Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed.

SECTION IV. Infectious Diseases


DIRECTIONS: Choose the one best response to each question.

IV-1. Deficits in the complement membrane attack complex (C5-8) are associated with infections of what variety?

A.  Catalase-positive bacteria

B.  Neisseria meningitis

C.  Pseudomonas aeruginosa

D.  Salmonella spp.

E.  Streptococcus pneumoniae

IV-2. A 48-year-old man is admitted to the intensive care unit for treatment of septic shock for an uncertain cause. He was well until 1 day before admission. His family reports that he developed myalgias and fevers at that time. He had no other specific complaints but reportedly had decreased oral intake and generalized malaise. He was brought to the hospital by ambulance this morning when he was lethargic and unresponsive at home. Upon arrival of emergency medical services, his initial blood pressure was 60/40 mmHg with a heart rate of 142 beats/min. He was tachypneic with a respiratory rate of 32 breaths/min with an oxygen saturation of 75% on room air, and his initial temperature was 104.9°F (40.5°C). He was intubated and placed on mechanical ventilation. The patient received 1 L of normal saline before arrival in the emergency department but continues to have hypotension (blood pressure, 75/40 mmHg). Ongoing volume resuscitation is ordered, and the patient is initiated on norepinephrine to maintain adequate blood pressure. The patient has a history of hypertension and hyperlipidemia. He takes amlodipine 10 mg daily and atorvastatin 20 mg daily. His only other history is an automobile accident at age 20 years, requiring exploratory laparotomy and splenectomy. Blood, sputum, and urine cultures are obtained. What are the most appropriate empiric antibiotics for the treatment of this patient?

A.  Ceftriaxone and vancomycin

B.  Ceftriaxone, ampicillin, and vancomycin

C.  Ceftriaxone, vancomycin, and amphotericin B

D.  Clindamycin, gentamicin, and vancomycin

E.  Clindamycin and quinine

IV-3. A 32-year-old woman is admitted to the hospital complaining of right thigh pain. She is treated empirically with oxacillin intravenously for a cellulitis. The admitting physician notes that the degree of pain appears to be disproportionate to the amount of overlying cellulitis. Over the course of the next 24 hours, the patient develops profound septic shock complicated by hypotension, acute renal failure, and evidence of disseminated intravascular coagulation. A CT scan of her right leg demonstrates a collection of fluid with gas in the deep fascia of her right leg. Emergent surgical evacuation is planned. What changes to the patient’s antibiotic therapy would be recommended?

A.  Continue oxacillin and add clindamycin.

B.  Continue oxacillin and add clindamycin and gentamicin.

C.  Discontinue oxacillin and add clindamycin, vancomycin, and gentamicin.

D.  Discontinue oxacillin and add piperacillin/tazobactam and vancomycin.

E.  Discontinue oxacillin and add vancomycin and gentamicin.

IV-4. Which type of bite represents a potential medical emergency in a febrile asplenic patient?

A.  Cat bite

B.  Dog bite

C.  Fish bite

D.  Human bite

IV-5. One goal of immunization programs is to eliminate a specific disease. In 2010, indigenous transmission of which of the following diseases had been eliminated in the United States?

A.  Diphtheria

B.  Mumps

C.  Pertussis

D.  Varicella

E.  None of the above

IV-6. A 63-year-old man has chronic obstructive pulmonary disease and presents to your office for routine follow-up. He has no complaints currently and feels well. He is being managed with tiotropium 18 μg once daily with albuterol metered-dose inhaler as needed. His most recent forced expiratory volume in 1 second (FEV1) was 55% predicted, and he is not on oxygen. He has received one dose of pneumococcal vaccine 5 years previously. He is asking if he should receive another dose of pneumococcal vaccine. According to the guidelines of the Centers for Disease Control and Prevention, what is your recommendation?

A.  He does not require further vaccination unless his FEV1 drops below 50% predicted.

B.  He does not require further vaccination until he reaches age 65 years.

C.  He should be revaccinated today.

D.  He should be revaccinated 10 years after his initial vaccine.

E.  No further vaccination is recommended because a single dose is all that is required.

IV-7. In which of the following patients is it appropriate to administer the vaccination against herpes zoster?

A.  A 35-year-old woman who has never had varicellazoster infection who is 12 weeks pregnant with her first child

B.  A 54-year-old man who has never had varicellazoster infection and is otherwise healthy

C.  A 62-year-old man with HIV on antiretroviral therapy with a CD4+ lymphocyte count of 450/μL

D.  A 64-year-old woman with dermatomyositis-associated interstitial lung disease treated with prednisone 20 mg daily and azathioprine 150 mg daily

E.  A 66-year-old woman who was recently diagnosed with non-Hodgkin lymphoma

IV-8. A 39-year-old woman received a liver transplant 2 years ago and is maintained on prednisone, 5 mg, and cyclosporine, 8 mg/kg per day. She has had two episodes of rejection since transplant, as well an episode of cytomegalo-virus syndrome and Nocardia pneumonia. She intends on taking a 2-week gorilla-watching trip to Rwanda and seeks your advice regarding her health while abroad. Which of the following potential interventions is strictly contraindicated?

A.  Malaria prophylaxis

B.  Meningococcal vaccine

C.  Rabies vaccine

D.  Typhoid purified polysaccharide vaccine

E.  Yellow fever vaccine

IV-9. A 19-year-old woman comes to your office after being bitten by a bat on the ear while camping in a primitive shelter. She is unable to produce a vaccination record. On physical examination, she is afebrile and appears well. There are two small puncture marks on the pinna of her left ear. What is an appropriate vaccination strategy in this context?

A.  Intravenous ribavirin

B.  No vaccination

C.  Rabies immunoglobulins

D.  Rabies inactivated virus vaccine

E.  Rabies inactivated virus vaccine plus immunoglobulins

IV-10. Which of the following immunizations is required for entry into many countries in sub-Saharan Africa?

A.  Hepatitis A

B.  Cholera

C.  Meningococcus

D.  Typhoid fever

E.  Yellow fever

IV-11. A 48-year-old woman is traveling to Haiti with a humanitarian aid group. What is the recommended prophylaxis against malaria for this patient?

A.  Atovaquone–proguanil

B.  Chloroquine

C.  Doxycycline

D.  Mefloquine

E.  Any of the above can be used

IV-12. A 46-year-old man wishes to travel to Kenya for a 2-week vacation. He is HIV positive and is taking antiretroviral therapy. His last CD4+ count was 625/μL and viral load was undetectable. His nadir CD4+ count was 250/μL. He has never had an AIDS-defining illness. In addition to HIV, he has a history of hypertension and is known to have proteinuria caused by to HIV-associated nephropathy. What is your recommendation to this patient regarding his travel plans?

A.  He should not receive the live measles vaccine before travel.

B.  He should receive the yellow fever vaccine before travel.

C.  He will be required to show proof of HIV testing upon entry into the country.

D.  His likelihood of response to the influenza vaccine would be less than 50%.

E.  With a CD4+ count greater than 500/μL, he is at no greater risk during travel than persons without HIV.

IV-13. Which of the following is the most common cause of native valve infective endocarditis in the community?

A.  Coagulase-negative staphylococci

B.  Coagulase-positive staphylococci

C.  Enterococci

D.  Fastidious gram-negative coccobacilli

E.  Non-enterococcal streptococci

IV-14. All of the following are minor criteria in the Duke criteria for the clinical diagnosis of infective endocarditis EXCEPT:

A.  Immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots)

B.  New valvular regurgitation on transthoracic echo-cardiogram

C.  Predisposing condition (heart condition, intravenous drug use)

D.  Temperature >380°C

E.  Vascular phenomena (arterial emboli, septic pulmonary emboli, Janeway lesions, and so on)

IV-15. Which of the following patients should receive antibiotic prophylaxis to prevent infective endocarditis?

A.  A 23-year-old woman with known mitral valve prolapse undergoing a gingival surgery

B.  A 24-year-old woman who had an atrial septal defect completely corrected 22 years ago who is undergoing elective cystoscopy for painless hematuria

C.  A 30-year-old man with a history of intravenous drug use and prior endocarditis undergoing operative drainage of a prostatic abscess

D.  A 45-year-old man who received a prosthetic mitral valve 5 years ago undergoing routine dental cleaning

E.  A 63-year-old woman who received a prosthetic aortic valve 2 years ago undergoing screening colonoscopy

IV-16. A 38-year-old homeless man presents to the emergency department with a transient ischemic attack characterized by a facial droop and left arm weakness lasting 20 minutes and left upper quadrant pain. He reports intermittent subjective fevers, diaphoresis, and chills for the past 2 weeks. He has had no recent travel or contact with animals. He has taken no recent antibiotics. Physical examination reveals a slightly distressed man with disheveled appearance. His temperature is 38.2°C, heart rate is 90 beats/min, and blood pressure is 127/74 mmHg. He has poor dentition. Cardiac examination reveals an early diastolic murmur over the left third intercostal space. His spleen is tender and 2 cm descended below the costal margin. He has tender painful red nodules on the tips of the third finger of his right hand and on the fourth finger of his left hand that are new. He has nits evident on his clothes consistent with body louse infection. His white blood cell count is 14,500/μL with 5% band forms and 93% polymorphonuclear cells. Blood cultures are drawn followed by empirical vancomycin therapy. These cultures remain negative for growth 5 days later. He remains febrile but hemodynamically stable but does develop a new lesion on his toe similar to those on his fingers on hospital day 3. A transthoracic echocardiogram reveals a 1-cm mobile vegetation on the cusp of his aortic valve and moderate aortic regurgitation. A CT scan of the abdomen shows an enlarged spleen with wedge-shaped splenic and renal infarctions. What test should be sent to confirm the most likely diagnosis?

A.  Bartonella serology

B.  Epstein-Barr virus (EBV) heterophile antibody

C.  HIV polymerase chain reaction (PCR)

D.  Peripheral blood smear

E.  Q fever serology

IV-17. In a patient with bacterial endocarditis, which of the following echocardiographic lesions is most likely to lead to embolization?

A.  5-mm mitral valve vegetation

B.  5-mm tricuspid valve vegetation

C.  11-mm aortic valve vegetation

D.  11-mm mitral valve vegetation

E.  11-mm tricuspid valve vegetation

IV-18. A patient is admitted with fevers, malaise, and diffuse joint pains. His initial blood cultures reveal methicillin-resistant Staphylococcus aureus (MRSA) in all culture bottles. He has no arthritis on examination, and his renal function is normal. Echocardiogram shows a 5-mm vegetation on the aortic valve. He is initiated on IV vancomycin at 15 mg/kg every 12 hours. Four days later, the patient remains febrile, and cultures remain positive for MRSA. In addition to a search for embolic foci of infection, which of the following changes would you make to his treatment regimen?

A.  No change.

B.  Add gentamicin.

C.  Add rifampin.

D.  Check the vancomycin serum peak and trough levels and consider tid dosing.

E.  Discontinue vancomycin, start daptomycin.

IV-19. All of the following organisms may cause bullae as a manifestation of their infection except:

A.  Clostridium perfringens

B.  Sporothrix schenckii

C.  Staphylococcus aureus

D.  Streptococcus pyogenes

E.  Vibrio vulnificus

IV-20. A 24-year-old man with no past medical history is brought to the emergency department complaining of left-sided chest pain for 2 days. He reports the skin over his left chest is tender and swollen. He has no history of HIV risk behavior and works as a landscaper. His physical examination is notable for a heart rate of 110 beats/min, blood pressure of 108/62 mmHg, and temperature of 101.8°F. He has pain and swelling of the left chest. His electrocardiogram is normal. A noncontrast CT scan of the chest (Figure IV-20) is obtained. Which of the following organisms is most likely causing his illness?



A.  Coxsackie virus A16

B.  Mycobacterium tuberculosis

C.  Rickettsia akari

D.  Streptococcus pyogenes

E.  Varicella-zoster virus

IV-21. All of the following statements regarding the etiology and epidemiology of osteomyelitis are true EXCEPT:

A.  After a foot puncture, 30% to 40% of patients with diabetes develop osteomyelitis.

B.  In patients with prosthetic joints, Staphylococcus aureus bacteremia will cause osteomyelitis in 25% to 30% of cases.

C.  Mycobacterium tuberculosis is an uncommon cause of osteomyelitis.

D.  The foremost bacterial cause of osteomyelitis is Staphylococcus aureus.

E.  The morbidity and economic consequences of MRSA osteomyelitis are greater than for MSSA osteomyelitis.

IV-22. A 79-year-old man has had a diabetic foot ulcer overlying his third metatarsal head for 3 months but has not been compliant with his physician’s request to offload the affected foot. He presents with dull, throbbing foot pain and subjective fevers. Examination reveals a putrid-smelling wound notable also for a pus-filled 2.5-cm-wide ulcer. A metal probe is used to probe the wound, and it detects bone as well as a 3-cm deep cavity. Gram stain of the pus shows gram-positive cocci in chains, gram-positive rods, gram-negative diplococci, enteric-appearing gram-negative rods, tiny pleomorphic gram-negative rods, and a predominance of neutrophils. Which of the following empirical antibiotic regimens is recommended while blood and drainage cultures are processed?

A.  Ampicillin–sulbactam, 1.5 g IV q4h

B.  Clindamycin, 600 mg PO tid

C.  Linezolid, 600 mg IV bid

D.  Metronidazole, 500 mg PO qid

E.  Vancomycin, 1 g IV bid

IV-23. A 45-year-old man with a history of alcoholism and presumed cirrhosis is brought to the emergency department by his friend complaining of 2 to 3 days of increasing lethargy and confusion. He has not consumed alcohol in the past 2 years. He currently takes no medications and works at home as a video game designer. He has no risk factors for HIV. He was referred by his primary care physician for a liver transplant evaluation and is scheduled to begin his evaluation next month. His vital signs included blood pressure of 90/60 mmHg, heart rate of 105 beats/min, temperature of 38.5°C, and respiratory rate of 10 breaths/min with O2 saturation of 97% on room air. He is somnolent but is able to answer questions accurately. His skin is notable for many spider telangiectasias and palmar erythema. He has a distended diffusely tender abdomen with a positive fluid wave. Paracentesis reveals slightly cloudy fluid with WBC 1000/μL and 40% neutrophils. His blood pressure increases to 100/65 mmHg, and his heart rate decreases to 95 beats/min after 1 L of intravenous fluids. Which of the following statements regarding his condition and treatment is true?

A.  Fever is present in more than 50% of cases.

B.  Initial empiric therapy should include metronidazole or clindamycin for anaerobes.

C.  The diagnosis of primary (spontaneous) bacterial peritonitis is not confirmed because the percentage of neutrophils in the peritoneal fluid is less than 50%.

D.  The mostly causative organism for his condition is enterococcus.

E.  The yield of peritoneal fluid cultures for diagnosis is greater than 90%.

IV-24. A 48-year-old woman with a history of end-stage renal disease caused by diabetic renal disease is admitted to the hospital with 1 day of abdominal pain and fever. She has been on continuous ambulatory peritoneal dialysis (CAPD) for the past 6 months. She reports that for the past day she has had poor return of dialysate and is feeling bloated. She has had complications from her diabetes, including retinopathy and peripheral neuropathy. She is uncomfortable but not toxic. Her vital signs include a temperature of 38.8°C, blood pressure of 130/65 mmHg, heart rate of 105 beats/min, and respiratory rate of 15 breaths/min with room air O2 saturation of 98%. Her abdomen is slightly distended and diffusely tender with rebound tenderness. A sample of dialysate reveals WBC 400/μL with 80% neutrophils. Empiric intraperitoneal antibiotic therapy should include:

A.  Cefoxitin

B.  Fluconazole

C.  Metronidazole

D.  Vancomycin

E.  Voriconazole

IV-25. A 77-year-old man presents to the hospital with 1 week of fever, chills, nausea, and right upper quadrant pain. His temperature is 39°C, and he appears toxic. His blood pressure is 110/70 mmHg, heart rate is 110 beats/min, and respiratory rate is 22 breaths/min with room air O2 saturation 92%. He has diminished breath sounds at the right base and diffuse tenderness in the right upper quadrant. He has a history of cholelithiasis but has declined elective cholecystectomy. His CT scan of the abdomen is shown in Figure IV-25A. Which of the following statements regarding his condition or therapy is true?



A.  Concomitant bacteremia is rare (<10%).

B.  He should receive empiric antibiotics targeting Candida species.

C.  He should receive empiric antibiotics targeting anaerobic organisms.

D.  He should undergo percutaneous drainage.

E.  His serum alkaline phosphatase is most likely normal.

IV-26. A 41-year-old man with hepatitis C–associated ascites presents with acute abdominal pain. Physical examination is notable for temperature of 38.3°C, heart rate of 115 beats/min, blood pressure of 88/48 mmHg, respiratory rate of 16 breaths/min, and oxygen saturation of 99% on room air. The patient is in moderate discomfort and is lying still. He is alert and oriented. His lungs are clear. Cardiac examination is unremarkable. His abdomen is diffusely tender with distant bowel sounds, mild guarding, and no rebound tenderness. Laboratory studies reveal a leukocyte count of 11,630/μL with 94% neutrophils, hematocrit of 29%, and platelet count of 24,000/μL. Paracentesis reveals 658 PMNs/μL, total protein of 1.2 g/dL, and glucose of 24 mg/dL and Gram stain showing gram-negative rods, gram-positive cocci in chains, gram-positive rods, and yeast forms. All of the following are indicated EXCEPT:

A.  Abdominal radiograph

B.  Broad-spectrum antibiotics

C.  Drotrecogin alfa

D.  Intravenous fluid

E.  Surgical consultation

IV-27. Enteric pathogens can produce diarrheal illness through a variety of mechanisms that lead to specific clinical characteristics. All of the following are characteristics of diarrhea caused by Vibrio cholerae EXCEPT:

A.  Disease localized to the proximal small intestine

B.  Fecal leukocytes

C.  Fecal lactoferrin

D.  Toxin production

E.  Watery diarrhea

IV-28. A 46-year-old woman travels to a rural area of Guatemala. Three days after arrival, she develops watery diarrhea with severe abdominal cramping. She reports two unformed stools daily for the past 2 days. She has noticed no blood in the stool and has not experienced a fever. What is the most likely cause of the patient’s illness?

A.  Campylobacter jejuni

B.  Enterotoxigenic Escherichia coli

C.  Giardia lamblia

D.  Norovirus

E.  Shigella spp.

IV-29. For the case above, which of the following treatments would you recommend?

A.  Azithromycin 10 mg/kg on day 1 with 5 mg/kg on days 2 and 3 if the diarrhea persists

B.  Ciprofloxacin 500 mg three times daily for 5 days

C.  Ciprofloxacin 750 mg once

D.  Loperamide 4 mg once followed by 2 mg after passage of each unformed stool

E.  Oral rehydration therapy only

IV-30. Two hours after attending a company picnic, many individuals who attended the picnic develop an acute gastrointestinal illness. Food poisoning caused by Staphylococcus aureus is suspected. All of the following characteristics would be a common feature of food poisoning due to this organism EXCEPT:

A.  Abdominal cramping

B.  Diarrhea

C.  Fever

D.  Vomiting

IV-31. You are the on-call physician practicing in a suburban community. You receive a call from a 28-year-old woman with a past medical history significant for sarcoidosis who is currently taking no medications. She is complaining of an acute onset of crampy diffuse abdominal pain and multiple episodes of emesis that are nonbloody. She has not had any lightheadedness with standing or loss of consciousness. When questioned further, the patient states that her last meal was 5 hours previously, when she joined her friends for lunch at a local Chinese restaurant. She ate from the buffet, which included multiple poultry dishes and fried rice. What should you do for this patient?

