Antibiotics

Cases –
Medicosis Perfectionalis




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Case 1:

A 35-year-old male presents with a “lesion down there” He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. On physical exam, there is a
single painless ulcer on his penis that measures 1-2 cm in diameter. The ulcer has a hard, indurated base
with a heaped-up border and a clean base. There is bilateral painless lymphadenopathy in the regional
lymph nodes. The patient recalls that it started as an elevated, small mass which used to secreted pus, but
now it’s flat and ulcerative.

• What’s the most likely diagnosis?

a. Chancroid
b. Chancre (1ry syphilis)
c. Condyloma lata
d. Condyloma accumunata
e. Gonorrhea
f. Chlamydia







Answer (b): chancre (1ry syphilis)





Case 2:

A 35-year-old male presents with a “lesion down there” He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. On physical exam, there is a
single painless ulcer on his penis that measures 1-2 cm in diameter. The ulcer has a hard, indurated base
with a heaped-up border and a clean base. There is bilateral painless lymphadenopathy in the regional
lymph nodes. The patient recalls that it started as an elevated, small mass which used to secreted pus, but
now it’s flat and ulcerative.

• If left untreated, what will happen to this ulcer?

a. Transforms into a malignant neoplasm.
b. Resolves on its own.
c. Increase in size and number.
d. Oozes yellow, purulent fluid and then malignantly transform.
e. Become indurated & fluctuant then forms a large draining sinus and buboes










Answer: (b): resolves on its own.


Case 3:

A 35-year-old male presents with a “lesion down there” He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. On physical exam, there is a
single painless ulcer on his penis that measures 1-2 cm in diameter. The ulcer has a hard, indurated base
with a heaped-up border and a clean base. There is bilateral painless lymphadenopathy in the regional
lymph nodes. The patient recalls that it started as an elevated, small mass which used to secreted pus, but
now it’s flat and ulcerative.

I- What’s the next step in diagnosis?
a. Dark field microscopy.
b. Culture of the base of the ulcer.
c. Needle biopsy of the inguinal lymph node
d. Serum rapid plasma reagin (RPR)
e. FTA-ABS.









Answer: a. dark field microscopy

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Case 4:
A 35-year-old male presents with a “lesion down there” He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. On physical exam, there is a
single painless ulcer on his penis that measures 1-2 cm in diameter. The ulcer has a hard, indurated base
with a heaped-up border and a clean base. There is bilateral painless lymphadenopathy in the regional
lymph nodes. The patient recalls that it started as an elevated, small mass which used to secreted pus, but
now it’s flat and ulcerative. Rapid plasma reagin (RPR) is positive.

• What’s the best treatment option?

a. 5 doses of oral cefepime.
b. 1 dose of intramuscular procaine penicillin.
c. 3 doses of intramuscular benzathine penicillin (penicillin G) 2.4 million units
d. 7 doses of oral penicillin V.
e. 1 dose of intramuscular ceftriaxone.
f. 3 doses of oral clindamycin.
g. 1 dose of intramuscular benzathine penicillin (penicillin G) 2.4 million units.









Answer: (g): 1 dose of intramuscular benzathine penicillin (penicillin G) 2.4 million units.


Case 5:

A 35-year-old male presents with a “lesion down there” He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. On physical exam, there is a
single painless ulcer on his penis that measures 1-2 cm in diameter. The ulcer has a hard, indurated base
with sloping edges. There is bilateral lymphadenopathy in the regional lymph nodes. The patient recalls
that it started as an elevated, small mass which used to secreted pus, but now it’s flat and ulcerative. Rapid
plasma reagin (RPR) is positive.

• If the patient is allergic to penicillin, what’s the drug of choice?
a. 5 doses of oral cefepime.
b. 1 dose of intramuscular ceftriaxone.
c. 3 doses of oral clindamycin.
d. Doxycycline twice a day for 14 days.
e. Single dose of oral Ciprofloxacin.










Answer (d): Doxycycline (twice a day for 14 days) or azithromycin (single dose).



Case 6:

A 26-year-old male presents with a rash and sore throat. He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. 2 months earlier, he noticed
a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on its own,
and that’s why he didn’t seek medical attention. His temperature is 38.5C (101.3 F). On physical exam, there
was symmetric, maculopapular involving the entire trunk and extremities including his palms and soles as
well as generalized, nontender lymphadenopathy.
is positive.
I- What’s the most likely diagnosis?

a. Chancroid
b. Chancre (1ry syphilis)
c. Condyloma lata
d. Condyloma accumunata
e. Gonorrhea
f. Chlamydia











Answer: c. condyloma lata = 2ry syphilis. “Fool me once, shame on chancre, fool me twice, shame on condyloma lata”


Case 7:

A 26-year-old male presents with a rash and sore throat. He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. 2 months earlier, he noticed
a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on its own,
and that’s why he didn’t seek medical attention. His temperature is 38.5C (101.3 F). On physical exam, there
was symmetric, maculopapular involving the entire trunk and extremities including his palms and soles as
well as generalized, nontender lymphadenopathy.
is positive.

