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CASE 1
While covering the weekend for your
multispecialty IM group you are called by
the ER for advice on evaluation and empiric
treatment of a patient with known
paroxysmal nocturnal hemoglobinuria
currently being treated eculizumab (Soliris).
The patient a 43 y/o man who emigrated
from China 10 years ago presents with T102,
RR 25, BP 115/70, plus mild confusion,
nausea, headache, and mild dyspnea. The
physical exam does not reveal significant
abnormalities aside from mild inattention.
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CASE 1
You are primarily concerned about
which of the following and advise
accordingly:
a. Pneumococcal sepsis
b. Acute histoplasmosis
c. Meningococcemia
d. Relapsed M. tuberculosis
e. Klebsiella pneumoniae bacteremia
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Case 2
A 68 y/o woman with ulcerative colitis on infliximab
(Remicade) who recently received prednisone for a
UC flare presents with pleuritic chest pain x2 weeks.
She reports 4-6 weeks of fatigue, low grade temps and
weight loss. She was seen by a colleague diagnosed
pneumonia and treated her with levofloxacin resulting
in slight but transient improvement.
Born in New Dehli - to US 40 yrs ago. Lives in Boston, no
travel to southwestern USA
PE: T 97.7, HR 109 , O2 sat 98% .Exam normal except
for decreased BS at L>R lung bases.
Labs: WBC 7000 58% PMN 27% L. Mild increase in
AST/ALT HIV neg. Quantiferon Gold neg 7 mos prior to
infliximab
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Case 2
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Case 2
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Case 2
Your most likely diagnosis is :
a. Residual bacterial pneumonia with
empyema
b. Malignancy with effusion
c. Cryptococcal pneumonia
d. Tuberculosis
e. Nocardiosis
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Case 2
Total nucleated cells 1208
RBC 10955
Lymphs 83%
T protein – 4.9 (serum 6.9)
Glu 100
LDH 117 (serum 157)
Neg cytology, AFB smear
Bacterial Cx Neg
Left thoracentesis yields
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Case 2
a. Thoracoscopy for pleural biopsy
b. Bronchoscopy for culture and smears
c. Serum and urine for Histoplasma and
Cryptococcal antigen
d. Open lung biopsy
Your next diagnostic step is:
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Thoracoscopy
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Question 3
A 65 year-old woman is admitted with altered
mental status and fever. Symptoms started 24
hours ago with fever, nausea, vomiting and
headache. She was started on unknown dose of
prednisone 3 months earlier for polymyalgia
rheumatica
PE: T 38.7 C, BP 95/78 mm Hg, HR 110/min. .
She is unresponsive except to painful stimuli.
There is nuchal rigidity. Fundi are normal. General
exam unrevealing.
You think this generally healthy, but prednisone
treated, woman has acute bacteria meningitis
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Question 3
How would you initiate management of this 65 year old woman?
a. Obtain blood culture and do head CT. If no mass on CT do LP send CSF then start ceftriaxone, vancomycinand ampicillin
b. Do blood culture and start ceftriaxone, vancomycinand ampicillin then send for CT re safe to do LP
c. Do blood culture and start dexamethasone, ceftriaxone, vancomycin and ampicillin, then send for CT re safe to do LP.
d. Do blood cultures and LP then start ceftriaxone, vacomycin and ampicillin; await CSF gran stain before starting dexamethasone
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Question 3 (cont’d.)
Spinal fluid examination shows 2,200
leukocytes/µL (82% neutrophils), protein 180
mg/dL, and glucose 33 mg/dL. Gram stain = no
organisms
Which of the following is the likely cause of her
meningitis?
a. Streptococcus pneumonia
b. Neisseria meningitides
c. Listeria monocytogenes
d. Haemophilus influenza
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Question 5
You see a 18 y/o man for sore throat, fever and
bilateral thigh abscesses at what he thinks were
mosquito bites. He has recently returned from a 3
-week service oriented trip northeast Thailand.
