Clincial Rounds Flashcards
Swelling + discharging sinus =
Myecetoma foot
[Despite name can be bacterial]
Acinomyecetoma usual cause? Characterised by?
Nocardia
Streptomyces
White/yellow soft grains
[White grains can be either bacteria or fungus]
(Fungal) eumycetoma usual cause? Characteristic?
Madurella mycetomatis
Pigmented - black grains
[Only from Fungal and almost always mardurella mycetomatis]
What is Botryomycosis
Bacteria (despite name) part of staph A
Also has white/yellow granules
[Technically not mycetoma as a staph despite having all features (swelling , sinus, granule]
66F born in Highlands. PMH cervical Ca,
Several years progressive weakness in lower limbs with urinary incontinence and constipation with back pain
No fevers or weight loss
Normal CSF / MRI brain/spine
Hiv negative
Increased reflexes and clonus on exam
Dx? Key Ix? Most common mode of acquisition?
Tropical spastic paraperesis
HTLV-1 serology
Breastfeeding [then sexual / blood transfusion]
Chronic cough + haemoptysis with negative TB
CXR clear
=?
On CT?
Nodules on CT and peribronchial mass common
Paragonimus
56 M previously healthy comes to donate blood. Positive on screening
What diseases are tested for at screening?
What is romanas sign?
Key rx in chagas?
HLTV-1, HIV, HepB/C, Chagas, syphilis
Romanas - orbital oedema in acute chagas inoculation
Beznidazole OR nifurtimox 90 days
Brazilian who is exercising then suddenly dies likely pathology
Arrhythmia secondary to chagas
How is blood bank screening of chagas done
ELISA
right sided back pain.
Issues with bloating when eating and biliary colic for several months. US shows biliary sludge. Likely Dx?
When do they lay eggs?
Key food to eat and get infected?
Seen on CT?
Dx acute?
Rx?
Liver fluke- fasicuola hepetica or fasicuola gigantia
Begin egg laying after 3 months
Water cress
CT may look like liver abscesses / mets or cause liver haematoma
Antigen in faeces- only eggs on microscopy sometimes / more likely in chronic
Triclabendazole
HIV poor controlled
Months of diarrhoea with blood
Then developed focal right arm weakness. Went on to reduced GCS and right sided spastic Paralysis and hypereflexia. Cd4 120
CSF normal
Mri - white matter L sided lesion - no midline shift not SOL
dx? rx?
Key DDx before imaging?
JC virus causing PML - treatment with ARV
CMV usually basal ganglia
HIV encephalopathy - more like a dementia picture
Mass
-Lymphoma
-Tuberculoma
-Toxoplasmosis
Bacteria
Eg pneumococcal / n meningitis…
TB or tuburculoma
Syphilis
Viral
-JC virus -> PML
-CMV
-EBV - Lymphoma
Fungal
-Cryptococcal
Toxoplasmosis
Neurocysticercosis
Non hiv releated eg stroke / tumour
74 M no PMH
Lived in andes until 40s growing coffee
Moved to amazon growing banana sugarcane…
6m hx of small papule on L chin which began to ulcerate and was painful
Given abx no improvement
Went on to cover all face including mucosa and had smaller lesions on rest of body
Initially ddx?
Cxr demonstrates fluffy infiltrates bilaterally - what’s most likely?
paracoccidioidomycosis
Ddx
Disseminated Leishmaniasis
Leprosy - occationaly painful
Cutaneous TB (lupus vulgaris)
Other atypical mycobacteria
Syphilis
Histoplasmosis
HIV with skin infection eg HTLV-1
Differentiate mucosal Leishmaniasis and paracoccidioidomycosis of face and oral mucosa?
paracoccidioidomycosis painful and often come with a cough as infects lungs
Tooth loss common
Haemorrhagic dots
Leishmaniasis tends to start in month and works Down
Nasal septum collapse
Which stain for paracoccidioidomycosis
KOH
10% of paracoccidioidomycosis also have?
TB
paracoccidioidomycosis rx if severe? Moderate?
Amphortericin B
Itraconazole 12m
[Occationaly co-trimox which would be 24m if itra not available]
Extensive painful facial ulceration with chest signs most likely? Transmission? What country would you be most suspicious from? Need to test for?
paracoccidioidomycosis
Inhaled
About 80% of recorded cases have occurred in Brazil
TB
41M
Lima whole life but visted wildlife park . 2m hx of skin lesion on distal part of R lower limb. Initially painless small papule which slowly broke down into an ulcer key ddx, stain?
