Fever Flashcards

Question

How is dengue diagnosed?

Answer 1

Dx: A. Clinical DOH 2011 Revised Dengue Classification 1. Probable Dengue Fever: Live/travel to dengue endemic area (SE Asia (70%), Africa, America, Eastern Mediterranean, western Pacific) with fever x 2-7d with >2 of the ff a. Headache b. Body malaise c. Arthralgia d. Retro-orbital pain e. Nausea, vomiting f. Anorexia g. Diarrhea h. Flushed skin i. Rash (petechial/Herman’s rash) j. Tourniquet test (+) AND a. CBC – leukopenia w/ or w/o thrombocytopenia b. And/or DNS1 (+) or Dengue IgM (+) 2. Confirmed Dengue fever a. Viral culture isolation b. PCR 3. Dengue w/ warning signs: Live/travel to dengue endemic area with fever x 2-7d with any of the ff: a. Abdominal pain/tenderness b. Mucosal bleeding c. Clinical sign of fluid accumulation d. Persistent vomiting e. Lethargy, restlessness f. Hepatomegaly g. Dec UO, or no UOx6h h. Lab: elev Hct, and/or dec plt 4. Severe Dengue: Live/travel to dengue endemic area with fever x 2-7d and any of the above CM for dengue w/ or w/o warning signs + any of the ff: a. Severe plasma leakage - Leading to: a. Shock (DSS) b. Fluid accumulation with respiratory distress b. Severe bleeding c. Severe organ impairment i. Liver ALT or AST >1000 ii. CNS: sz, impaired consciousness iii. Heart: myocarditis iv. Kidney: renal failure B. Laboratories Preferably D1-6 of fever: 1. CBC – leukopenia (WBC <5K), then thrombocytopenia (plt <100k), hemoconcentration (20% rise from baseline) during critical phase 2. Dengue Viral culture 3. RT-PCR 4. Dengue NS1 Ag test – useful D1-3 5. Dengue IgM, IgG – D7 onwards - Method of choice at the end of the acute phase of infection - Should not be collected earlier than d5 or 6 wks after onset - Primary infection IgG in low titers at end of 1st week the inc slowly after several mos - Secondary infection: IgG detected in acute phase and persists for 10mos 6. PT/PTT – not routinely indicated. Prolonged bleeding time. Moderately decreased PT 7. Elev AST, metabolic acidosis with hyponatremia, hypochloremia, elev BUN, hypoalbuminemia (<3.5g/dL) 8. CXR – right lateral decubitus; r/o pleural effusion 9. UTZ – edematous gall bladder wall, ascites, pleural effusion

Answer 2

Mgt Pxs with dengue w/o warning signs but w/signs of dehydration 1. Send home on ORS: pxs with all of the ff: a. Able to tolerate adequate volumes of oral fluids b. Pass urine at least once q6h c. Do not have any of the warning signs (esp when fever subsides) d. N hct (<40%) and N plt ct (>150K) e. Should have daily CBC, monitor defervescence, warning signs until out of critical period f. Advise to return immediately once with warning signs - Home care plan: a. ORS – reduced osmolarity ORS with Na 50- 70 mmol/L § No sports drinks or fluids containing high sugar/glucose § Plain water will cause electrolyte imbalance b. Paracetamol § Do not give ASA, Ibu, other NSAIDs § Tepid sponging § No Abx c. Dengue Home care card and advice on when to return to the hospital § Bed rest § Fluids § Fever management § Warning signs: bleeding, freq. vomiting, abdominal pain, drowsiness, mental confusion, seizures, pale, cold, or clammy hands and feet, DOB, decreased or no UO w/in 6h 2. Admit for oral rehydration fluids a. Px with any warning sign b. No warning sign but with any: complicated comorbidities: pregnancy, infancy, old age, obesity, DM, renal failure, chronic hemolytic ds; social circumstance: living alone, living far from HCC w/o reliable transport - In-hospital Oral ORS a. ORS b. IVF if ORS not tolerated: 0.9% saline or LR at M rate ORS after a few hrs of IVF 3. Admit to wards for IVF tx Admission criteria: strongly associated with severe dengue a. Shortness of breath b. Irritability or drowsiness c. Pleural effusion d. Abdominal pain e. Melena f. Elevated hematocrit (>20%) g. Decreased or decreasing platelet count (<100K) Vomiting not assoc with severe dengue, but may mean inability to tolerate ORS, thus consider admission IVF for pxs w/o warning signs/shock: 1. Judicious fluid therapy = fluid restriction, avoid fluid overloading 2. Calculated for IBW or ABW, whichever is less (max 50kg). 3. M+5% for critical phase (max = 50kg = 4600ml /48h) 4. IVF = isotonic solution: D5LRS, D5 acetated ringers, D5 NSS/D5 0.9 NaCl 5. For <6mos old: D5 0.45 NaCl = mix equal volumes D50.9 NaCL + D5W a. Do not use hypotonic fluids D5 0.3 NaCl 6. Hypotonic IVF is associated with hyponatremia 7. Compute M IVF 8. For mild dehydration, add replacement tx + maintenance tx to determine total fluid requirement (TFR) over 24h 9. Replacement Tx: a. <12mos: 50ml/kg b. >1 yo: 30ml/kg 10. Fluid rate should be adjusted according to the clinical condition, VS, UO, Hct levels (~3cc/kg/h) 11. Monitor: T pattern, volume of fluid intake and losses, UO (vol and freq), warning signs, CBC (hct, wbc, plt), CBG 4. Admit to ICU for IVF

