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1
Q

Primary TB

A

 Organism multiples at pleural surface = Ghon focus
 Macrophages take TB to LNs, which with lesion is known as Ghon complex
 Fibrosis of Ghon complex –> calcified nodule (Ranke complex)
 Usually asymptomatic
 Rarely in immunocompromised pts progresses to primary progressive TB

Primary progressive:
 resembles acute infxn with mid and lower zone consolidation, effusions and bihi lymphad
 Lymphohaematogenous spread → milliary TB (diffuse seeding of TB in lung) and extra-pulmonary

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2
Q

Latent and secondary TB

A

Latent TB:
 Infected but no clinical or x-ray signs of active TB, pt is non-infectious
 weakened host resistance leads to reactivation

Secondary TB:
 reactivation from weakened immune system or reinfxn
 typically develops in upper lobes and have cavitation with caseating granulomas

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3
Q

Extrapulmonary TB features

A

 CNS –> meningism with papilloedema and CN palsy (Rx = RIPE 2 months–>RI 10 mo +/- dexamethasone)
 GU –> sterile pyuria and symptoms of UTI
 LN –>Firm, painless lesions (scrofula) that eventually ulcerate with a granular base with no sign of infxn
 skin –> lupus vulgaris (apple-jelly nodules)
 adrenals –> addison’s

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4
Q

Ix for TB

A

 Latent TB: tuberculin skin test; if +ve then interferon gamma release assay (IGRA)
 NB tuberculin skin test can give false -ve with HIV, sarcoid and lymphoma

 Active TB: CXR showing upper lobe caviting lesions –> take 3 sputum samples (or BAL) and use Lowenstein-Jensen culture + Ziehl Neelsen stain

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5
Q

RIPE SE

A

R: orange urine (+hepatitis)
I: peripheral neuropathy (+hepatitis)
P: hepatitis (C/I: gout, porphyria)
E: optic neuritis

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6
Q

Other mycobacterium

A

 Leprosy / Hansen’s disease
 Mycobacterium avium-intracellulare - complicates HIV infxn with wide dissemination in lungs and hepatomegaly
 M. ulcerans - Buruli ulcer from initial nodule in Australia
 M. marinum - Fish tank granuloma

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7
Q

Leprosy

A

Tuberculoid
 Less severe
 TH1-mediated control of bacteria → paucibacillary  Anaesthetic hypopigmented macules
 Rx = 6 months Rif monthly and clofazamine daily

Lepromatous
 Weak TH1/2 → multibacillary
 Skin nodules
 Nerve damage (esp. ulnar and peroneal)
 Rx = 2 years Rif monthly clofazamine + dapsone daily
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8
Q

Reyes syndrome

A

rash, vomiting, ↑LFTs in children recovering from influenza and linked to them being given aspirin

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9
Q

Rx for influenza

A

Bed rest and paracetamol

If severe:
 Mx in ITU
 Cipro and co-amoxiclav: prevent Staph and Strep

High risk patients:
 Oseltamivir if >1yr with symptoms of <48hr. Can also be use as prophylactic
 Zanamivir if >5yrs with symptoms <48h

Trivalent vaccine for:
 >65yrs
 DM, COPD, heart, renal, liver failure
 Immunosuppression: splenectomy, steroids
 Medical staff
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10
Q

HIV effects

A

 Osteoporosis
 Dementia
 Neuropathy
 Nephropathy

AIDS-related complex (ARC) = AIDS prodrome  with FLAWS + minor opportunistic infxns e.g:
 Oral candida
 Oral hairy leukoplakia (EBV) 
 Recurrent HSV
 Seborrhoeic dermatitis
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11
Q

HIV Ix:

A

 ELISA: detect serum (or salivary) anti-HIV Abs
 Western Blot: for confirmation
 If recent exposure, may be window period; usually 1-3wks but can be 3-6mo
 PCR: can detect HIV virions in the window period
 Rapid Antibody Tests: false positives are a problem and results should be confirmed by Western Blot

Once HIV confirmed:
 CD4 count (<350 is indication for Rx)
 viral load
 Perform Mantoux test and serology for toxo, CMV, HBV, HCV, syphilis

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12
Q

HAART indications and regimes

A 
Indications
 CD4 ≤350
 AIDS-defining illness
 Pregnancy
 HIVAN (associated nephropathy)
 Co-infected with HBV when Rx is indicated for HBV

