CASE 1

A 40-year-old woman presents to her physician with an erythematous annular patchwith

central clearing on her left forearm. The patient states that the rash began asa small red
papule about 5 days ago and has grown progressively larger. She alsocomplains of fatigue,
headache, myalgias, and intermittent arthralgias. She has remained afebrile, and her vital signs
are stable. Physical examination is significant for 8×7-cm erythematous patch on her left
forearm thathas concentric rings of redness and a clearing center. She also has cervical and
axillarylymphadenopathy. The remainder of the examination is unremarkable. She has been
on a hiking trip with her family 10 days ago but nobody else developed any symptoms. She
recalls no sick contacts.

What is the most likely diagnosis?How did this patient got infected?
 Lyme disease,a multisystem inflammatory disease caused byborrelia burgdorferi, must
be considered in a patient with the history of hiking and a classic “bull’s-eye” rash of
erythema migrans in combination withconstitutional symptoms.
 Ixodes scapulris tick (deer tick) is the vector of this spirochete

How can this condition be diagnosed?

The diagnosis of Lyme disease is clinicaland is confirmed by serologic testing in laterdisease.
(sensitivityof serologic testing is approximately 50% in early disease and increasesto over 90%
by the later stages). The fact that the patient has gone hiking, and the history that the
rashexpanded over several days and surpassed 5 cm in diameter, are useful clues. Diagnosis is
aided by serologic testing in laterdisease, which should include antibody testing by enzyme-
linkedimmunosorbent assay (ELISA). If positive, follow-up with Westernblot testing.

The patient’s husband presents to the physician 6 months later complaining of bilateral
facial palsy. What is the most likely diagnosis?
This patient has Bell’s palsy, most likely caused by disseminated B. burgdorferi. Presentation of
disseminated disease can occur days tomonths after the tick bite. CNS involvement can include
meningitis and cranial nervepalsies

What other symptoms could this female patient expect to develop over time if the condition
is not treated?
Lyme disease can be divided in stages:
 Stage 1 – early localized infection: Erythrema migrans
 Stage 2 – early disseminated infection: Migratory musculoskeletal pain and migratory
arthralgias accompanied by malaise and fatigue are the most common, less likely (14 %
of patients): neurologic manifestations - encephalopathy, neurocognitive dysfunction,
peripheral neuropathy (VII CN palsy)and nonspecific symptoms (headache, fatigue) also
occur.Even less commonly (8%) – Cardiac involvement - carditis, fluctuating AV block of
any type; LV dysfunction, cardiomegaly
  Stage 3 – Late persistent infection: 60 % - develop arthritis: oligoarticular in large joints,
chronic neurologic involvement, Acrodermatitis Chronica artophicans,

What is the most appropriate treatment for this condition?

 Early Lyme disease – doxycycline (amoxicillin,cefuroxime, erythromycin - alternatives)
for children <9 years –– amoxicillin
 Neurologic involvement, 3rd degree AV cardiac block – IV ceftriaxone

CASE 2
A 22-year-old college student is your patient in the emergency room. Whenyou walk into the
room, he is lying on the examination table, withhis arm covering his eyes. You look at his chart
andsee that his temperature is39°C (102.3°F), heart rate 110 bpm, andblood pressure 120/80
mm Hg. When you ask how he has been feeling,he says that for the past 3 days he has had
fever, body aches, and a progressivelyworsening headache. The light hurts his eyes and he is
nauseated. He has vomited once. He reports no diarrhea, cough, or nasal congestion.On
examination, he has petechial skin rash on his trunk. Hispupils are reactive to light, but he feels
severe discomfort when you shine the light into his eyes and begs you to stop. Ears and
oropharynx arenormal. Heart, lung, and abdomen examinations are normal. Neurologic
examinationreveals no focal neurologic deficits, but passive flexion of his neck worsenshis
headache, and he is unable to touch his chin to his chest.According to him, one other student
in his dormitory has recently been hospitalized, but he doesn’t know why.

1.What condition are you concerned about?Bacterial meningitis

What bacterial organisms are the most common causes of this disease? Strep. Pneumo, N.
meningitides; L. monocytogenes – in very young or very old; H. Influenza type B – no longer
common in developed countries due to vaccination
Based on the information given above, what organism is the most likely cause of this
patient’s condition? Neisseria Meningitides (petechial rash)

2.What are the most likely symptoms of this disease?

Fever, nausea, vomiting, neck stiffness, photophobia, irritability, positive Kernig and Brudzinski
signs, decreased level of consciousness, seizures and focal neurologic signs in severe cases,
petechial or purpuric rash – present in 80% of cases with N. meningitidis

3.What diagnostic test would confirm the suspected diagnosis? Lumbar puncture
What is the classic findings seen on this test? turbid CS fluid, Increased WBCs –
Polymorphonuclear neutrophils; increased protein, decreased glucose; Gram negative
diplococcus
4. What is the appropriate treatment for this patient?
 Treatment is begun empirically without waiting for the LP results: IV 3 rd generation
cephalosporin (ceftriaxone) + IV Vancomycin - dexamethasone is added to decrease the
inflammation and reduce the rate of neurologic complications) - in this particular
patient this is the best initial treatment
 In immunocompromised patients or very young and very old – IV ampicillin – to cover
Listeria monocytogenes
5. What is the prognosis of this condition? 10% of patients die despite adequate therapy
What complications may follow this condition? Severe bacteremia and DIC; Permanent skin
scarring after purpuric skin lesions,amputation, neurologic complications, hearing loss,
temporary renal hypoperfusion. Waterhouse-Friedrichsen syndrome – Hemorrhagic necrosis
of one or both adrenal glands – due to overwhelming meningococcemia – lead to adrenal
insufficiency and death

CASE 3
You see a 25-year-old man in the clinic. You enter the room and see a healthy-appearing
young man, who seems nervous. He finally admits that he has been worried about a lesion on
his penis. He denies pain or dysuria. He has no previous history of sexually transmitted
diseases (STDs) and has an otherwise unremarkable medical history. He is afebrile, and his
examination is notable for a shallow clean ulcer on the shaft of his penis, which is nontender
to palpation. There are some nontender, inguinal lymph nodes bilaterally.
1.What is the most likely diagnosis? Syphilis
What is the cause of this disease? Treponema pallidum, a spirochete

2. What is the clinical course of this disease?

 PRIMARY SYPHILIS: Initial lesion of T pallidum infection, usually in the form of a firm,
nontender ulcer: the chancre.
  SECONDARY SYPHILIS: Disseminated infection manifesting in a pruritic, maculopapular
diffuse rash that classically involves the palms and soles, or the flat moist lesion of
condyloma lata.(WART)
 Latent syphilis
 TERTIARY (LATE) SYPHILIS: Symptomatic infection involving the central nervous system,
cardiovascular system (ascending aortic aneurysm, or the skin and subcutaneous
tissues(gummas).

