Skin Bone Jonit Infx Compremised Host

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Skin Bone Jonit Infx Compremised Host - Quiz

CTL: Infections in the immunecompromised host
CTL: Skin-primary-immunodeficiencies-infections-in-immunecompromised
CTL:Sepsis-syndrome-bone-and-joint-infections


Questions and Answers
  • 1. 

     A 35-year-old man with AIDS presents to his ophthalmologist with a 1-week history of floaters and blurred vision in his right eye. He denies fever, pain, or photophobia. His CD4+ cell count is 50/µL. He continues to maintain an active lifestyle. General physical examination is unremarkable. Funduscopic examination can be seen below. What is the most likely causative agent?

    • A.

      Cytomegalovirus

    • B.

      Cryptococcus neoformans

    • C.

      Herpes simplex virus

    • D.

      Epstein-Barr virus

    • E.

      Pneumocystis jirovecii

    Correct Answer
    A. Cytomegalovirus
    Explanation
    The most likely causative agent in this case is Cytomegalovirus (CMV). This is suggested by the patient's history of AIDS, low CD4+ cell count, and symptoms of floaters and blurred vision in the right eye. CMV is a common opportunistic infection in individuals with weakened immune systems, such as those with AIDS. It commonly affects the eyes, causing symptoms such as floaters and blurred vision. The other options listed are not typically associated with these symptoms in this patient population.

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  • 2. 

    You are working in an inner city hospital and your patient is a 4-year-old boy who has had a bone marrow transplant for the correction of an L-iduronidase deficiency.  During his recovery, he began to develop a maculopapular rash, a fever, and his CD4/CD8 + T cell ratio was found to be 0.1.  He was subsequently treated with methylprednisone in addition to cyclosporine.  He was already being treated with trimethoprim-sulfamethoxazole prophylactically.  His condition improved markedly for about a week until one morning he began to complain of a headache.  He was again febrile and rapidly became increasingly lethargic.  Over the next 2 days the patient became less responsive until drifting into a coma. What might you suspect is causing this condition?

    • A.

      Candida sp.

    • B.

      Streptococcus pneumonia

    • C.

      Naegleria fowleri

    • D.

      Cryptococcus neoformans

    Correct Answer
    D. Cryptococcus neoformans
    Explanation
    The patient's symptoms of maculopapular rash, fever, and low CD4/CD8 + T cell ratio suggest an immune system dysfunction, possibly due to the bone marrow transplant. The patient was treated with methylprednisone and cyclosporine, which are immunosuppressant drugs. The improvement followed by the sudden onset of headache, fever, and lethargy, leading to a coma, suggests a central nervous system infection. Cryptococcus neoformans is a fungus that commonly causes meningitis in immunocompromised individuals, and it is the most likely cause of the patient's condition.

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  • 3. 

    Patients with chronic mucocutaneous candidiasis (CMC) are often recognized to produce a poor or nonexistent immune response to candidal antigens. Which type of immune responses is lacking?

    • A.

      Th1

    • B.

      Th2

    • C.

      MAC of complement

    • D.

      B cells

    Correct Answer
    A. Th1
    Explanation
    Patients with chronic mucocutaneous candidiasis (CMC) have a deficiency in Th1 immune response. Th1 response is responsible for activating macrophages and cytotoxic T cells, which are crucial for clearing fungal infections like candidiasis. In CMC patients, the immune system fails to mount an effective Th1 response, leading to a poor or nonexistent immune response against candidal antigens. This deficiency in Th1 response contributes to the susceptibility of CMC patients to chronic and recurrent candidiasis infections.

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  • 4. 

    Your patient is a 52-year-old homosexual living in New York. He had previously been diagnosed with HIV and, due to lack of compliance with his medications, his condition has deteriorated. He had recently been treated for CMV retinitis and, while undergoing treatment, his condition had deteriorated further. His last CD4+ T cell count was 40 cells/µL.  Eventually the patient became unresponsive and drifted into a coma. CSF from a lumbar puncture was cloudy in appearance; 2,500 leukocytes/µL; increased protein; decreased glucose. An India ink preparation was positive. What organism would you expect to be responsible for the patient’s coma?

    • A.

