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ID I Answers
ID I Answers
Self-Assessment Questions
Infectious Diseases I
1. A 20-year-old man comes to the emergency department with a flu-like illness, rash (predominantly on
his trunk), fever, and pronounced lymphadenopathy.
He reports a sexual encounter 1 week prior with a male
partner of unknown HIV status. He reports being an
active smoker and intravenous drug user. Which one
of the following screening tests would be best to
perform in this patient?
A.
B.
C.
D.
2. Answer: A
Postexposure prophylaxis (PeP) should be offered
immediately after laboratory workup because this patient
presents within 72 hours (further within 36 hours) after
an act of anal intercourse (a high-risk behavior). Twodrug therapy with nucleoside reverse transcriptase inhibitors (NRTIs) is appropriate unless source data (e.g., known
HIV status and viral resistance) dictate a different approach
(Answer A is correct). Three-drug therapy has not proved
superior to two-drug therapy in PeP and may be associated
with more adverse drug events unless the source data are
known (Answer B is incorrect). Obtaining laboratory data
should not delay PeP initiation, especially when exposures
of less than 36 hours have been associated with improved
outcomes (Answer C is incorrect). The patient should be
offered PeP given the high-risk behavior and timing of
exposure (Answer D is incorrect).
1. Landovitz RJ, Currier JS. Postexposure prophylaxis for
HIV infection. N Engl J Med 2009;361:176875.
PubMed Link
2. Centers for Disease Control and Prevention. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure
to HIV in the United States. MMWR Recomm Rep
2005;54(RR-2):120.
PubMed Link
1. Answer: D
The HIV RNA viral load is the test of choice for identifying a patient with HIV during acute HIV syndrome
before antibody formation (Answer D is correct). CD4+
cell counts are not used as a definitive diagnosis of HIV
infection (Answer A is incorrect). Although a rapid HIV
test and enzyme-linked immunosorbent assay (ELISA)
may be performed clinically, given a syndrome consistent
with acute HIV, the patient might not have antibody formation for 26 weeks and thus would potentially have a falsenegative result (Answer B and Answer C are incorrect).
1. Greenwald JL, Burstein GR, Pincus J, Branson B. A rapid
review of rapid HIV antibody tests. Curr Infect Dis Rep
2006;8:12531.
PubMed Link
2. Self WH. Acute HIV infection: diagnosis and management in the emergency department. Emerg Med Clin
North Am 2010;28:38192.
PubMed Link
2. A 29-year-old HIV-negative man comes to the clinic
reporting receptive anal intercourse about 18 hours
ago. His partners HIV status was unknown. The
patient inquires about postexposure prophylaxis
PSAP-VII Infectious Diseases
Answers
Answers
G6PD deficiency, and although used clinically as monotherapy, it does not offer full protection against toxoplasmosis (Answer A is incorrect). Azithromycin, which is indicated for prophylaxis of MAC (CD4+ less than 50 cells/
mm3), should be included in the regimen. Acyclovir treatment in patients with herpes simplex is preferred because it
reduces herpes episodes and their potential impact on HIV
RNA, but it is not indicated because the patient has no history of herpes (Answer B is incorrect). Fluconazole is not
indicated as primary prophylaxis unless the patient has had
several recurrences of candidal infections. In addition, dapsone should be avoided in G6PD deficiency (Answer C is
incorrect).
1. Celum C, Wald A, Lingappa JR, Magaret AS, Wang RS,
Mugo N, et al. Acyclovir and transmission of HIV-1 from
persons infected with HIV-1 and HSV-2. N Engl J Med
2010;362:42739.
PubMed Link
2. Youngster L, Arcavi L, Schechmaster R, Akayzen Y,
Popliski H, Shimonov J, et al. Medications and glucose6-phosphate dehydrogenase deficiency: an evidencebased review. Drug Saf 2010;33:71326.
PubMed Link
7. A 25-year-old man comes to the clinic requesting preventive HIV therapy. He is currently single and discloses that he had four male partners in the past 6
months, with his last encounter 34 weeks ago. He uses
condoms for anal intercourse but rarely for oral intercourse. The patient has found several potential partners online and will be meeting all of them for a weekend getaway in 2 weeks. He has no specific medical history, he tested HIV negative 9 months ago, and he is
currently taking no long-term drugs. The patient did
experience the flu this past week but did not seek specific medical care. In addition to counseling on sexually transmitted diseases and proper condom use,
which one of the following would be best for this
patient?
6. Answer: D
Atovaquone is indicated for PCP (CD4+ less than 200
cells/mm3) and toxoplasmosis (CD4+ less than 100 cells/
mm3 and positive immunoglobulin G [IgG]) prophylaxis
given sulfa allergy and G6PD deficiency. Azithromycin is
indicated for prophylaxis of Mycobacterium avium complex
(MAC) (CD4+ less than 50 cells/mm3; Answer D is correct). Dapsone should not be used in patients with a known
PSAP-VII Infectious Diseases
7. Answer: D
Both tests (ELISA and HIV RNA) should be ordered
and confirmed negative before initiating any preexposure prophylaxis (PrEP) (Answer D is correct). Preexposure prophylaxis with tenofovir/emtricitabine may be
3
Answers
9. Answer: B
Fluconazole should be considered the most cost-effective option and is available for oral administration (Answer
B is correct). Although amphotericin B would work, the
risk-benefit ratio of this agent does not support its use as
first-line therapy (Answer A is incorrect). Nystatin should
not be used for esophageal disease (Answer C is incorrect).
Although micafungin is indicated, fluconazole should be
considered the more cost-effective treatment and offers an
oral option when the patient is able to swallow (Answer D
is incorrect).
1. Centers for Disease Control and Prevention. Guidelines
for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR
Recomm Rep 2009;58(RR-4):1207.
PubMed Link
2. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr,
Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for the management of candidiasis: 2009 updated
by the Infectious Diseases Society of America. Clin Infect
Dis 2009;48:50335.
PubMed Link
8. Which one of the following is the best empiric therapy for G.J.s pulmonary infection?
A. Trimethoprim/sulfamethoxazole 400 mg intravenously every 8 hours and prednisone 40 mg twice
daily to taper.
B. Levofloxacin 750 mg intravenously daily,
clindamycin 600 mg intravenously every 6 hours,
and primaquine 30 mg orally daily.
C. Atovaquone 750 mg orally twice daily, dapsone
100 mg/day, ceftriaxone 1 g intravenously daily,
and azithromycin 500 mg intravenously daily.
D. Trimethoprim/sulfamethoxazole 300 mg intravenously every 6 hours and levofloxacin 750 mg
intravenously daily.
