A previously healthy 38 yo male presents to your ER wit

1
Tropical and Travel Seminar Review Questions

• Monday December 1st, 2008

2
Bacteria, Fungi, and TB
3

• A previously healthy 38 yo male presents to your
  ER with fever x 5 days, significant shortness of
  breath and cough without any significant coryza.
  He just returned from rural New Mexico where he
  joined a house building mission for poverty
  stricken families with his church group. The
  primary project was to renovate an old rural
  house which was super-infested with rodents.
  Vitals BP 72/30, a pulse of 45, RR 35, oxygen
  saturation of 84 on room air. An EKG shows
  sinus bradycardia. Echo shows depressed LVEF of
  25, but normal valvular function and normal
  chamber sizes. His CXR shown below. Rapid HIV is
  negative and is not known to be immunocompromised
  for any other reason. LFTs are normal, WBC 16k
  with left shift, hgb 12, plt 98k, creatinine 1.7.
  No PMHx, no medications, no drugs, no smoking or
  alcohol use. The MOST LIKELY DIAGNOSIS is

A. Mycoplasma pneumonia B. Influenza pneumonia C.
Acute myocardial infarction D. Pneumocystis
jiroveci E. Sin Nombre virus(Hantavirus Pulmonary
Syndrome)
4

• A 24 yo African American 30 weeks pregnant female
  presents to your urgent care with flu-like
  illness, with fever, cough, headache, rash and
  muscle aches for the past 5 days. Today, she also
  noticed red, swollen, somewhat painful nodules on
  her shins. Her temperature is 38.8C, BP 128/82,
  pulse 74, RR 26, O2 sats 88. She spent the last
  summer overland trucking in Southern California.
  Her route was Bakersfield, CA to Fresno, CA and
  back. She returned to Minnesota to set up
  primary obstetrics care and make sure the
  impending delivery of her child would go
  smoothly. She has never traveled outside the
  country, has never been incarcerated, and had a
  negative TB test last spring when she was working
  as a nurses aide at a nursing home. Her CXR
  showed a LUL infiltrate and chest CT showed a
  cavitary lesion at the superior segment of the
  LLL with diffuse reticulonodular lesions
  throughout both lungs. Histopathology from
  bronchial tissue bx was positive with What is
  the most appropriate treatment choice for this
  patient?

A. AZT 3TC nevirapine B. Ceftriaxone
azithromycin C. Amphotericin B D. Rifampin
ethambutol pyrazinamide isoniazide E.
Itraconazole
5

• A 45 yo homeless Brazilian male with diet
  controlled diabetes mellitus and HTN presents to
  your office with chronic history of a dry
  smokers cough, white mouth sores, and loosing
  all his teeth. He was not going to see a doctor
  until he started to develop nodules on his neck.
  He denies any fever, chills, night sweats,
  significant dyspnea. He emigrated from Brazil 15
  years ago and has lived in Minnesota ever since.
  His physical exam was significant for temperature
  of 97.8, his mouth was edentulous and showed
  white plaque like lesions diffusely over his
  tongue Scrapings from his tongue showed What
  would be the drug of choice for this condition?

A. Cefotaxime B. Itraconazole C. Ganciclovir D.
Rifampin ethambutol pyrazinamide
isoniazide E. Amphotericin B
6

• An otherwise healthy 42-year-old Venezuelan
  farmer returned to your yearly medical brigade
  clinic to evaluate return of verrucous, keloidal
  lesions on his left leg. A year ago he had a
  similar but smaller(1 cm) lesion on his leg,
  which was surgically removed and treated with
  fluconazole due to presumed fungal infection. The
  surgical wound healed well, but 6 months later
  the lesions returned and have grown larger ever
  since. Other than the lesion on his leg, the
  physical examination were normal. Your biopsy
  results show deep granulomatous dermatitis with
  multinucleated giant cells. Intracellular and
  extracellular unstained fungal cells stained
  strongly with periodic acid-Schiff, Calcofluor
  white, and Grocott methenamine silver stains.
  The cells were spherical or lemon-shaped, chains
  of cells of uniform size, 6- to 12-µm in
  diameter, connected by thin tubelike isthmuses.

A. Coccidioides immitis B. Candida albicans C.
Blastomyces dermatitidis D. Lacazia
loboi(Lobomycosis) E. Leshmania donovani
7

• While working on a plastic surgery mission in
  Ghana, you encounter several young people with
  chronic ulcerative lesions, each patient at
  different stages of healing. An 18yo male shows
  you a lesion on his ankle. He claims that his
  lesion began as small laceration at the back of
  his heel incurred while walking along the shore
  of Lake Volta near his village. Over the next
  week, he developed a group of firm, nontender,
  nodules approximately 1-2 cm in diameter at the
  site of the wound. Over the next 1-2 months, the
  area became fluctuant, followed by the formation
  of a painless, undermined ulcer. After hearing
  about your mission, he traveled to see if you
  could help. As the medical physician of the
  group, you send a smear from the necrotic base of
  the lesion for histology. Acid fast bacilli are
  seen on Ziehl-Neelsen stain. On further
  exploration of the wound under anesthesia, you
  identify that the ulcer also affects the deep
  tissues of the lower leg and foot. You make a
  presumptive diagnosis and recommend which
  treatment?

• BCG vaccine
• Ethambutol clarithromycin
• Rifampin
• Surgical excision of infected tissue with skin
  graft closure

8

• While working in Chiang Mai, Thailand, a 24yo
  female commercial sex worker with known advanced
  HIV/AIDS noted by a most recent CD4 count of 42
  and previous infection with Pneumocystis
  jiroveci. She presents to the ER with fever to
  39C, pronounced weight loss, cough, and facial
  skin papules with a central necrotic
  umbilication. Other physical exam findings
  include lymphadenopathy in inguinal, axillary,
  and cervical distribution hepatomsplenomegaly.
  Laboratory work up yields Hgb of 7.8, and
  leukopenia of 3.2, no peripheral blasts are seen.
  A bone marrow biopsy results are shown below.
  What is the best diagnosis and treatment course?

