Infectious Diseases


DIRECTIONS: Each of the numbered items or incomplete statements in this section is followed by answers or by completion of the statements. Select the one lettered answer or completion that is best in each case.

426. A 25-year-old heterosexual man develops a urethral discharge and dysuria 5 days after having unprotected sexual intercourse with a new partner. Physical examination reveals meatal erythema. There are no penile lesions and no inguinal lymphadenopathy. A purulent ure-thral discharge is evident. Gram stain of the discharge reveals neu-trophils and intracellular gramnegative diplococci and the patient is treated for Neisseria gonorrhoeae. Two weeks after antibiotic therapy (ceftriaxone intramuscular injection), the patient returns with a clear urethral discharge and dys-uria. Gram stain reveals many neu-trophils but no organisms. Which of the following is the most likely diagnosis?

a. Resistant strain of Neisseria gonorrhoeae b. Lymphogranuloma venereum c. Chancroid d. Chlamydia trachomatis urethritis e. Syphilis infection

427. A 41-year-old woman presents with a maculopapular rash on her soles and palms. Both the VDRL (RPR) and FTA-ABS are positive. Two hours after being treated with penicillin, the patient develops fever, chills, myalgias, tachypnea, tachycardia, and a leukocytosis. Which of the following is the most likely diagnosis?

a. Neurosyphilis b. Tertiary syphilis c. Jarisch-Herxheimer reaction d. Rocky Mountain spotted fever e. Endocarditis

428. Which of the following deficiencies causes patients to be susceptible to gonococcemia and meningococcemia infections?

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429. A 19-year-old previously healthy college student presents with a 5-day history of fever, generalized malaise, and sore throat. He denies cough. He does not use illicit drugs and uses condoms with his one sexual partner. He has been vaccinated against hepatitis B. On physical examination the patient appears jaundiced and has a temperature of 101.7°F The pharynx is erythematous but has no exudate. There is bilateral tender cervical lymphadenopathy. Liver size is 14 cm in the MCL and the spleen tip is palpable 2 cm below the left costal margin. The white blood cell count is elevated and many atypical forms are reported. Which of the following is the most likely diagnosis?

a. Drug-induced hepatitis b. Mononucleosis syndrome c. Hepatitis B infection d. Hepatitis C infection e. Mycoplasma pneumoniae

430. A neonate develops meningitis and you suspect that the responsible organism was acquired during passage through the birth canal. Which of the following organisms is most likely responsible for the neonate's illness?

a. Staphylococcus aureus b. Pseudomonas c. Rubeola d. Listeria monocytogenes e. Salmonella

431. A 23-year-old man presents with the acute onset of fever, skin lesions that are papular and ery-thematous with a hemorrhagic and necrotic center, joint pain, and an acute tenosynovitis of the dorsum of his left foot. He has no past medical history and takes no medications. He does not smoke, drink alcohol, or use illicit drugs. On physical examination, the patient has a temperature of 102.4°h Passive flexion and extension of the left great toe causes severe pain over the dorsum of the midfoot and ankle. Which of the following is the most likely diagnosis?

a. de Quervain's tenosynovitis b. Reiter syndrome c. Acute gouty attack d. Disseminated gonococcal infection e. Still's disease

432. Which of the following organisms should be considered in a patient with bacterial endocarditis when blood cultures continuously remain negative?

a. Staphylococcus aureus b. Campylobacter jejuni c. Vibrio parahemolyticus d. Haemophilus aphrophilus e. Streptococcus viridans

433. A 40-year-old gardener presents with painless papules that appeared following a puncture wound from a rose thorn a few weeks earlier. Physical examination reveals a chain of erythematous nodules along the dorsal aspect of the arm. Which of the following is the most likely diagnosis?

a. Coccidioidomycosis b. Sporotrichosis c. Blastomycosis d. Cutaneous larva migrans e. Histoplasmosis

