Haem, Immunology and ID Flashcards
Sx of Polycythaemia Vera?
Pruitis particularly after a hot bath, splenomegaly, HTN, hyperviscosity (due to the increase in RBCs) and haemorrhages (due to abnormal platelet function)
What is seen on investigation of polycythaemia vera?
Jak 2 mutation
Increased Hb and haematocrit, WCC and platelets may be high
Low ESR
Mx of polycythaemia?
Low dose aspirin daily
Venesection = 1st line
Mx of chlamydia?
1st line = 7 days PO Doxycycline
2nd line/if pregnant = Azithromycin PO single dose
What should you always do with any under 24 year old presenting with unexplained petechiae or hepatosplenomegaly?
Immediately refer for specialist assessment to rule out leukaemia
When should we test for HIV? What test do we use?
Test at 4 weeks and 12 weeks after the possible exposure with a combination of antibody and antigen testing.
If positive after 4 weeks start on antiretrovirals immediately but still do confirmation test at 12 weeks
How should you treat adults over 50 for meningitis? When should you consider using vancomycin?
All adults >50 should be managed with IV cefotaxime and amoxicillin
Consider Vanc in any patient who has been outside the UK in the previous 3/12 or has used other antibiotics in the last 3/12
What is a syphilis chancre?
A single painless, indurated ulcer in the anus, mouth, vagina or penis.
What causes syphilis? How do we treat?
Treponema Pallidum
Mx = IM benzathine benzylpenicillin
Which conditions are spherocytes seen in? How can you differentiate clinically between the 2?
Hereditary spherocytosis and autoimmune haemolytic anaemia
Hereditary spherocytosis = mild chronic anaemia
Autoimmune haemolytic anaemia = severe acute anaemia
Describe Hereditary Spherocytosis?
Most common inherited form of haemolytic anaemia. AD.
Sx = jaundice, gallstones, splenomegaly and aplastic crisis in the presence of Parovirus B19
Ix = raised MCHC on FBC, spherocytes seen, increased reticulocytes
Mx = folate supplementation and splenectomy
Describe G6PD deficiency?
X-linked recessive
Sx = jaundice, anaemia, splenomegaly and gall stones secondary to illness, broad (fava) beans and drugs e.g. anti-malarials
Ix = Heinz bodies seen on blood film
Describe Autoimmune Haemolytic Anaemia?
Autoimmune destruction of RBCs. Warm type is the most common and is idiopathic. Cold type is usually secondary to something e.g. HIV
Ix = Direct antiglobulin (Coombe’s) test positive, increased spherocytes and reticulocytes, isolated raised bilirubin (prehepatic)
Mx = Steroids, Rituximab, Blood transfusions an d splenectomy
Describe Paroxysmal Nocturnal Haemoglobinuria?
A genetic mutation within the bone marrow
Sx = red urine in the morning containing haemoglobin and hemosiderin. Thrombosis and smooth muscle dystonia (e.g. oesophageal spasm or erectile dysfunction)
Mx = Eculizumab or bone marrow transplant
How does primary HSV infection often present (oral)?
Gingivostomatitis. Painful ulceration of the mouth and tongue
How do we manage HSV infections?
Primary oral HSV infection = oral acyclovir and chlorhexidine mouth wash
Cold sores = TOP acyclovir
Genital warts = oral acyclovir
What should you do if a primary HSV infection occurs >28 weeks of pregnancy?
Offer elective C-section and give oral acyclovir until delivery
Which Herpes virus causes oral and which causes genital herpes?
HSV 1 = oral
HSV 2 = genital
Under what circumstances should you NOT do an LP before giving antibiotics in bacterial meningitis?
If it can not be done in under 1 hours
If there are Sx of severe sepsis or a rapidly evolving rash
If there is a significant bleeding risk
If there is raised ICP
Sx of Hodgkin’s lymphoma?
Contiguous and asymmetrical lymphadenopathy which is painless except when drinking alcohol.
B symptoms
Ix of Hodgkin’s lymphoma?
Ix = Normocytic anaemia and eosinophilia
Reed Sternberg cells aka large multinucleated cells with eosinophilic nuclei, mirror image nuclei, bilobed nuclei or owl eye appearance
Hyposplenism can be seen secondary to coeliac disease. What will be seen on blood film?
Howell-Jolly bodies and siderocytes seen on blood film
What is seen in primary, secondary and tertiary syphillis?
Primary = chancre and lymphadenopathy
Secondary = systemic illness, rash, buccal ulcers, condylomata lata
Tertiary = gummas, ascending aortic aneurysms, Argyll-Robertson pupil
What are the causes of a false negative on a Mantoux skin test?
FAILS
Fever, Anaemia, Immunosuppression, Lymphoma, Sarcoidosis
What should you give to patients receiving chemotherapy who are considered high risk of febrile neutropenia?
Granulocyte-Colony Stimulating Factors (G-CSF) e.g. Filgrastim
Ix and Mx of Lyme disease?
Ix = Borrelia Burgdorferi antibodies (ELISA test)
Mx = 10 days doxycycline and ceftriaxone if disseminated disease
Sx of Multiple Myeloma?
CRABBI
hyperCalcaemia, Renal failure, Anaemia, Bleeding, Bone pain, Infection
Ix of Multiple Myeloma?
Roleaux formation on a peripheral blood film
Increased plasma cells on BM aspiration
Whole body MRI
You should always send and MSU for women with a UTI when they have what?
Visible or non-visible haematuria OR are >65
But do not delay starting treatment to do this
Sx of typhoid and paratyphoid?
Sx = systemic upset, relative bradycardia, abdo pain and distension, constipation or diarrhoea and rose spots on the trunk (more seen in paratyphoid)
What further investigation should you do for all people diagnosed with iron deficiency anaemia?
Ix for coeliac’s disease
What is an aplastic crisis?
Pancytopenia following Parovirus B19 infection in those with sickle cell or hereditary spherocytosis
Do you treat asymptomatic bacteriuria?
No unless they are pregnant
Should you give dexamethasone in bacterial meningitis?
Yes unless there is meningococcal septicaemia (indicated by the presence of a non-blanching rash) or patient is <3 months old
What condition should you suspect in patients with a fever on alternative days?
Malaria
Sx of Lyme Disease?
Painless bullseye rash (erythema migrans) and systemic upset. If disseminated disease = 3rd degree heart block, facial nerve palsy, myo/pericarditis and meningitis
What is the most common cause of viral meningitis?
Enteroviruses e.g. Coxsackie virus
Mx of Gonorrhoea?
1st line = IM ceftriaxone
2nd line = PO cefixime or PO ciprofloxacin
Sx of Staph aureus food poisoning?
Short incubation period and severe vomiting
Name 2 important side effects of trimethoprim? Is it safe in breastfeeding?
Hyperkalaemia and myelosuppression.
Yes it is safe when breastfeeding - nitro is not!
What is the commonest form of malaria?
Falciparum Malaria
Sx of Dengue Fever?
Fever, retro-orbital headaches, myalgia/bone pain/arthralgia, pleuritic chest pain, maculopapular rash and facial flushing
Ix and Mx of Dengue Fever?
Ix = Low WCC, low platelets and a raised ALT
Mx = supportive only
How can you differentiate between iron deficiency anaemia and anaemia of chronic disease?
Iron deficiency = low iron, high TIBC, low ferritin and low transferrin saturation
Anaemia of chronic disease = low iron, low TIBC, high ferritin and low transferrin saturation
Sx, Ix and Mx of Immune Thrombocytopenia?
Sx = Petechiae, purpura and bleeding
Ix = isolated thrombocytopenia
Mx = oral prednisolone, IVIG if active bleeding
When should you send MSU in a male with a UTI?
ALWAYS
Sx, Ix and Mx of Trichomonas Vaginalis?
Sx = offensive yellow/green frothy discharge, vulvovaginitis, strawberry cervix, pH >4.5 and urethritis in males
Ix = trophozoites on microscopy
Mx = 5-7 days oral metronidazole
Sx and Mx of Chlorea?
Sx = profuse watery diarrhoea, dehydration and hypoglycaemia
Mx = oral rehydration therapy and doxycycline/ciprofloxacin
Sx Staphylococcal Toxic Shock Syndrome?
Fever >38.9, hypotension, diffuse erythematous rash with desquamation in tampon users
Sx of Clostridium Botulinum infection?
Seen in IVDUs
Descending flaccid paralysis with bulbar palsy (slurred speech and difficulty swallowing), diplopia, ataxia and no sensory disturbance
How long should PEP be used after HIV exposure?
28 days
What can Polycythaemia Rubra Vera transform to? How can you differentiate?
AML = high WCC, low RBC and low platelets
Myelofibrosis = pancytopenia
What is the diagnosis if you have a macrocytic anaemia with an isolated raised GGT?
Alcohol XS
What is Factor V Leiden?
Most commonly inherited thrombophilia, leads to increased risk of clots.
Occurs due to activated protein C resistance
Name 5 drugs which can trigger haemolysis in G6PD deficiency?
Sulphonamides, Sulphonylureas and Sulphasalazine, Anti-Malarials and Aspirin
What is foetal hydrops?
Polyhydramnios, ascites and foetal skin oedema, often occurs secondary to Parovirus B19 infection
Describe Chronic Myeloid Leukaemia?
Anaemia, raised neutrophils and thrombocytosis (raised platelets) in the presence of the Philadelphia chromosome
Sx and Mx of Campylobacter?
Sx = headaches and malaise prodrome, bloody diarrhoea, abdo pain which may mimic appendicits
Mx = self limiting but give clarithromycin if severe of immunocompromised
Describe beta thalassaemia major?
Occurs due to mutation on Chromosome 11
Sx = microcytic anaemia with bone deformities, failure to thrive and hepatosplenomegaly in the 1st year of life
Mx = life long blood transfusions and desferoxamine iron chelation. Consider BM transplant and splenectomy
Which chromosome is affected in alpha thalassaemia? How can we treat it?
Chromosome 16.
BM transplant can be curative. Consider transfusions and splenectomy
What should you suspect if there is raised LDH in the context of anaemia?
Haemolytic anaemia
What is a sequestration crisis?
Seen in sickle cell
Blood pools in the organs (but does not occlude vessels), this leads to worsening anaemia with increased reticulocytes (in aplastic crisis reticulocytes are low)
How can EBV affect the white cells?
Increased WCC with increased lymphocytes and decreased neutrophils
When should you offer platelet transfusions?
If platelets are <30x10^9 and a clinically significant bleed or if <10x10^9 and no bleed.
What platelet level should you aim for before an invasive procedure?
> 50x10^9
What blood products should you give in clinically significant bleeds which are NOT major haemorrhages?
Fresh Frozen Plasma if prolonged PT or APTT
Cryoprecipitate if low fibrinogen
What is seen on bone profile in myeloma?
Raised calcium, normal or raised phosphate and normal Alk phosphate (but will be raised if metastatic disease)
Which type of transfusion is the highest risk for bacterial contamination?
Platelet transfusions
What is Jarisch-Herxheimer reaction? How do you manage it?
Seen in the 1st 24 hours after starting syphilis treatment due to the rapid killing of treponema pallidum.
Sx = fever, rash, headaches, tachycardia and myalgis
Mx = supportive with antipyretics
Sx, Ix and Mx of amoebiasis?
Profuse watery diarrhoea with a long incubation period. Can cause a liver abscess (leading to fever, RUQ pain and hepatomegaly).
Ix = USS of the liver and stool microscopy
Mx = oral metronidazole and a luminal agent e.g. diloxanide furoate
What is the 3rd most common cause of urethritis in males (i.e. it is not caused by chlamydia or gonorrhoea)?
Mycoplasma Genitalium
What conditions is pseudomonas aeruginosa associated with? How does it appear under a microscope?
Pneumonia in CF patients, skin burn/wound infections, hot tub folliculitis, otitis externa and UTI
It is a gram negative rod
Do you need PEP for HIV following a human bite (if the biter is HIV positive)?
NO
How do you manage a woman with anti-phospholipid syndrome using warfarin treatment if they become pregnanct?
Aspirin and LMW Heparin
What should you monitor before starting TB treatment?
U&Es, LFTs, FBC and vision testing
Sx of Legionella?
Flu like symptoms, dry cough, confusion, relative bradycardia, leukopenia, hyponatraemia, deranged LFTs and sometimes pleural effusions in a patient with recent travel
Ix and Mx of Legionella?
Ix = urinary antigen testing
Mx = erythromycin/clarithromycin
How do we manage contacts of someone with meningitis?
Oral ciprofloxacin or Rifampicin
Mx of MRSA?
Vancomycin
Sx of Pneumocystis Jiroveci Pneumonia (PCP)?
Sx = dyspnoea, dry cough, fever, exercise induced desaturation
Ix and Mx of Pneumocystis Jiroveci Pneumonia? How can we prevent it?
Ix = CXR = bilateral interstitial pulmonary infiltrates
Mx = Co-trimoxazole
It is an AIDS defying illness, if CD4 count is <200 offer PCP prophylaxis
What should you always do after the drug management of UTI in a pregnant women?
Send a urine sample for MSU to check for cure
Describe Hep A?
Faecal Oral Spread.
Doesn’t cause chronic disease
Sx = Flu like prodrome, RUQ pain, tender hepatomegaly, jaundice and deranged LFTs
Vaccine available!
Describe Hep B?
Blood borne or vertical transmission
Can cause chronic hepatitis (ground glass hepatocytes), hepatocellular carcinoma, polyarteritis nodosa and glomerulonephritis
Sx = fever, headache, jaundice and deranged LFTs
Vaccine Available!
Describe Hep C?
Blood borne or vertical transmission
Can cause chronic hepatitis, hepatocellular carcinoma, cirrhosis and eye/joint problems
Sx = fatigue, arthralgia, jaundice and deranged LFTs
No vaccine available
Describe Hep D
Blood borne
Hep B MUST be present to become infected. If a patient with Hep B develops hep D this is a super infection - can cause hepatitis, chronic hepatitis and cirrhosis
Describe Hep E?
Faecal-oral spread, often seen due to undercooked pork ingestion
Does not cause chronic disease
Sx = mild jaundice
Vaccine not yet available (in development)
Describe aspergilloma?
It commonly colonises existing lung cavities (e.g. secondary to TB, CA or CF)
Sx = cough +/- haemoptysis
Ix = rounded opacity with crescent sign on CXR
Describe acute chest syndrome?
Dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on CXR in patients with sickle cell
Which lymph nodes does ovarian cancer commonly spread to?
Para-aortic lymph nodes
Describe DIC?
Out of control haemostasis leading to organ ischaemia and easy bleeding (due to depleted platelets). Occurs secondary to sepsis, malignancy, obstetric complications, trauma or IV haemolysis.
Ix = low platelets and fibrinogen, raised PT, APTT, bleeding time and D-dimer
When can you have DIC with relatively normal investigations
In chronic DIC (due to large aortic aneurysm or solid tumour)
What is the clotting profile of warfarin like?
Raised PT, normal APTT, bleeding time and platelets
What is clotting profile of Aspirin like?
Normal PT, APTT and platelets, increased bleeding time
What is the clotting profile of Heparin like?
Normal or raised PT, raised APTT, normal platelets and bleeding time
What conditions is strep pyogenes associated with?
Rheumatic fever, scarlet fever, cellulitis and type 2 necrotising fascititis
Mx of typhoid or paratyphoid (caused by salmonella)?
Ciprofloxacin
Mx BV? Mx in pregnancy?
5-7 days oral metronidazole. Use this also in pregnancy
Describe Gas Gangrene?
Clostridium Perfringens infection of a wound
Sx = fever, pain +++, grey/dark red/purple/black skin, foul smelling discharging blisters and gas bubbles in the tissues
Mx of campylobacter infection?
Supportive or clarithromycin if severe
What is Koilonychia?
Spoon shaped nails, often seen in those with iron deficiency anaemia
What is leukonychia?
White discoloration of the nails, can be seen in healthy individuals or with hypoalbuminaemia
When can we give IV iron over PO iron?
When PO iron can not be tolerated or surgery is needed but there is not enough time to correct with PO (<1 month)
What class of drugs are DOACs?
Direct factor Xa inhibitors
What should you do to Ix ?spinal epidural abscess?
Do an MRI of the whole spine
Which drug can be given to reduce the frequency of acute chest syndrome in sickle cell
Hydroxycarabamide
Which sickle cell complication causes splenomegaly?
Sequestration crisis
What can we give to reverse Rivaroxaban and Apixaban?
Andexanet alpha
What should you do in a ?DVT when D-dimer is positive but the Doppler USS of the leg is normal?
Stop anti-coagulants and repeat US in 1 week
What can be seen in haemophillia?
Hemarthroses, haematomas, raised APTT but normal PT/bleeding time
Mx of ITP?
If platelets <30x10^9 give oral prednisolone
If there is a life/organ threatening bleed give IVIG, IV methylprednisolone and platelet transfusion
What happens if you drink alcohol whilst on Metronidazole?
Disulfiram like effects. Flushing, nausea and vomiting, headaches and palpatations
What is red man syndrome? How do you manage it?
Redness, pruritus and burning of the upper body seen if vancomycin is given too rapidly.
Mx = stop the transfusion and restart at a slower rate once symptoms have resolved
When should you give a booster vaccine and tetanus IG in a dirty wound?
If the vaccination history is unknown, incomplete or if the last vaccine was given >10 years ago.
Typically the last standard dose of the 5 tetanus doses is given before 18 years of age
Mx of CAP?
Amoxicillin. Clarithromycin if penicillin allergic
Sx and Mx of Leptospirosis?
Fever, red conjunctiva, AKI, hepatitis and aseptic meningitis
Mx = benzylpenicillin or doxycyline
Describe thrombotic crises?
Seen in sickle cell secondary to infection, dehydration and altitude
Sx = extreme pain and swelling often of the hands and feet.
Diagnosed clinically
Mx = supportive, prevent recurrence with hydroxyurea/hydroxycarabamide
Ix of genital herpes?
NAAT
Sx and Ix of myelofibrosis?
An elderly person with Sx of anaemia, massive splenomegaly, weight loss and night sweats
Ix = anaemia, raised WCC, raised platelets, tear drop poikilocytes, may be JAK 2 positive
Sx of Giardia infection?
Non-bloody diarrhoea and steatorrhea with flatulence, abdo pain, malabsorption, lactose intolerance and weight loss
Mx of non-falciparum malaria?
Chloroquine and Primaquine or Artemisin-based combinaiton therapy
Ix of BV?
pH >4.5 and clue cells on wet microscopy
True or false, if target like rash is present you do not need to do ELISA serology to diagnosed lymes disease?
True
Sx of yellow fever?
Fever, rigors, nausea and vomiting. Brief remission of symptoms then jaundice, haematemesis and oliguria
What should you do before giving the BCG vaccine?
TB skin test, vaccination may activate latent TB
How long after exposure can you give PEP?
Up to 72 hours after
Describe tumour lysis syndrome?
Uric acid release from cancer cells after chemotherapy
Leads to AKI, raised phosphate and potassium, low calcium.
Mx = allopurinol or rasburicase (in high risk patients give IV before chemo)
How do we measure the response to Hep C management?
