This action might not be possible to undo. Are you sure you want to continue?
after developing fever, rigors, generalized muscle aches, and mild respiratory symptoms. He is otherwise in excellent health. The patient mentions that he had not received an influenza vaccination in the fall. Physical examination is normal except for a temperature of 39.4 °C (103.0 °F) and coryza. Influenza A has been documented in your community, and you have seen several patients with similar symptoms this week. Which of the following is most appropriate for managing this patient? A. Obtain a chest radiograph and blood cultures B. Obtain a nasopharyngeal culture for influenza and treat only if the result is positive C. Prescribe either amantadine, rimantadine, zanamivir, or oseltamivir D. Prescribe a fluoroquinolone antibiotic E. Administer an intramuscular or intravenous dose of ceftriaxone and prescribe azithromycin Infectious Disease Medicine:Question 2 A 35-year-old man was found to be HIV positive when he applied for life insurance. He is not certain when he became infected, but this could have occurred as long as 10 years ago. The patients only symptom is occasional night sweats two to three times each month. He otherwise feels well, works full time, and has never been hospitalized. Physical examination discloses small white exudative patches on his soft palate that are consistent with thrush. His CD4 cell count is 260/μL, and his plasma HIV RNA viral load is 1550 copies/mL. Which of the following is the most appropriate management for this patient? A. Repeat the CD4 cell count; begin antiretroviral therapy only if the count is below 200/μL B. Repeat the plasma HIV RNA determination; begin antiretroviral therapy only if the viral load is greater than 10,000 copies/mL C. Antiretroviral therapy is not indicated at this time because the patient is asymptomatic D. Begin treatment now with a three-drug antiretroviral regimen E. Begin treatment now with a two-drug antiretroviral regimen Infectious Disease Medicine:Question 3 A 67-year-old woman is admitted to the intensive care unit following urgent surgery because of bowel perforation and peritonitis. Despite having a colostomy and careful peritoneal lavage, she remains hypotensive and intubated postoperatively. She improves somewhat after ceftazidime and metronidazole are started by intravenous infusion, but on hospital day 9 she develops a new fever and recurrent hypotension. All intravenous catheters are replaced, blood cultures are obtained, and vancomycin is added to her regimen. On hospital day 11, a blood culture and a catheter tip culture are both growing an Enterococcus faecalis strain that is resistant to vancomycin but susceptible to ampicillin. Repeat blood cultures are obtained, and intravenous ampicillin is substituted for vancomycin. Three days after ampicillin is started, her fever persists, and she has developed an extensive rash. The blood cultures obtained on days 9 and 11 are all growing the same strain of E. faecalis. Which of the following should be done next? A. No change in antibiotics is needed, as the infected intravenous catheter was removed B. Begin piperacillin/tazobactam; stop all other antibiotics C. Begin quinupristin/dalfopristin; stop ampicillin D. Begin linezolid; stop ampicillin E. Stop ampicillin; resume this drug after the patient completes a desensitization protocol
Infectious Disease Medicine:Question 4 A 25-year-old man comes to the emergency department in April with fever and a cough of 2 weeks duration. HIV infection was diagnosed when he was incarcerated 4 years ago. He was recently released on parole. On physical examination, he appears thin. Temperature is 38.3 °C (100.9 °F), and respiration rate is 22/mm. Breath sounds are decreased in the right mid-lung field. Arterial oxygen saturation is 98% by pulse oximetry with the patient breathing room air. A chest radiograph shows a right middle lobe infiltrate, and he is hospitalized. Which of the following should be included in this patient’s admitting orders? A. Contact isolation B. Airborne isolation (negative pressure) C. Droplet isolation D. Standard precautions only Infectious Disease Medicine:Question 5 A 30-year-old man with HIV infection is evaluated because of a 1-week history of increasing headaches, low-grade fever, anorexia, nausea, and vomiting. He has not received any prescribed medications for the past 3 years because he believes that herbs and vitamins provide better therapy. On physical examination, the patient appears lethargic. Temperature is 38.2 °C (100.8 °F). He has extensive seborrheic dermatitis of the face and appears to have lost weight. His neck is supple. There are no focal neurologic findings. Hematocrit is 32%, the leukocyte count is 2500/μL, and the platelet count is 150,000/μL. Lumbar puncture is performed. The opening pressure is 39 cm H2O, leukocyte count is 25/μL, protein is 65 mg/dL, and glucose is 50 mg/dL (simultaneous plasma glucose is 95 mg/dL). An India ink preparation shows many encapsulated budding yeasts, and the cryptococcal antigen titer is greater than 1:8192. In addition to beginning antifungal therapy, which of the following should be done next? A. No additional therapy is indicated B. Request that a neurosurgeon place a ventriculoperitoneal shunt as quickly as possible C. Perform lumbar punctures daily D. Give dexamethasone, 8 mg daily for 1 week E. Begin highly active antiretroviral therapy Infectious Disease Medicine:Question 6 A 51-year-old male accountant is being treated for his third episode of pneumococcal pneumonia in the last 15 months. Prior to the first episode, he had never had a major illness and had never been hospitalized. There have been no significant personal or occupational changes and no history of recent travel. His children are grown and live away from home. Physical examination and a chest radiograph are consistent with right lower lobe pneumonia. A CT scan of the chest shows no endobronchial or other mass lesions. The leukocyte count is 14,500/μL with a slight left shift. Determination of lymphocyte subsets shows a normal ratio of CD4/CD8 cells. Total hemolytic complement (CH5O) determination is normal. Serum protein electrophoresis shows gamma globulins in the low-normal range without a monoclonal spike. Which of the following disorders is the most likely cause of this patient’s multiple episodes of pneumonia? A. Terminal complement component deficiency B. Bronchogenic carcinoma C. Common variable hypogammaglobulinemia
D. Multiple myeloma
Infectious Disease Medicine:Question 7 A 75-year-old female nursing-home resident is brought to the emergency department because of a 2-day history of generalized weakness and fever. The patient requires a chronic indwelling urinary catheter. On physical examination, temperature is 38.4°C (101.1 °F), pulse rate is 95/min, respiration rate is 22/mm, and blood pressure is 132/72 mm Hg. Examination findings are otherwise normal for a patient of her age. The leukocyte count is 13,000/μL (with 11% immature band forms). Urinalysis shows 20-25 leukocytes/hpf. A complete metabolic profile is normal. Arterial oxygen saturation is 95% by pulse oximetry with the patient breathing room air. Urine culture and two sets of blood cultures obtained in the emergency department are growing Escherichia coli. Which of the following terms best describes this patient’s illness? A. Systemic inflammatory response syndrome B. Septic shock C. Bacteremia D. Sepsis E. Severe sepsis Infectious Disease Medicine:Question 8 A 54-year-old man is evaluated because of fatigue, backache, and intermittent fever of 3 months duration. He has no history of cardiac disease or drug allergies. On physical examination, there are three splinter hemorrhages under his fingernails but no other abnormalities of his skin. Ophthalmologic examination reveals a right conjunctival hemorrhage. Funduscopic examination is normal. The lungs are clear. Cardiac examination discloses a soft diastolic murmur of aortic insufficiency, which is a new finding. There is no splenomegaly. Neurologic examination is normal. Four sets of blood cultures grow a microorganism of the viridans streptococci group, which is sensitive to penicillin. A transthoracic echocardiogram shows a thickened bicuspid aortic valve with evidence of mild aortic insufficiency. A transesophageal echocardiogram confirms these findings and also shows an oscillating mass on the aortic valve. Which of the following intravenous agents is the most appropriate initial antibiotic therapy for this patient? A. Vancomycin for 4 weeks B. Penicillin G for 4 weeks C. Penicillin G plus gentamicin, both for 4 weeks D. Penicillin G plus gentamicin, both for 6 weeks E. Ceftriaxone for 8 weeks Infectious Disease Medicine:Question 9 Two days ago, a previously healthy 27-year-old man came to the emergency department because of a 2-day history of fever, headache, and general malaise. Other than a temperature of 37.9 °C (101.2 °F), physical examination was normal. Complete blood count, serum electrolytes, blood urea nitrogen, serum creatinine, CT scan of the head, and cerebrospinal fluid examination were normal. The patient was given an antipyretic agent and sent home with instructions to rest and drink sufficient fluids. The next day, he returned to the emergency department because of new skin lesions on his face and neck. These measured 2 to 3 mm in diameter and were erythematous and papular with a slight tendency to becoming vesicular. Chickenpox was diagnosed on clinical grounds. No additional laboratory tests were done, no medications were prescribed, and he was sent home again. Today, the patient returns to the emergency department because his general symptoms and the facial rash are worse, and more
no known allergies. and coworkers) who had close contact with the patient? A. Sexual contacts within a partner network with a high prevalence of syphilis D. Send all health care workers who had contact with the patient home from day 6 to day 18 after the exposure Infectious Disease Medicine:Question 10 A 45-year-old woman is planning a 2-week trip to Kenya. Occult HIV infection B.lesions are present on his face. The original facial lesions now measure 5 to 6 mm in diameter and are frankly pustular. Measurement of total hemolytic complement (CH50) B. He usually uses condoms but reports that they sometimes tear. Administer vaccinia immune globulin B. Which of the following diagnostic studies should be ordered next to help define the reason for the patients multiple bacterial infections? A. The patient is treated with oral amoxicillin and has a prompt response. Quinine C. He has also had two episodes of bacterial pneumonia during the same time period as well as probable bacterial pneumonia when he was 7 years old. Metronidazole E. Serum IgA subset quantification E. His last HIV test 9 months ago was negative. Lymphocyte subset quantification C. and the lesions on his arms and legs resemble the facial lesions seen yesterday. He asked why this happened on two different occasions. and most of his contacts have been with other men. friends. She seeks your advice regarding prevention of malaria. and legs. Repeat quantitative serum immunoglobulin determination D. Her itinerary includes overnight stays in several game parks. Chloroquine B. Administer vaccinia vaccine concurrently with vaccinia immune globulin E. Administer vaccinia vaccine D. and takes no prescription medications. Failure to treat occult Chlamydia infection C. She has mild osteoarthritis. Incomplete treatment of his previous episode of syphilis . He has been sexually active since 15 years of age. arms. Which of the following prophylactic measures should be done first for all persons (health care workers. Which of the following is the best explanation for his repeated episodes of syphilis? A. Administer ribavirin C. Serum lgG subset quantification Infectious Disease Medicine:Question 12 A 23-year-old man was seen at a local clinic for sexually transmitted diseases because of his second episode of symptomatic primary genital syphilis. Trimethoprim/sulfamethoxazole Infectious Disease Medicine: Question 11 A 19-year-old man is evaluated after his seventh episode of bacterial sinusitis in the last 10 years. Which of the following is indicated for prophylaxis of malaria in this patient? A. Quantitative serum immunoglobulin determination shows that the IgA is below the limits of detection and that the lgG and 1gM are both in the high-normal range. family members. Atovaquone/proguanil (Malarone ®) D.
Which of the following is most appropriate for initial management of this patient? A. She had been in the other hospital for 11 days following a cerebrovascular accident and a nosocomial urinary tract infection that had been treated with ceftazidime. and codeine.E. These findings are interpreted as being compatible with a hospitalacquired pneumonia. and high-dose dexamethasone is begun. including midline shift. Perform lumbar puncture for cerebrospinal fluid culture and cytologic studies D. Which of the following is most appropriate for treating this patient at this time? A. Infection with penicillin-resistant Treponema pallidum Infectious Disease Medicine:Question 13 A 32-year-old woman from New Jersey is evaluated because of a 3-day history of a slowly expanding lesion on her left thigh that is not painful or itching. Vital signs are normal. The patient removed a tick from the site of the lesion approximately 3 weeks ago. On physical examination. his CD4 cell count is 17/μL. burgdorferi assay in 6 weeks B. The following day. he is confused and disoriented but does not appear to be chronically ill. Toxoplasma 1gM titer is negative. A chest radiograph at the time of transfer shows two areas of consolidation in the right lung. sulfa drugs. Administer azithromycin for 21 days Infectious Disease Medicine:Question 14 A 36-year-old man who has been HIV positive for approximately 10 years is brought to the emergency department after a witnessed seizure. she has a 10-cm ovoid erythematous lesion with no central clearing on her thigh. The patient is hospitalized. Cytomegalovirus 1gM titer is negative. He had been receiving antiretroviral medications until approximately 5 years ago. She has documented allergies to doxycycline. Order stereotactic biopsy of the brain lesion C. andToxoplasma lgG titer is positive. On physical examination. Treat empirically for bacterial brain abscess Infectious Disease Medicine:Question 15 A 68-year-old woman is transferred to your institution from an outlying hospital because of worsening pneumonia and respiratory failure. Defer treatment pending the results of a repeat B. An MRI scan of the head shows a single ringenhancing lesion within the left cerebral hemisphere arising from the basal ganglia with significant mass effect. Examination is otherwise unremarkable. An antibody assay for Borrelia burgdorferi is negative. Administer amoxicillin for 21 days C. Which of the following is the most reasonable choice of antibiotics for this patient until further information is available? A. when he dropped out of care. The patient has taken no medications since that time and has no history of AIDS-related problems. Imipenem . Administer doxycycline for 21 days D. Family members report that he has had some memory loss and unusual behavior for the past 2 weeks. Emergency Gram stain of sputum shows numerous leukocytes and gram-negative coccobacillary forms. and cytomegalovirus lgG titer is positive. Treat empirically for toxoplasmic encephalitis B. Her transfer records are incomplete but note that a tracheal aspirate 2 days ago showed copious leukocytes and very resistantAcinetobacter baumannii. Treat empirically for cytomegalovirus encephalitis E.
Oral acyclovir.2 °F). The chaplain E. or valacyclovir daily to be taken indefinitely Infectious Disease Medicine: Question 17 An 18-year-old female college student is brought to the emergency department by her friends because of altered mental status and fever. Six weeks after his return to Georgia. An emergency department intern intubates the patient for airway protection. Hantavirus pulmonary syndrome . or famciclovir daily for 21 days D. Levofloxacin D. A nurse. Oral prednisone plus oral acyclovir daily for 1 week every month E. Following these procedures.B. Physical examination is normal. She was well until several hours ago. starts peripheral intravenous access for hydration and antibiotics. Intravenous acyclovir daily for 21 days C. Ertapenem E. All of the above Infectious Disease Medicine:Question 18 A 65-year-old retired male construction engineer spent 1 month helping to build houses on an Indian reservation in southern Arizona. Her lungs are clear. a 42-year-old woman mentions that her episodes of recurrent genital herpes have become more frequent. when she began complaining of a headache. Laboratory studies are normal except for a hematocrit of 35% and an erythrocyte sedimentation rate of 65 mm/h. Gentamicin Infectious Disease Medicine:Question 16 At a routine office visit. Which of the following treatment regimens will most likely reduce the number of episodes of genital herpes in this patient over the next year? A. The chaplain visits briefly in the patient’s room. Your records show that she received treatment for five episodes in the last 11 months. he consults you because of fever. famciclovir. and mild dyspnea on exertion. These symptoms have been present for about 3 weeks and are not improving with levofloxacin prescribed by his family physician. A chest radiograph shows patchy pulmonary infiltrates in the right middle and right lower lobes. Cefepime C. The radiology technician C. who is wearing only gloves. fatigue. She is tachycardic and hypotensive and has multiple petechiae and some purpura over her lower extremities. Which of the following hospital personnel requires meningococcal post-exposure prophylaxis? A. Oral acyclovir. and she states that she did not even seek therapy for three episodes.0 °C (102. The nurse B. A radiology technician obtains a portable chest film. valacyclovir. lumbar puncture is performed. cough productive of minimal sputum. which reveals Neisseria meningitidis. Topical acyclovir daily for 1 month B. The intern did not have time to put on a mask while doing this procedure. On physical examination. she is obtunded. Temperature is 39. Which of the following is the most likely diagnosis? A. The intern D. She asks if anything can be done to prevent these episodes. Abdominal examination is normal.
after a discussion with her physician. and azithromycin is prescribed. Penicillin B. Ceftriaxone C. A purpuric rash is present on her lower extremities. The leukocyte count is 25. Which of the following empiric antimicrobial regimens is most appropriate? A. Family members state that she developed an earache 3 days ago. One month after her annual physical examination. and protein is 230 mg/dL. Repeat the tuberculin skin test Infectious Disease Medicine: Question 21 A 25-year-old woman who has been documented to be HIV positive for 2 years is in the eighth week of her first pregnancy. .B. Nocardiosis C. she has no allergies. and her only medication is ciprofloxacin. Coccidioidomycosis E. Vancomycin D.000/μL. glucose is 20 mg/dL (simultaneous plasma glucose is 72 mg/dL). Her primary care physician diagnosed otitis media and prescribed ciprofloxacin. the patient is obtunded and has meningismus. The cerebrospinal fluid is cloudy. Order a swallowing evaluation B. she reports only slight improvement. and the density may even have increased. Ehrlichiosis Infectious Disease Medicine:Question 19 A 45-year-old woman is brought to the emergency department after she becomes unresponsive. she develops cough and fever. Three previous skin tests were negative with no palpable induration. Atypical mycobacterial infection D. A chest radiograph shows a hazy density in the posterior left upper lobe. On physical examination. A repeat chest radiograph shows no change.0°F). Which of the following should be done next? A. The result showed a 17-mm induration. Temperature is 40. respiration rate is 32/mm. Order a sputum smear and culture for acid-fast bacilli D. Medical history is noncontributory. She is asymptomatic. Change the azithromycin to levofloxacin C. When seen 1 week later. The leukocyte count is 2500/μL (with 99% neutrophils). and plasma HIV RNA viral loads have been undetectable. A lumbar puncture is performed. the patient did not improve and became increasingly lethargic. However. Vancomycin plus ceftriaxone E. and blood pressure is 80/50 mm Hg. pulse rate is 120/ min. A Gram stain of cerebrospinal fluid shows many neutrophils and gram-positive diplococci in pairs. and the platelet count is 20. She was advised to take isoniazid prophylaxis. However. CD4 cell counts have consistently been greater than 700/μL. The patient was especially concerned about drug side effects because she had recently learned that she has mild multiple sclerosis that does not require treatment. she decided not to take the drug because of concerns about potential hepatotoxicity. The patient has never taken antiretroviral medications.000/μL (with 25% band forms).0 °C (104. Vancomycin plus ampicillin Infectious Disease Medicine:Question 20 A 34-year-old female health care worker had a tuberculin skin test done as part of her annual physical examination.
but the patient continues to become somewhat worse over the next 2 days. Administer nevirapine as a single drug at the time of delivery E. Fasciitis D. Plasma glucose and serum electrolyte determinations are normal. including efavirenz. There is no meningismus. The patient returns to the emergency department 2 days later. Antiretroviral therapy is not needed because of the undetectable HIV RNA viral load D. Lumbar puncture is performed. He had been well the day before. but woke up with a painful area measuring about 6 X 9 cm on the volar surface of the forearm. Which of the following is most appropriate at this time? A.Which of the following is the most appropriate management during her pregnancy? A. 5 mg/kg intravenously every 8 hours B. He is slightly ill but does not appear toxic and is able to go to school and attend basketball practice. Await the results of a polymerase chain reaction test of CSF before beginning antiviral therapy D. Begin zidovudine as a single drug during her second trimester Infectious Disease Medicine:Question 22 An 18-year-old male high school basketball player came to the emergency department in February because of a red patch on his left forearm. She is healthy and takes no medications. Which of the following is the most likely cause of this patient’s clinical deterioration? A. Await the results of an MRI scan of the head before beginning antiviral therapy E. and glucose of 75 mg/dL (simultaneous plasma glucose is 88 mg/dL). She first noted the tick 9 hours ago. Begin acyclovir. even though the television set was turned off. An abscess C. he spent several hours changing the channels on the remote control. The emergency department physician identified the tick as an Ixodes scapularis nymph . Begin a three-drug antiretroviral regimen. The emergency department physician did not believe that incision and drainage were required and prescribed warm packs to the area and a course of dicloxacillin.1 °F). He is confused about where he is and what occurred today. The patient was on a 2-week college industrial-ecologic field trip. Await the results of a brain biopsy before beginning antiviral therapy Infectious Disease Medicine:Question 24 A 19-year-old woman from Indianapolis comes to the emergency department of a New Jersey hospital with a tick on her right arm. A β-lactam-resistant organism Infectious Disease Medicine:Question 23 A 58-year-old man is brought to your office by family members because he has been acting “childish” for 2 days. and raised but was not fluctuant. including zidovudine. Begin a three-drug antiretroviral regimen. temperature is 38. Begin acyclovir.4°C (101. now C. protein of 90 mg/dL. The patch is larger and more tender but is still not fluctuant. On physical examination. during which time she toured a factory or a nature habitat each day and returned to the hotel each evening. The emergency department physician changes the antibiotic to cephalexin. Today. CT scan of the head without contrast shows no abnormalities. Lyme disease B. as is the general physical examination. Cerebrospinal fluid shows 84 leukocytes/μL (93% lymphocytes and 7% neutrophils). now B. Funduscopic examination and the remainder of the neurologic examination are normal. The area was tender to touch. erythematous. She showered daily. 10 mg/kg intravenously every 8 hours C.
He was in his usual state of health until 2 days prior to admission when he developed a frontal headache that kept him awake that night. During the acute phase of her illness and again 2 weeks after recovery. he felt feverish and told his wife that his neck was aching. glucose is 22 mg/dL (simultaneous plasma glucose is 85 mg/dL). and 8 levels D. dexamethasone will improve his chance of survival Infectious Disease Medicine:Question 27 A 22-year-old man was admitted to the intensive care unit in a comatose state following a motor vehicle accident. pulse rate is 130/ min. Dexamethasone should be administered within 1 hour of the first dose of antimicrobial therapy B. dexamethasone will improve his chance of survival E. and protein is 200 mg/dL. Serum lgG subset quantification E. A chest radiograph showed a pulmonary infiltrate. fever. A Gram-stained tracheal aspirate showed many leukocytes and gram-negative bacilli. Acetaminophen provided some relief. and he was brought to the emergency department. he remained comatose and on mechanical ventilation and had also developed fever and purulent sputum. and . Which of the following diagnostic studies should be ordered next? A. No residual tick parts were left in the skin. After removing the tick. Dexamethasone will increase the risk of an unfavorable outcome in an adult patient with bacterial meningitis D. She responded promptly to intravenous ceftriaxone and had no sequelae. Gram stain of cerebrospinal fluid is negative. 1 g orally daily for 10 days D. Intubation and mechanical ventilation were begun. although the tick had definitely been attached. Empiric antimicrobial therapy with vancomycin. If this patient hasListeria meningitis.9°C (102. The following morning. If this patient has pneumococcal meningitis.that was not engorged. Leukocyte count is 1200/μL. On physical examination in the emergency department. The opening pressure is high. her total hemolytic complement (CH5O) values were in the mid-normal range. his wife was unable to arouse him from sleep. Which of the following is the most appropriate management at this time? A. Azithromycin. 500 mg orally three times daily for 10 days C. He is obtunded and has a stiff neck. Dexamethasone has no role in the adjunctive treatment of bacterial meningitis in an adult patient C. Which of the following statements is correct regarding administration of adjunctive dexamethasone to this patient? A. Measurement of alternative pathway complement components C. and altered sensorium. Cefuroxime-axetil. 500mg orally twice daily for 10 days E. Observation B. The next day. No additional studies are needed B. 200 mg orally once daily Infectious Disease Medicine:Question 25 A 33-year-old woman was hospitalized following her third episode of meningococcal meningitis in the last 20 years. Measurement of individual serum C5. temperature is 38. (with 95% neutrophils). respiration rate is 40/mm. 7. Lumbar puncture is performed. ampicillin. there was no evidence of redness or inflammation at the site of the bite. After 1 week. and blood pressure is 110/50 mm Hg. Doxycycline. Amoxicillin. T-cell subset quantification Infectious Disease Medicine:Question 26 An 80-year-old man is hospitalized because of headache.0 °F). 6. and ceftriaxone is begun.
Strongyloides stercoralis E. Taenia solium D. cariniiis negative by direct fluorescent antibody stain. An outbreak of influenza A is occurring in your community. which of the following should be done next? A. Nurses report no diarrhea. Start trimethoprim/sulfamethoxazole to complete a 2. Start oral cefixime to complete a 3-week course of antibiotic therapy E. Ascaris lumbricoides B. Physical examination findings are unchanged. Pneumocystis carinii C. a 56-year-old woman with chronic obstructive pulmonary disease and type 2 diabetes mellitus comes for a routine office visit. 10 days after starting ceftazidime. The patient has not received antiretroviral therapy and has no history of AIDS-related complications. but the patient failed to receive an influenza vaccination last fall. and trimethoprim/sulfamethoxazole. In addition to discontinuing ceftazidime. Bronchoscopy is performed.culture of the aspirate grew Enterobacter cloacae that was sensitive to third-generation cephalosporins. piperacillin.to 3-week course of antibiotic therapy B. Which of the following pathogens is most likely causing this patient’s current findings? A. the patient remains febrile. Intravenous ceftazidime was begun. urinalysis.to 3-week course of antibiotic therapy C. but the specimen was of poor quality. He is treated with intravenous trimethoprim/sulfamethoxazole and oral prednisone in standard doses. Which of the following is most appropriate for preventing influenza in this patient? . She is currently clinically stable and has no new or acute symptoms. Start metronidazole to complete a 3-week course of antibiotic therapy Infectious Disease Medicine:Question 28 A 45-year-old man with known HIV infection for many years is transferred from a community hospital for additional management of pneumonia. An induced sputum specimen for P. Repeat Gram stain of a tracheal aspirate shows many leukocytes and gram-negative bacilli. Admission arterial blood PO2 is 42 mm Hg with the patient breathing room air. and urine culture are negative. and repeat culture of the aspirate grows E. but his clinical condition deteriorates and hypoxemia worsens. Start imipenem to complete a 2. He is a migrant worker who was born in Mexico but spent most of his life in rural Georgia. cloacae that is now sensitive to trimethoprim/sulfamethoxazole and resistant to all β-lactams except imipenem. and microscopic examination of bronchoalveolar lavage fluid is shown. Cryptosporidium parvum Infectious Disease Medicine:Question 29 In January. No new antibiotics are required D. the pulmonary infiltrates are less extensive. Intubation and mechanical ventilation are required shortly after transfer. Blood cultures. However. An admission chest radiograph shows bilateral interstitial pulmonary infiltrates consistent with Pneumocystis carinii pneumonia. Today.
