Cardiology
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
146. A 60-year-old male patient on aspirin, nitrates, and a beta blocker,
being followed for chronic stable angina, presents to the ER with a history
of two to three episodes of more severe and long-lasting anginal chest pain
each day over the past 3 days. His ECG and cardiac enzymes are normal.
The best course of action of the following is to
a. Admit the patient and begin intravenous digoxin
b. Admit the patient and begin intravenous heparin
c. Admit the patient and give prophylactic thrombolytic therapy
d. Admit the patient for observation with no change in medication
e. Discharge the patient from the ER with increases in nitrates and beta blockers
147. A 60-year-old white female presents with epigastric pain, nausea and
vomiting, heart rate of 50, and pronounced first-degree AV block on ER
cardiac monitor. Blood pressure is 130/80. The coronary artery most likely
to be involved in this process is the
a. Right coronary
b. Left main
c. Left anterior descending
d. Circumflex
148. You are seeing in your office a patient with the chief complaint of relatively
sudden onset of shortness of breath and weakness but no chest
pain. ECG shows nonspecific ST-T changes. You would be particularly
attuned to the possibility of painless, or silent, myocardial infarction in the
a. Advanced coronary artery disease patient with unstable angina on multiple
medications
b. Elderly diabetic
c. Premenopausal female
d. Inferior MI patient
e. MI patient with PVCs
146. The answer is b. (Fuster, 10/e, pp 1246–1264.) This patient presents
with unstable angina, a change from the previous chronic stable state in that
chest pain has become more frequent and more severe. Intravenous heparin
is indicated. Subcutaneous administration of low-molecular-weight heparin
(such as enoxaparin) is an alternative. There is no role for digoxin, as this
may increase myocardial oxygen consumption and exacerbate the situation.
Thrombolytic therapy is reserved for the treatment, typically within 6 h, of
ECG-documented myocardial infarction and does not reduce cardiac events
in the setting of unstable angina. A more aggressive approach is early interventional
cardiac catheterization with angioplasty and/or stent placement,
possibly in conjunction with glycoprotein IIb/IIIa inhibitors.
147. The answer is a. (Fuster, 10/e, pp 52, 88.) The right coronary artery
supplies most of the inferior myocardium and supplies the AV node in over
70% of patients. Thus occlusion of this artery can cause ischemia of the AV
node with AV block or bradycardia, as well as symptoms of an inferior MI
as seen in this patient. AV block can occur with anterior MI related to LAD
occlusion, but this generally implies a greater area of myocardial involvement
and hemodynamic instability.
148. The answer is b. (Braunwald, 15/e, p 1387.) The classic presentation of
acute myocardial infarction (MI) involves heavy or crushing substernal chest
pain or pressure. However, 15 to 20% of infarctions may be painless, with
the greatest incidence in diabetics and the elderly. Dyspnea or weakness may
initially predominate in these patients. Other presentations include altered
mental status, the appearance of an arrhythmia, or hypotension. Diabetics
are likely to have abnormal or absent pain response to myocardial ischemia
due to generalized autonomic nervous system dysfunction. The other choices
have no specific link to greater likelihood of a silent MI.
149. A 75-year-old African American female is admitted with acute
myocardial infarction and congestive heart failure, then has an episode of
ventricular tachycardia. She is prescribed multiple medications and soon
develops confusion and slurred speech. The most likely cause of this confusion
is
a. Captopril
b. Digoxin
c. Furosemide
d. Lidocaine
e. Nitroglycerin
150. Two weeks after hospital discharge for documented myocardial
infarction, a 65-year-old returns to your office very concerned about lowgrade
fever and pleuritic chest pain. There is no associated shortness of
breath. Lungs are clear to auscultation and heart exam is free of significant
murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital.
The most effective therapy is likely
a. Antibiotics
b. Anticoagulation with warfarin (Coumadin)
c. An anti-inflammatory agent
d. An increase in antianginal medication
e. An antianxiety agent
151. A 72-year-old male presents to the ER with the chief complaint of
shortness of breath that awakens him at night and also night cough. Further
questioning confirms recent dyspnea on exertion. As you pursue the
diagnosis of congestive heart failure using the Framingham criteria, you
note the physical exam findings below. Which of the findings is considered
among the less specific minor criteria?
a. Neck vein distention
b. Rales
c. S3 gallop
d. Positive hepatojugular reflux
e. Extremity edema
149. The answer is d. (Fuster, 10/e, pp 902–905.) While the clinical picture
itself could lead to these neurological symptoms, the only cardiovascular
medication on this list likely to do so is lidocaine. Lidocaine is particularly
likely to cause confusion in the elderly patient, for whom a lower dose of
the drug should generally be given. Other potential adverse effects of lidocaine
include tremor, convulsions, respiratory depression, bradycardia, and
hypotension.
150. The answer is c. (Braunwald, 15/e, p 1369.) The history and physical
are consistent with post–cardiac injury syndrome (in the past also known as
Dressler syndrome or postmyocardial infarction syndrome). This generally
benign self-limited syndrome comprises an autoimmune pleuritis, pneumonitis,
or pericarditis characterized by fever and pleuritic chest pain, with
onset days to 6 weeks post cardiac injury with blood in the pericardial cavity,
as after a cardiac operation, cardiac trauma, or MI. Therefore the most
effective therapy is a nonsteroidal anti-inflammatory drug or occasionally a
glucocorticoid. Infection such as bacterial pneumonia, which would require
antibiotics, would typically cause dyspnea, cough with sputum production,
and rales on lung auscultation. Pulmonary embolus, which would require
anticoagulation, would cause dyspnea and tachypnea, often in conjunction
with physical findings of heat, swelling, and pain in the leg consistent with
deep vein thrombosis. Angina or recurrent myocardial infarction is always a
concern post MI (and what the patient usually fears in this situation), but
the nature of the pain—here pleuritic rather than pressurelike—and the
unchanged ECG are fairly reassuring and mitigate against an increase in
antianginal therapy. Anxiety can be present but would not cause fever.
151. The answer is e. (Braunwald, 15/e, pp 1322–1323.) Use of the Framingham
criteria (eight major and seven minor) is one method by which to
organize the signs and symptoms for the diagnosis of congestive heart failure.
Major criteria include paroxysmal nocturnal dyspnea, neck vein distension,
rales, cardiomegaly, acute pulmonary edema, S3 gallop, increased
venous pressure, and hepatojugular reflux. Minor criteria include extremity
edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion,
vital capacity reduced by one-third from normal, and tachycardia of
120 or more beats per minute. In addition, weight loss of 4.5 kg or more
over 5 days of treatment may be considered as a major or minor criterion.
To establish a clinical diagnosis of congestive heart failure, at least one
major and two minor criteria are required
152. A 55-year-old patient presents to you with a history of having
recently had a myocardial infarction with a 5-day hospital stay while away
on a business trip. He reports being told he had mild congestive heart failure
then, but is asymptomatic now with normal physical exam. You recommend
which of the following medications?
a. An ACE inhibitor
b. Digoxin
c. Diltiazem
d. Furosemide (Lasix)
e. Hydralazine plus nitrates
153. A 26-year-old female is referred to you from an OB-GYN colleague
due to the onset of extreme fatigue and dyspnea on exertion 3 months after
her second vaginal delivery. By history, physical, and echocardiogram,
which shows systolic dysfunction, you make the diagnosis of postpartum
cardiomyopathy. Which of the following is correct?
a. Postpartum cardiomyopathy may occur unexpectedly years after pregnancy
and delivery
b. About half of all patients will recover completely
c. Since the condition is idiosyncratic, future pregnancy may be entered into with
no greater than average risk
d. The postpartum state will require a different therapeutic approach than typical
dilated cardiomyopathies
152. The answer is a. (Braunwald, 15/e, pp 1323–1327.) The administration
of an angiotensin converting enzyme inhibitor has been shown to
prevent or retard the development of heart failure in patients with left ventricular
dysfunction and to reduce long-term mortality when begun shortly
after an MI. This relates to inhibition of the renin-angiotensin system and
to reduction of preload and afterload. Other agents that might be considered
for prevention of deterioration of myocardial function include a beta
blocker, an angiotensin II receptor blocker, and/or an aldosterone antagonist
such as spironolactone. General therapeutic measures also include salt
restriction and regular moderate exercise. Digoxin is reserved for those
with clear-cut systolic dysfunction. Calcium channel blockers are not indicated
for heart failure or routinely post MI. Loop or thiazide diuretics are
administered in those with fluid accumulation. The nitrate-hydralazine
combination is an option in ACE inhibitor–intolerant patients.
153. The answer is b. (Fuster, 10/e, p 1958.) Postpartum (or peripartum)
cardiomyopathy may occur during the last trimester of pregnancy or within
6 months of delivery. About half of patients will recover completely, with
most of the rest improving. However, current advice is to avoid future pregnancies
due to risk of recurrence. Treatment is as for other dilated cardiomyopathies,
except that ACE inhibitors are contraindicated in pregnancy.
154. Yesterday you admitted a 55-year-old white male to the hospital due
to chest pain and ruled out MI. The patient tends to be anxious about his
health. On admission, his lungs were clear, and his heart revealed a grade
II/VI systolic crescendo-decrescendo murmur at the upper right sternal
border; cardiac enzymes were normal, and resting ECG showed right bundle
branch block with less than 1 mm ST segment depression. The idea of
performing a routine Bruce protocol treadmill exercise test (stress test) to
further assess coronary artery disease was considered, but rejected primarily
due to which of the following?
a. Anticipated difficulty with the patient’s anxiety (i.e., he might falsely claim chest
pain during the test)
b. Pulmonary embolus suspected as the primary diagnosis
c. Concern about the presence of aortic stenosis, a contraindication to stress testing
d. The presence of RBBB, with this baseline ECG change obscuring typical diagnostic
ST-T changes
e. Concern that this represents the onset of unstable angina with unacceptable
risk of MI with stress testing
154. The answer is c. (Fuster, 10/e, pp 469–470, 475–476.) Cardiac auscultation
suggests aortic stenosis, a contraindication to stress testing. This
could be evaluated further with echocardiography. Anxiety or suspected
angina would not preclude a stress test. Pulmonary embolus is not likely by
history and physical. ST segment depression is the most common stress
test–induced manifestation of myocardial ischemia. This type of change is
difficult to assess in the presence of any bundle branch block in which the
ST segment is already abnormal. However, updated American College of
Cardiology/American Heart Association guidelines do support the use of
exercise stress testing in RBBB if the ST segment depression is 1 mm or less.
Radionuclide imaging would need to be considered to assess for angina in
the setting of LBBB, WPW, paced rhythm, or RBBB with 1 mm resting ST
segment depression.
155. A 75-year-old patient presents to the ER after a sudden syncopal
episode. He is again alert and in retrospect describes occasional substernal
chest pressure and shortness of breath on exertion. His lungs have a few
bibasilar rales, and his blood pressure is 110/80. On cardiac auscultation,
the classic finding you expect to hear is
a. A harsh systolic crescendo-decrescendo murmur heard best at the upper right
sternal border
b. A diastolic decrescendo murmur heard at the mid-left sternal border
c. A holosystolic murmur heard best at the apex
d. A midsystolic click
156. A 72-year-old male comes to the office with intermittent symptoms
of dyspnea on exertion, palpitations, and cough occasionally productive of
blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur
is faintly heard toward the apex. The origin of the patient’s problem probably
relates to
a. Rheumatic fever as a youth
b. Long-standing hypertension
c. Silent MI within the past year
d. Congenital origin
157. You are helping with school sports physicals and see a 13-year-old
boy who has had some trouble keeping up with his peers. He has a cardiac
murmur, which you correctly diagnose as a ventricular septal defect based
on which of the following auscultatory findings?
a. A systolic crescendo-decrescendo murmur heard best at the upper right sternal
border with radiation to the carotids; the murmur is augmented with transient
exercise
b. A systolic murmur at the pulmonic area and a diastolic rumble along the left
sternal border
c. A holosystolic murmur at the mid-left sternal border
d. A diastolic decrescendo murmur at the mid-left sternal border
e. A continuous murmur through systole and diastole at the upper left sternal
border
155. The answer is a. (Braunwald, 15/e, pp 1349–1350.) The classic
symptoms of aortic stenosis are exertional dyspnea, angina pectoris, and
92 Medicine
syncope. Physical findings include a narrow pulse pressure and systolic
murmur as described in option a (rather than the aortic insufficiency murmur
of option b, the mitral regurgitation murmur of option c, or the mitral
valve prolapse click of option d).
156. The answer is a. (Braunwald, 15/e, pp 1343–1345.) The history and
physical exam findings are consistent with mitral stenosis. Dyspnea may be
present secondary to pulmonary edema; palpitations are often related to
atrial arrhythmias (PACs, PAT, atrial flutter or fibrillation); hemoptysis may
occur as a consequence of pulmonary hypertension with rupture of
bronchial veins. A diastolic rumbling apical murmur is characteristic. An
accentuated first heart sound and opening snap may also be present. The
etiology of mitral stenosis is usually rheumatic, rarely congenital. Twothirds
of patients afflicted are women.
157. The answer is c. (Braunwald, 15/e, pp 207–211, 1260–1261,
1335–1336.) A holosystolic murmur at the mid-left sternal border is the
murmur most characteristic of a ventricular septal defect. Both the murmur
of ventricular septal defect and the murmur of mitral regurgitation are
enhanced by exercise and diminished by amyl nitrite. Options a, b, d, and
e describe the usual findings in aortic stenosis, atrial septal defect, aortic
insufficiency, and patent ductus arteriosus, respectively.
Items 158–159
158. A 40-year-old male presents to the office with a history of palpitations
that last for a few seconds and occur two or three times a week. There are no
other symptoms. ECG shows a rare single unifocal premature ventricular
contraction (PVC). The most likely cause of this finding is
a. Underlying coronary artery disease
b. Valvular heart disease
c. Hypertension
d. Apathetic hyperthyroidism
e. Idiopathic or unknown
159. Subsequent 24-h Holter monitoring in the preceding patient confirms
occasional single unifocal PVCs plus occasional premature atrial contractions
(PACs). The best antiarrhythmic management in this case is
a. Anxiolytics
b. Beta blocker therapy
c. Digoxin
d. Quinidine
e. Observation, no medication
158. The answer is e. (Braunwald, 15/e, p 1293.) PVCs are common in
patients with and without heart disease, and are detected in 60% of adult
males on Holter monitoring. Occasional unifocal PVCs do not suggest any
of the underlying diseases described.
159. The answer is e. (Braunwald, 15/e, p 1294.) Minimally symptomatic
PVCs do not require treatment. Antiarrhythmic therapy in this setting has
not been shown to reduce sudden cardiac death or overall mortality. A beta
blocker would be the best choice if symptoms began to interfere with daily
activities.
