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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 lag time to develop lyme arthritis after exposure to vector
Pregnacy - urologic procedure - hip arthoplastu
<5000 copies/ml
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer
4 months; characterized by knee joint effusion-large amount - joint stiffness - pain

2. 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
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Rifampin600mg q12. or cipro
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w

3. 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
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
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.

4. pathophysiology of toxic shock syndrom?
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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
Tampoon in nostril/vagina. think t for t - staph release exotoxin --activation of t cells directly--release of massive cytokines.
Bronchoalveolar washing and transbronchial biopsy

5. How to dx cryptococal meninggits
HIV present in very minimal quantities in human saliva. exposure/contact of saliva will never trasmit HIV
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
6-12 weeks
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

6. How to dx lyme arthritis?
Ampicillin-sublactam; most bites contain eikenella
Rifampin600mg q12. or cipro
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

7. What is characteristic for dx of rocky mountain spotted fever?
Need lumbar puncture to relieve pressure; they have high opening pressure >350
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

8. how CMV presents in immunocompromised patients
Fever of unknown orign - esophagiti - retinitis - diarrhoea - encephalits
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Viral load and CD4 count
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

9. What is the classic signs of nec fasc?
Pregnacy - urologic procedure - hip arthoplastu
Mainly clinical - epidemiological and seasonal setting
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
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

10. gas gangrene
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Rifampin600mg q12. or cipro
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
Clostridium perfringens after penetrative injuries/wounds

11. when we see echym gangrenosum?
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
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)

12. drugs work well on hypertriglyceridia?
Gemfibrozil and other fibrate drugs; statin and niacin also work not as good as fibrate drugs like gemfibrozil
High risk 19-64; 1-2 dose - above 65; one dose
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
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

13. What is used for prophylaxis against meningo..meningitis?
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Quinoloes (cipro/levo) cure rate 70% - TMP-SMZ
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
Rifampin600mg q12. or cipro

14. When to give prophylaxis against MAC
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
Reddish orange discoloration of urine - feces - sweat - tears - sputum
Rifampin600mg q12. or cipro
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate

15. what parameters increases risk of neurosyphilis in HIV patient
HBIG hep B immunoglobulin
Aspergillosis. common in bone marrow transplants. typically involves lungs and sinuses
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.
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose

16. after exposure of HIV when antibody testing is performed?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
ELISA; initial visit - 6 - 12 and 24 weeks;
Oropharyngeal secretions; hence named as kissing disease
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine

17. How to tx IM?
Every 3-4 hours to determine appropritate time to start HAART
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
Classic triad: fever - pharyngitis - postauricular lymaphdenopahty - caused by EBV
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads

18. What are the subjective /objective measure of encephalopathy?
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
CTP subjective; MELD objective; meld uses serum billirubin - inr and serum creatinin. meld used to determine 90 day mortality of liver diease

19. how im is transmitted?
Petechial rash developed 3-5th days of illness begins ankle or wrist and spread to palm/soles
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Oropharyngeal secretions; hence named as kissing disease
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash

20. wisconsin - missisipi - ohio
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Within 72hrs of unprotected sex with HIV pos person - give two nucleosidase inhibitors (eg. zidovudin - lamivudein - tenofovir -) X4w
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
Blastomycosis

21. What is fatal consequence of RMSF?
Upper lobes; any fibrosis in this area suggestive of latent TB
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)
AMS - focal neurological signs - seizures - multiorgan dysfunction - death; tx; doxycycline; for pregnant give chloramphenicle

22. What is the criteria for Spontaneous bact peritonitis
Hepatotoxitcity incidence 2.6% - commonly seen in alcoholic - liver disease - >50
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

23. What is tx for herpes zoster
Cd4 count
When cd4 count falls below 200. 2p in pcp =200
Immunocompromised patient ? dec vision - weakness/tingling of extremities or other neurological symptoms - MRI nonenhancing lesion in parietooccipital region
Acyclovir

24. INH
ELISA; initial visit - 6 - 12 and 24 weeks;
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
Similar pathophysiology as ITP - tx zidovudine
Vitamin B6 antagonist - can cause peripheral neuropathy if not give with b6

25. What is the prognosis of lyme arthritis?
<500 copies/ml
Voriconazol. mycetoma-surgical removal
Harrt ---rapid improvement of immune function---increased inflammatory reaction--worsening of clinical symptoms; self limiting....needs no tx
Tx with amoxicillin or ceftriaxone. 90% are disease free after one year after tx

26. How to confirm chlamydia infection?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
Chlamydia pcr - 88% sensitivity and 99% specificity; if negative think about MUT organims; mycoplasma - ureaplasma and trichomonas; tx MUT with metronidazole
Jarish-Herxheimer reaction; immunologica reaction due to rupture of sprochetes
Acyclovir

27. when HIV patient develop pcp?
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
Acyclovir
When cd4 count falls below 200. 2p in pcp =200

