Download A 72-year-old female nursing-home resident is hospitalized

Aan:
Opleiders Inwendige Geneeskunde
Regio Amsterdam II
23 februari 2007
Betreft: ROIG Infectieziekten 2007
Geachte collegae,
Op 28 maart 2006 is de ROIG over het genoemde onderwerp. We hebben de
opzet weer veranderd. We zullen nu vragen gaan beantwoorden uit de recent
verschenen MKSAP 14 Infectious Diseases. Op deze dag zullen aan de hand
van een aantal geclusterde vragen zes thema’s verder worden uitgediept door
verschillende docenten. Bijgevoegd vindt u 14 geselecteerde vragen met het
verzoek deze met uw AIOSsen voor te bespreken.
U kunt deze MKSAP bestellen direct via http://mksap.acponline.org/
Order now)
(klik aan
of via de NIV. Op uw verzoek krijgt u binnen een week een password
waarna u toegang heeft tot MKSAP-online met een heel aardige format. (De
syllabi zijn er pas na 6 weken). Alternatief is dat u de vragen maakt met Mandell
of Uptodate als naslagwerk.
De vragen zijn: 6,7,9,10,11,12,14,15,16,17,21,22, 69 en 71.
We hopen dat deze formule een levendige, interactieve dag zal opleveren! Tot dan,
Dr. Michiel van Agtmael
Internist-infectioloog
Opleider aandachtsgebied infectieziekten
6
A 72-year-old female nursing-home resident is hospitalized because of urosepsis
following development of a fever 2 days ago that did not respond to empiric
ceftriaxone, 1 g intramuscularly daily. The patient has a chronic indwelling urinary
catheter. She had a urinary tract infection 1 month ago that was treated with a
short course of ciprofloxacin. Urine cultures were not obtained.
On physical examination on admission, the patient is more confused than usual.
Temperature is 40 °C (104 °F), pulse rate is 152/min and regular, respiration rate
is 38/min, and blood pressure is 80/50 mm Hg. Left flank pain is present. There
are no focal neurologic findings.
The leukocyte count is 20,000/µL (20 × 10 9 /L) with 80% segmented neutrophils
and 5% band forms. Urinalysis shows 4+ leukocytes and bacteria. A urine
leukocyte esterase assay is positive. Urine cultures obtained in the nursing home
are growing 100,000 colonies/mL of Klebsiella species; results of susceptibility
testing are pending.
Which of the follow ing is the most appropriate empiric intravenous antibiotic
agent for this patient?
A
Imipenem
B
Ceftazidime
C
Ampicillin–sulbactam
D
Trimethoprim–sulfamethoxazole
E
Moxifloxacin
7
A 35-year-old man is diagnosed with HIV infection after he sought testing because
of sexual exposure to another man approximately 5 years ago who he
subsequently learned was HIV-infected. The patient is asymptomatic. Medical
history is unremarkable, and he takes no medications.
On physical examination, he appears healthy. Vital signs and general examination
are normal. The liver and spleen are not enlarged.
Laboratory Studies
CD4 cell count
184/µL (0.184 × 109/L)
Plasma HIV RNA viral load
13,043 copies/mL
Serum aspartate aminotransferase
63 U/L
Serum alanine aminotransferase
85 U/L
Serum alkaline phosphatase
88 U/L
Serum total bilirubin
0.9 mg/dL (15.39 µmol/L)
Antibodies to hepatitis C virus (anti-HCV)
Negative
Hepatitis B surface antigen (HBsAg)
Positive
Antibodies to hepatitis B core antigen (anti-HBc)
Positive
Antibodies to hepatitis B surface antigen (anti-HBs)
Negative
Which of the follow ing is the most appropriate antiretroviral therapy at this
time?
A
Delay treatment until the patient becomes symptomatic
B
Delay treatment until the patient's HIV RNA viral load exceeds 100,000 copies/mL
C
Begin treatment with zidovudine, didanosine, and nelfinavir
D
Begin treatment with lamivudine, efavirenz, and tenofovir
9
A 44-year-old man underwent elective laminectomy 3 days ago. He received two
doses of cefazolin, 2 g, for surgical prophylaxis. On the second postoperative day,
he developed watery diarrhea with bowel movements every 1 to 2 hours. A stool
assay for Clostridium difficile was positive, and oral metronidazole was begun. By
the end of the second day, the diarrhea had decreased, but he developed
confusion and abdominal pain and distention. Intravenous metronidazole and oral
vancomycin were begun.
Today, the third postoperative day, his condition has worsened, and he has severe
pain. On physical examination, he is confused and oriented only to person.
Temperature is 39.4 °C (102.9 °F), pulse rate is 122/min, respiration rate is
26/min, and blood pressure is 98/52 mm Hg. The abdomen is protuberant and
tense with tympany and marked tenderness to palpation in all areas. The
remainder of the examination is unremarkable.
