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1) One of three blood culture bottles drawn from a patient with unexplained fevers reveals grampositive cocci growing in clusters. Which of the following tests would be most useful in determining whether this organism is a part of the normal skin flora? A. Bacitracin resistance B. Catalase C. Coagulase D. Novobiocin resistance E. Optochin resistance Explanation: The correct answer is C. Gram-positive cocci in clusters are staphylococci. Staphylococcus aureus is a common pathogen that should not be considered normal skin flora. Other staphylococci, especially Staphylococcus epidermidis, may contaminate blood cultures and can be differentiated from Staphylococcus aureus by the coagulase test. S. aureus is the only coagulase-positive staphylococcus. Bacitracin sensitivity differentiates Streptococcus pyogenes from the other beta-hemolytic streptococci, which are bacitracin resistant (choice A). The catalase test (choice B) is used to differentiate streptococci from staphylococci. Staphylococci produce catalase and can generate oxygen bubbles in hydrogen peroxide, whereas streptococci cannot. Novobiocin resistance (choice D) differentiates the coagulase-negative staphylococci into S. epidermidis (novobiocin sensitive) and S. saprophyticus (novobiocin resistant). Optochin resistance (choice E) differentiates the major pathogenic alpha-hemolytic streptococci. S. pneumoniae is optochin- and bile-sensitive whereas S. viridans is resistant to both optochin and bile. 2) A 4-month-old infant presents with failure to thrive, progressive muscular weakness, and poor head control. On questioning, the mother states that she typically feeds the baby soy-based formula sweetened with honey. Which of the following organisms is most likely to be responsible for the child's presentation?

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A. Clostridium botulinum B. Clostridium difficile C. Clostridium perfringens D. Clostridium tetani E. Corynebacterium diphtheriae Explanation: The correct answer is A. The baby has infant botulism (floppy baby syndrome), which is due to germination of Clostridium botulinum spores (found in honey) in the baby's gastrointestinal tract. Patients improve when honey is removed from the diet. This disorder is most common in children under the age of six months; older children and adults do not appear to be vulnerable to this form of botulism, but are susceptible to botulism caused by ingestion of preformed toxin. Clostridium difficile(choice B) causes pseudomembranous colitis, especially after antibiotic therapy. Clostridium perfringens(choice C) causes gas gangrene and gastroenteritis, and it is not associated with ingestion of honey. Clostridium tetani (choice D) causes tetanus, and does not cause a food-borne illness in infants. Corynebacterium diphtheriae(choice E) causes diphtheria in susceptible individuals.

A 35-year-old woman presents to her gynecologist with complaints of burning on urination for the past 2 days. Dipstick test of her urine demonstrates marked positivity for leukocyte esterase, but no reactivity for nitrite. Urine culture later grows out large numbers of organisms. Which of the following bacteria are most likely to be responsible for this patient's infection? A. Enterobacter sp. B. Enterococcus faecalis C. Escherichia coli D. Klebsiella pneumoniae E. Pseudomonas aeruginosa

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Explanation: The correct answer is B. The positive leukocyte esterase test indicates the presence of neutrophils in the urine, suggesting a bacterial infection. The nitrite test exploits the fact that most Enterobacteria (gramnegative enteric rods) are able to form nitrite from nitrate; thus, the nitrite test is used to diagnose urinary tract infections. One limitation of this method is the fact that enterococci (gut streptococci) do not produce nitrite from nitrate, but can nonetheless cause urinary tract infections. Enterococcal urinary tract infections are often nosocomial and classically acquired in the intensive care unit, although they can occur in other settings. Enterobacter sp. (choice A), Escherichia coli(choice C), Klebsiella pneumoniae(choice D), and Pseudomonas aeruginosa(choice E) can cause urinary tract infections and would usually be picked up by the dipstick for nitrites. False-negative results might still be seen with these organisms if the infection was light, the bladder had been recently emptied prior to collection, and the urine was "new" and had not yet grown enough bacteria to produce a positive result.

A 37-year-old woman presents with 3 days of progressive joint pain in her ankles, knees, and wrists. She recalls three similar episodes over the past several years. On examination, she has a temperature of 38.7 C, her blood pressure is 110/70 mm Hg, and her heart rate is 90/min. She has a diffuse petechial rash over her trunk and extensor surfaces. Her ankles and knees are swollen, red, and tender with decreased range of motion, and there is tenderness over the tendon sheaths of her hands and forearms. Blood cultures are negative. Aspiration of joint fluid reveals a white cell count of 22,000/mm3 with no visible organisms, but culture on chocolate agar is positive. Which of the following is an attribute of the causative organism that allows it to produce recurrent infections? A. It is an intracellular pathogen B. It is resistant to ceftriaxone C. It is resistant to complement-mediated lysis D. Its capsule is not immunogenic

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E. Its pili undergo antigenic and phase Explanation:

variation

The correct answer is E. This is a case of Neisseria gonorrhoeae arthritis. Patients are continuously susceptible to reinfection because of antigenic variation and phase variation of the pili. N. gonorrhoeae is not an intracellular pathogen (choice A), although it may be found intracellularly in neutrophils after it has been phagocytized. Ceftriaxone (choice B) is the drug of choice for N. gonorrhoeae. Gonococci are especially susceptible to complement-mediated lysis, not resistant to it (choice C). N. gonorrhoeae has an insignificant capsule that does not play a major role in the pathogenesis, but its capsule is immunogenic (compare with choice D). Streptococcus pyogenes is the best known example of a nonimmunogenic capsule, made of hyaluronic acid, but virtually all other capsules are immunogenic.

3) A Pap smear from a woman with chronic cervicitis shows cytoplasmic inclusions within epithelial cells. Fluorescent antibodies identify both these inclusions and "elementary bodies." The intracellular organisms causing the infection are unusual because they cannot synthesize which of the following? A. ATP B. Cholesterol C. DNA D. Proteins E. RNA Explanation: The correct answer is A. The disease is chlamydial cervicitis. This venereally transmitted infection is usually suspected after treatment for gonorrhea fails to relieve symptoms. However, a few cases are picked up when cytoplasmic inclusions composed of aggregates of chlamydia are identified on Pap smears. Confirmation can be made with fluorescent antibodies that pick up both the aggregates and individual bacteria known as

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"elementary bodies." The organisms are obligate intracellular parasites because they have lost the ability to synthesize ATP. Although some authors consider them to be "bacteria," others do not, since this is such a fundamental difference between the chlamydia and free living bacteria. Failure to synthesize cholesterol (choice B) is not usually cited as a problem specific to any type of organism, although viruses are not able to do so without using host machinery. Some viruses cannot synthesize DNA (choice C), but the disease in question is not caused by a virus. Protein synthesis (choice D) by viruses requires host ribosomes. Some viruses cannot synthesize RNA (choice E), but the disease in question is not caused by a virus.

4) A patient with colorectal cancer develops septicemia complicated by endocarditis. You would expect the blood cultures to grow A. Streptococcus agalactiae B. Streptococcus bovis C. Streptococcus pneumoniae D. Streptococcus pyogenes E. Streptococcus viridans Explanation: The correct answer is B.Streptococcus bovis is a Group D streptococcus. There is a significant association between S. bovis bacteremia and endocarditis with carcinoma of the colon and other colonic diseases. Every patient with S. bovis bacteremia should undergo gastrointestinal and cardiac evaluation. Up to 50% of patients with S. bovis bacteremia are reported to have underlying colonic malignancies. In another study, 2550% of cases of S. bovis bacteremia were associated with endocarditis, especially in patients with preexisting valvular lesions. Streptococcus agalactiae(choice A) is an important cause of maternal and neonatal bacteremia and neonatal

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meningitis. It is part of the normal flora of the gastrointestinal tract and the female genital tract. Streptococcus pneumoniae(choice C) is a leading cause of community-acquired pneumonia, meningitis in adults, otitis media (especially in children), and sinusitis. Spontaneous peritonitis due to S. pneumoniae is reported in children with ascites from nephrotic syndrome. Asplenia predisposes patients to severe infections with S. pneumoniae and other encapsulated organisms. S. pneumoniae infections are also more frequent and unusually severe in patients with sickle cell anemia, multiple myeloma, alcoholism, and hypogammaglobulinemia. S. pneumoniae is now the leading cause of invasive bacterial respiratory disease in patients with AIDS. Streptococcus pyogenes(choice D) is the most common cause of bacterial pharyngitis. Complications include paratonsillar abscesses, otitis media, and sinusitis. Long-term sequelae include rheumatic fever and poststreptococcal glomerulonephritis. S. pyogenes is also responsible for many skin and soft tissue infections. The organism also produces many toxins that produce a variety of diseases. Streptococcus viridans(choice E), or the viridans Streptococci, are the most common cause of subacute bacterial endocarditis, which should be suspected in cases of viridans streptococcal bacteremia. One species of viridans Streptococci, Streptococcus milleri, is frequently associated with pyogenic abscesses, especially of the liver.

5) A 54-year-old woman suffering from influenza deteriorates and develops shaking chills and a high fever. Physical examination is remarkable for dullness to percussion at the left base and decreased breath sounds on the left. Chest x-ray confirms the diagnosis of lobar pneumonia, presumed to be caused by Streptococcus pneumoniae. The patient has no known drug allergies. Which of the following antibiotics would be most appropriate to treat the patient's condition? A. Cefotaxime B. Chloramphenicol C. Erythromycin D. Penicillin

Parvovirus D. Vancomycin (choice E) is not the first-line therapy. The third-generation cephalosporin cefotaxime (choice A) is not usually used for pneumococcal pneumonia. Variola Explanation: The correct answer is D. Cytomegalovirus B. except in patients with penicillin allergy and in the relatively few areas in which pneumococcal strains with high-level penicillin resistance exist. Herpesvirus 6 C. Erythromycin (choice C) is a good alternative therapy for pneumococcal pneumonia. Poxvirus E. The lesions are characteristic of molluscum contagiosum. which is a typically benign and self-limited condition caused by a poxvirus. An otherwise healthy 3-year-old child is brought to the pediatrician with umbilicated. flesh-colored papules on his trunk. The other viruses listed do not cause similar skin lesions. Penicillin remains the first-line drug of choice for pneumococcal pneumonia. Alternative therapies include erythromycin and vancomycin. Patients with advanced HIV . but is usually used only when a penicillin allergy is present. The disease can be transmitted either venereally or through non-venereal contact.7 E. Chloramphenicol (choice B) is not usually used for pneumococcal pneumonia. Vancomycin Explanation: The correct answer is D. This condition is related to infection with which of the following viruses? A. but it is a good alternative in patients allergic to penicillin or when high-level penicillin resistance (relatively uncommon) is present.

often involving the face and Cytomegalovirus (choice A) causes congenital infections and disseminated infections in immunosuppressed patients. A 39-year-old black man presents with complaints of anorexia. hepatitis C negative. This patient has acute hepatitis B. SGPT 1200 units.4%.8 infection may develop a severe. alcohol intake. upper body. Parvovirus (choice C) causes aplastic crises in patients with hemolytic anemia. SGOT 980 units. and jaundice. dark urine. Variola (choice E) is the smallpox virus. or intravenous drug abuse. Herpesvirus 6 (choice B)causes roseola (exanthem subitum). When this patient enters the window period. The "window period" refers to that period in infection when neither hepatitis B surface antigen (HBsAg) nor its antibody (HBsAb) can be detected in the serum of the patient. He will become HBsAg negative Explanation: The correct answer is E. It is an immunologically mediated phenomenon caused by the precipitation of . He will become HBsAb positive E. He will become HBcAg positive B. the patient has a temperature of 100. Serologic findings are as follows: anti-hepatitis A IgM negative. Liver function test results are as follows: total bilirubin 12. what would likely be the first change in his serologic findings? A. and persistent eruption. On physical examination. malaise. anti-HBsAb negative. anti-HBc IgM positive.2 degrees F. HBeAg positive. and there is moderate right upper quadrant tenderness. He will become HBeAg negative D. but denies blood transfusions. generalized. His liver is palpable below the right costal margin. HBsAg positive. and upper abdominal discomfort. fatigue. He admits to homosexuality. He will become HBc IgG positive C. scleral icterus.

thereby. Chicken C. Physical examination reveals multiple scratches on her right arm with a papule associated with one of the scratch marks. This patient has the classic symptoms of cat scratch disease caused by the bacillus Bartonella henselae. What type of animal is the most likely source of the infection? A. typically less than 1 year of age. Parrot Explanation: The correct answer is A. Levels of the c-core antibody HBc IgG (choice B) and HBeAg (choice C) do not have a relationship to the window period. The disease is self-limited with the onset of symptoms occurring 3-10 days following an inoculating scratch. Because of this. HBcAg is not typically measured (choice A) in the serum.9 antigen-antibody complexes in their zone of equivalent concentrations and. or from fleas. A history of a new kitten in the house and the papule at the site of a scratch with regional painful adenopathy defines the classic scenario. the first thing that will happen in the window period is that the serum will become negative for the surface antigen (HBsAg). their removal from the circulation. painful lymph nodes in her right axilla. 6) A 15-year-old girl in a rural community has swollen. Cat or kitten B. She states that the scratches occurred about 5 days ago. The organism can be isolated from kittens. and the patient is leaving the window period. . Levels of HBsAb (choice D) will not be detectable until there is antibody excess. Dog or puppy D. Horse E. as that antigen is precipitated out of the serum by developing levels of its specific antibody (HBsAb).

and rats (14%). She has swelling and tenderness over the left mastoid bone. A pale macular rash is also seen. multocida most commonly causes a localized soft tissue infection or cellulitis after an animal bite. but the patient develops cellulitis and fulminant septicemia. Which of the following microorganisms is the most likely causative agent? A. and pronounced involvement of the lungs. swine (50%). The human disease is a granulomatous infection involving the lungs and mimicking tuberculosis. or tenosynovitis.10 Chickens (choice B) can harbor Salmonella spp. These symptoms include osteomyelitis. Hemophilus influenzae B. The mycelial phase thrives in the rich soil. P. Mucor sp. and myalgias. producing a gastroenteritis or enterocolitis. Horses (choice D) and horse manure have been associated with a pulmonary opportunistic infection with cavitation caused by Rhodococcus equi that resembles tuberculosis in immunocompromised patients. or hematologic malignancies. lymphadenopathy. Klebsiella pneumoniae C. Psittacosis is associated with a dry. especially in asplenic patients. Dogs or puppies (choice C) carry Capnocytophaga canimorsus as part of the normal flora of the oral cavity. Cats have the highest rate of colonization (50-90%). This organism is also associated with cat bites. septic arthritis. . severe headache. 7) A 73-year-old woman with a history of diabetes presents with left ear pain and drainage of pus from the ear canal. hacking cough productive of scant sputum. an interstitial infiltrate in the lungs. but systemic symptoms may be present in about 40% of the cases. Infections from licking or biting range from a self-limited cellulitis to fatal septicemia. Patients at risk for more severe infections are those with asplenia. Parrots (choice E) are associated with psittacosis caused by Chlamydia psittaci. Pasteurella multocida is another pathogen that colonizes the nasopharynx and gastrointestinal tract of cats and dogs. Burkholderia mallei (the cause of glanders) is characterized by non-caseating granulomatous abscesses of skin. followed by dogs (50%). alcoholism. Chicken guano is also a favorable environment for the fungus Histoplasma capsulatum.

which is a severe necrotizing infection of the external ear canal.11 D.Influenzae is the third-most common cause of meningitis in children aged 1 month to 18 years. base of the skull. Pseudomonas aeruginosa E. Infection tends to spread to the mastoid bone. alcoholics. Streptococcus pyogenes(choice E) causes bacterial pharyngitis. and orbital swelling. Mucor (choice C) is a fungal infection that is particularly severe in the diabetic or the immunocompromised patient. since the organism can be cultured from the shoes. It is the most common cause of acute epiglottitis. including infection following traumatic wounds to the feet in persons wearing sneakers or rubbersoled shoes. and purulent. Klebsiella pneumoniae(choice B) is a gram-negative organism that produces a necrotizing pneumonia in diabetics and alcoholics. Patients at increased risk include the elderly. shaking chills. Patients typically complain of headache. and the immunocompromised. H.Pseudomonas aeruginosa causes malignant otitis externa. The infection begins in the nasal passages. and sinusitis. invasive rhinocerebral infection. the fungus produces a life-threatening. Pseudomonas is also associated with many other clinical syndromes. In the acidotic diabetic. those with diabetes. meninges. and brain. Hemophilus influenzae(choice A) produces a variety of clinical syndromes. A 29-year-old female diagnosed with AIDS has been suffering from a progressive blurring of vision in her right . facial pain. and spreads through the cribiform plate to the frontal lobes of the brain. sigmoid sinus. the most common cause of purulent bacterial conjunctivitis. foul-smelling sputum. Streptococcus pyogenes Explanation: The correct answer is D. otitis media. and young patients. splenectomized patients. Patients at risk include those with COPD and cystic fibrosis. extends into the paranasal sinuses. Patients typically present with an abrupt onset of fever. temporal bone. and the second-most common cause of otitis media. It is also associated with toxin-related diseases and skin infections.