3. Is this infection transmitted transplacentally? YES

What are the characteristics of congenital form of this disease?PULMONARY
HEMORRHAGR,INFECTON,SEVERE HEPATITIS

4. What diagnostic approaches are available for this infection?

 Nontreponemal tests: RPR and Venereal Disease Research Laboratory (VDRL) tests,
which actually are tests for antibodies against cardiolipin-lecithin-cholesterol complex
that occur as part of the host reaction to T pallidum - fairly sensitive for the detection of
disease - they may be nonspecific and may result in false-positive results.
 Confirmatory testing in the form of specific antibody testing for T pallidum - fluorescent
treponemalantibody absorption (FTA-ABS) or microhemagglutination assay for
Treponema pallidum (MHA-TP) test, is the next step.
 Dark-field microscopy, in which scrapings from an ulcer are placed under a phase
contrast lens to actually identify the organisms, is the classic method of diagnosis but is
rarely performed today
 Screening: VDRL, RPR; confirmation: (FTA-ABS); assessment of response to the
therapy: RPR, VDRL

5. What is the treatment of this condition?

Penicillin is the treatment of choice for syphilis
 Primary, secondary or early latent syphilis: 1 IM dose benzathine penicillin; Penicillin
allergic patients: Doxycycline, tetracycline
 Late latent, cardiovascular or benign tertiary (gummatous): benzathine penicillin
weekly for 3 weeks; Penicillin allergic patients: Doxycycline, tetracycline or ceftriaxone;
 Neurosyphilis; Syphilis during pregnancy: penicillin; Penicillin allergic patients –
desensitize and give penicillin

CASE 5
 A 20 year-old male college student presents with abdominal pain, diarrhea, and fever. He
says that his symptoms started one day ago. He has had 10 stools in the past day. He
usually eats at home but reports having eaten chicken in the college cafeteria three days
ago. He has no history of gastrointestinal (GI) disease. On examination he has a
temperature of 37.8C (100F) and appears to be in pain. His abdomen has hyperactive
bowel sounds and is diffusely tender but without rigidity, rebound tenderness, or guarding.
A stool sample tests positive for blood and fecal leukocytes. Stool cultures are sent and are
subsequently positive for a pathologic organism.

 What is the most likely diagnosis? Bacterial gastroenteritis

 What is the most likely pathologic organism?Campylobacter jejuni
 List the 4 most common causes of similar presentation:
1. Campylobacter jejuni
2. Salmonella
3. Shigella
4. E.Coli in same sequence.

What is the diagnostic approach this patient?

The differential diagnosis of acute gastroenteritis would include Salmonella, Shigella, Yersinia,
as well as Campylobacter.
Stools contain leukocytes, and/ or RBCs
Campylobacter often mimics ulcerative colitis and Crohn’s disease but is much more common
than either.
Definitive diagnosis would be made by culture of the stool and growth of Campylobacter.

What is the Treatment of this condition?

Most often Campylobacter jejuni infection is self-limited and does not require specific
antimicrobial therapy.
Supportive care –electrolytes andhydration, is often the only treatment needed.
If specific therapy is needed for severe disease, or infection in immunocompromised patients,
erythromycin, azithromycin, alternative fluoroquinolones
Antimotility agents – may prolong symptoms

What is the Prevention of this condition? involves care in food preparation. Foods, especially
chicken, should be completely cooked, and exposure to raw or undercooked chicken or
unpasteurized milk should be limited, especially in pregnant or immunocompromised persons
2 weeks later the patient wakes-up and is not able to move his feet. What is this
complication and what is the underlying pathophysiologic mechanism?Why is this condition
dangerous? What is the management of the patient?
Guillain-Barre syndrome – autoimmune demyelination of the peripheral nerves – leads to
ascending weakness/ paralysis of the muscles - may lead to respiratory paralysis;
management: intubation because it may lead to respiratory failure., plasmapheresis or IV
immunoglobulin; prognosis is excellent

CASE 6

A 26-year-old woman presents to the office with a 3-day duration of discomfort with urination
and increased urinary frequency. She has noted that her urine has a strong odor as well. She
denies abdominal pain, back pain, vaginal discharge, or skin rash. She is diagnosed with
uncomplicated cystitis.
What is the most common cause of this condition?
Extra-intestinal pathogenic E.coli (ExPEC)
Most likely mechanism of introduction of organism into the urinary tract:
Urethral contamination by colonic bacteria followed by ascension of the infection into the
bladder.

What are the most common symptoms and signs of this condition? Who is under increased
risk to develop urethritis/cystitis? - Females, pregnant patients
Burning/discomfort with urination – dysuria; No fever. No costovertebral angle tenderness.
Abdominal exam – shows suprapubic tenderness.

What can cystitis complicate with? What is the most common presentation of this
condition?
Pyelonephritis - Burning/discomfort with urination – dysuria; presence of fever. Costovertebral
angle tenderness, or back pain, nausea/vomiting

What is the appropriate diagnostic approach to this patient?

Diagnosis based on Clinical presentation plusMicroscopic examination of urine sample - white
blood cells and numerous gram-negative bacteria.

What are the appropriate treatment options for uncomplicated mild UTI?
1. Nitrofurantoin – 5 days
2. TMP-SMX – 3 days
3. Fosfomycin – 1 dose
4. Ciprofloxacin, levofloxacin
 CASE 7
A 33-year-old comes to your clinic for follow-up of recurrent upper abdominal pain. He initially
presented 3 weeks ago, complaining of an increase in frequency and severity of burning
epigastric pain, which he has experienced occasionally for more than 2 years. Now the pain
occurs three or four times per week, usually when he has an empty stomach. The pain usually
is relieved within minutes by food or antacids, but then recurs in 2 to 3 hours. He admits that
stress at work had recently increased and that because of long working hours, he is drinking
more caffeine and eating a lot of take-out foods. His medical history is otherwise
unremarkable, and other than the antacids, he takes no medications.

What is the most likely diagnosis? What bacteria can be associated with the development of
this condition?
Peptic ulcer – H. pylori
If the condition goes untreated, what conditions may develop?
1. Adenocarcinoma of the distal stomach
2. MALT lymphoma

What is the pathophysiologic mechanism of bacteria causing the disease? Infiltration of

mucosa by WBCs, inflammation-mediated damage of the GASTRIC mucosa and reduction of
somatostatin releasing D cells, that leads to uninhibited production of gastrin, that increases
HCL acid production, further damaging the gastric mucosa. H pylori protects itself from acid by
producing the enzyme urease – neutralizes acid.

What are the diagnostic approaches to this patient?

Noninvasive tests: urease breath test, stool antigen testing, detection of antibodies – stays
positive for long time - cannot assess response to the therapy
Invasive test: endoscopy and rapid urease testing of the biopsy sample; or histopathologic
exam of the sample taken

Explain the mechanism of urease breath test:

Patent drinks solution containing labeled urea (C13), H. pylori metabolizes urea with urease and
releases water and C13O2 - carbon is labeled, when the patent exhales the CO2 – it contains
labeled C13 and we are able to detect it .

If this condition is found to be caused by bacteria, what are drugs used in treatment?
 Triple therapy: Proton pump inhibitor (omeprazole, lansoprazole), clarithromycin,
amoxicillin (or metronidazole)
 Quadruple therapy: PPI, bismuth, tetracycline, metronidazole
Wait for 1 month after finishing the therapy and perform the urease breath test to assess the
cure
 CASE 8

A 26-year-old womanis hospitalized with symptoms of fever, chills, malaise, and joint
discomfort in her hands and knees. She looks unwell, temperature is 40.4°C, blood pressure
120/85 mm Hg, pulse 100/min. She is otherwise healthy, with no significant medical history.
She smokes cigarettes and marijuana regularly, drinks several beers on weekends, and
sometimes injects heroin intravenously. Lungs are clear, abdomen is soft, and hand joints are
normal. Cardiac murmur is auscultated and heard best over the second intercostal space on
the left. On her forearms she has small nodules overlying the superficial veinsfrom injection
drug use. She is diagnosed with Bacterial endocarditis.