Answer 3

1. No preventive BT (like plt transfusion) 2. Should be given only when there are definite and established indications and in practically all cases component therapy should be utilized. 3. Abnormal hemostasis: consumptive coagulopathy is not the major cause of bleeding but rather the profound shock and intractable acidosis. a. Fibrinogen is the most severely affected clotting factor 4. PRBC or FWB, plasma if with: a. Significant bleeding (melena, hematemesis) b. Decreasing hct inspite of IVF 5. plt concentrate a. if plt <50K with bleeding 6. cryoprecipitate 1bag/5kg or FFP 10-20ml/kg, plt concentrate a. for DIC

Answer 4

Criteria for discharge 1. afebrile x 24-48h 2. good well being 3. stable hct ivf and inc plt trend 4. at least 2-3d from last episode of shock

Answer 5

Complications 1. Fluid and electrolyte loss 2. Febrile sz COVID-19 + Dengue – leukopenia, vomiting, fever, rash. Prognosis: DF: good DHF: death in 40-50%, WOF overhydration

Answer 6

Prevention DOH 4S vs Dengue 1. Search and destroy mosquito-breeding sites 2. Secure self-protection measures: long pants, long sleeves, mosquito repellant - DEET, citronella (use EPA-approved products) 3. Seek early consultation 4. Support fogging/spraying in hotspot area Dengue vaccine – currently suspended by DOH due to Dengvaxia controversy. Currently out of market - CYD-TDV (2015) - For 9-45yo. Licensed in 20 other countries - Live recombinant tetravalent 3 dose series (0/6/12 mo sched) - Efficacy 78.2% to seropositive to prevent dengue infection vs 38.1% to seronegative pxs - Inc risk of hospitalization and severe dengue in seronegative pxs for 30mos after 1st dose - Recommendation: pre-vaccination screening strategy in w/c only seropositive pxs are vaccinated (Dengue IgG ELISA)

Answer 7

CH 198: TYPHOID FEVER Etiology - Salmonella enterica serovar Typhi - Salmonella paratyphi A, B, C Transmission - Most common: ingestion of food/water contaminated from human feces - Shellfish and vegetable grown in sewage contaminated water Communicability: as long as the infected person excretes S.typhi (after 1 week of illness to convalescence)

Answer 8

Patho - Risk factors: enable viable org to reach SI § Achlorydia § Buffering medications § Rapid gastric emptying after gastrectomy § Large inoculum § Prior abx tx, antimotility agents - Toxin production à proinflammatory cytokines à Enterocolitis with diffuse mucosal inflammation and edema, with erosions and microabscesses à bacteremia à localized infection and organ suppuration IP: 7-14d, range 3-30d

