Thieme Test Prep for the USMLE® Medical Microbiology and Immunology Q&A Melphine M. Harriott Michelle Swanson-Mungerson Samia Ragheb Matthew P. Jackson , ~Thieme Medical Microbiology and Immunology Q&A Melphine M. Harriott, PhD, D(ABMM), MT(ASCP)SM Technical Director Clinical Microbiology Laboratory Ascension Michigan Laboratory Services Detroit, Michigan, USA Michelle Swanson-Mungerson, PhD Associate Professor Department of Microbiology and Immunology Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois, USA Samia Ragheb†, PhD Formerly Assistant Professor Department of Biomedical Sciences (Immunology) William Beaumont School of Medicine Oakland University Rochester Hills, Michigan, USA Matthew P. Jackson, PhD Assistant Dean Academic and Student Programs Associate Professor Microbiology, Immunology and Biochemistry Wayne State University School of Medicine Detroit, Michigan, USA 260 illustrations Thieme New York • Stuttgart • Delhi • Rio de Janeiro Acquisitions Editor: Delia K. DeTurris Important note: Medicine is an ever-changing science undergoing Managing Editor: Nidhi Chopra continual development. Research and clinical experience are Director, Editorial Services: Mary Jo Casey continually expanding our knowledge, in particular our knowledge Production Editor: Shivika of proper treatment and drug therapy. Insofar as this book mentions International Production Director: Andreas Schabert any dosage or application, readers may rest assured that the Editorial Director: Sue Hodgson authors, editors, and publishers have made every effort to ensure International Marketing Director: Fiona Henderson that such references are in accordance with the state of knowledge International Sales Director: Louisa Turrell at the time of production of the book. Director of Institutional Sales: Adam Bernacki Nevertheless, this does not involve, imply, or express any Senior Vice President and Chief Operating Officer: Sarah Vanderbilt guarantee or responsibility on the part of the publishers in respect President: Brian D. Scanlan to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if Library of Congress Cataloging-in-Publication Data is available necessary in consultation with a physician or specialist, whether from the publisher the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. The knowledge base for medicine is always changing and expanding, especially regarding new methods for diagnosing diseases and proposed therapies or treatment regimens for those diseases. The author © 2019 Thieme Medical Publishers, Inc. and publisher of this book have used reliable resources to provide Thieme Publishers New York the information in this book; however, given both the possibility 333 Seventh Avenue, New York, NY 10001 USA for human error and the changing nature of medicine, neither the +1 800 782 3488, [email protected] author nor the publisher warrants that the material contained in this book is completely accurate or complete in coverage and they Thieme Publishers Stuttgart disclaim all responsibility for any errors or omissions. Users of this Rüdigerstrasse 14, 70469 Stuttgart, Germany book are encouraged to independently confirm any information +49 [0]711 8931 421, [email protected] contained herein believed to be in error. Although the contents Thieme Publishers Delhi of this book provide example patient vignettes and, through A-12, Second Floor, Sector-2, Noida-201301 the explanations for the questions, offer diagnoses for medical Uttar Pradesh, India conditions, the reader should not use the information contained +91 120 45 566 00, [email protected] herein for self-diagnosis, and should always seek the opinion of a health care provider if they suspect themselves to have an illness. Thieme Publishers Rio de Janeiro, Thieme Publicações Ltda. Edifício Rodolpho de Paoli, 25º andar Av. Nilo Peçanha, 50 – Sala 2508 Rio de Janeiro 20020-906, Brasil +55 21 3172 2297 Cover design: Thieme Publishing Group Typesetting by Thomson Digital This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the Printed in USA by King Printing Company, Inc. 5 4 3 2 1 narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in par- ISBN 978-1-62623-382-9 ticular to photostat reproduction, copying, mimeographing or Also available as an e-book: duplication of any kind, translating, preparation of microfilms, eISBN 978-1-62623-383-6 and electronic data processing and storage. To my husband, Alwyn, and my parents, Melchizedek and Josephine, thank you for your unconditional love and support while I worked on this seemingly never-ending project. To my current and future students, thanks for pushing me to be better, dig deeper, and to know more. To my fellow authors, Matt, Michelle, and Sam, thank you for saying yes and for being part of this project. Melphine M. Harriott I want to thank my family for their support and understanding, since this project significantly added to our already hectic lives. I love you guys so much! I also want to thank my colleagues in the Department of Microbiology and Immunology in the Chicago College of Osteopathic Medicine (CCOM) for their guidance and mentorship during my time at CCOM. Furthermore, I want to thank the students that I work with at Midwestern University for always keeping me on my toes and making me think about immunology and infectious diseases from many different angles. Michelle Swanson-Mungerson To my fellow authors, without whom this project would not have been possible. Special thanks go to my family for their never-ending love and enduring support throughout the years. Samia Ragheb† To my fellow authors, Michelle, Sam, and Melphine whose boundless energy made this project happen. To my wife and daughter for their enduring love and support. Matthew P. Jackson †Prior to publication, our dear friend Samia Ragheb passed away. We are grateful for her dedication to her students, colleagues, and the field of immunology. She is greatly missed.