C. A 43-year-old individual in the Peace Corps working in sub-Saharan Africa has a 10-mm PPD reaction. Eighteen months ago, the PPD reaction was 3 mm.
D. A 55-year-old man who is HIV positive has a negative PPD result. His partner was recently diagnosed with cavitary tuberculosis.
E. A 72-year-old man who is receiving chemotherapy for non-Hodgkin’s lymphoma has a 16-mm PPD reaction.
IV-118. All of the following statements regarding interferon-gamma release assays for the diagnosis of latent tuberculosis are true EXCEPT:
A. There is no booster phenomenon.
B. They are more specific than tuberculin skin testing.
C. They have a higher sensitivity than tuberculin skin testing in high HIV-burden areas.
D. They have less cross reactivity with BCG and non-tuberculous mycobacteria than tuberculin skin testing.
E. They may be used to screen for latent tuberculosis in adults working in low prevalence U.S. settings.
IV-119. All of the following statements regarding BCG vaccination are true EXCEPT:
A. BCG dissemination may occur in severely immune-suppressed patients.
B. BCG vaccination is recommended at birth in countries with high TB prevalence.
C. BCG vaccination may cause a false-positive tuberculin skin test result.
D. BCG vaccine provides protection for infants and children from TB meningitis and miliary disease.
E. BCG vaccine provides protection from TB in HIV-infected patients.
IV-120. A 76-year-old woman is brought into the clinic by her son. She complains of a chronic nonproductive cough and fatigue. Her son adds that she has had low-grade fevers, progressive weight loss over months, and “just doesn’t seem like herself.” A representative slice from her chest CT is shown in Figure IV-120. She was treated for tuberculosis when she was in her 20s. A sputum sample is obtained, as are blood cultures. Two weeks later, both culture sets grow acid-fast bacilli consistent with Mycobacterium avium complex. Which of the following is the best treatment option?
A. Bronchodilators and pulmonary toilet
B. Clarithromycin, ethambutol, and rifampin
C. Clarithromycin and rifampin
D. Moxifloxacin and rifampin
E. Pyrazinamide, isoniazid, rifampin, and ethambutol
IV-121. All of the following statements regarding antituberculosis therapeutic agents are true EXCEPT:
A. In the United States, M. tuberculosis resistance to isoniazid remains below 10%.
B. Optic neuritis is the most severe adverse effect of ethambutol.
C. Pyrazinamide has utility in the therapy of M. avium complex and M. kansasii infections.
D. Rifabutin should be used instead of rifampin in patients receiving concurrent treatment with protease inhibitors or nevirapine.
E. Rifampin can decrease the half-life of warfarin, cyclosporine, prednisone, oral contraceptives, clarithromycin, and other important drugs.
IV-122. Which of the following patients with latent syphilis should undergo lumbar puncture for assessment of possible neurosyphilis?
A. A 24-year-old woman with an RPR titer of 1:128
B. A 38-year-old man with an RPR titer of 1:32 who was treated with benzathine G penicillin 2.4 million units intramuscularly. Repeat RPR titer 12 months after treatment is 1:16.
