IDS Random Flashcards
- What is the treatment of choice for epididymitis caused by N. gonorrhoeae or C. trachomatis?
a.
Ceftriaxone 500 mg IM as a single dose followed by Moxifloxacin 400mg orally once a day for 14 days
b.
Ceftriaxone 500mg IM as a single dose followed by Azithromycin 500mg/tab 1tab PO, then 250mg/tab 1 tab orally for 4 days
c.
Ceftriaxone 500mg IM as a single dose followed by Metronidazole 500mg 2 tabs orally for 14 days
d.
Ceftriaxone 500mg IM as a single dose followed by Doxycycline 100mg orally 2x a day for 10 days
Answer: D. Ceftriaxone 500mg IM as a single dose followed by Doxycycline 100mg orally 2x a day for 10 days
Ceftriaxone (500 mg as a single dose IM) followed by doxycycline (100 mg by mouth twice daily for 10 days) constitutes effective treatment for epididymitis caused by N. gonorrhoeae or C. trachomatis. Neither oral cephalosporins nor fluoroquinolones are recommended for treatment of gonorrhea in the United States because of resistance in N. gonorrhoeae, especially (but not only) among MSM
- A 58 year old diabetic male sought consult at the clinic due to ~4 week history of urinary frequency, dysuria and perineal pain. He denied fevers, anorexia, or nausea/vomiting. He initially sought consult at the local health center and was prescribed a 2-week course of antibiotics, which only had minimal relief of symptoms. He had a urinalysis done after antibiotic treatment, which had findings of WBC 4-6/hpf, few epithelial cells, and few bacteria. What is the next best step in management?
a.
Request for urine and blood cultures then start fluoroquinolones as empiric treatment to complete 4-6 weeks
b.
Request for a KUB with prostate ultrasound and close follow up once with results
c.
Advise intake of cranberry juice for UTI prophylaxis
d.
Consider urology consult
D. Consider urology consult
- The following findings support the diagnosis of acute uncomplicated cystitis in a female presenting with dysuria, EXCEPT:
a.
Positive leukocyte esterase test and negative nitrite dipstick test
b.
Blood in the urine
c.
A colony count of ≥102 bacteria/mL on urine culture
d.
Mixed bacterial growth on urine cultures
D. Mixed bacterial growth on urine cultures
The bottom line for clinicians is that a urine dipstick test can confirm the diagnosis of uncomplicated cystitis in a patient with a reasonably high pretest probability of this disease; either nitrite or leukocyte esterase positivity can be interpreted as a positive result. Blood in the urine also may suggest a diagnosis of UTI.
If a woman with acute cystitis is forcing fluids and voiding frequently, the dipstick test for nitrite is less likely to be positive, even when E. coli is present.
Studies of women with symptoms of cystitis have found that a colony count threshold of ≥102 bacteria/mL is more sensitive (95%) and specific (85%) than a threshold of 105/mL for the diagnosis of acute cystitis in women.
In most instances,** a culture that yields mixed bacterial species is contaminated except in settings of long-term catheterization, chronic urinary retention, or the presence of a fistula between the urinary tract and the gastrointestinal or genital tract
**
- What is the clinical hallmark of Herpes simplex virus encephalitis?
a.
Fever with autonomic nervous dysfunction of the sacral region
b.
Fever with hypoesthesia of the skin innervated by the trigeminal nerve and vestibular system dysfunction
c.
Fever with focal neurologic signs especially in the temporal lobe
d.
Headache, fever and mild photophobia
Answer: C. Fever with focal neurologic signs especially in the temporal lobe
The clinical hallmark of HSV encephalitis has been the acute onset of fever and focal neurologic symptoms and signs, especially in the temporal lobe
Autonomic nervous system dysfunction, especially of the sacral region, has been reported in association with both HSV and VZV infections.
