Hepatitis, Pneumonia Flashcards
Common infections which may lead to varicies
Hepatitis
Shisto
Hep A incubation? Phases of illness? Kids?
Incubation period: 2-6 weeks
Prodromal Phase: ~7d
*Fever, malaise
*Anorexia, nausea, vomiting
*Abdominal pain
Icteric Phase:
*Jaundice, scleral icterus (40-70%)
*Dark urine, pale stools
*Hepatomegaly
Children: no or few symptoms.
HepB who receives rx? drug choice?
Treat if Cirrhosis (fibroscan or APRI score >2)
OR >30 years with abnormal ALT and viral load >20k
Tenofovir + entecavir
Just entecavir in age 1-10
[kids 10 or less don’t get TENofovir - same as HIV]
Oral options for HepB rx ? usual regime for HIV and HepB in rich countries
Tenofovir, Lamivudine and entecavir
Tenofovir + lamivudine + dolutegravir
What is in the vaccines for hepB
HBsAg
Worlds biggest iatrogenic epidemic of BBV was ?
Mass treatement with tartar emetic to treat schisto in egypt and yemen
-Used same needles
resulted in around 30% carrier of hep C
HepC rx
Direct acting antivirals
[+ daily oral ribavirin if genotype 1]
Which Hep virus can you get repeatedly ? Geographicly common where?
Hep E
India and central asia
HepE vaccine quality?
Very effective
-Only licenced in china
Key risks for hepatocellular Ca
HepB/C
Alcohol cirrrhosis
Alfatoxin (Aspergillus)
Pneumonia with ‘rusty’ sputum most commonly which bug? staining ?
S pneumo
Gram positive diplococci
Rx pneumonia caused by gram -ve eg klebsiella
Aminoglycoside eg Gent
[taz in rich contries]
Which pneumococcal vaccine best
PCV 20
Cause of tropical pulmonary eosinophilia? Geography? Sx?
Asthma-like disease caused by
-Wuchereria bancrofti or Brugia malayi
- Progresses to granulomatous and eventually fibrosis
India and west Africa
Tropical pulmonary eosinophilia ix? Found on Lung function tests?
Eosinophilia
CXR - diffuse alveolar mottling with 1-2mm nodules
Filarial antigen testing
LFTs - Restrictive [not obstructive]
Tropical pulmonary eosinophilia rx?
Diethylcarbamazine
-Add albendazole if not responding
[or doxy + ivermectin]
Tropical pulmonary eosinophilia control
Control of ades mosquito (eg breeding sites)
Causes of pneumonia in kids
Neonate vs <3m vs <5 y vs >5y
Neonates: Group B Srep, Gram -ve bacteria , CMV, Listeria, HSV
3w- 3m : Chlamydia trachomatis , RSV, PIV, S.
pneumoniae , B. pertussis, S. aureus
3m - 5y : viral (RSV, PIV, influenza, adeno, rhino),
[S. pneumoniae , H. influenzae , Mycoplasma,
TB .]
5y - 15y : Mycoplasma, Chlamydia pneumoniae ,
S. pneumoniae , TB
Main causes of severe pneumonia in kids
s pneumo
h influenza
RSV / viral
Key signs of severe CAP in kids
- Lower chest wall indrawing
- Nasal flaring
- Grunting (in young infants)
- Inability to feed
Abx in pneumonia kids mild vs severe? HIV?
Mild / some chest indrawing = amox
Severe / HIV - IV ampicillin + gent
Case. Septic 13 yo with fever and boils on buttocks and difficulty breathing
Multiple alveolar infiltrates with arthritis
Staph aureus
Penicillin resistance in s pneumo by location of bug?
Very high in meningitis ~60% -> use Ceftriaxone
Low in pneumonia - ie can still use amox
Loculated complex pleural effusion - addition in rx to abx + drain
Intrapleural fibrinolytic
VATS
Low income countries - how many are immune to HepA by age 10?