160. An active 78-year-old female has been followed for hypertension but
presents with new onset of mild left hemiparesis and the finding of atrial
fibrillation on ECG, which persists throughout the hospital stay. She had
been in sinus rhythm 6 months earlier. Optimal treatment by the time of
hospital discharge includes antihypertensives plus
a. Close observation
b. Permanent pacemaker
c. Aspirin
d. Warfarin (Coumadin)
e. Subcutaneous heparin
Items 161–162
161. A 36-year-old white female nurse comes to the ER due to a sensation
of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure
is 110/70. The following rhythm strip is obtained, which shows
a. Atrial fibrillation
b. Atrial flutter
c. Supraventricular tachycardia
d. Ventricular tachycardia
162. The initial pharmacologic therapy of choice in this stable patient is
a. Adenosine 6 mg rapid IV bolus
b. Verapamil 2.5 to 5 mg IV over 1 to 2 min
c. Diltiazem 0.25 mg /kg IV over 2 min
d. Digoxin 0.5 mg IV slowly
e. Lidocaine 1.5 mg /kg IV bolus
f. Electrical cardioversion at 50 joules
160. The answer is d. (Braunwald, 15/e, p 1296.) Aspirin alone might be
sufficient for a stroke patient without the complicating factor of atrial fibrillation.
However, in patients with atrial fibrillation, in whom the risk of stroke
approaches 30%, therapeutic anticoagulation with warfarin (Coumadin)
reduces the incidence of future stroke to a greater extent than the use of
aspirin. This particular patient may be a candidate for medical or electrical
cardioversion, which requires pretreatment with Coumadin for 3 weeks (if
the atrial fibrillation has been present for over 48 h or is of unknown onset).
Alternatively, a transesophageal echocardiogram (TEE) could be performed
to exclude the presence of left atrial thrombus, followed by cardioversion and
then maintenance warfarin anticoagulation for 4 weeks.
161. The answer is c. (Fuster, 10/e, pp 809–812, 820–825, 837–841.)
Paroxysmal supraventricular tachycardia due to AV nodal reentry typically
displays a narrow QRS complex without clearly discernable P waves, with
a rate in the 160 to 190 range. The atrial rate is faster in atrial flutter, typically
with a classic sawtooth pattern of P waves, with AV conduction ratios
most commonly 2:1 or 4:1, leading to ventricular rates of 150 or 75/min.
Atrial fibrillation would show an irregularly irregular rhythm. Wide QRS
complexes would be expected in ventricular tachycardia.
162. The answer is a. (Fuster, 10/e, pp 812–815.) Vagotonic maneuvers
such as carotid massage or the Valsalva maneuver could certainly be tried
first. If these are unsuccessful, adenosine, with its excellent safety profile
and extremely short half-life, is the drug of choice for supraventricular
tachycardia at an initial dose of 6 mg. Dosage can be repeated if necessary a
few minutes later at 12 mg. Verapamil is the next alternative; if the initial
dose of 2.5 to 5 mg does not yield conversion, one or two additional boluses
10 min apart can be used. Diltiazem and digoxin may be useful in rate
control and conversion, but have a much slower onset of action. Electrical
cardioversion would be reserved for hemodynamically unstable patients.
Lidocaine is useful in ventricular, not supraventricular, arrhythmias.
163. A 65-year-old man with diabetes, on an oral hypoglycemic, presents
to the ER with a sports-related right shoulder injury. His heart rate was
noted to be irregular and the following ECG was obtained. The best immediate
therapy is
a. Atropine
b. Isoproterenol
c. Pacemaker
d. Electrical cardioversion
e. Digoxin
f. Diltiazem
g. Observation
164. While at the grocery store, you see an elderly lady slump to the floor.
Going to her aid, your first step in Adult Basic Life Support (CPR) should
be the following
a. Check for a carotid pulse
b. Assess breathing
c. Establish an airway
d. Determine responsiveness
e. Institute chest compression
165. In the ICU, a patient suddenly becomes unresponsive, pulseless, and
hypotensive, with cardiac monitor indicating ventricular tachycardia. The
crash cart is immediately available. The first therapeutic step among the
following should be
a. Amiodarone 300 mg IV push
b. Lidocaine 1.5 mg /kg IV push
c. Epinephrine 1 mg IV push
d. Defibrillation at 200 joules
e. Defibrillation at 360 joules
163. The answer is g. (Braunwald, 15/e, p 1287.) This ECG shows Mobitz
type I second-degree AV block, also known as Wenckebach phenomenon,
characterized by progressive PR interval prolongation prior to block of an
atrial impulse. This rhythm generally does not require therapy. It may be
seen in normal individuals; other causes include inferior MI and drug
intoxications such as from digoxin, beta blockers, or calcium channel
blockers. Even in the post-MI setting, it is usually stable, although it has
the potential to progress to higher-degree AV block with consequent need
for pacemaker.
164. The answer is d. (Cummins, 1/e, pp 5–6.) One cannot automatically
assume initially that an individual has had a cardiac or respiratory arrest.
Therefore, first determine responsiveness by tapping or gently shaking the
victim and shouting, “Are you OK?” Then proceed with the ACLS
approach. Shout or phone for help, then position the victim and yourself.
Follow this with the ABCDs (establishing the Airway, assessing Breathing,
assessing Circulation, and managing any need for Defibrillation).
165. The answer is d. (Cummins, 1/e, pp 77–78, 82–83.) The standard
approach to ventricular fibrillation or pulseless ventricular tachycardia
involves defibrillation with 200 joules, then 300, then 360, followed if
needed by epinephrine 1 mg IV push every 3 to 5 min. Persistent ventricular
fibrillation or pulseless ventricular tachycardia leads to consideration
of amiodarone 300 mg IV push or lidocaine 1.0 to 1.5 mg/kg IV push. In
addition, magnesium sulfate 1 to 2 g IV may be given in torsade de pointes
or when arrhythmia due to hypomagnesemia is suspected. Procainamide
up to 50 mg/min (maximum total 17 mg/kg) is given to patients with intermittent
return of a pulse or non-VF rhythm, but then recurrence of VF/VT.
A precordial thump may be considered in this setting, but there is insufficient
evidence to recommend its use or avoidance.
166. A 55-year-old African American female presents to the ER with
lethargy and blood pressure of 250/150. Her family members indicate that
she was complaining of severe headache and visual disturbance earlier in
the day. They report a past history of asthma but no known kidney disease.
On physical exam, papilledema and retinal hemorrhages are present. The
best approach is
a. Intravenous labetalol therapy
b. Continuous-infusion nitroprusside
c. Clonidine by mouth to lower blood pressure slowly but surely
d. Nifedipine sublingually to lower blood pressure rapidly and remove the patient
from danger
e. Further history about recent home antihypertensives before deciding current
therapy
166. The answer is b. (Braunwald, 15/e, p 1428–1429.) This patient manifests
malignant hypertension with diastolic blood pressure 130 and acute
(or ongoing) target organ damage. She shows one subset of such damage,
namely hypertensive encephalopathy, including headache, visual disturbance,
and altered mental status. Immediate therapy with nitroprusside is
indicated in the ICU setting, although it would be avoided if renal insufficiency
were present. Other options include intravenous nitroglycerin or
intravenous enalaprilat. Intravenous labetalol is often used in hypertensive
urgencies, but, as a beta blocker, it is relatively contraindicated in asthma.
An oral medication such as clonidine would be difficult and slow-acting
in a lethargic patient. Sublingual nifedipine is no longer advised due to
increased potential for overshoot hypotension with adverse cardiovascular
events such as MI or stroke, and ischemic optic neuropathy.
Items 167–168
An 18-year-old male complains of fever and transient pain in both knees
and elbows. The right knee was red and swollen for 1 day the week prior
to presentation. On physical exam, the patient has a low-grade fever but
appears generally well. There is an aortic diastolic murmur heard at the
base of the heart. A nodule is palpated over the extensor tendon of the
hand. There are pink erythematous lesions over the abdomen, some with
central clearing. The following laboratory values are obtained:
Hct: 42
WBC: 12,000/L
20% polymorphonuclear leukocytes
80% lymphocytes
ESR: 60 mm/h
The patient’s ECG is shown on the facing page.
167. Which of the following tests is most critical to diagnosis?
a. Blood cultures
b. Antistreptolysin O antibody
c. Echocardiogram
d. Antinuclear antibodies
e. Creatinine phosphokinase
168. Based on the data available, the best approach to therapy is
a. Ceftriaxone
b. Corticosteroids plus penicillin
c. Acetaminophen
d. Penicillin plus streptomycin
e. Ketoconazole
169. A patient has been in the cardiac care unit with an acute anterior
myocardial infarction. He develops the abnormal rhythm shown below.
You should
a. Give digoxin
b. Consult for pacemaker
c. Perform cardioversion
d. Give propranolol
e. Give lidocaine
167–168. The answers are 167-b, 168-b. (Braunwald, 15/e, pp
1340–1342.) This 18-year-old presents with classic features of rheumatic
fever. His clinical manifestations include arthritis, fever, and murmur. A
subcutaneous nodule is noted, and a rash of erythema marginatum is
described. These subcutaneous nodules are pea-sized and usually seen
over extensor tendons. The rash is usually pink with clear centers and serpiginous
margins. Laboratory data shows an elevated erythrocyte sedimentation
rate as usually occurs in rheumatic fever. The ECG shows evidence
of first-degree AV block. An antistreptolysin O antibody is necessary to
diagnose the disease by documenting prior streptococcal infection. Most
experts recommend the use of glucocorticoids when carditis is part of the
picture of rheumatic fever. Therefore, in this patient with first-degree AV
block, corticosteroids would be indicated. Penicillin should also be given
to eradicate group A -hemolytic streptococci.
169. The answer is b. (Braunwald, 15/e, pp 1287–1290.) The ECG shows
complete heart block. Although at first glance the P waves and QRS complexes
may appear related, on closer inspection they are completely independent
of each other, i.e., dissociated. Complete heart block in the setting
of acute myocardial infarction requires at least temporary, and often permanent,
transvenous pacemaker placement. Atropine may be used as a
temporary measure. You would certainly want to avoid digoxin, beta
blockers, or any other medication that promotes bradycardia. There is no
indication on this strip for cardioversion such as for atrial fibrillation/
flutter or ventricular tachycardia/fibrillation. Lidocaine would be relatively
contraindicated in that it might suppress the ventricular pacemaker, leading
to asystole.
Rabu, 07 Mei 2008
Pulmonary Disease Pre test
Pulmonary Disease
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
104. A 50-year-old patient with long-standing chronic obstructive lung
disease develops the insidious onset of aching in the distal extremities, particularly
the wrists bilaterally. There is a 10-lb weight loss. The skin over
the wrists is warm and erythematous. There is bilateral clubbing. Plain film
is read as periosteal thickening, possible osteomyelitis. You should
a. Start ciprofloxacin
b. Obtain chest x-ray
c. Aspirate both wrists
d. Begin gold therapy
105. A patient with low-grade fever and weight loss has poor excursion on
the right side of the chest with decreased fremitus, flatness to percussion,
and decreased breath sounds all on the right. The trachea is deviated to the
left. The most likely diagnosis is
a. Pneumothorax
b. Pleural effusion
c. Consolidated pneumonia
d. Atelectasis
106. A 60-year-old female with a history of urinary tract infection, steroiddependent
chronic obstructive lung disease, and asthma presents with bilateral
infiltrates and an eosinophil count of 15%. The least likely diagnosis is
a. Bronchopulmonary aspergillosis
b. Hypersensitivity pneumonitis
c. Strongyloides hyperinfection syndrome
d. Drug effect of nitrofurantoin
107. A 40-year-old alcoholic develops cough and fever. Chest x-ray shows
an air-fluid level in the superior segment of the right lower lobe. The most
likely etiologic agent is
a. Streptococcus pneumoniae
b. Haemophilus influenzae
c. Legionella
d. Anaerobes
104. The answer is b. (Braunwald, 15/e, pp 2008–2010.) The clinical picture
suggests hypertrophic osteoarthropathy. This process, the pathogenesis
of which is unknown, is characterized by clubbing of digits, periosteal
new bone formation, and arthritis. Hypertrophic osteoarthropathy is associated
with intrathoracic malignancy, suppurative lung disease, and congenital
heart problems. Treatment is directed at the underlying disease
process. While x-rays may suggest osteomyelitis, the process is usually
bilateral and easily distinguishable from osteomyelitis. The first step in
evaluation of this patient is to obtain a chest x-ray looking for lung infection
and carcinoma.
105. The answer is b. (Braunwald, 15/e, pp 1444–1445.) The diagnosis in
this patient is suggested by the physical exam findings. The findings of
poor excursion, flatness of percussion, and decreased fremitus on the right
side are all consistent with a right-sided pleural effusion. A large rightsided
effusion may shift the trachea to the left. Histoplasmosis would be
one possible cause of such an effusion. A pneumothorax should result in
hyperresonance of the affected side. Atelectasis on the right side would
shift the trachea to the right. A consolidated pneumonia would characteristically
result in increased fremitus, flatness to percussion, and bronchial
breath sounds, and would not cause tracheal deviation.
106. The answer is b. (Braunwald, 15/e, pp 1460, 1465.) This 60-year-old
woman has peripheral eosinophilia in association with pulmonary infiltrates.
The differential diagnosis for eosinophilic pneumonia includes allergic
bronchopulmonary aspergillosis, parasitic infections, drug reactions,
and a category of idiopathic disease. Nitrofurdantoin and sulfonamides are
among the drugs most likely to cause eosinophilic pneumonia. Hypersensitivity
pneumonitis may cause bilateral infiltrates, but does not of itself
cause eosinophilia.
107. The answer is d. (Braunwald, 15/e, p 1478.) Of the organisms listed,
only anaerobic infection is likely to cause a necrotizing process. Type III
pneumococci have been reported to cause cavitary disease, but this is
unusual. The location of the infiltrate suggests aspiration, also making
anaerobic infection most likely. The superior segment of the right lower
lobe is the one most likely to develop an aspiration pneumonia.
Items 108–112
Match the disease entity with the type of pleural effusion.
a. pH less than 7.0
b. Right-sided effusion, protein 2.5 g/dL
c. Pleural fluid glucose less than 15 mg/dL
d. Exudate, 100% lymphocytes
e. Bloody effusion
f. Milky appearance
g. Low cholesterol
108. Congestive heart failure (CHOOSE 1 EFFUSION)
109. Tuberculosis (CHOOSE 1 EFFUSION)
110. Empyema (CHOOSE 1 EFFUSION)
111. Rheumatoid arthritis (CHOOSE 1 EFFUSION)
112. Mesothelioma (CHOOSE 1 EFFUSION)
108–112. The answers are 108-b, 109-d, 110-a, 111-c, 112-e.
(Braunwald, 15/e, pp 1513–1515.) The first step in determining the cause of
a pleural effusion is to categorize it as either a transudate or exudate. Transudative
effusions occur when factors alter the formation or absorption of
pleural fluid; exudative effusions occur when local factors produce an
inflammatory process. Exudative effusions have one of the following characteristics:
pleural fluid protein–to–serum protein ratio greater than 0.5,
pleural fluid LDH–to–serum LDH ratio greater than 0.6, or pleural fluid
LDH more than two-thirds the normal upper limit for serum. Congestive
heart failure usually produces a right-sided pleural effusion. Of all the disease
processes listed, it is the only one that usually results in a transudative
effusion.
Tuberculosis causes a hypersensitivity reaction to tuberculous protein
in the pleural fluid. It produces an exudative effusion with small lymphocytes.
The diagnosis is now established by demonstrating high levels of TB
markers such as adenosine deaminase or positive PCR for tuberculous DNA.
Empyema may be defined by the very low pH value. It is an exudative
effusion with a polymorphonuclear leukocyte predominance. A drainage
procedure is usually necessary when the pleural fluid pH is below 7.20,
when there is gross pus, or when the fluid shows a positive gram stain or
culture.