Occasionally, hypoesthesia and/or weakness of the lower extremities persists for many months. Transitory hypoesthesia of the area of skin innervated by the trigeminal nerve and vestibular system dysfunction (as measured by electronystagmography) are the predominant signs of disease.
HSV meningitis, which is usually seen in association with primary genital HSV infection, is an acute, self-limited disease manifested by headache, fever, and mild photophobia and lasting 2–7 days.
- Which is correct regarding treatment of Varicella zoster?
a.
Valacyclovir, a prodrug of acyclovir, accelerates healing and resolution of zoster-associated pain more promptly than acyclovir.
b.
Treatment for zoster ophthalmicus include the initial use of IV corticosteroids and atropine
c.
In patients with lymphoproliferative malignancies, the dose of acyclovir should be 800mg given orally five times daily for 7-10 days
d.
For low-risk immunocompromised hosts, oral therapy with acyclovir appears beneficial
A. Valacyclovir, a prodrug of acyclovir, accelerates healing and resolution of zoster-associated pain more promptly than acyclovir.
Persons with zoster ophthalmicus should be referred immediately to an ophthalmologist. Therapy for this condition consists of the administration of analgesics for severe pain and the use of atropine. Acyclovir, valacyclovir, and famciclovir all accelerate healing. Decisions regarding the use of corticosteroids should be made by the ophthalmologist.
In severely immunocompromised hosts (e.g., transplant recipients, patients with lymphoproliferative malignancies), both chickenpox and herpes zoster (including disseminated disease) should be treated, at least at the outset, with IV acyclovir, which reduces the occurrence of visceral complications but has no effect on healing of skin lesions or pain. The dose is 10 mg/kg every 8 h for 7 days.
For low-risk immunocompromised hosts, oral therapy with valacyclovir or famciclovir appears beneficial.
The correct answer is: Valacyclovir, a prodrug of acyclovir, accelerates healing and resolution of zoster-associated pain more promptly than acyclovir.
Which is a TRUE statement regarding mumps?
a.
Encephalitis is the most common CNS manifestation
b.
Serum lipase levels may be elevated as a result of inflammation and tissue damage in the parotid gland
c.
The development of anti-sperm antibodies, reduced testosterone production, and impaired sperm mobility may lead to permanent sterility.
d.
Virus in the perilymph can result in infection of the cochlea and damage to the organ of Corti, and the tectorial membrane, leading to transient or permanent deafness
D. Virus in the perilymph can result in infection of the cochlea and damage to the organ of Corti, and the tectorial membrane, leading to transient or permanent deafness
Source: HPIM 21st ed. Ch 207, p 1616
Mumps virus is highly neurotropic, with subclinical CNS involvement occurring in up to 55% of patients as manifested by CSF pleo- cytosis. However, symptomatic CNS infection is less common
Serum amylase levels may be elevated as a result of inflammation and tissue damage in the parotid gland
The development of anti-sperm antibodies, reduced testosterone production, and impaired sperm mobility may lead to temporary sterility or subfertility.
A 28 year old male, person living with human immunodeficiency virus, consulted the clinic due to malaise. He complained of 3-day history of undocumented febrile episodes accompanied by nonproductive cough and coryza. He is on antiretroviral therapy, with last known CD4 count 150 cells/mm3 3 months prior. Which physical examination finding will lead to the most likely diagnosis?
a.
Erythematous macules behind the ears, neck and hairline, progressing to involve the face, trunk and arms
b.
Bluish white dots~1 mm in the buccal mucosa surrounded by erythema
c.
Changes in sensorium
d.
Conjunctivitis
B. Bluish white dots~1 mm in the buccal mucosa
Source: HPIM 21st ed. Ch 207, p 1610
Koplik’s spots are pathognomonic of measles and consist of bluish white dots ~1 mm in diameter surrounded by erythema. The lesions appear first on the buccal mucosa opposite the lower molars but rapidly increase in number and may involve the entire buccal mucosa. They fade with the onset of rash.
