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Infectious Disease Board Review

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Presentation on theme: "Infectious Disease Board Review"— Presentation transcript:

1 Infectious Disease Board Review
Stephen Barone MD Pediatric Program Director Schneider Children's Hospital Associate Professor New York University School of Medicine Michael Lamacchia, MD Chairman St. Joseph’s Children’s Hospital Associate Professor Mount Sinai School of Medicine

2 Question 1 Viral laryngotracheitis Epiglottis Retropharyngeal abscess
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? Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis

3 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? Viral laryngotracheitis Epiglottis Retropharyngeal abscess Foreign body Bacterial tracheitis

4 Key Points # 1 Bacterial tracheitis Epiglottis Viral laryngotrachitis
Fever, toxic, stridor, secretions, S aureus Epiglottis Older, unimmunized, drooling , toxic, no cough, H. Influenza Viral laryngotrachitis Cough, stridor, non-toxic, parainfluenza Retropharyngeal abscess Young, drooling, stiff neck Foreign body Acute onset, afebrile, historical clues

5 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? High dose Amoxicillin Azithromycin Clindamycin Steroids Trimethroprim - sulfamethoxazole

6 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? High dose Amoxicillin Azithromycin Clindamycin Steroids Trimethroprim - sulfamethoxazole

7 Key Point #2 Pertussis Differential Diagnosis Infants or Adolescents
Macrolide - limit spread Differential Diagnosis Chlamydia trachomatis Staccato cough, tachypnea afebrile, PCP Hypoxic, toxic , immunodeficiency

8 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? Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease

9 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? Fifth disease Juvenile rheumatoid arthritis Rheumatic fever Systemic Lupus Lyme Disease

10 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

11 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? Lumbar puncture CT scan head and sinuses Lyme serology Maxillary sinus aspiration Slit lamp examination of the eyes?

12 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? Lumbar puncture CT scan head and sinuses Lyme serology Maxillary sinus aspiration Slit lamp examination of the eyes?

13 Key Points #4 Symptoms – 2 weeks Complications of sinusitis
Congestion, Nasal discharge Facial pain Complications of sinusitis Cerebral venous thrombosis Orbital cellulitis Brain abscess – Pott’s puffy tumor S. pneumoniae, M. catarrhalis, H. influenzae Chronic – S. aureus, anaerobes

14 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? Cholestatoma Chronic suppurative otitis media Serous otitis media Otitis externa Labyrinthitis

15 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? Cholestatoma Chronic suppurative otitis media Serous otitis media Otitis externa Labyrinthitis

16 Key Points #5 Acute Otitis Media Chronic Suppurative Otitis Media
S. pneumoniae, H. influenzae, M. catarrhalis Chronic Suppurative Otitis Media Above plus S. aureus, P.aeruginosa Cholesteatoma Cystic structure – chronic OM Otitis Externa Intact TM - P.aeruginosa and S. aureus

17 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? Isoniazid and Rifampin for 6 months A repeat PPD in 3 months A CT of the neck Excisional biopsy Azithromycin for 4 weeks

18 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? Isoniazid and Rifampin for 6 months A repeat PPD in 3 months A CT of the neck Excisional biopsy Azithromycin for 4 weeks

19 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

20 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? Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis

21 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? Acute airway obstruction Sensorineural hearing loss Orchitis Myocarditis Arthritis

22 Key Points #7 Parotitis Mumps Vaccine Bacterial – ill appearing Viral
Viral syndrome with swelling of parotid glands Complication Orchitis CSF pleocytosis – most asymptomatic Rare – myocarditis, arthritis etc. Vaccine Live vaccine

23 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? Tetanus Retropharyngeal abscess Infectious mononucleosis Peritonsillar abscess Herpangia

24 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? Tetanus Retropharyngeal abscess Infectious mononucleosis Peritonsillar abscess Herpangia

25 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

26 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? IV acyclovir IV nafcillin Topical nystatin Topical mupirocin IV steroids

27 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? IV acyclovir IV nafcillin Topical nystatin Topical mupirocin IV steroids

