Final

Question 1

Round worms

Answer 1

1. Vermin lady - Enterobius vermicularis (pinworm) is an intestinal nematode
2. Mice eating random bits of food near these egg-shaped rocks - female pinworms
3. Translucent cape with rocks stuck to it - use scotch tape test to diagnose pinworm infection (Enterobius vermicularis); will show eggs under the microscope
4. PAM - Pyrantel pamoate can be used to treat infections by pinworms
5. Bendy bars on the walls - can use Albendazole to treat pinworm infection
6. America Dude with rings around ankle and neck - Ancyclostoma duodenale and Necator americanus are intestinal nematodes
7. America Dude with hook and wearing red boots - Ancylostoma duodenale (hookworm) larvae penetrate skin of soles of feet
8. America Dude wearing golden arrow symbol that goes in a certain direction - Ancylostoma duodenale & Necator americanus (hookworms) go from the bloodstream to the lungs to the GI tract
9. America Dude using an iron - Hookworm (Ancylostoma duodenale & Necator americanus) infection can cause iron deficiency anemia
10. Grenades fallen in the water - Ancylostoma duodenale & Necator americanus (hookworms) will have eggs in the stool (diagnostic)
11. EO slingshot boy - Ancylostoma duodenale & Necator americanus (hookworms) infection presents with eosinophilia
12. America Dude “pamming!” the vermin and bendy bars - use pyrantel pamoate or albendazole to treat hookworm (Ancylostoma duodenale & Necator americanus) infection; also, just wear shoes
13. Lumbering tree man - Ascaris lumbricoides (giant roundworm) is a large intestinal nematode
14. Lumbering tree man wearing golden arrow symbol that goes in a certain direction - Ascaris lumbricoides goes from the bloodstream to the lungs to the GI tract
15. Lumbering tree man blocking a bunch of boulders in the tunnel - Ascaris lumbricoides (giant roundworm) infection causes intestinal obstruction
16. Lumbering tree man standing in puddle full of acorns - Ascaris lumbricoides presents with eosinophilia and eggs in the stool (diagnostic)
17. Lumbering tree man standing by bendy bars - use albendazole to treat Ascaris lumbricoides infection
18. Strong Guy wearing big red boots - Strongyloides stercoralis (threadworm) is an intestinal nematode; larvae pentrate skin of soles of feet
19. Strong Guy wearing golden arrow symbol that goes in a certain direction - Strongyloides stercoralis (threadworm) larvae may
20. Strong Guy kicking eggs into the wall - Strongyloides stercoralis (threadworm) larvae hatch from eggs laid in intestinal wall, repenetrate the wall, and enter the bloodstream (autoinfection)
21. Pink worms in puddle near Strong Guy - Strongyloides stercoralis (threadworm) presents with eosinophilia and Rhabditiform larvae in stool (diagnostic)
22. Bendy bars and “No Dumping, Drains to River” sign near Strong Man - use albendaole or ivermectin to treat Strongyloides stercoralis (threadworm) infection

Question 2

Bebesia

Answer 2

1.Vampire babes - Babesiosis causes primarily blood-related symptoms, including hemolytic anemia, hemoglobinuria, and resulting jaundice
2.Shields with tick symbols and antlers - Babesia is tick-borne parasite, specifically Ixodes tick, which is a deer tick
3.Red stained glass windows shattered - Babesiosis can cause hemolytic anemia
4.Vampire babe in yellow - the hemolytic anemia brought on by Babesiosis can lead to jaundice
5.Robin of Ixodes Robin is sweating and jagged garment - Babesiosis is accompanied by irregularly cycling fevers
6.Leader of vampire babes holding a sickle and certain shaped hole in Robin’s shirt - higher risk of severe babesiosis disease in sickle cell and asplenic patients
7.Thick red carpet with a cross and pointing in northeast direction - Maltese cross appearance in RBCs
8.Queen is named Atova and has crows on her shoulders - use Atovaquone and Azithromycin (a macrolide) to treat Babesiosis clindamycin quinene

Question 3

Malaria

Answer 3

1. Chest of gems with blood stain - use blood stain and Giemsa stain to see parasites in RBCs
2. Warlord malariae with four interestingly colored buttons - Plasmodium malariae presents with quartan fever cycle (72 hours, i.e. day 1, then day 4)
3. Warlord Vivax and Ovale swinging his pendulum like a hypnotist and holding shield with characteristic pattern - Plasmodium vivax and Plasmodium ovale produce dormant hypnozoites that hide out in hepatocytes
4. Plasmodium vivale/ovale warlord holding pendulum with alternating colors - Plasmodium vivax and plasmodium ovale undergo tertian fever cycle
5. Falciparum warlord with irregularly tattered garment, headdress, and gold belt and chest plate - irregular fever patterns and cerebral malaria; parasitized RBCs occlude vessels to lungs and kidneys
6. “Color queen” wearing beads (like a polymer) - Chloroquine (antimalarial) works by blocking plasmodium heme polymerase
7. “Primal queen” - primaquine can attack hypnozoites hiding in liver
8. “Me-fly queen” on a palanquin with luggage on top - mefloquine is an anti-malarial (one of the stronger ones)
9. “Ato-vampire queen” with an iguana and luggage on top of palanquin - atovaquone is an antimalarial
10. Artisan painting atovaquone queen and holding a sickle - use artemisins or atovaquone/proguanil for severe Plasmodium falciparum infections
11. Another artisan making another painting - use IV artesunate for severe malaria infections
12. Cans next to “Dining queen” - Quinidine may be used as an antimalarial, but it may result in cinchonism, which includes headaches and tinnitus
13. Ivy around dining queen and artist - Artesunate and quinidine are delivered IV for severe malaria
14. Mosquito on red mushrooms (spores) - Anopheles mosquitoes carry sporozoites of plasmodium in saliva
15. Mosquito goes over to the cow - Sporozoites mature to trophozoites in liver
16. Little spots going towards smaller spot - Trophozoites become schizonts, which divide into merozoites, which burst from hepatocyte and infect RBCs
17. Ring shaped spot - ring form of immature schizont shape in RBC
18. Male and female signs seared into the cow - Merozoite can also form gametocyte; cycle continues when mosquito bites patient and takes up gametocyte

