Case Scripts

Question 1

48M with fever, dyspnea and painful blistering lesions. Also loss of eyebrows and swelling of earlobes with diffuse alopecia. Biopsy revealed thrombosis of medium sized arteries with plasma cells and foamy macrophages. Acid Fast Bacilli noted.

What is this diagnosis?

What is the treatment?

*Side effect?

Answer 1

Lucios Phenomenon - necrotic skin lesions in diffuse lepromatous leprosy

treat with rifampin, clofazamine and dapsone as well as steroids and ACG

*clofaz AE: skin pigmentation, abdominal pain, eye irritation

Question 2

Patient develops asymptomatic elevations of AST/ALT.

Avid sausage-eater from Germany.

Answer 2

Hepatitis E!!

Question 3

Patient presents 2 months after getting bit by a wild skunk.

Should you provide RIG/Vaccinate?

What is the vaccine series?

Answer 3

YES! Incubation period is up to 90 days.

Rabies Vaccine: Day 0, 3, 7, 14

Question 4

Diarrhea outbreak among household contacts. Incubation period is 3-7 days.

Answer 4

most likely either norovirus or shigella - most communicable enteric pathogens

salmonella rarely causes secondary spread. Campy, non-cholera vibrios and aeromonas are less likely to have secondary spread.

Question 5

31M bilateral pneumonia non responsive to augmentin as outpatient.

All cultures negative. Found to have palpable spleen tip and red macules on abdomen.

Recent parrot exposure

Answer 5

Chlamydia psittacia

Rx doxycycline

Question 6

cosmetic procedure now growing AFB

which are the BAD ones?

which have inherent inducible resistance?

Empiric Treatment?

Answer 6

RGM (m. abscessus, fortuitum or chelonae)

abscessus and chelonae should get surgery “like tumors”

fortuitum and abscessus have erm gene (macrolides)

Some combination of linezolid, doxy, cipro, azithro +/- clofaz if you have it

Question 7

55F fevers, cytopenias and found to have granulomas in bone marrow 6 months after cardiac bypass surgery

Answer 7

Nosocomial M. Chimaera outbreak from Heater Cooler Units

High mortality 50%

Must remove prosthetic material and then at 1 year of therapy afterward

Question 8

bicyclist scrapes elbow in muddy pool of water. Develops tenderness/drainage - GNRs

Answer 8

aeromonas - rx with cipro

Question 9

HIV patient with “worst sore throat of my life” but OP exam is normal

Answer 9

Suspect: Epiglottitis

Question 10

crab fisherman from chesapeake p/w red painful hand - has progressed over 4 days. Finger joints feel stiff but there is no swelling on exam

Answer 10

erisipelothrix - subacute cellulitis due to inocculation with GP bacillus

can also disseminate - causing rash and endocarditis

Question 11

23M acute pain and blurred vision in R-eye.

How to treat?

Answer 11

Topical antivirals +/- debridement and systemic antiviral

triflueorothymidine, vidarabine, idoxuridine, acyclovir

Question 12

ocular pain, redness, increased lacrimation, photophobia, and blurred vision

what SYNDROME is this?

Answer 12

Uveitis/Iritis

Question 13

fried egg colonies on cell free medium

Answer 13

mycoplasma

Question 14

Oysters

Answer 14

Vibrio parahaemolyticus

vibrio vulnificus (septicemia and STI)

Question 15

differences between FMF and TRAPS?

Answer 15

Ethnicity

Pattern of inherentance (recessive - TRAPS is dominant)

TRAPS has myalgias and conjunctivitis

TNF-a in TRAPS, colchicine in FMF

both can be c/b amyloidosis

Question 16

Painless ulcer with TENDER inguinal adenopathy

Answer 16

LGV (chlamydia L1-3)

Rx with doxy

Question 17

painLESS ulcer NO adenoapthy

Answer 17

Granuloma Inguinale (Donovanosis/Klebsiella)

Rx with Doxy/Azithro

3 weeks!

Question 18

TORCH

Answer 18

Toxo, Other, Rubella, CMV, HSV

*Other: Syph, Listeria, VZV, Parvo

Can cause spontaneous abortion, premature birth, IUGR

Question 19

Hepatitis in a pregnant patient

Answer 19

HSV!

Also think of adenovirus - HSV and adeno can cause fulminant Hep in Preg/Immunosuppressed

Question 20

Clinically identifical to PCP except PCR is negative?

Answer 20

Toxoplasma Pneumonia

Rare, but Clinically identical to PJP, and would also be prevented by Bactrim ppx

Question 21

asian with recurrent blisters and aseptic meningitis - Rx?

Answer 21

Colchicine for behcets

Question 22

Answer 22

roseola (HHV6 “6th disease” - normally a mild febrile/rash illness in children, but can cause complications in IC hosts in adulthood)

Question 23

Answer 23

roth spot - red lesion with pale center in Bacterial Endocarditis

Question 24

HHV8 (3 syndromes)

Answer 24

KS

Castleman’s

PEL

Question 25

Answer 25

chediak higashi syndrome - giant neutrophil granules as a result of lysosomal trafficking gene mutation

Question 26

Answer 26

M. chelonae - often without systemic symptoms - portal of entry often unknown

Question 27

Answer 27

peliosis (bartonella, HIV, etc)

Question 28

intermittent erytthematous swelling, migrating every few weeks.

What else can this cause?

Answer 28

Gnathostomiasis (helminth infection from undercooked fish)

Can also cause eosinophilic meningitis

Question 29

months of worsening fever, headache, visual changes

found to have brain abscess and lymphocyotic pleocytosis

deadly granulomatous meningitis of immunocompetent patient

Answer 29

balamuthia - unclear etiology - complex treatment (pentamidine, ampho, fluconazole, macrolide, miltefosine, very deadly

Question 30

blueberry muffin rash, cataracts, deafness

Answer 30

congenital rubella syndrome

FYI - infants born with this shed for > 1 year

Question 31

roseola

rubeola

rubella

Answer 31

6th disease in children (mild rash, HHV6)

measles

rubella - mainly concern in pregos

Question 32

treatment of Q fever:

• Acute disease:
• Chronic Disease:

Answer 32

Acute: Doxy (bactrim, quinolone alternative)

Chronic: doxy+hydroxychloroquine 18 months (doxy+quinolone)

Question 33

Phase I/II of Q fever?

Answer 33

Phase II titers > 1:256 c/w ACUTE infection

Phase I titers > 1:800 c/w CHRONIC infection

If both > 1: 16 c/w ACTIVE infection (unclear acute/chronic - correlate with clinical)