International trak

International trak PREP

PREP 2004-21 • During the health supervision visit of a 3-year-old boy, his mother states that she recently was diagnosed as having active tuberculosis based on the results of a tuberculin skin test (TST) and chest radiography. Her tuberculosis is isoniazid-sensitive, and she is being treated appropriately. You perform a TST on the child, which is negative, and obtain a chest radiograph, which appears normal.

PREP 2004-21 • Of the following, the MOST appropriate management of this child is • A- No treatment • B- Separation from the mother for 4 weeks • C- Treatment with bacillus Calmette-Guérin (BCG) vaccine • D- Treatment with isoniazid and repeat TST after 12 weeks • E- Treatment with isoniazid for 9 months

PREP 2004-21- Explanation • Once clinical disease is excluded, any child or adult exposed to a potentially contagious case of tuberculosis within the past 3 months should receive a tuberculin skin test (TST) and chest radiograph as well as isoniazid therapy, even if the TST result is negative. This is especially true for contacts who have impaired immunity and all household contacts younger than 4 years of age exposed to any adult who has active tuberculosis

2004-105 • A 4-year-old girl, born and raised in the United States, has had a skin test with tuberculin purified protein derivative (PPD) placed as part of a preschool enrollment requirement. Seventy-two hours later there is 8 mm of induration. The child has been well and has no exposure or other risk factors for tuberculosis

2004-105 • Of the following, the MOST likely explanation for the induration is • A- a connective tissue disorder • B- cross-reactivity with nontuberculous mycobacteria • C- hypersensitivity to preservative in the PPD • D- previous bacillus Calmette-Guérin vaccination • E- recently acquired tuberculosis

2004-115 • A 5-year-old girl is referred to your clinic for evaluation of her tuberculin skin test. She had a Mantoux test containing 5 tuberculin units of purified protein derivative placed intradermally 48 hours ago. Evaluation of the test demonstrates 18 mm of induration. She moved to the United States 3 years ago and was immunized with bacillus Calmette-Guérin (BCG) vaccine at birth. Findings on chest radiography are negative.

2004-115 • Of the following, the MOST appropriate management is • A evaluation of three early morning gastric aspirates • B initiation of therapy with isoniazid alone • C initiation of therapy with isoniazid, rifampin, and pyrazinamide • D repeat of skin test in 3 months • E to consider this a false-positive test

2004-163 • Your colleague recently was prescribed isoniazid therapy due to a tuberculin skin test conversion accompanied by negative results on chest radiography

2004-163 • Of the following, the BEST policy for the clinic is to • A allow your colleague to work with no restrictions • B inform all patients of your colleague's infection • C initiate isoniazid therapy in all office contacts • D prohibit your colleague from providing patient care for 3 months • E require your colleague to wear a mask for the first 2 weeks of therapy while providing patient care

2004-195 • Of the following, the BEST direct stain to detect Mycobacterium tuberculosis is the calcofluor white stain • A calcofluor white stain • B Giemsa stain • C Gram stain • D Kinyoun stain • E periodic acid-Schiff stain

2004-195 • Two types of acid-fast stains are available for detecting mycobacterial organisms: Kinyoun (cold stain) and Ziehl-Neelsen (hot stain). With the use of either stain, mycobacterial organisms appear as bright red-staining rods against a blue background. The calcofluor white and periodic acid-Schiff stain are used to diagnose fungal disease. The Giemsa stain is used to detect blood parasites or fungi in tissues, and the Gram stain is for detection of routine aerobic or anaerobic bacteria. The most important laboratory tests for the diagnosis of tuberculosis are the acid-fast stains (Kinyoun, Ziehl-Neelsen) and mycobacterial culture. Because children who have tuberculosis rarely exhibit cavitary lesions on chest radiography and usually do not have a productive cough, sputum cultures for mycobacterial organisms are not helpful. The best culture specimen in a child is three early morning gastric aspirates obtained before the child has risen. Early morning gastric aspirates have a better yield than does bronchoscopy. Unfortunately, even under optimal conditions, the organism is recovered in fewer than 50% of cases. When this occurs, drug susceptibility testing of the source case can be used to direct antimicrobial therapy for the child

2004-218 • A 6-year-old boy presents with a 24-hour history of fever, malaise, and bruising. Physical examination reveals an ill-appearing child whose temperature is 103.1°F (39.5°C). He has widespread petechiae and areas of palpable purpura (Figure Q218A), especially on the buttocks and lower extremities. The hemoglobin is 10.5 g/dL (105 g/L), white blood cell count is 18.5 x 103/mcL (18.5 x 109/L), and platelet count is 25 x 103/mcL (25 x 109/L

2004-218 • Of the following, the MOST likely diagnosis is • A Henoch-Schِnlein purpura • B idiopathic thrombocytopenic purpura • C Lyme disease • D meningococcemia • E Rocky Mountain spotted fever

2004-229 • A 2-year-old girl whose parents are migrant farm workers presents with a 10-day history of vomiting, increasing lethargy, and altered consciousness. She had been healthy prior to this illness, experiencing normal growth and development. Her immunizations are up to date. On physical examination, she is afebrile, but lethargic. Laboratory evaluation reveals a white blood cell count of 12 x 103/mcL (12 x 109/L), with a differential count of 50% neutrophils, 42% lymphocytes, and 8% monocytes. Electrolyte concentrations are normal, except for a sodium level of 124 mEq/L (124 mmol/L) and a chloride level of 91 mEq/L (91 mmol/L). Head computed tomography reveals diffuse meningeal enhancement and hydrocephalus. A lumbar puncture reveals 25 white blood cells per high-power field (all monocytes), glucose of 25 mg/dL (1.4 mmol/L), and protein of 10 g/dL (100 g/L

2004-229 • Of the following, the MOST likely cause for this patient's meningitis is • A enterovirus infection • B meningococcus infection • C pneumococcus infection • D syphilis • E tuberculosis

2004-243 • A 7-year-old boy was bitten by a raccoon while he was camping with his family 3 days ago. His mother is concerned about her child developing rabies

2004-243 • Of the following, the MOST appropriate next step is to • A administer human rabies immunoglobulin (RIG) • B administer human rabies vaccine • C administer human rabies vaccine and human RIG • D attempt to capture the raccoon to observe it for signs of rabies • E reassure the mother that no treatment is indicated

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