Transcript 2013 ABIM - American College of Physicians

Self-Evaluation Process
2013 Update in Infectious Disease
Module A6P Version 13-1
Confidential
Only for use at the ACP – South Dakota Learning
Session held September 12 – 13, 2013
WARNING: This Self-Evaluation Process (SEP) is copyrighted work under the Federal Copyright Act. It is a federal
criminal offense to copy or reproduce this work in any manner or to make adaptations of this work. It is also a crime
to knowingly assist someone else in the infringement of a copyrighted work. No part of this work may be reproduced
by any means or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or
otherwise) without the prior written permission of the American Board of Internal Medicine. The making of
adaptations from this work also is strictly forbidden. In addition to criminal penalties, the Copyright Act, 17
U.S.C.§§101, et seq., provides a number of remedies for the infringement of a copyright, including injunctive relief,
the award of statutory and actual damages, the award of attorney fees and costs, and confiscation and destruction of
infringing works and materials. It is the policy of the Board to strictly enforce its rights to this copyrighted work.
Question 1
A 28-year-old woman is three months pregnant. She is in good
health, but she has not had immunization for tetanus,
diphtheria, and pertussis (Tdap) since childhood. You plan to
provide immunization to family members who will have close
contact with the infant.
Question 1 - Question
Which of the following is the most appropriate Tdap
immunization schedule for the mother?
1. No immunization now, and Tdap immunization
within two weeks of delivery
2. Tdap immunization now
3. Tdap immunization when the mother is more than
20 weeks pregnant
4. Tetanus and diphtheria immunization now, and
pertussis immunization shortly after delivery
5. Tdap immunization after the mother has
discontinued breast feeding her infant
Question 1 - Responses
50%
43%
45%
40%
36%
35%
30%
25%
20%
15%
14%
10%
7%
5%
0%
0%
1
2
3
4
5
Question 1 - Answer
Which of the following is the most
appropriate Tdap immunization schedule
for the mother?
(2) Tdap immunization now
Epidemiology of Pertussis in the U.S.
http://www.cdc.gov/pertussis/surv-reporting.html, Accessed 7/23/13.
Summary of Tdap Vaccination Rationale
 Very young infants depend on maternal Ab
 In healthy adults, Ab levels:
• Peak 1 month after vaccination
• Wane significantly after 1 year
 Single dose insufficient for future pregnancies
 Modeling showed prevention of more infant
cases, hospitalization, and deaths during
pregnancy compared with post-partum
 No excess risk of adverse effects
 Vaccination ideal in 3rd trimester (27-36 weeks)
ACIP. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid,
and Acellular Pertussis Vaccine (Tdap) in Pregnant Women. MMWR 2013;62(07):131-135.
ACIP Recommendations for Pregnant Women
 Health-care personnel should administer a dose
of Tdap during each pregnancy, irrespective of
the patient's prior history of receiving Tdap
 Guidance for use:
• Optimal timing is between 27 and 36 weeks gestation
• Tdap may be given at any time during pregnancy
• For women not previously vaccinated with Tdap, if
Tdap is not administered during pregnancy, Tdap
should be administered immediately postpartum.
ACIP. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid,
and Acellular Pertussis Vaccine (Tdap) in Pregnant Women. MMWR 2013;62(07):131-135.
Question 2
A 23-year-old dental student comes to your clinic because he
has had fevers, chills, myalgias, and headache for four days.
He was evaluated at the student health clinic two days ago and
given ciprofloxacin, but his symptoms have not improved. The
patient returned two weeks ago from a two-week vacation with
his fiancee in Costa Rica. He spent time in both rural and urban
environments. He rafted, swam in fresh and salt water, and ate
food from street vendors. He took chloroquine for malaria
prevention and says he did not miss a dose. Before his trip, he
was immunized against hepatitis A virus and typhoid. Three
years ago, he was immunized for hepatitis B virus. Five years
ago, he traveled to Rwanda for several weeks to view the
mountain gorillas. The patient does not use tobacco, rarely
consumes alcoholic beverages, and is monogamous with his
fiancee.
Question 2 - continued
On physical examination, the patient appears acutely ill.
Temperature is 39.4 C (103.0 F), pulse rate is 115 per minute,
and blood pressure is 110/70 mm Hg. The conjunctivae are
mildly injected, but the lymph nodes are not enlarged, and no
nuchal rigidity is present. Findings of cardiopulmonary
examination are normal. The abdomen has no organ
enlargement or tenderness. Skin examination reveals an
erythematous, blanching rash on the trunk and thighs.
Laboratory studies:
Hemoglobin
13.5 g/dL [14-18]
Leukocyte count
9100/mcL [4000-11,000]; 76% [50-70]
neutrophils, 16% [30-45] lymphocytes,
5% [0-6] monocytes, 3% [0-3] eosinophils
(Laboratory studies continued on next slide)
Question 2 - continued
Laboratory studies (continued):
Platelet count
180,000/mcL [150,000-300,000]
Serum alkaline phosphatase
77 U/L [30-120]
Serum aminotransferases:
117 U/L [10-40]
AST
2.1 mg/dL [0.3-1.0]
ALT
51 U/L [10-40]
Serum total bilirubin
2.1 mg/dL [0.3-1.0]
Serum creatinine
1.3 mg/dL [0.7-1.5]
HIV
Negative
Dengue IgM
Negative
Thick smears for malaria (x3) Negative
Question 2 - Question
Which of the following is the best treatment for this
patient at this time?
1.
2.
3.
4.
5.
Substitute doxycycline for ciprofloxacin
Continue ciprofloxacin
Substitute levofloxacin for ciprofloxacin
Add vancomycin
Substitute ceftriaxone for ciprofloxacin
Question 2 - Responses
80%
70%
67%
60%
50%
40%
30%
22%
20%
10%
6%
6%
0%
0%
1
2
3
4
5
Question 2 - Answer
Which of the following is the best treatment for
this patient at this time?
(1)
Substitute doxycycline for ciprofloxacin
Leptospirosis: A Spirochete




Transmitted through urine of infected animals
Highest risk in rainy season / tropical areas
Frequent recreational water exposures
Acute septicemic phase (5-7 d.):
• Abrupt, high fever, conjunctival suffusion, headache,
chills, rigors, myalgia, abd pain, diarrhea
• Nonspecific lab abnormalities
 Immune phase (4-30 d.)
• Symptoms similar to acute phase
• Multi-organ involvement – hepatic & renal
dysfunction, thrombocytopenia
Leptospirosis
Doxycycline is treatment of choice
Levett PN. Leptospirosis. Clin Microbiol Rev. 2001;14:296-326.
Typhoid Fever
 Fecal contamination of
food and water
 Fever, abd pain, rash,
relative bradycardia
 Labs: cytopenias, DIC,
elevated CK and LFTs
 Late: intestinal perf,
peritonitis, shock
 Ciprofloxacin, azithro,
or ceftriaxone
Rose Spots: ~ 30% of patients
have faint salmon-colored
maculopapular rash on the trunk
at the end of 1st week. Typically
resolves after 2 to 5 days.
Newton AE and Mintz E. CDC Yellow Book. http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter3-infectious-diseases-related-to-travel/typhoid-and-paratyphoid-fever, Accessed 8/8/13.
Question 3
A 60-year-old lawyer visited Victoria Falls when he was vacationing
in South Africa. While he was at the falls, a number of macaques
were in the vicinity. The patient was eating a mango, and one of
the monkeys, in an attempt to steal the fruit, attacked and bit his
arm in several places. The patient cleaned the wounds with
hydrogen peroxide, applied an antibacterial ointment, and began
taking azithromycin. On the advice of his colleagues, he took the
first available flight back to the United States. He was waiting for
you when your office opened at 8:00 AM, approximately 36 hours
after he was bitten by the macaque. Before his departure for South
Africa, the patient had received immunization for hepatitis A virus;
combined tetanus, diphtheria, and pertussis; and typhoid. He also
has been taking mefloquine for malaria prophylaxis. The patient's
medical history includes no significant diseases.
Question 3 - Question
On physical examination, the patient appears mildly anxious.
Temperature is 36.1 C (97.9 F), pulse rate is 84 per minute,
and blood pressure is 135/84 mm Hg. The left upper arm has
multiple scabbed-over scratches and bite marks. The lesions
are minimally inflamed. The remainder of the examination
reveals no abnormalities. You decide to administer rabies
prophylaxis.
Which of the following is the most appropriate additional
postexposure prophylaxis for this patient?
1.
2.
3.
4.
One dose of ceftriaxone and completion of a five-day course of azithromycin
Discontinuation of azithromycin and initiation of a five- day course of
amoxicillin-clavulanate
Valacyclovir, every eight hours for two weeks
No additional treatment
Question 3 – Responses
60%
53%
50%
40%
30%
26%
20%
11%
11%
10%
0%
1
2
3
4
Question 3 - Answer
On physical examination, the patient appears mildly anxious.
Temperature is 36.1 C (97.9 F), pulse rate is 84 per minute, and
blood pressure is 135/84 mm Hg. The left upper arm has multiple
scabbed-over scratches and bite marks. The lesions are minimally
inflamed. The remainder of the examination reveals no
abnormalities. You decide to administer rabies prophylaxis.
Which of the following is the most appropriate additional
postexposure prophylaxis for this patient?
(3)
Valacyclovir, every eight hours for two weeks
Macaques and B Virus
 Genus of Old World monkeys native to Asia and
Northern Africa, but found worldwide in research
facilities, zoos, parks, etc.
 B virus is an alphaherpesvirus commonly found
in macaques  minimal to no symptoms
 In humans, B virus
• Rapidly ascending encephalomyelitis
• 80% case fatality rate
 Veterinarians and lab workers at greatest risk
due to frequent bites, scratches, needle sticks
Cohen J, et al. Recommendations for prevention of and therapy for exposure to B virus. Clin Infect
Dis 2002 35:1191–203.