Cytomegalovirus B. Amantadine (choice B) is used either therapeutically or prophylactically for the influenza A virus. Herpes simplex . a small white opaque lesion is noted on the retina of her right eye. hepatosplenomegaly. Which of the following is the most appropriate therapy for this patient? A.12 eye. Hepatitis C D. A newborn is infected in utero with an enveloped virus containing double-stranded DNA. The best drug treatment for this infection is ganciclovir. Flucytosine (choice C) is an antifungal agent. With which of the following viruses is the newborn most likely infected? A. Ganciclovir E. It is used more for HSV type 1 and 2 infections. Hepatitis D E. Amantadine C. On funduscopic examination. The child develops petechiae. Brain calcifications are detected on computed tomography (CT). The drug by itself is ineffective against CMV retinitis. Zidovudine Explanation: The correct choice is D. Flucytosine D. and jaundice. Hepatitis B C. Acyclovir B. Zidovudine (choice E) is a first-line drug for the treatment of AIDS. This patient is most likely suffering from cytomegalovirus (CMV) retinitis. Acyclovir (choice A) is not effective in CMV infections.

and D). insignificant cough. Primary infection of the mother is strongly associated with more severe symptoms in affected infants. and Treponema pallidum. and elevated transaminase levels. herpes simplex virus. The most common agents causing congenital infection in the United States are cytomegalovirus. Congenital cytomegalovirus infection. lethargy. Herpes simplex (choice E) can also infect the neonate. and hydrops. C. but over the next few days he develops marked shortness of breath requiring assisted ventilation. The infection is usually acquired during the birth process. Sensorineural deafness is a common manifestation in affected infants. Infections with hepatitis viruses (choices B. which occurs in 1 to 2% of all live births in the U. therapy includes hyperimmune human anti-hepatitis B serum followed a few weeks later with active immunization with rHBsAg injections. a severe headache. Most infections are asymptomatic. Massive hepatic and adrenal necrosis is common. results from transplacental acquisition of a primary or recurrent maternal infection. Therapy is with acyclovir. The hallmark of infection is painful skin vesicles (present in 50% of affected infants). petechial hemorrhages. The mortality rate is 30% and most of the survivors will have neurologic impairment. Chest x-ray demonstrates homogeneous radiographic shadowing that initially . pneumonia. but about 5% will present with hepatosplenomegaly. CMV infections in children and adults are often asymptomatic. the virus is responsible for 10% of infectious mononucleosis cases (characterized by an absence of sheep RBC agglutinins). Hepatitis B(choice B) is the only viral hepatitis agent that is recognized as an important cause of neonatal disease. hepatitis. if symptomatic.colored stools. are characterized by jaundice. including bone marrow recipients and AIDS patients. failure to thrive. clay.S. shakes. and disseminated intravascular coagulopathy. and muscle pain. although foscarnet has also been used with some success. CMV also causes serious disease in immunosuppressed patients. periventricular brain calcification. 8) A 60-year-old alcoholic smoker abruptly develops high fever.. He initially has a dry. Ganciclovir is the drug of choice. abdominal distention. however.13 Explanation: The correct answer is A. other manifestations include encephalitis.

alcoholism. Streptococcus pneumoniae Explanation: The correct answer is A. but is easily cultured on routine media. Spirillium minus (choice C) is a cause of rat-bite fever and is not a notable cause of pneumonia. Culture on BCYE is the specific clue that the organism is Legionella pneumophila. A 33-year-old woman presents with fever. or immunosuppressive therapy. because the disease was first described when it occurred in epidemic form following an American Legion convention at a Philadelphia hotel. Staphylococcus aureus E. blood cultures indicate bacteremia. Listeria monocytogenes C. Which of the following is the most likely causative organism? A.14 involves the left lower lobe but continues to spread until both lungs are extensively involved. The patient has a severe. Spirillium minus D. vomiting. Laboratory evaluation reveals leukocytosis with a left shift. and pronounced costovertebral angle tenderness. Patients tend to be older (40-70 years old) and may have risk factors including cigarette use. Listeria monocytogenes(choice B) causes listeriosis and is not a notable cause of pneumonia. pneumonia with prominent systemic symptoms. also known as Legionnaire's disease. chronic illness. Staphylococcus aureus(choice D) can cause pneumonia. Culture of bronchoalveolar lavage fluid on buffered charcoal yeast extract (BCYE) demonstrates a coccobacillary pathogen. potentially fatal. and gram-negative bacteria. Legionella pneumophila B. Streptococcus pneumoniae(choice E) can cause pneumonia. Urinalysis shows pyuria. Ampicillin and gentamicin . Which of the following drugs would best treat this patient's infection? A. but is easily cultured on routine media. mild hematuria. severe irritative voiding symptoms. diabetes. The disease is respiratory Legionellosis.

Rubella . and Enterobacter. Which of the following infectious agents is the most likely cause of this child's presentation? A. Acute pyelonephritis is an infectious disease involving the kidney parenchyma and the renal pelvis. once the sensitivity results are available. Herpes simplex C. and urinalysis typically shows pyuria. This regimen may be need to be changed. Phenazopyridine (choice D) is a urinary analgesic. the patient should be hospitalized and empirically started on IV ampicillin and gentamicin.15 B. hemorrhagic. as well as cystitis. Although nitrofurantoin is indicated for the treatment of "mild" cases of pyelonephritis. however. Laboratory evaluation will often reveal leukocytosis with a left shift. this patient's condition is severe and should be treated with appropriate antibiotics. cutaneous lesions and does not respond to sound. and white cell casts. such as Escherichia coli. A newborn infant has multiple. Cytomegalovirus B. varying degrees of hematuria. Phenazopyridine and nitrofurantoin E. Erythromycin (choice B) and tetracycline (choice E) are both bacteriostatic antibiotics and would not be recommended in a patient with a severe infection. Head CT scan shows periventricular calcifications. Vancomycin (choice C) is primarily used in the treatment of severe gram-positive infections. Klebsiella. Erythromycin C. are the most common causative organisms in acute pyelonephritis. Gram-negative bacteria. Proteus. Tetracycline Explanation: The correct answer is A. and nitrofurantoin (choice D) is a urinary tract anti-infective. Since bacteremia is present. such as acute pyelonephritis with bacteremia. Gentamicin and vancomycin D.

encephalitis. and central nervous system. The infection is characterized by vesicles on the skin and mucous membranes. and periventricular CNS calcifications suggests congenital CMV infection. bones. Escherichia coli C. but more commonly is acquired during vaginal delivery. In utero infection with which of the following organisms is suggested by this finding? A. chorioretinitis. Listeria monocytogenes E. Severe infections can cause stillbirth. and motor abnormalities. Syphilis E. Toxoplasmosis (choice E) can be either acquired during delivery (mild) or congenital (severe). Neonatal herpes (choice B) may be congenital.or microcephaly. Toxoplasmosis Explanation: The correct answer is A. Congenital rubella (choice C) can cause mental retardation. Clostridium botulinum B.16 D. or a variety of problems including abnormal teeth. 9) A very ill neonate has widespread granulomas. Other manifestations include microcephaly and hepatosplenomegaly. intracerebral calcifications. The triad of cutaneous hemorrhages ("blueberry muffin baby"). Haemophilus influenzae D. and hydro. The infectious agents listed are all important causes of congenital disease. Congenital syphilis (choice D) can cause death in utero. deafness. the most common cause of intrauterine fetal viral infection. Neisseria gonorrhoeae . blindness. or disseminated disease. heart abnormalities. encephalitis.

and meningitis in infants. and otitis media in young children. Clostridium botulinum(choice A) can cause infant botulism. Neisseria gonorrhoeae(choice E) can be transmitted via the birth canal. pneumonia. Chest x-ray shows multiple patchy infiltrates in both lungs. Rheumatoid arthritis E. Rheumatic fever D. and causes ophthalmia neonatorum. Echocardiography and blood cultures suggest a diagnosis of acute bacterial endocarditis limited to the tricuspid valve. meningitis. All of the organisms listed can cause infection in infants. but Listeria monocytogenes is the one to cause potentially fatal granulomas (granulomatis infantiseptica) following in utero infection. which can introduce skin organisms into the venous system that then attack the tricuspid valve. Illicit drug use C. Staphylococcus aureus accounts for between 60% and 90% of cases of endocarditis in intravenous drug users. Systemic lupus erythematosus Explanation: The correct answer is B. characterized by failure to thrive. Which of the following is the most probable etiology? A. pneumonia. Escherichia coli(choice B) can cause diarrhea. and progressive muscular weakness. The endocarditis associated with congenital heart disease (choice A) typically involves either damaged valves .17 Explanation: The correct answer is D. Congenital heart disease B. 10) A 37-year-old female presents to the emergency room with a fever. Haemophilus influenzae(choice C) can cause acute epiglottitis. The most probable etiology of bacterial endocarditis involving the tricuspid valve is illicit intravenous drug use.

18 or atrial or ventricular septal defects. 11) A 4-year-old boy is brought to the emergency room in extreme respiratory distress. Epiglottitis is the most common disease of the upper respiratory tract produced by Haemophilus influenzae type b. and tricuspid damage is usually less severe and seen only when the mitral and aortic valves are heavily involved. and on physical examination. . Klebsiella pneumoniae C. bronchiolitis. He is drooling and has difficulty swallowing. Consequently. It is also a common cause of otitis media in children and may cause bronchitis. inspiratory stridor is noted. Rheumatic fever (choice C) most commonly damages the mitral and aortic valves. The vaccine is composed of the H. Rheumatoid arthritis (choice D) is not associated with bacterial endocarditis. with a temperature of 103. influenzae type b capsular polysaccharides coupled to a carrier molecule.8 degrees Fahrenheit. Systemic lupus erythematosus (choice E) can produce small. a gram-negative encapsulated rod. Which of the following agents is the most likely cause of these symptoms? A. but is not associated with bacterial endocarditis. The tricuspid valve is not particularly vulnerable. Haemophilus influenzae B. He has had no previous vaccinations. secondary bacterial endocarditis involving only the tricuspid valve in a patient with a history of rheumatic fever would be unusual. aseptic vegetations on valves. Streptococcus pyogenes Explanation: The correct answer is A. The incidence of serious disease caused by Haemophilus influenzae type b has decreased greatly with the introduction of an effective vaccine. Mycoplasma pneumoniae E. and pneumonia in adults. Legionella pneumophila D. A lateral x-ray shows swelling of the epiglottis.

Mycoplasma pneumoniae(choice D) causes community-acquired atypical pneumonia. Streptococcus pyogenes(choice E) is the most common cause of pharyngitis. It is the most common cause of pneumonia in young adults. or athlete's foot. A 15-year-old boy presents to his physician with several weeks of slowly worsening pruritus of both of his feet. Pigmented.19 given to children between 2 and 15 months of vaccine and therefore was susceptible to this organism. dry scaling lesions that are most obvious in the interdigital web spaces and on the soles. which are easily detected on alkali mounts of scraped skin as colorless. he has bilateral. On examination. but is not considered to be a pathogen in the upper respiratory tract. Branching. and blastoconidia E. however. Legionella pneumophila(choice C) causes pneumonia in man. erythematous. What would most likely be found in a potassium hydroxide (KOH) mount of a scraping of the affected skin? A. branching hyphae with cross-walls. arthroconidia. He is otherwise well and taking no medications. age. curved hyphae and round yeasts Explanation: The correct answer is B. Budding yeasts D. The patient had not received the Hib conjugate Klebsiella pneumoniae(choice B) causes pneumonia and pulmonary abscesses. This is a case of tinea pedis. Branching hyphae with rosettes of conidia B. septate hyphal fragments F. Short. The disease may be mild (an atypical pneumonia) or a fulminating disease with a high mortality (30%). . septate hyphae C. Hyphae. caused by a variety of dermatophytic fungi. this patient's presentation strongly suggests epiglottitis. There is no bleeding or exudate.

Short.20 Hyphae with rosettes of conidia (choice A) describes the environmental/transmission form for Sporothrix schenckii. which is a subcutaneous mycosis. diarrhea. a diverse group of cyst-forming subcutaneous. the agent of pityriasis versicolor. There are two intestinal protozoa specifically associated with AIDS that can cause transient diarrhea in immunocompetent individuals but can cause debilitating. Budding yeasts (choice C) describes the form found in clinical specimens from patients with sporotrichosis. and malabsorption.S. which is a superficial mycosis of the hair of the head. Diphyllobothrium latum B. Pigmented. curved hyphae and round yeasts (choice F). and blastoconidia (choice D) would be found in clinical specimens from patients infected with Trichosporon beigelii (white piedra). Oocysts are demonstrated in the stool. Which of the following organisms is most likely to be the cause of the patient's diarrhea? A. Hyphae. A 24-year-old AIDS patient develops chronic abdominal pain. the agent of rose gardener's disease. arthroconidia. low-grade fever. or the "spaghetti and meatball" presentation in clinical specimens. . Giardia lamblia D. septate hyphal fragments (choice E) would be found in cases of phaeohyphomycosis. rare in the U. Isospora belli E. Microsporidia Explanation: The correct answer is D. All of the organisms listed are protozoa. These organisms are Isospora belli. are characteristic of Malassezia furfur. treated with trimethoprim-sulfamethoxazole (or other folate antagonists) and Cryptosporidium parvum (no treatment presently available). Entamoeba histolytica C. pigmented (dematiaceous) fungi. and potentially life-threatening chronic diarrhea in AIDS patients.

Human papillomavirus and t(2.22) is the Philadelphia chromosome. although a link to cervical cancer has intermittently been proposed. Hepatitis B (choice B) is associated with hepatocellular carcinoma. Herpesvirus (choice C) does not have a strong tumor association. Entamoeba histolytica(choice B) and Giardia lamblia(choice C) are both causes of diarrhea. t(9.14) B. This type of tumor has been associated with which of the following? A.21 Diphyllobothrium latum(choice A) is the fish tapeworm and occasionally causes diarrhea.14) (q24. Hepatitis B and t(9. but they are not specifically associated with AIDS. but produce spores rather than oocysts. the association is weaker in sporadic cases.q32. Human immunodeficiency virus and CD4 E. The sporadic form is often in an abdominal site and occurs in young adults.l3.5) Explanation: The correct answer is A.22) C. The patient has Burkitt's lymphoma. The African form of Burkitt's lymphoma has been strongly associated with antibodies directed against Epstein-Barr virus.33) has been described. Herpesvirus and CD5 D. . Microsporidia (choice E) are a protozoan cause of diarrhea. Biopsy demonstrates sheets of medium-sized blast cells with admixed larger macrophages. A characteristic translocation. CD5 is a marker seen in small lymphocytic and mantle cell lymphomas. Epstein-Barr virus and t(8. which is seen in some cases of CML and AML. t(8. This type of lymphoma is a highgrade B-cell lymphoma that occurs in endemic form in Africa (it is the most common neoplasm in children in an equatorial belt that includes Africa and New Guinea) and sporadically in the United States and Europe. An African child develops massive unilateral enlargement of his lower face in the vicinity of the mandible.

genital condylomata. piriformis E. t(2.22 HIV (choice D) is linked to Kaposi's sarcoma (and AIDS). large flocculent masses are noted over the lateral lumbar back. psoas major Explanation: The correct answer is E. Some patients also develop primary lymphomas (not usually Burkitt's). but is now rare in clinical practice in this country. and is not related to the lumbar portion of the back. The gluteus maximus (choice B) gluteus minimus (choice C) and piriformis (choice D) are muscles of the buttock with no relationship to the groin.5) is linked to anaplastic large cell lymphoma. gluteus minimus D. and a similar mass is located in the ipsilateral groin. The psoas muscle is covered by a fibrous sheath known as the psoas fascia. CD4 is a marker for helper T cells and some T cell lymphomas. This pattern of involvement strongly suggests an abscess tracking along the A. Human papillomavirus (choice E) is linked with common warts. and genital cancers. This sheath is open superiorly. This is the classic presentation of a psoas abscess. gluteus maximus C. This clinical entity was formerly a fairly common complication of vertebral tuberculosis. A 49-year-old Vietnamese man is diagnosed with tuberculosis. The adductor longus (choice A) is a muscle of the anterior thigh. On physical examination. . permitting an infection involving the soft tissues around the spine to enter the sheath. adductor longus B. then track down to the groin.

the typical MRI appearance of the lesion (ring-enhancing mass). Toxoplasmosis associated with AIDS manifests with necrotizing lesions surrounded by chronic inflammation. Vascular occlusion ensues. Anopheles mosquitoes (choice A) transmit malaria parasites. toxoplasmosis causes extensive damage to brain parenchyma and retina. the most frequent causes of a ring-enhancing lesion are primary brain lymphoma and toxoplasmosis. Clues to the correct answer are the underlying disease (AIDS). A biopsy shows coagulative necrosis of brain parenchyma with macrophage-rich chronic inflammatory infiltration admixed with microscopic cysts that contain characteristic bradyzoites.23 A 36-year-old man with AIDS develops right-sided weakness involving the lower. In AIDS. Which of the following is the most common source of this type of infection? A. MRI scans reveal a ring-enhancing lesion within the white matter of the left frontal lobe. In the fetus. limb. but not the upper. Washbasins Explanation: The correct answer is C. Only immunodepressed patients and fetuses are vulnerable to this infection. Cooling systems E. which is able to adhere to endothelial cells of small cerebral vessels. In short. Cats D. which represents one of the most common opportunistic infections in AIDS. Bird droppings C. Toxoplasma gondii is a protozoon that infects humans who ingest the oocysts from cat feces or incompletely cooked lamb or pork. . resulting in numerous small infarcts. A ring-enhancing lesion is a mass that contains a rim of contrast enhancement (bright signal on MRI) surrounding a dark core corresponding to central necrosis. Anopheles mosquitoes B. which predisposes to opportunistic infections. and the histopathologic features (presence of encysted bradyzoites). Cerebral malaria is caused by Plasmodium falciparum. this patient has cerebral toxoplasmosis.

13) A 16-year-old girl presents with a painlessly enlarged lymph node in her right axilla. spreading the bacteria in aerosolized form.24 Bird droppings (choice B) represent the vehicle of infection for two of the most common opportunistic fungal infections affecting immunocompromised patients: cryptococcosis and histoplasmosis. which has also been isolated from respirator devices. and numerous granulomas filled with neutrophils and necrotic debris are observed. endocarditis. osteomyelitis. The lymph node is biopsied. Bartonella is a gram-variable . cribs. aeruginosa tends to affect patients with cystic fibrosis. severe burns. Coxiella burnetii E. a fatal form of pneumonia that first struck participants at a meeting of the American Legion. Chlamydia psittaci D. but not cerebral infection. P. not intracerebral necrotic lesions. It has been reported in immunocompromised patients as well. Which of the following organisms could produce this disease? A.Bartonella henselae is the infective agent of cat scratch disease. and antiseptic-containing bottles. which generally presents as regional lymphadenopathy with or without low fevers and headaches. external otitis. pneumoniae is a gram-negative bacterium that causes Legionnaire's disease. or immune impairment. Washbasins (choice E) frequently contain Pseudomonas aeruginosa. Borrelia burgdorferi C. It may cause bronchopneumonia. Bartonella henselae B. These fungi can be visualized in tissue sections by silver stains. Histoplasma capsulatum rarely affects the brain. and keratitis. Rickettsia prowazekii Explanation: The correct answer is A. L. Cooling systems (choice D) may harbor Legionella pneumophila. Peripheral blood counts are within normal limits. Cryptococcus neoformans causes meningoencephalitis.

Although the organism may reside in the lymph nodes in dormancy. diarrhea. The central nervous system may also be involved. It produces a self-limited granulomatous response in the draining lymph nodes. Borrelia burgdorferi (choice B) is a spirochetal organism that is transmitted by a tick bite (Ixodes spp. but lymph nodes are spared. Staphylococcus aureus D. Rickettsia prowazekii(choice E) produces epidemic (louse-borne) typhus. producing Lyme disease. Q fever. 14) A 28-year-old male intravenous drug user presents with a febrile illness that has lasted 2 weeks. it does not elicit granuloma formation. and small. Pseudomonas aeruginosa C.). and abdominal pain. The disease in humans. It may produce lymphadenopathy. weakness. Chlamydia psittaci (choice C) infection occurs after contact with infected bird droppings and produces an atypical pneumonia. an empiric antibiotic regimen should primarily be directed at which of the following organisms? A. along with small hemorrhages on the palms and soles. which is transmitted by body lice and produces a rash akin to Rocky Mountain spotted fever. cough.25 pleomorphic rickettsial organism that is introduced to the skin in a cat bite or scratch. Three sets of blood cultures are obtained from different veins. On examination. Streptococcus pneumoniae . headache and pain over about one month. dyspnea. Lyme disease progresses from a skin rash to fevers. Enterococci B. is marked by mild nonspecific symptoms or pneumonia. Coxiella burnetii(choice D) infection is transmitted by inhaling dusts or drinking milk from infected mammals. and may progress to myocarditis or hepatitis. a heart murmur is present. but is not associated with granuloma formation. tender nodules are found on the finger and toe pads. He also complains of chills. Chlamydia trachomatis is the chlamydial species that typically produces suppurative nodal granulomas (lymphogranuloma venereum). especially sheep and cows. While awaiting laboratory confirmation. arthralgia.

