestations, and treatment approaches.
Pediatric Acute Liver Failure (PALF) is defined as evidence of liver dysfunction within 8 weeks of symptoms onset in children, with uncorrectable coagulopathy and no evidence of chronic liver disease. Common etiologies include viral hepatitis, drugs, and other metabolic causes. Diagnostic workup involves general and etiology-specific tests. Key parameters to monitor include encephalopathy grade, coagulopathy, electrolytes, and complications. Treatment focuses on supportive care, complication management, and liver transplantation if indicated based on severity scores. Prognosis depends on etiology and degree of encephalopathy.
Osteomyelitis in children is caused by bacterial infection, most commonly Hemophilus influenzae or Kingella kingae. It presents with pain, fever, and swelling near the infected bone. Diagnosis involves blood tests showing elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Imaging like x-ray, bone scan, MRI can identify bone changes. Treatment is usually intravenous antibiotics for 2-6 weeks, sometimes with surgery to remove dead bone if the infection is not improving. Complications can include recurrence, bone damage affecting growth, or pathological fractures.
Severe hypertension that is a potentially life-threatening condition refers to a hypertensive crisis.
Severe hypertension is further classified into hypertensive emergencies or hypertensive urgencies.
Hypertensive emergency refers to a severe hypertension that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure should be reduced immediately to prevent or minimize organ dysfunction.
Hypertensive urgency refers to severe hypertension without evidence of new or worsening end-organ injury.
A hypertensive emergency is hypertension with acute impairment of one or more
organ systems that can result in irreversible organ damage. Especially:-
Central nervous system
Cardiovascular system
Renal system.
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120mmHg and/or systolic blood pressure greater than or equal to 180mmHg.
Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.
Cerebral malaria is a life-threatening complication caused by the Plasmodium parasite transmitted through the bites of infected female Anopheles mosquitoes. It primarily affects children and is characterized by impaired consciousness. The document outlines the criteria for diagnosing cerebral malaria, including unrousable coma, exclusion of other causes, and confirmation of P. falciparum infection. Proper management requires urgent antimalarial treatment as well as intensive care for complications, but the prognosis is often poor.
This document provides an overview of key aspects of pediatric trauma. It begins with the epidemiology, noting that trauma is a leading cause of death above infancy. The primary causes of injury-related death are discussed. The document then covers the primary and secondary survey, focusing on the ABCDE approach. Specific types of injuries are addressed, including head trauma, chest trauma, abdominal trauma, burns, and submersion injuries. Diagnostic tools and management strategies are outlined for each. The importance of early specialty involvement is emphasized.
This document discusses special situations and adverse events following immunization. It provides guidance on vaccinating preterm/low birth weight infants, those receiving corticosteroids or immunosuppressive therapy, children with malignancies, congenital immunodeficiencies, chronic diseases, allergies, bleeding disorders, or acute illness. It recommends that most vaccines can be administered according to chronological age for preterm/low birth weight infants. It also provides specific guidance on contraindications and precautions for different groups.
Fat embolism syndrome is caused by fat globules entering the bloodstream after trauma like long bone fractures. It can cause respiratory failure, neurological symptoms, and a rash. Diagnosis is based on clinical criteria like hypoxemia, thrombocytopenia, and petechial rash appearing 1-4 days after injury. Treatment focuses on respiratory support, fluid resuscitation, steroids to reduce lung inflammation, and early fracture fixation to prevent worsening.
This document discusses febrile neutropenia in children undergoing cancer treatment. It defines febrile neutropenia and describes its causes and risk factors. Potential sites of infection are outlined. Evaluation involves history, exam, and initial tests like blood cultures and chest x-ray. Patients are stratified as low or high risk. High risk patients require hospitalization and intravenous antibiotics. Management focuses on early antibiotic treatment and supportive care measures. Outcomes depend on identification and treatment of infection foci.
This document discusses principles of damage control resuscitation for traumatic hemorrhage. It describes how hemorrhage can lead to hypovolemic shock and coagulopathy, exacerbating blood loss. Damage control resuscitation aims to rapidly restore blood volume while limiting blood pressure increases to prevent further bleeding. It emphasizes early use of blood products rather than crystalloids to avoid dilutional coagulopathy, and maintaining hemostasis through permissive hypotension, tranexamic acid, and ratio-based blood component resuscitation. While controversial, this approach may improve outcomes compared to aggressive crystalloid resuscitation in severely bleeding trauma patients.
The document discusses the diagnosis of syphilis through various testing methods. Dark field microscopy can detect Treponema pallidum in lesions during primary or secondary syphilis. Non-treponemal tests like VDRL and RPR are screening tests but have low sensitivity in early and late syphilis. Treponemal specific tests like FTA-Abs are used to confirm syphilis diagnosis when non-treponemal tests are reactive. Both types of tests are used at different stages of syphilis to make or confirm the diagnosis.
This document provides information on puncture wounds and their management. It discusses the pathophysiology, risk factors, clinical features, diagnosis, and treatment of various types of puncture wounds including those from high pressure injection injuries, animal bites, needle sticks, and more. Complications are outlined along with prevention and management recommendations. Imaging, wound care, debridement, antibiotics, and tetanus prophylaxis are frequently recommended depending on the wound type and risk of infection.
This document provides guidance on diagnosing and treating common skin and soft tissue infections (SSTIs). It outlines treatment goals for different types of SSTIs including early diagnosis/treatment, incision and drainage of abscesses if present, and evidence-based antibiotic use. It provides treatment recommendations for infections like impetigo, cellulitis, abscesses, and necrotizing fasciitis. Empiric antibiotic options are suggested based on infection severity, with considerations for multidrug-resistant organisms. Close monitoring of patients is emphasized, especially those with risk factors like diabetes.
This document summarizes guidelines for diagnosing and treating various soft tissue and wound infections. It discusses the typical pathogens involved in different types of infections such as superficial cuts, abscesses, and necrotizing fasciitis. It provides recommendations for specimen collection, antibiotic selection, and treatment approaches based on infection severity. The document emphasizes the importance of early diagnosis and treatment to prevent spread of infection and systemic complications.
- Tetanus has an incubation period of 3 days to 3 weeks in adults and 3 to 30 days in newborns. It is caused by Clostridium tetani bacteria entering through puncture wounds. Treatments include antibiotics and wound cleaning.
- Meningitis has an incubation period of 1-10 days. It is caused by Neisseria meningitidis bacteria spread through respiratory droplets. Treatments include IV antibiotics, anticonvulsants, and acetaminophen.
- Encephalitis typically has an incubation period of 5 to 15 days. It is caused by arboviruses spread by mosquito bites. Treatments focus on promoting comfort and controlling fever and convulsions
Brain abscess may have hematogenous spread: Pneumococcus common or via Contiguous spread. Risk factors includes pulmonary abscess or AV fistulas, congenital cyanotic heart disease, immunocompromised, chronic sinusitis/otitis, dental procedures. Intraventricular rupture of abscess is life threatening. Timely diagnosis and treatment is the goal.
Tetanus is caused by Clostridium tetani bacteria. It enters the body through wounds and produces a neurotoxin. There are different types including traumatic (following injury), puerperal (after childbirth), and neonatal (umbilical cord). Symptoms include muscle spasms starting with the jaw and spreading to other muscles. Treatment involves wound cleaning, antibiotics, antitoxin immunoglobulins, and muscle relaxants. Prevention focuses on proper immunization, wound care, and improving sanitation. Maternal immunization helps prevent neonatal tetanus.
1. Tetanus is caused by Clostridium tetani bacteria which produces a toxin that causes painful muscle contractions. It enters through wounds and infects locally.
2. Symptoms include jaw stiffness, muscle spasms, and potentially death from respiratory failure. Treatment involves wound care, antibiotics, tetanus immunoglobulin, muscle relaxants, and sometimes ventilation in ICU.
3. Scabies is caused by the Sarcoptes scabies mite which burrows under the skin and causes itching. Symptoms include pustules, vesicles, and scratches between fingers and skin folds. Treatment involves scabicide creams or ointments applied to the entire body for
Tetanus is caused by Clostridium tetani bacteria entering the body through wounds. It causes painful muscle spasms. The disease is most common in agricultural workers and affects those aged 5-40. Immunization provides effective prevention, either through active immunization with tetanus toxoid vaccines or passive immunization with antitoxin immunoglobulins. Both methods provide temporary protection, while active immunization also confers long-lasting immunity and is the preferred prevention method.
This patient likely has sepsis from a surgical site infection after her kidney-pancreas transplant. Key findings include:
- Recent major surgery (transplant 4 days ago)
- Immunosuppression from anti-rejection medications
- Fever and hypotension consistent with sepsis
- No signs of localized infection at surgical site but increased erythema
The most appropriate initial management would be:
1. Obtain blood cultures and start broad-spectrum IV antibiotics covering common Gram-positive and Gram-negative pathogens.
