1.

An obese 32-year-old diabetic woman presents with complaint of red and painful skin in her
abdominal skin folds. Examination reveals a creamy white material at the base of the fold. It is
erythematous underneath and extends beyond the creamy material. Microscopic examination of
the exudate reveals oval budding structures (3 X 6 μm) mixed with more budding elongated
forms. The most likely causal agent is
(A) Aspergillus fumigatus
(B) Candida albicans
(C) Epidermophyton floccosum
(D) Microsporum canis
(E) Sporothrix schenckii

2. A 1 9-year-old migrant worker from the southwestern U.S. is brought to the family doctor
complaining of cough, pleuritic chest pain, fever, and malaise. He also complains of a backache
and headache. He is found to have an erythematous skin rash on his lower limbs. A chest
radiograph reveals several calcifying lesions. Which of the following structures is most likely to
be found?
(A) Broad-based budding yeast
(B) Monomorphic encapsulated yeast
(C) Nonseptate hyphae with broad angles
(D) Septate hyphae branching dichotomously at acute angles
(E) Spherules with endospores

3. An 18-year-old high school student in rural north Mississippi develops fever, cough, and chest
pain. The cough, associated with weight loss, persisted. Because of poor performance at football
practice, he was advised to see a physician. Lymph node biopsies stained with H and E reveal
granulomatous inflammation and macrophages engorged with oval structures measuring 2-4
μm. Cultures incubated at room temperature grow powdery white colonies, which on
microscopic study have tuberculate spores. The high school student most likely acquired the
infection from which of the following?
(A) Desert sand
(B) Cat feces
 (C) Soil enriched with bird excrement
(D) Another human via respiratory secretions
(E) Contaminated drinking water

4. A 32-year-old man from the southeastern U.S. is referred to a tertiary care center with chronic
pneumonia. He also complains of malaise, weight loss, night sweats, chest pain, breathlessness,
and hoarseness. Sputum smear revealed thick-walled, refractile, double-contoured yeast cells.
What is the most common site of dissemination for the causal organism?
(A) Heart
(B) Liver
(C) Mucocutaneous
(D) Skin
(E) Spleen

5. A 55-year-old man who recently recovered uneventfully from a heart valve transplant presents
to the emergency room with pleuritic chest pain, hemoptysis, fever, and chills. While he is
being examined, he has a myocardial infarction and the medical team is unable to revive him.
An autopsy revealed septate, acutely branching hyphae in many tissues. Which of the following
organisms is most likely to be identified?
(A) Aspergillus fumigatus
(B) Blastomyces dermatitidis
(C) Cryptococcus neoformans
(D) Histoplasma capsulatum
(E) Mucor species

6. A 33-year-old HIV-positive man complains of headache and blurred vision. Physical

examination reveals papilledema and ataxia. A head CT scan is normal, but CSF obtained by
lumbar puncture reveals encapsulated organisms visible by India ink. Which of the following is
true concerning this organism?
(A) It can also be seen as "spaghetti and meatballs" on KOH stain
 (B) It consists of branching septate hyphae
(C) It exists as a mycelial form at room temperature and a yeast at 37°C
(D) It is an encapsulated nondimorphic yeast found worldwide
(E) It is a nonencapsulated dimorphic yeast that reproduces by budding

7. A 32-year-old man who has AIDS presents to his physician with progressively increasing
dyspnea over the past 3 weeks. He also complains of a dry, painful cough, fatigue, and low-
grade fever. A chest x-ray reveals bilateral symmetrical interstitial and alveolar infiltration.
Which of the following agents is the most likely cause of the above?
(A) Cryptococcus neoformans
(B) Cryptosporidium parvum
(C) Histoplasma capsulatum
(D) Pneumocystis jiroveci
(E) Toxoplasma gondii

8. A biopsy of an infected lung from a 76-year-old woman who suffered a third-degree burn 2
months ago revealed uniform hyphae with regularly spaced septation and a parallel
arrangement. No yeast cells were observed. Which of the following is the most probable
diagnosis?
A. Actinomycosis
B. Aspergillosis
C. Blastomycosis
D. Cryptococcosis
E. Zygomycosis

9. Which of the following is the probable source of infection in aspergillosis in this patient ?
A. Contact with an infected animal
B. Implantation
C. Ingestion
D. Inhalation
E. Water used in preparing lemonade
10. An examination of sputum for a suspected case of fungal infection may reveal hyphae in which
of the following?
A. Aspergillosis
B. Cryptococcosis
C. Histoplasmosis
D. Paracoccidioidomycosis
E. Sporotrichosis

11. A 35-year-old man is HIV antibody-positive and has a CD4 count of 50 cells/mm3 (normal:
500–1000 cells/mm3). He has had a fever of 38.3°C (101oF) for a few weeks and “feels tired all
the time.” He has no other symptoms, and findings on physical examination are normal.
Complete blood count, urinalysis, and chest x-ray are normal. A bone marrow biopsy reveals
granulomas, and a culture grows an organism that is a budding yeast at 37oC (98.6oF), but
produces hyphae and tuberculated chlamydospores at 25oC (77oF). Of the following, which is
the most likely cause?
A. Aspergillus fumigatus
B. Coccidioides immitis
C. Cryptococcus neoformans
D. Histoplasma capsulatum
E. Mucor species

12. A 4-year-old girl who lives in Bakersfield, CA, has had a low-grade fever. Skin tests performed
for the first time give the following results:
Tuberculin (PPD) Positive (10 mm induration)
Coccidioidin test Positive (15 mm induration)
Dick test Positive (with erythema)
Dick control test (heated toxin) Negative (no erythema)
Schick test Negative (no erythema)
Schick control test (heated toxin) Negative (no erythema)
The test results suggest which of the following?
 A. The patient has been exposed to Coccidioides immitis.
B. The patient has been immunized against Coccidioides immitis.
C. The patient has had scarlet fever.
D. The patient has IgG antibody to Mycobacterium tuberculosis.
E. The patient lacks immunity to Corynebacterium diphtheriae.

13. A 50-year-old immunocompromised woman is diagnosed as having meningitis. A latex

agglutination test on the spinal fluid for capsular polysaccharide antigen is positive. Of the
following organisms, which one is the most likely cause?

