Immunologic And Inflammatory Post-test

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Immunology and Inflammatory Post Test. Rosen's Emergency Medicine, 7th Edition. Section Nine: Chapters 114 - 118.

Questions and Answers

1.

The distinction between monoarticular and polyartiular arthritis is an important distinction which helps narrow the differential diagnosis. Which of the following pairings below is correct?
- A.
  
  Pseudogout – polyarticular
- B.
  
  Gonocoocal arthritis – monoarticular
- C.
  
  Gout – polyarticular
- D.
  
  Lyme disease – monoarticular
- E.
  
  Rheumatoid arthritis – polyarticular
Correct Answer
E. Rheumatoid arthritis – polyarticular

Explanation
Typically monoartiular arthritides: gout, pseduogout, septic arthritis, osteoarthritis, trauma (hemarthrosis), Charcot’s joint
Typically polyarticular arthritides: gonococcal arthritis, rheumatoid arthritis, rheumatic fever, Lyme disease, Reiter’s syndrome, serum sickness, seronegative spondyloarthropathies, SLE, drug-induced arthritis
(Chapter 114)

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2.

Which of the following is the most common cause of bacterial septic arthritis?
- A.
  
  Neisseria gonorrhoeae
- B.
  
  Group A streptococcus
- C.
  
  Staphylococcus aureus
- D.
  
  E. coli
- E.
  
  Salmonella species
Correct Answer
C. Staphylococcus aureus

Explanation
The incidence of septic arthritis is approximately 2-10/100,000 per year, with a bimodal peak in age (young children and adults > 55yo.) Bacterial pathogens typically infect the joint space via hematogenous spread, but direct inoculation and continguous spread from bony or soft tissue infections occur as well. Overall, S aureus is the most common cause of septic arthritis. Other staph species, streptococci, gram-negatives, and anaerobes cause the remaining cases of monoarticular septic arthritis. N. gonorrhoeae causes approx 20% of monoarticular septic arthritis, but more commonly causes a polyarthritis. (Chapter 114)

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3.

A healthy 27 year old female presents with atraumatic joint pain and swelling. Over the past 4 days, she complains of left knee, right wrist and right ankle pain. She denies rash or fever. Which of the following statements is true regarding her diagnosis?
- A.
  
  She may be discharged home on oral antibiotics after a dose of IV antibiotics
- B.
  
  It is unnecessary to perform a cervical culture on this patient
- C.
  
  This type of arthritis is more commonly oligoarthritis than monoarthritis
- D.
  
  The etiology of this arthritis has a high liklihood of creating long-term joint pathology
- E.
  
  This type of arthritis is most common in children and adults > 55 years old
Correct Answer
C. This type of arthritis is more commonly oligoarthritis than monoarthritis

Explanation
Although it has declined over the past decade, gonococcal arthritis remains the most common form of septic arthritis in the sexually active population, with a 4:1 female predominance. Gonococcal arthritis is clinically and pathologically distinct from other bacterial infections and is less likely to create long-term joint pathology. This infection is more commonly oligoarthritis than monoarthritis, with the knee, ankle and wrist being the most commonly affected joints. Diagnosis is difficult as both synovial and blood cultures are positive in only 10-50% of cases. However, synovial fluid often yields a positive Gram’s stain. Cervical, urethral, rectal and pharyngeal cultures are positive in up to 75% of cases and therefore should be cultured appropriately. Treatment should be with a parenteral 3rd generation cephalosporin, with transition to oral antibiotics 24-48 hours after clinical improvement. (Chapter 114)

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4.

A 46 year old male presents with an isolated swollen knee joint. He has increased pain with both passive and active range of motion of the joint. You plan to perform an arthrocentesis, knowing that:
- A.
  
  Absolute cell count can be used to rule out a septic etiology
- B.
  
  Arthrocentesis is contraindicated if infection of any kind covers the joint
- C.
  
  If you obtain a very small amount of synovial fluid, the most important test to be run is cell count and differential
- D.
  
  The most concerning complication of arthrocentesis is a “dry tap”
- E.
  
