1.

You’re evaluating a 35-year-old man who presents with arthritis, fever, urethritis, and
conjunctivitis. This has been occurring a few days. He states that about a week ago, he came
down with what felt like a viral bug that went away. What is the likely cause of this person’s
symptoms?
a. Enterobius vermicularis
b. Plasmodium falciparum
c. Schistosomiasis
d. Shigella flexneri
e. Rotavirus
Explanation :
D. This man has reactive arthritis, or Reiter’s syndrome, likely caused by Shigella
flexneri. Reiter’s is a reactive illness that occurs after being infected by Shigella. Choices (A)
and (C), Enterobius vermicularis and schistosomiasis, are parasitic diseases that would
present with ongoing intestinal symptoms. Choice (B), Plasmodium falciparum, is one of the
most common causes of malaria; it causes flu-like symptoms and icterus. Rotavirus, Choice
(E), is a common cause of diarrhea in children.

2. Which one of the following would be used to treat tetanus?

a. Fluconazole (Diflucan)
b. Prednisone (Deltasone)
c. Metronidazole (Flagyl)
d. Doxycycline (Vibramycin)
e. Azithromycin (Zithromax)
Explanation :
C. Choice (C), metronidazole, is the treatment of choice for tetanus. Choices (A) and (B),
fluconazole and prednisone, are an antifungal and a steroid, respectively. They aren’t used in
the treatment of tetanus, which is caused by a bacteria, Clostridium tetani. Choice (D),
doxycycline, is used in treating Lyme disease. Choice (E), azithromycin, is used in treating
community-acquired pneumonia.

3. You’re evaluating a 55-year-old man with advanced HIV who presents with significant
diarrhea. He has a CD4 count of 100. What is the likely cause of his diarrhea?
 a. Cryptosporidium
b. Cryptococcus
c. Norwalk virus (norovirus)
d. Giardia
e. Salmonella
Explanation :
A. This person likely has a Cryptosporidium protozoan in him. This parasite is the most
common cause of diarrhea you’d expect, given his HIV status and the fact that his CD4 count
is less than 200. Choice (B), Cryptococcus, is a cause of meningitis. Choice (C), norovirus, is
a common viral cause of diarrhea in children. Don’t forget norovirus outbreaks on cruise
ships, too. Choice (D), Giardia, is a protozoan parasite that can cause diarrhea; it’s usually
related to infected well water. Choice (E), Salmonella, is a bacterial cause of diarrhea.

4. Which one of the following is a criterion for rheumatic fever?

a. Erythema migrans
b. Erythema nodosum
c. Leukopenia
d. Erythema marginatum
e. Meningitis
Explanation :
D. Erythema marginatum, a characteristic skin rash, is a criterion for rheumatic fever.
Choice (A), erythema migrans, is seen with Lyme disease. Choice (B), erythema nodosum,
occurs with sarcoidosis and other rheumatologic diseases. Choice (C), leukopenia, isn’t a
criterion for rheumatic fever; leukocytosis, not leukopenia, is a minor criterion. Meningitis,
Choice (E), isn’t a criterion for rheumatic fever, either.

5. Which of the following is recommended for treating a Chlamydia trachomatis infection?

a. Metronidazole (Flagyl)
b. Diflucan (Fluconazole)
c. Azithromycin (Zithromax)
d. Gentamicin
e. Amoxicillin (Trimox)
 Explanation :
C. There are two treatments for Chlamydia infection: One is giving one dose of
azithromycin, and the other is 7 days’ worth of doxycycline twice a day.

6. Which one of the following is recommended for treating Rocky Mountain spotted fever?
a. Metronidazole (Flagyl)
b. Doxycycline (Vibramycin)
c. Azithromycin (Zithromax)
d. Diflucan (Fluconazole)
e. Amoxicillin (Trimox)
Explanation :
B. The treatment for Rocky Mountain spotted fever is doxycycline.

7. A 24‐year‐old woman is admitted to the ICU with suspected bacterial meningitis. She is
treated empirically on admission with intravenous ceftriaxone and vancomycin.
Cerebrospinal fluid culture obtained in the Emergency Department grows Neisseria
meningitidis on hospital day 2. The patient's doctor calls you. The patient has received
ceftriaxone plus vancomycin for 48 hours and is improving but has not been on any isolation
precautions. The doctor asks which of the following options would be most appropriate at
this point.
a. Continue standard precautions.
b. Place the patient on airborne isolation.
c. Place the patient on contact precautions.
d. Place the patient on contact precautions and airborne isolation.
Explanation :
Correct answer: a
Neisseria meningitidis is transmitted person‐to‐person by respiratory droplets, which
travel about 3‐6 feet before being removed from the air by the force of gravity. N.
meningitidis is a common cause of bacterial meningitis, and therefore, patients with
suspected bacterial meningitis are placed on droplet precautions ‐‐ personnel mask when
within 6 feet of the patient. Patients are contagious 7 days prior to onset of meningitis. After
24 hours of “effective therapy,” patients with meningitis due to N. meningitidis are no longer
 considered contagious and hence in this case, in which the patient had been treated for >24
hours, isolation precautions were no longer indicated.

8. A 46‐year‐old woman is seen for fever and a rash. She was recently diagnosed with acute
myelocytic leukemia. Following induction chemotherapy, she developed neutropenic fever
that responded to antibiotics. Her marrow recovered, and she was well at home until four
days ago when she developed fever with no localizing symptoms. An outpatient CBC
showed a white blood cell count of 12,250 with 40% bands. She was admitted, blood cultures
were sent and she was started on broad spectrum antibiotics. Other than fever and
tachycardia, her exam was unremarkable. On the second hospital day, she developed the
acute onset of a rash consisting of multiple red to red‐purple tender, non‐pruritic papules
predominantly on her face, but also involving her neck and the dorsum of her hands. Blood
cultures were negative. Biopsy of two of the skin lesions was performed. Despite antibiotics
her fever continued; some of the papules turned into plaque‐like lesions with a central yellow
discoloration. Today, the biopsy was reported as showing dense dermal perivascular
infiltrates of neutrophils without evidence of vasculitis; stains for organisms were negative.
Which one of the following is the most likely diagnosis?
a. Ecthyma gangrenosum
b. Pyoderma gangrenosum
c. Sweet Syndrome
d. Leukemic infiltrates
e. Staphylococcal folliculitis
Correct answer: c
Explanation :
This patient has an acute neutrophilic dermatosis most consistent with Sweet Syndrome.
At least half of patients with Sweet Syndrome have underlying illnesses and half of those are
malignancies particularly acute myelocytic leukemia and other lymphoproliferative
disorders. Lesions ap pear abruptly and are papules or plaques most often found on the face
and extremities, particularly the dorsum of the hands. Biopsy shows neutrophilic dermal
infiltrates without vasculitis. Most patients have antecedent fever. Treatment is steroids.
Ecthyma gangrenosum is the necrotic skin lesion associated with Pseudomonas bacteremia.
 Pyoderma gangrenosum is associated with inflammatory bowel disease, and the lesions are
ulcerative with undermined borders. Leukemic infiltrates would be very unlikely given the
good response to chemotherapy and the absence of blasts on CBC. Staphylococcal
folliculitis is ruled out by the absence of organisms on biopsy stains.

9. An injection drug user is admitted with fever for four days. Exam shows a grade IV aortic
insufficiency murmur, and he is started on vancomycin 1gm q12h after three blood cultures
are obtained. Methicillin‐resistant Staphylococcus aureus is grown from all blood cultures,
and repeat blood cultures on days two and three also grow MRSA. The vancomycin M.I.C.
for his MRSA is 1.5. On day four of treatment he is short of breath, he has diffuse crackles
on chest exam, and x‐ray of the chest shows acute pulmonary edema. Which one of the
following is the most important next step in management of this patient?
a. Immediate aortic valve replacement
b. Valve replacement once blood cultures are negative
c. Change vancomycin to daptomycin
d. Add gentamicin to vancomycin
e. Increase vancomycin dose
Correct answer: a
Explanation :
Severe heart failure in endocarditis is an immediate indication for surgery, even in
patients who are still bacteremic. Delay in surgery increases mortality and infection risk for
the new valve is small. Changes to antimicrobial therapy, even if potentially useful, would
not supersede the need for surgery which may be life‐saving.
ACC/AHA Guideline‐Surgery for Native Valve Endocarditis
Strong Indication
 Valve stenosis or regurgitation leading to heart failure.
 Aortic or mitral regurgitation with hemodynamic evidence of elevated left ventricular
end‐diastolic or atrial pressures such as premature closure of the mitral valve with aortic
regurgitation, rapid decelerating mitral regurgitation signal by continuous wave Doppler
(v‐wave cutoff sign), or moderate to severe pulmonary hypertension.
 Endocarditis due to fungal or other highly resistant organisms.
  Complications such as heart block, annular or aortic abscess, or destructive penetrating
lesions such as fistula from the sinus of Valsalva to the right or left atrium or right
ventricle, mitral leaflet perforation with IE of the aortic valve, or infection in annulus
fibrosis.
Less Compelling Indication
 Recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.
Possible Indication
 Mobile vegetations larger than 10 mm with or without emboli.
J Am Coll Cardiol 2006; 48:e

10. A 38‐year‐old man from Nantucket was admitted three days ago with a dense pneumonia and
a pleural effusion. He has been treated with azithromycin and ceftriaxone but is not
improving. His illness began abruptly two days PTA with fever and chills; he began to cough
the following day and developed pleuritic pain. He has scant sputum production. On exam he
is febrile with a normal pulse; there are crackles and percussion dullness in the right chest.
The WBC is normal; the pleural fluid is exudative with a lymphocyte predominance.
Admission sputum culture grew normal flora; the pleural fluid was sterile. He is an
accountant, has no recent travel history, and no exposure to ill persons. His only possible
animal exposure occurred 4 days before he became ill when he was mowing his lawn, and
some kind of small animal darted out from behind a bush and was pulverized by the mower
blades. Which one of the following is the most likely diagnosis?
a. Primary tuberculosis
b. Q fever
c. Mycoplasma pneumonia
d. Plague
e. Tularemia
Correct answer: E
Explanation :
This patient likely has tularemic pneumonia acquired through inhalation when an infected
rabbit or rodent was aerosolized by his mower. Rapid onset, scant sputum, pleural
involvement (exudative and lymphocytic effusion), temperature‐pulse disparity, absence of
 visualization of the organism on sputum gram stain, and negative sputum cultures (many
strains needed cysteine added to media for growth), and normal WBC count are all common
findings. Primary TB can cause a lymphocytic pleural effusion but wouldn’t likely be
associated with a dense pneumonia and this kind of abrupt onset with chills. Q fever and
Mycoplasma pneumonias may be associated with temperature‐pulse disparity but the abrupt
onset and pleural involvement would be unlikely. Plague pneumonia patients are desperately
ill with pronounced leukocytosis.