Answer 9

CM: 1. HG fever, malaise, myalgia, abdominal pain, anorexia, hepatosplenomegaly, diarrhea, constipation, chills, diaphoresis, cough, sore throat, dizziness 2. T pattern: classic stepladder rise. rises in small increments then reaches 40C by the end of the 1st week 3. Diarrhea – (30%) small volume, greenish pea soup - Follows fever on the 2nd week 4. Constipation (50%) 5. Rose spots – MP rashes visible on d7-10 on lower chest or abdomen and lasts 2-3d 6. Relative bradycardia, neurologic manifestation, GI bleeding 7. Abdominal pain, abdominal distention, tenderness 8. Hepatosplenomegaly 9. Typhoid psychosis/encephalitis

Answer 10

Complic 1. Hepatitis, cholecystitis, jaundice, intestinal hemorrhage and perforation, myocarditis, CNS

Answer 11

WHO standard case definition 1. Probable – persistent fever (38C) lasting >3d with (+) serodx or Ag detection test, but no S.typhi isolation - A clinically compatible case epidemiologically linked to a confirmed case or outbreak 2. Confirmed case – with laboratory confirmed S.typhi (blood, BM, bowel fluid) 3. Chronic carrier – excretion of St.typhi in the urine or stool for >1yr after onset of typhoid fever (2-5%)

Answer 12

1.CBC with PC -leukopenia 4000-6000 cells/mm6 leukocytosis may be as high as 20,000-25,000 in the presence of pyogenic complications or intestinal perforation thrombocytopenia- marker for sever illness, WOF DIO normocytic anemia hypochromia with blood loss 2. Culture of appropriate specimen ***Blood CS-gold standard test for typhoid fever; highest during 1st week; taken at diff sites stool or urine culture--> 2nd-4th wk of illness bone marrow culture: not done routinely but indicated in highly suspicious cases with negative blood or stool culture Other: UA- transient albuminuria LFT- mild elevation of enzymes Renal function test stool for occult blood Serology: Salmonella IgG/IgM or typhidot=local studies revealed varying results. No local recommendation for its use at the moment Widal test- not recommended PCR and DNA probe of S. typhi=have not yet been developed for clinical use

Answer 13

Fully susceptible Uncomplicated: Amoxicillin 75-100 mkd x 14d Chloramphenicol 50- 75 mkd x 14-21d Alt: ciprofloxacin 15mkd x 5-7d Complicated/Severe: Ciprofloxacin 15mkd x 10-14d Alt: chloramphenicol 100 mkd x 14-21d MDR: Uncomplicated: MDR Ciprofloxacin 15mkd x 5-7d Cefixime 15-20mkd x 7-14d Alt: Azithromycin 8-10 mkd x 7d Complicated/Severe: Ciprofloxacin 15mkd x 10-14d Alt: ceftriaxone 60mkd x 10-14d Cefoxamine 60mkd x 10-14d QR Uncomplicated: Azithromycin 8-10 mkd x 7d Ceftriaxone 75 mkd x 10-14d Complicated/Severe: Ceftriaxone 60mkd x 10-14d Cefotaxime 80kd x 10- 14d Alt: ciprofloxacin 20mkd x 7-14d Azithromycin 10- 20mkd x 7d Non-typhoid salmonella enteritis: Cefotaxime 100-200 mkd q6-8 x 5-14d Ceftriaxone 75mkd q24 x7d Ampicillin 100mkd q6-8 x7d Cefixime 15mkd x 7-10d Multi-drug resistant (DRTF) - Indications: § Severe typhoid fever (shock, abN sensorium) § Potentially life-threatening complications (intestinal hemorrhage, perforation, DIC, myocarditis) § Clinical deterioration or devt of complication during tx § No improvement within 5-7d § Household contact of documented DRTF - Increasing rates of ciprofloxacin resistance – judicious use as Salmonella GE is usually a self-limited disease

Answer 14

Prevention 1. Central chlorination and domestic water purification 2. Avoid street food 3. Typhoid vaccine for high risk populations

