STUDY QUESTIONS FOR

PARASITOLOGY AND ZOONOSES

MARVIN J. BITTNER MD

1. A 23-year-old student returns from a one-week trip to Managua, Nicaragua. Most of the
trip was spent in visiting impoverished communities in Managua. The student feels well,
but is concerned that he might have acquired a parasitic infection. An examination of his
stool reveals structures somewhat resembling white blood cells. An experienced
laboratory technologist identifies them as Entamoeba dispar. What should you do?
A. Do not treat
B. Examine two more stool specimens before treating
C. Treat with metronidazole
D. Treat with a lumenal agent
E. Treat with metronidazole and a lumenal agent
ANSWER A. Do not treat. Entamoeba dispar designates nonpathogenic amebas. No
treatment is required. Metronidazole is the drug of choice for extraintestinal amebiasis.
However, an individual with intestinal amebiasis requires a so-called “lumenal agent,” with
activity against amebas in the bowel.

2. A 30-year-old man returns from a two-week hiking trip in southern Africa. About two
months after his return, he seeks medical attention because of malaise and fever.
Eosinophilia is present. Examination of his stool reveals some 60 x 140 micron eggs with
large lateral spines. You are concerned about an infection that ultimately could result in:
A. Bladder damage with hematuria
B. Cirrhosis of the liver
C. Lung cysts
D. Cerebral cysts with seizures
ANSWER B. Cirrhosis of the liver. These eggs are characteristic of Schistosoma mansoni,
which is found in southern Africa, among other sites. Eosinophilia is consistent with your
hypothesis of helminthic infection, as well. The characteristic chronic target organ of S.
mansoni is the liver, where eggs stimulate an inflammatory response resulting in cirrhosis. S.
haematobium causes bladder disease. The lung fluke Paragonimus westermani causes lung
cysts. Cerebral cysts with seizures are typical of neurocysticercosis due to ingestion of pork
containing Taenia solium. Because S. mansoni is a common pathogen on a worldwide basis,
a variety of unusual manifestations of infection may occur; but the characteristic lesion is
cirrhosis.

3. The patient in the previous question asks how his infection might have been prevented.
You suggest:
A. Take mefloquine
B. Get immunized
C. Wear shoes
D. Don’t swim
ANSWER D. Don’t swim. Schistosomiasis is acquired by contact of the skin with freshwater
containing cercaria released from infected snails. Avoiding swimming in fresh water (unless
you find out that a particular body of water is free of schistosomiasis) is recommended.
Mefloquine prevents many cases of malaria. Immunization prevents some disease, but there
is no schistosomiasis vaccine. Wearing shoes would protect the skin from terrestrial parasites
that penetrate the skin.
 4. A 23-year-old man seeks medical attention because of 2 weeks of back pain and malaise,
accompanied by paroxysms of chills and fever occurring every 48 hr on a regular basis for
the past week. He has taken no medications. He was previously in good health and had
traveled to Haiti to visit a missionary friend three weeks ago. Evaluation elsewhere,
including an automated complete blood count with differential, CT scan of the spine, and
blood cultures, was remarkable only for anemia and thrombocytopenia. You look at a
Giemsa-stained blood smear and see red cells that consist almost entirely of banana-
shaped pigment. About a third of his other red cells have other abnormalities. They are
ring-shaped. Some red cells have several ring-shaped lesions. You conclude that his
illness:
A. Is potentially fatal
B. Would not have occurred if he were Duffy antigen negative
C. Would not have occurred if he had sickle cell trait
D. Is affecting only his older red blood cells
ANSWER A. Is potentially fatal. Malaria is endemic to Haiti, and the patient reports no
medications that might have prevented it. His history of febrile illness after travel to a malaria-
endemic region raises the possibility of malaria. The pattern of fever seen every 48 hr does
not always occur in malaria. But this so-called tertian fever pattern is characteristic of
Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale. However, P. ovale is rare
outside of west Africa. Anemia and thrombocytopenia are characteristic of malaria. One
would hope that an automated differential count would detect abnormalities and lead to manual
examination of a blood smear. However, according to the history, no manual examination was
done elsewhere. Your manual examination of the smear reveals the banana-shaped
gametocytes characteristic of P. falciparum. Other P. falciparum characteristics are:
involvement of more than a few percent of his red cells and multiple parasites within a red cell.
Thus, this is a typical presentation of P. falciparum malaria. This is the deadliest form. It is
potentially fatal and requires immediate treatment. P. vivax malaria does not occur in Duffy
antigen negative individuals; instead, they (and everyone else) are susceptible to P. ovale.
Sickle cell trait provides some protection against P. falciparum malaria. However, this is by no
means absolute. People with sickle cell trait need to take malaria avoidance measures. P.
malariae affects only older red cells. P. ovale and P. vivax affect younger cells. P. falciparum
affects cells of all ages.

5. In the previous question, this illness was acquired from exposure to:
A. Ticks
B. Aedes mosquitos
C. Anopheles mosquitos
D. Tsetse flies
E. Reduviid bugs
ANSWER C. Malaria is transmitted by female Anopheles mosquitos. Ticks transmit a variety
of pathogens, including Rocky Mountain Spotted Fever. Aedes mosquitoes transmit dengue
fever and yellow fever. Tsetse flies transmit Trypanosoma brucei, the agent of African
trypanosomiasis, or sleeping sickness. Reduviid bugs transmit Trypanosoma cruzi, the agent
of Chagas disease.

6. In the previous question, the reservoir of this illness is:

A. Snails
B. Squirrels
 C. Pigs
D. Humans
ANSWER D. Humans. Malaria parasites tend to be species specific. So the reservoir for
malaria consists of other acutely infected humans as well as those semi-immune humans
with chronic infection. Snails are the reservoir for schistosomiasis. Squirrels and other
small rodents are the reservoir of Rocky Mountain Spotted Fever. Pigs may harbor
tapeworm (Taenia solium) or Trichinella.

7. Evaluation of a 23-year-old man who returned from a two-week visit to a missionary in

Haiti is centered around his complaint of abdominal discomfort and nausea, Examination
of stool reveals oval-shaped eggs without any apparent structures in the centers. The
borders of the eggs are undulated. He had reported seeing “earthworms” in his stool. He
could have avoided this illness by:
A. More rigorous food preparation
B. Wearing shoes whenever walking
C. Not eating pork
D. Not swimming
ANSWER A. The clinical picture is consistent with a so-called wormball resulting from a
heavy burden with Ascaris lumbricoides, an intestinal roundworm. The report of passage of
worms in the stool is consistent with this as is the description of the eggs. Ascaris transmitted
by ingestion of fecally contaminated food. Wearing shoes would have prevented skin
penetration by hookworms like Ancycostoma duodenale and Necator americanus. But the
presentation of hookworm is classically anemia. Not eating pork would have prevented
trichinellosis or infection with the pork tapeworm Taenia solium. However, this would not
protect against infection from eating food other than pork, which might have been the source of
his Ascaris. Swimming in freshwater may pose a risk of schistosomiasis.

