Which of the following viruses produce disease or sequelae that is/are more severe if the infection

occurs at a very young age?

A. Epstein-Barr virus

B. Hepatitis B virus

C. Measles virus

D. Poliovirus

E. Varicella zoster virus

Explanation:

The correct answer is B. Infection with Hepatitis B virus (HBV) at birth or a very young age is
associated with chronic HBV infection and the development of hepatocellular carcinoma later in
life. In fact, infants born to Hepatitis B surface antigen (HBsAg)-positive mothers are
commonly infected, and approximately 90% become chronic carriers of the virus. Chronic carriers
suffer from hepatocellular carcinoma at an incidence over 200 times higher than a noncarrier.
The current recommendation for infants born of HBsAg-positive mothers is administration of
hepatitis B immunoglobulin (HBIg) in the delivery room, with the first dose of the hepatitis B
vaccine given at the same time or within 1 week. The second and third dose of the vaccine are
then given at 1 and 6 months. With this protocol, 94% protection is achieved.

The Epstein-Barr virus (EBV; choice A) is the agent of heterophile-positive infectious

mononucleosis. In children, primary EBV infection is often asymptomatic.

The measles virus (choice C) often causes a more severe disease in adults. Over the age of 20,
the incidence of complications, including pneumonia, bacterial superinfection of the
respiratory tract, bronchospasm and hepatitis, is much higher than in children.

Poliovirus (choice D) causes asymptomatic or inapparent infections 95% of the time. Frank
paralysis occurs in approximately 0.1% of all poliovirus infections. However, the probability
of paralysis increases with increasing age.

Varicella zoster virus (choice E) is the agent of chickenpox and shingles. In immunocompetent
children, it is a benign illness with a mortality of less than 2 per 100,000 cases. This risk
is increased over 15-fold in adults. Much of the increase is due to varicella pneumonitis, a
complication that occurs more frequently in adults.

A 40-year-old otherwise healthy gardener presents with several subcutaneous nodules on his right hand,
where he had cut himself on rose thorns. Physical exam reveals several erythematous fluctuant
lesions. Which of the following organisms is most likely responsible for his condition?

A. Aspergillus

B. Malassezia

C. Onchocerca

D. Rhizopus

E. Sporothrix

Explanation:
The correct answer is E. Whenever you see a question on a gardener who works with roses, think
"Sporothrix schenckii." This organism is responsible for "rose gardener's disease," known
technically as sporotrichosis. The organism enters through skin breaks in the fingers or hands,
causing a chancre, papule, or subcutaneous nodule with erythema and fluctuance. Ulcerating
lesions appear along lymphatic channels, but the lymph nodes are not commonly infected.
Potassium iodide is the treatment of choice for the subcutaneous manifestations.

Aspergillus (choice A) causes pulmonary aspergillosis–a systemic mycotic infection. There

is an allergic type that is caused by a hypersensitivity reaction to the organism and an
infectious type that occurs more commonly in the immunocompromised. Hemoptysis is a common
symptom.

Malassezia (choice B), specifically M. furfur, causes tinea versicolor, a superficial mycotic
infection.

Onchocerca (choice C), specifically O. volvulus, causes river blindness. This organism is a
helminth that is transmitted by black flies in Africa, Central America, and South America.

Rhizopus (choice D) causes rhinocerebral infections in diabetics with ketoacidosis.

A 33-year-old man in Arkansas presents to the local clinic with fever, chills, headache, and generalized
myalgias and arthralgias. On physical examination, an ulcer with a black base is apparent on
his right hand, and epitrochlear lymphadenopathy is noted. A careful history reveals that the
man is a hunter and trapper, recently trapping and skinning rabbits. Which of the following
organisms is the most likely cause of this man's illness?

A. Borrelia

B. Brucella

C. Francisella

D. Leptospira

E. Listeria

Explanation:

The correct answer is C. The disease is tularemia, which may be spread by handling rabbits or
rabbit skins, or by bites from ticks that feed on the blood of wild rabbits. The causative
organism is Francisella tularensis, a gram-negative coccobacillus. The disease begins as a
rupturing pustule followed by an ulcer, with involvement of regional lymph nodes. More serious
cases can be complicated by bacteremia, splenomegaly, rash, pneumonia, or endotoxemic shock.

Borrelia(choice A) spp. cause relapsing fever (transmitted by ticks and lice) and Lyme disease
(transmitted by ticks).

Brucella(choice B) causes brucellosis after ingestion of contaminated milk or contact with

infected livestock.

Leptospira (choice D) causes leptospirosis and Weil's disease; the organism is acquired by
ingestion of water contaminated with animal urine.

Listeria (choice E) causes listeriosis after contact with contaminated milk, vegetables, or
with transplacental transmission.
A 28-year-old HIV-positive male complains of pain on swallowing. Physical examination is remarkable for
white plaque-like material on his tongue and buccal mucosa, which is scraped and sent to the
laboratory. Based on these findings, and on the laboratory results, the man is diagnosed with
acquired immunodeficiency syndrome (AIDS). With which of the following agents is the man most
likely infected?

A. Candida albicans

B. Cytomegalovirus

C. Herpes simplex I

D. Human herpesvirus 8

E. Human papilloma virus

Explanation:

The correct answer is A.Candida albicans produces oral thrush, an AIDS-defining lesion, which
is common in acute HIV disease, and becomes increasing common as the CD4 + cell count falls.
The lesions are usually painless. Diagnosis is by demonstration of pseudohyphae using a wet
smear with confirmation by culture.

Although cytomegalovirus (choice B) is associated with numerous clinical scenarios in the AIDS
population, including odynophagia (painful swallowing), it would not produce white plaques on
the oral mucosa.

Herpes Simplex I (choice C) produces vesicular lesions occurring in clusters in the oral
cavity. There is an increased risk of herpes infections in the AIDS group, but the lesions do
not resemble those described in the question.

Human herpesvirus 8 (choice D) is the causative agent of Kaposi's sarcoma, a malignancy arising
from endothelial cells that appears as hemorrhagic nodules in different organ systems. It is
the most common cancer in the HIV infected population.

Human papilloma virus (choice E) is associated with a variety of lesions, including warts and
intraepithelial neoplasias of the vulva and cervix. It is associated with anal condyloma, which
can occur in the AIDS population.

A 26-year-old obstetric patient becomes acutely ill during her first trimester with infectious
mononucleosis-like symptoms, but her heterophil antibody test was negative. A careful history
reveals that the family has two cats in the house. The appropriate laboratory tests indicate
the expectant mother is infected with Toxoplasma gondii. Months later, the woman delivers a
full term baby with no obvious signs of infection with the protozoan parasite. The best test to
diagnose acute infection in the neonate would be a parasite-specific ELISA for which isotype of
immunoglobulin?

A. IgA

B. IgE

C. IgG 1

D. IgG 4
E. IgM

Explanation:

The correct answer is E. IgM immunoglobulin directed against Toxoplasma would provide evidence
of infection in the newborn baby. IgM is the only antibody that a baby can form with an acute
infection. It is the first antibody that is formed in an infection and it is also the antibody
that is present on the surface of immature and mature B cells.

IgA (choice A) is the antibody that is produced in response to mucosal infections. It cannot
cross the placenta. The baby's immune system is still not well developed at birth and cannot
produce IgA immunoglobulin. In adults or older children, IgA is exists in serum in a monomeric
form but is present in seromucous secretions as a dimer.

IgE (choice B) is the antibody that is produced in response to an allergen. It cannot cross the
placenta, and is not present in the baby at birth or for some time after birth. The baby's
immune system is still not well developed at birth and can initially only form IgM
immunoglobulin.

IgG 1 (choice C) and IgG4 (choice D) immunoglobulins might be present in the baby, but would
not indicate infection in the infant. The presence of these isotypes would indicate that the
mother was infected with the organism and produced antibody that was transported across the
placenta in utero. IgG is the only immunoglobulin that can cross the placenta, providing
protection to the baby during the first few months of life.

Which of the following organisms is a natural transformer?

A. Escherichia coli

B. Neisseria gonorrhoeae

C. Plasmodium vivax

D. Pseudomonas aeruginosa

E. Staphylococcus aureus

Explanation:

The correct answer is B. Transformation is the uptake and integration of naked DNA by a
bacteria from the environment. Transformation can be induced in the laboratory (a technique
used to introduce gene-carrying plasmids into bacteria) or, relatively uncommonly, occurs
naturally. Only a few medically important species undergo natural transformation: Haemophilus
species, Streptococcus species, Neisseria gonorrhoeae, and Helicobacter pylori.

Which of the following structures is found only in Gram-negative microorganisms?

A. Cell envelope

B. Exotoxin

C. Peptidoglycan

D. Periplasmic space

E. Teichoic acids
Explanation:

The correct answer is D. This question requires you to appreciate the key structural difference
between gram-positive and gram-negative microorganisms. Most gram-negatives (other than
exceptional microorganisms, such as Mycoplasma, that lack a cell wall) have a more complex cell
envelope than gram-positive microorganisms. It includes both a cytoplasmic membrane as well as
an outer membrane. Between these two membranes is the periplasmic space, which contains enzymes
such as phosphatase and penicillinase, binding proteins for the transport of various nutrients,
and peptidoglycan, as well as a portion of the lipoprotein that firmly anchors the outer
membrane to the peptidoglycan. Gram-positives do not have outer membranes.

Choice A, the cell envelope, is incorrect because both gram-positive and gram-negative
microorganisms have this structure, which is defined as all the layers that enclose the cytosol
of the bacterium. It is the composition of the envelope that differs between gram-positives and
gram-negatives.

Choice B, exotoxin, is not exclusive to gram-negative microorganisms, but is also found in some
gram-positives. By contrast, endotoxin (lipopolysaccharide; LPS) is found exclusively in gram-
negatives.

Choice C, peptidoglycan, is found in the cell walls of both gram-positive and gram-negative
microorganisms. Note that there is a larger amount of peptidoglycan in gram-positive
microorganisms.

