Cases Flashcards
What's the diagnosis, investigations and management?
Travel to Milawi, freshwater exposure with positive Schistosoma serology
Lab: Stool/urine O&P negative
Rx: Praziquantel.
Sequelae: If untreated, ectopic CNS lesions, pulmonary haemorrhage.
Born in Malawi. Insidious onset of lethargy, mild mucohemorrhagic diarrhea, cramping, abdominal pain. Diffuse abdominal tenderness, minimal hepatomegaly, mild malnutrition. Mild eosinophilia.
Diagnosis: Schistosomiasis
Lab: S. mansoni ova in stool, mild eosinophilia, periportal fibrosis on U/S.
Rx: Praziquantel.
Sequelae: Associated with SCC bladder cancer.
Chronic cough with blood-streaked sputum, progressive chest discomfort, breathlessness on exertion following ingestion of freshwater crab in China/Japan/Korea/Taiwan
Paragonimus
Lab: CXR: patchy cystic infiltrate but can have nodule only
Eosinophilia; Paragonimus IgG positive
Eggs in sputum/BAL or stools
Mx: Praziquantel for 3 days.
Transient lymphedema, from DRC
- Lymphatic filariasis
- Wuchereria bancrofti
- Brugia malayi
Nocturnal microfilaria.
Symptomatic treatment
Consider annual MDA with DEC + albendazole
Expat from West Africa with an evanescent pruritus, maculopapular rash, often on the trunk with some subcutaenous nodules - diagnosis, diagnostics and management
Onchocerciasis
Other features including eye features, epilepsy.
Microfilariae in skin snips; eosinophilia, serology.
Ivermectin single dose. Doxycycline (target Wolbachia)
Expat from Central/West Africa (e.g. Gabon, Cameroon) with transient Calabar swellings, arthralgia, occasional pruritus and a visible eye worm - diagnosis, diagnostics,
Loa Loa (deerflies)
Eosinophilia; antifilarial IgG positive
DEC for 3 weeks
Had a recent barbeque with pork sausages. Initial diarrhea and non-specific abdominal complaints followed by fever, facial edema, painful swollen muscles, including respiratory and mastication muscles - diagnosis, diagnostics and management
Trichinosis
Eosinophilia, elevated IgE and CPK, positive T. spiralis IgG, larvae seen on muscle biopsy.
Rx: Albendazole with steroids
Patient with CD4 count 50, recently started ART presenting with an intensely itchy bumps over their head and trunk
Eosinophilic folliculitis
Skin biopsy reveals eosinophils under the skin surface and around the hair follicles and sebaceous glands
Treat with itraconazole, permetrhin
Or watch and wait for IRIS to settle
Fever, malaise, RUQ discomfort, wheezing in a 2-year-old who lives with dogs
Visceral Larva Migrans
Baylisascaris procyonis, Toxocara canis, Toxocara cati and Ascaris suum
Massive eosinophilia, elevated IgG, T. canis IgG positive; biopsy rarely needed
Treat with Albendazole; steroids may be considered
Severe headache, nausea, neck stiffness, paresthesias after eating some snails in Hawaii
Angiostrongylus cantonensis (Rat Lungworm)
CSF shows eosinophilia, elevated pressure, normal glucose, and high protein
Repeated lumbar puncture, analgesics, steroids. Avoid anthelmintics unless heavy steroids are used
Migratory subcutaneous swelling in a returning traveller who walked on the beach barefoot with lots of dog poo
Cutaneous larva migrans (CLM) is a self-limiting dermatosis caused by the migration of animal hookworm larvae (most commonly the dog hookworm Ancylostoma caninum and the cat hookworm Ancylostoma braziliense) in the skin.
Returning traveller, went on a fishing trip to Vietnam, presenting with migratory subcutaneous swelling
Gnathostomiasis
SE Asia, Latin America, rarely Africa
Eosinophilia; G. spinigerum ELISA positive.
Rarely an ectopic infection: eosinophilic meningoencephalitis or spinal cord involvement
Rx: Albendazole for 3 weeks or ivermectin for refractory cases.
