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Q1:

An 8-year-old girl presents with a 4-day history of fever, headache, and abdominal pain. Her mother
states that they live in a rural area and have multiple pets, including dogs, cats, horses,cows, and a pet
raccoon. There is no history of tick bites. On physical examination, the girl appears mildly toxic, has a
temperature of 102.2F (39C), and has a grade II/VI systolic ejection murmur best heard on the left side
of the sternal border. Her right upper quadrant is tender to palpation, but there is no hepatosplenomegaly.
Findings on her skin and extremity examination are normal. A complete blood count reveals a white blood
cell count of 1.2x103/mcL (1.2x109/L) with 90% neutrophils and 10% lymphocytes. Her hemoglobin is 10
g/dL (100 g/L), and her platelet count is 50x103/mcL (50x109/L). Her alanine aminotransferase is 600
U/L, and her
aspartate aminotransferase is 450 U/L. Her amylase and lipase values are normal. Serum sodium is 133
mEq/L (133 mmol/L), but the remainder of her electrolyte values are normal.
Of the following, the MOST likely diagnosis is
A. human monocytic ehrlichiosis
B. Lyme disease
C. Rocky Mountain spotted fever
D. tularemia
E. typhus
Answer :
A

Explanation

Human monocytic ehrlichiosis (HME) is a rickettsial


disease caused byEhrlichia chaffeensis,which is
transmitted to humans by the bite of a tick.
Clinically, the ehrlichioses are nonspecific illnesses. Fever (~100%) and headache (~75%) are most
common, but many patients also report myalgias, anorexia, nausea, and vomiting.
With HME, rash is more common in children (nearly 66%) than in adults (33%). The rash is usually
macular or maculopapular, but petechial lesions can occur.
Photophobia, conjunctivitis, pharyngitis, arthralgias, and lymphadenopathy are less consistent features.
Hepatomegaly and splenomegaly are detected in nearly 50% of children with ehrlichiosis.

Edema of the face, hands, and feet occurs more commonly in children than in adults, but arthritis is
uncommon in both groups.

A rash is described in approximately two thirds of children and one third of adults and starts as
maculopapular but may progress into petechial/purpuric.
Meningoencephalitis with a lymphocyte-predominant CSF pleocytosis is an uncommon but potentially
severe complication of HME
HME is clinically indistinguishable from Rocky Mountain spotted fever (RMSF).
Laboratory abnormalities common to both infections include thrombocytopenia and hyponatremia, but
patients who have HME are more likely to have elevated liver function test results and
leukopenia with lymphopenia. Approximately 50% to 75% of patients have no history of a tick
bite.

Patients who have Lyme disease typically do not appear toxic or have the laboratory abnormalities
described in the vignette.
Although there is a typhoidal form of illness due to Francisella tularensis (tularemia), it is extremely rare,
and most affected children present with glandular or ulceroglandular disease. Typhus can be endemic or
epidemic.
Epidemic typhus is due to the bite of the human louse, and endemic typhus is caused by a mite bite.
Although both of these rickettsial diseases can present with fever and a headache, patientsusually are not
toxic and do not have laboratory abnormalities such as those reported for the girl in the vignette.
-----Q2 :

A 4-year-old boy presents to your office for evaluation of a 3-day history of fever (temperature to 38.5C),
congestion, and sore throat. Physical examination of the well-appearing child shows only rhinorrhea and
pharyngeal erythema. His mother and 6-year-old sister have had colds over the past week.
Of the following, the MOST appropriate treatment for this child, pending the results of the throat culture, is
A. amoxicillin
B. azithromycin
C. nasal saline drops
D. prednisone
E. pseudoephedrine
Answer :

The congestion and sore throat described for the boy in the vignette, combined with the history of upper
respiratory tract infections in the family, strongly suggest that he has a viral illness. Supportive therapy
such as nasal saline drops to relieve congestion is appropriate.
Cough and cold remedies, including those containing the decongestant pseudoephedrine, have not been
demonstrated to be effective in treating viral upper respiratory tract infection symptoms, and based on
potential toxicities in young children, the American Academy of Pediatrics and United States Food and
Drug Administration have advised against their use in children younger than 6 years of age.
There is no indication for prednisone in this setting. However, high-dose, short-term corticosteroid
therapy may be beneficial in the treatment of the patient who has marked pharyngitis and impending
airway obstruction associated with acute infectious mononucleosis.
Antibiotics are not indicated to treat a viral illness and do not prevent development of possible secondary
bacterial infections (eg, otitis media, sinusitis).
Increased use of antibiotics has been associated with increased rates of carriage of resistant
bacteria (eg, penicillin-resistant Streptococcus pneumoniae, beta-lactamase-positive
Haemophilus influenzae, methicillin-resistant Staphylococcus aureus).
Other common illnesses that generally do not require antibiotic therapy in children include bronchitis,
middle ear effusion of short duration, mucopurulent rhinitis of less than 10 days duration, and most cases
of acute pharyngitis (unless group A streptococcal infection is confirmed).
Bronchitis in children is an acute cough illness that is generally self-limited and caused by viruses.
If the child in the vignette has a positive diagnostic test result (rapid antigen detection or throat culture),
antibiotic treatment would be appropriate.
Penicillin V is the drug of choice for streptococcal pharyngitis, although amoxicillin often is used instead
as first-line treatment.
A firstgeneration cephalosporin (eg, cephalexin or cefadroxil) also may be used. Broader-spectrum agents
(eg, amoxicillin-clavulanate, second- or third-generation cephalosporins) are not indicated routinely for
this infection.
Azithromycin should be reserved for treating streptococcal pharyngitis in the patient who is allergic to
penicillins and cephalosporins.
Streptococcal serogroups C and G rarely have been associated with symptomatic pharyngitis. They have
not
been associated with rheumatic fever, but antibiotic therapy (same agents as for group A streptococcal
infection) may be considered in the symptomatic patient who has a positive culture and no other cause
determined for the pharyngitis.

