1. LIBYAN MEDICAL BOARD FIRST PART REVISION
DR.MAGDI AWAD SASI
2016

2. LIBYAN MEDICAL BOARD
5TH PART

4. A 43-year-old woman presents for the evaluation
of bleeding gums. The patient reports that for the
past 2 months, her gums have bled more easily
when she brushes her teeth. Physical examination
reveals palatal petechiae and scattered petechiae
over the lower extremities bilaterally.
Which of the following laboratory tests is most
likely to identify the abnormality responsible for
this patient's bleeding disorder?
❑ A. Prothrombin time (PT) and international
normalized ratio (INR)
❑ B. Complete blood count (CBC)
❑ C. Partial thromboplastin time (PTT)
❑ D. A mixing study
 E. Renal function test

5. SUBCUTANEOUS BLEEDING AND MUCOSAL IN THE
FORM OF PETECHEA—PLATELET DISORDER.
To investigate ----CBC , BLEEDING TIME ,CLOTTING TIMT
TISSUE AND ORGAN BLEEDING ---CLOTTING FACTOR DEF.
To investigate -----PT ,INR ,APTT

6.  Bleeding occurs as a consequence of thrombocytopenia, deficiencies of
coagulation factors, or both.
 Thrombocytopenia usually presents as petechial bleeding that is first
observed in the lower extremities.
 Deficiencies in coagulation factor more often cause bleeding into the
gastrointestinal tract or joints.
 Intracranial bleeding, however, can occur with a deficiency of platelets
or coagulation factors and can be catastrophic.
 CBCs are routinely performed in most laboratories through the use of an
electronic particle counter, which determines the total white blood cell
and platelet counts and calculates the hematocrit and hemoglobin from
the erythrocyte count and the dimensions of the red cells.
 For this patient, a CBC would likely disclose a decreased platelet count
(thrombocytopenia). Impaired hepatic synthetic function and vitamin K
deficiency would result in prolongation of the PT and INR.
 Coagulation factor deficiencies and coagulation factor inhibitors would
result in prolongation of the PTT. A mixing study is obtained to
differentiate between a coagulation factor deficiency and a coagulation
factor inhibitor by mixing patient plasma with normal plasma in the
laboratory. (Answer: B—Complete blood count [CBC])

7. Regarding erythrpioetin ,all true except:
 A. The peritubular interstitial cells located in the inner
cortex and outer medulla of the kidney are the primary
sites for erythropoietin production.
 B. Erythropoietin treatment decreases the severity of
anemia and improves the quality of life for these patients.
 C. Treatment is maximally effective when the marrow has a
generous supply of iron and other nutrients, such as
cobalamin and folic acid.
 D. The most easily monitored immediate effect of increased
endogenous or exogenous erythropoietin is an increase in
the blood reticulocyte count.
 E.There is no benefit of it in In patients with anemia
caused by cancer and cancer chemotherapy

8. Erythropoietin shortens the transit time through the marrow,
leading to an increase in the number and proportion of
blood reticulocytes within a few days.
In some conditions, particularly chronic inflammatory
diseases, the effectiveness of erythropoietin can be predicted
from measurement of the serum erythropoietin level by
immunoassay.
It may be cost-effective to measure the level before
initiating treatment in patients with anemia attributable to
suppressed erythropoietin production, such as patients with
HIV infection, cancer, and chronic inflammatory diseases.
Several studies have shown that erythropoietin treatment
decreases the severity of anemia and improves the quality of
life for these patients.
In patients with anemia caused by cancer and cancer
chemotherapy, current guidelines recommend erythropoietin
treatment if the hemoglobin level is less than 10 g/dl

9. For this patient, which of the following statements regarding
iron deficiency anemia is true?
❑ A. In men and postmenopausal women, pica and a poor
supply of dietary iron are the most common causes of iron
deficiency anemia
❑ B. Pagophagia, or pica with ice, is a symptom that is
believed to be specific for iron deficiency
❑ C. Measurement of the serum iron concentration is the
most useful test in the detection of iron deficiency
❑ D. The preferred method of iron replacement for this
patient is parenteral therapy
❑ E. In older children, men, and postmenopausal women, a
poor supply of dietary iron is almost the only factor
responsible for iron deficiency.

