E-Lecture

Question 1

Night sweats are typically associated with…

• Malaria
• Pneumonia
• Gastroenteritis
• TB

Answer 1

TB is the classic association. However night sweats are seen in a wide range of other medical conditions such as endocarditis, abscesses, lymphoma, and antidepressant use.

Question 2

High fevers occurring every 2 or 3 days is common in…

• Gastroenteritis
• Malaria
• TB
• Pneumonia

Answer 2

Malarial fever occurs from the synchronised release of merozoites into the bloodstream. This typically occurs in cycles of 48-72 hours depending on the particular Plasmodium species.

Question 3

Fever and diarrhoea in a 2 year-old must be due to gastroenteritis- true or false?

Answer 3

False

Question 4

Diarrhoea: what type of stool do these produce?

• Melaena
• Bilious stool
• IBS
• Cholera

Answer 4

• Melaena - black tarry
• Bilious stool - green
• IBS - mucous
• Cholera - rice-water

Question 5

Acute diarrhoea and vomiting, 12 hours after eating cake with custard. What is the diagnosis?

• Salmonella
• Meningitis
• Malaria
• Cholera

Answer 5

Salmonella

Question 6

Headache developing over a few hours, with a purpuric rash and fever. What is the diagnosis?

• Cholera
• Salmonella
• Malaria
• Meningitis

Answer 6

Meningitis

Question 7

Malaria can be transmitted by needle stick injury. True or false?

Answer 7

True

Question 8

Dengue fever is associated with a bright red rash. True or false?

Answer 8

True -

the features of Dengue fever are

• scarlatiniform rash
• spontaneous bruising or bleeding
• fever
• thrombocytopenia

Question 9

Dengue fever is an example of a bacterial fever. True or false?

Answer 9

False - it is an example of a viral haemorrhagic fever.

Others include Lassa, Ebola & Marburg

Question 10

If a patient is suspected of having a viral haemorrhagic fever, the first step is to:

• Isolate patient & use contact precautions
• Give blood transfusion
• Give antiviral drugs

Answer 10

Isolate patient and use contact precautions

And inform the relevant infection control team. There are no anti-viral drugs available to treat viral haemorrhagic fever. Blood is transfused if clinically indicated.

Question 11

Is a headache a specific symptom?

Answer 11

No, it can occur due to fever causing vasodilation.

Question 12

True or false? Myalgia is muscle pain. If severe it may indicate Influenza or Typhoid.

Answer 12

True

Question 13

[blank-1] meningitis is life-threatening and has a [blank-2] onset over a few [blank-3]. [blank-4] meningitis is not immediately life-threatening and has a [blank-5] onset over a few [blank-6].

Answer 13

Bacterial meningitis is life-threatening and has a fast onset over a few hours. Viral meningitis is not immediately life-threatening and has a gradual onset over a few days.

Question 14

A [x1] spectrum antibiotic is first choice for immediate treatment of suspected bacterial meningitis. A GP might give [x2] where as a hospital doctor might be more likely to give [x3].

Answer 14

• Broad
• Penicillin
• Cefuroxime

In reality hospitals will have their own guidlelines for the first line treatment of most infections. Bacterial meningitis is life threatening and the important thing to understand is that getting antibiotics into people is life saving

Question 15

A 22 year old woman presents with a postcoital bleed but denies having other symptoms. She is currently in a relationship but is concerned that her partner is having sex with other women. Examination with a speculum reveals a mucopurulent yellow and cloudy discharge from the cervical os. The cervix is friable.

1. Bacterial vaginosis
2. Chlamydia
3. Trichomonas vaginitis
4. Vaginal candidiasis

Answer 15

This is genital tract chlamydia infection which is one of the most common STDs in the world. Remember that many infected individuals are asymptomatic. Women may present with cervical inflammation or yellow, cloudy discharge from the cervical os. A friable cervix is often also found on examination – the cervix bleeds easily with friction from a Dacron swab.

Question 16

A 5 year old boy presents with a fever, headache and a very itchy vesicular rash mainly on his chest and face. He has recently taking paracetamol for a sore throat. There has also been a high fever in the last 24 hours. Lung fields are however clear on CXR. In some areas the lesions are crusted over while in others they appear to be newly formed. A classmate at school has had similar symptoms recently.

