A 43-year-old man is admitted with acute onset of right sided hemiplegia and dysarthria. He had been in excellent health until one month previously when he presented with shortness of breath and was diagnosed with acute pulmonary emboli and adenocarcinoma of the lung. He was begun on eliquis and chemotherapy was deferred pending genetic testing.
The patient lives with his wife and 2 children in Chicago. He works as a municipal bus driver. He denies pet or animal exposure. On presentation, he is afebrile. Exam is notable for poor dentition and dense right hemiplegia.
CT head confirmed a left middle cerebral artery infarct.
TTE confirms a 6x9 mm mass on the mitral valve.
Blood cultures x3 sets taken prior to initiation of antibiotics are no growth at 5 days.
What is the most probable cause of endocarditis in this patient?
A. T whipplei
B. Mycobacterium chimaera
C. Bartonella henselae
D. Hypercoaguable state
E. Coxiella burnetii
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A 58-year-old HIV- negative gay man is evaluated for PrEP. His past medical history is notable for hypertension, treated for over 10 years with an ACE inhibitor. He is asymptomatic and weighs 145 lbs.
He is sexually active with multiple partners but “usually” practices safe sex.
Lab studies reveal: HIV 4th generation test negative, HIV-1 RNA negative, CBC normal, creatinine 1.4 with a
calculated creatinine clearance of 48 ml/min.
What do you recommend for PrEP?
A. No PrEP
B. Tenofovir disoproxil fumarate/emtricitabine 1 pill daily
C. Tenofovir disoproxil fumarate/emtricitabine 1 pill every other day
D. Tenofovir alafenamide/emtricitabine 1 pill daily
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A 44-year-old man was diagnosed with Pneumocystis pneumonia as his AIDS-defining illness and begun on antiretroviral therapy with 2 nucleosides and an integrase inhibitor during his hospitalization. He stabilizes and follows up for repeated outpatient visits with an HIV RNA consistently <20 copies/ml and a CD4 cell count of 44 that increased to 163 (at 3 months), 232 (at 6 months), 242 (at 9 months), and was repeated at 243 (at 12 months).
His current medications are: tenofovir alafenamide/emtricitabine, dolutegravir, trimethoprim-sulfa double strength daily, and azithromycin 1200 mg once weekly. He says he’s tired of taking pills and would like to stop some of them.
What do you recommend?
A. Stop tenofovir alafenamide/emtricitabine
B. Stop trimethoprim-sulfa
C. Stop azithromycin
D. Stop trimethoprim-sulfa and azithromycin
E. Continue the current regimen
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A 29-year-old man living with HIV on tenofovir alafenamide (TAF)/emtricitabine + dolutegravir (CD4 298, HIV RNA <20 cps/ml) develops pulmonary TB.
The plan is to start empiric INH, RIF, PZA, and ETH pending mycobacterial susceptibilities.
How do you manage his ART regimen?
A. Continue current regimen
B. Change dolutegravir to darunavir/ritonavir
C. Change dolutegravir to elvitegravir
D. Double the dose of dolutegravir
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A 56-year-old male with end-stage-renal disease due to hypertensive nephropathy is being evaluated for possible renal transplantation.
Routine pre-transplant serologies were obtained, which were notable for a positive Interferon-Gamma Release Assay (IGRA) for Mycobacterium tuberculosis. The patient is asymptomatic and has never been treated for TB.
Chest x-ray is normal.
The patient has a suitable living donor and the transplant team would like to proceed with transplantation as soon as possible.
Which one of the following would be the best course of action?
A. Inform the transplant team that patient is not a renal transplant candidate due to TB infection
B. Initiate treatment with isoniazid and vitamin B6 while proceeding with transplant; complete treatment for a total of 6-9 months
C. Initiate treatment with rifampin while proceeding with transplant; complete treatment for 4 months
D. Initiate treatment with once weekly isoniazid and rifapentine while proceeding with transplant; complete treatment for 12 weeks
E. Initiate treatment with isoniazid, rifampin, pyrazinamide and ethambutol for 6 months while proceeding with transplant
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A 63-year-old male underwent allogeneic stem cell transplant for chronic myelogenous leukemia 120 days
ago. He has had multiple episodes of acute graft-versus-host disease, for which he received multiple pulses
of corticosteroids and remains on maintenance cyclosporine. His absolute neutrophil count hovers
between 750 and 1000 cell/μL. He is receiving prophylactic doses of trimethoprim-sulfamethoxazole.
The patient developed a fever, patchy pulmonary infiltrates and hypoxia. He is intubated and undergoes
bronchoscopy. The micro lab reports that branched hyphae are present on wet mount of the BAL. No
pneumocystis was seen. PCR on the BAL is positive for CMV. Liposomal amphotericin (5 mg/kg/day) is
started.
