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Infectious Disease Board Review Stephen Barone MD Michael Lamacchia, MD Pediatric Program Director Schneider Children's Hospital Associate Professor New York University School of Medicine Chairman St. Joseph’s Children’s Hospital Associate Professor Mount Sinai School of Medicine Question 1 A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a 3 -day history of a “bark-like” cough, low grade fever and URI symptoms. She became acutely worse today and appears “toxic” The most likely diagnosis is? 1. 2. 3. 4. 5. Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis Question 1 A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a 3 -day history of a “bark-like” cough, low grade fever and URI symptoms. She became acutely worse today and appears “toxic” The most likely diagnosis is? 1. 2. 3. 4. 5. Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis Key Points # 1 Bacterial tracheitis Epiglottis Cough, stridor, non-toxic, parainfluenza Retropharyngeal abscess Older, unimmunized, drooling , toxic, no cough, H. Influenza Viral laryngotrachitis Fever, toxic, stridor, secretions, S aureus Young, drooling, stiff neck Foreign body Acute onset, afebrile, historical clues Question 2 A 2 month old infant presents with a 2 -week history of a cough, perioral cyanosis and posttussive vomiting. The treatment of choice is? 1. 2. 3. 4. 5. High dose Amoxicillin Azithromycin Clindamycin Steroids Trimethroprim sulfamethoxazole Question 2 A 2 month old infant presents with a 2 -week history of a cough, perioral cyanosis and posttussive vomiting. The treatment of choice is? 1. 2. 3. 4. 5. High dose Amoxicillin Azithromycin Clindamycin Steroids Trimethroprim sulfamethoxazole Key Point #2 Pertussis Infants or Adolescents Macrolide - limit spread Differential Diagnosis Chlamydia trachomatis Staccato cough, tachypnea afebrile, PCP Hypoxic, toxic , immunodeficiency Question 3 A 5 year-old presents with migratory arthritis and shortness of breath. On exam you notice a holosystoic murmur The most likely diagnosis is? 1. 2. 3. 4. 5. Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease Question 3 A 5 year-old presents with migratory arthritis and shortness of breath. On exam you notice a holosystoic murmur The most likely diagnosis is? 1. 2. 3. 4. 5. Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease Key Points #3 Group A Streptococcus infections Exudative pharyngitis, fever, anterior nodes Treatment – Penicillin Rheumatic fever Arthritis, chorea, carditis, nodules, erythema marginatum Prophylaxis Scarlet fever – no prophylaxis PSGN Skin infections, not preventable with antibiotics Question 4 A 12 year boy with a three week history of nasal congestion, cough and nasal discharge presents with a headache, vomiting and 6th nerve palsy The next step in his evaluation should be? 1. 2. 3. 4. 5. Lumbar puncture CT scan head and sinuses Lyme serology Maxillary sinus aspiration Slit lamp examination of the eyes? Question 4 A 12 year boy with a three week history of nasal congestion, cough and nasal discharge presents with a headache, vomiting and 6th nerve palsy The next step in his evaluation should be? 1. 2. 3. 4. 5. Lumbar puncture CT scan head and sinuses Lyme serology Maxillary sinus aspiration Slit lamp examination of the eyes? Key Points #4 Symptoms – 2 weeks Complications of sinusitis Congestion, Nasal discharge Facial pain Cerebral venous thrombosis Orbital cellulitis Brain abscess – Pott’s puffy tumor S. pneumoniae, M. catarrhalis, H. influenzae Chronic – S. aureus, anaerobes Question 5 A 5 year old with chronic ear infections who had a chronic inflammation of the middle ear, perforation and otorrhea has what condition? 1. 2. 3. 4. 5. Cholestatoma Chronic suppurative otitis media Serous otitis media Otitis externa Labyrinthitis Question 5 A 5 year old with chronic ear infections who had a chronic inflammation of the middle ear, perforation and otorrhea has what condition? 1. 2. 3. 4. 5. Cholestatoma Chronic suppurative otitis media Serous otitis media Otitis externa Labyrinthitis Key Points #5 Acute Otitis Media Chronic Suppurative Otitis Media Above plus S. aureus, P.aeruginosa Cholesteatoma S. pneumoniae, H. influenzae, M. catarrhalis Cystic structure – chronic OM Otitis Externa Intact TM - P.aeruginosa and S. aureus Question 6 A 3 year old presents with a 1 month history of unilateral cervical adenitis. The child has been well appearing, afebrile and has had not traveled. A PPD measures 6 mm The next step in the management is? 1. 2. 3. 4. 5. Isoniazid and Rifampin for 6 months A repeat PPD in 3 months A CT of the neck Excisional biopsy Azithromycin for 4 weeks Question 6 A 3 year old presents with a 1 month history of unilateral cervical adenitis. The child has been well appearing, afebrile and has had not traveled. A PPD measures 6 mm The next step in the management is? 1. 2. 3. 4. 5. Isoniazid and Rifampin for 6 months A repeat PPD in 3 months A CT of the neck Excisional biopsy Azithromycin for 4 weeks Key Points #6 Unilateral adenitis Acute S. aureus, Group A Streptococcus Antibiotics Sub acute Atypical Mycobacterium History, PPD, excisional biopsy Cat Scratch History, serology, no treatment Kawasaki Disease IVIG Chronic Malignancy Question 7 A 15 year old boy develops a fever to 101oF, headache and bilateral swelling of his parotid glands. The most likely complication of this illness is? 1. 