• Amphotericin B IV for 2 weeks, followed by
  itraconazole, 400 mg/day orally in two divided
  doses for the next 10 weeks
• Ethambutol clarithromycin
• Lifelong Itraconazole as secondary prophylaxis
• Fluconazole lifelong primary treatment and
  secondary prophylaxis
• Both A and C

9

• A 24yo male presents to the ER after sustaining a
  bite from a rat which has been seen living in the
  sewer system around the neighborhood and
  scavenging the garbage receptacles on his street.
  The animal bit him on the forearm and ran away.
  He has never been vaccinated against rabies in
  the past. He asks you whether he needs to worry
  about rabies. Which statement describes the most
  appropriate action to take?

• Immediately administer RIG into the wound
• Immediately initiate human diploid cell rabies
  vaccine post exposure prophylaxis
• Thoroughly cleanse the wound with water and
  povidone-iodine solution
• Call local animal control to try and capture
  animal for euthanization and medical examination
  for rabies
• All of the above

10

• Same story but the animal is an otherwise healthy
  neighborhood pit bull. Which statement describes
  the most appropriate action to take?

• Immediately administer RIG into the wound
• Immediately initiate human diploid cell rabies
  vaccine post exposure prophylaxis
• Thoroughly cleanse the wound with water and
  povidone-iodine solution
• Call local animal control to try and capture
  animal for euthanization and medical examination
  for rabies
• Reserve rabies postexposure prophylaxis only if
  the animal demonstrates signs of rabies during a
  10 day observation period
• Both C E
• All of the above

11

• Same story but the animal is the neighborhood
  raccoon who scavenges on nearby garbage cans.
  Which statement describes the most appropriate
  action to take?

• Immediately administer RIG into the wound
• Immediately initiate human diploid cell rabies
  vaccine post exposure prophylaxis
• Thoroughly cleanse the wound with water and
  povidone-iodine solution
• Call local animal control to try and capture
  animal for euthanization and medical examination
  for rabies
• Reserve rabies postexposure prophylaxis only if
  the animal demonstrates signs of rabies during a
  10 day observation period
• A,B,C, D
• All of the above

12

• Same story but the animal is a street dog
  encountered during a trip to India. The dog
  cannot be found. Which statement describes the
  most appropriate action to take?

• Immediately administer RIG into the wound
• Immediately initiate human diploid cell rabies
  vaccine post exposure prophylaxis
• Thoroughly cleanse the wound with water and
  povidone-iodine solution
• Reserve rabies postexposure prophylaxis only if
  the animal demonstrates signs of rabies during a
  10 day observation period
• A, B, C
• All of the above

13

• A 29 yo otherwise healthy Sudanese male seen in a
  refugee clinic in Chad presents with chronic
  progressive lesions on his feet. About 5 months
  ago, he noticed a small painless nodule on the
  medial side of his left foot. Intermittently, he
  has noticed odorous, purulent drainage containing
  dark black granular specks draining from
  eruptions in his foot. His foot has become
  progressively more deformed with these lesions.
  You perform a surgical biopsy, which reveals a
  sinus full of purulent material containing
  discrete black grains. You make a presumptive
  diagnosis and recommend the following initial
  treatment as most appropriate first choice

• Complete surgical amputation
• Streptomycin and cotrimoxazole
• C. Amphotericin B
• D. Rifampin ethambutol pyrazinamide
  isoniazide
• E. Ketoconazole

14

• A 56 yo otherwise healthy African-American male
  postal worker presents to the ER with abrupt
  onset on dyspnea, stridor, and diaphoresis. His
  wife tells you that he has had fever, malaise,
  anorexia, sore throat, headache, and a dry cough
  for the last 3 days. A CXR shows a widened
  mediastinum and clear lung fields. A Chest CT
  scan showed large mediastinal LN with
  hemorrhages. You make a presumptive diagnosis
  and recommend the following initial treatment?

• Surgical mediastinotomy
• Penicillin V
• C. Amphotericin B
• D. Heparin IV therapeutic drip
• E. TMP/SMX

15

• A 23yo female who is 20 weeks pregnant comes to
  your office requesting advice about toxoplamosis.
  She was freaked out by her friend who scolded
  her for taking care of her cats litter box since
  she has been pregnant. Aside from some mild
  morning sickness experienced for a 7 days at her
  12th week of pregnancy, she has not felt ill at
  all. Which of the following statements is true
  regarding toxoplasmosis and pregnancy?

• The risk of vertical transmission to fetus is
  highest if acute infection occurs in the first
  trimester.
• The risk of vertical transmission to fetus is
  highest if acute infection occurs in the third
  trimester.
• C. The severity of congenital infection in fetus
  is highest if acute infection occurs in the first
  trimester.
• D. The severity of congenital infection in fetus
  is highest if acute infection occurs in the third
  trimester.
• Both B C
• Both A D

16

• The same 23yo female who is now 21 weeks pregnant
  was referred to your clinic for workup of
  toxoplasmosis infection after an ultrasound
  demonstrated a fetus with symmetric IUGR. Her
  initial serology results showed IgM positive and
  IgG negative. Which interpretation of maternal
  serologies is the most accurate true?

• Possible acute infection or false-positive IgM
  result. Obtain a new specimen for IgG and IgM
  testing. If results from the second specimen
  remain the same, the IgM reaction is probably a
  false-positive.
• Definite acute infection, treat the mother to
  prevent congenital infection
• No serologic evidence for infection with T.
  gondii
• D. Perform amniocentesis to evaluate for fetal
  infection.

17

• The same pregnant 23yo female returns to your
  clinc for repeat testing given the initial
  results. Which interpretation of the repeat
  maternal serologies is true?

• Positive IgM, Negative IgG ? definite acute
  infection
• Negative IgM, Positive IgG ? definite acute
  infection in the last 2 months
• Positive IgM, Positive IgG ? acute infection in
  the last 12 months
• Negative IgM, negative IgG ? false negatives,
  test via an alternative method

18
Interpretation of maternal T. gondii serologies
in pregnancy
19
Risk of transplacental transmission of T. gondii
by gestational age of pregnancy
20

• A 35yo male presents to the clinic with fever,
  headache, and rash. Four days after returning
  from a 4 week house building mission in Brazil,
  he develops a fever to 104F, and severe frontal
  headache which radiates behind the eyes.
• Over the last 24 hours, he developed diffuse
  body aches, nausea, anorexia, and a diffuse
  rash. He always drank bottled water, and ate
  sufficiently cooked foods. No reported
  alteration in his bowel movements, but his urine
  seems red. He remembers being bitten by many
  mosquitoes during the day and the night. The
  skin shows focal petechiae and diffuse
  erythematous warm rash which leaves a residual
  blanched area after pressing on his skin. His
  rapid influenza antigen is negative, blood smear
  shows no parasites. Platelet count is 10k, Hct
  is 60, serum albumin 2.1. Which test is most
  likely to lead to a diagnosis?

