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ID Flashcards

1
Q

Definition of HIV Treatment failure

A

Viral load persistently >200 copies/ml after 24 weeks of Tx
Confirmed on 2nd test within 3-6 months
Adherence support between measurements

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2
Q

• Non-tuberculous mycobacterial (NTM) infection

-insidious, with a chronic cough usually productive of purulent sputum

A

MAC (Mycobacterium Avium Complex)

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3
Q

PJP prophylaxis in HIV

A

CD4 count <200

Bactrim daily

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4
Q

Toxo prophylaxis in HIV

A

CD4 count <200 and positive serology

Bactrim double strength daily

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5
Q

MAC prophylaxis in HIV

A

CD4 <50

Azithromycin 1g weekly or clarithromycin BD

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6
Q

Latent TB in HIV

A

TST >5 mm or positive IGRA

Isoniazid with pyridoxine for 9 months

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7
Q

HIV Transmission Risk factors for seroconversion in needlesticks

A

o Patient with untreated HIV and high viral load
o Deep injury (Odds ratio 15)
o Device visibly contaminated with patient’s blood (Odds ratio 6.2)
o Needle placement in a vein or artery (Odds Ratio 4.3)
o Terminal Illness in the source patient (Odds ratio 5.6)

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8
Q

Timing of PEP and duration

A

Within 1-2 hours of exposure up to 72 hours for most effect, but can be up to one week post exposure
Duration: 4 weeks

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9
Q

PEP Regimen

A

 Tenofovir DF + Emtricitabine + Dolutegravir

 Tenofovir DF + Emtricitabine + Raltegravir

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10
Q

Abacavir Hypersensitivity Gene - SJS

A

HLA B5701

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11
Q

Dolutegravir in pregnancy?

A

Safe in pregnancy as per WHO study in July 2019

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12
Q

Glycoproteins on HIV virus that aid its entry into CD4 T cells and macrophages

A

GP120, GP41, P24 antigen (viral capsid protein - can also be used to test for early detection)

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13
Q

Coreceptors on CD4 T cells HIV uses for cell entry

A

CCR5 and CXCR4

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14
Q

HIV Incubation period

A

2-4 weeks, up to 10 months

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15
Q

HIV Seroconversion Sx

A

Can be asymptomatic
Constitutional symptoms – Fever, fatigue, myalgia
Adenopathy – occasional hepatosplenomegaly
Sore throat
Mucocutaneous ulceration
Generalised rash
Headache – retro-orbital pain
Rarely - opportunistic infection - candidiasis

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16
Q

Protective mutation against HIV

A

CCR5 delta 32 mutation - no CCR5 expression on T cell

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17
Q

HIV Diagnosis testing

A
  • 1st-3rd generation - HIV antibody only
  • 4th generation – HIV antibody + HIV p24 antigen (can be detected 1-2 weeks after virus exposure)
  • -4th generation >99% sensitivity and specificity for chronic infection
  • -Only 80-90% for acute HIV
  • -If suspecting acute HIV should also test HIV RNA as routine
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18
Q

NRTIs (Names)

A

nucleoside reverse transcriptase inhibitors (NRTIs)

Tenofovir 
-disoproxil fumarate(TDF)
-alafenamide(TAF)
Abacavir (ABC)
Zidovudine (ZDV/AZT)
Emtricitabine (FTC)
Lamivudine (3TC)
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19
Q

NNRTIs (Names)

A

non-nucleoside reverse transcriptase inhibitor

Efavirenz (EFV)
Nevirapine (NVP)
Rilpivirine
Etravirine

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20
Q

PIs (Names)

A

Protease Inhibitors (PIs): “Navirs”

Atazanavir (ATV)
Darunavir
Lopinavir (LPV)
Ritonavir (RTV)

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21
Q

ISTIs (Names)

A

Integrase Strand Transfer Inhibitors (ISTIs): “Gravirs”

Raltegravir
Elvitegravir
Dolutegravir
*Bictegravir- licenced 2018

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22
Q

Entry Inhibitors

A

Maraviroc

Enfuvirtide

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23
Q

HIV Treatment Regimes

A

Usually 2 NRTIs and one other class.

Commonly:

  • Raltegravir / tenofovir/emtricitabine
  • Dolutegravir /tenofovir/emtricitabine
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24
Q

NRTI MOA

A

Mechanism: Inhibit viral replication through competitive binding to reverse transcriptase

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25
Q

NRTIs active against Hep B

A

Tenofovir, lamivudine and emtricitabine

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26
Q

NRTI SE

A

Side effects – historically MITOCHONDRIAL TOXICITY
Peripheral neuropathy, pancreatitis, lipoatrophy and hepatic steatosis
Now uncommon with current NRTIs

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27
Q

TAF interaction with rifampicin

A

reduces level of tenofovir

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28
Q

TDF Side effects

A

Renal failure: Characterised by raised creatinine, proteinuria, glycosuria, hypophosphatemia, and acute tubular necrosis – FANCONI syndrome – proximal renal tubular acidosis. Caution if eGFR <60
Bone loss - decreased bone mineral density - usually stabilizes with continued use

TAF – less toxicity than TDF

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29
Q

Abacavir SEs

A

Hypersensitivity reaction

May worsen CAD

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30
Q

Lamivudine SE

A

Pancreatitis

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31
Q

Emtricitabine SE

A

skin discolouration usually as hyperpigmentation on palms and/or soles

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32
Q

NNRTI MOA

A

Mechanism: different separate from target site of NRTIs. Bind to a hydrophobic pocket causes a stereochemical change in the protein, which reduces the ability of naturally occurring nucleosides to bind to the active site pocket

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33
Q

Efavirenz SE

A

Potent inducer of hepatic cytochrome P450
CNS toxicity, psychiatric – vivid dreams, confusion, dizziness
QTc prolongation
Elevated hepatic transaminases

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34
Q

PIs MOA

A

Competitively inhibit the cleavage of the Gag-Pol polyproteins in HIV-infected cells
Production of immature virions – non-infectious

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35
Q

What should be administered with a PI?