Management of Monkey Bites
 Wound care
• Vigorous flushing of the wound with water
• Consideration for use of iodine, chlorhexidine, or
0.25% hypochlorite solution (Dakin’s) for viral
inactivation
 Assess
•
•
•
•
Type of monkey – Old World monkey / macaque?
Timeliness and adequacy of first aid
Type of exposure, location, and depth
Type of source material (saliva, tissue, etc.)
Cohen J, et al. Recommendations for prevention of and therapy for exposure to B virus. Clin Infect
Dis 2002 35:1191–203.
Post-Exposure Prophylaxis Recommendations





Exposure to high-risk source (sick monkey)
Inadequately cleaned wound
Laceration of the head, neck, or torso
Deep puncture bite
Needlestick associated with CNS fluid/tissue or
from suspicious lesions
 Valacyclovir 1g po q8 hrs for 14 days
 Acyclovir 800 mg po 5 times/day for 14 days
Cohen J, et al. Recommendations for prevention of and therapy for exposure to B virus. Clin Infect
Dis 2002 35:1191–203.
Question 4 - Question
HIV-2, a lentivirus in the same genus as HIV-1, has a
number of clinically significant differences that must be
recognized by a clinician in order to provide proper
care for a patient infected with HIV-2.
In which of the following features does HIV-2 differ
from HIV-1?
1. HIV-2 is often missed on a standard HIV ELISA
screening test
2. Efavirenz is predictably ineffective against HIV-2
3. Approximately 20% of individuals infected with
HIV-2 are long-term nonprogressors
4. HIV-2 is more easily transmissible than HIV-1
Question 4 – Responses
45%
40%
40%
35%
30%
25%
25%
25%
20%
15%
10%
10%
5%
0%
1
2
3
4
Question 4 - Answer
HIV-2, a lentivirus in the same genus as HIV-1, has a
number of clinically significant differences that must be
recognized by a clinician in order to provide proper care
for a patient infected with HIV-2.
In which of the following features does HIV-2 differ from
HIV-1?
(2)
Efavirenz is predictably ineffective against HIV-2
HIV-2: The Basics
 Primarily found in West Africa and countries with
historical or socio-economic ties to W. Africa
 Estimated 1-2 million infected persons
 62 confirmed cases in U.S. since 2000 (although
actual numbers likely much higher)
 Same routes of infection as HIV-1, but some key
differences:
• Lower infectivity
• Longer asymptomatic phase
• Higher CD4 counts and lower viral loads
Campbell-Yesufu O and Gandhi R. Update on human immunodeficiency virus (HIV)-2 infection. Clin
Infect Dis 2011;52(6):780–787.
HIV-2 Testing
 Who to test:
• At risk sex partners or blood transfusions, non-sterile
injection, or needle sharing in endemic country
• OI suggestive of HIV with negative HIV-1 test
• Patients with indeterminate / unusual HIV-1 WB
 How to test:
• Current FDA-approved ELISAs detect both but do not
differentiate HIV-1 vs. HIV-2
• If suspicious or negative for HIV-1, obtain HIV-2
Western blot
• No commercially-available viral load assay
Campbell-Yesufu O and Gandhi R. Update on human immunodeficiency virus (HIV)-2 infection. Clin
Infect Dis 2011;52(6):780–787.
HIV-2 Treatment Pearls




Treat if symptomatic or CD4 < 350 cells/mm3
Consider treatment if CD4 < 500 cells/mm3
Genotyping not commercially available
Intrinsic resistance:
• 1st gen NNRTIs (efavirenz, delavirdine, nevirapine)
• Fusion inhibitor (enfuvirtide)
Ritonavir-boosted PI
NRTIs
Lopinavir / ritonavir
Tenofovir + emtricitabine or lamivudine
Darunavir / ritonavir
Zidovudine + lamivudine
Campbell-Yesufu O and Gandhi R. Update on human immunodeficiency virus (HIV)-2 infection. Clin
Infect Dis 2011;52(6):780–787.
Question 5
You are consulted in the case of a 25-year-old man who
received a kidney transplant six years ago for focal segmental
glomerular sclerosis. Since that time, he has been maintained
on a regimen of prednisone, tacrolimus, and mycophenolate
mofetil. His only additional medications are simvastatin and
one or two acetaminophen tablets daily for chronic headaches.
No liver abnormalities were observed after simvastatin had
been withheld for four months. The patient does not consume
alcohol. He has recently begun seeing a new primary care
physician, who found abnormalities in his serum transaminase
levels and referred him to you.
Question 5 - continued
In reviewing the patient's medical records, you found that for
the past four years he has had persistent transaminase
elevations in the range of 100-200 U/L [10-40]. Before that, his
transaminase levels were normal. You obtained laboratory
studies that showed that antibodies to HAV, HBV, and HCV
were negative; serum ceruloplasmin was normal; serum
alpha-1 antitrypsin quantitative testing was normal; and
antinuclear antibodies, antimitochondrial antibodies,
antismooth muscle antibody, and serum ferritin were normal.
Physical examination was unremarkable except for expected
surgical scars. An abdominal ultrasound scan showed mild
liver echogenicity of unknown significance, and a liver biopsy
revealed early bridging fibrosis.
Question 5 - Question
Which of the following tests is most likely to yield a
diagnosis for this patient's illness?
1.
2.
3.
4.
PCR testing for HCV
Urine drug screen
Serum acetaminophen levels
Antibody testing for HEV
Question 5 - Responses
70%
60%
60%
50%
40%
30%
30%
20%
10%
10%
0%
0%
1
2
3
4
Question 5 - Answer
Which of the following tests is most likely
to yield a diagnosis for this patient's
illness?
(1) PCR testing for HCV
Hepatitis C Testing
1. Anti-HCV immunoassay: screening & diagnosis
2. Quantitative HCV RNA: (+) anti-HCV, antiviral
treatment considered, or unexplained liver
disease in immunocompromised patients with
(-) anti-HCV
Anti-HCV
HCV RNA
Interpretation
Positive
Positive
Acute or chronic HCV depending on clinical context
Positive
Negative
Resolution of HCV; acute HCV during period of low viremia
Negative
Positive
Early acute HCV; chronic HCV in setting of
immunosuppression; false positive HCV RNA test
Negative
Negative
Absence of HCV infection
Ghany M, et al. Diagnosis, management and treatment of hepatitis C: an update. Hepatol
2009:49(4):335-1374.
Updated Hepatitis C Screening








Persons born from 1945 through 1965
IVDU
Recipients of clotting factors (pre-1987)
Recipients of blood or SOT (pre-1992)
Long-term hemodialysis
Known exposure to HCV
HIV infection
Signs or symptoms of liver disease
http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm, Accessed 7/26/13.
Chou E, et al. Screening for Hepatitis C Virus Infection in Adults: A Systematic Review for the U.S.
Preventive Services Task Force. Ann Intern Med 2013;158:101-108.
Hepatitis E: Acute Hepatitis
 Fecal-oral route & blood
 Endemic in parts of Asia
and Africa
 >3,000,000 symptomatic
cases and 70,000 deaths
worldwide / year
 Non-specific symptoms
 Pregnant women and preexisting liver disease at
highest risk of liver failure
Wedemeyer H, Pischke S, Manns M. Pathogenesis and treatment of hepatitis E infection.
Gastroenterol 2012;142:1388-1397.
Question 6
An outbreak of active cases of tuberculosis (TB) with the same
genotypic pattern occurred in individuals who had slept
overnight in a shelter for homeless men over the course of four
years. A study is planned to ascertain information such as time
spent at the shelter and time spent at other local venues to
determine further risk factors for acquisition of TB.
© 2013 ABIM
Question 6 - Question
Which of the following is the most appropriate
method for determining other potential risk factors
for acquisition of TB during the time of the
outbreak?
1. A case-control study comparing men who had
acquired active TB with those who had not
2. A case-control study comparing men who had
acquired active TB with those who had not
acquired either active or latent TB
3. A cohort study including all the men who had lived
at the shelter during the four-year outbreak period
4. A case series of men who were found to have
active TB
Question 6 - Responses
60%
48%
50%
38%
40%
30%
20%
10%
10%
5%
0%
1
2
3
4
Question 6 - Answer
Which of the following is the most appropriate method
for determining other potential risk factors for
acquisition of TB during the time of the outbreak?
(1) A case-control study comparing men who had
acquired active TB with those who had not
Did the researchers
assign patients to
an intervention or
exposure?
No
Yes
Observational
Study: Did the study
have a comparison
group?
Experimental Study:
Were the patients
randomly assigned
to groups?
No
Yes
Analytical Studies
Exposure assessed
before outcome –
Cohort Study
Descriptive Studies
Outcome assessed
before exposure –
Case-Control Study
Randomized Trial
Exposure and
outcome assessed
concurrently –
Cross-Sectional
Study
Lang TA and Secic M. (2006.) How to report statistics in medicine (2nd ed.). Philadelphia, PA:
American College of Physicians.
Non-Randomized
Trial
Analytical Study Pearls
 Cohort Study
• Track people forward in time, from exposure to
outcome to determine risks for developing a specific
outcome (prospective or retrospective)
• Can be prospective or retrospective
 Case-Control Study
• Identify people from the same population with and
without the outcome of interest and compare
exposure
• Best for rare conditions; commonly used for
outbreaks
Question 7
A 24-year-old woman was evaluated in the emergency department
after a witnessed generalized tonic-clonic seizure. Her husband
reported that two weeks earlier she had become increasingly
anxious, expressing paranoid thoughts that he attributed to workrelated stress. During the previous week, she had suffered
headaches, and her behavior had been peculiar. Her medical
history was insignificant and included no psychiatric evaluation.
She was taking no regular medications, did not abuse alcohol, and
took no recreational drugs. The patient was treated in the
emergency department with levetiracetam and lorazepam, without
further seizure activity.
