Infection Flashcards

Question

If a person has suspected or confirmed COVID-19, assessment for severe illness includes identifying:

Answer 1

Severe breathlessness; haemoptysis; hypoxia. Cyanosis; feeling cold and clammy; pale or mottled skin. Collapse or syncope. New confusion; drowsiness. Reduced urine output.

Answer 2

Take a lateral flow test if a person is at highest risk of becoming seriously ill. Try to stay at home and avoid contact with other people, for all other people. Self-manage symptoms and consider self-monitoring at home.

Answer 3

Is moderately or severely unwell. Has a suspected acute or life-threatening complication.

Answer 4

About antibody and antiviral treatments for people at highest risk of becoming seriously ill. To try to stay at home and avoid contact with other people, for all other people. To self-manage symptoms and consider self-monitoring at home. To notify any confirmed case to the local health protection team.

Answer 5

Getting vaccinated, ensuring adequate ventilation, good hygiene, and when to consider wearing a face covering or mask. Accessing mental health support, if needed. Entry requirements and travel warnings when travelling abroad. Support at work, self-employment and benefits.

Answer 6

92% or less in room air in adults (suggests severe hypoxia). >4% lower than usual levels (suggests severe hypoxia). 93–94% in room air in adults (suggests moderate hypoxia). below 91% in room air at rest in children and young people aged 17 years and under (suggests severe hypoxia). Consider using 'exertion oximetry' tests (such as the 40-step walk and one-minute sit-to-stand tests) if oxygen saturation is at least 93% and the person is aged 65 years or more and/or at highest risk of serious illness, to assess for oxygen desaturation on exercise — a 3% or greater reduction in oxygen saturation level is considered significant.

Answer 7

Down's syndrome or other chromosomal disorders known to affect immune competence. Certain types of solid cancer, and/or received or receiving treatment for certain types of cancer. Haematological diseases (such as some forms of leukaemia, lymphoma, myeloma, myelodysplastic syndrome, myelofibrosis, sickle cell disease) and recipients of haematological stem cell transplant. Renal disease (including renal transplant recipients, non-transplant renal patients who are immunosuppressed, chronic kidney disease [CKD] stage 4 or 5). Liver disease (some forms of cirrhosis especially decompensated liver disease, liver transplant recipients, liver disease on immunosuppressive therapy). Other solid organ transplant recipients. Immune-mediated inflammatory disorders (including people taking some forms of immunotherapy, biologics, JAK-inhibitors, corticosteroids, uncontrolled or clinically active disease, major organ involvement). Immune deficiencies (including common variable immune deficiency, severe combined immunodeficiency). HIV or AIDS (if immunosuppressed, have uncontrolled or untreated HIV, or acute presentation of AIDS-defining diagnosis). Rare neurological and neurodisability conditions (multiple sclerosis, motor neurone disease, myasthenia gravis, or Huntington's disease)

Answer 8

Two vaccines use an mRNA platform (Pfizer BioNTech BNT162b2 vaccine, Comirnaty®) and Moderna mRNA-1273 COVID-19 vaccine (Spikevax®). These vaccines have no whole or live virus involved, and the vaccines cannot cause disease. The mRNA naturally degrades after a few days. - Comirnaty 3 micrograms/dose mRNA COVID-19 vaccine is licensed for use in infants and children aged 6 months to 4 years. Two vaccines use an adenovirus vector (AstraZeneca COVID-19 ChAdOx1-S vaccine/Vaxzevria®) and COVID-19 Janssen Ad26.COV2-S (recombinant, less widely used). The adenovirus is modified so it cannot replicate in human cells, and cannot cause disease.

Answer 9

18 years and over: - Moderna mRNA (Spikevax) vaccine 50 micrograms , or - Pfizer-BioNTech mRNA (Comirnaty) vaccine 30 micrograms 12 to 17 years: - Pfizer-BioNTech mRNA (Comirnaty) vaccine 30 micrograms 5 to 11 years: - Pfizer-BioNTech mRNA (Comirnaty) vaccine 10 micrograms 6 months to 4 years. - Pfizer-BioNTech mRNA (Comirnaty) vaccine 3 micrograms

Answer 10

NOT but active illness is

Answer 11

Local injection site reactions, such as pain, swelling, redness, tenderness; fatigue; headache; chills; myalgia; arthralgia; fever. Lymphadenopathy (in the axillary, supraclavicular, or cervical areas on the ipsilateral side to injection).

Answer 12

black triangle drugs, and any adverse reactions should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA) using the Coronavirus Yellow Card reporting site.

Answer 13

Myocarditis and pericarditis Vaccine-induced immune thrombocytopenia and thrombosis (VITT) Acute disseminated encephalomyelitis (ADEM) — extremely rare cases have been reported following vaccination with the AstraZeneca vaccine, although a causal relationship has not been established. Cases with fatal outcome have been reported. Guillain-Barré syndrome Capillary leak syndrome Transverse myelitis Dizziness Paraesthesia and hypoaesthesia

Answer 14

If she is over the age of 18 years, the Pfizer BioNTech or Moderna vaccines should be offered. If she is under the age of 18 years, the Pfizer BioNTech vaccine should be offered. If she has already received a dose of the AstraZeneca vaccine, she can complete the course with the same vaccine or an mRNA vaccine. If a woman finds out she is pregnant after she has started a course of vaccine: She may complete vaccination during pregnancy, and should complete vaccination at the recommended interval. If a woman is breastfeeding: Advise there is no known risk associated with a non-live COVID-19 vaccine while breastfeeding.

Answer 15

influenza vaccine by at least 7 days.

Answer 16

common and do not require treatment unless painful, unsightly or a patient is requesting treatment for a persistent wart.

Answer 17

Most of them will resolve spontaneously within months or at most within 2 years. In adults it can take up to 10 years.

Answer 18

death of body tissue due to a lack of blood supply, infection, or both

Answer 19

anywhere but commonly in the extremities, such as the toes, fingers, feet, and hands

Answer 20

to prevent further tissue loss, systemic infection, and potentially life-threatening complications

Answer 21

involves the interruption of blood supply, leading to tissue ischaemia and necrosis

Answer 22

Arterial occlusion: Atherosclerosis, thrombosis, or embolism can obstruct blood flow. Infection: Bacteria, especially in wet and gas gangrene, can exacerbate tissue necrosis through toxin production. Trauma: Severe injuries can compromise blood supply and introduce pathogens. Chronic conditions: Diabetes mellitus and other chronic diseases can predispose individuals to gangrene by impairing vascular function and immune response.

Answer 23

1) Dry gangrene 2) Wet gangrene 3) Gas gangrene (Clostridial myonecrosis) 4) Necrotising fasciitis

Answer 24

chronic ischaemia, usually due to peripheral arterial disease (PAD).

Answer 25

Characterised by dry, shrivelled, and blackened tissue ('mummified'). Clear demarcation between healthy and necrotic tissue. Typically painless due to nerve damage.

Answer 26

Often develops slowly and is usually not associated with infection.

Answer 27

Results from a sudden lack of blood supply combined with bacterial infection.

Answer 28

Swollen, moist, and blistered tissue with a foul odour. Rapid spread and marked systemic symptoms such as fever and malaise. Severe pain and erythema around the affected area.

Answer 29

Progresses rapidly and can lead to systemic sepsis.

Answer 30

Caused by infection with Clostridium bacteria, which produce gas and toxins.

Answer 31

Severe pain and swelling at the site of infection. Crepitus due to gas production by Clostridium bacteria. Rapid onset of systemic symptoms, including tachycardia, hypotension, and shock.

Answer 32

Requires urgent medical intervention due to rapid progression and high mortality.

Answer 33

A severe form of gangrene involving the fascia and subcutaneous tissues.

Answer 34

Caused by mixed bacterial infections, often including Streptococcus pyogenes and Staphylococcus aureus.

Answer 35

Intense pain disproportionate to the visible signs. Rapid progression of erythema, swelling, and tissue necrosis. Systemic signs of sepsis, such as fever, tachycardia, and hypotension

Answer 36

urgent intervention to control infection, restore blood supply, and remove necrotic tissue

Answer 37

- surgical intervention - antibiotic therapy - supportive care - hyperbaric oxygen therapy

Answer 38

Debridement: Surgical removal of necrotic tissue to prevent the spread of infection. Amputation: In severe cases, partial or complete amputation of the affected limb may be necessary. Revascularisation: Procedures such as angioplasty or bypass surgery to restore blood flow in cases of arterial occlusion.

Answer 39

Empirical broad-spectrum antibiotics initially, followed by targeted therapy based on culture results. For gas gangrene, high-dose penicillin and clindamycin are often recommended.

Answer 40

high-dose penicillin and clindamycin

Answer 41

Management of systemic symptoms, including fluid resuscitation, pain control, and nutritional support. Monitoring and treatment of comorbid conditions such as diabetes and cardiovascular disease.

Answer 42

Used in some cases of gas gangrene to enhance oxygen delivery to ischaemic tissues and inhibit anaerobic bacterial growth.

Answer 43

may be due to the effects of the virus itself (HIV enteritis) or opportunistic infections

Answer 44

Cryptosporidium + other protozoa (most common) Cytomegalovirus Mycobacterium avium intracellulare Giardia

Answer 45

Cryptosporidium

Answer 46

an intracellular protozoa and has an incubation period of 7 days Presentation is very variable, ranging from mild to severe diarrhoea

Answer 47

A modified Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the characteristic red cysts of Cryptosporidium.

Answer 48

difficult, with the mainstay of management being supportive therapy (nitazoxanide is licensed in the US for immunocompetent patients)

Answer 49

an atypical mycobacteria seen with the CD4 count is below 50. Typical features include fever, sweats, abdominal pain and diarrhoea. There may be hepatomegaly and deranged LFTs. Diagnosis is made by blood cultures and bone marrow examination.

Answer 50

rifabutin, ethambutol and clarithromycin

Answer 51

may be hepatomegaly and deranged LFTs Diagnosis is made by blood cultures and bone marrow examination

Answer 52

HHV-8 (human herpes virus 8)

Answer 53

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

Answer 54

Kaposi's sarcoma

Answer 55

radiotherapy + resection

Answer 56

pt with HIV

Answer 57

at least three drugs, typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI)

Answer 58

viral replication but also reduces the risk of viral resistance emerging

Answer 59

as soon as they have been diagnosed with HIV, rather than waiting until a particular CD4 count, as was previously advocated.

Answer 60

maraviroc (binds to CCR5, preventing an interaction with gp41), enfuvirtide (binds to gp41, also known as a 'fusion inhibitor') prevent HIV-1 from entering and infecting immune cells

Answer 61

examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir general NRTI side-effects: peripheral neuropathy tenofovir: used in BHIVAs two recommended regime NRTI. Adverse effects include renal impairment and ostesoporosis zidovudine: anaemia, myopathy, black nails didanosine: pancreatitis

Answer 62

peripheral neuropathy

Answer 63

used in BHIVAs two recommended regime NRTI. Adverse effects include renal impairment and ostesoporosis

Answer 64

anaemia, myopathy, black nails

Answer 65

pancreatitis

Answer 66

examples: nevirapine, efavirenz side-effects: P450 enzyme interaction (nevirapine induces), rashes

Answer 67

examples: indinavir, nelfinavir, ritonavir, saquinavir side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition indinavir: renal stones, asymptomatic hyperbilirubinaemia ritonavir: a potent inhibitor of the P450 system

Answer 68

diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition

Answer 69

renal stones, asymptomatic hyperbilirubinaemia

Answer 70

a potent inhibitor of the P450 system

Answer 71

block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell examples: raltegravir, elvitegravir, dolutegravir

Answer 72

raltegravir, elvitegravir, dolutegravir

Answer 73

accounts for around 50% of cerebral lesions in patients with HIV constitutional symptoms, headache, confusion, drowsiness

Answer 74

single or multiple ring enhancing lesions, mass effect may be seen

Answer 75

sulfadiazine and pyrimethamine

Answer 76

accounts for around 30% of cerebral lesions associated with the Epstein-Barr virus

Answer 77

single or multiple homogenous enhancing lesions

Answer 78

involves steroids (may significantly reduce tumour size), chemotherapy (e.g. methotrexate) + with or without whole brain irradiation. Surgical may be considered for lower grade tumours

Answer 79

different treatment strategies.

Answer 80

Lymphoma= Single lesion; Solid (homogenous) enhancement; Thallium SPECT positive Toxoplasmosis= Multiple lesions, Ring or nodular enhancement, Thallium SPECT negative TB= single enhancing lesion

Answer 81

much less common than toxoplasmosis or primary CNS lymphoma

Answer 82

single enhancing lesion

Answer 83

may be due to CMV or HIV itself HSV encephalitis but is relatively rare in the context of HIV

Answer 84

oedematous brain

Answer 85

most common fungal infection of CNS headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit

Answer 86

high opening pressure elevated protein reduced glucose normally a lymphocyte predominance but in HIV white cell count many be normal India ink test positive

Answer 87

meningeal enhancement, cerebral oedema

Answer 88

meningitis is typical presentation but may occasionally cause a space-occupying lesion

Answer 89

Cryptococcus

Answer 90

widespread demyelination due to infection of oligodendrocytes by JC virus (a polyoma DNA virus)

Answer 91

subacute onset : behavioural changes, speech, motor, visual impairment

Answer 92

single or multiple lesions, no mass effect, don't usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen

Answer 93

caused by HIV virus itself symptoms: behavioural changes, motor impairment

Answer 94

cortical and subcortical atrophy

Answer 95

Oesophageal candidiasis

Answer 96

generally seen in patients with a CD4 count of less than 100

Answer 97

most common cause of oesophagitis in patients with HIV

Answer 98

dysphagia and odynophagia

Answer 99

1st line treatments= Fluconazole and itraconazole

Answer 100

Oral thrush Shingles Hairy leukoplakia Kaposi sarcoma

Answer 101

Candida albicans

Answer 102

herpes zoster

Answer 103

Cryptosporidiosis Cerebral toxoplasmosis Progressive multifocal leukoencephalopathy Pneumocystis jirovecii pneumonia HIV dementia

Answer 104

Whilst patients with a CD4 count of 200-500 may develop cryptosporidiosis the disease is usually self-limiting and similar to that in immunocompetent hosts

Answer 105

Aspergillosis Oesophageal candidiasis Cryptococcal meningitis Primary CNS lymphoma

Answer 106

Aspergillus fumigatus

Answer 107

Candida albicans

Answer 108

Cytomegalovirus retinitis Mycobacterium avium-intracellulare infection

Answer 109

Affects around 30-40% of patients with CD4 < 50 cells/mm³

Answer 110

Cytomegalovirus retinitis

Answer 111

Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use

Answer 112

an unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa most common opportunistic infection in AIDS

Answer 113

Pneumocystis jiroveci

Answer 114

PCP prophylaxis (Pneumocystis jiroveci)

Answer 115

dyspnoea dry cough fever very few chest signs

Answer 116

Pneumothorax

Answer 117

rare (1-2%) hepatosplenomegaly lymphadenopathy choroid lesions

Answer 118

CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal exercise-induced desaturation sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts)

Answer 119

typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal

Answer 120

silver stain shows characteristic cysts

Answer 121

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

Answer 122

Tx or the virus itself

Answer 123

intratubular crystal obstruction

Answer 124

Antiretroviral therapy If a patient is already taking antiretroviral therapy (which should be all HIV-diagnosed patients) adherence should be checked.

Answer 125

massive proteinuria resulting in nephrotic syndrome normal or large kidneys focal segmental glomerulosclerosis with focal or global capillary collapse on renal biopsy elevated urea and creatinine normotension

Answer 126

HIV-associated nephropathy (HIVAN)

Answer 127

HIV-associated nephropathy

Answer 128

nephrotic syndrome

Answer 129

focal segmental glomerulosclerosis with focal or global capillary collapse

Answer 130

glandular fever-type illness

Answer 131

HIV seroconversion

Answer 132

poorer long-term prognosi

Answer 133

3-12w after infection

Answer 134

sore throat lymphadenopathy malaise, myalgia, arthralgia diarrhoea maculopapular rash mouth ulcers rarely meningoencephalitis

Answer 135

1) Fusion of HIV to host cell surface 2) HIV RNA, reverse transcriptase, integrase and other viral proteins enter the host cell 3) Viral DNA is formed by reverse transcription 4) Viral DNA is transported across the nucleus and integrates into the host DNA 5) New viral RNA is used as genomic RNA and to make viral proteins 6) New viral RNA and proteins move to cell surface and a new immature HIV forms 7) The virus matures by protease releasing individual HIV proteins

Answer 136

period when the body produces antibodies to fight the HIV virus Seroconversion can be mild (not notice it), mistaken for the flu, or severe enough to require hospitalization period when someone with HIV is most infectious After seroconversion, most people feel well and don't have symptoms for several years However, the virus is still active and damaging the immune system

Answer 137

combination tests (HIV p24 antigen and HIV antibody) are now standard if the combined test is positive it should be repeated to confirm the diagnosis some centres may also test the viral load (HIV RNA levels) if HIV is suspected at the same time

Answer 138

may not be present in early infection, but most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months usually consists of both a screening ELISA (Enzyme Linked Immuno-Sorbent Assay) test and a confirmatory Western Blot Assay

Answer 139

a viral core protein that appears early in the blood as the viral RNA levels rise usually positive from about 1 week to 3 - 4 weeks after infection with HIV

Answer 140

combination tests (HIV p24 antigen and HIV antibody) if the combined test is positive it should be repeated to confirm the diagnosis some centres may also test the viral load (HIV RNA levels) if HIV is suspected at the same time

Answer 141

4 weeks after possible exposure

Answer 142

repeat test at 12w

Answer 143

- HIV antibody - HIV antibody and antigen - HIV RNA (qualitative or quantitative)

Answer 144

enzyme-linked immunosorbent assays (ELISAs) are often used for screening Western blot was previously used as a confirmation test but HIV-1/HIV-2 differentiation assays are now more commonly used most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months

Answer 145

often referred to as 'fourth-generation' tests p24 antigen can be detected as early as 2-3 weeks after exposure the sensitivity of these fourth-generation tests approaches 100% for patients with chronic HIV infection now the first-line test for HIV screening of asymptomatic individuals or patients with signs and symptoms of chronic infection

Answer 146

HIV antibody and HIV antigen

Answer 147

not routinely used for screening/testing however, may be useful for diagnosis of neonatal HIV infection and screening blood donors

Answer 148

retrovirus that preferentially infects and destroys cells of the immune system, in particular the CD4 cells (a class of T lymphocyte).

Answer 149

from infected body fluids: Through sexual activity. Vertically from mother to child — during pregnancy, childbirth, or through breastfeeding. By inoculation — via a contaminated needle, instrument, blood, or blood product; through direct exposure of mucous membranes or an open wound to infected bodily fluids; or by a human bite that breaks the skin.

Answer 150

a flu-like illness in the first few weeks following infection and can be mild or severe. - The person is highly infectious during PHI.

Answer 151

An asymptomatic stage once symptoms of PHI resolve — some people progress rapidly to advanced HIV infection or AIDS (acquired immunodeficiency syndrome) within 1–2 years, while others may remain immunocompetent more than 10 years later. Advanced HIV infection occurs when the number of CD4 cells is very low (less than 200 cells per microlitre) and certain opportunistic infections (such as pneumocystis pneumonia) or malignancies (such as Kaposi’s sarcoma) develop.

Answer 152

Common symptoms or infections that are unusually severe, prolonged, recurrent, or unexplained. Persistent enlarged lymph nodes other than in the inguinal area. Conditions related to immunosuppression. Glandular fever-like illness. Lifestyle and social risk factors for contracting HIV, such as living in, working in, or coming from a high prevalence area; men who have sex with men; and injecting drug users.

Answer 153

- As part of routine antenatal care. - If the person requests a test, has a risk factor for HIV, or has another sexually transmitted infection. - To people newly registering at a practice or having a blood test if they have not had an HIV test in the past 12 months, in areas where the prevalence of diagnosed HIV is greater than 2 in 1000. - To people presenting with symptoms of PHI or longstanding HIV infection. - Some HIV-related conditions such as pneumocystis pneumonia or cryptococcal meningitis can be life threatening and require urgent admission or referral to secondary care.

Answer 154

Antiretroviral therapy (ART) is initiated and monitored in secondary care — ART can be associated with serious or life-threatening adverse effects that may present in primary care.

Answer 155

ART can also have serious or life-threatening interactions with many drugs commonly prescribed in primary care — before prescribing, drug interactions should be checked in the British National Formulary, the online database of HIV drug interactions, or with an HIV specialist.

Answer 156

ART has improved the prognosis of HIV/AIDS significantly — people living with HIV who are adherent and clinically responding to ART can expect a normal or near-normal life span.

Answer 157

antiretroviral therapy

Answer 158

urgent referral for consideration of post-exposure prophylaxis is required.

Answer 159

first few weeks following infection with HIV (usually between 10 days and 6 weeks) and can be mild or severe.

Answer 160

Fever, sore throat, maculopapular rash, malaise, lethargy, arthralgia, myalgia, lymphadenopathy, and oral, genital or perianal ulcers. Less commonly, headache, meningitis, cranial nerve palsies, diarrhoea, and weight loss.