A

Should be administered with a pharmokinetic booster: Ritonavir or cobicistat

Increases trough plasma drug concentrations, and maximum plasma concentrations
Enables lower and less frequent dosing of the parent drug=decreasing pill burden

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36
Q

PI SEs

A

Nausea, diarrhoea!

Insulin resistance, hyperglycemia, diabetes, hyperlipidemia, lipodystrophy, hepatotoxicity

Interactions: Rifampicin!

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37
Q

ISTIs MOA

A

Integrase enzyme catalyzes the process by which viral DNA is integrated into the genome of the host cell
Target the strand transfer step of viral DNA integration
Prevent or inhibit the binding of the pre-integration complex (PIC) to host cell DNA

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38
Q

M184V mutation

A

HIV mutation often the first to appear.

REsistance to lamivudine and emtricitabine, BUT hypersusceptibility to TDF/TAF

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39
Q

IRIS definition

A

Collection of inflammatory disorders associated with paradoxical worsening of pre-existing infectious processes following the initiation of antiretroviral therapy (ART) in HIV-infected individuals

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40
Q

Crusted Scabies occurs in which populations

A

AIDS, human T cell lymphotropic virus type 1 (HTLV-1) infection, leprosy, and lymphoma

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41
Q

Treatment of Scabies

A

Topical permethrin and oral ivermectin

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42
Q

MOA Permethrin

A

Topical synthetic pyrethroid agent that impairs function of voltage-gated sodium channels in insects, leading to disruption of neurotransmission

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43
Q

Cause of Neurocystiercosis

A

Taenia solium -Pig tapeworm

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44
Q

How does IGRA work

A

IGRAs are in vitro assays that measure T-cell release of interferon-γ in response to stimulation with highly tuberculosis-specific antigens ESAT-6 and CFP-10 (QuantiFERON-TB Gold In-Tube and T-SPOT TB test).

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45
Q

Factors that increase the risk of developing active TB

A 
HIV
Immunosuppression
Genetic factors
Smoking 
Vit D deficiency
Diabetes/renal impairment
Low BMI
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46
Q

Which immune cells are involved in forming a TB granuloma

A

T cells and macrophages

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47
Q

Limitations of Tuberculin skin testing

A
  • Responses nor read
  • Inaccuracy of measuring induration
  • False positives due to sensitisation with related bacteria (BCG vaccine)
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48
Q

IGRA Specificity and Sensitivity

A
  • QFT: High Specificity: 96-100%

- QFT: Sensitivity: 80-85%

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49
Q

IGRA limitations

A

o Does not differentiate between latent and active TB
o May remain positive after successful treatment
o Negative IGRA does not exclude active TB

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50
Q

TB in CSF findings

A

– Lymphocytic pleocytosis, low glucose (DDX Cryptococcal meningitis)

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51
Q

o Recommendations for commencing ART in patients with TB

A

Risk of IRIS
 If CD4 < 50 – Early ART (<2 weeks)
 If CD4 > 50 then ART by 8 weeks after starting TB therapy

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52
Q

Treatment for TB meningitis

A

HRZM (moxifloxacin better than Ethambutol) 9-12 months

Dex reduces mortality

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53
Q

Standard TB treatment

A

 2HRZE/4HR = 98% Cure
 (H) Isoniazid – Most helpful with initial fast multiplying TB
 (R)Rifampicin – Usually daily therapy, but can be 3-5 x/wk; most effective on resistors (TB bugs that are hard to kill)
 (Z) Pyrazinamide – Slow multiplying TB – works in acidic environments
• If not used then therapy is for 9 months instead of 6 months
 (E)Ethambutol

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54
Q

Isoniazid SEs

A

 Hepatitis, rash, neuropathy

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55
Q

Rifampicin SEs

A

 Drug interactions, hepatitis

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56
Q

Pyrazinamide SEs

A

 Hepatitis, skin, joint (gout)

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57
Q

Ethambutol SEs

A

 Optic Neuropathy

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58
Q

Order of TB drugs that cause the most hepatitis

A

o Pyrazinamide >Isoniazid&raquo_space;Rifampicin

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59
Q

Mx of TB drugs in setting of derranged LFTs

A

o If 2-5x normal + asymptomatic = monitor closely

o If >5x normal or >3 x and symptoms = cease

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60
Q

Most common mono-drug resistance in TB?

A

Isoniazid

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61
Q

MDR TB definition

A

Resistance to INH + RIF +/- any other resistance

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62
Q

XDR TB definition

A

MDR TB + resistance to quinolones and injectables (1 of amikacin, kanamycin, or capreomycin)

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63
Q
  • fever
  • cough/coryzal Sx
  • Conjunctivitis
  • Koplik’s spots (bluish green elevations in buccal mucosa)
  • erythematous, maculopapular, blanching rash, which classically begins on the face and spreads cephalocaudally and centrifugally to involve the neck, upper trunk, lower trunk, and extremities
A

Measles

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64
Q

Incubation period for Typhoid

A

1-2 weeks

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65
Q

Clinical features of typhoid

A
  • rising (“stepwise”) fever and bacteremia
  • “rose spots” (faint salmon-colored macules on the trunk and abdomen)
  • fever with headache, arthralgia, myalgia, pharyngitis, and anorexia
  • hepatosplenomegaly, intestinal bleeding, and perforation due to ileocecal lymphatic hyperplasia of the Peyer’s patches
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66
Q

Incubation period of Dengue

A

3-14 days; Sx typically 4-7 days after transmission

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67
Q

Diagnosis of Dengue with warning signs

A

Diagnosis made as defined in previous column + any one of the following:

  • Abdominal pain/tenderness
  • Persistent vomiting
  • Clinical fluid accumulation (ascites/pleural effusion)
  • Mucosal bleeding
  • Lethargy/restlessness
  • Hepatomegaly >2 cm
  • Increase in haematocrit concurrent with rapid decrease in platelet count
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68
Q

Diagnosis of Dengue without warning signs

A

Diagnosis made in the setting of travel to endemic area + fever + 2 of the following:

  • N+V
  • Rash
  • Headache, eye pain, muscle ache, or joint pain
  • Leukopenia
  • Positive tourniquet test (Tourniquet inflated midway between sys and dys BPs for 5 mins and skin below is examined 1-2 mins post deflation – if 10 or more new petechiae in one sq inch, it is positive
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69
Q

Diagnosis of severe Dengue

A

Diagnosis made as defined in previous column + at least one of the following:

  • Severe plasma leakage leading to shock or fluid accumulation with resp distress
  • Severe bleeding
  • Severe organ involvement (AST or ALT >1000 units/L; Impaired consciousness; organ failure
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70
Q

What time period of symptoms should you monitor for warning signs

A

Day 3-7

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71
Q

What is the critical phase of dengue

A

o Present in Dengue Hemorrhagic fever and Dengue Shock Syndrome, but not Dengue Fever
o Involves systemic plasma leakage, bleeding, shock, and organ impairment
o Lasts for 24-48 hours
o Initially have adequate circulation, but then compensation occurs with pulse pressure narrowing
o Moderate to severe thrombocytopenia may occur with a nadir of platelets <20, which improves rapidly in the recovery phase

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72
Q

What is a clinical feature of entering the convalescent phase Dengue

A

“WHITE ISLANDS IN THE SEA OF RED”

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73
Q

Diagnosis of Dengue

A

Reverse transcriptase PCR (positive in first 5 days of illness)

NS1 (Viral antigen nonstructural protein 1) - positive in first 5 days

Dengue Serology - IgM dectected as early as 4 days after onset

  • Primary: IgG up in 7 days
  • Secondary: IgG in 4 days
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74
Q

Fever in Returned Traveller Incubation <10 Days

A 
Dengue
Influenza
Yellow fever
Chikungunya
Plague
Paratyphoid fevers
Legionella
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75
Q

Fever in Returned Traveller Incubation up to 21 days

A 
Malaria
Viral haemorrhagic fever
Q fever
African trypanosomiasis
Typhoid fever
Brucellosis
Leptospirosis
Relapsing Fever
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76
Q

Fever in Returned Traveller Incubation > 21 days

A 
Malaria
Viral hepatitis
HIV
Rabies
Visceral leishmaniasis
Amoebic liver abscess
Filariasis
TB
Q Fever
Acute schistosomiasis
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77
Q

Mx of Nec Fasc

A

Carbapenem + agents against MRSA + Clindamycin

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78
Q

Role of Clindamycin in Nec Fasc

A

antitoxin and other effects against toxin-elaborating strains of streptococci and staphylococci

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79
Q

Septic arthritis, tenosynovitis, vesicular pustules, negative synovial fluid culture and stain

A

Disseminated gonnococcal infection

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80
Q

Ix of Orbital cellulitis

A

Blood cultures

CT of sinuses

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81
Q

Mx of orbital cellulitis

A

3-14 days IVABx
-Cefotaxime OR Ceftriaxone +Fluclox

Followed by 10 day PO tail of Aug DF

Surgical Drainage if abscess found

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82
Q

Features of C. Diff suggesting need for early surgical referral

A

o Hypotension
o Fever ≥ 38.5
o Ileus or significant abdominal distension
o Peritonitis or significant abdominal tenderness
o Altered mental status
o WBC > 20 cells/mL
o Lactate > 2.2 mmol/L
o ICU admission
o End organ failure
o Failure to improve after 3-5 days of maximal medical therapy

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83
Q

Mx of C. Diff

A

Mild to Mod: PO Metro TDS for 10 days
Severe: PO Vanc QID for 10 days/Fidaxomicin
Complicated: PO Vanc and IV Metro

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84
Q

When to retest stool for C. Diff

A

IF needed to test, must be >6 weeks post treatment

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85
Q

Recurrent C Diff Mx

A

FMT if recurred 3x despite adequate treatment

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86
Q

Causes of infective bloody Diarrhea

A 
SEECSY = Bloody Diarrhea Doesn't Sound Sexy
S=Salmonella
E=E Coli EHEC, ETEC
E = Entamoeba 
C = Campylobacter
S=Shigella
Y=Yersinia
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87
Q

Which malria screening test allows for accurate speciation?

A

Thick blood films check for parasite burden, thin films allow for speciation

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88
Q

CAuse of painful genital ulcers vs painless

A

painful: herpes much more common than chancroid
painless: syphilis more common than lymphogranuloma venereum

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89
Q

Aciclovir and Ganciclovir MOA

A

inhibits the viral DNA polymerase

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90
Q

Amantadine MOA and Indication

A

Inhibits uncoating (M2 protein) of virus in cell. Also releases dopamine from nerve endings

Influenza, Parkinson’s

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91
Q

HIV Patient
CT: usually single or multiple ring enhancing lesions, mass effect may be seen
Thallium SPECT negative

A

Toxoplasmosis

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92
Q

Tx of Toxoplasmosis

A

sulfadiazine and pyrimethamine

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93
Q

HIV Patient
CT: single or multiple homogenous enhancing lesions
Thallium Spect Postive

A

CNS lymphoma

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94
Q

typically prodrome: fever, malaise

causes pyrexia of unknown origin, atypical pneumonia, endocarditis (culture-negative)

A

Q Fever

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95
Q

Coxiella burnetii, a rickettsia

A

Q fever

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96
Q

Bartonella henselae

A

Cat Scratch Disease

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97
Q

S. pneumoniae

Gram stain

A

gram positive diplococci/chain

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98
Q

E. coli

Gram Stain

A

gram negative bacilli

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99
Q

H. influenzae

Gram Stain

A

gram negative coccobacilli

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100
Q

L. monocytogenes

Gram stain

A

gram positive rod

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101
Q

Neisseria meningitis

Gram stain

A

gram negative diplococci

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102
Q

Fluctuating temperatures, transient arthralgia and myalgia, hyperhidrosis with a ‘wet hay’ smell. The clue in the history is his exposure to unpasteurised cheese.