On physical examination, temperature was 37.4 C (99.4 F), pulse
rate fluctuated from 80 to 120 per minute, respirations were 22 per
minute, and blood pressure ranged from 90/60 mm Hg to 130/70
mm Hg. The neck was supple, and the skin had no rash. Although
the patient was alert, she had difficulty finding words and was
apparently hallucinating. Intermittent choreiform
movements were noted.
© 2013 ABIM
Question 7 - continued
Laboratory studies:
Antinuclear antibodies
Negative
Complete blood count
Normal
Serum chemistries
Normal
Toxicology screen
Negative
Rapid HIV assay
Negative
Lumbar puncture:
Cell count
22 WBCs, with 98% [30-45]
lymphocytes, and 2 RBCs
[0-5 mononuclear cells]
Glucose
77 mg/dL [50-75]
Total protein
25 mg/dL [14-45]
Question 7 - Question
CT scan of the head was normal. Magnetic resonance imaging
of the head revealed a mildly increased cortical and subcortical
signal on FLAIR (fluid attenuated inversion recovery) sequences.
The patient was treated with intravenous acyclovir, 10 mg/kg
every eight hours, without improvement. A negative PCR of
herpes simplex virus was returned from the laboratory.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
5.
N-methyl-D-aspartate receptor encephalitis
West Nile encephalitis
Herpes simplex virus-1 encephalitis
Lyme disease
Enteroviral encephalitis
Question 7 - Responses
60%
55%
50%
40%
30%
20%
15%
15%
10%
10%
5%
0%
1
2
3
4
5
Question 7 - Answer
CT scan of the head was normal. Magnetic resonance
imaging of the head revealed a mildly increased cortical and
subcortical signal on FLAIR (fluid attenuated inversion
recovery) sequences.
The patient was treated with intravenous acyclovir, 10 mg/kg
every eight hours, without improvement. A negative PCR of
herpes simplex virus was returned from the laboratory.
Which of the following is the most likely diagnosis?
(1)
N-methyl-D-aspartate receptor encephalitis
Anti-NMDA Receptor Encephalitis
 Most common in young females
 Prodromal phase (5-14 days): non-specific flulike illness (70%)
 Psychotic / seizure phase:
• Emotional and behavioral disturbances
• Ataxia and choreiform movements
• Seizures
 Unresponsive phase
 Hyperkinetic phase: autonomic instability,
dyskinesias, motor automatisms
Peery H, et al. Anti-NMDA receptor encephalitis: the disorder, the diagnosis and the
immunobiology. Autoimmun Rev 2012;11:863-872.
Anti-NMDA Receptor Encephalitis
 Associated with teratomas and other neoplasms
 MRI shows non-specific cortical and subcortical
abnormalities in ~50%
 CSF shows lymphocytic pleocytosis
 Diagnosis: detection of antibodies to NR1
subunit of the NMDAR in serum or CSF (usually
positive at presentation)
 Treatment: high-dose corticosteroids, IVIG, antiinflammatory agents, plasma exchange and
monoclonal antibodies (e.g., rituximab)
Peery H, et al. Anti-NMDA receptor encephalitis: the disorder, the diagnosis and the
immunobiology. Autoimmun Rev 2012;11:863-872.
Question 8 - Question
For which of the following patients is postexposure
varicella immune globulin recommended?
1. An immunocompetent individual who has never had
varicella or varicella vaccine, with close exposure within
the past 24 hours to a person with active chickenpox
2. An immunocompromised individual who has never had
varicella or varicella vaccine, with close exposure one
week ago to a person with active chickenpox
3. A pregnant woman who has never had varicella or
varicella vaccine, with a history of shingles four years
ago and exposure 24 hours ago to a person with active
chickenpox
Question 8 - Responses
60%
48%
50%
40%
38%
30%
20%
14%
10%
0%
1
2
3
Question 8 - Answer
For which of the following patients is postexposure
varicella immune globulin recommended?
(2) An immunocompromised individual who has
never had varicella or varicella vaccine, with
close exposure one week ago to a person with
active chickenpox
Assessing Immunity to Varicella
 Documentation of age-appropriate vaccination
 Laboratory evidence of immunity or laboratory
confirmation of disease
 Birth in U.S. pre-1980 (except HCWs, pregnant
women, and immunocompromised persons)
 Diagnosis or verification of a history of varicella
or herpes zoster by a health care provider
http://www.cdc.gov/chickenpox/hcp/immunity.html, Accessed 7/28/13.
VariZig™
 Lyophilized human immune globulin product
 Reconstitutes to 5% IgG and can be given IM
 Obtain through expanded access IND program
(FFF Enterprises, Temecula, CA)
 Administer asap and within 10 d. of exposure to:
• Immunocompromised patients
• Neonates whose mothers have peri-partum VZV
• Premature infants >28 weeks with exposure or <28
weeks regardless
• Pregnant women
CDC. A new product (VariZIG™) for postexposure prophylaxis of varicella available under an
investigational new drug application expanded access protocol. MMWR 2006;55(08)209-210.
CDC. Update recommendations for use of VariZig – United States, 2013. MMWR 2013;62(28):574-576.
Question 9 - Question
During an annual screening for tuberculosis, a 30-year-old
nurse is newly found to have a positive response to a
tuberculin test. She is initially reluctant to undergo treatment
for latent tuberculosis, but she agrees to accept therapy if you
can provide a regimen that uses a minimum number of doses
over the shortest possible time.
Which of the following treatment regimens for latent
tuberculosis is most appropriate for this patient?
1.
2.
3.
4.
5.
Isoniazid
Rifampin
Rifampin and pyrazinamide
Isoniazid and rifapentine
Azithromycin
Question 9 - Responses
45%
40%
40%
40%
35%
30%
25%
20%
15%
15%
10%
5%
5%
0%
0%
1
2
3
4
5
Question 9 - Answer
During an annual screening for tuberculosis, a 30-year-old
nurse is newly found to have a positive response to a
tuberculin test. She is initially reluctant to undergo treatment for
latent tuberculosis, but she agrees to accept therapy if you can
provide a regimen that uses a minimum number of doses over
the shortest possible time.
Which of the following treatment regimens for latent
tuberculosis is most appropriate for this patient?
(4) Isoniazid and rifapentine
LTBI Treatment Recommendations
Drug/Dose
Frequency/Duration
Preferred:
INH 5 mg/kg daily (Max 300
mg daily)
Daily x 9 months (270 doses)
Alternate:
INH 15 mg/kg
Twice weekly x 9 months (DOT - 76 doses)
INH 5 mg/kg
Daily x 6 months (180 doses)
INH 15 mg/kg
Twice weekly x 6 months (DOT - 52 doses)
Rifampin 10 mg/kg
Daily x 4 months (120 doses)
Rifampin/PZA not acceptable due to the risk of hepatoxicity.
CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(6).
CDC. Update: adverse event data and revised ATS/CDC recommendations against the use of
rifampin and pyrazinamide for treatment of latent tuberculosis. MMWR 2003;52:735-9.
Newest LTBI Regimen
 Shortened treatment course to reduce risk of
adverse effects / cost and increase adherence
 Weekly rifapentine and INH effective in
treatment for low bacillary burden, so it was
reasoned that these would be effective for LTBI
 PREVENT TB Trial:
• Comparable rates of TB development (0.19% in INHRPT vs 0.43% with monotherapy)
• Improved treatment completion (82% vs. 69%)
• Lower rates of hepatotoxicity (0.4% vs 2.7%)
Sterling TR, et al. Three months of rifapentine and isoniazid for latent tuberculosis infection N Eng J
Med 2011;365;23:2155-2166.
INH-Rifapentine in Practice
 Healthy patients ≥ 12 years old
 NOT in HIV on HAART, pregnancy, or presumed
INH/rif resistance
 Needs to be given via DOT
 Isoniazid: 15 mg/kg (900 mg max) po weekly
 Rifapentine 900 mg po weekly (if ≥ 50.0 kg)
CDC. Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat
latent Mycobacterium tuberculosis infection. MMWR Dec 9 2011;60(48).
Question 10
You are seeing a 24-year-old man who has had a cochlear
implant for three years. He also has had well-controlled insulindependent diabetes mellitus for ten years. A hemoglobin A1C
value from two months ago was 5.4% [4.0-6.1]. Shortly after
he was found to have diabetes mellitus, he received the
pneumococcal 23-valent polysaccharide vaccine (PPS23). At
age 17, before attending college, he was immunized for
meningococcus; combined tetanus, diphtheria, and pertussis
(Tdap); measles, mumps, and rubella; and human
papillomavirus.
© 2013 ABIM
Question 10 - Question
Which of the following is the most appropriate
immunization strategy for this patient now?
1.
2.
3.
4.
Give a combined Tdap vaccine booster
Give a meningococcal vaccine booster
Give a booster dose of the PPS23 vaccine
Give the 13-valent pneumococcal conjugate
vaccine (PCV13)
5. No additional immunizations are indicated at
this time
Question 10 - Responses
45%
40%
40%
40%
4
5
35%
30%
25%
20%
15%
10%
10%
5%
5%
5%
2
3
0%
1
Question 10 - Answer
Which of the following is the most appropriate
immunization strategy for this patient now?
(4) Give the 13-valent pneumococcal
conjugate vaccine (PCV13)
Prevention of Meningitis in Cochlear Implants
 Higher risk of intracranial extension of infection
• 2 months post-op is period of highest risk
• Risk varies and cases have been reported years later
 Vaccine recommendations
• S. pneumoniae
• H. influenzae type b
• N. meningitidis
 Vaccinate at least 2 weeks prior to surgery
 Patient education regarding early warning signs
of otitis media and meningitis
http://www.cdc.gov/vaccines//vpd-vac/mening/cochlear/dis-cochlear-gen.htm, Accessed 8/7/13.
