brigham review medicine

T H E BR IG H A M I N T E N SI V E R E V I E W OF I N T E R N A L M E DIC I N E QU E S T ION

A N D A N S W E R C OM PA N ION

1Ajay K.Singh, MBBS, FRCP, MBAD I R E C T O R , G L O B A L P R O G R A M S

A S S O C I A T E P R O F E S S O R O F M E D I C I N E

H A R V A R D M E D I C A L S C H O O L

P H Y S I C I A N , R E N A L D I V I S I O N

D I R E C T O R , P O S T G R A D U A T E M E D I C A L

E D U C A T I O N

D E P A R T M E N T O F M E D I C I N E

B R I G H A M A N D W O M E N S H O S P I T A L

B O S T O N , M A S S A C H U S E T T S

Joseph Loscalzo, MD, PhDH E R S E Y P R O F E S S O R O F T H E T H E O R Y

A N D P R A C T I C E O F P H Y S I C

H A R V A R D M E D I C A L S C H O O L

C H A I R M A N , D E P A R T M E N T O F M E D I C I N E

P H Y S I C I A N - I N - C H I E F

B R I G H A M A N D W O M E N S H O S P I T A L

B O S T O N , M A S S A C H U S E T T S

THE BR IGH A M INTENSIV E R EV IEW OF INTER NAL MEDICINE QUESTION

A NDA NSW ER COMPA NION

E D I T E D B Y

1Oxford University Press is a department of the University of

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Library of Congress Cataloging-in-Publication DataThe Brigham intensive review of internal medicine question and answer companion / edited by Ajay K. Singh, MBBS, FRCP (UK), MBA, Director, Global Programs, Associate Professor of Medicine, Harvard Medical School Physician, Renal Division, Director, Postgraduate

MedicalEducation, Department of Medicine, Brigham and Womens Hospital, Boston, Massachusetts, Joseph Loscalzo, MD, PhD, Hersey Professor Of The Theory And Practice Of Physic, Harvard Medical School, Chairman, Department Of Medicine,

Physician-In-Chief, Brigham And Womens Hospital, Boston, Massachusetts.pages cm

ISBN 9780199358496 (alk. paper)1. Internal medicineExaminations, questions, etc. 2. American Board of Internal MedicineExaminationsStudy guides.

I. Singh, Ajay, 1960 editor. II. Loscalzo, Joseph, editor. RC58.B75 2014

616.0076dc232014019690

This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of

the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers

must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy

or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a

consequence of the use and/or application of any of the contents of this material.

1 3 5 7 9 8 6 4 2Printed in the United States of America

on acid-free paper

vPreparing for the American Board of Internal Medicine (ABIM) certifying or recertifying examination requires knowledge and clinical experience that can be evaluated by successfully answering questions in a test format. In this Question and Answer book, our goal is to provide you with 500 questions across 10 subspecialties in internal medicine. These questions test knowledge on topics relevant to the ABIM boards. As a companion to the Brigham Intensive Review of Internal Medicine, now in its second edition, this book is focused on how you apply knowledge to answer board questions successfully. The annotated answers are detailed, and they review the steps in critical thinking required to get to the correct answer.

The authors who have contributed questions and anno-tated answers to this book are some of our most senior

physicians in the department. We sincerely thank them for their efforts and commitment to this project. We asked them to put themselves in the head of the ABIM to iden-tify the topics that might be addressed in the board exami-nation. We believe this book will be a valuable study tool to gauge your knowledge as you prepare for the exaxmination.

We wish to thank Stephanie Tran and Michelle Deraney for supporting us in the development of this book. Thanks also to Anika Singh for helping with the final stages of the book. Without them this book would not have been possible. Our thanks also go to our families who have supported all of our academic activities, including this important project.

Ajay K.Singh, MBBS, FRCP, MBAJoseph Loscalzo, MD, PhD

PR EFACE

vii

Contributors ix

1. Infectious Diseases 1Jennifer A.Johnson, Michael S.Calderwood, Sarah P.Hammond, Rebeca M.Plank, DylanB.Tierney,andSigal Yawetz

2. Hematology and Oncology 27Lawrence Shulman, Ann LaCasce, Wendy Y.Chen, Yuksel Urun, Toni K.Choueiri, Jean M.Connors, Peter Enzinger, Nancy Berliner, Maureen M.Okam, Mark M.Pomerantz, David M.Jackman, Brett E.Glotzbecker, Edwin P.Alyea, DanielJ.DeAngelo,Robert I.Handin, JeffreyA.Meyerhardt, and Whitney W.Woodmansee

3. Rheumatology 49Derrick J.Todd and Jonathan S.Coblyn

4. Pulmonary and Critical Care Medicine 76Michael H.Cho and Christopher H.Fanta

5. Endocrinology 101Carolyn Becker, Amir Tirosh, Ole-Petter R.Hamnvik, Le Min, Klara Rosenquist, Anand Vaidya, Whitney W.Woodmansee, Bindu Chamarthi, and Matthew Kim

6. Nephrology and Hypertension 125Karandeep Singh and Ajay K. Singh

7. Digestive Diseases and Disorders of the Pancreas and Liver 141Robert S.Burakoff, Muthoka Mutinga, and Molly L.Perencevich

8. Cardiovascular Disease 160Thomas S.Metkus Jr., Patrick OGara, and Donna M.Polk

9. Neurology 185Galen V.Henderson

10. General Internal Medicine 202Nikhil Wagle, Christopher Gibson, Ami Bhatt, MollyL.Perencevich, William Martinez, Jason Ojeda, RoseKakoza, and Lindsay King

Index 223

CONTENTS

ix

Edwin P.Alyea III, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologistDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Carolyn Becker, MDAssociate Professor of MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Nancy Berliner, MDProfessor of MedicineHarvard Medical SchoolDivision of HematologyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Ami Bhatt, MD, PhDInstructor in MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Robert S.Burakoff, MD, MPHAssociate Professor of MedicineHarvard Medical SchoolDivision of Gastroenterology, Hepatology and EndoscopyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Michael S.Calderwood, MDInstructor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

Bindu Chamarthi, MDInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Wendy Y.Chen, MD, MPHAssistant Professor of MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Michael H.Cho, MD, MPHAssistant Professor in MedicineHarvard Medical SchoolDivision of Pulmonary and Critical Care MedicineDepartment of MedicineBrigham and Womens HospitalBoston, MA

Toni K.Choueiri, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologyDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

CONTR IBUTOR S

x Contr ibutors

Jonathan S.Coblyn, MDAssociate Professor of MedicineHarvard Medical SchoolDivision of Rheumatology, Immunology and AllergyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Jean M.Connors, MDAssistant Professor of MedicineHarvard Medical SchoolDivision of HematologyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Daniel J.DeAngelo, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologistDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Peter Enzinger, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologistDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Christopher H.Fanta, MDProfessor of MedicineHarvard Medical SchoolDivision of Pulmonary and Critical Care MedicineDepartment of MedicineBrigham and Womens HospitalBoston, MA

Christopher Gibson, MDInstructor in MedicineHarvard Medical SchoolMedical OncologyDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Brett E.Glotzbecker, MDInstructor of MedicineHarvard Medical SchoolMedical OncologyDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Sarah P.Hammond, MDInstructor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

Ole-Petter R.Hamnvik, MBChB, BAOInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Robert I.Handin, MDProfessor of MedicineHarvard Medical SchoolDivision of HematologyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Galen V.Henderson, MDAssistant Professor of MedicineHarvard Medical SchoolDepartment NeurologyBrigham and Womens HospitalBoston, MA

David M.Jackman, MDAssistant Professor of MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Jennifer A.Johnson, MDInstructor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

Rose Kakoza, MDResearch Fellow in MedicineHarvard Medical SchoolDivision of General Medicine and Primary CareDepartment of MedicineBrigham and Womens HospitalBoston, MA

Contr ibutors x i

Matthew Kim, MDInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Lindsay King, MDResearch Fellow in MedicineHarvard Medical SchoolGastrointestinal UnitDepartment of MedicineMassachusetts General HospitalBoston, MA

Ann LaCasce, MDAssistant Professor of MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

William Martinez, MD, MSAssistant Professor of MedicineDivision of General Internal Medicine and Public HealthVanderbilt University Medical CenterNashville, TN

Thomas S.Metkus, Jr., MDFellow in Cardiovascular MedicineDivision of Cardiovascular MedicineJohn Hopkins HospitalBaltimore, MD

Jeffrey A.Meyerhardt, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Le Min, MD, PhDInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Muthoka Mutinga, MDAssistant Professor of MedicineHarvard Medical SchoolDivision of Gastroenterology, Hepatology and EndoscopyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Patrick OGara, MDProfessor of MedicineHarvard Medical SchoolDivision of Cardiovascular MedicineDepartment of MedicineBrigham and Womens HospitalBoston, MA

Jason Ojeda, MDDepartment of Internal MedicinePrimary Care PhysicianJefferson University HospitalPhiladelphia, PA

Maureen M.Okam, MD, MPHInstructor in MedicineHarvard Medical SchoolDivision of HematologyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Molly L.Perencevich, MDInstructor in MedicineHarvard Medical SchoolDivision of Gastroenterology, Hepatology and EndoscopyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Rebeca M.Plank, MDInstructor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