II- How can you confirm the diagnosis?
a. Dark field microscopy
b. FTA-ABS
c. Rapid plasma reagin (RPR)
d. Culture from the penis.
e. KOH wet mount.












Answer: b: FTA-ABS.



Case 8:
A 26-year-old male presents with a rash and sore throat. He is a sex worker and sexually active with
multiple partners including foreigners. He doesn’t use protection during coitus. 2 months earlier, he noticed
a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on its own,
and that’s why he didn’t seek medical attention. His temperature is 38.5C (101.3 F). On physical exam, there
was symmetric, maculopapular involving the entire trunk and extremities including his palms and soles as
well as generalized, nontender lymphadenopathy.
is positive.

I- What’s the best treatment option?
a. 5 doses of oral cefepime.
b. 1 dose of intramuscular procaine penicillin.
c. 3 doses of intramuscular benzathine penicillin (penicillin G) 2.4 million units
d. 7 doses of oral penicillin V.
e. 1 dose of intramuscular ceftriaxone.
f. 3 doses of oral clindamycin.
g. 1 dose of intramuscular benzathine penicillin (penicillin G) 2.4 million units.
h. 3 doses of intramuscular benzathine penicillin (penicillin G) once a week, over a 3-week period.









Answer: (h): 3 doses of IM Penicillin G.
If allergic to penicillin, use doxycycline or azithromycin.


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Case 9:
A 49-year-old male presents with symptoms of weakness, inability to focus, memory problems, difficulty
speaking, tremors of his fingers and lips. He also complains of irritability and headaches. His mother says
that he “is no longer himself” and “he is acting weirdly and seems confused”. He vividly recalls that 2 year
ago, he had a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on
its own, and that’s why he didn’t seek medical attention. Then 6 weeks after the resolution of the ulcer, he
developed rash on his trunk, palms and soles, as well as large lymph nodes all over his body. He admits
visiting prostitutes at least once a month. On physical exam, his pupils show a normal near response, but
when you shone a flashlight, they fail to constrict. There is loss of fine touch and vibratory sensations and a
positive Romberg’s sign.

I- What’s the most likely diagnosis?
a. Alzheimer’s dementia
b. Wernicke-Korsakoff Syndrome
c. Condyloma accumunata
d. Pick’s disease (Frontotemporal dementia)
e. Vitamin B12 deficiency.
f. Vascular dementia
g. Tertiary Syphilis







-Answer (g): Tertiary syphilis (N.B. syphilis is called the great imitator)


Case 10:
A 49-year-old male presents with symptoms of weakness, inability to focus, memory problems, difficulty
speaking, tremors of his fingers and lips. He also complains of irritability and headaches. His mother says
that he “is no longer himself” and “he is acting weirdly and seems confused”. He vividly recalls that 2 year
ago, he had a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on
its own, and that’s why he didn’t seek medical attention. Then 6 weeks after the resolution of the ulcer, he
developed rash on his trunk, palms and soles, as well as large lymph nodes all over his body. He admits
visiting prostitutes at least once a month. On physical exam, his pupils show a normal near response, but
when you shone a flashlight, they fail to constrict. There is loss of fine touch and vibratory sensations and a
positive Romberg’s sign.

I- What part of the spinal cord is affected?
a. Anterior horn cell.
b. White commissure.
c. Lateral corticospinal tract.
d. Corticobulbar tract.
e. Dorsal column.
f. Lateral Spinothalamic tract
g. Spinocerebellar tract.

II- If left untreated, what would you expect to hear on cardiac auscultation 15 years from now?
a. Pansystolic murmur heard best at the cardiac apex and radiates to the apex.
b. Systolic crescendo decrescendo murmur heard best at the right 2nd intercostal space, radiates to carotids.
c. Diastolic decrescendo murmur that is accentuated when the patient holds his breath and leans forwards.
d. Pansystolic murmur heard best at the lower left sternal border.
e. S4 gallop rhythm.


Answers: I- (e) Dorsal column (and dorsal root ganglion). ----- II- (C) Diastolic decrescendo (aortic regurgitation)


Case 11:
A 49-year-old male presents with symptoms of weakness, inability to focus, memory problems, difficulty
speaking, tremors of his fingers and lips. He also complains of irritability and headaches. His mother says
that he “is no longer himself” and “he is acting weirdly and seems confused”. He vividly recalls that 2 year
ago, he had a painless ulcer on his penis, and painless large lymph node in the groin area which resolved on
its own, and that’s why he didn’t seek medical attention. Then 6 weeks after the resolution of the ulcer, he
developed rash on his trunk, palms and soles, as well as large lymph nodes all over his body. He admits
visiting prostitutes at least once a month. On physical exam, his pupils show a normal near response, but
when you shone a flashlight, they fail to constrict. There is loss of fine touch and vibratory sensations and a
positive Romberg’s sign.



What’s the treatment of choice?
a. Aqueous penicillin G, 3-4 million units IV every 4 hours for 10-14 days.
b. 3 doses of intramuscular benzathine penicillin (penicillin G) once a week, over a 3-week period.
c. 1 dose of intramuscular benzathine penicillin (penicillin G) 2.4 million units.
d. 1 dose of oral penicillin V.
e. Aztreonam
f. Ertapenem




Answer: (a) aqueous penicillin G (high dose) IV…for neurosyphilis (3ry syphilis)
(b) is for 2ry syphilis.
(c) is for 1ry syphilis.


