Transcript Question 1 - American Academy of Pediatrics

Infectious Disease Board Review
Stephen Barone MD
Michael Lamacchia, MD
Pediatric Program Director
Schneider Children's
Hospital
Associate Professor
New York University School
of Medicine
Chairman
St. Joseph’s Children’s
Hospital
Associate Professor
Mount Sinai School of
Medicine
Question 1
A healthy 3 year old
presents with a fever to
39.8 and stridor. The child
reportedly has had a 3 -day
history of a “bark-like”
cough, low grade fever and
URI symptoms. She
became acutely worse today
and appears “toxic”
The most likely diagnosis is?
1.
2.
3.
4.
5.
Viral laryngotracheitis
Epiglottis
Retropharyngeal
abscess
Foreign body
Bacterial tracheitis
Question 1
A healthy 3 year old
presents with a fever to
39.8 and stridor. The child
reportedly has had a 3 -day
history of a “bark-like”
cough, low grade fever and
URI symptoms. She
became acutely worse today
and appears “toxic”
The most likely diagnosis is?
1.
2.
3.
4.
5.
Viral laryngotracheitis
Epiglottis
Retropharyngeal
abscess
Foreign body
Bacterial tracheitis
Key Points # 1

Bacterial tracheitis


Epiglottis


Cough, stridor, non-toxic, parainfluenza
Retropharyngeal abscess


Older, unimmunized, drooling , toxic, no cough, H. Influenza
Viral laryngotrachitis


Fever, toxic, stridor, secretions, S aureus
Young, drooling, stiff neck
Foreign body

Acute onset, afebrile, historical clues
Question 2
A 2 month old infant
presents with a 2 -week
history of a cough,
perioral cyanosis and
posttussive vomiting.
The treatment of choice
is?
1.
2.
3.
4.
5.
High dose
Amoxicillin
Azithromycin
Clindamycin
Steroids
Trimethroprim sulfamethoxazole
Question 2
A 2 month old infant
presents with a 2 -week
history of a cough,
perioral cyanosis and
posttussive vomiting.
The treatment of choice
is?
1.
2.
3.
4.
5.
High dose
Amoxicillin
Azithromycin
Clindamycin
Steroids
Trimethroprim sulfamethoxazole
Key Point #2

Pertussis



Infants or Adolescents
Macrolide - limit spread
Differential Diagnosis

Chlamydia trachomatis


Staccato cough, tachypnea afebrile,
PCP

Hypoxic, toxic , immunodeficiency
Question 3
A 5 year-old presents with
migratory arthritis and
shortness of breath. On
exam you notice a
holosystoic murmur
The most likely diagnosis
is?
1.
2.
3.
4.
5.
Fifth disease
Juvenile rheumatoid
arthritis
Rheumatic fever
Systemic Lupus
Lyme Disease
Question 3
A 5 year-old presents with
migratory arthritis and
shortness of breath. On
exam you notice a
holosystoic murmur
The most likely diagnosis
is?
1.
2.
3.
4.
5.
Fifth disease
Juvenile rheumatoid
arthritis
Rheumatic fever
Systemic Lupus
Lyme Disease
Key Points #3

Group A Streptococcus infections



Exudative pharyngitis, fever, anterior nodes
Treatment – Penicillin
Rheumatic fever




Arthritis, chorea, carditis, nodules, erythema
marginatum
Prophylaxis
Scarlet fever – no prophylaxis
PSGN

Skin infections, not preventable with antibiotics
Question 4
A 12 year boy with a three
week history of nasal
congestion, cough and
nasal discharge presents
with a headache,
vomiting and 6th nerve
palsy
The next step in his
evaluation should be?
1.
2.
3.
4.
5.
Lumbar puncture
CT scan head and sinuses
Lyme serology
Maxillary sinus aspiration
Slit lamp examination of
the eyes?
Question 4
A 12 year boy with a three
week history of nasal
congestion, cough and
nasal discharge presents
with a headache,
vomiting and 6th nerve
palsy
The next step in his
evaluation should be?
1.
2.
3.
4.
5.
Lumbar puncture
CT scan head and
sinuses
Lyme serology
Maxillary sinus
aspiration
Slit lamp examination of
the eyes?
Key Points #4

Symptoms – 2 weeks




Complications of sinusitis




Congestion,
Nasal discharge
Facial pain
Cerebral venous thrombosis
Orbital cellulitis
Brain abscess – Pott’s puffy tumor
S. pneumoniae, M. catarrhalis, H. influenzae

Chronic – S. aureus, anaerobes
Question 5
A 5 year old with chronic
ear infections who had a
chronic inflammation of
the middle ear,
perforation and
otorrhea has what
condition?
1.
2.
3.
4.
5.
Cholestatoma
Chronic suppurative
otitis media
Serous otitis media
Otitis externa
Labyrinthitis
Question 5
A 5 year old with chronic
ear infections who had a
chronic inflammation of
the middle ear,
perforation and
otorrhea has what
condition?
1.
2.
3.
4.
5.
Cholestatoma
Chronic suppurative
otitis media
Serous otitis media
Otitis externa
Labyrinthitis
Key Points #5

Acute Otitis Media


Chronic Suppurative Otitis Media


Above plus S. aureus, P.aeruginosa
Cholesteatoma


S. pneumoniae, H. influenzae, M. catarrhalis
Cystic structure – chronic OM
Otitis Externa

Intact TM - P.aeruginosa and S. aureus
Question 6
A 3 year old presents
with a 1 month history of
unilateral cervical
adenitis. The child has
been well appearing,
afebrile and has had not
traveled. A PPD
measures 6 mm
The next step in the
management is?
1.
2.
3.
4.
5.
Isoniazid and Rifampin
for 6 months
A repeat PPD in 3 months
A CT of the neck
Excisional biopsy
Azithromycin for 4 weeks
Question 6
A 3 year old presents
with a 1 month history of
unilateral cervical
adenitis. The child has
been well appearing,
afebrile and has had not
traveled. A PPD
measures 6 mm
The next step in the
management is?
1.
2.
3.
4.
5.
Isoniazid and Rifampin
for 6 months
A repeat PPD in 3 months
A CT of the neck
Excisional biopsy
Azithromycin for 4 weeks
Key Points #6