Because the characteristic rash of measles is a consequence of the cellular immune response, it may not develop in persons with impaired cellular immunity (e.g., those with AIDS; Chap. 202)
- Which is NOT a factor that influences mortality risk of pneumocystis jiroveci pneumonia?
a.
Low serum albumin level
b.
Development of pneumothorax
c.
Extrapulmonary disease
d.
Age
Answer: C. Extrapulmonary disease
Source: HPIM 21st ed. Ch 220, p 1693
Factors that influence mortality risk of PCP include the patient’s age and degree of immunosuppression as well as the presence of preexisting lung disease, a low serum albumin level, the need for mechanical ventilation, and the development of a pneumothorax.
- A 25 year old male construction worker came in for a 2-week history of on and off high grade fevers, chills, and calf pains. On probing, he had waded in flood waters around 3 weeks prior. Which is an expected laboratory finding?
a.
Leptospira isolate in blood cultures
b.
Leptospira isolate in CSF
c.
Low antibody titers
d.
Positive urine Leptospira DNA-PCR
Answer: D. Positive urine Leptospira PCR
Source: HPIM 21st ed. Ch 187, p 1418, Table 184-3
The acute leptospiremic phase is characterized by fever of 3–10 days’ duration, during which time the organism can be cultured from blood and detected by polymerase chain reaction (PCR). During the immune phase, resolution of symptoms may coincide with the appearance of antibodies, and leptospires can be cultured from the urine.
- Which is uniquely associated with leptospiral nephropathy?
a.
Oliguric acute kidney injury
b.
Hypokalemia
c.
Hypomagnesemia
d.
Acute tubular necrosis
Hypomagnesemia
Acute kidney injury is common in severe disease, presenting after several days of illness, and can be either nonoliguric or oliguric. Typical electrolyte abnormalities include hypokalemia and hyponatremia. Loss of magnesium in the urine is uniquely associated with leptospiral nephropathy.
The dengue virus belongs to what family of viruses?
Flaviviridae
The most clinically significant flaviviruses that cause the fever and myalgia syndrome are dengue viruses 1–4. In fact, dengue without/with warning signs (“dengue,” historically called “dengue fever”—to be distinguished from severe dengue) is probably the most prevalent arthropod-borne viral disease worldwide, with ~400 million infections occurring per year, of which ~100 million (25%) cause clinical illness.
others:
Dengue virus (DENV) belongs to the Flaviviridae family, which includes other arboviruses (arthropod-borne viruses) like Zika virus, West Nile virus, and Yellow Fever virus.
It is an enveloped, single-stranded, positive-sense RNA virus transmitted by Aedes mosquitoes (Aedes aegypti, Aedes albopictus).
Why are the other options incorrect?
a. Hantaviridae → Incorrect. Hantaviruses belong to the Bunyaviridae family, causing hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS).
b. Togaviridae → Incorrect. Togaviruses include Alphaviruses (e.g., Chikungunya virus, Eastern equine encephalitis virus) but NOT dengue.
c. Arenaviridae → Incorrect. Arenaviruses cause Lassa fever and other viral hemorrhagic fevers, not dengue.
Risk factors for shock from severe dengue
The induction of vascular permeability and shock depends on multiple factors, such as the presence or absence of enhancing and non-neutralizing antibodies, age (susceptibility to severe dengue drops considerably after 12 years of age), sex (females are more often affected than males), **race **(whites are more often affected than Black people), nutritional status, and timing and sequence of infections (e.g., *dengue virus 1 infection followed by dengue virus 2 infection seems to be more dangerous *than dengue virus 4 infection followed by dengue virus 2 infection
- Which is/are obligatory test/s included in diagnostic work up for fever of unknown origin?
a.
AST, ALT
b.
CSF culture
c.
Echocardiogram
d.
