Emergency Physicians Monthly has teamed up with Rosh Review to bring you the flu quiz, so that you can test yourself during this flu season.
The Flu Quiz
1) Which of the following statements is correct regarding treatment of influenza?
- Amantadine is approved for the treatment and prevention of influenza B
- Oseltamivir acts as a reverse transcriptase inhibitor to inhibit viral replication
- Oseltamivir can be administered to patients as young as 2 weeks old
- Oseltamivir should be administered to the newborn immediately after birth if the mother has confirmed influenza
2) A 67-year-old woman presents with shortness of breath and a cough for 3 days. The patient admits to recently having a fever, chills, rhinorrhea, and myalgias for 10 days. She had one episode of diarrhea and has been nauseated. Her past medical history is positive for COPD. She does not smoke but she drinks two cans of beer daily. In the ED, her vital signs are BP 120/76, HR 108, RR 20, oxygen saturation 97% on room air, and temperature 101.2°F. A chest X-ray shows a left lower lobe consolidation. It is suspected that this patient has pneumonia caused by Staphylococcus aureus. Which aspect of this patient’s history parallels this suspicion?
- Alcohol consumption
- Gastrointestinal symptoms
- History of COPD
- Recent viral symptoms
3) A 71-year-old man with a history of diabetes, hypertension, COPD, asthma, and peptic ulcer disease presents to the ED with a complaint of 1 day of fatigue, myalgias, nasal congestion, nonproductive cough, and fever. Multiple members of his family are ill with the same constellation of symptoms. His rapid influenza swab is positive. Chest x-ray shows no sign of focal infiltrate. He is prescribed an antiviral and discharged home. About 36 hours later, he returns with worsening respiratory distress, pronounced expiratory wheezing in all lung fields, and difficulty speaking in full sentences due to dyspnea. Which of the following medications was most likely prescribed at his initial visit is responsible for his symptoms at this current visit?
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1) Answer C
There are two classes of antiviral medications for influenza. The first class to be discovered was the adamantine derivatives (amantadine and rimantadine). A more recent class of antiviral drugs is the neuraminidase inhibitors (oseltamivir and zanamivir). All are taken orally except for zanamivir, which is inhaled. Treatment is generally reserved for those populations who are at high risk for a more severe course of influenza infection such as those older than 65 years or younger than 2 years, those with chronic lung or cardiac disease, immunocompromised, and pregnant individuals. While oseltamivir initially was not approved for use in children younger than 1 year old because of concerns about neurological side effects, in 2012 the U.S. Food and Drug Administration (FDA) expanded the approved use of oseltamivir to treat children as young as 2 weeks old who have shown symptoms of flu for no longer than two days.
Oseltamivir (D) has been assigned to pregnancy category C by the FDA and is approved for use in newborns at 2 weeks old, but not immediately after birth. The older drugs, amantadine (A) and rimantadine, although approved for treatment and prevention of influenza A are rarely used since many strains of influenza, including the 2009 H1N1 influenza, are now resistant to these two drugs and all influenza B strains are resistant. Oseltamivir acts as a neuraminidase inhibitor (B). Reverse-transcriptase inhibitors (RTIs) are a class of antiretroviral drugs used to treat HIV infection and other retroviruses .
2) Answer D
The patient’s recent history of fever, chills, rhinorrhea, and myalgias raises suspicion for influenza. Staphylococcus aureus is a common pathogen causing pneumonia in those currently or recently infected with influenza virus. Patients with pneumonia often present with tachypnea, tachycardia, dyspnea, chest pain, cough, fevers, and rales. S. aureus, a common nosocomial pathogen in adults, can lead to a necrotizing pneumonia.
In those with gastrointestinal (B) or neurologic symptoms, Legionella pneumophilia should be considered. In those with excessive alcohol consumption (A), a common pathogen is Klebsiella pneumoniae. A history of COPD (C) raises suspicion for Haemophilius influenzae and Pseudomonas aeruginosa .
3) Answer D
This patient is suffering from influenza, a viral infection of the lower respiratory tract. Zanamivir is an inhaled neuraminidase inhibitor used to treat influenza or as chemoprophylaxis in exposed patients deemed to be high risk. It is associated with wheezing and has been connected to severe bronchospasm with subsequent death in patients who have underlying lung disease. For this reason, it is contraindicated in patients with asthma, COPD, and other structural lung diseases.
Amantadine (A) and rimantadine (C) are adamantine-derivative dopaminergic drugs also used as antivirals in the treatment of influenza (depending on the influenza variant and resistance patterns). They are associated with neuropsychiatric side effects, especially in the elderly. Oseltamivir (B) is an oral neuraminidase inhibitor associated primarily with gastrointestinal side effects, not wheezing or bronchospasm.
All exam review questions provided by Rosh Review. Find more test prep at roshreview.com
1. Wang K, Shun-Shin M, Gill P, Perera R, Harnden A . “Neuraminidase inhibitors for preventing and treating influenza in children”. In Harnden, Anthony. Cochrane Database Syst Rev 4 (2012) “Oseltamivir phosphate, Review, and Labeling Information”. Drugs@FDA. U.S. Food and Drug Administration (FDA).
2. Moran GJ, Talan DA: Pneumonia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 74:p 927-938.
3. Tintinnalli, 7th edition, Chapter 157, “Occupational Exposure, Infection Control, and Standard Precautions,” accessed via Access Emergency Medicine