Case 12:
A 38-year-old male patient - with history of uncontrolled diabetes - presents with a painful rash on his right leg.
His vitals are as follows: temperature: 39C (102F), BP 120/80 mmHg, HR 110 Beat/min, RR 20/min.
On Physical exam of the right leg, there is skin edema. The area is warm, tender with macular erythema with indistinct
borders on the skin. Regional lymph nodes are enlarged, painful and swollen. His left leg is normal.

I- What’s the most likely diagnosis?
a. Stasis dermatitis
b. Erythema migrans
c. Erythema marginatum
d. Necrotizing fasciitis
e. Contact dermatitis
f. Cellulitis
g. Folliculitis
h. Skin Abscess

II- What’s the most likely causative organism?
a. Methicillin-sensitive Staphylococcus aureus.
b. Methicillin Resistant Staphylococcus aureus.
c. Staphylococcus saprophyticus.
d. Alpha hemolytic streptococcus (Streptococcus. pneumoniae)
e. Alpha hemolytic streptococcus (Streptococcus. Viridans)
f. Group A beta hemolytic streptococcus (strept. pyogenes or GABS).
g. Enterococcus faecalis.



Answers:
I- (f) cellulitis
II- (f) GABS.


Case 13:
A 38-year-old male patient - with history of uncontrolled diabetes - presents with a painful rash on his right leg.
His vitals are as follows: temperature: 39C (102F), BP 120/80 mmHg, HR 110 Beat/min, RR 20/min.
On Physical exam of the right leg, there is skin edema. The area is warm, tender with macular erythema with indistinct
borders on the skin. Regional lymph nodes are enlarged, painful and swollen. His left leg is normal.
Unfortunately, the first doctor misdiagnosed him, and now he presents with a tender, fluctuant, erythematous, warm mass
on his right leg that measures > 2cm in diameter. A culture was sent to the lab and still pending.
I- What’s the most likely diagnosis now?
a. Stasis dermatitis
b. Erythema migrans
c. Erythema marginatum
d. Necrotizing fasciitis
e. Contact dermatitis
f. Cellulitis
g. Folliculitis
h. Skin Abscess

II- What’s the most likely causative organism?
a. Staphylococcus aureus.
b. Staphylococcus saprophyticus.
c. Alpha hemolytic streptococcus (Streptococcus. pneumoniae)
d. Alpha hemolytic streptococcus (Streptococcus. Viridans)
e. Group A beta hemolytic streptococcus (strept. pyogenes or GABS).
f. Enterococcus faecalis.



Answers:
I- (h) Skin abscess
II- (a) Staph aureus


Case 14:
A 38-year-old male patient - with history of uncontrolled diabetes - presents with a painful rash on his right leg.
His vitals are as follows: temperature: 39C (102F), BP 120/80 mmHg, HR 110 Beat/min, RR 20/min.
On Physical exam of the right leg, there is skin edema. The area is warm, tender with macular erythema with indistinct
borders on the skin. Regional lymph nodes are enlarged, painful and swollen. His left leg is normal.
Unfortunately, the first doctor misdiagnosed him, and now he presents with a tender, fluctuant, erythematous, warm mass
on his right leg that measures > 2cm in diameter. The culture came back, and he is positive for methicillin-resistant
staphylococcus aureus (MRSA).

I- What’s the best management plan?
a. Observation only.
b. Antibiotics only.
c. Incision and drainage only.
d. Incision and drainage plus antibiotics.
e. Consult the ethics committee.













Answer: (d): incision and drainage plus antibiotics…Why both? -because there is fever and it’s > 2cm.



Case 15:
A 38-year-old male patient - with history of uncontrolled diabetes - presents with a painful rash on his right leg.
His vitals are as follows: temperature: 39C (102F), BP 120/80 mmHg, HR 110 Beat/min, RR 20/min.
On Physical exam of the right leg, there is skin edema. The area is warm, tender with macular erythema with indistinct
borders on the skin. Regional lymph nodes are enlarged, painful and swollen. His left leg is normal.
Unfortunately, the first doctor misdiagnosed him, and now he presents with a tender, fluctuant, erythematous, warm mass
on his right leg that measures > 2cm in diameter. The culture came back, and he is positive for methicillin-resistant
staphylococcus aureus (MRSA).

I- If you decided to give a therapy once a day, which of the following is the best option?
a- Piperacillin-Tazobactam
b- Ticarcillin-Clavulanate
c- Imipenem-Cilastatin
d- Ceftaroline
e- Ertapenem
f- Daptomycin
II- Which of the following is the most common adverse effect of the antibiotic of choice?
a. Gray baby syndrome.
b. Red man syndrome.
c. Rhabdomyolysis.
d. Vestibular ototoxicity.
e. Cochlear ototoxicity.
f. Red-Orange discoloration of urine.
g. Red-Green color blindness


Answer:
I- (f) Daptomycin…Imipenem and piperacillin do NOT cover MRSA…Ceftaroline covers MRSA but it’s given twice a
day.
II- (c) Rhabdomyolysis with elevated CPK.


