Board Review

UTI and GI infections

 Question 1:
A 78-year-old woman undergoes routine evaluation. She has been feeling relatively well but experiences
occasional urinary incontinence when she coughs, sneezes, or laughs. Medical history is significant for
hypertension. Medications are chlorthalidone and lisinopril. On physical examination, vital signs and other
physical examination findings are normal.

On dipstick urinalysis, urine is yellow and clear, specific gravity is 1.010, pH is 7.0, and moderate leukocyte
esterase and nitrites are present; the urinalysis is negative for blood or glucose but 2+ for bacteria.

Which of the following is the most appropriate management?

A. Ciprofloxacin

B. Cystoscopy

C. Microscopic urinalysis

D. Urine culture and sensitivity

E. No further investigation or treatment

 Answer: E
Key Point : No treatment is indicated for asymptomatic bacteriuria in otherwise healthy, nonpregnant patients.

No treatment or further investigation is indicated in this asymptomatic older woman who has bacteriuria discovered on a routine dipstick
urinalysis. Although commonly performed, analysis of the urine is not warranted, except when evaluating a patient who presents with clear
signs or symptoms of a urinary tract infection (UTI), and may lead to unnecessary administration of antibiotics. Incontinence without urgency or
dysuria is not unexpected in many older women. The prevalence of asymptomatic bacteriuria (ASB) is as low as 1% to 5% in healthy
premenopausal women (2%-10% in pregnant women) and up to 100% in patients with long-term indwelling urinary catheters. However, most
ASB occurs in older adult women and men, with a respective prevalence of 11% to 16% and 4% to 19% in the community, increasing to 25% to
50% and 15% to 40% in long-term care facilities. Except in specific patient groups, well-designed studies have proven that although persons
with bacteriuria are at increased risk for symptomatic UTIs, ASB treatment does not decrease the frequency of symptomatic infections or
improve other outcomes. ASB is associated with a higher prevalence of potentially dangerous antibiotic-resistant strains in women who
progress to an active UTI. Except in pregnant women, who have a known increased prevalence of ASB, which has been demonstrated to lead to
serious complications, routine screening for infection in women without symptoms is unwarranted. Screening and treatment are also indicated
before invasive urologic procedures. The presence of pyuria accompanying ASB is not an indication for antimicrobial treatment.

This patient does not require treatment for her asymptomatic bacteruria; additionally, fluoroquinolone antibiotics are no longer recommended
for the treatment of symptomatic lower UTIs because of the significant rise in Escherichia coli isolates resistant to this class of agents.

Cystoscopy is recommended in the evaluation of microscopic hematuria for all patients older than 35 years or those with risk factors for
urologic malignancy. Cystoscopy would possibly be warranted in patients with recurring symptomatic UTIs but is not indicated in this patient.

Culture and sensitivity testing as well as microscopic urinalysis are not necessary in women presenting with classic lower UTI symptoms,
including frequency, urgency, and dysuria, without manifestations of systemic or upper tract disease. Urinalysis and urine culture are not
indicated as part of routine health surveillance in asymptomatic patients and should not be performed. They are not necessary in this patient
with asymptomatic bacteruria.
 Question: 2
A 24-year-old woman is evaluated for cystitis symptoms of 4 days' duration. She reports no fever, chills,
flank pain, or vaginal discharge. She has had similar symptoms three times within the past 10 months.
She has been treated each time with trimethoprim-sulfamethoxazole at an urgent care center. The last
episode was 5 weeks ago. She has sexual intercourse infrequently. Her only medication is an oral
contraceptive.

On physical examination, vital signs and other findings are unremarkable.

On microscopic urinalysis, leukocytes are too numerous to count, erythrocyte count is 10/hpf, 4+ bacteria
are present, and rare squamous epithelial cells are seen.

Which of the following is the most appropriate management?

A. Nitrofurantoin

B. Trimethoprim-sulfamethoxazole

C. Urine culture plus ampicillin

D. Urine culture plus cefpodoxime

E. Urine culture plus ciprofloxacin

 Answer: E
Key Point: Ciprofloxacin and levofloxacin are the preferred antimicrobial agents for the treatment of recurrent cystis when trimethoprim-
sulfamethoxazole local resistance rates are high or the patient has been treated with an antibiotic for a urinary tract infection within the
previous 3 months.