8. Answer: D
Trimethoprim/sulfamethoxazole is first-line therapy
for PCP, and empiric community-acquired pneumonia
Answers
11. Answer: A
The dose of maraviroc should be reduced to 150 mg
twice daily because of the potent 3A4 inhibition from
boosted darunavir despite induction from etravirine
(Answer A is correct). Dosage must be decreased because
of potent 3A4 inhibition from boosted darunavir (Answer
B is incorrect). When given with both a 3A4 inducer and
inhibitor, the dosage should be decreased to 150 mg twice
daily. Dose increases are not appropriate in this patient
(Answer C and Answer D are incorrect).
1. Kakuda TN, Abel S, Davis J, Hamlin J, Scholler-Gyure M,
Mack R, et al. Pharmacokinetic interactions of maraviroc
with darunavir/ritonavir, maraviroc with etravirine, and
maraviroc with etravirine/darunavir/ritonavir in healthy
volunteers: results of two drug interaction trials. Antimicrob Agents Chemother 2011;55:22906. [E-pub 2011
Mar 7]
PubMed Link
2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
12. Answer: A
Starting two-drug therapy for MAC is appropriate
(clarithromycin and ethambutol), and prophylaxis for PCP
(atovaquone given sulfa allergy) is appropriate (Answer
A correct). Single-drug therapy for MAC is not optimal
Answers
ate with maintenance of immune reconstitution inflammatory syndrome (IRIS) with symptomatic care (Answer D
is correct). Antiretroviral therapy (ART) should be continued unless life-threatening symptoms occur (Answer A
and Answer C are incorrect). Although prednisone can be
used, it should be used only in the presence of significant
symptoms. There is no specific advantage presented to discontinue fluconazole (Answer B is incorrect).
1. Muller M, Wandel S, Colebunders R, Attia S, Furrer H,
Egger M; IeDEA Southern and Central Africa. Immune
reconstitution inflammatory syndrome in patients
starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis
2010;10:25161.
PubMed Link
2. French MA. HIV/AIDS: immune reconstitution
inflammatory syndrome: a reappraisal. Clin Infect Dis
2009;48:1017.
PubMed Link
13. A 31-year-old man was recently admitted to the medical ward with severe headache and photophobia. He
has a CD4+ count of 15 cells/mm3 and HIV RNA of
105,350 copies/mL. His current laboratory values
are SCr 1.0 mg/dL, BUN 17 mg/L, AST 25 IU/mL,
ALT 38 IU/mL, hemoglobin 10.3 g/dL, platelet count
167,000 cells/mm3, and WBC 2.9 x 103 cells/mm3.
He has no drug allergies. He reports being off antiretrovirals for several years and does not recall his previous regimen. A lumbar puncture is performed, and a
cerebrospinal fluid stain is positive for yeast. Given the
high suggestion of cryptococcal disease, amphotericin B 60 mg intravenously daily and flucytosine 1500
mg orally every 6 hours are initiated. After 2 weeks of
induction therapy, the patient is discharged to continue
fluconazole and is initiated on tenofovir/emtricitabine,
darunavir and ritonavir, and raltegravir with scheduled clinic follow-up. Three weeks after initiating ART,
he begins to experience fever, fatigue, and lymphadenopathy, prompting a visit to the emergency department. Given the concern for immune reconstitution inflammatory syndrome (IRIS), which one of
the following is best for this patient?
14. Answer: C
Postexposure prophylaxis should be initiated in a
patient with known exposure to an HIV-positive source
patient, although the risk of acquisition is very low in this
case. The regimen chosen should be consistent with the
source patients regimen. Although two-drug therapy may
be appropriate, given the patient has maintained viral suppression on a known regimen, the exposed patient should
receive the same regimen (i.e., three drugs) unless contraindicated (Answer C is correct). Although two-drug therapy may be appropriate, given the patient has maintained
viral suppression on a known regimen, the exposed patient
should receive the same regimen (i.e., three drugs) unless
13. Answer: D
Answers
16. Answer: D
Antiretroviral therapy initiated within 28 weeks
of Mycobacterium tuberculosis (MTB)-targeted therapy
improves overall outcomes (Answer D is correct). To
reduce the risk of IRIS, the therapy should probably not
be initiated after 1 week of tuberculosis therapy (Answer A
is incorrect). Delays in therapy beyond 8 weeks have been
associated with worse clinical outcomes (Answer B and
Answer D are incorrect).
1. Velasco M, Castilla V, Sanz J, Gaspar G, Condes E, Barros
C, et al. Effect of simultaneous use of highly active antiretroviral therapy on survival of HIV patients with tuberculosis. J Acquir Immune Defic Syndr 2009;50:14852.
PubMed Link
2. Abdool Karim SS, Naidoo K, Grobler A, Padayatchi N,
Baxter C, Gray A, et al. Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med
2010;362:697706.
PubMed Link
15. Answer: C
The 2006 CDC guidelines recommend that all
patients aged 1364 be screened through an opt-out process (Answer C is correct). No specific written consent is
required, according to federal guidelines. State guidelines
should be consulted for varied levels of required documentation (Answer A is incorrect). Risk-based testing has not
been shown effective and is not recommended (Answer B
and Answer D are incorrect).
1. Centers for Disease Control and Prevention. Revised
recommendations for HIV testing of adults, adolescents,
and pregnant women in health-care settings. MMWR
Recomm Rep 2006;55(RR-14):117.
PubMed Link
2. National HIV/AIDS Clinicians Consultation Center.
2011 Compendium of State HIV Testing Laws. Available
at www.nccc.ucsf.edu/consultation_library/state_hiv_
testing_laws. Accessed April 9, 2012.
17. A 54-year-old man receives a diagnosis of HIV infection and, 6 weeks later, presents to the clinic to begin
ART. His baseline laboratory values are CD4+ count
388 cells/mm3, HIV RNA 121,000 copies/mL, SCr
0.7 mg/dL, BUN 20 mg/L, AST 45 IU/mL, ALT 28
IU/mL, hemoglobin 11.3 g/dL, platelet count 337,000
cells/mm3, and WBC 8.9 x 103 cells/mm3. He has a
documented allergy to sulfa (rash). His current daily
regimen includes hydrochlorothiazide 25 mg, esomeprazole 40 mg, and pravastatin 80 mg. Which one of
7
Answers
17. Answer: C
Tenofovir/emtricitabine and raltegravir is a first-line
treatment option (Answer C is correct). Atazanavir should
not be used with esomeprazole 40 mg because of impaired
absorption of atazanavir because of changes in gastric pH
(Answer A is incorrect). Rilpivirine with zidovudine/lamivudine is not a preferred option in treatment-naive patients
(Answer B is incorrect). Abacavir/lamivudine is not a preferred NRTI backbone (Answer D is incorrect).