Rheumatoid effusions are often exudative and may be lymphocytic,
but they are best characterized by their very low glucose levels. Pleural
fluid glucose levels below 60 mg/dL also occur in malignancy and bacterial
infections.
Mesotheliomas are primary tumors that arise from mesothelial cells
that line the pleural cavity. They produce a very bloody effusion. Thoracoscopy
or open pleural biopsy are often necessary to make a definitive
diagnosis.
117. A 30-year-old male is admitted to the hospital after a motorcycle
accident that resulted in a fracture of the right femur. The fracture is managed
with traction. Three days later the patient becomes confused and
tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation.
Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49.
The most likely diagnosis is
a. Unilateral pulmonary edema
b. Hematoma of the chest
c. Fat embolism
d. Pulmonary embolism
e. Early Staphylococcus aureus pneumonia
117. The answer is c. (Braunwald, 15/e, p 329.) Because the clinical signs
of neurologic deterioration and a petechial rash have occurred in the setting
of fracture and hypoxia, fat embolism is the most likely diagnosis. This
process occurs when neutral fat is introduced into the venous circulation
after bone trauma or fracture. The latent period is 12 to 36 hours, usually
earlier than a pulmonary embolus would occur after trauma.
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
104. A 50-year-old patient with long-standing chronic obstructive lung
disease develops the insidious onset of aching in the distal extremities, particularly
the wrists bilaterally. There is a 10-lb weight loss. The skin over
the wrists is warm and erythematous. There is bilateral clubbing. Plain film
is read as periosteal thickening, possible osteomyelitis. You should
a. Start ciprofloxacin
b. Obtain chest x-ray
c. Aspirate both wrists
d. Begin gold therapy
105. A patient with low-grade fever and weight loss has poor excursion on
the right side of the chest with decreased fremitus, flatness to percussion,
and decreased breath sounds all on the right. The trachea is deviated to the
left. The most likely diagnosis is
a. Pneumothorax
b. Pleural effusion
c. Consolidated pneumonia
d. Atelectasis
106. A 60-year-old female with a history of urinary tract infection, steroiddependent
chronic obstructive lung disease, and asthma presents with bilateral
infiltrates and an eosinophil count of 15%. The least likely diagnosis is
a. Bronchopulmonary aspergillosis
b. Hypersensitivity pneumonitis
c. Strongyloides hyperinfection syndrome
d. Drug effect of nitrofurantoin
107. A 40-year-old alcoholic develops cough and fever. Chest x-ray shows
an air-fluid level in the superior segment of the right lower lobe. The most
likely etiologic agent is
a. Streptococcus pneumoniae
b. Haemophilus influenzae
c. Legionella
d. Anaerobes
104. The answer is b. (Braunwald, 15/e, pp 2008–2010.) The clinical picture
suggests hypertrophic osteoarthropathy. This process, the pathogenesis
of which is unknown, is characterized by clubbing of digits, periosteal
new bone formation, and arthritis. Hypertrophic osteoarthropathy is associated
with intrathoracic malignancy, suppurative lung disease, and congenital
heart problems. Treatment is directed at the underlying disease
process. While x-rays may suggest osteomyelitis, the process is usually
bilateral and easily distinguishable from osteomyelitis. The first step in
evaluation of this patient is to obtain a chest x-ray looking for lung infection
and carcinoma.
105. The answer is b. (Braunwald, 15/e, pp 1444–1445.) The diagnosis in
this patient is suggested by the physical exam findings. The findings of
poor excursion, flatness of percussion, and decreased fremitus on the right
side are all consistent with a right-sided pleural effusion. A large rightsided
effusion may shift the trachea to the left. Histoplasmosis would be
one possible cause of such an effusion. A pneumothorax should result in
hyperresonance of the affected side. Atelectasis on the right side would
shift the trachea to the right. A consolidated pneumonia would characteristically
result in increased fremitus, flatness to percussion, and bronchial
breath sounds, and would not cause tracheal deviation.
106. The answer is b. (Braunwald, 15/e, pp 1460, 1465.) This 60-year-old
woman has peripheral eosinophilia in association with pulmonary infiltrates.
The differential diagnosis for eosinophilic pneumonia includes allergic
bronchopulmonary aspergillosis, parasitic infections, drug reactions,
and a category of idiopathic disease. Nitrofurdantoin and sulfonamides are
among the drugs most likely to cause eosinophilic pneumonia. Hypersensitivity
pneumonitis may cause bilateral infiltrates, but does not of itself
cause eosinophilia.
107. The answer is d. (Braunwald, 15/e, p 1478.) Of the organisms listed,
only anaerobic infection is likely to cause a necrotizing process. Type III
pneumococci have been reported to cause cavitary disease, but this is
unusual. The location of the infiltrate suggests aspiration, also making
anaerobic infection most likely. The superior segment of the right lower
lobe is the one most likely to develop an aspiration pneumonia.
Items 108–112
Match the disease entity with the type of pleural effusion.
a. pH less than 7.0
b. Right-sided effusion, protein 2.5 g/dL
c. Pleural fluid glucose less than 15 mg/dL
d. Exudate, 100% lymphocytes
e. Bloody effusion
f. Milky appearance
g. Low cholesterol
108. Congestive heart failure (CHOOSE 1 EFFUSION)
109. Tuberculosis (CHOOSE 1 EFFUSION)
110. Empyema (CHOOSE 1 EFFUSION)
111. Rheumatoid arthritis (CHOOSE 1 EFFUSION)
112. Mesothelioma (CHOOSE 1 EFFUSION)
108–112. The answers are 108-b, 109-d, 110-a, 111-c, 112-e.
(Braunwald, 15/e, pp 1513–1515.) The first step in determining the cause of
a pleural effusion is to categorize it as either a transudate or exudate. Transudative
effusions occur when factors alter the formation or absorption of
pleural fluid; exudative effusions occur when local factors produce an
inflammatory process. Exudative effusions have one of the following characteristics:
pleural fluid protein–to–serum protein ratio greater than 0.5,
pleural fluid LDH–to–serum LDH ratio greater than 0.6, or pleural fluid
LDH more than two-thirds the normal upper limit for serum. Congestive
heart failure usually produces a right-sided pleural effusion. Of all the disease
processes listed, it is the only one that usually results in a transudative
effusion.
Tuberculosis causes a hypersensitivity reaction to tuberculous protein
in the pleural fluid. It produces an exudative effusion with small lymphocytes.
The diagnosis is now established by demonstrating high levels of TB
markers such as adenosine deaminase or positive PCR for tuberculous DNA.
Empyema may be defined by the very low pH value. It is an exudative
effusion with a polymorphonuclear leukocyte predominance. A drainage
procedure is usually necessary when the pleural fluid pH is below 7.20,
when there is gross pus, or when the fluid shows a positive gram stain or
culture.
Rheumatoid effusions are often exudative and may be lymphocytic,
but they are best characterized by their very low glucose levels. Pleural
fluid glucose levels below 60 mg/dL also occur in malignancy and bacterial
infections.
Mesotheliomas are primary tumors that arise from mesothelial cells
that line the pleural cavity. They produce a very bloody effusion. Thoracoscopy
or open pleural biopsy are often necessary to make a definitive
diagnosis.
117. A 30-year-old male is admitted to the hospital after a motorcycle
accident that resulted in a fracture of the right femur. The fracture is managed
with traction. Three days later the patient becomes confused and
tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation.
Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49.
The most likely diagnosis is
a. Unilateral pulmonary edema
b. Hematoma of the chest
c. Fat embolism
d. Pulmonary embolism
e. Early Staphylococcus aureus pneumonia
117. The answer is c. (Braunwald, 15/e, p 329.) Because the clinical signs
of neurologic deterioration and a petechial rash have occurred in the setting
of fracture and hypoxia, fat embolism is the most likely diagnosis. This
process occurs when neutral fat is introduced into the venous circulation
after bone trauma or fracture. The latent period is 12 to 36 hours, usually
earlier than a pulmonary embolus would occur after trauma.
Infectious Disease Pre Test
Infectious Disease
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
1. A 30-year-old male patient complains of fever and sore throat for several
days. The patient presents to you today with additional complaints of
hoarseness, difficulty breathing, and drooling. On examination, the patient
is febrile and has inspiratory stridor. Which of the following is the best
course of action?
a. Begin outpatient treatment with ampicillin
b. Culture throat for β-hemolytic streptococci
c. Admit to intensive care unit and obtain otolaryngology consultation
d. Schedule for chest x-ray
2. A 70-year-old patient with long-standing type 2 diabetes mellitus presents
with complaints of pain in the left ear with purulent drainage. On
physical exam, the patient is afebrile. The pinna of the left ear is tender, and
the external auditory canal is swollen and edematous. The peripheral white
blood cell count is normal. The organism most likely to grow from the purulent
drainage is
a. Pseudomonas aeruginosa
b. Staphylococcus aureus
c. Candida albicans
d. Haemophilus influenzae
e. Moraxella catarrhalis
1. The answer is c. (Gorbach, 2/e, pp 542–544.) This patient, with the
development of hoarseness, breathing difficulty, and stridor, is likely to
have acute epiglottitis. Because of the possibility of impending airway
obstruction, the patient should be admitted to an intensive care unit for
close monitoring. The diagnosis can be confirmed by indirect laryngoscopy
or soft tissue x-rays of the neck, which may show an enlarged epiglottis.
Otolaryngology consult should be obtained. The most likely organism
causing this infection is Haemophilus influenzae. Many of these organisms
are β-lactamase-producing and would be resistant to ampicillin. The clinical
findings are not consistent with the presentation of streptococcal
pharyngitis. Lateral neck films would be more useful than a chest x-ray.
2. The answer is a. (Braunwald, 15/e, p 190.) Ear pain and drainage in an
elderly diabetic patient must raise concern about malignant external otitis.
The swelling and inflammation of the external auditory meatus strongly
suggest this diagnosis. This infection usually occurs in older diabetics and
is almost always caused by P. aeruginosa. H. influenzae and M. catarrhalis
frequently cause otitis media, but not external otitis.
Items 3–4
A 25-year-old male student presents with the chief complaint of rash. There
is no headache, fever, or myalgia. A slightly pruritic maculopapular rash is
noted over the abdomen, trunk, palms of the hands, and soles of the feet.
Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic,
flat, wartlike lesions are noted around the anal area. Laboratory
studies show the following:
Hct: 40%
Hgb: 14 g/dL
WBC: 13,000/μL
Diff:
Segmented neutrophils: 50%
Lymphocytes: 50%
3. The most useful laboratory test in this patient is
a. Weil-Felix titer
b. Venereal Disease Research Laboratory (VDRL) test
c. Chlamydia titer
d. Blood cultures
4. The treatment of choice for this patient is
a. Penicillin
b. Ceftriaxone
c. Tetracycline
d. Interferon α
e. Erythromycin
3–4. The answers are 3-b, 4-a. (Braunwald, 15/e, pp 1046–1047.) The diffuse
rash involving palms and soles would in itself suggest the possibility of
secondary syphilis. The hypertrophic, wartlike lesions around the anal area,
called condylomata lata, are specific for secondary syphilis. The VDRL slide
test will be positive in all patients with secondary syphilis. The Weil-Felix
titer has been used as a screening test for rickettsial infection. In this patient,
who has condylomata and no systemic symptoms, Rocky Mountain spotted
fever would be unlikely. No chlamydial infection would present in this way.
Blood cultures might be drawn to rule out bacterial infection such as chronic
meningococcemia; however, the clinical picture is not consistent with a systemic
bacterial infection. Penicillin is the drug of choice for secondary
syphilis. Ceftriaxone and tetracycline are usually considered to be alternative
therapies. Interferon α has been used in the treatment of condyloma acuminata,
a lesion that can be mistaken for syphilitic condyloma.
Items 5–7
A 20-year-old female college student presents with a 5-day history of cough,
low-grade fever (temperature 100�), sore throat, and coryza. On exam,
there is mild conjunctivitis and pharyngitis. Tympanic membranes are
inflamed, and one bullous lesion is seen. Chest exam shows few basilar
rales. Laboratory findings are as follows:
Hct: 38
WBC: 12,000/μL
Lymphocytes: 50%
Mean corpuscular volume (MCV): 83 nL
Reticulocytes: 3% of red cells
CXR: bilateral patchy lower lobe infiltrates
5. The sputum Gram stain is likely to show
a. Gram-positive diplococci
b. Tiny gram-negative coccobacilli
c. White blood cells without organisms
d. Acid-fast bacilli
6. This patient is likely to have
a. High titers of adenovirus
b. High titers of IgM cold agglutinins
c. A positive silver methenamine stain
d. A positive blood culture for Streptococcus pneumoniae
7. Treatment of choice is
a. Erythromycin
b. Supportive therapy
c. Trimethoprim-sulfamethoxazole
d. Cefuroxime
5–7. The answers are 5-c, 6-b, 7-a. (Braunwald, 15/e, pp 1073–1074.)
This young woman presents with symptoms of both upper and lower respiratory
infection. The combination of sore throat, bullous myringitis, and
infiltrates on chest x-ray is consistent with infection due to M. pneumoniae.
This minute organism is not seen on Gram stain. Neither S. pneumoniae nor
H. influenzae would produce this combination of upper and lower respiratory
tract symptoms. The patient is likely to have high titers of IgM cold
agglutinins. The low hematocrit and elevated reticulocyte count reflect a
hemolytic anemia that can occur from mycoplasma infection. These IgMclass
antibodies are directed to the I antigen on the erythrocyte membrane.
The treatment of choice for mycoplasma infection is erythromycin.
Items 8–10
A 19-year-old male presents with a 1-week history of malaise and anorexia
followed by fever and sore throat. On physical examination, the throat is
inflamed without exudate. There are a few palatal petechiae. Cervical
adenopathy is present. The liver is percussed at 12 cm and the spleen is
palpable.
Throat culture: negative for group A streptococci
Hct: 38%
Hgb: 12 g/dL
Reticulocytes: 4%
WBC: 14,000/μL
Segmented: 30%
Lymphocytes: 60%
Monocytes: 10%
Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2)
Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220)
Aspartate (AST): 40 U/L (normal 8 to 20 U/L)
Alanine (ALT): 35 U/L (normal 8 to 20 U/L)
Alkaline phosphatase: 40 IU/L (normal 35 to 125)
8. The most important initial test is
a. Liver biopsy
b. Strep screen
c. Peripheral blood smear
d. Toxoplasmosis IgG
e. Lymph node biopsy
9. The most important serum test is
a. Heterophile antibody
b. Hepatitis B IgM
c. Cytomegalovirus IgG
d. ASLO titer
e. Hepatitis C antibody
10. Corticosteroids would be indicated if
a. Liver function tests worsen
b. Fatigue lasts more than 1 week
c. Severe hemolytic anemia is demonstrated
d. Hepatitis B is confirmed
8–10. The answers are 8-c, 9-a, 10-c. (Braunwald, 15/e, pp 1109–1111.)
This young man presents with classic signs and symptoms of infectious
mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed. The symptoms described in association with atypical lymphocytes and apositive heterophile test are virtually always due to Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruction occurs. Neither fatigue nor the complication of hepatitis is an indication for corticosteroid therapy.
DIRECTIONS: Each group of questions below consists of lettered
options followed by a set of numbered items. For each numbered item,
select the one lettered option with which it is most closely associated. Each
lettered option may be used once, more than once, or not at all.
