132)

Rifampin is an antibiotic effective against many Gram-positive and Gram-negative bacteria. Which of the following would be an indication for rifampin monotherapy? A) Tuberculosis caused by susceptible bacteria B) Atypical mycobacterial infection C) Penicillin-resistant pneumococcal meningitis D) Staphylococcal endocarditis E) Meningococcal exposure Rifampin is a DNA dependent RNA polymerase used for mycobacterium infection, delays resistance to dapsone when used for leprosy, meningococcal prophylaxis, and chemoprophylaxis for children in contact with H. influenza type B. 133) A chemotherapeutic compound that is structurally similar to pyridoxine has been shown to inhibit the saturation of long, branched lipids within some bacterial cells. This compound is most likely to inhibit the growth of: A) Streptococcus B) Legionella C) Mycobacterium D) Treponema E) Mycoplasma Isoniazid is really similar to pyridoxine that is depleted during mycobacterium treatment. It inhibits the synthesis of mycolic acids, long branched fatty acids, in the cell wall. 134) Isolates of M. tuberculosis obtained from a 23 year old HIV positive male show significantly decreased activity of intracellular catalase-peroxidase. The isolates would most likely grow in the presence of: A) Isoniazid B) Rifampin C) Ethambutol D) Streptomycin E) Pyrazinamide Isoniazid is a prodrug requiring conversion to an active metabolite by mycobacterium catalase. This is also how resistance builds up against the drug deletions in the katG gene which encodes catalase needed for INH activation. 135) A 32 year old female is being treated with antibiotics for complicated cellulitis of the right foot. One week after starting treatment, she develops mild fever, nausea, and skin rash. Laboratory studies show elevated blood urea nitrogen and creatinine levels as well as eosinophilia. Which of the following medications is she receiving? A) Nafcillin B) Gentamicin C) Vancomycin D) Clindamycin E) Erythromycin Cellulitis is an acute, painful spreading infection of the dermis and subcutaneous tissue commonly caused by S aureus or S pyogenes. S pyogenes can be treated by Penicillin whereas S aureus is resistance to Penicillin must be treated with a least Nafcillin. If NRSA, then it should be treated with Vancomycin. Methicillin and other penicillin derivatives are known to cause hypersensitivity reactions hence the eosinophilia and drug induced interstitial nephritis which explains the fever, rash, and nausea.

136) After a positive PPD test, a 64 year old male begins isoniazid therapy. One month later he presents complaining of fever, anorexia, and nausea. What is the most likely cause of his symptoms? A) Peripheral nerve damage B) Hepatocyte damage C) Gastric mucosal damage D) Serum sickness E) Factitious disorder Isoniazid is known for its neuro- and heptatoxicity side effects. It increases ALT, AST, and bilirubin and known to produce fever, anorexia, and nausea. If Vit B6 is taken, it can prevent neurotoxicity but the symptoms seen would not be caused by peripheral nerve damage. 137) A 12 year old male is hospitalized with headache, nausea, and fever. A physical examination is significant for neck stiffness. Gram-negative cocci in pairs are revealed during CSF microscopy. Which of the following is the best way to prevent infection in his close contacts? A) Capsular polysaccharide vaccine B) Pilus protein vaccine C) Lipopolysaccharide vaccine D) Penicillin E) Sulfamethoxazole F) Rifampin Rifampin is a DNA dependent RNA polymerase used for mycobacterium infection, delays resistance to dapsone when used for leprosy, meningococcal prophylaxis, and chemoprophylaxis for children in contact with H. influenza type B. 138) A 32 year old HIV-positive male is diagnosed with pulmonary tuberculosis and started on four-drug combination therapy. Several days later, he presents complaining of red urine and red staining of his contact lenses. His sputum isolates of M. tuberculosis are resistant to several chemotherapeutic drugs. Which of the following best explains the bacterial resistance to the drug that is responsible for this patients complaints? A) Upregulation of beta-lactamase synthesis B) Decreased activity of bacterial catalase-peroxidase C) Altered structure of bacterial ribosomal proteins D) Altered structure of enzymes involved in DNA winding-unwinding E) Altered structure of enzymes involved in RNA synthesis Rifampin causes red orange bodily fluids which is non-toxic. Rifampin is a DNA dependent RNA polymerase. Resistance of tuberculosis occurs by altering the structure of enzymes involving in RNA synthesis. 139) A 21 year old female presents to your office with dysuria and burning on urination. Trimethoprim given to the patient leads to rapid resolution of symptoms. Which of the following drugs has the same intracellular target as the drug used in this patient? A) Sulfamethoxazole B) Metronidazole C) Imipenem D) Bacitracin E) Methotrexate Methotrexate, trimethorpim, and pryimethamine are dihydrofolate redutcatase inhibitors used for treatment of simple UTIs. Sulfamethoxazole inhibits dihydropteroate synthetase.