• Dengue serologies
• West Nile virus serologies
• Send stool for routine bacterial pathogens
• Japanese encephalitis serologies

21

• A 35yo male soldier working at an army base in
  Kuwait presents with a 6 day h/o tactile fevers,
  headache, and myalagias. Three days ago, he
  developed some shortness of breath, cough, and a
  single skin ulcer which began as painful with a
  yellow base and later turned into a black eschar
  on his hand. No ecchymoses or spontaneous
  bleeding is identified on history or physical
  exam. Which diagnosis is the most likely

A.Tularemia B. Polio C. Varicella(chicken
pox) D. Varicalla(shingles) E. Melioidosis
22

• While working in a large hospital in Vientienne,
  Laos, you encounter an 18yo female who presents
  to the ER with rapid onset of severe HA, high
  fever, neck stiffness, stupor, disorientation,
  and spasticity. No history of exposure to
  animals. Many mosquito are present around her
  village. In the ER, she has a generalized
  tonic-clonic seizure. Her fever is 103F. Her
  neurology exma shows lower extremity spastic
  paralysis. Head CT shows no intracranial
  pathology. Brain MRI shows preferential
  inflammation of the grey matter without white
  matter involvement. HIV test negative. His WBC
  is 15k. CSF shows an elevated opening pressure,
  mild pleocytosis with lymphocyte predominence,
  elevated protein, normal glucose, and no PMNs or
  organisms on gram stain. Which test is most
  likely to lead to a quick diagnosis?

• Dengue serologies
• West Nile virus serologies
• Cryptococcal serum antigen
• India Ink test on CSF
• Japanese encephalitis serologies on CSF and blood

23
Parasitology Images
24
19-year-old male from Louisiana travels to SE
Asia, and presents with abdominal complaints.
Stool Trichrome has

• Ascaris
• Hookworm
• Opisthorchiasis
• Strongyloides

25

• A concentrate formalin-ethyl acetate technique of
  a stool specimen was preserved in formalin.  The
  objects measured approximately 300 mm in length. 
  What is your diagnosis?
• Ancylostoma duodenale
• Necator americanus
• Hookworm unknown species
• Strongyloides stercoralis

26
19-year-old male from Louisiana with no known
travel history presented with a one-month history
of headache, fatigue, shortness of breath and
weight-loss.  CXR showed bilateral pleural
effusions with an infiltrate in the left lung. 
Bronchial alveolar lavage (BAL) and sputum showed

• Ascaris
• Hookworm
• Paragonimus
• Strongyloides

27
A survey was conducted to determine the
prevalence of geohelminth infections in
school-age children living in Haiti. The
laboratory aspect of the survey consisted of
processing stool specimens which were collected
in 10 formalin. Per protocol, the processing
included performing an FEA formalin-ethyl acetate
concentration and examination of a wet mount.
What is this?

• Cyclospora
• Isospora
• Schistosoma
• Trichuris
• Plant Pollen

50 mm
28
A survey was conducted to determine the
prevalence of geohelminth infections in
school-age children living in Haiti. The
laboratory aspect of the survey consisted of
processing stool specimens which were collected
in 10 formalin. Per protocol, the processing
included performing an FEA formalin-ethyl acetate
concentration and examination of a wet mount.
What is this?

• Cyclospora
• Isospora
• Schistosoma
• Trichuris
• Plant Pollen

50 mm
29

• A woman found a worm in her laundry basket and
  contacted the health department.  She reported
  small children in the household, as well as dogs
  and cats.  Eggs were removed from the worm and
  stained. What worm is this?
• Ascaris
• Hookworm
• Taenia
• Toxocara
• Delusional parasitosis

iodine-stained wet mount
100 mm
30
A 29-year-old Peace Corp volunteer returned to
the United States from Malawi with symptoms that
included mild gastrointestinal cramping and
intermittent blood in his urine. A urine wet
mount is performed. This is

• Schistosoma hematobium
• S. intercalatum
• S. japonicum
• S. mansoni
• S. mekongi
• Plant pollen

100 mm
31
A 29-year-old Peace Corp volunteer returned to
the United States from Malawi with symptoms that
included mild gastrointestinal cramping and
intermittent blood in his urine. This is

• Schistosoma hematobium
• S. intercalatum
• S. japonicum
• S. mansoni
• S. mekongi
• Plant pollen

100 mm
32
A friend of the Peace Corp volunteer returning
from elsewhere has vague abdominal symptoms and
submits a specimen. This is

• Schistosoma hematobium
• S. intercalatum
• S. japonicum
• S. mansoni
• S. mekongi
• Plant pollen

100 mm
33
A second friend of the Peace Corp volunteer
returning from Cameron has vague abdominal
symptoms and submits a specimen. They submit a
stool specimen. This is

• Schistosoma hematobium
• S. intercalatum
• S. japonicum
• S. mansoni
• S. mekongi
• Plant pollen

34
A thick blood smear stained with hematoxylin from
an adult male from Cameroon.Which ones are not
possible?

• Brugia malayi
• Loa loa
• Mansonella ozzardi
• Mansonella perstans
• Mansonella streptocerca
• Onchocerca volvulus
• Wuchereria bancrofti

35
A thick blood smear stained with hematoxylin from
an adult male from Cameroon.Which filariasis is
this?
230-250 µm long  The tail is tapered and nuclei
extend to the tip of the tail. 

• Loa loa
• Mansonella perstans
• Onchocerca volvulus
• Wuchereria bancrofti

36
A thick blood smear stained with hematoxylin from
an adult male from Cameroon.Which filariasis is
the smaller one?

• Brugia malayi
• Loa loa dimunata
• Mansonella perstans
• Onchocerca volvulus
• Wuchereria bancrofti

smaller microfilaria , 190-200 µm No sheath blunt
tail filled with nuclei to the tip
37
Images were taken from a thick blood smear
stained with hematoxylin from an unknown country.

