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PaEasy Infectious Disease
Terms in this set (24)
Which of the following is the appropriate treatment for acute Clostridium tetani infection?
tetanus immune globulin, tetanus toxoid, and metronidazole
Clostridial tetani infection is a vaccine-preventable disease that results in approximately 50 cases/yr in the United States. Even with modern medical resources, one of four or one of five patients with generalized tetanus dies. Almost all cases occur in individuals who are not properly immunized. Sixty percent of cases occur in older adults for whom immunity has waned. Tetanus presents in different forms including generalized, localized, cephalad, and neonatal. Generalized is the most common and symptoms include mood changes, trismus, diaphoresis, dysphagia, and drooling. Later symptoms include painful flexion and adduction of the arms and pain with extension of the legs. Convulsions and spasms are possible, along with a variety of autonomic symptoms. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole has been demonstrated to be the most effective antimicrobial. Labetalol may be used for catecholamine-induced hypertension but the patient must also be monitored for hypotension and bradycardia.
A 32-year-old man presents to the urgent care center with a concern of scrotal tenderness that began 3 days ago and has now worsened. Physical examination reveals a temperature of 100.7°F, positive tenderness in the posterolateral aspect of the right testis with swelling, spermatic cord tenderness with palpation, and no transillumination. What is this patient's most likely diagnosis?
D testicular torsion
A Pain and swelling are prominent features of epididymitis; fever and abdominal pain may also be present. Epididymitis is caused by an ascending infection that without treatment will continue to the testicles, causing a significant swelling that will make it difficult for the clinician to distinguish between the epididymis and the testicles (epididymo-orchitis). Orchitis alone is most commonly viral (mumps) and observed in prepubertal boys. In men younger than 30 years, epididymitis can be confused with torsion.
A 16-year-old boy presents to the office with complaints of a rash, low-grade fever, headache, and malaise. Symptoms began yesterday after he spent most of his free time in the past 4 days deer hunting in the woods around his house. He reports that he does check himself for ticks every night. He often finds them but has not noticed any this season that were latched on to his skin. On examination, his temperature is noted to be 99.9°F, his HEENT is unremarkable, and he has 1 to 2 mm red macules over wrists and ankles with remainder of skin clear. Heart, lungs, and abdomen unremarkable. The most likely diagnosis in this patient is
A Lyme disease
B Rocky Mountain spotted fever
D Q fever
B Rocky Mountain spotted fever (RMSF) is a rickettsial infection caused by Ricketsia ricketsii. The organism is transmitted to humans through the bite of the dog tick and is more common among those who spend time outdoors in a wooded area. The illness begins with generalized symptoms of fever, headache, nausea, vomiting, malaise, and myalgias. The rash of RMSF begins as a macular rash and progresses to nonblanching petechiae. The rash begins over the wrists and ankles and progresses to the arms, legs, and trunk. Untreated, it can progress to respiratory failure and/or central nervous system involvement. Serologic confirmation is not usually valid until 7 to 10 days after clinical symptoms begin so treatment is often begun empirically. Drug of choice is doxycycline 100 mg po bid until the patient is afebrile and clinically better for 2 to 3 days. Lyme disease is distinguished from RMSF by the pattern of the rash. Lyme disease is characterized by the classic erythema chronicum migrans rash, usually on the trunk. Ehrlichiosis usually does not manifest with a rash. It begins with the same general symptoms but can progress to a toxic shock syndrome. Q fever can be transmitted by ticks, but it is often acquired through contact with sheep, cattle, and goats. It has similar generalized symptoms but can progress to a cough and pneumonia. It is usually without rash. All of these illnesses respond to doxycycline.