Five days later, the lab reports that the BAL culture is growing Scedosporium apiospermum. PCR of
peripheral blood for CMV is undetectable. The patient is still febrile and the pulmonary status has
deteriorated.
At this point, you would recommend:
A. Raise the dose of liposome amphotericin B to 10 mg/kg
B. Add ganciclovir
C. Switch to fluconazole
D. Switch to voriconazole
E. Add caspofungin
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A 42-year-old woman newly diagnosed with HIV (CD4 425, HIV RNA 73,000, genotype with wild-type virus) starts tenofovir alafenamide/emtricitabine/bictegravir and has the following virologic response:
Weeks of Therapy HIV Viral Load
4 weeks HIV RNA 9,400
8 weeks HIV RNA 1,050
16 weeks HIV RNA 105
24 weeks HIV RNA 90
36 weeks HIV RNA 67
48 weeks HIV RNA 82
In addition to reinforcing adherence, what would you recommend?
A. Add darunavir/ritonavir
B. Add etravirine
C. Add darunavir/ritonavir and etravirine
D. Switch bictegravir to darunavir/ritonavir
E. Continue current regimen
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A 36-year-old obese white man (BMI 34) recently diagnosed with HIV (CD4 560, HIV RNA 52,000) is recommended to start antiretroviral therapy but is concerned about weight gain.
Which is true of antiretroviral-induced weight gain?
A. Raltegravir is associated with more weight gain than dolutegravir
B. Elvitegravir is associated with more weight gain than bictegravir
C. Tenofovir AF is associated with more weight gain than tenofovir DF
D. White men have the highest rates of weight gain on ART
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A 52-year-old woman with no prior medical conditions presents with a 6-month history of shortness of breath and cough. She has no fever, and her CBC and Chemistry panel is normal. Oxygen saturation on room air = 80%.
She reports that she installed a hot tub at home which she uses daily; she has no other unusual exposures.
If this syndrome is related to her hot tub, which of the following organisms is most likely related to the pulmonary process?
A. Acanthamoeba
B. Legionella pneumophila
C. Aeromonas hydrophila
D. Mycobacterium avium complex
E. Nocardia asteroides
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A 62-year-old nurse presents to your clinic with a six-month history of pain and swelling involving her third
finger.
She has been treated sequentially with cephalexin, amoxicillin-clavulanate, and clindamycin without effect.
She is an avid gardener and enjoys digging for clams in a marshy area near to her home. She admits to
frequent abrasions and scratches.
MRI has demonstrated diffuse soft tissue inflammation with tenosynovitis, septic arthritis of the
interphalangeal joints, and early phalangeal osteomyelitis.
What is the most likely microbiologic agent?
A. Methicillin-resistant Staphylococcus aureus
B. Aeromonas hydrophila
C. Nocardia nova complex
D. Nontuberculous mycobacteria
E. Sporothrix schenckii
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A 47-year-old female grew up in an impoverished farming community in Argentina. She moved to the
United States when she was 16 years of age.
Three years ago, she developed progressive dyspnea on exertion. A cardiac workup revealed a markedly
enlarged heart, ejection fraction of 25%, and no obstruction of the coronary arteries by angiography.
The most likely pathogen causing her cardiac disease, assuming it is due to an infection acquired in
Argentina, is:
A. Leishmania donovani
B. Taenia solium
C. Trypanosoma cruzi
D. Toxoplasma gondii
E. Trichinella spiralis
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A 62-year-old male was seen for low grade fever and weight loss over the past month.
He had undergone aortic valve replacement in 2015 with a bioprosthesis. Transesophageal
echocardiography found no evidence of endocarditis and routine blood cultures were negative.
Mycobacterial blood cultures grew Mycobacterium chimaera.
The patient lived in a rural area, drank well water and had a pond in this back yard with Koi fish.
The most likely source of this Mycobacterial infection is which of the following:
A. Operating room air
B. Bioprosthetic valve
C. Well water
D. Fish pond
E. Intestinal lesion
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A 37-year-old woman from New Jersey undergoes routine HIV testing with the following results:
• HIV 4th generation test: Reactive (antibody positive + p24 antigen negative)
• HIV-1/2 Supplemental Assay: HIV-1 antibody negative, HIV-2 antibody negative
• HIV-1 RNA: <20 copies/ml
What is the most likely interpretation of the results?
A. She is a long-term non-progressor
B. She has acute HIV-1 infection
C. She has acute HIV-2 infection
D. She has a false negative viral test
E. She has a false positive 4th generation test
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A 30-year-old female presents with a new diagnosis of smear-positive pulmonary TB.
She is also found to have a new diagnosis of HIV.
Labs show mild anemia, normal liver enzymes, CD4 cell count=25 cells/uL.