A

Brucellosis

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103
Q

Cutaneous leishmaniasis

A
  • spread by sand flies

- caused by Leishmania tropica or Leishmania mexicana

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104
Q

Mucocutaneous leishmaniasis

A

caused by Leishmania braziliensis

skin lesions may spread to involve mucosae of nose, pharynx etc

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105
Q

Visceral leishmaniasis (kala-azar)

A

mostly caused by Leishmania donovani
occurs in the Mediterranean, Asia, South America, Africa
fever, sweats, rigors
massive splenomegaly. hepatomegaly
poor appetite*, weight loss
grey skin - ‘kala-azar’ means black sickness
pancytopaenia secondary to hypersplenism
the gold standard for diagnosis is bone marrow or splenic aspirate

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106
Q

Jarisch-Herxheimer reaction

A

the Jarisch-Herxheimer reaction is sometimes seen following treatment of syphillus

  • fever, rash, tachycardia after the first dose of antibiotic
  • in contrast to anaphylaxis, there is no wheeze or hypotension
  • it is thought to be due to the release of endotoxins following bacterial death and
  • typically occurs within a few hours of treatment
  • No treatment is needed other than antipyretics if required
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107
Q

BCG vaccine

A

live

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108
Q

MMR vaccine

109
Q

yellow fever vaccine

110
Q

Hepatitis A vaccine

A

Inactivated

111
Q

Influenza vaccine

A

inactivated

112
Q

DTP vaccine

A

toxoid (inactivated)

113
Q

Yellow Fever

A

classic description involves sudden onset of high fever, rigors, nausea & vomiting. Bradycardia may develop. A brief remission is followed by jaundice, haematemesis, oliguria

Councilman bodies (inclusion bodies) may be seen in the hepatocytes

114
Q

Kaposis sarcoma

A

caused by HHV-8 (human herpes virus 8)
presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract)
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion
radiotherapy + resection

115
Q

PJP Tx

A

co-trimoxazole
IV pentamidine in severe cases
aerosolized pentamidine is an alternative treatment for Pneumocystis jiroveci pneumonia but is less effective with a risk of pneumothorax
steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

116
Q

3 EBV: associated malignancies:

A

Burkitt’s lymphoma
Hodgkin’s lymphoma
nasopharyngeal carcinoma

117
Q

Leptospirosis

A

-Infected rat urine

Features
fever
flu-like symptoms
renal failure (seen in 50% of patients)
jaundice
subconjunctival haemorrhage
headache, may herald the onset of meningitis

Mx - Benpen or doxy

118
Q

Schistosomiasis

A

worms deposit egg clusters (pseudopapillomas) in the bladder causinginflammation

Features

  • Swimmer’s itch in patients coming back from Africa
  • Urinary freq
  • Haematuria
  • Bladder calcification

Tx - Single dose praziquantel

Risk factor for SCC of bladder

Alternative one causes hepatosplenomegaly due to portal congestion

119
Q

What percent of pf penicillin skin test positive patients lose skin testing positivity to penicillin at 5 years

120
Q

What proportion of “penicillin allergic” patients are negative on pencillin skin testing

121
Q

What is a Type A ADR

A

Predictable
Dose Dependent
Non-immune mediated

122
Q

What is a Type B ADR

A

Unpredictable
Less dose dependent
Immune mediated
-T cell (delayed)/IgE (immediate)

123
Q

Mechanism behind Vancomycin Red Man Syndrome

A

Non IgE related mast cell activation

Anaphylactoid response

124
Q

Mast cell receptor associated with non IgE m mast cell activation with ABx use

A

MRGPRX2

Most common drugs:
Cipro, Clinda, vanc

125
Q

What is the major cause of cross-reactivity between penicillins and cephalosporins

A

R1 side chain

126
Q

Rate of cross reactivity of penicillin and cephalopsorins

127
Q

What is the cross reactivity if patient is known to have a cephazolin anaphylaxis

A

Cephazolin does not have any shared side chains

-NO other cross reactivity with other ABx

128
Q

Allergy with anaphylaxis to Ampicillin or Cephalexin

A

Shared R1 side chain

CROSS REACT

129
Q

Features of low risk beta lactam allergy that oral challenge can be given to

A

Unknown rxn >10 years
Type A ADR
MPE >10 years or benign childhood rash

130
Q

What is the negative predictive value of penicillin allergy testing in patients with a history of immediate penicillin hypersensitivity

131
Q

Gold standard testing for immediate penicillin allergy

A

skin prick testing/Intradermal testing

-This is less sensitive for cephalosporins

132
Q

Mechanisms for Abx resistance

A
  1. ABx inactivation
  2. Alteration of antibiotic target sites
  3. Decreased ABx permeability of the cell wall
  4. Active ABx efflux from bacteria
133
Q

Incubation period <10 days

A 
Dengue
Influenza
Yellow fever
Chikungunya
Paratyphoid fevers
Legionella
134
Q

Incubation period up to 21 days

A 
Malaria
Viral hemorrhagic fever
Rickettsial disease/Qfever
African Trypanosomiasis
Typhoid fever
Brucellosis
Leptospirosis
Relapsing fever
135
Q

Incubation period >21 days

A 
Malaria
Viral hepatitis
HIV
Rabies
Leishmaniasis 
TB
Q fever
Schisosomiasis
136
Q

First line treatment of uncomplicated malaria

A

artemether-lumefantrine(Riamet)

