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A 40-year-old patient returns to your office to have his PPD test read. You note 15 mm induration at the test site, to which the patient eagerly informs you that he was vaccinated with BCG as a child. What is an appropriate next step?

A. Initiate 4 drug therapy for 6 months

B. Order a chest x-ray and IGRA test

C. Repeat the PPD in 6 weeks

D. Repeat the PPD at another site immediately

E. No further steps needed. The test is meaningless after BCG vaccination

B. Per the CDC, remote BCG vaccination does not contraindicate TST testing. For cost reasons, it may still be preferable to use it as a screening test in this population. Follow up testing with IGRA +/− chest radiography should reveal if the test is a false-positive.

A Hansen patient has many patches and plaques, no anesthesia, and normal facies. Six months after starting treatment with clofazamine, rifampin, and dapsone, she reports increased erythema of her existing lesions and pain in her extremities and visual disturbances. What is the appropriate action?

A. Stop all antibiotics

B. Add minocycline

C. Start thalidomide

D. Stop dapsone only

E. Start prednisone

E. This patient has borderline leprosy and is experiencing a type 1 lepra reaction, representing an inflammatory shift toward the tuberculoid pole. Appropriate management is to continue multidrug therapy and minimize the risk of nerve and eye damage with systemic corticosteroids.

Which would you expect to find in a 1 year old with congenital syphilis?

A. Bowed tibia

B. Immobility of an arm

C. Depressed nose-bridge

D. Enlarged collar bone

E. Deafness

B. Parrot pseudoparalysis results from pain in an extremity due to syphilitic bone involvement and is a feature of early (< 2 years old) congenital syphilis. Saber shins, saddle-nose deformity, Higomenaki sign, and 8th cranial nerve deafness are classic for late congenital syphilis.

Intracytoplasmic inclusions within endothelial cells may be seen in:

A. Granuloma inguinale

B. Leprosy

C. Rhinoscleroma

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