8. An 18-year-old man seeks medical attention for bloating and diarrhea. His stool is greasy
but not bloody. He was previously in excellent health and took no medications. He
reports sex with men, including oral contact with his partner’s anus. Microscopic
examination of a fresh specimen of his stool discloses motile cells that resemble faces
with whiskers. Two large eye-like structures can be seen as well as strands that
constitute the whisker-like structures. What therapy do you recommend?
A. Ciprofloxacin
B. Metronidazole
C. Mebendazole
D. Albendazole
ANSWER B. Metronidazole. The symptoms are characteristic of the diarrhea related to
malabsorption that Giardia lamblia can cause when its presence on intestinal microvilli reduces
available absorptive surface. In particular, giardiasis is not enteroinvasive, so fecal blood is
not seen. Giardia lamblia is acquired through oral ingestion. This can occur through ingestion
of contaminated food and water or, as in this case, through direct oral contact with fecal
material from a sex partner. Microscopic examination shows organisms with characteristics of
Giardia, including flagella and motility. Metronidazole is the treatment of choice. Ciprofloxacin
is useful in many bacterial diarrheas. Mebendazole is useful for intestinal helminths like
Ascaris. Albendazole is useful for tapeworms like the pork tapeworm Taenia solium.

9. An 80-year-old man developed temporal arteritis and was begun on high-dose steroid
treatment. Several days into therapy, he developed abdominal pain, diarrhea, and
 wheezing. He also notices itching near his anus, where you see raised, serpiginous
lesions. Previously he had been in excellent health on no medications. 60 years earlier,
he was a prisoner of war of the Japanese in southeast Asia during World War II.
Eosinophilia is absent. What test would confirm your diagnostic impression?
A. Manual examination of the peripheral blood smear
B. Manual examination of the peripheral blood smear obtained at 2 a.m.
C. Stool examination for ova
D. Stool examination for parasites
ANSWER D. The setting of this illness contains two important facts: (1) He was a Japanese
POW in southeast Asia in World War II; chronic strongyloidiasis has been reported in this
population. (2) His illness developed in the face of immunosuppression due to the high dose
of steroids required to treat temporal arteritis. Hyperinfection with strongyloidiasis develops in
the face of immunosuppression. His symptoms are consistent with abdominal, pulmonary,
and dermatologic manifestations of hyperinfection syndrome. Ordinarily a tissue helminthic
infection would be associated with eosinophilia. However, steroids will reduce the eosinophil
count. Strongyloidiasis would be unlikely to cause characteristic abnormalities in the
peripheral blood smear. The 2 a.m. smear is useful in diagnosing bancroftian filariasis due to
Wucheria bancrofti, which can damage the lymphatics and cause elephantiasis. Because
Strongyloides females penetrate the intestinal wall, they do not release eggs into the intestinal
lumen and stool; so Strongyloides eggs would be unexpected. On the other hand, finding a
stage of the parasite, the rhabditiform larva of Strongyloides stercoralis, would be expected.

For the next 5 questions, use this set of answers:

A. Plasmodium falciparum
B. Plasmodium malariae
C. Plasmodium ovale
D. Plasmodium vivax

10. Evaluation of fever in a traveler returned from the topics reveals red-blood cells with
banana-shaped inclusions.
ANSWER A. Plasmodium falciparum

11. Species of malaria that is not found in those who are negative for the Duffy blood group
antigen.
ANSWER D. Plasmodium vivax

12. Most deadly species of malaria.

ANSWER A. Plasmodium falciparum

13. Sickle cell trait provides some protection against this species of malaria.
ANSWER A. Plasmodium falciparum

14. Malarial species attacking only older red cells.

ANSWER B. Plasmodium malariae

15. Returning from a visit to his family in West Africa, a Duffy-antigen-negative patient
presents with episodes of shaking chills and fever occurring every 48 hours. Examination
 of his blood smear reveals red cells with unusual structures and pink dots called
“Schüffner’s dots.” What do you conclude about his illness?
A. Is often fatal
B. Would not have occurred if he were Duffy-antigen-positive
C. Would not have occurred if he had sickle cell trait
D. Is affecting only his younger red blood cells
ANSWER D. Is affecting only his younger red blood cells. Travel to the tropics with the
subsequent development of periodic shaking chills and fever should suggest malaria. The
pattern of fever seen every 48 hr does not always occur in malaria. But this so-called tertian
fever pattern is characteristic of Plasmodium falciparum, Plasmodium vivax, and Plasmodium
ovale. However, the finding of Schüffner’s dots limits the differential diagnosis to P. vivax and
P. ovale. Duffy-antigen-negative patients do not acquire illness with P. vivax. Thus, you can
conclude that he has P. ovale malaria. This condition is found in West Africa, consistent with
his travel history. P. ovale malaria is ordinarily not fatal. Like P. vivax malaria, P. ovale affects
only younger red blood cells. This contrasts with P. falciparum malaria, which affects red cells
of all ages. Because P. falciparum can affect red cells of all ages, it can cause a much more
intense parasitemia, a much more severe illness, and a greater likelihood of death. Sickle cell
trait provides some protection against P. falciparum malaria. However, this is by no means
absolute. People with sickle cell trait need to take malaria avoidance measures.

16. Before the patient in the previous question began his journey, he consulted you for
advice. You advised him to take drugs to prevent malaria. He noted that no one in his
family in West Africa took antimalarial drugs on a preventive basis and rejected your
advice. Why was it that his family does not take prophylactic antimalarial drugs, but he
got sick on this trip?
A. His family lives in a village with few mosquitos, but he traveled through a mosquito-
infested region to reach the village.
B. He is Duffy-antigen negative, but the rest of his family is Duffy-antigen positive.
C. By remaining in the village, his family has been exposed to malaria, boosting its
immunity—unlike his situation in Nebraska.
D. His family regularly eats local plants with antimalarial drug properties, but he had eaten
ordinary Western food in Nebraska.
ANSWER C. By remaining in the village, his family has been exposed to malaria, boosting its
immunity—unlike his situation in Nebraska. This is the most likely answer. His exposure
during travel would be brief and less likely to explain his illness. Even if he were Duffy-antigen
negative, he would be at risk from P. ovale. There are no plants in West Africa with
recognized antimalarial properties.

17. A student spends four weeks in Kenya in a malaria-endemic zone. The student follows
malaria-prevention instructions to the letter. But, 6 months after returning, the student
presents with P. vivax malaria. Why?
A. Chloroquine-resistant P. vivax malaria is present in Kenya
B. It is possible to acquire malaria from a needlestick-type injury
C. Individuals with G6PD deficiency metabolize antimalarials rapidly
D. The standard regimen does not prevent delayed P. vivax infection
ANSWER D. The standard regimen does not prevent delayed P. vivax infection.
Chloroquine-resistant P. vivax is present on the island of New Guinea, but (1) the student was
in Kenya and (2) the student probably would have taken mefloquine, not chloroquine. If the
student was exposed to malaria from a needlestick injury in Kenya, his prophylaxis regimen
should have worked just as well as with mosquito exposure. A needlestick exposure to
malaria in the U.S. is extremely unlikely. Individuals with G6PD deficiency do not tolerate
primaquine; G6PD deficiency is not associated with abnormal antimalarial metabolism. The
standard regimen calls for taking antimalarials for four weeks after leaving an endemic zone.
This protects against P. falciparum, which is only released from the liver for four weeks after
exposure. This is worthwhile because P. falciparum is the deadliest species. However,
attacks due to other species may not be manifest for months or years. That is why: (1) in
cases with intense malaria exposure, so-called “radical cure” is attempted with (in individuals
who are not G6PD deficient) primaquine on return to the U.S. and (2) someone returning from
a malaria zone needs to report this if they see a physician with an acute illness.