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Question 4

E. Histolitica ( Amebiasis)

Answer 4

1.Two men holding hands, drinking water from some bubbly looking puddle - The cyst form of Entamoeba histolytica is infectious when ingested in contaminated waters
2.Hole in the excavation site and guy holding map - right lobe of liver is the most commonly involved site of amoebic liver abscess
3.Dude in hole holding to upper right quadrant of abdomen - Entamoeba histolytica infection can cause right upper quadrant pain (due to abscess in right lobe of liver)
4.Anchovy paste written across truck and archaeologists eating sandwiches with anchovy paste dripping out - liver abscess of Entamoeba histolytica infection is described as having “anchovy paste” consistency
5.Pipe with rusty spots and archaeologists using flasks - Entamoeba histolytica can cause intestinal amebiasis, which is ulcerations in the colon (flask-shaped)
6.Lady sitting on red stool and tons of stuff pouring out of pipe -the intestinal amebiasis from Entamoeba histolytica infection leads to bloody diarrhea
7.O&P on side of pipe - use stool O&P to diagnose Entamoeba histolytica
8.Puddle with red cups - look for trophozoites with endocytosed RBCs under microscope when examining O&P stool for Entamoeba histolytica infection
9.Flask in the pipe - intestinal biopsy of Entamoeba histolytica infection may show flask-shaped lesions
10.Metro in excavation site - use metronidazole to treat Entamoeba histolytica infection
11.Pair of mice running out of tunnel - can use Paramycin (a luminal agent) to eliminate cysts of Entamoeba histolytica
12.Queen Iodo’s tomb - can use Iodoquinol, a luminal agent, in combination with metronidazole to eliminate cysts of Entamoeba histolytica

Question 5

Giardiasis

Answer 5

1.Piece of poop contaminating the water - Giardia is transmitted fecal-orally (cysts in fecal-contaminated water)
2.Bubbles at waterfalls - Giardia transmitted by cysts
3.Kids with backpacks and water bottles - Giardia associated with campers and transmitted through poorly purified drinking water
4.Kids holding noses - Giardia infection presents with foul smelling diarrhea
5.Kid sitting on yellow fat stool - Giardia infection causes steatorrhea (“fatty diarrhea”)
6.Boat has distinct shields on the side - Giardia has distinct trophozoite shape
7.Man wearing OP shirt and pointing at shields that have fallen into the water -Giardia trophozoites can be passed into the stool, which can serve as a diagnostic; stool O&P is the diagnostic test to use
8.Boat named ELISA and floating in poop-filled water - Diagnose Giardia infection by ELISA stool antigen
9.Monorail in background - use metronidazole for treatment of Giardiasis

Question 6

Crytosporidium

Answer 6

1.Old dude with cane walking in brownish water - Cryptosporidium infection causes severe, watery diarrhea in HIV patients
2.Dude wearing a western style tassel - Cryptosporidium stains acid-fast
3.Bubbles all around - infectious oocysts of cryptosporidium are passed through the stool via contaminated water
4.Multifacted amethyst gems in the water -Cryptosporidium cysts are composed of 4 motile sporozoites, look gem like on stains
5.Pipe on the wall with stool running into the water - Cryptosporidium sporozoites attach to the intestinal wall, causing diarrhea and small intestine damage
6.Dude using a knitted sock to collect amethyst gems - Nitazoxanide treats Cryptosporidium infection (only use in immunocompetent hosts)

Question 7

Pneumocystis pnemonia

Answer 7

1.Old player with cane and coughing - Old player with cane and coughing -> symptoms of Pneumocystis pneumonia infection are evidence in immunocompromised patients
2.AID for AIDS tournament and 20-0 score - PCP is an AIDS defining illness; more susceptible to PCP infection when CD4 count is < 200 cells/ul (if HIV positive as well, should start prophylaxis at this point)
3.Cracked glass ping pong tables - PCP causes diffuse interstitial pneumonia that may take on a ground glass appearance on X-ray; also has traditional pneumonia symptoms, though with non-productive cough
4.Player drinking out of a bottle labeled “BAL” - PCP diagnosis can be confirmed with a bronchoalveolar lavage (BAL)
5.Silver discs on ping pong tables - BAL sample is stained with methamine silver to identify PCP that will look like disc shaped yeast (ovoid)
6.Crushed ping pong balls - Ground glass appearance on PCP pneumonia X-ray can look like crushed ping pong balls
7.Old dude using backhand and jar of eggs in the background - use Bactrim for prophylaxis and treatment of PCP; Sulfamethoxazole and Trimethoprim are the components of Bactrim
8.Paddles changed to pentagon shapes - Pentamidine may be used for prophylaxis and treatment of patients who are allergic to sulfa drugs

Question 8

Sporothrinx schenkii

Answer 8

1.Some generic greenery - Sporothrix is found in rose thorns, tree bark, and other plants
2.Butterfly in the garden - Butterfly in the garden -> Sporothrix is dimorphic
3.Branching rose stems - Sporothrix has branching hyphae (seen when growing cultures at 25 C)
4. Budding roses - Sporothrix causes “rose gardener’s disease”
5. Gardener is smoking a cigar - Sporothrix looks like cigar shaped yeast under a microscope
6. Vines along the walls and thorny roses along gardener’s arm - Sporothrix schenckii infection manifests with nodules that spread along the path of draining lymphatics
7. Pine cones - use Itraconazole to treat lymphocutaneous sporotrichosis

Question 9

Blastomyosis

Answer 9

1. River valley and a soldier with a map - Blastomycosis is geographically distributed in the Great Lakes region and Ohio River valley & east coast
2. Butterfly - Blastomycosis is dimorphic: mold in the cold (e.g. soil), and yeast in the heat (e.g. our bodies)
3. Cannon causing smoke, inhaled by coughing soldier - Blastomycosis is transmitted via inhaled aerosolized spores
4. Soldier holding cannon balls together in pairs - Blastomycosis, once inside the body, replicates via broad based budding
5. Cannon balls causing cracked ground and smoke - Blastomycosis presents with patchy alveolar infiltrate in lungs (“haziness”), as well as lesions or cavities in the lungs (basically presenting with pneumonia)
6. Old cracked statue of Robert E. Lee holding a cane - dissemination of Blastomycosis infection (systemic infection) most likely to occur in immunocompromised and in the skin and bone; note skin ulcers (cracks in the statue) and osteomyelitis
7. Yellow river - use urine antigen test to diagnose Blastomycosis
8. Pine cones - use azoles like Itraconazole for local infection of Blastomycosis, usually in immunocompetent patients
9. Frogs around the Robert E. Lee statue - use amphotericin B for severe, disseminated infection of Blastomycosis, usually in immunocompromised patients