• Loa loa
• Mansonella perstans
• Onchocerca volvulus
• Wuchereria bancrofti

Cells loosely packed, Cells do not extend to the
tip of the tail
38
A 45-year-old immigrant from Mexico was admitted
to the hospital after experiencing headaches,
fever, pulmonary symptoms, and adenopathy. 

• Brugia malayi
• Loa loa
• Mansonella ozzardi
• Mansonella perstans
• Mansonella streptocerca
• Onchocerca volvulus
• Wuchereria bancrofti

180 mm length
39
40yo F with complaints of abdominal pain and
diarrhea.  The symptoms began one week after
attending a social function where she ate only
dessert with fruit punch. Stool exam via

• All objects are 9 µm in diameter

• Giardia intestinalis
• Cryptosporidium parvum
• Cyclospora cayetanensis
• Ascaris lumbricoides

40

• A laboratory in one of the U.S. Trust territories
  in the Pacific Islands reported Entamoeba
  histolytica amebiasis in the stool specimens of
  patients with bloody diarrhea.  The laboratory
  made their diagnosis from unstained wet mounts. 
  What should be the next course of action?
• A. Treat for E. histolytica infection
• B. Send a team to the island to investigate the
  outbreak
• C. Confirm amebiasis at a reference lab
• D. Obtain water samples to examine for E.
  histolytica

41
A 45-year-old female noticed a long, worm-like
object in her stool. 

• Ascaris lumbrocoides
• Diphyllobothrium latum
• Taenia solium
• Taenia saginatum
• Ingested rubber bands

42
A 45-year-old female noticed a long, worm-like
object in her stool. 

• Ascaris lumbrocoides
• Taenia solium
• Taenia saginatum
• Taenia species NOS
• Toxocara canis

43
An 18-year-old woman sought medical attention due
to a painful lesion between her toes.  She
reported travel to Africa. 

• Tinea pedis
• Taenia pedis
• Taenia solium
• Tunga penetrans

500 mm
44
A call from the lab, this is

• Trypanosoma brucei gambiense
• Trypanosoma brucei rhodesiense
• Trypanosoma brucei complex, unknown subspecies
• Trypanosoma cruzi

45
A call from the lab, this is

• Trypanosoma brucei gambiense
• Trypanosoma brucei rhodesiense
• Trypanosoma cruzi

46
Trypanosoma spp.
kinetoplast
T. Brucei T. cruzi
47
7yo, previously healthy child developed flu-like
symptoms and rapidly progressive bulbar palsy,
coma, and eventually death.  Imaging revealed
florid ventriculitis. Autopsy revealed
granulomatous encephalitis with mixed
inflammatory, occasional giant cells,
peri-vascular in location.
48
7yo, previously healthy child developed flu-like
symptoms and rapidly progressive bulbar palsy,
coma, and eventually death.  Imaging revealed
florid ventriculitis. Autopsy revealed
granulomatous encephalitis with mixed
inflammatory, occasional giant cells,
peri-vascular in location.

• Balamuthia mandrillaris
• Herpes HSV-1
• Influenza
• Naegleria fowleri
• Toxoplasma gondii

49
Of the 4 causes of amebic encephalitis, which
does not form cysts in tissue?

• Acanthamoeba
• Balamuthia
• Naegleria
• Sappinia 

50
Vaccinology and Pre-travel Counselling
51
Excluding pre-existing disease, the most common
cause of death in travelers to tropical countries
is

• Malaria
• Typhoid Fever
• Homicide
• Accidental Injury

52
A 27yo woman who is 15 weeks pregnant seeks
pre-travel counseling prior to a 5-week trip to
Kenya in which she will spend 2 weeks on safari.
Regarding counseling for malaria prophylaxis, you
should recommend

• Delaying or canceling the trip until after
  delivery, since no antimalarials are safe in
  pregancy
• Atovaquone/proguanil
• Mefloquine
• Doxycycline
• Chloroquine

53
In two months a family in your office will be
going on a two month missionary trip to rural
northeastern Kenya. Vaccinations for their 3
month-old son should include

• Yellow Fever, Hep A, Hep B, JE Vaccine,
  Meningococcal vaccine, IPV, MMR, Varicella
• Hep A, Hep B, IPV
• Yellow Fever, Hep A, Hep B, IPV, Meningoccal
  vaccine, MMR, Injectable typhoid
• No vaccinations because he is too young

54
A 58yo Hmong male who has a history of depression
and post-traumatic stress disorder seeks
counseling prior to a 2-month visit to family
remaining in rural Laos. Pre-travel
recommendations could include all of the
following EXCEPT

• Japanese Encephalitis Vaccine
• Doxycycline for malaria prophylaxis
• Mefloquine for malaria prophylaxis
• Oral Typhoid Vaccine
• Azithromycin for travelers diarrhea treatment

55
A 35yo Egyptian male is planning on traveling to
the Hajj in Mecca. He asks questions about the
Menactra (quadrivalent conjugated meningococcal
vaccine). Which is NOT true about Menactra?

• Menactra covers strain B.
• Menactra covers strains A and C.
• Menactra covers strains W135 and Y.
• Menactra likely lasts for gt10 years.
• Can be used safely for asplenic patients if
  inidicated
• The embassy of Saudi Arabia mandates proof of
  vaccination prior to travel to the Haaj.

56
A 23yo HIV positive female presents for pretravel
advice prior to traveling to Nigeria for Peace
Corps work. She is currently taking HAART
medications and her CD4 count is 850. She
remembers that the last vaccination she received
was the tetanus booster at age 11 years. She
claims that she received all the recommended
pediatric immunizations while growing up in
Chicago, Illinois including 5 doses of DtaP, 4
doses of oral polio vaccine, 2 doses of MMR
vaccine, two doses of varicella vaccine. Which
vaccination is NOT recommended?