  • 4 tabs BD for 3 days
  • Take with fatty food for absorption
137
Q

Second Line treatment for uncomplicated malaria

A

atovaquone-proguanil(Malarone™)

-Slower parasite clearance, and increased treatment failure compared to first line

138
Q

Indications for IV therapy and/or ICU monitoring in severe malaria

A 

Unable to tolerate oral therapy

Altered consciousness

>2% parasitemia

Jaundice, oliguria, severe anemia, hypoglycemia, acidosis, ARDS
139
Q

Side effects of IV Artesunate

A

Cerebellar ataxia, abdo pain/diarr, ALT, delayed haemolysis

Less mortality with Artesunate compared to quinine

140
Q

Side effects of quinine

A

hypoglycemia, hearing loss, ↑ QT, diarrhea

141
Q

Cause of artesunate resistance in SE asia

A

single point mutation in the “propeller “region of P falciparum kelchprotein on chromosome 13

142
Q

Role for Primaquine in malaria

A

Eliminates liver forms of P vivax & ovale

Need G6PD screen

143
Q

Doxycycline Side effects

A

Photosensitivity (10%): avoid prolonged sun exposure

GIT upset: nausea, vomiting, diarrhoea, oesophageal ulcer

Vaginal thrush, OCP ineffective

144
Q

Mefloquine SEs

A

Resistance areas in SE asia
Significant SE’s: GI, cardiac, neurological
Psychotic episodes/seizures: <1 in 10,000

145
Q

Tx of Traveller’s Diarrhea

A

Azithro 1 gram stat or 500 mg PO daily for 3 days

Alt: Ciprofloxacin

146
Q

Tx of Giardia

A

Tinidazole 2g oral stat OR Metro 400 mg PO TDS for 7 days

147
Q

Zika and timing of contraception/pregnancy

A

3 or 6 months for men
8 weeks for women

Cx: microcephaly

148
Q

Zika Manifestatons

A

Fevers, rash, small joint arthritis, conjunctivitis, resolves in one week

149
Q

Warning signs of Dengue

A 
Abdo pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleeding
Letheragy, restlessness
Liver enlargement >2cm
Increase in HCT with decerease in platelets
150
Q

5 phases of classic dengue fever

A

1st phase
-Abrupt onset of fevers (39 to 40˚C) for 2 -3 days
-Severe back pain, HA, retro-orbital pain
-Arthralgias, myalgias, transitory maculopapular rash (70-75%)
-Metallic taste
2nd phase: D 3-6; A/N/V/D, lymphadenopathy
3rd phase: Defervescence for 1-2 days
4th phase: Fever recrudescence, morbilliform rash, skin desquamation
5th phase: Convalescence with prolonged lethargy

151
Q

4 Criteria for Dx of Dengue Hemorrhagic fever

A

Fever, or recent history of acute fever
Hemorrhagic manifestations
Low platelet count (≤100,000/mm3)
Objective evidence of “leaky capillaries:”
-Elevated hematocrit(20% or more over baseline)
-Low albumin
-Pleural or other effusions

152
Q

Criteria for Dx of Dengue shock syndrome

A

4 criteria for DHF plus evidence of circulatory failure (rapid weak pulse, hypotension)

153
Q

Features of Ebola

A 

Fever, myalgias, weakness,

vomiting diarrhoea,abdopain,

rash, easy bruising, conjunctival injection

Huge fluid shifts and electrolyte disturbances
154
Q

Chikungunya

A 

Alphavirus

Spread by aedes aegypti and albopictus mosquitos

Large outbreaks in India, Malaysia, Indian ocean islands, the Caribbean

Incubation 2-4 days ( range 1-14)

Fevers, arthralgias, rash, myalgia

Diagnosis –serology and alphavirus PCR
155
Q

Causes of early prosthetic valve endocarditis

A 
Coag neg staph
MSSA
MRSA
Corynebacterium
Propionibacterium
156
Q

Strep Veridans IE Tx

A
  • 2weeks IV Penicillin and Gent OR 4 weeks IV pencillin

- Ceftriaxone substitute if penicillin allergy

157
Q

Enterococcal IE Tx

A

4-6 weeks IV penicillin/ampicillin + Gent

158
Q

Staph IE Tx

A

4-6 weeks IV Fluclox/1st gen cephalosporin

MRSSA: Vanc 4-6 weeks +/- Rifampcin or fusidic acid for prosthetic valves

159
Q

Uncomplicated TV endocarditis

A

2 weeks IV fluclox and gent

If complicated: 4 weeks

160
Q

Tx of culture negative IE

A

Ceft and Gent

161
Q

Indications for surgery in IE

A

Heart failure
Paravalvular extension (abscess, fistula, heart block)
Uncontrolled infection (Bacteraemia >10 days)
Recurrent embolic events

162
Q

Tx of Orbital Cellulitis

A
  1. Cefotaxime IV 2 g TDS
  2. Combination of: Ceftriaxone IV 2 g Daily + Flucloxacillin IV 2 g QID

Must be followed by Oral tail of Augmentin DF PO 875/125 mg BD for 10 days

163
Q

Which ABx has been shown to reduce exacerbations in bronchiectasis with known colonisation with pseudomonas

164
Q

ESCAPPM intrinsic resistance

A

Inducible 3rd gen cephalosporin resistance
“ESBL”
AmpC gene in the chromosomes
-Cefepime still effective against AmpC organisms

165
Q

What other resistance is usually passed along with ESBL genes

A

Fluroquinolone resistance

166
Q

CRE Mx

A

High dose Meropenem w/ extended infusions (if MIC <8)
+Aminoglycloside OR Colistin
+Fosfomycin or Tigecycline

Other Drugs:
Ceftazadime-Avibactam (only for KPC)
Ceftolozone-Tazobactam

167
Q

Ceftolozane-tazobactam

A

Main role in MDR pseudomonas

-Inhibits PBPs more specific to pseudomonas

168
Q

Staph Aureus methicillin resistance gene

A

mecA

encodes the low-affinity pencillin-binding protein 2A (PBP2A)

