Infectious Diseases - Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed..pdf

 Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed. SECTION IV. Infectious Diseases QUESTIONS DIRECTIONS: Choose the one best response to each question. IV-1. Defic...

 Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed. SECTION IV. Infectious Diseases QUESTIONS DIRECTIONS: Choose the one best response to each question. IV-1. Deficits in the complement membrane attack complex (C5-8) are associated with infections of what variety? A. Catalase-positive bacteria B. Neisseria meningitis C. Pseudomonas aeruginosa D. Salmonella spp. E. Streptococcus pneumoniae IV-2. A 48-year-old man is admitted to the intensive care unit for treatment of septic shock for an uncertain cause. He was well until 1 day before admission. His family reports that he developed myalgias and fevers at that time. He had no other specific complaints but reportedly had decreased oral intake and generalized malaise. He was brought to the hospital by ambulance this morning when he was lethargic and unresponsive at home. Upon arrival of emergency medical services, his initial blood pressure was 60/40 mmHg with a heart rate of 142 beats/min. He was tachypneic with a respiratory rate of 32 breaths/min with an oxygen saturation of 75% on room air, and  his initial temperature was 104.9°F (40.5°C). He was intubated and placed on mechanical ventilation. The patient received 1 L of normal saline before arrival in the emergency department but continues to have hypotension (blood pressure, 75/40 mmHg). Ongoing volume resuscitation is ordered, and the patient is initiated on norepinephrine to maintain adequate blood pressure. The patient has a history of hypertension and hyperlipidemia. He takes amlodipine 10 mg daily and atorvastatin 20 mg daily. His only other history is an automobile accident at age 20 years, requiring exploratory laparotomy and splenectomy. Blood, sputum, and urine cultures are obtained. What are the most appropriate empiric antibiotics for the treatment of this patient? A. Ceftriaxone and vancomycin :  B. Ceftriaxone, ampicillin, and vancomycin C. Ceftriaxone, vancomycin, and amphotericin B D. Clindamycin, gentamicin, and vancomycin E. Clindamycin and quinine IV-3. A 32-year-old woman is admitted to the hospital complaining of right thigh pain. She is treated empirically with oxacillin intravenously for a cellulitis. The admitting physician notes that the degree of pain appears to be disproportionate to the amount of overlying cellulitis. Over the course of the next 24 hours, the patient develops profound septic shock complicated by hypotension, acute renal failure, and evidence of disseminated intravascular coagulation. A CT scan of her right leg demonstrates a collection of fluid with gas in the deep fascia of her right leg. Emergent surgical evacuation is planned. What changes to the patient’s antibiotic therapy would be recommended? A. Continue oxacillin and add clindamycin. B. Continue oxacillin and add clindamycin and gentamicin. C. Discontinue oxacillin and add clindamycin, vancomycin, and gentamicin. D. Discontinue oxacillin and add piperacillin/tazobactam and vancomycin. E. Discontinue oxacillin and add vancomycin and gentamicin. IV-4. Which type of bite represents a potential medical emergency in a febrile asplenic patient? A. Cat bite B. Dog bite C. Fish bite D. Human bite IV-5. One goal of immunization programs is to eliminate a specific disease. In 2010, indigenous transmission of which of the following diseases had been eliminated in the United States? A. Diphtheria B. Mumps C. Pertussis D. Varicella E. None of the above IV-6. A 63-year-old man has chronic obstructive pulmonary disease and presents to your office for routine follow-up. He has no complaints currently and feels well. He is being managed with tiotropium 18 µg once daily with albuterol metered-dose inhaler as needed. :  His most recent forced expiratory volume in 1 second (FEV1) was 55% predicted, and he is not on oxygen. He has received one dose of pneumococcal vaccine 5 years previously. He is asking if he should receive another dose of pneumococcal vaccine. According to the guidelines of the Centers for Disease Control and Prevention, what is your recommendation? A. He does not require further vaccination unless his FEV1 drops below 50% predicted. B. He does not require further vaccination until he reaches age 65 years. C. He should be revaccinated today. D. He should be revaccinated 10 years after his initial vaccine. E. No further vaccination is recommended because a single dose is all that is required. IV-7. In which of the following patients is it appropriate to administer the vaccination against herpes zoster? A. A 35-year-old woman who has never had varicellazoster infection who is 12 weeks pregnant with her first child B. A 54-year-old man who has never had varicellazoster infection and is otherwise healthy C. A 62-year-old man with HIV on antiretroviral therapy with a CD4+ lymphocyte count of 450/µL D. A 64-year-old woman with dermatomyositis-associated interstitial lung disease treated with prednisone 20 mg daily and azathioprine 150 mg daily E. A 66-year-old woman who was recently diagnosed with non-Hodgkin lymphoma IV-8. A 39-year-old woman received a liver transplant 2 years ago and is maintained on prednisone, 5 mg, and cyclosporine, 8 mg/kg per day. She has had two episodes of rejection since transplant, as well an episode of cytomegalo-virus syndrome and Nocardia pneumonia. She intends on taking a 2-week gorilla-watching trip to Rwanda and seeks your advice regarding her health while abroad. Which of the following potential interventions is strictly contraindicated? A. Malaria prophylaxis B. Meningococcal vaccine C. Rabies vaccine D. Typhoid purified polysaccharide vaccine E. Yellow fever vaccine IV-9. A 19-year-old woman comes to your office after being bitten by a bat on the ear while camping in a primitive