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Cases Flashcards

What's the diagnosis, investigations and management?

1
Q

Travel to Milawi, freshwater exposure with positive Schistosoma serology

A

Lab: Stool/urine O&P negative
Rx: Praziquantel.
Sequelae: If untreated, ectopic CNS lesions, pulmonary haemorrhage.

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2
Q

Born in Malawi. Insidious onset of lethargy, mild mucohemorrhagic diarrhea, cramping, abdominal pain.

A

Diagnosis: Schistosomiasis

Examination: Diffuse abdominal tenderness, minimal hepatomegaly, mild malnutrition.
Lab: S. mansoni ova in stool, mild eosinophilia, periportal fibrosis on U/S.
Rx: Praziquantel.
Sequelae: Associated with SCC bladder cancer.

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3
Q

Chronic cough with blood-streaked sputum, progressive chest discomfort, breathlessness on exertion following ingestion of freshwater crab in China/Japan/Korea/Taiwan

Diagnosis, diagnostics + management

A

Paragonimus
* Lab: CXR: patchy cystic infiltrate; eosinophilia; Paragonimus IgG positive; eggs in sputum or stools.
* Rx: Praziquantel for 3 days.

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4
Q

Transient lymphedema, from DRC

A
  1. Lymphatic filariasis
    - Wuchereria bancrofti
    - Brugia malayi

Nocturnal microfilaria.
Symptomatic treatment
Consider annual MDA with DEC + albendazole

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5
Q

Expat from West Africa with an evanescent pruritus, maculopapular rash, often on the trunk with some subcutaenous nodules - diagnosis, diagnostics and management

A

Onchocerciasis

Other features including eye features, epilepsy.

Microfilariae in skin snips; eosinophilia, serology.

Ivermectin single dose. Doxycycline (target Wolbachia)

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6
Q

Expat from Central/West Africa (e.g. Gabon, Cameroon) with transient Calabar swellings, arthralgia, occasional pruritus and a visible eye worm - diagnosis, diagnostics,

A

Loa Loa (deerflies)
Eosinophilia; antifilarial IgG positive
DEC for 3 weeks

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7
Q

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

A

Trichinosis
Eosinophilia, elevated IgE and CPK, positive T. spiralis IgG, larvae seen on muscle biopsy.
Rx: Albendazole with steroids

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8
Q

Patient with CD4 count 50, recently started ART presenting with an intensely itchy bumps over their head and trunk

A

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

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9
Q

Fever, malaise, RUQ discomfort, wheezing in a 2-year-old who lives with dogs

A

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

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10
Q

Severe headache, nausea, neck stiffness, paresthesias after eating some snails in Hawaii

A

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

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11
Q

Migratory subcutaneous swelling in a returning traveller who walked on the beach barefoot with lots of dog poo

A

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.

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12
Q

Returning traveller, went on a fishing trip to Vietnam, presenting with migratory subcutaneous swelling

A

Gnathostomiasis
SE Asia, Latin America
Eosinophilia; G. spinigerum ELISA positive.
Rare ectopic infection: eosinophilic meningoencephalitis or spinal cord involvement
Rx: Albendazole for 3 weeks or ivermectin for refractory cases.

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13
Q

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.

A

Strongyloides hyperinfection

Larvae in stool, eosinophilia, Strongyloides IgG positive

Treat: Ivermectin and antibiotics for superinfection

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14
Q

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

A

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

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15
Q

Fever, chills, headache. RCT positive. 15 weeks pregnant.

A

Malaria

Severity signs: High parasitemia, thrombocytopenia, elevated CK, lactic acidosis, hypoglycemia

Treat with IV artesunate in severe cases, ACT in non-severe

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16
Q

Travel to India, treated for malaria but within 2 weeks presenting with a fever again

A

Plasmodium vivax Relapse

Ring forms, schizonts in peripheral smear

Chloroquine for acute phase, primaquine 14 days for hypnozoite eradication following G6PD deficiency

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17
Q

30 year old from Bolivian with syncope and dilated cardiomyopathy with dysphagia

A

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

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18
Q

Seen in DRC with acute febrile illness and lymphadenopathy following a painful bite with a visible chancre

A

African trypanosomiasis - T brucei rhodesiense (more acute form)

Dx
Microscopy
Molecular approaches

Rx
Suramin (early), melarsoprol (late)

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19
Q

Seen in DRC with enlarged lymph nodes, mild fever, general malaise followed by personality changes and sleepiness

A

African sleeping sickness - T brucei gambiense (west african)

Dx
Microscopy
Molecular approaches

Rx
Pentamidine (early) +/- nifurtimox (late).

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20
Q

Grew up in India presenting with 3 weeks of fever, massive splenomegaly, hepatomegaly, pallor and weight loss

A

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

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21
Q

Nodules appearing following visceral leishmaniasis diagnosis

A

Post-Kala Azar Dermal Leishmaniasis (PKDL)

Dx Slit skin smeal

Mx Miltefosine monotherapy 12 weeks (teratogenic)

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22
Q

Chronic ulcerative skin lesion; painless, no systemic symptoms following sandfly bite

A

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?