Question 10

Histoplasmosis

Answer 10

1.Historian exploring a cave with a map - Histoplasma is endemic to midwestern and central U.S., along the Mississippi & Ohio river valley
2.Historian is coughing - Histoplasma transmission is via respiratory tract
3.Cage with a bird in it - histology of Histoplasmosis consists of macrophages with intracellular oval bodies within
4.Red and yellow stalactites dripping to the floor - can use serum rapid antigen test or urine rapid antigen test to diagnose Histoplasmosis; macrophages will have several ovoid bodies (smaller than RBCs) inside
5.Butterfly - Histoplasmosis is dimorphic: mold in the cold (e.g. soil), and yeast in the heat (e.g. our bodies)
6.Historian coughing, cracked walls in the back with mini stalactites, and book with wild west scene - most patients are asymptomatic, but when Histoplasmosis does present, it presents with pneumonia and cavitary lesions in upper lobes and fibrotic scarring in the lungs (calcifications, especially in hilar regions)
7.Pale columns with red spots - Histoplasmosis can present with erythema nodosum (reddish tender lumps on the legs)
8.Cave drawing of bull with certain pattern of spots - Histoplasmosis can result in hepatosplenomegaly with calcifications in these organs
9.Historian uses a cane - for Histoplasmosis, disseminated disease occurs in the immunocompromised
10.Pine cones in the cave - for local and mild infections, use azole (“-conzole”) drugs like Fluconazole or Ketoconazole to treat
11. Pictures of amphibian frogs - For systemic or disseminated infection of Histoplasmosis, use amphotericin B

Question 11

Coccidioidomycosis

Answer 11

1.Presidio San Joaquin with map on the fountain - Coccidioidomycosis is geographically distributed in the southwestern United States
2.Cracks in the ground with dust rising - Coccidioidomycosis is transmitted via inhalation of spores in dust; earthquakes usually cause rise in this dust and is thus a risk factor
3.Butterfly - Coccidiomycosis is dimorphic
4.Red tumbleweed across the ground - Cocci forms spherules filled with endospores inside lungs
5.Red sombrero alongside the tumbleweed - Cocci spherules are larger than RBCs
6.Soldier coughing, sweating, and hitting his knees on the ground - majority of Cocci infections are asymptomatic, but an infection can look like an acute pneumonia with cough, fever, and arthralgia
7.Cracks in the wall with some bricks, some missing - radiographic images of Cocci infection may show nothing in the lungs, or cavities and or nodules
8.Red spots on pillars in the wall - Cocci infection presents with Erythema nodosum (red, tender lumps, usually on the shins); usually only seen in healthy people as this indicates a robust immunogenic response
9.Cracked statue of some founder saint - disseminated Cocci infection usually spreads to the skin and lungs, and can also spread to the bone in immunocompromised patients
10.Soldier holding onto neck brace and leaning on cracked statue - Cocci infection can disseminate to the meninges in the immunocompromised and cause meningitis
11.Pine cones - use conazoles like ketoconazole to treat local lung infection
12.Frogs in the fountain - use amphotericin B to treat systemic Cocci infection

Question 12

Canadida

Answer 12

1.Butterfly - Candida is different from other dimorphic fungi in that it is a yeast in the cold and mold in the heat
2.37 Flavors ice cream stand - Candida forms germ tubes (mold) at 37 C (heat)
3.Shrubbery with some snow balls and a thermometer showing 20 C - Candida is a yeast in a cold temperature environment
4.Cat - Candida is catalase positive, making individuals with chronic granulomatous disease susceptible to infection
5.Crying red-faced baby with a red diaper - Candida causes diaper rash in a characteristic distribution due to the heat and humidity within a baby’s diaper
6.Old dude with a cane and a kid with snow on his tongue - Oral candidiasis is seen in immunocompromised patients or those using oral steroids
7.Kid with snow on his tongue and holding blue inhaler - Oral steroid use must be followed by oral rinsing to avoid development of oral candidiasis
8.Guy scraping off snow using KOH salt - Oral candidiasis can be scraped off the oral mucosa;KOH is used to prep oral scrapings when attempting to diagnose oral candidiasis
9.Weird monster at head of slide and bits of snow at the bottom - Candidal esophagitis (slide looks like esophagus) is an AIDS defining illness
10.Maximum of 100 lbs for the slide - Candidal esophagitis is seen when CD4 count is < 100
11.Female teacher getting hit in the crotch by snowball and dropping prescription drugs, birth control, and jar of candy - Candida can cause vaginal candidiasis, Diabetics are susceptible to candidal infections,Antibiotic use and birth control predispose women to yeast infections due to destruction of normal vaginal flora
12.Playground open until 4 pm - normal vaginal pH is 3.8 to 4.2 (acidic); Candida does not change vaginal pH, infection occurs below pH 4
13.Roof on playground with three pyramids with hearts - Candidal endocarditis is commonly seen in drug users, commonly affecting the tricuspid valve (Candida grows in drugs like heroin, injected IV, can seed the heart)
14.Frog rides on playground - use Amphotericin B to treat severe, disseminated infections of Candida
15.Pine cones - use conazoles to treat Candidiasis
16.”Play Nyce” sign on the playground - Nystatin is used for oral or esophageal candidiasis
17.Old man wearing a cap - Caspofungin may be used for disseminated Candidal infections resistant to amphotericin