  Most of the white blood cells in septic arthritis are PMNs, while in inflammatory arthritis, eosinophils predominate.
Correct Answer
B. Arthrocentesis is contraindicated if infection of any kind covers the joint

Explanation
One of the emergency indications for arthrocentesis is obtaining joint fluid for analysis. Arthrocentesis is contraindicated if infection of any kind covers the area to be punctured. The synovial fluid should be sent for cell count, differential, Gram’s stain, crystal analysis, and culture. A positive Gram’s stain is diagnostic, but a negative result does not rule out septic arthritis, therefore cultures should always be obtained. The likelihood ratio for septic arthritis increases as the joint WBC rises, however low WBC counts do occur early in infectious arthritis and partially treated arthritis. Most of the cells in both septic and severe inflammatory arthritis are PMNs. Cell counts should not be used to absolutely rule out a septic etiology; bacterial cultures should be obtained. The most serious complication of arthrocentesis is introducing infection into the joint space. Other complications include bleeding, allergic reaction to anesthetic agents, dry taps. (Chapter 114)

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5.

In evaluating a patient with acute arthritis, which laboratory study may be of any value in determining the underlying etiology?
- A.
  
  Platelet count
- B.
  
  CPK
- C.
  
  Serum protein level
- D.
  
  Sedimentation rate
- E.
  
  Uric acid level
Correct Answer
D. Sedimentation rate

Explanation
Laboratory tests other than synovial fluid analyses are of limited diagnostic value for evaluating acute arthritis in the ED. The 2 most general screening tests are a CBC and ESR, which is elevated in almost all cases of inflammatory arthritides. The serum uric acid level is not helpful in diagnosing acute gouty arthritis. In the acute phase of the disease, the serum uric acid level may be normal. (Chapter 114)

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6.

Which of the following statements regarding the seronegative spondyloarthropathies is NOT true?
- A.
  
  The most common extra-articular manifestation of ankylosing spondylitis is aortic root disease
- B.
  
  There is a genetic component to theses arthropathies related to the HLA-B27 marker
- C.
  
  Psoariatic arthropathy occurs in up to 20% of patients with psoriasis
- D.
  
  In patients with IBD, the peripheral arthritis tends to correlate with flare-ups of the bowel disease, but the spinal manifestations do not
- E.
  
  Reactive arthritis (Reiter’s syndrome) develops 2-6 weeks after an episode of urethritis or dysentery
Correct Answer
A. The most common extra-articular manifestation of ankylosing spondylitis is aortic root disease

Explanation
The seronegative spondyloarthropathies share the characteristics of sacroiliac involvement, peripheral inflammatory arthropathy, absence of rheumatoid factor, pathologic changes around the enthesis, and a genetic component related to the HLA-B27. The most important of these include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and the arthropathy of IBD.
Ankylosing spondylitis: back discomfort with radiologic evidence of sacroilitis, male predominance, uveitis is most common extra-articular manifestions, life-threatening aortic root disease rarely occurs
Arthropathy of IBD: acute migratory, inflammatory polyarthritis of the peripheral joints (most commonly knees) in10-20% of patients with IBD. Sacroilitis and spondylitis more common in males. The peripheral arthritis generally correlates with flare-ups of the bowel disease, but the spinal manifestations do not.
Psoriatic arthritis: 20% of patients with psoriasis. Several forms (asymmetrical oligoarthropathy, symmetrical polyarthropathy, spondylitis, DIP involvement, arthritis mutilans)
Reactive arthritis (Reiter’s): asymmetric, polyarticular arthritis in a genetically susceptible host 2-6 weeks after an infection in the GU tract (Chlamydia trahomatis) or GI tract (Salmonella, Shigella, Yersinia, or Campylobacter). Single episode (mean length 4-7 months) or recurrent episodes of arthritis. Antibiotics improve recovery time for patients with Chlamydia-triggered reactive arthritis, but not with a GI cause.
(Chapter 114)

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7.

Which of the following statements concerning the treatment of gout is true?
- A.
  
  Colchicine can be safely used in patients with chronic renal insufficiency
- B.
  
  Allopurinol increases uric acid elimination and is useful during an acute gouty attack
- C.
  
  Intramuscular injections of ACTH are useful if NSAIDs are contraindicated
- D.
  
  Treatment with NSAIDs should continue for at least one week after symptoms have abated
- E.
  
  There is a high likelihood that a single administration of IM ACTH may lead to suppression of the hypothalamic-pituitary-adrenomedullary axis
Correct Answer
C. Intramuscular injections of ACTH are useful if NSAIDs are contraindicated

Explanation
Indomethacin is the most commonly used NSAID and should continue for 24 hours after the symptoms abate. Colchicine inhibits microtuble formation and impedes the inflammatory response to crystals in the joint. Colchicine is contraindicated in patients with hematologic, renal, and hepatic insufficiency. Oral prednisone is useful in resistant cases and intra-articular injection of steroids may be effective for individuals with only 1 or 2 joints involved once septic arthritis has been excluded. ACTH (40-80 IU IM) is a useful alternative to the above therapies. With only a single administration, hypothalamic-pituitary-adrenomedullary axis suppression should not occur.
Long term therapy of gout is aimed to decrease serum uric acid by either decreasing production (allopurinol) or increasing excretion (probenecid.) Chronic prophylactic agents should not be stopped or initiated during an acute attack. (Chapter 114)

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8.