C. A 46-year-old man with HIV and a CD4 count of 150/μL
D. A 62-year-old woman with Bell’s palsy and a recent change in mental status
E. All of the above
IV-123. An 18-year-old man presents with a firm, nontender lesion around his anal orifice. The lesion is about 1.5 cm in diameter and has a cartilaginous feel on clinical examination. The patient reports that it has progressed to this stage from a small papule. It is not tender. He reports recent unprotected anal intercourse. Bacterial culture result of the lesion is negative. A rapid plasmin reagin (RPR) test result is also negative. Therapeutic interventions should include:
A. Acyclovir 200 mg orally 5 times per day
B. Ceftriaxone 1 g intramuscularly
D. Penicillin G benzathine 2.4 million U intramuscularly
E. Surgical resection with biopsy
IV-124. A 46-year-old man presents to the emergency department in Honolulu, Hawaii, with myalgias, malaise, and fevers. He is homeless and has alcoholism and frequently sleeps in alleys that are infested with rats. He recalls blacking out from alcohol ingestion and waking with his legs in a fetid pool. He noted scratches and bites around his ankles about 2 weeks ago. Since that time, he has felt increasingly
more ill. For the past day, he has also noted that his skin is increasingly yellow. In addition to alcohol abuse, he has a medical history of schizophrenia and smokes 1 to 2 packs of cigarettes daily. He currently receives olanzapine as an intramuscular injection at a dose of 300 mg monthly. On initial evaluation, his temperature is 38.6°C, pulse is 105 beats/min, respiratory rate is 24/min, and blood pressure is 98/59 mmHg with O2 saturations of 92% on room air. He appears acutely ill and markedly
jaundiced. His conjunctivae are injected bilaterally without discharge. Bibasilar crackles are present. His liver is enlarged and tender, but no splenomegaly is present. Laboratory results are notable for a BUN of 64 mg/dL, creatinine of 3.6 mg/dL, total bilirubin of 32.4 mg/dL, direct bilirubin of 29.8 mg/dL, AST of 80 U/L, ALT of 184 U/L, and alkaline phosphatase of 168 U/L. His complete blood count shows a white blood cell count of 12,500/μL with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets of 82,000/μL. Urinalysis reveals 20 white blood cells per high-power field, 3+ protein, and no casts. Coagulation study results are within normal limits. CT scan of the chest shows diffuse flame-like infiltrates consistent with pulmonary hemorrhage. What is the likely diagnosis?
A. Acute alcoholic hepatitis
B. Disseminated intravascular coagulation due to Streptococcus pneumoniae infection
C. Microscopic polyangiitis
D. Rat bite fever (Streptobacillus moniliformis infection)
E. Weil’s syndrome (Leptospira interrogans infection)
IV-125. A 26-year-old man presents to your office complaining of recurrent episodes of fever and malaise. He returned from a camping trip in the northwestern part of Montana about 3 weeks ago. While he was hiking, he denies eating or drinking any unpasteurized milk products. He sterilized all of his water before drinking. He had multiple insect bites, but did not identify any ticks. He primarily slept in cabins or tents and did not notice any rodent droppings in the areas where he camped. Two friends that accompanied him on the trip have not been ill. He initially experienced fevers as high as 104.7°F (40.4°C) with myalgias, headache, nausea, vomiting, and diarrhea beginning 5 days after his return home. These symptoms lasted for about 3 days and resolved spontaneously. He attributed his symptoms to the “flu” and returned to his normal functioning. Seven days later, the fevers returned with temperatures to 105.1°F (40.6°C). With these episodes, his family noted him to have intermittent confusion. Today is day 4 of his current illness, and the patient feels that his fevers have again subsided. What is the most likely cause of the patient’s recurrent fevers?
B. Colorado tick fever
D. Lymphocytic choriomeningitis
E. Tickborne relapsing fever
IV-126. A 36-year-old man presents to the emergency department in Pennsylvania complaining of lightheadedness and dizziness. On physical examination, the patient is found to have a heart rate of 38 beats/min, and the ECG demonstrates acute heart block. On further questioning, he reports that he lives in a wooded area. He has two dogs that often roam in the woods and have been found with ticks on many occasions. He takes no medications and is otherwise healthy. He is an avid hiker and is also
training for a triathlon. He denies any significant childhood illness. His family history is positive for an acute myocardial infarction in his father at age 42 years. His physical examination is normal with the exception of a slow but regular heartbeat. His chemistry panel shows no abnormalities. His chest radiograph is normal. What is the most likely cause of complete heart block in this individual?
A. Acute myocardial infarction
B. Chagas disease
C. Lyme disease
E. Subacute bacterial endocarditis
IV-127. Borrelia burgdorferi serology testing is indicated for which of the following patients, all of whom reside in Lyme-endemic regions?