Heart murmurs occur in approximately 90% of all patients. weakness. The factors that determine the clinical presentation of IE include the nature of the organism. but may be absent in patients with right-sided infections. Streptococcus pneumoniae(choice D) and Streptococcus pyogenes(choice E) are not common causes of IE. petechiae (small erythematous painless hemorrhagic lesions that may appear anywhere). and abdominal pain. but are not usually involved in endocarditis associated with intravenous drug abuse. empiric antibiotic therapy for Staphylococci. This patient is presenting with signs and symptoms of acute infective endocarditis (IE). Since Staphylococcus aureus accounts for most cases of acute IE. the valve infected. Once the blood cultures are obtained. The diagnosis of IE is dependent on positive blood cultures and echocardiographic evidence of "valvular vegetation" and/or valvular injury. and the route of the infection. The initial treatment measures of IE should be aimed at the stabilization of cardiac and/or respiratory symptoms. Streptococci. Streptococcus pyrogenes Explanation: The correct answer is C. and splinter hemorrhages (thin linear hemorrhages found under the nail beds of fingers and toes). dyspnea. empiric coverage should primarily be directed toward Staphylococcus aureus. . Gram-negative organisms such as Pseudomonas aeruginosa(choice B) are rarely the cause of IE. cough. most patients present with a febrile illness lasting several days to 2 weeks. A past medical history of intravenous drug abuse contributes to the diagnosis. The second priority is obtaining three blood cultures from different veins. This illness is often accompanied by a variety of nonspecific signs and symptoms such as chills.26 E. The fact that the patient is an intravenous drug user places him at a very high risk for the development of IE. diarrhea. Although the clinical characteristics of IE can vary. if applicable. Janeway lesions (hemorrhagic painless plaques on the palms and soles). with echocardiography the preferred method of diagnosis. and Enterococci should be instituted. Other clinical signs include Osler nodules (purplish or erythematous subcutaneous papules or nodules on the pads of the fingers and toes). arthralgia. Enterococci(choice A) cause a minority of cases of native valve endocarditis.

metronidazole Explanation: The correct answer is A. gonorrhoeae. Urinalysis reveals 14 white blood cells per high-powered field with many gram-negative rods. a diagnosis of vaginal candidiasis can be excluded. vaginitis. The infection is likely caused by urethral trauma during intercourse. there is a short history of dysuria. Giardiasis. fluconazole D. She states that she was recently married and was not sexually active prior to the marriage. ceftriaxone C. The patient's presentation is consistent with a simple urinary tract infection. Physical exam reveals a temperature of 100. Metronidazole (choice E) is an antibiotic typically used in the treatment of Trichomoniasis. and . or cervicitis. the most appropriate therapy would be ampicillin for around 10 days. Gynecological exam reveals no evidence of discharge. Intravenous ceftriaxone is a regimen reserved for the treatment of life-threatening infections.27 A 20-year-old female presents with a two day history of dysuria and increased urinary frequency. Fluconazole (choice C) is indicated for the treatment of vaginal candidiasis. increased urinary frequency and the appearance of white blood cells and gram-negative rods in the urine. ampicillin B. gentamicin E. now that most strains are resistant to penicillin. Since the majority of these infections are caused by Escherichia coli (a gram-negative rod). The most appropriate therapy would be A. Ceftriaxone (choice B) is the treatment of choice for uncomplicated infections with N. Since there is no vaginal discharge and the patient has gram-negative rods in the urine.7 °F with normal vital signs. Gentamicin (choice D) would be an inappropriate choice since the majority of urinary tract infections caused by gram negative rods are sensitive to ampicillin and the potential for toxicity secondary to gentamicin is great. which leads to bacterial contamination of the bladder. Urinary tract infections are common in women after they become sexually active.

one can conclude that these infections are not present and the patient instead has a urinary tract infection. Listeriosis B. Parvovirus E. resulting in red blood cell aplasia. Her 5-year-old son had been sent home from school approximately 3 weeks previously with red cheeks and a blotchy rash on his torso. Meningitis and bacteremia are common clinical manifestations. The symmetrical distribution of involved joints is similar to that in rheumatoid arthritis. A 36-year-old mother of two children presents with a 4-day history of swollen.S. neonates. Elderly. The white-footed mouse and the white-tailed . Adults typically do not get the facial rash. Lyme disease (choice B) is caused by Borrelia burgdorferi. Lyme disease C. as well as serious infections believed to be caused by anaerobic bacteria. The incidence is highest in the summer and fall. The 5-yearold boy has the classic "slapped cheek" appearance. Her wrists and metacarpophalangeal joints are boggy and inflamed bilaterally. Reiter's syndrome Explanation: The correct answer is D. The onset in adults is typically 3 to 4 weeks after exposure.28 Gardnerella. Listeriosis (choice A) is caused by the gram-positive rod Listeria monocytogenes. but have arthralgias and arthritis. Parvovirus B19 causes erythema infectiosum. It is the most common vector-borne disease (Ixodes ticks) in the U. Mumps D. Since there is no vaginal discharge and the patient has gram negative rods in the urine. pregnant women. and those taking steroids have the highest risk for infection. or Fifth disease. What is the most likely diagnosis? A. painful hands. Parvovirus infections may persist in immunosuppressed patients.

myalgia. From 3 to 32 days following a tick bite. It may be triggered by a C. caused by Listeria monocytogenes. Spirillium minus E. Which of the following organisms would most likely be isolated from the placental membranes? A. and then listeriosis was later implicated as a cause of spontaneous abortion in pregnant women. the patient develops fever. Mumps meningoencephalitis is one of the most common viral meningitides. or keratoderma. she has a spontaneous abortion. meningismus. Spontaneous abortion is a problem associated with Listeriosis. Listeria monocytogenes D. mucocutaneous disease such as balanitis. and orchitis are characteristic. Parotitis. Leptospira interrogans C. headache. asymmetric arthropathy predominantly affecting the lower extremities. 15) A 28-year-old pregnant woman develops a flu-like illness with fever.29 deer are zoonotic reservoirs. pancreatitis. The virus most commonly affects glandular tissue. patients may have urethritis (which is usually due to chlamydia). Mumps polyarthritis is most common in men between the ages of 20 and 30 years. Reiter's syndrome (choice E) is a seronegative. Mumps (choice C) is caused by a Paramyxovirus. Joint symptoms begin 1 to 2 weeks after the parotitis subsides and large joints are involved. lymphadenopathy. In addition to the arthritis. The rash enlarges and resolves over 3 to 4 weeks. notably sheep and cattle. Listeriosis can . Borrelia burgdorferi B. and back pain. trachomatis infection. Sequelae include arthritis. conjunctivitis. Streptobacillus moniliformis Explanation: The correct answer is C. and the characteristic rash (erythema migrans). As a complication of the illness. and neurologic abnormalities. Approximately 80% of patients are HLA-B27 positive. oral ulcerations. carditis. The pattern of abortions was first recognized in herd animals. Examination of the abortus demonstrates severe amnionitis.

30 occur in either epidemic (food-borne or hospital-acquired) forms or may be sporadic (noticed in animal or animal product handlers). Achalasia B. Splenomegaly Explanation: The correct answer is A. Soft cheeses like Brie are a particularly common source of food-borne listeriosis. Chest x-ray films demonstrate pulmonary congestion. and the presence of intracellular protozoan parasites. A 14-year-old boy has just moved with his family from Brazil to the U. Leptospira interrogans(choice B) causes leptospirosis. Spirillium minus(choice D) is a cause of rat-bite fever. He starts complaining of shortness of breath and palpitations. Chronic arthritis C. Echocardiography reveals biventricular dilatation with massive cardiac enlargement. The treatment of choice is intravenous administration of ampicillin or penicillin. chronic inflammation. to fatal illness in children or adults secondary to septicemia or meningoencephalitis. The patient may also develop which of the following complications? A. This infectious condition. Borrelia burgdorferi(choice A) causes Lyme disease. to spontaneous abortion or neonatal death. Cysts in the brain D. An endomyocardial biopsy shows diffuse interstitial fibrosis. primarily in the immunosuppressed. is endemic in vast areas of South America and is transmitted from person to person . and ECG shows alterations in heart rhythm. myocyte necrosis. to flu-like illness.S. Pleuritis E. Trimethoprim-sulfamethoxazole has been used successfully in patients with penicillin allergy. The patient has myocarditis due to Trypanosoma cruzi. Other localized infections can also occur. The disease may range in severity from asymptomatic carrier cases. known as Chagas disease. Streptobacillus moniliformis(choice E) is a cause of rat-bite fever. often in combination with an aminoglycoside.

and. T. A similar pathologic mechanism accounts for megacolon and megaureter in Chagas disease. is seen in patients with malaria. Her children take her to a local hospital. and skin. She treats herself with aspirin and ampicillin without any improvement." Experts assess the number of persons with Chagas disease at about 7 million with about 35 million at risk in South America. CNS. As in any form of viral myocarditis. in which the distal third of the esophagus dilates because of loss of its intrinsic innervation. and heart are the main targets of this infection. the myocardium is infiltrated by lymphocytes. Skin. and muscular pains. Cysts in the brain (cysticerci) (choice C) may develop as a consequence of infestation by the tapeworm Taenia solium. congestive heart failure. Plasmodium organisms can also invade the myocardium. Chagas disease is a cause of acquired achalasia. Humans acquire this parasite by ingesting the eggs from undercooked pork. A debilitated 72-year-old woman develops dry cough. leading to myocarditis and dysmotility of hollow organs. skeletal muscle. manifesting with fever. headache. and ureter. Cardiac involvement manifests with ventricular dilatation and congestive heart failure secondary to myocyte necrosis and fibrosis. The remaining choices refer to different infectious conditions that may also involve the myocardium: Chronic arthritis (choice B) is a manifestation of the chronic stage of Lyme disease. but there are no morphologic markers specific for Coxsackievirus infection. if myocarditis is severe. fever. where chest x-ray films reveal scattered opacities. Laboratory investigations demonstrate the . such the esophagus. Group B coxsackievirus infections cause pleuritis (choice D) and myocarditis.31 by triatomids known as "kissing bugs. which is caused by Borrelia burgdorferi and is transmitted to humans by deer ticks. cruzi is an intracellular protozoon that localizes mainly in the heart and nerve cells of the myenteric plexus. leading to myocarditis. colon. suggestive of interstitial infiltration. Splenomegaly (choice E). Cysticercosis may also affect the heart. chest pain. often of massive proportions. Intracellular parasites can be visualized in tissue sections.

or Coxiella burnetii . Mycoplasma pneumoniae C. characterized by .32 presence of cold agglutinins. P. respiratory syncytial virus. the patient responded quickly to treatment with erythromycin. The patient's clinical presentation is typical of primary atypical pneumonia. and her symptoms rapidly improve. Streptococcus pneumoniae Explanation: The correct answer is B. Which of the following is the most likely etiologic agent of this patient's condition? A. M. the cause of this patient's pneumonia? First. pneumoniae infections are often associated with the appearance of cold agglutinins in the serum. less frequently by viruses (influenza. pneumoniae. rhinoviruses. P. but obviously not effective in treating viral infections. an antibiotic effective against M. rather than intra-alveolar. primary atypical pneumonia presents with the following features: . and not influenza virus (choice A) or respiratory syncytial virus (choice D). carinii pneumonia (PCP) is characterized by accumulation of a frothy exudate containing numerous organisms within alveolar spaces. pneumoniae. Pneumocystis carinii(choice C) is a fungal organism causing pneumonia in severely immunocompromised hosts. In contrast to bacterial pneumonia. Also. Pneumocystis carinii D. Chlamydia. Influenza virus B. The drug of choice for treatment of PCP is trimethoprim-sulfamethoxazole. Respiratory syncytial virus E. carinii is not sensitive to erythromycin.Characterized clinically by nonspecific symptomatology and few "localizing" symptoms Why is M. inflammation . rubeola and varicella virus). especially AIDS patients.Caused by M. Streptococcus pneumoniae(choice E) is the usual causative agent of lobar pneumonia. pneumoniae.Characterized pathologically by interstitial. Second. She is treated with erythromycin. detection of which is diagnostically important. adenovirus.

the clinical presentation typically consists of an erythematous rash beginning on the head. . there is a high risk of congenital abnormalities or spontaneous abortion. and arthralgias. also called German measles or 3-day measles. Mild arthralgias and other symptoms may develop in 25% of immunized women. Roseola D. Approximately 40% of patients are asymptomatic or have mild symptoms. pneumoniae is highly sensitive to penicillin. The risk varies from 40%&ndash. Lyme disease C. which are small. The greatest danger from rubella is to the fetus. In symptomatic patients. Lobar pneumonia is more prevalent in young. symptoms include fever. Rubella. (+) linear RNA viruses. then spread downward over her trunk. with bilateral pain associated with the front and back of her neck. single-stranded. enveloped. Which of the following diseases does she most likely have? A.33 consolidation of a single lobe due to intraalveolar acute inflammatory exudation. If clinical rubella develops or seroconversion is demonstrated. lasting for approximately 3 days. Enteroviral rashes may mimic rubella and rubeola. posterior cervical lymphadenopathy.60% if infection occurs during the first 2 months of gestation to 10% by the 4th month. Infectious mononucleosis B. She also complains of joint pain. whereas primary atypical pneumonia favors old. healthy individuals. A 25-year-old female presents with a confluent maculopapular rash that began on her face. In addition to a transient rash. Females of childbearing age should be warned not to become pregnant within 2-3 months from the time of immunization. which spreads downward to involve the trunk. Rubella E. debilitated patients. S. is a disease caused by a Togavirus. She states that 3 days ago she started having a fever and headache. Rubeola Explanation: The correct answer is D.

is a disease caused by a paramyxovirus.34 Infectious mononucleosis (choice A) is caused by the Epstein-Barr virus. headache. but not painful or itchy. Classic findings include fever.3 days. The initial lesion is an annular rash with central clearing and a raised red border (erythema chronicum migrans) at the bite site. The non-pruritic maculopapular rash begins on the face and spreads to the trunk and extremities. occasionally. Ixodes dammini. His physician orders a complete blood count with differential. malaise. a herpesvirus. which reveals a megaloblastic anemia. severe malaise (most common complaint). Other names include exanthem subitum or sixth disease. exudative pharyngitis. Lyme disease (choice B) is caused by the spirochete Borrelia burgdorferi. or regular measles. A Michigan fisherman presents with complaints of chronic diarrhea and fatigue. neurologic findings. Patients also have fever. Roseola (choice C) is caused by human herpesvirus 6. The virus is not associated with risk to a fetus. Patients also have a posterior cervical lymphadenopathy. Rubeola (choice E). including palms and soles. The disease is transmitted by the bite of the tick. Patients present with an upper respiratory prodrome and characteristic oral lesions (Koplik's spots) that precede the rash. Taenia saginata E. The incubation period is 10&ndash. Which of the following organisms is the most likely cause of this patient's problems? A. and.14 days. Reservoirs in nature include the white-tailed deer and the white-footed mouse. Clonorchis sinensis B. generalized lymphadenopathy. Diphyllobothrium latum C. and hepatosplenomegaly. Children have a febrile period of 3&ndash. generalized lymphadenopathy.5 days with rapid defervescence followed by an erythematous maculopapular rash lasting 1&ndash. arthralgias. myalgias. Taenia solium Explanation: . Echinococcus granulosus D. The rash is warm. A rash is not a characteristic feature unless the patient has been treated with ampicillin.

A bone marrow aspirate contains no erythroid precursor cells. and a complete blood count shows severe anemia. Taenia solium(choice E) is the pork tapeworm. Echinococcus is prevalent in areas in which dogs are used to help raise livestock. Clonorchis sinensis(choice A) infections produce obstruction of the biliary tract or pancreatic duct and are associated with an increased risk of cholangiocarcinoma. The adult worm attaches to the small intestinal mucosa and releases eggs into the feces. Coxsackie virus B. Crustaceans living in contaminated water ingest free-swimming embryos that hatch from the eggs.35 The correct answer is B. Echinococcus granulosus(choice C) larvae infect humans and produce unilocular cystic lesions in the liver. Taenia saginata is the beef tapeworm (choice D). the girl is very pale. It occasionally causes diarrhea. but is better known as the cause of cysticercosis. The girl was probably infected with which of the following viruses? A. Her mother states that she has been feeling very tired lately. and may have "come down with a virus. it causes diarrhea but not megaloblastic anemia. Diphyllobothrium latum. Vitamin B12 deficiency can develop because the tapeworm absorbs vitamin B12 from the intestinal lumen and also interferes with ileal B12 absorption. Parvovirus . A child with sickle cell anemia is seen in a hematology clinic. found in Scandinavia and the Great Lakes. then humans acquire the infection by ingesting the undercooked or raw fish. Vitamin B12 deficiency with resulting megaloblastic anemia is specifically associated with infection with the fish tapeworm." On physical examination. It does not produce megaloblastic anemia. Echovirus C. Herpes virus E. Hepadnavirus D. Certain species of fish ingest the crustaceans.

He recalls that he felt "sick" at the time. but then partially resolved. Herpes viruses (choice D) cause a variety of acute to chronic infections including herpes simplex types I and II. but are not a cause of aplastic crises. Hepadnavirus (choice C) is the causative agent of hepatitis B.36 Explanation: The correct answer is E. of which only serotype B19 is pathogenic for humans. thalassemia. Coxsackie viruses (choice A) usually cause cold-like illness. and congenital infections that can present as stillbirth. Echoviruses (choice B) can infect a variety of organ systems (GI. A 43-year-old executive presents to a physician with chronic. Gram-positive cocci E. Gram-negative rod D. and developed knee pain that prevented him from climbing stairs for several months. eyes. Gram-negative cocci C. Spirochete Explanation: . symmetric polyarthritis involving the knees. etc). respiratory. Which of the following organisms is most likely etiologically related to the patient's arthritis? A. skin). heart. CMV infection. This virus causes three distinct syndromes: a childhood febrile rash known as erythema infectiosum ("Fifth disease"). hydrops fetalis (analogous to severe Rh incompatibility). and meningitis. or severe anemia. chronic herpes zoster. myocarditis. aplastic crisis in individuals with chronic hemolytic diseases (sickle cell anemia. Parvoviruses are small single-stranded DNA viruses. but can cause herpangina. Fungus B. CNS. and Epstein Barr virus infections. The man gives a history of having developed an extensive rash after a deer hunting trip in Connecticut several years earlier. chicken pox.

The clues are deer. The man's tongue has been severely bitten. An MRI of the head shows multiple ring-enhancing lesions. and candidiasis. N.37 The correct answer is E. A 39-year-old HIV-positive man is brought into the emergency room after experiencing a seizure witnessed by several friends. Cryptococcus neoformans B. Infection with which of the following agents is most likely responsible for this presentation? A. While all five pathogens can cause central nervous system (CNS) manifestations. Tachyzoites develop from cysts . Herpes simplex C. knees. The history is characteristic for Lyme disease. On physical examination. Toxoplasma gondii Explanation: The correct answer is E. Staphylococcus are gram-positive cocci (choice E) that can cause septic arthritis. unable to answer simple questions. Fungal arthritis (choice A) can be caused by coccidioidomycosis. and loss of bowel and bladder function is evident upon admission. JC virus E. rash. sporotrichosis. The observers relate that the patient suddenly lost consciousness and experienced both leg and arm jerking. Connecticut. toxoplasmosis (caused by Toxoplasma gondii) presents with seizures in 15-25% of cases. the patient is lethargic. and acute arthritis followed by chronic arthritis. caused by the spirochete Borrelia burgdorferi. The disease is spread by ingestion of cysts from undercooked meat or from cat feces. blastomycosis. gonorrhoeae are gram-negative cocci (choice B) that can cause septic arthritis. and has an obvious left-sided hemiparesis. Mycobacteria tuberculosis D. Haemophilus (young children) and Salmonella (sickle cell patients) are gram-negative rods (choice C) that can cause septic arthritis.