A.  Ask the patient to go to the nearest emergency department for resuscitation with IV fluids.

B.  Initiate antibiotic therapy with azithromycin.

C.  Reassure the patient that her illness is self-limited and no further treatment is necessary if she can maintain adequate hydration.

D.  Refer the patient for CT to assess for appendicitis.

E.  Refer the patient for admission for IV vancomycin and ceftriaxone because of her immunocompromised state resulting from sarcoidosis.

IV-32. Which of the following is a common manifestation of Clostridium difficile infection?

A.  Fever

B.  Nonbloody diarrhea

C.  Adynamic ileus

D.  Recurrence after therapy

E.  All of the above

IV-33. All of the following patients should be treated for Clostridium difficile infection EXCEPT:

A.  A 57-year-old nursing home resident with diarrhea for 2 weeks and pseudomembranes found on colon-oscopy with no evidence of toxin A or B in the stool

B.  A 63-year-old woman with fever, leukocytosis, adynamic ileus, and a positive PCR for C. difficile in the stool

C.  A 68-year-old woman with recent course of antibiotics admitted to the medical intensive care unit after presentation to the emergency department with abdominal pain and diarrhea. She was found to have severe abdominal tenderness with absent bowel sounds, systemic hypotension, and colonic wall thickening on CT of the abdomen.

D.  A 75-year-old woman who received recent therapy with amoxicillin for an upper respiratory tract infection and now has two loose bowel movements per day for the past 3 days

IV-34. A 78-year-old woman with dementia has been living in a nursing home for 5 years. She was been seen by her primary care provider for evaluation of diarrhea 4 weeks ago. At that time, a stool sample was positive by PCR for Clostridium difficile, and she was treated with oral metronidazole with some improvement in her symptoms. However, she has had five loose bowel movements per day starting 4 days ago and now has abdominal tenderness. Stool PCR remains positive. Which of the following is the most appropriate therapy?

A.  Fecal transplantation

B.  IV immunoglobulin

C.  Oral metronidazole

D.  Oral nitazoxanide

E.  Oral vancomycin

IV-35. Which of the following antibiotics has the weakest association with the development of Clostridium difficile–associated disease?

A.  Ceftriaxone

B.  Ciprofloxacin

C.  Clindamycin

D.  Moxifloxacin

E.  Piperacillin/tazobactam

IV-36. All of the following are common causes of urethritis in men EXCEPT:

A.  Gardnerella vaginalis

B.  Mycoplasma genitalium

C.  Neisseria gonorrhoeae

D.  Trichomonas vaginalis

E.  Ureaplasma urealyticum

IV-37. A 25-year-old woman presents with 2 days of urinary frequency, urgency, and pelvic discomfort. She has no pain in her vulva on urination. She has no other medical problems and does not have fevers. She is sexually active. A microscopic examination of her urine shows pyuria but no pathogens. After 24 hours, her urine culture does not grow any pathogens. Which of the following tests will likely confirm her diagnosis?

A.  Cervical culture

B.  Clue cells on microscopy of vaginal secretions

C.  Nucleic acid amplification test of urine for C. trachomatis

D.  Physical examination of the vulva and vagina

E.  Vaginal pH ≥5.0

IV-38. Which of the following diagnostic features characterizes bacterial vaginosis?

A.  Scant vaginal secretions, erythema of vaginal epithelium, and clue cells

B.  Vaginal fluid pH >4.5, clue cells, and profuse mixed microbiota on microscopic examination

C.  Vaginal fluid pH ≥5.0, motile trichomonads on microscopic exam, and fishy odor with 10% KOH

D.  Vaginal fluid pH <4.5, lactobacilli predominate on microscopic examination, and scant clear secretions

E.  Vaginal fluid pH <4.5, clue cells, and profuse mixed microbiota on microscopic examination

IV-39. Which of the following is most likely to be identified in a woman seen at a sexually transmitted disease clinic with mucopurulent cervicitis?

A.  Chlamydia trachomatis

B.  Herpes simplex virus

C.  Neisseria gonorrhoeae

D.  Trichomonas vaginalis

E.  No organism identified

IV-40. A 19-year-old woman is seen in the emergency department for pelvic pain. She reports 1 week of pain but has developed more severe pain on the right side of her lower abdomen over the past day with accompanying fever. Additionally, she reports pain in her right upper abdomen for the past day that is worsened by deep breathing. She is sexually active with multiple partners and only reports a past medical history of asthma. Examination is notable for fever, normal breath sounds, mild tachycardia, and a tender right upper quadrant without rebound, guarding, or masses. Pelvic examination shows a normal cervical appearance, but cervical motion tenderness and adnexal tenderness are present. No masses are palpated. A urine pregnancy test result is negative and leukocytosis is present, but otherwise renal and liver function laboratory study results are normal. Which of the following is true regarding her right upper quadrant tenderness?

A.  Acute cholecystitis is likely present; a tech HIDA scan should be ordered to confirm the diagnosis.

B.  If a liver biopsy were performed, herpes simplex virus could be cultured from the liver tissue.

C.  Laproscopic examination would show inflammation of her liver capsule.

D.  Plasma PCR is indicated for diagnosis of acute hepatitis C virus (HCV) infection as the etiology of her hepatitis.

E.  CT scan of the chest would confirm the presence of septic pulmonary emboli.

IV-41. A 23-year-old college student is seen in the student health clinic for evaluation of multiple genital ulcers that he noted developing over the past week. They started as pustules and after suppuration are now ulcers. The ulcers are extremely tender and occasionally bleed. Examination shows multiple bilateral deep ulcers with purulent bases that bleed easily. They are exquisitely tender but are soft to palpation. Which of the following organisms are likely to be found on culture of the lesions?

A.  Haemophilus ducreyi

B.  Herpes simplex virus

C.  Human immunodeficiency virus

D.  Neisseria gonorrhoeae

E.  Treponema pallidum

IV-42. All of the following infections associated with sexual activity correlate with increased acquisition of HIV infection in women EXCEPT:

A.  Bacterial vaginosis

B.  Chlamydia

C.  Gonorrhea

D.  Herpes simplex virus-2

E.  Trichomonas vaginalis

F.  All of the above are associated with increased acquisition

IV-43. After leaving which of the following patient’s room would the use of alcohol-based hand rub be inadequate?

A.  A 54-year-old man with quadriplegia admitted with a urinary tract infection caused by extended-spectrum β-lactamase–producing bacteria

B.  A 78-year-old nursing home resident with recent antibiotic use and Clostridium difficile infection

C.  A 35-year-old woman with advanced HIV and cavitary pulmonary tuberculosis

D.  A 20-year-old renal transplant recipient with varicella pneumonia

E.  A 40-year-old man with MRSA furunculosis

IV-44. During the first 2 weeks after solid organ transplantation, which family of infection is most common?

A.  Cytomegalovirus and Epstein-Barr virus reactivation

B.  Humoral immunodeficiency–associated infections (e.g., meningococcemia, invasive Streptococcus pneumoniae infection)

C.  Neutropenia-associated infection (e.g., aspergillosis, candidemia)

D.  T-cell deficiency–associated infections (e.g., Pneumocystis jiroveci, nocardiosis, cryptococcosis)

E.  Typical hospital-acquired infections (e.g., central line infection, hospital-acquired pneumonia, urinary tract infection)

IV-45. A 22-year-old woman underwent cadaveric renal transplantation 3 months ago for congenital obstructive uropathy. After a demanding college examination schedule during which she forgot to take some of her medications, she is admitted to the hospital with a temperature of 102°F, arthralgias, lymphopenia, and a rise in creatinine from her baseline of 1.2 mg/dL to 2.4 mg/dL. Which of the following medications did she most likely forget?

A.  Acyclovir

B.  Isoniazid

C.  Itraconazole

D.  Trimethoprim–sulfamethoxazole

E.  Valganciclovir

IV-46. Which of the following pathogens are cardiac transplant patients at unique risk for acquiring from the donor heart early after transplant when compared to other solid organ transplant patients?

A.  Cryptococcus neoformans

B.  Cytomegalovirus

C.  Pneumocystis jiroveci

D.  Staphylococcus aureus

E.  Toxoplasma gondii

IV-47. A 43-year-old woman undergoes allogeneic stem cell transplantation for acute myelogenous leukemia. Two weeks after the date of her transplantation, she is admitted to the hospital with a temperature of 101.1°F, pulse of 115 beats/min, blood pressure of 110/83 mmHg, and oxygen saturation of 89% on room air. Her white blood cell count is 500/μL, and 20% are polymorphonuclear cells. Because of hypoxia and infiltrates on plain chest radiograph, a CT scan is ordered. She is found to have diffuse nodules and masses, some with a halo sign. Which of the following tests is most likely to be diagnostic of her disease?

A.  Microscopic examination of buffy coat

B.  Plasma CMV viral load

C.  Serum galactomannan antigen test

D.  Sputum culture

E.  Urine Legionella assay

IV-48. Which of the following antibiotics inhibit cell wall synthesis?

A.  Ciprofloxacin, metronidazole, and quinupristin/dalfopristin

B.  Rifampin, sulfamycin, and clindamycin

C.  Tetracycline, daptomycin, and azithromycin

D.  Tobramycin, chloramphenicol, and linezolid

E.  Vancomycin, bacitracin, and penicillin

IV-49. A 23-year-old college student is admitted to the hospital with a fever and painful, erythematous purulent nodules on his forearm. He is an avid weightlifter and other than depression treated with citalopram has been otherwise healthy. These lesions have been present for approximately 1 week, and his primary care physician attempted to treat him with clindamycin as an outpatient. After admission, he develops hypotension and evidence of systemic inflammatory response syndrome, prompting transfer to the medical intensive care unit. There, dopamine is started, linezolid is administered, and hydrocortisone and fludrocortisone are given for possible adrenal insufficiency in the context of septic shock. After 6 hours, he develops an agitated delirium with diaphoresis, tachycardia, a temperature of 103.4°F, and diarrhea. His examination is notable for tremor; muscular rigidity; hyperreflexia; and clonus, especially in the lower extremities. Which of the following drug–drug interactions is most likely the culprit of this clinical syndrome?

A.  Citalopram–dopamine

B.  Citalopram–linezolid

C.  Dopamine–fludrocortisone

D.  Dopamine–linezolid

E.  Fludrocortisone–linezolid

IV-50. All of the following statements regarding pneumococcus are true EXCEPT:

A.  Asymptomatic colonization does not occur.

B.  Infants (younger than 2 years old) and elderly adults are at greatest risk of invasive disease.

C.  Pneumococcal vaccination has impacted the epidemiology of disease.

D.  The likelihood of death within 24 hours of hospitalization for patients with invasive pneumococcal pneumonia has not changed since the introduction of antibiotics.

E.  There is a clear association between prior viral upper respiratory infection and secondary pneumococcal pneumonia.

IV-51. A 75-year-old man who resides at a nursing home is brought to the hospital for altered mental status over 1 day. He has a history of Parkinson’s disease and COPD. Staff noticed that he was somnolent and confused on the day of admission. In the emergency department, his temperature is 38.5°C, blood pressure is 95/65 mmHg, heart rate is 105 beats/min, respiratory rate is 24 breaths/min, and room air oxygen saturation is 85%. He has egophony over the right posterior lung field. His chest radiograph is shown in Figure IV-51. All of the statements regarding this patient are true EXCEPT:



A.  Blood cultures are unlikely (<30%) to be positive.

B.  His radiograph demonstrates lobar consolidation.

C.  Meningitis is the most common focal complication.

D.  Penicillin may be appropriate therapy.

E.  Urinary antigen testing could be diagnostic.

IV-52. A 19-year-old college student is brought to the emergency department by friends from his dormitory for confusion and altered mental status. They state that many students have upper respiratory tract infections. He does not use alcohol or illicit drugs. His physical examination is notable for confusion, fever, and a rigid neck. Cerebro-spinal fluid (CSF) examination reveals a white blood cell count of 1800 cells/μL with 98% neutrophils, glucose of 1.9 mmol/L (35 mg/dL), and protein of 1.0 g/L (100 mg/dL). Which of the following antibiotic regimens is most appropriate as initial therapy?

A.  Ampicillin plus vancomycin

B.  Ampicillin plus gentamicin

C.  Cefazolin plus doxycycline

D.  Cefotaxime plus doxycycline

E.  Cefotaxime plus vancomycin

IV-53. In addition to antibiotics, which of the following adjunctive therapies should be administered to improve the chance of a favorable neurologic outcome in the patient in question IV-52?

A.  Dexamethasone

B.  Dilantin

C.  Gabapentin

D.  L-Dopa

E.  Parenteral nutrition

IV-54. Which of the following biochemical tests distinguishes S. aureus from S. epidermidis?

A.  Catalase

B.  Coagulase

C.  Lactose fermentation

D.  Oxidase

E.  Urease

IV-55. A 30-year-old woman with end-stage renal disease who receives her dialysis through a tunneled catheter in her shoulder presents with fever and severe low back pain. On examination, she is uncomfortable and diaphoretic but hemodynamically stable. She has a soft 2/6 early systolic flow murmur. Her line site is red and warm with no pustular exudates. She is very tender over her lower back. Neurologically, she is completely intact. There is no evidence of Janeway lesions, Osler nodes, or Roth spots. Her white count is 16,700/μL with 12% bands. Immediate evaluation should include all of the following EXCEPT:

A.  Admission to the hospital

B.  MRI of the lumbar spine

C.  Removal of her dialysis catheter

D.  Transthoracic echocardiogram

E.  Two sets of blood cultures followed by empiric therapy with vancomycin plus cefepime

IV-56. A 30-year-old healthy woman presents to the hospital with severe dyspnea, confusion, productive cough, and fevers. She had been ill 1 week earlier with a flulike illness characterized by fever, myalgias, headache, and malaise. Her illness almost entirely improved without medical intervention until 36 hours ago, when she developed new rigors followed by progression of the respiratory symptoms. On initial examination, her temperature is 39.6°C, pulse is 130 beats/min, blood pressure is 95/60 mmHg, respiratory rate is 40 breaths/min, and oxygen saturation is 88% on 100% face mask. On examination, she is clammy, confused, and very dyspneic. Lung examination reveals amphoric breath sounds over her left lower lung fields. She is intubated and resuscitated with fluid and antibiotics. Chest CT scan reveals necrosis of her left lower lobe. Blood and sputum cultures grow Staphylococcus aureus. This isolate is likely to be resistant to which of the following antibiotics?

A.  Doxycycline

B.  Linezolid

C.  Methicillin

D.  Trimethoprim–sulfamethoxazole (TMP/SMX)

E.  Vancomycin

IV-57. In the patient described above, all of the following may be efficacious therapy EXCEPT:

A.  Daptomycin

B.  Linezolid

C.  Quinupristin/dalfopristin

D.  Telavancin

E.  Vancomycin

IV-58. Which of the following organisms is most likely to cause infection of a shunt implanted for the treatment of hydrocephalus?

A.  Bacteroides fragilis

B.  Corynebacterium diphtheriae

C.  Escherichia coli

D.  Staphylococcus aureus

E.  Staphylococcus epidermidis

IV-59. A 42-year-old man with poorly controlled diabetes (HbA1c, 13.3%) presents with thigh pain and fever over several weeks. Physical examination reveals erythema and warmth over the thigh with notable woody, nonpitting edema. There are no cutaneous ulcers. CT of the thigh reveals several abscesses located between the muscle fibers of the thigh. Orthopedics is consulted to drain and culture the abscesses. Which of the following is the most likely pathogen?

A.  Clostridium perfringens

B.  Group A streptococcus

C.  Polymicrobial flora

D.  Staphylococcus aureus

E.  Streptococcus milleri

IV-60. A 19-year-old woman from Guatemala presents to your office for a routine screening physical examination. At age 4 years, she was diagnosed with acute rheumatic fever. She does not recall the specifics of her illness and remembers only that she was required to be on bed rest for 6 months. She has remained on penicillin V orally at a dose of 250 mg bid since that time. She asks if she can safely discontinue this medication. She has had only one other flare of her disease, at age 8 years, when she stopped taking penicillin at the time of her emigration to the United States. She is currently working as a day care provider. Her physical examination is notable for normal point of maximal impulse (PMI) with a grade III/VI holosystolic murmur that is heard best at the apex of the heart and radiates to the axilla. What do you advise the patient to do?

A.  An echocardiogram should be performed to determine the extent of valvular damage before deciding if penicillin can be discontinued.

B.  Penicillin prophylaxis can be discontinued because she has had no flares in 5 years.

C.  She should change her dosing regimen to IM benzathine penicillin every 8 weeks.

D.  She should continue on penicillin indefinitely because she had a previous recurrence, has presumed rheumatic heart disease, and is working in a field with high occupational exposure to group A streptococcus.

E.  She should replace penicillin prophylaxis with polyvalent pneumococcal vaccine every 5 years.

IV-61. A 36-year-old man is brought to the hospital by his wife because of a rapidly worsening skin infection. The patient has a history of type 1 diabetes, and his last documented HbA1c was 5.5%. His wife reports that he had a small insect bite on his calf a few days ago with some redness. Over the course of today, he has developed severe thigh pain initially with no redness, but over the past hour, he has had worsening pain and swelling with some mottling of the skin. He also reports that he feels like his thigh and calf are numb. He is febrile and tachycardic. Physical examination reveals marked tenderness and tenseness of the right leg from the thigh down. There is some redness and mottling. A femoral and posterior tibial pulse are present. CT scan of the leg shows extensive inflammation of the fascial planes but no evidence of muscle inflammation. Which of the following organisms is most likely responsible for his infection?

A.  Clostridium difficile

B.  Staphylococcus aureus

C.  Staphylococcus epidermidis

D.  Streptococcus pneumonia

E.  Streptococcus pyogenes

IV-62. A 24-year-old woman is brought to the hospital by her husband with fever and severe abdominal pain. She lives in rural Pennsylvania and home delivered a child 2 days ago. She did not receive routine prenatal care. Her labor was difficult with delivery over 18 hours after membrane rupture. Her baby has been feeding well over the past 48 hours and has had no fever. The patient noticed she had low-grade fever 24 hours after birth, and her abdominal pain has developed over the past 12 hours. She is febrile to 39°C and is tachycardic. Abdominal examination is notable for marked tenderness in the lower abdomen. A pelvic examination shows a purulent material emanating from her cervix with marked adnexal tenderness. A Gram stain shows extensive neutrophils and gram-positive cocci in chains. Which of the following organisms is the most likely cause of her disease?

A.  Chlamydia trachomatis

B.  Gardnerella vaginalis

C.  Neisseria gonorrhea

D.  Streptococcus agalactiae

E.  Trichomonas vaginalis

IV-63. All of the following statements regarding enterococci are true EXCEPT:

A.  Enterococci are the second most common cause of hospital-acquired infections.

B.  Infection with vancomycin-resistant strains of enterococci (VRE) does not increase the patient’s risk of death compared with infection with vancomycin-sensitive strains of enterococci.

C.  Patients with GI colonization by VRE are more likely to develop bacteremia than patients with GI colonization by vancomycin-sensitive strains of enterococci.

