1. TPHA and RPR à latent syphilis.

Because we cannot evaluate if it is early or late latent

à 3 injection of IM BP (2.4 million units) (long lasting in blood due to slow replication
cycle). But, because the patient has HIV, we may also suspect neurosyphilis à 10-14
days of aqueous IV penicillin G. allergic to penicillin, in pregnant females perform de-
sensitization treatment with small doses of penicillin and if not give doxycycline or
tetracycline orally, for 4 weeks.

2. High IgG avidity in CMV – avidity test measures the titer of IgG in blood. Generally, as
the avidity is higher, the older the infection. In high avidity, probably the infection was
more than 4 months ago. In related to CMV, probably it means that there is an old
infection, which don’t affect the fetus because it is localized in the nerves. But, IgM can
still be positive due to false positive (other agents), and in some cases, there could be high
avidity although it is a recent infection due to fast seroconversion. That’s why we will ask
also for neutralizing abs and look for CMV-DNA (usually found in primary infection) in
blood in order to have a broader evaluation for the current situation.

3. The most likely diagnosis is primary active TB. This is a child,

which is an immigrant, which may suggest mal-nutrition, and he
is coming from an endemic area with an ethnic predisposition for
a higher risk for infection. these three highly increase the chance
for TB infection. Moreover, the mother has TB, and it is a very
infective disease transmitted thru aerosols. Moreover, the child
has symptoms of TB which include fever, night sweats, cough
and weight loss. The X-ray is not clear, but there may be some
lung consolidation and infiltration. So, in order to confirm the
hypothesis, I would suggest quantiferon test which mesuare the interferon gamma,
sputum or BAL stained by ziehl neilsen, and PCR (also for antibiotic resistance).

4. The most likely diagnosis is a fecal-oral infection, and according the serology, is highly
suggestive for Hepatitis A. in order to be sure we can look for HAV-RNA in the stool, but
basically finding IgM-HAV in blood, is a confirmation of diagnosis. HbS-Anti-Abs,
 suggest that the patient was vaccinated. We can also suggest to test for HEV in stool and
blood both for RNA and IgM, because it is a fecal-oral infection. The precautions are
monitoring and giving fluids to the patient. In the past it was recommended to give Ig
against Hepatitis A. for contacts, vaccine and hygiene precautions are recommended.

5. Sepsis defined as life threatening event due to an infection which lead to an abnormal
immune response. The criteria for sepsis based on q-SOFA are Glasgow Mental Status <
15, Systolic Blood pressure < 100mmHg, respiratory rate > 22. In the past in order to
diagnosed SIRS criteria was used, today it can support q-SOFA diagnosis. Severe sepsis
is defined as severe life threatening event, due to a disseminated infection, which
alternate the blood circulation, body metabolism and cell functions. It is defined as q-
SOFA, with Lactate > 2mmol/l, and Mean Arterial Pressure < 65mmHg after IV fluids +
vasoconstrictors. The most common causes are E. coli, Staph aureus, Enterococcus
fecalis, strep pneumonia. And UTI, Lungs and Skin are the most common sites of
infections which causes sepsis. The difference with multi-organ failure is that sepsis is a
type of MODS. Which is multi organ dysfunction syndrome which require medical
intervention to achieve homeostasis, due to hypoperfusion, trauma and infection. Sepsis is
the most common cause of it.

6. E. coli:
a. Toxigenic – developing countries, water contamination. Cholera like toxin.
Traveler’s watery diarrhea.
b. Aggregative – developing countries, contamination of food and water. Enterotoxin.
Prolonged watery diarrhea.
c. Pathogenic – developing counties, affect children under 3, person to person, and food
and water contamination. Watery diarrhea, adhere to the small intestine.
d. Invasive – no toxin. Developing countries, causing inflammatory colitis. Bloody
diarrhea, abdominal pain and fever.
e. Hemorrhagic – developed counties. Contamination of milk, meat, vegetables. Can
affect children and adults. Shiga like toxin à HUS, bloody diarrhea and fever.
Incubation time more than 4 days. antibiotic is not recommended, because it increase
the chance for HUS development.

