Q 1:
During your morning nursery rounds, you find you have a new patient who was born to a mother
infected with human immunodeficiency virus (HIV). You introduce yourself to the mother, and
she asks you about any precautions she needs to take in the care of her newborn due to her
HIV infection.
Of the following, you are MOST likely to tell the mother that she should
A. add a teaspoon of liquid bleach to the infant’s bath water
B. avoid breastfeeding
C. avoid sharing eating utensils
D. take no specific action
E. wear gloves while changing diapers
Answer
B
Answer
B
The risk of transmission of human immunodeficiency virus (HIV) to an infant from an infected
mother without interventions is approximately 15% to 25%. Breastfeeding by an infected mother
increases the risk by 5% to 20% to a total of approximately 20% to 45%. Therefore, in countries
where safe alternatives to breastfeeding are readily acceptable, feasible, available, affordable,
and sustainable, avoidance of all breastfeeding by HIV infected mothers is recommended. In
countries where there are no safe alternatives to breastfeeding, the World Health Organization
supports exclusive breastfeeding for the first 6 postnatal months due to the higher death rates
for children who receive formula.
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Q 2:
A woman who has chorioamnionitis and had a positive group B streptococcal (GBS) screening
culture at 36 weeks’ gestation delivers an infant at term. The infant becomes ill in the first 4
hours after birth, demonstrating tachypnea, inability to maintain temperature, and poor perfusion.
He is admitted to the intensive care nursery. On physical examination, there are retractions of
the chest wall, coarse and shallow breath sounds, and delayed capillary refill. There is no heart
murmur or cyanosis, but arterial oxygen saturation determined by pulse oximetry is only 80% on
room air.
Of the following, the clinical manifestation that is observed MORE often in early-onset than lateonset
GBS infection is
A. cellulitis
B. meningitis
C. osteomyelitis
D. pneumonia
E. septic arthritis
Answer
D
Early-onset GBS typically presents in the first 24 hours after birth as a systemic sepsis
syndrome that involves apnea, respiratory distress from pneumonia or pulmonary hypertension,
shock, and occasionally meningitis (<10% of cases).
Late-onset GBS infection presents after the first 7 days of postnatal life, most commonly in the third or fourth week. Meningitis is far more common in late-onset GBS infection, but other presentations include septic shock and focal infections such as cellulitis, arthritis, and osteomyelitis.
The infant described in the vignette has early-onset GBS infection, with tachypnea and
temperature instability prompting an evaluation for sepsis. His mother, who is a GBS carrier, had
chorioamnionitis at the time of delivery, which increases his risk for acquiring GBS. The
respiratory distress may be due to pneumonia that is indistinguishable from hyaline membrane
disease on chest radiography. In cases of GBS bacteremia, a GBS toxin also may mediate
pulmonary vascular constriction and cause pulmonary hypertension, even when pneumonia is
not present. With GBS bacteremia or septicemia, approximately 10% of infants have
corresponding meningitis
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Q3:
A mother brings in her child because she found a tick on the girl’s shoulder yesterday and is
worried about Lyme disease. The mother found a site on the Internet that suggests her daughter
needs an antibiotic called ceftriaxone. You assure the mother that only very few children who
suffer tick bites actually develop a tick-associated disease.
Of the following, the manifestation of Lyme disease for which ceftriaxone administration is MOST
appropriate is
A. acute arthritis
B. carditis
C. disseminated erythema migrans
D. isolated facial palsy
E. peripheral neuropathy
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Q 3-6 :
A 10-day-old boy presents to the emergency department with a 1-day history of lesions on his lips. He was born at 38 weeks by Caesarean section because his mother had previously had a Caesarean section. The pregnancy was uneventful; in particular there was no history of Group B Streptococcus or herpes simplex virus infection. The baby was discharged home on day 2, feeding well. He developed sticky eyes on day 4, which his mother treated with overthe- counter medication. Otherwise, there had been no concerns and he continued to feed well.
On the morning of presentation, his mother had noticed yellow crusty lesions on his upper lip and at the angle of his mouth. Although feeding well, he seemed more unsettled
than normal. At triage, his observations were as follows:
Axillary temperature 36.4 1C
Heart rate 140 beats per minute
Central capillary refill time less than 2 s
Respiratory rate 35 breaths per minute.
Clinical assessment revealed the baby to be unsettled, and he disliked being examined. Cardiovascular, respiratory and abdominal examination was unremarkable. He had a yellow crusty lesion at the angle of his mouth and a small one on his central upper lip. There was yellow discharge from both eyes, but his conjunctivae were normal. His skin was diffusely erythematous and seemed to be tender. He was well hydrated.
3. What is the most likely diagnosis?
(a) Herpes simplex infection
(b) Neonatal bullous impetigo
(c) Neonatal erythema toxicum
(d) Staphylococcal scalded skin syndrome
(e) Toxic epidermal necrolysis
4. What is the most likely pathogen?
(a) Group B Streptococcus
(b) Human herpes virus 6
(c) Staphylococcus aureus enterotoxin
(d) Staphylococcus aureus epidermolytic toxins A and B
(e) Streptococcus pyogenes exotoxin
5. What would be the most appropriate treatment?
(a) High-dose oral flucloxacillin
(b) Intravenous benzylpenicillin and flucloxacillin
(c) Intravenous aciclovir
(d) A swab lip lesion and await sensitivities before
commencing the appropriate antibiotic
(e) Topical fucidin
6. What is the usual natural progression of this condition if treated appropriately and promptly?
(a) Drying of the erosions followed by desquamation and healing within 14 days
(b) The formation of pustules that burst, leaving hyperpigmented macules
(c) Septicaemia leading to circulatory collapse, with a high rate of morbidity and mortality
(d) Stripping of the epidermis followed by severe scarring with loss of the nails and hair
(e) Uncomplicated healing but a recurrence of the lesions precipitated by minor illness
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