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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. dame that has already occurred
Cd4 count
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
When cd4 count falls below 200. 2p in pcp =200

2. rifampin
6-12 weeks
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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

3. foot infections in DM
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Vaccine titer >10mU/ml
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

4. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
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
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

5. What is the criteria for Spontaneous bact peritonitis
Do EBV antibody test
Vaccine titer >10mU/ml
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

6. can HIV transmitted through human bite?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Upper lobes; any fibrosis in this area suggestive of latent TB
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

7. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
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.
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

8. What is the prognosis of lyme arthritis?
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
PML; focal neurological deficit like MM; no specific tx; regress with HAART
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. How to dx adequate response to HBV vaccine
Vaccine titer >10mU/ml
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

10. What are the subjective /objective measure of encephalopathy?
Vaccine titer >10mU/ml
HIV viral load
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
If a sample is ELISA positive - it is tested fro western blot for confirmation

11. What is the indication of corticosteroid in pcp infection?
Td every 10 years - tdap once before 65 and after 65
If a sample is ELISA positive - it is tested fro western blot for confirmation
Either TB or aspergillosis
AA gradient >35 or Po2 <70

12. INH
High risk 19-64; 1-2 dose - above 65; one dose
Mainly clinical - epidemiological and seasonal setting
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

13. hypertension in children
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Blastomycosis
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

14. When to give prophylaxis against MAC
Mainly clinical - epidemiological and seasonal setting
6-12 weeks
PML; focal neurological deficit like MM; no specific tx; regress with HAART
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

15. where TB normally affects
Upper lobes; any fibrosis in this area suggestive of latent TB
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Rifampin600mg q12. or cipro
High risk 19-64; 1-2 dose - above 65; one dose

16. What is lag time to develop lyme arthritis after exposure to vector
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Voriconazol. mycetoma-surgical removal
ELISA; initial visit - 6 - 12 and 24 weeks;
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

17. How to dx bacterial meningitis from CSF study?

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18. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
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
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
PML; focal neurological deficit like MM; no specific tx; regress with HAART

19. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
<5000 copies/ml
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
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

20. How to tx TSS?
ELISA; initial visit - 6 - 12 and 24 weeks;
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Clostridium perfringens after penetrative injuries/wounds

21. what would be viral load after 2-4m of HAART?
<500 copies/ml
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
<5000 copies/ml

22. HIV patient having fat deposition on back of neck and abdomen - like cushing
Need lumbar puncture to relieve pressure; they have high opening pressure >350
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Pregnacy - urologic procedure - hip arthoplastu
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

23. When to give abx to prevent recurrent uti
When cd4 count falls below 200. 2p in pcp =200
Viral load and CD4 count
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
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

24. When not to tx asymptomatic bacteriura?
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
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Non pregnant premanopausal - elderly - dm - sci - chronic foley

25. How to tx chronic hep B
Pegylated interferon and lamivudine
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
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
When cd4 count falls below 200. 2p in pcp =200

26. wisconsin - missisipi - ohio
Blastomycosis
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
When cd4 count falls below 200. 2p in pcp =200
HIV viral load

27. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
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
HBIG hep B immunoglobulin
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

28. infiltrate in upper lobe of lung?
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
<5000 copies/ml
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Either TB or aspergillosis

29. How to dx IM?
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Doesn't exceed more than 15 mm and size significantly decreases after 15 years

30. worsening of TB after starting HAART in HIV
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
High risk 19-64; 1-2 dose - above 65; one dose
ELISA; initial visit - 6 - 12 and 24 weeks;

31. How to differentiate gonococcal and nongonoccal urethritis?
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Either TB or aspergillosis
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
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

32. What is tetanus - diptheria - pertusis recommendation?
Td every 10 years - tdap once before 65 and after 65
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Viral load and CD4 count

33. systolic HTN in elderly
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Rifampin600mg q12. or cipro
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

34. low grade fever - maculopapular rash - lymphadenopathy
Immune mediated; circulating IgG and IgM to penicillin derivatives
HIV viral load
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
AA gradient >35 or Po2 <70

35. when HIV patient develop pcp?
When cd4 count falls below 200. 2p in pcp =200
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
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

36. How to differentiate different types of necrotizing fascitis?
Rifampin600mg q12. or cipro
Either TB or aspergillosis
HIV viral load
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

37. What is the mch of ampicillin induced rash in IM
Bronchoalveolar washing and transbronchial biopsy
HBIG hep B immunoglobulin
<5000 copies/ml
Immune mediated; circulating IgG and IgM to penicillin derivatives

38. What is the pathophysiology of Meningococcal meningitis?
PML; focal neurological deficit like MM; no specific tx; regress with HAART
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Either TB or aspergillosis
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

39. gas gangrene
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Clostridium perfringens after penetrative injuries/wounds
When cd4 count falls below 200. 2p in pcp =200

40. How to dx progressive multifocal leukoencephalopathy
Either TB or aspergillosis
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
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

41. pathophysiology of toxic shock syndrom?
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Rifampin600mg q12. or cipro
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

42. What is the Tx of cryptococcal meninngitis
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Monospot test which screen heteropile ab that agglutinate horse rbc
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

43. When to tx influenza with antiviral therapy?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
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
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

44. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Postcoital voiding - increased intake of cranberry juice
Clostridium perfringens after penetrative injuries/wounds

45. what if monospot test is neg in IM?
Clostridium perfringens after penetrative injuries/wounds
Every 3-4 hours to determine appropritate time to start HAART
Do EBV antibody test
Similar pathophysiology as ITP - tx zidovudine

46. aspergillosis
Similar pathophysiology as ITP - tx zidovudine
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Voriconazol. mycetoma-surgical removal
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

47. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

48. What is fatal consequence of RMSF?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Monospot test which screen heteropile ab that agglutinate horse rbc
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
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

49. after recent exposure - negative ELISA - How to confirm?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
<500 copies/ml
Every 3-4 hours to determine appropritate time to start HAART

50. causative organisms of uti
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
ELISA; initial visit - 6 - 12 and 24 weeks;
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

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USMLE Step3 Infectious Disease

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