ID 3

Question 1

Best recommended treatment for ESBL organisms.
(Extended Spectrum Beta-Lactamase producing organisms)

Answer 1

Carbapenems (Meropenem, Imipenem, Rrtapenem)

Question 2

Best initial treatment for Febrile Neutropenia ( ANC < 500)?

When to add vancomycin?

When to add Antifungal therapy?

Answer 2

Monotherapy with Zosyn, Cefepime or Carbapenem.

When Line Sepsis is suspected, hemodynamic instability, skin infections.

When pt is febrile > 7 days or evidence of candidemia.

Question 3

Pt presenting with paresthesia, neuropathy pain, areflexia, dysarthria, weakness in LE compare to UE, palpitations, arrhythmia and respiratory compromise after a Viral or GI infection.

Dx?
Next step in management?
Common CSF result?

Answer 3

GBS after viral or GI infection.

Next step is LP to r/o other causes.

CSF has Elevated Protein and Normal WBC.

Question 4

HIV pt presents Fever, AMS, has encapsulated yeast on india ink stain.
Dx?

What is the recommended management for when ICP is > 200 mmH20?

Answer 4

Cryptococcal Meningitis

Need to do Serial LPs (The only thing that works)

Question 5

1. HIV infected person with CD <50 presents with Lethargy, Confusion, Hemiparesis. MRI shows (1) Large RING ENHANCING lesion with edema and mass effect primarily in Subcortical White Matter.
2. HIV infected person with CD < 100 presenting with lethargy, confusion, MRI shows (Multiple) RING ENHANCING lesions with mass effect and edema primary in Basal Ganglia? Rx? What additional medication is needed and why?
3. HIV infected persons with CD4 < 50 presenting wtih Lethargy, Confusion MRI shows Diffuse Micronodular Encephalitis or Ventriculoencephalitis (Periventricular Inflammation)
4. Pt present with Rapidly Progressive Neurological Deficits. CD < 200
   MRI shows Asymmetric White Matter Lesions WITHOUT Enhancement, Mass Effect and Edema?

Answer 5

1. Primary CNS Lymphoma (PCL)
2. Toxoplasma Encephalitis

Pyrimethamine + Sulfadiazine. Give leucovorin ( Folic Acid) to prevent bone marrow suppression.

3. Ctyomegalovirus Encephalitis (CMV)
4. Progressive Multifocal Leukoencephalopathy

Question 6

1. Pt returning from Caribbean, South America, Parts of Asia with Myalgia, Retro-Orbital pain/Headache and Bleeding, Petechia, Thrombocytopenia.
   Dx?
   Test?
   Rx?
2. Pharyngitis, Lymphadenopathy, Splenomegaly and Lymphocytosis.
3. Pt present with Abdominal Pain, Faint Salmon-Colored Macules on Trunk and Abdomen can progress to Hepatosplenomegaly, Bleeding and Shock?

What do you need to give to prevent this?

Answer 6

1. Dengue Fever.
   Serology or Testing Viral Components.
   Supportive.
2. EBV
3. Typhoid Fever.
   Give Typhoid Vaccine before trip.

Question 7

Next step in management with a Diabetic patient presents with 2cmx2cm Ulcerated lesion with poor granulation tissue and visualization of bone ?

Xrays show Cortical Erosion with Elevated Periosteum

Answer 7

Order Bone biopsy with localized debridement and/or blood cultures. - helps guide therapy.
No need to do MRI

Question 8

Next step in Management with patient presenting with AMS, Fever, N/V and positive gram-positive baccili on CSF gram stain?

Answer 8

Start Ampillicin

Listeria (common in immunocompromised and, neonates and elderly.)

Question 9

Immunocompromised patient presents with Fever, Cough, HA and Weakness in upper extremities.
CXR shows patchy Alveolar Opacities and Abscess in BRAIN and LUNG and skin ulcers.

Dx?
Test?
Rx?

Answer 9

Nocardiosis (inhalation through soil).
Culture staining ACID-FAST shows gram positive rods.

