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USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


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  #1  
Old 10-20-2011
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Default Cardiology

A 50-year-old patient with COPD is in the intensive care unit (ICU) recovering from an acute exacerbation of chronic bronchitis that required intubation and intravenous steroids. He improves gradually and is weaned from mechanical ventilation by day three of his intensive care unit stay, though he continues to have low-grade fever. On day 4, however, the medical student assigned to his case finds that the patient has a cool, pulseless left leg on morning rounds. The lack of pulses is confirmed by Doppler study, and vascular surgery is consulted. The patient is brought immediately to the operating room and an emergent thrombectomy of the left femoral artery is performed. Histopathologic examination of the thrombectomy specimen shows hyphae, pseudohyphae, and yeast forms. Blood cultures, drawn from the evening before and the day of the surgery, grow similar organisms, consistent with Candida species. Bacterial blood cultures are negative. A bedside transesophageal echocardiogram is performed that shows a 2-cm vegetation on the aortic valve. Amphotericin B therapy is initiated. Which of the following is an additional appropriate therapy for this patientís presumed endocarditis?
A. Ampicillin and gentamicin
B. No additional therapy, 6-8 weeks of amphotericin
C. Oral ketoconazole
D. Surgery
E. Vancomycin
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  #2  
Old 10-20-2011
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My first thought was HACEK which would then answer ceftriaxone but once i ddint see that in the answers i rethought about fungal and remembered fugal infections as a whole are usually very bad in that they need more agressive treatment and in the case of endocarditus its amphoteracine and valve replacement
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Old 10-20-2011
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i will go with surgery??
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  #4  
Old 10-20-2011
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Default Answer

The correct answer is D. This patient has a fungal endocarditis, one of the most severe manifestations of candidemia. Although fungal endocarditis is rare, it is associated with a high mortality rate and demands aggressive treatment. Fungal infections are more common among ICU patients (because of line infections) and among immunosuppressed patients (e.g., those using steroids, patients with HIV, postchemotherapy or transplant patients). Fungal valve infections, because of the aggressiveness of the organism and the inherent resistance of fungal vegetations to treatment, are an indication for valve removal.
Isolated medical management with 6-8 weeks of amphotericin B (choice B) is not an adequate treatment.
Ampicillin and gentamicin (choice A) are used for enterococcal endocarditis and are not indicated for treatment of fungal infections. Likewise, vancomycin (choice E) is used for penicillin-resistant organisms. Neither should be used empirically if there are negative blood cultures.
Ketoconazole (choice C) is one of the first antifungals and is generally considered the weakest of the azoles. Itraconazole or fluconazole can be used suppressively after surgery. Ketoconazole generally is used only for mucocutaneous candidal infections or dermatophyte infections
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