Case 16:
A 35-year-old pregnant, female patient - in her 7th week of gestation- presents with a painful rash on her right leg.
Her vitals are as follows: temperature: 39C (102F), BP 118/78 mmHg, HR 110 Beat/min, RR 20/min.
On Physical exam of the right leg, there is skin edema. The area is warm, tender with macular erythema with indistinct
borders on the skin. Regional lymph nodes are enlarged, painful and swollen. Her left leg is normal.
The culture results came back, and she is positive for methicillin-resistant staphylococcus aureus (MRSA).

I- Which of the following is the best treatment option in an outpatient setting?
a- Piperacillin-Tazobactam
b- Ticarcillin-Clavulanate
c- Imipenem-Cilastatin
d- Clindamycin
e- Ertapenem
f- Doxycycline
g- Gentamycin

II- What is a serious side effect of that medication?
a. Gray baby syndrome.
b. Red man syndrome.
c. Rhabdomyolysis.
d. Vestibular ototoxicity.
e. Cochlear ototoxicity.
f. Red-Orange discoloration of urine.
g. Pseudomembranous colitis (C. diff)
h. Red-Green color blindness


Answers: i. (d). Clindamycin: very safe for pregnancy, covers MRSA, can be used outpatient.
ii. (g) c. diff colitis à diarrhea. C. diff colitis is treated with Metronidazole or Vancomycin.



Case 17:
A 19-year-old female is brought to the emergency room in an ambulance…She is in the ER now. She has neck stiffness,
headache, photophobia, a core body temperature of 40C (104F). On physical exam, there is positive Kernig’s test and
Brudzinski’s signs. She started vomiting, then had a tonic-clonic seizure. Lumbar puncture revealed a CSF that has high
opening pressure, low in glucose, high in protein, and high in WBC count (neutrophilic leukocytosis).

I- What is the best empirical treatment?
a. Aztreonam
b. Cefazolin
c. Imipenem-Cilastatin
d. Cefotaxime
e. Cefuroxime
f. Penicillin V
g. Cefalexin
h. Metronidazole
i. Cefdinir








Answer: d. Cefotaxime (3rd generation cephalosporin with good coverage against gram negative) …This patient has
bacterial meningitis (probably Neisseria Meningitidis) …Aztreonam only covers gram negative rods …Penicillin V,
Cefuroxime and Cefdinir are only available orally. Imipenem causes seizures …Cefazolin is inadequate to treat bacterial
meningitis because it covers gram positives more than negatives.


Case 18:
A 17-year-old male comes in complaining of fatigue and sore throat…He also says that he feels “tired all the time”. He is
sexually active with his girlfriend and uses condoms all the time. His temperature is 38.5C (101.3 F). On physical exam,
there is posterior cervical lymphadenopathy, symmetrical, generalized painful lymphadenopathy. There is
hepatosplenomegaly. On examining the throat, you’ve noticed enlarged tonsils with a whitish exudate and petechiae at the
junction between the hard and soft palate. His neutrophil count is low.

I- What’s the most likely diagnosis?
a. Scarlet fever.
b. Streptococcal pharyngitis.
c. Rheumatic fever.
d. Acute HIV infection.
e. Infectious mononucleosis.

II- What’s the most likely causative organism?
a. Epstein-Barr virus.
b. Cytomegalovirus.
c. Streptococcal pyogenes.
d. Human immunodeficiency virus.
e. Streptococcal agalactiae.

III- What’s the next step in diagnosis?
a. PCR.
b. Heterophile antibody test.
c. Lymph node biopsy.
d. Liver biopsy.
e. Spleen biopsy.
f. Western blot for HIV


Answers: I- (e): mono…. II- (a): EBV…. III- (b)

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Case 19: same patient

A 17-year-old male comes in complaining of fatigue and sore throat…He also says that he feels “tired all the time”. He is
sexually active with his girlfriend and uses condoms all the time. His temperature is 38.5C (101.3 F). On physical exam,
there is posterior cervical lymphadenopathy, symmetrical, generalized painful lymphadenopathy. There is
hepatosplenomegaly. On examining the throat, you’ve noticed enlarged tonsils with a whitish exudate and petechiae at the
junction between the hard and soft palate. His neutrophil count is low. You ordered a heterophile antibody test, and it
returned positive for cold immunoglobulin (IgM).

I- What is expected on peripheral smear?
a. Clue cell.
b. Target cell
c. Spur cell
d. Burr cell
e. Atypical T-lymphocyte.
f. Clock-face chromatin.
II- What class of antibiotics should be avoided in this patient?
a. Cephalosporins
b. Aminopenicillins.
c. Carbapenems.
d. Aztreonam.
e. Fluoroquinolones.