Pneumococcal Vaccine Choices
 Pneumococcal polysaccharide (PPSV23)
• Consists of capsular material from 23 pneumococcal
types (cause 85-90% of disease)
 Pneumococcal conjugate (PCV13)
• Consists of capsular polysaccharide antigens from
the 13 most common types that cause disease in
children, covalently linked to a non-toxic protein that
is nearly identical to diphtheria toxin
• Enhanced immunogenicity in immunocompromised
adults compared to polysaccharide vaccine
• Ongoing studies to determine if effective and
necessary for healthy adults
ACIP Recommendations for Adults
 No prior vaccination and immunocompromised,
asplenic, CSF leak, or cochlear implant
• PCV13 & PPSV23 8 wks later
• Subsequent doses of PPSV23 per guidelines
 Prior PPSV23 plus above conditions
• PCV13 ≥ 1 year after PPSV23
• Continue with same schedule if additional PPSV 23
doses required
 When indicated, PCV13 should be administered
to patients with unknown vaccination histories
http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html, Accessed 8/7/13.
Question 11
A 35-year-old man comes to the emergency department and
reports that he has had cough, dyspnea on exertion, and fever
for two weeks. He has no medical history, and he has not
traveled or had sick contacts.
The patient appears well developed and well nourished.
Temperature is 38.9 C (102.0 F), pulse rate is 105 per minute,
respirations are 22 per minute, and blood pressure is 110/70
mm Hg. Oxygenation on room air by pulse oximetry is 95% at
rest. Thrush is not present, but shotty enlargement of the
anterior cervical lymph nodes is noted. Faint crackles are
heard in both lungs. The heart has regular S1 and S2. The
abdomen is nontender, and liver and spleen are not enlarged.
The skin has no rash, and the arms and legs have no edema.
Neurologic evaluation reveals no abnormalities.
© 2013 ABIM
Question 11 - Question
Complete blood count and serum chemistries are normal. A
rapid HIV test in the emergency department confirms HIV
infection. Posteroanterior and lateral chest radiographs are
normal. Sputum induction is performed for cytology.
Given this patient's clinical presentation, which of the following
diagnostic tests is most likely to provide the correct diagnosis?
1.
2.
3.
4.
Serum lactate dehydrogenase
Serum 1-3-beta-D-glucan
Serum galactomannan
Serum interferon-gamma release (QuantiFERON-TB
Gold) assay
© 2013 ABIM
Question 11 - Responses
30%
25%
28%
28%
22%
22%
20%
15%
10%
5%
0%
1
2
3
4
Question 11 - Answer
Given this patient's clinical presentation, which of the
following diagnostic tests is most likely to provide the
correct diagnosis?
(2)
Serum 1-3-beta-D-glucan
© 2013 ABIM
1,3-Beta-D-Glucan
 Component of fungal cell wall
 Marker of invasive fungal infection
 Test characteristics vary based on fungal
pathogen and population tested
 For PCP
• HIV-infected patients with PCP had higher median
beta-D-glucan levels than those without (408 pg/mL
vs. 37 pg/mL)
• 92% sensitive and 65% specific
• Best used when pre-test probability is high
Sax PE, et al. Blood (1,3)-beta-D-glucan as a diagnostic test for HIV-related pneumocystis jirovecii
pneumonia. Clin Infect Dis 2011; 53:197.
Question 12
A 46-year-old man who had a fever and elevated serum
transaminases four months ago was found to have acute HCV
infection. He also had HIV infection, which was well controlled
on an antiretroviral regimen of tenofovir, emtricitabine, and
ritonavir-boosted darunavir. His CD4 lymphocyte count was
280/mcL [530-1570], and his viral load was less than 20
copies/mL [less than 400].
The patient's symptoms have now resolved. Serum aspartate
aminotransferase is 62 U/L [10-40] and serum alanine
aminotransferase is 55 U/L [10-40]. A qualitative PCR assay is
positive. The patient has HCV genotype 2 and interleukin-28B
genotype T/C. He has refrained from consumption of all
alcoholic beverages because he is concerned about the
additional risk factor for cirrhosis as a consequence of his HIV
infection.
© 2013 ABIM
Question 12 - Question
Which of the following is the best recommendation
for this patient now?
1. No treatment for his HCV infection, and no change
in his antiretroviral regimen
2. Peginterferon, ribavirin, and no change in his
antiretroviral regimen
3. Peginterferon, ribavirin, boceprevir, and
discontinuation of his antiretroviral regimen
4. Peginterferon, ribavirin, telaprevir, and substitution
of atazanavir for darunavir
5. Deferral of treatment until a liver biopsy shows
evidence of fibrosis
Question 12 - Responses
40%
37%
37%
35%
30%
25%
20%
15%
11%
11%
10%
5%
5%
0%
1
2
3
4
5
Question 12 - Answer
Which of the following is the best recommendation
for this patient now?
(2) Peginterferon, ribavirin, and no change in
his antiretroviral regimen
HCV and HIV: Treatment Pearls
 HCV genotype 1
• Treatment risks weighed with degree of fibrosis
• Peginterferon, ribavirin, and boceprevir or telaprevir
• Significant interactions between HCV PIs and HIV
PIs, NNRTIs, and tenofovir
 HCV genotype 2 and 3
• Consider peginterferon and ribavirin regardless of
stage of fibrosis
• Eradication rates high (>60%)
• HIV is risk for progressive liver disease
http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf, Accessed 8/8/13.
ART and Ribavirin Interactions
 Atazanavir + ribavirin  increase in bilirubin
• Increased ribavirin hemolysis
• Decreased clearance of bilirubin due to atazanavir
 Didanosine + ribavirin  mitochondrial toxicity
 Zidovudine + ribavirin  anemia
http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf, Accessed 8/8/13.
Question 13 = Question
Which of the following is the best use of malaria
rapid diagnostic testing (MRDT)?
1. The titer of MRDT can be used to quantify the
percent parasitemia in an infected patient
2. MRDTs are less sensitive than microscopy, but do
not require microscopic expertise
3. MRDTs should not be used to monitor the outcome
of therapy
4. MRDTs use PCR techniques to identify malarial
proteins
5. MRDTs are very specific for Plasmodium
falciparum but less specific for P. vivax
Question 13 - Responses
30%
26%
26%
25%
21%
21%
20%
15%
10%
5%
5%
0%
1
2
3
4
5
Question 13 - Answer
Which of the following is the best use of malaria
rapid diagnostic testing (MRDT)?
(2)
MRDTs are less sensitive than microscopy, but
do not require microscopic expertise
Rapid Malaria Diagnostics
 Test line: bound antibody
binds parasite antigen
 Control line: bound antibody
binds migrating labeled test
antibody
 Results in 12-15 min
 Use when microscopy not
available
 Requires microscopic
confirmation to determine %
parasitemia and species
http://www.cdc.gov/malaria/diagnosis_treatment/diagnosis.html, Accessed 8/8/13.
Question 14
A 36-year-old woman who immigrated to the United States
from Ethiopia comes to her primary care physician for
evaluation of a tender 2-cm ulcerating nodule at the base of her
left thumb. When she first noticed the lesion four days ago, it
was a smaller pink bump, which she thought might have been
a bug bite. She has had no fever and has otherwise been
comfortable. Her lymph nodes are not enlarged, and she has
no other lesions. She has no pets, has had no live animal
exposure, and is unaware of any rodent infestation in her
home. Ten days ago, she was preparing a lamb's head as part
of a specialty dish for a family gathering. She has had no
recent travel.
Question 14 - Question
Which of the following infections is most consistent
with this patient's history and clinical picture?
1.
2.
3.
4.
Orf
Anthrax
Monkeypox
Tularemia
© 2013 ABIM
Question 14 - Responses
70%
65%
60%
50%
40%
30%
20%
20%
15%
10%
0%
0%
1
2
3
4
Question 14 - Answer
Which of the following infections is most consistent
with this patient's history and clinical picture?
(1) Orf
© 2013 ABIM
Human Orf Virus Infection






Dermatotropic parapoxvirus in sheep and goats
Transmitted through contact with infected animal
3-7 d. incubation ulcerating nodule on hands
PCR for confirmation
Self-limited
Resolves in 4-8 weeks
CDC. Human Orf Virus Infection from Household Exposures — United States, 2009–2011. MMWR
April 13, 2012;61(14);245-248.
Picture Comparison
Anthrax: Cutaneous inoculation; localized
itching followed by papular lesion that turns
vesicular and subsequent development of
black eschar within 7–10 d. of initial lesion
Monkeypox: Flu-like illness and cervical
lymphadenopathy; synchronous evolution of
skin lesions from macules to papules to
vesicles and pustules; umbilication, crusting,
and desquamation follow.
http://emedicine.medscape.com/article/1134714-overview, Accessed 8/7/13.
http://emergency.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp, Accessed 8/7/13.
Picture Comparison
Tularemia: ulceroglandular form is most common  ulcer at site
of inoculation accompanied by swelling of regional lymph glands,
usually in the armpit or groin.
http://www.cdc.gov/tularemia/signssymptoms/, Accessed 8/7/13.
Question 15
A 31-year-old woman comes to your office because she has
had nasal and sinus drainage accompanied by fevers to 39.1 C
(102.3 F) for three days. Yesterday, she began to have rightsided maxillary pain and intermittent cough productive of light
yellow mucoid sputum. The patient is married and has two
young children. She reports that her second child has had a
cold for approximately one week. The patient has no
medication allergies.
On physical examination, temperature is 38.1 C (100.6 F),
pulse rate is 82 per minute, respirations are 16 per minute, and
blood pressure is 130/78 mmHg. Mild conjunctival injection and
right maxillary sinus tenderness are noted. Examination of the
throat reveals no ulcers or exudates. The chest is clear to
auscultation, and the lymph nodes are not enlarged.
Question 15 - Question
Based on a current treatment guideline of the
Infectious Disease Society of America, which of
the following is most appropriate for this patient
now?
1.
2.
3.
4.
5.
Amoxicillin
Clarithromycin
Trimethoprim-sulfamethoxazole
No treatment
Amoxicillin-clavulanate
Question 15 - Responses
80%
76%
70%
60%
50%
40%
30%
20%
14%
10%
10%
0%
1
0%
0%
2
3
4
5
Question 15 - Answer
Based on a current treatment guideline of the
Infectious Disease Society of America, which
of the following is most appropriate for this
patient now?