The most appropriate management of this patient is urine culture plus ciprofloxacin. This young woman has a classic presentation and
typical dipstick urinalysis findings of a lower urinary tract infection (UTI). Urine cultures are not generally necessary to confirm the
diagnosis; however, culture and susceptibility testing are indicated when infection is recurrent. Recurrent UTI is defined as three
episodes of UTI in the preceding 12 months or two episodes in the preceding 6 months. Recurrent UTI is common in women. A recurrent
UTI may be a relapse or reinfection. Relapse is defined as an infection caused by the same strain (by repeat culture) as the initial UTI
and occurs within 2 weeks of completing initial therapy. Reinfection is diagnosed if the UTI is caused by a different strain than that
causing the initial infection or if a sterile urine culture was documented between episodes. Most recurrences are reinfections. While
awaiting results, she should begin empiric treatment with ciprofloxacin twice daily for 7 days. Although fluoroquinolone antibiotics are
no longer recommended as first-line agents for the treatment of cystitis because of increasing concerns for potential adverse effects
and uropathogen antimicrobial resistance development, ciprofloxacin and levofloxacin are the preferred antimicrobial agents when
trimethoprim-sulfamethoxazole local resistance rates are high (>20%) or the patient has been treated with an antibiotic for a UTI within
the previous 3 months. Having recently received antibiotics defines this patient's UTI as complicated, warranting 7 to 10 days of
treatment with a fluoroquinolone antibiotic.

Nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, and oral β-lactams are not recommended as first-line empiric oral therapy in
complicated cystitis because of concerns regarding resistance to these agents. In the case of culture-proven sensitivity, these agents
can be used in the treatment of complicated UTI.

Ampicillin and amoxicillin are no longer acceptable UTI treatment options because more than one third of community-acquired
Escherichia coli harbor resistance to this agent.
Question: 3
A 38-year-old woman undergoes follow-up evaluation in the office. She was evaluated in the emergency
department 3 nights ago with fever and flank pain following 2 days of dysuria. A urine culture and two
sets of blood cultures were collected. She was given intravenous ceftriaxone and discharged with a 7-
day course of ciprofloxacin. She is now asymptomatic. Medications are ciprofloxacin and an oral
contraceptive.

On physical examination, vital signs and other findings are normal.

Escherichia coli susceptible to ciprofloxacin was isolated from her urine culture and one blood culture.

Which of the following is the most appropriate management?

A. Completion of oral ciprofloxacin course

B. Completion of oral ciprofloxacin course with follow-up blood cultures

C. Extended oral ciprofloxacin therapy for 2 weeks

D. Kidney ultrasonography

E. Intravenous ceftriaxone
Answer: D
Key Point: Acute, uncomplicated pyelonephritis can usually be managed with oral outpatient antimicrobial therapy, with the
fluoroquinolones ciprofloxacin and levofloxacin being the preferred, first-line agents

This patient should complete her prescribed 7-day course of oral ciprofloxacin. She has acute uncomplicated
pyelonephritis, which can usually be managed with outpatient oral antimicrobial therapy. Ciprofloxacin for 1 week or
levofloxacin for 5 days are the recommended first-line treatment regimens. An initial dose of a long-acting parenteral
antibiotic (such as ceftriaxone or aminoglycoside) is suggested when local fluoroquinolone resistance (>10%) is a concern.
When a fluoroquinolone antibiotic cannot be used or the bacterial isolate proves resistant, an alternative second-line oral
antibiotic should be substituted. Available options include trimethoprim-sulfamethoxazole or the less well-studied oral β-
lactam agents.

With the exception of pregnancy, follow-up microbiologic cultures and urinalysis are not required or indicated after
resolution of infection.

Extending the duration of ciprofloxacin therapy beyond 7 days would be warranted for complicated pyelonephritis but
should not be influenced by the discovery of the single bloodstream isolate in this otherwise healthy woman.

Transient bacteremia does not necessitate hospitalization for parenteral antimicrobial therapy except when the pathogen is
found to be multidrug resistant or when complicating features are present (severe illness, obstruction, pregnancy).