shelter. She is unable to produce a vaccination record. On physical examination, she is afebrile and appears well. There are two small puncture marks on the pinna of her left ear. What is an appropriate vaccination strategy in this context? :  A. Intravenous ribavirin B. No vaccination C. Rabies immunoglobulins D. Rabies inactivated virus vaccine E. Rabies inactivated virus vaccine plus immunoglobulins IV-10. Which of the following immunizations is required for entry into many countries in sub-Saharan Africa? A. Hepatitis A B. Cholera C. Meningococcus D. Typhoid fever E. Yellow fever IV-11. A 48-year-old woman is traveling to Haiti with a humanitarian aid group. What is the recommended prophylaxis against malaria for this patient? A. Atovaquone–proguanil B. Chloroquine C. Doxycycline D. Mefloquine E. Any of the above can be used IV-12. A 46-year-old man wishes to travel to Kenya for a 2-week vacation. He is HIV positive and is taking antiretroviral therapy. His last CD4+ count was 625/µL and viral load was undetectable. His nadir CD4+ count was 250/µL. He has never had an AIDS-defining illness. In addition to HIV, he has a history of hypertension and is known to have proteinuria caused by to HIV-associated nephropathy. What is your recommendation to this patient regarding his travel plans? A. He should not receive the live measles vaccine before travel. B. He should receive the yellow fever vaccine before travel. C. He will be required to show proof of HIV testing upon entry into the country. D. His likelihood of response to the influenza vaccine would be less than 50%. E. With a CD4+ count greater than 500/µL, he is at no greater risk during travel than persons without HIV. IV-13. Which of the following is the most common cause of native valve infective endocarditis in the community? :  A. Coagulase-negative staphylococci B. Coagulase-positive staphylococci C. Enterococci D. Fastidious gram-negative coccobacilli E. Non-enterococcal streptococci IV-14. All of the following are minor criteria in the Duke criteria for the clinical diagnosis of infective endocarditis EXCEPT: A. Immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots) B. New valvular regurgitation on transthoracic echo-cardiogram C. Predisposing condition (heart condition, intravenous drug use) D. Temperature >380°C E. Vascular phenomena (arterial emboli, septic pulmonary emboli, Janeway lesions, and so on) IV-15. Which of the following patients should receive antibiotic prophylaxis to prevent infective endocarditis? A. A 23-year-old woman with known mitral valve prolapse undergoing a gingival surgery B. A 24-year-old woman who had an atrial septal defect completely corrected 22 years ago who is undergoing elective cystoscopy for painless hematuria C. A 30-year-old man with a history of intravenous drug use and prior endocarditis undergoing operative drainage of a prostatic abscess D. A 45-year-old man who received a prosthetic mitral valve 5 years ago undergoing routine dental cleaning E. A 63-year-old woman who received a prosthetic aortic valve 2 years ago undergoing screening colonoscopy IV-16. A 38-year-old homeless man presents to the emergency department with a transient ischemic attack characterized by a facial droop and left arm weakness lasting 20 minutes and left upper quadrant pain. He reports intermittent subjective fevers, diaphoresis, and chills for the past 2 weeks. He has had no recent travel or contact with animals. He has taken no recent antibiotics. Physical examination reveals a slightly distressed man with disheveled appearance. His temperature is 38.2°C, heart rate is 90 beats/min, and blood pressure is 127/74 mmHg. He has poor dentition. Cardiac examination reveals an early diastolic murmur over the left third intercostal space. His spleen is tender and 2 cm descended below the costal margin. He has tender painful red nodules on the tips of the third finger of his right hand and on the fourth finger of his left hand that are new. He has nits evident on his clothes consistent with body louse infection. His white blood cell count is 14,500/µL with 5% band forms and 93% polymorphonuclear :  cells. Blood cultures are drawn followed by empirical vancomycin therapy. These cultures remain negative for growth 5 days later. He remains febrile but hemodynamically stable but does develop a new lesion on his toe similar to those on his fingers on hospital day 3. A transthoracic echocardiogram reveals a 1-cm mobile vegetation on the cusp of his aortic valve and moderate aortic regurgitation. A CT scan of the abdomen shows an enlarged spleen with wedge-shaped splenic and renal infarctions. What test should be sent to confirm the most likely diagnosis? A. Bartonella serology B. Epstein-Barr virus (EBV) heterophile antibody C. HIV polymerase chain reaction (PCR) D. Peripheral blood smear E. Q fever serology IV-17. In a patient with bacterial endocarditis, which of the following echocardiographic lesions is most likely to lead to embolization? A. 5-mm mitral valve vegetation B. 5-mm tricuspid valve vegetation C. 11-mm aortic valve vegetation D. 11-mm mitral valve vegetation E. 11-mm tricuspid valve vegetation IV-18. A patient is admitted with fevers, malaise, and diffuse joint pains. His initial blood cultures reveal methicillin-resistant Staphylococcus aureus (MRSA) in all culture bottles. He has no arthritis on examination, and his renal function is normal. Echocardiogram shows a 5-mm vegetation on the aortic valve. He is initiated on IV vancomycin at 15 mg/kg every 12 hours. Four days later, the patient remains febrile, and cultures remain positive for MRSA. In addition to a search for embolic foci of infection, which of the following changes would you make to his treatment regimen? A. No change. B. Add gentamicin. C. Add rifampin. D. Check the vancomycin serum peak and trough levels and consider tid dosing. E. Discontinue vancomycin, start daptomycin. IV-19. All of the following organisms may