Self evaluation questions

What is acute diarrhea?

Answer

• Diarrhea lasting two weeks or less is considered acute diarrhea.

What is the strategy of workup and treatment for acute diarrhea?

Answer

• Lasts two weeks or less
• Self-limited
• Requires no diagnostic work-up 
• Symptomatic treatment only (fluids) 

What are the common acute infectious diarrheas?

Answer

• Viruses
• Bacteria
  • toxins
    • S aureus
    • C difficile
    • Toxigenic E. Coli
  • invasion
    • Shiegella
    • Salmonella
• Parasites
  • Giardia
  • Cryptosporidium

What are the common acute non-infectious diarrheas?

Answer

• Drugs
  • laxatives
  • antacids
  • alcohol
  • antibiotics
• Food toxins
  • seafood
• Metabolic
  • hyperthyroidism
• Functional

Under what circumstances will you consider investigating acute diarrhea?

Answer

Acute diarrhea should be investigated if there is:

• Evidence of tissue invasion, such as blood or pus in the stool 
• Fever 
• Leukocytosis 
• Severity that produces significant fluid and electrolyte loss  
• E.g., shigella and salmonella infections

What questions should you ask a patient with diarrhea?

Answer

• Compare the patient’s usual or normal frequency with that of the current pattern 
• Characteristics of stool
• Change in odor
• Change in timing
• Precipitating events 
• Causes of relief
• Associated symptoms 
• Predisposing  factors 

What are the common viruses causing diarrhea?

Answer

• Rotavirus

• Norwalk virus

• Astrovirus

• Adenovirus

• Coronavirus

 Which season is rotavirus infection commonly encountered?

1. Winter
2. Spring
3. Summer
4. Fall

Answer: 

A. Winter

• It may be responsible for as 50% of pediatric hospitalizations during winter.

Rotavirus infection is common in:

1. Adults
2. Teens
3. Neonates
4. Children

Answer

D. Children

• Most common diarrheal pathogen seen in children less than 5-years old in United states.

Rotavirus infection is:

1. Sporadic
2. Widespread outbreaks
3. Day care center

Answer

A. Sporadic

Rotavirus can be isolated from:

1. Feces
2. Blood
3. Urine
4. Sputum

Answer

A. Feces

Diarrhea due to rotavirus will be improved  following fasting.

1. True
2. False

Answer

A. True

Diarrhea in rotavirus infection is due to:

1. Inflammation of bowel
2. Malabsorption
3. Secretary phenomenon

Answer

B. Malabsorption

• When diarrhea improves with fasting it is due mal-absorption - osmotic diarrhea.

Diarrhea in rotavirus is due to:

1. Viral endotoxin
2. Malabsorption
3. Both
4. Neither

Answer

C. Both

• Viral enterotoxin is responsible for acute diarrhea.  Malabsorption plays a role after initial enterotoxin induced diarrhea.

Diagnosis of rotavirus infection is best made by:

1. Antigen detection
2. Viral cultures
3. EM of virus in stool
4. Serum antibody
5. All of the above

Answer

A. Antigen detection

• Enzyme immunoassay and latex agglutination assays for Rv antigen in stool is available as a rapid test.

Treatment options for rotavirus infection is:

1. Supportive care to correct dehydration
2. Anti-viral agents
3. Immunoglobulins
4. All of the above

Answer

A. Supportive care to correct dehydration

Rotavirus infections can be prevented by:

1. Vaccines
2. Immunoglobulin
3. Interrupting enteric transmission

Answer

C. Interrupting enteric transmission

• The virus is transmitted by fecal-oral contamination. Strict hand washing and the use of gloves by health care workers is necessary.
• The vaccine has been withdrawn because of intussusceptions, otherwise it was reasonably effective.

People at high risk for developing rotavirus infection are:

1. Child care center
2. Homosexuals
3. Immunocompromised
4. Home contacts

Answer

A. Child care center

• It is a disease of children and is transmitted by fecal-oral contamination.

Can you get reinfected with rotavirus?

1. Yes
2. No

Answer

A. Yes

• Type specific immunity is generated in response to rotavirus infection, which provides partial protection from another infection. However , at least four serotypes of rotavirus exist.

Which is the target cell for rotavirus?

