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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. drugs work well on hypertriglyceridia?
Cd4 count
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Mainly clinical - epidemiological and seasonal setting
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

2. thrombocytopenia in HIV
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
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Similar pathophysiology as ITP - tx zidovudine

3. What are indicators for progression of HIV
Viral load and CD4 count
Every 3-4 hours to determine appropritate time to start HAART
Blastomycosis
Clostridium perfringens after penetrative injuries/wounds

4. How to dx progressive multifocal leukoencephalopathy
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region

5. patient with diagnosed case of cryptococcal meningitis p/w severe headache and vomiting
Need lumbar puncture to relieve pressure; they have high opening pressure >350
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

6. infiltrate in upper lobe of lung?
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Either TB or aspergillosis
Massive (even 20L/day) fluid resuscitaiton which may clear toxin

7. gas gangrene
High risk 19-64; 1-2 dose - above 65; one dose
Within 6 months viral load will be <50
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Clostridium perfringens after penetrative injuries/wounds

8. 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
High risk 19-64; 1-2 dose - above 65; one dose
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
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

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

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10. What is the classic signs of nec fasc?
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
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
If a sample is ELISA positive - it is tested fro western blot for confirmation
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

11. How to tx TSS?
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Postcoital voiding - increased intake of cranberry juice

12. dame that has already occurred
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Cd4 count
ELISA; initial visit - 6 - 12 and 24 weeks;
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol

13. How to dx IM?
Viral load and CD4 count
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
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

14. what parameters increases risk of neurosyphilis in HIV patient
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.
Pegylated interferon and lamivudine
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Reddish orange discoloration of urine - feces - sweat - tears - sputum

15. How to dx cryptococal meninggits
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
When cd4 count falls below 200. 2p in pcp =200
Cd4 count
Vaccine titer >10mU/ml

16. foot infections in DM
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
High risk 19-64; 1-2 dose - above 65; one dose
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

17. When to give prophylaxis against MAC
Pegylated interferon and lamivudine
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil

18. What is fatal consequence of RMSF?
Rifampin600mg q12. or cipro
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
S. pneumonie. differentitate this from atypical pneumonia and pcp which are gradual onset - non productive cough -
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin

19. What is the mch of ampicillin induced rash in IM
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
Immune mediated; circulating IgG and IgM to penicillin derivatives
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Td every 10 years - tdap once before 65 and after 65

20. how im is transmitted?
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
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
Others lesions are ring enhancing and have mass effect while PML don't
Oropharyngeal secretions; hence named as kissing disease

21. What is tetanus - diptheria - pertusis recommendation?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Mainly clinical - epidemiological and seasonal setting
Td every 10 years - tdap once before 65 and after 65
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

22. When to tx influenza with antiviral therapy?
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
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
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

23. oligodendrocyte with intranuclear inclusion and demyelination in HIV patient
Give nystatin suspension or clotrimazol with an oral antifungal eg. fluconazol
6-12 weeks
PML; focal neurological deficit like MM; no specific tx; regress with HAART
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

24. Tx of choice for human bites
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Pt who have been treated before for latent TB
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Ampicillin-sublactam; most bites contain eikenella

25. rifampin
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
Voriconazol. mycetoma-surgical removal
Others lesions are ring enhancing and have mass effect while PML don't

26. low grade fever - maculopapular rash - lymphadenopathy
HBIG hep B immunoglobulin
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

27. How to dx lyme arthritis?
ELISA and western blot of synovial fluid.
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Others lesions are ring enhancing and have mass effect while PML don't
Reddish orange discoloration of urine - feces - sweat - tears - sputum

28. When not to tx asymptomatic bacteriura?
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Non pregnant premanopausal - elderly - dm - sci - chronic foley
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)

29. When to tx asymptomatic bacteriurea >100 -000?
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain
Pregnacy - urologic procedure - hip arthoplastu
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles

30. When to give abx to prevent recurrent uti
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Ampicillin-sublactam; most bites contain eikenella
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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

31. What is lag time to develop lyme arthritis after exposure to vector
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
When cd4 count falls below 200. 2p in pcp =200
Immune mediated; circulating IgG and IgM to penicillin derivatives
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

32. where TB normally affects
Due to decrease elasticity of arterial wall; only systolic - diastolic normal - wide pulse pressure
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
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

33. chshould we tx IM with abx (ampicilin) if throat cx is positive?
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
HBIG hep B immunoglobulin
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
Aortic valve; endocardiits of AR p/w AV block and LBBB

34. What is characteristic for dx of rocky mountain spotted fever?
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Voriconazol. mycetoma-surgical removal

35. What is the Tx of STD uretheritis?
High risk 19-64; 1-2 dose - above 65; one dose
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Most common E coli; less common; klebsiella - enterobacter - proteus - staph - groupd d strep
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

36. when HIV patient develop pcp?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
Fever - facial swelling - nasal discha - maxilary pain and tenderness - headache - present in DKA - caused by zygomycetes tx surgical debridement and intranasal amphotericin
When cd4 count falls below 200. 2p in pcp =200
Cd4 count

37. How to confirm dx if pcp?
Do EBV antibody test
Pegylated interferon and lamivudine
Mainly clinical - epidemiological and seasonal setting
Bronchoalveolar washing and transbronchial biopsy

38. hypertriglyceridemia in HIV
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Bronchoalveolar washing and transbronchial biopsy
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

39. What is tx for herpes zoster
Acyclovir
HBIG hep B immunoglobulin
Similar pathophysiology as ITP - tx zidovudine
6-12 weeks

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

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41. Do we need to give vaccine or immunoglobulin for rabies exposure in previously vaccinated person?
When cd4 count falls below 200. 2p in pcp =200
6-12 weeks
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
Only vaccine. immunoglobuin not required. previously unvaccinated person will receive both.

42. worsening of TB after starting HAART in HIV
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
If a sample is ELISA positive - it is tested fro western blot for confirmation
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

43. what would be viral load after 4 weeks
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
<5000 copies/ml
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx

44. What is difference between uti relapse versus recurrence?
Pregnacy - urologic procedure - hip arthoplastu
Pt who have been treated before for latent TB
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
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

45. How to tx pseudomonas?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
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
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

46. damae that is about to occur?
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
Pt who have been treated before for latent TB
HIV viral load
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses

47. What is the prognosis of lyme arthritis?
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
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
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

48. How to dx?
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
If a sample is ELISA positive - it is tested fro western blot for confirmation
Mainly clinical - epidemiological and seasonal setting
AA gradient >35 or Po2 <70

49. How long abx is given in pseudomonas infection?
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
2 weeks in neutropenic patients and 7-10 days after catheter removed/patient improved
6-12 weeks

50. How often HIV postiive patients CD4 count needs to be evaluated?
AA gradient >35 or Po2 <70
Every 3-4 hours to determine appropritate time to start HAART
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
ELISA and western blot of synovial fluid.

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USMLE Step3 Infectious Disease

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