1. scabies
2. varicella zoster
3. bartonella
4. stevens-johnson syndrome

Answer 16

This is VZV infection (chickenpox) which typically presents with a fever, malaise and a widespread vesicular and pruritic rash which primarily affects the torso and face. Most countries in Europe do not immunise children against varicella.

Question 17

A 58 year old man with uncontrolled HIV infection and AIDS presents with 2 week history of blurred vision bilaterally. He also reports seeing visual floaters. Examination reveals a man who is severely cachectic with generalised lymphadenopathy. Fundoscopy reveals creamy coloured areas with overlying retinal haemorrhages.

1. Cytomegalovirus
2. Infectious mononucleosis
3. Mycobacteruim avium complex
4. HHV 6

Answer 17

This is a presentation of CMV retinitis, which is the most common manifestation of CMV disease in AIDS, the second most common being colitis. However do remember that virtually any organ can be affected by CMV and it can cause a range of conditions from encephalitis to pneumonitis. In CMV retinitis, fundoscopy will reveal areas of infarction, haemorrhage, perivascular sheathing and retinal opacification. These findings here are of chorioretinitis.

Question 18

A 18 year old student from Malaysia presents with 3 days of continuously high fevers. There are also general aches and pains and a predominantly frontal headache with retro-orbital pain which gets worse on eye movement. Examination reveals hypotension, tachycardia and a generalised skin flush with warm peripheries. There is also mild thrombocytopenia, elevated LFTs and low WBC count.

1. Dengue fever
2. Leptospirosis
3. Rickettsia
4. Rubella

Answer 18

Dengue in endemic in over 100 countries, especially SE Asia, Western Pacific and the Americas. It is an arbovirus which is transmitted by the Aedes aegypti mosquito found in the tropical and subtropical parts of the world. Clinical features include fever, headache, myalgia/arthralgia, skin flush and leucopenia, thrombocytopenia and elevated LFTs. Viral antigen or nucleic acid detection and serology are confirmatory tests to perform.

Question 19

A 35 year old homosexual man with HIV presents to his GP after a holiday in Barcelona having recently noticed the presence of painless purple skin plaques on his lower legs and some generalised rubbery lumps located over his body. Examnation reveals that there is also a purple coloured mass on his hard palate.

1. Seborrhoeic dermatitis
2. Photodermatitis
3. Kaposi sarcoma
4. HPV

Answer 19

This is Kaposi sarcoma which is a low-grade neoplasm caused by human herpesvirus-8 (or KSHV). It is associated with the acquired immunodeficiency associated with HIV infection. Oral KS can frequently affect the hard palate, gums and dorsum of the tongue. Cutaneous lesions are purple in colour and usually painless and non-pruritic. Histopathology of these vascular lesions will show characteristic atypical spindle-shape cells.

Question 20

A 64 year old smoker is referred to the doctors by his dentist, who noticed a white coloured plaque on the lateral tongue margin and the floor of the mouth. It has a thickened, white and leathery appearance on examination. The surrounding mucosa is clinically normal. He has recently has a kidney transplant. In situ hybridisation confirms the diagnosis.

1. Syphilitic leukoplakia
2. Candidiasis
3. Squamous cell carcinoma
4. Oral hairy leukoplakia

Answer 20

This is oral hairy leukoplakia which presents as a painless white plaque found along the lateral tongue borders. There is history here which suggests immunosuppression. In situ hybridisation here has demonstrated the presence of EBV in the tissue.

Question 21

A sexually active female student presents having noticed pearly umbilicated papules on her thigh which feel smooth to the touch. She tells you that these are itchy. Examination reveals local erythema around these lesions

1. Genital warts
2. Molluscum contagiosum
3. Lymphogranuloma venerum
4. Pelvic inflammatory disease

Answer 21

This is molluscum contagiosum which is sexually transmitted in adulthood. Lesions appear as the umbilicated pearly and smooth papules mentioned. About a third of patients will also develop symptoms of local redness, swelling or pruritis. Adults should be treated for this STD.

Question 22

A 22 year old man notices a painless penile ulcer. He has recently started his first sexually active relationship. His partner has no symptoms and he is also otherwise well. Examination reveals an indurated ulcer with rubbery and moderate inguinal lymphadenopathy.

