 Raynaud phenomenon 2-15

 Arthritis and arthralgia 22-58

 Joint contractures 26-27
 Fever 16-65
 Gastrointestinal signs and symptoms 8-37
 Restrictive pulmonary disease 4-32
 Interstitial lung disease 1-7
 Cardiac involvement 0-3
31.(D) Elevated serum levels of muscle-derived enzymes (creatine kinase [CK],
aldolase, aspartate transaminase, alanine transaminase [ALT], lactate
dehydrogenase) reflect muscle inflammation. Not all enzyme levels rise with
inflammation in a specific individual; ALT is usually elevated on initial
presentation, whereas CK level may be normal. The erythrocyte sedimentation
rate (ESR) is often normal, and the rheumatoid factor (RF) test result is typically
negative.
32.(D) Lipodystrophy and calcinosis are thought to be associated with long-
standing or undertreated disease. Dystrophic deposition of calcium phosphate,
hydroxyapatite, or fluoroapatite crystals occurs in subcutaneous plaques or
nodules, resulting in painful ulceration of the skin with extrusion of crystals or
calcific liquid.
33.(D) Scleredema is a transient, self-limited disease of both children and adults
that has sudden onset after a febrile illness (especially streptococcal infections).
34.(A) Linear Scleroderma
Linear lesions can extend through the dermis, subcutaneous tissue, and muscle
to underlying bone; more likely unilateral.
35.(B) Raynaud phenomenon (RP) is the most frequent initial symptom in
pediatric systemic sclerosis, present in 70% of affected children months to years
before other manifestations. RP refers to the classic triphasic sequence of
blanching, cyanosis, and erythema of the digits induced by cold exposure and/or
emotional stress.
36.(B) In patients without major organ involvement, colchicine significantly
improves oral and genital ulcers, skin features, and disease activity of Behçet
disease.
37.(B) Proposed Criteria for Pediatric Sjögren Syndrome
Diagnosis requires ≥4 criteria
I. CLINICAL SYMPTOMS
1. Oral: recurrent parotitis or enlargement of parotid gland, dry mouth
(xerostomia)
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2. Ocular: dry eyes (xerophthalmia) recurrent conjunctivitis without obvious
allergic or infectious etiology, keratoconjunctivitis sicca
3. Other mucosal: recurrent vaginitis
4. Systemic: fever, noninflammatory arthralgias, hypokalemic paralysis, and
abdominal pain
II. IMMUNOLOGIC ABNORMALITIES
Presence of at least 1 of the following antibodies: anti-SSA, anti-SSB, high-titer
antinuclear antibody, rheumatoid factor
III. OTHER ABNORMALITIES OR INVESTIGATIONS
1. Biochemical: elevated serum amylase
2. Hematologic: leukopenia, high erythrocyte sedimentation rate
3. Immunologic: polyclonal hyperimmunoglobulinemia
4. Renal: renal tubular acidosis
5. Histologic proof of lymphocytic infiltration of salivary glands or other organs
(i.e., liver)
6. Objective documentation of ocular dryness (rose bengal staining or Schirmer
test)
7. Positive findings of parotid gland scintigraphy
IV. Exclusion of all other autoimmune diseases
38.(A) Juvenile recurrent parotitis is characterized by intermittent unilateral
parotid swelling typically lasting only a few days. It is frequently associated with
fever and may undergo remission with puberty. Unlike in Sjögren syndrome,
there is a male predominance, juvenile recurrent parotitis is seen in the younger
children (3-6 yr), and there is a lack of focal lymphocytic infiltrates on biopsy.
39.(C) Prophylactic daily oral colchicine decreases the frequency, duration, and
intensity of FMF flares. This regimen also prevents the development of systemic
AA amyloidosis.
40.(A)
Diagnostic Indicators of Tumor Necrosis Factor Receptor–Associated Periodic
Syndrome (TRAPS)
1. Recurrent episodes of inflammatory symptoms spanning >6 mo duration
(several symptoms generally occur simultaneously)
a. Fever
b. Abdominal pain
c. Myalgia (migratory)
d. Rash (erythematous macular rash occurs with myalgia)
e. Conjunctivitis or periorbital edema
f. Chest pain
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g. Arthralgia or monoarticular synovitis
2. Episodes last >5 days on average (although variable)
3. Responsive to glucocorticosteroids but not colchicine
4. Affects family members in autosomal dominant pattern (although may not
always be present)
5. Any ethnicity may be affected
41.(B)
42.(D) Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis (PFAPA)
show dramatic response to a single oral dose of prednisone (0.6- 2.0 mg/kg),
although this approach does not prevent recurrence and may actually shorten