2. 3. 4. 5. Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis Question 7 A 15 year old boy develops a fever to 101oF, headache and bilateral swelling of his parotid glands The most likely complication of this illness is? 1. 2. 3. 4. 5. Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis Key Points #7 Parotitis Bacterial – ill appearing Viral Mumps Viral syndrome with swelling of parotid glands Complication Orchitis CSF pleocytosis – most asymptomatic Rare – myocarditis, arthritis etc. Vaccine Live vaccine Question 8 A 15 year old complains of a sore throat, fever and a muffled voice. She stepped on a sharp piece of metal 4 days ago. On examination The adolescent also has trismus. The most likely diagnosis is? 1. 2. 3. 4. 5. Tetanus Retropharyngeal abscess Infectious mononucleosis Peritonsillar abscess Herpangia Question 8 A 15 year old complains of a sore throat, fever and a muffled voice. She stepped on a sharp piece of metal 4 days ago. On examination The adolescent also has trismus. The most likely diagnosis is? 1. 2. 3. 4. 5. Tetanus Retropharyngeal abscess Infectious mononucleosis Peritonsillar abscess Herpangia Key Points #8 Peritonsillar abscesses Adolescent, sore throat, hot potato voice, trismus Dx – exam Organisms –S. aureus. Group A Streptococcus, Anaerobes Retropharyngeal abscess Toddler, stridor, stiff neck, dysphagia, torticollis Dx – CT scan Infectious Mononucleosis Adolescent, sore throat, lymphadepathy, fatigue, fever Tetanus Trismus and muscle spasm C. tetani Treatment Tdap, TIG Penicillin Herpangina Peritonsillar ulcers/vesicles Enteroviral infection Question 9 A 9 month old presents with vesicular lesions on his lips and bleeding gums. He is drooling and unable to eat. On his trunk is a “target lesion rash” In addition to hydration, Which therapeutic regime will be most effective? 1. 2. 3. 4. 5. IV acyclovir IV nafcillin Topical nystatin Topical mupirocin IV steroids Question 9 A 9 month old presents with vesicular lesions on his lips and bleeding gums. He is drooling and unable to eat. On his trunk is a “target lesion rash” In addition to hydration, Which therapeutic regime will be most effective? 1. 2. 3. 4. 5. IV acyclovir IV nafcillin Topical nystatin Topical mupirocin IV steroids Key Points #9 Herpes gingivostomatitis Herpangina Posterior vesicles Candida Young child, anterior vesicles, swollen gums Treatment – supportive, Acyclovir Complication – erythema multiforme Dx – Culture, DFA Cottage cheese plaques on buccal mucosa Impetigo Honey crust lesions on the skin Group A Streptococcus, S. aureus Question 10 A 3 year old presents with a three day history of fever and cough. Today he developed respiratory distress. In addition to supportive care what is the most appropriate treatment plan? 1. 2. 3. 4. 5. CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin Question 10 A 3 year old presents with a three day history of fever and cough. Today he developed respiratory distress. In addition to supportive care what is the most appropriate treatment plan? 1. 2. 3. 4. 5. CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin Key Points #10 Pneumococcal pneumonia Most common bacterial pneumonia Acute, fever, tachypnea, cough, focal infiltrate Round pneumonia Treatment Inpatient – Ceftriaxone Outpatient – High dose Amoxicillin Resistance – Lack of PCP’s Question 11 A 5 year old presents with a month history of cough, fever and weigh loss. His CXR shows a focal infiltrate with hilar lymphadenopathy. A PPD is 7 mm. The most appropriate treatment plan is? 1. 2. 3. 4. 5. Repeat PPD in 3 months Bronchoscopy Gastric lavage Isoniazid for nine months Isoniazid, Rifampin and Ethambutal for 6 months Question 11 A 5 year old presents with a month history of cough, fever and weigh loss. His CXR shows a focal infiltrate with hilar lymphadenopathy. A PPD is 7 mm. The most appropriate treatment plan is? 1. 2. 3. 4. 5. Repeat PPD in 3 months Bronchoscopy Gastric lavage Isoniazid for nine months Isoniazid, Rifampin and Ethambutal for 6 months Key Points # 11 Mycobacterium tuberculosis History PPD Immigrant, insidious, weight loss, hilar nodes 5 mm – high risk – symptoms, HIV 10 mm – medium – age less than 6, immigrant, travel 15 mm – low Diagnosis – gastric lavage Treatment Four drugs then based on sensitivities Side-effects Prophylaxis INH – 9 months Question 12 A ten year old boy presents with a four day history of cough, fever and myalgia. A rapid influenza test was positive two days ago in his physician’s office. Today he became acutely worse and is in respiratory distress. The most appropriate therapy is? 1. 2. 3. 4. 5. Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin Question 12 A ten year old boy presents with a four day history of cough, fever and myalgia. A rapid influenza test was positive two days ago in his physician’s office. Today he became acutely worse and is in respiratory distress. The most appropriate therapy is? 1. 2. 3. 4. 5. Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin Key Points #12 Influenza Fever, cough, myalgia Oseltamivir – within 48 hours Influenza vaccine – 2A, 1B Antigenic shift vs. antigenic drift Complications S. aureus pneumonia MRSA Clindamycin, Vancomycin Question 13 A febrile irritable 20 month old male presents with a two day history of a “crusty” excoriation under his nose This was followed by a diffuse erythematous painful rash. The most likely diagnosis is? 1. 