11. A 39‐year‐old female received allogeneic hematopoietic cell transplantation for acute
myelogenous leukemia, from an unrelated donor, using a myeloablative conditioning
regimen. Her post‐transplant course was complicated by skin and gut graft vs host disease
which was treated with methylprednisolone (2 mg/kg). She had a positive CMV PCR on day
40, at 3000 copies, and was treated with induction doses of ganciclovir (5 mg/kg twice daily,
Cr 1.0). During the second week of induction dosing of ganciclovir, her absolute neutrophil
count declined to 200/mm3 ; ganciclovir was changed to foscarnet (90 mg/kg twice daily).
Two weeks after switching to Foscarnet, her serum CMV PCR was undetectable but she
developed vaginal pain, with visual ulcers on her vulva and adjacent to her urethra. She has
no concurrent diarrhea, rash, or oral mucositis. WBC is now 5000 with 70% neutrophils.
What is the best therapeutic intervention for her vaginal ulcers at this point?
a. Continue foscarnet and increase hydration
b. Continue foscarnet and add topical trifluridine to vulva
c. Continue foscarnet and add topical corticosteroids to vulva
d. Switch foscarnet to acyclcovir
e. Switch foscarnet to ganciclovir
Correct answer: e
Explanation :
This patient likely has genital ulcers caused by foscarnet. Genital ulcers can occur during
foscarnet therapy, likely as a result of contact dermatitis caused by high concentrations of
foscarnet in the urine. Other causes of genital mucosal lesions include HSV; however,
breakthrough Herpes simplex vaginitis/cervicitis is highly unlikely for someone receiving
high dose foscarnet . A negative PCR for HSV on a swab of an ulcer would also help exclude
 HSV. She is unlikely to have graft vs host involving her vulva, since she has no other
manifestatations: no diarrhea, no oral mucositis, no rash. The appropriate first step is to
switch to an alternative anti CMV drug. There is no role for topical agents. Since the ANC
had improved on foscarnet, switching back to ganciclovir or oral valganciclovir is a
reasonable choice. If the ANC drops again, support with hematopoietic growth factors may
be needed to stabilize the counts. Given the improvement in her CMV viral load, she doesn’t
need to go back to the higher induction dosing of ganciclovir. Switching to acyclovir would
be inappropriate in this situation because the patient still requires suppression of CMV and
acyclovir (even at higher doses) is not an effective treatment.

12. A 43‐year‐old otherwise healthy male construction worker with a penicillin allergy (hives)
presents with a painful 2 cm red furuncle on his calf. Purulent material shows Gram positive
cocci in clusters; Staphylococcus aureus is identified. You initiate therapy with clindamycin
pending susceptibility results. The lab performs susceptibility tests and reports that the isolate
is resistant to penicillin and erythromycin but susceptible to clindamycin, oxacillin, rifampin,
trimethoprimsulfamethoxazole and linezolid. What therapeutic option would you select?
a. Continue clindamycin and request a D test to determine if clindamycin is likely to
induce resistance
b. Continue clindamycin. No further tests warranted.
c. Change to linezolid
d. Add gentamicin
e. Switch to Synercid
Correct answer: a
Explanation :
When a S. aureus is resistant to erythromycin, the lab may be requested to perform a D
test to determine if the Staphylococcus aureus has inducible resistance to clindamycin. With
a small lesion like this, the clindamycin can be continued while awaiting the D test results.
Rifampin use is not indicated. Trimethoprim‐sulfamethoxazole is a reasonable option but not
necessarily preferred in a clindamycin susceptible isolate. Linezolid is more expensive and
has potential toxicity. Although the clinical evidence is not strong, case reports have
suggested that inducible clindamycin resistance predicts a higher probability of clinical
 failure with that drug. Erythromycin (a macrolide) and clindamycin (a lincosamide) represent
two distinct classes of antimicrobial agents that inhibit protein synthesis by binding to the
50S ribosomal subunits of bacterial cells. In staphylococci, resistance to both of these
antimicrobial agents can arise when the isolate acquires an “erm” gene, named “erm” for
erythromycin resistance methylase. These genes lead to methylation of the ribosomal binding
site of the antibiotic in the staphylococcus and block antibiotic effect. This resistance can be
constitutive, where the rRNA methylase is always produced. Resistance can also be
inducible, in which case methylase is produced only in the presence of an inducing agent.
Erythromycin is a much better inducer of this gene than clindamycin. The D test allows
erythromycin to induce resistance that affects the clindamycin zone size next to the
erythromycin disc.

13. A 20‐year‐old male with refractory lymphoma received an HLA‐mismatched and T cell
depleted allogeneic stem cell transplant He engrafted his WBC on day 22, and developed a
faint diffuse erythematous rash and lowgrade fever on day 68, diagnosed as acute graft vs.
host disease, for which he was treated with prednisone, which was ultimately tapered. The
rash faded and he became afebrile. He is receiving trimethoprim‐sulfamethoxazole three
times a week and twice daily valacyclovir for prophylaxis.
 On day 110, he developed fever to 38°C, dyspnea, cough, and a faint erythematous rash.
 His WBC was 7,000, with a normal differential.
 Chest CT scan demonstrated bilateral ground glass opacities but cultures and/or stains of
a bronchoalveolar lavage for bacteria, fungi and pneumocystis were negative.
 Alkaline phosphatase was 309 U/L, AST 488 U/L, ALT 430 U/L, total bilirubin 1.9
mg/dl.
 Urinalysis revealed hematuria: 1500 RBC, 20 WBC, with no bacteria on stain.
 His CMV PCR on peripheral blood was undetectable.
What is the most likely cause of this syndrome?
a. HSV
b. VZV
c. Graft vs host disease
d. Adenovirus
 e. BK virus
Correct answer: d
Explanation :
Adenoviral diseases are well characterized in hematopoietic cell transplant (HCT)
recipients. Manifestations include pneumonia, colitis, hepatitis, hemorrhagic cystitis,
tubulointerstitial nephritis, encephalitis, and disseminated disease‐‐and this patient has many
of these manifestations. The T cell depleted graft and graft vs host disease are both risk
factors for disseminated adenovirus disease. Diagnosis of adenovirus disease in this setting is
complicated: serum PCR assays, sterile fluid PCR, bronchoalveolar lavage PCR and tissue
biopsies all have roles. There is no specific therapy that is clearly effective although T cell
infusions and perhaps cidofovir may have roles. The hematuria suggests adenovirus or BK
virus, but BK virus would not cause the pneumonitis, hepatitis, or other manifestations
outside the bladder in a stem cell recipient. HSV and VZV would be unusual causes of
hematuria, and unusual to occur in a patient receiving valacyclovir. BK virus causes
hemorrhagic and non‐hemorrhagic cystitis in bone marrow transplant recipients. This is in
contrast to kidney transplant recipients who rarely develop cystitis but who can develop other
syndromes: tubulointerstitial nephritis and ureteral stenosis.

14. A patient has catheter related Staphylococcus aureus bacteremia. An E test is done to
determine vancomycin susceptibility.

What is the mechanism of the resistance demonstrated by this E test?

a. Beta lactamase
b. Efflux pump
c. D lactase replacement of d alanine in staph aureus cell wall
d. Excess D alanine binding to vancomycin, i.e. thick cell wall
 Correct answer: d
Explanation :
This E test shows some colonies of Staphylococcus aureus growing within the area where
most Staph aureus have been inhibited by vancomycin. Were it not for these few colonies,
this Staph aureus would have an MIC of about 2.

15. You are consulted about an outbreak of conjunctivitis. In late August, in a period of 10 days,
15 of 30 college students attending a summer French language camp in upstate New York
developed eye pain and redness. Exams are notable for conjunctivitis without purulent
exudate, fever or preauricular adenopathy. All the students swim in the camp lake on a daily
basis and eat meals together in a dining hall. The camp cat has recently had a litter and all the
affected students say that they have played with the kittens. Which one of the following is the
most likely cause of the outbreak?
a. Enterovirus
b. Adenovirus
c. Bartonella
d. Acanthamoeba
e. Pneumococcus
Correct answer: b
Explanation :
 Adenoviruses are the most common cause of epidemic keratoconjunctivitis, a syndrome
characterized by eye pain and inflammation, fever, and preauricular lymphadenopathy.
Outbreaks at camps are common.
 Enteroviruses can cause similar outbreaks but are much less common than adenoviruses.
 Bartonella (cat scratch disease) can cause conjunctivitis and preauricular adenopathy,
but cases are sporadic and do not occur as outbreaks.
 Acanthamoeba can cause keratitis in those who swim in lakes, but again, cases are
sporadic.
 Pneumococcus has caused outbreaks of conjunctivitis on college campuses;
conjunctivitis is typically purulent and cases are much less common than those due to
adenoviruses.
16. A 30‐year old male with a history of obstructive hydrocephalus had implantation of a
ventriculoperitoneal shunt. Three months after implantation, he developed headache and
nausea over a period of about 1 week; he denied fever. On physical examination, he was a
febrile with normal vital signs. He was awake, but somewhat lethargic. There was no
tenderness or erythema along the area of the implanted shunt. His abdominal examination
was normal. Neurosurgery is consulted and cerebrospinal fluid removed from the shunt
reveals a WBC count of 500/mm3 with 80% segs, glucose of 45 mg/dL, and protein of 100
mg/dL. Gram stain was negative, but cultures grew Staphylococcus epidermidis. The
neurosurgeons are surprisingly willing to follow your advice. In addition to administration of
intravenous vancomycin, which of the following is the most appropriate management of this
patient?
a. Intraventricular vancomycin through the implanted shunt
b. Shunt removal and immediate implantation of a new shunt
c. Shunt removal, external drainage, and re‐shunting after cultures are negative
d. No additional management is required
Correct answer: c
Explanation :
This patient has a cerebrospinal fluid (CSF) shunt infection. Staphylococci are the most
likely infecting agents (55‐95% of cases), with most caused by coagulase‐negative
staphylococci. The most common clinical symptoms are headache, nausea, lethargy and
altered mental status; fever is reported in 14‐92% of cases. Numerous methods of treating
CSF shunt infections have been reported, but no randomized, prospective trials have been
performed. The principles of antimicrobial therapy are generally the same as for acute
bacterial meningitis. Direct instillation of antimicrobial agents into the ventricles (i.e.,
through an external ventriculostomy or shunt reservoir) is occasionally needed for difficult to
eradicate infections, but the indications for intraventricular administration are not well‐
defined. Early attempts to treat CSF shunt infections with use of antimicrobial agents alone
(given by the intravenous and/or intraventricular route) were not very successful (about a 34‐
36% success rate). Combining removal of shunt hardware with immediate shunt replacement
and intravenous antimicrobial therapy cures approximately 65‐75% of patients.
Antimicrobial use with removal of all components of the shunt along with some component
 of external drainage appears to be the most effective treatment, with treatment success
usually >85%.

17. A 29‐year‐old travels to Papua New Guinea. He takes mefloquine 250 mg weekly starting 2
weeks before and for 4 weeks after travel as recommended. He was not told to take other
drugs. Six months after the trip he becomes febrile and is diagnosed with smear positive
Plasmodium vivax infection. The explanation for this is most likely:
a. Primary infection with mefloquine resistant P. vivax
b. Lack of adequate adherence with the mefloquine regimen
c. Heavy exposure to P. vivax
d. Failure to eradicate the hepatic hypnozoite
Correct answer: D
Explanation :
This is a relapse of P. vivax due to failure to eradicate the hepatic hypnozoite. Malaria
prophylaxis does not prevent malaria infection. Mefloquine acts in the blood only, so this
drug provides only suppressive prophylaxis for either P. falciparum or P. vivax. Mefloquine
doesn’t penetrate the liver and is not active against the dormant hypnozoites of P. vivax in
the liver. The only drug active against hypnozoites (the stage that causes relapses of P. vivax
or P. ovale) (the only 2 species capable of relapse) is primaquine. This patient never received
terminal prophylaxis with primaquine after travel to a very high‐risk area. P. vivax primarily
resistant to mefloquine in the erythrocytic stages has not been described. If the patient had
been non‐compliant a primary clinical illness with P. vivax almost always occurs earlier than
6 months after exposure.

