A 55-year-old man presents to your oncology office and reports feeling very tired, feeling short of breath and losing weight for the last 3 weeks. Upon review of his history, you note that he also has fevers, bruising easily and bone pains on various locations in his body. Upon physical examination, you note that he is pale with a petechial rash and that he has an enlarged liver and spleen. You note a wound on his right foot, which has not healed for over two months. You sent him for some laboratory tests, which reveal the following: Test Result Normal range Leukocyte count (WBC) 105,000 /mm³ 4500-11,000/mm³ Platelets 75,000 /mm³ 150,000 – 400,000/mm³ Hemoglobin 7.2 g/dL Male:13.5-17.5 g/dL Female 12.0 – 16.0 g/dL Blasts 80% <5% Hematocrit 20% Male:41% - 53% Female: 36% - 46% Peripheral smear showed pancytopenia; some cells have rod-shaped; needle-like, cytoplasmic, azurophilic granules. Further cytogenetic tests were done; Immunological phenotypes detected: MPO, CD11b, CD13, CD15, CD33, CD117, HLA-DR positive myeloblasts. The blasts react with antibodies to myeloperoxidase and antibodies to CD13, CD33, and CD34. Of the following, which is the most likely diagnosis in this patient?

A concerned mother brings her 6 year-old son to your office. She tells you that over the past 3 months the boy has been having severe fatigue, easy bruising, recurrent infections, fever, night sweats, and unintentional weight loss. He has had four spontaneous nose bleeds in the last two weeks alone. He was born in an Amish family when his mother was 45-years old in Belleville, a rural town in Pennsylvania, USA. His family history is significant for genetic disorders. You notice that the boy has a pale flat face, wide-set eyes with white spots on the periphery of iris, epicanthal folds, a single palmar crease across each hand. Pharynx is normal with no tonsillar exudate. On cardiac auscultation, you hear a holosystolic murmur that is consistent with a ventricular septal defect. Other physical examination findings include hepatomegaly, splenomegaly, lymphadenopathy, and a petechial rash over his entire body. Of the following, which is the most likely diagnosis in this patient?

A 34 year-old presents to your office and reports that she was frightened this morning when she used the bathroom because ‘ she passed blood instead of urine’. Further questioning reveals she passed reddish-brown urine. For the last few weeks she has been experiencing headaches, trouble breathing, back pain, and palpitations. On physical examination, she appears somewhat pale, with normal vital signs.You ordered some laboratory tests to find the source of her symptoms. Her white blood cells and platelet counts are decreased and serum LDH is elevated. Peripheral blood film showed anisocytosis, anisochromia and poikilocytosis with notable ovalocytosis and spherocytosis. Bone marrow studies revealed cellular activity with increased erythropoiesis and marrow macrophages laden with iron-laden particles. Urinary sediment stained with Prussian blue showed intensely positive reactions reflecting urinary iron loss as a result of intravascular hemolysis. You suspected paroxysmal nocturnal hemoglobinuria in this patient. Of the following, which is the gold standard test for diagnosing this disorder?

A 34 year-old presents to your office and reports that she was frightened this morning when she used the bathroom because ‘ she passed blood instead of urine’. Further questioning reveals she passed reddish-brown urine. For the last few weeks she has been experiencing headaches, trouble breathing, back pain, and palpitations. On physical examination, she appears somewhat pale, with normal vital signs.You ordered some laboratory tests to find the source of her symptoms. Her white blood cells and platelet counts are decreased and serum LDH is elevated. Peripheral blood film showed anisocytosis, anisochromia and poikilocytosis with notable ovalocytosis and spherocytosis. Bone marrow studies revealed cellular activity with  increased erythropoiesis and marrow macrophages laden with iron-laden particles. Urinary sediment stained with Prussian blue showed intensely positive reactions reflecting urinary iron loss as a result of intravascular hemolysis. Acidified serum (Ham) test came back as a positive test.  Most symptoms in this disease are due to which of the following? 