2. Consult surgery team to evaluate surgical site for signs of infection requiring re-operation.
3. Given recent transplant and immunosuppression, empiric therapy should include vancomycin
This document discusses surgical infections and the use of antibiotics. It defines surgical infections and describes various pathogens that commonly cause infections, including Streptococcus, Staphylococcus, gram-negative organisms, and Clostridia. It also discusses specific infections such as surgical site infections, necrotizing fasciitis, tetanus, and pseudomembranous colitis. The document concludes by outlining guidelines for antibiotic prophylaxis and treatment based on the classification of surgical wounds.
This document summarizes information about zoonotic diseases that can be transmitted from animals to humans. It focuses on rabies, providing details on the causative agent, transmission, symptoms, incubation period, epidemiology, diagnosis, treatment and prevention. Rabies is a viral disease transmitted through animal bites that is nearly always fatal without post-exposure prophylaxis. It also briefly discusses anthrax, a bacterial infection transmitted through contact with infected animal tissues or inhalation of spores. Prevention involves vaccination, isolation of infected animals, and disinfection of materials like hides and wool.
This document summarizes information about zoonotic diseases that can be transmitted from animals to humans. It focuses on rabies, providing details on the causative agent, transmission, symptoms, incubation period, epidemiology, diagnosis, treatment and prevention. Rabies is a viral disease transmitted through animal bites that is nearly always fatal without post-exposure prophylaxis. It also briefly discusses anthrax, a bacterial infection transmitted through contact with infected animal tissues or inhalation of spores. Prevention involves vaccination, isolation of infected animals, and disinfection of materials like hides and wool.
The document discusses Tetanus (lockjaw), an infectious disease caused by the bacteria Clostridium tetani. Key points:
- C. tetani spores are found in soil and animal feces and enter the body through wounds, where they produce a toxin that causes painful muscle spasms.
- Symptoms include lockjaw, risus sardonicus (contraction of facial muscles), and opisthotonus (back arching). Diagnosis is clinical. Treatment focuses on wound debridement, antibiotics, antitoxins, and controlling spasms.
- Tetanus is preventable through active immunization with the tetanus toxoid vaccine
Animal and human bites can cause serious injuries beyond what is visible, including fractures, tendon damage, and nerve injuries. A complete history should be obtained and the wound thoroughly examined and cleaned. For high-risk wounds, antibiotics and delayed closure or non-closure are recommended to prevent infection. Tetanus prophylaxis and rabies treatment may also be needed depending on the type and circumstances of the bite.
Diphtheria is a highly infectious respiratory disease caused by Corynebacterium diphtheriae that is endemic in developing countries. It mainly affects children under 5 years of age and occurs more commonly in winter months. There are four main types - pharyngotonsillar, laryngotracheal, nasal and cutaneous. Diagnosis involves tests like the Schick test or culture. Prevention relies on early detection, treatment, immunization as per national schedules, and isolating cases and carriers. Complications can impact the respiratory, cardiac, neurological and renal systems if not treated promptly.
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Archer NCLEX Endocrine, DM, and Insulin - Live webinar.
Archer Review, a comprehensive reviewer for NCLEX-RN and NCLEX-PN exams, is focused on making quality and comprehensive test prep affordable to every nurse worldwide. Combine these crash courses along with Archer's highly popular NCLEX Qbanks with 2500 Qs that have consistently achieved a 97% pass rate.
This 3-hour Endocrinology, Diabetes, and insulin management crash course is one such webinar to shed light on one of the difficult and frequently tested topics on NCLEX. This is one of the several Archer content review crash courses to strengthen your concepts and face NCLEX more confidently. The idea of this webinar is to:
1. Go over all frequently tested NCLEX concepts in Endocrine disorders - Addison's, Cushing's, Thyroid, SIADH, Hyperparathyroidism, hypoglycemia, Diabetes, and Insulin management.
2. Endocrine diseases labs interpretation, Diabetes types/ concepts, insulin-related issues, diabetic diets, Client education, reduction of risk potential, and nursing interventions.
3. Provide you with challenge quizzes throughout the course after every class of disorders. You may actively participate by entering your answers or asking questions during Q and A sessions. Get your doubts clarified and understand concepts!
COST: just $10
Safety and infection control constitutes 12% of total items on NCLEX as per NCLEX-RN test plan. This webinar will explain all safety issues, isolation precautions frequently tested on NCLEX. Archer focus on SMART-PREP strategy by identifying th highly tested areas, preparing you thoroughly with content review webinars, and repeatedly challenging you with multiple questions from these areas in the Q-bank. Lowest focus is placed on areas that are tested less than 2% times but very high focus placed on areas tested more than 7% time in the test - this SMART-PREP strategy is the reason why Archer NCLEX achieves 99% PASS RATE even for the repeaters.
Slides from a must-know WEBINAR lecture for NCLEX -high-yield review of Dietary concepts and frequently tested nutrition topics with focus on client counseling, dietary advice in select in disease conditions, prioritization, and nursing interventions.
Syllabus for both ON-DEMAND and LIVE sessions - Syllabus - snapshot and detailed. Register at
ON-DEMAND access - 2months : -
https://ppv.audiovideoweb.com/ppvlnk/purchase/add/grp/160590567727448?id=06152009200616T
Live session: https://attendee.gotowebinar.com/register/8591903128354705678
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Slides and handouts from Archer NCLEX Live and OnDemand webinars. These cover extensive NCLEX Highyield concepts topic-wise providing in-depth learning. Combine the content review with NCLEX
Archer NCLEX Webinars offer most comprehensive coverage of highyield concepts that are frequently tested on NCLEX. The goal is to explain you the fundamentals and reinforce your understanding with concurrent quizzing during webinars. Attendance is limited to focus on every single attendee. These slides are snapshots of what will be discussed during ARCHER NCLEX Pharmacology Webinar.
This document provides an overview of thyroid disorders and diagnostic tests. It discusses various thyroid function tests including TSH, free T4, T3, and thyroid antibodies. It describes how to interpret abnormal thyroid function test results and outlines approaches to common thyroid disorders like Graves' disease, subacute thyroiditis, and hypothyroidism. Treatment options for hyperthyroidism such as antithyroid medications, radioiodine therapy, and surgery are also summarized. The document is intended as a brief review of key endocrinology concepts that will be covered in more detail in video lectures.
Archer USMLE Step 3 CCS Workshop - Strategies and Slides. To be used with Archer CCS Video demonstrations/ CCS software practice demonstrations. Learn why CCS is crucial to pass Step 3 exam @ https://archerreview.com/ccs-cases/
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Target Audience: Oncology fellows and Oncologists
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1. Infectious Diseases
Archer online USMLE reviews
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Archer Slides are intended for use with Archer USMLE step 3 video
lectures. Hence, most slides are very brief summaries of the concepts
which will be addressed in a detailed way with focus on High-yield
concepts in the Video lectures.
5. Skin and Soft Tissue
Infections
Impetigo
Cellulitis
Necrotizing Fasciitis
6. Impetigo
Infection of superficial layers of epidermis
Nonbullous impetigo starts as a single erythematous
macule that rapidly evolves into a vesicle or pustule, and
ruptures leaving a crusted yellow exudate over the
erosion.
Bullous impetigo begins as a rapid onset of blisters that
enlarge and rupture. ( cause mostly s.aureus, also
MRSA)
Common bugs : gram +ves - S.aureus and GABHS (
S.pyogenes)
Rx – Topical mupirocin for mild cases, Cephalexin p.o
for severe cases
7. Cellultis
Inflammation of skin and underlying
subcutaneous tissues – can be infectious or non
infectious.
Commonest causes – group A streptococci
(S.pyogenes) and S.aureus
Rx – usually a cephalosporin such a cephalexin
can be used. If allergic to penicillin, use
clindamycin
If MRSA is suspected, use oral drugs for mild/
moderate cellulitis such as Bactrim, Doxycycline,
Clindamycin or quinolone. For severe MRSA
cellulitis, use Vancomycin or Tigecycline IV. If
resistant to Vanco, use Linezolid
8. MRSA – Risk factors
Emperically, treat patients with moderate to severe
cellulitis with risk factors for MRSA infection:
Recent antibiotic use
Recent hospitalization
Hemodialysis
IV drug use
Diabetes
Previous MRSA infection or colonization
9. Recurrent MRSA
In patients with recurrent MRSA soft tissue
infections, consider NASAL CARRIAGE
Culture the nares of patients with recurrent
infection who are suspected of carrying
MRSA.
Treat nasal carriers with mupirocin to the
nares twice a day for 7 days
10. Cellultis from Bites
Pasteurella multocida – etiology in cat bites and
rarely, dog bites. Rx – Amoxicillin/clavulanate.