7. The most likely diagnosis is bacterial meningitis. Turbid CSF, low glucose, high protein,
and high PMN. Which are all highly suggestive for it. because of the rash, we will suspect
infection by Neisseria Meningitides. High fever and altered consciousness may
recommend to be alert for sepsis development. Until CSF culture, we I’ll give broad
spectrum antibiotics which include ceftriaxone and ampicillin. If the culture will be
positive for Neisseria à we will give only ceftriaxone and dexamthesaone which is found
as useful to reduce the inflammation. For people who made contact with the patient in the
last 7 days we will give prophylaxis therapy, ciprofloxacin for adults and rifampin for
children.
a. DD:
 i. hemophilia influenza – there may be ear infection and auxiliary nerve
involvement.
ii. Strep pneumonia – coming from mastoid, pharyngeal or ear infection. And high
chance for hydrocephalus.
iii. Listeria monocytogenes – can lead to ataxia, tremor, confusion.

8. Multidrug resistance microorganism is a microorganism that is resistant to fewer

antibiotics, then those it is susceptible for. The 2 mechanisms of resistance are based on
efflux pumps, and accumulation of genes that encoding for single drug resistant which
accumulate in the same bacteria (e.g. beta-lactamase formation ability). XDR is exactly
the opposite. The role of antibiotic stewardship is to reduce and prevent antibiotic
resistance development. Resistance occurs naturally, but wrong usage increases the rate
of resistance development. The stewardship is based on the appropriate usage which is
giving drug in the right dosage, duration, route of administration, reduce the usage of
wide-spectrum antibiotics, and give the right antibiotics to the right bacteria. Taking in
account the PK/PD, side effects, drug-drug interactions. Which all reduce resistance,
costs, side effects, over-use, un-necessary prolonged prophylaxis.

9. Diagnosis of schistosomiasis is based on history taking (endemic countries, bathing in

lakes), physical examination, symptoms and onset of infection (acute or chronic). If a
patient was coming from an endemic area, bathing in a lake, and had itch (swimmer’s),
we will think about schistosomiasis.
a. Acute – the symptoms are based on katayama fever (fever, weight loss, rash,
eosinophilia, hepatomegaly). Serology (ELISA), bladder/rectal biopsy (eggs
surrounded in granuloma), stool eggs – 3 times. In acute cases usually we won’t find
eggs, that is why we will try and repeat it 3 times. Moreover, serology isn’t
recommended for people living in the endemic areas.
b. Chronic:
i. Mansoni and Japnonicum (intestinal) – symptoms are abdominal pain, diarrhea,
hepatosplenomegaly, ascites, esophageal varices.
1. Serology (ELISA), Stool eggs (3 times), US – peri-portal fibrosis (syner’s
pipe) that can be diffused, peripheral and central.
ii. Hematobium (genitourinary) – hematuria, dysuria, epididymitis, salpinigitis,
increase chance for bladder cancer and infertility.
1. Serology (ELISA), eggs in urine, cystoscopy and US for bladder (fibrosis).
c. Treatment – praziquental.

10. Yes, chloroquine is resistant in sub-Saharan Africa. The prophylaxis suggested to prevent
malaria are mefloquine which is given once a week during the stay, but can generate
mental side effects which then is reccomneded to stop the therapy. Other prophylaxis are
malarone (atovaqoune-proganuil) which is given 2 days before enteric the area until one
 week after, and doxycycline which is given during the whole period, and until 4 weeks
after. Moreover, using mosquite-replent and long sleeves are recommended.