Unilateral adenitis
 Acute
 S. aureus, Group A Streptococcus
 Antibiotics
 Sub acute
 Atypical Mycobacterium
 History, PPD, excisional biopsy
 Cat Scratch
 History, serology, no treatment
 Kawasaki Disease
 IVIG
 Chronic
 Malignancy
Question 7
A 15 year old boy
develops a fever to 101oF,
headache and bilateral
swelling of his parotid
glands.
The most likely
complication of this
illness is?
1.
2.
3.
4.
5.
Acute airway
obstruction
Sensorineural hearing
loss
Orchitis
Myocarditis
Arthritis
Question 7
A 15 year old boy
develops a fever to 101oF,
headache and bilateral
swelling of his parotid
glands
The most likely
complication of this
illness is?
1.
2.
3.
4.
5.
Acute airway
obstruction
Sensorineural hearing
loss
Orchitis
Myocarditis
Arthritis
Key Points #7

Parotitis



Bacterial – ill appearing
Viral
Mumps


Viral syndrome with swelling of parotid glands
Complication




Orchitis
CSF pleocytosis – most asymptomatic
Rare – myocarditis, arthritis etc.
Vaccine

Live vaccine
Question 8
A 15 year old complains
of a sore throat, fever and
a muffled voice. She stepped
on a sharp piece of metal 4
days ago. On examination
The adolescent also has
trismus.
The most likely diagnosis is?
1.
2.
3.
4.
5.
Tetanus
Retropharyngeal abscess
Infectious mononucleosis
Peritonsillar abscess
Herpangia
Question 8
A 15 year old complains
of a sore throat, fever and
a muffled voice. She stepped
on a sharp piece of metal 4
days ago. On examination
The adolescent also has
trismus.
The most likely diagnosis is?
1.
2.
3.
4.
5.
Tetanus
Retropharyngeal abscess
Infectious mononucleosis
Peritonsillar abscess
Herpangia
Key Points #8





Peritonsillar abscesses
 Adolescent, sore throat, hot potato voice, trismus
 Dx – exam
 Organisms –S. aureus. Group A Streptococcus, Anaerobes
Retropharyngeal abscess
 Toddler, stridor, stiff neck, dysphagia, torticollis
 Dx – CT scan
Infectious Mononucleosis
 Adolescent, sore throat, lymphadepathy, fatigue, fever
Tetanus
 Trismus and muscle spasm
 C. tetani
 Treatment
 Tdap, TIG
 Penicillin
Herpangina
 Peritonsillar ulcers/vesicles
 Enteroviral infection
Question 9
A 9 month old presents
with vesicular lesions on
his lips and bleeding
gums. He is drooling
and unable to eat. On his
trunk is a “target lesion rash”
In addition to hydration,
Which therapeutic
regime will be most
effective?
1.
2.
3.
4.
5.
IV acyclovir
IV nafcillin
Topical nystatin
Topical mupirocin
IV steroids
Question 9
A 9 month old presents
with vesicular lesions on
his lips and bleeding
gums. He is drooling
and unable to eat. On his
trunk is a “target lesion rash”
In addition to hydration,
Which therapeutic
regime will be most
effective?
1.
2.
3.
4.
5.
IV acyclovir
IV nafcillin
Topical nystatin
Topical mupirocin
IV steroids
Key Points #9

Herpes gingivostomatitis





Herpangina


Posterior vesicles
Candida


Young child, anterior vesicles, swollen gums
Treatment – supportive, Acyclovir
Complication – erythema multiforme
Dx – Culture, DFA
Cottage cheese plaques on buccal mucosa
Impetigo


Honey crust lesions on the skin
Group A Streptococcus, S. aureus
Question 10
A 3 year old presents with a three
day history of fever and cough.
Today he developed respiratory
distress. In addition to supportive
care what is the most appropriate
treatment plan?
1.
2.
3.
4.
5.
CT Scan of chest
Ceftriaxone
PPD
Bronchoscopy
Amphotericin
Question 10
A 3 year old presents with a three
day history of fever and cough.
Today he developed respiratory
distress. In addition to supportive
care what is the most appropriate
treatment plan?
1.
2.
3.
4.
5.
CT Scan of chest
Ceftriaxone
PPD
Bronchoscopy
Amphotericin
Key Points #10

Pneumococcal pneumonia
Most common bacterial pneumonia
 Acute, fever, tachypnea, cough, focal infiltrate



Round pneumonia
Treatment
Inpatient – Ceftriaxone
 Outpatient – High dose Amoxicillin
 Resistance – Lack of PCP’s

Question 11
A 5 year old presents
with a month history of
cough, fever and weigh
loss. His CXR shows a
focal infiltrate with hilar
lymphadenopathy. A
PPD is 7 mm.
The most appropriate
treatment plan is?
1.
2.
3.
4.
5.
Repeat PPD in 3 months
Bronchoscopy
Gastric lavage
Isoniazid for nine
months
Isoniazid, Rifampin and
Ethambutal for 6 months
Question 11
A 5 year old presents
with a month history of
cough, fever and weigh
loss. His CXR shows a
focal infiltrate with hilar
lymphadenopathy. A
PPD is 7 mm.
The most appropriate
treatment plan is?
1.
2.
3.
4.
5.
Repeat PPD in 3 months
Bronchoscopy
Gastric lavage
Isoniazid for nine
months
Isoniazid, Rifampin and
Ethambutal for 6 months
Key Points # 11

Mycobacterium tuberculosis

History


PPD





Immigrant, insidious, weight loss, hilar nodes
5 mm – high risk – symptoms, HIV
10 mm – medium – age less than 6, immigrant, travel
15 mm – low
Diagnosis – gastric lavage
Treatment