the interval between flares. Cimetidine at 20-40 mg/kg/day is effective at
preventing recurrences in approximately one third of cases. Small series have
shown that anakinra may be effective during a flare, but because corticosteroids
are effective, this may not be a cost-effective approach. Colchicine may extend
the time between flares. Complete resolution has been reported after
tonsillectomy, although medical management should be the first approach.
43.(E) Although organ involvement may vary, AA amyloidosis most frequently
affects the kidneys; 90% of patients have some degree of renal involvement.
Unexplained proteinuria may be the presenting feature in some patients.
Nephrotic syndrome and renal failure may develop if the underlying
inflammatory condition is not controlled or if diagnosis is delayed.
44.(B) In adults and older children, pulmonary involvement is most frequent,
with infiltration of the thoracic lymph nodes and lung parenchyma. Isolated
bilateral hilar adenopathy on chest radiograph is the most common finding.
45.(B) There appear to be 2 distinct, age dependent patterns of disease among
children with sarcoidosis. The clinical features in older children are similar to
those in adults (pediatric-onset adult sarcoidosis), with frequent systemic
features (fever, weight loss, and malaise), pulmonary involvement, and
lymphadenopathy. In contrast, early-onset sarcoidosis manifesting in children
<4 yr of age is characterized by the triad of rash, uveitis, and polyarthritis.
46.(C) Several risk stratification models have been constructed to determine
which patients with Kawasaki disease (KD) are at highest risk for coronary artery
abnormalities CAA. Predictors of poor outcome across several studies include
young age, male gender, persistent fever, poor response to IVIG, and laboratory
abnormalities, including neutrophilia, thrombocytopenia, transaminitis,
hyponatremia, hypoalbuminemia, elevated levels of N-terminal–brain
natriuretic protein and elevated C-reactive protein (CRP) levels. Asian and
Pacific Islander race and Hispanic ethnicity are also risk factors for CAA.
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47.(B) Clinical features that are not consistent with KD include exudative
conjunctivitis, exudative pharyngitis, generalized lymphadenopathy, discrete
oral lesions (ulceration or exudative pharyngitis), splenomegaly, and bullous,
petechial, or vesicular rashes.
48.(C) Patients with acute KD should be treated with 2 g/kg of IVIG as a single
infusion, usually administered over 10-12 hr within 10 days of disease onset,
and ideally as soon as possible after diagnosis.
49.(B) Glucocorticoids such as oral prednisone (1-2 mg/kg/day), or in severe
cases, intravenous (IV) methylprednisolone for 1-2 wk, followed by taper,
reduce abdominal and joint pain but do not alter overall prognosis of Henoch
Schönlein purpura.
50.(D) The younger age, the nature of the lesions, absence of other organ
involvement, and a biopsy may help distinguish infantile acute hemorrhagic
edema from Henoch Schönlein purpura.
51.(A)
52.(D) Oral prednisone (1-2 mg/kg/day) or IV pulse methylprednisolone (30
mg/kg/day) are the mainstay of therapy of polyarteritis nodosa. Oral or IV
cyclophosphamide are often used as adjunctive therapy, and plasma exchange
may be warranted for life-threatening disease.
53.(B)
54.(E) Churg-Strauss syndrome CSS frequently causes inflammation of the upper
and lower respiratory tracts, but cartilage destruction is rare. CSS may initially
demonstrate chronic or recurrent rhinitis/sinusitis, nasal polyposis, non-fixed
pulmonary lesions, and difficult-to-treat asthma. Eosinophilia (>10% of
leukocytes) with pulmonary infiltrates may precede a vasculitic phase.
55.(A) Growing pains, more appropriately termed benign nocturnal pains of
childhood , growing pains affect 10–20% of children, with peak incidence
between age 4 and 12 yr. Pain does not occur during periods of rapid growth or
at growth sites. Pain often follows a day with exercise or other physical
activities. Physical findings are normal, and gait is not impaired.
56.(D) Restless legs syndrome (RLS , Willis-Ekbom disease), seen more
frequently among adolescents and adults, is a sensorimotor disturbance that
may be confused with growing pains. Often familial, RLS is a difficult-to-control
urge to move the leg that is exacerbated during rest and at night and is relieved
by movement. Iron supplementation may benefit pediatric patients with RLS.

