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NBME 20 Answers

nbme20/Block 3/Question#35

A 51-year-old man has the acute onset of fever and ...

Cytomegalovirus infection

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 +21  upvote downvote
submitted by amorah(43),

Fever -> rule out left ventricular failure TMP-SMX prophylaxis -> rule out Pneumocystis jiroveci Kidney transplant but no WBC/RBC in urine -> rule out transplant rejection

Leaving CMV and atypical mycobacterium as the remaining two options. CMV is more likely in a transplant patient.





 +3  upvote downvote
submitted by hayayah(536),

CMV is associated with infecting organ transplant patients. CMV is transmitted via sexual contact, organ transplant, or vertically via placenta. Reactivation of CMV occurs in the immunosuppressed.

Organ transplant patients are at an increased risk of CMV pneumonia.





 +0  upvote downvote
submitted by mrglass(4),

Why would this not be acute transplant rejection leading to ARDS? The creatinine is elevated, and I see any reason why it would be elevated beyond rejection

sammyj98  I selected the same. I think part of the question wanted us to recognize that the pt was not receiving CMV prophylaxis (hinted that they are getting TMP-SMX but no Gancyclovir) so they're at really high risk for CMV specifically. UpToDate: •Universal prophylaxis with valganciclovir or ganciclovir is typically given to patients at risk for cytomegalovirus (CMV) reactivation (eg, seropositive recipients and those with seropositive donors). The duration of therapy often depends on the type of organ transplanted, the risk status of the patient, and individual institutional practice. Some transplant centers prefer to use a pre-emptive approach (eg, routine CMV viral load monitoring within initiation of treatment when reactivation becomes evident) for specific patient populations. (See 'Cytomegalovirus' above.) +  


via @sammyj98 via UpToDate:

Universal prophylaxis with valganciclovir or ganciclovir is typically given to patients at risk for cytomegalovirus (CMV) reactivation (eg, seropositive recipients and those with seropositive donors). The duration of therapy often depends on the type of organ transplanted, the risk status of the patient, and individual institutional practice. Some transplant centers prefer to use a pre-emptive approach (eg, routine CMV viral load monitoring within initiation of treatment when reactivation becomes evident) for specific patient populations.

+/- drdoom(293),