(4) No treatment
Acute Bacterial Rhinosinusitis
 S/S compatible with acute rhinosinusitis, lasting
for ≥10 days without any clinical improvement
 Severe S/S with high fever (≥ 39°C) and
purulent nasal discharge or facial pain lasting for
at least 3–4 d. at the beginning of illness
 Worsening S/S characterized by the new onset
of fever, headache, or increase in nasal
discharge following a typical viral URI that lasted
5–6 d. and were improving (‘‘doublesickening’’)
Chow AW, et al. IDSA Clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis 2012;54(8):e72-e112.
Empiric Antibiotic Treatment
 Standard dose amoxicillin-clavulanate
• ~1/3 of H. influenzae isolates produce β-lactamase
• M. cattarhalis almost uniformly amoxicillin resistant
 High-dose amoxicillin-clavulanate (2 g po bid)
• Endemic (>10%) PCN-non-susceptible
pneumococcus, severe disease, age >65, recent
hospitalization, antibiotic use in past 1 month, or
immunocompromised state
Chow AW, et al. IDSA Clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis 2012;54(8):e72-e112.
Alternative Regimens
 Recommended alternatives:
• Doxycycline
• Levofloxacin or moxifloxacin (not cipro)
 Oral 3rd generation cephalosporin plus
clindamycin could be used in some situations
 NOT recommended
• Macrolides (~30% S. pneumo resistance)
• TMP-sulfa (~30-40% S. pneumo & H. flu resistance)
• 2nd or 3rd generation cephalosporin monotherapy
(variable rates of S. pneumo resistance)
Chow AW, et al. IDSA Clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis 2012;54(8):e72-e112.
Question 16
A 30-year-old Hispanic woman is examined because she has
had fatigue, jaundice, dark urine, and pain in her right upper
abdomen for two weeks. The patient is married, has two
children, and works as a maid in a motel. She drinks two or
three bottles of beer daily and has no history of illicit drug use.
She has not traveled outside the United States during the past
year, and she has had no contact with pets, farm animals, or
wild animals.
Temperature is 37.1 C (98.8 F), pulse rate is 88 per minute,
respirations are 18 per minute, and blood pressure is 118/70
mm Hg. The sclerae are icteric. No oral ulcers are present.
Cardiopulmonary examination reveals that the chest is clear to
auscultation, and the heart has no murmur or gallop.
Tenderness but no guarding is present in the right upper
abdomen. She has no genital ulcers, rash, or lymph node
enlargement.
Question 16 - continued
Laboratory studies:
Hematocrit
Leukocyte count
Platelet count
Serum alkaline
phosphatase
Serum aminotransferases:
ALT
AST
38% [37-47]
5200/mcL [4000-11,000]; 62%
[50-70] neutrophils, 32% [3045] lymphocytes, 6% [0-6]
monocytes
124,000/mcL [150,000-300,000]
320 U/L [30-120]
1268 U/L [10-40]
980 U/L [10-40]
(Laboratory studies continued on next page)
Question 16 - continued
Laboratory studies (continued)
Antimicrosomal antibody
Negative
Antinuclear antibodies
Negative
Serum total bilirubin
19.9 mg/dL [0.3-1.0]
Antibody to HBV
Antibody to HCV
HCV RNA
Urinalysis
Negative
Negative
Negative
No RBCs, 3 WBCs/hpf
Question 16 - Question
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
5.
Leptospirosis
HGV infection
HEV infection
Brucellosis
CMV infection
Question 16 - Responses
35%
29%
30%
25%
24%
24%
20%
18%
15%
10%
6%
5%
0%
1
2
3
4
5
Question 16 - Answer
Which of the following is the most likely diagnosis?
(1) Leptospirosis
Question 16 - continued
1. Leptospirosis: mild to moderate elevation of
transaminase, high bilirubin
2. HGV: rarely diagnosed, doesn’t cause hepatitis
3. HEV: feco-oral route, self limiting, fulminant in pregnant,
SE Asia, Africa, rare outside endemic areas
4. Brucellosis: zoonosis, sheep, cattle, meat processing
plants, consumption of soft cheese, unpasturized milk,
fever with profouse night sweats
5. CMV: mono like illness, lymphocytosis, jaundice
uncommon, transaminitis. In IC pts fever & leukopenia,
hepatitis, pneumonitis, colitis, retinitis
Leptospirosis:
 Rat urine, outbreaks in triathlons, swimming,
waterskiing, canoeing, farmer, sewer worker
 Asymptomatic to severe (Weil’s syndrome)
 Anicteric: flu like illness, fever, chills, headache,
retro orbital headache, conjunctival suffusion,
aseptic meningitis
 Weil’s Syndrome (severe): jaundice, renal
failure, hemorrhagic diathesis,
Question 17 - Question
Which of the following is NOT a component of the
Surgical Care Improvement Project (SCIP) core
measure set to improve surgical outcomes?
1. Euglycemia at 6:00 AM on postoperative day 1
2. Preoperative hair removal by clippers rather than a
blade
3. Urinary catheter removal on postoperative day 1
4. Administration of nasal mupirocin for MRSA
colonization
5. Discontinuation of antibiotics within 24 hours of
surgery end time
6. Perioperative normothermia
Question 17 - Responses
60%
56%
50%
40%
30%
25%
20%
10%
6%
6%
6%
0%
0%
1
2
3
4
5
6
Question 17 - Answer
Which of the following is NOT a component of the
Surgical Care Improvement Project (SCIP) core
measure set to improve surgical outcomes?
(4) Administration of nasal mupirocin for MRSA
colonization
Question 18
A 55-year-old white man who was uninfected with HIV was
evaluated for HCV infection. His medical history did not include
jaundice, icterus, variceal bleeding, hepatic encephalopathy, or
ascites. Medications were hydrochlorothiazide for hypertension,
pravastatin for hypercholesterolemia, and sildenafil for erectile
dysfunction.
On physical examination, temperature was 36.7 C (98.0 F), pulse
rate was 70 per minute, respirations were 15 per minute, and
blood pressure was 125/89 mm Hg. Head, eyes, ears, nose, and
throat were normal. The lungs were clear, and the heart rate and
rhythm were normal, with regular S1 and S2 and no murmur, rub,
or gallop. Mild gynecomastia was noted. The abdomen was
nontender, with a firm liver spanning 15 cm and a palpable spleen
tip. No edema was detected. A few spider angiomata were seen
on the upper chest. No asterixis was present. HCV treatment was
begun with telaprevir, peginterferon, and weight-based ribavirin,
600 mg twice daily.
Question 18 - continued
At the patient's four-week follow-up visit, he reported mild
dyspnea, fatigue, and difficulty sleeping. An intensely pruritic
maculopapular rash was present on his back and chest. His
temperature was normal, and he had no mucous membrane
involvement. A decision was made to decrease his ribavirin
dosage to 600 mg daily.
Question 18 - continued
Selected laboratory studies from baseline through week 12 of
follow-up therapy:
Baseline
Week 4 Week 8
HCV viral load
(ng/mL)
4.3 million
(log 6.63)
Less
than 43
Undetectable Undetectable
Leukocyte count
(/mcL)
6300
[4000-11,000]
2400
2200
2100
ANC (/mcL)
3400
[2000-8250]
800
700
600
Hemoglobin
(g/dL)
15.2 [14-18]
10.0
10.1
10.3
Platelet count
(/mcL)
105,000
[150,000300,000]
50,000
47,000
42,000
(Laboratory studies continued on next slide)
Week 12
Question 18 - continued
Laboratory studies (continued):
Baseline
Week 4
Week 8
Week 12
AST (U/L)
57 [10-40]
25
28
26
ALT (U/L)
85 [10-40]
31
32
30
HCV genotype
1a
Serum
aminotransferases:
Question 18 – Question
Which of the following should this patient be told
during his follow-up regarding further clinical
monitoring and counseling?
1. Because his HCV viral load was unquantifiable at week
4, he can be treated with a six-month course of therapy
2. The likelihood of his responding to HCV therapy should
not be affected by the ribavirin dosage reduction
3. The rash is most likely due to telaprevir therapy, which
should be discontinued immediately; peginterferon and
ribavirin should be continued
4. Because he is infected with HCV genotype 1a, he is
more likely to respond to telaprevir-based therapy than
if he were infected with HCV genotype 1b
© 2013 ABIM
Question 18 - Responses
45%
39%
40%
35%
28%
30%
25%
22%
20%
15%
11%
10%
5%
0%
1
2
3
4
Question 18 - Answer
Which of the following should this patient be told
during his follow-up regarding further clinical
monitoring and counseling?
(2) The likelihood of his responding to HCV
therapy should not be affected by the ribavirin
dosage reduction
© 2013 ABIM
Question 18 - continued
 A: RVR shorten therapy, Patients without
cirrhosis treated with telaprevir, peginterferon,
and ribavirin, whose HCV RNA level at weeks 4
and 12 is undetectable should be considered for
a shortened duration of therapy of 24 weeks
(Class 2a, Level A). Also the LLOQ not same as
UD, <25 PCR
 B.True
 C. Rash without systemic symptoms,less than
50% involved, first topical steroids, if persist or
worsen DC TPV, if persist/worsen DC all
 D. Telaprevir effective for genotype 1
Side effects
 Telaprevir: Rash
 Boceprevir: Fatigue, insomnia
 Ribavirin: hemolytic anemia, gout,
 Intereferon: cytopenia, depression
Question 19
A 63-year-old man is evaluated two days after receiving
diphtheria, pertussis, and tetanus vaccine. Swelling began to
develop in his arm 18 hours after he received the injection. The
swollen area now extends below the elbow to his mid-forearm.
His arm is slightly sore and has some slight itching, but he has
full range of motion (ROM) and is able to perform his daily
activities. He reports no fever or chills.
