E. Oxygen therapy to maintain oxygen saturation greater than 90%
IV-156. In March 2009, the H1N1 strain of the influenza A virus emerged in Mexico and quickly spread worldwide over the next several months. Ultimately, more than 18,000 people died from the pandemic. This virus had genetic components of swine influenza viruses, an avian virus, and a human influenza virus. The genetic process by which this pandemic strain of influenza A emerged is an example of:
A. Antigenic drift
B. Antigenic shift
C. Genetic reassortment
D. Point mutation
E. B and C
IV-157. A 65-year-old woman is admitted to the hospital in January with a 2-day history of fevers, myalgias, headache, and cough. She has a history of end-stage kidney disease, diabetes mellitus, and hypertension. Her medications include darbepoetin, selamaver, calcitriol, lisinopril, aspirin, amlodipine, and insulin. She receives hemodialysis three times weekly. Upon admission, her blood pressure is 138/65 mmHg, heart rate is 122 beats/min, temperature is 39.4°C, respiratory rate is 24 breaths/min, and oxygen saturation is 85% on room air. On physical examination, diffuse crackles are heard, and a chest radiograph confirms the presence of bilateral lung infiltrates concerning for pneumonia. It is known that the most common cause of seasonal influenza in this area is an H3N2 strain of influenza A. All of the following should be included in the initial management of this patient EXCEPT:
B. Assessment of the need for close household contacts to receive chemoprophylaxis if influenza swab result is positive
C. Droplet precautions
D. Nasal swab for influenza
E. Oxygen therapy
IV-158. In which of the following individuals has the intranasal influenza vaccine been determined to be safe and effective?
A. A 3-year-old child who was hospitalized on one occasion for wheezing in association with human respiratory syncytial virus infection at 9 months of age
B. A 32-year-old woman who is currently 32 weeks pregnant
C. A 42-year-old registered nurse who had a known exposure to an individual with pandemic H1N1 who is currently receiving chemoprophylaxis with oseltamivir. He does not have contact with transplant, oncology, or HIV-positive patients.
D. A 48-year-old hematologist whose primary specialty is bone marrow transplant
E. A 69-year-old man with hypertension
IV-159. A 17-year-old woman with a medical history of mild intermittent asthma presents to your clinic in February with several days of cough, fever, malaise, and myalgias. She notes that her symptoms started 3 days earlier with a headache and fatigue and that several students and teachers at her high school have been diagnosed recently with “the flu.” She did not receive a flu shot this year. Which of the following medication treatment plans is the best option for this patient?
A. Aspirin and a cough suppressant with codeine
B. Oseltamivir, 75 mg PO bid for 5 days
C. Rimantadine, 100 mg PO bid for 1 week
D. Symptom-based therapy with over-the-counter agents
E. Zanamivir, 10 mg inhaled bid for 5 days
IV-160. All of the following statements regarding human T-cell lymphotropic virus-I (HTLV-I) infection are true EXCEPT:
A. Acute T-cell leukemia is associated with HTLV-I infection.
B. HTLV-I endemic regions include southern Japan, the Caribbean, and South America.
C. HTLV- I infection is associated with a gradual decline in T-cell function and immunosuppression.
D. HTLV-I is transmitted parenterally, sexually, and from mother to child.
E. Tropical spastic paraparesis is associated with HTLV-I infection.
IV-161. A 28-year-old man is diagnosed with HIV infection during a clinic visit. He has no symptoms of opportunistic infection. His CD4+ lymphocyte count is 150/μL. All of the following are approved regimens for primary prophylaxis against Pneumocystis jiroveci infection EXCEPT:
A. Aerosolized pentamidine, 300 mg monthly
B. Atovaquone, 1500 mg PO daily
C. Clindamycin, 900 mg PO q8h, plus primaquine, 30 mg PO daily
D. Dapsone, 100 mg PO daily
E. Trimethoprim–sulfamethoxazole, 1 single-strength tablet PO daily
IV-162. All of the following statements regarding HIV epidemiology in the United States as of 2010 are true EXCEPT:
A. Most patients in the United States with HIV infection are nonwhite.
B. The annual number of AIDS-related deaths has fallen since 1995.
C. The percentage of AIDS cases attributed to male-to-male transmission has fallen steadily since 1985.
D. The proportion of prevalent HIV cases caused by injection drug use is currently decreasing.
E. Up to 20% of patients in the United States are unaware of being infected with HIV.
IV-163. Which of the following scenarios is most likely associated with the lowest risk of HIV transmission to a health care provider after an accidental needle stick from a patient with HIV?