1. Small intestinal villi
2. Large Intestine
3. Stomach
4. Liver

Answer

A. Small intestinal villi

"Winter-vomiting disease" is due to:

1. Rotavirus
2. Norwalk virus
3. Enterovirus

Answer

A. Rotavirus

Children admitted for diarrhea in the month of January, are most likely infected with:

1. Rotavirus
2. Norwalk virus
3. Enterovirus

Answer

A. Rotavirus

All children by the age of three are infected with rotavirus.

1. True
2. False

Answer

A. True

The best method by which to diagnose rotavirus infection in clinical practice is by:

1. Enzyme immunoassay for rotavirus antigen
2. Latex agglutination
3. Electron microscopy
4. RNA gel electrophoresis

Answer

A. Enzyme immunoassay for rotavirus antigen

• It is a rapid test. Latex agglutination is also useful.
• Virus isolation is not routinely performed in clinical setting.

The most common etiology for hepatitis is due to:

1. HAV
2. HAB
3. HAC

Answer

A. HAV

• HAV accounts for 20 - 50% of hepatitis cases.

Hepatitis A infection is common during:

1. Winter
2. Spring
3. Summer
4. Fall
5. No seasonal predilection

Answer

E. No seasonal predilection

HAV can survive in sea water:

1. True
2. False

Answer

A. True

Symptomatic hepatitis A infection is common in:

1. Adults
2. Teens
3. Neonates
4. Children

Answer

A. Adults

1. With HAV infection, symptomatic hepatitis occurs in approximately 30% of children and 70% of adults.

Hepatitis A can be isolated from:

1. Feces
2. Blood
3. Urine
4. Sputum

Answer

A. and B. Feces and  Blood

Diagnosis of hepatitis A infection is best made by:

1. Viral cultures
2. EM of Virus
3. Serum antibody
4. All of the above

Answer

C. Serum antibody

• The virus is not cultivable. Direct detection by immunologic or EM is not widely available.

What are the causes for infectious hepatitis?

Answer

• Hepatitis A, B, D, non-A and non-B viruses

• Epstein-Barr virus

• Cytomegalo virus

• Toxoplasmosis

• Leptospirosis

What are the causes for non-infectious hepatitis?

Answer

• Drug induced

• Alcoholic

Treatment options for symptomatic hepatitis A infection are:

1. Anti-viral agents
2. Immunoglobulins
3. Both
4. Neither

Answer

D. Neither

• Only supportive care. Immunoglobulin can prevent development of symptomatic infection, but probably of not much use once the patient has symptomatic infection.

Hepatitis A infections can be prevented by:

1. Vaccines
2. Immunoglobulin
3. Interrupting enteric transmission
4. All of the above

Answer

D. All of the above

People at high risk for developing hepatitis A infection are:

1. Child care center personnel
2. Homosexuals
3. International travelers
4. Home contacts

Answer

E. All of the above

Can you get reinfected with hepatitis A.

1. Yes
2. No

Answer

B. No

• You get lasting immunity.

Which is the target cell for hepatitis A?

1. Small intestinal villi
2. Large Intestine
3. Stomach
4. Liver

Answer

D. Liver

Symptomatic hepatitis is more common in HAV infection.

1. Adults
2. Children

Answer

A. Adults

Chronic hepatitis is more common with:

1. HAV
2. HBV

Answer

B. HBV

Risk for hepatic carcinoma is higher with:

1. HAV
2. HBV

Answer

B. HBV

• HAV infections are self limiting. HAB infections can progress to chronic stage and has a higher incidence of hepatic carcinoma.

HAV infection can be spread by eating uncooked:

1. Beef
2. Chicken
3. Oysters

Answer

C. Oysters

• Eating raw oysters (shell fish)  from fecally contaminated water is one way of getting infected with HAV.

Does this mean that one cannot eat oysters?

Answer

• Eating only adequately cooked seafood will eliminate the risk for HAV. The virus will be inactivated by boiling for 1 minute.

HAV infection results in:

1. Fulminat hepatitis
2. Progresses to chronic hepatitis
3. Benign self limited disease

Answer

C. Benign self limited disease

Carrier state for HAV is seen in:

1. Adults
2. Children

Answer

B. Children

• Children more frequently are asymptomatic carriers. Adults do not become carriers.

Which of the following test signifies recent infection?

1. IgM antibody to HAV
2. IgG antibody to HAV

Answer

A. IgM antibody to HAV

• IgG antibodies without IgM antibody indicates past infection and immunity.