18. You are called by a family physician friend who wants to ask about a patient, a 17‐year‐old
who she saw two days earlier for severe sore throat and malaise of five days duration. The
patient was well until he developed the sore throat accompanied by low grade fever “feeling
tired and sick.” He doesn’t know anyone else who is sick. He is sexually active with a single
partner and always uses condoms. On exam, his temperature was 100.8°F; pulse 86, BP
112/78. He had periorbital edema and bilateral anterior and posterior cervical nodes that were
more prominent posteriorly. His throat was red with small exudates. The spleen tip was
 palpable. A rapid strep test performed in the family physician’s office was negative. The
doctor thought the young man had mononucleosis and ordered a CBC and Monospot test
(heterophile antibody). The WBC count was 12,000; there were 32% lymphocytes and 12%
atypical lymphocytes and the platelet count was slightly low at 120,000. The Monospot test
was negative, so the doctor decided to give you a call. Which one of the following is most
likely responsible for the young man’s illness?
a. Cytomegalovirus
b. HIV
c. Epstein‐Barr virus
d. Toxoplasma
e. Human herpesvirus 6
Correct answer: C
Explanation :
This patient has a classic mononucleosis syndrome. About 90% of mononucleosis illness
in adolescents and young adults is due to Epstein‐Barr virus, and the peak age for EBV
mononucleosis in the US is 16‐17. The Monospot test, a rapid agglutinin test for heterophil
antibody, is highly specific but not highly sensitive The important point is: The false negative
rates are highest during the beginning of clinical symptoms (25 percent in the first week; 5 to
10 percent in the second week, 5 percent in the third week). Measurement of EBV‐specific
antibodies is usually not necessary since the majority of patients are heterophile positive.
However, testing for EBV‐specific antibodies may be useful in patients with suspected
mononucleosis who have a negative heterophile test. IgM and IgG antibodies directed against
viral capsid antigen have high (>95%) sensitivity and specificity for the diagnosis of
mononucleosis. Ten percent of mononucleosis syndromes are due to other agents including
HIV, CMV (sore throat less likely), toxoplasmosis, HHV‐6 and HHV‐7. For strep pharyngitis
there should be no splenomegaly and no severe fatigue.

19. An 18‐year‐old young man who lives in a group home in California and has severe
developmental disabilities is admitted to a hospital in coma with hypertonia and
hyperreflexia. The people at his residence say he had been sleepy and “wobbly” for the two
previous days. Initial laboratory studies showed peripheral eosinophilia (18% of 14,200
 white blood cells), and he had CSF eosinophilic pleocytosis (40% of 42 white blood cells);
CSF gram stain and cultures were negative. He was treated with cefipime, amphotericin B,
and ivermectin but remained unconscious. An investigation of the residential home by public
health officials showed evidence of raccoon feces in the yard in which the patient played
regularly. Which one of the following is the most likely cause of his encephalitic illness?
a. Coccidioides
b. Angiostrongylus
c. Rabies
d. West Nile virus
e. Baylisascaris
Correct answer: e
Explanation :
The raccoon roundworm, Baylisascaris, is an rarecause of eosinophilic meningitis and
encephalitis. Infected raccoons are found throughout the US with highest prevalence in the
Northeast, West coast and Midwest (60‐80%). Most cases occur in children. Humans become
infected by ingesting infective eggs shed in raccoon feces; the larvae migrate from the GI
tract to viscera, the eyes and the CNS. Baylisascaris encephalitis should be considered in
humans with acute onset of eosinophilic encephalitis and a history of potential exposure
(possible ingestion of feces or contaminated soil). There is no known effective treatment but
albendazole is often used. Coccidioides can cause eosinophilic meningitis but the onset here
is too acute and the encephalitic picture would be rare. The rat lung worm, Angiostrongylus,
is a common cause of eosinophilic meningitis in Southeast Asia and tropical Pacific islands.
Risk factors for Angiostrongylus infection include the ingestion of raw or undercooked
infected snails or slugs; or pieces of snails and slugs accidentally chopped up in vegetables or
salads; or foods contaminated by the slime of infected snails or slugs. Rabies and West Nile
virus are not associated with peripheral or CNS eosinophilia.

20. A 49‐year‐old male third grade school teacher with HIV infection (CD4 count 50 cells/μL,
viral load <40 copies/μL) has been stable on darunavir, ritonavir, tenofovir, and
emtricitabine. He had a urinary tract infection last week and was started on ciprofloxacin. He
also takes vitamin C and St. John’s Wort. No one in his household has been ill but some of
the children in his class had been out last month with fever and facial rash. The patient's
hemoglobin is 6 gm/dl. He returns complaining of severe fatigue. Which of the following
interventions is most likely to be beneficial for managing his anemia?
a. Stop St. John’s Wort.
b. Initiate erythropoietin.
c. Switch antiretroviral therapy from darunavir‐ritonavir to efavirenz.
d. Initiate corticosteroids.
e. Initiate IVIG.
Correct answer: e
Explanation :
This patient with such severe anemia but no clear evidence for hemolysis or
gastrointestinal blood loss likely has Erythrovirus (also called Parvovirus) B19 infection.
Note the two names for the virus, IgM and IgG antibody tests are useful diagnostically. In
immunosuppressed patients, nucleic acid amplification tests of blood are the most useful.
Giant abnormal pronormoblasts on bone marrow biopsy, when present, are also diagnostic.
IgG antibody may be negative in a large fraction of patients. This viral infection is controlled
in normal hosts by humoral immunity. In this HIV‐infected patient, Parvovirus B19 infection
with red cell aplasia may improve with intravenous immunoglobulin (400 mg/kg/d for 5 days
is effective in 75% of patients.) Patients may require a second course of IVIG and some
patients may require a maintenance regimen of 30 g per month plus iron and folate and B12.
The anemia typically develops over a long period of time since the pathogenesis is
suppression of reticulocytosis. Erythrovirus B19 spreads primarily by respiratory route and
has an incubation time of 4‐14 days. A typical scenario in an adult is a non‐immune pregnant
woman who acquires infection from her child in day care, and who then develops hydrops or
self‐limiting arthralgia. The other typical scenario is described in this case, which also could
have been a patient with stem cell transplant or some other form of immunosuppression.
Keep in mind that Erythorvirus B 19 causes several types of disease:
 Normal Children: self‐limiting fever with “slapped cheeks” followed by lacy body rash
 Healthy adults: asymptomatic or transient fever, occasionally especially in women with
small joint arthropathy plus rash that resolve in three weeks
 Patients with an underlying hemolytic disease: Aplastic crisis
  Pregnancy: Fetal death, hydrops fetalis
 Immunsuppressed: Chronic red cell aplasia due to failure to develop immune response
Keep in mind also that serology is useful for diagnosing prior infection, but acute
infection requires nucleic acid amplification of serum, plasma, or other body fluid.

21. A 62‐year‐old man vacationing in Alaska is taken to an emergency room by ambulance

because he developed sudden weakness and could not stand or sit up. He awakened from an
after lunch nap with tingling and numbness around his mouth and tingling in his hands. He
couldn’t sit up and called for help. First responders found him awake, alert, but unable to
stand or sit up. On exam in the emergency room, he was afebrile, oriented, with lower
extremity and truncal weakness. Cranial nerves were normal. Routine labs were normal.
While being evaluated, he began to complain of shortness of breath. Chest x‐ray was normal.
He reported that for lunch he had eaten steamed mussels that he and two friends had
harvested themselves that same morning. Two days earlier he had removed a large tick from
the back of his head. Which one of the following is the most likely diagnosis?
a. Paralytic shellfish poisoning
b. Tick paralysis
c. Botulism
d. Scombroid poisoning
e. Guillain‐Barré syndrome
Correct answer: a
Explanation :
 Paralytic shellfish poisoning occurs after ingestion of saxitoxins produced by marine
dinoflagellates that become concentrated in mollusks such as clams, cockles and mussels.
It is typically associated with noncommercially harvested shellfish since commercially
harvested shellfish are tested for saxitoxins. Neither cooking nor freezing destroys the
toxin. After a short incubation period of minutes to a few hours, victims develop
paresthesias of the mouth or extremities rapidly followed by paralysis which may
produce life‐threatening respiratory failure.
 Tick paralysis occurs while the tick is still attached.
 Botulism involves cranial nerves.
  Scombroid poisoning follows ingestion of certain bacterially contaminated fish and
produces a histamine‐like reaction.
 Guillain‐Barré is associated with an ascending paralysis without the paresthesias seen
here.

Question 22 and 23 refer to the following case study

A nonsmoking 26 years old woman sees a pulomonologist for evaluation of a 5-month
history of persistent cough, wheezing, nasal congestion, and weight loss. She reports no
reflux. She emigrated from Guyana 5 years ago and had no significant medical history in her
native country. She took no medications until recently when she was treated with antibiotics,
systemic and inhaled corticosteroids, and albuterol in an emergency department, despite
treatment, symptoms persisted and a leukotriene antagonist was added, again with little of
symptoms. Laboratory studies at that time showed leukocytosis ( leukocyte count 28 x
103/mm3) with a differential 16 x 103/mm3 (58 %) eosinophils, erythrocyte sedimentation rate
was 37 mm/h. Result of serum chemistries were normal, and an antinuclear antigen assay
was negative . Results of pulmonary function test were as follow; FVC 61 %; FEV1 65 % (
with a significant bronchodilator response) ; FEV1/FVC 85; total lung capacity 61 % ;
functional residual capacity 50 %; residual volume 54 %; diffusing capacity of the lung for
carbon monoxide 54 %. Arterial blood gas analysis revealed a pH of 7.41 , PCO2 of 36
mmHg; PO2 of 102 mmHg; oxygen saturation of 98 % on room air; and an alveolar arterial
gradient of 5 mmHg. Chest radiography revealed interstisial infiltrate and a hight resolution
computed tomography scan of the chest revealed a fine nodular pattern in both middle and
lower lung fields.

22. Which of the following diagnostic step is most appropriate to asses the patient’s condition?
a. Measure serum IgG4 level
b. Perform bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
c. Perform open lung biopsy
d. Test for Aspergillus precipitins
e. Test stool for ova and parasites
Correct answer : a
 Explanation :
The patient has eosinophilia out of proportion to her symptoms; it did not respond to
standard therapy for asthma and should prompt consideration of an alternate diagnosis. The
differential diagnosis is quite broad but should include Churg-Strauss syndrome, acute and
eosinophilic pneumonia, fungal infections, and tropical pulmonary eosinophilia (TPE). The
patient was born in an area endemic for filariasis. TPE occurs in less than 1 % of patient with
filariasis, but it is common in India, Southest Asia, The West Indies, Africa, and China. It is
the result of an immunologic reaction to the microfilarie liberated by gravid Wuchereria
bancrofti and Brugia malayi parasites that become trapped in the circulation of the lung. A
mosquito vector transmits the microfilariae; adults worm can live up to 10 years within
lymph nodes liberating millions of microfilariae. Chest radiography usually reveals
reticulonodular opacities, predominatly in the middle and lower lung zones (20 % can be
normal ). Computed tomographic scans are more sensitive in detecting abnormalities in this
disease. Pulmonary function test can reveal an obstructive ventilatory defect early in the
disease and mixed ventilator defect in the later stages with decrease diffusion. The diagnosis
is established by history of the residence in an endemic area; peripheral eosinophilia ( 3 x
103/mm3) elevated total serum Ig E level and elevated parasite-spesific IgG4 level. Although
the parasites can be found on biopsy specimens, biopsy is rarely necessary to establish a
diagnosis. If left untreated , TPE may progress to fibrotic lung disease. Although fiber optic
bronchoscopy, bronchoalveolar lavage, transbronchial biopsy, can aid in the diagnosis of
TPE, they are not necessary to make the diagnosis, they would be reasonable if results of the
work-up for TPE were negative. Stool for ova and parasites are usually negative in TPE
unless the patient is coinfected with another parasites. Testing for Aspergillus precipitins
would b useful to diagnose an Aspegillus infection, but it would not diagnose TPE.

