Infectious Diseases Serious Fungal Infections: Review Questions Pallavi Bhargava, MD Dr. Bhargava is a Fellow in the Division of Infectious Diseases at Wayne State University School of Medicine, Detroit, MI. Pranatharthi H. Chandrasekar, MD, FACP Dr. Chandrasekar is Professor of Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI. Choose the single best answer for each question.
	1. A 56-year-old man undergoes coronary artery bypass grafting after a myocardial infarction. He develops a temperature of 102.3°F a few days after surgery. On physical examination, the sternotomy wound margins are erythematous, and a purulent discharge is noted. Cultures obtained at the time of sternal wound débridement grow Pseudomonas aeruginosa. Intravenous (IV) therapy is begun with tobramycin and piperacillin; the fever resolves over next few days. A week later, the patient has rigors and a temperature as high as 102°F. The sternal wound is healing well, and repeat wound culture is negative for organisms. The subclavian triple lumen venous catheter site appears normal. One of 3 sets of blood cultures is positive for yeast. Which of the following is the most appropriate next step in the treatment of this patient? Remove the triple lumen catheter and observe Insert a new catheter over the guidewire and withhold antifungal therapy Remove the triple lumen catheter and initiate treatment with fluconazole Repeat the blood cultures, since the yeast in the blood is likely to be a contaminant Click here to compare your answer. 2. A 47-year-old woman in seen in her doctor’s office with a 1-day history of right eye redness and swelling and headache on the same side. Her past medical history is significant for poorly controlled diabetes mellitus. Physical examination shows a tachypneic woman with a low-grade temperature of 99.8°F, a mildly proptotic right eye, and decreased extraocular movements. The right cheek is erythematous, and nasal turbinates have a dusky appearance with a small area of black discoloration. Results of arterial blood gas analysis are pH 7.23, PCO2 25 mm Hg, PO2 70 mm Hg, bicarbonate 10 mEq/L, and oxygen saturation 98% while the patient is breathing room air. Which of the following is the most appropriate next step in the treatment of this patient? Initiate therapy with broad-spectrum antibiotics and obtain blood, sinus, and nasal cultures Obtain an immediate computed tomography (CT) scan of the nose, paranasal sinuses, orbit, and brain and request urgent surgical consultation for possible débridement Begin IV therapy with amphotericin B and observe Begin IV therapy with a high dose of fluconazole and observe Click here to compare your answer.		3. A 45-year-old woman is seen by her physician because of a 1-week history of fever, cough, breathlessness and pleuritic chest pain. She underwent allogeneic peripheral stem cell transplantation 2 months ago for myelodysplastic syndrome and developed graft-versus-host disease 1 month later. The patient reports no history of exposure to tuberculosis and had a negative tuberculin test prior to transplant. Her medications include prednisone 30 mg daily, cyclosporin A, trimethoprim-sulfamethoxazole (1 double-strength tablet) 3 times weekly, and oral administration of penicillin 250 mg twice daily. Physical examination reveals scattered crackles over both lung fields; the rest of the examination shows no abnormalities. A chest radiograph shows bilateral nodular infiltrates with cavitation and few pleural-based lesions. The patient’s peripheral leukocyte count is 4.8 x 103/mm3 (absolute neutrophil count 3 x 103/mm3, hemoglobin 9.8 g/dL, and platelet count 18 x 103/mm3). Which of the following is the most appropriate next step in the treatment of this patient? Perform venous Doppler ultrasonography of the lower extremities and obtain an immediate ventilation/perfusion scan of the lungs Send induced sputum samples for analysis for Pneumocystis carinii and initiate therapy with a high dose of trimethoprim-sulfamethoxazole Begin empiric antifungal IV therapy with fluconazole and attempt to decrease immunosuppression Perform a CT scan of the chest and possibly a bronchoalveolar lavage/open lung biopsy Click here to compare your answer.
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