Which of the following is the most likely causative organism? Why?

Staphylococcus aureus; risks - IV drug use, young healthy patient; involvement of the tricuspid
valve

What is the diagnostic approach to this patient?

Major Duke’s criteria:
 Positive Blood cultures
 Cardiac ultrasound- transthoracic, transesophageal – valvular vegetations
Minor Duke’s:
 Fever, predisposing lesion, risky behavior (IV drugs), ესენიჯერარიციანრასნიშნავს:
embolic phenomena, immunologic phenomena

A 34-year-old woman is at picnic, where she has a ham sandwich and potato salad. Three
hours after the meal, she feels nauseous and throws up. The same bacteria causing the
endocarditis in the previous patient is isolated from the potato salad. How is it responsible
for this woman’s symptoms?
S. aureus enterotoxin caused food poisoning. Toxin is heat stable. Symptoms Start soon, is
gone soon. Major symptom- vomiting, sometimes diarrhea.

Another patient, a 17-year-old menstruating female develops multisystem disease with

hypotension, diffuse erythematous rash with desquamation of skin on hands and feet. Same
bacteria is responsible for her condition.What is the pathophysiologic mechanism of the
disease in this case?
S. Aureus releases toxic shock syndrome toxin1 (TSST-1) – accumulates in tampons and acts as
a superantigen and activates excessive immune response – leads to multisystem damage
a 17-year-old menstruating female develops multisystem disease with hypotension, diffuse
erythematous rash with desquamation of skin on hands and feet. Same bacteria is
responsible for her condition.What is the management of this patient?
Entirely supportive, reversal of hypotension, no antibiotics,

CASE 9

A 19-year-old woman presents for the evaluation of vaginal discharge that has progressively
increased over the past week. She is sexually active, has had four lifetime partners, takes oral
contraceptive pills, and occasionally uses condoms. On examination, she appears in no acute
distress and does not have a fever. Her abdomen is soft with moderate lower abdominal
tenderness. On pelvic examination, she is noted to have a yellow cervical discharge and mild
cervical motion tenderness. No uterine masses. A Gram stain of the cervical discharge reveals
only multiple polymorphonuclear leukocytes.

What is the most likely diagnosis? Cervicitis / Pelvic inflammatory disease

What is the most likely cause of this symptoms? Chlamydia trachomatis

If this condition goes untreated, what complication is likely?PID, Fitzhugh Curtis syndrome
(perihepaitis)
infertility, ectopic pregnancy – ask why?
What can happen in population with HLAb27 genotype? – reactive arthritis – can’t see, can’t
pee can’t bend my knee

What is the diagnostic approach to this patient?

Cervical discharge swabbing – no organism, increased WBCs, A direct DNA probe test (NAAT)

What is the treatment of this patient?For uncomplicated infections - Tetracycline,

doxycycline, erythromicine – 7 days; 1 dose of Azithromycin, longer duration for PID or other
complic. Cases.
What is the prevention of this condition? Condoms, screening of high risk groups

What other diseases can be caused by the same bacteria, but different serotypes?
C. tachomatis serogpoups A,B,C: trachoma, conjunctivitis
C. tachomatis serogpoups D –K – STD– cervicitis, urthritis, PID
C. tachomatis serogpoups L1, L2, L3 – lymphogranuloma venereum

CASE 10
7-year-old boy is brought to your office in January with the 2-day history of fever, cough, and
rhinorrhea. He complains of left ear pain since yesterday. You diagnose him with acute
bacterial otitis media

1. What is the most likely bacterial cause of his symptoms? list 2 other pathogens causing
the similar presentation
Streptococcus pneumoniae – most common, H.influenza – nontypable strains,
Moraxella catharallis
2. What is the appropriate diagnostic approach to this patient? What are the characteristic
findings on the physical exam?– otoscopy – best initial test: red, swollen bulging
tympanic membrane; Golden test to find the etiologic agent: - tympanocentesis (too
invasive, almost never done)
3. List the other conditions most likely caused by the same pathogen;
S. pneumo is the most common cause of: pneumonia, sinusitis, otitis media, one of the
most common cause of meningitis;
4. What is the most appropriate Treatment of this patient’s condition? Empiric antibiotics
that cover all most common causes: amoxicillin+ clavulanic acid – the best initial
5. Who has increased risk to develop diseases caused by this microorganism and why?
Repeated pneumococcal infections: it’s an encapsulated bacteria, removal of that kind
of bacteria is facilitated by spleen; so asplenic patients - higher risk of encapsulated
organism infection

CASE 12

A 28-year-old female presents to your office. You diagnose her with post-infectious
glomerulonephritis. Three weeks ago, she had impetigo on her forearm, which resolved
without treatment.

1. Describe the most likely presenting symptoms of post-infectious glomerulonephritis;

Hypertension, hematuria, oliguria, edema, sometimes fever, nausea, anorexia,
headache)
2. What organism is the most likely cause of her renal disease? Streptococcus pyogenes -
GAS
3. What is the underlying pathophysiologic mechanism of her current illness? – type 3
hypersensitivity = circulating antigen-antibody complexes accumulate in glomeruli and
initiate the infection
4. List the other medical conditions caused by the same organism;- s.pyogens –
pharyngitis, impetigo, scarlet fever, erysipelas, cellulitis, necrotizing fasciitis, toxic shock
syndrome; rheumatic fever;
5. What could have prevented development of this condition? – nothing 
A 22-year-old female presents with edema, hematuria, hypertension and decreased urination.
Three weeks ago, she had impetigo, which resolved without treatment. Which of the following
organisms is the most likely cause of her renal disease?
S. pyogenes
CASE 13

A 9-year-old patient develops sore throat. He has fever 38.2oC. On physical exam, Pharynx is
erythematous with purulent exudates covering posterior wall. 2 small pustules are visualized
on tonsils. Patient has tender cervical lymphadenopathy.

1. What organism is the most likely cause of this patient’s illness? -Streptococcus
pyogenes - GAS
2. What is the appropriate diagnostic approach?
Clinical findings, rapid strep testing, Throat culture – golden standard
3. What is the serious complication of this infection if it is left untreated? What is the
prevention? Describe the pathophysiology of this condition – Rheumatic fever –type 2
hypersensitivity - antibodies mistakenly attack the host tissues due to antigenic mimicry
4. Talk about major and minor Jones criteria- Major: migratory polyarthritis, carditids –
may lead to mitral stenosis most commonly, subcutaneous nodules, erythema
marginatum, sydenham’s chorea; minor: fever, ESR, CRP – elevated; Leukocytosis,
prolonged PR on ECG, previous episode of RF
5. What is the possible renal complication of this patient’s condition? Describe the
pathophysiology of this condition: post streptococcal Glomerulonephritis – Type 3
hypersensit. – antigen-antibody complexes circulate and get accumulated in the
glomerulus – initiate inflammation

CASE 14
A 5-year-old child is taken to pediatrician because of severe sore throat and fever of 4 days’
duration. Today the patient abruptly developed a skin rash. You diagnose him with scarlet
fever.

