58.  Which of the following statements about the treatment of the above patient is correct?
a.  Oral antibiotic therapy is never appropriate
b.  Trimethoprim-sulfamethoxazole is the treatment of choice in the nonallergic
 patient
c.  Concomitant corticosteroids should always be avoided
d.  Tetracycline is more effective than erythromycin

59.  A 25-year-old male from East Tennessee had been ill for 5 days with fever, chills, and headache when he noted a rash that developed on his palms and soles. In addition to macular lesions, petechiae are noted on the wrists and ankles. The patient has spent the summer camping. The most important fact to be determined in the history is
a.  Exposure to contaminated springwater
b.  Exposure to raw pork
c.  Exposure to ticks
d.  Exposure to prostitutes

60.  A  19-year-old male has a history of athlete’s foot but is otherwise
healthy when he develops the sudden onset of fever and pain in the right
foot and leg. On physical exam, the foot and leg are fiery red with a well-
defined indurated margin that appears to be rapidly advancing. There is
tender inguinal lymphadenopathy. The most likely organism to cause this
infection is
a.  Staphylococcus epidermidis
b.  Tinea pedis
c.  Streptococcus pyogenes
d.  Mixed anaerobic infection

61.  An 18-year-old male has been seen in clinic for urethral discharge. He
is treated with ceftriaxone, but the discharge has not resolved and the cul-
ture has returned as no growth. The most likely etiologic agent to cause this
infection is
a.  Ceftriaxone-resistant gonococci
b.  Chlamydia psittaci
c.  Chlamydia trachomatis
d.  Herpes simplex

Items 62-68
Match the clinical description with the most likely etiologic agent.
a.  Candida albicans
b.  Aspergillus flavus
c.  Coccidioides immitis
d.  Herpes simplex type 1
e.  Herpes simplex type 2
f.  Hantavirus
g.  Tropheryma whippelii
h.  Coxsackievirus B
i.  Histoplasma capsulatum
j.  Human parvovirus
k.  Cryptococcus neoformans

62.  An HIV-positive patient develops fever and dysphagia; endoscopic biopsy shows yeast and hyphae. (CHOOSE 1 AGENT)
63.  A 50-year-old develops sudden onset of bizarre behavior. CSF shows 80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities. (CHOOSE 1 AGENT)
64.  A patient with a previous history of tuberculosis now complains of hemoptysis. There is an upper lobe mass with a cavity and a crescentshaped air-fluid level. (CHOOSE 1 AGENT)
65.  A Filipino patient develops a pulmonary nodule after travel through the American Southwest. (CHOOSE 1 AGENT)
66.  A 35-year-old male who had a fever, cough, and sore throat develops
chest pain after several days with diffuse ST segment elevations on ECG.
(CHOOSE 1 AGENT)

67.  Overwhelming pneumonia with adult respiratory distress syndrome occurs on an Indian reservation in the Southwest following exposure to deer mice. (CHOOSE 1 AGENT)
68.  A child develops an erythematous rash appearing as a slapped cheek. (CHOOSE 1 AGENT)

5-7.  The answers are 5-c, 6-b, 7-a. (Braunwald, 15/e, pp 1073-1074.)
This young woman presents with symptoms of both upper and lower res-
piratory infection. The combination of sore throat, bullous myringitis, and
infiltrates on chest x-ray is consistent with infection due to M. pneumoniae.
This minute organism is not seen on Gram stain. Neither S. pneumoniae nor
H. influenzae would produce this combination of upper and lower respira-
tory tract symptoms. The patient is likely to have high titers of IgM cold
agglutinins. The low hematocrit and elevated reticulocyte count reflect a
hemolytic anemia that can occur from mycoplasma infection. These IgM-
class antibodies are directed to the I antigen on the erythrocyte membrane.
The treatment of choice for mycoplasma infection is erythromycin.

8-10.  The answers are 8-c, 9-a, 10-c. (Braunwald, 15/e, pp 1109-1111.)
This young man presents with classic signs and symptoms of infectious
mononucleosis. In a young patient with fever, pharyngitis, lymphadenopa-
thy, and lymphocytosis, the peripheral blood smear should be evaluated for
atypical lymphocytes. A heterophile antibody test should be performed.
The symptoms described in association with atypical lymphocytes and a
positive heterophile test are virtually always due to Epstein-Barr virus. Nei-
ther liver biopsy nor lymph node biopsy is necessary. Workup for toxo-
plasmosis or cytomegalovirus infection or hepatitis B and C would be
considered in heterophile-negative patients, Hepatitis does not occur in the
setting of rheumatic fever, and an antistreptolysin O titer is not indicated.
Corticosteroids are indicated in the treatment of infectious mononucleosis
when severe hemolytic anemia is demonstrated or when airway obstruc-
tion occurs. Neither fatigue nor the complication of hepatitis is an indica-
tion for corticosteroid therapy.

11-14. The answers are 11-c, 12-d, 13-e, 14-a. (Braunwald, 15/e, pp
809-814, 882-885, 959, 1009, 1620.) The 30-year-old-female with mitral
valve prolapse has developed subacute bacterial endocarditis. The likely eti-
ologic agent is a viridans streptococci. Viridans streptococci cause most
cases of subacute bacterial endocarditis. No other agent listed is likely to
cause this infection. The 80-year-old-male with a Foley catheter in place has
developed a nosocomial infection likely secondary to urosepsis. Providencia
species frequently cause urinary tract infection in the hospitalized patient.
The young man with a fluctuant lesion and fistula over the mandible pre-
sents a classic picture of cervicofacial actinomycosis. The sickle cell anemia