The Ol' Switcheroo
Retro-Active
Swat Team
Ticked Off
In the Hot Seat
100
This ubiquitous herpesvirus (HHV-5) is a major cause of morbidity in the first 1 to 6 months post-renal or liver transplant, classically causing pneumonitis, retinitis, or colitis.
What is CMV?
What to watch for: Opportunistic infections and reactivation of latent viruses.
Key pathogens: Cytomegalovirus (CMV), Epstein-Barr virus (EBV), Pneumocystis jirovecii pneumonia (PCP), and invasive fungi like Aspergillus.
Treatment for CMV: Valganciclovir
100
This encapsulated yeast, diagnosed with an India Ink stain or antigen assay, classically causes an insidious meningitis in HIV patients with a CD4 count less than 100.
What is cryptococcus?
Opening pressure often elevated.
CT before LP, why?
Lymphocytic pleocytosis.
Patients with HIV may have essentially normal laboratories (or only mild elevation of white blood cell count or protein). Normal CSF chemistries don't exclude cryptococcal meningitis in the context of AIDS. Low cell count is actually a poor prognostic sign among patients with cryptococcal meningitis.
Treatment: Liposomal Amphotericin B 10 mg/kg one dose, followed by 14 days of combined therapy with high-dose fluconazole (1200 mg/day) plus flucytosine (100 mg/kg/day in four divided doses)
100
Nicknamed "bone break fever," this viral illness transmitted by the Aedes mosquito is characterized by severe myalgias, retro-orbital pain, and a maculopapular rash.
What is Dengue Fever?
Rx: supportive care
100
This classic targetoid skin lesion, erythema migrans, is the hallmark of early localized infection by this organism?
What is Borrelia burgdorferi?
Dx: Lyme Disease
Rx: First line doxycyline in adults / peds. Pregnant: Amoxicillin or Cefuroxime. Rocephin for severe/late stage lyme: severe neuro (not just Bell's Palsy, which can be bilateral), lyme carditis, persistent arthritis
100
The 2026 Surviving Sepsis Campaign guidelines recommend this number as the target Mean Arterial Pressure (MAP) for geriatric adults (age > 65) with sepsis induced hypotension or septic shock?
What is 60-65 mmHg?
From: The "65 Trial"
Effect of Reduced Exposure to Vasopressors on 90-day mortality in Older Critically Ill Patients With Vasodilatory Hypotension: a randomised clinical trial. JAMA 2020
- Subgroup analysis: the reduction in mortality was more pronounced in the permissive hypotension group patients who were identified to be chronically hypertensive and trended to greater survival the older you were
- Comparing permissive hypotensive group vs. standard care group
- Chronic hypertension subgroup – 90-day mortality 38.2% vs. 44.3% (adjusted OR 0.67, 95% C.I. 0.49-0.85)
- Patients without chronic hypertension – 90-day mortality:43.3% vs. 43.4%
- Comparing permissive hypotensive group vs. standard care group
200
In lung transplant recipients, prophylaxis with trimethoprim-sulfamethoxazole (Bactrim) is primarily targeted against this opportunistic fungus that causes bilateral ground-glass opacities.
What is Pneumocystis pneumonia?
Fungal etiology: Pneuocystis jiroveci
Sulfa allergic? Atovaquone, Trimethoprim+Dapsone, Primaquine+Clindamycin
Why not antifungals? Lacks ergosterol in cell membrane, azoles don't work.
200
Caused by Human Herpesvirus 8, this AIDS-defining illness presents as painless, violaceous plaques or nodules on the skin and mucous membranes.
What is Kaposi sarcoma?
200
Endemic to parts of Africa and South America, this mosquito-borne flavivirus gets its name from the severe hepatic dysfunction and scleral icterus that develops in toxic cases.
What is Yellow Fever?
Rx: Supportive care.
200
This tick-borne intraerythrocytic protozoan forms "Maltese cross" tetrads on a peripheral blood smear and can cause a severe malaria-like illness, especially in asplenic patients.
What is babesiosis?
Rx: Atovaquone combined with Azithromycin, alternative Quinine + Clindamycin
200
This preferred screening tool / scoring system has improved accuracy in the early detection of sepsis, septic shock and predicts sepsis related mortality.
What is NEWS2?
300
This polyomavirus is a classic cause of nephropathy and graft failure in renal transplant patients, often presenting with rising creatinine and "decoy cells" in the urine.
What is BK virus (Human polyomavirus 1)?
BK virus is an abbreviation of the name of the first patient, from whom the virus was isolated in 1971.
80% of the population contains a latent form of this virus in GU tract.
Decoy cells: urothelial cells infected with reactivated BK can be found in urine
300
This intracranial parasitic infection may be identified by neurologic symptoms, seizure, and the characteristic CT scan below.