A 17-year-old female patient presents to your family practice office complaining of a persistent sore throat for the past 2 weeks duration. She is extremely fatigued, and she tells you that her boyfriend has had similar symptoms for about a week. Her vital signs are a blood pressure of 116/72 mm Hg, pulse 88 beats/min, respirations of 16 beats/min, and temperature of 101.1˚F taken orally. Her white blood cell count (WBC) reveals 14,800 mcL with more than 10% atypical lymphocytes. On physical examination you find significant yellowish-grey pharyngeal exudate, cervical lymphadenopathy as well as an enlarged spleen. Her rapid strep is negative. What should be your treatment of this patient?
A Begin treatment with cephalexin.
B Send out a back-up throat culture and begin treatment with cephalexin pending those results.
C Send out a back-up throat culture and hold treatment pending those results.
D Draw a Monospot test and treat the patient supportively pending the results, insuring that they avoid contact sports until a definitive diagnosis has been made.
E Draw an Epstein-Barr virus (EBV) IgG level and treat the patient supportively if positive.
Draw a Monospot test and treat the patient supportively pending the results, insuring that they avoid contact sports until a definitive diagnosis has been made.
With this patient's presentation and a negative rapid strep test, other etiologies beyond group A beta-hemolytic strep should be seriously considered. In light of her symptoms including fatigue, her WBC, and that her significant other is having similar symptoms, infectious mononucleosis is highest on the differential diagnosis. A Monospot test would rule this possibility in or out. She should refrain from contact sports until her infection and any associated splenomegaly has resolved.
The two major risk factors for human immunodeficiency virus (HIV) infection in American women are intravenous drug use and which of the following?
A history of blood transfusion
B needle stick injuries
C pelvic inflammatory disease
D sexual contact with an infected male
E use of oral contraceptives
Sexual contact with an infected male
D The major risk factors for HIV infection in American women are intravenous drug use (33%) and heterosexual contact with an infected partner (65%). Thanks to universal blood donor screening using the HIV ELISA, antigen, and viral load testing, the risk for any person contracting HIV from a screened unit of blood is only 1:1,000,000. The risk for any person following a needle-stick injury is about 1:300 with deeper sticks, hollow bore needles, visible blood on the needle, and advanced stage of disease in the source increasing the risk. HIV infection puts a woman at increased risk for gynecologic complications such as pelvic inflammatory disease. Unlike the use of latex condoms, the use of oral contraceptives does not protect against HIV transmission, but is not, per se, a risk factor for HIV infection.
Of the following sexual practices, which poses the greatest risk of HIV transmission when practiced with an infected partner but without the use of a reliable barrier method of prophylaxis?
A insertive anal intercourse
B insertive vaginal intercourse
C receptive anal intercourse
D receptive fellatio with ejaculation
E receptive vaginal intercourse
Receptive anal intercourse
C In unprotected intercourse with an infected partner, receptive anal intercourse carries a risk of HIV transmission between 1:100 and 1:30. Insertive anal intercourse, receptive vaginal intercourse, and fellatio with ejaculation each carry a risk of about 1:1000. Insertive vaginal intercourse carries a risk of 1:10,000.
A 65-year-old female presents to the primary care office with epigastric pain and nausea. Which of the following is a spiral gram-negative rod that resides beneath the gastric mucosa layer and causes gastric mucosal inflammation, with polymorphonuclear cells and lymphocytes?
A Treponema pallidum
B Borrelia burgdorferi
C Corynebacterium diphtheriae
D Helicobacter pylori
E Giardia lamblia
D The correct answer is helicobacter pylori. Treponema pallidum is a spirochete that is capable of infection in almost any organ or tissue in the body, and causes protean clinical manifestations. It is most commonly associated with syphilis. Borrelia burgdorferi is a spirochete and is associated with Lyme disease. Corynebacterium diphtheriae is a bacterium that infects the respiratory tract and is associated with diphtheria. Giardia lamblia is a protozoal infection of the upper small intestine and is associated with giardiasis.
Which of the following statement or statements is/are true regarding influenza vaccination?
A The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for all persons six months of age and older without specific contraindications.
B In spite of the fact that the influenza vaccine is FDA category C, ACIP still recommends immunizing pregnant women or women who are planning to get pregnant during the upcoming influenza season.