Leishmaniasis
Giemsa
When is treatment failure cutaneous Leishmaniasis? Rx if this?
<50% improvement in size or ulcer after course complete
Amphotericin B
Oral option for Leishmaniasis. Spell it
Mil ter fosine
[More expensive than liposomal amphotericin B]
Treatment failure in Leishmaniasis risk factors
Children <5
Small ulcer <3cm
Lower limbs - especially if oedema in area
Immunosupressed
Which confection more likely to respond to Leishmaniasis rx
Stronglyotides
What class of drug is sodium stibogluconate,
Pentavalent antimonials
20F born in jungle but lived in lima for 10 years on farm
No PMH
2/12 hx of high fever, malaise, painless lesions on forehead erythematous papules -> ulcers/umbilicated/crusting
White Discharge from L lacrimal eye duct
Jaundice, lymphadenopathy
Diffuse tender hepatomegally with abdo mass
Presented in shock unwell
CT multiple pleural nodules and cavities + massive hepatosplenomegaly
Juvenile paracoccidioidomycosis
Ddx of massive splenomegaly? Key
HSVB
[Hyper shits visit bruh]
Hypereactice Malarial spenomegaly
Schistosomiasis (periportal fibrosis)
Visceral Leishmaniasis
Brucellosis
Paracoccidioidomycosis rx
Amphotericin B followed by itraconazole for 24 months
46F PMH mother TB
8/12 painful right paravertebal mass in lumbar region
Night sweats, weight loss
Worsened pain 1/12
Comsume unpasteurised dairy
Otherwise mosty unremarkable exam
2 key Ddx and differentiate
TB - younger, more likely thoracic, paravertebral abscess common
Lytic lesions (with NO remodelling)
Gibbus deformity common
Brucellosis - >40, Lumbar, abscess only in 10%, lytic and blastic lesions
60M no PMH
90 days ago went to highlands
2/52 fever, neck pain, jaundice amd confusion
Significant jaundice, hepatomegally and palor on exam
Rods seen infecting RBCs
Which infections do you see actual RBC invasion by pathogens?
Bartonella
Malaria
Babesia
17tr old peru HIV/HTLV-1 negative
Vomiting after meals for 2 months
Headaches
Developed jaundice / fever / night sweats predominant. Weight loss
Significant cervical lymphadenopathy
Papular skin lesions in inguinal and body
Living in jungle - visited caves 9m before sx
US - acute hepato splenomegaly and diffuse liver disease
Micronodules in lungs
TB positive Key DDx
Juvenile subacute paracoccidioidomycosis
Usually pulmonary compromise
-> peri oral ulcers
Ddx
Histoplasmosis
Disseminated TB
Dengue
Visceral Leishmaniasis
Schistosomiasis
Why always males in paracoccidioidomycosis
Oestrogen inhibits
Features of dimorphic fungi? Pathology?
Need to culture in 25 degrees and 37 degrees
- mold spores, which are the infectious particles, are inhaled into the lung
- undergo a morphological change into a pathogenic yeast form.
[Mould in the cold
Yeast in the heat]
Name 3 Examples of dimorphic fungi
Histoplasma capsulatum
Blastomyces dermatitidis
Talaromyces marneffei
Coccidioides immitis,
Paracoccidioides brasiliensis
Sporothrix schenckii
Typical of yeast under microscope? Key stain?
Has double wall
KOH
What triggers morphological change in dimorphic fungi
Temperature -> when increases from 25 to 37 degrees
What are we considering if Rx for tb meningitis then returns with worsening symptoms and new neutrophilic csf tap (2 key ddx)? Rx?
Secondary bacterial infection - need to cover with cef
TB Paradoxical reactive meningitis
- High dose steroids - as it is due to an immune response
- [Due to dying TB and immune response]
Why does cryptococcal not stain with India ink?