Escherichia D. meningismus. Primary CNS lymphoma in AIDS patients can present clinically in nearly the same manner as toxoplasmosis. altered sensorium. Cranial nerve palsies. and a stiff neck. vomiting. Pseudomonas E. and confusion. The disorder has a slow. focal cerebral ischemia. muscle. PML occurs in about 4% of patients with AIDS. you should be aware that only Bacillus (aerobic) and Clostridium (anaerobic) species produce spores. and other tissues. lethargy.38 phagocytized by macrophages. Cryptococcal meningitis (choice A) usually presents as a subacute meningitis with headache. nausea. but the course is usually much more indolent. This means . where they encyst and multiply. insidious onset. and personality changes. in which altered mental status is not a prominent feature. Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease caused by JC virus (choice D). and hydrocephalus are characteristic. Streptococcus Explanation: The correct answer is B. or can present acutely as confusion. Clostridium C. which can present insidiously with headache and mental changes over a week or two. Herpes simplex encephalitis (choice B) typically has a subacute onset with headache. a human polyomavirus. 17) of the following organisms would most likely cause infection after a sterilization procedure that killed vegetative cells but did not kill spores? A. Mycobacterium tuberculosis(choice C) is a cause of a basilar meningitis. then spread to the brain. Chlamydia B. Cranial nerve abnormalities are common with cryptococcal infections. Although bacterial spores are extensively discussed in microbiology courses.

and D. agalactiae and pneumococcus have a carbohydrate capsule (choice B). agalactiae can grow in bile (choice D). tetanus (Clostridium tetani). some forms of food poisoning (Bacillus cereus). B. Growth in bile E. None of the streptococci utilize cytochrome enzymes (choice C). Oxacillin sensitivity Explanation: The correct answer is A. Blood cultures grow a gram-positive coccus in chains that is presumed to be a streptococcus. S. Cytochrome enzyme system D. Both S. Which of the following characteristics would help to differentiate Streptococcus agalactiae from Streptococcus pneumoniae? A. Carbohydrate capsule C. botulism (Clostridium botulinum). agalactiae is the classic group B streptococcus. This ability is specific for the enterococcus group (group D) of streptococci. Beta-hemolytic streptococci include groups A. Alpha-hemolysis B. A newborn in the neonatal intensive care unit becomes tachypneic and irritable. although group B streptococci require a penicillinase-resistant type such as oxacillin (choice E). They derive all of their energy from the fermentation of sugars to lactic acid. an important virulence factor and means of subtyping streptococcal species. Both pneumococci and S. and pseudomembranous colitis (Clostridium difficile). gas gangrene (Clostridium perfringens and others). . agalactiae are usually treated with penicillin-type antibiotics. Streptococci are usually initially speciated by their hemolytic capacity on sheep blood agar. The non beta-hemolytic streptococci consist principally of the pneumococci and the viridans group. Neither pneumococcus nor S.39 that the list of diseases related to bacterial spore formation is also small: anthrax (Bacillus anthracis).

19) A 54-year-old truck driver in Oklahoma collides with a deer on the highway. non-productive cough. Staphylococcus saprophyticus E. and generalized lymphadenopathy. No skin lesions are noted. After several hours he passes a kidney stone. He takes the deer home and butchers it. patients on immunosuppressives/antimicrobials. not stones. shortness of breath. E. but they are responsible for urethritis. and cystic fibrosis patients). Five days later. It does not predispose to struvite stones. What is the most likely diagnosis? . coli(choice A) are by far the most common cause of urinary tract infections.40 18) A 35-year-old man presents to the emergency room with intense back pain. Escherichia coli B. He is hydrated and given pain medication. Infection with which of the following organisms promotes the production of such stones? A. which raises the urinary pH and promotes the production of struvite stones. Pseudomonas aeruginosa(choice C) can also cause urinary tract infections. Staphylococcus saprophyticus(choice D) is a common cause of urinary tract infections in sexually active young women. Pseudomonas aeruginosa D. Laboratory analysis of the stone reveals that it is composed of struvite (magnesium ammonium phosphate). Ureaplasma urealyticum Explanation: The correct answer is B. Proteus mirabilis C. Proteus species produce urease. but are not responsible for the development of struvite stones. most commonly in hospitalized or immunocompromised patients (especially burn patients. Ureaplasma urealyticum(choice E) can produce urease (like Proteus). he develops fever.

and hypotension. anthracis causes a localized skin lesion at the site of inoculation that develops into a black eschar surrounded by draining lymphadenitis. infective endocarditis. bacteremia. In more serious cases. Typically. Plague (choice D) is caused by Yersinia pestis. conjunctivitis. fever. infection with B. Arkansas. Anthrax B. severe muscle aches. Clinical presentations include lymphadenopathy with septicemia or pneumonia (which has the . with the leptospiremic phase characterized by abrupt-onset headache (98%). Pasteurella multocida(choice C) is associated with dog and cat bites. Pasteurella multocida infection D. It causes a rapidly progressing cellulitis. and Oklahoma. clinical progression. Anthrax (choice A) is caused by Bacillus anthracis. squirrels. interrogans is the most common isolate. muskrats. The diagnosis is suggested by the history of exposure. The immune stage occurs after a relatively asymptomatic period of 1 to 3 days and is characterized by recurrence of fever and generalized symptoms. chills. This phase lasts from 3 to 7 days. and deer. Woolsorter's disease is the inhalation form of anthrax. Tularemia Explanation: The correct answer is E. It is enzootic in the southwestern United States. changes in sensorium. Leptospirosis C. Meningeal symptoms often develop during the immune period. Infection can be transmitted by tick bites or by handling animal carcasses such as rabbits. Rats and fleas are the vectors. The ulceroglandular form of tularemia is the most common clinical presentation. hepatic dysfunction and renal failure may develop. beavers. Leptospirosis (choice B) is an infection caused by contact with urine from infected animals such as rats and dogs. and generalized lymphadenopathy. L. Tularemia is caused by Francisella tularensis. and.41 A. Plague E. The disease is biphasic. Fifty percent of the cases have been reported in Missouri. occasionally. gastrointestinal symptoms. rash.

which is characterized by fever. irritative voiding symptoms. respiratory. The treatment regimen for this bacterial infection is typically a 21-day course of ampicillin. as well as in the skin and soft tissues. Rectal examination is remarkable for a boggy. extremely tender prostate on rectal exam. A 67-year-old black man with a history of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency presents with fever. cefaclor C. exquisitely tender prostate. sulfamethoxazole/trimethoprim E. 21-day therapy with A. ampicillin B. a fluoroquinolone. or GI tracts. Ampicillin (choice A) is a broad-spectrum penicillin antibiotic commonly used in the treatment of infections in the genitourinary. and quinine. . nitrofurantoin. The patient has acute prostatitis. The risk for development of hemolytic anemia is highest if he receives high-dose. including those of the respiratory and GI tracts. or sulfamethoxazole/trimethoprim (SMX-TMP). and perineal pain. ciprofloxacin D. dapsone. chills. The sulfamethoxazole in the SMX-TMP combination is a sulfonamide. primaquine. Cefaclor (choice B) is a second-generation cephalosporin indicated for a variety of bacterial infections. The medications most commonly associated with the induction of hemolytic anemia in deficient patients are sulfonamides. and dysuria.42 highest case-fatality rate). tetracycline Explanation: The correct answer is D. with a swollen. G-6-PD deficiency is an X-linked recessive disorder affecting 10% to 15% of American black males. A urine Gram's stain is positive for gram-negative rods. The urine Gram's stain and culture will generally be positive. and can produce hemolytic anemia in patients with G-6-PD deficiency.

A test for anti-HIV antibodies is negative. and echocardiography shows bulky vegetations attached to the tricuspid valve leaflets. Because of its high virulence. commonly used in the treatment of serious Tetracycline (choice E) is most commonly used in the treatment of acne vulgaris and gonococcal infections. indicating that he has infective endocarditis. Viridans (&alpha.43 Ciprofloxacin (choice C) is a fluoroquinolone infections caused by gram-negative organisms. Staphylococcus aureus D. His condition deteriorates so rapidly that his friends decide to take him to the emergency department 24 hours after the onset of symptoms. The patient has a fever and is extremely ill. Fungal organisms. Physical examination reveals a systolic murmur. such as Candida albicans(choice A). The most important clue to the diagnosis is the presence of bulky vegetations on the tricuspid valve. this is likely a case of acute infective endocarditis. S. Candida albicans B. It commonly affects the tricuspid valve. aureus (commonly present on the skin) is the most frequent etiologic agent of infective endocarditis in intravenous drug abusers. which are also necessary to determine bacterial antibiotic sensitivity. such as those with AIDS. S. Staphylococcus epidermidis E.-hemolytic) streptococci Explanation: The correct answer is C. aureus-related endocarditis follows an acute course and may lead to death within a few days. Which of the following microorganisms will be most likely be isolated from this patient's blood cultures? A. . 20) A 25-year-old man presents with a high fever and generalized malaise. Hemophilus influenzae C. The causative agents of infective endocarditis differ depending on host factors. The diagnosis of this condition must be confirmed by blood cultures. may cause infective endocarditis in severely immunosuppressed patients. He has a history of intravenous drug abuse. On the basis of the rapid clinical course.

epidermidis(choice D) and other coagulase-negative staphylococci tend to produce endocarditis in recipients of prosthetic valves.-hemolytic) streptococci are less virulent than S. Cardiobacterium. Salmonella E. The infective organism most likely belongs to which of the following genera? A. S. Essentially. such as those damaged by rheumatic disease. 21) A newborn infant develops respiratory distress shortly after delivery and is taken to the neonatal intensive care unit for observation. aureus and are thus associated with a subacute (more prolonged) clinical course and a better prognosis. Actinobacillus. Escherichia B. Sputum recovered by the respiratory therapist reveals numerous neutrophils and gram-negative rods that grow as pink colonies on MacConkey's agar. Shigella Explanation: The correct answer is A. and consequently grow as pink colonies.. the "HACEK" group: Hemophilus(choice B). Coagulasenegative staphylococci and viridans (&alpha. and Kingella.e. Klebsiella. The next day she becomes febrile with persistent dyspnea and coughing. Proteus C. this question tests your understanding of MacConkey's agar and your knowledge of the biochemical characteristics of the Enterobacteriaceae. Viridans streptococci (choice E) are the most frequent agents causing endocarditis in previously abnormal valves. or congenitally abnormal valves. and Citrobacter species. MacConkey's agar is used to identify organisms that ferment lactose.44 A minority of cases of infective endocarditis are caused by a number of normal commensals in the oral cavity. Eikenella. i. Escherichia coli is one of several lactose-fermenting Enterobacteria. Neonatal pneumonia . Pseudomonas D. along with Serratia.

non-lactose fermenting bacteria that characteristically swarm on an agar plate. 22) Five days after returning to his military base in South Carolina after survival training in the nearby countryside. A few days later he returns to the infirmary with a maculopapular rash involving the hands and feet.45 due to aspirated E. Physical examination reveals a fever. Chickenpox B. coli during delivery is not generation cephalosporin and/or aminoglycoside. but may form a small portion of the bowel flora. an 18-year-old recruit reports to the infirmary complaining of a headache. The rash then spreads centripetally to involve the trunk. Proteus infections generally affect the genitourinary tract. They typically produce dysentery. Salmonella species (choice D) are non-lactose fermenters that may produce inflammatory diarrheas. Measles D. and it should be treated with a third- Proteus species (choice B) are motile. Pseudomonas utilizes cytochrome oxidase for energy production. non-lactose fermenting bacteria that live exclusively in the gastrointestinal tract of primates. but Proteus is an important nosocomial pathogen. it does not ferment any sugars. Mumps E. They are normally distinguished from the other Enterobacteriaceae by their ability to produce acid and gas from dextrose-containing media. Which of the following diseases should be suspected? A. German measles C. Pseudomonas species (choice C) are normally widespread in nature. Rocky Mountain spotted fever Explanation: . Shigella species (choice E) are non-motile. but no other abnormalities are noted. uncommon.

Physical examination is remarkable for lymphadenopathy and weight loss. then eventually form crusts. Several days later. 3-12 days after a tick bite. Rocky Mountain spotted fever is caused by the rickettsia R. A 47-year-old grocer complains of diarrhea and painful arthritis. Although the maculopapular rash of measles (choice C). Enterotoxigenic E.46 The correct answer is E. Clostridium B. The maculopapular rash of German measles (choice B). and secondary syphilis. thrombocytopenia. it typically begins along the hairline in frontal and temporal regions. Other manifestations can include hepatosplenomegaly. the rash described in the question stem develops. Tropheryma . and fever. Typical lesions first appear on the trunk and face and rapidly spread to involve other areas. particularly in south central and eastern portions (not the Rocky Mountains). and orchitis. and (potentially fatal) disseminated intravascular coagulation. is characterized by maculopapules that evolve into vesicles over hours to days. or rubeola. or rubella. parotitis. Electron microscopic examination of the macrophages reveals small rod-shaped structures. but not a rash. rickettsii. malaise. then spreads down the trunk to the limbs. meningococcemia. Chickenpox (choice A). and is found throughout the United States. Salmonella E. Biopsy of his small bowel reveals PAS-positive macrophages within the lamina propria. These structures are most likely A. patients develop malaise. frontal headache. can include the palms and soles. Take rashes involving the palms and soles (otherwise unusual sites) very seriously: only a small number of infections can cause this pattern. Isospora D. coli C. or varicella. then spreads down the body. including Rocky Mountain spotted fever. usually begins on the face. Mumps (choice D) is characterized by fever.

A 33-year-old G1P0 female at 6 months gestation returns from a visit to her parents house in Arizona. It is usually inoculated through an easily forgotten scratch.Bartonella henselae is a gram-negative bacillus that is the causative agent of cat scratch disease. especially kittens. Clostridium difficile(choice A) causes pseudomembranous colitis. Isospora bella(choice C) is a cause of diarrhea in AIDS patients. Coccidioides immitis C. Pasteurella multocida Explanation: The correct answer is A. generally after antibiotic administration. . Cryptococcus neoformans D. Approximately 7 days following her return. Whipple's disease was suspected of having a bacterial etiology because bacterial forms could be seen on electron microscopy. Histoplasma capsulatum E. It has recently been found to be a bacterium which is now named Tropheryma whippelii. harbor the organism. The patient states that she has pet birds at home. the identity of the causative agent remained elusive. For many years. accompanied by tender regional adenopathy. granulomas with central necrosis and organisms are observed.47 Explanation: The correct answer is E. and there was a new kitten at her mother's house. A pustule forms at the site within days to weeks. She does not remember receiving the scratch. she develops axillary lymphadenopathy and a low-grade fever. Cats. Normally. Which of the following organisms is most likely responsible for this illness? A. coli(choice B) is associated with tropical sprue. Salmonella sp. Enterotoxigenic E. Microscopically. However. Her physician notices a small papule and healing scratch on her arm on the affected side.(choice D) can cause diarrheal illness after ingestion of contaminated poultry or beef. Bartonella henselae B.

Cryptococcus neoformans(choice C) is a fungus found worldwide. usually from the soil. Treatment is with ciprofloxacin or doxycycline. but immunosuppressed and pregnant patients are more susceptible to dissemination. Aminoglycosides or erythromycin have also been employed. a week after her menstrual period. cough and sweats. which burst and spread. The disease is characterized by pulmonary symptoms. Histoplasma capsulatum(choice D) is an infection acquired by breathing dust that contains bird/bat droppings that contain spores of the organism. Can live within neutrophils C. it is common in the Ohio-Mississippi valley. immitis(choice B). swollen right knee. The main reservoir is pigeon droppings. Coccidioidomycosis is a disease caused by the fungus C. and can affect people after brief visits. but do not usually cause disease in immunocompetent individuals. Cryptococcus can cause pulmonary and CNS disease. In the immunosuppressed patient. Spores of the organism are inhaled. This organism is common in arid desert states like Arizona. Pasteurella multocida(choice E) is a gram-negative rod spread via dog and cat bites. the woman develops a painful. especially meningitis. There was no indication in this patient of an animal bite. Both hyphae and spores B. The most likely causative organism has which of the following characteristics? A. The small cryptococci are inhaled into the lungs.48 treatment is not required because this disease is benign and self-limited. Stains with silver stains . A 33-year-old woman begins seeing a new boyfriend. In the United States. Several weeks later. Cannot make ATP D. The infection is characterized by rapidly evolving cellulitis starting at the site of the bite. No true cell wall E. Symptoms include fever. but is usually self-limited. The primary infection is in the lungs. These spores enlarge to sporangia. and may be latent. or brief and self-limited.

Lumbar puncture demonstrates cerebrospinal fluid with markedly increased lymphocytes. Which of the following agents is the most likely cause of his symptoms? A. Haemophilus influenzae C. A 32-year-old man presents to the emergency room with a severe headache. The causative organism is Neisseria gonorrhoeae. The organism is the most common cause of septic arthritis in otherwise healthy. Mycobacterium tuberculosis E. which is confirmed by the abnormal . The Chlamydia are intracellular organisms that cannot make ATP (choice C) and do not usually cause septic arthritis. Other cell populations are not increased. The clinically suspected diagnosis is meningitis. Escherichia coli B. which usually causes arthritis as a rare complication of systemic candidiasis in immunocompromised patients. but the interval between acquiring the infection and developing the arthritis is usually months to years. Nuchal rigidity is found on physical examination. Hyphae and spores (choice A) would be features of Candida. Syphilis is caused by a spirochete that stains with silver stains (choice E). Secondary syphilis can (uncommonly) cause an acute arthritis. sexually active adults. Treponema pallidum Explanation: The correct answer is C.49 Explanation: The correct answer is B. which is a sexually transmitted gram-negative coccus that can live in phagocytic vacuoles in neutrophils and macrophages. Herpes virus D. Mycoplasma do not have true cell walls (choice D) and do not usually cause septic arthritis.

