Hospital

acquired,
Opportunistic,
Fungal and
Zoonotic
Pneumonia
 Q1. A man in his thirties developed weakness, fatigue, dry
cough, and progressive exertional dyspnea of 2 days' duration,
6 months after an allogeneic bone marrow transplant for
aplastic anemia which was complicated by graft versus host
disease (GVHD). Medications included prednisone (30 mg per
day), cyclosporine, mycophenolic acid. Physical Examination:
The temperature was 96.5°F (35.8°C). Oxygen saturation was
89% while breathing room air. Skin examination revealed a
desquamating rash consistent with his known GVHD. A BAL is
sent to the laboratory for microscopy. No organism seen on
Gram stain. Silver stain is attached. Which of the following is
the most likely cause for his infection?
A. Streptococcus pneumoniae
B. Pneumocystis jirovecii
C. Cryptococcus pneumoniae
D. Cytomegalovirus
E. Mycobacterium tuberculosis
Gomorri methanamine silver
stain
F. Atypical Mycobacteria
 Q2. Which of the following is a characteristic of the
organism?

A. Obligate intracellular fungus

B. Cannot be cultured on artificial media in the
laboratory
C. Infects Type II pneumocytes
D. Sensitive to azoles
E. Pneumonia caused by the organism in AIDS
prevented by prophylaxis when CD4 <50

Toluidine blue stain

Q3. A Fifty-six-year-old male presents to the acute care clinic with a two-week history
of fever, night sweats, cough, hemoptysis, headache, fatigue, myalgia and weight loss.
He works as a salesman for a company and travels a lot within the US. He has taken
leave from work as he cannot keep up with the travelling. He said he is on steroids and
Adalimumab to take care of painful joints.
Px: T 38.60 C, Pulse 96/min, RR 24/min, BP 124/82mmHg. Crackles were noted on
auscultation. Imaging-CXR: remarkable for multiple nodular infiltrates in both lung
fields, enlarged hilar and mediastinal nodes. Bronchial washings sent for Acid Fast stain
and Gram stain did not reveal any organisms. Giemsa stain revealed 2-4 micrometer
budding yeast (picture). Which of the following is a likely cause for his present illness?
a. Side effect of Adalimumab
b. Reactivation of tuberculosis
c. Candida pneumonia
d. Reactivation of Histoplasmosis
e. Lung abscess
Q4. Jenny and Danny both hail from Philippines. They are students of archeology at UCLA and
avid “outdoors persons” in their mid-30s. In the past 3 months, they had been spelunking
(cave exploring) and backpacking in northern Wisconsin, Utah and camping in Arizona. About
two weeks back they both suffered from a flulike illness, and Jenny developed a
nonproductive cough. They sought medical attention at the student practice clinic. At the
clinic, Danny appeared fine, but Jenny was noted to be quite short of breath and appeared ill.
She also had a rash as shown in the picture. The doctor thought it would be a good idea to get
a chest radiograph for Jenny. Danny got one too, just in case. Jenny’s chest radiograph showed
a diffuse infiltrates with enlarged hilar lymphnodes. Giemsa stain of BAL is shown below.
Which of the following is the infective form of the pathogen?

a. Tuberculate conidia
b. Arthrospores
c. Spherules
d. Broad based bud
e. Budding yeast
Q5. Which of the following finding is seen only in infections caused by
this organism when compared to infections caused by other dimorphic
fungi?

a. Yeast forms within macrophages

b. Dissemination to skin
c. Eosinophilia
d. Meningitis as a complication
e. Granuloma formation
f. Latency and reactivation
Prompt: Does Danny’s ethnic origin predispose him to
developing any complications?
Q6. A 55-year-old woman was admitted with a recurrence of
poorly differentiated squamous cell carcinoma of the cervix. She
underwent extensive gynecologic surgery and was maintained
post operatively on broad spectrum intravenous antibiotics. The
patient had a central venous catheter placed on the day of the
surgery. Beginning 3 days postoperatively, the patient had
temperatures of 38.50 C, which persisted without a clear source.
On day 8 post operatively, she had a temperature of 39.20C and
pneumonia.
Blood work shows neutropenia
Bronchial washings, cultures of blood, and tip of the central line
all grew an organism as shown in the picture.
Which of the following most likely contributed to the growth of
this organism in the blood of this patient?
A. Complement 5 deficiency
B. Hypogammaglobulinemia
C. Low eosinophil count
D. Low neutrophil count
E. Low T lymphocyte count
Q7. A man in his fifties with a history of non-Hodgkins lymphoma presented with facial
pain and diplopia of three days' duration. He had undergone chemotherapy two weeks
before presentation. Physical Examination: The temperature was 99.5°F (37.5°C). There
was left sided proptosis with pain and diplopia on upward gaze. white blood cells (WBC)
was 2,100 cells/mm³ and neutrophils 400 cells/mm³. The CT scan shows complete
opacification of the left maxillary sinus. There was erosion of the inferior orbital plate
with the mass extending into the orbit below the inferior rectus muscle. A surgical
debridement procedure was performed. Histologic examination of the resected
specimen is shown. Which of the following is the virulence of this pathogen?

A. Polysaccharide capsule
B. Angioinvasive
C. T cell suppression
D. Neurotropic
Q8. Which of the following is another risk factor for infection with this pathogen?

A. B cell deficiency
B. Agammaglubulinemia
C. Chronic granulomatous disease
D. T cell deficiency
E. Eosinophilia
Q9. A 35-year-old woman presents to the ER with confusion and lethargy. On PE she is
found to be tachypneic and tachycardic, and her breath smells like nail polish remover. A
review of her electronic record reveals that she was diagnosed with type 1 diabetes
mellitus at age 12. She is admitted to the hospital and treated for diabetic ketoacidosis,
and her symptoms begin to improve. However, 4 days after admission she develops fever,
mucoid nasal secretions and periorbital swelling. She is treated with empirical antibiotics
but fails to improve. The following day, an examination of nasal cavity revealed the
following under microscopy. Which of the following is a predisposing factor for infection
with this pathogen?
A. T cell deficiency
B. HIV
C. Neutropenia
D. B cell deficiency
E. IgA deficiency
Q10. Which of the following are the most common cause of community
acquired pneumonia in an AIDS patient? (more than one answer)

A. S. pneumoniae
B. Mycoplasma pneumoniae
C. Pneumocystis jirovecii
D. Mycobacterium avium intracellulare
E. Legionella pneumophila
F. Cytomegalovirus
Wrap up