On the 26th day. In addition to advice about barrier precautions.4 °F) without localizing signs. but he develops fever to 39. Patient-initiated 3-day course of ciprofloxacin. or oseltamivir for 2 weeks Infectious Disease Medicine:Question 30 A 35-year-old man was admitted to the intensive care unit (ICU) because of injuries sustained as a result of a gunshot wound. blood cultures are obtained. as he is about to be transferred from the ICU. rimantadine. The patient refused further work-up. On the 22nd day in the ICU. no additional diagnostic studies or treatment is indicated Infectious Disease Medicine:Question 31 A 20-year-old male college student is evaluated on Tuesday morning because of a 2-day history of urethral discharge and dysuria. who found no abnormalities during cystoscopy. and imipenem is restarted. his temperature is normal. 250 mg orally twice daily D. Repeat the blood cultures. Administer influenza vaccine and prescribe amantadine. and the renal failure continues to resolve. and treatment for gonorrhea and possible occult Chlamydia infection is begun. Prompt urination after sexual intercourse Infectious Disease Medicine:Question 33 A 63-year-old woman is hospitalized because of refractory cellulitis. He underwent repair of a perforated colon. 160/800 mg orally twice daily 0. All catheters are changed. begin fluconazole immediately after specimens are obtained C. Long-term low-dose amoxicillin. Do a funduscopic examination. Which of the following is the most appropriate next step in managing this patient? A. these problems are resolving. the laboratory reports that a yeast is growing in one bottle of each of two sets of blood cultures that were obtained on the day that he became febrile. begin fluconazole only if chorioretinitis is present D. She was referred to a urologist. or oseltamivir for 6 weeks E. An intravenous . Showering shortly after sex D. required hemodialysis for acute renal failure. Taking prophylactic antibiotics after sex Infectious Disease Medicine:Question 32 A 49-year-old woman has had four urinary tract infections in the past 7 months. Asking sexual partners if they might have gonorrhea C. Which of the following is the most appropriate management strategy to prevent recurrent urinary tract infections in this patient? A. Gram stain and smear of a thick discharge show copious leukocytes and numerous gram-negative intracellular diplococci. 250mg orally daily B. Administer influenza vaccine and prescribe amantadine. Long-term full-dose trimethoprim/sulfamethoxazole. or oseltamivir for 2 weeks D. Obtain a nasopharyngeal culture for influenza and treat only if the result is positive C. a chest radiograph shows no new pulmonary infiltrates. Removing the catheters is adequate. and was treated with imipenem for Enterobacter pneumonia. Tell the patient that it is too late for an influenza vaccination but prescribe amantadine. which of the following should be discussed as a way to prevent future sexually transmitted diseases in this patient? A. Repeat the blood cultures. Use of spermicides E. rimantadine. await culture results before beginning fluconazole B. Using caution about alcohol consumption B.7 °C (103. rimantadine. On the 23rd day in the ICU.A. Administer influenza vaccine and prescribe no new drugs B.
tachycardia. but the catheter tip and both sets of blood cultures grow Staphylococcus aureus that is reported to be sensitive to oxacillin. 2 g intravenously every 4 hours. ccli that is sensitive to ceftriaxone. The patient improves. continue the intravenous nafcillin for a total of 14 days E. Which of the following is the most appropriate next step in managing this patient? A. and urinary urgency and frequency. cefepime. fluoroquinolones.1 °F). and she appears to be improving. with minimal diffuse tenderness to deep palpation and normal bowel sounds. The catheter is removed. No additional diagnostic studies are needed. Change to imipenem D. she is transferred to another hospital 2 weeks later. if this does not show signs of endocarditis. imipenem. Discontinue all antibiotic therapy Infectious Disease Medicine:Question 36 A 29-year-old man was found to have late-stage HIV infection at the time of diagnosis of . After 2 days. fluoroquinolones. or urinary tract obstruction. Obtain a transesophageal echocardiogram. flank pain and tenderness. continue the intravenous nafcillin for a total of 6 weeks Infectious Disease Medicine:Question 35 A 74-year-old woman is hospitalized because of chills.5 °C (103. the patient appears ready for discharge. she develops profuse diarrhea and a low-grade fever. stop the intravenous nafcillin B. if this does not show signs of endocarditis. Obtain a transesophageal echocardiogram. he develops diaphoresis. Obtain CT scans of the abdomen E. and empiric vancomycin is begun. and a urine culture grows Escherichia coli that is sensitive to ceftriaxone but is resistant to ceftazidime. Obtain routine bacterial stool cultures B. and a temperature of 39. Continue ceftriaxone B. Institute contact isolation D. Which of the following is most appropriate regarding this patients antibiotic therapy? A. based on cardiac and hemodynamic parameters. Add an aminoglycoside to her current regimen Infectious Disease Medicine:Question 34 A 78-year-old man is admitted to the intensive care unit because of severe congestive heart failure that requires monitoring with a central venous catheter. dysuria. and trimethoprim/sulfamethoxazole. On hospital day 7.cephalosporin is started. and repeat blood cultures show no growth. The patient is treated with ceftriaxone for 10 days but remains febrile. blood culture specimens are drawn. Change to aztreonam C. nephrolithiasis. No signs of endocarditis are noted on physical examination. Because of persistent fever. and trimethoprim/sulfamethoxazole. CT scan of the abdomen and pelvis shows no renal or perirenal abscesses. Urine culture obtained at the second hospital again grows E. and piperacillin/tazobactam but is resistant to ceftazidime. Urinalysis shows pyuria. A small amount of purulent material is noted at the catheter site. Which of the following is the most appropriate management at this time? A. continue the intravenous nafcillin for a total of 8 weeks C. Vancomycin is changed to nafcillin. No additional diagnostic studies are needed. however. Start an antimotility agent C. substitute oral dicloxacillin for the intravenous nafcillin for a total of 10 days of antibiotics D. fever. Her abdomen is soft. On the fifth hospital day. No additional diagnostic studies are needed.
The spleen tip is palpable. Treat symptomatically for pain and fever Infectious Disease Medicine:Question 37 A 43-year-old male farmer comes to your office because he developed a blister at the vermilion border of his lower lip yesterday morning.9 mg/dL Serum electrolytes Normal Urinalysis Myriad erythrocytes/hpf. Substitute efavirenz for abacavir in the antiretroviral regimen C. fluctuant lymph nodes. Prescribe a 7-day course of oral acyclovir to be started today D. Prescribe topical penciclovir to be started today E. and blood pressure is 92/68 mm Hg. Which of the following organisms is least likely to be the etiologic agent causing this patients illness? A. Examination of the neck discloses bilateral enlarged. and she had spent time in their homes and in the fields where they worked. Perform a diagnostic thoracentesis E. She had direct contact with two of the patients and their families.6 °C (101 . A chest radiograph shows a new pleural effusion. where she covered a story about a small outbreak of a hemorrhagic fever. Neisseria meningitidis B. Which of the following is the most appropriate management at this time? A. She has just returned from Africa. Lymph node aspirate reveals no organisms on acid-fast stain. His initial CD4 cell count was 17/μL with a plasma HIV RNA viral load of 33. On physical examination. rifampin. Physical examination is normal except for one blister on his lip. He mentions that the lesions often appear after extended periods in the sun.1 °F). At a follow-up visit 4 weeks later. Add ethambutol to the antituberculous regimen B. headache.pulmonary tuberculosis. Obtain a virus culture of the lip lesion B. moderate protein. hypotension. Obtain an excisional lymph node biopsy D. lamivudine.5 g/dL Leukocyte count 2300/μL (with a marked left shift) Platelet count 29. Which of the following is most appropriate at this time? A. Yersinia pestis .520 copies/mL. Laboratory studies: Hemoglobin 8. discuss the option of immediate self-treatment with topical penciclovir for future episodes Infectious Disease Medicine:Question 38 A 53-year-old female reporter is evaluated because of fever.5 °F). a lumbar puncture was not done. On physical examination. otherwise normal Because of the platelet count and bleeding into the skin and urinary tract. temperature is 38. A petechial and purpuric rash is present on her trunk and extremities. Prescribe no treatment now. His weight is unchanged. tender. Other vital signs are normal. The patient denies fever or fatigue and otherwise feels well. and pyrazinamide) and a threedrug antiretroviral regimen (zidovudine. He has a long history of similar lesions. and rash. he reports recurrent fevers as well as neck pain and swelling.4°C (101. Prescribe a topical antibacterial ointment to be started today C. and abacavir).000/μL Blood urea nitrogen 55 mgldL Serum creatinine2. Cough and fever quickly improved following treatment with a three-drug antituberculous regimen (isoniazid. temperature is 38. which he refers to as cold sores.
Begin moxifloxacin E. Which of the following is most likely causing this patients current findings? A. Physical examination discloses a small dorsocervical fat pad. Cushing’s syndrome C. 4 μg/mL). His CD4 cell count has increased from 150/μL to 440/μL when last measured. He feels well and is working full time. the patient has had consistently undetectable plasma HIV RNA viral loads. HIV wasting . Marburg virus Infectious Disease Medicine:Question 39 A 17-year-old male adolescent is hospitalized because of a pyogenic liver abscess. HIV infection was diagnosed in 1995. He has had numerous episodes of bacterial pneumonia. and other infections for most of his life. However. he develops a petechial rash. Blood and sputum cultures growStreptococcus pneumoniae that is sensitive to levofloxacin (minimum inhibitory concentration. the patient remains febrile and hypotensive. Ebola virus D. which of the following is most appropriate at this time? A. Begin quinupristin/dalfopristin D. Which of the following laboratory studies is most appropriate to attempt to identify the cause of this patients multiple infections? A. C1 inhibitor (C1 INH) Infectious Disease Medicine:Question 40 A 25-year-old man is hospitalized because of right lower lobe pneumonia. Begin intravenous vancomycin B. Blood cultures drawn on day 5 again grow gram-positive diplococci. HIV lipodystrophy D. High-grade B-cell lymphoma B. Begin clindamycin C. C3 B. A total hemolytic complement (CH50) value was 3 standard deviations below the mean.C. wasting in all four extremities. On hospital day 5. and a protruding abdomen with mild hepatomegaly and some faint striae. Begin doxycycline Infectious Disease Medicine:Question 41 A 47-year-old man with longstanding HIV infection has a 6-month history of increasing abdominal girth. IgA E. Intravenous levofloxacin is begun. and his weight has decreased from 95 kg (209 Ib) to 90 kg (198 Ib) over the same period. In addition to discontinuing levofloxacin. C5 D. Since beginning this regimen. sinusitis. and treatment with a protease inhibitor-containing antiretroviral regimen was started 2 years ago. 2 μg/mL) but is resistant to erythromycin and penicillin (minimum inhibitory concentration. skin infections. Results of previous studies for immunoglobulin and neutrophil disorders were normal. Properdin C.
E. and Staphylococcus aureus catheterrelated bacteremia. acute graft-versus-host disease treated with corticosteroids and tacrolimus. she undergoes matched unrelated allogeneic stem cell transplantation. Six sets of blood cultures grow Enterococcus faecalis. and the patient is begun on vancomycin. which is resistant to penicillin and ampicillin but sensitive to vancomycin. general physical examination is noncontributory. By day 80 after transplant. pleuritic chest pain. a 48-year-old man has a cerebrovascular accident. Remove the central venous catheter B. 80mg intravenously every 8 hours (the patient weighs 76kg [167 Ib). and his gentamicin peak level is 3. Chronic hepatitis C infection Infectious Disease Medicine:Question 42 A 52-year-old woman from Kentucky has acute myeloid leukemia. cough. and hemoptysis. The technician notes that the vancomycin peak and trough levels and the gentamicin trough level are in the desirable range but that the laboratory’s therapeutic peak range for gentamicin is 4 to 8 μg/mL. the laboratory reports that his vancomycin peak level is 32 μg/mL with a trough level of 9 μg/mL. On day 90. 1 g intravenously every 12 hours. A highresolution CT scan of the chest is shown. Begin azithromycin Infectious Disease Medicine:Question 43 Two years after undergoing mitral valve replacement.9 °C (102. Begin fluconazole D.8 μg/mL. and high-dose corticosteroids are begun. Vancomycin and cefepime are begun. Repeat blood cultures show no growth. Which of the following should be done next? A. The laboratory also reports the absence of high-level resistance to gentamicin and streptomycin. Her course is complicated by Pseudomonas pneumonia and Clostridium difficile colitis prior to engraftment. she develops fever to 38. A transesophageal echocardiogram shows an oscillating mass on the mitral valve but no evidence of perivalvular extension or abscess. and complete . The cardiac examination is unchanged from previous findings. A chest radiograph shows a right lower lobe pulmonary infiltrate. After 3 days of therapy. and gentamicin. Except for fever. Begin amphotericin B C. chronic graft-versus-host disease is documented by biopsies of the gastrointestinal tract and skin. After several cycles of induction chemotherapy and subsequent relapse.0 °F). A decision is made to treat medically.2 μg/mL with a trough level of 0.
Erythromycin B. Yellow fever C. Three weeks ago. she is confused and oriented only to person. diet-controlled diabetes mellitus. and confusion. Which of the following antimicrobial agents should be started? A. The ulcer can be probed to the first metatarsal head.blood count and serum creatinine values are normal. Current medications are prednisone and azathioprine. Gram stain of cerebrospinal fluid shows gram-positive bacilli.500/μL. temperature is 39. Vancomycin E. Culture of the bone grows . On neurologic examination. (with 20% band forms).0 °F). indicative of osteomyelitis. Her neck is supple. fever returned and she developed a headache. keep the vancomycin unchanged B. Which of the following is most appropriate at this time? A. Increase the vancomycin dose. Which of the following is the single most important vaccine for this traveler? A. ataxia. Decrease the interval between the gentamicin doses. pulse rate is 100/ min. Plantar responses are extensor bilaterally. keep the gentamicin unchanged Infectious Disease Medicine:Question 44 A 35-year-old woman who underwent cadaveric renal transplantation 12 months ago is hospitalized because of fever. One day after the reunion. as she developed anaphylactic shock after receiving this drug. Keep both the gentamicin and the vancomycin doses unchanged D. The leukocyte count is 18. She is allergic to penicillin. keep the vancomycin unchanged C. He has hypertension. respiration rate is 30/mm. Current medications are hydrochlorothiazide and lisinopril. and protein is 300 mg/dL. and no known allergies. she attended a family reunion where she ate processed meats and cole slaw. headache. she developed loose stools and low-grade fever that lasted for 24 hours. Japanese encephalitis B. Cholera D. Levofloxacin Infectious Disease Medicine:Question 45 A 67-year-old man is planning a 3-week fishing trip to the Amazon basin areas of Peru and Brazil. Meningococcal Infectious Disease Medicine:Question 46 A 46-year-old man with diabetes mellitus develops a plantar foot ulcer.4 °C (103. glucose is 30 mg/dL (simultaneous plasma glucose is 81 mg/dL). Trimethoprim/sulfamethoxazole D. Haemophilus influenzae type b E. On physical examination. Increase the gentamicin dose. and blood pressure is 90/60 mm Hg. Chloramphenicol C. Cerebrospinal fluid leukocyte count is 1500/μL (with 50% neutrophils and 50% lymphocytes). Lumbar puncture is performed. Yesterday (the day prior to hospital admission).
vancomycin-resistant and penicillin-resistant Enterococcus faecium. imipenem-sensitive Acinetobacter species. He had been doing well until the current symptoms developed. Which of the following is the most appropriate treatment at this time? A. Some lesions are crusted. rifabutin. He has limited English language skills and cannot provide a detailed personal or family medical history. Ertapenem plus quinupristin/dalfopristin C. fever of 5 weeks duration. Isoniazid. face. Oral antihistamines to be taken as needed for itching E. Topical antibacterial ointment to be applied to the pustular lesions Infectious Disease Medicine:Question 49 A 57-year-old male Russian immigrant is hospitalized because of cough and fever. anorexia. but reasonable control was eventually achieved using a regimen of lamivudine. and weight loss. vesicles. Physical examination reveals several hundred lesions distributed in the aforementioned areas that are in various stages of development. HIV infection was diagnosed several years ago. He also had mild fever. including papules. ethambutol. Await culture results before beginning antimycobacterial therapy Infectious Disease Medicine:Question 48 A 20-year-old male college student is evaluated because of a 4-day history of vesicular lesions on his back. You also advise him and family members to contact you if respiratory or neurologic symptoms develop or if the skin lesions do not resolve within 7 to 10 days. and the patient is placed in a private room. arms. His CD4 cell count had been as low as 10/μL at a time when he had Pneumocystis carinii pneumonia. and ethambutol E. Imipenem plus linezolid Infectious Disease Medicine:Question 47 A 42-year-old man with known late-stage HIV infection is hospitalized because of a cough. Topical acyclovir in sufficient quantities to cover all lesions C. On the third hospital day. his lungs are clear. You diagnose chickenpox (primary varicella) and advise him to stay home until all lesions are crusted. Which of the following is also appropriate at this time? A. His last plasma HIV RNA viral load was 310 copies/mL with a CD4 cell count of 185/μL. pyrazinamide. Imipenem D. a right lower lobe pulmonary infiltrate. A chest radiograph shows a right upper lobe pulmonary infiltrate. The patient is placed in respiratory isolation. Ertapenem B. and small pustules. and rifabutin C. and the inside of his cheeks. and a right pleural effusion. stavudine. and neurologic examination is normal. and methicillinresistant Staphylococcus aureus. Cefotaxime and azithromycin are started. Several different antiretroviral regimens that included agents from all three classes were ineffective. rifampin. family members visit and state that the patient has several . Two of two sputum specimens stain positive for acid-fast bacilli. night sweats. chest. Clarithromycin and ethambutol B. Clarithromycin. and ritonavir. and pyrazinamide D. indinavir. which has since resolved. Isoniazid. Oral acyclovir B. He does not have lymphadenopathy. Which of the following antibiotic agents is most appropriate for this patient? A. An admission chest radiograph shows right hilar lymphadenopathy.imipenem-sensitive Pseudomonas aeruginosa. He does not have respiratory or neurologic symptoms. Home administration of intravenous acyclovir D.
On physical examination. and malaise. Ehrlichia antibody titer C. temperature is 40. Human T-cell lymphotropic virus-1 (HTLV-1) D. and 1gM levels (all were more than 2 standard deviations below the normal mean).0 °C (104. Bowel sounds are normal. myalgias. His physician declined to obtain serologic studies for Lyme disease but started treatment with doxycycline for 21 days. rifampin. Laboratory studies: Hemoglobin 7. IgA. Pallor and pale conjunctivae are present. the patient develops fevers. and pyrazinamide E. A grade 2/6 systolic murmur is heard. Epstein-Barr virus Infectious Disease Medicine:Question 51 A 45-year-old man from Cape Cod.’ Which of the following viruses would best explain the cause of these illnesses in the three family members? A. ethambutol. and a maternal uncle died during adolescence “after his bone marrow stopped making blood cells. HIV B. Tuberculin skin testing now and in 12 weeks B. Massachusetts. he is in good health and takes no medications. Which of the following is the most appropriate management for health care workers who participated in this patient’s care? A. A sputum smear is obtained from the patient. Serologic studies for Rocky Mountain spotted fever . Observation for clinical disease Infectious Disease Medicine:Question 50 A 19-year-old man with multiple episodes of sinusitis and pneumonia is found to have abnormal serum lgG.000/μL Serum haptoglobin 1 mg/dL Serum aspartate aminotransferase 250 U/L Serum alanine aminotransferase 150 U/L Serum bilirubin 3.relatives who had been incarcerated in Russia and have hemoptysis. which is strongly positive for acid-fast bacilli. Human herpesvirus 6 E. The abdomen has a long midline surgical scar. drenching night sweats. His older brother died of lymphoma at age 12 years. The liver is palpable 4 cm below the right costal margin in the midclavicular line. and the lesion quickly improved. Cytomegalovirus C. Two weeks later.0 mg/dL Serum alkaline phosphatase 375 U/L Serum lactate dehydrogenase 575 U/L Which of the following should be done next to establish the diagnosis? A. The lungs are clear. no further intervention if the chest film is normal C. developed a slowing expanding erythematous lesion on his back. Chest radiograph now.1 g/dL Hematocrit2l % Leukocyte count 4000/μL Platelet count 50. Immediate initiation of isoniazid D. He had a month-long febrile illness several months ago that remitted spontaneously and remains undiagnosed. and cough. There is no palpable spleen. Heart rate is regular. Other than a splenectomy 15 years ago following a motor vehicle accident. fever.0 °F). Serologic studies for Lyme disease B. Immediate initiation of isoniazid. There is no lymphadenopathy.
saline volume repletion. Change to quinupristin/dalfopristin D. the subclavian vein catheter is removed. ventilatory support.or Wright-stained peripheral blood smear Infectious Disease Medicine:Question 52 A 40-year-old female hospital employee is referred for evaluation of a positive tuberculin skin test (10-mm induration). The patient is hospitalized. On the third hospital day. Two sets of blood cultures are drawn on admission.D. 600 mg daily for 4 months Infectious Disease Medicine:Question 53 A 58-year-old man with a history of chronic alcoholism was admitted to the intensive care unit 3 days ago because of Streptococcus pneumoniae pneumonia and bacteremia. who requires chronic hemodialysis via a left subclavian vein catheter. The patient is currently receiving appropriate antibiotic therapy. Nutritional support C. stress ulcer prophylaxis. In addition. since her positive tuberculin skin test reaction is most likely due to the bacille Calmette-Guérin vaccination B. the patient again becomes febrile. Change to moxifloxacin . Administration of N-acetylcysteine D. vasopressor agents. hypotensive (systolic blood pressure of 80 mm Hg). Which of the following is most appropriate for this patient? A. Administration of nitric oxide E. No chemoprophylaxis is necessary. The patient was born in India and moved to the United States 10 years ago. and hypoxemic. She has not been tested since that time and has never received antituberculous medications. She knows of no definite exposure to anyone with active tuberculosis. has no chronic medical problems. Change to clindamycin. A recent chest radiograph was normal. and low-molecular-weight heparin. 300 mg daily for 9 months D. Continue intravenous vancomycin B. develops chills and fever while in the dialysis center. He also had lactic acidosis and soon after admission developed oliguria. and two additional sets of blood cultures are drawn. Administration of a corticosteroid B. No chemoprophylaxis is necessary. She received bacille Calmette-Guérin vaccination as a child and remembers having at least two tuberculin skin tests in her teens and twenties. sedation. subculture of the original two sets grows nonhemolytic colonies on blood agar plates (presumptively identified by the laboratory as an enterococcus). tachypneic. and takes no medications. Which of the following additional therapeutic measures is currently accepted as potentially beneficial for this patient? A. the microbiology laboratory reports that three of the four original blood culture bottles are growing gram-positive cocci in chains. The patient is symptom-free. and the catheter tip is cultured semiquantitatively. When admitted. Which of the following is the most appropriate antibiotic therapy pending definitive identification and sensitivity testing of the causative pathogen? A. Administration of colloid Infectious Disease Medicine:Question 54 A 76-year-old woman with diabetes mellitus and end-stage renal disease. and the fever resolves. On the fourth hospital day. which she was told were positive. On the fourth hospital day. Administration of rifampin. Also on the third day. Giemsa. He is hemodynamically stable and has adequate oxygenation. Administration of isoniazid. C. he was hypothermic. since she is a long-term tuberculin skin test reactor who is older than 35 years of age C. intravenous vancomycin is begun. the second two sets of blood cultures are also reported to be growing gram-positive cocci in chains.