      Candida albicans

    • B.

      Mycobacterium tuberculosis

    • C.

      Histoplasma capsulatum

    • D.

      Cryptococcus neoformans

    • E.

      Coccidiodes immitis

    Correct Answer
    D. Cryptococcus neoformans
    Explanation
    Cryptococcus neoformans is a fungus found worldwide. The main reservoir is pigeon droppings. The
    small cryptococci are inhaled into the lungs, but do not usually cause disease in immunocompetent individuals.
    In the immunosuppressed patient, Cryptococcus can cause pulmonary and CNS disease, especially meningitis.

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  • 5. 

    A 45-year-old man with a 10-year history of diabetes mellitus type 2 presents to your office complaining of a “painful boil” on his right arm.  The lesion began 3-4 days ago as a “pimple” and gradually enlarged and became increasingly painful.  He denies fever or chills.  Upon physical examination, you note a single, 4-cm erythematous mass encompassing multiple hair follicles.  It is tender to palpation and slightly fluctuant.  With pressure, purulent fluid drains through more than one opening in the skin.  His latest hemoglobin A1c was 8.7%. Which of the following is the best next step in the management of this patient’s infection?

    • A.

      Counsel the patient about improving glycemic control

    • B.

      Perform an incision and drainage of the mass

    • C.

      Apply moist heat to the mass

    • D.

      Submit pus for culture and sensitivity testing

    • E.

      Start topical antibiotic therapy

    Correct Answer
    B. Perform an incision and drainage of the mass
    Explanation
    The patient's presentation is consistent with a skin abscess, which is a localized collection of pus within the skin. The lesion is tender, fluctuant, and draining purulent fluid, indicating the presence of an abscess. The best next step in the management of this infection is to perform an incision and drainage of the mass. This procedure allows for the evacuation of pus and promotes healing. Antibiotic therapy alone is not sufficient for the treatment of an abscess, and submitting pus for culture and sensitivity testing can be done after the drainage. Improving glycemic control is important for overall management of diabetes but is not the immediate next step in managing the infection. Applying moist heat can provide symptomatic relief but does not address the underlying infection.

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  • 6. 

    A 67-year-old obese woman with a 10-year history of poorly controlled type 2 diabetes mellitus has had an ulcer on her left heel for a month.  She applied a homemade dressing and cut her shoes to try to relieve pressure on the ulcer; however, in the past week, areas around the ulcer have become painful.  She has a temperature of 37.7°C (100°F), a blood glucose level of 210 mg/dL (nl 70-110 mg/dL), and a total white blood cell count of 17,700/µL (nl 4,000-11,000/µL). Physical examination reveals a 1-cm deep (full thickness) ulcer showing a purulent drainage and surrounded by at least 4 cm of cellulitis.  The dorsum of the foot is warm and red.  The left dorsalis pedis pulse is undetectable.  Proprioception and pain sensation in both feet are very diminished or absent.  A sterile surgical probe inserted in the wound does not touch bone.  Radiographs of the foot reveal no changes that suggest osteomyelitis. Which of the following is the most appropriate management strategy for this patient?

    • A.

      Apply a total contact cast, instruct the patient in wound care, and advise her to limit ambulation for 4 weeks

    • B.

      Admit the patient to the hospital and arrange for an immediate surgical consultation for either revascularization or amputation

    • C.

      Apply a total contact cast, instruct the patient in wound care, and prescribe a 4-week course of orally administered broad-spectrum antibiotics as an outpatient

    • D.

      Admit the patient to the hospital and institute a strict non-weight-bearing regimen

    • E.

      Admit the patient to the hospital, initiate intravenous broad-spectrum antibiotics pending culture results, and arrange for surgical intervention for debridement and drainage

    Correct Answer
    E. Admit the patient to the hospital, initiate intravenous broad-spectrum antibiotics pending culture results, and arrange for surgical intervention for debridement and drainage
    Explanation
    The patient's presentation is consistent with a severe diabetic foot infection, indicated by the deep ulcer with purulent drainage, surrounding cellulitis, elevated temperature, elevated white blood cell count, and absence of pedal pulse. The lack of sensation in both feet suggests peripheral neuropathy, which increases the risk of infection and complications. Due to the severity of the infection and the risk of osteomyelitis, hospital admission is necessary. Intravenous broad-spectrum antibiotics should be initiated to cover likely pathogens, and surgical intervention for debridement and drainage is needed to remove infected tissue and promote healing.