23. Administration of which of the following is the most appropriate treatment for this patient?
a. Amphotericin B
b. Diethylcarbamazine
c. Inhaled corticosteroids
d. Itraconazole
e. Systemic corticosteroids
 Correct answer : B
Explanation :
The patient has TPE, which is a parasitic disease treated with Diethylcarbamazine ; a
favorable response is often considered the final criterion in diagnosis. Corticosteroids and
antifungal agains would not be an effective cure for this disease.

Question for 24-25 based on case study

A 31 years old woman from the Ivory Coast is admitted to the hospital because of a 3
month history of fever , chills, weight loss, and a productive cough. She came to the ED
when her sputum became tinged with blood. Chest radiography reveals a left upper lobe
infiltrate with a cavity. She is placed in respiratory isolation, sputum is collected and sent for
analysis for acid-fast bacillus (AFB) , along with blood for a CD4+ count and an HIV test.
Result of the sputum sample test are positive for AFB, her CD4+ count is 68/mm3, and she is
HIV-positive.

24. Which of the following is the most appropriate next step in this patient’s treatment?
a. Start 4 antituberculous medications
b. Start 4 antituberculous medications after obtaining AFB sensitivity
c. Start 4 antituberculous medications plus antiretroviral medications
d. Start highly active antiretroviral medications
Correct answer : a
Explanation :
The patient has a history and supporting data consistent with active TB and HIV
infections, both of which must be treated. The concomitant treatment of both disease has
produce paradoxical reactions, by delaying highly activeantiretroviral therapy (HAART) for
a less 2-month, these reactions can be avoided while simultaneously avoiding the drug
interactions associated with the rifamycins, which are used to treat TB and HAART.

25. The triage nurse in the ED is concerned because she was significantly exposed to the patient
had been coughing. Result of purified protein derivative (PPD) skin testing in the past have
 always been negative. Which of the following is the most appropriate next step for the
pulmonologist to take?
a. Offer reassurance
b. Perform a PPD skin test
c. Perform a PPD skin test and start preventive treatment if induration is greater than 5 mm
d. Start 4 antituberculous medications
e. Start preventive treatment
Correct answer : e
Explanation :
Patient exposed to TB may have negative results on PPD skin testing initially, however
they should be retested after 12 weeks. In the meantime they should receive preventive
treatment. If the results of PPD test remain negative, preventive negative may be
discontinued. Standard preventive therapy consist of isoniazid given daily for 9-month.

26. Your patient is evaluated because of fever, malaise, myalgia, and non-productive cough.
Laboratory testing confirms influenza A infection. A recommendation for antiviral therapy is
most appropriate in which of these scenarios?
a. The patient is unvaccinated
b. Age is <18 or >65 years
c. Symptom onset was <48 hours ago
d. The patient is immunocompromised
e. Inpatient hospitalization is required
Correct answer : c
Explanation :
Symptom onset was <48 hours ago. Antiviral therapy is recommended in adults and
children with laboratory-confirmed or highly suspected influenza virus presenting within 48
hours of symptom onset.

27. Your 45-year-old male patient has hepatitis C genotype 2 with compensated cirrhosis. He has
never received treatment. Which of these is the most appropriate treatment recommendation?
a. Sofosbuvir plus ribavirin for 12 weeks
b. Daclatasvir plus sofosbuvir for 16-24 weeks
 c. Elbasvir/grazoprevir for 12 weeks Your Answer
d. Paritaprevir/ritonavir/ombitasvir for 16 weeks

Correct answer : b
Explanation :
Daclatasvir plus sofosbuvir for 16-24 weeks. Daclatasvir plus sofosbuvir or sofosbuvir
and weight-based ribavirin for 16 to 24 weeks are recommended regimens for treatment-
naïve patients with HCV genotype 2 with compensated cirrhosis.

28. Your 79-year-old female patient has an infection of the prosthetic hip joint and is
hospitalized for debridement of the prosthesis. Which of these oral drugs is most appropriate
in combination with IV antimicrobial treatment in this patient?

a. Ciprofloxacin
b. Trimethoprim-sulfamethoxazole
c. Fluconazole
d. Rifampin
Correct answer : d
Explanation :
The patient should receive 2 to 6 weeks of a pathogen-specific IV antimicrobial therapy
in combination with rifampin 300-450 mg orally twice daily followed by rifampin plus a
companion oral drug for a total of 3 months for a total hip arthroplasty infection.
29. Your 47-year-old male patient is undergoing follow-up evaluation for community-acquired
pneumonia. He was diagnosed at an acute care clinic and treatment with azithromycin for 5
days was initiated. His symptoms have not improved. He has no prior medical history and
takes no other medications. He lives with his wife, 2 school-aged children, a cat, a dog, and a
parrot, and he enjoys gardening. He has not travelled outside of the country, but he
vacationed on Lake Michigan 1 month ago. A photomicrograph of a wet mount of a sputum
sample is shown. In addition to the examination findings, which of these is the most
suggestive of blastomycosis in this patient?

a. Owning a cat
b. Owning a parrot
c. Gardening
d. Vacation location
Correct answer : d
Explanation :
Blastomycosis is a systemic pyogranulomatous disease caused by the thermally
dimorphic fungus B dermatitidis. The photomicrograph shows budding yeast. This infection
occurs most commonly in defined geographic regions; in North America, infections are
usually seen in the southeastern and south-central states that border the Mississippi and Ohio
Rivers, the Midwestern states and Canadian provinces that border the Great Lakes, and a
small area of New York and Canada adjacent to the St. Lawrence Seaway.
30. Your 19-year-old patient who is a college student is evaluated because of fever, headache,
and increased nasal discharge. She reports that she had a cold that lasted for 5-6 days during
spring break. She was feeling better and then began to feel worse. Acute bacterial
rhinosinusitis is suspected, and initiation of an oral antibiotic is planned. Which of these
adjunctive treatments is most appropriate?
a. Oral pseudoephedrine
b. Intranasal phenylephrine
c. Oral chlorpheniramine
d. Intranasal saline
Correct answer : d
Explanation :
Intranasal saline. Intranasal saline irrigation with either physiologic or hypertonic saline
is recommended as an adjunctive treatment in adults with acute bacterial rhinosinusitis.
Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive
treatment.

31. Your 19-year-old female patient is undergoing follow-up evaluation for cutaneous
sporotrichosis. A photograph is shown. She has received itraconazole 200 mg orally once
daily for 4 weeks, but her lesions persist. Other medications include an oral contraceptive and
naproxen as needed for menstrual cramps. Which of these treatments is most appropriate?

a. Continue itraconazole daily for 4 more weeks

b. Increase itraconazole to 200 mg twice daily
c. Fluconazole 800 mg daily
d. Amphotericin B 3-5 mg/kg daily
 Correct answer : b
Explanation :
Increase itraconazole to 200 mg twice daily. Patients who do not respond to itraconazole
200 mg once daily for 2-4 weeks should be given a higher dosage of itraconazole (200 mg
twice daily), terbinafine 500 mg orally twice daily, or saturated solution of potassium iodide
(SSKI) initiated at a dosage of 5 drops (using a standard eye-dropper) 3 times daily and
increasing, as tolerated, to 40-50 drops 3 times daily. Fluconazole (400-800 mg daily) should
be used only if the patient cannot tolerate these other agents. Amphotericin B is
recommended for severe sporotrichosis that must be treated during pregnancy. Azoles should
be avoided.

32. Which of these drugs is most likely to result in HIV resistance in a patient with hepatitis B
(HBV) and HIV coinfection unless it is used as part of a fully suppressive ART regimen?
a. Emtricitabine
b. Entecavir
c. Lamivudine
d. Tenofovir
Correct answer : b
Explanation :
Entecavir. Although entecavir has activity against HBV, its use in patients with
coinfection may result in the selection of the M184V mutation that confers HIV resistance to
emtricitabine and lamivudine. Therefore, in coinfected patients, entecavir must be used with
a fully suppressive ART regimen. Emtricitabine, lamivudine, and tenofovir are active against
both HBV and HIV.

33. Your 53-year-old male patient who was recently diagnosed with HIV infection is undergoing
evaluation prior to initiation of ART. Serum creatinine concentration is 1.8 mg/dL. The
inclusion of which of these is most appropriate for this patient’s ART?
a. Emtricitabine-tenofovir
b. Abacavir-lamivudine
 c. Ritonavir-boosted atazanavir
d. Ritonavir-boosted lopinavir
Correct answer : b
Explanation :
Abacavir-lamivudine. Abacavir-lamivudine has no known nephrotoxicity. Emtricitabine-
tenofovir can cause renal impairment including proximal tubulopathy and acute or chronic
renal insufficiency. Ritonavir-boosted atazanavir can cause nephrotoxicity as well as
nephrolithiasis. Ritonavir-boosted lopinavir has been associated with nephrotoxicity.

34. Which of these approaches is most likely to resolve symptoms of cryptosporidiosis in a

severely immunosuppressed patient?
a. Treatment with trimethoprim-sulfamethoxazole
b. Treatment with paromomycin
c. Treatment with rifabutin and clarithromycin
d. ART to restore CD4 count to >100 cells/mm3
Correct answer : d
Explanation :
ART to restore CD4 count to >100 cells/mm3. In the setting of severe immune
suppression, ART with immune restoration to a CD4 count >100 cells/mm3 usually leads to
resolution of clinical cryptosporidiosis and is the mainstay of treatment. Therefore, patients
with cryptosporidiosis should be started on ART as part of the initial management of their
infection.

35. Your 31-year-old male patient with newly diagnosed HIV infection is undergoing evaluation.
He is asymptomatic. CD4 count is ≥300 cells/mm3. Tuberculin skin test is negative; he has
no known contact with anyone with active tuberculosis (TB). Which of these is the most
appropriate next step with regard to follow-up testing or prophylaxis for tuberculosis in this
patient?
a. Posterior-anterior chest radiograph; no prophylaxis
b. No testing; prophylaxis with isoniazid for 3 months
c. No testing; prophylaxis with isoniazid for 9 months
 d. No immediate follow-up or prophylaxis is indicated at this time
Correct answer : d
Explanation :
No immediate follow-up or prophylaxis is indicated at this time. In HIV-infected
individuals who are anergic and have not had recent contact with anyone with infectious TB,
treatment of latent TB infection is not associated with clinical benefit and is not
recommended.

36. Boceprevir, peginterferon alfa, and ribavirin should be discontinued at which of these points
in the treatment of a patient with chronic genotype 1 hepatitis C virus (HCV) infection
without cirrhosis?
a. Undetectable HCV RNA level at 12 weeks
b. HCV RNA level >100 IU/mL at 12 weeks
c. HCV RNA level >200 IU/mL at 12 weeks
d. HCV RNA level >500 IU/mL at 12 weeks
Correct answer : b
Explanation :
HCV RNA level >100 IU/mL at 12 weeks. Treatment with boceprevir, peginterferon alfa,
and ribavirin should be stopped if the HCV RNA level is >100 IU/mL at treatment week 12
or undetectable at treatment week 24 in patients without cirrhosis.

37. Which of these patients is most likely to have Mycobacterium avium complex (MAC) lung
disease that presents with nodular and interstitial nodular infiltrates frequently involving the
right middle lobe or lingula?
a. 49-year-old Caucasian male smoker
b. Postmenopausal Caucasian nonsmoking female
c. 31-year-old African American male drug abuser
d. 20-year-old Asian female with breast cancer
Correct answer : b
Explanation :
 Postmenopausal Caucasian nonsmoking female. MAC lung disease that presents with
nodular and interstitial nodular infiltrates that involves the right middle lobe or lingula is
most likely to be seen in postmenopausal, nonsmoking, Caucasian females (ie, Lady
Windermere syndrome). The traditional presentation of MAC lung disease apical
fibrocavitary lung disease is in males in their late 40s or early 50s who have a smoking
history and excessive alcohol use.

