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Category: Critical Care Medicine-Pulmonary Disorders--->Pulmonary Infections
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Question 6#Print Question

A 38-year-old man with human immunodeficiency virus (HIV) and a CD4+ count of 100 cells/µL is admitted to the ICU with respiratory failure from the medical ward. He reports 1 week of progressive dyspnea on exertion and chills. He had been treated with vancomycin and meropenem since his arrival to the ED 1 day ago. He is intubated and mechanically ventilated on volume controlassist control, tidal volume 6 mL/kg ideal body weight, respiratory rate 18/min, FiO2 0.7, and PEEP 8 cm H2O. His initial vital signs are:

  • T 38.5°C
  • BP 110/75 mm Hg
  • HR 85 beats per minute
  • SpO2 94%

Initial laboratory data are remarkable for a (1,3)-beta-d-glucan >200 pg/mL and LDH 100 U/L. On day 1 of his ICU stay, a bronchoscopy with bronchoalveolar lavage is performed and the Pneumocystis examination is negative.

Which of the following can result in an elevated 1-3 beta-d-glucan blood test in this patient?

A. Treatment with meropenem
B. Cryptococcus neoformans
C. Blastomyces dermatitidis
D. Treatment with vancomycin
E. Mucormycosis


Question 7#Print Question

A 58-year-old man with idiopathic pulmonary fibrosis is admitted to the ICU with an acute exacerbation of interstitial lung disease. He reports 4 days of worsening dyspnea and dry cough, without fevers, chills, night sweats, or other associated symptoms. His examination is notable for diffuse crackles throughout inspiration. He reports that he is originally from India and moved to the United States 20 years ago, where he has lived since. He is placed on high-flow nasal cannula with FiO2 0.5 and flow of 40 L/min. Methylprednisolone 50 mg daily is administered, along with vancomycin, ceftriaxone, and azithromycin. A chest CT reveals basilar predominant honeycombing with new superimposed multifocal ground glass opacities, along with new scattered right upper and middle lobe centrilobular nodules compared with CT scan 1 year prior. A sputum culture is obtained and sent for bacterial, fungal, and mycobacterial cultures along with acid-fast bacilli (AFB) stain. The sputum is found to have 2+ AFB. A nucleic acid amplification test (NAAT) for tuberculosis (TB) is negative. A repeat sputum sample is collected and again results with 2+ AFB and negative TB NAAT with no presence of NAAT inhibitors detected by the laboratory.

What is the best next step and interpretation of this finding?

A. Obtain past records of Bacille Calmette-Guérin (BCG) vaccination as this may cause a false-negative TB PCR
B. Order an interferon gamma release assay test to confirm TB infection
C. Await cultures, findings indicate nontuberculous mycobacterial infection
D. Await cultures, findings indicate latent tuberculosis infection
E. Await cultures and start antimicrobial therapy for tuberculosis


Question 8#Print Question

A 75-year-old woman is admitted to the ICU after coronary artery bypass graft complicated by cardiogenic shock. She is improving on ICU day 4, and her ventilator settings are pressure support 10 cm H2O, PEEP 8 cm H2O, and FiO2 0.4. She is noted later that day to have increased frequency of thick secretions requiring suctioning through her endotracheal tube and develops a new fever at 39°C. Over the course of the evening, she experiences frequent oxygen desaturation, requiring an increase in her FiO2 to 0.6. A chest radiograph reveals a new opacity in the right lower lung field, and she is started on vancomycin and levofloxacin. Sputum culture grows Acinetobacter baumannii after 48 hours without other organisms identified over the next 24 hours.

What is the BEST next step in her management?

A. Continue levofloxacin, discontinue vancomycin
B. Discontinue vancomycin and levofloxacin, start meropenem
C. Discontinue vancomycin, add ceftriaxone to levofloxacin
D. Discontinue vancomycin and levofloxacin, start linezolid
E. Continue vancomycin and levofloxacin


Question 9#Print Question

A 75-year-old man with hypertension, mild Alzheimer disease marked by occasional short-term memory difficulties, and a past history of squamous cell carcinoma of the tongue with prior surgical resection and radiation to the neck presents from his assisted living facility with productive cough and shortness of breath. The assisted living facility staff reports that he is routinely noted to be coughing while eating meals, and his dyspnea and cough began while eating yesterday. His medications include hydrochlorothiazide and amlodipine. In the ED, his vital signs are:

  • T 37.8°C
  • BP 110/70 mm Hg
  • HR 90 beats per minute
  • respiratory rate 20/min
  • SpO2 88% on ambient air

A CT scan of his chest reveals patchy bibasilar ground glass opacities and tree-in-bud opacities. Supplemental oxygen is provided via a venturi mask at FiO2 0.5 and admitted to the ICU.

Which of the following is most accurate concerning this patient’s pneumonia?

A. This patient has a healthcare-associated pneumonia (HCAP) and should receive appropriate broad spectrum antibiotics
B. Placement of a gastrostomy tube for future nutrition will reduce his risk of recurrent pneumonia
C. The patient’s Alzheimer disease is a significant risk factor for future pneumonia
D. Empiric antibiotics do not have to include anaerobic coverage


Question 10#Print Question

A 54-year-old woman develops fevers and cough on the final day of her vacation on a cruise ship in the Caribbean. She returns to her home in Florida, and over the following 3 days, she has continued fevers, productive cough, and new dyspnea on exertion. She presents to the ED and her vitals at that time are:

  • T 39°C
  • BP 110/80 mm Hg
  • HR 95 beats per minute
  • respiratory rate 21 breaths per minute
  • SpO2 85% breathing ambient air

Her chest radiograph demonstrates multifocal patchy opacities and increased interstitial markings throughout all lung fields. Ceftriaxone and azithromycin are administered, along with 2 L of lactated ringers solution intravenously and her urinary Legionella antigen subsequently returns positive. She is admitted to the ICU on highflow nasal cannula at FiO2 0.7 and flow 50 L per minute.

Which of the following statements is most accurate regarding Legionella pneumonia? 

A. Legionella pneumophila urine antigen is highly sensitive for both serogroups 1 and 2
B. Most recognized Legionella outbreaks occur in hotels, cruise ships, and healthcare facilities
C. Legionella culture from sputum has a sensitivity of greater than 95%
D. If Legionella does not grow from sputum culture quickly (<48 hours), it is unlikely to be the pathogen in question
E. Legionella is less likely to cause severe pneumonia than other atypical pneumonia pathogens




Category: Critical Care Medicine-Pulmonary Disorders--->Pulmonary Infections
Page: 2 of 2