Although she has fatigue and mild anorexia.E. Substitute another recommended agent for zidovudine D.000 copies/mL. Continue all medications. On questioning. nonproductive cough and fever to 38. Three days later. His only other symptoms are low-grade fever and weakness. She forgot to mention that she had taken the same antibiotic for a urinary tract infection 1 month before school started. Broad-spectrum antibiotics were started yesterday because of febrile neutropenia. which was obtained by gently scraping the lesion with a tongue blade. and his lungs are clear. Mupirocin ointment applied 3 times daily for 10 days B. Which of the following is the most appropriate therapy for this patient’s oral ulcers? A. 30 to 60 mg orally every 4 to 6 hours as needed E. the patient admits to a history of injection drug use and multiple sexual partners but states that he has been drug free and abstinent for 1 year. Which of the following is most appropriate at this time? A. a physician sustains a needlestick injury from a patient whose HIV status is not known.1 °C (100. He has never been tested for HIV and consents to being tested on the day of the injury. obtain a chest radiograph for possible Pneumocystis carinii pneumonia E. 30 to 60 mg intravenously every 6 hours for 3 days Infectious Disease Medicine:Question 57 A 19-year-old female college student comes to the student health service because of dysuria and urinary urgency. Methylprednisolone. Begin three-drug antiretroviral therapy immediately. Change to linezolid Infectious Disease Medicine:Question 55 A 34-year-old woman has newly diagnosed HIV infection.0 °F). There are no skin lesions. she develops a diffuse rash. She does not have a urinary tract infection D. She has a urinary tract reinfection Infectious Disease Medicine:Question 58 After performing an arterial puncture. 400 mg orally 5 times daily for 10 days C. She has been noncompliant with treatment C. and the patient is given a 3-day course of trimethoprim/sulfamethoxazole. One week later. Which of the following most likely explains this patient’s failure to improve? A.6 °F). Her CD4 cell count is 230/μL with a plasma HIV RNA viral load of 99. continue therapy for 1 month . Substitute another recommended agent for abacavir C. Acyclovir. her weight has been stable. Serum creatinine is 1. 5mg/kg intravenously every 12 hours for 14 days D. and abacavir are begun. He is able to swallow without much difficulty. temperature is 38.9°C (102. Continue all medications. nausea. A Tzanck smear of an oral lesion.0 mg/dL. Several shallow ulcers without exudate or odor are present on his palate and pharynx. reveals multinucleated giant cells. Codeine. Ganciclovir. and a chest radiograph is normal. A urinary tract infection is diagnosed. She is infected with a trimethoprim/sulfamethoxazole-resistant organism B. Zidovudine. Which of the following is the most appropriate management for the physician? A. begin treatment of symptoms Infectious Disease Medicine:Question 56 A 29-year-old man who is undergoing chemotherapy for acute myeloid leukemia develops blisters on his soft palate that quickly ulcerate. the patient reports that the dysuria improved during the first 2 days of therapy but became worse on day 3. On physical examination. lamivudine.
Ciprofloxacin or doxycycline plus clindamycin and vancomycin C. Obtain baseline serologic testing for HIV. The remainder of the examination is unremarkable. and protein is 190 mg/dL.5 mg/dL Serum electrolytes: Sodium 133 meq/L Potassium4.B. erythrocyte count is 20/μL. A sputum specimen cannot be obtained. azithromycin.350/μL Blood urea nitrogen 45 mg/dL Serum creatinine 1. fever. Hemoglobin 9. Examination of the chest reveals only a few scattered crackles bilaterally. Ciprofloxacin and doxycycline Infectious Disease Medicine:Question 60 A 25-year-old man comes to the emergency room because of severe pain and swelling of the right arm that began at the site of a small cut. and blood pressure is 80/40 mm Hg. repeat testing in 6 weeks and again in 6 months Infectious Disease Medicine:Question 59 A 57-year-old male city government clerk has missed 3 days of work because of increasingly severe malaise. The right arm is erythematous with tense edema and several bullous lesions.0 °F). respiration rate is 35/mm. and rifampin D. and vancomycin B. Await results of the patient’s HIV antibody test before beginning antiretroviral therapy.2 °F). hepatitis B. dry cough. Temperature is 40.2 g/dL Leukocyte count 1 5. and headache. the patient appears acutely ill. and hepatitis C for both the patient and the physician.0 mg/dL A chest radiograph shows vague scattered pulmonary infiltrates and a widened mediastinum. penicillin G.300/μL Platelet count 1 90.0 °C (104. discontinue therapy immediately if the patient’s HIV antibody test is negative D.0 g/dL Hematocrit 27% Leukocyte count27.0 °C (102. as the results will be available in 24 hours C. he is brought to the emergency department by ambulance. and respiration rate is 32/mm. Obtain HIV RNA viral load testing by polymerase chain reaction for both the patient and the physician now and in 6 weeks E. On the fourth day of his illness. Which of the following is the most appropriate initial therapy for this patient? A. generalized malaise. On physical examination. He also reports fever. pulse rate is 135/ min. Begin three-drug antiretroviral therapy immediately. Ceftriaxone. Ceftriaxone. Which of the following is the most appropriate diagnostic imaging study at this time? . On physical examination. glucose is 44 mg/dL (simultaneous plasma glucose is 155 mgldL). A Gramstained cerebrospinal fluid specimen shows multiple gram-positive bacilli. Lumbar puncture is performed. ampicillin. Cerebrospinal fluid leukocyte count is 1050/μL. temperature is 39.8 meq/L Chloride 102 meq/L Bicarbonate 15 meq/L Results of blood cultures and a surgical consultation are pending. and fatigue. Hemoglobin 14. shortness of breath.000/μL Blood urea nitrogen 61 mg/dL Serum creatinine2.
CT scan of the arm C. Colonoscopy shows diffuse colitis. Two months later. Droplet isolation C. 500 mg intravenously.A. watery diarrhea but has not passed any blood or mucus with her stools. Clindamycin D.2 °F). Linezolid B. Polymerase chain reaction shows that the MRSA is vanA ligase-positive. Oral prednisone for 7 to 10 days E. Contact and airborne isolation E. Oral zidovudine for 7 to 10 days D. Several genital ulcers and vesicles are present. Contact isolation B. the surgical incision is unchanged. This morning. his surgical incision became inflamed. temperature is 37. no special isolation precautions are needed Infectious Disease Medicine:Question 64 A 35-year-old woman had been vacationing in Cancun. Which of the following is the most appropriate antibiotic agent for this patient? A.9 °C (100. and biopsy findings are consistent with cytomegalovirus colitis. She has no history of similar lesions but did have unprotected sexual intercourse with a new partner 1 week ago. Which of the following is the most appropriate treatment for this patient’s lesions? A. Imipenem E. Both pathogens are resistant to vancomycin. The patient was treated intermittently with vancomycin. Ultrasound examination of the arm Infectious Disease Medicine:Question 61 A 53-year-old man underwent open reduction and internal fixation of a fractured tibia. Oral valganciclovir for 7 to 10 days C. Mexico. for the past week. Oral acyclovir or valacyclovir for 7 to 10 days B. No treatment is indicated Infectious Disease Medicine:Question 63 A 32-year-old man with advanced AIDS is hospitalized because of refractory diarrhea. The patient has diabetes mellitus and end-stage renal disease and requires hemodialysis by means of an arteriovenous graft in the left upper extremity. Culture of the discharge now grows Enterococcus faecalis in addition to MRSA. with an open section and drainage of cloudy yellow fluid. Quinupristin/dalfopristin Infectious Disease Medicine:Question 62 A 20-year-old female college student develops painful lesions on her vulva associated with fever and myalgias. Three weeks postoperatively. and her only other symptoms are mild . The remainder of the examination is normal. Trimethoprim/sulfamethoxazole C. Plain radiograph of the arm B. and tetracycline but sensitive to vancomycin and trimethoprim/sulfamethoxazole. she noted the sudden onset of crampy. Which of the following isolation precautions is most appropriate for this patient? A. clindamycin. She has no fever. Standard precautions. Culture of the discharge grew methicillin-resistant Staphylococcus aureus (MRSA) that was resistant to erythromycin. Airborne isolation (negative pressure) D. On physical examination. MRI scan of the arm D.
nausea and anorexia of 1 day’s duration. She has a history of occasional migraine headaches, has no known allergies, and takes no prescription medications. Which of the following organisms is most likely to be causing this patient’s diarrhea? A. Enterotoxigenic Escherichia coli (ETEC) B. Clostridium difficile C. Entamoeba histolytica D. Strongyloides stercoralis E. Salmonella enteritidis
Infectious Disease Medicine:Question 65 A 38-year-old man with HIV infection, who has recently moved to the area, is found to have elevated liver enzyme values. HIV positivity was diagnosed approximately 5 years ago. The patient is an injection drug user who has been in and out of jail and has not received consistent antiretroviral therapy. He currently takes no medications and feels well. His last CD4 cell count, approximately 6 months ago, was 554/μL. Physical examination is unremarkable except for a barely palpable spleen tip. There is no hepatomegaly and no findings suggestive of cirrhosis. Serum alanine aminotransferase is 172 U/L, and serum aspartate aminotransferase is 129 U/L. Serum bilirubin and alkaline phosphatase values are normal. Hepatitis testing shows the following: Antibodies to hepatitis C virus (anti-HCV)Negative Antibodies to hepatitis B surface antigen (anti-HB5Ag)Positive Antibodies to hepatitis B core antigen (anti-HBcAg)Positive Hepatitis B surface antigen (HB5Ag)Negative Antibodies to hepatitis A virus (anti-HAV)Positive Which of the following is the most appropriate next step in evaluating this patient’s liver enzyme abnormalities? A. No further testing is required B. Qualitative polymerase chain reaction for HCV RNA C. Percutaneous liver biopsy D. Hepatitis G virus serologic studies E. Blood culture for mycobacteria Infectious Disease Medicine:Question 66 An 89-year-old woman is hospitalized because of mental confusion and fever. The patient lives at home. She has had no serious illnesses and takes no long-term medications. On physical examination, temperature is 39.4 °C (103.0 °F). Examination of the lungs discloses crackles over the posterior right lower lobe. A chest radiograph confirms an infiltrate in this area. Community-acquired pneumonia is diagnosed, and an intravenous fluoroquinolone is begun. The patient initially becomes afebrile and more alert. However, on the third hospital night, she becomes hypotensive and develops a rapid heart rate. An electrocardiogram shows ventricular tachycardia. After resuscitation and restoration of normal sinus rhythm by cardioversion, which of the following antibiotic regimens would be most appropriate? A. Continue the fluoroquinolone B. Change to ceftriaxone C. Change to ceftriaxone plus a macrolide D. Change to ceftriaxone plus gentamicin E. Change to ampicillin/sulbactam
Infectious Disease Medicine:Question 67 A 32-year-old pregnant woman who works in a daycare center develops lesions on her back, chest, and arms. She also has fever, an increasing cough, and shortness of breath. There have been two cases of chickenpox at the daycare center. The patient has never had this infection. On physical examination, she is obviously dyspneic while talking and has skin lesions in various stages of development, including papules, vesicles, and pustules. A chest radiograph shows bilateral diffuse interstitial and nodular infiltrates. The patient is hospitalized and placed in airborne isolation. Which of the following antiviral agents is most appropriate at this time? A. Oseltamivir orally B. Ganciclovir orally C. Ganciclovir intravenously D. Acyclovir orally E. Acyclovir intravenously Infectious Disease Medicine:Question 68 A 61-year-old man who is receiving consolidation chemotherapy for acute myeloid leukemia develops a fever without chills or other symptoms. His last measured leukocyte count was 950/μL with an absolute neutrophil count of 390/μL. Platelet count was 145,000/μL. He lives with his wife, and their home is within 5 miles of his physicians office and the hospital. On physical examination in his physician’s office, temperature is 39.0 °C (102.2 °F). Other vital signs are normal, and there is no rash. A Hickman catheter is in place and shows no evidence of infection. The remainder of the examination is normal. Which of the following antimicrobial agents is most appropriate for treating this patient initially? A. Oral trimethoprim/sulfamethoxazole B. Oral ciprofloxacin plus amoxicillin/clavulanate C. Intravenous vancomycin D. Intravenous cefepime E. Intravenous vancomycin plus cefepime Infectious Disease Medicine:Question 69 Five patients with septic shock are being treated in an intensive care unit. In which one of the five patients would adjunctive use of recombinant human activated protein C (aPC or drotrecogin alfa [activated]) be most useful and least likely to cause additional complications? A. A 74-year-old man with an ischemic bowel B. A 68-year-old woman with staphylococcal bacteremia 1 day after undergoing coronary artery bypass graft surgery C. A 34-year-old male stem-cell-transplant recipient with pancytopenia and candidemia D. A 50-year-old woman with a ruptured appendix who is scheduled to undergo surgery in 2 hours E. A 55-year-old man with hepatic and renal dysfunction and blood cultures that are positive for Pseudomonas Infectious Disease Medicine:Question 70 A 24-year-old female medical assistant wants to be tested for HIV because of concerns about possible work-related exposure to bloodborne pathogens, although she denies any specific invasive incident. She has been in a monogamous heterosexual relationship for the past 10 months. She and her partner have occasionally engaged in unprotected sex. The patient is anxious about her HIV status but otherwise feels well, is asymptomatic, and has not had any recent illnesses. Routine serologic testing by enzyme immunoassay is positive. Western blot shows a
single band corresponding to the p24 protein, which is interpreted as indeterminate. A plasma HIV RNA viral load is 375 copies/mL. Which of the following best describes the test results and appropriate management for this patient? A. This is an indeterminate result; repeat the serologic studies at 6 weeks, 3 months, and 6 months B. This is an indeterminate result; obtain a CD4 cell count, as a count of less than 350/μL indicates likely HIV infection C. This is a false-positive test result; there is no need for further diagnostic testing D. This is a false-positive test result; recheck the plasma HIV RNA viral load in 3 months E. The patient has HIV infection; there is no need for further diagnostic testing
Infectious Disease Medicine:Question 71 A 64-year-old male lawyer has a 2-day history of a painful rash in a bandlike pattern on one side of his chest. The rash extends to his back but does not cross the midline. The patient has hypertension and diabetes mellitus for which he takes two antihypertensive medications and an oral hypoglycemic agent. He had chickenpox at 6 years of age. There is no history of immunodeficiency. Physical examination reveals several groups of vesicular lesions in the distribution of the right T5 dermatome. He does not have lymphadenopathy, his lungs are clear, and neurologic examination is normal. Which of the following is the most appropriate treatment at this time? A. Oral acyclovir, valacyclovir, or famciclovir for 7 days B. Topical acyclovir or penciclovir in sufficient quantities to cover all lesions C. A topical antibacterial ointment in sufficient quantities to cover all lesions D. Home administration of intravenous acyclovir E. Oral prednisone; no antiviral agents are indicated Infectious Disease Medicine:Question 72 A 35-year-old woman comes to your office for the first time. A cardiologist in another city told her that she has mitral valve prolapse and therefore needs to take antibiotics prior to dental procedures. A copy of her echocardiogram report states that she has Dopplerdemonstrated mitral regurgitation. She will have a tooth extracted in 4 days and asks for a 2-day supply of clindamycin, which she was given previously. She states that she is allergic to penicillin and that she had to go to an emergency department after she became flushed and her throat “closed-up’ the last time she took this antibiotic. Physical examination is normal except for a soft murmur of mitral regurgitation. According to current guidelines from the American Heart Association, which of the following is most appropriate for prophylaxis prior to this patients dental procedure? A. Tell her that she does not need prophylaxis for this procedure B. Prescribe a 2-day course of cephalexin to start 30 minutes before the procedure C. Prescribe a 7-day course of cephalexin to start today D. Prescribe a 2-day course of clindamycin to start 30 minutes before the procedure E. Prescribe a single 600-mg dose of clindamycin to be taken 1 hour before the procedure
Infectious Disease Medicine:Question 73 A 47-year-old man recently began chemotherapy for acute myeloid leukemia. His leukocyte count subsequently fell below 500/μL, and he was monitored closely for infection. When he developed a fever, ceftazidime and vancomycin were begun, following which his temperature decreased.
Antiretroviral therapy with zidovudine. and another course of chemotherapy was begun. Since beginning therapy. Stool cultures grow no enteric pathogens but do show a heavy growth of Enterococcus faecium that was resistant to ampicillin and vancomycin. Flucytosine C. Nystatin Infectious Disease Medicine:Question 74 A 37-year-old man has HIV infection that was diagnosed 3 years ago when he developed bilateral cytomegalovirus retinitis.A bone marrow examination 2 weeks after the conclusion of chemotherapy showed persistent tumor. Trimethoprim/sulfamethoxazole and azithromycin E. The patient has no other AIDS-related complications and feels well. Which of the following antimicrobial agents should be started next? A. Imipenem was substituted for ceftazidime and vancomycin. Valganciclovir. and nelfinavir was also begun at that time. Which of the following is most appropriate for managing this patient at this time? A. Nelfinavir D. his chest radiograph showed a small abnormal patch in the right mid-lung area. His last ophthalmologic examination showed no signs of active cytomegalovirus retinitis. The dose of imipenem is decreased. and azithromycin (1200 mg orally weekly). Liposomal amphotericin B E. his CD4 cell count has increased from a low of 1 24iL to a high of approximately 450/μL over the last 18 months. After intravenous broad-spectrum antibiotics (imipenem and vancomycin) were administered. On the 12th postoperative day. Stool specimens are negative for leukocytes. Postoperatively. Check for an intestinal leak . the patient would like to reduce the number of medications that he is taking. He refused bronchoscopy. which he tolerates poorly. His plasma HIV RNA viral load has been consistently undetectable. Valganciclovir if a cytomegalovirus IgM titer is negative C. Add oral vancomycin to her current regimen D. and the abnormal area on the chest radiograph grew larger. no special isolation precautions are needed C. underwent surgery for a bowel infarction caused by a volvulus. Valganciclovir B. In addition to his antiretroviral medications. Standard precautions. Change imipenem to ceftazidime and metronidazole E.1 mg/dL at baseline to 1. trimethoprim/sulfamethoxazole. he developed another fever. This time. On the 25th day of hospitalization. at a time when he had no measurable circulating granulocytes. trimethoprim/sulfamethoxazole (1 double-strength tablet daily). Amphotericin B colloidal dispersion D. and an assay forClostridium difficile toxin is negative on two occasions. His fever continues and he has developed chills.9 mg/dL. The retinitis was treated with intravenous ganciclovir and intraocular ganciclovir implants and has remained in remission. If possible. tube feedings are started. she required mechanical ventilation and had a difficult initial course in the intensive care unit. and azithromycin Infectious Disease Medicine:Question 75 A 65-year-old woman. Fluconazole B. but his temperature did not decrease. Which of the following medications can be safely discontinued at this time? A. His serum creatinine level has increased from 1. Contact isolation B. who was hospitalized because of severe abdominal pain. Sputum production was not increased. he takes valganciclovir (900 mg orally daily). The patient subsequently develops diarrhea but is afebrile and has diminishing abdominal pain and distention. lamivudine. she did fairly well for about 1 week.
1 °F).Infectious Disease Medicine:Question 76 A 55-year-old man underwent nonmyeloablative stem cell transplantation as part of the treatment regimen for chronic myelogenous leukemia. temperature is 39. The patient is homeless and has lived in a local mission periodically. The leukocyte count is 15. and the patient died 1 week after the onset of the pulmonary infection. and dyspnea. Poor oxygenation E.2 °F). Significant findings include poor dentition and scattered expiratory wheezes. hemoptysis. High cardiac index D. Crackles are heard in the left lower lung field. admission blood cultures show no growth. Urine and bronchoalveolar lavage fluid cultures did not grow bacteria or fungi. and blood pressure is 84/56 mm Hg. left-sided pleuritic chest pain. Epstein-Barr virus D. The patient is given one dose each of ceftriaxone and azithromycin. A chest radiograph shows a right upper lobe infiltrate with a suggestion of cavity formation.6 °F). On the second hospital day. Temperature now is 39. pulse rate is 110/ min. He has not felt well for at least 3 months because of the progressive cough and production of bloody sputum. Which of the following is the most likely explanation for this patients continued hypotension? A. and blood pressure is 92/60 mm Hg. she receives 5 liters of crystalloidcontaining fluids. he developed hemorrhagic cystitis followed by bilateral pneumonia. and dizziness. although he has had only limited medical care. Which of the following viruses was the most likely cause of this patients terminal illness? A. he appears cachectic. Because of increasing respiratory failure. pulse rate is 100/ min. She has a nonproductive cough and is barely able to speak because of increasing dyspnea. pulse rate is 110/ min. Arterial blood gas studies (with the patient breathing room air) show PCO2 of 26 mm Hg and PO2 of 85 mm Hg. Before signs of engraftment occurred. On physical examination on admission. and respiration rate is 22/mm. Low systemic vascular resistance C. and antibacterial therapy for communityacquired pneumonia and aspiration is begun. The patient also has been vomiting all day but does not have diarrhea or abdominal pain. A chest radiograph shows a dense infiltrate in the left lower lung field.500/μL with a left shift. The pneumonia progressed relentlessly despite aggressive antibiotic and antifungal therapy. weight loss. An adenovirus B.5 °C (103. chills. Cytomegalovirus C. Medical history is noncontributory. On physical examination.0 °C (102. Influenza virus Infectious Disease Medicine:Question 77 A previously healthy 25-year-old woman comes to the emergency department because of a 2-day history of fever. Respiratory syncytial virus E. shortness of breath. a routine sputum culture is growing normal respiratory . Over the next 2 hours. Ineffective antibiotic therapy B. respiration rate is 44/mm. Temperature is 39. she is admitted to the intensive care unit for intubation and mechanical ventilation. Elevated pulmonary capillary wedge pressure Infectious Disease Medicine:Question 78 A 48-year-old man is hospitalized because of cough. fever. The patient is placed in respiratory isolation.2 °C (102.
Culture of the catheter tip shows no growth.2 °F) and no subjective or objective . and ethambutol three times weekly by directly observed therapy (DOT) now. One of two sputum smears is positive for acid-fast bacilli. Start three new antiretroviral medications now D. Which of the following is the most appropriate treatment for this patient? A.420 3 168 6810 6 185 5325 7 192 6220 The patient claims to have adhered her medication schedule and has missed only two doses of all medications since she started therapy. temperature is 38. she continues to have daily fevers to 39. then change the regimen to isoniazid and rifam pin twice weekly by DOT for 16 weeks E. continue her current regimen E.flora. Defer treatment until the species of acid-fast bacilli has been identified Infectious Disease Medicine:Question 79 A 29-year-old woman is seen for ongoing management of HIV infection that was diagnosed 9 months ago. Continue her current regimen. Her initial CD4 cell count was 194/μL.0 °C (102. and her plasma HIV RNA viral load was 56. Start daily isoniazid and rifam pin now. if greater than 200/μL. change to efavirenz Infectious Disease Medicine:Question 80 A 52-year-old woman who has non-Hodgkin’s lymphoma and is receiving her third course of chemotherapy develops a fever. streptomycin. Order an HIV genotype. Start daily isoniazid. Her absolute neutrophil count has been less than 100/μL for 2 weeks. Six days after starting the antibiotic regimen.0 °F). Which of the following is the most appropriate management at this time? A. rifampin. Recheck her CD4 cell count now. Information from the local health department indicates no significant drug resistance among tuberculosis isolates in the area.780 1 172 18. Three days later. Start daily isoniazid. She looks and feels well. The remainder of the examination is noncontributory. Her response to treatment is shown: Months Since Initiation of HAART CD4 Cell Count (μL) Plasma HIV RNA Viral Load (copies/mL) 0 194 56. rifampin. and ethambutol now for 2 weeks. plan for a 24-week course C. the Hickman catheter tunnel shows signs of inflammation. recheck her HIV RNA viral load in 3 months B. She was immediately started on triple-drug highly active antiretroviral therapy (HAART) consisting of zidovudine (300 mg twice daily).9 °C (102. Trimethoprim/sulfamethoxazole was also begun. and the catheter is removed. pyrazinamide. Start isoniazid. rifampin. then reduce to twice weekly by DOT for 6 weeks. and blood cultures show no growth. and ethambutol now for 8 weeks.780 copies/mL. Assume nevirapine failure. Cefepime and gentamicin are begun. The patient remains severely neutropenic. Antibiotics are discontinued. plan for a 36-week course B. the Hickman catheter appears normal. Vancomycin is added to the regimen. change her regimen on the basis of genotype results and treatment history C. pyrazinamide. didanosine (400 mg at bedtime). but she had not had fever or other unexpected signs or symptoms until now On physical examination. then reduce administration to three times weekly by DOT for 16 weeks D. and nevirapine (200 mg twice daily).
add amphotericin B C. Stop all three antibiotics. if antibodies are inadequate. his sclerae and conjunctivae are normal. On physical examination. Intravenous acyclovir plus evaluation for antiretroviral therapy E. Which of the following post-exposure options is most appropriate for this health care worker? A. An ophthalmologist sees the patient that same day. Chioramphenicol B. Current laboratory studies include a leukocyte count of 4800/μL (92% neutrophils). no systemic therapy B. Intravenous ganciclovir or oral valganciclovir plus evaluation for antiretroviral therapy D. Ganciclovir by intravitreal injection into the right eye. round. scattered. A Gram-stained sputum specimen shows large numbers of polymorphonuclear leukocytes with pink-staining nuclei and small. and reactive to light and accommodation. add amphotericin B B. pleomorphic gram-negative rods. and his last known CD4 cell count was 4/μL. the nurse inadvertently stuck the needle into his own finger. Examination of the chest reveals profuse crackles bilaterally. High-dose oral prednisone plus evaluation for antiretroviral therapy Infectious Disease Medicine:Question 83 A 34-year-old nurse reports a needlestick injury.7 °F). The source patient is known to be positive for hepatitis B surface antigen. Continue all three antibiotics. and a serum creatinine of 2. but cultures of tracheal aspirates grew Francisella tularensis. A chest radiograph shows bilateral patchy pulmonary infiltrates involving at least four lobes. Gentamicin Infectious Disease Medicine:Question 82 A 39-year-old man with longstanding HIV infection and previously diagnosed AIDS develops blurred vision in his right eye. The nurse was vaccinated against hepatitis B when he was hired 3 years ago. Blood cultures showed no growth. He is not receiving antiretroviral therapy. Which of the following is the optimal first-line drug for treating this patients infection? A.8 mg!dL. After drawing blood from a patient. He completed the series of three injections but has never had serologic confirmation of his response. Administer hepatitis B immune globulin immediately and restart his immunization sequence B. Medical history is otherwise noncontributory. start ciprofloxacin E. temperature is 39. Continue all three antibiotics. and respiration rate is 34/mm. On physical examination. Doxycycline D. Make no changes to the antibiotic regimen Infectious Disease Medicine:Question 81 A 29-year-old male landscaper is evaluated by his primary care physician because of a 1day history of fever and increasing shortness of breath.changes on physical examination. Check his antibody response to the hepatitis B vaccination. and his pupils are equal. confirms your findings. add ciprofloxacin D. Ceftriaxone E. Which of the following is most appropriate at this time? A.3 °C (102. and reports that the lesions are most consistent with cytomegalovirus retinitis. Funduscopic examination shows several hemorrhages and exudates in the right eye. Which of the following is the most appropriate initial therapy for this patient? A. a normal platelet count. Three antiretroviral agents. administer hepatitis B immune globulin and restart his immunization . Stop cefepime and gentamicin. no cytomegalovirus therapy C. Ciprofloxacin C.