A. 19-year-old female camp counselor who presents with her second episode of an inflamed, red, and tender left knee and right ankle
B. A 23-year-old male house painter who presents with a primary erythema migrans lesion at the site of a witnessed tick bite
C. A 36-year-old female state park ranger who presents with a malar rash; diffuse arthralgias or arthritis of her shoulders, knees, and metacarpophalangeal and proximal interphalangeal joints; pericarditis; and acute glomerulonephritis
D. A 42-year-old woman with chronic fatigue, myalgias, and arthralgias
E. A 46-year-old male gardener who presents with fevers, malaise, migratory arthralgias or myalgias, and three erythema migrans lesions
IV-128. A previously healthy 17-year-old woman presents in early October with profound fatigue and malaise, as well as fevers, headache, nuchal rigidity, diffuse arthralgias, and a rash. She lives in a small town in Massachusetts and spent her summer as a camp counselor at a local day camp. She participated in daily hikes in the woods but did not travel outside of the area during the course of the summer. Physical examination reveals a well-developed young woman who appears extremely fatigued but not in extremis. Her temperature is 37.4°C, pulse is 86 beats/min, blood pressure is 96/54 mmHg, and respiratory rate is 12 breaths/min. Physical examination documents clear breath sounds, no cardiac rub or murmur, normal bowel sounds, a nontender abdomen, no organomegaly, and no evidence of synovitis. Several erythema migrans lesions are noted on her lower extremities, bilateral axillae, right thigh, and left groin. All of the following are possible complications of her current disease state EXCEPT:
A. Bell’s palsy
B. Large joint oligoarticular arthritis
D. Progressive dementia
E. Third-degree heart block
IV-129. In the patient described above, which of the following is appropriate therapy? A. Azithromycin, 500 mg PO daily
B. Ceftriaxone, 2 g IV daily
C. Cephalexin, 500 mg PO bid
D. Doxycycline, 100 mg PO bid
E. Vancomycin, 1 g IV bid
IV-130. A 48-year-old man is admitted to the intensive care unit in July with hypotension and fever. He lives in a suburban area of Arkansas. He became ill yesterday with a fever as high as 104.0°F (40.0°C). Today, his wife noted increasing confusion and lethargy. Over this same time, he has complained of headaches and myalgias. He has had nausea with two episodes of vomiting. Before the acute onset of illness, he had no medical complaints. He has no other medical history and takes no medications. He works as a landscape architect. The history is obtained from the patient’s wife, and she does not know if he has had any recent insect or tick bites. No one else in the family is ill, nor are the patient’s coworkers. On presentation, the vital signs are blood pressure of 88/52 mmHg, heart rate of 135 beats/min, respiratory rate of 22 breaths/min, temperature 101.9°F (38.8°C), and oxygen saturation of 94% on room air. His physical examination reveals an ill-appearing man, moaning quietly. He is oriented to person only. No meningismus is present. His cardiac examination reveals regular tachycardia. His chest and abdominal examinations are normal. He has no rash. His laboratory values are as follows:
He is fluid resuscitated and treated with intravenous ceftriaxone and vancomycin. A lumbar puncture shows no pleocytosis with normal protein and glucose. Despite this treatment, the patient develops worsening thrombocytopenia, neutropenia, and lymphopenia over the next 2 days. A bone marrow biopsy shows a hypercellular marrow with noncaseating granulomas. Which test is most likely to suggest the cause of the patient’s illness?
A. Antibodies to double-stranded DNA and Smith antigens
B. Chest radiography
C. Levels of IgM and IgG on cerebrospinal fluid
D. Peripheral blood smear
E. Polymerase chain reaction on peripheral blood
IV-131. A 27-year-old woman who lives in North Carolina presents to her primary care physician complaining of fever, headache, myalgias, nausea, and anorexia 7 days after returning from hiking on the Appalachian Trail. Physical examination is remarkable for a temperature of 101.5°F (38.6°C). She appears generally fatigued but not toxic. She does not have a rash. She is reassured by her primary care physician that this likely represents a viral illness. She returns to clinic 3 days later with a progressive rash and ongoing fevers. She states that small red spots began to appear on her wrists and ankles within 24 hours of her previous visit and have now progressed up her extremities and onto her trunk. She also is noting increasing headache, and her husband thinks she has had some confusion. On physical examination, the patient is noted to be lethargic and answers questions slowly. What would be a reasonable course of action?
A. Admit the patient to the hospital for treatment with intravenous ceftriaxone 1 g twice daily and vancomycin 1 g twice daily.