cause bullae as a manifestation of their infection except: A. Clostridium perfringens :  B. Sporothrix schenckii C. Staphylococcus aureus D. Streptococcus pyogenes E. Vibrio vulnificus IV-20. A 24-year-old man with no past medical history is brought to the emergency department complaining of left-sided chest pain for 2 days. He reports the skin over his left chest is tender and swollen. He has no history of HIV risk behavior and works as a landscaper. His physical examination is notable for a heart rate of 110 beats/min, blood pressure of 108/62 mmHg, and temperature of 101.8°F. He has pain and swelling of the left chest. His electrocardiogram is normal. A noncontrast CT scan of the chest (Figure IV- 20) is obtained. Which of the following organisms is most likely causing his illness? FIGURE IV-20 A. Coxsackie virus A16 B. Mycobacterium tuberculosis C. Rickettsia akari D. Streptococcus pyogenes E. Varicella-zoster virus IV-21. All of the following statements regarding the etiology and epidemiology of osteomyelitis are true EXCEPT: A. After a foot puncture, 30% to 40% of patients with diabetes develop osteomyelitis. B. In patients with prosthetic joints, Staphylococcus aureus bacteremia will cause osteomyelitis in 25% to 30% of cases. :  C. Mycobacterium tuberculosis is an uncommon cause of osteomyelitis. D. The foremost bacterial cause of osteomyelitis is Staphylococcus aureus. E. The morbidity and economic consequences of MRSA osteomyelitis are greater than for MSSA osteomyelitis. IV-22. A 79-year-old man has had a diabetic foot ulcer overlying his third metatarsal head for 3 months but has not been compliant with his physician’s request to offload the affected foot. He presents with dull, throbbing foot pain and subjective fevers. Examination reveals a putrid-smelling wound notable also for a pus-filled 2.5-cm-wide ulcer. A metal probe is used to probe the wound, and it detects bone as well as a 3-cm deep cavity. Gram stain of the pus shows gram-positive cocci in chains, gram-positive rods, gram-negative diplococci, enteric-appearing gram-negative rods, tiny pleomorphic gram-negative rods, and a predominance of neutrophils. Which of the following empirical antibiotic regimens is recommended while blood and drainage cultures are processed? A. Ampicillin–sulbactam, 1.5 g IV q4h B. Clindamycin, 600 mg PO tid C. Linezolid, 600 mg IV bid D. Metronidazole, 500 mg PO qid E. Vancomycin, 1 g IV bid IV-23. A 45-year-old man with a history of alcoholism and presumed cirrhosis is brought to the emergency department by his friend complaining of 2 to 3 days of increasing lethargy and confusion. He has not consumed alcohol in the past 2 years. He currently takes no medications and works at home as a video game designer. He has no risk factors for HIV. He was referred by his primary care physician for a liver transplant evaluation and is scheduled to begin his evaluation next month. His vital signs included blood pressure of 90/60 mmHg, heart rate of 105 beats/min, temperature of 38.5°C, and respiratory rate of 10 breaths/min with O2 saturation of 97% on room air. He is somnolent but is able to answer questions accurately. His skin is notable for many spider telangiectasias and palmar erythema. He has a distended diffusely tender abdomen with a positive fluid wave. Paracentesis reveals slightly cloudy fluid with WBC 1000/µL and 40% neutrophils. His blood pressure increases to 100/65 mmHg, and his heart rate decreases to 95 beats/min after 1 L of intravenous fluids. Which of the following statements regarding his condition and treatment is true? A. Fever is present in more than 50% of cases. B. Initial empiric therapy should include metronidazole or clindamycin for anaerobes. C. The diagnosis of primary (spontaneous) bacterial peritonitis is not confirmed because the percentage of neutrophils in the peritoneal fluid is less than 50%. D. The mostly causative organism for his condition is enterococcus. E. The yield of peritoneal fluid cultures for diagnosis is greater than 90%. :  IV-24. A 48-year-old woman with a history of end-stage renal disease caused by diabetic renal disease is admitted to the hospital with 1 day of abdominal pain and fever. She has been on continuous ambulatory peritoneal dialysis (CAPD) for the past 6 months. She reports that for the past day she has had poor return of dialysate and is feeling bloated. She has had complications from her diabetes, including retinopathy and peripheral neuropathy. She is uncomfortable but not toxic. Her vital signs include a temperature of 38.8°C, blood pressure of 130/65 mmHg, heart rate of 105 beats/min, and respiratory rate of 15 breaths/min with room air O2 saturation of 98%. Her abdomen is slightly distended and diffusely tender with rebound tenderness. A sample of dialysate reveals WBC 400/µL with 80% neutrophils. Empiric intraperitoneal antibiotic therapy should include: A. Cefoxitin B. Fluconazole C. Metronidazole D. Vancomycin E. Voriconazole IV-25. A 77-year-old man presents to the hospital with 1 week of fever, chills, nausea, and right upper quadrant pain. His temperature is 39°C, and he appears toxic. His blood pressure is 110/70 mmHg, heart rate is 110 beats/min, and respiratory rate is 22 breaths/min with room air O2 saturation 92%. He has diminished breath sounds at the right base and diffuse tenderness in the right upper quadrant. He has a history of cholelithiasis but has declined elective cholecystectomy. His CT scan of the abdomen is shown in Figure IV-25A. Which of the following statements regarding his condition or therapy is true? FIGURE IV-25A A. Concomitant bacteremia is rare (4.5, clue cells, and profuse mixed microbiota on microscopic examination C. Vaginal fluid pH ≥5.0, motile trichomonads on microscopic exam, and fishy odor with 10% KOH D. Vaginal fluid pH patient Z > patient X C. Patient Y > patient X > patient Z D. Patient X > patient Y > patient Z E. Patient Z > patient X > patient Y IV-202. A 72-year-old