Choice E, teichoic acids, are found exclusively in gram-positive organisms.

A 23-year-old, ill-appearing woman comes to the emergency room with a fever. She notes the recent
development of nausea, diarrhea, and a rash. Her last menstrual period began 3 days ago.
Physical examination is remarkable for blood pressure of 90/45 mm Hg and heart rate of 120 beats
per minute. A diffuse erythematous rash with areas of desquamation over the hands and feet is
noted. Infection with which of the following agents is the most likely cause of these signs and
symptoms?

A. Clostridium perfringens

B. HIV-1

C. Shigella dysenteriae

D. Staphylococcus aureus

E. Staphylococcus epidermidis

Explanation:

The correct answer is D. This patient has toxic shock syndrome (TSS), a multisystem syndrome
caused by a toxin (TSST-1) formed by certain strains of S. aureus. TSS usually affects several
organ systems (gastrointestinal, renal, hepatic, hematopoietic, musculoskeletal, pulmonary) and
can result in death. TSS has historically been associated with the use of tampons in young
women, but can also occur in other patient populations. Fever, hypotension, diarrhea, and
diffuse rash with desquamation of the hands and feet are common symptoms. Management of shock,
renal failure, and adult respiratory distress syndrome (ARDS) are a priority if these
conditions are present, in addition to appropriate antibacterial treatment.

C. perfringens(choice A) causes gas gangrene, with necrosis of soft tissues, usually after a
traumatic wound. It is also a cause of food poisoning.

Although HIV-1 (choice B) can cause many diverse findings and should never be immediately ruled
out, the findings in this patient are most specific for TSS.

Shigella dysenteriae(choice C) is a cause of dysentery characterized by fever, abdominal

cramps, and bloody diarrhea.

S. epidermidis(choice E) is part of the normal skin flora, but is notorious for causing
infections of intravenous lines and prosthetic heart valves.

A pregnant southeast Asian immigrant presents for prenatal care. Her past medical history is significant
for a severe illness 3 years ago characterized by fatigue, nausea, anorexia, vomiting, jaundice,
joint pains, and generalized skin lesions that slowly disappeared. She has felt well recently.
Which of the following laboratory tests should be ordered to investigate the patient's past
illness?

A. Hepatitis B surface antigen (HBsAg)

B. IgG cytomegalovirus (CMV) antibody levels

C. IgM antibody to HBsAg

D. IgM antibody to hepatitis B core antigen

E. Quantitation of hepatitis A virus (HAV) IgM antibody

Explanation:

The correct answer is A. The clinical signs suggest that this woman had hepatitis B three years
ago and the fact that she is now feeling better also suggests that she recovered from this
infection. Since she is pregnant, it is necessary to find out if she still has the organism in
her liver (chronic hepatitis B infection) by performing a test for HBsAg. This test will be
negative if she has completely recovered from the disease, but it would be positive if she is a
chronic carrier.

The clinical signs of the disease she had 3 years ago do not match those of CMV (choice B), and
CMV does not produce chronic infections.

Measurement of IgM antibody to hepatitis B core antigen (choice D) would be of no value at this
time. This antibody is positive in acute cases of hepatitis B, but would no longer be positive
in this case. Measurement of IgM anti-hepatitis B core antigen is one of the most important
tests in the hepatitis profile because the appearance of the antibody correlates with the
disappearance of HBsAg.

Examination of IgM antibody to HBsAg (choice C) would be of no value at this time. This IgM
antibody would be formed early during the recovery from acute hepatitis B, and would class
switch to IgG later on in the disease.

Quantitation of hepatitis A virus (HAV) IgM antibody (choice E) would be useless, since
hepatitis A virus (HAV) only causes acute infection.

The rationale for giving prophylactic antibiotics at the beginning of a surgical procedure can be
thought of as an attempt to prevent the bacteria from entering which of the following growth
phases?
A. Death phase

B. Lag phase

C. Log phase

D. Phase of decline

E. Stationary phase

Explanation:

The correct answer is C. A single dose of a prophylactic antibiotic given as surgery is about
to begin (sometimes given intravenously to assure the timing) has become more common because
it is associated with a decreased wound infection rate. Such antibiotic usage does not prevent
organisms from entering the tissues, but effectively prevents them from becoming established
as they try to grow and divide (e.g., leave the lag phase (choice B) and enter the log or
exponential phase of colony growth). The stationary phase (choice E) and phase of decline
(choice D) (formerly called death phase, choice A) would occur much later, after a colony had
been established (which is what the surgeons were trying to prevent).

A 10-year-old girl presents with sore throat and fever. She denies any cough or rhinorrhea. A throat
culture grows bacitracin-sensitive bacterial colonies. The infecting organism would be protected
from the lytic action of detergents by its

A. keratin-like proteins in the spore coat

B. lipopolysaccharide in the outer membrane

C. peptidoglycan layer

D. periplasmic space

E. Ca2+ chelators

Explanation:

The correct answer is C. This girl has streptococcal pharyngitis. The infecting organism is
group A beta-hemolytic streptococcus (S. pyogenes); its growth is inhibited by the placement of
a bacitracin disk on the throat culture plate. (Beta-hemolysis occurs as the result of the
bacterial hemolysin streptolysin S). This is a gram-positive bacterium and therefore possesses
a very thick peptidoglycan layer that would protect it from lysis by detergents. (Note that
gram-positives also contain teichoic acid.) In contrast, gram-negatives have a thin
peptidoglycan layer.

Keratin-like proteins in the spore coat (choice A) and calcium ion chelators (dipicolinic acid)
(choice E) are found in spores formed by species of Bacillus and Clostridium. These protect the
spores from the elements: dehydration, heat, chemicals, radiation, etc.

Lipopolysaccharide in the outer membrane (choice B) and a periplasmic space (choice D) are
found in gram-negative organisms. The lipopolysaccharide is an endotoxin and the periplasmic
space contains beta-lactamase in some species.

An antibiotic, such as penicillin, which modifies cell wall synthesis, tends to be most effective during
which phase of bacterial growth in a closed system?
A. Lag phase

B. Log phase

C. Phase of decline

D. Stationary phase

Explanation:

The correct answer is B. Bacterial growth in a closed system is characterized by four phases:

(1) In the initial lag phase, no growth occurs as the organisms adapt to the new environment.

(2) In the exponential, or log phase, the organisms grow at the fastest rate and antibiotics
that interfere with cell growth or division are most likely to be effective.

(3) In the stationary phase, when nutrients have been largely exhausted, organisms tend to
stop growing but may remain viable for long periods of time.

(4) In the phase of decline, cell deaths increase due to cell starvation or exposure to
toxins.

A 14-year-old patient is brought in by his parents because of a sore throat. On physical examination, he
is febrile, and has pharyngeal erythema with a tonsillar abscess. A throat culture on sheep
blood agar yields colonies of gram-positive cocci that are surrounded by a zone of complete
hemolysis. The organism was also plated on mannitol salt agar; it grew well and caused the
medium to turn yellow. Which of the following microorganisms is the most likely cause of the
patient's illness?

A. Corynebacterium diphtheriae

B. Haemophilus influenzae

C. Staphylococcus aureus

D. Streptococcus salivarius

E. Streptococcus pyogenes

Explanation:

The correct answer is C. The description of the agent is consistent with a staphylococcal
organism (catalase-positive, gram-positive cocci that grows on mannitol salt agar. The organism
is most likely S. aureus, as it was able to ferment mannitol (as evidenced by the color change
in the mannitol salt agar after incubation) and was beta-hemolytic. Other characteristics of
this organism are coagulase production and excretion of DNAse from colonies. Staphylococcal
organisms are also notorious for formation of abscesses; the patient had an abscess in the
tonsillar region.

The diphtheria bacilli (Corynebacterium diphtheriae; choice A) are gram-positive, pleomorphic

rods that are arranged in palisades. They are non-hemolytic and would not grow on mannitol salt
agar. These organisms produce a whitish-gray pseudomembrane on the pharynx or the larynx;
constitutional symptoms from toxemia are the major features of diphtheria.

Epiglottitis is the most common disease of the upper respiratory tract produced by Haemophilus
influenzae(choice B), a gram-negative, encapsulated rod. It is also a common cause of otitis
media in children and may cause bronchitis, bronchiolitis, and pneumonia in adults.

Streptococcus salivarius(choice D) is a gram-positive coccus that is usually alpha-hemolytic.

It is normal flora of the oral cavity and is sometimes implicated in subacute bacterial
endocarditis, but is not associated with tonsillar abscesses.

Streptococcus pyogenes(choice E) is a beta-hemolytic, gram-positive coccus that grows in

chains, as opposed to the random, grape-like clusters of the staphylococci. These organisms are
the most common cause of pharyngitis, which is usually manifested by severe sore throat, fever,
a beefy red pharynx, and a tonsillar exudate.

A 14-year-old boy is brought to the emergency department by his parents because of high fever, headache,
and stiff neck for the past 36 hours. He has become confused over the course of the morning. He
uses no medications, has no allergies, and is not sexually active. On examination, he has a
temperature of 38 C, moderate nuchal rigidity, and marked photophobia. Lumbar puncture is
performed, and the cerebrospinal fluid shows: WBC 3500 with 95% PMNs, elevated protein,
decreased glucose, and gram-positive cocci in pairs and short chains. By which of the following
mechanisms does this organism mediate its attachment to the respiratory mucosa?

A. Production of a C carbohydrate

B. Production of a hemolytic exotoxin

C. Production of a hyaluronic acid capsule

D. Production of an IgA protease

E. Production of an M protein

Explanation:

The correct answer is D. This is a case of Streptococcus pneumoniae meningitis. This organism
is able to attach to the respiratory mucosa because it has teichoic acids in its envelope, and
because it produces an IgA protease. The IgA protease physically cleaves the immunoglobulin
molecules, leaving the Fc parts to coat the bacterium. This allows the organisms to bind to the
Fc receptors on various mucosal cells.