Regimens
1 NNRTI + 2 NRTIs
 NNRTI = Efavirenz
 NRTI = emtricitabine + tenofovir (Truvada)
 Atripla = efavirenz + emtricitabine + tenofovir
PI + 2 NRTIs
 PI = lopinavir (+ low dose ritonavir = Kaletra)

NB PEP = truvada + Kaletra, continue at least 28 days

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13
Q

Major AIDS illnesses

A

4Cs 2Ps 2Ts KLM:
 Candidiasis: oesophageal or pulmonary
 Cryptococcal meningitis - halo on india ink CSF stain
 Cryptosporidiosis - chronic diarrhoea
 CMV retinitis - pizza sign on fundoscopy
 Kapsosi sarcoma - HHV8
 Lymphoma: Burkitt’s, 1O brain
 MAC - disseminated lung infxn
 PCP - bilat perihilar interstitial shadowing with dry cough and exertional dyspnoea
 PML
 Toxo - ring-shaped contrast enhancing lesion with encephalitis
 TB - may have false -ve in tests; also absence of characteristic granuloma (as no immune response). Increasing CD4 paradoxically worsens TB symptoms

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14
Q

Progressive multifocal leukoencephalopathy

A

Demyelinating inflammation of brain white matter
caused by JC virus.

Presentation
 Weakness
 Paralysis
 Visual loss
 Cognitive decline

Ix: JC viral PCR

Rx: HAART + mefloquine may halt progression

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15
Q

Toxoplasmosis Rx + prophylaxis:

A

ring-shaped contrast enhancing lesions

Rx: pyrimethamine + sulfadiazine + folate

Prophylaxis: Co-trimoxazole if CD4 <100 = lifelong 2ndary prophylaxis

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16
Q

Kaposi’s sarcoma Rx

A

 HAART

 Radiotherapy or chemotherapy

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17
Q

PCP Rx + prophylaxis:

A

Rx
 High-dose co-trimoxazole IV
 Or, pentamidine IVI
 Prednisolone if severe hypoxaemia

Prophylaxis
 Co-trimoxazole if CD4 <200 or after 1st attack

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18
Q

Cryptococcal meningitis Rx:

A

Amphotericin B + flucytosine for 2wks then fluconazole for for 6mo / until CD4 >200

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19
Q

CMV retinitis Rx

A

IV ganciclovir or eye implant of intravitreous ganciclovir

Owl’s eye inclusions seen

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20
Q

Herpes Encephalitis

A 
90% HSV-1, 10% HSV-2
Features:
Flu-like prodrome
Headache
focal neuro e.g. fits, odd behaviour
↓GCS
Haemorrhagic necrosis of temporal lobes
Rx: IV aciclovir
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21
Q

Mollaret’s Meningitis

A

HSV-2 mostly
Benign recurrent aseptic meningitis
Rx = IV aciclovir

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22
Q

Herpes Gladiatorum

A

Rugby players, wrestlers
Features:
Painful vesicular rash, lymphadenopathy, fever
Rx = PO aciclovir

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23
Q

Herpetic Whitlow

A

Healthcare workers, children
Features:
Painful red finger
Rx = topical aciclovir

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24
Q

Elseberg syndrome

A

genital herpes leading to sacral radiculomyelitis = urinary retention + sacral sensory loss

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25
Q

Herpetic keratitis

A

Unilat/bilat conjunctivitis + pre-auricular LNs

May cause a corneal ulcer = dendritic ulcer

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26
Q

Ramsay hunt syndrome

A

ear herpes zoster, facial palsy, ↓ taste, ↓ hearing

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27
Q

Varicella zoster Dx

A

Tzanck cells seen from scrapings

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28
Q

EBV Ix

A

+ve heterophile Ab - either paul bunnell or monospot test

Atypical lymphocytes seen

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29
Q

Burkitt’s lymphoma Ix

A

Starry-sky appearance CD10, BCL6

t(8;14)

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30
Q

Post-transplant lymphoproliferative disorder

A

EBV associated lymphoma post solid organ transplant

Rx: rituximab

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31
Q

Oral hairy leukoplakia

A

Painless shaggy white plaque along lateral tongue border in HIV +ve pts
Rx = aciclovir