169
Q

Pathophys for rheumatic fever

A

Autoimmune response due to molecular mimicry between M-proteins of strept pyogenes (group A beta-haemolytic strept) and cardiac myosin/laminin
Type II hypersensitivity reaction

170
Q

Modified Jones Critieria for Rheumatic fever

A

Dx – Modified Jones criteria (>2 major, 1 major + >2 minor)

  • Carditis= cardiomegaly, new murmur, CCF, percarditis, valvular disease
  • Migratory polyarthritis – temporary migrating arthritis usually of large joints; beings in legs and migrates upwards
  • Subcutaneous nodules
  • Erythema marginatum – pink/red, non-puritic rash involving trunks/arms; snake-like ring with clearing in middle, spares face
  • Sydenham’s chorea

Minor

  • Fever, arthralgia, previous episodes of RF
  • Incr ESR/CRP, leukocytosis, heart block on ECG, evidence of streptococal infection (ASOT titre, DNAse)
171
Q

Secondary prophylaxis against streptococcus pyogenes (Rheumatic Fever)

A

Benzathine pencilllin 900mg IM; every 3 or 4 weeks OR
Phenoxymethylpenicillin 250mg orally, BD

Prophylaxis should be considered

  • For a minimum of 10 years after the most recent episode of acute rheumatic fever
  • At least until 21 years in patients without carditis or clinically evident valve disease
  • Until 35 years of age in patients with residual moderate valve disease
  • Until 40 years of age or life in patients with severe residual valve disease and in those who have had valve surgery
172
Q

Enteroccus Faecium mutation that leads to ampicillin and vancomycin resistance

A

Amp - mutations in PBP5 (penicillin-binding protein)

Vancomycin – replacement of pepidoglycan component d-alanaine with d-lactate or d-serine

173
Q

Mechanism behind VRE

A

Vancomycin inhibits by binding to D-alanyla-D-alanaine – inhibits cell wall synthesis

Mutation in D-Ala-D-Ala = resistance

174
Q

Van A

A

high resistance to vancomycin and teicoplanin

175
Q

Van B

A

teicoplanin still generally effective; most common form of enterococci resistance

176
Q

Van C

A

low resistance to vancomycin; sensitive to teicoplanin

177
Q

HIV: OI with CD4 200-500

A

HSV
Pneumococcal pneumonia
oral candida
TB

178
Q

HIV: OI with CD4 50-200

A 
PJP
CNS Toxo
Cryptococcus
Kaposis sarcoma
Non Hodgkins lymphoma
Primary CNS Lymphoma
179
Q

HIV: OI with CD4 <50

A

MAC
CMV retinitis
Cryptosporidiosis

180
Q

Cat Bites: Pastuerella Multocida

A

Resistance to usual cellulitis Tx (pencillin and cephazolin)

-Tx: Tazocin or ceftriaxone

181
Q

MRSA mechanism of resistance

A

modified penicillin binding protein - altered site of beta lactam binding (mecA gene for PBP2a)
-Cant be overcome by beta lactamase inhibitor

182
Q

Panton Valentine Leucocidin

A

PVL is a pore forming necrotising exotoxin that causes leucocyte destruction and tissue necrosis
-PResent in a majority of nmMRSA

183
Q

Linezolid MOA and SE

A

Bacterostatic
Inhibits protein synthesis
Binds 50S ribosomal subunit

SE: reversible bone marrow depression with prolonged use, irreversible neuropathy, optic neuropathy,
Serotonin syndrome

184
Q

Daptomycin MOA and SE

A

cyclic lipopeptide bactericidal antibiotic that causes depolarisation of the bacterial cell membrane

SE: myopathy, peripheral neuropathy, eosinophilic pneumonia

Monitor CK

185
Q

Tigecycline MOA and SE

A

minocycline derivative
Protein synthesis inhibitor; binding at 30s ribosomal subunit - bacteriostatic

High Vd and eliminated via biliary tree not urine

SE: higher risk of Tx failure and increased death rates (last resort)

186
Q

Ceftaroline/Ceftobiprole

A

5th gen cephalosporin

For MRSA, VRE (faecalis)

SE:Eosinophilic pneumonia rarely

187
Q

Vancomycin MOA and SE

A

Inhibits synthesis of bacterial cell wall by binding to D-ala D-ala terminus of side chain preventing cross linking

SE: nephrotixicity, ototoxicity, Red man syndrome, neutropenia, thrombocytopenia, rash

188
Q

Teicoplanin MOA and AE

A

Similar to Vancomycin

SE: nephrotoxicity, ototoxicity

189
Q

MEchanism behind pneumococcal penicillin resistance

A

alteration in PBP

  • No role for beta lactamase inhibitors for this
  • MAy be overcome with high doses dependent on MIC
190
Q

Types of CRE

A 
KPC (US)
NDM(Aus/Nz/India)
OXA-48 (Turkey)
VIM
IMP
191
Q

What is the best prognostic indicator for survival in PJP

A

Level of oxygenation at diagnosis

-PaO2 <70 mmHg - Add pred (improves mortality)

192
Q

CNS Toxoplasmosis in HIV

A

CD4 usually <100
PResentation: fever, headache, mental state change, neuro deficits, seizure
Dx: IgG, multiple ring enhancing lesions
Tx: pyrimethamine/sulfasiazine OR Pyrimethamine/Clinda and Bactrim; Dexamethasone for mass effect

If not improved in 2 weeks on CT - Bx for ?CNS lymphoma

193
Q

Empical Tx for bacterial meningitis

A

IV 2g Ceftriaxone BD
IV 10 mg Dexamethasone Q6H
+Vanc if pneumococcal risk
+Benpen 2.4g IV Q4H if listeria risk