Answer 161

- constitutional symptoms= flu-like symptoms; fever; weight loss; sweats; lymphadenopathy - Opportunistic respiratory infections - neurological and visual problems - increased risk of malignancy - skin conditions - oral conditions - GI conditions - genital conditions= severe or difficult-to-treat genital candida, genital herpes, or genital warts - haematological= unexplained abnormalities on full blood count such as neutropenia, anaemia, thrombocytopenia, or other blood dyscrasias.

Answer 162

Opportunistic respiratory infections such as pneumocystis pneumonia (PCP), tuberculosis, bacterial lower respiratory tract infections; and occasionally Kaposi's sarcoma or lymphomas can result in symptoms including cough, sweats, breathlessness, and weight loss.

Answer 163

life-threatening condition that can be difficult to identify at onset and is typically insidious over several weeks. Symptoms include fever (in most but not all people), persistent dry cough of a few weeks’ duration, increasing breathlessness, decreasing exercise tolerance, chest discomfort, and difficulty in taking a full breath. Signs include fine crackles (although the chest may be clear, especially in early infection) and a drop in oxygen saturation on exertion. PCP can be fatal if diagnosed late.

Answer 164

TB is a common presenting condition in HIV. Atypical mycobacterial disease (such as Mycobacterium avium intracellulare) is less common and is associated with advanced HIV infection. Symptoms may include fever, night sweats, weight loss, fatigue, diarrhoea, and abdominal pain.

Answer 165

- Cryptococcal meningitis — may present as subacute meningitis with headache and fever, acute confusional state, or cranial nerve palsies. Typical symptoms and signs of meningism may be absent. - Cerebral toxoplasmosis — occurs owing to reactivation of previous toxoplasmosis infection. May present with confusion, headache, personality change, fever, fits, and focal neurological signs. - Cerebral lymphoma (in advanced HIV disease)= May present with confusion, lethargy, personality change, headache, fever, fits, and focal neurological signs. - Cytomegalovirus (CMV) retinitis= occurs owing to reactivation of previously acquired infection and can lead to loss of vision. Prognosis improves with earlier diagnosis. Symptoms include floaters (due to inflammatory cells in the vitreous), reduced vision, flashing lights, and scotomas.

Answer 166

Cytomegalovirus (CMV) retinitis

Answer 167

Lymphoma Kaposi's sarcoma Cervical ca

Answer 168

Can present with weight loss, fevers, night sweats, lymphadenopathy, and abdominal masses (lymph nodes, hepatomegaly, or splenomegaly).

Answer 169

Kaposi's sarcoma is the most common tumour in people with HIV infection and typically presents with dark purple or brown intradermal skin lesions that look like bruises but feel firmer. Tumours may occur anywhere on the skin or oropharynx — infiltration of the lungs or gut is rare but can be life threatening.

Answer 170

Abnormal cervical cytology may be a marker for underlying HIV infection.

Answer 171

Kaposi’s sarcoma Fungal skin and nail infections Viral infections such as herpes simplex (especially if the ulcers are unusually large or persistent), molluscum contagiosum, shingles (especially if more than one dermatome is affected), and warts. Bacterial infections such as impetigo and folliculitis. Seborrhoeic dermatitis and psoriasis

Answer 172

Oral candidiasis= Typically presents with thick white plaques covering the buccal mucosa that can be scraped off. Soreness of the mouth or pain on swallowing (odynophagia) may also be present. Aphthous ulcers Oral hairy leukoplakia Kaposi's sarcoma= Most often affects the hard and soft palate, gingiva, and dorsal tongue with plaques or tumours of variable colour from non-pigmented to brownish-red or purple. Gingivitis= Causes swelling and erythema of the gum margins that are usually painful and bleed on tooth brushing or flossing. Dental abscess= Typically presents with rapid onset of severe dental pain and may be associated with an unpleasant taste in the mouth, fever, and malaise.

Answer 173

Typically presents as asymptomatic corrugated whitish, hairy patches on the side of the tongue that cannot be scraped off (in contrast to oral candidiasis) and is pathognomic of immunosuppression.

Answer 174

Oesophageal candidiasis= Symptoms include retrosternal pain or dysphagia. Oral candidiasis is also likely to be present Diarrhoea= very common and may be persistent and mild or acute and severe. Infection due to bacteria, protozoa (such as Cryptosporidium), mycobacteria, or viruses; malignancy (such as non-Hodgkin's lymphoma or Kaposi's sarcoma), or the direct effects of HIV can all result in diarrhoea. Often no specific causative organism is identified. Hep B and C= Co-infection with hepatitis B or C is common and increases the risk of cirrhosis and hepatocellular carcinoma.

Answer 175

The laboratory is likely to telephone the result through and ask for a repeat sample. Emphasize the positive aspects — effective treatment can help prevent HIV-related illness and ensure that infection is not transmitted to contacts or in pregnancy. Explain the referral process — for further information, see the section on New diagnosis of HIV. Discuss concerns and sources of support. Arrange follow up within the next few days as the person is likely to have additional questions.

Answer 176

Conditions that would be AIDS defining in an individual living with HIV. Non-AIDS-defining conditions associated with an undiagnosed HIV seroprevalence >1 per 1000.

Answer 177

Antiretroviral therapy (ART) is taken regularly and viral load suppressed. The person's partner is also HIV positive (to prevent drug-resistant strains from being transferred).

Answer 178

combination of two antiretroviral drugs that are taken before and after sex to reduce the risk of HIV acquisition – it is offered on a case by case basis to HIV-negative people who are at high risk of HIV and who do not always use condoms. Signpost to a sexual health clinic people who may be eligible for PrEP — baseline HIV testing, counselling on risks and benefits, support to improve adherence, and regular HIV and STI screening is required.

Answer 179

Oral contraceptives and patches may have reduced effectiveness with some ART combinations. Long-acting reversible contraceptives such as the copper intrauterine device (Cu-IUD), the levonorgestrel-releasing intrauterine system (IUS), or depot medroxyprogesterone acetate (DMPA) injection do not appear to be affected by enzyme-inducing drugs.

Answer 180

A Cu-IUD is the recommended method of emergency contraception except in women with a CD4 less than 200 cells per microlitre and detectable HIV RNA (owing to potential higher risk of infection post procedure). If progesterone-only emergency contraception is used, a doubling of the standard dose may be advised (off-label).

Answer 181

Specialist fertility services input is recommended for all couples who wish to conceive where one or both partners are living with HIV. Options vary depending on concordance, treatment, and viral suppression and may include donor insemination, sperm washing, or self insemination.

Answer 182

Taking ART during pregnancy. Using ART at the time of delivery, together with a short course of ART for the newborn baby. Vaginal delivery for women on ART who have an undetectable viral load or elective Caesarean section for others. Avoidance of breastfeeding — be aware that avoidance of breastfeeding may lead to problems with speculation about, or even disclosure of, the mother’s HIV status. Advice and support should be available.

Answer 183

Confirm that the patient has capacity to make decisions. Explore their reasons for not attending — problems such as fear of being recognized at a local clinic may be addressed by changing to a geographically different service. Reinforce the benefits of attending specialist care. Consider, after discussion with the person's specialist and the local laboratory, assessing immunity by checking a CD4 count in primary care. Discuss with the person's specialist the option of prophylactic treatment against some opportunistic infections such as pneumocystis pneumonia.

Answer 184

present late or have co-morbidities. In people taking ART it can be more difficult to identify terminal illness — immunity may recover following a change in treatment regimen but the risk of overwhelming infection remains until this happens. Close communication between secondary and primary care services is particularly important.

Answer 185

Neoplasms: Cervical cancer. Non-Hodgkin lymphoma. Kaposi’s sarcoma. Bacterial infections: Mycobacterium tuberculosis, pulmonary or extrapulmonary. Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary. Mycobacterium, other species or unidentified species, disseminated or extrapulmonary. Pneumonia, recurrent (two or more episodes in 12 months). Salmonella septicaemia, recurrent. Viral infections: Cytomegalovirus retinitis. Cytomegalovirus, other (except liver, spleen, glands). Herpes simplex, ulcer(s) more than 1 month/bronchitis/pneumonitis. Progressive multifocal leukoencephalopathy. Parasitic infections: Cerebral toxoplasmosis. Cryptosporidiosis diarrhoea, more than 1 month. Isosporiasis, more than 1 month. Atypical disseminated leishmaniasis. Reactivation of American trypanosomiasis (meningoencephalitis or myocarditis). Fungal infections: Pneumocystis pneumonia (PCP). Candidiasis, oesophageal. Candidiasis, bronchial/tracheal/pulmonary. Cryptococcosis, extrapulmonary. Histoplasmosis, disseminated/extrapulmonary. Coccidioidomycosis, disseminated/extrapulmonary. Penicilliosis, disseminated.

Answer 186

Skin and skin wounds should be washed with soap and water, and mucous membranes irrigated with water. Squeezing the wound to express blood is not recommended. Eyes should be irrigated with saline or water before and after removing contact lenses. Puncture wounds should be encouraged to bleed freely, but should not be sucked. Small wounds and punctures may also be cleansed with an antiseptic, for example an alcohol-based hand hygiene solution.

Answer 187

course of antiretroviral therapy (ART).

Answer 188

They are an uninfected sexual partner of a person known to have HIV, to prevent infection after sex without a condom or where the condom has split. PEP is generally no longer recommended if the HIV-positive partner is adherent to ART and has been confirmed as having a sustained (more than 6 months) undetectable plasma HIV viral load (less than 200 copies/ml). They have had unprotected sex with a person in a high-risk group for HIV whose infection status is not known. PEPSE may be offered to victims of sexual assault depending on risk assessment.

Answer 189

72 hours of exposure and should be given as early as possible (ideally within 24 hours of exposure). Follow up should be arranged by the prescribing team — HIV testing is recommended 8–12 weeks after exposure. All people seeking PEPSE should be advised to attend for future regular sexual health checks.

Answer 190

Little risk of infections Hodgkin's lymphoma Cervical cancer

Answer 191

Bacterial skin infections Recurrent bacterial chest infections Tuberculosis Oropharyngeal candida Fungal infections Seborrhoeic dermatitis Direct HIV effects= Lymphadenopathy, Sweats

Answer 192

Oral hairy leukoplakia Shingles Pneumocystis pneumonia Persistent herpes simplex infection Non-Hodgkin's lymphoma Direct HIV effects= weight loss

Answer 193

Oesophageal candida Histoplasmosis Cryptococcal meningitis Cerebral toxoplasmosis Cryptosporidiosis ca= Kaposi's sarcoma Direct HIV effects= diarrhoea, wasting

Answer 194

Cytomegalovirus infections Atypical mycobacterium infections ca= Primary cerebral lymphoma Direct HIV effects= dementia

Answer 195

Methicillin-resistant Staphylococcus aureus

Answer 196

dangers of hospital acquired infections

Answer 197

all patients awaiting elective admissions (exceptions include day patients having terminations of pregnancy and ophthalmic surgery. Patients admitted to mental health trusts are also excluded) from 2011 all emergency admissions will be screened

Answer 198

nasal swab and skin lesions or wounds the swab should be wiped around the inside rim of a patient's nose for 5 seconds the microbiology form must be labelled 'MRSA screen'

Answer 199

nose: mupirocin 2% in white soft paraffin, tds for 5 days skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum

Answer 200

vancomycin teicoplanin linezolid

Answer 201

rifampicin macrolides tetracyclines aminoglycosides clindamycin

Answer 202

resistant cases

Answer 203

bacterium that colonizes the skin, nose, or gut of up to a third of the general population — it usually lives on intact skin harmlessly, but can cause infection if invasion through the skin or deeper tissues occurs.

Answer 204

lives on intact skin harmlessly, but can cause infection if invasion through the skin or deeper tissues occurs.

Answer 205

strains of S. aureus that have developed resistance to a number of commonly used antibiotics.

Answer 206

strains of MRSA identified in people who have had contact with healthcare services — they can present in hospital or in the community

Answer 207

Skin and soft tissue infections (such as boils, folliculitis, impetigo, cellulitis, and necrotising fasciitis). Urinary tract infection. Pneumonia and bronchiectasis. Joint and bone infections (such as osteomyelitis and septic arthritis). Sepsis and toxic shock syndrome. Infective endocarditis.

Answer 208

They have risk factors for MRSA (such as recent hospitalization, previous MRSA infection or colonization, nursing home contact, antibiotic use, chronic illness, surgical wounds, open ulcers, intravenous lines, or urinary catheters). There is no response to first line antibiotics. They have recurrent skin or soft tissue infections or a chronic non-healing ulcer.

Answer 209

thorough clinical assessment supported by confirmatory laboratory results from swabs of exudate (from lesions or wounds), urine samples, or sputum samples.

Answer 210

Appropriate infection control measures (in line with local policy) along with careful communication between healthcare professionals.

Answer 211

clinical features of severe or complicated infection or they require surgical intervention

Answer 212

discussed with a microbiologist or the local infection-control team. Routine treatment with oral or topical antibiotics is not advised, unless directed by microbiology. Follow up (after 48 hours, or sooner if worsening) is recommended to monitor for signs of complications (such as sepsis) and to ensure infection is resolving.

Answer 213

the person has risk factors (such as a wound or invasive device, or is resident in a care home).

Answer 214

skin & soft tissue infections bone and joint infection pneumonia UTI endocarditis sepsis

Answer 215

caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route.

Answer 216

foreign travel swimming/drinking water from a river or lake male-male sexual contact

Answer 217

often asymptomatic non-bloody diarrhoea= steatorrhoea bloating, abdominal pain lethargy flatulence weight loss malabsorption and lactose intolerance can occur

Answer 218

stool microscopy for trophozoite and cysts: sensitivity of around 65% stool antigen detection assay: greater sensitivity and faster turn-around time than conventional stool microscopy methods PCR assays are also being developed

Answer 219

metronidazole

Answer 220

first observed in Mexico in early 2009. In June 2009, the WHO declared the outbreak to be a pandemic.

Answer 221

subtype of the influenza A virus and the most common cause of flu in humans. The 2009 pandemic was caused by a new strain of the H1N1 virus.

Answer 222

patients with chronic illnesses and those on immunosuppressants pregnant women young children under 5 years old

Answer 223

flu-like illness: fever greater than 38ºC myalgia lethargy headache rhinitis sore throat cough diarrhoea and vomiting

Answer 224

an acute respiratory distress syndrome which may require ventilatory support

Answer 225

Oseltamivir (Tamiflu) (oral) Zanamivir (Relenza) (inhaled or IV)

Answer 226

oral medication a neuraminidase inhibitor which prevents new viral particles from being released by infected cells common side-effects include nausea, vomiting, diarrhoea and headaches

Answer 227

inhaled medication (or IV) also a neuraminidase inhibitor may induce bronchospasm in asthmatics

Answer 228

fever greater than 38ºC myalgia lethargy headache rhinitis sore throat cough diarrhoea and vomiting

Answer 229

1) The patient is in an at-risk group or is felt to be at risk of developing a serious complication 2) There is circulating influenza nationally- this would mean typically the winter months 3) The patient is able to start treatment within 48 hours from the onset of symptoms

Answer 230

> 65 years old pregnant women chronic disease of respiratory, cardiac, renal, hepatic or neurological nature diabetes immunosuppression morbid obesity.

Answer 231

First line: oseltamivir Second line: zanamivir

Answer 232

oseltamivir

Answer 233

RNA viruses of the family Orthomyxoviridae (influenza viruses)

Answer 234

occurs more frequently and is more virulent. It is responsible for local outbreaks, larger epidemics, and pandemics.

Answer 235

often co-circulates with influenza A during the yearly outbreaks. Generally, influenza B causes less severe clinical illness, although it can still be responsible for outbreaks.

Answer 236

usually causes a mild or asymptomatic infection similar to the common cold

Answer 237

winter months; typically between December and March

Answer 238

Acute bronchitis. Pneumonia. Exacerbations of asthma and chronic obstructive pulmonary disease. Otitis media. Sinusitis.

Answer 239

2d after exposure

Answer 240

coryza, nasal discharge, cough, fever, gastrointestinal symptoms, headache, malaise, myalgia, arthralgia, ocular symptoms, and sore throat

Answer 241

signs and symptoms that require hospital admission, involve the lower respiratory tract or central nervous system, or cause significant exacerbation of an underlying medical condition.

Answer 242

For otherwise healthy people, antiviral drugs (oseltamivir or zanamivir) are not usually recommended, unless they are at risk of developing serious complications.

Answer 243

oseltamivir should be prescribed if the national surveillance schemes indicate that influenza virus is circulating, and the person can start treatment within 48 hours.

Answer 244

if 'at risk' group antiviral, if the national surveillance schemes indicate that influenza virus is circulating, and the person can start treatment within 48 hours of the onset of symptoms (36 hours in the case of zanamivir in children). People considered to be in an 'at risk' group include: - Those with chronic respiratory, heart, kidney, liver, or neurological disease; diabetes mellitus; or those who are obese or immunosuppressed. - Those over the age of 65 years. - Women who are pregnant (or women up to 2 weeks postpartum). - Children aged under 6 months.

Answer 245

drink adequate fluids, take paracetamol or ibuprofen to relieve symptoms, rest, and stay off work or school until the worst symptoms have resolved (usually about 1 week).

Answer 246

The national surveillance scheme indicates that influenza is circulating. The person has been in close contact with a person (in the same household or residential setting) who has had recent symptoms of influenza. The person is in an 'at risk' group and has not been effectively immunized against influenza. The person is able to start treatment within 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir).

Answer 247

A complication such as pneumonia occurs. The person has a concomitant disease that may be affected by influenza (for example, type 1 diabetes). There is suspicion of a serious illness other than influenza (for example meningitis).

Answer 248

influenza is known to be circulating and if a person has a high fever

Answer 249

complicated influenza (although often this takes place in hospital). Initiation of antiviral treatment should not be delayed while awaiting laboratory confirmation.

Answer 250

an individual develops symptoms despite antiviral prophylaxis, or has a persistent infection despite antiviral treatment, to identify the potential development of antiviral resistance.

Answer 251

abruptly, around 2d after exposure

Answer 252

Signs and symptoms that require hospital admission. Presence of a lower respiratory tract infection (hypoxaemia, dyspnoea, and lung infiltrate). Central nervous system involvement. Significant exacerbation of an underlying medical condition.

Answer 253

Cervical adenopathy. Conjunctival erythema. Diarrhoea and vomiting — GI symptoms are more common in children than in adults. Fatigue. Fever (typically 38–40°C) — children can have a higher maximum temperature. They may also present with undifferentiated fever or febrile seizures. Hyperaemia of oropharynx. Irritability. Laryngotracheobronchitis (croup), bronchiolitis, or bronchitis. Myalgia or myositis — this can affect the calf muscles and be severe. It is a more common complication in children compared to adults. Tachypnoea.

Answer 254

no antiviral treatment is normally indicated, unless the person is at serious risk of developing serious complications from influenza, then prescribe oral oseltamivir.

Answer 255

prescribe oral oseltamivir. Do not wait for laboratory confirmation.

Answer 256

prescribe oral oseltamivir

Answer 257

prescribe inhaled zanamivir, or if this is unsuitable or inappropriate, prescribe oral oseltamivir and follow up.

Answer 258

To drink adequate fluids to avoid dehydration. To take paracetamol or ibuprofen for symptomatic relief. To rest in bed if they feel fatigued. To stay off work or school if they feel unable to attend — for most people, about 1 week will be adequate. That fever and associated systemic symptoms of uncomplicated influenza usually resolve after about 1 week, although some symptoms (such as cough and fatigue) may persist for up to 2 weeks after resolution of fever. About the symptoms of complicated influenza and to seek medical advice should their condition deteriorate.

Answer 259

14d before exposure

Answer 260

- The national surveillance scheme indicates that influenza is circulating. - The person has been exposed to a person (in the same household or residential setting) with an influenza-like illness. - The person is in an 'at risk' group and has not been adequately protected by vaccination, that is= They have not been vaccinated since the previous influenza season; The vaccination is not well matched to the circulating strain; There has been less than 14 days between vaccination and date of contact with influenza. - The person is able to start treatment within 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir). (after these times it is off label so get specialist advice)

Answer 261

Oral oseltamivir once daily for 10 days if the identified strain in the index case or dominant circulating strain is lower risk for oseltamivir resistance (for example, influenza A [H3N2], influenza B), or is known to be higher risk for oseltamivir resistance (for example, influenza A [H1N1]). Inhaled zanamivir daily for 10 days if the person has been exposed to suspected or confirmed oseltamivir-resistant influenza.

Answer 262

Oral oseltamivir once daily for 10 days if the identified strain in the index case or dominant circulating strain is lower risk for oseltamivir resistance (for example influenza A [H3N2] and influenza B). Inhaled zanamivir daily for 10 days if the identified strain in the index case or dominant circulating strain is higher risk for oseltamivir resistance (for example, influenza A [H1N1]), or if this is unsuitable or inappropriate, prescribe oral oseltamivir once daily for 10 days. Inhaled zanamivir daily for 10 days if the person has been exposed to suspected or confirmed oseltamivir-resistant influenza. If this is unsuitable or inappropriate seek specialist advice.

