Organ Transplantation Psychiatry — MCQs
An SSRI antidepressant, such as fluoxetine, will be prescribed for an adult patient. You should advise him or her that two of the most likely side effects or adverse responses that may eventually occur at therapeutic blood levels are which of the following?
A 30-year-old shows delusions, hallucinations, and marked thought disorder. Labs reveal anti-NMDA receptor antibodies. Best initial treatment?
What is the most common immunosuppressant regimen used in renal transplant for maintenance?
Most common infection post solid organ transplantation
A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
Which is the most common causative organism involved in infections after kidney transplantation?
All of the following are absolute contraindications for renal transplantation except:
Which of the following dependence-causing drugs is most commonly abused worldwide?
Which class of medications is known to worsen the symptoms of delirium in patients post-cardiac surgery?
What is the most common psychological feature of AIDS?
Organ Transplantation Psychiatry Indian Medical PG Practice Questions and MCQs
Question 1: An SSRI antidepressant, such as fluoxetine, will be prescribed for an adult patient. You should advise him or her that two of the most likely side effects or adverse responses that may eventually occur at therapeutic blood levels are which of the following?
- A. Sexual dysfunction and sleep disturbances (Correct Answer)
- B. Sexual dysfunction and nausea
- C. Headache and diarrhea
- D. Tremor and weight gain
Explanation: ***Sexual dysfunction and sleep disturbances*** - **Sexual dysfunction** is one of the most common and persistent adverse effects of SSRIs, affecting 40-65% of patients and continuing throughout treatment at therapeutic levels [2], [3]. - **Sleep disturbances** (insomnia or altered sleep architecture) can persist during long-term SSRI therapy and are among the eventual side effects patients experience [1], [2], [3]. - Both effects are characteristic of chronic SSRI use and significantly impact patient compliance and quality of life. *Sexual dysfunction and nausea* - While **sexual dysfunction** is indeed very common and persistent, **nausea** is typically a transient side effect that occurs during the first 1-2 weeks of treatment and usually resolves with continued use [2]. - The question specifically asks about *eventual* occurrence at therapeutic levels over time, making nausea less appropriate as it is not a chronic issue. *Tremor and weight gain* - **Tremor** is not among the most common side effects of SSRIs and occurs less frequently than sexual dysfunction or sleep disturbances. - **Weight gain** can occur with some SSRIs (particularly paroxetine), but fluoxetine is actually considered weight-neutral or may even cause weight loss in some patients, making this combination less likely for fluoxetine specifically [1]. *Headache and diarrhea* - Both **headache** and **diarrhea** are common initial side effects when starting SSRIs but typically improve or resolve within the first few weeks of treatment [1]. - These are transient effects rather than eventual persistent side effects that characterize long-term therapeutic use.
Question 2: A 30-year-old shows delusions, hallucinations, and marked thought disorder. Labs reveal anti-NMDA receptor antibodies. Best initial treatment?
- A. Immunotherapy (Correct Answer)
- B. Benzodiazepines
- C. ECT
- D. Antipsychotics
Explanation: ***Immunotherapy*** - The presence of **anti-NMDA receptor antibodies** indicates an autoimmune etiology for the psychiatric symptoms, making **immunotherapy** (e.g., corticosteroids, IVIG, plasmapheresis) the definitive first-line treatment. - Immunotherapy aims to reduce inflammation and remove autoantibodies, thereby reversing the neurological and psychiatric manifestations. *Benzodiazepines* - While useful for acute agitation or catatonia in psychiatric disorders, **benzodiazepines** do not address the underlying autoimmune pathology of anti-NMDA receptor encephalitis. - They would provide only symptomatic relief and would not prevent disease progression or long-term neurological damage. *ECT* - **Electroconvulsive therapy (ECT)** is a treatment for severe, refractory mood disorders or catatonia, which might be present in anti-NMDA receptor encephalitis. - However, ECT is a symptomatic treatment and does not target the autoimmune cause, making it less appropriate as the **initial definitive treatment**. *Antipsychotics* - **Antipsychotics** are used to manage psychosis, delusions, and hallucinations, which are prominent in anti-NMDA receptor encephalitis. - However, they do not treat the underlying **autoimmune inflammation** and may worsen some symptoms, such as autonomic instability or seizures, in this specific condition.
Question 3: What is the most common immunosuppressant regimen used in renal transplant for maintenance?