1. Khanlou H, Farthing C. Co-administration of atazanavir
with proton pump inhibitors and H2 blockers. J Acquir
Immune Defic Syndr 2005;39:503.
PubMed Link
2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
19. Answer: B
Almost 100% of patients on zidovudine therapy will
develop a macrocytic anemia with elevated mean corpuscular volume. Obtaining a refill history is always prudent to evaluate outpatient adherence (Answer B is correct). Therapeutic drug monitoring may not indicate sustained adherence and is not readily available in most institutions (Answer A is incorrect). Adherence to this regimen
could not be sufficiently evaluated with a metabolic panel
(Answer C is incorrect). Although a pill count could be
done, it might not provide accurate information (Answer D
is incorrect).
1. Romanelli F, Empey K, Pomeroy C. Macrocytosis as
an indicator of medication (zidovudine) adherence in
patients with HIV infection. AIDS Patient Care STDS
2002;16:40511.
PubMed Link
2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
18. Answer: A
Nonformulary drugs are a major risk factor for antiretroviral errors in the hospital, especially in combination
products. This often leads to incomplete regimens or delays
in therapy reinitiation (Answer A is correct). Concurrent
liver dysfunction would not be a specific risk factor for antiretroviral errors for this regimen (Answer B is incorrect).
Surgery might predispose the patient to the possibility of
missed doses, but it is not the most likely risk factor for
Answers
A. Tenofovir/emtricitabine/efavirenz.
B. Zidovudine/lamivudine/atazanavir/ritonavir.
C. Abacavir/lamivudine/lopinavir/ritonavir.
D. Tenofovir/emtricitabine/raltegravir.
20. A 23-year-old woman comes to the sexually transmitted diseases clinic inquiring about measures to help
prevent HIV acquisition. She admits to a monogamous
relationship with a known HIV-positive man. She
acknowledges that they use condoms regularly, and she
is tested every 6 months as recommended by her primary care physician. Which one of the following is
most appropriate for this patient?
21. Answer: D
In HIV-positive patients with risk factors for cardiovascular disease (CVD), care should be taken to ensure the
selection of an antiretroviral regimen that minimizes further CVD risk. Because several agents can adversely affect
serum lipids as well as contribute to the development of
metabolic disorders including lipodystrophy, agents not
linked to these effects should be chosen preferentially. The
selection of a combination regimen that includes tenofovir, emtricitabine, and raltegravir can minimize the development of lipid abnormalities and metabolic disorders
(Answer D is correct), whereas the selection of a regimen
that includes zidovudine can lead to insulin resistance and
lipodystrophy (Answer B is incorrect). In addition, the use
of a protease inhibitor (PI)-based regimen, particularly
one that includes lopinavir/ritonavir, can adversely affect a
patients serum lipid profile (Answer C is incorrect). Moreover, the patient is currently receiving simvastatin, which is
contraindicated in patients receiving PIs because of a significant drug interaction. Although the regimen of tenofovir, emtricitabine, and efavirenz does not adversely affect
lipid profiles to the same extent as PIs, its effects on raising low-density lipoprotein (LDL) cholesterol are greater
than the regimen of tenofovir, emtricitabine, and raltegravir
(Answer A is incorrect).
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
2. Lennox JL, DeJesus E, Berger DS, Lazzarin A, Pollard
RB, Ramalho Madruga JV, et al. Raltegravir versus efavirenz regimens in treatment-naive HIV-1-infected
patients: 96-week efficacy, durability, subgroup, safety,
and metabolic analysis. J Acquir Immune Defic Syndr
2010;55:3948.
PubMed Link
22. A 54-year-old man with diabetes and HIV is successfully being treated with tenofovir/emtricitabine/
darunavir/ritonavir. After 3 months of dietary and lifestyle changes, his lipid profile is as follows: total cholesterol, 259 mg/dL; low-density lipoprotein (LDL) cholesterol, 167 mg/dL; high-density lipoprotein (HDL)
cholesterol, 37 mg/dL; and triglycerides, 280 mg/dL.
Which one of the following would best manage this
patients hyperlipidemia at this time?
Answers
22. Answer: C
When managing hyperlipidemia in HIV-positive
patients who are currently receiving antiretroviral therapy
(ART), options consist of switching antiretroviral agents
or providing lipid-lowering therapy. In this case, the patient
is a receiving a preferred antiretroviral regimen (tenofovir/emtricitabine/darunavir/ritonavir) that has minimal
adverse lipid effects and to which his HIV has responded
successfully. Lipid-lowering therapy is therefore appropriate, and atorvastatin is the agent of choice (Answer C is correct). Tenofovir and emtricitabine have not been associated
with hyperlipidemia; therefore, switching these agents to
abacavir and lamivudine would not be useful (Answer A is
incorrect). Although changing this patient to an unboosted
PI would remove the adverse lipid effects of ritonavir, atazanavir must be boosted when combined with tenofovir
(Answer B is incorrect). When choosing a statin, pravastatin is often a safe and effective agent. However, there is
a significant drug interaction between pravastatin and
darunavir; therefore, low-dose atorvastatin is a safer and
potentially more effective option for this patient (Answer
D is incorrect).
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
2. Calza L, Manfredi R, Colangeli V, Tampellini L, Sebastiani T, Pocaterra D, et al. Substitution of nevirapine or
efavirenz for protease inhibitor versus lipid-lowering
therapy for the management of dyslipidaemia. AIDS
2005;19:10518.
PubMed Link
3. Sekar VJ, Spinosa-Guzman S, Marien K, et al. Pharmacokinetic drug-drug interaction between the new HIV
protease inhibitor darunavir (TMC114) and the lipidlowering agent pravastatin. 8th International Workshop
on Clinical Pharmacology of HIV Therapy. April 1618,
2007, Budapest, Hungary. Abstract 54.
10
symptoms (Answer B is incorrect). Maintaining the current regimen is also not optimal because lipoatrophy symptoms would remain, and insulin resistance might be present
(Answer C is incorrect). Finally, treatment with tesamorelin is indicated only for the management of visceral fat accumulation, not lipoatrophy (Answer D is incorrect).
1. Moreno S, Miralles C, Negredo E, Domingo P, Estrada
V, Gutierrez F, et al. Disorders of body fat distribution in
HIV-1-infected patients. AIDS Rev 2009;11:12634.