Answer 15

Leptospira Epid - Infect rats, mice, cattle, goats, sheep, horses, pigs, domestic dogs - Infected animals excrete spirochetes in urine for prolonged periods (in warm, moist environment --> flood) Transmission and Patho - Leptospira enter humans through mucus membrane (eyes, nose, mouth), wound, or ingestion of contaminated water --> circulation in blood stream to all organs --> endothelial lining damage of small BV with secondary ischemic damage to end organs

Answer 16

1) Anicteric leptospirosis – biphasic course A. Initial/septicemic phase – 2-3d. leptospires at blood, CSF a. Fever b. Flu-like sx: chills, lethargy, severe headache, malaise, nausea, vomiting c. Severe debilitating myalgia of LE>LS spine d. Abdominal pain e. Dec HR, hypotension f. Conjunctival suffusion with photophobia, orbital pain, (-)exudates/chemosis g. Gen. LNE h. Hepatomegaly i. Rash: transient (<24h) erythematous, MP, urticarial, petechial, purpuric, desquamating B. 2nd/Immune phase: tissue localization a) Fever b) Septic meningitis: elev CSF pressure, pleocytosis with PMN, N/elev protein, N glc x 1 wk c) uveitis 2) Icteric leptospirosis (Weil syndrome) 1. Severe (<10%) in adults >30 yo 2. Same initial phase 3. Immune phase: a. Jaundice, RUQ pain, hepatomegaly b. Renal failure (16-40%): #1 cause of death c. Dec plt, hemorrhage, CV collapse

Answer 17

Dx 1. Microscopic agglutination test (MAT): gold standard - >4x inc in titer at D12-3rd week, >1:200 or serial titers >1:100 2. ELISA, Latex agglutination, immunochrom. - D1-10: CSF - 2nd week: urine 3. UA: hematuria, ptn, casts (+) 4. BCS – definitive dx. Isolated 5d after sx onset (7-14d after exposure). 5. CBC – peripheral leukocytosis with a left shift, thrombocytopenia 6. Elev ESR 7. Mildly elev LFTs, bilirubin, ALP 8. CXR – blateral diffuse airspace disease, cardiomegaly, pulmonary edema, multiple patchy infiltrates (alveolar hemorrhage)

Answer 18

mild 1st line: <8yo: Amoxicillin 50mkd q8 x 7d >8yo: doxycycline 2-4 mkd BID x 7d 2nd line: Azithromycin 1g LD then 10mkd OD x 2d mod-severe 1st line: Pen G 250,000-400,000 U q4-6 x 7d (NAGCOM) Pen G 6-8M U/m2/d q4 x7 d (Nelsons) 2nd line: Ampicillin 100mkd q6 x 7d Cefotaxime 100- 150mkd q6-8 x7d Ceftriaxone 80-100mkd q21 x 7d

Answer 19

Prevention 1. Rodent control 2. Avoid contaminated water, soil 3. Vax livestock, dogs 4. Protective clothing 5. PrEP: not routine, unless to travelers, soldiers, those engaged in occupational and recreational activities in highly endemic areas 6. PEP: depends on risk type - Preferred: Doxycycline 4mkdose SD po per week (max 200mg regardless of age); can be 100mg BID x 1d - Alt: Amoxicillin 50mkd q8 x 3-5d, Azithromycin 10mkd SD - If exposed >7d, repeat dose after 1 week

Answer 20

Occult bacteremia

Answer 21

S. pneumoniae Other cause: HiB, N. meningitidis

Answer 22

Dx 1. BCS, CBC 2. UCS, UA 3. Fecalysis, CSF analysis

Answer 23

Paracetamol Antibiotics: Amoxicillin

Answer 24

a. Acute bacterial: Gram (+) or (-) b. Acute aseptic meningitis: virus c. Chronic: TB or fungal 2. Viral encephalitis a. Acute: HSV, Jap Enceph, enterovirus b. Chronic: SSPE (measles) 3. Congenital infection – TORCH

