A woman presents for a pre-employment physical. She received the hepatitis B vaccine in medical school. Her hepatitis B serologic profile would be hepatitis B surface antigen negative, core antibody positive, and surface antibody positive, indicating past infection that resolved. A man with a history of blood transfusions 10 years ago has elevated liver enzymes and tests positive for hepatitis C antibodies. A liver biopsy shows portal inflammation, indicating he has chronic hepatitis C. The incidence of this complication from HCV infection is 20%. Dengue fever is the only viral haemorrhagic fever listed that has not been reported in Saudi Arabia.

1. INTERNAL MEDICINE BOARD
REVIEW 2015 PART 1

2. VIRAL

3. • A 31-year-old woman presents at the hospital for a pre-employment
physical examination prior to beginning her year as a medical intern. She
had infectious mononucleosis while in college and received the
recombinant hepatitis B vaccine before starting medical school.
• Which of the following would describe her hepatitis B serologic profile?
• a) Hepatitis B surface antigen positive, core antibody positive, and surface
antibody negative
• b) Hepatitis B surface antigen negative, core antibody positive, and surface
antibody positive
• c) Hepatitis B surface antigen positive, core antibody negative, and surface
antibody negative
• d) Hepatitis B surface antigen negative, core antibody negative, and
surface antibody positive
• e) Hepatitis B surface antigen negative, core antibody negative, and
surface antibody negative.

6. • A 35-year-old man comes to the physician for a health maintenance examination.
He received blood transfusions for hypovolemic shock following a gunshot wound
10 years earlier. He is currently in good health, and physical examination is
unremarkable.
• A serum chemistry panel shows:ALT 250 U/L,AST 140 U/L,Alkaline phosphatase
70 U/L. Serologic evaluation for viral hepatitis reveals positive antibodies to
hepatitis C virus (HCV).A percutaneous liver biopsy shows marked portal
inflammatory infiltrate disrupting the limiting plate of hepatic lobules.
• Which of the following is the incidence rate of this complication following HCV
infection?
• a) 5%
• b) 10%
• c) 20%
• d) 40%
• e) 80%

9. • The following vial haemorrhagic fever has
been reported in Saudi Arabia except:
• 1- Rift valley fever
• 2- Alkhomra fever
• 3- Dengue fever
• 4- Yellow fever
• 5- Cernian congo hemorrhagic fever

10. • 25y old man with longstanding SCD presents with fever,
rash overlying his trunk, face and neck. His Hb dropped
from 9.8 to 6.6 . what is the most likely explanation
• a- Anemia of CRF
• b- A plastic cell crisis
• c- Parvovirus B19 infection
• d- BM infiltration
• e- Multiple hemarthroses

11. • which of the following statement regarding
herpes simplex virus is true
• a-Encephalitis complicates primary or recurrent
infection
• b- HSV type 2 causes only genital infection
• c- Recurrent infection is caused by repeated
viral exposure
• d- Serology is the most useful means of
diagnosis

12. • Middle east respiratory syndrome coronavirus (MERS-
CoV) is an emerging infectious agent.
• Current knowledge about the new virus is limited.
• Which of the following describes the recent MERS-CoV
outbreak?
• a) The genome of MERS-CoV is identical to a camels
betacoronavirus
• b) Mortality among confirmed cases was nearly 15%
• c) Children were less likely to be affected by the disease
• d) Liver failure was commonly seen as a complication of
MERS-CoV infection

13. • A previously healthy boy presented with chicken pox. His
mother stated that he never got immunized. She reported
that one of his classmates developed the disease. Nobody is
ill at the household. She is inquiring about the severity of
the disease.
• Which of the following most likely increases his risk for
moderate to severe varicella disease?
• a) Age younger than 12 year old
• b) Concurrent ear infection
• c) Recent antibiotic treatment
• d) Receipt of short term salicylate therapy
• e) Being a secondary case in the household

14. • A 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 patient's presentation.
She was unsure about her varicella immune status.
• What is the most appropriate next step in management?
• a) Ask her to present if a rash develops
• b) Check varicella IgG status
• c) Check varicella IgM status
• d) Give aciclovir prophylaxis
• e) Give human varicella zoster immunoglobulin

