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Multiple Choice Questions.

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1. An 18-month-old boy presented with 4 days of sudden onset, severe watery diarrhea, after 2 days of being nonspecifically unwell. He was passing stool approximately 15 times/day. He had vomited for one day, but this then stopped. There was no blood in the stool. He was also noted to have a dry cough and appeared to have coryzal symptoms. He had not had a wet nappy for 24 hours. He had stopped breast feeding at 12 months old. On examination, he was markedly dehydrated, with a temperature of 38.5 °C and a tachycardia. He required aggressive fluid resuscitation.
In addition to intravenous fluids or oral rehydration solutions, what agent would improve his outcome? A. Ascorbic acid B. Cholecalciferol C. Magnesium D. Thiamine E. Zinc CHAPTER 163 2. A 25-year-old primigravida presents at 34/40 with a 1-day history of fevers, rash, dry cough and coryzal symptoms. She had recently moved to the UK and was uncertain of her childhood vaccinations. On examination her temperature is 39 °C, and a generalized maculopapular rash which is coalescent on her trunk. Some small cervical lymph nodes are palpable bilaterally. There are small white spots on the buccal membrane beside her molars. She has bilateral conjunctivitis. She is concerned about the risk to her baby. What are the possible adverse effects that she should be made aware of? A. Cataracts B. Hydrops fetalis C. Intrauterine death D. No increased risk of fetal adverse outcome E. Sensorineural deafness CHAPTER 164 3. An 11-month-old boy developed a high fever. This was associated with malaise, irritability and poor feeding. After 48 hours he developed a macular rash along his arms and legs. There was extensive confluent blistering of the perineum, but otherwise the trunk and back were spared. There were no lesions on his scalp. There were a number of perioral lesions, but no lesions visible inside the mouth. Some of the lesions progressed into thin-walled vesicles containing clear fluid. There were macules on the soles of his feet. The fever resolved 24 hours after the rash appeared. The rash took 10 days to clear, but left no scars. 3 weeks later the skin on his feet began to desquamate. He attended a nursery for 3 days a week. He had had his vaccinations as per the UK schedule for his age. He had been born at full term and was meeting his developmental milestones. He lived at home with two older siblings.

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17. A 29-year-old intravenous drug user presented with a 1-day history of severe dyspnea, fevers, myalgia, cough and hemoptysis. He had been treated in the community for 2 days with oral amoxicillin but had deteriorated. He was known to be hepatitis C-positive, genotype 1a, and was on the waiting list for antiviral treatment. He had previously had a right leg above-knee DVT, and was on treatment dose low molecular weight heparin in the community. He also took methadone, diazepam and multivitamins. On examination he had a swollen erythematous external auditory canal on the left, with purulent debris and underlying granulation tissue on the floor of the canal; the right side was normal in appearance. It was not possible to visualize the tympanic membrane. There was erythema extending anteriorly over the temporomandibular joint, and posteriorly over the left mastoid process; the bony prominences and soft tissues were tender on palpation.
He had a left-sided lower motor neurone facial nerve palsy; other cranial nerves were intact.
What Examination of the oropharynx showed erythema over the soft palate and swollen tonsils. His neck movements were restricted and there was tenderness and induration over the right jugular vein. Investigations: Peripheral white cell count 28.7 ×10 9 /L (4.0-11.0) Platelets 67 ×10 9 /L (150-400) X-ray of chest -multifocal bilateral infiltrates CT neck -see image below What is the most likely causative organism? A. Bacteroides fragilis B. Eikenella corrodens C. Fusobacterium necrophorum D. Streptococcus dysgalactiae E. Streptococcus pyogenes DTaP/IPV/HiB, PCV, meningococcal B and rotavirus vaccines 1 week before she became unwell. She lived at home with her parents, grandmother and two older siblings. Initial investigations revealed a lymphocytosis. What microbiological findings would be most consistent with this infection? A. Bisected pearl colonies on charcoal cephalexin agar B. Blue-grey colonies on Thayer Martin agar with vancomycin, colistin, nystatin C. Grey colonies on Hoyle's agar with potassium tellurite D. Colonies on buffered charcoal yeast extract agar with L cysteine which fluoresce yellow-green under UV light E. Growth around combined X+V disc only on nutrient agar 26. A 55-year-old man was clinically diagnosed with infective endocarditis of a native aortic valve. Three sets of blood cultures were taken and he was started on empirical treatment with amoxicillin (2 g q4h) and gentamicin (1 mg/kg BD).
Blood cultures Gram-negative coccobacilli isolated from 3/6 bottles at 4 days Adherent star-shaped colonies of 1 mm on blood agar at 37 o C in enhanced CO 2 (5-10%) at 48 hours Catalase positive, oxidase positive, nonhemolytic What is the most appropriate antibiotic regimen pending identification and sensitivities? A. Change to benzylpenicillin 2.4 g q4h and gentamicin 1 mg/kg BD B. Change to ceftriaxone 2 g OD and gentamicin 1 mg/kg BD C. Change to doxycycline 100 mg BD po and hydroxychloroquine 200 mg TDS po D. Change to vancomycin 1 g BD and rifampin 600 mg BD po E. Continue amoxicillin and gentamicin CHAPTER 184 27. A 56-year-old man presented with a slow-growing painless soft tissue swelling of the perimandibular region over 2 months. It had started discharging small amounts of pus through a small opening in the skin 2 weeks earlier. It had responded temporarily to a short course of co-amoxiclav but had then relapsed. He had no weight loss, fever, chills or other constitutional symptoms. He was otherwise in good health, worked in an office and had a long-term male partner. He smoked 15 cigarettes a day. There was no history of recent dental work or trauma to the face or mouth. On examination there was a firm 4x5 cm mass in right submandibular region, tender to palpate and partially fixed on the deep tissue planes. The overlying skin was slightly bluish in color and there was a small sinus discharging thick yellow exudate.
Investigations: CT head/neck: ill-defined mass in the left pyriform fossa involving the perimandibular gland and platysma muscle. Mass is infiltrative, crossing tissue planes. Moderately enhancing with several low attenuating foci. No associated lymphadenopathy. 29. A 58-year-old woman developed an abrupt onset of high fever, which she had measured at home as 39.1 °C and flu-like symptoms. She presented four days later when a generalized rash appeared. She had returned 3 days before the onset of fever from a 4-week visit to family in Turkey in June. She had diet-controlled diabetes mellitus and well-controlled hypertension. She was taking regular amlodipine and Lisinopril. Her family lived in a rural village in the Thrakya region of Turkey. On examination she was alert and oriented, and her temperature was 38.3 °C. She had a widespread maculopapular rash which spared her face but involved her palms and the soles of her feet. There was an eschar on the medial aspect of her lower left calf. This was not associated with any edema or regional lymphadenopathy.
Serology and blood cultures were taken and a punch biopsy of the eschar performed. She was treated presumptively with oral doxycycline for 7 days. What

