Micro (6).

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96. A 6-day old infant was brought to the paediatrician as her mother complained that her child
does not feed well and she is hot to the touch. On physical examination; the child appeared to
be weak, lethargic and seemed to have lost her will to thrive. CSF cultures from the neonate
reveal motile Gram-negative rods that form pink colonies on MacConkey agar. Which of the
following is the most important bacterial factor in the development of this infection?

A. Capsule
B. Verotoxin
C. 0 antigen
D. Fimbrial antigen
E. Lipid A

97. A 48-year-old Caucasian male presents to the emergency department following an episode of
seizure. Blood works revealed that he was retropositve and Physical examination reveals oral
thrush and cervical lymphadenopathy. An MRI of his brain with contrast shows hypointense,
ring- enhancing lesions.

Which of the following is the most likely cause of his symptoms?

A. Neurocysticercosis
B. Mycobacterium tuberculosis
C. Toxoplasmosis
D. Aspergillus fumigatus
E. Glioblastoma multiforme
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98. A 23-year-old migrant electrician from Mexico was brought to the emergency room with painful
paroxysmal involuntary muscle contractions involving mainly the jaw, neck and trunk. Clinical
history revealed that he had had an accident recently at work that caused a tear in his neck area
around the sternocleido mastoid. The causative substance has most likely traveled by which of
the following routes?

A. Wound, neuron axons, salivary glands

B. Wound, motor neuron axons, spinal cord
C. Fibrinous exudate, systemic circulation, cortical neurons
D. Food, systemic circulation, meninges
E. Food, systemic circulation, peripheral nerves

99. A 22-year-old male is brought to the emergency room in delirium and with a high fever,
vomiting and headaches. Physical examination reveals nuchal rigidity and Kernig’s sign was
found positive and an echymotic purpuric rash was observed on his trunk. This infection could
have been prevented by a vaccine containing:

A. Heat-killed bacteria
B. Bacterial outer membrane protein
C. Capsular polysaccharide
D. Inactivated toxin
E. Live attenuated bacteria

100. A 7-year-old girl is brought to the emergency unit of the hospital by her worried mother
who told the clinician that the girl had been complaining of headaches for the past two days and
had vomited this morning before coming to the hospital. All of his vaccinations are up-to-date
and she has no significant past medical history. On examination, she has mild pharyngeal
erythema in addition to significant neck stiffness and fever. Cerebrospinal fluid analysis reveals
the following:

Glucose 85 mg/dL
Protein 80 mg/dL
Leukocytes 300 cells/µL

Differential
Neutrophils 15%
Lymphocytes 85%
Red blood cells none

Which of the following infectious agents is most likely to have caused his illness?
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A. Streptococcuspneumoniae
B. Echovirus
C. Mumps virus
D. Coronavirus
E. Neisseria meningitidis
F. Cryptococcus

101. A 59-year-old man reports to his primary care physician to get his rash evaluated that
caused him immense pain in that area. The patient has a localized rash on his chest which
follows a T7 dermatomal distribution and does not cross the midline. He said that he had
travelled to Portugal recently and denies having smoking or drinking while on his trip. Clinical
examination shows that the rash is vesicular on a red base. Serology reveals that the patient is
positive for varicella lgG antibodies. Which of the following is the most accurate statement
about this patient's condition?

A. The patient is susceptible to chickenpox

B. The patient has primary infection with varicella-zoster virus
C. The patient has reactivation of varicella-zoster virus
D. The patient has never been vaccinated against varicella-zoster virus
E. Strong cell-mediated immunity against varicella-zoster virus is likely

102. A young man aged 36 went on a trip to New Mexico to study insect and bat behavior in
the caves on the outskirts of the city limit. This was part of his research project for dissertation
and defense. But after three weeks; his friends noticed that he was disoriented with fever and
severe agitation. They administered paramol but to no effect as his condition worsened that he
could not stand the sight of food and water as he would spasm leading to choking and excessive
salivation. He also develops sensitivity to light and became aggressive as the days went by.
Several days later, he lapses into a coma and dies. The virulence of this infection is due to its
ability to bind to which of the following receptors?

