Lyme Disease. Question 3. A 5 year-old presents with

1
Infectious Disease Board Review

• Stephen Barone MD
• Pediatric Program Director
• Schneider Children's Hospital
• Associate Professor
• New York University School of Medicine

• Michael Lamacchia, MD
• Chairman
• St. Josephs Childrens Hospital
• Associate Professor
• Mount Sinai School of Medicine

2
Question 1

• A healthy 3 year old
• presents with a fever to
• 39.8 and stridor. The child
• reportedly has had a 3 -day
• history of a bark-like
• cough, low grade fever and
• URI symptoms. She
• became acutely worse today
• and appears toxic
• The most likely diagnosis is?

• Viral laryngotracheitis
• Epiglottis
• Retropharyngeal abscess
• Foreign body
• Bacterial tracheitis

3
Question 1

• A healthy 3 year old
• presents with a fever to
• 39.8 and stridor. The child
• reportedly has had a 3 -day
• history of a bark-like
• cough, low grade fever and
• URI symptoms. She
• became acutely worse today
• and appears toxic
• The most likely diagnosis is?

• Viral laryngotracheitis
• Epiglottis
• Retropharyngeal abscess
• Foreign body
• Bacterial tracheitis

4
Key Points 1

• Bacterial tracheitis
• Fever, toxic, stridor, secretions, S aureus
• Epiglottis
• Older, unimmunized, drooling , toxic, no cough,
  H. Influenza
• Viral laryngotrachitis
• Cough, stridor, non-toxic, parainfluenza
• Retropharyngeal abscess
• Young, drooling, stiff neck
• Foreign body
• Acute onset, afebrile, historical clues

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Question 2

• A 2 month old infant
• presents with a 2 -week
• history of a cough,
• perioral cyanosis and
• posttussive vomiting.
• The treatment of choice
• is?

• High dose Amoxicillin
• Azithromycin
• Clindamycin
• Steroids
• Trimethroprim - sulfamethoxazole

6
Question 2

• A 2 month old infant
• presents with a 2 -week
• history of a cough,
• perioral cyanosis and
• posttussive vomiting.
• The treatment of choice
• is?

• High dose Amoxicillin
• Azithromycin
• Clindamycin
• Steroids
• Trimethroprim - sulfamethoxazole

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Key Point 2

• Pertussis
• Infants or Adolescents
• Macrolide - limit spread
• Differential Diagnosis
• Chlamydia trachomatis
• Staccato cough, tachypnea afebrile,
• PCP
• Hypoxic, toxic , immunodeficiency

8
Question 3

• A 5 year-old presents with
• migratory arthritis and
• shortness of breath. On
• exam you notice a
• holosystoic murmur
• The most likely diagnosis
• is?

• Fifth disease
• Juvenile rheumatoid arthritis
• Rheumatic fever
• Systemic Lupus
• Lyme Disease

9
Question 3

• A 5 year-old presents with
• migratory arthritis and
• shortness of breath. On
• exam you notice a
• holosystoic murmur
• The most likely diagnosis
• is?

• Fifth disease
• Juvenile rheumatoid arthritis
• Rheumatic fever
• Systemic Lupus
• Lyme Disease

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Key Points 3

• Group A Streptococcus infections
• Exudative pharyngitis, fever, anterior nodes
• Treatment Penicillin
• Rheumatic fever
• Arthritis, chorea, carditis, nodules, erythema
  marginatum
• Prophylaxis
• Scarlet fever no prophylaxis
• PSGN
• Skin infections, not preventable with antibiotics

11
Question 4

• A 12 year boy with a three
• week history of nasal
• congestion, cough and
• nasal discharge presents
• with a headache,
• vomiting and 6th nerve
• palsy
• The next step in his
• evaluation should be?

• Lumbar puncture
• CT scan head and sinuses
• Lyme serology
• Maxillary sinus aspiration
• Slit lamp examination of the eyes?

12
Question 4

• A 12 year boy with a three
• week history of nasal
• congestion, cough and
• nasal discharge presents
• with a headache,
• vomiting and 6th nerve
• palsy
• The next step in his
• evaluation should be?

• Lumbar puncture
• CT scan head and sinuses
• Lyme serology
• Maxillary sinus aspiration
• Slit lamp examination of the eyes?

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Key Points 4

• Symptoms 2 weeks
• Congestion,
• Nasal discharge
• Facial pain
• Complications of sinusitis
• Cerebral venous thrombosis
• Orbital cellulitis
• Brain abscess Potts puffy tumor
• S. pneumoniae, M. catarrhalis, H. influenzae
• Chronic S. aureus, anaerobes

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Question 5

• A 5 year old with chronic
• ear infections who had a
• chronic inflammation of
• the middle ear,
• perforation and
• otorrhea has what
• condition?

• Cholestatoma
• Chronic suppurative otitis media
• Serous otitis media
• Otitis externa
• Labyrinthitis

15
Question 5

• A 5 year old with chronic
• ear infections who had a
• chronic inflammation of
• the middle ear,
• perforation and
• otorrhea has what
• condition?

• Cholestatoma
• Chronic suppurative otitis media
• Serous otitis media
• Otitis externa
• Labyrinthitis

16
Key Points 5

• Acute Otitis Media
• S. pneumoniae, H. influenzae, M. catarrhalis
• Chronic Suppurative Otitis Media
• Above plus S. aureus, P.aeruginosa
• Cholesteatoma
• Cystic structure chronic OM
• Otitis Externa
• Intact TM - P.aeruginosa and S. aureus

17
Question 6

• A 3 year old presents
• with a 1 month history of
• unilateral cervical
• adenitis. The child has
• been well appearing,
• afebrile and has had not
• traveled. A PPD
• measures 6 mm
• The next step in the
• management is?

• Isoniazid and Rifampin for 6 months
• A repeat PPD in 3 months
• A CT of the neck
• Excisional biopsy
• Azithromycin for 4 weeks

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Question 6

• A 3 year old presents
• with a 1 month history of
• unilateral cervical
• adenitis. The child has
• been well appearing,
• afebrile and has had not
• traveled. A PPD
• measures 6 mm
• The next step in the
• management is?

