Urethritis

1. Most likely diagnosis for of urethritis, if pt. has urethral discharge Urethritis
2. Best initial test for urethritis Urethral swab for gram stain
Urine testing for nucleic acid amplification can also detect gonorrhea & chlamydia
Increased WBC + gram negative dipplococcis Neiseria gonorrhea
3. Most accurate test for urethritis Urethral culture, DNA probe, nucleic acid amplification
4. Treatment for gonorrhea: Ceftriaxone or cefixime
5. Treatment for chlamydia: Azithromycin or doxycycline

PID

1. Pt. that presents with symptoms of PID, next step I management urine B-hcg to exclude
pregnancy.
2. Diagnose PID with cervical swab for culute, dna probe, or nucleic acid amplification
3. Most accurate test for PID laparoscopy, but rarely needed. Needed onl ehrn diagnosis is
unclear, symptoms persist despite therapy, recurrent episodes for unclear reasons.
4. Treatment of PID (consists of gonorrhea + chlamydia):
Inpatient Cefotetan or cefoxitin + doxycycline
Outpatient Ceftriaxone + doxycycline (possibly metronidazole)
5. Patients with anaphylaxis to penicillin:
Inpatient Clindamycin, gentamycin, and doxycycline
Outpatient Levofloxacin + metronidazole

Ulcerative genital disease

Most likely diagnosis:

Painless ulcer Syphilis
Painful ulcer Chancroid (Haemophilus ducreyi)
Lymph nodes tender and suppurating Lymphogranuloma venerum
Vesicles prior to ulcer and painful Herpes simplex
1. Syphilis:
i. Screen with VDRL, RPR;
ii. Confirm with serologic test FTA-ABS;
iii. Diagnose with darkfield microscopy.
iv. Treat Primary and secondary syphilis One dose of IM benzathine Penicillin
v. Treat Primary+ secondary syphilis in pt. allergic to penicillin oral doxyclycine
vi. Treat tertiary syphilis IV Penicillin
vii. Treat Pt. with tertiary that is allergic to penicillin Desensitize to penicillin
viii. Desensitization is the answer for neurosyphilis and pregnant woman.

2. Chandroid
i. diagnose stain and culture on specialized media
ii. Treat with Single dose of Azithromycin
 3. Lymphogranuloma venerum
i. diagnose Complement fixation titers in blood / Nucleic acid amplification on testing swab.
ii. Treat doxycycline

4. Herpes simplex:
i. Best initial test Tzanck prep
ii. Most accurate test Viral culture
iii. Treat Acyclovir, valacyclovir, famiclovir; Foscarnet for acyclovir resistant herpes.

Genital warts (Condyloma Acuminata)

i. Diagnose Based on visual appearance
ii, Treat Cryotherapy with liquid nitrogen, surgery for larger ones, melt with podophyllin or
trichloroacetic acid. Imiquimod applied locally results in sloughing off of lesion.

UTI

1. Best initial test urinalysis with more than 10 WBC

2. Most accurate test urine culture
3. Treatment 1, Nitrofurantoin or fosfomycin 2. TMP-SMX 3. Ciprofloxacin 4. Cefixime
4. All beta lactam antibiotics are considered safe in pregnancy.

Pyelonephritis
1. Best initial test urinalysis with more than 10WBC
2. Treatment 1. Ceftriaxone, ertapenem 2. Ampicillin and gentamycin 3. Ciprofloxacin (oral for
outpatient) (ceftriaxone is first for pyelonephritis)
Outpatient: Fluoroquinolones (ciprofloxacin, levofloxacin)
Inpatient: IV antibiotics (fluoroquinolone, aminoglycose +/- ampicillin)

Acute Prostratitis

1. Diagnostic yield urine culture is greatly increased with prostate massage.

2. Treatment 1. Ceftriaxone, ertapenem 2. Ampicillin and gentamycin 3. Ciprofloxacin (oral for
outpatient)

Chronic Prostatis:Long term therapy with TMP-SMZ for 6-8 weeks is used for chronic prostatitis.
Endocarditis
1. Most diagnosis for endocarditis Fever + new murmur
2. Diagnosed Blood culture, Transthoracic echocardiogram, Transesophagel
echocardiogram.
3. Best initial therapy Vancomycin + gentamycin

When cultures are available treatment is as indicated:

Viridans streptococci Ceftriaxone for 4 weeks
S. aureus sensitive Nafcillin, oxacillin, cefazolin
Fungal amphotericin and valve replacement
S. epidermitis or resistant S. aureusw Vancomycin
Enterococci Ampicillin + gentamycin

Add an aminoglycoside and extend duration of treatment of resistant organism

Add Rifampin for prosthetic valve endocarditis with S.aureus

4. Do surgery when have: endocarditis + CHF or endocarditic with ruptured valve.

5. Treatment for culture negative endocarditis (HAEK) ceftriaxone

Prophylaxis for endocarditis:

1. Best initial management amoxicillin prior to dental procedure
2. If patient is allergic to penicillin clindamycin, azithromycin pr clarithromycin.