28 Key Points #9 Herpes gingivostomatitis Herpangina Candida Impetigo
Young child, anterior vesicles, swollen gums Treatment – supportive, Acyclovir Complication – erythema multiforme Dx – Culture, DFA Herpangina Posterior vesicles Candida Cottage cheese plaques on buccal mucosa Impetigo Honey crust lesions on the skin Group A Streptococcus, S. aureus

29 Question 10 CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin
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? CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin

30 Question 10 CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin
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? CT Scan of chest Ceftriaxone PPD Bronchoscopy Amphotericin

31 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

32 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? Repeat PPD in 3 months Bronchoscopy Gastric lavage Isoniazid for nine months Isoniazid, Rifampin and Ethambutal for 6 months

33 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? Repeat PPD in 3 months Bronchoscopy Gastric lavage Isoniazid for nine months Isoniazid, Rifampin and Ethambutal for 6 months

34 Key Points # 11 Mycobacterium tuberculosis History PPD Treatment
Immigrant, insidious, weight loss, hilar nodes PPD 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

35 Question 12 Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin
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? Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin

36 Question 12 Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin
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? Oseltamivir Ribavirin Clindamycin Aztreonam Azithromycin

37 Key Points #12 Influenza Complications Fever, cough, myalgia
Oseltamivir – within 48 hours Influenza vaccine – 2A, 1B Antigenic shift vs. antigenic drift Complications S. aureus pneumonia MRSA Clindamycin, Vancomycin

38 Question 13 Kawasaki disease Staphylococcal scalded skin syndrome
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? Kawasaki disease Staphylococcal scalded skin syndrome Toxic shock syndrome Roseola Enteroviral infection

39 Question 13 Kawasaki disease Staphylococcal scalded skin syndrome
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? Kawasaki disease Staphylococcal scalded skin syndrome Toxic shock syndrome Roseola Enteroviral infection

40 Key Points #13 Staphylococcal Scalded Skin Syndrome
Symptoms Non-toxic, impetigo, painful, sunburn rash, skin peels readily. Toxic Shock Syndrome Hypotension Fever Rash Desquamation Plus three or more organ systems involved

41 Question #14 Which of these infectious diseases often is
accompanied by hyponatremia? Roseola Measles Rocky Mountain Spotted Fever Lyme disease Leptospirosis

42 Question #14 Which of these infectious diseases often is
accompanied by hyponatremia? Roseola Measles Rocky Mountain Spotted Fever Lyme disease Leptospirosis

43 Key Points # 14 Rocky Mountain Spotted Fever Lyme Disease
Epidemiology, distal petiechiae, headache, increased LFT’s, hyponatremia Treatment – doxycycline Lyme Disease Northeast, Wisconsin, Northern CA Rash, arthritis (mono), meningitis Treatment Amoxicillin, Doxycycline Ceftriaxone

44 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? Arthritis Febrile seizures Aseptic meningitis Thrombocytopenia Hepatitis

45 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? Arthritis Febrile seizures Aseptic meningitis Thrombocytopenia Hepatitis

46 Key Points # 15 Roseola Fever followed by rash Complications
HHV6 infection Complications Febrile seizures Parvovirus – arthritis EBV – hepatitis Aseptic meningitis – Kawasaki Thrombocytopenia - RMSF

47 Question 16 A child presents with abdominal pain, arthritis
and this rash. What is the most appropriate treatment? Ceftriaxone IVIG Doxycycline Clindamycin Supportive care

48 Question 16 A child presents with abdominal pain, arthritis
and this rash. What is the most appropriate treatment? Ceftriaxone IVIG Doxycycline Clindamycin Supportive care

49 Key Point #16 Henoch – Schonlein Purpura Differential Diagnosis
Palpable purpura, lower extremities, bloody stools (colitis, intussusception) ,arthritis, hematuria Treatment Supportive Steroids? Differential Diagnosis Meningococcal – Ceftriaxone RMSF – Doxycycline Kawasaki - IVIG

50 Question #17 Which vaccine(s) is (are) not routinely
recommended for catch up vaccination for children greater than 5 years of age? Varicella Hib Pneumococcal Hib &Pneumococcal DTaP

