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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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1. How to dx IM?
Monospot test which screen heteropile ab that agglutinate horse rbc
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

2. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
AA gradient >35 or Po2 <70
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

3. HIV patient having fat deposition on back of neck and abdomen - like cushing
Gonococcal with purulent discharges and presence of multiple diplococi and neurotrophils in urethral swab; non gonoccal (chlamydia) are watery disch - swab abacterial - sometimes have intracellular organism
6-12 weeks
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Monospot test which screen heteropile ab that agglutinate horse rbc

4. reddish colored papules with central umbilication in HIV or immunocompromised patient
Think about cutaneous cryptococous; lesions looks like molluscus contagiousm. present in face/trunk/anywherer; dx biopsy of lesion which shows granulomatous inflammation with multinucleated giant cell
When patient is older >65 - pregnant - cardiac of pulmonary disease; patient without above risks are treated when they come within 48 hours of symptom onset
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Pt who have been treated before for latent TB

5. how im is transmitted?
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Within 6 months viral load will be <50
Oropharyngeal secretions; hence named as kissing disease
Acyclovir

6. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Blastomycosis
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism

7. INH
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
When patient is older >65 - pregnant - cardiac of pulmonary disease; patient without above risks are treated when they come within 48 hours of symptom onset
Gonococcal with purulent discharges and presence of multiple diplococi and neurotrophils in urethral swab; non gonoccal (chlamydia) are watery disch - swab abacterial - sometimes have intracellular organism
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

8. How to differentiate different types of necrotizing fascitis?
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Voriconazol. mycetoma-surgical removal
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Type 1: patient with dm and pvd; caused by staph/GAS/ e coli/bacteroids; type2 - no associated medical illness - caused by laceration - trauma - surgery - IV drug abuse - caused mainly by GAS

9. What is fatal consequence of RMSF?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Mainly clinical - epidemiological and seasonal setting
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

10. what parameters increases risk of neurosyphilis in HIV patient
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
CD4 less than 350 and RPR >1:32; HIV infected patient with syphilis >1 yr should have CSF exam before tx. if csf normal tx with benzathine penicillin weekly for 3 weeks.
Within 6 months viral load will be <50
Similar pathophysiology as ITP - tx zidovudine

11. How to dx lyme arthritis?
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism
ELISA and western blot of synovial fluid.
High risk 19-64; 1-2 dose - above 65; one dose
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

12. What is characteristic for dx of rocky mountain spotted fever?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Immune mediated; circulating IgG and IgM to penicillin derivatives

13. gas gangrene
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Pts with pseudomonas bacerimia have this. they have perivascular bacterial invasion of the media and adventitia of arteries and veins. then ishcemic necrosis; skin and mucous membrane have nodular patches wtih hemorrhage and ulceration
Clostridium perfringens after penetrative injuries/wounds
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

14. When to give abx to prevent recurrent uti
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
More than two UTI in six months or more than 3 uti in a year; cipro/bactrim/nitrofurantoin; abx may be given continuous or postcoital
ELISA and western blot of synovial fluid.
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

15. What is tx for herpes zoster
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Voriconazol. mycetoma-surgical removal
Acyclovir
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

16. How to tx pseudomonas?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
High risk 19-64; 1-2 dose - above 65; one dose
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

17. What is difference between uti relapse versus recurrence?
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

18. What is used for prophylaxis against meningo..meningitis?
HIV viral load
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Rifampin600mg q12. or cipro

19. low grade fever - maculopapular rash - lymphadenopathy
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Ampicillin-sublactam; most bites contain eikenella
Cd4 count
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

20. causative organisms of uti
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
AA gradient >35 or Po2 <70

21. wisconsin - missisipi - ohio
Blastomycosis
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Bronchoalveolar washing and transbronchial biopsy
Vaccine titer >10mU/ml

22. What is tetanus - diptheria - pertusis recommendation?
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Td every 10 years - tdap once before 65 and after 65
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

23. worsening of TB after starting HAART in HIV
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Mainly clinical - epidemiological and seasonal setting

24. What is the pathophysiology of Meningococcal meningitis?
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
ELISA; initial visit - 6 - 12 and 24 weeks;
Clostridium perfringens after penetrative injuries/wounds
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges

25. when HIV patient develop pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Postcoital voiding - increased intake of cranberry juice
When cd4 count falls below 200. 2p in pcp =200
Think about cutaneous cryptococous; lesions looks like molluscus contagiousm. present in face/trunk/anywherer; dx biopsy of lesion which shows granulomatous inflammation with multinucleated giant cell

26. pneumococcal vaccine indication?
High risk 19-64; 1-2 dose - above 65; one dose
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
If a sample is ELISA positive - it is tested fro western blot for confirmation
Think about cutaneous cryptococous; lesions looks like molluscus contagiousm. present in face/trunk/anywherer; dx biopsy of lesion which shows granulomatous inflammation with multinucleated giant cell