18. You are camping in a region with malaria. You are sharing a tent with a friend. Your
friend is willing to follow only one mosquito avoidance measure. Thinking selfishly, what
single measure do you advise your friend to follow?
A. Treat clothes with permethrin
B. Apply DEET to skin
C. Wear longsleeved shirts
D. Avoid outdoor activities evenings and nights
E. Sleep in a screened area or under mosquito netting
ANSWER A. Permethrin is a so-called “knockdown” insect repellent. If mosquitos approach
clothing treated with permethrin, they will be killed. This is your preference since your friend
will act as a sort of mosquito exterminator. The other measures would be advisable for your
friend, but they won’t necessarily help you. DEET on skin repels insects and ticks.
Longsleeved shirts make less skin readily accessible for biting. The anopheline mosquitos that
transmit malaria prefer to bit evenings and nights; staying indoors then may avoid them.
Similarly, sleeping with a screen or netting that protects a person will reduce the risk of
mosquito bites.

19. A 60-year-old man returns from a vacation trip to Martha’s Vineyard with several days of
fever, chills, and malaise. Manual examination of the blood smear reveals red cells with
bits of pigment that is a picture reminiscent of malaria. Some red cells have tetrads of
these structures. The patient reports that he was often bitten by ticks. In deciding on
treatment, what would be the most important question to ask?
A. Have you been tested for G6PD deficiency?
B. Do you have a spleen?
C. Have you ever traveled to the tropics?
D. Do you have a rash?
ANSWER B. The patient traveled to one of the areas of the US known for human babesiosis;
the other is Cape Cod. He had exposure to ticks, which transmit Babesia microti. His clinical
picture is consistent with babesiosis. The blood smear is characteristic, particularly the
tetrads. G6PD deficiency is important if you are considering a drug like primaquine, which is
used in some cases of malaria. Although inquiring about tropical travel might be important in
considering malaria, this case has so many features of babesiosis that malaria seems
improbable. Some tickborne illnesses, like Lyme disease and Rocky Mountain Spotted Fever,
are associated with rash. But this case is very characteristic of babesiosis. For many patients
with babesiosis, the disease is self-limited. But for those without a spleen, it can be deadly.
These patients require aggressive treatment. Inquiring about a spleen is crucial.

20. You advise a patient to take mefloquine to prevent malaria. The patient refuses, citing a
magazine article reporting that mefloquine causes permanent psychosis. What do you
say?
A. All antimalarial drugs cause psychosis
B. Chloroquine with standby pyrimethamine-sulfa can be used as an alternative to
mefloquine
C. Controlled studies have failed to support his contention
D. He could take doxycycline instead, which was safer in marines in Somalia
ANSWER C. Controlled studies have failed to support his contention. Concerns about
neuropsychiatric effects of mefloquine grew out of studies in which it was used to prevent and
to treat malaria. However, because malaria itself can involve the brain, the inclusion of
neuropsychiatric morbidity reported in treatment studies is questionable; this morbidity can be
explained by the malaria itself. A controlled study published in 1997 failed to support his
contention of intolerance due to psychiatric problems. Chloroquine with standby
pyrimethamine-sulfa can be used as an alternative to mefloquine. However, this is not the
best answer because of compliance problems with this complex regimen. In Somalia, no
hospitalizations for prophylaxis-related morbidity occurred in marines taking mefloquine. There
were hospitalizations among doxycycline-takers with esophageal burns from failing to swallow
the pills with an adequate amount of liquid and remain upright for 30 minutes.

21. A woman gave birth to an infant who was noted to have chorioretinitis and a variety of
developmental problems. The condition was attributed to a protozoan infection in
pregnancy that might have been avoided if she had not:
A. Taken her dog on walks
B. Changed her cat’s litter
C. Had a pet turtle
D. Cared for a parrot
ANSWER B. A common cause of infection in pregnancy with resulting chorioretinitis and
developmental problems in the progeny is toxoplasmosis. Cats carry Toxoplasma gondii. So
pregnant women are advised not the change kitty litter. Dogs might transmit Toxocara canis,
the dog roundworm which causes visceral larva migrans as the worms move through the body
unable to complete their life cycle. Turtles have been linked to salmonellosis. Parrots are
associated with Q fever, a type of pneumonia.

22. A Central American immigrant had an ulcerating skin lesion that did not heal. Biopsy
showed evidence of a protozoan infection. How was this infection acquired?
A. From contact with a dog
B. From changing cat litter
C. From exposure to a stream contaminated with rat urine
 D. From the bite of phlebotomine sandflies
ANSWER D. An ulcerating lesion due to a protozoan infection acquired in Central America is
a description of cutaneous leishmaniasis. Dogs may be a reservoir of Leishmania. However,
the pathogen is transmitted by the bite of a phlebotomine sandfly. Cat litter exposure is
associated with a different protozoan infection, toxoplasmosis, in which ulcerating skin lesions
are not prominent. Central America is endemic for leptospirosis, a spirochetal disease
characterized by conjunctival suffusion and subsequent hepatic and renal manifestations.
Leptospirosis is transmitted from exposure to fresh water contaminated with animal urine, but
ulcerating skin lesions are not prominent.

23. A 40-year-old man was hospitalized with community-acquired pneumonia characterized

by bilateral interstitial infiltrates and marked hypoxia. He had not seen a physician in the
previous 20 years aside from treatment for genital herpes and chlamydia. He denies any
medication allergies. He denied injection drug use, transfusions, multiple sex partners,
and sex with men. Examination of expectorated sputum with a silver stain revealed
organisms resembling protozoans. What is the drug of choice?
A. Ceftriaxone
B. Erythromycin
C. Levofloxacin
D. Trimethoprim-sulfamethoxazole
ANSWER D. Trimethoprim-sulfamethoxazole. An important cause of community-acquired
pneumonia in young men is Pneumocystis jiroveci pneumonia in the setting of AIDS. The
clinical picture is consistent. The history of treatment for sexually transmissible diseases
raises the question of acquisition of HIV. Many HIV patients will initially be uncomfortable with
reporting risk factors like injection drug use, multiple sex partners, or sex with men; so his
denials are irrelevant. The sputum exam is characteristic of Pneumocystis jiroveci.
Levofloxacin or, possibly, erythromycin or ceftriaxone-erythromycin, would be preferred drugs
for bacterial community-acquired pneumonia. Trimethoprim-sulfamethoxazole is the drug of
choice for Pneumocystis jiroveci pneumonia. Pneumocystis jiroveci is the current name for the
human strains of an organism previously called Pneumocystis carinii. Now this organism is
classified as a fungus; previously it was classified as a protozoan.

