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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
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
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
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

2. can HIV transmitted through human bite?
Monospot test which screen heteropile ab that agglutinate horse rbc
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV

3. What are indicators for progression of HIV
Viral load and CD4 count
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

4. what would be viral load after 4 weeks
<5000 copies/ml
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit 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
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

5. What are the subjective /objective measure of encephalopathy?
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Ampicillin-sublactam; most bites contain eikenella
Pregnacy - urologic procedure - hip arthoplastu
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

6. what if monospot test is neg in IM?
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Do EBV antibody test

7. systolic HTN in elderly
Monospot test which screen heteropile ab that agglutinate horse rbc
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
High risk 19-64; 1-2 dose - above 65; one dose
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

8. What is the indication of corticosteroid in pcp infection?
AA gradient >35 or Po2 <70
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
HIV viral load

9. How long we tx chronic prostatis?
HIV viral load
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
6-12 weeks

10. How to dx?
Mainly clinical - epidemiological and seasonal setting
Bronchoalveolar washing and transbronchial biopsy
Ampicillin-sublactam; most bites contain eikenella
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

11. when we see echym gangrenosum?
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Pegylated interferon and lamivudine
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

12. 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
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
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
High risk 19-64; 1-2 dose - above 65; one dose

13. 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
High risk 19-64; 1-2 dose - above 65; one dose
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Postcoital voiding - increased intake of cranberry juice

14. When to give abx to prevent recurrent uti
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
HBIG hep B immunoglobulin
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

15. acute febrile reaction develops after starting penicilin tx to syphilis patient
Clostridium perfringens after penetrative injuries/wounds
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

16. gas gangrene
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Clostridium perfringens after penetrative injuries/wounds
Blastomycosis
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

17. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Pregnacy - urologic procedure - hip arthoplastu

18. What is the prognosis of lyme arthritis?
Mainly clinical - epidemiological and seasonal setting
Others lesions are ring enhancing and have mass effect while PML don't
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -

19. after recent exposure - negative ELISA - How to confirm?
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Pt who have been treated before for latent TB
When cd4 count falls below 200. 2p in pcp =200
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

20. how CMV presents in immunocompromised patients
Pt who have been treated before for latent TB
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
HBIG hep B immunoglobulin
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

21. aspergillosis
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Voriconazol. mycetoma-surgical removal
HBIG hep B immunoglobulin
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

22. what would be viral load after 2-4m of HAART?
<500 copies/ml
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Acyclovir
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

23. after exposure of HIV when antibody testing is performed?
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;
Monospot test which screen heteropile ab that agglutinate horse rbc
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

24. What is lag time to develop lyme arthritis after exposure to vector
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Voriconazol. mycetoma-surgical removal
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

25. pathophysiology of toxic shock syndrom?
Viral load and CD4 count
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Similar pathophysiology as ITP - tx zidovudine
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

26. How to tx IM?
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
6-12 weeks
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

27. What is used for prophylaxis against meningo..meningitis?
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Rifampin600mg q12. or cipro
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
Upper lobes; any fibrosis in this area suggestive of latent TB

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

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29. what parameters increases risk of neurosyphilis in HIV patient
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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.
Ampicillin-sublactam; most bites contain eikenella
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

30. 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.
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
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Cd4 count

31. hypertriglyceridemia in HIV
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Pegylated interferon and lamivudine
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

32. reddish colored papules with central umbilication in HIV or immunocompromised patient
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
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Clostridium perfringens after penetrative injuries/wounds

33. What is the classic signs of nec fasc?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Viral load and 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
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

34. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Aortic valve; endocardiits of AR p/w AV block and LBBB

35. rifampin
AA gradient >35 or Po2 <70
Clostridium perfringens after penetrative injuries/wounds
Vaccine titer >10mU/ml
Reddish orange discoloration of urine - feces - sweat - tears - sputum

36. How to differentiate gonococcal and nongonoccal urethritis?
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
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

37. drugs work well on hypertriglyceridia?
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
Similar pathophysiology as ITP - tx zidovudine
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
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 often HIV postiive patients CD4 count needs to be evaluated?
Every 3-4 hours to determine appropritate time to start HAART
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Ampicillin-sublactam; most bites contain eikenella
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

39. 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
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
Acyclovir
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep

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

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41. When not to tx asymptomatic bacteriura?
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Pegylated interferon and lamivudine
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

42. How to dx adequate response to HBV vaccine
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
<5000 copies/ml
Vaccine titer >10mU/ml
PML; focal neurological deficit like MM; no specific tx; regress with HAART

43. wisconsin - missisipi - ohio
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Mainly clinical - epidemiological and seasonal setting
Blastomycosis
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

44. infiltrate in upper lobe of lung?
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Ampicillin-sublactam; most bites contain eikenella
Either TB or aspergillosis
If a sample is ELISA positive - it is tested fro western blot for confirmation

45. How to confirm chlamydia infection?
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
AA gradient >35 or Po2 <70
Immune mediated; circulating IgG and IgM to penicillin derivatives
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

46. How long abx is given in pseudomonas infection?
ELISA; initial visit - 6 - 12 and 24 weeks;
When cd4 count falls below 200. 2p in pcp =200
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

47. acute onset +rusty sputum
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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
Cd4 count

48. When to tx asymptomatic bacteriurea >100 -000?
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
Pregnacy - urologic procedure - hip arthoplastu
<5000 copies/ml
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure

49. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
PML; focal neurological deficit like MM; no specific tx; regress with HAART

50. What is the pathophysiology of Meningococcal meningitis?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Others lesions are ring enhancing and have mass effect while PML don't
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
<500 copies/ml

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USMLE Step3 Infectious Disease

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