Skin Bone Jonit Infx Compremised Host

19 Questions | Total Attempts: 75

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Skin Bone Jonit Infx Compremised Host

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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

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