Spookster831

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Hey,

I have a sample exam question I am trying to answer... I think I know the answer but I'd just like to have a second opinion if anyone minds?

A 60 year old English man
- abdominal pain and abdominal tenderness.
- bloody diarrhea
- heart transplantation 2 years ago.
- past medical history included coronary artery disease, hypertension, deep venous thrombosis.
He is on cyclosporin and dexamethasone.
Exam - temp of 38 degrees C
- abdomen the doctor finds that it is rigid and tender
- X-Ray shows that there is free air under the diaphragm and distended loops of - Diagnosis of perforation - colostomy and tissue has numerous multi nucleated giant cells


a. acute HIV
b. aspergillus fumigatus
c. candida albicans
d. coagulase neg staph
e. cryptococcus neoformans
f. cryptosporidium parvum
g. cytomegalovirus
h. EBV
i. Giardia Iamblia
j. HHV 6
k. HHV 8
l. Legionalle pneumophilia
m. mucor species
n. mycobacteria tuberculosis
o. mycobacterium avium intracellularae
p. PCP
q. toxoplasma gondii

thanks!
 
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phospho

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Hey,

I have a sample exam question I am trying to answer... I think I know the answer but I'd just like to have a second opinion if anyone minds?

A 60 year old English man presents to his family doctor with increasing abdominal pain and abdominal tenderness. For the past couple of weeks he has had diarrhoea on and off which has occasionally been bloody. His past medical history included a heart transplantation 2 years ago. Other past medical history included coronary artery disease, hypertension, deep venous thrombosis. Meds include cyclosporin and dexamethasone. All meds were taken orally. On examination the patient has a temp of 38 degrees C and on examination of the abdomen the doctor finds that it is rigid and tender and he sends them to the A and E. An abdominal X-Ray taken in A and E shows that there is free air under the diaphragm and distended loops of bowel. A Diagnosis of perforation is made. The man is taken into surgery where a temporary colostomy is made and an area of inflamed colon is removed. On histological examination of the tissue numerous multi nucleated giant cells are seen.

a. acute HIV
b. aspergillus fumigatus
c. candida albicans
d. coagulase neg staph
e. cryptococcus neoformans
f. cryptosporidium parvum
g. cytomegalovirus
h. EBV
i. Giardia Iamblia
j. HHV 6
k. HHV 8
l. Legionalle pneumophilia
m. mucor species
n. mycobacteria tuberculosis
o. mycobacterium avium intracellularae
p. PCP
q. toxoplasma gondii

thanks!
Just a premed, but I'm gonna try doing this. I'll use google also.:laugh:

Multinucleated giant cells are associated with granulomas arising from immunological and nonimmunological inflammatory reactions. They are an integral part of the host immune response to chronic infectious diseases.


adverse rxns of cyclosporin can include gum hyperplasia, convulsions, peptic ulcers, pancreatitis, fever, vomiting, diarrhea, confusion, breathing difficulties

adverse rxns of dexamethasone are Stomach upset, increased sensitivity to stomach acid to the point of ulceration of esophagus, stomach, and duodenum. Also, Immunsuppressant action, particularly if given together with other immunosuppressants such as ciclosporine. Bacterial, viral, and fungal disease may progress more easily and can become life-threatening. Fever as a warning symptom is often suppressed.

okay, this isn't working....i just realized that the only answer option I've ever heard of is A...:D
 
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IHeartNerds

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CMV. Classic for patients on immunos s/p transplant. Most of the others don't make sense for a GI infection; of those that do, most are bacterial and would not cause giant cell formation. The other common agent, at least in HIV patients (dunno about s/p transplant), is MAC, but I don't know of it causing perforation or giant cells, rather there would be foamy macrophages.
 

Spookster831

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Thanks, I was thinking that but for some reason I also had it in my head it might be MAI (even though there wasn't much basis lol)
 

LadyWolverine

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The other common agent, at least in HIV patients (dunno about s/p transplant), is MAC, but I don't know of it causing perforation or giant cells, rather there would be foamy macrophages.
This is the other one that I got hung up on as well. I think MTB can actually infect the colon, too, although I'm not sure how often that really happens. And I thought you could see giant cells with MAC? I'm afraid that my path has gotten a little rusty.
 

Spookster831

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This is the other one that I got hung up on as well. I think MTB can actually infect the colon, too, although I'm not sure how often that really happens. And I thought you could see giant cells with MAC? I'm afraid that my path has gotten a little rusty.
Yeah I think you can.
 

IHeartNerds

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This is the other one that I got hung up on as well. I think MTB can actually infect the colon, too, although I'm not sure how often that really happens. And I thought you could see giant cells with MAC? I'm afraid that my path has gotten a little rusty.
MTB can infect the colon, at least according to RR Path. Not sure on how common that is either. MAC/MAI has no association with multinucleated giant cells that I'm aware of, although the macrophages can get pretty big.
 

njbmd

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I believe the key to answering this question is the presence of multinucleated giant cells. MAC can coexist with CMV (and crytosporidium) especially in the gut of the immunosuppressed patient. CMV can cause ulceration/perforation but has the inclusion body cells (Owl eyes). The only guy on that list that makes sense is MAC which does produce multinucleated giant cells (chronic inflammatory reaction). MTB causes caseous granulomas so it isn't a good candidate here. My guess from my rusty path (and transplant surgery rotation as an intern ) is MAC.
 

IHeartNerds

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for what it's worth, "transplant infections" which is a text we have online access to puts CMV at the top of the differential for a transplant patient with perforative colitis.
 

Flopotomist

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Interesting question.. my first pick was CMV, but then I don't recall that being assoc with the multinucleated giant cells. My second choice would be TB as that sounds vaguely familiar... what is the answer?
 

PeepshowJohnny

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Agreed. If you follow the classic "Read the last line first" you'll get this in half the time.
 
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