While there he was involved in construction,
agriculture and some recreational mud exposures.
His ROS is otherwise negative. He was not
sexually active while travelling. On PE he is a
nontoxic man with T 101, otherwise normal vital
signs. His PE is normal except for swollen right
inguinal lymph nodes and multiple skin lesions
(right >left leg). Chest and heart are normal.
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Question 5
You obtain a culture of the skin lesion
which yields:
a) MRSA
b) Pseudomonas aeruginosa
c) Burkholderia species
d) Aeromonas hydrophila
e) E. coli
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CASE 6
Patient is a 54 y/o Korean man with diabetes on metformin and
atorvastatin but stable health. Four days prior to admission note severe RUQ abdominal pain with chills and sweats that
resolved in 4 hrs. Two days later had fevers and chills
again with pain in right side. The next day had a similar episode with feverishness. No cardiorespiratory or urinary
symptoms. You send patient to ER .
HX: from Seoul Korea to US in 25 years ago. S/P
appendectomy and treated TB. Married - 2 children. No pets. No travel out side NE USA.
PE: T 103.4, BP 85/50, HR 130, RR 30 , 02 sat 98% Acutely ill Dry mucosa. Neck supple. Chest clear. Mild abdominal
tenderness. No rebound. BS present. No rash. Confused. No focal neurologic findings
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Case 6
LABS in ER :
WBC 9200, 78% P 10 Bds; Hct 43
Na 130 BUN20,Creat 1.2, Glu 383 Lactate 5.2. LFTs nl, UA no WBC bacteria.
CSF: 2 wbc, Glu164 prot 27, Smear negative. Blood cultures sent
Resuscitated vigorously with fluids and pressors and started on empiricvancomycin and meropenem.
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CT Abdomen/Pelvis
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CT Abdomen/Pelvis
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Case 6
Your most likely diagnosis:
a. Amoebic liver abscess
b. Streptococcus milleri liver abscess
c. Klebsiella liver abscess
d. Polymicrobial liver abscess
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Question 7
A 50 y/o woman 10 years after left groin lymph node resection following thigh melanoma presents to the ER with a temp of 102º and chills. She is otherwise generally healthy and has no focal symptoms except for pain and swelling in the left leg Exam is normal except for erythema, warmth and swelling involving ~ 400 cm2 of right pretibial area. There is no drainage for culture.
She reports that follow up for the me,anoma has revealed no recurrent disease.
In the past 2 years she has had 3 episodes with hospitalization that were similar this presentation.
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Question 7
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Case 7
You diagnose cellulitis and advise hospitalization and parenteral treatment with……..
1. Vancomycin
2. Linezolid
3. Ceftaroline
4. Vancomycin plus clindamycin
5. Cefazolin
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CASE 7
You see the patient 3 weeks later in you
office at which time she is doing well.
Cellulitis has resolved but there is
persistent edema which she says is typical
You advise:
a. Prophylaxis with TMP/SMZ
b. Go to ER promptly for recurrence
c. Support hose to reduce edema
d. Prophylaxis with penicillin V
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Question 10
You admit a 67 y/o Russian born diabetic man with fever
and cough. He is 5 yrs post deceased donor renal
transplant with good function on stable doses of
tacrolimus and prednisone (5mg qd). He has continued
fever, cough, scant phlegm and mild dyspnea 5 weeks
after cefpodoxime /azithromycin treatment elsewhere for
community acquired pneumonia. ROS otherwise negative.
Pretransplant Quantiferon gold test = negative. On PE:
T100.2, RR 20, O2 sat 88%., Heart nl, $breath sounds R
base, rales R mid lung. Normal abd, skin, neuro exam.
WBC15,000 87%PMNs; Cr 1.2, Nl lytes, LFTs. Chest xray
= RUL infiltrate. You order a CT brain and torso, and
sputum for smears and culture, blood cultures. Brain and
abdomen CT are negative.