Answers:
I- (e): atypical T-lymphocyte. (CD8 positive): reactive lymphocytosis
II- (b): aminopenicillins (e.g. ampicillin, amoxicillin): risk of developing a rash is ~ 100%




Case 20: same patient
A 17-year-old male comes in complaining of fatigue and sore throat…He also says that he feels “tired all the time”. He is
sexually active with his girlfriend and uses condoms all the time. His temperature is 38.5C (101.3 F). On physical exam,
there is posterior cervical lymphadenopathy, symmetrical, generalized painful lymphadenopathy. There is
hepatosplenomegaly. On examining the throat, you’ve noticed enlarged tonsils with a whitish exudate and petechiae at the
junction between the hard and soft palate. His neutrophil count is low. You ordered a heterophile antibody test, and it
returned positive for cold immunoglobulin (IgM). His doctor was STUPID and gave him ampicillin, and he developed a
maculopapular rash.

I- What’s the mechanism of this ampicillin rash?
a. Anaphylaxis (type I hypersensitivity)
b. Cytotoxic (type II) hypersensitivity.
c. Circulating immune complexes (type III hypersensitivity) [antibodies against the aminopenicillin]
d. Delayed type (type IV) hypersensitivity.
II- After the resolution of this mononucleosis, is it safe to give this patient ampicillin in the future?
a. Yes
b. No






Answers:
I- (c): circulating immune complexes (type III hypersensitivity) [antibodies against the aminopenicillin]
II- No…In cases of mononucleosis, rash caused by aminopenicillins doesn’t constitute allergy to the drug…and the
patient should not be categorized as having penicillin allergy…He doesn’t have a penicillin allergy.





Case 21: same patient
A 17-year-old male comes in complaining of fatigue and sore throat…He also says that he feels “tired all the time”. He is
sexually active with his girlfriend and uses condoms all the time. His temperature is 38.5C (101.3 F). On physical exam,
there is posterior cervical lymphadenopathy, symmetrical, generalized painful lymphadenopathy. There is
hepatosplenomegaly. On examining the throat, you’ve noticed enlarged tonsils with a whitish exudate and petechiae at the
junction between the hard and soft palate. His neutrophil count is low. You ordered a heterophile antibody test, and it
returned positive for cold immunoglobulin (IgM). His doctor was STUPID and gave him ampicillin, and he developed a
maculopapular rash. The diagnosis of infectious mononucleosis was confirmed.

I- What’s the best treatment option for this patient?
a. Aztreonam.
b. Bed rest and NSAIDs
c. Cyclophosphamide and Rituximab.
d. Hospitalization, endotracheal intubation with mechanical ventilation.
e. Head & Neck Surgery.
f. Transfuse platelets and perform plasmapheresis.

II- What piece of patient education (advice) should you give regarding sports?
a. Avoid kissing girls from now on.
b. Avoid taking penicillins throughout his entire life.
c. Avoid contact sports like football and boxing.
d. Avoid increasing his heart rate above 200 beats/min.

III- How can you differentiate between acute HIV infection and infectious mononucleosis by physical exam alone?

-------------------------------


Answers:
I- (b). Bed rest and NSAIDs (infectious mononucleosis is self-limiting)
II- (c). Avoid contact sports because it can rupture their spleen (their spleen is bid and vulnerable).
III-




 Answers for the previous cases of infectious mononucleosis?


What’s the most likely diagnosis?
-Mono

What’s the most likely causative organism?
-EBV

What’s the next step?
-Heterophile antibody test. -Cold autoantibodies (IgM)

What will you see on peripheral smear?
-atypical T-lymphocytes (CD8 positive): reactive lymphocytosis

What class of drugs should be avoided in this patient?
-aminopenicillins (amoxicillin or ampicillin) à rash.

If the patient developed a rash due to amoxicillin, does that mean that the patient is allergic to penicillins?
-No

What’s the mechanism of the ampicillin rash?
-circulating immune complexes (antibodies against the amino-penicillin)

What’s the treatment?
-Bed rest and NSAIDs (Self-limiting).

What piece of patient education (advice) should you give regarding sports?
-Avoid contact sports à can rupture the spleen.


How to differentiate between infectious mononucleosis and acute HIV infection?
- HIV has a rash
o In mono, rash is absent (unless antibiotics were given)
- HIV has diarrhea
o Mono: no diarrhea (less common)
- HIV has no tonsillar exudate
o Mono has tonsillar exudate with palatal petechiae.

Case 22: same patient

A 29-year-old pregnant female comes in for routine prenatal checkup…She is at 7 weeks of gestation. She is sexually active
with multiple partners and use protection occasionally. You ran some tests:
Rapid plasma reagin (RPR): positive
VDRL: positive
FTA-ABS: positive.

She is allergic to penicillin.


I- What’s the best next step in management of this patient?

a. Penicillin G intramuscularly.
b. 1 dose of intramuscular procaine penicillin
c. No treatment is necessary, just follow up.
d. Ciprofloxacin
e. 3 doses of oral clindamycin.
f. Penicillin desensitization via incremental doses of oral penicillin V
g. Doxycycline






Answer (f): desensitization.






Case 23: same patient

A 29-year-old pregnant female comes in for routine prenatal checkup…She is at 7 weeks of gestation. She is sexually active
with multiple partners and use protection occasionally. You ran some tests:
Rapid plasma reagin (RPR): positive
VDRL: positive
FTA-ABS: positive.

She is allergic to penicillin.
She refuses penicillin desensitization.

