Infection and immunity Flashcards

Question

What is CMV mononucleosis?

Answer 1

1. Infectious mononucelosis-like illness 2. May develop in immunocompetent individuals

Answer 2

1. Common in HIV patients with a low CD4 count (< 50) 2. Presents with visual impairment e.g. 'blurred vision'. 3. Fundoscopy shows retinal haemorrhages and necrosis, often called 'pizza' retina 4. IV ganciclovir is the treatment of choice

Answer 3

IV ganciclovir

Answer 4

1. Caused by a retrovirus that infects and replicates in human lymphocytes and macrophage 2. Erodes the integrity of the human immune system over a number of years 3. This results in immune deficiency and a susceptibility to a series of opportunistic and other infections as well as the development of certain malignancies

Answer 5

1. HIV is retrovirus that infects and replicates primarily in human CD4+ T cells and macrophages 2. It can be transmitted via blood, blood products, sexual fluids, other fluids containing blood, and breast milk

Answer 6

1. Sexual contact (most common) 2. Before birth or during delivery 3. During breastfeeding 4. When sharing contaminated needles and syringes (intravenous drug users)

Answer 7

Globally, the HIV incidence rate is believed to have peaked in the late 1990s and to have stabilised subsequently

Answer 8

1. Seroconversion: (4–8 weeks post-infection) 2. Early/asymptomatic: (18 months to 15 +years) 3. AIDS: Syndrome of secondary diseases reflecting severe immuno deficiency or direct effect

Answer 9

1. Typically occurs 3-12 weeks after infection 2. Presents as a glandular fever type illness 3. Symptomatic in 60-80% of patients 4. Increased symptomatic severity is associated with poorer long term prognosis

Answer 10

1. Sore throat 2. Lymphadenopathy 3. Malaise, myalgia, arthralgia diarrhoea 4. Maculopapular rash 5. Mouth ulcers 6. Rarely meningoencephalitis

Answer 11

1. After discussion and consent) 2. Serum HIV enzyme linked immunosorbent assay: positive/Serum HIV rapid test 3. HIV antibodies (usually positive by 12 weeks after exposure) 4. p24 antigen: viral core protein 5. PCR for viral RNA or incorporated proviral DNA 6. Monitor CD4+ count and viral load

Answer 12

Combination tests (HIV p24 antigen and HIV antibody): 1. For both diagnosis and screening of HIV 2. If the combined test is positive it should be repeated to confirm the diagnosis 3. Some centres may also test the viral load (HIV RNA levels) at the same time

Answer 13

1. Should be done at 4 weeks after possible exposure 2. After an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test at 12 weeks

Answer 14

1. Can be asymptomatic for years 2. Apparently well 3. Some patients may have persistent lymphadenopathy (>1 cm nodes, at 2 + extrainguinal sites for >3 months) 4. Progressive minor symptoms, e.g. rash, oral thrush, weight loss, malaise

Answer 15

1. AIDS: acquired immune deficiency syndrome 2. Presents as symptoms of opportunistic infections (linked to CD4 count)

Answer 16

1. Oral thrush: Secondary to Candida albicans 2. Shingles: Secondary to herpes zoster 3. Hairy leukoplakia: Secondary to EBV 4. Kaposi sarcoma: Secondary to HHV-8

Answer 17

1. Caused by HHV-8 (human herpes virus 8) 2. Presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract) 3. Skin lesions may later ulcerate 4. Respiratory involvement may cause massive haemoptysis and pleural effusion

Answer 18

Radiotherapy and resection

Answer 19

1. Cryptosporidiosis: The disease is usually self-limiting and similar to that in immunocompetent hosts 2. Cerebral toxoplasmosis 3. Progressive multifocal leukoencephalopathy: Secondary to the JC virus 4. Pneumocystis jirovecii pneumonia 5. HIV dementia

Answer 20

1. A unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa 2. PCP is the most common opportunistic infection in AIDS all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis

Answer 21

1. Dyspnoea 2. Dry cough 3. Fever 4. Very few chest signs

Answer 22

Pneumothorax

Answer 23

1. Rare (1-2%) 2. Hepatosplenomegaly 3. Lymphadenopathy 4. Choroid lesions

Answer 24

1. CXR: a. Typically shows bilateral interstitial pulmonary infiltrates b. Can present with other x-ray findings e.g. lobar consolidation c. May be normal 2. Exercise-induced desaturation 3. Bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts) a. Sputum often fails to show PCP