• Isoniazid and Rifampin for 6 months
• A repeat PPD in 3 months
• A CT of the neck
• Excisional biopsy
• Azithromycin for 4 weeks

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Key Points 6

• Unilateral adenitis
• Acute
• S. aureus, Group A Streptococcus
• Antibiotics
• Sub acute
• Atypical Mycobacterium
• History, PPD, excisional biopsy
• Cat Scratch
• History, serology, no treatment
• Kawasaki Disease
• IVIG
• Chronic
• Malignancy

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Question 7

• A 15 year old boy
• develops a fever to 101oF,
• headache and bilateral
• swelling of his parotid
• glands.
• The most likely
• complication of this
• illness is?

• Acute airway obstruction
• Sensorineural hearing loss
• Orchitis
• Myocarditis
• Arthritis

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Question 7

• A 15 year old boy
• develops a fever to 101oF,
• headache and bilateral
• swelling of his parotid
• glands
• The most likely
• complication of this
• illness is?

• Acute airway obstruction
• Sensorineural hearing loss
• Orchitis
• Myocarditis
• Arthritis

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Key Points 7

• Parotitis
• Bacterial ill appearing
• Viral
• Mumps
• Viral syndrome with swelling of parotid glands
• Complication
• Orchitis
• CSF pleocytosis most asymptomatic
• Rare myocarditis, arthritis etc.
• Vaccine
• Live vaccine

23
Question 8

• A 15 year old complains
• of a sore throat, fever and
• a muffled voice. She stepped
• on a sharp piece of metal 4
• days ago. On examination
• The adolescent also has
• trismus.
• The most likely diagnosis is?

• Tetanus
• Retropharyngeal abscess
• Infectious mononucleosis
• Peritonsillar abscess
• Herpangia

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Question 8

• A 15 year old complains
• of a sore throat, fever and
• a muffled voice. She stepped
• on a sharp piece of metal 4
• days ago. On examination
• The adolescent also has
• trismus.
• The most likely diagnosis is?

• Tetanus
• Retropharyngeal abscess
• Infectious mononucleosis
• Peritonsillar abscess
• Herpangia

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Key Points 8

• Peritonsillar abscesses
• Adolescent, sore throat, hot potato voice,
  trismus
• Dx exam
• Organisms S. aureus. Group A Streptococcus,
  Anaerobes
• Retropharyngeal abscess
• Toddler, stridor, stiff neck, dysphagia,
  torticollis
• Dx CT scan
• Infectious Mononucleosis
• Adolescent, sore throat, lymphadepathy, fatigue,
  fever
• Tetanus
• Trismus and muscle spasm
• C. tetani
• Treatment
• Tdap, TIG
• Penicillin
• Herpangina
• Peritonsillar ulcers/vesicles
• Enteroviral infection

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Question 9

• A 9 month old presents
• with vesicular lesions on
• his lips and bleeding
• gums. He is drooling
• and unable to eat. On his
• trunk is a target lesion rash
• In addition to hydration,
• Which therapeutic
• regime will be most
• effective?

• IV acyclovir
• IV nafcillin
• Topical nystatin
• Topical mupirocin
• IV steroids

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Question 9

• A 9 month old presents
• with vesicular lesions on
• his lips and bleeding
• gums. He is drooling
• and unable to eat. On his
• trunk is a target lesion rash
• In addition to hydration,
• Which therapeutic
• regime will be most
• effective?

• IV acyclovir
• IV nafcillin
• Topical nystatin
• Topical mupirocin
• IV steroids

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Key Points 9

• Herpes gingivostomatitis
• Young child, anterior vesicles, swollen gums
• Treatment supportive, Acyclovir
• Complication erythema multiforme
• Dx Culture, DFA
• Herpangina
• Posterior vesicles
• Candida
• Cottage cheese plaques on buccal mucosa
• Impetigo
• Honey crust lesions on the skin
• Group A Streptococcus, S. aureus

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Question 10

• A 3 year old presents with a three
• day history of fever and cough.
• Today he developed respiratory
• distress. In addition to supportive
• care what is the most appropriate
• treatment plan?

• CT Scan of chest
• Ceftriaxone
• PPD
• Bronchoscopy
• Amphotericin

30
Question 10

• A 3 year old presents with a three
• day history of fever and cough.
• Today he developed respiratory
• distress. In addition to supportive
• care what is the most appropriate
• treatment plan?

• CT Scan of chest
• Ceftriaxone
• PPD
• Bronchoscopy
• Amphotericin

31
Key Points 10

• Pneumococcal pneumonia
• Most common bacterial pneumonia
• Acute, fever, tachypnea, cough, focal infiltrate
• Round pneumonia
• Treatment
• Inpatient Ceftriaxone
• Outpatient High dose Amoxicillin
• Resistance Lack of PCPs

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Question 11

• A 5 year old presents
• with a month history of
• cough, fever and weigh
• loss. His CXR shows a
• focal infiltrate with hilar
• lymphadenopathy. A
• PPD is 7 mm.
• The most appropriate
• treatment plan is?

• Repeat PPD in 3 months
• Bronchoscopy
• Gastric lavage
• Isoniazid for nine months
• Isoniazid, Rifampin and Ethambutal for 6 months

33
Question 11

• A 5 year old presents
• with a month history of
• cough, fever and weigh
• loss. His CXR shows a
• focal infiltrate with hilar
• lymphadenopathy. A
• PPD is 7 mm.
• The most appropriate
• treatment plan is?

• Repeat PPD in 3 months
• Bronchoscopy
• Gastric lavage
• Isoniazid for nine months
• Isoniazid, Rifampin and Ethambutal for 6 months

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Key Points 11

• Mycobacterium tuberculosis
• History
• Immigrant, insidious, weight loss, hilar nodes
• PPD
• 5 mm high risk symptoms, HIV
• 10 mm medium age less than 6, immigrant,
  travel
• 15 mm low
• Diagnosis gastric lavage
• Treatment
• Four drugs then based on sensitivities
• Side-effects
• Prophylaxis
• INH 9 months

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Question 12

• A ten year old boy presents
• with a four day history of
• cough, fever and myalgia. A
• rapid influenza test was
• positive two days ago in his
• physicians office. Today he
• became acutely worse and is
• in respiratory distress.
• The most appropriate therapy
• is?