15. • Chickenpox is caused by primary infection with varicella zoster virus. Shingles is
reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk
to both the mother and also the fetus, a syndrome now termed fetal varicella
syndrome
• Fetal varicella syndrome (FVS) features of FVS include skin scarring, eye defects
(microphthalmia), limb hypoplasia, microcephaly and learning disabilities
• risk of FVS following maternal varicella exposure is around 1-2% if occurs before
20 weeks gestation studies have shown a very small number of cases occurring
between 20-28 weeks gestation and none following 28 weeks.
• Management of chickenpox exposure
• if there is any doubt about the mother previously having chickenpox maternal
blood should be checked for varicella antibodies
• if the pregnant women is not immune to varicella she should be given varicella
zoster immunoglobulin (VZIG) as soon as possible.
• VZIG is effective up to 10 days post exposure consensus guidelines suggest oral
aciclovir should be given if pregnant women with chickenpox present within 24
hours of onset of the rash

16. • A 16-year-old boy presented with a 2-day history of a rash.Two
weeks previously, he had visited a livestock farm (with sheep and
cows) on a school trip and had subsequently developed a sore
on his index finger that had scabbed over.
• On examination, he was a pyrexial. He had multiple target
lesions, of different sizes, all over his body.A 1-cm crusted scab
was present on his index finger that was easily removed.
• What is the most appropriate investigation?
• a) Biopsy and culture of lesion
• b) Electron microscopy of scab crust
• c) Mycoplasma IgM
• d) Parapoxvirus IgM
• e) Scrape of lesion base for herpes simplex virus PCR

17. • Orf is a zoonosis
transmitted to humans
from sheep and goats by
direct contact or by
fomites.
• known as ecthyma
contagiousum or
contagious pustular
dermatitis, is caused by a
prototypic member of
the genus Parapoxvirus.
PARAPOXVIRUS

18. BACTERIA

19. • which of the following organism cause
HUS?
• 1. shegella toxin
• 2. clostridium group
• 3. MSSA
• 4. Strptococcus group A

20. • HUS can occur with the following
infections:
• E. coli O157:H7
• Shigella
• Campylobacter
• variety of viruses

21. • 26 year old male came with cough, vomiting
and rash on legs
• Investigation : cold agglutinin test +ve
• CXR bilateral infiltrates
• 1. Mycoplasma
• 2. Legionella
• 3. Strept pneumonia
• 4. E.coli Pneumonia

22. • Infections with cold agglutinin test +ve
• 1. Mycoplasma pneumonia.
• 2. Mononucleosis.
• 3. HIV.
• Pneumonia with low Na and diarrhea think
atypical

23. • A 30-year-old male with sickle cell anemia is admitted with cough,
rusty sputum, and a single shaking chill. Physical examination reveals
increased tactile fremitus and bronchial breath sounds in the left
posterior chest.The patient is able to expectorate a purulent sample.
• Which of the following best describes the role of sputum Gram stain
and culture?
• a) Sputum Gram stain and culture lack the sensitivity and specificity
to be of value in this setting
• b) If the sample is a good one, sputum culture is useful in determining
the antibiotic sensitivity pattern of the organism, particularly
Streptococcus pneumoniae
• c) Empirical use of antibiotics for pneumonia has made specific
diagnosis unnecessary
• d) There is no characteristic Gram stain in a patient with
pneumococcal pneumonia

24. • A 32-year-old man with a history of injecting drug use was admitted with a 24-
hour history of worsening pain and redness around an injection site in his arm.
• On examination, his temperature was 40.0°C, his pulse was 120 beats per
minute and his blood pressure was 75/55 mmHg.There was marked erythema
of his left arm, with extreme tenderness to palpation. Investigations:
haemoglobin 106 g/L (130–180), white cell count 38.5 (4.0–11.0), serum
sodium 123 mmol/L (137–144), serum potassium 5.4 mmol/L (3.5–4.9), serum
creatinine 183 •mol/L (60–110).
• What organism is most likely to be associated with this presentation?
• a) Clostridium botulinum
• b) Clostridium perfringens
• c) Pseudomonas aeruginosa
• d) Staphylococcus aureus
• e) Streptococcus pyogenes

25. • Infection with all of these microorganisms
may be complicated by a neurological
symptom and /or signs EXCEPT:
• a) Clostridium tetani
• b) Clostridium diphtheria
• c) Clostridium perfringens
• d) Poliomyelitis virus
• e) Clostridium botulinum

26. • 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 38.2°C, his pulse was 50 beats per
minute and his blood pressure was 94/55 mmHg. His oxygen saturation was
89% (94–98) breathing room air.
• Investigations: blood culture (after 3 days) anaerobic Gram-negative bacillus,
• chest X-ray patchy consolidation in both lung fields.
• What is the most likely identity of the organism found on blood culture?
• a) Bacteroides fragilis
• b) Fusobacterium necrophorum
• c) Haemophilus influenzae
• d) Klebsiella pneumoniae
• e) Pseudomonas aeruginosa