10. B. Pagophagia, or pica with ice, is a symptom that
is believed to be specific for iron deficiency

11.  Measurement of the serum ferritin
concentration is the most useful test for the
detection of iron deficiency, because serum
ferritin concentrations decrease as body iron
stores decline. A serum ferritin concentration
below 12 mg/L is virtually diagnostic of
absent iron stores. In contrast, a normal
serum ferritin concentration does not confirm
the presence of storage iron, because serum
ferritin may be increased independently of
body iron by infection, inflammation, liver
disease, malignancy, and other conditions.

12. Which of the following statements regarding megaloblastic
anemia caused by folic acid deficiency is false?
❑ A. Serum folic acid levels more accurately reflect tissue
stores than do red blood cell folic acid levels
❑ B. Folic acid deficiency can be differentiated from cobalamin
deficiency by measuring methylmalonic acid and
homocysteine levels; both are elevated in cobalamin
deficiency, but only homocysteine is elevated in folic acid
deficiency
❑ C. Megaloblastic anemia caused by folic acid deficiency can
be masked by concurrent iron deficiency anemia, but
hypersegmented polymorphonuclear cells (PMNs) should
still be present on the peripheral smear
❑ D. Folinic acid can be used to treat patients with
megaloblastosis and bone marrow suppression associated
with the use of methotrexate

13. A—Serum folic acid levels more accurately
reflect tissue stores than do red blood cell folic
acid levels)

14. 1. A 73 year old woman has become progressively
kyphotic over the last 3 years. Past history
includes colon carcinoma and hysterectomy at
age 26 for fibroids. She now presents with acute
back pain and localised midthoracic tenderness.
CXR and lateral spine xrays are shown (wedged
shaped crush fracture in mid thoracic vertebrae
and osteopenia, NO lytic or sclerotic lesions) The
most likely diagnosis is?
A) multiple myeloma
B) bone metastases
C) osteoarthritis
D) osteoporosis
E) hyperparathyroidism

15. osteoporosis

16. 2. A28-year-old woman complains of a 3-week historyof
palpitations and shakiness. She attributes her insomnia to
her new baby, born 5 weeks previously. On examination
there is increased sweating, a fine tremor of outstretched
hands, and a small nontender goiter. Laboratory
investigations show TSH <0.002 mIU/L and free thyroxine 2.1
ng/dL (0.8-1.8). She is breastfeeding. Which one of the
following investigations is indicated to help establish the
diagnosis?
a. TSH receptor antibodies
b. Radioactive iodine uptake
c. Erythrocyte sedimentation rate (ESR)
d. Thyroid-binding globulin (TBG)
e. Epstein-Barr virus testing

17. Answer a
The differential diagnosis includes Graves disease and
postpartum thyroiditis.
Radioactive iodine uptake is elevated in the former and
suppressed in the latter.
However, this investigation is contraindicated in this setting
because radioactive iodine is excreted in breast milk and may
cause permanent hypothyroidism in the child.
The ESR and TBG level may be elevated in thyroiditis and
Graves disease.
TSH receptor antibodies are likely to be present in Graves
disease (>98% specificity; 90% sensitivity

18. 3. Which one of the following would not be considered a
high-risk marker for sudden cardiac death in
hypertrophic cardiomyopathy?
A. Family history of sudden cardiac death
B. Non-sustained VT on cardiac monitoring
C. LV septal thickness of 2.3cm
D. Drop in blood pressure on ETT
E. Syncope

