ID Flashcards
1
Q
Women in labor with genital herpes, list 4 risk factors for transmission to infant.
A
- first episode of herpes for mom (primary infection)
- prolonged rupture of membranes
- vaginal delivery
- use of instrumentation in delivery (forceps, vacuum, fetal scalp electrode)
2
Q
Woman in labour with genital herpes. If you are going to do investigations, in what situation would that be and what tests would you do on the infant? (list 2)
A
Mom has active primary lesions, baby asymptomatic, born by C/S after ROM - mucous membrane swabs and start IV acyclovir on spec. If swabs positive, then do blood and CSF PCR
*if infant symptomatic, admit, treat, swab and FSWU
3
Q
Mom is IVDU. Her blood work: HEB B + HepC +. Baby’s blood work at 6 mo, hep B and hep C ab negative. What to do:
a) Repeat Hepc in 6 months
b) No further investigations
c) PCR
A
b) No further investigations
- negative Hep C ab in child of any age indicates transmission did not occur
4
Q
Mom ivdu. Early latent syphilis. Titer from 6 months ago and now. They have dropped by 8 times. Baby is born. What do you do to for the baby:
a) Observe
b) Tryponemal screen and RPR
c) CSF RPR
d) Swab baby
A
b) Tryponemal screen and RPR
5
Q
Neonate with purpura and thrombocytopenia. Diagnosed with CMV. Give six other features of congenital CMV infection.
A
- hearing loss
- microcephaly
- SGA
- chorioretinitis
- jaundice
- HSM
6
Q
You are seeing a full term newborn born to a 25 year old mother with a history of genital herpes diagnosed 5 years ago. She had no active lesions at the time of
delivery and thus was untreated. The baby was born by SVD. a. What is your management of the newborn (1 line)?
A
- observe for signs of neonatal HSV and educate parents about what to look for. No swabs or other investigations indicated in this case
7
Q
A full term infant is born by vaginal delivery to a woman with a vaginal herpes lesion. In order to decrease infectivity you would:
a) place baby and mother in same room with no breastfeeding
b) place baby and mother in same room and allow breastfeeding
c) place baby and mother in separate rooms
d) discharge both immediately
e) contact isolation from other patients
A
ANSWER: b) place baby and mother in same room and allow breastfeeding
AND
e) contact isolation from other patients - until lesions crusted over, 14d infectivity period passed or swabs negative
d) discharge both immediately- no, await swabs
8
Q
An infant is born to a mother with a history of recurrent genital herpes which was not active at the time of vaginal delivery. For how long after delivery is it possible for this infant to develop herpes: a) 1-2 weeks b) 4-6 weeks c) 12-16 weeks d) 20-24 weeks e) up to 36 weeks
A
b) 4-6 weeks
9
Q
A baby is born by c-section at 6h since membranes ruptured. Mother has active HSV lesions. The baby is asymptomatic. When should cultures of the baby be done?
a. Immediately and start Acyclovir
b. After 48h
c. When the baby is symptomatic
d. Observe only
A
a. Immediately and start Acyclovir
10
Q
A women is diagnosed with chicken pox 10 days prior to delivery. The baby is normal at birth. You would:
a) give VZIG immediately
b) provide normal newborn care unless the infant develops varicella
c) isolate the baby from the mother
A
ANSWER: b) provide normal newborn care unless the infant develops varicella
a) give VZIG immediately- only if rash <5d prior to or 48h after delivery or prem
c) isolate the baby from the mother (usually lesions crusted by 5d after)
11
Q
What is the most common sequela of congenital CMV:
a) deafness
b) petechiae
c) cataracts
d) splenomegaly
e) jaundice
f) microcephaly
A
a) deafness
12
Q
A mother is exposed to parvovirus B19 in her first trimester. Most common result:
a) IUGR
b) microcephaly
c) limb abnormalities
d) cardiac malformation
e) non-immune hydrops fetalis
A
e) non-immune hydrops fetalis (from fetal anemia)
13
Q
Greatest risk of mortality with parvovirus B19 infection is associated with:
a) prematurity
b) sickle cell disease
c) ALL on chemotherapy
d) congenital heart disease
e) fetus of a mother infected with parvovirus B19
A
e) fetus of a mother infected with parvovirus B19 ~5%
14
Q
A pregnant women comes into contact with a child with parvovirus during her twelfth week of pregnancy. You would recommend:
a. isolate woman from child
b. perform parvovirus serology on the woman
c. IVIG
d. Abortion
A
b. perform parvovirus serology on the woman
- look for susceptibility (may have immunity) and evidence of acute infection
15
Q
Mother who is HBsAg positive. Management of newborn should consist of:
a. Hep B vaccine only
b. Hepatitis titres and if negative, Hep B vaccine in 1 week
c. Hep Ig q monthly if breastfeeding
d. Hep Ig within 12 hours and Hep B vaccine within 12 hours
e. Hep Ig at birth and Hep B vaccine within 7 days
A
d. Hep Ig within 12 hours and Hep B vaccine within 12 hours
16
Q
Baby born to a Hep B positive mom. He gets immunoglobulin and vaccine at birth. At nine months he is asymptomatic. What would his blood tests show?
- HbeAg+, HbcAg+, HbsAg+, HbsAb+
- HbeAg-, HbcAg-, HbsAg+, HbsAb+
- HbeAg-, HbcAg-, HbsAg-, HbsAb+
- HbeAg+, HbcAg-, HbsAg+, HbsAb-
- HbeAg-, HbcAg+, HbsAg+, HbsAb
A
- HbeAg-, HbcAg-, HbsAg-, HbsAb+
surface antigen should be negative (if it’s positive he has Hep B), and surface antibody should be positive (has immunity from vaccine)
17
Q
Complications of neonatal gonococcal eye infections include:
a. retinal hemorrhage and blindness
b. corneal perforation and blindness
c. anterior uveitis and fixed pupil
d. glaucoma
A
b. corneal perforation and blindness
18
Q
Infant born to mother with no prenatal care. Hepatosplenomegaly and copper rash especially on palms and soles. Rhinitis and cough. Diffuse consolidation on CXR. Appropriate investigation:
a. urine CMV
b. VDRL/FTA abs
c. blood culture
A
b. VDRL/FTA abs
19
Q
A woman has recently immigrated from China to Canada and has just delivered a healthy term infant. She does not know her hepatitis B status, but the results will be available in 2 days. What will be your management:
a) await results of HBsAg before treating infant
b) give HBIG now, but await results of HBsAg before giving Hep B vaccine or allowing breastfeeding
c) give Hep B vaccine now and allow breastfeeding
d) give HBIG and Hep B vaccine now; do not allow breastfeeding
e) give HBIG and Hep B vaccine now; allow breastfeeding
A
c) give Hep B vaccine now and allow breastfeeding
- unknown status: Hep B vaccine at birth, if mom ultimately tests positive give HBIG within 1 week of life
- if baby <2000g give Hep B vaccine and HBIG at birth
20
Q
Contraindication to breastfeeding
e. Hep B
f. Bilateral mastitis
g. Active TB
A
g. Active TB
21
Q
Picture of baby with rash: told cataracts, microcephaly, hepatosplenomegaly, bony changes
a) Syphilis
b) CMV
c) Rubella
d) toxoplasmosis
A
c) Rubella
- hearing loss, cataracts, MR, IUGR, hepatitis, osseous changes, cardiac defects
22
Q
6 mo baby of IV drug user. Mom is Hep C-positive. Baby’s anti-HepBs positive and anti-HCV positive. What do you do?
a. no further testing
b. repeat anti-HCV in 6 months
c. do HCV RNA PCR now
d. P24 antigen
A
b. repeat anti-HCV in 6 months
- HCV serology not reliable in infants because can reflect mom’s antibodies
- test at 12-18 months; if positive repeat testing in 6 months (if seropositive after 18 months, they are infected)
23
Q
Mother has herpes labialis. What do you advise regarding her 4 day old infant?
a) wear mask when breastfeeding
b) apply topical acyclovir to lesion
c) stop breastfeeding
d) infant needs IV acyclovir
A
a) wear mask when breastfeeding
24
Q
A pregnant woman with syphilis and a RPA of 1:512 receives a full course of treatment and
the titer falls to 1:256. Upon delivery of the child, the next appropriate step is:
a) treat the child as the fall in the titer is inadequate
b) test child’s serum for VDRL and anti-treponemal AB and treat if positive
c) test child’s CSF for VDRL and anti-treponemal AB and treat if positive
d) no treatment is necessary for syphilis but this child should be tested for HIV
A
a) treat the child as the fall in the titer is inadequate
- full work up (blood, CSF, X-ray) and treat
25
Baby born with rash, cataracts, bone lesions, big liver (photo of baby shown) most likely has:
a. Congenital syphilis
b. Congenital CMV
c. Congenital rubella
c. Congenital rubella
| cataracts - rubella; chorioretinitis - CMV
26
Which of the following maternal infections is a contraindication to breast feeding?
a) Hep A
b) Hep B
c) CMV
d) HIV
d) HIV
27
Baby with tachypnea, afebrile, nontoxic, has eosinophilia. CXR shows bilateral interstitial markings, areas of atelectasis. What is the likely pathogen?
a) GBS
b) Chlamydia trachomatis
c) Ureaplasma urealiticum
d) RSV
b) Chlamydia trachomatis
- onset of cough 1-3 months; no fever; staccato cough, eosinophilia
- treat with erythromycin (can cause pyloric stenosis)
28
Neonate born to mom who just revealed HIV positive status.
| a.) What treatment(s) would you start this baby on (1 line). How long would you treat for?