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Chapter 16
Infectious Diseases
Questions
USAMA A. AL JUMAILY
1. A 5-year-old boy with leukemia develops fever and chills; you suspect
infection with gram-negative bacilli.
Of the following, the best lab media that support growth of such organisms is
A. sheep blood agar
B. chocolate agar
C. Sabouraud dextrose agar
D. MacConkey agar
E. Inhibitory mold agar

2. A 6-year-old boy develops fever and decrease level of consciousness; he has

been diagnosed with posterior fossa low grade glioma since the age of 1 year
that was treated successfully by VP shunt insertion and tumor resection. He is
fully vaccinated. You suspect shunt infection.
Of the following, the MOST common organism isolated from shunt infection is
A. Haemophilus influenzae type b
B. Streptococcus pneumoniae
C. Propionibacterium
D. Mycobacterium tuberculosis
E. Cryptococcus

3. Parasitic infections are usually detected by microscopic examination of

clinical specimens like blood, bone marrow, or fecal smears.
Of the following, the parasite that is detected by serologic tests rather than
clinical specimens is
A. Plasmodium
B. Trichinella
C. Babesia
D. Leishmania
E. Giardia lamblia

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4. A 7-year-old boy has recurrent bacterial respiratory infections; he has been
diagnosed with cystic fibrosis since early childhood.
Of the following, the micro-organism that is strongly related with disease
severity is
A. Pseudomonas aeruginosa
B. Haemophilus influenzae
C. Staphylococcus aureus
D. Mycoplasma pneumoniae
E. Mycobacterium tuberculosis

5. Which of the following is the MOST effective measure to reduce the

likelihood of recurrent clostridium difficile-associated diarrhea (CDAD)?
A. Metronidazole
B. Fecal transplantation
C. Vancomycin
D. Avoid using antibiotics
E. Amoxicillin-clavulanate

6. A 5-year-old boy is going to receive immunoglobulin against hepatitis A

before travelling with his parents to a country endemic with hepatitis A. The
mother is concerned about adverse reactions of immunoglobulin
administration.
Of the following, the MOST common adverse reaction to immunoglobulin
administration is
A. flushing
B. headache
C. chills
D. pain at the injection site
E. nausea

7. A 4-year-old boy is exposed to his relative with varicella infection. He has

been diagnosed with primary immune deficiency disorder since infancy.
Varicella-zoster immunoglobulin is not available.
Of the following, the BEST alternative treatment is
A. intravenous immunoglobulin (IGIV)
B. intramuscular immunoglobulin (IGIM)
C. subcutaneous immunoglobulin (IGSC)
D. palivizumab
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 E. prophylactic acyclovir

8. Which of the following vaccines consists of whole inactivated

microorganisms?
A. Acellular pertussis
B. Hepatitis A
C. Hepatitis B
D. Varicella
E. Rotavirus

9. A 7-year-old boy developed AIDS due to HIV infection. Lab test shows that his
CD4+ T-lymphocytes count is 250 cells/mm3.
Of the following, the live attenuated vaccine that can be given to this child is
A. oral polio
B. small pox
C. yellow fever
D. BCG
E. varicella