27. • 42 years known case of DM on oral medication
presented with hx of Diarrhea 6 BM since 3
days with low grade fever stool culture done on
the 1st day reports Salmonella .T
• best treatment is
• Ciprofloxacin
• Augmantin
• Clindamycin
• Supportive treatment

28. SALMONELLA DIAGNOSIS
• Other than a positive culture, no specific laboratory test is diagnostic for enteric fever.
• The definitive diagnosis of enteric fever requires the isolation of S. typhi or S.
paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal
secretions.
• The sensitivity of blood culture is only 40–80%,.
• Bone marrow culture is 55–90% sensitive, and, unlike that of blood culture, its yield is not
reduced by up to 5 days of prior antibiotic therapy.
• Stool cultures, while negative in 60–70% of cases during the first week, can become
positive during the third week of infection in untreated patients.
• Several serologic tests, including the classic Widal test for “febrile agglutinins,”
are available. None of these tests is sufficiently sensitive or specific to replace culture-
basedmethods
• PCR and DNA probe assays to detect S. typhi in blood have been identified but have not
yet been developed for clinical use.

29. CIPROCIPRO
SEPTRASEPTRA
CEFTRIXONCEFTRIXON

30. PARASITE

31. • A 22-year old female medical student who
visited Sudan few months back, presents with
a history of haematuria. On investigation
schistosomal serology is shown to be
positive.
• Select the treatment of choice:
• a) Albendazole
• b) Ivermectin
• c) Mebendazole
• d) Praziquantel

32. schistosoma

34. LEISHMANIA
• Transmission : Sand Fly
• Hx PAINLESS ,Volcano like ulcer
cluster lesions along
lymphatics inflammatory satellite
papules
• Diagnosis :
1-Microscopy
2-Parasite culture
3-PCR
4-
Leishmania skin test
• NO SEROLOGY
• Ketoconazole ,Itra, Cryotherapy
intralesional sodium stibogluconate

35. LISHMANIA

36. id spacial

37. Mycobacterium marinum
• AFB+ ,Fast growing
• Most strains of M marinum
have been found to be
resistant to the
antituberculosis medications
isoniazid, streptomycin,
• . The organism is sensitive to
rifampin plus ethambutol,
tetracyclines, trimethoprim-
sulfamethoxazole (TMP-
SMZ), clarithromycin, and
fluoroquinolones.

38. • The day after hunting and skinning wild rabbits, a hunter develops an
inflamed papule on one finger.The papule rapidly enlarges and then bursts,
releasing pus and forming a clean ulcer cavity productive of thin, colorless
exudate (see image). Several days later, the patient develops severe illness
with atypical pneumonia and delirium. It is at this point that the patient
seeks medical care.
• The regional lymph nodes of the axilla of the affected arm are enlarged.
Reduced breath sounds and occasional rales are heard. Splenomegaly is
noted. Blood studies show a mild leukocytosis.
• Which of the following is the most likely diagnosis?
• a) Actinomycosis
• b) Brucellosis
• c) Melioidosis
• d) Plague
• e) Tularemia

40. Tularemia
• Caused by Francisella tularensis
• F. tularensis—a small (0.2 m by 0.2–0.7
m), gram-negative, pleomorphic,
nonmotile, non-spore-forming bacillus.
• Transmission by biting or blood-sucking
insects, contact with wild or domestic
animals, ingestion of contaminated water
or food, or inhalation of infective aerosols.
• An incubation period of 2–10 days
• fever, chills, headache, generalized
myalgias and arthralgias, lymphadenopathy
(Epitrochlear lymphadenopathy)

41. Tularemia
• In ulceroglandular tularemia, the ulcer is
erythematous, indurated, and nonhealing,
with a punched-out appearance that lasts
1–3 weeks. The papule may begin as an
erythematous lesion that is tender or
pruritic; it evolves over several days into
an ulcer with sharply demarcated edges
and a yellow exudate
• Direct microscopic, indirect fluorescent
antibody test but false-positive results due
to Legionella ,PCR and culture.
• Tularemia is most frequently confirmed by
agglutination testing.
• Steptomycin , cipro , gent 10 days

