Learning Microbiology and Infectious Diseases: Clinical Case Prep for the USMLE Book (2020)

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LearningMicrobiologyandInfectiousDiseases:ClinicalCasePrepfortheUSMLE®TraceyA.H.TaylorDwayneBaxa®=MatthewSims(%&)p—NEA—~»Jy4RkNol(moa57=A4-PAN[8\\fB\7?S17=(@)ThiemeE

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LearningMicrobiologyandInfectiousDiseases:ClinicalCasePrepfortheUSMLE®TraceyA.H.Taylor,PhDAssociateProfessorDepartmentofFoundationalMedicalStudiesOaklandUniversityWilliamBeaumontSchoolofMedicineRochester,Michigan,USADwayneBaxa,PhDAssistantProfessorDepartmentofFoundationalMedicalStudiesOaklandUniversityWilliamBeaumontSchoolofMedicineRochester,Michigan,USAMatthewSims,MD,PhDProfessorDepartmentofInternalMedicineOaklandUniversityWilliamBeaumontSchoolofMedicineRochester,Michigan,USA49illustrationsThiemeNewYork»Stuttgart«Delhi»RiodeJaneiro_Study

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LibraryofCongressCataloging-in-PublicationDataisImportantnote:Medicineisanever-changingscienceundergo-availablefromthepublisheringcontinualdevelopment.Researchandclinicalexperiencearecontinuallyexpandingourknowledge,inparticularourknowl-edgeofpropertreatmentanddrugtherapy.Insofarasthisbook‘mentionsanydosageorapplication,readersmayrestassuredthattheauthors,editors,andpublishershavemadeeveryefforttoensurethatsuchreferencesareinaccordancewiththestateofknowledgeatthetimeofproductionofthebook.Nevertheless,thisdoesnotinvolve,imply,orexpressanyguaranteeorresponsibilityonthepartofthepublishersinrespecttoanydosageinstructionsandformsofapplicationsstatedinthebook.Everyuserisrequestedtoexaminecare-fullythemanufacturers’leafletsaccompanyingeachdrugandtocheck,ifnecessaryinconsultationwithaphysicianorspecialist,whetherthedosageschedulesmentionedthereinorthecontraindicationsstatedbythemanufacturersdifferfromthestatementsmadeinthepresentbook.Suchexam-inationisparticularlyimportantwithdrugsthatareeitherrarelyusedorhavebeennewlyreleasedonthemarket.Everydosagescheduleoreveryformofapplicationusedisentire-lyattheuser'sownriskandresponsibility.Theauthorsandpublishersrequesteveryusertoreporttothepublishersanydiscrepanciesorinaccuraciesnoticed.Iferrorsinthisworkarefoundafterpublication,erratawillbepostedatwww.thieme.comontheproductdescriptionpage.Someoftheproductnames,patents,andregistereddesignsreferredtointhisbookareinfactregisteredtrade-‘marksorproprietarynameseventhoughspecificreferencetothisfactisnotalwaysmadeinthetext.Therefore,theap-pearanceofanamewithoutdesignationasproprietaryisnottobeconstruedasarepresentationbythepublisherthatitisinthepublicdomain.©2020.Thieme.Allrightsreserved.ThiemePublishersNewYork333SeventhAvenue,NewYork,NY10001USA+18007823488,customerservice@thieme.comGeorgThiemeVerlagKGRiidigerstrasse14,70469Stuttgart,Germany+49[0]7118931421,customerservice@thieme.deThiemePublishersDelhiA-12,SecondFloor,Sector-2,Noida-201301UttarPradesh,India+911204556600,customerservice@thieme.inThiemePublishersRiodeJaneiro,ThiemePublicacdesLtda.EdificioRodolphodePaoli,25°andarAv.NiloPeganha,50-Sala2508,RiodeJaneiro20020-906Brasil+55213172-2297Coverdesign:ThiemePublishingGroupTypesettingbyThomsonDigital,IndiaThisbook,includingallpartsthereof,islegallyprotectedbycopyright.Anyuse,exploitation,orcommercializationoutsidePrintedinUSAbyKingPrintingCompany,Inc.54321thenarrowlimitssetbycopyrightlegislation,withoutthepublisher'sconsent,isillegalandliabletoprosecution.ThisISBN978-1-62623-508-3appliesinparticulartophotostatreproduction,copying,mim-Alsoavailableasane-book:cograping,reparationofmicrofilms,andelectronicdataeISBN978-1-62623-509-0_Study