C In spite of the manufacturing method of the current influenza vaccine using chicken embryos, ACIP recommends vaccination persons with known allergies to eggs if they can eat baked products manufactured in the US without having an allergic reaction.
D If an unvaccinated person develops a flu-like illness early in the influenza season, ACIP recommends that they receive an influenza vaccine once their febrile illness has resolved.
E All of the above is true.
All of the above is true
Influenza (the flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death, especially in certain populations. Some people, such as older people, young children, and people with certain health conditions including pregnancy, are at the highest risk for serious flu complications. The best way to prevent the flu is by getting vaccinated each year. The vaccine contains three strains (two of influenza A and one of influenza B) and is derived from chicken embryos and people with severe egg allergies should not be vaccinated. However, if a person is able to eat backed goods manufactured in the United States, according to the CDC, their potential level of allergy is so low that the benefit of vaccination outweighs any reaction. Once a vaccine-eligible patient has a viral-like illness and their fever resolves, he or she should receive the annual influenza vaccine.
A 16-year-old girl presents to the office complaining of a very sore throat, swollen lymph nodes, fever, and general malaise. Her examination reveals a temperature of 102.2°F, enlarged exudative tonsils, tender cervical lymphadenopathy, and borderline enlarged spleen. Rapid strep screen is negative. Which of the following laboratory findings best supports the most likely diagnosis?
A decreased white blood cell count
B increased monocytes on white cell differential
D decreased levels of antibody to Epstein-Barr viral capsid antigen
E increased atypical lymphocytes on white blood cell differential
increased atypical lymphocytes on white blood cell differential
With a negative rapid strep screen, the most likely explanation for this presentation is acute infectious mononucleosis. The fever, fatigue, tonsillar hypertrophy, and splenomegaly are all classic symptoms and signs. Laboratory evaluation often includes an elevated total white blood cell count with increased atypical lymphocytes on differential. Platelets may be decreased. Initially, IgM antibodies for the Epstein-Barr virus, and viral capsid antigen (VCA) levels will be elevated. Later, the IgG levels increase and IgM normalizes.
A 7-year-old girl is brought in by her mom for evaluation of a rash. She has had a fever for a few days and woke up this morning looking like she had been slapped on both cheeks. Other than supportive care, which instruction below represents the best patient education for this patient?
A She should remain out of school because she is contagious until the rash resolves.
B She may return to school but stay out of physical education class to avoid splenic injury.
C It spreads by the fecal-oral route, so she should wash her hands after using the bathroom.
D She may resume normal activities as her energy level improves.
She may resume normal activities as her energy level improves.
The "slapped cheek" appearance to the rash is consistent with a Parvovirus B19 etiology for erythema infectiosum. It is a droplet infection that is no longer contagious once the rash breaks out. It generally has a benign course and patients recover fully with supportive care. Splenic involvement is not typically a part of the course, so she may resume activities as she feels able
14-year-old girl presents 1 week after the neighbor's cat bit her hand. In the first 3 days after the bite she developed a shallow ulcer at the bite site. Because her parents knew the cat was up to date on shots, they treated the ulcer with topical antibiotics and did not seek medical care. Now, the patient has low-grade fever and headache and feels tired. Axillary nodes on the affected side are swollen. The ulcer on the hand is nearly healed. The best treatment option is
A doxycycline 100 mg bid × 21 days
B Augmentin 500 mg po bid × 10 days
C azithromycin 500 mg po qd × 7 days
D acyclovir 400 mg po bid × 10 days
E no therapy required
no therapy required
E The history and course of illness are consistent with cat-scratch fever. It is caused by infection with Bartonella henselae. Cat scratch or bite transmits it to humans. Clinical course usually begins with papule or ulcer at the site within a few days of the bite. Fever, headache, and malaise develop 7 to 21 days later. Lymph drainage of the site may result in swollen, tender, and/or suppurative nodes. Clinical diagnosis is the norm but special cultures or biopsy is possible. The symptoms usually resolve spontaneously with no specific therapy required. Complications may include encephalitis or disseminated disease in immunocompromised patients
Which of the following patients, without laboratory evidence of HIV, meets the Centers for Disease Control and Prevention case definition for acquired immunodeficiency syndrome (AIDS)?
