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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. 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
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Voriconazol. mycetoma-surgical removal
Pt who have been treated before for latent TB

2. How to confirm dx if pcp?
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
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
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

3. foot infections in DM
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Pregnacy - urologic procedure - hip arthoplastu

4. How to dx?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Others lesions are ring enhancing and have mass effect while PML don't
Mainly clinical - epidemiological and seasonal setting

5. When to give abx to prevent recurrent uti
Ampicillin-sublactam; most bites contain eikenella
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
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

6. INH
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
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
<500 copies/ml

7. What is used for prophylaxis against meningo..meningitis?
Rifampin600mg q12. or cipro
Pt who have been treated before for latent TB
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)

8. chshould we tx IM with abx (ampicilin) if throat cx is positive?
When cd4 count falls below 200. 2p in pcp =200
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
HIV viral load

9. When to tx influenza with antiviral therapy?
Immune mediated; circulating IgG and IgM to penicillin derivatives
Similar pathophysiology as ITP - tx zidovudine
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

10. how HAART therapy affects HIV viral loads?
Within 6 months viral load will be <50
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
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

11. What is the mch of ampicillin induced rash in IM
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Immune mediated; circulating IgG and IgM to penicillin derivatives
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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

12. wisconsin - missisipi - ohio
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Blastomycosis
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

13. reddish colored papules with central umbilication in HIV or immunocompromised patient
Either TB or aspergillosis
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
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

14. Tx of choice for human bites
When cd4 count falls below 200. 2p in pcp =200
Ampicillin-sublactam; most bites contain eikenella
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Upper lobes; any fibrosis in this area suggestive of latent TB

15. How to tx chronic hep B
Cd4 count
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Vaccine titer >10mU/ml
Pegylated interferon and lamivudine

16. rifampin
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Within 6 months viral load will be <50
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Do EBV antibody test

17. How to confirm chlamydia infection?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Immune mediated; circulating IgG and IgM to penicillin derivatives
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

18. How to tx pcp?
Voriconazol. mycetoma-surgical removal
Rifampin600mg q12. or cipro
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

19. when western blot is done for HIV testing
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
When cd4 count falls below 200. 2p in pcp =200
If a sample is ELISA positive - it is tested fro western blot for confirmation
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

20. How to dx adequate response to HBV vaccine
Vaccine titer >10mU/ml
HIV viral load
Blastomycosis
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

21. pneumococcal vaccine indication?
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
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
High risk 19-64; 1-2 dose - above 65; one dose
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

22. when not to give INH therapy if ppd positive and patient asyptomatic
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Pt who have been treated before for latent TB
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley

23. what if monospot test is neg in IM?
Aortic valve; endocardiits of AR p/w AV block and LBBB
Do EBV antibody test
Clostridium perfringens after penetrative injuries/wounds
Need lumbar puncture to relieve pressure; they have high opening pressure >350

24. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
Acyclovir
Rifampin600mg q12. or cipro
HBIG hep B immunoglobulin
High risk 19-64; 1-2 dose - above 65; one dose

25. damae that is about to occur?
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
Viral load and CD4 count
HIV viral load
Either TB or aspergillosis

26. What is the prognosis of lyme arthritis?
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
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

27. How to dx bacterial meningitis from CSF study?

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

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29. acute onset +rusty sputum
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
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

30. How to dx IM?
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

31. How to differentiate gonococcal and nongonoccal urethritis?
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
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
6-12 weeks
Monospot test which screen heteropile ab that agglutinate horse rbc

32. which heart valve is closer to ventricular conduction system/
Aortic valve; endocardiits of AR p/w AV block and LBBB
ELISA and western blot of synovial fluid.
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
Pegylated interferon and lamivudine

33. How to dx cryptococal meninggits
Pt who have been treated before for latent TB
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
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

34. When not to tx asymptomatic bacteriura?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Either TB or aspergillosis
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Non pregnant premanopausal - elderly - dm - sci - chronic foley

35. drugs work well on hypertriglyceridia?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads

36. When to give prophylaxis against MAC
ELISA; initial visit - 6 - 12 and 24 weeks;
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
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

37. How to give postexposure prophylaxis for HIV
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
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
6-12 weeks
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

38. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Clostridium perfringens after penetrative injuries/wounds
Either TB or aspergillosis
Aortic valve; endocardiits of AR p/w AV block and LBBB

39. dame that has already occurred
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Cd4 count

40. When to tx asymptomatic bacteriurea >100 -000?
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Pregnacy - urologic procedure - hip arthoplastu
ELISA and western blot of synovial fluid.
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

41. What is lag time to develop lyme arthritis after exposure to vector
Clostridium perfringens after penetrative injuries/wounds
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Oropharyngeal secretions; hence named as kissing disease
Voriconazol. mycetoma-surgical removal

42. aspergillosis
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Voriconazol. mycetoma-surgical removal
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

43. after exposure of HIV when antibody testing is performed?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
ELISA; initial visit - 6 - 12 and 24 weeks;
6-12 weeks
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

44. after bone marrow transplant - patient develop headache - fever - cought and chest pain. What is dx?
Either TB or aspergillosis
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

45. pathophysiology of toxic shock syndrom?
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

46. What is fatal consequence of RMSF?
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
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
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

47. how im is transmitted?
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
Oropharyngeal secretions; hence named as kissing disease
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
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

48. acute febrile reaction develops after starting penicilin tx to syphilis patient
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

49. causative organisms of uti
Td every 10 years - tdap once before 65 and after 65
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

50. antibiotic with good prostate penetration?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Upper lobes; any fibrosis in this area suggestive of latent TB
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

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USMLE Step3 Infectious Disease

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