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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. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
High risk 19-64; 1-2 dose - above 65; one dose
Viral load and CD4 count
PML; focal neurological deficit like MM; no specific tx; regress with HAART
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

2. When to give abx to prevent recurrent uti
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
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Non pregnant premanopausal - elderly - dm - sci - chronic foley
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

3. dame that has already occurred
Voriconazol. mycetoma-surgical removal
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Cd4 count
Postcoital voiding - increased intake of cranberry juice

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

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5. when western blot is done for HIV testing
<5000 copies/ml
Pt who have been treated before for latent TB
If a sample is ELISA positive - it is tested fro western blot for confirmation
Bronchoalveolar washing and transbronchial biopsy

6. what would be viral load after 4 weeks
Others lesions are ring enhancing and have mass effect while PML don't
Cd4 count
<5000 copies/ml
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

7. when not to give INH therapy if ppd positive and patient asyptomatic
Rifampin600mg q12. or cipro
Pt who have been treated before for latent TB
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
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

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

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9. What is the pathophysiology of Meningococcal meningitis?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
If a sample is ELISA positive - it is tested fro western blot for confirmation
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Pregnacy - urologic procedure - hip arthoplastu

10. damae that is about to occur?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
HIV viral load
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

11. What is the criteria for Spontaneous bact peritonitis
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Monospot test which screen heteropile ab that agglutinate horse rbc
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

12. what parameters increases risk of neurosyphilis in HIV patient
6-12 weeks
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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.
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

13. What is difference between uti relapse versus recurrence?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
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
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
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

14. 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.
High risk 19-64; 1-2 dose - above 65; one dose
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

15. What is the classic signs of nec fasc?
Rifampin600mg q12. or cipro
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
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

16. How to dx adequate response to HBV vaccine
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
Vaccine titer >10mU/ml
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

17. What is tx for herpes zoster
Acyclovir
HIV viral load
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

18. systolic HTN in elderly
Acyclovir
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
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

19. acute febrile reaction develops after starting penicilin tx to syphilis patient
ELISA and western blot of synovial fluid.
HBIG hep B immunoglobulin
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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

20. what would be viral load after 2-4m of HAART?
<500 copies/ml
Aortic valve; endocardiits of AR p/w AV block and LBBB
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
Postcoital voiding - increased intake of cranberry juice

21. What are the subjective /objective measure of encephalopathy?
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
Cd4 count
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

22. How to tx chronic hep B
Bronchoalveolar washing and transbronchial biopsy
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Pegylated interferon and lamivudine

23. How to dx IM?
Within 6 months viral load will be <50
<500 copies/ml
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Monospot test which screen heteropile ab that agglutinate horse rbc

24. hypertriglyceridemia in HIV
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
High risk 19-64; 1-2 dose - above 65; one dose
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

25. aspergillosis
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
Voriconazol. mycetoma-surgical removal
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
HBIG hep B immunoglobulin

26. INH
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Others lesions are ring enhancing and have mass effect while PML don't
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Oropharyngeal secretions; hence named as kissing disease

27. How to tx IM?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Oropharyngeal secretions; hence named as kissing disease
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

28. when we see echym gangrenosum?
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.
Do EBV antibody test
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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

29. pneumococcal vaccine indication?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
High risk 19-64; 1-2 dose - above 65; one dose
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

30. How often viral load is monitored after HAART?
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Blastomycosis
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

31. after recent exposure - negative ELISA - How to confirm?
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.
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

32. infiltrate in upper lobe of lung?
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Either TB or aspergillosis
Do EBV antibody test
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

33. When not to tx asymptomatic bacteriura?
Acyclovir
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley

34. How to dx cryptococal meninggits
Others lesions are ring enhancing and have mass effect while PML don't
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Td every 10 years - tdap once before 65 and after 65

35. What is characteristic for dx of rocky mountain spotted fever?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Viral load and CD4 count
Similar pathophysiology as ITP - tx zidovudine
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

36. How long abx is given in pseudomonas infection?
Every 3-4 hours to determine appropritate time to start HAART
Td every 10 years - tdap once before 65 and after 65
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

37. How to dx?
Blastomycosis
AA gradient >35 or Po2 <70
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Mainly clinical - epidemiological and seasonal setting

38. How to tx TSS?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

39. How to tx pseudomonas?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
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
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

40. How long we tx chronic prostatis?
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
When cd4 count falls below 200. 2p in pcp =200
6-12 weeks
ELISA and western blot of synovial fluid.

41. how HAART therapy affects HIV viral loads?
Within 6 months viral load will be <50
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
<5000 copies/ml

42. What are the behavioral interventions decrease the risk of UTI
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Postcoital voiding - increased intake of cranberry juice
Do EBV antibody test
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

43. foot infections in DM
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
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
ELISA; initial visit - 6 - 12 and 24 weeks;
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

44. When to give prophylaxis against MAC
Similar pathophysiology as ITP - tx zidovudine
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
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 syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

45. Tx of choice for human bites
Cd4 count
Ampicillin-sublactam; most bites contain eikenella
AA gradient >35 or Po2 <70
Pt who have been treated before for latent TB

46. INH
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
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
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

47. What is the Tx of STD uretheritis?
Aortic valve; endocardiits of AR p/w AV block and LBBB
Vaccine titer >10mU/ml
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

48. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
HBIG hep B immunoglobulin
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
ELISA; initial visit - 6 - 12 and 24 weeks;

49. How often HIV postiive patients CD4 count needs to be evaluated?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Every 3-4 hours to determine appropritate time to start HAART
Rifampin600mg q12. or cipro

50. where TB normally affects
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Rifampin600mg q12. or cipro
Ampicillin-sublactam; most bites contain eikenella
Upper lobes; any fibrosis in this area suggestive of latent TB

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USMLE Step3 Infectious Disease

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