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Question 10
6.9 x 5.5 cm dense consolidation in the right upper
lobe abutting the pleural surface and small right
pleural effusion
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Question 10
Based on the clinical data and sputum smears your
provisional diagnosis is pneumonia due to:
a) Rhodococcus equi
b) Actinomyces israelii
c) Norcardia asteroides
d) Mycobacterium avium complex
e) Mycobacterium tuberculosis
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Question 13
You are called by a 45 y/o woman who is
healthy but complains of 24 hrs of dysuria,
urgency and frequency and notes cloudy
non-bloody urine . She has no fever, flank
pain . She has not traveled recently and
has taken no recent antibiotics. She has no
gynecologic complaints. She has had occasional
UTIs in the past. No allergies
Which of the following would you do?
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Question 13
a. Order clean void urine for analysis
and culture, ask patient to call in 24-
36 hrs for results.
b. Order UA and culture and start
cefpodoxime 100 mg bid PO x 3 days
c. Start Rx nitrofurantoin/macrocrystals
100 mg bid PO x 5 days
d. Start cirpofloxacin 250 mg bid PO x 3
days
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Question 14
A 55 year-old diabetic (type II) woman with a prior history of cystitis is seen for routine physical examination. She is asymptomatic and has a normal exam. Her Hbg1Ac is 5.7. A clean void urine specimen reveals 10 WBC/hpf and culture contains 105 E. coli cfu/ml. A repeat clean void specimen grows 105 E. coli. You ......
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Question 14
a. Treat with TMP/SMZ for 3 days
b. Treat with ciprofloxacin for 3 days
c. Treat with ciprofloxacin for 10 days
d. Order a “straight cath” urine for culture
e. Wish you had never ordered a cultureCOPYRIGHT
In January, 41 y/o female with HIV infection and a recent CD4 695 on HAART with truvada plus
atazanavir/ritonavir presents with approximately one week of headache.
The headache is frontal, 9/10, She initially attributed the headache to stress (she is originally from Haiti, and was worried about her family members), however, the headache continued to progress, and the patient presented to the ED for evaluation.
Question 16
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Question 16
In the ED, she was afebrile and non-toxic. She had no fevers, chills, or sweats, no nausea, vomiting, photophobia. She was given valium and tramadol, and discharged home.
Three months later she again had severe headache, stiff neck and some back pain. She presented again to the ER complaining as previously but with a temp 100.8 and mild neck stiffness.
No pets at homeNo recent travel
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On PE: VS: T 100.8 , BP 136/70, HR 94, RR 18, O2
sat 100% General: lying in bed with eyes closedSkin: no rashes Neurological: O x 3, mild stiff neck but no other signs of meningeal irritation. CN and motor/sensory/coordination – wnl; normal affect
Remainder of the PE was normal although pelvic and rectal exam were omitted
Question 16
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Question 16
WBC 7.7; Hgb 10.7; Platelets 312 Diff: 55N 5.6 eos
Chems, BUN, Creatinine and serum lactate are normal
UA - unremarkable
CSF: 2625 WBC, 3 RBC, 72 Lymphs, 20 PMN, 8 mono; protein 156, glucose 57CSF: GS: no orgs, Culture - pending,
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In the CSF three large granular cells of monocyte-
macrophage lineage are present (center), with a neutrophil
(upper left) and a lymphocyte (upper right)
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Question 16
The cause of meningitis is:
1. Coxsackie virus
2. Streptococcus pneumoniae
3. Cryptococcus neoformans
4. Herpes simplex virus
5. HIV
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Question 19
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Question 19
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Question 22
A 70 year-old man undergoes a partial colectomy for colon cancer. On the third postoperative day he develops a temperature to 103 and has rigors. His exam reveals BP 100/60, HR 100, RR 24 and rales in the left lower lung area. The wound is clean and dry and the abdominal exam is unremarkable. Laboratory evaluation is initiated and x-ray reveals LLL pneumonia.