2. 3. 4. 5. Kawasaki disease Staphylococcal scalded skin syndrome Toxic shock syndrome Roseola Enteroviral infection Question 13 A febrile irritable 20 month old male presents with a two day history of a “crusty” excoriation under his nose This was followed by a diffuse erythematous painful rash. The most likely diagnosis is? 1. 2. 3. 4. 5. Kawasaki disease Staphylococcal scalded skin syndrome Toxic shock syndrome Roseola Enteroviral infection Key Points #13 1. Staphylococcal Scalded Skin Syndrome 1. Symptoms 1. 2. Non-toxic, impetigo, painful, sunburn rash, skin peels readily. Toxic Shock Syndrome 1. 2. 3. 4. Hypotension Fever Rash Desquamation 1. Plus three or more organ systems involved Question #14 Which of these infectious diseases often is accompanied by hyponatremia? 1. 2. 3. 4. 5. Roseola Measles Rocky Mountain Spotted Fever Lyme disease Leptospirosis Question #14 Which of these infectious diseases often is accompanied by hyponatremia? 1. 2. 3. 4. 5. Roseola Measles Rocky Mountain Spotted Fever Lyme disease Leptospirosis Key Points # 14 Rocky Mountain Spotted Fever Epidemiology, distal petiechiae, headache, increased LFT’s, hyponatremia Treatment – doxycycline Lyme Disease Northeast, Wisconsin, Northern CA Rash, arthritis (mono), meningitis Treatment Amoxicillin, Doxycycline Ceftriaxone Question #15 A year old child presents with a four day history of irritability and recurrent fevers. Today he is afebrile and had a diffuse erythematous rash on his trunk. You diagnosis the child with roseola. Which of the following is a common complication of this disease? 1. 2. 3. 4. 5. Arthritis Febrile seizures Aseptic meningitis Thrombocytopenia Hepatitis Question #15 A year old child presents with a four day history of irritability and recurrent fevers. Today he is afebrile and had a diffuse erythematous rash on his trunk. You diagnosis the child with roseola. Which of the following is a common complication of this disease? 1. 2. 3. 4. 5. Arthritis Febrile seizures Aseptic meningitis Thrombocytopenia Hepatitis Key Points # 15 Roseola Fever followed by rash Complications HHV6 infection Febrile seizures Complications Parvovirus – arthritis EBV – hepatitis Aseptic meningitis – Kawasaki Thrombocytopenia - RMSF Question 16 A child presents with abdominal pain, arthritis and this rash. What is the most appropriate treatment? 1. 2. 3. 4. 5. Ceftriaxone IVIG Doxycycline Clindamycin Supportive care Question 16 A child presents with abdominal pain, arthritis and this rash. What is the most appropriate treatment? 1. 2. 3. 4. 5. Ceftriaxone IVIG Doxycycline Clindamycin Supportive care Key Point #16 Henoch – Schonlein Purpura Palpable purpura, lower extremities, bloody stools (colitis, intussusception) ,arthritis, hematuria Treatment Supportive Steroids? Differential Diagnosis Meningococcal – Ceftriaxone RMSF – Doxycycline Kawasaki - IVIG Question #17 Which vaccine(s) is (are) not routinely recommended for catch up vaccination for children greater than 5 years of age? 1. 2. 3. 4. 5. Varicella Hib Pneumococcal Hib &Pneumococcal DTaP Question #17 Which vaccine(s) is (are) not routinely recommended for catch up vaccination for children greater than 5 years of age? 1. 2. 3. 4. 5. Varicella Hib Pneumococcal Hib &Pneumococcal DTaP Key Point #17 Hib and Pneumococcal vaccines DTaP No catch up greater than 5 4 doses Varicella Always catch -up Question 18 A fourteen year old male presents to the ED after sustaining a laceration with a lawn motor blade. He cannot recall when he received his last tetanus vaccine. Although his mother say he received all his shots when he was a baby He should receive? 1. 2. 3. 4. 5. Td and TIG TdaP DT TdaP and TIG TIG Question 18 A fourteen year old male presents to the ED after sustaining a laceration with a lawn motor blade. He cannot recall when he received his last tetanus vaccine. Although his mother say he received all his shots when he was a baby He should receive? 1. 2. 3. 4. 5. Td and TIG TdaP DT TdaP and TIG TIG Key Points # 18 DTaP – under 7 TdaP – Adol and Adults Td – greater than 7 DT – less than 7 Vaccine Clean Td /TIG Dirty Td /TIG Unknown or < 3 doses Y/N Y/Y 3+ doses Y/N Y/N If greater 10 yrs If < 5 yrs Question #19 Which of these two vaccine pairs, if not give simultaneously (at the same visit) should be separated by at four least weeks? 1. 2. 3. 4. 5. Hepatitis A and Hepatitis B IPV and Pneumococcal DTaP and Hib MMR and Varicella MMR and Hepatitis B Question #19 Which of these two vaccine pairs, if not give simultaneously (at the same visit) should be separated by at four least weeks? 1. 2. 3. 4. 5. Hepatitis A and Hepatitis B IPV and Pneumococcal DTaP and Hib MMR and Varicella MMR and Hepatitis B Key Points #19 Live vaccines if not given simultaneously need to be separated by 4 weeks Learn contraindications of live vaccines “egg based” vaccines Influenza (injectable) Yellow fever Measles and mumps (chick embryo) Question # 20 A 5 year old presents with fever, jaundice and vomiting. A hepatitis profile reveals: Hepatitis A IgM – negative Hepatitis A IgG- positive Hepatitis BsAg –negative Hepatitis BsAb – positive Hepatitis BcAb – negative Interpretation? 1. 2. 3. 4. 