Laboratory Studies
Hemoglobin
13.9 g/dL (139 g/L)
Hematocrit
41%
Leukocyte count
33,500/µL (33.5 × 109/L)
Platelet count
228,000/µL (228 × 109/L)
Blood urea nitrogen
22 mg/dL (7.86 mmol/L)
Serum creatinine
1.5 mg/dL (132.63 µmol/L)
Serum electrolytes
Normal
Liver chemistry studies
Normal
Serum amylase
182 U/L
Serum lipase
124 U/L
Plain radiographs of the abdomen show severe, gas-filled dilatation of the entire
colon with the largest diameter of 7 cm. Stool cultures show no growth of
pathogenic organisms.
In addition to intravenous metronidazole and oral vancomycin, which of the
follow ing is most appropriate at this time?
A
Clindamycin orally
B
Ciprofloxacin orally
C
Ciprofloxacin per rectum
D
Vancomycin per rectum
10
A 28-year-old man who underwent renal transplantation 1 year ago is evaluated
because of a 5-week history of back pain. The pain is present at all times, even at
rest, but is particularly severe with any jarring motion of the spine, such as riding
his bike over a bumpy surface. The patient does not have fever, lower extremity
numbness, muscle weakness, or difficulty urinating. He continues to take
combination immunosuppressive therapy for the kidney transplant.
On physical examination, temperature is 37.1 °C (98.8 °F); other vital signs are
also normal. Palpation of the spine reveals localized tenderness and muscle
spasm at the upper lumbar spine. Neurologic examination, including reflexes,
sensation, and motor strength of the lower extremities, is normal.
A radiograph of the lumbar spine shows demineralization of the endplates and loss
of definition of the anterior aspect of the bony L1–L2 margin. Tuberculin skin
testing using intermediate-strength purified protein derivative shows 7 mm of
induration. A chest radiograph is normal.
Which of the follow ing diagnostic studies should be done next?
A
CT-guided needle biopsy of the spinal lesion
B
CT scan of the chest
C
MRI of the entire spine
D
Serum protein electrophoresis and urine immunoelectrophoresis
E
Testicular ultrasonography and whole-body positron emission tomography
11
A 24-year-old woman develops the sudden onset of fever, severe headache,
myalgias, arthralgias, and nausea that become debilitating within several hours.
Ten days ago, she returned from Puerto Rico, where she stayed at a first-class
resort, swam only in the ocean or the hotel pool, ate only at the hotel restaurant,
and had no sexual contacts. Medical history is unremarkable. One other person in
her group of five traveling companions has similar, but less severe, symptoms that
began 1 day ago.
On physical examination, the patient is awake and alert but is very uncomfortable
because of the headache. Temperature is 39.3 °C (102.7 °F), pulse rate is
118/min, respiration rate is 18/min, and blood pressure is 112/68 mm Hg. The skin
is clear, and optic fundi are normal. Flexion of the neck induces slight to moderate
pain without nuchal rigidity. Cardiopulmonary examination is normal except for
tachycardia. Abdominal examination discloses reduced bowel sounds and slight
tenderness to palpation in all quadrants. Palpation of the arm and leg muscles
induces mild tenderness. There is no peripheral edema. Cranial nerves are intact.
Sensation and muscle strength are normal. All reflexes are slightly hyperactive
symmetrically.
Laboratory Studies
Hemoglobin
12.9 g/dL (129 g/L)
Hematocrit
38%
Leukocyte count
2100/µL (2.1 × 109/L)
Platelet count
124,000/µL (124 × 109/L)
Blood urea nitrogen
16 mg/dL (5.71 mmol/L)
Serum creatinine
0.8 mg/dL (70.74 µmol/L)
Serum sodium
122 meq/L (122 mmol/L)
Serum potassium
3.9 meq/L (3.9 mmol/L)
Serum chloride
101 meq/L (101 mmol/L)
Serum bicarbonate
24 meq/L (24 mmol/L)
Serum aspartate aminotransferase
210 U/L
Serum alanine aminotransferase
360 U/L
Serum amylase
38 U/L
Serum lipase
44 U/L
Lumbar puncture is performed; examination of cerebrospinal fluid shows the
following:
Laboratory Studies
Leukocyte count
22/µL (22 × 106/L) (all lymphocytes)
Erythrocyte count
2/µL (2 × 106/L)
Protein
37 mg/dL (370 mg/L)
Glucose
74 mg/dL (4.11 mmol/L)
Radiographs of the chest and abdomen are normal.
Which of the follow ing is the most likely diagnosis?