The patient appears well. Temperature is 37.4 C (99.4 F),
pulse rate is 78 per minute, respirations are 16 per minute, and
blood pressure is 130/76 mm Hg. The right upper arm, which is
almost twice the size of the left, is mildly erythematous but not
tender. The right forearm is less noticeably swollen. The
patient has full ROM of the shoulder and elbow and no pain in
these areas. No lymph node enlargement is present in the
axilla or the subclavian area.
Question 19 - Question
Based on the most likely diagnosis, which of the
following is best for this patient now?
(1) Cephalexin, 500 mg three times daily
(2) Diphenhydramine, 25 mg three times daily as
needed
(3) Prednisone, 20 mg daily for five days
(4) Reassurance
(5) Enoxaparin, 30 mg every 12 hours for one
month
Question 19 - Responses
90%
78%
80%
70%
60%
50%
40%
30%
22%
20%
10%
0%
0%
1
0%
2
3
0%
4
5
Question 19 - Answer
Based on the most likely diagnosis, which of the
following is best for this patient now?
(4) Reassurance
Question 19 - continued
 Reassurance often the right answer (cost
effective)
 Arthus-type reaction: post cutaneous reaction
with skin necrosis (precaution)
 Extensive limb swelling not an Arthus type
reaction
 Other adverse reactions: local reaction,fever,
syncope, rarely GBS
Question 20
Three months ago, a 47-year-old man came to your office
because a screening program at his athletic club revealed that
he had HIV infection. Initial laboratory studies showed a CD4
lymphocyte count of 276/mcL [530-1570] and an HIV viral load
of 54,000 copies/mL [less than 400]. The patient also had
asthma and hypertension, which were well controlled with
inhaled fluticasone, lisinopril, and chlorthalidone. He said that
he felt well, and review of systems revealed no abnormalities.
His weight was stable, and his exercise capacity at the gym
was excellent. Findings of physical examination were normal.
After a discussion with the patient, you prescribed an
antiretroviral regimen of tenofovir, emtricitabine, and boosted
atazanavir.
Question 20 - continued
At his one-month follow-up visit, the patient had gained 5 kg
(10 lb), and his blood pressure was 145/85 mm Hg. His CD4
lymphocyte count had increased to 312/mcL, and his HIV viral
load had decreased to 450 copies/mL. Now, at his three-month
follow-up visit, the patient reports increasing fatigue. He has
gained 11 kg (25 lb) over his baseline weight, and his blood
pressure has increased to 160/100 mm Hg. He claims that he
has been rigorously adherent to his medications. His CD4
lymphocyte count is 372/mcL, and his HIV viral load is
negligible. His plasma glucose, which was normal one year
ago, is 213 mg/dL [70-99].
Question 20 - Question
Which of the following would be the most appropriate
change in this patient's medical regimen?
1. Add a third antihypertensive medication to the patient's
regimen; structure a diet and weight-loss program
2. Substitute a beclomethasone inhaler for the fluticasone
inhaler
3. Substitute boosted lopinavir for boosted atazanavir
4. Substitute hydrochlorothiazide for chlorthalidone
Question 20 - Responses
70%
60%
60%
50%
40%
35%
30%
20%
10%
5%
0%
0%
1
2
3
4
Question 20 - Answer
Which of the following would be the most appropriate
change in this patient's medical regimen?
(2) Substitute a beclomethasone inhaler for
the fluticasone inhaler
Ritonavir and Fluticasone
 Ritonavir, a potent inhibitor of CYP3A4 enzyme,
can lead to high systemic concentrations of
fluticasone.
 Exogenous Cushing syndrome (CS) in HIVinfected patients receiving ritonavir and
fluticasone has been reported frequently in
adults but not in children
 Weight gain and altered fat distribution
concerning for either lipodystrophy or CS
ANTIRETROVIRAL THERAPY: HHS GUIDELINES
Initiating Antiretroviral Therapy in Treatment-Naïve Patients
Change in CD4 Threshold in HHS Guidelines
2013
2009
500
2007
350
200
2003
ANTIRETROVIRAL THERAPY: HHS GUIDELINES
HHS Antiretroviral Therapy Guidelines: February 2013
Preferred Regimens for ARV-Naïve Patients: Pill Burden
Class
Therapy
NNRTI-Based Efavirenz-Tenofovir-Emtricitabine
*AWP (Monthly)
$2081
Ritonavir + Atazanavir + Tenofovir-Emtricitabine
$2860
Darunavir + Ritonavir + Tenofovir-Emtricitabine
$2925
Raltegravir + Tenofovir-Emtricitabine
$2562
PI-Based
INSTI-Based
*AWP = average wholesale price
Source: 2012 HHS Antiretroviral Therapy Guidelines. AIDS Info (www.aidsinfo.nih.gov)
Question 21
A 25-year-old man who has sex with men comes to your office
to ask about receiving quadrivalent human papillomavirus
(HPV)4 vaccine. He tells you that he has learned about the
vaccine by reading newspaper articles on the subject. The
patient is not infected with HIV and has no co-morbidities. He
has been sexually active since age 17. He estimates his level
of sexual activity as "moderate" and adds that he "usually
practices safe sex."
Question 21 - Question
Which of the following is most important for this patient to
understand about the HPV4 vaccine?
1. Vaccination will reduce the risk for intraepithelial
neoplasia and condylomata
2. Vaccination is not indicated for men older than 21 years
of age
3. Vaccination can prevent only acquisition of new HPV
serotypes and is therefore unlikely to benefit a sexually
active man
4. Vaccination will reduce the risk of anogenital
condylomata but will offer no other benefit
5. Vaccination will eliminate the risk of anal cancer
© 2013 ABIM
Question 21 - Response
80%
70%
67%
60%
50%
40%
30%
22%
20%
10%
6%
6%
0%
0%
1
2
3
4
5
Question 21 - Answer
Which of the following is most important for this
patient to understand about the HPV4 vaccine?
(1) Vaccination will reduce the risk for
intraepithelial neoplasia and condylomata
© 2013 ABIM
Gardasil (Quadrivalent HPV vaccine )






HPV 6/11 (genital warts) & 16/18 (cancer)
Prevention of HPV related disease
Decrease transmission to female sex partners
Prevention of oral cancers
Vaccinate before sexual activity (9yr, 13-21 yrs)
For MSM up to 26 yrs if not previously
vaccinated
Question 22
A 22-year-old man who has epilepsy that has been well
controlled with phenytoin was recently found to have HIV
infection when he sought treatment for Pneumocystis
pneumonia. His pneumonia resolved after treatment with
trimethoprim-sulfamethoxazole, and he now follows up in your
office for initiation of antiretroviral therapy.
© 2013 ABIM
Question 22 - Question
Which of the following therapeutic options is most
appropriate for this patient now?
1. Initiate treatment with tenofovir, emtricitabine, and
boosted darunavir
2. Initiate treatment with tenofovir, emtricitabine, and
boosted darunavir; substitute levetiracetam for
phenytoin
3. Initiate treatment with tenofovir, emtricitabine, and
rilpivirine (Complera)
4. Initiate treatment with abacavir, lamivudine,and
efavirenz
© 2013 ABIM
Question 22 - Responses
80%
71%
70%
60%
50%
40%
30%
20%
10%
12%
12%
3
4
6%
0%
1
2
Question 22 - Answer
Which of the following therapeutic options is most
appropriate for this patient now?
(B) Initiate treatment with tenofovir, emtricitabine,
and boosted darunavir; substitute levetiracetam
for phenytoin
© 2013 ABIM
Anti-epileptics and ART
 Avoid carbamazepine, phenobarb and phenytoin
with NNRTI and PI
 Keppra with PI
 Avoid raltegravir and phenytoin/phenobarb
ANTIRETROVIRAL THERAPY: HHS GUIDELINES
HHS Antiretroviral Therapy Guidelines: February 2013
Preferred Regimens for ARV-Naïve Patients: Pill Burden
Class
Therapy
NNRTI-Based Efavirenz-Tenofovir-Emtricitabine
*AWP (Monthly)
$2081
Ritonavir + Atazanavir + Tenofovir-Emtricitabine
$2860
Darunavir + Ritonavir + Tenofovir-Emtricitabine
$2925
Raltegravir + Tenofovir-Emtricitabine
$2562
PI-Based
INSTI-Based
*AWP = average wholesale price
Source: 2012 HHS Antiretroviral Therapy Guidelines. AIDS Info (www.aidsinfo.nih.gov)
Question 23
A 32-year-old woman from Senegal who is 16 weeks pregnant
(gravida 1, para 1) is told at her second prenatal visit that she has
HBV infection. She has had no icterus and has no recollection of
other symptomatic infection. She is sexually active with her
husband, who is her sole lifetime sexual partner. She has no
history of blood transfusions, hospitalizations, or intravenous drug
use, and she did not undergo any type of female circumcision as a
child.
The patient appears healthy and in no apparent distress. Vital
signs are normal. Findings of the abdominal examination are
normal, with no organ enlargement and a 16-cm gravid uterus.
© 2013 ABIM
Question 23 - continued
Laboratory studies:
HBV surface antigen
Positive
HBV core antibody
Positive
HBV surface antibody
Negative
HBV e antigen
Positive
HBV e antibody
Negative
HBV DNA
880 million copies/mL
Hemoglobin
11.0 g/dL [12-16]
Leukocyte count
4800/mcL [4000-11,000]; 75% [50-70]
neutrophils, 20% [30-45] lymphocytes,
3% [0-6] monocytes, 2% [0-3]
eosinophils
(Laboratory studies continued on next slide)
© 2013 ABIM
Question 23 - continued
Laboratory studies (continued):
Platelet count
205,000/mcL
[150,000-300,000]
HIV-1, HIV-2, ELISA
Negative
HCV antibody
Negative
Serum alkaline
phosphatase
90 U/L [30-120]
Serum aminotransferases:
AST
28 U/L [10-40]
ALT
32 U/L [10-40]
Serum total bilirubin
0.6 [0.3-1.0]
You recommend that the infant receive HBV immunoglobulin
postnatally, and that the HBV vaccine series be initiated at birth.