Answer 25

1. Co-trimoxazole 2. IV pentamidine in severe cases 3. Steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

Answer 26

1. Aspergillosis: Secondary to Aspergillus fumigatus 2. Oesophageal candidiasis: Secondary to Candida albicans 3. Cryptococcal meningitis 4. Primary CNS lymphoma: Secondary to EBV

Answer 27

1. The most common cause of oesophagitis in patients with HIV 2. It is generally seen in patients with a CD4 count of less than 100 3. Typical symptoms include dysphagia and odynophagia 4. Fluconazole and itraconazole are first-line treatments

Answer 28

1. Cytomegalovirus retinitis: Affects around 30-40% of patients with CD4 < 50 cells/mm³ 2. Mycobacterium avium-intracellulare infection

Answer 29

1. Toxoplasmosis (50%) 2. Primary CNS lymphoma (30%) 3. TB 4. Others: a. Encephalitis b. Cryptococcus c. Progressive multifocal leukoencephalopathy d. AIDS dementia complex

Answer 30

1. Opportunistic infection when CD4 count is between 100-200 cells/mm3 2. Accounts for 50% of cerebral lesions in HIV patients 3. Features: constitutional symptoms, headache, confusion, drowsiness 4. On CT: usually single or multiple ring enhancing lesions, mass effect may be seen 5. Management: sulfadiazine and pyrimethamine

Answer 31

1. Secondary to EBV when CD4 count is between 50-100 cells/mm3 2. Accounts for 30% of cerebral lesions in HIV patients 3. CT: single or multiple homogenous enhancing lesions 4. Treatment: a. Steroids (may significantly reduce tumour size), chemotherapy (e.g. methotrexate) + with or without whole brain irradiation b. Surgical may be considered for lower grade tumours

Answer 32

1. Toxoplasmosis: a. Multiple lesions b. Ring or nodular enhancement c. Thallium SPECT negative 2. Primary CNS lymphoma: a. Single lesion b. Solid (homogenous) enhancement c. Thallium SPECT positive

Answer 33

1. Much lesson common than toxoplasmosis and lymphoma 2. Single enhancing lesion

Answer 34

Cryptococcus: 1. Headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit 2. CSF: a. high opening pressure b. elevated protein c. reduced glucose d. normally a lymphocyte predominance but in HIV white cell count many be normal e. India ink test positive 3. CT: a. meningeal enhancement b. cerebral oedema c. meningitis is typical presentation but may occasionally cause a space-occupying lesion

Answer 35

1. May be due to the effects of the virus itself (HIV enteritis) or opportunistic infections 2. Possible causes: a. Cryptosporidium + other protozoa (most common) b. Cytomegalovirus c. Mycobacterium avium intracellulare d. Giardia

Answer 36

1. Antiretroviral therapy (ART): involves a combination of at least three drugs 2. Typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI) 3. This combination both decreases viral replication but also reduces the risk of viral resistance emerging

Answer 37

As soon as they have been diagnosed with HIV

Answer 38

1. E.g. zidovudine (AZT), abacavir, lamivudine, zalcitabine, tenofovir 2. General NRTI side-effects: peripheral neuropathy 3. Tenofovir: (recommended regime of two NRTIs), adverse effects include renal impairment and ostesoporosis 4. Zidovudine: anaemia, myopathy, black nails

Answer 39

1. Non-nucleoside reverse transcriptase inhibitors (NNRTI): a. e.g. nevirapine, efavirenz, b. P450 enzyme interaction (nevirapine induces), rashes 2. Protease inhibitors (PI): a. e.g. indinavir, nelfinavir, ritonavir, saquinavir b. SEs: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition, renal stones 3. Integrase inhibitors: a. block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell b. e.g. raltegravir, elvitegravir, dolutegravir

Answer 40

Infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendineae, sites of septal defects, or the mural endocardium

Answer 41

Staphylococcus aureus (particularly in the acute presentation and IVDU)