Escherichia coli(choice A) and Haemophilus influenzae(choice B) cause acute pyogenic meningitis. leukopenic E. They can. which is distinguished from acute pyogenic meningitis (increased neutrophils as well as lymphocytes). Most patients who develop arthritis express HLA-B27. however. and Coxsackie virus are the most common. The patient has also been complaining of joint pain.Yersinia enterocolitica is the pathogen producing this clinical syndrome. deficient in C1 esterase inhibitor activity C.. HLA-B27 positive D. A febrile 12-year-old child presents with severe right lower quadrant pain that is interpreted by the attending physician as acute appendicitis. A history of asthma (choice A) is not associated with Yersinia infections. use host-chelated iron stores or the drug deferoxamine (a siderophore produced by Streptomyces pilosus). thalassemia patients) are at increased risk of Yersinia infections because some strains are unable to synthesize bacterial iron chelators called siderophores. Acute lymphocytic meningitis is usually viral in origin. however.50 cerebrospinal fluid. Patients developing iron overload because of multiple transfusions (i. serologically positive for toxoplasmosis Explanation: The correct answer is C. the mesenteric lymph nodes are markedly enlarged and contain focal areas of microabscess formation on cut section. mumps. herpes. Yersinia is transmitted to patients via the oral route. via contaminated blood products. . the surgeon notes that the appendix is normal. Yersinia is associated with reactive arthritis following an infection by an enteropathogenic organism. Among the many viruses that have been implicated. At laparotomy. echovirus. This patient is most likely A. Mycobacterium tuberculosis(choice D) and Treponema pallidum(choice E) cause chronic meningitis.e. Epstein-Barr. or by cutaneous inoculation. The markedly increased lymphocytes suggests acute lymphocytic meningitis. an asthmatic B.

the main organ system involved is the central nervous system. there is diffuse conjunctival hyperemia associated with a mucoid discharge. Toxoplasmosis is also seen in immunocompromised patients such as those with AIDS. Antibiotics to inhibit normal flora B. affecting skin and mucosal surfaces such as the larynx and the GI tract. Gram's stain of the exudate shows pleomorphic. Egg yolk cholesterol D.51 Deficiency in C1 esterase inhibitor activity (choice B) produces the syndrome of angioedema. Cold temperature C. She reports minimal crusting upon awakening and denies eye pain or previous trauma. Staphylococcus aureus Explanation: . In this group of patients. Normal-toelevated leukocyte counts are the rule in Yersinia infection. which of the following must be used? A. gram-negative bacilli. Serological positivity for toxoplasmosis (choice E) is not suggested because toxoplasmosis produces a different clinical picture. 23) A 16-year-old girl presents to her physician complaining of redness and a yellowish discharge from her left eye for the past 2 days. The pupils dilate normally. Upon examination. although there is mild photophobia in the affected eye. This is an autosomal dominant trait associated with a deficiency of the serum inhibitor of the activated first complement component. Leukopenia (choice D) is not associated with the clinical scenario in the question. Toxoplasmosis can be acquired transplacentally with infected infants exhibiting a wide array of symptoms depending on when the mother was infected during gestation. Reduced oxygen tension E. The patients have multiple episodes of edema. To culture this organism with whole blood agar.

choice D). and Borrelia). and Listeria monocytogenes. Listeria is the genus commonly mentioned for which a cold temperature is necessary. which lyses the red blood cells. Low oxygen (choice D) tension is necessary for the growth of the microaerophiles (such as Campylobacter. Antibiotics (choice A) would not be necessary since. Escherichia coli(choice A). but not Hemophilus. or by co-culture with Staphylococcus aureus. decreased glucose. Cholesterol (choice C) is necessary for the growth of Mycobacteria. which must be released from whole blood preparations to be accessible to the organism. Helicobacter.52 The correct answer is E. a fastidious organism requiring factors V (nicotinamide adenine dinucleotide) and X (hematin). All can be found in the vaginal tract of normal women and may contaminate the infant during passage through the birth canal. This is called the satellite phenomenon. lumbar puncture revealed pleocytosis with increased protein. with proper culture techniques. The patient is suffering from conjunctivitis caused by Hemophilus. Listeria monocytogenes C. 24) A baby born at 32 weeks gestation with Apgar scores of 2 and 7 was placed in the neonatal intensive care unit. and gram-positive rods. but is not a condition for growth of Hemophilus. . Escherichia coli B. She developed a fever and leukocytosis. Streptococcus pneumoniae Explanation: The correct answer is B. Streptococcus agalactiae E. Cold temperature (choice B) would not be necessary because Hemophilus grows at normal body temperature. This can be done by gentle heating. The three major causes of neonatal meningitis are group B streptococci (Streptococcus agalactiae. no normal flora should be available to confuse the diagnosis from this site. which is beta hemolytic and lyses the red blood cells to provide the factors Hemophilus needs for growth. Which one of the following organisms was most likely isolated from the CSF? A. Neisseria meningitidis D.

sickle cell disease) who are at increased risk for the development of pneumococcal sepsis. monocytogenes is also associated with drinking unpasteurized milk.g. hence a motility test is done to confirm the identification. There is a vaccine composed of the capsular carbohydrate of 23 serotypes of this organism that is routinely given to individuals over the age of 60. Encapsulated yeast C. It is a fastidious. Mold with nonseptate hyphae D. It is the number one cause of pneumonia. Examination of the oropharynx reveals white plaques along the tongue and the oral mucosa. Which of the following best describes the microscopic appearance of the microorganism responsible for this patient's illness? A. septicemia. as well as to individuals with splenic abnormalities (e. non-motile. E. Streptococcus pneumoniae(choice E) is a gram-positive coccus that grows in pairs and short chains. A 27-year-old intravenous drug user presents with difficulty swallowing.. monocytogenes is a gram-positive pleomorphic rod. Neisseria meningitidis(choice C) is the most common cause of meningitis in school-age children and young adults.53 They colonize the upper respiratory tract and can cause pneumonia. the diphtheroid bacilli found in the upper respiratory tract and on the skin). and meningitis in the elderly. There are other gram-positive rods that resemble Listeria (e. the streptococci are gram-positive cocci in chains. L. coli is a gram-negative rod. They are readily distinguished on morphologic grounds. and/or meningitis in the neonate. monocytogenes is motile at room temperature but not when grown at 37 degrees C. This patient has Candida esophagitis. gram-negative diplococcus that would be a very rare cause of meningeal disease in very young patients. Any time a patient presents with dysphagia or . such as this one.g.. and L. septicemia. L. Mold with septate hyphae Explanation: The correct answer is A. Budding yeast and pseudohyphae B.

Heat stable toxins E. In immunocompromised patients. A 24-year-old woman in her third trimester of pregnancy presents with urinary frequency and burning for the past few days. P pili . Mucor and Rhizopus are molds with nonseptate hyphae (choice C). protein. GVVPQ fimbriae C. you can assume that the Candida is affecting the esophagus as well. Which of the following attributes of this uropathogenic organism is most strongly associated with its virulence? A. Aspergillus is a mold with septate hyphae (choice D). She takes no medications besides prenatal vitamins and is generally in good health. nausea.000 colonies of gram-negative bacilli. and a small amount of blood. Culture produces greater than 100. Now comes the hard part&ndash. aspergillosis can present with acute pneumonia. and a urine dipstick is positive for white blood cells. Candida appears as budding yeast with pseudohyphae in vivo. She denies fever. The fact that the patient is an IV drug user makes an opportunistic infection such as Candida more likely. Physical examination is remarkable for mild suprapubic tenderness. or chills. The other answer choices represent the morphology of other important opportunistic fungi: Cryptococcus are encapsulated yeast (choice B). You should think about Cryptococcus neoformans when you're presented with an immunocompromised patient with neurological symptoms. Heat labile toxins D. often with cavitation (aspergillomas = fungus balls in the lungs).remembering the morphology of Candida. vomiting.54 odontophagia and you note white plaques in the oropharnyx (thrush). You should think about Mucor when you are presented with a diabetic (especially ketoacidosis) or a leukemic patient with a severe sinus infection. Bundle-forming pili B. The classic clue is the presence of encapsulated organisms observable in an India ink preparation.

The syndrome represented by the clinical vignette is infectious mononucleosis. and tender hepatosplenomegaly.S. Type 1 pili (choice F) are a major pathogenic factor in ETEC. Heat stable toxins (choice D) are pathogenic factors in ETEC or EAEC. Diarrhea D. GVVPQ fimbriae (choice B) are found in EAEC. coli (EAEC). are caused by P pili-positive strains. 70% of cases in the U. Ascending cholangitis C. and a mild thrombocytopenia. cervical lymphadenopathy. Physical exam reveals exudative tonsillitis.55 F. cytomegalovirus is . Bundle-forming pili (choice A) are found in enteroaggregative E. Acute cholecystitis B. Type 1 pili Explanation: The correct answer is E. Coombs' test is positive. Heat labile toxins (choice C) are pathogenic factors in enterotoxic strains (ETEC). Immune complex vasculitis E. Urinary tract infections are the most common bacterial infections encountered during pregnancy. A complete blood count reveals mild anemia. lymphocytosis with about 30% of the lymphocytes exhibiting atypical features. Which of the following is the most likely complication of this syndrome? A. palatal petechiae. and Escherichia coli is the most commonly isolated organism. A febrile 23-year-old college coed presents with fatigue and difficulty swallowing. Splenic rupture Explanation: The correct answer is E. Epstein-Barr virus (EBV) is the usual cause of heterophile-positive infectious mononucleosis.

Macrophages D. Blood cultures are usually positive (E. Acute cholecystitis (choice A) is not associated with infectious mononucleosis. Mucoepithelial cells E. appearing over the past 2 days. Neurons of the trigeminal ganglia Explanation: . Diarrhea (choice C) is not usually produced by infectious mononucleosis. Klebsiella spp. Potential etiologic agents include Cytomegalovirus. Rarely. Staphylococcus spp. Lymphocytes C.56 responsible for a minority of cases. The most frequently isolated pathogens are E. A 37-year-old newly married man presents with multiple blister-like lesions on the glans of his penis. During the asymptomatic period between outbreaks. Neurons of the sacral ganglia F.. he recalls similar episodes over the past 2 years. Examination is remarkable for tender. coli is a common isolate). where would the causative agent likely have been found? A. Cryptosporidium parvum. Fibroblasts B. coli. There is also slight bilateral inguinal adenopathy. including Enterocytozoon cuniculi. Cholangitis usually presents with biliary colic. Immune complex vasculitis (choice D) is not associated with infectious mononucleosis. and Clostridium spp. drainage. presenting with abdominal pain and obstructive liver symptoms.. group D Streptococcus. On questioning. 3-4 mm vesicular lesions on the shaft of his penis with no apparent crusting. splenic rupture requiring splenectomy can result from splenomegaly and capsular swelling. Ascending cholangitis (choice B) is not associated with infectious mononucleosis. and Microsporidia. AIDS-related cholangitis has been reported. with an accompanying leukocytosis. usually occurring during the 2nd and 3rd weeks of the illness. or bleeding. jaundice. and spiking fever with chills (Charcot's triad).

Infection of mucoepithelial cells (choice D) by herpes simplex produces vesicular-like lesions on the mucous membranes during symptomatic periods. she develops high fever. Klebsiella pneumoniae C. aureus is the most likely cause of bacterial pneumonia complicated by abscess formation. Staph. Candida albicans B. This agent causes lytic infections in mucoepithelial cells.57 The correct answer is E. another herpesvirus. A 67-year-old woman in a skilled nursing facility complains of flu-like symptoms. but is usually associated with perioral lesions (cold sores). This is a classic example of an infection with herpes simplex virus (probably type 2). as evidenced by the chest radiograph. Haemophilus influenzae. Streptococcus pneumoniae Explanation: The correct answer is D. After several days. Which of the following organisms would most likely be identified from examination of her sputum? A. and Streptococcus pneumoniae. The woman has developed a pulmonary abscess. Pneumocystis carinii D. where it lays dormant during the asymptomatic phase of the disease. dyspnea. and she is transported to the nearby community hospital. Staphylococcus aureus E. A chest x-ray shows a cavitary lesion in her left lung. It is then retrogradely transported into neurons of the sacral ganglia. and a productive cough. Of the organisms listed. but Streptococcus . Bacteria commonly producing pneumonia developing in the context of influenza include Staphylococcus aureus. The nurses also notice mental status changes. Lymphocytes (choice B) and macrophages (choice C) may be infected by herpes simplex type 2 but are not the site of residence of the virus during quiescent periods. Neurons of the trigeminal ganglia (choice F) may be latently infected with herpes simplex type 1. Fibroblasts (choice A) may be infected by cytomegalovirus. but this produces a distinctive mononucleosis-like syndrome in most normal individuals. This agent is a possible cause of genital ulcers.

Candida albicans(choice A) would not be a likely cause of this woman's abscess.58 pneumoniae is not a frequent cause of lung abscesses. button-like mass called chancres. Tertiary syphilis. or suffering from chronic obstructive lung disease. 25) A man presents to a dermatologist because of a severe mucocutaneous rash that involves most of his body. and consequentially some cases are missed. notably including liver and bone. which is now rare. Neisseria gonorrhoeae E. Herpes simplex II C. and secondary syphilis should come to mind. has a propensity for involving the aorta and central nervous system and can also cause "gummas" (granulomatous-like lesions) in many sites. or of the pneumonia that preceded it. The rash described is that of secondary syphilis. Pneumocystis carinii(choice C) is associated with pneumonia in immunocompromised hosts. Which of the following is the most likely causative agent of this rash? A. Primary syphilis takes the form of a painless. Streptococcus pneumoniae(choice E) is only rarely associated with lung abscess. Questioning reveals that he is a merchant marine who several months previously had an encounter with a prostitute in Southeast Asia. Klebsiella pneumoniae(choice B) is more likely in men who are alcoholic or diabetic. but there is no indication of immune compromise in this patient. HIV D. Herpes simplex I B. . including his palms and soles. Not all patients with secondary syphilis have a severe form of the rash. Involvement of palms and soles by a rash is unusual. caused by Treponema pallidum. Treponema pallidum Explanation: The correct answer is E.

HIV (choice C) does not itself cause a rash. and typically cause anemia. Ancylostoma duodenale(choice A) and Necator americanus(choice D) are hookworms.Enterobius vermicularis (pinworm) inhabits the large intestine. Herpes simplex II (choice B) usually causes genital vesicular lesions. Necator americanus E. and the gravid females migrate at night into the perianal region to lay eggs. In the office. Enterobius vermicularis D. Ancylostoma duodenale B. The infection is easily treated with a single dose of mebendazole. . Physical examination reveals scaly skin in the perianal region. transmitted by ingestion of the eggs of the organism. Ascaris lumbricoides C. The microorganism most likely responsible for the child's symptoms is A.59 Herpes simplex I (choice A) usually causes perioral vesicular lesions. Neisseria gonorrhoeae(choice D) does not typically cause a rash. the tape is transferred to a microscope slide. A child is brought to the pediatrician because of perianal itching. which has been disturbing the child's sleep. The physician instructs the parents to place transparent tape on the perianal region the next morning. and then return to the office. Enterobiasis is characterized by extreme pruritus and is very contagious. Trichuris trichiura Explanation: The correct answer is C. and low-power examination of the tape reveals oval eggs that are flattened along one side. which can be identified by placing cellophane tape on the perianal skin and then looking at the tape with a microscope. although co-infection with other organisms can result in a rash.

60 Ascaris lumbricoides(choice B) is a large. may develop in severely debilitated or asplenic individuals and can be accompanied by severe hemolysis (up to 30% of RBCs may have the parasites) with subsequent hemoglobinuria. Babesia microti B. which may be fatal. Trichuris trichiura(choice E) is the whipworm. Plasmodium vivax E. The infecting protozoan is related to Plasmodium and is transmitted by the bite of the Ixodes dammini tick. headache. chills. the Eastern seaboard clue. not a blood protozoan. which can cause rectal prolapse with heavy infestations. intestinal roundworm that is very common. and the intra-erythrocyte parasites strongly suggest Babesia microti as the infecting organism. Rare severe cases. The combination of a one week incubation period. . symptomatic cases in reasonably healthy individuals have the features listed in the question stem. Leishmania donovania(choice B) is an intracellular tissue protozoan. especially in the tropics. A blood smear demonstrates protozoa within erythrocytes. Trypanosoma cruzi Explanation: The correct answer is A. Plasmodium falciparum D. Most patients are asymptomatic. Infection may be asymptomatic or can cause abdominal symptoms. Plasmodium falciparum(choice C) and Plasmodium vivax(choice D) are malarial parasites not encountered on the Eastern seaboard. Occasional cases have been transmitted by blood transfusions. and fatigue. hemolysis. a 50-year-old woman develops fever. The clinical disease is called babesiosis. Which of the following is the most likely pathogen? A. and renal failure. Leishmania donovania C. One week following a visit to the woods along an Eastern seaboard beach.

Shigella species D. Neisseria meningitidis E. Helicobacter jejuni B.61 Trypanosoma cruzi(choice E) is an blood cells. intracellular tissue protozoan. Treponema pallidum Explanation: The correct answer is E. 26) Which of the following organisms would be most likely to cause an outbreak of enteritis in a day care center in the United States? A. and does not infect A patient is referred to a neurologist because of ataxia. a form of tertiary syphilis caused by Treponema pallidum. Neisseria gonorrhoeae D. The neurologist diagnoses degeneration of the dorsal columns and dorsal roots of the spinal cord. Which of the following organisms most likely caused this pattern of damage? A. which usually does not involve the CNS. Vibrio cholerae . The findings described are those of tabes dorsalis. Neisseria gonorrhoeae(choice C) causes gonorrhea. Herpes simplex I C. Tabes dorsalis and other forms of tertiary syphilis are now uncommon in this country. Herpes simplex I (choice B) can cause an encephalitis that typically involves the frontal and temporal lobes. Haemophilus influenzae(choice A) and Neisseria meningitidis(choice D) can cause meningitis. Haemophilus influenzae B. possibly because the common use of antibiotics may "treat" many unsuspected cases of syphilis. which has caused impaired proprioception and locomotor ataxia. Salmonella typhi C.

Decreased ribosomal binding of antibiotic E. Formation of novel cell wall peptide bridges Explanation: The correct answer is E. appendicitis. but less commonly than children. Vibrio cholerae(choice D) causes cholera. Adults can also be affected. Helicobacter jejuni(choice A) is an important cause of hospital-acquired diarrhea.-lactamase production D. of pediatric diarrhea. which is vital in the synthesis of peptidoglycan peptide bridges. What is the mechanism of vancomycin resistance in this organism? A. Some diarrheal cases are severe (and occasionally fatal) and may be complicated by severe dysentery. The antibiotic property of vancomycin depends upon its ability to bind Dala-D-ala. .Yersinia enterocolitica is an important cause of &ldquo. A 60-year-old woman has been hospitalized for three weeks with widely metastatic ovarian adenocarcinoma. and she becomes septic with vancomycin-resistant enterococcus. Acetylation of antibiotic B. or chronic relapsing ileocolitis that may require antibiotics to shorten the course. Shigella species (choice C) causes epidemics of dysentery in military camps. Altered drug-binding protein C. Salmonella typhi(choice B) causes typhoid fever. Yersinia enterocolitica Explanation: The correct answer is E. and thus are resistant to the action of vancomycin. &beta.miniepidemics&rdquo. Vancomycin-resistant enterococci instead utilize D-lactic acid in their peptide bonds.62 E.

and phosphorylation. Klebsiella pneumoniae E. Modified ribosomes with decreased antibiotic affinity (choice D) confer resistance to protein synthesis-inhibiting antibiotics. but has no activity on vancomycin. chloramphenicol. and sulfonamides. gram-negative rod. Vancomycin is not a protein synthesis-inhibiting antibiotic. &beta.Pseudomonas aeruginosa is a gram-negative rod. minocycline. Penicillin that has penetrated the cell membrane is kept in place by binding to penicillin binding proteins (PBPs). adenylation. he develops a urinary tract infection. Proteus mirabilis F. Escherichia coli D. Vancomycin resistance does not depend on PBPs. Enterococcus faecalis C. including tetracycline. oxidase-positive. It can easily be distinguished from . Urine culture grows out a lactose-negative. Which of the following agents is the most likely cause of this boy's urinary tract infection? A. Penicillin resistance may be conferred through altered PBP affinity or number (choice B). with an indwelling urinary catheter in place. doxycycline and the macrolide antibiotics. Candida albicans B.63 Enzymatic deactivation of antibiotics is a common mode of resistance to aminoglycosides.-lactamase (choice C) is a bacterial enzyme that inactivates some of the penicillins and cephalosporins. Staphylococcus saprophyticus Explanation: The correct answer is F. The most common chemical modifications are acetylation (choice A). 27) A 2-year-old boy has surgery to correct a urinary tract obstruction. Post-operatively. Pseudomonas aeruginosa G.