6. What is the most likely cause of this illness? Streptococcus pyogenes – GAS, What
causes skin rash?erythrogenic toxins A,B, C
1. Describe the characteristic clinical findings on the physical exam;
pharyngeal injection, swollen bright-red tonsils and tongue with discrete white exudates;
enlarged tender anterior cervical lymph nodes. Examination of the skin reveals a diffuse
erythematous rash – slightly rough, sand-paper texture. Pastia’s lines - The rash intensifies
on the neck, chest folds of axilla and groin (flexor surfaces)
2. What is the management of this condition?Penicillin or erythromycin
7. What is the possible serious complication of this infection if it is left untreated? Describe
the pathophysiology of this complication; Rheumatic fever – type 2 hypersensitivity -
 antibodies mistakenly attack the host tissues due to antigenic mimicry; previous episode
of RF
3. Talk about major and minor Jones criteria Major and minor Jones criteria - Major:
migratory polyarthritis, carditids – may lead to mitral stenosis most commonly,
subcutaneous nodules, erythema marginatum, sydenham’s chorea; minor: fever, ESR,
CRP – elevated; Leukocytosis, prolonged PR on ECG,

CASE 15

5-year-old girl is brought to the emergency room by the worried parents. The girl has been
irritable for the past 4 days.Today morning, she complained of sore throat and refused to
swallow the food during the day.On admission, she refuses to lie down supine to be examined
and is bending forward with the neck extended. She has fever of 39.7oC and is drooling.
Respiratory rate is 40 - with shallow breaths and use of accessory respiratory muscles. Pharynx
is erythematous. Her lungs are clear.
1. Based on this clinical presentation, what is your primary diagnosis? What is the most
likely causing organism?Haemphilus influenza type B - epiglotitis
2. What could have prevented development of this condition? vaccination
3. What is the best next step in the management of this child? – keep the airway patent -
intubate
4. What is the treatment of this condition? – intubation and cephalosporin - ceftriaxone
5. While managing this child, what other infectious causes should be included in your
differential diagnosis? – strep pharyngitis, diphtheria

CASE 17
A 16-month-old child is brought to the emergency room following a seizure. His mother says
that he had a cold for 2 or 3 days with a cough, congestion, and low-grade fever, but today he
became much worse. He has been fussy and irritable. He then had two grand-mal seizures. His
mother reports that he has not received all of his immunizations. On examination his
temperature is 38.1°C (100.5°F), his pulse is 110 beats per minute, and he appears very ill. He
grimaces when you try to bend his neck. His skin is without rash and his HEENT (head, eyes,
ear, nose, throat), cardiovascular, lung, and abdominal examinations are normal. His white
blood cell count is elevated, and a CT scan of his head is normal. You perform a lumbar
puncture, which reveals numerous small gram-negative coccobacilli.
1. What organism is the most likely etiology of this illness?Haemophilus influenza type B
2. What could have prevented development of this condition? vaccination
3. What other clinical presentations can be caused by the same pathogen?Epiglottitis,
cellulitis
4. What is the treatment of this condition? - ceftriaxone
5. Non-encapsulated form of this bacteria can also cause human diseases. List several of
those; - otitis media, sinusitis, exacerbations in COPD patients

CASE 18
A 14-day-old infant is brought to the pediatric emergency room by her panicked mother. The
child has developed a fever and has been crying nonstop for the past 4 hours. She has fed only
once today and vomited all of the ingested formula. The baby was born by vaginal delivery
after an uncomplicated, full-term pregnancy to a healthy 22-year-old gravida1 para1 (one
pregnancy, one delivery) woman. The mother has no history of any infectious diseases and
tested negative for group B Streptococcus prior to delivery. The baby had a routine check-up in
the pediatrician’s office 3 days ago, and no problems were identified. On examination, the
child has a temperature of 38.3°C (100.9°F), pulse of 140 beats per minute, and respiratory
rate of 32 breaths per minute. She has poor muscle tone. Her anterior fontanelle is bulging.
Her mucous membranes are moist, and her skin is without rash. Her heart is tachycardic but
regular, and her lungs are clear. Her white blood count is elevated, a urinalysis is normal, and a
chest x-ray is clear. A Gram stain of her cerebrospinal fluid (CSF) from a lumbar puncture
shows gram-positive coccobacilli.

1. What is the most likely diagnosis?MeningitisWhat organism is responsible for this

infection?Listeria monocytogenes
2. What is the most likely clinical presentation of the infection with the same organism in
the healthy adult?Mild self-limited gastroenteritis
3. What is the most likely source of infection in healthy adults?Raw mild; soft cheese
made out of unpasteurized mild, unwashed vegetables, ready to eat delicatessen meats
- hams
4. What population is under the increased risk to develop serious infection with the
same organism?Very young or very old, immunocompromised
5. What is the treatment and prevention of this infection?Treat ampicillin, prevention –
cook the food, avoid soft cheese peel the vegetables or wash it
 CASE 19
A 19-year-old man is brought to the office for evaluation of a cough and fever. His illness
began 8 days ago with low-grade fever, headache, myalgias, and fatigue. He now has a
persistent hacking dry cough. He has no significant medical or family history. No family
members have been ill recently, but one of his good friends missed several days of school
approximately 2 weeks ago with “walking pneumonia.” On examination he is coughing
frequently but is not particularly ill-appearing. His temperature is 38.1°C (100.5°F), pulse is 85
beats per minute, and respiratory rate is 22 breaths per minute. His pharynx is red; otherwise,
a head and neck exam is normal. His lung exam is notable only for some scattered rhonchi. The
remainder of his examination is normal. A chest x-ray shows patchy infiltration. A sputum
Gram stain shows white blood cells but no organisms.

1. What is the most likely diagnosis?List 3 most common causes of this condition;
1.Mycoplasma pneumonia, 2. chlamydia pneumonia, 3. legionella pneumophilla
2. What Diagnostic and lab tests are helpful in diagnosing this infection?Chest x-ray, CBC,
serologic studies,
3. Gram staining of the sputum didn’t show any organism; What is the reason of that?
Most likely its mycoplasma – which doesn’t have a cell wall to stain it with the gram
4. What is appropriate treatment of this condition? – azithromycin, doxycycline,
fluoroquinolones
5. What are the characteristic symptoms and signs of typical CAP? - The “typical” community
acquired pneumoniais described as a sudden onset of fever, cough with productive sputum, often
associated with pleuritic chest pain, productive cough sometimesrust-colored sputum. Localized
Crackles on chest auscultation and lobar consolidation on the chest X-ray. This is the classic
description of pneumococcal pneumonia

CASE 20

A 23-year-old woman presents with chills, fever and productive cough. 7 days ago she
developed nasal congestion and myalgia. She became progressively fatigued and developed
cough, productive of 1 teaspoon of yellowish sputum. Today she saw flecks of blood in it and
panicked. Medical history is remarkable only for appendectomy 2 years ago and a fractured
humerus 15 years ago.On physical exam, she has fever – 39.1°C. Head and neck exam is
normal. Crackles are heard on pulmonary auscultation.