51 Question #17 Which vaccine(s) is (are) not routinely
recommended for catch up vaccination for children greater than 5 years of age? Varicella Hib Pneumococcal Hib &Pneumococcal DTaP

52 Key Point #17 Hib and Pneumococcal vaccines DTaP Varicella
No catch up greater than 5 DTaP 4 doses Varicella Always catch -up

53 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? Td and TIG TdaP DT TdaP and TIG TIG

54 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? Td and TIG TdaP DT TdaP and TIG TIG

55 Key Points # 18 DTaP – under 7 TdaP – Adol and Adults
Td – greater than 7 DT – less than 7 Vaccine Clean Td /TIG Dirty Unknown or < 3 doses Y / N Y / Y 3+ doses If greater 10 yrs If < 5 yrs

56 Question #19 Which of these two vaccine pairs, if not give
simultaneously (at the same visit) should be separated by at four least weeks? Hepatitis A and Hepatitis B IPV and Pneumococcal DTaP and Hib MMR and Varicella MMR and Hepatitis B

57 Question #19 Which of these two vaccine pairs, if not give
simultaneously (at the same visit) should be separated by at four least weeks? Hepatitis A and Hepatitis B IPV and Pneumococcal DTaP and Hib MMR and Varicella MMR and Hepatitis B

58 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)

59 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? 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

60 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? 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

61 Key Points #20 Hepatitis A IgM – Acute IgG – Acute, past, vaccine
Tests Results Interpretation BsAg BcAb BsAb Negative Positive Vaccine Past infection Acute Chronic

62 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

63 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

64 Key Points # 21 Small intestine Large 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

65 Question 22 Malaria Typhoid fever TB Hepatitis B Yellow fever
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? Malaria Typhoid fever TB Hepatitis B Yellow fever

66 Question 22 Malaria Typhoid fever TB Hepatitis B Yellow fever
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? Malaria Typhoid fever TB Hepatitis B Yellow fever

67 Key Points #22 Malaria Typhoid TB Hepatitis B Yellow fever
Fever, splenomegaly, hemolytic anemia Typhoid Flu- like illness, normal WBC TB Longer incubation period Hepatitis B No risk factor for traveling adolescents Yellow fever Africa, South America

68 Question 23 HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology
Which is the preferred diagnostic test to confirm an HIV infection in one month old infant born to an HIV positive mother? HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology CD4/CD8 ratio

69 Question 23 HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology
Which is the preferred diagnostic test to confirm an HIV infection in one month old infant born to an HIV positive mother? HIV p24 antigen assay HIV DNA PCR HIV culture HIV serology CD4/CD8 ratio

70 Key Points #23 HIV serology can be falsely positive for up to 18 months after birth HIV p24 antigen test – false positives and negatives Not recommended HIV culture – requires 4 weeks, not readily available HIV DNA PCR Highly sensitive and specific Considered infected if two separate positive tests CD4/CD8 ratio Not useful in the neonatal period

71 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 - 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

72 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 - 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

73 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

74 Question 25 Corynebacterium diphtheriae Clostridium botulinum
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 - Corynebacterium diphtheriae Clostridium botulinum S. dysenteriae serotype 1 Campylobacter jejuni Clostridium tetani

75 Question 25 Corynebacterium diphtheriae Clostridium botulinum
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 - Corynebacterium diphtheriae Clostridium botulinum S. dysenteriae serotype 1 Campylobacter jejuni Clostridium tetani

76 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

77 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)

78 Question 26 Congenital rubella syndrome is associated with which of the following? 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

79 Question 26 Congenital rubella syndrome is associated with which of the following? 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

80 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% weeks 25% during end of second trimester

81 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 - 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.

82 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 - 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.