11. Diagnosis is secondary syphilis, treatment IM benzathine penicillin (2.4 million units) X3
injections.

12. In the first trimester there is 45% of transmission with 10% chance to develop symptoms
for the fetus or baby. The significance of positive IgM with low IgG avidity, telling us
probably a sign for an acute infection. To further evaluate if it is an acute infection, we
will measure neutralizing Abs and DNA of CMV. Then, around the 20 week of gestation
we will perform amniocenthesis, if it will be positive for CMV infection (IgM, DNA), it
means that transmission occurred. Then, we would like to evaluate the chance for
development of symptoms. We will measure beta-2microglobulin > 11.5mg/l, PLT <
50,000 µL, IgM > 3.0, DNAemia > 30,000 copies. 3 out of 4 will indicate if the fetus will
become symptomatic or not. Furthermore, neonatal diagnosis and monitoring is reuired.
The implications are that the fetus may be infected and may be symptomatic to CMV.
Further evaluation of the pregnancy is required.
13. Most likely diagnosis is miliary TB, because in the X-ray we are able to see seeds like
lesion which are the sign for miliary. The symptoms are also symptoms of TB. Refugee.
Diagnosis was discussed previously. But, skin test is usually negative in miliary TB. PCR
is used to evaluate resistance to antibiotics. The main therapy is 2 months of (RIPE) and
then 4 months of isoniazid and rifampin. If the patient is resistance to isoniazid or
rifampin à use fluroquinolones and amikacin. It is recommended to have during the
treatment at least 5-6 drugs that are effective against the mycobacteria. In XDR we will
give bedaquiline (dexamathesone may be useful in the therapy as well).

14. The differential diagnosis:

a. First of all, the patient is vaccinated to HBV.
b. We should evaluate the wound to check for soft tissue infection or blood infection.
c. We should also check for steatohepatitis due to alcohol usage – so we will perform
US.
d. Hepatitis infections especially HCV and HEV so we will look for HCV-RNA in
blood and HEV-RNA in the stool.
e. US for the liver to look for abscess due to amoeba histolytica or bacteria – although
there is no RUQ and fever.s
f. Looking for neoplasms markers.
g. Other possibilities are development of hepatitis from CMV or EBV – which are both
although rare but can cause signs of hepatitis.
h. Liver cyst from echinococcus infection – US.
15. Fever is a change in the normal set-point of body temperature, above the range of the
circadian rhythm. Fever can be accompanied with other signs like delusion, headache
(vasodilation), photophobia and chills. There are different fever patterns which are not
diagnostic but they may suggest for a specific infection. The reason that they aren’t
diagnostic is the overuse of anti-pyoretic drugs and antibiotics which modify it. the
patterns are:
a. Intermittent – elevated peak of fever for certain period. In severe increase hectic
fever. It is common in drug fever, kala azar, deep seated infections.
b. Remittent – elevated temperature that don’t decrease below the normal. Common in
viral and bacterial infections.
c. Relapsing – malaria, borrelia. Interval of fever, then no fever.
d. Pel ebstein – high fever for 3-10, then the same number of days without fever.
Hodgkin’s and TB.
e. Relative bradycardia – no increase in pulse to meet higher metabolic rate during
fever. Happen in typhoid fever, leptospirosis, viral myocarditis, brucellosis.
f. Factitious fever – not a real fever, it is a manipulation of the patient on the
thermometer.
g. Fever of unknown origin – more than 38.3 for more than 3 weeks, which isn’t being
diagnosed after 1 week in hospital.

16. Standard precautions:

a. Work practice – hand hygiene, no food and drinks, no recapping.
i. Urine catheter – no irrigation, no cleaning just replacing, if there is an
asymptomatic infection don’t treat. If there is symptomatic infection remove the
catheter.
ii. Vascular catheter – hand hygiene. if infected remove the catheter. Insert in usual
common places (Subclavian).
iii. Respiratory support – try to prevent intubation. clean with chlorohexidine. control
blood glucose.
iv. Surveillance of surgery – clean the area, reduce the inoculum. Control blood
glucose for diabetes, and ask to stop smoking a month in advance.
v. Hand hygiene.
vi. Control prophylaxis.
b. Engineering - containers for needles, contaminated waste, sinks, coverage for the
needles, showers, separation between patients.
c. Personnel protective equipment – gloves, masks, cloths.
d. Others – cough ethic, make-up, no sick staff, and separate from visitors and contacts.