5. Acute hepatitis A and B infections Chronic hepatitis A and B infections Previous vaccination against hepatitis A and B Chronic hepatitis B infection and acute hepatitis B infection Past hepatitis B infection and acute hepatitis B infections Question # 20 A 5 year old presents with fever, jaundice and vomiting. A hepatitis profile reveals: Hepatitis A IgM – negative Hepatitis A IgG- positive Hepatitis BsAg –negative Hepatitis BsAb – positive Hepatitis BcAb – negative Interpretation? 1. 2. 3. 4. 5. Acute hepatitis A and B infections Chronic hepatitis A and B infections Previous vaccination against hepatitis A and B Chronic hepatitis B infection and acute hepatitis B infection Past hepatitis B infection and acute hepatitis B infections Key Points #20 Hepatitis A IgM – Acute IgG – Acute, past, vaccine Tests Results Interpretation BsAg BcAb BsAb Negative Negative Positive Vaccine BsAg BcAb BsAb Negative Positive Positive Past infection BsAg BcAb BsAb Positive Positive Negative Acute infection BsAg BcAb BsAb Positive Positive Negative Chronic infection Question 21 Which of these pathogens pairs typically infect the colon? Salmonella and Rotavirus Shigella and Giardia Campylobacter and Shigella Yesinia and Giardia Salmonella and Helicobacter Question 21 Which of these pathogens pairs typically infect the colon? Salmonella and Rotavirus Shigella and Giardia Campylobacter and Shigella Yesinia and Giardia Salmonella and Helicobacter Key Points # 21 Small intestine Watery, high volume, frequent Rotavirus. Norwalk, Adenoviurs, Giardia Large Intestine Blood, small volume, mucus, travel Salmonella – food, turtles Campylocbacter – unpasteurized milk, GBS Yersina – “chittlings” Shigella – food, neurotoxin E-coli O157H7- food, HUS E-coli – travel associated – watery C. difficle - antibiotics Question 22 An 12 year old returns from a three month trip to India. She complains of a 10 day history of fever, chills, abdominal pain and myalgia. Her examination is unremarkable Lab results WBC – 6,000 Hb – 13.6 Plt – 400,000 AST – 120 Her most likely diagnosis is? 1. 2. 3. 4. 5. Malaria Typhoid fever TB Hepatitis B Yellow fever Question 22 An 12 year old returns from a three month trip to India. She complains of a 10 day history of fever, chills, abdominal pain and myalgia. Her examination is unremarkable Lab results WBC – 6,000 Hb – 13.6 Plt – 400,000 AST – 120 Her most likely diagnosis is? 1. 2. 3. 4. 5. Malaria Typhoid fever TB Hepatitis B Yellow fever Key Points #22 Malaria Typhoid Longer incubation period Hepatitis B Flu- like illness, normal WBC TB Fever, splenomegaly, hemolytic anemia No risk factor for traveling adolescents Yellow fever Africa, South America Question 23 Which is the preferred diagnostic test to confirm an HIV infection in one month old infant born to an HIV positive mother? 1. 2. 3. 4. 5. HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology CD4/CD8 ratio Question 23 Which is the preferred diagnostic test to confirm an HIV infection in one month old infant born to an HIV positive mother? 1. 2. 3. 4. 5. HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology CD4/CD8 ratio Key Points #23 HIV serology can be falsely positive for up to 18 months after birth HIV p24 antigen test – false positives and negatives HIV culture – requires 4 weeks, not readily available Not recommended HIV DNA PCR Not recommended Highly sensitive and specific Considered infected if two separate positive tests CD4/CD8 ratio Not useful in the neonatal period Question 24 A full-term normal-appearing infant was born to a 26-year old female with a history of syphilis during the first trimester of pregnancy, as evidenced by the seroconversion of her VDRL result (titer 1:4, previously nonreactive). The woman received one injection of 2.4 million units of benzathine penicillin. At delivery, her VDRL had a titer of 1:64. In evaluating this infant the appropriate conclusion is that - A. B. C. D. The mother has been adequately treated, and the infant requires no further therapy The infant has a high probability of having congenital syphilis and requires evaluation and treatment If the infant’s long bone radiographs show no abnormality, no treatment is indicated This child may be given a shot of benzathine penicillin, and no further serologic evaluation is necessary Question 24 A full-term normal-appearing infant was born to a 26-year old female with a history of syphilis during the first trimester of pregnancy, as evidenced by the seroconversion of her VDRL result (titer 1:4, previously nonreactive). The woman received one injection of 2.4 million units of benzathine penicillin. At delivery, her VDRL had a titer of 1:64. In evaluating this infant the appropriate conclusion is that - A. B. C. D. The mother has been adequately treated, and the infant requires no further therapy The infant has a high probability of having congenital syphilis and requires evaluation and treatment If the infant’s long bone radiographs show no abnormality, no treatment is indicated This child may be given a shot of benzathine penicillin, and no further serologic evaluation is necessary Key Points #24 Evaluate infants for congenital syphilis if: • Fourfold increase in maternal titer • Infant has clinical manifestations of syphilis • Syphilis is untreated, inadequately treated, or treatment not documented • Mother treated with non-penicillin regimen • Mother treated <1 month before delivery • Treated before pregnancy but with insufficient serologic follow-up Evaluation for syphilis in an infant: • Quantitative nontreponemal