In adult women with acute kidney infections, urinary tract imaging by ultrasonography or CT is not routinely performed.
However, urologic imaging may be useful and is recommended in evaluating patients who do not clinically improve after
72 hours of adequate antimicrobial therapy or when complications such as obstruction or perinephric and renal abscesses
are suspected. Such studies should also be considered when evaluating women who experience an excessive number of
Question: 4
A 19-year-old man is evaluated for multiple episodes of nonbloody diarrhea, fever, occasional vomiting,
malaise, and crampy abdominal pain that began yesterday. He is a college student who adopted a pet corn
snake 2 months ago; the snake is healthy.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 110/60 mm Hg, pulse rate is
100/min, and respiration rate is 19/min. He appears to be in mild distress. On abdominal examination,
bowel sounds are present, as is tenderness to palpation. No rebound or guarding is noted. Stool testing for
occult blood is positive.

Which of the following is the most likely cause of this patient's diarrheal illness?

A. Chlamydia Psittaci
B. Erysipelothrix Rhusiopathiae
C. Mycobacterium Marinum
D. Nontyphoidal Salmonella species
Answer: D
Educational Objective: Diagnose nontyphoidal Salmonella infection.

● Key Point: Nontyphoidal Salmonella is commonly carried asymptomatically by reptiles and amphibians and transferred from the animals' feces to
people; human symptoms include crampy abdominal pain, fever, nonbloody diarrhea, and vomiting.
● The most likely diagnosis is nontyphoidal Salmonella infection. This patient's fever and nonbloody diarrhea are most likely caused by nontyphoidal
Salmonella, with infection resulting from contact with a colonized snake. Nontyphoidal Salmonella infection usually results from ingesting fecally
contaminated water or food of animal origin, including poultry, beef, eggs, and milk. Intestinally colonized reptiles and amphibians are asymptomatic
and intermittently shed the organism in their feces, creating the potential for fecal-oral route transmission. Handling infected snakes, turtles,
iguanas, frogs, or toads or anything in the enclosures in which they live can result in infection . Surfaces contaminated by feces may also serve as
a source of infection. The incubation period is usually less than 3 days, and symptoms typically include crampy abdominal pain, diarrhea (not usually
visibly bloody), fever, headache, nausea, and vomiting.
● Infection with Chlamydia psittaci is typically acquired by inhaling the organism in feces from a pet bird. The incubation period is about 1 week and
the clinical presentation usually consists of chills, dry cough, fever, headache, and myalgia. Diarrhea may be present but is much less common.
Chest radiograph abnormalities are common.
● Erysipelothrix rhusiopathiae is a bacterium that infects animals such as fish, swine, and poultry. Human infection is usually occupationally acquired in
butchers, fish handlers, and veterinarians. Localized cutaneous violaceous lesions of the fingers and hands are a classic finding, although more
diffuse cutaneous infections, bacteremia, and even infective endocarditis can develop.
● Mycobacterium marinum is a nontuberculous mycobacterium found worldwide in freshwater and saltwater aquatic environments. Skin infections
result from skin trauma and contact with fish tanks (“fish tank granuloma”), fish, or shellfish. Persons predisposed to infection include aquatic sports
enthusiasts, fish tank owners, fishermen, and seafood workers. The clinical course is often insidious, manifesting initially as a violaceous or
erythematous papule or nodule at the site of inoculation, which may ulcerate. Lesions may be solitary or multiple; occasionally a sporotrichoid
distribution along lymphatic vessels may develop. M. marinum does not cause diarrhea.
Question 5
A 25-year-old woman is evaluated for chronic intermittent nonbloody diarrhea with associated abdominal
cramping, burping, and bloating. Symptoms began several months ago. She has a history of selective IgA
deficiency with recurrent sinopulmonary infections. She has not taken antibiotics in the past 6 months.

On physical examination, temperature is 37.3 °C (99.1 °F); the vital signs are otherwise normal. On
abdominal examination, bowel sounds are present with minimal diffuse tenderness to palpation. Stool
testing for occult blood is negative.

Which of the following is the most likely cause of this patient's diarrheal illness?

A. Clostridium difficile
B. Enterohemorrhagic E. Coli
C. Giardia Lamblia
D. Listeria Monocytogenes
E. Nontyphoidal Salmonella
Answer: C
Educational Objective: Diagnose Giardia lamblia infection.