4-week history of diffuse abdominal pain, diarrhoea, nausea and weakness and pneumonia. Background of liver transplant on immunosuppression. Bowel obstruction and gram negative sepsis. Longstanding eosinophilia. From SE Asia.
Strongyloides hyperinfection
Larvae in stool, eosinophilia, Strongyloides IgG positive
Treat: Ivermectin and antibiotics for superinfection
Returning traveller from India with diarrhoea with some cramping, progressed over weeks to having blood/mucous in the stool Now presenting with RUQ pain and some weight loss
Amoebiasis (Entamoeba histolytica)
Stool microscopy (hot) or PCR
Serology
Imaging for liver abscess
Rx Metronidazole with a luminal agent (iodoquinol or paromycin), large abscesses need draining
Fever, chills, headache. RCT positive. 15 weeks pregnant.
Malaria
Severity signs: High parasitemia, thrombocytopenia, elevated CK, lactic acidosis, hypoglycemia
Treat with IV artesunate in severe cases, ACT in non-severe
Travel to India, treated for malaria but within 2 weeks presenting with a fever again
Plasmodium vivax Relapse
Ring forms, schizonts in peripheral smear
Chloroquine for acute phase, primaquine 14 days for hypnozoite eradication following G6PD deficiency
30 year old from Bolivian with syncope and dilated cardiomyopathy with dysphagia
Chagas disease (Trypanosoma cruzi)
Chagoma may occur at entry site, acute chagas may present with fever, malaise, lymphadenopathy,
Diagnosis:
Serology
PCR (most helpful in newborns)
Microscopy of blood or heart muscle
Rx: Benznidazole 60 days (associated with lots of toxicity) for immunosuppressed or to prevent vertical transmission
Seen in DRC with acute febrile illness and lymphadenopathy following a painful bite with a visible chancre
African trypanosomiasis - T brucei rhodesiense (more acute form)
Dx
Microscopy
Molecular approaches
Rx
Suramin (early), melarsoprol (late)
Seen in DRC with enlarged lymph nodes, mild fever, general malaise followed by personality changes and sleepiness
African sleeping sickness - T brucei gambiense (west african)
Dx
Microscopy
Molecular approaches
Rx
Pentamidine (early) +/- nifurtimox (late).
Grew up in India presenting with 3 weeks of fever, massive splenomegaly, hepatomegaly, pallor and weight loss
Visceral leishmaniasis (sandfly)
L. infantum, L donovani
Dx: Pancytopenia, hypergammaglobulinemia, hypoalbuminemia, microscopy of amastigotes in marrow, lymph or spleen aspirate
Serology in East Asia, not so helpful in Africa
Rx: Liposomal amphotericin B, miltefosine alternative
Nodules appearing following visceral leishmaniasis diagnosis
Post-Kala Azar Dermal Leishmaniasis (PKDL)
Dx Slit skin smeal
Mx Miltefosine monotherapy 12 weeks (teratogenic)
Chronic ulcerative skin lesion; painless, no systemic symptoms following sandfly bite
Cutaneous Leishmaniasis
Dx
Look for amastigotes on smears or tissue sections
No role for serology here (unlike visceral)
Can grow on culture
Mx - approach
American vs Non-American? If American are they Viannia? (i.e. are they at risk of mucosal involvement)
Immunosuppressed?
