A 69-year-old male citizen of Mexico who arrived a month ago to visit his son and daughter-in-law in Florida for the summer, was evaluated at an urgent-care center for a 3-day history of increasing pain in his left jaw, chest and shoulder. He also complained of sore throat, anxiety, insomnia, nausea and vomiting. He said he had received a spider bite on his left jaw and that the pain had started after that. His daughter-in-law commented that he had been somewhat confused since arriving here and that she couldn't remember a spider bite. He was transferred to the hospital and treated for chest pain, but evaluation ruled out cardiac disease and pneumonia. He rejected all oral fluids and continued to complain of the spider bite. He was sent to the mental health unit where he was noted to be anxious and have impaired memory. He was diagnosed with anxiety disorder and given tranquilizers and discharged.
Question 1 - Single Best Answer
Insects and other arthropods (ticks) are known to transmit a number of diseases of bacterial, viral, and parasitic origin. Are spiders implicated in the transmission of any common infectious diseases?
A) yes
B) no
Question 2 - Single Best Answer
Which of the following groups of diseases are all transmitted by insects or ticks?
A) yellow fever, Lyme disease, typhoid fever
B) syphilis, gonorrhea, AIDS
C) Rocky Mt. spotted fever, typhus, viral encephalitis
D) rabies, viral encephalitis, Lyme disease
E) African sleeping sickness, giardiasis, plague
Question 3 - Single Best Answer
Which of the following microbes can cause chest pain?
A) influenza virus
B) Streptococcus pneumoniae
C) Coxsackievirus B
D) rabies virus
E) all of the above
Question 4 - Single Best Answer
Which of the following groups of infectious diseases cause neurologic changes?
A) cat scratch disease, measles, meningitis
B) AAV infection, mycoplasma pneumonia, tetanus
C) meningitis, viral encephalitis, rabies
D) chicken pox, measles, rotavirus infection
E) gonorrhea, syphilis, Herpes infection
Two days later the gentleman returned in acute distress. He complained of a headache and also a terrible thirst. He had a fever of 39.6, hypersalivation, inability to swallow, and a staggering gait. As the technician tried to take a routine blood sample, the man snapped at her. None of the doctors or nurses had ever seen anything quite like it. However, a nurse from the Philippines thought she recognized the disease immediately. None of the doctors would listen to her, however.
Question 5 - Single Best Answer
What rare disease did the nurse think she recognized?
A) encephalitis
B) leishmaniasis
C) meningitis
D) cysticercosis
E) rabies
The doctors decided, instead, to do a spinal tap to diagnose the man's disease.
Question 6 - Single Best Answer
What diseases might they be considering when they ordered the spinal tap?
A) meningitis
B) encephalitis
C) both A and B
D) neither A nor B
Question 7 - Single Best Answer
What are the most common causes of acute meningitis?
A) Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae bacteria
B) Listeria monocytogenes, Escherichia coli, and Streptococcus agalactiae bacteria
C) measles, mumps, and herpes viruses
D) cryptococcus and histoplasmosis fungi
E) enteroviruses
The blood work and CSF (cerebral spinal fluid) evaluation showed the following:
Question 8 - Single Best Answer
The CSF glucose and protein profile is most characteristic of?
A) bacterial infection
B) viral infection
C) fungal infection
Question 9 - Single Best Answer
What does a negative Gram stain mean?
A) he doesn't have viral meningitis
B) he doesn't have meningitis
C) he doesn't have bacterial meningitis
D) he has encephalitis
E) no bacteria were visible in his CSF
Question 10 - Single Best Answer
EEEV, WEEV, VEEV and St. Louis Encephalitis virus all cause encephalitis. How are these viruses transmitted?
A) from horses
B) by bird droppings
C) by mosquitoes
D) by mosquitoes or ticks
E) via the respiratory route from other infected humans
Based on the analysis of the CSF and the negative Gram stain, the doctors decided he had a viral encephalitis. His condition rapidly deteriorated and even though he was placed on respiratory support he died the next day. Brain specimens were sent to the Department of Pathology where rabies was diagnosed on the basis of Negri bodies and detection of rabies antigen by a positive reaction after staining with fluorescent anti-rabies antibody. Correspondence with his family in Mexico revealed that a puppy had bitten him on the neck two weeks before he came to Florida (i.e., about six weeks ago). He had thoroughly cleaned the bite site and because it was not deep, he had not worried about it. The puppy had been taken to another neighborhood and abandoned because it had tried to bite both humans and other animals.
Question 11 - Single Best Answer
What behavior occurs in rabies that does not occur in other viral encephalitides?
A) excessive salivation
B) hydrophobia
C) biting (snapping)
D) all of the above
E) none of the above
Question 12 - Single Best Answer
How did the man get rabies?
A) the spider bite
B) the puppy bite
C) the drinking water in Mexico
D) via the respiratory route
E) from a corneal transplant
Question 13 - Single Best Answer
How could the man's rabies have been prevented?
A) vaccination prior to the bite
B) vaccination after the bite
C) prophylactic interferon after the bite
D) hyperimmune globulin
E) B and D
Question 14 - Single Best Answer
Who discovered that rabies could be prevented by post-exposure vaccination?
A) Salk
B) Sabin
C) Jenner
D) Koch
E) Pasteur
Twenty health care workers who had helped care for the gentleman were given rabies vaccination. His son and daughter-in-law also received it. None became sick though. Health authorities in Mexico were notified and administered vaccine to 4 children who had played with the dog. The abandoned puppy was never found, but they identified a 10-block area in which all owned dogs were vaccinated and all strays were destroyed. No other cases were reported however.
Question 15 - Single Best Answer
What other viruses are in the same family as rabies?
A) EEEV
B) Lyme disease virus
C) California Encephalitis virus
D) Norwalk virus
E) none of the above