24. A 45-year old man immigrated from South America to the US as a teenager. He has
heartburn and reflux. Radiologic evaluation reveals an esophageal dysmotility disorder.
This may be due to an infection acquired from which arthropod?
A. Tick
B. Anopheles mosquito
C. Aedes mosquito
D. Reduviid bug
E. Tsetse fly
ANSWER D. Reduviid bug. Exposure to Trypanosoma cruzi from the reduviid bug is relatively
common in South America. Late manifestations include esophageal dysmotility and
cardiomyopathy.
 25. A 60-year-old man returns from a 2-month trip to southern Africa to hunt game. He
suffered a number of tsetse fly bites. What illness might develop in the wake of these
bites?
A. Paroxysms of fever and chills every 48 hours, with hemolytic anemia
B. Vasculitic rash with severe headache and high fever
C. Fatal hepatitis
D. Esophageal dysmotility developing after decades
E. Deterioration in mental status and ultimately death
ANSWER E. Deterioration in mental status and ultimately death. The tsetse fly transmits the
African trypanosomiasis agent, Trypanosoma brucei. This causes sleeping sickness, for which
therapy is limited. It does not transmit malaria (fever, chills, hemolysis). Nor does it transmit
Rocky Mountain Spotted Fever (fever, rash, headache). Aedes mosquitos transmit yellow
fever (fatal hepatitis). South American trypanosomiasis causes Chagas disease, which may
manifest as esophageal dysmotility.

26. A 35-year-old calf handler reports watery diarrhea occurring after caring for sick calves.
Stool culture for Salmonella, Shigella, Campylobacter, Escherichia coli O157:H7, and
Aeromonas is negative. A Clostridium difficile toxin assay is negative. Routine
examination of 3 daily stool specimens for ova and parasites is negative. What test
should you order?
A. Special examination of the stool for parasites with acid-fast stain of supernatant
B. Duodenal aspirate for examination for parasites
C. Scotch tape coated paddle inserted in the gluteal cleft at night
D. Further examinations, with special attention to rhabditiform larvae in stool.
ANSWER A. This is the original setting in which cryptosporidiosis was described. As a
protozoan, cryptosporidium would not be expected to grow on media that support bacteria;
hence the negative stool cultures. Similarly, it would not produce a positive C. difficile toxin
assay. In routine examination of stool for ova and parasites, a stool specimen is centrifuged.
The pellet, thought to be more likely to contain ova and parasites, is examined. However, this
method does not detect Cryptosporidium. Examination of the supernatant of a special stool
preparation is needed; acid-fast stain may detect Cryptosporidium. A duodenal aspirate may
be useful to detect Giardia. Giardia typically produces bloating and greasy stools and is not
associated with calves. A Scotch tape coated paddle at night is used to detect pinworm
(Enterobius) because the females migrate out of the anus at night to lay eggs. Rhabditiform
larvae are characteristic of Strongyloides stercoralis; aside from diarrhea, nothing in this case
suggests strongyloidiasis.

27. A three-year-old child has severe nocturnal perianal itching. Microscopic examination of
material obtained on a Scotch tape coated paddle inserted into the gluteal cleft at night
reveals an explanation. How was this infection acquired?
A. Perinatally
B. By ingestion
C. By skin penetration
D. By a vector
ANSWER B. This is a description of pinworm (Enterobius). This is acquired by ingestion.
Hookworm (Necator americanus, Ancyclostoma duodenale) is acquired by skin penetration.
Intestinal worms are generally not transmitted by vector or perinatally.

28. A child from an impoverished rural Caribbean community with no dogs and cats comes
to a medical facility. The child is from a community without adequate facilities to safely
dispose of human feces and is found to have ova in the stool that have a smooth, oval
surface with a complex interior. The child acquired this condition by walking barefoot,
with penetration of the agent through the skin. What clinical condition would you expect
to see?
A. Anemia
B. Abdominal pain
C. Itching
D. Diarrhea
ANSWER A. Anemia. This is a description of hookworm. Dog and cat hookworms fail to
reach the intestine; migration through the skin produces cutaneous larva migrans. At initial
penetration, human hookworms Necator americanus or Ancyclostoma duodenale may produce
itching (“ground itch”). Some intestinal parasites have syndromes in which prominent findings
are abdominal pain (Ascaris “wormball”) or diarrhea (strongyloidiasis). But anemia is linked to
hookworm.

29. An elderly Norwegian woman who is in excellent health and maintains her activities
unfettered by medical conditions is concerned about increasing fatigue. Evaluation is
unremarkable except for a macrocytic anemia. She reports a balanced diet, including
green leafy vegetables and beef. This condition may reflect which of her activities:
A. Caring for her cat
B. Preparing lutefisk
C. Eating pork
D. Walking barefoot at a Minnesota lake
ANSWER B. Preparing lutefisk. Vitamin B12 deficiency occurs in infection with the fish
tapeworm, Diphyllobothrium latum. This may be acquired by tasting raw fish as lutefisk
(Scandinavian) or gefilte fish (Jewish) is prepared. The disease associated with cat care is
toxoplasmosis, not a cause of macrocytic anemia. Pork may transmit pork tapeworm (Taenia
solium), a cause of seizures or trichinellosis, which affects muscle. Hookworm may be
acquired by walking barefoot. However, it causes microcytic anemia, not macrocytic anemia.
Also, it requires incubation of eggs in a warm environment, not in Minnesota.

30. A 25-year-old man who immigrated to Nebraska from Durango, México 5 years ago
presents with new-onset seizures. When he is post-ictal, you need to ask him about
ingesting:
A. Flan
B. Guacamole
C. Tortillas
D. Pork
E. Shrimp
ANSWER D. Pork. A common cause of seizures in Mexican immigrants to the US is
neurocysticercosis. This is a late manifestation of ingestion of pork containing cysts of Taenia
solium, the pork tapeworm. Shrimp is not commonly associated with parasites causing
seizures. If flan is contaminated, this rich, chicken egg containing dessert might transmit
bacteria like Salmonella causing acute infection; but seizures after a period of years would not
be consistent with this picture. Guacamole is made from avocados, which can raise
cholesterol but are not particularly linked to infection. Neither are tortillas particularly risky.

Use these choices to answer the next 5 questions.

A. Schistosoma mansoni
B. Schistosoma haematobium
C. Schistosoma japonicum

31. Stool examination reveals a 60 x 140 micron egg with a large, lateral spine
ANSWER A. Schistosoma mansoni

32. Stool examination reveals a 70 x 90 micron egg, but it is difficult to discern a spine
ANSWER C. Schistosoma japonicum

33. Urine examination reveals a 60 x 140 micron egg with a large, terminal spine
ANSWER A. Schistosoma haematobium

34. Schistosomal species acquired in the Americas and causing liver disease
ANSWER A. Schistosoma mansoni

35. Schistosomal species acquired in East Asia

ANSWER C. Schistosoma japonicum

36. Several weeks after swimming in a lake in East Africa, a young man notes fever, chills,
and malaise. Leukocytosis, marked eosinophilia, and elevated immunoglobulins are
present. He has stool with large ova with large, lateral spines. What is the diagnosis?
A. Katayama syndrome
B. Kawasaki disease
C. Jarish-Herxheimer reaction
D. Erythema nodusum leprosum
ANSWER A. Katayama syndrome. This is seen in the intermediate stage of schistosomiasis,
particularly with S. haematobium, but also reported with S. mansoni, whose eggs are
described in the stool. Kawasaki disease is mucocutaneous lymph node syndrome. Jarisch-
Herxheimer reactions occur during the treatment of secondary syphilis. Erythema nodosum
leprosum occurs during the treatment of leptomatous leprosy. All of these are thought to have
some sort of immunologic basis.