- Conservative
- Local - intralesional antimonials
- Miltefosine (teratogenic)
- Pentavalent animonials e.g. meglumine
Gap year student ate lots of raspberries and lettuce in Peru and now has fever, vomiting, watery diarrhoea
Cyclospora cayetanensis
Dx
Stool with AFB positive oocytes (variably acid fast - pink on green background)
Mx co-trimoxazole 7-10 days
Patient with HIV with chronic diarrhoea and abdominal pain
Cryptosporidium
Stool AFB positive for oocysts (fuscia pink on a green background)
Most often self-limiting in healthy individuals, ARV in HIV
Sheep farmer who spends lots of time with sheepdog, RUQ pain, US shows a large >5cm multilocular cyst and a cough
Cystic echinococcosis (Echinococcus granulosus)
Dx: Serology + imaging
Primarily in the lungs and liver
Simple <5cm cyst treat with albendazole alone
Complex (solid components or daughter cysts) and/or >5cm needs PAIR + albendazole
Refugee from China, had contact with foxes due to being homeless presenting with RUQ pain, jaundice and weight loss with evidence of calcified lesions on liver US
Alevolar echinococcosis (echinococcus multilocularis)
Dx:
Imaging
Serology
Biopsy - if malignancy needs to be excluded
Mx
Radical surgery of solitary lesions with 2 years of albendazole
May require lifelong albendazole
Peruvian pig farmer presenting with headaches and new onset of seizures
Neurocysticercosis (Taenia solium)
Occurs from ingestion of the eggs and therefore faecal oral contamination (with potential for human to human transmission) - rather than eating pork containing cysts
Dx
Serology
Neuroimaging
Mx
albendazole to be considered but not without risk
Returning traveller from Pakistan with fever, headache, malaise, constipation then diarrhoea with hepatosplenomegaly on exam
Enteric fever (salmonella typhi/paratyphi)
Dx:
Blood culture (gold standard)
Bone marrow (highest yield)
Mx
Azithromycin or 3rd generation cefalosporins
Somalian patient with fever, night sweats, back pain, arthralgia, orchitis and a new murmur. Sister owns camel.
Brucellosis
Dx
Blood culture (slow growing) +/- PCR
Rose bengal test
Mx
Doxycycline 45 days + IV gentamicin or streptomycin
Bartonellosis
Bartonella bacilliformis
Vector borne found in the Andean valley in Peru
Sandfly vector
Haemolytic anaemia, malaise, fever
Complications - CNS, pericarditis, myocarditis
Plumber presenting with difficulty swallowing, trismus, neck rigidity, spasms triggered by minor stimuli
Tetanus (clostridium tetani)
Dx: Clinical diagnosis, cultures rarely helpful
Mx:
Tetanus immunoglobulin
- None required in complete vaccination
- Booster + TIG needed in incomplete/unvaccinated
Sedation (diazepam), wound debridement, antibiotics (metronidazole)
May require mechanical ventilation
Recent flooding in India. Initially presenting with fever, headache, conjunctival suffusion, jaundice and hepatomegaly. Followed by meningeal symptoms
High ESR, thrombocytopenia, bilirubin elevation, AKI
Urine/blood PCR
Serology
Rx: Ceftriaxone or penicillin, supportive care (N.B jarisch-herxheimer)
Fever, headache and rash following trip to North America, tick bite noted
Rickettsia rickettsii (Rocky mountain spotted fever)
Dx: serology
Mx: doxycycline
Asylum seeker, 7 days ago came to UK having been in a refugee camp. Presenting with persistent fever, rash and eschar
Epidemic typhus (rickettsia prowazekii)
Body louse faeces
Note sustained fever, vasculitis complications
Dx Serology
Mx Doxycycline
Patient from Uganda presenting with fever, chills, painful unilateral inguinal swelling with a blood smear showing bipolar staining with coccobacilli
Plague (yersinia pestis)
Bubonic, pulmonary, septicaemia
Dx
Blood smear or bubo aspirate culture growing yersinia pestis
Mx Streptomycin or gentamicin
A farmer from Ethiopia presenting with a painless black eschar
Anthrax (bacillus anthracis)
Also pulmonary presentation (inhalational) or GI due to ingestion of bad meat
Dx culture
Mx: Ciproflox/amox in simple cases or cipro + mero + linezolid + IVIg in severe
Patient presenting with an enlarged inguinal lymph node with a previous ulcerative lesion in genital area. HIV positive and previous syphilis
Lymphogranuloma venereum
Dx: Chlamydia trachomatis in aspirate
Mx Doxycycline or azithromycin
Painful genital ulcer with tender regional lymphadenopathy with swab from the ulcer growing Haemophilus ducreyi
Chancroid
Dx culture, exclude syphilis and HSV
Mx single dose azithromycin
Pregnant women has presented with what started as a painless chancre and 6 weeks later develop fever and rash on the palms and soles
Maternal syphilis
Dx:
Nontreponemal tests e.g. RPR (swirling card test) and VDRL (used to screen for syphilis but not specific to syphilis)
Confirmatory treponemal tests TPHA or EIA
Mx:
IM benzathine penicillin (3 doses often given in pregnancy if late latent or unclear of stage), IV penicillin for neurosyphilis
Profuse watery diarrhoea with oliguria in a refugee camp in the context of recent outbreak
Cholera - O1/O139 producint toxin
Dx Stool culture vibrio cholerae
Mx Aggressive fluid resuscitation (IVF, ORS), zinc PO <5 years, Doxycycline
A 10 year old boy in a rural village in Uganda presenting with a single painless nodule ulcerating with a wide undermined edge. No fever or lymphadenopathy.