Answer 25

Etiopatho - From metastatic caseous lesions in the cerebral cortex or meninges that develop during lymphohematogenous dissemination of primary infection - Gelatinous exudates infiltrate the corticomeningeal blood vessels à inflammation, obstruction à infarction of cerebral cortex - Brainstem: site of greatest involvement § CN III, VI, VII - Communicating hydrocephalus: exudates block CSF flow - Most common in 6mos-4yo - Accompanies miliary TB (50%)

Answer 26

CM - More rapid progression in infants and young children - Acute onset hydrocephalus, sz, cerebral edema - Obtain HC and check fontanels

Answer 27

3 stages: 1. 1st stage – lasts 1-2wks. - Non-specific s/sx (fever, headache, irritability, drowsiness, malaise) - Infants: loss of developmental milestones 2. 2nd stage - Focal neuro signs (nuchal rigidity, sz, (+) Kernig sign and Brudzinski signs, hypertonia, CN palsy - Hydrocephalus, inc ICP, vasculitis - Encephalitis (disorientation, movt disorder, speech impairment) 3. 3rd stage - Coma, hemiparaplegia, hypertension, deteriorating VS and death

Answer 28

Dx 1. CSF analysis: AFB almost never seen on smear. Ground glass appearance of fluid w/c forms pellicle when spun. 2. PCR, ELISA, latex agglutination 95 3. CT/MRI: radiologic triad: basilar enhancement, communicating hydrocephalus, cerebral infarction, cerebral edema 4. Refer to pulmonology for dx of TB 5. CBC, BCS – PMN leucocytosis with a left shift 6. Serum e’s, glu – determine dehydration and SIADH

Answer 29

Mgt 1. Anti-TB: 2HRZE + 10HR 2. Corticosteroids – improves survival but does not prevent severe disability x 2-4wks

Answer 30

Etiopatho - Echovirus - Coxsackie virus, adenovirus, CMV, HSV - Virus affects CNS parenchyma, causing encephalitis/ encephalomyelitis

Answer 31

CM 1. Fever, headache, altered sensorium, focal neuro signs, sz, meningeal signs, vomiting, poor feeding 2. Classical triad (older children): fever, headache, nuchal rigidity 3. Enterovirus – mild, self-limited ds with primary meningeal involvement to severe encephalitis - Most common cause of viral meningoencephalitis 4. Parechovirus – similar to enterovirus - more severe MRI lesions of cerebral cortex than enterovirus - important cause of septic meningitis/encephalitis in infants 5. HSV – focal brain involvement (frontal and temporal) - Temporal lobe encephalitis (HSV1) - Mild and transient meningoencephalitis (HSV2) - HSV1: severe sporadic encephalitis 6. VZV – most common manifestation is cerebellar ataxia - Severe encephalitis - Temporal presentation with chicken pox 7. Mumps – mild meningoencephalitis - Deafness from CN8 damage

Answer 32

Dx 1. CSF analysis – as above 2. EEG – slow wave activity without focal changes 3. CT/MRI – swelling of brain parenchyma 4. PCR, Ab titers for HSV, VZV, etc

Answer 33

Mgt 1. Supportive 2. Acyclovir 10-20 mkdose q8 x10-14d: HSV

Answer 34

Etiopatho - 1st 2 mos: GBS, gram (-) enteric bacilli, L.monocytogenes, E.coli, Pseudomonas, Klebsiella, Salmonella - 2mos-12 yo: S.pneumoniae, HiB, N.meningitidis - Overall: viral infections are common - Entry of bacteria into the CSF and bacterial growth in this compartment leading to inflammation within the CSF and adjacent brain tissue Transmission: hematogenous

Answer 35

CM 1. Headache, nausea, vomiting, anorexia, restlessness, irritability, fever, neck pain & rigidity, obtundation, coma, focal neurologic deficits (vascular occlusion) 2. Nuchal rigidity secondary to inflammation of spinal nerves and roots to produce meningeal signs of irritation (Brudzinski, Kernig sign) 3. 12-18mos: may not have Brudzinski/Kernig 4. Sz due to cerebritis, infarction, electrolyte losses