Q3 :
A 12-year-old boy presents with a 5-day history of sore throat, fever, and progressive rightsided neck pain
and swelling. On physical examination, his temperature is 40.0C, he has trismus, the right side of his
neck is swollen and tender to palpation, and his chest is clear to auscultation. His white blood cell count is
30.0x103/mcL (30.0x109/L), with 80% polymorphonuclear leukocytes, 15% lymphocytes, and 5%
monocytes. Computed tomography scan of the neck reveals a deep parapharyngeal abscess (Item
Q141).
Of the following, the MOST appropriate antimicrobial to include in his therapy is
A. ampicillin-sulbactam
B. azithromycin
C. clarithromycin
D. gentamicin
E. trimethoprim-sulfamethoxazole
Answer :
A

The boy described in the vignette has an abscess in the deep tissues of the neck. Streptococci, including
S pyogenes, and Staphylococcus aureus are the most common pathogens associated with infections of
the parapharyngeal space. However, oral anaerobic bacteria also are found frequently in these infections
because the primary portals of entry for organisms into the parapharyngeal space are the oropharynx,
lower molars, nasopharynx, paranasal sinuses, and mastoid.
The most common anaerobic bacteria isolated from parapharyngeal infections are Bacteroides,
Peptostreptococcus, and Fusobacterium. Most of these infections are polymicrobial.
Because the parapharyngeal space is contiguous with the retropharyngeal, submandibular, and
peritonsillar spaces, infection may spread in any number of directions and lead to a variety of clinical
manifestations and complications.
Ampicillin-sulbactam is a beta-lactamase-resistant semisynthetic penicillin that has activity
against anaerobes, susceptible aerobic gram-positive organisms, and respiratory tract gramnegative
pathogens, making it an appropriate initial drug for the patient described in the vignette.
Because group A streptococci are becoming increasingly resistant to macrolide antibiotics such as
azithromycin and clarithromycin and to trimethoprim-sulfamethoxazole, these drugs are not appropriate.
In addition, macrolide antibiotics have less activity than ampicillin-sulbactam against B fragilis and
Fusobacterium.
Gentamicin is not useful because aerobic enteric gram-negative rods do not play a significant role in

parapharyngeal infections.
---------------------------------------------------Q 4:

A five year old boy is admitted to the paediatric ward with a two day history of fever, myalgia and
jaundice.
His family live on a canal barge and have been moving around the country on a regular basis. He has
many
scabs on his knees and elbows, which his parents say result from his playing on the canal banks.
Observations show temperature 38.7 C,heart rate 150 beats per minute, respiratory rate 35. He looks
unwell but is fully
conscious. He has conjunctival suffusion and scleral icterus. Blood tests show: Haemoglobin 10.5 g/dL,
White cell count 22.5 x109/L,Neutrophils 19x109/L, Platelets 150x109/L, Urea22.5mmol/L,
Creatinine 250 micromol/L, Bilirubin 150 micromol/L, Aspartate Amino-Transferase 350 U/L.
The mostlikely diagnosis is:
A- Hepatitis B
B- Hepatitis A
C- Leptospirosis
D- Haemolytic uraemic syndrome
E- Reyes syndrome
Answer :
C

Leptospirosis is caused by a spirochete organism, of which there are many serovars. It is


contracted by contact with water contaminated with the urine or carcasses of infected
animals eg rats. There have been cases in the UK associated with rats around
waterways. It may cause asymptomatic infection, or an influenza like illness which may
progress to severe disease with jaundice and renal impairment (Weils disease).
Conjunctival suffusion is characteristic but not always present. Viral hepatitis is
characterised by a prodromal phase with fever in those who are symptomatic, followed
by hepatitis after the fever declined. Hepatitis A is frequently asymptomatic in children,
and hepatitis B rarely causes acute hepatitis. Haemolytic uraemic syndrome typically
follows a gastrointestinal disorder with bloody diarrhoea. The commonest aetiologic
agent is E Coli 0157:H7. Reyes syndrome is an acute and often fatal encephalopathy
associated with hepatic failure. It is becoming increasingly rare.
---------------------------Q5

A 5-year-old boy is hospitalized in January with fever and seizures. Lumbar puncture reveals clear
cerebrospinal fluid that has a white blood cell count of 47/cu mm, all of which are lymphocytes. On
physical examination, he appears obtunded but arouses with painful stimuli. Neurologic examination
reveals no focal findings.
Of the following, the diagnostic test that is MOST likely to reveal the etiology of this child's illness is:
A.
B.
C.
D.
E.

bacterial culture of cerebrospinal fluid


polymerase chain reaction test of cerebrospinal fluid for herpes simplex
Streptococcus pneumoniae bacterial antigen test of cerebrospinal fluid
viral culture of cerebrospinal fluid
viral culture of nasopharyngeal and rectal swabs

Answer :
B

The boy described in the vignette has symptoms suggestive of encephalitis. These symptoms, combined
with the cerebrospinal fluid (CSF) findings, are most consistent with a viral etiology. The most likely
pathogen in a sporadic case of viral encephalitis is herpes simplex virus (HSV).
In the past, HSV encephalitis was diagnosed by culture or direct fluorescence testing of brain biopsy
tissue. More recently, polymerase chain reaction (PCR) testing of CSF for HSV DNA has become the
preferred diagnostic modality.
Viral cultures of the CSF for herpes are rarely positive in HSV encephalitis beyond the neonatal period,
and the virus is not found in cultures of sites outside the central nervous system.
Bacterial culture of CSF or use of antigen detection tests for Streptococcus pneumoniae are not likely to
be positive in a child whose findings are consistent with encephalitis.
------------------------Q6:

A 3-year-old child is brought to the emergency department with a fever of 103.1F (39.5C) and diarrhea
of acute onset. The stool is guaiac-positive and contains leukocytes. There is no history of foreign travel,
and the child has not received antibiotics recently.
Of the following, the organism that is MOST likely to be isolated from this child's stool is:

A.

Clostridium difficile

B.

Giardia lamblia

C.

rotavirus

D.

Salmonella enteritidis

E.

Vibrio cholerae
Answer:

Infectious diarrhea is a common illness among children and is caused by a wide variety of pathogens.
The clinical presentation of the child can aid in identifying the likely pathogen.
Children who have viral diarrheas usually have low-grade fever; vomiting; and large, loose, watery stools.
Dehydration commonly accompanies rotavirus infection, which is the most common of the viral diarrheas.

The symptoms exhibited by the child in the vignette are most consistent with a bacterial diarrhea,
such as those caused by Salmonella or Shigella sp. Patients who have these infections often present with
high fevers and small, frequent stools that contain mucus or blood. Stool cultures reveal the pathogen,
and susceptibility testing of the isolate is useful because many Salmonella and Shigella isolates are
resistant to ampicillin and trimethoprim-sulfamethoxazole. Although antibiotic treatment is indicated for
Shigella infections, Salmonella gastroenteritis is self-limited in immunocompetent patients, and antibiotic
treatment usually is withheld because it may prolong carriage of the organism.

