NYACP Board Review Question of the Week

Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam.  Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.

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May 19th, 2026

MKSAP 19 Infectious Disease, Question 24

A 26-year-old woman undergoes consultation to update her vaccinations. She is an elementary school teacher. Medical history is significant for well-controlled HIV diagnosed 6 years ago. Medications are tenofovir alafenamide, emtricitabine, and dolutegravir.

The physical examination is normal.

Her CD4 cell count is 520/µL and has been stable for several years. HIV viral load is undetectable.

Which of the following vaccines is contraindicated in this patient?

A.    Human papillomavirus
B.    Inactivated influenza
C.    Measles-mumps-rubella
D.    Varicella
E.    No contraindications exist

Responses Received from Members (Graph is uploaded on Thursday afternoon):

The Correct Answer is: E. No contraindications exist

Educational Objective: Identify appropriate vaccines for patients with HIV infection.

This patient has no contraindications to routinely administered vaccines (Option E). Live vaccines, including varicella, measles-mumps-rubella, and influenza are not recommended for patients who are severely immunocompromised. Contraindications to live vaccines include persons with HIV with CD4 cell count ≤200/µL; pregnancy or probable pregnancy within 4 weeks; immunosuppressant therapy, including high-dose glucocorticoids; leukemia, lymphoma, or other bone marrow and lymphatic system malignancies; cellular immunodeficiency; solid organ transplant recipient; and recent hematopoietic stem cell transplantation.

The live-attenuated influenza vaccine is contraindicated in patients with HIV infection regardless of CD4 cell count, but the inactivated vaccine can be given (Option B). Numerous other immunizations are recommended for all persons with HIV, including COVID-19 and pneumococcal vaccines. Patients who are not already immune or infected with hepatitis B virus should receive the hepatitis B vaccine series. Tetanus-diphtheria-pertussis, hepatitis A, and human papillomavirus (HPV) vaccinations are indicated as for the general population (Option A). The Advisory Committee on Immunization Practices (ACIP) has expanded the age indications for HPV vaccination to 45 years, recommending that the decision to vaccinate between ages 26 and 45 years be determined through shared decision making with patients. The ACIP recommends that all persons with HIV infection be vaccinated for meningococcal disease with the quadrivalent meningococcal vaccine, including boosters every 5 years.

For prevention of varicella-zoster, the inactivated recombinant vaccine is recommended for patients with HIV infection aged 19 years and older. For patients without immunity, selected live vaccines such as the measles-mumps-rubella and varicella vaccines can be given to patients with HIV infection as long as the CD4 cell count is greater than 200/µL (Option C, D).

Key Point

• Selected live vaccines, including the varicella and measles-mumps-rubella vaccines, are safe to administer to nonimmune persons with HIV infection whose CD4 cell count has consistently been greater than 200/µL.
• The live influenza vaccine is contraindicated in immunocompromised patients and those with HIV regardless of CD4 cell count.

Bibliography

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.

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May 5th, 2026

MKSAP 19 Extension Questions Set 4, Question 1

A 72-year-old woman is evaluated for progressive fatigue of 3 months' duration. She has additionally noted mild left upper quadrant abdominal discomfort for the past month that is accompanied by early satiety. She has lost 6.8 kg (15 lb) since symptom onset. Medical history is significant for hypertension, and her only medication is hydrochlorothiazide.

On physical examination, vital signs are normal. Conjunctival pallor is noted. There is bruising on the lateral surfaces of the arms and legs. Splenomegaly is present 10 centimeters below the left inferior costal margin.

Laboratory studies:    
Activated partial thromboplastin time    31 s
Haptoglobin    109 mg/dL (1090 mg/L)
Hemoglobin    6.8 g/dL (68 g/L)
Leukocyte count    175,000/μL (175 × 109/L) (78% neutrophil, 0% lymphocytes,
8% basophils, 6% eosinophils)
Platelet count    22,000/μL (22 × 109/L)
Prothrombin time    11.9 s
Fibrinogen    227 mg/dL (2.27 g/L)
Lactate dehydrogenase    1272 U/L
 

Which of the following is the most appropriate diagnostic test to perform next?

A.    ADAMSTS13 activity
B.    Peripheral blood flow cytometry
C.    Peripheral blood smear
D.    Reverse transcriptase polymerase chain reaction for BCR:ABL1

Responses Received from Members (596 Responses):

The Correct Answer is: D. Reverse transcriptase polymerase chain reaction for BCR:ABL1

Educational Objective: Diagnose chronic phase chronic myeloid leukemia.

A reverse transcriptase polymerase chain reaction (RT-PCR) test for the BCR-ABL translocation to confirm the diagnosis of chronic myelogenous leukemia (CML) is the most appropriate diagnostic study to perform (Option D). CML is a clonal hematopoietic stem cell disorder defined by the presence of the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9, to the BCR gene on chromosome 22, resulting in a BCR-ABL fusion gene. Patients with CML often present with asymptomatic neutrophil elevation on routine laboratory testing, but may also experience symptoms such as weight loss, splenomegaly, fatigue, or fever.

A leukocytosis demonstrating elevations in the levels of myeloid-lineage leukocytes (such as neutrophils, basophils, or eosinophils) and thrombocytosis are often present. BCR-ABL studies are the key tools for diagnosing Philadelphia chromosome-positive CML and for differentiating CML from other myeloid neoplasms. RT-PCR tests are both sensitive and specific in diagnosing Philadelphia chromosome- positive CML. Direct bone marrow biopsy for molecular, flow cytometric, and morphologic evaluation are also important for differentiating CML from acute myeloid leukemia and classifying CML as chronic, accelerated, or blast phase. This patient's clinical presentation and available peripheral blood studies suggest leukocytosis consistent with chronic myeloid leukemia, and a RT-PCR BCR:ABL1 test is the best way of confirming the diagnosis.

ADAMSTS13 activity studies measure the activity of a zinc-containing metalloprotease enzyme important in cleaving von Willebrand factor. Reduced activities of ADAMSTS13 are associated with thrombotic thrombocytopenic purpura (TTP). Despite the presence of both anemia and thrombocytopenia, this patient's presentation is more consistent with CML than TTP given the presence of leukocytosis and the lack of intravascular hemolysis, as demonstrated by normal haptoglobin. ADAMSTS13 activity study would not be appropriate for this patient (Option A).
Peripheral blood flow cytometry is often most helpful in differentiating acute and chronic leukemia and ascertaining the phase of CML (Option B). Although peripheral blood flow cytometry could detect abnormalities present in the leukocyte count, it cannot fully prove the presence of CML and therefore would not be an appropriate diagnostic test for this patient.
A peripheral blood smear (Option C) is important for assessing morphologic changes and evaluating hematologic abnormalities but is neither as sensitive nor specific in diagnosing CML compared to RT- PCR for the BCR-ABL gene. At diagnosis, testing peripheral blood is as accurate as bone marrow samples.

Key Point

• Chronic myeloid leukemia is defined by the presence of the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9, to the BCR gene on chromosome 22, resulting in a BCR-ABL fusion gene.
• Patients with chronic myeloid leukemia may present with asymptomatic neutrophil elevation on routine laboratory testing, but can also experience symptoms such as weight loss, splenomegaly, fatigue, or fever.

Bibliography

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.

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Last Updated:  5.15.26