Pediatric Examination and Board Review (176 page)

(B) treatment of hepatosplenic candidiasis in a 3-year-old child with AML

(C) a premature neonate with
Candida tropicalis
fungemia and a renal fungus ball

(D) catheter-associated fungemia with
Candida krusei

(E)
Tinea capitis
in a healthy 8-year-old child

6.
The most common adverse reactions reported with the triazoles include

(A) hepatitis

(B) rash

(C) GI symptoms (nausea, vomiting, diarrhea)

(D) fatigue

(E) anemia

7.
A 12-year-old adolescent boy has fever, cough, and productive sputum production for 4 weeks. A chest radiograph reveals a right lower lobe infiltrate. A sputum culture grows
Blastomyces dermatitis
. He is not vomiting and requires no supplemental oxygen. The antifungal agent of choice for treatment of this infection is

(A) fluconazole

(B) terbinafine

(C) ketoconazole

(D) amphotericin B

(E) itraconazole

8.
Antifungal therapy is begun and the adolescent develops pedal edema. This finding is most likely an adverse effect associated with

(A) fluconazole

(B) itraconazole

(C) ketoconazole

(D) amphotericin B

(E) nystatin

9.
You are asked about the appropriate indications for the use of flucytosine (5-fluorocytosine). You indicate that flucytosine is the preferred treatment for the following infection in combination with amphotericin B

(A) chronic mucocutaneous candidiasis

(B) cryptococcal meningitis

(C) pulmonary aspergillosis

(D) disseminated histoplasmosis

(E) disseminated blastomycosis

10.
A 13-year-old adolescent with AML has persistent fever and neutropenia. Pulmonary infiltrates present are suspicious for aspergillus infection. The antifungal agent of choice for treatment of invasive aspergillosis refractory to amphotericin B is

(A) caspofungin

(B) fluconazole

(C) miconazole

(D) flucytosine

(E) voriconazole

11.
Itraconazole is the preferred antifungal therapy for moderate pulmonary infections caused by all but one of the following fungi

(A)
Histoplasma capsulatum

(B)
Cryptococcus neoformans

(C)
Blastomyces dermatitidis

(D)
Sporothrix schenckii

(E)
Coccidioides immitis

12.
A 13-year-old girl has developed soft disfigured nails with pits and grooves involving only the nails of her hands. A fungal culture grows
Tinea unguium
. The antifungal agent of choice for this infection is

(A) fluconazole

(B) griseofulvin

(C) itraconazole

(D) terbinafine

(E) voriconazole

13.
The duration of therapy for the 13-year-old adolescent with
T unguium
in the previous example should be

(A) 6 weeks

(B) 12 weeks

(C) 24 weeks

(D) 36 weeks

(E) 52 weeks

14.
A 3-year-old child presents to your office because of persistent itching for the past 2 weeks. On physical examination the child is afebrile. The examination of the skin reveals scattered papules and burrows involving the arms, legs, palms, soles, and the trunk. You make the diagnosis of scabies examining the scrapings of a burrow to which mineral oil is first applied. The treatment of choice for this condition includes

(A) lindane 1% lotion

(B) pyrethrins plus piperonyl butoxide

(C) crotamiton 10% cream

(D) single oral dose of ivermectin

(E) permethrin 5% cream

15.
A 3-year-old child develops abdominal pain and diarrhea about 4 weeks after returning with his family from a trip to South America. About 12 weeks later he is diagnosed with iron deficiency anemia and peripheral eosinophilia (20%). Intestinal hookworm infection is detected by identifying the hookworm eggs in feces. You recommend treatment with

(A) albendazole 400 mg in a single dose

(B) mebendazole 100 mg in a single dose

(C) pyrantel pamoate 11 mg/kg per dose (maximum: 1.0 g) for 1 dose

(D) niclosamide 1 g in a single dose

(E) ivermectin 150 μg/kg in a single dose

16.
A 2-year-old child returns with her parents from vacation in Southeast Asia. The child presents to your office with abdominal pain and bloody diarrhea with mucus. You diagnose infection with whipworm (
Trichuris trichiura
) by examination of stool for the characteristics of
T trichiura
eggs. Treatment of the infection should include

(A) albendazole 400 mg in a single dose

(B) mebendazole 100 mg twice daily for 3 days

(C) pyrantel pamoate 1 g in a single dose

(D) ivermectin 200 μg/kg in a single dose

(E) mebendazole 100 mg in a single dose

17.
Metronidazole has both antibacterial and antiprotozoal properties. Major indications for the use of metronidazole include all but