Donna M.Polk, MD, MPHLecturer on MedicineHarvard Medical SchoolDivision of Cardiovascular MedicineDepartment of MedicineBrigham and Womens HospitalBoston, MA

x i i Contr ibutors

Mark M.Pomerantz, MDAssistant Professor of MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Klara Rosenquist, MDResearch Fellow in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Lawrence Shulman, MDAssociate Professor of MedicineHarvard Medical SchoolMedical OncologyDana-Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Karandeep Singh, MDClinical Fellow in MedicineHarvard Medical SchoolRenal DivisionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Dylan B.Tierney, MDInstructor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

Amir Tirosh, MD, PhDInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Derrick J.Todd, MDInstructor in MedicineHarvard Medical SchoolDivision of Rheumatology, Immunology and AllergyDepartment of MedicineBrigham and Womens HospitalBoston, MA

Yuksel Urun, MDResearch FellowLank Center for Genitourinary OncologyDana-Farber Cancer InstituteBoston, MA

Anand Vaidya, MD, MMScInstructor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Nikhil Wagle, MDInstructor in MedicineHarvard Medical SchoolMedical OncologyDana Farber Cancer InstituteDepartment of MedicineBrigham and Womens HospitalBoston, MA

Whitney W.Woodmansee, MDAssistant Professor in MedicineHarvard Medical SchoolDivision of Endocrinology, Diabetes and HypertensionDepartment of MedicineBrigham and Womens HospitalBoston, MA

Sigal Yawetz, MDAssistant Professor in MedicineHarvard Medical SchoolDivision of Infectious DiseasesDepartment of MedicineBrigham and Womens HospitalBoston, MA

11.INFECTIOUS DISEASES

Jennifer A. Johnson, Michael S. Calderwood, Sarah P. Hammond, Rebeca M. Plank, DylanB.Tierney, and Sigal Yawetz

1. A28-year-old woman who has lived her entire life in Providence, Rhode Island, presents 3days after return-ing from a 2-week trip to Thailand complaining of fever to 102F, muscle aches, and severe retro-orbital head-ache. She has no gastrointestinal symptoms. She trav-eled only to the towns of Bangkok, Chiang Mai, and Phuket. She attended a travel clinic prior to traveling and was told there was no malaria in these towns, so she did not take prophylaxis. She denied contact with bodies of fresh water. Examination is unremarkable other than fever of 101.8F. Remarkable laboratory findings include a leukocyte count of 2,200 cells/L3, hematocrit of 37%, and platelets of 62,000 cells/L3. Chemistries are normal. Aperipheral blood smear for parasites is sent and is negative.

Which of the following is the most likely diagnosis in this traveler:

A. LeptospirosisB. MalariaC. TyphoidD. Hepatitis AE. Dengue

2. A 55-year-old male smoker with severe chronic obstructive pulmonary disease (COPD) is hospital-ized in the medical intensive care unit. He now requires intubation and mechanical ventilation for hypercar-bic respiratory failure after failing noninvasive ven-tilation. To reduce this patients risk for developing ventilator-associated pneumonia, you recommend:

A. Elevation of the head of the bed to 15 degrees to prevent aspiration

B. Suctioning of subglottic secretionsC. Twenty-four hours of prophylactic systemic

antibiotics, especially if the intubation was emergent

D. Daily changing of the ventilatory circuitE. Nasotracheal intubation rather than orotracheal

intubation

3. A 47-year-old woman with a history of renal trans-plantation who was recently treated for a urinary tract infection presents with 4 days of profuse nonbloody diarrhea and 2days of nausea and fevers. She received her kidney transplant 10years ago from a living unre-lated donor for polycystic kidney disease and has had no episodes of rejection since. Her donor was CMV IgG negative and she was CMV IgG positive prior to transplant. She is a third-grade teacher and has recently been taking care of a pet turtle for her class. On presentation she has a fever to 102.1F and has dif-fuse tenderness of the abdomen with more intense focal tenderness over the right lower quadrant, the location of her transplanted kidney.

The least likely cause of her present illness is:

A. SalmonellosisB. C.difficileassociated diarrheaC. Cytomegalovirus colitisD. Norovirus gastroenteritis complicated by bacterial

transplant pyelonephritis

4. A 25-year-old man who has a history of moderate asthma and depression presents in January for a first pri-mary care clinic visit with you as his new primary care physician. He was hospitalized in December for 2days for pneumonia; all cultures and viral swabs were nega-tive. He was treated empirically with a short course of levofloxacin and improved. He is feeling well today. He presents for the visit with his male partner, who is help-ing the patient manage his asthma by reminding him to use his inhalers and record his peak flow when he is ill. Physical examination is unremarkable; he is afebrile

2 thebr ighamintensiver ev iewofinternalmediCineQuestionandanswerCompanion

and well appearing. You review his immunization his-toryhe has not received any vaccines within the past 7years; his last vaccination was the tetanus, diphtheria (Td) vaccine at age 18.

All of the following vaccines would be appropriate for him based on his medical history, except:

A. Tetanus, diphtheria, pertussis (Tdap) vaccineB. Pneumococcal 13-valent conjugate (PCV13) vaccineC. Hepatitis AvaccineD. Human papillomavirus (HPV) vaccineE. Influenza vaccine

5. A 36-year old man is found to have a 17 mm reac-tion to tuberculin skin testing as part of a workplace screening program. He is originally from Bangladesh and immigrated to the United States 6months ago. He reports feeling well. He has no fever, cough, or weight loss. Physical examination is normal.

The next best step in his management should be:

A. Sputum for smear microscopy and mycobacterial culture

B. Initiation of isoniazid prophylaxis to prevent reactivation of latent tuberculosis infection

C. Chest X-ray to assess for active pulmonary diseaseD. Interferon gamma release assay to confirm skin test

result

6. A previously well 62-year-old man presents to the hospital with increasing weakness in his lower extremi-ties. An examination reveals decreased reflexes symmet-rically, which progressed proximally over the course of several hours. He was diagnosed with GuillainBarr syndrome and admitted to the intensive care unit for treatment. On history, he did report several days of nau-sea, vomiting, and diarrhea approximately 2 months prior.

The most likely infectious cause of his gastrointesti-nal illness was:

A. CampylobacterB. GiardiaC. SalmonellaD. CryptosporidiumE. Escherichia coli O157:H7

7. A24-year-old woman calls your office complaining of burning with urination, and increased urinary urgency and frequency. She has no fever, no nausea or vomiting, and no flank pain. She has been in a monogamous rela-tionship for 3years, and she had one prior episode of cys-titis, more than a year ago. According to the 2010 IDSA and International Guidelines, which of the following

agents is/are not recommended for the empiric manage-ment of acute uncomplicated cystitis:

A. Trimethoprim-sulfamethoxazole 160/800 mg (1double strength) twice daily, for 3days

B. Ciprofloxacin 250 mg twice daily, for 3daysC. Fosfomycin 3 grams, single-dose therapyD. Nitrofurantoin macrocrystals 100 mg twice daily,

for 5daysE. Amoxicillin 500 mg three times daily, for 7daysF. Options B and E

8. A 65-year-old woman with recently diagnosed dif-fuse large B cell lymphoma presents with malaise, nau-sea, and mild jaundice. She was diagnosed with diffuse large B cell lymphoma after developing a massive cer-vical lymphadenopathy and daily fevers 1 month ago. She was profoundly anemic when she presented and required a blood transfusion at that time. She started treatment for lymphoma with rituximab, cyclophos-phamide, doxorubicin, vincristine, and prednisone (R-CHOP) 2 weeks ago. Basic labs are notable for AST 527, ALT 495, total bilirubin 3.5, with a normal INR. Her past history is notable for immigrating to the United States from rural Vietnam 15years ago. She had a positive PPD at the time she immigrated and was also told she was a hepatitis B chronic carrier (hepatitis B surface antigen positive, hepatitis B e antibody positive, hepatitis B virus load

1. infeCtiousdiseases 3

recommend the following prophylaxis for close hospital contacts:

A. Amacrolide antibioticB. No prophylaxis is needed given that the patient has

been symptomatic for >1 week.C. Afluoroquinolone antibioticD. Administration of the pertussis vaccine to prevent

secondary casesE. Administration of immunoglobulin for passive

immunization

10. The criteria for prophylactic doxycycline 200 mg orally 1 against Lyme disease include all of the fol-lowing except:

A. Attached tick is identified as a deer tick, Ixodes scapularis, estimated to have been attached for at least 36 hours on the basis of engorgement or of certainty about the time of exposure

B. There is no potential risk for anaplasma or babesia coinfection.

C. Prophylaxis can be started within 72 hours of tick removal.

D. Local rate of infection of ticks with Borrelia burgdorferi is 20%; it generally occurs in parts of New England, in parts of the mid-Atlantic States, and in parts of Minnesota and Wisconsin.

