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A Leptospirosis B Aspergillosis C Lyme disease D

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A Leptospirosis B Aspergillosis C Lyme disease D Meningococcemia E Tularemia A 32y/o male comes to your office for evaluation of an acute illness. He ... – PowerPoint PPT presentation

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Title: A Leptospirosis B Aspergillosis C Lyme disease D


1
A 45-year-old man with asthma is evaluated
because of malaise, myalgias, coryza, and a
cough. Both influenza A and B are occurring in
the community, and the patient has not been
immunized against influenza. Medications include
an angiotensin-converting enzyme inhibitor, an
inhaled bronchodilator, and low-dose aspirin. The
patient has never traveled outside the United
States. On physical examination, he appears
ill. Temperature is 38.3 C (101 F), pulse rate
is 95/min, and respiration rate is 24/min. Blood
pressure is normal, and the examination is
otherwise unremarkable. A chest radiograph is
normal.
Which of the following antiviral agents is most
appropriate for this patient? A Zanamivir B
Amantadine C Oseltamivir D Rimantadine E
Urlachavir
2
A 45-year-old man with asthma is evaluated
because of malaise, myalgias, coryza, and a
cough. Both influenza A and B are occurring in
the community, and the patient has not been
immunized against influenza. Medications include
an angiotensin-converting enzyme inhibitor, an
inhaled bronchodilator, and low-dose aspirin. The
patient has never traveled outside the United
States. On physical examination, he appears
ill. Temperature is 38.3 C (101 F), pulse rate
is 95/min, and respiration rate is 24/min. Blood
pressure is normal, and the examination is
otherwise unremarkable. A chest radiograph is
normal.
Which of the following antiviral agents is most
appropriate for this patient? A Zanamivir B
Amantadine C Oseltamivir D Rimantadine E
Urlachavir
3
The presumptive diagnosis of influenza in this
patient is based on the history, clinical
findings, and influenza activity in the
community. Differentiating between influenza A
and B is not possible without performing a
point-of-care diagnostic study. However, both
viruses are circulating in the community, and an
antiviral agent that is effective against both
pathogens is required. Oseltamivir and
zanamivir are neuraminidase inhibitors, which are
a new class of antiviral agents licensed for
treatment of influenza A and B. However, only
oseltamivir is appropriate for this patient
because zanamivir is an inhaled medicine
associated with bronchospasm in 5 to 10 of
patients with asthma. Amantadine and rimantadine
should not be used because they are only active
against influenza A.
4
Influenza Mania
  • Why should you care?
  • Estimated 51,000 deaths per year in U.S.
  • Prefers to kill our grandparents and children
  • Its on tests
  • Orthomyxovirus family of viruses
  • Three serotypes A, B, and C
  • Although all three cause disease, the A serotype
    causes the most severe clinically significant
    disease, and is the only type to cause epidemics.
  • Influenza has a wide range of hosts humans,
    pigs, horses, seals, and most importantly birds.
  • Influenza has a polymorphic ultrastructure, and
    has several surface receptors that govern its
    virulence.

5
Briefly, a review
  • Hemagglutinin (HA)
  • trimeric protein that binds sialic acid on host
    cell surfaces.
  • After endocytosis, acidification of the
    endosome/lysosome causes a conformational change
    in HA which allows it to fuse with the endosomal
    membrane and dump the virion nucleic acids into
    the cytosol.
  • HA is the critical antigen in vaccines
  • Neuraminidase (NA)
  • tetramer of four identical moieties.
  • NA also binds sialic acid residues and cleaves
    them from the opposing cell surface, allowing
    wider dissemination of virus and preventing
    re-infection of the same cell.
  • NA is the target of oseltamivir and zanamivir
  • M2
  • a protein complex which allows protons to leak
    into virions interior once endocytosed, freeing
    virus RNA from protein complexes which allows for
    transport to host nucleus (necessary for
    replication).
  • M2 is the target of amantadine and rimantidine

6
Drift vs Shift
  • Antigenic drift is a term used to describe the
    variability of the sequence of the RNA genome due
    to the inherently error-prone RNA-dependent RNA
    replication of influenza. When mutations occur
    near the binding site for sialic acid, HA forms
    which were previously neutralized by host IgG,
    become virulent once again see figure. The
    result is an epidemic, which is much less severe
    than a pandemic.
  • Pandemics are severe, and are caused by antigenic
    shift. In a shift, flu antigens (almost always
    HA) which were not previously present in a
    specific species population are introduced via
    the simultaneous infection of one host with two
    flu strains of differing species (e.g. avian flu
    infects a human concomitantly infected with
    native human flu strain). The result is a
    completely novel surface glycoprotein due to
    intracellular swapping of viral RNA and
    assembling a virus with genes from two different
    flu strains.