• MMR
• Influenza, trivalent inactivated vaccine
• Meningococcal conjugated vaccine
• Diphtheria, Tetanus, and acellular pertussis
  booster
• Yellow fever vaccine

57
Vaccines

• Live Attenuated
• MMR
• OPV
• Yellow Fever
• Vaccinia
• Varicella
• Nasal Flu
• BCG
• Cholera
• Oral Typhoid

• Inactivated
• IPV
• JE Virus
• Hep A and B
• Influenza
• Acellular Pertussis
• HPV
• Pure Polysaccharide
• Pneumovax (23-valent)
• Meningoccal
• Injectable Typhoid
• Conjugated Polysaccharide
• HIB
• PCV-7
• Menactra

58
You are about to leave the office, when you get a
call that a patient you saw yesterday is having a
rash and swelling of his lips. He is wondering
if this could be a vaccine side-effect. He
received first doses of all the recommended
vaccines for a 6 month backpacking trip through
India, Cambodia, Laos, China, and Vietnam. Which
vaccine is the most likely culprit?

• TdaP booster
• Yellow Fever
• Oral Typhoid
• JE Vaccine
• Hepatitis A

59
You are counseling a 20 year-old student studying
abroad for a semester and staying with a
host-family. In which area will Chloroquine be
effective malaria prophylaxis?

• Guatemala
• Kenya
• Cambodia
• Colombia
• Peru

60
You are doing a new arrival screen on a 32
year-old Somali woman who has been in the U.S.
for 6 months. She received BCG vaccination as a
young child, and her PPD placed in clinic
measures 16mm induration. According to the CDC
you should recommend

• Repeat PPD in 1 year
• Follow chest x-ray annually and work-up further
  for TB if there are any changes
• Start treatment with triple-drug therapy now
  (INH, Rifampin, and pyrizinamide
• Treat with single-drug therapy (INH)
• Do nothing

61
Marine Medicine
62
A 47 yo male vacationing in Mexico develops
flushing, nausea, vomiting, pruritus, urticaria,
and bronchospasm minutes after consuming a fish
dinner. His symptoms are most likely due to a
toxin that

• Blocks Na channels
• Converts histadine to histamine
• Converts nitrogen to histamine
• Blocks glutamate
• 
  

63
Review of Marine Toxins

• Fish related toxic syndromes
• Scrombroid
• Produced by albacore, tuna, wahoo, mackerel,
  skipjack, bonito, mahi-mahi (worldwide
  distribution).
• Toxin production Bacteria within the fish
  transform histidine to histamine.
• Onset rapid (minutes).
• Treat with antihistamines, antiemetics
• Tetrodotoxin
• Produced by puffer fish, "fugu," porcupine fish
  (tropical and subtropical).
• Toxin is a Na channel blocker, also blocks
  axonal transmission.
• Onset minutes to hours.
• Symptoms include paresthesias of lip and tongue,
  hypersalivation, weakness, ataxia, tremor,
  dysphagia, seizure, bronchospasm, hypotension,
  nausea, vomiting, diarrhea, death.
• Treat with gastric lavage/charcoal, ionotropes,
  anticholinesterases

64
Review of Marine Toxins

• Algae bloom related toxic syndromes
• Ciguatera
• Tropical and semitropical reef fish such as
  barracuda, grouper, snapper, jack.
• Ciguatoxin, maitotoxin, GT1-4, palytoxin produced
  by algae Na channel blockers.
• Onset 2-6 hours.
• Symptoms generally gastroenteritis followed by
  neurologic symptoms dysesthesias, hot/cold
  reversal, weakness, respiratory paralysis.
• Supportive care, ? benefit with mannitol.
• Others related to shellfish
• Paralytic shellfish poisoning, amnestic shellfish
  poisoning (toxin glutamate antagonist),
  neurotoxic shellfish poisoning, diarrheal
  shellfish poisoning.

65
A 23 yo scuba diver in Australia is stung by a
box jellyfish. After rinsing the lesion with
saltwater, what is the most appropriate
management?

• Urinate on the sting.
• Start systemic steroids and use local lidocaine
  for pain control.
• Remove nematocysts by using shaving cream/sand
  paste and then shaving with sharp edged object.
• Soak the sting in acetic acid, wrap the area as
  you would a snake bite, then treat with
  antivenom.

66
Review of Jellyfish Stings

• Box jellyfish
• Most lethal, found only in Australia.
• Clinical symptoms frosted looking lesions with
  secondary blistering followed by necrosis.
  Incapacitating muscle spasm, parasympathetic
  overstimulation with cardiopulmonary arrest.
• Immediately rinse with saltwater followed by
  soaking in vinegar for at least 30 min. Wrap
  affected extremity as in snake bites. ANTIVENOM
  available in Australia.
• Sea anemones/coral, Portugese man of war, true
  jellyfish other than box
• Widespread, no antivenom available.
• Treat locally - immediately rinse with seawater.
  DO NOT RUB. Soak in acetic acid to prevent
  nematocyte discharge, then remove nematocysts by
  using shaving cream/sand paste and then shaving.
• Dont forget tetanus prophylaxis!

67
What is the treatment of choice for a Sting Ray
Sting?

• Soaking in water 37-40?C
• Soaking in water as hot as tolerable
• Anti-histamine
• CroFab Anti-venom
• Acetic Acid irrigation of the wound

68
What vitamin deficiency is associated with these
skin findings?

• Vitamin A
• Iron
• Vitamin B1
• Vitamin B3

69
A 9 year old malnourished boy presents with
shortness of breath and confusion. On exam, he
is found to have bilateral rales, elevated JVD,
and significant LE edema. Deficiency of what
vitamin is most likely responsible for his
symptoms?

• A. Vitamin B1
• B. Vitamin D
• C. Vitamin B12
• D. Vitamin E

70
Review of B vitamin defiencies

• Vitamin B1
• AKA thiamine
• Found in unrefined cereals, fresh meat, legumes,
  green vegetables, and milk.
• Look for deficiency in those subsisting on
  polished white rice.
• Deficiency leads to weight loss, change in mental
  status, impaired sensation, weakness and pain in
  the limbs, edema ? heart failure (beriberi).
• Vitamin B3
• AKA niacin
• Found in dairy products, poultry, fish, lean
  meats, nuts, and eggs.
• Look for deficiency in those subsisting on corn
  based diets.
• Deficiency leads to the 4 Ds diarrhea,
  dermatitis, dementia, death pellagra
• Vitamin B12
• Found only in animal products.
• Can also have deficiency related to malabsorption
  (pernicious anemia).
• Deficiency results in subacute combined
  degeneration of the spinal cord, dementia/change
  in mental status, megaloblastic anemia.

