Transcript Infectious Diseases Review Course

Infectious Diseases Review
Course
Hail M. Al-Abdely, MD
Consultant, Infectious Diseases
Human immunodeficiency virus (HIV) infected patients
have a greatly increased risk of all of the following cancers
EXCEPT
a.
b.
c.
d.
e.
Kaposi Sarcoma
Cervical Cancer
Non-Hodgkin's Lymphoma
Central Nervous System Lymphoma
Malignant Melanoma
An outpatient liver transplant recipient suddenly
develops fever, chills, and bacteremia 2 months after
transplantation. The most likely source of the
bacteremia is
a.
b.
c.
d.
e.
Lungs
Urinary tract
Wound infection
Biliary stricture
Sinuses
Syphilis in HIV-infected persons is characterized by all
of the following except
a.
b.
c.
d.
e.
A strong association between the two infections
A predilection for more florid clinical signs and
symptoms
An increased likelihood of treatment failure, especially
with benzathine penicillin
Uniform success of treatment with high-dose penicillin
or ceftriaxone
A propensity to develop high nontreponemal titers
A 47-year old man with HIV infection presents with
extensive purplish skin nodules. There are 32 lesions on
his arms, chest and legs, all of which have appeared in
the past 6 weeks. His CD4 cell count is 70/uL. Punch
biopsy of one lesion shows Kaposi’s sarcoma. Which
one of the following statements is true?
a.
b.
c.
d.
e.
Lesions appear at a rapid rate only in patients with very advanced
HIV disease – those with CD4 cell counts less than 100/uL
This patient is unlikely to respond to interferon alfa regardless of his
CD4 cell count
This patient is almost certainly homosexual or bisexual, because
Kaposi’s sarcoma rarely occurs in patients in other risk groups
the percent of HIV-infected homosexual men who develop Kaposi’s
sarcoma has been reasonably stable since 1982
Most patients with Kaposi’s sarcoma die due to visceral
involvement by the tumor, especially involvement of the lungs and
gastrointestinal tract
Which of the following is the most accurate statement
regarding Toxoplasma gondii encephalitis in persons
with HIV infection?
a.
b.
c.
d.
The absence of lesions on computed tomography (CT) of the
head obviates the need for further investigation into the possibility
of Toxoplasma gondii encephalitis
Generally, brain biopsy should be done in patients with
characteristic focal central nervous system lesions with positive
Toxoplasma gondii serology in order to rule out the possibility of
other treatable causes of focal central nervous system lesions
The most common findings on head CT scan are single ringenhancing lesion with mass effect
If a patient with the appropriate clinical findings has not improved
within 14 days of therapy with empiric pyrimethamine plus
sulfadiazine, brain biopsy should be done
All of the following statements are true about
fluconazole EXCEPT
a.
b.
c.
d.
e.
It is a fungistatic agent
It is inactive against Candida krusei
It is active against isolates of Trichosporon beigelii
It is useful in the long-term management of
cryptococcal meningitis
It is the drug of choice for the treatment of
disseminated histoplasmosis
Fungal infection remains a major source of morbidity and mortality
in marrow transplant recipients. Which of the following
statements regarding fungal infections is true?
a.
b.
c.
d.
e.
Candida tropicalis is more often found as a colonizer than as the
true etiology of infection in transplant recipients.
Aspergillus species may cause pneumonia, sinusitis, or infection
of the CNS.
Candida albicans rarely causes true infection in marrow transplant
recipients.
Pityrosporum species cause a disseminated skin rash in marrow
transplant recipients that usually require systemic antifungal
therapy.
Abnormal donor immune function remains the greatest risk for the
development of fungal infection.
The following regimens are acceptable
initial therapy for HIV-patients except:
a.
b.
c.
d.