A 29-year-old man with pulmonary tuberculosis
B 32-year-old man with Kaposi sarcoma
C 35-year-old woman with invasive cervical cancer
D 36-year-old man with recurrent Salmonella septicemia
E 40-year-old woman with recurrent pneumonia
B 32-year-old man with Kaposi sarcoma
B The Centers for Disease Control and Prevention AIDS case definition includes the following diseases that, with or without laboratory evidence of HIV infection, constitute a definitive diagnosis of AIDS: candidiasis of the esophagus, trachea, bronchi, or lungs; extrapulmonary cryptococcosis; cryptosporidiosis with diarrhea persisting more than 1 month; cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes; herpes simplex virus infection causing a mucocutaneous ulcer that persists longer than 1 month or causing bronchitis, pneumonitis, or esophagitis; Kaposi sarcoma in a patient younger than 60; lymphoma of the brain in a patient younger than 60; disseminated Mycobacterium avium complex or Mycobacterium kansasii disease; Pneumocystis jiroveci pneumonia; progressive multifocal leukoencephalopathy; or toxoplasmosis of the brain. Other conditions in the case definition require laboratory evidence of HIV infection.
What is the appropriate first line treatment of lyme disease in a non-pregnant adult female with erythema migrans and no other symptoms of lyme disease and no known drug allergies?
A Erythromycin 150 mg qid
B Ceftriaxone 1g IM
C Amoxicillin 500 mg q 8 hours
D Doxycycline 100 mg bid
Doxycycline 100 mg bid
D In patients over the age of 9 exhibiting skin or joint manifestations of lyme disease, the first line treatment is Doxycycline 100 mg bid. Patients less than 9 or those who are allergic to Doxycycline should be treated with amoxicillin. Erythromycin is fourth line treatment for all age groups. Ceftriaxone is first line for patients with nervous system involvement. (Wolff & Johnson, pg 691)
A physician assistant student suffers a needlestick injury while caring for an HIV-positive patient whose viral load is currently undetectable. Of the following, which is the most appropriate management for the student?
A no drug treatment unless HIV testing performed immediately and at 6 weeks, 3 months, and 6 months results become positive
B administration of zidovudine and lamivudine until results of baseline testing are received
C administration of zidovudine and lamivudine for 4 weeks
D administration of zidovudine, lamivudine, and indinavir for 4 weeks
administration of zidovudine and lamivudine for 4 weeks
After a needle-stick injury, a health-care worker should have baseline testing with follow-up testing at 6 weeks, 3 months, and 6 months. Risk of seroconversion is approximately 1:300. Administration of antiviral therapy decreases this risk by 79%, so the worker should be offered treatment with zidovudine and lamivudine as soon as possible after the injury, for a total of 4 weeks. However, workers with a high-risk exposure (source patient with advanced disease, a viral load >50,000, or with resistant organisms) should have a protease inhibitor added to the prophylactic regimen.
According to the Centers for Disease Control and Prevention (CDC), which of the following cannot be treated with a course of doxycycline 100 mg PO BID for 10 to 14 days?
B human monocytic ehrlichiosis (HME)
C Lyme disease
D Rocky Mountain spotted fever
E All can be treated with doxycycline.
All can be treated with Doxy
Human monocytic ehrlichiosis, Lyme disease and Rocky Mountain spotted fever are all tick-borne diseases causes by spirochetes and treated with doxycycline for 10 to 14 days. Babesiosis is an intracellular parasite and may not necessarily require treatment but, when warranted, the CDC recommends atovaquone plus azithromycin.
