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Infectious Disease board review

Infectious Disease board review. Patricia D. Jones, MD. Question 11.

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Infectious Disease board review

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  1. Infectious Diseaseboard review Patricia D. Jones, MD

  2. Question 11 A 28 yo man is evaluated at a community health center for a 10-day history of sore throat, HA, fever, anorexia, and muscle aches. Two days ago, a rash developed on his trunk and abdomen. He had been previously healthy and has not had any contact with ill persons. He has had multiple male and female sexual partners and infrequently uses condoms. He has been tested for HIV infection several times, most recently 8 months ago; all results were negative. On physical examination, temperature is 38.6 C There are several small ulcers on the tongue and buccal mucosa and cervical and supraclavicularlymphadenopathy. A faint maculopapular rash is present on the trunk and abdomen. A rapid plasma reagin test is ordered. Which of the following diagnostic studies should also be done at this time? • CD4 cell count measurement • Epstein- Barr virus IgM measurement • HIV RNA viral load measurement • Skin biopsy

  3. Definitive AIDS Diagnosis (w/ or w/o laboratory evidence of HIV infection: Candidiasis of esophagus, trachea, bronchi or lungs. Cryptococcosis, extrapulmonary Cryptosporidiosis w/ diarrhea >1 month CMV infection of organ other than liver, spleen or lymph nodes HSV infection causing a mucocutaneous ulcer that persists >1 month, or bronchitis, PNA or esophagitis of any duration Kaposi sarcoma in patient < 60 yo Lymphoma of the brain (primary) in patient <60 yo Mycobacterium avium complex or Mycobacterium kansasii infection, disseminated ( at a site other than or in addition to the lungs, skin, or cervical or hilar lymph nodes) Pneumocystis jirovecii pneumonia Progressive multifocal leukoencephalopathy Toxoplasmosis of the brain. CDC: Diagnosis of AIDS

  4. CDC: Diagnosis of AIDS Definitive AIDS Diagnosis (with laboratory evidence of HIV infection) • Coccidioidomycosis, disseminated (at a site other than or in addition to the lungs or cervical or hilar lymph nodes) • HIV encephalopathy • Histoplasmosis, disseminated (at a site other than or in addition to the lungs or cervical or hilar lymph nodes) • Isosporiasis with diarrhea persisting > 1month • Kaposi sarcoma at any age • Lymphoma of the brain (primary) at any age • Other non-Hodgkin lymphoma of B-cell or unknown immunologic phenotype • Any mycobacterial disease caused by mycobacteria other than or in addition to the lungs, skin, or cervical or hilar lymph nodes. • Disease caused by extrapulmonary M. tuberculosis • Salmonella (nontyphoid) septicemia, recurrent • HIV wasting syndrome • CD4 count <200/ul or a CD4 lymphocyte percentage below 14% • Pulmonary tuberculosis • Recurrent pneumonia • Invasive cervical cancer

  5. CDC: Diagnosis of AIDS Presumptive AIDS Diagnosis (with laboratory evidence of HIV infection) • Candidiasis of esophagus: (a) recent onset of retrosternal pain on swallowing and (b) oral candidiasis • CMV retinitis • Mycobacteriosis: specimen from stool or normally sterile body fluids or tissue from site other than lungs, skin, or cervical or hilar lymph nodes showing acid-fast bacilli of a species not identified by culture • Kaposi sarcoma: erythematous or violaceous plaque-like lesion on skin or mucous membrane • Pneumocystis jirovecii pneumonia • Toxoplasmosis of the brain • Recurrent pneumonia • Pulmonary tuberculosis

  6. Pathophysiology of HIV Infection http://www.nwabr.org/education/pdfs/hiv_lifecycle.jpg

  7. Acute Retroviral Syndrome • 2-6 weeks post infection • Check HIV RNA Viral Load and HIV antibody • Fever (96%) • Lymphadenopathy (74%) • Exudative Pharyngitis (70%) • Rash (70%) • Myalgia or arthralgia (54%) • Diarrhea (32%) • Headache (32%) • N/V (27%) • Hepatosplenomegaly (14%)) • Weight Loss (13%) • Thrush (12%) • Neurologic Symptoms (12%)

  8. Screening and Diagnosis • Screening: Routine HIV testing in all patients aged 13-64, those beginning treatment for TB, those being treated for STDs, those who engage in high-risk behaviors. • Diagnosis: Antibodies appear in the circulation 2-12 weeks following initial infection. • ELISA—99%specific, 98.5 % sensitive • Western Blot—100% sensitive, 100% specific • Detects antibodies to core (p17, p24, p55), polymerase (p31, p51, p66) and envelope (gp41, gp120, gp160) proteins • Positive: Reactive to gp120 and either gp41 or p24 • Negative: Nonreactive • Indeterminate: Other band pattern that is not clearly positive. • Exposed persons with negative initial ELISA should have repeat testing at 6 weeks and 3 months.