19.  C. A septal thickness of >3 cm is considered a high-risk
marke

20. Patients at risk of sudden death:
I. HISTORY:
1) Age <14 years at diagnosis
2) Syncope as presenting symptom
3) F/H at HCM with sudden death
II. HOLTER MONITORING:
Non sustained VT --
25% of patient with HCM
Occur at night when vagal tone is high
Asymptomatic
Remains the best marker of sudden death with sensitivity
69%+ specificity 80%
III. INVASIVE ELECTROPHYSIOLOGY:
Increased ECG fractation --paced RV electrograms at various
RV sites
Ventricular provocation

21. VI. PERIPHERAL VASCULAR RESPONSE:
Fall in systolic pressure on exercise or failing to increase systolic
pressure by >29mmHg.
1/3 of patients with HCM fail to increase pressure by exercise ,
WHY?
Possibly ---LV baroreceptors firing off under very high pressue
causing vasodilatation peripherally.
Occurs in :
Young patient
F/H of sudden death
Patient with small LV cavity
V. PROGNOSTIC GENOTYPING:
 Identification of the mutation type appears to carry prognostic
significance .
 Troponin T mutation is the worst ((dying 18—24age)).

22. 4. Which of the following is NOT an indication for mitral balloon valvotomy?
A. Mild mitral stenosis with the pulmonary artery systolic pressure
increasing to greater than 60 mmHg during exercise, favorable valve
morphology and New York Heart Association functional class II symptoms
B. Moderate mitral stenosis, favorable valve morphology and New York
Heart Association functional class II symptoms
C. Severe mitral stenosis with moderate mitral regurgitation, favorable
valve morphology and New York Heart Association functional class III
symptoms
D. Severe mitral stenosis, unfavorable valve morphology (Wilkins score > 8),
New York Heart Association functional class III symptoms in a patient not
a candidate for surgical mitral valve repair/replacement.

23. C. Severe mitral stenosis with moderate mitral
regurgitation, favorable valve morphology and
New York Heart Association functional class III
symptoms

24. C/I:
1. MR
2. Left atrial thrombus
3. Dilated LA

25. 5. A 25-year-old man presents with 4 days of
fever, retro-orbital pain and severe myalgia
following travel to the Indian subcontinent. He
has red eyes and a faint, blanching,
maculopapular rash. A peripheral smear for
malarial parasites is negative and his white cell
count and chest X-ray are normal. What
is the most likely diagnosis?
A. Malaria
B. Typhoid fever
C. Bubonic plague
D. Dengue fever
E. Tuberculosis

26. 
Dengue fever is transmitted from the bite of infected
Aedes aegypti mosquitoes. It is commonly seen in the
tropics where epidemics occur.
 After an incubation period of 3–4 days, patients
develop fever, severe myalgias and headaches (mainly
retro-orbital). Painful red eyes are commonly seen,
along with lymphadenopathy.
 A faint, blanching, maculopapular rash is
characteristic. White cell counts are normal and
platelets may be low, along with mildly abnormal liver
function tests.
 It can be diagnosed during the fever by detection of
the viral genome by reverse transcriptase polymerase
chain reaction (RT-PCR). Paired sera can provide a
retrospective diagnosis.
 A small proportion of patients may develop dengue
haemorrhagic fever with disseminated intravascular
coagulation.
 Treatment is supportive

27. 6. A 55-year-old man has non-infective, necrotising
ulcers on his lower limbs. A diagnosis of pyoderma
gangrenosum is made. Which of the following
conditions is associated with this disorder?
A. Multiple myeloma
B. Haemochromatosis
C. Gout
D. Non-Hodgkin’s lymphoma
E. Autoimmune thrombocytopenia

29.  Pyoderma gangrenosum start as inflammatory pustules
or papules that appear on the limbs and trunk.
 They enlarge rapidly to produce large necrotic ulcers
with a sloughy base, which undermines a raised purplish
prominent rim.
 It is associated with multiple myeloma, acute
leukaemia, inflammatory bowel disease, polycythaemia
vera and rheumatoid arthritis.
 No cause can be found in 50% of patients.