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  • 7. 

    A 30-year-old female drug abuser was hospitalized 3 days after the onset of a dry mouth and progressive bilateral arm weakness along with difficulty speaking, swallowing, and breathing. Physical examination revealed a deep abscess on her right arm at the site of an attempt to inject heroin 1 week ago. She is febrile and has a leukocytosis.  She had a tetanus shot 2 years ago when she went to the emergency department after stepping on a dirty, broken beer bottle. In addition to debridement of the wound, which of the following would pertain to the proper treatment of this patient? (1) No antibiotics                                                     (4) Appropriate antibiotics (2) Specific human-derived antitoxin                       (5) Specific equine-derived antitoxin (3) No tetanus toxoid booster                                  (6) Tetanus toxoid booster

    • A.

      1, 2, 3

    • B.

      2, 4, 6

    • C.

      2, 3, 4

    • D.

      3, 4, 5

    • E.

      1, 5, 6

    Correct Answer
    D. 3, 4, 5
    Explanation
    The patient's symptoms, including dry mouth, progressive bilateral arm weakness, difficulty speaking, swallowing, and breathing, along with the presence of a deep abscess at the site of an injection, suggest the possibility of botulism. Botulism is caused by the neurotoxin produced by Clostridium botulinum bacteria, which can contaminate drug paraphernalia. Therefore, treatment should include appropriate antibiotics to target the bacteria causing the infection (option 4). Additionally, specific antitoxins, both human-derived and equine-derived, should be administered to neutralize the botulinum toxin and prevent further progression of symptoms (option 5). A tetanus toxoid booster is not necessary in this case as the patient had a tetanus shot 2 years ago (option 3). Therefore, options 3, 4, and 5 are the correct choices for the proper treatment of this patient.

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  • 8. 

    Which of the following best describes the images shown?

    • A.

      Keratacanthoma showing keratinization and hyperkeratosis

    • B.

      Actinic keratosis showing scale formation, parakeratosis and hyperkeratosis

    • C.

      Invasive squamous cell carcinoma showing a cutaneous horn made of keratin

    • D.

      Basal cell carcinoma showing vacuolization and hyperkeratosis

    • E.

      Malignant melanoma showing vertical growth phase and invasion

    Correct Answer
    B. Actinic keratosis showing scale formation, parakeratosis and hyperkeratosis
    Explanation
    The correct answer is Actinic keratosis showing scale formation, parakeratosis, and hyperkeratosis. Actinic keratosis is a precancerous skin condition caused by prolonged sun exposure. It is characterized by the presence of scales, parakeratosis (retention of nuclei in the stratum corneum), and hyperkeratosis (thickening of the outer layer of the skin). This condition is commonly found in fair-skinned individuals and can progress to squamous cell carcinoma if left untreated.

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  • 9. 

    A 59-year-old East-European man presents with multiple non-pruritic reddish-purple confluent skin plaques and nodules. The gross and microscopic appearance of the lesion is shown for your evaluation below.  Which of the following is the most likely diagnosis?

    • A.

      Capillary hemangioma

    • B.

      Pyogenic granuloma

    • C.

      Kaposi sarcoma

    • D.

      Hemangiosarcoma

    Correct Answer
    C. Kaposi sarcoma
    Explanation
    The most likely diagnosis for the patient's presentation is Kaposi sarcoma. This is supported by the presence of multiple non-pruritic reddish-purple skin plaques and nodules, which are characteristic of Kaposi sarcoma. Additionally, the patient's age and East-European background are risk factors for this condition. The gross and microscopic appearance of the lesion can further confirm the diagnosis. Capillary hemangioma, pyogenic granuloma, and hemangiosarcoma are less likely due to differences in clinical presentation and histopathological features.

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  • 10. 

    Which of the following skin lesions will most likely progress to invasive squamous cell carcinoma?

    • A.

      Actinic keratosis

    • B.