• Oseltamivir
• Ribavirin
• Clindamycin
• Aztreonam
• Azithromycin

36
Question 12

• A ten year old boy presents
• with a four day history of
• cough, fever and myalgia. A
• rapid influenza test was
• positive two days ago in his
• physicians office. Today he
• became acutely worse and is
• in respiratory distress.
• The most appropriate therapy
• is?

• Oseltamivir
• Ribavirin
• Clindamycin
• Aztreonam
• Azithromycin

37
Key Points 12

• Influenza
• Fever, cough, myalgia
• Oseltamivir within 48 hours
• Influenza vaccine 2A, 1B
• Antigenic shift vs. antigenic drift
• Complications
• S. aureus pneumonia
• MRSA
• Clindamycin, Vancomycin

38
Question 13

• A febrile irritable 20 month old
• male presents with a two
• day history of a crusty
• excoriation under his nose
• This was followed by a
• diffuse erythematous painful
• rash.
• The most likely diagnosis
• is?

• Kawasaki disease
• Staphylococcal scalded skin syndrome
• Toxic shock syndrome
• Roseola
• Enteroviral infection

39
Question 13

• A febrile irritable 20 month old
• male presents with a two
• day history of a crusty
• excoriation under his nose
• This was followed by a
• diffuse erythematous painful
• rash.
• The most likely diagnosis
• is?

• Kawasaki disease
• Staphylococcal scalded skin syndrome
• Toxic shock syndrome
• Roseola
• Enteroviral infection

40
Key Points 13

• Staphylococcal Scalded Skin Syndrome
• Symptoms
• Non-toxic, impetigo, painful, sunburn rash, skin
  peels readily.
• Toxic Shock Syndrome
• Hypotension
• Fever
• Rash
• Desquamation
• Plus three or more organ systems involved

41
Question 14

• Which of these infectious
• diseases often is
• accompanied by
• hyponatremia?

• Roseola
• Measles
• Rocky Mountain Spotted Fever
• Lyme disease
• Leptospirosis

42
Question 14

• Which of these infectious
• diseases often is
• accompanied by
• hyponatremia?

• Roseola
• Measles
• Rocky Mountain Spotted Fever
• Lyme disease
• Leptospirosis

43
Key Points 14

• Rocky Mountain Spotted Fever
• Epidemiology, distal petiechiae, headache,
  increased LFTs, hyponatremia
• Treatment doxycycline
• Lyme Disease
• Northeast, Wisconsin, Northern CA
• Rash, arthritis (mono), meningitis
• Treatment
• Amoxicillin, Doxycycline
• Ceftriaxone

44
Question 15

• A year old child presents
• with a four day history of
• irritability and recurrent
• fevers. Today he is afebrile
• and had a diffuse
• erythematous rash on his
• trunk. You diagnosis the
• child with roseola.
• Which of the following is a
• common complication of this
• disease?

• Arthritis
• Febrile seizures
• Aseptic meningitis
• Thrombocytopenia
• Hepatitis

45
Question 15

• A year old child presents
• with a four day history of
• irritability and recurrent
• fevers. Today he is afebrile
• and had a diffuse
• erythematous rash on his
• trunk. You diagnosis the
• child with roseola.
• Which of the following is a
• common complication of this
• disease?

• Arthritis
• Febrile seizures
• Aseptic meningitis
• Thrombocytopenia
• Hepatitis

46
Key Points 15

• Roseola
• Fever followed by rash
• HHV6 infection
• Complications
• Febrile seizures
• Complications
• Parvovirus arthritis
• EBV hepatitis
• Aseptic meningitis Kawasaki
• Thrombocytopenia - RMSF

47
Question 16

• A child presents with
• abdominal pain, arthritis
• and this rash.
• What is the most
• appropriate treatment?

• Ceftriaxone
• IVIG
• Doxycycline
• Clindamycin
• Supportive care

48
Question 16

• A child presents with
• abdominal pain, arthritis
• and this rash.
• What is the most
• appropriate treatment?

• Ceftriaxone
• IVIG
• Doxycycline
• Clindamycin
• Supportive care

49
Key Point 16

• Henoch Schonlein Purpura
• Palpable purpura, lower extremities, bloody
  stools (colitis, intussusception) ,arthritis,
  hematuria
• Treatment
• Supportive
• Steroids?
• Differential Diagnosis
• Meningococcal Ceftriaxone
• RMSF Doxycycline
• Kawasaki - IVIG

50
Question 17

• Which vaccine(s)
• is (are) not routinely
• recommended for catch
• up vaccination for
• children greater than 5
• years of age?

• Varicella
• Hib
• Pneumococcal
• Hib Pneumococcal
• DTaP

51
Question 17

• Which vaccine(s)
• is (are) not routinely
• recommended for catch
• up vaccination for
• children greater than 5
• years of age?

• Varicella
• Hib
• Pneumococcal
• Hib Pneumococcal
• DTaP

52
Key Point 17

• Hib and Pneumococcal vaccines
• No catch up greater than 5
• DTaP
• 4 doses
• Varicella
• Always catch -up

53
Question 18

• A fourteen year old male
• presents to the ED after
• sustaining a laceration
• with a lawn motor blade.
• He cannot recall when he
• received his last tetanus
• vaccine. Although his
• mother say he received all his
• shots when he was a baby
• He should receive?

• Td and TIG
• TdaP
• DT
• TdaP and TIG
• TIG

54
Question 18

• A fourteen year old male
• presents to the ED after
• sustaining a laceration
• with a lawn motor blade.
• He cannot recall when he
• received his last tetanus
• vaccine. Although his
• mother say he received all his
• shots when he was a baby
• He should receive?

