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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. How to dx cryptococal meninggits
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
<5000 copies/ml
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

2. When to give abx to prevent recurrent uti
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Upper lobes; any fibrosis in this area suggestive of latent TB
Either TB or aspergillosis
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

3. How to tx TSS?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

4. after bone marrow transplant - patient develop headache - fever - cought and chest pain. What is dx?
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
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Others lesions are ring enhancing and have mass effect while PML don't

5. What is lag time to develop lyme arthritis after exposure to vector
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
AA gradient >35 or Po2 <70
HBIG hep B immunoglobulin
Pregnacy - urologic procedure - hip arthoplastu

6. How often viral load is monitored after HAART?
Bronchoalveolar washing and transbronchial biopsy
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Monospot test which screen heteropile ab that agglutinate horse rbc

7. clinical manifestation of mucomycosis
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
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
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

8. when western blot is done for HIV testing
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
If a sample is ELISA positive - it is tested fro western blot for confirmation
Cd4 count
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

9. How to dx adequate response to HBV vaccine
Postcoital voiding - increased intake of cranberry juice
Immune mediated; circulating IgG and IgM to penicillin derivatives
Vaccine titer >10mU/ml
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

10. chshould we tx IM with abx (ampicilin) if throat cx is positive?
Ampicillin-sublactam; most bites contain eikenella
ELISA; initial visit - 6 - 12 and 24 weeks;
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

11. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Non pregnant premanopausal - elderly - dm - sci - chronic foley
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
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

12. What are the subjective /objective measure of encephalopathy?
Postcoital voiding - increased intake of cranberry juice
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Others lesions are ring enhancing and have mass effect while PML don't

13. When to tx influenza with antiviral therapy?
Need lumbar puncture to relieve pressure; they have high opening pressure >350
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
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
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

14. foot infections in DM
ELISA; initial visit - 6 - 12 and 24 weeks;
<5000 copies/ml
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
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

15. HIV patient having fat deposition on back of neck and abdomen - like cushing
Similar pathophysiology as ITP - tx zidovudine
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

16. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Cd4 count
Td every 10 years - tdap once before 65 and after 65
If a sample is ELISA positive - it is tested fro western blot for confirmation
PML; focal neurological deficit like MM; no specific tx; regress with HAART

17. how HAART therapy affects HIV viral loads?
Within 6 months viral load will be <50
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Voriconazol. mycetoma-surgical removal
Rifampin600mg q12. or cipro

18. What are the behavioral interventions decrease the risk of UTI
Postcoital voiding - increased intake of cranberry juice
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
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
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

19. 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
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
Within 6 months viral load will be <50

20. When to give prophylaxis against MAC
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
High risk 19-64; 1-2 dose - above 65; one dose
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

21. What is used for prophylaxis against meningo..meningitis?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Rifampin600mg q12. or cipro

22. How to give postexposure prophylaxis for HIV
ELISA and western blot of synovial fluid.
Upper lobes; any fibrosis in this area suggestive of latent TB
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

23. When to tx asymptomatic bacteriurea >100 -000?
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
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Pregnacy - urologic procedure - hip arthoplastu
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges

24. How to differentiate gonococcal and nongonoccal urethritis?
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
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
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
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

25. How to confirm chlamydia infection?
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

26. How to tx pseudomonas?
Voriconazol. mycetoma-surgical removal
HIV viral load
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

27. causative organisms of uti
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
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

28. How long abx is given in pseudomonas infection?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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

29. damae that is about to occur?
High risk 19-64; 1-2 dose - above 65; one dose
Others lesions are ring enhancing and have mass effect while PML don't
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
HIV viral load

30. Tx of choice for human bites
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Ampicillin-sublactam; most bites contain eikenella
<500 copies/ml
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

31. worsening of TB after starting HAART in HIV
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
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
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

32. drugs work well on hypertriglyceridia?
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
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

33. What is fatal consequence of RMSF?
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
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
If a sample is ELISA positive - it is tested fro western blot for confirmation

34. low grade fever - maculopapular rash - lymphadenopathy
Pt who have been treated before for latent TB
Upper lobes; any fibrosis in this area suggestive of latent TB
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Mainly clinical - epidemiological and seasonal setting

35. when we see echym gangrenosum?
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
HBIG hep B immunoglobulin
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
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

36. rifampin
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Reddish orange discoloration of urine - feces - sweat - tears - sputum

37. What is characteristic for dx of rocky mountain spotted fever?
Blastomycosis
Ampicillin-sublactam; most bites contain eikenella
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

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

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39. infiltrate in upper lobe of lung?
Either TB or aspergillosis
Bronchoalveolar washing and transbronchial biopsy
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
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

40. gas gangrene
Clostridium perfringens after penetrative injuries/wounds
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Postcoital voiding - increased intake of cranberry juice

41. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
PML; focal neurological deficit like MM; no specific tx; regress with HAART
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

42. How to dx lyme arthritis?
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
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
ELISA and western blot of synovial fluid.
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

43. What is tx for herpes zoster
Acyclovir
Td every 10 years - tdap once before 65 and after 65
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

44. What is difference between uti relapse versus recurrence?
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
Voriconazol. mycetoma-surgical removal
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
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

45. hypertension in children
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
Every 3-4 hours to determine appropritate time to start HAART
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Pegylated interferon and lamivudine

46. How to tx IM?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Upper lobes; any fibrosis in this area suggestive of latent TB
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Vaccine titer >10mU/ml

47. after recent exposure - negative ELISA - How to confirm?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Postcoital voiding - increased intake of cranberry juice
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
ELISA; initial visit - 6 - 12 and 24 weeks;

48. What is the mch of ampicillin induced rash in IM
Do EBV antibody test
Immune mediated; circulating IgG and IgM to penicillin derivatives
Others lesions are ring enhancing and have mass effect while PML don't
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

49. How to dx?
Mainly clinical - epidemiological and seasonal setting
Clostridium perfringens after penetrative injuries/wounds
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

50. How to dx bacterial meningitis from CSF study?

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USMLE Step3 Infectious Disease

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