PubMed Link
2. Wohl DA, Brown TT. Management of morphologic
changes associated with antiretroviral use in HIV-infected
patients. J Acquir Immune Defic Syndr 2008;49(suppl
2):S93S100.
PubMed Link
A.
B.
C.
D.
26. Answer: C
Infection with HIV should be considered a risk factor
for premature bone loss. Therefore, these patients should fit
into the category of earlier dual-energy x-ray absorptiometry (DXA) screening consisting of postmenopausal women
and men 50 years and older (Answer C is correct). Furthermore, in women with HIV who are younger than 50 or 50
years or older but premenopausal, DXA screening is not
required (Answer A is incorrect). In those with HIV infections who are younger than 50 and have not had a previous
fragility fracture, DXA screening is also not required, even
in the presence of other risk factors like hypogonadism
(Answer B is incorrect) or vitamin D deficiency (Answer D
is incorrect).
1. McComsey GA, Tebas P, Shane E, Yin MT, Overton ET,
Huang JS, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers.
Clin Infect Dis 2010;51:93746.
PubMed Link
2. Foundation NO. Clinicians Guide to Prevention and
Treatment of Osteoporosis. Washington, DC: National
Osteoporosis Foundation, 2010.
25. Answer: D
This patient shows low-grade changes on anal PaPap
smear testing. Although definitive recommendations are
unavailable, most authorities agree that, if there are any
abnormal findings on Pap smear, all patients should receive
high-resolution anoscopy with subsequent biopsy of any
irregular areas (Answer D is correct). This is because even
with low-grade lesions found on Pap smear, patients can still
have a significant risk (46% to 56%) of high-grade lesions
or intraepithelial neoplasia on biopsy. Follow-up Pap smear
testing is not appropriate until anoscopy and biopsy are
performed (Answer A and Answer B are incorrect). Finally,
the role of HPV (human papillomavirus) testing in this setting is not well defined; therefore, it is not recommended
for this patient (Answer C is incorrect).
1. New York State Department of Health. Neoplastic Complications of HIV Infection. July 2007:133. Available at
www.hivguidelines.org/clinical-guidelines/adults/neoplastic-complications-of-hiv-infection/. Accessed April 9, 2012.
2. Chin-Hong PV, Palefsky JM. Natural history and clinical management of anal human papillomavirus disease
in men and women infected with human immunodeficiency virus. Clin Infect Dis 2002;35:112734.
PubMed Link
27. A 45-year-old man with an extensive ART history presents with a CD4+ cell count of 89 cells/mm3 and signs
of oral thrush. He states that he is aware he requires
HIV treatment but that he is fearful of the adverse
effects, particularly those consistent with lipodystrophy that he has experienced with treatment in the past.
Which one of the following ART regimens was this
patient most likely treated with in the past?
A.
B.
C.
D.
27. Answer: C
Of the regimens listed in this question, the one that
includes a thymidine analog (zidovudine and stavudine)
is most likely to be associated with lipodystrophy-related
adverse effects (Answer C is correct). Although lipodystrophy can occur with other ART agents, of the options listed,
it is much less likely to occur with abacavir, lamivudine, and
11
Answers
29. Answer: A
With an odds ratio of 0.57 and a 95% confidence interval that does not include the null value of 1, the patients who
are naive to therapy have a lower risk of coronary heart disease (CHD) than those receiving PIs (Answer A is correct).
Those receiving nonPI-based regimens and patients who
are former antiretroviral recipients both have odds ratios
that may indicate a lower risk of CHD. However, the 95%
confidence intervals for these values include the null value
of 1. Therefore, it is possible that the risk of CHD is similar in patients receiving PIs and non-PI regimens as well as
those who are former users of ART (Answer B, Answer C,
and Answer D are incorrect).
1. Kaplan RC, Kingsley LA, Sharrett AR, Li X, Lazar J,
Tien PC, et al. Ten-year predicted coronary heart disease
risk in HIV-infected men and women. Clin Infect Dis
2007;45:107481.
PubMed Link
2. Law MG, Friis-Moller N, El-Sadr WM, R, Reiss P,
DArminio Monforte A, et al. The use of the Framingham equation to predict myocardial infarctions in HIVinfected patients: comparison with observed events in
the D:A:D Study. HIV Med 2006;7:21830.
PubMed Link
28. Answer: B
Human immunodeficiency virusassociated nephropathy (HIVAN) is usually seen in African American patients
who are not newly infected and will most often present with
an elevated serum creatinine (SCr) and mild to severe proteinuria (Answer B is correct). It is much less likely to be
present in a newly HIV-positive patient with a normal SCr
(Answer A and Answer C are incorrect) or in a white man
with a lack of proteinuria or glucosuria present on urinalysis
(Answer D is incorrect). A definitive diagnosis of HIVAN
requires kidney biopsy because this presentation can overlap with other glomerular diseases.
1. Gupta SK, Eustace JA, Winston JA, Boydston II, Ahuja
TS, Rodriguez RA, et al. Guidelines for the management
of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the
Infectious Diseases Society of America. Clin Infect Dis
2005;40:155985.
PubMed Link
2. Fine DM, Perazella MA, Lucas GM, Atta MG.
Renal disease in patients with HIV infection. Drugs
2008;68:96380.
PubMed Link
Answers
and prednisone, although it plays a role in managing HIVassociated nephropathy, is not helpful in patients with tenofovir toxicity (Answer D is incorrect).
1. Gupta SK, Eustace JA, Winston JA, Boydston II, Ahuja
TS, Rodriguez RA, et al. Guidelines for the management
of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the
Infectious Diseases Society of America. Clin Infect Dis
2005;40:155985.
PubMed Link
2. Goicoechea M, Liu S, Best B, Sun S, Jain S, Kemper C,
et al. Greater tenofovir-associated renal function decline
with protease inhibitor-based versus nonnucleoside
reverse-transcriptase inhibitor-based therapy. J Infect Dis
2008;197:1028.
PubMed Link
HIV-associated nephropathy.
Hypertension-associated CKD.
Tenofovir-associated nephrotoxicity.
Diabetic nephropathy.
30. Answer: C
This patient most likely has tenofovir-associated nephrotoxicity (Answer C is correct). The onset of this patients
decline in kidney function is temporally associated with initiating tenofovir and likely does not represent CKD associated with hypertension (this patient also has controlled
hypertension) or diabetes (he has new-onset diabetes)
(Answer B and Answer D are incorrect). Furthermore,
disease onset occurred in proximity to the patients starting tenofovir. It also presented with a urinalysis with mild
hematuria and glucosuria, which is uncharacteristic of HIVassociated nephropathy (Answer A is incorrect).