Pseudogout differs from gout in that:
- A.
  
  The attacks tend to be more severe
- B.
  
  The typical patient is younger
- C.
  
  The crystals cannot be identified using microscopy
- D.
  
  Treatment with colchicines is contraindicated
- E.
  
  The knee is the most commonly involved joint
Correct Answer
E. The knee is the most commonly involved joint

Explanation
Pseudogout (calcium pyrophosphate dihydrate deposition disease) presents very similarly to gout, however these patients tend to be older and the knee is more commonly involved (the knee is the most common joint involved followed by the wrist, ankle and elbow). The average attack is not as severe as acute gout. Synovial fluid examination shows rhomboidal, weakly positive birefringent crystals of calcium pyrophosphate dihydrate. Treatment for an acute attack is identical for acute gout: NSAIDs, steroids, ACTH, or oral colchicine, although colchicine is not as effective as with gout. Prophylaxis is generally less effective. (Chapter 114)

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9.

The tendon most commonly involved in a rotator cuff injury is:
- A.
  
  Teres minor
- B.
  
  Supraspinatus
- C.
  
  Infraspinatus
- D.
  
  Deltoid
- E.
  
  Subscapularis
Correct Answer
B. Supraspinatus

Explanation
The muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. There are three progressive stages of impingement syndrome as a result of overuse. 1st – young athletes who participate in sports that require repetitive overhead motions of the shoulder; no weakness or loss of motion is present. 2nd – fibrosis and thickening of the tendon and subacromial bursa can occur, the pain becomes more constant and active motion may be limited by pain & any overhead movement exacerbates the symptoms. 3rd – range of motion of the shoulder is usually decreased due to disuse or a partial rotator cuff tear and pathologically tendon degeneration and attrition may be present. The supraspinatus tendon is the most often involved in rotator cuff tendinopathy. The “empty can test” (or Jobe’s sign) assesses the supraspinatus tendon against resistance. (Chapter 115)

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10.

In regards to provocative testing for tendinopathies, which of the following pairings is NOT correct?
- A.
  
  De Quervain’s tenosynovitis – Finkelstein test
- B.
  
  Rotator cuff tendinopathy – Neer test
- C.
  
  Achilles tendon rupture – Thompson test
- D.
  
  Bicipital tendinopathy – Empty can test
- E.
  
  Lateral epicondylitis – Cozen test
Correct Answer
D. Bicipital tendinopathy – Empty can test

Explanation
Provocative testing for teninopathies:
Rotator cuff tendinopathy:
- Empty can test – with the arms abducted at 90 degrees, the arms are internally rotated with the thumbs pointed downward, downward force is placed on the arms against resistance (weakness or pain = supraspinatus tendinopathy)
- Neer test – the examiner forward-flexes the arms causing impingement of the greater tuberosity of the humerus with the anterior & inferior edge of the acromium (pain = mechanical impingement of rotator cuff)
- Hawkins test – forcibly internally rotating the proximal humerus while the shoulder is forward-flexed to 90 degrees and the elbow is flexed to 90 degrees (pain = mechanical impingement of the rotator cuff)
- Drop arm test – the arm is passively abducted to 90 degrees and the patient is asked to maintain abduction (arm drops = complete rotator cuff tear)
- Shrug sign – when the arm is abducted to 90 degrees, the patient appears to be shrugging on that side (acute macrotrauma to the rotator cuff)
Bicipital teninopathy:
- Yergason’s sign – flex the elbow to 90 degrees with the arm against the body and resist supination of the forearm (pain in proximal biceps tendon = bicipital tendinopathy)
- Speed test – with the elbow extended and the forearm supinated, the patient resists forward flexion of the adducted shoulder at 60 degrees (pain in bicipital groove = bicipital tendinopathy or labral pathology)
Lateral epicondylitis:
- Cozen test – patient keeps fist clenched while extending the wrist while examiner grasps the forearm with one hand and pulls the patient’s hand toward flexion again the patient’s resistance (pain at lateral epicondyle = lateral epicondylitis)
De Quervain’s tenosynovitis:
- Finkelstein test – patient holds the affected thumb in the palm by the fingers and the wrist is then ulnar-deviated (pain near radial styloid = de Quervain’s)
Achilles tendon rupture:
- Thompson test (Simmonds test) – examiner squeezes the calf muscles with the patient prone and feet hanging over the edge of the bed (absence of plantar flexion = Achilles tendon tear)
(Chapter 115)

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11.