Answer 42

The endocardium can be colonized by virtually any organism, but the most common are: 1. Streptococci: Mainly a-haemolytic 2.Staphylococci: Staphylococcus aureus (most common) 3. Enterococci (20%) 4. Historical sources of bacteraemia should be considered, such as indwelling vascular catheters, recent dental work, and intravenous drug use

Answer 43

1. Staphylococcus aureus: IVDU (and acute presentatin) 2. Streptococcus viridans: found in the mouth, poor dental hygiene or following a dental procedure 3. Staphylococcus epidermidis: commonly colonize indwelling lines, most common in prosthetic valves (< 2 months, after which returns to Staph A) 4. Streptococcus bovis: associated with colorectal cancer

Answer 44

1. Systemic lupus erythematosus (Libman-Sacks) 2. Malignancy: marantic endocarditis

Answer 45

1. Previously normal valves (50%, typically acute presentation), the mitral valve is most commonly affected 2. Rheumatic valve disease (30%) 3. Prosthetic valves 4. Congenital heart defects 5. Intravenous drug users (IVDUs) e.g. typically causing tricuspid lesion) 6. Others: recent piercings

Answer 46

1. Fever with sweats/chills/rigors (may be relapsing and remitting) 2. Malaise 3. Fatigue 4. Weight loss 5. Headache 6. Arthralgia 7. Myalgia 8. Dyspnoea 9. Confusion (particularly in elderly) 10. Skin lesions

Answer 47

1. Petechiae particularly on retinae (Roth's spots) 2. Pharyngeal and conjunctival mucosa vasculitic lesions 3. Janeway lesions (painless palmar macules, which blanch on pressure) 4. Osler's nodes (tender nodules on finger/toe pads) 5. Splinter haemorrhages (nail-bed haemorrhages)

Answer 48

1. Bloods: a. FBC (leukocytosis, normocytic anaemia) b. Raised ESR and CRP c. U&Es: mildly elevated urea d. Rheumatoid factors: may be positive (minor criteria for diagnosis) e. Complement levels: decreased 2. Blood culture: At least three sets 1h apart: bacteraemia or fungaemia 3. ECG: progression of the infection may lead to conduction system disease 4. Echocardiography: a. Should be performed in all cases of suspected IE b. Detection of vegetations and valve abscess c. Diagnosis of prosthetic valve endocarditis and assessment of embolic risk

Answer 49

1. Pathological criteria positive, or 2. 2 major criteria, or 3. 1 major and 3 minor criteria, or 4. 5 minor criteria Also known as Modified Duke criteria

Answer 50

1. Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery 2. E.g. valve tissue, vegetations, embolic fragments or intracardiac abscess content

Answer 51

1. Positive blood cultures 2. Evidence of endocardial involvement e.g. positive echocardiogram or new valvular regurgitation

Answer 52

1. Persistent bacteraemia from two blood cultures taken > 12 hours apart or 2. Three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis

Answer 53

1. Predisposing heart condition or IVDU 2. Microbiological evidence does not meet major criteria 3. Fever > 38ºC 4. Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura 5. Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots

Answer 54

1. Native valve: amoxicillin, consider adding low-dose gentamicin 2. If penicillin allergic, MRSA or severe sepsis: vancomycin + low-dose gentamicin 3. If prosthetic valve: vancomycin + rifampicin + low-dose gentamicin

Answer 55

1. Native valve: a. Flucloxacillin b. If pen allergic or MRSA: vancomycin + rifampicin 2. Prosthetic valve: a. Flucloxacillin + rifampicin + low-dose gentamicin b. If pen allergic or MRSA: vancomycin + rifampicin + low-dose gentamicin

Answer 56

1. Fully sensitive: a. Benzylpenicillin b. If penallergic: vancomycin + low-dose gentamicin 2. If less sensitive: a. Benzylpenicillin + low-dose gentamicin b. If pen allergic: vancomycin + low-dose gentamicin

Answer 57

1. Severe valvular incompetence 2. Aortic abscess (often indicated by a lengthening PR interval) 3. Infections resistant to antibiotics/fungal infections 4. Cardiac failure refractory to standard medical treatment 5. Recurrent emboli after antibiotic therapy

