Q 1 :

An 8-year-old girl presents with a 4-day history of fever, headache, and abdominal pain. Hermother states that they live in a rural area and have multiple pets, including dogs, cats, horses,cows, and a pet raccoon. There is no history of tick bites. On physical examination, the girlappears mildly toxic, has a temperature of 102.2F (39C), and has a grade II/VI systolic ejectionmurmur best heard on the left side of the sternal border. Her right upper quadrant is tender topalpation, but there is no hepatosplenomegaly. Findings on her skin and extremity examinationare normal. A complete blood count reveals a white blood cell count of 1.2x103/mcL (1.2x109/L)with 90% neutrophils and 10% lymphocytes. Her hemoglobin is 10 g/dL (100 g/L), and herplatelet count is 50x103/mcL (50x109/L). Her alanine aminotransferase is 600 U/L, and heraspartate aminotransferase is 450 U/L. Her amylase and lipase values are normal. Serumsodium is 133 mEq/L (133 mmol/L), but the remainder of her electrolyte values are normal.Of the following, the MOST likely diagnosis is

A. human monocytic ehrlichiosisB. Lyme diseaseC. Rocky Mountain spotted feverD. tularemiaE. typhus

Answer :

A

Explanation

Human monocytic ehrlichiosis (HME)is a rickettsial disease caused byEhrlichia chaffeensis,which is transmitted to humans by the bite of a tick.

Clinically, the ehrlichioses are nonspecific illnesses. Fever (~100%) and headache (~75%) are most common, but many patients also report myalgias, anorexia, nausea, and vomiting.

With HME, rash is more common in children (nearly 66%) than in adults (33%). The rash is usually macular or maculopapular, but petechial lesions can occur.

Photophobia, conjunctivitis, pharyngitis, arthralgias, and lymphadenopathy are less consistent features.

Hepatomegaly and splenomegaly are detected in nearly 50% of childrenwith ehrlichiosis.

Edema of the face, hands, and feet occurs more commonly in children than in adults, but arthritis is uncommon in both groups.

A rash is described in approximately two thirds of childrenand one third of adults and starts as maculopapular but may progress into petechial/purpuric.

Meningoencephalitis with a lymphocyte-predominant CSF pleocytosis is an uncommon but potentially severe complication of HME

HME is clinically indistinguishable from Rocky Mountain spotted fever (RMSF).

Laboratoryabnormalities common to both infections includethrombocytopenia and hyponatremia, butpatients who have HMEare more likely to have elevated liver function testresults andleukopenia with lymphopenia.Approximately 50% to 75% of patients have no history of a tickbite.

Patients who haveLyme diseasetypically do not appear toxic or have the laboratoryabnormalities described in the vignette.

Although there is a typhoidal form of illness due toFrancisella tularensis(tularemia), it is extremely rare, and most affected children present withglandular or ulceroglandular disease. Typhus can be endemic or epidemic.

Epidemic typhus isdue to the bite of the human louse, and endemic typhus is caused by a mite bite. Although bothof these rickettsial diseases can present with fever and a headache, patientsusually are nottoxic and do not have laboratory abnormalities such as those reported for the girl in the vignette.

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Q2 :

A 4-year-old boy presents to your office for evaluation of a 3-day history of fever (temperatureto 38.5C), congestion, and sore throat. Physical examination of the well-appearing child showsonly rhinorrhea and pharyngeal erythema. His mother and 6-year-old sister have had colds overthe past week.Of the following, the MOST appropriate treatment for this child, pending the results of the throatculture, is

A. amoxicillinB. azithromycinC. nasal saline dropsD. prednisoneE. pseudoephedrine

Answer :

C

The congestion and sore throat described for the boy in the vignette, combined with thehistory of upper respiratory tract infections in the family, strongly suggest that he has a viralillness. Supportive therapy such as nasal saline drops to relieve congestion is appropriate.

Cough and cold remedies, including those containing the decongestant pseudoephedrine,have not been demonstrated to be effective in treating viral upper respiratory tract infectionsymptoms, and based on potential toxicities in young children, the American Academy ofPediatrics and United States Food and Drug Administration have advised against their use inchildren younger than 6 years of age.

There is no indication for prednisone in this setting.However, high-dose, short-term corticosteroid therapy may be beneficial in the treatment of thepatient who has marked pharyngitis and impending airway obstruction associated with acuteinfectious mononucleosis.

Antibiotics are not indicated to treat a viral illness and do not preventdevelopment of possible secondary bacterial infections (eg, otitis media, sinusitis).

Increaseduse of antibiotics has been associated with increased rates of carriage of resistant bacteria(eg, penicillin-resistant Streptococcus pneumoniae, beta-lactamase-positive Haemophilusinfluenzae, methicillin-resistant Staphylococcus aureus).

Other common illnesses that generally do not require antibiotic therapy in children includebronchitis, middle ear effusion of short duration, mucopurulent rhinitis of less than 10 daysduration, and most cases of acute pharyngitis (unless group A streptococcal infection isconfirmed).

Bronchitis in children is an acute cough illness that is generally self-limited andcaused by viruses.

If the child in the vignette has a positive diagnostic test result (rapid antigen detection orthroat culture), antibiotic treatment would be appropriate.

Penicillin V is the drug of choice forstreptococcal pharyngitis, although amoxicillin often is used instead as first-line treatment.

A firstgenerationcephalosporin (eg, cephalexin or cefadroxil) also may be used. Broader-spectrumagents (eg, amoxicillin-clavulanate, second- or third-generation cephalosporins) are notindicated routinely for this infection.

Azithromycin should be reserved for treating streptococcalpharyngitis in the patient who is allergic to penicillins and cephalosporins.

Streptococcalserogroups C and G rarely have been associated with symptomatic pharyngitis. They have notbeen associated with rheumatic fever, but antibiotic therapy (same agents as for group Astreptococcal infection) may be considered in the symptomatic patient who has a positiveculture and no other cause determined for the pharyngitis.