Candida albicans(choice A) is a yeast that can cause urinary tract infections in poorly controlled diabetics. Culture on blood agar and Lowenstein-Jensen medium shows no growth. Enterococcus faecalis(choice B) is a gram-positive coccus that commonly causes urinary tract infections in elderly men with prostate problems. These findings are most consistent with which of the following diagnoses? A. because glucose in the urine enhances its growth. It is an opportunistic pathogen that has an increased chance of causing urinary tract infections in patients with indwelling catheters. oxidase-negative. coagulase-negative. erythematous nodules on her ears and nose with significant associated sensory loss. Biopsy of the lesions shows dermal granulomas with giant cells but no acid-fast bacteria. Proteus predisposes for the development of stones). oxidase-negative. creating a more hospitable environment for the organism. A 65-year-old Laotian immigrant has developed thick.64 the family Enterobacteriaceae because Pseudomonas is oxidase positive. gram-positive coccus that causes urinary tract infections in young women. It is lactose-negative. but contains urease. gram-negative rod that is the most common cause of community acquired urinary tract infections. Escherichia coli(choice C) is a lactose-positive. or who are on antibiotics. Klebsiella pneumoniae(choice D) is a lactose-positive. Proteus mirabilis(choice E) is a gram-negative rod that is a member of family Enterobacteriaceae. Cutaneous leishmaniasis . The nodules have grown slowly over the course of many years. gram-negative rod that can cause urinary tract infections in poorly controlled diabetics because glucose in the urine enhances its growth. raises the pH of the urine. which in turn. Staphylococcus saprophyticus(choice G) is a catalase-positive. which splits urea to yield ammonia. Patients with stones are at increased risk for this organism because it is able to hide in the stones (conversely.

Smallpox (choice D). The infection is transmitted through a sandfly bite. but non-granulomatous tissue response. 28) Which of the following organisms would most likely be isolated from the vagina of a normal 5 yearold girl? . Tuberculoid leprosy Explanation: The correct answer is E. Tuberculoid leprosy is an indolent disease. producing dermal granulomas with very rare. Asia. is a roundworm infection transmitted by black flies of Africa and South America. Rhinoscleroma (choice C) is a destructive granulomatous infection of the nasopharynx caused by Klebsiella rhinoscleromatis. Smallpox has been eradicated through worldwide vaccination.65 B. and cause an inflamed subcutaneous nodule. Rhinoscleroma D. which is progressive and invasive and generally characterized by the presence of numerous acid-fast bacteria in a histiocytic. and a macular/pustular rash involving the face and distal extremities. leprae has not been grown in any culture medium. Gram-negative rods can be cultured from the lesions. produces malaise. and South America. Onchocerciasis (choice B). the infection caused by the variola virus (a DNA poxvirus). Granulomas are not formed. Cutaneous leishmaniasis (choice A) is due to Leishmania species that show a worldwide distribution.Mycobacterium leprae is endemic to parts of Africa. The organism is seen on tissue sections. M. Histology shows intracellular parasites within the dermis and epidermis. The microfilaria grow at the site of inoculation. This is in marked contrast to lepromatous leprosy. headaches. Smallpox E. acid-fast bacilli and damage to peripheral nerves. such as the nose and ears. typically affecting cooler parts of the body. Onchocerciasis C. or river blindness. and the skin lesion is typically ulcerated.

Physical examination is remarkable for dullness to percussion. Candida B. 29) A 58-year-old homeless man is brought in to the emergency room by police. One of the nurses notes the production of thick. bloody sputum when the man coughs. and Streptococcus species (choice E). gonorrhoeae (the cause of gonorrhea). Staphylococcus aureus E. The most likely causative organism is A. Lactobacillus C. Chest x-ray reveals consolidation of the right upper lobe. The vagina of women of child-bearing age tends to be colonized by Lactobacillus (choice B) species. Pseudomonas aeruginosa D. such as N. and he smells of cheap wine. in the vagina of a 5 year-old strongly suggests sexual abuse. Haemophilus influenzae B.8°F rectally. increased vocal fremitus.66 A. The presence of Neisseria (choice C). Staphylococcus E. Streptococcus Explanation: The correct answer is D. The vagina of prepubertal girls and post-menopausal women is colonized by colonic and skin bacteria. and decreased breath sounds and wet crackles on the right. Klebsiella pneumoniae C. Streptococcus pneumoniae Explanation: . His temperature is 101. Neisseria D. yeasts such as Candida (choice A). including Staphylococcus epidermidis. which is normally found on the skin.

. Spirillium minus E. but may also produce an ordinary bronchopneumonia. The pustule then ruptures to form a black eschar surrounded by expanding brawny edema. Francisella tularensis D. Although it is far better to rely on microbiology lab results than physical exam and history. and lobar pneumonia. Streptococcus pneumoniae(choice E) is a classic cause of lobar pneumonia. Which of the following organisms is the most likely cause of this condition? A. deep) dirt in Israeli and Arabian excavation sites. Borrelia burgdorferi C. in fact. The pustule described in the question stem is called a "malignant pustule" and may . some classic clues for an infection with Klebsiella pneumoniae are a patient who is an elderly alcoholic or diabetic. but does not classically produce lobar pneumonia or currant-jelly sputum. 30) An archaeologist who has been excavating a very old Middle Eastern site develops a pustule on his hand. but does not produce currant-jelly sputum or show a particular predilection for alcoholics.67 The correct answer is B. and is associated with cystic fibrosis rather than alcoholism. Pseudomonas aeruginosa(choice C) classically produces greenish sputum. Bacillus anthracis. The causative organism. Hemophilus influenzae(choice A) is a frequent cause of community-acquired pneumonia. Yersinia pestis Explanation: The correct answer is A. been encountered in very old (i.e. Bacillus anthracis B. Anthrax forms extremely stable spores and has. "currant-jelly" sputum (containing blood clots). Staphylococcus aureus(choice D) often produces pulmonary abscess. is found in many animal species. and humans can acquire the organism either through contact with the animals or from locally contaminated soil.

Yersinia pestis(choice E) causes bubonic plague. there is a localized expanding erythematous rash rather than an eschar. but death can occur as the result of complications such as bacteremia. She recalls that before coming back to the United States. and pneumonia. Which of the following organisms is the most likely cause of her illness? A.S. Salmonella typhi E. In the first stage of this disease. A 33-year-old woman who has recently returned from several years in the Peace Corps in Guatemala presents with severe. Spirillium minus(choice D) is one of the causes of rat-bite fever. which spread the infection. CT scan of the liver demonstrates lesions that are interpreted to be abscesses. Most cases remain localized. Lyme disease occurs in the U. Europe. The organism can persist for weeks to months but does not form spores that could survive for hundreds or thousands of years.S. There is no indication the man was bitten by a rat. Ascaris lumbricoides B. Furthermore.. This organism does not form stable spores that could survive for extended periods of time. Enterobius vermicularis D. acute. most human cases occur in the endemic areas of the U. Entamoeba histolytica C. corresponding to the distribution of Ixodid ticks. Also. she had several months of bloody diarrhea. meningitis.68 be accompanied by lymphadenopathy. which is a life-threatening complication of . Francisella tularensis(choice C) causes tularemia. Shigella species Explanation: The correct answer is B. right upper quadrant abdominal pain. and Asia. Borrelia burgdorferi(choice B) causes Lyme disease. The patient probably has hepatic amebiasis.

with amoebae located along the edges of the abscess. Vibrio Explanation: The correct answer is D. . Clostridium C. but does not usually cause hepatic abscesses.E. she begins to pass blood per rectum. Enterobius vermicularis(choice C) is the pinworm. Salmonella D. and is characterized by bleeding.coli. Klebsiella. Bloody diarrhea can also be seen with some strains of Salmonella (choice D) and Shigella (choice E). Bacterial causes of hepatic abscesses include E.69 intestinal infection with Entamoeba histolytica. histolytica is transmitted via the fecaloral route. and is hospitalized for dehydration. After several days. 31) A previously healthy 11-year-old girl develops a gastrointestinal infection with cramping and watery stools. Streptococcus. oliguria. Staphylococcus. which inhabits the rectum. Campylobacter B. This patient has developed hemolytic-uremic syndrome (HUS). she is noted to have decreasing urine output with rising blood urea nitrogen (BUN). Intestinal colonization (which may be asymptomatic) always precedes infection of the liver. Ascaris lumbricoides(choice A) can cause intestinal obstruction. and Pseudomonas. Bacteroides. and the peripheral smear is remarkable for fragmented red cells (schistocytes). Infection with which of the following bacterial genera is most likely responsible for this syndrome? A. In the hospital. Shigella E. The abscesses generally contain necrotic debris. but these organisms do not usually cause hepatic abscesses. Total blood count reveals anemia and thrombocytopenia. a complication of the Shiga toxin or Shiga-like toxin: exotoxins released by Shigella species and the enterohemorrhagic E. HUS in children usually develops after a gastrointestinal or flu-like illness. coli.

but not HUS. but do not elicit HUS. producing a simple enterocolitis that may proceed to sepsis in some cases. Salmonella infections (choice C) are almost all non-typhoid inflammatory diarrhea. Mandible D. Clostridial enterocolitis is produced by Clostridium difficile(choice B).70 hematuria and microangiopathic hemolytic anemia. The incorrect choices are all bacteria which may produce an enterocolitis. Zygomatic bone Explanation: . paratyphi) produces a protracted illness that progresses over several weeks and includes rash and very high fevers. He later develops meningoencephalitis localized to the base of his brain. Cribriform plate B. Nasal bone E. A 20-year-old man visiting Europe dives into a secluded natural pool. and may fragment the red cell membrane. Typhoid fever (produced by Salmonella typhi and S. a normal inhabitant of the gut that produces pseudomembranous colitis when other gut flora are suppressed by treatment with antibiotics. Presumably the Shiga toxin is toxic to the microvasculature. Lacrimal bone C. and the major risk of cholera and other Vibrio enteritides is shock due to hypovolemia or electrolyte loss. The causative organism is found to be the free-living amoeba. Vibrio (choice E) infections produce copious amounts of watery diarrhea. Which of the following structures did he probably damage during the dive? A. A long-term consequence of Campylobacter (choice A) infection is a reactive arthritis or full-blown Reiter's syndrome. Naegleria fowleri. producing microthrombi that consume platelets and RBCs. In the United States.

meningoencephalitis caused by Naegleria fowleri apparently ensues when the organism enters the body through the nasal mucosa and crosses the cribriform plate to enter the brain via the olfactory nerves. she appears dehydrated. Rotavirus. It has a complex double-stranded DNA genome B. nonbloody diarrhea. . The mouth and its associated bones. Its genome consists of 11 segments of double-stranded RNA. The lacrimal bone (choice B) of the medial aspect of the orbit does not appear to be involved in amoebic infection. looks like a wheel (which ROTAtes) and possesses a double-shelled icosahedral capsid with no envelope. The zygomatic bone (choice E). Rotavirus is the most common cause of gastroenteritis in children between 3 months and 2 years of age.71 The correct answer is A. A 1-year-old girl presents with a 2-day history of fever. It is most prevalent in the winter. It has a segmented. On physical exam. It has a single-stranded circular RNA genome E. vomiting. It has a single-stranded RNA genome Explanation: The correct answer is C. The nasal bones (choice D). located on the superior surface of the nose. including the mandible (choice C). does not appear to be a route of infection for this organism. double-stranded RNA genome D. but lifethreatening. one of the reoviruses. do not appear to be a route of infection for this organism. which forms the cheekbone. It has a partially double-stranded circular DNA genome C. The rare. and watery. do not appear to be a route of infection for this organism. Which of the following best describes the most likely infecting organism? A. It has been speculated that trauma to the nose during diving predisposes to this infection.

cough. Its envelope consists of HBsAg.72 A complex double-stranded DNA genome (choice A) is found in enteric adenoviruses. Its envelope contains surface antigen (HBsAg). Streptococcus pneumoniae Explanation: The correct answer is E. Its capsid is icosahedral and contains the genome along with DNAdependent DNA polymerase. The organism is A. including astrovirus and Norwalk virus. A single-stranded RNA genome (choice E) is characteristic of several viruses that cause gastroenteritis in children. Its capsid consists of one structural protein. Streptococcus pneumoniae. Astrovirus is the second most common cause of viral gastroenteritis in young children. His spleen has autosplenectomized and he has suffered from other minor infections in the past. and chest pain. 32) A 16-year-old male with sickle cell disease is hospitalized for a severe infection. chills. Haemophilus influenzae C. A single-stranded circular RNA genome (choice D) is characteristic of hepatitis D virus. This organism possesses an icosahedral nucleocapsid. His symptoms include fever. Bacteria from the patient's sputum yield optochin-sensitive organisms with a positive Quellung reaction. Norwalk virus is the most common cause of gastroenteritis outbreaks in older children and adults. the third most common cause of gastroenteritis in infants and children. Neisseria gonorrhoeae E. The combination of optochin sensitivity and positive Quellung reaction are properties of a single organism. Klebsiella pneumoniae D. A partially double-stranded circular DNA genome (choice B) is characteristic of hepatitis B. The other encapsulated organisms that have . Escherichia coli B. The virus is defective and is able to replicate only in cells infected with hepatitis B. which also has reverse transcriptase activity. Three structural proteins form its capsid.

Petechiae are present in his mouth and conjunctivae. none of these organisms are optochin sensitive.73 Quellung-positive reactions are Haemophilus influenzae(choice B). Squamous cell carcinoma of the bladder D. Transitional cell carcinoma of the bladder E. are not encapsulated. However. and splinter hemorrhages are visible under the fingernails. Adenocarcinomas of the renal pelvis and bladder (choices A and B) are rare. Antibodies to p24 capsid antigen . Adenocarcinoma of the bladder B. a cough occasionally productive of blood. and pleuritic chest pain. An active intravenous drug abuser presents to the emergency department with fever of 5 days' duration. Escherichia coli(choice A) and Neisseria gonorrhoeae(choice D). and Klebsiella pneumoniae(choice C). Schistosoma haematobium infection (where Schistosomes lay eggs in the veins near the bladder. Some authors have suggested that medications used to kill the worms may contribute to the etiology. The other choices. thereby inducing a marked inflammatory response) is associated with squamous metaplasia and squamous cell carcinoma of the bladder. Which of the following is specifically associated with infection with Schistosoma haematobium? A. Which of the following test results would most likely confirm the identity of the causative agent? A. Neisseria meningitidis. Transitional cell carcinoma of the renal pelvis Explanation: The correct answer is C. However. Adenocarcinoma of the renal pelvis C. Carcinomas of the bladder and renal pelvis are usually transitional cell (choices D and E) carcinomas.

gram-positive coccus E. In intravenous drug abusers. Antibodies to p24 capsid antigen (choice A) would be likely in an HIV-positive drug abuser. gram-positive coccus D. rather than in association with intravenous drug abuse. Blood culture of a coagulase-positive. Enterococci are gamma-hemolytic. but would not be the most likely agent given the other symptoms. Blood culture of an alpha-hemolytic. gram-positive coccus (choice F). Streptococcus viridans is an alpha-hemolytic. Blood culture of a gamma-hemolytic. and Staphylococcus aureus is the only coagulase positive member of its genus. optochin-sensitive. Staphylococcus aureus is the most common causative agent. It is implicated in subacute bacterial endocarditis after oral or dental treatments but would not be the most likely agent. novobiocin-sensitive. Blood culture of an alpha-hemolytic. optochin-resistant. It is sometimes implicated in subacute bacterial endocarditis. but is less common as a causative agent in drug abusers than in normal individuals. gram-positive coccus Explanation: The correct answer is D. because it is the most common normal flora organism on the skin of these patients. Blood culture of a catalase-positive. Enterococci can cause subacute bacterial endocarditis.74 B. gram-positive coccus G. . rather than a patient with endocarditis. gram-positive coccus (choice C). Antibodies to Trichinella spiralis antigen C. given the acute nature of this patient's presentation. novobiocin-sensitive. gram-positive coccus on bile-esculin agar F. Catalase positivity distinguishes the genus Staphylococcus from Streptococcus. gram-positive cocci that grow on bile-esculin agar (choice E). and choice D is the classic description of this species. catalase positive. Staphylococcus epidermidis is a catalase-positive. The patient is exhibiting the classic signs of acute bacterial endocarditis. chiefly after urologic instrumentation in men. Trichinella spiralis(choice B) can cause splinter hemorrhages during the larval migration period. optochin-resistant.

Order the germ tube test E. unless gram-negative diplococci are found within polymorphonuclear leukocytes. Culture on Thayer-Martin medium (choice A) is indeed the choice for culture of N. serological tests for the gonococcus have proven insensitive and nonspecific. with results available in 2-4 hours. The mucosa is friable. Culture the blood on Thayer-Martin agar B. but would yield slower results. it is not possible to distinguish the gonococcus from normal flora organisms such as Acinetobacter. Potassium hydroxide (KOH) mount is negative. A 22-year-old woman presents with a 1-week history of mild lower abdominal pain and a yellowish vaginal discharge.75 Streptococcus pneumoniae is an alphahemolytic. Gram's stain of the exudate reveals gram-negative cocci. Order DNA probe assays of endocervical exudates C. She describes the pain as dull in nature. swollen cervix without motion tenderness. gonorrhoeae does not have a significant capsule (the meningococcus does). gonorrhoeae. Pelvic examination reveals a red. but would be an unlikely cause of bacterial endocarditis. gram-positive coccus (choice G) that produces cough and chest pain. The symptoms suggest infection with Neisseria gonorrhoeae. The fastest and most reliable assay specific for diagnosis of gonorrhea is the use of commercial DNA probes. . and therefore be a secondary choice. however. Serology (choice C) is not a good choice because N. Order the rapid plasma reagin (RPR) test Explanation: The correct answer is B. and furthermore. with Gram's stain results alone. Order serologic tests to identify specific capsular antigens D. Which of the following procedures would most likely lead to the correct diagnosis? A. and wet mount does not reveal clue cells. optochin-sensitive. relieved slightly by acetaminophen and worsened by intercourse.

Pneumocystis carinii pneumonia is seen in immunocompromised patients. Congestive heart failure (choice B) predisposes the patient to pulmonary edema. can cause formation of lung nodules similar to subcutaneous rheumatoid nodules. A patient develops fever. and appears to be quite ill. particularly in miners. Systemic lupus erythematosus (choice E) can cause pleuritis. which is caused by an agent now believed to be a fungus rather than a true bacteria.76 The germ tube test (choice D) is one of the diagnostic tests for Candida albicans. Systemic lupus erythematosus Explanation: The correct answer is A. Pulmonary embolus D. but this case presentation is not characteristic of candidiasis. but this case presentation is not suggestive of syphilis. Which predisposing condition is most likely to be present in this patient? A. and in malnourished children. cancer. X-ray demonstrates bilateral interstitial lung infiltrates. It can be the AIDSdefining illness. Pulmonary embolus (choice C) can cause pulmonary infarction or sudden death. The RPR (choice E) is a test for reaginic (heterophilic) antibodies formed early in infection with Treponema pallidum. Congestive heart failure C. Bronchial washings demonstrate small "hat-shape" organisms visible on silver stain within alveoli. AIDS B. Rheumatoid arthritis (choice D). . shortness of breath. The disease is Pneumocystis pneumonia. but is not associated with a significantly increased incidence of pneumonia. Rheumatoid arthritis E. particularly in those with AIDS.