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ContentsPIEfACE..oovvveeeeeeesresssssesseeeessssssssssssesesssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssnssVLCase1AdultwithaCoughofaLongDUFation...........cemmccessssscesssssssssssssssnsess1Case2ChildwithaSoreThroatandRedEyes............ccuccmmmssccmssnsccssssssssssenees7Case3AdultinRespiratoryDIStress.......meccmmmmmcssssscssssssssssssssssssssssssssssssssasess11Case4AdolescentwithSoreThroatandMalaise.............ccoeeeeeeeessssssssssssssensnnee15Case5ToddlerwithUpperRespiratorySymptoms...........cmeccsssesccsssssssssssenees19Case6ElderlyMalewithTwoDaysofFever,Chills,andCough.....ccseeeee.23Case7SeverelylllElderlyMaleinRespiratoryDiStress.......cmmcesssensscsssenees27Case8TeenagerwithaTwo-Week-LongCough.....mcemmnnscessnscssssscsssseees31Case9AdultMalewithPersistentCoughandMalaise...........ccooeccervenscemsssccsssenees35Case10InfantwithSevereCONGeStioN..........ceummccssssncesssssemsssssssssssssssssssssssssssss39Case11AdultMalewithFever,Myalgias,andRespiratoryDistress...43Case12AdultMalewithFever,Chills,andNightSweats..........ccocccvensccuesscessenees47Case13ChildwithBloodyDIarrhea.........meccummccissnccssssssssssnssssssssssssssssssssusss.91Case14ChildwithStomachPainandFeVer........eeeeemmsssseesssessssssssssssssssssnnne33Case15OutbreakofDiarrhealIlINess.........oceeeessussssssenssessssssssseesssessssssssssssssssssssse39Case16HospitalizedAdultFemaleWhoDevelopsDiarrhea............ccoouvccumevsvcrseneee63Case17HIV-PositiveMaleWithDiarrhea...........ccoeeeeeesssssnnsseeenseessssssssssssssssssnne67Case18AdultWithJAUNCICE...cuuucerneecsssncessnsescssssacsssssssesssssssssssssssssssssssssssssssssusess71Case19AdultwithRightUpperQuadrantPain............ccuccmmmnccmssesscssssssssssenses79Case20AdultFemalewithEpigastricPainafterEating..........ceeeecusnsccessssccsssenees79Case21ElderlyFemalewithFeverandFlankPain........cccmsnsccsssnsscssenees83Case22AdultMaleWithRaSheeeeerstesessssssssseessssssssssssssssssssssnsnee87Case23YoungFemaleWithJOINtPaiN.........ceccummccissnscmmsssnsssssssssssssssssssssssssssasess91Case24TeenagerWithSYNCOPY......ccuscssmnssssssesssssssssssssssssssssssssssmsssssssssssssssssssss99Case25AdultMalewithPainfulPenileUlcers......oooeeeermmurrreeenreenssssssssessssssnnnnnee99Case26AdultMalewithBackPain........eeeeeeseseeneenenssssssssessssssssssssssssesssssssssassnes103.||