38. Your 41-year old female patient is undergoing elective laparoscopic cholecystectomy. She
has had 2 episodes of biliary colic within the past 30 days, and she has a documented allergy
to β-lactam drugs. Which of these is the most appropriate surgical prophylaxis?
a. Cefazolin alone
b. Metronidazole plus gentamicin
c. Gentamicin alone
d. Ampicillin-sulbactam plus cefotetan
Correct answer : b
Explanation :
Metronidazole plus gentamicin. Antimicrobial prophylaxis is recommended in patients
with an increased risk of infectious complications who are undergoing laparoscopic
cholecystectomy. Cefazolin and ampicillin-sulbactam cannot be used in this patient because
of her documented β-lactam allergy. Alternative regimens include gentamicin plus
vancomycin or clindamycin, aztreonam, or metronidazole plus gentamicin or a
fluoroquinolone.

39. Your 29-year-old patient who is HIV positive is being transitioned to suppressive treatment
of cryptococcal meningoencephalitis after a course of amphotericin B. CD4 T-lymphocyte
count is <100 cells/μL. Which of these is most appropriate for suppressive therapy in this
patient?
a. Caspofungin
b. Voriconazole
c. Fluconazole
d. Micafungin
 Correct answer : c
Explanation :
Fluconazole. Maintenance (suppressive) treatment with fluconazole is recommended for
HIV-positive patients with a CD4 T-lymphocyte count <100 cells/μL.

40. Which of these is the MINIMUM follow-up testing schedule after baseline testing that
should be performed in a health care provider who has had an exposure to known or
suspected HIV-positive sources?
a. At 2 and 4 weeks, 4 and 6 months, and 1 year after exposure
b. At 4 and 8 weeks, 6 months, and 1 year after exposure
c. At 6 and 8 weeks, 4 months, and 1 year after exposure
d. At 6 and 12 weeks, and 6 months after exposure
Correct answer : d
Explanation :
At 6 and 12 weeks, and 6 months after exposure. At the time of exposure, baseline
testing should be performed. Follow-up testing is indicated at 6 weeks, 12 weeks, and 6
months after exposure. Routine extension of the duration of postexposure follow-up is not
warranted.

41. Which of these is the most appropriate duration of antimicrobial treatment for a patient with
catheter-associated urinary tract infection (CA-UTI) who has prompt resolution of
symptoms?
a. 3 days
b. 7 days
c. 10 days
d. 14 days
Correct answer : b
Explanation :
7 days. Seven days is the recommended duration of antimicrobial treatment for patients
with CA-UTI who have prompt resolution of symptoms, and 10-14 days of treatment is
 recommended for those with a delayed response, regardless of whether the patient remains
catheterized or not.

42. Your 80-year-old male patient is admitted to the hospital because of a small bowel
obstruction. A nasogastric tube is inserted and a central venous catheter is placed. On
hospital day 8, the small bowel obstruction has not resolved. He has a fever and is
hypoxemic. Chest x-ray is shown. Laboratory studies show elevated serum 1,3-β-D-glucan.
Which of these additional tests is most likely to be positive in this patient?

a. NS1 antigen
b. Anti-mannan antibody
c. Anti-nucleosome antibody
d. Aerobic bacterial culture
Correct answer : b
Explanation :
Anti-mannan antibody. Diagnostic workup of invasive candidiasis involves the use of
1,3-β-D-glucan assay and anti-mannan antibody assays.

43. An elderly resident of a long-term care facility has diarrhea, low-grade fever, and symptoms
of colitis. She has not taken antibiotics during the past 30 days. Stool is negative for
 Clostridium difficile toxins. Which of these is the most appropriate next step in care for this
patient?
a. Treat for C difficile infection
b. Test for IgA anti-tissue transglutaminase antibody
c. Obtain CT scan of the abdomen and pelvis
d. Test stool for other causes of invasive enteropathogens
Correct answer : d
Explanation :
Test stool for other causes of invasive enteropathogens. Patients in long-term care
facilities without recent antibiotic use, who have symptoms of colitis but stool samples
negative for C difficile, should have stool tested for other pathogens such as Campylobacter
jejuni, Salmonella and Shigella species, and Escherichia coli.

44. Your immunocompromised adult patient is undergoing evaluation. His wife is

immunocompetent and recently received a zoster vaccine. Which of these is the most
appropriate recommendation regarding contact with his wife after vaccination?
a. Avoid all skin-to-skin contact for 3 days
b. Avoid contact if she develops a rash
c. Avoid contact if she develops a cough
d. Wear a mask for 2 weeks when in contact
Correct answer : b
Explanation :
Avoid contact if she develops a rash. If a household contact develops a rash or skin
lesions following immunization for varicella or zoster, an immunocompromised person
should avoid contact until the lesions subside.

45. Your 58-year-old female patient has a catheter-associated urinary tract infection (CA-UTI)
without upper urinary tract symptoms following removal of her indwelling catheter. An
antimicrobial regimen of which of these durations is most appropriate in this patient?
a. Single dose
b. 3 days
 c. 7 days Your Answer
d. 14 days
Correct answer : b
Explanation :
3 days. According to the International Clinical Practice Guidelines of the IDSA, an
antimicrobial regimen lasting 3 days may be considered for women aged ≤65 years who have
a CA-UTI without upper urinary tract symptoms following removal of an indwelling
catheter. A regimen of 7 days is the recommended regimen for patients with CA-UTI with
prompt resolution of symptoms. A 10-14 day regimen is recommended for those with a
delayed response, regardless of whether the catheter is still in place.

46. Which of these best describes the number of days of continuous hospitalization prior the
onset of illness that is required to meet the definition of definite nosocomial Legionnaire
disease (LD)?
a. ≤5 days
b. ≤7 days
c. ≥10 days
d. ≥14 days
Correct answer : c
Explanation :
≥10 days. The incubation period for LD is typically 2 to 10 days, so laboratory-confirmed
legionellosis that occurs in a patient who has been hospitalized continuously for at least 10
days before the onset of illness is regarded as a definite case of nosocomial LD. A
laboratory-confirmed infection that occurs 2 to 9 days after hospital admission is a possible
case of nosocomial LD.

47. Your patient is evaluated because of nonspecific symptoms of infection 22 days after
undergoing hematopoietic cell transplantation (HCT). Which of these is the most likely
causal pathogen?
a. Candida spp.
b. Cytomegalovirus
 c. Encapsulated bacteria
d. Varicella-zoster virus
Correct answer : a
Explanation :
Candida spp. Prolonged neutropenia and breaks in the mucocutaneous barrier result in
substantial risk for bacteremia and fungal infections involving Candida spp <15 to 45 days
after HCT. Herpes viruses, particularly cytomegalovirus (CMV), are common infectious
agents observed 30 to 100 days after HCT. Common pathogens seen later include CMV,
varicella-zoster virus, and infections with encapsulated bacteria (eg, Streptococcus
pneumoniae).

48. Which of these is the most appropriate antibiotic regimen for antimicrobial prophylaxis for
neutropenia lasting ≥7 days following hematopoietic cell transplantation (HCT)?
a. Levofloxacin alone
b. Vancomycin alone
c. Levofloxacin plus teicoplanin
d. Vancomycin plus levofloxacin
Correct answer : a
Explanation :
Levofloxacin alone. Antibacterial prophylaxis with a fluoroquinolone (ie, levofloxacin)
to prevent bacterial infections should be strongly considered for adult HCT patients with
anticipated neutropenic periods of ≥7 days. The addition of an anti-gram–positive agent to
the prophylaxis regimen is not indicated. Specifically, glycopeptides (eg, vancomycin,
teicoplanin) should not be used for routine bacterial prophylaxis, either systemically or for
the prevention of catheter-related infections (DIII). These agents lack benefit for prophylaxis
and their use may promote the emergence of resistant microorganisms.

49. A fourth-generation HIV immunoassay involves the use of a synthetic peptide or

recombinant protein antigen that binds to HIV antibodies in addition to which of these
features?
a. Ability to distinguish between HIV-1 and HIV-2 infections
 b. Labeled antihuman IgG to detect IgG antibodies
c. Quantification of plasma HIV RNA
d. Inclusion of monoclonal antibodies to detect p24 antigen
Correct answer : d
Explanation :
Inclusion of monoclonal antibodies to detect p24 antigen. This allows for detection of
HIV-1 infection before seroconversion. Antihuman IgG is a feature of earlier generation
immunoassays. HIV-1 nucleic acid testing can differentiate between HIV-1 and HIV-2
infection.

50. Your patient is undergoing routine follow-up evaluation of his ART regimen. On his last
evaluation, viral load was undetectable. Currently, HIV RNA is 150 copies/mL. If viral load
returns to an undetectable level, which of these is the most appropriate change to this
patient’s management?
a. Discontinue ART
b. Continue ART with the addition of another agent
c. Discontinue current ART and begin a different ART regimen
d. No change would be indicated
Correct answer : d
Explanation :
No change would be indicated. Transient increases in HIV RNA in patients with levels
that are typically below the lower limit of detection don’t require a change in treatment. ART
can be continued while monitoring HIV RNA level at least every 3 months.

51. Your 36-year-old HIV-positive patient is undergoing follow-up evaluation. He has no

complaints. At his previous visit, CD4 count was 180 cells/mm3. Current medications include
pyrimethamine-sulfadiazine for toxoplasmosis. Currently, CD4 count is 150 cells/mm3.
Initiation of which of these medications is most appropriate for Pneumocystis pneumonia
(PCP) prophylaxis?
a. Prophylaxis is not indicated at this time
b. Trimethoprim-sulfamethoxazole
 c. Dapsone
d. Aerosolized pentamidine
Correct answer :a
Explanation :
Prophylaxis is not indicated at this time. Prophylaxis against PCP should be initiated
when CD4 count is <200 cells/mm3; however, patients receiving pyrimethamine-sulfadiazine
for toxoplasmosis treatment do not require additional prophylaxis.

52. Your male patient with HIV infection reports “eye floaters” and changes in his visual field.
An image obtained on ophthalmoscopic examination through a dilated pupil is shown. Which
of these is the most appropriate management?

a. Trimethoprim-sulfamethoxazole
b. Pyrimethamine + sulfadiazine + leucovorin
c. Nitazoxanide
d. Valganciclovir
e. Azithromycin
Correct answer : d
Explanation :
Valganciclovir. The patient’s symptoms and the fluffy, yellow-white retinal lesions
shown in the image are consistent with cytomegalovirus retinitis. Effective treatments are
valganciclovir, ganciclovir, foscarnet, and cidofovir.

53. Which of these cell types is Rickettsia rickettsii most likely to invade?
 a. Erythrocytes
b. Endothelial cells
c. Granulocytes
d. Monocytes
Correct answer : b
Explanation :
Endothelial cells. R. rickettsii invades endothelial cells and causes vasculitis that leads to
rash and life-threatening damage to the brain, lungs, and other viscera. Ehrlichia and
Anaplasma species invade monocytes or granulocytes, respectively. R. rickettsii is not seen
in blood smears; the bacteria do not stain with the majority of conventional stains.

54. Which of these symptoms is most likely to be the first complaint that is indicative of
Clostridium botulinum infection?
a. Abdominal pain
b. Diarrhea
c. Dry mouth
d. Nausea
Correct answer : c
Explanation :
Dry mouth. The clinical syndrome of botulism is dominated by neurologic symptoms and
signs consistent with a toxin-induced blockade of the voluntary motor and autonomic
cholinergic junctions. Dry mouth, the inability to focus on a near point, and diplopia are
usually the earliest neurologic complaints.

