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USMLE Step3 Infectious Disease

Subjects : health-sciences, usmle-step-3

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1. INH
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

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

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3. What is the Tx of cryptococcal meninngitis
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
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.
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

4. after exposure of HIV when antibody testing is performed?
Pt who have been treated before for latent TB
Viral load and CD4 count
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
ELISA; initial visit - 6 - 12 and 24 weeks;

5. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Aortic valve; endocardiits of AR p/w AV block and LBBB

6. What is fatal consequence of RMSF?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Either TB or aspergillosis
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

7. patient is taking inhaled corticosteroid for asthma - now p/w oral candidiasis
Bronchoalveolar washing and transbronchial biopsy
AA gradient >35 or Po2 <70
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
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.

8. When to tx influenza with antiviral therapy?
Vaccine titer >10mU/ml
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
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
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

9. what would be viral load after 2-4m of HAART?
<500 copies/ml
Td every 10 years - tdap once before 65 and after 65
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months

10. How to tx TSS?
Bronchoalveolar washing and transbronchial biopsy
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
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

11. acute onset +rusty sputum
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Pregnacy - urologic procedure - hip arthoplastu
ELISA and western blot of synovial fluid.
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

12. What is used for prophylaxis against meningo..meningitis?
ELISA and western blot of synovial fluid.
Others lesions are ring enhancing and have mass effect while PML don't
Rifampin600mg q12. or cipro
Aortic valve; endocardiits of AR p/w AV block and LBBB

13. thrombocytopenia in HIV
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Similar pathophysiology as ITP - tx zidovudine
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

14. How often HIV postiive patients CD4 count needs to be evaluated?
Within 6 months viral load will be <50
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Every 3-4 hours to determine appropritate time to start HAART
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

15. How to tx pseudomonas?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
ELISA and western blot of synovial fluid.
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

16. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
AA gradient >35 or Po2 <70
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
Reddish orange discoloration of urine - feces - sweat - tears - sputum

17. how CMV presents in immunocompromised patients
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Reddish orange discoloration of urine - feces - sweat - tears - sputum

18. when not to give INH therapy if ppd positive and patient asyptomatic
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
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
Pt who have been treated before for latent TB
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

19. What is the criteria for Spontaneous bact peritonitis
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Clostridium perfringens after penetrative injuries/wounds
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ

20. reddish colored papules with central umbilication in HIV or immunocompromised patient
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
If a sample is ELISA positive - it is tested fro western blot for confirmation
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

21. How to confirm chlamydia infection?
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
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

22. clinical manifestation of mucomycosis
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
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
Others lesions are ring enhancing and have mass effect while PML don't

23. What are the subjective /objective measure of encephalopathy?
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Rifampin600mg q12. or cipro
ELISA and western blot of synovial fluid.
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

24. What is tetanus - diptheria - pertusis recommendation?
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
Acyclovir
Td every 10 years - tdap once before 65 and after 65
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

25. systolic HTN in elderly
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
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

26. when western blot is done for HIV testing
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
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
<5000 copies/ml
If a sample is ELISA positive - it is tested fro western blot for confirmation

27. What is difference between uti relapse versus recurrence?
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
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
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

28. acute febrile reaction develops after starting penicilin tx to syphilis patient
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
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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.
Pregnacy - urologic procedure - hip arthoplastu

29. infiltrate in upper lobe of lung?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
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
Either TB or aspergillosis

30. How to give postexposure prophylaxis for HIV
High risk 19-64; 1-2 dose - above 65; one dose
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
If a sample is ELISA positive - it is tested fro western blot for confirmation

31. What are indicators for progression of HIV
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Viral load and CD4 count

32. When not to tx asymptomatic bacteriura?
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
Non pregnant premanopausal - elderly - dm - sci - chronic foley
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
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges

33. How to dx 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
Either TB or aspergillosis
Monospot test which screen heteropile ab that agglutinate horse rbc
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

34. When to tx asymptomatic bacteriurea >100 -000?
Pregnacy - urologic procedure - hip arthoplastu
Monospot test which screen heteropile ab that agglutinate horse rbc
<5000 copies/ml
Reddish orange discoloration of urine - feces - sweat - tears - sputum

35. pneumococcal vaccine indication?
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)
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
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

36. how im is transmitted?
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
ELISA and western blot of synovial fluid.
Either TB or aspergillosis
Oropharyngeal secretions; hence named as kissing disease

37. How to dx bacterial meningitis from CSF study?

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38. What is tx for herpes zoster
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Acyclovir
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

39. How to tx chronic hep B
Pegylated interferon and lamivudine
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Immune mediated; circulating IgG and IgM to penicillin derivatives
Similar pathophysiology as ITP - tx zidovudine

40. Tx of choice for human bites
Ampicillin-sublactam; most bites contain eikenella
Postcoital voiding - increased intake of cranberry juice
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

41. What is the mch of ampicillin induced rash in IM
Do EBV antibody test
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Immune mediated; circulating IgG and IgM to penicillin derivatives
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

42. antibiotic with good prostate penetration?
Pegylated interferon and lamivudine
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
When cd4 count falls below 200. 2p in pcp =200
Clostridium perfringens after penetrative injuries/wounds

43. How long abx is given in pseudomonas infection?
Blastomycosis
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved

44. How to tx pcp?
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
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

45. What are the behavioral interventions decrease the risk of UTI
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Clostridium perfringens after penetrative injuries/wounds
Postcoital voiding - increased intake of cranberry juice
Cd4 count

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

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47. hypertension in children
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Bronchoalveolar washing and transbronchial biopsy
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid

48. when HIV patient develop pcp?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Do EBV antibody test
When cd4 count falls below 200. 2p in pcp =200
Similar pathophysiology as ITP - tx zidovudine

49. drugs work well on hypertriglyceridia?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
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

50. 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
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.
<500 copies/ml
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

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USMLE Step3 Infectious Disease

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