37. What is a common target organ of chronic infection with S. mansoni?

A. Liver
B. Bladder
 C. Skeletal muscle
D. Brain
ANSWER A. Liver. S. mansoni copulating pairs occupy the inferior mesenteric circulation and
may produce granulomatous reactions to ova in the bowel as well as (when the portal
circulation carries the eggs) the liver and lungs. Bladder involvement is associated with S.
haematobium.

38. How do snails contribute to the transmission of schistosomiasis to humans?

A. Serve as the definitive host
B. Serve as the intermediate host
C. Transmit when they are eaten raw
D. Transmit when they contact skin
ANSWER B. Serve as the intermediate host. Humans are the definitive host, i.e., where sex
occurs. Snails are a host at other stages. Schistosomiasis is transmitted when human skin
contacts schistosomal cercariae swimming in fresh water, not when skin contacts snails.

39. You suspect that a patient acquired schistosomiasis in the Caribbean several months ago.
What laboratory test should you order?
A. Examination of stool for ova
B. Examination of urine for ova
C. Examination of stool for worms
D. Examination of urine for worms
E. Serum for IgE schistosomal antibodies
F. Serum for IgG schistosomal antibodies
ANSWER A. Examination of stool for ova. The only schistosomal species found in the New
World is S. mansoni. After several weeks, S. mansoni releases characteristic ova into the
stool. The worms remain in a copulatory embrace in the venous system and are not found in
the stool. Serology is a developing area, but the finding of ova is the preferred diagnostic
method.

40. A few years after returning from Africa, a patient seeks medical attention because of
hematuria. Bacterial cultures of the urine are negative. Radiologic and cystoscopic
examination revealed no evidence of stone or tumor. You wonder about the possibility of
schistosomiasis. This could reflect infection with which schistosomal species?
A. S. mansoni
B. S. haematobium
C. S. japonicum
D. S. mekongi
ANSWER B. S. haematobium. S. mansoni and S. haematobium are found in Africa, but it is
S. haematobium that is associated with hematuria because of its bladder involvement.

41. A West African man has severe visual impairment and his anterior chamber is abnormal.
What test should you perform?
A. Skin snips for microscopic exam
B. Giemsa-stained smear of peripheral blood drawn at 2 am
 C. Scotch-tape coated paddle inserted into the gluteal cleft at night
D. Evaluation of reduviid bug on his skin
ANSWER A. Skin snips for microscopic exam. Blindness in West Africa associated with
anterior chamber problems may be due to onchocerciasis, or river blindness. This is caused
by subcutaneous invasion of microfilariae of Onchocerca volvulus, which also migrate to the
anterior chamber. Giemsa staining of superficial skin snips is the classic diagnostic method.
The taxonomically related Wuchereria bancrofti has microfilariae that tend to invade the blood
at night; hence the 2 am Giemsa smear. The Scotch-tape coated paddle is used to diagnose
the intestinal pinworm. Reduviid bugs are placed on the skin of Chagas disease
(Trypanosoma cruzi) suspects and evaluated for infection to diagnose Chagas disease.

42. A Filipino has marked swelling of the extremities which you attribute to impaired lymphatic
drainage. What test should you perform?
A. Skin snips for microscopic exam
B. Giemsa-stained smear of peripheral blood drawn at 2 am
C. Scotch-tape coated paddle inserted into the gluteal cleft at night
D. Evaluation of reduviid bug on his skin
ANSWER B. Giemsa-stained smear of peripheral blood drawn at 2 am. Blindness in West
Africa associated with anterior chamber problems may be due to onchocerciasis, or river
blindness. This is caused by subcutaneous invasion of microfilariae of Onchocerca volvulus,
which also migrate to the anterior chamber. Giemsa staining of superficial skin snips is the
classic diagnostic method. The taxonomically related Wuchereria bancrofti has microfilariae
that tend to invade the blood at night; hence the 2 am Giemsa smear. W. bancrofti causes
lymphatic inflammation and elephantiasis. The Scotch-tape coated paddle is used to diagnose
the intestinal pinworm. Reduviid bugs are placed on the skin of Chagas disease
(Trypanosoma cruzi) suspects and evaluated for infection to diagnose Chagas disease.

43. A 7-year-old boy returns from a hike in the Wisconsin woods in June. The next day he
complains of weakness. A neurologic exam discloses a spotty flaccid paralysis. A
procedure is performed in the office, resulting in complete relief of the symptoms. This
procedure is most likely:
A. Injection of multivalent botulinum anti-toxin.
B. Injection of a short-acting anticholinesterase agent.
C. Injection of polio hyperimmune globulin.
D. Tick removal.
ANSWER B. Tick removal. Botulism, myasthenia gravis, and polio are in the differential
diagnosis of weakness. However, none of them is particularly common in this epidemiologic
setting: a walk in a tick-filled environment by a child old enough to do some walking but young
enough to be careless about self-inspection for ticks. Furthermore, there is no such agent as
polio hyperimmune globulin nor would it make sense in reversing paralysis due to polio’s
attack on lower motor neurons. Tick paralysis is a toxin-mediated phenomenon associated
with flaccid paralysis and readily reversed on tick removal.

44. A patient returns from 10 days of camping in the Colorado Rockies. Ticks were prevalent.
 The patient has fever, neutropenia, and thrombocytopenia. There is no rash. The most
likely diagnosis is:
A. Rocky Mountain Spotted Fever
B. Colorado tick fever
C. Dengue fever
D. Bartonellosis
ANSWER B. Colorado tick fever. In Colorado, Colorado tick fever is more common than
Rocky Mountain Spotted Fever. Colorado tick fever is (as the name implies) transmitted by
ticks from small rodents and associated with neutropenia and thrombocytopenia. Unlike Rocky
Mountain Spotted Fever, Colorado tick fever lacks a rash. Dengue fever is transmitted by
Aedes aegypti mosquitos in the tropics. Bartonellosis is transmitted by sandflies in the
mountain valleys of Peru, Ecuador, and Colombia.

45. Least likely in a patient with Rocky Mountain Spotted Fever:

A. Rocky Mountain states travel history
B. Rash
C. Fever
D. Headache
ANSWER A. Rocky Mountain states travel history. Rash, fever, and headache make up a
triad that should bring to mind the possibility of rickettsial disease. Rocky Mountain Spotted
Fever is the prototype rickettsial disease. Although the first description of the disease in the
medical literature was based on an investigation by Howard Taylor Ricketts, M.D. in the
northern reaches of the Rockies, at present the disease is reported more frequently from the
South Atlantic states (notably North Carolina) and Oklahoma.