17. (General guideline) First thing is to ask for history of the patient, other symptoms like
dysuria, frequency. Check for Jordan sign (back pain), fever. Ask if the patient had a
trauma, hospitalized with catheter. Ask if the blood is for all the urinating process or only
at the beginning which can differentiate between upper and lower. If the Jordan sign is
positive, and blood in urine is prolonged, we will suspect pyelonephritis. Then we will
run urine dipstick check the nitrite level – mark for bacterial infection. We will perform
urine microscopy to look for blood and WBC. Check the pH, color, smell of urine.
 perform blood and urine culture. If it is pyelonephritis CT and cystoscopy are
recommended.
a. UTI is one of the main cause of sepsis – so we should monitor and think about it.
The treatment is dependent on the type of infection. If it is uncomplicated low UTI or
recurrence of infection you will give 3 days of nitrofurantoin or TMN-SMX. If it is
complicated infection you will give 7 days of the same drugs. In case of pyelonephritis
you will give between 10-14 days of ceftriaxone/ gentamycin. In case of resistance to
them we will use meropenem. Also water hydration and drinking cranberry juice for the
acidity are very useful.

18. Endocarditis diagnostic approaches – history + physical examination à signs are fever,
murmur, small emboil (osler node, ruth spot, splinter hemorrhage, ganeway lesion). The
criteria:
a. Major – 3 blood cultures (staph, strep, enterococcus, HACEK) for microorganism
except in coxiela brunetti only 1. TEE – vegetation, abscess and aneurysm, look
around prosthetic valve and more.
b. Minor – 1 blood culture (which don’t meet the major criteria), fever > 38, history of
heart condition and IV drug use, vascular (emboli) and immunological phenomenon
(e.g. osler).
19. ZIKA – not relevant.

20. The most likely diagnosis is plasmodium falciparum malaria. The women is coming from
an area which is highly endemic for malaria. It is not true that malaria has lower
prevalence by the sea, it is exactly the opposite. Moreover, the patient didn’t take any
prophylaxis. At the beginning of malaria infection there could be continuous fever.
According to the thin blood smear which is more specific than the thick smear we can see
the accole and the banana shaped gametocytes which are signs for plasmodium
falciparum. In order to confirm our diagnosis, we can run rapid diagnostic test. If there is
inconsistency between them, we should perform PCR. The treatment indicated for
plasmodium falciparum is artemisinin and mefloquine. Artemisinin responsible for
removal of the large number of parasite, and mefloquine is supposed to remove the rest.
 We cannot use chloroquine as the drug of choice because it is an area of resistance for it.
another drug that can be given is quinine.

21. According to the information it is an elderly patient with a weak immune system due to
DM, which increase the chance to develop infections. The patient has 2 out of 3 signs of
q-SOFA which are Glasgow scale lower than 15, and respiratory rate higher than 22.
Moreover, the patient also has 2 out of 5 signs of SIRS, which are fever higher than 38,
and high respiratory rate. This information suggests for sepsis. Although the surgical
wound is healing well and no abdominal tenderness we should suspect infection or
dissemination of infection from that area. but we should also suspect lung involvement,
because the patient had intubation and has coarse crackles which may suggest an
infection in the lungs, although it may be also be related to the fact that the patient is
smoking for the last 30 years. The clinical approach will be first of all to perform physical
examination and clinical history of the patient. After that, we should take blood culture
and sputum culture, at least 2 samples to prevent contamination. Then, you will give
broad spectrum antibiotics which should cover lung infections and maybe also for the
area of the wound. Then, we should give the patient IV fluids in order to prevent a
development of septic shock. We should also collect other information, like Lactate level
which should be monitored for septic shock, Pro-calcitonin which is a marker for
bacterial sepsis. We should perform X-ray to the chest of the patient. If after 3-6 hours,
the patient mean arterial pressure isn’t stabilized above 65, we should give
vasoconstrictors. After getting positive blood or sputum culture, we should narrow our
antibiotic therapy.