● Key Point: Patients with selective IgA deficiency are susceptible to Giardia lamblia infection, manifesting as abdominal cramping, bloating, and chronic
diarrhea.
● This patient with selective IgA deficiency most likely has chronic diarrhea due to a Giardia lamblia infection. Typical symptoms of Giardia include watery
diarrhea that is fatty and foul smelling, bloating, crampy abdominal pain, flatulence, and nausea; fever is uncommon. In immunocompetent
hosts, Giardia infection symptoms typically resolve within 2 to 4 weeks, but in patients with humoral immunodeficiency, such as hypogammaglobulinemia
or selective IgA deficiency, Giardia infection may be prolonged because of impaired protection against Giardia adherence to the intestinal epithelium.
Patients with selective IgA deficiency have impaired humoral immunity but no impairment in neutrophil, T-cell, or complement function. Infectious
complications of selective IgA deficiency typically include recurrent respiratory tract infections and chronic diarrhea caused by Giardia.
● Although Clostridium difficile can cause recurrent disease, this patient does not have a history of recent antibiotic use or any other risk factors for C.
difficile infection such as advanced age, chemotherapy, gastrointestinal surgery, inflammatory bowel disease, or gastric acid suppression with proton
pump inhibitors.
● Enterohemorrhagic Echerichia coli (EHEC) infection is usually spread by ingestion of undercooked meat or fecally contaminated food. EHEC typically
presents with bloody acute diarrhea, crampy abdominal pain, and no fever.
● Listeria monocytogenes can cause an acute gastroenteritis syndrome associated with diarrhea, emesis, fever, headache, and nonbloody watery diarrhea
associated with pain in muscles and joints. But such an infection typically lasts less than 2 days. Invasive complications of infection, including bacteremia
and meningitis, are seen in conditions primarily associated with cell-mediated immune dysfunction such as pregnancy, use of glucocorticoids, and
extremes of age (neonates or those older than 65 years).
● Nontyphoidal Salmonella is the most common cause of foodborne illness. Infection usually results from ingesting fecally contaminated water or food of
animal origin. Symptoms are typically self-limited and include crampy abdominal pain, fever, headache, nonbloody diarrhea, nausea, and vomiting.
Severe invasive disease may occur in patients with cell-mediated immunodeficiency, but the clinical presentation is not significantly altered in selective
IgA deficiency.
Question 6:
An 18-year-old man is evaluated for a 4-day history of frequent, large-volume diarrhea, with associated
abdominal cramping, emesis, fever, and nausea. He is a lifeguard at a freshwater municipal pool, and
several other swimmers who use the pool have recently developed similar symptoms. On physical
examination, temperature is 37.5 °C (99.5 °F); the vital signs are otherwise normal. On abdominal
examination, bowel sounds are present, palpation elicits minimal tenderness, and no guarding or rebound
is noted.

Modified acid-fast staining of the stool reveals oocysts that are about 5 microns in diameter.

Which of the following is the most likely cause of this patient's diarrhea?
A. Cryptosporidium
B. EHEC
C. Norovirus
D. Nocardia
E. Vibrio Parahemolyticus
Answer: A

Educational Objective: Diagnose Cryptosporidium infection.

● Key Point: The protozoan Cryptosporidium is the most common cause of swimming pool–related outbreaks of diarrhea; diagnosis is made by
microscopic examination of the stool or by stool antigen testing.
● This patient has watery diarrhea associated with swimming pool exposure, and the oocysts observed microscopically represent Cryptosporidium.
This parasitic protozoan is tolerant to chlorine and can persist for days in a chlorinated pool. Cryptosporidium has become the leading cause of
swimming pool–related outbreaks of diarrheal illness. Swallowing infected water can result in infection. The incubation period is about 1 week,
and the clinical presentation typically includes watery diarrhea, crampy abdominal pain, dehydration, fever, malaise, nausea, vomiting, and
weight loss. The infection typically resolves in immunocompetent persons, but infection can be more serious and prolonged in those with
immunocompromise, particularly in persons with AIDS who are not receiving combination antiretroviral therapy. Diagnosis can be established
microscopically by visualization of oocysts with modified acid-fast staining. Because oocysts are shed intermittently, diagnosis may require stool
antigen testing using polymerase chain reaction, enzyme immunoassay, or direct fluorescent antibody testing.
● Although enterohemorrhagic Escherichia coli (EHEC) infection can be acquired by aspiration of contaminated swimming pool water, it typically
produces bloody diarrhea. EHEC is a gram-negative rod that does not exhibit modified acid-fast staining.
● Norovirus is the most common cause of gastroenteritis and is characterized by explosive vomiting and diarrhea. It is spread person to person
through the fecal-oral route, leading to community outbreaks. But the virus is not visualized with modified acid-fast staining. A diagnostic assay
for viral gastroenteritis with polymerase chain reaction testing is reserved for public health investigation.
● Modified acid-fast staining can detect Nocardia species, but the organisms are filamentous branching rods. Infection usually involves the lungs,
central nervous system, and skin, but not the gastrointestinal tract.
● Vibrio parahaemolyticus lives in salt water and causes diarrhea, usually after consumption of undercooked shellfish, especially oysters. This
gram-negative rod is not detected with a modified acid-fast stain and requires special culture media with high salt content for growth.
Question 7:
A 46 y/o woman is hospitalized with pyelonephritis and receives empiric ceftriaxone. Medical history
is significant for two urinary tract infections in the previous 15 months treated with ciprofloxacin;
her last infection 3 months ago was caused by Escherichia coli resistant to ampicillin and
cephalexin. She takes no other medications.
On physical examination, temperature is 38.4 °C (101.2 °F), blood pressure is 105/70 mm Hg, pulse
rate is 106/min, and respiration rate is 21/min. She has left flank tenderness to palpation.
Urine culture reveals more than 105 cfu/mL of E. coli sensitive to cefepime, ertapenem, and
fosfomycin and resistant to ceftriaxone, ceftazidime, and cefotaxime. Blood cultures grow gram-
negative rods. Ceftriaxone is discontinued. What is the most approrpirate treatment?