Zidovudine x 6 weeks + 3 doses of nevirapine during 1 st week of life (@ birth, 48h after first dose and 96h after 2nd dose)
29
Neonate born to mom who just revealed HIV positive status. When would you start the treatment? (1 line)
Within 12 hours of birth
30
What infection is the worst prognosis in HIV for an infant
a) Lymphoid interstitial pneumonia
b) Pneumocystis Carinii Pneumonia
c) Cardiomyopathy
d) Nephropathy
e) Candida
b) Pneumocystis Carinii Pneumonia
| - PCP is an AIDS defining illness - if present in first 6 months of life is associated with poor prognosis
31
Baby born to HIV-positive mother discovered during pregnancy and treatment initiated. How to test the baby to confirm diagnosis?
a) ELISA
b) Western blot
c) HIV DNA PCR
d) p24 Ag
c) HIV DNA PCR - preferred test for <18m
* a) ELISA- screening in >18m
b) Western blot - confirmatory test
d) p24 not as sensitive - never recommended
o Testing with HIV DNA or RNA assays at 14-21d
o Repeat at 1-2m and 4-6m if negative then ELISA at 18m
o Test <48h if in utero infection suspected
32
The leading cause of HIV in women in Canada is due to:
a. homosexual transmission
b. heterosexual transmission
c. IV drug use
d. blood transfusion
e. occupational exposure
b. heterosexual transmission
33
All of the following are features of HIV infection EXCEPT:
a) hypogammaglobulinemia
b) CD4 leukopenia
c) reverse CD4/CD8 ratio
d) poor response to tetanus and diptheria vaccines
e) poor response to TB skin test
d) poor response to tetanus and diptheria vaccines
| (can have a reduced response, but this is the most correct answer)
34
A 1 year old child has a cough, and mom wants to know if she can use an over-the- counter cough preparation for him/her. What do you tell her?
OTC cough medications are not helpful in kids and can be harmful. Not recommended in kids under 6 years.
35
Child develops rash on both cheeks. Then a reticulated lacy rash is seen on his body. His mother is pregnant. What infection does this child have (1) How would you manage the mother (1)?
Parvo B19
| - serologies for mom
36
One of your patients has mono like symptoms. Your
blood work comes back. IgM negative; IgG positive; Early D antigen negative; Nuclear capsid antigen was positive. Interpret these results.
This patient had a previous (remote) infection, but this is not the explanation for current symptoms
● IgM = early rise and then drop off by 1-2 mo.
● IgG = early rise and stay elevated
● Early D antigen = peak week two then decreases by 4 mo. = (+) in acute or
recent primary infection
● Nuclear capsid antigen= low then rise 6 mo. onwards
37
4 year old boy presents with a pruritic rash over his chest and axilla. 2-5mm flesh coloured papules w/ central depression or umbilication. Provide most likely diagnosis.
Molluscum contagiosum
38
8? Year old with vesicle on erythematous base on uvula, tonsils, soft palate. What is the diagnosis?
Herpangina (coxsackie virus)
39
Winnipeg Doc..calls family concerned about west nile. 4 suggestions to help prevent west nile virus in his patients
o community-level mosquito control programs to reduce vector density
o personal protective measures to decrease exposure of infected mosquitoes (e.g. long sleeved shirts, limit outdoor from dusk to dawn, mosquito repellent, using air conditioning, installing window screens)
o screen of blood and organ donors
40
A child is brought to see you with 3 days of high fever of 40.1 degrees and feeling unwell. The only thing you see on physical exam is clear rhinorrhea. A CBC shows the following : Hb 118, WBC 2.0 x 10^9 (2000/m3), platelets of 250. The differential shows neutrophils 2%, lymphocytes 70%, eosinophils 8%. What are TWO things that you will do in the management of this child?
Viral infection - ensure adequate fluid intake, analgesia and antipyretics for comfort
41
Robert is a 6 year old boy with Varicella. In the last 24 hours he has become unwell. On exam, his temperature is 40, HR 140, BP 95/60, RR 24. He has obvious lesions consistent with chicken pox. He has a red, swollen left arm that is tender.
a) Outline a prioritized differential diagnosis.
b) Outline your initial investigations.
c) Outline your management plan.
```
a) Ddx:
● infected rash = cellulitis,
● Cellulitis ddx: abscess, osteomyelitis
● Nec Fas
b) Ix:
- CBCD, CRP, blood culture
c) mgmt: admit and IV cefazolin
```
42
Varicella. With nec fash/or purpura fulminans. What is your management:
a) vanc cefotax
b) pen G and clinda
c) amp gent
b) pen G and clinda
43
You diagnosed a toddler with Chicken pox a few days ago. Now he is in your office. Mother tells you he’s refusing to weight bear since this morning. Photo of his foot is shown. Area of erythema over 3 rd -4 th metatarsals and phalanges, with black necrotic looking areas. What is the diagnosis? How will you treat him (4)?
1. Dx: necrotizing fasciitis
2. mgmt:
- admit to hospital
- blood future, CBCD, CRP
- start pen G and clindamycin IV
- surgical consult for debridement
44
Child presents with ataxia and inability to sit up two weeks after having chicken pox.
A) What is the diagnosis?
B) How do you differentiate this from meningoencephalitis? List three.
A) acute cerebellar ataxia
B) no fever, no nuchal rigidity, CSF normal or shows mild lymphocyte pleocytosis vs meningitis which shows PMN pleocytosis
45
Name 4 indications for VZIG
PEP in high risk kids who are exposed:
- immunocompromised without immunity (e.g. leukaemia, on steroids)
- newborns of mom with varicella 5d before of 48h after delivery
- pregnant women without immunity
- hospitalized prems <28 weeks or <1000g
46
Kid with exudative pharyngitis. 1y/o. What is most likely dx
a) Viral pharyngitis
b) MONO
c) Strep
a) Viral pharyngitis
47
31 week GA baby, now 3 mos old. It is October. Parents are non-smokers. Mother planning to stay at home with babe.
A) What one intervention can you do to minimize risk of severe RSV bronchiolitis?
B) How does paluvizumab decrease risk and by what mechanism does it work?
A) this baby does not qualify for paluvizumab
- protective factors are: breastfeeding, hand hygiene and not smoking
B) decreases rate of hospitalization in some groups of prem babies (if hospitalized, does not reduce severity or mortality); confers passive immunity (immunoglobulin)
48
A 4 year old child comes to your Emergency department with a history of a fever for 3 days. You do a CBC and find that the WBC count is low at 3.2.
a. What is the most common reason for this clinical scenario?
b. On a differential, which cell line, if low, increases the risk of serious infection?
a. viral suppression
| b. neutropenia
49
Hep A. When can return to school?
a. 1 wk
b. when no fever
c. if washing hands well
d. when no symptoms
a. 1 wk (red book, CPS)
50
Girl returns from mexico and begins to have vomiting, diarrhea and jaundice. Her abdomen is tender. Her LFTS are elevated. When can she return to daycare?
a) 7 days
b) When symptoms stop
c) When LFTs normal
d) Now
a) 7 days
| - risk of transmission minimal 1 week after jaundice onset
51
Biting incident at daycare, breaks skin superficially, both kids are previously healthy and have all their immunizations but no HepB shots. What do you do?
a. screen them for HIV
b. start Hep B vaccinations in both kids
c. test Hep B serology only in the biter
d. tetanus immunoglobulin
b. start Hep B vaccinations in both kids
52
Which virus is associated with transient arthropathy:
a) RSV
b) rubella
c) measles
d) Hepatitis A
b) rubella
53
Wheezing toddler with URTI symptoms. Which is a proven therapy?
a. O2
b. racemic epi
c. iv steroids
d. bronchodilators
a. O2
| assuming bronchiolitis
54
Child admitted with known RSV bronchiolitis. On third day of his admission, develops a fever and CXR shows a small RML infiltrate. What is the most likely cause of his fever?
a. Strep pneumo
b. Chlamydia trichamotas
c. RSV
d. GBS
c. RSV
55
A 13 y.o. boy with HIV is diagnosed with measles. The only proven treatment is:
a) Acyclovir
b) Vitamin A
c) Inhaled amantadine
d) Vitamin E
b) Vitamin A (more severe disease if vit A deficient)
● WHO recommends Vit A for treatment of all children
with measles
o Daily for 2d
o 50 000 IU <6m
o 100 000 IU 6-11m
o 200 000 IU >12m
56
Child sucks on finger. Lesions on finger for 10 days. Finger hurts when mom touches it – picture of a finger with vesicles but also a central area of ulceration, some diffuse erythema of finger. What is your management?