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ContentsCase27AdultFemalewithVaginalDischarge...........occucemmnsccrnsssccssnnsssssneees107Case28AdultMalewithaRedEye........ccuccessccessscensssnscsssssssssssssssssssssssssanees111Case29AdultFemalewithLesiononLabia......ceeeeemsucesssnsessssssssssessessennnsssanaee115Case30AdultMalewithBackPainafterTrauma..........ccccooeenseeeeerssssssessensenesssssnnee119Case31TeenageGirlwithExpandingSkinLeSion..........ccemmmnsccsssesccssssnssssnnees123Case32AdultMaleWithFOOtUIC.uurerrmmnsenessenssssssssesssssssssssssssssssssssssssnsnes127Case33AdultMalewithFlu-LikeIllnessandRash.........cccoeeeeeeressmnnesssssssnnnnnnns131Case34FebrileTeenagerwithDisseminatedRash...........cocccumnsccssssccssnrssssnneees135Case35AdultMalewithWorseningShortnessofBreath.........ccuveceerccunnenee.139Case36AdultFemalewithFacialPain...........coeeeeeeeesssnssssssssssssssssssssessssnsssssnses143Case37AdultFemalewithPainfulRash...........eeeeemssceeennsnssrssssneessensesesssssnane147Case38AdultFemalewithHeadacheandConfusion........eeeeeeesscesensensnnnnnen.151Case39AdultMalewithPainful,SwollenLymphNodes..........ccocccmvunecervsrecrsseee.155Case40ToddlerwithHighFeverandUpperRespiratorySymptoms..................159Case41AdultFemalewithFebrilellINess.........ccoooeenerrererssmsncssnenssesssssssssenssnenssssnanee163Case42AgitatedMalewithRapidProgressiontoCOMa.........ceeueccsssenccesssssssssseees167Case43TeenagerwithHeadacheandFever...cmccmsmsscsssessssssssssssees171Case44ElderlyFemalewithSevereHeadacheandNausea..........cooveceverecrsseeee.175Case45AdultFemalewithHeadacheandDisorientation............coeeeeeseeesssssnneee179Case46AdultMalewithHeadacheforSeveralMonths.............cccooeseeeenrrrerrrnaneee.183Case47FebrileTeenagerwithHeadacheandNeckStiffness..........ccooeeccrverecrnneeee.187Case48TravelerswithAcuteFebrileIlINess.......ccoooeeneeeeeeresnrereenennnnnssssssesssssssnnnnnene191Case49NewbornwithJaundice...ccccersccesscenssscsssssssssssssssssenss195Case50TeenagerWithPaininGroin.....ecmmecessccmmssscsmsmssssssssssssssssssssssssssss1992TLoTLEeTe o—.|INAEXcovvurrrrreerrrssssssssssessssssssssssssssssssssssssssssssssssssssssssssssssssssssssssasssssnssssssssssssssssnsssssssssssasssssssss219-||