A. Aspergillus fumigatus
B. Cryptococcus neoformans
C. Histoplasma capsulatum
D. Nocardia asteroides
E. Toxoplasma gondii

14. Which of the following is the most common portal of entry in Blastomyces dermatitidis
infection?
A. Genitourinary tract
B. Lymphatic system
C. Mouth
D. Respiratory tract
E. Skin

15. Candida albicans can be differentiated from other Candida species on cornmeal agar by its
unique ability to form which of the following?

A. Arthrospores
B. Aseptate hyphae
C. Chlamydospores
D. Germ tubes
E. Tuberculate macroconidia
16. A young man in his mid-twenties presented with mucosal lesions in his mouth. Based on his
CD4 cell count and other signs during the past few months, he was diagnosed as having AIDS.
Which of the following is the most likely etiology of the oral lesions?

A. Aspergillus
B. Candida
C. Cryptococcus
D. Mucor
E. Rhizopus

17. Which of the following morphologic structures is not associated with Candida albicans?

A. Chlamydospore
B. Hyphae
C. Pseudohyphae
D. Sporangium
E. Yeast

18. Which of the following is the main reason that individuals taking tetracycline often develop
candidiasis?

A. Candida albicans is capable of degrading the antibiotic.

B. The action of the antibiotic is neutralized by the protein of C. albicans.
C. The antibiotic damages the host mucous membrane.
D. The antibiotic is nutritionally favorable for the growth of C. albicans.
E. The normal bacterial flora is drastically altered by tetracycline.

19. A 32-year-old man who lives in downtown Philadelphia presents to his physician with a 4-day
history of terrible headache, fever, and stiff neck. He has always been in good health and
attributes this to his healthy eating habits and his daily running through the city parks near his
 apartment. The physician suspects the man may have cryptococcal meningitis and collects CSF
for examination. Which of the following results would you most likely expect from this
patient’s CSF studies?
A. Elevated CSF pressure with increased white cell counts
B. Elevated polymorphonuclear cells with high protein levels
C. Elevated lymphocytes with normal glucose levels
D. Normal CSF pressure with a positive Gram stain reaction
E. Normal CSF pressure with negative Gram stain reaction

20. Which of the following laboratory tests would best definitely diagnose cryptococcal infection in
the above patient?

A. Quelling reaction capsular swelling

B. Latex agglutination test for polysaccharide capsular antigen
C. Ouchterlony test for fungal infection
D. India ink test for the presence of capsulated yeast
E. Gram stain reaction

21. A 35-year-old man with AIDS presents to the local clinic with complaints of nausea, vomiting,
confusion, fever and staggering gait. A lumbar puncture is performed, and an organism with a
halo is noted with India ink preparation. What drug would be most beneficial?

A. Ketoconazole and amphotericin B

B. Fluconazole and amphotericin B
C. Nystatin and ketoconazole
D. Nystatin and miconazole
E. Griseofulvin

22. A 34-year-old white homeless man in New York city is brought in by the police to the
emergency room because he was found wandering the streets confused with a staggering gait.
 On physical exam, he is noted to have acne like lesions over a large part of his body
accompanied with skin ulcers. He is febrile and has some cranial nerve deficits. A short time
later the man becomes short of breath, which was determined to be caused by severe cerebral
edema compressing the medulla. Which of the following is the most likely causative agent?

A. Histoplasma capsulatum
B. Coccidioides immitis
C. Exophiala werneckii
D. Sporothrix schenckii
E. Cryptococcus neoformans

23. Pneumocystis jiroveci is now considered a fungus. Which of the following statements
accurately describes this organism?

A. In immunocompromised patients the organism invades blood vessels causing thrombosis and
infarction.
B. It grows best in a culture medium containing tissue fluid.
C. It is now classified as a fungus because it grows into septate hyphae in Sabouraud agar.
D. It is sensitive to antifungal agents such as amphotericin B.
E. Methenamine silver stain is used to visualize the organism in the clinical specimen.

24. Which of the following statements best describes the laboratory diagnosis of Pneumocystis
jiroveci?

A. India ink stain of bronchoalveolar lavage material

B. KOH stain of lung biopsy tissue
C. Growth of the organism on Sabouraud agar
D. Methenamine silver stain of induced sputum

25. Pneumocystis jiroveci produces disease under what conditions listed below?
 A. In individuals with CD4 lymphocyte counts above 400/μL
B. In the presence of immunosuppression
C. Infection in early childhood
D. Prophylaxis with SMX-TMP

26. Which of the following fungi is most likely to cause cutaneous disease?

A. Aspergillus fumigatus
B. Candida albicans
C. Cryptococcus neoformans
D. Histoplasma capsulatum
E. Sporothrix schenckii

27. A woman who pricked her finger while pruning some rose bushes develops a local pustule that
progressed to an ulcer. Several nodules then developed along the local lymphatic drainage. The
most reliable method to identify the etiologic agent is which of the following?

A. Culture of the organism in the laboratory

B. Gram stain of smear prepared from the lesion
C. India ink preparation
D. Skin test for delayed hypersensitivity
E. Stain the culture with potassium iodide

28. About 90 days post-bone marrow transplant, a 55-year-old white woman began to complain of
dry cough, shortness of breath, and chest pain. She was started on antibiotics and blood culture
obtained at the time was negative and there was not improvement. A computed tomography
(CT) scan of the lungs showed a halo of low attenuation around a nodular lesion. Analysis of
lung biopsy was similar to methenamine silver-stained section below. The most likely
diagnosis for this patient is
 (Courtesy of Dr. William Kaplan; Public Health Image Library, Centers for Disease Control
and Prevention; Atlanta, Georgia.)
a . Aspergillosis
1. b. Candidiasis
2. c. Histoplasmosis
3. d. Mucormycosis

29. A 65-year-old man was diagnosed with pseudomembranous candidiasis and given a prescription
for oral fluconazole. This drug acts by:

a. Binding to membrane ergosterol

b. Incorporation into RNA leading to mistranslation and inhibits DNA synthesis
c. Inhibition of 1,3-β-glucan biosynthesis
d. Inhibition of mitosis
e. Inhibition of squalene 2,3-epoxidase
f. Inhibition P450-dependent sterol demethylase (lanosterol 14α-demethylase)
30. An AIDS patient with a CD4 count in the range 100 to 50 cells/mm3 complains of headache
and neck stiffness and appears disoriented. The possibility of fungal meningitis is considered
and tests for the common fungal etiology of meningitis ordered. Tests included direct
examination of spinal fluid for the organism and serology. The purpose of the serology test is
detection of

a . Antibody to capsular polysaccharide

b. Antibody to cell wall mannoprotein
c. Capsular polysaccharide
d. Cell wall mannoprotein