      Seborrheic keratosis

    • C.

      Seborrheic dermatitis

    • D.

      Epidermal inclusion cyst

    • E.

      Steatocystoma multiplex

    Correct Answer
    A. Actinic keratosis
    Explanation
    Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is characterized by rough, scaly patches on the skin that may be red or brown in color. If left untreated, actinic keratosis has the potential to progress to invasive squamous cell carcinoma, a type of skin cancer. The other options, seborrheic keratosis, seborrheic dermatitis, epidermal inclusion cyst, and steatocystoma multiplex, are not associated with an increased risk of developing invasive squamous cell carcinoma.

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  • 11. 

    A 3-year-old boy has had recurrent respiratory infections with multiple bacterial pathogens. His mother brings him to the pediatrician, because she is concerned about the rash involving his trunk and extremities. She indicates that he scratches the rash so much that it bleeds very easily. What is the most common cause of this form of immunodeficiency?

    • A.

      Mutation in the Btk tyrosine kinase gene

    • B.

      Mutation of WASP gene of the X chromosome

    • C.

      Mutation in the gamma gene of IL-2

    • D.

      Mutation in the CD40 ligand gene

    • E.

      Deletion of a region of chromosome 22q11

    Correct Answer
    B. Mutation of WASP gene of the X chromosome
    Explanation
    Wiskott–Aldrich syndrome (WAS) is a rare X-linked recessive disease characterized by eczema, thrombocytopenia (low platelet count), immune deficiency, and bloody diarrhea (secondary to the thrombocytopenia). It is also sometimes called the eczema-thrombocytopenia-immunodeficiency syndrome in keeping with Aldrich's original description in 1954. The WAS-related disorders of X-linked thrombocytopenia (XLT) and X-linked congenital neutropenia (XLN) may present similar but less severe symptoms and are caused by mutations of the same gene
    Due to its mode of inheritance, the overwhelming majority of patients are male. The first signs of WAS are usually petechiae and bruising, resulting from thrombocytopenia (low platelet counts). Spontaneous nose bleeds and bloody diarrhea are common. Eczema develops within the first month of life. Recurrent bacterial infections develop by three months. Splenomegaly is not an uncommon finding. The majority of WAS children develop at least one autoimmune disorder, and malignancies (mainly lymphoma and leukemia) develop in up to a third of patients.
    IgM levels are reduced, IgA and IgE are elevated, and IgG levels can be normal, reduced, or elevated

    In Wiskott–Aldrich syndrome, the platelets are small and do not function properly. They are removed by the spleen, which leads to low platelet counts.
    Wiskott–Aldrich syndrome was linked in 1994 to mutations in a gene on the short arm of the X chromosome, which was termed Wiskott-Aldrich syndrome protein (WASp). It was later discovered that the disease X-linked thrombocytopenia (XLT) was also due to WASp mutations, but different ones from those that cause full-blown Wiskott–Aldrich syndrome. Furthermore, the rare disorder X-linked neutropenia has been linked to particular mutations of the WASp gene.
    The WASp gene codes for the protein by the same name, which is 502 amino acids long and is mainly expressed in hematopoietic cells (the cells in the bone marrow that develop into blood cells). The main function of WASp is to activate actin polymerization by binding to the Arp2/3 complex. In T-cells, WASp is important because it is known to be activated via T-cell receptor (TCR) signaling pathways to induce cortical actin cytoskeleton rearrangements that are responsible for forming the immunological synapse.
    The immune deficiency is caused by decreased antibody production, and the inability of T cells to become polarized (making it a combined immunodeficiency). This leads to increased susceptibility to infections, particularly of the ears and sinuses. T cells are unable to reorganize their actin cytoskeleton. The type of mutation to the WASp gene correlates significantly with the degree of severity: those that led to the production of a truncated protein caused significantly more symptoms than those with a missense mutation but a normal-length WASp. Although autoimmune disease and malignancy may occur in both types of mutations, those patients with truncated WASp carry a higher risk.
    A defect in CD43 molecule has been found in patients with Wiskott–Aldrich syndrome.

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  • 12. 