1. Based on the information given, what is the most likely diagnosis? List 4 most
common bacterial causes of this condition;
 Community-acquired pneumonia (CAP)
1. S. pneumonia
2. C. pneumonia
3. M. Pneumonia
4. L. Pneumophila
 2. What are the characteristic symptoms and signs of this condition?
 The “typical” pneumoniais described as a sudden onset of fever, cough with productive sputum,
often associated with pleuritic chest pain, and possibly rust-colored sputum. Localized Crackles on
chest auscultation and lobar consolidation on the chest X-ray. This is the classic description of
pneumococcal pneumonia.
 The“atypical” pneumonia is characterized as having a more insidious onset, with a dry cough,
accompanying extrapulmonary symptoms such as headache, myalgias, sore throat, absent or mild
findings on chest auscultation and a chest X-ray that appears much worse than the auscultatory
findings. This type of presentation usually is classic to Mycoplasma pneumoniae.
 Although these characterizations are of some diagnostic value, it is very difficult to reliably distinguish
between typical and atypical organisms based on clinical history and physical examination alone.

3. What Diagnostic and lab tests are you going to order? Which test is considered to
be the “golden test” for to find the causing organism?
Best initial test – Chest X-ray - gives you characterization (lobar, interstitial), location of inflammatory
process (right middle lobe, Left upper lobe, etc.), presence or absence of pleural effusion. (CT scan is even
more informative, but rarely needed)
 Microbiologic studies - sputum Gram stain and culture - important to try to identify the specific
etiologic agent causing the illness – Most cases are diagnosed using this method. However, use of this
method is limited by the frequent contamination by upper respiratory flora. Blood cultures can also be
helpful - 30% to 40% of patients with pneumococcal pneumonias are bacteremic.
 Serologic studies - to diagnose organisms not easily cultured - Legionella, Mycoplasma, or C
pneumoniae.
 Nonspecific helpful lab tests that gives you information about the general condition of the
patient:CBC – elevated PMNs, liver and kidney function tests, serum electrolytes,
 Fiberoptic bronchoscopy with bronchoalveolar lavage often is performed in seriously ill or
immunocompromised patients
Gold Standard test for etiologic diagnosis = biopsy of the lung tissue and culturing the specimen –
invasive;done in very complicated cases that does not respond to standard antimicrobial therapy

5. What is the treatment of this condition?

For outpatients without comorbidities - macrolide (azithromycin) or doxycycline - gives adequate coverage
For outpatients withcomorbiditiesgood choices for treatment of S pneumoniae, Mycoplasma, and other
common organisms:
1. Combination of macrolide with beta-lactam antibiotic OR
2. Anti-pneumococcal quinolones, such as moxifloxacin or levofloxacin

Hospitalized patients with community acquired pneumonia:

1. usually are treated with an intravenous third-generation cephalosporin plus a macrolide OR
2. antipneumococcal quinolone - moxifloxacin or levofloxacin
 6. What population has an increased risk of repeated infections with this organism?
What is the prevention?
Asplenic patients, smokers, alcoholics, liver disease - vaccinate

CASE 21
A 31-year-old man presents to the emergency room with 2 days of crampy abdominal pain
relived by defecation, nausea, and diarrhea. He has not had any blood in his stool. He denies
contact with anyone with similar symptoms recently. The only food that he did not prepare
himself in the past week was scrambled eggs and bacon that he had at a diner the day before
his symptoms started. On examination, he is tired appearing; his temperature is 37.7°C
(99.9°F); and his heart rate is 120 beats per minute when he sits up. His blood pressure is
110/60 mm Hg when sitting. His mucous membranes appear dry. His abdominal exam is
notable for diffuse tenderness but no palpable masses, rebound, or guarding. A rectal exam
reveals heme-positive stool containing flecks of mucus.
1. What is the most likely etiologic agent of this infection?Shigella
2. dysentria type 1- hus ,watery diarrria

3. List at least 3 other microorganisms causing the similar presentation: campylobacter,

shigella, salmonella, E. coli
4. What is the diagnostic approach to this patient? Based history and clinical findings,
stool testing for WBCs, blood, bacteria, CBC, electrolytes
5. What is the management of this patient?Supportive – fluids, electrolytes; antibiotics for
severely ill patients ciprofloxacin
6. What is the prevention of this infection?Adequately cooking the food, washing hands
thoroughly while handling the food

CASE 22
A 16-year-old male presents with progressive weakness of the legs two evenings before
admission. He has a history of a diarrheal illness 2 weeks prior. On examination, he has
moderate leg and mild arm weakness; Respiratory function is normal. His muscle reflexes are
diminished in arms and absent in lower extremities. Mental status is clear;
1. What is the most likely diagnosis? Guillian-barre syndrome
2. Describe the underlying pathophysiologic mechanism of this presentation; antibodies
mistakenly attack and destroy the myelin – weakness and paralysis results
3. What microorganism is the most likely cause of his current condition? Campylobacter
jejuni
4. What is the most likely food source that this patient ingested?Poultry, meat
5. What is the appropriate management of this patient?If necessary intubate,
plasmapheresis, IV IG
 CASE 23

A 20-year-old female is hospitalized with severe symptoms of hemolytic uremic syndrome. Her
medical history is significant for diarrheal disease that started 3 days prior to development of
her current symptoms.

1. What microorganism would most likely be isolated from a stool specimen?

Enterohemorrhagic E coli (shiga-toxin producing E. coli – STEC) 0175:07;
2. List the most likely sources that this patient got infected from; poorly washed
vegetables – cucumbers, lettuce, spinach,ham burger
3. Explain the underlying pathophysiologic mechanism of her current condition inhibit
protein synthesis of cell binding to Gb3 receptor.
4. Describe the symptoms and signs of hemolytic uremic syndrome; hemolytic
anemia,thrombocytopenia,acute kidney disease.
5. What is the appropriate management of this patient? Fluids and electrolytes
azitromycin,fluroquinolone

CASE 24
A 30-year-old traveler drinks glass of fresh orange juice that he bought in the street while
sightseeing Nepal. Next day he develops watery diarrhea accompanied by severe crampy
abdominal pain. He has no fever; no blood or mucus is seen in his stool. He is symptom-free in
3 days.

1. What is his most likely diagnosis? Traveler’s diarrhea

2. This presentation is typical for which microorganism? ETEC – enterotoxigenic e.coli
3. What is the underlying pathophysiologic mechanism of diarrhea in this case? Bacteria
produces 2 toxins: heat-stable toxin – fluid secretion in jejunum and ileum and heat-labile
toxin – structurally similar to cholera toxin
4. What is the appropriate management of this patient? Supportive – fluid and electolytes

1. What is the most likely diagnosis of this child? What microorganism can be the cause
of this presentation? Congenital syphilis – treponema pallidum
2. Although not seen in this child, what are the other findings also associated with the
same disease? Early signs – rhinitis – snuffles,
3. What could have prevented this presentation in this child? Screening and treatment of
mother during pregnancy
4. What is the clinical course of the infection with this microorganism if it infects an
adult? Stage 1 chancre – painless ulcer on genitals; painless inguinal lymphadenopathy;
stage 2 – papulosquamous generalized rash, condyloma lata, generalized
lymphadenopathy; latent syphilis; tertiary syphilis: neurosyphilis, cardiovascular, or
gummatous syphilis
 5. What is the treatment of this infection in an adult? Penicillin -1st choice, doxycycline in
allergic patients, in pregnancy or neurosyphilis – penicillin; if allergic to penicillin,
desensitize and give penicillin

Case 30

A 3-year-old boy presents with “barking” cough and fever. The cough started suddenly in the
middle of the night. On physical examination, the patient’s temperature is 38.5°C and he
appears frightened and anxious. He has a heart rate of 160 beats/min and a respiratory rate of
36/min. His breathing is labored and he is using his accessory muscles of respiration. Marked
inspiratory stridor is audible. Lung examination is unremarkable.