Tmp/smx in penicillin allergic patient.
Eikenella cordans – human bites. Rx –
Amoxicllin/ clavulanate or Ampicillin/sulbactam.
TMP/SMX plus clindamycin in penicillin-allergic
patient
Capnocytophaga tonsurans – cellulitis,
disseminated infection seen in asplenic patients
after Dog bites ( meningitis, endocarditis, renal
failure).
11. Bites
Risk of wound infection:
2-30% in dog bites
15-50% in cat bites ( since cat bites are more likely
to be puncture wounds, risk of infection is high)
9-50% of human bites
Risk of infection is particularly high in
( high grade wounds):
puncture wounds
hand injuries
full-thickness wounds
wounds involving joints, tendons, ligaments, or
fractures.
12. Bites – Antibiotic Prophylaxis
In case of cat and dog bites, there is no necessity for giving
prophylactic antibiotics if it is a low grade non-infected bite. Cleansing
with sterile/ tap water and debridement are sufficient.
However, remember that cat bite that is a true puncture wound will
need antibiotic prophylaxis as even when they are small they can
cause a deep puncture and carry 50% risk of infection. So, if it is a
minor scrape or nip , there is no necessity for antibiotics but if there is
a puncture, antibiotic should be given. ( Dog bites have less risk of
infection)
If it is a high grade non infected wound, antibiotic prophylaxis should
be given to prevent cellulitis ( i.e; if the wound involves the hands, feet,
cartilaginous structures, or is deeper than the epidermal
layer(puncture).)
Human bites have the highest risk of getting infected. However,
antibiotic prophylaxis is recommended only in high grade wounds.
13. Bites – Wound Closure
Primary closure with sutures
not recommended for non-facial bite wounds, deep
punctures, bites to the hand, clinically infected wounds and
wounds greater than 6 hours old 9 due to high risk of
infection) . Delayed closure is appropriate in this conditions.
Facial wounds may need sutures to prevent scarring and
improve cosmetic outcome. owever, the risk of such closure
is uncertain, but in most cases this is safe if the person has
presented early and the wound has been thoroughly cleaned.
Delayed primary closure (after 3-5 days)
Recommended for bites to the hand, bites with extensive
crush injury, wounds needing a considerable amount of
debridement, and wounds more than 6 hours old.
14. Human Bites – HIV Transmission
HIV transmission has been reported only very rarely
after a human bite.
Exposure to saliva alone is not regarded as a risk factor
for transmission of HIV (or hepatitis). So, CDC does not
recommend routine prophylaxis in human bites.
Transmission risk in human bites is significant when :
If the biter has HIV, his saliva is mixed with his blood and the bite caused a
breach in the skin of the victim.
If the Victim has HIV, the blood drawn from him should come in to contact
with mucous membranes of the biter ( Victim to biter transmission) .
CDC (2005) recommends postexposure prophylaxis with
active antiretroviral therapy (HAART) ( 28 day course)
ONLY in either of the above two scenarios
15. Human Bites – Closed Fist Injury
Closed-fist injuries:
Consult a hand surgeon
Requires exploration under anesthesia for joint
space violation or tendon injury.
Patients with tendon injury or joint space violation
or underlying fractures should be admitted for
inpatient treatment.
Management :
Thorough cleansing and antibiotics. This is a high grade wound.
Antibiotic should be started even when there is no evidence of
infection.
If discharged, close follow up is needed as outpatient.
In a infected closed fist injury, patients should be admitted for IV
antibiotic therapy ( ampicillin/ sulbactam). Surgical debridement is
needed. ( Remember that these infected close fist wounds need
aggressive care because of poor vascular supply to the tendons
and because of the deep nature of this infection.)
16. Tetanus Prophylaxis
Tetanus prone wounds:
Age > 6 hours
Configuration : avulsion, stellate
Depth > 1cm ( puncture wounds)
If devitalized tissue is present
If contaminants ( dirt, saliva i.e; bites) are
present.
17. Tetanus Prophylaxis
If hx of tetanus immunization is unknown or < 3
doses give Td+TIG for a dirty tetanus prone
wound. Td alone for a clean, non tetanus prone
wound.
If hx of Tetanus immunization is present and if
the patient has already received 3 or more
doses no TIG needed. In case of dirty wound,
Give Td only if it is greater than 24 hour old or if
greater than 5 years since last booster ( bites
are dirty). In case of clean wound, give Td
booster if greater than 10 years since last
booster.
18. Rabies Post-Exposure Prophylaxis
All wounds must be thoroughly cleansed with soap and
water.
In case of Dogs and cats if the animal is healthy and
available for 10 day observation, do not start prophylaxis
until animal develops symptoms. If animal develops
symps, start HRIG+HDCV ( if patient is not previously
vaccinated). If pt is previously vaccinated, give HDCV
alone ( don’t give HRIG)
If animal is known rabid or suspected rabid, immediate
vaccination.
If animal is a skunk, bat or a fox considered as rabid
always! Immediate vaccination eg: even if the bat was
found flying in the room
19. Necrotizing Fascitis
- Infection of the fascial planes resulting in the death of the affected tissues.
- Skin color – blue-black (Black necrotic eschar may be seen at the borders
of the affected areas). Crepitance at the site, Fever, malaise and
leukocytosis can be seen
- Common bugs – Group A strep, S.aureus, C.Perfringens Rx – Aggressive
debridement + Clindamycin.
- Rare causes – Vibrio vulnificus ( clue : necrotizing fasciitis after immersion
in warm salt water) Rx - Tetracycline
- Diagnosis – mainly clinical, however in early cases CT may be obtained.
Finding of gas or inflammatory stranding on CT is very suspicious of
necrotizing fasciitis.
Differentiate simple cellulitis from skin changes associated with a deeper
infection, such as necrotizing fasciitis or gas gangrene, in patients with:
A rapid increase in lesion size
Evolution of bullous lesions
Reddish-purple coloring of the skin
Systemic toxicity (Hypotension, altered mental status)
Pain out of proportion to the clinical findings (extreme local tenderness)
20. Toxic Shock Syndrome
Caused by an exotoxin that acts as a
superantigen
Fever, Nausea, vomiting, diarrhea, Shock and
Skin rash characterized by exfoliation.
The initial lesion might be cellulitis or necrotizing
fasciitis
Causes : S.aureus, Group A Streptococci
Rx – shock appropriately
Drug of choice : clindamycin as it blocks toxin
production.
21. Ecthyma Gangrenosum
Caused by P.aeruginosa/ can be associated
with pseudomonas septicemia ( obtain blood
cultures and local cultures).
Usually affects critically ill and
immunocompromised hosts – AIDS, Steroid use,
Cancer, Chemotherapy.
Characteristic lesions hemorrhagic pustules
or infracted-appearing areas with surrounding
erythema that evolve into necrotic ulcers
surrounded by erythema
Rx with antipseudomonal antibiotic
25. Clinical Stages
Primary Syphilis : a solitary, painless chancre that develops at the site of
infection three weeks after exposure Screen with Dark Field microscopy of skin
lesion.
Secondary Syphilis: Without treatment, blood-borne spread of T. pallidum over
the next several weeks to months results in secondary syphilis c/f are fever,
lymphadenopathy, diffuse rash ( including palms and soles) , and genital or
perineal condyloma latum If lesions present Screen with dark filed
microscopy. If no lesion, screen with Non Treponemal tests and confirm with
Treponemal Specific tests
Latent syphilis : Skin lesions resolve, and patients are asymptomatic. However,
serologic tests are positive for T. pallidum. Diagnosis – Screen with Non
Treponemal and confirm with Treponemal Specific tests
Tertiary or late syphilis: develops years after the initial infection and can involve
any organ system. Complications are neurosyphilis and Aortic Aneurysms).
Diagnosis – Screen with Treponemal Specific tests.
Neurosyphilis: A type of late syphilis. ( TABES DORSALIS) Seizures, ataxia,
aphasia, paresis, hyperreflexia, personality changes, cognitive disturbance,
visual changes, hearing loss, neuropathy ( Vibration/ Position lost) , loss of bowel
or bladder function. Dx is by CSF examination.
28. What is the next step in diagnosis ?
A. VDRL
B. RPR
C. FTABS
D. Cultures
E. Dark field
microscopy of the
scraping
ANS. ???
29. Dark Field microscopy
Most specific technique for diagnosing syphilis
when an active chancre or condyloma latum is
present ( Lesion must be present – so usually
good for primary/ secondary syphilis if lesion is
present)
T. pallidum is identified by its characteristic
corkscrew appearance its accuracy depends
on operator experience, number of treponemes
in the lesion and the presence of non-
pathological treponemes in oral/ anal lesions.