7
  • All known subtypes of NA (9) and HA (15) infect
    waterfowl, only a handful infect other species.
  • Since the 1918 pandemic, only three HA subtypes
    and two NA subtypes have been stable in the human
    population for influenza A.
  • Only one subtype of HA and NA have been
    recognized for influenza B.

8
Treatment
  • Best treatment is prophylaxis with vaccination
  • Oseltamivir zanamivir active against both
    Influenza AB
  • Adamantanes only active against Influenza A
  • http//www.cdc.gov/flu/professionals/antivirals/ag
    ents.htm

9
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10
A 63-year-old man is brought to the emergency
department because of a 1-day history of rapidly
progressing pain, swelling, and erythema of his
right leg associated with fever, chills, and
delirium. The patient was vacationing on the Gulf
Coast of Florida. One day ago, he noted redness
and swelling of his foot in an area that had been
abraded while walking in the ocean. The area of
redness quickly spread proximally and has now
progressed beyond the calf. Hemorrhagic bullae
formed, the skin began to darken, and the patient
became delirious. Medical history is
unremarkable. On physical examination, the
patient is awake but disoriented and is writhing
in pain. Temperature is 39.8 C (103.6 F), pulse
rate is 122/min, respiration rate is 24/min, and
blood pressure is 88/40 mm Hg. In addition,
necrosis of skin up to the thigh has developed.
The remainder of the examination is unremarkable.
Which of the following pathogens is most likely
causing this patient's current findings? A
Pasteurella multocida B Vibrio haemolyticus C
Vibrio cholerae D Vibrio vulnificus E Carlos
Zambrano
11
A 63-year-old man is brought to the emergency
department because of a 1-day history of rapidly
progressing pain, swelling, and erythema of his
right leg associated with fever, chills, and
delirium. The patient was vacationing on the Gulf
Coast of Florida. One day ago, he noted redness
and swelling of his foot in an area that had been
abraded while walking in the ocean. The area of
redness quickly spread proximally and has now
progressed beyond the calf. Hemorrhagic bullae
formed, the skin began to darken, and the patient
became delirious. Medical history is
unremarkable. On physical examination, the
patient is awake but disoriented and is writhing
in pain. Temperature is 39.8 C (103.6 F), pulse
rate is 122/min, respiration rate is 24/min, and
blood pressure is 88/40 mm Hg. In addition,
necrosis of skin up to the thigh has developed.
The remainder of the examination is unremarkable.
Which of the following pathogens is most likely
causing this patient's current findings? A
Pasteurella multocida B Vibrio haemolyticus C
Vibrio cholerae D Vibrio vulnificus E Carlos
Zambrano
12
This patient has rapidly progressing necrotizing
fasciitis resulting from Vibrio vulnificus
infection of a skin abrasion acquired from warm
sea water. This organism is found in warm waters
throughout the world and is responsible for many
serious infections in the United States each year
as a result of exposure to fish and seawater. V.
vulnificus has now been reported as far north as
Alaska but is much more common in warmer
climates. Ingestion of filter-feeding shellfish
such as oysters which contain high levels of the
organism can also cause sepsis via the
gastrointestinal tract, especially in patients
with cirrhosis or other liver diseases.
Pasteurella multocida infection occurs after
animal bites and is much less likely to cause
such severe necrotizing fasciitis with
hemorrhagic bullae. Vibrio haemolyticus and
Vibrio cholerae do not cause necrotizing
fasciitis, although they may cause serious
gastrointestinal and systemic disease. Carlos
Zambrano is a malignancy, and a blathering
simpleton.
13
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14
A 32y/o male comes to your office for evaluation
of an acute illness. He returned from a camping
and canoeing trip from southern Illinois the week
prior. Currently he complains of subjective
fevers, myalgias, and general malaise. He
does not recall being bitten by any ticks or
other insects, and has not noticed any rash. He
did not ingest any atypical foods or handle any
animals, but did drink from and bathe in a
nearby creek. Two fellow campers have similar
symptoms. Temp is 99.0, rest of exam
unremarkable. He is given the diagnosis of a
viral syndrome, and sent home with supportive
management. 1 week later he is brought to the
ED by his brother due to mild confusion at home.
Exam now reveals a temp of 101.2, icteric
sclerae, mild RUQ tenderness, there are no skin
lesions. CXR reveals patchy airspace opacities
bilaterally. Labs are significant for mild
anemia and thrombocytopenia, bili of 4, normal
AST/ALT, WBC of 14 differential shows 85
PMNs, and BUN/Cr ratio 26/2.7. UA reveals mild
protein, few WBCs and hyaline and granular
casts. LP is performed.
What is the most likely diagnosis? A
Leptospirosis B Aspergillosis C Lyme disease D
Meningococcemia E Tularemia
15
A 32y/o male comes to your office for evaluation
of an acute illness. He returned from a camping
and canoeing trip from southern Illinois the week
prior. Currently he complains of subjective
fevers, myalgias, and general malaise. He
does not recall being bitten by any ticks or
other insects, and has not noticed any rash. He
did not ingest any atypical foods or handle any
animals, but did drink from and bathe in a
nearby creek. Two fellow campers have similar
symptoms. Temp is 99.0, rest of exam
unremarkable. He is given the diagnosis of a
viral syndrome, and sent home with supportive
management. 1 week later he is brought to the
ED by his brother due to mild confusion at home.
Exam now reveals a temp of 101.2, icteric
sclerae, mild RUQ tenderness, there are no skin
lesions. CXR reveals patchy airspace opacities
bilaterally. Labs are significant for mild
anemia and thrombocytopenia, bili of 4, normal
AST/ALT, WBC of 14 differential shows 85
PMNs, and BUN/Cr ratio 26/2.7. UA reveals mild
protein, few WBCs and hyaline and granular
casts. LP is performed.
What is the most likely diagnosis? A
Leptospirosis B Aspergillosis C Lyme disease D
Meningococcemia E Tularemia
16
Leptospirosis
  • Zoonotic spirochetal disease with a worldwide
    distribution
  • Reservoirs are primarily rodents, although gt160
    mammalian species have been found to harbor it
  • Contracted via direct contact with infected
    fluids (usually urine) or tissue
  • Excreted leptospires can survive in water for
    months