55. Your 66-year-old female patient is evaluated in an urgent care center because of a 3-day
history of cough, dyspnea, and a temperature of 101°F that have not responded to over-the-
counter medications. A decision to admit for hospital admission will be based on CURB-65
criteria. Which of these is included in CURB-65 criteria?
a. Upper respiratory infection Your Answer
b. Unintentional weight loss
c. Uremia
 d. Steroid use
Correct answer : c
Explanation :
Uremia. A BUN concentration of ≥20 mg/dL is a severity-of-illness criterion in CURB-
65 along with confusion, respiratory rate, low blood pressure, and age ≥65 years.

56. Your 42-year-old patient is undergoing evaluation because of shortness of breath,

nonproductive cough, and arthralgia. He has a 1-day history of fevers to 102.2°F. He
frequently travels nationally and internationally for his job. Testing for Legionella spp should
be performed in this patient if he has traveled within which of these time frames before onset
of symptoms?
a. 1 week
b. 2 weeks
c. 3 weeks
d. 4 weeks
Correct answer : b
Explanation :
2 weeks. Legionella spp testing should be performed for patients with community-
acquired pneumonia who have traveled within 2 weeks before the onset of symptoms.

57. Your 53-year-old male patient with a history of diabetes and asthma is evaluated in the
emergency department because of cough, fever to 101.3°F, and wheezing. He is allergic to
penicillin. Community-acquired pneumonia (CAP) is diagnosed. Which of these is the
antibiotic of choice for this patient?
a. Azithromycin
b. Cephalexin
c. Amoxicillin
d. Levofloxacin
Correct answer : d
Explanation :
 Levofloxacin. In the presence of comorbidities, such as diabetes, a respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin) is preferred for CAP (Level 1
evidence). High-dose amoxicillin (1 g three times daily) is an alternative (Level 1 evidence),
but the patient is allergic to penicillin.

58. Infection with which of these types of pathogens is the most common cause of health care-
associated pneumonia (HCAP)?
a. Bacteria only
b. Fungus only
c. Virus only
d. Mixed infection with bacteria and fungus
e. Mixed infection with fungus and virus
Correct answer : a
Explanation :
Bacteria only. HCAP is usually caused by bacteria, and is the second most common
nosocomial infection in the US.

59. Which of these is the most common multidrug-resistant (MDR) gram-negative bacterial
pathogen causing hospital-acquired pneumonia or ventilator-associated pneumonia?
a. Enterobacter spp
b. Klebsiella pneumoniae
c. Pseudomonas aeruginosa
d. Serratia marcescens
Correct answer : c
Explanation :
Pseudomonas aeruginosa. P. aeruginosa is the most common MDR gram-negative
bacterial pathogen causing hospital-acquired pneumonia or ventilator-associated pneumonia.

60. Which of these antibiotics has activity against Klebsiella spp that produce extended-spectrum
β-lactamases (ESBLs)?
a. Aminoglycosides
 b. Aztreonam
c. Carbapenems
d. Cephalosporins
Correct answer : c
Explanation :
Carbapenems. Klebsiella spp are intrinsically resistant to ampicillin and other
aminopenicillins and can acquire resistance to cephalosporins and aztreonam by producing
ESBLs. Plasmids encoding ESBLs often carry resistance to aminoglycosides and other drugs,
but ESBL-producing strains remain susceptible to carbapenems.

61. A 78-year-old male patient with no risk factors for multidrug-resistant infection is receiving
empiric treatment with levofloxacin for hospital-acquired pneumonia. After 36 hours, he has
not significantly improved, but he is clinically stable. Which of these is the most appropriate
change to this patient’s antimicrobial regimen?
a. Change to ceftriaxone
b. Change to ertapenem
c. Add an aminoglycoside
d. No change is indicated at this time
Correct answer : d
Explanation :
No change is indicated at this time. Clinical improvement usually becomes apparent after
the first 48 to 72 hours of therapy, and therefore antibiotic therapy should not be changed
during this time unless there is rapid clinical decline.

62. Which of these is the most appropriate range of serum glucose concentration measurements
in a patient who is receiving intensive insulin therapy in in the ICU?
a. 70-100 mg/dL
b. 80-110 mg/dL
c. 90-115 mg/dL
d. 100-120 mg/dL
Correct answer : b
 Explanation :
80-110 mg/dL. Maintenance of serum glucose levels between 80 and 110 mg/dL in ICU
patients is recommended to reduce nosocomial blood stream infections, duration of
mechanical ventilation, ICU stay, morbidity, and mortality.

63. Your patient with prolonged granulocytopenia has a fever consistent with bacteremia or
fungemia. Which of these blood culture approaches is the most appropriate method for
isolating the causal organism?
a. 2 cultures from different arterial sites
b. 3 total cultures drawn at 10 minute intervals
c. 3-4 cultures drawn from different sites
d. 3-4 cultures drawn from multiple ports of the same intravascular catheter
Correct answer : c
Explanation :
3-4 cultures drawn from different sites. The cumulative yield of pathogens is optimized
with 3-4 cultures (20-30 mL each) obtained within the first 24 hrs of suspected bacteremia or
fungemia. Each sample should be drawn by separate venipuncture or through a separate
intravascular device; however, it is not recommended to obtain the sample through multiple
ports of the same intravascular catheter. There is no evidence that the yield of cultures drawn
from an artery is different than those drawn from a vein. Separating blood cultures by spaced
intervals has not been shown to enhance microbial recovery.

64. Which of these is the approximate maximum time allowable for urine collected for culture
and sensitivity testing to remain unrefrigerated?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 2 hours
Correct answer : c
Explanation :
 1 hour. Urine collected for culture should be transported to the laboratory and processed
promptly to prevent the multiplication of insignificant numbers of microorganisms to high
levels within the receptacle. This could lead to the misdiagnosis of infection. If the transport
of urine will be delayed, the specimen should be refrigerated. For transport to a remote
laboratory site, the use of a urine preservative device containing boric acid is recommended.

65. Your catheterized patient is undergoing evaluation because of suspected urosepsis. Which of
these methods is most likely to provide valuable information for selection of empirical
antimicrobial therapy in this patient?
a. Rapid dipstick testing to detect leukocyte esterase and nitrite
b. Gram stain of a centrifuged urine specimen
c. Leukocyte esterase test of urine specimen
d. Nitrite test of urine specimen
Correct answer : b
Explanation :
Gram stain of a centrifuged urine specimen. A gram-negative result on a centrifuged
urinary specimen will show microorganisms most of the time if infection is present. It can
also provide valuable information to the clinician when selecting empirical antimicrobial
therapy in this scenario. The rapid dipstick tests that detect leukocyte esterase and nitrite are
unreliable in the setting of catheter-related urinary tract infection.

66. Proactive family care conferences for the identification of advance directives and treatment
goals should be initiated within which of these times following ICU admission?
a. 72 hours
b. 96 hours
c. 1 week
d. When the prognosis is firmly established
Correct answer : a
Explanation :
72 hours. The use of proactive family care conferences to identify advanced directives
and treatment goals within 72 hours of ICU admission promotes communication and
 understanding between the patient’s family and the care team; improves family satisfaction;
decreases stress, anxiety, and depression in surviving relatives; facilitates end-of-life decision
making; and shortens length of stay for patients who die in the ICU.

67. Which of these is the most appropriate interval for STI screening in a male patient who has
frequent or anonymous sex with male partners, but who does not use illicit drugs?
a. Once monthly
b. Once every 3-6 months
c. Once yearly
d. Once every 2 years
Correct answer : b
Explanation :
Once every 3-6 months. Guidelines suggest an interval of once every 3-6 months in men
who have sex with men (MSM) who have multiple or anonymous sexual partners. More
frequent screening can be initiated in MSM who have sex in conjunction with illicit drug use
(particularly involving methamphetamines) or those whose sexual partners are involved in
such activities.

68. Which of these is the current recommendation for postoperative antimicrobial prophylaxis in
patients with indwelling drains and intravascular catheters?
a. Continue until indwelling drains are removed only
b. Continue until intravascular catheters are removed only
c. Continue until indwelling drains & intravascular catheters are removed
d. Antimicrobial prophylaxis is not indicated in this scenario
Correct answer : d
Explanation :
Antimicrobial prophylaxis is not indicated in this scenario. There are no data to support
the continuation of antimicrobial prophylaxis until all indwelling drains and intravascular
catheters are removed
69. Which variable is a risk factor for fibrosis in patients with chronic hepatitis C virus (HCV)
infection as assessed by both FIB-4 plus imaging and FIB-4 alone?
a. Obesity
b. Hispanic ethnicity
c. Heavy alcohol use
d. Being uninsured
Correct answer : c
Explanation :
Heavy alcohol use. As well as older age. Noninvasive measures are widely used to assess
fibrosis.

70. Your patient has been hospitalized with S. aureus bacteremia (SAB). Identify which variable
leads you to predict the likelihood of infective endocarditis (IE) in your patient:
a. Presence of a cardiac device
b. None of the answers is correct (Your Selection)
c. Community-acquired SAB
d. Prolonged bacteremia (≥72 hours)
e. All of the answers are correct
Corrrect answer : a
Explanation :
All of the answers are correct. IE is a serious complication of SAB.

71. Which factor is associated with poorer OS in patients with chronic necrotizing pulmonary
aspergillosis treated with radiotherapy to resolve hemoptysis?
a. Presence of COPD
b. Female sex
c. Both answers are correct
d. Neither answer is correct
Correct answer : c
Explanation :
 Both answers are correct. Those findings came from a recent study in which radiotherapy
resolved hemoptysis in all patients. Five-year overall survival rate was 59%.

72. Which hepatitis B virus (HBV) genomic factor is associated with hepatitis B surface antigen
(HBsAg) loss in HBeAg-negative patients?
a. None of the answers is correct
b. Basal core promoter (BCP) mutants
c. All of the answers are correct
d. Genotype C
e. HBV pre-core stop codon (Your Selection)
Correct answer : d
Explanation :
Genotype C. Genotype C patients had a greater lifetime chance of HBsAg loss vs patients
with genotype B. Additional factors associated with increased chances of HBsAg loss
included male sex, elevated ALT levels, and lower serum HBV DNA and HBsAg levels.

73. Exotoxins are proteins secreted by bacteria that cause cellular injury and disease. Which of
the following type of exotoxin is secreted by Bacillus anthracis, Vibrio cholerae and some
strains of Escherichia coli?
a. Enzyme
b. A-B toxin
c. Neurotoxin
d. Superantigen
Correct answer : b
Explanation :
A-B toxins have an Active subunit and a Binding subunit. The binding subunit binds to
receptors on the cell surface and delivers the active subunit into the cell cytoplasm where it
alters intracellular signalling or regulatory pathways. p359

74. Exotoxins are proteins secreted by bacteria that cause cellular injury and disease. Which of
the following types of exotoxin can be secreted by Staphylococcus aureus?
 a. Enzyme and Superantigen
b. A-B toxin and Superantigen
c. Neurotoxin and Enzyme
d. A-B toxin and Neurotoxin
Correct answer : a
Explanation :
The enzyme is a protease that cleaves proteins that link epidermal cells together.
Superantigens stimulate very large numbers of T lymphocytes leading to massive T
lymphocyte proliferation and cytokine release which can lead to capillary leakage and shock.
Streptococcus pyogenes also secretes superantigens.