B. Admit the patient to the hospital for treatment with doxycycline 100 mg twice daily.
C. Initiate treatment with doxycycline 100 mg orally twice daily as an outpatient.
D. Initiate treatment with trimethoprim–sulfamethoxazole DS twice daily.
E. Order rickettsial serologies and withhold treatment until a firm diagnosis is made.
IV-132. A previously healthy 20-year-old college student presents in September with several days of headache, extensive cough with scant sputum, and fever of 101.5°F (38.6°C). Several individuals in his dormitory have also been ill with a similar illness. On examination, pharyngeal erythema is noted, and lung examination reveals bilateral expiratory wheezing and scattered crackles in the lower lung zones. He coughs frequently during the examination. Chest radiography reveals bilateral peribronchial pneumonia with increased interstitial markings. No lobar consolidation is seen. Which organism is most likely to cause the patient’s presentation?
B. Chlamydia pneumoniae
C. Legionella pneumophila
D. Mycoplasma pneumoniae
E. Streptococcus pneumoniae
IV-133. A previously healthy 19-year-old man presents with several days of headache, cough with scant sputum, dyspnea, and fever of 38.6°C. On examination, pharyngeal erythema is noted, and lung fields show scattered wheezes and some crackles. Chest radiography reveals focal bronchopneumonia in the lower lobes. His hematocrit is 24.7%, down from a baseline measure of 46%. The only other laboratory abnormality is an indirect bilirubin of 3.4. A peripheral smear reveals no abnormalities. A cold agglutinin titer is measured at 1:64. What is the most likely infectious agent?
A. Coxiella burnetii
B. Legionella pneumophila
C. Methicillin-resistant Staphylococcus aureus
D. Mycoplasma pneumoniae
E. Streptococcus pneumoniae
IV-134. A 42-year-old woman is admitted to the intensive care unit with hypoxemic respiratory failure
and pneumonia in August. She was well until 2 days before admission, when she developed fevers, myalgias, and headache. She works in a poultry processing plant and is originally from El Salvador. She has been in the United States for 15 years. She has no major health problems. Her PPD result was negative upon arrival to the United States. Several other workers have been ill with a similar illness, although no one else has developed respiratory failure. She is currently intubated and sedated. Her oxygen saturation is 93% on an FiO2 of 0.80 and positive end-expiratory pressure of 12 cm H2O. On physical examination, crackles are present in both lung fields. There is no cardiac murmur. Hepatosplenomegaly is present. Laboratory studies reveal a mild transaminitis. The influenza nasal swab result is negative for the presence of influenza A. Which of the following test results is most likely to be positive in this patient?
A. Acid-fast bacilli stain and mycobacterial culture for Mycobacterium tuberculosis
B. Blood cultures growing Staphylococcus aureus
C. Microimmunofluorescence testing for Chlamydia psittaci
D. Urine Legionella antigen
E. Viral cultures of bronchoscopic samples for influenza A
IV-135. A 20-year-old woman is 36 weeks pregnant and presents for her first evaluation. She is diagnosed with Chlamydia trachomatis infection of the cervix. Upon delivery, for what complication is her infant most at risk?
C. Hutchinson triad
E. Sensorineural deafness
IV-136. A 19-year-old man presents to an urgent care clinic with urethral discharge. He reports three new female sexual partners over the past 2 months. What should his management be?
A. Nucleic acid amplification test for Neisseria gonorrhoeae and Chlamydia trachomatis and return to clinic in 2 days
B. Ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient and his recent partners
C. Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient
D. Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1 and azithromycin 1 g PO × 1 for the patient and his recent partners
E. Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus ceftriaxone 250 mg IM × 1, azithromycin 1 g PO × 1, and Flagyl 2 g PO × 1 for the patient and his partners
IV-137. All of the following viruses have been implicated as a cause of human cancer EXCEPT:
A. Dengue fever virus
B. Epstein-Barr virus
C. Hepatitis B virus
D. Hepatitis C virus
E. Human papillomavirus
IV-138. All of the following antiviral medications are correctly matched with a significant side effect EXCEPT:
A. Acyclovir—thrombotic thrombocytopenic purpura
B. Amantadine—anxiety and insomnia
C. Foscarnet—acute renal failure
D. Ganciclovir—bone marrow suppression
E. Interferon—fevers and myalgias
IV-139. All of the following regarding herpes simplex virus-2 (HSV-2) infection are true EXCEPT:
A. Approximately one in five Americans harbors HSV-2 antibodies.
B. Asymptomatic shedding of HSV-2 in the genital tract occurs nearly as frequently in those with no symptoms as in those with ulcerative disease.