17
Leptospirosis
  • Causes a viral or flu-like prodrome in initial
    stages of infection /- aseptic meningitis
  • Renal dysfunction is nearly universal in
    symptomatic infection, commonly presents in 2nd
    week of infection
  • Organisms replicate in tubules and are excreted
    in urine for months
  • Severe Infection Weils syndrome
  • Hyperbilirubinemia
  • Renal dysfunction
  • Capillary leak/bleeding diasthesis

18
Diagnosis
  • Culture (blood, urine, CSF)
  • Seroconversion

19
The patient was diagnosed with positive IgM
titers and blood cultures. IV Penicillin G 1.5
million U Q6hrs was begun. Several hours later,
the patient has a temperature of 102.3 F,
rigors, and hypotension (BP 82/55). IV fluids are
begun and he is transferred to the MICU. The
patient has no known history of drug allergies,
and completed a course of amoxicillin for
sinusitis last year without complications. What
is the most likely diagnosis? A Nosocomial gram
negative bacteremia B Allergic reaction to
penicillin C Serum sickness D
Jarisch-Herxheimer reaction E After-effects of
Bears-Cowboys game
20
The patient was diagnosed with positive IgM
titers and blood cultures. IV Penicilin G 1.5
million U Q6hrs was begun. Several hours later,
the patient has a temperature of 102.3 F,
rigors, and hypotension (BP 82/55). IV fluids are
begun and he is transferred to the MICU. The
patient has no known history of drug allergies,
and completed a course of amoxicillin for
sinusitis last year without complications. What
is the most likely diagnosis? A Nosocomial gram
negative bacteremia B Allergic reaction to
penicillin C Serum sickness D
Jarisch-Herxheimer reaction E After-effects of
Bears-Cowboys game
21
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22
A 25-year-old man has a pre-employment physical
examination before beginning a medical residency
program at an urban teaching hospital. He is from
India, where he completed his medical training.
He is in good health and takes no medications.
Physical examination is normal. A tuberculin
skin test induces 22 mm of induration. The
patient subsequently remembers having received
bacille CalmetteGuérin vaccine as a child and
has a scar on his right shoulder compatible with
such a vaccination. A follow-up chest radiograph
is normal.
Which of the following is most appropriate at
this time? A Repeat the chest radiograph in 6
months B Obtain an induced sputum sample for
Mycobacterium tuberculosis stain/culture C
Treat with isoniazid for 9 months D Treat with
isoniazid, pyrazinamide, and ethambutol for 1
month E Repeat tuberculin skin test in 4 weeks
23
A 25-year-old man has a pre-employment physical
examination before beginning a medical residency
program at an urban teaching hospital. He is from
India, where he completed his medical training.
He is in good health and takes no medications.
Physical examination is normal. A tuberculin
skin test induces 22 mm of induration. The
patient subsequently remembers having received
bacille CalmetteGuérin vaccine as a child and
has a scar on his right shoulder compatible with
such a vaccination. A follow-up chest radiograph
is normal.
Which of the following is most appropriate at
this time? A Repeat the chest radiograph in 6
months B Obtain an induced sputum sample for
Mycobacterium tuberculosis stain/culture C
Treat with isoniazid for 9 months D Treat with
isoniazid, pyrazinamide, and ethambutol for 1
month E Repeat tuberculin skin test in 4 weeks
24
TB Factoids
  • BCG vaccine is prepared by