Q3 :

A 12-year-old boy presents with a 5-day history of sore throat, fever, and progressive rightsidedneck pain and swelling. On physical examination, his temperature is 40.0C, he has trismus,the right side of his neck is swollen and tender to palpation, and his chest is clear to auscultation.His white blood cell count is 30.0x103/mcL (30.0x109/L), with 80% polymorphonuclearleukocytes, 15% lymphocytes, and 5% monocytes. Computed tomography scan of the neckreveals a deep parapharyngeal abscess (Item Q141).Of the following, the MOST appropriate antimicrobial to include in his therapy is

A. ampicillin-sulbactamB. azithromycinC. clarithromycinD. gentamicinE. trimethoprim-sulfamethoxazole

Answer :

A

The boy described in the vignette has an abscess in the deep tissues of the neck.Streptococci, including S pyogenes, and Staphylococcus aureus are the most commonpathogens associated with infections of the parapharyngeal space.However,oral anaerobicbacteria also are found frequentlyin these infections because the primary portals of entry fororganisms into the parapharyngeal space are the oropharynx, lower molars, nasopharynx,paranasal sinuses, and mastoid.

The most common anaerobic bacteria isolated fromparapharyngeal infections areBacteroides, Peptostreptococcus, and Fusobacterium.Most ofthese infections are polymicrobial.

Because the parapharyngeal space is contiguous with theretropharyngeal, submandibular, and peritonsillar spaces, infection may spread in any number ofdirections and lead to a variety of clinical manifestations and complications.

Ampicillin-sulbactam is a beta-lactamase-resistant semisynthetic penicillinthat has activityagainst anaerobes, susceptible aerobic gram-positive organisms, and respiratory tract gramnegativepathogens, making it an appropriate initial drug for the patient described in the vignette.

Because group A streptococci are becoming increasingly resistant to macrolide antibiotics suchas azithromycin and clarithromycin and to trimethoprim-sulfamethoxazole, these drugs are notappropriate.

In addition, macrolide antibiotics have less activity than ampicillin-sulbactam againstB fragilis and Fusobacterium.

Gentamicin is not useful because aerobic enteric gram-negativerods do not play a significant role in parapharyngeal infections.

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Q 4:A five year old boy is admitted to the paediatric ward with a two day history of fever, myalgia and jaundice.His family live on a canal barge and have been moving around the country on a regular basis.He has manyscabs on his knees and elbows, which his parents say result from his playing on the canal banks.Observations show temperature 38.7 C,heart rate 150 beats per minute, respiratory rate 35. He looks unwell but is fullyconscious. He has conjunctival suffusion and scleral icterus. Blood tests show: Haemoglobin 10.5 g/dL,White cell count 22.5 x109/L,Neutrophils 19x109/L, Platelets 150x109/L, Urea22.5mmol/L,Creatinine 250 micromol/L, Bilirubin 150 micromol/L, Aspartate Amino-Transferase 350 U/L.

The mostlikely diagnosis is:

A-Hepatitis BB-Hepatitis AC-LeptospirosisD-Haemolytic uraemic syndromeE-Reyes syndrome

Answer :

C

Leptospirosis is caused by a spirochete organism, of which there are many serovars. It is contracted by contact with water contaminated with the urine or carcasses of infected animals eg rats. There have been cases in the UK associated with rats around waterways. It may cause asymptomatic infection, or an influenza like illness which may progress to severe disease with jaundice and renal impairment (Weils disease). Conjunctival suffusion is characteristic but not always present. Viral hepatitis is characterised by a prodromal phase with fever in those who are symptomatic, followed by hepatitis after the fever declined. Hepatitis A is frequently asymptomatic in children, and hepatitis B rarely causes acute hepatitis. Haemolytic uraemic syndrome typically follows a gastrointestinal disorder with bloody diarrhoea. The commonest aetiologic agent is E Coli 0157:H7. Reyes syndrome is an acute and often fatal encephalopathy associated with hepatic failure. It is becoming increasingly rare.

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Q 5

A 5-year-old boy is hospitalized in January with fever and seizures. Lumbar puncture reveals clear cerebrospinal fluid that has a white blood cell count of 47/cu mm, all of which are lymphocytes. On physical examination, he appears obtunded but arouses with painful stimuli. Neurologic examination reveals no focal findings.Of the following, the diagnostic test that is MOST likely to reveal the etiology of this child's illness is:

A.bacterial culture of cerebrospinal fluidB.polymerase chain reaction test of cerebrospinal fluid for herpes simplexC.Streptococcus pneumoniae bacterial antigen test of cerebrospinal fluidD.viral culture of cerebrospinal fluidE.viral culture of nasopharyngeal and rectal swabs

Answer :

B

The boy described in the vignette has symptoms suggestive of encephalitis. These symptoms, combined with the cerebrospinal fluid (CSF) findings, are most consistent with a viral etiology. The most likely pathogen in a sporadic case of viral encephalitis is herpes simplex virus (HSV).

In the past, HSV encephalitis was diagnosed by culture or direct fluorescence testing of brain biopsy tissue. More recently, polymerase chain reaction (PCR) testing of CSF for HSV DNA has become the preferred diagnostic modality.

Viral cultures of the CSF for herpes are rarely positive in HSV encephalitis beyond the neonatal period, and the virus is not found in cultures of sites outside the central nervous system.

Bacterial culture of CSF or use of antigen detection tests for Streptococcus pneumoniae are not likely to be positive in a child whose findings are consistent with encephalitis.

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Q 6 :

A 3-year-old child is brought to the emergency department with a fever of 103.1F (39.5C) and diarrhea of acute onset. The stool is guaiac-positive and contains leukocytes. There is no history of foreign travel, and the child has not received antibiotics recently.

Of the following, the organism that is MOST likely to be isolated from this child's stool is:

A.Clostridium difficile

B.Giardia lamblia

C.rotavirus

D.Salmonella enteritidis

E.Vibrio cholerae

Answer:

D

Infectious diarrhea is a common illness among children and is caused by a wide variety of pathogens. The clinical presentation of the child can aid in identifying the likely pathogen.

Children who have viral diarrheas usually have low-grade fever; vomiting; and large, loose, watery stools. Dehydration commonly accompanies rotavirus infection, which is the most common of the viral diarrheas.

The symptoms exhibited by the child in the vignette are most consistent with a bacterial diarrhea, such as those caused by Salmonella or Shigella sp. Patients who have these infections often present with high fevers and small, frequent stools that contain mucus or blood. Stool cultures reveal the pathogen, and susceptibility testing of the isolate is useful because many Salmonella and Shigella isolates are resistant to ampicillin and trimethoprim-sulfamethoxazole. Although antibiotic treatment is indicated for Shigella infections, Salmonella gastroenteritis is self-limited in immunocompetent patients, and antibiotic treatment usually is withheld because it may prolong carriage of the organism.

Clostridium difficile is most common in the setting of antibiotic-induced colitis.

