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

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2. How long we tx chronic prostatis?
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
6-12 weeks
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
When cd4 count falls below 200. 2p in pcp =200

3. after exposure of HIV when antibody testing is performed?
Pegylated interferon and lamivudine
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
ELISA; initial visit - 6 - 12 and 24 weeks;
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

4. how im is transmitted?
Oropharyngeal secretions; hence named as kissing disease
<5000 copies/ml
Monospot test which screen heteropile ab that agglutinate horse rbc
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

5. what would be viral load after 4 weeks
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
<5000 copies/ml
Voriconazol. mycetoma-surgical removal

6. What are indicators for progression of HIV
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Viral load and CD4 count
Monospot test which screen heteropile ab that agglutinate horse rbc
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

7. pneumococcal vaccine indication?
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
High risk 19-64; 1-2 dose - above 65; one dose
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Clostridium perfringens after penetrative injuries/wounds

8. when HIV patient develop pcp?
When cd4 count falls below 200. 2p in pcp =200
Non pregnant premanopausal - elderly - dm - sci - chronic foley
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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

9. How to dx bacterial meningitis from CSF study?

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10. When to give abx to prevent recurrent uti
Others lesions are ring enhancing and have mass effect while PML don't
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
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
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

11. How to dx progressive multifocal leukoencephalopathy
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Postcoital voiding - increased intake of cranberry juice
Vaccine titer >10mU/ml

12. What is characteristic for dx of rocky mountain spotted fever?
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Ampicillin-sublactam; most bites contain eikenella
PML; focal neurological deficit like MM; no specific tx; regress with HAART

13. What are the behavioral interventions decrease the risk of UTI
Postcoital voiding - increased intake of cranberry juice
ELISA; initial visit - 6 - 12 and 24 weeks;
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

14. How to tx chronic hep B
If a sample is ELISA positive - it is tested fro western blot for confirmation
Pegylated interferon and lamivudine
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
Oropharyngeal secretions; hence named as kissing disease

15. hypertriglyceridemia in HIV
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.
If a sample is ELISA positive - it is tested fro western blot for confirmation
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

16. rifampin
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Monospot test which screen heteropile ab that agglutinate horse rbc
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

17. thrombocytopenia in HIV
Similar pathophysiology as ITP - tx zidovudine
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Oropharyngeal secretions; hence named as kissing disease
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

18. worsening of TB after starting HAART in HIV
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Aortic valve; endocardiits of AR p/w AV block and LBBB
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

19. How to dx IM?
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Monospot test which screen heteropile ab that agglutinate horse rbc
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

20. how HAART therapy affects HIV viral loads?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
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
Do EBV antibody test
Within 6 months viral load will be <50

21. How to give postexposure prophylaxis for HIV
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Similar pathophysiology as ITP - tx zidovudine
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Reddish orange discoloration of urine - feces - sweat - tears - sputum

22. What is tx for herpes zoster
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
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
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

23. How to dx adequate response to HBV vaccine
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Pregnacy - urologic procedure - hip arthoplastu
Similar pathophysiology as ITP - tx zidovudine
Vaccine titer >10mU/ml

24. clinical manifestation of mucomycosis
Acyclovir
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

25. can HIV transmitted through human bite?
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
ELISA; initial visit - 6 - 12 and 24 weeks;
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

26. What is the criteria for Spontaneous bact peritonitis
Upper lobes; any fibrosis in this area suggestive of latent TB
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
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.

27. What is the Tx of cryptococcal meninngitis
Clostridium perfringens after penetrative injuries/wounds
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
When cd4 count falls below 200. 2p in pcp =200
Non pregnant premanopausal - elderly - dm - sci - chronic foley

28. How to tx TSS?
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

29. causative organisms of uti
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
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
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

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

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31. How to dx IM?
Within 6 months viral load will be <50
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
HIV viral load
Rifampin600mg q12. or cipro

32. low grade fever - maculopapular rash - lymphadenopathy
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Reddish orange discoloration of urine - feces - sweat - tears - sputum
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

33. HIV patient having fat deposition on back of neck and abdomen - like cushing
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 present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

34. damae that is about to occur?
Every 3-4 hours to determine appropritate time to start HAART
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
HIV viral load
High risk 19-64; 1-2 dose - above 65; one dose

35. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Do EBV antibody test

36. pathophysiology of toxic shock syndrom?
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
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

37. When not to tx asymptomatic bacteriura?
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Pt who have been treated before for latent TB
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Acyclovir

38. 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
6-12 weeks
ELISA and western blot of synovial fluid.
Doesn't exceed more than 15 mm and size significantly decreases after 15 years

39. How to confirm chlamydia infection?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

40. aspergillosis
Non pregnant premanopausal - elderly - dm - sci - chronic foley
If a sample is ELISA positive - it is tested fro western blot for confirmation
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Voriconazol. mycetoma-surgical removal

41. INH
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
Mainly clinical - epidemiological and seasonal setting
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

42. wisconsin - missisipi - ohio
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.
Blastomycosis
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
<500 copies/ml

43. How often viral load is monitored after HAART?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

44. infiltrate in upper lobe of lung?
Either TB or aspergillosis
Voriconazol. mycetoma-surgical removal
Vaccine titer >10mU/ml
<5000 copies/ml

45. When to tx asymptomatic bacteriurea >100 -000?
Pregnacy - urologic procedure - hip arthoplastu
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
<5000 copies/ml

46. How to differentiate different types of necrotizing fascitis?
Immune mediated; circulating IgG and IgM to penicillin derivatives
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
If a sample is ELISA positive - it is tested fro western blot for confirmation
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

47. What is the classic signs of nec fasc?
Aortic valve; endocardiits of AR p/w AV block and LBBB
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
If a sample is ELISA positive - it is tested fro western blot for confirmation
Td every 10 years - tdap once before 65 and after 65

48. foot infections in DM
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Similar pathophysiology as ITP - tx zidovudine
When cd4 count falls below 200. 2p in pcp =200

49. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
<5000 copies/ml
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

50. where TB normally affects
Monospot test which screen heteropile ab that agglutinate horse rbc
Upper lobes; any fibrosis in this area suggestive of latent TB
Similar pathophysiology as ITP - tx zidovudine
HIV viral load

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USMLE Step3 Infectious Disease

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