Answer 36

Dx 1. Lumbar puncture and CSF GS/CS – pleocytosis >100/mm3, high CSF protein >1g/L, neu predominance, low sugar <40% - Contraindications: focal neuro signs, shock, extensive spreading purpura, unstable sz, coag abN, plt <50L, anticoag tx, local infection, RD, inc ICP (from any SOL) 2. BCS – reveals etiology in 80-90% 3. High CRP, ESR, procalcitonin – differentiates bacterial from viral causes 4. CBC - PMN leucocytosis with a left shift

Answer 37

Mgt 1. Empiric Abx: ceftriaxone 100mkd q12 IV or Cefotaxime 200 mkd IV q6 - Chloramphenicol 75-100 mkd IV q6 for >1mo old and allergic to penicillin - Vancomycin 45-60 mkd IV q6/8 + rifampin 20 mkd po q12 x 2 d - NAGCOM: Ampicillin/Cefotaxime + Amikacin/ Gentamicin 2. N.meningitidis: penicillin G x 5-7d - Alternative for pen allergy: meropenem 120 mkd IV q8 or vancomycin 3. S.pneumoniae: vancomycin + 3rd gen ceph or pen x 10- 14d 4. Penicillin-resistant: vancomycin 5. L.monocytogenes: ampicillin 200-400 mkd IV q4/6 - Alternative: TMP-SMX 20 mkd IV/po q6/8 6. HiB: ampicillin/ceftriaxone 100 mkd IV q12 7. E.coli: cefotaxime or ceftriaxone x 3 wks or at least 2 weeks after CSF sterilization 8. P.aeruginosa: ceftazidime 150 mkd q8 IV x3wks or at least after 2 weeks after CSF sterilization 9. Partially treated: Ceftriaxone or cefotaxime x 7-10d 10. GBS: Cefotaxime 11. Neonate: Ampicillin/cefotaxime/ceftriaxone + aminoglycoside (Gentamicin 7.5mkd IV q8) 12. 2mos-5yo: Ceftriaxone 100mkd q12-24/ chloramphenicol 100mkd IV q8 13. >5yo: Ceftriaxone/ Chloramphenicol 14. Dexamethasone 0.15mkdose q6h x 2d: for HiB, 2hrs before abx - Less fever, lower CSF protein, reduced CN8 damage

Answer 38

Complications 1. Communicating hydrocephalus 2. Subdural effusion 3. SIADH: may exacerbate cerebral edema à hyponatremic seizures

Answer 39

- Most common between 4-8yo - Embolization due to CHD with R to L shunts, meningitis, chronic OM, mastoiditis (streptococci, HiB, pseudomonas), face & scalp infections, orbital cellulitis, dental infections (streptococci, fusobacterium, gram (-) bacilli), penetrating head injury (S.aureus, aerobic strep, G(-) bacilli, VP shunt infection - Affects cerebrum (80%), occipital lobe, cerebellum, brain stem (20%) - Majority single abscess - S.aureus, streptococci, anaerobes, gram (-) aerobic bacilli (Proteus, pseudomonas, haemophilus, Citrobacter) - May be contiguous infection (OM, mastoiditis, sinusitis, dental infection, face/scalp infection); hematogenous spread (lung, osteomyelitis, cardiac); or cranial trauma

Answer 40

Triad: fever, headache, focal deficit

Answer 41

CM 1. Triad: fever, headache, focal deficit 2. Early: LG fever, headache, lethargy 3. Late: vomiting, severe headache, sz, focal neuro signs (hemiparesis), papilledema, coma

Answer 42

Dx 1. BCS – (+) in 10% 2. Cranial CT/MRI – most reliable method - Hypodense center with outer uniform ring enhancement surrounded by variable hypodense region of brain edema Do not do CSF analysis/lumbar puncture to avoid herniation