Streptococcus pneumoniae does not produce a C carbohydrate (choice A), and thus cannot be
grouped by the Lancefield terminology.

Although the organism does produce the pneumolysin, which is an alpha-hemolytic exotoxin
(choice B), this toxin mediates damage to the respiratory epithelium and inhibition of
leukocytic responses, not attachment to the mucosa.

Streptococcus pneumoniae does not produce an hyaluronic acid capsule (choice C); Streptococcus
pyogenes does. Most capsules serve to inhibit phagocytosis, rather than to mediate adhesion.

Only the group A Streptococci possess an M protein (choice E), which is used to "type" them and
helps inhibit phagocytosis.

In a closed system, spores are formed during which of the following phases of bacterial growth?

A. Decline phase

B. Exponential phase
C. Lag phase

D. Log phase

E. Stationary phase

Explanation:

The correct answer is E. Spore formation usually occurs during the stationary phase, when cell
growth ceases because of a developing lack of nutrients or accumulation of toxins.

During the phase of decline (choice A), the lack of nutrients and the accumulation of toxin
become so severe that any viable organisms usually die before they can form spores.

The exponential phase (choices B) and log phase (choice D) are descriptors for the steady state
of active growth occurring after the lag phase and before the stationary phase. Many
antibiotics are most effective in this period.

The lag phase (choice C) is the initial period of adaptation, prior to growth, which occurs
when organisms are introduced to a new environment.

A 33-year-old HIV-positive male complains of headache and blurred vision. Physical exam reveals
papilledema and ataxia. Head CT is normal but CSF obtained by lumbar puncture reveals
encapsulated organisms observable with India ink. What is the treatment of choice for this
infection?

A. Amphotericin B

B. Isoniazid

C. Ketoconazole

D. Metronidazole

E. Nystatin

Explanation:

The correct answer is A. Amphotericin B is the most appropriate drug listed for the treatment
of cryptococcal meningitis. It is a polyene antibiotic that binds to ergosterol in the fungal
cell membrane, creating an artificial pore. Flucytosine is often prescribed as an adjunct
medication. Fluconazole is used long-term to prevent recurrence in AIDS patients.

Isoniazid (choice B) inhibits the biosynthesis of mycolic acids in the mycobacterial cell wall.
It is the primary drug used against tuberculosis. It is used alone for TB prophylaxis and is
used in combination with other antituberculars to treat patients with active disease.

Ketoconazole (choice C) is an orally administered imidazole antifungal medication. It inhibits

14-alpha-demethylase to block the synthesis of fungal cell membrane ergosterol. Note the
difference in mechanism between the polyenes, which alter ergosterol structure, and the
imidazoles, which block ergosterol synthesis. Ketoconazole is often used to treat
coccidioidomycosis (prevalent in California), histoplasmosis (prevalent in the Midwest),
blastomycosis (prevalent in the Eastern US), paracoccidioidomycosis (prevalent in Latin
America), and mucocutaneous candidiasis.
Metronidazole (choice D) is an antiprotozoal drug useful in treating a variety of parasitic
infections. It is the drug of choice for trichomoniasis and giardiasis and provides general
anaerobic coverage. This makes it useful for treating postsurgical abdominal and pelvic
Bacteroides fragilis infections or flare-ups of intestinal diverticulitis.

Nystatin (choice E) is an antifungal polyene that's usually used topically but can be taken
orally for oral and esophageal candidiasis. Candidal infections of the skin, mucous membranes,
and vagina usually respond well to this drug. It may also be used to prevent intestinal fungal
overgrowth in patients on chemotherapy.

A 37-year-old man is admitted to the hospital with shortness of breath, cyanosis, and fever. Chest x-ray
films reveal consolidation of the right lower lobe with relative sparing of the remaining lobes.
A clinical diagnosis of lobar pneumonia is made and supported by the results of sputum cultures.
Which of the following is the genus of the bacterium most likely to be isolated from this
patient's sputum?

A. Haemophilus

B. Klebsiella

C. Streptococcus, alpha-hemolytic

D. Streptococcus, beta-hemolytic

E. Streptococcus, gamma-hemolytic

Explanation:

The correct answer is C. The clinical and radiologic characteristics of this patient's
condition are consistent with lobar pneumonia, a respiratory infection that, in its classic
presentation, involves a single pulmonary lobe. In 90% to 95% of cases, the etiologic agent is
Streptococcus pneumoniae (AKA pneumococcus), an alpha-hemolytic streptococcus present in the
throat of 40% to 70% of healthy individuals. A small minority of cases of lobar pneumonia are
due to Klebsiella pneumoniae, staphylococci, streptococci other than pneumococcus, Haemophilus
influenzae, Pseudomonas, and Proteus. Penicillin is the drug of choice for pneumococcal
pneumonia, but sputum cultures are necessary to identify the infectious agent and determine its
antibiotic sensitivity. S. pneumoniae is a major cause of purulent meningitis in the elderly.
Other alpha-hemolytic streptococci (viridans streptococci) cause subacute endocarditis in
patients with previously altered cardiac valves. Streptococcus mutans and other oral
streptococci have been associated with dental caries.

Bacteria belonging to the genera Haemophilus(choice A) and Klebsiella (choice B) cause

respiratory infections; however, in immunocompetent individuals, these bacterial infections
usually result in bronchopneumonia, which leads to multilobar, and often bilateral, pulmonary
involvement.

Beta-hemolytic streptococci (choice D) cause countless infections in humans. Recall that

classification of β-hemolytic streptococci is based on their surface antigens known as
Lancefield antigens. Human diseases caused by this group of bacteria include:

- Streptococcus pyogenes (group A): pharyngitis, scarlet fever, erysipelas, impetigo, rheumatic
fever, and glomerulonephritis

- Streptococcus agalactiae (group B): neonatal sepsis and urinary infections

- Enterococcus faecalis (group D): endocarditis and urinary infections

Gamma-hemolytic streptococci (choice E) are streptococci that do not produce hemolysins
(nonhemolytic streptococci) and are not a significant cause of human disease.

A 67-year-old man with moderate renal dysfunction presents with influenza-like symptoms. The patient
also has a red macular rash that first appeared on the ankles, then spread centrally. He reports
nausea, vomiting, and profound restlessness. He states that he was recently hiking with some
friends in the mountains, about a week ago. Rickettsia rickettsiae is demonstrated by
immunohistochemistry on skin biopsy. Which of the following agents would be most appropriate to
treat this patient's infection?

A. Demeclocycline

B. Doxycycline

C. Methacycline

D. Oxytetracycline

E. Tetracycline

Explanation:

The correct answer is B. This patient has Rocky Mountain spotted fever. This diagnosis can be
confirmed with the immunohistologic demonstration of R. rickettsiae in the skin biopsy. The
tetracyclines are a class of antibiotics commonly used in the treatment of rickettsial
infections, acne, and various sexually transmitted diseases, as well as in the treatment of
infections caused by susceptible organisms in penicillin-allergic patients. The key to this
question is knowing which tetracycline antibiotic is safest to administer to a patient with
renal dysfunction. Doxycycline is secreted in an inactive form into the intestinal lumen and
eliminated in the feces; therefore, its half-life is largely independent of renal or hepatic
function. The other tetracyclines listed are concentrated by the liver in the bile and excreted
in the urine and feces unchanged. Therefore, dosage adjustments need to be made in patients
with renal impairment because of accumulation of the drug in the body. In other words,
demeclocycline (choice A), methacycline (choice C), oxytetracycline (choice D), and
tetracycline (choice E) will accumulate in patients with renal impairment.

A 33-year-old HIV-positive male complains of headache and blurred vision. Physical exam reveals
papilledema and ataxia. Head CT is normal but CSF obtained by lumbar puncture reveals
encapsulated organisms observable with India ink. Which of the following is true concerning this
organism?

A. It can also be identified with methenamine silver stain

B. It consists of branching septate hyphae

C. It exists as a mycelial form at room temperature and as yeast at 37° C

D. It is an encapsulated nondimorphic yeast found worldwide

E. It is a nonencapsulated dimorphic yeast that reproduces by budding

Explanation:

The correct answer is D. This patient has cryptococcal meningitis, as evidenced by the
"encapsulated organisms observable with India ink" in the CSF (a classic clue). Cryptococcus is
a nondimorphic yeast, meaning that it exists only in the yeast form. It is encapsulated (that's
why the India ink stain works so well) and it reproduces by budding. It is found worldwide in
bird droppings (think pigeons). It can also cause transient pulmonary illness in otherwise
healthy individuals.

The methenamine silver stain (choice A) is used primarily to demonstrate Pneumocystis carinii
in tissues.

Branching septate hyphae (choice B) are characteristic of Aspergillus fumigatus, among other
fungi.

Mycoses that exist in mycelial and yeast forms (dimorphism; diphasic; choice C) are Histoplasma
capsulatum, Coccidioides immitis, Blastomyces dermatidis, and Sporothrix schenckii.

C. neoformans is not dimorphic and it has a capsule (choice E).

A 5-year-old child who has not had routine pediatric care develops a febrile disease with cough and a
blotchy rash, and is brought to the emergency room. On physical examination, there is cervical
and axillary lymphadenopathy. Also noted is an erythematous, maculopapular rash behind the ears
and along the hairline, involving the neck and, to a lesser extent, the trunk. Examination of
this patient's oropharynx would likely reveal which of the following lesions?

A. Adherent thin, whitish patch on gingiva

B. Cold sores on the lips

C. Curdy white material overlying an erythematous base on the oral mucosa

D. Large shallow ulcers on the oral mucosa

E. Multiple small white spots on the buccal mucosa

Explanation:

The correct answer is E. The disease described is measles (rubeola), which has the typical
presentation described in the question stem. Measles is caused by a Morbillivirus, an RNA virus
belonging to the Paramyxovirus family. Koplik's spots, which are pathognomonic for measles, are
small, bluish-white spots on the buccal mucosa in the early stages of measles. These lesions
appear just before the onset of the characteristic rash (which can also involve the
extremities) and fade as the rash develops.