A. Acetylcholine receptors
B. Cellular integrins
C. CD4 receptors
D. CR2 (CD21) receptors
E. ICAM-1

103. A 21-year-old Caucasian male was brought to the hospital as he was complaining of
fever and headache. On physical examination; he was found to have rashes on his extremities
and trunk with positive Brudzinski’s sign. CSF specimen was collected and reveals bean-shaped
Gram-negative cocci in pairs. Which of the following is the most likely route of meningeal
contamination in this patient?
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A. Pharynx, lymphatics, meninges

B. Middle ear, contiguous tissues, meninges
C. Traumatic wound, leaking CSF, meninges
D. Pharynx, blood, choroid plexus, meninges
E. Primary lung focus, blood, meninges

104. A 2.5-month-old infant is brought to the hospital as the concerned parents related to
the paediatricain stating that their child was irritable, fed poorly, was lethargic with fever. His
current weight is at the 45th percentile and his head circumference is at the 96th percentile.
Head CT shows enlarged ventricles and scattered intracranial calcifications. Which of the
following is the most likely cause of this patient's condition?

A. Chromosomal abnormality
B. Single gene disease
C. ln-utero infection
D. lntrapartum infection
E. Postpartum infection

105. A recent outbreak in the community; prompted health officials to survey the symptoms
and the cause for the morbidity and mortality of the people affected. A number of them,
showed signs of nausea, vomiting and headaches. Food poisoning was ruled out as a cause.
Further investigations into the symptoms revealed that most who were affected had distinctive
rash and these patients were sent to the nearest emergency department for further workup
and treatment. Several of the blood cultures revealed gram-negative diplococci. The blood
concentration of which of the following microbial components would show the closest
correlation with these patients' morbidity and mortality?

A. Outer membrane lipooligosaccharide

B. Outer membrane protein
C. Inner membrane protein
D. Capsular polysaccharide
E. Exotoxin

106. A 37-year old male, presents with focal dystonia of the sternocleidomastoid muscle such
as torticollis. In order to relieve his pain, the doctor injects a specific bacterial product that,
produces a dramatic but temporary relief of symptoms for about 3 months. This substance is
produced by bacteria that demonstrate:

A. Antiphagocytic capsule
B. Hypervariable pili
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C. lgG-binding outer membrane protein

D. Intracellular polyphosphate granules
E. Subterminal spore formation

107. An 8-year-old boy, an immigrant from Indonesia, complains of difficulty walking. He

reports that several days ago, he had an episode of fever, headache and diarrhoea that lasted
for 2-3 days. He was also photophobic and experienced pain on eye movement. On physical
exam today, there is weakness of right leg extension and the right patellar reflex is 1+. Lumbar
puncture and PCR yield viral RNA from the CSF. This patient has an infection that was most likely
transmitted through which of the following routes?

A. Fecal-oral
B. Respiratory
C. Sexual
D. Insect bite
E. Blood transfusion

108. The following vignette applies to the next 2 items. The items in the set must be
answered in sequential order.

A 43-year-old HIV-retropositive male with a history of non-compliance to HAART is brought to

the emergency department with new-onset symptoms of fever, headache and altered mental
status. He had recently suffered generalized tonic-clonic seizures as well. According to his
family, , he has not had much of an appetite and has recently spent most of his time in bed. An
MRI of the head demonstrates two spherical hypointense lesions with surrounding edema in the
right frontal lobe.

Item 1 of 2
Initial treatment of this patient should include which of the following?

