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Resident Board Review. Joseph G. Timpone Jr. MD Georgetown University Hospital. Case One.

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Resident board review l.jpg

Resident Board Review

Joseph G. Timpone Jr. MD

Georgetown University Hospital


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Case One

  • An 80 y.o. female presents to the ER with a 3 day history of fatigue, abdominal cramps and bloody diarrhea. She denies any fevers and states that 10 days ago she was at a State Fair where she ate hotdogs, baked beans, coleslaw, and drank fresh apple cider. PEX: T=37 BP=140/90 P=100 ABDON: generalized tenderness LABS: WBC 12.0 HCT 19.0 PLTS 90,000 BUN/Cr 50/3.0 LDH 400 T.Bili 4.0


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The most likely causative pathogen is:

  • A) S. aureus

  • B) B. Cereus

  • C) Norwalk virus

  • D) Listeria

  • E) E.coli O157:H7


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E. Coli 0157:H7

  • 21,000 Cases/YR; 6% pts. Develop HUS; 12% Mortality

  • Epidemiology: Young children & elderly; undercooked ground beef, unpasteurized milk, apple cider, water/vegetables contaminated with manure.

  • Incubation 3-4 days; ABD. cramping; bloody diarrhea (35 - 90%); fever uncommon (30%)

  • HUS: MAHA, Thrombocytopenia, ARF, can also see TTP.

  • Diagnosis: colorless, Sorbitol non-fermenting colonies on Sorbitol-Maconkey agar; 0157 Antisera Agglutination test.

  • Treatment: antibiotic use may increase risk of HUS


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Case Two

  • A 30 y.o. healthy male is brought to the ER by his co-workers after a syncopal episode at work. In the ER the pt is arousable and noted to be afebrile. BP=70/40 P=40 EKG:3° Heart block. The pt states that he had recently returned from a hiking trip in New England one month ago.


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The most likely causative pathogen is:

  • A) S. aureus

  • B) B. Burgdorferi

  • C) S. pyogenes

  • D) R. rickettsii

  • E) Coxsackie virus


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Lyme Disease

  • North America: Borrelia Burgdorferi; Europe: B. Afzelii; Asia: B. Garinii

  • Southern New England, Middle Atlantic, Wisconsin, Minnesota, California

  • Ixodes Scapularis (Deer Tick): Nymphal stage must be attached for > 72 Hrs. to result in transmission

  • Stage 1: Viral-like illness associated with erythema migrans (60 - 80%). Expanding annular lesion with central clearing (at least 5cm by CDC criteria)


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Acute Disseminated Lyme Disease (Stage 2)

  • Neurologic (occurs in 15% of patients)

    • Lymphocytic meningitis

    • Cranial Neuritis (Bell’s Palsy)

    • Motor-sensory polyradiculo neuritis

    • Mono-neuritis multiplex; myelitis

  • Cardiac (occurs in 5% of patients)

    • Atrio-ventricular block

    • Myo-pericarditis

    • Cardiomegaly/LV dysfunction (rare)


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Chronic Lyme Disease (Stage 3)

  • Arthritis: (60% of untreated patients)

    • Oligo-articular/Mono-articular (Kness)

    • Treatment resistant arthritis in 10%

    • More common in North America

  • Neurologic

    • Cognitive dysfunction/encephalopathy

    • Polyneuropathy

    • More common in Europe

  • Chronic Skin Lesions

    • Acrodermatitis chronicum atrophicans

    • Associated with polyneuropathy


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Lyme Disease: Diagnosis

  • 70% - 80% pts. have (+) IgM by 2 - 4 wks.

  • (+) IgG @ > 4 wks.

  • An isolated (+) IgM in the absence of a (+) IgG after one month of symptoms is likely a false (+) IgM

  • IgM and IgG can remain (+) for years

  • False (+): endocarditis, parvovirus B19, syphilis, EBV, SLE, RA

  • Elisa must be confirmed by W.B.

  • 5% of pts. In non-endemic area can be false (+)

  • PCR -> CSF; C6 Ab


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Lyme Disease: Treatment

  • Stage 1 (E.M.): Doxycycline, Amoxicillin, Cefuroxime, Erythromycin for 14 - 21 days

  • Neurologic/cardiac: IV Ceftriaxone, Cefotaxime, PCN

    • Bell’s Palsy -> ? Doxycycline

  • Arthritis: Doxycycline x 30 days or IV Ceftriaxone x 14 - 28 days


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Lyme Disease: Prevention

  • Prophylaxis: Doxycycline 200 mg x 1 dose has 87% efficacy for I. scaplilaris tick bits (0.4% vs. 3.2% - Doxy vs. placedo)

  • Recombinant OspA vaccine is 78% effective (0, 1, 12 mos. Or 0, 1, 2 mos.)

    Steere NeJM vol. 345; July 12, 2001

    Nadelman , et.al NeJM vol. 345; July 12, 2002


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Case Three

  • A 75 y.o. male with a history of HTN presents with a 1 wk history of fevers and fatigue. His PCP obtains some labs which reveal WBC 5.0 HCT 20.0 PLTS 40,000 AST 100 ALT 50 T.Bili. 3.5 LDH 525. The pt recently returned from his summer home in Nantucket.