I- What’s the best next step in management of this patient?
a. Penicillin G intramuscularly.
b. 1 dose of intramuscular procaine penicillin
c. No treatment is necessary, just follow up.
d. 3 doses of oral clindamycin.
e. Penicillin desensitization via incremental doses of oral penicillin V
f. Doxycycline






Answer (f): Doxycycline.







Case 24:
A 12-year-old male comes in with his mum because his cat has bitten his finger. On exam, there is a cut surrounded by
erythema and mild tenderness. Vital signs are normal.

I- What’s the best method for anaphylaxis?
a. Penicillin V
b. TMP-SMX
c. Piperacillin-Tazobactam.
d. Amoxicillin-Clavulanate
e. Levofloxacin
f. Doxycycline
II- What if he is allergic to penicillin?
a. Penicillin V
b. TMP-SMX
c. Piperacillin-Tazobactam.
d. Amoxicillin-Clavulanate
e. Levofloxacin
f. Doxycycline




Answers:
I- D. amoxicillin/clavulanate
II- F. doxycycline






Case 25:
Sam is a heroin addict has decided to take control of his life and change…He sought medical help, and is now on
methadone…He then developed fever, night sweat, night fever, weight loss, cough that is productive of blood-tinged
sputum, as well as frank hemoptysis. Sputum analysis revealed an acid-fast bacillus. His doctor prescribed a medication to
take care of his lung infection. Later, he developed mood changes, anxiety, irritability, insomnia, aches, pain, diarrhea, fever
as well as heroin craving.

I- What was the drug that was prescribed to take care of the lung infection?
a. Dapsone
b. Rifampin
c. Isoniazid
d. Ethambutol
e. Pyrazinamide
f. Hydroxychloroquine
g. Metronidazole






Answer: (b) rifampin…This patient is experiencing “withdrawal symptoms” while on methadone, which means that the
methadone is no longer present in the system, may be because it’s been metabolized too fast (P450 inducer)…Therefore,
rifampin is the correct answer.








Case 26:
A newborn baby presents with hepatosplenomegaly, jaundice, anemia, hyperbilirubinemia and intermittent fever. You
noticed a saddle nose, clear rhinorrhea and secretions around his nose. On examining the oral cavity, there are blunted
upper incisors.
Abdominal exam reveals hepatosplenomegaly. There are some ulcerative lesions on his palms and soles. X-rays show
metaphyseal dystrophy as well as periostitis. His tibia has a sharp anterior bowing.

I- What’s the most likely diagnosis?
a. Congenital Toxoplasmosis.
b. Congenital Syphilis.
c. Congenital Rubella.
d. Congenital CMV infection.
e. Neonatal herpes simplex.
f. Chickenpox.

II- Which of the following could have prevented this newborn’s disease if given earlier?
a. 1 dose of intramuscular benzathine penicillin (penicillin G) 2.4 million units.
b. 3 doses of intramuscular benzathine penicillin (penicillin G) once a week, over a 3-week period.
c. Aqueous penicillin G, 3-4 million units IV every 4 hours for 10-14 days.
d. Procaine penicillin G, 50,000 U/kg dose IM a day in a single dose for 10 days
e. Aztreonam.


Answer:
I- (a) Congenital syphilis
II- (d) Procaine Penicillin G 50,000 U/kg IM for 10 days.
You have 2 options to prevent congenital syphilis in newborns:
i. Aqueous penicillin G 50,000 units/kg intravenously (IV) every 12 hours (for infants ≤7 days of age) and
every 8 hours (for infants >7 days of age) for a total of 10 days, or
ii. Procaine penicillin G 50,000 units/kg intramuscularly (IM) as a single daily dose for 10 days.


Case 27:
A 21-year-old male comes in complaining of fatigue, headache, muscle aches.
Vital signs: temperature is 38C (100.4F), BP 120/80 mmHg, HR 100 Beat/min, RR 20/min.
On first look, his physical exam was non-concerning.
He mentioned that he went hiking in Maine 10 days ago. So, you decided to repeat the exam again, and discovered a
circular, red-to bluish, erythematous rash with central clearing on his left buttock. He doesn’t recall being bit by any bug.
He also owns a cat.

I- What’s the most likely diagnosis?
a. Babesiosis.
b. Cat scratch disease.
c. Toxoplasmosis.
d. Early localized Lyme disease.
e. Early disseminated Lyme disease.
f. Late disseminated Lyme disease.

II- What’s the best treatment option?
a. IV ceftriaxone
b. Pyrimethamine-Sulfadiazine
c. Penicillin G
d. Doxycycline
e. Aztreonam
f. Gentamycin
g. Amoxicillin

III- What should the patient avoid as much as possible?
a. Alcohol consumption.
b. Sunlight exposure.
c. Contact sports.
d. Kissing.
e. NSAIDs

Answers: I. (d) early localized Lyme…….. II. (d) Doxy is DOC for early localized Lyme…….III. (b) sunlight exposure (Tetracyclines are photoToxic).
Alternatives to doxycycline are amoxicillin, azithromycin, or cefuroxime (2nd generation cephalosporin).
Doxycycline is preferred because it’s also the DOC for other tick-borne illnesses such as Anaplasma phagocytophilum which may co-exist with lyme.
 AfraTafreeh.com exclusive

Case 28: (same patient)

A 21-year-old male comes in complaining of fatigue, headache, muscle aches.
Vital signs: temperature is 38C (100.4F), BP 120/80 mmHg, HR 100 Beat/min, RR 20/min.
On first look, his physical exam was non-concerning.
He mentioned that he went hiking in Maine 10 days ago. So, you decided to repeat the exam again, and discovered a
circular, red-to bluish, target-like rash on his left buttock. He doesn’t recall being bit by any bug.
He also owns a cat.