Chancroid/syphilis/genital herpes/primary HIV infection

Answer 22

The chance of primary syphilis is usually a solitary, painless and clean ulcer with an indurated base. This is a common sexually transmitted infection caused by the spirochete Treponema pallidum. Treatment is with penicillin – untreated infection can cause considerable morbidity and facilitates HIV transmission

Question 23

A 35 year old woman who loves birds presents with a 10 day history of a low grade fever and a recent 2 day history of a cough which is non-productive. Examination reveals diffuse crackles on chest examination and mild hepatomegaly which is tender on palpation.

legionella/ psittacosis/ mycoplasma/ Q fever

Answer 23

Mycoplasma

Chlamydia psittaci causes a community-acquired atypical pneumonia. It is often acquired from domesticated or commercially raised birds or exotic imported birds. The presentation can be similar to Mycoplasma and Chlamydophila pneumoniae. Tetracyclines are the preferred treatment. Hepatomegaly can occur in this condition with pain on palpation but is uncommon, as can splenomegaly. Both organs, if enlarged, are diffusely so

Question 24

A 3 year old girl presents with a week history of pain in the abdomen and watery diarrhoea which became bloody after the first 8 hours. Three days before, she had distinctly recalled consuming a burger which may have been undercooked. Investigations show a mild anaemia and thrombocytopenia with blood smear demonstrating multiple schistocytes. Creatinine is also raised.

haemolytic uraemic syndrome/ DIC/ HELLP syndrome/ antiphospholipid syndrome

Answer 24

This is haemolytic uraemic syndrome which is characterised by MAHA, thrombocytopenia and nephropathy. Most cases are in children and related to gastroenteritis caused by verotoxin producing E. coli (O157:H7). The presence of schistocytes establishes the presence of thrombotic microangiopathy. The anaemia, thrombocytopenia and renal dysfunction characterised by creatinine rise mark this diagnosis.

Question 25

A 12 year old boy came back from summer camp and was taken to A&E feeling hot with vomiting and a sore throat. Laboratory tests and CXR is unremarkable and he is discharged. He returns later the same day with paraesthesias of the right arm and scalp, dysphagia and ataxia. When presented with water, he goes into laryngeal spasm and feels he is choking. Placement of nasal cannulae to give oxygen has the same effect.

west nile virus/attention seeking behaviour/rabies/guillain-barre syndrome

Answer 25

This is rabies, which can be difficult to diagnose if there is the absence of identifiable rabies exposure. There is non-specific prodrome of fever, chills, malaise, sore throat, vomiting, headaches and paraesthesias. The most specific signs of the disease are displayed here with hydrophobia and aerophobia (elicited by the placement of nasal cannulae). This patient is going to die and palliative care is needed. Rabies is considered 100% fatal.

Question 26

A 13 year old presents with fever and sore joints. She has had a sore throat about 3 weeks ago but did not see a doctor about it. While waiting in A&E she develops choreiform movements of the whole body and head with facial expressions that resemble grimaces.

borrelia burgdorferi/ clostridium tetani/ sepic arthritis/ streptococcus pyogenes

Answer 26

Streptococcus pyogenes

This girl has rheumatic fever which is caused by an autoimmune process following infection with group A streptococci. The 5 major manifestations of acute rheumatic fever is something you need to be aware of. They are carditis, polyarthritis, chorea, erythema marginatum and SC nodules. Various other signs can also be seen such as spooning sign and pronator sign.

Question 27

A man from Tanzania presents with occassional diarrhoea accompanied by frank blood. Examination reveals mild hepatomegaly and a palpable spleen. On further questioning, he tells you he has been swimming in the local lake.

1. Salmonella
2. Schistosomiasis
3. Toxoplasmosis
4. Leishmaniasis

Answer 27

Schistosomiasis

This is caused by a fluke which is acquired through exposure of the skin to contaminated freshwater (it is a snail-borne parasite). Patients can present acutely with bloody diarrhoea and hepatosplenomegaly is a common finding too. Diagnosis is made on microscopic visualisation of eggs in stools or urine. The preferred treatment for schistosome infections is with a drug called praziquantel.

Question 28

A 73 year old cut his hand while gardening. He presents with lock jaw which results in a grimace. There are also intermittent tonic contractions of his muscles which are painful and last for minutes.These are sometimes triggered by noise.

Hypocalcaemia/diptheria/generalised seizures/tetanus

Answer 28

This is caused by the exotoxin of Clostridium tetani and there is trismus here (lock jaw) which has resulted in risus sardonicus. The intermittent tonic contractions are also characteristic and the spasms can be triggered by both external and internal stimuli.