Internal-Medicine

Answers: 28–46 221
health authorities should be consulted to determine
the potential risk of rabies in the animal
based on local rates of rabies in wild animals.
Alternatively if there is a high risk the animal is
infected, then postexposure prophylaxis should
be started with rabies vaccination on days 0, 3,
7, 14, and 28 as well as one dose of rabies
immune globulin on day 0. (Kasper, p. 1156)
38. (C) EBV genetic material has been found in
association with many malignancies. In Africa,
about 90% of patients with Burkitt’s lymphoma
have an association with EBV, but in the United
States, only 15% of cases are associated with
EBV. In contrast, almost all cases of anaplastic
nasopharyngeal carcinoma and also HIVrelated
CNS lymphomas are associated with
EBV genetic material. (Kasper, p. 1047)
39. (C) Splenic rupture occurs during the second or
third week of the illness and can be insidious or
abrupt in presentation. Surgery is required.
Hemorrhage is not a usual complication of
infectious mononucleosis. Over 90% of cases
are benign and uncomplicated, but liver
involvement is clinical in 5–10%. Over 85% of
EBV-associated neurologic problems resolve
spontaneously. Although hemorrhage does not
occur, autoimmune hemolytic anemia can
occur. It is usually mediated by IgM antibodies
with anti-i specificity. (Kasper, p. 1047)
40. (B) Coccidioidomycosis may present with a
syndrome of erythema nodosum, fever, and
conjunctivitis. Serious complications include
cavitating lung lesions or meningitis. (Kasper,
p. 1181)
41. (D) CMV is probably transmitted in the leukocyte
component of transfusions. The syndromes
include fever and lymphocytosis.
Screening donors for this virus reduces the incidence
of transmission. (Kasper, p. 1050)
42. (A) TSS is most characteristically seen in
females using vaginal tampons and is secondary
to staphylococcal enterotoxins called TSS
toxin 1 (TSST-1). Abrupt onset is characteristic.
The clinical criteria for diagnosis include high
fever, a diffuse rash that desquamates on the
palms and soles over the subsequent 1–2
weeks, hypotension, and involvement in three
or more organ systems. This involvement can
include GI dysfunction (vomiting and diarrhea),
renal insufficiency, hepatic insufficiency,
thrombocytopenia, myalgias with elevated
creatine kinase (CK) levels, and delirium.
Staphylococcal scaled skin syndrome most
often affects newborns and children. It results
in localized or quite extensive fluid-filled blisters
that easily rupture to expose denuded skin.
It is caused by an exfoliative toxin. (Kasper, p. 819)
43. (A) In epidemics, N. meningitidis is usually the
cause, generally serotype A (sub-Saharan Africa)
or C (North America). Serotype B is more
common in sporadic outbreaks. (Kasper, p. 849)
44. (A) Several antibiotic combinations could be
used and may vary with the indigenous organisms.
Aminoglycoside and cephalosporin are
commonly used in combination. The antibiotic
combination must cover both Gram-positive
and Gram-negative organisms. Antifungal or
viral agents are not empirically started unless
there is an appropriate clinical fungal or viral
infection. In some centers, empiric antifungal
agents are started if the patient remains febrile
on antibiotics after 5 days. Observation alone is
not an option, since these individuals usually
have some form of bacteremia causing the
fever. (Kasper, p. 479)
45. (A) Hospital-acquired pneumonia is defined
as pneumonia occurring >48 hours after admission
and not incubating at the time of admission.
It is caused by S. aureus, Gram-negative
bacilli, or Streptococcus pneumoniae. Mixed aerobic
and anaerobic infections are also common.
Pulmonary embolism is always a consideration
in the diagnosis based on clinical probability.
The elevated WBC makes atelectasis
unlikely and the normal JVP rules out congestive
heart failure. (Kasper, p. 1538)
46. (B) Legionnaires’ disease is transmitted via
infectious aerosols and may cause severe disease
characterized by dry cough and fevers.
Mild infections and asymptomatic seroconversion
also occur. Natural reservoirs for the