INTERNAL MEDICINE BOARD REVIEW 2015 PART 1

VIRAL

• A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning her year as a medical intern. She had infectious mononucleosis while in college and received the recombinant hepatitis B vaccine before starting medical school.

• Which of the following would describe her hepatitis B serologic profile?

• a) Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative

• b) Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive

• c) Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative

• d) Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive

• e) Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative.

• A 35-year-old man comes to the physician for a health maintenance examination. He received blood transfusions for hypovolemic shock following a gunshot wound 10 years earlier. He is currently in good health, and physical examination is unremarkable.

• A serum chemistry panel shows: ALT 250 U/L, AST 140 U/L, Alkaline phosphatase 70 U/L. Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus (HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate disrupting the limiting plate of hepatic lobules.

• Which of the following is the incidence rate of this complication following HCV infection?

• a) 5% • b) 10% • c) 20% • d) 40% • e) 80%

•The following vial haemorrhagic fever has been reported in Saudi Arabia except:

•1- Rift valley fever•2- Alkhomra fever•3- Dengue fever•4- Yellow fever •5- Cernian congo hemorrhagic fever

• 25y old man with longstanding SCD presents with fever, rash overlying his trunk, face and neck. His Hb dropped from 9.8 to 6.6 . what is the most likely explanation

• a-   Anemia of CRF• b-   A plastic cell crisis• c-   Parvovirus B19 infection • d-   BM infiltration• e-   Multiple hemarthroses

• which  of the following statement regarding  herpes simplex virus is true

•a-Encephalitis complicates primary or recurrent infection

•b- HSV type 2 causes only genital infection

•c- Recurrent infection is caused by repeated viral exposure

•d- Serology is the most useful means of diagnosis

• Middle east respiratory syndrome coronavirus (MERS-CoV) is an emerging infectious agent.

• Current knowledge about the new virus is limited. • Which of the following describes the recent MERS-

CoV outbreak? • a) The genome of MERS-CoV is identical to a camels

betacoronavirus • b) Mortality among confirmed cases was nearly 15% • c) Children were less likely to be affected by the

disease • d) Liver failure was commonly seen as a

complication of MERS-CoV infection

• A previously healthy boy presented with chicken pox. His mother stated that he never got immunized. She reported that one of his classmates developed the disease. Nobody is ill at the household. She is inquiring about the severity of the disease.

• Which of the following most likely increases his risk for moderate to severe varicella disease?

• a) Age younger than 12 year old • b) Concurrent ear infection • c) Recent antibiotic treatment • d) Receipt of short term salicylate therapy • e) Being a secondary case in the household

• A old woman presented to her general practitioner for advice.

• She was 14 weeks pregnant, and 2 weeks previously she had been in contact with a 2-year-old child who had subsequently developed chickenpox the day before the patient's presentation. She was unsure about her varicella immune status.

• What is the most appropriate next step in management? • a) Ask her to present if a rash develops • b) Check varicella IgG status • c) Check varicella IgM status • d) Give aciclovir prophylaxis • e) Give human varicella zoster immunoglobulin

• Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome

• Fetal varicella syndrome (FVS) features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

• risk of FVS following maternal varicella exposure is around 1-2% if occurs before 20 weeks gestation studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks.

• Management of chickenpox exposure• if there is any doubt about the mother previously having chickenpox

maternal blood should be checked for varicella antibodies• if the pregnant women is not immune to varicella she should be given

varicella zoster immunoglobulin (VZIG) as soon as possible. • VZIG is effective up to 10 days post exposure consensus guidelines

suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

• A 16-year-old boy presented with a 2-day history of a rash. Two weeks previously, he had visited a livestock farm (with sheep and cows) on a school trip and had subsequently developed a sore on his index finger that had scabbed over.

• On examination, he was a pyrexial. He had multiple target lesions, of different sizes, all over his body. A 1-cm crusted scab was present on his index finger that was easily removed.