A
Dengue fever
B
Dengue hemorrhagic fever
C
Herpes virus encephalitis
D
Babesiosis
12
A 62-year-old man comes to the emergency department because of a 2-day history
of fever, cough, and yellow-green sputum production. The patient had severe
pneumonia at age 40 years, following which he developed a daily cough and
whitish-yellow sputum production. He typically receives one or two courses of
antibiotics each year when his sputum increases in volume and becomes darker.
He is a lifelong nonsmoker.
On physical examination, temperature is 38.7 °C (101.6 °F). Coarse breath sounds
are heard at the posterior base of the right lung. Scattered crackles and rhonchi
are also auscultated. The leukocyte count is 13,500/µL (13.5 × 10 9 /L) with 74%
neutrophils, 12% band forms, and 14% lymphocytes. A chest radiograph shows a
patchy right lower lobe infiltrate. A chest film obtained 2 years ago showed
nonspecific increased markings at the base of the right lung but was otherwise
unremarkable.
In choosing an antimicrobial regimen for this patient, coverage should be
included for which of the following organisms?
A
Mycobacterium tuberculosis
B
Respiratory syncytial virus
C
Nocardia brasiliensis
D
Pseudomonas aeruginosa
E
Chlamydophila pneumoniae (formerly Chlamydia pneumoniae
14
A 24-year old woman is brought to the emergency department because of fever,
photophobia, and a stiff neck. On physical examination, the patient is irritable.
Temperature is 40 °C (104 °F). There is nuchal rigidity, and a purpuric rash is
seen on dependent areas of the body. While in the emergency department, the
patient develops respiratory distress and requires intubation. She is subsequently
admitted to the intensive care unit (ICU).
During transfer, the patient is isolated with droplet precautions, and all health care
workers wear masks and use the appropriate barriers. Lumbar puncture is done in
the ICU, and cerebrospinal fluid examination shows gram-negative diplococci,
consistent with meningitis.
Which of the follow ing health care workers requires antibiotic prophylaxis?
A
All staff who were present in the emergency department and ICU when the patient
was in these areas
B
All staff who examined the patient in the emergency department and ICU
C
The resident who intubated the patient in the emergency department
D
Prophylaxis is not required for any staff
15
A 72-year-old woman with a history of hypertension and asthma has a laceration
of her left ankle sutured in the emergency department. One week later, she
returns to the emergency department because of pain and discharge from the
suture site.
On physical examination, she is afebrile. The left ankle shows purulent drainage
from the previous suture site and dehiscence of the wound over the lateral
malleolus. There is no evidence of exposed bone.
Which of the follow ing studies will be most sensitive and specific for
establishing a diagnosis in this patient?
A
Triple-phase bone scan
B
Gallium scan
C
Indium-labeled leukocyte scan
D
Conventional bone radiograph
E
MRI
16
A 45-year-old woman who has a 3-day history of progressive earache and fever is
hospitalized after becoming unresponsive. Medical history is unremarkable; she
has no allergies; and she takes no medications.
On physical examination on admission, temperature is 40 °C (104 °F), pulse rate
is 120/min, respiration rate is 32/min, and blood pressure is 80/50 mm Hg. The
patient is obtunded and had meningismus. The leukocyte count is 25,000/µL (25 ×
10 9 /L) with 25% band forms, and the platelet count is 20,000/µL (20 × 10 9 /L).
Lumbar puncture is performed; cerebrospinal fluid examination shows the
following:
Laboratory Studies
Appearance
Cloudy
Leukocyte count
2500/µL (2500 × 106/L) with 99% neutrophils
Glucose
20 mg/dL (1.11 µmol/L)
Protein
230 mg/dL (2300 mg/L)
A Gram stain of unspun cerebrospinal fluid is shown (Figure 16)
.
Which of the follow ing empiric treatment regimens should be initiated?
A
Penicillin plus dexamethasone
B
Ceftriaxone plus dexamethasone
C
Vancomycin plus dexamethasone
D
Vancomycin plus ceftriaxone and dexamethasone
E
Vancomycin plus ceftriaxone
17
A 34-year-old man is evaluated because of fever, mild headache, and malaise that
began while on a flight to the United States from South Africa. One day later, he
developed a slight rash and swelling in the right axilla. The patient had been on a
hunting safari. His group lived in tents and often walked through fields with low
scrub. He had taken appropriate antimalarial prophylaxis and did not skin the
animals or dress the meat. Medical history is unremarkable.
On physical examination 2 days after the flight, temperature is 38 °C (100.4 °F),
pulse rate is 82/min, respiration rate is 16/min, and blood pressure is 132/88 mm
Hg. There is a firm swelling in the right axilla without fluctuance or erythema. No
edema is noted. Approximately 15 to 20 small pruritic vesicles on erythematous
bases are seen on the anterior chest and upper arms, and one vesicle appears on
the left cheek. A 1-cm red-brown eschar is present over the right lateral clavicle.