• Td and TIG
• TdaP
• DT
• TdaP and TIG
• TIG

55
Key Points 18

• DTaP under 7
• TdaP Adol and Adults
• Td greater than 7
• DT less than 7

56
Question 19

• Which of these two
• vaccine pairs, if not give
• simultaneously (at the
• same visit) should be
• separated by at four least
• weeks?

• Hepatitis A and Hepatitis B
• IPV and Pneumococcal
• DTaP and Hib
• MMR and Varicella
• MMR and Hepatitis B

57
Question 19

• Which of these two
• vaccine pairs, if not give
• simultaneously (at the
• same visit) should be
• separated by at four least
• weeks?

• Hepatitis A and Hepatitis B
• IPV and Pneumococcal
• DTaP and Hib
• MMR and Varicella
• MMR and Hepatitis B

58
Key Points 19

• Live vaccines if not given simultaneously need to
  be separated by 4 weeks
• Learn contraindications of live vaccines
• egg based vaccines
• Influenza (injectable)
• Yellow fever
• Measles and mumps (chick embryo)

59
Question 20

• A 5 year old presents with
• fever, jaundice and
• vomiting. A hepatitis profile
• reveals
• Hepatitis A IgM negative
• Hepatitis A IgG- positive
• Hepatitis BsAg negative
• Hepatitis BsAb positive
• Hepatitis BcAb negative
• Interpretation?

• Acute hepatitis A and B infections
• Chronic hepatitis A and B infections
• Previous vaccination against hepatitis A and B
• Chronic hepatitis B infection and acute
  hepatitis B infection
• Past hepatitis B infection and acute hepatitis B
  infections

60
Question 20

• A 5 year old presents with
• fever, jaundice and
• vomiting. A hepatitis profile
• reveals
• Hepatitis A IgM negative
• Hepatitis A IgG- positive
• Hepatitis BsAg negative
• Hepatitis BsAb positive
• Hepatitis BcAb negative
• Interpretation?

• Acute hepatitis A and B infections
• Chronic hepatitis A and B infections
• Previous vaccination against hepatitis A and B
• Chronic hepatitis B infection and acute
  hepatitis B infection
• Past hepatitis B infection and acute hepatitis B
  infections

61
Key Points 20

• Hepatitis A
• IgM Acute
• IgG Acute, past, vaccine

62
Question 21

• Which of these
• pathogens pairs typically
• infect the colon?

• Salmonella and Rotavirus
• Shigella and Giardia
• Campylobacter and Shigella
• Yesinia and Giardia
• Salmonella and Helicobacter

63
Question 21

• Which of these
• pathogens pairs typically
• infect the colon?

• Salmonella and Rotavirus
• Shigella and Giardia
• Campylobacter and Shigella
• Yesinia and Giardia
• Salmonella and Helicobacter

64
Key Points 21

• Small intestine
• Watery, high volume, frequent
• Rotavirus. Norwalk, Adenoviurs, Giardia
• Large Intestine
• Blood, small volume, mucus, travel
• Salmonella food, turtles
• Campylocbacter unpasteurized milk, GBS
• Yersina chittlings
• Shigella food, neurotoxin
• E-coli O157H7- food, HUS
• E-coli travel associated watery
• C. difficle - antibiotics

65
Question 22

• An 12 year old returns from a
• three month trip to India.
• She complains of a 10 day
• history of fever, chills,
• abdominal pain and myalgia.
• Her examination is
• unremarkable
• Lab results
• WBC 6,000
• Hb 13.6
• Plt 400,000
• AST 120
• Her most likely diagnosis is?

• Malaria
• Typhoid fever
• TB
• Hepatitis B
• Yellow fever

66
Question 22

• An 12 year old returns from a
• three month trip to India.
• She complains of a 10 day
• history of fever, chills,
• abdominal pain and myalgia.
• Her examination is unremarkable
• Lab results
• WBC 6,000
• Hb 13.6
• Plt 400,000
• AST 120
• Her most likely diagnosis is?

• Malaria
• Typhoid fever
• TB
• Hepatitis B
• Yellow fever

67
Key Points 22

• Malaria
• Fever, splenomegaly, hemolytic anemia
• Typhoid
• Flu- like illness, normal WBC
• TB
• Longer incubation period
• Hepatitis B
• No risk factor for traveling adolescents
• Yellow fever
• Africa, South America

68
Question 23

• Which is the preferred
• diagnostic test to confirm an
• HIV infection in one month
• old infant born to an
• HIV positive mother?

• HIV p24 antigen assay
• HIV DNA PCR
• HIV culture
• HIV serology
• CD4/CD8 ratio

69
Question 23

• Which is the preferred
• diagnostic test to confirm an
• HIV infection in one month
• old infant born to an
• HIV positive mother?

• HIV p24 antigen assay
• HIV DNA PCR
• HIV culture
• HIV serology
• CD4/CD8 ratio

70
Key Points 23

• HIV serology can be falsely positive for up to 18
  months after birth
• HIV p24 antigen test false positives and
  negatives
• Not recommended
• HIV culture requires 4 weeks, not readily
  available
• Not recommended
• HIV DNA PCR
• Highly sensitive and specific
• Considered infected if two separate positive
  tests
• CD4/CD8 ratio
• Not useful in the neonatal period

71
Question 24

• A full-term normal-appearing infant was born
  to a 26-year old female with a history of
  syphilis during the first trimester of pregnancy,
  as evidenced by the seroconversion of her VDRL
  result (titer 14, previously nonreactive). The
  woman received one injection of 2.4 million units
  of benzathine penicillin. At delivery, her VDRL
  had a titer of 164. In evaluating this infant
  the appropriate conclusion is that -

• The mother has been adequately treated, and the
  infant requires no further therapy
• The infant has a high probability of having
  congenital syphilis and requires evaluation and
  treatment
• If the infants long bone radiographs show no
  abnormality, no treatment is indicated
• This child may be given a shot of benzathine
  penicillin, and no further serologic evaluation
  is necessary