Question 13

Aspergillus fumigatus

Answer 13

1.Cat on top of scarecrow - Aspergillus fumigatus is catalase positive
2.Peanut plant and wheat field Peanuts and grains (e.g. wheat) are associated with aflatoxins produced by Aspergillus flavus (not fumigatus)
aflatoxins can result in hepatocellular carcinoma (induce p53 mutations)Cow with certain shaped spot in front of a tractor with a crab symbol
3.Stems of peanut plant have acute angles - hyphae of Aspergillus form acute angles (< 45 degrees)
4.Budding flowers on the peanut plant - Aspergillus is transmitted by inhalation
5.ABPA plane flying over running migrant worker, who’s sweating and holding an inhaler - Aspergillus fumigatus can cause Allergic Bronchopulmonary Aspergillosis (ABPA), a type I hypersensitivity reaction that causes wheezing/asthma, fever, and migratory pulmonary infiltrate
6.Farm worker sweating and walking behind cacti Peanuts in soil under the plant - Aspergillus fumigatus can cause aspergillomas, which are fungus balls located within TB-like lung cavities, Fungus balls within cavities are gravity dependent, and will thus be at the bottom of a cavity in a chest x-ray
7.Sweating farm worker with cane, next to red sprinkler system - Aspergillus can cause angioinvasive aspergillosis, which affects immunocompromised patients, such as patients with neutropenia from leukemia or lymphoma, Invades blood vessels and disseminates through the body; causes fever, cough, and hemoptysis
8.Scarecrow with straw patches at the sides and chest, as well as head and face - Scarecrow with straw patches at the sides and chest, as well as head and face
9.Vortex with pine cones - voriconazole
10.Frogs - use Amphotericin B for more serious Aspergillus infections e.g. angioinvasive aspergillosis

angioinvasive aspergillosis can lead to spread to kidney, causing kidney failure; heart, causing endocarditis; brain, causing ring enhancing brain lesions; and paranasal sinuses, causing necrosis around nose (also seen in Mucor, which differentiates by having right-angle branching)

Question 14

Crytococcoi

Answer 14

1. Mummies in sarcophagi - Cryptococci are heavily encapsulated
2. Repeating pattern on one of the sarcophagi - Cryptococci capsule is made of repeating polysaccharide capsular antigens
3. Pigeons with falling feathers and coughing archaeologist - Cryptococci are found in soil and pigeon droppings, and is transmitted via inhalation
4. Archaeologist holding NH3 spray bottle - Cryptococci are urease positive
5. Mummy holding a cane - opportunistic infection that commonly affects immunocompromised patients
6. Coughing archaeologist - cough, dyspnea, and other serious lung infections
7. Archaeologist wearing neck brace - Can lead to permanent neuro deficits and be lethal
8. Archaeologist is sweating - Main symptoms in summary: 1. fever, 2. pneumonia, 3. meningitis
9. Mummy with bubbles on chest - bronchopulmonary washings can be used to diagnose Cryptococcal infection
10. Tombs with red and silver design - tissue samples can be stained with mucicarmine (red) or methanamine silver stains
11. Vat with a skull and some random bones inside - India ink outlines Cryptococci capsules as “halos”
12. Archaeologist with latex glove next to repeating tomb pattern-latex agglutination detects capsular antigen and causes agglutination
13. Soap bubbles on the mummy’s head - Cryptococcal meningitis can result in gross pathology: “soap bubble” lesions in gray matter of the brain
14. Hieroglyphics showing dude playing flute and frogs followed by picture of pine cone - order of treatment for cryptococcal meningitis: amphotericin + flucytosine followed by maintenance therapy using fluconazole

Question 15

Mucromycosis

Answer 15

1.Dude with a cane Jar of candy Baguette - immunocompromised patients are at particular risk of Mucormycosis infection, specifically those with leukemia or neutropenia
2.Mechanic coughing from fumes - Saphrophytic fungi (e.g. Mucor, Rhizopus, Absidia species) is transmitted via spore inhalation & causes mucormycosis
3.Ketone auto parts sale - Diabetic ketoacidosis (DKA) is the most common predisposing factor to infection with Mucor/Rhizopus/Absidia
4.Right angle tire irons - Mucor has hyphae that are nonseptate and branch at wide angles (like right angles)
5.Jumper cables - Mucor likes to proliferate in blood vessels
6.Crate with holes in it, leaking oil - after invading blood vessels, Mucor penetrates the cribiform plate and invades the brain, can cause necrosis of tissues
7.Mechanic with oil dripping on his face- after penetrating cribiform plate and proliferating in the brain, Mucormycosis presents necrosis of tissue, such as a black eschar on the face and in nasal cavity
8.Car looks like a frog and has “FROGLVR” license plate-use amphotericin B for medical management and treatment of Mucormycosis
*must remove dead tissue from surgical debridement as well

Question 16

Toxoplasma

Answer 16

1. Pregnant woman kneeling down - pregnant women are at risk of transplacental transfer of toxoplasma
2. Litter box - Toxoplasma gondii can be transmitted by cat feces
3. Egg dropping into litter box - Toxoplasma gondii can be transmitted via oocysts in cat feces (fecal-oral transmission)
4. Cat with cane and glasses with rings - Immunocompromised patients, especially HIV patients, are at increased risk of toxoplasmosis; would see ring enhancing lesions on CT or MRI
5. Cat wearing red turban - Toxoplasmosis can cause encephalitis
6. Cat with needle in red turban - use a brain biopsy to differentiate toxoplasmosis encephalitis (multiple ring-enhancing lesions) from CNS lymphoma
7. Cat kicking aside bowl of bubbly-looking meat - Toxoplasma gondii can be transmitted via cysts in undercooked meat (most common mode of transmission)
8. Cat representing Statue of Liberty and holding a torch - Cat representing Statue of Liberty and holding a torch -> Toxoplasma is a ToRCHeS infection, can infect via in utero
9. Kitten drinking milk and with milk on its head - Congenital toxoplasmosis presents with intracranial calcifications
10. Kitten trying to shake glass bowl off head - Congenital toxoplasmosis presents with hydrocephalus and seizures
11. Flash bulb on camera - congenital toxoplasmosis presents with chorioretinitis
12. Cat dressed like Beethoven - congenital toxoplasmosis can also lead to deafness (sensorineural hearing loss)
13. Sulfur eggs with pyramids drawn upon them - use sulfadiazine + pyrimethamine to treat toxoplasmosis
14. Ben Franklin cat using cane, holding $100 bill and kite with certain-shaped keys - begin prophylaxis treatment for toxoplasmosis gondii for HIV patients with CD4 count < 100 and seropositive for IgG
15. Sulfur egg right by Ben Franklin cat - use TMP-SMX for prophylaxis treatment for toxoplasmosis

