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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. What are the behavioral interventions decrease the risk of UTI
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
High risk 19-64; 1-2 dose - above 65; one dose
Postcoital voiding - increased intake of cranberry juice
Vaccine titer >10mU/ml

2. acute onset +rusty sputum
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Clostridium perfringens after penetrative injuries/wounds
Acyclovir

3. when we see echym gangrenosum?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
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
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Similar pathophysiology as ITP - tx zidovudine

4. dame that has already occurred
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
Either TB or aspergillosis
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Cd4 count

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

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6. worsening of TB after starting HAART in HIV
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Ampicillin-sublactam; most bites contain eikenella
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

7. What is the prognosis of lyme arthritis?
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
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

8. INH
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
HBIG hep B immunoglobulin
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

9. rifampin
Mainly clinical - epidemiological and seasonal setting
Pegylated interferon and lamivudine
Postcoital voiding - increased intake of cranberry juice
Reddish orange discoloration of urine - feces - sweat - tears - sputum

10. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Bronchoalveolar washing and transbronchial biopsy
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

11. low grade fever - maculopapular rash - lymphadenopathy
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
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Do EBV antibody test

12. INH
Monospot test which screen heteropile ab that agglutinate horse rbc
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

13. acute febrile reaction develops after starting penicilin tx to syphilis patient
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Oropharyngeal secretions; hence named as kissing disease

14. How to confirm chlamydia infection?
Rifampin600mg q12. or cipro
Immune mediated; circulating IgG and IgM to penicillin derivatives
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

15. pathophysiology of toxic shock syndrom?
When cd4 count falls below 200. 2p in pcp =200
AA gradient >35 or Po2 <70
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Vaccine titer >10mU/ml

16. What is the criteria for Spontaneous bact peritonitis
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
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
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

17. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
AA gradient >35 or Po2 <70
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
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

18. When to give prophylaxis against MAC
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Blastomycosis
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

19. What is lag time to develop lyme arthritis after exposure to vector
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.
Td every 10 years - tdap once before 65 and after 65
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
AA gradient >35 or Po2 <70

20. what if monospot test is neg in IM?
Do EBV antibody test
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
6-12 weeks
Td every 10 years - tdap once before 65 and after 65

21. What is the mch of ampicillin induced rash in IM
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Immune mediated; circulating IgG and IgM to penicillin derivatives
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

22. where TB normally affects
Upper lobes; any fibrosis in this area suggestive of latent TB
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Acyclovir
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

23. gas gangrene
ELISA and western blot of synovial fluid.
Clostridium perfringens after penetrative injuries/wounds
Blastomycosis
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

24. antibiotic with good prostate penetration?
6-12 weeks
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
Bronchoalveolar washing and transbronchial biopsy
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

25. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
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
ELISA and western blot of synovial fluid.
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.

26. How to dx cryptococal meninggits
Need lumbar puncture to relieve pressure; they have high opening pressure >350
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
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Aortic valve; endocardiits of AR p/w AV block and LBBB

27. after exposure of HIV when antibody testing is performed?
ELISA; initial visit - 6 - 12 and 24 weeks;
Monospot test which screen heteropile ab that agglutinate horse rbc
Mainly clinical - epidemiological and seasonal setting
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. What is the indication of corticosteroid in pcp infection?
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
AA gradient >35 or Po2 <70
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Monospot test which screen heteropile ab that agglutinate horse rbc

29. How often viral load is monitored after HAART?
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

30. What is used for prophylaxis against meningo..meningitis?
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Rifampin600mg q12. or cipro
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Blastomycosis

31. 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
Aortic valve; endocardiits of AR p/w AV block and LBBB
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Blastomycosis

32. when HIV patient develop pcp?
When cd4 count falls below 200. 2p in pcp =200
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Pegylated interferon and lamivudine

33. How to differentiate different types of necrotizing fascitis?
HBIG hep B immunoglobulin
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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
<5000 copies/ml

34. What are the subjective /objective measure of encephalopathy?
Oropharyngeal secretions; hence named as kissing disease
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

35. thrombocytopenia in HIV
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
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Similar pathophysiology as ITP - tx zidovudine

36. What is tx for herpes zoster
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Clostridium perfringens after penetrative injuries/wounds
Acyclovir
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

37. causative organisms of uti
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
AA gradient >35 or Po2 <70
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

38. reddish colored papules with central umbilication in HIV or immunocompromised patient
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Every 3-4 hours to determine appropritate time to start HAART
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
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

39. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Similar pathophysiology as ITP - tx zidovudine
Voriconazol. mycetoma-surgical removal
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

40. how CMV presents in immunocompromised patients
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
<500 copies/ml
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

41. How to dx?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
If a sample is ELISA positive - it is tested fro western blot for confirmation
Mainly clinical - epidemiological and seasonal setting
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

42. after bone marrow transplant - patient develop headache - fever - cought and chest pain. What is dx?
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
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

43. hypertension in children
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
HIV viral load
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

44. What is the pathophysiology of Meningococcal meningitis?
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

45. drugs work well on hypertriglyceridia?
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Td every 10 years - tdap once before 65 and after 65
Ampicillin-sublactam; most bites contain eikenella

46. what would be viral load after 4 weeks
Monospot test which screen heteropile ab that agglutinate horse rbc
Vaccine titer >10mU/ml
<5000 copies/ml
HIV viral load

47. How often HIV postiive patients CD4 count needs to be evaluated?
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.
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Every 3-4 hours to determine appropritate time to start HAART
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

48. what parameters increases risk of neurosyphilis in HIV patient
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
<500 copies/ml
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.
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

49. How to tx pcp?
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
When cd4 count falls below 200. 2p in pcp =200

50. hypertriglyceridemia in HIV
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

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USMLE Step3 Infectious Disease

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