E. Doxycycline treatment is not contraindicated due to concurrent condition, such as pregnancy.

11. A 53-year-old woman with well-controlled non- insulin-dependent diabetes, obesity, and chronic lower-extremity edema presented 4days previously with erythema, swelling, and pain of the right lower leg. She was treated empirically with dicloxacillin, but her symp-toms worsened, and a fluctuant collection developed in a skin fold on her leg. She presented to the emergency room, where she was found to have a low-grade fever but was otherwise stable. The collection was lanced, producing a small amount of purulent material, which was drained and swabbed for culture. The culture of the wound grew Staphylococcus aureus, which was resistant to penicillin and oxacillin/methicillin but otherwise susceptible to all other antibiotics that were tested. In addition to excellent wound care, all of the following antibiotics would be appropriate choices for outpatient single-drug treatment at this point except:

A. LinezolidB. DoxycyclineC. Trimethoprim-sulfamethoxazoleD. ClindamycinE. Rifampin

12. A26-year-old graduate student presents for evalu-ation after being bitten on the right shin by her neigh-bors playful Labrador puppy. Her past medical history is notable for undergoing splenectomy for treatment of idiopathic thrombocytopenic purpura at age 24, which was curative. She takes no medications and has no aller-gies. On examination she has normal vital signs and appears well. On the right shin are two puncture marks, which are still bleeding slightly. There is no purulence and no surrounding erythema of the skin.The most appropriate management is:

A. Sequester the puppy and treat the patient with human rabies immunoglobulin

B. Oral trimethoprim-sulfamethoxazoleC. No therapy is necessaryD. Intravenous ceftriaxoneE. Oral amoxicillin-clavulanate

13. A67-year-old female is recovering following an elec-tive total hip arthroplasty. On postoperative day 5, she complains of worsening diarrhea and abdominal pain. Her white blood cell count has risen from 9,000 to 21,000 cells/L. Testing of the stool reveals a positive glutamate dehydrogenase antigen and a positive toxin A/B assay confirming the diagnosis of Clostridium dif-ficile. The team notes that this is the third patient with Clostridium difficile infection on their unit in the past 2 weeks. To help reduce further horizontal transmission, you recommend:

A. Identification and treatment of asymptomatic carriers

B. Strict adherence to standard precautions, including hand hygiene with an alcohol hand rub

C. Use of a chlorine-containing cleaning agent to address environmental contamination

D. Contact precautions for any patient suspected of having Clostridium difficile infection until 48 hours of therapy have been given

E. Prophylactic metronidazole for all patients on the unit

14. A 49-year-old incarcerated man is diagnosed with latent tuberculosis infection. He has no evidence of active disease. Options for treatment include all of the following except:

A. Isoniazid 300 mg daily for 9monthsB. Directly observed rifapentine 900 mg and isoniazid

900 mg weekly for 3monthsC. Rifampin 600 mg daily for 4monthsD. Rifampin 600 mg and pyrazinamide 1750 mg daily

for 2months


15. A43-year-old woman calls to state she is very con-cerned because she found a large lump under her left arm. She has no personal or family history of malig-nancy. She has no other complaints. On examination her vital signs are normal. She has one tender 2 3cm mobile mass under her left arm, with overlying ery-thema. She works at an urban animal shelter. At home she has two cats, a dog, and a rabbit. The rabbit lives indoors but had been sick with ileus. The dog has been well. One of her young cats (adopted at 5 weeks from the animal shelter) was ill about 2months earlier, and she tried force feeding it antibiotics, and due to this she was bitten and scratched repeatedly.

Among cat-associated zoonoses, the most likely pathogen in this case is:

A. Bartonella henselaeB. Francisella tularensisC. Toxocara catiD. Toxoplasma gondiiE. Yersinia pestis

16. A 42-year-old woman presents to the urgent care clinic complaining of 2 weeks of progressive abdominal pain, bloating, nausea, and vomiting. Three weeks earlier she developed a severe reaction to poison ivy while hiking, and she was prescribed a 7-day course of high-dose pred-nisone. Around the time of completion of the prednisone she started to develop abdominal discomfort and nausea, which are now significant. She has a history of hyper-tension and depression, for which she takes lisinopril and citalopram regularly. She immigrated to the United States from Vietnam 10 years previously, lives with her husband and two children, and works as an office man-ager. She previously smoked cigarettes but quit several years ago, she does not drink alcohol, and she has never used recreational drugs. Family history is significant for a sister with diabetes mellitus and mother with hepatitis B. On physical examination she appears uncomfortable, has mild tachycardia and tachypnea, and she is tender in the right upper quadrant. Laboratory data are notable for WBC 12,000/L with 82% neutrophils, hemato-crit 36%, platelets 140,000/L, electrolytes are normal, BUN 11 mg/dL, creatinine 0.9 mg/dL, AST/SGOT 524/L, ALT/SGPT 789/L, alkaline phosphatase 247/L, total bilirubin 1.9. Serologies for viral hepatidities are most likely to show:

A. HAV IgG positive, HBSAb positive, HBSAg positive, HBcAb positive, HCV Ab positive

B. HAV IgG positive, HBSAb negative, HBSAg positive, HBcAb positive, HCV Ab negative

C. HAV IgG positive, HBSAb negative, HBSAg negative, HBcAb positive, HCV Ab positive

D. HAV IgG positive, HBSAb positive, HBSAg negative, HBcAb negative, HCV Ab negative

E. HAV IgG negative, HBSAb negative, HBSAg positive, HBcAb negative, HCV Ab negative

17. A 45-year-old woman was diagnosed with HIV infection (224 CD4 T cells/m3) and smear-negative, culture-positive pulmonary tuberculosis after present-ing with chronic cough. Chest computed tomography (CT) showed mild left lower lobe interstitial infiltrates. Rapid tuberculosis drug susceptibility testing showed no evidence of drug resistance. The patient was started on isoniazid, rifampin, ethambutol, and pyrazinamide. After 2 weeks, the patient was started on antiretroviral therapy with emtricitabine/tenofovir and efavirenz. Her cough initially improved but then worsened after about 1month of tuberculosis treatment. She also developed progressive shortness of breath. A chest X-ray showed new extensive right upper lobe opacities. Sputum smear microscopy was negative.

The patient should now:

A. Switch to an empiric regimen for treatment of multidrug-resistant tuberculosis.

B. Initiate systemic corticosteroids to control symptoms of paradoxical tuberculosis immune reconstitution inflammatory syndrome.

C. Enroll in directly observed tuberculosis treatment given the high likelihood of poor adherence to therapy.

D. Begin trimethoprim/sulfamethoxazole for treatment of Pneumocystis jerovici infection.

18. A 45-year-old man presents to the emergency room with 2 days of severe headache over the left eye and fevers. He reports nearly constant tearing of the left eye and tenderness over the left eye for 24 hours. His medi-cal history is notable for type 1 diabetes mellitus com-plicated by peripheral neuropathy and chronic kidney disease. His examination is notable for an ill-appearing middle-aged man with chemosis of the left eye and peri-orbital and palpebral erythema extending over the left side of the nose. Laboratory data are notable for a blood glucose of 527 mg/dL. Urinalysis is remarkable for ketones and glucose. CT of the sinuses reveals thicken-ing of the left frontal, sphenoid, and ethmoid sinuses. Endoscopic evaluation by an otolaryngologist reveals a black eschar over the left middle turbinate.

In addition to treatment with insulin for diabetic ketoacidosis, appropriate management includes:

A. VoriconazoleB. Lipid formulation of amphotericin BC. CaspofunginD. Fluconazole


19. Antibiotic treatment is often indicated for persons with deeply penetrating animal bites. All of the follow-ing are acceptable antibiotic choices except:

A. Amoxicillin/clavulanateB. Ampicillin/sulbactamC. CiprofloxacinD. ImipenemE. Piperacillin/tazobactam

20. A 25-year-old woman presents to the emergency department with fever and back pain. The patient has been using intravenous heroin for the past few years; she had one prior episode of soft tissue abscess after injec-tion but no other illnesses in the past. She now com-plains of 2 weeks of progressive lower back pain and fevers. On examination she is tachycardic, diaphoretic, febrile (102F), and ill appearing. Cardiac examination reveals a new systolic murmur. There is marked tender-ness to palpation over the lumbar spine. Blood is drawn for basic labs and blood cultures (two sets). Given his ill appearance, the admitting physician decides to start empiric antibiotics for the most likely pathogens imme-diately. The best empiric antibiotic regimen for this patient is:

A. Vancomycin + ceftriaxoneB. Vancomycin + gentamicin + rifampinC. Nafcillin + gentamicinD. Vancomycin + caspofunginE. Ampicillin + gentamicin

21. A 47-year-old male with quadriplegia secondary to a motor vehicle accident as a young adult presents with fever, fatigue, and foul-smelling urine. He has a chronic indwelling Foley catheter due to urinary retention, and he reports multiple hospitalizations for catheter-associ-ated urinary tract infections. On arrival to the emergency department, he is noted to be confused with a tempera-ture of 102.3F, a heart rate of 116 beats per minute, and a blood pressure of 75/43 mm Hg. Urinalysis finds 3+ leukocyte esterase and positive nitrite with microscopy revealing 100200 WBC/hpf with 3+ bacteria. After diagnosing urosepsis, you recommend:

A. Administration of broad-spectrum antibiotics within 4 hours

B. Initiation of dopamine as a vasopressorC. Administration of intravenous hydrocortisoneD. Administration of 30 mL/kg of crystalloidE. Initiation of norepinephrine as a vasopressor

22. A 23-year-old woman with acute myeloid leu-kemia (AML) who underwent standard induction

chemotherapy with cytarabine and daunorubicin 11 days ago has recurrent fever to 103.1F associated with malaise and sweats. She also endorses a sore mouth and throat as well as mild diarrhea, which she attributes to her recent chemotherapy. Her labs are notable for an absolute neutrophil count of 28. She first developed fever and neutropenia 8days ago and was treated with empiric cefepime. Her fevers resolved within 24 hours and she remained afebrile until 2days ago. When fevers redeveloped, blood cultures were drawn and empiric caspofungin was added 2days ago; yeast is now growing in one of four blood culture bottles. Based on the infor-mation given, possible pathogens are:

A. Aspergillus fumigatusB. Candida albicansC. Cryptococcus neoformansD. B or CE. A, B, or C

23. A 22-year-old man presents to his primary care physi-cians office with fever and sore throat. The patient was feeling well until 1 week ago when he developed fever, malaise, fatigue, and sore throat; he later developed diar-rhea. He has lost 5 pounds in the past month. The patient is a student at a local college, he does not smoke, drinks alcohol a few times per week, and does not use any rec-reational drugs. He is sexually active with men and has had two new males partner over the past few months. He is up to date on all of his vaccinations. On examination he is thin, febrile, and mildly tachycardic. His orophar-ynx is erythematous without exudates; he has palpable small lymphadenopathy in bilateral cervical and groin distribution. He has a maculopapular rash over his chest and back. Laboratory data: WBC 2,200/L, hematocrit 30%, platelets 103,000/L, BUN 20 mg/dL, creatinine 1.0 mg/dL, AST/AGOT 66/L, ALT/SGPT 72/L, alkaline phosphatase 120/L, total bilirubin 0.9 mg/dL. Blood cultures are drawn. Which of the following is the most appropriate panel of tests to order next:

A. Hepatitis A, B, and C serologiesB. Urine gonorrhea and chlamydia probes, syphilis

serologyC. Rheumatic factor (RF), echocardiogramD. Blood smear, LDH, bone marrow biopsyE. Blood smear, EBV serologies, CMV serologies, HIV

antibody, HIV RNA

24. A 38-year-old male presents to the emergency department complaining of shortness of breath and cough productive of thick sputum that has been wors-ening over the past 2days. He is noted to have a room air oxygen saturation of 89% and a respiratory rate of


35 breaths per minute. Achest X-ray reveals consolida-tion in the left lower lobe of his lung. On review of his past medical history you learn that he has severe type 1 diabetes mellitus complicated by nephropathy requir-ing hemodialysis for the past year. Based on clinical and radiologic evidence suggesting pneumonia, you recommend:

A. LevofloxacinB. Ertapenem plus vancomycinC. Piperacillin/tazobactam plus amikacinD. Imipenem plus ciprofloxacinE. Cefepime plus levofloxacin plus vancomycin

25. A 21-year-old college student with moderate to severe asthma presents to the student health center with a sore mouth for several days. Though it is bother-some, it has not interfered with his eating or drinking. He denies odynophagia. Ten days ago he was hospi-talized for 2 days with a severe asthma flare. He was treated with a 2-week prednisone taper for his asthma and with a 5-day course of azithromycin for possible respiratory tract infection. His regular medications include inhaled salmeterol and fluticasone. On exami-nation he is a relatively well-appearing young man with white curd-like plaques adherent to the soft and hard palate.

Appropriate management includes any or all of the following except:

A. Oral nystatin swish and swallowB. Education about rinsing the mouth after using a

steroid inhalerC. Consideration of HIV testingD. Oral voriconazoleE. Clotrimazole troches

26. A 26-year-old female is hospitalized in a burn unit after suffering deep burns over 55% of her body in a house fire. She remains intubated with access via central venous catheter. On hospital day 10, the microbiology lab calls with the result of a blood cul-ture that was sent in the setting of a fever to 102F. The lab reports that Acinetobacter baumannii is growing in the blood, which is testing positive for extended-spectrum beta-lactamases and a carbapen-emase. Based on these results, you select the follow-ing antibiotic as most likely to be effective against this pathogen:

A. MeropenemB. ColistimethateC. Trimethoprim-sulfamethoxazoleD. CiprofloxacinE. Piperacillin/tazobactam

27. A 37-year-old woman with HIV (CD4 count 523/L, HIV viral load


When is the best time to start antiretroviral therapy for this patient:

A. Immediately; start the same day as clarithromycin and ethambutol

B. Afew days after initiation of clarithromycin and ethambutol but within 2 weeks

C. After 2 weeks on clarithromycin and ethambutol, if no side effects

D. After completion of 6 weeks of clarithromycin and ethambutol, to decrease risk of immune reconstitution inflammatory syndrome (IRIS)

E. After the patient is discharged from the hospital, in the outpatient setting with documented patient capacity for adherence to follow-up and medications

30. A49-year-old man with a long-standing history of well-controlled HIV presents to his primary care phy-sician for a routine visit. He is feeling well, with no symptomatic complaints. He reports 100% adherence to his antiretroviral regimen:tenofovir, emtricitabine, and efavirenz. He works in real estate and lives with his husband and their dog. He smokes approximately one pack of cigarettes per day, as he has for the past 20years. He drinks six alcoholic beverages per week, and he does not use recreational drugs. Vital signs: heart rate 82 beats per minute, blood pressure 137/86mm Hg, BMI 32 kg/m2, and physical examination is unremarkable. Labs show CD4 count 470/L, HIV viral load is


33. A 29-year-old woman who is otherwise healthy presents for a routine prenatal visit at 14 weeks gesta-tional age. She is feeling well and has no symptomatic complaints, and physical examination is consistent with normal pregnancy, otherwise unremarkable. She has routine prenatal laboratories checked, which show the following results:hemoglobin 11.2 g/dL, Rubella IgG positive, HIV antibody negative, Treponemal IgG (by EIA) positive. Follow-up RPR is also positive, with a titer of 1:16, and FTA-ABS is also positive. The patient has never had prior syphilis testing. She reports a his-tory of severe allergy to penicillin with a feeling of throat closing.

The most appropriate management for this patient is:

A. No treatment now due to risk of toxicity; follow clinically and repeat syphilis testing at 20 weeks gestational age

B. Treat with doxycycline 100 mg orally twice daily for a 21-day course

C. Treat with ceftriaxone 1 g IM once daily for 10 daysD. Treat with azithromycin 2 g orally in a single doseE. Allergy consultation and admission for

desensitization to penicillin in order to facilitate treatment with benzathine penicillin G 2.4 million units intramuscularly once weekly for 3 weeks

34. A24-year-old man with well-controlled HIV pres-ents for routine follow-up primary care visit and notes some dysuria for the past several days. Physical exami-nation is unremarkable. Urinalysis shows 10 WBC, no epithelial cells, 2 RBC, no bacteria per high-powered field (HPF). Urine testing for gonorrhea is positive by NAAT probe. The patient has no known drug allergies.All of the following treatments are appropriate, except:

A. Levofloxacin 500 mg orally once daily for 7 days plus doxycycline 100 mg orally twice daily for 7 days

B. Cefixime 400 mg orally single dose plus azithromycin 1 g orally single dose

C. Ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 7 days

D. Cefixime 400 mg orally single dose plus doxycycline 100 mg orally twice daily for 7 days

E. Ceftriaxone 250 mg IM single dose plus azithromycin 1 g orally single dose

35. A 32-year-old man presents to his primary care physician complaining of painful perianal lesions. The patient is sexually active with multiple male partners. He has had negative screening for sexually transmitted diseases, including HIV, gonorrhea, and chlamydia, in the pasthis last screening tests were 6 months ago. On physical examination he is over-all well appearing, but in the perianal area he has

multiple shallow ulcerations grouped in the right perianal area. There is no rectal discharge and no pal-pable lymphadenopathy, but the ulcerations are ten-der and painful even when not palpated. The type of diagnostic test that is most likely to confirm the diag-nosis of this active condition is:

A. Bacterial culture of a swab of the ulcersB. Viral culture of a swab of the ulcersC. Urine NAAT probeD. Blood serologic testE. PCR of a swab of the ulcers

36. A 47-year-old man presents to the emergency department with complaint of hemoptysis. He was born and raised in upstate NewYork, currently works as an investment banker, and is married with two children. He has been healthy until approximately 6months prior when he developed sinusitis. He has been treated by his primary care physician with courses of amoxicillin, amoxicillin-clavulanate, and moxifloxacin for episodes of sinusitis over the past few months, but his symptoms persist. Over the past 2 weeks he developed a cough, which was initially nonproductive, but during the past 2days he had a few episodes of hemoptysis. On physi-cal examination he has lost 5 lb since his last examina-tion 1month prior, he is thin but comfortable, and on sinonasal examination he has septal perforation with no obvious exudates or other abnormalities. Blood tests show white blood cell count of 4,200/L, hemoglobin 9.1 g/dL, and creatinine 2.2 mg/dL. Chest X-ray shows some abnormal opacities, so chest CT is obtained, which shows multiple pulmonary nodules.

The test most likely to confirm the diagnosis in this case is:

A. Sputum smear for acid-fast bacilli (AFB)B. AFB smear of biopsy of a pulmonary noduleC. Serum test for antineutrophilic cytoplasmic

antibodies (ANCA)D. Serum test for galactomannanE. Serum interferon-gamma release assay (IGRA)

37. A62-year-old woman with multiple sclerosis and a neurogenic bladder now has a chronic indwelling uri-nary catheter, after failing management with intermit-tent use of urinary straight catheters. She presents for a routine primary care visit and has no current symptom-atic complaints. She is interested in discussing strate-gies to decrease the risk of urinary tract infections in the future. In the past when she has developed urinary tract infections they often precipitate a worsening of her multiple sclerosis, and she often requires hospital-ization, so she hopes to prevent need for hospitalization in the future.