Buruli ulcer (mycobacterium ulcerans)
Dx: PCR gold standard, culture + histology
Mx: Rifampicin + streptomycin for 8 weeks, debridement of necrotic tissue
A 35 year old man from India presenting with a scaly anaesthetic lesion on his forearm
Paucibacillary leprosy - mycobacterium leprae
Dx: slit skin smear, biopsy siehl-nielseon staining
Mx: Rif + dapsone 6 months
A 26 year old woman presenting with multiple hypopigmented anaethetic patches over the trunk with palpable thickened peripheral nerve
Multibacillary leprosae (mycobacterium leprae)
Dx: slit skin smear, biopsy siehl-nielseon staining
Mx: Rif + dapsone + clofazimine for 12 months
8 year old from Thailand presenting with parotid abscess and culture shows an oxidase positive gram negative bacillus
Meliodosis (burkholderia pseudomallei)
Dx: culture blood, sputum, abscesses
Mx: IV ceftazidime or meropenem for 10 days –> co-trimoxazole maintenance 20 weeks
50 year old man from Japan with a background of spastic paraparesis, chronic dermatitis. Mother died of some form of leukaemia.
HTLV1 –> HAM or spastic parapareis and ATL
Dx: Serology/PCR
Mx: No treatment or vaccine
90 year old patient from a nursing home presenting with intense itch and hyperkeratosis of the hands
Scabies
Dx: clinical, scrapings showing mites
Mx: Ivermectin or pemethrin
65 year old from India presenting with fever, retro-orbital headache and a macular rash. Leukopenia, thrombocytopenis and elevated transaminases. Now presenting with pulmonary odoema
Severe dengue
Dx: Serology
Mx: Supportive care
20 year old returning from Brazil with a history of fever, diffuse rash and polyarthritis with a knee effusion
Chikungunya
Dx: Serology
Mx:Supportive care
27 year old in rural Nigeria presenting with fever, sore throat and hearing loss. It’s harvest and he sleeps on the floor
Lassa fever
Dx: Serology/PCR
Mx: Early ribavirin
45 year old VFR in DRC presenting with fever and severe headache and sore throat, 3 days later started to get vomiting, diarrhoea and GI bleed
Ebola
Dx: PCR
Mx: supportive
5 year old child in Bangladesh presenting with fever, hydrophobia, agitation and seizures following a dog bite 3 months ago
Furious rabies
Dx: PCR from saliva/CSF
Mx: palliation
Farmer in rural Uganda presenting with a chronic painless swelling in the foot with sinus tracts and drainage of black grains
Madura foot (eumycetoma fungal more common in Africa)
Triad: Grains + painless swelling + sinus tracts
Dx: Slow growing culture of madurella mycetomatis
Mx: Itraconazole or ketoconazole
Returning traveller who visited a bat cave in Ohio and now presents cough, shortness of breath and fever
Histoplasmosis
May also have hepatosplenomegaly, diffuse rash, pancytopenia, elevated LDH
Dx: Yeast form in the peripheral blood (like mickey mouse)
Mx: Amphotericin B 1-2 weeks followed by chronic supporession with itraconazole 12 months in severe disease
A patient with HIV CD4 <200 presenting with headache, fever, neck stiffness and low GCS. CRAG positive on CSF
Cryptococcosis
Serum/CSF cryptococcal antigen, CSF may be india ink or culture positive
Mx: Amphotericin B + flucytosine, followed by fluconazole
Single papular lesion following a scratch whilst gardening followed by more diffuse nodular lesions in lymphatic distribution
Sporotrichosis
Dx: sporothrix schenckii on culture
Mx: itraconazole for 3 months
A 27 year old with a background of HIV visiting from California with flu-like symptoms, cough, weight loss, verrucous skin lesions
Coccidiomycosis
Dx: culture, serology, PCR, histopathology
Mx: Fluconazole 3-6 months
A 37 year old alcoholic returning from a walking/camping holiday in Brazil with longstanding mucocutaenous lesions, oral ulcers and exertional dyspnoea.