- A. Calcineurin inhibitors + Purine antagonists + Basliximab
- B. Glucocorticoids + Cyclophosphamide
- C. Cyclophosphamide + Purine antagonists + Glucocorticoids
- D. Calcineurin inhibitors + Purine antagonists + Glucocorticoids (Correct Answer)
Explanation: ***Calcineurin inhibitors + Purine antagonists + Glucocorticoids*** - This triple therapy regimen is the **most common and effective** approach for long-term maintenance immunosuppression in renal transplant recipients [1]. - **Calcineurin inhibitors** (e.g., tacrolimus, cyclosporine) are the cornerstone for preventing T-cell activation, **purine antagonists** (e.g., mycophenolate mofetil, azathioprine) inhibit lymphocyte proliferation, and **glucocorticoids** provide broad anti-inflammatory effects [1]. *Calcineurin inhibitors + Purine antagonists + Basliximab* - **Basiliximab** is typically used for **induction therapy** (immediately post-transplant) to prevent acute rejection by blocking the IL-2 receptor, not as a long-term maintenance component. - The standard maintenance regimen *replaces* induction agents like basiliximab with a long-term steroid or calcineurin inhibitor alongside a purine antagonist. *Glucocorticoids + Cyclophosphamide* - **Cyclophosphamide** is a potent alkylating agent primarily used in specific autoimmune diseases or certain cancers, and its use in transplant is generally limited to cases of organ rejection resistant to standard therapy due to its significant toxicity. - This combination is **not a standard maintenance regimen** for renal transplant due to the high toxicity and side effects of cyclophosphamide. *Cyclophosphamide + Purine antagonists + Glucocorticoids* - As mentioned, **cyclophosphamide** is not a first-line agent for maintenance immunosuppression in renal transplant due to its severe side effect profile, including myelosuppression and hemorrhagic cystitis. - While purine antagonists and glucocorticoids are components of maintenance therapy, the inclusion of cyclophosphamide makes this an **uncommon and usually unfavorable regimen** for long-term use.
Question 4: Most common infection post solid organ transplantation
- A. EBV
- B. CMV (Correct Answer)
- C. HSV
- D. HPV
Explanation: ***CMV*** - **Cytomegalovirus (CMV)** is the most common viral infection in solid organ transplant recipients, often reactivating in immunosuppressed patients [1]. - It can cause a wide range of clinical syndromes including **fever**, **leukopenia**, **hepatitis**, **pneumonitis**, and **gastroenteritis**, and is a significant cause of morbidity and mortality [1]. *EBV* - **Epstein-Barr virus (EBV)** is also common in transplant recipients but is most notably associated with **post-transplant lymphoproliferative disorder (PTLD)**, a serious complication [1]. - While present, it is not as frequently the cause of symptomatic infection as CMV in the immediate post-transplant period. *HSV* - **Herpes simplex virus (HSV)** infections can occur, manifesting as mucocutaneous lesions or, less commonly, severe systemic disease in transplant patients. - However, its incidence and severity are generally lower compared to CMV in the overall transplant population. *HPV* - **Human papillomavirus (HPV)** infections are typically associated with **warts** and increased risk of **malignancies** (e.g., anogenital cancers) in immunosuppressed individuals, including transplant recipients. - While important for long-term surveillance, HPV does not represent the most common acute infection post-transplant.
Question 5: A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
- A. Alzheimer's disease
- B. Delirium (Correct Answer)
- C. Depression
- D. Post-traumatic psychosis
Explanation: ***Delirium*** - The **acute onset** of memory loss and confusion **2 days after cardiac bypass surgery** is characteristic of **postoperative delirium**. - Delirium is a disturbance in **attention**, **awareness**, and **cognition** that develops over a short period (hours to days) and is directly related to a medical condition or procedure. - **Cardiac surgery** is a well-known risk factor, with delirium occurring in **10-50%** of cardiac bypass patients due to factors like anesthesia, hypoperfusion, inflammation, and physiological stress. - Key features here: **acute onset**, **temporal relationship to surgery**, and **memory/cognitive deficits** without psychotic symptoms. *Alzheimer's disease* - Alzheimer's is a **chronic, progressive neurodegenerative disorder** with **gradual onset** over months to years. - The **sudden appearance** of symptoms immediately after surgery cannot be explained by Alzheimer's disease. - While Alzheimer's causes memory impairment, it does not present acutely in the postoperative setting. *Depression* - Depression can cause **pseudodementia** with cognitive complaints, but the primary features would be **persistent low mood**, **anhedonia**, **sleep disturbance**, and **appetite changes**. - The **acute temporal link** to surgery and absence of mood symptoms make depression unlikely. - Cognitive symptoms in depression are typically subjective complaints rather than objective deficits. *Post-traumatic psychosis* - This would involve **psychotic symptoms** such as **hallucinations**, **delusions**, or **disorganized behavior**, which are not described in this case. - The presentation of simple **memory deficits** without psychotic features does not support this diagnosis. - Surgery itself is not typically considered a psychologically traumatic event that would trigger psychosis.