Zidovudine, stavudine, nelfinavir
Stavudine, lamivudine, indinavir
Stavudine, didonasine, nelfinavir
Zidovudine, nevirapine, nelfinavir
e. Zidovudine, lamivudine, efavirenz
A 19 year-old Saudi female with sickle-cell disease
presented to the ER with 2 day history of fever, cough
and SOB. O/E was febrile 39C, RR 30 and BP 80/50.
Has crackles bilaterally and CXR revealed bilateral
lower lobe consolidation. WBC 24000 with 35% band
forms, HgB 39 gm/l. The appropriate antibiotic regimen
for this patient is:
a.
b.
c.
d.
e.
Penicilin G 3 MU every 4 hours
Ceftriaxone 2gm every 24 hours
Ceftazidime 2gm every 8 hours and gentamicin 2mg/kg every
12 hours
Vancomycin 1gm every 12 hours and Ceftriaxone 2gm every
24 hours
Nafcillin 2gm every 4 hours and ciprofloxacin 400mg i.v every
12 hours
A 50 year/old male who had a liver transplant one year
ago. He is on tacrolimus with normal LFT. He
presented to the ER with one day history of diffuse
vesicular skin rash all over his body. Chest, abdomen
and neurological examinations were normal. CXR was
normal. What will be your action?
a.
b.
c.
d.
e.
Admit and start intravenous acyclovir 10mg/kg Q8hrs
Admit and start intravenous acyclovir and ceftriaxone
Admit and start intravenous acyclovir and oral predisone
Discharge from ER on valacyclovir (Valtrex) 1gm Q8hrs
Discharge from ER on famciclovir (Famvir) 500mg Q8hrs
20 year-old Saudi male with acute myeloid leukemia who
developed E. coli, coagulase negative staph and C. albicans
blood streem infections during neutropenia. He was treated with
cefepime, gentamicin and amphotericin B for which he has an
excellent response. Treatment was continued throughout
neutropenia and for three days after recovery of white cells, and
was discharged home. One week later the patient presented with
fever, rigors and malaise for 2 days. He was admitted, and 2 sets
of blood culture were negative and had a negative CXR. WBC
4.5. CT abodomen showed mutliple enhancing lesions in the liver,
spleen and R-kidney. The most appropriate theray is.
a.
b.
c.
d.
e.
Piperacillin/tazobactam and gentamicin
Piperacillin/tazobacam, gentamicin and vancomycin
Meropenem and vancomycin
Amphotericin B
Meropenem, vancomycin and amphotericin B
All of the following are poor prognostic
factors in Cryptococcal meningitis
except:
a. Cerebrospinal fluid (CSF) leukocytosis
b. Serum of CSF cryptococcal antigen titer
>1:32
c. Elevated CSF opening pressure
d. Altered mental status
e. Low CSF glucose
All true about Listeria monocytogenes except:
a. Is a gram positive motile rod.
b. Can be treated effectively with
trimethoprim/sulfamethoxazole.
c. Can cause illness in immune competent
individuals
d. The highest risk group to have infection is
bone marrow transplant recipients.
e. Pasteurization kills this organism
Which of the following microbes is most likely to cause a
cerebrospinal fluid showing elevated protein and a
polymorphonuclear pleocytosis in late-stage HIV
infection?
a.
b.
c.
d.
Toxoplasma gondii
Cytomegalovirus
Treponema pallidum
JC virus (Progressive multifocal
leukoencephalopathy)
e. Herpes simplex
A 52 year old man with 20 years of Type 2 diabetes
mellitus undergoes pancreas and renal transplantation.
His post-operative course is complicated by
severe sinusitis. Cultures reveal Rizopus spp. Local
sinus surgery is performed, and Amphotericin B
deoxycholate is administered with shakes,
hypokalemia, and deterioration in renal function. The
best course of action is:
a.
b.
c.
d.
Continue amphotericin B and reduce cyclosporine levels
Replace amphotericin B with itraconazole
Replace amphotericin B with liposomal formulation of
amphotericin B
Replace amphotericin B with fluconazole
e.