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The most likely causative organism is:

  • A) B. Burgdorferi

  • B) B. Microti

  • C) F. Tularensis

  • D) R. Rickettsii

  • E) E. Chaffeensis


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Babesioses

  • Caused by B. microti and B . equi

  • Vector: Ixodes scapularis

  • N.E. (Cape Cod), California

  • Can be transmitted by transfusions

  • Elderly, splenectomized pts.

  • Fever, myalgias, H/A, hemolytic anemia, thrombocytopenia, elevated LFTs

  • Diagnosis: Peripheral smear, serology, PCR

  • Treatment: Quinine + Clindamycin; Atovaquone + Azithromycine; exchange transfusion

  • 20% co-infection with B. burgdorferi


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Case Four

  • A 29 y.o. female presents to the ER with fevers, cough, and S.O.B. PEX: T 39.5 BP 110/80 P 120 O2 SAT. 88% CXR: diffuse pulmonary infiltrates LABS: WBC 25.0 HCT 55.0 PLTS 50,000 PT/PTT 16/60

    The pt recently traveled to Arizona where she stayed on an Indian reservation to learn how to make jewelry.


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The most likely causative organ

  • A) S. pyogenes

  • B) Listeria

  • C) C. Immitis

  • D) C. Neoformans

  • E) Hanta Virus


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Hantavirus

  • Hanta virus: RNA virus; Bunyaviridae(Sin NOMBRE virus)

  • Hantavirus Pulmonary Syndrome

  • S.W. U.S. (New Mexico, Arizona, Utah, Colorado) has been reported in all States

  • Rodent exposure (Peromyscus maniculatus)

  • 4 Phages: febrile, shock, diuresis, convalescent

  • Clinical: fever, myalgias, cough, dyspnea, H/A, GI symptoms

  • Labs: leukocytosis, hemoconcentration, thrombocytopenia, prolonged PT/PTT

  • Rapidly progressive pulmonary edema with hypotension

  • Diagnosis: IFA of sputum, lung tissue

  • Treatment: ? Ribavirin

  • Case Fatality 76%


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Case Five

  • A 32 y.o. male presents to the ER with fever and a ulcerative skin lesion on his arm. In the ER he has a T=103, and you notice ipsilateral axillary lymphadenopathy. Ten days ago he returned from a hunting trip where he killed and skinned a rabbit, fox, and deer.


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The most likely causative pathogen is:

A) B.burgdorferi

B) B. anthracis

C) Y. Pestis

D) V. Vulnificus

E) F. Tularensis


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Tularemia: Francisella Tularensis

  • Gm (-) coccobacillus; requires cysteine for growth

  • Contact with infected animals (rabbits, squirrels, cats), inhalation, tick bite

  • Peak occurs with tick-borne exposure and hunting season

  • Southcentral and Southwestern United States- Oklahoma, Arkansas, Texas

  • Hunters, trappers, lab workers



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Tularemia: Incidence

  • 1990-2000 – 1368 cases.

  • Approximately 124 cases/year reported to the CDC.

  • 56% cases were reported from Arkansas, Missouri, South Dakota, and Oklahoma.

  • Endemic on Martha’s vineyard.

  • 70% cases between May and August.

    (MMWR 2002 Mar 8; 51 (9) 182-184)



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Francisella Tularensis

  • Small non-motile gm (-) cocci bacillus.

  • Can survive for weeks at low temperatures in water, moist soil, hay and decaying animal carcasses.

  • Voles, mice, rabbits, hares, squirrels are reservoirs.

  • Vectors: Ticks, flies, mosquitoes.

  • Human infection

  • Tick bites

  • Handling infected animals or animals products.

    • Ingestion.

    • Inhalation.


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Tularemia: Clinical

  • 50% of patients with ulcer node disease

  • Patients develop ulcerative lesion at site of exposure which is associated with ipsilateral lymphadenopathy

  • Bacteremia, pneumonia, oculo-glandular disease

    • Pneumonia in gardeners on Martha’s Vineyard




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Pneumonic Tularemia: Clinical

  • Fever and non-productive cough

  • 3 -5 day incubation period (range 1- 14 days)

  • CXR: pneumonia, pleural effusion, and hilar lymphadenopathy


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Diagnosis, Treatment and Prevention

  • Diagnosis: grows on media enriched with cysteine; serology

  • Treatment: streptomycin, gentamicin, doxycycline, ciprofloxacin

  • P.E.P.: doxycycline or ciprofloxacin

  • Live attenuated vaccine: lab workers

  • Respiratory isolation not needed


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Case Six

  • A 25 y.o. male presents to the ER with fevers, myalgias, LBP, nausea, and vomiting. In the ER he has a T=39.5, BP 80/40, P=120 and you notice a rash. Labs: WBC 25,000, HCT 45, PLT 40,000, BUN/Cr 40/2.2. The patient has returned from a camping trip in North Carolina one week ago.