Clostridium difficile is most common in the setting of antibiotic-induced


colitis.
Vibrio cholerae is acquired from contaminated seafood or water and rarely is seen in
the United States. Infection with Giardia lamblia is more likely to result in chronic or
persistent diarrhea with malabsorption
--------------------Q7:
A 2-year-old girl presents with a swollen, tender, erythematous knee. Two weeks ago she had fever and
bloody diarrhea that lasted 4 days.
Of the following, the MOST likely organism to be associated with arthritis in this patient is:

A. Escherichia coli

B. Giardia lamblia
C. Norwalk virus
D. rotavirus
E. Shigella flexneri

Answer :
E

Postinfectious or reactive arthritis often occurs several weeks or months after an acute infection.
Reactive arthritis frequently follows enteric infections with Shigella, Salmonella, Yersinia, and
Campylobacter sp.
As described in the vignette, affected children initially develop bloody diarrhea, followed by the onset of
arthritis, typically 1 to 2 weeks after the triggering infection.
Reactive arthritides are usually acute and self-limited, resolving within weeks or months.
There is no specific treatment for reactive arthritis. The patient may need analgesics for pain relief. Of the
choices listed, Shigella would be the most likely organism to cause bloody diarrhea and arthritis.
Other important examples of reactive arthritis include postvenereal reactive arthritis (especially
with Chlamydia trachomatis) and virus-related arthritis.
A variety of viruses have been associated with reactive arthritis, including rubella, hepatitis B, mumps,
parvoviruses, and herpesviruses.
Poststreptococcal reactive arthritis and acute rheumatic fever (ARF) are two other examples of reactive
arthritis.
Reactive arthritis does not typically follow infections with Escherichia coli, Giardia lamblia, Norwalk
virus, or rotavirus.
----Q8

A 12-year-old girl who has systemic lupus erythematosus was exposed to varicella 24 hours ago. She has
been receiving prednisone 40 mg bid for 9 weeks because of an exacerbation of nephropathy. She has
not had varicella or received varicella immunization.

Of the following, the MOST appropriate next step is to:

A. administer varicella vaccine


B. administer varicella-zoster immune globulin
C. begin prophylactic doses of acyclovir
D. discontinue the prednisone
E. provide stress doses of prednisone
--Q9

A 5-year-old girl complains of perianal pruritus. Results of a clear adhesive tape test are positive.
Of the following, the drug of CHOICE for this infection is:
A. iodoquinol
B. ivermectin
C. mebendazole
D. praziquantel
E. thiabendazole

Answer
C

Perianal pruritus is a common symptom of infection with Enterobius vermicularis (pinworms).


Although infection may appear in all age groups and socioeconomic levels, it is most prevalent in
preschool and school-age children.
Typically, embryonated eggs are ingested and migrate to the duodenum, where they hatch and
undergo sexual maturation before reaching the cecum. Adult pinworms reside in the cecum, emerge at
night through the anus, and migrate to the perianal region, where gravid females deposit their eggs and
die. The eggs cause anal pruritus, which leads to scratching and accumulation under the fingernails,

thereby promoting autoinfection and spread to close contacts. The eggs remain infective for 2 to 3 weeks.
Aberrant migration of the adult worm from the perineum rarely may give rise to urethritis, vaginitis,
salpingitis, or pelvic peritonitis.
Some physicians treat the infestation based only on the history, but a definitive diagnosis should
be made. Eggs are detected easily on clear adhesive tape that is applied to the perianal area early in the
morning on awakening. The tape is applied to a slide and viewed under a low-power microscopic lens.
Repeated examinations on successive mornings may be necessary. Because Enterobius vermicularis
eggs are not excreted in the stool, examination of feces is not a useful test.
The drugs of choice for treatment of enterobiasis are either mebendazole (100 mg regardless of
weight), pyrantel pamoate (11 mg/kg, not to exceed 1 g), or albendazole (400 mg) administered as a
single dose. Because none of these drugs is completely effective against eggs or developing larvae, a
second treatment 2 weeks after the first is recommended. Frequently, all family members are treated in
an attempt to break the cycle of reinfection.
Because pinworm infection often carries substantial unwarranted social stigma, reassurance of families
that this infection is very common, often recurs, and does not reflect uncleanliness is an important
component of therapy.
Reinfection with pinworms occurs easily. Measures that may reduce egg contamination of the
local environment are helpful and include:
having the infected person bathe in the morning, which removes a large proportion of the eggs;
frequent changing of the infected persons underclothes, bed clothes, and bedsheets;
hygienic measures such as washing hands prior to eating or preparing food, keeping fingernails
short, and avoiding nail biting.
Measures such as cleaning or vacuuming the entire house or washing bed clothes and bedsheets
daily are not necessary.
Mebendazole also is an effective treatment for other roundworm infections, such as ascariasis,
capillariasis, hookworm infections, trichinosis, whipworm infections, and visceral larva migrans. Iodoquinol
is used to eradicate intestinal carriage of Entamoeba histolytica. Ivermectin is recommended for treatment
of cutaneous larva migrans, river blindness (infection with Onchocerca volvulus), and strongyloidiasis.
Praziquantel is the drug of choice for treatment of fluke and tapeworm infections, such as schistosomiasis
and cysticercosis. Thiabendazole is effective in treating strongyloidiasis and cutaneous larva migrans.
---Q 10

A 2-year-old boy presents with rales, pallor, chronic failure to thrive, recurrent thrush, diarrhea, and
oxygen saturation of 84% on room air. Echocardiography demonstrates an enlarged left ventricle with
diminished systolic function.
Of the following, the blood test MOST likely to establish the diagnosis in this child is:
A. antibody testing for Epstein-Barr virus

B.
C.
D.
E.

antibody testing for human immunodeficiency virus


antibody testing for human parvovirus
serum carnitine level
serum selenium level

Answer
B

It is now appreciated that varying degrees of myocardial dysfunction are common in human
immunodeficiency virus (HIV) infection in children, especially when the infection has reached the point of
clinical immunodeficiency. Pallor is common in affected children from the combination of anemia and
congestive heart failure. Diarrhea probably is related more to the acquired immunodeficiency syndrome
(AIDS) than to the cardiomyopathy. The unusually low oxygen saturation may be explained by interstitial
pneumonitis, sometimes due to Pneumocystis jiroveci (carinii) infection. Although maternal HIV
screening and treatment have decreased significantly the number of children who present in the first few
years of life with cardiomyopathy and frank AIDS symptoms, cases still do occur in clinical practice.
It has been proposed that the dilated cardiomyopathy of childhood AIDS is due primarily to chronic
viral myocarditis from coxsackievirus, adenovirus, or cytomegalovirus that is not cleared effectively by the
damaged immune system.
Epstein-Barr viral infection of the myocardium has bee
n diagnosed by polymerase chain reaction analysis of myocardial biopsy in some children who have
dilated cardiomyopathy. Clinical signs of Epstein-Barr virus-related myocarditis are not specific and
include cardiomegaly, poor systolic left ventricular function, and physical signs of congestive heart failure.
Human parvovirus may cause a number of clinical illnesses, including erythema infectiosum (fifth
disease) or papulopurpuric gloves and socks syndrome. It does not have any important association with
myocarditis.
Serum carnitine levels may be normal or decreased in children who have cardiomyopathy from a
variety of causes. Low serum carnitine concentrations do not define or suggest a single specific etiology
in cardiomyopathy.