46. The etiologic agent of Rocky Mountain Spotted Fever is:

A. Readily grown by the laboratory on routine culture media
B. Treated successfully with penicillin or a cephalosporin
C. Responsible for many deaths of squirrels in the wild
D. Transmitted to humans by tick bite
ANSWER D. Transmitted to humans by tick bite. Rickettsia rickettsii (named after Dr.
Ricketts) causes Rocky Mountain Spotted Fever. Like most rickettsia pathogenic for humans,
R. rickettsii is not grown on routine cell-free culture media. Rickettsia are bacteria. However,
they occupy a twilight zone between most bacteria and the viruses. Like viruses, R. rickettsii
does not grow in routine cell-free culture media. This has an important implication: If a patient
comes in with Rocky Mountain Spotted Fever and you (not suspecting RMSF) obtain a
specimen for routine culture, you will not get a lab report that will make you think of RMSF.
Nothing will grow. You need to suspect RMSF yourself. Beta-lactams, like penicillin and the
cephalosporins, generally are ineffective against rickettsiae. Vertebrate hosts of RMSF, like
squirrels, generally tolerate infection with R. rickettsii well. R. rickettsii shuttles between
squirrels and ticks. Occasionally an infected tick will bite a human, transmit R. rickettsii, and
RMSF will result.

47. Rocky Mountain Spotted Fever and human ehrlichiosis are both:
A. Caused by rickettsial organisms
 B. Transmitted from rodent reservoirs
C. Transmitted by ticks
D. Generally associated with a prominent rash
ANSWER C. Transmitted by ticks. Rocky Mountain Spotted Fever (RMSF) is caused by the
prototype rickettsial organism R. rickettsii. Human ehrlichiosis is attributed to a related
organism. RMSF commonly is transmitted from a rodent reservoir, but the reservoir of human
ehrlichiosis is unknown (although the disease is caused by an organism resembling one found
in dogs). Both are thought to be transmitted by ticks. The two diseases have a similar clinical
picture (headache and fever in a tick-exposed person), but rash is generally common in RMSF
and absent in human ehrlichiosis.

48. Ticks transmit all of the following except:

A. Typhus
B. Q fever
C. Tularemia
D. Human babesiosis
ANSWER A. Typhus. Typhus (due to R. prowazekii) is transmitted by lice, particularly in
wartime settings of crowding with infrequent change of clothing. Among its most famous
victims were: Dr. Howard Taylor Ricketts (who died while studying it in Mexico City) and Anne
Frank (who had written a diary in hiding in Amsterdam during World War II and who died
during an outbreak in the Bergen-Belsen concentration camp). Ticks can transmit Coxiella
burnetii (agent of Q fever), which is often spread in an airborne route from material in
mammalian placentas. Ticks can transmit Francisella tularensis (agent of tularemia), which is
also acquired by rabbit hunters who nick themselves with knives while skinning rabbits. Ticks
are the ordinary mechanism of transmission of Babesia microti, cause of human babesiosis,
which produces a blood film picture resembling Plasmodium falciparum malaria but which
resolves (in the immune intact) without specific intervention. With these diseases, as is true for
many vectorborne diseases and zoonoses, exceptional mechanisms of transmission may
occur occasionally. For example, both babesiosis and malaria may be transmitted by blood
transfusion. Yet such an event is quite uncommon. Thus, it is worthwhile to emphasize the
more common occurrences.

49. Q fever:
A. Is seen in individuals with tick bites, exposed to sheep placentas, or employed in
slaughterhouses
B. Causes a pneumonia which resembles legionnaires’ disease and psittacosis
C. Does not respond to penicillin
D. All of the above
ANSWER D. All of the above. Q fever (name came from the medical slang for “Query fever”
indicating a fever of unclear etiology) is caused by Coxiella burnetii. Tick bites can transmit it.
However, its airborne mode of transmission and concentration in placentas makes it a risk to
those exposed to sheep placentas or employed in slaughterhouses. It produces an “atypical
pneumonia.” In contrast to “typical pneumonia” (pneumococcal pneumonia), an atypical
pneumonia is not associated with a sputum Gram stain showing Gram-positive cocci and
routine sputum culture does not yield any growth of organisms. Other atypical pneumonias
include Mycoplasma pneumoniae pneumonia (the prototype), legionnaires’ disease, and
psittacosis. Penicillin is ineffective against atypical pneumonias.

50. A publication from the Centers for Disease Control and Prevention notes the following
yellow fever requirement for travelers to Taiwan: A certificate indicating the administration
of protection is required of travelers arriving from infected areas. A 30-year-old business
executive in excellent health is planning to fly nonstop from the United States to Taiwan.
You advise the person to:
A. Take weekly medication to prevent yellow fever
B. Receive a yellow fever immunization in your office
C. Call the county health department to locate an officially designated yellow fever
immunization center
D. None of the above
ANSWER D. None of the above. This is a trick question. Taiwan requires a certificate
indicating protection only for those arriving from infected areas. Your patient is going to be
arriving from the United States. The United States is not an area infected with yellow fever.
Therefore, Taiwan will not require anything of your patient! You may wonder why I wrote a
question that seems as silly as this. There’s a reason. Repeatedly, medical offices in Omaha
have told travelers like the Taiwan-bound executive: you need a yellow fever certificate. I don’t
want you to be careless in reading immunization requirements! Even if a yellow fever
certificate were required, taking weekly medication would not suffice. Why? There is no
medication available to prevent or treat yellow fever. Contrast this with malaria. We do
recommend medication to prevent and treat malaria. There is no malaria vaccine, but there is
a yellow fever vaccine. You could administer it in your office. But . . . it would not suffice for
an international certificate of vaccination unless you had your office designated as a yellow
fever immunization center. The demand for yellow fever vaccine in the U.S. is small enough
that few offices are designated as yellow fever immunization centers. To find such an officially
designated center, check with a travel clinic. Generally your county health department will run
such a clinic or know where one is.

51. A patient is planning a two-week trip to the Amazon to observe wildlife. He is up to date on
all routine US vaccines and three months ago had typhoid vaccine and hepatitis A
vaccine. What additional immunization is indicated?
A. Dengue
B. Malaria
C. Chagas disease
D. Yellow fever
ANSWER D. Yellow fever. All of these diseases have increased risk on this trip. However,
yellow fever is the only condition for which a vaccine is available.

52. How can the risk of dengue fever be reduced?

A. Applying a DEET-containing insect repellent
B. Mefloquine prophylaxis
C. Vaccine
 D. Self-treatment with anti-dengue drugs for fever
ANSWER A. Applying a DEET-containing insect repellent. This will reduce the risk of bites
from the day-biting Aedes mosquitos that carry dengue. Mefloquine works for malaria, not
dengue. There is no dengue vaccine; indeed, the immune system may play a role in the
development of more severe causes on reinfection with dengue. There are no anti-dengue
drugs for self-treatment in the event of fever.

