Johns Hopkins HIV/AIDS Specialty Test

We would appreciate it if you would answer the first three questions. However, if you choose not to tell us your e-mail address and you are a health care provider, we would appreciate it if you would at least tell us the number of HIV seropositive patients you care for. This will help us to correlate exam scores with the experience of the provider. Thank You.

Are you a health care provider?
NoYes

If you do provide health care, how would you describe yourself professionally?

If you provide health care, how many HIV-infected patients do you care for?
None
1-10
11-50
51 or more

Your E-mail Address(Optional)

Please answer every question. There is only one correct answer for each question. You will see the correct answers and receive your score after you have answered all of the questions.

1. Which of the following drugs accelerates the p450 metabolic pathway?
Indinavir
Delavirdine
Saquinavir (Fortovase)
Nevirapine
Lopinavir

2. Which of the following protease inhibitors is most likely to be hepatotoxic?
Nelfinavir
Ritonavir
Saquinavir
Indinavir
Nelfinavir

3. A 40-year-old man with AIDS and a CD4 count of 80/mm3 has a fever and a right lower lobe infiltrate. Which of the following organisms would be considered to be the most likely cause of his pneumonia if recovered from BAL fluid (bronchoalveolar lavage)?
Cytomegalovirus
Herpes simplex
Legionella pneumophila
Enterobacter cloacea
Candida albicans

4.A patient receiving initial treatment with AZT + 3TC + nelfinavir has a viral load that decreased from 60,000 copies/ml at baseline to 4,000 copies/ml at 12 weeks. The intensification that makes most sense is:
Add hydroxyurea
Add efavirenz
Add abacavir
Substitute indinavir for nelfinavir
Add ritonavir

5. A 32-year-old man with advanced HIV infection presents with cough and low grade fever of two weeks duration. He has a history of PCP, thrush, ITP, and wasting. Recent medications include ddI, d4T, nelfinavir, dapsone, nystatin, and prednisone. Chest x-ray shows a cavity lesion measuring 4 cm in the right lower lobe. A BAL yields Candida albicans, Nocardia asteroides, P. aeruginosa, and CMV. Which of the following antibiotics should be given?
Ganciclovir
Amphotericin B
Fluconazole
Ceftazidime
Trimethoprim-sulfamethoxazole

6. Which of the following shows the best penetration into the central nervous system?
Nevirapine
Indinavir
Nelfinavir
ddI
ddC

7. Which of the following best predicts long-term HIV suppression?
The nadir of plasma HIV RNA levels following treatment
Treatment in relatively early stage disease as indicated by a CD4 count >200/mm3
A relatively low plasma HIV RNA level at the time antiretroviral therapy is initiated
Absence of an AIDS-defining opportunistic infection
Use of a regimen that contains 2 protease inhibitors

8. A 25-year-old HIV-infected man presents to your office with severe herpes proctitis. The patient has been treated with acyclovir, 200 mg five times daily for six weeks without improvement in the lesions. On repeat culture of the rectum, herpes simplex virus 2 is again isolated and further testing reveals that this is a thymidine kinase-deficient strain. Which is the preferred treatment option for this condition?
Foscarnet
Vidarabine
Ganciclovir
Valacyclovir
Famciclovir

9. Which of the following is least likely to cause peripheral neuropathy?
3TC
d4T
ddI
ddC

10. A 43-year-old man with AIDS presents with a four-week history of ataxia, progressive right hand weakness, and tremor. Physical examination confirms his symptoms. His CD4 cell count is 56/mm3, and serum antitoxoplasma IgG antibody titer was negative one year ago. An MRI of the head reveals a solitary 2 x 4 cm lesion in the left cerebellar hemisphere which gives a high signal intensity on T2-weighted images but does not enhance with gadolinium. No mass effect is demonstrated. The most likely diagnosis is:
Toxoplasmosis
A fungal abscess
Primary CNS lymphoma
Progressive multifocal leukoencephalopathy (PML)
A mycobacterial abscess

11. A 37-year-old man with advanced HIV infection hospitalized with a fever to 103F, BP 80/60, chills, headache, and diarrhea with 3-5 stools/day for two days. He has a history of PCP x 2, CMV retinitis treated with IV ganciclovir, aphthous ulcers in the mouth, and thrush. Current medications include d4T, ddI, ritonavir, Fortovase, ganciclovir, fluconazole, dapsone, Megace, and vitamins. PE shows only fever and thrush; the Hickman catheter site appears clean and fundoscopic exam shows no new CMV lesions. Lab studies show:
WBC 4,200/dL, hematocrit 22%;
SMA-12 (chemistry panel) normal except for AST 56 U/L, creatinine 1.3 mg/dL;
Clear chest x-ray;
Negative CSF analysis (cryptococcal antigen pending);
Stool studies including C. difficile toxin assay are pending. After cultures, treatment should begin immediately with which of the following?
Trimethoprim-sulfamethoxazole
Oral vancomycin
Ceftazidime plus vancomycin
Amphotericin B
No antimicrobial treatment pending results of cultures (blood, urine and stool)