71
A young child has diminished night vision and
this finding on exam. What is the etiology of his
symptoms?

• Trachoma
• Vitamin A deficiency
• Congenital CMV infection
• Protein malnutrition

72
Vitamin A deficiency

• Foods with high levels liver, beef, chicken,
  eggs, fortified milk, carrots, mangoes, sweet
  potatoes, and leafy green vegetables.
• First signs abnormal visual adaptation to
  darkness, dry skin, dry hair, broken fingernails,
  and decreased resistance to infections.
• Can progress to blindness.
• For severe disease treat with 60,000 mcg (200,000
  IU) PO for at least 2 d.

73
What is the treatment of choice for high-altitude
pulmonary edema (HAPE)?

• Immediately descend at least 500 feet, use O2,
  and start acetazolamide.
• Stop ascent and start acetazolamide.
• Slow rate of ascent and use O2 and furosemide or
  other diuretic for symptomatic improvement.
• Immediately descend at least 2000 feet, use O2
  and start nifedipine.

74
Review of High Altitude Illness

• Categories
• Acute mountain sickness (AMS)
• Headache, plus at least one of the following
  Fatigue or weakness, GI sx, dizziness or
  lightheadedness, difficulty sleeping
• High-altitude pulmonary edema (HAPE)
• At least two of the following Dyspnea at rest,
  cough, weakness or decreased exercise
  performance, chest pain/congestion
• PLUS at least two of the following signs Central
  cyanosis , rales or wheezing in at least one lung
  field, tachypnea, tachycardia
• High-altitude cerebral edema (HACE)
• Either the presence of a change in mental status
  and/or ataxia in a person with AMS or the
  presence of both mental status changes and ataxia
  in a person without AMS

75
Review of High Altitude Illness

• Treatment
• Acute mountain sickness (AMS)
• Stop ascent, acclimatize at the same altitude and
  give acetazolamide (Diamox), 125 to 250 mg orally
  two times a day.
• OR descend 460 m (1,500 ft) or more until
  symptoms have resolved.
• High-altitude pulmonary edema (HAPE)
• Descend at least 610 m (2,000 ft) and keep
  descending until the symptoms have resolved.
• Other measures oxygen, nifedipine, keep the
  person warm and minimize exertion, use a Gamow or
  Chamberlite bag for hyperbaric therapy if
  available.
• High-altitude cerebral edema (HACE)
• Descend at least 610 m (2,000 ft) and keep
  descending until symptoms have resolved.
• If that is impossible, temporize with oxygen
  give dexamethasone hyperbaric therapy if
  possible.

76
Which of the following are absolute
contraindications for high altitude travel?

• Seizure disorders not controlled on medication
• Sleep apnea
• Sickle cell disease
• High-risk pregnancy

77
Contraindications for High Altitude Travel

• Contraindications Uncompensated congestive heart
  failure Pulmonary hypertension Sickle cell
  anemia Severe COPD
• Cautions Compensated congestive heart failure
  Troublesome arrhythmias Sickle cell trait
  Moderate COPD Seizure disorders (not controlled
  on medication) Stable angina or coronary artery
  disease Sleep apnea High-risk pregnancy

78
A mail sorter presents to the ER with fever,
shortness of breath, nonproductive cough,
myalgias and chest pain. CXR demonstrates
mediastinal widening and bilateral pleural
effusions. This presentation is most consistent
with infection with what bioterrorism agent?

• A. Yersinia pestis (Pneumonic plague)
• B. Francisella tularensis (Tularemia)
• C. Bacillus anthracis (Anthrax)
• D. Burkholderia mallei (Glanders)

79
Choose an antibiotic that can be used to treat
this condition.

• Ciprofloxacin
• Metronidazole
• Trimethoprim/Sulfa
• Ceftriaxone

80
Anthrax

• Encapsulated, aerobic, gram-positive,
  spore-forming, rod-shaped bacterium.
• Cutaneous, inhalational, GI, oropharyngeal.
• Symptoms of inhalational disease flu like sx
  progressing to respiratory distress, death in
  24-48 hours.
• CXR mediastinal widening, pleural effusion,
  rarely infiltrates.
• Ciprofloxacin, doxycycline and penicillin all FDA
  approved for treatment
• Do NOT use TMP/sulfa or extended spectrum
  cephalosporins due to resistance.

81
How would you manage an individual who has had
direct contact with a patient with confirmed
pneumonic plague?

• Treat with ciprofloxacin.
• Treat with streptomycin.
• Quarantine only.
• Treat with inhaled tobramycin.

82
Plague

• Pneumonic plague occurs when Y. pestis infects
  the lungs - can spread from person to person
  through the air.
• Clinical symptoms fever, headache, weakness, and
  rapidly developing pneumonia with SOB, chest
  pain, cough, /- bloody sputum.
• Treat EARLY with streptomycin, gentamicin, the
  tetracyclines, and chloramphenicol.
• Also treat close contacts within 7 days.

83
Choose 2 features that distinguish smallpox from
chickenpox.

• In smallpox, there is a predominance of lesions
  on face and extremities rather than on the trunk.
• In smallpox, lesions develop at different stages
  and come in crops.
• In smallpox, lesions are all at the same stage of
  development.
• In smallpox, lesions do not scab.

84
Smallpox

• Incubation 7-17 days.
• Starts with prodrome malaise, fever, rigors,
  vomiting, headache, backache, confusion
• Then rash develops looks like chickenpox except
• Smallpox lesions can be seen on palms and soles.
• Smallpox lesions are more deeply imbedded in the
  dermis.
• There is no treatment.

85
TTM Review QuestionsMalaria

• December 1, 2008
• Ann Settgast, MD, DTMH

86
Which of these patients presenting to your clinic
with fever is most likely to have infection with
P. falciparum?

• 42 y/o Liberian refugee who arrived in the US 12
  months ago and has not traveled since
• 42 y/o American 6 months after returning from
  working with an NGO in Liberia (no malaria
  prophylaxis used)
• 42 y/o Liberian living in the US who returned
  from visiting relatives in Liberia one week ago
  (given malaria prophylaxis by primary MD)
• 42 y/o American one week after returning from a
  one-month trip to Morocco (no malaria
  prophylaxis)

87
Which of these patients presenting to your clinic
with fever is most likely to have infection with
P. falciparum?

• 42 y/o Liberian refugee who arrived in the US 12
  months ago and has not traveled since
• 42 y/o American 6 months after returning from
  working with an NGO in Liberia (no malaria
  prophylaxis used)
• 42 y/o Liberian living in the US who returned
  from visiting relatives in Liberia one week ago
  (given malaria prophylaxis by primary MD)
• 42 y/o American one week after returning from a
  one-month trip to Morocco (no malaria
  prophylaxis)

88
Which of the following blood smear slides reveals
evidence of Plasmodium falciparum malaria?

• You may choose one or more than one.