Question 17

Varicella

Answer 17

1. General blue schematic - Varicella Zoster Virus (VZV) is a double-stranded DNA virus
2. Little statuette of Hermes - VZV is part of the herpes virus family
3. Zeus in a robe - VZV is enveloped
4. Little kids with some chickens, sweating, and one holding her head and another squirting a water gun - VZV manifests as an exanthem (widespread rash in children – chickenpox), accompanied by headache and fever and transmitted by respiratory droplets
5. Rose petals strewn all over the floor - VZV chickenpox rash is classically described as a vesicular “dew drops on a rose” rash
6. Sign stating “All Ages Welcome” - virus infection will have lesions in all different stages of healing
7. Little kid holding a toy tank- in a VZV infection, a Tzank smear will show multinucleated giant cells
8. Adult actor wearing a turban and holding a cane, coughing and sweating - VZV chickenpox infection in adults can manifest as pneumonia, which is a major cause of morbidity and mortality; also manifests as encephalitis
   Immunocompromised are at particular risk of developing both complications
   9.Sign stating “Live Show” and with a pointy end - Sign stating “Live Show” and with a pointy end -> a live attenuated vaccine for VZV chickenpox is available for children
   10.Recycling bin - use Acyclovir to treat VZV infection in children ages 12+, adults, and those immunocompromised
   11.Person taking a nap on tree roots extending into the background - VZV remains latent in dorsal root ganglia (sensory neurons)
   12.Elderly people with canes and underneath a roof with shingles - reactivation of latent VZV occurs with stress, aging, or immunocompromised state, and is called Herpes zoster, or shingles
   13.Angry audience member throwing roses at Zeus and rose petals distributed in a certain way on the man - ermatomal distribution (dew drop like vesicles on an erythematous base, travels down the sensory nerve fibers from dorsal root ganglia until reaching the skin); typically in lumbar or thoracic dermatome, rarely cross the midline
   14.Zeus stabbing dude with a lightning bolt and audience member with lightning bolt sign on chest- the rash from Herpes zoster/shingles infection is extremely painful, and after the rash subsides, pain may still occur in what’s called postherpetic neuralgia
   15.Dude holding cane and with red eye patches - Herpes zoster/shingles infection typically affects thoracic area but may affect the eyes in what is called Herpes Zoster Opthalmicus, which may result in vision loss if V1 distribution of trigeminal nerve is affected
   16.Signs stating “Live Show,” and “Seniors Only, 60 and Over,” and “Max Occupancy 200” - ve attenuated Zoster vaccine for Herpes zoster/shingles is recommended for adults over 60; do not give to actively immunocompromised patients e.g. pregnant women or those with lymphoma, but can give to HIV patients if CD4 count is over 200
   17.Family wearing same colored t-shirt for recycling and violet recycling bin - use Famciclovir or Valacylovir to treat shingles
   18.Torches around the stage - VZV is one of the ToRCHeS viruses, capable of vertical transmission
   19.Pregnant woman and child horrified at chicken plucking at doll, which has stubby arms and pegged legs, stuffing coming out, and an eye plucked out - if a pregnant woman becomes infected with VZV in first two trimesters, congenital varicella syndrome may occur, which is accompanied by limb hypoplasia, cutaneous dermatomal scarring, and blindness

Question 18

Rubella

Answer 18

1.Ottoman city in warm daylight, with scene taking place outside nucleus-shaped dome - Togavirus is a positive sense RNA virus that replicates in the cytoplasm
2.Man on horse hitting head on arbor and with mosquitos buzzing around - Arbovirus is a major Togavirus, short for Arthropod-borne virus, and transmitted via arthropods such as mosquitos
3.Horse with dude with red turban and compass drape - Western equine encephalitis virus (found in western U.S.)
- Eastern equine encephalitis virus (found in eastern U.S.)
- Venezuelan equine encephalitis virus (found in Central and South America)
4.Young child emperor in toga and with rubies everywhere - Rubella is a childhood exanthem (childhood rash) Togaviruses are enveloped
5.Emperor with chains behind ears and back of neck - hildhood Rubella causes tender postauricular (behind ear) and occipital lymphadenopathy
6.Emperor getting fanned with water droplets - Rubella is transmitted via respiratory droplets
7.Torches - congenitally acquired infections
8.Aqueductus arteriosus with open sign Bunch of creepy looking babies with glossy eyes, covering their ears - congenital Rubella has a classic triad of symptoms: Patent ductus arteriosus Congenital cataracts (“white pupils”)
Sensory-neural deafness
9.Blue gems, Yellow baby - Blue gems -> purpuric blueberry muffin rash
Yellow baby -> jaundice
10.Servants with knee pain - adult Rubella presents with arthritis
11.Puppet show, with one puppet with a needle and another pregnant
Ticket count of 200 - MMR is a live attenuated vaccine that induces both a humoral and cell-mediated response; should not be given to immunocompromised patients or to pregnant women
HIV positive patients should receive vaccine only with CD4 count above 200
12.Ticket counter with broken off tickets - Togaviruses produce long polyprotein products that are cleaved by proteases

Question 19

HSV 1 and 2

Answer 19

1.Blue tones - Herpes is a DNA virus
2.Hermes wearing a robe -> Herpes is enveloped
3.Two straight lines on the road -> Herpes is double-stranded and linear; replicates in the nucleus
4.Hermes wearing cowhide for robe -> Herpes manifests as intranuclear inclusion bodies called Cowdry bodies in host cells, look like targets
5.Hermes holding a torch -> Herpes can be transmitted vertically (TORCHES mnemonic)
6.Hermes with bleeding mouth and cold sores - HSV-1 causes gingivostomatitis as a first sign of infection – affects mouth and gums (tender sores) that frequently occurs in children; progresses to herpes labialis (
7.Hermes with bloody eyes and snakes around his staff - HSV-1 causes keratoconjunctivitis, an eye infection with serpiginous corneal ulcers seen upon Fluorescein slit lamp exam
8.Hermes with black helmet and red wings - causes temporal lobe encephalitis, which causes hemorrhage & necrosis of inferior and medial temporal lobes; also includes fever, headache, seizure, altered mental status, bizarre behavior, personality changes
9.Three gems on Hermes’ helmet - HSV-1 is latent in the trigeminal ganglia, often reactivated by stress or immunocompromisation
10.Hermes falling and dropping batch of roses with dew drops, some of which going on his finger - Herpes rash has “dew drops on rose petal” appearance (clear vesicles sitting atop erythematous base); herpes also causes herpetic whitlow (more common in dentists and other people who use their hands in other people’s mouths; could also come from genitals for HSV-2)
11.Postage stamps all over Hermes’s arm - Erythema multiforme may appear 1-2 weeks after infection (HSV-1 more commonly than HSV-2)
12.Hermes with tusses around his skirt - HSV-2 is associated with painful inguinal lymphadenopathy
13.Hermes wearing piece over crotch - HSV-2 lies dormant in the sacral ganglia
14.Hermes wearing neck brace - HSV-2 may cause aspetic meningitis in adolescents and adults
15.Little kid playing with a tank with a certain kind of camo - to diagnose herpes, can perform Tzank smear showing multinucleated giant cells, characteristic of herpes infections
16.Violet recycling bin - use Acyclovir or Valacyclovir to prevent herpes breakouts

