Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Infections and Immunologic Disease--->Infections in the Immunocompromised Host
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Question 1# Print Question

A 38-year-old female with no significant past medical history was brought to the emergency department with confusion and lethargy. Her family noted that the patient had been complaining of worsening headaches for the last several days. On admission, she was afebrile and hemodynamically stable. Initial laboratory workup showed leukopenia (white blood cell [WBC] count of 3 000 cells/mL) with absolute lymphopenia. Human immunodeficiency virus (HIV) testing was positive with a ribonucleic acid (RNA) viral load of 68 000 copies/mL and CD4 count of 25 cells/µL. Magnetic resonance imaging (MRI) of the brain revealed multiple ring-enhancing lesions of different sizes with surrounding edema and mass effect.

What is the NEXT BEST step to diagnose her disease process?

A. India ink staining
B. Toxoplasma gondii IgG antibody
C. Stereotactic brain biopsy
D. Cytomegalovirus CSF polymerase chain reaction (PCR)
E. Quantiferon tuberculosis testing

Question 2# Print Question

A 29-year-old male is admitted from the emergency department with fevers. He complained of night sweats and painful cervical lymphadenitis for the last 7 days. He was diagnosed with HIV/AIDS 1 month ago when he was admitted with an episode of communityacquired pneumonia. His CD4 count was 80 cells/µL and HIV RNA viral load was 1 million copies/mL at the time of diagnosis. He was started on anti-retroviral therapy (ART) with tenofovir-emtricitabine and raltegravir. On examination, his blood pressure is 90/45 mm Hg and pulse rate is 106 beats per minute. Blood cultures are in process. He is appropriately fluid resuscitated and started on vancomycin and piperacillin-tazobactam to cover potentially hospital-acquired pathogens. Immune reconstitution inflammatory syndrome (IRIS) secondary to disseminated mycobacterium avium complex (MAC) infection is suspected.

What is the NEXT BEST step regarding his ART during this admission?

A. Hold ART and resume in 1 week
B. Hold ART and resume in 2 weeks
C. Continue ART
D. Optimize ART by increasing the dose of current medications
E. Optimize ART by changing the ART regimen to include two new medications

Question 3# Print Question

A 65-year-old male is admitted to the hospital with malaise and fatigue for the past week. His WBC count on admission was 27 000 cells/mL. The patient was ultimately diagnosed with high-grade acute promyelocytic leukemia. A tunneled central venous catheter was placed and the patient was started on all-trans-retinoic acid, daunorubicin, and cytarabine. Four days after initiation of chemotherapy, he developed a fever of 39.1°C (102.3°F) and altered mental status. His blood pressure was 90/54 mm Hg, heart rate 108 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 94% on 5 L of supplemental oxygen. Laboratory evaluation was significant for neutropenia (absolute neutrophil count 300 cells/µL). His chest x-ray showed a focal consolidation in the right middle lobe. He was admitted to the intensive care unit and blood cultures were obtained.

What is the BEST empiric intravenous antibiotic regimen for this patient?

A. Ciprofloxacin and ampicillin-sulbactam
B. Meropenem alone
C. Piperacillin-tazobactam alone
D. Piperacillin-tazobactam and vancomycin
E. Meropenem and vancomycin and micafungin

Question 4# Print Question

A 60-year-old female was admitted to the ICU with acute hypoxic respiratory failure. She endorsed malaise, fevers, and neck swelling for 2 weeks prior to presentation. She received a bilateral lung transplant [cytomegalovirus (CMV) donor negative/recipient negative, Epstein-Barr virus (EBV) donor negative/recipient positive] 4 months ago for idiopathic pulmonary fibrosis and is currently on immunosuppression with azathioprine 200 mg daily and tacrolimus 2 g twice daily. Her antimicrobial prophylaxis includes trimethoprim-sulfamethoxazole one double-strength tablet thrice weekly and itraconazole 200 mg daily. On admission, she was alert and oriented, afebrile, and hemodynamically stable. Cervical lymphadenopathy was present. Her:

  • WBC count was 5600 cells/µL
  • hemoglobin 9.6 g/dL
  • alkaline phosphatase 125 U/L
  • aspartate aminotransferase (AST) 100 U/L
  • alanine aminotransferase (ALT) 130 U/L

Her chest x-ray showed bilateral diffuse infiltrates. Blood cultures showed no growth on culture at 24 hours of collection. Serum EBV quantitative deoxyribonucleic acid (DNA) PCR was 100 000 copies/mL (undetectable on prior measurement 1 month ago). Posttransplant lymphoproliferative disease is suspected.

What is the NEXT BEST step in the management of this patient?

A. Start treatment with rituximab
B. Reduce the current dose of immunosuppressants
C. Start treatment with rituximab and chemotherapy
D. Start treatment with acyclovir
E. Start treatment with valganciclovir

Question 5# Print Question

A 62-year-old male who underwent bilateral lung transplantation (CMV donor positive/recipient negative, EBV donor positive/recipient negative) for end-stage lung disease due to chronic obstructive pulmonary disease is admitted to the ICU with left lower quadrant abdominal pain, diarrhea, and hypotension. His symptoms started 5 days ago and have been progressively worsening. Diarrhea is mainly watery and frequency ranges from four to five times per day. On examination, the patient was afebrile with blood pressure 84/60 mm Hg, heart rate of 100 beats per minute, and dry oral mucosa. His abdomen was diffusely tender to palpation. An x-ray of the abdomen demonstrated colonic ileus with no evidence of gas under the diaphragm. Stool Clostridium difficile PCR, stool ova and parasites testing, and stool cultures are negative. CMV is undetectable by PCR in the plasma.

What is the next BEST step in managing this patient?

A. CT scan of the abdomen with contrast
B. Colonoscopy and biopsies
C. Check serum EBV quantitative viral load
D. 24-hour stool fat test
E. Empiric treatment with micafungin and valganciclovir

Category: Critical Care Medicine-Infections and Immunologic Disease--->Infections in the Immunocompromised Host
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