Which of the following strategies would be most suc-cessful at achieving her goals:

A. Monitoring for early signs and symptoms of urinary tract infection, with expedited early urinalysis, urine culture, and empiric treatment while awaiting culture results when symptoms develop

B. Routine screening with urinalysis for pyuria at regular intervals with early empiric treatment for urinary tract infection if pyuria is detected, even in the absence of symptoms

C. Addition of gentamicin solution to the catheter drainage bag at regular intervals

D. Chronic prophylaxis with methenamine salts to decrease bacteria

E. Chronic prophylaxis with ciprofloxacin to decrease bacteria and infections

38. A 45-year-old man with a history of prior open reduction and internal fixation (ORIF) of a left femur fracture in the past now presents with his third episode of cellulitis in the left leg. He was well until 1day prior when he developed sudden onset of malaise, fever, nau-sea, and erythema and pain in the left leg. He presented to the emergency room overnight and was treated empirically with vancomycin overnight. He improves gradually overnight. In discussion the following day he asks whether there are any strategies to decrease the fre-quency of his episodes of cellulitis in the future. Which of the following antibiotics, when taken regularly as prophylaxis, has been shown to decrease the incidence of cellulitis among patients with recurrent cellulitis:

A. Sulfamethoxazole-trimethoprimB. DoxycyclineC. ClarithromycinD. LevofloxacinE. Penicillin

39. A 22-year-old woman with well-controlled HIV infection is now pregnant and presents for routine pre-natal care at 12 weeks gestational age. She is taking her antiretroviral regimen of tenofovir, emtricitabine, ritonavir, and atazanavir with 100% adherence and no significant side effects. Her most recent CD4 count was 373/L and HIV viral load was undetectable. Prior lab-oratory studies have shown Toxoplasma IgG negative.

Which of the following is not a recommended strat-egy for primary prevention of acute Toxoplasmosis dur-ing pregnancy:

A. Cook meat to well doneB. Avoid ingestion of pork or any pork productsC. Avoid contact with materials potentially

contaminated with cat feces

D. Disinfect emptied cat-litter box with near-boiling water before refilling

E. Wash fruits and vegetables before eating

40. A 74-year-old man with poorly controlled diabe-tes, coronary artery disease, end-stage renal disease, and peripheral vascular disease presents with pain at a chronic foot ulcer site. The patient has had a nonheal-ing ulcer on his left great toe for several months with intermittent drainage but no other symptoms. Over the past few days he developed increasing purulent drain-age from the ulcer bed, as well as erythema, pain, and swelling of the toe, which is now tracking up the foot. The margins of the toe ulcer have also started to turn black. He has a low-grade fever with temperature of 100.7F at the time of presentation. Blood cultures are sent and a swab of the discharge from the ulcer is sent for culture as well. Which of the following antibiotic regimens would be appropriate initial therapy for this patient while awaiting culture results:

A. Vancomycin aloneB. Vancomycin and ampicillin-sulbactamC. Vancomycin and ceftriaxoneD. Vancomycin and ceftazidimeE. Linezolid and ertapenem

41. A 67-year-old woman presents to the emergency room with right ear pain. She is otherwise healthy at baseline and takes no medications. She lives in New Hampshire, spends time walking her dog in the woods frequently, but does not remember any specific tick bites. Approximately 10 days earlier she developed upper respiratory infection (URI) symptoms, which improved over a few days and then resolved after 7days. Over the past 34days she developed right ear pain. On physical examination she is noted to have a right facial droop and some lesions with serous drainage in the right external ear canal. Her mucous membranes are dry.

Which of the following is the most appropriate treat-ment for this patient:

A. Doxycycline 100 mg orally twice daily for 14 daysB. Valacyclovir 1000 mg orally three times daily for

14daysC. Ciprofloxacin otic solution to the right ear 4 times

per day for 7daysD. Ciprofloxacin otic solution plus amoxicillin-

clavulanate 875/125 mg orally twice daily for 10days

E. Prednisone 60 mg orally once daily for 5 days

42. A26-year-old man presents with dysuria, which has been persistent for more than 1 week. Urinalysis shows 12 WBC, 1 RBC, and no bacteria HPF, respectively,


and the urine culture is negative. Urine NAAT probes for chlamydia and gonorrhea are negative. Serum test-ing for HIV 1 and 2 antibodies are negative. Which of the following organisms is least likely responsible for the patients symptoms:

A. Trichomonas vaginalisB. Herpes simplex virusC. Mycoplasma genitaliumD. Haemophilus ducreyiE. Ureaplasma urealyticum

43. A 51-year-old woman with rheumatoid arthritis initiated treatment with infliximab after having nega-tive screening tests for tuberculosis and HIV. Five weeks after initiation of infliximab therapy she devel-oped cough and shortness of breath, which persisted despite empiric treatment with azithromycin by her pri-mary care physician. She is evaluated in the emergency department, where she is found to have a temperature of 100.6F, respiratory rate of 38 breathes per minute, and oxygen saturation of 85% while breathing ambient air. Achest X-ray shows bilateral interstitial infiltrates. Serum beta-glucan was >500 pg/mL. The diagnosis in this case is confirmed by toluidine blue staining of cysts from a bronchoalveolar lavage specimen.

Which of the following treatments is most appropri-ate for this patient:

A. IvermectinB. Trimethoprim-sulfamethoxazoleC. Trimethoprim-sulfamethoxazole plus prednisoneD. Liposomal amphotericinE. Liposomal amphotericin plus prednisone

44. A27-year-old man presents for follow-up visit after recent routine health maintenance screening. He is sexually active with men, with three partners in the past year. He reported 80% condom use during his last pri-mary care appointment. As a part of that appointment a routine screening HIV antibody test was sent and returned positive. Additional tests revealed CD4 count 526/L and HIV viral load (by PCR) of 12,436/L. The patient now presents for discussion of further HIV care.

What is the appropriate counseling to give regarding initiation of antiretroviral therapy (ART):

A. Antiretroviral therapy is indicated only when an opportunistic infection develops.

B. Antiretroviral therapy is indicated only when the CD4 count falls below 250/L.

C. Antiretroviral therapy is indicated only when the CD4 count falls below 350/L.

D. The risks of antiretroviral therapy outweigh the benefits when the CD4 count is greater than 500/L.

E. Antiretroviral therapy should be offered to all HIV-positive patients regardless of CD4 count because the benefits often outweigh the risks even at high CD4 counts.

45. A 55-year-old man with a history of hypertension, coronary artery disease, and depression presents with a soft tissue infection on the leg. He has no prior his-tory of soft tissue infections. His current medications are lisinopril, clopidogrel, aspirin, atorvastatin, and duloxetine. He has no known medication allergies. On examination he has a fever, temperature is 101.2F, but vital signs are otherwise normal. There is an area of ery-thema on the lower left leg, originating from a punctate wound where the patient states he sustained a spider bite. The area is warm, swollen, tender, and there is a central 4cm area of fluctuance. Incision and drainage of the abscess is performed at the bedside and puru-lence is drained and irrigated. Aculture of the drained fluid grows methicillin-resistant Staphylococcus aureus (MRSA). The patient is treated with vancomycin while an inpatient and is then discharged with oral linezolid for another 10days. After 7days he returns to the emer-gency room complaining of fever and malaise. His temperature is 103.7F, heart rate 116 beats per minute, blood pressure 180/92 mm Hg, sat 98% on room air. On examination he is somewhat agitated and unable to sit still. Lungs are clear to auscultation bilaterally, there are no murmurs on cardiac exam, abdomen is soft and nontender, and the lower left leg prior incision and drainage (I&D) site is healing well with no residual ery-thema or fluctuance.

The most likely cause of this patients new symptomsis:

A. Drugdrug interactionB. Recurrent MRSA abscessC. MRSA bacteremia due to endocarditisD. Hospital-acquired pneumoniaE. Clostridium difficile colitis

46. A 53-year-old man with a prior history of splenec-tomy after a splenic laceration in a motor vehicle accident 10 years previously now presents with fever and chills. The patient spent a week on Nantucket island for a sum-mer vacation and was feeling well until 2 days after she returned from vacation, when she developed fevers, with temperature as high as 103.2F, shaking chills, head-ache, and neck stiffness. She presented to a local hospi-tal, where initial complete blood count showed: WBC 12,000/L, hemoglobin 8.2 g/dL, platelets 80,000/L, normal electrolytes, serum creatinine 2.1 mg/dL, and alkaline phosphatase 206/L. A blood smear showed parasites within the red blood cells; the parasit-emia burden was assessed as 12%.


Which of the following is the most appropriate treat-ment regimen for this patient at this point:

A. Quinine and clindamycinB. Quinine and clindamycin and initiation of red cell

exchange transfusionC. Ceftriaxone and doxycycline and initiation of

intravenous immune globulin (IVIG)D. Azithromycin and atovaquone and initiation of

plasmapheresisE. Azithromycin and atovaquone

47. A36-year-old man with psoriasis, for which he takes methotrexate, traveled to Arizona for 2 weeks for a fam-ily reunion and developed a fever 2days prior to return-ing to his home in NewYork. He was feeling well during the trip and enjoyed the first week of the reunion. He bunked with extended family, including small children and two dogs. He ate food at the hotel and drank primar-ily bottled water. He went hiking in the desert on three occasions. He swam in the hotel pool, but engaged in no fresh water swimming. It was dry weather through-out the trip and very windy at times. Two days prior to returning home he developed fever, fatigue, malaise, dry cough, and chest pain. He took acetominophen and rested, then returned home to NewYork. After 10days the symptoms had not significantly improved, so he presented to his primary care provider. Physical exami-nation was remarkable only for low-grade fever. Chest X-ray showed mild left hilar infiltrate and adenopathy. He was treated with a 5-day course of azithromycin with no change in his symptoms.