27. When to give prophylaxis against MAC
Within 6 months viral load will be <50
When cd4 count falls below 200. 2p in pcp =200
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

28. clinical manifestation of mucomycosis
Viral load and CD4 count
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism
Similar pathophysiology as ITP - tx zidovudine
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

29. What are the subjective /objective measure of encephalopathy?
Need lumbar puncture to relieve pressure; they have high opening pressure >350
CD4 less than 350 and RPR >1:32; HIV infected patient with syphilis >1 yr should have CSF exam before tx. if csf normal tx with benzathine penicillin weekly for 3 weeks.
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Immune mediated; circulating IgG and IgM to penicillin derivatives

30. How often HIV postiive patients CD4 count needs to be evaluated?
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Similar pathophysiology as ITP - tx zidovudine
Every 3-4 hours to determine appropritate time to start HAART
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

31. thrombocytopenia in HIV
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
ELISA and western blot of synovial fluid.
Similar pathophysiology as ITP - tx zidovudine
HBIG hep B immunoglobulin

32. What is the Tx of STD uretheritis?
HIV viral load
Tx emptirically both gonococcus and chlamydia; 30% gono have coexsiting chlamydial infection; single dose ceftriaxone for gono and Azithromycin for chlamydia. if no improvement give metronidazol for trichomonas infection
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Vaccine titer >10mU/ml

33. How to dx progressive multifocal leukoencephalopathy
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Blastomycosis
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

34. can HIV transmitted through human bite?
When patient is older >65 - pregnant - cardiac of pulmonary disease; patient without above risks are treated when they come within 48 hours of symptom onset
Pegylated interferon and lamivudine
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Pregnacy - urologic procedure - hip arthoplastu

35. When to tx influenza with antiviral therapy?
When patient is older >65 - pregnant - cardiac of pulmonary disease; patient without above risks are treated when they come within 48 hours of symptom onset
Upper lobes; any fibrosis in this area suggestive of latent TB
<500 copies/ml
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

36. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Do EBV antibody test

37. how HAART therapy affects HIV viral loads?
Within 6 months viral load will be <50
When cd4 count falls below 200. 2p in pcp =200
<5000 copies/ml
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

38. What is the mch of ampicillin induced rash in IM
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Immune mediated; circulating IgG and IgM to penicillin derivatives
Rifampin600mg q12. or cipro
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

39. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Upper lobes; any fibrosis in this area suggestive of latent TB
<500 copies/ml
HBIG hep B immunoglobulin

40. what would be viral load after 4 weeks
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
<5000 copies/ml
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

41. How to dx bacterial meningitis from CSF study?

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42. How to tx IM?
Clostridium perfringens after penetrative injuries/wounds
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

43. foot infections in DM
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Voriconazol. mycetoma-surgical removal
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Relapse: infecting organism is same as original infecting organism within 2 weeks of tx completion; recurrence: if the infecting organism is different from that of the original organism

44. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Gonococcal with purulent discharges and presence of multiple diplococi and neurotrophils in urethral swab; non gonoccal (chlamydia) are watery disch - swab abacterial - sometimes have intracellular organism
Bronchoalveolar washing and transbronchial biopsy
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

45. What is the criteria for Spontaneous bact peritonitis
Vaccine titer >10mU/ml
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Mainly clinical - epidemiological and seasonal setting
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

46. hypertension in children
CD4 less than 350 and RPR >1:32; HIV infected patient with syphilis >1 yr should have CSF exam before tx. if csf normal tx with benzathine penicillin weekly for 3 weeks.
Think about cutaneous cryptococous; lesions looks like molluscus contagiousm. present in face/trunk/anywherer; dx biopsy of lesion which shows granulomatous inflammation with multinucleated giant cell
Either TB or aspergillosis
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads

47. what would be viral load after 2-4m of HAART?
<500 copies/ml
No skin changes but pain out of proportion; infection spreads along fascial plane rapidly with blister - erythema - and bullae formation; marked tenderness on palpation - and CREPITUS
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Gonococcal with purulent discharges and presence of multiple diplococi and neurotrophils in urethral swab; non gonoccal (chlamydia) are watery disch - swab abacterial - sometimes have intracellular organism

48. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
ELISA; initial visit - 6 - 12 and 24 weeks;
Immune mediated; circulating IgG and IgM to penicillin derivatives
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

49. How to tx chronic hep B
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Pegylated interferon and lamivudine
Either TB or aspergillosis
More than two UTI in six months or more than 3 uti in a year; cipro/bactrim/nitrofurantoin; abx may be given continuous or postcoital

50. How to confirm dx if pcp?
Bronchoalveolar washing and transbronchial biopsy
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Pregnacy - urologic procedure - hip arthoplastu
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

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USMLE Step3 Infectious Disease

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