31. A 6-year-old African American girl resident of a very large US city presents to a clinic with
scaly patches and areas of alopecia on the scalp with hair shafts broken off close to the scalp.
The hair did not fluoresce under Wood’s light. If this child has tinea capitis, the most likely
etiology is

a . Epidermophyton floccosum
b. Microsporum audouinii
c. Microsporum canis
d. Trichophyton rubrum
e. Trichophyton tonsurans

32. A 25-year-old male physical therapist trains regularly with the hope of qualifying for the
Boston Marathon. He develops itching in interdigital spaces on his left foot. Suspecting tinea
pedis he treats the area with an over-the-counter product. The area improves after a course of
treatment but two months later reappears and again responded to the same treatment. However,
there was reappearance 3 months later. If the self-diagnosis is correct, the normal habitat of the
etiologic agent is most likely described as

a . Anthropophilic
b. Geophilic
 c. Zoophilic

33. A patient receiving corticosteroid treatment for lupus developed headache and fever and when
she began to display some memory loss she was brought to her physician by her spouse.
Considered in the differential diagnosis was cryptococcal meningitis . Which of the following,
if found upon examination of cerebrospinal fluid would support that diagnosis?

a . Encapsulated yeast cells

b. Hyphae
c. Intracellular yeast cells
d. Yeast cells with multiple buds
e. Yeast cells with a broad base between mother and daughter cells

34. A 35-year-old male, a legal resident in the USA, presented with a complaint of a lesion on the
bottom of his foot that was smooth and shiny and somewhat discolored. He reported that it
bothered him when wearing some shoes . He reported no chronic diseases or recent illnesses
and he was a nonsmoker. Travel history determined that he frequently visited relatives in India .
Histopathology of the biopsy specimen showed at 2.4-mm granule surrounded by neutrophils .
Tissue staining suggested that the granule contained filaments >1 μm in width. The most likely
diagnosis is
a . Actinomycetoma
b. Aspergillosis
c. Chromomycosis
d. Eumycetoma
e. Phaeohyphomycosis

35. A healthy 55-year-old man resident of Louisville, Kentucky, presented to his physician
complaining of fever, headache, nonproductive cough, and chest pain of 10 days duration. As
part of the history, the patient reported that he was still employed as a construction worker and
for several weeks prior to becoming ill had been engaged in tearing down houses and
 structures as part of an urban renewal project. The most likely fungal infection considered in
the differential diagnosis is
a . Blastomycosis
b. Coccidioidomycosis
c. Cryptococcosis
d. Histoplasmosis
e. Paracoccidioidomycosis
f. Sporotrichosis

36. A 40-year-old woman sees her primary care physician complaining of an ulcer on her finger.
She reported that it started as a red bump. Knowing that her patient was a long-time avid
gardener, the physician asked if that finger had been injured by a thorn. The patient responded
that she did not remember about that particular finger but she certainly had received thorn
punctures in past weeks . Based on this information, which of the following is the most likely
fungal etiology?
a . Fonsecaea pedrosoi
b. Malassezia furfur
c. Microsporum canis
d. Sporothrix schenckii
e. Stachybotrys chartarum

37. Several young men from the local high school football team complain of a sudden onset of
athlete’s foot (tinea pedis). Which of the following observations in a skin scraping will support
the diagnosis?
a . Hyaline hyphae and arthroconidia
b. Pigmented hyphae
c. Sclerotic bodies
d. spherules
e. yeast cell
38. A 57-year-old obese, white female with type 1 diabetes mellitus is diagnosed with strep
throat and prescribed penicillin. A week later she returns complaining of a sore mouth and
white patches on the tongue. Your examination confirms the white pseudomembranous
lesions . Material from the lesion is obtained and prepared for microscopic examination.
Your suspicion of the most likely clinical diagnosis will be confirmed by observation of
buccal epithelial cells, leukocytes, and which of the following
a . Gram-positive bacteria
b. Gram-negative bacteria
c. Hyphae with septa and acute angle branching
d. Spherules containing endospores
e. Yeast cells, hyphae, and pseudohyphae

39. A small brownish irregular macule on the palm of a 13-year-old girl is examined by a
dermatologist in her Louisiana home town. A skin scraping from the lesion is obtained for
microscopic observation and culture. Microscopic examination of the specimen shows
brownish filaments or hyphae and yeast cells . The most likely diagnosis is
a . Tinea capitis
b. Tinea corporis
c. Tinea manuum
d. Tinea nigra
e. Tinea pedis

40. You have been designated as a coordinator of construction of a bone marrow transplant unit
(BMTU). There will be extensive removal of walls and floors in order to install the laminar
flow rooms required for a BMTU. From the standpoint of frequency and lethality, which of the
following fungi should be your biggest concern?
a . Aspergillus species
b. Candida species
c. Cryptococcus species
d. Penicillium species
e. Pneumocystis jiroveci
41. A 50-year-old man, newly employed by a commercial farm that supplies eggs and chickens to
industry, develops a flu-like syndrome with fever, chills, myalgia, headache, and a
nonproductive cough. He is diagnosed with histoplasmosis . A positive tissue biopsy would
show the presence of
a . Arthrospores
b. Oval budding yeast cells inside macrophages
c. Spherules containing endospores
d. Tuberculate macroconidia
e. Yeast cells, hyphae, and pseudohyphae
f. Yeast cells with broad-based bud

42. A 65-year-old female patient with a long history of diabetes is brought the emergency room by
her daughter with an immediate complaint of sudden swelling on the right side of the face and
bleeding from the right nostril . Questioning of the patient and daughter suggests the possibility
of ketoacidosis . The nasal bleeding is troublesome and a swab of the nares is rushed to the
clinical laboratory for immediate attention along with blood to test for acidosis . The patient
was admitted. The facial lesion became partially necrotic and there was slight protrusion of the
right eye and facial paralysis . The patient died on the second day. If this patient died of a
fungal infection, histopathologic examination of the lesions would most likely show…
a . Hyphae, some with arthroconidia
b. Septate dematiaceous hyphae
c. Septate hyphae with acute angle branching
d. Nonseptate hyphae
e. Narrow (<1 μm) Gram-positive filaments
f. Yeast cells