1. po cephalexin
2. I & D
3. po acyclovir
4. flamazine dressing
3. po acyclovir
Herpetic whitlow - treat with acyclovir if immunocompromised or severely infected; otherwise can do nothing
57
Mom wants to know where her 18 month old daughter acquired perineal warts. You tell her from:
a. perinatal acquisition
b. sexual abuse
c. day care
d. from bathing with her older sister
e. from dad changing diapers
a. perinatal acquisition
58
What is the best test for HSV encephalitis?
a) PCR on CSF
b) Viral culture of CSF
c) HSV IG in CSF
d) Differential on CBC
a) PCR on CSF
59
Mom concerned about possibility of west nile in her child. What is the most common presentation of west nile in children?
a. Asymptomatic
b. Mild fever
c. Encephalitis
a. Asymptomatic
(70-80% of WNV infections are asymptomatic)
- if symptomatic: febrile illness with myalgia, arthralgia, headache, GI upset, maculopapular rash
60
3 year old with a history of fevers. Occur every 4 to 12 weeks for 1-4 days. Growing well. Treated for numerous otitis and pharyngitis.
A) multiple viral infections
B) familial med fever
C) CVID
A) multiple viral infections
61
11 year old girl with vague abdominal pain, vomiting, and jaundice. Her labs show ALT 1000, total bilirubin 100. What test will likely confirm the diagnosis?
a) Hep A IgM
b) CMV urine
c) Heb B serology
d) monospot
a) Hep A IgM
- Hep A accounts for 50% of all clinically apparent acute viral hepatitis
- clinical presentation of hep A
- fever, malaise, jaundice, anorexia, nausea, vomiting
62
6 year old girl has recent history of gastroenteritis. She develops bilateral decreased sensation in her feet. Her respirations are normal. What is her diagnosis (1)? What test or procedure would you do and what are your expected findings? What is the likely organism that caused her gastroenteritis (1)?
1. guillain-barre syndrome
2. LP - elevated protein (>2x ULN), glucose normal, no CSF pleocytosis, cultures negative
- can also do MRI: thickening of cauda equina and intrathecal nerve roots with gad enhancement
3. campyobacter jejuni
63
Native girl, received BCG in past, PPD 13mm.
a. ) How do you interpret this?
b. ) What is your approach to treatment? (1 line)
a) positive test - in kids who are vaccinated, if they have been exposed to TB or are at high risk for disease the cutoffs for a positive test are the same as if they hadn't been vaccinated
b) 9 months of isoniazid for LTBI
64
Child gets a puncture wound of the foot through the sneaker. He is Limping. Bone scan confirms osteomyelitis. What is the likely causative organism? List 2 treatment
modalities.
1. pseudomonas
| 2. - irrigation and debridement under GA, abx x14 days (pip-tazo, cefuroxime, cipro gent all antipseudomonal)
65
Name 4 drugs with pseudomonas coverage
- pip-tazo
- cefuroxime
- aminoglycosides (gent, tobra)
- cipro
66
Child has worsening swelling around an eye. List 2 signs that would make you worried about orbital cellulitis.
- proptosis
- pain with extraoccular movements
- decreased visual acuity
67
A child has bacterial meningitis. Soon after starting his vancomycin infusion, he breaks out in a red rash. Blood pressure is normal. What is your IMMEDIATE management? What are TWO things that can be done so this doesnʼt happen the next time?
1. stop infusion; give benadryl and ranitidine
2. premedicate with diphenydrydramine +/- ranitidine
- run infusion at slower rate
Red man syndrome - not true allergy; is a rate dependent infusion reaction
68
Description of a mom who presents with her child who has otitis media. What are 4 risk factors for otitis media?
- pacifier use
- exposure to cigarette smoke
- certain syndromes (e.g. T21 - flatter angle of ear canals)
- orofacial abnormalities (e.g. cleft palate)
- over crowded housing
- shorter duration of breast feeding
69
Kid with pain with movement both directions. Supple neck, slight red throat otherwise normal oral pharynx. Drooling.
a) Peritonsilar abcess
b) Retropharyngeal abcess
c) Mono
d) URTI
b) Retropharyngeal abscess
70
Teen can’t open mouth. Has fever. Dx?
a. Retropharyngeal abscess
b. Peritonsillar abscess
b. Peritonsillar abscess
71
Bite in daycare Q. What to do:
a) Reassure mom of low risk of hiv infection
b) HIV serologies for both kids
c) initiate HIV prophylaxis for both kids
d) HIV prophylaxis for kid who was bitten only
a) Reassure mom of low risk of hiv infection
- PEP after a bite by a child known to be infected with HIV is rarely indicated and should only be given in consult with ID
72
3 year old with a bite on his cheek. List 4 characteristics of the bite that would have an impact on the management of this patient.
- depth
- signs of infection
- what bit him - animal versus human (puncture wound vs graze)
- infective/immune status of biter if known
- tetanus status
- duration since bite (do not close if >24 hours)
73
3 week old with RSV, day 2 of admission. Fever of 39. RML infiltrate that was new.
a) cefotax
b) amp and gent
c) supportive management
b) amp and gent
| - because fever in <1 month
74
Inuit grandmother diagnosed with active TB. His child has a TB skin test which shows 8 mm of induration. What are two possible reasons for this test result (2)
- latent TB infection (in otherwise asymptomatic)
- indicative of previous BCG vaccine
Positive test is >5mm in a child with close contact with persons with active TB
75
2 year old with fever and right ear pain. She was treated with clarithrymycin a few weeks ago for a respiratory infection. ON exam has an otitis media. What are three possible antibiotics for her (3)
- amoxicillin
- amoxicillin-clavulanic acid
- cefuroxime
76
Family comes to you from an area endemic for Lyme disease – What is the organism and vector causing it (2)?
- borrelia burgdoferi; from black-legged ticks
77
What are two antibiotics that are effective
| against lyme disease (2)? When is IV and treatment indicated?
1. - doxycycline (kids 8+ years)
- amoxicillin
- cefuroxime
2. ceftriaxone/pen G for endocarditis, meningitis, encephalitis
78
What are three things to do for prevention if you live in a lyme endemic area (3)
- use landscaping to separate play spaces from wooded areas
- 20-30% DEET bug spray
- full body check for ticks after coming inside and promptly remove any that are found
- showed within 2 hours of coming inside to wash off unattached ticks
79
List 4 clinical signs to distinguish orbital from periorbital cellulitis.
- pain with EOM
- rapid afferent pupillary defect
- proptosis
- decreased visual acuity
- chemosis
80
18 month old child with URTI. He develops higher fever 3 days later, pulling at ear and has erythematous right tympanic membrane, not bulging. Do you treat for AOM? Explain why or why not?
No treatment. No bulge suggests there is no middle ear effusion, and erythematous TMs are common in viral infections. Since patient is over 6 months watchful waiting x24-48 hours is appropriate
81
What are the five major criteria for rheumatic fever?
```
Joints: migratory polyarthritis
Carditis: new murmur/valve disease on echo
Subcutaneous nodules
Erythema marginatum
Sydenham's chorea
```
82
Child presents with bloody diarrhea, anemia and thrombocytopenia. What is the diagnosis?
Hemolytic uremic syndrome
| - triad: microangiopathic hemolytic anemia, TCP, renal insufficiency
83
Which of the following is TRUE as regards TB in children:
a) tine test and PPD are equally specific and sensitive
b) 10% of children with active disease are PPD negative
c) prior vaccination with BCG is a contraindication to PPD testing
b) 10% of children with active disease are PPD negative
84
4 y.o. with chronically draining cervical node. Most likely bug:
a. Staph Aureus
b. Atypical mycobacterium
c. Cat scratch
d. Tuberculosis
b. Atypical mycobacterium
85
Child with a supraclavicular lymph node 1.5 by 2 cm, firm, nontender, mobile no surrounding erythema . what is best management
a. skin testing for atypical mycobacteria
b. PPD (TB skin test)
c. excision biopsy
c. excision biopsy
86
Greek 6 y/o girl with fever to 40 degrees. WBC 38. Pain in the right hypochondrium. Tender in right hypogastrium but no guarding or rebound. What is the diagnosis:
1. Pleurodynia
2. Bacterial pneumonia
3. First presentation of Familial Mediterranean Fever
4. Fitz-Hugh-Curtis
5. Cholecystitis
2. Bacterial pneumonia
87
Adolescent male whose partner is positive for gonorrhea. Your management would be
a. Amoxil
b. tetracycline
c. ceftriaxone
d. doxycycline
e. erythromycin
c. ceftriaxone 250mg IM x1
- same treatment for partners as for confirmed cases
- also give one dose of azithro 1g PO (or 7d doxy)
88
12 month old who is toxic with a lobar infiltrate. Which antibiotic do you use:
1. IV Cefuroxime and IV Erythromycin
2. IV Vancomycin
3. IV Ampicillin
4. PO Amoxicillin
5. PO Clarithromycin
3. IV Ampicillin
- ceftriaxone for life threatening infection/shock
- if rapidly progressing multi lobar pneumonia add vance for MRSA
89
First line for treatment for sinusitis:
1. Amoxicillin
2. Azithromycin
3. Clarithromycin
4. TMP/SMX
1. Amoxicillin
90
6 y/o boy with 2 weeks of sudden onset of OCD behaviours. Which infectious agent would you be concerned about:
1. Strep pneumonia
2. Group A Strep
3. E. Coli
4. H. Flu
5. Echovirus
2. Group A Strep
| (PANDAS)
91
A child eats at a picnic and develops vomiting and diarrhea four hours later. What is the likely causative organism:
1. E Coli
2. S Aureus
3. Shigella
4. Campylobacter
5. Salmonella
2. S Aureus
| onset 1-6 hours after exposure
92
An epileptic who has been on carbamazepine for the past year presents with otitis media. You prescribe Ceclor for the otitis. Two days later he returns with an urticarial rash. The otitis is still present. What would be the next drug of choice:
a) amoxicillin
b) erythromycin-sulfa
c) clarithromycin
d) TMP-sulfa
e) cefixime
a) amoxicillin- 1 st line for AOM; if you have a cephalosporin allergy it is usually to the side chain, not the beta lactam, so don't tend to have penicillin allergy
cefixime is also a cephalosporin so not a good idea (though is a good choice for kids with pen allergies because does not cross react with penicillins
eryrtho, clarithro and septa all have interaction with carbamazepine (could induce toxicity)
93
A mother brings her 3 children to your office because she thinks they all have strep throat. The 18-month-old and 2½ -year-old both have exudative tonsillitis. The 4-year-old has a red pharynx and mild anterior cervical lymphadenopathy.
