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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. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Bronchoalveolar washing and transbronchial biopsy
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

2. What is lag time to develop lyme arthritis after exposure to vector
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Mainly clinical - epidemiological and seasonal setting

3. after exposure of HIV when antibody testing is performed?
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; initial visit - 6 - 12 and 24 weeks;
When cd4 count falls below 200. 2p in pcp =200
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.

4. How to dx IM?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Pegylated interferon and lamivudine
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Monospot test which screen heteropile ab that agglutinate horse rbc

5. low grade fever - maculopapular rash - lymphadenopathy
Vaccine titer >10mU/ml
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
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. aspergillosis
Either TB or aspergillosis
AA gradient >35 or Po2 <70
Voriconazol. mycetoma-surgical removal
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes

7. what would be viral load after 2-4m of HAART?
<500 copies/ml
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
Do EBV antibody test

8. What is characteristic for dx of rocky mountain spotted fever?
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 lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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

9. pathophysiology of toxic shock syndrom?
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
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.
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

10. when we see echym gangrenosum?
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
<5000 copies/ml
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

11. How often viral load is monitored after 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
ELISA and western blot of synovial fluid.
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Upper lobes; any fibrosis in this area suggestive of latent TB

12. What is used for prophylaxis against meningo..meningitis?
HBIG hep B immunoglobulin
Pregnacy - urologic procedure - hip arthoplastu
Similar pathophysiology as ITP - tx zidovudine
Rifampin600mg q12. or cipro

13. INH
<500 copies/ml
<5000 copies/ml
When cd4 count falls below 200. 2p in pcp =200
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50

14. what would be viral load after 4 weeks
If a sample is ELISA positive - it is tested fro western blot for confirmation
<5000 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
Td every 10 years - tdap once before 65 and after 65

15. What is the indication of corticosteroid in pcp infection?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
AA gradient >35 or Po2 <70
HIV viral load
Reddish orange discoloration of urine - feces - sweat - tears - sputum

16. How to dx lyme arthritis?
ELISA and western blot of synovial fluid.
Oropharyngeal secretions; hence named as kissing disease
ELISA; initial visit - 6 - 12 and 24 weeks;
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

17. what parameters increases risk of neurosyphilis in HIV patient
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Pt who have been treated before for latent TB
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.

18. damae that is about to occur?
<500 copies/ml
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
HIV viral load
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

19. how CMV presents in immunocompromised patients
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6
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

20. What is the Tx of cryptococcal meninngitis
Vaccine titer >10mU/ml
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Either TB or aspergillosis
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

21. how HAART therapy affects HIV viral loads?
Either TB or aspergillosis
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.
Within 6 months viral load will be <50
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)

22. Tx of choice for human bites
Viral load and CD4 count
Ampicillin-sublactam; most bites contain eikenella
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.

23. gas gangrene
Clostridium perfringens after penetrative injuries/wounds
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
Rifampin600mg q12. or cipro
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

24. How often HIV postiive patients CD4 count needs to be evaluated?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
ELISA; initial visit - 6 - 12 and 24 weeks;
Others lesions are ring enhancing and have mass effect while PML don't
Every 3-4 hours to determine appropritate time to start HAART

25. How to tx IM?
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Oropharyngeal secretions; hence named as kissing disease
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

26. How to dx progressive multifocal leukoencephalopathy
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits

27. How to dx adequate response to HBV vaccine
Pegylated interferon and lamivudine
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Vaccine titer >10mU/ml
Clostridium perfringens after penetrative injuries/wounds

28. How to dx IM?
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
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)

29. thrombocytopenia in HIV
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
Similar pathophysiology as ITP - tx zidovudine
Postcoital voiding - increased intake of cranberry juice

30. acute febrile reaction develops after starting penicilin tx to syphilis patient
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
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
AA gradient >35 or Po2 <70

31. How to confirm dx if pcp?
Blastomycosis
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Bronchoalveolar washing and transbronchial biopsy
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

32. 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
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

33. dame that has already occurred
Cd4 count
AA gradient >35 or Po2 <70
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

34. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
PML; focal neurological deficit like MM; no specific tx; regress with HAART
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.
HBIG hep B immunoglobulin

35. when not to give INH therapy if ppd positive and patient asyptomatic
Ampicillin-sublactam; most bites contain eikenella
Pt who have been treated before for latent TB
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
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

36. How to confirm chlamydia infection?
Td every 10 years - tdap once before 65 and after 65
Acyclovir
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole

37. What is the criteria for Spontaneous bact peritonitis
Pregnacy - urologic procedure - hip arthoplastu
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Immune mediated; circulating IgG and IgM to penicillin derivatives
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

38. foot infections in DM
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

39. hypertriglyceridemia in HIV
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
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
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Need lumbar puncture to relieve pressure; they have high opening pressure >350

40. When to tx asymptomatic bacteriurea >100 -000?
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Pregnacy - urologic procedure - hip arthoplastu

41. drugs work well on hypertriglyceridia?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
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

42. How to dx?
Viral load and CD4 count
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Mainly clinical - epidemiological and seasonal setting
Within 6 months viral load will be <50

43. When not to tx asymptomatic bacteriura?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Non pregnant premanopausal - elderly - dm - sci - chronic foley
ELISA; initial visit - 6 - 12 and 24 weeks;
Immune mediated; circulating IgG and IgM to penicillin derivatives

44. How long we tx chronic prostatis?
Pegylated interferon and lamivudine
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
6-12 weeks
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -

45. what if monospot test is neg in IM?
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
Bronchoalveolar washing and transbronchial biopsy
Do EBV antibody test
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

46. What is the classic signs of nec fasc?
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
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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

47. How to tx TSS?
Vaccine titer >10mU/ml
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Every 3-4 hours to determine appropritate time to start HAART

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

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49. when HIV patient develop pcp?
HIV viral load
Pt who have been treated before for latent TB
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
When cd4 count falls below 200. 2p in pcp =200

50. wisconsin - missisipi - ohio
Voriconazol. mycetoma-surgical removal
Blastomycosis
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
6-12 weeks

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USMLE Step3 Infectious Disease

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