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NBME 23 Answers

nbme23/Block 1/Question#25 (44.5 difficulty score)
A 5-year-old boy who is undergoing induction ...
Varicella-zoster virusπŸ”,πŸ“Ί
tags: micro 

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submitted by sajaqua1(535),
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Clritcai nosipt orf thsi oq:esnuit 5 eary lod y,bo resmsipsudepnmou besceau of th,reoephmayc 2 yda ytoshri of e,rfev h,cogu enhsosrst fo ,brteah eelfbir (.8110 F,) tpirirsoaens m,n46/i hiwt oscsyain dan ieergeazndl lacvsruei ahs.r veiEtxsne nudrola rif.itlnaoint

fO the ptnisoo eidtls yonl lsaesem nad ZVV ievg a arhs. A hras omfr essemla llyuaus rttass yatosrrll dan ndcdesse acdl,yula nda si flta dan auetyetohsr.m By ,nostcart VZV )(cchinpkoxe ersnpest with zgdeaerneil hsar that ilcyqku tnriiotssan fmor acmlaur ot arluapp hnet ot ruvsa.ielc

sympathetikey  Good call. +6  
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +5  
nwinkelmann  What threw me off was that it didn't mention the synchronicity of the rash. I stupidly took failure to mention to mean that the rash was synchronous, which doesn't fit VZV because chickenpox rash is characterized as a dyssynchronous rash (i.e. all stages of the macule to papule to vesicle to ulceration are seen at the same time). MUST REMEMBER: don't add information not given! +5  
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +2  

submitted by justherefortheyield(2),

Per multiple sources: measles can be vesicular and also can lead to giant cell pneumonia in the immunocompromised. ?!?!?!?

elephantbuddy  I was stuck on that too, but I think that measles more commonly presents with a maculopapular rash whereas a vesicular rash is more typical of VZV. +2  

submitted by seagull(1583),
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Did aoenny nhtik ttha fnuznliea saw tghir? I tdrdensuan tath HserZ-ep nca uasec npoueiamn but yhw is hsit rsawne treteb over fnuznaeli?

jrod77  I believe it's the vesicular rash that gives it away. I thought it was influenza too, but i re-read the questions and I realized they included a rash which disqualifies influenza. +4  
charcot_bouchard  Also h/o of immunsupression, disseminated VZV. Influenza itself doesnt cause severe disease. secondary PNA does. which u will see in elderly. usually +1