FDG PET-CT
nswer: A. AST, ALT
Source: HPIM 21st ed. Ch 20, p 147
Fever of unknown origin is defined as follows:
Fever ≥38.3°C (≥101°F) on at least two occasions
Illness duration of ≥3 weeks
No known immunocompromised state
Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations: determination of** erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST) or interferon γ release assay (IGRA).**
Required diagnostic work up for FUO
erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST) or interferon γ release assay (IGRA).
Definition of FUO
Fever ≥38.3°C (≥101°F) on at least two occasions
Illness duration of ≥3 weeks
No known immunocompromised state
Which statement is TRUE regarding fever of unknown origin (FUO)?
a.
Tuberculosis is the most common infectious disease associated with FUO in younger patients, occurring much often than in elderly patients
b.
Among the young adult population, FUO results from a typical manifestation of a common disease, among which giant cell arteritis and polymyalgia rheumatica are most frequently involved
c.
Although most tumors can present with fever, malignant lymphoma is by far the most common diagnosis of FUO among the neoplasms.
d.
In patients with recurrent fever lasting >1 year, it is very unlikely that the fever is caused by infection or malignancy.
Answer: C. Although most tumors can present with fever, malignant lymphoma is by far the most common diagnosis of FUO among the neoplasms.
Source: HPIM 21st ed. Ch 20, p 147
Tuberculosis is the most common infectious disease associated with FUO in elderly patients, occurring much often than in younger patients
Among the elderly population, FUO results from a typical manifestation of a common disease, among which giant cell arteritis and polymyalgia rheumatica are most frequently involved
In patients with recurrent fever lasting >2 years, it is very unlikely that the fever is caused by infection or malignancy.
- Which is central to the pathogenesis of falciparum malaria?
a.
Endotoxicity
b.
Splenic sequestration
c.
Cytoadherence and agglutination
d.
Monocyte/macrophage activation
Erythrocytes containing more mature parasites stick inside and eventually block capillaries and venules. These infected RBCs may also adhere to uninfected RBCs (to form rosettes) and to other parasitized erythrocytes (agglutination). The processes of cytoadherence, rosetting, and agglutination are central to the pathogenesis of falciparum malaria.
Which is the best biochemical prognosticator in severe malaria?
a.
Hypoglycemia
b.
Elevated plasma lactate
c.
Indirect hyperbilirubinemia
d.
Elevated blood urea nitrogen
elevated plasma lactate
Plasma concentrations of bicarbonate or lactate are the best biochemical prognosticators in severe malaria.
When accompanied by other vital-organ dysfunction (often renal impairment), liver dysfunction carries a poor prognosis. Hepatic dysfunction contributes to hypoglycemia, lactic acidosis, and impaired drug metabolism.
- A 32 year old male was rushed to the ER due to decrease in sensorium. He had a 2-week history of on and off undocumented febrile episodes with irregular patterns, body malaise, and fatigue. He denied cough/colds, dysuria or BM changes. He self-medicated with Paracetamol but had little relief of symptoms. Around 2 days prior, he had onset of postural dizziness, nausea and vomiting, making him bed bound. 1 hour prior, he was found to be unarousable, prompting consult at the ER. His ancillary history revealed that he had no comorbidities, no known vices, and works as a scuba diving instructor with frequent travels to Palawan. On assessment at the triage, he was GCS 8, with an RR of 30 with subcostal retractions, with BP of 80/50 and temperature of 36.3C. A spot CBG showed hypoglycemia at 35 mg/dL. Regional PE showed icteric sclerae, flat neck veins, occasional bibasal crackles, tachycardia with no murmurs, a soft nondistended abdomen and thready pulses with no bipedal edema. Neuro PE showed briskly reactive pupils with intact corneal reflexes, no facial asymmetry and intact gag. The limbs are normotonic with hyperreflexia on all extremities. Babinski and clonus are absent. Brudzinki and Kernig signs are negative. Which finding is true for his case?