30. 7. A 16-year-old man presents with difficulty in
walking and foot drop. There is weakness of
dorsiflexion and eversion of the right foot, with a
small area of sensory loss over the dorsum of that
foot. What is the most likely diagnosis?
A. Posterior tibial nerve lesion
B. Sciatic nerve lesion
C. L5 root lesion
D. Common peroneal nerve lesion
E. Deep peroneal nerve lesion

31.  The commonperoneal (L5, S1) nerve arisesfromthe division of the
sciatic nerve in the poplitealfossa.
 It passes close to the head of the fibulaand can be damaged by
pressure in this area.
 It divides into a superficial and a deep branch.
 The deep peroneal nerve supplies thetibialisanterior, extensor
hallucis longus andextensor digitorumlongus muscles, which
dorsiflex the foot and toes.
 The superficial nerve suppliesthe peroneus longus and brevis
muscles, which evert the foot.
 Damage to the posterior tibial nerve produces weakness of planter
flexion and inversion of the foot.

33. 8. A 75-year-old man is noted by his family to be increasingly
confused. His mental state fluctuates considerably and he appears
to be hallucinating at times. His daughter commented that his gait
has become abnormal over the preceding months, and that his GP
had tried a tablet for the nocturnal confusion that apparently made
him much worse. On examination he has a Mini-Mental score of
20/30, has generally increased tone and difficulty in performing
rapidly alternating movements. His tendon reflexes are slightly
brisk but the plantar responses are normal and no primitive
reflexes are detected. Which of the following is the most likely
explanation of this clinical scenario?
A. Vascular dementia
B. Senile dementia of Alzheimer’s type
C. Creutzfeldt–Jakob disease
D. Temporal variant of frontotemporal dementia
E. Dementia with Lewy bodies

34. The associated extrapyramidal features and variable
psychiatric features with complex hallucinations are
typical of dementia with Lewy bodies (DLB).
This condition is now recognised to be the second most
common cause of neurodegenerative disease in older
people (after senile dementia of Alzheimer’s type,
SDAT).
Typically, standard antipsychotic drugs such as
haloperidol worsen DLB, and indeed potentially fatal
neuroleptic sensitivity reactions can occur.
It is one of a group of conditions caused by abnormal
aggregation of the synaptic protein a-synuclein.
The cholinesterase inhibitor drugs, initially developed for
SDAT, look promising for the treatment of DLB

35.  A 40-year-old male was admitted with
sudden onset headache and generalised tonic-
clonic convulsion. MRI scan and subsequent
MRI venography revealed sagittal sinus
thrombosis. He recently recovered from an
episode of aplastic anaemia. Investigation
reveals anaemia with reticulocytosis. What is
the most likely diagnosis?
a) Homocystinuria
b) Thrombotic thrombocytopaenic purpura
c) Paroxysmal Cold Haemoglobinuria
d) Paroxysmal Nocturnal Haemoglobinuria
e) Thalassaemia

36. d)

Paroxysmal Nocturnal Haemoglobinuria (PNH) is
an intracorpuscular defect acquired at the stem
cell level.
 Three common manifestations are haemolytic
anaemia, venous thrombosis and deficient
haematopoiesis.
 Granulocytopaenia and thrombocytopaenia are
common and reflect deficient haematopoiesis.
Clinical haemoglobinuria is intermittent in most
patients and never occurs in some, but
haemosiderinuria is usually present.
 Venous thrombosis is a common complication of
patients of European origin. Thrombosis can occur
in cerebral venous sinuses and is a common cause
of death in a patient with PNH.