D.  Physical proximity to a room colonized with VRE is a risk factor for patients developing gut colonization with VRE.

E.  Strains of E. faecium are more likely to be resistant to vancomycin than strains of E. faecalis.

IV-64. A 74-year-old man with a recent history of diver-ticulitis is admitted to the hospital with 1 week of fever, malaise, and generalized weakness. His physical examination is notable for a temperature of 38.5°C, a new mitral heart murmur, and splinter hemorrhages. Three blood cultures grow Enterococcus faecalis, and an echocardiogram shows a small vegetation on the mitral valve. The organism is reported as being sensitive to ampicillin with no high-level resistance to aminoglycosides. Based on this information, which of the following is recommended therapy?

A.  Ampicillin

B.  Ampicillin plus gentamicin

C.  Daptomycin

D.  Linezolid

E.  Tigecycline

IV-65. Which of the following drugs is bactericidal and approved by the FDA for some infections caused by vancomycin-resistant E. faecium?

A.  Ceftriaxone

B.  Cefoxitin

C.  Linezolid

D.  Quinupristin/dalfopristin

E.  Vancomycin

IV-66. A 42-year-old man with HIV has been developing worsening disease because of HAART resistance and worsening viremia. Over the past 6 months, his CD4 T-cell count has fallen below 100/μL. He has not been compliant with prophylactic medication because he is tired of taking pills. He comes to clinic reporting 3 weeks of productive cough and low-grade fever. A chest radiograph shows multiple small necrotizing nodules in the bilateral lower lobes. A percutaneous needle biopsy reveals some neutrophils and small gram-positive coccobacilli that the laboratory says looks like corynebacterium. A culture grows Rhodococcus equi. All of the following are effective therapy EXCEPT:

A.  Azithromycin

B.  Cefotaxime

C.  Linezolid

D.  Tigecycline

E.  Vancomycin

IV-67. An 87-year-old nursing home resident is brought by ambulance to a local emergency department. He is obtunded and ill-appearing. Per nursing home staff, the patient has experienced low-grade temperatures, poor appetite, and lethargy over several days. A lumbar puncture is performed, and the Gram stain returns gram-positive rods and many white blood cells. Listeria meningitis is diagnosed and appropriate antibiotics are begun. Which of the following statements regarding Listeria meningitis distinguishes it from other causes of bacterial meningitis?

A.  There is more frequent nuchal rigidity.

B.  More neutrophils are present on the cerebrospinal fluid (CSF) differential.

C.  Photophobia is more common.

D.  Presentation is often more subacute.

E.  White blood cell (WBC) count is often more elevated in the CSF.

IV-68. Several family members present to a local emergency department 2 days after a large family summer picnic at which deli meats and salads were served. They all complain of profuse diarrhea, headaches, fevers, and myalgias. Their symptoms began about 24 hours after the picnic. It appears that everyone who ate Uncle Sandy’s Salami Surprise was affected. Routine cultures of blood and stool are negative to date. Which of the following is true regarding Listeria gastroenteritis?

A.  Antibiotic treatment is not necessary for uncomplicated cases.

B.  Carriers are asymptomatic but can easily spread infection via the fecal–oral route.

C.  Gastrointestinal illness can result from ingestion of a single organism.

D.  Illness is toxin mediated, and organisms are not present at the time of infection.

E.  Person-to-person spread is a common cause of outbreaks.

IV-69. A 26-year-old woman presents late in the third trimester of her pregnancy with high fevers, myalgias, backache, and malaise. She is admitted and started on empirical broad-spectrum antibiotics. Blood cultures return positive for Listeria monocytogenes. She delivers a 5-lb infant 24 hours after admission. Which of the following statements regarding antibiotic treatment for this infection is true?

A.  Clindamycin should be used in patients with penicillin allergy.

B.  Neonates should receive weight-based ampicillin and gentamicin.

C.  Penicillin plus gentamicin is first-line therapy for the mother.

D.  Quinolones should be used for Listeria bacteremia in late-stage pregnancy.

E.  Trimethoprim–sulfamethoxazole has no efficacy against Listeria spp.

IV-70. A 64-year-old man with a long history of heroin abuse is brought to the hospital because of fever and worsening muscle spasms and pain over the past day. Because of longstanding venous sclerosis, he no longer injects intravenously but “skin pops,” often with dirty needles. On examination, he is extremely sweaty and febrile to 101.4°F. There are widespread muscle spasms, including the face. He is unable to open his jaw because of muscle spasm and has severe back pain because of diffuse spasm. On his leg, there is a skin wound that is tender and erythematous. All of the following statements regarding this patient are true EXCEPT:

A.  Culture of the wound may reveal Clostridium tetani.

B.  Intrathecal antitoxin administration is recommended therapy.

C.  Metronidazole is the recommended therapy.

D.  Permanent muscle dysfunction is likely after recovery.

E.  Strychnine poisoning and antidopaminergic drug toxicity should be ruled out.

IV-71. A 34-year-old injection drug user presents with a 2-day history of slurred speech, blurry vision that is worse with bilateral gaze deviation, dry mouth, and difficulty swallowing both liquids and solids. He states that his arms feel weak as well but denies any sensory deficits. He has had no recent illness but does describe a chronic ulcer on his left lower leg that has felt slightly warm and tender of late. He frequently injects heroin into the edges of the ulcer. On review of systems, he reports mild shortness of breath but denies any gastrointestinal symptoms, urinary retention, or loss of bowel or bladder continence. Physical examination reveals a frustrated, nontoxic appearing man who is alert and oriented but noticeably dysarthric. He is afebrile with stable vital signs. Cranial nerve examination reveals bilateral cranial nerve VI deficits and an inability to maintain medial gaze in both eyes. He has mild bilateral ptosis, and both pupils are reactive but sluggish. His strength is 5/5 in all extremities except for his shoulder shrug, which is 4/5. Sensory examination and deep tendon reflexes are within normal limits in all four extremities. His oropharynx is dry. Cardiopulmonary and abdominal examination findings are normal. He has a 4 cm × 5 cm well-granulated lower extremity ulcer with redness, warmth, and erythema noted on the upper margin of the ulcer. What is the treatment of choice?

A.  Glucocorticoids

B.  Equine antitoxin to Clostridium botulinum neurotoxin

C.  Intravenous heparin

D.  Naltrexone

E.  Plasmapheresis

IV-72. A 19-year-old man presents to the emergency department with 4 days of watery diarrhea, nausea, vomiting, and low-grade fever. He recalls no unusual meals, sick contacts, or travel. He is hydrated with IV fluid, given antiemetics, and discharged home after feeling much better. Three days later, two of three blood cultures are positive for Clostridium perfringens. He is called at home and says that he feels fine and is back at work. What should your next instruction to the patient be?

A.  Return for IV penicillin therapy.

B.  Return for IV penicillin therapy plus echocardiography.

C.  Return for IV penicillin therapy plus colonoscopy.

D.  Return for surveillance blood culture.

E.  Reassurance

IV-73. Which of the following is the most common clinical manifestation of Neisseria meningitidis infection?

A.  Asymptomatic nasopharyngeal colonization

B.  Chronic meningitis

C.  Meningitis

D.  Petechial or purpuric rash

E.  Septicemia

IV-74. A 21-year-old college student is admitted to the hospital with meningitis. CSF cultures reveal N. meningitides type B. The patient lives in a dormitory suite with five other students. Which of the following is recommended for the close household contacts?

A.  Culture all close contacts and offer prophylaxis to those with positive culture results

B.  Immediate administration of ceftriaxone to all close contacts

C.  Immediate administration of rifampin to all close contacts

D.  Immediate vaccination with conjugate vaccine

E.  No therapy necessary

IV-75. A 19-year-old man comes to clinic complaining of 2 days of severe dysuria and urethral discharge. Urine analysis shows pyuria. He reports unprotected sexual contact with a new partner within the past week. DNA probe is positive for N. gonorrhea. Which of the following is the most effective therapy?

A.  Intravenous ceftriaxone

B.  Intramuscular penicillin

C.  Oral azithromycin

D.  Oral cefixime

E.  Oral levofloxacin

IV-76. A 44-year-old man presents to the emergency department for evaluation of a severe sore throat. His symptoms began this morning with mild irritation on swallowing and have gotten progressively severe over the course of 12 hours. He has been experiencing a fever to as high as 39°C at home and reports progressive shortness of breath. He denies antecedent rhinorrhea and tooth and jaw pain. He has had no ill contacts. On physical examination, the patient appears flushed and in respiratory distress with use of accessory muscles of respiration. Inspiratory stridor is present. He is sitting leaning forward and is drooling with his neck extended. His vital signs are as follows: temperature of 39.5°C, blood pressure of 116/60 mmHg, heart rate of 118 beats/min, respiratory rate of 24 breaths/min, and oxygen saturation of 95% on room air. Examination of his oropharynx shows erythema of the posterior oropharynx without exudates or tonsillar enlargement. The uvula is midline. There is no sinus tenderness and no cervical lymphadenopathy. His lung fields are clear to auscultation, and cardiovascular examination reveals a regular tachycardia with a II/VI systolic ejection murmur heard at the upper right sternal border. Abdominal, extremity, and neurologic examinations are normal. Laboratory studies reveal a white blood cell count of 17,000/μL with a differential of 87% neutrophils, 8% band forms, 4% lymphocytes, and 1% monocytes. Hemoglobin is 13.4 g/dL with a hematocrit of 44.2%. An arterial blood gas on room air has a pH of 7.32, a PCO2 of 48 mmHg, and a PO2 of 92 mmHg. A lateral neck radiograph shows an edematous epiglottis. What is the next most appropriate step in evaluation and treatment of this individual?

A.  Ampicillin, 500 mg IV q6h

B.  Ceftriaxone, 1 g IV q24h

C.  Endotracheal intubation and ampicillin, 500 mg IV q6h

D.  Endotracheal intubation, 1 g IV q24h of ceftriaxone, and 600 mg IV q6h of clindamycin

E.  Laryngoscopy and close observation

IV-77. All of the following statements regarding Moraxella catarrhalis as an upper respiratory pathogen are true EXCEPT:

A.  Clinical features allow distinction between COPD exacerbations caused by M. catarrhalis and H. influenzae.

B.  It causes otitis media in children.

C.  It is the second most common bacterial cause of COPD exacerbations.

D.  Most strains are susceptible to azithromycin.

E.  Most strains express β-lactamase activity.

IV-78. A 75-year-old patient presents with fevers and wasting. He describes fatigue and malaise over the past several months and is concerned that he has been losing weight. On examination, he is noted to have a low-grade fever, and a soft diastolic heart murmur is appreciated. Laboratory tests reveal a normocytic, normochromic anemia. Three separate blood cultures grow Cardiobacterium hominis. Which of the following statements is true about this patient’s clinical condition?

A.  Antibiotics are not likely to improve his condition.

B.  Echocardiography findings will likely be normal.

C.  He has a form of endocarditis with a high risk of emboli.

D.  He will likely need surgery.

E.  The positive blood culture results are likely because of a skin contaminant.

IV-79. A 38-year-old woman with frequent hospital admissions related to alcoholism comes to the emergency department after being bitten by a dog. There are open wounds on her arms and right hand that are purulent and have necrotic borders. She is hypotensive and is admitted to the intensive care unit. She is found to have disseminated intravascular coagulation and soon develops multiorgan failure. Which of the following is the most likely organism to have caused her rapid decline?

A.  Aeromonas spp.

B.  Capnocytophaga spp.

C.  Eikenella spp.

D.  Haemophilus spp.

E.  Staphylococcus spp.

IV-80. A 56-year-old man with a history of hypertension and cigarette smoking is admitted to the intensive care unit after 1 week of fever and nonproductive cough. Imaging shows a new pulmonary infiltrate, and urine antigen test result for Legionella is positive. Each of the following is likely to be an effective antibiotic EXCEPT:

A.  Azithromycin

B.  Aztreonam

C.  Levofloxacin

D.  Tigecycline

E.  Trimethoprim/sulfamethoxazole

IV-81. All of the following are risk factors for the development of Legionella pneumonia EXCEPT:

A.  Glucocorticoid use

B.  HIV infection

C.  Neutropenia

D.  Recent surgery

E.  Tobacco use

IV-82. A 72-year-old woman is admitted to the intensive care unit with respiratory failure. She has fever, obtundation, and bilateral parenchymal consolidation on chest imaging. Which of the following is true regarding the diagnosis of Legionella pneumonia?

A.  Acute and convalescent antibodies are not helpful because of the presence of multiple serotypes.

B.  Legionella can never be seen on a Gram stain.

C.  Legionella cultures grow rapidly on the proper media.

D.  Legionella urinary antigen maintains utility after antibiotic use.

E.  Polymerase chain reaction for Legionella DNA is the “gold standard” diagnostic test.

IV-83. An 18-year-old man seeks attention for a severe cough. He reports no past medical history and excellent health. Approximately 7 days ago, he developed an upper respiratory syndrome with low-grade fever, coryza, some cough, and malaise. The fever and coryza has improved, but over the past 2 days, he has had an episodic cough that often is severe enough to result in vomiting. He reports receiving all infant vaccinations but only tetanus in the past 12 years. He is afebrile, and while not coughing, his chest examination is normal. During a coughing episode, there is an occasional inspiratory whoop. Chest radiography findings are unremarkable. Which of the following is true regarding his likely illness?

A.  A fluoroquinolone is recommended therapy.

B.  Cold agglutinin results may be positive.

C.  Nasopharyngeal aspirate for DNA testing is likely to be diagnostic.

D.  Pneumonia is a common complication.

E.  Urinary antigen testing results remain positive for up to 3 months.

IV-84. Which of the following is the most common cause of traveler’s diarrhea in Latin America?

A.  Campylobacter jejuni

B.  Entamoeba histolytica

C.  Enterotoxigenic Escherichia coli

D.  Giardia lamblia

E.  Vibrio cholerae

IV-85. In the inpatient setting, extended-spectrum β-lactamase (ESBL)–producing gram-negative infections are most likely to occur after frequent use of which of the following classes of antibiotics?

A.  Carbapenems

B.  Macrolides

C.  Quinolones

D.  Third-generation cephalosporins

IV-86. A 25-year-old woman presents to the clinic complaining of several days of worsening burning and pain with urination. She describes an increase in urinary frequency and suprapubic tenderness but no fever or back pain. She has no past medical history with the exception of two prior episodes similar to this in the past 2 years. Urinalysis shows moderate white blood cells. Which of the following is the most likely causative agent of her current symptoms?

A.  Candida spp.

B.  Escherichia coli

C.  Enterobacter spp.

D.  Klebsiella spp.

E.  Proteus spp.

IV-87. All of the following statements regarding intestinal disease caused by strains of Shiga toxin–producing and enterohemorrhagic E. coli are true EXCEPT:

A.  Antibiotic therapy lessens the risk of developing hemolytic uremic syndrome.

B.  Ground beef is the most common source of contamination.

C.  Gross bloody diarrhea without fever is the most common clinical manifestation.

D.  Infection is more common in industrialized than developing countries.

E.  O157:H7 is the most common serotype.

IV-88. A 63-year-old man has been in the ICU for 3 weeks with slowly resolving ARDS after an episode of acute pancreatitis. He remains on mechanical ventilation through a tracheostomy. Over the past week, he has had gradual lessening of his mechanical ventilator needs and slight improvement of his radiograph. He has been afebrile with a normal WBC for the past 10 days. Over the past 24 hours, his FiO2has been increased from 0.60 to 0.80 to maintain adequate oxygenation. In addition, he has developed newly purulent sputum with a right lower lobe infiltrate, fever to 101.5°C, and a rising WBC. Sputum gram stain shows gram-negative plump coccobacilli that are identified as Acinetobacter baumannii. All of the following are true about this organism EXCEPT:

A.  Mortality from bloodstream infection approaches 40%.

B.  Multidrug resistance is characteristic.

C.  They are a growing cause of hospital-acquired pneumonia and bloodstream infections in the United States.

D.  They are not yet a significant problem in Asia or Australia.

E.  Tigecycline is treatment of choice for bloodstream infection.

IV-89. Helicobacter pylori colonization increases the odds ratio of developing all of the following conditions EXCEPT:

A.  Duodenal ulcer disease

B.  Esophageal adenocarcinoma

C.  Gastric adenocarcinoma

D.  Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

E.  Peptic ulcer disease

IV-90. One month after receiving a 14-day course of omeprazole, clarithromycin, and amoxicillin for Helicobacter pylori–associated gastric ulcer disease, a 44-year-old woman still has mild dyspepsia and pain after meals. What is the appropriate next step in management?

A.  Empirical long-term proton pump inhibitor therapy

B.  Endoscopy with biopsy to rule out gastric adeno-carcinoma

C.  H. pylori serology testing

D.  Second-line therapy for H. pylori with omeprazole, bismuth subsalicylate, tetracycline, and metronidazole

E.  Urea breath test

IV-91. In the developed world, seroprevalence of Helicobacter pylori infection is currently

A.  Decreasing

B.  Increasing

C.  Staying the same

D.  Unknown

IV-92. A 42-year-old man with heme-positive stools and a history of epigastric pain is found to have a duodenal ulcer that is biopsy-proven positive for H. pylori. All of the following are effective eradication regimens EXCEPT:

A.  Amoxicillin and levofloxacin for 10 days

B.  Omeprazole, clarithromycin, and metronidazole for 14 days

C.  Omeprazole, clarithromycin, and amoxicillin for 14 days

D.  Omeprazole, bismuth, tetracycline, and metronidazole for 14 days

E.  Omeprazole and amoxicillin for 5 days followed by omeprazole, clarithromycin, and tinidazole for 5 days

IV-93. A sputum culture from a patient with cystic fibrosis showing which of the following organisms has been associated with a rapid decline in pulmonary function and a poor clinical prognosis?

A.  Burkholderia cepacia

B.  Pseudomonas aeruginosa

C.  Staphylococcus aureus

D.  Staphylococcus epidermidis

E.  Stenotrophomonas maltophilia

IV-94. Which single clinical feature has the most specificity in differentiating Pseudomonas aeruginosa sepsis from other causes of severe sepsis in a hospitalized patient?

A.  Ecthyma gangrenosum

B.  Hospitalization for severe burn

C.  Profound bandemia

D.  Recent antibiotic exposure

E.  Recent mechanical ventilation for >14 days

IV-95. All of the following agents may be effective when used as monotherapy in a nonneutropenic patient with Pseudomonas aeruginosa bacteremia EXCEPT:

A.  Amikacin

B.  Cefepime

C.  Ceftazidime

D.  Meropenem

E.  Piperacillin/tazobactam

IV-96. Five healthy college roommates develop a rapid (<8 hours) onset of abdominal pain, cramping, fever to 38.5°C, vomiting, and copious nonbloody diarrhea while camping. They immediately return for hydration and diagnosis. A stool culture grows Salmonella enteritidis. All of the statements regarding their clinical syndrome are true EXCEPT:

A.  Antibiotic therapy is not indicated.

B.  Bacteremia occurs in fewer than 10% of cases.

C.  The most likely source was undercooked eggs.

D.  There is no vaccine available for this illness.

E.  They have enteric (typhoid) fever.

IV-97. Two days after returning from a trip to Thailand, a 36-year-old woman develops severe crampy abdominal pain, fever to 40°C, nausea, and malaise. The next day, she begins having bloody mucopurulent diarrhea with worsening abdominal pain and continued fever. She reports she was in Bangkok during monsoonal flooding and ate fresh food from stalls. A stool examination shows many neutrophils, and culture grows Shigella flexneri. Which of the following statements regarding her clinical syndrome is true?

A.  An effective vaccine for travelers is available.

B.  Antibiotic therapy prolongs the carrier state and should not be administered unless she develops bacteremia.

C.  Antimotility agents are effective in reducing the risk of dehydration.

D.  Ciprofloxacin is recommended therapy.

E.  Her disease can be distinguished from illness caused by Campylobacter jejuni on clinical grounds by the presence of fever.