Which are the two most common sites of acute bursitis?
- A.
  
  Subacromial and anserine bursitis
- B.
  
  Olecrenon and trochanteric bursitis
- C.
  
  Iliopsoas and subacromial bursitis
- D.
  
  Prepatellar and subacromial bursitis
- E.
  
  Prepatellar and olecrenon bursitis
Correct Answer
E. Prepatellar and olecrenon bursitis

Explanation
The two most common identifiably inflamed bursae are the olecranon and prepatellar bursea. When inflamed, they are generally recognizable over the extensor surface of the elbow or knee, respectively. Many cases of bursitis are idiopathic, but common identifiable causes included infection (most commonly S. aureus), trauma, rheumatologic disorders, and other systemic diseases. The olecranon bursa is easily traumatized and is a the most common site of septic bursitis. (Chapter 115)

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12.

All of the following factors predispose a patient to develop septic bursitis except:
- A.
  
  Diabetes mellitus
- B.
  
  Trauma
- C.
  
  Advanced age
- D.
  
  Alcohol abuse
- E.
  
  Rheumatoid arthritis
Correct Answer
C. Advanced age

Explanation
Distinguishing septic from nonseptic bursitis is not always straightforward. Patients with septic bursitis generally present earlier in the clinical course, have more pain, tenderness, erythema, and warmth compared to those with an inflammatory process. The most important predisposing factor in septic bursitis is trauma (precedes septic arthritis in up to 70% of cases.) Other predisposing factors include: chronic illness (such a diabetes mellitus, alcohol abuse), chronic skin conditions, previous noninfectious inflammation of the bursae such as rheumatoid arthritis or gout, occupations in which there is repetitive trauma to the area. (Chapter 115)

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13.

All of the following conditions are part of the criteria used by the American Rheumatism Association for the diagnosis of systemic lupus erythematous except:
- A.
  
  Pericarditis
- B.
  
  Oral ulcers
- C.
  
  Positive antinuclear antibody
- D.
  
  Leukocytosis
- E.
  
  Proteinuria >0.5 g/24 hours
Correct Answer
D. Leukocytosis

Explanation
Although the triad of fever, joint pain, and rash in a woman of childbearing age suggests lupus, the diagnosis of systemic lupus erythematosus is made based on the American Rheumatism Association Revised Criteria for the Classification of Lupus. Patients must have four of eleven criteria, serially or simultaneously, to be given the diagnosis of SLE. (Chapter 116)

American College of Rheumatology Revised Criteria for the Classification of Systemic Lupus Erythematosus:
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis
- Serositis
o Pleuritis
o Pericarditis
- Renal disorders
o Persistent proteinuria > 0.5 g/24 hours or 3+ persistently
o Cellular casts
- Neurologic disorders
o Seizures
o Psychosis
- Hematologic disorders
o Hemolytic anemia
o Leukopenia
o Lymphopenia
o Thrombocytopenia
- Immunologic disorders
o Raised anti-native DNA antibody binding
o Anti-Sm antibody
o Positive antiphospholipid antibody (abnormal serum IgG or IgM anticardiolipin antibody or + lupus anticoagulant or false + serologic test for syphilis x 6 months confirmed by treponema pallidum fluorescent treponemal antibody absorption test)
- Positive antinuclear antibody
(Chapter 116)

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14.

The triad of fever, joint pain, and rash in a woman of childbearing age should suggest the diagnosis of systemic lupus. You also know that:
- A.
  
  70% of patients develop hitchhiker’s thumb
- B.
  
  Renal biopsy is not useful in the work-up or management of patients with SLE
- C.
  
  Bundle branch block is the most common cardiac manifestation, reported in 30% of patients
- D.
  
  Neurologic presentations, such as seizures, stroke, psychosis, migraines, are frequently the first signs of disease
- E.
  