Selenium deficiency is a rare mineral deficiency disorder believed to be


associated with cardiomyopathy. Some investigators believe that selenium
deficiency is common in AIDS and postulate a role for it in the cardiac dysfunction of
AIDS infection. However, as noted previously, others believe that chronic viral
infection
------Q 11

A 10 year old child has just been diagnosed with meningococcal meningitis.
In discussing chemoprophylaxis with his family, you are MOST likely to include the statement that
rifampin:
A.
B.
C.
D.
E.

causes a reactive arthritis


causes discoloration of body fluids
decreases the reliability of depot medroxyprogesterone
is contraindicated if she has asthma
is safely used during pregnancy

Answer
B

Rifampin penetrates the central nervous system and is found in most body fluids. It can cause
orange-colored secretions, including urine, sweat, and tears. Patients should be advised that contact
lenses may be stained orange.
Rifampin is metabolized by the liver and excreted in bile and urine. It can alter the serum
concentrations of many drugs and possibly interfere with the efficacy of oral contraceptives. The reliability
of intramuscular medroxyprogesterone is not altered with rifampin use. Neither rifampin nor ciprofloxacin
is recommended for use during pregnancy. A single intramuscular dose of ceftriaxone is the
recommended prophylaxis during pregnancy.
Rifampin therapy is not contraindicated for patients who have asthma, although its use may
decrease the efficacy of corticosteroids. Reactive arthritis is not a common adverse reaction associated
with rifampin.
--Q 11

A child who has acute myelogenous leukemia is being treated for Pseudomonas bacteremia with
intravenous doses of piperacillin and gentamicin. Gentamicin levels are measured after 2 days of therapy.
How long after completing a 30-minute infusion should blood for peak gentamicin concentrations be
drawn?:

A. 30 minutes
B. 60 minutes
C. 90 minutes

D. 120 minutes
E. 150 minutes
Answer
B

Therapeutic drug monitoring is used to prevent or decrease the risk of toxic effects of medication.
Monitoring serum concentrations of most antibiotics is unnecessary because these drugs are effective
over a wide range of serum levels, therapeutic levels are achieved easily, and levels associated with
toxicity rarely are encountered when standard dosing schedules are employed and patients have normal
clearance mechanisms. However, certain antibiotics, especially chloramphenicol, vancomycin, and the
aminoglycosides, have narrow therapeutic windows and are associated with potential adverse reactions.
Therefore, careful monitoring of serum concentrations of these drugs is critical.
Measurement of serum drug levels can help determine the dose and frequency of administration
that allow for maximum therapeutic benefit with minimum toxicity. Appropriately timed blood samples are
essential for accurate interpretation of serum drug levels. The best times to obtain blood samples for most
parenterally administered antibiotics is 30 minutes after a 20- to 30-minute intravenous infusion, when the
level is presumed to be highest (peak level), and immediately before the next dose, when the level is
presumed to be lowest (trough level). For oral antibiotics, peak levels should be obtained 30 minutes to 1
hour after oral liquid or 1.5 hours following oral capsule administration.
The principles of therapeutic drug monitoring are based on two pharmacokinetic parameters:
volume of distribution (Vd) and half-life (t1/2). Vd is the hypothetical volume within which the drug is
distributed and is used to determine the dose required to maximize activity. The t1/2 reflects the rate of
drug elimination and, thus, is used to determine the most appropriate frequency of dosing. The blood
sample obtained 1 hour after completing the infusion provides information about the Vd after the drug has
begun to be dispersed through the body but before significant amounts have been eliminated. The trough
level, drawn immediately before the next dose, helps to determine elimination kinetics and t1/2.
A level drawn 30 minutes after completing a gentamicin infusion will not be a reliable indicator of
Vd because not enough time has passed for drug distribution to begin. Serum samples drawn 90, 120, or
150 minutes after completing the infusion are not as reliable as a sample obtained 1 hour after completing
the infusion because drug elimination will have begun.
Aminoglycoside antibiotics (eg, gentamicin, tobramycin, amikacin) have a high profile of toxic side
effects, such as nephrotoxicity and ototoxicity. Although aminoglycoside-induced renal injury usually is
reversible, ototoxicity, characterized by both auditory and vestibular nerve damage, is not. Individual risk
factors may contribute to the development of toxicity, but the major association with organ damage is
elevated peak and trough serum drug concentrations. Sustained peak serum gentamicin concentrations
of more than 12 to 14 mg/L and trough serum concentrations of more than 2 mg/L have been associated
with a significantly increased risk of both toxicities.
Monitoring of serum aminoglycoside peak and trough concentrations has been shown to decrease
the incidence of nephrotoxicity, although these toxicities still can occur in patients whose serum
concentrations are in the desired therapeutic range. Thus, regular monitoring of levels is recommended to

assure the adequacy of the dosing regimen and to monitor for drug accumulation and potential toxicity.
Serial trough concentrations correlate better than peak levels with the rising tissue accumulation of drug
during a course of treatment.
Peak and trough serum concentrations should be measured following the fifth or sixth dose of the
aminoglycoside. If these levels are appropriate, serial trough concentrations should be obtained every 4
to 7 days, depending on the clinical status of the patient. Sustained elevation of the trough concentration
in excess of 25% over a 2- to 4-day period has been found to place patients at measurable risk for
aminoglycoside-induced toxicity.
--------------------------------------------Q12

A child is bitten on the hand by a neighbor's dog. Within 24 hours there is erythema, pain, and swelling at
the site of the bite. The child is taken to the emergency department where cultures are taken of
sanguinopurulent drainage from the wound.
Of the following, the MOST likely organism infecting the wound is:
A. Eikenella corrodens
B. Francisella tularensis
C. Pasteurella multocida
D. Staphylococcus aureus
E. Streptococcus pyogenes
Answer
C

Pasteurella multocida is the organism most likely to infect animal bite wounds. Clinical infection with P
multocida is characterized by the rapid evolution of an intense inflammatory response, with substantial
pain and swelling developing within 24 hours of the initial injury in 70% of cases and by 48 hours in 90%
of patients who develop an infection. P multocida infection has resulted in abscess formation, septic
arthritis, osteomyelitis, sepsis, meningitis, endocarditis, and pneumonia. Infections usually exhibit
localized cellulitis and purulent discharge. Fever, regional adenopathy, and lymphangitis are seen in fewer
than 20% of patients.

The drug of choice for treatment of P multocida infections is penicillin. Other


effective agents include ampicillin, amoxicillin-clavulanate, cefuroxime,
cefpodoxime, trimethoprim-sulfamethoxazole, and tetracycline. For patients allergic
to beta-lactam agents, tetracycline is effective, but it should not be administered to
children younger than 8 years of age

ECTION II

INFECTIOUS DISEASES
1.

DIAGNOSTIC METHODS:
26.1
Match the following statements:

i.)
ii.)
iii.)
iv.)
v.)

Chlamydia
Pneumocystis carinii
Plasmodium leishmania
Respiratory syncytial virus
Borrelia (relapsing fever)

1.)
2.)
3.)
4.)
5.)

Wrights stain
Romanowsky stain
Fluorescent antibody test
Direct examination
Giemsa stain

26.2

Answer true or false for the following statements:

i.)
ii.)
iii.)
iv.)
v.)