IV-98. A previously healthy 32-year-old graduate student at the University of Wisconsin describes 1 to 2 days of fever, myalgia, and headache followed by abdominal pain and diarrhea. He has experienced up to 10 bowel movements over the past day. He has noted mucus and blood in the stool. The patient notes that 3 days ago, he was at a church barbecue, where several people contracted a diarrheal illness. He has not traveled in more than 6 months and has no history of GI illness. Physical examination is unremarkable except for a temperature of 38.8°C and diffuse abdominal tenderness. Laboratory findings are notable only for a slightly elevated leukocyte count and an elevated erythrocyte sedimentation rate. Wright’s stain of a fecal sample reveals the presence of neutrophils. Colonoscopy reveals inflamed mucosa. Biopsy of an affected area discloses mucosal infiltration with neutrophils, monocytes, and eosinophils; epithelial damage, including loss of mucus; glandular degeneration; and crypt abscesses. Which of the following microbial pathogens is most likely to be responsible for his illness?

A.  Campylobacter

B.  Escherichia coli

C.  Norwalk agent

D.  Rotavirus

E.  Staphylococcus aureus

IV-99. In the patient described in question IV-98, which of the following is recommended therapy?

A.  Azithromycin

B.  Ceftriaxone

C.  Lomotil only for symptoms

D.  Metronidazole

E.  Tinidazole

IV-100. While working for a relief mission in Haiti, you are asked to see a 19-year-old patient with profuse watery diarrhea as shown in Figure IV-100. The patient is mildly hypotensive and tachycardic and is afebrile. There is no abdominal tenderness. All of the statements regarding this patient’s illness are true EXCEPT:


FIGURE IV-100 (see Color Atlas)

A.  Antibiotic therapy shortens the duration of disease and hastens clearance of the organism from stool.

B.  Morbidity or death is mediated by bacteremia and multiorgan failure.

C.  Point of care antigen testing is available.

D.  The diarrhea is toxin mediated.

E.  Vaccines with moderate efficacy are available outside the United States.

IV-101. A 45-year-old man from western Kentucky presents to the emergency department in September complaining of fevers, headaches, and muscle pains. He recently had been on a camping trip with several friends during which they hunted for their food, including fish, squirrels, and rabbits. He did not recall any tick bites during the trip but does recall having several mosquito bites. For the past week, he has had an ulceration on his right hand with redness and pain surrounding it. He also has noticed some pain and swelling near his right elbow. None of the friends he camped with have been similarly ill. His vital signs are blood pressure of 106/65 mmHg, heart rate of 116 beats/min, respiratory rate of 24 breaths/min, and temperature of 38.7°C. His oxygen saturation is 93% on room air. He appears mildly tachypneic and flushed. His conjunctiva are not injected, and his mucous membranes are dry. The chest examination reveals crackles in the right mid-lung field and left base. His heart rate is tachycardic but regular. There is a II/VI systolic ejection murmur heard best at the lower left sternal border. His abdominal examination is unremarkable. On the right hand, there is an erythematous ulcer with a punched-out center covered by a black eschar. He has no cervical lymphadenopathy, but there are markedly enlarged and tender lymph nodes in the right axillae and epitrochlear regions. The epitrochlear node has some fluctuance with palpation. A chest radiograph shows fluffy bilateral alveolar infiltrates. Over the first 12 hours of his hospitalization, the patient becomes progressively hypotensive and hypoxic, requiring intubation and mechanical ventilation. What is the most appropriate therapy for this patient?

A.  Ampicillin, 2 g IV q6h

B.  Ceftriaxone, 1 g IV daily

C.  Ciprofloxacin, 400 mg IV twice daily

D.  Doxycycline, 100 mg IV twice daily

E.  Gentamicin, 5 mg/kg twice daily

IV-102. A 35-year-old man comes to the emergency department complaining of an acute-onset high fever, malaise, and a tender lymph node. The patient returned from a camping trip in the Four Corners region of the United States (junction area of New Mexico, Arizona, Colorado, and Utah) 4 days ago and reports being bitten by fleas. He has no past medical history and works as a university professor. He denies illicit drug use. On physical examination, he is lethargic but oriented and has a temperature 39.4°C, heart rate of 105 beats/min, and blood pressure of 100/65 mmHg. There are numerous crusted flea bites on the upper legs. In the right inguinal region, there is an exquisitely tender 3- to 4-cm tense lymph node with surrounding edema but no lymphangitis. An aspirate of the node reveals small gram-negative coccobacilli that appear bipolar on Wright’s stain. Which of the following is the most likely causative organism?

A.  Bartonella henselae

B.  Epstein-Barr virus

C.  Rickettsia rickettsia

D.  Staphylococcus aureus

E.  Yersinia pestis

IV-103. In the patient in question IV-102, which of the following therapeutic options is recommended?

A.  Azithromycin

B.  Gentamicin

C.  No therapy; it is a self-limited disease

D.  Vancomycin

E.  Voriconazole

IV-104. A 24-year-old man with advanced HIV infection presents to the emergency department with a tan painless nodule on the lower extremity (see Figure IV-104). He is afebrile and has no other lesions. He does not take antiretroviral therapy, and his last CD4+ T-cell count was 20/μL. He lives with a friend who has cats and kittens. A biopsy shows lobular proliferation of blood vessels lined by enlarged endothelial cells and a mixed acute and chronic inflammatory infiltrate. Tissue stains show gram-negative bacilli. Which of the following is most likely to be effective therapy for the lesion?


FIGURE IV-104 (see Color Atlas)

A.  Azithromycin

B.  Cefazolin

C.  Interferon-α

D.  Penicillin

E.  Vancomycin

IV-105. A 38-year-old homeless man presents to the emergency department with a transient ischemic attack characterized by a facial droop and left arm weakness lasting 20 minutes and left upper quadrant pain. He reports intermittent subjective fevers, diaphoresis, and chills for the past 2 weeks. He has had no recent travel or contact with animals. He has taken no recent antibiotics. Physical examination reveals a slightly distressed man with disheveled appearance. His temperature is 38.2°C, heart rate is 90 beats/min, and blood pressure is 127/74 mmHg. He has poor dentition. Cardiac examination reveals an early diastolic murmur over the left third intercostal space. His spleen is tender and 2 cm descended below the costal margin. He has tender painful red nodules on the tips of the third finger of his right hand and on the fourth finger of his left hand that are new. He has nits evident on his clothes consistent with body louse infection. White blood cell count is 14,500/μL, with 5% band forms and 93% polymorphonuclear cells. Blood cultures are drawn followed by empirical vancomycin therapy. These culture results remain negative for growth 5 days later. He remains febrile but hemodynamically stable but does develop a new lesion on his toe similar to those on his fingers on hospital day 3. A transthoracic echocardiogram reveals a 1-cm mobile vegetation on the cusp of his aortic valve and moderate aortic regurgitation. A CT scan of the abdomen shows an enlarged spleen with wedge-shaped splenic and renal infarctions. What test should be sent to confirm the most likely diagnosis?

A.  Bartonella serology

B.  Epstein-Barr virus heterophile antibody

C.  HIV polymerase chain reaction

D.  Peripheral blood smear

E.  Q fever serology

IV-106. A 26-year-old female college student presents with tender epitrochlear and axillary tender, firm, 3-cm lymph nodes on her left side. She has a 0.5-cm painless nodule on her left second finger. She reports low-grade fever and malaise over 2 weeks. She enjoys gardening and exotic fish collecting and owns several pets, including fish, kittens, and a puppy. She is sexually active with one partner. She traveled extensively throughout rural Southeast Asia 2 years before her current illness. The differential diagnosis includes all of the following EXCEPT:

A.  Bartonella henselae infection

B.  Lymphoma

C.  Sporothrix schenckii infection

D.  Staphylococcal infection

IV-107. A 24-year-old man seeks evaluation for painless penile ulcerations. He noted the first lesion about 2 weeks ago, and since that time, two adjacent areas have also developed ulceration. He states that there has been blood staining his underwear from slight oozing of the ulcers. He has no past medical history and takes no medication. He returned 5 weeks ago from a vacation in Brazil, where he did have unprotected sexual intercourse with a local woman. He denies other high-risk sexual behaviors and has never had sex with prostitutes. He was last tested for HIV 2 years ago. He has never had a chlamydial or gonococcal infection. On examination, there are three well-defined red, friable lesions measuring 5 mm or less on the penile shaft. They bleed easily with any manipulation. There is no pain with palpation. There is shotty inguinal lymphadenopathy. On biopsy of one lesion, there is a prominent intracytoplasmic inclusion of bipolar organisms in an enlarged mononuclear cell. Additionally, there is epithelial cell proliferation with an increased number of plasma cells and few neutrophils. A rapid plasma reagin test result is negative. Cultures grow no organisms. What is the most likely causative organism?

A.  Calymmatobacterium granulomatis (donovanosis)

B.  Chlamydia trachomatis (lymphogranuloma venereum)

C.  Haemophilus ducreyi (chancroid)

D.  Leishmania amazonensis (cutaneous leishmaniasis)

E.  Treponema pallidum (secondary syphilis)

IV-108. A 35-year-old man is seen 6 months after a cadaveric renal allograft. The patient has been on azathioprine and prednisone since that procedure. He has felt poorly for the past week with fever to 38.6°C (101.5°F), anorexia, and a cough productive of thick sputum. Chest radiography reveals a left lower lobe (5-cm) mass with central cavitation. Examination of the sputum reveals long, crooked, branching, beaded gram-positive filaments. The most appropriate initial therapy would include the administration of which of the following antibiotics?

A.  Ceftazidime

B.  Erythromycin

C.  Penicillin

D.  Sulfisoxazole

E.  Tobramycin

IV-109. A 67-year-old woman with a history of systemic hypertension presents to her local emergency department with 2 weeks of right jaw pain that now has developed an area of purulent drainage into her mouth. She reports an accompanying fever. She denies recent dental work. Aside from osteoporosis, she is healthy. Her only medications are alendronate and lisinopril. Physical examination is notable for a temperature of 101.1°F, right-sided facial swelling, diffuse mandibular tenderness, and an area of yellow purulent drainage through the buccal mucosa on the right side. Microscopic examination of the purulent secretions is likely to show which of the following?

A.  Auer rods

B.  Sialolith

C.  Squamous cell carcinoma

D.  Sulfur granules

E.  Weakly acid-fast branching, beaded filaments

IV-110. In the patient described above, what is the most appropriate therapy?

A.  Amphotericin B

B.  Itraconazole

C.  Penicillin

D.  Surgical debridement

E.  Tobramycin

IV-111. A 68-year-old homeless man with a long history of alcohol abuse presents to his primary care physician with several weeks of fever, night sweats, and sputum production. He denies nausea, vomiting, and other gastrointestinal symptoms. Examination is notable for a low-grade temperature, weight loss of 15 lb since the previous visit, and foul breath but is otherwise normal. Blood work, including complete blood count and serum chemistries, is unremarkable. A PPD is placed, and the result is negative. His chest radiograph is shown in Figure IV-111. Which of the following is appropriate as initial therapy?



A.  Bronchoscopy with biopsy of the cavity to diagnose squamous cell lung cancer

B.  Esophagogastroduodenoscopy to diagnose hiatal hernia with aspiration

C.  Immediate hospitalization and isolation to prevent spread of mycobacterium tuberculosis

D.  Intravenous ceftriaxone and azithromycin for aspiration pneumonia

E.  Oral clindamycin for lung abscess

IV-112. Which of the following is a major reservoir for anaerobic organisms in the human body?

A.  Duodenum

B.  Female genital tract

C.  Gallbladder

D.  Lung

E.  Prostate

IV-113. All of the following factors influence the likelihood of transmitting active tuberculosis EXCEPT:

A.  Duration of contact with an infected person

B.  Environment in which contact occurs

C.  Presence of extrapulmonary tuberculosis

D.  Presence of laryngeal tuberculosis

E.  Probability of contact with an infectious person

IV-114. Which of the following individuals with a known history of prior latent tuberculosis infection (without therapy) has the lowest likelihood of developing reactivation tuberculosis?

A.  A 28-year-old woman with anorexia nervosa, a body mass index of 16 kg/m2, and a serum albumin of 2.3 g/dL

B.  A 36-year-old intravenous drug user who does not have HIV but is homeless

C.  A 42-year-old man who is HIV-positive with a CD4 count of 350/μL on highly active antiretroviral therapy

D.  A 52-year-old man who works as a coal miner

E.  An 83-year-old man who was infected while stationed in Korea in 1958

IV-115. A 42-year-old Nigerian man comes to the emergency department because of fevers, fatigue, weight loss, and cough for 3 weeks. He complains of fevers and a 4.5-kg weight loss. He describes his sputum as yellow in color. It has rarely been blood streaked. He emigrated to the United States 1 year ago and is an undocumented alien. He has never been treated for tuberculosis, has never had a purified protein derivative (PPD) skin test placed, and does not recall receiving BCG vaccination. He denies HIV risk factors. He is married and reports no ill contacts. He smokes 1 pack of cigarettes daily and drinks 1 pint of vodka on a daily basis. On physical examination, he appears chronically ill with temporal wasting. His body mass index is 21 kg/m2. Vital signs are blood pressure of 122/68 mmHg, heart rate of 89 beats/min, respiratory rate of 22 breaths/min, SaO2 of 95% on room air, and temperature of 37.9°C. There are amphoric breath sounds posteriorly in the right upper lung field with a few scattered crackles in this area. No clubbing is present. The examination is otherwise unremarkable. His chest radiograph is shown in Figure IV-115. A stain for acid-fast bacilli is negative. What is the most appropriate approach to the ongoing care of this patient?



A.  Admit the patient on airborne isolation until three expectorated sputums show no evidence of acid-fast bacilli.

B.  Admit the patient without isolation as he is unlikely to be infectious with a negative acid-fast smear.

C.  Perform a biopsy of the lesion and consult oncology.

D.  Place a PPD test on his forearm and have him return for evaluation in 3 days.

E.  Start a 6-week course of antibiotic treatment for anaerobic bacterial abscess.

IV-116. A 50-year-old man is admitted to the hospital for active pulmonary tuberculosis with a positive sputum acid-fast bacilli smear. He is HIV positive with a CD4 count of 85/μL and is not on highly active antiretroviral therapy. In addition to pulmonary disease, he is found to have disease in the L4 vertebral body. What is the most appropriate initial therapy?

A.  Isoniazid, rifampin, ethambutol, and pyrazinamide

B.  Isoniazid, rifampin, ethambutol, and pyrazinamide; initiate antiretroviral therapy

C.  Isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin

D.  Isoniazid, rifampin, and ethambutol

E.  Withhold therapy until sensitivities are available.

IV-117. All of the following individuals receiving tuberculin skin purified protein derivative (PPD) reactions should be treated for latent tuberculosis EXCEPT:

A.  A 23-year-old injection drug user who is HIV negative has a 12-mm PPD reaction.

B.  A 38-year-old fourth grade teacher has a 7-mm PPD reaction and no known exposures to active tuberculosis. She has never been tested with a PPD previously.

C.  A 43-year-old individual in the Peace Corps working in sub-Saharan Africa has a 10-mm PPD reaction. Eighteen months ago, the PPD reaction was 3 mm.

D.  A 55-year-old man who is HIV positive has a negative PPD result. His partner was recently diagnosed with cavitary tuberculosis.

E.  A 72-year-old man who is receiving chemotherapy for non-Hodgkin’s lymphoma has a 16-mm PPD reaction.

IV-118. All of the following statements regarding interferon-gamma release assays for the diagnosis of latent tuberculosis are true EXCEPT:

A.  There is no booster phenomenon.

B.  They are more specific than tuberculin skin testing.

C.  They have a higher sensitivity than tuberculin skin testing in high HIV-burden areas.

D.  They have less cross reactivity with BCG and non-tuberculous mycobacteria than tuberculin skin testing.

E.  They may be used to screen for latent tuberculosis in adults working in low prevalence U.S. settings.

IV-119. All of the following statements regarding BCG vaccination are true EXCEPT:

A.  BCG dissemination may occur in severely immune-suppressed patients.

B.  BCG vaccination is recommended at birth in countries with high TB prevalence.

C.  BCG vaccination may cause a false-positive tuberculin skin test result.

D.  BCG vaccine provides protection for infants and children from TB meningitis and miliary disease.

E.  BCG vaccine provides protection from TB in HIV-infected patients.

IV-120. A 76-year-old woman is brought into the clinic by her son. She complains of a chronic nonproductive cough and fatigue. Her son adds that she has had low-grade fevers, progressive weight loss over months, and “just doesn’t seem like herself.” A representative slice from her chest CT is shown in Figure IV-120. She was treated for tuberculosis when she was in her 20s. A sputum sample is obtained, as are blood cultures. Two weeks later, both culture sets grow acid-fast bacilli consistent with Mycobacterium avium complex. Which of the following is the best treatment option?



A.  Bronchodilators and pulmonary toilet

B.  Clarithromycin, ethambutol, and rifampin

C.  Clarithromycin and rifampin

D.  Moxifloxacin and rifampin

E.  Pyrazinamide, isoniazid, rifampin, and ethambutol

IV-121. All of the following statements regarding antituberculosis therapeutic agents are true EXCEPT:

A.  In the United States, M. tuberculosis resistance to isoniazid remains below 10%.

B.  Optic neuritis is the most severe adverse effect of ethambutol.

C.  Pyrazinamide has utility in the therapy of M. avium complex and M. kansasii infections.

D.  Rifabutin should be used instead of rifampin in patients receiving concurrent treatment with protease inhibitors or nevirapine.

E.  Rifampin can decrease the half-life of warfarin, cyclosporine, prednisone, oral contraceptives, clarithromycin, and other important drugs.

IV-122. Which of the following patients with latent syphilis should undergo lumbar puncture for assessment of possible neurosyphilis?

A.  A 24-year-old woman with an RPR titer of 1:128

B.  A 38-year-old man with an RPR titer of 1:32 who was treated with benzathine G penicillin 2.4 million units intramuscularly. Repeat RPR titer 12 months after treatment is 1:16.

C.  A 46-year-old man with HIV and a CD4 count of 150/μL

D.  A 62-year-old woman with Bell’s palsy and a recent change in mental status

E.  All of the above

IV-123. An 18-year-old man presents with a firm, nontender lesion around his anal orifice. The lesion is about 1.5 cm in diameter and has a cartilaginous feel on clinical examination. The patient reports that it has progressed to this stage from a small papule. It is not tender. He reports recent unprotected anal intercourse. Bacterial culture result of the lesion is negative. A rapid plasmin reagin (RPR) test result is also negative. Therapeutic interventions should include:

A.  Acyclovir 200 mg orally 5 times per day

B.  Ceftriaxone 1 g intramuscularly

C.  Observation

D.  Penicillin G benzathine 2.4 million U intramuscularly

E.  Surgical resection with biopsy

IV-124. A 46-year-old man presents to the emergency department in Honolulu, Hawaii, with myalgias, malaise, and fevers. He is homeless and has alcoholism and frequently sleeps in alleys that are infested with rats. He recalls blacking out from alcohol ingestion and waking with his legs in a fetid pool. He noted scratches and bites around his ankles about 2 weeks ago. Since that time, he has felt increasingly more ill. For the past day, he has also noted that his skin is increasingly yellow. In addition to alcohol abuse, he has a medical history of schizophrenia and smokes 1 to 2 packs of cigarettes daily. He currently receives olanzapine as an intramuscular injection at a dose of 300 mg monthly. On initial evaluation, his temperature is 38.6°C, pulse is 105 beats/min, respiratory rate is 24/min, and blood pressure is 98/59 mmHg with O2 saturations of 92% on room air. He appears acutely ill and markedly jaundiced. His conjunctivae are injected bilaterally without discharge. Bibasilar crackles are present. His liver is enlarged and tender, but no splenomegaly is present. Laboratory results are notable for a BUN of 64 mg/dL, creatinine of 3.6 mg/dL, total bilirubin of 32.4 mg/dL, direct bilirubin of 29.8 mg/dL, AST of 80 U/L, ALT of 184 U/L, and alkaline phosphatase of 168 U/L. His complete blood count shows a white blood cell count of 12,500/μL with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets of 82,000/μL. Urinalysis reveals 20 white blood cells per high-power field, 3+ protein, and no casts. Coagulation study results are within normal limits. CT scan of the chest shows diffuse flame-like infiltrates consistent with pulmonary hemorrhage. What is the likely diagnosis?