serologic test of serum from infant • VDRL test of CSF, cell count, protein concentration • Long-bone Xrays • CBC w/platelets • Other clinically indicated tests (C Xray, LFT’s, US, eye exam, auditory brain stem) • Pathologic examination of placenta or umbilical cord using FTA staining if possible Question 25 A 10-year-old child develops ascending paralysis with peripheral neuropathy (cranial nerves are normal); the CSF is normal except for an elevated protein level. The likely infectious agent precipitating this syndrome is - A. B. C. D. E. Corynebacterium diphtheriae Clostridium botulinum S. dysenteriae serotype 1 Campylobacter jejuni Clostridium tetani Question 25 A 10-year-old child develops ascending paralysis with peripheral neuropathy (cranial nerves are normal); the CSF is normal except for an elevated protein level. The likely infectious agent precipitating this syndrome is - A. B. C. D. E. Corynebacterium diphtheriae Clostridium botulinum S. dysenteriae serotype 1 Campylobacter jejuni Clostridium tetani Keypoints #25 Guillain-Barre Syndrome • Motor polyradiculoneuropathy • Muscle pain, symmetric, ascending paresis with minor sensory abnormality Diagnostic criteria: Required – Progressive muscle weakness of more than 1 limb Areflexia Strongly supportive – Relative symmetry Mild or no sensory Cranial nerve involvement Autonomic dysfunction Absence of fever Disease progression halts by 4 weeks Recovery Keypoint #25 - continued CSF features – Elevated protein after first week Fewer than 10 mononuclear cells Electrodiagnostic features – Nerve conduction slowing Etiology: Campylobacter jejuni CMV EBV M. pneumoniae Vaccine ie., swine flu, Menactra, rabies, tetanus toxoid, Hep. B, influenza, enteroviruses, west nile Food borne diseases (Shighella, Enteroinvasive E. coli, Yersinia enterocolitica, vibrio parahaemolyticus) Question 26 Congenital rubella syndrome is associated with which of the following? A. B. C. D. E. Patent ductus arteriosus (PDA) and branch pulmonary artery stenosis Ventricular septal defect (VSD) and PDA Atrial septal defect (ASD) and PDA VSD and ASD VSD and pulmonary artery stenosis Question 26 Congenital rubella syndrome is associated with which of the following? A. B. C. D. E. Patent ductus arteriosus (PDA) and branch pulmonary artery stenosis Ventricular septal defect (VSD) and PDA Atrial septal defect (ASD) and PDA VSD and ASD VSD and pulmonary artery stenosis Keypoint #26 Congenital Rubella Syndrome Manifestations – • Ophthalmologic Cataracts, pigmentary retinopathy, micro phthalmos congenital glaucoma • Cardiac Patent ductus arteriosus, peripheral pulmonary artery stenosis • Auditory Sensorineural hearing impairment • Neurologic Behavioral disorders, meningoencephalitis, mental retardation • Neonatal Growth retardation, interstitial pneumonitis, radiolucent bone disease, hepatosplenomegaly, thrombacytopenis, dermal erythropoiesis Occurrence of Congenital Defects – • 85% if mother has rash in first 12 weeks • 34% 13-16 weeks • 25% during end of second trimester Question 27 A 4-year-old male is brought to your office because of a circular reddish rash under his armpit. The child has been afebrile and has had no other systemic symptoms. The rash is not pruritic. The child’s parents state that they have recently returned from a vacation in Massachusetts on Cape Cod and that a small tick had been removed from the same area where the rash is now. The only abnormality on the examination is the circular, flat, erythematous rash that is about 6 cm in diameter and is not tender. The appropriate next step in treating this patient is to - A. B. C. D. E. Order a test for serum antibodies against Borrelia burgdorferi to confirm that the child has Lyme disease Begin treatment with doxycycline Begin treatment with amoxicillin Begin treatment with ceftriaxone Perform a lumbar puncture to be certain that the child’s central nervous system (CNS) is not involved. Question 27 A 4-year-old male is brought to your office because of a circular reddish rash under his armpit. The child has been afebrile and has had no other systemic symptoms. The rash is not pruritic. The child’s parents state that they have recently returned from a vacation in Massachusetts on Cape Cod and that a small tick had been removed from the same area where the rash is now. The only abnormality on the examination is the circular, flat, erythematous rash that is about 6 cm in diameter and is not tender. The appropriate next step in treating this patient is to - A. B. C. D. E. Order a test for serum antibodies against Borrelia burgdorferi to confirm that the child has Lyme disease Begin treatment with doxycycline Begin treatment with amoxicillin Begin treatment with ceftriaxone Perform a lumbar puncture to be certain that the child’s central nervous system (CNS) is not involved. Keypoint #27 Lyne Disease • Early localized disease Erthema migrans at site of tick bite • Early disseminated Multiple erythema migrans Cranial nerve palsies Lymphocytic meningitis Conjunctivitis Arthritis Carditis • Late Recurrent arthritis Peripheral neuropathy CNS Diagnosis – • Clinical (EM) during early stages • Clinical and serologic in early disseminated or late • Serology EIA or IFA for screening Western Immunoblot 1 gG 5 bands 1 gM 2 bands Question 28 Primary pulmonary histoplasmosis in normal children is usually - A. B. C. D. E. Asymptomatic Associated