C. Asymptomatic shedding of HSV-2 is associated with transmission of virus.
D. HSV-2 seropositivity is an independent risk factor for HIV transmission.
E. Seroprevalence rates of HSV-2 are lower in Africa than in the United States.
IV-140. A 23-year-old woman is newly diagnosed with genital herpes simplex virus-2 (HSV-2) infection. What can you tell her that the chance of reactivation disease will be during the first year after infection?
IV-141. A 65-year-old man is brought to the hospital by his wife because of new onset of fever and confusion. He was well until 3 days ago but then developed a high fever, somnolence, and progressive confusion. His current medical history is unremarkable except for an elevated cholesterol level, and his only medication is atorvastatin. He is a civil engineer at an international construction company. His wife reports that he obtains regular health screening and has always been PPD negative. On admission, his temperature is 40°C, and his vital signs are otherwise normal. He is confused and hallucinating. Soon after admission, he develops a tonic-clonic seizure that requires lorazepam to terminate. His head CT shows no acute bleeding or elevated ICP. An EEG shows an epileptiform focus in the left temporal lobe, and diffusion-weighted MRI shows bilateral temporal lobe inflammation. Which of the following is most likely to be diagnostic?
A. CSF acid-fast staining
B. CSF India ink stain
C. CSF PCR for herpes virus
D. CSF oligoclonal band testing
E. Serum cryptococcal antigen testing
IV-142. Which of the following statements regarding administration of varicella-zoster vaccine to patients above the age of 60 is true?
A. It is a killed virus vaccine, so it is safe in immuno-compromised patients.
B. It is not recommended for patients in this age group.
C. It will decrease the risk of developing postherpetic neuralgia.
D. It will not decrease the risk of developing shingles.
E. It will not decrease the burden of disease.
IV-143. A 19-year-old college student comes to clinic reporting that he has been ill for 2 weeks. About 2 weeks ago, he developed notable fatigue and malaise that prevented him from his usual exercise regimen and caused him to miss some classes. Last week, he developed low-grade fevers, sore throat, and swollen lymph nodes in his neck. He has a history of strep pharyngitis, so 3 days ago, he took some ampicillin that he had in his possession. Over the past 2 days, he has developed a worsening slightly itchy rash as shown in Figure IV-143. His physical examination is notable for a temperature of 38.1°C, pharyngeal erythema, bilateral tonsillar enlargement without exudates, bilateral tender cervical adenopathy, and a palpable spleen. All of the following statements regarding his illness are true EXCEPT:
FIGURE IV-143 (see Color Atas)
A. Greater than 10% atypical lymphocytosis is likely.
B. Heterophile antibody testing will likely be diagnostic.
C. If the heterophile antibody test result is negative, testing for IgG antibodies against viral capsid antigen will likely be diagnostic.
D. It is spread via contaminated saliva.
E. The patient can receive ampicillin in the future if indicated.
IV-144. In the patient described above, which of the following is indicated treatment?
B. Acyclovir plus prednisone
E. Rest, supportive measures, and reassurance
IV-145. Which of the following manifestations of cytomegalovirus (CMV) infection is least likely to occur after lung transplantation?
A. Bronchiolitis obliterans
B. CMV esophagitis
C. CMV pneumonia
D. CMV retinitis
E. CMV syndrome (fever, malaise, cytopenias, transaminitis, and CMV viremia)
IV-146. Which of the following serology patterns places a transplant recipient at the lowest risk of developing cytomegalovirus (CMV) infection after renal transplantation?