4 °C (103. 600mg orally every 12 hours. All surgical sites are clean without evidence of drainage. and physical examination is otherwise unremarkable. Because of an allergy to vancomycin. Vancomycin plus rifampin C. She was taken to the operating room. Thrombotic thrombocytopenic purpura Infectious Disease Medicine:Question 85 A 30-year-old woman was hospitalized after the sudden onset of severe headache. temperature is 39. and mild meningismus. and blood pressure is 110/72 mm Hg. if antibodies are adequate. pulse rate is 100/ min. administer only hepatitis B immune globulin D. On physical examination. and blood pressure is 120/70mm Hg. conjunctival injection. The patient recently went camping in North Carolina. the patient was started on linezolid. and vomiting. Findings include a petechial rash that is most prominent on the wrists and hands (including the palms). 500 mg orally every 6 hours. linezolid. and quinupristin/dalfopristin but was resistant to all other antibiotics tested. Infectious Disease Medicine:Question 84 A 46-year-old man with diabetes mellitus had a recurrent plantar foot ulcer over the second left metatarsal head that did not probe to bone. glucose of 30 mg/dL (simultaneous plasma glucose of 85 mg/dL). she develops fever. The ventriculostomy tube is draining clear CSF. No therapy is required. Cerebrospinal fluid analysis shows a leukocyte count of 500/μL (with 90% neutrophils). the leukocyte count is 2500/μL (with an absolute neutrophil count of 1 000/μL). Evaluation revealed a subarachnoid hemorrhage secondary to a leaking aneurysm. Which of the following is most likely causing this patient’s petechial rash? A. as this patient has postoperative chemical meningitis Infectious Disease Medicine:Question 86 A 22-year-old male college student comes to the emergency department in June because of fever. Vancomycin plus ceftriaxone D.sequence C. The plantar ulcer is somewhat smaller. The leukocyte count is 15. chills. An adverse reaction to linezolid C. Urinalysis and chest radiograph are normal. where the aneurysm was clipped and a ventriculostomy tube was placed to drain CSF. A Gram stain of CSF is negative. Hemoglobin 10. and protein of 150 mg/dL. but he now has a petechial rash on his legs. Neurologic examination is normal. stiff neck. worsening headache.0 g/dL . respiration rate is 24/mm. Hypersensitivity vasculitis due to antibiotic therapy E. The patient is confused. temperature is 39. Culture of deep soft tissue grew both Bacteroides fragilis and methicillin-resistantStaphylococcus aureus that was sensitive to vancomycin.0 °F). Temperature is normal.000/μL. and a severe bilateral frontal headache. no intervention is necessary. Vancomycin B.000/μL without a left shift. Vancomycin plus ceftazidime E. An adverse reaction to metronidazole B. Hemoglobin is 10.8 g/dL.0 °C (102. On physical examination.Four days postoperatively. Which of the following empiric antimicrobial regimens should be initiated at this time? A. and the platelet count is 22. plus metronidazole. As the nurse has completed his hepatitis B vaccination series. Disseminated intravascular coagulation due to methicillin-resistant Staphylococcus aureus D.2 °F). He is re-evaluated 2 weeks later. Check his antibody response to the hepatitis B vaccination. myalgias. erythrocyte count of 900/μL. and change in mental status.
2 °F).0 g/dL Leukocyte count 8900/μL (normal differential) .0 meq/L Chloride 97 meq/L Bicarbonate2l meq/L Serum bilirubin 1 . and vancomycin. Begin voriconazole E. The fever failed to resolve after 5 days. Borrelia burgdorferi D. Begin caspofungin D. chronic obstructive pulmonary disease. She was referred from a psychiatric hospital where she had recently been admitted for severe auditory and visual hallucinations. Increase the dose of fluconazole Infectious Disease Medicine:Question 88 A 62-year-old man with chronic atrial fibrillation. the infusion was restarted very slowly.8 mgldL Serum alkaline phosphatase 140 U/L Serum alanine aminotransferase 300 U/L Serum aspartate aminotransferase 250 U/L Which of the following organisms is most likely causing this patients symptoms? A.4 mg/dL Serum electrolytes: Sodium 128 meq/L Potassium4. During a period of neutropenia. After 1 hour. and obesity was hospitalized because of shortness of breath. The patient takes warfarin. An antihistamine and a corticosteroid were begun immediately. Hemoglobin 16. cefepime. The patient was intubated and immediately admitted to the intensive care unit for observation. Rickettsia rickettsii B. Which of the following should also be started for management of a potential fungal infection in this patient? A. Neisseria meningitidis C. he was given 2 doses of a short-acting benzodiazepine. Babesia microti Infectious Disease Medicine:Question 87 A 34-year-old woman with schizophrenia was found to have leukemia after she was seen in a hematology clinic because of an elevated leukocyte count. and the infusion was stopped. pulse rate is 80/ min. and chemotherapy was started for chronic myelogenous leukemia with blast crisis.000/μL Blood urea nitrogen 35 mg/dL Serum creatinine 1. Review of old records from another hospital showed that she had leukemia 4 years ago but was lost to follow-up. Because the patient was anxious during the CT scanning. Begin a lipid formulation of amphotericin B C. The patient subsequently developed hives and hypotension. He stopped breathing. Spiral CT scan of the chest was ordered on admission to rule out a pulmonary embolism. and a code was called in the radiology suite. The patient was subsequently hospitalized.Hematocrit 30% Leukocyte count 9000/μL Platelet count 80. Twelve hours later. No treatment is indicated because the risks of giving amphotericin B outweigh the benefits B. but the hives promptly returned. and amphotericin B by infusion was added to the treatment regimen. she developed a fever and was treated with fluconazole. he becomes febrile.0 °C (102. On physical examination. temperature is 39. and blood pressure is 130/72 mm Hg without administration of vasopressor agents.
Recombinant human activated protein C (aPC or drotrecogin alfa [activated]) Infectious Disease Medicine:Question 89 A 34-year-old man returned from a 10-day trip to Europe with dysuria and a mild urethral discharge. and empiric antibiotics are started. add prednisone. add azithromycin . Cough and low-grade fever developed 1 week prior to admission. and ceftriaxone.9 Blood urea nitrogen Normal Serum creatinine Normal Serum electrolytes Normal A chest radiograph shows some diffuse changes suggestive of early acute respiratory distress syndrome. Ranitidine prevented the absorption of ciprofloxacin Infectious Disease Medicine:Question 90 A 28-year-old man with newly diagnosed HIV infection is hospitalized because of worsening cough. Continue current antibiotics. and PO2 of 62 mm Hg. His course of treatment was too short B.6 °C (103. begin highly active antiretroviral therapy D. and fever. 40 mg twice daily E.5 mm Hg of positive end-expiratory pressure (PEEP). 500 mg daily. the patient has become severely dyspneic and hypoxemic and requires endotracheal intubation and mechanical ventilation. 1 g intravenously every 12 hours. Amphotericin B E. HIV testing was also done prior to hospitalization. and he was given levofloxacin. On physical examination on admission. An induced sputum specimen shows Pneumocystis carinii organisms by direct fluorescent antibody stain. Continue current antibiotics. add pentamidine C. PCO2 of 28 mm Hg. An admission chest radiograph reveals diffuse bilateral interstitial infiltrates. Over the next 7 days until his hospitalization. The causative organism was resistant to ciprofloxacin C. On the 8th day of his trip. An inferior vena cava filter D. Arterial blood gas studies with the patient breathing room air show a pH of 7. he noted the beginning of a discharge and took some ciprofloxacin tablets that he had from a previous trip to a developing country. Arterial blood PO2 is now 82 mm Hg with the patient receiving 60% fractional inspired oxygen (FiO2) and 7. However. A rapid probe test indicated that he had gonorrhea but not Chlamydia infection. Continue current antibiotics.48.INR 3. While traveling. Which of the following is the most appropriate treatment at this time? A. Supportive care B.3 °F) and respiration rate is 28/mm. he had only mild relief after taking the tablets for 3 days. By the third hospital day. he had sexual relations with commercial sex workers. Which of the following is also most appropriate for managing this patient at this time? A. his cough and fever worsened and he became increasingly dyspneic. and a positive result was reported a few days later. temperature is 39. dyspnea. The patient’s only other medical condition is dyspepsia for which he takes ranitidine. Which of the following is the most likely reason for his lack of response to ciprofloxacin? A. Blood cultures are obtained. He has also lost 7 kg (15 Ib) over the past 2 months. Vitamin K C. Because of HIV risk behavior. Continue current antibiotics. Change from trimethoprim/sulfamethoxazole to pentamidine B. The patient is given supplemental oxygen and treated empirically with trimethoprim/sulfamethoxazole (20 mg/kg/day intravenously divided into every-8-hour doses). He has concomitant syphilis D.
the erythrocyte sedimentation rate is 95 mm/h. the patient seems to be doing well. or headache. Prior to travel. Which of the following diseases is the most important to consider in the initial management of this patient? A. Low-dose prednisone daily E. Trimethoprim/sulfamethoxazole daily plus interferon-γ D. Your records show that she has a history of recurrent genital herpes infections. which is abnormal. and liver enzyme values are mildly elevated. Prophylactic antibiotics as long as the endotracheal tube is in place B.Infectious Disease Medicine:Question 91 A 30-year-old man presents with a 4-day history of fever. CT scan of the abdomen shows a large hepatic abscess. Other than being drowsy and minimally arousable.2 °C (102. Dicloxacillin daily C. Yellow fever C.6 °F). He had several episodes of bacterial pneumonia during childhood and a perirectal abscess that was slow to heal when he was 13 years old. that were occasionally treated with oral acyclovir. A cooling blanket to prevent a rise in temperature above 37. A nitroblue tetrazolium test is subsequently performed. Hepatitis B B. Nasal placement of the endotracheal tube C. and took no prescription medications during his trip. On physical examination. She denies fever. There is no rash or lymphadenopathy. Cardiopulmonary and abdominal examinations are normal.6 °F) Infectious Disease Medicine:Question 93 An 18-year-old man is evaluated because of fever and weight loss of 3 weeks duration. The gastric tube used to irrigate her stomach is still in place and is being used for feedings. occurring about 2 to 3 times yearly. lnterleukin-2 Infectious Disease Medicine:Question 94 A 35-year-old woman calls because she has had a tingling sensation of her vulva for about 4 hours. his temperature is 39. Amebic liver abscess D. Culture of the abscess fluid grows Staphylococcus aureus. No long-term antibiotic agents or other drugs are needed B. Plasmodium falciparum malaria Infectious Disease Medicine:Question 92 A 36-year-old woman is admitted to the intensive care unit from the emergency department after ingesting an intentional overdose of a long-acting barbiturate. Which of the following medications is most appropriate to minimize the risk of further infections in this patient? A. The leukocyte count is 12. Endotracheal intubation was performed in the emergency department. he received hepatitis A and typhoid vaccines but took no other preventive measures. Medical history is otherwise noncontributory. Which of the following additional measures is appropriate to prevent complications in this patient? A. The patients recovery is slow but complete. He has no significant medical history. She reminds you that most of her episodes . Semi-erect positioning in bed D. has no allergies. and ill-defined abdominal discomfort 1 week after returning from a trip to mostly rural areas of Cambodia and Vietnam. myalgias.0 °C (98. which is subsequently drained percutaneously. and intravenous nafcillin is begun. chills.400/μL. Changing the endotracheal tube every 2 to 3 days E.
and his plasma HIV RNA viral load was 115. HIV infection was diagnosed approximately 15 months ago. The daughter probably acquired Chlamydia nonsexually. Arterial oxygen saturation is 99% by pulse oximetry with the patient breathing room air. Over the last 24 hours.500 copies/mL. The patient became ill approximately 5 days ago. The lungs are clear. when he developed nausea.are preceded by a tingling sensation similar to what she is experiencing now. and his CD4 cell count has increased to 138/μL.6 °F). he has become progressively more short of breath. . Which of the following is the most appropriate response? A. respiration rate is 32/mm. Initially. His HIV RNA viral load has been undetectable for the past 8 months. He has mild scleral icterus. stavudine (40 mg twice daily).0 °C (98. the patient is dyspneic and appears to be acutely ill. Oral prednisone plus oral acyclovir for 7 days E. and anorexia. and blood pressure is 112/72 mm Hg. since growingChlamydia is very difficult D. Most cases ofChlamydia occur in older adults (> 35 years of age). Standard precautions. Contact and airborne isolation E. indinavir (800 mg twice daily). abdominal pain. although the current lesions involve a larger area. His initial CD4 cell count was 294/μL. the daughter went to the clinic to learn about birth control. Chlamydia is very common in young people who have had even a limited amount of sexual experience B. His wife mentions that he drinks one or two cans of beer on most days and does not use illicit drugs. No treatment is indicated Infectious Disease Medicine:Question 95 A mother brings her 16-year-old daughter to a gynecologist because of a report from a family planning clinic that the daughter has a Chlamydia infection. Which of the following isolation precautions is most appropriate for this patient? A. pulse rate is 122/ min. The test result was probably a false positive. but rare cases occur in adolescents C. or famciclovir for 3 to 5 days D. The patient states that the rash is similar to a prior outbreak of shingles that she had last year. Previous tests for chronic hepatitis A and B were negative. Airborne isolation (negative pressure) D. Droplet isolation C. valacyclovir. She has had two sexual partners in her life. Temperature is 37. and her partners usually use condoms. she develops a vesicular rash on her left flank that is pruritic and somewhat painful. Her mother asks how she could develop this infection at such a young age especially since she did not have symptoms. As part of the clinic’s screening program for sexually transmitted diseases. On the fifth hospital day. Abdominal examination discloses mild hepatomegaly. no special isolation precautions are needed Infectious Disease Medicine:Question 97 A 48-year-old man is evaluated because of severe dyspnea and profound weakness. consisting of didanosine (400 mg at bedtime). An antiretroviral regimen was started. the spleen is not enlarged. Contact isolation B. and ritonavir (100 mg twice daily). from a family pet or an inanimate object Infectious Disease Medicine:Question 96 A 63-year-old woman with leukemia has been receiving chemotherapy on the inpatient oncology floor. Oral acyclovir daily to be taken indefinitely C. On physical examination. Oral acyclovir. severe myalgias. Topical acyclovir for 5 days B. Which of the following is the most appropriate initial treatment for this patient? A. vomiting. testing was performed that indicated that the daughter had a Chlamydia infection.
Infectious Disease Medicine:Question 2 The correct answer is D . Acute viral hepatitis B. 12% band forms. and blood and urine cultures are negative. his clinical findings are unchanged. as results of virus cultures require several days but therapy should be started within the first 2 days of symptom development and is continued for only 5 days. if a patient presents during the summer and has not recently traveled outside the Northern Hemisphere). However.4 mg/dL Serum electrolytes: Sodium 136 meq/L Potassium 3.9 mg/dL Serum lactate dehydrogenase 1255 U/L Serum creatine kinase 894 U/L Venous blood lactic acid 9 mg/dL Which of the following is the most likely diagnosis? A. although only the neuraminidase inhibitors (zanamivir and oseltamivir) would be appropriate if influenza B had been documented in the community. A chest radiograph and blood cultures are unnecessary for a patient without concomitant medical problems and no signs of lower respiratory tract infection.8 meq/L Chloride 108 meq/L Bicarbonate 9 meq/L Serum alanine aminotransferase 579 U/L Serum aspartate aminotransferase 310 U/L Serum bilirubin3. Any of the four drugs listed can be used to treat influenza A. 3% eosinophils) Blood urea nitrogen 62 mg/dL Serum creatinine 1. Acute bacterial sepsis C. Empiric treatment is appropriate for someone who presents within 48 hours with a compatible illness if influenza has been documented in the community. A nasopharyngeal culture might be useful for epidemiologic purposes. his chest radiograph is normal. Lactic acidosis/hepatic steatosis E. Antibacterial agents are not indicated because this patient has no suggestion of pneumonia or bacterial sinusitis. empiric therapy for influenza alone would be inappropriate if the patient possibly had pneumonia.Forty-eight hours after admission. However. Critique This patient likely has influenza based on the clinical presentation and the epidemiologic information. Hypovolemic shock ANSWERS Infectious Disease Medicine:Question 1 The correct answer is C Educational Objectives Understand how to diagnose and treat influenza during a community outbreak. Current laboratory studies are as follows: Leukocyte count7200/μL (71% segmented neutrophils. Alcoholic hepatitis D. However. it would not be helpful for deciding whether to treat this patient. Therapy would also be inappropriate if the epidemiologic data were not consistent with influenza (for example. 5% lymphocytes. 9% monocytes. which would require additional evaluation for a bacterial source.
Not treating the pathogen is appropriate for a patient with transient bacteremia but is inadvisable for a critically ill patient who continues to have positive blood cultures. . Resistance of E. but less than 10% of strains of E. Airborne isolation is needed becauseM. Quinupristin/dalfopristin is a reasonable alternative for resistant Enterococcus faecium. The timing is more controversial for asymptomatic patients. Infectious Disease Medicine:Question 4 The correct answer is B Educational Objectives Recognize the need for airborne isolation in a hospitalized patient at high risk for tuberculosis. He should therefore requires empiric airborne isolation (negative pressure). Although ampicillin can be given safely to patients with IgE-mediated allergies after completion of an appropriate desensitization protocol. but the likelihood of adverse reactions in a patient with a recent penicillin allergic reaction is very high.Educational Objectives Recall the indications for initiation of antiretroviral therapy. Critique There are many controversies concerning the proper time to initiate antiretroviral therapy. Prophylaxis for Pneumocystis carinii pneumonia should also be started. The key to decision making for this patient is the presence of thrush. irrespective of the HIV RNA viral load. other types of allergic reactions do not abate following desensitization. although it is prudent to evaluate this possibility. faecalis are susceptible to this agent. Thrush indicates a poor prognosis for survival and an increased likelihood of opportunistic complications in AIDS patients. or severe symptoms. Repeating the CD4 cell count and plasma HIV RNA viral load is not needed. Therefore. faecalis to linezolid is very rare. Most experts suggest beginning therapy when the CD4 cell count is between 200 and 350/μL. Critique This patient is at high risk forMycobacterium tuberculosis infection because of his immunocompromised state and recent incarceration. The fact that the patient has a low viral load at the beginning of treatment may influence the choice of agents but not the decision to use three versus two drugs. low CD4 cell count (< 200/ μL). When ampicillin is not a choice (because of resistance or intolerance). Experts agree that treatment is indicated for patients with an AIDS-defining condition. linezolid is probably the best available antibiotic for vancomycin-resistant strains of Enterococcus faecalis. Critique This is a complicated case study. Piperacillin/tazobactam is a reasonable choice in terms of the treatment spectrum. he should be offered antiretroviral therapy at this time with one of several recommended three-drug regimens. even though this patients CD4 cell count is above 200/μL. Infectious Disease Medicine:Question 3 The correct answer is D Educational Objectives Determine the role of various antibiotic agents for treating severe vancomycinresistantEnterococcus faecalis infection.
tuberculosis may not have the classic isolated upper lobe pattern on chest radiographs. which now occurs primarily in patients who do not benefit from or refuse to take antiretroviral therapy and in those who present with cryptococcal meningitis as the first manifestation of their HIV infection. cough. Patients with suspected M. and the serum protein electrophoresis results are suggestive. He undoubtedly has a CD4 cell count of less than 200/μL (perhaps even less than 50/μL). Multiple myeloma is usually. in any event. Infectious Disease Medicine:Question 5 The correct answer is C Educational Objectives Recall how to treat life-threatening increased intracranial pressure in a patient with HIV infection and cryptococcal meningitis. In immunocompromised patients. However.tuberculosis is spread by droplet nuclei. preferably by daily lumbar punctures in order to drain enough cerebrospinal fluid to normalize the pressure. although not always. neither antiretroviral agents nor antifungal agents will lower the intracranial pressure. this diagnosis is not suggested by the radiographic findings and time course of this patient’s disorder. Although both should be given. Infectious Disease Medicine:Question 6 The correct answer is C Educational Objectives Recognize the diagnosis of common variable hypogammaglobulinemia in a patient with multiple episodes of bacterial pneumonia. and. Increased intracranial pressure is associated with a high mortality rate in AIDS patients who have cryptoccocal meningitis. or sneeze. The postulated mechanisms of increased intracranial pressure include cerebral edema secondary to the osmotic effect of the huge amount of polysaccharide capsular material as well as diminished absorption of cerebrospinal fluid because of plugging of the arachnoid villi with the same capsular material. measurement of opening pressure at the time of lumbar puncture is especially important. The remaining laboratory results are not consistent with any of the other diagnoses. The use of corticosteroids in this setting is controversial and may be associated with a poorer outcome. accompanied by a monoclonal spike in the gamma globulin region. Some patients may require a ventriculoperitoneal shunt. Patients with AIDS tend to have a huge burden of cryptococcal organisms and a minimal host response. Although bronchogenic carcinoma is a cause of postobstructive pneumonia. which are aerosolized when patients with pulmonary infection speak. The normal total hemolytic complement (CH50) value effectively rules out terminal complement component deficiencies. Some patients with a predominance of light chain production may have a normal serum protein . tuberculosis infection do not require contact or droplet isolation. Increased intracranial pressure due to cryptococcal meningitis is found most often in patients with HIV infection but may also occur in patients with cryptococcal meningitis who do not have AIDS. The clinical picture is typical. this is not an emergent procedure and should not be done before antifungal agents are started. such deficiencies would not be expected to lead to bacterial pneumonia. although not conclusive. for this disorder because of the low gamma globulin values. Critique The most likely diagnosis of those given is common variable hypogammaglobulinemia. Therefore. Measures to decrease the pressure should be instituted immediately. Critique This patient with untreated HIV infection has cryptococcal meningitis. as shown by the cerebrospinal fluid findings in this patient. The high mortality rate is directly related to the height of the pressure.
and multiple organ dysfunction syndrome are as follows: Systemic inflammatory response syndrome (SIRS): The systemic inflammatory response to a wide variety of severe clinical insults. tachycardia. Patients receiving inotropic or vasopressor agents may no longer be hypotensive by the time they develop hypoperfusion abnormalities or organ dysfunction. tachypnea. heart rate greater than 90/mm. the term that best defines her illness is sepsis. Infectious Disease Medicine:Question 7 The correct answer is D Educational Objectives Recognize the clinical manifestations of sepsis and differentiate this from systemic inflammatory response syndrome.000/μL or less than 4000/μL or with greater than 10% immature band forms. and conjunctival hemorrhage (but not the splinter hemorrhages) fulfills three of the minor Duke criteria for endocarditis. Septic shock: A subset of severe sepsis. the addition of gentamicin decreases the total treatment course from 4 weeks to 2 weeks. In association with infection. hypoperfusion. In a patient with uncomplicated endocarditis. Critique Although this patient has documented bacteremia (defined as bacteria present in the blood and confirmed by culture). vancomycin is inappropriate. Although not necessary to meet the diagnostic criteria in this case. manifestations of sepsis are the same as those described for SIRS. Severe sepsis: Sepsis associated with organ dysfunction. they would still be considered to have septic shock. or hypotension. defined as sepsis-induced hypotension despite adequate fluid resuscitation plus the presence of perfusion abnormalities.electrophoresis. leukocyte count greater than 12. sepsis. She does not have organ dysfunction or perfusion abnormalities. The American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus Conference definitions of systemic inflammatory response syndrome.4 °F) or less than 36. respiration rate greater than 20/mm or arterial blood Pco2 less than 32 mm Hg. however. . and septic shock. In the absence of penicillin allergy or penicillin resistance. severe sepsis.0 °C (100. and an elevated leukocyte count with immature band forms). quantitative serum immunoglobulin determination should be done next. bacteremia. Endocarditis due to sensitive viridans streptococci on native valves can be treated for 4 weeks with penicillin or ceftriaxone or for 2 weeks when either agent is combined with synergistic low-dose gentamicin. which occur in patients with severe sepsis or septic shock. Critique The patient meets both major Duke criteria for definite endocarditis (that is. fever. Infectious Disease Medicine:Question 8 The correct answer is B Educational Objectives Understand how to diagnose and treat native valve endocarditis. Sepsis: The systemic inflammatory response to a documented infection.8 °F). Multiple organ dysfunction syndrome (MODS): Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. Since none of the tests performed to date definitively rules out any of the potential diagnoses. the presence of the bicuspid aortic valve. manifested by at least two of the following conditions: temperature greater than 38. Therefore. a typical microorganism grown on two blood cultures and evidence of endocardial involvement met either by echocardiography because of the oscillating intracardiac mass or by physical examination because of the new aortic regurgitant murmur). His history also raises suspicion of endocarditis. she also has evidence of a systemic response to infection (fever. severe sepsis. septic shock.0 °C (96.
and atovaquone/proguanil (Malarone®). as this may negate the protective effects of the vaccine. As a result. Critique The diagnosis of smallpox must be considered in this case. if they do not receive the vaccine. Furlough is not recommended by the Centers for Disease Control and Prevention for health care workers who receive vaccinia vaccine. and the choice is based primarily on a consideration of convenience. Infectious Disease Medicine:Question 9 The correct answer is C Educational Objectives Know the prophylactic management of persons in contact with a patient with possible smallpox. Currently available medications include mefloquine. Vaccination with vaccinia can modify or prevent disease in contacts of this patient if given within several days of exposure to smallpox. North Africa. cost (atovaquone/proguanil is the most expensive). they should remain relatively isolated at home for the usual incubation period (7 to 17 days) in order not to expose others to the disease if they possibly become infected. quinine can be used for the treatment of malaria. Vaccinia immune globulin and vaccine should not be administered concurrently.Although adding synergistic doses of gentamicin is appropriate. ceftriaxone can be substituted for penicillin in a standard 4-week regimen but would not be used for 8 weeks for a patient with uncomplicated endocarditis. and parts of China). The efficacy of these agents is similar. Each chemoprophylactic regimen must begin prior to entry into the malaria-risk area and be continued for 1 week (atovaquone/proguanil) to 4 weeks (doxycycline and mefloquine) after leaving the area. Critique There are several effective forms of malaria chemoprophylaxis for the protection of travelers to areas of risk within sub-Saharan Africa. Infectious Disease Medicine: Question 11 The correct answer is E Educational Objectives Understand the pathophysiology of IgA deficiency Critique . using this combination regimen for 4 (or 6) weeks is not part of a standard treatment regimen. doxycycline. Similarly. Central America. but this drug is not currently recommended for chemoprophylaxis. and likely adverse effects. However. Chloroquine is not an appropriate prophylactic agent for the prevention of malaria in any area of sub-Saharan Africa. The health care workers should not be sent home at this time. chloroquine chemoprophylaxis is still effective in only a few areas of the world (for example. Chloroquine resistance is widespread. In some instances. Vaccinia immune globulin has no effect on smallpox. Metronidazole and trimethoprim/sulfamethoxazole have no significant anti-Plasmodium activity and therefore play no role in the chemoprophylaxis of any form of malaria. the Caribbean. Ribavirin also has no known effect on smallpox. Infectious Disease Medicine:Question 10 The correct answer is C Educational Objectives Select the correct medication for chemoprophylaxis of malaria. One should not wait for confirmatory evidence of smallpox infection because confirmation may take too long to allow effective prevention.