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Vancomycin and piperacillin-tazobactam are
initiated. The following 2 days he remains
febrile and dyspneic. Blood cultures reveal
Klebsiella pneumoniae sensitive to cefepime,
piperacillin-tazobactam, imipenem,
gentamicin, and tobramycin but resistant to
ciprofloxacin, cefazolin, and ceftazidime.
Sputum cultures also yield Klebsiella
pneumoniae.
Question 22
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Question 22
You choose to :
1. Continue same antibiotics
2. Add gentamicin
3. D/C vancomycin and add gentamicin
4. D/C piperacillin-tazobactam, start cefepime
5. D/C current antibiotics, begin imipenem
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Question 23
A 38 year-old man with Crohn’s disease treated with sulfasalazine, metronidazole, and prednisone who is receiving parenteral alimentation is hospitalized with temperatures to 100.6-101.4 for 3 days. Two weeks earlier he completed a 7 day course of fluconazolefor thrush. Except for sporadic fever, vital signs and the physical exam are normal as is an abdominal CT scan. Blood cultures were drawn and treatment with vancomycin plus piperacillin-tazobactam was begun on admission. On day 3, one bottle of 4 blood cultures (8 bottles) yields yeast.
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Question 23
You order fungal blood cultures x 2 and ….
a. Fluconazole 400 mg IV daily
b. Micafungin 100 mg IV daily
c. Ophthalmology consultation
d. Voriconazole 300mg IV QD
e. b and c
f. d and c
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Case 24
45 year old female with 2 week history of sore throat, odynophagia
and fevers/chills who presents with progressive neck swelling
and decreased movement of her neck.
From Oct 1-16 she is seen 3 times as out patient. Rapid strep test
positive. Because of penicillin allergy, she is treated with
azithromycin (5 days) then clindamycin plus prednisone (10 days).
Symptoms and right neck swelling persist. Monospot =
negative. CT scan showed lymphadenopathy. ENT consult -
treated with clarithromycin, valacyclovir and fluconazole but
symptoms and swelling with overlying erythema increased. CT
scan was repeated.
PE: T 98.8,m BP 101/70, HR 88.RR 19, O2Sat 96% on RA
Large R neck mass 5-6 c, erythema and induration.
Decreased range motion neck. Lungs clear. Remainder PE
normal.
WBC 7,900, Hct 31, Pl 219. Lytes, BUN, Creat, LFTs normal
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Case 24 CT Neck w/ Contrast
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Case 24
Your diagnosis is:
a. Scrofula - non tuberculous mycobacteria
b. Lemierre’s syndrome
c. Polymicrobial abscess
d. Group A streptococcal lymphadenitis
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Case 25
You admit a 49 y/o man with fatigue, low grade fever
and weight loss over past 2 months. Three years ago
he had an uneventful aortic valve replacement. Over
past 2 weeks he noted an erythematous area with
Scant drainage in upper part of his sternotomy
wound. He has had no recent dental work, animal
exposure, and has not traveled out of the northeast
US.
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CASE 25
On PE: T100.8, BP 130/60, HR 84.HEENT nl.
Chest clear to P&A, A 0.5 cm open area in sternal
wound with slight tenderness. Heart: GII/VI diastolic
murmur LSB. Abd ? Spleen tip. Skin and extremities
nl.
Labs: WBC 5,700 Hct 34%, CRP 30, LFTs nl, Sternal
Wound smear no PMNs, culture = scant CN staph,
bld cultures x 6 neg at 4 days. TEE paravalvular leak
and thickened tissue but no vegetation. Abd CT=
splenomegaly.
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CASE 25
You biopsy the tissue at wound site for
histology & culture, and send 16S-rRNA PCR.
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You suspect sternal wound infection, possible
osteomyelitis and prosthetic valve endocarditis
due to …..
a. Bartonella henselae
b. Coxiella burnetii
c. Mycobacterium cheloni
d. Mycobacterium chimera
e. Coagulase negative staphylococci
Case 25
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