22. CMV and Toxoplasma are part of TORCH infections, which can cause congenital
infections and developmental abnormalities. A mother with an acute infection of CMV or
Toxoplasma, may transmit the infection thru the placenta into the fetus. It is important to
say, that as the acute infection of mother was earlier in the pregnancy around the 1st
trimester, the chance for symptomatic infection is higher, while the chance of
asymptomatic transmission is higher at the end of the pregnancy. The newborn should be
tested for CMV and Toxoplasma when he is born. In the case of CMV, we can look for
symptoms like hydrocephalus, mental retardation, deafness, hypotonia and more. We
should also perform ELISA and PCR for urine and blood of the newborn to check for
IgM and DNA. IgG is irrelevant at that stage, because it can pass from the mother thru the
placenta. Moreover, it is crucial to perform the test in the first 7 days, to exclude intra-
 partum infection. If the newborn is positive treatment and monitoring must be performed.
In the case of toxoplasma, if the amniocenthesis and immunoblot for IgM were positive
during the pregnancy, the newborn must receive a therapy of pyramethamine +
sulfonamide. If the newborn was negative, we should perform Immunoblot and PCR for
IgM and DNA in his blood to check if it is positive. In case it is positive, we should treat,
if not, we should monitor it for a year. In both infections we would like to see that IgG
disappear overtime, which means that it is only came from the mother, and the newborn
wasn’t infected.

23. The differential diagnosis should be between the different mycobacteria, the main
suspicion is for TB, but also Mycobacteria avium, and M. bovis, and atypical
mycobacteria. The reason we suspect it, is that acid-fast staining bacilli is staining for
these mycobacteria. The lung involvement, mass and hilar lymphadenopathy may suggest
progressive secondary infection of TB which is prevalent in immunocompromised
patients especially with very low CD4 AIDS. In these type of patients with low CD4,
usually TB disseminate in blood and can reach different organs. We should also ask for
sputum or BAL, and perform acid fast staining and PCR. We should also assess brain and
liver involvement. Usually the imaging of HIV patient with TB, supposed to be clear
because of lack of immunity. But, because the initiation of ART, there is a chance for
IRS, which exacerbate the inflammation. If PCR is positive for TB, we should check for
resistance to antibiotics and then start therapy (written already). Moreover, TB therapy
and ART therapy has interaction in the liver so we should check for drugs that can work
together.

24. According to the blood smear we suspect malaria, we should also perform RDT. If there
is inconsistency, we will ask for PCR for defining the specific malaria strain. If it is
plasmodium falciparum which fit the endemic area, we should give artemisinin +
amodaquine as treatment (because he used mefloquine as prophylaxis). If the patient has
 plasmodium vivax or ovale, we should treat the same, but add also primaquine to prevent
relapse due to liver hypnozoites. Because it is sub-saharan country, we cannot treat with
chloroquine due to resistantce. Quinine may be an alternative therapy.

25. The most likely diagnosis is visceral Leishmania, also known as kala azar. The signs and
symptoms of anemia, thrombocytopenia, continuous fever, weight loss,
hepatosplenomegaly are all found in kala azar. From the bone marrow aspirate we can
find enlarge macrophages with amastigote inside them, and small basophilic dots which
are called kinetoplasts. This is a direct confirmation of the disease. The treatment of
choice may be Amphotericin B or pentavalent antimony (in India there is resistance for
pentavalent) or milfetosine which is more recommended for Kala Azar from India.

26. The most likely diagnosis is TB with Scrofula, which is an enlargement of lymph node in
the neck area. the investigation of choice is fine needle aspiration of the scrofula fluid.
first we will use US in order to evaluate if there is actual fluid inside. Then, after the
aspiration we will perform acid fast Ziel Nielsen + PCR, which supposed to give us the
confirmation for TB. If it is not TB, we should think about Staph Aureus.