43. A normally healthy young man in Arizona was diagnosed with coccidioidomycosis . The most
likely route of infection for the etiologic agent is
a . Aspiration
b. Cutaneous contact
c. Ingestion
 d. Inhalation
e. Implantation

44. An immunocompromised patient is suspected of having aspergillosis due to A. fumigatus.

Which of the following clinical conditions is most likely to occur?
a . Allergic bronchopulmonary response
b. Aspergilloma
c. Invasive pulmonary infection
d. Otomycosis
e. Wound infection

45. A 25-year-old pregnant woman, living in the San Joaquin Valley (California), experiences an
influenza -like illness with fever and cough. She is diagnosed with Coccidioides infection.
The most likely recommended treatment for the infection of this patient is
a . Amphotericin B or fluconazole
b. 5-fluorocytosine
c. None, the infection resolves without treatment
d. Supportive treatment only for symptoms
e. Terbinafine

46. Months after a kidney transplant, a 45-year-old woman who was receiving
immunosuppressive therapy experienced a rapid onset of respiratory insufficiency and a dry
cough. High-resolution computed tomographic scanning was ordered of the lungs . There
were findings of interstitial disease. Bronchoalveolar lavage was performed and the material
examined by Giemsa staining. The report stated that trophic forms and cysts were observed.
The most likely infecting organism is
a . Aspergillus fumigatus
b. Candida albicans
c. Pneumocystis jiroveci
d. Rhizopus arrhizus (oryzae)
47. Bacteria and fungi share some common mechanisms of resistance to drugs used in
treatment of bacterial or fungal infection. However, bacteria have a resistance mechanism
not described in fungi . This mechanism is
a . Alteration in the drug target
b. Efflux of drug
c. Inactivation of drug
d. Influx of drug
e. Overexpression of drug target

48. An isolate of Candida albicans was found to be resistant to caspofungin due to mutation in the
drug target which is
a . Cytosine permease
b. Ergosterol
c. P450 14-α-demethylase
d. Squalene 2,3-epoxidase
e. Subunit of β-1,3-glucan synthase

49. 25-year-old man made a self-diagnosis of athlete’s foot and purchased a product advertised to
treat this condition that listed the active ingredient as tolnaftate. The mode of action of this drug
is
a . Binding to membrane ergosterol
b. Incorporation into RNA leading to mistranslation and inhibition DNA synthesis
c. Inhibition of 1,3-β-glucan biosynthesis
d. Inhibition of mitosis
e. Inhibition of squalene 2,3-epoxidase
f. Inhibition P450-dependent sterol demethylase (lanosterol 14α-demethylase)

50. A 37-year-old HIV-positive male presented with fever, cough, facial papules, and pustules .
Microscopic examination of a stained smear of material obtained from a pustule showed
structures that could be described as those stained red or dark in the periodic acid Schiff stained
tissue specimen below. These pustular lesions are most likely attributable to infection with
 (Courtesy of Dr. Libero Ajello; Public Health Image Library, Centers for Disease Control and
Prevention; Atlanta, Georgia.)
a . Blastomyces dermatitidis
b. Candida albicans
c. Cryptococcus spp.
d. Histoplasma capsulatum
e. Penicillium marneffei

51. An 18-year-old white male high-school student visits the family physician complaining of a
diffuse, painful rash extending from his midthigh to his navel region. In recounting the history
of the rash, he indicates that one of his football teammates gave him topical hydrocortisone to
treat a minor groin rash. A KOH scraping of the lesion reveals hyaline hyphae and a portion of
the scraping is submitted for culture. A schematic of the microscopic observation of the culture
is shown below. The most likely etiology is
a . Epidermophyton floccosum
b. Microsporum canis
c. Trichophyton rubrum
d. Trichophyton tonsurans
52. A 37-year-old male presented with a lesion on the left leg. He reported receiving abrasions in
the area 3 or 4 months earlier while on tour in Brazil . The lesion was a pink, smooth papular
lesion, which he reported itched. The lesion was biopsied and the clinical pathology laboratory
reported the presence of short, brownish hyphal fragments and sclerotic or Medlar bodies . The
most likely diagnosis for this patient is
a . Blastomycosis
b. Chromoblastomycosis
c. Lacaziosis
d. Eumycetoma
e. Sporotrichosis

53. An 87-year-old man complained that his feet hurt when he put on shoes because of his
toenails . Upon inspection several toenails on both feet showed yellowing and thickening. A
scraping was obtained from one nail as well as subungual debris and prepared for culture and
direct examination with potassium hydroxide and Calcofluor. Microscopic examination
showed fluorescent hyphae. The most likely diagnosis is
a . Tinea capitis
b. Tinea corporis
c. Tinea manuum
d. Tinea pedis
e. Tinea unguium

54. A 55-year-old man from Mississippi presented with a lesion below his left eye. Examination
showed a well -demarcated lesion with a raised border, scaling, and pustules . He reported no
pain. Material from the edge of the lesion was submitted for histopathology and culture. The
pathology laboratory reported the presence of broad-based budding yeast cells . The diagnosis
for this patient is
a . Blastomycosis
b. Chromomycosis
c. Paracoccidioidomycosis
d. Penicilliosis
 e. Sporotrichosis

55. A 47-year-old man from Cincinnati, Ohio, suspected to have community-acquired pneumonia
was treated with antibiotics . When he failed to improve, histoplasmosis was considered.
Among the tests ordered were serology, direct examination, and culture of induced sputum. In
culture, the microscopic morphology most useful in identification of the etiologic agent is
a . Arthroconidia
b. Microconidia
c. Sclerotic bodies
d. Spherules
e. Tuberculate macroconidia