1. What is the diagnosis ? respiratory virus infection

2. Which of the most likely viral cause of his symptoms? Parainfluenza virus, croup,
3. What is the management of this patient? Ribavirin , CROUP bed rest,
ventilation,glucocorticosteroid.
4. Symptom croup,sore throat,fever,bronclitis,fever,coryza,horseness,barking cough
5. Diagnosis? Throat swab or nasopharyngeal washing, RT PCR, ELISA.
6. Types: 1croup laryngotracheobronchitis in children
2 similar but mild
3 bronchiolitis and pneumonia in infants.

An 11-year-old boy attending summer camp develops sore throat, headache, fatigue and
bilateral conjunctivitis. He is seen by the camp medical staff and on examination is found to
have a slight fever of 37.8oC but no rash. Within the next 2 days, several of the other campers
develop similar symptoms.

1. What is the most likely cause of this infection? Adenovirus ( pharyngoconjuntival

fever)

2. How is this infection spread? Contaminated objects, fluid secretions in camps

 3. What is the diagnostic approach to this infection? Throat swab, RT PCR, ELISA

4 What is the treatment of this infection? Supportive nsaids and antipyretics.

5 What is the best action to prevent the spread vaccination, maintain hygiene.

NP is a 29-year-old female from Tbilisi, Georgia presenting to the Emergency Department in

January with 1-day history of fever, myalgia, and rhinorrhea. Her symptoms are continuous,
steadily getting worse. She is having significant nasal discharge but no cough. She has no
significant past medical history, and takes no medications. 2 of her co-workers have skipped
the work recently due to high fever. Her review of systems is significant for fever, lethargy,
nasal discharge, shortness of breath, and severe muscle soreness. On the physical exam, she is
a well-nourished young woman who is in moderate distress; Skin is warm, flushed and
diaphoretic; Pulmonary exam reveals mild wheezing, no crackles are auscultated; Abdominal
and Cardiac exams are within normal limits; Mild tenderness upon palpation of extremities;
Temperature is 39.4oC, Heart rate is 105 bpm; blood pressure is 120/76 mm Hg; respirations
25/min;

1. What is the most likely causing organism of this patient’s symptoms? Influenza virus
Discuss the epidemiology and pathogenesis of this illness; childrens,old
adults,immunocompromise patients…. Airbourne droplet, cytokine IL 1,IL6, TNF ,INF
IL8

2. List the available diagnostic approaches for this disease; throat swab,RT PCR,rapid
influenza test

3. What is the appropriate management of this patient?antiviral zanamivir-

neuraminidase inhibitor

4. Discuss the mechanisms of action of available medications –amantadine –block

NMDA receptor

5. What are the possible complications of this illness? Pneumonia,cardiovascular disease,

pregnancy complications

6. What is the prevention of this infectious disease? annual vaccine.

A 20-year-old student presents to you in Januaryfor evaluation of her respiratory symptoms. 3
days ago, she developed nasal congestion and clear rhinorrhea accompanied by sneezing. Next
day she woke up with malaise and scratching sensation in her throat. Today on physical exam,
the patient is in no acute distress, but notes fatigue; Head and neck exam is within the normal
limits, pharynx is nonerythematous. Her temperature is 37.20C. Lungs are clear.

1. Based on this clinical presentation, what is the most likely diagnosis? Common cold

2. What organism is the most likely cause of her illness? Rhino virus

3. How did this patient most likely got infected? Respiratory droplets.

4. Although rarely done, what diagnostic approaches are available to detect the causing
agent? Rhinovirus RNA by PCR, throat swab.

5. What is the management of this patient? Antipyretics and antihistamins

6. The patient wants to know about the effects of vitamin C and amoxicillin for her
symptoms. What is the adequate response? These are infective in rhinovirus.

A 20-month-old boy developed fever and irritability 3 days ago. Mother brought the child to
your office today, because of appearance of erythematous rash. On the physical Exam now,
the boy is tired and ill-appearing, he has fever of 38.7oC. Bilateral redness of conjunctiva and
tearing is noted. There is a brick-red maculopapular rash present on the face and trunk.
According to mother, the rash started on the forehead and spread down and out.

1. According to the physical exam findings, what is the most likely diagnosis? measles
What is the pathognomic feature of this illness? Ability to cell to cell fusion

2. Compare similarities and differences between this patient’s illness and other
infectious agents, that should be in your differential diagnosis;
mump and rubella [ in mumps bilateral parotitis and in rubella lymphadenopathy

3. What diagnostic tests are available to make the etiologic diagnosis?

 4. Throat swab,serologyigM rise 4 times, rt-pcr.

5. What is the treatment of this boy’s illness?antipyretic, plenty of fluids,vitamin a

6. What could have prevented development of this infection? Mmr vaccine, 1 dose at 6-
15 months, 2 dose at 4-6 year

A 8-year-old boy is brought to your office for evaluation of fever, ear pain, and swollen cheeks.
His mother reports that he’s had 4 days of low-grade fever and seemed tired. Yesterday he
developed the sudden onset of ear pain and swelling of the cheeks along with a higher fever.
He is an only child, and neither of the parents has been ill recently. He has had no significant
medical illnesses in his life, but his parents decided not to give him any vaccines because they
read that it could cause autism. On examination, his temperature is 38.6°C (101.5°F), and his
pulse is 108 beats per minute. He has swollen parotid glands bilaterally to the point that his
earlobes are pushed up, his tympanic membranes appear normal. Opening his mouth causes
pain, but the pharynx appears normal. He has bilateral cervical adenopathy.

1. What is the cause of this child’s illness? mumps

What is the prognosis? Uncomplicated mumps resolve,for meningitis

good,deafness,facial paralysis.

2. What diagnostic approach can be used?clinical finding,CSF for meningitis,RT PCR,

ELISA

3. What is the best prevention of this infection? Mmr vaccine

4. List the possible complications of this illness;

meningitis,encephalitis,prostatitis,pancreatitis,pneumonia.

5. What is the appropriate management of this child? antipyretic, fluid, apply ice pack.
Finally vaccine.

A 19-year-old woman presents for the evaluation of vaginal discharge that has progressively
increased over the past week. She is sexually active, has had three lifetime partners, takes oral
contraceptive pills and occasionally uses condoms. On examination, she appears in no acute
distress and does not have a fever. Her abdomen is soft with moderate lower abdominal
tenderness. On pelvic examination, she is noted to have a yellow cervical discharge. No uterine
masses. A Gram stain of the cervical discharge reveals multiple polymorphonuclear leukocytes.

1. What is the suspected diagnosis?cervicitis What are the most likely causes of her
symptoms?
2. Chlamydia and gonococcal

3. What is the diagnostic approach to this patient? Vaginal swab,PCR,ELISA,NAATS.

4. If this condition goes untreated, what complications are likely? May spread to uterus
and fallopian tube resulting in PID which may cause infertility.

5. Discuss the clinical course of at least 4

complications;INFERTILITY,HIV,PID,urethritis,reactive arthritis.

6. What is the treatment of this condition? Doxacyclin,erythromycin,tetracycline or

single dose azitromycine.