A. The needle is visibly contaminated with the patient’s blood.
B. The needle stick injury is a deep tissue injury to the health care provider.
C. The patient whose blood is on the contaminated needle has been on antiretroviral therapy for many years with a history of resistance to many available agents but most recently has had successful viral suppression on current therapy.
D. The patient whose blood is on the contaminated needle was diagnosed with acute HIV infection 2 weeks ago.
IV-164. Abacavir is a nucleoside transcription inhibitor that carries which side effect unique for HIV antiretroviral agents?
A. Fanconi’s anemia
C. Lactic acidosis
E. Severe hypersensitivity reaction
IV-165. A 38-year-old man with HIV/AIDS presents with 4 weeks of diarrhea, fever, and weight loss. Which of the following tests makes the diagnosis of cytomegalovirus (CMV) colitis?
A. CMV IgG
B. Colonoscopy with biopsy
C. Serum CMV polymerase chain reaction
D. Stool CMV antigen
E. Stool CMV culture
IV-166. A 40-year-old man is admitted to the hospital with 2 to 3 weeks of fever, tender lymph nodes,
and right upper quadrant abdominal pain. He reports progressive weight loss and malaise over 1 year. On examination, he is found to be febrile and frail with temporal wasting and oral thrush. Matted, tender anterior cervical lymphadenopathy smaller than 1 cm and tender hepatomegaly are noted. He is diagnosed with AIDS (CD4+ lymphocyte count = 12/μL and HIV RNA = 650,000 copies/mL). Blood cultures grow Mycobacterium avium. He is started on rifabutin and clarithromycin, as well as dapsone for Pneumocystis prophylaxis, and discharged home 2 weeks later after his fevers subside. He follows up with an HIV provider 4 weeks later and is started on tenofovir, emtricitabine, and efavirenz. Two weeks later, he returns to clinic with fevers, neck pain, and abdominal pain. His temperature is 39.2°C, heart rate is 110 beats/min, blood pressure is 110/64 mmHg, and oxygen saturations are normal. His cervical nodes are now 2 cm in size and extremely tender, and one has fistulized to his skin and is draining yellow pus that is acid-fast bacillus stain positive. His hepatomegaly is pronounced and tender. What is the most likely explanation for his presentation?
A. Cryptococcal meningitis
B. HIV treatment failure
C. Immune reconstitution syndrome to Mycobacterium avium
D. Kaposi’s sarcoma
E. Mycobacterium avium treatment failure caused by drug resistance
IV-167. Per-coital rate of HIV acquisition in a man who has unprotected sexual intercourse with an HIV-infected female partner is likely to increase under which of the following circumstances?
A. Acute HIV infection in the female partner
B. Female herpes simplex virus (HSV-2)–positive serostatus
C. Male nongonococcal urethritis at the time of intercourse
D. Uncircumcised male status
E. All of the above
IV-168. Current Centers for Disease Control and Prevention recommendations are that screening for HIV be performed in which of the following?
A. All high-risk groups (injection drug users, men who have sex with men, and high-risk heterosexual women)
B. All U.S. adults
C. Injection drug users
D. Men who have sex with men
E. Women who have sex with more than two men per year
IV-169. A 38-year-old woman is seen in the clinic for a decrease in cognitive and executive function. Her husband is concerned because she is no longer able to pay bills, keep appointments, or remember important dates. She also seems to derive considerably less pleasure from caring for her children and her hobbies. She is unable to concentrate for long enough to enjoy movies. This is a clear change from her functional status 6 months prior. A workup reveals a positive HIV antibody by enzyme immunoassay and Western blot. Her CD4+ lymphocyte count is 378/μL with a viral load of 78,000/mL. She is afebrile with normal vital signs. Her affect is blunted, and she seems disinterested in the medical interview. Neurologic examination for strength, sensation, cerebellar function, and cranial nerve
function is nonfocal. Funduscopic examination is normal. Mini-Mental Status Examination score is 22 of 30. A serum rapid plasmin reagin (RPR) test result is negative. MRI of the brain shows only cerebral atrophy disproportionate to her age but no focal lesions. What is the next step in her management?