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The most likely causative pathogen is:

A) B. burgdorferi

B) S. Pneumoniae

C) R. Rickettsii

D) B. Microti

E) Leptospiria


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Rocky Mountain Spotted Fever

  • Caused by Rickettsia rickettsii

  • D. andersoni & D. variabilis

  • South Atlantic Coastal, western and south central states (North Carolina, South Carolina, Oklahoma, and Tennessee)

  • > 95% cases April - September

  • Dogs, wooded areas, males


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RMSF: Clinical

  • Incubation 5 - 7 days (2 to 14 days)

  • Fever, H/A, malaise, nausea, vomiting, abd. pain

  • Rash: 1 - 5 days after onset of illness; macules on wrists & ankles; spread to trunk, palms, and soles; 10% pts. without rash

  • Thrombocytopenia, DIC, elevated [email protected] ARF, ARDS


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RMSF: Diagnosis & Treatment

  • Mortality: 5 - 25%

  • Diagnosis: DFA of skin biopsy - Serology

  • Treatment: Tetracyclines & chloramphenicol


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Case seven

  • A 50 y.o. male with a history of hemachromatosis was brought in by his friends with fevers, diarrhea, & severe weakness. They had recently returned from a boating trip on the Chesapeake bay where they ate fresh crab and other assorted shellfish. On exam T=39 BP 70/40 P130


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The most likely causative pathogen is:

  • A) S. aureus

  • B) Campylobacter jejuni

  • C) Shigella

  • D) Mycobacterium marinum

  • E) Vibrio vulnificus


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Vibrio Vulnficus

  • Seawater or raw seafood/shellfish (oysters)

  • Chesapeake bay, Gulf coast (hurricane Katrina)

  • Liver disease, cirrhosis, hemachromatosis, ETOH

  • Septicemia with metastatic skin lesions

  • Diarrhea

  • rapidly progressive cellulitis

  • 50% mortality

  • Tetracycline/doxycycline; combination therapy with doxycycline + 3rd generation sephalosporin (ceftriaxone, cefotaxime)


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A Trip to the Zoo

Joseph G. Timpone, M.D.

Division of Infectious Diseases


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A 35 year old male is brought to a NYC E.R. with fevers H/A and (R) inguinal pain. In the E.R. he is noted to have T = 40oC, P = 120, and BP = 80/40. There is a 3x3 cm tense lymph node in (R) inguinal region. WBC = 25,000, PLTs = 60,000, Bun/Cr = 40/2.0.


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The patient reports that he is visiting from Colorado where he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.


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The most likely causative agent would be: he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.

  • a.) Sin Nombre Virus

  • b.) Francisella Tularensis

  • c.) Coxiella Burnettii

  • d.) Yersinia Pestis

  • e.) Bacillus Anthracis


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Plague: Yersinia Pestis he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.

  • gm(-) Cocco-Bacillus (bipolar appearance - “safety pin”)

  • Rats, ground squirrels, prairie dogs, cats

  • Rodent Flea: Xenopsylla cheopis

  • S.W. US (New Mexico, Arizona, Colorado, California)

  • Recreational/occupational : hunting, camping, military


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Plague: Clinical he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.

  • Incubation: 2 -6 days

  • Bubonic: Tense, Tender, Fluctuant nodes (inguinal, axillary, cervical)

  • Pneumonic: cough, hemoptysis, watery sputum; patchy/lobar infiltrates

  • Septicemic: hypotension, DIC, gangrene

  • Meningitis, Pharyngitis


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Plague: Diagnosis he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.

  • 50% mortality with out treatment: 5% with treatment

  • Aspirate/culture of Bubo -> Wayson’s stain (bipolar staining - “safety pin”)

  • DFA staining

  • PCR

  • Serology


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Plague: Treatment he is employed as a veterinarian. He has recently cared for a few sick cats, a rabbit and assisted in the birth of a calf.

  • Streptomycin or gentamicin

  • Alternative: Doxycycline, Ciprofloxacin

  • P.E.P: Doxycycline

  • respiratory isolation x 48 - 72 hrs.


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A 28 year old male presents to the E.R. with fevers, H/A, Rash, Dyspnea and a dry, non-productive cough of 3 days duration. His PEx reveals a T = 40oC, P = 60, and 02SAT = 95%. There are crackles at the (R) Lung base; (+) Splenomegaly, and a pink macular rash on his face and trunk.


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His CXR reveals a (R) lower lobe consolidation. He reports that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.


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The most likely Causative Pathogen is: that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.

  • a.) Histoplasma Capsulatum

  • b.) Cryptococcus Neoformans

  • c.) Chlamydophila Psittaci

  • d.) Legionella Pneumophila

  • e.) Mycoplasma Pneumoniae


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Chlamydophila that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.

  • Obligate intra-cellular pathogen

  • Parrot, finch families, turkeys, pigeons, poultry

  • Transmission: aerosolized secretions, excrement

  • Pet owners, pet shops, vets, abattoir workers, farmers


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C. psittaci Clinical that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.

  • Incubation 5 - 15 days post exposure

  • Fever, H/A, dry cough, and SOB

  • Splenomegaly

  • Horders spots: pink macular rash on face, trunk

  • CXR lower lobe consolidation

  • Labs: nl WBC, elevated LFTs


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C. psittaci that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.

  • Diagnosis: serology, culture (lab hazard)

  • Treatment: doxycycline x fourteen - 21 days; Macrolides, quinolones

  • Miscellaneous; Meningitis, Myocarditis, Pericarditis


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Case 4 that he has been feeling fatigued during the past week due to his overtime hours at the Turkey Farm. His flag football team - The Turkey Torturers are scheduled to play in the Thanksgiving Turkey Bowl this week - But 3 teammates/co-workers are also sick.

