EM E2: Infectious Disease

What is the test for gonorrhea and chlamydia?

PCR assay

What is the tx for Chlamydia?

Doxy 100 BID x 7 days OR Azithro 1g PO

What is the tx for gonorrhea?

Ceftriaxone 500mg IM (>150kg 1 g)

What is no longer recommended to tx chlamydia or gonorrhea d/t resistant strains?

FQs

What is the MCC of nongonococcal urethritis?

Chalmydia

*also Ureaplasma urea., Mycoplasma, trich

What is the tx for Trichomonas?

Metronidazole 500 BID x 7 days

*must AVOID alcohol while taking

What is the hallmark sign Trichomonas?

strawberry cervix (erythematous, edematous, w/ petechial hemorrhages)

How does the ulcer assoc w/ primary syphilis present?

painless sore

What organism causes syphilis?

T. pallidum -spirochete

What is the tx for Syphilis?

PCN G

alt: Doxy

What is the tx for a Chancroid (Haemophilus ducreyi)?

Azithro 1g PO x1 or Ceftriaxone/Cipro/Erythro

*tx partners if contact w/in last 7 days regardless of sx

What is the tx for Lymphogranuloma venereum (LGV)?

Doxy x 21 days or Erythromycin x 21 days

*mild untx cases resolves spontaneously in 8-12 weeks

*ALSO drain infected buboes

What is the test for HSV?

Tzanck smear

What is the tx for herpes (HSV)?

Acyclovir, Famciclovir, Valacyclovir

How does Granuloma inguinale present?

subcutaneous nodules progress to painless ulcerative lesions

What is the tx for Granuloma inguinale?

Azithro 1g weekly until healed

alt: doxy or TMP-SMX DS x 3 weeks

What types of HPV (genital warts) may coalesce to form condylomata acuminata?

6 & 11

What is the tx for HPV?

Podofilox soln/gel, Imiquimod cream, cryotherapy

Should STDs be treated even if they are only suspected not confirmed?

yes -especially gonorrhea/chlamydia

*single-dose tx in ER when possible

What causes most cases of TSS?

Staph: pts 15-24 yo

Strep: pts 20-50 yo

What are sx of TSS?

fever, chills, N/V, prodromal period, watery diarrhea, lightheaded, syncope, myalgia, HA, confusion, pharyngitis, severe pain at infection site

What is seen on the PE of TSS?

fever > 102, diffuse macular rash, hyperemia, desquamation 1-2 wks after onset, hypotension, multisystem involvement

What is the tx for TSS?

hemodynamic optimization, isolate infection, remove FB, IVF, manage shock, foley cath, start abx (Vanc + Clinda), ICU

What differentiates TSS from streptococcal TSS?

strep develops in association w/ severe soft tissue infection; higher-mortality rate

*culture must reveal GAS

What is the tx for Streptococcal TSS?

hemodynamic optimization, isolate infection, remove FB, IVF, manage shock, foley cath, start abx (PCN G + Clinda; (PCN allergy → erythromycin), debridement of infection site, fasciotomy or amputation

Which type of influenza has greater virulence?

Influenza A

Who is more likely to get the flu?

children; but higher mortality in adults, elderly

When is the flu contagious?

24 hr before sx onset, declines over 3-7days (prolonged in kids)

*2 day incubation period

What are sx of the flu?

acute, rapid onset of fever w/ chills, HA, myalgia, dry cough, rhinorrhea, sore throat, eye pain

elderly have atypical sx (AMX, fever, malaise)

What is the best test for the flu?

viral culture (serologic testing takes days)

What are complications of the flu?

pneumonitis, bacterial PNA, croup, COPD exacerbation, Reye syndrome, rarely GBS, myocarditis, or pericarditis

What is the prophylaxis for the flu?

vaccine - 2 strains of A, 1 of B

*70-90% effective in those < 65 yo

What is the tx for the flu?

Influenza A: amantadine or rimantadine

Oseltamivir (Tamiflu), Anamivir (13+ yo)

- start w/in 48hr sx onset, reduce systemic sx

How is HSV 1 & 2 transmitted?

via contact of infected secretions (saliva or genital) to mucous membranes, open skin

What are sx of primary HSV infection?

vesicular rash (then becomes latent)

What is the tx for primary HSV 1 (oral)?

Acyclovir

What might primary HSV 1 present in children < 5 yo?

pharyngitis or gingivostomatitis, mild lesion last 1-2 weeks

What triggers recurrent oral HSV?

local trauma, sunburn, stress

*prodromal sx: adenopathy, pain, tingling

What is the tx for recurrent HSV 1?

Acyclovir, topic Penciclovir, prophylactic Acyclovir can reduce outbreaks

What must be done if woman has an active HSV infection when labor commences?

C-section

What are sx of ocular HSV?

ulcerative keratitis -MC, herpetic vesicles, conjunctiva, regional adenopathy, can cause blindness

What is the tx for ocular HSV?

emergency optho consult; begin antiviral tx IMMEDIATELY

What are sx of HSV encephalitis?

HA, fever, AMS, seizures

Temporal abnormalities on CT, MRI, EEG

What is the gold standard dx test for HSV encephalitis?

brain biopsy

What is the tx for HSV encephalitis?

start once suspected: IV acyclovir

What are sx of Bell’s Palsy (HSV 1)?

palsy of CN VII, facial hemiplegia or hemiparesis, taste disturbance, dry eyes or tearing, jaw or face pain and numbness

What is the tx for Bell’s Palsy?