Given the difficulties of dark-field microscopy,
negative examinations on three different days
are necessary before a lesion is considered
negative for T. pallidum.
30. Non Treponemal Tests VDRL, RPR
Principle: Syphilitic infection leads to the production of nonspecific
antibodies that react to cardiolipin the basis of traditional non-
treponemal tests such as the VDRL test and rapid plasma reagin test.
Mainly used as screening tests Sensitivity, however, is very low in Early
Primary syphilis and during late syphilis during these periods, 1/3 of pts
may be non reactive. So, if suspicion is very high despite a negative
screening test, go ahead with treponemal specific test ( FTA-Abs)
False Positives are common in pregnancy, autoimmune diseases and
infections
False negative reactions can occur too : large amounts of antibody block
the antibody-antigen reaction, causing a false-negative test in the undiluted
sample ( Prozone phenomenon – similar to hook effect)
Use in Monitoring treatment adequacy : In many cases nontreponemal tests
become nonreactive after adequate syphilis treatment – so, use VDRL/ RPR
for follow-up after treatment. However, remember that even with sufficient
treatment, patients sometimes have a persistent low-level positive
nontreponemal test (referred to as a serofast reaction). However, this drop
in titers can help in follow up
Remember Titers are not interchangeable between different test types.
Hence, the same nontreponemal test should be used for follow-up
evaluations.( If used RPR for screening, use the same for follow up)
31. Treponemal Tests
Treponemal-specific tests detect antibodies to antigenic
components of T. pallidum.
Used primarily to confirm the diagnosis of syphilis in patients with
a reactive nontreponemal test. ( So, if you have a positive RPR, the
next step is FTA-Abs or TPHA)
Treponemal-specific tests : EIA for anti-treponemal IgG, the T.
pallidum hemagglutination (TPHA) test, the microhemagglutination
test with T. pallidum antigen, the fluorescent treponemal antibody-
absorption test (FTA-abs), and the enzyme-linked immunosorbent
assay.
Treponemal tests have sensitivities and specificities equal to or
higher than those for nontreponemal tests. However, treponemal-
specific tests are more difficult and expensive to perform, which
limits their usefulness as screening tests.
False-positive results can occur, especially when the FTA-abs test
is used in patients with systemic lupus erythematosus or Lyme
disease.
32. Treponemal Tests
Can they be used for follow-up?
Unlike nontreponemal tests, which
show a decline in titers or become
nonreactive with effective treatment,
treponemal-specific tests usually
remain reactive for life Therefore,
treponemal-specific test titers are not
useful for assessing treatment efficacy.
33. Genital Lesions – Differential Diagnosis
Disorder or disease Characteristics of genital lesion Etiology
Primary syphilis: chancre Solitary, painless ulcer with indurated
border
Treponema
pallidum
Secondary syphilis:
condyloma latum
Slightly raised or flat, round or oval
papules covered by gray exudate
T. pallidum
Genital herpes Cluster of shallow, small, painful ulcers
on a red base
Herpes
simplex
virus
Chancroid Painful ulcers with sharp, undermined
borders + tender lymphadenopathy
Haemophilu
s
ducreyi
Venereal warts Soft, usually painless skin-colored or
red papules
Human
papillom
avirus
Lymphogranuloma
venereum: primary
stage
Painless papule, shallow erosion, or
ulcer; may be multiple or single
( Bubos or unilateral massive inguinal
nodes will be helpful in
differentiating it from syphilitic
Chlamydia
trachom
atis
34. Treatment
Primary Syphilis : Diagnosed by dark-field microscopy of a
suspected lesion or by serologic testing. Either technique can
have a false-negative result early in the course of the disease.
Thus, if clinical suspicion is high, treatment for syphilis should
be initiated.
Clinical Manifestation : Chancre
Treatment: -Penicillin G benzathine, 2.4 million units IM (single
dose)
Alternatives in nonpregnant patients with penicillin allergy:
doxycycline (Vibramycin), 100 mg orally twice daily for 2 weeks
or tetracycline, 500 mg orally four times daily for 2 weeks.
ceftriaxone (Rocephin), 1 g once daily IM/IV for 10 days; or
azithromycin (Zithromax), 2 g orally (single dose)
Follow-up : At six and 12 months after treatment, reexamine
and repeat serologic testing. Treatment failure is defined as
recurrent or persistent symptoms or a sustained fourfold
increase in nontreponemal test titers despite appropriate
treatment.
Patients with treatment failure should be tested for HIV
infection and evaluated for neurosyphilis with a cerebrospinal
fluid (CSF) examination.
35. Treatment
Secondary Syphilis : The diagnosis of
secondary syphilis is confirmed by
nontreponemal and treponemal-specific
tests.
Treatment employs the same antibiotic
regimens used for primary syphilis. Follow-
up is the same as that for primary syphilis.
Definition of treatment failure is the same.
36. Treatment
Latent Syphilis : early/ late Latent
CNS involvement may be asymptomatic. Therefore, the
possibility of neurosyphilis should be considered in patients
with early or late latent syphilis.
Early latent syphilis Rx the same way as primary and secondary
syphilis.
Late latent syphilis RX with 2.4 million units of penicillin G
benzathine IM once a week for three weeks. Alternative regimens
in nonpregnant patients with penicillin allergy include
doxycycline 100 mg po twice daily for four weeks, or tetracycline
500 mg po four times daily for four weeks.
Follow- up: After treatment of early or late latent syphilis,
quantitative nontreponemal titers should be measured at six, 12,
and 24 months.
Neurosyphilis should be strongly considered in patients who
show a fourfold increase in titers, patients who have an initially
high titer (1:32 or greater) that fails to decline at least fourfold,
patients who have HIV infection, and patients who develop signs
or symptoms of neurosyphilis.
37. NeuroSyphilis
Occurs in up to 10% of patients with untreated syphilis.
Neurosyphilis consider in patients with signs or symptoms of neurologic
involvement at any stage of T. pallidum infection and in all patients with late
latent or tertiary syphilis, although asymptomatic neurosyphilis is the most
common presentation.
Neurologic involvement strongly suspect and evaluate in patients who
previously have been treated for neurosyphilis, patients who have not responded
to treatment for primary, secondary, or latent syphilis, and patients who have HIV
infection/ other immunocompromised states. in pts with HIV, newly diagnosed
of Syphilis, next step is always LUMBAR PUNCTURE TO R/O NEUROSYPHILIS
Diagnosis : Lumbar puncture. CSF should be tested for white blood cell count
and protein level, and for reactivity on a VDRL test Although a positive CSF
VDRL test result is specific for neurosyphilis, a negative result does not exclude
the possibility of this infection, because sensitivity is less than 100 percent. A
CSF white blood cell count greater than 10 per mm3 (10 3 106 per L) or a CSF
protein level greater than 50 mg per dL (0.50 g per L) indicates possible
neurosyphilis.
Treponemal-specific testing (e.g., TPHA) has high negative-predictive value is
helpful only when the result is negative (i.e., it rules out neurosyphilis). Because
IgG can cross the blood-brain barrier, a positive test may falsely imply CNS
involvement. ( so not used for diagnosis)
38. Neurosyphilis
C/F : seizures, ataxia, aphasia, paresis, hyperreflexia,
personality and cognitive changes, visual changes, hearing
loss, neuropathy, and loss of bowel and bladder functions.
Penicillin is the only drug that has proved effective in the
treatment of neurosyphilis. If pen-allergic , desensitize and
treat.
Follow-up : following treatment, follow-up depends on the
initial CSF findings. If pleocytosis was present, the CSF should
be reexamined every six months until the white blood cell
count is normal. Retreatment should be considered if the CSF
white blood cell count does not decline after six months or
completely normalize after two years.
The CSF also can be reexamined to look for serial decreases in
antibodies on the VDRL test or serial decreases in protein
levels. It is expected that CSF parameters will normalize within
two years. Failure to normalize may warrant retreatment. Most
treatment failures occur in immunocompromised patients
39.
40. Genital Herpes
A recurrent, lifelong disease with no cure
Two types of HSV (i.e., HSV-1 and HSV-2) are
distinguished by antigenic differences in their envelope
proteins HSV-1 normally is associated with oral
infections and HSV-2 with genital infections, but either
type can infect a person anywhere on the skin.
41. Risk Factors for Genital HSV
Advent of sexual activity at or before 17
years of age
History of sexually transmitted diseases
History of undiagnosed genital lesions or
discharge
Human immunodeficiency virus infection
Multiple sex partners
Multiple lifetime sex partners strongest
predictor for genital Herpes
Partner diagnosed with genital HSV infection
42. Clinical Features
Prodrome: lasts 2-24 hrs characterized by localized or regional pain,
tingling, and burning may have constitutional symptoms such as headache,
fever, inguinal lymphadenopathy, anorexia, and malaise.