a) no treatment is necessary now; reassess in a few days
b) treat all 3 children with penicillin V tid x 10 days
c ) take throat swabs and await the results before treating
d) take throat swabs and treat empirically with penicillin V
e) take throat swabs and do CBCs; if increased WBC then start penicillin V
c ) take throat swabs and await the results before treating
94
A child has Campylobacter cultured from his stool. He is toxic. Which antibiotic:
a) PO Erythromycin
b) PO Septra
c) PO Flagyl
d) IV Ampicillin
e) no antibiotics
a) PO Erythromycin
- gram negative bacilli
- leading cause of acute diarrhea worldwide
95
A 10-year-old child has completed a 2-week course of oral erythromycin as treatment for pertussis. His mother complains that her child is still coughing. You advise:
a) chest x-ray
b) ventolin
c) oral prednisone
d) another 14 days of erythromycin
e) reassure that nothing further needs to be done
e) reassure that nothing further needs to be done
| - 100 day cough
96
A 7 year old with CP, severe GERD and frequent choking spells while eating is admitted to the hospital with fever and increased RR. On CXR there is an air bubble in the LLL with surrounding consolidation and pleural effusion. What is the most likely organism that is causative:
a. Staphylococcus
b. Haemophilus
c. Anaerobes
d. Mycoplasma
a. Staphylococcus
| - causes necrotizing pneumonitis - pneumatocele
97
A 13 year old boy has had a 3 week history of fever, malaise and a weight loss of ten pounds. On examination he has diffuse lymphadenopathy including a right supraclavicular node and his spleen tip is palpable. His WBCs are 10, Hgb is 120 and Plts are 150. HIV and mono testing are negative. Which of the following tests is the next step in your investigations:
a. CT abd
b. BM aspirate
c. ANA
d. CXR
d. CXR
| - mediastinal mass for cancer; hilar adenopathy for TB
98
12 month old girl is seen with fever, tachypnea and vomiting. She appears unwell but her vitals are stable. On CXR there is a lobar consolidation. What antibiotics do you start:
a. IV cefuroxime
b. IV cefuroxime and IV azythromycin
c. IV vancomycin and cefotaxime
d. IV ampicillin
d. IV ampicillin
99
A 3 year presents to your office with 3 days of low grade temperature, rhinorrhea, and occasional cough. On exam he looks well and has green crusted nasal discharge. A culture of his nasal secretions is growing small amounts of H. influenzae. What is your treatment:
a. no treatment
b. amoxicillin
c. trimethoprim-sulfmethoxazole
d. ENT consult
a. no treatment
| - h flu is normal part of respiratory flora in 60-90% of children
100
A 7 year old boy visited a farm recently. He now presents with a cough, hepatomegaly and a slight elevation of his AST and ALT. What is the likely diagnosis? what is the treatment?
a. Psittacosis
b. Legionella
c. Q fever
c. Q fever
- coxsiella burnetti (rickettsial infection)
- supportive only; can treat with doxycycline if diagnosed within 3 days of onset (otherwise abx ineffective)
101
You see a 4 year old child with a history of an enlarged left axillary lymph node for the past 14 days which is slowly enlarging in size. He has not been traveling outside the country. On examination the node is soft, mobile and mildly tender but there is no overlying redness. He is afebrile and there is no obvious skin infection over the left arm. What investigation is most likely to confirm the diagnosis:
a. Bartonella hensellae serology
b. PPD testing
c. Excisional biopsy
a. Bartonella hensellae serology
- self limited
- axillary lymph node common
102
Otitis media → complications of “watch and wait” approach
a. Bacteremia
b. Mastoiditis
c. Prolonged fever
d. Prolonged pain
c. Prolonged fever
103
12 month girl is diagnosed with otitis media by her family doctor. She is started on amoxil 80 mg/kg/day and returns to you three days later still febrile. Her tympanic membrane is red and bulging. She appears well. What antibiotics should you give her:
a. Amoxil/clavulinic acid-
b. Cefuroxime
c. Ceftriaxone
d. Clarithromycin
a. Amoxil/clavulinic acid-
104
3 yo F with 1 wk of yellow discharge on panties. On exam inside of labia majora red and yellow secretions pooled in posterior fourchette and around urethra. Most likely diagnosis.
a. Candida
b. Foreign body
c. GAS
d. Pinworms
c. GAS
105
A 10-year-old boy has painful swelling behind his right mandible. He has torticollis on the same side and a red pharynx. Remainder of the exam is normal. Most important diagnostic test:
a) lateral neck x-ray
b) blood culture
c) monospot
d) amylase
a) lateral neck x-ray
| - consider amylase - mumps
106
A 3-month-old child has had tender swelling over the mandible bilaterally for 1 week, along with fever and irritability. There is hyperostosis on x-ray. Most likely diagnosis:
a) Caffey’s
b) parotitis
c) cherubism
d) osteomyelitis
e) hypervitaminosis A
a) Caffey’s (infantile hyperostosis of jaw, scapula, clavicles, diaphysis of long bones, can have fever and irritability)- resolves by 2y
● Cortical hyperostosis (bone thickening) with inflammation of fascia and muscle
● Avg onset 10 weeks (can be prenatal and severe- hydrops)
● Most commonly involves mandible
107
Why do you treat Salmonella bacteremia in a 2 month old child?
a) To eliminate the carrier state
b) To decrease the duration of symptoms
c) To prevent meningitis
d) To eliminate shedding from the GI tract
c) To prevent meningitis
108
Child with symptoms consistent with orbital cellulitis. What should be done?
a) IV Ceftriaxone
b) surgical drainage
c) PO clindamycin
a) IV Ceftriaxone
109
Child appears toxic and has lobar pneumonia. What antibiotics should be used?
a) PO Amoxil
b) Cefuroxime IV
c) Cefuroxime IV and Azithromycin PO
d) Vanco and ampicillin
b) Cefuroxime IV - best of available; really IV amp is best
110
4nmo infant. Grandfather, who lives in child’s home has been diagnosed with cavitating TB. How should the infant be managed?
a) Treat with rifampin
b) give BCG
c) Treat with INH
d) Do CXR
d) Do CXR
- should have TST or IGRA, physical exam and CXR
- at minimum will be treated for LTBI with INH BUT need CXR to rule out active disease which will change management
111
15 yo male with severe retropharyngeal abscess, requiring surgical decompression. On day 3, he has new onset headache. What is the most likely cause?
a) meningitis
b) jugular thrombosis
c) migraine
b) jugular thrombosis
| - thrombophlebitis of internal jugular vein ultimately causing central venous sinus thrombosis
112
Child was bitten on the hand by a cat 24 hours ago. He has been taking Clavulin, but the hand has become very erythematous and swollen. What do you do?
a) IV Ticarcillin/clavulanate
b) IV Cefuroxime
c) IV Cloxacillin
d) Call Ortho to do Surgical Debridement and irrigation
a) IV Ticarcillin/clavulanate (pip-tazo would also work)
113
A young boy is walking in the street. Suddenly a stray dog, unprovoked, bites him. What do you do with regard to rabies?