For house contacts with HAV the best agent for preventive measure is:

1. Immunoglobulin
2. HAV Vaccine

Answer

A. Immunoglobulin

• The incubation period is 2 - 8 weeks. Immunoglobulin when given within two weeks after exposure to HAV is greater than 85% effective.in preventing symptomatic infection.
• Onset of protection with HAV vaccine most likely requires 2 - 4 weeks.

A missionary is planning a visit  to India for a one year stay. What advise will you give in regards to protecting him from HAV infection?

Answer

Immune globulin should be given when one is traveling to endemic areas for HAV infection. Protection lasts for only six months and the immunoglobulin should be repeated at six month intervals.

Who are the candidates for receiving vaccine for HAV infection?

Answer

• International travelers

• Children in high risk community

• Homosexual men

• Food handlers

Norwalk infection is common during:

1. Winter
2. Spring
3. Summer
4. Fall
5. No seasonal predilection

Answer

E. No seasonal predilection

Norwalk infection is common in:

1. Adults
2. Teens
3. Neonates
4. Children
5. No special predilection

Answer

E. No special predilection

Norwalk infection is:

1. Sporadic
2. Outbreaks

Answer

B. Outbreaks

Norwalk can be isolated from:

1. Feces
2. Blood
3. Urine
4. Sputum

Answer

A. and B. Feces and Blood

Diarrhea in norwalk infection is due to:

1. Inflammation of bowel
2. Malabsorption
3. Secretary phenomenon

Answer

B. Malabsorption

In the clinical setting, the diagnosis of norwalk infection is best made by:

1. Clinical manifestations
2. Viral cultures
3. EM of Virus in stool
4. Serum antibody
5. All of the above

Answer

A. Clinical manifestations

•  CDC relies on EM and seroconvertion studies, mainly for investigation of outbreaks.

Treatment options for norwalk infection is:

1. Supportive care to correct dehydration
2. Antiviral agents
3. Immunoglobulins
4. All of the above

Answer

A. Supportive care to correct dehydration

Norwalk infections can be prevented by:

1. Vaccines
2. Immunoglobulin
3. Interrupting enteric transmission

Answer

C. Interrupting enteric transmission

• Active immunization against this group is not possible.

Outbreaks of  norwalk infection occurs in:

1. Child care centers
2. School camps
3. Nursing homes
4. Swimming facilities
5. All of the above

Answer

E. All of the above

Which is the target cell for norwalk?

1. Upper jejunal mucosa
2. Large Intestine mucosa
3. Stomach mucosa
4. Liver

Answer

A. Upper jejunal mucosa

Enterovirus infection is common during:

1. Winter
2. Spring
3. Summer
4. Fall

Answer

C. Summer

• In temperate climates, enteroviral infections are more common in summer and early fall, but the seasonal pattern are less evident in the tropics.

Enterovirus infection is common in:

1. Adults
2. Teens
3. Neonates
4. Children

Answer

D. Children

• Infections and clinical attack rates typically are highest in infants and young children.

Enterovirus can be spread by:

1. Feces
2. Sputum
3. Fomites
4. All of the above

Answer

D. All of the above

• Fecal shedding for up to three months. Respiratory tract shedding is limited to a week or less. Enterovirus may survive on environmental surfaces, for periods long enough to allow transmission from fomites also.

Treatment options for enterovirus infection is:

1. Supportive care to correct dehydration
2. Anti-viral agents
3. Immunoglobulins
4. All of the above

Answer

A. Supportive care to correct dehydration

• No specific therapy is available. Immunoglobulins has been useful in life threatening neonatal infections and in immunocompromised hosts.

Enterovirus infections can be prevented by:

1. Vaccines
2. Immunoglobulin
3. Interrupting enteric transmission

Answer

C. Interrupting enteric transmission

People at high risk for developing enterovirus infection are:

1. Child care center
2. Homosexuals
3. Immunocompromised
4. Home contacts

Answer

A. Child care center

Can you get reinfected with enterovirus?

1. Yes
2. No

Answer

A. Yes

• Type specific immunity is generated in response to enterovirus infection, which provides protection from another infection with that specific serotype of enterovirus.. However , at least 64 serotypes of enterovirus exist with little, if any cross-protection.

Which is the target cell for coxsackievirus A16?

1. Small intestinal villi
2. Large Intestine
3. Stomach
4. Liver
5. Endothelial cell (Hand, foot, Mouth)

Answer

E. Endothelial cell (Hand, foot, Mouth)