As the disease progresses, papules, vesicles on an erythematous base, and
erosions appear over hours to days.
Patterns of HSV-1 and HSV-2 infection appear identical: vesicles usually are
uniform in size, and the tense center umbilicates to form a depressed center.
These lesions usually crust and then re-epithelialize and heal without scarring.
In women, ulcers can occur on the introitus, urethral meatus, labia, and
perineum. In men, ulcers often appear on the shaft or glans of the penis. In
both men and women, lesions may appear on the perianal area, thighs, or
buttocks.
Recurrent HSV outbreaks usually are milder than the initial episode: there
typically are fewer grouped lesions and viral shedding occurs at a lower
concentration and for a shorter duration (i.e. about 3 days).
Recurrence rates for HSV-2 vary greatly, but the median is four recurrences
per year.
Patients who experience more severe primary infections (i.e., lasting 35 days
or more) have recurrent episodes twice as often.
Recurrences are spontaneous, but various factors such as fever; nerve or
tissue damage; physical or emotional stress; exposure to heat, cold, and
ultraviolet light; immunosuppression; menses; concurrent infection; fatigue;
and sexual intercourse have been associated with recurrences
43. Prevention
Most genital herpes is spread asymptomatically In the U.S., 22% of persons age
14 years or older are infected with HSV-2, and almost 90% do not know they are
infected Most transmission occurs from persons who have no recognized lesions
and who do not know they are infected
As many as one third of new genital herpes cases may be caused by HSV-1, which
is usually transmitted by oral sex; however, only 5% to 10% of recurrent genital
herpes is due to HSV-1 infection
The use of condoms has been shown to reduce transmission rates of HSV-2
significantly in susceptible women but not in men.
Using condoms during 25 percent or more instances of sexual intercourse was
associated with reduced rates of HSV transmission, which suggests that even
occasional condom use can protect women from acquisition of HSV-2.
To be effective, the condom must completely cover lesions on an infected man.
Inform patients that asymptomatic shedding is common and that condoms should be
used routinely, even when no lesions are recognized
44. Diagnosis
Clinical exam/ high risk history
Swab test : swab from HSV lesions taken for culture or PCR
1. Viral Culture : Not very sensitive but it is the preferred method for identifying HSV infection,
when pts present with lesions. Also, very helpful in differentiating HSV-1 from HSV-2
2.POLYMERASE CHAIN REACTION TESTING for HSV DNA : greater sensitivity than the
traditional viral culture (sensitivity > 95%, compared with 75% for culture) High cost is
its limitation hence, used only for the diagnosis of HSV encephalitis because the
results are more rapid than viral culture
3. SEROLOGIC TESTING
HSV antibodies form during the first several weeks after infection and remain
indefinitely.
Fifty to 90 percent of adults have antibodies to HSV, but only about 30 percent have
antibodies specific to HSV-2.
Type-specific serologic assays can be used to confirm HSV infection in persons with a
questionable history or in those who have unrecognized or subclinical infections.
Serologic testing also is helpful in the presence of a false-negative culture, which is
common in patients with recurrent infection or healing lesions. Because HSV-2 infection
is almost exclusively sexually acquired, HSV-2 antibodies are consistent with an
anogenital infection. However, HSV-1 antibodies may be present in anogenital and
orolabial infections; they cannot be used to differentiate between infections.
If HSV antibodies are present, testing for other causes of genital ulcers (e.g., syphilis,
chancroid) should be considered, especially in high-risk populations..
45. Screening
Consider offering type-specific serologic testing for HSV-
2 to:
Persons with undiagnosed past or present genital symptoms or
lesions, especially if recurrent
Patients who have a current or past partner with genital herpes
Patients who have been diagnosed by clinical exam only and
want confirmation of their diagnosis or typing of their infection
Patients requesting a full STD screen
Persons who are HIV positive
Be aware that the false-positive rate can be high in
populations with a low prevalence of infection;
confirmation of the initial serology with another assay
can be used to increase the specificity.
Universal screening for HSV antibodies is not
recommended
46. Management Hospitalization is indicated for patients with genital
Herpes if they also have
Symptoms of meningitis: Severe headache, Stiff neck,
Photophobia
Symptoms of autonomic nervous system dysfunction:
Urinary retention, Constipation , Dysesthesias of the
perineal, sacral, or lower back regions
Symptoms of transverse myelitis: Leg weakness ,
Decreased deep tendon reflexes , Autonomic nervous
system dysfunction
If meningitis is suspected, send CSF for PCR to detect
HSV DNA.
Next step: Begin therapy with intravenous acyclovir, 5 to
10 mg/kg every 8 hours. ( do not wait for PCR results
to come back if pt has genital lesions suspicious of
HSV and has above indications for aggressive
therapy)
When symptoms improve, switch to oral therapy for a
total of 10 to 14 days of treatment
47. Treatment
FIRST CLINICAL EPISODE must be treated with anti HSV
agents ( Acyclovir/ Famciclovir/ valacyclovir) as soon as
possible. Studies have shown prompt Rx for initial episode
reduced constitutional symptoms by three days, local pain by
two days, viral shedding by seven days, time until all lesions
were crusted by three days, and time until all lesions were
healed by six days. Counsel patients about the high
frequency of recurrences, the inevitability of asymptomatic
shedding, and the risk of transmission even after initial therapy.
48. Rx – Recurrent herpes
Recurrences :
For mild, infrequent recurrences Episodic therapy is the best. To be efective, it is
very important that treatment is started early during prodromal phase or within 1 day of
lesion onset. So, counsel pts to recognize the recurrences early and self-initiate the
treatment ASAP. Provide prescriptions in advance.
The goal of episodic therapy is to reduce symptoms and to reduce infectivity during the
episodes. This therapy does not prevent future recurrences or asymptomatic shedding
between the episodes.
Topical Acyclovir is not effective.
For Frequent recurrences six or more episodes per year START LONG TERM
SUPPRESSIVE THERAPY ( ACYCLOVIR/ FAMACYCLOVIR/ VALACYCLOVIR)
Inform patients that continuous suppressive therapy decreases, but does not
eliminate, transmission:
Instruct patients taking suppressive therapy to continue to use
condoms, although they are only 50% effective in reducing
transmission
Explain to patients that treatment is not curative and will not affect the
severity or frequency of recurrences when stopped
Inform patients that long-term, continuous treatment is safe and does
not require laboratory-test monitoring
49. Treatment
Immunocompromised pts : Genital herpes
Rx in HIV pts is similar to that without HIV
But recognize that immunosuppressed patients
often develop extensive genital lesions that may
not respond to routine courses of antiviral therapy
So, be sure to treat aggressively and early.
Treat early lesions that are not extensive with
usual doses of oral medications If no
improvement occurs, or if initial involvement is
extensive, try higher doses of oral medications.
If still not responding Treat with high-dose
intravenous acyclovir or foscarnet, or topical
trifluridine, foscarnet, or cidofovir; note that
prolonged treatment may be required.
50. Preventing Mother-Infant Transmission
Advise pregnant women to avoid acquiring genital herpes infection,
especially late in pregnancy, in order to prevent exposing the infant to
herpetic lesions during birth:
In general, recommend abstinence or only protected coital activity in
late pregnancy (week 34 onward)
Advise patients that both HSV-1 and HSV-2 can cause neonatal herpes
Inform women that if they acquire HSV 1 or 2 during the third trimester,
there is a 30% to 50% chance of transmitting HSV to their neonate
Ask pregnant women regarding h/o genita or orolabial herpes. However,
remember 90% of those infected with HSV would deny a history of
genital herpes, making history taking of limited value
Advise pregnant women with no history of orolabial herpes or genital
HSV-1 infection to avoid vaginal intercourse with a partner who has or
may have genital HSV-1 infection and to avoid cunnilingus in the third
trimester with partners who may have orolabial herpes, even if no
lesions are present at the time of sexual contact
Inform women who do experience their first episode of genital herpes
late in pregnancy that:
They are at high risk of perinatal transmission
Mother and child should be managed by a specialist
Cesarean section is generally recommended
Acyclovir treatment should usually be given
Exposed infants often are monitored with surveillance cultures
and treated with acyclovir
51. Preventing Mother-Infant Transmission
Identify women who are at risk for reactivation of HSV-2 at time of delivery:
Consider type-specific antibody testing for some pregnant women (or
women who plan to become pregnant) and their partners to determine
the risk of acquiring HSV-1 or HSV-2, but do not obtain periodic viral
cultures from pregnant patients with a history of recurrent genital herpes
if no lesions are present
Inform women with a history of recurrent genital herpes that they have a
low risk (<1%) for perinatal transmission:
If during labor they have no symptoms of genital herpes or its
prodrome and if a careful clinical examination shows no genital
lesions in the entire area innervated by the sacral ganglia, they
may deliver vaginally
If herpetic lesions are present, cesarean section is usually
recommended
Culture lesions during pregnancy, especially those present during labor,
to determine whether they contain herpes virus
Administer intravenous acyclovir to all pregnant women with severe HSV
infection or disseminated infection, pneumonitis, hepatitis, or CNS infection.