A. Cefepime
B. Colistin
C. Ertapenem
D. Fosfomycin
Answer: C
Educational objective: multidrug resistance

● Ertapenem is the most appropriate treatment (Option C). This patient has pyelonephritis caused by extended-spectrum β-
lactamase (ESBL)–producing Escherichia coli suggested by the antibiotic susceptibility pattern demonstrating resistance to
oxyimino-β-lactam substrates (e.g., cefotaxime, ceftazidime, ceftriaxone). Laboratory identification of ESBLs is difficult because
they are a heterogeneous group of enzymes. ESBL-producing gram-negative organisms are capable of hydrolyzing higher
generation cephalosporins that have an oxyimino side chain such as cefotaxime, ceftazidime, ceftriaxone, and cefepime . The
carbapenem class of antibiotics (imipenem, meropenem, doripenem, ertapenem) is the preferred group of agents for treating
infections with ESBL-producing organisms. Ertapenem has an advantage over the other carbapenems with once-daily oral dosing,
but some ESBL-producing organisms are resistant to it.
● An oxyimino cephalosporin (e.g., cefepime) (Option A) should not be used even if an ESBL-producing organism appears to be
susceptible through laboratory testing. Treatment failures are common, even with higher doses.
● Colistin (Option B) is generally reserved for the treatment of multidrug-resistant gram-negative infections, including those caused
by carbapenem-resistant Enterobacteriaceae. Unless a patient has antibiotic allergies that preclude the use of a carbapenem or
another agent active against ESBL-producing E. coli, colistin should be avoided.
● Fosfomycin (Option D) is a bactericidal, oral antibiotic (in the United States) with gram-negative and gram-positive activity
(including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci). It achieves high concentrations in the
urine and may be used for treating uncomplicated urinary tract infections caused by vancomycin-resistant enterococci and other
multidrug-resistant uropathogens, including ESBL-producing gram-negative organisms. Because of limited systemic absorption,
fosfomycin should not be used for pyelonephritis or bacteremia.
Question 8:
A 77-year-old woman is hospitalized for decompensated heart failure. An indwelling
urinary catheter is placed to monitor hourly urine output, and intravenous diuretics are
administered. Medical history is significant for hypertension and untreated urinary
incontinence. Her medications are carvedilol, furosemide, and lisinopril.
On physical examination, blood pressure is 154/92 mm Hg, pulse rate is 100/min, and
respiration rate is 18/min. Cardiopulmonary examination reveals bibasilar crackles and an
S3. Bilateral lower extremity pitting edema is present to the mid calf.

Which of the following is the most appropriate management to prevent a UTI?

