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Author [[PageAuthor::Ahmed Zaghw, M.D. [1]]]
Exam Type USMLE Step 2 CK
Main Category
Sub Category Gastrointestinal, Infectious Disease
Prompt A 30 year old adult male comes to the clinic of progressive weight loss over 10 pounds, the condition started 18 months earlier when he noticed progressive non bloody diarrhea. He reports that he feels malaise and aching in multiple joints allover his body and his energy level is low for the last couple of months. He admits that he has few unprotected sexual relationships. The past medical history is non-relevant. He denies taking any alcohol or cigarette. He works as DJ composer and get used to travel out of United States frequently for business trips. The vital signs shows a temperature of 37.0 C with soft non tender abdomen and negative fecal occult blood stool. The laboratory is negative for antiendomysial antibodies. The small intestine biopsy shows a PAS staining macrophages. Which is the best next step?
Answer A Start Antibiotic
Answer A Explanation [[AnswerAExp::Incorrect- Antibiotics could be started to treat Whipple's disease. Whipple's disease is caused by bacteria Tropheryma whippelii and presents with arthralgias, abdominal pain, diarrhea and weight loss. Patient may also have fever, chills and hyperpigmentation. Joint involvement is most frequently in the form of migratory polyarthralgia. Small intestinal biopsy is of high yield diagnostic test of choice. The biopsy shows villous atrophy and Periodic Acid-Schiff positive deposits in lamina propria. Those findings are pathognomonic of Whipple's disease.]]
Answer B Repeat colonscopy after cortisone
Answer B Explanation Incorrect- Colonscopy is needed for follow up in crohn's disease. First, we need to investigate the reason for the diarrhea.
Answer C Check HIV ELISA
Answer C Explanation [[AnswerCExp::Correct- AIDS could manifest initially with low-grade fever, lymphadenopathy, diarrhea, and malnutrition, but it is less likely to be associated with skin hyperpigmentation. Given the history of extensive travel history and unprotected sexual intercourse should raise the suspicion of HIV infection.]]
Answer D Gluten free diet
Answer D Explanation [[AnswerDExp::Incorrect- Celiac disease is due to gluten sensitivity. It typically occurs between 10-40 years of age. The patient presents with features of malabsorption-like chronic diarrhea, steatorrheaand flatulence.]]
Answer E Pancreatic enzymes replacement.
Answer E Explanation Incorrect- Pancreatic enzymes replacement is indicated in chronic pancreatitis, when the exocrine functions of the pancreas are deteriorating.
Right Answer C
Explanation [[Explanation::

Educational Objective: AIDS could manifest initially with low-grade fever, lymphadenopathy, diarrhea, and malnutrition.
References: First Aid USMLE 2CK]]

Approved No
Keyword HIV, Diarrhea
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