Answer 263

Prescribe oral oseltamivir once daily for 10 days if the identified strain in the index case or dominant circulating strain is lower risk for oseltamivir resistance (for example, influenza A [H3N2], influenza B), or is known to be higher risk for oseltamivir resistance (for example, influenza A [H1N1]). If the child has been exposed to suspected or confirmed oseltamivir-resistant influenza, seek specialist advice.

Answer 264

Arrange for the person to receive influenza immunization if this has not already been done in the present influenza season. Note: the efficacy of the vaccine may be reduced if it is administered within 2 weeks of use of an influenza antiviral agent. Inform the person that although antiviral drugs help prevent influenza, they are not completely effective. Provide advice about symptomatic treatment and when to seek medical attention if influenza develops.

Answer 265

Plasmodium protozoa

Answer 266

female Anopheles mosquito

Answer 267

Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae

Answer 268

Plasmodium falciparum

Answer 269

Plasmodium vivax (most common) also Plasmodium ovale Plasmodium malariae

Answer 270

- sickle cell trait - G6PD deficiency - HLA-B53 - absence of Duffy antigens

Answer 271

1) the mosquito ingests the parasite during blood feeding 2) the mosquito injects the parasite when it bites the human 3) sporozoites to human liver cell then into human blood cell 4) sexual stage= male and female gametocytes form 5) early mosquito stages= gametes to zygote to ookinete 6) oocyst, grows and releases sporozoites repeats

Answer 272

Falciparum malaria

Answer 273

with symptoms suggestive of a flu-like illness. The classical triad of symptoms includes paroxysms of fever, chills, and sweating. These symptoms may occur every 48 hours corresponding to the erythrocytic cycle of the Plasmodium falciparum parasite. Fever is often high, intermittent, and may be accompanied by rigors. Initial manifestations can be non-specific and include malaise, headache, and myalgia, which might be mistaken for a viral syndrome.

Answer 274

paroxysms of fever, chills, and sweating

Answer 275

the erythrocytic cycle of the Plasmodium falciparum parasite

Answer 276

The hallmark of malaria, typically cyclical, often accompanied by sweating and sometimes rigors. often high, intermittent, and may be accompanied by rigors

Answer 277

non-specific and include malaise, headache, and myalgia, which might be mistaken for a viral syndrome

Answer 278

- Fever - GI - Resp - MSK - Neuro - Cardiovascular - Haematological - Renal

Answer 279

anorexia, nausea, vomiting, and abdominal pain are frequent diarrhoea can occasionally be a feature, more commonly in children patients may exhibit mild jaundice and occasional pruritus

Answer 280

Cough and, in some cases, mild tachypnoea may occur, though primary respiratory complications are rare in non-severe cases.

Answer 281

Generalised body aches and joint pains are common.

Answer 282

headache is prominent and often severe. dizziness and sleep disturbances may also be observed.

Answer 283

Tachycardia may be evident, and although hypotension is more typical of severe malaria, it can occasionally be seen in non-severe cases as well.

Answer 284

thrombocytopaenia is the most significant haematological finding and can occur in the absence of severe disease. mild anaemia may also be present.

Answer 285

While acute kidney injury is associated with severe malaria, non-severe cases might show mild to moderate increases in creatinine or blood urea nitrogen levels.

Answer 286

schizonts on a blood film parasitaemia > 2% hypoglycaemia acidosis temperature > 39 °C severe anaemia complications

Answer 287

cerebral malaria: seizures, coma acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown acute respiratory distress syndrome (ARDS) hypoglycaemia disseminated intravascular coagulation (DIC)

Answer 288

strains resistant to chloroquine are prevalent in certain areas of Asia and Africa artemisinin-based combination therapies (ACTs) as first-line therapy - examples include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine

Answer 289

a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state intravenous artesunate is now recommended by WHO in preference to intravenous quinine if parasite count > 10% then exchange transfusion should be considered shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse

Answer 290

Plasmodium vivax, with Plasmodium ovale and Plasmodium malariae accounting for the other cases

Answer 291

Central America and the Indian Subcontinent whilst Plasmodium ovale typically comes from Africa

Answer 292

another non-falciparum species which causes clinical pathology, found predominantly in South East Asia

Answer 293

general features of malaria: fever, headache, splenomegaly Plasmodium vivax/ovale: cyclical fever every 48 hours. Plasmodium malariae: cyclical fever every 72 hours Plasmodium malariae: is associated with nephrotic syndrome.

Answer 294

relapse following treatment

Answer 295

in areas which are known to be chloroquine-sensitive then WHO recommend either an artemisinin-based combination therapy (ACT) or chloroquine in areas which are known to be chloroquine-resistant an ACT should be used ACTs should be avoided in pregnant women patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy liver hypnozoites and prevent relapse

Answer 296

life-threatening illness caused by infection of red blood cells by Plasmodium parasites. Transmission of malaria to humans occurs through the bite of infected female Anopheles mosquitoes.

Answer 297

Plasmodium falciparum — responsible for the majority of malaria related deaths worldwide. Plasmodium vivax and Plasmodium ovale — these species have dormant liver stages which can cause ‘relapses’ of malaria months or years after initial infection. Plasmodium malariae — if untreated can cause lifelong chronic infection. Plasmodium knowlesi — a malaria parasite of monkeys in South-East Asia which can cause severe and sometimes fatal illness in humans.

Answer 298

if identified promptly, appropriate treatment is given, and no organ dysfunction has occurred, most people make a rapid and complete recovery. If malaria treatment is delayed or inappropriate, severe or fatal malaria can develop.

Answer 299

anyone who has returned from or previously visited an area endemic for malaria who is unwell or has a fever or history of fever, regardless of malaria chemoprophylaxis. Most missed malaria infections are misdiagnosed as non-specific viral infections, influenza, gastroenteritis, or hepatitis.

Answer 300

Fever, sweats, and/or chills — absence of fever does not exclude the possibility of malaria. Headache. Confusion. General malaise, lethargy, and fatigue — somnolence is more common in children than in adults. Myalgia and arthralgia. Gastrointestinal disturbance (such as nausea, abdominal pain, vomiting, and diarrhoea). Anorexia, poor feeding in children. Jaundice. Sore throat, cough, lower respiratory tract symptoms, and respiratory distress.

Answer 301

Impaired conscious level, seizures, or prostration (inability to stand or sit). Renal impairment (may present with oliguria). Acidosis (may present with acidotic breathing). Hypoglycaemia — common in pregnant women. Respiratory distress which may be due to pulmonary oedema or acute respiratory distress syndrome (ARDS) – common in pregnant women. Severe anaemia (may present with pallor). Spontaneous bleeding/disseminated intravascular coagulation. Shock. Sepsis – more common in pregnant women. Haemoglobinuria — falciparum can cause severe haemolysis with dark red urine (‘blackwater fever’).

Answer 302

People with suspected severe or complicated malaria. People with suspected falciparum malaria. Pregnant women. Children. People who are older than 65 years of age.

Answer 303

infectious disease specialist — where capacity exists for close clinical and parasitological monitoring, clinicians experienced in the management of malaria may treat adults with malaria as outpatients.

Answer 304

notified to Public Health England

Answer 305

Severe malaria is more likely in children, pregnant women, older people, and immunocompromised people (for example those with splenectomy or HIV/AIDS).

Answer 306

species of Plasmodium parasite, severity of infection, tolerability of specific drugs, and patterns of drug resistance.

Answer 307

neurological and psychiatric symptoms Artesunate-type drugs are more efficacious and better tolerated in pregnancy than quinines Treatment failures are rare but have been noted and clinicians should be aware of the possibility

Answer 308

Artesunate= Parenteral artesunate is used to treat severe or complicated malaria; Intravenous artesunate can cause haemolysis and follow-up blood tests are required. Quinine= may be used initially to treat severe or complicated malaria if artesunate is unavailable. Artemisinin combination therapy (ACT)= ACT may be used to treat uncomplicated malaria and is the preferred treatment for mixed infection. Atovaquone-proguanil= may be used to treat uncomplicated falciparum malaria if ACT is unavailable. Quinine plus doxycycline= may be used to treat uncomplicated falciparum malaria if ACT is unavailable. Doxycycline should not be given to children younger than 12 years of age. Chloroquine= may be used to treat uncomplicated P. malariae, P. ovale, P. knowlesi, and most cases of P. vivax malaria but use depends upon patterns of resistance and tolerance. Primaquine= only currently effective drug for the eradication of hypnozoites (dormant parasites which persist in the liver after treatment of P. vivax and P. ovale). It is contraindicated in pregnancy and breastfeeding.

Answer 309

Screening for G6PD deficiency is essential before treatment with primaquine is started as it can cause haemolysis in G6PD deficient individuals, which can be fatal. It is contraindicated in pregnancy and breastfeeding.

Answer 310

LP if contraindicated (any signs of raised ICP) then blood cultures and PCR for meningococcus

Answer 311

any signs of raised ICP: - focal neuro signs - papilloedema - signif bulging of fontanelle - disseminated intravascular coagulation - signs of cerebral herniation

Answer 312

1) Abx 2) Dexamethasone in all <3m or if LP shows certain features 3) Fluids- Tx any shock 4) Cerebral monitoring= mechanical ventilation if resp impairment 5) public health notification and Abx prophylaxis of contacts

Answer 313

>3m= IV cefotaxime (or ceftriaxone) <3m or >50= IV amoxicillin (or ampicillin) + IV cefotaxime

Answer 314

if <3m or if LP shows= frankly purulent CSF; WBC >1000/microlitre; raised CSF WBC with protein conc >1g/litre; bacteria on gram stain

Answer 315

ciprofloxacin (preferred) or rifampicin

Answer 316

Group B Streptococcus (most common cause in neonates) E. coli Listeria monocytogenes

Answer 317

group B strep

Answer 318

Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae

Answer 319

Neisseria meningitidis Streptococcus pneumoniae

Answer 320

Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes

Answer 321

Listeria monocytogenes

Answer 322

sensorineural hearing loss (most common) seizures focal neurological deficit infective= sepsis, intracerebral abscess pressure= brain herniation, hydrocephalus

Answer 323

sensorineural hearing loss

Answer 324

Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage).

Answer 325

(adrenal insufficiency secondary to adrenal haemorrhage)

Answer 326

1) cloudy 2) glucose low (<1/2 plasma) 3) protein high (>1g/l) 4) white cells= 10-5000 polymorphs/mm3 5) opening pressure= high (>20)

Answer 327

1) clear/cloudy 2) glucose normal (60-80% of plasma glucose) 3) protein normal/high 4) white cells= 15-1000 lymphocytes/mm3 5) opening pressure= normal/high

Answer 328

1) slight cloudy, fibrin web 2) glucose low (<1/2 plasma) 3) protein high (>1g/l) 4) white cells= 30-300 lymphocytes/mm3 5) opening pressure= high

Answer 329

1) cloudy 2) glucose low (<1/2 plasma) 3) protein high (>1g/l) 4) white cells= 20-200 lymphocytes/mm3 5) opening pressure= high/very high

Answer 330

The Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR is sometimes used (sensitivity = 75%)

Answer 331

mumps and herpes encephalitis

Answer 332

fungal meningitis

Answer 333

TB meningitis

Answer 334

viral meningitis

Answer 335

bacterial meningitis

Answer 336

intertwined given the potential negative impact of delayed antibiotic treatment

Answer 337

give IM benzylpenicillin as long as doesn't delay transit to hospital

Answer 338

urgently transferred to hospital

Answer 339

1) A to E approach 2) senior review if any warning signs 3) consider LP 4) Mx

Answer 340

Airway Breathing Circulation Disability: GCS, ; focal neurological signs; seizures; papilloedema;

Answer 341

examples: rapidly progressive rash poor peripheral perfusion respiratory rate < 8 or > 30 / min or pulse rate < 40 or > 140 / min pH < 7.3 or WBC< 4 *109/L or lactate > 4 mmol/L GCS < 12 or a drop of 2 points poor response to fluid resuscitation

Answer 342

delay if contraindicated LPs require an aseptic technique and are potentially technical difficult - this means they make take time and delay other treatment on the other hand, having a CSF sample can be very useful in confirming the diagnosis and guiding antibiotic treatment as always, patient safety means that if there is any doubt IV antibiotics should be given as a priority

Answer 343

signs of severe sepsis or a rapidly evolving rash severe respiratory/cardiac compromise significant bleeding risk signs of raised intracranial pressure= focal neurological signs; papilloedema; continuous or uncontrolled seizures; GCS ≤ 12

Answer 344

Mx of pts without indication for delayed LP Mx of pts with signs of raised intracranial pressure Mx of pts with signs of severe sepsis or rapidly evolving rash

Answer 345

1) IV access= bloods and blood cultures 2) LP within 1hr (if not start Abx) 3) IV Abx 4) IV dexamethasone CT not normally indicated

Answer 346

if this cannot be done within the first hour, IV antibiotics should be given after blood cultures have been taken

Answer 347

consider adjunctive Tx with dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery

Answer 348

avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery'

Answer 349

1) get critical care input 2) secure airway + high-flow oxygen 3) IV access → take bloods and blood cultures 4) IV dexamethasone 5) IV antibiotics 6) arrange neuroimaging

Answer 350

1) get critical care input 2) secure airway + high-flow oxygen 3) IV access → take bloods and blood cultures 4) IV fluid resuscitation 5) IV antibiotics as above

Answer 351

full blood count renal function glucose lactate clotting profile CRP

Answer 352

glucose, protein, microscopy and culture lactate meningococcal and pneumococcal PCR enteroviral, herpes simplex and varicella-zoster PCR consider investigations for TB meningitis

Answer 353

3m-50yrs= IV cefotaxime (or ceftriaxone) <3m= IV cefotaxime + amoxicillin (or ampicillin) >50yrs= IV cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)

Answer 354

IV benzylpenicillin or cefotaxime (or ceftriaxone)

Answer 355

IV cefotaxime (or ceftriaxone)

Answer 356

IV cefotaxime (or ceftriaxone)

Answer 357

IV amoxicillin (or ampicillin) + gentamicin

Answer 358

chloramphenicol

Answer 359

households and close contacts of patients affected with meningococcal meningitis. Prophylaxis should also be offered to people who have been exposed to respiratory secretion, regardless of the closeness of contact.

Answer 360

risk to contacts is highest in the first 7 days but persists for at least 4 weeks

Answer 361

7d before onset

Answer 362

meningococcal vaccination should be offered to close contacts when serotype results are available, including booster doses to those who had the vaccine in infancy

Answer 363

no prophylaxis is generally needed. There are however exceptions to this. If a cluster of cases of pneumococcal meningitis occurs the HPA have a protocol for offering close contacts antibiotic prophylaxis.

Answer 364

inflammation of the leptomeninges and the cerebrospinal fluid of the subarachnoid space

Answer 365

inflammation attributed to a viral agent

Answer 366

viral may be considered to be a more benign condition and is much more common. Approximately 3,000 cases of confirmed viral meningitis are reported yearly, however, the actual number of cases is likely to be much higher, as patients often do not present to medical services.

Answer 367

non-polio enteroviruses e.g. coxsackie virus, echovirus mumps herpes simplex virus (HSV), cytomegalovirus (CMV), herpes zoster viruses HIV measles

Answer 368

patients at the extremes of age (< 5 years and the elderly) immunocompromised, e.g. patients with renal failure, with diabetes intravenous drug users

Answer 369

common features: - headache - evidence of neck stiffness - photophobia (often milder than the photophobia experienced by a patient with bacterial meningitis) - confusion - fevers less common features: - focal neurological deficits on examination - seizures: suggests a meningoencephalitis

Answer 370

LP viral PCR may demonstrate and underlying organism

Answer 371

Opening Pressure= 10 - 20 cm³ H²O (10 - 20 cm³ H²O) Cell count= 10-300 cells/µL (0 - 5 cells/µL) Cell differential= Lymphocytes (0 - 5 cells/µL lymphocyte-predominant) Glucose= 2.8 - 4.2 mmol/L or 2/3 serum glucose mmol/L ( 2.8 - 4.2 mmol/L or 2/3 paired serum glucose mmol/L) Protein= 0.5 - 1 g/dL (0.15 - 0.45 g/L)

Answer 372

whilst awaiting the results of the LP, Tx should be supportive and if there is any question of bacterial meningitis or of encephalitis, the patient should be commenced on broad-spectrum Abx with CNS penetration e.g. ceftriaxone and aciclovir intravenously. This is particularly the case if the patient has risk factors e.g. elderly, immunocompromised generally speaking, viral meningitis is self-limiting, with symptoms improving over the course of 7 - 14 days and complications are rare in immunocompetent patients aciclovir may be used if the patient is suspected of having meningitis secondary to HSV

Answer 373

broad-spectrum antibiotics with CNS penetration e.g. ceftriaxone and aciclovir intravenously. This is particularly the case if the patient has risk factors e.g. elderly, immunocompromised

Answer 374

babies and children

Answer 375

close contact, droplets, or direct contact with respiratory secretions

Answer 376

With prompt and adequate antimicrobial treatment and supportive therapy, the outcome of acute bacterial meningitis is excellent. The case-fatality rates for bacterial meningitis are 4–10% in children and 25% in adults.

Answer 377

pneumococcal meningitis and occur in about 30% of people compared with 7% with meningococcal meningitis.

Answer 378

Age — fatality rates are higher at extremes of age. The causative organism. Presence of comorbidities. Severity at presentation.

Answer 379

Fever. Headache. Neck stiffness. Altered level of consciousness or cognition (including confusion or delirium).

Answer 380

Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura). Rapidly progressive and/or spreading non-blanching petechial or purpuric rash. Any symptoms and signs of bacterial meningitis.

Answer 381

Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura). Rapidly progressive and/or spreading non-blanching petechial or purpuric rash.

Answer 382

Non-specific symptoms: fever, nausea and vomiting, lethargy, irritable or unsettled mood, refusal of food and drink, headache, muscle ache or joint pain, and respiratory symptoms such as a cough. More specific symptoms and signs: stiff neck, altered mental state (confusion, delirium and drowsiness, impaired consciousness), non-blanching rash, back rigidity, bulging fontanelle (in children younger than 2 years of age), photophobia, Kernig's sign, Brudzinski's sign, coma, paresis, focal neurological deficit, and seizures.

Answer 383

bacterial meningitis

Answer 384

Bacterial meningitis if there is likely to be a clinically significant delay in transfer to hospital. Meningococcal disease as soon as possible, unless this will delay transfer to hospital.

Answer 385

Fever, headache, neck stiffness, and altered level of consciousness or cognition (including confusion or delirium) Fever and neck stiffness are less common in babies. Headache and neck stiffness are harder to identify in babies and young children Bulging fontanelle In babies and young children with an open fontanelle Fever, headache, neck stiffness and altered level of consciousness or cognition are the red flag combination for bacterial meningitis Fever is less common in babies Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify Ask the child or young person (or their family members or carers) if they have taken antipyretics, because this may make ill appearance harder to identify Non-blanching petechial or purpuric rash= Mainly in meningococcal disease; Check all over the body and look for petechiae in the conjunctivae; May be difficult to see on brown, black or tanned skin Pale, mottled skin or cyanosis Irritability, lethargy agitated, aggressive or subdued. Ask family members or carers about changes in the child or young person's behaviour Weak, high-pitched or continuous cry Babies and children and young people with cognitive impairment or communication difficulties may not be able to report headache Tachypnoea, apnoea, and grunting. Non-specific signs of illness, including sepsis and meningitis in babies

Answer 386

Fever is less common in older adults Headache and neck stiffness are harder to identify in adults with cognitive impairment Neck stiffness is harder to identify in adults with dementia or arthritis Altered level of consciousness or cognition may be missed in young adults and older adults Non-blanching petechial or purpuric rash= Mainly in meningococcal meningitis and meningococcal disease (with or without meningococcal meningitis). Check all over the body and look for petechiae in the conjunctivae. May be difficult to see on brown, black or tanned skin Pale, mottled skin or cyanosis. May be difficult to see on brown, black or tanned skin. Lethargy in older adults. Bacterial meningitis may be missed in older adults with delirium or altered consciousness. In young people and young adults, altered behaviour may be incorrectly assumed to be caused by alcohol or substance misuse, and bacterial meningitis can be missed as a result.

Answer 387

adults with cognitive impairment, communication difficulties, dementia or arthritis children and young people with cognitive impairment or communication difficulties

Answer 388

Non-blanching petechial or purpuric rash

Answer 389

meningitis caused by meningococcal bacteria (Neisseria meningitidis) this type can lead to meningococcal septicemia (meningococcemia)

Answer 390

Ask the person (or their family members or carers) if they have taken antipyretics, because this may make fever harder to identify Fever is a particular concern for babies at the following levels: 39°C or higher in children aged 3 to 6 months 38°C or higher in children younger than 3 months

Answer 391

non-specific symptoms and signs, including fever, vomiting, irritability, reduced feeding in babies, and upper respiratory tract symptoms. These may be difficult to distinguish from other viral infections. Some children with bacterial meningitis present with seizures.

Answer 392

bacterial meningitis or meningococcal septicaemia, and the symptoms and signs may become more severe and more specific over time.