  • A previously healthy male presents to the ER with fevers, H/A and cough. He is employed as a detective and his hobbies include hiking, camping, and hunting. His most recent camping trip was approximately 8weeks ago. Ten days ago, he was playing poker in his friend’s basement, and witnessed the birth of a litter of kittens. In the ER, he has a T=102, P=80, and BP=130/60. Crackles are heard at the bases. WBC 5.0 Hct 42 Plts 105,000 AST 68 ALT85. CXR reveals bilateral lower lobe airspace disease. The pt. reports that all of his buddies have been diagnosed with pneumonia.


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The most likely explanation for the cluster of pneumonia cases is:

A. An act of bioterrorism

B. Inhalation of infected birth products

C. Ingestion of poorly cooked Mexican cheese (on the nachos at the poker game)

D. Participation in a bachelor party at “Good Guys”

E. Water exposure while camping


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Poker Player’s Pneumonia cases is:

  • Q - Fever pneumonia (Coxiella Burnetii)

  • Urban outbreak amongst poker players

  • Exposure: parturient Cat -> kittens


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Q Fever: Background cases is:

  • 1935: Derrick described febrile illness in abattoir workers in Australia

  • Q Fever - (query)

  • MacFarlane-Burnet and Freeman isolated organism from guinea pigs inoculated with blood of febrile patients

  • Cox and Davis isolated GM(-) organism from ticks in Montana

  • Coxiella burnetii


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Q Fever: Microbiology cases is:

  • Caused by C.burnetii

  • SmallGM(-) bacterium that grows exclusively in eukaryotic cells

  • Gamma subgroup of proteobacteria; related to Legionella

  • LPS -> antigenic shift/phase variation

  • Phase 1-> infectious form


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Q Fever: Epidemiology cases is:

  • Cattle, goats, sheep, cats, rabbits, dogs, birds, ticks

  • Farmers, veterinarians, abattoir workers

  • Transmission via inhalation of organisms or ingestion of raw milk

  • Parturient cats and farm animals

  • Worldwide geographic distribution


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Q Fever: Clinical cases is:

  • 54% of cases are asymptomatic

  • Incubation period 2-6 weeks

  • Abrupt onset of fever and headache

  • Fever (90%), Pneumonia (45%), and Elevated LFTs (69)

  • Atypical Pneumonia

  • Granulomatous Hepatitis

  • Maculopapular/purpuric rash in 20% (Leukocytoclastic Vasculitis)


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Q Fever: Chronic cases is:

  • Culture (-) endocarditis of damaged or prosthetic valves

  • Decreased cell-mediated immune response to C.burnetii

  • Clubbing, hepatomegaly, splenmegaly, purpuric rash, and arterial emboli

  • Hypergammaglobulinemia, microscopic hematuria, elevated ESR


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Q Fever: Miscellaneous cases is:

  • Myocarditis/pericarditis

  • Meningoencephalitis

  • Osteomyelitis

  • Hemolytic anemia

  • Epididymitis/orchitis


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Q Fever: Laboratory cases is:

  • Normal white blood cell count (90%)

  • Thrombocytopenia (25%)

  • Increased transaminase levels (70%)

  • Smooth muscle autoantibodies (65%)

  • Anti-phospholipase antibodies (50%)


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Q Fever: Diagnosis cases is:

  • Cell culture (shell vial -> immunofluorescence)

  • Incubation period 8-12 days

  • Culture of buffy-coat and biopsy specimens

  • PCR of biopsy specimens

  • Granuloma: “doughnut” appearance


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Q Fever: Serology cases is:

  • CF, IFA, and ELISA

  • IFA phase II antigen > 1:200

    • IgG > 1:200

    • IgM > 1:50

  • Serology (+) at 2-4 weeks

  • IgM serology (+) for 6-8 months


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Q Fever: Treatment cases is:

  • Doxycycline, TMP/SMX, Ciprofloxacin, Rifampin

  • Acute: duration 15-21 days

  • Chronic: duration (?) 3 years

  • Relapses are common

  • (?) Hydroxychloroquine + Doxycycline


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Case 5 cases is:

  • Dan Rather presents for evaluation of a skin lesion. He reports that he recently returned from Afghanistan where he was in hot pursuit of Usama Bin Laden. He states that he had to sleep on the floors of caves, wade across some murky waters, an use a camel for transportation. His diet consisted of nuts, berries and insects. His exam reveals an eschar on the dorsum of his right hand with surrounding edema. His only other complaint is that he is very depressed due to some comments that he received in his fan mail.


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The most likely causative pathogen is: cases is:

A. Bacillus anthracis

B. Variola

C. Bartonella henselae

D. Borrelia burgdorferi

E. Histoplasma capsulatum


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Anthrax: Microbiology cases is:

  • Aerobic

  • Nonmotile

  • Spore forming

  • Gram + bacillus

  • Spores survive > 30 yrs in soil


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Anthrax: Epidemiology cases is:

  • Zoonotic disease in herbivores

  • Human infection can occur via contact with infected animals or animal products, ingestion or inhalation

    • NO person-to-person transmission

  • Early 1900s: 130 cases annually in the US

    • >95% of disease is cutaneous

    • Last naturally occurring cutaneous case 1992

  • 20th century 18 inhalation cases

    • Last naturally occurring inhalation case 1976

  • 2001 Bioterrorism threat in Postal Workers, News Reporters, and Federal Government Employees


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Cutaneous anthrax cases is:

  • Direct contact with spores

  • Does not affect intact skin

  • Commonly seen on the head, forearms or hands

  • Incubation 1-12 days

  • Localized itching, followed by a papular lesion  vesicular  painless depressed black eschar

  • Mortality up to 20% without abx; rare with abx

  • Abx do not change the progression of the lesion

  • DDX: Spider bite, Ecthyma gangrenosum, tularemia, plague, cellulitis

    JAMA 1999; 281:18


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Inhalational anthrax cases is:

  • Incubation period avg 1-7d

  • Flu-like prodrome

  • Brief improvement

  • Abrupt respiratory failure and collapse

  • CXR: widened mediastinum, pleural effusions, infiltrates, ? consolidation

  • 50% hemor. meningitis

  • Mortality: 89%

  • DDX: atypical pneumonia, tularemia, Q fever, fungal pneumonia


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TRAVEL NIBLETS cases is:

Joseph G. Timpone Jr., MD

Georgetown University Hospital


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A 28 y.o. male PCV has returned from a two year assignment in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

WBC 15,000, AST 80, ALT 90, ALK PHOS 250.


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The most appropriate diagnostic study would be: in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

A) stool for O and P

B) Blood cultures

C) Aspiration of the liver lesion

D) Serology

E) ERCP


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Amebiasis in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

  • Entamoeba histolytica causative agent

  • 90 % of infections asymptomatic, remaining 10 % produce spectrum of clinical syndromes

  • Acquired by ingestion

  • 10 % of world's population is infected

    • Third most common cause of death from parasitic disease (after schistosomiasis and malaria)

  • Invasive amebiasis have unique virulence properties compared with noninvasive


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Intestinal Amebiasis in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

  • Asymptomatic cyst passage most common

  • Symptomatic colitis develops 2 to 6 weeks after the ingestion of infectious cysts

  • Stools contain little fecal material and consist mainly of blood and mucus

  • Rare intestinal forms:

    • Fulminant intestinal infection

    • Toxic megacolon

    • Chronic amebic colitis (confused with IBD)


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Amebic Liver Abscess in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

  • Always preceded by intestinal colonization

  • 95 % occur within 5 months of exposure

  • Majority present with fever and RUQ pain

  • Only 1/3 of patients have active diarrhea

  • 10 to 15 % present only with fever

  • Complications of amebic liver abscess:

    • Pleuropulmonary involvement (20 to 30 %)

    • Rupture into peritoneum

    • Rupture into pericardium


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Diagnostic Tests in Africa and presents to the ER with a 3 day hx/o fever, nausea, vomiting, RUQ pain. He denies any diarrhea. Exam reveals T=38.5, and RUQ tenderness.

  • Stool examinations:

    • Positive test for heme

    • Paucity of WBC’s

    • Important to examine 3 fresh stools

    • Confirms diagnosis in 75 to 95 % of cases

    • Cysts must be differentiated from Entamoeba hartmanni, Entamoeba coli & Endolimax nana

  • Serologic tests

    • 70 % positive with colitis or 90% positive for abscess

    • Suggest active disease because serologic findings usually revert to negative within 6 to 12 months

  • Noninvasive imaging of the liver

  • Treatment: metronidazole + paronomycin

  • Stool antigen for E.Histolytica


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A 20 y.o. male presents with watery diarrhea. He has had recurrent infections with the pathogen shown on the previous slide.


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The most likely cause of recurrent infection is: recurrent infections with the pathogen shown on the previous slide.

A) Neutropenia

B) HIV infection

C) Lymphocytopenia

D) Compliment deficiency

E) IgA deficiency


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Giardia lamblia recurrent infections with the pathogen shown on the previous slide.

  • Worldwide distribution

  • Most common intestinal parasite in USA (found in 4 to 7% of O&P specimens)

  • Transmission:

    • Water contamination most common (not killed be standard chlorine concentrations)

    • Person-to-person (daycare, homosexual etc.)

    • Foodborne

  • Hypogammaglobulinemic and achlorhydric patients at greater risk


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Giardia lamblia recurrent infections with the pathogen shown on the previous slide.

  • Incubation period of 1 to 2 weeks

  • Spectrum of disease varies widely

  • Of 100 people ingesting cysts:

    • ~5-15% become asymptomatic cyst passers

    • ~25-50% have diarrheal syndrome

    • ~35-70% have no trace of infection

  • Diarrheal syndrome typically acute lasting 1-3 weeks but can be chronic with weight loss

  • Giardia does not invade mucosal tissue

  • Lactase deficiency after infection common


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Giardia lamblia recurrent infections with the pathogen shown on the previous slide.

  • Diagnosis:

    • O&P test of choice (90% yield from 3 specimens)

    • Giardia stool antigen (85-98% sensitive)

    • Duodenal sampling (seldom needed)

      • String test

      • Duodenal aspiration/biopsy

  • Therapy:

    • Metronidazole for 7 days (efficacy 80-95%)

    • Furazolidone and paromomycin alternatives


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A 24 y.o. male Marine has recently returned from a tour of duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.


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The most likely causative pathogen would be: duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.

A) Group A streptococcus

B) MRSA

C) Bacillus anthracis

D) Herpes simplex

E) Leishmania


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Leishmaniasis duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.