A. Antiretroviral therapy
B. Cerebrospinal fluid (CSF) JV virus polymerase chain reaction (PCR)
C. CSF mycobacterial PCR
D. CSF VDRL test
E. Serum cryptococcal antigen
F. Toxoplasma IgG
IV-170. Indinavir is a protease inhibitor that carries which side effect unique for HIV antiretroviral agents?
A. Abnormal dreams
B. Benign hyperbilirubinemia
C. Hepatic necrosis in pregnant women
IV-171. In an HIV-infected patient, Isospora belli infection is different from Cryptosporidium infection in which of the following ways?
A . Isospora causes a more fulminant diarrheal syndrome, leading to rapid dehydration and even death in the absence of rapid rehydration.
B. Isospora infection may cause biliary tract disease, but cryptosporidiosis is strictly limited to the lumen of the small and large bowel.
C. Isospora spp. are more likely to infect immuno-competent hosts than Cryptosporidium spp. D . Isospora spp. are less challenging to treat and generally respond well to trimethoprim– sulfamethoxazole treatment. E. Isospora spp. occasionally cause large outbreaks among the general population.
IV-172. A 27-year-old man presents to your clinic with 2 weeks of sore throat, malaise, myalgias, night sweats, fevers, and chills. He visited an urgent care center and was told that he likely had the flu. He was told that he had a “negative test for mono.” The patient is homosexual and states that he is in a monogamous relationship and has unprotected receptive and insertive anal and oral intercourse with one partner. He had several partners before his current partner 4 years ago but none recently. He reports a negative HIV-1 test 2 years ago and recalls being diagnosed with Chlamydia infection 4 years ago. He is otherwise healthy with no medical problems. You wish to rule out the diagnosis of acute HIV. Which blood test should you order?
A. CD4+ lymphocyte count
B. HIV enzyme immunoassay (EIA)/Western blot combination testing
C. HIV resistance panel
D. HIV RNA by polymerase chain reaction (PCR)
E. HIV RNA by ultrasensitive PCR
IV-173. A 47-year-old woman with known HIV/AIDS (CD4+ lymphocyte, 106/μL and viral load, 35,000/mL) presents with painful growths on the side of her tongue as shown in Figure IV-173. What is the most likely diagnosis?
FIGURE IV-173 (see Color Atas)
A. Aphthous ulcers
B. Hairy leukoplakia
C. Herpes stomatitis
D. Oral candidiasis
E. Oral Kaposi’s sarcoma
IV-174. Which of the following patients should receive HIV antiretroviral therapy?
A. A 24-year-old man with newly diagnosed acute HIV infection by viral PCR
B. A 44-year-old man who reports having unprotected anal intercourse with another man who has active HIV infection
C. A 26-year-old pregnant women found at screening to have HIV infection of unknown duration and a CD4 lymphocyte count of 700/μL
D. A 51-year-old man found to at screening to have HIV infection of unknown duration and a CD4 lymphocyte count of 150/μL
E. All of the patients should receive antiretroviral therapy
IV-175. All of the following statements regarding antiretroviral therapy for HIV are true EXCEPT:
A. CD4+ lymphocyte count should rise by more than 100 cells/mm3 within 2 months of initiation of therapy.
B. Intermittent administration regimens have equivalent efficacy to constant administration regimens.
C. Plasma HIV RNA should fall by 1 log order within 2 months of initiation of therapy.
D. Recommended initial regimens include three drugs.
E. Viral genotype should be checked before initiation of therapy.
IV-176. All of the following statements regarding Norwalk virus gastroenteritis are true EXCEPT:
A. Fever is common.
B. Incubation period is typically 5 to 7 days.
C. Infection is common worldwide.
D. It is a major cause of nonbacterial diarrhea outbreaks in the United States.
E. Transmission is typically fecal–oral.
IV-177. All of the following statements regarding rotavirus gastroenteritis are true EXCEPT:
A. Fever occurs in more than 25% of cases.
B. Inflammatory diarrhea distinguishes rotaviral illness from Norwalk agent gastroenteritis.
C. It is a major cause of diarrheal death among children in the developing world.
D. Nausea is common.
E. Vaccination is recommended for all children in the United States.
IV-178. A 9-year-old boy is brought to a pediatric emergency department by his father. He has had 2 days of headache, neck stiffness, and photophobia and this morning had a temperature of 38.9°C (102°F). He has also had several episodes of vomiting and diarrhea overnight. A lumbar puncture is performed, which reveals pleocytosis in the cerebrospinal fluid (CSF). Which of the following is true regarding enteroviruses as a cause of aseptic meningitis?
A. An elevated CSF protein level rules out enteroviruses as a cause of meningitis.
B. Enteroviruses are responsible for up to 90% of aseptic meningitis in children.
C. Lymphocytes will predominate in the CSF early on, with a shift to neutrophils at 24 hours.
D. Symptoms are more severe in children than in adults.
E. They occur more commonly in the winter and spring.
FIGURE IV-179 (see Color Atas)
A. Candida albicans
IV-179. A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F); sore throat; dysphagia; and a number of grayish-white papulovesicular lesions on the soft palate, uvula, and anterior pillars of the tonsils (see Figure IV-179). The patient is most likely infected with which of the following?
E. Staphylococcus lugdunensis
IV-180. The human enterovirus family includes poliovirus, coxsackieviruses, enteroviruses, and echovirus. Which of the following statements regarding viral infection with one of the members of this group is true?
A. Among children infected with poliovirus, paralysis is common.
B. Enteroviruses are not transmitted via blood transfusions and insect bites.
C. In utero exposure to maternal enteroviral antibodies is not protective.
D. Infections are most common in adolescents and adults, although serious illness is most common in young children.
E. Paralysis from poliovirus infection was more commonly seen in developing countries.
IV-181. A 23-year-old previously healthy female letter carrier works in a suburb in which the presence of rabid foxes and skunks has been documented. She is bitten by a bat, which then flies away. Initial examination reveals a clean break in the skin in the right upper forearm. She has no history of receiving treatment for rabies and is unsure about vaccination against tetanus. The physician should:
A. Clean the wound with a 20% soap solution.
B. Clean the wound with a 20% soap solution and administer tetanus toxoid.
C. Clean the wound with a 20% soap solution, administer tetanus toxoid, and administer human rabies immune globulin intramuscularly.
D. Clean the wound with a 20% soap solution, administer tetanus toxoid, administer human rabies immune globulin IM, and administer human diploid cell vaccine.
E. Clean the wound with a 20% soap solution and administer human diploid cell vaccine.
IV-182. While working at a new medical school in Kuala Lumpur, Malaysia, a 35-year-old previously healthy man from Baltimore develops a sudden onset of malaise, fever, headache, retro-orbital pain, backache, and myalgias. On examination, his temperature is 39.6°C with normal blood pressure and slight tachycardia. He has some vesicular lesions on his palate and scleral injection. Laboratory studies are notable for a platelet count of 100,000/μL. All of the following are true regarding his illness EXCEPT:
A. A second infection could result in hemorrhagic fever.
B. After resolution, he has lifelong immunity.
C. IgM ELISA may be diagnostic.
D. In equatorial areas, year-round transmission occurs.
E. The disease is transmitted by mosquitoes.
IV-183. Which of the following fungi is considered dimorphic?