Question 6: Which is the most common causative organism involved in infections after kidney transplantation?
- A. Klebsiella
- B. Epstein Barr virus
- C. Cytomegalovirus (Correct Answer)
- D. Herpes simplex virus
Explanation: ***Cytomegalovirus*** - **Cytomegalovirus (CMV)** is the most common opportunistic infection after kidney transplantation, occurring in **50-80%** of transplant recipients. - CMV infection or reactivation typically occurs **1-6 months post-transplant** due to intense **immunosuppression** required to prevent graft rejection. - Highest risk is in **donor-positive/recipient-negative (D+/R-)** serostatus, but reactivation can occur in seropositive recipients. - CMV can cause **fever, leukopenia, graft dysfunction**, and invasive disease affecting multiple organ systems. *Klebsiella* - While *Klebsiella* can cause serious bacterial infections, particularly **urinary tract infections** and **pneumonia** in transplant patients, it is not the most common overall causative organism for post-transplant infections. - Bacterial infections like *Klebsiella* are often related to indwelling catheters or surgical sites but are less ubiquitous than viral reactivations in immunosuppressed patients. *Epstein Barr virus* - **Epstein-Barr Virus (EBV)** is another significant viral pathogen in transplant recipients, primarily associated with **post-transplant lymphoproliferative disorder (PTLD)**. - While important, EBV infection or reactivation is not as universally prevalent or as frequently symptomatic as CMV in the post-transplant period. *Herpes simplex virus* - **Herpes simplex virus (HSV)** can cause infections in transplant patients, leading to **mucocutaneous lesions** and occasionally disseminated disease. - HSV infections are generally less severe and less common than CMV, which can affect multiple organ systems and has a higher morbidity burden in this population.
Question 7: All of the following are absolute contraindications for renal transplantation except:
- A. Active infection
- B. Active malignancy
- C. Active drug abuse
- D. Reduced life expectancy (Correct Answer)
Explanation: ***Reduced life expectancy*** - While a significantly reduced life expectancy due to certain **comorbidities** may influence the decision to transplant, it is not an absolute, but rather a relative, contraindication, as individual cases vary. - Ethical considerations and the potential for improved quality of life may still support transplantation in some cases, even with a **limited prognosis**. *Active infection* - An **active systemic infection** is an absolute contraindication due to the high risk of severe complications, including sepsis and infection of the transplanted organ, especially with immunosuppression. - The patient must be free of active infection before transplantation to ensure the safety and success of the procedure. *Active malignancy* - The presence of an **active malignancy** is an absolute contraindication because immunosuppressive therapy post-transplant can accelerate cancer progression and metastasis. - Patients typically require a **disease-free interval** (e.g., 2-5 years) after cancer treatment before being considered for transplantation. *Active drug abuse* - **Active illicit drug abuse** is an absolute contraindication due to concerns about adherence to the complex post-transplant medical regimen, potential for infections, and overall poor health outcomes. - Successful transplantation requires strict adherence to medication schedules and follow-up, which is jeopardized by **active substance use**.
Question 8: Which of the following dependence-causing drugs is most commonly abused worldwide?
- A. Cannabis (Correct Answer)
- B. Heroin
- C. Amphetamine
- D. Cocaine
Explanation: ***Cannabis*** - **Cannabis** is the most widely cultivated and consumed illicit drug globally, with the highest prevalence of past-year use. - Its widespread availability, relatively lower perception of harm compared to other drugs, and varied forms of consumption (smoking, edibles) contribute to its extensive abuse. *Heroin* - **Heroin** is a highly addictive opioid that causes severe physical dependence and withdrawal symptoms, but its global prevalence is significantly lower than that of cannabis. - Its high cost, illicit nature, and significant health risks, including overdose, limit its abuse to a smaller, though critically affected, population. *Amphetamine* - **Amphetamines**, including methamphetamine, are potent central nervous system stimulants with a significant abuse potential, leading to psycho-behavioral and physical dependence. - While prevalent in certain regions and among specific populations, their overall global abuse statistics are lower than those for cannabis. *Cocaine* - **Cocaine** is a powerful stimulant derived from the coca plant, known for its strong psychological dependence and significant health consequences. - Its abuse is concentrated in specific geographical areas and demographic groups, making its global prevalence of abuse lower than that of cannabis.