12. All of the following are correct about the skin lesion at the scalp and "butterfly area" except:
It usually responds to topical steroids
It is caused by a fungus infection
It is often pruritic
It usually responds to topical ketoconazole
It usually responds to PUVA therapy

13. Which of the following may cause a deceptively high CD4 cell count?
HTLV II co-infection
Splenectomy
Major surgery
Pregnancy
Acute administration of corticosteroids

14. Which of the following vaccines is contraindicated in patients with HIV infection due to the potential to cause infection?
Tetanus
Influenza
Varicella
Haemophilus influenzae type B
Hepatitis A virus

15. Positive serology showing antibody usually indicates which of the following organisms is not present?
Toxoplasma gondii
Cytomegalovirus
Epstein-Barr virus
Hepatitis B virus
Varicella-zoster

16. Patients with lipodystrophy who switch from a protease inhibitor-containing regimen to nevirapine will most likely have:
Virologic failure
Reversal of lipoatrophy
Improvement in hypercholesterolemia
Improvement in fat accumulation
Intolerance to the new regimen

17. Which of the following microbes is most likely to cause a cerebrospinal fluid showing elevated protein and a polymorphonuclear pleocytosis in late-stage HIV infection?
Toxoplasma gondii
Cytomegalovirus
Treponema pallidum
JC virus (Progressive multifocal leukoencephalopathy)
Herpes simplex

18. The most common cause of fever of unknown origin with no focal symptoms in a previously untreated patient with a CD4 count of 10/mm3 is:
Disseminated M. avium infection
Disseminated cytomegalovirus
Pneumocystis carinii pneumonia
Toxoplasmosis
Lymphoma

19. Which of the following fungi is an agent of disseminated infections primarily in southeastern or eastern Asia?
Penicillium marneffei
Coccidioides immitis
Histoplasma capsulatum
Blastomyces dermatitidis
Paracoccidioides brasiliensis

20. A 45-year-old woman donated blood prior to elective surgery for urinary incontinence. The blood bank reports that the unit is repeatedly reactive in a HIV-1 enzyme immunoassay (EIA), with a negative HIV-1 Western blot. A test done 1 year previously showed the same results. She was born in Pennsylvania, has no history of blood transfusion or injection drug use, and has been sexually monogamous for ten years with a single partner who has no known HIV risk factors. Your advice is:
Defer surgery until repeat HIV testing can be done at three months
Advise the patient that she has early HIV infection
Perform testing on her sexual partner to determine if he is the source of the infection
Test the patient's sexual partner for HIV
Inform the patient that HIV infection is unlikely given the absence of risk factors and the negative Western blot result

21. All of the following are correct about this lesion except:
It will respond to treatment with acyclovir
It will respond to treatment with ganciclovir
This lesion is a rare complication of diseases other than HIV infection
This lesion is usually not treated
Scrapings of lesions will show pseudomycelia

22. The predominant subtype of HIV-1 in Latin America is:
A
B
C
D
E

23. A 27-year-old intravenous drug abuser is referred to you with positive HIV serology. He is asymptomatic but continues to practice high risk behavior. Past medical history indicates herpes zoster involving the right leg one year ago. Initial evaluation shows the following:
WBC 3,400 with 72% PMNs, 5% bands, 15% lymphocytes, 3% monocytes;
CD4 count 240/mm3;
Chemistry panel normal;
Hepatitis serology HBsAg neg and anti-HBs positive;
VDRL negative;
Chest x-ray negative;
PPD negative. Treatment at this time should include which of the following?
Pneumovax
Azithromycin prophylaxis
PCP prophylaxis
Hepatitis B vaccine
Acyclovir

24. The best explanation for abacavir hypersensitivity is that it:
is regulated by MHC haplotype
is IgE mediated
is IgA mediated
results from chemokime receptor changes
results from drug transport changes

25. Which of the following conditions in a person with HIV infection is suggestive of the greatest degree of immunosuppression?
Peripheral generalized lymphadenopathy
Thrush
Pneumonia due to S. pneumoniae
Cavitary pulmonary tuberculosis
Vaginal candidiasis

26. A HIV-infected patient has cough, fever, and sputum production for 4 days. A chest x-ray shows a left lower lobe infiltrate, the WBC is 4,200/mm3 and a CD4 count is 150/mm3. He takes no medication. The most likely microbial pathogen is:
S. pneumoniae
Mycobacterium tuberculosis
Rhodococcus equii
P. carinii
Cryptococcosis

27. A HIV-infected woman has headache, fever, and a seizure. The CD4 count is 56/mm3, WBC is 3,200/mm3, and a MRI shows two ring-enhancing lesions. She takes no medicines other than methadone. The most likely diagnosis is:
Lymphoma
Toxoplasmosis
Cryptococcosis
PML
Herpes simplex encephalitis


28. Which of the following is most likely to cause methadone withdrawal when the two are co-administered?
Lopinavir
Ritonavir
ddI
Nevirapine
Nelfinavir