A. lsoniazide and rifampin

B. Pyrimethamine and sulfadiazine
C. Ganciclovir
D. Ampicillin
E. Amphotericin B
F. Radiation

Item 2 of 2
The patient does not improve with treatment and a blood sample taken for analysis shows
positive reaction for heterophile antibodies and viral DNA sequences are detected in the
cerebrospinal fluid. Tissue biopsy from the frontal lobe lesions is most likely to contain a
population of which of the following cells?
Micro (6).docx

A. Macrophages
B. B-lymphocytes
C. T-lymphocytes
D. Eosinophils
E. Oligodendrocytes

109. A 64-year-old man suffers severe headache and nausea. His care-taker noticed that he
was confused and dazed. She brought him to the local clinic for assessment. On physical
examination, his temperature is 38.3 C (101 F) and nuchal rigidity is present. Lumbar puncture
and cerebrospinal fluid (CSF) examination show:

Opening pressure 300 mm Hg

Glucose 20 mg/dL
Protein 200 mg/dL
RBCs 4 cells/µL
Leukocytes 760 cells/µL
Neutrophils 90%
Lymphocytes 10%

Gram stain of the CSF would most likely reveal which of the following?

A. Bean-shaped, Gram-negative cocci in pairs

B. Lancet-shaped, Gram-positive cocci in pairs
C. Gram-positive cocci in clusters
D. Non-motile Gram-negative coccobacilli
E. Motile Gram-positive rods

110. A 47-year-old male who was hospitalized six months ago with viral esophagitis and two
months ago with pneumocystic pneumonia is brought to the ER with a one-week history of
headaches and progressive confusion. CSF that was obtained was subject to preliminary
microscopy under nigrosine staining and subsequently serology followed with a positive latex
agglutination.
Light microscopy of this patient's CSF is most likely revealed:

A. Non-septate hyphae
B. Germ tubes
C. Budding yeast
D. Spherules
E. Sporangium
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111. A 54-year-old Caucasian male with a CD count of < 150 cells/mm 3 complains of nausea,
headaches and fever. Lumbar puncture was done and his CSF shows a positive serology for a
polysaccharide antigen on latex agglutination. Which of the following is the most likely primary
focus of this patient's infection?

A. Nasopharynx
B. Lungs
C. Intestine
D. Skin
E. Urinary tract

112. A 25-year-old male is hospitalized with complaints of a sudden onset dysphaigia and
diplopia. He recalled that he had never had such symptoms like this before. Routine nerve
stimulation studies show normal nerve conduction velocity but decreased compound muscle
action potential. The patient should be carefully questioned about:

A. Missed vaccinations
B. Recent travel
C. Unprotected sexual contacts
D. Home-canned food consumption
E. Family history
F. Recent antibiotic use

113. A child aged 9 years was admitted to the hospital with difficulty walking over the last
two days accompanied by tingling in his feet. Physical examination reveals decreased muscular
strength in the bilateral lower extremities with absent deep tendon reflexes. His review of
systems and past medical history are unremarkable except that his mother recalled that a one of
the puppies in the brood had had diarrhoea two weeks ago that resolved spontaneously, after
which her child fell sick. Which of the following agents is most likely associated with this
patient's condition?

A. Vibrio
B. Campylobacter
C. Salmonella
D. Shigella
E. Escherichia
F. Clostridium

114. A spate of reports from Sudan indicate that there is rise in the incidence of neonatal
tetanus (first 28 days after the birth). Which of the following measures would be the most
appropriate prevention measure to control the problem?
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A. Routine vaccination at birth

B. Peripartal antibiotics
C. Vaccination of young adults
D. Early postpartum breastfeeding
E. Extended postpartum hospital stay

115. A young teenager aged 16 years is brought to the hospital with symptoms of fever,
headache and vomiting with lowered pulse pressure. He was found to be sensitive to light. On
clinical examination; he was found to have echymotic rashes on his thorax and hands. He was
immediately admitted to the ICU for treatment and management when he succumbed the
following day due to shock. Autopsy shows extensive hyperemia and infarcts of his internal
organs and hemorrhagic destruction of both adrenals are also present. The organism most likely
responsible for this patient's death more commonly causes which of the following?

A. Urinary tract infection

B. Pneumonia
C. Infectious diarrhea
D. Endocarditis
E. Meningitis
F. Skin infection

116. If a pharmaceutical company embarks on a research project to develop monoclonal

antibodies to the meningococcal pilus, believing that these antibodies may decrease the risk of
infection by meningococci, these antibodies would directly interfere with which of the following
processes?