Has a capsule
Name 10 causes of meningoencephalitis
Bacterial - listeria, pneumococcal, HIB, meningococcal, neurosyphilis
Mycobacteria- TB
Viral - CMV, HSV, JCV, VZV, HIV (more cognitive), EBV, enterovirus (acute)
Fungal
Yeast - Cryptococcal, , candida (very rare primary CNS)
Filamentous - Aspergillus,
Dimorphic (Histoplasmosis, paracoccidioidomycosis, Talaromyces marneffei, Coccidioides immitis)
Parasites
-Protozoa - Toxoplasmosis, malariae,
-flagellate - Trypanosomiasis esp chagaoma, Leishmaniasis
- Free living amoeba
-helminth - angiostrongyloides, racoon ascaris, stronglyotides (hyperinflection),
Neuro Shisto, Neurocysticercosis
Hydatid
Key thing to monitor with amphotericin b
Renal / Liver toxicity - [much less with liposomal version]
Key thing to monitor with flucytosine
Levels as risk of bone marrow suppression
How long for induction/consolidation/ maintenance phase in cryptococcal
2 weeks
8 weeks
1 year minimum
Key monitoring in cryptococcal meningitis after 2 weeks
Repeat culture -> if positive need resistance testing
Disseminated cryptococcal skin lesions look like?
Umbilicated papules (bit like moluscum)
Which stain AFB positive stool culture not Mycobacterial
Cryptosporidiosis, cystospora, cyclospora
travel 5 weeks ago
Itchy, serpiginous rash tracking over the course of several days, then disappeared and then he noted the mass reappearing elsewhere
On exam - firm mass with clear margins 3×8 cm in size
Classic of?
Acquired by?
Rx?
How to rule out differentials?
gnathostomiasis
eating raw fish
albendazole 400 mg BD for 21 days or ivermectin 200 μg/kg on two consecutive days.
CNS - add steroids
-Loa presents similar but incubation longer (5months)
-Strongyloides more likely fine, serpiginous tracks and not with a large mobile mass
Dengue diagnosis
NS1 antigen or PCR
IgM/IgG
What happens in severe dengue
Capillary leakage and bleeding
hyperkeratotic skin crusts that may be loose and flaky or thick and adherent. covering lots of areas with fissures rx?
Crusted scabies
Rx ivermectin
Will likely have secondary bacterial infection of fissures too
All patients with spinal cord symtoms should be tested for?
-HIV
-Schistosoma spp. in urine and stool
-evidence of tuberculosis or neoplasia on chest and spinal radiography.
-LP
Gold standard Ix for Potts
CT-guided percutaneous vertebral or paravertebral biopsy and aspiration
Multiple painful genital ulcers 2 key Differentials and rx
Herpes simplex - may need acyclovir if HIV / pronounced
Chancroid with a single dose of azithromycin 1 g PO or ciprofloxacin 500 mg bid forthree days or erythromycin 500 mg qds for seven days.
[syphilis with a single dose of IM benzathine penicillin 2.4 million units. USUALLY PAINLESS And single]
H durecyi grows best at what temp
33 degrees
-Notoriously difficult to culture
S. typhi seems to favour chronic carriage if co infection with what?
Schisto - Should give praziquantel if endemic place
Salmonella actually reduced rate with what infection
HIV
Watery stool sample shows shows small slender curved bacilli with darting motility? how to confirm?
Cholera
- by using Vibrio cholerae antiserum O1 which will completely inhibit motility
unilateral parotitis in children is usually? What about in SE Asia - key bug?
Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae
Burkholderia pseudomallei = melioidosis,
the commonest cause of suppurative parotitis in children in SE asia.
Top 3 most common cause of death in Thailand
HIV
TB
Melioidosis (Burkholderia pseudomallei) Causes abscesses
[Be aware this is actually quite common]
Where does Melioidosis (Burkholderia pseudomallei) usually affect
Parotid gland in 40% (kids)
Lungs
Melioidosis rx
May need surgical drainage
-ceftazidime, meropenem or imipemem for 14 days
-co-trimoxazole monotherapy for 3-5 months
Raw fish in history
Then erythema rash looks like cellulitis
But then migrates?
Gnathostoma spinigerum
- Fresh water fish consumption
Raised crusted lesion verrucous arm
Looks similar to Leishmaniasis / cutaneous TB
Small black dots on dermatoscope?Ix? Rx?
Chromoblastomycosis- small black dots typical
Usually just 1 lesion which expands
Use tape on lesion then place on slide
Itraconazole- for years
66M
Dactylitis with Papules and nodules / cold abscesses + arthralgia
Xray shows osteolytic lesions in fingers
Biopsy - tuberculoid granulomas (granulomas with necrosis)
Tuberculoid granulomas - central necrosis seen in which conditions?