• What is the most appropriate investigation? • a) Biopsy and culture of lesion • b) Electron microscopy of scab crust • c) Mycoplasma IgM • d) Parapoxvirus IgM • e) Scrape of lesion base for herpes simplex virus PCR

• Orf is a zoonosis transmitted to humans from sheep and goats by direct contact or by fomites.

• known as ecthyma contagiousum or contagious pustular dermatitis, is caused by a prototypic member of the genus Parapoxvirus.

PARAPOX VIRUS

BACTERIA

•which of the following organism cause HUS?

•1. shegella toxin •2. clostridium group •3. MSSA•4. Strptococcus group A

•HUS can occur with the following infections:

•E. coli O157:H7• Shigella• Campylobacter • variety of viruses

•26 year old male came with cough, vomiting and rash on legs

•Investigation : cold agglutinin test +ve

•CXR bilateral infiltrates•1. Mycoplasma •2. Legionella •3. Strept pneumonia •4. E.coli Pneumonia

•Infections with cold agglutinin test +ve

•1. Mycoplasma pneumonia.• 2. Mononucleosis.• 3. HIV.•Pneumonia with low Na and

diarrhea think atypical

• A 30-year-old male with sickle cell anemia is admitted with cough, rusty sputum, and a single shaking chill. Physical examination reveals increased tactile fremitus and bronchial breath sounds in the left posterior chest. The patient is able to expectorate a purulent sample.

• Which of the following best describes the role of sputum Gram stain and culture?

• a) Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting

• b) If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae

• c) Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary

• d) There is no characteristic Gram stain in a patient with pneumococcal pneumonia

• A 32-year-old man with a history of injecting drug use was admitted with a 24-hour history of worsening pain and redness around an injection site in his arm.

• On examination, his temperature was 40.0°C, his pulse was 120 beats per minute and his blood pressure was 75/55 mmHg. There was marked erythema of his left arm, with extreme tenderness to palpation. Investigations: haemoglobin 106 g/L (130–180), white cell count 38.5 (4.0–11.0), serum sodium 123 mmol/L (137–144), serum potassium 5.4 mmol/L (3.5–4.9), serum creatinine 183 •mol/L (60–110).

• What organism is most likely to be associated with this presentation? • a) Clostridium botulinum • b) Clostridium perfringens • c) Pseudomonas aeruginosa • d) Staphylococcus aureus • e) Streptococcus pyogenes

• Infection with all of these microorganisms may be complicated by a neurological symptom and /or signs EXCEPT:

•a) Clostridium tetani •b) Clostridium diphtheria •c) Clostridium perfringens •d) Poliomyelitis virus •e) Clostridium botulinum

• An 18-year-old man presented with fever, cough and shortness of breath. He had been previously well. He recalled having a severe sore throat 4 days before presentation.

• On examination, he had a temperature of 38.2°C, his pulse was 50 beats per minute and his blood pressure was 94/55 mmHg. His oxygen saturation was 89% (94–98) breathing room air.

• Investigations: blood culture (after 3 days) anaerobic Gram-negative bacillus,

• chest X-ray patchy consolidation in both lung fields. • What is the most likely identity of the organism found on blood

culture? • a) Bacteroides fragilis • b) Fusobacterium necrophorum • c) Haemophilus influenzae • d) Klebsiella pneumoniae • e) Pseudomonas aeruginosa

•42 years known case of DM on oral medication presented with hx of Diarrhea 6 BM since 3 days with low grade fever stool culture done on the 1st day reports Salmonella .T

•best treatment is •Ciprofloxacin•Augmantin •Clindamycin •Supportive treatment

SALMONELLA DIAGNOSIS• Other than a positive culture, no specific laboratory test is diagnostic for

enteric fever. • The definitive diagnosis of enteric fever requires the isolation of S.

typhi or S. paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions.