37. 9. Which one of the following disorders is MOS commonly
associated with Stevens-Johnson syndrome?
A. Herpes simplex infection
B. Sarcoidosis
C. Systemic lupus erythematosus
D. Herpes zoster infection
E. Coeliac disease

39. Stevens-Johnson syndrome is an immunological reaction in the
skin and mucous membrane characterised by iris skin lesion
(erythema multiforme) in the skin and extensive bullae
formation in the mouth and conjunctivae.
The commonest disease association is with a preceding herpes
simplex or Mycoplasma pneumoniae infection.
Other causes include drug sensitivity (e.g. sulfonamides,
penicillins, barbiturate, phenytoin and possibly the
contraceptive pill).

40. 10. A 65-year-old man, with a history of smoking,
presents with chronic cough, haemoptysis and weight
loss. His Chest X-Ray shows a cavitating lesion. What is
the likely diagnosis?
A. adenocarcinoma
B. alveolar cell carcinoma
C. large cell carcinoma
D. small cell carcinoma
E. squamous cell carcinoma

41. 11. A patient is brought to the emergency department
after a seizure leading to prolonged immobility on a
sidewalk. He has dark urine and myalgias. What is the
most urgent step in the management of this patient?
a. Urinalysis
b. Urine myoglobin level
c. EKG
d. CPK level
E. Creatinine

42. Answer: C.
 EKG is the most urgent step in an acute case of
rhabdomyolysis.
 This case tests your knowledge of how people die with
rhabdomyolysis.
 Severe muscle necrosis leads to hyperkalemia, which leads to
arrhythmia.
 A specific diagnosis with urinalysis or urine myoglobin is not
as important as detecting and treating potentially life-
threatening conditions, such as hyperkalemia with peaked T
waves.
 This condition would be treated with immediate intravenous
calcium gluconate, insulin, and glucose

43. 12. A 40-year-old woman presents with progressive confusion and
mild neck stiffness with headache of a month . A CT scan showed
basal meningeal enhancement. A lumbar puncture showed an
opening pressure of 200 mmH2O, a turbid CSF with 500
leucocytes/ml (90% lymphocytes), a glucose concentration of 1
mmol/l and negative results with Gram, Indian ink and Ziehl–
Neelsen stains. What is the best treatment?
A. Rifampicin + INAH + pyrazinamide + ethambutol
B. Ceftriaxone
C. Aciclovir
D. Corticosteroids
E. Liposomal amphotericin B

44.  Rifampicin + INAH (isonicotinic acid hydrazide) +
pyrazinamide + ethambutol are used to treat
tuberculous meningitis (TBM), which is the most
likely diagnosis based on the subacute history, CT
findings and the modest lymphocytic
lymphocytosis accompanied by severe
hypoglycorrhacia.
 A negative Ziehl–Neelsen stain is not unusual in
such cases, except when large volumes of spun CSF
are examined.
 Almost without exception, patients with bacterial
meningitis have a high neutrophil pleocytosis and a
few days’ history at presentation. Apparently, the
patient had not been receiving antibiotics, which
can modify the CSF in those with bacterial
meningitis.

45.  Viral meningitis is unlikely since the cell type is
mononuclear and the sugar concentration normal
(except in patients with mumps meningitis). There is
no reason to suspect fungal meningitis as she has no
immunocompromising conditions, although the CSF
changes may be indistinguishable from TBM.
 However, cryptococcal meningitis occasionally
presents in a normal host, but here the Indian-ink
stain is usually positive. There is no evidence that the
patient has benign intracranial hypertension or
collagen vascular disease, so steroids are not indicated
and are contraindicated for the treatment of
infectious meningitis alone.
 Bacterial meningitis is treated with ceftriaxone, viral
meningitis with aciclovir and fungal meningitis with
liposomal amphotericin B.