Increase fluid intake to reduce nephrotoxicity
A 55 year-old man underwent his third cycle of
chemotherapy for Non-Hodgkin's Lymphoma 10 days prior
to presentation. He presents with erythema and pain at the
Hickman Catheter entry site in his skin and a fever of 39.7°.
He was well for one week after the chemotherapy infusion,
which he tolerated well. However, over the last several days
he developed increasing fatigue and had a fever to 37.8° 24
hours ago. He took two acetaminophen and felt better. He
developed a rigor this morning, and presents now. Physical
exam reveals an erythematous, tender Hickman entry site
without surrounding crepitus. The lungs are clear, there are
no other skin lesions, and the perianal area is normal without
obvious fissures. The next step is:
a.
b.
c.
d.
e.
Determine the neutrophil count, obtain blood cultures including one
set through the Hickman line, begin vancomycin, ceftazidime and an
aminoglycoside
Determine the neutrophil count, obtain blood cultures including one
set through the Hickman line, begin ceftazidime and an
aminoglycoside
Obtain blood cultures including one through the Hickman line;
Determine the neutrophil count; if the patient is neutropenic, begin
vancomycin and ceftazidime; if the patient is not neutropenic, begin
vancomycin alone
Obtain blood cultures including one through the Hickman line;
Determine the neutrophil count; if the patient is neutropenic, begin
vancomycin and ceftazidime and an aminoglycoside; if the patient is
not neutropenic, begin vancomycin alone
Obtain blood cultures including one through the Hickman line;
Determine the neutrophil count, and begin vancomycin only
(whether neutropenic or not)
For which of the following exposures would the
use of HIV PEP be recommended?
a.
b.
c.
d.
e.
A housekeeper sustains a percutaneous injury while emptying
a needle box on a pediatric ward with no known cases of HIV
infection.
A nurse has a urine splash to the eye while emptying an AIDS
patient's urine.
A resident, after assisting with an emergency insertion of a
central venous line into an HIV-infected patient, notices a small
tear in his/her glove but does not observe any blood on his/her
skin.
A phlebotomist sustains a percutaneous injury while
performing phlebotomy on an HIV-infected patient with low
viral load.
All of the above.
A 32-year-old man with advanced HIV infection
presents with cough and low grade fever of two weeks
duration. He has a history of PCP, thrush, ITP, and
wasting. Recent medications include ddI, d4T,
nelfinavir, dapsone, nystatin, and prednisone. Chest xray shows a cavity lesion measuring 4 cm in the right
lower lobe. A BAL yields Candida albicans, Nocardia
asteroides, P. aeruginosa, and CMV. Which of the
following antibiotics should be given?
a.
b.
c.
d.
e.
Ganciclovir
Trimethoprim-sulfamethoxazole
Amphotericin B
Fluconazole
Ceftazidime
A patient with HIV
infection, treated with
HAART, and a CD4 count
of 240/mm3 has the
findings shown in the
photograph on retinal
(funduscopic) exam. The
most appropriate therapy
is:
1. Pyrimethamine plus
sulfamethoxazole
2. Intravenous
ganciclovir
3. Intravenous
cidofovir
4. Amphotericin B
5. No treatment
A 30-year-old man with HIV infection with a CD4 count of
680/mm3 is referred for evaluation of refractory sinusitis. He
reports headaches, purulent nasal drainage and nasal stuffiness
for 2 weeks. There has been no documented fever. Prior
treatment consisted of amoxicillin x 5 days, then TMP-SMX,
one DS bid x 3 days; epinephrine nasal spray and ibuprofen
has been given for 2 to 3 weeks. Diagnostic studies included
the following:
CT scan--bilateral air fluid levels in maxillary sinuses
Nasal drainage--PMNs and eosinophils
Culture--moderate S. aureus sensitive to methicillin
WBC--7,800 with 62% PMNs, 4% bands, 20% lymphocytes,
9% monocytes, 5% eosinophils.