Give oral acyclovir to pregnant women with an uncomplicated first episode
of genital herpes or severe recurrences of genital herpes.
Consider suppressive antiviral therapy (acyclovir, 400 mg tid or
valacyclovir, 500 mg bid) beginning at 36 weeks' gestation for women
with first-episode genital herpes during pregnancy and for pregnant
women with frequent recurrent episodes.
53. Prevention
Most commonly acquired STD, affecting 50% to 75% of sexually
active men and women.
Abstinence is the most effective strategy to prevent HPV
infection. Maintain monogamy. Condoms do not
efficiently protect against HPV.
HPV can spread by skin-skin contact without exchange
of body fluids.
Treating HPV-related genital warts MAY reduce
infectivity but will not eliminate it.
Counsel pregnant women with HPV infection about the
risk of peripartum transmission of HPV infection, pointing
out that:
Infection with HPV types 6 and 11 can result in
respiratory papillomatosis in infants and children
The role of cesarean section in reducing
peripartum transmission of HPV is unknown
SO, NOT RECOMMENDED
54. Screening
Screening modalities
Papanicolaou test (Pap)
Liquid-based cytology
For women > 30 years of age, combined cytology (either Pap or
liquid-based) and HPV DNA testing.
Start to Screen ( pap smear) for HPV-related cervical lesions (e.g., cervical
cancer, LSIL, HSIL) in sexually active women 3 years after onset of sexual
intercourse or at the age of 21, whichever is earlier.
HIV associated with increased risk of cervical cancer/ dysplasia Perform
cervical cytology screening in HIV-seropositive women twice in the first
year after HIV diagnosis, then annually if the results are normal.
Perform cervical cytology screening in women under age 30 on an annual
basis.
If three consecutive cytologies are normal , consider increasing the
interval between cervical cytology screening in women > 30 years of age
without a history of either CIN-2 or CIN-3, immune compromise, HIV
infection, or in utero exposure to diethylstilbestrol to every 2 to 3 years.
Consider HPV DNA testing in addition to cervical cytology screening in
women < 30 years of age.
Do not screen women who are negative by both HPV DNA testing and
cytology before 3 years.
Repeat HPV DNA testing and cervical cytology testing at 6 to 12 months in
women whose results are negative by cytology but who are high-risk HPV
DNA positive.
55. Stop Screening!
Discontinue routine cervical cytology
screening (pap) in women who have had a
hysterectomy for benign disease.
Consider discontinuing routine cervical
cytology screening in women at age 65 or 70
who have had adequate recent cervical
cytology screening and have no other risk
factors for cervical cancer.
56. Diagnosis
History, physical exam
the morphologic characteristics of cutaneous or
genital warts.
Hx of smoking – increases risk of cervcal ca
Symptoms – Pruritis, burning, vaginal bleeding/
post coital bleeding.
Consider differential diagnosis:
Benign lesions mimicking warts : Pearly penile papules (
surrounding corona) , Achrocordon ( skin tag), Vulvar
lymphangiomata, Vestibular papillae in females and
sebaceous glands
Other infectious etiologies : molluscum contagiosum (
immunocompromised pts), HSV, condyloma lata.
Malignancies : Squamous cell ca, Bowens disease,
malignant melanoma
58. Ans. Vestibular Papillae
•For more pictures on benign lesions mimicking warts, please refer Dermatology
Slides.
• Vestibular Papillae are common benign lesions that are often mistaken as genital
warts and cause unnecessary concern to the patients. So, questions like these are
often high yield on the USMLE.
• Vestibular papillae are flesh-colored, soft pearly papules found on the inner aspects
of labia minora. They are usually symmetrically distributed on either side of the
vulva and can be easily separated from each other on examination.
•On the other hand, genital warts are not confined to the vestibule. The cauliflower
or filiform projections of genital warts tend to fuse at the base and cannot be
seperated easily.
• Acetic acid test : When 5% acetic acid is applied to condyloma acuminatum, a
whitening occurs. There is usually no whitening with Vestibular papillae.
•Vestibular papillomatosis is a normal vulvar anatomical condition. It is a female
counterpart of male pearly penile papules. A correct diagnosis is important and
prevents unnecessary stress to the patient.
59. Diagnosis
Biopsy not routinely done. Consider it for
excluding intraepithelial lesions/ cancer/
dysplasia in:
Atypical appearing lesions
Vaginal/ Cervical warts
Uncertain diagnosis
Progression of disease during treatment
Frequent recurrence
Warts that are pigmented, indurated, ulcerated, or
fixed to underlying tissue
Warts >1 cm
Suspected neoplasia (e.g., blue or black
discoloration)
Occurrence in immunocompromised patients
60. Treatment Options – Drug therapy
Mechanisms of action – drug therapy
Patient-applied therapies include podophyllotoxin and imiquimod
Provider-applied therapies include podophyllin resin and TCA
Imiquimod (Aldara) : Cell-mediated immune response modifier;
induces interferon production
Interferon: Antiviral, antiproliferative, and immunomodulatory
activity
Podofilox (Condylox)solution or gel : Cytotoxic, antimitotic; major
biologically active component of podophyllin resin
Podophyllin resin: Cytotoxic, antimitotic (causes tissue necrosis)
Trichloroacetic acid : Protein coagulation of wart tissue
Surgical therapy
Cryotherapy: Destruction by thermal-induced cytolysis
Excision
Electrosurgery
Laser surgery
RECURRENCES ARE COMMON EVEN AFTER SURGERY OR DRUG
THERAPY
61. Treatment
The choice of therapy is based on the
number, size, site, and morphology of
lesions, as well as patient preference,
treatment cost, convenience, adverse
effects, and provider experience.
Consider gynecology consult in pts with
cervical/ vaginal warts – r/o CIN/ cancer
63. Treatment in Pregnancy
TCA has been used in pregnant patients without adverse effects.
Podophyllin, podofilox, and fluorouracil should not be used in
pregnant patients because of possible teratogenicity.
Imiquimod is not approved for use in pregnant women, although
treatment with this agent can be considered after informed consent
has been obtained.
Surgical excision, cryotherapy, and electrocautery are appropriate
treatment options during pregnancy if treatment is necessary.
The goal of treatment in pregnant women primarily is to minimize
neonatal exposure to the virus by reducing the number of lesions
present during delivery. Anogenital warts and laryngeal
papillomatosis are potential complications in infected children. (
children born to mother with anogenital warts)
66. Screening
Test all pregnant women for gonorrhea at the first prenatal
visit if they are at risk for acquisition (defined as report of
new or multiple sex partners) or if they live in an area with
high prevalence.
Screen for gonorrhea and chlamydia in all patients by the
third trimester
Screen young women (under age 25) at risk for STD
acquisition if they are seeking care in a clinic with high
gonorrhea prevalence
Screen men who have sex with men on an annual basis or
more frequently depending on risk behavior.
Use any approved test, including culture, nucleic acid probe
( cervical probe for N.gonorrheae) , and nucleic acid
amplification methods, for screening
67. Clinical Features - Men
Suspect gonorrhea as a likely cause of urethritis in a man with purulent or
mucopurulent urethral discharge.
Could be a possible infectious cause of epididymitis, particularly in sexually
active men under age 35. ( In older men, likely cause is E.coli)
A possible cause of proctitis (esply among men who have sex with men).
Recognize that pharyngeal infection with N. gonorrhoeae is usually
asymptomatic but occasionally causes mild sore or “scratchy” throat.
Consider gonorrhea in the differential diagnosis of conjunctivitis, especially
if it is associated with copious, purulent conjunctival discharge.
Disseminated Gonococcal infection can occur in men and, if considered,
should prompt examination of mid- to large-sized joints and major tendon
sheaths and their insertions for tenderness and inflammation.
Be aware that N. gonorrhoeae is an unusual cause of endocarditis and
meningitis
68. Clinical Features - Women
Consider gonorrhea as a cause of mucopurulent cervicitis (defined by the
presence of mucopurulent discharge or easily induced endocervical
bleeding) or PID.
Be aware that while N. gonorrhoeae is a major cause of mucopurulent
cervicitis (along with C. trachomatis), infection of the cervix most frequently
causes neither signs nor symptoms.
Evaluate sexually active women with mucopurulent cervicitis or a
laboratory-confirmed diagnosis of gonorrhea for the presence of PID.