a. Prophylaxis
b. Prophylaxis if dog shows signs of rabies
c. No prophylaxis
a) treat child prophylactically
| - if dog healthy and could be quarantined, could delay prophylaxis and only start if animal became symptomatic
114
A 3 year with 5 days low grade temperature, rhinorrhea, occasional cough. On exam he looks well, has green crusted nasal discharge. Mom has been giving acetaminophen 6 to 7x/day. Next test:
a) Sinus x-rays and treat if fluid level present
b) treat with amoxil
c) consult with ENT
d. counsel on Tylenol dosing and risk of too much acetaminophen
d. counsel on Tylenol dosing and risk of too much acetaminophen
115
15 year old with h. pylori. You should treat with:
A) h2 blocker
B) amox, clarithro and proton pump inhibitor
C) clarithro and h2 blocker
D) amox and proton pump inhibitor
B) amox, clarithro and proton pump inhibitor
116
Photo shown of antecubital fossa demonstrating Pastia’s lines. Etiology:
a) staph
b) strep
c) roseola
d) rubeola
e) rubella
b) strep
117
Strep throat in children aged 1 to 3 years may present with all of the following EXCEPT:
a) low grade temperature
b) prolonged fever
c) decreased appetite
d) exudative tonsillopharyngitis
e) seromucoid rhinorrhea
d) exudative tonsillopharyngitis
| - kids under 3 rarely have strep but when they do they present atypically
118
A 13-year-old aboriginal female who lives on a reserve presents with tender erythematous induration of her shins bilaterally. What should you investigate for:
a) sarcoidosis
b) tuberculosis
c) Cat-scratch disease
d) inflammatory bowel disease
e) drug hypersensitivity
tuberculosis
- erythema nodosum can be caused by TB, cat scratch, sarcoid, IBD - so multiple answers could be correct but given Aboriginal on reserve has increased risk of TB
119
12 m with crusty yellow discharge from Left eye and conjunctivitis. Normal visual acuity, no proptosis, no periorbital swelling, normal EOM. You prescribe cipro topical drops. At 36 h exam, unchanged. What is your next step?
a. Refer to ophto
b. Prescribe IV antibiotic
c. Continue and return in 48 h
d. Prescribe fucidic acid drops
c. Continue and return in 48 h
120
3 months old with seromucoid discharge from one eye, and occasional yellow crusting from the other eye. What do you do?
a. refer to an ophthalmologist
b. reassure
c. give daily antimicrobial eye drops
b. reassure
121
Child with fever, purulent nasal drainage x 14 days. What to treat him/her with?
a. amoxicillin
b. Keflex
a. amoxicillin
122
What would be an indication to do radiological studies in sinusitis?
a . orbital cellulitus
b. adolescent with no fever and mucopurulent discharge
a. orbital cellulitus
123
What are 3 complications of sinusitis?
- orbital/periorbital cellulities
- epidural abscess
- meningitis
- cerebral venosinous thrombosis
- brain abscess
- Pott's puffy tumour (osteomyelitis of frontal bone)
124
PANDAS would be suspected in a child with
a. recurrent Sydenham’s chorea
b. new onset of tics after a group A strep infection
c. pancreatitis and depression after strep A infection
b. new onset of tics after a group A strep infection
125
Picture of lateral neck xray (++ prevertebral soft tissue swelling), febrile with difficulty opening the mouth. Presents with neck pain, what is the dx?
a. bacterial trachieitis
b. peritonsillar abscess
c. retropharyngeal abscess
d. epiglottis
c. retropharyngeal abscess
126
Child with CP, has a fluid-filled thing in his lung surrounded by an area of
consolidation. History of recurrent aspiration. What is this?
a. CLE (congenital lobar emphysema)
b. pulmonary abscess
c. pulmonary sequestration
b. pulmonary abscess
127
Toxic child with high fever, respiratory distress. White-out on 1 side of the lung on CXR. What to do?
a. decubitus x-ray
b. chest ultrasound
c. consult surgery
d. bronch
b. chest ultrasound – fluid vs consolidation/atelectasis/tumor
* a. decubitus x-ray – can show shift in fluid (tells you if effusion versus consolidation
128
Child with pulmonary findings, eosinophilia, slightly elevated calcium (2.8)
a. miliary TB
b. sarcoidosis
c. cryptococcus
d. blastomycosis
ANSWER: b. sarcoidosis = lung (non-caseating granulomas) + hypercalcemia + eosinophilia - non infectious
a. miliary TB lung + hypercalcemia
c. cryptococcus lung + eosinophilia + hypercalcemia? (but often in immunocompromised)
d. blastomycosis lung +eosinophilia (+ hypercalcemia in dogs)
129
```
A 6y M has always lived on a farm. For the last 3 months he has had intermittent fever, vomiting, diarrhea and weight loss. A test shows narrowing of distal ileum. Which
is the causative agent?
a. Entameoba histolytica
b. Yersinia
c. Salmonella
d. Giardia
```
b. Yersinia- ileitis
- mesenteric adenitis causes abdo pain and fever (mimics appendicitis)
- terminal ileitis and diarrhea (mimics IBD)
130
Kid with bloody diarrhea 1 month ago which has now resolved. Now has weight loss and abdominal pain. Which was the most likely organism?
a. Yersinia
b. Campylobacter
c. E Coli
d. Shigella
Yersinia – can be cause of chronic abdominal pain/weight loss (not in nelsons)- crohns mimicker- can last months (Toronto notes)
131
Chlid with 4+ proteinuria, distended abdo, fever. Most likely organism causing acute abdomen?
a. Ecoli
b. Strep pneumo
b. Strep pneumo
| - nephrotic syndrome complicated by spontaneous bacterial peritonitis
132
Teenage male treated for Chlamydia with azithromycin. When can he resume sexual activity?
a) once he has completed his medication
b) once his partner is treated
c) after seven days after completing treatment
d) once his symptoms appear to have resolved
c) after seven days after completing treatment
| if same partner, then also after 7 days after partner completes treatment
133
Treatment of Lyme disease in a 6 year old:
a. clarithromycin
b. amoxicillin
c. doxycycline
d. erythromycin
b. amoxicillin
134
Head lice - which one is least likely to increase resistance?
a. permethrin 1%
b. R&C
c. lindane
d. Resultz shampoo
d. Resultz shampoo (isopropyl myristate)
- R&C = pyrethrin - same resistance to permethrin and pyrethrin
- lindane - high failure rate and potentially neurotoxic
- per CPS, increasing resistance to pyrethrin, permethrin and lindane
135
Child presents with pinworms. How do you treat?
Albendazole - single dose repeated 2 weeks later to kill any worms that have hatched from eggs in the meantime
136
Asymptomatic child with Giardia spores in stool. Stool sent after another child in daycare diagnosed with giardiasis. Do you treat this child and explain why yes or no? If you would treat, what would you prescribe?
1. No because do not need to treat asymptomatic carriers, unless they share a household with a child with CF/hypogammaglobulinemia.
2. metronidazole x5-10 day course
* not recommended to test asymptomatic children
137
You are seeing a child with a very itchy rash. The older sibling has (or had?) a similar itchy rash. Photo shown of child’s ankle. (scabies) What is the diagnosis and how do you treat?
1. scabies
| 2. 5% permethrin cream from neck down; leave on for 12 hours, then rinse; repeat in 7 days
138
A child with marked eosinophilia is suspected of having visceral larva migrans (toxocariasis).
Physical examination would likely reveal:
a) splenomegaly and lymphadenopathy
b) hepatomegaly
c) serpiginous rash
d) arthralgias
e) myalgias
b) hepatomegaly
139
Which of the following infections causes eosinophilia?
a. Giardia lamblia
b. Entamoeba fragilis
c. Ascaris lumbricoides
d. cryptosporidium
e. pinworms
c. Ascaris lumbricoides
- giardia and cryptosporidium are protozoa not helminths
- hallmark of helminths is eosinophilia
140
A child with marked eosinophilia is suspected of having visceral larva migrans (toxocariasis). Physical examination would likely reveal:
a) splenomegaly and lymphadenopathy
b) hepatomegaly
c) serpiginous rash
d) arthralgias
e) myalgias
b) hepatomegaly
Toxocariasis
o Roundworms of dogs/cats especially puppies/kittens
o Visceral
▪ Fever, leukocytosis, eosinophilia, hypergammaglobulinemia, wheezing, abdominal pain, hepatomegaly ▪ Malaise, anemia, cough, pneumonia, myocarditis, encephalitis, hemorrhagic rash, seizures
141
What are THREE indications for giving the conjugated quadrivalent vaccine for meningococcus?
- functional or anatomic asplenia
- persistent complement deficiencies
- travel to country where meningococcal disease is hyper endemic or epidemic
- as part of routine vaccine schedule
142
3 yr old boy with confirmed pertussis. Lives with 3 sibs, all of whom are immunized. What treatment, if any, do you recommend?
- patient should be treated
| - post-exposure prophylaxis for immunized household contacts (azithro x5 days)
143
Apnea and pneumonia are common complications of pertussis in infants. This is not true of adults and adolescents. List 2 presentations of pertussis in adults
and adolescents. What is the main reason for instituting a generalized immunization program for pertussis in adolescents?
1. mild URTI symptoms followed by prolonged cough (paroxysms of coughing with inspiratory whoop)
2. immunity from primary series wanes in adolescents so booster protects herd immunity and infants who have not yet been vaccinated
144
You are planning to institute a universal vaccination program in your community. List 4 considerations in planning this program.