The best diagnostic test to send at this point wouldbe:

A. Blood serologic testB. Sputum cultureC. Bronchoalveolar lavage for cultureD. Biopsy of the hilar lymph node for pathologyE. CT angiography of the chest

48. A 31-year-old man with a mechanical prosthetic aortic valve presents with fevers. He had his aortic valve replaced with mechanical prosthesis at age 24 due to congenital bicuspid aortic valve, and he has been doing well since then. His medications are warfarin and lisin-opril. He has no known drug allergies. At the time of admission to the hospital blood cultures are positive for MRSA. After extensive evaluation, no source for the bacteremia is identified. He is treated for presumed prosthetic valve endocarditis, even in the absence of suggestive findings on transesophageal echocardio-gram. His antibiotic regimen is vancomycin, gentami-cin, and rifampin. After 3days the blood cultures begin to be free of bacteria, he clinically improves, and is

eventually discharged to a rehab facility to complete a course of vancomycin, gentamicin, and rifampin. After 3 weeks he returns to the emergency room with an acute stroke, which appears embolic on MRI/MRA of the brain. Laboratories show WBC 12,000/L; hemoglo-bin 9.8 g/dL, platelets 167,000/L, creatinine 0.9 mg/dL, liver function tests are normal, PTT 36.0 seconds, and INR 1.2. Blood cultures are negative at 48 hours of incubation.

The most likely cause of the patients new stroke is:

A. Persistent infectious vegetation on the prosthetic aortic valve

B. Toxicity from gentamicinC. Aortic valvular dysfunction due to perivalvular

abscessD. Hypercoaguable state due to loss of gut flora while

on antibioticsE. Drugdrug interaction of warfarin with rifampin

49. A 53-year-old woman who is otherwise healthy develops fever, headache, malaise, and then cough, which is persistent and worsens over a couple of days. The patient lives in Missouri, where she works on a dairy farm, and also tends sheep for wool as an additional source of income. She spends her spare time hunting deer and rabbits. She is married and is monogamous with her husband. At the time of presen-tation she was mildly hypoxic and febrile, and rapidly worsened, ultimately requiring mechanical ventila-tion. Chest imaging showed multifocal infiltrates and progressive pleural effusions, as well as hilar lymphadenopathy. At the time of admission her labs were normal with the exception of WBC 14,000/L. However, she developed progressive renal failure and abnormal liver function tests over the first 2 days after admission. Blood, urine, and sputum cultures are all negative repeatedly. She has been treated with vancomycin, cefepime, and metronidazole with no improvement.

The most likely etiologic organism for her current condition is:

A. Tropheryma whippleiB. Babesia microtiC. Borelia lonestariD. Francisella tularensisE. Anaplasma phagocytophilum

50. A 22-year-old woman who is healthy at baseline sustains minor blunt trauma to the right thigh after she bumps her leg on the edge of a table. Within hours after the bump she develops fever and severe right leg pain such that she is barely able to walk. She presents to a local emergency room, where she is febrile and

1 2 thebr ighamintensiver ev iewofinternalmediCineQuestionandanswerCompanion

hypotensive. Her right thigh appears dusky, and she complains of pain tracking down to the foot and up to the lower abdomen. She is taken immediately to the operating room, where operative exploration reveals necrotizing myositis of the muscles of the thigh with-out gas formation, with necrotizing soft tissue infection tracking down the leg and up to the groin. Some of the debrided tissue is sent for expedited gram stain to aid with choice of antibiotics.

The most likely gram stain result in this case would be:

A. Gram-positive rods that are aerobicB. Gram-negative rods that are anaerobicC. Gram-positive cocci in pairs and chains, with

beta-hemolysisD. Gram-positive cocci in pairs and chains, with

alpha-hemolysisE. Gram-positive cocci in clusters, with beta-hemolysis

1. infeCtiousdiseases 1 3

C H A P T E R 1 A N S W E R S

1. ANSWER:E. Dengue

Leptospirosis can present in many different ways, including headache, muscle aches, and fever, but it is almost always associated with freshwater exposure, such as swimming or white-water rafting. Although all travelers returning with fever should be evaluated for malaria (even in cases where they had reported taking prophylaxis), the normal hematocrit and lack of other laboratory abnormalities in this young woman are reassuring. Typhoid can also pres-ent with only headache and fever, and in fact although it is cause by Salmonella spp. it can often cause little to no gastrointestinal symptoms. The marked thrombocytope-nia would be unusual for this diagnosis. Hepatitis Ais also a risk for travelers, but the lack of gastrointestinal symp-toms and lack of liver enzyme elevation argue against it. Dengue is now the second most common cause of fever in returning travelers (10.4%), after malaria, and dengue was the most frequently identified cause of systemic febrile ill-ness among travelers returning from Southeast Asia (32%) [Freedman. N Engl J Med. 2006;354(2):119]. Diagnosis is generally clinical, although acute and convalescent sera can be sent. Treatment is supportive.

2. ANSWER:B. Suctioning of subglottic secretions

There are a number of strategies that can help reduce the risk of ventilator-associated pneumonia in an intubated patient. These usually focus around preventing aspiration, reducing colonization of the airway and digestive tract, and mini-mizing contamination of the ventilatory circuit. To prevent aspiration, the head of the bead should be maintained in a semirecumbent position (elevated 3045 degrees) rather than in a fully recumbent position. One should also use a cuffed endotracheal tube with cuff pressure set at 20cm H2O with subglottic secretion drainage. To reduce coloni-zation of the airway and digestive tract, orotracheal intu-bation is preferred to nasotracheal intubation to decrease the risk of sinusitis, acid-reducing medications such a his-tamine receptor 2 (H2)blocking agents and proton pump inhibitors should be avoided except in patients at high risk for ulcers/gastritis, and regular oral care with an antiseptic solution (e.g., chlorhexidine) should be performed. Routine use of oral or intravenous antibiotics for prophylaxis is not recommended. Finally, to minimize contamination of the ventilatory circuit, the tubing should only be changed when visibly soiled or malfunctioning.

3. ANSWER:C. CMV colitis

Infection risk after solid organ transplantation depends on two key factors:when the transplant occurred and whether the patient has recently been treated for organ rejection. Transplant recipients who underwent transplantation less than a month ago are typically at highest risk for nosocomial infections and infections that result directly from surgery (e.g., wound infection). Those transplanted 16months before or those recently treated for rejection are at risk for opportunis-tic infections (such as CMV disease, PCP pneumonia, etc.). Those transplanted more than 6months ago and not treated for rejection recently (as in this case) are at highest risk for community-acquired pathogens, including Salmonella and norovirus. In addition, this history gives several risk favors for these three pathogens, including recent antibiotics exposure (increased risk for C.difficile), turtle contact (a potential car-rier of Salmonella), and classroom exposure to young children (a potential way to be exposed to norovirus). CMV colitis is unlikely here given that the patient is many years past trans-plant and has not had recent rejection.

4. ANSWER:B. Pneumococcal 13-valent conjugate (PCV13) vaccine

This patient is a 25-year-old men who have sex with men (MSM) with chronic lung disease, but otherwise with no known history of immunocompromising condition. Since his last tetanus vaccination was a Td at age 18, he has not had a Tdap vaccination since reaching adulthood. Tdap is recommended for all adults (age 19 and older) who have not previously received Tdap or for whom vaccine status is unknown, and it can be administered regardless of inter-val since the most recent tetanus vaccination. Thus, Tdap (option A) would be appropriate for this patient, even though his last tetanus vaccination was given fewer than 10 years previously. Hepatitis A vaccination (option C) is indicated for all MSM, so this would be appropriate for this patient. HPV vaccination (option D) is recommended for all MSM through age 26 years, so this would be appropriate for this patient. Influenza vaccination (option E) is recom-mended annually for all adults, so this would be appropriate for this patient, and it would be especially important given his history of asthma and pneumonia. Pnuemococcal vac-cination with the pneumococcal polysaccharide (PPSV23) vaccination would be appropriate for this patient given his chronic lung disease; however, the pneumococcal conju-gate 13-valent vaccination (PCV13) is recommended only for adults with immunocompromising conditions. Thus,


the pneumococcal conjugate 13-valent vaccine (option B) would not be appropriate for this patient. Please see the CDC Guidelines for Adult Vaccination schedule (http://www.cdc.gov/mmwr/ preview/mmwrhtml/su6201a3.htm) for more information and details.

5. ANSWER:C. Chest X-ray to assess for active pulmonary disease

The patient should undergo chest X-ray to evaluate for active pulmonary tuberculosis. Radiologic disease can be present in the absence of symptoms. There is no indication for an interferon gamma release; the positive skin test is sufficient to diagnose latent infection. Sputum evalua-tion should only be pursued if the patient has concerning symptoms or signs of active disease on chest imaging.