man is admitted to the hospital with bacteremia and pyelonephritis. He is HIV-negative and has no other significant past medical history. Two weeks into his treatment with antibiotics, a fever evaluation reveals a blood culture positive for Candida albicans. Examination is unremarkable. White blood cell count is normal. The central venous catheter is removed, and systemic antifungal agents are initiated. What further evaluation is recommended? A. Abdominal CT scan to evaluate for abscess B. Chest radiography C. Funduscopic examination D. Repeat blood cultures E. Transthoracic echocardiography :  IV-203. A local oncology center is concerned about the occurrence of an outbreak of cases of invasive Aspergillus in patients receiving bone marrow transplants. Which of the following is the most likely source of Aspergillusinfection? A. Contaminated air source B. Contaminated water source C. Patient-to-patient spread in outpatient clinic waiting rooms D. Provider-to-patient spread because of poor hand washing technique E. Provider-to-patient spread because of poor utilization of alcohol disinfectant IV-204. A 23-year-old man receiving chemotherapy for relapsed acute myelogenous leukemia has had persistent neutropenia for the past 4 weeks. Over the past 5 days, his absolute neutrophil count has risen from zero to 200 cells/mm3, and he has had persistent fevers despite receiving cefepime and vancomycin empiric therapy. Other than fever, tachycardia, and malaise, he has no focal findings, and his vital signs are otherwise unremarkable, including a normal oxygen saturation on room air. A chest and abdomen CT performed because of the fever shows a few scattered 1- to 2-cm nodules with surrounding ground glass infiltrates in the lower lobes. Which of the following test results will most likely be positive in this patient? A. Serum cryptococcal antigen B. Serum galactomannan assay C. Sputum fungal culture D. Urine Histoplasma antigen E. Urine Legionella antigen IV-205. In the patient described above, which of the following medications should be initiated immediately? A. Amphotericin B B. Caspofungin C. Fluconazole D. Trimethoprim–sulfamethoxazole E. Voriconazole IV-206. A 40-year-old male smoker with a history of asthma is admitted to the inpatient medical service with fever, cough, brownish-green sputum, and malaise. Physical examination shows a respiratory rate of 15 breaths/min, no use of accessory muscles of breathing, and bilateral polyphonic wheezes throughout the lung fields. There is no :  clubbing or skin lesions. You consider a diagnosis of allergic bronchopulmonary aspergillosis. All the following clinical features are consistent with allergic broncho- pulmonary aspergillosis EXCEPT: A. Bilateral peripheral cavitary lung infiltrates B. Elevated serum IgE C. Peripheral eosinophilia D. Positive serum antibodies to Aspergillus spp. E. Positive skin testing for Aspergillus spp. IV-207. A 26-year-old patient with asthma continues to have coughing fits and dyspnea despite numerous steroid tapers and frequent use of albuterol over the past few months. Persistent infiltrates are seen on chest radiography. A pulmonary consultation suggests an evaluation for allergic bronchopulmonary aspergillosis. Which of the following is the best diagnostic test for this diagnosis? A. Bronchoalveolar lavage (BAL) with fungal culture B. Galactomannan enzyme immunoassay (EIA) C. High-resolution CT D. Pulmonary function tests E. Serum IgE level IV-208. Patients with which of the following have the lowest risk of invasive pulmonary Aspergillus infection? A. Allogeneic stem cell transplant with graft-versus-host disease B. HIV infection C. Long-standing high-dose glucocorticoids D. Post-solid organ transplant with multiple episodes of rejection E. Relapsed or uncontrolled leukemia IV-209. Patients with all of the following conditions have increased risk of developing mucormycosis EXCEPT: A. Deferoxamine therapy B. Factitious hypoglycemia C. Glucocorticoid therapy D. Metabolic acidosis E. Neutropenia :  IV-210. A 36-year-old woman with a history of diabetes mellitus, hypertension, and chronic renal insufficiency reports comes to the emergency department complaining of double vision for 1 day. She is on chronic hemodialysis and missed her last appointment. She also notes 12 hours of facial swelling and difficulty speaking. Her vital signs are notable for a temperature of 39.0°C and blood pressure 155/95 mmHg. Her facial examination is shown in Figure IV-210. Laboratory examination reveals a white blood cell count of 15,000/µL, serum glucose of 205 mg/dL, serum creatinine of 6.3 mg/dL, and hemoglobin A1c of 9.7%. Arterial blood gas on room air is pH of 7.24, PCO2 of 20 mmHg, and PO2 of 100 mmHg. Needle biopsy of a retro-orbital mass reveals wide, thick–walled, ribbon-shaped nonseptate hyphal organisms that branch at 90 degrees with tissue and vascular invasion on PAS stain. All of the following are components of the initial therapy EXCEPT: FIGURE IV-210 (see Color Atas) A. Hemodialysis B. Insulin C. Liposomal amphotericin B D. Surgical debridement E. Voriconazole :  IV-211. Which of the following is the most common form of infection in patients with mucormycosis? A. Cutaneous B. Gastrointestinal C. Hematogenous dissemination D. Pulmonary E. Rhinocerebral IV-212. A 21-year-old college student seeks your opinion because of a lesion on his head. He has no significant medical history and reports a solitary lesion on the crown of his head for more than month that has been growing slowly. He has had no fever and reports that although the area is itchy, he feels well. On examination, you note a 3-cm round area of alopecia without redness, pain, or inflammation. It is well demarcated with central clearing, scaling, and broken hair shafts at the edges. There is no redness or pain. Which of the following should you recommend? A. Caspofungin B. Clindamycin C. Doxycycline D. Minoxidil E. Terbinafine