Repeat quantitative immunoglobulin determination is unnecessary because of the small likelihood of laboratory error. as 70% to 80% of patients with early disease will have a negative B. Infectious Disease Medicine:Question 13 The correct answer is B Educational Objectives Recall the most appropriate therapy for early Lyme disease. the patient is allergic to this drug. and serum lgG subset quantification should therefore be obtained. Although occult chlamydial infections may occur in men or women. The presence of low levels of one or more of the four lgG subsets is the most likely explanation for his increased bacterial infections. Since IgA was not detectable. Critique Although the prevalence of syphilis transmission is currently low in the United States. Measurement of total hemolytic complement (CH 50) is unlikely to be helpful. treatment should not await serologic confirmation. burgdorferi titer. When syphilis treatment is incomplete. this disorder alone is not generally associated with multiple bacterial infections. but a negative HIV test in the past year makes HIV-related syphilis extremely unlikely. there are populations in whom the disease is still relatively common. but they also apply to populations of people with multiple sexual partners within a limited demographic setting. She had a tick bite while in an endemic area. prudent to test all patients with newly diagnosed syphilis for HIV infection. . Although testing of clinical specimens for resistance is not available. in vitro testing and clinical experience support this conclusion. Amoxicillin is the most appropriate therapy for this patient. Critique The patient has a classic history of early Lyme disease. In these groups involving certain sexual partner networks. the diagnosis is based on clinical guidelines alone. and doxycycline. especially since the lgG and 1gM values are normal or high normal. even the documentation of low or absent values for only one of the two IgA subsets would not satisfactorily explain this patients increased number of infections. the manifestations are of secondary or tertiary syphilis. The sexual partner networks have been described in the context of Internet chat rooms. Consequently. HIV infection can be subtle. It is as effective as cefuroxime-axetil but is significantly less expensive.Although this patient has IgA deficiency. Gonorrhea is the most common setting for such concomitant chlamydial infections. Also. At this stage of the illness. To date. Doxycycline may be the treatment of choice in adults because it provides prophylaxis against other tick-borne infections (ehrlichiosis and Rocky Mountain spotted fever). Lymphocyte disorders that cause abnormal lymphocyte subset quantification are also unlikely to be associated with enhanced susceptibility to bacterial infections. these infections do not seem to be related to the acquisition of syphilis. However. since the complement deficiencies associated with multiple pyogenic infections are quite rare (with the exception of neisserial infections). serum IgA subset quantification cannot be done. It is. there are no penicillin-resistant strains of syphilis. Azithromycin is less effective than amoxicillin and should only be used in patients who are intolerant of amoxicillin. however. followed by a lesion consistent with erythema migrans. Infectious Disease Medicine:Question 12 The correct answer is C Educational Objectives Understand the importance of partner networks in the transmission of sexually transmitted diseases. the probability of acquiring syphilis from any given sexual encounter is many fold higher than in the general population. cefuroxime.
This test is reported to be both sensitive and specific for lymphoma in this setting. However. Primary central nervous system lymphoma is a possible diagnosis for which lumbar puncture can be done to detect Epstein-Barr virus DNA. His presentation is therefore somewhat atypical. Differentiating between colonization and infection can sometimes be difficult. these titers are unlikely to be positive or. with the exception of ertapenem. whereas at least two thirds of patients with toxoplasmic encephalitis have multiple ring-enhancing lesions. not all patients who are colonized will become infected. Each hospital tends to have certain organisms that predominate. since infection is almost always preceded by a variable duration of colonization. Some Acinetobacter strains are broadly antimicrobial susceptible. Many of these infections begin by colonization of patients in intensive care units. and 2) serologic studies indicate past infection consistent with reactivation of quiescent infection that occurs with AIDS-related immunodeficiency. Biopsy of the lesion is indicated only if he does not respond to initial treatment. The potent carbapenems are usually equally active against Acinetobacter. Critique Resistant gram-negative bacillary infections are common in very ill hospitalized patients. Some of the β-lactamase inhibitors (especially sulbactam) also demonstrate activity.Although it is possible that the patient is co-infected withEhrlichia or Babesia. early use of an active drug is strongly recommended when an infection is highly likely. if positive. imipenem and meropenem) and some of the aminoglycosides (for example. Ertapenem is a once-a-day carbapenem with activity similar to other drugs in that class except that the spectrum does not include Pseudomonas . a bacterial abscess would be more likely. may indicate past infection. Critique The dilemma in managing this AIDS patient. In the absence of clinical symptoms. Cytomegalovirus encephalitis would not present as a mass lesion. However. Infectious Disease Medicine:Question 15 The correct answer is A Educational Objectives Determine the role of various antibiotics in the treatment of resistant Acinetobacter infection. and a bacterial brain abscess is no more common in AIDS patients than in other hosts. Usually the potent carbapenems (for example. If his CD4 cell count were considerably higher than 200/μL. he does have other features that are more typical of toxoplasmosis: 1) the lesion arises from the basal ganglia. However. The most appropriate management is to treat this patient presumptively for toxoplasmosis with pyrimethamine plus either sulfadiazine or clindamycin and to monitor his clinical and radiographic treatment response. Cephalosporins such as cefepime and fluoroquinolones such as levofloxacin are usually ineffective. is that he has a single mass lesion of the brain. who is at risk for all major AIDS-related complications. it would be inappropriate to test for them at this time. although these change over time. lumbar puncture is contraindicated in this patient because of the significant mass effect seen on the MRI scan. Although there is no substitute for knowing all in vitro data. amikacin and tobramycin) are most active in vitro. but many are multidrug resistant and difficult to treat. Acinetobacter baumannii is seldom found in ambulatory patients but is one of the most commonly isolated gram-negative organisms in some hospitals. Infectious Disease Medicine:Question 14 The correct answer is A Educational Objectives Recall the management of an AIDS patient presenting with a solitary brain lesion.
the radiology technician. There currently are no data to suggest (and no theoretical basis to believe) that any regimen other than daily therapy indefinitely with a drug active against herpes simplex virus can suppress genital herpes. Only the intern who intubated the patient without personal protective equipment is at increased risk of contracting meningococcal disease. outside of endemic areas. Critique Patients are increasingly presenting with endemic mycoses. Infectious Disease Medicine: Question 17 The correct answer is C Educational Objectives Recognize the indications for meningococcal post-exposure prophylaxis. The nurse. A combination of drugs may be better for the most critically ill patients. In contrast. or valacyclovir (500 or 1000 mg daily) can be used. Infectious Disease Medicine:Question 18 The correct answer is D Educational Objectives Know when to suspect an endemic mycosis in a patient who does not live in an endemic area. The usefulness of aminoglycosides alone or in combination has not been resolved for treating Acinetobacter pneumonia. so that transmission to others may theoretically be reduced. famciclovir (250 mg twice daily). Critique Frequent recurrences of genital herpes can be effectively prevented by chronic suppressive therapy with an oral drug active that is against herpesvirus. Chronic use of these drugs also suppresses asymptomatic virus shedding. Post-exposure prophylaxis is recommended for household contacts and for those health care workers and other hospital personnel who had close contact with the patient’s respiratory secretions. . although resistance to amikacin is fairly low. The organism is transmitted via close contact with an infected patient’s respiratory secretions. but this issue is unresolved at present. although there is no evidence that suppressive therapy will decrease the frequency of episodes after the drug is stopped.aeruginosa. This increase is related to more frequent travel to areas that are endemic for these fungi and to increased vocational or leisure activities that allow exposure to the organism. such as coccidioidomycosis and histoplasmosis. Occasional interruption of therapy is reasonable in order to judge the pattern of recurrences. Most patients will experience some benefit. However. Resistance to these drugs is variable. Infectious Disease Medicine:Question 16 The correct answer is E Educational Objectives Understand how to suppress recurrent genital herpesvirus infections. Critique Neisseria meningitidisinfection is common in communal living settings such as dormitories. Simply residing in or even passing through an endemic area can lead to development of coccidioidomycosis. Aminoglycosides may not be well suited for treating lung infections despite having good minimal inhibitory concentrations. and 40% to 72% will be free of recurrences at 1 year. patients on suppressive regimens should be told that they may still transmit herpes simplex virus to their partners. and the chaplain did not have close contact with this patient’s respiratory secretions and do not require chemoprophylaxis. Acyclovir (400 mg twice daily). and some gram-positive bacteria. Chronic suppression is usually initiated when a patient has at least six episodes yearly. Acinetobacter species.
the upper lobe is an uncommon site. Although atypical mycobacterial infections cause pneumonia. This patient had pneumonia that was suggestive of reactivation tuberculosis because of the upper lobe location and the failure to respond to antibiotics. At least 50% of the lifetime risk of tuberculosis occurs within 1 or 2 years of conversion. Hantavirus pulmonary syndrome is an acute severe pneumonia that occurs mostly among young Native Americans and other residents who are from southwest states adjoining the Four Corners area (Arizona. since aspiration pneumonia tends to occur in lung segments favored by the gravitational movement of oral or gastric flora. and Utah) and who have come in contact with mice that carry the virus.histoplasmosis usually requires participating in an activity related to disruption of the soil or spelunking for aerosolization of the organism and development of subsequent infection. The addition of ampicillin to vancomycin does not provide increased activity against S. Empiric antimicrobial therapy for pneumococcal meningitis is vancomycin plus a thirdgeneration cephalosporin (either cefotaxime or ceftriaxone). Colorado. Critique This patient has meningitis caused byStreptococcus pneumoniae. and she was placed on an inappropriate antimicrobial agent (ciprofloxacin) that has no significant activity against pneumococci. Although aspiration pneumonia could account for the findings in this setting. Infectious Disease Medicine:Question 19 The correct answer is D Educational Objectives Select the appropriate empiric antimicrobial regimen for a patient with pneumococcal meningitis. Critique This patient requires a sputum smear and culture for acid-fast bacilli. Finally. The development of reactivation tuberculosis often follows closely after tuberculin skin test conversion. this patient has no clinical manifestations of such disorders and does not require a swallowing function evaluation. pending in vitro susceptibility testing. There is no specific link to the Southwest. since the risk of tuberculosis (and possible transmission of tuberculosis to others) exceeds the risk of the medication. Infectious Disease Medicine:Question 20 The correct answer is C Educational Objectives Be aware that reactivation tuberculosis occurs early in many patients. Chemoprophylaxis is therefore desirable for anyone with known conversion. and antimicrobial therapy should be targeted at the causative organism. Recognizing the manifestations of endemic mycoses and taking a complete travel history are essential for diagnosis and appropriate treatment. administering either penicillin or ceftriaxone alone may not achieve adequate cerebrospinal fluid concentrations to kill these organisms. findings are usually similar to those of tuberculosis in that they include upper lobe cavitary infiltrates in persons with underlying pulmonary disease or diffuse disease in persons who are immunocompromised.S. Older adults appear to be at greater risk for developing more serious infection with Coccidioides immitis and are the fastest growing group reported with symptomatic coccidioidomycosis. pneumoniae meningitis can be diagnosed presumptively based on the positive cerebrospinal fluid Gram stain. Although vancomycin has good in vitro activity against resistant pneumococci. Nocardiosis occurs mostly in immunocompromised hosts. If the pneumococci are highly resistant to penicillin or the cephalosporins. pulmonary infiltrates are extremely uncommon in patients with ehrlichiosis. New Mexico. . it should not be used alone for treating pneumococcal meningitis because of its unreliable penetration into the cerebrospinal fluid. pneumoniae. although it can occur in normal hosts. Although swallowing disorders do predispose to aspiration. The infection likely originated in her middle ear.
it usually improves faster with appropriate antibiotics. Despite her low viral load. This asymptomatic woman with early-stage infection has no indications for first-trimester therapy. infections caused by CAMRSA can be very serious. Antiretroviral therapy should be avoided during the first trimester unless there is a compelling reason to begin (or continue) such therapy. tetracyclines. When treating patients with severe infection caused by more broadly resistant CAMRSA. Conventional cellulitis is often a mild to moderately severe disease. However. beginning between weeks 14 and 34 of pregnancy. would not require antiretroviral therapy. this patient should receive zidovudine monotherapy. This patient has satisfactory CD4 cell counts and viral load levels and. Nevirapine alone at the time of delivery is effective in reducing the vertical transmission rate but is not as effective as standard treatment begun earlier in the pregnancy. and therapy is sometimes changed because of concerns regarding the efficacy of the initial treatment. if not pregnant. Although cellulitis can resolve without treatment. and deaths have occurred in children and healthy adults from progressive infectionafter treatment is initiated. levofloxacin is usually preferred to azithromycin for treating resistantStreptococcus pneumoniae. the infection rate for newborns in the United States has dropped below 3%. Critique The best explanation for this patient’s persistent infection is the presence of resistant bacteria. linezolid would be an expensive but reasonable alternative. However. Persistent skin infections can be worrisome because they sometimes are an indication of more serious deep soft-tissue infections such as fasciitis or myositis. In this healthy young man. Clindamycin. The rate of resolution is variable. When such therapy is combined with the judicious use of cesarean section. Infectious Disease Medicine:Question 22 The correct answer is D Educational Objectives Recall the clinical presentation of methicillin-resistant Staphylococcus aureus in the community. However. Critique Antiretroviral therapy during pregnancy has been proved to be unequivocally effective in reducing vertical transmission of HIV infection. which this patient seems unlikely to have because of the slow progression of her infection. Adding rifampin may also be helpful. the skin lesion was actually progressing at a time when he . Repeating a positive tuberculin skin test is not necessary unless this is being done for the evaluation of anergy. Levofloxacin is not very effective for treating aspiration pneumonia because of its limited activity against oral anaerobes. efavirenz has been shown to be teratogenic in animals. These strains have been in circulation for a few years and differ from hospitalassociated strains in several ways. or trimethoprim/sulfamethoxazole is usually effective. depending on the underlying health of the patient. Infectious Disease Medicine: Question 21 The correct answer is E Educational Objectives Recall the appropriate management of a pregnant woman with HIV infection. treatment is indicated to further reduce the already low risk of vertical transmission.Changing antibiotics is sometimes helpful if a resistant organism is a concern. most likely community acquired methicillin-resistant Staphylococcus aureus (CAMRSA). Most important clinically is that they are not as broadly antibiotic resistant as the nosocomial strains and can usually be treated with a number of available oral agents. Moreover.
but should either have begun to respond to these antibiotics (all S. since development of various tick-borne illnesses is possible. which is higher than that used for other infections caused by herpes simplex virus. which is the area most often affected in patients with herpes simplex virus encephalitis. Although brain biopsy had been the standard approach to diagnosis. pyogenes strains are susceptible to penicillins and most cephalosporins) or have caused a much more toxic presentation by this time. three key factors should be considered before initiating prophylaxis or early treatment following a tick bite: species of the tick. Similarly. formerly called Ixodes dammini). However. New Jersey is a state with a high incidence of Lyme disease and a low to medium incidence of babesiosis and ehrlichiosis. Intravenous acyclovir at 5 mg/kg every 8 hours is used for systemic herpes simplex virus infections. However. therapy should not be delayed to obtain another imaging study. deep softtissue infection that can progress rapidly. this invasive test is now reserved for patients who are not responding to therapy or have other indications for neurosurgery. Critique It is tempting to consider any tick bite as a cause for intervention. since an experienced observer determined that it was a deer tick 4xodes scapularis. the minimal time of tick attachment for transmission of Borrelia burgdorferi infection is 24 hours (and most likely 48 hours or more). geographic location of acquisition. and duration of attachment. Intravenous acyclovir significantly reduces mortality from herpes simplex virus encephalitis and should be started promptly when this diagnosis is a serious consideration.was taking antibiotics. In this case. and cerebrospinal fluid showing lymphocytic pleocytosis. geriatric patients. injection drug users). Critique This patient has encephalitis (fever. and the rapid progression. elevated protein. the history suggests involvement of the temporal lobe. Infectious Disease Medicine:Question 23 The correct answer is B Educational Objectives Recall how to diagnose and treat herpes simplex virus encephalitis. Therapy should not be delayed in order to confirm the etiologic diagnosis because survival in these patients is directly related to the level of consciousness at the onset of treatment. . but this dose is considered inadequate for central nervous system infections. Fasciitis is a serious. Although a positive polymerase chain reaction test of cerebrospinal fluid may be used to confirm the diagnosis and a negative test may be an indication for discontinuation of empiric therapy. Lyme disease usually presents with a progressive local rash. there was no uncertainty about the species of tick. but the time course is much slower. Abscesses can complicate skin infections and may not resolve without drainage (either spontaneous or surgical). in both humans and animals. the tick is usually engorged and is much easier to see. However. the presence of pain. confusion. treatment must begin before this result is available. Infection caused by “flesh-eating bacteria. can be severe and rapid. and lesions are typically painless. Moreover. such as the need to evaluate a mass that could be an abscess or a tumor. Ticks on parts of the body that are difficult for the patient to see are more likely to go unnoticed than are ticks on the arm. By this time. This might be explained by erythema migrans except for the time of year. The dose of acyclovir for this indication is 10 to 15 mg/kg every 8 hours. Infectious Disease Medicine:Question 24 The correct answer is A Educational Objectives Recall the most appropriate management for a patient with a low-risk tick bite. diabetics.” such as Streptococcus pyogenes. fasciitis most often occurs in persons who are otherwise ill or weak (for example. and normal glucose). However. this patient had no evidence of abscess either at the time of initial presentation or later.
Azithromycin is a less suitable alternative and has a higher failure rate than amoxicillin. Serum lgG subset quantification and T-cell subset quantification are incorrect because defects in lgG or T-cell subsets are not known to lead to increased susceptibility to neisserial infections. if given as a choice. determination of the serum C9 level would have been an acceptable answer. Critique Complement component deficiencies of the alternative pathway components properdin and factor D are associated with susceptibility to meningococcal disease but not with low levels of total hemolytic complement (OH 50). Although dexamethasone has been shown to decrease penetration of antimicrobial agents into cerebrospinal fluid. the high dose needed (200 mg) may provoke nausea. Infectious Disease Medicine:Question 25 The correct answer is B Educational Objectives Understand the more uncommon complement deficiencies associated with neisserial disease and which laboratory studies are most appropriate for diagnosing these disorders. Critique The rationale for use of adjunctive dexamethasone in patients with bacterial meningitis is to attenuate the subarachnoid space inflammatory response that results from antimicrobial agent-induced lysis of meningitis pathogens. have demonstrated that adjunctive dexamethasone is beneficial for patients with meningitis caused byHaemophilus influenzae type b and. Infectious Disease Medicine:Question 26 The correct answer is D Educational Objectives Recognize the appropriate use of adjunctive dexamethasone in patients with bacterial meningitis. Previous studies.Although all the oral regimens listed are fairly safe. they offer little advantage over observation. adjunctive dexamethasone was beneficial in the subset of patients with pneumococcal meningitis and was associated with a reduction in the number of patients who had an unfavorable outcome or who died. the CH5O value would have been significantly lower than normal for the laboratory where the test was done. Infectious Disease Medicine:Question 27 The correct answer is B . Determination of individual C5. evidence shows that a single dose of doxycycline is effective in preventing most cases of Lyme disease. predominantly in infants and children. this has not been associated with a worse outcome. may be beneficial for patients with pneumococcal meningitis. and 8 levels is not needed because if any of these complement components had been low or absent. 6. In a recently published trial in adults with bacterial meningitis. or a cephalosporin. Many oral and parenteral cephalosporins are effective for the treatment of Lyme disease. When treatment is indicated. if started along with or prior to parenteral antimicrobial therapy. amoxicillin is a suitable agent and is the drug of choice for treating erythema migrans in children. If used. However. and. doxycycline. most experts would order additional diagnostic studies of alternative pathway complement components. If the duration of tick attachment is significant and exposure occurred in a highly endemic area. 7. Because the likelihood of a complement abnormality increases substantially after each neisserial infection. This is also true of C9 deficiency. adjunctive dexamethasone must be administered concomitant with or just prior to the first dose of antimicrobial therapy. since this patient has an infinitesimally small risk of developing Lyme disease.
such as Clostridium difficile. drug-induced fever on an allergic basis is the most likely cause of his persistent fever. There is no role for surveillance . nosocomial pneumonia due to this derepressed mutant is unlikely. Without an infectious etiology. developing influenza.Educational Objectives Recall the treatment of Enterobacter cloacae infection. Trimethoprim/sulfamethoxazole should therefore be started. The U. Cefepime is also a β -lactam and is not active against derepressed mutants.Cryptosporidium parvum is a nonhelminthic parasite that causes profound diarrhea in AIDS patients. A low circulating eosinophil count (eosinopenia) is thought to be a poor prognostic finding. In general. and oseltamivir (but not zanamivir at the time of this writing) for prophylaxis of influenza A and B.Taenia solium is the pork tapeworm whose major extraintestinal complication is focal brain lesions (cysticercosis). For patients with various immunodeficiency disorders such as AIDS. the prognosis in this setting is poor. since it is a β-lactam and may cause a cross-reaction in patients who have an allergic reaction to β-lactams. Administration of vaccine alone is not sufficient if influenza is already occurring in the community. This patient is at risk for acquiring influenza virus. unvaccinated individuals at high risk for complications of influenza or those who are caring for high-risk persons can begin chemoprophylaxis. after influenza has been documented in a community. Ascaris lumbricoides helminths are macroscopic and are not encountered in this setting. This results in disseminated bacterial infections secondary to carriage of gut bacteria to sterile sites and/or massive invasion of various organs (usually the lungs) by the larvae themselves. Infectious Disease Medicine:Question 28 The correct answer is D Educational Objectives Recognize the pathogens that cause pneumonia in AIDS patients. such asE. resulting in severe respiratory compromise. chemoprophylaxis need only be continued for 2 weeks. Most HIV-infected patients withS. Food and Drug Administration has approved amantadine and rimantadine for prophylaxis of influenza A. If concomitant vaccination is performed. Critique Emergence of a derepressed mutant of Enterobacter cloacae is the most likely cause of this patients second positive tracheal culture. Pneumocystis carinii organisms certainly do not look like the parasites shown. eggs laid by adult worms hatch within the gut and release filariaform larvae that can “autoinfect” the host. and dying—all before immunity develops from the vaccine. infection withS. cloacae. Imipenem should not be given. Strongyloidiasis is a helminthic infection that causes chronic intestinal infection in normal hosts. stercoralis hyperinfection have late-stage disease. Critique Vaccination is the primary way to prevent influenza. Infectious Disease Medicine:Question 29 The correct answer is C Educational Objectives Understand how to prevent influenza in a high-risk unvaccinated patient when an influenza outbreak is occurring in the community. In addition metronidazole is inactive against facultative anaerobes.S. In such patients. Metronidazole is only active against obligate anaerobes. In view of the absence of new or progressive infiltrates on chest radiographs. Gram-negative bacillary pneumonia is usually treated for 2 to 3 weeks. by which time adults are presumed to have developed protective antibody levels. so that changing to another antibiotic to which the organism is susceptible is required. stercoralis can cause severe disease. Critique This patient has Strongyloides stercoralishyperinfection. However.
but they have not been found to reduce the incidence of sexually transmitted diseases. none of them has been completely effective.influenza cultures in deciding how to manage such a patient. Critique Candida infections are the fourth most common cause of nosocomial bloodstream infections. Infectious Disease Medicine:Question 31 The correct answer is A Educational Objectives Be aware of the role of alcohol and impulsivity in the transmission of sexually transmitted diseases. Fluconazole. There is information. vertebral osteomyelitis. It is reasonable to discuss risks for more serious sexually transmitted diseases such as HIV infection. The most common extrinsic reasons for impulsive behavior relate to alcohol and drug use. therapy should be changed to amphotericin B or caspofungin. the frequent need for parenteral nutrition supplied through a central venous catheter. although using barrier precautions is still prudent since some people are not aware of their HIV status. Focal infections such as chorioretinitis may take weeks to develop. 400 mg daily. While it may be possible to ask potential sexual partners if they have any sexually transmitted diseases. even an honest answer may be inaccurate. Therefore. Hygiene measures such as showering are reasonable. and treatment should not be withheld until such an infection is documented. Even transient candidemia can lead to endophthalmitis. the frequent occurrence of acute renal failure requiring hemodialysis. however. is appropriate for treating candidemia in patients with normal renal function and should be adequate for treating most Candida bloodstream infections. If vaccine is administered. and the use of broad-spectrum antibiotics. for the duration of influenza activity in the community). The source is usually from the patients gastrointestinal tract or from a central venous catheter. or other serious focal Candida infections. The fact that only two of four culture bottles grew Candida reflects the obligate aerobic nature of the organism. Several decades ago. the bottles incubated anaerobically will not support the growth of Candida. Candida should never be assumed to be a contaminant in a blood culture. Critique Many strategies have been suggested to prevent sexually transmitted diseases. prophylactic antibiotics were shown to reduce the incidence of gonorrhea in military personnel such as sailors on . Infectious Disease Medicine:Question 30 The correct answer is B Educational Objectives Understand the reasons for the current practice of recommending antifungal treatment for a patient with candidemia. And given the possibility of asymptomatic infection with Neisseria gonorrhoeae. Patients in surgical intensive care units are at great risk for candidemia because of surgical procedures involving the gut. it is unlikely that anyone will offer this information even on direct inquiry. Reducing alcohol consumption in adolescents and young adults can lower the risk of sexually transmitted diseases. that impulsive behavior can increase the risk of acquiring sexually transmitted diseases. chemoprophylaxis is given for 2 weeks rather than 6 weeks. Aside from abstinence. However. chemoprophylaxis can be used for a longer course (that is. Because influenza can persist in an area for several weeks. removing the catheter alone is not adequate therapy. vaccination is useful even after influenza has been documented in a community. if vaccination is not possible or if the vaccine is not expected to protect against the current virus strain. This patient requires immediate treatment with fluconazole to prevent development of a focal infection. If the organism is identified as Candida krusei or Candida glabrata.