Answer 393

infants with bacterial meningitis.

Answer 394

Petechial rash (red or purple non-blanching macules smaller than 2 mm in diameter). Purpuric (haemorrhagic) rash (spots larger than 2 mm in diameter) — this may be absent in the early phase of the illness and may initially be blanching or macular in nature.

Answer 395

Examine the whole body systematically (including nappy areas) for rash and unusual skin colour — particularly for non-blanching rashes and petechiae. Advise to look for any changes in the rash, as it can change from blanching to non-blanching. Consider checking for non-blanching rashes using the 'glass test'. Be aware that the glass test should not be used solely for diagnosing bacterial meningitis and meningococcal septicaemia. A rash may be hard to detect on brown, black or tanned skin (even when using the glass test). Check paler areas of the body (such as the soles of the feet or palms of the hands) or the conjunctivae or palate.

Answer 396

This involves pressing the side of a glass or tumbler firmly against the rash to see if the rash fades or loses colour under pressure. A petechial or purpuric rash does not fade. Be aware that the glass test should not be used solely for diagnosing bacterial meningitis and meningococcal septicaemia.

Answer 397

The petechiae start to spread. The rash becomes purpuric. There are signs of bacterial meningitis. There are signs of meningococcal septicaemia. The child or young person appears unwell.

Answer 398

Meningococcal septicaemia is a type of blood poisoning that is caused by the same type of bacteria that cause the most common form of bacterial meningitis. Meningococcal meningitis and septicaemia are together known as meningococcal disease.

Answer 399

Capillary refill time of more than 2 seconds, cold hands and feet. Unusual skin colour. Tachycardia and/or hypotension. Respiratory symptoms or breathing difficulty. Leg pain. Toxic/moribund state. Altered mental state/decreased conscious level. Poor urine output.

Answer 400

Children aged 1-11 months — 300 mg. Children aged 1–9 years — 600 mg. Adults and children aged 10 years or over — 1200 mg.

Answer 401

Children aged 1 month–11 years (body-weight up to 50 kg) — 80 mg/kg (intramuscularly). Maximum dose 2000 mg. Children 9–11 years (body-weight 50 kg and above) — 2000 mg. Adults and children aged 12–17 years — 2000 mg.

Answer 402

rapidly spreading, life-threatening bacterial infection that destroys skin, fat, and muscle tissue. It is commonly referred to as a "flesh-eating disease." medical emergency

Answer 403

recognise in the early stages

Answer 404

the causative organism type 1 & type 2

Answer 405

caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type

Answer 406

caused by Streptococcus pyogenes

Answer 407

skin factors: recent trauma, burns or soft tissue infections diabetes mellitus= the most common preexisting medical condition; particularly if the patient is treated with SGLT-2 inhibitors intravenous drug use immunosuppression

Answer 408

the perineum (Fournier's gangrene)

Answer 409

necrotising fasciitis affecting he perineum

Answer 410

acute onset pain, swelling, erythema at the affected site often presents as rapidly worsening cellulitis with pain out of keeping with physical features extremely tender over infected tissue with hypoaesthesia to light touch skin necrosis and crepitus/gas gangrene are late signs fever and tachycardia may be absent or occur late in the presentation

Answer 411

skin necrosis and crepitus/gas gangrene

Answer 412

rapidly worsening cellulitis with pain out of keeping with physical features

Answer 413

urgent surgical referral debridement intravenous antibiotics

Answer 414

average mortality of 20%

Answer 415

The 'Proper Officer' at the Local Health Protection Team needs to be notified. They in turn will notify the Health Protection Agency on a weekly basis. HIV notified different.

Answer 416

Dysentery Ophthalmia neonatorum Leptospirosis Relapsing fever

Answer 417

Acute encephalitis Acute infectious hepatitis Acute meningitis Acute poliomyelitis Anthrax Botulism Brucellosis Cholera COVID-19 Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Haemolytic uraemic syndrome (HUS) Infectious bloody diarrhoea Invasive group A streptococcal disease Legionnaires Disease Leprosy Malaria Measles Meningococcal septicaemia Mumps Plague Rabies Rubella Severe Acute Respiratory Syndrome (SARS) Scarlet fever Smallpox Tetanus Tuberculosis Typhus Viral haemorrhagic fever (VHF) Whooping cough Yellow fever

Answer 418

relatively common complication of cancer therapy, usually as a consequence of chemotherapy

Answer 419

7-14d after chemotherapy

Answer 420

neutrophil count of < 0.5 * 109 in a patient who is having anticancer treatment and has one of the following: - a temperature higher than 38ºC or - other signs or symptoms consistent with clinically significant sepsis

Answer 421

neutropenic sepsis

Answer 422

coagulase-negative, Gram-positive bacteria are the most common cause, particularly Staphylococcus epidermidis this is probably due to the use of indwelling lines in patients with cancer

Answer 423

if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 109 as a consequence of their treatment they should be offered a fluoroquinolone

Answer 424

antibiotics must be started immediately, do not wait for the WBC following this initial treatment patients are usually assessed by a specialist and risk-stratified to see if they may be able to have outpatient treatment

Answer 425

piperacillin with tazobactam (Tazocin) many units add vancomycin if the patient has central venous access but NICE do not support this approach

Answer 426

alternative antibiotic such as meropenem is often prescribed +/- vancomycin if patients are not responding after 4-6 days the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT), rather than just starting therapy antifungal therapy blindly there may be a role for G-CSF in selected patients

Answer 427

potentially life-threatening complication of neutropenia. It is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower.

Answer 428

most common complication of anticancer treatment, and describes the presence of fever in a person with neutropenia.

Answer 429

cytotoxic chemotherapy and other immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders such as aplastic anaemia and myelodysplastic syndromes, and nutritional deficiencies. The risk of infection and/or sepsis increases with severe and/or prolonged neutropenia, and a rapid decline in neutrophil count.

Answer 430

death, organ failure, invasive and atypical infection, coagulopathy, encephalopathy and delirium, and long term physical, psychological and/or cognitive sequelae.

Answer 431

Has confirmed infection, or symptoms or signs indicating possible infection (may be minimal, atypical, or absent). Has a temperature greater than 38°C (may be afebrile or have a low temperature). Has clinical features of possible sepsis (may be minimal, atypical, or absent). Appears unwell or there is concern from a relative or carer that there is a change in appearance or behaviour.

Answer 432

Evaluation for physiological symptoms and signs to identify the risk of serious complications.

Answer 433

should include implementation of the 'Sepsis Six' bundle of care within the first hour following recognition of sepsis by: Arranging emergency transfer to hospital (usually by 999 ambulance) if the person is critically unwell. Arranging emergency transfer to the local oncology or haematology unit, or medical assessment unit, if the person is clinically stable, depending on local referral pathways.

Answer 434

Liaising with the person's specialist if there is any uncertainty or concern regarding the clinical presentation, such as persistent fever. Providing advice on the nature of sepsis, what to expect during recovery after sepsis, and sources of information and support. Providing information on how and when to seek specialist advice on any symptoms or concerns, and when to seek emergency care, for example if there is fever, signs of infection, or the person is feeling unwell. Assessing and managing any complications following sepsis.

Answer 435

hypothermia. In addition, medication such as corticosteroids may mask an elevated temperature.

Answer 436

life-threatening organ dysfunction caused by dysregulated host response to an infection

Answer 437

life-threatening organ dysfunction caused by a dysregulated host response to infection

Answer 438

a more severe form sepsis, technically defined as 'in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone'

Answer 439

sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection septic shock: a more severe form sepsis, technically defined as 'in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone'

Answer 440

quickSOFA (qSOFA) score meeting >= 2 of the following criteria: respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100mmHg or less

Answer 441

Respiratory rate > 22/min Altered mentation Systolic blood pressure < 100 mm Hg Within an ICU setting a full SOFA score is often used.

Answer 442

Adult patients outside of ICU with suspected infection are identified as being at heightened risk of mortality if they have quickSOFA (qSOFA) score meeting >= 2

Answer 443

Responds only to voice or pain/ unresponsive Acute confusional state Systolic B.P <= 90 mmHg (or drop >40 from normal) Heart rate > 130 per minute Respiratory rate >= 25 per minute Needs oxygen to keep SpO2 >=92% Non-blanching rash, mottled/ ashen/ cyanotic Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr Lactate >=2 mmol/l Recent chemotherapy

Answer 444

Relatives concerned about mental status Acute deterioration in functional ability Immunosuppressed Trauma/ surgery/ procedure in last 6 weeks Respiratory rate 21-24 Systolic B.P 91-100 mmHg Heart rate 91-130 OR new dysrhythmia Not passed urine in last 12-18 hours Temperature < 36ºC Clinical signs of wound, device or skin infection

Answer 445

the underlying cause

Answer 446

1) Give oxygen 2) Take blood cultures 3) Give broad spectrum Abx 4) Give IV fluid challenge= bolus of 500ml crystalloid (saline) over less than 15mins 5) Measure serum lactate 6) Measure hourly urine output

Answer 447

a vasopressor requirement to maintain a MAP ≥ 65mmHg and serum lactate >2mmol/L in the absence of hypovolemia

Answer 448

abnormality by organ system and accounts for clinical interventions. However, laboratory variables, namely, PaO2, platelet count, creatinine level, and bilirubin level, are needed for full computation.

Answer 449

score 0= >400 score 1= <400 score 2= <300 score 3= <200 score 4= <100

Answer 450

score 0= >150 score 1= <150 score 2= <100 score 3= <50 score 4= <20

Answer 451

score 0= 20 score 1= 20-32 score 2= 33-101 score 3= 102-204 score 4= >204

Answer 452

score 0= MAP >70mmHg score 1= MAP 70mmHg score 2= Dopamine <5 or dobutamine (any dose) score 3= Dopamine 5.1-15 or epinephrine 0.1 or norepinephrine 0.1 score 4= Dopamine >15 or epinephrine >0.1 or norepinephrine >0.1

Answer 453

score 0= 15 score 1= 13-14 score 2= 10-12 score 3= 6-9 score 4= <6

Answer 454

score 0= <110 score 1= 110-170 score 2= 171-299 score 3= 300-440 score 4= >440

Answer 455

score 0= >500 score 1= >500 score 2= >500 score 3= <500 score 4= <200

Answer 456

prompt and appropriate intervention, if not already being instituted

Answer 457

syndrome defined as life-threatening organ dysfunction due to a dysregulated host response to infection

Answer 458

subset of sepsis, which describes circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality than sepsis alone

Answer 459

multifactorial response to an infecting pathogen that may be amplified by host factors (such as genetics, age, and co-morbidities), the pathogen (type, virulence, and burden), and the environment.

Answer 460

respiratory, gastrointestinal, renal, and genitourinary tracts

Answer 461

extremes of age; people who are frail, immunocompromised, or immunosuppressed; people who have had recent trauma or surgery; people with a breach in skin integrity; and women who are pregnant, are post-partum, or have had a recent termination of pregnancy or miscarriage

Answer 462

organ failure, recurrent or secondary infection, and death

Answer 463

any person presenting with: - Symptoms or signs indicating possible infection causing significant illness or deterioration. These may be non-specific and non-localized, such as general malaise, agitation, or behavioural change. - One or more risk factor(s) for sepsis, and who looks unwell. - Concern from a relative or carer that there is a change in appearance or behaviour.

Answer 464

Evaluation for physiological symptoms and signs to identify markers of increased risk of severe illness or death. Use of a sepsis risk stratification tool to assess the risk of clinical deterioration from sepsis.

Answer 465

high risk of severe illness or death from sepsis, or moderate-to-high risk in certain clinical situations

Answer 466

if they are at high risk of severe illness or death from sepsis, but transfer of care to hospital would be unnecessarily burdensome or inappropriate, for example people who are very frail or approaching the end of life they are at low risk of severe illness or death from sepsis, and providing safety-netting information.

Answer 467

any underlying condition and arranging follow-up in primary care, if there are any moderate-to-high risk criteria for severe illness or death from sepsis, and a definitive diagnosis has been identified, and this can be treated in primary care.

Answer 468

Providing the person and/or carers with advice on the nature of sepsis, what to expect during recovery, and sources of information and support. Assessing and managing any complications following sepsis, such as anxiety and/or post-traumatic stress disorder; persistent fatigue; or chronic pain.

Answer 469

Older children may present with a focus of infection, while infants and neonates usually present with non-specific symptoms and signs.

Answer 470

lowered core temp

Answer 471

normal blood pressure does not exclude sepsis.

Answer 472

High risk of severe illness or death from sepsis if they meet any of the relevant high risk criteria. Moderate to high risk of severe illness or death from sepsis if they meet any of the relevant moderate to high risk criteria.

Answer 473

No response to social cues; Appears ill to a healthcare professional; Does not wake, or if roused does not stay awake; Weak high pitched or continuous cry Resp: - any= Grunting; Apnoea; Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline - <1yrs= RR 60+ - 1-2yrs= RR 50+ - 3-4yrs= RR 40+ Circulation: - any= HR <60 - <1yrs= HR 160+ - 1-2yrs= HR 150+ - 3-4yrs= HR 140+ Skin= Mottled or ashen appearance; Cyanosis of skin, lips, or tongue; Non-blanching rash of skin or purpric rash Temp: - any= <36C - <3m= 38C+

Answer 474

Not responding normally to social cues; No smile; Wakes only with prolonged stimulation; Decreased activity; Parent or carer concern that child is behaving differently from usual Resp: - Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline; Nasal flaring - <1yr= RR 50-59 - 1-2yrs= RR 40-49 - 3-4yrs= RR 35-39 Circulation: - Capillary refill time of 3 seconds or more; Reduced urine output; For catheterized patients, passed less than 1 ml/kg of urine per hour - <1yrs= HR 150-159 - 1-2yrs= HR 140-149 - 3-4yrs= HR 130-139 Skin: - Pallor of skin, lips, or tongue Temp: - 3-6m= 39C + Other= leg pain, cold hands or feet

Answer 475

Objective evidence of altered behaviour or mental state; Appears ill to a healthcare professional; Does not wake or if roused does not stay awake Resp: - any= Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline - 5yrs= RR 29+ - 6-7yrs= RR 27+ - 8-11yrs= RR 25+ Circulation: - any= HR <60 - 5yrs= HR 130+ - 6-7yrs= HR 120+ - 8-11yrs= HR 115+ Skin= Mottled or ashen appearance; Cyanosis of skin, lips, or tongue; Non-blanching rash of skin

Answer 476

Not behaving normally; Decreased activity; Parent or carer concern that the child is behaving differently from usual Resp: - any= Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline - 5yrs= RR 24-28 - 6-7yrs= RR 24-26 - 8-11yrs= RR 22-24 Circulation: - any= Capillary refill time of 3 seconds or more; Reduced urine output; For catheterized patients, passed less than 1 ml/kg of urine per hour - 5yrs= HR 120-129 - 6-7rs= HR 110-119 - 8-11yrs= HR 105-114 Tympanic T <36 Leg pain; cold hands or feet

Answer 477

Objective evidence of new altered mental state Resp= Raised respiratory rate: 25 breaths per minute or more; New need for oxygen (40% FiO2 or more) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) BP= Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40 mmHg below normal Circulation= Raised heart rate: more than 130 beats per minute; Not passed urine in previous 18 hours; For catheterized patients, passed less than 0.5 ml/kg of urine per hour Mottled or ashen appearance; Cyanosis of skin, lips, or tongue; Non-blanching petechial or purpuric rash

Answer 478

History from patient, friend, or relative of new onset of altered behaviour or mental state; History of acute deterioration of functional ability; Impaired immune system (illness or drugs including oral steroids); Trauma, surgery, or invasive procedures in the last 6 weeks RR 21-24 Systolic blood pressure 91–100 mmHg Raised heart rate: 91–130 beats per minute (for pregnant women 100–130 beats per minute) or new onset arrhythmia; Not passed urine in the past 12–18 hours; For catheterized patients, passed 0.5–1 ml/kg of urine per hour Tympanic temperature less than 36°C Signs of potential infection, including redness, swelling, or discharge at surgical site or breakdown of wound

Answer 479

Blood gas including glucose and lactate measurement — hypoglycaemia may result from depleted glycogen stores; hyperglycaemia may result from the stress response to sepsis; hyperlactataemia is a non-specific indicator of cellular or metabolic stress and is a marker of illness severity, with a higher level predictive of higher mortality rates. Blood culture — ideally done before antibiotic administration, to identify a primary bacteraemia. FBC — white cell count may be high or low; thrombocytopenia may indicate disseminated intravascular coagulation (DIC). CRP — may indicate infection and/or inflammation. Creatinine, urea, and electrolytes — may indicate dehydration and/or acute kidney injury. LFTs — increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction. Clotting screen — if abnormal may indicate coagulopathy/DIC. Urine analysis and culture, CXR, and additional investigations depending on the person's clinical presentation — this may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.RP

Answer 480

central venous access and initiation of inotropes (increase cardiac output by increasing cardiac contractility) or vasopressors (increase blood pressure by increasing peripheral vascular resistance), to maintain perfusion pressure.

Answer 481

severe systemic reaction to staphylococcal exotoxins, the TSST-1 superantigen toxin. It came to prominence in the early 1980s following a series of cases related to infected tampons.

Answer 482

infected tampons

Answer 483

fever: temperature > 38.9ºC hypotension: systolic blood pressure < 90 mmHg diffuse erythematous rash desquamation of rash, especially of the palms and soles involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)

Answer 484

removal of infection focus (e.g. retained tampon) IV fluids IV antibiotics

Answer 485

breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality.

Answer 486

pts own body

Answer 487

Shaving the wound using a razor (disposable clipper preferred) Using a non-iodine impregnated incise drape if one is deemed to be necessary Tissue hypoxia Delayed administration of prophylactic antibiotics in tourniquet surgery

Answer 488

Don't remove body hair routinely If hair needs removal, use electrical clippers with a single-use head (razors increase infection risk) Abx prophylaxis if: - placement of prosthesis or valve - clean-contaminated surgery - contaminated surgery Use local formulary: - Aim to give single-dose IV antibiotic on anaesthesia - If a tourniquet is to be used, give prophylactic antibiotics earlier

Answer 489

Abx prophylaxis if: - placement of prosthesis or valve - clean-contaminated surgery - contaminated surgery Use local formulary: - Aim to give single-dose IV antibiotic on anaesthesia - If a tourniquet is to be used, give prophylactic antibiotics earlier

Answer 490

Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI) Cover surgical site with dressing A recent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCTs Wound edge protectors do not appear to confer benefit

Answer 491

Tissue viability advice for management of surgical wounds healing by secondary intention.

Answer 492

typically a benign, self-limiting disease, with a serious outcome being very rare

Answer 493

RNA picornavirus

Answer 494

faecal-oral spread, often in institutions

Answer 495

- flu-like prodrome - abdominal pain: typically right upper quadrant - tender hepatomegaly - jaundice - deranged liver function tests

Answer 496

rare and there is no increased risk of hepatocellular ca

Answer 497

an effective vaccine is available after the initial dose a booster dose should be given 6-12 months later

Answer 498

men who have sex with men people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old people with chronic liver disease patients with haemophilia injecting drug users individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates

Answer 499

double-stranded DNA hepadnavirus

Answer 500

exposure to infected blood or body fluids, including vertical transmission from mother to child

Answer 501

fever, jaundice, elevated liver transaminases

Answer 502

chronic hepatitis (5-10%). fulminant liver failure (1%) hepatocellular carcinoma glomerulonephritis polyarteritis nodosa cryoglobulinaemia

Answer 503

chronic hepatitis due to hep B

Answer 504

'Ground-glass' hepatocytes

Answer 505

- children at 2,3 & 4m - a risks groups

Answer 506

healthcare workers, intravenous drug users, sex workers, close family contacts of an individual with hepatitis B, individuals receiving blood transfusions regularly, chronic kidney disease patients who may soon require renal replacement therapy, prisoners, chronic liver disease patients

Answer 507

HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology

Answer 508

around 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine. Risk factors include age over 40 years, obesity, smoking, alcohol excess and immunosuppression

Answer 509

only recommended for those at risk of occupational exposure (i.e. Healthcare workers) and patients with chronic kidney disease. In these patients anti-HBs levels should be checked 1-4 months after primary immunisation

Answer 510

Indicates adequate vaccine response, no further testing required. Should still receive booster at 5 years

Answer 511

Suboptimal response to vaccine - one additional vaccine dose should be given. If immunocompetent no further testing is required

Answer 512

Non-responder to vaccine. Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus.

