Specialty Certificate in Infectious Diseases Sample Questions

Question: 1 A 65-year-old man presented with a 4-week history of generalised fatigue. He was found to have bacterial endocarditis caused by Streptococcus bovis. He was treated with penicillin and gentamicin. One week after starting the treatment the patient was symptomatically much improved. His appetite had returned and he no longer had fever. What further action is most appropriate? A B C D E colonoscopy CT scan of abdomen cystoscopy dental assessment gastroscopy

SCEIDSampleQs-Dec-11

Question: 2 A 28-year-old woman presented with symmetrical pain in her elbows, shoulders and knees, 4 weeks after starting quadruple therapy for pulmonary tuberculosis. Investigations: haemoglobin white cell count platelet count erythrocyte sedimentation rate antinuclear antibodies rheumatoid factor What is the most likely cause of her symptoms? A B C D E ethambutol arthropathy isoniazid-induced systemic lupus erythematosus paradoxical reaction pyrazinamide arthropathy rheumatoid arthritis 116 g/L (115165) 6.4 109/L (4.011.0) 184 109/L (150400) 24 mm/1st h (<20) 1:40 (negative at 1:20 dilution) 45 kIU/L (<30)

SCEIDSampleQs-Dec-11

Question: 3 A 55-year-old woman, originally from Thailand, presented with significant weight loss and was found to have HIV infection. Investigations: HIV viral load CD4 count hepatitis B surface antigen hepatitis B surface antigen anti-hepatitis B core antibody anti-hepatitis B surface antibody hepatitis B DNA 156 250 copies/mL (lower detection limit 40) 285 106/L (4301690) positive positive positive negative 950 IU/mL (lower detection limit 250)

What is the most appropriate anti-retroviral therapy? A B C D E abacavir, lamivudine and efavirenz abacavir, lamivudine and nevirapine tenofovir, emtricitabine and efavirenz tenofovir, emtricitabine and nevirapine zidovudine, lamivudine and nevirapine

SCEIDSampleQs-Dec-11

Question: 4 A 22-year-old woman was admitted with fever, severe myalgia and a rash 8 days after returning from a holiday in Thailand. She had not taken any antimalarial prophylaxis or had any immunisations prior to travel, and had only visited Bangkok, Phuket and Koh Samui. Four days before admission, she had seen her general practitioner, who had given her a course of amoxicillin. On examination, her temperature was 38.4C. There was mild erythema in the pharynx and a widespread macular rash that was becoming confluent in some areas. A few small cervical lymph nodes were palpable. Investigations: haemoglobin haematocrit white cell count neutrophil count lymphocyte count eosinophil count platelet count blood film 106 g/L (115165) 0.32 (0.360.47) 2.4 109/L (4.011.0) 1.1 109/L (1.57.0) 0.7 109/L (1.54.0) 0.3 109/L (0.040.40) 84 109/L (150400) no malarial parasites; a few atypical lymphocytes seen 21 mol/L (122) 117 U/L (535) 143 U/L (45105)

serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase What is the most likely diagnosis? A B C D E

allergic reaction to amoxicillin dengue fever HIV seroconversion illness infectious mononucleosis due to EpsteinBarr virus malaria

SCEIDSampleQs-Dec-11

Question: 5 A 27-year-old woman presented with a short history of general malaise, increased frequency of passing urine and dysuria. She was attempting to conceive and was reluctant to take any antibiotic that could be harmful in pregnancy. Which antibiotic is most appropriate? A B C D E cefalexin ciprofloxacin co-trimoxazole doxycycline trimethoprim

SCEIDSampleQs-Dec-11

Question: 6 A 45-year-old man presented with a 6-month history of weight loss and anorexia. He had a long history of alcohol abuse. Ten years previously, he had been found to be hepatitis C antibody-positive and PCR-positive. On examination, he appeared lean and unkempt. The liver edge was smooth and palpable three finger-breadths below the costal margin. Investigations: haemoglobin white cell count platelet count serum albumin serum alanine aminotransferase serum gamma glutamyl transferase serum -fetoprotein 102 g/L (130180) 3.3 109/L (4.011.0) 65 109/L (150400) 29 g/L (3749) 375 U/L (535) 306 U/L (<50) 503 kU/L (<10)