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PrefaceThisbookisanassortmentofclinicalcasesintendedLicensingExamination(COMLEX)oftheUnitedStatestoadvancethelearningofmicrobiologyandinfec-Step1andStep2.Fivechoicesareprovidedforeverytiousdiseasesusingcasestudies.Workingwithcasesquestion,butforeachquestionthereisonlyonebestisthemostidealapproachtoinvolvestudentsintheanswer.learningprocessbecause:Foreachquestion,answersandexplanationsareprovidedonaseparatepage.Thisallowsstudentsto*Everycaseshowsagenuinecircumstance,veryself-testtheentireseriesofquestionsbeforerevealingclosetothoseseenineverydaypractice.theanswersandexplanationssothattheymaycom-+Everycasecanelicitseveralproblemsthatmustpletelyworkthroughthecaseandreceiveoptimalbeunderstoodandsolved.Inotherwords,itisaformativefeedback.Theexplanationsincludebothproblem-basedlearningprocess.thereasonswhyagivenansweriscorrectandwhy+Everycasenotonlyrequirestheknowledgeofthedistractorsarewrong.Manyquestionsarerelatedseveraldisciplinesbutalsotheproperutiliza-tgthehigherlevelsofBloom'staxonomy(e.g.analyztionoftheknowledgetoexplicitclinicalcir-ing,applying,orevaluating)ratherthanbeingsimplecumstances.recallquestions.Intermsoftheorganizationofthecases,wepur-LCFeachcase.keywordsareprovidedsothatstu-posefullyintermingledbacteriology,virology,mycol-dentsmaysearchforaparticularareaofinterest.;1008astly,wehaveprovidedabibliographysectionforogy,andparasitologycasesinthisbook,aswellasthestudents.Studentsareinvitedtousethoserefer-organsystems.Wefeelthatstudentswillgainabetter;heydiscoverthattheyrequireadeeperunderstandingofthetopicswhentheyconsiderall">caeYhorthPtypesoforganismsforeachcase,aswillbethecaseoeonoi"8OfthematerialorIftheybecomein-;38Wispiredtoseekadditionalinformation.whentheyareconsideringthediagnosisofrealpa-31\qrationaleforthisbookisrelatedtothecurrenttients.Theformatofeachcaseisasfollows:trendsinmedicaleducation.Now,itisevidentthat*Eachcaseprovidesrelevantclinicalinformation;themereretentionofinformationprovidedbypresentingsymptomsandrelevantduration,DOOKSisinsufficientformeaningfullearning.Therelevantmedicalhistory(whichmayincludeUtilizationofinformationisprogressivelysignificant.vaccinations),relevantfamilyhistory,relevantAvastarrayofmedicalproblemsisavailableintherecenttravel,physicalexaminationfindings,literaturetoday,buttherearefewclinicalcasebooksandlabfindings.relatedtomicrobiologyandinfectiousdisease.This+Imagesareusedtosupportthecases,ImagesinD0OKlinksclinicalcasestotheapplicationofbasiccludemicroscopicimagessuchasGramstains,knowledgeofmicrobiology,aswellasexplainstheelectronmicrographs,wetmounts,andacid.[€asonsforusingspecificdrugsinrealinfectiousfaststains,aswellasclinicalimagesandskindiseaseproblems,withthegoalofpromotingrashesorlesions.criticalthinking.+Eachcaseisfollowedbyaseriesoffivemultiple-Themainaudienceofthebookismedicalschoolchoicequestions.students.Thisbookwillaidthesestudentsintheir©Inmostcases,thefirstquestionrequiresMedicalschoolcoursework,aswellasinpreparationthestudenttoidentifythemostlikelycaus-fortheUSMLEand/orCOMLEXStep1exam.Medicalativeagent.studentsinyears3and4mayalsofindthesecasesoOtherquestionsaddresstheknowledgeof©behelpfulwhenpreparingfortheUSMLEand/ormicrobiologyandinfectiousdiseasestharCOMLEXStep2exams,shelfexams,andfortheirclin-thestudentneedsfoassessthecase,Foricalrotationcoursework.Inaddition,thisbookisalsoexample,preventionandprecautionmea.Usefulorstudentsinothermedicalprofessionsedu-sures,transmission,mechanismofaction C2ton.includingphysicianassistantstudents,nursingofpathogenesis,diagnosticmethods,possi-Students.andpharmacystudents.blecomplications,etc.Clinicalmedicineisafast-evolvingdiscipline.TheoThelastquestionisoftenrelatedtotheAuthorshavereferredtoreliablesourcesinordertopharmacotherapyofthedisease.provideinformationinaccordancewithcurrentlyacceptedstandards.However,theauthorsareawareThequestionsaredesignedtopreparestudentsthatinseveralinstances,theinformationmaybecon-fortheUnitedStatesMedicalLicensingExaminationtroversial.Wehavetried,asmuchaspossible,toavoid(USMLE)and/orComprehensiveOsteopathicMedicalquestionsaddressingcontroversialissues._Study

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PrefaceThisbookismeanttobeacompaniontothemicrobiologyformorein-depthcoverageoftheThiememicrobiologyquestionbook,therebygivingsubjectmatter.studentsmorethanoneoptionforlearningandstudyingmicrobiology.ThisbookisnotintendedtoTraceyA.H.Taylor,PhDbeasubstituteformicrobiologytextbooks.StudentsDwayneBaxa,PhDarestronglyadvisedtoconsulttheirtextbooksofMatthewSims,MD,PhD_Study