Items 11–14
Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae
b. Staphylococcus aureus
c. Viridans streptococci
d. Providencia stuartii
e. Actinomyces israelii
f. Haemophilus ducreyi
g. Neisseria meningitidis
h. Listeria monocytogenes
11. A 30-year-old female with mitral valve prolapse and mitral regurgitant
murmur develops fever, weight loss, and anorexia after undergoing a dental
procedure. (CHOOSE 1 ORGANISM)
12. An 80-year-old-male, hospitalized for hip fracture, has a Foley
catheter in place when he develops shaking chills, fever, and hypotension.
(CHOOSE 1 ORGANISM)
13. A young man develops a painless, fluctuant purplish lesion over the
mandible. Cutaneous fistula is noted after several weeks. (CHOOSE 1
ORGANISM)
14. A sickle cell anemia patient presents with high fever, toxicity, signs of
pneumonia, and stiff neck. (CHOOSE 1 ORGANISM)
11–14. The answers are 11-c, 12-d, 13-e, 14-a. (Braunwald, 15/e, pp
809–814, 882–885, 959, 1009, 1620.) The 30-year-old-female with mitral
valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most
cases of subacute bacterial endocarditis. No other agent listed is likely to
cause this infection. The 80-year-old-male with a Foley catheter in place has
developed a nosocomial infection likely secondary to urosepsis. Providencia
species frequently cause urinary tract infection in the hospitalized patient.
The young man with a fluctuant lesion and fistula over the mandible presentsa classic picture of cervicofacial actinomycosis. The sickle cell anemiapatient who presents with concomitant pneumonia and meningitis hasoverwhelming infection with S. pneumoniae due to functional asplenia.
S. pneumoniae causes a particularly severe infection associated with sickle
cell disease.
Items 15–18
Select an antiviral agent for each patient.
a. Ganciclovir
b. Acyclovir
c. Interferon α
d. Didanosine
e. Ribavirin
f. Amantadine
g. Vidarabine
h. Zalcitabine
15. A military recruit develops pneumonia secondary to influenza A.
Symptoms began 24 h prior to physician visit. (SELECT 1 AGENT)
16. An HIV-positive patient with a CD4 count of 50 complains of the
onset of visual blurring; opacity is seen on funduscopic exam. (SELECT 1
AGENT)
17. A sexually active young woman has anogenital warts and requests
intralesional therapy. (SELECT 1 AGENT)
18. An infant with respiratory syncytial virus infection requires mechanical
ventilation. (SELECT 1 AGENT)
15–18. The answers are 15-f, 16-a, 17-c, 18-e. (Braunwald, 15/e, pp
1092–1100.) Amantadine has been shown to alter the course of influenza A
favorably, particularly when begun within 48 h of the start of symptoms.
The HIV-positive patient with a low CD4 count and visual blurring has
developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnethas also been used effectively). Interferon α has been approved for
intralesional therapy of condyloma acuminatum (venereal warts caused by
papillomavirus). Ribavirin improves mortality in mechanically ventilated
infants with RSV infection.
Items 19–21
Select the fungal agent most likely responsible for the disease process
described.
a. Histoplasma capsulatum
b. Blastomycosis dermatitidis
c. Coccidioides immitis
d. Cryptococcus neoformans
e. Candida albicans
f. Aspergillus fumigatus
g. Zygomycosis
19. A young, previously healthy male presents with verrucous skin
lesions, bone pain, fever, cough, and weight loss. Chest x-ray shows nodular
infiltrates. (SELECT 1 AGENT)
20. A diabetic patient is admitted with elevated blood sugar and acidosis.
The patient complains of headache and sinus tenderness and has black,
necrotic material draining from the nares. (SELECT 1 AGENT)
21. A young woman presents with asthma and eosinophilia. Fleeting pulmonaryinfiltrates occur with bronchial plugging. (SELECT 1 AGEnt)
19–21. The answers are 19-b, 20-g, 21-f. (Braunwald, 15/e, pp
1173–1179.) Blastomycosis presents with signs and symptoms of chronic
respiratory infection. The organism has a tendency to produce skin lesions
in exposed areas that become crusted, ulcerated, or verrucous. Bone pain is
caused by osteolytic lesions. Mucormycosis is a zygomycosis that originates
in the nose and paranasal sinuses. Sinus tenderness, bloody nasal discharge,
and obtundation occur usually in the setting of diabetic ketoacidosis.
Aspergillus can result in several different infectious processes, including
aspergilloma, disseminated Aspergillus in the immunocompromised patient,
or allergic bronchopulmonary aspergillosis. Bronchopulmonary aspergillosis
is the most likely diagnosis in the young woman with asthma and
eosinophilia. Bronchial plugs, often filled with hyphal forms, result in
repeated infiltrates and exacerbation of wheezing.
Items 22–24
A 40-year-old male develops bilateral facial weakness after returning from
a camping trip in Wisconsin that lasted 6 weeks. The patient gives a history
of arthralgias. On exam, he cannot close either eye well or raise either eyebrow.
The first heart sound is diminished. There is no evidence of arthritis.
Hgb: 14 g/dL
WBC: 10,000/L
VDRL: negative
FTA-Abs: positive
ECG: first-degree AV block
22. Which of the following would be most useful?
a. CT scan of head
b. MRI of head
c. More detailed history
d. Kveim test
23. The likely cause of these symptoms is
a. Intracranial infection
b. Lyme disease
c. Endocarditis
d. Herpes simplex
Infectious Disease 7
24. Treatment of choice is
a. Penicillin or ceftriaxone
b. Acyclovir
c. Corticosteroids
d. Aminoglycoside
22–24. The answers are 22-c, 23-b, 24-a. (Braunwald, 15/e, pp
1061–1065.) This patient presents with a symptom complex that includes
facial nerve palsies, arthralgia, and first-degree AV block. Facial nerve palsy
has been increasingly recognized as a first manifestation of Lyme disease.
Within several weeks of the onset of illness, about 8% of patients develop
cardiac involvement, with heart block being the most common manifestation.
During this stage of early disseminated infection, musculoskeletal
pain is common. The diagnosis of Lyme disease is based on careful history
and physical exam with serologic confirmation by detection of antibody to
Borrelia burgdorferi. Neither CT or MRI of head would be indicated as the
lesion is a peripheral facial palsy. Sarcoidosis can also cause both facial
nerve palsy and AV block, but it is much less likely, and the Kveim test is
rarely used to pursue this diagnosis. The treatment of choice for Lyme disease
at this stage would be penicillin or ceftriaxone.
25. You are a physician in charge of the patients who reside in a nursing
home. Several of the patients have developed influenza-like symptoms,
and the community is in the midst of an influenza A outbreak. None of the
nursing home residents have received the influenza vaccine. What course
of action is most appropriate?
a. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine (i.e., allergy to eggs)
b. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give amantadine for 2 weeks
c. Give amantadine alone to all residents
d. Do not give any prophylactic regimen
26. An elderly male develops fever 3 days after cholecystectomy. He
becomes short of breath, and chest x-ray shows a new right lower lobe
infiltrate. Sputum Gram stain shows gram-positive cocci in clumps, and
preliminary culture results suggest staphylococci. The initial antibiotic of
choice is
a. Penicillinase-resistant penicillin such as nafcillin
b. Vancomycin
c. Antibiotic therapy should be based on the incidence of methicillin-resistant
staphylococci in that hospital
d. Quinolones have become the drug of choice for pneumonia
27. A 30-year-old male with sickle cell anemia is admitted with cough,
rusty sputum, and a single shaking chill. Physical examination reveals
increased tactile fremitus and bronchial breath sounds in the left posterior
chest. The patient is able to expectorate a purulent sample. Which of the
following best describes the role of sputum Gram stain and culture?
a. Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting
b. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae
c. Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary
d. There is no characteristic Gram stain in a patient with pneumococcal pneumonia
25. The answer is b. (Braunwald, 15/e, pp 1125–1131.) Influenza A is a
potentially lethal disease in the elderly and chronically debilitated patient.
In institutional settings such as nursing homes, outbreaks are likely to be
particularly severe. Thus prophylaxis is extremely important in this setting.
All residents should receive the vaccine unless they have known egg allergy
(patients can choose to decline the vaccine). Since protective antibodies to
the vaccine will not develop for 2 weeks, amantadine can be used for protection
against influenza A during the interim 2-week period. A reduced
dose is given to elderly patients.
26. The answer is c. (Braunwald, 15/e, p 896.) In the treatment of hospitalacquired
staphylococcal pneumonia, the incidence of methicillin-resistant
staph in the local facility will be very important. In most hospitals,
methicillin-resistant staph is common enough to require initial therapy with
vancomycin. Oxacillin would be the drug of choice only if the incidence of
methicillin-resistant staph is very low. Quinolones are often useful in the
treatment of community-acquired pneumonia, but they would not be effective
against methicillin-resistant staph.
27. The answer is b. (Braunwald, 15/e, p 1479.) The Infectious Disease
Society of America’s guidelines on the treatment of community-acquired
pneumonia still recommend the use of sputum gram stain and culture. This
is particularly important in the era of multi-antibiotic-resistant S. pneumoniae.
Sputum culture and sensitivity can direct specific antibiotic therapy for the
patient as well as provide epidemiologic information for the community as a
whole. A good sputum sample showing many polymorphonuclear leukocytes
and few squamous epithelial cells can give important clues to etiology.
A Gram stain that shows gram-positive lancet-shaped diplococci intracellularly
is good evidence for pneumococcal infection. Empirical antibiotic therapy
becomes more difficult in community-acquired pneumonia as more
pathogens are recognized and as the pneumococcus develops resistance to
penicillin, macrolides, and even quinolones.
28. A 30-year-old man who has spent 5 of the last 10 years in prison in New
York City is referred from the prison because of hemoptysis. He has a history of tuberculosis diagnosed 3 years ago and took isoniazid and rifampin for about a month. A cavitary lesion is seen on chest x-ray. The physician should
do all the following except
a. Obtain sputum for acid-fast bacilli (AFB) stain, culture, and sensitivity
b. Start supervised isoniazid and rifampin administration
c. Start a supervised multiple drug combination to treat multidrug-resistant
tuberculosis
d. Place the patient in respiratory isolation
e. Perform routine screening of inmates and staff for tuberculosis
28. The answer is b. (Braunwald, 15/e, pp 1031–1034.) Multidrugresistant
tuberculosis (TB) has become an increasing problem in several
settings, including correctional facilities and health care institutions. Noncompliance
or poor compliance with prescribed anti-TB medications is the
major factor in the development of multiple drug resistance. When the disease
is suspected, patients should be placed in respiratory isolation and
sputum should be obtained for AFB stain, culture, and sensitivity. Treatment
of high-risk patients, such as this patient, should be supervised, and
multidrug resistance should be assumed. Regular screening of inmates and
staff for TB is important for preventing the spread of TB within the facility
and for early diagnosis of new infections.
29. A recent outbreak of severe diarrhea is currently being investigated.
Several children developed bloody diarrhea, and one remains hospitalized
with acute renal failure. A preliminary investigation has determined that all
the affected children ate at the same restaurant. The food they consumed
was most likely to be
a. Pork chops
b. Hamburger
c. Gefilte fish
d. Sushi
e. Soft-boiled eggs
30. A 40-year-old female nurse was admitted to the hospital because of
fever to 103�. Despite a thorough workup in the hospital for over 3 weeks,
no etiology has been found, and she continues to have temperature spikes
greater than 102�. The least likely diagnosis in this patient is
a. Occult bacterial infection
b. Influenza
c. Lymphoma
d. Adult Still’s disease
e. Factitious fever
31. In a patient who has mitral valve insufficiency, which procedure does
not require prophylactic antibiotic therapy?
a. Cardiac catheterization
b. Prostatectomy
c. Cystoscopy
d. Tonsillectomy
e. Periodontal surgery
32. Rabies, an acute viral disease of the mammalian central nervous system,
is transmitted by infective secretions, usually saliva. Which of the following
statements about this disease is correct?
a. The disease is caused by a reovirus that elicits both complement-fixing and
hemagglutinating antibodies useful in the diagnosis of the disease
b. The incubation period is variable, and, although 10 days is the most common
elapsed time between infection and symptoms, some cases remain asymptomatic
for 30 days
c. Only 30% of infected patients will survive
d. In the United States, the skunk and the raccoon have been important recent
sources of human disease
e. Wild animals that have bitten and are suspected of being rabid should be killed
and their brains examined for virus particles by electron microscopy
29. The answer is b. (Braunwald, 15/e, pp 242, 954.) The outbreak
described is similar to those previously attributed to Escherichia coli
0157:H7. Ingestion of and infection with this organism may result in a spectrum
of illnesses, including mild diarrhea, hemorrhagic colitis with bloody
diarrhea, acute renal failure, and death. Infection has been associated with
ingestion of contaminated beef (in particular ground beef), ingestion of raw
milk, and contamination via the fecal-oral route. Cooking ground beef so
that it is no longer pink is an effective means of preventing infection, as are
hand washing and pasteurization of milk.
30. The answer is b. (Stobo, 23/e, pp 547–551.) Patients may develop
fever as a result of infectious or noninfectious diseases. The term fever of
unknown origin (FUO) is applied when significant fever persists without a
known cause after an adequate evaluation. Several studies have found the
leading causes of FUO to include infections, malignancies, collagen vascular
diseases, and granulomatous diseases. As the ability to more rapidly
diagnose some of these diseases increases, their likelihood of causing undiagnosed
persistent fever lessens. Infections such as intraabdominal
abscesses, tuberculosis, hepatobiliary disease, endocarditis (especially if
the patient had previously taken antibiotics), and osteomyelitis may cause
FUO. In immunocompromised patients, such as those infected with HIV, a
number of opportunistic infections or lymphomas may cause fever and
escape early diagnosis. Self-limited infections such as influenza should
not cause fever that persists for many weeks. Neoplastic diseases such as
lymphomas and some solid tumors (e.g., hypernephroma and primary or
metastatic disease of the liver) are associated with FUO. A number of collagen
vascular diseases may cause FUO. Since conditions such as systemic
lupus erythematosus are more easily diagnosed today, they are less frequent
causes of this syndrome. Adult Still’s disease, however, is often difficult to
diagnose. Other causes of FUO include granulomatous diseases (i.e., giant
cell arteritis, regional enteritis, sarcoidosis, and granulomatous hepatitis),
drug fever, and peripheral pulmonary emboli. Factitious fever is most common
among young adults employed in health-related positions. A prior
psychiatric history or multiple hospitalizations at other institutions may be
clues to this condition. Such patients may induce infections by selfinjection
of nonsterile material, with resultant multiple abscesses or
polymicrobial infections. Alternatively, some patients may manipulate their
thermometers. In these cases, a discrepancy between temperature and
pulse or between oral temperature and witnessed rectal temperature will be
observed.
31. The answer is a. (Mandell, 5/e, pp 917–923.) Although no evidence
exists that prophylactic antibiotic therapy prevents endocarditis, prophylaxis
is recommended for all procedures that may generate bacteremias.
Following cardiac catheterization, blood cultures obtained from a distal
vein are rarely positive. Thus, prophylactic antibiotics are not currently
recommended for cardiac catheterization. Bacteremia commonly occurs
following other procedures such as periodontal surgery, tonsillectomy, and
prostate surgery.
32. The answer is d. (Mandell, 5/e, pp 1811–1819.) Rabies is caused by a
bullet-shaped rhabdovirus. In the United States, dogs are seldom rabid.