Four drugs then based on sensitivities


Side-effects
Prophylaxis

INH – 9 months
Question 12
A ten year old boy presents
with a four day history of
cough, fever and myalgia. A
rapid influenza test was
positive two days ago in his
physician’s office. Today he
became acutely worse and is
in respiratory distress.
The most appropriate therapy
is?
1.
2.
3.
4.
5.
Oseltamivir
Ribavirin
Clindamycin
Aztreonam
Azithromycin
Question 12
A ten year old boy presents
with a four day history of
cough, fever and myalgia. A
rapid influenza test was
positive two days ago in his
physician’s office. Today he
became acutely worse and is
in respiratory distress.
The most appropriate therapy
is?
1.
2.
3.
4.
5.
Oseltamivir
Ribavirin
Clindamycin
Aztreonam
Azithromycin
Key Points #12

Influenza
Fever, cough, myalgia
 Oseltamivir – within 48 hours
 Influenza vaccine – 2A, 1B
 Antigenic shift vs. antigenic drift


Complications

S. aureus pneumonia

MRSA

Clindamycin, Vancomycin
Question 13
A febrile irritable 20 month old
male presents with a two
day history of a “crusty”
excoriation under his nose
This was followed by a
diffuse erythematous painful
rash.
The most likely diagnosis
is?
1.
2.
3.
4.
5.
Kawasaki disease
Staphylococcal
scalded skin
syndrome
Toxic shock
syndrome
Roseola
Enteroviral infection
Question 13
A febrile irritable 20 month old
male presents with a two
day history of a “crusty”
excoriation under his nose
This was followed by a
diffuse erythematous painful
rash.
The most likely diagnosis
is?
1.
2.
3.
4.
5.
Kawasaki disease
Staphylococcal
scalded skin
syndrome
Toxic shock
syndrome
Roseola
Enteroviral infection
Key Points #13
1.
Staphylococcal Scalded Skin Syndrome
1.
Symptoms
1.
2.
Non-toxic, impetigo, painful, sunburn rash, skin peels
readily.
Toxic Shock Syndrome
1.
2.
3.
4.
Hypotension
Fever
Rash
Desquamation
1.
Plus three or more organ systems involved
Question #14
Which of these infectious
diseases often is
accompanied by
hyponatremia?
1.
2.
3.
4.
5.
Roseola
Measles
Rocky Mountain
Spotted Fever
Lyme disease
Leptospirosis
Question #14
Which of these infectious
diseases often is
accompanied by
hyponatremia?
1.
2.
3.
4.
5.
Roseola
Measles
Rocky Mountain
Spotted Fever
Lyme disease
Leptospirosis
Key Points # 14

Rocky Mountain Spotted Fever

Epidemiology, distal petiechiae, headache,
increased LFT’s, hyponatremia


Treatment – doxycycline
Lyme Disease

Northeast, Wisconsin, Northern CA

Rash, arthritis (mono), meningitis

Treatment
 Amoxicillin, Doxycycline
 Ceftriaxone
Question #15
A year old child presents
with a four day history of
irritability and recurrent
fevers. Today he is afebrile
and had a diffuse
erythematous rash on his
trunk. You diagnosis the
child with roseola.
Which of the following is a
common complication of this
disease?
1.
2.
3.
4.
5.
Arthritis
Febrile seizures
Aseptic meningitis
Thrombocytopenia
Hepatitis
Question #15
A year old child presents
with a four day history of
irritability and recurrent
fevers. Today he is afebrile
and had a diffuse
erythematous rash on his
trunk. You diagnosis the
child with roseola.
Which of the following is a
common complication of this
disease?
1.
2.
3.
4.
5.
Arthritis
Febrile seizures
Aseptic meningitis
Thrombocytopenia
Hepatitis
Key Points # 15

Roseola

Fever followed by rash


Complications


HHV6 infection
Febrile seizures
Complications




Parvovirus – arthritis
EBV – hepatitis
Aseptic meningitis – Kawasaki
Thrombocytopenia - RMSF
Question 16
A child presents with
abdominal pain, arthritis
and this rash.
What is the most
appropriate treatment?
1.
2.
3.
4.
5.
Ceftriaxone
IVIG
Doxycycline
Clindamycin
Supportive care
Question 16
A child presents with
abdominal pain, arthritis
and this rash.
What is the most
appropriate treatment?
1.
2.
3.
4.
5.
Ceftriaxone
IVIG
Doxycycline
Clindamycin
Supportive care
Key Point #16

Henoch – Schonlein Purpura


Palpable purpura, lower extremities, bloody stools
(colitis, intussusception) ,arthritis, hematuria
Treatment



Supportive
Steroids?
Differential Diagnosis



Meningococcal – Ceftriaxone
RMSF – Doxycycline
Kawasaki - IVIG
Question #17
Which vaccine(s)
is (are) not routinely
recommended for catch
up vaccination for
children greater than 5
years of age?
1.
2.
3.
4.
5.
Varicella
Hib
Pneumococcal
Hib &Pneumococcal
DTaP
Question #17
Which vaccine(s)
is (are) not routinely
recommended for catch
up vaccination for
children greater than 5
years of age?
1.
2.
3.
4.
5.
Varicella
Hib
Pneumococcal
Hib &Pneumococcal
DTaP
Key Point #17

Hib and Pneumococcal vaccines


DTaP


No catch up greater than 5
4 doses
Varicella

Always catch -up
Question 18
A fourteen year old male
presents to the ED after
sustaining a laceration
with a lawn motor blade.
He cannot recall when he
received his last tetanus
vaccine. Although his
mother say he received all his
shots when he was a baby
He should receive?
1.
2.
3.
4.
5.
Td and TIG
TdaP
DT
TdaP and TIG
TIG
Question 18
A fourteen year old male
presents to the ED after
sustaining a laceration
with a lawn motor blade.
He cannot recall when he
received his last tetanus
vaccine. Although his
mother say he received all his
shots when he was a baby
He should receive?
1.
2.
3.
4.
5.
Td and TIG
TdaP
DT
TdaP and TIG
TIG
Key Points # 18
DTaP – under 7
TdaP – Adol and Adults
Td – greater than 7
DT – less than 7
Vaccine
Clean
Td /TIG
Dirty
Td /TIG
Unknown
or < 3
doses
Y/N
Y/Y
3+
doses
Y/N
Y/N
If greater
10 yrs
If < 5 yrs
Question #19
Which of these two
vaccine pairs, if not give
simultaneously (at the
same visit) should be
separated by at four least
weeks?
1.
2.
3.
4.
5.
Hepatitis A and
Hepatitis B
IPV and Pneumococcal
DTaP and Hib
MMR and Varicella
MMR and Hepatitis B
Question #19
Which of these two
vaccine pairs, if not give
simultaneously (at the
same visit) should be
separated by at four least
weeks?
1.
2.
3.
4.
5.
Hepatitis A and
Hepatitis B
IPV and Pneumococcal
DTaP and Hib
MMR and Varicella
MMR and Hepatitis B
Key Points #19