Leukoplakia is a premalignant condition characterized by adherent whitish patches on the

gingiva (choice A) and other sites in the oral cavity.

Cold sores of the lips (choice B) are due to infection with herpes viruses.

Candida infection (thrush) produces curdy white material loosely attached to an erythematous
base (choice C).

Aphthous ulcers are large shallow ulcers of the oral mucosa (choice D), commonly known as
canker sores.

Which of the following is associated with Babesiosis rather than with Ehrlichiosis or Lyme disease?

A. A characteristic rash
B. Arthritis of the knee

C. Hemolytic anemia

D. Macrophages containing intracellular organisms

E. Transmission by ixodid ticks

Explanation:

The correct answer is C. Babesiosis is a syndrome characterized by malaise, fatigue, chills,

fever, myalgia, and arthralgia lasting for weeks. The protozoans Babesia microti and Babesia
divergens cause most human babesiosis. The organisms parasitize red blood cells, and have been
transmitted by blood transfusions. Hemolytic anemia and hepatosplenomegaly are features of
infection with these organisms; asplenic persons may have a life-threatening infection.

In Lyme disease, a characteristic rash (choice A), known as erythema chronicum migrans, forms
at the tick-bite site. In ehrlichiosis and babesiosis, low platelet counts may produce
nonspecific purpuric lesions, but there is not characteristic rash.

Arthritis of the knee (choice B) is a classic sign in untreated Lyme disease caused by Borrelia
burgdorferi.

Macrophages containing intracellular organisms (choice D) is the classic finding in multiple

tissues infected with Ehrlichia chaffeensis.

Ixodid ticks or hard-bodied ticks (choice E) are vectors for Babesiosis, Lyme disease, and
human granulocytic ehrlichiosis.

A United Nations representative from a poor African country has an influenza-like illness that resolves
in a few days. Less than a week later, however, he develops muscle pain, spasms, and sensory
disturbances. Two days after this, flaccid paralysis occurs. Which of the following is most
likely to be immediately life-threatening in this patient?

A. Acute renal failure

B. Bowel paralysis

C. Fulminant liver failure

D. Gastrointestinal bleeding

E. Respiratory paralysis

Explanation:

The correct answer is E. The disease is poliomyelitis. Most infections with poliovirus cause
only the influenza-like symptoms, but a small percentage progress to paralytic poliomyelitis.
The most common causes of death are aspiration and airway obstruction as a result of bulbar
paralysis and paralysis of respiratory muscles. Arrhythmias can also be life-threatening.

Acute renal failure (choice A) is usually not seen in poliomyelitis, although the bladder may
become paralyzed.

Bowel paralysis (choice B) can be seen, but is not usually life-threatening.

Fulminant liver failure (choice C) is not a feature of poliomyelitis.

Gastrointestinal bleeding (choice D) can be seen in poliomyelitis, but is not usually life-
threatening.

Evaluation of an adult third world immigrant to this country demonstrates chronic headaches accompanied
by chronic mild nuchal rigidity. Cerebrospinal fluid sampling demonstrates a chronic
inflammatory infiltrate with lymphocytes, plasma cells, macrophages, and fibroblasts. Which of
the following is the most likely etiologic agent?

A. Herpes virus

B. Mumps virus

C. Mycobacterium tuberculosis

D. Neisseria menigitidis

E. Streptococcus pneumoniae

Explanation:

The correct answer is C. Nuchal rigidity suggests meningitis. It is convenient to classify

meningitis based on the cerebrospinal fluid (CSF) findings: 1) acute pyogenic meningitis if
neutrophils are markedly increased; 2) acute lymphocytic meningitis if lymphocytes (alone) are
markedly increased, and 3) chronic meningitis if lymphocytes, plasma cells, macrophages, and
fibroblasts are increased. This patient has chronic meningitis. The classical cause of chronic
meningitis is tuberculosis, whose etiologic agent is Mycobacterium tuberculosis. Other causes
include other indolent meningeal infections such as syphilis, brucellosis, and chronic fungal
infections. The granulomas that are characteristic findings in other tissues may or may not be
present in the meningeal tissue, and are usually not recognizable in CSF. Tubercular meningitis
is now uncommon in this country. In immigrants from third world countries, a history of
pulmonary tuberculosis may be distant, undiagnosed, or deliberately concealed.

Herpes virus (choice A) and mumps virus (choice B) are causes of acute lymphocytic meningitis.

Neisseria menigitidis(choice D) and Streptococcus pneumoniae(choice E) are causes of acute

pyogenic meningitis.

A 14-year-old girl with cystic fibrosis is admitted to the hospital with fever and shortness of breath,
and is diagnosed with pneumonia. During a respiratory therapy session, she coughs up mucus that
is distinctly greenish in color. Which of the following organisms should be suspected?

A. Klebsiella pneumoniae

B. Mycoplasma pneumoniae

C. Pneumocystic carinii

D. Pseudomonas aeruginosa

E. Streptococcus pneumoniae

Explanation:

The correct answer is D. The clues suggesting infection with Pseudomonas aeruginosa are the
green-tinged sputum (due to the formation of blue and green pigments by P. aeruginosa), and the
association with cystic fibrosis. Unfortunately, P. aeruginosa is very difficult to treat with
most antibiotics, and presents a very difficult therapeutic challenge in the management of
cystic fibrosis patients.

Klebsiella pneumoniae(choice A) is most often seen in alcoholics, the elderly, and diabetics.

Mycoplasma pneumoniae(choice B) is a common cause of community-acquired atypical pneumonia, and

is characterized by a dry, non-productive cough.

Pneumocystic carinii(choice C) usually causes pneumonia in immunocompromised patients, e.g.,

AIDS patients.

Streptococcus pneumoniae(choice E) is an important cause of typical community-acquired lobar

pneumonia.

A truck driver was involved in a serious accident and received second- and third-degree burns over his
body. He was placed in the burn unit and, on his twelfth day of his admission, developed a wound
infection with a bluish-green exudate. Treatment with chloramphenicol and tetracycline was
unsuccessful. A gram-negative, motile organism was isolated that was oxidase-positive, did not
ferment lactose, sucrose, or glucose, but grew on MacConkey's agar and produced a fruity aroma
on that medium. Which of the following organisms was most likely isolated?

A. Candida albicans

B. Clostridium perfringens

C. Escherichia coli

D. Klebsiella pneumoniae

E. Proteus mirabilis

F. Proteus vulgaris

G. Pseudomonas aeruginosa

H. Serratia marcescens

Explanation:

The correct answer is G.Pseudomonas aeruginosa is a very common opportunist in burn patients,
in whom it classically causes secondary wound infections and septicemia. It may also cause
cystitis in patients with urinary catheters and pneumonia in patients with cystic fibrosis. The
organism is found in water and usually gains access to the body via this source, as a
contaminant in the water used in respirators or in water baths, etc. used to cleanse wounds.
This organism is a non-fermenter, that is, it does not metabolize sugars by classic pathways.
It produces a blue-green, water-soluble pigment (pyocyanin), and has a fruity odor when growing
on laboratory media. It has a propensity for developing antibiotic resistance; current therapy
employs the synergistic combination of an aminoglycoside, such as amikacin, with a cell wall
synthesis inhibitor (carbenicillin, ticarcillin, or piperacillin).

Candida albicans(choice A) is a normal flora yeast that will appear as very large, gram-
positive, spherical-to-ovoid organisms with budding daughter cells in Gram-stained
preparations. Candidiasis is an opportunistic infection in individuals with a compromised
immune system. The fungus usually causes mucocutaneous lesions, but in severely compromised
individuals like AIDS patients, systemic disease may occur. Oral candidiasis appears as creamy,
white patches of exudate that can be scraped off an inflamed tongue or buccal mucosa.

Clostridium perfringens(choice B) is a gram-positive, spore-forming, anaerobic rod. It is a

common cause of gas gangrene when it is introduced into a wound. The organism produces a
variety of toxins and enzymes that enable it to destroy muscle tissue and spread through the
soft tissues of the body.

Escherichia coli(choice C) is a lactose-fermenting, gram-negative rod commonly seen as normal

flora of the intestine of man. It is the most common cause of urinary bladder infections,
pyelonephritis, and sepsis in patients with indwelling urinary catheters. It is also the major
cause of traveler's diarrhea with watery stools and is a very important pathogen in neonates,
who become infected during passage through the birth canal.

Klebsiella pneumoniae(choice D) is a gram-negative, highly encapsulated rod that is a

significant pulmonary pathogen in individuals with a compromised respiratory apparatus. It is a
common cause of aspiration pneumonia and pulmonary abscesses in alcoholics and patients with
chronic obstructive pulmonary disease. The organism is readily grown on standard laboratory
media such as blood agar or MacConkey's enteric agar.

Proteus mirabilis(choice E) and P. vulgaris(choice F) are highly motile, gram-negative rods

that ferment glucose, but not lactose. Other distinguishing features include "swarming" growth
on solid media (due to the high degree of motility and production of urease and hydrogen
sulfide). These organisms are not commonly associated with wound infections but usually cause
urinary tract infections. The ability to break down urea is thought to contribute to the
development of struvite kidney stones due to the elevation of urine pH by production of
ammonia.

Serratia marcescens(choice H) is a gram-negative organism that is found in the environment in

water, soil, and, occasionally, as normal flora of humans. It is an opportunistic pathogen that
causes respiratory disease in hospitalized patients. Many strains produce a pigment, but the
colonies are usually red, pink, or orange. Interestingly, the pathogenic varieties are most
often non-pigmented.