Question 9: Which class of medications is known to worsen the symptoms of delirium in patients post-cardiac surgery?
- A. Antipsychotics
- B. Anticholinergics (Correct Answer)
- C. Benzodiazepines (BZD)
- D. Antihistamines
Explanation: **Explanation:** **1. Why Anticholinergics are the Correct Answer:** Delirium is fundamentally characterized by a neurochemical imbalance, most notably a **cholinergic deficiency** and a dopaminergic excess. Medications with anticholinergic properties (e.g., atropine, scopolamine, or certain tricyclic antidepressants) block acetylcholine receptors in the brain, directly precipitating or severely worsening the symptoms of delirium (confusion, disorientation, and cognitive impairment). In post-cardiac surgery patients, the brain is already vulnerable due to systemic inflammation and micro-emboli; adding an anticholinergic agent further destabilizes the neurotransmitter balance. **2. Analysis of Incorrect Options:** * **A. Antipsychotics:** These are actually the **treatment of choice** for the agitation associated with delirium. Low-dose Haloperidol is frequently used because it antagonizes dopamine, helping to restore the neurochemical balance. * **C. Benzodiazepines (BZD):** While BZDs can worsen delirium in the elderly or cause "paradoxical agitation," they are not the primary pharmacological *cause* of the underlying cholinergic deficit. They are generally avoided in delirium **unless** the delirium is caused by Alcohol Withdrawal or BZD withdrawal. * **D. Antihistamines:** While first-generation antihistamines (like diphenhydramine) have anticholinergic side effects and can cause delirium, "Anticholinergics" as a class is the more specific and direct answer regarding the underlying pathophysiology. **3. High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for Delirium:** Haloperidol (IV/IM/Oral). * **Delirium vs. Dementia:** Delirium is acute, reversible, and characterized by **fluctuating levels of consciousness** and impaired attention. * **The "BZD Exception":** Use Benzodiazepines for delirium *only* if the etiology is Alcohol or Sedative-Hypnotic withdrawal. * **Post-Op Risk:** Post-cardiac surgery delirium is common (up to 30-50%) and is associated with increased mortality and longer ICU stays.
Question 10: What is the most common psychological feature of AIDS?
- A. Depression (Correct Answer)
- B. Mania
- C. Suicidal tendency
- D. None of the above
Explanation: **Explanation:** **1. Why Depression is the Correct Answer:** Depression is the most common psychiatric manifestation in patients living with HIV/AIDS, with a prevalence significantly higher than in the general population (estimated between 20% to 40%). The etiology is multifactorial: * **Biological:** Direct neurotoxic effects of the HIV virus on the subcortical structures and the release of pro-inflammatory cytokines. * **Psychosocial:** The stigma associated with the diagnosis, loss of social support, chronic physical debilitation, and the burden of lifelong medication. * **Pharmacological:** Certain antiretroviral drugs (like Efavirenz) are known to induce depressive symptoms. **2. Analysis of Incorrect Options:** * **B. Mania:** While "AIDS Mania" is a recognized clinical entity (often occurring in late stages due to organic brain involvement), it is far less common than depression. It is usually characterized by irritability rather than euphoria. * **C. Suicidal tendency:** While HIV patients have a higher risk of suicide compared to the general population (especially shortly after diagnosis), it is considered a complication or a severe symptom of underlying depression rather than the most common psychological feature itself. **3. NEET-PG High-Yield Pearls:** * **Most common psychiatric disorder in HIV:** Depression. * **Most common CNS opportunistic infection:** Toxoplasmosis (though Cryptococcus is the most common fungal infection). * **HIV-Associated Neurocognitive Disorder (HAND):** Ranges from mild impairment to **AIDS Dementia Complex (ADC)**, characterized by subcortical dementia (psychomotor slowing, memory loss). * **Drug Alert:** **Efavirenz** (an NNRTI) is frequently associated with neuropsychiatric side effects, including vivid dreams, insomnia, and depression. * **Treatment:** SSRIs are the first-line treatment for depression in AIDS, but clinicians must monitor for drug-drug interactions with Protease Inhibitors (CYP450 inhibition).
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