7. What is the prevention of this condition? Protective sex,use condoms,screening.

A 16-year-old female comes to your office for evaluation of a sore throat and fever. Her
symptoms started approximately 1 week ago and have been worsening. She has been
extremely fatigued for the last. She denies any ill contacts. She has no significant medical
history, takes no medications, and has no allergies. On examination, she is tired and ill
appearing. Her temperature is 38.5°C. Examination of her pharynx shows her tonsils to be
markedly enlargedand erythematous. She has prominent cervical adenopathy, which is mildly
tender. A cardiovascular examination is normal, and her abdomen is soft, nontender, mild
hepatomegaly is palpated.

1. What is the most likely diagnosis of this patient? Infectious mononucleosis

What is the most likely cause of her infection?EBV (cervical adenopathy, hepatomegaly)
 2. How is this agent transmitted? Oral contact kissing, respiratory droplets.

3. what cells in the host does it infect? B cells

4. What is the diagnostic approach to this patient? CBC-WBC elevated, serology-

heterophil antibody test-sheep RBC , EBV antibody testing.

5. What is the appropriate management of this patient? Supportive , corticosteroids,

avoid splenic rupture.

6. List other conditions associated with the same infectious agent; burkitts lymphoma,
hodgkins disease, gastric carcinoma,hairy cell luekmia.

A 15-year-old girl presents to her pediatrician with fatigue and a sore throat of severalweeks’
duration. She says that she is still able to attend classes at her high school butfalls asleep as
soon as she gets home. She has never had anything like this before but notes that one of her
close friends has missed school recently. On physicalexamination, her vital signs include a
temperature of 38.6° C, heart rate of 72/min, blood pressure of 120/75 mm Hg, and
respiratory rate of 14/min. Her throatis markedly erythematous with occasional exudates on
the tonsils. She has tenderposterior cervical lymphadenopathy bilaterally. Mild
hepatosplenomegaly is palpated on abdominal exam. Theremainder of her exam is within
normal limits. A peripheral blood smear revealsatypical lymphocytosis.

What is the most likely diagnosis? EBV

What is the pathogenesis of this condition? ATTACK on B cell of immune system

What tests could be used to confirm the diagnosis? Wbc elevated, heterophil antibody test ,
EBV antibody test- shows IgM .

What is the most appropriatemanagement for this condition? Supportive ,acyclovir.

What are the potential complications of this condition? / What other conditions are
associated with the same virus? Burkitt lymphoma, hodking diease, gastric
carcinoma.anaphylactic nasopharyngeal carcinoma.
n

You are called to examine a 1-day-old male because the nurse is concerned that he is
jaundiced. He was born by spontaneous vaginal delivery to a 21-year-old
gravida1 para1 after a full-term, uncomplicated pregnancy. The mother had no illnesses during
her pregnancy; and the only medication that she took was prenatal vitamins. There is no
family history of genetic syndromes or illnesses among children. The infant is mildly jaundiced
and has several petechias over his abdomen. Inspection is notable for an abnormally small
head circumference (microcephaly). His cardiovascular examination is normal. His liver and
spleen are enlarged. There is no startle response to a loud noise. CT scan of his head reveals
intracerebral calcifications.

1. What is the most likely cause of this infant’s condition? CMV

2. How did he likely acquire this infection? Through vaginal delivery

3. What is the most common presentation of infection with the same agent in a healthy
adult? CMV mononucleosis- elevated aminotrasferase,splenomegaly,leukocytosis.

4. What is the presentation of infection with the same agent in an immunocompromised

host? Colitis,ulcers,hepatitis,cholecystitis ,rhinitis,DIC

5. What are the diagnostic methods both in infants and adults? CMV DNA by PCR ,
serology, culture.

6. Treatment? Antiviral-Ganciclovir,valaganciclovir or foscarnet.

7. Prevention- prophylaxsis of CMV, safe sex.

a 3-year-old girl is brought to your office by concerned mother. The girl has “warts" around her
mouth and it seems that they cause pain. On examination you see a well appearing child. She
has fever of 37.6oC. There is a cluster of small vesicles with a faint area of surrounding
erythema around the right upper corner of her mouth. Some of the blisters are ruptured with
yellow crusts stuck on the skin surface. The remainder of the child's examination is normal.

1. What virus is the most likely cause of this skin lesion? What is the prognosis of her
illness?hsv 1 , good prognosis.

2. Discuss the life cycle of the infectious agent; site of latency is trigeminal ganglion
where this virus replicate and future cause complication.
 3. List the other illnesses associated with this virus other symptoms are: keratitis ,
gingivostomatitis, encheplitis.

4. What are the diagnostic approach to this infection?Tzank smear {gaint cells
apperence} confirmatory is PCR of CSF, MRI for encephalitis, clinical evaluation.
What is the treatment of this infection? Acyclovir, vancyclovir, famciclovir for 10-14 days. In
resistance case use penciclovir

A 63-year-old man comes to your office for the evaluation of lower back pain. For the past 3
days, he has had a sharp, burning pain in his left lower back, which would radiate to his flank
and, sometimes, all the way around to his abdomen. The pain comes and goes, feels like an
“electric shock,” and is unrelated to activity. He has had no injury to his back and has no
history of back problems in the past. He denies fever, urinary symptoms, or gastrointestinal
symptoms. His examination today, including careful back and abdominal examination, is
normal. You prescribe a nonsteroidal anti-inflammatory drug for the pain relief. The next day,
he returns to your office stating that he has had an allergic reaction to the medication because
he’s developed a rash. The rash is in the area where he had the pain the day before. On
examination now, he has an eruption consisting of patches of erythema with clusters of
vesicles extending in a dermatomal distribution from his left lower back to the midline of his
abdomen.

1. What is the diagnosis of this patent? What infectious agent is cause of this rash?
Reactivation zoaster, hhv3
2. What is the underlying pathophysiologic mechanism of this infectious agent causing
the disease in this patient? Latent is dorsal root ganglion and trigeminal ganglion t3 to
l2.

3. Describe the clinical features of primary infection with the same infectious agent;
primary infection are macular eruption ,papules,vesicle, pistular, crust. Last 20 days.

4. What is the diagnostic approach to this patient? Tzank smear [ giant cell]
Confirmatory serology and culture.
5. What is the management of this patient? What is the prevention of this condition?
Symptomatic or acyclovir, vancyclovir, famciclovir
6. Prevention with2 doses of live attenuated vaccine varicella.
A 24-year-old woman presents complaining of 2-days of itchy vaginal discharge. One week ago
you treated her for a urinary tract infection (UTI) with sulfamethoxazole and trimethoprim
(SMX-TMP). She completed her medication as ordered and developed the vaginal discharge
shortly thereafter. She denies abdominal pain, and her dysuria has resolved. She is not
currently taking any medications. On examination, she is comfortable appearing and has
normal vital signs. Her general physical examination is normal. A pelvic examination reveals a
thick, curd-like, white discharge in her vagina that is adherent to the vaginal sidewalls. There is
no cervical discharge or cervical motion tenderness, and bimanual examination of the uterus
and adnexa is normal.

1. What is the diagnosis? What is the most likely cause of this patient’s symptoms?
Vaginitis cause by candida albican,

2. What are the risk-factors that predispose patients to develop this condition? Recent
antibiotic use, pregnancy , poor hygyien, diabeties mellitus

3. What is the diagnostic approach for this patient’s symptoms?

Koh wet mount, culture,tissue biopsy.