    A 3-year-old boy has a history of recurrent infections caused by Staphylococcus aureus since infancy. Although each infection was treated with appropriate antibiotics, it would recur after the course of antibiotics was completed. A nitroblue tetrazolium dye reduction test confirmed the diagnosis of chronic granulomatous disease. What is the cellular abnormality found in the most common form of CGD?

    • A.

      Myeloperoxidase deficiency

    • B.

      Defective NADPH oxidase

    • C.

      Defective cell adhesion molecule

    • D.

      Defective vesicle fusion

    • E.

      Impaired chemotaxis

    Correct Answer
    B. Defective NADPH oxidase
    Explanation
    Patients with CGD can usually resist infections of catalase-negative bacteria. Catalase is an enzyme that catalyzes the breakdown of hydrogen peroxide in many organisms. In organisms that lack catalase (catalase-negative), normal metabolic functions will cause an accumulation of hydrogen peroxide which the host's immune system can use to fight off the infection. In organisms that have catalase (catalase-positive), the enzyme breaks down any hydrogen peroxide that was produced through normal metabolism. Therefore hydrogen peroxide will not accumulate, leaving the patient vulnerable to catalase-positive bacteria.
    Phagocytes (i.e., neutrophils, monocytes, and macrophages) require an enzyme to produce reactive oxygen species to destroy bacteria after they ingest the bacteria in a process called phagocytosis, a process known as the respiratory burst. This enzyme is termed "phagocyte NADPH oxidase" (PHOX). The initial step in this process involves the one-electron reduction of molecular oxygen to produce superoxide anion, a free radical. Superoxide then undergoes a further series of reactions to produce products such as hydrogen peroxide (through the action of superoxide dismutase), hydroxyl radical and hypochlorite (bleach - through the action of myeloperoxidase on hydrogen peroxide). The reactive oxygen species this enzyme produces are toxic to bacteria and help the phagocyte kill them once they are ingested. Defects in one of the four essential subunits of this enzyme can all cause CGD of varying severity, dependent on the defect. There are over 410 known possible defects in the PHOX enzyme complex that can lead to chronic granulomatous disease.
    Diagnosis
    The nitroblue-tetrazolium (NBT) test is the original and most widely-known test for chronic granulomatous disease. It is negative in CGD, meaning that it does not turn blue. The higher the blue score, the better the cell is at producing reactive oxygen species. This test depends upon the direct reduction of NBT by superoxide free radical to form an insoluble formazan. This test is simple to perform and gives rapid results, but only tells whether or not there is a problem with the PHOX enzymes, not how much they are affected. A similar test uses dihydrorhodamine (DHR) where whole blood is stained with DHR, incubated, and stimulated to produce superoxide radicals which oxidize DHR to rhodamin in cells with normal function. An advanced test called the cytochrome C reduction assay tells physicians how much superoxide a patient's phagocytes can produce. Once the diagnosis of CGD is established, a genetic analysis may be used to determine exactly which mutation is the underlying cause
    People with CGD are sometimes infected with organisms that usually do not cause disease in people with normal immune systems. Among the most common organisms that cause disease in CGD patients are:

    •BACTERIA (particularly those that are catalase-positive)
    o--Staphylococcus aureus.
    o--Serratia marcescens.
    o--Salmonella species.
    o--Klebsiella species.
    o--Pseudomonas cepacia, a.k.a. Burkholderia cepacia.
    o--Nocardia.

    •FUNGI
    o--Aspergillus species. Aspergillus has a propensity to cause infection in people with CGD and of the Aspergillus species, Aspergillus fumigatus seems to be most common in CGD.
    o--Candida species.

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  • 13. 

    A 66-year-old man with a history of cirrhosis secondary to alcohol abuse presents to the emergency department with excruciating pain in his left forearm. He reported spending the previous night fishing in Corpus Christi Bay (Texas), where he accidentally pierced his left index finger with an oyster shell. Large, blood-filled vesicles are present, extending from his hand to upper arm. How would you describe the organisms observed in a Gram stain of fluid from the vesicles?

    • A.

      Gram-negative, comma-shaped rods

    • B.

      Gram-negative bacilli

    • C.

      Gram-positive cocci in clusters

    • D.

      Gram-negative coccobacilli

    • E.