1. Gupta SK, Eustace JA, Winston JA, Boydston II, Ahuja
TS, Rodriguez RA, et al. Guidelines for the management
of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the
Infectious Diseases Society of America. Clin Infect Dis
2005;40:155985.
PubMed Link
2. Fine DM, Perazella MA, Lucas GM, Atta MG.
Renal disease in patients with HIV infection. Drugs
2008;68:96380.
PubMed Link
32. Answer: B
A hazard ratio of 1.49 with a 95% confidence interval
of 1.042.11 can be interpreted as the treatment interruption groups having a risk of CVD as much as 2 times greater
than the continuous ART group (Answer B is correct). An
incorrect interpretation would be that the continuous ART
group had a greater risk of CVD (Answer A is incorrect). In
addition, because the confidence interval does not include
1, there was a statistically significant difference between
groups (Answer C is incorrect). Finally, a hazard ratio of
1.49 does not indicate a 150% increase in the total number
of events for the treatment interruption group (Answer D is
incorrect). Instead, it represents a 50% increase.
1. Strategies for Management of Antiretroviral Therapy
(SMART) Study Group; Emery S, Neuhaus JA, Phillips AN, Babiker A, Cohen CJ, Gatell JM, et al. Major
clinical outcomes in antiretroviral therapy (ART)-naive
13
Answers
34. Answer: D
This patient has a single fasting blood glucose concentration greater than 125 mg/dL, requiring a repeat test
with similar results for a diagnosis of diabetes. The diagnosis of diabetes in patients with HIV infection should be performed using previously recommended strategies including abnormal fasting serum blood glucose concentrations
(125 mg/dL or greater) observed on two separate occasions or using a glucose tolerance test (Answer D is correct). Newer recommendations that allow the use of hemoglobin A1C (A1C) testing for diabetes diagnosis in the general population should not be used at this time in patients
with HIV infection given the inaccuracies in the results of
this test in this population (Answer C is incorrect). An oral
glucose tolerance test can be used for diagnosing diabetes
in patients with HIV infection but is not required (Answer
A is incorrect), and fasting blood glucose concentrations
should remain accurate in these patients despite inaccuracies in A1C measurements (Answer B is incorrect).
1. Kim PS, Woods C, Georgoff P, Crum D, Rosenberg A,
Smith M, et al. A1C underestimates glycemia in HIV
infection. Diabetes Care 2009;32:15913.
PubMed Link
2. American Diabetes Association. Standards of medical
care in diabetes 2010. Diabetes Care 2010;33(suppl
1):S11S61.
PubMed Link
33. Answer: D
The most appropriate initial option for the management of this condition in a patient who is not currently
receiving ART is the initiation of ART alone (Answer D is
correct). The initiation of ART improves the prognosis of
HIVAN and is considered to provide the best outcomes,
given the direct role of the HIV virus in the pathogenesis of
this condition. Although prednisone and angiotensin-converting enzyme (ACE) inhibitors have a role in the treatment of HIVAN, they are not considered first-line options
(Answer A, Answer B, and Answer C are incorrect).
1. Gupta SK, Eustace JA, Winston JA, Boydston II, Ahuja
TS, Rodriguez RA, et al. Guidelines for the management
of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the
Infectious Diseases Society of America. Clin Infect Dis
2005;40:155985.
PubMed Link
2. Fine DM, Perazella MA, Lucas GM, Atta MG.
Renal disease in patients with HIV infection. Drugs
2008;68:96380.
PubMed Link
Questions 34 and 35 pertain to the following case.
T.Y. is a 48-year-old man who received stavudine, lamivudine, and nelfinavir as his initial ART regimen at the time of
HIV diagnosis 12 years ago. He achieved virologic suppression on this regimen; however, because of the availability
Answers
A.
B.
C.
D.
Atorvastatin 20 mg.
Rosuvastatin 10 mg.
Simvastatin 20 mg.
Lovastatin 40 mg.
completed should the use of calcium and vitamin D supplementation or the application of bisphosphonate therapy be
considered (Answer B and Answer C are incorrect). Many
of these secondary causes can be common in HIV-positive
patients and include the following: low testosterone in men,
adrenal insufficiency, CKD, and poor nutrition. In addition,
although tenofovir has been associated with increased bone
loss in patients with HIV infection, there is no evidence that
discontinuing this agent will prevent a fracture (Answer D
is incorrect).
1. McComsey GA, Tebas P, Shane E, Yin MT, Overton ET,
Huang JS, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers.
Clin Infect Dis 2010;51:93746.
PubMed Link
2. Mondy K, Yarasheski K, Powderly WG, Whyte M, Claxton S, DeMarco D, et al. Longitudinal evolution of bone
mineral density and bone markers in human immunodeficiency virus-infected individuals. Clin Infect Dis
2003;36:48290.
PubMed Link
35. Answer: B
Of the options available, rosuvastatin 10 mg represents the best choice (Answer B is correct). When selecting
rosuvastatin or atorvastatin, it is important to begin therapy with the lowest dose of the agent when given in combination with PIs to minimize potential adverse effects, even
when a patient requires a significant LDL reduction. Therefore, initiating therapy with atorvastatin 20 mg is not recommended (Answer A is incorrect). In addition, the patient
is currently receiving a PI, which would have a significant
interaction with simvastatin (Answer C is incorrect) or lovastatin (Answer D is incorrect).
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
2. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark
LT, Hunninghake DB, et al. National Heart Lung and
Blood Institute; American College of Cardiology Foundation; American Heart Association Implications of
recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:22739.
PubMed Link
3. Singh S, Willig JH, Mugavero MJ, Crane PK, Harrington
RD, Knopp RH, et al. Comparative effectiveness and toxicity of statins among HIV-infected patients. Clin Infect
Dis 2011;52:38795.
PubMed Link
36. Which one of the following would be best to recommend for an HIV-positive patient recently given a
diagnosis of osteoporosis?
A. Assess for secondary causes of osteoporosis.
B. Initiate supplementation with calcium and vitamin D.
C. Initiate pharmacologic therapy with zoledronic
acid.
D. Discontinue tenofovir therapy if it is part of the
patients ART regimen.
36. Answer: A
The first step in assessing an HIV-positive patient
with osteoporosis is evaluating for the presence of secondary causes (Answer A is correct). Only after this step is
15
Answers
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. Department of
Health and Human Services. October 14, 2011; 1167.
Available at aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 9, 2012.
