Pediatric Examination and Board Review (177 page)

13.
(A)
The duration of treatment recommended for onychomycosis of the fingernails is 6 weeks and 12 weeks for toenail onychomycosis.

14.
(E)
Permethrin 5% cream is a safe and effective therapy for scabies. The cure rate is greater than 90%. Side effects of permethrin 5% are minimal. In infants and young children the cream is applied to the entire head, neck, and body and then removed by bathing 8-14 hours later. Prophylaxis with permethrin 5% cream is also recommended for household members.

15.
(A)
The advantage of albendazole over mebendazole is its activity in a single oral dose of 400 mg for treatment of hookworm infection. Mebendazole (100 mg twice daily for 3 days) and pyrantel pamoate (11 mg/kg per day not to exceed 1 g/day for 3 days) are alternative treatments for hookworm infection.

16.
(B)
Either mebendazole or albendazole can be administered for the treatment of whipworm infection. Both should be given for a 3-day course. Albendazole (400 mg) and ivermectin (200 μg/kg) given together each in a single dose have been effective for treatment of whipworm infection.

17.
(A)
Metronidazole is an important drug as part of the treatment regimen for intra-abdominal anaerobic infections and brain abscess. It is also effective therapy for the treatment of intestinal or extraintestinal (such as liver abscess) disease caused by
Entamoeba histolytica
.

18.
(B)
Travelers to areas where chloroquine-resistant
Plasmodium falciparum
exists can take 1 of 3 regimens that include mefloquine hydrochloride, doxycycline, or atovaquone-proguanil. Chloroquine is still the drug of choice for malaria prophylaxis in areas in which
P falciparum
is still susceptible or nonfalciparum malaria (
P vivax
,
P ovale
,
P malariae
) only exist.

S
UGGESTED
R
EADING

John CC. Drug treatment of malaria.
Pediatr Infect Dis J.
2003;22:649-651.

Steinbach WJ, Dvorak CC. Antifungal agents. In: Long SS, Pickering LK, Prober CG, eds.
Principles and Practices of Infectious Diseases.
3rd ed. Philadelphia, PA: Churchill Livingstone; 2008: 1452.

CASE 101: A 15-YEAR-OLD ADOLESCENT GIRL WITH FEVER, SHORTNESS OF BREATH, AND AN ABNORMAL CHEST RADIOGRAPH

A 15-year-old adolescent girl comes to your office on Friday morning with her 25-year-old sister. She indicates she has not been feeling well for 1-2 months. She remembers having a fever, sore throat, and rash about 2 months ago that resolved after 2 weeks. Her older sister tells you that the adolescent was seen at the emergency department for the acute illness. She recalls that blood was drawn and in a follow-up phone call later was told that the adolescent did not have infectious mononucleosis. Since then the adolescent has had fatigue and decreased appetite and thinks she may have lost some weight. She has also been too tired to try out for the high school basketball team. Her sister has also noticed a change in her younger sister’s activity level and insisted that she come to your office today because she was short of breath.

On physical examination the adolescent girl was alert and cooperative but appeared tired. Her temperature is 100.5°F (38.1°C). A fine white exudate is present on the buccal mucosa, posterior pharynx, and tongue. Posterior cervical and axillary adenopathy are noted. The respiratory rate is 30 per minute and scattered rales are heard at both the right and left lung bases. The heart and abdominal examinations are normal.