Live vaccines if not given simultaneously
need to be separated by 4 weeks


Learn contraindications of live vaccines
“egg based” vaccines
Influenza (injectable)
 Yellow fever
 Measles and mumps (chick embryo)

Question # 20
A 5 year old presents with
fever, jaundice and
vomiting. A hepatitis profile
reveals:
Hepatitis A IgM – negative
Hepatitis A IgG- positive
Hepatitis BsAg –negative
Hepatitis BsAb – positive
Hepatitis BcAb – negative
Interpretation?
1.
2.
3.
4.
5.
Acute hepatitis A and B
infections
Chronic hepatitis A and B
infections
Previous vaccination
against hepatitis A and B
Chronic hepatitis B
infection and acute
hepatitis B infection
Past hepatitis B infection
and acute hepatitis B
infections
Question # 20
A 5 year old presents with
fever, jaundice and
vomiting. A hepatitis profile
reveals:
Hepatitis A IgM – negative
Hepatitis A IgG- positive
Hepatitis BsAg –negative
Hepatitis BsAb – positive
Hepatitis BcAb – negative
Interpretation?
1.
2.
3.
4.
5.
Acute hepatitis A and B
infections
Chronic hepatitis A and B
infections
Previous vaccination
against hepatitis A and B
Chronic hepatitis B
infection and acute
hepatitis B infection
Past hepatitis B infection
and acute hepatitis B
infections
Key Points #20

Hepatitis A
IgM – Acute
IgG – Acute, past, vaccine
Tests
Results
Interpretation
BsAg
BcAb
BsAb
Negative
Negative
Positive
Vaccine
BsAg
BcAb
BsAb
Negative
Positive
Positive
Past
infection
BsAg
BcAb
BsAb
Positive
Positive
Negative
Acute
infection
BsAg
BcAb
BsAb
Positive
Positive
Negative
Chronic
infection
Question 21
Which of these
pathogens pairs typically
infect the colon?





Salmonella and Rotavirus
Shigella and Giardia
Campylobacter and
Shigella
Yesinia and Giardia
Salmonella and
Helicobacter
Question 21
Which of these
pathogens pairs typically
infect the colon?





Salmonella and Rotavirus
Shigella and Giardia
Campylobacter and
Shigella
Yesinia and Giardia
Salmonella and
Helicobacter
Key Points # 21

Small intestine

Watery, high volume, frequent


Rotavirus. Norwalk, Adenoviurs, Giardia
Large Intestine

Blood, small volume, mucus, travel







Salmonella – food, turtles
Campylocbacter – unpasteurized milk, GBS
Yersina – “chittlings”
Shigella – food, neurotoxin
E-coli O157H7- food, HUS
E-coli – travel associated – watery
C. difficle - antibiotics
Question 22
An 12 year old returns from a
three month trip to India.
She complains of a 10 day
history of fever, chills,
abdominal pain and myalgia.
Her examination is
unremarkable
Lab results
WBC – 6,000
Hb – 13.6
Plt – 400,000
AST – 120
Her most likely diagnosis is?
1.
2.
3.
4.
5.
Malaria
Typhoid fever
TB
Hepatitis B
Yellow fever
Question 22
An 12 year old returns from a
three month trip to India.
She complains of a 10 day
history of fever, chills,
abdominal pain and myalgia.
Her examination is
unremarkable
Lab results
WBC – 6,000
Hb – 13.6
Plt – 400,000
AST – 120
Her most likely diagnosis is?
1.
2.
3.
4.
5.
Malaria
Typhoid fever
TB
Hepatitis B
Yellow fever
Key Points #22

Malaria


Typhoid


Longer incubation period
Hepatitis B


Flu- like illness, normal WBC
TB


Fever, splenomegaly, hemolytic anemia
No risk factor for traveling adolescents
Yellow fever

Africa, South America
Question 23
Which is the preferred
diagnostic test to confirm an
HIV infection in one month
old infant born to an
HIV positive mother?
1.
2.
3.
4.
5.
HIV p24 antigen assay
HIV DNA PCR
HIV culture
HIV serology
CD4/CD8 ratio
Question 23
Which is the preferred
diagnostic test to confirm an
HIV infection in one month
old infant born to an
HIV positive mother?
1.
2.
3.
4.
5.
HIV p24 antigen assay
HIV DNA PCR
HIV culture
HIV serology
CD4/CD8 ratio
Key Points #23


HIV serology can be falsely positive for up to 18
months after birth
HIV p24 antigen test – false positives and negatives


HIV culture – requires 4 weeks, not readily available


Not recommended
HIV DNA PCR



Not recommended
Highly sensitive and specific
Considered infected if two separate positive tests
CD4/CD8 ratio