A. Aspergillus fumigatus
B. Candida glabrata
C. Cryptococcus neoformans
D. Histoplasma capsulatum
E. Rhizopus spp.
IV-184. All of the following antifungal medications are available in an oral form EXCEPT:
IV-185. All of the following antifungal medications are approved for the treatment of Candida albicans fungemia EXCEPT:
IV-186. Clinically useful serum or urine diagnostic tests exist for all of the following invasive fungal infections EXCEPT:
IV-187. A 24-year-old female student at the Ohio State University is seen in the emergency department for shortness of breath and chest pain. She has no significant past medical history. Her only medication is an oral contraceptive. As a component of her evaluation, she receives a contrast-enhanced CT scan of the chest. Fortunately, there is no pulmonary embolism (she is diagnosed with viral pleuritis), but there are numerous lung, mediastinal, and splenic calcifications. Based on these findings, which of the following remote infections was most likely?
IV-188. A 43-year-old woman with a history of rheumatoid arthritis is admitted to the hospital with respiratory failure. She was started on infliximab 2 months ago because of refractory disease. Before initiation of the medication, her physician found no evidence of latent tuberculosis infection. She reports 2 days of fever and worsening shortness of breath. On admission, she is hypotensive and hypoxemic with a chest radiograph showing bilateral interstitial and reticulonodular infiltrates. After administration of fluids, broad-spectrum antibiotics, intubation, and initiation of mechanical ventilation,
a bronchoalveolar lavage is performed. A silver stain of the BAL fluid shows the organisms shown in Figure IV-188. Which of the following is the most likely causative organism?
FIGURE IV-188 (see Color Atas)
A. Aspergillus fumigatus
C. Histoplasma capsulatum
D. Mycobacteria avium complex
E. Mycobacterial tuberculosis
IV-189. In the patient described above, which of the following therapies should be continued?
B. Clarithromycin, rifampin, and ethambutol
D. INH, rifampin, PZA, and ethambutol
E. Liposomal amphotericin B
IV-190. A 24-year-old man is brought to the emergency department by his friends because of worsening mental status, confusion, and lethargy. He has been complaining of a severe headache for more than 1 week. The patient works as a migrant farm worker, most recently in the Fresno, California, area. He is originally from the Philippines and has been in the United States for 4 years with no medical therapy. Vital signs include blood pressure of 95/45 mmHg, heart rate of 110 beats/min, respiratory rate of 22 breaths/min, oxygen saturation of 98%, and temperature of 101.1°F. He appears cachectic and is confused. There is minimal nuchal rigidity but notable photophobia. His CBC is notable for a WBC of 2000/μL (95% neutrophils) and a hemoglobin of 9 g/dL. An LP reveals a WBC count of 300/μL (90% lymphocytes), glucose of 10 mg/dL, and protein of 130 mg/dL. Silver stain of the CSF reveals large (30–100 μm) round structures measuring with thick walls containing small round spores and internal
septations. Which of the following is the most appropriate therapy?
B. Ceftriaxone plus vancomycin
D. INH, rifampin, ethambutol, and pyrazinamide (PZA)
E. Penicillin G
IV-191. You are a physician for an undergraduate university health clinic in Arizona. You have evaluated three students with similar complaints of fever, malaise, diffuse arthralgias, cough without hemoptysis, and chest discomfort, and one of the patients has a skin rash on her upper neck consistent with erythema multiforme. Chest radiography is similar in all three, with hilar adenopathy and small pleural effusions. Her CBC is notable for eosinophilia. Upon further questioning, you learn that all three students are in the same archaeology class and participated in an excavation 1 week ago. Your leading diagnosis is:
B. Primary pulmonary aspergillosis
C. Primary pulmonary coccidioidomycosis
D. Primary pulmonary histoplasmosis
E. Streptococcal pneumonia
IV-192. A 62-year-old man returns from a vacation to Arizona with fever, pleurisy, and a nonproductive cough. All of the following factors on history and laboratory examination favor a diagnosis of pulmonary coccidioidomycosis rather than community-acquired pneumonia EXCEPT:
B. Erythema nodosum
C. Mediastinal lymphadenopathy on chest radiography
D. Positive Coccidioides complement fixation titer result
E. Travel limited to Northern Arizona (Grand Canyon area)
IV-193. In a patient with lung and skin lesions, a travel history to which of the following regions would be most compatible with the potential diagnosis of blastomycosis?