43. LeptospirosisLeptospirosis
• Acquired when exposed to fresh waterAcquired when exposed to fresh water
• Acute leptospirosis – fever, myalgia, headache,
rash
• Conjunctival suffusion is characteristic but may
not occur
• May lead to aseptic meningitis, uveitis, elevated
liver enzymes, proteinuria, microscopic hematuria
• Diagnosis – acute and convalescent phase
antibody titers
• Treatment – penicillin or tetracycline

45. Q Fever
• Coxiella Burnetii
• Inhalation ,incubation 9-40 d
• endocarditis ,atyp pnue,hepatitis e
fever
• Serology AB even with ch inf
• doxy,cipro,tetra in pregnant septra

46. Whipple’s disease
• Diagnosis : Colon biopsy
with PSA stain
• Treatment septra for 1
year

48. • Early localized : The classic sign of early local
infection with Lyme disease is a circular,
outwardly expanding rash called erythema
chronicum migrans , which occurs at the site of
the tick bite 3 to 30 days after the tick bite.
• Early disseminated infection:Within days to
weeks after the onset of local infection,
purplish lumps , arthralgia , Bell’s palsy.
encephalitis
• Late : Polyneuropathy , Heart block
• Diagnosis Clinically , clinically , Then
Serology ELISA and then Western blot IgM
Sensitivity 70%
• Treatment Doxycycline , Amoxilline ,
ceftrixone

49. • A 30-year-old HIV-positive man presented with a 3-week history of
fever, malaise and weight loss.
• On examination, his temperature was 38.0°C.There were several small
painless, raised, purple skin lesions on his legs and trunk. Investigations:
CD4 count 22 (430–1690), lesional biopsy non-specific inflammatory
changes.There was no evidence of Kaposi's sarcoma and stains for
HHV-8 were negative. Bacillary angiomatosis was considered as a
possible diagnosis.
• What is the most appropriate investigation to confirm this diagnosis?
• a) Bartonella culture of biopsy tissue
• b) Bartonella serology
• c) Blood for bartonella culture
• d) Giemsa stain of biopsy tissue
• e) Warthin–Starry stain of biopsy tissue

50. • Bacillary angiomatosis is a vascular,
proliferative form of Bartonella infection
that occurs primarily in
immunocompromised persons.
• Solitary or multiple red, purple, flesh-
colored, or colorless papules
(hemangiomalike lesions) varying in size
from 1 mm to several centimeters
• Hyperpigmented, hyperkeratotic,
indurated plaques, typically on the
extremities and often overlying osseous
defects
• Lab studies
• Histology of Bartonella DNA in tissue
specimens by (PCR) assay
• Bartonella antigens
• Treatment erythromycin or a tetracycline
Bacillary angiomatosis

51. • A 34 year old man with diabetic ketoacidosis develops headache,
nasal congestion, periorbital swelling and a bloodstained nasal
discharge. Over a period of a week he becomes drowsy and
unresponsive. ENT examination shows black, necrotic lesions on
the nasal septum, which is perforated. Culture of the nasal
discharge shows a heavy growth of Streptococcus pneumoniae
and Staphylococcus aureus.
• The most likely diagnosis is:
• a) Lemierre’s syndrome
• b) Ludwig’s angina
• c) Orbital cellulitis
• d) Rhinocerebral mucormycosis
• e) Aspergillus sinusitis

52. • A 35-year-old Asian woman presented with a 4-week history of painful
swollen glands in her neck. She described night sweats, but no weight loss.
There were no preceding dental problems or sore throat.
• On examination, there was a non-tender, 3-cm anterior cervical lymph
nodes bilaterally.There were no other abnormal findings.
• Investigations: full blood count normal erythrocyte sedimentation rate 65
mm/1st h (<20), serum C-reactive protein 40 mg/L (<10), HIV serology
negative, lymph node biopsy marked paracortical expansion by small
lymphocytes, blast cells and large numbers of histiocytes, with prominent
apoptosis resulting in confluent areas of 'necrosis'.
• What is the most likely diagnosis?
• a) Acute Epstein–Barr virus infection
• b) Acute toxoplasmosis
• c) Atypical mycobacterial infection
• d) Kikuchi's disease
• e) Secondary syphilis

53. • Kikuchi disease, also called
histiocytic necrotizing
lymphadenitis or Kikuchi-Fujimoto
disease, is an uncommon,
idiopathic, generally self-limited
cause of lymphadenitis
• The most common clinical
manifestation of Kikuchi disease is
cervical lymphadenopathy, with or
without systemic signs and
symptoms.
• Clinically and histologically, the
disease can be mistaken for
lymphoma or systemic lupus
erythematosus (SLE)
Kikuchi disease

54. THANKYOU