25
TB Factoids
  • BCG vaccine is prepared by culturing an
    attenuated strain of Mycobacterium bovis
  • Persons who received BCG vaccine usually have a
    negative tuberculin skin test unless they are
    infected with TB or are given a second tuberculin
    skin test shortly after the first.
  • Occasional persons who have received BCG vaccine
    may have positive skin test results without
    having latent tuberculosis, but PPD induration is
    usually lt10mm and wanes after 10-15 years
  • No currently available test or prediction rule
    can distinguish true-positive from false-positive
    skin test reactivity.
  • Therefore, in general, disregard BCG in
    evaluation of PPD

26
TB Factoids
  • Blood tests for tuberculosis based on
    interferon-? production after exposure to M.
    tuberculosis (Quantiferon-TB Gold) are available
    and have a sensitivity and specificity comparable
    to tuberculin skin testing.
  • However, these tests have not been as widely used
    as the tuberculin skin test and are not yet part
    of algorithms used for prevention and treatment
    of health care workers with a positive tuberculin
    skin test.
  • http//www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.
    htm
  • http//www.guideline.gov/summary/summary.aspx?doc_
    id8504

27
A 25-year-old man has a pre-employment physical
examination before beginning a medical residency
program at an urban teaching hospital. He is from
India, where he completed his medical training.
He is in good health and takes no medications.
Physical examination is normal. A tuberculin
skin test induces 22 mm of induration. The
patient subsequently remembers having received
bacille CalmetteGuérin vaccine as a child and
has a scar on his right shoulder compatible with
such a vaccination. A follow-up chest radiograph
is normal.
Which of the following is most appropriate at
this time? A Repeat the chest radiograph in 6
months B Obtain an induced sputum sample for
Mycobacterium tuberculosis stain/culture C
Treat with isoniazid for 9 months D Treat with
isoniazid, pyrazinamide, and ethambutol for 1
month E Repeat tuberculin skin test in 4 weeks
28
(No Transcript)
29
Given the CT findings below, which of the
following is the LEAST LIKELY associated
diagnosis?
A H. influenzae infection B Pseudomonas
infection C Immotile cilia syndrome D Tuberous
sclerosis E M. intracellulare infection
30
Given the CT findings below, which of the
following is the LEAST LIKELY associated
diagnosis?
A H. influenzae infection B Pseudomonas
infection C Immotile cilia syndrome D Tuberous
sclerosis E M. intracellulare infection
31
Bronchiectasis
  • Abnormal permanent dialtion of bronchi
  • Rare disease which is a common endpoint of a
    variety of chronic infectious/inflammatory
    conditions
  • Has diffuse or focal forms
  • 4 major classes
  • Cylindrical / tubular
  • Varicose
  • Cystic
  • Traction

32
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33
Given the CT findings below, which of the
following is the LEAST LIKELY associated
diagnosis?
A H. influenzae infection B Pseudomonas
infection C Immotile cilia syndrome D Tuberous
sclerosis E M. intracellulare infection
34
(No Transcript)
35
In Summary
36
Influenza
  • Best treatment is prophylaxis with vaccination
  • Oseltamivir zanamivir active against both
    Influenza AB
  • Adamantanes (amantadine/rimantidine) only active
    against Influenza A and are no longer recommended

37
Necrotizing fasciitis from Vibrio vulnificus
infection
  • Secondary to skin abrasion acquired from warm sea
    water or ingestion of shellfish.
  • This organism is found in warm waters throughout
    the world

38
Leptospirosis
  • Zoonotic spirochetal disease with a worldwide
    distribution
  • Contracted via direct contact with infected
    fluids (usually urine) and contaminated water
    supplies

39
Leptospirosis
  • Causes a viral or flu-like prodrome in initial
    stages of infection /- aseptic meningitis
  • Renal dysfunction is nearly universal in
    symptomatic infection
  • Organisms replicate in tubules and are excreted
    in urine for months
  • Severe Infection Weils syndrome
  • Hyperbilirubinemia
  • Renal dysfunction
  • Capillary leak/bleeding diasthesis

40
TB Factoids
  • Persons who received BCG vaccine usually have a
    negative tuberculin skin test unless they are
    infected with TB or are given a second tuberculin
    skin test shortly after the first.
  • Occasional persons who have received BCG vaccine
    may have positive skin test results without
    having latent tuberculosis, but PPD induration is
    usually lt10mm and wanes after 10-15 years
  • No currently available test or prediction rule
    can distinguish true-positive from false-positive
    skin test reactivity.
  • Therefore, in general, disregard BCG in
    evaluation of PPD

41
Bronchiectasis
  • Common infections in bronchiectasis
  • S. aureus
  • Psedomonas
  • H. influenzae
  • MAI
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