The animals that present the most danger are wild skunks and bats; foxes
are also possible carriers. Raccoons are responsible for an increasing number of cases in the mid-Atlantic states. The incubation period ranges from 4 days to many years, but is usually between 20 and 90 days. The incubation period is usually shorter with a bite to the head than with one to anextremity. In humans, only four definite recoveries from established infection have been reported. Nonimmunized animals that have been bitten
should be killed and their brains submitted for virus by immunofluorescent
antibody examination. A negative fluorescent test removes the need to
treat the bite victim either actively or passively.
Items 33–36
Match each clinical description with the appropriate infectious agent.
a. Herpes simplex virus
b. Epstein-Barr virus
c. Parvovirus B19
d. Staphylococcus aureus
e. Neisseria meningitidis
33. Slapped-cheek rash
34. Desquamation of skin on hands and feet
35. Petechiae on trunk
36. Diffuse rash after administration of ampicillin
33–36. The answers are 33-c, 34-d, 35-e, 36-b. (Gorbach, 2/e, pp
1334–1335, 1387, 1648, 1692.) Parvovirus B19 is the agent responsible for
erythema infectiosum, also known as fifth disease. This disease most commonly
affects children between the ages of 5 and 14 years, but it can also
occur in adults. The disease is characterized by a slapped-cheek rash,
which may follow a prodrome of low-grade fever. A diffuse lacelike rash
may also occur. Complications in adults include arthralgias, arthritis,
aplastic crisis in patients with chronic hemolytic anemia, spontaneous
abortion, and hydrops fetalis. Desquamation of the skin usually occurs
during or after recovery from toxic shock syndrome (associated with a
toxin produced by S. aureus). Peeling of the skin is also seen in Kawasaki
disease, scarlet fever, and some severe drug reactions. Petechial rashes are
often seen with potentially life-threatening infections, including meningococcemia,
gonococcemia, rickettsial disease, infective endocarditis, atypical
measles, and disseminated intravascular coagulation (DIC) associated
with sepsis. Infectious mononucleosis is the usual manifestation of infection
with Epstein-Barr virus. Since it is a viral disease, antibiotic therapy is
not indicated. A diffuse maculopapular rash has been observed in over
90% of patients with infectious mononucleosis who are given ampicillin.
The rash does not represent an allergic reaction to -lactam antibiotics.
Items 37–41
Match the following diseases with their appropriate signs or associations.
a. Koplik spots
b. Agammaglobulinemia
c. A vesicular and pustular eruption that begins when the patient is afebrile
d. Acute cerebellar ataxia
e. Pancreatitis
37. Mumps (CHOOSE 1 SIGN)
38. Chickenpox (CHOOSE 1 SIGN)
39. Smallpox (CHOOSE 1 SIGN)
40. Echovirus infection (CHOOSE 1 SIGN)
41. Measles (CHOOSE 1 SIGN)
37–41. The answers are 37-e, 38-d, 39-c, 40-b, 41-a. (Mandell, 5/e, pp
1555, 1776–1780, 1801–1807.) Although salivary adenitis is the most
prominent feature of the communicable disease of viral origin, mumps,
involvement of the gonads, meninges, and pancreas is not uncommon.
Males who develop mumps after puberty have a 20 to 35% chance of
developing a painful orchitis. Central nervous system involvement is common
but usually mild, with 50% of cases causing an increase in lymphocytes
detectable in the CSF. Myocarditis, thrombocytopenic purpura, and
polyarthritis may also occur as complications of this disease. An inflammatory
change in the pancreas is a potentially serious problem; symptoms
consist of abdominal discomfort and a gastroenteritis-like illness. Although
a polyneuritis and a transverse myelitis have been described, the most
common manifestation of CNS infection with varicella (chickenpox) is
acute cerebellar ataxia. While chickenpox is usually a benign illness in children,
other complications such as myocarditis, iritis, nephritis, orchitis,
and hepatitis may occur. Pneumonitis occurs more commonly in adults
than children It can be difficult to distinguish between the vesicular lesions of smallpox
and chickenpox. Classically, however, a history of rash with vesicles
that develop over a few hours would be typical of a chickenpox infection;
vesiculation that develops over a period of days is the rule in smallpox.
While fever is characteristic of the prodrome of smallpox, it subsides prior
to focal eruptions. Lesions of smallpox are typically all at the same stage
of development, in contrast to the various stages seen in a patient with
chickenpox. Preparations of vesicular fluid under electron microscopy
show characteristic brick-shaped particles with poxvirus. A more readily
available test, the Tzanck smear, performed by scraping the base of the
lesion, should reveal multinucleated giant cells microscopically in a patient
with chickenpox. Humoral immunity appears to be very important in the
recovery from enteroviral infections. One of the most common complications
for patients with sex-linked or acquired agammaglobulinemia is a
chronic central nervous system infection with an echovirus. In the absence
of the ability to produce antibodies, this virus spreads rapidly and usually
produces a fatal illness. The administration of intravenous preparations of
gamma globulin intraventricularly has controlled this serious complication
of immune deficiency in some patients.
It may take from 9 to 11 days after exposure for the first symptoms of
measles to develop. Malaise, irritability, and a high fever often associated
with conjunctivitis with prominent tearing are common symptoms. This
prodromal syndrome may last from 3 days to 1 week before the characteristic rash of measles develops. One or two days before the onset of the rash,
characteristic Koplik spots (small, red, irregular lesions with blue-white
centers) may be visible on the mucous membranes and occasionally on the
conjunctiva. Classically, the measles rash will begin on the forehead and
spread downward, and the Koplik spots will rapidly resolve.
Items 42–46
Match the clinical illness with the appropriate opportunistic pathogen in
patients with AIDS.
a. Pneumocystis carinii
b. Toxoplasma gondii
c. Cryptosporidium
d. Cytomegalovirus
e. Salmonella
42. Pneumonia (CHOOSE 1 PATHOGEN)
43. Retinitis (CHOOSE 1 PATHOGEN)
44. Seizures (CHOOSE 1 PATHOGEN)
45. Bacteremia (CHOOSE 1 PATHOGEN)
46. Diarrhea diagnosed by direct examination of stool (CHOOSE 1
PATHOGEN)
42–46. The answers are 42-a, 43-d, 44-b, 45-e, 46-c. (Braunwald,
15/e, pp 1880–1896.) Pneumonia due to P. carinii was among the first recognized
manifestations of AIDS. The chest radiograph typically shows a
diffuse bilateral interstitial pattern, but other patterns, including a normal
radiograph, may occur. Pneumocystis infection may also occur at extrapulmonary
sites. Cytomegalovirus (CMV) is a frequent disseminated pathogen
that causes retinitis that may lead to blindness. CMV may also cause pneumonitis,
adrenalitis, and hepatitis, as well as colitis with significant diarrhea.
The protozoan Cryptosporidium may cause a chronic diarrhea that
Infectious Disease Answers 23
leads to malabsorption and wasting. It can be diagnosed by direct examination
of the stool with special concentration or staining techniques or
both. Salmonella infections have been recognized with increased frequency
in patients with HIV. These patients are typically bacteremic and develop
bacteremic relapse; they do not usually present with a diarrheal illness.
Patients who present with seizures warrant evaluation for toxoplasmosis.
CNS lymphoma and certain other infections may also cause seizures.
Patients with toxoplasmic encephalitis may also have toxoplasmic chorioretinitis,
although CMV remains the most common identified cause of
retinitis in patients with AIDS.
Items 47–51
For each of the sexually transmitted diseases, select the treatment of choice.
a. Penicillin
b. Doxycycline
c. Ceftriaxone plus doxycycline
d. Metronidazole
e. Acyclovir
47. Presumed gonococcal urethritis (SELECT 1 TREATMENT)
48. Nongonococcal urethritis (SELECT 1 TREATMENT)
49. Severe primary genital herpes (SELECT 1 TREATMENT)
50. Trichomoniasis (SELECT 1 TREATMENT)
51. Syphilis (SELECT 1 TREATMENT)
47–51. The answers are 47-c, 48-b, 49-e, 50-d, 51-a. (Braunwald,
15/e, pp 936–937, 1050–1052, 1230.) Treatment of gonococcal infections
should be guided by the increasing frequency of antibiotic-resistant Neisseria
gonorrhoeae and high frequency of co-infection with Chlamydia trachomatis.
Because of the increased frequency of resistance to penicillin and
tetracyclines, ceftriaxone is recommended as the treatment of choice.
Doxycycline is added to treat chlamydial and other causes of nongonococcal
urethritis. First episodes of genital herpes may be particularly severe.
Oral acyclovir will accelerate the healing but will not reduce the risk of
recurrence once the drug is stopped. Trichomoniasis is usually diagnosed
by a wet preparation microscopic examination or by culture. Both the
patient and sexual partner should be treated with metronidazole. Penicillin
remains the drug of choice for treatment of syphilis. The route of administration
and duration of therapy depend on the stage of disease and presence
of CNS involvement and may also be influenced by the HIV serostatus
of the patient.
Items 52–55
Identify the antimicrobial agent associated with the adverse effects listed
below.
a. Gentamicin
b. Imipenem
c. Tetracycline
d. Clindamycin
52. Photosensitivity (CHOOSE 1 AGENT)
53. Acute tubular necrosis (CHOOSE 1 AGENT)
54. Progressive weakness in a patient with myasthenia gravis (CHOOSE
1 AGENT)
55. Seizures (CHOOSE 1 AGENT)
56. A previously healthy 25-year-old music teacher develops fever and a
rash over her face and chest. The rash is itchy and on exam involves multiple
papules and vesicles in varying stages of development. One week later
she complains of cough and is found to have an infiltrate on x-ray. The
most likely etiology of the infection is
a. Streptococcus pneumoniae
b. Mycoplasma pneumoniae
c. Pneumocystis carinii
d. Varicella virus
Items 57–58
57. A 22-year-old male complains of fever and shortness of breath.
There is no pleuritic chest pain or rigors and no sputum production. A
chest x-ray shows diffuse perihilar infiltrates. The patient worsens while
on erythromycin. A silver methenamine stain shows cystlike structures.
Which of the following is correct?
a. Definitive diagnosis can be made by serology
b. The organism will grow after 48 h
c. History will likely provide important clues to the diagnosis
d. Cavitary disease is likely to develop
58. Which of the following statements about the treatment of the above
patient is correct?
a. Oral antibiotic therapy is never appropriate
b. Trimethoprim-sulfamethoxazole is the treatment of choice in the nonallergic
patient
c. Concomitant corticosteroids should always be avoided
d. Tetracycline is more effective than erythromycin
59. A 25-year-old male from East Tennessee had been ill for 5 days with
fever, chills, and headache when he noted a rash that developed on his
palms and soles. In addition to macular lesions, petechiae are noted on the
wrists and ankles. The patient has spent the summer camping. The most
important fact to be determined in the history is
a. Exposure to contaminated springwater
b. Exposure to raw pork
c. Exposure to ticks
d. Exposure to prostitutes
60. A 19-year-old male has a history of athlete’s foot but is otherwise
healthy when he develops the sudden onset of fever and pain in the right
foot and leg. On physical exam, the foot and leg are fiery red with a welldefined
indurated margin that appears to be rapidly advancing. There is
tender inguinal lymphadenopathy. The most likely organism to cause this
infection is
a. Staphylococcus epidermidis
b. Tinea pedis
c. Streptococcus pyogenes
d. Mixed anaerobic infection
61. An 18-year-old male has been seen in clinic for urethral discharge. He
is treated with ceftriaxone, but the discharge has not resolved and the culture
has returned as no growth. The most likely etiologic agent to cause this
infection is
a. Ceftriaxone-resistant gonococci
b. Chlamydia psittaci
c. Chlamydia trachomatis
d. Herpes simplex
Items 62–68
Match the clinical description with the most likely etiologic agent.
a. Candida albicans
b. Aspergillus flavus
c. Coccidioides immitis
d. Herpes simplex type 1
e. Herpes simplex type 2
f. Hantavirus
g. Tropheryma whippelii
h. Coxsackievirus B
i. Histoplasma capsulatum
j. Human parvovirus
k. Cryptococcus neoformans
62. An HIV-positive patient develops fever and dysphagia; endoscopic
biopsy shows yeast and hyphae. (CHOOSE 1 AGENT)
63. A 50-year-old develops sudden onset of bizarre behavior. CSF shows
80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities.
(CHOOSE 1 AGENT)
64. A patient with a previous history of tuberculosis now complains of
hemoptysis. There is an upper lobe mass with a cavity and a crescentshaped
air-fluid level. (CHOOSE 1 AGENT)
65. A Filipino patient develops a pulmonary nodule after travel through
the American Southwest. (CHOOSE 1 AGENT)
66. A 35-year-old male who had a fever, cough, and sore throat develops
chest pain after several days with diffuse ST segment elevations on ECG.
(CHOOSE 1 AGENT)
67. Overwhelming pneumonia with adult respiratory distress syndrome
occurs on an Indian reservation in the Southwest following exposure to
deer mice. (CHOOSE 1 AGENT)
68. A child develops an erythematous rash appearing as a slapped cheek.
(CHOOSE 1 AGENT)
52–55. The answers are 52-c, 53-a, 54-a, 55-b. (Braunwald, 15/e, pp
875–882.) The tetracyclines are associated with photosensitization, and
patients taking these antibiotics should be warned about exposure to the sun.
Imipenem, a carbapenem, may cause central nervous system toxicity such as
seizures, especially when administered at high dosages. The major toxicity of gentamicin, an aminoglycoside, is acute tubular necrosis; thus, drug levels
should be closely monitored. The aminoglycosides may be ototoxic, with
effects on vestibular or auditory function or both. This class of drugs can
also produce neuromuscular blockade, especially when administered with
concomitant neuromuscular blocking agents or to patients with impairment
of neuromuscular transmission, such as myasthenia gravis.
56. The answer is d. (Braunwald, 15/e, p 1107.) Varicella pneumonia
develops in about 20% of adults with chickenpox. It occurs 3 to 7 days
after the onset of the rash. The hallmark of the chickenpox rash is papules,
vesicles, and scabs in various stages of development. Fever, malaise, and
itching are usually part of the clinical picture. The differential can include
some coxsackievirus and echovirus infections, which might present with
pneumonia and vesicular rash. Rickettsialpox, a rickettsial infection, has
also been mistaken for chickenpox.
57. The answer is c. (Braunwald, 15/e, pp 1182–1184.) Patients with
P. carinii pneumonia frequently present with shortness of breath and no
sputum production. The interstitial pattern of infiltrates on chest x-ray distinguishes the pneumonia from most bacterial infections. Diagnosis is
made by review of silver methenamine stain. Serology is not sensitive or
specific enough for routine use. The organism does not grow on any media.
Cavitation can occur but is quite unusual. The history is likely to suggest a
risk factor for HIV disease.
58. The answer is b. (Gantz, 4/e, pp 455–459.) Trimethoprim-sulfa is the
drug of choice for P. carinii pneumonia in the nonallergic patient. Oral therapy
is recommended for mild to moderate disease. Prednisone has been
shown to improve the mortality rate in moderate to severe disease when
the PO2 is less than 70 mmHg. Neither tetracycline nor erythromycin has
any effect on the organism.