IV-213. A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand. She reports that the area on the back of her right hand was initially red and not painful. There appeared to be a puncture wound in the center of the area, and she thought she had a simple scratch acquired while gardening. Over the next several days, the lesion became verrucous and ulcerated. Now the patient has noticed several nodular areas along the arm, one of which ulcerated and began draining a serous fluid today. She is also noted to have an enlarged and tender epitrochlear lymph node on the right arm. A biopsy of the edge of the lesion shows ovoid and cigar-shaped yeasts. Sporotrichosis is diagnosed. What is the most appropriate therapy for this patient? A. Amphotericin B intravenously B. Caspofungin intravenously C. Clotrimazole topically D. Itraconazole orally E. Selenium sulfide topically :  IV-214. A 35-year-old woman with long-standing rheumatoid arthritis has been treated with infliximab for the past 6 months with improvement of her joint disease. She has a history of positive PPD and takes INH prophylaxis. For the past week, she reports worsening dyspnea on exertion with low-grade fevers and a nonproductive cough. On examination, her vital signs are notable for normal blood pressure, temperature of 38.0°C, heart rate of 105 beats/min, respiratory rate of 22 breaths/min, and SaO2 of 91% on room air. Her lungs are clear. Within one flight of steps, she becomes dyspneic, and her SaO2 falls to 80%. A chest CT scan is shown in Figure IV-214. Which of the following is the most likely diagnosis? FIGURE IV-214 A. Aspergillus fumigatus pneumonia B. Nocardia asteroides pneumonia C. Pneumocystis jiroveci pneumonia D. Rheumatoid nodules E. Staphylococcal bacteremia and septic pulmonary emboli IV-215. Which of the following patients should receive prophylaxis against Pneumocystis jiroveci pneumonia? A. A 19-year-old woman with acute myelogenous leukemia initiating induction chemotherapy B. A 24-year-old man with HIV initiated on HAART therapy 9 months ago when his CD4 count was 100/µL and now has a CD4 count of 500/µL for the past 4 months C. A 36-year-old man with newly diagnosed HIV and a CD4 count of 300/µL :  D. A 42-year-old woman with rheumatoid arthritis who recovered from an episode of Pneumocystis pneumonia while taking infliximab who is now initiating therapy with abatacept E. A 56-year-old man with COPD receiving prednisone for an acute exacerbation IV-216. A 45-year-old woman with known HIV infection and medical nonadherence to therapy is admitted to the hospital with 2 to 3 weeks of increasing dyspnea on exertion and malaise. A chest radiograph shows bilateral alveolar infiltrates, and induced sputum is positive for Pneumocystis jiroveci. Which of the following clinical conditions is an indication for administration of adjunct glucocorticoids? A. Acute respiratory distress syndrome B. CD4+ lymphocyte count 5% affected erythrocytes on peripheral smear D. Serum bilirubin level of >2 mg/dL E. The presence of headache IV-221. A 51-year-old woman is diagnosed with Plasmodium falciparum malaria after returning from a safari in Tanzania. Her parasitemia is 6%, hematocrit is 21%, bilirubin is 7.8 mg/dL, and creatinine is 2.7 mg/dL. She is still making 60 mL/hr of urine. She rapidly becomes obtunded. Intensive care is initiated with frequent creatinine checks, close monitoring for hypoglycemia, infusion of phenobarbital for seizure prevention, mechanical ventilation for airway protection, and exchange transfusion to address her high parasitemia. Which of the following regimens is recommended as first-line treatment for her malarial infection? A. Chloroquine B. Intravenous artesunate C. Intravenous quinine D. Intravenous quinidine E. Mefloquine IV-222. A 28-year-old woman presents with fevers, headache, diaphoresis, and abdominal pain 2 days after returning from an aid mission to the coast of Papua New Guinea. Several of her fellow aid workers developed malaria while abroad, and she stopped her doxycycline prophylaxis because of a photosensitivity reaction 5 days earlier. You send blood cultures, routine labs, and a thick and thin smear to evaluate the source of her fevers. Which of the following statements is accurate in reference to diagnosis of malaria? A. A thick smear is performed to increase sensitivity compared with a thin smear but can only be performed in centers with experienced laboratory personnel and has a longer processing time. B. Careful analysis of the thin blood film allows for prognostication based on estimation of parasitemia and morphology of the erythrocytes. C. In the absence of rapid diagnostic information, empirical treatment for malaria should be strongly considered. D. Morphology on blood smear is the current criterion used to differentiate the four species of Plasmodium that infect humans. :  E. All of the above are true. IV-223. A 19-year-old college student is employed during the summer months on Nantucket Island in Massachusetts. She is evaluated in the local emergency department with 5 days of fever, malaise, and generalized weakness. Although she does recall a tick bite approximately 6 weeks ago, she denies rash around that time or presently. Physical examination is unremarkable with the exception of a temperature of 39.3°C. Which of the following statements is true regarding her most likely illness? A. B. duncani is the most likely organism to be found in her peripheral blood smear. B. First-line therapy for severe disease in this patient is immediate complete RBC exchange transfusion in addition to clindamycin and quinine. C. If babesiosis is not demonstrated on thick or thin preparations of peripheral blood, PCR amplification of babesial 18S rRNA is recommended. D. The ring form of B. microti seen in red blood cells on microscopy is indistinguishable from Plasmodium falciparum. E. Without a current or historical rash, she is unlikely to have babesiosis. IV-224. A 35-year-old man