—Editors Contents Preface ................................................................................................................................................................................ix Acknowledgments ...........................................................................................................................................................ix Contributors ........................................................................................................................................................................x Abbreviations ....................................................................................................................................................................xi How to Use This Series ..................................................................................................................................................xii Laboratory Values ..........................................................................................................................................................xiv Additional Normal Laboratory Values .....................................................................................................................xvi Section I Immunology 1 General Immunology ........................................................................................................................................................1 Alexander S. Maris, Samia Ragheb†, and Thomas C. Bolig 2 Infl ammation ...................................................................................................................................................................17 Samia Ragheb† 3 Autoimmune Disease .....................................................................................................................................................29 Samia Ragheb† 4 Immunodefi ciency Disorders ......................................................................................................................................49 Michelle Swanson-Mungerson 5 Hypersensitivity Reactions ..........................................................................................................................................95 Michelle Swanson-Mungerson 6 Transplant Rejection and Cancer Immunology ....................................................................................................113 Michelle Swanson-Mungerson Section II Microbiology 7 General Microbiology ..................................................................................................................................................129 Melphine M. Harriott, Thomas C. Bolig, and Matthew P. Jackson 8 Nervous System Infections .........................................................................................................................................157 Melphine M. Harriott 9 Head, Neck, and Respiratory Infections ..................................................................................................................185 Matthew P. Jackson, Alexander S. Maris, Melphine M. Harriott, and Thomas C. Bolig 10 Infections of the Esophagus, Stomach, Small and Large Bowel/Rectum, Liver, and Biliary Tree ............217 Melphine M. Harriott 11 Renal and Urinary Tract Infections ..........................................................................................................................257 Melphine M. Harriott vii Contents 12 Reproductive and Sexually Transmitted Infections ............................................................................................267 Melphine M. Harriott 13 Congenital and Neonatal Infections ........................................................................................................................291 Melphine M. Harriott 14 Skin, Soft Tissue, and Musculoskeletal Infections ...............................................................................................297 Matthew P. Jackson and Melphine M. Harriott 15 Cardiovascular, Systemic, Lymph Nodes, and Multisystem Infections ..........................................................331 Melphine M. Harriott, Matthew P. Jackson, and Michelle Swanson-Mungerson Appendices ......................................................................................................................................................................355 Index .................................................................................................................................................................................................387 viii Preface This book is a collection of multiple choice questions and an explanation. The explanation includes both (MCQs) for the first- and second-year medical students the reasons why a given answer is correct and why to promote the learning of medical immunology and the distractors are wrong. Some explanations include microbiology. The questions in this book reflect high images to aid in the explanation. yield information covered in a preclinical medical In addition, each question is marked with a immunology/microbiology course and in the United difficulty level. There are three levels of difficulty: States Medical Licensing Examination (USMLE) Step easy (1), medium (2), and hard (3). Many questions 1 and Comprehensive Osteopathic Medical Licensing are related to the highest levels of Bloom’s taxonomy Examination (COMLEX) Level 1. (e.g., interpretation of data and solution of problems) This book contains 550 questions. It is divided into rather than being simple recall questions. two sections, Immunology and Microbiology. For the Both immunology and microbiology are fast- Immunology section, where possible, the chapters are evolving disciplines. The authors have checked separated by subject matter. Some questions could sources believed to be reliable, in order to provide not be categorized into one chapter; hence, these information that is accurate and