Not useful in the neonatal period
Question 24
A full-term normal-appearing
infant was born to a 26-year old
female with a history of syphilis
during the first trimester of
pregnancy, as evidenced by the
seroconversion of her VDRL
result (titer 1:4, previously
nonreactive). The woman
received one injection of 2.4
million units of benzathine
penicillin. At delivery, her
VDRL had a titer of 1:64. In
evaluating this infant the
appropriate conclusion is that -
A.
B.
C.
D.
The mother has been
adequately treated, and the
infant requires no further
therapy
The infant has a high
probability of having
congenital syphilis and
requires evaluation and
treatment
If the infant’s long bone
radiographs show no
abnormality, no treatment is
indicated
This child may be given a shot
of benzathine penicillin, and
no further serologic evaluation
is necessary
Question 24
A full-term normal-appearing
infant was born to a 26-year old
female with a history of syphilis
during the first trimester of
pregnancy, as evidenced by the
seroconversion of her VDRL
result (titer 1:4, previously
nonreactive). The woman
received one injection of 2.4
million units of benzathine
penicillin. At delivery, her
VDRL had a titer of 1:64. In
evaluating this infant the
appropriate conclusion is that -
A.
B.
C.
D.
The mother has been
adequately treated, and the
infant requires no further
therapy
The infant has a high
probability of having
congenital syphilis and
requires evaluation and
treatment
If the infant’s long bone
radiographs show no
abnormality, no treatment is
indicated
This child may be given a shot
of benzathine penicillin, and
no further serologic evaluation
is necessary
Key Points #24
Evaluate infants for congenital syphilis if:
• Fourfold increase in maternal titer
• Infant has clinical manifestations of syphilis
• Syphilis is untreated, inadequately treated, or treatment not documented
• Mother treated with non-penicillin regimen
• Mother treated <1 month before delivery
• Treated before pregnancy but with insufficient serologic follow-up
Evaluation for syphilis in an infant:
• Quantitative nontreponemal serologic test of serum from infant
• VDRL test of CSF, cell count, protein concentration
• Long-bone Xrays
• CBC w/platelets
• Other clinically indicated tests (C Xray, LFT’s, US, eye exam, auditory brain stem)
• Pathologic examination of placenta or umbilical cord using FTA staining if possible
Question 25
A 10-year-old child
develops ascending
paralysis with
peripheral neuropathy
(cranial nerves are
normal); the CSF is
normal except for an
elevated protein level.
The likely infectious
agent precipitating this
syndrome is -
A.
B.
C.
D.
E.
Corynebacterium
diphtheriae
Clostridium botulinum
S. dysenteriae serotype 1
Campylobacter jejuni
Clostridium tetani
Question 25
A 10-year-old child
develops ascending
paralysis with
peripheral neuropathy
(cranial nerves are
normal); the CSF is
normal except for an
elevated protein level.
The likely infectious
agent precipitating this
syndrome is -
A.
B.
C.
D.
E.
Corynebacterium
diphtheriae
Clostridium botulinum
S. dysenteriae serotype 1
Campylobacter jejuni
Clostridium tetani
Keypoints #25
Guillain-Barre Syndrome
• Motor polyradiculoneuropathy
• Muscle pain, symmetric, ascending paresis with minor sensory abnormality
Diagnostic criteria:
Required –
Progressive muscle weakness of more than 1 limb
Areflexia
Strongly supportive –
Relative symmetry
Mild or no sensory
Cranial nerve involvement
Autonomic dysfunction
Absence of fever
Disease progression halts by 4 weeks
Recovery
Keypoint #25 - continued
CSF features –
Elevated protein after first week
Fewer than 10 mononuclear cells
Electrodiagnostic features –
Nerve conduction slowing
Etiology:
Campylobacter jejuni
CMV
EBV
M. pneumoniae
Vaccine ie., swine flu, Menactra, rabies, tetanus toxoid, Hep. B, influenza,
enteroviruses, west nile
Food borne diseases (Shighella, Enteroinvasive E. coli, Yersinia enterocolitica,
vibrio parahaemolyticus)
Question 26
Congenital rubella
syndrome is associated
with which of the
following?
A.
B.
C.
D.
E.
Patent ductus arteriosus
(PDA) and branch
pulmonary artery stenosis
Ventricular septal defect
(VSD) and PDA
Atrial septal defect (ASD)
and PDA
VSD and ASD
VSD and pulmonary
artery stenosis
Question 26
Congenital rubella
syndrome is associated
with which of the
following?
A.
B.
C.
D.
E.
Patent ductus arteriosus
(PDA) and branch
pulmonary artery stenosis
Ventricular septal defect
(VSD) and PDA
Atrial septal defect (ASD)
and PDA
VSD and ASD
VSD and pulmonary
artery stenosis
Keypoint #26
Congenital Rubella Syndrome
Manifestations –
• Ophthalmologic
Cataracts, pigmentary retinopathy, micro phthalmos congenital glaucoma
• Cardiac
Patent ductus arteriosus, peripheral pulmonary artery stenosis
• Auditory
Sensorineural hearing impairment
• Neurologic
Behavioral disorders, meningoencephalitis, mental retardation
• Neonatal
Growth retardation, interstitial pneumonitis, radiolucent bone disease,
hepatosplenomegaly, thrombacytopenis, dermal erythropoiesis
Occurrence of Congenital Defects –
• 85% if mother has rash in first 12 weeks
• 34% 13-16 weeks
• 25% during end of second trimester
Question 27
A 4-year-old male is brought to your
office because of a circular reddish
rash under his armpit. The child
has been afebrile and has had no
other systemic symptoms. The rash
is not pruritic. The child’s parents
state that they have recently
returned from a vacation in
Massachusetts on Cape Cod and
that a small tick had been removed
from the same area where the rash
is now. The only abnormality on
the examination is the circular, flat,
erythematous rash that is about 6
cm in diameter and is not tender.
The appropriate next step in
treating this patient is to -
A.
B.
C.
D.
E.
Order a test for serum antibodies
against Borrelia burgdorferi to
confirm that the child has Lyme
disease
Begin treatment with doxycycline
Begin treatment with amoxicillin
Begin treatment with ceftriaxone
Perform a lumbar puncture to be
certain that the child’s central
nervous system (CNS) is not
involved.
Question 27
A 4-year-old male is brought to your
office because of a circular reddish rash
under his armpit. The child has been
afebrile and has had no other systemic
symptoms. The rash is not pruritic.
The child’s parents state that they have
recently returned from a vacation in
Massachusetts on Cape Cod and that a
small tick had been removed from the
same area where the rash is now. The
only abnormality on the examination is
the circular, flat, erythematous rash that
is about 6 cm in diameter and is not
tender. The appropriate next step in
treating this patient is to -
A.
B.
C.
D.
E.
Order a test for serum antibodies
against Borrelia burgdorferi to
confirm that the child has Lyme
disease
Begin treatment with doxycycline
Begin treatment with amoxicillin
Begin treatment with ceftriaxone
Perform a lumbar puncture to be
certain that the child’s central
nervous system (CNS) is not
involved.
Keypoint #27
Lyne Disease
• Early localized disease
Erthema migrans at site of tick bite
• Early disseminated
Multiple erythema migrans
Cranial nerve palsies
Lymphocytic meningitis
Conjunctivitis
Arthritis
Carditis
• Late
Recurrent arthritis
Peripheral neuropathy
CNS
Diagnosis –
• Clinical (EM) during early stages