Treatment of C. the dose for prophylaxis should be lower than the full therapeutic dose in order to minimize the risk of side effects that are somewhat dose. This is an important issue because drug resistance in strains of N. This is a cost-effective treatment that has the least effect on bacterial ecology. Infectious Disease Medicine:Question 32 The correct answer is C Educational Objectives Recall management strategies for the prevention of recurrent urinary tract infections. Because the patient has a soft abdomen and normal bowel sounds. Many drugs have been tested. difficile diarrhea. A patient-initiated fluoroquinolone given for several days is effective in the early treatment of urinary tract infections. difficile infection. radiologic imaging is not indicated. This. Shigellaand Campylobacter. Spermicides increase the risk of urinary tract infections. In high-risk patients with suspectedC. Factors such as sexual positioning. Critique This patient is at high risk forCiostridium difficile infection on the basis of her hospitalization and treatment with antibiotics. in turn. Antimotility agents are contraindicated in patients withC. The use of β -lactams is disappointing for prophylaxis because gastrointestinal flora can be quickly altered so that β -lactam-resistant organisms proliferate. difficile diarrhea requires discontinuing the causative antibiotic and starting metronidazole or vancomycin. nitrofurantoin. empiric contact isolation should be instituted until the pathogen can be ruled out. Adding an aminoglycoside without stopping the cephalosporin provides no benefit. Most women are able to distinguish urinary tract infections from other illnesses with a high degree of accuracy. can cause recurrent urinary tract infections even during periods of treatment or prophylaxis. Critique Antimicrobial agents can be useful in preventing recurrences of urinary tract infections. Infectious Disease Medicine:Question 33 The correct answer is C Educational Objectives Recognize the indications for empiric contact isolation for a patient with probableClostridium difficile infection. Routine bacterial cultures are rarely helpful.and durationdependent. asC. and the best outcomes are associated with trimethoprim/sulfamethoxazole. since they primarily determine foodborne pathogens such as Salmonella. difficile is easily spread by contact and may cause outbreaks of nosocomial diarrhea. There is currently no information about prophylaxis for gonorrhea. post-coital voiding. Use of trimethoprim/sulfamethoxazole for prophylaxis may be of concern because the number of strains of uropathogens resistant to this agent has been gradually increasing. Therefore. Infectious Disease Medicine:Question 34 The correct answer is D . patients with recurrent infections should be advised to use some other form of contraception. and fluoroquinolones.shore leave. Furthermore. which are all uncommon in hospitalized patients. gonorrhoeae has increased markedly. and post-toileting habits have not been shown to correlate with the risk of developing acute or recurrent urinary tract infections.
given the current information. Hyperproduction of ESBLs may overcome inhibition by β -lactamase inhibitors. Critique This patient presents with paradoxical worsening of his tuberculosis following the initiation of antiretroviral and antituberculous therapy. the optimal duration of treatment in this setting is uncertain. which is usually more resistant to β -lactamases than are other extended-spectrum cephalosporins. some clinicians may want to treat conservatively for 4 (or even 6) weeks without performing an echocardiogram. transthoracic echocardiogram) and consider stopping the intravenous antibiotics after 2 weeks. Infectious Disease Medicine:Question 36 The correct answer is E Educational Objectives Recognize immune reconstitution syndrome in a patient with late-stage HIV infection who recently began taking antiretroviral therapy. Therefore. Changing to an oral antibiotic is not considered a reliable option for treating S.Educational Objectives Understand how to manage Staphylococcus aureus bacteremia. such as aminoglycosides. if a transesophageal echocardiogram is done and does not show endocarditis. Critique The patient has an intravascular catheter-related bloodstream infection. Perhaps 25% of such patients have endocarditis. although some investigators have used a combination of oral rifampin and a fluoroquinolone. Critique Klebsiella pneumoniae and Escherichia coli strains that are resistant to ceftazidime should be suspected of producing an extended-spectrum β -lactamase (ESBL) that is capable of inactivating all extended-spectrum cephalosporins. and trimethoprim/sulfamethoxazole. and may inactivate cefepime. Finally. there is no reason to provide treatment for 6 weeks. such as tazobactam. aureus bacteremia. aureus bacteremia. The carbapenems are usually active against these organisms. This type of immune reconstitution syndrome reaction has also . Others may choose to be guided by their clinical assessment (with or without a less invasive. Such reactions are thought to be due to partial immune reconstitution. Although the focus of infection was removed. although published reports suggest that clinical judgment may not be reliable in this setting. The other options are inappropriate because many of these strains are resistant to multiple chemically unrelated classes of antimicrobial agents. penicillins. 8 weeks would be an unnecessarily long antibiotic course. the only option that falls within these parameters is obtaining a transesophageal echocardiogram and treating with intravenous nafcillin for 14 days if this study does not show endocarditis. tetracyclines. although some investigators have used such a short course in selected patients who have a normal transesophageal echocardiogram. Seven days of intravenous antibiotics would generally not be considered sufficient forS. However. Of the choices given. fluoroquinolones. but less sensitive. However. Infectious Disease Medicine:Question 35 The correct answer is C Educational Objectives Recall the treatment of extended-spectrum β -lactamase Escherichia coli infection. the most appropriate therapy for this patient is treatment with a carbapenem such as imipenem. which can be detected most reliably by transesophageal echocardiography. Two studies suggest that the most costeffective approach for patients with native valves is to obtain a transesophageal echocardiogram and then treat for 4 weeks if endocarditis is diagnosed but for only 2 weeks if endocarditis is not diagnosed. which occurs following effective control of HIV by antiretroviral therapy. Infections caused by these organisms may be unresponsive to the antibiotics listed. and aztreonam despite in vitro assay results to the contrary.
no large published series have addressed the safety or efficacy of this approach. His current treatment should therefore be continued along with the addition of a nonsteroidal anti-inflammatory drug for control of pain and fever. Antibacterial agents are not indicated for treatment of viral infections and should not be used to prevent bacterial superinfections. Infectious Disease Medicine:Question 39 The correct answer is A Educational Objectives Recall the complement component deficiencies that may be associated with increased pyogenic infections. but are probably unnecessary at this time. Critique Neisseria meningitidi Ebola virus. some clinicians advocate administering short. tapering courses of corticosteroids is advocated by some clinicians. This patients findings are unlikely to be due to failure of either treatment regimen. is also FDA-approved for herpes labialis and has benefits similar to those of penciclovir when started within hours of the onset of symptoms. Infection control measures should include contact and droplet isolation procedures. using two large oral doses 12 hours apart. docosanol (Abreva ®). acyclovir is not FDA-approved for this indication. bubonic or pneumonic. Therefore. Infectious Disease Medicine:Question 38 The correct answer is B Educational Objectives Recognize the clinical presentation of hemorrhagic viral illness and some of the other illnesses to be included in the differential diagnosis. To date. valacyclovir was approved for 1-day treatment of orolabial herpes. A culture to confirm the diagnosis of uncomplicated herpes labialis is unnecessary.been described in patients with other AIDS-related opportunistic infections. however. Critique Recurrent herpes labialis is a self-limited illness for which interventions are probably of marginal value. Infectious Disease Medicine:Question 37 The correct answer is E Educational Objectives Understand the management of herpes labialis in an otherwise healthy individual. No treatment would be expected to help if started the day after the lesion was noted. Lymph node biopsy and diagnostic thoracentesis are unlikely to be harmful. including disseminated Mycobacterium avium complex infection and cytomegalovirus retinitis. An over-the-counter cream containing a long-chain alcohol. at least until the diagnosis is known. and Marburg virus are all capable of causing this patients clinical picture. Specific treatment is not available for the two possible viral infections. Another possibility is to prescribe oral acyclovir in an attempt to suppress frequent recurrences or prevent sun-induced episodes of herpes labialis. Critique C3 deficiency is one of the most severe complement component deficiencies because it is . Although not listed as an option. Use of topical penciclovir was found to have small but statistically significant benefits in the management of herpes labialis (time to healing and loss of pain were reduced by less than 1 day when patients began application within 1 hour of the first sign or symptom and applied the drug every 2 hours while awake for 4 days). Although there is support in the literature for this approach. Recently. he should be treated with ceftriaxone or cefotaxime to cover the possibility of meningococcal meningitis. The clinical picture is not typical of plague ‘ersinia pestis) in either of its major forms.
Resistance has been reported to the other antibiotics. There are no findings at this time to support a diagnosis of lymphoma in this patient. have also been implicated. so there is no need to repeat this study. The syndrome has also developed in patients who have never received antiretroviral therapy. These strains exhibit no predictable cross-resistance to vancomycin. streptogramin b (a component of quinupristin/dalfopristin). However. The mechanism for this disorder is not well understood but may involve a complex interplay between viral infection and antiretroviral therapy. or linezolid. fluoroquinolones. No effective treatment has been identified to date. Findings of lipodystrophy consist of some combination of fat wasting. Protease inhibitors are most closely associated with this syndrome. Cl inhibitor (Cl INH) deficiency is the cause of hereditary angioedema and is not known to be associated with increased numbers of infections. The most appropriate antibiotic for this critically ill patient is intravenous vancomycin.associated with large numbers of serious pyogenic infections. primarily involving the face and extremities (lipoatrophy). Infectious Disease Medicine:Question 41 The correct answer is C Educational Objectives Recognize long-term complications of HIV antiretroviral therapy. and may also be resistant to clindamycin. Infectious Disease Medicine:Question 42 The correct answer is B Educational Objectives Understand the emerging epidemiology of aspergillosis in a hematopoietic stem cell transplant patient and the usefulness of high-resolution CT scanning in helping to define the probability of invasive aspergil losis. such as the macrolides and trimethoprim/sulfamethoxazole. Critique With the advent of highly active antiretroviral therapy came the recognition of a fat redistribution syndrome termed HIV lipodystrophy. asS. breasts (in women). Properdin and C5 deficiencies are associated only with increased numbers of neisserial infections. most notably stavudine. HIV wasting is a late-stage complication that is associated with profound and progressive weight loss and cachexia. A total hemolytic complement (CH50) level would be expected to be low in the presence of a low to absent C3 value. Critique Streptococcus pneumoniae that is resistant to penicillin is usually resistant to multiple other chemically dissimilar antibiotics. and sometimes in the face and dorsum of the neck (fat accumulation in the face and neck may mimic features of Cushings syndrome). Although chronic hepatitis C is a possibility. Infectious Disease Medicine:Question 40 The correct answer is A Educational Objectives Recall the treatment of levofloxacin-resistant Streptococcus pneumoniae infection. but nucleoside analogues. Critique . HIV lipodystrophy may be associated with hyperlipidemia and glucose intolerance. with fat accumulation in the abdomen (visceral adiposity). The patients IgA value was previously normal. Such strains may exhibit cross-resistance to all the fluoroquinolones. and doxycycline. hepatitis would not explain all of this patients physical findings. pneumoniae resistance to this agent has not been reported to date. this patient has likely developed levofloxacin resistance because of inadequate serum concentrations of levofloxacin relative to the minimal inhibitory concentration of the pathogen.
which is another way to increase the total daily dose. azithromycin is not indicated. Similarly. prior use of broad-spectrum antibiotics for bacterial infections. Recent data suggest that most transplant recipients with invasive aspergillosis do not develop infection in the pre-engraftment phase. Critique This patient. The standard duration of treatment for prosthetic valve enterococcal endocarditis is 6 weeks of combination therapy. Critique Many laboratories test enterococci for high-level resistance against gentamicin and streptomycin. and. the central venous catheter should not be removed. Scans also frequently show a pulmonary infiltrate with a “ground-glass” appearance around the nodule. or vancomycin (assuming that the bacteria are also sensitive to these agents). Higher peak levels are considered ‘therapeutic” only when aminoglycosides are used to treat gram-negative rod infections. This dose maximizes the clinical benefit while minimizing nephrotoxic side effects. The patient’s presentation is not typical of a catheter-related infection. chronic graft-versus-host disease treated with high-dose corticosteroids. although a recent report questioned the need to continue the aminoglycoside beyond 2 weeks. When gentamicin is used as synergistic therapy for gram-positive infections. no adjustment in either medication is necessary. hematopoietic stem cell transplantation. Therefore. there is no reason to decrease the interval between gentamicin doses. As with all aminoglycoside regimens. on fluconazole prophylaxis. infection occurs when they develop graft-versus-host disease that is treated with highdose corticosteroid therapy. and may still be. . Her risk factors include leukemia. Atypical pneumonia such as Legionnaires’ disease is not usually associated with hemoptysis. the starting dose is only 1 mg/kg of body weight every 8 hours (with adjustments for obesity and renal function). termed a halo sign. ampicillin. such asAspergillus. Infectious Disease Medicine:Question 43 The correct answer is C Educational Objectives Understand key aspects of antibiotic management when treating gram-positive prosthetic valve endocarditis. Infectious Disease Medicine:Question 44 The correct answer is C Educational Objectives Select the appropriate antimicrobial agent for a patient with Listeria meningitis who has a severe allergy to penicillin.This woman has symptoms strongly suggesting invasive pulmonary aspergillosis for which amphotericin B is indicated. and there is a high likelihood that the patient was. and the goal is to obtain peak levels just over 3 ig/mL. since several angioinvasive fungi have the same clinical and radiologic features. For the reasons discussed above. trough levels should be low to reduce the risk of toxicity. there is no reason to increase the gentamicin dose. therefore. most importantly. For this patient. prior neutropenia. despite being informed that the level is subtherapeutic according to the laboratory’s guidelines. High-resolution CT scanning of the chest should be followed by bronchoscopy to identify the exact etiologic agent. The halo sign indicates bleeding and is characteristic of changes induced by angioinvasive fungi. Lack of high-level resistance correlates with synergistic killing when the aminoglycoside is added to penicillin. High-resolution CT scanning frequently allows visualization of multiple pulmonary nodules that are not seen on chest radiographs. and there is no reason to change that dose. instead. who underwent renal transplantation and is on immunosuppressive therapy. The vancomycin levels are appropriate. Fluconazole is not effective for aspergillosis.
the decision to vaccinate must be individualized and is based on the estimated risk of infection balanced by the potential severity of an adverse reaction. Levofloxacin has not been studied for treatment of meningitis. The grampositive bacilli on Gram stain of cerebrospinal fluid indicate that Listeria should be highly suspected as the causative organism. In such cases. Quinupristin/dalfopristin is usually inactive against gram-negative bacilli. but the evidence is not conclusive. chloramphenicol. Potential contraindications include age less than 9 months. The therapy of choice for Listeria meningitis is ampicillin or penicillin G combined with an aminoglycoside. and enterococci. With the exception of a minority of persons who have potential contraindications. aureus Infectious Disease Medicine:Question 47 The correct answer is D Educational Objectives . monocytogenes but are associated with unacceptably high failure rates in patients withListeria meningitis. Infectious Disease Medicine:Question 46 The correct answer is D Educational Objectives Recall the most appropriate antibiotic therapy for osteomyelitis of the metatarsal head. Critique Yellow fever is caused by a flavivirus transmitted by mosquitoes. as such. The disease occurs only in tropical areas of Africa and South America. meropenem. Acinetobacter species. Yellow fever is a potentially life-threatening viral hemorrhagic fever with a case fatality rate of 25% to 50% and. Given the patient’s severe allergy to penicillin. are inactive against methicillinresistant S. immunosuppression. For any person with a potential contraindication. faecium. yellow fever vaccination is recommended for all travelers to endemic areas. history of hypersensitivity to a component of the vaccine. and all β-lactams. following consumption of cole slaw and/or processed meats. Infectious Disease Medicine:Question 45 The correct answer is B Educational Objectives Recognize the indications for yellow fever vaccination in a traveler. Some surveillance data suggest that elderly persons may be more prone to severe reactions. consultation with an expert in the area of travelers health is usually recommended. including the carbepenems (imipenem. Serious adverse reactions to yellow fever vaccine are quite rare and include hypersensitivity reactions. encephalitis.has meningitis caused byListeria monocytogenes She likely acquired the infection through the gastrointestinal tract. Linezolid is active againstEnterococcus faecium and methicillin-resistant Staphylococcus aureus. Imipenem susceptibility testing does not predict ertapenem susceptibility forPseudomonas aeruginosa. and about 99% do so within 30 days. trimethoprim/sulfamethoxazole is the alternative antimicrobial agent of choice. and pregnancy. and a multiorgan failure syndrome resembling naturally acquired yellow fever infection. Critique Linezolid plus imipenem is the most appropriate choice to provide coverage for all pathogens. and ertapenem). vaccination should be considered for all travelers to areas of risk. both of which are vehicles of transmission in outbreaks of Listeria infection. Erythromycin. About 90% of individuals receiving the vaccine produce neutralizing antibodies within 10 days of immunization. against which ertapenem is inactive. and vancomycin have in vitro activity againstL. Imipenem is not active againstE. and imipenem is active against gram-negative bacilli.
When started within 24 hours of onset of rash. Although many health care workers do not develop tuberculosis even after close and long-term exposure. Waiting for culture results before starting therapy is inadvisable. Rifampin is known to interfere with many protease inhibitors and should be avoided. Although Mycobacterium avium complex (MAC) infection is a well-known complication of AIDS. adolescents. Most institutions have policies that require regular tuberculin skin testing. Infectious Disease Medicine:Question 48 The correct answer is D Educational Objectives Recall when and how to treat uncomplicated chickenpox (primary varicella). Infectious Disease Medicine:Question 49 The correct answer is A Educational Objectives Recall the management of health care workers exposed to Mycobacterium tuberculosis. Because lesions have been present for 4 days. Critique This patients presentation is most consistent with tuberculosis. An antiretroviral genotype or phenotype determination is unlikely to be helpful. and adults. given the radiographic features and the positive smear for acid-fast bacilli. There are also no data to support the use of topical or intravenous acyclovir in this setting. Having a protocol for evaluating this possibility is therefore important. high-dose oral acyclovir can shorten the duration of fever by about 1 day and decrease the number of new chickenpox lesions in children. Critique This patient most likely has severe tuberculosis because of his history and the positive sputum smear. A positive test result . This patients HIV infection is under good (but not perfect) control after what appears to be several failed attempts with regimens that included nucleoside analogues and nonnucleoside reverse transcriptase inhibitors. no benefit was noted when adults started treatment 25 to 72 hours after the rash developed. All employees who are exposed to patients with active tuberculosis should have repeat skin testing at the time of exposure and again in about 12 weeks. pending identification and sensitivity testing of this patients sputum isolate. The risk of disseminated MAC infection is drastically reduced by immune reconstitution following highly active antiretroviral therapy (HAART). A streptomycin-containing regimen is a possibility but is likely to be more toxic. Furthermore. antibiotics should not be given to prevent bacterial superinfections but instead should be reserved for established bacterial infections. Substituting rifabutin for rifampin is appropriate. and antibacterial agents are not needed for these small pustules. isolated MAC pneumonia is much less common than disseminated MAC infection. Critique This patient has the classic presentation of chickenpox (note that lesions at multiple stages on the same part of the body are not consistent with smallpox). disseminated infection usually develops in patients with profoundly low CD4 cell counts (< 50/μL).Recognize the unique pharmacologic issues in the treatment of tuberculosis in an HIVinfected patient. since his viral load is too low for such a measurement to be obtained. some exposed workers do contract the disease. A persistently negative test result requires no further intervention. There is no easy way to avoid continuing this patients protease inhibitor-based regimen. In addition. since results can take many weeks and the patient may decline significantly or die in the interim. However. Clouding of the liquid within vesicles is expected as the lesions evolve. the most appropriate management is to provide anticipatory guidance about complications of varicella and offer symptomatic treatment.
