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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. foot infections in DM
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

2. What is difference between uti relapse versus recurrence?
Monospot test which screen heteropile ab that agglutinate horse rbc
HBIG hep B immunoglobulin
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
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

3. How to dx lyme arthritis?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
ELISA and western blot of synovial fluid.
Immune mediated; circulating IgG and IgM to penicillin derivatives

4. When to tx asymptomatic bacteriurea >100 -000?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Pregnacy - urologic procedure - hip arthoplastu
<5000 copies/ml
Vaccine titer >10mU/ml

5. What are the behavioral interventions decrease the risk of UTI
Blastomycosis
Postcoital voiding - increased intake of cranberry juice
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
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

6. How to dx?
Mainly clinical - epidemiological and seasonal setting
Immune mediated; circulating IgG and IgM to penicillin derivatives
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

7. antibiotic with good prostate penetration?
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
If a sample is ELISA positive - it is tested fro western blot for confirmation
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Do EBV antibody test

8. what parameters increases risk of neurosyphilis in HIV patient
When cd4 count falls below 200. 2p in pcp =200
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
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.
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

9. pathophysiology of toxic shock syndrom?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

10. How to differentiate gonococcal and nongonoccal urethritis?
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
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
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
When cd4 count falls below 200. 2p in pcp =200

11. how CMV presents in immunocompromised patients
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Acyclovir
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Need lumbar puncture to relieve pressure; they have high opening pressure >350

12. what if monospot test is neg in IM?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Do EBV antibody test
ELISA; initial visit - 6 - 12 and 24 weeks;

13. how im is transmitted?
PML; focal neurological deficit like MM; no specific tx; regress with HAART
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.
Oropharyngeal secretions; hence named as kissing disease
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

14. What is tetanus - diptheria - pertusis recommendation?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Td every 10 years - tdap once before 65 and after 65

15. How to differentiate different types of necrotizing fascitis?
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
Pt who have been treated before for latent TB
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Aortic valve; endocardiits of AR p/w AV block and LBBB

16. pneumococcal vaccine indication?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
High risk 19-64; 1-2 dose - above 65; one dose
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Blastomycosis

17. infiltrate in upper lobe of lung?
HBIG hep B immunoglobulin
Either TB or aspergillosis
Every 3-4 hours to determine appropritate time to start HAART
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

18. acute febrile reaction develops after starting penicilin tx to syphilis patient
High risk 19-64; 1-2 dose - above 65; one dose
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

19. INH
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Reddish orange discoloration of urine - feces - sweat - tears - sputum

20. dame that has already occurred
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
Cd4 count
Ampicillin-sublactam; most bites contain eikenella

21. What is the Tx of STD uretheritis?
Cd4 count
Blastomycosis
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
Similar pathophysiology as ITP - tx zidovudine

22. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

23. How to dx IM?
Voriconazol. mycetoma-surgical removal
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Others lesions are ring enhancing and have mass effect while PML don't
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

24. where TB normally affects
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Every 3-4 hours to determine appropritate time to start HAART
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Upper lobes; any fibrosis in this area suggestive of latent TB

25. What is the criteria for Spontaneous bact peritonitis
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

26. What is the Tx of cryptococcal meninngitis
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Aortic valve; endocardiits of AR p/w AV block and LBBB
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
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. Tx of choice for human bites
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Clostridium perfringens after penetrative injuries/wounds
Ampicillin-sublactam; most bites contain eikenella

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

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29. How long abx is given in pseudomonas infection?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

30. acute onset +rusty sputum
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Non pregnant premanopausal - elderly - dm - sci - chronic foley
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

31. HIV patient having fat deposition on back of neck and abdomen - like cushing
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

32. worsening of TB after starting HAART in HIV
Others lesions are ring enhancing and have mass effect while PML don't
Monospot test which screen heteropile ab that agglutinate horse rbc
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

33. thrombocytopenia in HIV
HBIG hep B immunoglobulin
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Similar pathophysiology as ITP - tx zidovudine
Pregnacy - urologic procedure - hip arthoplastu

34. When not to tx asymptomatic bacteriura?
Every 3-4 hours to determine appropritate time to start HAART
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
HBIG hep B immunoglobulin

35. INH
Td every 10 years - tdap once before 65 and after 65
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

36. When to give abx to prevent recurrent uti
<5000 copies/ml
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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

37. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
6-12 weeks
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

38. How to tx IM?
If a sample is ELISA positive - it is tested fro western blot for confirmation
Vaccine titer >10mU/ml
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Need lumbar puncture to relieve pressure; they have high opening pressure >350

39. What is fatal consequence of RMSF?
If a sample is ELISA positive - it is tested fro western blot for confirmation
Either TB or aspergillosis
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

40. gas gangrene
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Viral load and CD4 count
Clostridium perfringens after penetrative injuries/wounds
Vaccine titer >10mU/ml

41. wisconsin - missisipi - ohio
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Do EBV antibody test
Blastomycosis

42. What is the pathophysiology of Meningococcal meningitis?
Reddish orange discoloration of urine - feces - sweat - tears - sputum
HBIG hep B immunoglobulin
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges

43. How to tx chronic hep B
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Pegylated interferon and lamivudine
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

44. 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
Pegylated interferon and lamivudine
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

45. which heart valve is closer to ventricular conduction system/
Others lesions are ring enhancing and have mass effect while PML don't
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
Rifampin600mg q12. or cipro
Aortic valve; endocardiits of AR p/w AV block and LBBB

46. aspergillosis
Voriconazol. mycetoma-surgical removal
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

47. clinical manifestation of mucomycosis
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Upper lobes; any fibrosis in this area suggestive of latent TB

48. What is lag time to develop lyme arthritis after exposure to vector
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
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 and western blot of synovial fluid.
Do EBV antibody test

49. rifampin
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Oropharyngeal secretions; hence named as kissing disease
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Vaccine titer >10mU/ml

50. How to dx adequate response to HBV vaccine
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Vaccine titer >10mU/ml
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Rifampin600mg q12. or cipro

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USMLE Step3 Infectious Disease

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