  1. Conservative
  2. Local - intralesional antimonials
  3. Miltefosine (teratogenic)
  4. Pentavalent animonials e.g. meglumine
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23
Q

Gap year student ate lots of raspberries and lettuce in Peru and now has fever, vomiting, watery diarrhoea

A

Cyclospora cayetanensis

Dx
Stool with AFB positive oocytes (variably acid fast - pink on green background)

Mx co-trimoxazole 7-10 days

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24
Q

Patient with HIV with chronic diarrhoea and abdominal pain

A

Cryptosporidium

Stool AFB positive for oocysts (fuscia pink on a green background)

Most often self-limiting in healthy individuals, ARV in HIV

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25
Q

Sheep farmer who spends lots of time with sheepdog, RUQ pain, US shows a large >5cm multilocular cyst and a cough

A

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

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26
Q

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

A

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

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27
Q

Peruvian pig farmer presenting with headaches and new onset of seizures

A

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

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28
Q

Returning traveller from Pakistan with fever, headache, malaise, constipation then diarrhoea with hepatosplenomegaly on exam

A

Enteric fever (salmonella typhi/paratyphi)

Dx:
Blood culture (gold standard)
Bone marrow (highest yield)

Mx
Azithromycin or 3rd generation cefalosporins

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29
Q

Somalian patient with fever, night sweats, back pain, arthralgia, orchitis and a new murmur. Sister owns camel.

A

Brucellosis

Dx
Blood culture (slow growing) +/- PCR
Rose bengal test

Mx
Doxycycline 45 days + IV gentamicin or streptomycin

30
Q

Bartonellosis

A
31
Q

Plumber presenting with difficulty swallowing, trismus, neck rigidity, spasms triggered by minor stimuli

A

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

32
Q

Recent flooding in India. Initially presenting with fever, headache, conjunctival suffusion, jaundice and hepatomegaly. Followed by meningeal symptoms

A

High ESR, thrombocytopenia, bilirubin elevation, AKI
Urine/blood PCR
Serology

Rx: Ceftriaxone or penicillin, supportive care (N.B jarisch-herxheimer)

33
Q

Fever, headache and rash following trip to North America, tick bite noted

A

Rickettsia rickettsii (Rocky mountain spotted fever)

Dx: serology

Mx: doxycycline

34
Q

Asylum seeker, 7 days ago came to UK having been in a refugee camp. Presenting with persistent fever, rash and eschar

A

Epidemic typhus (rickettsia prowazekii)
Body louse faeces

Note sustained fever, vasculitis complications

Dx Serology
Mx Doxycycline

35
Q

Patient from Uganda presenting with fever, chills, painful unilateral inguinal swelling with a blood smear showing bipolar staining with coccobacilli

A

Plague (yersinia pestis)
Bubonic, pulmonary, septicaemia
Dx
Blood smear or bubo aspirate culture growing yersinia pestis
Mx Streptomycin or gentamicin

36
Q

A farmer from Ethiopia presenting with a painless black eschar

A

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

37
Q

Patient presenting with an enlarged inguinal lymph node with a previous ulcerative lesion in genital area. HIV positive and previous syphilis

A

Lymphogranuloma venereum
Dx: Chlamydia trachomatis in aspirate
Mx Doxycycline or azithromycin

37
Q

Painful genital ulcer with tender regional lymphadenopathy with swab from the ulcer growing Haemophilus ducreyi

A

Chancroid

Dx culture, exclude syphilis and HSV

Mx single dose azithromycin

38
Q

Pregnant women has presented with what started as a painless chancre and 6 weeks later develop fever and rash on the palms and soles

A

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

39
Q

Profuse watery diarrhoea with oliguria in a refugee camp in the context of recent outbreak

A

Cholera - O1/O139 producint toxin

Dx Stool culture vibrio cholerae

Mx Aggressive fluid resuscitation (IVF, ORS), zinc PO <5 years, Doxycycline

40
Q

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.

A

Buruli ulcer (mycobacterium ulcerans)

Dx: PCR gold standard, culture + histology

Mx: Rifampicin + streptomycin for 8 weeks, debridement of necrotic tissue

41
Q

A 35 year old man from India presenting with a scaly anaesthetic lesion on his forearm

A

Paucibacillary leprosy - mycobacterium leprae

Dx: slit skin smear, biopsy siehl-nielseon staining

Mx: Rif + dapsone 6 months

42
Q

A 26 year old woman presenting with multiple hypopigmented anaethetic patches over the trunk with palpable thickened peripheral nerve

A

Multibacillary leprosae (mycobacterium leprae)

Dx: slit skin smear, biopsy siehl-nielseon staining

Mx: Rif + dapsone + clofazimine for 12 months

43
Q

8 year old from Thailand presenting with parotid abscess and culture shows an oxidase positive gram negative bacillus

A

Meliodosis (burkholderia pseudomallei)

Dx: culture blood, sputum, abscesses

Mx: IV ceftazidime or meropenem for 10 days –> co-trimoxazole maintenance 20 weeks

44
Q

50 year old man from Japan with a background of spastic paraparesis, chronic dermatitis. Mother died of some form of leukaemia.