(A) actinomycosis

(B) brain abscess secondary to chronic sinusitis

(C) giardiasis

(D)
Trichomonas
vaginitis

(E) liver abscess secondary to
Entamoeba histolytica

18.
A 4-year-old girl is going to travel with her family to West Africa where chloroquine-resistant
Plasmodium falciparum
is reported. Appropriate chemoprophylaxis for the child would include

(A) doxycycline

(B) atovaquone-proguanil

(C) sulfadoxine-pyrimethamine

(D) clindamycin

(E) chloroquine

ANSWERS

1.
(D)
Fungi are common causes of secondary infection among neutropenic patients who have received courses of broad-spectrum antibiotic therapy. Fungi can also cause primary infections. Studies have indicated that up to a third of febrile neutropenic patients who do not respond to a 1-week course of antibiotic therapy have a systemic fungal infection.

2.
(B)
Nephrotoxicity is the most frequent adverse event, which can result in renal tubular acidosis, hypokalemia, hypomagnesemia from its effect on the kidneys as well as anemia. Amphotericin B inhibits erythropoietin production in the kidney resulting in anemia as the cumulative dose increases. The nephrotoxicity of liposomal amphotericin is much lower than that occurring with the nonliposomal form.

3.
(A)
The premature neonate likely has catheterrelated fungemia caused by
Candida
. The infant could also have disseminated candidiasis. In both these instances a blood culture will yield
Candida
. Amphotericin B deoxycholate is the drug of choice for treatment of suspected fungal infections in premature infants. Renal toxicity in this age group with nonliposomal amphotericin is infrequent.

4.
(B)
Griseofulvin has a time-honored experience in treating
Tinea capitis
. It is given orally and is ineffective topically. Hepatotoxicity is an occasional problem with prolonged use. Liver enzymes should be checked every 8 weeks during use.

5.
(A)
Fluconazole is also effective in preventing relapse of cryptococcal meningitis in patients with AIDS.
C krusei
is resistant to fluconazole.

6.
(C)
Patients may also have transient asymptomatic elevations of liver enzymes. Rashes have been reported, and rare reports of an exfoliative dermatitis in patients with AIDS receiving fluconazole have been described.

7.
(E)
Itraconazole is the preferred treatment for mild to moderate pulmonary disease caused by
B dermatitidis
. Fluconazole can be used as an alternative treatment for pulmonary blastomycosis (
Table 100-1
). For children who are immunocompromised or who have evidence of disseminated disease, amphotericin B is the treatment of choice.

8.
(B)
Itraconazole at high doses can cause hypokalemia and pedal edema. Life-threatening ventricular tachycardias can occur when the antihistamines terfenadine or astemizole are administered with itraconazole.

TABLE 100-1
Preferred Drugs for Initial Treatment of Serious Fungal Infections

*
Alternative therapy for invasive aspergillosis is AmB.
†
Flucytosine has been used in combination with AmB (particularly for meningitis).
Abbreviations: AmB, amphotericin B; Flu, fluconazole; Itr, itraconazole; Vor, voriconazole.

9.
(B)
Flucytosine can be used in combination with amphotericin B for meningeal or other serious cryptococcal infections as well as for
C albicans
infection involving the CNS. Drug levels in the CSF are up to 75% of those found in serum (
Table 100-1
).

10.
(E)
Voriconazole is a triazole derivative of fluconazole that exhibits a wide spectrum of activity against many important fungi including
Candida, Aspergillus, Cryptococcus,
and
Fusarium
. Voriconazole was superior to amphotericin B in a randomized study in adults. A new class of antifungal agents, the echinocandins, are recommended for the treatment of candidemia in adults with neutropenia, but this new class of drugs has not yet been approved by the FDA for treatment in children younger than 12 years (
Table 100-1
).

11.
(B)
For immunocompetent individuals with isolated symptomatic pulmonary infection, fluconazole is the drug of choice for pulmonary cryptococcosis.

12.
(D)
In the past, griseofulvin was the drug of choice for treatment of
T unguium
. Topical antifungal agents are ineffective because of the inability to penetrate the nail bed. Oral terbinafine is well absorbed and penetrates the nail bed. Oral terbinafine is now the treatment of choice for onychomycosis because it has been used successfully to treat
T unguium
in a much shorter period of time than previous antifungal medications.