140) A 45 year old male is diagnosed with pulmonary tuberculosis. Acid-fast bacterial isolates obtained from this patient are resistant to some antimycobacterial drugs. Adding ethambutol to this patients regimen would most likely require periodic testing of: A) Visual acuity B) Hepatic function C) Hearing and vestibular function D) Complete blood count E) Renal function Ethambutol decreases carbohydrate polymerization of mycobacterium cell wall by blocking arabinosyltransferase. Toxicitiy is red green color blindless (optic neuropathy). It would require often visual acuity tests. 141) A 45 year old male treated for pulmonary tuberculosis experiences decreased visual acuity in both eyes. After one of the drugs is eliminated from his treatment regimen, his vision gradually improves. The withdrawn drug most likely affects bacterial: A) Mycolic acid synthesis B) Carbohydrate polymerization C) DNA winding-unwinding D) RNA synthesis E) Folic acid utilization This sounds like Ethambutol which decreases carbohydrate polymerization of mycobacterium cell wall. 142) A 21 year old female is taking medication for a recently diagnosed medical problem. While at a college party, she develops facial flushing, headache, nausea, vomiting, and abdominal cramps immediately after having an alcoholic drink. This patient is most likely being treated for which of the following conditions? A) Chlamydial urethritis B) Candida vaginitis C) Hypothyroidism D) Pharyngitis E) Menstrual cramps F) Trichomonas vaginitis Cephalosporins and metronidazole are drugs known with disulfiram-like reaction with alcohol. Since metronidazole is the only one that treats Trichomonas infections, it would have to be the culprit. 143) A 43 year old Caucasian male undergoing treatment for invasive aspergillosis with amphotericin B experiences headaches, hypotension and a decline in renal function. Many of amphotericin Bs toxic effects are due to its binding of: A) Cytochrome P450 enzymes B) Cell membrane cholesterol C) Microtubular proteins D) Ribosomal subunits E) Mitochondrial enzymes Amphotericin tears holes in the fungal membrane causing leakage of electrolytes. It is from this that the toxicity occurs. 144) A 31 year old male farm worker comes to the physician complaining of an itchy rash on his chest. Physical examination reveals an annular and scaling plaque five centimeters in diameter with central clearing on the chest. KOH

preparation of skin scrapings shows branching septate hyphae, and topical application of terbinafine was prescribed. Which of the following mechanisms of action explains the antifungal activity of the drug? A) Binds to ergosterol B) Inhibition of squalene epoxidase C) Blocking beta-D-glucan synthesis D) Preventing mitosis by binding tubulin E) Inhibition of fungal protein synthesis Terbinafine inhibits squalene -> lanosterol. Azole inhibits lanosterol -> ergosterol. 145) A new medication inhibits fungal colony growth by altering the fungal cell membrane composition. In human volunteers, the drug inhibits liver cytochrome P450-dependent metabolism of several drugs. This new drug is most similar to which of the following? A) Amphotericin B B) Itraconazole C) Terbinafine D) Griseofulvin E) Capsofungin F) Flucytosine Azoles like Itraconazole inhibit P450 whereas Griseofulvin increase their production. 146) In the experimental setting, certain microorganisms have demonstrated treatment resistance by decreasing ergosterol incorporation into the cell membrane. These organisms would most likely be resistant to which of the following agents? A) Penicillin B) Flucytosine C) Griseofulvin D) Nystatin E) Capsofungin F) Cyclosporine The only drug listed that acts on the cell membrane here is Nystatin. It works on the same principal as Amphotericin binds ergosterol and forms membrane pores but is the topical form of Amphotericin. The others work by a different mechanism altogether. 147) A 43 year old male with advanced HIV infection is admitted for impaired vision. On the third day of hospitalization, he develops generalized seizures and is found to be hypocalcemic and hypomagnesemic. Which of the following drugs is most likely responsible for the observed effects? A) Acyclovir B) Ganciclovir C) Foscarnet D) Indinavir E) Lamivudine Foscarnet is used for CMV retinitis in immunocompromised patients when ganciclovir fails. Side effects include nephrotoxicity.