      Gram-positive, sporeforming bacilli

    Correct Answer
    A. Gram-negative, comma-shaped rods
    Explanation
    VIBRIO VULNIFICUS is a species of Gram-negative, motile, curved, rod-shaped bacteria of the genus Vibrio. Present in marine environments such as estuaries, brackish ponds, or coastal areas, V. vulnificus is related to V. cholerae, the causative agent of cholera.[1],[2] Infection with V. vulnificus leads to rapidly expanding cellulitis or septicemia.
    Vibrio vulnificus causes an infection often incurred after eating seafood, especially raw or undercooked oysters; the bacteria can also enter the body through open wounds when swimming or wading in infected waters, or via PUNCTURE WOUNDS from the spines of fish such as tilapia.
    Symptoms include vomiting, diarrhea, abdominal pain, and a blistering dermatitis that is sometimes mistaken for pemphigus or pemphigoid.
    V. vulnificus is eighty times more likely to spread into the blood stream in people with compromised immune systems, especially those with chronic liver disease. When this happens, severe symptoms including blistering skin lesions, septic shock, and even death can occur. This severe infection may occur regardless of whether the infection began via contaminated food or via an open wound.
    Vibrio vulnificus wound infections have a mortality of approximately 25%. In patients in whom the infection worsens into septicemia, typically following ingestion, the mortality rate rises dramatically to 50%. The majority of these patients die within the first 48 hours of infection. The optimal treatment is not known, but, in one retrospective study of 93 patients in Taiwan, use of a third-generation cephalosporin and a tetracycline (e.g., ceftriaxone and doxycycline, respectively) were associated with an improved outcome.[8] Prospective clinical trials are needed to confirm this finding, but in vitro data support the supposition this combination is synergistic against Vibrio vulnificus. Similarly, the American Medical Association and the Centers for Disease Control and Prevention recommend treating the patient with a quinolone or intravenous doxycycline with ceftazidime.

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  • 14. 

    A 46-year-old man with lymphoma was receiving chemotherapy through a central intravenous catheter. He came to the clinic complaining of fever and pain at the catheter insertion site. The resident noted erythema and tenderness around the catheter insertion site. His temperature was 39.20 C, pulse 130, and BP 102/78. Other lab tests included white blood cells 18,000 per mm3, platelets 160,000 per mm3, normal serum lactate, and PaO2 88 mmHg. A blood culture was positive for Staphylococcus epidermidis. What is your diagnosis?

    • A.

      Local inflammatory response syndrome

    • B.

      Positive blood culture due to skin contaminant

    • C.

      Sepsis

    • D.

      Severe sepsis

    • E.

      Septic shock

    Correct Answer
    C. Sepsis
    Explanation
    According to the American College of Chest Physicians and the Society of Critical Care Medicine, there are different levels of sepsis.

    •Systemic inflammatory response syndrome (SIRS). Defined by the presence of two or more of the following findings:
    o--Body temperature < 36 °C (96.8 °F) or > 38 °C (100.4 °F) (hypothermia or fever).
    o--Heart rate > 90 beats per minute.
    o--Respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) (tachypnea or hypocapnia due to hyperventilation).
    o--White blood cell count < 4,000 cells/mm3 or > 12,000 cells/mm3 (< 4 × 109 or > 12 × 109 cells/L), or greater than 10% band forms (immature white blood cells). (leukopenia, leukocytosis, or bandemia).

    •Sepsis: Defined as SIRS in response to an infectious process. Infection can be suspected or proven (by culture, stain, or polymerase chain reaction (PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or cerebrospinal fluid (CSF)); evidence of a perforated viscus (free air on abdominal x-ray or CT scan; signs of acute peritonitis); abnormal chest x-ray (CXR) consistent with pneumonia (with focal opacification); or petechiae, purpura, or purpura fulminans.

    •Severe sepsis: Defined as sepsis with organ dysfunction, hypoperfusion, or hypotension.

    •SEPTIC SHOCK: Defined as sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. Signs of systemic hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/L. Other signs include oliguria and altered mental status. Patients are defined as having septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid solution).

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  • 15. 