A 3-month-old infant presents with a 3-day history of fever, cough, and poor feeding. On examination,
the baby appears ill and has a temperature of 102 F and a respiratory rate of 32. A chest x-ray
film shows bilateral patchy infiltrates in the lungs. Which of the following is the most likely
etiologic agent?

A. Coronavirus

B. Influenza type A

C. Parainfluenza type 1

D. Respiratory syncytial virus

E. Rhinovirus

Explanation:

The correct answer is D. Respiratory syncytial virus is the most common cause of bronchiolitis
and pneumonia in children younger than 1 year. Outbreaks occur seasonally in winter and early
spring. Infection does not result in lasting immunity, and reinfection can occur.

Coronavirus (choice A) causes the common cold (nasal obstruction and discharge, sneezing, no
fever or mild fever, occasional sore throat, and/or cough) and acute pharyngitis (sore throat,
with or without cervical adenopathy, ulceration, and conjunctivitis).

Influenza type A (choice B) is the leading cause of influenza. Influenza is a systemic illness
characterized by the sudden onset of fever, headache, myalgias, malaise, and prostration,
followed by cough, nasal obstruction, and sore throat. The lower respiratory tract may also be
involved.

Parainfluenza viruses (choice C) are the leading cause of croup, or acute

laryngotracheobronchitis, in children. This infection involves both the upper and lower
respiratory tracts. Inflammation in the subglottal area leads to hoarseness, dyspnea, a barking
cough, and inspiratory stridor.

Rhinovirus (choice E) is the most common cause of the common cold.

A 3-year-old girl with a history of hydrocephalus is brought to the neurologist by her parents with a
severe headache and fever. The girl underwent a revision of a ventricular-peritoneal shunt 1
month ago, and the neurologist suspects that an infection has occurred. Which of the following
organisms would most likely be isolated from the shunt tubing?

A. Bacteroides fragilis

B. Corynebacterium diphtheriae

C. Escherichia coli

D. Staphylococcus epidermidis

E. Streptococcus pneumoniae

Explanation:

The correct answer is D. Staphylococcal meningitis is fairly rare, occurring mostly in patients
with indwelling ventricular-peritoneal shunts. Staphylococcus epidermidis, which normally
colonizes the skin, is the most common organism causing this disorder; Staphylococcus aureus
meningitis occasionally occurs.

Bacteroides fragilis(choice A) is a common cause of anaerobic infections, including sepsis and

peritonitis, but it does not commonly cause meningitis.

Diphtheroids (including Corynebacterium diphtheriae, choice B) are sometimes isolated from

indwelling shunts, but in many cases they are simply contaminants, since some diphtheroids are
normal skin flora.

Escherichia coli(choice C) is isolated from 30% to 50% of neonates with bacterial meningitis,
but is not typically associated with shunt infections.

Streptococcus pneumoniae(choice E) is the most common cause of bacterial meningitis in people

older than 30 years; it is much less common in children.

A 1-year-old child develops voluminous watery diarrhea and vomiting. She is brought to the pediatrician
by her parents and evaluated, then sent home with instructions for the parents to give the
child an electrolyte replacement solution. Which of the following viruses is the most likely
cause of the child's diarrhea?

A. Coronavirus
B. Lymphocytic choriomeningitis virus

C. Norwalk agent

D. Orbivirus

E. Rotavirus

Explanation:

The correct answer is E. Rotavirus is the major cause of diarrhea in infants and children under
the age of 2. The replicates in the intestinal mucosa, producing a profuse, watery, non-bloody
diarrhea, often coupled with nausea and vomiting. Transmission is by the fecal-oral route.

Coronaviruses (choice A) usually cause cold-like illnesses.

Lymphocytic choriomeningitis virus (choice B) can cause headache, malaise, myalgia,

conjunctivitis, and, occasionally, meningitis.

Norwalk agent (choice C) can also cause diarrhea, but usually affects patients older than 2
years.

Orbivirus (choice D) is the cause of Colorado tick fever, which is the only tick-borne viral
disease in the United States.

A 3-year-old child with cystic fibrosis presents with weight loss, irritability, and a chronic
productive cough. On physical exam, he is febrile and lung exam reveals intercostal retractions,
wheezing, rhonchi, and rales. Chest x-ray demonstrates patchy infiltrates and atelectasis and
Gram's stain of the sputum reveals slightly curved, motile gram-negative rods that grow
aerobically. The microorganism responsible for this child's pneumonia is also the most common
cause of which of the following diseases?

A. Croup

B. Epiglottitis

C. Meningitis

D. Otitis externa

E. Otitis media

Explanation:

The correct answer is D. Anytime you see pneumonia in a cystic fibrosis patient you should
suspect Pseudomonas aeruginosa. The Gram's stain revealing aerobic, gram-negative rods confirms
your suspicion in this case. Now the question is: which of the diseases listed is also caused
by Pseudomonas? The answer is otitis externa. P. aeruginosa is often found in the external ear,
especially if the conditions are moist ("swimmer's ear") and there is any sort of inflammation.
External otitis is usually a benign process with the only symptoms being an itchy, painful ear.
If, however, the organism penetrates the epithelium and invades the soft tissue, cartilage, and
cortical bone, the process becomes malignant otitis externa, which can progress to
osteomyelitis leading to cranial nerve palsies. This condition is most common in diabetics.

Croup (choice A), also called laryngotracheobronchitis, is a respiratory disease of children

that presents with a characteristic "barking" cough. Croup is caused by parainfluenza virus.

Epiglottitis (choice B) is a potentially fatal infection in children, caused by H. influenzae,

which presents with drooling, difficulty breathing, and stridor. The incidence of this disease
has dropped dramatically with the introduction of the H. influenzae type b (Hib) vaccine.

Meningitis (choice C) is caused by numerous different bacteria, depending on the age of the
patient. The most common causes include S. pneumoniae (elderly), H. influenzae (unvaccinated
children), Group B Strep and E. Coli (neonates) and N. meningitidis (1 month - adult). While P.
aeruginosa can cause meningitis, it is not a common cause.

The most common causes of otitis media (choice E) include S. pneumoniae and H. influenzae. Even
in cases of external ear infections with P. aeruginosa, the middle ear is typically spared.

A pastry chef cut his finger while slicing a cake. After a week, the site of the injury is warm, red,
and swollen, and begins draining pus. While preparing some cream pies, he contaminates the
custard with drainage from the lesion. The pies were eaten several days later by patrons of the
restaurant. Within 4 hours they developed diarrhea and vomiting with no fever. Which of the
following organisms would be most likely to cause these symptoms?

A. Bacillus cereus

B. Clostridium perfringens

C. Escherichia coli

D. Shigella sonnei

E. Staphylococcus aureus

Explanation:

The correct answer is E. The chef had a staphylococcal abscess on his finger. S. aureus,
produces enterotoxin A, which was likely present in the cream pies. When ingested, the toxin
causes severe nausea and vomiting within a few hours (the average incubation time is 3-6
hours). There is little diarrhea associated with this type of food poisoning outbreak.

Bacillus cereus(choice A) is a gram-positive spore-forming rod that is associated with food

poisoning outbreaks following the ingestion of fried rice. The time of onset and symptoms would
mimic staphylococcal disease; the major differentiating feature is the food involved. The
organism survives the boiling of the rice because it is a spore-former. It germinates as the
rice cools, grows, and elaborates an enterotoxin that is responsible for the nausea and
vomiting characteristic of the disease.

Clostridium perfringens(choice B) is a gram-positive spore-forming anaerobe that can cause a

longer incubation (18-24 hour) food poisoning, typically with marked diarrhea. Once again, the
spores allow the organism to survive the heating process used in the preparation of the food.
Both Clostridium perfringens and Clostridium botulinum are associated with home-canned
vegetable and sausages.

The symptoms of Escherichia coli(choice C) food poisoning are usually watery diarrhea
(traveler's diarrhea) with minimal nausea and vomiting, or a bloody diarrhea caused by
enteroinvasive strains of the agent. Also, E. coli would be an unlikely cause of the primary
infection in the chef.

Shigella sonnei (choice D) causes enterocolitis characterized by fever, cramps, and diarrhea
after an incubation period of one to four days. Transmission is fecal-oral, associated with
poor hygiene. A wide range of foods has been implicated.

After passing his physical exam, a 19-year-old army recruit gives urine and blood samples for further
testing. Serum analysis yields elevated ALT, HBsAg, Anti-HBc, HBeAg, and bilirubin. All other
values are normal. Which of the following is the hepatitis B status of this recruit?

A. Asymptomatic carrier

B. Chronic active carrier

C. Fulminant hepatitis B

D. Recovered from acute self-limited HBV

E. Vaccinated against HBV

Explanation:

The correct answer is B. The presence of elevated ALT, HBsAg, anti-HBc, HBeAg, and bilirubin
all point to active hepatitis B.

An asymptomatic carrier (choice A) does not have elevated ALT and bilirubin.

The absence of findings on physical examination rules out fulminant hepatitis B (choice C).

Recovery from acute self-limited HBV (choice D) is associated with the presence of anti-HBs and
the decrease in HBsAg and HBeAg.

Someone who is vaccinated with HBV (choice E) has anti-HBs only in their serum.

A 4-year-old child living in a slum is bitten by a rat while sleeping. Two days later, the child
develops a rash characterized by discrete erythematous 1-4 mm macules on the extremities and
face, most obvious on the palms and soles. Which of the following organisms is the most likely
cause of this child's disease?

A. Borrelia burgdorferi

B. Pseudomonas mallei

C. Pseudomonas pseudomallei

D. Spirillium minus

E. Streptobacillus moniliformis

Explanation:

The correct answer is E. The child has "rat-bite fever." This occurs in two forms with somewhat
similar clinical manifestations. The form this child has is the Haverhill fever form, caused by
Streptobacillus moniliformis and characterized by a short (often 1-3 days) incubation period.
The Haverhill form is more common in the United States than the Sodoku form, which is caused by
Spirillium minus, has a 1-4 week incubation period, and is most prevalent in Japan. One of the
problems with diagnosing these diseases is that the victims are usually young children, and the
bite site may be inapparent by the time the disease becomes severe enough for the child to be
taken to a doctor.
Borrelia burgdorferi(choice A) causes Lyme disease, which is characterized by an expanding
erythematous rash, arthralgias, and eventual nervous system involvement.

