Beruflich Dokumente
Kultur Dokumente
BOARD REVIEW
Patricia D. Jones, MD
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 supraclavicular lymphadenopathy.
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?
A. CD4 cell count measurement
B. Epstein- Barr virus IgM measurement
C. HIV RNA viral load measurement
D. Skin biopsy
CDC: Diagnosis of AIDS
Definitive AIDS Diagnosis (w/ or w/o 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
CDC: Diagnosis of AIDS
Presumptive AIDS Diagnosis (with laboratory evidence of HIV infection)
http://www.nwabr.org/education/pdfs/hiv_lifecycle.jpg
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%)
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.
Toxoplasmosis:
Indications: CD4<100, positive Toxoplasma IgG antibody titer
Treatment: TMP-SMX, Dapsone, Pyrimethamine, Leucovorin,
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
http://img.thebody.com/thebody/2008/virus_life_cycle.gif
Efavirenz contraindicated in women of child-bearing
age.
Complications of HIV Infection/Therapy
Cardiovascular:
Increased exposure to protease inhibitors increases dyslipidemia and
increased risk of MI.
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.
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.
Osteomyelitis
Intense suppurative reaction in bone
associated with edema and thrombosis
which can compromise vascular supply
leading to areas of dead bone
sequestra
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
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
Diabetes Mellitus-Associated Osteomyelitis
http://biomarker.cdc.go.kr:8080/diseaseimg/pneumonia-Community_acquired.jpg
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
Laboratory +30
Arterial pH less than 7.35
+10
Hematocrit less than 30% (0.30)
Arterial PO2 less than 60 mm Hg (8.0 kPa) or SaO2 less than 90 percent +10
70 or less II 0.6-0.7
91-130 IV 8.2-9.3
Inpatient Treatment
Special Concerns