The patient eagerly agrees with these
recommendations.
Question 23 - Question
Which of the following is the best counsel for this patient
regarding her risk of transmitting HBV infection to her
child?
1.
2.
3.
4.
5.
Postnatal immunization of the infant will decrease the risk of
transmission to less than 1%
To decrease the risk of transmission, the patient should not
breast feed her child
Because she is now in the second trimester of her pregnancy,
there is no role for antiviral therapy to further decrease the risk
of HBV transmission
The evident increase in birth defects associated with use of
tenofovir during pregnancy precludes its use in this setting
The mother's risk of transmission may still be greater than 10%;
initiating antiviral therapy in the third trimester of her pregnancy
may decrease this risk
© 2013 ABIM
Question 23 - Responses
50%
45%
45%
40%
35%
30%
25%
20%
15%
15%
15%
15%
10%
10%
5%
0%
1
2
3
4
5
Question 23 - Answer
Which of the following is the best counsel for this patient
regarding her risk of transmitting HBV infection to her
child?
(3) Because she is now in the second trimester of her
pregnancy, there is no role for antiviral therapy to further
decrease the risk of HBV transmission
© 2013 ABIM
HBV and Pregnancy
 HBeAg positive mother without prophylaxis: 90%
 HBIG plus HBV vaccine series: 5-10%
 Active viral replication and high HBV VL
increase risk factor despite vaccination
 Potential role for antiviral short term treatment in
third trimester (@32 wk)
 Lamivudine (cat C), Tenofovir and Telbivudine
(cat B)
Question 24
A 38-year-old plumber from Nashville, Tennessee, has had
low-grade fevers, a cough, central chest pain, and night sweats
for two and a half weeks. Otherwise, the patient is healthy and
takes no medications. His job involves both indoor and outdoor
work, and his main recreational activity is golf.
The patient coughs occasionally but generally appears well.
Temperature is 37.5 C (99.5 F), pulse rate is 88 per minute,
respirations are 18 per minute, and blood pressure is 132/82 mm
Hg. Oxygen saturation on room air by pulse oximetry is 97%. A
few rhonchi, but no crackles or wheezes, are heard posteriorly in
the chest. Cardiac examination reveals no murmur, gallop, or rub.
No cervical or axillary lymph node enlargement is present. The
abdomen, liver, spleen, and inguinal area have no abnormalities.
© 2013 ABIM
Question 24 - continued
Laboratory studies:
Hematocrit
42% [42-50]
Leukocyte count
7240/mcL [4000-11,000];
70% [50-70] neutrophils,
24% [30-45] lymphocytes,
6% [0-6] monocytes
265,000/mcL
[150,000-300,000]
Platelet count
Serum aminotransferases:
AST
38 U/L [10-40]
ALT
28 U/L [10-40]
Serum alkaline phosphatase
92 U/L [30-120]
Serum total bilirubin
0.9 mg/dL [0.3-1.0]
© 2013 ABIM
Question 24 - Question
Chest radiograph shows right-sided mid-lung opacities, and
CT scan reveals a nodular infiltrate in the peripheral right
lung, as shown (click here for photo).
Which of the following is most likely to establish this
patient's diagnosis?
1. Fungal culture of sputum
2. Histoplasma complement fixation antibody
testing
3. Histoplasma testing of urine and serum antigen
4. Silver stain of expectorated sputum
© 2013 ABIM
Question 24 - Responses
120%
100%
100%
80%
60%
40%
20%
0%
0%
1
2
0%
0%
3
4
Question 24 - Answer
Chest radiograph shows right-sided mid-lung opacities, and CT
scan reveals a nodular infiltrate in the peripheral right lung, as
shown (click here for photo).
Which of the following is most likely to establish this patient's
diagnosis?
(3)
Histoplasma testing of urine and serum antigen
© 2013 ABIM
Pulmonary Histoplasmosis : Diagnosis
 Histopathology: granulomas, mononuclear
infiltrates, narrow base budding yeast,
intracellular, rapid results, sensitivity and
specificity depend on pathologist experience, on
tissue samples, low yield on sputum
 Fungal Culture: useful in chronic pul infection,
BAL increased sensitivity, low sensitivity in acute
infections, take several weeks
 Antigen Detection Tests: Rapidly available,
combined urine and serum Ag detection high
sensitivity
Pulmonary Histoplasmosis : Diagnosis
 Antibody testing: (limiting factors)
Take about 2 months to be
positive, in acute cases may
be negative early in disease,
remain positive for many years
Sensitivity/specificity varies
depending upon method used:
CF or EIA
Question 25
A 33-year-old woman comes to your office because of headache,
malaise, fever, and nausea. She reports that she, her husband,
and their 2-year-old son flew to Colorado two weeks ago. For one
week they stayed with relatives who have a cabin in the Rocky
Mountains, one hour west of Denver. While there, the patient did
not wade through any water or drink from streams. She and her
son fed peanuts to the chipmunks that were nesting around the
cabin. She does not recall any tick or other insect bites. The
patient notes that she had similar symptoms on the return flight
from Colorado one week ago and for two days after she arrived
home. She was then well until her symptoms recurred yesterday.
She lives in an apartment and works in an office building, both in
New York City. She has no pets and recently has spent no time
outdoors except for trips to the local playground with her son and
their chipmunk-feeding activities while on vacation. Her husband
and son are well, and she is unaware of contact with any sick
individuals.
Question 25 - continued
The patient is in no acute distress and appears comfortable.
Temperature is 38.3 C (101.0 F), pulse rate is 95 per minute,
respirations are 15 per minute, and blood pressure is 120/75 mm
Hg. Findings of head, eyes, ears, nose, and throat examinations
are normal. Lungs are clear, and heart rate and rhythm are
regular. Abdomen is nontender. Arms and legs are normal. No
rash is present. Neurologic examination reveals no abnormalities.
© 2013 ABIM
Question 25 – continued
Laboratory studies:
Hemoglobin
10.5 g/dL [12-16]
Leukocyte count
18,000/mcL [4000-11,000];
85% [50-70] neutrophils
Platelet count
90,000/mcL
[150,000-300,000]
Serum alkaline phosphatase
200 U/L [30-120]
Serum aminotransferases:
AST
65 U/L [10-40]
ALT
50 U/L [10-40]
Serum total bilirubin
1.1 mg/dL [0.3-1.0]
Serum creatinine
1.6 mg/dL [0.7-1.5]
© 2013 ABIM
Question 25 - Question
A blood smear is obtained and read, which reveals the presence of
rare spirochetes.
Based on the information available, which of the following is the
most likely transmitter of this patient's pathogen?
1.
2.
3.
4.
An Ornithodoros hermsii tick that attached briefly (for approximately
one-half hour) to the patient while she slept in the mountain cabin
A Dermacentor andersoni tick that attached to the patient for at least
six hours during her stay in Colorado
A Dermacentor andersoni tick that became attached to the patient in
Colorado; if still present, removal might aid in symptom resolution
An Ixodes scapularis tick that six weeks ago became attached to the
patient in Central Park in New York City and remained for 48 hours
© 2013 ABIM
Question 25 - Responses
50%
44%
45%
39%
40%
35%
30%
25%
20%
15%
10%
11%
6%
5%
0%
1
2
3
4
Question 25 - Answer
A blood smear is obtained and read, which reveals the
presence of rare spirochetes.
Based on the information available, which of the following is
the most likely transmitter of this patient's pathogen?
(1)
An Ornithodoros hermsii tick that attached briefly (for
approximately one-half hour) to the patient while she
slept in the mountain cabin
© 2013 ABIM
Tick-borne Diseases of North America General
Principles
 Presentation non-specific: usually “flu-like
illness” (e.g. fever, headache, myalgias)
 Diagnosis is clinical; i.e., treatment should be
initiated prior to diagnostic testing results return
 May have characteristic rash
 Asymptomatic: symptomatic ratio is high
Tick-borne Diseases of North America General
Principles
 Seasonal; geographic distribution suggestive
 Abnormalities in CBC, LFT’s frequent
 Doxycycline is preferred therapy for most
common illnesses (e.g., Lyme, RMSF,
ehrlichiosis...) even in children
 Prognosis in children generally good; most
serious complications in adults, especially the
elderly
 Convergence in tick vectors; co-infection
underestimated
The Major Tick-borne Diseases of NorthAmerica











Lyme disease
Rocky Mountain spotted fever(RMSF)
Ehrlichiosis/Anaplasmosis
Colorado tick fever
Tularemia
Relapsing fever
Babesiosis
Tick-borne encephalitis (Flavirvirus-2)
Tick paralysis
R. parkeri
Southern tick associated rash illness (STARI) • R
Relapsing fever: Borrelia sp
 Tick-borne relapsing fever:
B hermsii (mountains of West)
B turcatae (SW and SC US)
 Louse-borne relapsing fever:
B recurrentis: developing countries,
epidemics, body louse
 Ornithodoros hermsii
Relapsing Fever
 Dermacentor andersoni
Rocky mountain wood tick,RMSF
 Dermacenter variabilis
Dog tick, RMSF
 Ixodes scapularis
Lyme, Babesiosis, Anaplasma
 Ambylomma americanum
Ehrlichiosis, STARI
Question 26
A 35-year-old man who has HIV and HCV co-infection comes
to your office for treatment of his genotype 1, Metavir stage 2
(scarring has occurred and extends outside the areas in the
liver that contain blood vessels) HCV infection. He has been
treated for HCV infection with ribavirin and peginterferon and
has achieved a reduction in viral load, but he has been unable
to sustain a viral response. His HIV infection is well controlled
on a regimen of tenofovir, emtricitabine and ritonavir-boosted
darunavir. He has never had antiretroviral treatment failure,
and he is believed to have no retroviral resistance. He has no
other co-morbidities, and he takes no other medications.
© 2013 ABIM
Question 26 - Question
In addition to peginterferon and ribavirin, which of the
following will effectively treat this patient's co-infection?