10. Children with primary immunodeficiency may not receive vaccines, whether
live-attenuated or killed ones. In which of the following diseases, all vaccines
can be administered?
A. Chronic granulomatous disease
B. DiGeorge syndrome
C. Properdin deficiency
D. Severe combined immunodeficiency (SCID)
E. Common variable immunodeficiency

11. A 5-year-old girl is going to receive her scheduled BCG vaccine. She has been
diagnosed with immune thrombocytopenia 3 weeks ago and has been treated
with prednisolone 2mg/kg/day, since that time. What is your recommendation
regarding vaccine administration?
A. She can receive her vaccine immediately
B. She should not receive vaccine any more
C. Stop corticosteroids for 2 weeks before resuming her vaccination
D. Stop corticosteroids for at least 1 month before resuming her
vaccination

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 E. She can receive her vaccine immediately once corticosteroids are
discontinued

12. A preterm baby is born to a HBsAg-positive mother. His birth weight is 1.9
kg. Your proper management for this baby is to
A. give birth dose of hepatitis B vaccine
B. defer hepatitis B vaccine until chronological age of 1 month
C. give hepatitis B immunoglobulin (HBIG) within 12 hr of birth
D. give hepatitis B vaccine within 12 hr of birth
E. give hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine within 12
hr of birth

13. Which of the following vaccines should be deferred for at least 3 months
after immunoglobulin administration?
A. Pertussis
B. Measles
C. Diphtheria
D. Rotavirus
E. Live attenuated influenza vaccine (LAIV)

14. Which of the following is the MOST common route of nosocomial infection
during hospitalization?
A. Hands
B. Medical equipment
C. Toys
D. Hospital furnishings
E. Phones

15. A 5-year-old boy is admitted to ICU because of pending septic shock. He has
been diagnosed with acute myeloblastic leukemia and received intensive
chemotherapy with subsequent febrile neutropenia. He is on prolonged course
of antibiotics since 3 weeks.
Of the following, the MOST common type of infection is
A. rota virus
B. respiratory viruses
C. fungi
D. staphylococci
E. gram-negative bacilli
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16. Which of the following pathogens requires droplet isolation rather than
contact isolation?
A. Enterohemorrhagic Escherichia coli O157:H7
B. Hepatitis A virus
C. Shigella species
D. Neisseria meningitidis
E. Clostridium difficile

17. A 6-year-old boy is going to receive hepatitis A vaccine before travelling to

hepatitis A- endemic country. The parents ask about the time needed for the
vaccine to provide adequate protection for safe travel.
Protective immunity after receiving hepatitis A vaccine will develop within
A. 1 week
B. 2 weeks
C. 4 weeks
D. 8 weeks
E. 12 weeks

18. Which of the following is the MOST common pathogen that may cause
traveler`s diarrhea?
A. Enterotoxigenic Escherichia coli
B. Enteroaggregative Escherichia coli
C. Campylobacter
D. Entamoeba histolytica
E. Shigella

19. A 7-month-old infant develops diarrhea during a travel with his parents to a
country in the Southeast Asia.
Of the following, the MOST appropriate antibiotic for this infant is
A. amoxicillin
B. trimethoprim-sulfamethoxazole
C. ciprofloxacin
D. azithromycin
E. erythromycin

20. Which of the following drugs is well known to cause fever?

A. Amoxicillin
B. Azithromycin
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 C. Amphotericin B
D. Cefixime
E. Teicoplanin

21. Which of the following disorders is characterized by periodic fever?

A. Cyclic neutropenia
B. Familial Mediterranean fever
C. TNF receptor–associated periodic syndrome
D. Hyper-IgD syndrome
E. Muckle-Wells syndrome

22. Which of the following conditions is MOST likely associated with relative
tachycardia rather than bradycardia?
A. Brucellosis
B. Diphtheria
C. Chlamydia pneumonia
D. Legionnaire's disease
E. Leptospirosis

23. Which of the following conditions is classically associated with double

quotidian fever (fever that peaks twice in 24 hr)?
A. Familial Mediterranean fever
B. Cyclic neutropenia
C. Behçet disease
D. Inflammatory arthritis
E. Crohn's disease