A

HTLV1 –> HAM or spastic parapareis and ATL

Dx: Serology/PCR

Mx: No treatment or vaccine

45
Q

90 year old patient from a nursing home presenting with intense itch and hyperkeratosis of the hands

A

Scabies

Dx: clinical, scrapings showing mites

Mx: Ivermectin or pemethrin

46
Q

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

A

Severe dengue

Dx: Serology

Mx: Supportive care

47
Q

20 year old returning from Brazil with a history of fever, diffuse rash and polyarthritis with a knee effusion

A

Chikungunya

Dx: Serology
Mx:Supportive care

48
Q

27 year old in rural Nigeria presenting with fever, sore throat and hearing loss. It’s harvest and he sleeps on the floor

A

Lassa fever

Dx: Serology/PCR

Mx: Early ribavirin

49
Q

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

A

Ebola

Dx: PCR

Mx: supportive

50
Q

5 year old child in Bangladesh presenting with fever, hydrophobia, agitation and seizures following a dog bite 3 months ago

A

Furious rabies

Dx: PCR from saliva/CSF

Mx: palliation

51
Q

Farmer in rural Uganda presenting with a chronic painless swelling in the foot with sinus tracts and drainage of black granular material

A

Madura foot (eumycetoma)

Dx: Slow growing culture of madurella mycetomatis

Mx: Itraconazole or ketoconazole

52
Q

Returning traveller who visited a bat cave in Ohio and now presents cough, shortness of breath and fever

A

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

53
Q

A patient with HIV CD4 <200 presenting with headache, fever, neck stiffness and low GCS. CRAG positive on CSF

A

Cryptococcosis

Serum/CSF cryptococcal antigen, CSF may be india ink or culture positive

Mx: Amphotericin B + flucytosine, followed by fluconazole

54
Q

Single papular lesion following a scratch whilst gardening followed by more diffuse nodular lesions in lymphatic distribution

A

Sporotrichosis

Dx: sporothrix schenckii on culture

Mx: itraconazole for 3 months

55
Q

A 27 year old with a background of HIV visiting from California with flu-like symptoms, cough, weight loss, verrucous skin lesions

A

Coccidiomycosis

Dx: culture, serology, PCR, histopathology

Mx: Fluconazole 3-6 months

56
Q

A 37 year old alcoholic returning from a walking/camping holiday in Brazil with longstanding mucocutaenous lesions, oral ulcers and exertional dyspnoea.

A

Paracoccidiomycosis

Dx: Bilateral fibronodular disease on CXR and serology

Mx: Itraconazole 1 year

57
Q

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

A

Viper bite

Dx: Coagulopathy, elevated CK and myoglobulinuria

Mx: Antivenom, supportive care

58
Q

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

A

Snake bite - Elapid e.g. krate

Dx: Usually normal labs

Mx: Ventilatory support

59
Q

A patient presenting with swelling of the leg but ruled out causes of lymphatic filariasis

A

Podoconiosis

60
Q

Get a wriggly rash on the tummy after going for a walk on the beach barefoot in Brazil

A

Ancylostoma braziliense

61
Q

A 5 year old child presenting with unilateral flaccid paralysis

A

Polio - enterovirus
Faecal oral transmission

Dx: Stool samples, throat swabs, or cerebrospinal fluid (CSF) within 14 days of symptom onset for PCR

Mx: supportive

62
Q

A 27 year old man who works as a farmer in Uganda presenting with headache, nausea, excessive salivation, muscle twitching and seizure

A

Organophosphate poisoning

Inhibits acetylcholinesterase

Mx: Atropine

63
Q

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!!

A

Myiasis

Sub-Saharan Africa - Mango/Tumbu fly
South America - human botfly

Mx: cover with petroleum jelly and then pull it out

64
Q

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.

A

Spinal TB
Spinal metastases
Disc prolapse
Transverse myelitis
Schistosomiasis

65
Q

Differentials for parotitis in a 6 year old in Loas

A

Staph aureus
Strep pyogenes
Haemophilus influenzae
Burkholderia pseudomallei
Bartonella henselae
TB

Parainfluenza
Enterovirus
Flu
Mumps (although normally bilateral)
CMV/EBV

66
Q

A 35 year old man from Thailand who presents with fever, widespread lymphadenopathy and a widespread papular rash with umbilicated centre

A

Differentials:
HIV + molluscum
+ talaromycosis
+ histoplasmosis
+ penicilliosis
+ cryptococcosis
CMV/EBV
Bartonella - bacillary angiomatosis
Meliodosis

67
Q

A 35 year old farmer in the US presenting with a painless central ulcer with surrounding odoema ++ - 5 differentials

A

Bacillus anthrax (cutaneous) - Tx docycycline
Bubonic plaque
Rickettsia
Bacterial acthyma
Necrotic spider bite

68
Q

AN HIV positive man presenting with shortness of breath on exertion, fevers and weightloss with bilateral infiltrates on CXR

A

PCP

Dx: BAL/grocott methenamine staining

Mx: High dose co-trimoxazole 21 days

69
Q
A

ID study (22 decks)

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