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She denies any fevers and states that 10 days back she was at a State ... Pet proprietors, pet shops, vets, abattoir specialists, agriculturists. C. psittaci Clinical. Hatching 5 ...
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Inhabitant Board Review Joseph G. Timpone Jr. MD Georgetown University Hospital

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Case One A 80 y.o. female presents to the ER with a 3 day history of weakness, stomach spasms and grisly looseness of the bowels. She denies any fevers and states that 10 days prior she was at a State Fair where she ate sausage, heated beans, coleslaw, and drank new apple juice. PEX: T=37 BP=140/90 P=100 ABDON: summed up delicacy 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 no doubt causative pathogen is: A) S. aureus B) B. Cereus C) Norwalk infection D) Listeria E) E.coli O157:H7

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E. Coli 0157:H7 21,000 Cases/YR; 6% pts. Create HUS; 12% Mortality Epidemiology: Young youngsters & elderly; undercooked ground hamburger, unpasteurized milk, apple juice, water/vegetables debased with fertilizer. Brooding 3-4 days; ABD. cramping; ridiculous loose bowels (35 - 90%); fever remarkable (30%) HUS: MAHA, Thrombocytopenia, ARF, can likewise see TTP. Conclusion: dismal, Sorbitol non-maturing provinces on Sorbitol-Maconkey agar; 0157 Antisera Agglutination test. Treatment: anti-microbial use may expand danger of HUS

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Case Two A 30 y.o. sound male is conveyed to the ER by his collaborators after a syncopal scene at work. In the ER the pt is arousable and noted to be afebrile. BP=70/40 P=40 EKG:3 ° Heart piece. The pt expresses that he had as of late come back from a climbing trip in New England one month prior.

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The in all probability causative pathogen is: A) S. aureus B) B. Burgdorferi C) S. pyogenes D) R. rickettsii E) Coxsackie infection

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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 joined for > 72 Hrs. to bring about transmission Stage 1: Viral-like ailment connected with erythema migrans (60 - 80%). Growing annular sore with focal clearing (no less than 5cm by CDC criteria)

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Acute Disseminated Lyme Disease (Stage 2) Neurologic (happens in 15% of patients) Lymphocytic meningitis Cranial Neuritis (Bell\'s Palsy) Motor-tangible polyradiculo neuritis Mono-neuritis multiplex; myelitis Cardiac (happens in 5% of patients) Atrio-ventricular piece Myo-pericarditis Cardiomegaly/LV brokenness (uncommon)

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Chronic Lyme Disease (Stage 3) Arthritis: (60% of untreated patients) Oligo-articular/Mono-articular (Kness) Treatment safe joint inflammation in 10% More normal in North America Neurologic Cognitive brokenness/encephalopathy Polyneuropathy More basic 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. A disengaged (+) IgM without a (+) IgG following one month of indications is likely a false (+) IgM and IgG can remain (+) for quite a long time False (+): endocarditis, parvovirus B19, syphilis, EBV, SLE, RA Elisa must be affirmed by W.B. 5% of pts. In non-endemic territory 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/cardiovascular: 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 measurement has 87% viability for I. scaplilaris tick bits (0.4% versus 3.2% - Doxy versus placedo) Recombinant OspA antibody is 78% compelling (0, 1, 12 mos. On the other hand 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 background marked by HTN presents with a 1 wk history of fevers and weakness. His PCP gets a few labs which uncover WBC 5.0 HCT 20.0 PLTS 40,000 AST 100 ALT 50 T.Bili. 3.5 LDH 525. The pt as of late came back from his mid year home in Nantucket.

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The in all probability causative creature 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 paleness, thrombocytopenia, lifted LFTs Diagnosis: Peripheral smear, serology, PCR Treatment: Quinine + Clindamycin; Atovaquone + Azithromycine; trade transfusion 20% co-disease with B. burgdorferi

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Case Four A 29 y.o. female presents to the ER with fevers, hack, and S.O.B. PEX: T 39.5 BP 110/80 P 120 O 2 SAT. 88% CXR: diffuse aspiratory invades LABS: WBC 25.0 HCT 55.0 PLTS 50,000 PT/PTT 16/60 The pt as of late headed out to Arizona where she kept focused Indian reservation to figure out how to make gems.