A. Intestinal attachment
B. Endothelial adhesion
C. Pharyngeal colonization
D. Incomplete phagocytosis
E. Hematogenous dissemination

117. A 12-year-old boy complains of headache and vomiting to his mother. She noticed that
he had high fever. She rushed him to the local clinic and explained to the physician that her child
became unresponsive on the way to the hospital. On physical examination, his temperature is
38.3° C (101° F), and passive flexion of the neck results in spontaneous flexion of the hips and
knees. Blood cultures grow coagulase-negative Staphylococcus. Which of the following is the
most important virulence mechanism by which this bacterium causes disease?

A. Intracellular existence
B. Outer polysaccharide capsule
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C. Presence of protein A on the cell wall

D. Release of exotoxins
E. Synthesis of an extracellular polysaccharide matrix

118. A 42-year-old man treated on chemotherapy, comes to the emergency department with
a 2-week history of headaches and fever. Lumbar puncture reveals an elevated opening
pressure and cerebrospinal fluid analysis shows moderately increased protein levels with a low
glucose concentration. Light microscopy of his cerebrospinal fluid shows the following:

The patient should be treated initially with which of the following?

A. Ceftriaxone
B. Ampicillin
C. Acyclovir
D. Amphotericin B
E. Isoniazid
F. Pyrimethamine

119. A 20-year-old exchange student from the US was deputed for a period of 50 days, on a
project to Malawi bat caves. Quite recently his friends noticed that he suffered with recent
onset insomnia, headaches, periodic agitation and dysphagia. He was brought to the hospital
when he grew aggressive with excessive salivation. His past medical history is insignificant.
Despite hospitalization and treatment, he becomes comatose and dies. Which of the following
interventions would have most likely prevented this student's illness?

A. Live attenuated vaccine

B. Viral component vaccine
C. Killed vaccine
D. Toxoid vaccine
E. Viral enzyme inhibitor drug
F. Cellular receptor inhibitor drug
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G. Interferons
120. A sexually active young woman aged 24 years consults her gynaecologist due to her
painful, vesicular lesions on her genitalia. She was initiated for treatment and six months later;
foreign double-stranded DNA fragments in the neuron bodies of a sacral sensory ganglia were
isolated and these are strongly associated with which of the following conditions?

A. Chronic demyelinating disease

B. Recurring painful genital rash
C. Invasive cervical carcinoma
D. Tabes dorsalis
E. High-grade non-Hodgkin lymphoma

121. A 49-year-old male was admitted to the hospital due to altered sensorium, fever,
headache and vomiting. His past medical history is significant for a recent kidney transplantation
and he is on prednisolone for the past 5 weeks. Lumbar puncture reveals CSF pleocytosis and a
normal CSF glucose concentration. Gram positive rods with tumbling motility at room
temperature are seen on CSF microscopy. How was this patient's infection most likely
transmitted?

A. Unprotected sex
B. Contaminated food
C. Respiratory droplets
D. Arthropod bite
E. Needle stick

122. Sustained state of contractions were observed in an Australian aborigine who was
rushed to the hospital. This was surmised to be due to neurotransmitter release from certain
spinal cord inhibitory interneurons that inhibit polysynaptic spread of impulses and insures
proper functioning of agonist and antagonist skeletal muscles leading to tonic contractions.
Absence of agonist/antagonist muscle coordination and sustained impulse spread leading to
spasm can result from inadequate release of:

A. GABA due to C.difficile toxin

B. Acetylcholine due to C.botulinum toxin
C. Glycine due to C.tetanitoxin
D. Serotonin due to P.aeruginosa toxin
E. Norepinephrine due to S.aureus toxin

123. Placental biopsy of a still born neonate revealed granulomatous infiltrations. Autopsy
findings indicated granulomas in the liver and spleen. Blood was cultured that yielded motile
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Gram-positive rods that produce a very narrow zone of beta-hemolysis on sheep blood agar.
Which of the following processes is most important in eliminating these bacteria from the body?

A. Terminal complement cascade

B. Eosinophil action
C. lmmunoglobulin secretion
D. Neutrophil oxidative burst
E. Cell-mediated immunity

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