Pseudomonas mallei(choice B) causes glanders, which generally affects horses or humans in close
contact with equines.

Pseudomonas pseudomallei(choice C) causes melioidosis, a rare pulmonary disease found mostly in

Southeast Asia.

Spirillium minus(choice D) causes the Sodoku form of rat-bite fever.

A 35-year-old man develops hemiparesis, ataxia, homonymous hemianopia, and cognitive deterioration. An
MRI of the brain demonstrates widespread areas of abnormal T2 signal in the white matter. An
electroencephalogram is remarkable for diffuse slowing over both cerebral hemispheres. Brain
biopsy reveals demyelination with abnormal giant oligodendrocytes, some of which contain
eosinophilic inclusions. This patient's condition is most closely related to which of the
following diseases?

A. AIDS

B. Chickenpox

C. Measles

D. Syphilis

E. Tuberculosis

Explanation:

The correct answer is A. The condition is progressive multifocal leukoencephalopathy, which is

a rapidly progressive demyelinating disorder in which the JC virus (a papovavirus) infects
oligodendroglial cells in the brain. The eosinophilic inclusions represent accumulations of JC
virus. PML occurs in about 1% of AIDS patients, and is the AIDS-defining illness in half of the
patients who develop the condition. There is no effective treatment for this disorder.

Shingles and post-infectious encephalitis can follow chickenpox (choice B), but varicella is
not associated specifically with demyelination.

Measles (choice C) can cause an encephalitis, and in some cases, subacute sclerosing
panencephalitis (SSPE) may follow previous measles infection. These disorders would affect not
only white matter, but gray matter as well. Also, SSPE usually occurs before the age of 18.

Syphilis (choice D) can cause meningitis, encephalitis, and spinal cord damage, but the disease
process would not be limited to the white matter.

Tuberculosis (choice E) can cause a granulomatous meningitis, typically affecting the base of
the brain.

An otherwise healthy patient who has just received a prosthetic aortic valve develops postoperative
fever. Blood cultures are done and she is placed on broad-spectrum antibiotics. Two days later
she is still febrile and clinically deteriorating. Which of the following organisms is the most
probable etiologic agent?

A. Actinomyces israelii
B. Candida albicans

C. Histoplasma capsulatum

D. Nocardia asteroides

E. Trichophyton rubrum

Explanation:

The correct answer is B. The patient likely has a candidal infection of the prosthetic aortic
valve. That is why she did not respond favorably to antibacterial therapy, which is known to
promote fungal infection. Note that Candida tends to colonize foreign bodies such as IV and
Foley catheters, prosthetic valves, and ventricular shunts.

Actinomyces israelii(choice A) is known to cause cervicofacial infections in patients having

undergone dental work.

Histoplasma capsulatum(choice C) causes histoplasmosis, a pulmonary infection common in the

midwestern river valleys. Multi-organ involvement is usually seen only in the
immunocompromised. Transmission of the organism occurs through the inhalation of airborne
microconidia (infectious) spores. The organism is found in bird and bat droppings and in the
soil.

Nocardia asteroides(choice D) is an actinomycete that causes a chronic lobar pneumonia that may
metastasize to the brain. It is more common in the immunocompromised. It is found in soil and
aquatic environments.

Trichophyton rubrum(choice E) is one of the organisms that commonly produces a variety of

cutaneous mycoses, including tinea corporis (ringworm), tinea cruris (jock itch), and tinea
pedis (athlete's foot).

An 18-year-old college student presents to the student health center complaining of a sore throat and
fever. He describes feeling tired for the past few days and reports a loss of appetite. On
examination, he has pharyngitis with cervical lymphadenopathy. Blood tests reveal lymphocytosis
and the presence of heterophil antibodies. Which of the following best describes the virus
responsible for his illness?

A. Double-stranded, enveloped DNA virus

B. Double-stranded, nonenveloped DNA virus

C. Single-stranded, enveloped RNA virus

D. Single-stranded, nonenveloped DNA virus

E. Single-stranded, nonenveloped RNA virus

Explanation:

The correct answer is A. This is one of those USMLE-style items where figuring out the
diagnosis is the easy part and remembering the basic science details is much tougher. In this
case, the patient has all the hallmarks of mononucleosis (the heterophil antibodies should have
confirmed your suspicion from the history and physical). Mononucleosis is caused by the
Epstein-Barr virus, which, in turn, belongs to the herpesvirus family. The herpesviruses are
enveloped viruses with double-stranded DNA. Remember that in addition to Epstein-Barr virus,
the herpesvirus family also includes herpes simplex (1 and 2), varicella-zoster (chickenpox,
shingles), and cytomegalovirus (infection in immunocompromised). Cytomegalovirus also causes
infectious mononucleosis, but in these patients the heterophil test is negative.

There are two families of viruses that are nonenveloped with double-stranded DNA (choice B):
papovaviruses and adenoviruses.

There are many families of viruses that are enveloped with single-stranded RNA (choice C):
arenaviruses, bunyaviruses, coronaviruses, filoviruses, flaviviruses, paramyxoviruses,
orthomyxoviruses, retroviruses, rhabdoviruses, and togaviruses.

Parvoviruses are the only family of DNA virus with single-stranded DNA. They do not have an
envelope (choice D).

There are two families of RNA virus that are single-stranded without an envelope (choice E):
caliciviruses and picornaviruses.

A 4-year-old African child develops an infection with Chlamydia trachomatis. How does infection with
this organism cause blindness?

A. Cataract formation

B. Hemorrhage into the anterior chamber

C. Hemorrhage into the posterior chamber

D. Retinal detachment

E. Scarring of the cornea

Explanation:

The correct answer is E.Chlamydia trachomatis (serotypes A, B, and C) causes a conjunctival and
corneal infection that is spread in developing countries by eye-seeking flies. The lesions
begin with formation of lymphoid follicles in the conjunctiva. With disease progression, there
is tissue necrosis, granulation tissue deposition, and scar formation, leading to lacrimal duct
obstruction and distortion of the eyelids. With the loss of an adequate tear system, the cornea
becomes vulnerable to dehydration and opacification. Also, the vigorous inflammatory response
can directly involve the cornea, with resulting opacity. In developed countries, chlamydial eye
infections are often transmitted venereally rather than by flies, and may cause conjunctivitis
in the newborn and in sexually active young adults.

A mother brings her 3-year-old boy into the emergency room because he has developed a harsh, "barking"
cough with hoarseness. The virus responsible for this child's illness belongs to which of the
following families?

A. Papovavirus

B. Paramyxovirus

C. Parvovirus

D. Picornavirus

E. Poxvirus
Explanation:

The correct answer is B. This question is difficult for two reasons—it asks for the viral
family instead of the virus itself, and it includes distracters that all look alike. You
probably realized that the child in question suffers from croup (laryngotracheobronchitis); the
classic clue here is the "barking cough." You might have remembered that the virus responsible
for croup is the parainfluenza virus. The toughest part was remembering that parainfluenza
virus (along with measles virus, mumps virus, and respiratory syncytial virus) belongs to the
paramyxovirus family. These viruses all have negative-strand RNA and an enveloped helical
nucleocapsid.

The papovaviruses (choice A) are DNA viruses with a naked icosahedral nucleocapsid. This family
includes the human papilloma viruses (which cause warts and are associated with penile,
laryngeal, and especially, cervical cancer), the BK virus that can affect immunosuppressed
patients, the JC virus associated with progressive multifocal leukoencephalopathy, and the
simian SV40 virus.

The parvoviruses (choice C) are small, single-stranded DNA viruses. Only one serotype (B19)
causes diseases in humans. It causes erythema infectiosum in children (characteristic "slapped
cheek" rash), aplastic crises in patients with hemolytic diseases, and hydrops fetalis or
stillbirth in anemic fetuses.

The picornaviruses (choice D) are positive single-stranded RNA viruses with a naked icosahedral
nucleocapsid. This family includes the polioviruses, echoviruses, coxsackieviruses, enterovirus
72 (HepA virus), and the rhinoviruses (common cold).

The poxviruses (choice E) are double-stranded DNA viruses. This family includes the viruses
responsible for smallpox and molluscum contagiosum.

A 24-year-old man presents with fever, rash, a mild headache, and a sore throat. He denies HIV risk
factors, although he is sexually active. On examination, his temperature is 100.8°F and his
pulse is 90/min. There is a diffuse, erythematous, maculopapular rash over most of his body.
Generalized adenopathy is appreciated, and photophobia is noted when funduscopic examination is
attempted. If this man is not treated, which of the following changes in his serologic status
will most likely occur?

A. The FTA-ABS titer would fall

B. The FTA-ABS titer would rise

C. The VDRL titer would fall

D. The VDRL titer would rise

E. Both FTA-ABS and VDRL would fall

F. Both FTA-ABS and VDRL would rise

Explanation:

The correct answer is C. This is a case of syphilis, which is diagnosed serologically, using
either treponemal or nontreponemal tests. The FTA-ABS (fluorescent treponemal antibody-absorbed
test) is the most widely used of the specific tests and depends on fluorescent labeling of the
organisms with anti-treponemal antibody. The specific tests tend to rise early in titer and
stay elevated throughout the lifetime of the host, or at least until well after drug therapy
has been completed. The VDRL (Venereal Disease Research Laboratory) is a nontreponemal test
that detects antibodies that cross-react with mammalian cardiolipid called reaginic antibodies.
This test will become positive after the specific test, and its titer will fall late in
infection, with or without drug therapy.

The FTA-ABS titer would fall (choice A) is incorrect because this titer will remain high
throughout the life of the host, falling off only very slowly after drug cure.

