Quiz 3

Ref: Harrison 20th edition, p 1425, 26, 27; Harrison 19th edition, page 1246-47
After accidental needle stick injury the chances of developing HIV infection are 0.3%. S. ELISA test can become positive any time after 6 weeks to 6 months of actual infection. Hence p24 antigen is favoured for early detection.

Ref: Harrison 20th edition, p 1125, 1128; Harrison 19th edition, page 1003
A teenager has come back with same symptoms which implies that he may be continuing with same high sexual behavior with same or different partner. His Partner should always be treated otherwise there is an increased chance of re infection from further sexual contact
Gonococcal urethritis
 Treat with ceftriaxone 250 mg IM+azithromycin lg PO or Doxycycline 100 mg BD for 7 days
 Cetixime 400 mg single dose is alternative for ceftriaxone
 Strains of gonococci are resistant to penicillin cephalosporin tetracycline or ciprofloxacin
 The partners should be treated and tested Or HIV and syphilis

Ref: Harrison 20th edition. p 1002; Chapter 602, Nelson 18th edition, Harrison 19th p 889
 Therapy for uncomplicated penicillin-sensitive S. pneumoniae meningitis should be completed with 10 to 14 days with a 3rd-generation cephalosporin or intravenous penicillin (400,000 U/kg/24 hr, given every 4-6 hr). If the isolate is
resistant to penicillin and the 3rd-generation cephalosporin, therapy should be completed with vancomycin.

Ref: Harrison 20th edition, p 1245; Harrison 19th p 1112
 Fundus examination may reveal choroidal tubercles, which are pathognomonic of miliary TB, in up to 30% of cases.
 Meningismus occurs in < 10% of cases.
 A high index of suspicion is required for the diagnosis of miliary TB. Frequently, chest radiography reveals a miliary reticulo-nodular pattern (more easily seen on underpenetrated film), although no radiographic abnormality may be evident early in the course and among HIV-infected patients. Other radiologic findings include large infiltrates, interstitial infiltrates (especially in HIV-infected patients), and pleural effusion.

Ref: Nelson 18th edition ch. 212, Harrison 19th p 1111
 During early stage I, the CSF may resemble that of viral aseptic meningitis only to progress to the more severe CSF profile over several weeks. Hence normal CSF sugar may be seen and choice A is correct.
 Since the advent of CT, the paradoxical development of tuberculomas in patients with tuberculous meningitis who are receiving ultimately effective chemotherapy has been recognized. The cause and nature of these tuberculomas are poorly understood, and do not represent failure of drug treatment. This phenomenon should be considered whenever a child with tuberculous meningitis deteriorates or develops focal neurologic findings while on treatment.
 Corticosteroids may help alleviate the occasionally severe clinical signs and symptoms that occur. These lesions may persist for months or even years.
 As disease progresses, basilar enhancement and communicating hydrocephalus with signs of cerebral edema or early focal ischemia are the most common findings. Some small children with tuberculous meningitis may have 1 or several clinically silent tuberculomas, occurring most often in the cerebral cortex or thalamic regions.

Ref: Harrison 20th edition, p 1358; Harrison 19th p 1187
 CLL is seen in adults and CML presents with massive splenomegaly and arc hence ruled out. ALL has a stormy onset but a peripheral smear finding negates the possibility.
 Infectious mononucleosis presents with Fever, sore throat, fatigue, malaise, anorexia, and myalgia and below mentioned findings.
Physical findings
1. Lymphadenopathy (discrete, non-Suppurative, slightly painful, especially along the posterior cervical chain)
2. Transient bilateral upper lid Edema (Hoagland sign),
3. Splenoinegaly (in up to 50% of patients).
4. Maculo-papular or occasionally petechial rash occurs in < 15% of patients unless ampicillin is given.
5. Conjuctival Hemorrhage, exudative pharyngitis, uvular edema, tonsillitis, or gingivitis may occur and soft palatal petechiae may he seen
Investigations: The white blood cell count is usually elevated and peaks at 10,000-20,000/μL during the second or third week of illness. Lymphocytosis is usually demonstrable, with >10% atypical lymphocytes. The latter cells are enlarged lymphocytes that have abundant cytoplasm, vacuoles, and indentations of the cell membrane

Ref: Harrison 20th edition, p 1314; Harrison 19th p 1164
 Acute M. pneumoniae infection can he diagnosed by polymerase chain reaction detection of the organism in respiratory tract secretions.
 Oropharyngeal, nasopharyngeal, and pulmonary spec-imens are all acceptable for diagnosing M. pneumoniae pneumonia.
 M. pneumoniae culture requiring special media is not recommended for routine diagnosis because the organism may take weeks to grow and is often difficult to
isolate from clinical specimens. In contrast, PCR allows rapid, specific diagnosis earlier in the course of clinical illness