434. An ill-looking 58-year-old man with a 20-year history of diabetes mellitus presents with severe pain and swelling of his right arm that started 2 days ago after some minor trauma. He has a temperature of 103.6°F Examination of the arm reveals a 13-cm area of dark red epidermal induration. Large bullae filled with purple fluid are seen in the center of the wound. Some parts of the wound are friable and appear black in color. Crepitus is felt with palpation of the arm. Laboratory data reveals a leukocyto-sis and an elevated serum creatinine phosphokinase. Which of the following is the most likely diagnosis?

a. Erysipelas b. Folliculitis c. Cellulitis d. Necrotizing fasciitis e. Fournier's gangrene

435. A 54-year-old man presents with a 2-wk history of headache, fever, chills, and night sweats. He complains of myalgias and easy fati-gability. He has just returned from a business trip to Africa and the Middle East. Before the trip, the patient received immunizations against poliomyelitis, hepatitis A, hepatitis B, and dengue fever. Throughout the trip, he took chloroquine prophylaxis against malaria. On physical examination, the patient has a temperature of 103.2°F and is diaphoretic. There is no neck stiffness, photophobia, or lymphadenopathy. Heart and lung examinations are normal. There is mild splenomegaly. Which of the following is the most likely diagnosis in this patient?

a. Malaria b. Tuberculosis c. Mononucleosis d. Trypanosomiasis e. Toxoplasmosis

436. A 68-year-old man with endocarditis and bacteremia from Streptococcus bovis infection has a high incidence of which of the following malignancies?

a. Prostate cancer b. Pancreatic cancer c. Lymphoma d. Colon cancer e. Lung cancer

437. Which of the following statements regarding lymphadenopathy is true?

a. The harder the node, the more likely it is to be benign b. The more discrete the node, the more likely it is to be benign c. The more tender the node, the more likely it is to be inflammation d. Lymph nodes may occasionally be pulsatile e. A palpable left supraclavicular node is often benign f. A sentinel node is usually a benign lymph node g. A Sister Joseph node is a benign lymph node

438. A 35-year-old woman presents with fever, diarrhea, and right upper quadrant pain. She has recently returned from a 2-mo business trip in Mexico. Physical examination reveals no jaundice. She has point tenderness over the liver and has a positive FOBT. CT scan of the abdomen reveals several oval lesions in the liver. Which of the following is the most likely diagnosis in this patient?

a. Hepatitis A infection b. Hepatocellular carcinoma c. Metastatic liver disease d. Entamoeba histolytica e. Campylobacter jejuni f. Salmonella

439. A 46-year-old woman with a history of sinusitis presents with a severe headache. She complains of neck stiffness and photophobia. On physical examination she has a temperature of 103.4°F Blood pressure is normal and heart rate is 110/min. She has a normal fundu-scopic examination and no focal neurologic deficit. She has nuchal rigidity. Brudzinski and Kernig signs are positive. Which of the following is the most likely diagnosis?

a. Migraine headache b. Cluster headache c. Torticollis d. Bacterial meningitis e. Cysticercosis f. Fever of unknown origin

440. A 16-year-old boy is bitten on the leg by a neighbor's dog. The dog is healthy and has proof of a rabies vaccination. The next day, the patient develops a cellulitis at the site of the bite accompanied by a purulent, foul-smelling discharge. There is unilateral inguinal lym-phadenopathy. Which of the following organisms is most likely responsible for the patient's symptoms?

a. Rabies virus b. Pasteurella multocida c. Aeromonas hydrophila d. Pseudomonas aeruginosa e. Vibrio parahemolyticus

441. A 41-year-old woman develops abdominal cramps and diarrhea 2 h after eating fried rice. Physical examination is normal except for some mild abdominal tenderness with palpation. Examination of the stool reveals no fecal leukocytes. Which of the following is the most likely etiology for the symptoms?