• The sensitivity of blood culture is only 40–80%,.• Bone marrow culture is 55–90% sensitive, and, unlike that of blood culture,

its yield is not reduced by up to 5 days of prior antibiotic therapy. • Stool cultures, while negative in 60–70% of cases during the first week, can

become positive during the third week of infection in untreated patients.• Several serologic tests, including the classic Widal test for “febrile

agglutinins,” are available. None of these tests is sufficiently sensitive or specific to replace culture-basedmethods

• PCR and DNA probe assays to detect S. typhi in blood have been identified but have not yet been developed for clinical use.

CIPROCIPROSEPTRASEPTRA

CEFTRIXONCEFTRIXON

PARASITE

•A 22-year old female medical student who visited Sudan few months back, presents with a history of haematuria. On investigation schistosomal serology is shown to be positive.

•Select the treatment of choice: •a) Albendazole •b) Ivermectin •c) Mebendazole •d) Praziquantel

schistosoma

LEISHMANIA• Transmission : Sand Fly

• Hx PAINLESS , Volcano like ulcer cluster lesions along lymphatics inflammatory satellite papules

• Diagnosis : 1-Microscopy 2-Parasite culture 3-PCR 4- Leishmania skin test

• NO SEROLOGY

• Ketoconazole ,Itra, Cryotherapy intralesional sodium stibogluconate

LISHMANIA

id spacial

Mycobacterium marinum

• AFB+ ,Fast growing

• Most strains of M marinum have been found to be resistant to the antituberculosis medications isoniazid, streptomycin,

• . The organism is sensitive to rifampin plus ethambutol, tetracyclines, trimethoprim-sulfamethoxazole (TMP-SMZ), clarithromycin, and fluoroquinolones.

• The day after hunting and skinning wild rabbits, a hunter develops an inflamed papule on one finger. The papule rapidly enlarges and then bursts, releasing pus and forming a clean ulcer cavity productive of thin, colorless exudate (see image). Several days later, the patient develops severe illness with atypical pneumonia and delirium. It is at this point that the patient seeks medical care.

• The regional lymph nodes of the axilla of the affected arm are enlarged. Reduced breath sounds and occasional rales are heard. Splenomegaly is noted. Blood studies show a mild leukocytosis.

• Which of the following is the most likely diagnosis? • a) Actinomycosis • b) Brucellosis • c) Melioidosis • d) Plague • e) Tularemia

Tularemia

• Caused by Francisella tularensis

• F. tularensis—a small (0.2 m by 0.2–0.7 m), gram-negative, pleomorphic, nonmotile, non-spore-forming bacillus.

• Transmission by biting or blood-sucking insects, contact with wild or domestic animals, ingestion of contaminated water or food, or inhalation of infective aerosols.

• An incubation period of 2–10 days

• fever, chills, headache, generalized myalgias and arthralgias, lymphadenopathy (Epitrochlear lymphadenopathy)

Tularemia

• In ulceroglandular tularemia, the ulcer is erythematous, indurated, and nonhealing, with a punched-out appearance that lasts 1–3 weeks. The papule may begin as an erythematous lesion that is tender or pruritic; it evolves over several days into an ulcer with sharply demarcated edges and a yellow exudate

• Direct microscopic, indirect fluorescent antibody test but false-positive results due to Legionella ,PCR and culture.

• Tularemia is most frequently confirmed by agglutination testing.

• Steptomycin , cipro , gent 10 days

LeptospirosisLeptospirosis• Acquired when exposed to fresh waterAcquired when exposed to fresh water

• Acute leptospirosis – fever, myalgia, headache, rash

• Conjunctival suffusion is characteristic but may not occur

• May lead to aseptic meningitis, uveitis, elevated liver enzymes, proteinuria, microscopic hematuria

• Diagnosis – acute and convalescent phase antibody titers

• Treatment – penicillin or tetracycline

Q Fever•Coxiella Burnetii

• Inhalation ,incubation 9-40 d

• endocarditis ,atyp pnue,hepatitis e fever

• Serology AB even with ch inf

• doxy,cipro,tetra in pregnant septra

Whipple’s disease

•Diagnosis : Colon biopsy with PSA stain

• Treatment septra for 1 year

• Early localized : The classic sign of early local infection with Lyme disease is a circular, outwardly expanding rash called erythema chronicum migrans , which occurs at the site of the tick bite 3 to 30 days after the tick bite.