Question 20

HSV - 8

Answer 20

1.Katie’s Posies has an emblem shaped like an 8 and witih Hermes with a bouquet of roses -> HHV-8 is in the Herpes virus family and causes Kaposi’s Sarcoma
2.General blue and cool colors -> HHV-8 is a double-stranded DNA virus
3.Old lady with a cane and wearing a characteristic ribbon on shirt -> Kaposi’s Sarcoma is associated with immunosuppressed patients and is an AIDS-defining illness
4.Old lady with bouquet of violets and petals on nose and extremities - HHV-8 Kaposi’s Sarcoma causes violacious lesions on the nose, extremities, and mucous membranes
5.Shop worker unrolling a bunch of red tubing -> HHV-8 Kaposi’s Sarcoma causes proliferation of vasculature (angiogenesis)
6.Bag of “VEG Fertilizer” with a symbol of red branching plant - causes dysregulation of VEG-F, the mechanism by which it causes angiogenesis
7.Flower bed underneath a pillowy case - during HHV-8 Kaposi’s Sarcoma, lesions can be found within the GI tract
8.Posies all over arched ceiling - most commonly occur on the hard palate (arched ceiling of the mouth)
9.Katie’s Posies gets a “B” rating, displayed next to statue of archer - HHV-8 can infect B cells and cause Primary Effusion Lymphoma (a type of B-cell lymphoma)
10.Flowers native to Africa and Russia - HHV-8 Kaposi’s Sarcoma has higher incidence in Russian men and African populations
11.Bart the leopard standing over the red tubing - HHV-8 Kaposi’s Sarcoma & Bacillary Angiomatosis (Bartonella henselae) closely resemble each other

Question 21

Epstein bar (mono)

Answer 21

1.General blue color scheme -> Epstein-Barr Virus is a double-stranded DNA virus
2.Girl pursing her lips, readying for a kiss -> Epstein-Barr virus is transmitted primarily through saliva
3.Guy is sweating and knocked over drink to spill onto a knight, who grabs him by the neck -> Epstein-Barr virus (mono) causes fever and tender lymphadenopathy
4.Angry reactive toxic knight has wine stains on clothes - in an Epstein-Barr virus (mono) infection, reactive cytotoxic CD8+ T cells
5.Random cow with certain pattern - Epstein-Barr virus (mono) causes T-cell proliferation
6.Sleeping archer with certain shaped arrows -> during infection of a new host, Epstein-Barr virus invades B cells and remains latent there
7.Sign stating “must ‘B’ 21” to be in the bar - Epstein-Barr virus envelope glycoprotein binds CD21 (CR2) to infect B cells
8.Dude drooling copiously - Epstein-Barr virus (mono) infection exhibits symptoms of pharyngitis and tonsillar exudates
9.Dude pranking the sleeping archer by drawing spots on his face - If a patient with EBV (mono) infection is mistakenly given amoxicillin or ampicillin [horn = AMPicillin] (types of penicillin), the patient can develop maculopapular rash [
10.Painting of owl and black kid with African clothes eating crab that puffs out his cheeks - Hodgkin’s lymphoma (Reed-Sternberg cells that look like owl’s eyes), Non-Hodgkin’s lymphoma (e.g. Burkitt lymphoma, Primary CNS lymphoma)
11.Crab pinching Asian man’s nose - Nasopharyngeal carcinoma is associated with Asian Epstein-Barr virus patients
12.Old man with cane and bushy beard - Epstein-Barr virus (mono) infection associated with oral hairy leukoplakia, particularly in HIV patients,however, unlike Candida, cannot scrape off
13. Dartboard with five-sided darts all clumped together on center target - can use the monospot test to diagnose EBV (mono) infection; based on agglutination of heterophile antibodies produced in response to EBV infection
14. Sign stating “No Contact Jousting in bar” - Sign stating “No Contact Jousting in bar” -> patients with EBV (mono) infection should avoid contact sports due to risk of splenic rupture (50-60% of patients have splenomegaly)

Question 22

HHV - 6 Roseola

Answer 22

1.General blue tones -> HHV-6 is a double-stranded DNA virus
2.Squire with four feathers in his cap and a #4 in his belt -> HHV-6 infects CD4+ cells and can thus cause immunosuppression
3.Hermes symbol on horse with #6 -> HHV-6 is in the Herpes virus family, and is also known as the sixth disease
4.Squire sweating underneath a banner with 4 suns - fever generally lasting 4 days (fever is high grade, can be over 104 F) + maculopapular rash on chest & trunk once fever subsides
5.Squire trembling in awe at hallucination of Mary and child - children with HHV-6 Roseola can develop febrile seizures
6.Mother in blue flames and wearing a pink spotted robe Mother is holding a young infant - in HHV-6 Roseola, after the fever subsides, a diffuse lacy body rash occurs, sparing the face, affects children ages 6 months to 2 years, and is usually self-limiting; treatment is generally supportive care

Note: contrast with measles (which has a rash that occurs DURING fever and does NOT spare the face)