Vibrio cholerae is acquired from contaminated seafood or water and rarely is seen in the United States. Infection with Giardia lamblia is more likely to result in chronic or persistent diarrhea with malabsorption

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Q 7:A 2-year-old girl presents with a swollen, tender, erythematous knee. Two weeks ago she had fever and bloody diarrhea that lasted 4 days.

Of the following, the MOST likely organism to be associated with arthritis in this patient is:

A.Escherichia coli

B.Giardia lamblia

C.Norwalk virus

D.rotavirus

E.Shigella flexneri

Answer :

E

Postinfectious or reactive arthritisoften occurs several weeks or months after an acute infection.

Reactive arthritisfrequently follows enteric infections with Shigella, Salmonella, Yersinia, and Campylobacter sp.

As described in the vignette, affected children initially develop bloody diarrhea, followed by the onset of arthritis,typically 1 to 2 weeksafter the triggering infection.

Reactive arthritides are usually acute and self-limited, resolving within weeks or months.

There is no specific treatment for reactive arthritis. The patient may need analgesics for pain relief. Of the choices listed, Shigella would be the most likely organism to cause bloody diarrhea and arthritis.

Other important examples of reactive arthritis include postvenereal reactive arthritis (especially with Chlamydia trachomatis) and virus-related arthritis.

A variety of viruses have been associated with reactive arthritis, includingrubella, hepatitis B, mumps, parvoviruses, and herpesviruses.

Poststreptococcal reactive arthritis and acute rheumatic fever (ARF) are two other examples of reactive arthritis.

Reactive arthritis does not typically follow infections with Escherichia coli, Giardia lamblia, Norwalk virus, or rotavirus.

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Q8

A 12-year-old girl who has systemic lupus erythematosus was exposed to varicella 24 hours ago. She has been receiving prednisone 40 mg bid for 9 weeks because of an exacerbation of nephropathy. She has not had varicella or received varicella immunization.

Of the following, the MOST appropriate next step is to:

A.administer varicella vaccine

B.administer varicella-zoster immune globulin

C.begin prophylactic doses of acyclovir

D.discontinue the prednisone

E.provide stress doses of prednisone

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Q 9

A 5-year-old girl complains of perianal pruritus. Results of a clear adhesive tape test are positive.Of the following, the drug of CHOICE for this infection is:

A.iodoquinolB.ivermectinC.mebendazoleD.praziquantelE.thiabendazole

Answer

C

Perianal pruritus is a common symptom of infection with Enterobius vermicularis (pinworms).

Although infection may appear in all age groups and socioeconomic levels, it is most prevalent in preschool and school-age children.

Typically, embryonated eggs are ingested and migrate to the duodenum, where they hatch and undergo sexual maturation before reaching the cecum. Adult pinworms reside in the cecum, emerge at night through the anus, and migrate to the perianal region, where gravid females deposit their eggs and die. The eggs cause anal pruritus, which leads to scratching and accumulation under the fingernails, thereby promoting autoinfection and spread to close contacts. The eggs remain infective for 2 to 3 weeks. Aberrant migration of the adult worm from the perineum rarely may give rise to urethritis, vaginitis, salpingitis, or pelvic peritonitis.

Some physicians treat the infestation based only on the history, but a definitive diagnosis should be made. Eggs are detected easily on clear adhesive tape that is applied to the perianal area early in the morning on awakening. The tape is applied to a slide and viewed under a low-power microscopic lens. Repeated examinations on successive mornings may be necessary. Because Enterobius vermicularis eggs are not excreted in the stool, examination of feces is not a useful test.

The drugs of choice for treatment of enterobiasis are either mebendazole (100 mg regardless of weight), pyrantel pamoate (11 mg/kg, not to exceed 1 g), or albendazole (400 mg) administered as a single dose. Because none of these drugs is completely effective against eggs or developing larvae, a second treatment 2 weeks after the first is recommended. Frequently, all family members are treated in an attempt to break the cycle of reinfection.Because pinworm infection often carries substantial unwarranted social stigma, reassurance of families that this infection is very common, often recurs, and does not reflect uncleanliness is an important component of therapy.

Reinfection with pinworms occurs easily. Measures that may reduce egg contamination of the local environment are helpful and include: having the infected person bathe in the morning, which removes a large proportion of the eggs; frequent changing of the infected persons underclothes, bed clothes, and bedsheets; hygienic measures such as washing hands prior to eating or preparing food, keeping fingernails short, and avoiding nail biting.Measures such as cleaning or vacuuming the entire house or washing bed clothes and bedsheets daily are not necessary.

Mebendazole also is an effective treatment for other roundworm infections, such as ascariasis, capillariasis, hookworm infections, trichinosis, whipworm infections, and visceral larva migrans. Iodoquinol is used to eradicate intestinal carriage of Entamoeba histolytica. Ivermectin is recommended for treatment of cutaneous larva migrans, river blindness (infection with Onchocerca volvulus), and strongyloidiasis. Praziquantel is the drug of choice for treatment of fluke and tapeworm infections, such as schistosomiasis and cysticercosis. Thiabendazole is effective in treating strongyloidiasis and cutaneous larva migrans.

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Q 10

A 2-year-old boy presents with rales, pallor, chronic failure to thrive, recurrent thrush, diarrhea, and oxygen saturation of 84% on room air. Echocardiography demonstrates an enlarged left ventricle with diminished systolic function.Of the following, the blood test MOST likely to establish the diagnosis in this child is:

A.antibody testing for Epstein-Barr virusB.antibody testing for human immunodeficiency virusC.antibody testing for human parvovirusD.serum carnitine levelE.serum selenium level

Answer

B

It is now appreciated that varying degrees of myocardial dysfunction are common in human immunodeficiency virus (HIV) infection in children, especially when the infection has reached the point of clinical immunodeficiency. Pallor is common in affected children from the combination of anemia and congestive heart failure. Diarrhea probably is related more to the acquired immunodeficiency syndrome (AIDS) than to the cardiomyopathy. The unusually low oxygen saturation may be explained by interstitial pneumonitis, sometimes due toPneumocystisjiroveci (carinii)infection. Although maternal HIV screening and treatment have decreased significantly the number of children who present in the first few years of life with cardiomyopathy and frank AIDS symptoms, cases still do occur in clinical practice.

It has been proposed that the dilated cardiomyopathy of childhood AIDS is due primarily to chronic viral myocarditis from coxsackievirus, adenovirus, or cytomegalovirus that is not cleared effectively by the damaged immune system.Epstein-Barr viral infection of the myocardium has been diagnosed by polymerase chain reaction analysis of myocardial biopsy in some children who have dilated cardiomyopathy. Clinical signs of Epstein-Barr virus-related myocarditis are not specific and include cardiomegaly, poor systolic left ventricular function, and physical signs of congestive heart failure.Human parvovirus may cause a number of clinical illnesses, including erythema infectiosum (fifth disease) or papulopurpuric gloves and socks syndrome. It does not have any important association with myocarditis.

