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 6# Print Question

A 50-year-old female underwent allogeneic stem cell transplantation for acute myeloid leukemia 10 days ago. She is brought to the ICU with fevers and hypotension. She is neutropenic. She noticed a red rash on her trunk and extremities yesterday. On examination, she appears ill and is febrile (38°C). Her blood pressure is 84/60 mm Hg, heart rate 120 beats per minute, and respiratory rate 36 breaths per minute. Her central venous catheter site is clean and nontender. Physical examination demonstrates grade 3 mucositis of her buccal mucosa, a diffuse erythematous, blanchable rash, and bilateral crackles on auscultation of her posterior lung fields. Her chest x-ray demonstrated bilateral diffuse infiltrates. A bedside echocardiogram showed normal valves with preserved left ventricular function. Her blood cultures grow gram positive cocci in pairs and chains in both sets of aerobic and anaerobic bottles collected on transfer.

What is the MOST LIKELY diagnosis? 

A. Catheter-related infection due to coagulase-negative staphylococci
B. Staphylococcal toxic shock syndrome
C. Engraftment syndrome
D. Infective endocarditis due to Enterococcus faecalis
E. Septic shock due to viridans group Streptococci

Question 7# Print Question

A 39-year-old male who underwent a haploidentical allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia 2 years ago is admitted to the ICU with acute hypoxic respiratory failure requiring supplemental oxygen through a highflow nasal cannula. His HSCT was complicated by graft-versus-host disease (GVHD) of the skin and gastrointestinal tract 6 weeks ago for which he was treated with pulse dose steroids. He was recovering from an upper respiratory tract infection caused by rhinovirus (nasopharyngeal swab PCR positive) 3 weeks ago when he started to experience shortness of breath that progressively worsened. His WBC count was 4.5 cells/µL with 80% neutrophils on admission. His creatinine was elevated at 2.1 mg/dL (baseline: 1 mg/dL). A CT scan of the chest without contrast revealed multifocal nodular opacities with right-sided predominance. Blood cultures, urine histoplasma antigen, serum cryptococcal antigen, and serum Aspergillus galactomannan were negative. His serum β-1,3-d-glucan assay was positive. The patient’s sputum culture grew normal respiratory flora. He was started on intravenous vancomycin and piperacillintazobactam, but his respiratory status continued to decline eventually requiring intubation 2 days into his admission. Bronchoscopy was performed with bronchoalveolar lavage (BAL). Initial stains on the BAL fluid showed nonpigmented, septate hyphae branching at right angles.

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

A. Add IV micafungin
B. Add PO voriconazole
C. Add IV voriconazole
D. Start IV amphotericin B
E. Continue current management and wait for final pathogen identification

Question 8# Print Question

A 26-year-old female with a history of sickle cell disease complicated by multiple sickle cell crises in the past year is admitted to the ICU with acute hypoxic respiratory failure and shock. On arrival to the ICU:

  • she is febrile to 39.1°C
  • with a blood pressure of 82/36 mm Hg
  • and heart rate 110 beats per minute

She is intubated and mechanically ventilated. Initial laboratory evaluation demonstrates a neutrophilic- predominant leukocytosis to 14 000 cells/µL. Her chest x-ray on admission shows a left lower lung infiltrate with an associated pleural effusion. Blood cultures are in process.

What would be the NEXT BEST STEP to confirm this patient’s diagnosis?

A. CT scan of the chest with and without IV contrast
B. Sputum cultures
C. Streptococcus pneumoniae urine antigen
D. Legionella urine antigen
E. Bronchoscopy with BAL

Question 9# Print Question

A 45-year-old female who underwent bilateral lung transplantation 6 days ago is brought to the ICU intubated following a seizure episode. Her transplantation was uneventful and she was transferred to a regular nursing floor on postoperative day 4. She was intubated at bedside for airway protection and brought to the ICU. On examination, the patient is sedated and her pupils were mildly dilated but equally reactive to light. Her blood pressure was 110/90 mm Hg and heart rate 120 beats per minute. Mild purulence is noted from the lower part of sternotomy site with no obvious instability or bony crepitations. The output from her chest drains was nonpurulent. An arterial blood gas shows an elevated lactate of 2.5 mmol/L, partial pressure of oxygen of 92 mm Hg, and partial pressure of carbon dioxide of 38 mm Hg. Her laboratory results demonstrate:

  • a WBC count of 16 500 cells/µL
  • hemoglobin of 9.1 g/dL
  • platelet count of 350 000/µL

Blood cultures are collected. Wound cultures sent from the regular nursing floor prior to transfer show numerous neutrophils but a negative gram stain. A CT scan of the brain did not show any acute abnormalities. Debridement of sternal wound is done and the patient is started on empiric vancomycin and piperacillin-tazobactam.

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

A. Wait for final culture results, no additional antibiotics
B. Lumbar puncture, empirical IV acyclovir to treat Herpes simplex encephalitis
C. Check serum ammonia level; start IV doxycycline to cover Mycoplasma hominis
D. Start IV micafungin for empiric fungal coverage
E. Order an MRI of the brain to rule out posterior reversible leukoencephalopathy

Question 10# Print Question

A 65-year-old former Vietnam War veteran male was admitted to the intensive care unit with shock. He had underwent orthotopic liver transplantation 3 months ago for cirrhosis due to alcohol abuse and hepatitis C infection. His posttransplant course had been complicated by graft-versus-host disease treated with pulse dose methylprednisolone for 3 days followed by prednisone 60 mg daily, which he was currently on. He presented to the emergency room with complaints of headache and wheezing for the last 2 days and was also found to be somnolescent. On the first day of admission, he was noted to have intermittent bouts of cough with two episodes of small volume hemoptysis. Chest x-ray showed bilateral patchy nodular opacities for which he was started on vancomycin and piperacillin/tazobactam. However, on the second day of admission, his condition acutely worsened with tachycardia, hypoxemia, and hypotension requiring vasopressor support. Lactate was elevated raising suspicion of sepsis, and workup for an infectious source was initiated. Urinalysis was unremarkable, stool Clostridioides difficile PCR was negative, and CMV PCR was undetectable in blood. CT scan of the head was unremarkable. Two sets of blood cultures were sent. Gram stain of cerebrospinal fluid (CSF) showed gram-negative rods identified later the same day as Escherichia coli by PCR, and consequently piperacillin/tazobactam was changed to cefepime. Chest imaging the next day showed marked worsening of opacities on the left upper lobe and right lower lobe, and he was intubated for worsening hypoxia. The tracheal aspirate was sent for culture; however, you received a call from the microbiology lab the same day informing you of an unexpected finding on the gram stain of tracheal aspirate. A representative image below:

Which of the following describes the best treatment plan for this patient?

A. Continue cefepime
B. Continue cefepime and add ivermectin
C. Discontinue cefepime and start ivermectin
D. Discontinue cefepime, reduce the dose of prednisone and start ivermectin
E. Continue cefepime, reduce the dose of prednisone and start ivermectin

Category: Critical Care Medicine-Infections and Immunologic Disease--->Infections in the Immunocompromised Host
Page: 2 of 2