Even slight bacterial growth is significant with


suprapupic urine collection
Urine specimen of > 10 WBCs in symptomatic men is
suggestive of UTI
Optimal blood culture is 3 specimens of 5 ml each, 30
minutes apart
Regular fecal cultures can detect vibrio para
hemolyticus
Single throat swab culture is 90% positive for
streptococcal pharyngitis

26.3

i.)
ii.)
iii.)
iv.)
v.)

2.

Pneumococci
Staphylococci
Group D streptococci
H. influenza
Meningococci

INFECTIONS IN THE COMPROMISED HOST:

27.1

i.)
ii.)
iii.)
iv.)
v.)

27.2

i.)
ii.)
iii.)
iv.)
v.)

3.

In cerebrospinal fluid, counter immuno-electrophoresis (CIE) is


very sensitive test to detect the antigens of:

INFECTIONS IN THE COMPROMISED HOST:

Ataxia-telangiectasia and T-lymphocyte dysfunction


Multiple myeloma and B cell dysfunction
Sickle cell disease and alternate pathway defect
Chedak-Higashi syndrome and impaired cellular
phagocytosis
Wiskolt-Aldrich syndrome and mixed T- and B-cell
dysfunction

The following correlations are correct:

Jobs syndrome and staphylococcus aureus


Splenectomy and Salmonella species
Selective IgA deficiency and Escherichia-Coli
Brutons x-linked agammaglobulinemia and Herpes
simplex
Sickle cell disease and Streptococcus penumoniae

HOSPITAL-AQUIRED INFECTIONS:

28.1

i.)
ii.)
iii.)
iv.)
v.)

4.

Gram-negative bacilli can acquire and transfer


antibiotic resistance by plasmids
Wound infections caused by staphylococci usually
occur 24-48 hours post operatively
Pneumonia is the most common cause of mortality
from hospital acquired infections
Putting obtunded patients in a swimmers position can
predispose to post-operative pneumonia
Legionnaires disease can be prevented by
hyperchlorination or superheating of hospital tap
water

SEPTIC SHOCK:

29.1

i.)
ii.)
iii.)
iv.)
v.)

5.

The following statements are correct:

Answer T or F.

It is usually due to release of bacterial endotoxins


ARDS is the most important cause of death
Platelets are usually normal
Early respiratory alkalosis is followed later by
metabolic acidosis
Glucocorticoids are ineffective mode of therapy

ANTIBIOTIC THERAPY:

30.1

i.)

The following drug-disease correla-tions are correct:

Azocillin and pseudomonas infections

ii.)
iii.)
iv.)
v.)

30.2

i.)
ii.)
iii.)
iv.)
v.)

30.3

i.)
ii.)
iii.)
iv.)
v.)

6.

Sulfadiazine and toxoplasmosis


Chloramphenicol and chlamydia
Metronidazole and Shigella
Influenza A and rimantadine

Ceftriaxone is active against:

E. Coli
S. faecalis
Psuedomonas infections
N. meningitides
S. pneumoniae

The following statements about drug therapy are


correct:

One in 25,000 patients develop aplastic anemia after


taking chloramphenicol
Erythromycin decreases blood levels of theophylline
Rifampicin increases the effect of steroids
Metronidazole should not be given in pregnancy
Acyclovir is more effective than vidarabine for herpes
simplex encephalitis.

PREVENTION OF INFECTION BY IMMUNIZA-TION:

31.1

i.)
ii.)
iii.)

Sabin type vaccine against poliomyelitis is different


from Salk type by the fact that it is:

A live attenuated vaccine


Formalin-inactivated
Given orally

iv.)
v.)

31.2

i.)
ii.)
iii.)
iv.)
v.)

31.3

i.)
ii.)
iii.)
iv.)
v.)

7.

Preferred during epidemic


Selectively used in unimmunized adults

The following statements about immunization are


correct:

Cholera vaccine is only 50% effective in decreasing


transmission of disease
Plague active vaccine is a formaldehyde dehydrozole
inactivated Yersinia pestis
Typhoid fever active vaccine is usually given
subcutaneously in two doses
Influenza vaccine reduces morbidity and mortality in
those at risk of complications of influenza
BCG vaccine is an inactivated bacilli, given
intradermally

Passive immunization for measles with


immunoglobumin is indicated in:

Susceptible household contacts less than 1 year old


Exposed susceptible pregnant females
Exposed immunodeficient persons
Infants who have severe disease
None of the above

SEXUALLY TRANSMITTED DISEASES:

32.1

i.)

Microorganisms associated with Reiters syndrome


include:

C. trachomatis

ii.)
iii.)
iv.)
v.)

32.2

i.)
ii.)
iii.)
iv.)
v.)

32.3

i.)
ii.)
iii.)
iv.)
v.)

8.

N. gonorrhoea
Yersinia
Campylobacter
Rickettsia

Treatment of gonococcal infections. Mark T or F:

Uncomplicated infections can be treated successfully


by one does of ceftriazone 250 mg intramuscularly
Spectinomycin is used for penicillin resistant cases
particularly pharyngeal infection
Tetracycline 0.5 g P.O. QID for 7 days should follow
treatment of each case of gonorrhoea
Disseminated infection is best treated by a third
generation cephalosporin
VDRL should be checked after therapy in all patients

In lymphogranuloma venereum:

Primary lesion is a painless vesicle or papule


Painful inguinal adenopathy is a known feature
Diagnosis is obtained by culture of aspirated bubo
Compliment fixation of 1:32 is suggestive of diagnosis
Treatment of choice is metronidazole 500 mg P.O. Q8h
for 7 days

INFECTIOUS DIARRHEA:

33.1

i.)
ii.)

Enterotoxogenic E. coli. Mark T or F.

It causes the majority of travelers diarrhea


Incubation period is usally 12-24 hours

iii.)
iv.)
v.)

33.2

i.)
ii.)
iii.)
iv.)
v.)

9.

It is a non invasive pathogen causing watery diarrhea


most of the time
Antibiotics offer symptomatic relief but duration of the
illness remains the same
Prophylaxis can be achieved by doxycycline 100 mg
once daily

The following statements about pathogens causing


diarrhea are correct:

Clostridium perfringens diarrhea rarely lasts more than


24 hours
Staphylococcus aureus diarrhea has a high attack rate
Campylobacter jejuni is transferred by contaminated
water or raw milk
Campylobacter fetus is usually non-pathogenic in
humans
Rota virus is responsible for 40-50% of travelers
diarrhea

PNEUMOCOCCAL INFECTIONS:

34.1

i.)
ii.)
iii.)
iv.)
v.)

