10 Infections of the Esophagus, Stomach, Small and Large Bowel/Rectum, Liver, and Biliary Tree
Consider the following case for questions 4 to 5:
10.1 Questions
1. A 40-year-old HIV-positive woman presents
with heartburn and difficulty swallowing. Her tem-
perature is 37.7°C (99.8°F). Physical examination
reveals white patches in the posterior oral cavity.
Endoscopy and histology show raised, white plaque-
like lesions on the esophageal mucosa. Masses of
hyphae and budding yeast are seen on a periodic
acid-Schiff (PAS) stain. Her CD4 count is 86 cells/µL.
Which of the following is the most likely mode of
transmission for this infection?
A. Contact with cat feces
B. Displacement of micro biota
C. Fecal-oral
D. Oral secretions
E. Sexual
Consider the following case for questions 2 to 3:
A 38-year-old immigrant from Brazil presents with
difficulty swallowing and chest pain. Her vitals and
physical examination are unremarkable. Her chest
X-ray shows a dilated esophagus and a barium
swallow reveals narrowing of the distal esophagus.
Manometry demonstrates a nonrelaxing esopha-
geal sphincter and loss of peristaltic movement in
the lower esophagus. Pertinent laboratory results
include:
• Trypanosoma cruzi lgM: negative
• Trypanosoma cruzi IgG: positive
2. Which of the following findings is most likely to
be in this woman's recent history?
A. Bloody stools with mucous and tenesmus
B. Circular red rash with central clearing
C. Paroxysms of fever and chills
D. Ulcerative skin lesion
E. Unilateral swelling of eyelid
3. The causative agent of this disease was most
likely transmitted by a:
A. Chigger
B. Mosquito
C. Sandfly
D. Tick
E. Triatomine bug
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A 46-year-old woman presents to her primary care
physician complaining of abdominal pain that has
been worsening for the past 2 weeks. She states she
also has frequent indigestion, nausea, vomiting, and
lack of appetite. She denies diarrhea and blood in her
stool. Her vitals are unremarkable. Physical examina-
tion reveals mild midepigastric tenderness. Endos-
copy shows a 2 mm ulcer on the gastric antrum.
4. Detection of which of the following enzymes
would best confirm the diagnosis?
A. Coagulase
B. Hyaluronidase
C. Phospholipase
D. Protease
E. Urease
5. The woman is given a 14-day regimen of lanso-
prazole, amoxicillin, and clarithromycin. She returns
to her physician 5 weeks later for a follow-up appoint-
ment. Which of the following diagnostic tests would
best confirm eradication of the pathogen?
A. Bacterial culture
B. Serum lgG testing
C. Stool Gram stain
D. Toxin analysis
E. Urea breath testing
Consider the following case for questions 6 to 8:
A 7-year-old boy is brought to the emergency
department with a 3-day history of stomach ache
and diarrhea. His father is concerned because the
child noticed blood in his stool earlier that day. The
previous weekend the family attended a picnic and
consumed hamburgers. The boy's temperature is
36.1 °C (97.9°F). Physical examination shows diffuse
abdominal tenderness but no rebound tenderness
or guarding. CBC demonstrates a leukocyte count of
14.2 x1Q 9 /L.
Which of the following pathogens produces
a toxin with the same mechanism of action as the
most likely agent of this infection?
A. Clostridium tetani
B. Enterotoxigenic Escherichia coli (ETEC)
C. Shigella dysenteriae
D. Staphylococcus aureus
E. Vibrio cholerae