with severe flu-like symptoms Treated with assisted ventilation and steroid therapy Associated with sarcoidlike disease Complicated by mediastinal fibrosis Question 28 Primary pulmonary histoplasmosis in normal children is usually - A. B. C. D. E. Asymptomatic Associated with severe flu-like symptoms Treated with assisted ventilation and steroid therapy Associated with sarcoidlike disease Complicated by mediastinal fibrosis Keypoint #28 Histoplasmosis • Causes symptoms in fewer than 5% of infected people • Site (pulmonary, extrapulmonary, disseminated) • Duration (acute, chronic) • Pattern (primary vs. reactivation) • Mississippi, Ohio, Missouri River Valley Coccidiomycosis • Asymptomatic or self-limited 60% • May resemble influenza, diffuse erythematous maculopapular rash, erythema multiforme, erythema nodosum • dissemination to skin, bones, joints, CNS is rare • California, Arizona, New Mexico, Texas, Utah, northern New Mexico, certain areas of Central and South America Blastomycosis • May be asymptomatic or acute, chronic or fulminant disease • Pulmonary and cutaneous lesions • Can disseminate to bones, CNS, abdominal viscera, kidneys • Southeastern and central states and those bordering Great Lakes Question 29 All of the following are consistent with the diagnosis of congenital toxoplasmosis in an infant EXCEPT - A. B. C. D. E. An infant with normal findings on newborn evaluation An infant who is small for gestational age A CSF protein level of 3 g/dL An infant whose mother has no serologic evidence of Toxoplasma gondii infection An infant who mother has AIDS and is chronically infected with T. gondii Question 29 All of the following are consistent with the diagnosis of congenital toxoplasmosis in an infant EXCEPT - A. B. C. D. E. An infant with normal findings on newborn evaluation An infant who is small for gestational age A CSF protein level of 3 g/dL An infant whose mother has no serologic evidence of Toxoplasma gondii infection An infant who mother has AIDS and is chronically infected with T. gondii Keypoint #29 Congenital Toxoplasmosis • Asymptomatic at birth 70-90% • Many will go on to have visual impairment, learning disabilities, mental retardation • At birth, may have maculopapular rash, generalized lymphadenopathy, hepatomegaly, splenomegaly, jaundice, thrombocytopenia • CNS manifestations: hydrocephalus, microcephaly, chorioretinitis, seizures, deafness • Cerebral calcifications are diffuse • Members of cat family are definitive hosts Question 30 A 5-month-old previously healthy female is brought to her pediatrician because of fever, irritability, and poor feeding. She is the second child in her daycare center to be diagnosed with meningitis within a week. She has received all recommended immunizations. The most likely cause of her meningitis is - A. B. C. D. E. Haemophilus influenzae Neisseria meningitidis Group B streptococci Herpes simplex virus Listeria monocytogenes Question 30 A 5-month-old previously healthy female is brought to her pediatrician because of fever, irritability, and poor feeding. She is the second child in her daycare center to be diagnosed with meningitis within a week. She has received all recommended immunizations. The most likely cause of her meningitis is - A. B. C. D. E. Haemophilus influenzae Neisseria meningitidis Group B streptococci Herpes simplex virus Listeria monocytogenes Keypoint #30 Neisseria Meningitidis • Children younger than 5, greatest attack rate in less than 1 year • Adolescents 15-18 years • Freshmen college students who live in dormitories • Close contacts of patients with meningococcal disease • Deficiency of terminal complement, properdin, or anatomic or functional asplenia • A, B, C, Y, W-135 • Meningococcemia, meningitis • Waterhouse-Friderichsen-purpura, DIC, shock, coma, death Question 31 Of the following drugs, the one most commonly associated with acute interstitial nephritis is - A. B. C. D. E. Sulfisoxazole Methicillin Nafcillin Penicillin Phenytoin Question 31 Of the following drugs, the one most commonly associated with acute interstitial nephritis is - A. B. C. D. E. Sulfisoxazole Methicillin Nafcillin Penicillin Phenytoin Keypoint #31 Antibiotic Complications Aminoglycosides • Amikacin, gentamicin, kanamycin, tobramycin, streptomycin • Ototoxicity and nephrotoxicity • Ototoxicity: destruction of cochlear hair cells in the organ of Corti producing a high-frequency irreversible hearing loss (amikacin, kanamycin) • Vestibular dysfunction: damage to vestibular hair cells (streptomycin, gentamicin) • Can occur early or after cessation of antibiotic Tetracyclines • Nausea and vomiting are most common • Hepatotoxicity following high doses, intravenous usage, or in pregnancy • Nephrotoxicity in pre-existing renal disease • Tetracycline-calcium orthophosphate complex that inhibits bone growth in neonates and produces teeth staining • Photosensitivity • Decreased prothrombin activity • Overgrowth of resistant bacterial organisms • Esophageal ulcers • Intravenous administration: pain, phlebitis, tissue injury if extravasation occurs Keypoint #31 - continued Antibiotic Complications Chloramphenicol • Bone marrow suppression 1. Dose, duration related and reversible (>7 days) elevated serum iron, low reticulocyte count, and low hemoglobin 2. Severe, irreversible, idiosyncratic aplastic anemia (occurs anytime during therapy or weeks