56. A 25-year-old female had surgery for a crush injury to the chest. She had a central venous
catheter, was intubated, and was on a mechanical ventilator. Three days postsurgery she
developed a fever and was treated empirically for bacterial infection but fever persisted.
Fungemia was suspected and blood culture for fungi was ordered. Empiric antifungal therapy
was initiated and the central venous catheter line was removed. Removal of the catheter is
indicated because
a . Of the suspected presence of Aspergillus fumigatus biofilm
b. Of the suspected presence of Candida albicans biofilm
c. Of the suspected presence of Cryptococcus neoformans biofilm
d. Of the suspected presence of Aspergillus fumigatus planktonic organisms
e. Of the suspected presence of Candida albicans planktonic organisms
f. Of the suspected presence of Cryptococcus neoformans planktonic organisms

57. A 75-year-old African American male who had recently retired to the Tucson, Arizona area
from Ohio, presented with history of cough, fever, and chills for 3 weeks . Because of the
recent move and ethnicity, the patient was tested for coccidioidomycosis . This infection is
initiated following inhalation of structures best described as
a . Arthroconidia
b. Blastoconidia
 c. Endospores
d. Spherules
e. Sporangiospores

58. A 4-year-child develops tinea corporis (ringworm). The lesions clear using a preparation for
treatment of athlete’s foot obtained from local drug store. The lesions reappear on the child and
a playmate in a few weeks . Internet research suggested to the mother that the family pet might
be the source of infection and should be taken to a veterinarian. If this is the mode of
transmission, the etiology is most likely
a . Epidermophyton floccosum
b. Hortaea werneckii
c. Malassezia spp.
d. Microsporum canis
e. Trichosporon beigelii

59. A patient from a small Mississippi town presented with a complaint of several weeks of
productive cough, hemoptysis, weight loss, and chest pain. Radiologic findings were consistent
with a pulmonary infiltrate. Among the possible diagnoses, blastomycosis was considered and
culture for this organism was included in the orders for the clinical laboratory. The structure
distinctive for identification in microscopic examination of a culture of the etiologic agent is
a . Arthroconidia
b. Broad-based budding yeast cells
c. Encapsulated yeast cells
d. Multiply budding yeast cells
e. Tuberculate macroconidia

60. Candida albicans is isolated in blood culture from a patient in a surgical intensive care unit.
This most likely source of the infecting organism is
a . A health care worker
b. A visitor
c. Ambient air
 d. The patient
e. The surgeon

61. A 30-year-old female of the US military was on assignment in a subtropical area . She
reported to the physician with a complaint of patchy light-colored lesions on her chest and
upper arms . She reported no other symptoms . Upon examination the lesions were irregular
and well demarcated. Included in the differential diagnosis was pityriasis versicolor. A
scraping on an affected area was obtained. If the diagnosis of pityriasis versicolor is correct,
the best description of what will be observed in a positive specimen is
a . Hyaline hyphae
b. Hyaline hyphae and arthroconidia
c. Dematiaceous hyphae
d. Yeast cells with broad-based buds
e. Yeast cells and short hyphae

62. A 56-year-old man retired from the military to his hometown in Wisconsin. While in the
military he had been stationed in several states and served in several parts of the world
including South America, Africa, Southeast Asia, and most recently in Iraq and Afghanistan.
He complained to his physician of a lesion inside his mouth on the left side. Histopathology of
a biopsy specimen stained with methenamine silver was similar to that shown below. The most
likely diagnosis is
 (Courtesy of the Public Health Image Library, Centers for Disease Control and Prevention;
Atlanta, Georgia.)
a . Blastomycosis
b. Candidiasis
c. Histoplasmosis
d. Leishmaniasis
e. Paracoccidioidomycosis

63. The overexpression of drug efflux pumps in Candida albicans is an important mechanism in
reduced susceptibility to
a . Azole class drugs
b. Echinocandin class drugs
c. Flucytosine
d. Polyene class drugs

64. A 28-year-old woman experienced vaginal and vulvar itching, a slightly watery discharge and
pain with intercourse. Her gynecologist performed physical examination of the vulva, vagina,
and cervix. The vaginal pH was estimated as 4.4. Microscopic examination was performed on
some Gram-stained discharge material . The observation was similar to below. The most likely
diagnosis is
 (Courtesy of Dr. Stuart Brow; Public Health Image Library, Centers for Disease Control and
Prevention; Atlanta, Georgia.)
a . Bacterial vaginosis
b. Candidiasis
c. Chlamydial vaginitis
d. Trichomoniasis
e. Viral vaginitis

65. A 53-year-old white woman with end-stage renal disease received a kidney transplant and was
maintained on an immunosuppressive regimen. Three months later she had a fever (38.3°C)
and was found to have acute renal failure. Renal transplant biopsy was performed. Periodic
acid-Schiff staining of a biopsy section showed yeast cells and hyphae. The most likely
diagnosis for this patient is infection with
a . Aspergillus fumigatus
b. Candida albicans
c. Candida glabrata
d. Cryptococcus neoformans
e. Rhizopus arrhizus (oryzae)

66. Amphotericin B is noted for both its antifungal efficacy and side effects when administered to
humans . The basis for the side effects is most likely
a. Binding of drug to cholesterol
b. Binding of drug to ergosterol
c. Binding of drug to phospholipids
d. Inhibition of cholesterol biosynthesis
e. Inhibition of ergosterol biosynthesis

67. A fungal teleomorph is

a . Asexual reproductive form
b. Infective form for humans
c. Sexually reproductive form
d. Dormant form
ESSAY

68. A 29-year-old woman comes into the clinic for evaluation of a cough. Her symptoms started a
few weeks ago and have progressively worsened. The cough is not productive. She has had
intermittent, low-grade fevers and feels short of breath. She has tried some over-the-counter
cough medications, which don’t seem to help. She smokes approximately a half-pack of
cigarettes a day. She denies any history of pulmonary diseases. On examination, her
temperature is 37.5°C (99.5°F), pulse is 100 beats per minute, respiratory rate is 26 breaths per
minute, and oxygen saturation is 89 percent on room air. Her blood pressure is normal, but
when applying the blood pressure cuff, you notice numerous scars in her antecubital region
consistent with “needle tracks.” In general, she is a thin woman who appears to be in moderate
respiratory distress and is coughing frequently. Her head and neck examination is normal. Her
lung examination is notable for decreased breath sounds and rhonchi in all fields. Her
cardiovascular and abdominal examinations are normal. A chest x-ray shows a bilateral
interstitial infiltrate with a “ground-glass” appearance. She confides that she is HIV positive.