Paracoccidiomycosis
Dx: Bilateral fibronodular disease on CXR and serology
Mx: Itraconazole 1 year
Snake bite - intense pain and swelling at the site of the bite with systemic bleeding, shock and blistering. Saw the snake and it had a short, thick body and some zigzags on its back
Viper bite
Dx: Coagulopathy, elevated CK and myoglobulinuria
Mx: Antivenom, supportive care
Snake bite - no local swelling or pain, ptosis, descending flaccid paraparesis and progressive respiratory distress. Caught sight of the snake which had a long thin body and a long tail
Snake bite - Elapid e.g. krate
Dx: Usually normal labs
Mx: Ventilatory support
A patient presenting with swelling of the leg but ruled out causes of lymphatic filariasis
Podoconiosis
Get a wriggly rash on the tummy after going for a walk on the beach barefoot in Brazil
Ancylostoma braziliense
A 5 year old child presenting with unilateral flaccid paralysis
Polio - enterovirus
Faecal oral transmission
Dx: Stool samples, throat swabs, or cerebrospinal fluid (CSF) within 14 days of symptom onset for PCR
Mx: supportive
A 27 year old man who works as a farmer in Uganda presenting with headache, nausea, excessive salivation, muscle twitching and seizure
Organophosphate poisoning
Inhibits acetylcholinesterase
Mx: Atropine
A 26 year old backpacker has returned from Ghana with some localised swelling on the back and a black scab. She is otherwise systemically well. On examination there is a white pulsating mass underneath the scab of the lesion. She didn’t iron a single t shirt whilst she was away!!
Myiasis
Sub-Saharan Africa - Mango/Tumbu fly
South America - human botfly
Mx: cover with petroleum jelly and then pull it out
Differentials for a 45 year old male in malawi presenting with back pain and difficulty walking. On examination he has a spastic paraparesis and sensory level between T9-11.
