QUESTION: 53

A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal.
What further diagnostic test is the most appropriate?

Perform a West Nile virus IgM on the CSF.
Perform a serum cryptococcal antigen.
Perform immitis complement fixation tests.
Perform a sinus series.
Perform a purified protein derivative (PPD) skin test.

Answer(s): A

Explanation:

This is a clinical presentation of West Nile virus infection. The tongue fasciculations go along with an inflammation at the base of the brain. The patient is at the right age for West Nile virus infection and he is immunocompromised due to diabetes. The diagnosis can be made by performing a West Nile virus IgM titer on the CSF. Diabetics can have cryptococcal meningitis. Lumbar puncture in this setting is usually normal with increased opening pressure, and rhabdomyolysis is not a feature of this disease. Diabetics are more at risk for candidiasis. However, the patient has no history of instrumentation, IV catheters, or other situations that would lead to disseminated candidiasis. Diabetics are at increased risk for C. immitis infection, but we have no history of the patient living in an area endemic for this organism. Diabetics are at increased risk for rhinocerebral mucormycosis. An MRI of the head might have shown involvement of the sinus. However, this patient's presentation is not consistent with rhinocerebral mucormycosis.

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QUESTION: 54

A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101.1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis?

erythematous tonsils
cough
tonsillar exudates
posterior cervical lymphadenopathy
halitosis

Answer(s): C

Explanation:

Pharyngitis is a commonly encountered problem in primary care. Patients with upper respiratory symptoms are often convinced that they need antibiotics. Often the etiology is viral, but ruling out bacterial etiology is crucial as the secondary complications can be severe. In terms of group Astrep pharyngitis, it is often difficult to make a clinical diagnosis based on one or two factors. Many studies have been performed to guide the clinician in making an empiric diagnosis of group A strep pharyngitis. Fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough and tonsillar hypertrophy are all positive predictors. A patient who has at least two of these criteria should have a rapid strep test or culture--with treatment initiated if the test is positive. When a patient meets three or more criteria and is ill appearing, empiric treatment may be justified. If the patient has a negative rapid strep test and the clinician is suspicious, empiric treatment may be started and throat culture should be obtained. Apatient with a positive culture or rapid strep test should be treated, but a test of cure does not need to be performed. The throat culture has a sensitivity of 97% and specificity of 99%, while the rapid strep test has a sensitivity of 8097% and a specificity of >95%.

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QUESTION: 55

A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101.1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis?

Which of the following is the recommended first-line agent for the treatment of group A streptococcal pharyngitis?

levofloxacin
amoxicillin
penicillin
amoxicillin-clavulinic acid
clindamycin

Answer(s): C

Explanation:

Pharyngitis is a commonly encountered problem in primary care. Patients with upper respiratory symptoms are often convinced that they need antibiotics. Often the etiology is viral, but ruling out bacterial etiology is crucial as the secondary complications can be severe. In terms of group Astrep pharyngitis, it is often difficult to make a clinical diagnosis based on one or two factors. Many studies have been performed to guide the clinician in making an empiric diagnosis of group A strep pharyngitis. Fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough and tonsillar hypertrophy are all positive predictors. A patient who has at least two of these criteria should have a rapid strep test or culture--with treatment initiated if the test is positive. When a patient meets three or more criteria and is ill appearing, empiric treatment may be justified. If the patient has a negative rapid strep test and the clinician is suspicious, empiric treatment may be started and throat culture should be obtained. Apatient with a positive culture or rapid strep test should be treated, but a test of cure does not need to be performed. The throat culture has a sensitivity of 97% and specificity of 99%, while the rapid strep test has a sensitivity of 8097% and a specificity of >95%.

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QUESTION: 56

A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy.

Which of the following is true about this patient's condition?

The causative agent is a virus.
Light microscopy of fluid from the lesions will reveal gram-negative rods in chains.
The presence of multiple distinct lesions is uncommon.
There is a latent phase in which patients are asymptomatic.
Although associated with persistent symptoms if left untreated, it does not carry a significant risk for mortality.

Answer(s): D

Explanation:

This patient's presentation is consistent with primary syphilis. Primary syphilis manifests itself usually in the form of solitary or multiple raised, firm papules which eventually erode to form ulcerative craters with raised, indurated margins surrounding the centralized ulcer. These lesions, called chancres, most commonly involve the glans penis in males and the vulva or cervix in females, although they may appear rarely in other areas. Syphilis is caused by the spirochete, T. pallidum, which can be visualized by darkfield microscopy, by silver stain, or by fluorescent antibody microscopy. There is an incubation period of approximately 3 weeks separating the time of initial exposure to T. pallidum and the time of chancre formation. Syphilis is characterized by the presence of latent stages in which there are no signs of clinical disease present. Penicillin is the drug of choice for the treatment of syphilis. In addition to treating patients with diagnosed syphilis, it is recommended that treatment also be administered to all sexual contacts of the past 90 days. It has been demonstrated that up to 30% of asymptomatic sexual contacts of patients with infectious lesions within the past 30 days go on to develop syphilis if left untreated. If left untreated, patients may ultimately develop tertiary syphilis characterized by significant destructive neurologic and cardiovascular symptoms. The mortality rate for untreated tertiary syphilis is approximately 20%.

Cephalosporins and penicillin antibiotics act by interfering with the late stages of bacterial cell wall synthesis, although the precise biochemical reactions are not entirely understood. Peptidoglycan provides mechanical stability to the cell wall because of its high degree of cross-linking with alternating amino pyranoside sugar residues (N-acetylglucosamine and N-acetylmuramic acid). The completion of the cross- linking occurs by the action of the enzyme transpeptidase. This transpeptidase reaction, in which the terminal glycine residue of the pentaglycine bridge is joined to the fourth residue of the pentapeptide (D- alanine) thereby releasing the fifth residue (D-alanine), is inhibited by beta- lactams.

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