6. ANSWER:A. Campylobacter

Campylobacter infection can result in Guillain-Barr syn-drome (GBS) several weeks after diarrhea. Approximately 1/1,000 reported Campylobacter illnesses leads to GBS and up to 40% of GBS in the United States may be triggered by Campylobacter. Acute Campylobacter gastrointestinal illness can present with diarrhea (possibly bloody), cramp-ing, abdominal pain, and fever, sometimes with nausea and vomiting, and can last from 2 to 10days. It is not usually spread from one person to another, but most cases are asso-ciated with contact with raw or undercooked poultry. As few as 100 organisms can cause illness. Illness can also result from contact with stool of an ill pet dog or cat. Antibiotics are indicated in severe cases.

7. ANSWER:F. Options B andE

Recommended

EmpiricNitrofurantoinmacrocrystals100mgorallytwice daily 5 days (minimal resistance/collateral damage) or

EmpiricTMP/SMXDSorallytwicedaily3daysifE.colis TMP/SMX resistance rates are


have not been shown to be effective as prophylaxis. In addition, vaccination after exposure and administration of immunoglobulin do not appear to prevent secondary cases.

10. ANSWER:B. There is no potential risk for anaplasma or babesia coinfection.

In Massachusetts, the deer tick Ixodes scapularis can carry B. burgdorferi (Lyme), A. phagocytophilum (HGA), and Babesia microti (red blood cell parasite causing Babesiosis). Asplenia and other immune suppression increases risk of serious Babesiosis. Doxycycline has been shown to be some-what protective against Lyme disease but not against other tick-borne illnesses, and those who experience a tick bite should still be vigilant for signs and symptoms of illness and seek medical attention if symptoms develop [Wormser. Clin Infect Dis. 2006;43:1089134].

11. ANSWER:E. Rifampin

This patient initially had a skin/soft tissue infection that appeared to be nonpurulent, so management with a B-lactam antibiotic (dicloxacillin, in this case) was appropri-ate. However, she then developed a purulent complication and was found to have an MRSA skin/soft tissue infection (SSI) that was appropriately drained, which is the mainstay of treatment. It is appropriate to give postdrainage antibi-otics as well, especially in this case, which is complicated by obesity and lymphedema. There are multiple oral anti-biotics that are active against MRSA. All of the following are available in oral formulations with good oral bioavail-ability and are recommended for the treatment of MRSA SSI when the organism is susceptible:linezolid (option A), doxycycline (option B), trimethoprim-sulfamethoxazole (option C), and clindamycin (option D). Rifampin (option E) is an oral antibiotic with good oral bioavailability and activity against MRSA. However, rifampin should not be used as monotherapy in the treatment of MRSA infec-tions due to a low barrier to resistance. For treatment of MRSA, the role of rifampin is primarily as a second agent that is often added in cases of infection involving pros-thetic material (e.g., prosthetic heart valves, prosthetic joints, and other orthopedic hardware). Thus, rifampin should not be used in the treatment of this SSI, and cer-tainly not as monotherapy. Additional information about treatment of skin and soft tissue infections can be found in the Infectious Diseases Society of America (IDSA) guide-lines at http://www.idso ciety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/ PDF_Library/Skin%20and%20Soft%20Tissue.pdf.

12. ANSWER:E. Oral amoxicillin-clavulanate

Splenectomy results in increased vulnerability to over-whelming infection and sepsis due to certain organisms, including Streptococcus pneumoniae, Haemophilus influ-enzae, Neisseria meningitidis, and Capnocytophaga cani-morsus. C. canimorsus is an anaerobic gram-negative rod that is part of canine and feline oral flora. When inocu-lated into humans, C. canimorsus can cause severe infec-tion in certain hosts, including those without a spleen. Given this risk, typically asplenic patients who sustain a dog or cat bite in which the skin is broken are treated with a short course of preventative oral antibiotics. First-generation cephalosporins (such as cephalexin) and trimethoprim-sulfamethoxazole are not typically active; beta lactam-beta lactamase inhibitors and third-generation cephalosporins are usually active. In this case the patient is well clinically so has no indication for intravenous anti-biotics (ceftriaxone); thus, amoxicillin-clavulanate is the most appropriate choice. Rabies is unlikely in this case since the puppy is a domestic pet.

13. ANSWER:C. Use of a chlorine-containing cleaning agent to address environmental contamination

Standard environmental cleaning detergents are not spo-ricidal. To adequately clean the room of a patient with Clostridium difficile infection, it is necessary to use a chlorine-containing cleaning agent (1,0005,000 ppm available chlorine) or other sporicidal agent. Even in out-break settings, routine identification of asymptomatic car-riers is not recommended and treatment is not effective in reducing horizontal transmission. Strict adherence to con-tact precautions, including gowning and gloving on entry to a patients room and hand hygiene with soap and water, are key measures in reducing horizontal transmission of Clostridium difficile. The spore form of Clostridium diffi-cile is resistant to killing by alcohol. Contact precautions should continue at least for the duration of the diarrhea, with many hospitals continuing contact precautions for the duration of the inpatient admission. There is no evidence at this time to support the use of prophylactic antibiotics to prevent horizontal transmission.

14. ANSWER:D. Rifampin 600 mg and pyrazinamide 1750 mg daily for 2months

Daily isoniazid for 9months is the most common treatment regimen for latent tuberculosis infection. The combination of directly observed rifapentine and isoniazid is equally effective to daily isoniazid and may be best implemented in


congregate settings that can administer directly observed therapy. Daily rifampin for 4months is an accepted alter-native regimen, although efficacy has yet to be conclusively proven. The 2-month regimen of rifampin and pyrazin-amide is associated with unacceptably high rates of hepatitis and is no longer recommended by the Centers for Disease Control and Prevention as a possible treatment for latent tuberculosis infection.

15. ANSWER:A. Bartonella henselae

Systemic bartonellosis can sometimes present with a pri-mary lesion that develops 310days following inoculation from a bite or scratch from an infected cat (usually kitten). Tender lymphadenopathy may develop proximally after 110 weeks with overlying erythema that can suppurate and may last weeks. Rare complications include neuroretinitis (stellate macular exudates macular star), encephalopathy/transverse myelitis, or endocarditis. Differential includes mycobacteria, tularemia, plague, toxoplasmosis, histoplas-mosis, sporotrichosis, Kikuchis, lupus, and malignancy. In immune-suppressed individuals disseminated illness can present as bacillary angiomatosis.

16. ANSWER:B. HAV IgG positive, HBSAb negative,HBSAg positive, HBcAb positive, HCV Abnegative

Of the viral hepatidities, this patient is most likely to have chronic hepatitis B, which would have been acquired by vertical transmission from her mother. Hepatitis B remains a major public health problem in Vietnam and in much of Southeast Asia, and the hepatitis B vaccine and immunoglobulin are not universally available to newborns exposed to the virus, so vertical transmission continues. This patient has likely had subclinical chronic

hepatitis B since birth, which has now become apparent after increased replication of the virus in the setting of prednisone course and then increased immune response to the virus after completion of prednisone. This could be called a hepatitis B flare. Her laboratory tests show liver inflammation consistent with this. She does not report any food exposures or recent travel that might predispose her to hepatitis Ainfection (which is transmitted by fecal-oral route and is an acute infection). She does not report any exposure to hepatitis C, which may also be transmitted from mother to child (her mother does not have a his-tory of hepatitis C) but most commonly is transmitted by needle-sharing in injection drug use, and recently increas-ingly reported as acquired by receptive anal intercourse. So the object is to find the serologies that are consistent with flare of chronic hepatitis B infection; the hepatitis Aand hepatitis C serologies are irrelevant. Patients with active hepatitis B infection will produce surface antigen (HBSAg) and will have positive core antibody (HBcAb) due to ongoing exposure to the virus. But patients with active chronic hepatitis B usually do not have positive surface antibody (HBSAb) because this is a protective antibody that prevents chronic infection and is typically found only in patients that have received the hepatitis B vaccine or have been exposed to hepatitis B virus in the past and cleared the infection. Thus, the correct answer is option B (HBSAb negative, HBSAg positive, HBcAb positive). See Table 1.1 for anticipated results with hepati-tis B serologies depending on patient status.

17. ANSWER:B. Initiate systemic corticosteroids to control symptoms of paradoxical tuberculosis immune reconstitution inflammatory syndrome (IRIS).

The clinical syndrome is classic for paradoxical tuberculosis immune reconstitution inflammatory syndrome, which is characterized by new or worsening findings of tuberculo-sis disease within 23months of initiation of antiretroviral

Table1.1 ANTICIPATED R ESULTS WITH HEPATITIS B SEROLOGIES DEPENDING ON PATIENT STATUS

SEROLOGIC TEST

HEPB VACCINATION

ACUTE HEPATITIS B

R ECOVER ED HEPATITIS B

CHRONIC ACTIVE

INACTIVE CAR R IER

HBsAb + +

HBcAb (total) + + + +

HBeAb + +

HbsAg + + +

HBeAg + +

HBV DNA + High (>105) Detectable


therapy. Manifestations can be seen within lung parenchyma, the central nervous system, and at serosal surfaces (pleural effusions, ascites, or pericardial effusions). Symptoms are controlled with systemic corticosteroids. Multidrug-resistant tuberculosis is unlikely given the negative drug susceptibility test. The rapid onset of symptoms is not consistent with loss of control of tuberculosis infection due to poor adherence. Pneumocystis jerovici is in the differential diagnosis but less likely given the CD4 T cell count above 200 cells/L3.