I- Suppose that the patient was younger than 8 years old, what would be the drug of choice?
a. Amphotericin B
b. Pyrimethamine-Sulfadiazine
c. Penicillin G
d. Oral Doxycycline
e. Aztreonam
f. Gentamycin
g. Oral Amoxicillin

II- Suppose that the patient was a pregnant woman, what would be the drug of choice?
a. IV ceftriaxone
b. Pyrimethamine-Sulfadiazine
c. Penicillin G
d. Oral Doxycycline
e. Aztreonam
f. Gentamycin
g. Oral Amoxicillin






Answers:
I. (g): Doxycycline is a tetracycline: it’s teratogenic and can cause irreversible teeth discoloration, bone growth problems à growth stunting.
II. (g): Doxycycline is a tetracycline: it’s teratogenic and can cause irreversible teeth discoloration, bone growth problems à growth stunting.



Case 29: same patient
A 21-year-old male comes in complaining of a red, dry eye as well as joint pain. He says: “I feel as if there is sand in my eye”
Vital signs: temperature is 39C (102F), BP 120/80 mmHg, HR 50 Beat/min, RR 20/min.
On physical exam, there is generalized lymphadenopathy, bilateral Bell’s palsy, conjunctivitis, multiple skin rashes, each
one is circular, red-to bluish, and target-like.
ECG revealed an AV nodal block.
He mentioned that he went hiking in Maine 1 month ago.

I- What’s the most likely diagnosis?
a. Babesiosis.
b. Cat scratch disease.
c. Toxoplasmosis.
d. Early localized Lyme disease.
e. Early disseminated Lyme disease.
f. Late disseminated Lyme disease.

II- Suppose that the patient was a pregnant woman, what would be the drug of choice?
a. IV ceftriaxone
b. Pyrimethamine-Sulfadiazine
c. Penicillin G
d. Oral Doxycycline
e. Aztreonam
f. Gentamycin
g. Amoxicillin





Answers:
I. (e): early disseminated Lyme disease
II. (a): IV ceftriaxone: the treatment of choice for early disseminated Lyme or late disseminated Lyme is IV ceftriaxone.





Case 30:
A 32-year-old man has recently migrated from Tanzania. He complains of a painful lesion on his penis. He is sexually active with multiple
partners. On physical exam, his penis is uncircumcised, there are multiple, tender ulcers on his penis. Each ulcer measures about 1-2 cm in
diameter, has a soft base, a sharply defined, irregular, ragged border with undermined edges and yellow/grey pus in the base. There is an
enlarged, tender inguinal lymph node. You took a sample and examined it under the microscope using the Gram stain and Wright- Geimsa stain.
You observed pleomorphic, gram-negative rods clumping in parallel strands in a “school of fish” pattern. He is allergic to penicillin.

I- What’s the most likely causative organism?
a. Treponema pallidum
b. Hemophilus ducreyi
c. Herpes simplex virus-2 (HSV-2)
d. Chlamydia trachomatis.
e. Neisseria gonorrhea.

The culture confirmed your diagnosis

II- What’s the next step in management?
a. Ceftriaxone
b. Azithromycin
c. Penicillin G
d. Penicillin V
e. Metronidazole


Answers:
I- (b) Hemophilus ducreyi (Chancroid)
II- (b) azithromycin.
The treatment of choice is
Ceftriaxone or
Erythromycin or Azithromycin or
Ciprofloxacin
But, since this patient is allergic to penicillin, so you cannot use ceftriaxone, therefore azithromycin is the correct answer.

Complications: Become indurated & fluctuant —> Form a large draining sinus —> buboes.


Case 31:
A 23-year-old male with — a history of bronchiectasis since childhood — comes in complaining of coughing up mucus with
brown plugging. He says that his medications are not working any more…He has also noticed that he has coughed up
blood twice in the last month…He doesn’t smoke and denies any blood in the urine...CBC is evident of eosinophilic
leukocytosis and increased serum IgE. Several chest x-rays over the course of 3 months revealed recurrent fleeting,
transient pulmonary infiltrates with tram-tracking. Also, there was a cavity in the apex of the right lung.

I- What’s the most likely diagnosis?
a. Acute interstitial pneumonia (AIP)
b. Chronic interstitial pneumonia (CEP)
c. Mild persistent asthma.
d. Langerhans cell histiocytosis (LCHC)
e. Allergic bronchopulmonary Aspergillosis (ABPA)
f. Lymphangioleiomyomatosis (LAM)

II- What’s the best treatment option?
a. Clindamycin.
b. Metronidazole.
c. Itraconazole plus oral steroids.
d. Piperacillin-Tazobactam.
e. Gentamycin.
f. Nystatin

Answer:
I- e. Allergic bronchopulmonary Aspergillosis (ABPA)
II- c. Itraconazole + oral steroids.