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32
Q

Hep B Ix

A

 HBsAg +ve = current infection (+ve >6mo = chronic disease)
 HBeAg +ve = high infectivity
 Anti-HBc IgM = recent infection
 Anti-HBc IgG = past infection
 Anti-HBs = cleared infection or vaccinated
 HBV PCR: monitoring response to Rx
NB chronic infxn in 5%; can get cryoglobulinaemina

33
Q

Hep B Rx

A

Chronic disease: PEGinterferon α2b

34
Q

Hep C Rx

A

Indications
 Chronic haepatitis
 ↑ ALT
 Fibrosis

Rx = PEGinterferon α2b + ribavirin. ↓ efficacy if:
 Genotype 1, 4, 5 or 6
 ↑ VL
 Older
 Black
 Male
35
Q

Hep D Ix

A

anti-HDV Ab

36
Q

Campyelobacter jejuni

A

Unpasterised milk or animal feces

Features:
Bloody diarrohoea, fever
Guillain-Barre (ascending paralysis)
Reactive arthritis

Rx: cipro

37
Q

Listeria

A

Soft cheese / pates

Features:
Watery diarrhoea, cramps, flu-like
Pneumonia
Meningoencephalitis
Miscarriage

Rx: ampicillin

38
Q

C. botulinum

A

Canned food:
Kids = honey
students = beans

Features:
Afebrile
Descending symmetric flaccid paralysis
No sensory signs
Autonomic: dry mouth, fixed dilated pupils

Rx = antitoxin, benpen + metro

39
Q

C. perfringes

A

Reheated meat

Features:
watery diarrhoea + cramps

Rx = benpen + metro

40
Q

Norovirus

A

commonest causes in adults

Fever, diarrhoea, projectile vomiting

41
Q

Rotavirus

A

commonest cause in children

secretory diarrhoea and vomiting

42
Q

Typhoid Rx

A

Cefotaxime or cipro

43
Q

Yersinia entero

A

Abdo pain, diarrhoea, fever
Mesenteric adenitis
Reactive arthritis, pharyngitis, pericarditis Erythema Nodosum
Rx = cipro

44
Q

Entamaeoba histolytica

A

MSM or travellers

Features
Dysentery, wind, tenesmus
Wt. loss if chronic
Liver abscess
- RUQ pain, swinging fever, sweats
- Mass in R lobe
Flask shaped ulcer on histology
- Micro = motile trophozoite with 4 nuclei

Rx = metro or tinidazole if abscess or severe

45
Q

Giardia Rx

A

Tinidazole

46
Q

Jarisch-Herxheimer Reaction

A

hours after 1st pen dose for syphillis get fever, tachy and vasodilation
Rx = steroids

47
Q

LGV

A

Chlamydia L1,2,3
Primary stage:
- painless genital ulcer, heals fast
- balanitis, proctitis, cervicitis

Inguinal Syndrome:
- Painful inguinal buboes
- Fever, malaise
→ genital elephantiasis

Anogenitorectal syndrome:
- Proctocolitis
→ Rectal strictures
→ Abscesses and fistulae

Rx = azithromycin/doxy

48
Q

Gonorrhoea Rx

A

IM ceftriaxone + azithromycin for chlam

49
Q

Granuloma inguinale

A

Painless beefy-red ulcer from klebsiella

Shows donovan bodies on giemsa stain

Rx = erythromycin

50
Q

Chancroid

A

H. ducreyi

Painful ulcer progressing to inguinal buboes

Rx: azithromycin

51
Q

Argyll-Robertson pupil

A

accomodates but doesn’t react to light

52
Q

Tabes dorsalis

A

 Degeneration of sensory neurones, esp. legs
 Ataxia and +ve Romberg’s
 Areflexia
 Plantars ↑↑
 Charcot’s joints (occurs in DM as well)

53
Q

Syphillis Ix

A

Cardiolipin Ab on VDRL or RPR (not specific)

Treponeme specific Ab via THPA and FTA (remains +ve after Rx)

Treponemes can be seen by dark ground microscopy

54
Q

Leptospirosis (Weil’s disease)

A

Infected rat urine

Presentation:
High fever, headache, myalgia / myositis, cough, chest pain ± haemoptysis
± hepatitis with jaundice
± meningitis