Which investigation is most likely to establish the diagnosis? A B C D E CT scan of liver hepatic elastography (FibroScan) hepatitis C viral load and genotype HIV antibody test hyaluronic acid assay

SCEIDSampleQs-Dec-11

Question: 7 A 53-year-old woman with no previous medical history or healthcare exposure was admitted in septic shock. Her husband said that she had been pruning roses the day before and had sustained scratches in the process. On examination, she was febrile (39.5C), her pulse was 132 beats per minute and her blood pressure was 80/40 mmHg. Her right arm showed extensive spreading cellulitis with blistering over the hand and distal forearm. She had marked pain on all movements of the fingers and wrist. What is the most appropriate antimicrobial treatment? A B C D E benzylpenicillin and clindamycin benzylpenicillin and gentamicin ceftriaxone and vancomycin flucloxacillin and gentamicin vancomycin and meropenem

SCEIDSampleQs-Dec-11

Question: 8 A 33-year-old man was admitted to hospital with a 5-week history of fevers and night sweats. He had lost 3 kg in weight over the previous 2 months, and complained of anorexia, fatigue, arthralgia and intermittent non-specific macular rashes. On examination, his temperature was 38.2C, his pulse was 95 beats per minute and his blood pressure was 105/85 mmHg. His chest was dull to percussion over the lower lungs with reduced air entry basally. Abdominal examination revealed minor hepatosplenomegaly. He was given empirical treatment with intravenous ceftriaxone but was still intermittently febrile after 5 days. Investigations: haemoglobin white cell count neutrophil count platelet count serum alkaline phosphatase serum gamma glutamyl transferase serum C-reactive protein chest X-ray 107 g/L (130180) 18.5 109/L (4.011.0) 15.9 109/L (1.57.0) 540 109/L (150400) 125 U/L (45105) 55 U/L (<50) 295 mg/L (<10) bilateral pleural effusions; no cardiomegaly hepatosplenomegaly

ultrasound scan of abdomen What is the most likely diagnosis? A B C D E adult Stills Disease erythrovirus B19 familial Mediterranean fever polyarteritis nodosa sarcoidosis

SCEIDSampleQs-Dec-11

Question: 9 An 88-year-old woman was admitted from a residential care home with confusion secondary to a urinary tract infection, which had been treated by her general practitioner with a course of antibiotics. Shortly after admission, she developed persistent diarrhoea. She was given intravenous fluids, but her condition deteriorated over the next 48 hours. On examination, her temperature was 38.5C and she appeared unwell with tachycardia, hypotension and a tender distended abdomen. Investigations: haemoglobin white cell count neutrophil count platelet count serum urea serum creatinine faecal Clostridium difficile toxin X-ray of abdomen 116 g/L (115165) 31.8 109/L (4.011.0) 28.1 109/L (1.57.0) 185 109/L (150400) 9.5 mmol/L (2.57.0) 130 mol/L (60110) negative dilated large bowel with thickened bowel wall

What is the most likely diagnosis? A B C D E campylobacter gastroenteritis diverticulitis Escherichia coli O157 infection norovirus infection pseudomembranous colitis

SCEIDSampleQs-Dec-11

Question: 10 A 45-year-old office worker presented having felt unwell since returning from a 4-week holiday in Egypt. On examination, he was jaundiced. Investigations: HBsAg anti-hepatitis A virus IgM anti-hepatitis A virus IgG anti-hepatitis C virus antibody not detected detected not detected not detected

For how long should he be excluded from working in his office? A B C D E no exclusion necessary until 7 days from onset of jaundice until 14 days from onset of symptoms until asymptomatic until faecal samples are negative for hepatitis A virus

SCEIDSampleQs-Dec-11

Question: 11 A 37-year-old South African man was reviewed in the HIV clinic. He had arrived in the UK 2 months previously. He was asymptomatic, with no significant medical history other than HIV infection. There were no abnormalities on physical examination. He was taking zidovudine/lamivudine (Combivir) and efavirenz and was very reluctant to change his medication. Investigations: CD4 count serum albumin serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase HBsAg HBeAg hepatitis C antibody HIV viral load 485 106/L (4301690)

35 g/L (3749) 13 mol/L (122) 25 U/L (535) 120 U/L (45105) positive negative negative undetectable