72
Question 24

• A full-term normal-appearing infant was born
  to a 26-year old female with a history of
  syphilis during the first trimester of pregnancy,
  as evidenced by the seroconversion of her VDRL
  result (titer 14, previously nonreactive). The
  woman received one injection of 2.4 million units
  of benzathine penicillin. At delivery, her VDRL
  had a titer of 164. In evaluating this infant
  the appropriate conclusion is that -

• The mother has been adequately treated, and the
  infant requires no further therapy
• The infant has a high probability of having
  congenital syphilis and requires evaluation and
  treatment
• If the infants long bone radiographs show no
  abnormality, no treatment is indicated
• This child may be given a shot of benzathine
  penicillin, and no further serologic evaluation
  is necessary

73
Key Points 24

• Evaluate infants for congenital syphilis if
• Fourfold increase in maternal titer
• Infant has clinical manifestations of syphilis
• Syphilis is untreated, inadequately treated, or
  treatment not documented
• Mother treated with non-penicillin regimen
• Mother treated lt1 month before delivery
• Treated before pregnancy but with insufficient
  serologic follow-upEvaluation for syphilis in
  an infant
• Quantitative nontreponemal serologic test of
  serum from infant
• VDRL test of CSF, cell count, protein
  concentration
• Long-bone Xrays
• CBC w/platelets
• Other clinically indicated tests (C Xray,
  LFTs, US, eye exam, auditory brain stem)
• Pathologic examination of placenta or umbilical
  cord using FTA staining if possible

74
Question 25

• A 10-year-old child develops ascending
  paralysis with peripheral neuropathy (cranial
  nerves are normal) the CSF is normal except for
  an elevated protein level. The likely infectious
  agent precipitating this syndrome is -

• Corynebacterium diphtheriae
• Clostridium botulinum
• S. dysenteriae serotype 1
• Campylobacter jejuni
• Clostridium tetani

75
Question 25

• A 10-year-old child develops ascending
  paralysis with peripheral neuropathy (cranial
  nerves are normal) the CSF is normal except for
  an elevated protein level. The likely infectious
  agent precipitating this syndrome is -

• Corynebacterium diphtheriae
• Clostridium botulinum
• S. dysenteriae serotype 1
• Campylobacter jejuni
• Clostridium tetani

76
Keypoints 25

• Guillain-Barre Syndrome
• Motor polyradiculoneuropathy
• Muscle pain, symmetric, ascending paresis with
  minor sensory abnormality Diagnostic
  criteria Required Progressive muscle
  weakness of more than 1 limb Areflexia
  Strongly supportive Relative symmetry Mild or
  no sensory Cranial nerve involvement Autonomic
  dysfunction Absence of fever Disease
  progression halts by 4 weeks Recovery

77
Keypoint 25 - continued
CSF features Elevated protein after first
week Fewer than 10 mononuclear cells
Electrodiagnostic features Nerve
conduction slowing Etiology Campylobacter
jejuni CMV EBV M. pneumoniae
Vaccine ie., swine flu, Menactra, rabies, tetanus
toxoid, Hep. B, influenza,
enteroviruses, west nile Food borne diseases
(Shighella, Enteroinvasive E. coli, Yersinia
enterocolitica, vibrio
parahaemolyticus)
78
Question 26

• Congenital rubella syndrome is associated
  with which of the following?

• Patent ductus arteriosus (PDA) and branch
  pulmonary artery stenosis
• Ventricular septal defect (VSD) and PDA
• Atrial septal defect (ASD) and PDA
• VSD and ASD
• VSD and pulmonary artery stenosis

79
Question 26

• Congenital rubella syndrome is associated
  with which of the following?

• Patent ductus arteriosus (PDA) and branch
  pulmonary artery stenosis
• Ventricular septal defect (VSD) and PDA
• Atrial septal defect (ASD) and PDA
• VSD and ASD
• VSD and pulmonary artery stenosis

80
Keypoint 26

• Congenital Rubella Syndrome
• Manifestations
• Ophthalmologic Cataracts, pigmentary
  retinopathy, micro phthalmos congenital glaucoma
• Cardiac Patent ductus arteriosus,
  peripheral pulmonary artery stenosis
• Auditory Sensorineural hearing
  impairment
• Neurologic Behavioral disorders,
  meningoencephalitis, mental retardation
• Neonatal Growth retardation,
  interstitial pneumonitis, radiolucent bone
  disease, hepatosplenomegaly,
  thrombacytopenis, dermal erythropoiesisOccurrence
  of Congenital Defects
• 85 if mother has rash in first 12 weeks
• 34 13-16 weeks
• 25 during end of second trimester

81
Question 27

• A 4-year-old male is brought to your office
  because of a circular reddish rash under his
  armpit. The child has been afebrile and has had
  no other systemic symptoms. The rash is not
  pruritic. The childs parents state that they
  have recently returned from a vacation in
  Massachusetts on Cape Cod and that a small tick
  had been removed from the same area where the
  rash is now. The only abnormality on the
  examination is the circular, flat, erythematous
  rash that is about 6 cm in diameter and is not
  tender. The appropriate next step in treating
  this patient is to -

• Order a test for serum antibodies against
  Borrelia burgdorferi to confirm that the child
  has Lyme disease
• Begin treatment with doxycycline
• Begin treatment with amoxicillin
• Begin treatment with ceftriaxone
• Perform a lumbar puncture to be certain that the
  childs central nervous system (CNS) is not
  involved.

82
Question 27

• A 4-year-old male is brought to your office
  because of a circular reddish rash under his
  armpit. The child has been afebrile and has had
  no other systemic symptoms. The rash is not
  pruritic. The childs parents state that they
  have recently returned from a vacation in
  Massachusetts on Cape Cod and that a small tick
  had been removed from the same area where the
  rash is now. The only abnormality on the
  examination is the circular, flat, erythematous
  rash that is about 6 cm in diameter and is not
  tender. The appropriate next step in treating
  this patient is to -

• Order a test for serum antibodies against
  Borrelia burgdorferi to confirm that the child
  has Lyme disease
• Begin treatment with doxycycline
• Begin treatment with amoxicillin
• Begin treatment with ceftriaxone
• Perform a lumbar puncture to be certain that the
  childs central nervous system (CNS) is not
  involved.