  • Obligate intracellular protozoa (genus Leishmania)

  • Syndrome caused by ~21 leishmanial species

  • Vector is the sandfly (~30 species)

  • 1.5 to 2 million new cases yearly

  • Three clinical syndromes caused by replication of parasite inside macrophages :

    • Visceral

    • Cutaneous

    • Mucocutaneous


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Cutaneous Leishmaniasis duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.

  • Traditionally classified as New World or Old World

  • Most cases occur in men who have forest-related occupational exposures

    • chiclero ulcer


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Leishmaniasis duty in Iraq. He reports a month history of a non-healing skin ulcer. He was given two courses of antibiotics (Cephalexin, Levofloxacin) without any improvement. He has no other complains.

  • Types: Cutaneous, Mucocutaneous, Visceral

  • Old world: L. tropica; New world: L. braziliensis

  • Cutaneous Leishmaniasis: Chronic non-healing ulcer or nodule

  • Visceral: fevers, N.S. wt. Loss, massive splenomegaly

    • caused by L. donvani (can see L.tropica in Gulf War Vets.)

    • AIDS - defining illness in Southern Europe

  • Treatment: Antimony, AMB, Pentamidine


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  • The most likely cause of her seizures would be: because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.

  • A) MTB

  • B) N. meningitidis

  • C) T. cruzii

  • D) T. solium

  • E) HSV


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T. Solium And Cysticercosis because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.

  • Pork tapeworm T. solium causative agent

  • Two distinct forms of infection:

    • Intestinal tapeworms by ingesting undercooked pork

    • Cysticercosis (larval forms in tissues) follows ingestion of T. solium eggs

      • Usually from fecally contaminated food

      • Autoinfection

      • Reflux from intestine into the stomach.

  • Exists worldwide (10% prevalence in some areas)


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Clinical Manifestations because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.

  • Intestinal infection:

    • Usually asymptomatic

    • Tapeworm ~3 meters in length

    • Normally, only one worm (live up to 25 years)

    • Fecal passage of proglottids may be noted

  • Cysticercosis:

    • Larvae location (most commonly brain and muscle) and size determine clinical presentation

    • Neurologic manifestations most common


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Diagnosis because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.

  • Intestinal infections:

    • Detection of eggs or proglottids by O&P

  • Cysticercosis:

    • Definitive diagnosis requires examination of larvae in involved tissue

    • Diagnosis often based on clinical presentation with radiographic studies and serologic tests


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Treatment because of new onset seizures. She’s currently employed as a daycare worker. She denies any fevers, night sweats, weight loss or other symptoms. She has a negative PPD. In the ER the patient is a febrile and post-ictal.

  • Intestinal infection treated with praziquantel

  • Asymptomatic patients with calcified lesions generally require no treatment

  • Symptomatic neurocysticercosis:

    • Albendazole treatment of choice (better CSF levels)

    • Praziquantel alternative

    • Treatment provokes inflammation around dying cysticerci  hospitalize and give glucocorticoids

    • Ventricular obstruction may need VP shunting


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The most appropriate therapy would be: presents with the abrupt onset of fevers, photophobia, H/A, and diarrhea 48 hours upon return to the US. On the Exam her T=39.5. There is no meningimus or rash. WBC 5.0, HCT 29, PLT 55,000, LDH 400, bili 3.0, BUN/Cr 25/1.8.

A) Ceftriaxone + Vancomycin

B) Chloroquine

C) Mefloquine

D) Quinine + Doxycycline

E) Primaquine


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Fever in Travelers presents with the abrupt onset of fevers, photophobia, H/A, and diarrhea 48 hours upon return to the US. On the Exam her T=39.5. There is no meningimus or rash. WBC 5.0, HCT 29, PLT 55,000, LDH 400, bili 3.0, BUN/Cr 25/1.8.

  • Malaria

  • Dengue Fever

  • Typhoid Fever

  • Meningococcemia

  • MTB

  • Leptospirosis

  • SARS


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Malaria presents with the abrupt onset of fevers, photophobia, H/A, and diarrhea 48 hours upon return to the US. On the Exam her T=39.5. There is no meningimus or rash. WBC 5.0, HCT 29, PLT 55,000, LDH 400, bili 3.0, BUN/Cr 25/1.8.

  • P. falciparum, P. vivaz, P.ovale, P. malariae

  • Sub-Saharan Africa, S.E.A., Latin America, Middle East

  • Fever in Travelers: Malaria, Typhoid Fever, Dengue Fever, Meningococcemia

  • Fever, H/A, rigors, photophobia, HSM, hemolytic anemia, thrombocytopenia, hyerbilirubinemia, hypoglycemia, ARF

  • P. falciparum: ARDS, Cerebral Malaria

  • Prophylaxis: Mefloquine, Doxycycline, Proguanil/Atovaquone; Chloroquine in Mexico, Central America, Caribbean

  • Treatment: P. falcip. - Quinine+Doxycycline (Quinidine for severe cases)


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A 60 y.o. male with AML is s/p induction chemotherapy and has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.