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The no doubt causative organ A) S. pyogenes B) Listeria C) C. Immitis D) C. Neoformans E) Hanta Virus

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Hantavirus Hanta infection: RNA infection; Bunyaviridae(Sin NOMBRE infection) Hantavirus Pulmonary Syndrome S.W. U.S. (New Mexico, Arizona, Utah, Colorado) has been accounted for in all States Rodent presentation (Peromyscus maniculatus) 4 Phages: febrile, stun, diuresis, improving Clinical: fever, myalgias, hack, dyspnea, H/A, GI indications Labs: leukocytosis, hemoconcentration, thrombocytopenia, delayed PT/PTT Rapidly dynamic pneumonic 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 injury on his arm. In the ER he has a T=103, and you see ipsilateral axillary lymphadenopathy. Ten days back he came back from a chasing trip where he killed and cleaned a rabbit, fox, and deer.

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The no doubt 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 development Contact with contaminated creatures (rabbits, squirrels, felines), inward breath, tick chomp Peak happens with tick-borne presentation and chasing season Southcentral and Southwestern United States-Oklahoma, Arkansas, Texas Hunters, trappers, lab laborers

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Amblyoma Americanum

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Tularemia: Incidence 1990-2000 – 1368 cases. Roughly 124 cases/year answered to the CDC. 56% cases were accounted for from Arkansas, Missouri, South Dakota, and Oklahoma. Endemic on Martha\'s vineyard. 70% cases amongst May and August. (MMWR 2002 Mar 8; 51 (9) 182-184)

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Endemic Regions

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Francisella Tularensis Small non-motile gm (- ) cocci bacillus. Can get by for quite a long time at low temperatures in water, damp soil, feed and rotting creature remains. Voles, mice, rabbits, bunnies, squirrels are stores. Vectors: Ticks, flies, mosquitoes. Human disease Tick chomps Handling contaminated creatures or creatures items. • Ingestion. • Inhalation.

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Tularemia: Clinical half of patients with ulcer hub infection Patients create ulcerative sore at site of presentation which is connected with ipsilateral lymphadenopathy Bacteremia, pneumonia, oculo-glandular ailment Pneumonia in plant specialists on Martha\'s Vineyard

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Ulceroglandular Tularemia

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Oculoglandular Tularemia

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Pneumonic Tularemia: Clinical Fever and non-beneficial hack 3 - 5 day brooding period (range 1-14 days) CXR: pneumonia, pleural emanation, and hilar lymphadenopathy

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Diagnosis, Treatment and Prevention Diagnosis: develops on media improved with cysteine; serology Treatment: streptomycin, gentamicin, doxycycline, ciprofloxacin P.E.P.: doxycycline or ciprofloxacin Live lessened immunization: lab laborers Respiratory separation not required

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Case Six A 25 y.o. male presents to the ER with fevers, myalgias, LBP, sickness, and heaving. In the ER he has a T=39.5, BP 80/40, P=120 and you see a rash. Labs: WBC 25,000, HCT 45, PLT 40,000, BUN/Cr 40/2.2. The patient has come back from an outdoors trip in North Carolina one week prior.

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The in all likelihood 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 focal states (North Carolina, South Carolina, Oklahoma, and Tennessee) > 95% cases April - September Dogs, lush territories, guys

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RMSF: Clinical Incubation 5 - 7 days (2 to 14 days) Fever, H/A, discomfort, queasiness, heaving, abd. torment Rash: 1 - 5 days after onset of disease; macules on wrists & lower legs; spread to trunk, palms, and soles; 10% pts. without rash Thrombocytopenia, DIC, lifted LFTS@ 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 background marked by hemachromatosis was gotten by his companions with fevers, looseness of the bowels, & serious shortcoming. They had as of late come back from a sailing stumble on the Chesapeake inlet where they ate new crab and other grouped shellfish. On exam T=39 BP 70/40 P130

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The in all probability 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 crude fish/shellfish (clams) Chesapeake sound, Gulf coast (typhoon Katrina) Liver malady, cirrhosis, hemachromatosis, ETOH Septicemia with metastatic skin injuries Diarrhea quickly dynamic cellulitis half mortality Tetracycline/doxycycline; mix treatment with doxycycline + third era sephalosporin (ceftriaxone, cefotax

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