Prednisone w/ Acyclovir; f/u w/ ENT or neuro

eyes: artifical tears prn

What is herpetic whitlow?

HSV infection of the finger (usually one digit)

*tx: suppressive therapy w/ acyclovir

What are sx of Chickenpox (VZV)?

prodome: fever, myalgia, sore throat → clear vesicles that progress to scabbing

*avoid ASA → Reyes

What is the tx for Chickenpox?

Acyclovir (neonates need IV)

varicella vax if > 1 yo

What are sx of Shingles?

vesicular lesions limited to a dermatome; do not cross midline

*ophthalmicus : CN V; Ramsay Hunt: CN VII

What is the tx for Shingles?

Acyclovir (start w/in 72 hrs) -dec risk of post-herpetic neuralgia

systemic analgesia, narctoics or amitriptyline for pain

What is the main criteria to admit a pt w/ COVID?

hyopoxia

*CXR may look bad but if not hypoxic d/c

What are sx of COVID?

cough, fever, SOB, HA, congestion, myalgia, N/V/D, sore throat, loss of smell or taste; B/L ground glass opacities on CXR

What is the MCC of IVDU infective endocarditis?

S. aureus

What are sx of infective endocarditis?

FROM JANE: fever, roth’s spots, osler’s nodes, murmur, janeway lesions, anemai, nail (splinter) hemorrhage, emboli

What is the major duke criteria of IE?

(+) blood culture & evidence of endocardial involvement

What are the minor duke criteria for IE?

predisposing factor, temp > 38 C, vascular phenomena, immunologic phenomena microbiolgic evidence

What Duke criteria must be met to make a definitive dx of IE?

Two major OR 1 major + 3 minor OR 5 minor

What is the tx of IE in the ED?

stabilize pt: tx CHF prn, oxygen, hemodialysis prn, draw 3 sets of blood cultures

Empiric abx (can substitute Vanc for PCN)

• native valve: PCN G and Gentamicin

• artificial valve: Vanc & Gentamicin

• IVDU: Nafcillin & Gentamicin

How is tetanus diagnosed?

solely on clinical evidence -d/t wound contamination; often fatal

What is the tx for tetanus?

managed in ICU: immediate neuromuscular blockade, intubate, debride wound, Metronidazole IV alt: PCN G IV

Tetanus immunoglobulin (TIG) -reduces mortality, give prior to wound debridement

When should pts receive the tetanus toxoid?

in ED at time of presentation, 6 weeks, 6 months after injury

What are the age ranges for each tetanus vaccine?

Td: > 65 yo OR < 2 yo

DTap: 2-65 yo

What age ranges have the highest attack rate of E. coli?

children < 5 yo & adults > 65 yo

When should you get a stool culture for food poisoning?

febrile, bloody diarrhea, severe abd pain, severe/persistent illness

What is the tx for food borne gastroenteritis?

most self-limiting, fluids, supportive care; avoid antidiarrheals in infants and young children

*suspect E.coli → Cipro

What are the types of seafood illnesses?

Ciguatera fish poisoning, Scombroid (pseudoallergic fish poisoning), Paralytic Shellfish Poisoning

What is the MC nonbacterial fish poisoning in the US?

Ciguatera fish poisoning → toxin accumulated in fish

(barracuda, snapper, jack, grouper, sea bass)

Can Ciguatera toxins be destroyed by cooking, freezing, or drying the contaminated fish?

Nope, remain stable

*also do not affect odor, color, or taste

What are sx of Ciguatera poisoning?

all afflicted in 24 hrs (usually 3-6); Abd pain, N/V/D, chills, prurutis, HA, arthralgia, etc (very wide range) -death rare, resolve w/o tx

What are pathognomonic sx for ciguatera poisoning?

reversal of hot/cold tactile perception, develops after 3-5 days and can last months

How is ciguatera poisoning dx?

suspect in seafood related gastroenteritis

Oceanit Test systems or Cigua-Check Fish poison Test kit

What is the tx for Ciguatera poisoning?

supportive and sx based; IVF, antiemetic (Phenergan IV), benadryl, mannitol; no proven tx

What are sx of malaria?

fever, splenomegaly, anemia

*confirm w/ lab of blood-borne protozoa

What are sx of Dengue fever?

w/in 2 weeks tropical travel, facial flushing, conjunctival injection, retro-orbital pain, facial edema

What are sx of Typhoid fever?

HA, abd distention, myalgia

*found in Mexico, Indonesia, Peru, India

What are sx of RMSF?

tick bite, rash, use serologic test to confirm

tx: Doxy

What are sx of Leptospirosis?

contact w/ dogs, contamianted water, farmed or gardened

HA, chills, myalgia, jaundice

*isolate leptospires in blood or CSF

What are sx of Typhus?

nonspecific, maculopapular rash, HA (epidemic Louse-borne)

What are sx of relapsing fever?

relapsing sx of fever, chills, HA, myalgia, abd pain, jaundice transmitted by lice or ticks

What is the tx for relapsing fever?

Doxy or Chloramphenicol

What are rare, but considered a public health and medical emergency?

viral hemorrhagic fevers

What is Yellow Fever?

VHF that occurs among non-immunized travelers to endemic areas, high mortality, jaundice, black emesis, albuminuria

What disease has a fever and CNS involvement?

cysticerocosis: larvae of pork tapeworm

What are sx of Neurocysticerocosis?

seizures, obstructive hydrocephalus, meningoencephaltiis, CVAs

What is the tx for Neruocysticercosis?

antihelminthic agents