The following statements are correct:

50% of cases of pneumococcal pneumonia are


associated with pleural effusion which is usually
sterile and resolves spontaneously
Blood cultures are positive in 10-15% of cases of
pneumococcal pneumonia
CSF latex agglutination or CIE are positive in 80% of
cases of pneumococcal meningitis
Pneumococcal endocarditis is usually a complication
of pneumonia or meningitis
Incidence of pneumococcal peritonitis is increased in
post-partum period

34.2

i.)
ii.)
iii.)
iv.)
v.)

Chest tuber insertion is indicated if pleural effusion


shows:

Presence of bacteria
PUS
Ph < 7.0.
Glucose < 50 mg/dl
LDH of fluid to serum ratio > 0.6

10. STAPHYLOCOCCAL INFECTIONS

35.1

i.)
ii.)
iii.)
iv.)
v.)

35.2

i.)
ii.)
iii.)
iv.)

Diagnostic criteria of toxic shock syndrome include:

Diffuse sunburn rash that desquamates on palms


and soles over 1-2 weeks
Thrombocytopenia
Myalgia with normal C.K.
Disorientation with normal CSF
Profuse vaginal discharge

In staphylococcal osteomyelitis:

Children younger than 6 years are especially


susceptible
Preceding superficial staphylococcal infection occurs
in only 10% of the cases
Radionuclide scan may be abnormal in the first week
of the illness
Sinus tract cultures are not reliable in chronic disease

v.)

Vancomycin is the drug of choice in penicillin allergic


patients

11. STREPTOCOCCAL INFECTIONS:

36.1

i.)
ii.)
iii.)
iv.)
v.)

36.2

i.)

Streptococcal pharyngitis. Mark T or F.

Most common age is 5 15 years


It is normally group B
High ASO titre confirms diagnosis of streptococcal
infection
Treatment with penicillin prevents acute rheumatic
fever if given within 3 days of onset of infection
Erythromycin is an alternative drug in penicillinallergic patients

Match the following on acute skin streptococcal


infections.

v.)

Spreading erythema on the face with vesicles and


bullae
Affects skin and subcutaneous tissue with fever, pain
and erythema, margins not elevated
Localized purulent infection, papules and vesicles with
surrounding erythema especially in lower limbs
Diffuse rash, blanching erythema sparing palms and
soles, sandpaper texture, followed by desquamations
Red linear streaks with chills, fever and malaise

1.)
2.)
3.)
4.)
5.)

Scarlet fever
Erysipelas
Lymphangitis
Cellulits
Impetigo

ii.)
iii.)
iv.)

12. ANAEROBIC INFECTIONS:

37.1

i.)
ii.)
iii.)
iv.)
v.)

37.2

i.)
ii.)
iii.)
iv.)
v.)

13.

In tetanus:

Only 10 20% give history of injury


10-20% have no detectable lesion
Rigidity and reflex spasms occur 2 3 days after onset
of the disease
Complete recovery usually occurs in 4 weeks
Clostridium tetani is recovered from wound in only
30% of the cases

In botulism:

Incubation period is 2-21 days


Wound botulism is cause by contamination with solid
containing viable pathogens
Cathartics and enemas are indicated to remover
unabsorbed toxin
Food-borne botulism can occur after contamination
with spores only
Trivalent antitoxin is given only after sensitivity testing
to horse serum

DISEASES CAUSED BY OTHER GRAM-POSITIVE ORGANISMS:

38.1

i.)
ii.)

In diphtheria:

Spread is usually by droplet transmission


Wounds, burns or abrasion may be invaded

iii.)
iv.)
v.)

38.2

i.)
ii.)
iii.)
iv.)
v.)

Erythromycin is effective in chronic carrier states


Club-shaped gram-positive rod organisms are seen on
methylene blue
Culture is done using Loefflers medium

In listeria moncyutogenes:

Food-borne outbreaks occur


Incidence in diabetic patients is increased
Sepsis is seen in newborns
Amphotericin B is effective therapy
Bloody diarrhea may occur

14. MENINGOCOCCAL MENINGITIS:

39.1

i.)
ii.)
iii.)
iv.)
v.)

Answer T or F.

Attack rate is highest between ages 2 and 6 years


Petechial rash is seen in about 75% of the patients
Waterhouse-Friderichsen syndrome occurs in 10-20%
of patients
Abrupt onset of confusion is a very common
presentation
Cranial nerve palsies occurring as a complication of
meningitis usually clear within 2 4 months

15. HAEMOPHILUS INFECTIONS

40.1

Haemophilus influenza:

i.)
ii.)
iii.)
iv.)
v.)

16.

Primarily affects children 6 to 48 months old


Increased incidence in patients with sickle cell disease
Most common bacterial meningitis in children 4 6
years old
Antigens detected from serum, CSF or urine
Prophylaxis can be achieved by rifampicin 20 mg/kg
dialy for 4 days

DISEASES CAUSED BY GRAM-NEGATIVE ORGANISMS:

41.1

i.)
ii.)
iii.)
iv.)
v.)

Match the following set of statements:

Malignant otitis in diabetics


Causes > 75% of urinary tract infections
Grams stain may be suggestive of diagnosis because
of large capsule
Associated with obstructive uropathy
Punched out skin ulcers with regional
lymphadenopathy

1.)
2.)
3.)
4.)
5.)

Proteus mirabilis
Pseudomonas auraginosa
Klebsiella Francisella tularensis
Francisella tularensis
E. Coli

41.2

In brucellosis:

i.)
ii.)
iii.)
iv.)
v.)

Exposure occurs through infected tissue


Spleen is enlarged in 40-50% of patients
IgG correlates with active infection
Titers of > 1:80 is suggestive of the diagnosis
Tetracycline is an effective prophylaxis

17. TUBERCULOSIS & OTHER MYCOBACTERIAL INFECTIONS:

42.1

i.)
ii.)
iii.)
iv.)
v.)

42.2

i.)
ii.)
iii.)
iv.)
v.)

42.3

i.)
ii.)
iii.)
iv.)
v.)

Tuberculous pleural effusion. Mark T or F.

It usually occurs in young patients


Simultaneously pulmonary tuberculosis is very
common
PPD skin test is negative in 30% of the cases
It has good response to treatment
Empyema requires surgical drainage

In military tuberculosis:

Fine nodules on chest x-ray occur 4 6 weeks after


onset of illness
Liver and bone marrow biopsies are positive in twothirds of the cases
PPD skin test is often negative
Choroid tubercles are known features
Steroid therapy is an essential part of the treatment

Match the following:

Small painless nodule which progresses to


granulomatous lesion on extremeties
Infection form exposure to fresh water, responds to
tetracycline
Organism develops pigment with exposure to light
identified by prominent transverse bonding
Lymphadenitis is children
Grows within 1 5 weeks on most media, and
responds to cefoxitin or erythromycin

1.)
2.)
3.)
4.)
5.)

M.
M.
M.
M.
M.

murinum
scrofulaceum
scrofulaceum
Kansasi
forotuitum

18. INFLUENZA AND OTHER VIRAL RESPIRATORY DISEASES:

43.1

i.)
ii.)
iii.)
iv.)
v.)