83
Keypoint 27

• Lyne Disease
• Early localized disease Erthema migrans
  at site of tick bite
• Early disseminated Multiple erythema
  migrans Cranial nerve palsies
  Lymphocytic meningitis Conjunctivitis
  Arthritis Carditis
• Late Recurrent arthritis
  Peripheral neuropathy CNS
• Diagnosis
• Clinical (EM) during early stages
• Clinical and serologic in early disseminated or
  late
• Serology EIA or IFA for screening
  Western Immunoblot 1 gG 5 bands 1 gM 2 bands

84
Question 28

• Primary pulmonary histoplasmosis in normal
  children is usually -

• Asymptomatic
• Associated with severe flu-like symptoms
• Treated with assisted ventilation and steroid
  therapy
• Associated with sarcoid-like disease
• Complicated by mediastinal fibrosis

85
Question 28

• Primary pulmonary histoplasmosis in normal
  children is usually -

• Asymptomatic
• Associated with severe flu-like symptoms
• Treated with assisted ventilation and steroid
  therapy
• Associated with sarcoid-like disease
• Complicated by mediastinal fibrosis

86
Keypoint 28

• Histoplasmosis
• Causes symptoms in fewer than 5 of infected
  people
• Site (pulmonary, extrapulmonary, disseminated)
• Duration (acute, chronic)
• Pattern (primary vs. reactivation)
• Mississippi, Ohio, Missouri River
  ValleyCoccidiomycosis
• Asymptomatic or self-limited 60
• May resemble influenza, diffuse erythematous
  maculopapular rash, erythema multiforme,
  erythema nodosum
• dissemination to skin, bones, joints, CNS is
  rare
• California, Arizona, New Mexico, Texas, Utah,
  northern New Mexico, certain areas of
  Central and South America
• Blastomycosis
• May be asymptomatic or acute, chronic or
  fulminant disease
• Pulmonary and cutaneous lesions
• Can disseminate to bones, CNS, abdominal
  viscera, kidneys
• Southeastern and central states and those
  bordering Great Lakes

87
Question 29

• All of the following are consistent with the
  diagnosis of congenital toxoplasmosis in an
  infant EXCEPT -

• An infant with normal findings on newborn
  evaluation
• An infant who is small for gestational age
• A CSF protein level of 3 g/dL
• An infant whose mother has no serologic evidence
  of Toxoplasma gondii infection
• An infant who mother has AIDS and is chronically
  infected with T. gondii

88
Question 29

• All of the following are consistent with the
  diagnosis of congenital toxoplasmosis in an
  infant EXCEPT -

• An infant with normal findings on newborn
  evaluation
• An infant who is small for gestational age
• A CSF protein level of 3 g/dL
• An infant whose mother has no serologic evidence
  of Toxoplasma gondii infection
• An infant who mother has AIDS and is chronically
  infected with T. gondii

89
Keypoint 29

• Congenital Toxoplasmosis
• Asymptomatic at birth 70-90
• Many will go on to have visual impairment,
  learning disabilities, mental retardation
• At birth, may have maculopapular rash,
  generalized lymphadenopathy, hepatomegaly,
  splenomegaly, jaundice, thrombocytopenia
• CNS manifestations hydrocephalus,
  microcephaly, chorioretinitis, seizures,
  deafness
• Cerebral calcifications are diffuse
• Members of cat family are definitive hosts

90
Question 30

• A 5-month-old previously healthy female is
  brought to her pediatrician because of fever,
  irritability, and poor feeding. She is the
  second child in her daycare center to be
  diagnosed with meningitis within a week. She has
  received all recommended immunizations. The most
  likely cause of her meningitis is -

• Haemophilus influenzae
• Neisseria meningitidis
• Group B streptococci
• Herpes simplex virus
• Listeria monocytogenes

91
Question 30

• A 5-month-old previously healthy female is
  brought to her pediatrician because of fever,
  irritability, and poor feeding. She is the
  second child in her daycare center to be
  diagnosed with meningitis within a week. She has
  received all recommended immunizations.
• The most likely cause of her meningitis is -

• Haemophilus influenzae
• Neisseria meningitidis
• Group B streptococci
• Herpes simplex virus
• Listeria monocytogenes

92
Keypoint 30

• Neisseria Meningitidis
• Children younger than 5, greatest attack rate
  in less than 1 year
• Adolescents 15-18 years
• Freshmen college students who live in
  dormitories
• Close contacts of patients with meningococcal
  disease
• Deficiency of terminal complement, properdin,
  or anatomic or functional asplenia
• A, B, C, Y, W-135
• Meningococcemia, meningitis
• Waterhouse-Friderichsen-purpura, DIC, shock,
  coma, death

93
Question 31

• Of the following drugs, the one most commonly
  associated with acute interstitial nephritis is -

• Sulfisoxazole
• Methicillin
• Nafcillin
• Penicillin
• Phenytoin

94
Question 31

• Of the following drugs, the one most commonly
  associated with acute interstitial nephritis is -

• Sulfisoxazole
• Methicillin
• Nafcillin
• Penicillin
• Phenytoin

95
Keypoint 31

• Antibiotic Complications
• Aminoglycosides
• Amikacin, gentamicin, kanamycin, tobramycin,
  streptomycin
• Ototoxicity and nephrotoxicity
• Ototoxicity destruction of cochlear hair
  cells in the organ of Corti producing a
  high-frequency irreversible hearing loss
  (amikacin, kanamycin)
• Vestibular dysfunction damage to vestibular
  hair cells (streptomycin, gentamicin)
• Can occur early or after cessation of
  antibioticTetracyclines
• Nausea and vomiting are most common
• Hepatotoxicity following high doses,
  intravenous usage, or in pregnancy
• Nephrotoxicity in pre-existing renal disease
• Tetracycline-calcium orthophosphate complex
  that inhibits bone growth in neonates and
  produces teeth staining
• Photosensitivity
• Decreased prothrombin activity
• Overgrowth of resistant bacterial organisms
• Esophageal ulcers
• Intravenous administration pain, phlebitis,
  tissue injury if extravasation occurs