89
A
B
C
90
How will you treat this Liberian VFR patient if
she has uncomplicated P. falciparum malaria
(taking po easily)?

• A. Primaquine phosphate 30 mg base daily for 14
  days
• B. Oral quinine sulfate 650 mg salt tid
  doxycycline 100 mg bid for 3 days
• C. Malarone (atovaquone/proguanil) 1 tablet daily
  for 3 days
• D. Chloroquine phosphate 600 mg (base) now
  followed by 300 mg at 6, 24, and 48 hours

91
How will you treat this Liberian VFR patient if
she has uncomplicated P. falciparum malaria
(taking po easily)?

• A. Primaquine phosphate 30 mg base daily for 14
  days
• B. Oral quinine sulfate 650 mg salt tid
  doxycycline 100 mg bid for 3 days
• C. Malarone (atovaquone/proguanil) 1 tablet daily
  for 3 days
• D. Chloroquine phosphate 600 mg (base) now
  followed by 300 mg at 6, 24, and 48 hours

92
You are the night float at Regions Hospital
admitting a patient who has just returned from
Tanzania with severe malaria. What is the
treatment of choice?

• A. IV quinidine gluconate loading dose followed
  by infusion
• B. Malarone (atovaquone-proguanil)
• C. IV artesunate doxycycline
• D. IV quinidine gluconate loading dose followed
  by infusion doxycycline

93
You are the night float at Regions Hospital
admitting a patient who has just returned from
Tanzania with severe malaria. What is the
treatment of choice?

• A. IV quinidine gluconate loading dose followed
  by infusion
• B. Malarone (atovaquone-proguanil)
• C. IV artesunate doxycycline
• D. IV quinidine gluconate loading dose followed
  by infusion doxycycline

94
IV quinidine is on the Regions Hospital
formulary, but not always in stock. While
awaiting its arrival from another local hospital,
what could you use as a temporizing measure?

• IV vancomycin gentamicin
• Mefloquine via NGT
• Quinine via NGT IV clindamycin
• IV ceftriaxone
• Zosyn

95
IV quinidine is on the Regions Hospital
formulary, but not always in stock. While
awaiting its arrival from another local hospital,
what could you use as a temporizing measure?

• IV vancomycin gentamicin
• Mefloquine via NGT
• Quinine via NGT IV clindamycin
• IV ceftriaxone
• Zosyn

96
Which life-threatening complication during
malaria treatment w/ quinidine are you least
likely to see?

• Pulmonary embolus
• Hypotension
• Hypoglycemia
• Cardiac arrhythmia

97
Which life-threatening complication during
malaria treatment w/ quinidine are you least
likely to see?

• Pulmonary embolus
• Hypotension
• Hypoglycemia
• Cardiac arrhythmia

98
You are seeing a 45 y/o male patient with
recurrent fevers, diagnosed w/ P. vivax malaria
(backpacked across India a few years ago). How
will you treat him?

• Malarone 4 tablets daily x 3 days plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)
• Mefloquine 750 mg salt followed by 500 mg 12
  hours later plus primaquine treatment to
  eradicate the hypnozoite stage (after G6PD
  testing)
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)

99
You are seeing a 45 y/o male patient with
recurrent fevers, diagnosed w/ P. vivax malaria
(backpacked across India a few years ago). How
will you treat him?

• Malarone 4 tablets daily x 3 days plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)
• Mefloquine 750 mg salt followed by 500 mg 12
  hours later plus primaquine treatment to
  eradicate the hypnozoite stage (after G6PD
  testing)
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)

100
Plasmodium vivax
101
How would your management of P. vivax change if
the patient in the last scenario were a pregnant
female?

• Malarone 4 tablets daily x 3 days plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)
• Mefloquine 750 mg salt followed by 500 mg 12
  hours later plus primaquine treatment to
  eradicate the hypnozoite stage (after G6PD
  testing)
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)

102
How would your management of P. vivax change if
the patient in the last scenario were a pregnant
female?

• Malarone 4 tablets daily x 3 days plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)
• Mefloquine 750 mg salt followed by 500 mg 12
  hours later plus primaquine treatment to
  eradicate the hypnozoite stage (after G6PD
  testing)
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours
• Chloroquine phosphate 600 mg base followed by 300
  mg at 6, 24, and 48 hours plus primaquine
  treatment to eradicate the hypnozoite stage
  (after G6PD testing)

103
You are providing pre-travel advice to a 24 y/o
American male with epilepsy (well-controlled on
phenytoin). He is going to work in Haiti with an
NGO for 4 months. What will you recommend for
malaria prophylaxis?

• Doxycycline 100 mg daily begun one day prior to
  travel and continued for four weeks after return
• Chloroquine 500 mg weekly begun one week prior to
  travel and continued for four weeks after return
• Mefloquine 250 mg weekly begun one week prior to
  travel and continued for four weeks after return
• Malarone one tablet daily begun one day prior to
  travel and continued for one week after return

104
You are providing pre-travel advice to a 24 y/o
American male with epilepsy (well-controlled on
phenytoin). He is going to work in Haiti with an
NGO for 4 months. What will you recommend for
malaria prophylaxis?

• Doxycycline 100 mg daily begun one day prior to
  travel and continued for four weeks after return
• Chloroquine 500 mg weekly begun one week prior to
  travel and continued for four weeks after return
• Mefloquine 250 mg weekly begun one week prior to
  travel and continued for four weeks after return
• Malarone one tablet daily begun one day prior to
  travel and continued for one week after return

105
You are advising a 12-week pregnant Somali female
regarding malaria prevention for her upcoming
trip to visit relatives in Kenya (Nairobi rural
areas). Which medication would you prescribe?