A.  Acute alcoholic hepatitis

B.  Disseminated intravascular coagulation due to Streptococcus pneumoniae infection

C.  Microscopic polyangiitis

D.  Rat bite fever (Streptobacillus moniliformis infection)

E.  Weil’s syndrome (Leptospira interrogans infection)

IV-125. A 26-year-old man presents to your office complaining of recurrent episodes of fever and malaise. He returned from a camping trip in the northwestern part of Montana about 3 weeks ago. While he was hiking, he denies eating or drinking any unpasteurized milk products. He sterilized all of his water before drinking. He had multiple insect bites, but did not identify any ticks. He primarily slept in cabins or tents and did not notice any rodent droppings in the areas where he camped. Two friends that accompanied him on the trip have not been ill. He initially experienced fevers as high as 104.7°F (40.4°C) with myalgias, headache, nausea, vomiting, and diarrhea beginning 5 days after his return home. These symptoms lasted for about 3 days and resolved spontaneously. He attributed his symptoms to the “flu” and returned to his normal functioning. Seven days later, the fevers returned with temperatures to 105.1°F (40.6°C). With these episodes, his family noted him to have intermittent confusion. Today is day 4 of his current illness, and the patient feels that his fevers have again subsided. What is the most likely cause of the patient’s recurrent fevers?

A.  Brucellosis

B.  Colorado tick fever

C.  Leptospirosis

D.  Lymphocytic choriomeningitis

E.  Tickborne relapsing fever

IV-126. A 36-year-old man presents to the emergency department in Pennsylvania complaining of lightheadedness and dizziness. On physical examination, the patient is found to have a heart rate of 38 beats/min, and the ECG demonstrates acute heart block. On further questioning, he reports that he lives in a wooded area. He has two dogs that often roam in the woods and have been found with ticks on many occasions. He takes no medications and is otherwise healthy. He is an avid hiker and is also training for a triathlon. He denies any significant childhood illness. His family history is positive for an acute myocardial infarction in his father at age 42 years. His physical examination is normal with the exception of a slow but regular heartbeat. His chemistry panel shows no abnormalities. His chest radiograph is normal. What is the most likely cause of complete heart block in this individual?

A.  Acute myocardial infarction

B.  Chagas disease

C.  Lyme disease

D.  Sarcoidosis

E.  Subacute bacterial endocarditis

IV-127. Borrelia burgdorferi serology testing is indicated for which of the following patients, all of whom reside in Lyme-endemic regions?

A.  19-year-old female camp counselor who presents with her second episode of an inflamed, red, and tender left knee and right ankle

B.  A 23-year-old male house painter who presents with a primary erythema migrans lesion at the site of a witnessed tick bite

C.  A 36-year-old female state park ranger who presents with a malar rash; diffuse arthralgias or arthritis of her shoulders, knees, and metacarpophalangeal and proximal interphalangeal joints; pericarditis; and acute glomerulonephritis

D.  A 42-year-old woman with chronic fatigue, myalgias, and arthralgias

E.  A 46-year-old male gardener who presents with fevers, malaise, migratory arthralgias or myalgias, and three erythema migrans lesions

IV-128. A previously healthy 17-year-old woman presents in early October with profound fatigue and malaise, as well as fevers, headache, nuchal rigidity, diffuse arthralgias, and a rash. She lives in a small town in Massachusetts and spent her summer as a camp counselor at a local day camp. She participated in daily hikes in the woods but did not travel outside of the area during the course of the summer. Physical examination reveals a well-developed young woman who appears extremely fatigued but not in extremis. Her temperature is 37.4°C, pulse is 86 beats/min, blood pressure is 96/54 mmHg, and respiratory rate is 12 breaths/min. Physical examination documents clear breath sounds, no cardiac rub or murmur, normal bowel sounds, a nontender abdomen, no organomegaly, and no evidence of synovitis. Several erythema migrans lesions are noted on her lower extremities, bilateral axillae, right thigh, and left groin. All of the following are possible complications of her current disease state EXCEPT:

A.  Bell’s palsy

B.  Large joint oligoarticular arthritis

C.  Meningitis

D.  Progressive dementia

E.  Third-degree heart block

IV-129. In the patient described above, which of the following is appropriate therapy?

A.  Azithromycin, 500 mg PO daily

B.  Ceftriaxone, 2 g IV daily

C.  Cephalexin, 500 mg PO bid

D.  Doxycycline, 100 mg PO bid

E.  Vancomycin, 1 g IV bid

IV-130. A 48-year-old man is admitted to the intensive care unit in July with hypotension and fever. He lives in a suburban area of Arkansas. He became ill yesterday with a fever as high as 104.0°F (40.0°C). Today, his wife noted increasing confusion and lethargy. Over this same time, he has complained of headaches and myalgias. He has had nausea with two episodes of vomiting. Before the acute onset of illness, he had no medical complaints. He has no other medical history and takes no medications. He works as a landscape architect. The history is obtained from the patient’s wife, and she does not know if he has had any recent insect or tick bites. No one else in the family is ill, nor are the patient’s coworkers. On presentation, the vital signs are blood pressure of 88/52 mmHg, heart rate of 135 beats/min, respiratory rate of 22 breaths/min, temperature 101.9°F (38.8°C), and oxygen saturation of 94% on room air. His physical examination reveals an ill-appearing man, moaning quietly. He is oriented to person only. No meningismus is present. His cardiac examination reveals regular tachycardia. His chest and abdominal examinations are normal. He has no rash. His laboratory values are as follows:



He is fluid resuscitated and treated with intravenous ceftriaxone and vancomycin. A lumbar puncture shows no pleocytosis with normal protein and glucose. Despite this treatment, the patient develops worsening thrombocytopenia, neutropenia, and lymphopenia over the next 2 days. A bone marrow biopsy shows a hypercellular marrow with noncaseating granulomas. Which test is most likely to suggest the cause of the patient’s illness?

A.  Antibodies to double-stranded DNA and Smith antigens

B.  Chest radiography

C.  Levels of IgM and IgG on cerebrospinal fluid

D.  Peripheral blood smear

E.  Polymerase chain reaction on peripheral blood

IV-131. A 27-year-old woman who lives in North Carolina presents to her primary care physician complaining of fever, headache, myalgias, nausea, and anorexia 7 days after returning from hiking on the Appalachian Trail. Physical examination is remarkable for a temperature of 101.5°F (38.6°C). She appears generally fatigued but not toxic. She does not have a rash. She is reassured by her primary care physician that this likely represents a viral illness. She returns to clinic 3 days later with a progressive rash and ongoing fevers. She states that small red spots began to appear on her wrists and ankles within 24 hours of her previous visit and have now progressed up her extremities and onto her trunk. She also is noting increasing headache, and her husband thinks she has had some confusion. On physical examination, the patient is noted to be lethargic and answers questions slowly. What would be a reasonable course of action?

A.  Admit the patient to the hospital for treatment with intravenous ceftriaxone 1 g twice daily and vancomycin 1 g twice daily.

B.  Admit the patient to the hospital for treatment with doxycycline 100 mg twice daily.

C.  Initiate treatment with doxycycline 100 mg orally twice daily as an outpatient.

D.  Initiate treatment with trimethoprim–sulfamethoxazole DS twice daily.

E.  Order rickettsial serologies and withhold treatment until a firm diagnosis is made.

IV-132. A previously healthy 20-year-old college student presents in September with several days of headache, extensive cough with scant sputum, and fever of 101.5°F (38.6°C). Several individuals in his dormitory have also been ill with a similar illness. On examination, pharyngeal erythema is noted, and lung examination reveals bilateral expiratory wheezing and scattered crackles in the lower lung zones. He coughs frequently during the examination. Chest radiography reveals bilateral peribronchial pneumonia with increased interstitial markings. No lobar consolidation is seen. Which organism is most likely to cause the patient’s presentation?

A.  Adenovirus

B.  Chlamydia pneumoniae

C.  Legionella pneumophila

D.  Mycoplasma pneumoniae

E.  Streptococcus pneumoniae

IV-133. A previously healthy 19-year-old man presents with several days of headache, cough with scant sputum, dyspnea, and fever of 38.6°C. On examination, pharyngeal erythema is noted, and lung fields show scattered wheezes and some crackles. Chest radiography reveals focal bronchopneumonia in the lower lobes. His hematocrit is 24.7%, down from a baseline measure of 46%. The only other laboratory abnormality is an indirect bilirubin of 3.4. A peripheral smear reveals no abnormalities. A cold agglutinin titer is measured at 1:64. What is the most likely infectious agent?

A.  Coxiella burnetii

B.  Legionella pneumophila

C.  Methicillin-resistant Staphylococcus aureus

D.  Mycoplasma pneumoniae

E.  Streptococcus pneumoniae

IV-134. A 42-year-old woman is admitted to the intensive care unit with hypoxemic respiratory failure and pneumonia in August. She was well until 2 days before admission, when she developed fevers, myalgias, and headache. She works in a poultry processing plant and is originally from El Salvador. She has been in the United States for 15 years. She has no major health problems. Her PPD result was negative upon arrival to the United States. Several other workers have been ill with a similar illness, although no one else has developed respiratory failure. She is currently intubated and sedated. Her oxygen saturation is 93% on an FiO2 of 0.80 and positive end-expiratory pressure of 12 cm H2O. On physical examination, crackles are present in both lung fields. There is no cardiac murmur. Hepatosplenomegaly is present. Laboratory studies reveal a mild transaminitis. The influenza nasal swab result is negative for the presence of influenza A. Which of the following test results is most likely to be positive in this patient?

A.  Acid-fast bacilli stain and mycobacterial culture for Mycobacterium tuberculosis

B.  Blood cultures growing Staphylococcus aureus

C.  Microimmunofluorescence testing for Chlamydia psittaci

D.  Urine Legionella antigen

E.  Viral cultures of bronchoscopic samples for influenza A

IV-135. A 20-year-old woman is 36 weeks pregnant and presents for her first evaluation. She is diagnosed with Chlamydia trachomatis infection of the cervix. Upon delivery, for what complication is her infant most at risk?

A.  Jaundice

B.  Hydrocephalus

C.  Hutchinson triad

D.  Conjunctivitis

E.  Sensorineural deafness

IV-136. A 19-year-old man presents to an urgent care clinic with urethral discharge. He reports three new female sexual partners over the past 2 months. What should his management be?

A.  Nucleic acid amplification test for Neisseria gonorrhoeae and Chlamydia trachomatis and return to clinic in 2 days

B.  Ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient and his recent partners

C.  Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient

D.  Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient and his recent partners

E.  Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1, azithromycin 1 g PO × 1, and Flagyl 2 g PO × 1 for the patient and his partners

IV-137. All of the following viruses have been implicated as a cause of human cancer EXCEPT:

A.  Dengue fever virus

B.  Epstein-Barr virus

C.  Hepatitis B virus

D.  Hepatitis C virus

E.  Human papillomavirus

IV-138. All of the following antiviral medications are correctly matched with a significant side effect EXCEPT:

A.  Acyclovir—thrombotic thrombocytopenic purpura

B.  Amantadine—anxiety and insomnia

C.  Foscarnet—acute renal failure

D.  Ganciclovir—bone marrow suppression

E.  Interferon—fevers and myalgias

IV-139. All of the following regarding herpes simplex virus-2 (HSV-2) infection are true EXCEPT:

A.  Approximately one in five Americans harbors HSV-2 antibodies.

B.  Asymptomatic shedding of HSV-2 in the genital tract occurs nearly as frequently in those with no symptoms as in those with ulcerative disease.

C.  Asymptomatic shedding of HSV-2 is associated with transmission of virus.

D.  HSV-2 seropositivity is an independent risk factor for HIV transmission.

E.  Seroprevalence rates of HSV-2 are lower in Africa than in the United States.

IV-140. A 23-year-old woman is newly diagnosed with genital herpes simplex virus-2 (HSV-2) infection. What can you tell her that the chance of reactivation disease will be during the first year after infection?

A.  5%

B.  25%

C.  50%

D.  75%

E.  90%

IV-141. A 65-year-old man is brought to the hospital by his wife because of new onset of fever and confusion. He was well until 3 days ago but then developed a high fever, somnolence, and progressive confusion. His current medical history is unremarkable except for an elevated cholesterol level, and his only medication is atorvastatin. He is a civil engineer at an international construction company. His wife reports that he obtains regular health screening and has always been PPD negative. On admission, his temperature is 40°C, and his vital signs are otherwise normal. He is confused and hallucinating. Soon after admission, he develops a tonic-clonic seizure that requires lorazepam to terminate. His head CT shows no acute bleeding or elevated ICP. An EEG shows an epileptiform focus in the left temporal lobe, and diffusion-weighted MRI shows bilateral temporal lobe inflammation. Which of the following is most likely to be diagnostic?

A.  CSF acid-fast staining

B.  CSF India ink stain

C.  CSF PCR for herpes virus

D.  CSF oligoclonal band testing

E.  Serum cryptococcal antigen testing

IV-142. Which of the following statements regarding administration of varicella-zoster vaccine to patients above the age of 60 is true?

A.  It is a killed virus vaccine, so it is safe in immuno-compromised patients.

B.  It is not recommended for patients in this age group.

C.  It will decrease the risk of developing postherpetic neuralgia.

D.  It will not decrease the risk of developing shingles.

E.  It will not decrease the burden of disease.

IV-143. A 19-year-old college student comes to clinic reporting that he has been ill for 2 weeks. About 2 weeks ago, he developed notable fatigue and malaise that prevented him from his usual exercise regimen and caused him to miss some classes. Last week, he developed low-grade fevers, sore throat, and swollen lymph nodes in his neck. He has a history of strep pharyngitis, so 3 days ago, he took some ampicillin that he had in his possession. Over the past 2 days, he has developed a worsening slightly itchy rash as shown in Figure IV-143. His physical examination is notable for a temperature of 38.1°C, pharyngeal erythema, bilateral tonsillar enlargement without exudates, bilateral tender cervical adenopathy, and a palpable spleen. All of the following statements regarding his illness are true EXCEPT:


FIGURE IV-143 (see Color Atas)

A.  Greater than 10% atypical lymphocytosis is likely.

B.  Heterophile antibody testing will likely be diagnostic.

C.  If the heterophile antibody test result is negative, testing for IgG antibodies against viral capsid antigen will likely be diagnostic.

D.  It is spread via contaminated saliva.

E.  The patient can receive ampicillin in the future if indicated.

IV-144. In the patient described above, which of the following is indicated treatment?

A.  Acyclovir

B.  Acyclovir plus prednisone

C.  Ganciclovir

D.  Prednisone

E.  Rest, supportive measures, and reassurance

IV-145. Which of the following manifestations of cytomegalovirus (CMV) infection is least likely to occur after lung transplantation?

A.  Bronchiolitis obliterans

B.  CMV esophagitis

C.  CMV pneumonia

D.  CMV retinitis

E.  CMV syndrome (fever, malaise, cytopenias, transaminitis, and CMV viremia)

IV-146. Which of the following serology patterns places a transplant recipient at the lowest risk of developing cytomegalovirus (CMV) infection after renal transplantation?

A.  Donor CMV IgG negative; recipient CMV IgG negative.

B.  Donor CMV IgG negative; recipient CMV IgG positive.

C.  Donor CMV IgG positive; recipient CMV IgG negative.

D.  Donor CMV IgG positive; recipient CMV IgG positive.

E.  The risk is equal regardless of serology results.

IV-147. All of the following statements regarding human herpes virus-8 (HHV-8) are true EXCEPT:

A.  It has been implicated causally in invasive cervical carcinoma.

B.  It has been implicated causally in Kaposi’s sarcoma.

C.  It has been implicated causally in multicentric Castleman’s disease.

D.  It has been implicated causally in primary pleural lymphoma.

E.  Primary infection may manifest with fever and maculopapular rash.

IV-148. All of the following clinical findings are consistent with the diagnosis of molluscum contagiosum EXCEPT:

A.  Involvement of the genitals

B.  Involvement of the soles of the feet

C.  Lack of inflammation or necrosis at the site of the rash

D.  Rash associated with an eczematous eruption

E.  Rash spontaneously resolving over 3 to 4 months

IV-149. A 42-year-old man with AIDS and a CD4+ lymphocyte count of 23 cells/mm3 presents with shortness of breath and fatigue in the absence of fevers. On examination, he appears chronically ill with pale conjunctiva. Hematocrit is 16%. Mean corpuscular volume is 84/fl. Red blood cell distribution width is normal. Bilirubin, lactose dehydrogenase, and haptoglobin are all within normal limits. Reticulocyte count is zero. White blood cell count is 4300/μL with an absolute neutrophil count of 2500. Platelet count is 105,000/ul. Which of the following tests is most likely to produce a diagnosis?

A.  Bone marrow aspirate and biopsy

B.  Parvovirus B19 IgG

C.  Parvovirus B19 polymerase chain reaction

D.  Parvovirus B19 IgM

E.  Peripheral blood smear

IV-150. A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists. Two weeks earlier, she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. Which of the following tests is most likely to reveal her diagnosis?

A.  Antinuclear antibody

B.  Chlamydia trachomatis ligase chain reaction of the urine

C.  Joint aspiration for crystals and culture

D.  Parvovirus B19 IgM

E.  Rheumatoid factor

IV-151. Which of the following statements regarding the currently licensed human papillomavirus (HPV) vaccines is true?

A.  Both protect against genital warts.

B.  After becoming sexually active, women will derive little protective benefit from vaccination.

C.  They are inactivated live virus vaccines.

D.  They are targeted toward all oncogenic strains of HPV but are only 70% effective at decreasing infection in an individual.