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||.AdultwithaCoughofaLong.DurationA36-year-oldmalepresentstohisprimarycarephysicianwithacoughof4weeksduration.Thecoughisparoxysmal,andhesometimesvomitsaftercoughing.Twootherpeoplewithwhomheworkshaveasimilarcough.Thepatientworksatalocalautomobileassemblyplant;heismarriedwitha2-year-oldchild;andhehasnohistoryofcigarettesmoking.Onphysicalexamination,thepatientinitiallyappearsinnoacutedistress,thenexpe-riencesaseverecoughingattack,whichleaveshimweakandoutofbreath.Examinationofthehead,eyes,ears,nose,andthroat(HEENT)revealedasmallconjunctivalhemorrhageontheleft,andseveralpetechiaewerenotedontheface.Lungswerecleartoauscultation.Theremainderofthephysicalexaminationwasbenign.Laboratorystudieswereobtained,andthecompletebloodcount(CBC)withdifferentialshowedawhitebloodcell(WBC)countof8,000/ulwithanormaldifferential.Posterior-ante-rior(PA)andlateralchestX-rayswerealsoobtainedandfoundtobenormal.Thephysicianobtainsanasopharyngealaspiratethatwassenttothemicrobiologylab-oratoryforGramstainandculture.Anorganismnottypicalfororal-pharyngealfloraandpresumedtobethecausativepathogengrewonRegan-Loweagarafterovernightincubationat37°C.TheGramstainisshowninthefollowingfigure.Aconfirmatorydirectfluorescentantibody(DFA)stainingoftheorganismisolatedfromtheaspiratewasalsopositive.SEE.WRTsORraFUNEaTAaer«SOF2aRagast$a|osreputeiides,.BEamtate8CsyyTEROS.ARKNto)ARN.4SRE.aCTAerrImagecourtesy:(DC-||

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Questions[|Thephysicianrecommendsa5-daycourseofazithromycin,andthepatient[il]Whichofthefollowingorganismsistakesitappropriately.Hereturnstothethemostlikelycausativeagent?officeaftercompletingthecourseofA.BordetellBytherapycomplainingthathiscoughisordetelapCrisisunchanged.WhichofthefollowingistheB.HaemophilusinfluenzaebestexplanationthatthephysiciancanC.Klebsiellapneumoniaegiveforthelackofresolutionofthecough?D.LegionellapneumophilaA.AzithromycinisnotexpectedtoclearE.Pseudomonasaeruginosathisinfection,butitwasgivenbecausepatientsexpectanantibiotic[|HowwasthisinfectionmostlikelyB.Coinfectionwithasecondorganismisacquired?commoninthisdisease,anditislikelyA.Aerosolpersontopersonthatadministrationofasecondantibi-B.Arthropodbite©iiwarrante...C.tislikelythattheinfectionwasC.Ingestionoffood©3©:resistanttoazithromycin,andtherapyD.IngestionofwaterwillneedtobealteredE.SexualtransmissionD.Thepurposeoftheantibioticwasnottotreatthesymptomsofthe=HForthemostlikelycausativeagent,diseasebuttoreducetransmissionofwhichofthefollowingbestdescribesthetheorganismpathogenicmechanismleadingtotheclin-E.Thestandarddoseofazithromycinwasicalsymptoms?toolowforthispatient'sdisease,andA.ActivationofadenylatecyclasebythedosewillneedtobedoubleddisablingGiB.Cleavageofcirculatingimmunoglobu-linA(IgA)C.Inactivationofthe60SribosomebycleavageofribosomalRNA(rRNA)D.Inactivationofhostelongationfactor2E.PreventionofthereleaseofinhibitoryneurotransmitteraWhichofthefollowingbestdescribesthevaccinecurrentlyavailableforpreven-tionofthisinfection?A.DNAvaccineB.KilledwholecellvaccineC.LiveattenuatedvaccineD.RecombinantvectorvaccineE.Subunitvaccine2_Study.

