MCQs & tweetorials about fungal infections and diagnostics, an educational project by @TxID_Edu and @MikeMeliaMD. Profile images courtesy of @richdavisphd.
80F nursing home resident presents w/ 3 days of fever, cough, & SOB
Vitals: T 38.6C, HR 110, BP 120/80, O2 94% on 3L. Exam notable for left basilar rhonchi & crackles
CXR shows LLL opacity. She is started on ceftriaxone & doxy
2/ 2 days later, she is still having intermittent fevers with Tmax 38.1C, O2 94% on 3L, RR 30
A CT chest reveals a dense LLL consolidation
In addition to sputum cultures, which of the following tests should be ordered?
65F presents w/ 8 days of SOB. T 38C, HR 115, BP 100/60, RR 22, O2 92% on 100% non-rebreather & then intubated
Exam notable for crackles. CT chest shows GGO bilaterally
She has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
2/ After remdesivir, dexamethasone, ceftriaxone & doxy, she defervesces. 3 weeks later, she has worsening SOB
Repeat CT chest shows worsening GGO & new pulm nodules
Which of the following is the most sensitive diagnostic modality for COVID-19 associated pulmonary aspergillosis?
50F w/ EtOH cirrhosis & DM presents to ED w/ AMS & decreased UOP. She is febrile & hypotensive
She is started on vasopressors & CVVHD via central lines in the ICU
Due to concern for SBP, she is started on ceftriaxone
2/ Initial blood & ascites cultures show no growth. She remains critically ill for 7 days and still having fevers
In addition to blood cultures, which of the following is the next best test to order?
45F w/ chronic lung disease and bronchiectasis presents to clinic w/ a chronic cough for the past 3 months.
She works as a construction worker in California. Exam is notable for poor dentition
2/ CT chest shows several nodules bilaterally in lung parenchyma with some cavitations
A bronch w/ BAL is performed & shows gram-positive bacilli, & a serum beta-d-glucan (BDG) is positive at 110 (positive > 80)
60M w/ asthma from China presents w/ SOB secondary to an asthma exacerbation. He has never smoked cigarettes. A CT chest shows a 7mm right upper lobe nodule
Which of the following tests should be ordered for further evaluation of the nodule?
1/14
Answer: AFB sputum culture
Without knowing much about the patient, other than age, geographic risk, smoking status, & normal immune status, most common infectious cause of a solitary pulmonary nodule (SPN) is TB.
75F w/ lupus, HTN, recent diagnosis of HIV (viral load 30,000, CD4- 57), presents to ED in winter w/ 4 weeks of shortness of breath & cough. T 38.5C, HR 105, BP 105/80, RR 20, O2 94% on 3L. Exam is notable for crackles & rhonchi in both lungs
2/ Labs: WBC 2,600, Hb 7.5 g/dL, platelet 70,000. CXR shows diffuse opacities. You have suspicion for Pneumocystis jirovecii pneumonia
Which of the following is the best non-invasive test to order to help confirm the diagnosis?
65F w/ history of heart transplant on tacrolimus, prednisone, & mycophenolate, presents w/ SOB and fatigue. Vitals are normal. Exam is notable for tender red bumps on the shins bilaterally. Labs are notable for absolute eosinophil count of 800
2/ CT chest shows scattered pulmonary nodules throughout. The team decides to order a serum beta-d-glucan (BDG)
Which of the following potential causes of her skin and pulmonary nodules is most likely to result in a positive serum BDG?
60M presents w/ 7 days of fevers & SOB. T 38.1C, HR 105, BP 110/70, RR 22, O2 95% on 6L & then intubated. Exam notable for diffuse crackles. CT chest shows GGO bilaterally. He has a +SARSCoV2 NAT resp swab; sputum & blood cultures are negative
2/ After remdesivir, dexamethasone, ceftriaxone & doxy, he defervesces. 3 weeks later, he has worsening SOB. Repeat CT chest shows RUL cavitation. Serum BDG is 75 (positive>80) & serum GM is 0.4 (positive>0.5)
Which of the following diagnostics would have the highest yield?
44M from Maine w/ myelodysplastic syndrome s/p BMT 6 weeks ago has fevers. He is on voriconazole, moxifloxacin, atovaquone, & valacyclovir. He is taking topical steroids for the past 25 days due to mild skin graft versus host disease.
2/
T 38.2C, HR 101, BP 115/80, RR 16, O2 98% on RA. Labs notable for WBC 1000 (neutrophil count 200), hemoglobin 6.1, platelets 3,000. Which of the following puts the patient at increased risk for developing invasive aspergillosis?
30M from Indiana w/ peptic ulcer disease presents w/ abdominal pain & hematemesis. He reports taking ibuprofen 4000mg daily for the past 3 weeks. T 38.5C, HR 120, BP 100/60, RR 18, O2 93% on RA. Labs notable for WBC 11,000, Hb 4, plt 155,000
2/
Over the next 2 days, the patient receives 10 units of blood products. On day 3, the patient has a fever. A serum beta-d-glucan is ordered and results at 90 (positive > 80). What is the likely cause of the beta-d-glucan elevation?
55F w/ COPD has 3 days of fevers, SOB & cough. T 38.2C, HR 112, BP 100/75, RR 22, O2 93% on 100% non-rebreather. Exam- crackles b/l
CT chest- ground-glass opacities b/l
Rapid flu swab + for influenza A, sputum & blood cultures negative
2/ W/ oseltamivir, ceftriaxone & azithro, she defervesces. 3 wks later, has fevers & worsening SOB. Repeat CT chest- new 2cm RUL cavitary lesion. Resp viral panel +influenza A, blood & sputum cultures neg. Which of the following is the most likely cause of the cavitary lesion?
37M w/ cirrhosis on the liver transplant list has been in the ICU for 1 week for management of hepatorenal syndrome. His initial presentation was notable for fevers & dyspnea, but he was otherwise hemodynamically stable w/o hypoxia
2/ His fevers continued & then developed worsening hypoxemia requiring 2L O2. CT chest showed bilateral sub-centimeter lung nodules. Labs are sent and a diagnosis of Crypto is made. Serum beta-d-glucan later results; what would you expect its value to be? (ref range <31 pg/mL)?
62M w/ PMHx of liver transplant 8 months ago presents w/ 3 weeks of cough & fevers. He recently moved from Indiana (where he had his transplant) to Florida. He has been adherent to his meds (tacro, mycophenolate, pred, trim/sulfa)
2/ T 38.1C, HR 99, BP 115/85, RR 16, 95% on RA. Exam notable for shallow ulcer on soft palate. CT chest shows new nodules bilaterally in lung parenchyma. Serum BDG assay is 85 (positive>80), serum GM index is 0.55 (positive>0.5). Patient likely has which infection?
40M with no PMHx presents to ED with 3 days of fever, cough, & SOB. Vitals: T 39C, HR 120, BP 130/80, O2 93% on 4L. Exam notable for R basilar rhonchi & crackles. CXR shows RLL opacity. He is started on ceftriaxone
2/
4 days later, he is still having intermittent fevers with Tmax 38.1C, O2 94% on 2L. He does not have dysuria or hematuria. The team orders a CT chest, which reveals a dense RLL consolidation. In addition to sputum cultures, which of the following tests should be ordered?