4. What is the appropriate management of her symptoms?fluconazole and ampoterecin

b

5. List the other infections caused by the same infectious agent;

Oral thrush , cutaneous infection , oesophagitis, septicimea,

endocarditis, gastritis

A 32-year-old man with known HIV is brought to the hospital with respiratory distress. He
describes increasing shortnessof breath over the past 2 weeks with a nonproductive cough. On
physical examination,he is a thin and ill-appearing man in respiratory distress. He is notably
using his accessory muscles to breathe. Vital signs include a temperature of 38.3° C (101.8°
F),heart rate of 122/min, blood pressure of 122/66 mm Hg, respiratory rate of 34/min,and
oxygen saturation of 84%. Auscultation of the lungs reveals bibasilar crackles withrelatively
clear middle and upper lung fields. His oral cavity reveals a white film on his tongue and buccal
mucosa.

1. What is the most likely diagnosis? Pneumocytis jirovecii

 2. What risk factors are associated with an increased incidence of this condition? Hiv
infection cause decrease cd4 count.

3. Below what CD4 count is this condition common? , <200/l remain for three months

4. What prophylactic treatment is generally administered in such patients? Tmp smx, doc
cotrimoxazole + streroids

5. This patient’s CD4 T cell count is found to be 45 cells/mm 3. List the opportunistic
pathogens that this patient has an increased risk of; CMV,mycobacterial avium
infection

6. Diagnostic test –broncho-alveolar lavage, PCR, biopsy , ELISA, lactate dehydrogenase

elevated.

A 38-year-old woman with chronic asthma presents for evaluation of a cough.

She has a history of asthma for most of her life and is managed with inhaled bronchodilators
and inhaled steroids. 3 days ago, she developed a cough productive of brown mucous and,
occasionally, blood. She has a low-grade fever as well. Her asthma control has been
significantly worsened since she developed the cough. On examination, she has a temperature
of 37.7°C and a respiratory rate of 22 breaths per minute, and her saturation of oxygen is
slightly low (96% on room air). She is coughing frequently. Her head and neck exam is
unremarkable. Her pulmonary examination is notable for diffuse expiratory wheezing. A chest
x-ray shows a lobular infiltrate that is reminiscent of a cluster of grapes. A complete blood
count (CBC) shows a mildly elevated white blood cell count with a markedly elevated
eosinophil count. A microscopic examination of her sputum is also notable for the presence of
numerous eosinophils. Her IgE levels are strikingly high. You suspect fungal etiology of her
worsened symptoms.

What is the most likely diagnosis? aspergillosis

What fungus is most likely causing her symptoms? Aspergillus fumigates

Describe the morphologic characteristics of this fungus; colour of steps - grey around apex,
smooth surface, small columnous globuse

What are the risk factors for acquiring this fungus?

Neutropenia, long- term corticosteroid therapy, AIDS, Organtransplant.

List different forms of disease caused by the same fungus; invasive aspergillosis, allergic
bronchopulmoary aspergillosis, superficial aspergillosis, endocarditis , chronic
granulomatous sinusitis

List the helpful diagnostic approaches to diagnose infection with this fungus positive culture
and sputum culture, CXR – halo sign, aspergillus antigen test, biopsy of nodules
Tx- voriconazole OR amphotericin B,
Prevention – discountinuation of corticosteroid therapy

A previously unvaccinated nurse incurs a needle stick from a patient with known active
hepatitis B infection.

1. What is the appropriate management for the health care worker? Single dose hep b
immunoglobulin +3 doses of hep vaccine within 1 week of exposure.

2. What are the symptoms and signs of acute viral Hepatitis? Jaundice,abdominal
pain,dark urine,headache,fatigue.

3. What viral proteins are used for serologic diagnosis of HBV infection?envelop antigen
antibody, Hepatitis B surface antigen, Hepatitis B surface antibody, hepatitis B core
antibody.
4. What are the transmission routes of HBV? Sharing needles,sexual
contact,transplacental,blood transfusion.

5. What are the complications of HBV? Fulminant hepatitis, serum sickness like
syndrome, chronic hepatitis.

6. What is the prognosis of the HBV infection? Is good 95% recover,only 5% ptns goes to
cirrhosis if left untreated. Give entecavir or tenofovir.
A 59-year-old male presents to your office for follow-up of some abnormal blood test results.
His liver enzymes are elevated by approximately three times the upper limits of normal. The
patient denies alcohol or drug use and is not taking any medications. He gives no history of
jaundice. His past medical history is significant only for hospitalization at the age of 35 for a
bleeding stomach ulcer. He required surgery and transfusion of 5 units of blood. His physical
examination is normal: it shows no signs of jaundice, no hepatosplenomegaly, and no findings
suggestive of portal hypertension. You suspect an infectious etiology;

1. What is the most likely infectious cause of his abnormal liver function tests?
Hepatitis c virus

2. How did he most likely acquire this infection? Blood transfusion from past past history

3. Discuss the epidemiology of this infectious agent: What are the transmission routes,
what population is under increased risk of having this infection, who needs
4. to be screened-organ transplant ptn , health care worker.What is the prevention- safe
sex,use of double gloves by HCW. Avoid needle ingection in drug abuser.
5. 90% by transfusion.hemodialysis,injection drug user,organ transplant.

6. Describe clinical course characteristic to the suspected infectious agent; infection

leads to chronic liver disease.

7. Treatment-sofosbuvir/ledipasvir, Grazoprevir

8. What diagnostic tests are you going to order to find out the exact cause of his
abnormal liver function tests? Anti hep c assay, HCV RNA PCR.

A 26-year-old man comes to your clinic complaining of a 5-day history of nausea, vomiting,
diffuse abdominal pain, fever and muscle aches. He has lost his appetite, but he is able to
tolerate liquids and has no diarrhea. He has no significant medical or family history, and he
has not traveled outside the country. He admits to having 12 different lifetime sexual
partners, denies illicit drug use, and drinks alcohol occasionally, but not since this illness
began. He takes no medications. On examination, his temperature is 38°C °F, heart rate 98
bpm, and blood pressure 120/74 mm Hg. He appears jaundiced, his chest is clear to
auscultation, and his heart rhythm is regular without murmurs. His liver percusses 4 cm
 below the costal margin and is smooth and slightly tender to palpation. He has no abdominal
distention or peripheral edema. Laboratory values are significant for a normal complete
blood count, creatinine 1.1 mg/dL, alanine aminotransferase (ALT) 3440 IU/L (normal: 7 - 55
U/L), aspartate aminotransferase (AST) 2705 IU/L (normal: 8 - 48 IU/L), total bilirubin 24.5
mg/dL (normal: 0.1 - 1.2 mg/dL);

1. What tests are going to order to find the exact infectious cause of your patient’s
disease? Explain why;
serological tes t =

Recovery phase - HBsAb+ve, anti HBc IgG +ve

Chronic phase- HBsAg +ve upto 6 months, anti HBeAg +ve

Window phase-anti hbc + ve

Vaccinated – HbsAb +ve and anti HBc –ve.

Discuss the transmission modes and prognosis for each possible infectious cause of this
patient’s symptoms:

2. Hepatitis A fecal -oral 100 percent recovery

3. Hepatitis B sexual transmission , mother to fetus. Less by transfusion 90

percent recovery 5percent chronic
4. Hepatitis C blood transfusion , iv drug abuser. Less by trans placentally. 85
percent chronic
5. Hepatitis E fecal oral 100 percent
Treatment – entcavir , tenovofir other are interferon alf, lemivudine, adenofovir.
Prevention hbv ig g with in 48 hour.