194
Q

Risk Risk criteria for TOE in ?IE

A

Community acquired bacteraemia
IVDU
High risk cardiac condition
Indeterminate or positive TTE

195
Q

Common Culture negative endocarditis bugs

A 
Bartonella
Coxiella burnetti
Brucella
LEgionella 
Tropheryma whipplei
196
Q

Specific Streptococcal IE Tx

A 
IV Benpen 1.8 Q4H for 4 weeks
OR
IV Ceftriaxone 2g daily for 4 weeks
OR
IV Benpen + Gent for 2 weeks
197
Q

Specific Enterococcal IE Tx

A

IV Benpen 2.4g Q4H + gent for 4-6 weeks
OR
IV Vanc + Gent for 4-6 weeks

If Gent contraindicated: Benpen and Ceftriaxone for 6 weeks

198
Q

Specific HACEK IE Tx

A

Ceftriaxone +/- Gent for 4-6 weeks

199
Q

Prosthetic valve and staph aureus IE Tx

A

Fluclox + Rifampicin + Gent (for first 2 weeks) for a total of 6 weeks

200
Q

High risk heart conditions needing IE prophylaxis for high risk procedures

A
  • Prosthetic heart valve
  • Rheumatic valve disease
  • Previous IE
  • Unrepaired cyanotic congenital heart disease (or repaired in last 6 months)
201
Q

High risk procedures needing IE prophylaxis for high risk groups

A
  • Dental procedure that manipulates gingival tissues or perforates mucosa
  • Tonsillectomy or adenoidectomy
  • Surgery at site of established infection
202
Q

ABx choice for IE prophylaxis

A

Amoxycillin 2 gram - PO then one hour prior - IV just before procedure

Penicillin allergy or penicillin/cephalosporin taken in the last month:
-Clindamycin or clarithromycin

203
Q

CURB 65

A 
Confusion
Urea > 7 mmol/L
RR >30
BP <90 or dia <60
Age >65
204
Q

L-Amphotericin B MOA

A

Intercalated between phopholipid layer
Binds to ergosterols in the cell membrane.
Increased Membrane permeability and
Pore formation

Good CSF penetration

205
Q

SE of L-AmB

A 
Nephrotoxicity
Infusion reaction (fevers, chills, hypotension, bronchospasm, myalgias, N+V, tachycardia
206
Q

Indications for L-AmB

A 
Cryptococcal meningitis
Alt to Voriconazole for IA
Invasive candidaemia
Zygomycosis
Fusariosis
Empiric fungal therapy
207
Q

MOA of Tiazoles

A

Inhibit the C-14alpha demethylase required for fungal cell membrane (ergosterol) synthesis

208
Q

MOA of Echinocandins (Fungins)

A

Inhibits synthesis of beta-1,3-D-glucan this inhibiting cell wall synthesis

209
Q

MOA of Flucytosine

A

converted by cytosine deaminase to fluorouracil in fungal cells; after phosphorylation fluorouracil inhibits fungal DNA synthesis and is also incorporated into fungal RNA, affecting protein synthesis.

210
Q

First line treatment for invasive candidiasis

A

Echinocandin (caspofungin)
-If confirmed sensitivities can switch to azole

Micafungin better for C.auris and obese patients

211
Q

SE of echinocandins

A

Relatively well tolerated
N+V
Some LFT derrangement
Unclear urianry penetrance

212
Q

Indication for posaconazole

A

o Prophylaxis in AML and MDs undergoing intensive induction-remission chemotherapy and post HSCT or GVHD

213
Q

Voriconazole SEs

A

o Elevation of LFTs
o Photosensitive rash
o Transient dose related visual disturbances (increased brightness and blurred vision)
o IV formulation – exacerbates pre-existing renal disease (relative contraindication if eGFR<50ml/min

214
Q

Which triazoles need monitoring

A

Vori and Posa

215
Q

First line treatment for invasive aspergillosis

A

Voriconazole (Excellent CNS penetration)

216
Q

Drugs that interact with Echinocandins

A
  • Cyclosporin A
  • Tacrolimus
  • Antiretroviral agents
  • Phenytoin
  • Carbamazepine
  • Rifampicin
217
Q

Indication for Flucytosine

A

Used with amphotericin for synergy in cryptococcal infn (esp meningitis)

218
Q

Tx of oesophageal candidiasis

A

Fluconazole

If resistant and intolerant of L-AmB, then caspofungin

219
Q

New Anti CMV treatment in patients with HSCT - can be used for prophylaxis

A

Letermovir and Maribavir

  • Bind to CMV terminase complex rather than the polymerase (like ganciclovir)
  • Very specific to CMV virus
  • Minimal myelotoxicity
220
Q

Mx of Toxic Shock Syndrome

A

Clindamycin + vancomycin as empirical cover

-IVIG may be good adjunctive

221
Q

Most common cause of Traveller’s diarrhea

A

Enterotoxigenic (ETEC)

E. Coli

222
Q

Most common cause of community acquired inflammatory enteritis

A

Campylobacter jejuni

223
Q

Risk factors for salmonellosis

A

Sickle cell disease, malaria, schistosomiasis, bartonellosis, pernicious anaemia

224
Q

Botulinum toxin target

A

= blocks acetylcholine release

225
Q

Tetanus toxin MOA

A

= travels to CNS by retrograde axonal transport

Inteferes with GABA transmission so that alpha-motor neurons are no longer under inhibitory control

226
Q

Cholera MOA

A

Chlorea toxin = causes persistent activation of adenylate cyclase
Increase in cAMP in intestinal mucosa and leads to increased Cl secretion and decreased Na absorption which leads to diarrhoea

227
Q

Antigenic shift

A

Antigenic shift occurs in major changes

-causes pandemics or epidemics

228
Q

Antigenic Drift

A

Antigenic drift – minor, point mutations occur leading to local outbreaks

229
Q

Rheumatic fever Pathophysiology

A

Autoimmune response due to molecular mimicry between M-proteins of strept pyogenes (group A beta-haemolytic strept) and cardiac myosin/laminin
-Type II hypersensitivity reaction