24. Which of the following CSF parameters is not affected by prior antibiotic
administration in bacterial meningitis?
A. PCR
B. Culture
C. Cell
D. Glucose
E. Protein

25. A 3-year-old boy develops fever, drooling of the mouth, difficulty in

swallowing, noisy breathing, and neck pain. Examination is unremarkable.
Of the following, the MOST appropriate diagnostic study is
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 A. lumbar puncture
B. MRI of the brain
C. MRI of the spinal cord
D. CT scan of the neck
E. lateral X-ray of the head and neck

26. An 18-month-old girl develops prolonged fever of 3 weeks duration. It has

been preceded by a flue like illness. The mother describes that the fever has
been subsided after 5 days followed by recurrent spikes every 2-4 days. Other
medical history is insignificant. Examination is unremarkable.
Of the following, the MOST likely diagnosis is
A. nephrogenic diabetes insipidus
B. familial dysautonomia
C. pseudo-FUO
D. familial Mediterranean fever (FMF)
E. hyper IgD syndrome

27. Which of the following conditions is accompanied by fever in the absence of

sweating?
A. Hodgkin lymphoma
B. Tuberculosis
C. Hyperthyroidism
D. Hypoglycemia
E. Familial dysautonomia

28. Which of the following is the MOST likely diagnosis in a 1-year-old male
child with prolonged fever associated with bulbar conjunctivitis?
A. Measles
B. Lymphogranuloma venereum
C. Kawasaki disease
D. Coxsackievirus infection
E. Tuberculosis

29. Fever, lack of tears, absent corneal reflex, and smooth tongue with absence
of fungiform papillae is highly suggestive of which of the following diseases?
A. Familial dysautonomia
B. Ectodermal dysplasia
C. Kawasaki disease
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 D. Dermatomyositis
E. Scleroderma

30. A 3-year-old boy with chronic granulomatous disease (CGD) develops fever,
chills, toxicity, and tachycardia consistent with sepsis.
Of the following, the MOST common micro-organism causing sepsis in this child
is
A. Staphylococcus aureus
B. Aspergillus
C. Chromobacterium violaceum
D. Streptococcus pneumoniae
E. Candida albicans

31. In which of the following primary immunodeficiency diseases, Pneumocystis

jiroveci pneumonia (PCP) infection is more likely to occur?
A. X-linked agammaglobulinemia (XLA)
B. Common variable immunodeficiency
C. Selective IgA deficiency
D. IgG 2 subclass deficiency
E. Hyper IgM syndrome

32. A 12-year-old boy develops fever and severe oral mucositis; he has been
diagnosed with acute lymphoblastic leukemia 3 months ago; he has received
intensive chemotherapy 1 week before and kept on ciprofloxacin prophylaxis.
His absolute neutrophil count (ANC) is 100/mm3.
Of the following, the MOST appropriate antibiotic that should be given to this
boy is
A. cefepime
B. vancomycin
C. piperacillin
D. ceftriaxone
E. amphotericin

33. A 12-year-old boy with AML develops fever and oral mucositis 1 week after
high dose cytarabine chemotherapy administration. He has been kept on
ciprofloxacin prophylaxis after completion of chemotherapy. His ANC is
300/mm3.
Of the following, the MOST commonly encountered pathogen in this boy is

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 A. Candida albicans
B. Mucor mycosis
C. Aspergillus fumigatus
D. Staphylococcus aureus
E. Streptococcus viridans

34. Which of the following is the MOST commonly used intravenous antibiotic
as 1st line monotherapy in children with fever and neutropenia?
A. Ceftazidime
B. Cefepime
C. Vancomycin
D. Meropenem
E. Gentamicin

35. A 9-year-old boy develops lymphoma few years after liver transplantation.
Which of the following viral infections that may lead to such complication?
A. Cytomegalovirus (CMV)
B. Varicella-zoster virus (VZV)
C. Hepatitis B virus (HBV)
D. Hepatitis C virus (HCV)
E. Epstein-Barr virus (EBV)

