ID

Question 1

VAP/HAP

Answer 1

Avoid tigecycline

Question 2

Aspergillus

Answer 2

• Initial therapy for invasive: Vori +/- caspofungin
• If intolerant of vori, use isavuconazole or lipid ampho
• no pleural effusions
• halo signs
• posaconozole for prophylaxis
• chronic necrotizing - vori, or itraconazole

Question 3

Influenza Vaccine

Answer 3

Decreased COPD exacerbations

Question 4

Pertussis

Answer 4

Bordetella pertussis
Posttussive emesis
Cough lasts for weeks
Macrolides early in course effective

Question 5

ESBL

Answer 5

Can be treated with tigecyline, colistin or possibly aminoglycoside but all cause renal tox

Question 6

Hanta virus

Answer 6

Rapidly progressive PNA
Thrombocytopenia
Immunoblasts on smear
Deer mice droppings
Capillary leak

Question 7

TB Meningitis

Answer 7

Steroids recommended for 6-8 weeks

ART should NOT be started within first 8 weeks in HIV

Question 8

Pulmonary TB

Answer 8

• ART should be started within 2 weeks for patients with CD4<50 and within 8-12 weeks for CD4>50
• Daily isoniazid, rifampin, pyranzinamide and ethambutol in first 8 weeks
• PZA, streptomycin, fluoroquinolones not recommended in pregnancy

Question 9

Pleural TB

Answer 9

• Effusions in up to 1/3 of Pulm TB
• increased risk as CD4 goes down
• pleural biopsy shows caseating granulomas
• ADA > 40 - very sensitive. Very sensitive when exudate is lymphocytic

Question 10

MAC

Answer 10

• Can cause granulomas in the airway
• For HIV treatment is clarithromycin, ethambutol and usually rifabutin
• associated with hormonal and immune abnormalities
• presents in 2 distinct ways
  
  • existing lung disease
    
    • fibrocavitary disease
  • non existing lung disease
    
    • fatigue, weight loss common
    • fever not common
    • older women, white, non smokers
    • pectus excavatum, scoliosis, mitral valve prolapse
    • may have CF mutation
• INH not active against MAC
• macrolide + ethambutol + a rifamycin
• relapse is common

Question 11

Actinomycosis

Answer 11

• treatment with high dose Pen G
• pen allergic - tetracyclines, erythromycin, clinda
• often originates in cervicofacial region
• invades mediastinum

Question 12

CVID

Answer 12

• get pneumonia that are covered by childhood vaccines
• mixed obstructive and restrictive
• impaired B-cell differentiation
• average age of diagnosis 20-40 years
• bronchiectasis +/- granulomatous lymphocytic disease
• encapsulated organisms

Question 13

Pneumonia Vaccine

Answer 13

• PPSV23 - 23 purified capsular polysaccharides
  
  • covers 60-70% of invasive pneumococcus
  • decreases infection risk
  • does not decrease mortality
  • everyone over 65
  • every 5 years
• PCV13 - protein-conjugate polysaccharide vaccine
  
  • stimulates better immunity because of protein bound
  • no reduction in mortality
  • repeat not needed
• vaccine naive - PCV13 given first
  
  • PPSV23 at least 1 year later

Question 14

Cocci

Answer 14

• treatment for lung with risk of dissemination with fluconazole or itraconazole
• dimorphous fungus
• septated hyphae in the soil
• forms spherules in the lung
• arthralgias
• eosinophilia
• hilarious LAD
• EN
• diagnosed with antibodies
• or by identifying spherules
• grows easily on culture
• most don’t need treatment

Question 15

Legionella

Answer 15

• culture on buffered charcoal yeast agar (BCYE)

Question 16

Lipoid Pneumonia

Answer 16

• extensive basilar opacities
• can have crazy paving
• GGOs and reticular opacities
• supportive care treatment

Question 17

Tularemia

Answer 17

• caused by Francisella tularensis
• found in
  
  • water or soil
  • ticks
  • wild or domesticated animals
  • decaying animals
• Marthas Vineyard in Mass
• treat with streptomycin
  
  • less severe - tetracycline
• diagnosed with direct fluorescent ab
  
  • or immuno-histochemical
  • or PCR

Question 18

Histo

Answer 18

• GMS stain - round ovoid yeast
• biopsy - granulomatous inflammation with necrosis
• itraconazole
• dimorphic
• bird or bat droppings
• construction
• caving
• difficult to grow
• mild disease - observe
• moderate disease - itraconazole
• ## severe - ampho

Question 19

Nocardia

Answer 19

• Gram positive rod that are branching and filamentous
• bactrim first line
  
  • ertapnenem second line
  • amikacin second line
• grows on aerobic media
• weakly acid fast
  
  • differentiates between other actinomycetes

Question 20

Blastomycosis

Answer 20

• exposed to soil and decaying
• broad based budding
• East Coast
• severe disease or pregnant
  
  • ampho
• non severe disease - itraconazole
• causes ulcerative skin lesions
• diagnoses with culture
• urine, serum or BAL antigen

Question 21

Candida

Answer 21

• many risk factors for candidemia
• skin nodules
• optho
• ## treat with capos/mica first

Question 22

Mucormycosis

Answer 22

• non septated
• right angle branches
• can get pleural involvement - oppose to aspergillus
• does not produce 1,3 beta diglucan or galactomannan
• treatment - ampho B