Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Infections and Immunologic Disease--->Immunological Effects of Infections
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Question 1# Print Question

A 44-year-old female with no known medical history is admitted to the intensive care unit (ICU) with septic shock, presumably from influenza. She is treated with mechanical ventilation, vasopressors, and broad-spectrum antimicrobials including oseltamivir, vancomycin, cefepime, flagyl, and azithromycin. Despite 5 days of treatment, she fails to improve. She has persistent fever to 38.9°C and requires norepinephrine and vasopressin to treat hypotension. Arterial blood gas (ABG) is 7.32/34/98 on FiO2 of 0.5. She is noted to have hepatosplenomegaly, but no rash, asymmetric lower extremity edema, or lymphadenopathy. Laboratory data reveal:

  • hemoglobin 7.1 g/dL
  • platelets 40/µL
  • creatinine 0.5 mg/dL

Chest x-ray reveals resolving bilateral patchy opacities and mild pulmonary edema. Point of care cardiac ultrasound shows hyperdynamic biventricular function. Culture data are negative to date.

Which of the following tests would BEST to confirm her diagnosis:

A. Ferritin, triglycerides, fibrinogen, soluble IL-2 receptor levels
B. Antineutrophil cytoplasmic antibody (ANCA)
C. Peripheral smear and flow cytometry
D. Platelet factor 4 Ab, serotonin release assay

Question 2# Print Question

A 68-year-old diabetic man, who had open sigmoidectomy 10 days ago for diverticulitis, is brought to emergency department (ED) after his son found him altered at home. Initial vitals are notable for:

  • fever to 40°C
  • heart rate (HR) of 120 beats per minute
  • blood pressure 78/42 mm Hg
  • respiratory rate of 34
  • O2 saturation 92% on room air

His blood glucose is normal. Blood cultures, chest x-ray, urinalysis, and urine culture are obtained. He is given vancomycin, cefepime, metronidazole, and 2 L of lactated Ringer’s and is subsequently intubated for airway protection. CT scans of the head, chest, abdomen, and pelvis, obtained before the ICU admission, are unremarkable.

On ICU arrival, detailed physical examination reveals diffuse erythematous blanching rash and hyperemic mucus membranes of the mouth and conjunctiva. His abdominal incision is slightly erythematous but without frank purulence

Subsequent management should include which of the following?

A. Intravenous (IV) piperacillin-tazobactam monotherapy
B. Continuation of IV vancomycin, cefepime, metronidazole, and addition of IV clindamycin
C. Discontinuation of vancomycin because of skin reaction
D. IV diphenhydramine and hydrocortisone

Question 3# Print Question

A 68-year-old man with bronchiectasis and severe pneumonia is mechanically ventilated in the ICU. He is treated with empiric meropenem and vancomycin based on the culture data obtained during prior admission, and his blood pressure is supported with norepinephrine. On ICU day 3, his sputum culture reveals ceftriaxone-susceptible Streptococcus pneumoniae. Thirty minutes after the dose of ceftriaxone, he is noted to have worsening hypotension and requires increasing doses of norepinephrine. As ICU physician prepares to perform cardiac ultrasound, he notices urticaria on his chest.

Which of the following laboratory tests would clarify the diagnosis?

A. Angiotensin-converting enzyme (ACE) level
B. Tryptase level
C. Histamine level
D. Complete blood count (CBC)

Question 4# Print Question

A 23-year-old female with refractory acute lymphoblastic leukemia now 28 days postallogeneic hematopoietic stem cell transplant (HSCT) is transferred to the ICU for respiratory distress. On arrival, vital signs are:

  • temperature 38.2°C
  • HR 110 beats per minute
  • blood pressure 88/52 mm Hg
  • respiratory rate 38 breaths per minute

She is saturating 88% on 10 L O2 via nonrebreather. Pulmonary examination is notable for diffuse rales. She does not have a rash, and her sclerae are mildly icteric. She is subsequently intubated and started on norepinephrine infusion for hypotension with improvement in hemodynamics. Broad-spectrum antibiotics are administered for concern of pneumonia. Chest x-ray shows diffuse bilateral patchy opacities. 

The next BEST diagnostic step is:

A. CT chest and bronchoalveolar lavage
B. Serum galactomannan, 1-3-beta-d-glucan
C. No additional workup needed, continue antibiotics
D. Herpes simplex virus (HSV) and cytomegalovirus (CMV) serum PCR

Question 5# Print Question

A 65-year-old male who is postoperative day (POD) 3 from right hemicolectomy for cancer is admitted to the ICU for hypoxemia. His HR is 120/min, oxygen saturation is 88% on 15 L oxygen, and he requires intubation. Chest x-ray shows right middle and lower lobe opacities consistent with pneumonia. Mean arterial pressure (MAP) is 65 mm Hg on 5 µg/min of norepinephrine. He is started on broadspectrum antibiotics including vancomycin, cefepime, and metronidazole. Laboratory results are notable for:

  • Hgb of 7.5 g/dL
  • platelets of 45/µL
  • schistocytes in the blood smear
  • International normalized ratio (INR) is 1.7
  • activated partial thromboplastin time (aPTT) 45 seconds
  • d-dimer of 10 000 µg/L,
  • fibrinogen is undetectable

Physical examination reveals digital necrosis of several fingers and toes.

What is the most likely cause of his coagulopathy?

A. Sepsis-induced thrombocytopenia
B. Thrombotic thrombocytopenic purpura
C. Disseminated intravascular coagulation (DIC)
D. Heparin-induced thrombocytopenia (HIT)

Category: Critical Care Medicine-Infections and Immunologic Disease--->Immunological Effects of Infections
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