36. A 5-year-old boy has greenish discharge at the exit site of central venous line
(CVC).
Of the following, the MOST likely offending causative micro-organism is
A. Staphylococcus aureus
B. Coagulase-negative staphylococci
C. Streptococcus pneumoniae
D. Candida albicans
E. Mycobacteria

37. A 7-year-old boy has persistent candidemia after removal of central line
venous catheter. He is on daily liposomal amphotericin B for the last 2 weeks.
Of the following, the MOST appropriate management in this setting is to
A. stop antifungal treatment
B. add itraconazole
C. add fluconazole
D. continue amphotericin for 6 weeks
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 E. replace amphotericin by fluconazole

38. A 3-year-old boy develops fever. Examination reveals ill child with neck
stiffness. Vaccination history is negative upon parental refusal.
Of the following, the MOST common causative organism is
A. Haemophilus influenzae type b
B. Escherichia coli
C. Streptococcus pneumoniae
D. Neisseria meningitidis
E. Staphylococcus aureus

39. A 5-year-old boy develops fever. Blood culture reveals Streptococcus

pneumoniae pathogens.
Of the following, the MOST appropriate antibiotic effective against this
pathogen is
A. ampicillin
B. ampicillin-sulbactam
C. amoxicillin-clavulanate
D. ticarcillin-clavulanic acid
E. vancomycin

40. Which of the following cephalosporins is highly effective against

pseudomonas aeruginosa?
A. Cefazolin
B. Cefuroxime
C. Ceftriaxone
D. Cefotaxime
E. Ceftazidime

41. A 3-year-old girl develops erythema, swelling and tenderness of the right
hand. Swab culture reveals methicillin-resistant staphylococcus aureus (MRSA).
Of the following, the cephalosporin that is MOST effective against this pathogen
is
A. cefepime
B. ceftazidime
C. ceftaroline
D. cefazolin
E. cefuroxime

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42. Which of the following pathogens is resistant to meropenem?
A. Streptococcus pneumoniae
B. Pseudomonas aeruginosa
C. Stenotrophomonas maltophilia
D. Klebsiella
E. Acinetobacter

43. Which of the following aminoglycosides is particularly effective against

Francisella tularensis infection?
A. Streptomycin
B. Kanamycin
C. Gentamicin
D. Tobramycin
E. Netilmicin

44. Which of the following is the MOST effective antibiotic against extended
spectrum beta lactamase (ESBL) organisms?
A. Meropenem
B. Ceftazidime
C. Amikacin
D. Colistin
E. Ertapenem

45. Staphylococcus aureus pathogens can affect the host by direct invasion or
through toxin elaboration. Which of the following diseases is caused by direct
invasion of the staphylococcus aureus rather than by toxin-mediated process?
A. Food poisoning
B. Pericarditis
C. Scarlet fever
D. Scalded skin syndrome
E. Toxic shock syndrome

46. Skin lesions caused by S. aureus may be indistinguishable from those caused
by group A streptococci.
Which of the following manifestations is MORE specific for the former?
A. slow expansion
B. less erythema

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 C. more tenderness
D. more swelling
E. less fluctuation

47. Which of the following organisms may mimics S. aureus infection by causing
cavitary pneumonia?
A. Group A streptococcus
B. Mycoplasma pneumoniae
C. Streptococcus pneumoniae
D. Klebsiella pneumoniae
E. Pseudomonas aeruginosa

48. A 2-year-old boy develops gluteal abscess. After draining of the abscess, the
culture reveals methicillin susceptible S. aureus (MSSA).
Of the following, the MOST appropriate initial antibiotic treatment is
A. ampicillin
B. cefazolin
C. amoxicillin
D. azithromycin
E. ciprofloxacin

49. Toxic shock syndrome (TSS) closely resembles Kawasaki disease clinically.
However, some clinical manifestations are more common in TSS.
Of the following, the clinical manifestation that is MORE specific for TSS is
A. fever
B. hypotension
C. erythematous rash
D. conjunctival hyperemia
E. skin desquamation

50. Which of the following strains of coagulase-negative staphylococci (CoNS) is

commonly causing urinary tract infections (UTI)?
A. Staphylococcus epidermidis
B. Staphylococcus hominis
C. Staphylococcus haemolyticus
D. Staphylococcus saprophyticus
E. Staphylococcus lugdunensis