Answer 513

pegylated interferon-alpha used to be the only treatment available NICE still advocate the use of pegylated interferon firstl-line other antiviral medications are increasingly used with an aim to suppress viral replication (not in a dissimilar way to treating HIV patients) examples include tenofovir, entecavir and telbivudine (a synthetic thymidine nucleoside analogue)

Answer 514

pegylated interferon-alpha

Answer 515

reduces viral replication in up to 30% of chronic carriers

Answer 516

female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy

Answer 517

all pregnant women

Answer 518

complete course of vaccination + hepatitis B immunoglobulin studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy there is little evidence to suggest caesarean section reduces vertical transmission rates

Answer 519

NO (HIV can)

Answer 520

hep B surface antigen

Answer 521

the first marker to appear and causes the production of anti-HBs

Answer 522

acute disease (present for 1-6m)

Answer 523

HBsAg present for >6m

Answer 524

chronic disease (i.e. infective)

Answer 525

Hepatitis B surface antibody

Answer 526

implies immunity (either exposure or immunisation); negative in chronic disease

Answer 527

Hepatitis B core antibody

Answer 528

previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists

Answer 529

IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists

Answer 530

Hepatitis B virus (HBV) e antigen is a small polypeptide, which exists in a free form in the serum of individuals during the early phase of hepatitis B infection, soon after hepatitis B virus surface antigen (HBsAg) becomes detectable.

Answer 531

results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity

Answer 532

anti-HBs positive, all others negative

Answer 533

anti-HBc positive, HBsAg negative

Answer 534

anti-HBc positive, HBsAg positive

Answer 535

HBsAg = ongoing infection, either acute or chronic if present > 6 months anti-HBc = caught, i.e. negative if immunized

Answer 536

200,000 in UK

Answer 537

intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs)

Answer 538

RNA flavivirus

Answer 539

IVDU most common the risk of transmission during a needle stick injury is about 2% the vertical transmission rate from mother to child is about 6%. The risk is higher if there is coexistent HIV the risk of transmitting the virus during sexual intercourse is probably less than 5%

Answer 540

only 30% have features - transient rise in serum aminotransferaes/jaundice - fatigue - arthralgia

Answer 541

HCV RNA Ix of choice for acute infection whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies

Answer 542

around 15-45% of patients will clear the virus after an acute infection (depending on their age and underlying health) and hence the majority (55-85%) will develop chronic hepatitis C

Answer 543

persistence of HCV RNA in the blood for 6m

Answer 544

rheumatological problems: arthralgia, arthritis eye problems: Sjogren's syndrome cirrhosis (5-20% of those with chronic disease) hepatocellular cancer cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal) porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse membranoproliferative glomerulonephritis

Answer 545

the viral genotype so this should be tested prior to Tx

Answer 546

clearance rates of around 95%

Answer 547

sustained virological response (SVR) defined as undetectable serum HCV RNA 6m after the end of therapy

Answer 548

undetectable serum HCV RNA 6m after the end of therapy

Answer 549

combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

Answer 550

side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic

Answer 551

side-effects: flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Answer 552

vertical transmission rate from mother to child is about 6%. The risk is higher if there is a high viral load or coexistent HIV

Answer 553

standard drug therapy cannot be used in pregnancy due to concerns about teratogenicity HCV-positive pregnant women should be monitored throughout pregnancy HCV RNA and LFTs should be done as early as possible into prenatal care to assess the risk of transmission and degree of liver disease if pruritic or they develop jaundice, suspect intrahepatic cholestasis of pregnancy and perform LFTs. invasive procedures should be minimised in mother and fetus to prevent vertical transmission not routine to offer c-section

Answer 554

exposure to maternal blood eg. due to perineal tears

Answer 555

single stranded RNA (it is an incomplete virus) requires hepatitis B surface antigen to complete its replication and transmission cycle.

Answer 556

similar to hep B- exchange of bodily fluids (through blood-to-blood contact or sexual contact)

Answer 557

an incomplete RNA virus that requires hepatitis B surface antigen to complete its replication and transmission cycle.

Answer 558

Hepatitis B and Hepatitis D infection at the same time.

Answer 559

A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection.

Answer 560

high risk of fulminant hepatitis (acute liver failure), chronic hepatitis and cirrhosis

Answer 561

Diagnosis is made via reverse polymerase chain reaction of hepatitis D RNA

Answer 562

Interferon but poor evidence base.

Answer 563

RNA hepevirus

Answer 564

faecal-oral route

Answer 565

Central and South-East Asia, North and West Africa and Mexico

Answer 566

hep A but carries a significant mortality (about 20%) during pregnancy

Answer 567

does not cause chronic disease or an increased risk of hepatocellular cancer

Answer 568

currently in development but not yet in widespread use

Answer 569

inflammation of the liver caused by infection with the hepatitis A virus. Transmission is through the faecal-oral route.

Answer 570

uncommon in the UK and usually presents as sporadic cases, community-wide outbreaks (from person-to-person transmission), or point-of-source outbreaks (related to contaminated food).

Answer 571

usually a self-limiting illness with a good prognosis — unlike hepatitis B and C, it does not cause chronic liver disease. Complications include relapsing hepatitis (in about 15% of infected symptomatic people) and, rarely, acute liver failure (in less than 0.1% of people).

Answer 572

The prodromal phase includes flu-like symptoms, gastrointestinal symptoms (such as anorexia, nausea, vomiting, and abdominal right upper quadrant discomfort), and occasionally headache, cough, pharyngitis, constipation, diarrhoea, itch, and urticaria. There may be no specific signs on examination. The icteric phase includes jaundice, pale stools, and dark urine (if there is cholestasis); pruritus; fatigue; anorexia; nausea; and vomiting — symptoms often improve once jaundice occurs. Hepatomegaly, splenomegaly, lymphadenopathy, and hepatic tenderness may be present on examination. The convalescent phase includes malaise and hepatic tenderness.

Answer 573

Meeting the clinical case definition and having IgM and IgG antibodies to hepatitis A. Having hepatitis A RNA (HAV RNA) detected regardless of clinical features. Being asymptomatic with no recent history of immunisation, but having anti-HAV IgM in oral fluid or serum, and having an epidemiological link to a confirmed hepatitis A case.

Answer 574

Admission to hospital if they are severely unwell. Provision of symptomatic supportive care if admission is not indicated. Notifying the local Health Protection Unit promptly. Providing information and advice about hepatitis A, including the need to avoid alcohol during the acute illness. Offering referral to a genito-urinary medicine clinic or drug rehabilitation centre, if appropriate. Arranging follow up and monitoring liver function and prothrombin time, at a frequency dependent on clinical judgement, the person's symptoms, and liver function test results. Advising the person to seek medical attention if their symptoms worsen.

Answer 575

The person to avoid work, school, or nursery, until they are no longer infectious (typically 7 days after the onset of jaundice or 7 days after the onset of symptoms if there is no history of jaundice). The person and all close contacts about thorough hand washing after using the toilet, changing nappies, and helping with child toileting; ensuring good general personal hygiene; avoiding handling food; thorough hand washing before food preparation; practising safe sex until they are no longer infectious; and avoiding sharing drug paraphernalia.

Answer 576

hepatitis A vaccination if they are not already immune

Answer 577

Jaundice, pale stools, and dark urine if cholestasis — jaundice may occur in 70-80% of infected adults. Pruritus — common in the icteric phase. Fatigue, anorexia, nausea, and vomiting — symptoms often improve once jaundice occurs. Hepatomegaly and right upper quadrant tenderness — often present on examination; hepatomegaly may occur in up to 80% of symptomatic people. Splenomegaly and lymphadenopathy occur less commonly.

Answer 578

malaise, anorexia, muscle weakness, and hepatic tenderness. Recovery usually takes about a month in young people but may take up to 6 months in others. Complications are more likely in people with pre-existing liver disease and older people. Hepatitis A does not cause chronic liver disease and following clearance of infection lifelong immunity is acquired.

Answer 579

HAV-IgM antibodies are typically present 5-10 days before the onset of symptoms, peak within a month of illness, and usually remain positive for 45-60 days but can persist for 6 months or more. HAV-IgG antibodies are typically detectable at or just before the onset of symptoms and then persist to provide lifelong immunity.

Answer 580

acute hepatitis A infection is likely.

Answer 581

suggests hepatitis A infection in the recent past rather than current acute infection.

Answer 582

gM result may be a false positive.

Answer 583

uggests past hepatitis A infection or immunity from previous vaccination.

Answer 584

Timing of illness onset —if serology is taken in the first 5 days after the onset of symptoms, there is a small risk of a false negative result — serology should be repeated. The age of the person — false IgM results are more likely in older people, a group likely to have had hepatitis A in childhood. Co-morbidities — HAV IgM serology may not be reliable in patients who are significantly immunocompromised — consider referring for HAV PCR. Risk factors for hepatitis A. Results of liver function tests (see below)

Answer 585

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be significantly increased (usually between 500 and 10,000 IU/L). Bilirubin may be elevated (usually between 85.5 and 171 micromols/L, but can reach up to 500 micromols/L). Alkaline phosphatase is generally less than 2x the upper limit of normal, but higher if there is cholestasis. Prothrombin time may be prolonged (3 seconds or more suggests severe hepatitis and 50 seconds or more suggests acute liver failure).

Answer 586

a booster dose 6-12 months later if the person remains at long-term risk of contracting hepatitis A.

Answer 587

Infection in early pregnancy is not thought to increase the risk of congenital malformation in the infant. They may be at increased risk of preterm labour if infection occurs in the second or third trimester and should seek urgent medical advice if symptoms develop or they are concerned. Breastfeeding is not known to pose a specific risk — thorough hand washing and personal hygiene should be maintained.

Answer 588

Consider more frequent follow-up if the person is symptomatic, and/or has jaundice, and depending on the results of liver function tests). Repeat liver function tests until amino-transferase levels are normal (usually 4–12 weeks). Seek specialist advice if the person has significantly abnormal liver function tests or coagulation screen, or if liver function appears to be worsening. Advise the person to seek medical attention if symptoms worsen (particularly if they include vomiting and dehydration) and to be aware of the signs of hepatic decompensation (change in personality or level of consciousness). Admit the person to hospital if they become severely unwell.

Answer 589

Contact the local Health Protection Unit (HPU) immediately, who will advise on further management if the person has not previously received the hepatitis A vaccine. This may include giving hepatitis A vaccination and/or arranging for the administration of human normal immunoglobulin, depending on the timing and circumstances of contact, as well as other factors including the person's age and co-morbidities.

Answer 590

transmission occurs through contact with infected blood or body fluids. In areas of low endemicity (such as the UK), most HBV infections are acquired in adulthood through sexual transmission or sharing of contaminated injecting drug use equipment. In areas of high endemicity, HBV infection is predominantly acquired through perinatal transmission or horizontal transmission among young children.

Answer 591

overseas in endemic countries prior to arrival in the UK. Most acute HBV infections in the UK are acquired through sexual transmission and injecting drug use.

Answer 592

hepatitis B surface antigen (HBsAg) and IgM antibodies to hepatitis B core antigen (anti-HBc).

Answer 593

Children, in particular infants and younger children, are usually asymptomatic during acute infection. Up to a third of adults develop symptoms (which may include fever, malaise, right upper quadrant abdominal pain and jaundice) with acute infection. Jaundice occurs in about 10% of younger children and in 30-50% of adults. When present, symptoms usually last between 1 and 6 weeks. Hepatitis B surface antigen (HBsAg) is cleared in around 95% of immunocompetent adults. Fulminant hepatitis occurs in fewer than 1% of people but can be fatal.

Answer 594

persistence of HBsAg for six months or more after acute infection with hepatitis B virus.

Answer 595

90% of infants infected perinatally (if not vaccinated); 20-50% of children infected between one and five years of age and about 5% of immunocompetent adults. Most people with chronic hepatitis B infection are asymptomatic. Approximately 20-25% of people with chronic HBV infection develop progressive liver disease, which can lead to cirrhosis and increased risk of hepatocellular cancer.

Answer 596

Infants, as part of the routine childhood immunisation programme. People at high risk of exposure to the virus or complications of the disease. People potentially exposed to HBV through accidental inoculation (such as needlestick or other ‘sharp’, bites, or scratch injuries) or contamination of mucous membranes or non-intact skin — hepatitis B immunoglobulin (HBIG) prophylaxis may also be indicated. Babies born to pregnant women living with Hepatitis B — HBIG prophylaxis may also be indicated.

Answer 597

Admission if severely unwell. Referral to a liver specialist for further investigation, treatment (where indicated) and follow-up. Offering symptomatic supportive treatment (rest, pain relief, and treatment of nausea and itch) if needed while the person is awaiting referral. Notifying the Health Protection Unit. Offering advice on avoidance of alcohol and prevention of transmission of infection. Offering referral to a genito-urinary medicine clinic and/or drug rehabilitation agency, if appropriate.

Answer 598

A prodromal illness that includes fever, arthralgia, or a rash (that may appear about 2 weeks before the onset of jaundice, then resolves). Non-specific malaise (which may be profound), fatigue, nausea, and poor appetite. Right upper quadrant abdominal pain. Jaundice (with dark urine and/or pale stools if cholestasis is present) — occurs in about 10% of younger children and in 30-50% of adults. Extrahepatic manifestations such as glomerulonephritis, vasculitis, and polyarteritis.

Answer 599

there are often no physical signs or symptoms. After many years of infection, depending on the severity and duration, signs of chronic liver disease may develop, such as: Spider naevi. Finger clubbing. Jaundice. Palmar erythema. Hepatosplenomegaly. In severe cases thin skin, bruising, ascites, liver flap, and encephalopathy.

Answer 600

Acute hepatitis B infection is asymptomatic in almost all infants and children and 10-50% of adults. Fulminant hepatitis is a rare complication of acute hepatitis B infection (affects less than 1% of people). If present, however, it can progress rapidly to life-threatening liver failure with coagulopathy, encephalopathy, and cerebral oedema.

Answer 601

In acute hepatitis B: - ALT and AST levels may be significantly increased (usually between 500 and 10,000 IU/L). - Bilirubin may be elevated (can reach up to 500 micromols/L). - ALP is usually less than twice the upper limit of normal but can be higher in the presence of cholestasis. - Prothrombin time may be prolonged (5 seconds or more suggests severe hepatitis and 50 seconds or more suggests acute liver failure). In chronic hepatitis B: - For most, the only indicator is a mildly elevated serum AST level; in many, liver enzymes will be normal.

Answer 602

serological markers (antigens and antibodies) in plasma or serum

Answer 603

indicates presence of viral envelope and suggests that the person is infectious. It rises during the incubation period and may be cleared early in the course of the disease. It is undetectable in around 10% of people by the time the test is performed. Chronic HBV infection is indicated by the persistence of serum HBsAg for more than 6 months.

Answer 604

detectable in the serum during both the early phases of acute infection and some chronic infections. Usually associated with relatively high levels of virus replication. People with chronic HBV tend to be more infectious if HBeAg is detected. If HBeAg has been cleared, anti-HBe is usually detected, and infectivity is lower.

Answer 605

present following clearance of HBeAg from the plasma. Disappearance of HBeAg, development of anti-HBe, and a decline in HBV-DNA, indicates control of viral replication and predict resolution of acute hepatitis B.

Answer 606

indicates current or previous HBV infection. Appears at the onset of symptoms in acute infection and generally persists for life. May be absent very early in acute infection.

Answer 607

generally persists for life and is indicative of past infection.

Answer 608

indicates recent (within the last six months) HBV infection. Quantification may be useful to distinguish between acute and chronic infection. It is usually replaced gradually by immunoglobulin G (IgG) anti-HBc.

Answer 609

indicates recovery from and immunity to HBV. Anti-HBs without anti-HBc is a marker of immunisation. Anti-HBs is quantified to measure vaccination response.

Answer 610

Additional tests include quantification of HBV DNA (often referred to as HBV viral load), and HBV core avidity testing: High levels of HBV DNA are associated with a greater risk of progression to cirrhosis and hepatocellular cancer. Core avidity testing can differentiate between acute and chronic core IgM infection.

Answer 611

Initial testing should ideally include (at least) HBsAg and anti-HBc. Further tests (such as Hepatitis B e antigen, or antibody status (anti-HBe); HBV DNA level; IgM antibody to hepatitis B core antigen (anti-HBc IgM) may be required depending on the findings. Positive HBsAg and positive anti-HBc IgM confirm an acute infection, particularly if supported by clinical suspicion and raised ALT. Positive HBsAg and anti-HBc (total or IgG) but negative anti-HBc IgM confirm a chronic infection. Different combinations of antibodies and antigens, alongside other findings, can indicate the phase of a chronic infection which is used in determining appropriate treatment options.

Answer 612

Acute hep B

Answer 613

immunity following infection

Answer 614

immunity due to vaccination

Answer 615

Chronic hep B - active

Answer 616

Chronic hep B- inactive carrier

Answer 617

Hepatitis B vaccine is not routinely available free of charge. People requesting vaccination against hepatitis B in relation to travel abroad may be charged. Vaccination indicated for treatment (for example, following a human bite) or to address a lifestyle-related risk (such as injected drug use) must be offered free of charge. Combination hepatitis A and B vaccines must be offered free of charge, but should only be used where protection against both illnesses is clinically indicated. Where a person is at occupational risk of hepatitis B, it is the responsibility of their employer (or themselves if self-employed) to arrange and fund immunization.

Answer 618

Metoclopramide (for people aged over 20 years for a maximum duration of treatment 5 days) or cyclizine, if liver impairment is mild.

Answer 619

Simple measures (such as maintaining a cool, well-ventilated environment, wearing loose clothing, and avoiding hot baths or showers). Chlorphenamine at night — avoid in severe liver impairment.

Answer 620

The infant should be immunised against hepatitis B from birth — there is a 90% risk of the infant contracting hepatitis B unless immunisation takes place at birth. There may be an increased risk of preterm delivery and low infant birth weight. Breastfeeding is safe providing the infant has been immunised.

Answer 621

regular review by a liver specialist. The frequency of monitoring depends on a number of factors, such as serology results (which collectively indicate the phase of disease), the person's age, and whether they are taking antiviral drugs. Specialist follow-up is required to: - Monitor serology. - Screen for complications including hepatocellular cancer. - Assess the person's need for treatment on an ongoing basis (depending on the findings of any tests and assessments). Antivirals initiated in secondary care may subsequently be prescribed in primary care as part of a shared care arrangement.

Answer 622

hepatologist, gastroenterologist or infectious disease specialist (depending on local service provision), to consider the need for additional treatment, follow up, and monitoring.

Answer 623

Seek medical attention urgently if symptoms worsen (particularly if they include vomiting and dehydration) or do not improve within 4 weeks and to be aware of the signs of hepatic decompensation such as confusion or change in level of consciousness. Avoid drinking alcohol as this can increase the risk of cirrhosis and hepatocellular cancer in people with chronic hepatitis B. Take steps to minimize the risk of transmission to partners and contacts. The person should: - Avoid sharing items that might be contaminated with small amounts of blood (such as toothbrushes, razors, and scissors). - Avoid unprotected sexual intercourse. - Avoid sharing needles and other drug-injecting equipment. For further information on injecting drug use, see the CKS topic on Opioid dependence. - Not donate blood or semen, or carry an organ donor card. Be aware that treatments that affect the immune system (such as chemotherapy or immunosupressants) can cause recurrence and they may need prophylaxisis while on these medications.

Answer 624

slow, progressive disease of the liver caused by the hepatitis C virus (HCV). It is an important, underdiagnosed, and undertreated cause of morbidity and mortality in the UK.

Answer 625

Acute infection refers to the period immediately following incubation to within 6 months of acquiring infection. Chronic infection follows acute infection in about 55–85% of people, and refers to the continued presence of HCV 6 months or more after acquiring infection.

Answer 626

contact with infected blood. Parenteral spread accounts for the majority of cases in the UK, through sharing of needles or other injecting paraphernalia, blood transfusion (pre 1990s), re-use or inadequate sterilization of medical equipment, needlestick injury, and exposure to infected blood by other means (for example sharing a razor with an infected person). Less common routes include sexual transmission and vertical transmission (from mother to baby).

Answer 627

cirrhosis, liver failure, and hepatocellular carcinoma.

Answer 628

Risk factors for hepatitis C. Clinical features of possible HCV infection, such as fatigue, arthralgia, and jaundice. Abnormal liver function tests.

Answer 629

antibody test (which indicates if a person has ever been infected with HCV) and HCV ribonucleic acid (RNA) test (to check if HCV infection is active and for genotype analysis). If hepatitis C is suspected in an immunocompetent person, blood should be tested for HCV antibodies. If the antibody test is positive, or in immunocompromised people, blood should be tested for HCV RNA. A person has active hepatitis C if they have a positive HCV antibody test and positive HCV RNA test.

Answer 630

Same-day assessment or immediate specialist advice should be sough

Answer 631

Urgent referral to a specialist should be arranged for ongoing management and monitoring.

Answer 632

The local Health Protection Team

Answer 633

Ensuring the person is attending specialist appointments. Offering sources of information and support. Advising on measures to reduce the risk of disease progression, such as reducing alcohol consumption and stopping smoking. Advising on measures to prevent the spread of the infection, such as not sharing razors, toothbrushes, toiletries, or other items that may be contaminated with blood. Advising on the risk of sexual transmission, which is greater in people with multiple partners, in people co-infected with HIV, and with risky sexual practices (for example anal sex). Encouraging the person to inform injecting or sexual contacts, so that they can be tested for hepatitis C. Monitoring for adverse effects of specialist drug treatment (for example hypoglycaemia). Offering people at continued risk of a blood-borne infection immunization against hepatitis A and B.

