A thirty-seven-year-old Caucasian male presents to the University Hospital Emergency Room with a complaint of severe diarrhea, abdominal cramps, vomiting and fever. He warns you at the beginning of the interview that he tested positive for HIV four years ago, but has been very well and has not seen a doctor until now. You assure him that the house staff follow universal precautions to prevent the spread of infectious diseases.
His present illness began roughly a day and a half ago. He began to have frequent diarrhea, then he experienced abdominal cramps. He had hoped that this was just a minor stomach upset due to something he ate, but when the fever developed he knew he had better seek some assistance. He prepares most of his own food, and eats out only on special occasions. He did eat at an Italian restaurant several days ago to celebrate the birthday of a friend. While there he had the house special of fettucini ala Guido, and a Caesar salad.
Question 1 - Single Best Answer
It is wise for HIV+ individuals to be careful of what they eat. What types of foods could be a problem for someone that is HIV positive? Bugs Database
A) foods high in fat
B) high-fiber foods
C) raw oysters
D) undercooked meat
E) all of the above
Question 2 - Single Best Answer
What is/are the possible mechanism(s) for diarrheal problems in individuals who are HIV positive? Bugs Database
A) infectious
B) loss of lactase enzyme
C) malabsorption
D) drug toxicity
E) all of the above
Question 3 - Single Best Answer
All of the organisms mentioned below are a particular problem for HIV+ individuals. Which list below is the list of infectious agents likely to cause diarrhea in a person with HIV infection? Bugs Database
A) salmonella, cryptosporidia, MAC (mycobacterium avium complex)
B) treponema, staphylococcus, pneumococcus
C) candida, coccidioides, cryptococcus
D) pneumocystis, microsporidium, toxoplasma
E) CMV, HSV, Epstein-Barr virus
Question 4 - Single Best Answer
The most likely ingredient in the traditional Caesar salad that could cause an infectious diarrheal problem is? Bugs Database
A) croutons
B) raw egg
C) parmesan cheese
D) lettuce
E) nothing in a salad could cause GI problems.
You continue with the patient's history. He has no drug related allergies, nor is he allergic to any foods or pollen. He is taking no drugs except for ibuprofen, and a daily mega-vitamin. He denies the use of illegal drugs. You begin your examination and find his temperature to be roughly 102 F, and he is perspiring. EENT exam reveals no abnormalities. His abdomen and extremities reveal no sign of trauma. Upon auscultation, his lung and heart are normal, though his heart is mildly tachycardic. His bowel sounds are hypermotile, but his abdomen is not tender. His prostate is normal, but his rectum appears to be inflamed. There are no lesions upon his penis, nor is there a purulent discharge. His skin is tenting. You draw blood, and collect a stool sample and then begin IV fluids with antibiotic.
Question 5 - Single Best Answer
Tenting skin is an indication of? Bugs Database
A) low blood pressure
B) immunosuppression
C) fever
D) dehydration
E) zoonotic diseases
| LABORATORY RESULTS(AT 6 HOURS) | |
|---|---|
| GRAM STAIN OF STOOL SAMPLE | + PMNS, MIXED FLORA no AFB* seen |
| URINE | + KETONES |
| HEMATOCRIT | 0.62 |
| ECG | MILD TACHYCARDIA |
| ABDOMINAL X RAY | AIR IN BOWELS |
| WBC COUNT | 5X10^9/L |
| Normal Lab Values | |
| none | (AT 24 HOURS) |
| BLOOD CULTURE | WHITE COLONIES ON MACCONKEY, GR- RODS |
| Normal Lab Values |
*Acid-fast bacteria
Question 6 - Single Best Answer
The fact that there are PMN's in the stool would eliminate which of the following? Bugs Database
A) Campylobacter
B) Shigella
C) enterotoxigenic E. coli
D) Vibrio cholera
E) more than one of the above
Question 7 - Single Best Answer
What does it mean that colonies are white (or colorless) on McConkey's agar? Bugs Database
A) they are gamma hemolytic
B) they are fastidious
C) they cannot metabolize lactose
D) they do not have a glycolytic cycle
E) they are Gram negative
Question 8 - Single Best Answer
At this point, what organisms should you consider as causing his problem? Bugs Database
A) enterococcus or MAC
B) Shigella and Salmonella
C) Campylobacter or rota virus
D) Staphylococcus aureus
E) all of the above
| LAB RESULTS( AT 48 HRS) | |
|---|---|
| BACTERIAL H2S PRODUCTION | POSITIVE |
| BACTERIAL UREASE | NEGATIVE |
| HEK AGAR | BLACK COLONIES, GR- RODS |
| MOTILITY | POSITIVE |
| LACTOSE UTILIZATION | NEGATIVE |
| Normal Lab Values |
Question 9 - Single Best Answer
What organism does this identify? Bugs Database
A) Shigella
B) Salmonella
C) E. coli
D) Proteus
E) none of the above
Question 10 - Single Best Answer
What happens when an immunocompromised individual contracts Salmonellosis? Bugs Database
A) the enterotoxin is not neutralized and the secretory diarrhea is worse than in a normal individual.
B) the cytotoxin is not neutralized and the dysentery is worse
C) it can invade the bloodstream and cause a typhoid-like disease
D) the endotoxin is not neutralized and endotoxic shock ensues
E) the organism adheres to the intestinal epithelium and causes malabsorption syndrome
You place the patient on a six week regimen of ampicillin and cephalosporin to avoid a recurrence of this organism. Because he is immunocompromised his body cannot overcome the infection on its own.
Question 11 - Single Best Answer
HIV+ individuals are treated differently from normal individuals when they have a Salmonella infection. The best treatment for a case of uncomplicated Salmonellosis in an otherwise healthy person (no HIV) would be which of the following? Bugs Database
A) radical colonectomy
B) an appropriate antibiotic
C) immunization with flagellar antigen
D) a laxative
E) nothing except fluid replacement
Question 12 - Single Best Answer
While this HIV+ individual who does not have a regular physician is in your care, are there other things you should do that are not related to his primary complaint? Bugs Database
A) counsel regarding HIV transmission
B) CD4 counts
C) CMV IgG
D) chest x-ray
E) all of the above
Question 13 - Single Best Answer
What is the purpose of the CD4 counts? Bugs Database
A) determine the degree of immunosuppression
B) determine need for AZT
C) determine need for pneumocystis pneumonia prophylaxis
D) all of the above
Question 14 - Single Best Answer
The pneumovax vaccine should also be given to HIV+ individuals. What is the composition of the pneumovax vaccine? Bugs Database
A) inactivated influenza virus
B) tetanus toxoid
C) bacterial polysaccharides
D) inactive hepatitis B vaccine
E) antibody to pneumococcal polysaccharide capsule
Question 15 - Single Best Answer
The digestive system of HIV+ individuals can be compromised in ways other than GI infection. If a person cannot eat because he has difficulty swallowing, what is a likely cause? Bugs Database
A) Corynebacterium
B) Streptococcus epidermidis
C) Candida albicans
D) MAC
E) PCP