Answer 58

1. Staphylococcus aureus infection 2. Prosthetic valve (especially 'early', acquired during surgery) 3. Culture negative endocarditis 4. Low complement levels

Answer 59

1. Prior antibiotic therapy 2. Coxiella burnetii 3. Bartonella 4. Brucella 5. HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Answer 60

1. Staphylococci - 30% 2. Bowel organisms - 15% 3. Streptococci - 5%

Answer 61

1. Valve incompetence 2. Intracardiac fistulae or abscesses 3. Aneurysm formation 4. Heart failure 5. Renal failure 6. Glomerulonephritis 7. Arterial emboli from the vegetations (brain, kidneys, lungs, spleen) 8. Fatal if untreated

Answer 62

1. A parasitic infection caused by protozoa of the genus Plasmodium 2. Five species are known to infect humans; Plasmodium falciparum is the most life-threatening

Answer 63

1. It is naturally transmitted to humans through a bite by an infected female Anopheles mosquito 2. May potentially be transmitted by blood transfusion or organ transplantation

Answer 64

1. High degree of clinical suspicion in any feverish traveller: a. incubation up to 1 year, but usually 1–2 weeks 2. Cyclical symptoms of high fever, flulike symptoms, severe sweating and shivering cold/rigors

Answer 65

1. Pyrexia/rigors 2. Anaemia 3. Hepatosplenomegaly

Answer 66

1. Sickle cell anaemia 2. G6PD deficiency 3. HLA-B53

Answer 67

The most common and severe form of Malaria

Answer 68

Thick and thin blood films stained using Field's or Giemsa's stain

Answer 69

1. Schizonts on a blood film 2. Parasitaemia > 2% 3. Hypoglycaemia 4. Acidosis 5. Temperature > 39 °C 6. Severe anaemia 7. Complications: cerebral malaria, acute renal failure, ARDS, DIC

Answer 70

Artemisinin-based combination therapy (ACT) or chloroquine (avoided in pregnant women)

Answer 71

1. Describes inflammation of the myocardium 2. Acute inflammation and necrosis of cardiac muscle in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease

Answer 72

1. Can be idiopathic 2. Viral: coxsackie B, HIV 3. Bacteria: diphtheria, clostridia 4. Spirochaetes: Lyme disease 5. Protozoa: Chagas' disease, toxoplasmosis 6. Autoimmune 7. Drugs: doxorubicin

Answer 73

1. Usually a pro-dromal flu illness 2. Present acutely as a young patient with chest pain 3. Dyspnoea 4. Arrhythmias 5. Absence of pericarditis features e.g. relived when sitting forward, saddle shape ST elevation

Answer 74

1. Bloods: a. Raised inflammatory markers b. Raised cardiac enzymes c. Raised BNP 2. ECG: a. Tchycardia b. Arrhythmias c. ST/T wave changes including ST-segment elevation and T wave inversion

Answer 75

1. Treatment of underlying cause e.g. antibiotics if bacterial cause 2. Supportive treatment e.g. of heart failure or arrhythmias

Answer 76

1. Heart failure 2. Arrhythmia, possibly leading to sudden death 3. Dilated cardiomyopathy: usually a late complication

Answer 77

1. A life-threatening subcutaneous soft-tissue infection that may extend to the deep fascia, but not into the underlying muscle 2. A medical emergency that is difficult to recognise in the early stages

Answer 78

1. Type 1: caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics), the most common type 2. Type 2: caused by Streptococcus pyogenes

Answer 79

1. Skin factors: recent trauma, burns or soft tissue infections 2. Diabetes mellitus: a. the most common preexisting medical condition b. particularly if the patient is treated with SGLT-2 inhibitors 3. IVDU 4. Immunosuppression

Answer 80

Perineum (Fournier's gangrene)

Answer 81

1. Acute onset 2. Pain, swelling, erythema at the affected site 3. Often presents as rapidly worsening cellulitis with pain out of keeping with physical features 4. Extremely tender over infected tissue with hypoaesthesia to light touch 5. Skin necrosis and crepitus/gas gangrene are late signs 6. Fever and tachycardia may be absent or occur late in the presentation