Sporothrix, TB, Nocardia, atypical mycobacteria, paracoccidioidomycosis, sarcoid
15M now 22
Works in agriculture
Small injury to foot which went on to swell and have lots of discharging sinuses, with grape like lesions
No bone involvement Dx?
Botryomycosis- [botryo = grapes]
Ddx mycetoma
35F no PMH
3m Cough dyspnoea Vomiting weight loss, no haemoptysis
1m fevers
CT - pneumonia with cavitation given abx
Continues to deteriorate
3x sputum negative, HIV negative
GeneXpert positive Rif resistant
Rx options?
Short option BPaLM 6m
18m regime of 4 drugs. Ideally 4 that they’ve never been exposed to eg levo, moxi, amikasin, mero (+co-amox)
If treat TB with Meropenem what other drug do you need to use?
clavulanic acid - Eg in Co-amox
Before discharge home with MDR-TB what needs to happen?
Clear sputum.
DSTs
have a suitable TB regime for OP
Derranged LFTs >5x normal on TB rx. Plan?
Stop all meds
Re challenge 1 at a time
If need a 3 drug TB regime how long is Rx?
Eg. Levo amikacin and ethambutol
Continue for 12 months
Anterior superior lyric lesion of vertebrae typical of?
Brucellosis
Acute histoplasmosis why retrosternal pain?
Rapid enlargement of lymphnodes
Erythematous lesions on legs and body
Not itchy or painful
Given prednisolone and had resolution of sx
Year later re appeared and worse on limbs
Bloods - mild raised ESR, otherwise unremarkable. ANA / RF negative
Notice evidence of burn injuries yo arms and hands
Leprosy
Burns and other injuries are due to Anaesthetic lesions
In what circumstances would a Anaesthetic lesion not be leprosy
If there is hyperkeratosis
Key thing when examining leprosy
Anaesthetic lesions
Clinical assessment of nerves in sequence to determine which are affected
When is a lesion mid borderline leprosy?
Lesions with a ‘donut’
Centre has normal skin
mycetoma - grains
Chronic cough and then sudden popping sensation and coughs up this salty liquid
Hydatid
Hydatid
Leishmaniasis amastigotes
Paracoccidioidomycosis
India ink cryptococcus
Histoplasmosis
Blood film. Rods and cocci. Intraerythrocytic. Inside red blood cell. Bartonella
What is this? Why would the inflammatory infiltrate be linear?
Mycobacterium leprae
Linear as follows a nerve / vessle
92
Small papule that slowly grew. Minor discharge. Slightly itchy but Not painful.
No one in home with same Sx, but some in community. No oral/nasal sx
Key contra indication to sodium stibogluconate?
Milterfosine key side effect?
Sodium stibogluconate - Long QT/arrhythmias
Milterfosine side effects - GI upset
Key groups who have failed Leishmaniasis rx?
Children
Leg lesions
Immunocompromised
74M
Ulcerating lesion on arm
Painless and no other symptoms
Tracking lymph nodes
Ddx?
Slan
Sporotrichosis
Leish
Atypical mycobacteria
Nocardia
61M PMH
Leishmaniasis lesion but negative smear
No access to PCR, what test can you do? Issue with this?
Leishmaniasis antigen skin test
- Will be positive for life - low specificity
10M - lives in jungle
Erythematous papule on face
Leishmaniasis confirmed
2 rounds of rx with sodium stibogluconate but relapsed after each
2nd line?
Amphotericin B
If limited cutaneous- Thermotherapy/imiquimod etc
When would amphotericin B be first line for cutaenous Leishmaniasis?
Diffuse or Disseminated disease
59F t2dm, hemicolectomy
2/12 diarrhoea no blood/mucus 5kg weight loss. Afebrile
1/12 nausea + Vomiting + swallowing difficulty + abdo discomfort + reduced appetite
Hiv positive
Colonoscopy ulcers
Biopsy shows …. cells with massive cytoplasm ?
And spindle cells ?
Massive cytoplasm - CMV
Spindle cells - colonic kaposis sarcoma
Ulcers on oesophagus in HIV with reduced cd4 2 key ddx?
CMV
HSV
Name 3 causes of atypical lymphocytosis
CLL
EBV
HTLV-1 causes ATLL and lymphocytic ‘flower cells’
When does HTLV-1 usually get transmitted? When does it cause ATLL? 3 Key complications of HTLV-1?