Answer 634

Non-specific fatigue, myalgia, anxiety, depression, poor memory or concentration (may be indicative of chronic hepatitis C infection). Nausea and vomiting. Right upper quadrant abdominal pain. Jaundice (with dark urine and/or pale stools if cholestasis). Signs of chronic liver disease (in advanced chronic hepatitis C). Note that only 25–35% of people experience symptoms in the early stages of infection, and infection occurs after an incubation period. Therefore, a person may not connect their present symptoms to the time of risk exposure.

Answer 635

People who intend to donate blood or organs/tissue. People with end-stage chronic kidney disease requiring renal replacement therapy. Healthcare workers who perform invasive or exposure-prone procedures (for example surgeons).

Answer 636

no However, testing is recommended if the woman is at increased risk for HCV infection. They should be tested at their prenatal visits. If the initial results in pregnant women with on-going risk factors for hepatitis C infection are negative, this should be repeated later on in the third trimester.

Answer 637

People who have ever injected drugs. People who received a blood transfusion before 1991 or blood products before 1986, when screening of blood donors for hepatitis C infection, or heat treatment for inactivation of viruses were introduced. People born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis C, including Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East, and the Pacific islands. Babies born to mothers infected with hepatitis C. Prisoners, including young offenders. Looked-after children and young people, including those living in care homes. People living in hostels for the homeless or sleeping on the streets. HIV-positive men who have sex with men. Close contacts of someone known to be chronically infected with hepatitis C, including family members, close friends, household contacts, or sexual partners.

Answer 638

People who have ever snorted or smoked drugs (such as cocaine), particularly if they have shared straws or pipes. People who are at risk through sharing of contaminated items, such as razors or toothbrushes. Healthcare workers who have been accidentally exposed to blood where there is a risk of hepatitis C (for example needlestick injuries). People who have received medical, cosmetic, or dental treatment (or any other invasive treatment) in countries where hepatitis C is common and infection control may be poor (including people who have received blood transfusion products that have not been screened for hepatitis C). People who have had tattoos, body piercing, acupuncture, or electrolysis, where unsterilized equipment may have been used (especially consider tattooing and piercing received in the UK before the mid 1980s or in other countries at any time). People who have tested positive for hepatitis B or HIV — HIV-positive men who have sex with men should be offered regular testing for hepatitis C.

Answer 639

an antibody test (which indicates if a person has ever been infected with HCV) and HCV ribonucleic acid (RNA) test (to check if HCV infection is active and for genotype analysis).

Answer 640

send a plain (clotted) blood sample for testing for antibodies to HCV. Detection of antibodies indicates resolved or current HCV infection. If the antibody test is positive, test a second blood sample to confirm the diagnosis. Consider taking an additional blood sample at the same time as the first sample if venepuncture is difficult (for example if the person injects drugs). If the antibody test is negative, consider repeating it (especially if the person is at high risk of infection). Repeat the antibody test at an appropriate time if the last risk exposure occurred within the 3–6 month 'window period' of the test, as it can take at least 3 months for antibodies to become detectable. Seek specialist advice if there is uncertainty about the optimal time to repeat the test.

Answer 641

If the HCV RNA test is positive, send a repeat sample for confirmation. A positive HCV RNA result means the person has current infection with active hepatitis C, which will require specialist antiviral treatment. If the HCV RNA result is negative, repeat the test after a period of 6 months. If the negative result is confirmed, this means the person has a previously resolved HCV infection, but they are not immune to future HCV infection. Give information and advice on measures to prevent re-infection.

Answer 642

Advise that they will need HCV antibody testing at 12 and 24 weeks, and HCV RNA testing at 6, 12, and 24 weeks. This should be arranged through their Occupational Health department.

Answer 643

seek specialist advice

Answer 644

offer annual testing for HCV.

Answer 645

hepatologist or specialist gastroenterologist.

Answer 646

Arrange a same-day assessment or seek immediate specialist advice.

Answer 647

Arrange an urgent referral. Confirm the person's address and telephone number at the time of referral, and use the practice's address for correspondence if necessary, for example if the person frequently changes address, has an insecure address, or is homeless.

Answer 648

spontaneously clear the virus within 6 months of infection without any treatment

Answer 649

(defined as loss of HCV ribonucleic acid [RNA] within the first 6 months) occurs, no antiviral treatment is necessary

Answer 650

If spontaneous resolution (defined as loss of HCV ribonucleic acid [RNA] within the first 6 months) occurs, no antiviral treatment is necessary [BASHH, 2017a]. If needed, treatment should be started promptly. There is clear evidence that treatment given during the acute phase is more likely to clear infection and reduces the risk of chronic HCV infection and progression of liver disease than treatment in the chronic phase [BASHH, 2017a]. Treatment should be the same as for chronic infection [BMJ, 2019].

Answer 651

The goal of treatment is to eradicate the virus, achieve a sustained virological response (SVR), and prevent disease progression [Ahmad, 2017; BMJ, 2019]. SVR (undetectable HCV RNA in the blood 12 weeks after treatment completion) is considered equivalent to a cure. The treatment regimen and duration will depend on the HCV genotype, viral load, severity of liver disease, prior HCV treatment history, the presence of comorbidities, and the person's ability to tolerate treatment. Interferon-based treatment regimens are no longer recommended for HCV infection [Ahmad, 2017], as direct-acting antivirals (DAAs) are now considered first-line treatment. DAAs target different stages in the HCV lifecycle and are successful for over 90% of people with HCV infection. The treatment is usually a once daily, oral tablet regimen for either 8 or 12 weeks and is most effective when given before the onset of cirrhosis. DAAs are well tolerated with minimal adverse effects and result in high rates of SVR.

Answer 652

Blood tests may include: Viral load — to assess response to treatment. Clotting studies — clotting may be affected if there is significant liver damage. Autoantibodies — which are non-specific markers for autoimmune disease. Transient elastography can be offered to diagnose cirrhosis. If unsuitable, liver biopsy can be offered. Liver ultrasound is carried out in people with advanced fibrosis or cirrhosis to screen for hepatocellular cancer. Ultrasound cannot accurately assess the degree of inflammation or liver fibrosis, or predict the prognosis. Liver biopsy may be considered in individual cases, for example to assess the extent of liver damage caused by inflammation, fibrosis, or cirrhosis; to identify iron overload; and to exclude other causes of liver damage.

Answer 653

Ensure the person is attending specialist appointments, and provide appropriate support if needed to help the person attend. Provide the person with sources of information and support on hepatitis C and its treatment. Monitor the person for adverse effects of specialist treatment, and manage appropriately. - Hypoglycaemia — monitor glucose levels closely in people with diabetes during treatment with direct-acting antivirals (DAAs), particularly within the first 3 months of treatment, and modify diabetes treatment when necessary. Concurrent treatment with antidiabetic drugs may result in symptomatic hypoglycaemia. - Fluctuations of international normalised ratio (INR) — monitor INR closely in people on anticoagulant treatment and, if necessary, adjust the dose of the anticoagulant. Changes in liver function due to treatment with DAAs may result in fluctuations of INR values. Give the person ongoing lifestyle advice to reduce the risk of disease progression, such as stopping smoking. Offer all people at continued risk of a blood-borne infection immunization against hepatitis A and B (available free on the NHS for this indication).

Answer 654

caused by Entamoeba histolytica (an amoeboid protozoan) and spread by the faecal-oral route. It is estimated that 10% of the world's population is chronically infected. Infection can be asymptomatic, cause mild diarrhoea or severe amoebic dysentery. Amoebiasis also causes liver and colonic abscesses.

Answer 655

profuse, bloody diarrhoea there may be a long incubation period stool microscopy may show trophozoites if examined within 15 minutes or kept warm (known as a 'hot stool')

Answer 656

oral metronidazole a 'luminal agent' (to eliminate intraluminal cysts) is recommended usually as well e.g. diloxanide furoate

Answer 657

usually a single mass in the right lobe (may be multiple). The contents are often described as 'anchovy sauce'

Answer 658

fever right upper quadrant pain systemic symptoms e.g. malaise hepatomegaly

Answer 659

ultrasound serology is positive in > 95%

Answer 660

oral metronidazole a 'luminal agent' (to eliminate intraluminal cysts) is recommended usually as well e.g. diloxanide furoate

Answer 661

caused by Bacillus anthracis, a Gram positive rod. It is spread by infected carcasses. It is also known as Woolsorters' disease. Bacillus anthracis produces a tripartite protein toxin - protective antigen - oedema factor: a bacterial adenylate cyclase which increases cAMP - lethal factor: toxic to macrophages

Answer 662

causes painless black eschar (cutaneous 'malignant pustule', but no pus) typically painless and non-tender may cause marked oedema anthrax can cause gastrointestinal bleeding

Answer 663

initial management of cutaneous anthrax is ciprofloxacin further treatment is based on microbiological investigations and expert advice

Answer 664

Amoxicillin or tetracycline or clarithromycin

Answer 665

Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)

Answer 666

Clarithromycin

Answer 667

Within 5 days of admission: co-amoxiclav or cefuroxime More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Answer 668

Trimethoprim or nitrofurantoin. Alternative: amoxicillin or cephalosporin

Answer 669

Broad-spectrum cephalosporin or quinolone

Answer 670

Quinolone or trimethoprim

Answer 671

Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread

Answer 672

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Answer 673

Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)

Answer 674

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Answer 675

Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Answer 676

Flucloxacillin

Answer 677

Phenoxymethylpenicillin (erythromycin alone if penicillin-allergic)

Answer 678

Phenoxymethylpenicillin

Answer 679

Amoxicillin (erythromycin if penicillin-allergic)

Answer 680

Flucloxacillin (erythromycin if penicillin-allergic) combined topical antibiotic and corticosteroid is generally used for mild/moderate cases of otitis externa

Answer 681

Amoxicillin

Answer 682

Metronidazole

Answer 683

Intramuscular ceftriaxone

Answer 684

Doxycycline or azithromycin

Answer 685

Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Answer 686

Benzathine benzylpenicillin or doxycycline or erythromycin

Answer 687

Oral or topical metronidazole or topical clindamycin

Answer 688

First episode: oral vancomycin Second or subsequent episode of infection: oral fidaxomicin

Answer 689

Clarithromycin

Answer 690

Ciprofloxacin

Answer 691

Ciprofloxacin

Answer 692

aminoglycosides tetracyclines chloramphenicol clindamycin macrolides

Answer 693

Binds to 30S subunit causing misreading of mRNA

Answer 694

Nephrotoxicity, Ototoxicity

Answer 695

Discolouration of teeth, photosensitivity

Answer 696

Binds to 30S subunit blocking binding of aminoacyl-tRNA

Answer 697

Binds to 50S subunit, inhibiting peptidyl transferase

Answer 698

Aplastic anaemia

Answer 699

common cause of c diff

Answer 700

Binds to 50S subunit, inhibiting translocation (movement of tRNA from acceptor site to peptidyl site)

Answer 701

Binds to 50S subunit, inhibiting translocation (movement of tRNA from acceptor site to peptidyl site)

Answer 702

Nausea (especially erythromycin), P450 inhibitor, prolonged QT interval

Answer 703

pts who are allergic to penicillin

Answer 704

Azithromycin Clarithromycin Erythromycin Fidaxomicin

Answer 705

doxycycline lymecycline

Answer 706

gentamicin, tobramycin, amikacin, neomycin, plazomicin, paromomycin, and streptomycin

Answer 707

azoles amphotericin B terbinafine griseofulvin flucytosine caspofungin nystatin

Answer 708

Inhibits 14α-demethylase which produces ergosterol

Answer 709

P450 inhibition Liver toxicity

Answer 710

Clotrimazole Fluconazole Itraconazole

Answer 711

Abx (NOT ANTIFUNGAL)

Answer 712

Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage

Answer 713

Nephrotoxicity, flu-like symptoms, hypokalaemia, hypomagnaseamia

Answer 714

systemic fungal infections

Answer 715

Inhibits squalene epoxidase

Answer 716

oral form to treat fungal nail infections

Answer 717

Interacts with microtubules to disrupt mitotic spindle

Answer 718

Induces P450 system, teratogenic

Answer 719

When a substance "induces" the P450 system, it essentially triggers the body to produce more of these enzymes, increasing their activity level. This can be clinically important because if a person takes multiple medications, one of which induces the P450 system, it can lead to decreased effectiveness of other drugs that are metabolized by the same enzymes.

Answer 720

Converted by cytosine deaminase to 5-fluorouracil, which inhibits thymidylate synthase and disrupts fungal protein synthesis

Answer 721

Inhibits synthesis of beta-glucan, a major fungal cell wall component

Answer 722

Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage

Answer 723

As very toxic can only be used topically (e.g. for oral thrush)

Answer 724

a mycetoma (mass-like fungus ball) which often colonises an existing lung cavity (e.g. secondary to tuberculosis, lung cancer or cystic fibrosis).

Answer 725

Usually asymptomatic but features may include cough haemoptysis (may be severe)

Answer 726

chest x-ray containing a rounded opacity. A crescent sign may be present high titres Aspergillus precipitins

Answer 727

gram-positive rod, which is highly adaptable to extremes of pH and oxygen levels. It is chiefly associated with food poisoning but may also be associated with nosocomial infection in the immunocompromised.

Answer 728

Due to its relative environmental resilience, members of the B. cereus group are almost ubiquitous in nature: they are found in soil, fresh water and salt water. They also frequently considered a transient commensal organism in the human GI tract. Isolates have even been found in disinfectant alcohol hand gel. B. cereus is often considered a contaminant when grown from a blood culture or other sterile site, but is also a significant cause of infection in immunosuppressed patients, intravenous drug users and neonates.

Answer 729

Significant exposures to B. cereus occur most commonly in the context of food poisoning. Under-cooked or reheated rice is most classically associated with B. cereus . The bacterial exotoxin cereulide is stable at for short periods of very high temperatures such as in stir frying.

Answer 730

Bacillus cereus

Answer 731

An emetic syndrome resulting from ingestion of the heat-stable toxin cereulide. Disease can occur from toxin ingestion even if the bacteria are killed during cooking. Symptoms typically occur between 0.5 and 6 hours of ingestion. Diarrhoea symptoms may also occur. A diarrhoeal syndrome associated with separate exotoxins such as haemolysin BL. Patients typically complain of crampy abdominal pain and diarrhoea. Usual onset time 8-16 hours. Symptoms typically resolve within 24 hours in both syndromes. In immunosuppressed patients: bacteraemia, endocarditis, musculoskeletal and CNS infection may occur.

Answer 732

rarely required for food poisoning syndrome. Most strains produce beta-lactamase and vancomycin is suggested as the empiric antibiotic of choice in some guidelines.

Answer 733

gram positive anaerobic bacillus 7 serotypes A-G produces botulinum toxin, a neurotoxin which irreversibly blocks the release of acetylcholine may result from eating contaminated food (e.g. tinned) or intravenous drug use neurotoxin often affects bulbar muscles and autonomic nervous system

Answer 734

patient usually fully conscious with no sensory disturbance flaccid paralysis diplopia ataxia bulbar palsy

Answer 735

botulism antitoxin and supportive care antitoxin is only effective if given early - once toxin has bound its actions cannot be reversed

Answer 736

generally caused by the Gram negative rod Bartonella henselae

Answer 737

fever history of a cat scratch regional lymphadenopathy headache, malaise

Answer 738

by Vibro cholerae - Gram negative bacteria contaminated water

Answer 739

profuse 'rice water' diarrhoea dehydration hypoglycaemia

Answer 740

oral rehydration therapy antibiotics: doxycycline, ciprofloxacin

Answer 741

staphylococci + streptococci (including enterococci)

Answer 742

Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis

Answer 743

mnemonic = ABCD L Actinomyces Bacillus anthracis (anthrax) Clostridium Diphtheria: Corynebacterium diphtheriae Listeria monocytogenes

Answer 744

Escherichia coli Haemophilus influenzae Pseudomonas aeruginosa Salmonella sp. Shigella sp. Campylobacter jejuni

Answer 745

Gram-positive cocci = staphylococci + streptococci (including enterococci) Gram-negative cocci = Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis Gram-positive rods (bacilli) = ABCD L Actinomyces Bacillus anthracis (anthrax) Clostridium Diphtheria: Corynebacterium diphtheriae Listeria monocytogenes Remaining organisms are Gram-negative rods, e.g.: Escherichia coli Haemophilus influenzae Pseudomonas aeruginosa Salmonella sp. Shigella sp. Campylobacter jejuni

Answer 746

gram-positive, obligate anaerobic bacilli.

Answer 747

C. perfringens: - produces α-toxin, a lecithinase, which causes gas gangrene (myonecrosis) and haemolysis - features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation C. botulinum: - typically seen in canned foods and honey prevents acetylcholine (ACh) - release leading to flaccid paralysis C. difficile: - causes pseudomembranous colitis, typically seen after the use of broad-spectrum antibiotics - produces both an exotoxin and a cytotoxin C. tetani: - produces an exotoxin (tetanospasmin) that prevents the release of glycine from Renshaw cells in the spinal cord causing a spastic paralysis

Answer 748

commonest protozoal cause of diarrhoea in the UK. Two species, Cryptosporidium hominis and Cryptosporidium parvum account for the majority cases. Cryptosporidiosis is more common in immunocompromised patients (e.g. HIV) and young children.

Answer 749

watery diarrhoea abdominal cramps fever in immunocompromised patients, the entire gastrointestinal tract may be affected resulting in complications such as sclerosing cholangitis and pancreatitis

Answer 750

stool: modified Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the characteristic red cysts of Cryptosporidium

Answer 751

is largely supportive for immunocompetent patients if the patient has HIV and is not on antiretroviral therapy then this should be started and often will be enough to resolve the infection nitazoxanide may be used for immunocompromised patients rifaximin is also sometimes used for immunocompromised patients/patients with severe disease

Answer 752

dermatological condition prevalent in tropical and subtropical regions, largely attributable to cutaneous penetration and subsequent migration of nematode larvae, primarily from the Ancylostoma genus (e.g. Ancyclostoma braziliense). Typically, the transmission vectors are faecal-contaminated soil or sand, posing significant risks to individuals with a history of barefoot beach visits or direct soil contact.

Answer 753

intensely pruritic, 'creeping', serpiginous, erythematous cutaneous eruption that advances over time. Symptoms can last for weeks to months, potentially leading to secondary bacterial infection due to excessive scratching. Diagnosis is typically clinical, based on exposure history and characteristic skin manifestations.

Answer 754

anthelmintic agents, such as ivermectin or albendazole. Topical therapy with thiabendazole can also be effective, although it's generally less preferred due to a lower efficacy rate and higher side effect profile.

Answer 755

largely involve patient education about appropriate protective measures, particularly avoiding direct skin contact with potentially contaminated soil. Given the zoonotic nature of cutaneous larva migrans, public health measures for animal defecation control can also contribute to reducing the prevalence of this condition.

Answer 756

one of the herpes viruses. It is thought that around 50% of people have been exposed to the CMV virus although it only usually causes disease in the immunocompromised, for example people with HIV or those on immunosuppressants following organ transplantation.

Answer 757

infected cells have a 'Owl's eye' appearance due to intranuclear inclusion bodies

Answer 758

Congenital CMV infection CMV mononucleosis CMV retinitis CMV encephalopathy CMV penumonitis CMV colitis

Answer 759

in the immunocompromised, for example people with HIV or those on immunosuppressants following organ transplantation.

Answer 760

features include growth retardation, pinpoint petechial 'blueberry muffin' skin lesions, microcephaly, sensorineural deafness, encephalitiis (seizures) and hepatosplenomegaly

Answer 761

infectious mononucelosis-like illness may develop in immunocompetent individuals

Answer 762

common in HIV patients with a low CD4 count (< 50) presents with visual impairment e.g. 'blurred vision'. Fundoscopy shows retinal haemorrhages and necrosis, often called 'pizza' retina IV ganciclovir is the treatment of choice

Answer 763

seen in patients with HIV who have low CD4 counts

Answer 764

viral infection that can progress to viral haemorrhagic fever (other examples include yellow fever, Lassa fever, Ebola).