The treatment that is likely to be most effective is:
a.
b.
c.
d.
e.
Dicloxacillin
Decongestant nasal spray
Cortisone nasal spray
Ipratropium bromide nasal spray
Cough syrup containing dextromethorphan
A pregnant woman has a CD4 count of 550/mm3
and viral load of 860 c/ml with no antiretroviral
therapy. Which of the following has demonstrated
benefit in preventing perinatal transmission in this
setting?
1.
2.
3.
4.
5.
AZT monotherapy
Nevirapine
HAART
C-section
None of the above
The frequency of HIV perinatal
transmission is low when the viral
load is <1,000 c/ml, but a review
of seven prospective studies of
perinatal transmission in the U.S.
and Europe showed that there
was a significant reduction even
further when AZT was given (JID
2001;183:539).
A 30-year-old woman presents
with watery diarrhea with 6-8
stools/day for nearly 2 months.
She is discovered to have HIV
infection with a CD4 count of
22/mm3. A stool AFB smear is
shown. Which of the following
treatments is most likely to
eradicate the pathogen?
1.
2.
3.
4.
5.
Paromomycin
Trimethoprimsulfamethoxazole
Albendazole
Nitrazoxanide
Highly active antiretroviral
therapy
(HAART
A lymph node biopsy from an HIV-positive patient currently
residing in the state prison is submitted to the laboratory for
acid-fast smear and culture. The acid-fast smear is reported
as positive. Acid-fast organisms are recovered on solid
medium after 3 days of incubation. This organism is likely
to be:
a.
b.
c.
d.
e.
Mycobacterium xenopi
Mycobacterium kansasii
Mycobacterium fortuitum.
Mycobacterium tuberculosis
Mycobacterium avium
A 32-year-old drug user is seen in an emergency department with
abdominal pain and fever. He has known HIV infection and a recent
CD4 count was 10/mm3. He reports that he has had intermittent
diarrhea with 2 to 6 loose stools daily for about 2 weeks, and then
noted nausea, vomiting, and right upper quadrant abdominal pain.
Physical exam shows a temperature of 38.5 C and right upper
quadrant tenderness. Medications include AZT, ddI, TMP- SMX,
fluconazole, acyclovir, and megavitamins.
Laboratory tests show the following:
Hematocrit: 29%
WBC: 3200 (72% PMNs, 8% bands, 10% lymphs, 5% monocytes,
and 5% eosinophils)
Platelet count: 88,000/mm3
Bilirubin: 1.4 mg/dL, AST: 121 U/L, ALT: 135 U/L
Alkaline phosphatase: 860 U/L
Chest x-ray: Negative
Abdominal flat plate: Negative
Ultrasound of abdomen: Dilated biliary ducts without stones
Stool ova and parasite exam with AFB stain: Negative
The most likely cause is:
a.
b.
c.
d.
e.
An adverse drug reaction
Cryptosporidia
Cyclospora
Entamoeba histolytica
Mycobacterium avium
The diagnosis of progressive multifocal
leukoencephalopathy is supported by which of
the following findings?
1.
2.
3.
4.
5.
Cerebrospinal fluid pleocytosis
Cerebrospinal fluid elevated protein
Fever
Rapid onset of symptoms
Brain biopsy with positive stain for SV-40 virus
Which of the following drugs is least likely to
cause lactic acidosis?
1.
2.
3.
4.
5.
AZT
3TC
ddC
ddI
Tenofovir
A 30-year-old man has been treated with AZT, 3TC,
ritonavir, and indinavir for three years. His CD4
count increased from 230 to 550/mm3 with VL<50
c/ml for over two years. He decides to stop therapy.
When should HIV become detectable?
1.
2.
3.
4.
5.