from India is seen for evaluation of several weeks of fever that has decreased in intensity, but he now has developed abdominal swelling. He has no significant past medical history. Physical examination shows palpable splenomegaly and hepatomegaly and diffuse lymphadenopathy. Diffuse hyperpigmentation is present in his skin. Visceral leishmaniasis is suspected. Which of the following diagnostic techniques is most commonly used? A. Culture of peripheral blood for Leishmania spp. B. PCR for L. infantum nucleic acid in peripheral blood C. Rapid immunochromatographic test for recombinant antigen rK39 from L. infantum D. Smear of stool for amastigotes E. Splenic aspiration to demonstrate amastigotes IV-225. All of the following statements regarding infection with Trypanosoma cruzi are true EXCEPT: A. It is found only in the Americas. B. It is the causative agent of Chagas disease. C. It is transmitted to humans by the bite of deer flies. D. It may be transmitted to humans by blood transfusion. E. It may cause acute and chronic disease. :  IV-226. A 36-year-old man is admitted to the hospital with 3 months of worsening dyspnea on exertion and orthopnea. Over the past 2 weeks, he has been sleeping upright. He denies any chest pain with exertion or syncope. There is no history of hypertension, hyperlipidemia, or diabetes. He is a lifelong nonsmoker and since arriving to the United States from rural Mexico 16 years ago works as an electrician. His physical examination is notable for being afebrile with a heart rate 105 beats/min, blood pressure of 100/80 mmHg, respiratory rate of 22 breaths/min, and oxygen saturation of 88% on room air. He has notable jugular venous distension upright with no Kussmaul sign, 3+ pitting edema to the knees, and bilateral crackles two-thirds up the lung fields. Cardiac examination shows a laterally displaced PMI, a 2/6 systolic murmur at the apex and axilla, an S3, and no friction rub or pericardial knock. Which of the following is likely to reveal the most likely diagnosis? A. Coronary angiography B. Right heart catheterization C. Serum PCR for T. cruzi DNA D. Serum T. cruzi IgG antibodies E. Serum troponin IV-227. A 36-year-old medical missionary recently returned from a 2-week trip to rural Honduras. During the trip, she lived in the jungle, where she received multiple bug bites and developed open sores. One week after her return, she comes to the clinic reporting 2 days of malaise, fever to 38.5°C, and anorexia. There is an indurated swollen area of erythema on her calf and femoral adenopathy. Because of her exposure history, you obtain a thin and thick blood smear that demonstrates organisms consistent with T. cruzi. Which of the following is the best next intervention? A. Immediate therapy with benznidazole B. Immediate therapy with primaquine C. Immediate therapy with voriconazole D. Observation only E. Serologic confirmation with specific T. cruzi IgG testing IV-228. A 44-year-old man who recently returned from a safari trip to Uganda seeks attention for a painful lesion on the leg and new fevers. He was on a safari tour, where he stayed in the animal park that was populated extensively with antelope, lions, giraffes, and hippos. They often toured savannah and jungle settings. He returned within the past week and noticed a painful lesion on his neck at the site of some bug bites. He reports fever over 38°C, and you find palpable cervical lymphadenopathy. Review of systems is notable for malaise and anorexia for 2 days. A thick and thin smear of the blood reveals protozoa consistent with trypanosomes. All of the following are true about his disease EXCEPT: A. Humans are the primary reservoir. :  B. If untreated, death is likely. C. It was transmitted by the bite of a tsetse fly. D. Lumbar puncture should be performed. E. Suramin is effective treatment. IV-229. A 36-year-old man with HIV/AIDS is brought to the hospital after a grand mal seizure at home. He has a history of ongoing IV drug use and is not taking HAART. His last CD4 T-cell count was below 50/µL more than 1 month ago. Further medical history is unavailable. Vital signs are normal. On examination, he is barely arousable and disoriented. He is cachectic. There is no nuchal rigidity or focal motor deficits. Serum creatinine is normal. An urgent head MRI with gadolinium is performed, and the results of the T1-gated images are shown in Figure IV-229. Which of the following will be the most effective therapy? A. Caspofungin B. INH, rifampin, PZA, and ethambutol C. Pyrimethamine plus sulfadiazine D. Streptokinase E. Voriconazole FIGURE IV-229 IV-230. Which of the following intestinal protozoal infections can be diagnosed with stool ova and parasite examination? A. Cryptosporidium spp. B. Cyclospora spp. C. Giardia spp. D. Isospora spp. :  E. Microsporidia spp. F. All of the above IV-231. A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge. She is sexually active with multiple partners, and she is interested in getting tested for sexually transmitted diseases. A wet-mount microscopic examination is performed, and trichomonal parasites are identified. Which of the following statements regarding trichomoniasis is true? A. A majority of women are asymptomatic. B. No treatment is necessary because the disease is self-limited. C. The patient’s sexual partner need not be treated. D. Trichomoniasis can only be spread sexually. E. Trichomoniasis is 100% sensitive to metronidazole IV-232. A 19-year-old college student presents to the emergency department with crampy abdominal pain and watery diarrhea that has worsened over 3 days. He recently returned from a volunteer trip to Mexico. He has no past medical history and felt well throughout the trip. Stool examination shows small cysts containing four nuclei, and stool antigen immunoassay is positive for Giardia spp. Which of the following is a recommend treatment regimen for this patient? A. Albendazole B. Clindamycin C. Giardiasis is self-limited