NMS Q&A Family Medicine

194 NMS Q&A Family Medicine10. The answer C. The tricuspid valve is the one mostoften involved in intravenous drug abuse and, as a rightsidedlesion, is subject to septic emboli. Deep venousthromboembolic disease may result in pulmonary embolias well, but the patient is not febrile and the emboli arenot; hence, they show up as radiographic densities after aperiod of delay, rather than seen as infectious infiltrates.11. The answer is D. Although the presence of a ventricularseptal defect (VSD) (as well as atrial septal defect) is a riskfactor for bacterial endocarditis, the risk has disappeared6 months after clinically satisfactory repair. Each of theother conditions is a risk factor. Mitral valve prolapseassociated with a murmur is a risk, but not so MVP with aclick if unassociated with a murmur.12. The answer is E. Lyme disease. Classically, Lyme diseaseconsists of three stages. Stage 1 features flulike symptoms(arthralgia, headache, malaise, and weakness) andthe typical single skin lesion of erythema migrans at thesite of the tick bite. Stage 2, after a latent period, features arash similar to the one described here and systemic symptomssimilar to those of stage 1. Stage 3, after a greatlyvarying prolonged asymptomatic period, ranging frommonths to years, features synovitis, arthritis, centralnervous system impairment, dermatitis, keratitis, andneurologic and myocardial abnormalities. Stage 3 greatlyresembles an autoimmune mechanism. An importantpoint is that a great percentage of cases do not follow thisneatly described sequence. Moreover, a significant proportionof afflicted patients give no history of a tick bite.Stage 2 disease may be seen quite early; erythema migransmay not occur or go unrecognized.13. The answer is C. Diagnosis of pertussis cannot bemade within 48 hours of the culture inoculation, althoughculture is taken from the nasopharynx. Direct fluorescentantibody testing is not available for rapid diagnosis as ofthis writing. The culture requires at least 7 days for reportingout. All other statements given are true. Althoughapproximately 29% of cases occur in the classic age group,infancy, the remainder are spread throughout all agegroups, and 20% are found in people over the age of20 years. Timely treatment with macrolide antibioticsreduces the severity and length of the period of symptoms.In the milieu of 2007, pertussis should be consideredin any patient whose cough lasts 2 weeks or more.14. The answer is C. Early therapy with recently developedantiviral agents cannot cure the disease. Herpes simplexremains an incurable disease. Genital or (classically)type 2 disease is more liable for recurrence over time butdecreasingly over time, whereas type 1 recurs at a rapidlydecreasing rate. The vast majority of cases is treatedaccording to clinical diagnosis, but culture of vesicularfluid is the standard; type-specific serological testing isavailable. Polymerase chain reaction testing is 95% sensitivebut not in general use mostly due to the costs incurred.Viral culture is only 70% sensitive but when positive differentiatesHSV-1 from HSV-2 infection. Suppressanttherapy is employed with any of a number of antiviralagents, for example, acyclovir and related famciclovir,valacyclovir, and the newer trifluridine, vidarabine, foscarnet,and cidofovir. These can reduce the recurrencerate by 70% to 80% and can also significantly reduce therisk of heterosexual transmission in HSV-2 discordantcouples.15. The answer is B. A recent review of the literatureindicates that, of all the common laboratory studies usuallyperformed, only an elevated creatine kinase level separatesthe other pneumonitides from Legionnaire. This isa typical presentation of Legionnaire disease. A coughmay be nonexistent or mild compared to the remainingclinical picture, including chest x-ray. The incubationperiod for Legionnaire disease is only 2 to 10 days. Diarrhea,not constipation, is an associated finding. Ear painfrom an associated otitis media can be seen with mycoplasmapneumonia and even with some streptococcalinfections but is not typical of Legionnaire disease. Manymore neutrophils than bacteria are usually seen in Gramstains from patients with Legionnaire disease. Anorexia,myalgia, and hyponatremia are also frequently seen. Treatmentis accomplished with the macrolides and rifampin.ReferencesBauman JG . Genital herpes: A review . Am Fam Physician. 2005 ;72 ( 8 ): 1527 – 1534 , 1541 – 1542 .Bratton RL , Corey GR . Tick-borne disease . Am Fam Physician.2005 ; 71 : 2323 – 2330 , 2331 – 2332 .Campos-Altcalt D . Practice alert – pertussis: A disease re-emerges .J Fam Practice . 2005 ; 54 : 699 – 702 .Chambers HF . Infectious diseases: Bacterial and chlamydial . In:Tierney LM , McPhee SJ , Papadakis MA , eds. Medical Diagnosisand Treatment . 45th ed . New York/Chicago: Lange ; 2006 .Haddy RI . Less common infectious diseases in primary care . In:Rudy DR , Kurowski K , eds. Family Medicine: House OfficerSeries . Baltimore : Williams & Wilkins ; 1997 : 501 – 512 .Hay WW , Levin MJ , Sondheimer JM , Deterding RR , eds. CurrentDiagnosis & Treatment Pediatrics . New York/Chicago :McGraw-Hill/Lange ; 2009 .Headley AJ . Narcotizing soft tissue infections: a primary carereview . Am Fam Physician . 2003 ; 68 : 323 – 328 .Moran A , Shandera WX . Infectious diseases: Viral and ricketsial .In: Tierney LM , McPhee SJ , Papadakis MA , eds. Current MedicalDiagnosis and Treatment . 45th ed . New York : McGraw-Hill/Appleton & Lange ; 2006 : 1349 – 1399 .R ake l RE , B op e ET , e ds. Conn’s Current Therapy 2009 . Philadelphia: Saunders/Elsevier ; 2009 .