Vertical
not until 6th decade usually
Tropical spastic paraperesis
Strongy hyperinfection
ATLL
33F lived in jungle 10 years ago. Pmh strongyloides and htlv-1 positive
Watery diarrhoea- takes co trimox and stops
Several months intermittent- malnourished
No blood or mucus or fevers or rash.
Stool shows this Dx?
Rx?
Cystoisospora belli
Co trimox - often needs higher dose in Immunocompromised
21M med student from mountains
Fever, headache, myalgia, diffuse macula rash which resolved
Then new diffuse erythematous rash
Low platelets
Ddx of ‘white islands in sea of red’
Dengue
Zika, chikungunya, HIV seroconversion
49M Chef
Visited jungle 2 months ago Did not visit caves
3 days after return - fever, myalgia
Slowly Worsened generally unwell mild GI sx
Became Jaundiced
No lymphadenopathy, severe hepatosplenomegaly
Resp unremarkable
Anaemic, very mild eosinophilia
Bilirubin / transaminases very high
HIV positive on admission
PAS (image) and silver stain positive yeast within histocytes
=?
Rx disseminated disease?
Histoplasmosis
Amphotericin B followed by itraconazole
Silver stain below
Which cells make granulomas
Histocytes
59F no PMH
Born in jungle moved to lima as a child. Copper IUD
Yellow Vaginal discharge for 1 year
No LUTS
No TB contact
US - thickened cervix, no changes in ovaries
CT-AP - Unremarkable
Hep/hiv/syphilis/htlv-1 negative
Biopsy -> granules surrounded by Splendore–Hoeppli phenomenon
Filamentous bacteria on silver stain =?
Key risk factor for cervical disease? Rx?
Cervical actinomycosis
IUDs
IV Penicillin
22M no PMH Born in jungle
1m Weakness / SOB / mild abdo pain which slowly Worsened
Now headache and 1 episode Vomiting
Hb 26 and mild oedema in limbs
Liver/renal tests normal
Raised eosinophils
Hookworm
Which diseases cause hypereosinophilia >1500
[Raised eosinophils are only >500]
Parasite that go through tissues
-Fasciola
-Paragonimus
- lava migrans Toxocariasis/gnathostomiasis / Ancylostoma braziliensis etc
-Strongyloides
Why HTLV-1 not transmitted intrauterine?
Lives in lymphocytes which do not cross placenta
HTLV-1 positive- what should you screen for?
Strongy
TB
ATLL / T cell lymphoma
Evidence of tropical spastic paraperesis
HTLV-1 causes which cancer? Rx of limited cutaneous
T-cell leukaemia/lymphoma
zidovudine
24F born in southern Highlands. PMH nil
1 day right sided abdo pain sudden onset
Vomiting
No fever, no other sx
Raised eosinophils
Tender Hepatomegaly on exam
Why eosinophilia?
Ruptured hydatid cyst
19M no pmh
2-3days headache over eye
The developed painful lymph nodes in neck
No fever
Bloods unremarkable
New pain + swelling in elbow with high fever
Has a new cat
ix?
Rx?
Bartonella IgM - weak positive = recent infection
Azithromycin
Needs follow up as lots of long term eg neuroretinitis , hepatitis
Name 2 diseases from cats
Bartonella henselae
Toxoplasmosis
Sporothrix braziliensis
46F noticed plaque on finger slowly increasing in size
Began to notice a some new proximal nodules
Dx?
Gold standard ix?
Rx?
Sporothrix schenckii
Gold standard - culture (white then turns grey/dark) then microscopy -> grows quick over 3 days
Itraconazole
70M
itchy painful red lesion on finger and wrist of same hand which rapidly Worsened with oedema and ulceration =?
Rx?
Loxosceles laeta (recluse spider) bite with superinfection
Usually only oedematous on face
Antiserum only works if in <24hrs
Loxosceles ssp. Fine for exam
Key difference snake vs spider bite
YOU PROBABLY JUST SEE IT
Snake = oedema
Ocular lesions of toxoplasmosis looks like Salt and pepper
Key cause of deviation of eye with retinitis and granulomas
Toxocara (ocular lava migrans)
Hypereosinophilia, persistent eczema, visual problems
Toxoxcara
Infective dermatitis
HTLV-1
10months RUQ pain and annorexia + diarrhoea
some fevers
7kg weight loss
raised WCC + eosinophilia and negative stool O&P
CT -?