28. What is tetanus - diptheria - pertusis recommendation?
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
<5000 copies/ml
If a sample is ELISA positive - it is tested fro western blot for confirmation
Td every 10 years - tdap once before 65 and after 65

29. what if monospot test is neg in 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
Do EBV antibody test
Pregnacy - urologic procedure - hip arthoplastu
Upper lobes; any fibrosis in this area suggestive of latent TB

30. HIV patient having fat deposition on back of neck and abdomen - like cushing
HIV lipodystrophy; no correlation with viral load; p/w insulin resistance and dyslipidemia (inc cholesterol - dec HDL)
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
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads

31. which heart valve is closer to ventricular conduction system/
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;
N meningitidis colonize in nasopharynx; cause mucosal invasion - systemic bacterimia and seeding in the meninges
Aortic valve; endocardiits of AR p/w AV block and LBBB

32. How to tx TSS?
Voriconazol. mycetoma-surgical removal
Massive (even 20L/day) fluid resuscitaiton which may clear toxin
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
Similar pathophysiology as ITP - tx zidovudine

33. How long we tx chronic prostatis?
Throat cx of positive of GAS means bacteria are colonized bur not infected in IM. tx with ampi can trigger maculopaular rash
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
6-12 weeks
Pt who have been treated before for latent TB

34. How to give postexposure prophylaxis to patient who received vaccine but titer inadequate
Pt who have been treated before for latent TB
HBIG hep B immunoglobulin
Leukocytosis >100 cells - dec glucose - inc protien - inc opening pressure; in viral there will be lymphocytosis - normal glucose (virus doesn't eat) -
Pregnacy - urologic procedure - hip arthoplastu

35. 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
Viral load and CD4 count
Pregnacy - urologic procedure - hip arthoplastu
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol

36. when not to give INH therapy if ppd positive and patient asyptomatic
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
At first 4 weeks - then 8-12weks; remeasusing every 2m until viral load is undetectatable. then every 3 months
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

37. what would be viral load after 2-4m of HAART?
<500 copies/ml
Do EBV antibody test
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Reddish orange discoloration of urine - feces - sweat - tears - sputum

38. low grade fever - maculopapular rash - lymphadenopathy
HIV syndrome or anti-retroviral syndrome; 2-3w after virus exposure. similar to IM.
Within 6 months viral load will be <50
Reddish orange discoloration of urine - feces - sweat - tears - sputum
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.

39. How to tx pseudomonas?
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Doesn't exceed more than 15 mm and size significantly decreases after 15 years
Antipseudomonal penicillin (pipercillin) or cephalosporin (ceftazdidime/cefepime) and aminoglycoside (tobramycin/amikacin)
Td every 10 years - tdap once before 65 and after 65

40. damae that is about to occur?
Markedly elevated csf pressure >200 - inc protein - low glucose ; tx amphotericin and flucytosine
PML; focal neurological deficit like MM; no specific tx; regress with HAART
HIV viral load
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

41. infiltrate in upper lobe of lung?
Either TB or aspergillosis
Start with amphotericin B and flucytosin for 2 weeks - if there is clinical improvement discontinue them and start with fluconazol
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma
6-12 weeks

42. where TB normally affects
Ampicillin-sublactam; most bites contain eikenella
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
Upper lobes; any fibrosis in this area suggestive of latent TB
Similar pathophysiology as ITP - tx zidovudine

43. How to tx chronic hep B
Pegylated interferon and lamivudine
Upper lobes; any fibrosis in this area suggestive of latent TB
When cd4 count falls below 200. 2p in pcp =200
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

44. after recent exposure - negative ELISA - How to confirm?
Exacerbate by HAART; give statin - if triglyceride >500 - give a fibrate
250 neutrophil/mm3 in peritoneal fluid - tx empiric abx; if tremor or other neuro sign give lactulose
Bed rest - NSAID - avoid contact sports; if patient develop SOB due to pharyngeal edema - give corticosteroid
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.

45. How to dx bacterial meningitis from CSF study?

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46. aspergillosis
ELISA and western blot of synovial fluid.
Voriconazol. mycetoma-surgical removal
HIV RNA PCR assay; there may be small amount of virus that are not detectable in ELISA.
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

47. What are indicators for progression of HIV
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
Viral load and CD4 count
Need lumbar puncture to relieve pressure; they have high opening pressure >350
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

48. hypertension in children
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
Most common; fibromuscular dysplasia - Rt renal artery more common - angiography string of beads
Every 3-4 hours to determine appropritate time to start HAART
For mac - we give azithromycin - mac has a for azithromycin; cd4 <50; remember CML designates for <50 c-cmv; m- mac - L-cns lymphoma

49. How to tx pcp?
Trimethoprime-sulphamethoxazole if intolerant give pentamidine (cause pancreatitis p for p)
PML; focal neurological deficit like MM; no specific tx; regress with HAART
Rifampin600mg q12. or cipro
Staph - GBS - proteus - pseudomona - e coli - candida - bacteroids; organisms isolated only from deep curettage of ulcer

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

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USMLE Step3 Infectious Disease

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