53. A patient returns from a trip to Peru, including its Andean valleys. The patient reports
being bitten by sandflies. Fever and malaise are present. Examination of the peripheral
blood smear reveals deformed red blood cells. Unusual skin nodules are present a few
weeks later. What disease do you suspect?
A. Bartonellosis (Oroya fever, Verruga peruana)
B. Malaria
C. Leishmaniasis
D. Chagas disease
ANSWER A. Bartonellosis (Oroya fever, Verruga peruana). Bartonellosis is remarkable for its
distinctive epidemiology, arising from its transmission almost entirely by sandflies which exist
only in mountain valleys of Peru, Ecuador, and Colombia at altitudes of 2,000 to 8,000 feet.
An earlier phase (Oroya fever) and a later phase involving hemangiomatous skin lesions
(Verruga peruana) have been identified. The etiologic agent Bartonella bacilliformis replicates
within red blood cells, deforming them. The unusual characteristics of this illness make it of
some interest to those who write boards questions. Malaria presents with fever and abnormal
red blood cell morphology. However, skin nodules are not characteristic and transmission is
by Anopheles mosquitos, not sandflies. Leishmaniasis is transmitted by sandflies and
produces skin lesions. However, they are ulcerative, not nodular. Chagas disease is
transmitted by the reduviid bug. It is seen in South America. However, it is not associated
with red blood cell deformities nor with skin nodules.

54. A South American native has heart disease. There is no evidence of congenital heart
disease, hypertensive heart disease, rheumatic heart disease, atherosclerotic coronary
artery disease, or alcoholic cardiomyopathy. By what mechanism do you suspect the
patient acquired the illness?
A. From saliva drooled out of the mouth of a female Anopheles mosquito after a bite
B. From an organism from the salivary gland of a tsetse fly
C. From feces of an infected reduviid bug reaching a break in the skin
D. From contact with rat urine in a contaminated stream
ANSWER C. From feces of an infected reduviid bug reaching a break in the skin. A form of
heart disease endemic to South America is Chagas disease, which may also manifest as
esophageal dysmotility. This is acquired from Trypanosoma cruzi, transmitted through reduviid
bug feces. Anopheles mosquitos transmit malaria. Tsetse fly salivary glands spread African
trypanosomiasis (sleeping sickness, T. brucei). Rat urine spreads leptospirosis, a spirochetal
disease.

55. May be seen as a manifestation of Chagas disease:

A. Fever, malaise, lymphadenopathy, and splenomegaly
 B. Esophageal motility disorder
C. Cardiomyopathy
D. All of the above
ANSWER D. All of the above

56. A ten-year-old boy was hiking in New Mexico. He found a prairie dog lying on the ground.
He spent some time poking it with a stick. Several days later the boy developed painful
axillary adenopathy and high fever. You should suspect:
A. Tularemia
B. Q fever
C. Plague
D. Rocky Mountain Spotted Fever
ANSWER C. Plague. Although only a handful of cases occur in the U.S. each year, New
Mexico is one of the states most involved with plague. Fleas abandon rodents dying of the
disease, seek new hosts, and cause painful adenopathy and a toxic picture. Tularemia is
more associated with rabbits and generally cause ulcers. However, streptomycin would treat
both plague and tularemia. Q fever is a pneumonia; this boy lacks lung symptoms. Rocky
Mountain Spotted Fever is characterized by fever, headache, and often rash (which is absent
here). Also, Rocky Mountain Spotted Fever is more common in Oklahoma and the Southeast
than in the Rocky Mountains!

57. A syndrome of severe, often rapidly fatal, pulmonary disease was recognized in a June
1993 outbreak in the Four Corners area of the Western United States. Studies for a
known bacterial etiology were negative. Evidence of fungal or parasitic etiology was also
absent. What was this condition ascribed to?
A. A hantavirus
B. Pneumonic plague
C. Anthrax
D. Pneumocystis carinii
ANSWER A. A hantavirus, known as Sin Nombre virus. Plague and anthrax are bacterial;
they may cause rapid pulmonary death. Pneumocystis carinii was though to be a protozoan
but is now thought to be a fungus.

58. The outbreak of severe pulmonary disease recognized in a June 1993 outbreak in the
Four Corners area of the Western United States probably reflected exposure to:
A. Excreta of deer mice
B. Contaminated piñon nuts
C. Ticks
D. Rodent bites
ANSWER A. Excreta of deer mice. Abundant rainfall in the months before the outbreak
resulted in an abundance of piñon nuts, resulting in an abundance of deer mice. These mice
carry the Sin Nombre virus, a newly discovered hantavirus. Contact with their excreta
occurred in homes that weren’t mouseproof and in those who spent time outdoors where the
mice lived. In this way a number of people acquired Sin Nombre virus infection, which resulted
in noncardiogenic pulmonary edema.
59. A traveler returning from a visit to West Africa, including time spent living with families
whose homes were subject to visits by mice, seeks medical care for fever, malaise,
nausea, vomiting, sore throat, and myalgia. He had been in a village where 10% of the
population died in the local hospital. Pharyngeal inflammation and conjunctivitis are seen.
Hypotension is present. You realize that:
A. The patient will die
B. The patient must be transported to a special containment isolation unit in Atlanta
C. Laboratory tests should be carried out in special high-containment facilities
D. All of the above
ANSWER C. Laboratory tests should be carried out in special high-containment facilities. This
picture suggests Lassa fever. It is caused by an arenavirus transmitted primarily through
contact with rodent excreta. Hospitalized cases have a 15% mortality rate. This—and the risk
of nosocomial transmission—generate fear in hospitals. However, the nosocomial infection
rate is low in African hospitals with more experience with Lassa fever. An ordinary hospital
can manage Lassa fever with strict isolation. Because of the risk of transmission via a
laboratory incident, laboratory tests should be carried out in special high-containment facilities.

60. Investigation of a cluster of cases of meningoencephalitis in a small town in the U.S.

shows that they occurred in children, no bacteria were grown on blood or spinal fluid
culture, and that good recoveries were noted. What is the most likely cause?
A. A day care center with extensive colonization with meningococcus
B. Wild poliovirus in the sewage
C. A pet shop with hamsters infected with lymphocytic choriomeningitis virus
D. Failure to use Haemophilus influenzae type b vaccine in that community
ANSWER C. A pet shop with hamsters infected with lymphocytic choriomeningitis virus. The
meningococcus and Haemophilus influenzae type b ordinarily produce meningitis, with growth
of bacteria demonstrable on spinal fluid cultures. Wild poliovirus disease is on the verge of
eradication from the Americas. This description is compatible with lymphocytic
choriomeningitis virus disease, which is associated with contact with mouse or hamster
excreta.