=?
ix?
rx?
Fasciola ssp.
CT - Hypodense lesions in right love
Serology - Fas2 ELISA [make sure you know Fas2*]
Triclabendazole 2 days (taken with fatty food eg yogurt)
Fasiola eggs look like which other worm?
Faciola looks like diphillobotrium but 3x bigger (and usually open)
45M HIV 8 years on ARV intermittent. Prev TB and syphilis. MSM
Cusco and had 2 weeks intermittent fevers which progressed to constant associated with diarrhoea + mucus
Returned to lima and had worsening headaches with neck stiffness followed by a seizure
Visual issues
LP- Raised opening pressure, lymphocytes predominant, Glucose low India ink positive
Colonoscopy - ulceration and nodules (dark red)
Ophthalmoscope- pizza pie appearance
Dx?
Rx?
Cryptococcal meningitis - Ampho / flucytosine / fluconazole
Visceral kaposis sarcoma - rx chemo eg paclitaxel
Cmv retinitis - gancyclovir
ART - After 4 weeks
When would you use steroids with hiv and cryptococcal infection?
Only in IRIS
[Mortality worse in acute cryptomeningitis ]
15M PMH HIV/TB diagnosed 1 year ago
3/52 intermittent abdo pain , 2/52 diarrhoea no blood or mucus , 1/52 nausea and Vomiting
On exam very malnourished. Mild tachy. Multiple hypopigmented lesions Poor AE to bases and tender hepatomegaly.
Loss of vili with PAS/AFB positive elongated bacilli
How to exclude ddx of these stains? Rx?
[PAS stain]
Mycobacterium avium complex - or other atypical mycobacteria
- Rifampin, ethambutol, azithromycin
-Tb AFB positive, PAS negative
-Whipple PAS-positive, AFB negative
38M
7 days dysphagia dry cough and nausea and left elbow swelling
Xr diffuse nodular bilat infiltrates and osteomyelitis on elbow xr
Biopsy demonstrates -
Pt develops significant transaminitis in first 2 weeks likely culprit? What it was after 6 weeks?
Which for lfts in first 2 weeks - isoniazid Most
Lfts deranged after 6 weeks likely - pyrazinamide
19M fever headache confusion over 4 days. Recent return from Vietnam
CSF raised white cells - neutrophilic, mildly raised glucose, normal protein.
Ix?
Why CSF neutrophilic?
Positive IgM Japanese encephalitis
[More sensitive than PCR as often CSF viral load has come down by time of presentation]
-Early in viral meningitis you can get neutrophils -> later turns to lymphocytes
25F 3 weeks illness, headache constipation and fatigue raw fish in Hx
-> red sub cut nodules which turned to plaques on her RUQ
->moved to R iliac crest
Eosinophilia
Fas2 -ve, Stool O&P -ve
=? Rx?
Gnathostoma spinigerum (most common)
Ivermectin (or albendazole)
6M
1 week of fever and irritability.
Pallor blood film=? Phases? Geography? Transmission?
Rx?
Bartonella bacilliformis
Acute - fever and haemolysis
Eruptive - nodular eruptions
Transmitted by sandflies bite - Lutzomia
Peru, Ecuador, Colombia - Andean valleys
Cipro (add ceftriaxone in complicated disease)
Kids - Co-amox if mild [cipro+cef in severe]
Only warts - Azithromycin
6M USA
headache and vomiting, mild fever and slightly stiff neck otherwise unremarkable exam
LP - raised wcc + eosinophils
MRI - meningeal enhancement
Most likely?
DDx?
-Angiostrongylus cantonensis - (snail eating/contaminated food) is the most common infective
Drug allergy - most common in wealthy countries
-Baylisascaris procyonis
-Angiostrongylus cantonensis
-Toxocara
-Gnathostoma
-Cysticercosis
[Fungal rarely]
[BATGC]
Angiostrongylus cantonensis key Ix? rx?
PCR (Serology not great)
-LP - eosinophilic
Steroids + albendazole
15M from el salvador admitted with seizure
Bitemporal headache and nausea
Intermittent haemoptysis
CT: Lung and CNS nodular lesions
Lung biopsy -> this
Paragonimus mexicana (as in latin america)
praziquantel
43M Croatian in Thailand with fever (2 week holiday)
Headaches sweat chills
Malaria/urine negative
Given azithromycin
-> 1/12 non-productive cough and ongoing fever
Developed ‘1inch red nodular lesion below knee
biopsy->?
