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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