A. Administer prophylactic TMP-SMX
B. Check UA and urine culture on 3rd day of catheterization
C. Remove indwelling urinary catheter
D. Replace indwelling catheter with an antiseptic-coated catheter
Answer: C
Educational objective: prevent catheter-associated UTI

● Removing this patient's indwelling urinary catheter is the most appropriate management (Option C). Patients who are female and
older than 50 years are at increased risk for catheter-associated urinary tract infection (CAUTI); a serum creatinine level greater
than 2 mg/dL (177 µmol/L) in this population is also a risk factor. Without an accepted indication for an indwelling urinary catheter,
it should be removed. Accurate monitoring of urine output in a critically ill patient is an accepted indication, but this patient is not
critically ill. Indwelling urinary catheters may be used in the management of stage III or IV or unstageable perineal or sacral
pressure ulcers in patients who are incontinent. External catheters (e.g., condom catheters for men or female external urinary
collection device with suction for women) can be used for patients with incontinence or increased urination (e.g., diuretic
treatment) when frequent toileting does not adequately address the issue. Early removal of urinary catheters should be considered
whenever possible.
● In patients with short-term or long-term requirements for an indwelling urinary catheter, administration of antibiotics such as
trimethoprim-sulfamethoxazole (Option A) is not indicated. Such therapy promotes the development of resistant bacteria without
improving patient care.
● Random urinalysis and urine culture is not helpful in monitoring for CAUTI (Option B). Without symptoms, the results are likely to
represent catheter colonization rather than infection and may lead to inappropriate antibiotic use. Patients with indwelling urinary
catheters should be assessed daily for signs and symptoms of infection.
● Antimicrobial-impregnated or antiseptic-coated catheters (Option D) may decrease the incidence of asymptomatic bacteriuria, but
they have not been shown to decrease CAUTI or urinary catheter–associated bloodstream infection with short-term (<7 days)
catheterization. Little information is available regarding benefits with long-term urinary catheters.
Question 9:
A 42 y/o woman seeks pre-travel advice. She is traveling to Guatemala City
and will be there for 1 wk. She will be visiting nearby villages during the first 4
days of her trip. Medical history is notable for ulcerative colitis with occasional
flares requiring glucocorticoid treatment. Her only medication is mesalamine.

Which of the following is the most appropriate preventative measure?

A. Bismuth subsalicylate
B. Ciprofloxacin
C. Compact water filter
D. Probiotics
E. Rifaximin
Answser: E
Educational objective: preventing traveler’s diarrhea

● This patient should be prescribed daily antibiotic prophylaxis with rifaximin (Option E). Travelers' diarrhea is the most frequently acquired
infectious illness encountered by international travelers. It is generally mild to severe, with variable symptoms from loose stools and
cramps to bloody dysentery and systemic illness. Most cases occur in the initial few weeks and decrease thereafter.
Enterotoxigenic Escherichia coli, Campylobacter, Shigella, and Salmonella are estimated to account for 80% to 90% of infecting organisms.
Viruses (e.g., rotavirus, norovirus) and, to a lesser extent, protozoal parasites (e.g., Giardia, Cyclospora) are mostly responsible for the
remainder. Most illness resolves within 3 to 7 days even without therapy, although those involving parasites can persist for longer periods
of time. Daily prophylactic antibiotics are effective at reducing the rate of diarrhea, but risks of adverse effects and increasing
antimicrobial resistance must be considered before prescribing. In patients with underlying conditions that place them at higher risk of
infection or disease complications (e.g., immune compromise, inflammatory bowel disease, chronic kidney disease) their use should be
considered. This patient has ulcerative colitis, which increases her risk for travelers' diarrhea becoming severe and disruptive to travel;
prophylaxis with rifaximin should be considered for this patient.
● Bismuth subsalicylate (Option A) taken in multiple daily doses can help prevent diarrhea but is not as convenient as rifaximin and carries
the risk of salicylate toxicity.
● Fluoroquinolones (such as ciprofloxacin) (Option B) are not recommended because of increasing safety concerns and bacterial resistance.
● Compact commercial water filters (Option C) have not been proven effective and should not be relied on as a safe method of disinfecting
water.
● Randomized clinical trials studying the benefits of probiotics (Option D) in preventing travelers' diarrhea are lacking; therefore, they
cannot be recommended.
Question 10:
39 y/o man is seen in a follow-up visit for an 8-wk history of intermittent and fluctuating
fevers that began after returning from Guyana 2 months ago. He also reports fatigue,
muscle, bone, and joint aches, and depression. During his trip he ate and slept in rural
villages. He has adhered to his tafenoquine malaria prophylaxis.