PfHRP2 dipstick or card test - Robust and relatively inexpensive; rapid; sensitivity similar to or slightly lower than that of thick films (~0.001% parasitemia) - Detects only Plasmodium falciparum; remains positive for weeks after high- density infections; does not quantitate P. falciparum parasitemia; evasion of detection by certain strains due to polymorphisms in HRP2 gene
For P. falciparum, a thick blood smear would show banana shaped gametocytes or infected erythrocytes with black pigment
A poor prognosis is indicated by > 20% of parasites with visible pigment in peripheral blood smear or by the presence of phagocytosed malarial pigment in >5% of neutrophils
There is slight monocytosis, lymphopenia, and eosinopenia, with reactive lymphocytosis and eosinophilia in the weeks after acute infection.
- Which of the following conditions is considered as an AIDS-defining opportunistic illness?
a.
Oral candidiasis
b.
Non-tuberculous mycobacterial pneumonia
c.
Anal squamous cell carcinoma
d.
JC virus infection of the brain
D. JC virus infection of the brain
Source: HPIM 21st ed. Ch 202, p. 1527; Table 202-1
Progressive multifocal leukoencephalopathy (PML), an infection caused by the JC virus, is an AIDS-defining opportunistic illness.
Which of the following statements is TRUE regarding Human Immunodeficiency Virus?
a.
The most common mode of infection in developing countries is male-to-male sexual transmission
b.
Nonspecific serologic markers of inflammation and/or coagulation such as IL-6 has been shown to have a high correlation with all-cause mortality
c.
The HIV RNA viral load is the laboratory test generally accepted as the best indicator of the immediate state of immunologic competence of the patient with HIV infection
d.
A CD4+ T cell count of <200 would warrant prophylaxis for MAC
B. Nonspecific serologic markers of inflammation and/or coagulation such as IL-6 has been shown to have a high correlation with all-cause mortality
Source: HPIM 21st ed. Ch 202, p. 1561, Table 202-9
The CD4+ T-cell count is the laboratory test generally accepted as the best indicator of the immediate state of immunologic competence of the patient with HIV infection
Which is associated with a poor prognosis in tetanus?
a.
Heart rate of >120 beats per minute
b.
Period of onset < 72 hours
c.
Postsurgery entry site
d.
Age > 50 years
Age of > 70 years
Incubation period of < 7 days
SHort time from first symtpom to admission
Puerpueral IV post surgery entry site
Period of Onset <48 hours!
Heart rate 140!!!
SBP > 140
Temp 38.5C
Severe disesase or spasms
Which is the correct treatment for tetanus?
a.
The preparation of choice for tetanus antitoxin is equine-derived antitoxin, administered at a dose of 500-5000 IU after hypersensitivity testing with a portion injected around the wound
b.
Cardiovascular stability in severe tetanus is improved by IV magnesium sulfate to achieve plasma concentration of 1-2 mmol/L
c.
Metronidazole 400mg rectally every 6 hours for 7 days is a preferred first line treatment
d.
Long-acting betablockers are preferred as treatment for rapid fluctuations in heart rate
Answer: C
Metronidazole (400 mg rectally or 500 mg IV every 6 h for 7 days) is preferred for antibiotic therapy.
Equine-derived antitoxin is available widely and is used in low-income countries; after hypersensitivity testing, 10,000–20,000 U is administered IM as a single dose or as divided doses.
Cardiovascular stability is improved by increasing sedation with IV magnesium sulfate (plasma concentration, 2–4 mmol/L or titrated against disappearance of the patella reflex), morphine, fentanyl, or other sedatives
In addition, drugs acting specifically on the cardiovascular system (e.g., esmolol, calcium antagonists, and inotropes) may be required. Short-acting drugs that allow rapid titration are preferred
Which is the treatment of choice for multidrug resistant, fluoroquinolone resistant enteric fever?
a.
Azithromycin 1g tablet 1 tab PO for 5 days
b.
Chloramphenicol 25mg/kg TID PO or IV for 14 days
c.