and requires no antibiotic therapy D. Paromomycin E. Tinidazole IV-233. A 28-year-old woman is brought to the hospital because of abdominal pain, weight loss, and dehydration. She has been diagnosed with HIV/AIDS for the past 2 years with a history of oral candidiasis and pneumocystis pneumonia. She reports voluminous watery diarrhea over the past 2 weeks. Because of medical nonadherance, she has not taken any antiretroviral therapy. Routine stool ova and parasite examination is normal, but stool antigen testing reveals Cryptosporidium spp. Which of the following is the recommended therapy? A. Metronidazole B. Nitazoxanide C. No therapy recommended because the diarrhea is self-limited. D. No effective specific therapy is available. E. Tinidazole :  IV-234. Which of the following has resulted in a significant decrease in the incidence of trichinellosis in the United States? A. Adequate therapy that allows for eradication of infection in index cases before person- to-person spread can occur B. Earlier diagnosis because of a new culture assay C. Federal laws limiting the import of foreign cattle D. Laws prohibiting the feeding of uncooked garbage to pigs E. Requirements for handwashing by commercial kitchen staff who handle raw meat IV-235. A patient comes into the clinic and describes progressive muscle weakness over several weeks. He has also experienced nausea, vomiting, and diarrhea. One month ago, he had been completely healthy and describes a bear hunting trip in Alaska, where they ate some of the game they killed. Soon after he returned, his gastrointestinal symptoms began followed by muscle weakness in his jaw and neck that has now spread to his arms and lower back. Examination confirms decreased muscle strength in the upper extremities and neck. He also has slowed extraocular movements. Laboratory examination shows panic values for elevated eosinophils and serum creatine phosphokinase. Which of the following organisms is most likely the cause of his symptoms? A. Campylobacter spp. B. Cytomegalovirus C. Giardia spp. D. Taenia solium E. Trichinella spp. IV-236. A 3-year-old boy is brought by his parents to the clinic. They state that he has experienced fevers, anorexia, weight loss, and most recently has started wheezing at night. He had been completely healthy until these symptoms started 2 months ago. The family had travelled through Europe several months earlier and reported no unusual exposures or exotic foods. They have a puppy at home. On examination, the child is ill- appearing and is noted to have hepatosplenomegaly. Laboratory results show a panic value of 82% eosinophils. Total white blood cells are elevated. A complete blood count is repeated to rule out a laboratory error, and eosinophils are 78%. Which of the following is the most likely organism or process? A. Cysticercus spp. B. Giardiasis C. Staphylococcus lugdunensis D. Toxocariasis E. Trichinellosis :  IV-237. The patient described above continues to decline over the next 2 to 3 days, developing worsening respiratory status, orthopnea, and cough. On physical examination, his heart rate is 120 beats/min, blood pressure is 95/80 mmHg, respiratory rate is 24 breaths/min, and oxygen saturation is 88% on room air. His neck veins are elevated, there is an apical S3, and his lungs have bilateral crackles halfway up the lung fields. An echocardiogram shows an ejection fraction of 25%. Which of the following therapies should be initiated? A. Albendazole B. Methylprednisolone C. Metronidazole D. Praziquantel E. Vancomycin IV-238. A 28-year-old man is brought to the emergency department by his wife for altered mental status, fevers, vomiting, and headache. He developed a bilateral headache began about 1 day ago that has progressively worsened. He and his wife returned from a trip to Thailand and Vietnam, where they spent a lot of time in rural settings eating local mollusks, seafood, and vegetables. His physical examination is notable for fever, nuchal rigidity, confusion, and lethargy. Lumbar puncture reveals elevated opening pressure; elevated protein; normal glucose; and white blood cell count of 200/µL with 50% eosinophils, 25% neutrophils, and 25% lymphocytes. Which of the following is the most likely etiology of his meningitis? A. Angiostrongylus cantonensis B. Gnathostoma spinigerum C. Trichinella murrelli D. Trichinella nativa E. Toxocara canis IV-239. While attending the University of Georgia, a group of friends go on a 5-day canoeing and camping trip in rural southern Georgia. A few weeks later, one of the campers develops a serpiginous, raised, pruritic, erythematous eruption on the buttocks. Strongyloides larvae are found in his stool. Three of his companions, who are asymptomatic, are also found to have Strongyloides larvae in their stool. Which of the following is indicated in the asymptomatic carriers? A. Fluconazole B. Ivermectin C. Mebendazole D. Mefloquine :  E. Treatment only for symptomatic illness IV-240. All of the following are clinical manifestations of Ascaris lumbricoides infection EXCEPT: A. Asymptomatic carriage B. Fever, headache, photophobia, nuchal rigidity, and eosinophilia C. Nonproductive cough and pleurisy with eosinophilia D. Right upper quadrant pain and fever E. Small bowel obstruction IV-241. A 21-year-old college student in Mississippi comes to student health to ask advice about treatment for ascaris infection. He is an education major and works 1 day a week in an elementary school, where a number of the students were recently diagnosed with ascariasis over the past 3 months. He feels well and reports being asymptomatic. A stool O&P reveals characteristic ascaris eggs. Which of the following should you recommend? A. Albendazole B. Diethylcarbamazine (DEC) C. Fluconazole D. Metronidazole E. Vancomycin IV-242. A 38-year-old woman presents to the emergency department with severe abdominal pain. She has no past medical or surgical history. She recalls no recent history of