On exam, temperature is 37.5; other vital signs are normal; scattered LAD is noted; liver
edge is palpable 2 cm below the rib cage; low back discomfort is present with flexion and
distension. Exam is otherwise normal. Blood cultures (-); US shows hepatosplenomegaly.
Hematocrit 33%
Leukocyte count 3400
ALP 167
ALT 71
AST 46
Question 10 (contd):

What’s the diagnosis?

A. Bucellosis
B. Coxiella (Q fever)
C. Histoplasmosis
D. Malaria
Answer: A
Educational objective: diagnose brucellosis

● The most likely diagnosis is brucellosis (Option A), commonly referred to as “undulant fever” because of its up-and-down fever pattern.
Although the incidence of infection with this gram-negative, intracellular, coccobacillus is highest in Mediterranean countries, it is also
commonly encountered in the Middle East and South and Central America. Infection with the Brucella species that cause illness in humans
(B. abortus, B. melitensis, B. suis, B. canis) generally follows ingestion of undercooked meat, raw milk, or contaminated milk products or
through direct contact with secretions and excretions of infected animals. Symptom onset may be sudden, with chills and fever, severe
headache, joint and back pain, malaise, and overall lethargy. Intermittent fever with periods of remission lasting several weeks is common
and may persist for months. Depression is commonly reported. Hepatosplenomegaly and lymphadenopathy are frequently detected on
physical examination. Cytopenias and abnormal liver chemistry results are nonspecific laboratory findings. Diagnosis is best made by
isolation of the bacteria from blood cultures; however, the rate of detection is variable. The organism may also be isolated from bone
marrow culture, especially in chronic disease. Serologic testing is often relied on when cultures are negative.
● Coxiella burnetii is the causative agent of Q fever (Option B). Inhalation of aerosolized soil contaminated with excrement or birth by-
products from infected goats, sheep, and cattle is the major mode of transmission to humans. A mild, self-limited febrile illness,
sometimes with pneumonia and hepatitis, is the most frequent clinical presentation, and endocarditis is a major chronic manifestation.
This patient's chronic febrile illness is not typical for Q fever.
● Most patients infected with Histoplasma capsulatum (Option C) experience fever, a nonproductive cough, and chest discomfort as the
most common manifestations. In those who develop chronic infection, lung involvement is predominant. Cavitary lesions and mediastinal
lymphadenopathy are typical findings, which are not present in this patient.
● Malaria (Option D) is one of the most common diagnoses in returning travelers with fever. However, it would be rare to develop infection
while taking tafenoquine chemoprophylaxis.
Question 11:
Question 11 (contd):
Which of the following steps is recommended?

A. Serologic testing for celiac disease

B. Urea Breath Test
C. EGD
D. Esophageal pH probe testing
E. Empiric triple therapy with lansoprazole, amoxicillin and
clarithromycin, without testing for H pylori infection
Answer: B
Question 12:
A 24 y/o M reports a 12 week history of epigastric discomfort that has been
unresponsive to a 2 week course of over the counter proton pump inhibitor therapy.
The patient denies any family history of gastric cancer, current use of NSAIDS, weight
loss, or GI bleeding. Deep palpation of the abdomen reveals epigastric tenderness.
The presentation prompts concern for Helicobacter pylori infection. Which of the
following diagnostic approaches is most appropriate for this patient?

A. H. pylori fecal Ag test after PPIs have been DC’d for 2 weeks
B. H. pylori urea breath test w/o DCing PPI Tx
C. Endoscopic biopsy + culture
D. H. pylori serology after PPIs have been DC’d for 2 weeks
E. Endoscopic biopsy w/urease testing after PPIs have been DC’d for 2 weeks
Answer: A
Question 13:
A 50 y/o M presents for follow up 8 weeks after being hospitilized for upper gastrointestinal bleeding.
He had not been using NSAIDS.

An upper endoscopy at the time of admission revealed a clean based duodenal ulcer, and a biopsy
showed evidence of Helicobacter pylori infection. He completed a course of amoxicillin, clarithromycin,
and omeprazole 6 weeks ago and is feeling well with no further bleeding. On exam, his abdomen is
soft and nontender. Which of the following tests is most appropriate in this case?

A. Repeat Upper endoscopy with rapid urease test

B. H. Pylori serology testing
C. Repeat upper endoscopy with biopsy for histology
D. Helicobacter pylori stool antigen testing
E. Lactulose breath test
Answer: D
That’s all,
folks!!