The FTA-ABS titer would rise (choice B) is incorrect because the specific antibody test will
reach a high positive titer and remain at that level in untreated late stage syphilis.

The VDRL titer would rise (choice D) is incorrect because reaginic antibody levels will fall in
late stage syphilis, with or without drug treatment.

Both FTA-ABS and VDRL would fall (choice E) is incorrect because specific antibody levels would
remain high, while reaginic antibodies would fall.

Both FTA-ABS and VDRL would rise (choice F) is incorrect because specific antibody levels would
remain high, while reaginic antibodies would fall.

A 22-year-old male military recruit complains of a headache and stiff neck. He is examined, blood is
drawn, and a lumbar puncture performed. The glucose in the CSF is 100 mg/dL and the serum
glucose is 120 mg/dL. The CSF shows 3 lymphocytes and 0 neutrophils/microliter. Which of the
following conclusions concerning the interpretation of these findings is most accurate?

A. The CSF glucose level suggests bacterial meningitis

B. The CSF glucose level suggests viral meningitis

C. The lymphocytes suggest bacterial meningitis

D. The lymphocytes suggest viral meningitis

E. There is no evidence for meningitis

Explanation:

The correct answer is E. Both the CSF glucose level and the small number of lymphocytes present
are within normal limits. It is normal for the CSF glucose to be less than serum glucose, often
about 2/3 of the serum value.

Bacterial meningitis (choices A and C) can profoundly lower CSF glucose levels. CSF from
bacterial meningitis cases also usually shows large numbers of neutrophils.

Viral meningitis (choices B and D) will not alter the CSF glucose level, but the CSF often
contains many lymphocytes.

Autopsy of a 23-year-old male victim of a motor vehicle accident reveals a small cluster of caseating
granulomas in the right lung just above the interlobar fissure and similar granulomas in the
hilar lymph nodes. Acid-fast staining demonstrates acid-fast bacilli within these lesions. No
other lesions were found in the remaining organs and systems. Which of the following is the most
accurate interpretation of these findings?

A. Cavitary tuberculosis

B. Ghon complex
C. Histoplasma infection

D. Miliary tuberculosis

E. Remote healed tuberculosis

Explanation:

The correct answer is B. The Ghon complex is the most frequent pathologic form of primary
pulmonary tuberculosis. Mycobacterium tuberculosis first localizes in the lung parenchyma, then
in the hilar lymph nodes. In both these locations, a granulomatous reaction takes place. These
lesions usually heal by fibrosis, leaving only small scars at the sites of remote tuberculous
infection. In some cases, owing to immunosuppression (e.g., AIDS, immunosuppressant treatment,
and lymphomas), reactivation of dormant bacilli in old lesions or additional re-exposure leads
to secondary tuberculosis, with progression of lesions. Sometimes, active lesions of the Ghon
complex are discovered by chance at autopsy. More frequently, scars due to remote healed
tuberculosis (choice E) are found postmortem and listed in autopsy reports as incidental
findings

Cavitary tuberculosis (choice A) and miliary tuberculosis (choice D) are expressions of

secondary infection, following reactivation of old, usually clinically silent, lesions. The
cavitary form is characterized by development of large areas of liquefactive necrosis that
empty into the airspaces, leading to cavities within the lung parenchyma. The miliary form is
due to lymphohematogenous dissemination and subsequent seeding of tubercle bacilli throughout
the body, with myriad small granulomas forming in the lungs, spleen, liver, bone marrow,
retina, and adrenals, for example.

Acid-fast bacilli suggest tuberculosis, rather than an infection with a fungus such as
Histoplasma(choice C).

A 53-year-old woman with diarrhea and lower abdominal pain of 3 days duration comes to her physician
after failing to relieve her symptoms with various home remedies. She denies any recent travel
and states that there is blood and pus in her stool. Fecal cultures yield several flagellated,
curved, oxidase-positive, gram-negative rods. The organism isolated is most likely

A. Campylobacter jejuni

B. Escherichia coli

C. Salmonella

D. Shigella

E. Vibrio cholera

Explanation:

The correct choice is A. Campylobacter is a motile, curved, oxidase-positive, gram-negative rod

with a polar flagella. The illness typically begins 1 to 7 days following ingestion of the
organism. The presentation is usually lower abdominal pain and diarrhea with blood and pus. The
illness is self-limited after 3 to 5 days and can last up to 2 weeks. The organisms grow
optimally at 42° C under microaerophilic conditions.

Escherichia coli(choice B), although a flagellated gram-negative organism, is not the correct
choice since it is not as common a cause of bloody diarrhea in this age group and is not
oxidase positive.

Salmonella (choice C) is incorrect because it is oxidase negative.

Shigella (choice D) is incorrect because it is oxidase negative.

Vibrio cholera(choice E) has many physical features in common with C. jejuni. However, V.
cholera is not enteroinvasive and does not produce bloody diarrhea.

A hospitalized patient develops dysuria and suprapubic pain and is treated with ciprofloxacin. What is
the mechanism of action of this antibiotic?

A. It inhibits dihydrofolate reductase

B. It inhibits DNA-dependent RNA polymerase

C. It inhibits protein synthesis by binding to the 30s ribosomal subunit

D. It inhibits protein synthesis by binding to the 50s ribosomal subunit

E. It inhibits topoisomerase II (DNA gyrase)

Explanation:

The correct answer is E. This is a straightforward question where the introductory clinical
details are really irrelevant. Ciprofloxacin and norfloxacin belong to a category of antibiotics
called the fluoroquinolones. They are bactericidal and work by inhibiting topoisomerase II (DNA
gyrase). They are effective against gram-negative rods and are the only oral agents effective
against Pseudomonas. Ciprofloxacin is effective for treating UTIs, gonorrhea, diarrheal
diseases, and soft tissue infections. It is also used to treat Pseudomonas infections in cystic
fibrosis.

The wrong answer choices provide us with the opportunity to discuss important mechanisms of
action for other antimicrobials:

Inhibition of dihydrofolate reductase (choice A) is the mechanism of action of trimethoprim.

Trimethoprim is typically used in combination with sulfonamides (trimethoprim-sulfamethoxazole).
Sulfonamides inhibit an earlier step in folate synthesis (dihydropteroate synthase), so the
combination with trimethoprim is an effective "one-two" punch. Trimethoprim-sulfa is used in the
treatment of Shigella, Salmonella, recurrent UTIs, and in Pneumocystis carinii pneumonia.

Inhibition of DNA-dependent RNA polymerase (choice B) is the mechanism of action of rifampin.

Rifampin is used (along with other drugs) in the treatment of tuberculosis. You should also
remember that rifampin can be used to treat individuals exposed to Meningococcus or H.
influenzae type B.

Inhibition of the 30s ribosomal subunit (choice C) is the mechanism of action of two important
classes of antibiotic—the tetracyclines (tetracycline, doxycycline, demeclocycline) and
the aminoglycosides (gentamicin, tobramycin, streptomycin, etc.). The tetracyclines inhibit the
attachment of the aminoacyl-tRNA to the ribosome while the aminoglycosides inhibit the formation
of the initiation complex.

Inhibition of the 50s ribosomal subunit (choice D) is the mechanism of action of the macrolides
(e.g., erythromycin), the lincosamides (e.g., lincomycin, clindamycin), and chloramphenicol.
Chloramphenicol inhibits the 50s peptidyl transferase, while erythromycin blocks translocation.
Cefuroxime is believed to exert its antibacterial effect by which of the following mechanisms?

A. Competitive inhibition of para-aminobenzoic acid (PABA)

B. Inhibition of bacterial cell wall synthesis

C. Inhibition of DNA-gyrase

D. Irreversible binding to the 30S subunit of bacterial ribosomes

E. Irreversible binding to the 50S subunit of bacterial ribosomes

Explanation:

The correct answer is B. Cephalosporins, such as cefuroxime, are believed to exert their
antibacterial effect by binding to one or more of the penicillin-binding proteins located on the
cell walls of susceptible organisms. This action results in the inhibition of the third, and
final, stage of bacterial cell wall synthesis. This is also the mechanism of action of the
penicillins. Cefuroxime is a second generation cephalosporin used to treat infections in the
lower respiratory and urinary tracts, as well as otitis media. It is also efficacious in the
treatment of gonorrhea and is used for perioperative prophylaxis in various surgical procedures,
such as coronary artery bypass grafting.

Sulfonamide antibiotics, such as sulfamethoxazole-trimethoprim, exert their antibacterial effect

through the competitive inhibition of para-aminobenzoic acid (PABA) (choice A), thereby
inhibiting folic acid biosynthesis required for bacterial growth.

Quinolone antibiotics, such as ciprofloxacin, inhibit DNA-gyrase (choice C), which is an enzyme
necessary for bacterial DNA replication and repair.

Aminoglycosides, such as gentamicin, irreversibly bind to the 30S subunit of bacterial ribosomes
(choice D), inhibiting bacterial protein synthesis.

Lincosamides, such as clindamycin, irreversibly bind to the 50S subunit of bacterial ribosomes
(choice E), suppressing bacterial protein synthesis. Note that macrolides, such as erythromycin,
reversibly bind to the 50S subunit of bacterial ribosome.

A 19-year-old college student presents to the student health clinic complaining of weakness, malaise,
and a chronic cough. He has a fever of 100 degrees F and a dry cough; no sputum can be obtained
for laboratory analysis, so a bronchial lavage is performed and the washings are submitted to
the laboratory. The laboratory reports that the organism is "slow-growing." Serodiagnosis
reveals Strep MG agglutinins in the patient's serum. Which of the following organisms is the
most likely cause of this student's illness?