Which is most appropriate approach to therapy:
A. Start HIV treatment immediately, defer TB treatment
B. Start TB treatment immediately, defer HIV treatment until after 6 months of TB treatment
C. Start TB treatment immediately, and start HIV treatment in 8-12 weeks
D. Start TB treatment immediately, and start HIV treatment within 2 weeks
E. Start HIV treatment immediately, and start TB treatment within 2 weeks
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A 40-year-old female is admitted with a 3-week history of daily fever accompanied by a non-pruritic skin
eruption. She was initially seen at a walk-in clinic 5 weeks ago for cough and given a 7-day course of
Augmentin for bronchitis with resolution of respiratory symptoms. In the last 2 weeks she has developed
diffuse arthritis of hands, knees, elbows, and ankles.
Labs include WBC of 7.8 (82% seg, 15% lymph, 3% eos), platelets of 159, alkaline phosphatase of 454, ALT/AST
137/118 and bilirubin 1.9.
CRP is 183.6, rheumatoid factor <10, ANA negative. Ferritin is 8622
CT scan of the abdomen shows hepatosplenomegaly and peri-portal lymphadenopathy.
What is the most likely diagnosis for this patient?
A. Adult-onset Still’s disease
B. DRESS (drug associated rash with eosinophilia and systemic symptoms)
C. SLE (systemic lupus erythematosus)
D. HLH (hemophagocytic lymphohistiocytosis)
E. Acute CMV infection
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A 62-year-old man with a history of hypertension has taken HIV PrEP with tenofovir DF/emtricitabine for 5
years.
His baseline creatinine clearance was 85 cc/min, but this has trended down with his latest creatinine
clearance 55 cc/min (repeated at 60 cc/min).
He is in a monogamous relationship with his partner who has HIV and is taking a bictegravir-based regimen
with HIV RNA <20 for years.
How would you manage his PrEP?
A. Continue tenofovir DF/emtricitabine, follow creatinine clearance monthly
B. Change to tenofovir AF/emtricitabine
C. Change to injectable cabotegravir every other month
D. Stop PrEP
This 52 minute session, called an HIV bootcamp, is taken from the extensive teaching material on the infectious disease board review website, available to persons who subscribe to the Home study course, the live or the virtual course. This lecture by Dr. Gulick is for physicians who need introductory material before progressing to more advanced topics likely to be on certifying or recertifying examinations given by the American Board of Internal Medicine.
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An 80-year-old resident of a nursing home has severe dementia, type 2 diabetes mellitus and a chronic indwelling Foley catheter which is in place to manage his persistent incontinence. He has no remarkable medical history and is quite healthy except for his dementia. He has received antibiotics for presumed urinary tract infection twice in the last year.
The nursing home staff decided to obtain a urinalysis and urine culture: they call you because the urine culture is growing Candida albicans with a colony count of 100,000 cfu/ml. His UA shows 30-40 WBC and 10-20 RBC per HPF, with a 1+ leukocyte esterase.
He is in his usual state of health with no fever, no urinary symptoms that you can elicit from him, and no flank tenderness.
What would you recommend?
A. Observe and do nothing more unless the patient becomes symptomatic
B. Observe but obtain repeat urinalysis and culture in one week
C. Change Foley catheter and give oral fluconazole for 1 week
D. Change Foley catheter and IV caspofungin for 1 week
E. Change the Foley catheter and order Amphotericin B deoxycholate bladder washes daily for 5-7days
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A 42-year-old male presents with a deformed foot and draining sinuses. The patient is a native of Mexico, where he does manual labor. He noted the onset of persistent swelling 2 years earlier in Mexico after dropping a heavy wooden box on his foot. He received various treatments, but his foot has become more deformed. He is visiting family in the United States and comes to you for advice.
He is afebrile, with normal vital signs. He looks well. His exam is normal except for his left foot, which is swollen and firmly indurated, particularly over the metatarsals, but not very tender. Several draining sinuses are present.
His routine lab work, including CBC, is normal. An x-ray of his foot shows soft tissue defects without bony erosions.
The appropriate approach would be:
A. An empiric course of trimethoprim-sulfamethoxazole
B. An empiric course of amphotericin
C. An empiric course of itraconazole
D. Smear and culture of the sinus discharge before initiating therapy
E. Surgical biopsy and culture of deep tissue
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Two hours after eating at a hotel buffet in Hawaii, a 56-year-old man experiences abdominal pain, vomits once, and has one loose stool. Two days later he experiences numbness of his extremities, tongue, and throat.
He finds that cold objects feel hot and hot objects feel cold, and his teeth feel numb and loose. He develops weakness, gait ataxia, and vertigo. He is hospitalized where he has a slow convalescence. Neurological symptoms persist for one month before he is completely well.
What is the likely diagnosis?
A. Ciguatera
B. Scombroid
C. Paralytic Shellfish Poisoning
D. Botulism
E. Staphylococcal food poisoning
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