◆ What organism is the likely cause of her symptoms?

◆ Describe the sexual phase of reproduction of this organism.

69. A 32-year-old man with known AIDS is brought to the emergency room with headache and
fever for the past 3 days. According to family members who are with him, he has been
confused, forgetful, and irritable for a few weeks prior to the onset of these symptoms. They
state that he has advanced AIDS with a low CD4 count and has had bouts of pneumocystis
pneumonia, candida esophagitis, and Kaposi sarcoma. He is on multiple medications, although
they don’t know whether he is actually taking them. On examination, he is cachetic and frail
appearing. He is confused and only oriented to his name. His temperature is 37.8°C (100°F),
and his other vital signs are normal. Examination of his cranial nerves is normal. He has
minimal nuchal rigidity. Cardiovascular, pulmonary, and abdominal examinations are normal.
He is hyperreflexic. A head CT scan is normal. A report of the microscopic examination of his
cerebrospinal fluid obtained by lumbar puncture comes back from the laboratory and states that
 there were numerous white blood cells, predominantly lymphocytes, and no organisms
identified on Gram stain but a positive India ink test.

◆ What organism is the likely cause of this illness?

◆ What characteristic of this organism is primarily responsible for its virulence?

70. A 28-year-old woman presents complaining of 2-days of itchy vaginal discharge. One week ago
you saw and treated her for a urinary tract infection (UTI) with sulfamethoxazole and
trimethoprim (SMX-TMP). She completed her medication as ordered and developed the vaginal
discharge shortly thereafter. She denies abdominal pain, and her dysuria has resolved. She is not
currently taking any medications. On examination, she is comfortable appearing and has normal
vital signs. Her general physical examination is normal. A pelvic examination reveals a thick,
curd-like, white discharge in her vagina that is adherent to the vaginal sidewalls. There is no
cervical discharge or cervical motion tenderness, and bimanual examination of the uterus and
adnexa is normal.

◆ What is the most likely cause of these symptoms?

◆ What are the most likely reservoirs of this organism in this patient?

71. A 52-year-old man presents to the physician’s office for the evaluation of a cough and fever. He
has had these symptoms for approximately a week. He has also noted a sharp chest pain that is
worse when he coughs or takes a deep breath. He has had some associated fatigue, headaches,
achy joints, and sweatiness at night. He has been using an over-the-counter flu medication,
which helps to reduce the cough, but he wanted to be checked because his symptoms are
lingering. He has no history of pulmonary diseases and has never smoked cigarettes. He has had
no exposure to ill contacts. His only recent travel was a weeklong golf vacation to Phoenix,
which he took 3 weeks ago. On examination, he is comfortable appearing and in no respiratory
distress. His temperature is 37.7°C (99.9°F), and his vital signs are otherwise normal. His
 pulmonary examination is notable for some faint expiratory wheezing and crackles in the left
upper lung field. The remainder of his physical examination is unremarkable. A chest x-ray
shows hilar adenopathy. A CBC shows a normal total white blood cell count but with a high
percentage of circulating eosinophils. Microscopic examination of a fresh sputum sample
treated with KOH reveals numerous spherules.

◆ What organism is the likely cause of this patient’s symptoms?

◆ For this organism, how do spherules form and what is their role in propagating

infection?

72. A 42-year-old woman with chronic asthma presents for evaluation of a cough. She has had
severe asthma for most of her life and currently uses both inhaled and oral corticosteroids, oral
leukotriene modifiers, and inhaled albuterol to manage her symptoms. While in the process of
tapering down her dose of oral steroids, she developed a cough productive of brown mucous
and, occasionally, blood. She has had a low-grade fever as well. Her asthma control has been
significantly worsened since she developed the cough. On examination, she has a temperature
of 37.7°C (99.9°F) and a respiratory rate of 22 breaths per minute, and her saturation of oxygen
is slightly low (96 percent on room air). She is coughing frequently. Her head and neck exam is
unremarkable. Her pulmonary examination is notable for diffuse expiratory wheezing. A chest
xray shows a lobular infiltrate that is reminiscent of a cluster of grapes. A complete blood count
(CBC) shows a mildly elevated white blood cell count with a markedly elevated eosinophil
count. A microscopic examination of her sputum is also notable for the presence of numerous
eosinophils.

◆ What organism is most likely causing her cough?

◆ What is the characteristic morphology of this organism seen on microscopic

examination?
73. A 65-year-old man comes to your office for the evaluation of lower back pain. For the past 3
days, he has had a sharp, burning pain in his left lower back, which would radiate to his flank
and, sometimes, all the way around to his abdomen. The pain comes and goes, feels like an
“electric shock,” is unrelated to activity, and can be severe. He has had no injury to his back and
has no history of back problems in the past. He denies fever, urinary symptoms, or
gastrointestinal symptoms. His examination today, including careful back and abdominal
examination, is normal. You prescribe a nonsteroidal anti-inflammatory drug for the pain. The
next day, he returns to your office stating that he has had an allergic reaction to the medication
because he’s developed a rash. The rash is in the area where he had the pain for which he was
seen the day before. On examination now, he has an eruption consisting of patches of erythema
with clusters of vesicles extending in a dermatomal distribution from his left lower back to the
midline of his abdomen.

◆ What is the cause of this rash?

◆ What is the mechanism for the dermatomal distribution of the rash?

74. You are asked to consider being vaccinated with smallpox vaccine to serve as a first-responder
in the event of a biological warfare attack. After considering the risks and benefits, you consent.
You are given the vaccine by the standard technique—a small, bifurcated needle is used to
create multiple punctures in the skin overlying your deltoid. The area is covered, and you are
instructed not to touch the actual site. In 2 days, a small papule and erythema appear at the
vaccine site. A few days later, multiple vesicles are noted. These progress to form larger
pustules. In approximately 2 weeks, the whole vaccine site has formed a scab and this
subsequently falls off in another week. When complete recovery has occurred, you have a scar
left at the vaccine site.

◆ What is the actual virus used as the smallpox vaccine?

 ◆ Why must the virus used in the vaccine carry or encode its own enzymes for DNA and

mRNA synthesis?