230
Q

Jones Criteria for Rheumatic fever

A

Dx – Modified Jones criteria (>2 major, 1 major + >2 minor)

  • Carditis= cardiomegaly, new murmur, CCF, percarditis, valvular disease
  • Migratory polyarthritis – temporary migrating arthritis usually of large joints; beings in legs and migrates upwards

Subcutaneous nodules

Erythema marginatum – pink/red, non-puritic rash involving trunks/arms; snake-like ring with clearing in middle, spares face

Sydenham’s chorea

Minor
Fever, arthralgia, previous episodes of RF
Incr ESR/CRP, leukocytosis, heart block on ECG, evidence of streptococal infection (ASOT titre, DNAse)

231
Q

Scarlet Fever pathophysiology

A

Diffuse erythematous eruption; due to delayed type skin reactivity to pyogenic exotoxin (erythrogenic toxin)

232
Q

Intracellular bacteria

A 
Listeria
Mycobacterium
Brucella
Rickettsia
Chlamydia
233
Q

Clostridium botulinum presentation

A

Symmetric descending paralysis

Normal reflexes

234
Q

Most common cause of traveller’s diarrhea

235
Q

Most common cause of community acquired diarrhea

A

Camplyobacter jejuni

236
Q

SE Flucloxacillin

A

cholestatic jaundice (especially older patients on prolonged therapy)

237
Q

Which of the cephalosporins is the only one excreted via biliary tree rather than kidneys

A

Ceftriaxone

238
Q

SE Vancomycin

A

Red man Syndrome
-Mx: Stop infusion, antihistamine, start infusion slower

Nephrotoxicity
Ototoxicity
Neutropenia

239
Q

SE Coistin

A

Nephrotoxicity
Neurotoxicity
Hypersensitivity

240
Q

50S ribosomal subunit inhibitors

A 
Macrolides
Lincosamides = clindamycin
Fusidic acid
Chloramphenicol
Linezolid
241
Q

30S subunit inhibitors

A

Aminoglycosides
Tetracycline
Tigecycline

242
Q

Which ABx class worsens Myasthenia gravis

A

Quinolones

243
Q

SE of Quinolones

A

Tendon rupture/tendonitis
-Risk factors – concomitant steroid use, advanced age, renal impairment, prolonged therapy

QT prolongation

Photosensitivity

CNS toxicity – nightmares, dizziness, confusion

244
Q

SE of Metronidazole

A

Metallic taste

Peripheral neuropathy

Seizures if prolonged large doses

Avoid in pregnancy/lactation

245
Q

Side effects of Bactrim

A

Hypersenstivity rash
Bone marrow suppression
Teratogenesis and causes kernicterus – avoid in pregnant/lactating women
Hepatitis – rare
Causes rise in creatinine but does not represent renal failure

246
Q

Function of HA and NA in Influenza

A

HA – binds virus to host cells

NA – release of progeny cells

247
Q

Which receptor does EBV enter from

A

Host cells = B-cells; enters B-cells via CD21 receptor

248
Q

Cancers associated with EBV

A

nasopharyngeal carcinomas, Burkitt’s lymphoma, Hodgkin’s disease and B-cell lymphoma

249
Q

CMV - Renal Bx finding

A

cytoplasmic inclusion bodies

250
Q

BK Virus - Renal Bx finding

A

intranuclear inclusion bodies

251
Q

BK virus staining

A

Positive SV40 staining

252
Q

Rickettsia

A

Triad: Fever, rash, Hx of tick bite

  • Non specific features
  • Palm/sole rash is characteristic (late disease)

RF: Kids, Exposure to dogs, woods, seasonal

Tx: Doxy/Azithro

253
Q

Ross river fever

A

From mosquitos

Features:
-Polyarthralgia - acute and symmetric, fever, rash,

254
Q

LEptospirosis

A

Weils’ disease – jaundice, acute kidney injury, hypotension and haemorrhage (commonly lungs but can also affect GIT, pericardium brain)

255
Q

Tx of schisto

A

Praziquantel

256
Q

Chancroid

A

painful pustules that bursts and forms deep ulcers with erythematous bases; LND

haemophilus ducreyi

257
Q

Lymphogranuloma venereum

A

chlamydia trachomatis

Painless ulcerations
Lymph involvement  large tender LN, anorectal masses/proctitis/tenesmus
Late – fibrosis and strictures

Tx: doxy/azithro

258
Q

Gonorrhoea Tx

A

Ceftriaxone + azithro/doxy

259
Q

Chlamydia

A

azithro/doxy

260
Q

Tx of cryptococcus

A

amphotericin B deoxyscholate PLUS flucytosine for at least 2 weeks

Then consolidation with fluconazole

261
Q

Colistin SE

A 
Nephrotoxicity
Urine infection 
Neurotoxicity
Hypersensitivity
Bronchospasm when aerolised; give ventolin first
262
Q

50s Protein synthesis inhibitors

A

Clindamycin

Erythromycin

263
Q

30s Protein synthesis inhibitors

A

Aminoglycosides

Tetracyclines

264
Q

Both 30s and 50s protein synthesis inhibitors

265
Q

Blocks folic acid synthesis in the cytoplasm

A

Sulfonamides

Trimethoprim

266
Q

Cell wall inhibitors

A 
Penicillins
Cephalosporins
Carbapenems
Vancomycin
Fosfomycin
Isoniasid
267
Q

Attacks cell membranes and causes loss of selective permability

A

Daptomycin

Polymyxins

268
Q

Inhibits RNA polymerase

269
Q

Inhibit replication and transcription. Inhibit gyrase (unwinding enzyme)

A

Quinolones

Bpt (15 decks)

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