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Type 4 renal tubular acidosis — ABIM Board MCQ

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HardNephrologyType 4 renal tubular acidosisABIM Board

A 44-year-old woman receiving AML induction has an absolute neutrophil count below 100/mm3 expected to persist for two weeks. She remains febrile after five days of cefepime; repeated cultures are negative, examination is unrevealing and CT shows no focal infection. She was receiving fluconazole, which lacks mold activity. Which next anti-infective step is appropriate?

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Correct answer: A — Add empiric mold-active antifungal therapy while continuing diagnostic evaluation

The best answer is “Add empiric mold-active antifungal therapy while continuing diagnostic evaluation”. High-risk prolonged neutropenia with unexplained fever persisting four to seven days despite broad-spectrum antibacterial therapy warrants empiric mold-active antifungal treatment or a structured biomarker-driven strategy. Fluconazole does not protect against molds. Persistent fever alone does not mandate vancomycin, and negative cultures neither justify antibacterial withdrawal nor support outpatient management in this high-risk patient.

Reference: IDSA 2016 Clinical Practice Guideline for the Diagnosis and Management of Aspergillosis: https://www.idsociety.org/practice-guideline/aspergillosis/