You are an expert medical education specialist creating advanced board exam questions.

Using the following comparison table, generate a complete board exam question including vignette, question stem, answer choices, and explanations.

**Comparison Table:**
{{ comparison_table }}

**Requirements for CHALLENGING Board Exam Questions:**

1. **CRITICAL Diagnostic Clue Distribution:**
   - **Correct diagnosis ONLY**: Must have exactly 3 clear but subtle diagnostic clues
   - **Each distractor**: Should have 1-2 misleading clues suggesting that diagnosis
   - **Create confusion**: Include overlapping symptoms, labs, imaging between diagnoses
   - **Avoid giveaways**: NO obvious exposure + classic symptoms + confirmatory tests

2. **Clinical Vignette Complexity**: Create a realistic, challenging clinical scenario that:
   - Uses specific patient demographics, medical history, and presentation timeline
   - Includes detailed vital signs, physical exam findings, and laboratory results
   - Incorporates specific imaging findings and diagnostic test results
   - **Includes confounding elements**: Red herrings from differential diagnoses
   - **Atypical presentations**: Avoid textbook classic presentations
   - **Expert-level reasoning required**: Should challenge ID specialists
   - Uses realistic medical details (specific lab values, medication names, dosages)
   - **Multiple comorbidities/factors** that complicate the clinical picture

3. **Question Stem**: 
   - For diagnosis questions: "Which of the following is the most likely diagnosis?"
   - For treatment questions: "Which of the following is the most appropriate next step in management?"
   - For identification questions: "Which of the following is the most likely causative organism?"

4. **Answer Choices**: Extract the condition names from the comparison table:
   - A. [Correct answer condition]
   - B. [Distractor 1 condition]  
   - C. [Distractor 2 condition]
   - D. [Distractor 3 condition]
   - E. [Distractor 4 condition]

4. **Explanations**:
   - **Correct Answer**: Explain why this diagnosis is most consistent with the clinical presentation, citing specific discriminating features
   - **Each Distractor**: Explain why this diagnosis is less likely, highlighting key differences in presentation, lab findings, or clinical context

**Quality Standards:**
- Board exam level complexity and clinical accuracy
- Specific medical details that demonstrate expertise
- Clear clinical reasoning that teaches key concepts
- Appropriate difficulty for advanced learners

**Topic**: {{ topic }}
**Question Type**: {{ question_type }}
**Difficulty**: {{ difficulty_level }}

**Output Format:**
Return a JSON object with this exact structure:
```json
{
  "vignette": "Detailed clinical scenario with specific medical details...",
  "question_stem": "Complete question including vignette + question",
  "answer_choices": [
    "A. Correct condition name",
    "B. Distractor 1 condition name", 
    "C. Distractor 2 condition name",
    "D. Distractor 3 condition name",
    "E. Distractor 4 condition name"
  ],
  "explanations": {
    "correct_explanation": "Why A is correct with specific clinical reasoning...",
    "distractor_explanations": [
      "Why B is incorrect with specific differences...",
      "Why C is incorrect with specific differences...", 
      "Why D is incorrect with specific differences...",
      "Why E is incorrect with specific differences..."
    ]
  }
}
```