What is the most appropriate investigation to guide antiviral therapy? A B C D E hepatic elastography (FibroScan) HIV resistance (genotype) assay HIV tropism assay quantitative HBV DNA assay ultrasound scan of liver

SCEIDSampleQs-Dec-11

Question: 12 A 22-year-old Indian student was found to have pulmonary tuberculosis. He was treated with rifampicin, isoniazid, pyrazinamide and ethambutol. What is the mechanism of action of rifampicin in the treatment of mycobacterial infection? A B C D E increases mycobacterial cell wall permeability inhibits mycobacterial protein synthesis inhibits mycobacterial RNA polymerase inhibits synthesis of mycobacterial fatty acids inhibits synthesis of mycolic acid in mycobacterial cell wall

SCEIDSampleQs-Dec-11

Question: 13 A 48-year-old man with a past history of prostatic carcinoma presented with a 4-week history of fever and back pain secondary to L1/L2 discitis. Escherichia coli was isolated from blood cultures and he was treated with intravenous ertapenem. His condition improved and his temperature settled within 5 days. Two weeks into treatment, his fever returned. On examination, his temperature was 39.0C; there were no other abnormal clinical signs. Investigations: haemoglobin white cell count platelet count serum C-reactive protein blood cultures What is the most likely cause of his fever? A B C D E antibiotic-associated fever endocarditis paraspinal abscess prostatic carcinoma resistant Escherichia coli infection 115 g/L (130180) 3.4 109/L (4.011.0) 164 109/L (150400) 14 mg/L (<10) negative at 48 h

SCEIDSampleQs-Dec-11

Question: 14 A 76-year-old man with a prosthetic aortic valve replacement developed macroscopic haematuria. Urine cultures were sterile, and an elective cystoscopy was planned. What antimicrobial prophylaxis against infective endocarditis is most appropriate? A B C D E intravenous amoxicillin plus gentamicin intravenous teicoplanin plus gentamicin none oral amoxicillin oral clindamycin

SCEIDSampleQs-Dec-11

Question: 15 A 45-year-old woman from the Dominican Republic presented with a 1-day history of severe headache, fever and photophobia. She had been unwell for the previous month with persistent diarrhoea. On examination, she had a temperature of 38.5C, neck stiffness and a positive Kernigs sign. Diffuse generalised lymphadenopathy was present. Investigations: cerebrospinal fluid (CSF): total protein white cell count lymphocyte count neutrophil count CSF culture chest X-ray

1.2 g/L (0.150.45) 2000/L ( 5) 200/L ( 3) 1800/L (0) Enterococcus faecalis patchy opacities throughout both lung fields Strongyloides stercoralis larvae seen

sputum microscopy What is the most likely underlying diagnosis? A B C D E colonic carcinoma diverticulitis HTLV-1 infection intestinal tuberculosis Schistosoma mansoni infection

SCEIDSampleQs-Dec-11

Question: 16 An 18-year-old man was admitted to hospital with a rash. Before admission, his general practitioner had prescribed amoxicillin for a presumptive streptococcal pharyngitis. On examination, he had a rash (see image).

What is the most likely diagnosis? A B C D E infectious mononucleosis measles primary HIV infection scarlet fever secondary syphilis

SCEIDSampleQs-Dec-11

Question: 17 A 34-year-old man presented to hospital with excruciating pain in his right shin, having sustained a blow to it 24 hours previously. He had a rigor and was admitted to hospital. On examination, he was pyrexial (38.5C) and hypotensive (blood pressure 90/60 mmHg). He had extensive cellulitis extending up his right leg and was taken to theatre for debridement. Investigations: Gram stain of tissue received from theatre see image

What is the most likely pathogen? A B C D E Clostridium perfringens Staphylococcus aureus Streptococcus agalactiae Streptococcus pneumoniae Streptococcus pyogenes

SCEIDSampleQs-Dec-11

Question: 18 A 25-year-old soldier presented 7 months after a 3-month tour in Afghanistan. He had a 5day history of malaise, rigors and fever. He had completed a full course of doxycycline chemoprophylaxis. Investigations: blood film see image

What is the most appropriate treatment? A B C D E artemether/lumefantrine (Riamet) and clindamycin artemether/lumefantrine (Riamet) and primaquine chloroquine and doxycycline chloroquine and primaquine quinine and doxycycline