    A 64-year-old man underwent intestinal surgery for cancer of the colon. While in the recovery room for 24 hours, his temperature rose to 39.4⁰ C, the pulse rate rose to 135, the BP was 78/52 mm Hg, the WBC count was 18,000 per mm3, and the platelet count was 75,000 per mm 3. The surgeon suspected peritonitis from intestinal leakage after surgery. He was given 2 liters of saline with the result that his pulse was 119 and BP was 86/68. The correct diagnosis was which one of the following?

    • A.

      Sepsis due to bacteria in peritoneal space

    • B.

      Severe sepsis due to surgical wound infection

    • C.

      Septic shock due to intestinal bacteria in blood

    • D.

      Systemic inflammatory response syndrome

    • E.

      Allergic reaction to antibiotics given during surgery

    Correct Answer
    C. Septic shock due to intestinal bacteria in blood
    Explanation
    According to the American College of Chest Physicians and the Society of Critical Care Medicine, there are different levels of sepsis.

    •Systemic inflammatory response syndrome (SIRS). Defined by the presence of two or more of the following findings:
    o--Body temperature < 36 °C (96.8 °F) or > 38 °C (100.4 °F) (hypothermia or fever).
    o--Heart rate > 90 beats per minute.
    o--Respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) (tachypnea or hypocapnia due to hyperventilation).
    o--White blood cell count < 4,000 cells/mm3 or > 12,000 cells/mm3 (< 4 × 109 or > 12 × 109 cells/L), or greater than 10% band forms (immature white blood cells). (leukopenia, leukocytosis, or bandemia).

    •Sepsis: Defined as SIRS in response to an infectious process. Infection can be suspected or proven (by culture, stain, or polymerase chain reaction (PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or cerebrospinal fluid (CSF)); evidence of a perforated viscus (free air on abdominal x-ray or CT scan; signs of acute peritonitis); abnormal chest x-ray (CXR) consistent with pneumonia (with focal opacification); or petechiae, purpura, or purpura fulminans.

    •Severe sepsis: Defined as sepsis with organ dysfunction, hypoperfusion, or hypotension.

    •SEPTIC SHOCK: Defined as sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. Signs of systemic hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/L. Other signs include oliguria and altered mental status. Patients are defined as having septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid solution).

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  • 16. 

    Your patient is admitted to an emergency ward with fever (104°F), severe hypotension, vomiting, and headache.  He also has a prominent sunburn-like rash over the body.  Further investigation reveals that 3 days ago the patient had been admitted after a traffic accident. He had been sitting at a red light when his vehicle had been hit from behind by another car, whose driver happened to be “texting” at the time.  The rescue crew had discovered your patient to be conscious with severe epistaxis, but was transported to the hospital with a few other injuries.  The patient admitted he had been picking his nose when the incident occurred and that it had caused him to violently push his finger up one nostril. The patient was held in the ED for 4 hours until the bleeding was stopped and then discharged with nasal packing and orders to visit his own physician 48 hours after the accident which he failed to do. What do you think may be the cause of the patient’s current condition?

    • A.

      Endotoxic shock

    • B.

      Toxic shock syndrome

    • C.

      Shock from loss of blood

    • D.

      Gram-positive septicemia

    Correct Answer
    B. Toxic shock syndrome
    Explanation
    The patient's symptoms, including fever, severe hypotension, vomiting, headache, and a sunburn-like rash, are consistent with toxic shock syndrome. The patient's history of a traffic accident and subsequent nosebleed, along with the fact that he failed to follow up with his physician, suggests that he may have developed an infection from not properly treating his nasal injury. This infection could have led to toxic shock syndrome, a potentially life-threatening condition caused by toxins produced by certain bacteria.

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  • 17. 

    A 30-year-old woman presents to the ED with malaise, myalgias, fever, and a spreading purpuric rash. Her boyfriend, who has accompanied her to the ED, says that she has been vomiting, has appeared to be in pain with movement, and has even had intermittent confusion during the night.  She has developed a headache of moderate intensity that is diffuse, radiating to her neck, and worsens with movement. Lab results are as follows: WBC = 17.6 × 103/µL (nl 4-10) Platelet count = 54,000/µL (nl 150,000-350,000/µL) C-reactive protein (CRP) = 22 mg/dL (nl <3.0) Partial thromboplastin time (PTT) = >120 seconds (nl 25-35) International normalized ratio (INR) = 2.14 (nl 1.0) D-dimer = >10 µg/mL (nl <0.5 µg/mL)    While awaiting further lab results, which of the following would be your most likely diagnosis?