  9. Laboratory Testing • HIV RNA Viral Load: predicts prognosis and the rate of decline of CD4 lymphocytes. • Opportunistic infections, blood transfusions, herpes outbreaks and immunizations may transiently increase viral load. • Check 4 weeks after initiation or changes in therapy. • Goal <50 copies/ml—should be achieved within 6 months of beginning effective therapy. • Monitor every 3-4 months

  10. Preventative Care • Routine Immunizations • Routine Breast, Colon Cancer and Hyperlipidemia Screening • Cervical Cancer/Anal Cancer Screening • Opportunistic Disease Prophylaxis • Pneumovax every 5 years • Influenza annually • Hep B, A unless documented immunity • PPD annually

  11. Prophylaxis for Opportunistic Infections: • Pneumocystic jirovecii (PCP): • Indications: CD4<200, CD4<14%, Recurrent Candidiasis, Persistent Fevere, Previous PCP • Treatment: TMP-SMX, Dapsone, Atovaquone, Pentamidine-aerosolized • Toxoplasmosis: • Indications: CD4<100, positive Toxoplasma IgG antibody titer • Treatment: TMP-SMX, Dapsone, Pyrimethamine, Leucovorin, • Mycobacterium avium complex infection: • Indications: CD4 <50 • Treatment: Azithromycin, Clarithromycin, Rifabutin

  12. Treatment of HIV Infection • When: AIDS-defining illness, CD4 <350, HIV-associated nephropathy, Co-infection with chronic Hepatitis B, Pregnancy. • 2 NRTIs + NNRTI or PI • Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs) • Abacavir, Didanosine, Emtricitabine, Lamivudine, Stavudine, Tenofovir, Zalcitabine, Zidovudine • Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) • Delavirdine, Efavirenz, Etravirine, Nevirapine • Protease Inhibitors • Atazanavir, Darunavir, Fosaprenavir, Indinavir, Lopinavir/Ritonavir, Nelfinavir, Ritonavir, Saquinavir HGC, Saquinavir SGC, Tipranavir • Fusion Inhibitors • Enfuvirtide • Co-receptor Antagonists • Araviroc • Integrase Inhibitors • Raltegravir • Efavirenz contraindicated in women of child-bearing age. http://img.thebody.com/thebody/2008/virus_life_cycle.gif

  13. Complications of HIV Infection/Therapy • Cardiovascular: • Increased exposure to protease inhibitors increases dyslipidemia and increased risk of MI. • Immune Reconstitution Inflammatory Syndrome: • Suppression of viral replication allows the immune system to regenerate-pathologic inflammatory state that tends to occur in patient with advanced HIV just starting HAART. Occurs 3 days-5years after initiation: • Unmasking: Occult subclinical infection-HAART improves immune function and the ability to mount an effective response against pathogens. • Paradoxical: Recurrence of a previously successfully treated infection. Primarily due to the presence of persistent antigens. • Management-Conservative and Steroids in severe reactions.

  14. Opportunistic Infections • Cryptococcal Infection: • Induction: Amphotericin B+/- Flucytosine for 14 days • Consolidation: Fluconazole for 8 weeks • CMV Infection: Retina, GI tract, Nervous system • Induction/Maintenance: Ganciclovir • Alternatives: Foscarnet/Cidofovir • Mycobacterium avium complex Infection: • Fever, weight loss, HSM, Malaise, Abdominal pain • Treatment: Macrolide and Ethambutol +/-Rifampin • Pneumocystis jirovecii Pneumonia • Fever, dry cough, dyspnea, bilateral interstitial infiltrates • Diagnose by silver stain of induced sputum or bronchoscopic sample showing cysts • 3 week TMP/SMX • Steroids for PaO2 <70 mm Hg, A-a gradient >35 mm Hg • Toxoplasmosis: • Fever, Neurologic deficits, Ring-enhancing lesions on MRI • Sulfadiazine + Pyrimethamine + Folinic Acid • F/U MRI after 14 days. If no improvement, biopsy to rule out CNS lymphoma.

  15. Question 8 A 75 yo man with type 2 DM is evaluated in the ED for a draining chronic ulcer on the left foot, erythema, and fever. Drainage initially began 3 weeks ago. Current medications include metformin and glyburide. On physical examination, he is not ill appearing. Temperature is 37.9 C; other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the 4th metatarsal joint. A metal probe makes contact with the bone. The remainder of the examination is normal. The leukocyte count is normal , and ESR is 70 mm/h. A plain radiograph of the foot is normal. Gram stain of the purulent drainage at the ulcer base shows numerous leukocytes, gram-positive cocci in clusters, and gram-negative rods. Which of the following is the most appropriate management now? A. Begin Imipenem B. Begin Vancomycin and Ceftazidime C. Begin Vancomycin and Metronidazole D. Perform bone biopsy.