( pelvic exam discharge, cervical motion tenderness, adnexal
tenderness; fever; elevated ESR/ CRP – aid in diagnosis maintain high
index of suspicion for PID and treat in view of high incidence of infertility
and morbidity)
Consider gonorrhea as a possible cause of proctitis in women who have
been exposed through receptive anal sex.
Recognize that pharyngeal infection with N. gonorrhoeae is usually
asymptomatic but occasionally causes mild sore or “scratchy” throat.
DGI occurs more commonly in women than in men
69. Diagnosis – Best tests
In men with urethral discharge perform a Gram stain
smear of urethral secretions.
In women with mucopurulent cervicitis or PID obtain
DNA Probe or nucleic acid amplification of discharge and
urine ( not gram stain)
Obtain urine for nucleic acid amplification tests at least 1
hour after last void, and be sure that it contains the initial
15 to 20 mL of the urine stream (“first catch”).
Proctitis or Pharyngitis get cultures ( not gram
stain)
If DGI (rash, arthritis) is suspected, obtain blood cultures
and also cultures from mucosal sites exposed during
sex (e.g., cervix, urethra, oropharynx, and rectum), even
if no signs or symptoms are evident at these sites.
70. Diagnosis
In sexually active patients with acute,
monoarticular, nontraumatic arthritis, perform
bacterial culture and Gram stain of aspirate from
affected joints.
N. gonorrhoeae is a rare cause of bacterial
meningitis; the overwhelming majority of
meningitis cases presenting with gram-negative
intracellular diplococci in the cerebrospinal fluid
are due to N. meningitidis.
71. Diagnosis
Test for other common STDs
Chlamydia
HIV
Syphilis
When gonorrhea is suspected in the setting of urethritis, cervicitis, or
proctitis, also consider infection with C. trachomatis, which can
cause presentations identical to gonorrhea.
In men whose urethritis does not respond to antibiotic treatment for
gonorrhea and chlamydia, consider less common causes of
urethritis, including T. vaginalis.
Among women with pelvic pain, also consider noninfectious
etiologies, including ovarian cyst, ectopic pregnancy, endometriosis,
ovulation, and gastrointestinal causes
In case of DGI, D/D includes other causes of acute, nontraumatic,
oligoarticular arthritis in young adults, including Reiter's syndrome,
Lyme disease, and various viral infections.
72. Hospitalization
Indicated only if
Patients with DGI if they are moderately severely or
severely ill (including temperature >38.0°C [100.4°F] or
inability to take oral antibiotics).
All patients with documented or suspected gonococcal
endocarditis or meningitis
Hospitalize women with PID in any of the following
circumstances:
If surgical emergencies, such as appendicitis, cannot be
excluded
Pregnancy
Failure to respond to previously administered oral or
outpatient parenteral antibiotics
Inability to take oral therapy ( VOMITING/ NAUSEA)
Severe illness (nausea and vomiting, high fever, hemodynamic
instability)
Presence of tubo-ovarian abscess
IMMUNOCOMPROMISED STATES
73. Treatment
Quinolones are no longer recommended for Rx
of gonorrhea in the USA due to increasing
resistance.
Treat patients with gonococcal cervicitis for
chlamydial infection as well, even if laboratory
confirmation of the latter is not obtained ( vice
versa is not needed)
In sexually active men under age 35, treat
epididymitis empirically with an antibiotic
regimen active against both N. gonorrhoeae and
C. trachomatis Ceftriaxone + doxycycline
Always treat sexual partners.
74. Treatment – uncomplicated gonorrhea
For uncomplicated cervicitis due to gonorrhea :
Ceftriaxone 125 mg IM. Also effective for rectal
gonorrhea.(proctitis)
For endometritis/ uncomplicated PID Ceftriaxone 250
mg IM.
Cefixime Oral single dose Rx for uncomplicated
gonorrhea ( 400mg single dose)
For gonococcal pharyngitis use 1gm single dose
ceftriaxone cure rates for pharyngeal gonorrhea
lesser when compared to other sites
Provide concomitant Rx to chlamydia Doxycycline
100mg po bid x 7 days is first line Rx in non pregnant pts
or alternative is Azythromycin 1gm single dose ( also
preferred in pregnant pts). Also, Amoxicillin 500 po tid x
7 days alternative Rx for Chlamydia in Pregnancy
75. Treatment – Uncomplicated Gonorrhea
Penicillin Allergic Patients : due to cross
reactivity with cephalosporins, use
spectinomycin therapy as a choice.
Alternatively, use Azithromycin 2gm po dose in
penicillin allergy pts ( double the dose required
for chlamydia)
Neonates : Treat all newborns prophylactically
for gonococcal conjunctivitis with topical silver
nitrate solution, tetracycline ointment, or
erythromycin ointment.
76. Treatment - DGI
For Disseminated Gonococcal infection
Hospitalize the patient
Obtain blood, cervical and pharyngeal cultures
Start IV therapy with Ceftriaxone 1gm/d until
clinical improvement occurs and then switch to oral
antibiotics to complete total 7 days of Therapy
Oral choices : Cefixime 400/d, cefpodoxime 400
bid
77. COUNSEL
Counsel persons with gonorrhea to
abstain from sexual contact for at least 1
week after treatment and until all sex
partners have been treated
OTHERWISE, RE-INFECTION CAN
OCCUR!
79. Acute Retroviral Syndrome
Occurs within 4 to 28 days after infection corresponding
to exponential increase in HIV viral load. Occurs in 50-
90% of patients
Diagnosis often missed due to confusion with other
illnesses
Most common complaints : low grade fever, headache
and malaise. Symptoms last 1-4 weeks and involves
lymphadenopathy, anorexia, weightloss and a
maculopapular rash that may extend to palms and soles.
Pharyngeal erythema, oral ulcerations and oro-
pharyngeal candidiasis are common.
Severe cases include meningo-encephalitis, neuropathy,
radiculopathy and Guillianne-barre syndrome
A similar type illness can occur in 5% pts who
discontinued HAART owing to exponential increase in
HIV viral load
80. Acute Retroviral Syndrome
D/D :
Infectious mononucleosis ( EBV/ CMV)
Secondary syphilis
Acute early hepatitis B or A
Influenza
Acute Toxoplasmosis
Roseola
Acute HSV infection
Still disease
Diagnosis : one of the two criteria sets below
1. symptoms consistent with Acute retroviral syndrome + Negative HIV ELISA in past
6 months + Positive HIV ELISA at current testing (or)
2. symptoms consistent with Acute retroviral syndrome + Negative HIV ELISA at
current testing + High HIV RNA titer at current testing ( usually > 100,000 copies/
ml)
Once Acute Retroviral syndrome is diagnosed screen pt for
Syphilis, chlamydia, gonorrhea, HSV and HPV.
Baseline Genotype testing recommended to r/o resistant mutations,
regardless of whether or not you are starting PT on HAART
As per current guidelines, HAART is optional in Rx of Acute
retroviral illness
81. When to start HAART?
When to start depends on symptoms, CD4
counts, and to a lesser extent, viral load. Current
(March 2004) North American guidelines state
that treatment should be:
Considered at CD4 counts below 350 cells/mm3,
Definitely started before CD4 counts fall below 200,
and
definitely started if there are serious symptoms or
AIDS-related illnesses irrespective of CD4 count
Also consider HAART if viral load > 50,000 by RT
PCR
82. Question
A 27-year-old man with HIV presents to your clinic to establish
care. He believes he acquired his infection from a blood
transfusion he received in sub-Saharan Africa while serving in
the Peace Corps 3 years ago. He is currently asymptomatic and
has a strong social support network. His examination is
unremarkable. During the clinic visit, he asks about starting
medical therapy for his HIV. His CD4+ T cell count is 450/mm3,
and his HIV RNA level is 20,000 copies/ml.
Which of the following is an indication to initiate HAART?
1. CD4+ T cell count of less than 500/mm3
2. HIV RNA level of 50,000 copies/ml and a normal CD4+ T cell
count
3. Oral thrush
4. HIV RNA level of 75,000 copies/ml and CD4+ T cell percentage of
28%
84. Prophylaxis in HIV
Prophylaxis against Pneumocystis jiroveci (PCP) when CD4 count is
<200 cells/µL with trimethoprim/sulfamethoxazole, one double-
strength tablet daily or every other day. In pts allergic to Bactrim,
atovaquone.
If CD4 count < 100, do IgG serology for Toxoplasmosis. If +ve
serology, give trimethoprim/sulfamethoxazole.
In patients with positive PPD skin tests (>5 mm induration in an HIV-
infected patient), evaluate and treat for either active or latent
tuberculosis.
When CD4 count is <50 cells/µL, begin prophylaxis against
Mycobacterium avium complex with azithromycin, 1200 mg/week
Recognize that patients with refractory, frequent, or severe mucosal
candidiasis may require long-term systemic antifungal therapy ( oral
diflucan).