What is toxoplasmosis?
Ring enhancing lesions, vasogenic edema.
Rx: pyrimethamine + sulfadiazine + leucovorin
300
This species of Plasmodium is responsible for the most severe form of malaria—characterized by cerebral malaria and microvascular sludging—and uniquely lacks a dormant liver stage (hypnozoites).
What is Plasmodium falciparum?
Rx: oral Artemisinin-based Combination Therapies (ACTs) like artemether-lumefantrine. Severe cases require immediate hospitalization and intravenous (IV) artesunate
300
Transmitted by the lone star tick, this illness presents similarly to RMSF but classically without a rash. Labs typically show leukopenia, thrombocytopenia, and morulae inside monocytes.
What is Erlichiosis?
Rx: Doxycycline. Alt in pregnancy: Rifampin
300
To maximize the pharmacokinetic principle of "time above MIC," guidelines strongly recommend utilizing this specific dosing strategy for maintenance beta-lactam antibiotics after administering the initial bolus.
What is a prolonged (or extended/continuous) infusion?
400
Transplant patients are explicitly warned to avoid unpasteurized cheeses and cold deli meats to prevent meningitis caused by this motile, gram-positive rod.
What is Listeria monocytogenes?
Tx: Ampicillin
400
DAILY DOUBLE:
An HIV patient presents with altered mental status and CT without ring-enhancing lesions, but MRI shows non-enhancing white matter demyelination.
Hint: this is caused by reactivation of the JC Virus.
What is Progressive Multifocal Leukoencephalopathy (PML)?
400
This Togavirus, transmitted by Aedes mosquitoes, is infamous for causing severe, debilitating, and often chronic bilateral polyarthralgias that can last for years.
What is Chikungunya?
- High fever
- Severe joint pain and swelling (often in the hands and feet)
- Muscle pain and headache
- Rash
Rx: Supportive care.
400
A bite from the lone star tick can induce a delayed, IgE-mediated allergic reaction to galactose-alpha-1,3-galactose, causing anaphylaxis several hours after consuming this specific food group.
Mammalian Meat
400
Validated by the ANDROMEDA-SHOCK trial, the guidelines suggest guiding early fluid resuscitation to normalize this simple, low-tech bedside metric rather than relying exclusively on serum lactate clearance.
What is capillary refill time (CRT)?
How to perform:
- Tool: Glass microscope slide (this bypasses variables like skin pigmentation or nail polish).
- Site: Apply firm, steady pressure to the ventral surface (pad) of the right index finger at the distal phalanx.
- Compression: Press until the skin completely blanches (turns white/blank). Maintain this pressure consistently for 10 seconds.
- Timing: Release the pressure and use a timer to measure the exact time it takes for normal skin color to return.
- Normal: < 3 seconds.
- Abnormal (Delayed): >3 seconds.
- Goal: The primary objective of the intervention is to normalize the patient's CRT to < 3 seconds over a 6-hour resuscitation period.
500
A bone marrow transplant recipient presents to the ED with gross hematuria and lower abdominal pain. This non-enveloped double-stranded DNA virus is the most common viral culprit for their hemorrhagic cystitis.
What is adenovirus?
500
This paradoxical immune recovery phenomenon occurs shortly after starting antiretroviral therapy (ART), causing a massive inflammatory response to a previously subclinical opportunistic infection.
What is Immune Reconstitution Inflammatory Syndrome (IRIS)?
When the immune system recovers rapidly—indicated by a rising CD4 cell count and a dropping viral load—it suddenly regains the ability to recognize pathogens it previously ignored (TB, HSV/VZV, MAC, CMV, EBV, Hep B/C). The resulting "overreaction" causes intense, localized, or systemic inflammation.
Tx: steroids, antimicrobial therapy against concerning pathogen, supportive care.
500
Once available only via the CDC, this intravenous medication is now the FDA-approved first-line drug of choice for severe, life-threatening malaria in the United States.
What is Artesunate?
500
While the Ixodes tick needs 36 to 48 hours of attachment to transmit Lyme disease, it can transmit this severe, neuroinvasive flavivirus in as little as 15 minutes, leaving up to half of survivors with permanent neurological deficits like hemiplegia or altered mentation.
Primarily found in the Northeastern U.S. and the Great Lakes/Upper Midwest regions, as well as parts of Canada and eastern Russia.
- Initial symptoms: Fever, headache, vomiting, and generalized weakness.
- Severe (Neuroinvasive) symptoms: Confusion, loss of coordination, difficulty speaking, and seizures
Rx: Supportive
500
Rather than continuously escalating a single agent, guidelines recommend adding vasopressin when your norepinephrine dose hits this specific weight-based threshold range.
(Answer in mcg/kg/min)
What is 0.25 to 0.5 mcg/kg/min?