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Answersand[2GisAllEG).TransmissionofB.pertussisfromperson-Explanationsto-personoccursviaaerosolizedrespiratorydroplets.Therearenoidentifiedanimalor"1.Correct:Bordetellapertussis(A)environmentalreservoirsforthispathogen.Thiscasedescribeswhoopingcough,orHumansarethereservoirforB.pertussis.Bordetellapertussisinfection.B.pertussisTheincubationperiodis7to10daysonisafastidiousgram-negativecoccoba-averagewithamaximumofupto20days.cillusthatprimarilyinfectschildrenandBArthropodbiteisincorrectbecauseper-unvaccinatedsusceptibleindividuals.Thetussisisnotvector-borne.presentationofpertussisisseparatedintoCIngestionoffoodisincorrectbecausethreestages:thecatarrhalphase,whichpertussisisnotfood-borne.appearsasatypicalupperrespiratorytractDIngestionofwaterisincorrectbecauseinfection;theparoxysmalphase,whichpertussisisnotwater-borne.presentswithintensecoughingjagsandESexualtransmissionisincorrectbecausefrequentlytheclassicwhoopingsoundofpertussisisnotsexuallytransmitted.inspirationagainstapartiallyclosedair-way,post-tussiveemesisisoftenseen;andtheconvalescentphase,whichhasachroniccoughthatcanlastforweeks.InThevirulencefactorsproducedbyadults,particularlythosewhowerepre-B.pertussisincludeadherencetociliatedviouslyimmunized,theclassicsymptomsepithelialcellsofthetracheaandbronchisuchascoughingparoxysms,thewhoop-viapiliandfilamentoushemagglutinin,ingsound,andpost-tussiveemesismaynotendotoxin,pertussistoxin,hemolysin,beseen.Thepresenceoftheclassicsymp-adenylatecyclasetoxin,andtrachealcyto-tomstypicallyindicatesanunvaccinatedtoxin.PertussistoxinisanA-B5exotoxinorundervaccinatedindividual.Inchildren,thatissecretedbyatypeIVsecretionsys-ahighWBCcount(often>20,000)isseentemandbindstotheG-alphainhibitorywithalymphocytosisfrequentlyover50%.subunitinhibitingsignaltransduction,SeeingayoungchildwithacoughandresultinginincreasedcyclicadenosinehighWBCwithsignificantlymphocytosismonophosphate(cAMP)andasubsequentisoftenadiagnosticclueforpertussis.Inincreaseinmucusproductionanddeathadults,however,theelevatedWBCisrare,ofthehostcell.Thismechanismofactionandlymphocytosisisgenerallynotseen.ofthepertussistoxinmimicsadenylateBHaemophilusinfluenzaeisincorrectcyclaseactivity.becauseinfectionsdonotpresentwithaBCleavageofcirculatingIgAisincorrect.paroxysmalcough,andH.influenzaeareThecleavageofIgAbybacterialproteases,gram-negativebacilli.suchasinthecaseofH.influenzae,resultsCKlebsiellapneumoniaeisincorrectintheimpairmentofantibody-inducedbecauseinfectionsdonotpresentwithaentrapmentofmicrobesinmucussecretions.paroxysmalcough,andK.pneumoniaeareCInactivationofthe60Sribosomebycleav-gram-negativebacilli.ageofrRNAisincorrect.ThisdescribestheDLegionellapneumophilaisincorrectmechanismofactionofShigatoxin.becausetheyarerarelyabletobevisual-DToxincausinginactivationofhostelon-izedbyGramstain,andinfectionsdonotgationfactor2isincorrect.Thisdescribespresentwithaparoxysmalcough.themechanismofactionofP.aeruginosaEPseudomonasaeruginosaisincorrectexotoxinA.becausetheseinfectionsaremoreoftenEToxinthatpreventsthereleaseofnosocomialorrelatedtocysticfibrosis,inhibitoryneurotransmitterisincorrect.whichthispatientdoesnothave.Also,ThisdescribesthemechanismofactionofP.aeruginosaaregram-negativebacilli.Clostridiumbotulinum.3_Study