85. Vaccinations in HIV
Administer annual influenza vaccination to
all HIV-infected patients.
Administer pneumococcal vaccine to all
HIV-infected patients (and strongly
consider repeating at intervals of 5 to 10
years).
Administer vaccination to patients who are
at risk for hepatitis A and B.
86. Progressive Multifocal
Leucoencephalopathy
Cause : Papova virus JC
c/f : Dementia a common presenting symptom. Other
c/f - hemiparesis, aphasia, dysarthria
Dx : MRI/ CT. If +ve for white matter lesions, next step
is CSF analysis for JC virus by PCR
Rx – HAART
87. Toxoplasmosis
Screen all patients with HIV with CD4 less than 100. screening test
toxoplasma IgG
Screen all patients undergoing organ transplantation
C/F – encephalitis, pneumonitis, myocarditis in
immunocompromised. Mononucleosis like syndrome and
chorioretinitis in immunocempetant
If Suspected Toxoplasmosis get IgM and IgG serologies. If
neurological symptoms get CT/MRI. If patients are seronegative
for Toxoplasma or if lesions don’t respond to toxoplasma Rx in 2
weeks r/o Lymphoma. Get a stereotactic brain biopsy
Rx Sufladiazine + pyremethamine + folate ( Start emperic Rx in
patients with ring enhancing lesions in brain and +ve IgG serology for
toxoplasma and CD4 less than 200). If CD4 goes higher than 200,
may d/c therapy
88. Cryptococcal Meningitis
AIDS with CD4 less than 50
Headache, fever, delirium are present
Diagnosis : LP, India ink and Cryptococcal
antigen in serum and CSF
Rx: Amphotericin + Fluconozole
Increased CSF pressure is associated with
increased mortality do a daily therapeutic
lumbar punctures to keep CSF pressures < 20
90. Prevention
Advise Patients to avoid exposure to
vector ticks in endemic areas and to
promptly remove attached ticks.
Wear protective clothing
Use insect repellant containing
diethyltoluamide (DEET) or a tick-killing spray
containing permethrin, the latter to be applied
to clothing, not skin
91. Lymes
Acute, localized Lyme disease:
Erythema migrans and other symptoms (e.g., fever, fatigue, headache,
arthralgias, myalgias) occuring within 30 days of possible tick exposure
( this is sufficient to diagnose Lyme disease)
Acute, disseminated Lyme disease :
Multiple, secondary erythema migrans lesions, Acute carditis (heart
block) , CNS Disease (e.g., cranial neuropathy, radiculoneuropathy,
lymphocytic meningitis) and brief episodes of monoarticular or
oligoarticular inflammatory arthritis occuring within weeks to months
after tick exposure
Late Lyme disease:
Occuring within months to years after possible tick exposure
Chronic (>1 year) inflammatory monoarthritis or oligoarthritis
Nervous system complications : peripheral neuropathy or
encephalomyelitis
92. Diagnosis and Rx
Erythema migrans in an endemic area is
sufficient for diagnosis do not get serology (
can be negative in acute disease - ). Start
therapy as next step – oral doxycycline or
amoxicillin or cefuroxime.
Disseminated Lymes Get serologic testing.
Use 2 step approach – first ELISA. If ELISA
indeterminate, get western blot.
Arthritis, Carditis ( except third degree block,
cranial nerve palsy without meningitis Rx
similar to erythema migrans
Third degree block or Meningitis/
neuroborreliosis Rx with ceftriaxone IV
93. Q
A 30 y/o pregnant woman has a one week
history of a slowly enlarging red lesion on her
right thigh. She reports having gone on a
camping trip about 3 weeks ago and now
recalls that she removed a tick from the site of
the lesion. An ELISA test is negative for
Lymes. What is the next step?
A. Re-assurance
B. Ampicillin
C. Doxycycline
D. Western blot testing
E. Medical termination of pregnancy
94. Ans. B
Acute lymes – serology is often –ve. No
need to do western blot – give rx wioth
ampicillin
Doxycycline is contraindicated in
pregnancy.
95. Other
RMSF Rash starting on ankles and
wrists few days after fever.
Doxycycline. If pregnant, cholramphenicol
Ehrilichiosis central distribution of rash,
no involvement of periphery. Dx
inclusions in leucocytes
97. Meningitis
Symptoms : Fever, Photophobia, Headache,
Neck stiffness, vomiting, seizures
Use physical exam findings to confirm a
diagnosis of meningitis.
Look for:
Fever
Nuchal rigidity
Brudzinski's sign
Kernig's sign
Signs of encephalitis, such as weakness and change
in mental status
98. Meningitis
Do lumbar puncture to obtain CSF for:
Protein, glucose, and cell count determinations
Gram stain and bacterial culture
PCR testing for enterovirus and HSV if bacterial Gram stain and culture
results are negative and cell counts suggest viral meningitis
Obtain CT scan before lumbar puncture in patients with: ( HIPFAN)
Immunucompromised state (I)
History of CNS disease (H)
New onset seizures (N)
Papilledema (P)
Altered level of consciousness ( suggests encephalitis)(A)
Focal neurologic signs (F)
Be aware that delay in initiating appropriate antibiotics while awaiting
results of CT scan in patients with bacterial meningitis may result in an
adverse clinical outcome.
100. Meningitis – Empiric Rx
Base empiric antibiotic therapy on:
Patient's age
CSF gram-stain result
Potential bacterial pathogens
Knowledge of local resistance patterns for those
pathogens
Thereafter, base targeted antibiotic therapy on
culture results and susceptibility data.
Administer dexamethasone 15 to 20 minutes
before the first antimicrobial dose in adult
patients with suspected meningitis.
101. Meningitis – Emperical therapy
Predisposing Factor
AGE
Common Bacterial
Pathogens
Antimicrobial Rx
<1 month Streptococcus
agalactiae, Escherichia
coli, Listeria
monocytogenes,
Klebsiella species
Ampicillin plus
cefotaxime or ampicillin
plus an aminoglycoside
1 - 23 months Streptococcus
pneumoniae, Neisseria
meningitidis, S.
agalactiae, Haemophilus
influenzae, E. coli
Vancomycin plus a third-
generation
cephalosporin
2- 50 years N . meningitidis, S.
pneumoniae
Vancomycin plus a third-
generation
cephalosporin
>50 years S. pneumoniae, N.
meningitidis, L.
monocytogenes, aerobic
gram-negative bacilli
Vancomycin plus
ampicillin plus a third-
generation
cephalosporin
102. Meningitis – Emperical therapy
Predisposing Factor
HEAD TRAUMA
Common Bacterial Pathogens Antimicrobial Rx
Basilar skull fracture S. pneumoniae, H.
influenzae, group A -
hemolytic streptococci
Vancomycin plus a third-
generation cephalosporin
Penetrating trauma Staphylococcus aureus,
coagulase-negative
staphylococci (especially
Staphylococcus epidermidis),
aerobic gram-negative bacilli
(including Pseudomonas
aeruginosa)
Vancomycin plus cefepime,
vancomycin plus ceftazidime,
or vancomycin plus
meropenem YOU ARE
Adding an antipseudomonal
antibiotic.
Postneurosurgery Aerobic gram-negative bacilli
(including P. aeruginosa), S .
aureus, coagulase-negative
staphylococci (especially S.
epidermidis)
Vancomycin plus cefepime,
vancomycin plus ceftazidime,
or vancomycin plus
meropenem
CSF shunt Coagulase-negative
staphylococci (especially S.
epidermidis), S. aureus,
aerobic gram-negative bacilli
(including P. aeruginosa),
Propionibacterium acnes
Vancomycin plus cefepime,c
vancomycin plus
ceftazidime,c or vancomycin
plus meropenem
105. Catheter Related
Infections
Indwelling catheters suspect candida. R/o
endophthalmitis in candida sepsis, get
Ophthal consult
If catheter site looks infected remove
catheter. Do not use same site.
106. Febrile Neutropenia
Absolute neutropenia - < 500
Consider Neupogen
Start Gram - ve emperic therapy with
cefepime or imipenem.
If very critically ill or MRSA risk, add
vancomycin
If no response in 48 hours, add antifungals
107. Neutropenic Precautions
Remove any offending drugs or agents.
Use careful oral hygiene to prevent
infections of the mucosa and teeth.
Avoid rectal temperature
measurements and rectal
examinations.
Use good skin care for wounds and
abrasions
109. Anti-flu drugs
ZANAMAVIR
OSTELTAMAVIR ( Tamiflu)
These drugs are effective only if given in
48hrs of onset of flu symptoms.
Zanamavir can cause bronchoconstriction
caution in asthmatics ( keep a bronchodilator
inhaler handy)
Osteltamavir causes nausea and vomiting.