SCEIDSampleQs-Dec-11

Question: 19 A randomised controlled trial was carried out in patients presenting with an influenza-like illness. The aim was to determine whether oseltamivir is useful in preventing hospital admission. The null hypothesis stated that there would be no difference between treatment and no-treatment arms in the proportion of patients requiring hospital admission. Six hundred and forty patients were randomly allocated to receive oseltamivir or no treatment in an open-label study. The study was designed to have 80% power to find a clinically important difference between groups with 95% confidence. Fifteen per cent of the study participants were lost to follow-up, and 20% did not complete the originally allocated treatment. Which feature of the study is most likely to result in a type 1 error (that is, falsely rejecting the null hypothesis)? A failure to use double-blind, placebo-controlled study design B large number of patients lost to follow-up C large number of patients who did not complete the treatment to which they were originally allocated D recruitment of inadequate number of patients E use of insufficiently strict probability value to declare statistically significant difference between groups

SCEIDSampleQs-Dec-11

Question: 20 A 23-year-old man presented with a 3-day history of worsening abdominal pain and fever following a dog bite. He had a history of splenectomy. On examination, he was obtunded, with a temperature of 37.9C, a pulse of 138 beats per minute and a blood pressure of 80/45 mmHg. Investigations: blood culture What is the most likely organism? A B C D E Capnocytophaga canimorsus Eikenella corrodens Haemophilus influenzae Kingella kingae Pseudomonas aeruginosa oxidase-positive, Gram-negative rod

SCEIDSampleQs-Dec-11

Question: 21 A 55-year-old woman, originally from Thailand, presented with significant weight loss and was found to have HIV infection. Investigations: HIV viral load CD4 count HBsAg hepatitis B e antigen anti-hepatitis B core antibody HBV DNA 156 250 (log 5.2) copies/mL (lower detection limit 40) 285 106/L (4301690) positive negative positive 950 (log 2.9) IU/mL (lower detection limit 250)

What is the most appropriate antiretroviral therapy? A B C D E abacavir/lamivudine (Kivexa) and efavirenz abacavir/lamivudine (Kivexa) and nevirapine tenofovir/emtricitabine (Truvada) and efavirenz tenofovir/emtricitabine (Truvada) and nevirapine zidovudine/lamivudine (Combivir) and nevirapine

SCEIDSampleQs-Dec-11

Question: 22 A 22-year-old man was bitten on the hand by a monkey, on the last day of his backpacking holiday in India. He had not sought medical attention at the time but presented to the emergency department in the UK the next day, 28 hours after the bite. He had received rabies vaccine before travel. On examination, there was a small wound with broken skin on the back of his hand, which appeared clean. What is the most appropriate intervention? A rabies vaccine, five doses on days 0, 3, 7, 14 and 30 B rabies vaccine, five doses on days 0, 3, 7, 14 and 30 plus rabies immunoglobulin on day 0 C rabies vaccine, five doses on days 0, 3, 7, 14 and 30 plus rabies immunoglobulin on days 0 and 7 D rabies vaccine, two doses on days 0 and 3 E rabies vaccine, two doses on days 0 and 3 plus rabies immunoglobulin on day 0

SCEIDSampleQs-Dec-11

Question: 23 A 76-year-old Caucasian man presented with a 2-week history of increasing breathlessness and cough productive of yellow sputum. He had a 40 pack-year history of smoking. He was known to have chronic obstructive lung disease, and he had never been in close contact with anyone with tuberculosis as far as he was aware. On examination, his temperature was 37.2C, his pulse was 96 beats per minute and his blood pressure was 120/76 mmHg. He was treated with oral amoxicillin and prednisolone and nebulised salbutamol. Investigations: haemoglobin white cell count serum C-reactive protein interferon- release assay ZiehlNeelsen stain sputum 155 g/L (130180) 11.2 109/L (4.011.0) 24 mg/L (<10) negative acid-fast bacilli seen; mycobacterial culture awaited hyperexpanded lung fields; no focal shadowing

chest X-ray

Which organism is most likely to explain the sputum microscopy result? A B C D E Mycobacterium abscessus Mycobacterium avium complex Mycobacterium bovis Mycobacterium chelonae Mycobacterium tuberculosis