History of asthma or cystic fibrosis that is not responding to Tx, chronic cough, mucus plugging, eosinophilia& recurrent
transient lung infiltrates = ABPA.



Case 32:

A 39-year-old HIV-positive patient comes in complaining of cough that is productive of thick sputum.
His temperature is 38.8 C (101.84 F), other vital signs were within normal limits. On percussion, there was dullness on the
right lower side. On palpation, there was increased tactile vocal fremitus. On auscultation, there were diminished breath
sounds in the same location.
Sputum sample revealed branched, irregular, gram-positive, filamentous rods.
Chest x-ray revealed a 4-cm nodule in the right lower lobe with cavitation and right-sided pleural effusion.

I- What’s the most likely diagnosis?
a. Allergic bronchopulmonary aspergillosis (ABPA)
b. Lymphangioleiomyomatosis (LAM)
c. Primary tuberculosis.
d. Histoplasmosis.
e. Nocardia infection
f. Pneumocystis jirovecii pneumonia.
II- What’s the treatment of choice?
a. TMP-SMX
b. Penicillin V
c. Doxycycline
d. Ceftriaxone
e. Ciprofloxacin
f. Moxifloxacin

Answer
I- (e) -Nocardia
II- (a)- TMP-SMX (sulfonamide) is the drug of choice for nocardia





Case 33:

A 52-year-old male comes in complaining of cough and dyspnea…He has a pack year smoking history of 35…His
cough is productive of cupfuls of mucus. Vital signs are normal except for a respiratory rate of 8/min....He has central
cyanosis on physical exam. He experience frequent exacerbations. He is not compliant with his inhalers.
His ABG lab results:
• pH: 7.2
• PaCO2: 50 mmHg.
• HCO3: 30 mEq/L.


I- Which of the following antibiotics can help?
o a. Piperacillin- tazobactam
o b. azithromycin.
o c. clindamycin.
o d. rifampin
o e. streptomycin.
o f. fluoroquinolones





Answer:
I- (b) azithromycin can help in cases of COPD exacerbations.






Case 34:
A 59-year-old patient was endotracheally intubated and mechanically ventilated, then 3 days later, he developed new
fever of 104F (40C), leukocytosis, lung infiltrates on radiograph, and cough productive of purulent sputum.
A diagnosis of ventilator-associated pneumonia was made.

I- What’s the best empirical treatment if the pneumonia started within 1-4 days after admission?
a. Clindamycin
b. Doxycycline
c. Metronidazole
d. Piperacillin-tazobactam.
e. A Beta-lactam + respiratory fluoroquinolone.
f. Two antipseudomonal penicillins + Vancomycin.
g. TMP + SMX

II- What’s the best empirical treatment if the pneumonia started after 5 days of admission?
a. Clindamycin
b. Doxycycline
c. Metronidazole
d. Piperacillin-tazobactam.
e. A Beta-lactam + respiratory fluoroquinolone.
f. Two antipseudomonal penicillins + Vancomycin.
g. TMP + SMX

Answers:
I- (e): beta-lactam + fluoroquinolone
II- (f): 2 anti-pseudomonal antibiotics (for pseudomonas) + vancomycin/ Linezolid (for MRSA)
Explanation: the treatment of ventilator-associated pneumonia depends on the time frame.
• 1-4 days after admission: the organism is usually streptococcus pneumoniae, Hemophilus influenza, or klebsiella
(CAP)
• ≥5 days after admission: the organism is Staph aureus, MRSA or Pseudomonas.


Case 35:

A 48-year-old homeless man was brought to the emergency department because of loss of consciousness…He has regained
his consciousness and is hemodynamically stable. His temperature is 104F (40C). He has a very bad oral hygiene and many
rotten teeth. His sputum is foul-smelling. His coughing changes with changing body positions. While he was talking to you,
he suddenly coughed up blood. CXR revealed a cavity with an air-fluid level in the upper lobe of his right lung. CBC reveals
neutrophilic leukocytosis.

Which of the following is the treatment of choice?
a- TMP-SMX
b- Moxifloxacin
c- Metronidazole
d- Clindamycin
e- Ampicillin
f- Piperacillin-tazobactam
g- Ceftriaxone
h- Doxycycline
i- Vancomycin







Answer:
(d) Clindamycin: is the treatment of choice for lung abscess.






Some notes about nocardia.

Nocardia is:
• Gram positive bacillus
• aerobic
• branching,
• filamentous
• weakly-acid-fast
• found in the soil and dead decaying matter,
• Pulmonary nocardiosis
o immunocompromised (HIV, post-transplant).
o inhalation exposure
o fever, cough, sputum
o localized pneumonia, endobronchial mass. (consolidation)
o lung abscess, cavitation, empyema
o pleural effusion.
o can mimic TB.
o Tx:
§ antibiotics for 6 moths.
§ Sulfonamide is the #1 choice.
§ e.g. sulfisoxazole.
















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