  16. Osteomyelitis • Intense suppurative reaction in bone associated with edema and thrombosis which can compromise vascular supply leading to areas of dead bone—sequestra • New bone reforms around the sequestra—involucrum • 20% Hematogenous • Most common site intervertebral disk space and two adjacent vertebrae • Patients on HD, sickle cell, bacteremia and endocarditis • 40-60% cases S. aureus • 80% Contiguous • Most infections are polymicrobial http://www.eorthopod.com/images/ContentImages/child/child_back_pain/child_back_pain_osteomyelitis.jpg

  17. Diagnosis of Osteomyelitis • Bone Biopsy: Gold Standard • Open vs. CT-guided aspirate • Radiograph: • Takes 2 weeks to show acute changes. • Sensitivity 60%, Specificity 60% • MRI • Acute changes noted within days • Sensitivity 90%, Specificity 80% • False-positives: Fractures, Tumors, Healed Osteomyelitis • Nuclear Studies

  18. Diabetes Mellitus-Associated Osteomyelitis • Superficial foot infections lead to cellulitis and disseminate to cause abscess, necrotizing fasciitis and osteomyelitis. • Physical Exam: • Visible bone in ulcer base or contact with bone upon insertion of metal probe at the ulcer base (PPV 90%, NPV 60%) • Ulcers > 2x2 cm and present for >2 weeks and ESR >70 associated with underlying osteomyelitis. • Cultures obtained from a sinus tract or ulcer base usually do not correlate with deep pathogens causing bone infection. • Treatment • Zosyn, Unasyn, Timentin • 3rd/4th generation Cephalosporin + Flagyl • PCN-allergic: Clindamycin + Fluoroquinolone • IV Antibiotics for 4-6 weeks • Debridement

  19. Vertebral Osteomyelitis • S. aureus-most common organism, CONS, GNR and Candida • Gradually worsening back/neck pain, fever (50% pts), point tenderness. • Blood cultures positive in up to 75% pts • If blood cultures negative, CT-guided biospy to guide therapy • Treatment: • Vanc + Antipseudomonal cephalosporin or extended-spectrum beta-lactam antibiotic. • 6-8 weeks duration

  20. Question 43 A 70 yo man is evaluated in the ED for the acute onset of fever, cough productive of yellow sputum, right-sided pleuritic chest pain, and dizziness. He has a history of DM, HTN treated with HCTZ, lisinopril, glyburide, and metformin. On physical examination, temperature is 35C, BP 110/70, P 120, RR 36. He appears to be in acute respiratory distress. Pulmonary examination reveals dullness to percussion, increased fremitus, and crackles at the right lung base. He is oriented only to person. Laboratory Studies: ABG: (Ambient Air) Hct 42% pO2 50 mm Hg WBC 23,000 pCO2 30 mm Hg Platelet 150,000 pH 7.48 BUN 46 Creatinine 1.4 CXR shows a right lower lobe infiltrate. Which of the following is the most appropriate management of this patient? A. Admit to general medical floor B. Admit to the ICU C. Observe in the ED for 12 hours D. Treat as an outpatient.

  21. Community-Acquired Pneumonia • Definition: Infectious PNA in patient living independently in the community of hospitalized for less than 48 hours. • Typical: • Rapid onset of high fever, productive cough, pleuritic chest pain • Usual microorganisms: S. pneumo, H. influenzae, M. catarrhalis • Atypical: • Low grade fever, nonproductive cough, no chest pain • M. pneumonia, Chlamydophila pneumoniae, Legionella pneumophila

  22. Diagnosis • CXR • Cavitary lesions w/ air-fluid levels—abscess due to staphylococci, anaerobes or GNR • Cavitary lesions w/o air-fluid levels suggest TB or fungal infection • Blood cultures and sputum gram stain/culture are particularly useful in severely ill patients • Urine Legionella antigen-only positive in cases caused by serogroup I. • Influenza http://biomarker.cdc.go.kr:8080/diseaseimg/pneumonia-Community_acquired.jpg

  23. CURB-65 Clinical Feature Points • Confusion (defined as a Mental Test Score of 8, or disorientation in person, place, or time) 1 • Uremia: blood urea 7 mmol/L (~19 mg/dL) 1 • Respiratory rate: 30 breaths/minute 1 • Blood pressure: systolic 90 mm Hg or diastolic 60 mm Hg 1 • Age 65 years 1 Score Group Treatment Options 0 or 1 Group 1; mortality Low risk; consider home treatment low (1.5%) 2 Group 2; mortality Consider hospital-supervised intermediate (9.2%) treatment (either short-stay inpatient or hospital-supervised outpatient) 3 Group 3; mortality Manage in hospital as severe high (22%) pneumonia; consider admission to intensive care unit, especially with CURB-65 score of 4 or 5

  24. PSI/PORT

  25. PSI/PORT

  26. Treatment • Administer ASAP-preferably while patient still in ED. • Duration of therapy: 7-10 days

  27. THANKS!!!!!

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