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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. What is the criteria for Spontaneous bact peritonitis
ELISA and western blot of synovial fluid.
<500 copies/ml
Pegylated interferon and lamivudine
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

2. hypertension in children
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Viral load and CD4 count
Bronchoalveolar washing and transbronchial biopsy
Pregnacy - urologic procedure - hip arthoplastu

3. worsening of TB after starting HAART in HIV
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Monospot test which screen heteropile ab that agglutinate horse rbc
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

4. dame that has already occurred
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Cd4 count
Upper lobes; any fibrosis in this area suggestive of latent TB

5. What is fatal consequence of RMSF?
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Oropharyngeal secretions; hence named as kissing disease
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

6. 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
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Voriconazol. mycetoma-surgical removal

7. How to tx pcp?
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Pegylated interferon and lamivudine
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Viral load and CD4 count

8. How to confirm dx if pcp?
Bronchoalveolar washing and transbronchial biopsy
<5000 copies/ml
Aortic valve; endocardiits of AR p/w AV block and LBBB
Vaccine titer >10mU/ml

9. gas gangrene
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Clostridium perfringens after penetrative injuries/wounds
Blastomycosis
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.

10. when HIV patient develop pcp?
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Rifampin600mg q12. or cipro
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
When cd4 count falls below 200. 2p in pcp =200

11. Tx of choice for human bites
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Ampicillin-sublactam; most bites contain eikenella
Acyclovir
<5000 copies/ml

12. What is the indication of corticosteroid in pcp infection?
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
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
AA gradient >35 or Po2 <70
Monospot test which screen heteropile ab that agglutinate horse rbc

13. What are the behavioral interventions decrease the risk of UTI
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
Postcoital voiding - increased intake of cranberry juice
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

14. thrombocytopenia in HIV
Similar pathophysiology as ITP - tx zidovudine
<500 copies/ml
Do EBV antibody test
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

15. What is the mch of ampicillin induced rash in IM
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
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.
Immune mediated; circulating IgG and IgM to penicillin derivatives
Monospot test which screen heteropile ab that agglutinate horse rbc

16. How to tx IM?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
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
<5000 copies/ml

17. systolic HTN in elderly
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Oropharyngeal secretions; hence named as kissing disease

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

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19. what if monospot test is neg in IM?
Similar pathophysiology as ITP - tx zidovudine
Pt who have been treated before for latent TB
Either TB or aspergillosis
Do EBV antibody test

20. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
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
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
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

21. INH
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Td every 10 years - tdap once before 65 and after 65

22. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Do EBV antibody test
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

23. pneumococcal vaccine indication?
High risk 19-64; 1-2 dose - above 65; one dose
Need lumbar puncture to relieve pressure; they have high opening pressure >350
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

24. antibiotic with good prostate penetration?
HIV viral load
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
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

25. reddish colored papules with central umbilication in HIV or immunocompromised patient
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
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

26. When to give prophylaxis against MAC
ELISA; initial visit - 6 - 12 and 24 weeks;
Oropharyngeal secretions; hence named as kissing disease
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

27. 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.
6-12 weeks
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

28. after exposure of HIV when antibody testing is performed?
Immune mediated; circulating IgG and IgM to penicillin derivatives
Voriconazol. mycetoma-surgical removal
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
ELISA; initial visit - 6 - 12 and 24 weeks;

29. INH
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

30. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
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
Bronchoalveolar washing and transbronchial biopsy
PML; focal neurological deficit like MM; no specific tx; regress with HAART

31. when we see echym gangrenosum?
Viral load and 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
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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

32. What is tx for herpes zoster
Acyclovir
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
Similar pathophysiology as ITP - tx zidovudine
Voriconazol. mycetoma-surgical removal

33. How to tx pseudomonas?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
AA gradient >35 or Po2 <70
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

34. acute onset +rusty sputum
Td every 10 years - tdap once before 65 and after 65
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

35. When to tx influenza with antiviral therapy?
Give nystatin suspension or clotrimazol with an oral antifungal eg. 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
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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

36. How to tx TSS?
Viral load and CD4 count
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Reddish orange discoloration of urine - feces - sweat - tears - sputum

37. How to differentiate different types of necrotizing fascitis?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Others lesions are ring enhancing and have mass effect while PML don't
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
Rifampin600mg q12. or cipro

38. can HIV transmitted through human bite?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Upper lobes; any fibrosis in this area suggestive of latent TB
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

39. How to dx progressive multifocal leukoencephalopathy
AA gradient >35 or Po2 <70
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Others lesions are ring enhancing and have mass effect while PML don't

40. What is the prognosis of lyme arthritis?
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
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
Acyclovir

41. How to dx?
Mainly clinical - epidemiological and seasonal setting
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

42. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
Aortic valve; endocardiits of AR p/w AV block and LBBB
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Every 3-4 hours to determine appropritate time to start HAART
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

43. what would be viral load after 2-4m of HAART?
Oropharyngeal secretions; hence named as kissing disease
AA gradient >35 or Po2 <70
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
<500 copies/ml

44. pathophysiology of toxic shock syndrom?
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
When cd4 count falls below 200. 2p in pcp =200
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Mainly clinical - epidemiological and seasonal setting

45. damae that is about to occur?
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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.
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
HIV viral load

46. How to differentiate gonococcal and nongonoccal urethritis?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

47. when not to give INH therapy if ppd positive and patient asyptomatic
Pt who have been treated before for latent TB
ELISA and western blot of synovial fluid.
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Oropharyngeal secretions; hence named as kissing disease

48. When to give abx to prevent recurrent uti
Immune mediated; circulating IgG and IgM to penicillin derivatives
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
If a sample is ELISA positive - it is tested fro western blot for confirmation
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

49. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
Others lesions are ring enhancing and have mass effect while PML don't
When cd4 count falls below 200. 2p in pcp =200
Need lumbar puncture to relieve pressure; they have high opening pressure >350

50. rifampin
Similar pathophysiology as ITP - tx zidovudine
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Pegylated interferon and lamivudine
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

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USMLE Step3 Infectious Disease

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