in accordance with questions are included in a chapter titled “General the currently accepted evidence-based standards. Immunology.” The Microbiology section is subdivided This book is not intended to be a substitute for by organ system. Again, some questions could not be immunology or microbiology textbooks. Students are categorized under an organ system and were placed strongly advised to consult their textbooks for more in the chapter on “General Microbiology.” in-depth coverage of the subject matter. The majority of the MCQs are similar to the type of questions that students may see on Step 1 medical Melphine M. Harriott, PhD, D(ABMM), MT(ASCP)SM board exams in the United States and are written using Michelle Swanson-Mungerson, PhD patient-centered vignettes. All questions are “one best Samia Ragheb†, PhD answer”; in most cases, there are five answer choices. Matthew P. Jackson, PhD Each MCQ is provided with the correct answer Acknowledgments Several medical students played vital roles in the at Vanderbilt University Medical Center and plans development of this book. to be a clinical microbiologist in the future. Thomas C. Bolig—Tom worked on this book Tom and Alex’s contribution to this book is inva- while he was a fourth-year medical student at luable. Wayne State University School of Medicine. He Other medical students who reviewed and provi- wrote several immunology and microbiology ded feedback on the questions include: questions and provided feedback to the faculty Jocelyn Durlacher—third-year medical student at authors. He is currently finishing a research fel- Vanderbilt University School of Medicine. lowship at the National Institutes of Health and Lauren McNickle—third-year medical student at will pursue an Internal Medicine Residency after Frank H. Netter MD School of Medicine/Quinnipiac graduating from medical school. University. Alexander S. Maris—Alex was a fourth-year me- Paige Peterson—fourth-year medical student at dical student at Vanderbilt University School of Frank H. Netter MD School of Medicine/Quinnipiac Medicine while working on this project. He contri- University. buted several multiple choice questions to both the Melphine M. Harriott, PhD, D(ABMM), MT(ASCP)SM immunology and microbiology sections. He also Michelle Swanson-Mungerson, PhD reviewed and provided feedback for many of the Samia Ragheb†, PhD chapters. He will be starting a Pathology Residency Matthew P. Jackson, PhD ix Contributors Matthew P. Jackson, PhD Thomas C. Bolig, MS, MD Assistant Dean Resident Physician Academic and Student Programs Department of Internal Medicine Associate Professor University of Michigan Microbiology, Immunology and Biochemistry Ann Arbor, Michigan, USA Wayne State University School of Medicine Detroit, Michigan, USA Melphine M. Harriott, PhD, D(ABMM), MT(ASCP)SM Alexander S. Maris, MD Technical Director Resident Physician Clinical Microbiology Laboratory Department of Pathology, Microbiology and Immunology Ascension Michigan Laboratory Services Vanderbilt University Medical Center Detroit, Michigan, USA Nashville, Tennessee, USA This work was completed in part while the author had Samia Ragheb†, PhD the following affiliations: Formerly Assistant Professor Department of Biomedical Sciences (Immunology) William Beaumont School of Medicine Fellow, Clinical Microbiology Oakland University Department of Pathology, Microbiology and Immunology Rochester Hills, Michigan, USA Vanderbilt University Medical Center Nashville, Tennessee, USA Michelle Swanson-Mungerson, PhD Assistant Professor Associate Professor Department of Microbiology and Immunology Department of Microbiology and Immunology Chicago College of Osteopathic Medicine Chicago College of Osteopathic Medicine Midwestern University Midwestern University Downers Grove, Illinois, USA Downers Grove, Illinois, USA x Abbreviations ACh acetylcholine ETEC enterotoxigenic Escherichia coli ADP adenosine diphosphate ribose GABA gamma aminobutyric acid AFB acid-fast bacilli GI gastrointestinal AIDS acquired immunodeficiency syndrome GNC gram-negative cocci ALT alanine amino transferase GNR gram-negative rod AST aspartate amino transferase GPC gram-positive cocci ATP adenosine triphosphate GPR gram-positive rod cGMP cyclic GMP HIV human immunodeficiency virus CAMP Christie, Atkins, Munch-Peterson IFN interferon cAMP cyclic adenosine monophosphate IL interleukin CBC complete blood count IV intravenous CDC Centers for Disease Control and Prevention IVDU intravenous drug use CFU colony forming unit KOH potassium hydroxide cGMP cyclic guanosine monophosphate LPS lipopolysaccharide CO carbon dioxide MAP mitogen-activated protein 2 COPD chronic obstructive pulmonary disease MCV mean corpuscular volume CSF cerebrospinal fluid MHC major histocompatibility complex CT computed tomography MRI magnetic resonance imaging DIC disseminated intravascular coagulation O&P ova and parasite DFA direct fluorescent antibody PCR polymerase chain reaction EAEC enteroaggregative Escherichia coli PMNs polymorphonuclear cell EAST enteroaggregative heat stable toxin RBC red blood cell EHEC enterohemorrhagic Escherichia coli SNARE soluble attachment protein receptor EPEC enteropathogenic Escherichia coli STEC shiga-toxin producing E. coli EIA enzyme immunoassay TNF tumor necrosis factor EIEC enteroinvasive Escherichia coli UTIs urinary tract infections ELISA enzyme-linked immunosorbent assay WBC white blood cell xi How to Use This Series Green box = Easy question Yellow box = Medium question Chapter Red box = Hard question Head Section Header Question Stem Answer Options In general, an easy question requires only a diagnosis based upon the question stem. A medium question requires not just the diagnosis of the condition based upon the question stem, but knowledge about that diagnosis so as to answer a question about it. Hard questions are a combination of medium questions with less commonly known material about the diagnosis. xii