a. Shigella b. Salmonella c. Vibrio cholerae d. Bacillus cereus e. Staphylococcus aureus f. Vibrio parahemolyticus

442. Fecal leukocytes are seen with which of the following gastrointestinal pathogens?

a. Vibrio cholerae b. Giardia lamblia c. Campylobacter jejuni d. Clostridium perfringens e. Aeromonas hydrophila f. Cryptosporidium g. Rotovirus h. Norwalk virus

443. Patients with glucoses-phosphate dehydrogenase deficiency are afforded protection against which of the following?

a. Rickettsia typhi b. Borrelia burgdorferi c. Plasmodium falciparum d. Hantavirus e. Monkeypox virus

444. A 52-year-old woman presents to the emergency room 5 h after eating some grouper at a seafood restaurant while on vacation in Hawaii. She has abdominal cramps, nausea, vomiting, and watery diarrhea. She also complains of tingling and numbness of her lips and extremities. Physical examination reveals a fine tremor and some mild ataxia. Which of the following is the most likely diagnosis in this patient?

a. Ciquatera poisoning b. Scromboid poisoning c. Traveler's diarrhea d. Pseudomembranous colitis e. Mycobacterium marinum

445. Helicobacter pylori is associated with which of the following disorders?

a. Squamous cell carcinoma of the esophagus b. Adenocarcinoma of the esophagus c. Barrett's esophagus d. Gastroesophageal reflux disease e. Mucosa-associated tissue lymphomas (MALT)

f. Non-Hodgkin's lymphoma of the small intestine

446. A 22-year-old woman with sickle cell disease presents with a painful pretibial ulcer. Physical examination reveals the presence of purulent material draining from the wound site. The patient has a low-grade fever. Radiographs reveal soft tissue swelling and a periosteal reaction. Which of the following is the most likely pathogen responsible for the symptoms?

a. Staphylococcus epidermis b. Salmonella c. Shigella d. Streptococcus pyogenes e. Mycobacterium tuberculosis

DIRECTIONS: Each set of matching items in this section consists of a list of lettered options followed by several numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all. Each item will state the number of options to select. Choose exactly this number. Items 447-450

For each patient with symptoms, choose the most likely responsible pathogen.

a. Giardia lamblia b. Trichinella c. Chlamydia psittacosis d. Acanthamoeba castellanii e. Brucellosis f. Clostridium tetani g. Cysticercosis

447. A 41-year-old man presents with periorbital edema, myalgias, and eosinophilia 3 wk after eating some undercooked pork at an outdoor restaurant. (CHOOSE 1 PATHOGEN)

448. A 19-year-old college student develops a keratitis thought to be secondary to use of disposable soft contact lenses. (CHOOSE 1 PATHOGEN)

449. A 22-year-old veterinary student develops fever, myalgias, joint pain, and headache. He has lym-phadenopathy and hepatospleno-megaly. A murmur is heard on auscultation of the heart. (CHOOSE 1 PATHOGEN)

450. A 28-year-old immigrant from Mexico is brought to the emergency room because of new onset of seizures. CT scan of the head reveals several discrete calcified densities throughout the frontal lobe, brainstem, and cerebellum. (CHOOSE 1 PATHOGEN)

Items 451-452

For each patient with neurologic symptoms, choose the most likely diagnosis.

a. Toxoplasmosis b. Cryptococcal meningitis c. Progressive multifocal leukoen-cephalopathy d. HIV dementia

451. A 37-year-old woman with HIV presents with headache, irritability, and confusion. Fundu-scopic examination reveals bilateral papilledema. India ink smear of the spinal fluid is positive. (CHOOSE 1 DIAGNOSIS)

452. A 47-year-old woman with HIV presents with new right-sided arm and leg weakness. CT scan of the head reveals multiple ring-enhancing lesions located in both hemispheres and involving the basal ganglia and corticomedullary junction. (CHOOSE 1 DIAGNOSIS)

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