2. Calza L, Manfredi R, Chiodo F. Statins and fibrates
for the treatment of hyperlipidaemia in HIV-infected
patients receiving HAART. AIDS 2003;17:8519.
PubMed Link
38. A 47-year-old postmenopausal woman given a diagnosis of HIV in 1994 has an extensive history of ART. She
has been clinically stable during the past 2 years on her
current regimen (tenofovir, lamivudine, and lopinavir/
ritonavir); her current CD4+ cell count is 280 cells/
mm3 and her viral load is undetectable. Her total cholesterol is 350 mg/dL, HDL cholesterol is 35 mg/dL,
and triglycerides are 600 mg/dL. Her LDL cholesterol
could not be calculated because of her high triglyceride concentration. Which one of the following would
best manage this patients dyslipidemia?
A. Switch the antiretroviral regimen to tenofovir,
lamivudine, and atazanavir/ritonavir.
B. Switch lopinavir/ritonavir to darunavir/ritonavir,
and add lipid-lowering therapy with pravastatin
and fenofibrate.
C. Maintain the antiretroviral regimen, and recommend diet, exercise, and lifestyle modification.
D. Maintain the antiretroviral regimen, and add
lipid-lowering therapy with pravastatin and
fenofibrate.
38. Answer: D
This patient has dyslipidemia, including hypertriglyceridemia that requires intervention. The elevations in total
cholesterol and triglycerides observed in this patient are
likely the result of several factors, including the presence of
lopinavir and ritonavir. In this case, the patient has extensive antiretroviral experience and is currently clinically stable on her present regimen. Given her history, it may be
very difficult to change agents and ensure virologic efficacy.
As a result, the best option for this patient is to maintain her
current antiretroviral regimen while initiating lipid-lowering therapy (Answer D is correct). Switching these agents
to another regimen is a possibility, although the impact
of this intervention would be less than that observed with
providing lipid-lowering pharmacotherapy (Answer A and
Answer B are incorrect). In addition, the drug-drug interaction between pravastatin and darunavir should be avoided
(Answer B is incorrect). Finally, given the degree of dyslipidemia present in this patient, diet, exercise, and lifestyle
modification alone would not affect the lipid profile to the
desired extent (Answer C is incorrect).
Answers
40. Which one of the following therapeutic interventions would be best for K.B.?
A. Initiate metformin and lifestyle interventions.
B. Initiate glipizide and lifestyle interventions.
C. Change efavirenz to darunavir/ritonavir.
D. Change tenofovir/emtricitabine to lamivudine/
zidovudine.
16
40. Answer: B
This patient should be treated with an oral glucoselowering medication, in this case glipizide, in addition to
lifestyle interventions (Answer B is correct). This patients
elevated SCr is a contraindication to receiving metformin;
otherwise, this agent would be preferred over glipizide as
initial therapy (Answer A is incorrect). The patients current antiretroviral regimen has been virologically successful, and it carries a very low risk of diabetes and glucose
intolerance as opposed to other agents. As a result, changing the patients regimen is not indicated and would not
improve his diabetes diagnosis (Answer C and Answer D
are incorrect).
1. Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Medical management of
hyperglycemia in type 2 diabetes: a consensus algorithm
for the initiation and adjustment of therapya consensus statement of the American Diabetes Association and
the European Association for the study of diabetes. Diabetes Care 2009;32:193203.
PubMed Link
2. Adeyemi O, Vibhakar S, Max B. Are we meeting the American Diabetes Association goals for HIV-infected patients
with diabetes mellitus? Clin Infect Dis 2009;49:799802.
PubMed Link
Tuberculosis
41. A 62-year-old woman has been treated for 3 months
with isoniazid, rifampin, and pyrazinamide using
directly observed therapy (DOT). The sputum collected at the end of 2 months is culture positive for
Mycobacterium tuberculosis (MTB). Clinically, the
patient is still symptomatic, with cough and occasional
night sweats, and chest radiography has not changed
from 3 months earlier. In addition to continuing current therapy, which one of the following is the best
option to add for this patient?
A. Streptomycin.
B. Ethambutol and streptomycin.
C. Ethionamide and clofazimine.
D. Ethambutol.
42. Answer: A
Ethambutol is associated with retrobulbar neuritis.
Patients may report changes in visual acuity, an inability to
see the color green, or both. Ethambutol should be discontinued in this case. Because the patient received 2 months
of pyrazinamide and is culture negative, pyrazinamide also
should be discontinued (Answer A is correct). The patient
is experiencing these adverse effects at an ethambutol dose
of 15 mg/kg; lowering the dose could result in lower-thandesired serum concentrations and irreversible ocular damage (Answer D is incorrect). Because there is no need to
continue pyrazinamide, a dose reduction or discontinuation of ethambutol alone would be inappropriate (Answer
C and Answer B are incorrect).
1. Yee D, Valiquette C, Pelletier M, Parisien I, Rocher I,
Menzies D. Incidence of serious side effects from first-line
antituberculosis drugs among patients treated for active
tuberculosis. Am J Respir Crit Care Med 2003;167:1472.
PubMed Link
2. Peloquin CA. Therapeutic drug monitoring in the treatment of tuberculosis. Drugs 2002;62:216983.
PubMed Link
41. Answer: B
First-line drugs for treatment of active tuberculosis
(TB) include isoniazid, rifampin, pyrazinamide, and ethambutol. The patient is not responding to therapy, as evidenced by her still being culture positive at 2 months
and clinically still symptomatic while receiving isoniazid,
rifampin, and pyrazinamide. Adding a combination of ethambutol and streptomycin to the current therapy is the best
choice (Answer B is correct). Because a single drug should
never be added to a failing regimen, streptomycin and
17
Answers
A.
B.
C.
D.
44. Answer: A
About 10% of infected patients develop reactivation
disease, and the greatest risk is within 2 years of infection.
The main issue is that the index case is from an area of high
isoniazid resistance (i.e., Philippines). Therefore, rifampin
might be a better choice, at least until susceptibility tests
can be performed for the index case (Answer A is correct).
Because of resistance rates, isoniazid is not the best option
in this case (Answer B is incorrect). Rifampin and pyrazinamide are no longer recommended, and ethambutol and
pyrazinamide would be used only for cases of suspected
multidrug-resistant (MDR) TB exposure (Answer C and
Answer D are incorrect).
1. Saukkonen JJ, Cohn DL, Jasmer RM, Schenker S, Jereb
JA, Nolan CM, et al. An official ATS statement: hepatotoxicity of antituberculosis therapy. Am J Respir Crit
Care Med 2006;174:935.
