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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. 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
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
High risk 19-64; 1-2 dose - above 65; one dose

2. reddish colored papules with central umbilication in HIV or immunocompromised patient
Cd4 count
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
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
Rifampin600mg q12. or cipro

3. when we see echym gangrenosum?
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Oropharyngeal secretions; hence named as kissing disease
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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

4. what would be viral load after 4 weeks
<5000 copies/ml
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
HBIG hep B immunoglobulin
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

5. acute onset +rusty sputum
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
ELISA and western blot of synovial fluid.
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

6. systolic HTN in elderly
Pt who have been treated before for latent TB
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
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
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

7. What is the pathophysiology of Meningococcal meningitis?
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
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

8. What is the Tx of cryptococcal meninngitis
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
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
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

9. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Pegylated interferon and lamivudine
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Within 6 months viral load will be <50

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

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11. How to tx TSS?
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
HBIG hep B immunoglobulin
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

12. What is the classic signs of nec fasc?
Upper lobes; any fibrosis in this area suggestive of latent TB
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
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
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

13. How to confirm dx if pcp?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
AA gradient >35 or Po2 <70
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Bronchoalveolar washing and transbronchial biopsy

14. dame that has already occurred
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Cd4 count
Either TB or aspergillosis
HIV viral load

15. How to differentiate different types of necrotizing fascitis?
Postcoital voiding - increased intake of cranberry juice
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 lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

16. acute febrile reaction develops after starting penicilin tx to syphilis patient
HBIG hep B immunoglobulin
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Every 3-4 hours to determine appropritate time to start HAART

17. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Do EBV antibody test
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

18. damae that is about to occur?
HIV viral load
<5000 copies/ml
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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

19. what would be viral load after 2-4m of HAART?
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
<500 copies/ml
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

20. INH
ELISA; initial visit - 6 - 12 and 24 weeks;
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
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
Postcoital voiding - increased intake of cranberry juice

21. How often HIV postiive patients CD4 count needs to be evaluated?
Every 3-4 hours to determine appropritate time to start HAART
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

22. gas gangrene
Clostridium perfringens after penetrative injuries/wounds
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Others lesions are ring enhancing and have mass effect while PML don't
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

23. What is lag time to develop lyme arthritis after exposure to vector
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Oropharyngeal secretions; hence named as kissing disease

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

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25. How to tx chronic hep B
Pegylated interferon and lamivudine
ELISA and western blot of synovial fluid.
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.
Mainly clinical - epidemiological and seasonal setting

26. aspergillosis
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Voriconazol. mycetoma-surgical removal
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley

27. What are indicators for progression of HIV
Do EBV antibody test
Aortic valve; endocardiits of AR p/w AV block and LBBB
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Viral load and CD4 count

28. When to give prophylaxis against MAC
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
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

29. How to dx bacterial meningitis from CSF study?

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30. clinical manifestation of mucomycosis
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
HIV viral load
Within 6 months viral load will be <50
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

31. pneumococcal vaccine indication?
AA gradient >35 or Po2 <70
High risk 19-64; 1-2 dose - above 65; one dose
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

32. How often viral load is monitored after HAART?
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Viral load and CD4 count
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
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

33. wisconsin - missisipi - ohio
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Blastomycosis
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Need lumbar puncture to relieve pressure; they have high opening pressure >350

34. How to dx progressive multifocal leukoencephalopathy
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Acyclovir
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Pt who have been treated before for latent TB

35. What is difference between uti relapse versus recurrence?
Clostridium perfringens after penetrative injuries/wounds
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
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
ELISA; initial visit - 6 - 12 and 24 weeks;

36. which heart valve is closer to ventricular conduction system/
Postcoital voiding - increased intake of cranberry juice
Aortic valve; endocardiits of AR p/w AV block and LBBB
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
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

37. how CMV presents in immunocompromised patients
Either TB or aspergillosis
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Others lesions are ring enhancing and have mass effect while PML don't
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

38. when not to give INH therapy if ppd positive and patient asyptomatic
Acyclovir
Pt who have been treated before for latent TB
<5000 copies/ml
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

39. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
HBIG hep B immunoglobulin
Immune mediated; circulating IgG and IgM to penicillin derivatives
Non pregnant premanopausal - elderly - dm - sci - chronic foley
<500 copies/ml

40. How to tx pseudomonas?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
ELISA and western blot of synovial fluid.
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

41. what if monospot test is neg in IM?
Bronchoalveolar washing and transbronchial biopsy
Do EBV antibody test
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
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

42. antibiotic with good prostate penetration?
ELISA and western blot of synovial fluid.
Oropharyngeal secretions; hence named as kissing disease
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

43. When to give abx to prevent recurrent uti
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
High risk 19-64; 1-2 dose - above 65; one dose
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

44. after recent exposure - negative ELISA - How to confirm?
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 viral load
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

45. hypertriglyceridemia in HIV
High risk 19-64; 1-2 dose - above 65; one dose
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
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

46. When to tx influenza with antiviral therapy?
<5000 copies/ml
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
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

47. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Either TB or aspergillosis

48. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

49. When not to tx asymptomatic bacteriura?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

50. thrombocytopenia in HIV
Similar pathophysiology as ITP - tx zidovudine
Viral load and CD4 count
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Doesn't exceed more than 15 mm and size significantly decreases after 15 years

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USMLE Step3 Infectious Disease

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