IDBR Infectious Disease Board Review

Blood culture negative endocarditis - Trip Gulick, MD/ John Bennett, MD

A 43-year-old man is admitted with acute onset of right sided hemiplegia and dysarthria. He had been in excellent health until one month previously when he presented with shortness of breath and was diagnosed with acute pulmonary emboli and adenocarcinoma of the lung. He was begun on eliquis and chemotherapy was deferred pending genetic testing. The patient lives with his wife and 2 children in Chicago. He works as a municipal bus driver. He denies pet or animal exposure. On presentation, he is afebrile. Exam is notable for poor dentition and dense right hemiplegia. CT head confirmed a left middle cerebral artery infarct. TTE confirms a 6x9 mm mass on the mitral valve. Blood cultures x3 sets taken prior to initiation of antibiotics are no growth at 5 days. What is the most probable cause of endocarditis in this patient? A. T whipplei B. Mycobacterium chimaera C. Bartonella henselae D. Hypercoaguable state E. Coxiella burnetii ⁠www.idbrcourse.org/⁠ [https://www.idbrcourse.org/]  © 2024 IDBR LLC | All Rights Reserved

Preventing HIV with antiretrovirals - Trip Gulick, MD/ Trip Gulick, MD

A 58-year-old HIV- negative gay man is evaluated for PrEP. His past medical history is notable for hypertension, treated for over 10 years with an ACE inhibitor. He is asymptomatic and weighs 145 lbs. He is sexually active with multiple partners but “usually” practices safe sex. Lab studies reveal: HIV 4th generation test negative, HIV-1 RNA negative, CBC normal, creatinine 1.4 with a calculated creatinine clearance of 48 ml/min. What do you recommend for PrEP? A. No PrEP B. Tenofovir disoproxil fumarate/emtricitabine 1 pill daily C. Tenofovir disoproxil fumarate/emtricitabine 1 pill every other day D. Tenofovir alafenamide/emtricitabine 1 pill daily ⁠www.idbrcourse.org/⁠ [https://www.idbrcourse.org/]  © 2024 IDBR LLC | All Rights Reserved

Stopping PJP prophylaxis in HIV - Trip Gulick, MD/ Michael Saag, MD

A 44-year-old man was diagnosed with Pneumocystis pneumonia as his AIDS-defining illness and begun on antiretroviral therapy with 2 nucleosides and an integrase inhibitor during his hospitalization. He stabilizes and follows up for repeated outpatient visits with an HIV RNA consistently <20 copies/ml and a CD4 cell count of 44 that increased to 163 (at 3 months), 232 (at 6 months), 242 (at 9 months), and was repeated at 243 (at 12 months). His current medications are: tenofovir alafenamide/emtricitabine, dolutegravir, trimethoprim-sulfa double strength daily, and azithromycin 1200 mg once weekly. He says he’s tired of taking pills and would like to stop some of them. What do you recommend? A. Stop tenofovir alafenamide/emtricitabine B. Stop trimethoprim-sulfa C. Stop azithromycin D. Stop trimethoprim-sulfa and azithromycin E. Continue the current regimen ⁠www.idbrcourse.org/⁠ [https://www.idbrcourse.org/]  © 2024 IDBR LLC | All Rights Reserved

Which antiretroviral with rifampin? - Trip Gulick, MD/ Frank Maldarelli, MD

A 29-year-old man living with HIV on tenofovir alafenamide (TAF)/emtricitabine + dolutegravir (CD4 298, HIV RNA <20 cps/ml) develops pulmonary TB. The plan is to start empiric INH, RIF, PZA, and ETH pending mycobacterial susceptibilities. How do you manage his ART regimen? A. Continue current regimen B. Change dolutegravir to darunavir/ritonavir C. Change dolutegravir to elvitegravir D. Double the dose of dolutegravir ⁠www.idbrcourse.org/⁠ [https://www.idbrcourse.org/]  © 2024 IDBR LLC | All Rights Reserved

Latent TB and renal transplantation - Trip Gulick, MD/ Susan Dorman, MD

A 56-year-old male with end-stage-renal disease due to hypertensive nephropathy is being evaluated for possible renal transplantation. Routine pre-transplant serologies were obtained, which were notable for a positive Interferon-Gamma Release Assay (IGRA) for Mycobacterium tuberculosis. The patient is asymptomatic and has never been treated for TB. Chest x-ray is normal. The patient has a suitable living donor and the transplant team would like to proceed with transplantation as soon as possible. Which one of the following would be the best course of action? A. Inform the transplant team that patient is not a renal transplant candidate due to TB infection B. Initiate treatment with isoniazid and vitamin B6 while proceeding with transplant; complete treatment for a total of 6-9 months C. Initiate treatment with rifampin while proceeding with transplant; complete treatment for 4 months D. Initiate treatment with once weekly isoniazid and rifapentine while proceeding with transplant; complete treatment for 12 weeks E. Initiate treatment with isoniazid, rifampin, pyrazinamide and ethambutol for 6 months while proceeding with transplant ⁠www.idbrcourse.org/⁠ [https://www.idbrcourse.org/]  © 2024 IDBR LLC | All Rights Reserved