Critique Therapy for latent tuberculosis is indicated for this patient. Cytomegalovirus. burgdorferi. Babesiosis is often compared with malaria.suggests conversion and should be followed by appropriate treatment or prophylaxis. and is asplenic. the prior treatment with doxycycline should have eradicated all Ehrlichia organisms. burgdorferi since treatment may have aborted the immunogenicity. She is from a developing country where tuberculosis is widespread and where she received bacille Calmette-Guérin . Although the possibility of ehrlichiosis does exist in New England. Finally. persons with X-linked lymphoproliferative disease can have any of the findings noted in this patient. Critique After infection with Epstein-Barr virus. and his maternal uncle. since the single-cell organism for each infection is a parasite of the erythrocyte and both illnesses cause fever and hemolysis. as results would be positive because of this patients prior exposure toBorrelia burgdorferi or because of his recent (or even a remote) episode of clinical Lyme disease. HIV can be associated with lymphoma and pancytopenias but is not known to cause profound hypogammaglobulinemia. Infectious Disease Medicine:Question 51 The correct answer is D Educational Objectives Diagnose babesiosis in a patient co-infected with Lyme disease. He also resides in an endemic area. Critique This patients current presentation is compatible with babesiosis. but more than one drug may be necessary after exposure to a source patient with resistantMycobacterium tuberculosis. Alternatively. there are several problems with this diagnosis. isoniazid alone for 9 months is adequate. the tick that transmits Rocky Mountain spotted fever is different from the tick that transmitsB. had contact with an appropriate tick (as attested to by his prior bout of Lyme disease). Infectious Disease Medicine:Question 50 The correct answer is E Educational Objectives Understand the manifestations of X-linked lymphoproliferative disease. human T-call lymphotropic virus-i (HTLV-i) and HTLV-2. the presence of these antibodies would provide support for this diagnosis. Definitive proof would require molecular techniques to demonstrate mutation of the SH2D1A gene that is responsible for the disorder. Chest radiographs are useful in managing patients with clinical tuberculosis or with positive tuberculin skin tests. and human herpesvirus 6 are not known to cause any of the findings identified in the patient. or his uncle. his brother. Therapy can be modified based on the results of cultures obtained from the source patient. his older brother. Infectious Disease Medicine:Question 52 The correct answer is C Educational Objectives Recall the management of a patient with latent tuberculosis infection. Although finding positive Epstein-Barr virus antibody titers would not prove that he had infectious mononucleosis.The febrile illness that this patient had several months ago was presumably infectious mononucleosis. The diagnostic test for babesiosis is visualization of the causative organism on a peripheral blood smear. Doing serologic studies for Lyme disease is not indicated. In most cases. The time from exposure to disease development is much too long. he may not make any antibodies toB. They have no role in screening if tuberculin skin testing has not been done. and there should be no evidence of significant hemolysis.
route of delivery. use of corticosteroids. judicious use of sedation. skin breakdown. Although older guidelines suggested not using chemoprophylaxis for tuberculin skin test reactors older than 35 years of age because of the risk of hepatotoxicity. Although most vancomycin-resistant enterococci are E. The decreased mortality rates in some subgroups of patients with severe sepsis suggest that improved basic supportive measures are beneficial. Some experts administer colloid. Linezolid is active against both Enterococcus faecium and Enterococcus faecalis and exhibits no cross-resistance with vancomycin. The first-line regimen for chemoprophylaxis in all patients is isoniazid. These include nutritional support. age is no longer a factor when deciding about therapy. and monitoring method are debated. Persistent bacteremia may be a consequence of either the intravenous catheter remaining in place. Infectious Disease Medicine:Question 53 The correct answer is B Educational Objectives Recall the currently accepted management of a patient with septic shock.(BCG) vaccination. Although nutritional support appears to be beneficial. faecium. the enterococcus being vancomycin-resistant. . faecalis. linezolid is the most appropriate antibiotic in this situation. timing. or both. Enterococci are inherently resistant to clindamycin and are unpredictably susceptible to fluoroquinolones. 300 mg daily for 9 months. Alternative regimens such as rifam pin and pyrazinamide for 2 months or rifam pin for 4 months should be considered only for patients who cannot tolerate isoniazid or who are likely to be infected with an isoniazid-resistant strain. Infectious Disease Medicine:Question 54 The correct answer is E Educational Objectives Recall the treatment of enterococcal bacteremia secondary to a central intravenous catheter. Despite the encouraging results of some pilot studies. Critique This patient had septic shock from pneumococcal pneumonia with bacteremia. some are E. and deep venous thrombosis. Any patient for whom tuberculin skin testing is indicated and who has a positive test result should be considered for chemoprophylaxis unless underlying medical conditions such as chronic liver disease make such treatment hazardous. treatment of septic shock continues to focus on eradicating infection and supporting failing organs. or N-acetylcysteine is not accepted therapy and is not indicated currently. The history of BCG vaccination should be ignored when considering whether to recommend chemoprophylaxis because of the high prevalence of tuberculosis in this patient’s country of origin and the marginal effectiveness of the BCG vaccine. nutritional formula. but this has not been documented to be more effective than crystalloid fluid administration. faecalis and quinupristin/dalfopristin is not active againstE. Therefore. nitric oxide. the optimal level. In addition to prompt use of antibiotic agents. Critique The patient most likely has enterococcal bacteremia secondary to a central intravenous catheter infection. There is no evidence that parenteral nutrition is superior to enteral feeding. and prevention of stress ulcers.
Critique This patient presents with advanced HIV infection. Such reactions have been fatal. abacavir should never be reinstituted. Critique In the United States. Nevertheless. most women with susceptible organisms respond to very small doses of antibiotics. Therefore. The patients CD4 cell count may be somewhat high for development of P. Failure to complete therapy is associated with relapse and treatment failure. there is no role for antibacterial agents in the treatment of viral infections. which appears to be mild at this point.S. Pneumocystis carinii pneumonia can cause a dry cough and fever but would not be expected to induce a rash. Although only the topical and intravenous forms of acyclovir are approved by the U. carinii pneumonia. the oral form is a reasonable option for this patient. Food and Drug Administration for treatment of mucocutaneous herpes simplex virus in immunocompromised patients. Because of her low CD4 cell count and some symptoms. Infectious Disease Medicine:Question 57 The correct answer is A Educational Objectives Be aware of changing patterns of resistance of uropathogens in the community. although this can occur in patients with CD4 cell counts as high as 250/μL. This is variable by region but has been noted in persons utilizing student health services and is apparently caused in part by a nationally disseminated epidemic strain of resistant uropathogenicEscherichia coli. Corticosteroids are not indicated for treatment of herpes simplex virus infections and may exacerbate the disorder. One study reported that oral acyclovir reduced the duration of various clinical end points by 5 to 13 days in bone marrow transplant recipients with this viral infection. Zidovudine causes nausea and fatigue but has not been known to cause this patients other symptoms. Although pain medication may be necessary as adjunctive therapy for patients with herpetic stomatitis. some bacterial strains with in vitro resistance will respond to therapy. Ganciclovir is active against any virus for which acyclovir is used (and is also effective for cytomegalovirus). Infectious Disease Medicine:Question 56 The correct answer is B Educational Objectives Know the treatment of herpes labialis in an immunocompromised patient.Infectious Disease Medicine:Question 55 The correct answer is A Educational Objectives Recognize the adverse effects of antiretroviral agents. uropathogens have become increasingly resistant to trimethoprim/sulfamethoxazole over the past several years. Most of the fatalities have occurred in patients who restarted abacavir after temporarily stopping this agent until symptoms subsided. nothing in the clinical vignette suggests that pain relief is necessary for this patient. Limited improvement and early clinical failure are common markers of this problem. and the intravenous form must be used if the patient cannot take oral medications or if there is evidence of visceral involvement. Mupirocin is used for staphylococcal and streptococcal skin infections. Critique The patient has herpetic stomatitis due to herpes simplex virus. The topical form may be used for limited skin disease. it is reasonable to begin antiretroviral therapy with a regimen such as the one used. However. the new symptoms that develop 1 week after starting treatment are consistent with abacavir hypersensitivity reaction. but the response is unpredictable and probably occurs in less than 50% of patients with these strains. A . However. and substituting another drug for this agent is required. but ganciclovir is more toxic and more expensive than acyclovir.
therapy should be discontinued. Finally. Administration of ceftriaxone. If the source patient is HIV negative. although this approach is currently seldom used. Infectious Disease Medicine:Question 60 The correct answer is C Educational Objectives Select the best imaging modality for diagnosing necrotizing fasciitis. Because antiretroviral agents should be started as quickly as possible. but reinfection rarely occurs when trimethoprim/sulfamethoxazole is used. hollow needle) from a highrisk patient (for example. However. Infectious Disease Medicine:Question 58 The correct answer is C Educational Objectives Recognize the indications for post-exposure prophylaxis for HIV. would be inadequate. there is good evidence that women are usually able to identify such infections themselves . inhalational anthrax with central nervous system (CNS) involvement is the major diagnostic possibility. Critique After a high-risk exposure to blood (for example. Although this would be a reasonable regimen for a patient with community-acquired meningitis or community-acquired pneumonia. because all antiretroviral agents have potential side effects. therapy should be continued only if HIV is confirmed in the source patient. Infectious Disease Medicine:Question 59 The correct answer is B Educational Objectives Recall the initial therapy for a patient with a presumptive diagnosis of anthrax pneumonia with central nervous system involvement. However. This allows the use of telephone-based prescribing as well as patient-initiated treatment of recurrent infections. a bloody. Differentiating reinfection and new infection requires a urine culture at the start of treatment and at the time of apparent reinfection. an injection drug user with multiple sexual partners). All persons with high-risk exposures should be treated with post-exposure prophylaxis rather than simply being followed by serologic testing. ciprofloxacin and doxycycline. and rifampin is incorrect for the same reasons. giving just two agents.single-dose treatment regimen is often successful. A combined regimen of ciprofloxacin or doxycycline plus clindamycin and vancomycin is most appropriate for treating the majority of known strains of anthrax with CNS involvement. Reinfection may possibly explain this patient’s recurrent symptoms. ampicillin. Critique Because of the clinical presentation and cerebrospinal fluid findings. preferably within 20 minutes of the exposure. this patient had gram-positive rods on a stained cerebrospinal fluid specimen and a clinical picture most consistent with anthrax pneumonia with CNS involvement. waiting for the test results is inappropriate. penicillin G. and vancomycin is incorrect because cephalosporins are not active against anthrax. Critique . HIV testing by polymerase chain reaction is not indicated for diagnosing HIV and has been associated with false-positive results. Obtaining a urinalysis (or at the minimum a dipstick examination of the urine) is customary when a woman has symptoms suggesting a urinary tract infection. especially in a patient with CNS involvement. Antiretroviral therapy should be initiated as quickly as possible. azithromycin. Administration of ceftriaxone.especially if they have had similar problems before. prevention of HIV transmission is paramount.
Prolonged and perhaps inadequate vancomycin treatment of these patients possibly allowed emergence of vancomycin-resistant MRSA. speed healing by several days. she also requires evaluation for other causes of genital ulcers and for other sexually transmitted diseases.Necrotizing fasciitis is a life-threatening infection that requires immediate surgery. these forms are not commonly used.S. and the finding of high intensity of the fascia in T2-weighted images is highly suggestive of fasciitis. but does not affect the rate of recurrence of the lesions. Food and Drug Administration for this indication) can reduce symptoms. Infectious Disease Medicine:Question 62 The correct answer is A Educational Objectives Understand the treatment of primary genital herpesvirus infection. Corticosteroids are not indicated for treating herpes simplex virus infection and may exacerbate the disorder. Imipenem is a β-lactam and is therefore not active against MRSA. although this agent is not yet approved by the U. Valganciclovir is a new oral agent that is converted by the body into ganciclovir. Administration of linezolid is the most effective treatment for this patient. Empiric treatment for herpesvirus is reasonable for this patient. Zidovudine is used for treating HIV infection and would not be used as a single drug for post-exposure prophylaxis against HIV. however. Critique The patient appears to have primary genital herpesvirus infection. acquisition of this plasmid by methicillinresistantStaphylococcus aureus (MRSA) has recently been reported in two patients in the United States. The patient frequently presents with severe sepsis and pain that is disproportionate to the physical findings. Topical and intravenous forms of acyclovir are also approved by the U. quinupristin/dalfopristin is not active against Enterococcus faecalis (despite usually being active againstEnterococcus faecium). Trimethoprim/sulfamethoxazole and clindamycin are not active against enterococci. However. However. Critique The plasmid that encodes for vancomycin resistance is usually found only in vancomycinresistant enterococci. A plain radiograph is suitable for detecting gas in the tissues and is more sensitive than palpation. and diminish virus shedding. Infectious Disease Medicine:Question 61 The correct answer is A Educational Objectives Recall the treatment of a patient with vancomycin-resistant and methicillin-resistant Staphylococcus aureus infection. It is active against any virus for which acyclovir is useful (and is also effective for cytomegalovirus). MRI is the most sensitive imaging study for diagnosing necrotizing fasciitis. Tense edema and bullous skin lesions are also frequent findings. Ultrasound examination is an insensitive study for detecting this disorder. Food and Drug Administration for treating initial episodes of genital herpes. but valganciclovir is more toxic and more expensive than acyclovir. .S. which often is severe and may be associated with systemic symptoms. gas is not always present in necrotizing fasciitis. CT is sensitive for diagnosing an abscess or a fluid collection but is less sensitive than MRI for diagnosing fasciitis. Finally. Treatment with acyclovir or valacyclovir (and probably famciclovir. However.
and saliva can be intermittent and can persist for months to years after clinical infection has resolved. ETEC is by far the most common organism causing typical traveler’s diarrhea. and airborne isolation are not necessary. tears. The virus is transmitted only by persistent. droplet. Critique Strains of enterotoxigenicEscherichia coli (ETEC) are among the most commonly implicated causes of diarrheal disease in international travelers. In addition to oral rehydration therapy. the usual clinical presentation of disease due to these pathogens differs markedly from that of ETEC-associated diarrhea. because of his late-stage HIV . hepatitis C co-infection would be expected. However. Clostridium difficile is not associated with episodes of diarrhea in travelers. Virus shedding in urine. In these situations. a former injection drug user with HIV infection. prolonged contact with secretions. sweat. medical treatment of traveler’s diarrhea usually consists of an antimotility agent (such as loperamide) administered in conjunction with a short course of an appropriate antibiotic (usually a fluoroquinolone). In the United States. and contact.Entamoeba histolytica and Strongyloides stercoralis are only rare causes of traveler’s diarrhea. Therefore. In addition. Critique Cytomegalovirus is transmitted by infected body secretions of patients with prior cytomegalovirus infection. Infectious Disease Medicine:Question 65 The correct answer is B Educational Objectives Recall the approach to diagnosing hepatitis in an HIV-infected patient. antibiotic resistance to fluoroquinolones is increasing. Critique This patient. Various other enteric bacterial. In addition. Of the potential pathogens included for this case presentation. standard precautions are adequate to protect against infection. In certain areas of the world. 30% to 40% of persons with HIV infection are co-infected with hepatitis C. Given this patient’s long history of injection drug use. and parasitic pathogens have also been reported to cause some form of diarrheal syndrome in travelers. Infectious Disease Medicine:Question 64 The correct answer is A Educational Objectives Recognize the most common pathogens implicated as causes of traveler’s diarrhea. The enzyme immunoassay for hepatitis C antibodies is both sensitive and specific.Infectious Disease Medicine:Question 63 The correct answer is E Educational Objectives Recall the appropriate isolation precautions for an AIDS patient with cytomegalovirus infection. viral. Traveler’s diarrhea can be prevented by strict attention to food and water precautions. the vast majority of hepatitis C infections occur in injection drug users. erythromycin or azithromycin) may be substituted. a macrolide antibiotic (for example. has elevated serum aminotransferase values. Salmonella enteritidis is a possibility but is a much less common cause of diarrhea.
valacyclovir would probably not be used in this setting because of the life-threatening nature of the illness and the greater need for reliable serum drug levels. diarrhea. the mortality rate from this complication is increased in pregnant women. However. for unknown reasons. Intravenous administration of acyclovir is appropriate despite the lack of prospective controlled studies for this indication and concerns about using drugs that interfere with DNA synthesis during pregnancy. Critique The patient probably has chickenpox (primary varicella) and varicella pneumonia (note that the presence of lesions at multiple stages on the same part of the body is not consistent with smallpox). patients with uncorrected hypokalemia. an oral prodrug that is converted to acyclovir. such as a liver biopsy. changing to ceftriaxone alone is likely to be the best option for this patient. Oral acyclovir would not achieve the serum levels thought to be necessary for this life-threatening illness. which would not explain the skin rash. since macrolides can also prolong the QTc interval. Qualitative polymerase chain reaction to detect HCV RNA should be done before beginning a more expensive and potentially invasive workup. The patient does not have chronic hepatitis B infection and is immune to this disorder. especially pregnant women. but there is no clear association between infection and active hepatitis G. Critique Fluoroquinolones may elevate the QTc interval and increase the risk for ventricular tachyarrhythmias. there is no reason to choose this more toxic and more expensive agent. Although ganciclovir would also treat varicella-zoster virus. Pneumonia as a complication of varicella is more common in adults. night sweats. Infectious Disease Medicine:Question 67 The correct answer is E Educational Objectives Recognize and treat varicella pneumonia in a pregnant woman. Infectious Disease Medicine:Question 66 The correct answer is B Educational Objectives Recall the treatment of community-acquired pneumonia in a patient with fluoroquinoloneinduced tachyarrhythmia. Oseltamivir is used for influenza virus. the appropriate dose for varicella infections is 10 mg/kg every 8 hours because varicella-zoster virus is less sensitive than herpes simplex virus to acyclovir. Although the appropriate intravenous dose of acyclovir for herpes simplex virus infections is 5 mg/kg every 8 hours. administration of valacyclovir. A large retrospective study of the treatment of community-acquired pneumonia in hospitalized Medicare patients found that either a fluoroquinolone alone or a combination of a non-pseudomonal third-generation cephalosporin (such as ceftriaxone) plus a macrolide was the most effective treatment for community-acquired pneumonia and that a β -lactam/ β -lactamase inhibitor combination or any combination with an aminoglycoside was detrimental. can by itself result in serum levels of acyclovir that approach those obtained with intravenous acyclovir. and patients receiving class IA or class Ill antiarrhythmic agents. Hepatitis G virus seropositivity may be detectable. especially in women. As an aside. However.infection. but this infection is often accompanied by fever. In fact. Moreover. Disseminated Mycobacterium avium complex infection is possible because of his low CD4 cell count. the anti-HCV test result may be negative. and weight loss. hepatitis G coinfection may improve the clinical course of HIV infection. These drugs should not be used for patients with known prolongation of the QTc interval. which this patient does not have. Infectious Disease Medicine:Question 68 The correct answer is B .
000 copies/mL) indicates acute HIV infection. Indications for use of aPC include a high risk of death from underlying sepsis. as may occur with an intravascular catheter infection. The man with an ischemic bowel is likely to undergo an emergency surgical procedure and is therefore at higher risk for bleeding. Bleeding is the major risk of therapy with aPC. acute onset of organ failure. and a very high viral load (> 10.000 copies/mL) have erroneously been interpreted as indicating acute HIV infection in individuals who were later found not to be infected. and lives close to medical facilities. and intravenous cefepime alone or combined with an intravenous aminoglycoside has been used effectively when an oral regimen is contraindicated. Vancomycin should not be used as initial therapy unless β -lactam-resistant staphylococci are suspected. If the serologic test results are still . as are the woman recovering from coronary artery bypass grafting and the woman about to undergo surgery for a ruptured appendix. or both. lives with a responsible family member. the presence of systemic inflammatory response syndrome. Gram-negative organisms are a likely cause of fever in neutropenic patients. has no signs of sepsis. although this test sometimes provides indeterminate results. The patient with Pseudomonas infection should be given this drug. Low-level viral loads (< 10. Infectious Disease Medicine:Question 69 The correct answer is E Educational Objectives Recognize the indications for use of recombinant human activated protein C (aPC or drotrecogin alfa [activated]) and the complications associated with its use. such as single bands at p24. Although routine HIV screening tests by enzyme immunoassay are highly accurate (both sensitive and specific). Such findings likely represent a false-positive result for patients with no HIV risk behavior. Western blot is useful for distinguishing some false-positive results. has no evidence of an intravascular catheter infection. Critique A large double-blind clinical trial recently showed that recombinant human activated protein C (aPC or drotrecogin alfa [activated]) is effective for the treatment of severe sepsis. Critique The patient requires antibiotic treatment. as he is least likely to have bleeding complications following administration. false-positive results do occur. for patients with risk behavior. such as the young woman described here.Educational Objectives Understand the current recommendations for antibiotic treatment of a patient with febrile neutropenia. Infectious Disease Medicine:Question 70 The correct answer is A Educational Objectives Understand the interpretation and management of tests for HIV infection. Patients who benefited most had APACHE II (Acute Physiology and Chronic Health Evaluation II) scores greater than 24 and multiple organ dysfunction. The appropriate interpretation is to consider this an indeterminate result and repeat serologic testing at various intervals for 6 months. p55. a negative plasma HIV RNA viral load is somewhat reassuring. Critique This patient’s presentation is not uncommon. The transplant recipient who has thrombocytopenia is also more likely to develop bleeding complications following the use of a drug with anticoagulant properties. this patient’s low result of 375 copies/mL is not really helpful and is potentially misleading. and shock. Under such circumstances. Trimethoprim/sulfamethoxazole has not been shown to be effective in this setting. Hence. the result could mean impending seroconversion. However. An oral regimen such as ciprofloxacin plus amoxicillin/clavulanate has been shown to be as good as or better than an intravenous regimen when a patient has an absolute neutrophil count greater than 1 OO4iL.
Infectious Disease Medicine:Question 72 The correct answer is E Educational Objectives Know when and how to provide endocarditis prophylaxis prior to a dental procedure for a patient with mitral regurgitation. this study excluded patients with relative contraindications to corticosteroids. For example. Despite previous suggestions that corticosteroids alone can prevent postherpetic neuralgia. In addition to the antiviral agent. therapy should be started within 72 hours of the onset of rash. published in 1997. and famciclovir are all approved by the U. based on a study that showed accelerated healing and improved quality of life (but no decrease in postherpetic neuralgia) when prednisone was added to a 3-week course of acyclovir. However. Intravenous acyclovir would be expected to be at least as effective as oral acyclovir but would not be used in a normal host with herpes zoster. There is no role for repeat viral load testing or CD4 cell count determination in this setting. No data suggest that topical antiviral agents are beneficial for treating shingles. Antibacterial agents are not indicated for treatment of viral infections and should not be used to prevent bacterial superinfections. although clinical judgment is needed in deciding whether to treat. but a longer period is acceptable if the eye is involved. dental extractions and other procedures during which bleeding is anticipated are indications for antibiotics. such as hypertension or diabetes mellitus. Although not all dental procedures are considered to require prophylaxis in patients at high or moderate risk. The most recent American Heart Association recommendations. Critique Persons with Doppler-demonstrated mitral regurgitation or an audible murmur of mitral regurgitation are considered to be at moderate risk for endocarditis and are candidates for dental prophylaxis. None of the currently recommended oral prophylactic regimens for dental procedures requires more than one dose of an antibiotic given 1 hour before the procedure. Acyclovir. Critique This patient has a typical clinical presentation of shingles (herpes zoster). Infectious Disease Medicine:Question 71 The correct answer is A Educational Objectives Understand the management options for shingles (herpes zoster). many experts would use intravenous acyclovir for an immunocompromised patient with herpes zoster. However. Although data are not always consistent. Infectious Disease Medicine:Question 73 The correct answer is D . Food and Drug Administration for treatment. although mitral valve prolapse without regurgitation generally is not considered an indication for prophylaxis. Moreover. valacyclovir. include a discussion of these issues.indeterminate. there is consensus that all three drugs can hasten resolution of the rash and may also prevent some cases of postherpetic neuralgia.S. giving a cephalosporin to a person with a history of an immediate-type hypersensitivity penicillin reaction is risky. Clindamycin is the first alternative to amoxicillin for a patient with a history of a significant penicillin allergy. the patient should be considered HIV seronegative. there now is good evidence that these agents do not provide this benefit. Azithromycin or clarithromycin can also be considered. Some experts would reserve treatment for those over 50 years of age or for patients with moderate or severe rash or pain and/or ophthalmologic involvement. a 3-week course of corticosteroids could be considered. although cephalexin or cefadroxil can be used if the allergy is mild.