90%
HepA Dx? Which liver enzyme is highest?
ALT>AST (opposite to alcoholics)
IgM anti-HAV
By the time Sx start - should have detectable IgM
HepA Rx? Prevention?
No Rx - supportive only
Vaccine - 2 doses = 95% protection
[PEP - HAV vaccine / Ig within 2 weeks
Cooking appropriately, iodine, chlorine etc]
HepE has 4 sero groups. Which in developing regions? which has animal reservoirs?
HEV 1&2 - Developing regions, Human reservoirs
-> contaminated drinking water with faeces
HEV 3&4 - Developed countries, animal reservoirs (mostly pig)
-> consumption of undercooked meat
Pigs have 4 legs, humans have 2 (animal farm)
Key complications of HEV? Who is at high risk?
Neuro: Guillain-Barre syndrome, neuralgic amyotrophy, encephalitis, myelitis
Renal: All the renal things [IgA nephropathy, membranoproliferative glomerulonephritis with or without cryoglobulinaemia, membranous glomerulonephritis]
Pregnant women high risk mortality ~20%
HEV dx? When would you call HEV chronic?
anti-HEV IgM and/or HEV RNA
Chronic HEV infection: detection of HEV RNA in serum > 6 months
HEV rx?
Ribavarin
*contraindicated in pregnancy
HEV immunocompetent vs suppressed.
Which genotype? ALT? Dx? outcomes?
Supressed - Only HEV 3
-Lower ALT ~300 vs >1000
-Need PCR (lack of immune response)
-More likely chronic infection
-Interferon a + ribavirin for Rx
HepC which genotype is most common? Which in SE Asia? Which in Africa / middle east?
Genotype 1: 44% of all HCV infections.
*More common in high-and middle-income countries (60%)
Genotype 3: 25% of all HCV infections.
*More common in LMIC (75% south Asia)
Genotype 4: 25% of all HCV infections.
*More common in north Africa and Middle East
[Order of wealth]
How many untreated would go on to develop chronic HCV infection? How many develop complications?
80%
20% develop complications by 20 years - Cirrhosis / HCC
HCV Dx? Rx example drugs?
HCV RNA - early infection
HCV antibodies appear after 12 weeks
All should get - Direct acting antivirals
Eg Sofosbuvir + velpatasvir or other -tasvir drugs
Monitoring in HCV
US / AFP every 6m for HCC
Check HCV RNA 12 weeks following Rx to see sustained virological response
Combination of which respiratory pathogens is particularly bad for old people?
Influenza (which gets rid of the bronchial lining)
followed by strep pneumonia
Name 2 flu treatments
M2 ion channel blockers
- (amantadine, rimantidine)
Neuraminidase inhibitors
- oseltamivir (Tamiflu ™
- zanamivir (Relenza ™) inhaled or IV
- peramivir (Rapivab ™) IV
- Laninimuvir (long-acting inhaled Japan only)
Intrahepatic cholestasis leads to what hyperbilirubinaemia
Conjugated
Erythrocyte destruction leads to which type of jaundice
Unconjugated
72yo from Anta (close to Cusco)
Presents with 3 days of acute onset severe epigastric pain, mild fever. No PMHx. Good diet. No ETOH.
Physical exam: Jaundice, tender epigastric abdominal pain
WBC 12,200 (70% PMNs, 2% eos)
Tbili 3.8, Dbili 2.8
Alk Phosh elevated x5; Amylase x10, ALT x2 upper limit of normal
CT /ERCP: pancreatitis and filling defect
DDx of biliary obstruction with eosinophilia?
Which if no eosinophilia in HIV?
Nematodes (Ascaris)
Trematodes (Clonorchis, Opstorchis, fasciola)
Echinococcus (only because of the size)
Protozoans (cryptosporidium parvum associated with cholangiopathy in immunosuppressed HIV patient
Which liver fluke in?