• Clinical and serologic in early disseminated or late
• Serology
EIA or IFA for screening
Western Immunoblot
1 gG 5 bands
1 gM 2 bands
Question 28
Primary pulmonary
histoplasmosis in
normal children is
usually -
A.
B.
C.
D.
E.
Asymptomatic
Associated with severe
flu-like symptoms
Treated with assisted
ventilation and steroid
therapy
Associated with sarcoidlike disease
Complicated by
mediastinal fibrosis
Question 28
Primary pulmonary
histoplasmosis in
normal children is
usually -
A.
B.
C.
D.
E.
Asymptomatic
Associated with severe
flu-like symptoms
Treated with assisted
ventilation and steroid
therapy
Associated with sarcoidlike disease
Complicated by
mediastinal fibrosis
Keypoint #28
Histoplasmosis
• Causes symptoms in fewer than 5% of infected people
• Site (pulmonary, extrapulmonary, disseminated)
• Duration (acute, chronic)
• Pattern (primary vs. reactivation)
• Mississippi, Ohio, Missouri River Valley
Coccidiomycosis
• Asymptomatic or self-limited 60%
• May resemble influenza, diffuse erythematous maculopapular rash, erythema
multiforme, erythema nodosum
• dissemination to skin, bones, joints, CNS is rare
• California, Arizona, New Mexico, Texas, Utah, northern New Mexico, certain
areas of Central and South America
Blastomycosis
• May be asymptomatic or acute, chronic or fulminant disease
• Pulmonary and cutaneous lesions
• Can disseminate to bones, CNS, abdominal viscera, kidneys
• Southeastern and central states and those bordering Great Lakes
Question 29
All of the following are
consistent with the
diagnosis of congenital
toxoplasmosis in an
infant EXCEPT -
A.
B.
C.
D.
E.
An infant with normal findings
on newborn evaluation
An infant who is small for
gestational age
A CSF protein level of 3 g/dL
An infant whose mother has
no serologic evidence of
Toxoplasma gondii infection
An infant who mother has
AIDS and is chronically
infected with T. gondii
Question 29
All of the following are
consistent with the
diagnosis of congenital
toxoplasmosis in an
infant EXCEPT -
A.
B.
C.
D.
E.
An infant with normal findings
on newborn evaluation
An infant who is small for
gestational age
A CSF protein level of 3 g/dL
An infant whose mother has
no serologic evidence of
Toxoplasma gondii infection
An infant who mother has
AIDS and is chronically
infected with T. gondii
Keypoint #29
Congenital Toxoplasmosis
• Asymptomatic at birth 70-90%
• Many will go on to have visual impairment, learning disabilities, mental
retardation
• At birth, may have maculopapular rash, generalized lymphadenopathy,
hepatomegaly, splenomegaly, jaundice, thrombocytopenia
• CNS manifestations: hydrocephalus, microcephaly, chorioretinitis,
seizures, deafness
• Cerebral calcifications are diffuse
• Members of cat family are definitive hosts
Question 30
A 5-month-old previously
healthy female is brought
to her pediatrician
because of fever,
irritability, and poor
feeding. She is the
second child in her
daycare center to be
diagnosed with
meningitis within a
week. She has received
all recommended
immunizations. The
most likely cause of her
meningitis is -
A.
B.
C.
D.
E.
Haemophilus influenzae
Neisseria meningitidis
Group B streptococci
Herpes simplex virus
Listeria monocytogenes
Question 30
A 5-month-old previously
healthy female is brought
to her pediatrician
because of fever,
irritability, and poor
feeding. She is the
second child in her
daycare center to be
diagnosed with
meningitis within a
week. She has received
all recommended
immunizations.
The most likely cause of her
meningitis is -
A.
B.
C.
D.
E.
Haemophilus influenzae
Neisseria meningitidis
Group B streptococci
Herpes simplex virus
Listeria monocytogenes
Keypoint #30
Neisseria Meningitidis
• Children younger than 5, greatest attack rate in less than 1 year
• Adolescents 15-18 years
• Freshmen college students who live in dormitories
• Close contacts of patients with meningococcal disease
• Deficiency of terminal complement, properdin, or anatomic or functional
asplenia
• A, B, C, Y, W-135
• Meningococcemia, meningitis
• Waterhouse-Friderichsen-purpura, DIC, shock, coma, death
Question 31
Of the following drugs,
the one most
commonly associated
with acute interstitial
nephritis is -
A.
B.
C.
D.
E.
Sulfisoxazole
Methicillin
Nafcillin
Penicillin
Phenytoin
Question 31
Of the following drugs,
the one most
commonly associated
with acute interstitial
nephritis is -
A.
B.
C.
D.
E.
Sulfisoxazole
Methicillin
Nafcillin
Penicillin
Phenytoin
Keypoint #31
Antibiotic Complications
Aminoglycosides
• Amikacin, gentamicin, kanamycin, tobramycin, streptomycin
• Ototoxicity and nephrotoxicity
• Ototoxicity: destruction of cochlear hair cells in the organ of Corti producing
a high-frequency irreversible hearing loss (amikacin, kanamycin)
• Vestibular dysfunction: damage to vestibular hair cells (streptomycin,
gentamicin)
• Can occur early or after cessation of antibiotic
Tetracyclines
• Nausea and vomiting are most common
• Hepatotoxicity following high doses, intravenous usage, or in pregnancy
• Nephrotoxicity in pre-existing renal disease
• Tetracycline-calcium orthophosphate complex that inhibits bone growth in
neonates and produces teeth staining
• Photosensitivity
• Decreased prothrombin activity
• Overgrowth of resistant bacterial organisms
• Esophageal ulcers
• Intravenous administration: pain, phlebitis, tissue injury if extravasation occurs
Keypoint #31 - continued
Antibiotic Complications
Chloramphenicol
• Bone marrow suppression
1. Dose, duration related and reversible (>7 days) elevated serum iron, low reticulocyte
count, and low hemoglobin
2. Severe, irreversible, idiosyncratic aplastic anemia (occurs anytime during therapy or
weeks after)
Mechanism: thought to be direct toxicity of nitrosochloramphenicol on DNA
Rifamycins
• Rifampin, rifabutin
• Contraindicated in pregnancy
• Orange colored urine, tears and all biologic secretions in 80% of patients
• Rapid and potent inducers of CYP3A4, the most abundant human cytochrome P450 found
predominately in the liver and small intestine
Keypoint #31 - continued
Antibiotic Complications
Sulfonamides
• Rashes are the most common problem
• Acute lgE-medicated hypersensitivity reactions and drug-induced lupus
erythematosus reactions
• Self-resolving granulocytopenia, megaloblastic anemia, thrombocytopenia have
been described
• Renal failure with crystalluria and reversible hepatocellular dysfunction with
jaundice have been described with sulfamethoxazole
• Aseptic meningitis
Quinolones
• Rare adverse reactions: arthralgia, crystalluria, acute renal failure, antibiotic
associated colitis, serum sickness like reactions, eosinophilia, leukopenia,
thrombocytopenia
• Not approved for children <18 years of age
• Interference with cartilage growth in beagle puppies
• Human studies in cystic fibrosis patients and other infants have failed to show
these problems
Keypoint #31 - continued
Antibiotic Complications
Natural Penicillins
• Nonfatal anaphylaxis in adults (1/1000 exposures)
• Fatal anaphylaxis is rare
• Other hypersensitivity reactions: serum sickness, cutaneous rashes, contact
dermatitis
• Allergic reactions seem to be most prominent with procaine penicillin (up to 90%)
• Other reactions: hemolytic anemia, interstitial nephritis, seizures, hyperkalemia
associated with high doses or prolonged exposure