Question 23

CMV

Answer 23

1.Blue walls -> Cytomegalovirus is a double-stranded DNA virus
2.Hermes statue in background and sleeping dude being prodded
Knights, archers, and prisons in background - CMV in particular is latent in mononuclear cells i.e. WBCs with one nucleus including lymphocytes, monocytes, and macrophages,part of the herpes virus family
3.Old woman prodding guy with cane -> CMV can be reactivated from latency via immunosuppression
4.Torches -> CMV is a ToRCHeS infection (capable of crossing the placenta and vertical transmission)
5.Blueberry muffins everywhere - thrombocytopenia, which can cause petechial rash characterized as a “blueberry muffin” rash
6.Yellow cow with certain shaped spots over dairy section - CMV infection presents with jaundice and hepatosplenomegaly
7.Little kid coveirng his ears, wearing a helmet with a certain weird design, and milk spilling everywhere - CMV infection in fetuses presents with sensorineural deafness, periventricular calcifications [B], and ventriculomegaly (dilated lateral ventricles in brain)
8.Dude slipping on the milk -> the changes in brain structure in fetuses caused by CMV virus can result in mental retardation or seizures
9.80-90% off sign -> 80-90% of newborns infected with CMV are asymptomatic
Note: 15% of these kids eventually develop hearing loss (usually unilateral but sometimes bilateral), thus important to test hearing at birth and as they get older
10.Balloon animals, with one in a puddle of water -> highest risk of CMV infection in utero occurs during second trimester; can result in hydrops fetalis in the fetus, which is heart failure leading to severe edema in numerous compartments; most often leads to spontaneous abortion
11.Kid wearing #1 on shirt - #1 cause of sensorineural hearing loss in children, #1 cause of congenital viral infection, and #1 cause of mental retardation from congenital viral infection
12.Butcher coughing with stains on apron (looks like lungs) and meats of various sizes on ice - organ transplant patients are at risk for developing CMV pneumonia (e.g. lung transplant pt developing CMV pneumonitis)
13.Old cashier with cane looking over sign for Charity Drive costing 50 cents -> AIDS patients with CD4 count < 50 are at increased risk of CMV infection
14.Cashier holding pizza box - most common manifestation of CMV infection in AIDS patients is CMV retinitis (chorioretinitis), “pizza pie” retinopathy”:
15.Conveyor belt that looks like an esophagus - linear ulcerations in esophagus can also occur in AIDS patients with CMV infection CMV ulcerations are usually singular, deep, and linear, while herpes ulcerations are multiple and shallow
16.Pink grocery bags with red dots with tears in them - AIDS patients with CMV infection can present with CMV colitis with ulcerated walls
17.Owl books - CMV presents w/ enlarged cells w/ intranuclear inclusion bodies
18.Green recycling bin for cans only -> first line treatment for CMV infection is Gancyclovir
19.Fast car with a net and UL97 sticker-mutations in the UL97 gene; must use Foscarnet instead
20.Angry mom with inflamed throat and holding “No Mo’ Spots” detergent -> CMV infection can cause mono with same symptoms as EBV mono; difference is that EBV infection has positive monospot test, while CMV infection has negative monospot test

Question 24

Norovirus

Answer 24

1.Nice warm, sunny day -> Calicivirus is a positive sense RNA virus
2.Statue of David -> Calicivirus is a naked virus
3.Dude taking tickets - Calicivirus produces one long polyprotein that is cleaved by viral proteases
4.Three dragons -> Khaleesi -> Calicivirus
5.Narwhal - Norovirus (aka Norwalk virus) is the most common Calicivirus, happens usually on cruises
6.Children passengers - outbreaks of Norovirus is common in daycare centers and schools
7.Shellfish buffet -> consumption of shellfish (especially if touched or uncooked) is associated with Norovirus, can be transmitted this way
8.Ship’s aft with propellor turning up lots of brown stuff -> Norovirus causes explosive watery diarrhea

Question 25

RotaVirus

Answer 25

1.Rio Grand Prix being held at sunset, in a nice orange-ish setting without sun or moon -> Reovirus is a double-stranded RNA virus (neither positive nor negative sense)
2.Rock formation that looks like David -> Reovirus is a naked virus
3.11 boats, separated into two lanes - Reovirus is a double-stranded RNA virus with 11 segments
4.Boat with propellor mustering up some brown stuff - Rotavirus is a type of Reovirus that causes explosive watery diarrhea
5.Motor is “Nine SPeed 4 stroke” and boat is called “Chlo-rider” - NSP4 is Rotavirus’s enterotoxin that causes the watery, secretory diarrhea; does so by increasing chloride permeability
6.Snow-capped mountains in the distance - Rotavirus (type of Reovirus) occurs more commonly in winter
7.The racers are children + fan holding up #1 sign - Children and young infants (e.g. those in daycare) are at risk of Rotavirus infection, which is the #1 cause of severe diarrhea in this population
8.Colorado sign with a tick on it and a kid coming up on his knees, vomiting and sweating -> Colorado tick virus is a type of Reovirus that causes myalgia, fever, and vomiting (no rash!)
9.Kid holding water bottle -> treatment for Rotavirus is oral rehydration
10.Reporter shooting live and holding a mic that looks like a syringe close to his mouth -> can use a live attenuted vaccine for Rotavirus, taken orally
11.Fan holding a telescope near the reporter - side effect of Rotavirus vaccine is intussusception, which is telescoping of the bowel

Question 26

Hep B

Answer 26

1.Hippie pad - Hepatitis B Virus is part of the hepadnavirus family
2.Blue tones and hippies in a circle in oversized hippie garb - Hepatitis B Virus is an enveloped DNA virus
3.Hippies both inside the dome and out - Hepatitis B Virus undergoes both intranuclear and cytoplasmic replication (unique to Hep B)
4.Hippies in a circle and another line of hippies in a partial outer circle - Hepatitis B Virus is a circular, partially double-stranded DNA virus
5.Free spirited fortune teller holding spellbook called “Reverso Transcriptum” - Hepatitis B Virus uses a reverse transcriptase for replication:
6.Hippie girl holding sign stating “Sex, Drugs, Rock & Roll” and with a baby in a stroller by a couple of torches - Hepatitis B Virus is transmitted via sex and sharing blood products (e.g. needles); can also occur via vertical transmission during delivery (mixing of blood; too large to cross placenta), and is considered a ToRCHeS infection
7.Mom and baby sharing a cookie, with mom taking 10% and baby taking 90% - newborns infected with HBV have a 90% chanceAdults usually experience full resolution of disease
8.henna tattoo, pain at her knees, beading, glomerular-shaped strings & kidney-shaped boxes - exhibits prodromal serum sickness-type illness with purpuric, pruritic urticarial vasculitis rash with non-blanching dark macules and arthralgias, polyarteritis nodos,membranous glomerulonephritis
9.Hippie playing with a volleyball labeled “ALT” and toddler with deflated “ALT” ball - ALT is higher than AST in viral hepatitis, ALT will fall after symptomatic phase is over, ALT is normal during early neonatal hepatitis
10.Van painted with rainbow colors and displaying message “We are all one SPECIES” - Beginning of infection is symptomatic:
First marker of active Hep B infection is HbSAg (Hep B surface antigen)
HBeAg (Hep B E antigen) appears next and is highly correlated with infectivity
During window period (patient developing anti-Hep B antibodies to bind Hep B surface antigens):
Anti-HBc (anti-Hep B core antibody) is positive
Anti-HBe (anti-Hep B E antibody) is positive
Once Anti-HBs (anti-Hep B surface antibody) develops, the infection is over and the patient has recovered; someone vaccinated/immunized will test positive for nothing except Anti-HBs
distinguish between those immunized and those who have had the disease and recovered -> those immunized will have only Anti-HBs, while those who have recovered will have Anti-HBs and at least Anti-HBc as well (and possibly Anti-HBe)
11.Fortunate teller showing a card of a crab over a rock that looks like a liver - Hepatitis B Virus is associated w/ cirrhosis and hepatocellular carcinoma
12.Hippie dad with little kids wearing orange flowy robes, moon necklaces, and orange headbands - Hepatitis D Virus is an enveloped, negative-sense RNA virus that has a circular genome
13.Hippie mom handing kid some kind of surface thingy - Hepatitis D Virus requires HBsAg to be infectious
14.Hippie mom and dad holding kid’s hands, and other kid on top of dad with dad looking not so happy about it - co-infection occurs when both viruses (Hep B and Hep D) are transmitted simultaneously, superinfection occurs when Hep D is transmitted on top of existing Hep B infection (has worst outcomes than co-infection)
15.”Make Peace Not War” sign with symbol of lamb and monster with mace, and twisted antenna with interference on van - use Lamivudine or other nucleoside reverse transcriptase inhibitors (NRTIs), or IFN-α to treat HBV
16.Kid with deflated “ALT” ball given keys to the minivan - if new mother is HBV⊕, give at-risk newborn kids anti-Hep B immunoglobulins along with vaccination