E.  Vaccinees should continue to receive standard Pap smear testing.

IV-152. A 32-year-old woman experiences an upper respiratory illness that began with rhinorrhea and nasal congestion. She also is complaining of a sore throat but has no fever. Her illness lasts for about 5 days and resolves. Just before her illness, her 4-year-old child who attends day-care also experienced a similar illness. All of the following statements regarding the most common etiologic agent causing this illness are true EXCEPT:

A.  After the primary illness in a household, a secondary case of illness will occur in 25% to 70% of cases.

B.  The seasonal peak of the infection is in early fall and spring in temperate climates.

C.  The virus can be isolated from plastic surfaces up to 3 hours after exposure.

D.  The virus grows best at a temperature of 37°C, the temperature within the nasal passages.

E.  The virus is a single-stranded RNA virus of the Picornaviridae family.

IV-153. All of the following respiratory viruses is a cause of the common cold syndrome in children or adults EXCEPT:

A.  Adenoviruses

B.  Coronaviruses

C.  Enteroviruses

D.  Human respiratory syncytial viruses

E.  Rhinoviruses

IV-154. All of the following viruses are correctly matched with their primary clinical manifestations EXCEPT:

A.  Adenovirus—Gingivostomatitis

B.  Coronavirus—Severe acute respiratory syndrome

C.  Human respiratory syncytial virus—Bronchiolitis in infants and young children

D.  Parainfluenza—Croup

E.  Rhinovirus—Common cold

IV-155. A 9-month-old infant is admitted to the hospital with a febrile respiratory illness with wheezing and cough. Upon admission to the hospital, the baby is tachypneic and tachycardic with an oxygen saturation of 75% on room air. Rapid viral diagnostic testing confirms the presence of human respiratory syncytial virus. All of the following treatments should be used as part of the treatment plan for this child EXCEPT:

A.  Aerosolized ribavirin

B.  Hydration

C.  Immunoglobulin with high titers of antibody directed against human respiratory syncytial virus

D.  Nebulized albuterol

E.  Oxygen therapy to maintain oxygen saturation greater than 90%

IV-156. In March 2009, the H1N1 strain of the influenza A virus emerged in Mexico and quickly spread worldwide over the next several months. Ultimately, more than 18,000 people died from the pandemic. This virus had genetic components of swine influenza viruses, an avian virus, and a human influenza virus. The genetic process by which this pandemic strain of influenza A emerged is an example of:

A.  Antigenic drift

B.  Antigenic shift

C.  Genetic reassortment

D.  Point mutation

E.  B and C

IV-157. A 65-year-old woman is admitted to the hospital in January with a 2-day history of fevers, myalgias, headache, and cough. She has a history of end-stage kidney disease, diabetes mellitus, and hypertension. Her medications include darbepoetin, selamaver, calcitriol, lisinopril, aspirin, amlodipine, and insulin. She receives hemodialysis three times weekly. Upon admission, her blood pressure is 138/65 mmHg, heart rate is 122 beats/min, temperature is 39.4°C, respiratory rate is 24 breaths/min, and oxygen saturation is 85% on room air. On physical examination, diffuse crackles are heard, and a chest radiograph confirms the presence of bilateral lung infiltrates concerning for pneumonia. It is known that the most common cause of seasonal influenza in this area is an H3N2 strain of influenza A. All of the following should be included in the initial management of this patient EXCEPT:

A.  Amantadine

B.  Assessment of the need for close household contacts to receive chemoprophylaxis if influenza swab result is positive

C.  Droplet precautions

D.  Nasal swab for influenza

E.  Oxygen therapy

IV-158. In which of the following individuals has the intranasal influenza vaccine been determined to be safe and effective?

A.  A 3-year-old child who was hospitalized on one occasion for wheezing in association with human respiratory syncytial virus infection at 9 months of age

B.  A 32-year-old woman who is currently 32 weeks pregnant

C.  A 42-year-old registered nurse who had a known exposure to an individual with pandemic H1N1 who is currently receiving chemoprophylaxis with oseltamivir. He does not have contact with transplant, oncology, or HIV-positive patients.

D.  A 48-year-old hematologist whose primary specialty is bone marrow transplant

E.  A 69-year-old man with hypertension

IV-159. A 17-year-old woman with a medical history of mild intermittent asthma presents to your clinic in February with several days of cough, fever, malaise, and myalgias. She notes that her symptoms started 3 days earlier with a headache and fatigue and that several students and teachers at her high school have been diagnosed recently with “the flu.” She did not receive a flu shot this year. Which of the following medication treatment plans is the best option for this patient?

A.  Aspirin and a cough suppressant with codeine

B.  Oseltamivir, 75 mg PO bid for 5 days

C.  Rimantadine, 100 mg PO bid for 1 week

D.  Symptom-based therapy with over-the-counter agents

E.  Zanamivir, 10 mg inhaled bid for 5 days

IV-160. All of the following statements regarding human T-cell lymphotropic virus-I (HTLV-I) infection are true EXCEPT:

A.  Acute T-cell leukemia is associated with HTLV-I infection.

B.  HTLV-I endemic regions include southern Japan, the Caribbean, and South America.

C.  HTLV-I infection is associated with a gradual decline in T-cell function and immunosuppression.

D.  HTLV-I is transmitted parenterally, sexually, and from mother to child.

E.  Tropical spastic paraparesis is associated with HTLV-I infection.

IV-161. A 28-year-old man is diagnosed with HIV infection during a clinic visit. He has no symptoms of opportunistic infection. His CD4+ lymphocyte count is 150/μL. All of the following are approved regimens for primary prophylaxis against Pneumocystis jiroveci infection EXCEPT:

A.  Aerosolized pentamidine, 300 mg monthly

B.  Atovaquone, 1500 mg PO daily

C.  Clindamycin, 900 mg PO q8h, plus primaquine, 30 mg PO daily

D.  Dapsone, 100 mg PO daily

E.  Trimethoprim–sulfamethoxazole, 1 single-strength tablet PO daily

IV-162. All of the following statements regarding HIV epidemiology in the United States as of 2010 are true EXCEPT:

A.  Most patients in the United States with HIV infection are nonwhite.

B.  The annual number of AIDS-related deaths has fallen since 1995.

C.  The percentage of AIDS cases attributed to male-to-male transmission has fallen steadily since 1985.

D.  The proportion of prevalent HIV cases caused by injection drug use is currently decreasing.

E.  Up to 20% of patients in the United States are unaware of being infected with HIV.

IV-163. Which of the following scenarios is most likely associated with the lowest risk of HIV transmission to a health care provider after an accidental needle stick from a patient with HIV?

A.  The needle is visibly contaminated with the patient’s blood.

B.  The needle stick injury is a deep tissue injury to the health care provider.

C.  The patient whose blood is on the contaminated needle has been on antiretroviral therapy for many years with a history of resistance to many available agents but most recently has had successful viral suppression on current therapy.

D.  The patient whose blood is on the contaminated needle was diagnosed with acute HIV infection 2 weeks ago.

IV-164. Abacavir is a nucleoside transcription inhibitor that carries which side effect unique for HIV antiretroviral agents?

A.  Fanconi’s anemia

B.  Granulocytopenia

C.  Lactic acidosis

D.  Lipoatrophy

E.  Severe hypersensitivity reaction

IV-165. A 38-year-old man with HIV/AIDS presents with 4 weeks of diarrhea, fever, and weight loss. Which of the following tests makes the diagnosis of cytomegalovirus (CMV) colitis?


B.  Colonoscopy with biopsy

C.  Serum CMV polymerase chain reaction

D.  Stool CMV antigen

E.  Stool CMV culture

IV-166. A 40-year-old man is admitted to the hospital with 2 to 3 weeks of fever, tender lymph nodes, and right upper quadrant abdominal pain. He reports progressive weight loss and malaise over 1 year. On examination, he is found to be febrile and frail with temporal wasting and oral thrush. Matted, tender anterior cervical lymphadenopathy smaller than 1 cm and tender hepatomegaly are noted. He is diagnosed with AIDS (CD4+ lymphocyte count = 12/μL and HIV RNA = 650,000 copies/mL). Blood cultures grow Mycobacterium avium. He is started on rifabutin and clarithromycin, as well as dapsone for Pneumocystis prophylaxis, and discharged home 2 weeks later after his fevers subside. He follows up with an HIV provider 4 weeks later and is started on tenofovir, emtricitabine, and efavirenz. Two weeks later, he returns to clinic with fevers, neck pain, and abdominal pain. His temperature is 39.2°C, heart rate is 110 beats/min, blood pressure is 110/64 mmHg, and oxygen saturations are normal. His cervical nodes are now 2 cm in size and extremely tender, and one has fistulized to his skin and is draining yellow pus that is acid-fast bacillus stain positive. His hepatomegaly is pronounced and tender. What is the most likely explanation for his presentation?

A.  Cryptococcal meningitis

B.  HIV treatment failure

C.  Immune reconstitution syndrome to Mycobacterium avium

D.  Kaposi’s sarcoma

E.  Mycobacterium avium treatment failure caused by drug resistance

IV-167. Per-coital rate of HIV acquisition in a man who has unprotected sexual intercourse with an HIV-infected female partner is likely to increase under which of the following circumstances?

A.  Acute HIV infection in the female partner

B.  Female herpes simplex virus (HSV-2)–positive serostatus

C.  Male nongonococcal urethritis at the time of intercourse

D.  Uncircumcised male status

E.  All of the above

IV-168. Current Centers for Disease Control and Prevention recommendations are that screening for HIV be performed in which of the following?

A.  All high-risk groups (injection drug users, men who have sex with men, and high-risk heterosexual women)

B.  All U.S. adults

C.  Injection drug users

D.  Men who have sex with men

E.  Women who have sex with more than two men per year

IV-169. A 38-year-old woman is seen in the clinic for a decrease in cognitive and executive function. Her husband is concerned because she is no longer able to pay bills, keep appointments, or remember important dates. She also seems to derive considerably less pleasure from caring for her children and her hobbies. She is unable to concentrate for long enough to enjoy movies. This is a clear change from her functional status 6 months prior. A workup reveals a positive HIV antibody by enzyme immunoassay and Western blot. Her CD4+ lymphocyte count is 378/μL with a viral load of 78,000/mL. She is afebrile with normal vital signs. Her affect is blunted, and she seems disinterested in the medical interview. Neurologic examination for strength, sensation, cerebellar function, and cranial nerve function is nonfocal. Funduscopic examination is normal. Mini-Mental Status Examination score is 22 of 30. A serum rapid plasmin reagin (RPR) test result is negative. MRI of the brain shows only cerebral atrophy disproportionate to her age but no focal lesions. What is the next step in her management?

A.  Antiretroviral therapy

B.  Cerebrospinal fluid (CSF) JV virus polymerase chain reaction (PCR)

C.  CSF mycobacterial PCR

D.  CSF VDRL test

E.  Serum cryptococcal antigen

F.  Toxoplasma IgG

IV-170. Indinavir is a protease inhibitor that carries which side effect unique for HIV antiretroviral agents?

A.  Abnormal dreams

B.  Benign hyperbilirubinemia

C.  Hepatic necrosis in pregnant women

D.  Nephrolithiasis

E.  Pancreatitis

IV-171. In an HIV-infected patient, Isospora belli infection is different from Cryptosporidium infection in which of the following ways?

A.  Isospora causes a more fulminant diarrheal syndrome, leading to rapid dehydration and even death in the absence of rapid rehydration.

B.  Isospora infection may cause biliary tract disease, but cryptosporidiosis is strictly limited to the lumen of the small and large bowel.

C.  Isospora spp. are more likely to infect immuno-competent hosts than Cryptosporidium spp.

D.  Isospora spp. are less challenging to treat and generally respond well to trimethoprim–sulfamethoxazole treatment.

E.  Isospora spp. occasionally cause large outbreaks among the general population.

IV-172. A 27-year-old man presents to your clinic with 2 weeks of sore throat, malaise, myalgias, night sweats, fevers, and chills. He visited an urgent care center and was told that he likely had the flu. He was told that he had a “negative test for mono.” The patient is homosexual and states that he is in a monogamous relationship and has unprotected receptive and insertive anal and oral intercourse with one partner. He had several partners before his current partner 4 years ago but none recently. He reports a negative HIV-1 test 2 years ago and recalls being diagnosed with Chlamydia infection 4 years ago. He is otherwise healthy with no medical problems. You wish to rule out the diagnosis of acute HIV. Which blood test should you order?

A.  CD4+ lymphocyte count

B.  HIV enzyme immunoassay (EIA)/Western blot combination testing

C.  HIV resistance panel

D.  HIV RNA by polymerase chain reaction (PCR)

E.  HIV RNA by ultrasensitive PCR

IV-173. A 47-year-old woman with known HIV/AIDS (CD4+ lymphocyte, 106/μL and viral load, 35,000/mL) presents with painful growths on the side of her tongue as shown in Figure IV-173. What is the most likely diagnosis?


FIGURE IV-173 (see Color Atas)

A.  Aphthous ulcers

B.  Hairy leukoplakia

C.  Herpes stomatitis

D.  Oral candidiasis

E.  Oral Kaposi’s sarcoma

IV-174. Which of the following patients should receive HIV antiretroviral therapy?

A.  A 24-year-old man with newly diagnosed acute HIV infection by viral PCR

B.  A 44-year-old man who reports having unprotected anal intercourse with another man who has active HIV infection

C.  A 26-year-old pregnant women found at screening to have HIV infection of unknown duration and a CD4 lymphocyte count of 700/μL

D.  A 51-year-old man found to at screening to have HIV infection of unknown duration and a CD4 lymphocyte count of 150/μL

E.  All of the patients should receive antiretroviral therapy

IV-175. All of the following statements regarding antiretroviral therapy for HIV are true EXCEPT:

A.  CD4+ lymphocyte count should rise by more than 100 cells/mm3 within 2 months of initiation of therapy.

B.  Intermittent administration regimens have equivalent efficacy to constant administration regimens.

C.  Plasma HIV RNA should fall by 1 log order within 2 months of initiation of therapy.

D.  Recommended initial regimens include three drugs.

E.  Viral genotype should be checked before initiation of therapy.

IV-176. All of the following statements regarding Norwalk virus gastroenteritis are true EXCEPT:

A.  Fever is common.

B.  Incubation period is typically 5 to 7 days.

C.  Infection is common worldwide.

D.  It is a major cause of nonbacterial diarrhea outbreaks in the United States.

E.  Transmission is typically fecal–oral.

IV-177. All of the following statements regarding rotavirus gastroenteritis are true EXCEPT:

A.  Fever occurs in more than 25% of cases.

B.  Inflammatory diarrhea distinguishes rotaviral illness from Norwalk agent gastroenteritis.

C.  It is a major cause of diarrheal death among children in the developing world.

D.  Nausea is common.

E.  Vaccination is recommended for all children in the United States.

IV-178. A 9-year-old boy is brought to a pediatric emergency department by his father. He has had 2 days of headache, neck stiffness, and photophobia and this morning had a temperature of 38.9°C (102°F). He has also had several episodes of vomiting and diarrhea overnight. A lumbar puncture is performed, which reveals pleocytosis in the cerebrospinal fluid (CSF). Which of the following is true regarding enteroviruses as a cause of aseptic meningitis?

A.  An elevated CSF protein level rules out enteroviruses as a cause of meningitis.

B.  Enteroviruses are responsible for up to 90% of aseptic meningitis in children.

C.  Lymphocytes will predominate in the CSF early on, with a shift to neutrophils at 24 hours.

D.  Symptoms are more severe in children than in adults.

E.  They occur more commonly in the winter and spring.

IV-179. A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F); sore throat; dysphagia; and a number of grayish-white papulovesicular lesions on the soft palate, uvula, and anterior pillars of the tonsils (see Figure IV-179). The patient is most likely infected with which of the following?


FIGURE IV-179 (see Color Atas)

A.  Candida albicans

B.  Coxsackievirus

C.  Herpesvirus


E.  Staphylococcus lugdunensis

IV-180. The human enterovirus family includes poliovirus, coxsackieviruses, enteroviruses, and echovirus. Which of the following statements regarding viral infection with one of the members of this group is true?

A.  Among children infected with poliovirus, paralysis is common.

B.  Enteroviruses are not transmitted via blood transfusions and insect bites.

C.  In utero exposure to maternal enteroviral antibodies is not protective.

D.  Infections are most common in adolescents and adults, although serious illness is most common in young children.

E.  Paralysis from poliovirus infection was more commonly seen in developing countries.

IV-181. A 23-year-old previously healthy female letter carrier works in a suburb in which the presence of rabid foxes and skunks has been documented. She is bitten by a bat, which then flies away. Initial examination reveals a clean break in the skin in the right upper forearm. She has no history of receiving treatment for rabies and is unsure about vaccination against tetanus. The physician should:

A.  Clean the wound with a 20% soap solution.

B.  Clean the wound with a 20% soap solution and administer tetanus toxoid.

C.  Clean the wound with a 20% soap solution, administer tetanus toxoid, and administer human rabies immune globulin intramuscularly.

D.  Clean the wound with a 20% soap solution, administer tetanus toxoid, administer human rabies immune globulin IM, and administer human diploid cell vaccine.

E.  Clean the wound with a 20% soap solution and administer human diploid cell vaccine.

IV-182. While working at a new medical school in Kuala Lumpur, Malaysia, a 35-year-old previously healthy man from Baltimore develops a sudden onset of malaise, fever, headache, retro-orbital pain, backache, and myalgias. On examination, his temperature is 39.6°C with normal blood pressure and slight tachycardia. He has some vesicular lesions on his palate and scleral injection. Laboratory studies are notable for a platelet count of 100,000/μL. All of the following are true regarding his illness EXCEPT:

A.  A second infection could result in hemorrhagic fever.

B.  After resolution, he has lifelong immunity.

C.  IgM ELISA may be diagnostic.

D.  In equatorial areas, year-round transmission occurs.

E.  The disease is transmitted by mosquitoes.

IV-183. Which of the following fungi is considered dimorphic?

A.  Aspergillus fumigatus

B.  Candida glabrata

C.  Cryptococcus neoformans

D.  Histoplasma capsulatum

E.  Rhizopus spp.

IV-184. All of the following antifungal medications are available in an oral form EXCEPT:

A.  Caspofungin

B.  Fluconazole

C.  Griseofulvin

D.  Itraconazole

E.  Posaconazole

F.  Terbinafine

IV-185. All of the following antifungal medications are approved for the treatment of Candida albicans fungemia EXCEPT:

A.  Caspofungin

B.  Fluconazole

C.  Micafungin

D.  Posaconazole

E.  Voriconazole

IV-186. Clinically useful serum or urine diagnostic tests exist for all of the following invasive fungal infections EXCEPT:

A.  Aspergillus

B.  Blastomycosis

B.  Coccidioidomycosis

C.  Cryptococcosis

D.  Histoplasmosis

IV-187. A 24-year-old female student at the Ohio State University is seen in the emergency department for shortness of breath and chest pain. She has no significant past medical history. Her only medication is an oral contraceptive. As a component of her evaluation, she receives a contrast-enhanced CT scan of the chest. Fortunately, there is no pulmonary embolism (she is diagnosed with viral pleuritis), but there are numerous lung, mediastinal, and splenic calcifications. Based on these findings, which of the following remote infections was most likely?

A.  Blastomycosis

B.  Coccidioidomycosis

C.  Cryptococcosis

D.  Histoplasmosis

E.  Tuberculosis

IV-188. A 43-year-old woman with a history of rheumatoid arthritis is admitted to the hospital with respiratory failure. She was started on infliximab 2 months ago because of refractory disease. Before initiation of the medication, her physician found no evidence of latent tuberculosis infection. She reports 2 days of fever and worsening shortness of breath. On admission, she is hypotensive and hypoxemic with a chest radiograph showing bilateral interstitial and reticulonodular infiltrates. After administration of fluids, broad-spectrum antibiotics, intubation, and initiation of mechanical ventilation, a bronchoalveolar lavage is performed. A silver stain of the BAL fluid shows the organisms shown in Figure IV-188. Which of the following is the most likely causative organism?


FIGURE IV-188 (see Color Atas)

A.  Aspergillus fumigatus

B.  Cytomegalovirus

C.  Histoplasma capsulatum

D.  Mycobacteria avium complex

E.  Mycobacterial tuberculosis

IV-189. In the patient described above, which of the following therapies should be continued?