  Oral ulcerations commonly accompany disease flares
Correct Answer
E. Oral ulcerations commonly accompany disease flares

Explanation
The vast majority of patients with SLE will experience arthritis. Arthritis in the hands, specifically the proximal interphalangeal and metacarpophalangeal joints is symmetrical and nonerosive. Thirty percent of patients develop hitchhiker’s thumb, hyperextension of the IP joint of the thumb. Up to 30% of patients have coexisting fibromyalgia. Chronic nephritis is seen in approx. 50% of patients. Renal biopsy can be useful in making treatment decisions in patients with renal disease. Pericarditis is the most common cardiac manifestation of SLE, reported in 30% of patients, with an associated effusion in 20% of patients. This rarely progresses to tamponade. The neurologic manifestations of SLE are varied (including seizures, stroke, psychosis, migraines, peripheral neuropathies) and may appear early in disease, but are rarely the initial sign of SLE. Approx 50% of patients with SLE will have CNS involvement. GI complaints in SLE are common and oral ulcerations usually accompany disease flares. Other more rare GI complaints include esophageal dysmotility, intestinal pseudo-obstruction, pancreatitis, SBP, portal hypertension, and intestinal vasculitis (the most serious GI complication.) (Chapter 116)

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15.

Drug-induced lupus usually presents with skin and joint manifestations. This condition is usually reversible when the agents are stopped. Which of the following medications is not commonly implicated in a lupus-like syndrome?
- A.
  
  Procainamide
- B.
  
  Acetaminophen
- C.
  
  Sulfonamides
- D.
  
  Phenytoin
- E.
  
  Hydralazine
Correct Answer
B. Acetaminophen

Explanation
Many agents have been implicated in drug-induced lupus. These patients usually present with skin and joint manifestations and the condition is usually reversible when the agents are stopped, although manifestations lasting for years have been reported. The most common causes are hydralazine, quinidine, and procainamide. Other drugs implicated are amiodarone, methyldopa, reserpine, isoniazid, penicillin, sulfonamides, streptomycin, tetracycline, nitrofurantoin, phenytoin, ethosuximide, primidone, PTU, chlorpromazine, lithium, D-penicillamine, phenylbutazone, allopurinol. (Chapter 116; see Table 116-1)

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16.

A 77-year-old woman complains of headache, low-grade fever, malaise, myalgias, intermittent blurred vision, jaw claudication, and other nonspecific symptoms. Regarding your suspected diagnosis, you know that:
- A.
  
  Absence of temporal artery tenderness would eliminate the possibility of this condition
- B.
  
  Polycythemia is a common finding
- C.
  
  Elevated ESR level may be a helpful diagnostic clue
- D.
  
  Onset of this disease is typically the age 40 years or younger
- E.
  
  Steroids must be withheld until arterial biopsy can be done
Correct Answer
C. Elevated ESR level may be a helpful diagnostic clue

Explanation
Temporal or giant cell arteritis is most common in branches of the carotid artery but may involve any large or medium artery. The disease is most commonly seen in women in the sixth and seventh decades of life. The classic symptoms of TA are consistent with ischemia to the organs fed by branches of the internal and external carotid artery: visual loss in one eye, temporal artery tenderness, and jaw claudication. Patients may complain of nonspecific, vague symptoms such as malaise, weight loss, and fever. Headache may be the initial complaint. Although the diagnosis is made clinically, helpful laboratory findings include elevated ESR (usually > 100 mm/hr on a Westergren blot), elevated CRP, and anemia. The definitive diagnosis is made by temporal artery biopsy. Most patients are extremely sensitive to glucocorticoids, and treatment should be started for any patient with a high clinical suspicion of TA. The steroids do not significantly change the results of the biopsy and may prevent progression to visual loss. (Chapter 116)

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17.

Which of the following statements regarding the small vessel vasculitides is false:
- A.
  
  Goodpasture’s syndrome is characterized by deposition of anti-glomerular basement membrane antibodies and results in alveolar hemorrhage and progressive glomerulonephritis
- B.
  
  The hallmark of Behcet’s disease is oral ulceration, which is required to make the diagnosis
- C.
  
  Approximately 2/3 of cases of HSP follow an upper respiratory tract infection
- D.
  
  Erythema nodosum more commonly affects men than women
- E.
  