One week
Two weeks
Four weeks
Eight weeks
Three months
Which of the following decreases blood levels of
indinavir?
1.
2.
3.
4.
5.
Delavirdine
Efavirenz
Nelfinavir
d4T
Ketoconazole
Efavirenz decreases the AUC of
indinavir by 31%. The practical
application is that the dose of
indinavir when these two drugs are
used together should be increased
to 1,000 mg q8h. All of the other
drugs that are listed increase the
levels of indinavir.
Which of the following drugs is most likely to
increase the fasting blood glucose?
1.
2.
3.
4.
5.
Tenofovir
Hydroxyurea
Nevirapine
Indinavir
IL-2
There is some substantial
confusion about the agents and
mechanisms of lipodystrophy, but
this is not the case with insulin
resistance resulting in elevated
blood sugar. All protease
inhibitors are associated with
insulin resistance, which can be
measured within days of
administration. Thus, indinavir is
the best option since this is the
only PI on the list.
Food should be given with:
1.
2.
3.
4.
5.
Amprenavir
Indinavir
AZT
Nevirapine
Lopinavir
A 37-year-old man with AIDS is receiving AZT, ddI
and nelfinavir. He has done well with a viral burden
that decreased from 88,000 copies/dL to
undetectable. At his last clinic visit he is noted to
have a CBC showing an absolute neutrophil count of
400/mm3; neutropenia is confirmed. A review of
prior CBCs shows all had ANC values >1800/mm3.
The preferred regimen for this patient among the
options given is:
1.
2.
3.
4.
5.
ddI, d4T, and saquinavir (Fortovase)
d4T, ddI and nelfinavir
3TC, ddI and indinavir
ddC, ddI and ritonavir
ddI, ritonavir and saquinavir
A 40-year-old man with HIV infection and a CD4
count of 360/mm3 is taking INH due to a positive
PPD skin test. After one month of treatment the ALT
increased from 30 IU/dL at baseline to 90 IU/dL.
The upper limit of normal is 35 IU/dL. The patient
is asymptomatic. What treatment should be given?
1.
2.
3.
4.
5.
The current recommendations
Continue INH in same dose
with INH and hepatic function
Discontinue prophylaxis
testing is that increases of 3 - 5Substitute rifampin
fold for transaminase levels
Substitute rifampin + ethambutol should lead to careful
monitoring, but discontinuation
Biopsy the liver and then continue INH
if there is no
of INH is not necessary unless
evidence of drug-induced hepatitis the increase is 5 - 10-fold
higher of the upper limits of
normal.
For the average patient, which of the following
treatments gives the longest delay in relapse of
CMV retinitis?
The median times to progression with initial
with CMV retinitis are:
1.
2.
3.
4.
5.
IV ganciclovir
IV foscarnet
IV cidofovir
Ganciclovir implant
Oral ganciclovir
ganciclovir IV of 47 - 104 days,
foscarnet IV 53 - 93 days,
ganciclovir plus foscarnet IV 129 days,
oral ganciclovir 29 - 53 days,
cidofovir IV 64 - 120 days,
ganciclovir implant (Vitrasert) 216 - 226 days.
Most patients in late-stage HIV infection develop
toxoplasmosis from which of the following?
1. New infection following exposure to cat stool
2. New infection following exposure to undercooked meat
3. New infection from exposure to a patient with
toxoplasmosis
4. New infection from contaminated water
5. Activation of latent infection
The risk of which of the following HIV-associated
complications is the least reduced by immune
reconstitution with HAART?
1.
2.
3.
4.
5.
Kaposis sarcoma
HIV-associated dementia
Non-Hodgkins lymphoma
Thrush
Pneumococal pneumonia
A patient sees you complaining of a
sore mouth for 2 days. There is a
history of genital herpes,
pneumococcal pneumonia,zoster,
oral hairy leukoplakia and a positive
PPD. The CD4 count is 205/mm3
and current medications include
nevirapine, nelfinavir, ddI,
hydroxyurea, trimethoprimsulfamethoxazole, and sertraline
(Zoloft). Oral exam is shown in the
figure. A Tzanck prep of the lesion
is negative. Which of the following
is most likely to provide relief?