A. Donor CMV IgG negative; recipient CMV IgG negative.
B. Donor CMV IgG negative; recipient CMV IgG positive.
C. Donor CMV IgG positive; recipient CMV IgG negative.
D. Donor CMV IgG positive; recipient CMV IgG positive.
E. The risk is equal regardless of serology results.
IV-147. All of the following statements regarding human herpes virus-8 (HHV-8) are true EXCEPT:
A. It has been implicated causally in invasive cervical carcinoma.
B. It has been implicated causally in Kaposi’s sarcoma.
C. It has been implicated causally in multicentric Castleman’s disease.
D. It has been implicated causally in primary pleural lymphoma.
E. Primary infection may manifest with fever and maculopapular rash.
IV-148. All of the following clinical findings are consistent with the diagnosis of molluscum contagiosum EXCEPT:
A. Involvement of the genitals
B. Involvement of the soles of the feet
C. Lack of inflammation or necrosis at the site of the rash
D. Rash associated with an eczematous eruption
E. Rash spontaneously resolving over 3 to 4 months
IV-149. A 42-year-old man with AIDS and a CD4+ lymphocyte count of 23 cells/mm3 presents with shortness of breath and fatigue in the absence of fevers. On examination, he appears chronically ill with pale conjunctiva. Hematocrit is 16%. Mean corpuscular volume is 84/fl. Red blood cell distribution width is normal. Bilirubin, lactose dehydrogenase, and haptoglobin are all within normal limits. Reticulocyte count is zero. White blood cell count is 4300/μL with an absolute neutrophil count of 2500. Platelet count is 105,000/ul. Which of the following tests is most likely to produce a diagnosis?
A. Bone marrow aspirate and biopsy
B. Parvovirus B19 IgG
C. Parvovirus B19 polymerase chain reaction
D. Parvovirus B19 IgM
E. Peripheral blood smear
IV-150. A 22-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists. Two weeks earlier, she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. Which of the following tests is most likely to reveal her diagnosis?
A. Antinuclear antibody
B. Chlamydia trachomatis ligase chain reaction of the urine
C. Joint aspiration for crystals and culture
D. Parvovirus B19 IgM
E. Rheumatoid factor
IV-151. Which of the following statements regarding the currently licensed human papillomavirus (HPV) vaccines is true?
A. Both protect against genital warts.
B. After becoming sexually active, women will derive little protective benefit from vaccination.
C. They are inactivated live virus vaccines.
D. They are targeted toward all oncogenic strains of HPV but are only 70% effective at decreasing infection in an individual.
E. Vaccinees should continue to receive standard Pap smear testing.
IV-152. A 32-year-old woman experiences an upper respiratory illness that began with rhinorrhea and nasal congestion. She also is complaining of a sore throat but has no fever. Her illness lasts for about 5 days and resolves. Just before her illness, her 4-year-old child who attends day-care also experienced a similar illness. All of the following statements regarding the most common etiologic agent causing this illness are true EXCEPT:
A. After the primary illness in a household, a secondary case of illness will occur in 25% to 70% of cases.
B. The seasonal peak of the infection is in early fall and spring in temperate climates.
C. The virus can be isolated from plastic surfaces up to 3 hours after exposure.
D. The virus grows best at a temperature of 37°C, the temperature within the nasal passages.
E. The virus is a single-stranded RNA virus of the Picornaviridae family.
IV-153. All of the following respiratory viruses is a cause of the common cold syndrome in children or adults EXCEPT:
D. Human respiratory syncytial viruses
IV-154. All of the following viruses are correctly matched with their primary clinical manifestations EXCEPT:
B. Coronavirus—Severe acute respiratory syndrome
C. Human respiratory syncytial virus—Bronchiolitis in infants and young children
E. Rhinovirus—Common cold
IV-155. A 9-month-old infant is admitted to the hospital with a febrile respiratory illness with wheezing and cough. Upon admission to the hospital, the baby is tachypneic and tachycardic with an oxygen saturation of 75% on room air. Rapid viral diagnostic testing confirms the presence of human respiratory syncytial virus. All of the following treatments should be used as part of the treatment plan for this child EXCEPT:
A. Aerosolized ribavirin
C. Immunoglobulin with high titers of antibody directed against human respiratory syncytial virus