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51. Most of coagulase-negative staphylococci (CoNS) are resistant to methicillin.
Which of the following strains is methicillin susceptible?
A. Staphylococcus epidermidis
B. Staphylococcus hominis
C. Staphylococcus haemolyticus
D. Staphylococcus saprophyticus
E. Staphylococcus lugdunensis

52. Treatment of S. epidermidis infections often requires effective antibiotics

with removal of indwelling medical devices.
Of the following, the indwelling medical device infection that is treated with
antibiotics without its removal is
A. central venous line catheter
B. prosthetic heart valve
C. peritoneal dialysis catheter
D. CSF shunt
E. prosthetic bone

53. A 2-year-old girl develops fever, cough, and shortness of breath secondary
to right middle lobe empyema. She is not vaccinated upon parental refusal. You
suspect invasive pneumococcal infection.
Of the following, the MOST appropriate initial treatment is
A. amoxicillin
B. ampicillin
C. penicillin G
D. ceftriaxone
E. vancomycin

54. A 5-year-old boy develops otitis media due to pneumococcal infection. He

has a history of non-type I allergic reaction to penicillin.
Of the following, the BEST alternative treatment is
A. cephalexin
B. clindamycin
C. levofloxacin
D. trimethoprim-sulphamethaxazole
E. azithromycin

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55. A 4-year-old boy develop bacterial meningitis due to invasive pneumococcal
infection.
Of the following, the MOST commonly encountered adverse neurological sequel
is
A. hearing loss
B. epilepsy
C. intellectual deficits
D. paralysis
E. blindness

56. Which of the following is the MOST common infection caused by

Streptococcus pyogenes?
A. Pharyngitis
B. Perianal cellulitis
C. Pneumonia
D. Osteomyelitis
E. Suppurative arthritis

57. Erysipelas is an acute infection involving the deeper layers of the skin and
the underlying connective tissue.
What is the MOST characteristic finding of this infection?
A. Cutaneous swelling
B. Skin erythema
C. Very tender affected skin
D. Sharply defined, slightly elevated border
E. Reddish streaks of lymphangitis projecting out from the margins of the
lesion

58. A 5-year-old boy develops nonbullous impetigo involving the face and
extremities. The skin lesions have been resolved after antibiotics administration.
Of the following, the MOST reliable test that confirms evidence of preceding
group A streptococcal infection in this child is
A. anti–streptolysin O
B. anti–DNase B
C. streptozyme test
D. Streptococcal rapid antigen detection
Isothermal loop amplification

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59. A 5-year-old boy develops oral pharyngitis secondary to group A
streptococcal (GAS) infection. You recommend starting therapy with oral
penicillin. To achieve maximal pharyngeal eradication of GAS and prevention of
rheumatic fever, the oral penicillin must be administered for a maximal duration
of
A. five days
B. seven days
C. ten days
D. fourteen days
E. twenty-one days

60. A 4-year-old girl develops oral pharyngitis due to group A streptococcal

(GAS) infection; she has had a history of immediate (anaphylactic-type)
hypersensitivity to penicillin.
Of the following, The MOST appropriate treatment for this girl is oral
A. cephalosporins
B. clindamycin
C. sulphonamides
D. tetracyclines
E. penicillin

61. A 5-year-old boy develops acute arthritis following an episode of group A

streptococcal (GAS) pharyngitis. The characteristic distinct feature that
differentiate post streptococcal reactive arthritis (PSRA) from arthritis due to
rheumatic fever (RF) is
A. involvement of large joints
B. nonmigratory arthritis
C. long latent period between the antecedent episode of GAS pharyngitis
and arthritis
D. dramatic response to aspirin therapy
E. concurrent high grade fever

62. Which of the following Jones criteria is required as the only sole criterion to
diagnose acute rheumatic fever (RF)?
A. Acute carditis
B. Polyarthritis
C. Erythema marginatum
D. Subcutaneous nodules
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 E. Chorea

