mksap -id- 8 - vikasi

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Infectious Disease Medicine:Question 8
A 54-year-old man is evaluated because of fatigue, backache, and intermittent fever of 3 months duration. He has no history of cardiac disease or drug allergies.
On physical examination, there are three splinter hemorrhages under his fingernails but no other abnormalities of his skin. Ophthalmologic examination reveals a right conjunctival hemorrhage. Funduscopic examination is normal. The lungs are clear. Cardiac examination discloses a soft diastolic murmur of aortic insufficiency, which is a new finding. There is no splenomegaly. Neurologic examination is normal. Four sets of blood cultures grow a microorganism of the viridans streptococci group, which is sensitive to penicillin. A transthoracic echocardiogram shows a thickened bicuspid aortic valve with evidence of mild aortic insufficiency. A transesophageal echocardiogram confirms these findings and also shows an oscillating mass on the aortic valve. Which of the following intravenous agents is the most appropriate initial antibiotic therapy for this patient?
A. Vancomycin for 4 weeks
B. Penicillin G for 4 weeks
C. Penicillin G plus gentamicin, both for 4 weeks
D. Penicillin G plus gentamicin, both for 6 weeks
E. Ceftriaxone for 8 weeks

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D...
6 wks coz of the vegetation!!

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Infectious Disease Medicine:Question 8
The correct answer is B
Educational Objectives
Understand how to diagnose and treat native valve endocarditis.
Critique
The patient meets both major Duke criteria for definite endocarditis (that is, a typical microorganism grown on two blood cultures and evidence of endocardial involvement met either by echocardiography because of the oscillating intracardiac mass or by physical examination because of the new aortic regurgitant murmur). His history also raises suspicion of endocarditis. Although not necessary to meet the diagnostic criteria in this case, the presence of the bicuspid aortic valve, fever, and conjunctival hemorrhage (but not the splinter hemorrhages) fulfills three of the minor Duke criteria for endocarditis. Endocarditis due to sensitive viridans streptococci on native valves can be treated for 4 weeks with penicillin or ceftriaxone or for 2 weeks when either agent is combined with synergistic low-dose gentamicin. In a patient with uncomplicated endocarditis, the addition of gentamicin decreases the total treatment course from 4 weeks to 2 weeks.
In the absence of penicillin allergy or penicillin resistance, vancomycin is inappropriate. Although adding synergistic doses of gentamicin is appropriate, using this combination regimen for 4 (or 6) weeks is not part of a standard treatment regimen. Similarly, ceftriaxone can be substituted for penicillin in a standard 4-week regimen but would not be used for 8 weeks for a patient with uncomplicated endocarditis.