SCEIDSampleQs-Dec-11

Question: 24 An 18-year-old man presented with fever, cough and shortness of breath. He had been previously well. He recalled having a severe sore throat 4 days before presentation. On examination, he had a temperature of 38.2C, his pulse was 50 beats per minute and his blood pressure was 94/55 mmHg. His oxygen saturation was 89% (9498) breathing room air. Investigations: blood culture (after 3 days) chest X-ray anaerobic Gram-negative bacillus patchy consolidation in both lung fields

What is the most likely identity of the organism found on blood culture? A B C D E Bacteroides fragilis Fusobacterium necrophorum Haemophilus influenzae Klebsiella pneumoniae Pseudomonas aeruginosa

SCEIDSampleQs-Dec-11

Question: 25 A 35-year-old woman presented with a 2-day history of fever, dysuria and increased urinary frequency. She had recently returned from visiting relatives in Pakistan. During her visit, she had been admitted to hospital following a road traffic accident. Investigations: urine microscopy urine culture susceptibility results pus cells 3+ Klebsiella pneumoniae resistant to cefotaxime, ceftazidime, aztreonam, ciprofloxacin, gentamicin, amikacin, ertapenem and meropenem

What is the most appropriate therapy? A B C D E colistin daptomycin imipenem tigecycline tobramycin

SCEIDSampleQs-Dec-11

Question: 26 A 32-year-old woman was admitted with a 2-day history of flu-like illness during an epidemic of H1N1 influenza. She was 30 weeks pregnant. She had been vaccinated against H1N1 influenza 4 weeks previously. What is the most appropriate management? A B C D E intravenous pooled human immunoglobulin intravenous zanamivir oral amoxicillin oral oseltamivir symptomatic treatment

SCEIDSampleQs-Dec-11

Question: 27 A 67-year-old man presented with a 3-day history of progressive breathlessness, productive cough and intermittent confusion. He had a past medical history of ischaemic heart disease, hypercholesterolaemia, type 2 diabetes mellitus and chronic kidney disease stage 3. On examination, he had a temperature of 38.2C, with a blood pressure of 140/70 mmHg and a respiratory rate of 25 breaths per minute. He had an abbreviated mental test score of 7/10. There was reduced air entry at the right base associated with coarse crackles. Investigations: white cell count neutrophil count serum urea serum creatinine chest X-ray What is the CURB-65 score for this patient? A B C D E 1 2 3 4 5 22.0 19.4 109/L (4.011.0) 109/L (1.57.0)

17.9 mmol/L (2.57.0) 154 mol/L (60110) right basal consolidation

SCEIDSampleQs-Dec-11

Question: 28 Five patients who required admission arrived in the emergency department. Patient 1 was a 17-year-old girl with meningococcal meningitis. Patient 2 was a 23-yearold man with acute varicella pneumonia. Patient 3 was a 79-year-old man with chronic leg ulcers and previous colonisation with MRSA. Patient 4 was an 89-year-old nursing home resident with unexplained diarrhoea following a course of co-amoxiclav for a lower respiratory tract infection. Patient 5 was a 22-year-old man with a peritonsillar abscess. There was only one single room available in the department. From an infection control perspective, which patient should be given highest priority for immediate placement in the single room? A B C D E Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

SCEIDSampleQs-Dec-11

Question: 29 A 19-year-old woman presented to her general practitioner for advice. She was 14 weeks pregnant, and 2 weeks previously she had been in contact with a 2-year-old child who had subsequently developed chickenpox the day before the patients presentation. She was unsure about her varicella immune status. What is the most appropriate next step in management? A B C D E ask her to present if a rash develops check varicella IgG status check varicella IgM status give aciclovir prophylaxis give human varicella zoster immunoglobulin

SCEIDSampleQs-Dec-11

Answers 1. Answer: A 2. Answer: D 3. Answer: C 4. Answer: B 5. Answer: A 6. Answer: A 7. Answer A 8. Answer A 9. Answer E 10. Answer B 11. Answer D 12. Answer C 13. Answer A 14. Answer C 15. Answer C 16. Answer A 17. Answer E 18. Answer D 19. Answer A 20. Answer A 21. Answer C 22. Answer D 23. Answer B 24. Answer B 25. Answer A 26. Answer D 27. Answer C 28. Answer B 29. Answer A

SCEIDSampleQs-Dec-11