PubMed Link
2. Yee D, Valiquette C, Pelletier M, Parisient I, Rocher I,
Manzies D. Incidence of serious side effects from first-line
antituberculosis drugs among patients treated for active
tuberculosis. Am J Respir Crit Care Med 2003;167:1472.
PubMed Link
45. Answer: A
The criteria for discontinuing isoniazid for suspected
liver toxicity is 3 times the upper limit of normal (ULN)
with symptoms or 5 times the ULN without symptoms.
The patients liver function tests have increased to about 3
times baseline since therapy initiation. The patient is not
symptomatic; therefore, isoniazid can be continued with
18
46. A 68-year-old Asian man with active TB has been taking rifampin, isoniazid, pyrazinamide, and ethambutol
for 5 weeks. He reports that his right big toe has been
painful for 2 weeks, and recently, he has had difficulty
walking around the house. On examination, the right
big toe is tender and red. His current a uric acid level
is 9 mg/dL compared with a baseline of 4 mg/dL at
the beginning of therapy. Which one of the following
plans is most appropriate for this patient?
A.
B.
C.
D.
47. Answer: A
Because of the relatively high proportion of adult
patients with TB caused by organisms that are resistant to
isoniazid, four drugs are necessary in the initial phase for
the 6-month regimen to be maximally effective. In most
circumstances, the treatment regimen for all adults with
previously untreated TB should consist of a minimum of
2 months of isoniazid, rifampin, pyrazinamide, and ethambutol until susceptibility results are available (Answer
A is correct). Starting a two- or three-drug regimen would
be inappropriate because susceptibilities are not available
yet (Answer B and Answer D are incorrect). The patient
is not taking any drugs that would require the substitution
of rifampin with rifabutin to minimize drug interactions
(Answer C is incorrect).
1. American Thoracic Society/Centers for Disease Control/Infectious Diseases Society of America. Treatment of tuberculosis. Am J Respir Crit Care Med
2003;167:60362.
PubMed Link
2. Caminero JA. Treatment of multidrug-resistant tuberculosis: evidence and controversies. Int J Tuberc Lung Dis
2006;10:82937.
PubMed Link
46. Answer: C
Hyperuricemia may occur in patients receiving pyrazinamide, but acute gout is uncommon. Pyrazinamide
causes uric acid retention. The patients baseline uric acid
concentration was normal. Repeat testing is recommended
if a gouty attack occurs, as in this case. Pyrazinamide therapy should be discontinued because this patient has developed acute gouty arthritis with hyperuricemia (Answer C
is correct). Changing isoniazid or rifampin to moxifloxacin
will not affect the uric acid (Answer A and Answer B are
incorrect). Although ethambutol can cause increases in uric
acid levels, pyrazinamide is more likely to be the cause of a
gouty attack (Answer D is incorrect).
1. Yee D, Valiquette C, Pelletier M, Parisient I, Rocher I,
Manzies D. Incidence of serious side effects from first-line
antituberculosis drugs among patients treated for active
tuberculosis. Am J Respir Crit Care Med 2003;167:1472.
PubMed Link
2. American Thoracic Society/Centers for Disease
Control/Infectious Diseases Society of America.
Answers
48. Answer: D
Multidrug-resistant TB, by definition, is resistant to
both isoniazid and rifampin but may be resistant to additional drugs as well. Discontinuing isoniazid and rifampin
and beginning streptomycin and levofloxacin provides two
bactericidal drugs, with levofloxacin being the next best
drug to add in this situation (Answer D is correct). For this
case, waiting for a longer time with the incorrect regimen
is not appropriate (Answer A is incorrect). Adding streptomycin is incorrect because it adds a single drug to an inadequate regimen (Answer B is incorrect). Discontinuing isoniazid and rifampin and beginning streptomycin and cycloserine could be used in a more extreme case of drug resistance, but it is not needed in this case (Answer C is incorrect). This option also introduces a fairly toxic drug, cycloserine, before it is essential to do so.
1. American Thoracic Society/Centers for Disease Control/Infectious Diseases Society of America. Treatment of tuberculosis. Am J Respir Crit Care Med
2003;167:60362.
PubMed Link
2. World Health Organization. 2011. WHO Guidelines
for the Programmatic Management of Drug Resistant
tuberculosis: 2011 Update. Available at http://whqlibdoc.who.int/publications/2011/9789241501583_eng.pdf.
Accessed April 9, 2012.
50. A 26-year-old woman presents to her personal physician with a cough, fatigue, and night sweats for 2 weeks.
She works as an emergency department nurse and
reports having been exposed to TB about 3 months
ago. Her PPD is read at 12 mm; QuantiFERON and
AFB are positive. She is 4 months pregnant. Which
one of the following regimens would be best for this
patient?
A.
B.
C.
D.
50. Answer: B
Treatment with isoniazid, rifampin, and ethambutol appears to be the safest option with supporting data
for this pregnant woman (Answer B is correct). Treatment with isoniazid, rifampin, and pyrazinamide is used
in some countries, but it is not recommended currently
by the CDC because information on pyrazinamide safety
is lacking for pregnant women (Answer A is incorrect).
Treatment with isoniazid, ethambutol, and pyrazinamide
deprives the patient of rifamycin, one of the most important drugs (Answer C is incorrect). Treatment with isoniazid, rifampin, and streptomycin introduces streptomycin,
which is avoided in pregnant women because of toxicity
(Answer D is incorrect).
1. Mnyani CN, McIntyre JA. Tuberculosis in pregnancy.
BJOG 2011;118:22631.
PubMed Link
2. Hamadeh MA, Glassroth J. Tuberculosis and pregnancy.
Chest 1992;101:111420.
PubMed Link
49. Answer: C
All factors mentioned (diabetes, cancer chemotherapy, HIV, and recent positive PPD) are risk factors for progression to active disease after infection. Of all of these factors, HIV infection is by far the greatest risk. The risk of TB
in an HIV-positive person is about 10% per year (Answer
C is correct) compared with a 10% lifetime risk of most
other patients (Answer A, Answer B, and Answer D are
incorrect).
1. Centers for Disease Control and Prevention (CDC).
Reported Tuberculosis in the United States, 2009, U.S.
Answers
A. Ethambutol.
B. Isoniazid.
C. Pyrazinamide.
D. Rifabutin.
20
51. Answer: D
Rifabutin can cause uveitis, which typically causes
the eye to become painful and red and should be temporarily discontinued in this case (Answer D is correct). In
HIV-positive patients taking ART as well as being treated
for TB, rifabutin is often used instead of rifampin because
of drug interactions. Once resolved, rifabutin can be reinitiated at a lower dose, but this may run the risk of an inadequate dose and selecting for acquired rifamycin resistance.