Treat with Bactrim.

Question 10

Pt presents with progressive lethargy, confusion, shaking Chills, Diarrhea, Hypotension, Pealing skin.
Had Nasal Fracture 3 days ago and now has Nasal Packing.
Pt has Diffuse Erythema of Mucous Membranes on Skin, Palms and Soles.

Dx?
Rx?

Answer 10

TSS (Toxic Shock Syndrome).

Vancomycin, Clindamycin and Cefepime

(Help inhibit Toxin production)

Question 11

Fever, AMS, Hypotension and Petechial Rash.

Dx?
Rx?

Answer 11

Meningococcemia.

Ceftriaxone and Vancomycin in Adults < 50.

Question 12

Pt presents with Fever, Malaise, Anorexia, Eye redness, Congestion, White Papules on Buccal Mucosa and a maculopapular rash after traveling from Bangladesh?

Answer 12

Measles.

Air Bone Precautions.

Question 13

Next Step in Management with a patient presenting with Lyme Carditis.

Answer 13

Hospitalization with Next step is IV abx (Ceftriaxone).
( If patient has 1st or 2nd degree heart block that can progress to complete heart block. )

Question 14

Pt presenting with Fever, Chills, HA, Nausea, vomiting, Scleral Icterus after a trip to Southern Africa. He took doxy of Malaria ppx but stopped after arriving in US. Dx?

Answer 14

Malaria.
He did not complete his ppx.

Question 15

Malaria Ppx:

1. When to give Atovaquone-proguanil?
2. Mefloquine ?
3. Chloroquine-Hydroxychloroquine? When to give?
4. Primaquine? What should you screen for?

Answer 15

1. Chloroquine-Resistant P falciparum . They attack the liver Forms. (Sub-Saharan Africa)
2. Pregnant patients
3. Needs to be started weeks in Advance - Giving in Chloroquine- Susceptible P Falciparum
4. Given in areas Without P Falciparum ( South America, Mexico. ) Good for P. Vivax or P Ovale.
   G6PD

Question 16

Tickborne Diseases:

1. Travel to Northeast/Midwest, Influzenza-like Symptoms + Central Clearing rash?
2. Influenza like symptoms, High Fever, Cytopenias and Elevated LFTs, rash is uncommon? Test?
3. Travel to Southeast US Georgia, Texas. Influenza like symptoms + Cytopenias (LEUKOPENIA AND THROMBOCYTOPENIA)+ LFTs+ Rash W/O central clearing
4. Influenza like symptoms+ Rash develops centripetally, petechial on ankles and wrist.

Answer 16

1. Lyme Disease (Cytopneia is atypical for Lyme)
2. Human Granulocytic Anaplasmosis. Ixodes tick like lyme,
   (Buffy Coat or Blood smear that shows (intraleukocytic morulae)
3. Ehrlichia (Lone Star Tick)
4. Rocky Mountain Spotted Fever

Question 17

1. Broader distribution of Ohio, Mississippi presenting with Pulmonary Symptoms (Chronic PNA, Cavitation) and Hepatosplenomegaly. Common sign of Pulmonary involvement? Dx? Test? Rx?
2. Travel to Ohio, Mississippi Area and pt presents with Foot pain with Lytic lesions of R foot, Lesions on skin, Opacities in R Upper lobe.
3. Travel to Southern Arizona/California/New Mexico. It causes skin lesion, lymph nodes bone and Osteoarthritis.

Answer 17

1. Disseminated Histoplasmosis
   Pulmonary Histoplasmosis
2. Disseminated Blastomycosis
3. Coccidioidomycosis

Itracanazole x 12 weeks - 12 months.
Amp B for Severe

Question 18

Rx for Mycobacterium Avium Complex?

Answer 18

Azithromycin, Ethambutol and Rifamycin

Need 2 positive cultures to confirm

Question 19

Which 3 organisms is catheter removal usually indicated in?

Answer 19

Pesudomonas, Staph Aureus, Fungi