- China, Japan, Korea, Taiwan, Vietnam
- China, Laos, Thailand, Vietnam, Cambodia, Myanmar
- Europe
- World wide (especially Peru and bolivia)
Clonorchis sinensis: China, Japan, Korea, Taiwan, Vietnam
opistorchis Viverrini: China, Laos, Thailand, Vitnam, Cambodia, Myanmar
Opistorchis Felineus: Southeast asia, cenetral and eastern Europe
Fasciola hepatica:
61 year old male from Iquitos, 7 days of fever, generalized muscle pain, jaundice; works as logger no insect repellent, eats at local market, goes swimming in the pool
Physical exam with febrile, tachycardia; muscle pain, hepatomegaly; Jaundice
Lab workup: Hgb 9.8, WBC 13, 94,000 Plt, Tbili 18 (9.6 direct); ALT 72, Alk phosph 150; CPK 4x ULN, Creatinine 8.2
Dx? Confirm with? Rx?
Ddx?
Myositis + Hepatic involvement + renal involvement =
leptospirosis
-PCR for early or urine for late disease (after the first week)
-Serology (usually after first week Ab will be detectable
Rx - Doxy / azithro for mild
-Ceftriaxone for severe
[ddx: Malaria (severe malaria) v. hepatitis (severe viral) v. Severe leptospirosis v. yellow fever (consider hemorrhagic) v. dengue (doesn’t quite fit) v. visceral leish]
Liver biopsy shows:
Councilman bodies: hepatocytes with eosinophilic degeneration
Yellow fever
[Acute viral hepatitis / other viral syndromes]
hemolytic anaemia with unconjugated bilirubinemia
ddx?
DDx of intravascular hemolysis:
severe dengue v. typhoid v. malaria v. bartonella v. visceral leish
-Malaria
-Bartonellosis
-C. Perfrinens
-Babesia
73yoM with 16 days of abdominal pain
-Diffuse, then right upper quadrant pain< associated with high fever, chills, jaundice 12 days prior to admission, then vomiting and worsening abdominal pain
-From Pucallpa (Central amazon)
Physical exam: afebrile, jaundice, liver 3cm below R costal margin, no splenomegaly
Hgb 10.6, WBC 14200 84% PMNs, no eos, plt normal
ALT 56, Alkphosph 395, bilirubin 7.6 (direct 4.8), protein 5.8
Most likely?
dx?
rx?
obstructive cholestasis picture : Amoebic abscess
-Usually diagnosed by serology (only really from stool, not from the fluid from the liver abscess)
Metronidazole + paramomycin
Kwy things in your DDX when
Hemolysis:
Biliary obstruction:
Intrahepatic cholestasis: With raised bili
Hepatocellular injury with transminase >bili?
Hemolsysis: Think of viruses (intraerythrocytic pathogens)
Biliary obstruction: Think of trematodes
Intrahepatic cholestasis: think of bacterial-lepto (LFTs are not as elevated as Bili), Brucella, Typhoid fever (severe clinical presentation) TB (miliary dissemination), Pyogenic/Amebic liver abscess
Hepatocellular injury: Think of yellow fever (transaminase>bili)
Bartonella baciliformis vector?
Lutzomyia
HBV - when do antibodies become detectable? How many people develop Sx?
Progression to chronic?
After 4-6 weeks
Approx 1/3 develop Sx
*90% of infants <1 year
*30% of children aged 1-5 y
*5-10% of adults
How do define chronic HepB? how many get complications?
detection of HBsAg on 2 occasions measured 6 months apart
25% - HCC or cirrhosis
Interpretation of HBsAg, Anti-HBs, Anti-HBc, HBV DNA
Active infection? resolved infection?
Immunity?