• Doxycycline
• Malarone
• Chloroquine
• Mefloquine

106
You are advising a 12-week pregnant Somali female
regarding malaria prevention for her upcoming
trip to visit relatives in Kenya (Nairobi rural
areas). Which medication would you prescribe?

• Doxycycline
• Malarone
• Chloroquine
• Mefloquine

107
Your last patient of the day in travel clinic is
a 28 y/o U of M resident going to spend two
months in Chiang Mai, Thailand for an
international rotation. She will be traveling
throughout Thailand and Cambodia during her stay.
What drug will you recommend for malaria
prevention?

• Malarone
• Doxycycline
• Mefloquine
• Chloroquine

108
Your last patient of the day in travel clinic is
a 28 y/o U of M resident going to spend two
months in Chiang Mai, Thailand for an
international rotation. She will be traveling
throughout Thailand and Cambodia during her stay.
What drug will you recommend for malaria
prevention?

• Malarone
• Doxycycline
• Mefloquine
• Chloroquine

109
Which lab test is useful for diagnosing a patient
with splenomegaly with HMS (hyperactive malarial
splenomegaly)?

• Thick and thin blood smear for malaria.
• CBC looking for thrombocytopenia eosinophilia
• Total malaria IgM antibody level
• Rapid diagnostic card test for malaria

110
Which lab test is useful for diagnosing a patient
with splenomegaly with HMS (hyperactive malarial
splenomegaly)?

• Thick and thin blood smear for malaria.
• CBC looking for thrombocytopenia eosinophilia
• Total malaria IgM antibody level
• Rapid diagnostic card test for malaria

111
Treatment?

• Splenectomy
• Chemotherapy for malignancy
• Antimalarial drugs specific choice is based on
  the pattern and prevalence of drug resistance in
  the patient's geographic area. In endemic areas,
  treatment should be prolonged and continued
  regularly.

112
HIV in the Tropics -Questions
113
Question 1 34 yo male HIV, newly diagnosed
presents to healthcare.To determine whether HIV
antiretroviral medications are needed, most
developing country programs base need for ARVs
on

• History and Physical
• CD4 Count
• HIV Viral Load
• All of the Above

114
Question 2

• At which WHO clinical stage is HIV therapy
  typically started in developing countries?
• Stage 1
• Stage 2
• Stage 3
• Stage 4

115
Question 3

• First Line HIV therapy is generally provided from
  either PEPFAR or the Global Fund sources.
• Which one of the following is not a first line
  regimen?
• stavudine, lamivudine, nevirapine (d4T / 3TC /
  NVP)
• zidovudine, lamivudine, efavirenz (AZT / 3TC /
  EFV)
• tenofovir, emtricitabine, lopinavir/ritonavir
  (TDF/FTC/ LPVr)

116
Question 4

• With d4T / 3TC / NVP )stavudine, lamivudine,
  nevirapine)
• Which of the following is NOT a common side
  effect?
• Hepatotoxicity
• Hypersensitivity rash
• Lactic Acidosis
• Neuropathy
• Pancreatitis
• Renal Insufficiency

117
ART Toxicities

• d4T / 3TC / NVP
• stavudine, lamivudine, nevirapine
• Which of the following is NOT a common side
  effect?
• Hepatotoxicity (NVP) early women,CD4gt250
• Hypersensitivity rash (NVP) 25 early 14 day
  lead in
• Lactic Acidosis (d4T) 0.5-1
• Neuropathy (d4T) 40 switch rate in 3 yrs
• Pancreatitis (d4T, ddI) 1-7
• Renal Insufficiency (TDF)

118
Question 5

• AZT / 3TC / EFV
• zidovudine, lamivudine, efavirenz
• Which of the following are NOT a common side
  effect?
• Anemia
• Cardiomyopathy
• Hypersensitivity reaction
• Neuropsychiatric exacerbations
• Insomnia / Vivid thoughts

119
Toxicities

• AZT / 3TC / EFV
• zidovudine, lamivudine, efavirenz
• Which of the following are NOT a common side
  effect?
• Anemia (AZT) 10
• Cardiomyopathy (AZT) 5
• Hypersensitivity reaction (Abacavir) HLA B5701
• Neuropsychiatric exacerbations (EFV) common
• Insomnia / Vivid thoughts (EFV) common

120
Bonus Images
121
An 8-year-old child was taken to a hospital with
fever, hepatomegaly, and persistent cough. The
child commonly eats dirt. A liver biopsy was
performed. 

• Capillaria hepatica
• Entamoeba histolytica
• Isospora belli
• Schistosoma mansoni

122
HIV-related Common OIs
123
Question

• A newly diagnosed HIV-infected person who is
  asymptomatic presents to clinic. After thorough
  history and exam, they are still asymptomatic,
  WHO Stage I.
• The most appropriate therapy is
• HIV antiretroviral therapy
• Cotrimoxazole daily
• Azithromycin weekly
• Chloroquine weekly
• None of the Above

124
Question

• Cotrimoxazole (TMP/SMZ) prophylaxis is
  prescribed. In asymptomatic HIV-infected persons,
  TMP/SMZ was been shown to reduce all except
• Death
• Malaria
• PCP Pneumocystis jirovecii
• Toxoplasmosis
• None of the Above

125
Question Pulmonary

• 34yo M, HIV presents with pulmonary symptoms
  with a cough and fever of 5 days duration.
• Which is the most likely etiologic diagnosis?
• Streptococcus pneumoniae
• Mycobacteria tuberculosis
• Pneumocystis jirovecii pneumonia

126
Question Pulmonary

• 34yo M HIV presents with pulmonary symptoms with
  a dry cough and fever of 4 weeks duration.
• Which is the most likely etiologic diagnosis?
• Streptococcus pneumoniae
• Mycobacteria tuberculosis
• Pneumocystis jirovecii pneumonia

127
Diagnostic and Management Algorithm for PCP
Suspects

• PCP Suspect
• HIV and WHO clinical Stages 3 or 4 or CD4 count
  lt200 cells/mL
• Exertional dyspnea, non-productive cough, fever
• Symptoms gt2 weeks

CXR
Reticular or granular opacities
Normal
Ambulatory pulse oximetry
Sputum for AFB
desaturation
normal