Cephalosporins
• Anaphylaxis
• Hypersensitivity reactions may be compound specific (e.g., cefaclor)
• Hypersensitivity reactions include interstitial nephritis, autoimmune thrombocytopenia, pulmonary eosinophilia, serum sickness like reaction, drug fever
• Seizures and nephrotoxicity associated with high doses and poor renal function
• Gastrointestinal upset is most common with oral agents
• Ceftriaxone: reversible biliary pseudolithiasis and rapidly fatal immune-mediated
hemolytic anemia
Keypoint #31 - continued
Antibiotic Complications
Macrolides
• Generalized pruritus, maculopapular rash, serum sickness like reactions,
erythema multiforme major associated with large doses or in patients with
renal failure
• Intravenous administration has been associated with cardiac toxicity
(prolonged QT interval, ventricular tachycardia, premature ventricular
contractions, nodal bradycardia, sinus arrest), hepatotoxicity, and venous
venous irritation (rate associated)
Question 32
A gravida 1, para 0 woman
is at 38 weeks’ gestation.
A vaginal culture taken 48
hours ago is now reported
positive for herpes
simplex, type II. Her
obstetrician asks your
advice concerning
immediate management of
delivery for obstetric
reasons. You should
advise -
A.
B.
C.
D.
E.
Vaginal delivery after the
spontaneous onset of labor
Cesarean delivery before the
onset of labor
Topical treatment with
tetramethyl acridine followed
by phototherapy and vaginal
delivery
Immediate induction of labor
and vaginal delivery
Oral administration of
acyclovir to the mother and
induction of labor and vaginal
delivery
Question 32
A gravida 1, para 0 woman
is at 38 weeks’ gestation.
A vaginal culture taken 48
hours ago is now reported
positive for herpes
simplex, type II. Her
obstetrician asks your
advice concerning
immediate management of
delivery for obstetric
reasons. You should
advise -
A.
B.
C.
D.
E.
Vaginal delivery after the
spontaneous onset of labor
Cesarean delivery before the
onset of labor
Topical treatment with
tetramethyl acridine followed
by phototherapy and vaginal
delivery
Immediate induction of labor
and vaginal delivery
Oral administration of
acyclovir to the mother and
induction of labor and vaginal
delivery
Keypoint # 32
Neonatal Herpes Infections
• Delivery by C-Section prior to rupture of membranes
• Risk of HSV infection at delivery in an infant born vaginally to a mother
with primary infection of 33-50%
• If born to a mother with reactivated infection of less than 5%
• Neonatal HSV may be –
1) disseminated
2) localized to CNS
3) localized to skin, eyes, mouth
Question 33
For each of the
following sources of
infection (1,2,3), select
the most likely
associated organism
(A,B,C,D,E)
A.
B.
C.
D.
E.
1.
2.
3.
Francisella tularensis
Giardia intestinalis
Toxoplasma gondii
Trichinella spiralis
Shigella species
Contact with cats
Drinking water
Rabbit-hunting in
American southwest
Question 33
For each of the
following sources of
infection (1,2,3), select
the most likely
associated organism
(A,B,C,D,E)
A.
B.
C.
D.
E.
1.
2.
3.
Francisella tularensis
Giardia intestinalis
Toxoplasma gondii
Trichinella spiralis
Shigella species
Contact with cats
Drinking water
Rabbit-hunting in
American southwest
Keypoint #33
Giardia intestinalis
• Protozoan that exists in trophozoite and cyst forms
• Acute watery diarrhea with abdominal pain
• Protracted, intermittent, foul-smelling stools
• Humans are reservoir
• Can infect dogs, cats, beavers that contaminate water
Tularemia
• Sources are rabbits, hares, prairie dogs, muskrats, rats, moles, ticks,
livestock
• Abrupt onset fever, chills, myalgia, headache
• Ulceroglandular
• Glandular
• Oropharyngeal
• Intestinal
• Pneumonic
Question 34
Abdominal pain and bloody
diarrhea develop in a 2-year-old
boy after completion of a 10-day
course of ampicillin for
treatment of otitis media. The
child is febrile and has
abdominal distention. Results
of a complete blood count and
stool culture are normal.
Psuedomembranous lesions are
noted on sigmoidoscopy of the
colon. The most appropriate
medication for this child could
be -
A.
B.
C.
D.
E.
Trimethoprim with
sulfamethoxazole
Metronidazole
Chloramphenicol
Erythromycin
Gentamicin
Question 34
Abdominal pain and bloody
diarrhea develop in a 2-year-old
boy after completion of a 10-day
course of ampicillin for
treatment of otitis media. The
child is febrile and has
abdominal distention. Results
of a complete blood count and
stool culture are normal.
Psuedomembranous lesions are
noted on sigmoidoscopy of the
colon. The most appropriate
medication for this child could
be -
A.
B.
C.
D.
E.
Trimethoprim with
sulfamethoxazole
Metronidazole
Chloramphenicol
Erythromycin
Gentamicin
Keypoint #34
C. Difficile
• Pseudomembranous colitis – diarrhea, abdominal cramps, fever, systemic
toxicity, abdominal tenderness, stools with blood and mucous
• At risk groups for severe or fatal disease are: leukemics with fever and
neutropenia, Hirschsprung, IBD
Treatment
• Discontinue antibiotics
• In severe disease, if diarrhea persists – metronidazole, vancomycin
Question 35
The organism most likely
responsible for meningitis
in a 2-week-old infant is -
A.
B.
C.
D.
E.
Group B streptococcus
Escherichia coli
Listeria monocytogenes
Chlamydia trachomatis
Staphylococcus aureus
Question 35
The organism most likely
responsible for meningitis
in a 2-week-old infant is -
A.
B.
C.
D.
E.
Group B streptococcus
Escherichia coli
Listeria monocytogenes
Chlamydia trachomatis
Staphylococcus aureus
Keypoint #35
Group B Streptococcus
• Major cause of invasive disease birth-3 months
• Early-onset 0-6 days (most in first day) respiratory distress, apnea, shock,
pneumonia and less frequently meningitis
• Late-onset 7 days-3 months (most 3-4 weeks) bacteremia, meningitis,
osteomyelitis, septic arthritis, adenitis, cellulitis
• Pregnant women colonized 15-40%
• Maternal intrapartum prophylasix has decreased early-onset GBS by 81%
Question 36
For each of the following types
of osteomyelitis (1,2,3), select
the most likely etiologic agent
(A,B,C,D,E) -
A.
B.
C.
D.
E.
1.
2.
3.
Group B streptococcus
Pasteurella multocida
Salmonella
Pseudomonas aeruginosa
Hemophilus influenza type b
Osteomyelitis in a neonate
Osteomyelitis in children with
sickle cell disease
Osteomyelitis in a patient who
has received a puncture would
in the foot through a tennis
shoe
Question 36
For each of the following types
of osteomyelitis (1,2,3), select
the most likely etiologic agent
(A,B,C,D,E) -
A.
B.
C.
D.
E.
1.
2.
3.
Group B streptococcus
Pasteurella multocida
Salmonella
Pseudomonas aeruginosa
Hemophilus influenza type b
Osteomyelitis in a neonate
Osteomyelitis in children with
sickle cell disease
Osteomyelitis in a patient who
has received a puncture would
in the foot through a tennis
shoe
Question 37
For each of the following
side effects (1,2,3), select
the most likely associated
drug (A,B,C,D) -
A.
B.
C.
D.
1.
2.
3.
Isoniazid
Rifampin
Streptomycin
Ethambutol
Hepatitis
Inhibition of the
metabolism of oral
contraceptives
Optic neuritis
Question 37
For each of the following
side effects (1,2,3), select
the most likely associated
drug (A,B,C,D) -
A.
B.
C.
D.
1.
2.
3.
Isoniazid
Rifampin
Streptomycin
Ethambutol
Hepatitis
Inhibition of the
metabolism of oral
contraceptives
Optic neuritis
Question 38