Answer 765

dengue virus is a RNA virus of the genus Flavivirus transmitted by the Aedes aegypti mosquito incubation period of 7 days

Answer 766

dengue fever: without warning signs with warning signs severe dengue (dengue haemorrhagic fever)

Answer 767

fever headache (often retro-orbital) myalgia, bone pain and arthralgia ('break-bone fever') pleuritic pain facial flushing (dengue) maculopapular rash haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis 'warning signs' include: abdominal pain hepatomegaly persistent vomiting clinical fluid accumulation (ascites, pleural effusion)

Answer 768

this is a form of disseminated intravascular coagulation (DIC) resulting in: thrombocytopenia & spontaneous bleeding around 20-30% of these patients go on to develop dengue shock syndrome (DSS)

Answer 769

typically blood results= leukopenia, thrombocytopenia, raised aminotransferases diagnostic tests: - serology - nucleic acid amplification tests for viral RNA - NS1 antigen test

Answer 770

entirely symptomatic e.g. fluid resuscitation, blood transfusion etc no antivirals are currently available

Answer 771

Gram positive bacterium Corynebacterium diphtheriae

Answer 772

releases an exotoxin encoded by a β-prophage exotoxin inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2 Diphtheria toxin commonly causes a 'diphtheric membrane' on tonsils caused by necrotic mucosal cells. Systemic distribution may produce necrosis of myocardial, neural and renal tissue

Answer 773

recent visitors to Eastern Europe/Russia/Asia sore throat with a 'diphtheric membrane' - grey, pseudomembrane on the posterior pharyngeal wall bulky cervical lymphadenopathy - may result in a 'bull neck' appearanace neuritis e.g. cranial nerves heart block

Answer 774

culture of throat swab: uses tellurite agar or Loeffler's media

Answer 775

intramuscular penicillin diphtheria antitoxin

Answer 776

Double-stranded, linear Enveloped Herpes simplex virus, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus

Answer 777

Double-stranded, circular Enveloped Hepatitis B virus

Answer 778

Double-stranded, linear Naked Common cold, conjunctivitis

Answer 779

Single-stranded, linear Naked Parvovirus B19

Answer 780

Double-stranded, circular Naked HPV

Answer 781

Double-stranded, linear Enveloped Smallpox, molluscum contagiosum

Answer 782

Double-stranded, circular Naked JC virus (progressive multifocal leukoencephalopathy)

Answer 783

HHAPPPPy! - Hepadna; Herpes; Adeno; Pox; Parvo; Papilloma; Polyoma

Answer 784

part of the Filoviridae virus family and causes a rare but often fatal disease. The average fatality rate during previous outbreaks is 50%. The most recent outbreak in West Africa is the largest known outbreak, mainly centred around Guinea, Sierra Leone and Liberia.

Answer 785

through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. This puts healthcare workers at particular risk and appropriate precautions should be taken.

Answer 786

The incubation period is 2 to 21 days, and patients are not infectious until they develop symptoms. First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding.

Answer 787

Ebola should be suspected in patients presenting to primary care services who have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have recently visited any of the affected areas (see maps) within the previous 21 days OR Have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF.

Answer 788

If a patient reports these symptoms over the telephone, they should be advised not to attend the surgery. If they do attend the surgery then they should be isolated in a single room to limit contact with staff/other patients. If the GP elicits the possibility of VHF during their consultation, they should avoid further physical contact and keep the patient isolated in their room. In all of these cases PHE should be contacted for further advice.

Answer 789

The Salmonella group contains many members, most of which cause diarrhoeal diseases. They are aerobic, Gram-negative rods which are not normally present as commensals in the gut. Typhoid and paratyphoid are caused by Salmonella typhi and Salmonella paratyphi (types A, B & C) respectively. They are often termed enteric fevers, producing systemic symptoms such as headache, fever, arthralgia.

Answer 790

typhoid is transmitted via the faecal-oral route (also in contaminated food and water)

Answer 791

initially systemic upset (headache, fever, arthralgia) relative bradycardia abdominal pain, distension constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid

Answer 792

osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens) GI bleed/perforation meningitis cholecystitis chronic carriage (1%, more likely if adult females)

Answer 793

positive-sense single stranded RNA viruses. The family contains the Coxsackievirus, echovirus and rhinovirus as well as others. It is the most common cause of viral meningitis in the adult population but can cause a range of different diseases, in both adults and children. Although the range of diseases caused by these viruses is broad, notable disease entities include Hand, Foot and Mouth disease, herpangina and pericarditis.

Answer 794

Burkitt's lymphoma Hodgkin's lymphoma nasopharyngeal carcinoma HIV-associated central nervous system lymphomas

Answer 795

hairy leukoplakia

Answer 796

caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route.

Answer 797

foreign travel swimming/drinking water from a river or lake male-male sexual contact

Answer 798

often asymptomatic non-bloody diarrhoea steatorrhoea bloating, abdominal pain lethargy flatulence weight loss malabsorption and lactose intolerance can occur

Answer 799

stool microscopy for trophozoite and cysts: sensitivity of around 65% stool antigen detection assay: greater sensitivity and faster turn-around time than conventional stool microscopy methods PCR assays are also being developed

Answer 800

metronidazole

Answer 801

purple/blue following the gram staining. Microscopy will then reveal the shape, either cocci or rods.

Answer 802

Actinomyces Bacillus antracis Clostridium Corynebacterium diphtheriae Listeria monocytogenes

Answer 803

makes catalase: Staphylococci does not make catalase: Streptococci

Answer 804

makes coagulase: S. aureus does not make coagulase: S. epidermidis (novobiocin sensitive), S. saprophyticus (novobiocin resistant)

Answer 805

partial haemolysis (green colour on blood agar): α-haemolytic complete haemolysis (clear): β-haemolytic no haemolysis: γ-haemolytic

Answer 806

optochin sensitive: S. pneumoniae optochin resistant: Viridans streptococci

Answer 807

bacitracin sensitive: Group A: S. pyogenes bacitracin resistant: Group B: S. agalactiae

Answer 808

between september and early november as flue season typically starts middle of november

Answer 809

A, B and C A and B most common

Answer 810

Children, elderly and at risk groups. Remember that the type of vaccine given routinely to children and the one given to the elderly and at risk groups is different (live vs. inactivated) - this explains the different contraindications

Answer 811

it is given intranasally the first dose is given at 2-3 years, then annually after that it is a live vaccine (cf. injectable vaccine below) children who were traditionally offered the flu vaccine (e.g. asthmatics) will now be given intranasal vaccine unless this is inappropriate, for example if they are immunosuppressed. In this situation the inactivated, injectable vaccine should be given only children aged 2-9 years who have not received an influenza vaccine before need 2 doses it is more effective than the injectable vaccine

Answer 812

immunocompromised aged < 2 years current febrile illness or blocked nose/rhinorrhoea current wheeze (e.g. ongoing viral-induced wheeze/asthma) or history of severe asthma (BTS step 4) egg allergy pregnancy/breastfeeding if the child is taking aspirin (e.g. for Kawasaki disease) due to a risk of Reye's syndrome

Answer 813

blocked-nose/rhinorrhoea headache anorexia

Answer 814

two subtypes of influenza A and one subtype of influenza B.

Answer 815

chronic respiratory disease (including asthmatics who use inhaled steroids) chronic heart disease (heart failure, ischaemic heart disease, including hypertension if associated with cardiac complications) chronic kidney disease chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis chronic neurological disease: (e.g. Stroke/TIAs) diabetes mellitus (including diet controlled) immunosuppression due to disease or treatment (e.g. HIV) asplenia or splenic dysfunction pregnant women adults with a body mass index >= 40 kg/m² Other at risk individuals include: - health and social care staff directly involved in patient care (e.g. NHS staff) - those living in long-stay residential care homes - carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill (at the GP's discretion)

Answer 816

it is an inactivated vaccine, so cannot cause influenza. A minority of patients however develop fever and malaise which may last 1-2 days should be stored between +2 and +8ºC and shielded from light contraindications include hypersensitivity to egg protein. in adults the vaccination is around 75% effective, although this figure decreases in the elderly it takes around 10-14 days after immunisation before antibody levels are at protective levels

Answer 817

systemic Aspergillus infection (Aspergillus fumigatus, Aspergillus flavus, and Aspergillus terreus) that is a leading cause of death in immunocompromised patients.

Answer 818

HIV Leukaemia Following broad-spectrum antibiotics

Answer 819

infectious thrombophlebitis of the internal jugular vein. It most often occurs secondary to a bacterial sore throat caused by Fusobacterium necrophorum leading to a peritonsillar abscess. A combination of spread of the infection laterally from the abscess and compression lead to thrombosis of the IJV.

Answer 820

Patients will present with a history of bacterial sore throat followed by neck pain, stiffness and tenderness (may be mistaken for meningitis) and systemic involvement (fevers, rigors, etc). Septic pulmonary emboli may also occur.

Answer 821

a granulomatous disease primarily affecting the peripheral nerves and skin. It is caused by Mycobacterium leprae.

Answer 822

patches of hypopigmented skin typically affecting the buttocks, face, and extensor surfaces of limbs sensory loss

Answer 823

The degree of cell mediated immunity

Answer 824

lepromatous leprosy ('multibacillary') - extensive skin involvement - symmetrical nerve involvement

Answer 825

tuberculoid leprosy ('paucibacillary') - limited skin disease - asymmetric nerve involvement → hypesthesia - hair loss

Answer 826

WHO-recommended triple therapy: rifampicin, dapsone and clofazimine

Answer 827

caused by the spirochaete Leptospira interrogans (serogroup L. icterohaemorrhagiae), classically being spread by contact with infected rat urine.

Answer 828

leptospirosis is commonly seen in questions referring to sewage workers, farmers, vets or people who work in an abattoir however, on an international level, leptospirosis is far more common in the tropics so should be considered in the returning traveller

Answer 829

Weil's disease

Answer 830

the early phase is due to bacteraemia and lasts around a week: - may be mild or subclinical - fever - flu-like symptoms - subconjunctival suffusion (redness)/haemorrhage second immune phase may lead to more severe disease (Weil's disease): - acute kidney injury (seen in 50% of patients) - hepatitis: jaundice, hepatomegaly - aseptic meningitis

Answer 831

serology: antibodies to Leptospira develop after about 7 days PCR culture= growth may take several weeks so limits usefulness in diagnosis; blood and CSF samples are generally positive for the first 10 days; urine cultures become positive during the second week of illness

Answer 832

mild-moderate disease: doxycycline or azithormycin severe disease: IV benzylpencillin

Answer 833

type of antibiotic that works by forming reactive cytotoxic metabolites inside the bacteria.

Answer 834

disulfiram-like reaction with alcohol increases the anticoagulant effect of warfarin

Answer 835

Ancylostoma braziliense Strongyloides stercoralis Toxocara canis

Answer 836

most common cause of cutaneous larva migrans common in Central and Southern America

Answer 837

acquired percutaneously (e.g. walking barefoot) causes pruritus and larva currens - this has a similar appearance to cutaneous larva migrans but moves through the skin at a far greater rate abdo pain, diarrhoea, pneumonitis may cause Gram negative septicaemia due carrying of bacteria into bloodstream eosinophilia sometimes seen management: thiabendazole, albendazole. Ivermectin also used, particularly in chronic infections

Answer 838

commonly acquired by ingesting eggs from soil contaminated by dog faeces commonest cause of visceral larva migrans other features: eye granulomas, liver/lung involvement

Answer 839

term used to describe the presence of urethritis when a gonococcal bacteria are not identifiable or the initial swab. A typical case would be a male who presented to a GUM clinic with a purulent urethral discharge and dysuria. A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram-negative diplococci (i.e. no evidence of gonorrhoea). Clearly, this patient requires immediate treatment prior to waiting for the Chlamydia test to come back and hence an initial diagnosis of NGU is made.

Answer 840

No cause is found in around half of cases. Possible causative organisms include: Chlamydia trachomatis most common cause Mycoplasma genitalium thought to cause more symptoms than Chlamydia less common causes: - Ureaplasma urealyticum - Trichomonas vaginalis - Escherichia coli

Answer 841

contact tracing the BNF and British Association for Sexual Health and HIV (BASHH) both recommend either oral azithromycin or doxycycline

Answer 842

also known as the winter vomiting bug, is one of the most common causes of gastroenteritis in the UK according to NHS England. 1 in 5 cases of infectious gastroenteritis are caused by norovirus, with 685 million cases per year worldwide.

Answer 843

It is a genus that encompasses a range of non encapsulated RNA virus species

Answer 844

Develop within 15 - 50 hours of infection (quoted from the European Centre of Disease Control and Prevention), with patients experiencing nausea, vomiting, and diarrhoea, which may be accompanied by headaches, low-grade fevers, and myalgia. The majority of patients experience both vomiting and diarrhoea 10 - 22% reported a headache and up to 47% of patients reported fevers (Clinical Microbiology Reviews, Norovirus, January 2015)

Answer 845

Faecal-oral route, with the virus becoming aerosolized when the patient vomits or when a toilet containing infected bodily fluids (vomit or faeces) is flushed. Viral particles are transmitted directly to surrounding potential hosts and to surrounding surfaces, from which they can be transmitted by cross-contamination (for example a patient visitor touching the patient environment, then eating without first washing their hands). Infection may also be transmitted from an infected individual in the process of direct physical contact, or contact with food preparation. The virus enters the cell via host receptor-mediated endocytosis and replicates in the small intestine. Norovirus is highly contagious, the European Centre of Disease Control and Prevention estimates that only 10 - 100 viral particles are required to cause an active infection. Norovirus is not at present considered to be a notifiable disease in the UK.

Answer 846

Isolation of infected strongly recommended where possible, particularly in areas where the risk of person to person transmission is high, for example, in hospitals schools, and care facilities Good hand hygiene using soap and water is essential Alcohol hand gel has been shown to be less effective in reducing transmission

Answer 847

Clinical history and stool culture viral PCR (polymerase chain reaction).

Answer 848

Features most suggestive of norovirus include sudden onset vomiting, relatively short duration of symptoms and contact with others with similar symptoms. Rotavirus, E. coli and Salmonella infections will all cause similar clinical pictures, however, there are some important differentiating features. Salmonella infection has an incubation period of 6 - 72 hours and is often the result of contact with contaminated animal products, for example, unpasteurized eggs or milk. Unlike norovirus, salmonella gastroenteritis can cause bloody diarrhoea and patients often have a high fever. Rotavirus gastroenteritis causes symptoms very similar to those of norovirus, but predominantly affects children under the age of 5 years. E. coli infection, like Norovirus, causes vomiting and diarrhoea but has a longer incubation period (between 3-4 days but can be up to 10 days following pathogen exposure) and unlike Norovirus, E Coli infection commonly causes severe abdominal cramping and frequently causes bloody diarrhoea.

Answer 849

The infection is self-limiting in immunocompetent patients and symptoms generally resolve within 72 hours Dehydration and electrolyte imbalances may arise as a result of vomiting and diarrhoea, leading to significant morbidity and mortality and patients should be managed supportively with rehydration and electrolyte supplementation where necessary.

Answer 850

an aerobic Gram-negative rod. It causes a number of clinically important infections in humans: - chest infections (especially in cystic fibrosis) - skin: burns, wound infections, 'hot tub' folliculitis - otitis externa (especially in diabetics who may develop malignant otitis externa) - urinary tract infections

Answer 851

Gram-negative rod non-lactose fermenting oxidase positive

Answer 852

produces both an endotoxin (causes fever and shock) and exotoxin A (inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2)

Answer 853

a prolonged febrile illness with temperatures exceeding 38.3°C on several occasions over a period of at least 3 weeks, with no established diagnosis after one week of inpatient investigation.

Answer 854

Classical PUO: Often related to infections, malignancies, or non-infectious inflammatory diseases. Hospital-acquired PUO: Fevers that develop in hospitalized patients, commonly due to nosocomial infections, thromboembolic diseases, or drug fevers. Neutropenic PUO: Observed in neutropenic patients, typically those undergoing chemotherapy, where febrile episodes are predominantly due to infections. HIV-associated PUO: In patients with HIV, where fever can be attributed to various opportunistic infections, malignancies, or HIV itself.

Answer 855

Infections (30%): - Tuberculosis - Abscess Malignancies (20%) - Lymphoma - Hypernephroma - Leukaemia - Atrial myxoma Non-infectious inflammatory diseases -Systemic lupus erythematosus - Temporal arteritis - Rheumatoid arthritis. Miscellaneous (50%) - Drug fevers - Factitious fever

Answer 856

History and physical examination: Focus on travel history, occupational exposures, animal exposures, past medical history, and medication use. Laboratory tests: Initial tests include full blood count, ESR/CRP, HIV test, blood cultures, urine analysis, and chest radiography. Imaging: CT scans, MRI, and PET scans to identify hidden abscesses, malignancies Biopsies and specialised tests: Depending on the clinical suspicion, targeted biopsies, bone marrow examination

Answer 857

Many patients can undergo evaluation in an outpatient setting given the prolonged nature of the symptoms Empirical antibiotic therapy is generally not used, unless the patient is suspected of having a potentially life-threatening infection

Answer 858

Up to 50% of patients with classic FUO remain without a diagnosis after extensive evaluation The majority who remain undiagnosed have a good prognosis

Answer 859

caused by Coxiella burnetii, a rickettsia. The source of infection is typically an abattoir, cattle/sheep or it may be inhaled from infected dust

Answer 860

typically prodrome: fever, malaise causes pyrexia of unknown origin transaminitis atypical pneumonia endocarditis (culture-negative)

Answer 861

doxycycline

Answer 862

viral disease that causes an acute encephalitis. The rabies virus is classed as a RNA rhabdovirus (specifically a lyssavirus) and has a bullet-shaped capsid. The vast majority of cases are caused by dog bites but it may also be transmitted by bat, raccoon and skunk bites.

Answer 863

If untreated then nearly always fatal. Rabies is estimated to still kill around 25,000-50,000 people across the world each year. The vast majority of the disease burden falls on people in poor rural areas of Africa and Asia. Children are particularly at risk.

Answer 864

After entry, the virus replicates in muscle tissue near the site of the bite before entering the peripheral nervous system. It then travels up to the central nervous system, where it causes encephalitis, leading to severe neurological symptoms. The virus eventually reaches the salivary glands, facilitating transmission.

Answer 865

prodrome: headache, fever, agitation hydrophobia: water-provoking muscle spasms hypersalivation Negri bodies: cytoplasmic inclusion bodies found in infected neurons

Answer 866

now considered to be 'no risk' of developing rabies following an animal bite in the UK and the majority of developed countries. Following an animal bite in at-risk countries: - the wound should be washed - if an individual is already immunised then 2 further doses of vaccine should be given - if not previously immunised then human rabies immunoglobulin (HRIG) should be given along with a full course of vaccination. If possible, the dose should be administered locally around the wound

Answer 867

bronchiolitis

Answer 868

common cold

Answer 869

most common cause of CAP

Answer 870

CAP Most common cause of bronchiectasis exacerbations Acute epiglottitis

Answer 871

pneumonia, esp following influenza

Answer 872

Atypical pneumonia Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme

Answer 873

Atypical pneumonia Classically spread by air-conditioning systems, causes dry cough. Lymphopenia, deranged liver function tests and hyponatraemia may be seen

Answer 874

Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea

Answer 875

Causes tuberculosis. A wide range of presentations from asymptomatic to disseminated disease are possible. Cough, night sweats and weight loss may be seen.

Answer 876

an antibiotic which is used to treat a variety of infections. It is frequently used to treat tuberculosis (in combination with other medications). Rifampicin can also be used for prophylaxis in those who have had close contact with tuberculosis or meningitis.

Answer 877

inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA

Answer 878

potent CYP450 liver enzyme inducer hepatitis orange secretions flu-like symptoms

Answer 879

'CALL PICO and FLAVA. There's a RETRO TOGA party with lots of CORONAs'

Answer 880

Reoviridae

Answer 881

Reoviridae Picornaviridae Caliciviridae Togaviridae Arenaviridae Flaviviridae Orthomyxoviridae Paramyxoviridae Bunyaviridae Rhabdoviridae Filoviridae Coronaviridae Hepeviridae

Answer 882

Reoviridae Double-stranded, linear Naked Icosahedral Reovirus, Rotavirus

Answer 883

Single-stranded +, linear Naked Icosahedral Enterovirus, Rhinovirus, Poliovirus, Coxsackie

Answer 884

Single-stranded +, linear Naked Icosahedral Norwalk virus

Answer 885

Single-stranded +, linear Enveloped Icosahedral Rubella virus

Answer 886

Single-stranded -, circular Enveloped Helical Lymphocytic choriomeningitis virus

Answer 887

Single-stranded +, linear Enveloped Icosahedral Dengue virus, Hepatitis C virus, Yellow fever virus

Answer 888

Single-stranded -, linear Enveloped Helical Influenzavirus A, Influenzavirus B, Influenzavirus C,

Answer 889

Single-stranded -, linear Enveloped Helical Measles virus, Mumps virus, Respiratory syncytial virus

Answer 890

Single-stranded -, circular Enveloped Helical California encephalitis virus, Hantavirus

Answer 891

Single-stranded -, linear Enveloped Helical Rabies virus

Answer 892

Single-stranded -, linear Enveloped Helical Ebola virus, Marburg virus

Answer 893

Single-stranded +, linear Enveloped Helical Corona virus

Answer 894

Single-stranded +, linear Naked Icosahedral Hepatitis E virus

Answer 895

a parasitic flatworm infection. The three main species of schistosome are S. mansoni, S. japonicum and S. haematobium.

Answer 896

Acute symptoms typically only develop in people who travel to endemic areas, as they don't have any immunity to the worms. Acute manifestations may include: - swimmers' itch - acute schistosomiasis syndrome (Katayama fever)= fever, urticaria/angioedema, arthralgia/myalgia, cough, diarrhoea, eosinophilia

Answer 897

These worms deposit egg clusters (pseudopapillomas) in the bladder, causing inflammation. The calcification seen on x-ray is actually calcification of the egg clusters, not the bladder itself. Depending on the site of these pseudopapillomas in the bladder, they can cause an obstructive uropathy and kidney damage.