Extra-hepatic HBV
Polyarteritis nodosa
Membranous glomerulonephritis
Membranoproliferative glomerulonephritis
Aplastic anaemia
Vasculitis
Why might Anti-HBc be the only one positive in HepB panel
There is a window period of a couple weeks
Assess cirrhosis without a fibro scan - eg resource-poor
AST to platelet ratio index
>2 = cirrhosis
[((AST/AST ULN) / Platelet count)
x 100]
HDV - what does it cause? Rx?
HDV superinfection with HBV
-More likely fulfilment hepatitis in acute infection
-Chronic HDV leads to severe and progressive chronic hepatitis with a high rate of cirrhosis
-Suppresses HBV
It can be cured by either
-Curing HBV
- Pegylated interferon - acts on HDV (NRTIs don’t)
61
7 day history of fever, diffuse myalgia, dyspnea, jaundice and several episodes of hemoptysis
Swims in a non authorized pool
Marked jaundice, bilateral rales in both lung fields
WBC: 13,100 with left shift
platelets: 93,000
total bilirubin: 18 mg/dl (10 direct)
ALT 42 IU/L (<40)
creatinine: 7 mg/dl; BUN 339 (<20)
Dx?
Leptospirosis
Ceftriaxone
51M
with 8 month history of fever, cough, weight loss, painful oral lesions
Poor farmer in the high jungle of Peru
Heavy smoker and drinker
Painful oral lesions with easy bleeding dots, cervical adenopathies, bilateral pulmonary rales
Paracoccidioidomycosis
26
2 month history of fever, dry cough, progressive dyspnea, and weight loss of 10Kg
Born in the high jungle of Colombia
HIV not on ART; CD4 23 cells/mm
Wasted; cervical adenopathies, diffuse rales in both lungs, organomegaly
WBC: 2,100 with marked lymphopenia;
platelets: 93,000, Hb 8 g/dl
LDH 1200 U/L (<150)
Histoplasmosis
Amphotericin B followed by itraconazole
42M,
2 year history of fever, dry cough, several episodes of hemoptysis
Started TB treatment 2 months ago
Born in the highlands of Cajamarca, Peru
School teacher; no travel history
Normal physical examination
WBC: 6,100 with 10% eosinophils
Multiple negative studies including ZN stain, Xpert MTB/RIF, KOH, Gram stain and cultures
Paragonimiasis
praziquantel
32M
2 day history of fever, cough, progressive dyspnea, pleuritic chest pain and several episodes of hemoptysis
Lives in the rural highlands of Peru
BP 70/35. HR 122, resp 28, 89%StHb
WBC: 26,100 with 10% bands
A Gram negative rod identified in the sputum
Yersinia pestis
Gent + cipro / doxy
[Streptomycin + fluorquinolone]
45M
4 day history of fever, cough, pleuritic chest pain, myalgia
Contact with farm animals in French Guiana
BP 120/85, HR 92, resp 24, 94%StHb
WBC: 8,100 with no bands, 100,000 platelets
ALT 250 U/l (<40)
Negative blood cultures
Coxiella burnetii
Doxycycline
Q fever acute vs chronic
Acute (pneumonia, hepatitis)
-usually mild pneumonia
- involvement may be lobar, segmental, or patchy
-opacities may be oval, wedge shaped, perihilar, or round
-round opacities may be more frequent than in other types of pneumonia
chronic (endocarditis, osteomyelitis, FUO)
Asymptomatic
Raised eosinophils
Dirofilaria immitis (dogs; coin nodule)
-dog heartworm
Clinical diagnosis; surgical excision
55F
2 day history of fever, shaking chills, severe headache, dyspnea
Mother and sister died of lymphoma
PMx intermittent diarrhea for last 2 years
Febrile, no rash, + ve meningeal signs
WBC: 19,100, no eosinophils
CSF: 1000 WBC, 90% PMNs, low glucose
E. coli isolated from blood and CSF
Strongyloides stercolis Hyperinfection syndrome; disseminated disease
Ivermectin