Rx = doxycycline

55
Q

Brucellosis

A

Unpasteurised milk/cheese

Undulant fever (PUO) which peaks PM and normal AM

Ix: pancytopenia with positive rose bengal test and anti-O-polysaccharide Ag

Rx: doxy + Rifam + gent

56
Q

Cat scratch disease

A

Tender regional LN

Rx = azithromycin

57
Q

Rabies

A

Bullet-shaped RNA virus and negri bodies

Rx
Immunised = diploid vaccine
Unimmunised = vaccine + rabies Ig

58
Q

Toxoplasmosis Rx

A

Pyrimethamine + sulfadiazine

Septrin prohylaxis in HIV

59
Q

Anthrax features

A

Spread by infected carcasses or hides

Features
Ulcer with BLACK centre and rim of oedema

60
Q

Anthrax Ix and Rx

A

Gram +ve spore forming rod

Rx = cipro + clindamycina

61
Q

Antimalarial SE

A

 Chloroquine: retinopathy
 Fansidar: SJS, ↑LFTs, blood dyscrasias
 Primaquine: haemolysis if G6PD deficient
 Malarone: abdo pain, nausea, headache
 Mefloquine: dysphoria, neuropsychiatric signs

62
Q

Uncomplicated Ovale, Vivax and Malariae Mx

A

Chloroquine and primaquine

63
Q

Uncomplicated falciparum Mx

A

Artemether-lumefantrine (riamet)
OR
Quinine + Doxy

64
Q

Severe Falciparum Mx

A

 Need ITU Mx

 IV antimalarials

65
Q

Falciparum Complications

A 
 Cerebral malaria: confusion, coma, fits
 Lactic acidosis → Kussmaul respiration
 Hypoglycaemia
 Acute renal failure: 2O to ATN
 ARDS
66
Q

Malaria Ix

A 
 Serial thick and thin blood films
 Parasitaemia level
 FBC: anaemia, thrombocytopenia
 Clotting: DIC
 Glucose
 ABG: lactic acidosis
 U+E: renal failure
 Urinalysis: haemoglobionuria
67
Q

African Trypanosomiasis

Sleeping sickness

A

Tsetse fly
T. gambiense: West Africa
T. rhodesiense: East Africa
- More severe than gambiense

Posterior cervical nodes (Winterbottom’s sign)

Sleeping sickness occurs months after original infxn

68
Q

American Trypanosomiasis

Chagas Disease

A 
Reduviids fly:
T. cruzi
- Erythematous nodule, fever, LN, HSM
- Swelling of eyelid (Romana’s Sign)
- Cardiac disease
69
Q

Leishmaniasis

A

Sandflies:

 Cutaneous (Major, tropica)
 Mucocutaneous (Braziliensis)
 Visceral / Kala Azar (Donovani)

70
Q

Kala Azar

A

L Donovani

Features:

  • Dry, warty hyperpigmented skin lesions (dark face and hands)
  • Prolonged fever
  • Massive splenomegaly, LNs, abdo pain

Visualisation of Leishman-Donovan bodies on Ix and pancytopenia

71
Q

Mucocutaneous leish

A

Ulcer in mucous mems of mouth and nose

72
Q

Cutaneous leish

A

skin ulcer @ bite → depigmented scar

Widespread nodules (fail to ulcerate)

73
Q

Filariasis

A

Wuchereria bancrofti

Elephantiasis
Ix:
Eosinophilia
Microfilariae in the blood

74
Q

Dengue Fever Ix

A

Tourniquet test
Serology

can exclude if fever starts >2wks after leaving endemic area

75
Q

Schistosomiasis

A

Itchy papular rash at site of penetration - Swimmer’s Itch

76
Q

Schistosomiasis Mansoni

A
  • abdo pain D&V
  • later hepatic fibrosis and portal HTN
  • HSM
77
Q

Schistosomiasis Haematobium

A
  • frequency, dysuria, haematuria
  • may → hydronephrosis and renal failure
  • ↑ risk of bladder SCC
78
Q

Tetanus Rx

A

 Mx on ITU: may need intubation
 Human tetanus Ig
 Metronidazole, benpen

79
Q

Actinomycosis Rx

A

ampicillin for 30d, then pen V for 100d

From subcut infxn (esp on jaw)

Finals PACES (12 decks)

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