27. T – Toxoplasma, Other (Zika, HIV, Flu, Syphilis, Parvovirus B19, HBV, HCV), Rubella,
HCMV, Herpes (1-2, VZV). These are infections which are able to pass from the mother
 into the fetus thru the placenta or intra-partum (during delivery) and may lead to
development of congenital disease. In order to prevent:
a. Primary – to prevent maternal infection. Vaccines (rubella, HBV, VZV, Flu),
screening (to everything), Hygiene (CMV, Toxoplasma).
b. Secondary – prevent the transmission between mother to fetus. Screening
(amniocentesis), prophylaxis (toxoplasma, syphilis).
c. Tertiary – prevent sequale of the disease in the newborn. Diagnosis and follow-up,
treatment.

28. The diagnostic hypothesis is for NCC. The patient is coming from an endemic area of T.
Solium. Moreover, seizures for 2 years, don’t suggest for bacterial infection which is
usually more acute. The MRI pictures are suggestive for NCC. As a can see from the

MRI, there is a lesion in the parenchyma of the brain, which is more common than extra-
parenchymal involvement. Moreover, the sign for the parenchymal involvement is
seizures. Usually the stool O&P and Serology are negative in that case. The diagnosis of
this disease is a bit complicated and require a diagnostic criterion which is divided into
absolute, major and minor criteria. The absolute criteria include funduscopic evaluation
of the eye to find for the cysticerci, MRI/CT in which you can see the cyst with the
parasite, or biopsy + histology with the scolex or eggs. The major criteria are positive
immunoblot for antibodies, lesions highly suggestive for the disease in imaging, treatment
with albendazole that reduce the symptoms. The minor criteria are epidemiological
criteria, ELISA of CSF or blood and finding cysticerci in a different location in the body.
The treatment for NCC is based on praziquental / albendazole or anti-epileptic drugs.
29. The hypothesis is schistosomiasis due to bathing in fresh water of Lake Victoria which is
an endemic area for it + the appearance of itchy rash (swimmer’s itch) which is a sign for
this type of infection. The patient has low grade fever, sore throat and fatigue. Because
she took malaria prophylaxis, most of the chances she doesn’t have malaria but we can
perform RDT in order to exclude it. ten days later the patient return with very high fever,
eosinophilia which are signs for katayama fever as part of schistosomiasis infection. The
tests to diagnose acute infection are stool O&P at least different samples, because it is
difficult to find it at the acute stage. We can perform serology – ELISA, to look for
antibodies in the blood for the infection. We can also for rectal or bladder biopsy to look
for eggs surrounded by granulomas in histology. The recommended therapy is
praziquental.