A 34 year-old male comes to your office with fever, chills, headache, fatigue, myalgias, arthralgia, anorexia, nausea, sweats,and depression. He returned from a hunting trip after spending two weeks in St.Paul, Minnesota. He reports that he is not sure but he might have had some tick bites during this trip. His past medication history is significant for splenectomy after a motor vehicle accident four years ago. Physical examination is significant for tenderness in the right upper quadrant. Laboratory tests showed anemia, thrombocytopenia, elevated transaminases and  intraerythrocytic ring-shaped parasites in tetrads on Giemsa-stained blood smears and later confirmed by a PCR assay which showed the DNA of the organism. Which of the following medications is not used in the treatment of this disorder? 

A 34 year-old male comes to your office with fever, chills, headache, fatigue, myalgias, arthralgia, anorexia, nausea, sweats,and depression. He returned from a hunting trip after spending two weeks in St.Paul, Minnesota. He reports that he is not sure but he might have had some tick bites during this trip. His past medication history is significant for splenectomy after a motor vehicle accident four years ago. Physical examination is significant for tenderness in the right upper quadrant. Laboratory tests showed anemia, thrombocytopenia, elevated transaminases and intraerythrocytic parasites on Giemsa-stained blood smears and later confirmed by a PCR assay which showed the DNA of the organism. You suspect babesiosis in this patient. Of the following, which is the characteristic diagnostic feature of babesiosis?

A 34 year-old male comes to your office with fever, chills, headache, fatigue, myalgias, arthralgia, anorexia, nausea, sweats,and depression. He returned from a hunting trip after spending two weeks in St.Paul, Minnesota. He reports that he is not sure but he might have had some tick bites during this trip. His past medication history is significant for splenectomy after a motor vehicle accident four years ago. Physical examination is significant for tenderness in the right upper quadrant. Laboratory tests showed anemia, thrombocytopenia, elevated transaminases and  intraerythrocytic ring-shaped parasites in tetrads on Giemsa-stained blood smears and later confirmed by a PCR assay which showed the DNA of the organism.  You suspect babesiosis in this patient.  Regarding the transmission of this disease, which of the following is true? 

A 34 year-old male comes to your office with fever, chills, headache, fatigue, myalgias, arthralgia, anorexia, nausea, sweats,and depression. He returned from a hunting trip after spending two weeks in another state. He reports that he is not sure but he might have had some tick bites during this trip. His past medication history is significant for splenectomy after a motor vehicle accident four years ago. Physical examination is significant for tenderness in the right upper quadrant. Laboratory tests showed anemia, thrombocytopenia, elevated transaminases and  intraerythrocytic ring-shaped parasites in tetrads on Giemsa-stained blood smears and later confirmed by a PCR assay which showed the DNA of the organism.  You suspect Babesiosis in this patient. It is is found in which of the following areas of the United States?

A 22-year-old medical student comes to the urgent care clinic and reports a sudden onset of high fever, chills, severe headache, pain around the eyeballs and behind the eyes, muscle pain, bone pain, nausea and vomiting. She attends a medical school in the Caribbean Islands and is now visiting her family in the United States. On further questioning, she reports that her apartment building is surrounded by many mud pits infested with Aedes mosquitoes and she had many mosquito bites over the last few weeks. One of her classmates got ‘breakbone fever’ last week. On examination, she has a faint, generalized macular rash that looks like ‘islands of white in a sea of red’. Laboratory tests demonstrated thrombocytopenia, monocytosis, elevated albumin, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. A PCR test confirmed the diagnosis. When she was told that she was infected with a virus that belongs to the flaviviridae family, she rightly worried about the possibility of a hemorrhagic fever. What is the mainstay of care for this patient?

A 32-year-old woman presents to the emergency department with a four-day history of high-grade fever, severe headache, retro-orbital pain, and muscle aches. She also reports significant fatigue, nausea, and decreased appetite. On the second day of her illness, she developed a skin rash that started on her trunk and later spread to her extremities. She mentions a recent trip to a tropical region. On examination, the patient appeared lethargic and febrile with a temperature of 39.5°C. Her blood pressure was 100/70 mmHg, with a pulse of 100 beats per minute. The rash was erythematous and maculopapular, sparing the palms and soles. Petechiae were noted on her arms, and a positive tourniquet test suggested increased capillary fragility. Laboratory investigations revealed leukopenia with a white blood cell count of 3,000/μL, thrombocytopenia with a platelet count of 90,000/μL, and mildly elevated liver enzymes. Based on her recent travel history, you suspect dengue in this patient. Of the following, which is the most common symptom of dengue?