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32. A 39-year-old woman presented with a painful right eye, describing a foreign-body-like sensation and tearing. She wore soft contact lenses on a daily basis and admitted to poor practice, including showering while wearing her contact lenses, and wearing them for prolonged periods. She was otherwise well, and had no significant comorbidities. On examination: see photograph 1. A corneal scraping was taken: see photograph 2. What is the most likely causative organism? A. Acanthamoeba spp. B. Balamuthia mandrillaris C. Encephalitozoon hellem D. Naegleria fowleri E. Sappinia pedata CHAPTER 194 33. A 54-year-old farmer in Massachusetts became acutely unwell in late August. He had had nonspecific symptoms which came on gradually for 1 week, including fatigue, anorexia and headache. He then developed high sustained fevers, sweats, myalgia and dark urine. His medical history included splenectomy following a road traffic accident 15 years earlier, hypercholesterolemia and hypertension. He was up to date with his immunizations and took amlodipine and atorvastatin. He had not traveled outside of the USA in the preceding 10 years, and had not left Massachusetts in the preceding 6 months. He lived with his wife and two teenage daughters, all of whom were well. On examination, he was visibly icteric, with pale conjunctivae, and was dyspneic at rest. His temperature was 38.5 °C, heart rate 124 beats per minute, blood pressure 85/50 mmHg, respiratory rate 34 breaths per minute. He had inspiratory crackles to midzones bilaterally. His liver was palpable 2 cm below the right costal margin and his spleen tip was also palpable.

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10. E. Western Europe (including Germany) is free of rabies in terrestrial animals. As such, even though a bite that penetrates skin is high risk, the epidemiology means that rabies postexposure prophylaxis is not warranted. If this had been a bat bite, this would not be the case. Hint: A postexposure risk assessment for rabies includes elements such as the vaccination status of the patient, the animal involved, the body part exposed and the country where the exposure took place. See Chapter 171.

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11. B. This is a recognized complication of zanamivir use in patients with a history of asthma. The CDC recommends that zanamivir is not used in patients with an underlying respiratory disease. Public Health England do not have the same restriction. Hint: See Chapter 172,

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12. D. Parainfluenza is one of the more common causes of respiratory viral infections in patients with hematologic malignancies, hematopoietic stem cell transplantation, or solid organ transplantation and is associated with a high rate of progressive disease involving the lower airway and an increased mortality rate. Parainfluenza viruses are transmitted by direct person-to-person contact through large respiratory droplets and contact with fomites contaminated with respiratory secretions. Respiratory precautions are not necessary, because the droplets are large and do not aerosolize. PIV can cause asymptomatic shedding, particularly among HSCT recipients, which may contribute to nosocomial spread. Risk factors in this patient for progressive disease include allogeneic BMT and reduced intensity conditioning. Lower airway involvement may be characterized by small peribronchial nodules on CT radiography. Hint: See Chapter 173.
23. D. The role of postexposure prophylaxis for leptospirosis is debatable, with local guidelines varying. Current UK guidelines are that postexposure management is limited to advice on showering promptly after water exposure, to minimize the swallowing of water and to thoroughly clean abrasions caused during the water exposure. The contraindication to doxycycline in this patient due to his isotretinoin treatment means that the most appropriate option is no antimicrobial prophylaxis, but heightened awareness and self-monitoring for fever and flu-like symptoms. Hint: See Chapter 182, section on prevention of leptospirosis.
24. C. The CTA1 subunit of the cholera toxin catalyses ADP ribosylation of stimulatory G proteins leading to elevated levels of cAMP intracellularly. This leads to an increase in intestinal chloride secretion and a decrease in sodium chloride absorption resulting in a passive watery excretion, and diarrhea. The volume typically exceeds 10 mL/kg/hour in children and one liter per hour in adults.
aureus necrotizing pneumonia. The efficacy of antibiotics in necrotizing pneumonia is affected by the requirement for penetration into necrotic tissue and activity within anaerobic conditions. Public Health England suggest an empiric combination of clindamycin, linezolid and rifampin to start with, plus consideration of intravenous immunoglobulin (IVIG) and admission to a side room in intensive care.