Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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