63. A 5-year-old boy develops acute rheumatic fever manifested by fever and
polyarthritis.
Of the following, the LEAST commonly involved joint is
A. hip
B. knee
C. ankle
D. elbow
E. wrist

64. Characteristic feature of arthritis due to acute rheumatic fever that

distinguishes it from arthritis due to other causes is
A. hotness
B. non tender
C. dramatic response to small dose of salicylates
D. polyarticular
E. deforming

65. Carditis, whether clinical or subclinical, is a major criterion for diagnosis of

acute rheumatic fever. The MOST commonly involved cardiac valve is
A. mitral
B. aortic
C. pulmonary
D. tricuspid
E. both aortic and pulmonary

66. A 15-year-old male adolescent has been diagnosed with acute rheumatic
fever at the age of 5 year. His initial manifestations were clinical carditis and
migratory arthritis.
Of the following, the MOST common echocardiographic finding at this age is
A. mitral regurgitation
B. mitral stenosis
C. tricuspid regurgitation
D. tricuspid stenosis
E. pulmonary stenosis

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67. A 5-year-old boy develops acute rheumatic fever. The parents are concerned
about future development of valvular heart disease.
Of the following, the feature that is highly correlated with significant rheumatic
heart disease is
A. number of initial joints involvement
B. fever more than 38 C°
C. chorea
D. erythema marginatum
E. subcutaneous nodules

68. A 6-year-old girl develops acute rheumatic fever manifested by fever,

arthritis and carditis. Chest radiography shows cardiomegaly with pulmonary
edema. She is on oral amoxicillin treatment.
Of the following, the MOST appropriate initial treatment for this girl is
A. prophylactic benzathine penicillin
B. oral salicylate
C. oral acetaminophen
D. oral prednisolone
E. NSAIDs

69. You are discussing acute rheumatic fever with medical students. Risk of
recurrent carditis is raised during the discussion.
Of the following, the statement that should be included in the discussion is
A. the more severe the initial cardiac involvement, the lesser the risk for
residual heart disease
B. patients without carditis during the initial episode are less likely to have
carditis with recurrent attack
C. there is a stepwise decrease in cardiac involvement as the number of
episodes increases
D. patients with initial episode of carditis never have carditis with
recurrences
E. the risk for permanent heart damage decreases with each recurrence.

70. A 2-day-old neonate develops recurrent attacks of apnea and respiratory

distress; he is lethargic, with bradycardia, and poor feeding. He is a full term
baby, a product of normal vaginal delivery. The mother has a history of
prolonged rupture of membranes 24 hours before delivery.
Of the following, the MOST likely causative pathogen is
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 A. Staphylococcus aureus
B. group A streptococci
C. Streptococcus pneumoniae
D. group B streptococcus
E. Haemophilus influenzae

71. Invasive group B streptococci (GBS) disease in children beyond early infancy
is uncommon. The MOST common infection associated with childhood GBS is
A. bacteremia
B. meningitis
C. pneumonia
D. endocarditis
E. arthritis

72. A 10-day-old neonate develops apnea, bradycardia, and respiratory distress.

He is a ex- preterm baby by normal vaginal delivery at a gestational age of 28.
He has been admitted to NCU and an intravascular catheter has been inserted.
Of the following, the MOST likely causative pathogen is
A. group A Streptococcus
B. group B Streptococcus
C. Staphylococcus aureus
D. Enterococcus
E. Listeria monocytogenes

73. A 3-year-old boy develops sepsis. Blood culture revealed Enterococcus with
susceptibility to penicillin. The child is allergic to penicillin.
Of the following, the MOST appropriate treatment for this boy is
A. cephalexin
B. azithromycin and gentamicin
C. vancomycin
D. cephalexin and gentamicin
E. vancomycin and gentamicin

74. A 6-year-old child develops fever, toxicity, tachycardia, and borderline blood
pressure. He has been diagnosed with acute myeloid leukemia 3 months ago
and received intensive chemotherapy. Blood culture revealed vancomycin-
resistant Enterococcus faecalis.
Of the following, the MOST appropriate initial treatment is
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