SELECT THE ONE BEST ANSWER

1.
You are concerned about the possibility of an immunodeficiency disorder in this adolescent girl. The first laboratory test to order for the evaluation for immunodeficiency should be

(A) complete blood count (CBC) with differential

(B) quantitative immunoglobulin levels

(C) T-lymphocyte subsets

(D) total hemolytic complement activity

(E) HIV enzyme immunoassay

2.
Human immunodeficiency virus infection is confirmed in this adolescent girl. In her case the most likely route of acquisition of HIV would likely be

(A) injecting drug use

(B) heterosexual contact with an HIV-infected person

(C) coagulation disorder

(D) perinatal exposure

(E) needlestick injury from an unknown source

3.
The illness occurring in the adolescent girl 2 months before evaluation by her primary care pediatrician was acute HIV infection. The laboratory test to diagnose acute HIV infection is

(A) HIV EIA

(B) HIV Western blot

(C) HIV rapid test

(D) lymphocyte subsets

(E) HIV RNA PCR

4.
A chest radiograph reveals bilateral alveolar disease with involvement of perihilar regions. The most likely diagnosis for the pulmonary abnormalities is

(A) CMV pneumonia

(B) pulmonary candidiasis

(C)
Mycobacterium avium
complex pneumonia

(D)
Pneumocystis jiroveci
pneumonia

(E)
Legionella pneumophila
pneumonia

5.
The major risk factor for development of
P jiroveci
infection in HIV-infected individuals is

(A) suppression of cell-mediated immunity measured by the number of CD4+ lymphocytes in blood

(B) impaired specific antibody production after immunization with T-cell independent antigens

(C) depressed neutrophil superoxide production

(D) diminished capability of natural killer (NK) lymphocytes to mediate antibody-dependent cell-mediated cytotoxicity of HIV-infected cells

(E) complement deficiency involving the classical complement pathway

6.
A 10-month-old male infant develops fever and shock, and a blood culture drawn before the start of antibiotic therapy grows
Pseudomonas aeruginosa
. The infant appears malnourished and has a weight less than 2 standard deviations below the mean for sex and age. The most likely underlying reason for the gram-negative septic shock is

(A) X-linked agammaglobulinemia

(B) immunodeficiency with hyperimmunoglobulinemia M

(C) protein-calorie malnutrition

(D) leukocyte adhesion deficiency type I

(E) common variable immunodeficiency

7.
Protein calorie malnutrition can result in major immunodeficiency. The immune deficit associated with malnutrition is primarily

(A) T-cell cellular immunity

(B) B-cell humoral immunity

(C) neutrophil function

(D) complement system

(E) combined T-cell cellular and B-cell humoral immunity

8.
A 4-year-old girl with a severe brain injury from IVH as a newborn does not develop fever in response to a documented infection with influenza virus. The most likely reason for this finding is

(A) damage to the thermoregulatory center in the hypothalamus

(B) inability to generate production of tumor necrosis factor-alpha

(C) inability to generate production of interleukin-1-beta

(D) deficiency of interferon-gamma in the systemic circulation

(E) deficiency of interleukin-2

9.
A 3-year-old child presents to your office with fever of 103°F (39.4°C), cough, and rhinorrhea during the peak of an epidemic of influenza A. The child’s mother is very concerned about the fever. You counsel her regarding the fever that

(A) the high fever can increase the replication of influenza virus

(B) fever can enhance some immunologic responses such as movement and function of certain white blood cells

(C) fever is best treated with a cooling blanket

(D) antipyretic agents will shorten the duration and contagiousness of influenza

(E) high fever is less likely to occur in children compared with adults

10.
A 12-month-old boy develops septic arthritis of the left knee with a positive blood and joint fluid culture for
S pneumoniae
. Protection against recurrent infection with this bacterial species correlates best with

(A) recruitment of T-helper cells (CD4+ cells)

(B) anti-C-polysaccharide antibody

(C) IgG 1 and IgG 3 subclass antibody

(D) maturation of the classical pathway of the complement system

(E) type-specific IgG anticapsular antibody

11.
A 16-year-old previously healthy adolescent male presents with a 2-week history of fever associated with malaise, anorexia, and weight loss. He is diagnosed with pneumonia but when three blood cultures are reported positive for
S aureus
, an echocardiogram is performed. The results reveal tricuspid valve endocarditis. The major risk factor for development of endocarditis in this adolescent is