after) Mechanism: thought to be direct toxicity of nitrosochloramphenicol on DNA Rifamycins • Rifampin, rifabutin • Contraindicated in pregnancy • Orange colored urine, tears and all biologic secretions in 80% of patients • Rapid and potent inducers of CYP3A4, the most abundant human cytochrome P450 found predominately in the liver and small intestine Keypoint #31 - continued Antibiotic Complications Sulfonamides • Rashes are the most common problem • Acute lgE-medicated hypersensitivity reactions and drug-induced lupus erythematosus reactions • Self-resolving granulocytopenia, megaloblastic anemia, thrombocytopenia have been described • Renal failure with crystalluria and reversible hepatocellular dysfunction with jaundice have been described with sulfamethoxazole • Aseptic meningitis Quinolones • Rare adverse reactions: arthralgia, crystalluria, acute renal failure, antibiotic associated colitis, serum sickness like reactions, eosinophilia, leukopenia, thrombocytopenia • Not approved for children <18 years of age • Interference with cartilage growth in beagle puppies • Human studies in cystic fibrosis patients and other infants have failed to show these problems Keypoint #31 - continued Antibiotic Complications Natural Penicillins • Nonfatal anaphylaxis in adults (1/1000 exposures) • Fatal anaphylaxis is rare • Other hypersensitivity reactions: serum sickness, cutaneous rashes, contact dermatitis • Allergic reactions seem to be most prominent with procaine penicillin (up to 90%) • Other reactions: hemolytic anemia, interstitial nephritis, seizures, hyperkalemia associated with high doses or prolonged exposure Cephalosporins • Anaphylaxis • Hypersensitivity reactions may be compound specific (e.g., cefaclor) • Hypersensitivity reactions include interstitial nephritis, autoimmune thrombocytopenia, pulmonary eosinophilia, serum sickness like reaction, drug fever • Seizures and nephrotoxicity associated with high doses and poor renal function • Gastrointestinal upset is most common with oral agents • Ceftriaxone: reversible biliary pseudolithiasis and rapidly fatal immune-mediated hemolytic anemia Keypoint #31 - continued Antibiotic Complications Macrolides • Generalized pruritus, maculopapular rash, serum sickness like reactions, erythema multiforme major associated with large doses or in patients with renal failure • Intravenous administration has been associated with cardiac toxicity (prolonged QT interval, ventricular tachycardia, premature ventricular contractions, nodal bradycardia, sinus arrest), hepatotoxicity, and venous venous irritation (rate associated) Question 32 A gravida 1, para 0 woman is at 38 weeks’ gestation. A vaginal culture taken 48 hours ago is now reported positive for herpes simplex, type II. Her obstetrician asks your advice concerning immediate management of delivery for obstetric reasons. You should advise - A. B. C. D. E. Vaginal delivery after the spontaneous onset of labor Cesarean delivery before the onset of labor Topical treatment with tetramethyl acridine followed by phototherapy and vaginal delivery Immediate induction of labor and vaginal delivery Oral administration of acyclovir to the mother and induction of labor and vaginal delivery Question 32 A gravida 1, para 0 woman is at 38 weeks’ gestation. A vaginal culture taken 48 hours ago is now reported positive for herpes simplex, type II. Her obstetrician asks your advice concerning immediate management of delivery for obstetric reasons. You should advise - A. B. C. D. E. Vaginal delivery after the spontaneous onset of labor Cesarean delivery before the onset of labor Topical treatment with tetramethyl acridine followed by phototherapy and vaginal delivery Immediate induction of labor and vaginal delivery Oral administration of acyclovir to the mother and induction of labor and vaginal delivery Keypoint # 32 Neonatal Herpes Infections • Delivery by C-Section prior to rupture of membranes • Risk of HSV infection at delivery in an infant born vaginally to a mother with primary infection of 33-50% • If born to a mother with reactivated infection of less than 5% • Neonatal HSV may be – 1) disseminated 2) localized to CNS 3) localized to skin, eyes, mouth Question 33 For each of the following sources of infection (1,2,3), select the most likely associated organism (A,B,C,D,E) A. B. C. D. E. 1. 2. 3. Francisella tularensis Giardia intestinalis Toxoplasma gondii Trichinella spiralis Shigella species Contact with cats Drinking water Rabbit-hunting in American southwest Question 33 For each of the following sources of infection (1,2,3), select the most likely associated organism (A,B,C,D,E) A. B. C. D. E. 1. 2. 