75. A 10-month-old female is brought to the pediatric emergency room in late December with a
cough and fever. She started getting sick with a mild cough and runny nose approximately 3
days ago, but has progressively worsened. She is now coughing frequently and has vomited
after coughing. She has no history of asthma or other respiratory illness. She was born after an
uncomplicated, full-term pregnancy and has no significant medical history. She attends day care
3 days a week. On examination, her temperature is 38.3 C (100.9 F), pulse is 110 beats per
minute, respiratory rate is 30 breaths per minute, and her oxygen saturation is low at 91 percent
by pulse oximetry. Her head and neck examination shows her to have a right otitis media but is
otherwise normal. Her cardiac exam is notable only for tachycardia. Her pulmonary
examination shows her to be in moderate respiratory distress. She has prominent nasal flaring
and subcostal retractions on inspiration. She has loud expiratory wheezes in all lung fields. The
remainder of her examination is normal. A chest x-ray shows hyperaeration but no infiltrates.

◆ What is the likely infectious cause of her respiratory illness?

◆ Following resolution of this illness, her mother asks whether she is protected from

getting this disease again. How do you respond?

76. A 3-year-old male infant is brought to the emergency room in the middle of January with fever,
vomiting, and diarrhea for the past day. He has not been able to keep anything down by mouth
and has had profuse, very watery stools.He attends day care, and several of his classmates have
been out sick recently as well. No adult members of the household have been ill. He has no
significant past medical history. On examination, his temperature is 37.9 C (100.2 F), and he
has tachycardia. His mucous membranes are dry, and eyes appear somewhat sunken. His
abdomen has active bowel sounds and is nontender. His stool is watery and pale. The stool tests
negative for blood and fecal leukocytes.
 ◆ What is the most likely cause of this child’s illness?

◆ How is this virus activated to form an infectious particle?

77. A 62-year-old man presents to the emergency room after suddenly losing the use of his right
leg. He reports that he had a few days of headache, fever, and sore throat, which was treated
with oral antibiotics and resolved approximately 4 days ago. He was feeling fine until this
morning, when he could not lift his right leg to get out of bed. All of his other limbs are
functioning normally, and he has normal sensation in them. He has a medical history significant
for lung cancer for which he is receiving chemotherapy, with his most recent cycle having been
completed a few days prior to the onset of his febrile illness. He denies having any recent falls,
injuries, current headache, or neurologic symptoms other than in the right leg. He has not
traveled outside of the United States. His only current medication is amoxicillin/clavulanic acid,
which was prescribed for his recent febrile illness. He lives with his son, daughter-in-law, and
two young grandchildren. The children are healthy, and each had their routine well-child
checkups and vaccinations about a month ago, including an oral vaccine. On examination, he is
anxious appearing but has normal vital signs and has unremarkable head and neck,
cardiovascular, pulmonary, and abdominal examinations. He has flaccid paralysis with normal
sensation of the right leg, with normal movement and strength in all other extremities and a
normal cranial nerve examination. A head CT scan and lumbar magnetic resonance imaging
(MRI) are also normal.

◆ What is the most likely infectious cause of this man’s flaccid paralysis?

◆ Assuming that he was infected at home, what is the most likely source of his infection?

78. An 8-year-old boy is brought in to the physician’s office with a 3-day history of fever and a
rash. He has also had a mild sore throat and felt somewhat fatigued. His mother is concerned
that he could have “scarlet fever.” The rash started on his face and then spread to his arms and
 legs. He has only been given acetaminophen for the fever. He takes no other medications, has
no known allergies, has no significant medical history, and has had no contact with anyone
known to be ill. On examination, his temperature is 37.7 C (99.8 F), and his other vital signs
are normal. His cheeks are notably red, almost as if they had been slapped. His pharynx is
normal appearing, and the remainder of his head and neck exam is normal. On his extremities
there is a fine, erythematous, maculopapular rash but no vesicles or petechiae. A rapid group A
streptococcal antigen test done in the office is negative.

◆ What virus is the likely cause of this illness?

◆ In which human cells does this virus cause lytic infections?

79. A 6-year-old boy is brought to your office for evaluation of fever, ear pain, and swollen cheeks.
His mother reports that he’s had 3 or 4 days of low-grade fever and seemed tired. Yesterday he
developed the sudden onset of ear pain and swelling of the cheeks along with a higher fever. He
is an only child, and neither of the parents has been ill recently. He has had no significant
medical illnesses in his life, but his parents decided not to give him the measles, mumps, rubella
(MMR) vaccine because they read that it could cause autism. On examination, his temperature
is 38.6 C (101.5 F), and his pulse is 105 beats per minute. He has swollen parotid glands
bilaterally to the point that his earlobes are pushed up, and the angle of his mandible is
indistinct. His tympanic membranes appear normal. Opening his mouth causes pain, but the
posterior pharynxappears normal. You do note some erythema and swelling of Stensen duct. He
has bilateral cervical adenopathy.

◆ What is the cause of this child’s illness?

◆ What factor has reduced the incidence of this disease by over 99 percent in the United

States?
80. A 4-year-old girl is brought in by her mother for the evaluation of multiple skin growths on her
neck and upper chest. They have been present for a month or two. They are not pruritic or
painful. The mother thinks that they are “pimples” because she squeezed a couple of them and
some white material was expressed. She has been treating the lesions with an over-the-counter
acne preparation, but it hasn’t helped. The child has no significant medical history, takes no
medications, and has no allergies. On examination you see multiple discrete, isolated 1–2-mm
papules on her upper chest and lower neck. They are flesh colored, have a central umbilication,
and feel firm on palpation. The remainder of her examination is normal. You suspect
Molluscum contagiosum.

◆ How did the girl most likely acquire this infection?

◆ What would you see microscopically on a stained slide of material expressed from the

core of one of these lesions that would confirm your diagnosis?

81. A 42-year-old woman presents to the physician’s office for a routine gynecologic exam. She is
feeling well and has no specific complaints at this visit. While reviewing your records, you see
that she has not come in for a Papanicolaou (Pap) smear in approximately 5 years. She admits
that she has not come in because she has been feeling fine and didn’t think it was really
necessary. She has a history of three pregnancies resulting in three full-term vaginal deliveries
of healthy children. She was treated at the age of 22 for Chlamydia. She has never had an
abnormal Pap smear. Her social history is notable for a one-pack per day smoking history for
the past 25 years. She is divorced from her first husband and is sexually active with a live-in
boyfriend for the past 3 years. She has had 7 sexual partners in her lifetime. Her examination
today is normal. You perform a Pap smear as part of the examination. The report arrives 10
days later with the diagnosis “high-grade squamous intraepithelial lesion.”