Serum carnitine levels may be normal or decreased in children who have cardiomyopathy from a variety of causes. Low serum carnitine concentrations do not define or suggest a single specific etiology in cardiomyopathy.

Selenium deficiency is a rare mineral deficiency disorder believed to be associated with cardiomyopathy. Some investigators believe that selenium deficiency is common in AIDS and postulate a role for it in the cardiac dysfunction of AIDS infection. However, as noted previously, others believe that chronic viral infection

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Q 11

A 10 year old child has just been diagnosed with meningococcal meningitis.

In discussing chemoprophylaxis with his family, you are MOST likely to include the statement that rifampin:

A.causes a reactive arthritisB.causes discoloration of body fluidsC.decreases the reliability of depot medroxyprogesteroneD.is contraindicated if she has asthmaE.is safely used during pregnancy

Answer

B

Rifampin penetrates the central nervous system and is found in most body fluids. It can cause orange-colored secretions, including urine, sweat, and tears. Patients should be advised that contact lenses may be stained orange.

Rifampin is metabolized by the liver and excreted in bile and urine. It can alter the serum concentrations of many drugs and possibly interfere with the efficacy of oral contraceptives. The reliability of intramuscular medroxyprogesterone is not altered with rifampin use. Neither rifampin nor ciprofloxacin is recommended for use during pregnancy. A single intramuscular dose of ceftriaxone is the recommended prophylaxis during pregnancy.

Rifampin therapy is not contraindicated for patients who have asthma, although its use may decrease the efficacy of corticosteroids. Reactive arthritis is not a common adverse reaction associated with rifampin.

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Q 11

A child who has acute myelogenous leukemia is being treated for Pseudomonas bacteremia with intravenous doses of piperacillin and gentamicin. Gentamicin levels are measured after 2 days of therapy.

How long after completing a 30-minute infusion should blood for peak gentamicin concentrations be drawn?:

A.30minutesB.60minutesC.90minutesD.120minutesE.150minutes

Answer

B

Therapeutic drug monitoring is used to prevent or decrease the risk of toxic effects of medication. Monitoring serum concentrations of most antibiotics is unnecessary because these drugs are effective over a wide range of serum levels, therapeutic levels are achieved easily, and levels associated with toxicity rarely are encountered when standard dosing schedules are employed and patients have normal clearance mechanisms. However, certain antibiotics, especially chloramphenicol, vancomycin, and the aminoglycosides, have narrow therapeutic windows and are associated with potential adverse reactions. Therefore, careful monitoring of serum concentrations of these drugs is critical.Measurement of serum drug levels can help determine the dose and frequency of administration that allow for maximum therapeutic benefit with minimum toxicity. Appropriately timed blood samples are essential for accurate interpretation of serum drug levels. The best times to obtain blood samples for most parenterally administered antibiotics is 30 minutes after a 20- to 30-minute intravenous infusion, when the level is presumed to be highest (peak level), and immediately before the next dose, when the level is presumed to be lowest (trough level). For oral antibiotics, peak levels should be obtained 30 minutes to 1 hour after oral liquid or 1.5 hours following oral capsule administration.

The principles of therapeutic drug monitoring are based on two pharmacokinetic parameters: volume of distribution (Vd) and half-life (t1/2). Vd is the hypothetical volume within which the drug is distributed and is used to determine the dose required to maximize activity. The t1/2 reflects the rate of drug elimination and, thus, is used to determine the most appropriate frequency of dosing. The blood sample obtained 1 hour after completing the infusion provides information about the Vd after the drug has begun to be dispersed through the body but before significant amounts have been eliminated. The trough level, drawn immediately before the next dose, helps to determine elimination kinetics and t1/2.

A level drawn 30 minutes after completing a gentamicin infusion will not be a reliable indicator of Vd because not enough time has passed for drug distribution to begin. Serum samples drawn 90, 120, or 150 minutes after completing the infusion are not as reliable as a sample obtained 1 hour after completing the infusion because drug elimination will have begun.

Aminoglycoside antibiotics (eg, gentamicin, tobramycin, amikacin) have a high profile of toxic side effects, such as nephrotoxicity and ototoxicity. Although aminoglycoside-induced renal injury usually is reversible, ototoxicity, characterized by both auditory and vestibular nerve damage, is not. Individual risk factors may contribute to the development of toxicity, but the major association with organ damage is elevated peak and trough serum drug concentrations. Sustained peak serum gentamicin concentrations of more than 12 to 14 mg/L and trough serum concentrations of more than 2 mg/L have been associated with a significantly increased risk of both toxicities.

Monitoring of serum aminoglycoside peak and trough concentrations has been shown to decrease the incidence of nephrotoxicity, although these toxicities still can occur in patients whose serum concentrations are in the desired therapeutic range. Thus, regular monitoring of levels is recommended to assure the adequacy of the dosing regimen and to monitor for drug accumulation and potential toxicity. Serial trough concentrations correlate better than peak levels with the rising tissue accumulation of drug during a course of treatment.

Peak and trough serum concentrations should be measured following the fifth or sixth dose of the aminoglycoside. If these levels are appropriate, serial trough concentrations should be obtained every 4 to 7 days, depending on the clinical status of the patient. Sustained elevation of the trough concentration in excess of 25% over a 2- to 4-day period has been found to place patients at measurable risk for aminoglycoside-induced toxicity.

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Q12

A child is bitten on the hand by a neighbor's dog. Within 24 hours there is erythema, pain, and swelling at the site of the bite. The child is taken to the emergency department where cultures are taken of sanguinopurulent drainage from the wound.Of the following, the MOST likely organism infecting the wound is:

A.Eikenella corrodensB.Francisella tularensisC.Pasteurella multocidaD.Staphylococcus aureusE.Streptococcus pyogenes

Answer

C

Pasteurella multocida is the organism most likely to infect animal bite wounds. Clinical infection with P multocida is characterized by the rapid evolution of an intense inflammatory response, with substantial pain and swelling developing within 24 hours of the initial injury in 70% of cases and by 48 hours in 90% of patients who develop an infection. P multocida infection has resulted in abscess formation, septic arthritis, osteomyelitis, sepsis, meningitis, endocarditis, and pneumonia. Infections usually exhibit localized cellulitis and purulent discharge. Fever, regional adenopathy, and lymphangitis are seen in fewer than 20% of patients.