  The initial complaints of patients presenting with Wegener’s granulomatosis are typically upper respiratory tract symptoms
Correct Answer
D. Erythema nodosum more commonly affects men than women

Explanation
Goodpasture’s syndomre is characterized by the linear deposition of anti-glomerular basement membrane antibodies in the glomerular and alveolar basement membrane resulting in alveolar hemorrhage and progressive glomerulonephritis. Environmental factors and genetic susceptibility are thought to play a role, but no clear etiology has been identified. All age groups are affected, with a peak incidence in men age 20-30 and second peak in both sexes age 50-70. Behcet’s disease is a chronic relapsing vasculitis characterized by oral and genital ulcerations, cutaneous lesions, and ophthalmologic, neurologic or GI manifestations. Oral ulceration is the hallmark of disease, tends to be the earliest manifestation, and is required for the diagnosis. An additional hallmark of the disease is a hypopyon uveitis, which is rarely seen. HSP is a small vessel vasculitis involving the skin, gut, and kidney which particularly affects children. The symptoms most often occur in winter and early spring and in 2/3 of cases follows an URI infection, with onset an average of 10 days after the start of the symptoms. Other inciting agents associated with HSP include insect stings and drugs. Erythema nodosum is a vasculitis of the venules in the subcutaneous layers of the skin. The cause is unclear, but usually the result of a hypersensitivity vasculitis caused by a circulating immune complex-mediated process from infections, drugs, or a systemic disease. Women are more commonly affected than men in a 6:1 ratio, with the peak incidence in the third decade of life. Wegener’s granulomatosis is a necrotizing granulomatous vasculitis involving the respiratory tract, kidneys, and the medium to small vessels in other organs. The mean age of onset is 45 and both sexes are affected equally. Patients first complain of upper respiratory tract symptoms with sinusitis, otitis, and nasal ulceration, and lower respiratory tract symptoms such as cough, dyspnea, hemoptysis, and asymptomatic pulmonary infiltrates. (Chapter 116)

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18.

Which of the following is not a commonly sited cause of anaphylaxis?
- A.
  
  Cat hair
- B.
  
  Crustaceans
- C.
  
  Wasp stings
- D.
  
  Penicillin
- E.
  
  Radiocontrast medium
Correct Answer
A. Cat hair

Explanation
The cause of anaphylaxis remains unidentified in more than one third of cases. When a cause can be determined, food, drugs, insect stings, and latex are the most common etiologic agents. Food is the cause in one third of known cases, most commonly peanuts and crustaceans. Insect stings, particularly bee and wasp stings, are an important cause of anaphylaxis, occurring in 0.5 to 5% of the population and accounting for 50 to 100 deaths per year in the United States. Penicillin allergy occurs at a frequency of one to five reactions per 10,000 treatments, with 1 per 50,000 to 100,000 treatments resulting in a fatality. Radiocontrast medium (RCM) reactions occur in 0.22% of patients given the hyperosmolar contrast agents but in only 0.04% of patients given the newer nonionic agents. Latex, the natural rubber widely used in the manufacture of medical products (latex gloves and latex medical devices), is a common source of allergy but an uncommon cause of anaphylactic reactions. (Chapter 117)

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19.

A healthy 27 year old male presents to the ED after being “stung” by something while apple picking. He complains of throat tightness and shortness of breath. On exam there is no rash and his lungs are clear to auscultation. His initial vitals are HR 119, BP 68/42, RR 26, O2 98% RA. What is the most appropriate initial treatment?
- A.
  
  Methylprednisolone 125 mg IV
- B.
  
  Diphenhydramine 50 mg IV
- C.
  
  Epinephrine 0.3 mg 1:10,000 solution IM
- D.
  
  Nebulized albuterol 2.5 mg diluted to 3 mL of normal saline
- E.
  
  Epinephrine 0.1 mg of 1:10,000 solution IV over 5 minutes
Correct Answer
E. Epinephrine 0.1 mg of 1:10,000 solution IV over 5 minutes

Explanation
Since most of the morbidity and mortality associated with anaphylaxis originates from acute respiratory failure or cardiovascular collapse, the immediate goal in the ED is to stabilize any cardiorespiratory insufficiencies while confirming the diagnosis of anaphylaxis and anaphylactic shock along with other diagnostic alternatives. If the patient demonstrates severe upper airway obstruction, acute respiratory failure, or shock, intravenous epinephrine should be administered. Use of the intravenous route with epinephrine increases the risk of supraventricular, accelerated idioventricular, and ventricular tachydysrhythmia; accelerated hypertension; and myocardial ischemia, including the stunned heart syndrome. Because of these risks, dilution and slow administration are recommended and continuous cardiac monitoring should be done at all times. See Rosen’s Chapter 117, Box 117-5 for treatment options for anaphylaxis.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Circulation. 2005;112:IV-143 – IV-145.)
Epinephrine:
* Administer epinephrine by IM injection early to all patients with signs of a systemic reaction, especially hypotension, airway swelling, or definite difficulty breathing.
* Use an IM dose of 0.3 to 0.5 mg (1:1000) repeated every 15 to 20 minutes if there is no clinical improvement.
–Administer IV epinephrine if anaphylaxis appears to be severe with immediate life-threatening manifestations.12
* Use epinephrine (1:10 000) 0.1 mg IV slowly over 5 minutes. Epinephrine may be diluted to a 1:10 000 solution before infusion.
* An IV infusion at rates of 1 to 4 µg/min may prevent the need to repeat epinephrine injections frequently.
(Chapter 117)

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20.