59. The answer is c. (Braunwald, 15/e, pp 1065–1066.) The rash of Rocky
Mountain spotted fever (RMSF) occurs about 5 days into an illness characterized
by fever, malaise, and headache. The rash may be macular or
petechial, but almost always spreads from the ankles and wrists to the
trunk. The disease is most common in spring and summer. North Carolina
and East Tennessee have a relatively high index of disease. RMSF is a rickettsial disease with the tick as the vector. About 80% of patients will give a history of tick exposure. Doxycycline is considered the drug of choice, but chloramphenicol is preferred in pregnancy because of the effects of tetra-cycline on fetal bones and teeth. Overall mortality from the infection isnow about 5%.
60. The answer is c. (Braunwald, 15/e, pp 823, 893.) Erysipelas, the cellulitis
described, is typical of infection caused by S. pyogenes group A
β-hemolytic streptococci. There is often a preceding event such as a cut in
the skin, dermatitis, or superficial fungal infection that precedes this
rapidly spreading cellulitis. Anaerobic cellulitis is more often associated
with underlying diabetes. S. epidermidis does not cause rapidly progressive
cellulitis. Staphylococcus aureus can cause cellulitis that is difficult to distinguish from erysipelas, but it is usually more focal and likely to produce
furuncles, or abscesses.
61. The answer is c. (Braunwald, 15/e, pp 1074–1076, 1620–1622.) About
half of all cases of nongonococcal urethritis are caused by C. trachomatis.
Ureaplasma urealyticum and Trichomonas vaginalis are rarer causes of urethritis. Herpes simplex would present with vesicular lesions and pain. C. psittaci is the etiologic agent in psittacosis. All gonococci are susceptible to ceftriaxone at recommended doses.
62–68. The answers are 62-a, 63-d, 64-b, 65-c, 66-h, 67-f, 68-j. (Gorbach,
2/e, pp 592, 1334–1335, 2094–2095, 2142, 2164–2168, 2314–2315,
2327–2329.) There are several causes for dysphagia in the HIV-positive
patient, including C. albicans, herpes simplex, and cytomegalovirus. The
biopsy result in this patient confirms Candida infection with the typical picture
of both yeast and hyphae seen on smear. Herpes simplex encephalitis
can occur in patients of any age—usually in immunocompetent patients.
The bizarre behavior includes personality aberrations, hypersexuality, or
sensory hallucinations. CSF shows lymphocytes with a close to normal
sugar and protein. Focal abnormalities are seen in the temporal lobe by CT
scan, MRI, or EEG.
The patient who has had a previous history of tuberculosis and now
complains of hemoptysis would be reevaluated for active tuberculosis.
However, the chest x-ray described is characteristic of a fungus ball—
almost always the result of an aspergilloma.
The Filipino patient who has developed a pulmonary nodule after
travel through the Southwest would be suspected of having developed
coccidioidomycosis. Individuals from the Philippines have a higher incidence of the disease and are more likely to have complications of dissemination. The 35-year-old with cough, sore throat, and fever went on to developsymptoms of myopericarditis with typical ECG findings. Coxsackievirus Binfection is the most likely cause of URI symptoms that evolve into a pictureof myocarditis. Myocarditis may be asymptomatic or can present with chestpain, both pleuritic and ischemic-like. Enteroviruses rarely if ever attack the pericardium alone without involving the subepicardial myocardium.Hantavirus pulmonary syndrome begins with a prodromal illness ofcough, fever, and myalgias that is difficult to distinguish from other viral illnesses such as influenza. However, the illness progresses to increased dyspnea,hypoxia, and hypotension. The picture resembles adult respiratory distress syndrome (ARDS), and most patients require mechanical ventilation.
The infection should be suspected when a previously healthy adult
develops unexplained pulmonary edema or ARDS without known causes.
Thrombocytopenia is also a useful clue. Transmission of hantavirus usually
occurs through aerosolization of urine from infected rodents or through the
bite of an infected rodent.
The slapped-cheek appearance in the child, previously called fifth disease,
is now known to be the result of a parvovirus B19. Its occurrence may
be epidemic in nature. Children are usually not very ill, but adults can
develop a polyarthralgia or true arthritis.
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.
1. A 30-year-old male patient complains of fever and sore throat for several
days. The patient presents to you today with additional complaints of
hoarseness, difficulty breathing, and drooling. On examination, the patient
is febrile and has inspiratory stridor. Which of the following is the best
course of action?
a. Begin outpatient treatment with ampicillin
b. Culture throat for β-hemolytic streptococci
c. Admit to intensive care unit and obtain otolaryngology consultation
d. Schedule for chest x-ray
2. A 70-year-old patient with long-standing type 2 diabetes mellitus presents
with complaints of pain in the left ear with purulent drainage. On
physical exam, the patient is afebrile. The pinna of the left ear is tender, and
the external auditory canal is swollen and edematous. The peripheral white
blood cell count is normal. The organism most likely to grow from the purulent
drainage is
a. Pseudomonas aeruginosa
b. Staphylococcus aureus
c. Candida albicans
d. Haemophilus influenzae
e. Moraxella catarrhalis
1. The answer is c. (Gorbach, 2/e, pp 542–544.) This patient, with the
development of hoarseness, breathing difficulty, and stridor, is likely to
have acute epiglottitis. Because of the possibility of impending airway
obstruction, the patient should be admitted to an intensive care unit for
close monitoring. The diagnosis can be confirmed by indirect laryngoscopy
or soft tissue x-rays of the neck, which may show an enlarged epiglottis.
Otolaryngology consult should be obtained. The most likely organism
causing this infection is Haemophilus influenzae. Many of these organisms
are β-lactamase-producing and would be resistant to ampicillin. The clinical
findings are not consistent with the presentation of streptococcal
pharyngitis. Lateral neck films would be more useful than a chest x-ray.
2. The answer is a. (Braunwald, 15/e, p 190.) Ear pain and drainage in an
elderly diabetic patient must raise concern about malignant external otitis.
The swelling and inflammation of the external auditory meatus strongly
suggest this diagnosis. This infection usually occurs in older diabetics and
is almost always caused by P. aeruginosa. H. influenzae and M. catarrhalis
frequently cause otitis media, but not external otitis.
Items 3–4
A 25-year-old male student presents with the chief complaint of rash. There
is no headache, fever, or myalgia. A slightly pruritic maculopapular rash is
noted over the abdomen, trunk, palms of the hands, and soles of the feet.
Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic,
flat, wartlike lesions are noted around the anal area. Laboratory
studies show the following:
Hct: 40%
Hgb: 14 g/dL
WBC: 13,000/μL
Diff:
Segmented neutrophils: 50%
Lymphocytes: 50%
3. The most useful laboratory test in this patient is
a. Weil-Felix titer
b. Venereal Disease Research Laboratory (VDRL) test
c. Chlamydia titer
d. Blood cultures
4. The treatment of choice for this patient is
a. Penicillin
b. Ceftriaxone
c. Tetracycline
d. Interferon α
e. Erythromycin
3–4. The answers are 3-b, 4-a. (Braunwald, 15/e, pp 1046–1047.) The diffuse
rash involving palms and soles would in itself suggest the possibility of
secondary syphilis. The hypertrophic, wartlike lesions around the anal area,
called condylomata lata, are specific for secondary syphilis. The VDRL slide
test will be positive in all patients with secondary syphilis. The Weil-Felix
titer has been used as a screening test for rickettsial infection. In this patient,
who has condylomata and no systemic symptoms, Rocky Mountain spotted
fever would be unlikely. No chlamydial infection would present in this way.
Blood cultures might be drawn to rule out bacterial infection such as chronic
meningococcemia; however, the clinical picture is not consistent with a systemic
bacterial infection. Penicillin is the drug of choice for secondary
syphilis. Ceftriaxone and tetracycline are usually considered to be alternative
therapies. Interferon α has been used in the treatment of condyloma acuminata,
a lesion that can be mistaken for syphilitic condyloma.
Items 5–7
A 20-year-old female college student presents with a 5-day history of cough,
low-grade fever (temperature 100�), sore throat, and coryza. On exam,
there is mild conjunctivitis and pharyngitis. Tympanic membranes are
inflamed, and one bullous lesion is seen. Chest exam shows few basilar
rales. Laboratory findings are as follows:
Hct: 38
WBC: 12,000/μL
Lymphocytes: 50%
Mean corpuscular volume (MCV): 83 nL
Reticulocytes: 3% of red cells
CXR: bilateral patchy lower lobe infiltrates
5. The sputum Gram stain is likely to show
a. Gram-positive diplococci
b. Tiny gram-negative coccobacilli
c. White blood cells without organisms
d. Acid-fast bacilli
6. This patient is likely to have
a. High titers of adenovirus
b. High titers of IgM cold agglutinins
c. A positive silver methenamine stain
d. A positive blood culture for Streptococcus pneumoniae
7. Treatment of choice is
a. Erythromycin
b. Supportive therapy
c. Trimethoprim-sulfamethoxazole
d. Cefuroxime
5–7. The answers are 5-c, 6-b, 7-a. (Braunwald, 15/e, pp 1073–1074.)
This young woman presents with symptoms of both upper and lower respiratory
infection. The combination of sore throat, bullous myringitis, and
infiltrates on chest x-ray is consistent with infection due to M. pneumoniae.
This minute organism is not seen on Gram stain. Neither S. pneumoniae nor
H. influenzae would produce this combination of upper and lower respiratory
tract symptoms. The patient is likely to have high titers of IgM cold
agglutinins. The low hematocrit and elevated reticulocyte count reflect a
hemolytic anemia that can occur from mycoplasma infection. These IgMclass
antibodies are directed to the I antigen on the erythrocyte membrane.
The treatment of choice for mycoplasma infection is erythromycin.
Items 8–10
A 19-year-old male presents with a 1-week history of malaise and anorexia
followed by fever and sore throat. On physical examination, the throat is
inflamed without exudate. There are a few palatal petechiae. Cervical
adenopathy is present. The liver is percussed at 12 cm and the spleen is
palpable.
Throat culture: negative for group A streptococci
Hct: 38%
Hgb: 12 g/dL
Reticulocytes: 4%
WBC: 14,000/μL
Segmented: 30%
Lymphocytes: 60%
Monocytes: 10%
Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2)
Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220)
Aspartate (AST): 40 U/L (normal 8 to 20 U/L)
Alanine (ALT): 35 U/L (normal 8 to 20 U/L)
Alkaline phosphatase: 40 IU/L (normal 35 to 125)
8. The most important initial test is
a. Liver biopsy
b. Strep screen
c. Peripheral blood smear
d. Toxoplasmosis IgG
e. Lymph node biopsy
9. The most important serum test is
a. Heterophile antibody
b. Hepatitis B IgM
c. Cytomegalovirus IgG
d. ASLO titer
e. Hepatitis C antibody
10. Corticosteroids would be indicated if
a. Liver function tests worsen
b. Fatigue lasts more than 1 week
c. Severe hemolytic anemia is demonstrated
d. Hepatitis B is confirmed
8–10. The answers are 8-c, 9-a, 10-c. (Braunwald, 15/e, pp 1109–1111.)
This young man presents with classic signs and symptoms of infectious
mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed. The symptoms described in association with atypical lymphocytes and apositive heterophile test are virtually always due to Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruction occurs. Neither fatigue nor the complication of hepatitis is an indication for corticosteroid therapy.
DIRECTIONS: Each group of questions below consists of lettered
options followed by a set of numbered items. For each numbered item,
select the one lettered option with which it is most closely associated. Each
lettered option may be used once, more than once, or not at all.
Items 11–14
Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae
b. Staphylococcus aureus
c. Viridans streptococci
d. Providencia stuartii
e. Actinomyces israelii
f. Haemophilus ducreyi
g. Neisseria meningitidis
h. Listeria monocytogenes
11. A 30-year-old female with mitral valve prolapse and mitral regurgitant
murmur develops fever, weight loss, and anorexia after undergoing a dental
procedure. (CHOOSE 1 ORGANISM)
12. An 80-year-old-male, hospitalized for hip fracture, has a Foley
catheter in place when he develops shaking chills, fever, and hypotension.
(CHOOSE 1 ORGANISM)
13. A young man develops a painless, fluctuant purplish lesion over the
mandible. Cutaneous fistula is noted after several weeks. (CHOOSE 1
ORGANISM)
14. A sickle cell anemia patient presents with high fever, toxicity, signs of
pneumonia, and stiff neck. (CHOOSE 1 ORGANISM)
11–14. The answers are 11-c, 12-d, 13-e, 14-a. (Braunwald, 15/e, pp
809–814, 882–885, 959, 1009, 1620.) The 30-year-old-female with mitral
valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most
cases of subacute bacterial endocarditis. No other agent listed is likely to
cause this infection. The 80-year-old-male with a Foley catheter in place has
developed a nosocomial infection likely secondary to urosepsis. Providencia
species frequently cause urinary tract infection in the hospitalized patient.
The young man with a fluctuant lesion and fistula over the mandible presentsa classic picture of cervicofacial actinomycosis. The sickle cell anemiapatient who presents with concomitant pneumonia and meningitis hasoverwhelming infection with S. pneumoniae due to functional asplenia.
S. pneumoniae causes a particularly severe infection associated with sickle
cell disease.
Items 15–18
Select an antiviral agent for each patient.
a. Ganciclovir
b. Acyclovir
c. Interferon α
d. Didanosine
e. Ribavirin
f. Amantadine
g. Vidarabine
h. Zalcitabine
15. A military recruit develops pneumonia secondary to influenza A.
Symptoms began 24 h prior to physician visit. (SELECT 1 AGENT)
16. An HIV-positive patient with a CD4 count of 50 complains of the
onset of visual blurring; opacity is seen on funduscopic exam. (SELECT 1
AGENT)
17. A sexually active young woman has anogenital warts and requests
intralesional therapy. (SELECT 1 AGENT)
18. An infant with respiratory syncytial virus infection requires mechanical
ventilation. (SELECT 1 AGENT)
15–18. The answers are 15-f, 16-a, 17-c, 18-e. (Braunwald, 15/e, pp
1092–1100.) Amantadine has been shown to alter the course of influenza A
favorably, particularly when begun within 48 h of the start of symptoms.
The HIV-positive patient with a low CD4 count and visual blurring has
developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnethas also been used effectively). Interferon α has been approved for
intralesional therapy of condyloma acuminatum (venereal warts caused by
papillomavirus). Ribavirin improves mortality in mechanically ventilated
infants with RSV infection.
Items 19–21
Select the fungal agent most likely responsible for the disease process
described.
a. Histoplasma capsulatum
b. Blastomycosis dermatitidis
c. Coccidioides immitis
d. Cryptococcus neoformans
e. Candida albicans
f. Aspergillus fumigatus
g. Zygomycosis
19. A young, previously healthy male presents with verrucous skin
lesions, bone pain, fever, cough, and weight loss. Chest x-ray shows nodular
infiltrates. (SELECT 1 AGENT)
20. A diabetic patient is admitted with elevated blood sugar and acidosis.
The patient complains of headache and sinus tenderness and has black,
necrotic material draining from the nares. (SELECT 1 AGENT)
21. A young woman presents with asthma and eosinophilia. Fleeting pulmonaryinfiltrates occur with bronchial plugging. (SELECT 1 AGEnt)
19–21. The answers are 19-b, 20-g, 21-f. (Braunwald, 15/e, pp
1173–1179.) Blastomycosis presents with signs and symptoms of chronic
respiratory infection. The organism has a tendency to produce skin lesions
in exposed areas that become crusted, ulcerated, or verrucous. Bone pain is
caused by osteolytic lesions. Mucormycosis is a zygomycosis that originates
in the nose and paranasal sinuses. Sinus tenderness, bloody nasal discharge,
and obtundation occur usually in the setting of diabetic ketoacidosis.