Answer 43

Mgt 1. Empiric abx - Duration: 4-6 wks - Unknown cause: 3rd gen ceph + metronidazole 30 mkd IV q6; oxacillin 100-200 mkd IV q4/6 + ceftriaxone 100 mkd IV q12/ cefotaxime 200 mkd IV q6 - Head trauma/neurosx: nafcillin/oxacillin or vancomycin 45-60 mkd IV q6/8with 3rd gen ceph (ceftriaxone/cefotaxime)+ metronidazole - CHD: penicillin + metronidazole; ceftriaxone/cefotaxime + aminoglycoside (S.viridans, HiB) NAGCOM: Ceftriaxone 100mkd q12 + Metronidazole 7.5mkd q6 or 15mkd q12 - VP shunt: vancomycin + ceftazidime 150 mkd IV q8 - Immunocompromised: broad spectrum + amphotericin B 0.5-1 mkd OD IV - Spinal abscess: oxacillin (S.aureus, strep) - Cavernous sinus thrombosis: oxacillin + ceftriaxone/cefotaxime (S.aureus, s.pneumo, HiB) 2. Surgery - Aspiration for encapsulated abscess - Indications: gas in abscess, multiloculated, posterior fossa location, fungal cause, assoc with mastoiditis, periorbital cellulitis, sinusitis

Answer 44

Prognosis - High mortality: multiple abscess, coma - Long term sequelae: behavior and learning problems, hydrocephalus, sz, hemiparesis

Answer 45

Cryptococcus neoformans Other cause:- Histoplasma capsulatum, candida, coccidiodes immitis - Immunocompromised pxs

Answer 46

Pathophysio - Pulmonary exposure to fungi by inhalation of airborne fungal spores --> inhalation --> primary pulmonary and LN focus --> impaired immune system disseminate infection to CNS

Answer 47

CM 1. Fever, headache, neck stiffness/pain, deterioration of mental status, CN deficits, sz

Answer 48

Dx 1. CSF analysis – as above 2. India ink – ID cryptococcus showing prominent capsule 3. CALAS – cryptococcal latex agglutination test – ID cryptococcal Ag causing agglutination of CSF 4. Fungal Cx

Answer 49

Mgt: 1. Candida: Amphotericin B 0.1-1 mkd IV OD 2. Cryptococcal: Amphotericin B 0.7-1 mkd OD x 6 wks then Fluconazole LD 12 mkdose then MD 6-12 mkd OD po/IV x 10-12 wks

Answer 50

CH 163: PERIODIC FEVER, APHTHOUS STOMATITIS, PHARYNGITIS, ADENITIS (PFAPA) SYNDROME - Most common recurrent fever syndrome

Answer 51

CM: 1. Recurring fever, malaise, exudative appearing tonsillitis with (-) throat culture, cervical LNE, oral aphthae 2. Headache, abdominal pain, arthralgia 3. Episodes last 4-6d, often with clock-like regularity (q3- 6wks) 4. Mild hepatosplenomegaly 5. Frequency and intensity of episodes decrease with increasing age

Answer 52

Dx: 1. CBC – mild leukocytosis 2. Elev CRP, ESR

Answer 53

Mgt: 1. Prednisone 0.6-2mg/kg SD 2. Cimetidine 20-40mkd – prevent recurrence

Answer 54

Fever >38C documented by health professional w/o identifiable cause for >3wks (OPD)/ >1wk (in-px) A. Neonates - GBS, E.coli, Listeria, HSV - ALL should be hospitalized - Tx: ampicillin + cefotaxime or ampicillin+gentamicin + acyclovir B. 1-3 mos old - Mostly viral - E.coli most common bacterial. - GBS, L.monocytogenes, Salmonella, N.menigitidis, S.pneumonia, HiB, S.aureus - UTI is most serious bacterial infection (E.coli) - Rochester criteria (low risk): well child +: 97 § WBC 5-15K: ANC <1500 § Urine <10 WBC (-) RBC, LE § Stool <5 (-)RBC - Tx: ampicillin + ceftriaxone or cefotaxime - Add vancomycin if with meningitis C. 3-36 mos old - Mostly viral - S.pneumonia, N.meningitidis, Samonella - Risk factors for bacteremia: T>39C, WBC >1500, elev ANC, band, ESR, CRP - Dx: UA, UCS – if uncircumcised or F<2yo D. Drug fever - Fever lyses after 72h off drug

Answer 55

DDx: URTI (p. 26) Bacterial sinusitis (p.45) Bronchiolitis (p.28) Pneumonia (p.29) Viral syndromes (p.54-69)

Fever Flashcards

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