7. One week later the boy develops complications
from this infection. Which of the following condi-
tions is most likely to be observed as a result of this
complication?
A. Ascending paralysis
B. Joint pain
C. Pallor
D. Tonic-clonic seizures
E. Violaceous pretibial nodules
8. Growth on which of the following culture
media would best confirm the identity of the caus-
ative agent?
A. Agar enriched with X and V factors
B. Agar supplemented with charcoal and yeast
extract
C. Hektoen agar
D. MacConkey agar supplemented with sorbitol
E. Thiosulfate-citrate-bile salts-sucrose (TCBS) agar
Consider the following case for questions 9 and 1O:
A 13-month-old infant in Ghana develops watery
diarrhea. His mother brings him to the village
clinic after she notices that he has been less active
than normal. On examination, the child is restless
and irritable. He is afebrile, his eyes appear slightly
sunken, and skin turgor is poor. Stool from the boy
grows a lactose positive (fermenter), sorbitol posi-
tive (fermenter) organism on MacConkey agar that
grows best at 37°C.
9. Which of the following is the most likely caus-
ative agent?
A. Campylobacter jejuni
B. Enterohemorrhagic Escherichia coli (EHEC)
C. Enteropathogenic Escherichia coli (EPEC)
D. Rotavirus
E. Shigella sonnei
10. Which one of the following mechanisms is
most likely contributing to this infection?
A. Destruction of microvilli
B. Endotoxin
C. Enterotoxin that inactivates actin polymerization
D. Exotoxin that inhibits protein synthesis
E. Invasion into host cell
10.1 Questions
- A 19-year-old college student returns from
spring break in Mexico with watery diarrhea. She
claims she ate in reputable restaurants and not from
street venders. She admits that she brushed her teeth
with the faucet water in her hotel. Which of the fol-
lowing pathogens has a similar mechanism of patho-
genesis as the most likely agent of this infection?
A. Bacillus cereus
B. Clostridioides (Clostridium) difficile
C. Clostridium perfringens
D. Shigella dysenteriae
E. Staphylococcus aureus
12. Five children (age range 2-3 years old) are
sent home from a day care center with diarrhea and
fever within a 2-day period. All of the children had
more than 4 to 5 loose stools the day they were sent
home. The next day, two of the day care workers call
in sick with similar symptoms. One of the workers
visits the urgent care clinic when she notices blood
in her stool. Which of the following is the most likely
causative agent?
A. Enteropathogenic Escherichia coli (EPEC)
B. Rotavirus
C. Salmonella typhi
D. Shigella sonnei
E. Vibrio cholerae
13. A 10-year-old boy presents with a 2-day his-
tory of bloody diarrhea, vomiting, stomach ache,
and fever. On examination, his temperature is 38.8°C
(101.9°F). His abdominal examination reveals right
upper quadrant tenderness. A computed tomog-
raphy (CT) scan rules out appendicitis. Laboratory
results show elevated peripheral blood leukocytes
and fecal leukocytes. After 2 days, the stool culture
grows lactose negative (non-fermenter) organisms
on MacConkey agar at 37°C. The unknown pathogen
was later found to produce H2S. Which of the follow-
ing is the most likely to be part of his recent history?
A. Camping trip in the mountains
B. Contact with a sick dog
C. Hamburger eating contest
D. Field trip to the reptile zoo
E. Vacation to Mexico
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10 Infections of the Esophagus, Stomach, Small and Large Bowel/Rectum, Liver, and Biliary Tree

14. A previously healthy 25-year-old woman pres-
ents with a 3-day history of fever, abdominal cramps,
diarrhea, and vomiting. She denies hematochezia and
has no previous medical issues. She states that about
5 days ago she ate an entire batch of uncooked cookie
dough. Her temperature is 37.9°C (100.3°F). Physical
examination reveals mild abdominal tenderness.
Stool culture shows black colonies on Hektoen agar,
and ova and parasite examination is negative. Which
of the following is the most appropriate therapy for
this patient?
A. Azithromycin
B. Ciprofloxacin
C. Metronidazole
D. Vancomycin
E. No antibiotic therapy should be administered
17. A 54-year-old man presents with diarrhea of
3-day duration. He has had 8 to 9 bowel movements
per day and has been periodically vomiting. The man
returned 4 days ago from vacation in several South
Asian countries. His temperature is 37.2°C (98.9°F)
and his blood pressure is 92/63 mm Hg. On examina-
tion the man seems lethargic, his eyes are sunken,
his skin feels cold and clammy, and his skin turgor
is poor. Stool for culture is collected and an organ-
ism grows on selective media. A Gram stain from the
colonies growing on this media is shown here:

15. A previously healthy 40-year-old woman pres-

ents to the emergency department with diarrhea
and severe abdominal pain. She has had 6 to 7 bowel
movements per day for the past 3 days and during
the last 24 hours has noticed blood in her stool. She
states she had a fever and felt "flu-like" the first day
'
of her illness but does not feel like that anymore. She
attended a family picnic a week ago and ate grilled
chicken. On examination, her temperature is 37.7°C
(99.9°F). Physical examination reveals abdominal
tenderness. The stool culture recovers curved gram- Source: CDC
negative rods on selective media. Which of the fol-
lowing is a characteristic of the most likely causative Which of the following is most likely to be observed
agent of this infection? from this patient?
A. Growth at 4°C A. Blood in the stool
B. Growth at 42°C B. Clay-colored stool
C. Growth in strict anaerobic conditions C. Greasy stool
D. Growth in high salt concentration D. Mucous in the stool
E. Growth with green metallic sheen on eosin E. White cells in the stool
methylene blue (EMB) agar
Consider the following case for questions 18 to 19:
- A 5-year-old boy presents with a 2-day history A 52-year-old man leaves work shortly after lunch
of pronounced abdominal pain, bloody diarrhea, with nausea, abdominal cramps, and vomiting. Early
fever, and a sore throat. The family lives on a farm that morning he had consumed several chocolate
and drinks unpasteurized milk. The boy's tempera- eclairs at an office party. Several of his coworkers
ture is 38.7°C (10l.8°F). The boy's throat is erythem- are also experiencing similar symptoms. By the next
atous and his tonsils are edematous. An abdominal morning he is feeling fairly well and is able to return
examination reveals tenderness of the right lower to work.
quadrant and rebound with guarding. A CBC demon-
strates elevated peripheral leukocytes. Fecal leuko- 18. Which of the following is the most likely caus-
cytes are present and fecal occult blood is positive. ative agent?
The causative agent of this infection is most likely to
infect the: A. Aerobic gram-negative rods
B. Aerobic gram-positive rods with spores
A. Duodenum
C. Aerobic gram-positive cocci in clusters
B. Gallbladder
D. Anaerobic gram-positive rods with spores
C. Liver
E. Microaerophilic curved gram-negative rods
D. Mesenteric lymph nodes
E. Stomach
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 10.1 Questions

19. Which one of the following factors is most Consider the following case for questions 22 to 24:
likely mediating this infection? A previously healthy 23-year-old man is admitted
A. Coagulase to the hospital following a motor vehicle collision.
One week after his admission he develops watery
B. Hyaluronidase
diarrhea. He is on several medications including
C. Protein A clindamycin. His temperature is 37.6°C (99.7°F). A
D. Superantigen CBC shows a leukocyte count of 13.8 x 109/L. Glu-
E. Exfoliative toxin tamate dehydrogenase (GOH) antigen and enzyme
immunoassay (EIA) toxin analysis from a stool speci-
20. A 23-year-old medical student wakes up in the men are positive and confirm the diagnosis. The
middle of the night with abdominal pain, cramping, patient has no history of previous infection with this
and watery diarrhea. He has had four bowel move- pathogen.
ments within 3 hours. He does not notice any blood
in his stool and he does not feel feverish and is not 22. Which of the following is the most appropriate
vomiting. While he was on clerkship rotation the therapy?
previous day, the hospital was celebrating Thanks- A. Fecal transplant
giving and he ate in the cafeteria. By early afternoon B. Levofloxacin
of the next day he is feeling better. Later, it is dis-
C. Penicillin
covered that several other employees were also ill
following the same meal. A toxin from an anaerobic D. Probiotics
gram-positive rod is identified from the tainted food. E. Vancomycin
Which of the following foods is the most likely to be
involved in the transmission of this infection? 23. The most likely causative agent of this infec-
A. Cream puffs tion produces a toxin that:
B. Gravy A. Activates T cells
C. Raweggs B. Depolymerizes actin
D. Shellfish C. Hydrolyzes lecithin
E. Soft cheese D. Inhibits protein synthesis
E. Interacts with G protein
21. A 46-year-old man suddenly feels ill and starts
vomiting at 1 :00 a.m. He continues vomiting approx- 24. Which of the following would safely and effec-
imately 2 to 3 times per hour for the next 4 hours. tively disinfect the surfaces of this patient's room?
The man had leftover Chinese takeout for dinner the
A. Hypochlorite
previous evening and consumed vegetable fried rice
and beef lo mein. By the next afternoon he is feeling B. lodophor
better. Which of the following is the most likely caus- C. Isopropanol
ative agent of this infection? D. Phenol
A. Aerobic gram-positive rod E. Quaternary ammonium compound
B. Aerobic gram-positive cocci
C. Anaerobic gram-positive rod
D. Flagellated protozoan parasite
E. Single-stranded RNA virus

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