96
Keypoint 31 - continued

• Antibiotic Complications
• Chloramphenicol
• Bone marrow suppression 1. Dose, duration
  related and reversible (gt7 days) elevated serum
  iron, low reticulocyte count, and low
  hemoglobin
• 2. Severe, irreversible, idiosyncratic
  aplastic anemia (occurs anytime during therapy
  or weeks after) Mechanism thought
  to be direct toxicity of nitrosochloramphenicol
  on DNARifamycins
• Rifampin, rifabutin
• Contraindicated in pregnancy
• Orange colored urine, tears and all biologic
  secretions in 80 of patients
• Rapid and potent inducers of CYP3A4, the most
  abundant human cytochrome P450 found
  predominately in the liver and small intestine

97
Keypoint 31 - continued

• Antibiotic Complications
• Sulfonamides
• Rashes are the most common problem
• Acute lgE-medicated hypersensitivity reactions
  and drug-induced lupus erythematosus
  reactions
• Self-resolving granulocytopenia, megaloblastic
  anemia, thrombocytopenia have been described
• Renal failure with crystalluria and reversible
  hepatocellular dysfunction with jaundice have
  been described with sulfamethoxazole
• Aseptic meningitisQuinolones
• Rare adverse reactions arthralgia,
  crystalluria, acute renal failure, antibiotic
  associated colitis, serum sickness like
  reactions, eosinophilia, leukopenia,
  thrombocytopenia
• Not approved for children lt18 years of age
• Interference with cartilage growth in beagle
  puppies
• Human studies in cystic fibrosis patients and
  other infants have failed to show these
  problems

98
Keypoint 31 - continued

• Antibiotic Complications
• Natural Penicillins
• Nonfatal anaphylaxis in adults (1/1000
  exposures)
• Fatal anaphylaxis is rare
• Other hypersensitivity reactions serum
  sickness, cutaneous rashes, contact
  dermatitis
• Allergic reactions seem to be most prominent
  with procaine penicillin (up to 90)
• Other reactions hemolytic anemia,
  interstitial nephritis, seizures, hyperkalemia
  associated with high doses or prolonged
  exposureCephalosporins
• Anaphylaxis
• Hypersensitivity reactions may be compound
  specific (e.g., cefaclor)
• Hypersensitivity reactions include interstitial
  nephritis, autoimmune thrombo- cytopenia,
  pulmonary eosinophilia, serum sickness like
  reaction, drug fever
• Seizures and nephrotoxicity associated with
  high doses and poor renal function
• Gastrointestinal upset is most common with oral
  agents
• Ceftriaxone reversible biliary
  pseudolithiasis and rapidly fatal
  immune-mediated hemolytic anemia

99
Keypoint 31 - continued

• Antibiotic Complications
• Macrolides
• Generalized pruritus, maculopapular rash, serum
  sickness like reactions, erythema multiforme
  major associated with large doses or in patients
  with renal failure
• Intravenous administration has been associated
  with cardiac toxicity (prolonged QT interval,
  ventricular tachycardia, premature ventricular
  contractions, nodal bradycardia, sinus arrest),
  hepatotoxicity, and venous venous irritation
  (rate associated)

100
Question 32

• A gravida 1, para 0 woman is at 38 weeks
  gestation. A vaginal culture taken 48 hours ago
  is now reported positive for herpes simplex, type
  II. Her obstetrician asks your advice concerning
  immediate management of delivery for obstetric
  reasons. You should advise -

• Vaginal delivery after the spontaneous onset of
  labor
• Cesarean delivery before the onset of labor
• Topical treatment with tetramethyl acridine
  followed by phototherapy and vaginal delivery
• Immediate induction of labor and vaginal delivery
• Oral administration of acyclovir to the mother
  and induction of labor and vaginal delivery

101
Question 32

• A gravida 1, para 0 woman is at 38 weeks
  gestation. A vaginal culture taken 48 hours ago
  is now reported positive for herpes simplex, type
  II. Her obstetrician asks your advice concerning
  immediate management of delivery for obstetric
  reasons. You should advise -

• Vaginal delivery after the spontaneous onset of
  labor
• Cesarean delivery before the onset of labor
• Topical treatment with tetramethyl acridine
  followed by phototherapy and vaginal delivery
• Immediate induction of labor and vaginal delivery
• Oral administration of acyclovir to the mother
  and induction of labor and vaginal delivery

102
Keypoint 32

• Neonatal Herpes Infections
• Delivery by C-Section prior to rupture of
  membranes
• Risk of HSV infection at delivery in an infant
  born vaginally to a mother with primary
  infection of 33-50
• If born to a mother with reactivated infection
  of less than 5
• Neonatal HSV may be 1) disseminated
  2) localized to CNS 3) localized
  to skin, eyes, mouth

103
Question 33

• For each of the following sources of
  infection (1,2,3), select the most likely
  associated organism (A,B,C,D,E)

• Francisella tularensis
• Giardia intestinalis
• Toxoplasma gondii
• Trichinella spiralis
• Shigella species
• Contact with cats
• Drinking water
• Rabbit-hunting in American southwest

104
Question 33

• For each of the following sources of
  infection (1,2,3), select the most likely
  associated organism (A,B,C,D,E)

• Francisella tularensis
• Giardia intestinalis
• Toxoplasma gondii
• Trichinella spiralis
• Shigella species
• Contact with cats
• Drinking water
• Rabbit-hunting in American southwest

105
Keypoint 33

• Giardia intestinalis
• Protozoan that exists in trophozoite and cyst
  forms
• Acute watery diarrhea with abdominal pain
• Protracted, intermittent, foul-smelling stools
• Humans are reservoir
• Can infect dogs, cats, beavers that contaminate
  waterTularemia
• Sources are rabbits, hares, prairie dogs,
  muskrats, rats, moles, ticks, livestock
• Abrupt onset fever, chills, myalgia, headache
• Ulceroglandular
• Glandular
• Oropharyngeal
• Intestinal
• Pneumonic