The drug of choice for treatment of P multocida infections is penicillin. Other effective agents include ampicillin, amoxicillin-clavulanate, cefuroxime, cefpodoxime, trimethoprim-sulfamethoxazole, and tetracycline. For patients allergic to beta-lactam agents, tetracycline is effective, but it should not be administered to children younger than 8 years of ageECTION IIINFECTIOUS DISEASES1.DIAGNOSTIC METHODS:26.1Match the following statements:i.)Chlamydiaii.)Pneumocystis cariniiiii.)Plasmodium leishmaniaiv.)Respiratory syncytial virusv.)Borrelia (relapsing fever)1.)Wrights stain2.)Romanowsky stain3.)Fluorescent antibody test4.)Direct examination5.)Giemsa stain26.2Answer true or false for the following statements:i.)Even slight bacterial growth is significant with suprapupic urine collectionii.)Urine specimen of>10 WBCs in symptomatic men is suggestive of UTIiii.)Optimal blood culture is 3 specimens of 5 ml each, 30 minutes apartiv.)Regular fecal cultures can detect vibrio para hemolyticusv.)Single throat swab culture is 90% positive for streptococcal pharyngitis26.3In cerebrospinal fluid, counter immuno-electrophoresis (CIE) is very sensitive test to detect the antigens of:i.)Pneumococciii.)Staphylococciiii.)Group D streptococciiv.)H. influenzav.)Meningococci2.INFECTIONS IN THE COMPROMISED HOST:27.1INFECTIONS IN THE COMPROMISED HOST:i.)Ataxia-telangiectasia and T-lymphocyte dysfunctionii.)Multiple myeloma and B cell dysfunctioniii.)Sickle cell disease and alternate pathway defectiv.)Chedak-Higashi syndrome and impaired cellular phagocytosisv.)Wiskolt-Aldrich syndrome and mixed T- and B-cell dysfunction27.2The following correlations are correct:i.)Jobs syndrome and staphylococcus aureusii.)Splenectomy and Salmonella speciesiii.)Selective IgA deficiency and Escherichia-Coliiv.)Brutons x-linked agammaglobulinemia and Herpes simplexv.)Sickle cell disease and Streptococcus penumoniae3.HOSPITAL-AQUIRED INFECTIONS:28.1The following statements are correct:i.)Gram-negative bacilli can acquire and transfer antibiotic resistance by plasmidsii.)Wound infections caused by staphylococci usually occur 24-48 hours post operativelyiii.)Pneumonia is the most common cause of mortality from hospital acquired infectionsiv.)Putting obtunded patients in a swimmers position can predispose to post-operative pneumoniav.)Legionnaires disease can be prevented by hyperchlorination or superheating of hospital tap water4.SEPTIC SHOCK:29.1Answer T or F.i.)It is usually due to release of bacterial endotoxinsii.)ARDS is the most important cause of deathiii.)Platelets are usually normaliv.)Early respiratory alkalosis is followed later by metabolic acidosisv.)Glucocorticoids are ineffective mode of therapy5.ANTIBIOTIC THERAPY:30.1The following drug-disease correla-tions are correct:i.)Azocillin and pseudomonas infectionsii.)Sulfadiazine and toxoplasmosisiii.)Chloramphenicol and chlamydiaiv.)Metronidazole and Shigellav.)Influenza A and rimantadine30.2Ceftriaxone is active against:i.)E. Coliii.)S. faecalisiii.)Psuedomonas infectionsiv.)N. meningitidesv.)S. pneumoniae30.3The following statements about drug therapy are correct:i.)One in 25,000 patients develop aplastic anemia after taking chloramphenicolii.)Erythromycin decreases blood levels of theophyllineiii.)Rifampicin increases the effect of steroidsiv.)Metronidazole should not be given in pregnancyv.)Acyclovir is more effective than vidarabine for herpes simplex encephalitis.6.PREVENTION OF INFECTION BY IMMUNIZA-TION:31.1Sabin type vaccine against poliomyelitis is different from Salk type by the fact that it is:i.)A live attenuated vaccineii.)Formalin-inactivatediii.)Given orallyiv.)Preferred during epidemicv.)Selectively used in unimmunized adults31.2The following statements about immunization are correct:i.)Cholera vaccine is only 50% effective in decreasing transmission of diseaseii.)Plague active vaccine is a formaldehyde dehydrozole inactivated Yersinia pestisiii.)Typhoid fever active vaccine is usually given subcutaneously in two dosesiv.)Influenza vaccine reduces morbidity and mortality in those at risk of complications of influenzav.)BCG vaccine is an inactivated bacilli, given intradermally31.3Passive immunization for measles with immunoglobumin is indicated in:i.)Susceptible household contacts less than 1 year oldii.)Exposed susceptible pregnant femalesiii.)Exposed immunodeficient personsiv.)Infants who have severe diseasev.)None of the above7.SEXUALLY TRANSMITTED DISEASES:32.1Microorganisms associated with Reiters syndrome include:i.)C. trachomatisii.)N. gonorrhoeaiii.)Yersiniaiv.)Campylobacterv.)Rickettsia32.2Treatment of gonococcal infections.Mark T or F:i.)Uncomplicated infections can be treated successfully by one does of ceftriazone 250 mg intramuscularlyii.)Spectinomycin is used for penicillin resistant cases particularly pharyngeal infectioniii.)Tetracycline 0.5 g P.O. QID for 7 days should follow treatment of each case of gonorrhoeaiv.)Disseminated infection is best treated by a third generation cephalosporinv.)VDRL should be checked after therapy in all patients32.3In lymphogranuloma venereum:i.)Primary lesion is a painless vesicle or papuleii.)Painful inguinal adenopathy is a known featureiii.)Diagnosis is obtained by culture of aspirated buboiv.)Compliment fixation of 1:32 is suggestive of diagnosisv.)Treatment of choice is metronidazole 500 mg P.O. Q8h for 7 days8.INFECTIOUS DIARRHEA:33.1Enterotoxogenic E. coli.Mark T or F.i.)It causes the majority of travelers diarrheaii.)Incubation period is usally 12-24 hoursiii.)It is a non invasive pathogen causing watery diarrhea most of the timeiv.)Antibiotics offer symptomatic relief but duration of the illness remains the samev.)Prophylaxis can be achieved by doxycycline 100 mg once daily33.2The following statements about pathogens causing diarrhea are correct:i.)Clostridium perfringens diarrhea rarely lasts more than 24 hoursii.)Staphylococcus aureus diarrhea has a