A.  Caspofungin

B.  Clarithromycin, rifampin, and ethambutol

C.  Ganciclovir

D.  INH, rifampin, PZA, and ethambutol

E.  Liposomal amphotericin B

IV-190. A 24-year-old man is brought to the emergency department by his friends because of worsening mental status, confusion, and lethargy. He has been complaining of a severe headache for more than 1 week. The patient works as a migrant farm worker, most recently in the Fresno, California, area. He is originally from the Philippines and has been in the United States for 4 years with no medical therapy. Vital signs include blood pressure of 95/45 mmHg, heart rate of 110 beats/min, respiratory rate of 22 breaths/min, oxygen saturation of 98%, and temperature of 101.1°F. He appears cachectic and is confused. There is minimal nuchal rigidity but notable photophobia. His CBC is notable for a WBC of 2000/μL (95% neutrophils) and a hemoglobin of 9 g/dL. An LP reveals a WBC count of 300/μL (90% lymphocytes), glucose of 10 mg/dL, and protein of 130 mg/dL. Silver stain of the CSF reveals large (30–100 μm) round structures measuring with thick walls containing small round spores and internal septations. Which of the following is the most appropriate therapy?

A.  Caspofungin

B.  Ceftriaxone plus vancomycin

C.  Fluconazole

D.  INH, rifampin, ethambutol, and pyrazinamide (PZA)

E.  Penicillin G

IV-191. You are a physician for an undergraduate university health clinic in Arizona. You have evaluated three students with similar complaints of fever, malaise, diffuse arthralgias, cough without hemoptysis, and chest discomfort, and one of the patients has a skin rash on her upper neck consistent with erythema multiforme. Chest radiography is similar in all three, with hilar adenopathy and small pleural effusions. Her CBC is notable for eosinophilia. Upon further questioning, you learn that all three students are in the same archaeology class and participated in an excavation 1 week ago. Your leading diagnosis is:

A.  Mononucleosis

B.  Primary pulmonary aspergillosis

C.  Primary pulmonary coccidioidomycosis

D.  Primary pulmonary histoplasmosis

E.  Streptococcal pneumonia

IV-192. A 62-year-old man returns from a vacation to Arizona with fever, pleurisy, and a nonproductive cough. All of the following factors on history and laboratory examination favor a diagnosis of pulmonary coccidioidomycosis rather than community-acquired pneumonia EXCEPT:

A.  Eosinophilia

B.  Erythema nodosum

C.  Mediastinal lymphadenopathy on chest radiography

D.  Positive Coccidioides complement fixation titer result

E.  Travel limited to Northern Arizona (Grand Canyon area)

IV-193. In a patient with lung and skin lesions, a travel history to which of the following regions would be most compatible with the potential diagnosis of blastomycosis?

A.  Brazil (Amazon River basin)

B.  Malaysia

C.  Northern Wisconsin

D.  Southern Arizona

E.  Western Washington state

IV-194. A 43-year-old man comes to the physician complaining of 1 month of low-grade fever, malaise, shortness of breath, and a growing skin lesion. He resides in the upper peninsula of Michigan and works as a landscaper. He avoids medical care as much as possible. He is on no medications and smokes 2 packs per day of cigarettes. Over the past month, he notices that his daily productive cough has worsened and the phlegm in dark yellow. He also reports that he has developed a number of skin lesions that start as a painful nodule and then over 1 week ulcerate and discharge pus (see Figure IV-194). His physical examination is notable for egophony and bronchial breath sounds in the right lower lobe, and approximately five to 10 ulcerating 4- to 8-cm skin lesions on the lower extremities consistent with the one shown in the figure. His chest radiograph shows right lower lobe consolidation with no pleural effusion and no evidence of hilar or mediastinal adenopathy. After obtaining sputum for cytology and culture and a biopsy of the skin lesion, which is the next most likely diagnostic or therapeutic intervention?


FIGURE IV-194 (see Color Atas(Used with permission from Elizabeth M. Spiers, MD.)

A.  Colonoscopy to evaluate for inflammatory bowel disease

B.  INH, rifampin, PZA, and ethambutol

C.  Itraconazole

D.  PET scan to evaluate for metastatic malignant disease

E.  Vancomycin

IV-195. A 34-year-old female aviary worker who has no significant past medical history, is taking no medications, has no allergies, and is HIV negative presents to the emergency department with fever, headache, and fatigue. She reports that her headache has been present for at least 2 weeks, is bilateral, and is worsened by bright lights and loud noises. She is typically an active person who has recently been fatigued and has lost 8 lb because of anorexia. Her work involves caring for birds and maintaining their habitat. Her vital signs are notable for a temperature of 101.8°F. The neurologic examination findings are normal except for notable photophobia. Head CT examination is normal. Lumbar puncture is significant for an opening pressure of 20 cmH2O, white blood cell count of 15 cells/μL (90% monocytes), protein of 0.5 g/L (50 mg/mL), glucose of 2.8 mmol/L (50 mg/dL), and positive India ink stain. What is the appropriate therapy for this patient?

A.  Amphotericin B for 2 weeks followed by lifelong fluconazole

B.  Amphotericin B plus flucytosine for 2 weeks followed by oral fluconazole for 10 weeks

C.  Caspofungin for 3 months

D.  Ceftriaxone and vancomycin for 2 weeks

E.  Voriconazole for 3 months

IV-196. An HIV-positive patient with a CD4 count of 110/μL who is not taking any medications presents to an urgent care center with complaints of a headache for the past week. He also notes nausea and intermittently blurred vision. Examination is notable for normal vital signs without fever but mild papilledema. Head CT does not show dilated ventricles. The definitive diagnostic test for this patient is:

A.  Cerebrospinal fluid culture

B.  MRI with gadolinium imaging

C.  Ophthalmologic examination, including visual field testing

D.  Serum cryptococcal antigen testing

E.  Urine culture

IV-197. All of the following have been identified as a predisposing factor or condition associated with the development of hematogenously disseminated candidiasis EXCEPT:

A.  Abdominal surgery

B.  Indwelling vascular catheters

C.  Hyperalimentation

D.  Pulmonary alveolar proteinosis

E.  Severe burns

IV-198. A 19-year-old young man is undergoing intensive chemotherapy for acute myelogenous leukemia. He has been neutropenic for more than 5 days and has been taking prophylactic meropenem and vancomycin for 3 days in addition to parenteral alimentation. His absolute neutrophil count yesterday was 50 cells/mm3, and today it is 200 cells/mm3. He had a fever spike to 101°F yesterday. A chest and abdomen CT at that time was unremarkable. You are asked to see him because over the past 3 hours, he has developed fever greater than 102°F, severe myalgias and joint pains, and new skin lesions (see Figure IV-198). New skin lesions are appearing in all body areas. Initially, they are red areas that become macronodular and are mildly painful. Vital signs are otherwise notable for a blood pressure of 100/60 mmHg and heart rate of 105 beats/min. An urgent biopsy of the skin lesion is most likely to show:


FIGURE IV-198 (see Color Atas)

A.  Branching (45°) septated hyphae on methenamine silver stain

B.  Budding yeast on methenamine silver stain

C.  Encapsulated yeast on India ink stain

D.  Pseudohyphae and hyphae on tissue Gram stain

E.  Rounded internally septated spherules on methenamine silver stain

IV-199. In the patient described above, all of the following medications are appropriate additions to the current antibiotic regimen EXCEPT:

A.  Amphotericin

B.  Caspofungin

C.  Fluconazole

D.  Flucytosine

E.  Voriconazole

IV-200. Which of the following statements regarding the use of antifungal agents to prevent Candida infections is true?

A.  HIV-infected patients should receive prophylaxis for oropharyngeal candidiasis when CD4 count is below 200 cells/mm3.

B.  Most centers administer fluconazole to recipients of allogeneic stem cell transplants.

C.  Most centers administer fluconazole to recipients of living related renal transplants.

D.  Voriconazole has been shown to be superior to other agents as prophylaxis in liver transplant recipients.

E.  Widespread candida prophylaxis in postoperative patients in the SICU has been shown to be cost effective.

IV-201. Candida albicans is isolated from the following patients. Rate the likelihood in order from greatest to least that the positive culture represents true infection rather than contaminant or noninfectious colonization.

Patient X: A 63-year-old man admitted to the intensive care unit (ICU) with pneumonia who has recurrent fevers after receiving 5 days of levofloxacin for pneumonia. A urinalysis drawn from a Foley catheter shows positive leukocyte esterase, negative nitrite, 15 white blood cells/hpf, 10 red blood cells/hpf, and 10 epithelial cells/hpf. Urine culture grows Candida albicans.

Patient Y: A 38-year-old woman on hemodialysis presents with low-grade fevers and malaise. Peripheral blood cultures grow C. albicans in one of a total of three sets of blood cultures in the aerobic bottle only.

Patient Z: A 68-year-old man presents with a 2-day history of fever, productive cough, and malaise. Chest radiography reveals a left lower lobe infiltrate. A sputum Gram stain shows many PMNs, few epithelial cells, moderate gram-positive cocci in chains, and yeast consistent with Candida spp.

A.  Patient X > patient Z > patient Y

B.  Patient Y > patient Z > patient X

C.  Patient Y > patient X > patient Z

D.  Patient X > patient Y > patient Z

E.  Patient Z > patient X > patient Y

IV-202. A 72-year-old man is admitted to the hospital with bacteremia and pyelonephritis. He is HIV-negative and has no other significant past medical history. Two weeks into his treatment with antibiotics, a fever evaluation reveals a blood culture positive for Candida albicans. Examination is unremarkable. White blood cell count is normal. The central venous catheter is removed, and systemic antifungal agents are initiated. What further evaluation is recommended?

A.  Abdominal CT scan to evaluate for abscess

B.  Chest radiography

C.  Funduscopic examination

D.  Repeat blood cultures

E.  Transthoracic echocardiography

IV-203. A local oncology center is concerned about the occurrence of an outbreak of cases of invasive Aspergillus in patients receiving bone marrow transplants. Which of the following is the most likely source of Aspergillusinfection?

A.  Contaminated air source

B.  Contaminated water source

C.  Patient-to-patient spread in outpatient clinic waiting rooms

D.  Provider-to-patient spread because of poor hand washing technique

E.  Provider-to-patient spread because of poor utilization of alcohol disinfectant

IV-204. A 23-year-old man receiving chemotherapy for relapsed acute myelogenous leukemia has had persistent neutropenia for the past 4 weeks. Over the past 5 days, his absolute neutrophil count has risen from zero to 200 cells/mm3, and he has had persistent fevers despite receiving cefepime and vancomycin empiric therapy. Other than fever, tachycardia, and malaise, he has no focal findings, and his vital signs are otherwise unremarkable, including a normal oxygen saturation on room air. A chest and abdomen CT performed because of the fever shows a few scattered 1- to 2-cm nodules with surrounding ground glass infiltrates in the lower lobes. Which of the following test results will most likely be positive in this patient?

A.  Serum cryptococcal antigen

B.  Serum galactomannan assay

C.  Sputum fungal culture

D.  Urine Histoplasma antigen

E.  Urine Legionella antigen

IV-205. In the patient described above, which of the following medications should be initiated immediately?

A.  Amphotericin B

B.  Caspofungin

C.  Fluconazole

D.  Trimethoprim–sulfamethoxazole

E.  Voriconazole

IV-206. A 40-year-old male smoker with a history of asthma is admitted to the inpatient medical service with fever, cough, brownish-green sputum, and malaise. Physical examination shows a respiratory rate of 15 breaths/min, no use of accessory muscles of breathing, and bilateral polyphonic wheezes throughout the lung fields. There is no clubbing or skin lesions. You consider a diagnosis of allergic bronchopulmonary aspergillosis. All the following clinical features are consistent with allergic broncho-pulmonary aspergillosis EXCEPT:

A.  Bilateral peripheral cavitary lung infiltrates

B.  Elevated serum IgE

C.  Peripheral eosinophilia

D.  Positive serum antibodies to Aspergillus spp.

E.  Positive skin testing for Aspergillus spp.

IV-207. A 26-year-old patient with asthma continues to have coughing fits and dyspnea despite numerous steroid tapers and frequent use of albuterol over the past few months. Persistent infiltrates are seen on chest radiography. A pulmonary consultation suggests an evaluation for allergic bronchopulmonary aspergillosis. Which of the following is the best diagnostic test for this diagnosis?

A.  Bronchoalveolar lavage (BAL) with fungal culture

B.  Galactomannan enzyme immunoassay (EIA)

C.  High-resolution CT

D.  Pulmonary function tests

E.  Serum IgE level

IV-208. Patients with which of the following have the lowest risk of invasive pulmonary Aspergillus infection?

A.  Allogeneic stem cell transplant with graft-versus-host disease

B.  HIV infection

C.  Long-standing high-dose glucocorticoids

D.  Post-solid organ transplant with multiple episodes of rejection

E.  Relapsed or uncontrolled leukemia

IV-209. Patients with all of the following conditions have increased risk of developing mucormycosis EXCEPT:

A.  Deferoxamine therapy

B.  Factitious hypoglycemia

C.  Glucocorticoid therapy

D.  Metabolic acidosis

E.  Neutropenia

IV-210. A 36-year-old woman with a history of diabetes mellitus, hypertension, and chronic renal insufficiency reports comes to the emergency department complaining of double vision for 1 day. She is on chronic hemodialysis and missed her last appointment. She also notes 12 hours of facial swelling and difficulty speaking. Her vital signs are notable for a temperature of 39.0°C and blood pressure 155/95 mmHg. Her facial examination is shown in Figure IV-210. Laboratory examination reveals a white blood cell count of 15,000/μL, serum glucose of 205 mg/dL, serum creatinine of 6.3 mg/dL, and hemoglobin A1c of 9.7%. Arterial blood gas on room air is pH of 7.24, PCO2 of 20 mmHg, and PO2 of 100 mmHg. Needle biopsy of a retro-orbital mass reveals wide, thick–walled, ribbon-shaped nonseptate hyphal organisms that branch at 90 degrees with tissue and vascular invasion on PAS stain. All of the following are components of the initial therapy EXCEPT:


FIGURE IV-210 (see Color Atas)

A.  Hemodialysis

B.  Insulin

C.  Liposomal amphotericin B

D.  Surgical debridement

E.  Voriconazole

IV-211. Which of the following is the most common form of infection in patients with mucormycosis?

A.  Cutaneous

B.  Gastrointestinal

C.  Hematogenous dissemination

D.  Pulmonary

E.  Rhinocerebral

IV-212. A 21-year-old college student seeks your opinion because of a lesion on his head. He has no significant medical history and reports a solitary lesion on the crown of his head for more than month that has been growing slowly. He has had no fever and reports that although the area is itchy, he feels well. On examination, you note a 3-cm round area of alopecia without redness, pain, or inflammation. It is well demarcated with central clearing, scaling, and broken hair shafts at the edges. There is no redness or pain. Which of the following should you recommend?

A.  Caspofungin

B.  Clindamycin

C.  Doxycycline

D.  Minoxidil

E.  Terbinafine

IV-213. A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand. She reports that the area on the back of her right hand was initially red and not painful. There appeared to be a puncture wound in the center of the area, and she thought she had a simple scratch acquired while gardening. Over the next several days, the lesion became verrucous and ulcerated. Now the patient has noticed several nodular areas along the arm, one of which ulcerated and began draining a serous fluid today. She is also noted to have an enlarged and tender epitrochlear lymph node on the right arm. A biopsy of the edge of the lesion shows ovoid and cigar-shaped yeasts. Sporotrichosis is diagnosed. What is the most appropriate therapy for this patient?

A.  Amphotericin B intravenously

B.  Caspofungin intravenously

C.  Clotrimazole topically

D.  Itraconazole orally

E.  Selenium sulfide topically

IV-214. A 35-year-old woman with long-standing rheumatoid arthritis has been treated with infliximab for the past 6 months with improvement of her joint disease. She has a history of positive PPD and takes INH prophylaxis. For the past week, she reports worsening dyspnea on exertion with low-grade fevers and a nonproductive cough. On examination, her vital signs are notable for normal blood pressure, temperature of 38.0°C, heart rate of 105 beats/min, respiratory rate of 22 breaths/min, and SaO2 of 91% on room air. Her lungs are clear. Within one flight of steps, she becomes dyspneic, and her SaO2 falls to 80%. A chest CT scan is shown in Figure IV-214. Which of the following is the most likely diagnosis?



A.  Aspergillus fumigatus pneumonia

B.  Nocardia asteroides pneumonia

C.  Pneumocystis jiroveci pneumonia

D.  Rheumatoid nodules

E.  Staphylococcal bacteremia and septic pulmonary emboli

IV-215. Which of the following patients should receive prophylaxis against Pneumocystis jiroveci pneumonia?

A.  A 19-year-old woman with acute myelogenous leukemia initiating induction chemotherapy

B.  A 24-year-old man with HIV initiated on HAART therapy 9 months ago when his CD4 count was 100/μL and now has a CD4 count of 500/μL for the past 4 months

C.  A 36-year-old man with newly diagnosed HIV and a CD4 count of 300/μL

D.  A 42-year-old woman with rheumatoid arthritis who recovered from an episode of Pneumocystis pneumonia while taking infliximab who is now initiating therapy with abatacept

E.  A 56-year-old man with COPD receiving prednisone for an acute exacerbation

IV-216. A 45-year-old woman with known HIV infection and medical nonadherence to therapy is admitted to the hospital with 2 to 3 weeks of increasing dyspnea on exertion and malaise. A chest radiograph shows bilateral alveolar infiltrates, and induced sputum is positive for Pneumocystis jiroveci. Which of the following clinical conditions is an indication for administration of adjunct glucocorticoids?

A.  Acute respiratory distress syndrome

B.  CD4+ lymphocyte count <100/μL

C.  No clinical improvement 5 days into therapy

D.  Pneumothorax

E.  Room air PaO2 <70 mmHg

IV-217. All of the following statements regarding the drug mefloquine are true EXCEPT:

A.  Dose adjustment is necessary in patients with renal insufficiency.

B.  It is only available in oral form.

C.  It is the preferred drug for prophylaxis of chloroquine-resistant malaria.

D.  It should not be administered concurrently with halofantrine.

E.  Psychiatric side effects limit it use in certain patients.

IV-218. A 45-year-old migrant worker originally from Mexico is evaluated for right upper quadrant pain, fever, and hepatic tenderness. He reports no diarrhea or bloody stool. He is found to have a large hepatic abscess on CT scan of the abdomen. Of note, he has been in the United States for approximately 10 years and was well until approximately 10 days ago. Which of the following tests can be used to confirm the diagnosis?

A.  Examination of stool for trophozoites

B.  Liver biopsy

C.  PCR of stool for Campylobacter spp.

D.  Response to empiric trial of iodoquinol

E.  Serologic test for antibody to E. histolytica

IV-219. A 23-year-old woman is seen in the emergency department for fever and altered mental status. She is from Tanzania and arrived in the United States earlier that day. She reported 3 days of episodic fever before leaving home. Over the course of the day, her family describes deteriorating mental status. Now she is confused and lethargic. Her physical examination is notable for a temperature of 40°C, heart rate of 145 beats/min, and systemic blood pressure of 105/62 mmHg. She has a clearly gravid uterus, approximately 24 weeks of gestational age, and a neurologic examination shows confusion but no focal findings. A thick and thin smear are shown in Figure IV-219. Treatment with IV quinidine is started immediately. Which of the followings are potential complications of this therapy?