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Stool for O & P would most likely yield: has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

A) S. stercoralis

B) E. histolytica

C) G. lamblia

D) A. lumbricoides

E) A. duodenale


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Strongyloidiasis has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • Strongyloides Stercoralis

  • Clinical; diarrhea, ADB. Pain, urticaria, larva currens, pulmonary, infiltrates, eosinophilia

  • O&P, duodenal aspirate (string test)

  • Strongloidis AB

  • Hyperinfection: steroids, chemotherapy, AIDS, transplantation, HTLV infection

    • polymicrobial gm(-) bacteremia

  • Treatment: Ivermectin, Thiabendazole, Albendazole


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Cryptosporidiosis has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • Caused by C. parvum

  • Immunocompromised (AIDS) & Immunocompetent patients

  • Water borne illness (Milwaukee, WI 400,000 cases)

  • Watery diarrhea, abd. Pain, n/v, cholangiopathy in AIDS patients

  • Diagnosis: modified AFB stain

  • Treatment: ? Paronomycin, azithromycin; Nitazoxanide


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PUTTING THE FUN IN FUNGUS has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

Joseph G. Timpone, Jr. M.D.

Georgetown University Hospital


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CASE ONE has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • A 45 y.o. male with DM and ESRD s/p renal transplant three months ago presents with fevers, n.s. and S.O.B. His meds include CYA, MMF, Prednisone. In the ER T=39, BP=80/40, there are oral ulcers. CXR reveals interstitial infiltrates. WBC 2.0, PLT 50K, INR =3.0, LDH 400. The patient is employed as a chicken farmer.


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Histoplasmosis: Etiology has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • Histoplasma capsulatum

  • Dimorphic fungus

  • Grows in soil

  • Chicken, starling, & bat excrement


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Histoplasmosis: Epidemiology has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • Endemic in east/central U.S.

  • Ohio and Mississippi River Valleys

  • Farming, rural, urban settings

  • High rate of infection in endemic regions


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Histoplasmosis: Clinical Features has fevers and neutropenia. Blood cultures reveal E.coli, K. pneumonia, Ps. Aeruginosa. The patient has immigrated from Vietnam 20 years ago.

  • 90% asymptomatic

  • Fever, night sweats, weight loss

  • Cough, pleurisy, SOB

  • Arthralgias, myalgias

  • Lymphadenapathy

  • E. nodosum/multiforme


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Risk Factors for Progressive Disseminated Histoplasmosis (PDH)

  • Depressed cell mediated immunity

  • Advanced HIV disease

  • Corticosteroids, Methotrexate

  • Infliximab, Etanercept (Anti-TNF-Alpha therapies)

  • Solid organ transplantation

  • Elderly

  • Defects in the IFN-GAMMA-ILI2 Pathway

  • DM, ESLD, ESRD


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PDH: Clinical Features (PDH)

  • Fulminant course in AIDS/Transplant pts.

  • Most common AIDS defining illness in endemic areas

  • Can occur as acute exogenous infection and as reactivation

  • Fever, night sweats, wt. Loss, oral ulcers, lymphadenopathy, Hepatosplenomegaly

  • Pulmonary involvement: CXR with diffuse interstitial infiltrates

  • GI involvement (ILEO-CECAL region; can mimic IBD)

  • Adrenal insufficiency

  • Leukopenia, anemia, thrombocytopenia, DIC, elevated LDH


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PDH: Diagnosis and Treatment (PDH)

  • Urinary & serum histoplasma Ag (90% urine; 70% serum)

  • 95% sensitivity in HIV (+)

  • 82% in non-HIV immunosuppressed patients

  • Treatment Amphotericin B (Lipid preparation; Itraconazole)


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CASE TWO (PDH)

  • A 35 y.o. male lumber jack from Wisconsin presents to the ER with a two week history of cough and sputum production. His CXR reveals a dense alveolar inflitrates.


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Blastomycosis: Etiology & Epidemiology (PDH)

  • Caused by Blastomyces dermatitides

  • Isolated from soil and decaying wood

  • Midwest near Great Lakes, Canada, South central states bordering Ohio & Mississippi River Valleys

  • Occupational & recreational exposure near waterways

  • Inoculation via inhalation, skin, dog bites


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Blastomycosis: Clinical (PDH)

  • Acute Pulmonary Blastomycosis: fever, chills, myalgias, arthralgias, cough, sputum production

  • CXR: alveolar infiltrates in lower lobes

  • Chronic complications

  • Pulmonary

  • Skin: verrucous & ulcerative lesions (40-80%)

  • Bone & joint disease

  • Genitourinary: prostatitis, epididymitis


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Blastomycosis: Treatment (PDH)

  • Acute pulmonary:

    • Treatment indicated for severe disease only

    • Amphotericin B, 1.5-2.5 gm

  • Chronic:

    • Ketoconazole, 400-800 mg/day x 6 months

    • Itraconazole, 200 mg BID x 6 months


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CASE THREE (PDH)

  • A 30 y.o. male construction worker presents with fevers and H/A of two weeks duration. His PMH is significant for HIV with a CD4=75. He has refused all medication. In the ER an LP reveals WBC=100, 5% PMN, 70% LY, 25% EOS, T.P=100, GLU=20. His PPD is negative.

  • His most recent work was at a site in Phoenix.