Aspergillus can result in several different infectious processes, including
aspergilloma, disseminated Aspergillus in the immunocompromised patient,
or allergic bronchopulmonary aspergillosis. Bronchopulmonary aspergillosis
is the most likely diagnosis in the young woman with asthma and
eosinophilia. Bronchial plugs, often filled with hyphal forms, result in
repeated infiltrates and exacerbation of wheezing.
Items 22–24
A 40-year-old male develops bilateral facial weakness after returning from
a camping trip in Wisconsin that lasted 6 weeks. The patient gives a history
of arthralgias. On exam, he cannot close either eye well or raise either eyebrow.
The first heart sound is diminished. There is no evidence of arthritis.
Hgb: 14 g/dL
WBC: 10,000/L
VDRL: negative
FTA-Abs: positive
ECG: first-degree AV block
22. Which of the following would be most useful?
a. CT scan of head
b. MRI of head
c. More detailed history
d. Kveim test
23. The likely cause of these symptoms is
a. Intracranial infection
b. Lyme disease
c. Endocarditis
d. Herpes simplex
Infectious Disease 7
24. Treatment of choice is
a. Penicillin or ceftriaxone
b. Acyclovir
c. Corticosteroids
d. Aminoglycoside
22–24. The answers are 22-c, 23-b, 24-a. (Braunwald, 15/e, pp
1061–1065.) This patient presents with a symptom complex that includes
facial nerve palsies, arthralgia, and first-degree AV block. Facial nerve palsy
has been increasingly recognized as a first manifestation of Lyme disease.
Within several weeks of the onset of illness, about 8% of patients develop
cardiac involvement, with heart block being the most common manifestation.
During this stage of early disseminated infection, musculoskeletal
pain is common. The diagnosis of Lyme disease is based on careful history
and physical exam with serologic confirmation by detection of antibody to
Borrelia burgdorferi. Neither CT or MRI of head would be indicated as the
lesion is a peripheral facial palsy. Sarcoidosis can also cause both facial
nerve palsy and AV block, but it is much less likely, and the Kveim test is
rarely used to pursue this diagnosis. The treatment of choice for Lyme disease
at this stage would be penicillin or ceftriaxone.
25. You are a physician in charge of the patients who reside in a nursing
home. Several of the patients have developed influenza-like symptoms,
and the community is in the midst of an influenza A outbreak. None of the
nursing home residents have received the influenza vaccine. What course
of action is most appropriate?
a. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine (i.e., allergy to eggs)
b. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give amantadine for 2 weeks
c. Give amantadine alone to all residents
d. Do not give any prophylactic regimen
26. An elderly male develops fever 3 days after cholecystectomy. He
becomes short of breath, and chest x-ray shows a new right lower lobe
infiltrate. Sputum Gram stain shows gram-positive cocci in clumps, and
preliminary culture results suggest staphylococci. The initial antibiotic of
choice is
a. Penicillinase-resistant penicillin such as nafcillin
b. Vancomycin
c. Antibiotic therapy should be based on the incidence of methicillin-resistant
staphylococci in that hospital
d. Quinolones have become the drug of choice for pneumonia
27. A 30-year-old male with sickle cell anemia is admitted with cough,
rusty sputum, and a single shaking chill. Physical examination reveals
increased tactile fremitus and bronchial breath sounds in the left posterior
chest. The patient is able to expectorate a purulent sample. Which of the
following best describes the role of sputum Gram stain and culture?
a. Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting
b. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae
c. Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary
d. There is no characteristic Gram stain in a patient with pneumococcal pneumonia
25. The answer is b. (Braunwald, 15/e, pp 1125–1131.) Influenza A is a
potentially lethal disease in the elderly and chronically debilitated patient.
In institutional settings such as nursing homes, outbreaks are likely to be
particularly severe. Thus prophylaxis is extremely important in this setting.
All residents should receive the vaccine unless they have known egg allergy
(patients can choose to decline the vaccine). Since protective antibodies to
the vaccine will not develop for 2 weeks, amantadine can be used for protection
against influenza A during the interim 2-week period. A reduced
dose is given to elderly patients.
26. The answer is c. (Braunwald, 15/e, p 896.) In the treatment of hospitalacquired
staphylococcal pneumonia, the incidence of methicillin-resistant
staph in the local facility will be very important. In most hospitals,
methicillin-resistant staph is common enough to require initial therapy with
vancomycin. Oxacillin would be the drug of choice only if the incidence of
methicillin-resistant staph is very low. Quinolones are often useful in the
treatment of community-acquired pneumonia, but they would not be effective
against methicillin-resistant staph.
27. The answer is b. (Braunwald, 15/e, p 1479.) The Infectious Disease
Society of America’s guidelines on the treatment of community-acquired
pneumonia still recommend the use of sputum gram stain and culture. This
is particularly important in the era of multi-antibiotic-resistant S. pneumoniae.
Sputum culture and sensitivity can direct specific antibiotic therapy for the
patient as well as provide epidemiologic information for the community as a
whole. A good sputum sample showing many polymorphonuclear leukocytes
and few squamous epithelial cells can give important clues to etiology.
A Gram stain that shows gram-positive lancet-shaped diplococci intracellularly
is good evidence for pneumococcal infection. Empirical antibiotic therapy
becomes more difficult in community-acquired pneumonia as more
pathogens are recognized and as the pneumococcus develops resistance to
penicillin, macrolides, and even quinolones.
28. A 30-year-old man who has spent 5 of the last 10 years in prison in New
York City is referred from the prison because of hemoptysis. He has a history of tuberculosis diagnosed 3 years ago and took isoniazid and rifampin for about a month. A cavitary lesion is seen on chest x-ray. The physician should
do all the following except
a. Obtain sputum for acid-fast bacilli (AFB) stain, culture, and sensitivity
b. Start supervised isoniazid and rifampin administration
c. Start a supervised multiple drug combination to treat multidrug-resistant
tuberculosis
d. Place the patient in respiratory isolation
e. Perform routine screening of inmates and staff for tuberculosis
28. The answer is b. (Braunwald, 15/e, pp 1031–1034.) Multidrugresistant
tuberculosis (TB) has become an increasing problem in several
settings, including correctional facilities and health care institutions. Noncompliance
or poor compliance with prescribed anti-TB medications is the
major factor in the development of multiple drug resistance. When the disease
is suspected, patients should be placed in respiratory isolation and
sputum should be obtained for AFB stain, culture, and sensitivity. Treatment
of high-risk patients, such as this patient, should be supervised, and
multidrug resistance should be assumed. Regular screening of inmates and
staff for TB is important for preventing the spread of TB within the facility
and for early diagnosis of new infections.
29. A recent outbreak of severe diarrhea is currently being investigated.
Several children developed bloody diarrhea, and one remains hospitalized
with acute renal failure. A preliminary investigation has determined that all
the affected children ate at the same restaurant. The food they consumed
was most likely to be
a. Pork chops
b. Hamburger
c. Gefilte fish
d. Sushi
e. Soft-boiled eggs
30. A 40-year-old female nurse was admitted to the hospital because of
fever to 103�. Despite a thorough workup in the hospital for over 3 weeks,
no etiology has been found, and she continues to have temperature spikes
greater than 102�. The least likely diagnosis in this patient is
a. Occult bacterial infection
b. Influenza
c. Lymphoma
d. Adult Still’s disease
e. Factitious fever
31. In a patient who has mitral valve insufficiency, which procedure does
not require prophylactic antibiotic therapy?
a. Cardiac catheterization
b. Prostatectomy
c. Cystoscopy
d. Tonsillectomy
e. Periodontal surgery
32. Rabies, an acute viral disease of the mammalian central nervous system,
is transmitted by infective secretions, usually saliva. Which of the following
statements about this disease is correct?
a. The disease is caused by a reovirus that elicits both complement-fixing and
hemagglutinating antibodies useful in the diagnosis of the disease
b. The incubation period is variable, and, although 10 days is the most common
elapsed time between infection and symptoms, some cases remain asymptomatic
for 30 days
c. Only 30% of infected patients will survive
d. In the United States, the skunk and the raccoon have been important recent
sources of human disease
e. Wild animals that have bitten and are suspected of being rabid should be killed
and their brains examined for virus particles by electron microscopy
29. The answer is b. (Braunwald, 15/e, pp 242, 954.) The outbreak
described is similar to those previously attributed to Escherichia coli
0157:H7. Ingestion of and infection with this organism may result in a spectrum
of illnesses, including mild diarrhea, hemorrhagic colitis with bloody
diarrhea, acute renal failure, and death. Infection has been associated with
ingestion of contaminated beef (in particular ground beef), ingestion of raw
milk, and contamination via the fecal-oral route. Cooking ground beef so
that it is no longer pink is an effective means of preventing infection, as are
hand washing and pasteurization of milk.
30. The answer is b. (Stobo, 23/e, pp 547–551.) Patients may develop
fever as a result of infectious or noninfectious diseases. The term fever of
unknown origin (FUO) is applied when significant fever persists without a
known cause after an adequate evaluation. Several studies have found the
leading causes of FUO to include infections, malignancies, collagen vascular
diseases, and granulomatous diseases. As the ability to more rapidly
diagnose some of these diseases increases, their likelihood of causing undiagnosed
persistent fever lessens. Infections such as intraabdominal
abscesses, tuberculosis, hepatobiliary disease, endocarditis (especially if
the patient had previously taken antibiotics), and osteomyelitis may cause
FUO. In immunocompromised patients, such as those infected with HIV, a
number of opportunistic infections or lymphomas may cause fever and
escape early diagnosis. Self-limited infections such as influenza should
not cause fever that persists for many weeks. Neoplastic diseases such as
lymphomas and some solid tumors (e.g., hypernephroma and primary or
metastatic disease of the liver) are associated with FUO. A number of collagen
vascular diseases may cause FUO. Since conditions such as systemic
lupus erythematosus are more easily diagnosed today, they are less frequent
causes of this syndrome. Adult Still’s disease, however, is often difficult to
diagnose. Other causes of FUO include granulomatous diseases (i.e., giant
cell arteritis, regional enteritis, sarcoidosis, and granulomatous hepatitis),
drug fever, and peripheral pulmonary emboli. Factitious fever is most common
among young adults employed in health-related positions. A prior
psychiatric history or multiple hospitalizations at other institutions may be
clues to this condition. Such patients may induce infections by selfinjection
of nonsterile material, with resultant multiple abscesses or
polymicrobial infections. Alternatively, some patients may manipulate their
thermometers. In these cases, a discrepancy between temperature and
pulse or between oral temperature and witnessed rectal temperature will be
observed.
31. The answer is a. (Mandell, 5/e, pp 917–923.) Although no evidence
exists that prophylactic antibiotic therapy prevents endocarditis, prophylaxis
is recommended for all procedures that may generate bacteremias.
Following cardiac catheterization, blood cultures obtained from a distal
vein are rarely positive. Thus, prophylactic antibiotics are not currently
recommended for cardiac catheterization. Bacteremia commonly occurs
following other procedures such as periodontal surgery, tonsillectomy, and
prostate surgery.
32. The answer is d. (Mandell, 5/e, pp 1811–1819.) Rabies is caused by a
bullet-shaped rhabdovirus. In the United States, dogs are seldom rabid.
The animals that present the most danger are wild skunks and bats; foxes
are also possible carriers. Raccoons are responsible for an increasing number of cases in the mid-Atlantic states. The incubation period ranges from 4 days to many years, but is usually between 20 and 90 days. The incubation period is usually shorter with a bite to the head than with one to anextremity. In humans, only four definite recoveries from established infection have been reported. Nonimmunized animals that have been bitten
should be killed and their brains submitted for virus by immunofluorescent
antibody examination. A negative fluorescent test removes the need to
treat the bite victim either actively or passively.
Items 33–36
Match each clinical description with the appropriate infectious agent.
a. Herpes simplex virus
b. Epstein-Barr virus
c. Parvovirus B19
d. Staphylococcus aureus
e. Neisseria meningitidis
33. Slapped-cheek rash
34. Desquamation of skin on hands and feet
35. Petechiae on trunk
36. Diffuse rash after administration of ampicillin
33–36. The answers are 33-c, 34-d, 35-e, 36-b. (Gorbach, 2/e, pp
1334–1335, 1387, 1648, 1692.) Parvovirus B19 is the agent responsible for
erythema infectiosum, also known as fifth disease. This disease most commonly
affects children between the ages of 5 and 14 years, but it can also
occur in adults. The disease is characterized by a slapped-cheek rash,
which may follow a prodrome of low-grade fever. A diffuse lacelike rash
may also occur. Complications in adults include arthralgias, arthritis,
aplastic crisis in patients with chronic hemolytic anemia, spontaneous
abortion, and hydrops fetalis. Desquamation of the skin usually occurs
during or after recovery from toxic shock syndrome (associated with a
toxin produced by S. aureus). Peeling of the skin is also seen in Kawasaki
disease, scarlet fever, and some severe drug reactions. Petechial rashes are
often seen with potentially life-threatening infections, including meningococcemia,
gonococcemia, rickettsial disease, infective endocarditis, atypical
measles, and disseminated intravascular coagulation (DIC) associated
with sepsis. Infectious mononucleosis is the usual manifestation of infection
with Epstein-Barr virus. Since it is a viral disease, antibiotic therapy is
not indicated. A diffuse maculopapular rash has been observed in over
90% of patients with infectious mononucleosis who are given ampicillin.
The rash does not represent an allergic reaction to -lactam antibiotics.
Items 37–41
Match the following diseases with their appropriate signs or associations.
a. Koplik spots
b. Agammaglobulinemia
c. A vesicular and pustular eruption that begins when the patient is afebrile
d. Acute cerebellar ataxia
e. Pancreatitis
37. Mumps (CHOOSE 1 SIGN)
38. Chickenpox (CHOOSE 1 SIGN)
39. Smallpox (CHOOSE 1 SIGN)
40. Echovirus infection (CHOOSE 1 SIGN)
41. Measles (CHOOSE 1 SIGN)
37–41. The answers are 37-e, 38-d, 39-c, 40-b, 41-a. (Mandell, 5/e, pp
1555, 1776–1780, 1801–1807.) Although salivary adenitis is the most
prominent feature of the communicable disease of viral origin, mumps,
involvement of the gonads, meninges, and pancreas is not uncommon.
Males who develop mumps after puberty have a 20 to 35% chance of
developing a painful orchitis. Central nervous system involvement is common
but usually mild, with 50% of cases causing an increase in lymphocytes
detectable in the CSF. Myocarditis, thrombocytopenic purpura, and
polyarthritis may also occur as complications of this disease. An inflammatory
change in the pancreas is a potentially serious problem; symptoms
consist of abdominal discomfort and a gastroenteritis-like illness. Although
a polyneuritis and a transverse myelitis have been described, the most
common manifestation of CNS infection with varicella (chickenpox) is
acute cerebellar ataxia. While chickenpox is usually a benign illness in children,
other complications such as myocarditis, iritis, nephritis, orchitis,
and hepatitis may occur. Pneumonitis occurs more commonly in adults
than children It can be difficult to distinguish between the vesicular lesions of smallpox
and chickenpox. Classically, however, a history of rash with vesicles
that develop over a few hours would be typical of a chickenpox infection;
vesiculation that develops over a period of days is the rule in smallpox.