A. Klebsiella pneumoniae

B. Mycoplasma pneumoniae

C. Parainfluenza virus

D. Respiratory syncytial virus

E. Streptococcus pneumoniae

Explanation:
The correct answer is B. The patient has primary atypical pneumonia caused by Mycoplasma
pneumoniae. This organism is fastidious and difficult to culture in the laboratory, however
serodiagnosis can be most helpful. Patients typically produce one or two heterophile antibodies
during the course of the infection; one agglutinates human O+ RBCs in the cold (the cold
hemagglutinin) while the other causes the agglutination of a strain of Streptococcus salivarius
termed strain MG (the Strep MG agglutinins).

Klebsiella pneumoniae(choice A) is readily cultured on routine laboratory media and

characteristically produces pneumonia with blood clots in the sputum (red currant jelly
sputum), which may be indicative of pulmonary abscess development.

Parainfluenza viruses (choice C) cause croup, which is characterized by a dry, "barking" cough.
It is more of a tracheitis, bronchitis, and bronchiolitis than a pneumonitis. No heterophile
antibodies are produced in these patients.

Respiratory syncytial virus (choice D) causes an atypical pneumonitis in infants. It is usually

diagnosed by the observation of syncytial masses in respiratory secretions. Cold hemagglutinins
and Strep MG agglutinins are absent.

Streptococcus pneumoniae (choice E) is the number one cause of pneumonia in adults. It also
causes septicemia and meningitis in the elderly. The patient has a classical acute pneumonia
with a productive cough, high fever with chills, leukocytosis, tachycardia, rapid respirations
and other signs of serious respiratory disease. A vaccine, composed of the capsular
carbohydrate of 23 serotypes of this organism, is routinely given to individuals over the age
of 60, as well as to individuals with splenic abnormalities (e.g., sickle cell disease) who are
at increased risk for pneumococcal sepsis.

An 8-month-old baby presents to the emergency room with a 1-day history of poor feeding and generalized
weakness. The mother states that she often feeds the baby honey to pacify her. The toxin
responsible for this presentation works by which of the following mechanisms?

A. It blocks the release of acetylcholine from the nerve terminal

B. It blocks the release of inhibitory neurotransmitters such as glycine and GABA

C. It has a subunit that inactivates an elongation factor by ADP-ribosylation

D. It is a lecithinase

E. It stimulates guanylate cyclase

Explanation:

The correct answer is A. The clinical history suggests infant botulism. The clue here is that
the mother feeds the baby honey. Clostridium botulinum (a common honey contaminant) was
ingested and produced toxin in the infant. The toxin, which blocks the release of acetylcholine
from nerve terminals, is responsible for the floppiness. Acetylcholine is the neurotransmitter
at the neuromuscular junction and impairment of this can lead to muscle weakness, failure to
thrive, and in more serious cases, respiratory impairment.

Glycine and GABA (choice B) release is inhibited by C. tetani. This leads to the muscular
spasms of tetanus.

ADP-ribosylation of an elongation factor (choice C) is a mechanism of action of diphtheria and

Pseudomonas exotoxins.
Alpha toxin from C. perfringens is a lecithinase (choice D) responsible for the development of
gas gangrene.

Guanylate cyclase (choice E) is stimulated by a heat-stable toxin produced by E. coli.

A 7-year-old boy presents to the pediatrician because his mother noticed a "smoky" color to his urine.
Upon questioning the mother, it is revealed that the child suffered a sore throat several weeks
ago that was left untreated. Physical examination reveals hypertension and mild generalized
edema. Urinalysis is significant for red blood cell casts. Which of the following accurately
describes the microorganism responsible for this child's illness?

A. It causes alpha-hemolysis on blood agar

B. It is catalase positive

C. It is coagulase positive

D. It is sensitive to bacitracin

E. It is sensitive to optochin

Explanation:

The correct answer is D. This is one of the "higher order" questions the USMLE often favors. In
this case, you need to figure out what disease the child has, what organism causes the disease,
and which of the listed features is true of the microorganism. The disease in question is
poststreptococcal glomerulonephritis, as evidenced by the smoky urine, hypertension, edema, and
red blood cell casts in the urine sediment. The history of the prior sore throat is a tip-off
that this is a nonsuppurative sequela of an infection due to Streptococcus pyogenes (group A
β-hemolytic Streptococci). You must remember the features of S. pyogenes. S. pyogenes can
be differentiated from Streptococcus pneumoniae and viridans Streptococci by its hemolytic
pattern; it is beta-hemolytic, while the others are alpha-hemolytic (choice A). It can be
distinguished from the other beta-hemolytic Streptococci by its sensitivity to the antibiotic
bacitracin. Other important things to remember about S. pyogenes are its many virulence
factors, including M protein, antiphagocytic capsule, hyaluronidase, streptolysins O and S, and
erythrogenic toxins.

Choice B is incorrect because Streptococci are catalase negative, in contrast to Staphylococci,

which are catalase positive.

Choice C is incorrect because S. pyogenes is coagulase negative. (In fact, a coagulase test
should NOT be done on a catalase-negative organism.) The coagulase test is an important means
of differentiating Staphylococcus aureus, which are coagulase positive, from all other species
of Staphylococcus, which are coagulase negative.

Choice E is incorrect because optochin is used to differentiate the viridans Streptococci

(resistant) from S. pneumoniae (sensitive).

An AIDS patient with clinical pneumonia has a bronchoalveolar lavage that demonstrates small, "hat-
shaped" structures in alveoli that are about the size of an erythrocyte and stain with silver
stains. The microorganism involved is most likely which of the following?

A. Aspergillus fumigatus

B. Blastomyces dermatitidis
C. Mycobacterium avium

D. Mycobacterium tuberculosis

E. Pneumocystis carinii

Explanation:

The correct answer is E. This is the classic appearance of Pneumocystis cysts. Pneumocystis is
a common (and dangerous) cause of pneumonia in AIDS patients. The diagnosis is now frequently
made by bronchoalveolar lavage, which is much more effective at demonstrating the organism than
is either sputum or blood culture.

Aspergillus fumigatus(choice A) is a typical fungus, and hyphae would probably have been seen
in the lavage material.

Blastomycosis (choice B) is caused by a dimorphic fungus that grows in mammalian tissues as a

round, multinucleate, budding cell 8-15 micrometers in diameter.

Mycobacteria (choices C and D) are small, acid-fast rods.

Which of the following viruses is capable of replication in enucleated cells?

A. Adenovirus

B. Cytomegalovirus

C. Influenza virus

D. JC virus

E. Poliovirus

Explanation:

The correct answer is E. Most RNA viruses (eg, poliovirus) replicate in the cytoplasm and
therefore can replicate in enucleated cells. Poliovirus belongs to the family Picornaviridae.
These viruses are nonenveloped and have an icosahedral nucleocapsid that contains positive-
sense RNA.

The exception to the rule regarding RNA viruses is the family Orthomyxoviridae, the influenza
viruses (choice C). Orthomyxoviruses undergo transcription and RNA replication in the nucleus
of the host cell because they need to cannibalize the capped 5' termini of cellular RNAs for
use as primers for viral mRNA transcription.

For most DNA viruses, transcription and DNA replication occur in the nucleus of the host cell.
The exception to this observation is the family Poxviridae, which carries out its replication
in the cytoplasm. Poxviridae includes variola virus, vaccinia virus, molluscum contagiosum, and
orf virus.

Adenoviruses (choice A) are nonenveloped and have an icosahedral nucleocapsid that contains a
double-stranded linear DNA genome.

Cytomegalovirus (choice B) is a member of family Herpesviridae. It is an enveloped virus with

an icosahedral nucleocapsid that contains a double-stranded linear DNA genome.
JC virus (choice D) belongs to family Papovaviridae. It is nonenveloped and has an icosahedral
nucleocapsid that contains a double-stranded circular DNA genome.

A 47-year-old man with a history of sickle cell disease has had numerous hospitalizations requiring the
placement of intravenous lines. The patient has poor peripheral venous access, and a catheter is
placed in the right subclavian vein. The patient subsequently develops right arm discomfort and
swelling and a temperature of 40.1 degrees C with chills. Multiple blood cultures are taken, and
gram-positive cocci are isolated. The organism is catalase positive and grows on mannitol salt
agar, but does not turn the agar yellow; the colonies are gamma-hemolytic on a sheep blood agar
plate. Which of the following organisms is the most likely cause of this patient's symptoms?

A. Enterococcus faecalis

B. Staphylococcus aureus

C. Staphylococcus epidermidis

D. Streptococcus agalactiae

E. Streptococcus pyogenes

Explanation:

The correct answer is C. The patient has developed bacteremia; the description of the causative
agent is consistent with a staphylococcal organism (catalase positive, gram-positive cocci that
grow on mannitol salt agar). The organism is most likely S. epidermidis as it was not able to
ferment mannitol, and was not hemolytic. Both of those characteristics tend to rule out S.
aureus(choice B). Two other tests that are commonly used are coagulase production and excretion
of DNAse from colonies. S. aureus is positive in both tests, S. epidermidis is negative.

Enterococcus faecalis(choice A) might grow on the mannitol salt agar as it is relatively

haloduric but these organisms are catalase negative. The enterococci are extremely variable in
hemolytic ability so this characteristic is not useful in species identification.

Both streptococcal organisms (choices D and E) are catalase negative and beta-hemolytic on
sheep blood agar plates. Also, neither would grow on the mannitol salt agar. S. pyogenes is
sensitive to growth inhibition by bacitracin while S. agalactiae (group B streptococci) is not.

Microbiologic studies on a gram-positive coccus isolated from a skin abscess demonstrate a positive
catalase test and a positive coagulase test. This is most consistent with which of the following
organisms?

A. S. aureus

B. S. epidermidis

C. S. pneumoniae

D. S. pyogenes

E. S. saprophyticus

Explanation:

The correct answer is A. All of the organisms listed are gram-positive cocci. The positive
catalase test excludes the Streptococci, S. pyogenes(choice D), and S. pneumoniae(choice C). Of
the Staphylococci, only S. aureus has a positive coagulase test. S. epidermidis(choice B) and
S. saprophyticus(choice E) are coagulase-negative Staphylococci.