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Category: Critical Care Medicine-Infections and Immunologic Disease--->Immune Suppression: Congenital, Acquired, Drugs
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Question 1# Print Question

A 52-year-old woman diagnosed with granulomatosis with polyangiitis (Wegener’s) 3 months ago and treated with cyclophosphamide and prednisone (40 mg daily) presents to ED due to shortness of breath and dry cough. Last time she noted bloodtinged sputum was more than 2 months ago. Her vitals on arrival are notable for temperature of 39.2°C, heart rate 110 beats/min, blood pressure 104/54, respiratory rate 25 breaths/min, and oxygen saturation 86% on room air. Chest x-ray reveals bilateral infiltrates and cystic-appearing round opacities (fig below):

She is placed on high flow nasal cannula at 55 L/min and FiO2 of 0.8, but her respiratory distress continues to worsen, and she requires endotracheal intubation. Her labs are notable for Arterial blood gas:

  • pH 7.48
  • pCO2 23
  • pO2 58 (before intubation)

Lactate dehydrogenase (LDH): 664 (normal: 110-210 U/L)

Which of the following treatment regimens would MOST likely improve her condition?

A. Ceftriaxone and azithromycin
B. Trimethoprim/sulfamethoxazole
C. Oseltamivir
D. Isoniazid

Question 2# Print Question

A 34-year-old male with recently diagnosed Hodgkin lymphoma is admitted to the hospital for induction chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine. On day 7 of the induction, he develops fever as high as 38.4°C and rigors. His blood pressure is 80/52 mm Hg, heart rate is 110 beats/min, respiratory rate is 22 breaths/min, and his oxygen saturation is 92% on 4 L O2 via nasal canula. He is given 2 L of lactated Ringer’s after which his blood pressure improves to 98/64. Internal jugular central line site is examined, and no erythema or purulence at the site of insertion is noted. Labs are notable for:

  • pancytopenia with a white blood cell count of 0.2 K/µL with 0% neutrophils
  • hemoglobin of 7.1 g/dL
  • platelets of 24 K/µL
  • lactate of 2.8 mmol/L

Which of the following interventions is MOST likely to decrease this patient’s mortality?

A. Vancomycin and cefepime
B. Neutropenic precautions
C. Granulocyte colony-stimulating factor (filgrastim)
D. Removal of central line

Question 3# Print Question

A 53-year-old man with celiac disease is admitted to hospital from primary physician’s office for a workup of weakness and anemia. His hemoglobin is 6.0 g/dL and is suspected to be a result of a slow GI bleed. His vitals are notable for:

  • heart rate of 100 beats/min
  • blood pressure of 92/50 mm Hg
  • oxygen saturation of 96% on room air

Two units of cross-matched packed red blood cells are ordered. Ten minutes into the blood transfusion, patient becomes febrile (38.6°C), but other vitals remain unchanged. Transfusion is continued. Fifteen minutes later the patient develops worsening hypotension to 75/40 mm Hg, urticarial rash, and wheezing. 

Which of the following is the MOST likely etiology of the patient’s decompensation?

A. Bacterial contamination of blood product
B. Hemolytic transfusion reaction related to ABO incompatibility
C. IgA deficiency with exposure to Immunoglobulin A (IgA) in the blood product
D. Worsening GI bleed

Question 4# Print Question

A 52-year-old male with history of end-stage renal disease on hemodialysis is recovering in PACU following deceased donor renal transplant. He is receiving infusion of rabbit antithymocyte globulin (ATG) which was started intraoperatively. On a regular nursing check, he is found to have fever of 38.5°C. His heart rate is 90 beats/min, blood pressure is 110/60 mm Hg (baseline 150/80 mm Hg), CVP is 8, and oxygen saturation is 98% on room air. He is anuric. He has no specific complaints, and his surgical site appears normal.

Which of the following is the next BEST step in management of his condition?

A. Decrease ATG infusion rate, obtain cultures, CBC
B. Start infusion of phenylephrine
C. Administer 2 L of lactated Ringer’s
D. Administer 1 U of PRBCs

Question 5# Print Question

A 62-year-old man with refractory non-Hodgkin lymphoma is admitted to hospital for infusion of chimeric antigen receptor T cells (CAR T). On day 3 following the infusion of CAR T cells, he becomes febrile to 38.9°C, hypotensive, and somnolent. Neurological examination is nonfocal. His blood pressure remains 75/40 mm Hg despite quick administration of 2 L lactated Ringer’s, and he is transferred to the ICU for further management. The infusion of norepinephrine is initiated. He now requires 6 L/min O2 via nasal cannula to maintain oxygen saturation >90%.

Which of the following is the next BEST step in management?

A. Administration of tocilizumab while ruling out infection
B. Immediate administration of empiric vancomycin and cefepime
C. Fluid and vasopressor management to support hemodynamics while cytokine release syndrome resolves
D. IV hydrocortisone

Category: Critical Care Medicine-Infections and Immunologic Disease--->Immune Suppression: Congenital, Acquired, Drugs
Page: 1 of 2