46. REMEMBER:
H/O symptoms of headache ,confusion ,cranial nerve
palsy with basal meningeal irritation of a month or
two in apatient with CSF study of lymphocytosis and
hypoglycemis is TB

47. 13. Which is not a paraneoplastic
syndrome associated with Lung
Cancer
A. SIADH
B. Lambert-Eaton Syndrome
C. Sweet’s Syndrome
D. Dermatomyositis
E. GBS like syndrome

48.  The syndrome was first described in 1964 by Dr. Robert D
Sweet. It was also known as Gomm-Button disease in honour
of the first two patients diagnosed. It is characterized by
erythematous well defined cutaneous papules associates
with fever and is associated with haematologic malignancies
like leukaemia, Rheumatoid Arthritis, IBD, Behcets Syndrome

49. 14. A 45-year-old male executive comes to your office
complaining of epigastric pain for 2 months. His
primary physician prescribed him H2-blockers 3 weeks
ago, which have produced only partial relief of his
symptoms. His weight is stable. His physical exam is
normal. An upper endoscopy reveals a 1-cm duodenal
ulcer. Which of the following risk factors is not
associated with the development of ulcer disease?
A.Daily use of nonsteroidal anti-inflammatory drugs(NSAIDs)
B. Gastric infection with H. pylori
C. Emotional stress
D. Cigarette smoking
E. Gastrin-secreting tumors

50. Although considered a risk factor in the past, several
studies showed that emotional stress is not a risk
factor for the development of duodenal ulcer.
Daily NSAID use significantly increases the risk of
ulcer disease (risk ratio, 10- to 20-fold).
Gastric infection with H. pylori increases risk about
five- to sevenfold.
Cigarette smoking doubles the risk of duodenal ulcer.
At least 90% of those patients with Zollinger-Ellison
syndrome have duodenal ulcer.

51. 15. A 51-year-old woman presents with abdominal
pain, weight loss, early satiety, and night sweats. On
physical exam she appears cachectic, multiple enlarged
lymph nodes are present in her neck (supraclavicular
area), and a mass is palpated in the epigastrium.
Laboratory data reveal a hemoglobin of 8 g/dL and a
normal WBC count. Which of the following is the most
appropriate next step in establishing the diagnosis?
A. Upper GI series
B. Peripheral blood smear
C. CT of the abdomen
D. Upper endoscopy with biopsy
E. Exploratory laparotomy

52. This patient has lymphoma of the stomach.
Lymphoma of the stomach can resemble superficially
spreading carcinoma, linitis plastica, or solitary
adenocarcinoma.
Gastroscopy with directed biopsy and brush cytology
gives a higher yield than was previously appreciated,
especially in the presence of exophytic lesions.
Lymphoma of the stomach frequently presents
radiographically as a bulky mass and less frequently as
a diffusely infiltrating tumor-the most common form
of secondary lymphoma-giving the appearance of
large folds on upper GI series, frequently associated
with multiple nodular defects and ulcerations.
Although CT may be useful to evaluate the extent of
disease, it will not provide a specific diagnosis.
Exploratory laparotomy is useful for staging and
therapeutic resection where possible.

53. 16. A 49-year-old man presents to the emergency room
because of melena of 3 days' duration. He denies abdominal
pain. Vital signs reveal a resting pulse of 104 per minute
and a 25-mm Hg orthostatic drop in BP. Physical findings
include bilateral temporal wasting, pale conjunctivae, spider
angiomas on his upper torso, muscle wasting,
hepatosplenomegaly, and hyperactive bowel sounds without
abdominal tenderness to palpation. His stool is melenic.
Nasogastric tube aspiration reveals coffee grounds material.
Hematocrit is 31%. The appropriate next step in the
management of this man's illness would be to
A. Pass a Sengstaken-Blakemore tube.
B. Obtain an upper GI series.
C. Insert a transjugular intrahepatic portosystemic shunt
(TIPS).
D. Obtain immediate visceral angiography.
E. Perform upper endoscopy.