    • A.

      Meningococcal septicemia

    • B.

      Toxic shock syndrome

    • C.

      Acute respiratory distress syndrome

    • D.

      Acute necrotizing pancreatitis

    Correct Answer
    A. Meningococcal septicemia
    Explanation
    The patient's symptoms, including malaise, myalgias, fever, purpuric rash, vomiting, pain with movement, confusion, and headache, are consistent with meningococcal septicemia. The lab results also support this diagnosis, as the patient has leukocytosis, thrombocytopenia, elevated CRP, prolonged PTT and INR, and elevated D-dimer, which are all indicative of a severe systemic infection. Meningococcal septicemia is a life-threatening condition caused by the bacteria Neisseria meningitidis and requires immediate medical attention.

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  • 18. 

    A 50 year old man reports with right knee pain for 48 hours. He denies any history of trauma. This morning his knee became swollen and developed chills and body aches.  On physical examination, his knee is hot, red, tender and swollen and the slightest movement causes pain.  His WBC is 18,000 cells/mm3 and his ESR is 45 (normal 0-20).  Arthrocentesis shows 60,000 WBC/mm3 with 80% PMNs; no crystals are seen.  Of the following, which is the next best step?

    • A.

      Order a Western Blot Lyme test

    • B.

      Admit to hospital for IV antibiotics

    • C.

      Send home with a prescription for a 3rd generation cephalosporin

    • D.

      Refer to a rheumatologist

    • E.

      Order an MRI of his knee

    Correct Answer
    B. Admit to hospital for IV antibiotics
    Explanation
    The patient's presentation is consistent with septic arthritis, which is supported by the presence of a hot, red, tender, and swollen knee, along with systemic symptoms such as chills and body aches. The elevated WBC count and elevated ESR further suggest an inflammatory process. Arthrocentesis findings of 60,000 WBC/mm3 with 80% PMNs indicate an infection. Prompt initiation of intravenous antibiotics is crucial in the management of septic arthritis to prevent joint destruction and systemic spread of infection. Therefore, admitting the patient to the hospital for IV antibiotics is the next best step.

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  • 19. 

    A 63-year-old physically active, diabetic man presented to his podiatrist’s office with a plantar ulcer of the left 5th metatarsophalangeal joint. The patient had recently returned from a hunting trip in Africa, where he began to notice increased swelling and redness of his foot during the previous week. He initiated self treatment including daily cleansing of the foot and taking acetaminophen for fever. His most recent hemoglobin A1c was 9.8%.   Physical examination revealed erythema and local edema with a plantar ulcer and sinus tract. Manual palpation of the sinus tract yielded a purulent exudate. A metal probe inserted in the sinus tract showed direct communication with the 5th metatarsal joint. His temperature was 39°C (102.3°F). Initial laboratory reports revealed a total WBC count of 19,800/µL, random glucose level of 326 mg/dL, and an ESR of 80 mm/hr.   Which major risk factor has predisposed this patient to developing this medical condition?

    • A.

      History of diabetes mellitus for >10 years

    • B.

      Previous history of amputation

    • C.

      Smoking

    • D.

      Limited joint mobility and bone deformities

    • E.

      Chronic hyperglycemia

    • F.

      Obesity

    Correct Answer
    E. Chronic hyperglycemia
    Explanation
    Chronic hyperglycemia, or consistently high blood sugar levels, is a major risk factor for the development of this medical condition. In this case, the patient's hemoglobin A1c level of 9.8% indicates poor long-term blood sugar control. Chronic hyperglycemia can lead to impaired wound healing, increased risk of infection, and damage to blood vessels and nerves, making individuals with diabetes more susceptible to foot ulcers and infections. This patient's history of diabetes, along with the high glucose level and the presence of a plantar ulcer with purulent exudate, all point to chronic hyperglycemia as the major risk factor.

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