Lyme disease
1. Diagnose- based on visual inspection of rash
2. Do serologic testing for manifestation of joint, neurologic and cardiac manifestation
3. Testing ith IgM, IgG, ELISA, Western blot, PCR.
4. Treatment:
Asymtoptomatic tick bite no treatment
Rash doxyxycline or amoxicillin or cefurime
Joint, 7th cranial nerve palsy Doxycyline, or amoxicillin or cefurime
Cardiac and neurologic manifestations other tha 7th nerve palsy IV ceftriaxone

HIV
1. Best initial test ELISA
2. Confirm with Western blot
3.Infected infants are diagnosed with PCR or viral culture.

*treatment failure first manifests with a rising PCR-RNA viral load.

HIV treatment best initial drug regimen emtricitabine, tenofovir, efavirenz.

Additional second line agents for drug resitance: Maraviroc, enfurvirtide (entry inhibitors); Integrase
inhibitor (Raltegravir).
Post exposure prophylaxis of HIV (needle stick injury , sexual exposure) 4 weeks of emcitrabine,
tenofovir, efavirenz. Or zidovudine and lamivudine

Prevention of perinaal transmission:

If patient is HIV positive and pregnant and already on antiretroviral meds continue regimen
If pregnant HIV pt is not on antiretroviral meds emcitrabine, tenofovir (2NRTIS) + PI or
NNRTI, except do not use enfavirenz since it is teratogenic.
Pregnant mothers with HIV should receive treatment to keep viral load low zidovudine
Baby should be given zidovudine for 6 weeks afterwards to help prevent transmission.

Angioedema
1. Next step ensure airway prtection first
2. Best initial test decreased level of C2 and C4 in the complement pathway; deficiency of C1
esterase inhibitor
3. Treatment fresh frozen plasma or ecallinitide (ecallinitide is specific therapy for angioedema)
4. Long term management androgens: danazol and stanazol

Common variable immunodeficiency

1. Etiology B cells are present in normal numbers but they do not make effective amounts of
immunoglobulinas. There is a decrease in IgG, IgM, IgA
2. Presentation recurrent sinopulmonary infection in adults, bronchitis , pneumonia, sinusitis and otitis
media.
3. CVID increased risk of lymphoma
4. Diagnose Immunoglobin levels are decreased and there is a decreased response to antigen
stimulation of B cells.
5. Treatment antibiotics for each infection that develops. Chronic maintenance is wth regular infusions
of IVIG.
The clue of CVID is a decrease in the output of B lymphocytes with a normal number of B cells as well as
normal amounts of lymphoid tissue such as nodes, adenoids, and tonils.

X-linked Brutons Agammaglobulinemia

Presents In male children with increased sinopulmonary infectios. B cells and lymphoid tissue are
diminished. There is decrease of absence of tonsilsm adenoids, lymph nodes and spleen.
Treat: infections as they arise. Long term IVIG.

IgA deficiency
These patients also present with sinopulmonary infections.
Presentation atopic disease, anaphylaxis to lood transfusions when blood is given from a pt. who
has normal levels of IgA, sprue like condition with malabsorption, Increase in risk of vitiligo, thyroiditis,
and RA.
Treat infections as thy arise, only use IgA deficient blood from donors.

Hyper IgE syndrome

Presentation recurrent skin infections with Staphyloccosu.
Treatment treat infections as they arise;
Prophylactic treatment dicloxacillin or cephaxelin
Severe combined immunodeficiency
Deficiency in B and T cells results in:
B cells decreased mmunoglobulin production leads to sinopulmonary infection beginning as 6
months.
T cells decreased T cells result in PCP infection, varicella, and candida
Treatment: Treat infections, bone marrow transplant is curative.

Wiskott-Aldrich syndrome
This is an immunodeficiency with thrombocytopenia and eczema
Treatment Bone marroe transplantation only definitive treatment.

Chronic granulomatous disease

Ths is a disease with extensive inflammatory reactions, which eads to lymph nodes with purulent
material leaking out.
Presentation: Aphthous ulcers and inflammation of the nares is common,
Diagnose nitroblue tetrazlium testing