54.  After this patient has been hemodynamically
stabilized, the next most important step is to perform
a diagnostic/therapeutic upper endoscopy.
 If the source of his bleeding is from esophageal
varices, then these can be obliterated with sclerosis or,
preferably, endoscopic band ligation.
 The use of a Sengstaken-Blakemore tube should be
reserved for patients in whom upper endoscopy was
unsuccessful in controlling the hemorrhage.
 A TIPS should be considered in patients in whom
medical and endoscopic therapy have failed.
 Barium studies have no role in the evaluation of
patients with suspected variceal hemorrhage

55. 17. A 67-year-old man in previously good health is hospitalized
because of a 2-day history of fever and diminished consciousness.
The patient responds inconsistently to verbal commands. His
temperature is 39.5 °C (103.1 °F); he has tachycardia, and his blood
pressure is 80/58 mm Hg. There is no bleeding. His hemoglobin is
12.1 g/dL, leukocyte count is 29,000/μL with 80% neutrophils, and
platelet count is 20,000/μL. Which of the following studies should
be obtained in this patient?
A. Bone marrow aspiration and biopsy
B. Factor VIII level
C. Measurement of platelet-associated IgG
D. Measurements of fibrin D-dimer and total fibrinogen
E. Bleeding time

56. D. Measurements of fibrin D-
dimer and total fibrinogen
This is a case of DIC.

57. 18. A 18 year female was HBsAg positive in health check
up,but without symptoms and signs,and the liver
functions were normal. In May the following year, she
was admitted for fever,weakness,vomiting and jaundice
of sclera.ALT 200U/L,Hb 140g/L, anti-HAV IgM(+).Anti-
HBc IgG(+) HBsAg(+).The diagnosis may be:
A. Acute hepatitis A(icteric type) and HBsAg chronic
carrier.
B. Chronic hepatitis B(CPH).
C. Chronic active hepatitis B.
D. Acute hepatitis A and acute hepatitis B.
E. Acute hepatitis A and chronic persistent hepatitis B.

58. 19. A 27-year-old man with a history of IV drug use was found to
have abnormal liver function tests
Further work-up including serologic tests for viral hepatitis show
Hepatitis B surface antibody (HBsAb) negative
Hepatitis B surface antigen (HBsAg) positive
Hepatitis core antibody (HBcAb) positive
Hepatitis B e antibody (HBeAb) positive
Hepatitis B e antigen (HBeAg) negative
Which of the following statements is true regarding this patient?
A. He is a chronic hepatitis B virus (HBV) carrier with high
infectivity.
B. He is in the incubation period of HBV.
C. He is a chronic HBV carrier with low infectivity.
D. He has recovered from HBV infection and is immune to HBV
E. He had chronic active hepatitis

59. Answer: C
In the interpretation of results of hepatitis B serologic tests, the following
facts should be considered:
 During the incubation period (i.e., before the onset of clinical
manifestations) HbsAg, HbeAg, and HBV DNA become detectable in the
serum.
 At the onset of clinical symptoms (e.g., jaundice), an increase in the
serum transaminases antibodies occurs and antibodies to HBc become
detectable (HBc antibodies).
 Initially, the HBc antibodies are IgM and thereafter IgG; these latter
antibodies persist for years.
 HBs antibodies become detectable late in convalescence.
 A rise in HBs antibodies in combination with a loss of HbsAg, HbeAg, and
HBV DNA indicate the presence of immunity to HBV.
 HbeAg and HBV DNA are markers of active viral replication and thus
indicate high infectivity.
 The loss of HbeAg and appearance of anti-HbeAb indicates a less infective
stage.

60.  Acute HBV infection ------IgM anti HBc AB
 Early diagnosis of acute HBV infection-------- HBsAg in serum
 Most reliable indicator of recent HB infection -----IgM anti HBc
 After 15 days of HBsAg --------- HBV DNA by PCR
 Indicators of HBV replication are:
 1. HBV DNA
 2. DNA POLYMERASE
 3. Hbe Ag