abdominal discomfort, diarrhea, melena, bright red blood per rectum, nausea, or vomiting before this acute episode. She ate ceviche (lime-marinated raw fish) at a Peruvian restaurant 3 hours before presentation. On examination, she is in terrible distress and has dry heaves. Her temperature is 37.6°C, heart rate is 128 beats/min, and blood pressure is 174/92 mmHg. Examination is notable for an extremely tender abdomen with guarding and rebound tenderness. Bowel sounds are present and hyperactive. Rectal examination findings are normal, and Guaiac test result is negative. The pelvic examination is unremarkable. The white blood cell count is 6738/µL and hematocrit is 42%. A complete metabolic panel and lipase and amylase levels are all within normal limits. CT of the abdomen shows no abnormality. What is the next step in her management? A. CT angiogram of the abdomen B. Pelvic ultrasonography C. Proton pump inhibitor therapy and observation D. Right upper quadrant ultrasonography E. Upper endoscopy :  IV-243. While participating in a medical missionary visit to Indonesia, you are asked to see a 22-year-old man with new onset of high fever, groin pain, and a swollen scrotum. His symptoms have been present for about 1 week and worsening steadily. His temperature is 38.8°C, and his examination is notable for tender inguinal lymphadenopathy, scrotal swelling with a hydrocele, and lymphatic streaking. All of the following may be useful in diagnosing his condition EXCEPT: A. Examination of blood B. Examination of hydrocele fluid C. Scrotal ultrasonography D. Serum ELISA E. Stool O&P IV-244. The patient described above should be treated with which of the following medications? A. Albendazole B. Diethylcarbamazine (DEC) C. Doxycycline D. Ivermectin E. Praziquantel IV-245. A 45-year-old woman is brought to the Emergency department by her daughter because she saw something moving in her mother’s eye. The patient is visiting from Zaire, where she lives in the rain forest. The patient reports some occasional eye swelling and redness. On examination, you find a worm in the subconjunctiva (Figure IV-245). Which of the following medications is indicated for therapy? :  FIGURE IV-245 (see Color Atlas) A. Albendazole B. Diethylcarbazine (DEC) C. Ivermectin D. Terbinafine E. Voriconazole IV-246. All of the following statements regarding the epidemiology of schistosomal infection are true EXCEPT: A. S. haematobium infection is seen mostly in South America. B. S. japonicum infection is seen mostly in China, Philippines, and Indonesia. C. S. mansoni infection is seen in Africa, South America, and the Middle East. D. Schistosomal infection causes acute and chronic manifestations. E. Transmission of all human schistosomal infections is from snails. IV-247. A 48-year-old female presents to her physician with a 2-day history of fever, arthralgias, diarrhea, and headache. She recently returned from an ecotour in tropical sub- Saharan Africa, where she went swimming in inland rivers. Notable findings on physical examination include a temperature of 38.7°C (101.7°F); 2-cm tender mobile lymph nodes in the axilla, cervical, and femoral regions; and a palpable spleen. Her white blood cell count is 15,000/µL with 50% eosinophils. She should receive treatments with which of the following medications? A. Chloroquine :  B. Mebendazole C. Metronidazole D. Praziquantel E. Thiabendazole IV-248. A person with liver disease caused by Schistosoma mansoni would be most likely to have what condition? A. Ascites B. Esophageal varices C. Gynecomastia D. Jaundice E. Spider nevi IV-249. A 26-year-old man is brought to the emergency department after the onset of a grand mal seizure. On arrival to the hospital, the seizure had terminated, and he was somnolent without focal findings. Vital signs were normal except for tachycardia. The patient has no known medical history and no history of illicit drug or alcohol use. He takes no medications. At a routine clinic visit 3 months earlier, he was documented to be HIV antibody and PPD negative. He is originally from rural Guatemala and has been in the United States working as a laborer for the past 3 years. A contrast CT shows multiple parenchymal lesions in both hemispheres that are identical to the one shown in the posterior right brain (Figure IV-249). After acute stabilization, including anticonvulsant therapy, which of the following is the most appropriate next step in this patient’s management? :  FIGURE IV-249 A. Echocardiogram with Doppler examination of aortic and mitral valves B. Initiation of praziquantel therapy C. Initiation of pyrimethamine and sulfadiazine therapy D. Measurement of HIV viral load E. Neurosurgical consultation for brain biopsy IV-250. A 44-year-old woman presents to the emergency department with recurrent episodes of right upper quadrant pain, typically soon after meals. These episodes have been present for at least 1 month and seem to be worsening. The patient emigrated from Lebanon more than 20 years ago and works as an attorney. She takes no medications and is physically active. On examination, she is jaundiced and in obvious discomfort because of right upper quadrant pain. She is afebrile and tachycardic. Her physical examination is notable for an enlarged liver. Ultrasound examination confirms the large liver and demonstrates a complex 14-cm cyst with daughter cysts extending to the liver edge with associated biliary tract dilation. Which of the following is the most appropriate management approach to this patient? A. Albendazole medical therapy B. Albendazole followed by surgical resection C. Needle biopsy of the cystic lesion D. PAIR (percutaneous aspiration, infusion of scolicidal agent, and reaspiration) :  E. Serologic testing for E. granulosus Previous Page Next Page  Contents If you find an error or have any questions, please email us at  [email protected]. Thank you! :      Doctorlib © 2015-2023 / Historical Library / Privacy Policy :