106
Question 34

• Abdominal pain and bloody diarrhea develop
  in a 2-year-old boy after completion of a 10-day
  course of ampicillin for treatment of otitis
  media. The child is febrile and has abdominal
  distention. Results of a complete blood count
  and stool culture are normal. Psuedomembranous
  lesions are noted on sigmoidoscopy of the colon.
  The most appropriate medication for this child
  could be -

• Trimethoprim with sulfamethoxazole
• Metronidazole
• Chloramphenicol
• Erythromycin
• Gentamicin

107
Question 34

• Abdominal pain and bloody diarrhea develop
  in a 2-year-old boy after completion of a 10-day
  course of ampicillin for treatment of otitis
  media. The child is febrile and has abdominal
  distention. Results of a complete blood count
  and stool culture are normal. Psuedomembranous
  lesions are noted on sigmoidoscopy of the colon.
  The most appropriate medication for this child
  could be -

• Trimethoprim with sulfamethoxazole
• Metronidazole
• Chloramphenicol
• Erythromycin
• Gentamicin

108
Keypoint 34

• C. Difficile
• Pseudomembranous colitis diarrhea, abdominal
  cramps, fever, systemic toxicity, abdominal
  tenderness, stools with blood and mucous
• At risk groups for severe or fatal disease are
  leukemics with fever and neutropenia,
  Hirschsprung, IBDTreatment
• Discontinue antibiotics
• In severe disease, if diarrhea persists
  metronidazole, vancomycin

109
Question 35

• The organism most likely responsible for
  meningitis in a 2-week-old infant is -

• Group B streptococcus
• Escherichia coli
• Listeria monocytogenes
• Chlamydia trachomatis
• Staphylococcus aureus

110
Question 35

• The organism most likely responsible for
  meningitis in a 2-week-old infant is -

• Group B streptococcus
• Escherichia coli
• Listeria monocytogenes
• Chlamydia trachomatis
• Staphylococcus aureus

111
Keypoint 35

• Group B Streptococcus
• Major cause of invasive disease birth-3 months
• Early-onset 0-6 days (most in first day)
  respiratory distress, apnea, shock, pneumonia
  and less frequently meningitis
• Late-onset 7 days-3 months (most 3-4 weeks)
  bacteremia, meningitis, osteomyelitis, septic
  arthritis, adenitis, cellulitis
• Pregnant women colonized 15-40
• Maternal intrapartum prophylasix has decreased
  early-onset GBS by 81

112
Question 36

• For each of the following types of
  osteomyelitis (1,2,3), select the most likely
  etiologic agent (A,B,C,D,E) -

• Group B streptococcus
• Pasteurella multocida
• Salmonella
• Pseudomonas aeruginosa
• Hemophilus influenza type b
• Osteomyelitis in a neonate
• Osteomyelitis in children with sickle cell
  disease
• Osteomyelitis in a patient who has received a
  puncture would in the foot through a tennis shoe

113
Question 36

• For each of the following types of
  osteomyelitis (1,2,3), select the most likely
  etiologic agent (A,B,C,D,E) -

• Group B streptococcus
• Pasteurella multocida
• Salmonella
• Pseudomonas aeruginosa
• Hemophilus influenza type b
• Osteomyelitis in a neonate
• Osteomyelitis in children with sickle cell
  disease
• Osteomyelitis in a patient who has received a
  puncture would in the foot through a tennis shoe

114
Question 37

• For each of the following side effects
  (1,2,3), select the most likely associated drug
  (A,B,C,D) -

• Isoniazid
• Rifampin
• Streptomycin
• Ethambutol
• Hepatitis
• Inhibition of the metabolism of oral
  contraceptives
• Optic neuritis

115
Question 37

• For each of the following side effects
  (1,2,3), select the most likely associated drug
  (A,B,C,D) -

• Isoniazid
• Rifampin
• Streptomycin
• Ethambutol
• Hepatitis
• Inhibition of the metabolism of oral
  contraceptives
• Optic neuritis

116
Question 38

• For each of the following diseases or disease
  causing agents (1,2,3,4), select the most
  appropriate chemotherapeutic agent (A,B,C,D,E)

• Podophyllin
• Acyclovir
• Metronidazole
• Trimethoprim withsulfamethoxazole
• Clotrimazole
• Vaginal trichomoniasis
• Vulvovaginal candidosis
• Human papilloma virus
• Primary genital herpes simplex infection

117
Question 38

• For each of the following diseases or disease
  causing agents (1,2,3,4), select the most
  appropriate chemotherapeutic agent (A,B,C,D,E)

• Podophyllin
• Acyclovir
• Metronidazole
• Trimethoprim withsulfamethoxazole
• Clotrimazole
• Vaginal trichomoniasis
• Vulvovaginal candidosis
• Human papilloma virus
• Primary genital herpes simplex infection

118
Keypoint 38

• Trichomonas Vaginalis Infections
• Asymptomatic in 90 of men and 50 of women
• Frothy vaginal discharge and mild vulvovaginal
  itching and burning, pale-yellow to
  green-gray DC, musty odor
• More severe symptoms before menses
• Deeply erythematous vaginal mucousa, friable
  cervix
• Wet-mount prep
• Metronidazole or Tinidazole
• Vulvovaginal Candidiasis
• C. albicans is most common
• Microscopic evaluation and KOH prep
• Topical treatment clotrimazole, miconazole
• Oral agents fluconazole, itraconazole in
  recurrent or refractory cases

119
Keypoint 38

• Human Papilloma Virus
• Condylomata Acuminata skin colored warts with
  a cauliflower-like surface
• In females, occurs in the vulva or perineum,
  cervix, vagina
• In males, penis, scrotum, anus
• Clinically inapparent dysplastic lesions can be
  associated with cancer
• HPV involved in 90 of cervical cancers
• Podophyllum resin, cryotherapy, laser, surgery
• Genital Herpes Simplex Infection
• Primary mild clinical manifestations may go
  on to develop severe or prolonged symptoms
• Treat with acyclovir, valcyclovir, famciclovir
• Recurrent herpes can be treated episodically or
  continuously (6 or more/year)