83 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

84 Question 28 Primary pulmonary histoplasmosis in normal children is usually - Asymptomatic Associated with severe flu-like symptoms Treated with assisted ventilation and steroid therapy Associated with sarcoid-like disease Complicated by mediastinal fibrosis

85 Question 28 Primary pulmonary histoplasmosis in normal children is usually - Asymptomatic Associated with severe flu-like symptoms Treated with assisted ventilation and steroid therapy Associated with sarcoid-like disease Complicated by mediastinal fibrosis

86 Keypoint #28 Blastomycosis
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

87 Question 29 All of the following are consistent with the diagnosis of congenital toxoplasmosis in an infant EXCEPT - 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

88 Question 29 All of the following are consistent with the diagnosis of congenital toxoplasmosis in an infant EXCEPT - 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

89 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

90 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 - Haemophilus influenzae Neisseria meningitidis Group B streptococci Herpes simplex virus Listeria monocytogenes

91 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 - Haemophilus influenzae Neisseria meningitidis Group B streptococci Herpes simplex virus Listeria monocytogenes

92 Keypoint #30 Neisseria Meningitidis
Children younger than 5, greatest attack rate in less than 1 year Adolescents 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

93 Question 31 Of the following drugs, the one most commonly associated with acute interstitial nephritis is - Sulfisoxazole Methicillin Nafcillin Penicillin Phenytoin

94 Question 31 Of the following drugs, the one most commonly associated with acute interstitial nephritis is - Sulfisoxazole Methicillin Nafcillin Penicillin Phenytoin

95 Antibiotic Complications
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

96 Antibiotic Complications
Keypoint #31 - continued Antibiotic Complications Chloramphenicol Bone marrow suppression 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

97 Antibiotic Complications
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

98 Antibiotic Complications
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 thrombo- cytopenia, 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

99 Antibiotic Complications
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)

100 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 - 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

101 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 - 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

102 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 – ) disseminated ) localized to CNS ) localized to skin, eyes, mouth

103 Question 33 For each of the following sources of infection (1,2,3), select the most likely associated organism (A,B,C,D,E) Francisella tularensis Giardia intestinalis Toxoplasma gondii Trichinella spiralis Shigella species Contact with cats Drinking water Rabbit-hunting in American southwest

104 Question 33 For each of the following sources of infection (1,2,3), select the most likely associated organism (A,B,C,D,E) Francisella tularensis Giardia intestinalis Toxoplasma gondii Trichinella spiralis Shigella species Contact with cats Drinking water Rabbit-hunting in American southwest

105 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

106 Question 34 Trimethoprim with sulfamethoxazole Metronidazole
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 - Trimethoprim with sulfamethoxazole Metronidazole Chloramphenicol Erythromycin Gentamicin

107 Question 34 Trimethoprim with sulfamethoxazole Metronidazole
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 - Trimethoprim with sulfamethoxazole Metronidazole Chloramphenicol Erythromycin Gentamicin

108 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

109 Question 35 The organism most likely responsible for meningitis in a 2-week-old infant is - Group B streptococcus Escherichia coli Listeria monocytogenes Chlamydia trachomatis Staphylococcus aureus

110 Question 35 The organism most likely responsible for meningitis in a 2-week-old infant is - Group B streptococcus Escherichia coli Listeria monocytogenes Chlamydia trachomatis Staphylococcus aureus

111 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%

112 Question 36 For each of the following types of osteomyelitis (1,2,3), select the most likely etiologic agent (A,B,C,D,E) - 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

113 Question 36 For each of the following types of osteomyelitis (1,2,3), select the most likely etiologic agent (A,B,C,D,E) - 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

114 Question 37 For each of the following side effects (1,2,3), select the most likely associated drug (A,B,C,D) - Isoniazid Rifampin Streptomycin Ethambutol Hepatitis Inhibition of the metabolism of oral contraceptives Optic neuritis

115 Question 37 For each of the following side effects (1,2,3), select the most likely associated drug (A,B,C,D) - Isoniazid Rifampin Streptomycin Ethambutol Hepatitis Inhibition of the metabolism of oral contraceptives Optic neuritis

116 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) Podophyllin Acyclovir Metronidazole Trimethoprim with sulfamethoxazole Clotrimazole Vaginal trichomoniasis Vulvovaginal candidosis Human papilloma virus Primary genital herpes simplex infection

117 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) Podophyllin Acyclovir Metronidazole Trimethoprim with sulfamethoxazole Clotrimazole Vaginal trichomoniasis Vulvovaginal candidosis Human papilloma virus Primary genital herpes simplex infection

118 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

119 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)


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