A. Brazil (Amazon River basin)
C. Northern Wisconsin
D. Southern Arizona
E. Western Washington state
IV-194. A 43-year-old man comes to the physician complaining of 1 month of low-grade fever, malaise, shortness of breath, and a growing skin lesion. He resides in the upper peninsula of Michigan and works as a landscaper. He avoids medical care as much as possible. He is on no medications and smokes 2 packs per day of cigarettes. Over the past month, he notices that his daily productive cough has worsened and the phlegm in dark yellow. He also reports that he has developed a number of skin lesions that start as a painful nodule and then over 1 week ulcerate and discharge pus (see Figure I V-
194). His physical examination is notable for egophony and bronchial breath sounds in the right lower lobe, and approximately five to 10 ulcerating 4- to 8-cm skin lesions on the lower extremities consistent with the one shown in the figure. His chest radiograph shows right lower lobe consolidation with no pleural effusion and no evidence of hilar or mediastinal adenopathy. After obtaining sputum for cytology and culture and a biopsy of the skin lesion, which is the next most likely diagnostic or therapeutic intervention?
FIGURE IV-194 (see Color Atas) (Used with permission from Elizabeth M. Spiers, MD.)
A. Colonoscopy to evaluate for inflammatory bowel disease
B. INH, rifampin, PZA, and ethambutol
D. PET scan to evaluate for metastatic malignant disease
IV-195. A 34-year-old female aviary worker who has no significant past medical history, is taking no medications, has no allergies, and is HIV negative presents to the emergency department with fever, headache, and fatigue. She reports that her headache has been present for at least 2 weeks, is bilateral, and is worsened by bright lights and loud noises. She is typically an active person who has recently been fatigued and has lost 8 lb because of anorexia. Her work involves caring for birds and maintaining their habitat. Her vital signs are notable for a temperature of 101.8°F. The neurologic examination findings are normal except for notable photophobia. Head CT examination is normal. Lumbar puncture is significant for an opening pressure of 20 cmH2O, white blood cell count of 15 cells/μL (90%
monocytes), protein of 0.5 g/L (50 mg/mL), glucose of 2.8 mmol/L (50 mg/dL), and positive India ink stain. What is the appropriate therapy for this patient?
A. Amphotericin B for 2 weeks followed by lifelong fluconazole
B. Amphotericin B plus flucytosine for 2 weeks followed by oral fluconazole for 10 weeks
C. Caspofungin for 3 months
D. Ceftriaxone and vancomycin for 2 weeks
E. Voriconazole for 3 months
IV-196. An HIV-positive patient with a CD4 count of 110/μL who is not taking any medications presents to an urgent care center with complaints of a headache for the past week. He also notes nausea and intermittently blurred vision. Examination is notable for normal vital signs without fever but mild papilledema. Head CT does not show dilated ventricles. The definitive diagnostic test for this patient is:
A. Cerebrospinal fluid culture
B. MRI with gadolinium imaging
C. Ophthalmologic examination, including visual field testing
D. Serum cryptococcal antigen testing
E. Urine culture
IV-197. All of the following have been identified as a predisposing factor or condition associated with the development of hematogenously disseminated candidiasis EXCEPT:
A. Abdominal surgery
B. Indwelling vascular catheters
D. Pulmonary alveolar proteinosis
E. Severe burns
IV-198. A 19-year-old young man is undergoing intensive chemotherapy for acute myelogenous leukemia. He has been neutropenic for more than 5 days and has been taking prophylactic meropenem and vancomycin for 3 days in addition to parenteral alimentation. His absolute neutrophil count yesterday was 50 cells/mm3, and today it is 200 cells/mm3. He had a fever spike to 101°F yesterday. A chest and abdomen CT at that time was unremarkable. You are asked to see him because over the past 3 hours, he has developed fever greater than 102°F, severe myalgias and joint pains, and new skin lesions (see Figure IV-198). New skin lesions are appearing in all body areas. Initially, they are red areas that become macronodular and are mildly painful. Vital signs are otherwise notable for a blood pressure of 100/60 mmHg and heart rate of 105 beats/min. An urgent biopsy of the skin lesion is most likely to show: