Forgotten things! Flashcards
Hep C treatment
If no cirrhosis, or pregnant - Maviret - “M for Mum”
Glecaprevir (protease inhibitor)
Pibrentasvir (NS5A inhibitor)
If cirrhotic - Epclusa “C for cirrhosis”
Velpatasvir (NS5a inhibitor)
Sofosbuvir (Nucleoside RNA polymerase inhibitors)
Hep B serology
Acute infection < 6 months
HBsAg +
HBcAb + IgM
HBsAb -
Chronic infection
HBsAG + > 6 months
HBcAB + IgG
HbsAB -
Resolved infection
HBsAg -
HBcAB+ IgG
HBsAB+ (marker of immunity!)
Vaccinated
HBsAg -
HBcAB -
HBsAB + (will wain over time, vaccination is titre at > 10 on ONE instance)
Susceptible
HBsAG -
HBcAB -
HBsAB -
MEN syndrome
Men 1 - Pituatory adenoma, parathyroid hyperplasia, pancreatic tumours - P’s!
Men 2a - Parathyroid hyperplasia, Medullary thyroid malignancies, pheochromocytoma - associated with RET gene gain of function mutation (loss of function Hirshsprung)
Men 2b - Mucosal neuromas, Marfans, Parathyroid Hyperplasia, Pheochromocytoma
Syphilis testing
Screening w trepenomal test;
- TP-EIA IgM and IgG serology
- TP-EIA will be confirmed in the lab against TPPA
Diagnosis w non-trepenomal tests
- RPR - Used to confirm diagnosis of new infection, old infection or re-infection
- VDRL - only used on CSF
Live Vaccines
MMR
Polio
Yellow fever - uses eggs, can cause hypersensitivity reaction (along with Q fever vaccine)
Varicella Zoster
Mb BCG
Typhoid
Tb treatment
Latent Tb (only treat immunocompromised, Health Care workers, Early infection or those < 35);
Isoniazid - 9 months, or
Rifampicin - 4 months, or
Isoniazid and Rifampicin -3 months
Active Tb
2 months - 4 drugs
Isoniazid + B6 if risk neuropathy
Rifampicin
Ethambutol
Pyrazinamide
followed by;
4 months - 2 drugs
Isoniazid w B6
Rifampicin
Tb Meningitis
Rx 12 months Rifampicin, Isoniazid w B6, Pyrazinamide and Moxifloxacin (better CNS penetration than Ethambutol)
HIV medications
Nucleotide reverse transcriptase inhibitors - stop RNA to DNA transcriptase via binding at deoxynucleotide binding site
Non-nucleotide reverse transcriptase inhibitors - stop RNA to DNA transcriptase by binding at an alternative site to the deoxynucleotide
Integrase inhibitors - stop viral replicated DNA being integrated with host DNA
Protease inhihbitors - stop budding and maturation of virus from host cells, main role is to inhibit CYP3A4 to increase efficiency of other HIV drugs
Mechanism of Anti-fungals
Azoles - inhibit D-14 alpha demethylase at CP450 to stop ergosterol synthesis at cell walls
Echinocandins - inhibit beta 1,3 D glucan to inhibit cell wall synthesis
Amphotericin (polyenes) - binds ergosterol to stop membrane function and create pores
Side effects of Tb Rx
Rifampicin - orange secretions and hepatitis
Isoniazid - Peripheral neuropathy and hepatitis
Ethambutol - Optic neuropathy
Pyrazinamide - Gout and hepatitis
Types of Lupus Nephritis
No Man Faces Diffuse Menstrual Situation
Normal - ACE/ARB
Mesengial - ACE/ARB
Focal - Methyl Pred induction -> Cyclophosphomide/MMF -> Ritux salvage
Diffuse - Methyl Pred induction -> Cyclophosphomide/MMF -> Ritux salvage
Membranous - Methyl Pred induction -> Cyclophosphomide/MMF -> Ritux salvage
Sclerosing - Dialysis
ANCA Vasculitis
- Granulomatosis with polyangitis (Wegners) - cANCA/PR3 - GN, Lung, Sinus, ENT
- Microscopic polyangitis - pANCA, MPO - GN and Lung
- Eosinophilic polyangitis Granulomatosis (Churg-Strauss) - pANCA - Asthma, Nasal polyps, atopy, GN
Types of GN
Nephrotic
- Membranous - Anti-PLA2R, ++ prothrombotic, associated with malignancy and SLE
- Minimal change - Podocyte effacement on Light microscopy, normal electron microscopy. Children and Elderly. Associated with thymoma, lymphoma
- FSGS - APOL1, < 50% sclerosis on electron microscopy
Nephritic
- IgA nephropathy
- Post-strep GN
- Membranoproliferative - Compliment activation. Type 1 - all compliment factors, Type 2 - only C3 (dense deposit disease, C3GN). Tram track appearance w subendothelial deposits
SLE - No Man Faces Diffuse Menstrual Situation
- Normal, Mesengial, Focal, Diffuse, Membranous, Sclerosing
ANCA GN
- pANCA - MPO - Microscopic polyangitis, Churgg Strauss/Eosinophilic
- cANCA - PR3 - Wegners/Granulomatous polyangitis
Anti-GBM - against alpha 3 Type 4 collagen, worsened by Alemtuzumab and Hydrocarbons
Dx Polycystic Kidney disease
PKD1 gene on Chromosome 16 - wrose prognosis, early ESRD
PKD2 gene on chromosome 4
If FHx
USS;
Total 3 cysts < 40
2 cysts each kidney 40 - 60
3 cysts each kidney > 60
If No FHX
> 10 cysts each kidney
On MRI;
If > 5 cysts < age 40
If no cysts on MRI by 18, diagnosis unlikely
Type 1 RTA
- Loss of H+ ATPase at collecting duct
- Increased retention H+ with metabolic acidosis
- Decreased Na+/H+ exchange, leading to overactivity of Na+/K+ exchange and hypoklaemia
- Hypercalcaemia as Ca drawn from bones to buffer H+, but consequence of reduced renal reabsorption calcium leading to Nephrocalcinosis
Electrolyte disturbances
- NAGMA
- Hypokalemia, urine pH > 5.5
- Hypercalcaemia
Rx with HCO3- which will increase urine pH and drive H+ excretion, reduces need for Na+/K+ exchange and decreasing hypokalaemia
Causes - Autoimmune conditions - Sjogrens, RA
Type 2 RTA
Decreased capacity to resorb HCO3- at proximal tubule resulting in increased K+ secretion at DCT as compensatory mechanism
Electrolyte disturbance
- Hypokalaemia - made worse with BiCarb Rx given ++ renal wasting
- Serum bicarb 12-20
- Lower urine pH
- Can occur with other defects including impaired resorption of phosphate, glucose, uric acid and amnio acids
Due to Fanconi’s syndrome, monoclonal gammopathies, Tenofovir
Foot Drop
Due to Peroneal Nerve injury (branch of Sciatic nerve)
- Common peroneal - Dorsiflexion and eversion
- Deep peroneal - Just dorsiflexion
(The other branch of the sciatic nerve is the Tibial Nerve which supplies plantarflexion)
Anti-Parkinsons Medication
For Tremor;
- Anti-NMDA glutamate antagonists - Amantadine
- Anti- Ach - Benztropine
For PD;
- L-Dopa - Levodopa/Carbidopa, Benserazide
- Dopamine agonists - Pramipexole, Rotigotine Patch
- MAOi inhibitors - Selegiline
- COMT inhibitors - Entacapone
- Apomorphine subcut injections
- Duodopa infusions
Intranuclear Opthalmoplegia
Interruption of ipsilateral medial longitudinal fasciculus
- Leading eye nystagmus
- Failure of adduction of affected eye
Common in MS
MS medications
“DONT ForGet Preload In ACS”
Maintenance;
Dimethyl Fumurate - mechanism not well understood
Ocrelizumab - Anti-CD20
Natalizumab - Anti- alpha 4 integrin
Teriflunomide - Pyrimidine synthesis inhibition
Fingolimide - S1P inhibition to inhibit lymphocyte migration from LN
Glatiramer - Shunts Th1 to Th2
Peg IFN
Interferon Beta
Immune reconstitution;
Alemtuzumab - Anti-CD52
Cladrabine - Inhibits purine synthesis
Stem Cell Transplant
Side Effects and Benefits MS drugs
DONT ForGet Preload In ACS
Dimethyl Fumurate - Best in pregnancy
Ocrelizumab - works for progressive MS
Natalizumab - JC virus/PML
Teriflunomide - teratogenic, alopecia
Fingolomide - Heart block, Macular oedema, CI CVD
Glatiramer - panic attacks & flushing, safe in pregnancy
Peg IFN & IFN Beta - Hepatitis, Flu-like illness, Depression
Alemtuzumab - Autoimmune conditions, thyroiditis, haemolytic anaemia, Anti-GBN GN, ITP, Breast Ca, Melanoma
Cladribine - Increased Cancer risk, PML
Stem Cell Treatment
Inclusions in Neurological Conditions
A
Tau
- PSP
- Corticobasal degeneration
- Picks disease/frontotemporal dementia
Synuclein
- Parkinsons Disease
- Lewy body dementia
- Multisystem Atrophy
Amyloid
- Alzheimers
- Vascular Dementia
Prion
- CJD
Types Motor Neurone Disease
Amyotrophic lateral sclerosis
Upper and lower motor neurone involvement
ALS plus
Upper and lower motor neurone involvement with subtle executive deficits and behavioural change
ALS-FTD
Upper and lower motor neurone involvement
Frontotemporal dementia
Poorer prognosis
Primary lateral sclerosis
UMN signs only
Primary muscular atrophy
LMN signs only
Types of MND
Amyotrophic lateral Sclerosis (ALS) - UMN +LMN
ALS plus - UMN + LMN + executive dysfunction
ALS-FTD - UMN + LMN + Frontoremporal dementia
Primary lateral sclerosis - UMN only
Primary muscular atrophy - LMN (remember because LMN denervation causes muscle atrophy!)
Indications NIV in MND
- NIV - increases survival and QOL if commenced before bulbar dysfunction
- indications
- VIC < 50%
- Sniff Negative Inspiratory Pressure < 30
- Low Mean Inspiratory Pressure indicative of diaphragm muscle
- Low Mean Expiratory Pressure indicative of abdominal muscles
Early “prophylactic” ventilation worsens prognosis!
Genetic pre-disposition to Alzheimers
APO E4 - Late onset Alzheimer’s and cardiovascular disease
Presenilin 1 and 2, Amyloid Precurser Protein - Early onset Alzheimers disease
APO E2 - protective Gene!
Types of Amyloid
Mutations in Leukaemias/Lymphoma
Carbonic Anhydrase inhibitors
Act at proximal convoluted tubule - Inhibit HCO3- resorption, leading to decreased activity of Na/H+ exchange and more urinary Na having a weak diuretic effect
I.e. Acetazolamide and Topiramate
Will cause a metabolic acidosis (Type 2 renal tubular acidosis)
Bartter Syndrome
Autosomal recessive
Ineffective Na/K/Cl transporter at LOH - mimicking loop diuretics
- Young children with growth and mental delays
- Interrupts gradient for Mg, Ca
- Low volume leads to hyperaldosteronism & increased Na uptake with H+ secretion.
- Increased renin with high prostaglandins
Leads to
- Low K
- Low H+ with metabolic alkalosis
- Low Mg
- Low Ca
Treat with NSAIDs to block prostaglandin production. Replace electrolytes
Gitelman Syndrome
Autosomal recessive
Interrupts Na/Cl- transporter at DCT to mimic thiazide diuretics
Presents in adulthood with polyuria and craps
Interrupts the electrochemical gradient of Mg resorption causing hypomagnesium
Type 1 RTA
- Loss of H+ ATPase at collecting duct
- Increased retention H+ with metabolic acidosis
- Decreased Na+/H+ exchange, leading to overactivity of Na+/K+ exchange and hypoklaemia
- Hypercalcaemia as Ca drawn from bones to buffer H+, but consequence of reduced renal reabsorption calcium leading to Nephrocalcinosis
Electrolyte disturbances
- NAGMA
- Hypokalemia, urine pH > 5.5
- Hypercalcaemia
Rx with HCO3- which will increase urine pH and drive H+ excretion, reduces need for Na+/K+ exchange and decreasing hypokalaemia
Causes - Autoimmune conditions - Sjogrens, RA
Type 2 RTA
Decreased capacity to resorb HCO3- at proximal tubule resulting in increased K+ secretion at DCT as compensatory mechanism
Electrolyte disturbance
- Hypokalaemia - made worse with BiCarb Rx given ++ renal wasting
- Serum bicarb 12-20
- Lower urine pH
- Can occur with other defects including impaired resorption of phosphate, glucose, uric acid and amnio acids
Due to Fanconi’s syndrome, monoclonal gammopathies, Tenofovir
Type 4 RTA
Hyperkalemia NOT hypokalaemia as with other RTA. Can be secondary to Heparin due to toxic effect on adrenal glomerulosa cells, Tacrolimus, Addisons
Due to hypoaldosteronism
Rx Fludrocortisone (has mineralocorticoid activity)
Cyclosporin Side effects
Gum Hypertrophy
Hirsutism
Mycophenolate MOA
Pro-drug of Mycophenolic Acid. Inhibits Inosine-5- Monophosphate dehydrogenase (IMPDH) to reduce purine synthesis (Guanine) and cell replication of T and B cells
Side effects are diarrhoea and BM suppression (within 6 months)
Types of renal transplant rejection
T- Cell (Donar APC: Host T cell)-> treat with pulse methyl pred +/- thymoglobulin and increase maintenance therapy.
Antibody mediated (Host APC: Host T cell) -> requires IVIG or PLEX +/- Rituximab. C4D positive
Mixed
BK Virus
Polyoma virus
Post transplant nephropathy
Risk factors; female, HLA mismatch, Older age, immunosuppression
Ix;
- SV 40 stain shows intracellular inclusions on biopsy
- BK Virus PCR (100% of patients!), should be screened at 12 months
- Viral load
Rx with reduction in immunosuppression, Cidofovir