A 57 year old female presents to the Emergency Department in anaphylactic shock. Since her arrival, she has received epinephrine, methylprednisolone, diphenhydramine and ranitidine. Despite the aggressive treatment, she remains hypotensive. You suspect she is taking which of the following medications?
- A.
  
  Amlodipine
- B.
  
  Aspirin
- C.
  
  Levothyroxine
- D.
  
  Metoprolol
- E.
  
  Amiodarone
Correct Answer
D. Metoprolol

Explanation
Beta-blocker therapy is associated with an increase in the severity and, possibly, the incidence of acute anaphylaxis. Anaphylaxis in these patients may be severe, protracted and resistant to conventional treatment of epinephrine and antihistamines because of the beta adrenergic blockade. Some even consider beta blockers to be relatively contraindicated in patients who are susceptible to recurrent anaphylaxis. (Chapter 117)

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21.

The next therapy that should be administered to the patient in the previous question is:
- A.
  
  Atropine 0.3-0.5 mg IV
- B.
  
  Glucagon 1 mg IV
- C.
  
  Vasopressin 40 units IV
- D.
  
  Isoproterenol 0.05-0.2 g/kg/min
- E.
  
  Dopamine 5 g/kg/min
Correct Answer
B. Glucagon 1 mg IV

Explanation
Patients on beta blockers may be resistant to converntional treatments for anaphylaxis. Glucagon, with positive inotropic and chronotropic cardiac effects mediated independently of alpha- and beta-receptors, may be helpful in patients who are receiving beta-blockers and who do not respond to epinephrine and antihistamines. Glucagon is thought to effect positive inotropism by augmenting cAMP synthesis through a nonadrenergic pathway. The initial dose is 1 mg for adults and 0.5 mg for children subcutaneously, intramuscularly, or intravenously, and the patient may require a glucagon infusion of 1 to 5 mg/hr to sustain its therapeutic effect. Atropine (0.3–0.5 mg IV) and isoproterenol (0.05–0.2 µg/kg/min) can be tried as second-line therapy. Atropine is probably more useful for bradycardia and isoproterenol should be used as the last resort for the rare patient who is in refractory shock after all the preceding therapy. (Chapter 117)

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22.

A 48 year old male with a history of HTN presents with several hours of swelling of the lips and tongue. On further questioning, you determine that the patient takes an ACE inhibitor. Which of the following statements regarding this condition is incorrect?
- A.
  
  Angioedema involves the deeper dermal and subcutaneous tissue and commonly involves the face, mouth, lips, extremities, and genitalia
- B.
  
  10% of cases are classified as chronic with recurrent episodes persisting longer than 6 weeks
- C.
  
  There is a subset of angioedema which is hereditary due to an autosomal recessive condition caused by C1 esterase inhibitor deficiency or functional deficiency
- D.
  
  ACE inhibitor-induced angioedema may occur as many as 10 years after initiation of therapy
- E.
  
  All types of angioedema result in elevated bradykinin levels
Correct Answer
C. There is a subset of angioedema which is hereditary due to an autosomal recessive condition caused by C1 esterase inhibitor deficiency or functional deficiency

Explanation
Angioedema involves the deeper dermal and subcutaneous tissue and commonly involves the face, mouth, lips, tongue, extremities, and genitalia. Recurrent episodes of angioedema that last less than 6 weeks are considered acute (90%), and those that persist longer than 6 weeks are classified as chronic (10%). Angioedema without urticaria and pruritis is usually kinin related and causes include hereditary angioedema (HAE), acquired C1 inhibitor deficiency (ACID), and ACE inhibitors. All three result in elevated bradykinin levels. Substance P is also thought to play a role in ACE inhibitor-associated angioedema. HAE is an autosomal dominant condition caused by C1 esterase inhibitor deficiency or functional deficiency, which is biochemically confirmed by low levels of C4 and C1 esterase inhibitor activity. ACID is clinically indistinguishable from HAE attacks and is often associated with underlying lymphoproliferative diseases. The underlying disease results in consumption of C1 inhibitor or the development of anti-C1 inhibitor autoantibodies. ACE inhibitor-induced angioedema has an incidence of 0.1% to 0.7% and has a predilection for the tongue, lips, and laryngeal soft tissue. The highest incidence occurs in the first month of therapy, but it can occur as many as 10 years after therapy is started. Increased risk factors include African American race, smoking, older age, and female gender, while diabetes decreases the risk. The pathophysiology is thought to be prevention of the metabolism of bradykinin and substance P, both of which are potent mediators of tissue inflammation. Most patients who develop angioedema on ACE inhibitors should be able to tolerate ARB drugs. (Chapter 117)

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23.