Viral load
What should you do if syphilis is identified in a woman who is <16 weeks pregnant?
Give IM Benzathine Penicillin
Sx and complications of mumps?
Fever, malaise and inflammation of the parotid glands (leading to ear ache and jaw pain).
Orchitis is the most common complication in post-pubertal males.
Also hearing loss, meningoencephalitis and pancreatitis
Mx of rabies?
If previous vaccination = 2 further vaccine doses
If no previous vaccination = human rabies IG and full course of vaccination
What is seen in thrombotic thrombocytopenic purpura?
Thrombocytopenia in a very unwell person. There will likely be an autoimmune history
What is seen in haemorrhagic haemolytic telangiectasis?
Epistaxis, GI bleeds and telangiectasia
How do you interoperate the results of a Well’s score in ?DVT
> = 2 do a limb USS
<2 do a d-dimer, if positive do limb USS
What is idarucizumab?
The reversal agent for dabigatran
How can prednisolone assist in the Mx of ITP?
It suppresses the immune system
True or false, NSAIDs can precipitate renal failure in AKI?
True!
What is seen on FBC in sickle cell?
Normocytic anaemia with an increased reticulocyte count
True or false prosthetic heart valves can cause haemolytic anaemia?
True!
Blood results in CLL?
Persistently mildly raised WCC and lymphocytes with smudge/smear cells and small/medium sized lymphocytes on blood film
Complications of CLL?
Recurrent infections, warm autoimmune haemolytic anaemia and transformation to high grade lymphoma (Richter’s transformation)
What should you consider in a sickle cell patient with a sudden anaemia and low reticulocytes?
Parovirus B19 leading to aplastic crises
Sx of lead poisoning?
Abdo pain, constipation, neuropsychatric symptoms and basophilic stippling
Mx of TTP?
Corticosteroids and IVIG. Do NOT give platelet transfusion!!
When you are diagnosing G6PD deficiency when should you take a G6PD enzyme platelet assay?
At the time of the acute haemolytic episode and after 3 months
True or false, polycythaemia rubra vera can transform to AML?
TRUE
What is the definitive diagnosis for sickle cell?
Hb electrophoresis
What should you always consider the diagnosis if there is a deranged coagulation in sepsis? What is seen on coagulation profile
DIC
Anaemia, low platelets, low fibrinogen, high PT and APTT and high fibrinogen degradation products
Mx of DVT/PE in pregnancy?
S/C LMW Heparin
What is the coagulation profile like in Haemophillia?
Normal PT and bleeding time but a prolonged APTT
Which clotting factors are deficient in haemophilia?
In Haemophilia A (most common) - Factor VIII is deficient
In Haemophilia B - Factor IX is deficient
What is the most common type of hodgkin’s lymphoma?
Nodular sclerosing
Ix of Myeloma?
Serum protein electrophoresis or urinary antigen bence-jones protein
What is the universal donor for blood products and FFP?
Blood = O Rhesus negative
FFP = AB Rhesus negative
What is seen on Ix of AML (Promyelocytic leukaemia)?
Auer rods
Can acute haemolytic reaction occur in FFP transfusion?
NO! there are no RBCs. However anaphylaxis can occur (seen as wheeze, hypotension and fever)
Mx of anaphylaxis vs Mx of acute haemolytic reaction?
Anaphylaxis = stop transfusion and give IM adrenaline
AHR = stop transfusion and give IV fluids
What is the most common bleeding disorder?
Von Willebrand’s disease
What implies a poor prognosis in lymphoma?
The presence of B symptoms
Ix of Polycythaemia Vera?
Jak 2 mutation
Which antibiotic is known to cause haemolysis in G6PD deficiency?
Ciprofloxacin
Bite and blister cells are seen on blood film in what condition?
G6PD deficiency
How can you differentiate between Haemophilia and Von Willebrand’s on clotting profile?
Haemophilia = APTT increased only
VwD = Bleeding time and APTT increased