18. ANSWER:B. Lipid formulation of amphotericinB

The case patients presentation is consistent with a severe sinus infection with an angioinvasive mold resulting in a rapidly progressive infection with an intranasal eschar. The most common infection syndromes in this clinical con-text include mucormycosis and aspergillosis. Appropriate empiric antifungal therapy in suspected cases of fun-gal sinusitis includes an antifungal agent active against Mucorales and Aspergillus species such as amphotericin B or a lipid formulation of amphotericin (which may be less nephrotoxic in this individual with chronic kidney disease). Voriconazole and caspofungin are active against Aspergillus species but do not have activity against Mucorales when given alone. Fluconazole has no activity in Aspergillus spe-cies or Mucorales.

19. ANSWER:C. Ciprofloxacin

Treatment for animal bites should cover Pasteurella species and anaerobic organisms, as well as Capnocytophaga canimor-sus. Aquinolone such as ciprofloxacin could be used if given together with metronidazole or clindamycin for anaerobic coverage, but ciprofloxacin alone is not adequate empiric treatment. Capnocytophaga canimorsus is a gram-negative rod that is part of normal oral flora of canines and other ani-mals, including cats and rabbits. Those who are asplenic and those with liver disease or other immune suppression are at increased risk for severe disease and can develop shock, pur-puric lesions, and disseminated intravascular coagulopathy (DIC). Capnocytophaga canimorsus can take up to 14days to culture, so in suspected cases treat empirically with amoxicillin/clavulanate or imipenem for critical illness, or piperacillin-tazobactam would also be acceptable.

20. ANSWER:A. Vancomycin + ceftriaxone

This patient most likely has bacterial endocarditis and vertebral osteomyelitis. Since this patient is febrile and ill

appearing, it is appropriate to start empiric antibiotics as soon as blood cultures have been drawn in order to pre-vent further complications of infection. The most common pathogens in this type of presentation are Staphylococcus aureus and the viridans Streptococci (oral flora)empiric treatment should be targeted toward treating these organ-isms. Enterococci are a less frequent cause of endocarditis, though still important to considerempiric treatment for Staph and Strep will also include empiric treatment for Enterococci. Coagulase-negative Staphylococci are most common in patients with indwelling central venous cath-eters, prosthetic heart valves, or other implanted cardiac devices. Candidal endocarditis is most common among injection drug users but still less common than the bacterial pathogens. Option A:vancomycin provides empiric treat-ment for Staphylococcus aureus (including MRSA) and the penicillin-resistant Enterococci, and ceftriaxone provides empiric treatment for viridans Streptococci, so this is the cor-rect answer. Option B might be considered for prosthetic valve endocarditis with MRSA, but this patient does not have a prosthetic valve, rifampin is not indicated, and use of rifampin during active bacteremia may lead to the devel-opment of rifampin resistance; hence, this should not be used empirically or early in therapy. Option C:nafcillin is excellent therapy for methicillin-susceptible Staphylococcus aureus, but the possibility of MRSA has not been ruled out in this patient, so he should receive vancomycin until cul-tures are documented, and aminoglycosides (gentamicin) are no longer indicated for Staphylococcus aureus bactere-mia due to risk of nephrotoxicity and minimal evidence of benefit. Option D: caspofungin (or micafungin, both echinocandins) is excellent therapy for Candida infec-tions, but Candidal endocarditis is much less common than bacterial endocarditis, even in injection drug users, so would not be chosen for empiric treatment. Option E:ampicillin and gentamicin might be used for treatment of penicillin-susceptible Enterococcal endocarditis, but it would not be appropriate for empiric therapy in the absence of culture data.

21. ANSWER:C. Administration of 30 mL/kg ofcrystalloid

The Surviving Sepsis Campaign recommends that the following be completed within 3 hours: measurement of lactate, obtaining blood cultures prior to antibiotics, administration of broad-spectrum antibiotics, and admin-istration of 30 mL/kg of crystalloid for hypotension or lactate 4 mmol/L. There is good evidence that early antibiotics (within 1 hour of recognizing sepsis) improves patient outcomes. Norephinephrine is the first-choice vaso-pressor to maintain a mean arterial pressure 65; however, vasopressors should be reserved for hypotension that is


nonresponsive to fluid resuscitation. Dopamine is not rec-ommended except in highly select circumstances. Likewise, intravenous hydrocortisone is not recommended if hemo-dynamic stability is restored with fluid resuscitation and vasopressors.

22. ANSWER:E. B orC

Neutropenic patients with fever that persists or recurs after 47days of empiric antibiotics are at high risk for fungal infection. These patients should be treated with empiric antifungal therapy, as the patient in this case was based on Infectious Diseases Society of America guidelines. In this case the patient grew yeast from blood cultures. Aspergillus fumigatus is a mold; thus, it is not a potential cause of this infection. Only Candida albicans or Cryptococcus neofor-mans, both of which grow as yeast in blood cultures, could cause this infection. Without further microbiologic infor-mation the exact pathogen causing the infection cannot be determined.

23. ANSWER:E. Blood smear, EBV serologies, CMVserologies, HIV antibody, HIV RNA

This patient has a mono-like illness, characterized by fever, sore throat, malaise, fatigue, rash, and lymphade-nopathy. Mild hepatitis and pancytopenia may also be a part of the syndrome. The most common causes of this syn-drome in young adults are viral pathogens, including EBV and CMV for those who were not already infected during childhood. Serologies for both EBV and CMV are helpful diagnostics here. Acute retroviral syndrome, or acute HIV, may also present as a mono-like illness, often with concur-rent diarrhea and weight loss just as this patient had. The incidence of new HIV infections in the United States is highest among MSM at present, so this patient has a doc-umented risk factor as well. Acute HIV is the most likely diagnosis for this patient. In acute HIV the HIV antibody is often still negative, prior to seroconversion, but the HIV RNA (or viral load) should be positive and is usually very high. It is important to check both the HIV antibody and HIV RNA (viral load) when acute HIV is suspected. Although hepatitis serologies may be helpful at some point if the liver function tests continue to be abnormal, viral hepatitis would not explain the full constellation of this patients symptoms or lab abnormalities, and the transami-nases are not high enough to be consistent with acute viral hepatitis, so these would not be the appropriate next tests to order. It is appropriate to consider the possibility of new sexually transmitted infections (STIs) given his new sexual partners, and secondary syphilis can also present with fever

and rash and lymphadenopathy but would be unlikely to present with diarrhea, weight loss, and pancytopenia. An echocardiogram might be an appropriate test if the blood cultures are positive, but there are no other clues specific to endocarditis here aside from the fever. A blood smear and LDH may be appropriate tests at this point given the patients pancytopenia of uncertain etiology, but a bone marrow biopsy should not be pursued until further nonin-vasive diagnostics have been performed.

24. ANSWER:C. Cefepime plus levofloxacin plus vancomycin

While this patient is presenting from the community, he meets criteria for a health careassociated pneumonia (HCAP). These criteria include hospitalization for 2days within 90days of infection, residence in a chronic care facil-ity, attending a hemodialysis clinic, and receipt of intra-venous antibiotic therapy, chemotherapy, or wound care within 30days of infection. Based on the patients underly-ing diagnosis of diabetes and receipt of hemodialysis, he is at increased risk for multidrug-resistant pathogens, includ-ing Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). While awaiting culture results, it is recommended to start combination therapy with the following: (1) an antipseudomonal cephalo-sporin (cefepime, ceftazidime) or an antipseudomonal carbapenem (imipenem, meropenem) or a beta-lactam/beta-lactamase inhibitor (piperacillin-tazobactam); plus (2) an antipseudomonal fluoroquinolone (ciprofloxacin, levofloxacin) or an aminoglycoside (amikacin, gentamicin, tobramycin); plus (3)a drug that is active against MRSA (vancomycin, linezolid). These antibiotics can be adjusted based on clinical improvement and culture results at 48 to 72 hours.

25. ANSWER:D. Oral voriconazole

The patient in this case has clinical evidence of oral candidi-asis (thrush). He recently received treatment with systemic steroids and antibiotics and is also on a chronic inhaled ste-roid, all of which raise his potential risk for thrush. In order to minimize the possibility that the thrush resulted from the use of an inhaled steroid, reviewing proper oral hygiene after use could be helpful. Despite these risk factors, it is also reasonable to consider HIV testing; the CDC cur-rently recommends testing for all patients in the health care setting. Appropriate treatment for uncomplicated thrush includes oral nystatin, clotrimazole troches, or oral flucon-azole. Voriconazole is a broader spectrum antifungal agent and would not be indicated in this clinical context.


26. ANSWER:A. Colistimethate

Acinetobacter baumannii is an aerobic gram-negative coc-cobacillus that can cause hospital outbreaks with high rates of mortality. Outbreaks are typically associated with colonized respiratory support equipment, irrigation solu-tions, and intravenous solutions. The most common infec-tions include ventilator-associated pneumonia, infection of surgical wounds and burns, and bacteremia. Over 50% of Acinetobacter baumannii isolates in US hospitals are multidrug resistant. Colistimethate (colistin) is virtually always active in vitro. The presence of a beta-lactamase means that both cefepime and piperacillin/tazobac-tam, the two most active beta-lactam antibiotics against Acinetobacter baumannii, are likely to be ineffective. The presence of a carbapenemase means that imipenem/ci

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