Question 27

Hep A

Answer 27

1.Hippos labeled A with a baby and a certain shaped spot, in warm daylight -> Hepatitis A is a positive sense RNA picornavirus that causes hepatitis
2.Hippos hanging out on rocks in the middle of a pool of acid -> Hepatitis A is an acid stable virus, thus can be transmitted fecal-orally (stable in stomach acid)
3.Statue of David - Hepatitis A is a naked virus
4.Hippo droppings -> Hepatitis A is transmitted fecal-orally
5.Water purification system with sign stating the steps -> Hepatitis A can be inactivated via chlorination, bleaching, UV irradiation, or boiling, which is done to water as HepA in feces can contaminate water Note: contaminated water is a common source of the virus in developing countries
6.Shellfish stand and woman catching shellfish out of the pond with backpack -> contaminated shellfish (especially uncooked) can cause HepA in developed countries, particularly if shellfish were caught from contaminated water This is commonly seen in travelers to endemic areas (especially Southern Hemisphere)
7.Dude in yellow jumpsuit vomiting, kid vomiting, and smoker disgusted by cigarette - HepA can cause jaundice (especially in adults), anicteric hepatitis (without jaundice) in young children and infants, and an aversion to smoking in smokers
8.Sign on shellfish stand stating one month only, limit one per customer, no carrying out of food - HepA has a one month duration of symptoms, is self-limiting, and has no carrier or chronic state
9.Shellfish zookeeper with tranquilizer -> HepA vaccine is available, and is an inactivated vaccine

Question 28

measles, mumps, rsv, influenza

Answer 28

1.Room with warm, orange colors at nighttime - Paramyxovirus is a negative sense RNA virus
2.Ghosts are in sheets and holding envelopes - Paramyxovirus is enveloped
3.Droplets from sprinkler system - Paramyxovirus is transmitted via respiratory droplets
4.Live puppet show with ghosts - MMR vaccine is live attenuated;
5.Female weasel in ruby-colored dress - Measles is also known as Rubeola
6.Weasel with vest (with 4 C’s), coughing, sweating, and red eyes, and eating some blue stuff - 4 “C”s of measles: (prodromal/early symptoms)
- cough
- coryza (runny/stuffy nose caused by inflammation of upper airway)
- conjunctivitis
- Koplik spots (pathognomonic for measles – small, bluish-white spots found on buccal mucosa on inside of cheek)
7.Female weasel with rubies falling off her crown - Measles: itchy, maculopapular rash starts on the face and moves downwards
8.Weasel with gigantic, untied bow tie that looks like two lungs - Measles may cause Giant cell pneumonia (rare except in immunosuppressed)
9.Weasel with a turban and sign for the play called “Tales of SSPEnce” - Subacute sclerosing panencephalitis (SSPE) is associated w/ an abnormal measles virus that persists in the CNS of these pts for years after recovery from measles infection
10.Strips of berries and chocolate stuck together - hemagglutinin (HA) - measles virulence factor
11.Weasle with turban and his hands stuck together - fusion protein (a measles virulence factor): formation of syncytia (multinucleated giant cells formed from fused lymphocytes); virus transfers cell-to-cell evading immune response
12.Weasel wearing party hat that looks like an A - vitamin A has been shown to reduce measles morbidity and mortality
13.Mummy with big cheeks - mumps replicates in the salivary (parotid) glands and causes parotitis
14.Mummy holding single orchid - seen when teenage boy or man is infected with mumps, can result in testicular atrophy or impaired fertility
15.Mummy wearing neck brace - mumps causes meningitis
16.Mummy child enjoying the puppet show - mumps is covered in the MMR vaccine
17.Mummy holding scalpel and hor d’oeuvres Mummy child with hands stuck - mumps has virulence factors of neurominadase (NA), fusion protein, and hemagglutinin
18. RSV grave with ghost babies, with one holding a G-shaped worm - Respiratory Syncytial Virus - seen in infants < 6 months old
19. Infant ghosts with bronchioles on their chests - RSV is the #1 cause of pneumonia and bronchiolitis in infants
20. Ghost baby with sticky hands - RSV has fusion protein as its virulence factor
21. Ghost babies surrounded by teeth - treat RSV with Ribavirin
22. Extra pale ghost baby holding an IgG-shaped rattle - prevent RSV via prophylaxis w/ Palivizumab, a
23. Seal trying to bark with crew of wolves, Three wolves - arainfluenzae virus causes croup, which is characterized by seal bark cough and inspiratory strider
24. Eerie looking steeple - croup (from parainfluenzae virus) has “steeple sign” x-ray finding, which is narrowing of subglottal region
25. Wind blowing into the church - Inspiratory stridor is a characteristic finding of croup