75. Following infection with ______ streptococci, antibodies can cross react with cardiac
proteins and become deposited in the heart leading to _______, and/or antistreptococcal
antibody/streptococcal antigen complexes can form and be deposited in the renal glomeruli
causing post streptococcal _______.
a. α haemolytic, rheumatic fever, glomerulosclerosis
b. α haemolytic, infective endocarditits, glomerulonephritis
c. β haemolytic, rheumatic fever, glomerulonehpritis
d. β haemolytic, infective endocarditis, glomerulosclerosis

76. This is an acute intestinal infection caused by a bacterium. Its incubation period is typically
1-5 days. Symptoms include an excessive, painless watery diarrhea and usually vomiting.
There may also be leg cramps. Severe dehydration and death can occur if not treated
promptly. What is diagnosed about this case?
a. Cholera
b. Rhotavirus
c. Dysentery
d. Malaria
Correct answer : a
Explanation :
 Cholera is spread by contaminated food and water and only rarely through direct person-
to-person contact. Careful handwashing is essential to prevent spreading of the infection as
the bacteria can remain in the feces for a long while. Raw shellfish are also a potential source
of cholera.

77. This disease is spread from person to person through inhaling droplets from the throat of a
contaminated person. Incubation period is from 2-5 days. It will usually attack the tonsils,
pharynx, larynx and sometimes the skin. Complications can also affect the heart and
peripheral nerves. This disease is potentially fatal even when properly treated. What is it?
a. Tuberculosis
b. Typhoid fever
c. Diphtheria
d. Cholera
Correct answer : c
Explanation :
Patients with diphtheria are treated with antibiotics. After 24 hours on antibiotics, a
person is no longer thought to be contagious. An untreated person remains contagious for 2-3
weeks.

78. The incubation period of this infectious disease is about 5 years and symptoms can take as
long as 20 years to develop. It is not considered highly infectious but is spread through close
and frequent contact with an untreated, infectious person. This disease attacks mainly the
skin, nerves and eyes and will cause progressive and permanent damage. Which one of the
following is the most likely diagnosis?
a. Pityriasis
b. Dermatomyositis
c. Leprosy
d. Scabies
Correct answer : c
Explanation :
 Leprosy has been documented as far back as 600 B.C. Back then, people with leprosy
were banished out of fear of the disease. Today it is completely curable if treated.

79. This infectious disease is contracted when people eat or drink water that is contaminated by
the feces or urine of an infected person. There is a sudden onset of fever, a severe headache,
nausea, anorexia, and a slow heart rate. It may also be accompanied by a hoarse cough and
constipation or diarrhea. Which one of the following is the most likely diagnosis?
a. Typoid fever
b. Plague
c. Dengue fever
d. Yellow fever plus Typoid Fever
Correct answer : a
Explanation :
As of the year 2000, it is estimated that there are as many as 17 million cases of typhoid
fever, per year, worldwide. Incidentally, this is the disease that took the lives of Anne and
Margot Frank as well as thousands of other people in WW II concentration camps.

80. This infectious viral disease usually has two phases. During the first 'acute' phase, there is
fever, muscle pain, headache, shivers, no appetite, nausea and vomiting. After a few days the
patient appears to be getting well only to enter the 'toxic' phase. Fever returns, the patient
becomes jaundiced and experiences abdominal pain and vomiting. Bleeding can occur from
the mouth, nose, eyes and stomach. Half of these patients will die within 10-14 days. Which
one of the following is the most likely diagnosis?
a. Dengue fever
b. Yellow fever
c. Ebola virus
d. Lassa fever
Corrrect answer : b
Explanation :
 Yellow fever is once again becoming a serious health issue. There is a vaccination
available that will protect against yellow fever for up to 10 years. Yellow fever makes its
home in the jungles of South America and Africa.

81. This infectious disease is also called 'guinea worm disease'. A parasite migrates through the
body and eventually emerges through the skin, usually the soles of the feet. This is extremely
painful. It is usually accompanied by fever, nausea and vomiting. Which one of the following
is the most likely diagnosis?
a. Onchocerciasis
b. Shigellosis
c. Dracunculiasis
d. African trypanosomiasis
Correct answer : c
Explanation :

The most common way of ingesting this parasite is through contaminated drinking water.
This disease is most prevalent in Africa.

Questions 82 and 83 refer to the following case.

An 82-year-old man weighing 154 lb with chronic kidney disease and a history of
hemorrhagic stroke that occurred 2 months prior presents to the emergency department
(ED) with cough and confusion. Rectal temperature is 104.1°F, respiratory rate is 32
breaths/min, and oxygen saturation is 91% on room air. On examination, rhonchi are noted
as well as a pronounced neurologic deficit from his previous stroke. Laboratory testing
reveals leukopenia and a blood urea nitrogen level of 70 mg/dL. A chest radiograph reveals
a left lower lobe consolidation. The patient is diagnosed with community acquired
pneumonia (CAP)

82. In addition to providing supplemental oxygen and antipyretics, which of the following is the
most appropriate in the management of this patient?
a. Administer an intravenous (IV) macrolide and discharge home on oral formulation
b. Administer oral doxycycline within 4 hours and admit to a floor bed for observation
c. Obtain blood cultures, administer IV piperacillin-tazobactam, and admit to the intensive
care unit (ICU)
d. Obtain blood cultures, administer IV ceftriaxone and a respiratory fluoroquinolone,
and admit to the ICU
e. Obtain blood cultures, administer IV vancomycin within 4 hours, and admit to the
Correct answer : d
Explanation :
The 2007 Joint Infectious Diseases Society of America/American Thoracic Society
guidelines on management of adult CAP recommend the use of severity of illness scores,
such as CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age ≥65 yr) or
prognostic scoring systems (eg, Pneumonia Severity Index), to assist in determining
candidates for outpatient therapy. Patients with 1 or more major criteria (septic shock
requiring vasopressors or respiratory failure requiring mechanical ventilation) or 3 or more
minor criteria (respiratory rate > 30 breaths/min; PaO2/FiO2 ratio < 250; multilobar
infiltrates; confusion; blood urea nitrogen > 20 mg/dL; leukopenia resulting from infection;
thrombocytopenia; hypothermia; or hypotension requiring aggressive fluid resuscitation)
should be admitted to the ICU. Pre-antibiotic blood cultures should be obtained for all CAP
patients requiring ICU admission. Patients admitted to an ICU should receive a β-lactam
and either azithromycin or a respiratory fluoroquinolone. If Pseudomonas or CA-MRSA is
suspected, antibiotic choice should be altered accordingly. Rather than supporting a specific
time frame in which to initiate therapy, the guidelines recommend that the first dose of
antibiotics be administered in the ED; however, the Joint Commission and the Centers for
Medicare and Medicaid Services core measures require hospitals to publicly report time to
first dose of antibiotics, with a goal of 4 hours from hospital arrival. This patient’s CURB-65
and Pneumonia Severity Index scores exclude outpatient treatment. Although this patient
does not meet any major criteria, he does have 3 minor criteria suggesting that admission to
the ICU is appropriate. Piperacillin-tazobactam or vancomycin alone are inappropriate
antibiotic choices for managing CAP.
83. While in the ED, the patient becomes transiently hypotensive, which resolves with 1 L of
normal saline administered as an IV bolus. A serum lactate level is 6.2 mmol/L. Which of
the following interventions has been shown to reduce mortality in this setting?
a. Corticosteroids
b. Early goal-directed therapy (EGDT)
c. Mechanical ventilation with tidal volumes of 10 mL/kg and low respiratory rate
d. Procalcitonin
e. Recombinant-activated protein C
Correct answer : b
Explanation :
This patient has severe sepsis. Sepsis is defined by the presence of an infection and the
systemic inflammatory response syndrome (eg, hyper/hypothermia, heart rate > 90 bpm,
tachypnea, altered mental status, leukocytosis/leukopenia/bandemia, or elevated C-reactive
protein or procalcitonin levels). Severe sepsis is sepsis plus the presence of organ dysfunction
or evidence of tissue hypoperfusion (serum lactate > 4 mmol/L). EGDT consists of
administering IV fluids, vasopressors, packed red blood cells, and inotropic agents to target
a central venous pressure of 8 to 12 mm Hg, a mean arterial pressure of 65 to 90 mmHg, and
a central venous oxygen saturation of greater than 70% within 6 hours of identification.
EGDT reduced absolute mortality by 16.5% in patients with severe sepsis or septic shock
compared with standard therapy in a single-center randomized trial. Similar mortality
reductions have been found in other studies using historical controls or comparing actual
mortality with predicted mortality using APACHE II scores. Corticosteroids have been
shown to reduce mortality in patients with vasopressor-dependent septic shock, in those
requiring mechanical ventilation, and in those who fail a cosyntropin stimulation test.
However, this finding has recently been disputed in a large trial not yet published.
Recombinant-activated protein C, an endogenous anticoagulant with anti-inflammatory
properties, has been shown to reduce mortality in patients with an APACHE II score of 25 or
more, sepsis-induced multiorgan failure, septic shock, or sepsis-induced acute respiratory
distress syndrome who have no absolute contraindication related to bleeding risk (including
a hemorrhagic stroke within 3 months, as in this patient). Elevated procalcitonin levels may
be sensitive markers of bacterial sepsis, but procalcitonin has no therapeutic role. Protective
 ven tilation strategies using low tidal volumes (6 mL/kg) have been associated with a
reduction in mortality

84. A 77-year-old man presents to the ED with a 5-day history of burning and aching on his left
flank. He developed a rash 1 day prior to presentation. Physical examination revealsan
erythematous rash with clusters of clear vesicles in a single dermatome distribution on his
back. Which of the following is the preferred treatment?
a. Acyclovir
b. Gabapentin
c. Lidocaine 5% patch
d. Prednisone
e. Valcyclovir
Correct answer : e
Explanation :
Valcyclovir is the preferred treatment for this patient with classic herpes zoster. Antiviral
therapy with or without corticosteroids is the mainstay of acute management of herpes
zoster. Valcyclovir and famcyclovir have a superior pharmacokinetic profile and simpler
dosing regimens than acyclovir. Gabapentin is one of several options for postherpetic
neuralgia, but it is not generally indicated in the acute setting. Lidocaine patches are used to
treat postherpetic neuralgia and should only be applied to well-healed skin with no active
lesions. Anticonvulsants (nortriptyline or desipramine) and capsaicin cream can also be
used for the treatment of postherpetic neuralgia.