high attack rateiii.)Campylobacter jejuni is transferred by contaminated water or raw milkiv.)Campylobacter fetus is usually non-pathogenic in humansv.)Rota virus is responsible for 40-50% of travelers diarrhea9.PNEUMOCOCCAL INFECTIONS:34.1The following statements are correct:i.)50% of cases of pneumococcal pneumonia are associated with pleural effusion which is usually sterile and resolves spontaneouslyii.)Blood cultures are positive in 10-15% of cases of pneumococcal pneumoniaiii.)CSF latex agglutination or CIE are positive in 80% of cases of pneumococcal meningitisiv.)Pneumococcal endocarditis is usually a complication of pneumonia or meningitisv.)Incidence of pneumococcal peritonitis is increased in post-partum period34.2Chest tuber insertion is indicated if pleural effusion shows:i.)Presence of bacteriaii.)PUSiii.)Ph < 7.0.iv.)Glucose < 50 mg/dlv.)LDH of fluid to serum ratio > 0.610.STAPHYLOCOCCAL INFECTIONS35.1Diagnostic criteria of toxic shock syndrome include:i.)Diffuse sunburn rash that desquamates on palms and soles over 1-2 weeksii.)Thrombocytopeniaiii.)Myalgia with normal C.K.iv.)Disorientation with normal CSFv.)Profuse vaginal discharge35.2In staphylococcal osteomyelitis:i.)Children younger than 6 years are especially susceptibleii.)Preceding superficial staphylococcal infection occurs in only 10% of the casesiii.)Radionuclide scan may be abnormal in the first week of the illnessiv.)Sinus tract cultures are not reliable in chronic diseasev.)Vancomycin is the drug of choice in penicillin allergic patients11.STREPTOCOCCAL INFECTIONS:36.1Streptococcal pharyngitis.Mark T or F.i.)Most common age is 5 15 yearsii.)It is normally group Biii.)High ASO titre confirms diagnosis of streptococcal infectioniv.)Treatment with penicillin prevents acute rheumatic fever if given within 3 days of onset of infectionv.)Erythromycin is an alternative drug in penicillin-allergic patients36.2Match the following on acute skin streptococcal infections.i.)Spreading erythema on the face with vesicles and bullaeii.)Affects skin and subcutaneous tissue with fever, pain and erythema, margins not elevatediii.)Localized purulent infection, papules and vesicles with surrounding erythema especially in lower limbsiv.)Diffuse rash, blanching erythema sparing palms and soles, sandpaper texture, followed by desquamationsv.)Red linear streaks with chills, fever and malaise1.)Scarlet fever2.)Erysipelas3.)Lymphangitis4.)Cellulits5.)Impetigo12.ANAEROBIC INFECTIONS:37.1In tetanus:i.)Only 10 20% give history of injuryii.)10-20% have no detectable lesioniii.)Rigidity and reflex spasms occur 2 3 days after onset of the diseaseiv.)Complete recovery usually occurs in 4 weeksv.)Clostridium tetani is recovered from wound in only 30% of the cases37.2In botulism:i.)Incubation period is 2-21 daysii.)Wound botulism is cause by contamination with solid containing viable pathogensiii.)Cathartics and enemas are indicated to remover unabsorbed toxiniv.)Food-borne botulism can occur after contamination with spores onlyv.)Trivalent antitoxin is given only after sensitivity testing to horse serum13.DISEASES CAUSED BY OTHER GRAM-POSITIVE ORGANISMS:38.1In diphtheria:i.)Spread is usually by droplet transmissionii.)Wounds, burns or abrasion may be invadediii.)Erythromycin is effective in chronic carrier statesiv.)Club-shaped gram-positive rod organisms are seen on methylene bluev.)Culture is done using Loefflers medium38.2In listeria moncyutogenes:i.)Food-borne outbreaks occurii.)Incidence in diabetic patients is increasediii.)Sepsis is seen in newbornsiv.)Amphotericin B is effective therapyv.)Bloody diarrhea may occur14.MENINGOCOCCAL MENINGITIS:39.1Answer T or F.i.)Attack rate is highest between ages 2 and 6 yearsii.)Petechial rash is seen in about 75% of the patientsiii.)Waterhouse-Friderichsen syndrome occurs in 10-20% of patientsiv.)Abrupt onset of confusion is a very common presentationv.)Cranial nerve palsies occurring as a complication of meningitis usually clear within 2 4 months15.HAEMOPHILUS INFECTIONS40.1Haemophilus influenza:i.)Primarily affects children 6 to 48 months oldii.)Increased incidence in patients with sickle cell diseaseiii.)Most common bacterial meningitis in children 4 6 years oldiv.)Antigens detected from serum, CSF or urinev.)Prophylaxis can be achieved by rifampicin 20 mg/kg dialy for 4 days16.DISEASES CAUSED BY GRAM-NEGATIVE ORGANISMS:41.1Match the following set of statements:i.)Malignant otitis in diabeticsii.)Causes > 75% of urinary tract infectionsiii.)Grams stain may be suggestive of diagnosis because of large capsuleiv.)Associated with obstructive uropathyv.)Punched out skin ulcers with regional lymphadenopathy1.)Proteus mirabilis2.)Pseudomonas auraginosa3.)Klebsiella Francisella tularensis4.)Francisella tularensis5.)E. Coli41.2In brucellosis:i.)Exposure occurs through infected tissueii.)Spleen is enlarged in 40-50% of patientsiii.)IgG correlates with active infectioniv.)Titers of>1:80 is suggestive of the diagnosisv.)Tetracycline is an effective prophylaxis17.TUBERCULOSIS & OTHER MYCOBACTERIAL INFECTIONS:42.1Tuberculous pleural effusion.Mark T or F.i.)It usually occurs in young patientsii.)Simultaneously pulmonary tuberculosis is very commoniii.)PPD skin test is negative in 30% of the casesiv.)It has good response to treatmentv.)Empyema requires surgical drainage42.2In military tuberculosis:i.)Fine nodules on chest x-ray occur 4 6 weeks after onset of illnessii.)Liver and bone marrow biopsies are positive in two-thirds of the casesiii.)PPD skin test is often negativeiv.)Choroid tubercles are known featuresv.)Steroid therapy is an essential part of the treatment42.3Match the following:i.)Small painless nodule which progresses to granulomatous lesion on extremetiesii.)Infection form exposure to fresh water, responds to tetracyclineiii.)Organism develops pigment with exposure to light identified by prominent transverse bondingiv.)Lymphadenitis is childrenv.)Grows within 