3. Francisella tularensis Giardia intestinalis Toxoplasma gondii Trichinella spiralis Shigella species Contact with cats Drinking water Rabbit-hunting in American southwest Keypoint #33 Giardia intestinalis • Protozoan that exists in trophozoite and cyst forms • Acute watery diarrhea with abdominal pain • Protracted, intermittent, foul-smelling stools • Humans are reservoir • Can infect dogs, cats, beavers that contaminate water Tularemia • Sources are rabbits, hares, prairie dogs, muskrats, rats, moles, ticks, livestock • Abrupt onset fever, chills, myalgia, headache • Ulceroglandular • Glandular • Oropharyngeal • Intestinal • Pneumonic Question 34 Abdominal pain and bloody diarrhea develop in a 2-year-old boy after completion of a 10-day course of ampicillin for treatment of otitis media. The child is febrile and has abdominal distention. Results of a complete blood count and stool culture are normal. Psuedomembranous lesions are noted on sigmoidoscopy of the colon. The most appropriate medication for this child could be - A. B. C. D. E. Trimethoprim with sulfamethoxazole Metronidazole Chloramphenicol Erythromycin Gentamicin Question 34 Abdominal pain and bloody diarrhea develop in a 2-year-old boy after completion of a 10-day course of ampicillin for treatment of otitis media. The child is febrile and has abdominal distention. Results of a complete blood count and stool culture are normal. Psuedomembranous lesions are noted on sigmoidoscopy of the colon. The most appropriate medication for this child could be - A. B. C. D. E. Trimethoprim with sulfamethoxazole Metronidazole Chloramphenicol Erythromycin Gentamicin Keypoint #34 C. Difficile • Pseudomembranous colitis – diarrhea, abdominal cramps, fever, systemic toxicity, abdominal tenderness, stools with blood and mucous • At risk groups for severe or fatal disease are: leukemics with fever and neutropenia, Hirschsprung, IBD Treatment • Discontinue antibiotics • In severe disease, if diarrhea persists – metronidazole, vancomycin Question 35 The organism most likely responsible for meningitis in a 2-week-old infant is - A. B. C. D. E. Group B streptococcus Escherichia coli Listeria monocytogenes Chlamydia trachomatis Staphylococcus aureus Question 35 The organism most likely responsible for meningitis in a 2-week-old infant is - A. B. C. D. E. Group B streptococcus Escherichia coli Listeria monocytogenes Chlamydia trachomatis Staphylococcus aureus Keypoint #35 Group B Streptococcus • Major cause of invasive disease birth-3 months • Early-onset 0-6 days (most in first day) respiratory distress, apnea, shock, pneumonia and less frequently meningitis • Late-onset 7 days-3 months (most 3-4 weeks) bacteremia, meningitis, osteomyelitis, septic arthritis, adenitis, cellulitis • Pregnant women colonized 15-40% • Maternal intrapartum prophylasix has decreased early-onset GBS by 81% Question 36 For each of the following types of osteomyelitis (1,2,3), select the most likely etiologic agent (A,B,C,D,E) - A. B. C. D. E. 1. 2. 3. Group B streptococcus Pasteurella multocida Salmonella Pseudomonas aeruginosa Hemophilus influenza type b Osteomyelitis in a neonate Osteomyelitis in children with sickle cell disease Osteomyelitis in a patient who has received a puncture would in the foot through a tennis shoe Question 36 For each of the following types of osteomyelitis (1,2,3), select the most likely etiologic agent (A,B,C,D,E) - A. B. C. D. E. 1. 2. 3. Group B streptococcus Pasteurella multocida Salmonella Pseudomonas aeruginosa Hemophilus influenza type b Osteomyelitis in a neonate Osteomyelitis in children with sickle cell disease Osteomyelitis in a patient who has received a puncture would in the foot through a tennis shoe Question 37 For each of the following side effects (1,2,3), select the most likely associated drug (A,B,C,D) - A. B. C. D. 1. 2. 3. Isoniazid Rifampin Streptomycin Ethambutol Hepatitis Inhibition of the metabolism of oral contraceptives Optic neuritis Question 37 For each of the following side effects (1,2,3), select the most likely associated drug (A,B,C,D) - A. B. C. D. 1. 2. 3. Isoniazid Rifampin Streptomycin Ethambutol Hepatitis Inhibition of the metabolism of oral contraceptives Optic neuritis Question 38 For each of the following diseases or disease causing agents (1,2,3,4), select the most appropriate chemotherapeutic agent (A,B,C,D,E) A. B. C. D. E. 1. 2. 3. 4. Podophyllin Acyclovir Metronidazole Trimethoprim with sulfamethoxazole Clotrimazole Vaginal trichomoniasis Vulvovaginal candidosis Human papilloma virus Primary genital herpes simplex infection Question 38 For each of the following diseases or disease causing agents (1,2,3,4), select the most appropriate chemotherapeutic agent (A,B,C,D,E) A. B. C. D. E. 1. 2. 3. 4. Podophyllin Acyclovir Metronidazole Trimethoprim with sulfamethoxazole Clotrimazole Vaginal trichomoniasis Vulvovaginal candidosis Human papilloma virus Primary genital herpes simplex infection Keypoint #38 Trichomonas Vaginalis Infections • Asymptomatic in 90% of men and 50% of women • Frothy vaginal discharge and mild vulvovaginal itching and burning, pale-yellow to green-gray DC, musty odor • More severe symptoms before menses • Deeply erythematous vaginal mucousa, friable cervix • Wet-mount prep • Metronidazole or Tinidazole •Vulvovaginal Candidiasis • C. albicans is most common • Microscopic evaluation and KOH prep • Topical treatment: clotrimazole, miconazole • Oral agents: fluconazole, itraconazole in recurrent or refractory cases Keypoint #38 Human Papilloma Virus • Condylomata Acuminata – skin colored warts with a cauliflower-like surface • In females, occurs in the vulva or perineum, cervix, vagina • In males, penis, scrotum, anus • Clinically inapparent dysplastic lesions can be associated with cancer • HPV involved in 90% of cervical cancers • Podophyllum resin, cryotherapy, laser, surgery Genital Herpes Simplex Infection • Primary – mild clinical manifestations may go on to develop severe or prolonged symptoms • Treat with acyclovir, valcyclovir, famciclovir • Recurrent herpes can be treated episodically or continuously (6 or more/year)