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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. thrombocytopenia in HIV
Similar pathophysiology as ITP - tx zidovudine
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
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
High risk 19-64; 1-2 dose - above 65; one dose

2. foot infections in DM
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

3. What is the pathophysiology of Meningococcal meningitis?
Within 6 months viral load will be <50
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

4. how HAART therapy affects HIV viral loads?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Within 6 months viral load will be <50
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
<500 copies/ml

5. Tx of choice for human bites
ELISA; initial visit - 6 - 12 and 24 weeks;
Ampicillin-sublactam; most bites contain eikenella
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
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

6. How to confirm dx if pcp?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
<500 copies/ml
Bronchoalveolar washing and transbronchial biopsy
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

7. What is the mch of ampicillin induced rash in IM
Immune mediated; circulating IgG and IgM to penicillin derivatives
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.
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Acyclovir

8. How to differentiat PML from toxoxplasmosis - cns lymphoma adn brain abscess

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9. causative organisms of uti
Pegylated interferon and lamivudine
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Aortic valve; endocardiits of AR p/w AV block and LBBB

10. What is tx for herpes zoster
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
Acyclovir
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

11. How often viral load is monitored after HAART?
Every 3-4 hours to determine appropritate time to start HAART
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Voriconazol. mycetoma-surgical removal

12. How long abx is given in pseudomonas infection?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
<500 copies/ml
Need lumbar puncture to relieve pressure; they have high opening pressure >350

13. How to tx IM?
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Need lumbar puncture to relieve pressure; they have high opening pressure >350
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
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

14. What is the Tx of STD uretheritis?
When cd4 count falls below 200. 2p in pcp =200
Clostridium perfringens after penetrative injuries/wounds
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
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

15. after exposure of HIV when antibody testing is performed?
Td every 10 years - tdap once before 65 and after 65
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; initial visit - 6 - 12 and 24 weeks;
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

16. reddish colored papules with central umbilication in HIV or immunocompromised patient
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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
Ampicillin-sublactam; most bites contain eikenella

17. When not to tx asymptomatic bacteriura?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Td every 10 years - tdap once before 65 and after 65

18. When to tx asymptomatic bacteriurea >100 -000?
Pregnacy - urologic procedure - hip arthoplastu
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
Postcoital voiding - increased intake of cranberry juice
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

19. How often HIV postiive patients CD4 count needs to be evaluated?
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Every 3-4 hours to determine appropritate time to start HAART
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
ELISA and western blot of synovial fluid.

20. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Acyclovir
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

21. How to tx TSS?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

22. when not to give INH therapy if ppd positive and patient asyptomatic
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
<5000 copies/ml
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Pt who have been treated before for latent TB

23. pneumococcal vaccine indication?
High risk 19-64; 1-2 dose - above 65; one dose
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
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

24. How to tx chronic hep B
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Pegylated interferon and lamivudine

25. after bone marrow transplant - patient develop headache - fever - cought and chest pain. What is dx?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

26. acute onset +rusty sputum
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Pt who have been treated before for latent TB

27. What is used for prophylaxis against meningo..meningitis?
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
Rifampin600mg q12. or cipro
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

28. how CMV presents in immunocompromised patients
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

29. What is the indication of corticosteroid in pcp infection?
AA gradient >35 or Po2 <70
Every 3-4 hours to determine appropritate time to start HAART
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
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

30. When to give abx to prevent recurrent uti
AA gradient >35 or Po2 <70
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
Rifampin600mg q12. or cipro
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

31. hypertension in children
Clostridium perfringens after penetrative injuries/wounds
HBIG hep B immunoglobulin
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

32. INH
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

33. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
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
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Voriconazol. mycetoma-surgical removal

34. which heart valve is closer to ventricular conduction system/
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Aortic valve; endocardiits of AR p/w AV block and LBBB
Clostridium perfringens after penetrative injuries/wounds
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

35. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Rifampin600mg q12. or cipro
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

36. How to differentiate gonococcal and nongonoccal urethritis?
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
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Pregnacy - urologic procedure - hip arthoplastu
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

37. How to dx?
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
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Mainly clinical - epidemiological and seasonal setting
Others lesions are ring enhancing and have mass effect while PML don't

38. INH
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

39. if a patient received BCG vaccine - how big is his PPD induration

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40. pathophysiology of toxic shock syndrom?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

41. What are indicators for progression of HIV
Viral load and CD4 count
Cd4 count
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
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.

42. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
ELISA; initial visit - 6 - 12 and 24 weeks;
ELISA and western blot of synovial fluid.
Need lumbar puncture to relieve pressure; they have high opening pressure >350

43. antibiotic with good prostate penetration?
Clostridium perfringens after penetrative injuries/wounds
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
Voriconazol. mycetoma-surgical removal
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

44. how im is transmitted?
Oropharyngeal secretions; hence named as kissing disease
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

45. what would be viral load after 2-4m of HAART?
<500 copies/ml
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Within 6 months viral load will be <50
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

46. hypertriglyceridemia in HIV
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Every 3-4 hours to determine appropritate time to start HAART
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

47. where TB normally affects
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Upper lobes; any fibrosis in this area suggestive of latent TB
Oropharyngeal secretions; hence named as kissing disease
If a sample is ELISA positive - it is tested fro western blot for confirmation

48. what parameters increases risk of neurosyphilis in HIV patient
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.
Vaccine titer >10mU/ml
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
6-12 weeks

49. What is the prognosis of lyme arthritis?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Need lumbar puncture to relieve pressure; they have high opening pressure >350
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

50. 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.
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; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

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USMLE Step3 Infectious Disease

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