1.
2.
3.
4.
Acyclovir therapy
Thalidomide therapy
Discontinue nevirapine
Discontinue trimethoprim
sulfamethoxazole
5. Discontinue nelfinavir
Human herpes virus 8 has been most
convincingly implicated in which of the
following:
1.
2.
3.
4.
5.
Hepatocellular carcinoma
CNS lymphoma
Castleman's disease
Acute myelocytic leukemia
Hypernephroma
Which of the following drugs shows the best
penetration across the blood-brain barrier?
1.
2.
3.
4.
5.
Zidovudine (AZT).
Stavudine (d4T)
Lamivudine (3TC)
Didanosine (ddI)
Zalcitabine (ddC)
With the exception of
abacavir, AZT shows the
best penetration of the
NRTIs across the bloodbrain barrier with CSF
levels that are
approximately 60% of
serum levels (Lancet
1998; 351: 1547).
A 25-year-old HIV-infected man presents to your office with
severe herpes proctitis. The patient has been treated with
acyclovir, 200 mg five times daily for six weeks without
improvement in the lesions. On repeat culture of the rectum,
herpes simplex virus 2 is again isolated and further testing
reveals that this is a thymidine kinase-deficient strain. Which
is the preferred treatment option for this condition?
1.
2.
3.
4.
5.
Foscarnet
Vidarabine
Ganciclovir
Valacyclovir
Famciclovir
A 43-year-old man with AIDS presents with a four-week
history of ataxia, progressive right hand weakness, and tremor.
Physical examination confirms his symptoms. His CD4 cell
count is 56/mm3, and serum antitoxoplasma IgG antibody titer
was negative one year ago. An MRI of the head reveals a
solitary 2 x 4 cm lesion in the left cerebellar hemisphere
which gives a high signal intensity on T2-weighted images but
does not enhance with gadolinium. No mass effect is
demonstrated. The most likely diagnosis is:
1.
2.
3.
4.
5.
Toxoplasmosis
A fungal abscess
Primary CNS lymphoma
Progressive multifocal leukoencephalopathy (PML)
A mycobacterial abscess
Which of the following best predicts long-term HIV
suppression?
1. The nadir of plasma HIV RNA levels following treatment
2. Treatment in relatively early stage disease as indicated by a
CD4 count >200/mm3
3. A relatively low plasma HIV RNA level at the time
antiretroviral therapy is initiated
4. Absence of an AIDS-defining opportunistic infection
5. Use of a regimen that contains 2 protease inhibitors
Which of the following is least likely to cause peripheral
neuropathy?
1.
2.
3.
4.
5.
Lamivudine (3TC)
Stavudine (d4T)
Didanosine (ddI)
Zalcitabine (ddC)
Zidovdine (AZT)
Which of the following statements is correct
about cryptococcosis in patients with AIDS.
a. 70 percent of patients present with respiratory
symptoms
b. Sequestered infection within the prostate is
implicated as the cause of relapse in men
c. Photophobia and neck stiffness occur in the majority
of patients with cryptococcal meningitis
d. A neurotoxin elaborated by cryptococcus is
responsible for the neurological symptoms of
cryptococcosis
e. The onset of disease is rapid
Which of the following statements is correct
about cryptococcosis in patients with AIDS.
a. 70 percent of patients present with respiratory
symptoms
b. Sequestered infection within the prostate is
implicated as the cause of relapse in men
c. Photophobia and neck stiffness occur in the majority
of patients with cryptococcal meningitis
d. A neurotoxin elaborated by cryptococcus is
responsible for the neurological symptoms of
cryptococcosis
e. The onset of disease is rapid