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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. infiltrate in upper lobe of lung?
Acyclovir
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Either TB or aspergillosis
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

2. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Viral load and CD4 count
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges

3. when HIV patient develop pcp?
HIV viral load
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
Pregnacy - urologic procedure - hip arthoplastu
When cd4 count falls below 200. 2p in pcp =200

4. How to dx lyme arthritis?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
ELISA and western blot of synovial fluid.

5. What is used for prophylaxis against meningo..meningitis?
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Rifampin600mg q12. or cipro
Similar pathophysiology as ITP - tx zidovudine

6. hypertension in children
Every 3-4 hours to determine appropritate time to start HAART
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

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

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8. How to dx cryptococal meninggits
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
6-12 weeks
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

9. 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)
ELISA and western blot of synovial fluid.
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Acyclovir

10. thrombocytopenia 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
ELISA and western blot of synovial fluid.
Similar pathophysiology as ITP - tx zidovudine
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

11. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
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
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
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

12. When to give abx to prevent recurrent uti
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
High risk 19-64; 1-2 dose - above 65; one dose
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
Ampicillin-sublactam; most bites contain eikenella

13. How to dx adequate response to HBV vaccine
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
<5000 copies/ml
Vaccine titer >10mU/ml

14. how HAART therapy affects HIV viral loads?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Oropharyngeal secretions; hence named as kissing disease
Immune mediated; circulating IgG and IgM to penicillin derivatives
Within 6 months viral load will be <50

15. What is the indication of corticosteroid in pcp infection?
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Others lesions are ring enhancing and have mass effect while PML don't
AA gradient >35 or Po2 <70

16. What is the prognosis of lyme arthritis?
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
6-12 weeks
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
HIV viral load

17. 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
Pregnacy - urologic procedure - hip arthoplastu
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Upper lobes; any fibrosis in this area suggestive of latent TB

18. What is tetanus - diptheria - pertusis recommendation?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Td every 10 years - tdap once before 65 and after 65
Immune mediated; circulating IgG and IgM to penicillin derivatives
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

19. after exposure of HIV when antibody testing is performed?
<500 copies/ml
Others lesions are ring enhancing and have mass effect while PML don't
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
ELISA; initial visit - 6 - 12 and 24 weeks;

20. acute onset +rusty sputum
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
HBIG hep B immunoglobulin
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Postcoital voiding - increased intake of cranberry juice

21. How to tx pcp?
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Ampicillin-sublactam; most bites contain eikenella
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Mainly clinical - epidemiological and seasonal setting

22. rifampin
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Do EBV antibody test
Reddish orange discoloration of urine - feces - sweat - tears - sputum

23. pneumococcal vaccine indication?
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
High risk 19-64; 1-2 dose - above 65; one dose
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

24. When not to tx asymptomatic bacteriura?
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Cd4 count
<5000 copies/ml
Non pregnant premanopausal - elderly - dm - sci - chronic foley

25. How long abx is given in pseudomonas infection?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
PML; focal neurological deficit like MM; no specific tx; regress with HAART

26. How to dx progressive multifocal leukoencephalopathy
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Upper lobes; any fibrosis in this area suggestive of latent TB
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

27. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
Pregnacy - urologic procedure - hip arthoplastu
Ampicillin-sublactam; most bites contain eikenella
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

28. How to confirm dx if pcp?
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Bronchoalveolar washing and transbronchial biopsy
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Clostridium perfringens after penetrative injuries/wounds

29. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
HBIG hep B immunoglobulin
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

30. How to tx chronic hep B
Pegylated interferon and lamivudine
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
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV

31. What are the subjective /objective measure of encephalopathy?
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
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
Do EBV antibody test

32. antibiotic with good prostate penetration?
AA gradient >35 or Po2 <70
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Others lesions are ring enhancing and have mass effect while PML don't
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

33. What is difference between uti relapse versus recurrence?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
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
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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

34. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Cd4 count
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

35. What is the Tx of STD uretheritis?
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

36. What are indicators for progression of HIV
6-12 weeks
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Viral load and CD4 count
Pregnacy - urologic procedure - hip arthoplastu

37. pathophysiology of toxic shock syndrom?
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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

38. How to tx TSS?
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Cd4 count
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

39. When to tx influenza with antiviral therapy?
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
When cd4 count falls below 200. 2p in pcp =200
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

40. worsening of TB after starting HAART in HIV
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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
HIV viral load
<5000 copies/ml

41. How often viral load is monitored after HAART?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Others lesions are ring enhancing and have mass effect while PML don't
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

42. drugs work well on hypertriglyceridia?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Pregnacy - urologic procedure - hip arthoplastu
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

43. How long we tx chronic prostatis?
6-12 weeks
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Postcoital voiding - increased intake of cranberry juice

44. reddish colored papules with central umbilication in HIV or immunocompromised patient
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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

45. dame that has already occurred
Cd4 count
<5000 copies/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
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

46. how im is transmitted?
Vaccine titer >10mU/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.
Cd4 count
Oropharyngeal secretions; hence named as kissing disease

47. What are the behavioral interventions decrease the risk of UTI
Postcoital voiding - increased intake of cranberry juice
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

48. when western blot is done for HIV testing
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
If a sample is ELISA positive - it is tested fro western blot for confirmation
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

49. What is tx for herpes zoster
Aortic valve; endocardiits of AR p/w AV block and LBBB
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Acyclovir

50. What is the Tx of cryptococcal meninngitis
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

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USMLE Step3 Infectious Disease

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