Since highly active antiretroviral therapy (HAART) has been introduced. or itraconazole could also be used. for cryptococcal meningitis) was recommended to be continued indefinitely. Critique Prior to the advent of antiretroviral therapy. cytomegalovirus retinitis. Liposomal amphotericin B is preferred for this patient because it is the least nephrotoxic formulation and has mild infusion-related side effects. Amphotericin B deoxycholate has a high rate of infusional side effects and is associated with early onset of nephropathy. . In this case. Caspofungin has been approved for treating patients withAspergillus infections who have not responded to amphotericin B or for patients who are intolerant of amphotericin B. Even bronchoscopy has limitations in a person with severe thrombocytopenia. cryptococcosis. and toxoplasmosis. Four types of amphotericin B are now available: amphotericin B deoxycholate (the conventional form). Furthermore. Fluconazole and flucytosine are not effective against Aspergillus species. Other correct choices would be amphotericin B deoxycholate with careful monitoring for nephrotoxicity or amphotericin B lipid complex with careful monitoring for infusional reactions. it is not possible to determine this noninvasively.Educational Objectives Understand the proper uses of amphotericin B derivatives in treating a patient with a severe fungal infection. All are more or less equally effective but vary in their degree of nephrotoxicity and how well they are tolerated by the patient. Amphotericin B is the best studied antifungal agent and is usually active in vitro and in vivo againstspergillus species. Caspofungin. beginning an antifungal agent with reasonable activity againstAspergillus is a well-established principle. but it has a high incidence of infusional toxicity and is not used extensively in the United States. This patient’s prophylactic medications (valganciclovir. amphotericin B colloidal dispersion. the relapse rate for most HIV-related opportunistic infections was sufficiently high that secondary prophylaxis (for example. Although knowing which fungus is present is desirable. and amphotericin B lipid complex. the patient simply refused the procedure. When new pulmonary infiltrates develop in this setting. liposomal amphotericin B. Nystatin can inhibit the growth of fungi when given topically. Infectious Disease Medicine:Question 74 The correct answer is E Educational Objectives Understand the appropriate management of antibiotic prophylaxis for opportunistic infections in an HIV-infected patient successfully treated with antiretroviral therapy. including P. the overall incidence of opportunistic infections has decreased dramatically. However. but this preparation is not suited for systemic therapy. cariniipneumonia. voriconazole. forPneumocystis carinii pneumonia) or maintenance therapy (for example. several studies have shown that the relapse rate for a number of opportunistic infections is extremely low when a patient’s CD4 cell count has recovered with HAART. trimethoprim/sulfamethoxazole. Each has a different formulation. whether or not secondary prophylaxis or maintenance therapy has been discontinued. Amphotericin B colloidal dispersion may work well and will probably cost less. the experience with these drugs is limited (but promising) to date. disseminated Mycobacterium avium complex infection. guidelines for opportunistic infection prophylaxis and management now recommend that long-term therapy can be safely discontinued for the major AIDS-related opportunistic infections. As a result. Critique The development of fever and a new pulmonary infiltrate in the setting of prolonged neutropenia strongly suggests the presence of pulmonary fungal infection. Voriconazole may become the standard of care for fungal infections if new data confirm the results of a comparative trial with liposomal amphotericin B showing equivalent outcomes with fewer side effects when voriconazole is used.
poor oxygenation alone is not an explanation for the . toxins from microorganisms. and low pulmonary capillary wedge pressure associated with volume depletion. His antiretroviral regimen should not be reduced to a two-drug regimen because of the known risk of viral rebound. the patients clinical findings are not consistent withC. Oral vancomycin has no role in treating or preventing vancomycin-resistant enterococci and may actually be a predisposing factor. and influenza virus may cause pneumonia in this setting. In addition. and increased respiration rate). and/or insensitive fluid losses (caused by fever. Critique All patients with vancomycin-resistant enterococci have colonization of the gastrointestinal tract.and azithromycin) can therefore be stopped. which may be due to the effects of lactic acidosis. since the patient was intubated and is being mechanically ventilated. Intestinal leaks can occur after bowel surgery. hand washing. Imipenem is not active against most strains of vancomycinresistantEnterococcus faecium. but this patient has no features of peritonitis or other indications of bowel leakage. Once intravascular volume is restored. What is important is to try to prevent spread of this organism to other patients. respiratory syncytial virus. tachycardia. Critique Shock is defined as a systolic blood pressure of less than 90 mm Hg that is not corrected by fluid resuscitation or that necessitates use of vasoactive agents. and as many as 50% of these infections are fatal. Poor oxygenation is unlikely. Initial cardiac parameters reveal a low cardiac index. The other organisms listed are less likely to have caused this patients findings. Patients with shock caused by severe sepsis often present with hypovolemia due to poor oral intake. persistent hypotension is frequently the result of decreased systemic vascular resistance. gastrointestinal losses. Although vancomycin may be reasonable for treating Clostridium difficile. careful attention to use of gloves. Since organisms are often transmitted from the hands of health care workers. normal or increased systemic vascular resistance. Critique Adenovirus infection may occur in as many as 20% of patients following stem cell transplantation. The antibiotics that this patient is receiving are appropriate for the empiric treatment of community-acquired pneumonia and would be expected to be effective against the likely causative organisms. they are unlikely to be associated with hemorrhagic cystitis. Infectious Disease Medicine:Question 76 The correct answer is A Educational Objectives Understand infectious complications that develop in an immunosuppressed patient. or inflammatory mediators. The high cardiac index associated with sepsis would not contribute to hypotension. and other means of preventing spread are best implemented by contact isolation. Epstein-Barr virus would not be expected to cause either hemorrhagic cystitis or pneumonia. There is currently no way to eradicate this carriage. difficile infection. Infectious Disease Medicine:Question 77 The correct answer is B Educational Objectives Recognize the mechanisms underlying cardiovascular dysfunction secondary to severe sepsis. Infectious Disease Medicine:Question 75 The correct answer is A Educational Objectives Recall the appropriate management of a patient with vancomycin-resistant enterococci. Hemorrhagic cystitis and pneumonia are both common manifestations of adenoviral infection in this setting. Although cytomegalovirus.
pyrazinamide. such as isoniazid and rifampin daily for 36 weeks. rifampin. rifampin. are no longer recommended. and ethambutol for 2 weeks. Empiric antituberculous therapy should be started without waiting for culture and sensitivity results. when the incidence of tuberculosis in the United States was on the rise. pyrazinamide. Short-term virologic outcomes have been shown to be superior when the results of resistance testing are used to assist in decisionmaking regarding antiretroviral regimen changes. directly observed therapy utilizing a twice or three times weekly regimen should be employed for most of his treatment course. particularly from the late 1 980s through the early 1 990s. Most experts would change the therapy at this time. primarily because of poor adherence. which have been sites for transmission of tuberculosis. Infectious Disease Medicine:Question 78 The correct answer is D Educational Objectives Recall the treatment of pulmonary reactivation tuberculosis. and he was placed in respiratory isolation to protect hospital staff members. Although his initial presentation could have been due to aspiration pneumonia. The alternative regimens are 1) isoniazid. pyrazinamide. There is no real role for a CD4 cell count or HIV RNA viral load determination for this . Daily isoniazid. the pulmonary capillary wedge pressure would be normal (or high if cardiac contractility is significantly impaired in association with cardiac failure) and would not correlate with the presence of hypotension. The response rate for patients in clinical practice is substantially lower. Infectious Disease Medicine:Question 79 The correct answer is B Educational Objectives Understand the principles of antiretroviral management for a patient who fails to benefit from therapy. data consistently show that 60% to 80% of treatment-naïve patients achieve an undetectable HIV RNA viral load by 6 months. followed by the same drugs twice weekly by directly observed therapy for 6 weeks. The possibility of tuberculosis was recognized early in his hospital course. unless drug resistance is documented. A three-drug ethambutol-containing regimen is not recommended unless the patient has definite intolerance for or a contraindication to administration of pyrazinamide. 24-week regimen is unnecessarily complex and likely to be considerably more toxic. Whichever regimen is chosen for this patient. rifampin. In clinical studies of antiretroviral therapy. Finally. and 2) daily isoniazid.hypotension. and ethambutol or streptomycin for 8 weeks followed by daily. the positive smear for acid-fast bacilli is strongly suggestive of reactivation tuberculosis. or thrice weekly isoniazid and rifampin (either daily or twice weekly or three times weekly) for 16 weeks by directly observed therapy. This patient appears to have followed her treatment regimen but has had a suboptimal response. Two-drug regimens. given his vagrancy. and ethambutol or streptomycin three times weekly for 24 weeks by directly observed therapy. followed by isoniazid and rifampin twice weekly by directly observed therapy for 16 weeks is one of three recommended regimens for the management of tuberculosis when drug resistance is neither known nor suspected. a five-drug. Critique This patient has a classic presentation of reactivation tuberculosis. He is homeless and has spent time in shelters. a resistance assay should be performed (genotype or phenotype) to learn which resistance pattern has developed and choose the most appropriate treatment regimen based on this pattern. twice. In order to optimize this change. In a patient who has received adequate volume replacement. Critique This case exemplifies some of the difficulties of antiretroviral drug management.
) Infectious Disease Medicine:Question 82 The correct answer is C Educational Objectives Understand the treatment of cytomegalovirus retinitis in a patient with AIDS. the possibility of a bioterrorism event must be considered when this infection is encountered.patient. and the tetracyclines are second-line drugs for treating tularemia. Switching from nevirapine to efavirenz is not indicated. Evaluation should also begin for an appropriate . Moreover. Ciprofloxacin is unlikely to be effective against causative organisms that are not covered by the current therapeutic regimen. especially if the fevers continue without an etiologic agent being identified. Critique Cytomegalovirus (CMV) retinitis in patients with AIDS usually responds to ganciclovir. Ganciclovir is more toxic to the bone marrow. Candida and Aspergillus. Critique Although the pneumonic form of tularemia may occur naturally. since a single base substitution at the 103 position of reverse transcriptase renders the virus resistant to all non-nucleoside reverse transcriptase inhibitors. Food and Drug Administration for treatment of CMV retinitis in AIDS patients and provides a more convenient option for this patient.S. Treatment is the same regardless of the cause. ciprofloxacin. This patient should be treated with ganciclovir because he has better bone marrow reserve than renal function. Ceftriaxone is not considered effective for this disease. Chloramphenicol. an oral prodrug of ganciclovir. or cidofovir. foscarnet. Infectious Disease Medicine:Question 80 The correct answer is B Educational Objectives Understand the current recommendations for antibiotic treatment of a patient with febrile neutropenia. Her counts have changed very little over the 7 months of treatment. Making no change in the therapeutic regimen is incorrect because amphotericin B should be added. progressive immunologic or clinical decline would be an indication for a treatment change. was recently approved by the U. Critique This patient has been profoundly neutropenic for a long time. (It is worth noting that landscapers are more susceptible to acquiring pulmonic tularemia because of their exposure to aerosols contaminated with portions of animal carcasses or excretions of infected animals. Gentamicin (and streptomycin) are the preferred firstline antibiotic agents because of many years of experience using these drugs for treatment of all forms of tularemia. as well as other fungi. Infectious Disease Medicine:Question 81 The correct answer is E Educational Objectives Recall the treatment of a patient with pneumonic tularemia. In addition. Her infection did not improve while she was on an adequate antibacterial regimen. Cefepime and gentamicin should not be stopped. Amphotericin B should be started even though a fungal infection has not been identified at this time. Valganciclovir. regardless of the viral load response. and a fungal infection should therefore be considered. require empiric treatment in this setting. the change from nevirapine to efavirenz would not be helpful. since resistance test results are not known and making single-drug substitutions is generally not advisable. These recommendations may change in the future as new antifungal agents become available. The choice of drug is guided by the need to avoid the significant toxicities of these agents in a specific patient. whereas foscarnet and cidofovir are more nephrotoxic.
malaise. A regimen of highly active antiretroviral therapy (HAART) will take time to increase the CD4 cell count. the manufacturer recommends that all patients receiving linezolid have a complete blood count each week. Because postexposure hepatitis B prophylaxis is effective if administered within the first 72 hours after exposure. This nurse may be immune to hepatitis B because of his prior vaccinations. and granulocytopenia is noted even less frequently in these patients. Finally.antiretroviral drug regimen. hepatitis B is the easiest to acquire via percutaneous exposure in the absence of immunity. hepatitis C. For this reason. These findings usually occur after 2 weeks of therapy but may develop earlier and are reversible after discontinuing the drug. which is an important consideration in such a severely immunocompromised patient. neurologic events. Direct delivery of an anti-CMV drug into the eye is an option for patients with CMV retinitis. Critique This patients thrombocytopenia and granulocytopenia are probably secondary to an adverse reaction to linezolid. no prophylaxis is required. there is time to wait for the results of immunity testing. Acyclovir has insufficient in vitro activity against CMV to be useful. Disseminated intravascular coagulation usually develops in patients with sepsis and uncontrolled infection. If the nurse is not immune. and renal failure. but his status is unknown at the time of the exposure. Thrombotic thrombocytopenic purpura is usually associated with evidence of intravascular hemolysis. urticaria. Any treatment plan must therefore include immediate use of an anti-CMV drug. Infectious Disease Medicine:Question 84 The correct answer is B Educational Objectives Recognize an adverse reaction to linezolid administration. such as fever. the first thing to do is to check his immunity. Relapse can be expected. unless he receives an anti-CMV maintenance drug regimen or his immune status improves with antiretroviral therapy. However. and eosinophilia. Therefore. Infectious Disease Medicine:Question 85 The correct answer is D Educational Objectives Select the appropriate empiric antimicrobial regimen for a patient with purulent . If he is found to have adequate immunity. polyarthralgias. and HIV). he will require hepatitis B immune globulin and his vaccination series should be restarted. Hypersensitivity vasculitis may be accompanied by other manifestations of an allergic reaction. Critique Of the three most common viral bloodborne pathogens (hepatitis B. intravitreal injection would not protect this patients currently uninvolved eye. however. Thrombocytopenia develops in about 3% of patients who receive linezolid. there is no role for corticosteroids in the treatment of CMV retinitis. but this patient is at risk of losing his sight before that happens. Confirmation of the immune status of health care workers with an unknown response to vaccination is required at the time of the exposure. Infectious Disease Medicine:Question 83 Correct answer is B Educational Objectives Recall the appropriate management of hepatitis B exposure in a health care worker.
Meningococcal infection can produce similar symptoms. the failure to respond to antibacterial agents or a breakthrough fever while receiving antibiotics is an indication for administration of antifungal drugs. A true allergic reaction to one formulation should be considered a reaction to all. Infectious Disease Medicine:Question 88 The correct answer is A Educational Objectives . Infectious Disease Medicine:Question 87 The correct answer is C Educational Objectives Recognize the indications for caspofungin for a patient with a refractory fungal infection and intolerance to amphotericin B. low glucose. Infectious Disease Medicine:Question 86 The correct answer is A Educational Objectives Recall the diagnosis of Rocky Mountain spotted fever. although they may cause serious adverse effects. although they have varying rates of adverse reactions. the patient’s recent history of hallucinations may make this possible side effect especially unsettling for her. All amphotericin formulations contain the same underlying drug. but not unheard of. Critique The patient presents with fevers. chills. each patient with febrile neutropenia requires appropriate cultures and other laboratory tests followed by administration of suitable antibiotics. Nevertheless. Although the patient could have chemical meningitis. which is a highly endemic area for this infection. Critique The management of fever in a neutropenic patient has been so well studied that death from infectious complications is now rare. based on the CSF findings of elevated neutrophils. His symptoms developed during the endemic season (April through September) for Rocky Mountain spotted fever. Second. First. and he resides in North Carolina. Lyme disease does not usually cause septic findings. and elevated protein. amphotericin B (or one of its lipid formulations) is the drug of choice.meningitis after neurosurgery. and more importantly. and Babesia infection rarely produces a petechial rash. However. this patient has two risk factors that make voriconazole a less attractive choice. and a petechial rash. However. voriconazole may induce hallucinations. which has recently been approved for patients who cannot tolerate amphotericin B. In addition to careful clinical evaluation. Voriconazole shows good efficacy and safety for treatment of febrile neutropenia. These agents have been studied the longest and are usually fairly well tolerated. this patient had an allergic reaction to amphotericin B. Critique This patient developed meningitis following surgical repair of a leaking aneurysm and has a ventriculostomy tube in place postoperatively. Traditionally. an empiric antimicrobial regimen should be initiated pending culture results. The use of antifungal agents is not indicated for most neutropenic patients at the first sign of fever. However. the prior use of fluconazole may select for relatively voriconazole-resistant fungi. which are usually mild and self-limited. However. Because of her allergic reaction. The most likely causative organisms are staphylococci (both Staphylococcus aureus and coagulasenegative staphylococci) and gram-negative bacilli (including Pseudomonas aeruginosa). the petechial rash is usually on the trunk and is not limited to the wrists. the patient should be started on caspofungin. which are characteristic of a rickettsial infection. Vancomycin plus ceftazidime is the only regimen listed that will provide adequate coverage against these organisms and should be initiated pending culture results. Allergic reactions to this drug are uncommon.
oversedation. since the patient has no evidence of bleeding but does have atrial fibrillation. Absorption of oral ciprofloxacin is usually very good. reversing the anticoagulation with vitamin K is not needed. In some cases. Nonetheless. transient hypotension. Although recombinant human activated protein C (aPC or drotrecogin alfa [activated]) would seem to be potentially useful. Antifungal therapy is unlikely to be beneficial. Critique This patient’s rapid decline is somewhat confusing at this early time. and continuing the evaluation. a vena cava filter is not indicated. First. the initial steps should include providing supportive care. Given the extensive differential diagnosis.Recall that mild sepsis does not require recombinant human activated protein C (aPC or drotrecogin alfa [activated]) therapy. However. Infectious Disease Medicine:Question 90 The correct answer is D Educational Objectives . this resistance is marginal. which carries a high risk for embolic disease. with bioavailability of 80% or more. Therefore. the elevated INR may increase the risk of bleeding (which is increased by the intrinsic activity of aPC). he had a poor clinical response most likely because of fluoroquinolone-resistant Neisseria gonorrhoeae. and lung injury. and a good treatment outcome can be achieved by increasing the dose. a pulmonary embolism is unlikely at this time because the patient has only diffuse chest radiographic changes and a therapeutic INR. Critique Despite the patient’s self-treatment with ciprofloxacin. The histamine blocker that he was taking should not interfere with the bioavailability of ciprofloxacin. The degree of anticoagulation is adequate and perhaps somewhat higher than adequate. Infectious Disease Medicine:Question 89 The correct answer is B Educational Objectives Be aware of the effects of increased fluoroquinolone-resistant gonorrhea on the treatment of this disorder. some strains are sufficiently resistant so that fluoroquinolone therapy is ineffective. The normal course of ciprofloxacin treatment for gonorrhea is very brief (usually a single dose). especially because of the risks and cost of this agent. Some clinicians use an APACHE II (Acute Physiology and Chronic Health Evaluation II) score of greater than 24 to decide about suitability of aPC in someone with suspected or documented sepsis. gonorrhoeae strains to fluoroquinolones is an increasing problem. Therefore. Drugs that interfere with absorption of fluoroquinolones include divalent cations such as calcium and magnesium that are most commonly taken as antacids or food supplements. since fungal infections are seldom encountered as nosocomial processes in this patient population. Although the patient may also have acquired syphilis during his travels. Resistance of N. this should not interfere with treatment of gonorrhea. There is no advantage to administering aPC therapy. The most likely causes relate to infection. However. it should not be given for two reasons. but this patient is not yet that ill. underdosing is unlikely to explain this treatment failure. and there are no indications of a primary fungal disease. beginning treatment of the most serious disorders. the illness does not yet seem to involve multiple organs. Second.
Although patients with sulfonamide-resistant P. However.Understand the management of an HIV-infected patient presenting with P. Changing antibiotics or adding an additional antibiotic forP. In addition to the standard tests and cultures indicated for the workup of an acutely febrile patient. it could conceivably worsen the inflammatory response and thereby worsen this patients respiratory injury. because of his low arterial blood Po2 at the time when P. the addition of azithromycin to cover “atypical pathogens would not be important at this time. His time in rural areas of Cambodia and Vietnam does indeed represent a significant exposure risk. Although such treatment may induce early beneficial immune reconstitution. The choice of the most appropriate chemoprophylactic agent is based on the traveler’s exact itinerary. carinii pneumonia was diagnosed. since the diagnosis is known and since prednisone was not started earlier. Critique This is a typical presentation ofPneumocystis carinii pneumonia in a patient with newly diagnosed late-stage HIV infection. Infectious Disease Medicine:Question 91 The correct answer is D Educational Objectives Consider malaria as a potential diagnosis in all ill travelers returning from a malaria-risk area. Other causes of fever should also be considered. he should also have received adjunctive corticosteroid therapy. carinii pneumonia might be considered later in his course. carinii pneumonia. carinii pneumonia. and personal medical profile. Finally. carinii pneumonia have been described. the most important first step in this patient’s management is to establish or exclude this diagnosis. it may be prudent to begin empiric antimalarial treatment while waiting for the blood smear results. if he fails to benefit from the current antibiotic regimen and the addition of corticosteroid therapy. Infectious Disease Medicine:Question 92 The correct answer is C Educational Objectives . yellow fever. and he was appropriately treated with high-dose parenteral trimethoprim/sulfamethoxazole. his classic chest radiographic findings were correctly interpreted as likely to be due toP. The patient was appropriately diagnosed as HIV positive. For travelers at risk. He was taking no prescription medications. The key to management is recognizing that his hypoxemia at the time of hospital admission indicative of a poor prognosis. Corticosteroids have been shown to improve both morbidity and mortality in this setting. Repeating the malarial blood smears several times over the next few days may be necessary if the initial smears are negative but the patient remains ill. Critique The first consideration in the evaluation of this patient is to determine whether his itinerary could have placed him at risk for the development of malaria. Hepatitis B. thick and thin blood smears should be examined. most cases of malaria can effectively be prevented by the use of anti-mosquito personal protection measures in combination with appropriate chemoprophylaxis. the management of such patients has never been adequately established. including malaria prophylaxis. Because malaria is potentially fatal in a nonimmune host. and an amebic liver abscess are not the first considerations in diagnosing this patient’s illness. The value of starting highly active antiretroviral therapy in an AIDS patient who has an acute opportunistic infection is also controversial. In the case of a moderately to severely ill individual in whom no definitive alternative diagnosis can be made. length of stay.
However. which can predispose to nosocomial sinusitis. there are interventions for preventing ventilator-associated pneumonia. Careful inspection and management of the tubing can help reduce infections slightly. However. Low-dose prednisone and interleukin-2 are not correct because corticosteroids and interleukin-2 have not been shown to be effective when given as long-term prophylaxis to a patient with chronic granulomatous disease. Reducing the density of gastric bacteria by use of prophylactic antibiotics is tempting.Recall interventions to prevent ventilator-associated pneumonia. Therefore. and so on). However. careful drainage of accumulated condensate into patientspecific drainage containers is advocated. but reintubation is associated with certain risks (intubating the esophagus. Patients with chronic granulomatous disease have been shown to have fewer infections when given prophylactic antibiotics. use of I-Q-receptor blockers permits a high density of bacteria in the stomach. cooling blankets are uncomfortable for awake patients and do not prevent complications related to infections. precipitating hypoxia during the procedure. Critique This patient has chronic granulomatous disease. However. no benefit will be gained by changing from an orotracheal to a nasotracheal tube. treatment is indicated. and this regimen is now the standard of care. there is little support for this measure. presumably because of ineffective intracellular concentrations of these antibiotics. bacteria from the stomach can reach the lungs and cause pneumonia. There are relatively few proven interventions to help reduce the risk of infection in an IOU. Whether all nasal tubes should be replaced by oral tubes is unclear. as penicillins and other β-lactam antibiotics are not as effective as other antibiotic agents. Such patients commonly develop infections due to Staphylococcus aureus and other catalase-positive organisms. Infectious Disease Medicine:Question 93 The correct answer is C Educational Objectives Recognize the clinical presentation and recall the long-term treatment of a patient with chronic granulomatous disease. Critique Prevention of infections in an intensive care unit (ICU) is difficult. Oral placement of endotracheal tubes is currently believed to be superior to nasal placement because nasogastric and nasotracheal tubes cause some degree of obstruction of the ostia in the nose. Because the tubing has a tendency to collect water. Dicloxacillin is not indicated. In addition. In many patients in ICUs. Reintubation may also increase the risk of nosocomial pneumonia. Several studies show that trimethoprim/sulfamethoxazole plus interferon-γ is the most effective regimen. this approach is ineffective and serves to select for even more resistant strains. with or without interferony. Cooling blankets are often used to control body temperature in patients who are critically ill. Infectious Disease Medicine:Question 94 The correct answer is C Educational Objectives . Semierect positioning in bed is useful because it prevents the excursion of bacteria from the stomach into the upper airways. as demonstrated by the clinical course and the abnormal nitroblue tetrazolium test. Even when a cuffed tube is in place. These organisms are frequently pathogenic and resistant to standard antibiotics. Changing endotracheal tubes seems logical.
However. psittaci or C. which seem to be especially common in young people. Infectious Disease Medicine:Question 96 The correct answer is D Educational Objectives Recall appropriate isolation precautions for a patient with herpes zoster. which were slow and insensitive. contact isolation. Although topical acyclovir is approved by the U. Infectious Disease Medicine:Question 95 The correct answer is A Educational Objectives Understand the widespread prevalence of Chlamydia infection in young women. more recent tests. Infection of the lungs can occur with C. Although 5 days has been the standard duration for treatment of recurrent episodes (compared with 10 days for initial episodes). As a result. pneumoniae. Therefore. these infections seem to be less common in older women—perhaps as a result of changes in the genital mucosa. or airborne isolation alone would be inadequate. although episodic treatment may be more appropriate for this patient who has only two to three episodes each year and a recognizable prodrome. it is less useful for recurrences. at which time the institution of antiviral therapy is most beneficial. starting oral acyclovir. new data suggest that even shorter regimens may be used for recurrences. The older system of detecting Chlamydia utilized cultures. trachomatis. are quicker. Most screening programs have been directed towards young women. both airborne and contact isolation are required. Finally. Therefore. Critique Several infectious diseases are caused byChlamydia. Critique The patient appears to be having the prodrome of recurrent genital herpes. Chronic suppressive therapy is typically used for patients with at least six recurrences yearly. Critique Varicella-zoster virus can be transmitted from patients with shingles by both airborne transmission and direct contact. such as ligase chain reaction. Each of these agents can also be used to suppress frequent recurrences of genital herpes.S. Droplet isolation is not indicated. Curiously. although young men also seem to have a high rate of positive test results. Infectious Disease Medicine:Question 97 The correct answer is D Educational Objectives . we now are more aware of how common asymptomatic Chlamydia infections can be. or famciclovir is appropriate. valacyclovir.Understand the treatment of recurrent genital herpesvirus infections. easier to perform. Food and Drug Administration for treating initial episodes of genital herpes. Infection of the eye can occur withC. and more sensitive than cultures. corticosteroids are not indicated for herpes simplex virus infections and could exacerbate the condition. This last species also causes genital infections. and standard precautions. There is no evidence that genital Chlamydia infections occur in animals or are transmitted in ways that do not involve genital contact.
Suggested therapeutic measures have included the administration of riboflavin and 1-carnitine. the patient does not appear to be in shock. all the agents in this class have the potential to cause this syndrome. particularly the fatty liver infiltration. both of which this patient is taking. Hepatitis.Recognize severe complications of nucleoside analogue treatment in an HIV-infected patient. The mechanism of injury is likely to be mitochondrial in nature. especially stavudine and didanosine. due to either viral agents or alcohol. This patient’s entire antiretroviral regimen should be discontinued. Finally. Lactic acidosis/hepatic steatosis has a high fatality rate. Treatment involves discontinuing the suspected agent(s). . Critique This patient presents with a rare complication of nucleoside analogue treatment. Acute bacterial sepsis is a possible diagnosis but would not account for all the findings. also would not explain all the findings. Lactic acidosis resolves slowly over weeks to months. especially when a patient has very high lactic acid levels. This complication has most often been associated with the dideoxynucleotide agents. Imaging studies of the abdomen will usually demonstrate fatty infiltration of the liver. However. lactic acidosis/hepatic steatosis.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.