Neurologic examination is normal.
Laboratory Studies
Hemoglobin
14.9 g/dL (149 g/L)
Hematocrit
44%
Leukocyte count
6500/µL (6.5 × 109/L)
Platelet count
270,000/µL (270 × 109/L)
Blood urea nitrogen
Normal
Serum creatinine
Normal
Serum electrolytes
Normal
Liver chemistry studies
Normal
Urinalysis
Normal
Which of the follow ing is the most likely diagnosis?
A
Herpes zoster virus
B
Dengue fever
C
African tick bite fever
D
Cutaneous leishmaniasis
21
A 73-year-old man has a 1-day history of increasing cough, dyspnea, fever, and
chills. He has chronic obstructive pulmonary disease and type 2 diabetes mellitus
complicated by mild azotemia. The patient has a 60-pack-year smoking history and
continues to smoke. Current medications are inhaled ipratropium bromide, inhaled
salmeterol, and glyburide.
On physical examination, he is obese and in mild respiratory distress.
Temperature is 38 °C (100.4 °F), pulse rate is 100/min, respiration rate is 20/min,
and blood pressure is 135/85 mm Hg. Chest examination discloses decreased
breath sounds bilaterally, scattered rhonchi, and a few crackles at the left base
posteriorly. Arterial oxygen saturation is 86% by pulse oximetry with the patient
breathing room air.
The leukocyte count is 9700/µL (9.7 × 10 9 /L) with 72% neutrophils, 10% band
forms, and 18% lymphocytes. Blood urea nitrogen is 40 mg/dL (14.3 mmol/L), and
serum creatinine is 2.4 mg/dL (112.16 µmol/L). A chest radiograph shows a patchy
infiltrate at the left lung base. The patient is hospitalized.
Which of the follow ing is the most appropriate intravenous antibiotic therapy
at this time?
A
Ceftriaxone plus azithromycin
B
Amoxicillin–clavulanic acid
C
Ticarcillin plus tobramycin
D
High-dose penicillin
E
Trimethoprim–sulfamethoxazole
22
A 24-year-old woman who is 4 months pregnant has an abnormal rapid plasma
reagin test for syphilis (titer of 1:128) and a reactive fluorescent treponemal
antibody absorption (FTA-ABS) assay. She is asymptomatic and has no history of
sexually transmitted diseases. Her pregnancy has been uncomplicated, and her
only medication is a prenatal vitamin. Physical examination, including pelvic
examination, is normal for her stage of pregnancy.
The patient developed “hives” when taking amoxicillin 4 years ago. At that time,
she had a sore throat, fatigue, and enlarged cervical lymph nodes. Symptoms
lasted for more than 1 month and did not respond to the course of amoxicillin.
Which of the follow ing is most appropriate at this time?
A
Perform skin test for penicillin allergy
B
Begin penicillin now
C
Desensitize; then begin penicillin
D
Begin ceftriaxone now
E
Begin doxycycline now
69
A 42-year-old man with HIV infection is evaluated because of a 5-week history of
night sweats and weight loss of 2.2 kg (5 lb). He moved to New York City from his
home in the Dominican Republic 3 months ago, when he started highly active
antiretroviral therapy. His CD4 cell count before starting antiretroviral therapy was
240/µL (0.24 × 10 9 /L). Following initiation of treatment, his CD4 cell count rose to
350/µL (0.35 × 10 9 /L) and his plasma HIV RNA viral load fell from 500,000
copies/mL to an undetectable level. The patient takes no other medications.
Physical examination is normal except for an enlarged right cervical lymph node. A
chest radiograph is normal. The lymph node is subsequently excised and stains
positive for acid-fast bacilli.
Which of the follow ing is the most likely diagnosis?
A
Mycobacterium avium complex infection
B
Mycobacterium marinum infection
C
Mycobacterium kansasii infection
D
Mycobacterium tuberculosis infection
E
Immune reconstitution inflammatory syndrome
71
A 25-year-old man is evaluated because of pain and swelling of his right hand.
Three days ago, he was involved in an altercation during which he punched
another man in the mouth with his right fist.
On physical examination, temperature is 38.3 °C (101 °F). Examination of the right
hand discloses pain and swelling over the second metacarpophalangeal joint and
evidence of decreased range of motion. Aspiration of the joint reveals a small
amount of purulent material; samples are submitted for culture.
While aw aiting culture results, w hich of the following is most appropriate?
A
Amoxicillin–clavulanic acid
B
Cefazolin
C
Trimethoprim–sulfamethoxazole
D
Metronidazole plus ciprofloxacin
E
Observation only until culture results are available