Rx?
‘Safety pin’ appearance of Burkholderia pseudomallei
[Meliodosis]
-Forms abscesses in many organs
-May cause a pneumonia
Ceftazidime OR Meropenem
then Co-trimoxazole
Child with 3/12 fever visited costarica 10 months ago , splenomegaly and mild pancytopenia
Bone marrow - no malignancy but this:
PE: mild hepatosplenomegaly, pallor
Dx?
Rx?
Visceral leishmaniasis
Liposomal amphotericin B
Cruz ship worker from India (US/Mexico/Jamacia) with 5/7 fever, abdo pain, myalgia
Worsened with RUQ pain, nausea + vomiting + chest pain
CT - hypodense
How to differentiate echinococcus cysts, amoebic and pyogenic abscesses in a liver?
Echinococcus - NEVER fever unless superinfection
Aspirate
[Give metronidazole - > amoebic recovers quickly]
‘Welts all over’ just returned from Africa
fever, athralgias
Numerous lesions with eschar and diffuse rash
African tick bite fever
Rickettsia Africae
Doxy
50M in Kenya
Failed malaria Rx with
Developed RUQ pain + conjunctival erythema + scleral jaundice
Recent flooding and Lots of sick livestock around….
Rift valley fever
Verrucous lesion ?
DDx without microscope?
Sporothrix schneckii
[Chromo, verrucous leish, TB]
Which leprosy
Lepromatous
30F HIV positive. Diagnosed pulm TB 1/12 ago
2 weeks into RIPE -> Headache and blurred vision.
Fundoscopy …
Note clear margins of nerve = not optic neuritis
Vessles normal
Large white lesion
= choroid TB
40MSM
Chronic headache, weight loss and diarrhoea
LP OP 27cm, India ink positive
HIV positive
Given ampho b and fluconazole -> focal signs. Why?
DDx
TB granuloma co-infection [this is what happened]
Toxoplasmosis co-infection
Infarct
Vasculitis
30F HIV positive. Diagnosed pulm TB 1/12 ago
2 weeks into RIPE -> Headache and blurred vision.
Fundoscopy …
Note clear margins of nerve = not optic neuritis
Vessels normal
Large white lesion = choroidal TB
62M pmh completed RX TB. NHL 2022 on chemo. On co-trimox, fluconazole and acyclovir
Weeks of diarrhoea no blood no mucus
Progressed to fever headache and weakness
No rash. Works in fields without shoes
Wheeze, hepatomegaly with cervical lymph nodes
Hb 8.5
Mild thrombocytopenia and neutropenia with a few eosinophils =?
Stronglyloides stercolis hyperinfection
Why mild/no eosinophilia in strongy hyperinfection?
Stongy itself has anti-inflammatory properties
-> inhibits IL-5 -> reduced eosinophils
8M
1 day hx Headache and fever, swimming recently.
CT cerebral oedema
CSF raised protein, 500 white cells 80% neut
Naegleria fowleri
Amphotericin B ± intrathecal + Rifampin + Fluconazole + Miltefosine + azithromycin
20F abdo lumbar pain
Chronic abdo pain and symptoms with pain 3 weeks ago that has settled
Large cystic mass in spleen on CT
key ix for dx?
Benefit of albendazole and prazi?
Western blot - E Granulosus
Albendazole - better penetration into cyst
Praziquantel - better killing eg of rupture
When is adult diarrhoea classed as chronic?
2 weeks or more
Wasting syndrome in HIV is? Top 3?
Weight loss, Chronic diarrhoea, hepatomegaly, Anaemia/neutropenia
Histoplasmosis
TB
MAC
Differentiate leish and histo by stain used?
Histo = PAS positive stain
Leish = giemsa
Cheap way of determining Disseminated histo
Histo buffy coat
-Take blood in EDTA
-Centrifuge -> layer on top of RBCs
-Microscopy - if histo = Disseminated
Itraconazole particularly reduces which ART med
Efavirenz
Venezuelan with purpuric nodular painful lesions involving all 4 limbs which drain pus
and inguinal lymphadenopathy
ANCA/ANA negative, given pred and hydroxychloroquine-> improvement
Mild reduced sensatio
=?