While fever is characteristic of the prodrome of smallpox, it subsides prior
to focal eruptions. Lesions of smallpox are typically all at the same stage
of development, in contrast to the various stages seen in a patient with
chickenpox. Preparations of vesicular fluid under electron microscopy
show characteristic brick-shaped particles with poxvirus. A more readily
available test, the Tzanck smear, performed by scraping the base of the
lesion, should reveal multinucleated giant cells microscopically in a patient
with chickenpox. Humoral immunity appears to be very important in the
recovery from enteroviral infections. One of the most common complications
for patients with sex-linked or acquired agammaglobulinemia is a
chronic central nervous system infection with an echovirus. In the absence
of the ability to produce antibodies, this virus spreads rapidly and usually
produces a fatal illness. The administration of intravenous preparations of
gamma globulin intraventricularly has controlled this serious complication
of immune deficiency in some patients.
It may take from 9 to 11 days after exposure for the first symptoms of
measles to develop. Malaise, irritability, and a high fever often associated
with conjunctivitis with prominent tearing are common symptoms. This
prodromal syndrome may last from 3 days to 1 week before the characteristic rash of measles develops. One or two days before the onset of the rash,
characteristic Koplik spots (small, red, irregular lesions with blue-white
centers) may be visible on the mucous membranes and occasionally on the
conjunctiva. Classically, the measles rash will begin on the forehead and
spread downward, and the Koplik spots will rapidly resolve.
Items 42–46
Match the clinical illness with the appropriate opportunistic pathogen in
patients with AIDS.
a. Pneumocystis carinii
b. Toxoplasma gondii
c. Cryptosporidium
d. Cytomegalovirus
e. Salmonella
42. Pneumonia (CHOOSE 1 PATHOGEN)
43. Retinitis (CHOOSE 1 PATHOGEN)
44. Seizures (CHOOSE 1 PATHOGEN)
45. Bacteremia (CHOOSE 1 PATHOGEN)
46. Diarrhea diagnosed by direct examination of stool (CHOOSE 1
PATHOGEN)
42–46. The answers are 42-a, 43-d, 44-b, 45-e, 46-c. (Braunwald,
15/e, pp 1880–1896.) Pneumonia due to P. carinii was among the first recognized
manifestations of AIDS. The chest radiograph typically shows a
diffuse bilateral interstitial pattern, but other patterns, including a normal
radiograph, may occur. Pneumocystis infection may also occur at extrapulmonary
sites. Cytomegalovirus (CMV) is a frequent disseminated pathogen
that causes retinitis that may lead to blindness. CMV may also cause pneumonitis,
adrenalitis, and hepatitis, as well as colitis with significant diarrhea.
The protozoan Cryptosporidium may cause a chronic diarrhea that
Infectious Disease Answers 23
leads to malabsorption and wasting. It can be diagnosed by direct examination
of the stool with special concentration or staining techniques or
both. Salmonella infections have been recognized with increased frequency
in patients with HIV. These patients are typically bacteremic and develop
bacteremic relapse; they do not usually present with a diarrheal illness.
Patients who present with seizures warrant evaluation for toxoplasmosis.
CNS lymphoma and certain other infections may also cause seizures.
Patients with toxoplasmic encephalitis may also have toxoplasmic chorioretinitis,
although CMV remains the most common identified cause of
retinitis in patients with AIDS.
Items 47–51
For each of the sexually transmitted diseases, select the treatment of choice.
a. Penicillin
b. Doxycycline
c. Ceftriaxone plus doxycycline
d. Metronidazole
e. Acyclovir
47. Presumed gonococcal urethritis (SELECT 1 TREATMENT)
48. Nongonococcal urethritis (SELECT 1 TREATMENT)
49. Severe primary genital herpes (SELECT 1 TREATMENT)
50. Trichomoniasis (SELECT 1 TREATMENT)
51. Syphilis (SELECT 1 TREATMENT)
47–51. The answers are 47-c, 48-b, 49-e, 50-d, 51-a. (Braunwald,
15/e, pp 936–937, 1050–1052, 1230.) Treatment of gonococcal infections
should be guided by the increasing frequency of antibiotic-resistant Neisseria
gonorrhoeae and high frequency of co-infection with Chlamydia trachomatis.
Because of the increased frequency of resistance to penicillin and
tetracyclines, ceftriaxone is recommended as the treatment of choice.
Doxycycline is added to treat chlamydial and other causes of nongonococcal
urethritis. First episodes of genital herpes may be particularly severe.
Oral acyclovir will accelerate the healing but will not reduce the risk of
recurrence once the drug is stopped. Trichomoniasis is usually diagnosed
by a wet preparation microscopic examination or by culture. Both the
patient and sexual partner should be treated with metronidazole. Penicillin
remains the drug of choice for treatment of syphilis. The route of administration
and duration of therapy depend on the stage of disease and presence
of CNS involvement and may also be influenced by the HIV serostatus
of the patient.
Items 52–55
Identify the antimicrobial agent associated with the adverse effects listed
below.
a. Gentamicin
b. Imipenem
c. Tetracycline
d. Clindamycin
52. Photosensitivity (CHOOSE 1 AGENT)
53. Acute tubular necrosis (CHOOSE 1 AGENT)
54. Progressive weakness in a patient with myasthenia gravis (CHOOSE
1 AGENT)
55. Seizures (CHOOSE 1 AGENT)
56. A previously healthy 25-year-old music teacher develops fever and a
rash over her face and chest. The rash is itchy and on exam involves multiple
papules and vesicles in varying stages of development. One week later
she complains of cough and is found to have an infiltrate on x-ray. The
most likely etiology of the infection is
a. Streptococcus pneumoniae
b. Mycoplasma pneumoniae
c. Pneumocystis carinii
d. Varicella virus
Items 57–58
57. A 22-year-old male complains of fever and shortness of breath.
There is no pleuritic chest pain or rigors and no sputum production. A
chest x-ray shows diffuse perihilar infiltrates. The patient worsens while
on erythromycin. A silver methenamine stain shows cystlike structures.
Which of the following is correct?
a. Definitive diagnosis can be made by serology
b. The organism will grow after 48 h
c. History will likely provide important clues to the diagnosis
d. Cavitary disease is likely to develop
58. Which of the following statements about the treatment of the above
patient is correct?
a. Oral antibiotic therapy is never appropriate
b. Trimethoprim-sulfamethoxazole is the treatment of choice in the nonallergic
patient
c. Concomitant corticosteroids should always be avoided
d. Tetracycline is more effective than erythromycin
59. A 25-year-old male from East Tennessee had been ill for 5 days with
fever, chills, and headache when he noted a rash that developed on his
palms and soles. In addition to macular lesions, petechiae are noted on the
wrists and ankles. The patient has spent the summer camping. The most
important fact to be determined in the history is
a. Exposure to contaminated springwater
b. Exposure to raw pork
c. Exposure to ticks
d. Exposure to prostitutes
60. A 19-year-old male has a history of athlete’s foot but is otherwise
healthy when he develops the sudden onset of fever and pain in the right
foot and leg. On physical exam, the foot and leg are fiery red with a welldefined
indurated margin that appears to be rapidly advancing. There is
tender inguinal lymphadenopathy. The most likely organism to cause this
infection is
a. Staphylococcus epidermidis
b. Tinea pedis
c. Streptococcus pyogenes
d. Mixed anaerobic infection
61. An 18-year-old male has been seen in clinic for urethral discharge. He
is treated with ceftriaxone, but the discharge has not resolved and the culture
has returned as no growth. The most likely etiologic agent to cause this
infection is
a. Ceftriaxone-resistant gonococci
b. Chlamydia psittaci
c. Chlamydia trachomatis
d. Herpes simplex
Items 62–68
Match the clinical description with the most likely etiologic agent.
a. Candida albicans
b. Aspergillus flavus
c. Coccidioides immitis
d. Herpes simplex type 1
e. Herpes simplex type 2
f. Hantavirus
g. Tropheryma whippelii
h. Coxsackievirus B
i. Histoplasma capsulatum
j. Human parvovirus
k. Cryptococcus neoformans
62. An HIV-positive patient develops fever and dysphagia; endoscopic
biopsy shows yeast and hyphae. (CHOOSE 1 AGENT)
63. A 50-year-old develops sudden onset of bizarre behavior. CSF shows
80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities.
(CHOOSE 1 AGENT)
64. A patient with a previous history of tuberculosis now complains of
hemoptysis. There is an upper lobe mass with a cavity and a crescentshaped
air-fluid level. (CHOOSE 1 AGENT)
65. A Filipino patient develops a pulmonary nodule after travel through
the American Southwest. (CHOOSE 1 AGENT)
66. A 35-year-old male who had a fever, cough, and sore throat develops
chest pain after several days with diffuse ST segment elevations on ECG.
(CHOOSE 1 AGENT)
67. Overwhelming pneumonia with adult respiratory distress syndrome
occurs on an Indian reservation in the Southwest following exposure to
deer mice. (CHOOSE 1 AGENT)
68. A child develops an erythematous rash appearing as a slapped cheek.
(CHOOSE 1 AGENT)
52–55. The answers are 52-c, 53-a, 54-a, 55-b. (Braunwald, 15/e, pp
875–882.) The tetracyclines are associated with photosensitization, and
patients taking these antibiotics should be warned about exposure to the sun.
Imipenem, a carbapenem, may cause central nervous system toxicity such as
seizures, especially when administered at high dosages. The major toxicity of gentamicin, an aminoglycoside, is acute tubular necrosis; thus, drug levels
should be closely monitored. The aminoglycosides may be ototoxic, with
effects on vestibular or auditory function or both. This class of drugs can
also produce neuromuscular blockade, especially when administered with
concomitant neuromuscular blocking agents or to patients with impairment
of neuromuscular transmission, such as myasthenia gravis.
56. The answer is d. (Braunwald, 15/e, p 1107.) Varicella pneumonia
develops in about 20% of adults with chickenpox. It occurs 3 to 7 days
after the onset of the rash. The hallmark of the chickenpox rash is papules,
vesicles, and scabs in various stages of development. Fever, malaise, and
itching are usually part of the clinical picture. The differential can include
some coxsackievirus and echovirus infections, which might present with
pneumonia and vesicular rash. Rickettsialpox, a rickettsial infection, has
also been mistaken for chickenpox.
57. The answer is c. (Braunwald, 15/e, pp 1182–1184.) Patients with
P. carinii pneumonia frequently present with shortness of breath and no
sputum production. The interstitial pattern of infiltrates on chest x-ray distinguishes the pneumonia from most bacterial infections. Diagnosis is
made by review of silver methenamine stain. Serology is not sensitive or
specific enough for routine use. The organism does not grow on any media.
Cavitation can occur but is quite unusual. The history is likely to suggest a
risk factor for HIV disease.
58. The answer is b. (Gantz, 4/e, pp 455–459.) Trimethoprim-sulfa is the
drug of choice for P. carinii pneumonia in the nonallergic patient. Oral therapy
is recommended for mild to moderate disease. Prednisone has been
shown to improve the mortality rate in moderate to severe disease when
the PO2 is less than 70 mmHg. Neither tetracycline nor erythromycin has
any effect on the organism.
59. The answer is c. (Braunwald, 15/e, pp 1065–1066.) The rash of Rocky
Mountain spotted fever (RMSF) occurs about 5 days into an illness characterized
by fever, malaise, and headache. The rash may be macular or
petechial, but almost always spreads from the ankles and wrists to the
trunk. The disease is most common in spring and summer. North Carolina
and East Tennessee have a relatively high index of disease. RMSF is a rickettsial disease with the tick as the vector. About 80% of patients will give a history of tick exposure. Doxycycline is considered the drug of choice, but chloramphenicol is preferred in pregnancy because of the effects of tetra-cycline on fetal bones and teeth. Overall mortality from the infection isnow about 5%.
60. The answer is c. (Braunwald, 15/e, pp 823, 893.) Erysipelas, the cellulitis
described, is typical of infection caused by S. pyogenes group A
β-hemolytic streptococci. There is often a preceding event such as a cut in
the skin, dermatitis, or superficial fungal infection that precedes this
rapidly spreading cellulitis. Anaerobic cellulitis is more often associated
with underlying diabetes. S. epidermidis does not cause rapidly progressive
cellulitis. Staphylococcus aureus can cause cellulitis that is difficult to distinguish from erysipelas, but it is usually more focal and likely to produce
furuncles, or abscesses.
61. The answer is c. (Braunwald, 15/e, pp 1074–1076, 1620–1622.) About
half of all cases of nongonococcal urethritis are caused by C. trachomatis.
Ureaplasma urealyticum and Trichomonas vaginalis are rarer causes of urethritis. Herpes simplex would present with vesicular lesions and pain. C. psittaci is the etiologic agent in psittacosis. All gonococci are susceptible to ceftriaxone at recommended doses.
62–68. The answers are 62-a, 63-d, 64-b, 65-c, 66-h, 67-f, 68-j. (Gorbach,
2/e, pp 592, 1334–1335, 2094–2095, 2142, 2164–2168, 2314–2315,
2327–2329.) There are several causes for dysphagia in the HIV-positive
patient, including C. albicans, herpes simplex, and cytomegalovirus. The
biopsy result in this patient confirms Candida infection with the typical picture
of both yeast and hyphae seen on smear. Herpes simplex encephalitis
can occur in patients of any age—usually in immunocompetent patients.
The bizarre behavior includes personality aberrations, hypersexuality, or
sensory hallucinations. CSF shows lymphocytes with a close to normal
sugar and protein. Focal abnormalities are seen in the temporal lobe by CT
scan, MRI, or EEG.
The patient who has had a previous history of tuberculosis and now
complains of hemoptysis would be reevaluated for active tuberculosis.
However, the chest x-ray described is characteristic of a fungus ball—
almost always the result of an aspergilloma.
The Filipino patient who has developed a pulmonary nodule after
travel through the Southwest would be suspected of having developed
coccidioidomycosis. Individuals from the Philippines have a higher incidence of the disease and are more likely to have complications of dissemination. The 35-year-old with cough, sore throat, and fever went on to developsymptoms of myopericarditis with typical ECG findings. Coxsackievirus Binfection is the most likely cause of URI symptoms that evolve into a pictureof myocarditis. Myocarditis may be asymptomatic or can present with chestpain, both pleuritic and ischemic-like. Enteroviruses rarely if ever attack the pericardium alone without involving the subepicardial myocardium.Hantavirus pulmonary syndrome begins with a prodromal illness ofcough, fever, and myalgias that is difficult to distinguish from other viral illnesses such as influenza. However, the illness progresses to increased dyspnea,hypoxia, and hypotension. The picture resembles adult respiratory distress syndrome (ARDS), and most patients require mechanical ventilation.
The infection should be suspected when a previously healthy adult
develops unexplained pulmonary edema or ARDS without known causes.
Thrombocytopenia is also a useful clue. Transmission of hantavirus usually
occurs through aerosolization of urine from infected rodents or through the
bite of an infected rodent.
The slapped-cheek appearance in the child, previously called fifth disease,
is now known to be the result of a parvovirus B19. Its occurrence may
be epidemic in nature. Children are usually not very ill, but adults can
develop a polyarthralgia or true arthritis.
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