Meropenem 1g IV every 8 hours for 10-14 days
d.
Amoxicillin 1g PO 3x a day for 14 days
Empiric: Ceftri or Azith
Optimal: Cipro or Azith Alternative: Amoxicillin, Chloramphenicol, Co-Trimoxazole
MDR: Ceftri Azith, Cipro (A)
Fluroquinolone resistant: Ceftri, Azith
Ceftri Resistant: MEropenem, Azithromycin
Eradication of carriage: Ciprofloxacin, Alternate: Amoxicillin
Which is TRUE regarding salmonella infections:
a.
The hallmark features of enteric fever are fever and diarrhea
b.
A concurrent infection with Schistosoma haematobium is more common among chronic carriers
c.
Common complications include hepatosplenic abscesses
d.
Chronic carriage is associated with cholangiocarcinoma
A concurrent infection with Schistosoma haematobium is more common among chronic carriers
Source: HPIM 21st edition, Ch. 165, p. 1293
Enteric fever is a misnomer, in that the hallmark features of this disease—fever and abdominal pain—are variable.
Uncommon complications whose incidences are reduced by prompt antibiotic treatment include disseminated intravascular coag- ulation, hematophagocytic syndrome, pancreatitis, hepatic and splenic abscesses and granulomas, endocarditis, pericarditis, myocarditis, orchitis, hepatitis, glomerulonephritis, pyelonephritis and hemolytic- uremic syndrome, severe pneumonia, arthritis, osteomyelitis, endoph- thalmitis, and parotitis.
Chronic carriage is associated with an increased risk of gallbladder cancer, which is much more common in locales where S. Typhi is common, such as the Indian subcontinent.
A 38 year old female was admitted due to a 7-day history high grade fevers, rashes and abdominal pain. Pertinent physical examination findings were faint, salmon-colored, blanching maculopapular rash on the trunk and chest and LUQ tenderness with obliterated Traube’s space. Which of the following tests will have the highest diagnostic sensitivity?
a.
Bone marrow culture
b.
Serologic testing
c.
Blood culture
d.
Duodenal string test
D. Duodenal string test
Source: HPIM 21st edition, Ch. 165, p. 1294
Bone marrow culture is >80% sensitive, and, unlike that of blood culture, its yield is not reduced by up to 5 days of prior antibiotic therapy.
Culture of intestinal secretions (best obtained by a noninvasive duodenal string test) can be positive despite a negative bone marrow culture
The classic Widal serologic test for “febrile agglutinins” is simple and rapid but has limited sensitivity and specificity, especially in endemic regions because of inability to differentiate active from prior infection or vaccination. Other rapid serologic tests, including IDL Tubex and Typhidot, have greater accuracy than the Widal test, but cost has limited their routine use in developing countries.
The diagnostic sensitivity of blood culture is only ~60% and is lower with low blood sample volume and among patients with prior antimicrobial use or in the first week of illness, reflecting the small number of S. Typhi organisms (i.e., <15/mL) typically present in the blood.
. Which of the following statements best describe the most characteristic pathologic finding in rabies?
a.
Mononuclear inflammatory infitlration in the leptomeninges, perivascular regions and parenchyma, include microglial nodules
b.
Commonly observed in cortical and brainstem neurons
c.
Basophilic cytoplasmic inclusions in brain neurons
d.
Occur in a minority of infected neurons
D. Occur in a minority of infected neurons
Source: HPIM 21st edition, Ch. 208, p. 1620
The most characteristic pathologic finding in rabies is the Negri body. Negri bodies are **eosinophilic cytoplasmic inclusions brain neurons that are composed of rabies virus **proteins and RNA. These inclusions occur in a minority of infected neurons, are commonly observed in the Purkinje cells of the cerebellum and in pyramidal neurons of the hippocampus, and are less frequently seen in cortical and brainstem neurons. Negri bodies are not observed in all cases of rabies