30. For primary and secondary infection syphilis and HIV negative patient we give one shot
of Benzathine penicillin IM, 2.4million units which is long lasting due to slow replication
of the bacteria. if the patient is allergic to penicillin, two weeks of oral doxycycline or
tetracycline. If the patient is pregnant we will do de-sensitization approach, to give in
lower dosage of penicillin. In some secondary syphilis cases we can give 3 shots of
benzathine penicillin IM, 2.4 million units. Non-treponemal test can be performed to
evaluate the therapy. We should also be aware from Jarisch Herxhiemer reaction.
Moreover, the patient should be re-examined after therapy 6 months and 1 year later.
31. DD between Latent and Active TB – the biological difference between latent and active
TB is that in active TB, the mycobacteria develop and replicate inside macrophages, and
the immune system is unable to fight against it. while in latent TB, the mycobacteria is
surrounded by a granuloma after the immune system became active against it. in order to
differentiate between the two, we will look for symptoms in the active state which are
fever, weight loss, chills, cough and unexplained pleural effusion. Quantiferon and
Mantoux cannot distinguish between active and latent infection. In latent TB, regular
sputum test for acid-fast can be negative for the bacilli. In order to identify them in latent
we should perform stimulation of sputum or take BAL and then perform acid-fast staining
+ PCR. X-ray should also be performed to evaluate lung situation which can show us
specific signs for TB. In many cases latent TB is under-diagnosed, so we should evaluate
it carefully, and in any case we should treat both active and latent TB.
32. Can we immunize against bacterial meningitis and if so for which pathogens – yes
for some pathogens we can immunize against bacterial meningitis. These pathogens are
encapsulated bacteria. the vaccines are against:
a. Neisseria meningitides which can have a tetravalent vaccine against strain A, C, W-
135, Y, or monovalent against strains C and B.
b. Streptococcus pneumonia – children vaccination with 13 serotypes or adults’
vaccination with 23 serotypes.
 c. Hemophilia influenza against serotype B which cause the meningitis.
33. Does chronic hepatitis B develop more frequently in newborns and toddlers in
compare to adulthood – yes chronic infection is higher in newborn and toddlers in
compare to adults. That is the reason why we vaccinate at 3 months. If the mother was a
carrier of HBV, we give to the newborn hyper-Ig for HBV at the day he/she was born and
then in a different location we inject the vaccine. The reason is that neonate carry the
maternal virus which lead to tolerance of T cells against it, which cannot kill the virus.
34. List bacterial meningitis with clear CSF – listeria monocytogenes (although can be also
turbid), TB mycobacterium, Treponema Pallidum, Leptospirosis, Brucella, Borellia.
35. An 82-year-old white man living in a nursing home presents with a 5-day history of
abdominal pain, nausea, severe foul smelly diarrhea, fever and malaise. He was
started on levofloxacin for pneumonia 2 weeks’ prior with resolution of his
pulmonary symptoms. Exam reveals a fever of 38.3 and mild abdominal distension
with minimal tenderness. Laboratory tests revealed a peripheral WBC of 12,000 and
a stool test which is mildly positive for occult blood. What is the most likely
diagnosis and how would you manage? The most likely diagnosis is clostridium
difficle. The patient is elderly, coming from a nursing home, and was being treated for 2
weeks with levofloxacin which is a prolong therapy. These are major risk factors for
development of clostridium difficle infection. Moreover, the patient has fever, smelly
diarrhea (anerobic bacteria), abdominal pain, and nausea which are symptomatic signs for
it. We will perform stool ELISA for Toxin A of clostridium difficle. We can give oral
vancomycin or metronidazole for therapy, and we will give IV fluids and electrolytes to
monitor blood volume and pressure after the diarrhea.
36. A 34-year-old man presents 2 weeks after returning from a month long trip to India.
He denies attending pre-travel vaccination clinic and didn’t take prophylaxis of any
sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain,
nausea, with emesis and dark urine. He admits to dietary indiscretion and consumed
raw seafood at a roadside vendor 2 weeks before onset of symptoms. On
examination he is jaundiced, his ALT is 5660 units/L, and total bilirubin 9mg/dL.
Please list all the lab tests necessary to obtain an accurate etiologic diagnosis – the
most likely diagnosis is orally transmitted agent, probably hepatitis A or E. Both types of
hepatitis fits to the incubation periods, moreover, the patient confirm that he ate raw sea-
food, which is a risk factor. The symptoms of jaundice, abdominal pain, nausea, emesis
and dark urine, fits to the description of acute hepatitis. The lab tests necessary for
diagnosis are serology for HAV, HEV, but we can also run serology for the rest of the
hepatitis viruses. If we find Anti-HEV or Anti-HAV, we don’t need to look for RNA in
blood or stool. But if we don’t find it, we should ask for it. In both cases, the chances to
find the RNA is higher in the stool in compare to the blood.
37. Treatment of Echinococcosis granulosus cyst (was in the revision with professor Felici,
but 99% not for exam) – echnococcsis has high prevalence in north Africa, causing cysts
in 80% of the cases in the liver and lungs, but it can also be found in other areas in the
body like brain. Diagnosis is made by imaging (US – liver cysts), or serology – looking
for antibodies for the parasite. According to the WHO, cyst is classified to live (contain
fluid) or dead cyst (solid component without fluid). The treatment in the past was based
on surgery, but today it is based or on administering Mbendazole or by PAIR – method of
cyst aspiration from the liver. Puncture, Aspirate the cyst fluid, Inject 95% alcohol, and
then re-aspirate the alcohol.