43.2

i.)
ii.)
iii.)
iv.)
v.)

19.

Complications of influenza infection include:

S. aureus pneumonia
Reyes syndrome
Persistent hyponatremia
Myositis and rhabdomyolysis
Chorioretinitis

The following associations are correct:

Rhinovirus: spread by contact with infected secretions


Coronaviurs: major respiratory pathogen of young
children
Respiratory syncytial virus: causes 10-20% of cases
of common cold
Para influenza virus: major cause of croup
Adenovirus: hemorrhagic cystitis and epidemic
keratoconjunctivitis

RUBEOLA, RUBELLA, CHICKEN POX AND OTHER VIRAL EXANTHEMS:

44.1

Complications of measles include:

i.)
ii.)
iii.)
iv.)
v.)

Croup
Interstitial giant cell pneumonia
Vaccinia gangrenosum
Acute glomerulonephritis
Subacute bacterial endocarditis

44.2

i.)
ii.)
iii.)
iv.)
v.)

In herpes zoster:

Latent virus reactivation originates from dorsal root


ganglia
Cutaneous dissemination occurs in 75% of cases if
associated with lymphoma
Granulomatous angiitis with contralateral hemiplegia
is a known complication
Tzanck smear is a useful method for diagnosis
Live attenuated vaccine should be given as
prophylaxis

20. MUMPS:

45.1

i.)
ii.)
iii.)
iv.)
v.)

In mumps. Mark T or F for the following:

Paramyxovirus reservoir is present only in humans


Virus is transmitted by infected salivary secretions or
urine for 6 days prior to parotitis and up to 2 weeks
later
Marked leukocytosis is seen if orchitis occurs
Prednisone may give symptomatic relief in orchitis
Prevention is achieved by a live attenuated vaccine
given after 1 year of age

21. ENTEROVIRUSES AND REOVIRUSES:

46.1

i.)
ii.)
iii.)
iv.)
v.)

The following statements are correct:

Picornaviruses are small RNA viruses that can survive


in sewage and chlorinated water
Risk of paralysis from oral poliovaccine is 1 in 1.7
million doses
Herpangina is caused by coxsackie B-viurs
Epidemic myalgia is caused by coxsackie virus A.
Reoviruses are single stranded RNA viruses that cause
upper respiratory infections

22. HERPES SIMPLEX VIRUSES (HSV):

47.1

i.)
ii.)
iii.)
iv.)
v.)

23.

The following statements are correct about drug


treatment of HSV:

Treatment of choice for the first episode of genital


herpes is oral acyclovir 200 mg orally 5 times per
day for 10-14 days
In symptomatic recurrent genital herpes, short course
of oral acyclovir has modest benefit in shortening
lesions and viral excretion time
Prolonged use of oral acyclovir 2 3 times daily
prevents reactivation of symptomatic recurrences of
genital herpes
Acyclovir given intravenously in HSV encephalitis has
no effect on overall mortality
In oral-labial HSV infection topical acyclovir is of no
clinical benefit

CYTOMEGALOVIRUS (CMV) AND EPSTEIN-BARR VIRUS (EBV)


INFECTIONS:

48.1

i.)
ii.)
iii.)
iv.)
v.)

48.2

i.)
ii.)
iii.)
iv.)
v.)

48.3

i.)
ii.)
iii.)
iv.)
v.)

48.4

CMV infection. Mark T or F.

Maximum risk is 2-3 weeks after organ transplant


CMV pneumonia occurs in 20% of bone marrow
recipients
CMV infection is very frequent in patients with AIDS
Urine or saliva may be culture positive for months or
years after infection with CMV
Most congenital CMV infections are clinically
inapparent at birth

In EBV infections:

EBV is rarely transmitted by blood transfusiosn


Infected B lymphocytes are polyclonally stimulated to
produce immunoglobulins
Splenomegaly occurs in almost all the cases
Corticosteroids are contraindicated
Burkitts lymphoma is a known association

Complications of EBV infection include:

Autoimmune hemolytic anemia


Splenic rupture during the early phase of disease
Spontaneous pneumothorax
Encephalitis
Pericarditis

Correct statements about diagnosis of EBV infection


include:

i.)
ii.)
iii.)
iv.)
v.)

Heterophil antibodies are antibodies to sheep red


blood cells removed by absorption with beef red
blood cells
20-30% of cases may be negative for HA in the first
week of the illness
HA may be positive upto 9 months after onset of the
illness
Atypical lymphocytes that are usually seen are in fact
activated B-lymphocytes
IgM to viral capsid antigens are diagnostic of primary
infection

1. IN RABIES:

49.1

i.)
ii.)
iii.)
iv.)
v.)

2.

Mark T or F.

Human to human transmission can occur


Prominence of early brain stem dysfunction distinguishes
rabies encephalitis from other encephalitis
Hydrophobia occurs in almost all cases
Neutralizing antibody titer of > 1:64 should be maintained
for effective pre-exposure prophylaxis
Active immunization is achieved by giving human rabies
immune globulin (RIG)

FUNGAL AND RELATED INFECTIONS:

50.1

i.)

In cryptococcosis:

Infection occurs through inhalation or skin abrasions

ii.)
iii.)
iv.)
v.)

50.2

i.)
ii.)
iii.)
iv.)
v.)

50.3

i.)
ii.)
iii.)
iv.)
v.)

Meningoencephalitis, pneumonitis and uveitis are


known clinical manifestations
India ink stain of CSF is positive in about 50% of the
cases
Lung biopsy is required for diagnosis
Flucytosine and ketoconazole are equally effective
therapy

In candidiasis:

Diagnosis is by demonstration of psuedohyphae on


wet smear
Chronic mucocutaneous candidiasis is associated with
hyperparathyroidism, hyperthyroidism or T cell
function defects
Appearance of retinal abscess is a feature of
hematogenous spread
Imidazole cream is effective for cutaneous candidiasis
Urine infection is treated by bladder irrigation with
amphotericin B or flucytosine diluted solutions for 15
days

Aspergillosis: Mark T or F.

It is acquired through inhalation of spores of the


fungus
Aspergilloma represents a ball of hyphae within a lung
cyst or cavity
Chronic sinusitis occurs usually in the non immunosuppressed
Repeated isolation of aspergillous from sputum more
than two times is indicative of infection
Amphotericin B can arrest or cure hemoptysis due to
aspergilloma

50.4

i.)
ii.)
iii.)
iv.)
v.)

50.5

i.)
ii.)
iii.)
iv.)
v.)

50.6

i.)
ii.)
iii.)
iv.)
v.)

3.