85. A 25-year-old man presents to the ED for evaluation of multiple skin eruptions. The patient
reports that he may have been bitten by a spider. Physical examination reveals a well
appearing man with normal vital signs and multiple raised red lesions with necrotic areas.
Given the high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the
area, the patient is diagnosed with community-acquired MRSA (CA-MRSA). Which of the
following is the most appropriate antibiotic?
a. Cephalexin orally
b. Ciprofloxacin orally
 c. Erythromycin orally
d. Trimethoprim-sulfamethoxazole (TMP-SMX) orally
e. Vancomycin intravenously
Correct answer : d
Explanation :
Oral TMP-SMX is the appropriate treatment for a well-appearing patient with CA-
MRSA. CAMRSA isolates have high rates of susceptibility to TMP-SMX, rifampin,
vancomycin, and linezolid. Many isolates of CA-MRSA are resistant to fluoroquinolones
and erythromycin; thus, these antibiotics are not recommended to treat CA-MRSA
infection. In most areas, clindamycin and doxycycline are potential treatment options. It is
important for clinicians to be aware of local organism susceptibility patterns to appropriately
treat MRSA infection

86. A healthy 3 year old presents with a fever to 39.8 and stridor. The child reportedly has had a
3 day history of a “bark-like” cough, low grade fever and URI symptoms. She became
acutely worse today and appears “toxic”. The most likely diagnosis is?
a. Viral laryngotracheitis
b. Epiglottis
c. Retropharyngeal abscess
d. Foreign body
e. Bacterial tracheitis
Correct answer : e
Explanation :
Bacterial tracheitis
–Fever, toxic, stridor, secretions, S aureus
Epiglottis
–Older, unimmunized, drooling , toxic, no cough, H. Influenza
Viral laryngotrachitis
–Cough, stridor, nontoxic, parainfluenza
Retropharyngeal abscess
–Young, drooling, stiff neck
 Foreign body
–Acute onset, afebrile, historical clues

87. A 5 year-old presents with migratory arthritis and this rapidly changing rash. The most
likely diagnosis is?

a. Fifth disease
b. Juvenile rheumatoid arthritis
c. Rheumatic fever
d. Systemic Lupus
e. Lyme Disease
Correct answer : c
Explanation :
Group A Streptococcus infections
– Exudative pharyngitis, fever, anterior nodes
– Rheumatic fever
• Arthritis, chorea, carditis, nodules, erythema marginatum
• Prophylaxis
• Scarlet fever-no prophylaxis
– PSGN
• Skin infections, not preventable with antibiotics

88. An a febrile 12 year boy with nephrotic syndrome presents with a headache, vomiting and
6th nerve palsy. His sensorium is intact. The most likely diagnosis is?
a. Meningitis
 b. Sinus venous thrombus
c. Brain abscess
d. Sinusitis
e. Lyme Disease
Correct answer : b
Explanation :
Sinus Venous Thrombosis
– Symptoms
• Headache
• Weakness
• Seizures
– Predisposing conditions
• Nephrotic syndrome
• Thrombophilia
• Meningitis
• Dehydration

89. A child entering kindergarten has had multiple episodes of otitis media and a second episode
of radiographically documented pneumonia. What is the most appropriate initial test for a
possible immunodeficiency?
a. Serum complement levels
b. Serum immunoglobulin levels
c. CD4/CD8 ratio
d. Serum IgE levels
e. Serial complete blood counts for 6 weeks
Correct answer : b
Explanation :
• AOM and Pneumonia
– Encapsulated organisms
• Immunoglobulin Deficiency
– X–Linked Agammaglobulinemia
 – Common Variable Immunodeficiency
– IgA immunodeficiency
• Screening Tests
– Immunoglobulins
– Response to vaccines

90. A 3 year old presents with a 1 month history of unilateral cervical adenitis. The child has
been well appearing, a febrile and has had not traveled. A PPD measures 6 mm. The next
step in the management is?
a. Isoniazid and Rifampin for 6 months
b. A repeat PPD in 3 months
c. A CT of the neck
d. Excisional biopsy
e. Azithromycin for 4 weeks
Correct answer : d
For Atypical Mycobacterium
– History, PPD, excisional biopsy

91. Your patient is an 81 year old male with a history of hypertension, type 2 diabetes mellitus,
hyperlipidemia, and congestive heart failure. He takes metformin, lisinopril, and pravastatin.
He lives in a nursing home. He presents by ambulance to the emergency department for
evaluation of new onset confusion. He appears acutely ill and confused about the date and
place. His blood pressure is 90/60 mm Hg. His heart rate is 92 beats per minute and his
respiratory rate is 22/minute. His temperature is 35 degrees Centigrade. SaO2 is 92%. He has
crackles in his lung bases. Auscultation of the heart reveals a regular rhythm without
murmur, rub, or gallop. Lower abdomen is tender without rebound or guarding. He wears an
adult diaper for incontinence, and his intertriginous pelvic folds are red and excoriated with a
rash pictured below. He has no cyanosis, clubbing, or edema. Hemoglobin is 8 g/dL.
Hematocrit is 24%. White blood cell count is 18,000/mm^3. Platelets are 55,000/mm^3.
Serum lactate is 42 mg/dL. Blood glucose is 160 mg/dL. BUN and creatinine are 30/2.0.
Which of the following is appropriate for this patient?
a. Mechanical ventilation, CVP monitoring, Vancomycin and imipenem pending cultures,
renal dose dopamine, and intensive insulin therapy targeted to normoglycemia.
b. Mechanical ventilation, vancomycin and imipenem pending cultures, add empiric
treatment for systemic candidiasis, begin dopamine and insulin infusion.
c. Empiric antibiotics with coverage for systemic candidiasis, platelet and packed red blood
cell transfusion.
d. Renal dose dopamine, transfuse PRBCs, platelets, empiric antibiotics with coverage for
candidiasis, intensive insulin therapy.
e. Cultures, empiric antibiotics including coverage for disseminated candidiasis.
Supplemental oxygen. Maintain blood pressure. Consider dobutamine.
Correct answer : e
Explanation :
This patient has a mean arterial pressure of 70 mm Hg and is breathing on his own. It is
reasonable to add supplemental oxygen, and empiric antibiotics should be started
immediately after obtaining clinically appropriate cultures. Because this patient has evidence
of candida, disseminated candidiasis should be considered a potential source of infection.
The Surviving Sepsis guidelines indicate that cultures should be done before antimicrobial
therapy if there is no significant delay before the start of therapy. With respect to the other
therapies, mechanical ventilation is not indicated at this time. Central venous pressure
monitoring will be useful to determine if the patient has high filling pressures that may
indicate a need for a cardiac inotrope. Renal dose dopamine is not recommended. Intensive
insulin therapy is not recommended except in patients with a blood glucose level > 180
mg/dL. Platelet transfusions are not indicated unless the platelet count is less than
 10,000/mm3, <20,000/mm^3 in patients at risk for bleeding, or at 50,000/mm3 in patients
who are actively bleeding, or undergoing surgery or an invasive procedure. Routine red
blood cell transfusions are not recommended in sepsis for hemoglobin above 7 g/dL.

92. A 37 year old male with past medical history only significant for drug abuse that came to the
emergency room with complaints of pressure like chest pains, pleuritic in nature associated
with fevers and chills for five days. The patient had a DTAP vaccine placed five days prior to
the admission after which his symptoms began. Upon arrival to the emergency room an
electrocardiogram was performed which showed ST elevations in leads II, III, AVF, v4 and
v5 . An emergency echocardiogram done at bedside showed an ejection fraction 40% with
moderate global hypokinesis but no evidence of pericardial fluid. Immediate cardiac
catheterization revealed normal coronary arteries. First Troponin I level was elevated at 30.
Rheumatologic screening and serum viral antibody titers for suspected acute infectious
causes were all negative. The patient was treated with Colchicine and NSAIDs and his
symptoms improved significantly over the following 3 days. Which one of the following is
the most likely diagnosis?
a. Endocarditis Infective
b. Myocarditis
c. Pleuritis
d. Rheumatic Heart Disease
e. Hypertension Enchelopathy
Correct answer : b
Explanation :
Myocarditis has multiple etiologies however vaccine related causes are rare. In a
thorough review of literature, we found only two cases of myocarditis induced by tetanus
vaccine. Both were reported in the juvenile population: one in a 3 month old after a DTAP
vaccine and the other in a 13 year old male after tetanus vaccination. DTAP induced
myocarditis should be suspected in patients with chest pains and fevers with an antecedent of
the vaccine and promptly evaluated as it can cause detrimental repercussions.
93. A patient came to doctor with complaints of fever, dyspnea on exertion, dry cough, weight
loss, and fatigue. The result of laboratory test ; lactate dehydrogenase is elevated, and PaO2
depressed. In addition, pulmonary exam is normal and chest x-ray have showed
demonstrates an interstitial butterfly pattern. The doctors diagnosed the patient with
pneumocystis jiroveci pneumonia (PCP). what is the drug of choice for treatment according
to the case?
a. Trimethaporin-sulfamethazole
b. Prednisone-methoxazole
c. Pentamidine aerosol
d. Sulfadiazine-clyndamicin
e. Prymethamine
Correct answer : a
Explanation :
Trimethoprim–sulfamethoxazole is the drug of choice for treatment PCP.

94. You are treating a patient with H. pylori infection. You would expect all of the following to
be increased in this patient, EXCEPT:
a. Triglyceride levels
b. BMI
c. Systolic blood pressure
d. High-density lipoproteins
Correct answer : d
Explanation :
High-density lipoproteins. A recent study determined that H. pylori infection is positively
associated with metabolic syndrome. H. pylori infection was also associated with higher
fasting blood glucose and HOMA-IR scores and lower levels of high-density lipoproteins.

95. What would you predict to be the incidence rate of metachronous gastric cancer more than 5
years after H. pylori eradication in patients who received endoscopic resection for early
gastric cancer?
a. 9, 8 %
 b. 11.0%
c. 15.0%
d. 29.9%
e. 50 %
Correct answer : b
Explanation :
11.0%. In a recent study, male sex, severe gastric mucosal atrophy, and multiple gastric
cancers before successful H. pylori eradication were independent risk factors for
metachronous gastric cancer. Surveillance endoscopy in patients who have undergone
endoscopic resection for early gastric cancer should be performed even after successful H.
pylori eradication.

96. Cytomegalovirus (CMV) infection is associated with which variable among inpatients with
exacerbated inflammatory bowel disease (IBD)?
a. Age ≥30 years
b. Disease duration <60 months
c. Immunosuppressive therapy
d. All of the answers are correct
e. None of the answers is correct
Correct answer : d
Explanation :
All of the answers are correct. CMV infection was also associated with a blood leukocyte
count <11/nL in this patient population. Prevalence of CMV infection was 22.7% and 16.0%
in patients with ulcerative colitis and Crohn’s disease, respectively.

97. Which species of Acrophialophora was recently identified as an emerging opportunistic

fungus capable of human infection?
a. Fusispora
b. Levis
c. Seudatica
d. None of the answers is correct
 Correct answer : a
Explanation :
Fusispora. This according to a recent study. The taxonomy of the genus is not yet fully
resolved.

98. Compared to troughs of 10-14.9 mg/L, achieving vancomycin serum trough concentrations
of 15-20 mg/L in patients with presumed MRSA infection results in:
a. Increased attainment of the AUC/MIC ≥400
b. Increased risk of nephrotoxicity
c. Both answers are correct
d. Neither answer is correct
Correct answer : b
Explanation :
Increased risk of nephrotoxicity. Higher trough concentrations did not achieve increased
attainment of AUC/MIC target.

99. Which outcome is observed when ivermectin is added to diethylcarbamazine and albendazole
therapy for lymphatic filariasis?
a. Significant increase in albendazole serum levels
b. Patients become microfilia negative 1 year later
c. Adverse events were significantly less with triple-drug therapy
d. All of the answers are correct
e. None of the answers is correct
Correct answer : b
Explanation :
Patients become microfilia negative 1 year later. Triple-drug therapy is safe and more
effective than diethylcarbamazine + albendazole for Bancroftian filariasis and has the
potential to accelerate elimination of lymphatic filariasis.

100. A 44-year-old man presents to the ED with 16 hours of fever, headache, and neck stiffness.
On physical examination, the patient is alert and oriented with a normal neurologic
examination except for meningismal signs. Antibiotics and dexamethasone are ordered.
Which of the following is true when using dexamethasone to treat meningitis?
a. Administration increases the risk of gastrointestinal bleeding
b. Administration should occur before or with the first dose of antibiotics
c. Administration increases blood-brain permeability
d. Administration should continue until symptoms resolve
Correct answer : b
Explanation :
Dexamethasone administered before or with the first dose of antibiotics improves
outcomes in patients with acute bacterial meningitis. The recommended dose for adults is 10
mg intravenously every 6 hours for 4 days. This treatment plan does not increase the risk of
gastrointestinal bleeding. Of note, dexamethasone decreases the blood-brain permeability,
which could impede penetration of vancomycin into the subarachnoid space. Treatment
failures have been noted in adults receiving vancomycin and dexamethasone. In children,
treatment with dexamethasone did not reduce levels of vancomycin in cerebrospinal fluid.