Spinal TB
Spinal metastases
Disc prolapse
Transverse myelitis
Schistosomiasis
Differentials for parotitis in a 6 year old in Loas
Staph aureus
Strep pyogenes
Haemophilus influenzae
Burkholderia pseudomallei
Bartonella henselae
TB
Parainfluenza
Enterovirus
Flu
Mumps (although normally bilateral)
CMV/EBV
A 35 year old man from Thailand who presents with fever, widespread lymphadenopathy and a widespread papular rash with umbilicated centre - differentials
Differentials:
HIV + molluscum
+ talaromycosis
+ histoplasmosis
+ penicilliosis
+ cryptococcosis
CMV/EBV
Bartonella - bacillary angiomatosis
Meliodosis
A 35 year old farmer in the US presenting with a painless central ulcer with surrounding odoema ++ - 5 differentials
Bacillus anthrax (cutaneous) - Tx docycycline
Bubonic plaque
Rickettsia
Bacterial acthyma
Necrotic spider bite
AN HIV positive man presenting with shortness of breath on exertion, fevers and weightloss with bilateral infiltrates on CXR
PCP
Dx: BAL/grocott methenamine staining
Mx: High dose co-trimoxazole 21 days
Over the course of 1 week, spastic paraparesis in a 14 year old boy from Tanzania, recent famine
Konzo
Symmetrical spastic paraparesis
No sensory or GU involvement
Abrupt onset <1 week
Cassava growing area
14 year old in Malawi bitten by a snake, did not move out of the way but puffed up and bit him
African puff-adder
Viperidae family
More localised systemic swelling and necrosis with systemic shock and bleeding
Mx:
Anti-venom IV if systemic symptoms
Abx
Tetanus
Debridement
Pressure pad
A 14 year old Sri Lankan boy presenting with fever, hepatomegaly, subconjunctival haemorrhage and muscle pain after a fishing trip
Leptospirosis
Dx
PCR urine/blood
Serology
Mx
Doxycycline
Ceftriaxone to cover typhoid as well
12 year old boy from a village in rural Western Kenya presenting with 9 month history of eye pain and visual loss. The upper lids are swollen and turned inwards. There is corneal scarring with whitening/opacification. He has been to see a traditional healer.
What are the main differentials?
Vitamin A deficiency
Corneal ulcer
Chemical trauma as a result of traditional medicine
Trachoma - chlamydia trachomatis
Peruvian farmer presenting with what started as a painless nodule but now has underlying abscess and multiple neighbouring subcutaneous nodules. He has failed treatment with antibiotics and cutaenous leishmaniasis treatment
Sporotrichosis (rose gardners)
Mx: itraconazole/Amphotericin B if systemic involvement (lung or bony)
A monk from myanmar presenting with a 3 month history of unilateral scrotal swelling. It is a very common presentation in his local region. Differentials.
DDx: lymphatic filariasis, testicular tumour, hydrocele, inguinal hernia, testicular TB, urogenital schisto
Lymphatic filariaris
Dx: blood smear (nocturnal), Circulating filarial antigen (CFA), PCR if available, US
Mx: Albendazole or DEC (not in oncho/loa loa areas)
Doxycycline
A 35 year old lady from Malawi presenting with diarrhoea and a photosensitive rash. More recently she is becoming confused. It is the rainy season. They eat two meals a day which is mainly maize porridge.
Pellagra - vitamin B3 deficiency
Maize does not have much trytophoran which is needed for niacin synthesis.
Mx niacin (PO) or IV in severe cases
A 28 year old woman presenting with a 1 year history of focal seizures with evidence of cysts on MRI. She previously went backpacking across South America and South East Asia. She is vegan.
Neurocysticercosis
T solium egg ingestion (i.e. NOT from pork meat) but from salad leaves
Mx: Albendazole, steroids, antiepileptics
Lady from Malawi living with HIV presenting with a greyish/white raised gelatinous lesion on the conjunctiva
Ocular surface squamous neoplasia
Differentials for a child presenting with a 4 week history of fever, splenomegaly and wasting
- TB
- HIV
- Visceral leishmaniasis
- Malaria
- Brucellosis
- Malignancy (leukaemia/lymphoma)
A 56 year old woman who has been travelling in Laos and ate lots of raw fish presents with explosive diarrhoea, colicky pain and anaemia. A stool sample shows eggs which look like peanuts
Capillaria philippensis
Can lead to auto-infections
Mx abendazole
27 year old lady living with HIV in Sub Saharan Africa presenting with a maculopapular rash including haemorrhagic crusts on the eyelids and lips. She started co-trimoxazole and ART 1 month ago.
Stevens Johnson Syndrome
19 year old presenting with subacute spastic paraparesis with no back pain and bladder/bowel involvement after a period of famine. He ate mostly lathyrus grasspea plant
Neurolathyrism
Recent travel to Vietnam working in a dog rescue centre has tried eating some frog presenting with migratory subcutaneous swelling
Spargnanosis
Canine/feline tapeworm infection