148) A 78 year old nursing home resident develops fever and myalgias and is treated with oseltamivir. Which of the following is most likely impaired in the patients infected cells as a result of the treatment? A) Viral uncoating B) Foreign protein synthesis C) Foreign protein splitting D) Viral RNA replication E) Virion particle release Oseltamivir inhibits influenza neuraminidase decreasing the release of the virus. Amantadine would be viral uncoating. 149) A 32 year old male with advanced HIV infection receives zidovudine therapy. Intracellular synthesis of viral DNA decreases precipitously once the treatment is initiated. Zidovudine inhibits which of the following components of viral genome replication? A) Nucleotide phosphorylation B) Folate dependent uracil methylation C) 5 3 phosphodiester linkage formation D) Proper base pairing and hydrogen bond formation NTRI Zidovudine works by competitively inhibiting nucleotide bonding to reverse transcriptase thereby terminating the DNA chain which lacks a 3-OH group. It must be phosphorylated by thymidine kinase to be active, not inhibited. It has nothing to do with folate methylation or proper base pairing as long as it is integrated into the DNA chain. 150) A 43 year old HIV-positive male presents to the ED complaining of progressive vision impairment. He was previously placed on antiretroviral therapy but has been noncompliant with prescribed medications. His last CD4+ cell count was 47/mcL. Ophthalmoscopy reveals the following:

Which of the following medications is the best initial therapy for this patient? A) Pentamidine B) Clarithromycin C) Acyclovir D) Ganciclovir E) Flucytosine F) Interferon-alpha The most common cause of retinitis in immunodeficiency patients such as this one would be CMV. CMV spreads to the eye and results in retinal necrosis and edema. It is commonly treated by Ganciclovir or Foscarnet when Gangciclovir fails.

151) The infected lymphocytes of a 25 year old male treated with Drug A are unable to synthesize viral DNA from the RNA template. Drug A is not phosphorylated intracellularly and is structurally unrelated to nucleosides. Drug A is most similar to which of the following agents? A) Zidovudine B) Zalcitabine C) Ritonavir D) Nevirapine E) Enfurvitide Nevirapine is an NNRTI that, unlike NTRIs, does not require activation by phosphorylation. Reverse transcriptases prevent synthesis of viral DNA from RNA template. 152) A 34 year old male with advanced HIV infection is hospitalized with a vesicular skin rash suggestive of varicella zoster virus infection. Viral strains isolated from this patient lack phosphosylating enzymes. Which of the following drugs is most likely to be effective in treating this patients infection? A) Acyclovir B) Ganciclovir C) Valacyclovir D) Famciclovir E) Cidofovir The 2 types of treatment for VZV in this scenario would be acyclovir and cidofovir. Since acyclovir works by phosphorylation by viral thymidine kinase and Cidofovir doesnt, it is easily to conclude that the current drug is Cidofovir. 153) A 23 year old male hospitalized for confusion and seizures is treated with IV high-dose acyclovir. On the third day of hospitalization, his serum creatinine level increases to 3.4 mg/dL from a baseline of 0.9 mg/dL at admission. The observed finding could have been potentially prevented by which of the following? A) Careful allergy history taking B) Monitoring the blood drug levels C) Pre-treatment with allopurinol D) Pre-treatment with prednisone E) Aggressive intravenous hydration Elevation of creatinine suggests nephrotoxicity, one of the side effects of acyclovir when its concentration exceeds its solubility. Thus the proper management would be to ensure adequate hydration. 154) A new antiviral agent is shown to selectively bind to HIV gp41. This antiviral agent is most likely to inhibit which of the following? A) Viral attachment to target cells B) Viral penetration into target cells C) Viral DNA synthesis from RNA template D) Viral polyprotein cleavage E) Viral DNA integration into the host genome Gp41 is a fusion inhibitor which inhibits the fusion of the virus to the target CD4 cells blocking entry and thus replication.