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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. can HIV transmitted through human bite?
Either TB or aspergillosis
<5000 copies/ml
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

2. When to tx asymptomatic bacteriurea >100 -000?
Monospot test which screen heteropile ab that agglutinate horse rbc
Pregnacy - urologic procedure - hip arthoplastu
High risk 19-64; 1-2 dose - above 65; one dose
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

3. How to dx IM?
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Monospot test which screen heteropile ab that agglutinate horse rbc
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

4. after exposure of HIV when antibody testing is performed?
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
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
ELISA; initial visit - 6 - 12 and 24 weeks;
Reddish orange discoloration of urine - feces - sweat - tears - sputum

5. What is the Tx of cryptococcal meninngitis
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Oropharyngeal secretions; hence named as kissing disease
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

6. what if monospot test is neg in IM?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
HBIG hep B immunoglobulin
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
Do EBV antibody test

7. when we see echym gangrenosum?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
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
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. 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
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

9. What are indicators for progression of HIV
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Viral load and CD4 count
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
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

10. When to give abx to prevent recurrent uti
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
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
Aortic valve; endocardiits of AR p/w AV block and LBBB
Blastomycosis

11. how HAART therapy affects HIV viral loads?
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.
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Within 6 months viral load will be <50

12. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Monospot test which screen heteropile ab that agglutinate horse rbc
HIV viral load
Either TB or aspergillosis

13. How to confirm chlamydia infection?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
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
High risk 19-64; 1-2 dose - above 65; one dose

14. rifampin
Viral load and CD4 count
Reddish orange discoloration of urine - feces - sweat - tears - sputum
<500 copies/ml
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

15. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
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.
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

16. What are the behavioral interventions decrease the risk of UTI
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Postcoital voiding - increased intake of cranberry juice

17. HIV patient having fat deposition on back of neck and abdomen - like cushing
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Rifampin600mg q12. or cipro
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

18. How to tx chronic hep B
Pregnacy - urologic procedure - hip arthoplastu
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Pegylated interferon and lamivudine
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

19. worsening of TB after starting HAART in HIV
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
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

20. foot infections in DM
Rifampin600mg q12. or cipro
Postcoital voiding - increased intake of cranberry juice
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

21. What is the classic signs of nec fasc?
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
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
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
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

22. which heart valve is closer to ventricular conduction system/
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Aortic valve; endocardiits of AR p/w AV block and LBBB
<5000 copies/ml
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

23. What is fatal consequence of RMSF?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Non pregnant premanopausal - elderly - dm - sci - chronic foley

24. What is the prognosis of lyme arthritis?
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
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

25. clinical manifestation of mucomycosis
Viral load and CD4 count
ELISA; initial visit - 6 - 12 and 24 weeks;
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Pt who have been treated before for latent TB

26. How to give postexposure prophylaxis for HIV
If a sample is ELISA positive - it is tested fro western blot for confirmation
Either TB or aspergillosis
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

27. infiltrate in upper lobe of lung?
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
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Either TB or aspergillosis
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

28. 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
Clostridium perfringens after penetrative injuries/wounds
6-12 weeks
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

29. What is tetanus - diptheria - pertusis recommendation?
ELISA and western blot of synovial fluid.
<5000 copies/ml
Pregnacy - urologic procedure - hip arthoplastu
Td every 10 years - tdap once before 65 and after 65

30. where TB normally affects
Upper lobes; any fibrosis in this area suggestive of latent TB
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Do EBV antibody test
<5000 copies/ml

31. acute febrile reaction develops after starting penicilin tx to syphilis patient
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
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

32. how CMV presents in immunocompromised patients
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Bronchoalveolar washing and transbronchial biopsy

33. pneumococcal vaccine indication?
High risk 19-64; 1-2 dose - above 65; one dose
Others lesions are ring enhancing and have mass effect while PML don't
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

34. drugs work well on hypertriglyceridia?
Within 6 months viral load will be <50
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
6-12 weeks
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

35. How often HIV postiive patients CD4 count needs to be evaluated?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Every 3-4 hours to determine appropritate time to start HAART
Clostridium perfringens after penetrative injuries/wounds

36. When to give prophylaxis against MAC
Pegylated interferon and lamivudine
Every 3-4 hours to determine appropritate time to start HAART
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Similar pathophysiology as ITP - tx zidovudine

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

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38. when not to give INH therapy if ppd positive and patient asyptomatic
Pt who have been treated before for latent TB
Pregnacy - urologic procedure - hip arthoplastu
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Cd4 count

39. hypertriglyceridemia in HIV
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley

40. what would be viral load after 4 weeks
Vaccine titer >10mU/ml
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
Td every 10 years - tdap once before 65 and after 65
<5000 copies/ml

41. How to dx progressive multifocal leukoencephalopathy
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
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
ELISA and western blot of synovial fluid.
When cd4 count falls below 200. 2p in pcp =200

42. How to differentiate gonococcal and nongonoccal urethritis?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
High risk 19-64; 1-2 dose - above 65; one dose
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
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. How to tx IM?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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

44. after recent exposure - negative ELISA - How to confirm?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Clostridium perfringens after penetrative injuries/wounds
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

45. hypertension in children
ELISA and western blot of synovial fluid.
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Every 3-4 hours to determine appropritate time to start HAART

46. What is the pathophysiology of Meningococcal meningitis?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

47. How to confirm dx if pcp?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Bronchoalveolar washing and transbronchial biopsy
Clostridium perfringens after penetrative injuries/wounds
Immune mediated; circulating IgG and IgM to penicillin derivatives

48. Tx of choice for human bites
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Oropharyngeal secretions; hence named as kissing disease
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Ampicillin-sublactam; most bites contain eikenella

49. How to dx IM?
Do EBV antibody test
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

50. how im is transmitted?
Viral load and CD4 count
If a sample is ELISA positive - it is tested fro western blot for confirmation
Oropharyngeal secretions; hence named as kissing disease
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.

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USMLE Step3 Infectious Disease

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