1.
2.
3.
4.
5.
Continue the current antiretroviral regimen and add
boceprevir
Continue the current antiretroviral regimen and add
telaprevir
Continue tenofovir and emtricitabine from the current
antiretroviral regimen, and add efavirenz and boceprevir
Continue tenofovir and emtricitabine from the current
antiretroviral regimen, and add lopinavir and telaprevir
Continue tenofovir and emtricitabine from the current
antiretroviral regimen, and add raltegra and telaprevir
© 2013 ABIM
Question 26 - Responses
35%
33%
33%
30%
25%
20%
15%
13%
13%
10%
7%
5%
0%
1
2
3
4
5
Question 26 - Answer
In addition to peginterferon and ribavirin, which of the
following will effectively treat this patient's co-infection?
(5) Continue tenofovir and emtricitabine from the current
antiretroviral regimen, and add raltegravir and
telaprevir
© 2013 ABIM
HIV/HCV co-infection:
 Never use Telaprevir or Boceprevir
monotherapy
 Never use Telaprevir or Boceprevir combination
 Drug interaction: avoid both with boosted PI
Lowers level of
Telaprevir/Boceprevir
 Raltegravir safe with both
 Boceprevir + Tenofovir + Emtricitabine +
Raltegravir
 Telaprevir + Tenofovir + Emtricitabine +
efavirenz or Raltegravir
Question 27
You are seeing a 38-year-old man who has had a targetoid
rash, malaise, joint and muscle pain, and a low-grade fever.
Both ELISA and Western blot assay were positive for Borrelia
burgdorferi. The patient's symptoms resolved after treatment.
He wants to know where he acquired the disease. He lives in
St. Louis, Missouri, and works as an auditor for a hotel chain.
His job requires him to travel around the country for two to
three days at a time. In the three weeks preceding his illness,
he visited Portland, Maine; Charleston, South Carolina;
Asheville, North Carolina; and Hot Springs, Virginia.
© 2013 ABIM
Question 27 - Question
In which of the following geographic locales did the
patient most likely become infected with B.
burgdorferi?
1.
2.
3.
4.
5.
St. Louis, Missouri
Charleston, South Carolina
Asheville, North Carolina
Portland, Maine
Hot Springs, Virginia
© 2013 ABIM
Question 27 - Responses
60%
56%
50%
40%
30%
25%
20%
12%
10%
6%
0%
0%
1
2
3
4
5
Question 27 - Answer
In which of the following geographic locales did the
patient most likely become infected with B.
burgdorferi?
(4) Portland, Maine
© 2013 ABIM
LYME vs STARI
Lyme
STARI
NE
Southern state
Ioxedes
Amblyomma (lone
star)
B burgdorfei
B lonestari
EM, systemic sx
EM, systemic sx
abscent
Arthritis, neurologic symptoms
May be present
absent
Question 28
A 21-year-old college student who has just returned home
after studying abroad and subsequently traveling in Europe
has a urethral discharge and discomfort as well as mild
pharyngitis. He reports having had unprotected oral and
insertive anal sex with a man he met in Paris one week ago.
The patient appears in no acute distress. Temperature is
normal. The pharynx is mildly erythematous without exudate,
and the pharyngeal lymph nodes are not enlarged. A slightly
cloudy urethral discharge is noted, but the inguinal lymph
nodes are not enlarged. A urethral swab is sent for gonorrhea
culture and Chlamydia nucleic acid detection. The patient is
counseled on screening for HIV infection and syphilis.
© 2013 ABIM
Question 28 - Question
Given the information available, which of the
following is the most appropriate treatment
at this
© 2013
ABIM
time?
1. Azithromycin, 1000 mg orally
2. Ciprofloxacin, 500 mg orally, and azithromycin,1000 mg
orally
3. Ceftriaxone, 125 mg intramuscularly, and azithromycin,
1000 mg orally
4. Ceftriaxone, 250 mg intramuscularly
5. Ceftriaxone, 250 mg intramuscularly, and azithromycin,
1000 mg orally
© 2013 ABIM
Question 28 - Responses
80%
74%
70%
60%
50%
40%
30%
20%
10%
0%
11%
11%
3
4
5%
0%
1
2
5
Question 28 - Answer
Given the information available, which of the following
is the most appropriate treatment at this time?
© 2013 ABIM
(5) Ceftriaxone, 250 mg intramuscularly, and
azithromycin, 1000 mg orally
© 2013 ABIM
New STD Guidelines
 Ceftriaxone 250 mg as a single intramuscular
dose, plus either azithromycin 1 g orally in a
single dose or doxycycline 100 mg orally twice
daily for 7 days
 Cefixime not recommended any more unless
ceftriaxone unavailable
 Severe Cephalosporin allergy: 2 gm
azithromycin x 1 dose
 Fluroquinolones no longer recommended
 Test of cure 1 week after treatment
High Yield: Genital ulcer buzz words
 Syphilis: painless, single, heaped up boarders,
clean base, heaped up bilateral LAD
 HSV: multiple, painful, erythematous base,
vesicle or ulcers
 Chancroid: painful, indurated, ragged, tender
LN, kissing lesion
 GI: painless, progressive destructive, no LN,
highly vascular
 LGV: painless ulcer, painful inguinal LN, groove
sign
PAIN and GUD
PAINFUL
PAINLESS
HSV
Chancroid
Syphilis
LGV (painful LN)
Granuloma Inguinale
STD: High Yield
 PCN allergic pregnant pts treatment: desensitise
 Treatment of primary, secondary and latent
syphilis
 CS only in HSV with active lesions
 Diagnosis and treatment
 DGI: pustular or petechial acral lesion,
asymmetrical, often migratory arthalgia,or monoarticular septic arthritis
 DGI risk factor: terminal compliment deficiency
 Treatment of partners: Chlamydia, Gonorrhea,
trichomonas, NOT needed in Bacterial vaginosis
Question 29
A 52-year-old man has had a nonproductive cough without
fever for two weeks. The cough interferes with his sleep and
daily activities. On two occasions, he has vomited after a
particularly severe paroxysm of coughing. He cannot recall
having had a similar episode in the past. He has no personal
or family history of asthma. The patient has never received
vaccination for diphtheria, tetanus, and pertussis.
The patient appears tired, and the physical examination is
frequently interrupted by paroxysms of nonproductive
coughing. Temperature is 37.0 C (98.6 F), pulse rate is 80 per
minute, and blood pressure is 130/60 mm Hg. No lesions are
noted on the head, eyes, ears, nose, or throat. No wheezing or
crackles are heard in the chest.
© 2013 ABIM
Question 29 - Question
Which of the following tests is most likely to
confirm the suspected diagnosis of pertussis?
1. Direct fluorescent antibody testing on gargle
specimen
2. IgA anti-pertussis antibody
3. ELISA using whole Bordetella pertussis antigen
4. PCR on posterior pharyngeal swab specimen
5. Throat culture
© 2013 ABIM
Question 29 - Responses
70%
65%
60%
50%
40%
30%
24%
20%
10%
6%
6%
0%
0%
1
2
3
4
5
Question 29 - Answer
Which of the following tests is most likely to confirm
the suspected diagnosis of pertussis?
(4) PCR on posterior pharyngeal swab specimen
© 2013 ABIM
Pertussis Diagnosis:
 Depends on the duration of illness
 Samples from posterior-nasopharynx should be
collected not from nares or throat
 Culture: 100%specificity, low sensitivity,
fastidious organism, 7-10 days, high yield with in
first 2 weeks
 PCR: high sensitivity and specificity, not affected
by prior antibiotic use
 Serology: epidemiologic or researc, useful for
more than 4 weeks of illnes,
Question 30
You are consulted in the case of a 24-year-old nurse who has
recurrent meningitis. Her first episode occurred three years ago,
and she has had an average of four recurrences yearly since that
time. Each episode is characterized by symptoms of acute-onset
fever and headache, which resolve after five to seven days. During
her first episode, she was treated with vancomycin and ceftriaxone
until cultures were negative and a PCR analysis for herpes
simplex virus (HSV)-2 was positive. CSF was examined during
four subsequent episodes; on each occasion, PCR analysis for
HSV-2 was positive. Between episodes, the patient feels well. She
recalls that at age 17 she had a single episode of genital herpes,
but she has not had a clinical recurrence of the cutaneous
disease. Complete blood count and chemistry screens have been
normal. HIV assays have been negative on two occasions during
the past four years. The patient is otherwise healthy and takes no
medications. She is an active triathlete.
© 2013 ABIM
Question 30 - Question
Which of the following is most likely to decrease or
prevent recurrences of HSV-2 infection in this patient?
1. No prophylactic medications
2. Medroxyprogesterone, 250 mg every three
months
3. Prednisone, 5 mg daily
4. Valacyclovir, 500 mg twice daily
5. Intravenous immune globulin every three
months
© 2013 ABIM
Question 30 - Responses
80%
76%
70%
60%
50%
40%
30%
20%
10%
10%
10%
5%
0%
0%
1
2
3
4
5
Question 30 - Answer
Which of the following is most likely to decrease or
prevent recurrences of HSV-2 infection in this patient?
(1) No prophylactic medications
© 2013 ABIM
Recurrent (Mollaret's) meningitis




Benign lymphocytic meningitis
Fever and meningismus, 2-5 days
Spontaneous resolution
HSV-2 most common cause, esp with primary
HSV-2 infection + meningitis
 Valacyclovir 500 mg BID was not shown to
prohibit recurrent meningitis and cannot be
recommended
 Protection against mucocutaneous lesions was
observed. The higher frequency of meningitis,
after cessation of active drug, could be
interpreted as a rebound phenomenon.
Recurrent (Mollaret's) meningitis
 IVIG q 3 months for agammaglobulinemic pts
with chronic enteroviral meningitis
 Little evidence for:
Acyclovir 400 mg 2-3 times a day
Famciclovir 250 mg twice daily
Valacyclovir 500 mg once daily