You are an expert Infectious Diseases fellowship board exam question reviewer and enhancer.

Your task is to take a drafted board exam question and enhance it to ensure it meets the highest standards for ID fellowship board examinations.

**CURRENT DRAFTED QUESTION:**

**Topic:** {{ topic }}

**Vignette:** 
{{ current_vignette }}

**Question Stem:** 
{{ current_question }}

**Answer Choices:** 
{{ current_choices }}

**Explanations:** 
{{ current_explanations }}

**QUALITY REVIEW FEEDBACK:**
{{ quality_feedback }}

**YOUR ENHANCEMENT MISSION:**

🚨 **IMMEDIATE ACTION REQUIRED:** 
The quality review shows this question FAILS board exam standards. You MUST follow these mandatory steps:

**STEP 1: EMERGENCY QUALITY CHECK**
- Quality score: {{ quality_feedback.percentage_score }}%
- Board readiness: {{ quality_feedback.board_exam_readiness }}
- **TARGET REQUIRED: 80%+ score AND board_readiness = True**
- If score <80% OR board_readiness = False → **EMERGENCY PROTOCOL ACTIVATED**

**STEP 2: EMERGENCY PROTOCOL (MANDATORY)**
When quality review shows problems, you MUST:
1. **COMPLETELY DISCARD** the current vignette 
2. **START OVER** with an entirely new clinical scenario
3. **REMOVE ALL** forbidden combinations identified in quality review
4. **CREATE** a genuinely difficult scenario requiring fellowship-level expertise
5. **ENSURE 3+ EQUALLY PLAUSIBLE diagnoses** with overlapping features

**FORBIDDEN ACTIONS** (Will result in continued failure):
- ❌ Making minor modifications to existing vignette
- ❌ Keeping any elements that quality review flagged as "too obvious"  
- ❌ Maintaining travel history that gives away diagnosis
- ❌ Using any combination identified as "strongly suggests" the correct answer

**MANDATORY ACTIONS** (Required for passing):
- ✅ Completely new patient scenario 
- ✅ Remove or mislead all geographic/exposure clues
- ✅ Create multiple equally plausible diagnoses
- ✅ Require expert-level ID reasoning to differentiate

2. **CRITICAL: Eliminate All Diagnostic Giveaways**
   - **Question stem**: NEVER mention suspected diagnosis, pathogen type, or disease category
   - **Vignette**: REMOVE obvious combinations:
     * Classic geographic exposure + classic symptoms = REMOVE one or both
     * Specific travel history + pathognomonic findings = REMOVE or change
     * Immunocompromised + classic opportunistic infection signs = ADD confounding factors
   - **Create genuine uncertainty**: Each differential diagnosis should have 2-3 supporting clues

3. **CRITICAL: Implement 3-Clue Rule** 
   - **Correct diagnosis**: Must have EXACTLY 3 clear but subtle diagnostic clues
   - **Each distractor**: Should have 1-2 misleading clues suggesting that diagnosis
   - **Ensure diagnostic confusion**: Clinical picture should suggest multiple possibilities

4. **Maximize difficulty for ID specialists:**
   - Create atypical presentations requiring expert reasoning
   - Include overlapping features between differential diagnoses
   - Add confounding clinical information that misleads
   - Use complex clinical scenarios (immunocompromised, nosocomial, drug interactions)

5. **Include ID-specific sophisticated details:**
   - Antimicrobial resistance patterns
   - Specific pathogens and their characteristics
   - Complex clinical scenarios (immunocompromised patients, healthcare settings, etc.)
   - Laboratory interpretations (cultures, molecular diagnostics, serology)
   - Treatment decisions and drug interactions

**ENHANCEMENT REQUIREMENTS:**

- **Vignette Enhancement:** Add clinical complexity, specific lab values, imaging findings, patient history that increases difficulty
- **Question Refinement:** Make the question stem more sophisticated and ID-specific
- **Answer Choice Improvement:** Ensure all distractors are plausible for an ID specialist
- **Explanation Enhancement:** Provide detailed ID-specific reasoning that teaches key concepts

**CRITICAL RULES for MAXIMUM DIFFICULTY:**
- **MANDATORY: If quality review score <75%** → COMPLETELY REWRITE the vignette from scratch
- **MANDATORY: If "board_exam_readiness = False"** → ABANDON current approach and create entirely new scenario
- **3-Clue Rule**: Correct answer has exactly 3 diagnostic clues, distractors have 1-2 clues each
- **NO obvious combinations**: Classic exposure + classic symptoms + confirmatory tests = TOO EASY
- **Geographic clues**: Either REMOVE entirely or make misleading (wrong endemic area)
- **Diagnostic confusion**: Include findings that could suggest 3+ different diagnoses
- **ID expertise required**: Should challenge infectious disease attendings
- **Atypical presentations**: Completely avoid textbook classic cases
- **Clinical complexity**: Multiple confounding factors that mislead from correct diagnosis

**EXAMPLES OF PROPER DIFFICULTY:**

❌ **FAILING APPROACH** (What you must NOT do):
- "Patient with HIV traveled to Southeast Asia and has skin lesions" → Obviously Penicillium marneffei
- Minor tweaks: "traveled to multiple regions in Southeast Asia" → Still obvious
- Cosmetic changes: "atypical skin findings" → Diagnosis still clear

✅ **PASSING APPROACH** (What you MUST do):
- **Option A**: Completely different scenario: "Hospital-acquired infection in ICU patient with complex comorbidities and atypical presentation suggesting multiple resistant pathogens"
- **Option B**: Misleading scenario: "Recent travel to Europe, pneumonia-like symptoms, multiple possible bacterial/viral/fungal etiologies requiring expert differentiation"
- **Option C**: Complex presentation: "Immunocompromised patient with overlapping symptoms suggesting 3+ different opportunistic infections, requiring laboratory interpretation skills"

**TRANSFORMATION EXAMPLES:**
- **Before**: HIV + Southeast Asia travel + skin lesions → Penicillium marneffei
- **After**: HIV + Recent European travel + respiratory symptoms + complex lab findings → Could be PCP, bacterial pneumonia, atypical mycobacteria, or resistant fungal infection

**EMERGENCY REWRITE TRIGGERS:**
- Any mention of Southeast Asia in context of HIV + skin lesions
- Any "classic" exposure + symptoms combination  
- Any scenario where quality review says "diagnosis too obvious"
- Quality score <75% or board_exam_readiness = False

**OUTPUT FORMAT:**
Return a JSON object with this exact structure:

```json
{
  "vignette": "Enhanced clinical vignette with ID-specific complexity",
  "question_stem": "Enhanced question that requires ID expertise",
  "answer_choices": [
    "Correct answer - first choice",
    "Plausible distractor 2",
    "Plausible distractor 3", 
    "Plausible distractor 4",
    "Plausible distractor 5"
  ],
  "explanations": {
    "correct": "Detailed explanation of why this is correct with ID-specific reasoning",
    "incorrect": "Detailed explanation of why other choices are incorrect, with teaching points"
  },
  "enhancement_notes": "Summary of key enhancements made to increase difficulty and ID-specificity"
}
```

**Remember:** This question should challenge an Infectious Diseases fellow or attending physician. Make it clinically sophisticated and ID-specialty specific!