For each of the following
diseases or disease causing
agents (1,2,3,4), select the
most appropriate
chemotherapeutic agent
(A,B,C,D,E)
A.
B.
C.
D.
E.
1.
2.
3.
4.
Podophyllin
Acyclovir
Metronidazole
Trimethoprim with
sulfamethoxazole
Clotrimazole
Vaginal trichomoniasis
Vulvovaginal candidosis
Human papilloma virus
Primary genital herpes simplex
infection
Question 38

For each of the following
diseases or disease causing
agents (1,2,3,4), select the
most appropriate
chemotherapeutic agent
(A,B,C,D,E)
A.
B.
C.
D.
E.
1.
2.
3.
4.
Podophyllin
Acyclovir
Metronidazole
Trimethoprim with
sulfamethoxazole
Clotrimazole
Vaginal trichomoniasis
Vulvovaginal candidosis
Human papilloma virus
Primary genital herpes simplex
infection
Keypoint #38
Trichomonas Vaginalis Infections
• Asymptomatic in 90% of men and 50% of women
• Frothy vaginal discharge and mild vulvovaginal itching and burning,
pale-yellow to green-gray DC, musty odor
• More severe symptoms before menses
• Deeply erythematous vaginal mucousa, friable cervix
• Wet-mount prep
• Metronidazole or Tinidazole
•Vulvovaginal Candidiasis
• C. albicans is most common
• Microscopic evaluation and KOH prep
• Topical treatment: clotrimazole, miconazole
• Oral agents: fluconazole, itraconazole in recurrent or refractory cases
Keypoint #38
Human Papilloma Virus
• Condylomata Acuminata – skin colored warts with a cauliflower-like
surface
• In females, occurs in the vulva or perineum, cervix, vagina
• In males, penis, scrotum, anus
• Clinically inapparent dysplastic lesions can be associated with cancer
• HPV involved in 90% of cervical cancers
• Podophyllum resin, cryotherapy, laser, surgery
Genital Herpes Simplex Infection
• Primary – mild clinical manifestations may go on to develop severe or
prolonged symptoms
• Treat with acyclovir, valcyclovir, famciclovir
• Recurrent herpes can be treated episodically or continuously (6 or more/year)