Mycobacterium leprae E. aviumintracellulare and M.77 33) An Hispanic male is referred to the dermatology clinic of a major medical center. that is they retain the carbol fuchsin dye in the face of acid-alcohol decolorization. M. although it is able to be cultured on lifeless media. The . Both of the mycobacteria. gram-negative bacterium that is closely related to the rickettsia. In addition. It is the cause of cat-scratch disease. the man has several disfiguring lesions on his face and there is loss of cutaneous sensation to fine touch. leprae has a predilection for the skin and cutaneous nerves. thereby producing the symptoms of depigmentation and anesthetic cutaneous lesions. a local. because the patients do not have normal pain sensation. Listeria monocytogenes(choice B) is a ubiquitous microbe that causes disease in over 100 animal species. Nocardia asteroides Explanation: The correct answer is D. chronic lymphadenitis most commonly seen in children. Bartonella henselae B. the organism attacks cartilage and causes granuloma formation in the skin. Mycobacterium avium-intracellulare D. and bacillary angiomatosis. Listeria monocytogenes C. it is a cause of multiple other diseases. Bartonella henselae(choice A) is a very small. leprae are strongly acid-fast. M. they sustain repeated injuries. On physical examination. or Hansen's disease. Which of the following organisms is the most likely cause of this patient's disease? A. A characteristic feature of these infections is the development of granulomas at the site of the infection. pain. a disease seen particularly in AIDS patients. An acid-fast organism is observed in scrapings from a skin lesion. and temperature. leading to some of the facial disfigurement. The disease in question is leprosy. Although it is best known as an agent of meningitis in the newborn. A key feature in the description is the fact that the organism is acid-fast. This loss of peripheral nerve function leads to many of the disfiguring features of the disease.

M. or through direct contact with infected animals. Vibrio cholera Explanation: The correct answer is A. and fever. The major .78 organism is not acid-fast and has no particular predilection for skin or nervous tissues. abdominal pain." Enterotoxigenic E. The infection is non-invasive and is acquired via the fecal-oral route through consumption of unbottled water or uncooked vegetables. Staphylococcus aureus E. The patients typically have bloody diarrhea. Comma-shaped organisms were found in the fecal smear along with red blood cells and leukocytes. ingestion of contaminated poultry that has not been sufficiently cooked is the most common means of acquiring the infection. fecal leukocytes.S. Nocardia asteroides(choice E) primarily produces pulmonary infections in humans. the organisms will retain the carbolfuchsin primary stain. 35) A 23-year-old man develops explosive watery diarrhea with blood. The organism is consider to be "weakly" acid-fast. The organism is a gram negative rod with a "commashape. The presence of fecal leukocytes indicates an invasive infection. Campylobacter jejuni B. Enterotoxigenic E. Which of the following pathogens is the most likely cause of these symptoms? A. coli(choice B) causes the classic traveler's diarrhea. Shigella sonnei D. and mucus approximately 3 days after eating chicken that was improperly cooked.. avium-intracellulare(choice C) causes tuberculosis-like pulmonary disease in the immunosuppressed. meaning that if the amount of HCl used in the decolorization step is reduced. coli C.Campylobacter jejuni is a pathogen causing an invasive enteric infection associated with ingestion of raw or undercooked food products. In the U.

Cerebellum C. Blood cultures are positive for Staphylococcus aureus. followed by diarrhea beginning 1-6 hours after ingestion of the enterotoxin. and a sweet odor. gray. Vibrio cholerae(choice E) produces a secretory diarrhea due to increases in cAMP in the intestinal cells. Brainstem B. The patient presents with the sudden onset of painless. custard. He develops central nervous system symptoms. vomiting.79 manifestation is a copious outpouring of fluid from the GI tract presenting as explosive diarrhea. Parietal lobe Explanation: . jejuni. and a cerebral abscess is suspected. The patient presents with nausea. the organism appears as a gram-negative rod on Gram's stain. followed by vomiting. It does not have a comma shape. The stool appears nonbilious. watery diarrhea that becomes voluminous. However. and slightly cloudy with flecks of mucus. The organism is present in food that is high in salt content such as potato salad. and mayonnaise. The organism is not invasive. and abdominal pain. Which part of the brain is most often affected by septic emboli in patients with infective endocarditis? A. no blood. Shigella sonnei(choice C) produces a syndrome very similar to C. Infection requires a low infective dose since the organism is fairly resistant to gastric acidity. Transmission is from person to person via the fecal-oral route. Staphylococcus aureus(choice D) produces food poisoning due to the ingestion of a pre-formed enterotoxin. A 37-year-old. milk shakes. Occipital lobe E. intravenous drug-abusing male presents with fever and chills. Frontal lobe D. This is due to the action of one of two types of enterotoxins on the GI tract mucosa.

due to reactivation of the herpes zoster-varicella virus. Herpes zoster-varicella E. In otherwise healthy adults. A 33-year-old male with AIDS and a history of shingles develops a severe. and the lack of response to acyclovir. Embolization from infective endocarditis typically causes multiple. Herpes simplex type II D. but is less likely in this patient. Herpes simplex type I (choice B) and herpes simplex type II (choice C) can cause disseminated disease (including brain infection) in AIDS patients. given the past history of shingles. the virus can cause a severe. Cytomegalovirus (choice A) can cause disseminated disease (including brain infection) in AIDS patients. In AIDS patients. small parietal lobe abscesses. multifocal encephalitis.80 The correct answer is E. the virus (which is usually introduced to the body as a childhood case of chickenpox) remains dormant in a dorsal root ganglion. Which of the following viruses is the most likely cause of his encephalitis? A. The specific clue to the cause of the severe encephalitis in this AIDS patient is the history of shingles. and their treatable cardiac disease may be completely unsuspected. only to reactivate in later life. Therapy is instituted with acyclovir. . This "factoid" is worth knowing because some patients with infective endocarditis present with what clinically looks like multiple small "strokes". but is less likely in this patient. Cytomegalovirus B. Herpes simplex type I C. Measles virus Explanation: The correct answer is D. given the past history of shingles. but the man dies on the fourth day of his hospital admission. causing a painful vesicular eruption that characteristically conforms to the distribution of a single dermatome. multifocal encephalitis that may be resistant to acyclovir therapy.

including: heat-resistant enterotoxin. but does respond to nafcillin. . The enzyme thus confers resistance to the beta-lactam antibiotics (penicillins and cephalosporins). D Explanation: The correct answer is D. toxic shock syndrome toxin. an enzyme that cleaves the amide bond of beta-lactam antibiotics (the molecule shown is penicillin). The infecting organism most likely produced an enzyme that would hydrolyze which bond in the above molecule? A. Abscesses are often caused by Staphylococcus aureus. You should be familiar with other important enzymes and toxins produced by this organism. It does not improve with administration of a cephalosporin. an organism that may produce penicillinase. Several days later. an abscess has formed at the surgical site. to subacute sclerosing panencephalitis. A B. and coagulase. aureus. C D. but this A 35-year-old male undergoes an appendectomy. B C. exfoliatin (causes scalded-skin syndrome in children). Nafcillin (a semisynthetic penicillin) is very effective against penicillinase-producing S.81 Measles virus (choice E) appears to be related condition is not specifically increased in AIDS patients. alpha toxin (kills leukocytes).

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A 10-year-old boy is attending summer camp in Texas. After 2 weeks of camp, he complains of a sore throat, headache, cough, and malaise. On physical examination, he also has a low-grade fever and keratoconjunctivitis. Within hours, several other campers and counselors visit the infirmary with similar symptoms. All of the patients had been swimming in the camp swimming pool. Eventually, more than 50% of the camp complain of symptoms similar to the initial case that last 5 to 7 days. Which of the following is the most likely causative organism? A. Adenovirus B. Chlamydia C. Gram-negative diplococcus D. Gram-positive enterococcus E. Herpesvirus Explanation: The correct answer is A. Adenoviruses are non-enveloped (naked), icosahedral DNA viruses causing a variety of clinical syndromes. Adenoviruses cause a pharyngoconjunctivitis that affects children and sometimes adults who are living in the same household. Contaminated swimming pools have been implicated as sources for the virus. The virus is latent in the lymphoepithelial tissue of the nasopharynx and other sites. Adenoviruses also cause watery, non-bloody diarrhea. Chlamydia spp. (choice B) produce a variety of clinical syndromes, including a sexually transmitted urethritis, pelvic inflammatory disease, neonatal pneumonia and inclusion conjunctivitis, lymphogranuloma venereum, adult interstitial pneumonia, and a zoonotic pneumonitis. A gram-negative diplococcus (choice C) would be a Neisseria spp. or Moraxella. Neisseria meningitidis would be the logical choice, since it is associated with outbreaks among children. However, the clinical syndrome caused by infection with the meningococcus is one of a fulminating, progressive septicemia and/or meningitis with fever, vascular collapse, and disseminated intravascular coagulation. N. gonorrhoeae does not cause a clinical

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syndrome as described in the question. with chronic obstructive pulmonary disease.

Moraxella catarrhalis causes pneumonia in patients

Gram-positive enterococcus (choice D) would refer to Group D streptococcus. These organisms are associated with endocarditis and genitourinary infections. Herpesviruses (choice E) are large, enveloped DNA viruses with an icosahedral shape. Possible diagnoses for this patient include Epstein-Barr virus, producing infectious mononucleosis, or cytomegalovirus, producing a mononucleosis-like syndrome. The patients in the question did not have hepatosplenomegaly (characteristic of mononucleosis), but did have keratoconjunctivitis. The organism causing the outbreak in the question also has a higher level of infectivity and a short incubation time.

36) A 35-year-old sexually active male presents to his internist with a painless penile vesicle. Physical exam reveals inguinal lymphadenopathy. The infecting organism is definitively diagnosed and is known to exist in distinct extracellular and intracellular forms. Which of the following is the most likely pathogen? A. Calymmatobacterium granulomatis B. Chlamydia trachomatis C. Haemophilus ducreyi D. Neisseria gonorrhoeae E. Treponema pallidum Explanation: The correct answer is B. This patient has lymphogranuloma venereum caused by Chlamydia trachomatis (type L1, 2, or 3). Chlamydia exhibit distinct infectious and reproductive forms. The extracellular infectious form is known as the elementary body (EB), which is incapable of reproduction. It attaches to the host cell and enters through endocytosis. Once inside the cell, the EB is transformed into the reticulate body (RB) within the endosome. The RB is capable of binary fission and divides within the endosome; fusion with other endosomes

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occurs to form a single large inclusion. Eventually, the RBs undergo DNA condensation and disulfide bond bridgings of the major outer membrane protein, forming EBs. The EBs are then released. Note that C. trachomatis is responsible for several sexually or perinatally transmitted diseases, including ocular trachoma (types A, B, and C), neonatal conjunctivitis, nongonococcal urethritis, cervicitis, and pelvic inflammatory disease (types D-K). Calymmatobacterium granulomatis(choice A) is a gram-negative rod that causes superficially ulcerated genital or inguinal papules that coalesce to form substantial lesions. The appearance of Donovan bodies in histiocytes is diagnostic of this infection. Haemophilus ducreyi(choice C) is a gram-negative rod that causes a soft, painful penile chancre, unlike that of a chlamydial or syphilitic lesion. This infection is common in the tropics. Neisseria gonorrhoeae(choice D) is a gram-negative diplococcus responsible for gonorrhea. Patients typically present with purulent penile discharge, not genital lesions. Treponema pallidum(choice E) is the spirochete responsible for syphilis. It may cause a firm, painless ulcer as a manifestation of primary syphilis, but the organism does not exist in distinct extracellular and intracellular forms as does Chlamydia. Secondary syphilis is associated with the appearance of condyloma lata–flat, gray, wart-like lesions.

A 45-year-old white male with a history of alcohol abuse and periodontal disease is brought to the emergency room for a spiking fever and chills. Physical examination is significant for signs of lung consolidation. A chest x-ray shows a cavity in the right lower lobe that has an air/fluid level. A transtracheal aspiration is performed and the specimen is submitted to the laboratory for routine cultures and Gram's stain. Based upon the clinical presentation, which of the following would be the most likely finding? A. Anaerobic bacteria B. Aspergillus fumigatus C. Entamoeba histolytica

This syndrome is typical of which of the pathogenic strains of E. Enteroaggregative B. Enterotoxigenic . resulting in a watery diarrhea. Enteropathogenic E.85 D. Enteroinvasive D. Entamoeba histolytica(choice C) is associated with pulmonary abscesses as an extension of a liver abscess across the diaphragm. Staphylococcus aureus E. Colombia drinks a glass of fruit juice with ice cubes made from tap water. coli contaminating the water supply grow in the traveler's intestine and synthesize a protein that causes his intestinal epithelium to overproduce cyclic AMP. Staphylococcus aureus(choice D) usually presents as multiple lung lesions in non-contiguous sites since the spread is embolic. Enterohemorrhagic C. The source of the infection is usually tricuspid endocarditis in IV drug abusers. Streptococcus pyogenes Explanation: The correct answer is A. Anaerobic bacteria derived from the oral flora in the clinical setting of periodontal disease are the most common isolates from lung abscesses. Streptococcus pyogenes(choice E) typically produces a bronchopneumonia pattern following an upper respiratory infection. coli? A. Aspergillus fumigatus(choice B) presents in the lung as hemorrhagic infarctions. or as allergic bronchopulmonary aspergillosis. E. aspergillomas (fungus balls) in cavitary tuberculosis cavities. Single lung abscesses are the most common pattern. with the superior segment of a lower lobe or the posterior segment of an upper lobe being affected most often. A traveler in Bogota.

Enteroaggregative E. are produced. Superior vena cava Explanation: . The resulting dysentery-like inflammatory diarrhea generally necessitates vigilant hydration. Internal carotid artery D. Cavernous sinus B. Villous atrophy. a destructive fungal infection of the sinuses. but no antibiotics are indicated. classically associated with strain O157:H7 and present in undercooked hamburgers. but rather is pathogenic through its capacity to invade the colonic mucosa and evoke an inflammatory response. Enteropathogenic E. an important cause of traveler's diarrhea. mucosal thinning. Superior sagittal sinus E. Enterohemorrhagic E. coli (EIEC. choice B). choice C) does not express a toxin. External carotid artery C. resulting in a mild and self-limited secretory diarrhea. expresses a Shiga-like toxin that causes bloody diarrhea and hemolyticuremic syndrome. coli (ETEC). Although occasionally found in patients with chronic diarrhea. resulting in impaired absorption and diarrhea. no clear mechanism for mucosal pathophysiology has been determined for EAEC. coli (EPEC. Zygomycosis. the intestinal mucosa overexpresses cAMP.86 Explanation: The correct answer is E. coli (EHEC. but is seen to cluster over the colonic mucosa in some individuals. is likely to reach the brain by which of the following routes? A. coli (EAEC. Enteroinvasive E. Enterotoxigenic E. and inflammation in the lamina propria. but adheres tightly to the glycocalyx of the colonic mucosa and disrupts the microvilli. Consequently. choice A) does not express a toxin. produces a toxin that activates intestinal adenylate or guanylate cyclase. choice D) does not produce any known toxins.

The cavernous sinuses are located on either side of the body of the sphenoid bone.87 The correct answer is A. The route from the face to the brain is not arterial (choices B and C). and myalgia. Which of the following techniques would be most helpful for the diagnosis of this patient? A. The patient probably has trichinosis. Trichinosis is uncommon in this country because the organisms are usually found in pork and can be killed by adequate cooking. can produce either CNS infection or cavernous sinus thrombosis. eosinophilia.. from which it eventually drains into the jugular vein. Scotch tape test D. and become a potential route of infection because they receive blood both from the face (via the ophthalmic veins and sphenoparietal sinus) and some of the cerebral veins. both of which are potentially fatal. periorbital edema. Stool for ova E. The spread of infection. especially by Mucor sp. Muscle biopsy C. She does not remember eating anything unusual recently. Cases in the United States are usually due to tasting of raw pork . The superior sagittal sinus (choice D) is located in the falx cerebri. A farmer's wife develops abdominal pain and diarrhea. into the cavernous sinus. followed several days later by fever. Gastric biopsy B. and drains venous blood from the brain to other dural sinuses. The superior vena cava (choice E) drains blood from the upper part of the body into the heart. Zygomycosis does not reach the brain by way of the superior sagittal sinus. Stool for protozoal parasites Explanation: The correct answer is B. but notes that she does make her own pork sausage. the diagnosis is confirmed by demonstration of cysts in a muscle biopsy.