FIGURE IV-219 (see Color Atas)

A.  Hyperthyroidism

B.  Hypoglycemia

C.  Nightmares

D.  Retinopathy

E.  Seizures

IV-220. A 20-year-old man is seen in the university walk-in health clinic for evaluation of recurrent fever. He reports fever greater than 101°F lasting less than a day occurring approximately weekly for the past 3 weeks. He feels otherwise relatively poorly with diffuse myalgias and headache that are much worse during the febrile episodes. Of note, he returned recently from a mission trip to Central America and reports not taking malaria prophylaxis. Examination of the peripheral smear confirms the diagnosis of Plasmodium vivax. If present, which of the following findings indicates that the patient has severe malaria and is not a candidate for outpatient therapy?

A.  Fever >40°C

B.  One seizure last week

C.  Parasitemia of >5% affected erythrocytes on peripheral smear

D.  Serum bilirubin level of >2 mg/dL

E.  The presence of headache

IV-221. A 51-year-old woman is diagnosed with Plasmodium falciparum malaria after returning from a safari in Tanzania. Her parasitemia is 6%, hematocrit is 21%, bilirubin is 7.8 mg/dL, and creatinine is 2.7 mg/dL. She is still making 60 mL/hr of urine. She rapidly becomes obtunded. Intensive care is initiated with frequent creatinine checks, close monitoring for hypoglycemia, infusion of phenobarbital for seizure prevention, mechanical ventilation for airway protection, and exchange transfusion to address her high parasitemia. Which of the following regimens is recommended as first-line treatment for her malarial infection?

A.  Chloroquine

B.  Intravenous artesunate

C.  Intravenous quinine

D.  Intravenous quinidine

E.  Mefloquine

IV-222. A 28-year-old woman presents with fevers, headache, diaphoresis, and abdominal pain 2 days after returning from an aid mission to the coast of Papua New Guinea. Several of her fellow aid workers developed malaria while abroad, and she stopped her doxycycline prophylaxis because of a photosensitivity reaction 5 days earlier. You send blood cultures, routine labs, and a thick and thin smear to evaluate the source of her fevers. Which of the following statements is accurate in reference to diagnosis of malaria?

A.  A thick smear is performed to increase sensitivity compared with a thin smear but can only be performed in centers with experienced laboratory personnel and has a longer processing time.

B.  Careful analysis of the thin blood film allows for prognostication based on estimation of parasitemia and morphology of the erythrocytes.

C.  In the absence of rapid diagnostic information, empirical treatment for malaria should be strongly considered.

D.  Morphology on blood smear is the current criterion used to differentiate the four species of Plasmodium that infect humans.

E.  All of the above are true.

IV-223. A 19-year-old college student is employed during the summer months on Nantucket Island in Massachusetts. She is evaluated in the local emergency department with 5 days of fever, malaise, and generalized weakness. Although she does recall a tick bite approximately 6 weeks ago, she denies rash around that time or presently. Physical examination is unremarkable with the exception of a temperature of 39.3°C. Which of the following statements is true regarding her most likely illness?

A.  B. duncani is the most likely organism to be found in her peripheral blood smear.

B.  First-line therapy for severe disease in this patient is immediate complete RBC exchange transfusion in addition to clindamycin and quinine.

C.  If babesiosis is not demonstrated on thick or thin preparations of peripheral blood, PCR amplification of babesial 18S rRNA is recommended.

D.  The ring form of B. microti seen in red blood cells on microscopy is indistinguishable from Plasmodium falciparum.

E.  Without a current or historical rash, she is unlikely to have babesiosis.

IV-224. A 35-year-old man from India is seen for evaluation of several weeks of fever that has decreased in intensity, but he now has developed abdominal swelling. He has no significant past medical history. Physical examination shows palpable splenomegaly and hepatomegaly and diffuse lymphadenopathy. Diffuse hyperpigmentation is present in his skin. Visceral leishmaniasis is suspected. Which of the following diagnostic techniques is most commonly used?

A.  Culture of peripheral blood for Leishmania spp.

B.  PCR for L. infantum nucleic acid in peripheral blood

C.  Rapid immunochromatographic test for recombinant antigen rK39 from L. infantum

D.  Smear of stool for amastigotes

E.  Splenic aspiration to demonstrate amastigotes

IV-225. All of the following statements regarding infection with Trypanosoma cruzi are true EXCEPT:

A.  It is found only in the Americas.

B.  It is the causative agent of Chagas disease.

C.  It is transmitted to humans by the bite of deer flies.

D.  It may be transmitted to humans by blood transfusion.

E.  It may cause acute and chronic disease.

IV-226. A 36-year-old man is admitted to the hospital with 3 months of worsening dyspnea on exertion and orthopnea. Over the past 2 weeks, he has been sleeping upright. He denies any chest pain with exertion or syncope. There is no history of hypertension, hyperlipidemia, or diabetes. He is a lifelong nonsmoker and since arriving to the United States from rural Mexico 16 years ago works as an electrician. His physical examination is notable for being afebrile with a heart rate 105 beats/min, blood pressure of 100/80 mmHg, respiratory rate of 22 breaths/min, and oxygen saturation of 88% on room air. He has notable jugular venous distension upright with no Kussmaul sign, 3+ pitting edema to the knees, and bilateral crackles two-thirds up the lung fields. Cardiac examination shows a laterally displaced PMI, a 2/6 systolic murmur at the apex and axilla, an S3, and no friction rub or pericardial knock. Which of the following is likely to reveal the most likely diagnosis?

A.  Coronary angiography

B.  Right heart catheterization

C.  Serum PCR for T. cruzi DNA

D.  Serum T. cruzi IgG antibodies

E.  Serum troponin

IV-227. A 36-year-old medical missionary recently returned from a 2-week trip to rural Honduras. During the trip, she lived in the jungle, where she received multiple bug bites and developed open sores. One week after her return, she comes to the clinic reporting 2 days of malaise, fever to 38.5°C, and anorexia. There is an indurated swollen area of erythema on her calf and femoral adenopathy. Because of her exposure history, you obtain a thin and thick blood smear that demonstrates organisms consistent with T. cruzi. Which of the following is the best next intervention?

A.  Immediate therapy with benznidazole

B.  Immediate therapy with primaquine

C.  Immediate therapy with voriconazole

D.  Observation only

E.  Serologic confirmation with specific T. cruzi IgG testing

IV-228. A 44-year-old man who recently returned from a safari trip to Uganda seeks attention for a painful lesion on the leg and new fevers. He was on a safari tour, where he stayed in the animal park that was populated extensively with antelope, lions, giraffes, and hippos. They often toured savannah and jungle settings. He returned within the past week and noticed a painful lesion on his neck at the site of some bug bites. He reports fever over 38°C, and you find palpable cervical lymphadenopathy. Review of systems is notable for malaise and anorexia for 2 days. A thick and thin smear of the blood reveals protozoa consistent with trypanosomes. All of the following are true about his disease EXCEPT:

A.  Humans are the primary reservoir.

B.  If untreated, death is likely.

C.  It was transmitted by the bite of a tsetse fly.

D.  Lumbar puncture should be performed.

E.  Suramin is effective treatment.

IV-229. A 36-year-old man with HIV/AIDS is brought to the hospital after a grand mal seizure at home. He has a history of ongoing IV drug use and is not taking HAART. His last CD4 T-cell count was below 50/μL more than 1 month ago. Further medical history is unavailable. Vital signs are normal. On examination, he is barely arousable and disoriented. He is cachectic. There is no nuchal rigidity or focal motor deficits. Serum creatinine is normal. An urgent head MRI with gadolinium is performed, and the results of the T1-gated images are shown in Figure IV-229. Which of the following will be the most effective therapy?

A.  Caspofungin

B.  INH, rifampin, PZA, and ethambutol

C.  Pyrimethamine plus sulfadiazine

D.  Streptokinase

E.  Voriconazole



IV-230. Which of the following intestinal protozoal infections can be diagnosed with stool ova and parasite examination?

A.  Cryptosporidium spp.

B.  Cyclospora spp.

C.  Giardia spp.

D.  Isospora spp.

E.  Microsporidia spp.

F.  All of the above

IV-231. A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge. She is sexually active with multiple partners, and she is interested in getting tested for sexually transmitted diseases. A wet-mount microscopic examination is performed, and trichomonal parasites are identified. Which of the following statements regarding trichomoniasis is true?

A.  A majority of women are asymptomatic.

B.  No treatment is necessary because the disease is self-limited.

C.  The patient’s sexual partner need not be treated.

D.  Trichomoniasis can only be spread sexually.

E.  Trichomoniasis is 100% sensitive to metronidazole

IV-232. A 19-year-old college student presents to the emergency department with crampy abdominal pain and watery diarrhea that has worsened over 3 days. He recently returned from a volunteer trip to Mexico. He has no past medical history and felt well throughout the trip. Stool examination shows small cysts containing four nuclei, and stool antigen immunoassay is positive for Giardia spp. Which of the following is a recommend treatment regimen for this patient?

A.  Albendazole

B.  Clindamycin

C.  Giardiasis is self-limited and requires no antibiotic therapy

D.  Paromomycin

E.  Tinidazole

IV-233. A 28-year-old woman is brought to the hospital because of abdominal pain, weight loss, and dehydration. She has been diagnosed with HIV/AIDS for the past 2 years with a history of oral candidiasis and pneumocystis pneumonia. She reports voluminous watery diarrhea over the past 2 weeks. Because of medical nonadherance, she has not taken any antiretroviral therapy. Routine stool ova and parasite examination is normal, but stool antigen testing reveals Cryptosporidium spp. Which of the following is the recommended therapy?

A.  Metronidazole

B.  Nitazoxanide

C.  No therapy recommended because the diarrhea is self-limited.

D.  No effective specific therapy is available.

E.  Tinidazole

IV-234. Which of the following has resulted in a significant decrease in the incidence of trichinellosis in the United States?

A.  Adequate therapy that allows for eradication of infection in index cases before person-to-person spread can occur

B.  Earlier diagnosis because of a new culture assay

C.  Federal laws limiting the import of foreign cattle

D.  Laws prohibiting the feeding of uncooked garbage to pigs

E.  Requirements for handwashing by commercial kitchen staff who handle raw meat

IV-235. A patient comes into the clinic and describes progressive muscle weakness over several weeks. He has also experienced nausea, vomiting, and diarrhea. One month ago, he had been completely healthy and describes a bear hunting trip in Alaska, where they ate some of the game they killed. Soon after he returned, his gastrointestinal symptoms began followed by muscle weakness in his jaw and neck that has now spread to his arms and lower back. Examination confirms decreased muscle strength in the upper extremities and neck. He also has slowed extraocular movements. Laboratory examination shows panic values for elevated eosinophils and serum creatine phosphokinase. Which of the following organisms is most likely the cause of his symptoms?

A.  Campylobacter spp.

B.  Cytomegalovirus

C.  Giardia spp.

D.  Taenia solium

E.  Trichinella spp.

IV-236. A 3-year-old boy is brought by his parents to the clinic. They state that he has experienced fevers, anorexia, weight loss, and most recently has started wheezing at night. He had been completely healthy until these symptoms started 2 months ago. The family had travelled through Europe several months earlier and reported no unusual exposures or exotic foods. They have a puppy at home. On examination, the child is ill-appearing and is noted to have hepatosplenomegaly. Laboratory results show a panic value of 82% eosinophils. Total white blood cells are elevated. A complete blood count is repeated to rule out a laboratory error, and eosinophils are 78%. Which of the following is the most likely organism or process?

A.  Cysticercus spp.

B.  Giardiasis

C.  Staphylococcus lugdunensis

D.  Toxocariasis

E.  Trichinellosis

IV-237. The patient described above continues to decline over the next 2 to 3 days, developing worsening respiratory status, orthopnea, and cough. On physical examination, his heart rate is 120 beats/min, blood pressure is 95/80 mmHg, respiratory rate is 24 breaths/min, and oxygen saturation is 88% on room air. His neck veins are elevated, there is an apical S3, and his lungs have bilateral crackles halfway up the lung fields. An echocardiogram shows an ejection fraction of 25%. Which of the following therapies should be initiated?

A.  Albendazole

B.  Methylprednisolone

C.  Metronidazole

D.  Praziquantel

E.  Vancomycin

IV-238. A 28-year-old man is brought to the emergency department by his wife for altered mental status, fevers, vomiting, and headache. He developed a bilateral headache began about 1 day ago that has progressively worsened. He and his wife returned from a trip to Thailand and Vietnam, where they spent a lot of time in rural settings eating local mollusks, seafood, and vegetables. His physical examination is notable for fever, nuchal rigidity, confusion, and lethargy. Lumbar puncture reveals elevated opening pressure; elevated protein; normal glucose; and white blood cell count of 200/μL with 50% eosinophils, 25% neutrophils, and 25% lymphocytes. Which of the following is the most likely etiology of his meningitis?

A.  Angiostrongylus cantonensis

B.  Gnathostoma spinigerum

C.  Trichinella murrelli

D.  Trichinella nativa

E.  Toxocara canis

IV-239. While attending the University of Georgia, a group of friends go on a 5-day canoeing and camping trip in rural southern Georgia. A few weeks later, one of the campers develops a serpiginous, raised, pruritic, erythematous eruption on the buttocks. Strongyloides larvae are found in his stool. Three of his companions, who are asymptomatic, are also found to have Strongyloides larvae in their stool. Which of the following is indicated in the asymptomatic carriers?

A.  Fluconazole

B.  Ivermectin

C.  Mebendazole

D.  Mefloquine

E.  Treatment only for symptomatic illness

IV-240. All of the following are clinical manifestations of Ascaris lumbricoides infection EXCEPT:

A.  Asymptomatic carriage

B.  Fever, headache, photophobia, nuchal rigidity, and eosinophilia

C.  Nonproductive cough and pleurisy with eosinophilia

D.  Right upper quadrant pain and fever

E.  Small bowel obstruction

IV-241. A 21-year-old college student in Mississippi comes to student health to ask advice about treatment for ascaris infection. He is an education major and works 1 day a week in an elementary school, where a number of the students were recently diagnosed with ascariasis over the past 3 months. He feels well and reports being asymptomatic. A stool O&P reveals characteristic ascaris eggs. Which of the following should you recommend?

A.  Albendazole

B.  Diethylcarbamazine (DEC)

C.  Fluconazole

D.  Metronidazole

E.  Vancomycin

IV-242. A 38-year-old woman presents to the emergency department with severe abdominal pain. She has no past medical or surgical history. She recalls no recent history of abdominal discomfort, diarrhea, melena, bright red blood per rectum, nausea, or vomiting before this acute episode. She ate ceviche (lime-marinated raw fish) at a Peruvian restaurant 3 hours before presentation. On examination, she is in terrible distress and has dry heaves. Her temperature is 37.6°C, heart rate is 128 beats/min, and blood pressure is 174/92 mmHg. Examination is notable for an extremely tender abdomen with guarding and rebound tenderness. Bowel sounds are present and hyperactive. Rectal examination findings are normal, and Guaiac test result is negative. The pelvic examination is unremarkable. The white blood cell count is 6738/μL and hematocrit is 42%. A complete metabolic panel and lipase and amylase levels are all within normal limits. CT of the abdomen shows no abnormality. What is the next step in her management?

A.  CT angiogram of the abdomen

B.  Pelvic ultrasonography

C.  Proton pump inhibitor therapy and observation

D.  Right upper quadrant ultrasonography

E.  Upper endoscopy

IV-243. While participating in a medical missionary visit to Indonesia, you are asked to see a 22-year-old man with new onset of high fever, groin pain, and a swollen scrotum. His symptoms have been present for about 1 week and worsening steadily. His temperature is 38.8°C, and his examination is notable for tender inguinal lymphadenopathy, scrotal swelling with a hydrocele, and lymphatic streaking. All of the following may be useful in diagnosing his condition EXCEPT:

A.  Examination of blood

B.  Examination of hydrocele fluid

C.  Scrotal ultrasonography

D.  Serum ELISA

E.  Stool O&P

IV-244. The patient described above should be treated with which of the following medications?

A.  Albendazole

B.  Diethylcarbamazine (DEC)

C.  Doxycycline

D.  Ivermectin

E.  Praziquantel

IV-245. A 45-year-old woman is brought to the Emergency department by her daughter because she saw something moving in her mother’s eye. The patient is visiting from Zaire, where she lives in the rain forest. The patient reports some occasional eye swelling and redness. On examination, you find a worm in the subconjunctiva (Figure IV-245). Which of the following medications is indicated for therapy?


FIGURE IV-245 (see Color Atlas)

A.  Albendazole

B.  Diethylcarbazine (DEC)

C.  Ivermectin

D.  Terbinafine

E.  Voriconazole

IV-246. All of the following statements regarding the epidemiology of schistosomal infection are true EXCEPT:

A.  S. haematobium infection is seen mostly in South America.

B.  S. japonicum infection is seen mostly in China, Philippines, and Indonesia.

C.  S. mansoni infection is seen in Africa, South America, and the Middle East.

D.  Schistosomal infection causes acute and chronic manifestations.

E.  Transmission of all human schistosomal infections is from snails.

IV-247. A 48-year-old female presents to her physician with a 2-day history of fever, arthralgias, diarrhea, and headache. She recently returned from an ecotour in tropical sub-Saharan Africa, where she went swimming in inland rivers. Notable findings on physical examination include a temperature of 38.7°C (101.7°F); 2-cm tender mobile lymph nodes in the axilla, cervical, and femoral regions; and a palpable spleen. Her white blood cell count is 15,000/μL with 50% eosinophils. She should receive treatments with which of the following medications?

A.  Chloroquine

B.  Mebendazole

C.  Metronidazole

D.  Praziquantel

E.  Thiabendazole

IV-248. A person with liver disease caused by Schistosoma mansoni would be most likely to have what condition?

A.  Ascites

B.  Esophageal varices

C.  Gynecomastia

D.  Jaundice

E.  Spider nevi

IV-249. A 26-year-old man is brought to the emergency department after the onset of a grand mal seizure. On arrival to the hospital, the seizure had terminated, and he was somnolent without focal findings. Vital signs were normal except for tachycardia. The patient has no known medical history and no history of illicit drug or alcohol use. He takes no medications. At a routine clinic visit 3 months earlier, he was documented to be HIV antibody and PPD negative. He is originally from rural Guatemala and has been in the United States working as a laborer for the past 3 years. A contrast CT shows multiple parenchymal lesions in both hemispheres that are identical to the one shown in the posterior right brain (Figure IV-249). After acute stabilization, including anticonvulsant therapy, which of the following is the most appropriate next step in this patient’s management?



A.  Echocardiogram with Doppler examination of aortic and mitral valves

B.  Initiation of praziquantel therapy

C.  Initiation of pyrimethamine and sulfadiazine therapy

D.  Measurement of HIV viral load

E.  Neurosurgical consultation for brain biopsy

IV-250. A 44-year-old woman presents to the emergency department with recurrent episodes of right upper quadrant pain, typically soon after meals. These episodes have been present for at least 1 month and seem to be worsening. The patient emigrated from Lebanon more than 20 years ago and works as an attorney. She takes no medications and is physically active. On examination, she is jaundiced and in obvious discomfort because of right upper quadrant pain. She is afebrile and tachycardic. Her physical examination is notable for an enlarged liver. Ultrasound examination confirms the large liver and demonstrates a complex 14-cm cyst with daughter cysts extending to the liver edge with associated biliary tract dilation. Which of the following is the most appropriate management approach to this patient?

A.  Albendazole medical therapy

B.  Albendazole followed by surgical resection

C.  Needle biopsy of the cystic lesion

D.  PAIR (percutaneous aspiration, infusion of scolicidal agent, and reaspiration)

E.  Serologic testing for E. granulosus