61. An army reservist who recently trained in Central America noted redness of his eyes.
Several days later he developed fever, jaundice, and renal failure. A diagnosis of
leptospirosis was entertained after a history was taken. Exposure to what source raised
this concern?
A. Panamanian prostitutes
B. Wading through streams contaminated with rat urine
C. Contaminated food
D. Sandflies
ANSWER B. Wading through streams contaminated with rat urine. Leptospirosis is caused by
a spirochete, but it is not sexually transmitted. It is most commonly transmitted by exposure of
non-intact skin or of mucous membranes to water contaminated with the urine of infected
animals. A wide range of mammals, wild and domestic, may be infected. Contaminated food
is an unusual mode of transmission. Arthropod-borne transmission is not recognized.
62. An otherwise healthy five-year-old child develops a self-limited pustule on the right
forearm. The child has a pet cat. A month later axillary adenopathy develops. Histology
of the node reveals suppurative lymphadenitis with granulomas and microabscesses.
You suspect:
A. Cat scratch disease
B. Bacillary angiomatosis
C. Kaposi sarcoma
D. Bartonellosis
ANSWER A. Cat scratch disease. This is a textbook presentation of cat scratch disease.
Bacillary angiomatosis is generally confined to the immunosuppressed, particularly those with
HIV. The same can be said for Kaposi sarcoma. Bartonellosis due to Bartonella bacilliformis
does not produce prominent lymphadenopathy; its skin lesions are more persistent. Keep in
mind that the major etiologic agent of cat scratch disease is now identified as a member of
Bartonella.

63. Studies of 16S RNA suggest that the agents of cat scratch disease, bacillary
angiomatosis, and bacillary peliosis hepatis:
A. Are all Bartonella henselae
B. Are identical to the agent of bartonellosis
C. Are all caused by Afipia felis
D. Are unrelated
ANSWER A. Are all Bartonella henselae. In recent years, a remarkable series of
investigations, of great fascination to those who write boards questions, has used studies of
16S ribosomal RNA to classify some microorganisms. 16S ribosomal RNA is highly conserved
and is a valuable tool for determining the relatedness of microorganism. Although not without
some dispute, it seems quite likely that Bartonella henselae causes cat scratch disease,
bacillary angiomatosis, and bacillary peliosis hepatis, the latter two being vascular lesions seen
uncommonly in immunosuppression, notably in HIV infection. 16S ribosomal RNA studies
show that the agent of bartonellosis, Bartonella bacilliformis, which, like bacillary
angiomatosus, is associated with vascular skin lesions (verruga peruana), is closely related to
B. henselae, but not identical. Previously, cat scratch disease was attributed to Afipia felis.

64. Brucellosis:
A. No longer occurs in the U.S. because of programs to eradicate bovine brucellosis
B. Acutely presents with a pathognomonic picture of arthralgia and undulating fever
C. Can be diagnosed readily with a standard tube agglutination test for antibodies
D. May cause chronic fatigue syndrome
ANSWER D. May cause chronic fatigue syndrome. Although cattle were the major reservoir
of brucellosis and although the U.S. has been very successful in controlling bovine brucellosis,
eradication is not complete. A few human cases occur from exposure to cattle and swine.
Unpasteurized goat’s milk, laboratory incidents, unintentional injections of humans with the live
veterinary vaccine, and cases acquired abroad account for the persistence of brucellosis in the
United States. Its clinical presentation is protean. Fever, chills, night sweats, and arthralgias
are classic features. However, undulant fever is, despite old textbook assertions, not an
invariant finding. Multiple complications may occur. Serologic diagnosis is laden with
ambiguity. It may be necessary to inactivate IgM antibodies to see if a titer represents recent
infection. Blocking antibodies may cause false-negative tests. Chronic brucellosis is an older
cause of chronic fatigue syndrome. Given the difficulty in objectively diagnosing chronic
brucellosis, it is hard to be sure of the role of brucellosis in any particular case of chronic
fatigue syndrome, though.

65. Drug of choice for trichomoniasis:

A. Doxycycline
B. Mefloquine
C. Metronidazole
D. Praziquantel
E. Streptomycin
ANSWER: C. Metronidazole. Doxycycline is used for a variety of bacterial infections and for
malaria. Mefloquine is an antimalarial. Praziquantel is used for schistosomiasis.
Streptomycin is used for a variety of bacterial infections and tuberculosis; however, it is not
generally available.

66. Rat-bite fever is caused by:

A. Streptobacillus moniliformis
B. Spirillum minor
C. Either
D. Neither
ANSWER C. Either. Spirillum minor is a spirochete which does not grow on artificial media. It
accounts for most cases of rat-bite fever in Asia. The rat-bite wound heals initially. But 1-4
weeks later a painful, purple, swollen lesion with lymphangitis ushers in constitutional
symptoms (fever, chills, malaise) and headache. An extensive rash may occur. Recurrent
fevers and even endocarditis may ensue. Streptobacillus moniliformis accounts for nearly all
rat-bite fever in the United States. Following a 10-day incubation period, constitutional
symptoms and arthralgias emerge. Disseminated rash, arthritis, and recurrent fever may
develop. Multiple complications may ensue.

67. After a cat bite, a patient starts taking some dicloxacillin left over from a previous skin
infection. However, the bite wound becomes swollen, tender, red, and purulent. Why
didn’t dicloxacillin therapy succeed?
A. Outdated drug
B. Low blood levels from oral therapy
C. Lack of activity against Eikenella corrodens
D. Lack of activity against Pasteurella multocida
ANSWER D. Lack of activity against Pasteurella multocida. Pasteurella multocida in
commonly found in oral flora of dogs and cats. It must be considered in management of dog
and cat bites. Cat bites have a propensity for infection. Semisynthetic penicillinase resistant
penicillins like dicloxacillin and nafcillin, despite activity against Staphylococcus aureus, cannot
be relied on for P. multocida. Ironically, other penicillins (penicillin, ampicillin, amoxicillin),
though not active against S. aureus, are active against P. multocida. E. corrodens has a
similar susceptibility pattern. However, it is a component of human, not cat, flora. The
resistance considerations make the relevance of outdated drug and low blood levels
speculative at best.

68. Eikenella corrodens is susceptible to penicillin and also susceptible to:

A. Nafcillin
B. Clindamycin
C. Metronidazole (Flagyl)
D. None of the above
ANSWER D. None of the above. Eikenella corrodens is found in 59% of human gingival
plaque. Its presence as part of mouth flora explains why it is found in 25% of clenched fist
injuries. (A clenched fist injury is a laceration that occurs when one person strikes another in
the mouth with a clenched fist.) As a result, Eikenella corrodens should be considered in the
empiric treatment of clenched fist injury wound infections. Other organisms, including
anaerobes and Staphylococcus aureus, may also be found in clenched fist injuries. As a
result, one might seek an antimicrobial agent effective against both Eikenella corrodens as well
as the other microorganism. However, Eikenella corrodens has an unusual susceptibility
pattern. Although it is susceptible to penicillin, it is not susceptible to penicillinase-resistant
semisynthetic penicillins, like nafcillin. This is somewhat unusual. Neither is it susceptible to
clindamycin or metronidazole. The result is that we like to include penicillin in a clenched fist
injury regimen. How do we do this? Eikenella corrodens is susceptible to amoxicillin.
Amoxicillin is available in combination with the beta-lactamase inhibitor clavulanic acid as
Augmentin. Augmentin (amoxicillin-clavulanic acid) is active against Staphylococcus aureus,
as well, because of the beta-lactamase inhibitor.