By transcription from proviral DNA G. Multiple small vesicular lesions are visible in this area on an erythematous base. Some of the lesions are fluid-filled. The scotch tape test (choice C) is for Enterobius (pinworms). By transcribing the genomic DNA F. The organism is not usually demonstrated in stool (choices D and E) or gastric biopsies (choice A). On examination. By producing a negative sense intermediate D. Positive RNA viruses use direct translation from the genome (choice A) to make protein. . The genomic RNA is used directly on the ribosome Explanation: The correct answer is E. a stress-activated secondary disease caused by reactivation herpes zoster. He has been receiving external beam radiation to spinal metastases of his prostate cancer for the past several weeks. Retroviruses produce a double-stranded DNA intermediate (choice B) to effect genomic duplication. By producing a double-stranded DNA intermediate C.88 sausage (for seasoning purposes) or ingestion of poorly cooked bear meat. Herpesviruses are DNA viruses that use the mechanisms used by our own cells to transcribe an RNA strand from their genomic DNA and use the transcribed RNA as messenger RNA. By direct translation from the genome B. there is marked tenderness along the right side of the chest wall in a 4-6 cm stripe from the midline to the flank. and some are crusted. How do members of the virus family responsible for his condition produce messenger RNA? A. not messenger RNA. By producing a positive sense intermediate E. A 70-year-old man with a history of prostate cancer presents with a chief complaint of pain on the right side of his chest for the past several days. This is a classic case of shingles.

gram-positive cocci D. Pulmonary symptoms are consistent with ARDS. negative sense intermediate (choice C) to produce a Negative sense RNA viruses produce a positive sense intermediate (choice D) to produce messenger RNA and a genomic duplicate. or Moraxella catarrhalis. It is part of the normal flora of the GI tract. E. gram-positive diplococci E. coli is a gramnegative rod. gram-negative rods C. and Kingella kingae are gramnegative . Moraxella spp.89 Positive sense RNA viruses produce a genomic duplicate. Transcription from proviral DNA (choice F) is used by the retroviruses to make messenger RNA. The patient described in the history has an obstructive lesion of the urinary tract that predisposes him to the overgrowth of microorganisms such as E. coli. Gram-negative diplococci (choice A) might be Neisseria spp. 37) A 66-year-old man with urinary retention secondary to prostatic hyperplasia develops a spiking fever and tachypnea. or may be asymptomatic. A chest x-ray exhibits bilateral interstitial and alveolar infiltrates.Escherichia coli is a very common pathogen associated with urinary tract infections and is a common cause of cystitis. Blood cultures would most likely reveal A. gram-negative diplococci B. gram-positive rods Explanation: The correct answer is B. sexually active males. Physical exam reveals intercostal muscle retractions and bilateral inspiratory crackles. Patients with cystitis can develop bacteremia and subsequent septic shock and adult respiratory distress syndrome (ARDS). Genomic RNA used directly on the ribosomes (choice G) characterizes the production of messenger RNA by positive sense RNA viruses. Neisseria gonorrhea is the cause of gonorrhea. a sexually transmitted disease that presents with urethritis. Patients are usually younger. Arterial blood gases demonstrate severe hypoxemia.

which is the most common cause of community-acquired pneumonia. rarely cause cystitis. The only significant member of this group to produce urinary tract infections is Corynebacterium urealyticum. such as Staphylococcus aureus and S. epidermidis and Streptococci. jeikeium). E. or as a cause of purulent tracheobronchitis and pneumonia in a population of patients who are over 50 and have underlying obstructive lung disease. Mycobacterium tuberculosis C. N. and the coryneform bacteria. Escherichia coli B. Needle biopsy demonstrates a prominent leukocytic infiltrate with numerous neutrophils. Gram-positive cocci (choice C). sexually active women. but the patients are typically young. Patients are usually immunocompromised or have had recurrent urinary tract infections. gonorrhoeae can produce . Which of the following organisms is the most likely cause of this man's infection? A. Listeria. Neisseria gonorrhoeae D. 38) A sexually active 25-year-old man develops epididymitis and orchitis. Pseudomonas sp. Treponema pallidum Explanation: The correct answer is C. Gram-positive diplococci (choice D) would be a description of Streptococcus pneumoniae. Gram-positive rods (choice E) would include members of the following genera: Clostridium. Staphylococcus saprophyticus causes urinary tract infections.90 cocci that can cause a wide variety of infections. Acute epididymitis and orchitis with prominent neutrophils in a sexually active male are most likely due to infection with Neisseria gonorrhoeae or Chlamydia trachomatis. (C. Moraxella catarrhalis is usually implicated as a cause of otitis media and sinusitis in children. The organism creates an alkaline urine environment with the potential for stone formation. Bacillus.

Streptococcus pneumoniae Explanation: The correct answer is E. Mycobacterium tuberculosis(choice B) can cause tuberculosis of the epididymis and testes. Treponema pallidum(choice E). but are not the most frequent causes. and Haemophilus influenzae. Pseudomonas sp. B. When community-acquired pneumonia occurs in elderly patients or patients with comorbidity. aerobic gram-negative bacilli and Staphylococcus aureus are added to the list. and/or a prominent plasma cell infiltrate.91 a nonspecific pattern of acute inflammation (nonspecific epididymitis and orchitis) or can be sufficiently severe as to cause frank abscesses within the epididymis. The organisms listed in choices A. Chlamydia pneumoniae. Escherichia coli(choice A) is an important cause of nonspecific epididymitis and orchitis in children with congenital genitourinary abnormalities and in older men. can cause testicular involvement with gumma formation. Staphylococcus aureus E. endarteritis. Other organisms frequently implicated in patients less than age 60 without comorbidity include Mycoplasma pneumoniae. Haemophilus influenzae C. respiratory viruses.(choice D) has been implicated as an important cause of nonspecific epididymitis and orchitis in older men. the causative agent of syphilis. . Chlamydia pneumoniae B. Streptococcus pneumoniae. Mycoplasma pneumoniae D. Which of the following organisms is the most common cause of community-acquired pneumonia? A. The most common bacteria implicated in community-acquired pneumonia is the pneumococcus. and C are important causes of community-acquired pneumonia. characterized by granuloma formation.

Herpes simplex type II .Entamoeba histolytica is an intestinal amoebic parasite that either can cause relatively mild diarrhea. but would not be expected to cause a liver abscess. Physical examination demonstrates a large. Which of the following viruses is the most likely pathogen in this setting? A. Trichomonas vaginalis(choice E) is not a cause of diarrhea. A patient with a history of chronic diarrhea and bloody stools presents to the emergency department with right upper quadrant pain and fever.92 Staphylococcus aureus(choice D) is an important cause of community-acquired pneumonia (particularly in the elderly and in patients with comorbidity). Entamoeba histolytica C. Eastern equine encephalitis virus B. causing dysentery (bloody diarrhea with abdominal pain and dehydration). or can behave more aggressively. Giardia lamblia D. or liver abscess formation (such as this patient has). Cryptosporidium parvum B. Giardia lamblia(choice C). Trichomonas vaginalis Explanation: The correct answer is B. Treatment is with metronidazole. but instead causes vaginitis. and Isospora belli(choice D) can cause chronic diarrhea. tender liver. with a severe. A neonate is born in very poor condition. peritonitis. generalized encephalitis. Isospora belli E. but is not the most frequent cause. Which of the following would be most likely to have caused the patient's problems? A. Cryptosporidium parvum(choice A).

They all were served the daily luncheon special. Poliomyelitis virus (choice D) is a gastrointestinally transmitted virus that is not usually encountered in neonates (or anyone else in the U. EHEC (Enterohemorrhagic E. Bacillus cereus B.S. abdominal pain.93 C. which consisted of sweet and sour pork with vegetables and fried rice. Which of the following is the most likely cause of these symptoms? A. and focal neurologic problems. Eastern equine encephalitis virus (choice A) and St. Herpes zoster-varicella virus D. currently). Staphylococcus aureus . is not usually a cause of neonatal encephalitis. unlike herpes simplex. St. coli) E. Louis encephalitis virus Explanation: The correct answer is B. Viral causes of neonatal encephalitis include three members of the herpes family of viruses: herpes simplex I. Herpes zoster-varicella virus (choice C). Poliomyelitis virus E. and cytomegalovirus. and diarrhea within 6 hours of eating lunch. 39) A 15-year-old high school student and several of her friends ate lunch at a local Chinese restaurant. seizures. Clostridium perfringens D. Louis encephalitis virus (choice E) are causes of epidemic encephalitis but are not the most likely cause of neonatal encephalitis. All three types can have devastating effects on the neonate. Acyclovir may be of some help in modifying these infections. but both treatment and prognosis remain very problematic. herpes simplex II. Clostridium botulinum C. vomiting. with extensive CNS damage leading to mental retardation. All of the girls developed nausea.

Clostridium botulinum(choice B) produces a neurotoxin that blocks the release of acetylcholine. shrimp. and abdominal pain followed by diarrhea beginning 1-6 hours after ingestion of the enterotoxin.Bacillus cereus produces a self-limited diarrhea due to ingestion of the preformed enterotoxin in contaminated fried rice and seafood. Vibrio cholerae(choice F) typically produces a watery. milk shakes. vomiting. cholerae called non-01 is also found along the Gulf coast. which causes germination of the clostridial spores. Some patients develop a life-threatening complication called hemolytic-uremic syndrome. The organism is found in foods such as potato salad. and dysphonia. dysphagia. The degree of vomiting is greater than the diarrhea. resulting in a symmetric descending paralysis that may lead to respiratory complications causing death.S. and then warmed. and mayonnaise. non-bloody diarrhea with flecks of mucus (rice-water stools). The incubation period is typically around 4 hours. Most cases are associated with the ingestion of contaminated home-canned food. Vibrio cholerae Explanation: The correct answer is A. Staphylococcus aureus(choice E) produces a self-limited food poisoning syndrome with nausea. EHEC-Enterohemorrhagic E. photophobia. A strain of V. The 0157:H7 serotype typically produces this syndrome. Clostridium perfringens(choice C) produces a severe diarrhea with abdominal pain and cramping (sometimes called "church picnic" diarrhea). custard. The incubation period is 8-24 hours after ingesting contaminated meat. Abdominal pain is not a feature. In the U. produces a bloody. or poultry. producing a corneal ring abscess.. nausea. cases of cholera (El Tor 01 strain) are associated with the Gulf coast and ingestion of poorly cooked or poorly stored crabs. . cereus is also associated with keratitis. meat products. vomiting. non-invasive diarrhea due to the ingestion of verotoxin found in undercooked hamburger at fast food restaurants.94 F. or oysters. Massive fluid loss and electrolyte imbalance are complications. B. Symptoms include blurred vision. The meats have usually been cooked. coli(choice D). allowed to cool.

pulmonary edema. Episodes occur with an irregular periodicity with fever spikes at 48-hour intervals during symptomatic periods. which has a propensity for being severe and having life-threatening complications. Falciparum malaria may have very severe anemia with hemoglobin less than 5 g/dL and more than half of the erythrocytes bearing parasites. Plasmodium malariae D. Plasmodium ovale E. Babesia microti(choice A) is an intraerythrocytic parasite that causes relatively mild. self-limited disease called babesiosis. The man subsequently develops a disabling illness complicated by severe anemia. who examines him. and cerebral malaria. Plasmodium malariae(choice C) causes relatively mild malaria characterized by fever spikes with a 72-hour periodicity. hypoglycemia. . and A 29-year-old news correspondent returns from covering an earthquake and its aftermath in a third world country. Which of the following organisms is the most likely pathogen? A. Complications of this form of malaria include pulmonary edema. experience fever. shock. The exception is malaria caused by Plasmodium falciparum (sometimes still called malignant tertian malaria). Plasmodium vivax Explanation: The correct answer is B. and shock. copious watery diarrhea. renal failure with or without hemoglobinuria. so he consults a physician. but decides not to admit him to the hospital. Plasmodium falciparum C.95 Patients who ingest contaminated shellfish abdominal cramps within 48 hours after eating. renal failure. Babesia microti B. The man feels tired and has sore muscles. Most forms of malaria cause chronic disease with significant morbidity but very little mortality.

they both have a DNA genome. Hepatitis C (choice B) is an enveloped. not the intestinal tract. as all vaccinated infants will shed virus for a period of time after immunization with OPV. single-stranded +RNA virus. its major target organ is the liver. so the decision is made to defer further immunizations. The live virus vaccine had colonized the intestinal tract of the infant and was still being shed 2 weeks after the earlier oral dose. Bacteriologic examination of a stool culture is unremarkable. nonenveloped) and hence will not be inactivated by lipid solvents such as ether. The viral isolate was not inactivated by ether. however. Hepatitis C C. Poliovirus. is likely to be found in sewage. A 9-month-old infant is brought to the Health Department to receive the second dose of OPV (oral polio vaccine) 2 weeks after the first vaccination.96 Plasmodium ovale(choice D) and Plasmodium vivax(choice E) cause relatively mild malaria characterized by fever spikes with a 48-hour periodicity. Adenovirus B. Parvovirus B19 D.. which is a single-stranded +RNA virus. This same agent was isolated from sewage effluent the preceding week. This same virus. however. . It is a fragile agent that does not survive well outside the body and would not be isolated from raw sewage effluent. single-stranded. is naked (i. The child has mild diarrhea. Rotavirus Explanation: The correct answer is D. a small. the vaccine strain. Adenoviruses (choice A) and parvovirus B19 (choice C) also may cause diarrheal disease and both are non-enveloped. Poliovirus E. positive RNA virus is isolated from the specimen.e. Which of the following viruses was most likely isolated? A.

and inguinal adenopathy is evident. the man is afebrile. is double-stranded. This virus causes hospitalization of 30% to 40% of the infected infants and kills hundreds of thousands of infants in developing nations where access to hospitals is not readily available. Iodine-staining intracellular inclusion bodies (choice B) would be found with genital lesions of Chlamydia trachomatis. A 24-year-old male Asian immigrant presents with an ulcerative genital lesion. as such. Epithelial cells with intranuclear inclusion bodies B. Spirochetes visible by darkfield microscopy Explanation: The correct answer is E. Therapy for the watery diarrhea produced by this agent is fluid and electrolyte replacement. Iodine-staining intracellular inclusion bodies C. but these lesions would not have the appearance described in this case history. which eventually became ulcerated and painful. Koilocytotic squamous epithelial cells D. It is a member of the reovirus family and. but this lesion is generally nonpainful. the causative agent of lymphogranuloma venereum. The lesion first appeared 1 month ago as a papule with an erythematous base. Epithelial cells with intranuclear inclusion bodies (choice A) would be found with herpes simplex infections. a pleomorphic gram-negative rod that displays a characteristic pattern on Gram's stained slides. . Pleomorphic gram-negative rods in a "school of fish" pattern F. Which of the following would be the most likely microscopic finding in a scraping from the rash? A. Neutrophils containing gram-negative diplococci E.97 Rotavirus (choice E) is the major cause of diarrheal disease in infants under the age of 2 years. A tender ulcerative lesion is present on his prepuce. caused by Haemophilus ducreyi. On physical examination. This is a typical case description of chancroid. Koilocytotic squamous epithelial cells (choice C) would be found in infections with human papilloma virus (HPV).

This organism is a non-fermenter. A gram-negative. non-fermenting rod is isolated from his sputum. it does not metabolize sugars by classic pathways. Spirochetes (choice F) would be found on darkfield microscopy if this were a case of syphilitic chancre. Pseudomonas aeruginosa E. 40) A burn patient at the university hospital has been progressively deteriorating. It may also cause cystitis in patients with urinary catheters and pneumonia in patients with cystic fibrosis. in whom it classically causes secondary wound infections and septicemia. that is. It produces a blue-green. water-soluble pigment (pyocyanin). Escherichia coli B. The organism most likely isolated is A. Escherichia coli(choice A) is a lactose-fermenting. Serratia marcescens Explanation: The correct answer is D. Klebsiella pneumoniae C. It produces a blue-green pigment on growth media and has a grape-like fruity odor.98 which is associated with venereal warts. but that chancre would be hard and nontender. for which he was intubated and is now ventilatordependent. but the case symptoms are not consistent with this disease. gram-negative rod commonly seen as normal flora of the . and has a fruity odor when grown on laboratory media. He was catheterized for several days and developed a severe pneumonia. Pseudomonas aeruginosa is a very common opportunist in burn patients. Neutrophils containing gram-negative diplococci (choice D) would be found if this were gonorrhea. Legionella pneumophila D. The organism is found in water and usually gains access to the body as a contaminant in the water used in respirators or in water baths used to cleanse wounds.

but identification is usually accomplished by immunofluorescent examination of the pulmonary specimen. Citrobacter diversus B. or orange. Providencia stuartii D. 41) A 57-year-old fisherman with a history of alcoholism is hospitalized in Gulfport. watery diarrhea after eating several raw oysters. Enterotoxigenic E. It is an opportunistic pathogen that causes respiratory disease in hospitalized patients. he becomes severely hypotensive and dies. Interestingly. It is also the major cause of traveler's diarrhea and is a very important pathogen in neonates who become infected during passage through the birth canal. Which of the following pathogens is the most likely cause of this man's death? A. Serratia marcescens(choice E) is a gram-negative organism that is found in water. gram-negative respiratory pathogen that may cause either a fulminating disease or a mild "walking pneumonia-like" condition (i. Legionella pneumophila(choice C) is a fastidious. It is a common cause of aspiration pneumonia and pulmonary abscesses in alcoholics and patients with chronic obstructive pulmonary disease. coli C. pink. Vibrio cholerae E. highly encapsulated rod that is a significant pulmonary pathogen in individuals with a respiratory compromise.99 intestine of man. Klebsiella pneumoniae(choice B) is a gram-negative. It is the most common cause of urinary bladder infections. Vibrio vulnificus . pyelonephritis. and as an occasional normal flora of humans. but the colonies are usually red.e. He is badly dehydrated on admission. Mississippi with a 1day history of severe. and within 12 hours. soil.. Many strains produce a pigment. and sepsis in patients with indwelling urinary catheters. the pathogenic varieties are most often non-pigmented. The organism is readily grown on standard laboratory media such as blood agar or MacConkey's enteric agar. an atypical pneumonia). The organism can be cultured on a charcoal yeast extract medium.

Citrobacter diversus(choice A) produces neonatal meningitis and can be frequently cultured from the umbilicus. Which of the following is an accurate description of the morphology of the infectious form of the organism responsible for the man's illness? A. Cerebrospinal fluid (CSF) reveals 4 WBC. Broad-based. coli(choice B) produces the classic traveler's diarrhea. A 38-year-old AIDS patient presents to his physician's office in Kansas City. diabetes mellitus. Vibrio cholerae(choice D) produces a non-invasive. cellulitis.100 Explanation: The correct answer is E. Current medications are trimethoprim/sulfa and indinavir. non-inflammatory. and immunosuppression.Vibrio vulnificus is an extremely invasive organism. Enterotoxigenic E. Encapsulated budding yeasts E. or causing wound infections. Providencia stuartii(choice C) is a gram-negative rod related to Proteus. Patients at high risk for septicemia include those with liver disease. complaining of fever for the past week and an increasing headache. budding yeasts B. Missouri. fasciitis. His past medical history is significant for Pneumocystis pneumonia and a total CD4 count of 89. Cylindrical arthroconidia D. hemochromatosis. congestive heart failure. Budding yeasts in a "pilot's wheel" arrangement C. high-volume secretory diarrhea that is toxin-mediated. The diarrhea is non-inflammatory and treatment is supportive. It is a common cause of nosocomial bacteremia in nursing home patients with chronic catheterization. The toxin is ingested in water and salads. He also states that sunlight hurts his eyes and that he has been feeling nauseated and weak. The incubation period is approximately 12 hours. renal failure. and myositis after exposure to seawater or after cleaning shellfish. and budding encapsulated yeast forms grow on Sabouraud's agar. Filamentous molds . producing a septicemia in patients after eating raw shellfish.

S. unlike many of the classic pathogens within the fungal group. Filamentous molds (choice E) are the transmission forms of several of the fungal agents (eg. and diagnostic form (encapsulated yeast). geographic area (Mississippi and Missouri river beds). budding yeasts (choice A) would be the forms expected to be found in clinical specimens (not environmental forms) from patients infected with Blastomyces dermatitidis. Budding yeasts in a "pilot's wheel" arrangement (choice B) would be the form expected to be found in clinical specimens (not environmental forms) from patients infected with Paracoccidioides brasiliensis. which is not an encapsulated yeast in spite of its name. Broad-based. This is a classic case of Cryptococcus neoformans meningitis. Septate hyphae with microconidia and macroconidia (choice F) are the transmission (environmental) forms of Histoplasma capsulatum. so the encapsulated yeast form would be found both in clinical specimens and in the environment as the infectious form. Blastomyces. which is limited in geographic region to Central and South America and typically presents as a primary pulmonary disease. (San Joaquin valley fever). It is primarily a pulmonary infection acquired by exposure to the droppings of birds or bats. . Cylindrical arthroconidia (choice C) would be the transmission forms characteristic of Coccidioides immitis. but is geographically restricted to the sub-Sonoran desert zone of the U. Coccidioides. Paracoccidioides) but Cryptococcus does not have a filamentous form. Clues included the patient population (HIV positive). which may be a cause of fungal meningitis in immunologically compromised individuals.101 F. Cryptococcus is a monomorphic fungus. which is far more likely to present with skin and bone lesions than with meningitis. Septate hyphae with microconidia and Explanation: macroconidia The correct answer is D.

102 .

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