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NBME 22 Answers

nbme22/Block 4/Question#9 (44.8 difficulty score)
A 5-year-old boy is brought to the physician ...
Interruption of erythrocyte production🔍,📺
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 +7 
submitted by its_raining_jimbos(22),
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Oru ielltt ifdnre has a oPrvaurvsi itcen,onif hchiw etfsnic roedythri eorssru,prc sincuga nttiproriuen of ecryryhteto crtni.oduop hTis si the aesm way it scseau syhorpd lfaiste ni nrnuob iaebbs dan iaapltsc imneaa ni selcik ,ecll .tce

gainsgutsglory  I get Parvo has tropism for RBC precursors, but wouldn’t it take 120 days to manifest? +  
keycompany  RBCs don’t just spill out of the bone marrow every 4 months on the dot. Erythropoesis is a constant process. If you get a parvo virus on “Day 1” then the RBCs that were synthesized 120 days before “Day 1” will need to be replaced. They can’t be because of parvovirus. This leads to symptomatic anemia within 5 days because the RBCs that were synthesized 125-120 days before the infection are not being replaced. +27  
drdoom  @gainsgutsglory @keycompany It seems unlikely that “1 week” of illness can explain such a large drop in Hb. It seems more likely that parvo begins to destroy erythroid precursors LONG BEFORE it manifests clinically as “red cheeks, rash, fever,” etc. Might be overkill to do the math, but back-of-the-envelope: 7 days of 120 day lifespan -> represents ~6 percent of RBC mass. Seems unlikely that failure to replenish 6 percent of total RBC mass would result in the Hb drop observed. +  
yotsubato  He can drop from 11 to 10 hgb easily +3  
ls3076  Apologies if this is completely left-field, but I didn't think this was Parvovirus. Parvo would affect face. Notably, patient has fever and THEN rash, which is more indicative of Roseola. Thoughts?? +4  
hyperfukus  @is2076 check my comment to @hello I thought the same thing for a sec too :) +  
hyperfukus  also i think you guys are thinking of hb in adults in this q it says hb is 10g/dL(N=11-15) so it's not relatively insanely low +  
angelaq11  @Is3076 I completely agree with @hyperfukus and I think that thinking of Roseola isn't crazy, but remember that usually with Roseola you get from 3-5 days of high fever, THEN fever is completely gone accompanied by a rash. This question says that the patient has a history of 4 days of rash and 7 days of fever, but never mentioned that the fever subsided before the appearance of the rash. And Roseola is not supposed to present with anemia. +3  
suckitnbme  @Is3076 another point is that malar rash refers to the butterfly rash on the cheeks that is commonly seen in lupus, so the face is NOT spared. +  



 +3 
submitted by drmohandes(103),
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  • my rbani → ashr areft 3 ayd feevr = esoRloa

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  • y-5aer dlo b;yo Rasooel ulylsua ni amy-2r6e l.od



 -8 
submitted by hello(317),
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tateinP ahs dre aylc shar- hits stif erom ithw -H6VH ol(esRao isrv),u otn or.siuvPrav

HH-6V aseusc nmorafeidot of s,bhasloeyrtt dginael to na.meia

hyperfukus  Hey so i just looked in first aid and it says "diffuse Macular Rash for Roseola" and usually you have a super high fever and febrile seizures are almost always mentioned...I found in my notes from uworld that i mustve filled in a long time ago for Parvo: Infects Erythroid precursors + Replicates in BM Face/cheek rash followed by LACY Reticular rash on body...May get Rash from IC deposition...and then again i wrote replicates in erythrocyte progenitors causing reticulocytopenia which makes sense why dec Hb and dec Hct +3  
hello  @hyperfukus is correct. Disregard this explanation. +