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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. what would be viral load after 2-4m of HAART?
High risk 19-64; 1-2 dose - above 65; one dose
Voriconazol. mycetoma-surgical removal
<500 copies/ml
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

2. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

3. How to dx lyme arthritis?
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
ELISA and western blot of synovial fluid.
Clostridium perfringens after penetrative injuries/wounds
Either TB or aspergillosis

4. What is the classic signs of nec fasc?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
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
Viral load and CD4 count
Postcoital voiding - increased intake of cranberry juice

5. what parameters increases risk of neurosyphilis in HIV patient
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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.

6. 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
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
Acyclovir
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

7. When to give abx to prevent recurrent uti
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Every 3-4 hours to determine appropritate time to start HAART
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
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.

8. infiltrate in upper lobe of lung?
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
PML; focal neurological deficit like MM; no specific tx; regress with HAART
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
Either TB or aspergillosis

9. Tx of choice for human bites
Monospot test which screen heteropile ab that agglutinate horse rbc
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
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
Ampicillin-sublactam; most bites contain eikenella

10. when we see echym gangrenosum?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Pegylated interferon and lamivudine
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

11. How to tx IM?
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
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
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

12. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
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
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Immune mediated; circulating IgG and IgM to penicillin derivatives
PML; focal neurological deficit like MM; no specific tx; regress with HAART

13. what would be viral load after 4 weeks
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
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
<5000 copies/ml

14. antibiotic with good prostate penetration?
Upper lobes; any fibrosis in this area suggestive of latent TB
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
<500 copies/ml

15. What is fatal consequence of RMSF?
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
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

16. worsening of TB after starting HAART in HIV
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
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
Viral load and CD4 count
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

17. gas gangrene
Td every 10 years - tdap once before 65 and after 65
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Clostridium perfringens after penetrative injuries/wounds
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

18. What is the Tx of STD uretheritis?
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
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
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
PML; focal neurological deficit like MM; no specific tx; regress with HAART

19. What is the prognosis of lyme arthritis?
Td every 10 years - tdap once before 65 and after 65
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
ELISA; initial visit - 6 - 12 and 24 weeks;
High risk 19-64; 1-2 dose - above 65; one dose

20. damae that is about to occur?
Either TB or aspergillosis
Every 3-4 hours to determine appropritate time to start HAART
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
HIV viral load

21. What is the criteria for Spontaneous bact peritonitis
Do EBV antibody test
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Every 3-4 hours to determine appropritate time to start HAART

22. HIV patient having fat deposition on back of neck and abdomen - like cushing
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Pt who have been treated before for latent TB
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
AA gradient >35 or Po2 <70

23. What is difference between uti relapse versus recurrence?
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
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
<5000 copies/ml
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

24. How often HIV postiive patients CD4 count needs to be evaluated?
Pegylated interferon and lamivudine
High risk 19-64; 1-2 dose - above 65; one dose
Every 3-4 hours to determine appropritate time to start HAART
HBIG hep B immunoglobulin

25. thrombocytopenia in HIV
Similar pathophysiology as ITP - tx zidovudine
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Bronchoalveolar washing and transbronchial biopsy
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

26. acute febrile reaction develops after starting penicilin tx to syphilis patient
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
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
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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

27. what if monospot test is neg in IM?
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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
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

28. What is the pathophysiology of Meningococcal meningitis?
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
HIV viral load

29. What is the mch of ampicillin induced rash in IM
Immune mediated; circulating IgG and IgM to penicillin derivatives
Do EBV antibody test
Within 6 months viral load will be <50
Vaccine titer >10mU/ml

30. How to confirm chlamydia infection?
Bronchoalveolar washing and transbronchial biopsy
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Aortic valve; endocardiits of AR p/w AV block and LBBB
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

31. hypertriglyceridemia in HIV
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

32. What is tx for herpes zoster
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
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Acyclovir
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads

33. rifampin
6-12 weeks
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Bronchoalveolar washing and transbronchial biopsy

34. How to tx pseudomonas?
AA gradient >35 or Po2 <70
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

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

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36. hypertension in children
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Pt who have been treated before for latent TB

37. clinical manifestation of mucomycosis
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Every 3-4 hours to determine appropritate time to start HAART
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

38. INH
<5000 copies/ml
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Td every 10 years - tdap once before 65 and after 65
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

39. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Ampicillin-sublactam; most bites contain eikenella

40. How to differentiate different types of necrotizing fascitis?
Pregnacy - urologic procedure - hip arthoplastu
Acyclovir
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
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

41. What is tetanus - diptheria - pertusis recommendation?
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
Td every 10 years - tdap once before 65 and after 65
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

42. low grade fever - maculopapular rash - lymphadenopathy
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Bronchoalveolar washing and transbronchial biopsy

43. When to give prophylaxis against MAC
Viral load and CD4 count
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
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

44. How to dx cryptococal meninggits
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

45. How to tx pcp?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
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
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

46. How to dx IM?
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
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

47. How long abx is given in pseudomonas infection?
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

48. aspergillosis
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
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
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

49. wisconsin - missisipi - ohio
High risk 19-64; 1-2 dose - above 65; one dose
Td every 10 years - tdap once before 65 and after 65
<500 copies/ml
Blastomycosis

50. which heart valve is closer to ventricular conduction system/
Pegylated interferon and lamivudine
If a sample is ELISA positive - it is tested fro western blot for confirmation
Aortic valve; endocardiits of AR p/w AV block and LBBB
Immune mediated; circulating IgG and IgM to penicillin derivatives

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USMLE Step3 Infectious Disease

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