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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. hypertension in children
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Rifampin600mg q12. or cipro
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
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

2. drugs work well on hypertriglyceridia?
Within 6 months viral load will be <50
ELISA and western blot of synovial fluid.
Voriconazol. mycetoma-surgical removal
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

3. What is the Tx of cryptococcal meninngitis
Mainly clinical - epidemiological and seasonal setting
Bronchoalveolar washing and transbronchial biopsy
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

4. What are the subjective /objective measure of encephalopathy?
Either TB or aspergillosis
Voriconazol. mycetoma-surgical removal
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

5. How to tx pcp?
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
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
Monospot test which screen heteropile ab that agglutinate horse rbc
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

6. INH
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Within 6 months viral load will be <50
Need lumbar puncture to relieve pressure; they have high opening pressure >350

7. How to tx TSS?
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
Mainly clinical - epidemiological and seasonal setting
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

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

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9. How long we tx chronic prostatis?
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
6-12 weeks
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
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

10. when we see echym gangrenosum?
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
Bronchoalveolar washing and transbronchial biopsy
Every 3-4 hours to determine appropritate time to start HAART
Postcoital voiding - increased intake of cranberry juice

11. What is used for prophylaxis against meningo..meningitis?
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Pegylated interferon and lamivudine
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Rifampin600mg q12. or cipro

12. low grade fever - maculopapular rash - lymphadenopathy
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Non pregnant premanopausal - elderly - dm - sci - chronic foley
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

13. How to confirm dx if pcp?
Rifampin600mg q12. or cipro
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Oropharyngeal secretions; hence named as kissing disease
Bronchoalveolar washing and transbronchial biopsy

14. can HIV transmitted through human bite?
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
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
Pt who have been treated before for latent TB
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

15. where TB normally affects
Upper lobes; any fibrosis in this area suggestive of latent TB
HBIG hep B immunoglobulin
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
Every 3-4 hours to determine appropritate time to start HAART

16. How to dx?
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Mainly clinical - epidemiological and seasonal setting
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
Cd4 count

17. when HIV patient develop pcp?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Viral load and CD4 count
When cd4 count falls below 200. 2p in pcp =200
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

18. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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
When cd4 count falls below 200. 2p in pcp =200

19. What is fatal consequence of RMSF?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Every 3-4 hours to determine appropritate time to start HAART
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Mainly clinical - epidemiological and seasonal setting

20. When to give prophylaxis against MAC
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

21. How long abx is given in pseudomonas infection?
Oropharyngeal secretions; hence named as kissing disease
Non pregnant premanopausal - elderly - dm - sci - chronic foley
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

22. When not to tx asymptomatic bacteriura?
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Either TB or aspergillosis
High risk 19-64; 1-2 dose - above 65; one dose

23. What is the pathophysiology of Meningococcal meningitis?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Mainly clinical - epidemiological and seasonal setting
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

24. How to tx chronic hep B
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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
Upper lobes; any fibrosis in this area suggestive of latent TB
Pegylated interferon and lamivudine

25. How often viral load is monitored after HAART?
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Bronchoalveolar washing and transbronchial biopsy
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

26. rifampin
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
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
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Bronchoalveolar washing and transbronchial biopsy

27. How to differentiate gonococcal and nongonoccal urethritis?
<500 copies/ml
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
If a sample is ELISA positive - it is tested fro western blot for confirmation
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

28. pneumococcal vaccine indication?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
High risk 19-64; 1-2 dose - above 65; one dose
Ampicillin-sublactam; most bites contain eikenella
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

29. How to tx pseudomonas?
<500 copies/ml
When cd4 count falls below 200. 2p in pcp =200
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

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

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31. after exposure of HIV when antibody testing is performed?
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
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
ELISA; initial visit - 6 - 12 and 24 weeks;
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

32. What is the Tx of STD uretheritis?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
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
Either TB or aspergillosis
Ampicillin-sublactam; most bites contain eikenella

33. How to dx IM?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Within 6 months viral load will be <50
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

34. What are indicators for progression of HIV
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Postcoital voiding - increased intake of cranberry juice
Viral load and CD4 count
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

35. when not to give INH therapy if ppd positive and patient asyptomatic
Cd4 count
Pegylated interferon and lamivudine
Pt who have been treated before for latent TB
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

36. how CMV presents in immunocompromised patients
Upper lobes; any fibrosis in this area suggestive of latent TB
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.
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Ampicillin-sublactam; most bites contain eikenella

37. damae that is about to occur?
HIV viral load
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Rifampin600mg q12. or cipro
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

38. What are the behavioral interventions decrease the risk of UTI
Immune mediated; circulating IgG and IgM to penicillin derivatives
Postcoital voiding - increased intake of cranberry juice
Td every 10 years - tdap once before 65 and after 65
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

39. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
Do EBV antibody test
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

40. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
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.
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

41. INH
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
<500 copies/ml
Mainly clinical - epidemiological and seasonal setting

42. clinical manifestation of mucomycosis
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Every 3-4 hours to determine appropritate time to start HAART
Monospot test which screen heteropile ab that agglutinate horse rbc

43. How to dx lyme arthritis?
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
ELISA and western blot of synovial fluid.
Mainly clinical - epidemiological and seasonal setting
Voriconazol. mycetoma-surgical removal

44. oligodendrocyte with intranuclear inclusion and demyelination 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.
Similar pathophysiology as ITP - tx zidovudine
PML; focal neurological deficit like MM; no specific tx; regress with HAART
If a sample is ELISA positive - it is tested fro western blot for confirmation

45. antibiotic with good prostate penetration?
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Non pregnant premanopausal - elderly - dm - sci - chronic foley

46. What is lag time to develop lyme arthritis after exposure to vector
Td every 10 years - tdap once before 65 and after 65
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
HIV viral load
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

47. HIV patient having fat deposition on back of neck and abdomen - like cushing
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
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

48. infiltrate in upper lobe of lung?
Similar pathophysiology as ITP - tx zidovudine
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Upper lobes; any fibrosis in this area suggestive of latent TB
Either TB or aspergillosis

49. How often HIV postiive patients CD4 count needs to be evaluated?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Rifampin600mg q12. or cipro
Every 3-4 hours to determine appropritate time to start HAART
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

50. how HAART therapy affects HIV viral loads?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Within 6 months viral load will be <50
<500 copies/ml
Aortic valve; endocardiits of AR p/w AV block and LBBB

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USMLE Step3 Infectious Disease

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