◆ What is the most likely infectious etiology of this lesion?

◆ What specific virus types confer a high-risk of cervical neoplasia?

 ◆ Where on a cellular level does this organism tend to replicate in benign diseases? In

malignancies?

82. A 28-year-old man presents to the physician’s office for evaluation of a rash on his chest. He
started with one oval-shaped purplish area that he thought was a bruise but has subsequently
developed multiple new lesions. The growths don’t hurt, itch, or bleed, but he continues to get
new ones, and the existing ones are getting larger. He has never had anything like this before,
has no history of allergies and denies exposure to any new medications, foods, lotions, or soaps.
His past medical and family histories are unremarkable. His review of systems is significant for
a 15-lb weight loss in the past 2 months, approximately 6 weeks of diarrhea, and a 3-week
history of a sore throat. On examination, he is a thin but generally well appearing male. His
vital signs are normal. Examination of his pharynx shows thick white plaques on the posterior
pharynx and soft palate. On the skin of his chest are multiple oval-shaped purple or brown
macules. They are firm on palpation and vary in size from 0.5 to 4 cm in length. Several of
them appear to be growing together into larger, confluent plaques. You perform a punch biopsy
of one of the lesions. In 5 days you get the pathology report with the diagnosis of Kaposi
sarcoma.

◆ With what virus is this patient likely infected?

◆ What specific cell types are most commonly infected with this virus? What cell surface

receptor is the binding site of this virus?

◆ What serologic testing is most frequently performed to make this diagnosis?

83. The mother of a 3-year-old girl brings the child in for the evaluation of a “wart” on her thumb.
It has been present for 3 or 4 days and seems to cause some pain. The week prior, the child had
a “head cold” and “cold sores” around her mouth, all of which have resolved. She has never had
warts, and the mother says that the child is otherwise healthy. On examination, you see a well
appearing child who is sitting in her mother’s lap and sucking her thumb. Her head and neck
 exam is normal. On her left thumb, just proximal to the base of the thumbnail, is the lesion
about which the mother is concerned. It is a cluster of small vesicles with a faint area of
surrounding erythema. The remainder of the child’s examination is normal.

◆ What virus is the most likely cause of this skin lesion?

◆ How was it transmitted to this patient’s thumb?

84. A 62-year-old male presents to your office for follow-up of some abnormal blood test results.
You had seen him 2 weeks ago as a new patient for a routine physical examination. You
ordered blood tests and found that his liver enzymes were elevated by approximately three
times the upper limits of normal. The patient says that to his knowledge he’s never had
abnormal liver tests before, although he has not been to a doctor in several years. He denies
alcohol or drug use and is not taking any medications. He gives no history of jaundice. His past
medical history is significant only for hospitalization at the age of 45 for a bleeding stomach
ulcer. He required surgery and had transfusion of 4 units of blood. He recovered from this
episode without further complication and has had no recurrences. Your complete physical
examination 2 weeks ago was normal, and a focused physical examination today shows no signs
of jaundice, no hepatosplenomegaly, and no physical exam findings suggestive of portal
hypertension. You diagnose an infectious etiology for the laboratory findings (elevated liver
enzymes).

◆ What is the most likely infectious cause of his abnormal liver function tests?

◆ How did he most likely acquire this infection?

85. A 17-year-old female is brought to the physician’s office for evaluation of a sore throat and
fever. Her symptoms started approximately 1 week ago and have been worsening. She has been
extremely fatigued and has spent most of the last 3 days in bed. She denies any ill contacts. She
has no significant medical history, takes no medications, and has no allergies. On examination,
 she is tired and ill appearing. Her temperature is 38.5°C (101.3°F). Examination of her pharynx
shows her tonsils to be markedly enlarged, almost touching in the midline. They are
erythematous and covered with white exudates. She has prominent cervical adenopathy, which
is mildly tender. A cardiovascular examination is normal, and her abdomen is soft, nontender,
and without palpable organomegaly. A rapid streptococcal antigen test in the office is negative.
You send a throat culture and decide to start amoxicillin for strep pharyngitis, assuming that the
office test was a false-negative. Two days later, you get a call from her mother stating that she
has had an allergic reaction to the amoxicillin, and she now has a red rash from head to toe.

◆ What is the most likely diagnosis of this patient?

◆ What is the most likely cause of her infection?

◆ In what human cells can this virus replicate? In what cells can it cause latent infection?

86. You are called to examine a 1-day-old male because the nurse is concerned that he is jaundiced.
He was born by spontaneous vaginal delivery to a 19-year-old gravida1 para1 after a full-term,
uncomplicated pregnancy. The mother had no illnesses during her pregnancy; she did not use
tobacco, alcohol, or drugs; and the only medication that she took was prenatal vitamins. She
denied any significant medical history, and there is no family history of genetic syndromes or
illnesses among children. The infant is mildly jaundiced but has a notable abnormally small
head circumference (microcephaly). His cardiovascular examination is normal. His liver and
spleen are enlarged on palpation of the abdomen. Neurologic exam is notable for the lack of a
startle response to a loud noise. CT scan of his head reveals intracerebral calcifications. The
pediatrician explains to the child’s mother that the virus involved is the most commonly
transmitted transplacental viral infection in the United States.

◆ What is the most likely cause of this infant’s condition?

◆ How did he likely acquire this?

◆ What is the test of choice to confirm the diagnosis?

87. A 5-year-old girl is brought to the physician’s office because of “pink eye.” She was sent home
from kindergarten yesterday by the school nurse because her left eye was red. When she
awakened this morning, the right eye was red as well. She has had watery drainage but no
purulent discharge. She’s had a mild head cold with a runny nose and a mild sore throat but no
fever. When her mother called the school this morning, she was told that five of her daughter’s
classmates were out with pink eye today. On examination, the child has injected conjunctiva
bilaterally with clear drainage. No crusting of the lashes is noted, and the corneas are clear. She
has mildly tender preauricular adenopathy. The remainder of her examination is unremarkable.

◆ What organism is the most likely cause of this infection?

◆ How does this organism gain entry into host cells?