- which diseases to target (pick diseases which are a priority for that community, consider disease burden)
- consider if other control measures could be more effective than vaccination for a given disease
- effectiveness of vaccine
- availability of supply of vaccine
- cost of vaccine
- ability of the community to adopt and implement a universal program given available resources
145
A mother has come in with her 12 month old, and is concerned by the “number of shots” that is getting today. She has read in the paper about how is it bad to expose a child to a large number of “antigens” all at once, and is worried about overwhelming his immune system. What advice can you give to help alleviate this motherʼs worries?
- rigorous vaccine safety system (premarket studies and post market active and passive surveillance looking for rare complications)
- children are exposed to many more antigens on a daily basis than they will get from the vaccines (food, bacteria, etc)
- important for safety of child to stay on track with vaccine schedule (highest risk of severe disease when younger)
146
Rotavirus question: what do you tell her regarding vaccine:
a) Protects 95 against rotavirus
b) 75% against all diarrhea
c) Significantly Decreased hospitalizations
d) Decreased virus shedding
c) Significantly Decreased hospitalizations
- 85% efficacy in kids under age 2 years
- decreased incidence of rotavirus hospitalization in areas with immunization programs
- 79% decrease in rota hospitalizations for kids under 1 and 73% decrease for kids 12-23 months in Ontario after vaccine introduced
147
A newborn baby comes in for a routine care visit. In terms of the 13 valent pneumoccocal vaccine, what is the routine schedule for it? (1) - question used to be about 7 valent which is no longer used
Schedule across Canada is 2, 4, 12 months almost everywhere (different in territories)
148
Pregnant woman in contact with meningococcal meningitis. Tx:
a. Cipro
b. Rifampin
c. Ceftriaxone
d. Penicillin
c. Ceftriaxone
- cipro and rifampin would treat it but should not be given to pregnant women
- close contacts should get prophylaxis regardless of immunization status
149
Which of the following is the most common side effect of the varicella vaccine?
a. chickenpox
b. flu-like symptoms
c. herpes zoster
d. fever
d. fever
- pain, redness and swelling at injection site are actual most common side effects
- rash and fever may not appear until up to 2 weeks after the injection
150
Which vaccine is contraindicated in egg allergic patients?
a. Pertussis
b. Influenza
c. Varicella
d. Polio
e. MMR
f. Hib
g. yellow fever
g. yellow fever (not to egg or chicken allergic patients)
* b. Influenza (yes egg but new CPS statement says fine)
- trace amounts of egg protein in flu, MMR, MMRV, rabies vaccines
- intranasal influenza vaccine should not be given to egg allergic patients because there is no safety data
151
All are excluded from day care except:
1. 3 y/o suspect of having scabies
2. pertussis treatment for 2 days
3. shigella day 2
4. campylobacter day 2
5. Hepatitis A after 10 days
5. Hepatitis A after 10 days - exclude for 7 days after onset
- scabies: back once treatment completed
- pertussis: back after 5d antibiotics or 21d from cough if not treated
- shigella: 24h after diarrhea stopped
- campy: if in diapers, no daycare until diarrhea done
152
Which of the following infections would not prevent a child from attending daycare:
a. Chicken pox
b. Impetigo
c. Hepatitis A
d. Hepatitis B
e. Pertussis
d. Hepatitis B
| - impetigo exclude until 24h after treatment started
153
Give 2 examples of patients who should get pneumovax (pneumococcal polysaccharide 23 talent vaccine)
- cyanotic heart disease/CHF
- CLD, including asthma with chronic high dose oral corticosteroids
- DM
- CSF leak, cochlear implant
- functional/anatomic asplenia
- immunocompromise: HIV, chronic renal failure, immunosupp drugs for cancer/AI disease, primary immune deficiency
154
A four year child presents with pertussis. His 3 month old sibling has had her first immunization. What would you do regarding the sibling:
a. treat with erythromycin if she becomes symptomatic
b. isolate from her brother for 5 days
c. treat her with erythromycin for 2 weeks
c. treat her with erythromycin for 2 weeks (is one option; azithro x5d, claritho x7d, TMP-SMX x14d also options)
- continue pertussis vaccination according to routine schedule
155
An 11-month-old child develops nephrotic syndrome and is going to be on prednisone. He has completed his 2, 4, and 6 month immunizations. Which is true regarding
subsequent immunizations:
a) he should continue his regular immunization schedule
b) he should not receive any further immunizations until he has been off prednisone for 2 years
c) he should not receive live-virus vaccines while on prednisone
c) he should not receive live-virus vaccines while on prednisone
- inactivated vaccines can be given during immunosuppressive treatment, but need to be repeated once off as will not mount sufficient immune response
- live vaccines cannot be given as are dangerous to the patient
- common live vaccines: flu, rotavirus, MMR, varicella, BCG
156
An infant born at 31 weeks gestation is now 2 months old, but has never left the hospital. What should be done about the immunizations:
a) delay immunizations until discharge
b) start routine immunization schedule at 8 weeks corrected age
c) give DTaP, hemophilus influenza conjugate, and IPV now
d) give DtaP, hemophilus influenza conjugate, and OPV now
e) give half dose of DTaP and IVP now and repeat in one month
c) give DTaP, hemophilus influenza conjugate, and IPV now
157
A 2 year old child sustains a laceration on the playground. She has not received any immunizations and is otherwise healthy. You clean and suture her laceration. What further
management do you offer:
a. Start tetanus immunization series
b. Tetanus immunization and tetanus immunoglobulin
c. Tetanus immunoglobulin and tetanus anti-toxin
b. Tetanus immunization and tetanus immunoglobulin
158
Pre-splenectomy immunization
a) polysacc meng A+E, polysacc pneumo and hep B
b) hep B, conjugated mening, conjugated pneumo
c) Hep A + B, mening
b) hep B, conjugated mening, conjugated pneumo
| - at least 2 weeks prior to surgery
159
You are trying to set up an infection control program in your hospital. Which intervention will result in the best form of infection control for RSV?
a) Hand wash with soap and water
b) Gown and glove
c) Hand wash with alcohol
d) Isolate everyone with respiratory symptoms
c) Hand wash with alcohol
waterless hand hygiene products save time and improve compliance and are therefore the recommended method of hand hygiene if hands are not visibly soiled
160
List 3 common causes of neutropenia
- transient viral suppression of bone marrow
- drug induced marrow suppression (antipsychotics, antidepressants, some antimicrobials)
- secondary autoimmune (SLE, Crohn's, RA) - destruction by autoantibodies
- chronic benign neutropenia of childhood
161
Neutropenic child with central line site red. Which antibiotic?
Piptazo (for febrile neutropenia) + Vancomycin (for central line infection)
162
Kid has had several infections. What other 4 findings would suggest immunodeficiency?
- persistent thrush
- recurrent abscesses
- failure to thrive
- needing prolonged courses of antibiotics (2 months with little effect)
- family history of immune deficiency
163
Name two organ systems and two organisms that are typically affected by granulocyte defects
1. skin (abscesses, cellulitis), LNs (suppurative adenitis), internal organ abscesses, osteomyelitis
2. staphylococcus, klebsiella, pseudomonas, salmonella, fungi and parasites
164
Description of a child who is having multiple episodes of otitis media and pneumonia. Lab results given are IgG 8 (normal), IgM normal and IgA 0.01 (decreased). What important piece of advice would you warn this child
about?
Selective IgA deficiency
| - at risk of anaphylactic reactions to transfusion of blood products
165
15 year old male immunocompromised in a hot tub afterwards develops folliculitis and enlarged lymph nodes. Name the organism.
hot tub folliculitis - pseudomonas
166
Child post bone marrow transplant. Significant exposure to varicella.
A) What therapy do you give him?
B) What is the time frame for this therapy to be effective?
C) How long do you isolate this patient from other immunocompromised patients?