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Coccidioidamycosis: Etiology & Epidemiology (PDH)

  • Caused by Coccidioides immitis

  • Endemic to Southwestern U.S. & Mexico

  • 100,000 new infections per year

  • Arid climate, low altitudes, alkaline soil


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Coccidioidomycosis: Acute Infection (PDH)

  • 60% of patients are asymptomatic

  • 40% have viral-like illness (fever, myalgias, H/A, non-productive cough lasting 1-3 weeks)

  • CXR: alveolar infiltrate or solitary pulmonary nodule (5% have persistent CXR abnormalities)

  • Most commonly a self-limited illness

  • Allergic manifestations: E. nodosum & multiforme are good prognostic indicators


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Coccidioidomycosis: Disseminated Disease (PDH)

  • Occurs in <0.5% of patients

    • Increased risk:

      • African-Americans, Filipinos, Latinos

      • Pregnant women

      • Cytotoxic chemotherapy

      • Glucocorticoids

      • Organ transplantation

      • HIV disease

  • Disseminates to skin, bone, meninges

  • Severe pulmonary disease


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Coccidioidomycosis: Meningitis (PDH)

  • Often occurs 6 months after initial infection

  • Causes a basilar meningitis

  • Fever, H/A, confusion

  • CSF:

  • Mononuclear cell pleocytosis with eosinophils

    • (+) CF Ab in 70%

    • (+) Culture in 1/3 of cases


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Coccidioidomycosis: Diagnosis (PDH)

  • Skin test

  • Culture: (+) in sputum, joint fluid, CSF

  • Giant spherule on H&E, Pap, KOH prep

  • Serology:

    • 75% Have (+) IgM @ 2-3 weeks

    • 90% Have (+) IgG CF Ab @ 3 months

  • 95% of patients without disseminated disease with < 1:32


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Coccidioidomycosis: Treatment (PDH)

  • Acute: No therapy; consider therapy in high risk groups (Amphotericin B, 0.5-1.5 gm or fluconazole, 400-800 mg qd)

  • Single cavitary disease: No therapy

  • Chronic fibrocavitary disease: Ketaconazole or fluconazole

  • Disseminated: Amphotericin B, 2.5 gm

  • Meningitis: Amphotericin B, IV & Intrathecal; fluconazole

  • Skin & Bone: Ketoconazole or fluconazole


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CASE FOUR (PDH)

  • A 50 y.o. male with ESLD due to HCV is three months S/P OLT. The patient presents with a one week history of low grade fevers and H/A. He’s also noted to have several papular skin lesions. His meds include Tacrolimus and Prednisone. He recently received high dose steroids for a bout of rejection.


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Medical: (PDH)

Ampho B, 0.7 mg/kg/day x 14 days

Flucytosine, 100 mg/kg/day orally in 2-4 divided doses x 14 days

Consolidation from week 2-10 w/fluconazole, 400 mg once daily

Suspected acute cerebral hypertension:

CT or MRI scan to assess obstructive hydrocephalus

If absent, lumbar puncture; if present, ventriculostomy

If cerebrospinal fluid pressure >25 cm, use large-bore needle to lower CSF pressure until it's stable <25 cm H2O

Recommended Management of Cryptococcal Meningitis in AIDS Patients: Initial Rx


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Recommended Management of Cryptococcal Meningitis in AIDS Patients

  • Chronic suppressive management from week 1 0 continued indefinitely: fluconazole, 200 mg qd po.

  • Use of Cryptococcal antigen:

    • Serum: Diagnostic only, should prompt lumbar puncture. If no antigen in CSF and culture of CSF is negative, consider starting fluconazole, 200 mg per day to prevent CNS disease.

    • CSF: Pre-treatment titer>1,1024associatedw/ adverse outcome Post-treatment titer stable or rising suggests relapse


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CASE FIVE Patients

  • A 40 y.o. female with AML is S/P induction chemotherapy and has had an ANC <250 for the past three weeks. She has been treated with Impenem, Vancomycin, and Amphotericin B. She’s developed a cough with hemoptysis.


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Aspergillosis Patients

  • Risk factors: prolonged neutropenia, immunosuppressive therapy, corticosteroids, BMT, organ transplant, hematologic malignancies

  • Highest risk in allogeneic BMT with GVHD

  • Invasive pulmonary disease

  • CNS involvement

  • Diagnosis: BAL, biopsy, serum galactomannan

  • Therapy: Voriconazole, liposomal amphotericin B, itraconazole, caspofungin, surgical resection


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CASE SIX Patients

  • A 60 y.o. diabetic male is brought to the ER by his wife because of mental confusion. She reports that he has been complaining of sinus congestion. In the ER the patient is obtunded and unresponsive. Labs: GLU=450, HCO 3=14, Anion gap=17.


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The most likely causative organism is: Patients

  • A) Nocardia

  • B) Candida albicans

  • C) Rhizopus species

  • D) Pseudomonas aeruginosa

  • E) MRSA


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Zygomycosis/ Mucormycosis Patients

  • Rhizopus, Absidia, Cunninghamella

  • Broad hyphae (5-15 Mm) without septations

  • Have an enzyme keton-reductase which allows it to thrive in high glucose/ acidic environments

  • Iron overload & deferoxamine therapy promote growth

  • DM, Hematologic malignancies, metabolic acidosis, steroids, AIDS, IDU, trauma/burns, malnutrition


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Mucormycosis Patients

  • DM (DKA), leukemia/neutropenia, transplant, deferoxamine therapy

  • Rhinocerebral Mucormycosis

  • Fever, sinus/facial pain/edema, H/A, CN palsies, retinal vein thrombosis, cavernous sinus thrombosis

  • Surgical debridement & Amphotericin B: Posaconazole (60% response rate)


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