Which of the following organisms causes dysentery and has a cystic form that contaminates the water supply through poor handling of human sewage and can be spread through anal intercourse in homosexual men?
A Vibrio cholera
B Entamoeba histolytica
Entamoeba histolytica has two stages in its life cycle. In the active stage in the human intestine, it causes symptoms of dysentery, abdominal pain, stool mucus, and tenesmus. In the dormant stage, the cystic form is excreted in the stool and in developing nations frequently contaminates the supply of drinking water. When the amoeba is in the dormant stage, the cystic form can be excreted in the stool and, in the case of food handlers with poor personal hygiene, be transmitted to others. In addition, because of the cystic stage, individuals engaging in anal intercourse can transmit the infection unknowingly. Diagnosis is made by microscopic evaluation of a stool wet prep and confirmed by serology. Treatment includes agents such as metronidazole or tinidazole.
A 42-year-old man who is HIV positive develops fever of 38.8°C, mild nonproductive cough, and shortness of breath. He takes no medications other than a multivitamin tablet, does not smoke cigarettes, or use alcohol or illicit drugs. Of the following findings on diagnostic studies, which is most consistent with a diagnosis of Pneumocystic jiroveci pneumonia in this man?
A apical infiltrates on chest radiography
B bronchiolar consolidation on computed tomographic (CT) scan
C CD4 count of 300 cells/mL
D PO2 of 54 mm Hg
E serum lactate dehydrogenase (LDH) level of 54 units/L
PO2 of 54 mm Hg
Severe hypoxemia is a common finding in Pneumocystis pneumonia even when symptoms are not severe. The characteristic chest radiograph findings are diffuse or perihilar infiltrates. Apical infiltrates are more likely to be seen in patients who have been receiving aerosolized pentamidine prophylaxis. High-resolution chest CT scanning would most likely demonstrate interstitial lung disease. This pneumonia is rare unless the CD4 count is less than 250. An elevated LDH is found in about 95% of patients, but this is not specific.
What is the most serious complication of the influenza B virus?
A Multi-lobar pneumonia
C Reye's syndrome
D Renal failure
A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well-developed, well-nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits. What is the most likely cause of her symptoms?
1 Shigella flexneri
2 Staphylococcus aureus
3 Giardia lamblia
4 Salmonella typhimurium
Giardia lamblia is a flagellate protozoon that exists in trophozoite and cyst forms. The infective form is the cyst. Infection is found in the small intestine and the biliary tract. Symptomatic infections cause a wide array of clinical disease, ranging from asymptomatic infections to occasional acute watery diarrhea to a protracted illness that is characterized by flatulence, foul-smelling stools, abdominal pain and distention, and anorexia.
Humans are the main reservoir of infection, but organisms can infect dogs, cats, beavers, and other animals. Contaminated water supplies, mountain streams, and person-to-person contact are major sources for infection. The incubation period is 1 to 4 weeks.
The most widely used diagnostic tests include direct smear examination of stool specimens for trophozoites or cysts as well as immunofluorescence antibody testing of stool specimens or duodenal fluid. Treatment includes correction of any dehydration or electrolyte abnormalities present. Metronidazole is the drug of choice. Other alternatives include furazolidone, albendazole, and nitazoxanide.
A 20-year-old man spent his summer working in the forest on eastern shore of Maryland. A month after returning home to Virginia, he experienced a sudden onset of fever, nausea, muscle aches, and headaches. Blood and stool cultures were negative for obvious bacterial and parasitic pathogens. His symptoms subsided and he assumed he had recovered. 2 weeks later, the symptoms reappeared, now accompanied by marked splenomegaly. He also noticed a single, spreading rash with a pale halo surrounding a brighter red rash on the back of his right shoulder. It has been increasing in size and sensitivity. This time, a blood smear showed the presence of spirochetes. What is the MOST probable etiologic agent for the above illness?