A) VZIG
B) as soon as possible - ideally within 96 hours but can give up to 10 days after exposure
C) isolate for 28 days after VZIG given
167
A 6-year-old boy with acute lymphocytic leukemia completed a course of chemotherapy 1 month ago. He has a household contact with chickenpox, and he has never had it before. Management:
a) isolate the patient and observe for symptoms
b) IM VZIG
c) IM VZIG + oral acyclovir
d) Admit + IV acyclovir
e) Admit + IM VZIG + IV acyclovir
b) IM VZIG
- no evidence that acyclovir works for immune compromised children (is given prophylactically to immune competent children 7 days after exposure)
- vaccine within 3 days ideally but up to 5 days after exposure for immune COMPETENT people, 12+ months who do not have varicella immunity (no varicella vaccine for immune suppressed people)
168
Teenager with Sickle cell disease presents with cough and fever. CXR shows pneumonia. She looks toxic. What do you treat her with
a) Cefuroxime and eryhtromycin
b) Ceftriaxone and erythromycin
c) Amoxicillin
a) Cefuroxime and eryhtromycin
| - cefuroxime better than ceftriaxone because ceftriaxone can increase hemolysis in sickle cell patients
169
Child with eczema and recurrent pneumonia. Hepatomegaly, petechiae, otitis media
and low platelets. What do you expect?
a. elevated IgA and IgE
b. immune response to polysaccharide vaccine
c. oral Candida
d. abnormal mitogen proliferation
a. elevated IgA and IgE
- poor response to polysaccharide vaccines (important they get conjugate)
- Wiscott-Aldrich
170
Which of the following is not associated with recurrent candida infection:
a. complement deficiency
b. prolonged antibiotic therapy
c. hypoparathyroidism
d. Addison’s disease
a. complement deficiency
- autoimmune polyendocrinopathy type I - presents with chronic mucocutaneous candidiasis, hypopara, adrenocortical insufficiency (Addison's)
- other primary immune deficiencies that present with candida are congenital neutropenia, CGD, leukocyte adhesion deficiency
171
The most common bug in febrile neutropenia:
a. Pseudomonas
b. PCP
c. gram positive organisms
d. candida
c. gram positive organisms
172
Asplenic child, febrile, what organisms do you need to cover with your abx?
a. staph aureus, strep pyogenes, group a strep
b. strep pneumo, h flu, n. meningitides
c. nocardia, aspergillus, etc
b. strep pneumo, h flu, n. meningitides
| * nocardia, aspergillus, etc (cause opportunistic infections in immunocompromised patients)
173
teen girl with sickle cell anemia with evidence of pneumonia, what do you do
a. discharge home on po antibiotic
b. treat with cefuroxime and erythro IV
c. treat with ceftriaxone IV
b. treat with cefuroxime and erythro IV
| - need macrolide since atypicals are common cause of chest crisis
174
Child has Neisseria meningitidis arthritis. Prior history of Neisseria meningitidis meningitis. Which of the following tests could be positive.
a) C3, C4, CH 50
b) CBC diff
c) IgG, IgA, IgM, IgE
a) C3, C4, CH 50
| - people with complement deficiency have 1000X increased risk of acquiring meningococcal disease
175
Management of a child with asplenia:
a) pneumococcal vaccine at 6 months
b) meningococcal vaccine at 2 years
c) antibiotic prophylaxis with daily Septra
d) antibiotic prophylaxis until pneumococcal vaccine given
a) pneumococcal vaccine at 6 months
- PCV13 (prevnar-13) at 2, 4, 6, 12-15 months
- quadrivalent meningococcal conjugate vaccine (MCV4 - menveo) at 2, 4, 6, 12-15 months
- antibiotic prophylaxis (with pen V) until age 5 and 2 years post splenectomy
176
Kid with 1.5X2cm LN in the supraclavicular fossa for a few
days. NO overlying erythema. P/E otherwise normal. Most helpful test?
a. Excise LN
b. Bartonealla Henselae serology
c. Monospot/EBV serology
d. TB skin test
a. Excise LN
| - LN biopsy is contraindicated if there is evidence of overlying infection - rule out leukemia/lymphoma
177
Child with inguinal adenopathy found 1 week ago by parent while bathing. Give 4 indications for biopsy.
- weight loss
- night sweats
- unexplained fevers
- no decrease in size over 4-6 weeks
- increase in size over 2 weeks
- hard or non mobile node
178
Kid with kawasaki disease. Received IVIG and ASA. Now has massive hematuria. Low haptoglobin. GN picture. High bili and LDH and liver enzymes
1) renal vein thrombosis from thrombocytosis
2) hemolysis from iVIG
3) ASA mediated platelet dysfunction
4) Kawasaki mediated Gn
2) hemolysis from iVIG
| - passive transfer of antiA or antiB antibodies in IVIG is a known phenomenon and can cause hemolytic anemia
179
An 8mo old Caucasian child presents to the ER with a 24h history of fever. His temperature is 39.2 degrees. His immunizations are up to date. He has no travel history. He is otherwise asymptomatic. On exam, he is a happy, smiling child with appropriate vital signs aside from the temperature. What is the next best step?
A) Admit for IV antibiotics
B) Do a CBC and blood culture
C) Give a dose of ceftriaxone and discharge home
D) Discharge home with follow-up the next morning
D) Discharge home with follow-up the next morning
- should check a urine culture
- if not immunized need to be more conservative (CBC and culture, abs if WBC >15)
180
A 2 year old presents with a fever for 5 days and soft stools. Urine culture, urinalysis and blood tests are negative. What would be your next investigation?
a) CXR
b) ECHO
c) serology for hep A
d) stool cultures
d) stool cultures
| - 2 year old unlikely to be symptomatic with Hep A
181
12 yo girl presents with >5 days of fever, unwell. Hepatomegaly. HR 85 despite the temperature of 39.5, BP normal. CBC und urine tests normal. Blood culture shows
gram negative bacilli. What is the cause?
a) pyelonephritis
b) ovarian torsion
c) typhoid fever
c) typhoid fever
| - salmonella typhi
182
A 3 year old girl with fever, arthralgia and lethargy for 10 days has lymphadenopathy, moderate hepatosplenomegaly, no obvious arthritis but screams in pain with minimal examination. WBC 9.5 Hgb 98 Plts 140, smear Normal. Next test:
a) bone marrow aspirate
b) EBV titers
c) follow
a) bone marrow aspirate
183
Family comes to you from an area endemic for Lyme disease – What is the organism and vector causing it (2)? What are two antibiotics that are effective against it (2) What are three things to do for prevention if you live in an endemic area (3)
1. borrelia burgdorferi; black legged tick
2. doxycycline, amoxicillin (kids under 8), cefuroxime
3. 20-30% deet to clothes and skin
- shower within 2 hours of coming inside
- full body tick check daily
- landscape to create barriers where play areas adjoin wooded areas
184
Child camping in New Brunswick. Had an expanding skin lesion with central clearing in axilla. Now he has fever, myalgia, malaise and chills but no other symptoms. What is the likely diagnosis. Name 3 systems involved and their specific involvement.
1. lyme disease
2. skin - erythema migrans
- CNS - facial nerve palsy, meningitis, peripheral neuropathy
- heart - lyme carditis, heart block
- rheumatologic - oligoarticular arthritis
185
9 yo immigrated to Canada. NO previous immunizations. What 2 immunizations would you give on first visit?
Tdap-IPV and Men-C (kids 7-17)
186
7 month old child has recently been adopted from another country. All immunizations are up to date. Should you vaccinate against meningitis? (1) If so, what would you use and what schedule (2 lines)
1. Yes should vaccinate
2. give Meningococcal conjugate vaccine for serotype C at 12 months of age (some recommend to not trust vaccine documentation and start from scratch using catch-up vaccine schedule)
187
A 7 year old child has just returned to Canada from sub-Saharan Africa. She has fever and chills. List 3 common causes of her symptoms.
- malaria
- typhoid fever
- dengue fever
- viral illness
188
A teenage girl presents with a one week history of periumbilical pain, fever of 39.2 degrees. She has just returned from a trip to Pakistan. She looks unwell and a blood C&S shows gram negative rods. Despite her fever and condition her HR is only 85. Which antibiotic will you treat her with:
a. Ciprofloxacin
b. Gentamicin
c. Metronidazole
d. Penicillin
a. Ciprofloxacin
- treat empirically with ceftriaxone or fluoroquinolone
- IV antibiotics x minimum 14 days for uncomplicated typhoid fever
189
```
Child recently visited farm, presents with high fever, hepatosplenomegaly and pneumonia
a. legionella
b . Q fever
c . cat scratch
d. Psittacosis
```
ANSWER: b . Q fever (goat, sheep, cattle) - coxsiella burnetti (gram negative)
- treatment decreases duration and severity
a. legionella (usually contaminated water)
c . cat scratch (cat bite/scratch, kittens, HSM can occur)
d. Psittacosis (usually caged birds)
190
8 year old girl with fever, nausea, vomiting, diarrhea, malaise and mild jaundice upon returning from Mexico. Labs show AST >1,000. Which of the following is true
regarding her return to school/day care?
a. she can’t return for 1 week
b. she can’t return until she’s feeling better
c. she can return if everyone is toilet trained
d. as long as they wash their hands there, she can go back immediately
a. she can’t return for 1 week
| Hep A - out of school for 7 days
191
```
A 6 year old presents with an erythematous lesion on the back and arthritis. He has been camping with his family recently in the U.S. You diagnose Lyme disease. What
should he be treated with?
a) PO doxycycline
b) IV ceftriaxone
c) PO amoxicillin
```
c) PO amoxicillin
- under 8 - amox, 8+ - doxycycline
- IV treatment for heart block, carditis, meningitis or encephalitis
192
Newborn to a mum who has recently come from Vietnam. Her Hepatitis B status is unknown however her serology results will be back in two days. What do you do with
infant?
a) immunize with Hep B vaccine and if results from mum are positive, give Hep B IG at that time
b) Immunize with hep B vaccine and hep B IG now
c) Hep B IG now
d) HBIG now and Hep B vaccine later if mum positive
a) immunize with Hep B vaccine and if results from mum are positive, give Hep B IG at that time
- Hep B vaccine should be given within 12 hours of birth
- HBIG ideally within 12 hours, but within 7 days acceptable if waiting for mom's results
193
List 4 other signs of endocarditis in a child with a fever, murmur, tachycardia and hepatospenomegaly.