• Early disseminated infection:Within days to weeks after the onset of local infection, purplish lumps , arthralgia , Bell’s palsy. encephalitis

• Late : Polyneuropathy , Heart block

• Diagnosis Clinically , clinically , Then Serology ELISA and then Western blot IgM Sensitivity 70%

• Treatment Doxycycline , Amoxilline , ceftrixone

• A 30-year-old HIV-positive man presented with a 3-week history of fever, malaise and weight loss.

• On examination, his temperature was 38.0°C. There were several small painless, raised, purple skin lesions on his legs and trunk. Investigations: CD4 count 22 (430–1690), lesional biopsy non-specific inflammatory changes. There was no evidence of Kaposi's sarcoma and stains for HHV-8 were negative. Bacillary angiomatosis was considered as a possible diagnosis.

• What is the most appropriate investigation to confirm this diagnosis?

• a) Bartonella culture of biopsy tissue • b) Bartonella serology • c) Blood for bartonella culture • d) Giemsa stain of biopsy tissue • e) Warthin–Starry stain of biopsy tissue

• Bacillary angiomatosis is a vascular, proliferative form of Bartonella infection that occurs primarily in immunocompromised persons.

• Solitary or multiple red, purple, flesh-colored, or colorless papules (hemangiomalike lesions) varying in size from 1 mm to several centimeters

• Hyperpigmented, hyperkeratotic, indurated plaques, typically on the extremities and often overlying osseous defects

• Lab studies

• Histology of Bartonella DNA in tissue specimens by (PCR) assay

• Bartonella antigens

• Treatment erythromycin or a tetracycline

Bacillary angiomatosis

• A 34 year old man with diabetic ketoacidosis develops headache, nasal congestion, periorbital swelling and a bloodstained nasal discharge. Over a period of a week he becomes drowsy and unresponsive. ENT examination shows black, necrotic lesions on the nasal septum, which is perforated. Culture of the nasal discharge shows a heavy growth of Streptococcus pneumoniae and Staphylococcus aureus.

• The most likely diagnosis is: • a) Lemierre’s syndrome • b) Ludwig’s angina • c) Orbital cellulitis • d) Rhinocerebral mucormycosis • e) Aspergillus sinusitis

• A 35-year-old Asian woman presented with a 4-week history of painful swollen glands in her neck. She described night sweats, but no weight loss. There were no preceding dental problems or sore throat.

• On examination, there was a non-tender, 3-cm anterior cervical lymph nodes bilaterally. There were no other abnormal findings.

• Investigations: full blood count normal erythrocyte sedimentation rate 65 mm/1st h (<20), serum C-reactive protein 40 mg/L (<10), HIV serology negative, lymph node biopsy marked paracortical expansion by small lymphocytes, blast cells and large numbers of histiocytes, with prominent apoptosis resulting in confluent areas of 'necrosis'.

• What is the most likely diagnosis? • a) Acute Epstein–Barr virus infection • b) Acute toxoplasmosis • c) Atypical mycobacterial infection • d) Kikuchi's disease • e) Secondary syphilis

• Kikuchi disease, also called histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease, is an uncommon, idiopathic, generally self-limited cause of lymphadenitis

• The most common clinical manifestation of Kikuchi disease is cervical lymphadenopathy, with or without systemic signs and symptoms.

• Clinically and histologically, the disease can be mistaken for lymphoma or systemic lupus erythematosus (SLE)

Kikuchi disease

THANK YOU