1 5 weeks on most media, and responds to cefoxitin or erythromycin1.)M. murinum2.)M. scrofulaceum3.)M. scrofulaceum4.)M. Kansasi5.)M. forotuitum18.INFLUENZA AND OTHER VIRAL RESPIRATORY DISEASES:43.1Complications of influenza infection include:i.)S. aureus pneumoniaii.)Reyes syndromeiii.)Persistent hyponatremiaiv.)Myositis and rhabdomyolysisv.)Chorioretinitis43.2The following associations are correct:i.)Rhinovirus:spread by contact with infected secretionsii.)Coronaviurs:major respiratory pathogen of young childreniii.)Respiratory syncytial virus:causes 10-20% of cases of common coldiv.)Para influenza virus:major cause of croupv.)Adenovirus:hemorrhagic cystitis and epidemic keratoconjunctivitis19.RUBEOLA, RUBELLA, CHICKEN POX AND OTHER VIRAL EXANTHEMS:44.1Complications of measles include:i.)Croupii.)Interstitial giant cell pneumoniaiii.)Vaccinia gangrenosumiv.)Acute glomerulonephritisv.)Subacute bacterial endocarditis44.2In herpes zoster:i.)Latent virus reactivation originates from dorsal root gangliaii.)Cutaneous dissemination occurs in 75% of cases if associated with lymphomaiii.)Granulomatous angiitis with contralateral hemiplegia is a known complicationiv.)Tzanck smear is a useful method for diagnosisv.)Live attenuated vaccine should be given as prophylaxis20.MUMPS:45.1In mumps.Mark T or F for the following:i.)Paramyxovirus reservoir is present only in humansii.)Virus is transmitted by infected salivary secretions or urine for 6 days prior to parotitis and up to 2 weeks lateriii.)Marked leukocytosis is seen if orchitis occursiv.)Prednisone may give symptomatic relief in orchitisv.)Prevention is achieved by a live attenuated vaccine given after 1 year of age21.ENTEROVIRUSES AND REOVIRUSES:46.1The following statements are correct:i.)Picornaviruses are small RNA viruses that can survive in sewage and chlorinated waterii.)Risk of paralysis from oral poliovaccine is 1 in 1.7 million dosesiii.)Herpangina is caused by coxsackie B-viursiv.)Epidemic myalgia is caused by coxsackie virus A.v.)Reoviruses are single stranded RNA viruses that cause upper respiratory infections22.HERPES SIMPLEX VIRUSES (HSV):47.1The following statements are correct about drug treatment of HSV:i.)Treatment of choice for the first episode of genital herpes is oral acyclovir 200 mg orally 5 times per day for 10-14 daysii.)In symptomatic recurrent genital herpes, short course of oral acyclovir has modest benefit in shortening lesions and viral excretion timeiii.)Prolonged use of oral acyclovir 2 3 times daily prevents reactivation of symptomatic recurrences of genital herpesiv.)Acyclovir given intravenously in HSV encephalitis has no effect on overall mortalityv.)In oral-labial HSV infection topical acyclovir is of no clinical benefit23.CYTOMEGALOVIRUS (CMV) AND EPSTEIN-BARR VIRUS (EBV) INFECTIONS:48.1CMV infection.Mark T or F.i.)Maximum risk is 2-3 weeks after organ transplantii.)CMV pneumonia occurs in 20% of bone marrow recipientsiii.)CMV infection is very frequent in patients with AIDSiv.)Urine or saliva may be culture positive for months or years after infection with CMVv.)Most congenital CMV infections are clinically inapparent at birth48.2In EBV infections:i.)EBV is rarely transmitted by blood transfusiosnii.)Infected B lymphocytes are polyclonally stimulated to produce immunoglobulinsiii.)Splenomegaly occurs in almost all the casesiv.)Corticosteroids are contraindicatedv.)Burkitts lymphoma is a known association48.3Complications of EBV infection include:i.)Autoimmune hemolytic anemiaii.)Splenic rupture during the early phase of diseaseiii.)Spontaneous pneumothoraxiv.)Encephalitisv.)Pericarditis48.4Correct statements about diagnosis of EBV infection include:i.)Heterophil antibodies are antibodies to sheep red blood cells removed by absorption with beef red blood cellsii.)20-30% of cases may be negative for HA in the first week of the illnessiii.)HA may be positive upto 9 months after onset of the illnessiv.)Atypical lymphocytes that are usually seen are in fact activated B-lymphocytesv.)IgM to viral capsid antigens are diagnostic of primary infection1.IN RABIES:49.1Mark T or F.i.)Human to human transmission can occurii.)Prominence of early brain stem dysfunction distinguishes rabies encephalitis from other encephalitisiii.)Hydrophobia occurs in almost all casesiv.)Neutralizing antibody titer of>1:64 should be maintained for effective pre-exposure prophylaxisv.)Active immunization is achieved by giving human rabies immune globulin (RIG)2.FUNGAL AND RELATED INFECTIONS:50.1In cryptococcosis:i.)Infection occurs through inhalation or skin abrasionsii.)Meningoencephalitis, pneumonitis and uveitis are known clinical manifestationsiii.)India ink stain of CSF is positive in about 50% of the casesiv.)Lung biopsy is required for diagnosisv.)Flucytosine and ketoconazole are equally effective therapy50.2In candidiasis:i.)Diagnosis is by demonstration of psuedohyphae on wet smearii.)Chronic mucocutaneous candidiasis is associated with hyperparathyroidism, hyperthyroidism or T cell function defectsiii.)Appearance of retinal abscess is a feature of hematogenous spreadiv.)Imidazole cream is effective for cutaneous candidiasisv.)Urine infection is treated by bladder irrigation with amphotericin B or flucytosine diluted solutions for 15 days50.3Aspergillosis:Mark T or F.i.)It is acquired through inhalation of spores of the fungusii.)Aspergilloma represents a ball of hyphae within a lung cyst or cavityiii.)Chronic sinusitis occurs usually in the non immuno-suppressediv.)Repeated isolation of aspergillous from sputum more than two times is indicative of infectionv.)Amphotericin B can arrest or cure hemoptysis due to aspergilloma50.4Features of allergic bronchial aspergillosis include:i.)Pre-existing asthmaii.)Eosinophiliaiii.)IgG antiboidies to aspergillusiv.)Hilar adenopathyv.)Fleeting pulmonary infiltrate50.5Findings in mucormycosis include:i.)Rhizopus fungus infectionii.)Malignant otitis