Rx?
Erythema nodosum leprosum
-painful erythematous lesions
Steroids
(Thalidomide held as child baring age)
[This case was given 100mg minocycline]
Type 2 erythema nodosum are immune complex deposition
Get reactions for years after rx as have a lack of cell-mediated immunity - dead mycobacteria and their antigen load will persist for a long time.
WHO criteria for severe Malaria
19F highlands 35/40 pregnant
occipital headache and dypnea Calf pain -> difficulty walking.
Septic shock on admission
Fetus dead and pt jaundiced with haematuria Tender hepatomegaly, GCS 14
AKI, with ++direct bilirubin
=? Rx?
Co-infection common with?
Bartonella bacilliformis
Cipro + ceftriaxone
Salmonella bacteraemia
77M highlands no PMH
3m diarrhoea + mucus which progressed to include pus
With pain and Vomiting. 20kg weight loss
Low albumin, mild raised bili / ALP
Colonic perf - biopsy
=? Rx?
Balantioides coli (old name Balantidium coli)
Rx Tetracycline
Or metronidazole
21F - 4 years ago fell and cut knee and has papular painless lesions on knee
Developed new lesion on thigh
Biopsy shows
Dx?
Essential extra Ix?
Rx?
Balamuthia mandrillaris
MRI brain
Fluconazole (or Itraconazole) + Albendazole +Miltefosine
[FAM this disease is rough]
42M septic shock
4 days fever, lymphnodes in cervical axilla and groin. Groin lymph node ++ pain . Mild dyspnoea
Today reduced GCS, conjunctival suffusion
Hepatosplenomegaly
Hepatorenal insult
ARDS on CXR. Lepto and Dengue negative.
dx?
rx?
Yersina pestis
Gent + cipro
Name 2 fungi causing eosinophilia
Aspergillus
Coccidioides immitis
Cold abscess 3 ddx
ANT no Fever here
Actinomycosis
Nocardia
Tb
[Fungi]
‘Tripple’ species to cause rapid liver/lung/renal failure over a short period
Leptospira interrograns
Hanta virus
Yellow fever
malaria assoc + EBV in first 5 years of life -> high risk of?
burkits lymphoma
found in stool
schistosoma intercalatum
39/40 neonate. 4th pregnancy
Mum positive RPR. Treated with Penicillin G
No issues at birth and normal physical exam.
When treat as congenital syphilis if no findings on neonate exam ?
Inadequate treatment - Mum must complete therapy at least 4 weeks before delivery
+ no abnormalities on Neonate workup Eg LP
35M Cd4 250 . Recent rx cutaneous TB -> had other umbilicated papules on face which improved. Finished Rx and now:
14 days papular lesions on face and pain in hands. Some are umbilicated
Osteolytic lesions in bones of hands on Xray.
Dx?
Explain the partial improvement of the lesions
Disseminated histoplasmosis
Lesions improved with RIPE as histo sensitive to rifampicin
24 new diagnosis of HIV on admission
1 Month papules and fever. 2 key ddx?
Treponema pallidum
Mpox
33F PMH diabetes
1 week history of cough, rhinorrhoea and vesicular lesion on nose -> given acyclovir
3 day hx of jaw pain
Pain developed in ear and facial asymmetry
Found confused next morning
R hemiparesis and left eye proptosis
CT carotid stenosis left eye proptosis
Dx?
Rx?
Mucor ssp - rhinocerebralorbital
surgical debridement
Control of immunocompromising features
Ampho B (posiconazole / isavuconazole
Extrapulmonary TB bedside test?
FASH
Focused assessment sonography in HIV
Itraconazole administration tips
With food
With acid eg coke and stop PPIs if possible
28M prev pulm TB completed rx
Unwell for 3 weeks with diarrhoea and abdo pain. No blood
4 days of confusion
O/E Reduced GCS, hr 78, hypotensive, no fever
Pale, HIV, HTLV negative
Csf mild raised protein and lymphocytes
CT chest - multiple cavities and inflam infiltrate
Given TB meningitis rx -> eosinophollia and worsening abdo sx
What happened?
Chronic strongy + TB
-> steroids for TB meningitis precipitated strongy hyperinfection
What type of meningitis do you get in strongy hyperinfection?
Bacterial eg e coli / salmonella
-Translocation