Features of allergic bronchial aspergillosis include:

Pre-existing asthma
Eosinophilia
IgG antiboidies to aspergillus
Hilar adenopathy
Fleeting pulmonary infiltrate

Findings in mucormycosis include:

Rhizopus fungus infection


Malignant otitis media
Non septate hyphae
Immunocompromised host
Poor response to amphoreticin B

The following correlations are true:

Weekly acid-fast organisms and actinomycosis


Painless red papule at the site of inoculation and
sporotrichosis
Response to sulfisoxazole and nocardiosis
Osteolytic lesions and histoplasmosis
Hilar or paratracheal lymphadenopathy and
coccidioidomycosis

RICKETTSIAL INFECTIONS:

51.1

The following features favor endemic type (murine)


rather than the epidemic type (louse-borne).

i.)
ii.)
iii.)
iv.)
v.)

51.2

i.)
ii.)
iii.)
iv.)
v.)

4.

Q-fever. Mark T or F.

It is acquired by inhalation of dust or drinking


contaminated milk
Coxiella burnetti is the causative organism
Granulomatus hepatitis occurs in one-third of the
cases
Culture negative subacute bacterial endocarditis is a
known complication
Chloramphenicol is an effective treatment

MYCOPLASMA INFECTIONS:

i.)
ii.)
iii.)
iv.)
v.)

5.

Infection by Rickettsia prowazekii


Maculcopapular rash affecting axilla, upper abdomen
with little involvement of the extremities
Azotemia, thrombosis and cutaneous gangrene
Rapid recovery with little fatalities in most cases
Positive Weil-Felix OX-19

Protective antibodies from an infection give a life long


immunity
IgM antibodies to I antigen on type O RBC are positive
in about half of the cases
Tetracycline is an effective therapy
WBC count is normal in over 80% of the cases
Stevens-Johnson syndrome is a recognized
complication

CHLAMMYDIAL INFECTIONS:

53.1

Chlamydia trachomatis genital infection. Mark T or F:

i.)
ii.)
iii.)
iv.)
v.)

53.2

i.)
ii.)
iii.)
iv.)
v.)

53.3

i.)
ii.)
iii.)
iv.)
v.)

6.

Chlamydia is a major cause of epididymitis in men


under the age of 35 years
Complications include peri-rectal abscess, fistula and
strictures
Up to 70% of men with non-diarrheal Reiters disease
have a positive test
Mucopurulent cervicitis and pelvic inflammatory
disease are known clinical manifestations in females
All patients with gonorrhea and their sexual partners
should be treated for chlamydia infection

In psittacosis:

Respiratory transmission occurs from any avian


species
Splenomegaly is uncommon
Liver function tests are usually normal
Diagnosis can be obtained by culture or serology
Six weeks course of tetracycline is the regimen of
choice

In lymphogranuloma venereum (LGV):

Two strains (L1 and L2) are recognized pathogenic


forms
Primary genital lesions occurs 3 to 10 days after
exposure
Inguinal syndrome is unilateral in 10 20% of the
cases
Headache and menigismus are known constitutional
symptoms
Complement fixation titre of > 1:64 is suggestive of
the diagnosis

PARASITIC DISEASES:

54.1

i.)
ii.)
iii.)
iv.)
v.)

54.2

i.)

In amebiasis:

There is increased SGOT and bilirubin in the hepatic


form
Pleuropulmonary extension occurs in 1 3% cases
Motile trophozoites can be recovered from liquid
stools
Pericarditis is a recognized extra-intestinal
manifestation
Serology is positive in over 90% of patients with
hepatic abscess

Match the following statement on malaria blood


smear:

iv.)

Small rings with two chromatin dots and bananashaped gametocyts


Band forms
Immature (enlarged) red blood cells and diffuse red
dots (Schuffners dots).
Oval shaped red blood cells

1.)
2.)
3.)
4.)

P.
P.
P.
P.

54.3

The following statement are correct about malaria:

ii.)
iii.)

i.)
ii.)

vivax
falciparum
malariae
ovale

Parasitemia is limited in patients with thalassemia


Blackwater fever is triggered by immunecomplex
nephropathy

iii.)
iv.)
v.)

54.4

i.)
ii.)
iii.)
iv.)
v.)

54.5

i.)
ii.)
iii.)
iv.)
v.)

54.6

i.)

Exchange transfusion is indicated if parasitemia


reaches > 10%
Dexamethazone and/or manitol are indicated in
severe falciparum infection
Amodiaquine prevents relapse of P. vivax and P. ovale

In toxoplasmosis:

Acute acquired infection is usually seen in an


immunocompetent host
The disease is responsible for about one third of all
chorioretinitis cases
CNS is rarely affected even in an
immunocompromised host
Trophozoites can be demonstrated in histology of
tissue sections
Combination of sulfadiazine and primaquine is the
best therapy

In pneumocystic carinii pneumonia:

Infection is a reactivation in most cases


Risk of infection is increased in children with primary
immunodeficiency
Diagnosis is usually obtained by methenamine silver
stain of sputum
Cotrimoxazole causes drug rash in about 50% of
treated AIDS patients
Pentamidine could be given by inhalation, IM, or IV
routes

Pentamidine can cause:

Hypoglycemia

ii.)
iii.)
iv.)
v.)

54.7

i.)
ii.)
iii.)
iv.)
v.)

54.8

i.)
ii.)
iii.)
iv.)
v.)

7.

Hyperglycemia
Hypocalcemia
Hyperuricemia
Hepatic dysfunction

In schistosomiasis:

Pathology is dependent on duration and intensity of


exposure
Acute schistosomiasis syndrome may last 2-3 months
Liver fibrosis can be caused by S. Mansoni or S.
Japonicum
Glomerulonephritis and systemic hypertension are
known clinical manifestations
Hydronephrosis and renal failure are common
sequelae of S. hematobium infection

The following associations are correct about intestinal


nematodes:

Trichuriasis (whipworm) and pruritus ani


Ascariasis and malabsorption
Ankylostoma and subconjunctional hemorrhage
Trichinosis and autoinfection
Isosporiasis and infection by penetration of the skin

OTHER INFECTIONS OF CLINICAL IMPORTANCE:

55.1

i.)

Legionella infections. Mark T or F.

They are anaerobic gram-negative rods with complex


growth requirement

ii.)
iii.)
iv.)
v.)

55.2

i.)
ii.)
iii.)
iv.)
v.)

55.3

i.)
ii.)

Risk of infection is increased with smoking


Gastrointestinal symptoms are seen in almost all
cases
10-15% of cases are complicated by respiratory failure
Erythromycin or tetracycline are effective therapy

The following statements are in favor of tuberculous


leprosy rather than lepromatous type

Hypopigmented macules
Palpable greater auricular nerve
Corneal ulceration
Nasal obstruction
Loss of the lateral eyebrow

The following statement are correct about Lyme


disease:

Borrelia birgdoroferi is the causative organism


Erythema chronicum migrans indicates the beginning
of stage 2 disease
iii.)
Stage 3 is manifested by CNS abnormalities
iv.)
Increased IgG titre may cross react with Trepanoma
pallidum
v.)
Penicillin is an effective therapy