- conjunctival hemorrhage
- janeway lesions (non tender macules on fingers and soles)
- osler nodes (painful lesions on hands and feet)
- glomerulonephritis
- splinter hemorrhages
194
GBS positive mom.11 days old. On TPN from peripheral line. Three attempts at obtaining central access failed.In a tertiary care center. Now is septic. Culture shows gram positive cocci in clusters. What is the bug? What is the treatment
1. staph aureus (or coagulase negative staph)
| 2. vancomycin
195
What are four clinical signs that would be considered a contraindication for a lumbar puncture?
- infection of skin over intended LP site
- spinal deformities
- bulging fontanelle
- focal neurologic deficit
- cardioresp instability
- signs of bleeding diathesis (e.g. petechiae)
196
Child previously treated with course of Amox for otitis media. Then presents signs of meningismus irritability and lethargy. LP high protein low sugar high WBC count. No
organisms on gram stain. Gave one dose of ceftriaxone. Defervesced after dose. Doc calls you because culture has come back negative. What is the likely diagnosis. How would you tell the Doc to proceed
1. culture negative bacterial meningitis
2. will need treatment with IV antibiotics (ceftrixone empiric usage, depends on local susceptibilities, may need vanco also - strep pneumo resistance) for 2-3 weeks
3. recommend consult ID
197
5 year old immigrant from Pakistan. Drooling with SOB and dysphagia. Lateral Neck. (thumb sign) What organism is the likely cause? How would you manage this patient?
1. hemophilus influenza B (epiglottitis)
2. keep patient as calm as possible, call ENT and anesthesia to intubate, needs IV antibiotics but if kid is going to freak out with IV insertion wait until airway secured
- abx: ceftriaxone and vanco (for staph coverage)
198
Description of child with Necrotizing fasciitis lower leg- some respiratory distress. Already started IV fluids and oxygen. 5 additional things in the management.
- abx: piptazo + vanco (MRSA) + clinda (antitoxin effect)
- consult surgery - exploration and debridement
- pain control (morphine)
- anticipate multiorgan failure (watch U/O, BP, may need pressors)
- blood cultures
- consult ID, consider IVIG
199
Nephrotic syndrome has peritonitis what is most likely org:
a) Strep pneumo
b) Ecoli
c) Enterococus
d) B fragilis
a) Strep pneumo
| - increased risk of infection with encapsulated bacteria (since lose complement and immunoglobulins)
200
What are three high risk groups for invasive pneumococcal disease (3)
- functional asplenia
- structural asplenia
- humoral immune deficiency
- HIV
- DM
- chronic renal failure
- cochlear implants, CSF leak
201
How do you confirm the diagnosis of endocarditis?
- positive blood culture and vegetations on echo (these are the 2 major criteria - if have both can make diagnosis)
- also, 1 major and 3 minor OR 5 minor (Duke criteria)
202
A 4-month-old septic child. CSF gram stain shows GPC. Initial antibiotic therapy:
a) Ampicillin + Gentamycin
b) Ampicillin + Cefotaxime
c) Ceftriaxone
d) Ceftriaxone + Dexamethazone
e) Cefotaxime + Vancomycin
e) Cefotaxime + Vancomycin
| - third generation cephalosporin + vanco for resistant strep pneumo (which is a gram positive coccus)
203
3 week child with suspected meningitis. Initial antibiotics?
Ampicillin and cefotaxime (amp for gram positive coverage, cefotax for gram negative coverage - gent does not have good CNS penetration)
204
With respect to steroid use in bacterial meningitis:
a) little is know about its effect
b) needs to be given within 30 minutes of first dose of antibiotics
c) helps the antibiotics penetrate the brain
d) reduces incidence of hearing loss following infection
d) reduces incidence of hearing loss following infection
- should be given before first dose of antibiotics, at same time or within 30 minutes
- decreases hearing loss with Hib, and maybe strep pneumo
- continue if culture positive for Hib or s pneumo
205
What is true regarding the spread of meningococcal disease:
a) household contacts are at greater risk than school contacts
b) penicillin is the drug of choice for prophylaxis
c) Neisseria meningitidis type B vaccine is use to prophylax against school outbreaks
d) healthcare workers should be routinely immunized against Neisseria meningitides
e) a negative NP swab will determine whether or not to treat exposed individuals
ANSWER: a) household contacts are at greater risk than school contacts
- prophylaxis with rifampin, ceftriaxone or cipro
- mening B vaccine used for lab and military personnel, not routine for school outbreaks
- decision to treat exposed individuals is based on risk of exposure, not cultures
206
A child is brought to ER very unwell. She has a preceding sore throat, headache and fever. She is beginning to have a purple rash that doesn’t blanche. How do you prophylaxis her family?
a. Penicillin
b. Ceftiaxone
c. Rifampin
c. Rifampin
| - can also use ceftriaxone and cipro
207
A child has been receiving IV Penicillin for meningococcemia for the past 7 days. He has now developed a warm swollen right knee. What should be done:
a) provide NSAIDs
b) add a second antibiotic
c) change to a different antibiotic
d) aspirate and culture
e) bone scan
a) provide NSAIDs
- allergic immune complex mediated arthritis (also vasculitis, pericarditis, episcleritis)
- self limiting, occurs in first 10 days of disease onset
- good response to NSAIDs
- child with menigococcal disease who develops fever after 5 days on antibiotics - investigate for immune complex medicated disease
208
A 10-year-old who underwent recent dental surgery now presents with fever, arthralgias, splenomegaly, and lesions on the hands and feet.
a) septic emboli
b) subacute endocarditis
c) acute rheumatic fever
d) juvenile rheumatoid arthritis
e) coxsackie virus
b) subacute endocarditis
209
3 year old child, 2-3 day history of viral prodrome, sudden onset this morning of stridor, temperature of 40 degrees. In your ED is anxious but not drooling and very stridorous. There is no significant change with one dose of neb racemic epinephrine. What is the most likely diagnosis:
a. Croup
b. Bacterial tracheitis
c. Retropharyngeal abscess
b. Bacterial tracheitis
| - high fever, toxic appearance, poor response to nebulized epi
210
Kid with varicella, now has a deep bluish lesion to his leg, very painful, looks unwell, high fever. What antibiotics do you start?
a. penicillin, clindamycin
b. pipercillin, tazobactam
c. ampicillin, cefotaxime
d. vanco, cefotaxime
a. penicillin, clindamycin - good if documented GAS
- varicella gangrenosa (necrotic lesions)/necrotizing fasciitis
- other abs regimens: vanco + pip/tazo or ceftriaxone + flagella
211
Adolescent with ascending leg weakness and areflexia. Which of the following infectious agents would you worry about:
1. Campylobacter jejuni
2. E Coli
3. Yersinia
4. Cryptosporidium
5. Shigella
1. Campylobacter jejuni
| - GBS
212
2 mo baby comes in with meningitis and focal seizure. Symptoms of shock described. GCS 6. What is the FIRST step in management?
a) Culture and antibiotics
b) Intubation
c) CT
d) LP
b) Intubation
213
What are 3 major criteria for staph toxic shock?
- fever (T>38.8)
- hypotension
- eryrthroderma rash
214
Premature baby. You are counseling mom about the risks of Transfusion. Which infection is the highest risk:
a) HIV
b) HEPB
c) CMV
d) HepC
b) HEPB
- HIV 1/8-12 million
- Hep C 1/5-7 million
- Hep B 1/1.1-1.7million
- should request CMV negative blood for premature baby
215
A child diagnosed 14 days ago with Hepatitis A and is currently symptomatic. What to do with family members?
1. Hyperimmume immune globulin against Hepatitis A
2. Hepatitis A vaccine
3. No treatment
4. Antibiotic prophylaxis
2. Hepatitis A vaccine
- hep A vaccine for pre-exposure protection (e.g. travelling to endemic area)
- hep A vaccine equal effectiveness to Ig within 2 weeks of exposure; serologic testing not recommended
216
Young child with periorbital edema and diarrhea. His albumin is 12. What is your differential diagnosis (4)?
- infectious diarrhea (parasitic infection)
- cow's milk protein intolerance
- food protein induced enterocolitis syndrome
- IBD
- HUS
217
Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash . What is his diagnosis?
HUS
218
Teenage girl with a history of ulcerative colitis, status post
total colectomy. Had a “J- pouch” and an anal pull-through ostomy that was later removed. Did have an ileostomy, but that was closed following an end-to-end anastomosis. Now she presents with a 5-day history of bloody diarrhea 8 times per day. Stool cultures are all negative. What is the diagnosis? What 1 treatment would be the best?
1. pouchitis - chronic inflammatory reaction in pouch leading to bloody diarrhea, abdo pain, and sometimes low grade fever
2. PO metronidazole or Ciprofloxacin X 14 days