A 4 year old female presents with several days of yellow crusting lesions only on her face. She is afebrile and nontoxic. The lesions are pruritic, but not painful. Which of the following statements is true?
- A.
  
  These lesions are not contagious
- B.
  
  Systemic antibiotics have been shown to prevent later occurrence of glomerulonephritis
- C.
  
  Group A streptococcus is the most common causative organism
- D.
  
  Without treatment, these lesions will heal in 3-6 weeks
- E.
  
  Systemic antibiotics have a higher cure rate than topical agents
Correct Answer
D. Without treatment, these lesions will heal in 3-6 weeks

Explanation
Impetigo is a slowly evolving pustular eruption, most common in preschool children. S. aureus is the most common pathogen, with group A strep a distant second. Impetigo is found most often on the face and other exposed areas and is highly contagious among infants and young children (less so in older children and adults.) The rash begins as pustular lesions with an erythematous base. When the lesions break, they leave red erosions covered with a yellow crust. Systemic and topical therapies are equally successful in treating impetigo. For extensive lesions, systemic treatment should be used. There is no evidence that systemic antibiotics prevent the development of acute glomerulonephritis. Treatment options include topical mupirocin, oral erythromycin (in adults), or cephalexin (in children.) Without, treatment, impetigo heals within 3-6 weeks. (Chapter 118)

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24.

A 23 year old healthy female presents 4 days after an elective rhinoplasty. She complains of fever and flu-like symptoms and she is now vomiting and somewhat confused. Her vital signs are: temperature 102.9, HR 126, BP 82/53. On exam, you note diffuse erythema. In regards to her diagnosis, which of the following is incorrect?
- A.
  
  This illness has been associated with an exotoxin-producing S. aureus and severe group A beta-hemolytic streptococcal infections
- B.
  
  The diagnosis of this illness requires fever, hypotension, and rash
- C.
  
  You can see pharyngitis, a “strawberry tongue,” conjunctivitis or vaginitis with this illness
- D.
  
  The rash associated with this illness is initially a diffuse, blanching erythroderma followed by full-thickness desquamation
- E.
  
  Antibiotics are not indicated in the treatment of this illness
Correct Answer
E. Antibiotics are not indicated in the treatment of this illness

Explanation
Toxic shock syndrome (TSS) is an acute febrile illness characterized by a diffuse desquamating erythroderma. Most cases occur in the postoperative setting. TSS has been linked to exotoxin-producing S. aureus and with severe group A beta-hemolytic streptococcal infections. Non-specific symptoms are followed by septic shock and multi-system organ failure. Diagnosis of TSS requires (1) fever of at least 38.9 C, (2) hypotension (SBP < 90 mmHg), (3) skin rash, and (4) involvement of at least three organ systems. The rash is typically a diffuse, blanching, macular erythroderma, often with mucous membrane inflammation. Pharyngitis, a “strawberry tongue,” conjunctivitis, or vaginitis may also be seen. The rash fades within approximately 3 days and is followed by full-thickness desquamation, most commonly of the hands and feet. Treatment consists of IVF, ventilatory support, vasopressors, penicillinase-resistant antibiotics, and drainage of any infected sites. (Chapter 118)

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25.

A young woman is concerned about some patches on her back and chest that did not tan over the summer. Her diagnosis is likely:
- A.
  
  Seborrheic dermatitis
- B.
  
  Tinea versicolor
- C.
  
  Vitiligo
- D.
  
  Pityriasis rosea
- E.
  
  Erythema multiforme
Correct Answer
B. Tinea versicolor

Explanation
Tinea versicolor is a superficial yeast infection caused by Pityrosporum ovale. Superficial scaling patches occur primarily on the chest and trunk, but may involve the head and limbs. Lesions can be a variety of colors and may be pruritic. These lesion do not tan. A KOH preparation shows short hyphae mixed with spores (“chopped spaghetti and meatballs.”) Tineas versicolor is treated with selenium sulfide shampoo, imidazole creams, or oral ketoconazole, but the recurrence rate is 15-50%.

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Dec 01, 2009

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