Lyme disease, first detected in Lyme, Connecticut, is a bacterial infection caused by the spirochete Borrelia burgdorferi. It is a zoonotic (animal-to-human) infection within the deer and rat populations and accidentally transmitted to man through the bite of the deer tick, Ixodes dammini. Different arthropod vectors are instrumental in the transmission of other Borrelia infections. The extremely small size (< 2 mm) of deer ticks makes them difficult to detect, compared to the larger wood tick (Dermacentor andersoni) or dog tick (D. variabilis). A large, circular, red petechial rash usually develops at the site of the tick bite. It may grow to over 10 cm in diameter and can become surrounded by an even more extensive halo of less intense rash. The bacteria may cause joint pain (arthlagia) resulting in a form of arthritis.
The primary lesion grows into an enlarged rash as the spirochete proliferates and invades the blood and lymphatic vessels. The lesion usually disappears after several weeks. Some individuals progress into a second stage of infection involving neurologic or cardiac abnormalities. An arthritic response may develop months to years after the initial infection, probably due to an autoimmune response. This is indicative of the third stage of Lyme disease.
Relapsing fever is another disease caused by bacteria of the genus Borrelia. It can be either epidemic (louse-borne) or endemic (tick-borne). Syphilis and leptospirosis are diseases also caused by different spirochetes.
What class of medications are the antibiotics of choice for adults with acute pertussis?
Erythromycin, azithromycin, and clarythromycin are all acceptable choices for the acute treatment of pertussis. Trimethoprim-sulfamethoxazole is an acceptable alternative to the macrolides for allergy or macrolide intolerant patients.
A 49-year-old male presents with night sweats, weight loss, coughing, and shortness of breath. A urinalysis demonstrates hematuria. The patient has had a positive PPD skin test six months ago, but did not receive treatment. Which of the following suggests reactivation tuberculosis on chest x-ray?
A Fibrocavitary apical disease
B Diffuse small nodular densities
C Ghon complex
D Kerley B lines
E Pleural scarring
A Fibrocavitary apical disease
Primary tuberculosis, caused by inhalation and infection with M tuberculosis, is often without marked systemic symptoms or lung changes. Radiologic findings may include atelectasis, small infiltrates, and lympadenopathy (greatest in the hilar region), but initial x-rays may be negative. The immune system often contains the infection, and it remains latent until reactivated or appropriately treated. In some cases of primary tuberculosis, but more often in reactivated latent infection, systemic symptoms and lung infection with x-ray findings will occur. X-ray findings may include infiltrates, cavitary lesions, and nodules, with the apices and upper lobes commonly being involved.
A Ghon complex represents a calcified focus of previous infection, typically containing viable bacteria.
A pleural effusion may be present with active infection, and may lead to pleural scarring.
Kerley B lines are associated with congestive heart failure.
A 25-year-old woman presents not feeling well 1 week after returning from a trip to central Africa. She has had steadily increasing fever, abdominal distention, and diarrhea. She also has rashes on her abdomen, chest, and back, which are characterized by 3-mm pink papules, which blanch with pressure. Heart rate is 60 beats/min. Blood culture is positive but final identification is pending. Most likely diagnosis is
A typhoid fever
B yellow fever
A typhoid fever
Typhoid fever is caused by Salmonella typhus. It is contracted by contaminated food or water. There are several endemic areas throughout Africa. Symptoms and signs may be nonspecific but often include blanchable, pink, papular rash over the trunk and fever that increases in stepwise fashion. Blood culture is positive in 80% of cases in the first week. Abdominal symptoms may include distention and constipation, initially, followed by diarrhea and, possibly, splenomegaly. Prevention is accomplished by multidose oral or single-dose vaccine.
A 42-year-old male presents with a history of low grade fever, cough, and myalgias for five days. He states that these symptoms began after a cave exploration trip along the Ohio River two weeks ago, and have since worsened. An x-ray reveals focal consolidation, and you suspect Histoplasmosis pneumonia. Which of the following is the first line treatment of choice?
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