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||4.Correct:Subunitvaccine(E)mayshortenthecourseanddecreasethePreventionofinfectionisprimarilybyseverityifgivenearlyinthecatarrhalphase.routinevaccinationofinfants,children,Sincepertussisisrarelydiagnosedduringandadults.Thoughitwasnotmentionedthecatarrhalphase,theadditionofanti-explicitly,thepatientwaslikelyeitherbioticsistoeradicatetheB.pertussisfromunvaccinatedorundervaccinated.Appro-thenasopharynxtoreducethespreadofpriatevaccinationmayhaveprotectedhimtheinfection(particularlyinthiscaseasfrominfection.Thediphtheria,tetanus,andthispatientliveswithachildathomeandpertussis(DTap)vaccineinfullstrengthisworksnapopulatedenvironment).Thegiventoinfantsandchildren,whiletheantibioticofchoiceisazithromycin(duereduceddosetetanus-diphtheria-pertus-todosingschedule,bioavailability,andsis(Tdap)vaccineisofferedtoteensandlowsideeffectprofile).Alternativeantibi-adults.Thecurrentvaccineforpertussisisoticsincludeclarithromycin,erythromy-anacellularsubunitvaccine,consistingofcn,andforpatientsolderthan2monthsinactivatedpertussistoxin+filamentousintolerantofmacrolides,trimethoprim-hemagglutinin(FHA),fimbriae,andpert-sulfamethoxazole(TMP-SMX)isarea-actin(adhesin).Thecurrentvaccinedoessonablealternative.TMP-SMXshouldbenotgivelifelongimmunity,andboostinginavoidedinchildrenyoungerthan2monthsadultsisrecommendedbytheCentersforduetoriskforkernicterus.AzithromycinDiseaseControlandPrevention(CDC)toanderythromycinarebothassociatedwithhelppreventtransmissiontochildren.anincreasedriskofinfantilehypertrophicADNAvaccineisincorrect.Thepertussispyloricstenosis,anditisunclearifsuchavaccineisasubunitvaccine.Thereareno.riskexistsforclarithromycin.Neitherazi-DNAvaccinesapprovedforuseinhumansthromycinnorclarithromycinisapprovedatpresent.bytheFoodandDrugAdministration(FDA)BKilledwholecellvaccineisincorrect.Theforuseinchildrenyoungerthan6months.pertussisvaccineisasubunitvaccine.AnMacrolideRt1sveryuncommon,exampleofakilledwholecellvaccineisandantibiotictestingisgenerallynotthepreviouspertussisvaccine,whichisnoperformed.CLlongerusedintheUnitedStates.AAzithromycinisnotexpectedtoclearCLiveattenuatedvaccineisincorrect.Thethisinfection,butitwasgivenbecausepertussisvaccineisasubunitvaccine.patientsexpectanantibiotic.Thisisincor-ExampleofaliveattenuatedvaccineisrectbecauseitisnevercorrecttogiveantheMMR,nasalinfluenza,andchickenpoxantibioticjustbecauseapatientwantsit.(varicella).BCoinfectionwithasecondorganismisDRecombinantvectorvaccineisincorrect.commoninthisdisease,anditislikelythatThepertussisvaccineisasubunitvaccine.administrationofasecondantibioticisTherearenorecombinantvectorvaccineswarranted,Thisisincorrectbecausecain-approvedforuseinhumansatpresent.fectionwithasecondorganismisnotcom-moninthisdisease.Cltislikelythattheinfectionwasresistanttoazithromycin,andtherapywillneedtobealtered.Thisisincorrectbecauseazi-thromycinresistanceisnotcommonlydescribedinpertussis.Treatmentofpertussisisgenerallysup-ETheandardoseofazithromycinwastooBoeparticularyinLoViechidren.lowforthispatient'sdiseaseandthedoseoughsuppressants:havelittleimpact.willneedtobedoubled.ThisisincorrectHSEesEebecauseastandarddoseisallthatisneeded.4.||

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AdditionalDiagnosticand8weeksbutupto12weeksfollowing.theonsetofcough.Nasopharyngealspec-InformationimenscollectedbyDacronswabmustbeDiagnosisofB.pertussisinfectionisbyna-obtainedfromtherespiratoryepitheliumonoobandcultRevoftheposteriornasopharynxwherebac-Tope.tnoroeoerterialevelswillbegreater.Nasopharyngealwithinthefirst2oeoocoughing,oraspiratesifavailableprovidethebestspec-ithiughing,:Ndirectfluorescenceantibodydetectionmenforbacterialrecovery:respiratory(againearlyininfectionwhenlargernum-pathogenscanoccurandmaycompli-bersofviablebacteriaarestilpresent)catedifferentialdiagnosis,particularlyin(PCR)testingJoniconductedupto4adults.Infectioninpreviouslyvaccinated‘weeksaftertheonsetofcough.Serologicalorundervaccnated2dotscanleadtoatyp-testingusingthecomplement-dependentica)presentationhoessenparaxys-cytotoxicity(CDC)assayisusefulfordiag-malsymptomsleadingtomisdiagnosis.nosislaterininfectionusuallybetween2Keywords:Pertussis,whoopingcough,Bordetellapertussis,Regan-Lowe,subunitvaccine,nasopharyngeal,azithromycin5_Study.

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