Answer 898

This typically presents as a 'swimmer's itch' in patients who have recently returned from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder cancer. Features: - frequency - haematuria - bladder calcification

Answer 899

for asymptomatic patients serum schistosome antibodies are generally preferred for symptomatic patients the gold standard for diagnosis is urine or stool microscopy looking for eggs

Answer 900

single oral dose of praziquantel

Answer 901

These worms mature in the liver and then travel through the portal system to inhabit the distal colon. Their presence in the portal system can lead to progressive hepatomegaly and splenomegaly due to portal vein congestion. These species can also lead to complications of liver cirrhosis, variceal disease and cor pulmonale.

Answer 902

These are less prevalent than the other three forms, but are both attributed to intestinal schistosomiasis.

Answer 903

collection of pus encapsulated by a pyogenic membrane.

Answer 904

a collection of pus that is superficial to the dura mater (of the meninges) that cover the spinal cord. It is an emergency requiring urgent investigation and treatment to avoid progressive spinal cord damage.

Answer 905

In SEA, bacteria enters the spinal epidural space by contiguous spread from adjacent structures (e.g. discitis), haematogenous spread from concomitant infection (e.g. bacteraemia from IVDU), or by direct infection (e.g. spinal surgery). Immunosuppression is another major risk factor, which may be caused by congenital immune disorders, acquired immune disorders (such as HIV, diabetes or alcoholism or by iatrogenic means (e.g. chemotherapy or steroids).

Answer 906

most typically bacterial and the most common causative micro-organism is Staphylococcus aureus

Answer 907

fever back pain focal neurological deficits according to the segment of the cord affected.

Answer 908

Bloods (including inflammatory markers, HIV, Hep B, Hep C, and preoperative blood tests (coagulation and group and screen)) Blood cultures Infection screen (including chest x-ray and urine culture): If the primary source of infection is not clear, a wide search for sources requires investigations including echocardiography and dental x-rays. MRI whole spine (the entire spine is imaged since skip lesions may be present)

Answer 909

All patients will require a long-term course of antibiotics which is at first broad spectrum but maybe later refined based on culture results. Patients with large or compressive abscesses, patients with significant or progressive neurological deficits or those who are not responding to antibiotics alone are considered for surgical evacuation of the abscess.

Answer 910

common type of bacteria that are often found normal commensal organisms but may also cause invasive disease

Answer 911

Gram-positive cocci facultative anaerobes produce catalase

Answer 912

Staphylococcus aureus Staphylococcus epidermidis

Answer 913

* Coagulase-positive * Causes skin infections (e.g. cellulitis), abscesses, osteomyelitis, toxic shock syndrome

Answer 914

* Coagulase-negative * Cause of central line infections and infective endocarditis

Answer 915

gram-positive cocci

Answer 916

alpha and beta haemolytic types

Answer 917

The most important alpha haemolytic Streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans

Answer 918

A-H Only groups A, B & D are important in humans.

Answer 919

most important organism is Streptococcus pyogenes responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis erythrogenic toxins cause scarlet fever

Answer 920

Streptococcus agalactiae may lead to neonatal meningitis and septicaemia

Answer 921

Enterococcus

Answer 922

a human parasitic nematode worm. The larvae are present in soil and gain access to the body by penetrating the skin. Infection with Strongyloides stercoralis causes strongyloidiasis.

Answer 923

diarrhoea abdominal pain/bloating papulovesicular lesions where the skin has been penetrated by infective larvae e.g. soles of feet and buttocks larva currens: pruritic, linear, urticarial rash if the larvae migrate to the lungs a pneumonitis similar to Loeffler's syndrome may be triggered

Answer 924

ivermectin and albendazole are used

Answer 925

class of drug that work by inhibiting dihydropteroate synthetase

Answer 926

sulfamethoxazole

Answer 927

a combination of sulfamethoxazole + trimethoprim that is used in the management of Pneumocystis jiroveci pneumonia sulfadiazine sulfisoxazole

Answer 928

sulfasalazine sulfonylureas

Answer 929

hyperkalaemia headache rash (including Steven-Johnson Syndrome)

Answer 930

Staphylococcus aureus Streptococcus pyogenes Escherichia coli Campylobacter jejuni Helicobacter pylori

Answer 931

Facultative anaerobe Gram-positive coccus Haemolysis on blood agar plates Catalase positive 20% population are long term carriers Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively Ideally treated with penicillin although many strains now resistant through beta-lactamase production. In the UK less than 5% of isolates are sensitive to penicillin. Resistance to methicillin (and other antibiotics) is mediated by the mec operon, essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues Common cause of cutaneous infections and abscesses

Answer 932

Gram-positive, forms chain like colonies, Lancefield Group A Streptococcus Produces beta haemolysis on blood agar plates Rarely part of normal skin microflora Catalase negative Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction Releases superantigens such as pyogenic exotoxin A which results in scarlet fever Remains sensitive to penicillin, macrolides may be used as an alternative.

Answer 933

Gram-negative rod Facultative anaerobe, non-sporing Wide range of subtypes and some are normal gut commensals Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via cAMP activation) Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in the case of enteroinvasive E-Coli significant) invasive component produces enteritis and large volume diarrhoea together with fever. They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta-lactamases

Answer 934

Curved, Gram-negative, non-sporulating bacteria One of the commonest causes of diarrhoea worldwide Produces enteritis which is often diffuse and blood may be passed Remains a differential for right iliac fossa pain with diarrhoea Self-limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective.

Answer 935

Gram-negative, helix-shaped rod, microaerophilic Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria Flagellated and mobile Those carrying the cag A gene may cause ulcers It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. Usually, colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection, gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylori- these patients get gastric ulcers. Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. In patients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma.

Answer 936

caused by the tetanospasmin exotoxin released from Clostridium tetani. Tetanus spores are present in soil and may be introduced into the body from a wound, which is often unnoticed. Tetanospasmin prevents the release of GABA, In developed countries, tetanus may be seen in intravenous drug users.

Answer 937

prodrome fever, lethargy, headache trismus (lockjaw) risus sardonicus: facial spasms opisthotonus (arched back, hyperextended neck) spasms (e.g. dysphagia)

Answer 938

supportive therapy including ventilatory support and muscle relaxants intramuscular human tetanus immunoglobulin for high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue) metronidazole is now preferred to benzylpenicillin as the antibiotic of choice

Answer 939

class of antibiotics which are commonly used in clinical practice.

Answer 940

doxycycline tetracycline

Answer 941

tetracyclines

Answer 942

protein synthesis inhibitors binds to 30S subunit blocking binding of aminoacyl-tRNA

Answer 943

increased efflux of the bacteria by plasmid-encoded transport pumps, ribosomal protection

Answer 944

acne vulgaris Lyme disease Chlamydia Mycoplasma pneumoniae

Answer 945

discolouration of teeth: therefore should not be used in children < 12 years of age photosensitivity angioedema black hairy tongue

Answer 946

should not be given to women who are pregnant or breastfeeding due to the risk of discolouration of the infant's teeth.

Answer 947

an obligate intracellular protozoan that infects the body via the gastrointestinal tract, lung or broken skin. It's oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease.

Answer 948

Most infections are asymptomatic. Symptomatic patients usually have a self-limiting infection, often having clinical features resembling infectious mononucleosis (fever, malaise, lymphadenopathy). Other less common manifestations include meningoencephalitis and myocarditis.

Answer 949

Serology is the investigation of choice. No treatment is usually required unless the patient has a severe infection or is immunosuppressed.

Answer 950

Cerebral toxoplasmosis accounts for around 50% of cerebral lesions in patients with HIV: - constitutional symptoms, headache, confusion, drowsiness - CT: usually single or multiple ring-enhancing lesions, mass effect may be seen - management: pyrimethamine plus sulphadiazine for at least 6 weeks Immunosuppressed patients may also develop a chorioretinitis secondary to toxoplasmosis.

Answer 951

Congenital toxoplasmosis is due to transplacental spread from the mother. It causes a variety of effects to the unborn child including neurological damage: - cerebral calcification - hydrocephalus - chorioretinitis ophthalmic damage: - retinopathy - cataracts

Answer 952

antibiotic, mainly used in the management of urinary tract infections

Answer 953

interferes with DNA synthesis by inhibiting dihydrofolate reductase may, therefore, interact with methotrexate, which also inhibits dihydrofolate reductase

Answer 954

myelosuppression transient rise in creatinine: trimethoprim competitively inhibits the tubular secretion of creatinine resulting in a temporary increase which reverses upon stopping the drug trimethoprim blocks the ENaC channel in the distal nephron, causing a hyperkalaemic distal RTA (type 4). It also inhibits creatinine secretion, often leading to an increase in creatinine by around 40 points (but not necessarily causing AKI)

Answer 955

competitively inhibits the tubular secretion of creatinine resulting in a temporary increase which reverses upon stopping the drug trimethoprim blocks the ENaC channel in the distal nephron, causing a hyperkalaemic distal RTA (type 4). It also inhibits creatinine secretion, often leading to an increase in creatinine by around 40 points (but not necessarily causing AKI)

Answer 956

Teratogenic risk in first trimester (folate antagonist). Manufacturers advise avoid during pregnancy.

Answer 957

Two main form of this protozoal disease are recognised - African trypanosomiasis (sleeping sickness) and American trypanosomiasis (Chagas' disease).

Answer 958

Two forms of African trypanosomiasis, or sleeping sickness, are seen - Trypanosoma gambiense in West Africa and Trypanosoma rhodesiense in East Africa. Both types are spread by the tsetse fly. Trypanosoma rhodesiense tends to follow a more acute course. Clinical features include: Trypanosoma chancre - painless subcutaneous nodule at site of infection intermittent fever enlargement of posterior cervical lymph nodes later: central nervous system involvement e.g. somnolence, headaches, mood changes, meningoencephalitis

Answer 959

early disease: IV pentamidine or suramin later disease or central nervous system involvement: IV melarsoprol

Answer 960

caused by the protozoan Trypanosoma cruzi. The vast majority of patients (95%) are asymptomatic in the acute phase although a chagoma (an erythematous nodule at site of infection) and periorbital oedema are sometimes seen. Chronic Chagas' disease mainly affects the heart and gastrointestinal tract myocarditis may lead to dilated cardiomyopathy (with apical atophy) and arrhythmias gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation

Answer 961

treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox chronic disease management involves treating the complications e.g., heart failure

Answer 962

a glycopeptide antibiotic used in the treatment of Gram-positive infections, particularly methicillin-resistant Staphylococcus aureus (MRSA).

Answer 963

inhibits cell wall formation by binding to D-Ala-D-Ala moieties, preventing polymerization of peptidoglycans

Answer 964

alteration to the terminal amino acid residues of the NAM/NAG-peptide subunits (normally D-alanyl-D-alanine) to which the antibiotic binds

Answer 965

nephrotoxicity ototoxicity thrombophlebitis red man syndrome; occurs on rapid infusion of vancomycin

Answer 966

Type of viral haemorrhagic fever (also dengue fever, Lassa fever, Ebola). zoonotic infection: spread by Aedes mosquitos incubation period = 2 - 14 days

Answer 967

may cause mild flu-like illness lasting less than one week classic description involves sudden onset of high fever, rigors, nausea & vomiting. Bradycardia may develop. A brief remission is followed by jaundice, haematemesis, oliguria if severe jaundice, haematemesis may occur Councilman bodies (inclusion bodies) may be seen in the hepatocytes

Answer 968

Broadly speaking, the management of venom allergy in the acute phase is supportive. Anaphylaxis should be managed with intramuscular adrenaline, intravenous steroids and intravenous anti-histamines as required. Oxygen and nebulised bronchodilators may also be required. People who've had a systemic reaction to an insect bite should be referred to an allergy specialist. Venom immunotherapy (VIT) is considered to be one of the most effective immunotherapies in use and may be recommended for patients with a history of a previous reaction which presented with airway and/or haemodynamic compromise and raised levels of venom-specific immunoglobulin E on either skin prick or in vitro testing.

Answer 969

any patient with a history of a systemic reaction causing airway compromise or haemodynamic instability. It may also be beneficial in patients with a history of a systemic cutaneous reaction where the allergen is felt to be difficult to avoid e.g. an allergy to bee stings in a beekeeper. Patients with a history of a systemic reaction should be provided with a self-management plan, including guidance on the use of anti-histamines and adrenaline auto-injectors. Patients should also be advised to wear a medical alert device.

Answer 970

Repeat allergy testing should be considered in those with a clear reaction history but no evidence of a venom-specific IgE. A baseline tryptase level should also be performed to exclude indolent mastocytosis (relevant because this may predict subsequent systemic reactions during the course of immunotherapy also should prompt further tests to exclude systemic mastocytosis or monoclonal mast cell activation syndrome). Research suggests that 'VIT is 95-100% and about 80% successful in preventing systemic reactions in wasp and bee sting allergy respectively...(and) has been shown to induce a clinically significant improvement in health-related QOL (quality of life) in patients with anaphylactic reactions as well as generalized non-life-threatening responses to yellow jacket stings...'

Answer 971

cytokines released by the body in response to viral infections and neoplasia. They are classified according to cellular origin and the type of receptor they bind to. IFN-alpha and IFN-beta bind to type 1 receptors whilst IFN-gamma binds only to type 2 receptors.

Answer 972

produced by leucocytes antiviral action useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia adverse effects include flu-like symptoms and depression bind to type 1 receptors

Answer 973

produced by fibroblasts antiviral action reduces the frequency of exacerbations in patients with relapsing-remitting MS bind to type 1 receptors

Answer 974

predominately natural killer cells. Also by T helper cells weaker antiviral action, more of a role in immunomodulation particularly macrophage activation may be useful in chronic granulomatous disease and osteopetrosis bind to type 2 receptors

Answer 975

Gell and Coombs classification

Answer 976

anaphylactic

Answer 977

Antigen reacts with IgE bound to mast cells * Anaphylaxis * Atopy (e.g. asthma, eczema and hayfever)

Answer 978

Cell bound

Answer 979

IgG or IgM binds to antigen on cell surface * Autoimmune haemolytic anaemia * ITP * Goodpasture's syndrome * Pernicious anaemia * Acute haemolytic transfusion reactions * Rheumatic fever * Pemphigus vulgaris / bullous pemphigoid

Answer 980

Immune complex

Answer 981

Free antigen and antibody (IgG, IgA) combine * Serum sickness * Systemic lupus erythematosus * Post-streptococcal glomerulonephritis * Extrinsic allergic alveolitis (especially acute phase)

Answer 982

Delayed hypersensitivity

Answer 983

T-cell mediated * Tuberculosis / tuberculin skin reaction * Graft versus host disease * Allergic contact dermatitis * Scabies * Extrinsic allergic alveolitis (especially chronic phase) * Multiple sclerosis * Guillain-Barre syndrome

Answer 984

Antibodies that recognise and bind to the cell surface receptors. This either stimulating them or blocking ligand binding * Graves' disease * Myasthenia gravis

Answer 985

5 (just added)

Answer 986

ACID Anaphylactic-Type 1 Cell bound- Type 2 Immune Complex- Type 3 Delayed hypersensitivity- Type 4

Answer 987

IgG IgA IgM IgD IgE

Answer 988

75% monomer

Answer 989

15% monomer/dimer

Answer 990

10% pentamer

Answer 991

1% monomer

Answer 992

0.1% monomer

Answer 993

IgG but IgA most commonly produced in the body (blood concs lower than IgG)

Answer 994

* Enhance phagocytosis of bacteria and viruses * Fixes complement and passes to the fetal circulation * Most abundant isotype in blood serum

Answer 995

* IgA is the predominant immunoglobulin found in breast milk. It is also found in the secretions of digestive, respiratory and urogenital tracts and systems * Provides localized protection on mucous membranes * Most commonly produced immunoglobulin in the body (but blood serum concentrations lower than IgG.) * Transported across the interior of the cell via transcytosis

Answer 996

* First immunoglobulins to be secreted in response to an infection * Fixes complement but does not pass to the fetal circulation * Anti-A, B blood antibodies (note how they cannot pass to the fetal circulation, which could of course result in haemolysis) Pentamer when secreted

Answer 997

* Role in immune system largely unknown * Involved in activation of B cells

Answer 998

* Mediates type 1 hypersensitivity reactions * Synthesised by plasma cells * Binds to Fc receptors found on the surface of mast cells and basophils * Provides immunity to parasites such as helminths * Least abundant isotype in blood serum

Answer 999

a serious bacterial or viral infection in the blood affects babies within the first 28 days of life

Answer 1000

early-onset (EOS, within 72 hours of birth) and late-onset (LOS, between 7-28 days of life) sepsis, with each category tending to have a distinct group of causes and common presentations

Answer 1001

account for 10% of all neonatal mortality and therefore must be promptly identified and managed to prevent significant consequences, as untreated, the mortality can be very high.

Answer 1002

Male:female incidence 1:1 Incidence of neonatal sepsis: 1-5 per 1000 live births * Term neonates: 1-2 per 1000 live births * Late pre-term infants: 5 per 1000 live births * Birth weight <2.5kg: 0.5 per 1000 live births Black race is an independent risk factor for group B streptococcus-related sepsis

Answer 1003

life-threatening sepsis

Answer 1004

group B strep (GBS) and E.coli

Answer 1005

GBS infection (75%) Infective causes in early-onset sepsis are usually due to transmission of pathogens from the mother to the neonate during delivery

Answer 1006

usually occurs via the transmission of pathogens from the environment post-delivery, this is normally from contacts such as the parents or healthcare workers Infective causes are more commonly coagulase-negative staphylococcal species such as Staphylococcus epidermidis, Gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella and Enterobacter, and fungal species

Answer 1007

Staphylococcus aureus Enterococcus Listeria monocytogenes Viruses including herpes simplex and enterovirus

Answer 1008

Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates Low birth weight (<2.5kg): approximately 80% are low birth weight Evidence of maternal chorioamnionitis

Answer 1009

subacute onset of.... Respiratory distress (85%)= Grunting, Nasal flaring, Use of accessory respiratory muscles, Tachypnoea Tachycardia: common, but non-specific Apnoea (40%) Apparent change in mental status/lethargy Jaundice (35%) Seizures (35%): if cause of sepsis is meningitis Poor/reduced feeding (30%) Abdominal distention (20%) Vomiting (25%) Temperature: not usually a reliable sign as the temperature can vary from being raised, lowered or normal Term infants are more likely to be febrile Pre-term infants are more likely to be hypothermic The clinical presentation can vary from very subtle signs of illness to clear septic shock Frequently, the symptoms will be related to the source of infection (e.g. pneumonia + respiratory symptoms, meningitis + neurological symptoms)

Answer 1010

Grunting Nasal flaring Use of accessory respiratory muscles Tachypnoea

Answer 1011

not usually a reliable sign as the temperature can vary from being raised, lowered or normal Term infants are more likely to be febrile Pre-term infants are more likely to be hypothermic

Answer 1012

Blood culture: this will usually establish the diagnosis, as the sensitivity for septicaemia is around 90%. Should usually obtain two blood cultures if possible to distinguish from contamination, however one culture is still sufficient depending on hospital protocol Full blood examination: neonatal sepsis is often associated with abnormal neutrophil counts (both neutrophilia and neutropenia), however in neonates, parameters on full blood examination are usually not always useful for diagnosis, rather may help to exclude healthy neonates C-reactive protein: not useful for diagnosis, but sequential assessment will help to guide management and patient progress with treatment. CRP will usually be raised, and a persistently normal level is likely to exclude neonatal sepsis Blood gases: metabolic acidosis is particularly concerning for neonatal sepsis, particularly a base deficit of ≥10 mmol/L Urine microscopy, culture and sensitivity: rarely positive in EOS, more useful in LOS. Will show signs of infection (e.g. raised leukocytes, positive culture, haematuria, proteinuria) if urinary tract infection is the source of sepsis Lumbar puncture: particularly if there is concern of meningitis as the source of sepsis based on clinical features, however many hospitals will require lumbar puncture as part of a septic screen in any baby below the age of 28 days

Answer 1013

metabolic acidosis esp if a base deficit of ≥10 mmol/L

Answer 1014

early identification and treatment IV benzylpenicillin with gentamicin as a first-line regimen for suspected or confirmed neonatal sepsis - The exception to this is if microbiological surveillance data reveal local bacterial resistance patterns, in which case an alternative antibiotic should be considered Maintaining adequate oxygenation status Maintaining normal fluid and electrolyte status: severely ill neonates may require volume and/or vasopressor support. Body weight needs to be measured daily for accurate assessment of fluid status Prevention and/or management of hypoglycaemia Prevention and/or management of metabolic acidosis

Answer 1015

- CRP should be re-measured 18-24 hours after presentation in babies given antibiotics to monitor ongoing progress and guide duration of therapy - The evidence suggests that antibiotics can be ceased at 48 hours in neonates who have CRP of <10 mg/L and a negative blood culture at presentation and at 48 hours - In all other neonates, the duration of antibiotic treatment will depend on the ongoing investigations and clinical picture, this will involve specialist decision making. Normally, in neonates with culture-proven sepsis, duration will be approximately 10 days

Answer 1016

body weight measured daily

Answer 1017

IV benzylpenicillin + gentamicin unless microbiological surveillance data reveal local bacterial resistance patterns, in which case an alternative antibiotic should be considered