mediaiii.)Non septate hyphaeiv.)Immunocompromised hostv.)Poor response to amphoreticin B50.6The following correlations are true:i.)Weekly acid-fast organisms and actinomycosisii.)Painless red papule at the site of inoculation and sporotrichosisiii.)Response to sulfisoxazole and nocardiosisiv.)Osteolytic lesions and histoplasmosisv.)Hilar or paratracheal lymphadenopathy and coccidioidomycosis3.RICKETTSIAL INFECTIONS:51.1The following features favor endemic type (murine) rather than the epidemic type (louse-borne).i.)Infection by Rickettsia prowazekiiii.)Maculcopapular rash affecting axilla, upper abdomen with little involvement of the extremitiesiii.)Azotemia, thrombosis and cutaneous gangreneiv.)Rapid recovery with little fatalities in most casesv.)Positive Weil-Felix OX-1951.2Q-fever.Mark T or F.i.)It is acquired by inhalation of dust or drinking contaminated milkii.)Coxiella burnetti is the causative organismiii.)Granulomatus hepatitis occurs in one-third of the casesiv.)Culture negative subacute bacterial endocarditis is a known complicationv.)Chloramphenicol is an effective treatment4.MYCOPLASMA INFECTIONS:i.)Protective antibodies from an infection give a life long immunityii.)IgM antibodies to I antigen on type O RBC are positive in about half of the casesiii.)Tetracycline is an effective therapyiv.)WBC count is normal in over 80% of the casesv.)Stevens-Johnson syndrome is a recognized complication5.CHLAMMYDIAL INFECTIONS:53.1Chlamydia trachomatis genital infection.Mark T or F:i.)Chlamydia is a major cause of epididymitis in men under the age of 35 yearsii.)Complications include peri-rectal abscess, fistula and stricturesiii.)Up to 70% of men with non-diarrheal Reiters disease have a positive testiv.)Mucopurulent cervicitis and pelvic inflammatory disease are known clinical manifestations in femalesv.)All patients with gonorrhea and their sexual partners should be treated for chlamydia infection53.2In psittacosis:i.)Respiratory transmission occurs from any avian speciesii.)Splenomegaly is uncommoniii.)Liver function tests are usually normaliv.)Diagnosis can be obtained by culture or serologyv.)Six weeks course of tetracycline is the regimen of choice53.3In lymphogranuloma venereum (LGV):i.)Two strains (L1 and L2) are recognized pathogenic formsii.)Primary genital lesions occurs 3 to 10 days after exposureiii.)Inguinal syndrome is unilateral in 10 20% of the casesiv.)Headache and menigismus are known constitutional symptomsv.)Complement fixation titre of>1:64 is suggestive of the diagnosis6.PARASITIC DISEASES:54.1In amebiasis:i.)There is increased SGOT and bilirubin in the hepatic formii.)Pleuropulmonary extension occurs in 1 3% casesiii.)Motile trophozoites can be recovered from liquid stoolsiv.)Pericarditis is a recognized extra-intestinal manifestationv.)Serology is positive in over 90% of patients with hepatic abscess54.2Match the following statement on malaria blood smear:i.)Small rings with two chromatin dots and banana-shaped gametocytsii.)Band formsiii.)Immature (enlarged) red blood cells and diffuse red dots (Schuffners dots).iv.)Oval shaped red blood cells1.)P. vivax2.)P. falciparum3.)P. malariae4.)P. ovale54.3The following statement are correct about malaria:i.)Parasitemia is limited in patients with thalassemiaii.)Blackwater fever is triggered by immunecomplex nephropathyiii.)Exchange transfusion is indicated if parasitemia reaches > 10%iv.)Dexamethazone and/or manitol are indicated in severe falciparum infectionv.)Amodiaquine prevents relapse of P. vivax and P. ovale54.4In toxoplasmosis:i.)Acute acquired infection is usually seen in an immunocompetent hostii.)The disease is responsible for about one third of all chorioretinitis casesiii.)CNS is rarely affected even in an immunocompromised hostiv.)Trophozoites can be demonstrated in histology of tissue sectionsv.)Combination of sulfadiazine and primaquine is the best therapy54.5In pneumocystic carinii pneumonia:i.)Infection is a reactivation in most casesii.)Risk of infection is increased in children with primary immunodeficiencyiii.)Diagnosis is usually obtained by methenamine silver stain of sputumiv.)Cotrimoxazole causes drug rash in about 50% of treated AIDS patientsv.)Pentamidine could be given by inhalation, IM, or IV routes54.6Pentamidine can cause:i.)Hypoglycemiaii.)Hyperglycemiaiii.)Hypocalcemiaiv.)Hyperuricemiav.)Hepatic dysfunction54.7In schistosomiasis:i.)Pathology is dependent on duration and intensity of exposureii.)Acute schistosomiasis syndrome may last 2-3 monthsiii.)Liver fibrosis can be caused by S. Mansoni or S. Japonicumiv.)Glomerulonephritis and systemic hypertension are known clinical manifestationsv.)Hydronephrosis and renal failure are common sequelae of S. hematobium infection54.8The following associations are correct about intestinal nematodes:i.)Trichuriasis (whipworm) and pruritus aniii.)Ascariasis and malabsorptioniii.)Ankylostoma and subconjunctional hemorrhageiv.)Trichinosis and autoinfectionv.)Isosporiasis and infection by penetration of the skin7.OTHER INFECTIONS OF CLINICAL IMPORTANCE:55.1Legionella infections.Mark T or F.i.)They are anaerobic gram-negative rods with complex growth requirementii.)Risk of infection is increased with smokingiii.)Gastrointestinal symptoms are seen in almost all casesiv.)10-15% of cases are complicated by respiratory failurev.)Erythromycin or tetracycline are effective therapy55.2The following statements are in favor of tuberculous leprosy rather than lepromatous typei.)Hypopigmented maculesii.)Palpable greater auricular nerveiii.)Corneal ulcerationiv.)Nasal obstructionv.)Loss of the lateral eyebrow55.3The following statement are correct about Lyme disease:i.)Borrelia birgdoroferi is the causative organismii.)Erythema chronicum migrans indicates the beginning of stage 2 diseaseiii.)Stage 3 is manifested by CNS abnormalitiesiv.)Increased IgG titre may cross react with Trepanoma pallidumv.)Penicillin is an effective therapy