Ethambutol-induced optic neuritis is not painful (Answer
A is incorrect). Isoniazid peripheral neuropathy does not
present with eye symptoms (Answer B is incorrect). Pyrazinamide is not known to cause optic neuritis (Answer C is
incorrect).
1. Centers for Disease Control and Prevention. Managing Drug Interactions in the Treatment of HIV-Related
Tuberculosis. Available at www.cdc.gov/tb/publications/guidelines/TB_HIV_Drugs/default.htm.
Accessed April 9, 2012.
2. Centers for Disease Control and Prevention. Guidelines
for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR
2009;58:RR-4. Available at www.cdc.gov/mmwr/pdf/rr/
rr5804.pdf. Accessed April 9, 2012.
53. Answer: D
Because of rifampins intense induction effects on
many drugs metabolized by the cytochrome P450 (CYP)
enzyme system, it should be used with caution. In particular, a patient on concomitant ART should not be prescribed rifampin. Rifabutin is a less potent enzyme inducer
than rifampin and is the preferred agent in patients who
are receiving protease inhibitors (PIs) or nonnucleoside
reverse transcriptase inhibitors (NNRTIs) (Answer D is
correct). Rifamycins and isoniazid should always be firstline treatment of TB. Therefore, replacing rifampin with
moxifloxacin is inappropriate (Answer A is incorrect). The
patient is stable on his current antiretroviral regimen; thus,
discontinuing antiretrovirals is inappropriate (Answer B is
incorrect). Rifapentine is a long-acting rifamycin that can
be used once weekly in the continuation phase of treatment
(after the first 2 months) only for selected HIV-negative
patients and is not an option for this patient. Unlike rifabutin, rifapentine does not offer any advantage in sparing the
drug interactions (Answer C is incorrect).
1. Centers for Disease Control and Prevention. Managing Drug Interactions in the Treatment of HIV-Related
Tuberculosis. Available at www.cdc.gov/tb/publications/
guidelines/TB_HIV_Drugs/default.htm. Accessed April
9, 2012.
2. Abdool Karim SS, Naidoo K, Grobler A, Padayatchi N, Baxter C, Gray A, et al. Timing of initiation of
21
Answers
55. Answer: D
The basic principles that underlie treatment of pulmonary disease also apply to extrapulmonary disease. There
are limited clinical data pertaining to extrapulmonary disease and the therapy duration. Current guidelines suggest 9
months for bone disease (Answer D is correct). Continuing
therapy for 12 months is not necessary because the patient
is showing clinical improvement at follow-up (Answer A
and Answer B are incorrect). Six months of therapy is inadequate for the treatment of osteomyelitis caused by TB
(Answer C is incorrect).
1. Medical Research Council Working Party on Tuberculosis of the Spine. Five-year assessment of controlled
trials of short-course chemotherapy regimens of 6, 9 or
18 months duration for spinal tuberculosis in patients
ambulatory from the start or undergoing radical surgery.
Int Orthop 1999;23:7381.
PubMed Link
2. Dutt AK, Moers D, Stead WW. Short-course chemotherapy for extrapulmonary tuberculosis. Nine years experience. Ann Intern Med 1986;104:712.
PubMed Link
Answers
56. Answer: B
Latent TB infection (LTBI) treatment is effective
in preventing active disease in people who have positive
tuberculin skin tests and who are at risk of reactivated TB.
The recommended regimen for all adults is daily isoniazid
for 9 months (Answer B is correct). Secondary or alternative therapies include isoniazid for 6 months; less strongly
recommended is 4 months of rifampin. Randomized, prospective trials support using LTBI treatment in HIV-positive and HIV-negative people. Twelve months of isoniazid
will work, but this is not needed (Answer A is incorrect).
Treatment with isoniazid and rifampin is not indicated
because the patient does not have active disease (Answer C
and Answer D are incorrect).
1. Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment
of latent tuberculosis infection in HIV infected persons.
Cochrane Database Syst Rev 2010;1:CD000171.
22
PubMed Link
2. Centers for Disease Control and Prevention. Guidelines
for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR
2009;58:RR-4. Available at www.cdc.gov/mmwr/pdf/rr/
rr5804.pdf. Accessed April 9, 2012.
58. Answer: B
The recommended regimen for susceptible TB in HIVinfected adults is a 6-month regimen consisting of an initial
phase of isoniazid and a rifamycin, pyrazinamide, and ethambutol for the first 2 months, followed by a continuation
phase of isoniazid and a rifamycin for 4 months. Although
some clinicians elect to extend treatment of TB for HIVpositive patients, in this case, the patient is responding well,
and at this point, there is no reason to extend the treatment
beyond 6 months (Answer B is correct). Continuing current
treatment for another 7 months is unnecessary (Answer A
is incorrect), as is continuing with isoniazid and a rifamycin
for 6 additional months (Answer C is incorrect). Continuing current treatment for another 2 months would provide
only 4 months of therapy (Answer D is incorrect).
1. Centers for Disease Control and Prevention. Guidelines
for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR
2009;58:RR-4. Available at www.cdc.gov/mmwr/pdf/rr/
rr5804.pdf. Accessed April 9, 2012.
2. Swaminathan S, Narendran G, Venkatesan P, Iliayas
S, Santhanakrishnan R, Menon PA, et al. Efficacy of a
6-month versus 9-month intermittent treatment regimen
in HIV-infected patients with tuberculosis: a randomized
clinical trial. Am J Respir Crit Care Med 2010;181:743.
PubMed Link
59. Answer: A
23
Answers
Obtain an IGRA.
Place another PPD.
Obtain sputum culture.
Obtain chest radiography.
60. Answer: B
A negative PPD result may indicate that a person has
not been exposed to TB, that the person is not infected with
TB, that his or her immune system has not responded to
the antigen in the test, or that it is too early to detect exposure. It has been more than 6 weeks since the patient was
exposed. To confirm a negative or indeterminate result,
the best option at this time would be to place another
PPD (Answer B is correct). It is too late to obtain an IGRA
because they should be performed no more than 3 days after
a PPD is placed (Answer A is incorrect). A sputum culture
or chest radiography is unnecessary at this time because the
patient is not symptomatic (Answer C and Answer D are
incorrect).
1. Mazurek GH, Jereb J, Vernon A, LoBue P, Goldberg S,
Castro K, et al. Updated guidelines for using interferon
gamma release assays to detect Mycobacterium tuberculosis infectionUnited States, 2010. MMWR Recomm
Rep 2010;59(RR-5):125.
PubMed Link
Answers
24