Answer 82

1. Medical emergency: A to E 2. Bloods and ABG: hypoxaemia, acidosis, elevated lactate 3. Blood cultures 4. Imaging: CT/MRI show oedema extending along fascial plane and/or soft tissue gas

Answer 83

1. Urgent surgical referral debridement 2. Intravenous antibiotics

Answer 84

Average mortality of 20%

Answer 85

1. Infection of the bone 2. Can be classified into: a. Haematogenous (from bacteraemia) b. Non-haematogenous (contiguous spread from local tissue) 3. Most common cause is staphylococcus aureus (but Salmonella in sickle cell patients)

Answer 86

1. Results from bacteraemia 2. Usually monomicrobial 3. Most common form in children 4. Vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults 5. Risk factors include: a. sickle cell anaemia b. IVDU c. Immunosuppression due to either medication or HIV d. Infective endocarditis

Answer 87

1. Results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone 2. Is often polymicrobial 3. Most common form in adults 4. Risk factors include: a. Diabetic foot ulcers/pressure sores b. Diabetes mellitus c. Peripheral arterial disease

Answer 88

MRI: imaging modality of choice, with a sensitivity of 90-100%

Answer 89

1. Flucloxacillin for 6 weeks 2. Clindamycin if penicillin-allergic

Answer 90

Develops following an immunological reaction to a recent (2-4 weeks ago) Streptococcus pyogenes infection

Answer 91

1. 2–5 weeks after GAS infection: recent sore throat 2. General: a. Fever b. Malaise c. Anorexia 3. Joints: a. Painful, swollen, reduced movement/function 4. Cardiac: a. Breathlessness b. Chest pain, palpitations

Answer 92

1. Major criteria: a. Erythema marginatum: transient erythematous rash with raised edges, seen on trunk and proximal limbs (rare in adults) b. Sydenham's chorea: this is often a late feature c. Polyarthritis d. Carditis and valvulitis (eg, pancarditis) e. Subcutaneous nodules 2. Minor ciriteria: a. Raised ESR or CRP b. Pyrexia c. Arthralgia (not if arthritis a major criteria) d. Prolonged PR interval

Answer 93

1. Evidence of recent streptococcal infection: a. Raised or rising streptococci antibodies b. Positive throat swab c. Positive rapid group A streptococcal antigen test 2. Accompanied by: a. 2 major criteria or b. 1 major with 2 minor criteria

Answer 94

1. Antibiotics: oral penicillin V 2. Anti-inflammatories: NSAIDs are first-line 3. Treatment of any complications that develop e.g. heart failure, mitral stenosis

Answer 95

Rheumatic Fever

Answer 96

Joint inflammation resulting from intra-articular (occurring within a joint) infection

Answer 97

1. Most common organism overall: Staphylococcus aureus a. In young adults who are sexually active, Neisseria gonorrhoeae 2. Most common cause is hematogenous spread (may be from distant bacterial infections e.g. abscesses)

Answer 98

1. Acute, swollen joint: a. restricted movement in 80% of patients b. examination findings: warm to touch/fluctuant 2. Fever: present in the majority of patients

Answer 99

1. Synovial fluid sampling is obligatory: a. Should be done prior to the administration of antibiotics if necessary! b. May need to be done under radiographic guidance 2. Blood cultures: the most common cause is hematogenous spread 3. Joint imaging

Answer 100

1. IV antibiotics which cover Gram-positive cocci are indicated: flucloxacillin or clindamycin if penicillin allergic 2. Antibiotic treatment is normally be given for several weeks (BNF states 4-6 weeks) 3. Patients are typically switched to oral antibiotics after 2 weeks 4. Needle aspiration should be used to decompress the joint 5. Arthroscopic lavage may be required

Answer 101

1. Fever >38.5 degrees C 2. Non-weight bearing 3. Raised ESR 4. Raised WCC

Answer 102

1. An autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces 2. Particularly dry eyes (keratoconjunctivitis sicca) and dry mouth

Answer 103

It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset

Answer 104

Much more common in females (ratio 9:1)

Answer 105

A marked increased risk of lymphoid malignancy (40-60 fold)

Answer 106

1. Dry eyes: keratoconjunctivitis sicca 2. Dry mouth 3. Vaginal dryness 4. Arthralgia 5. Raynaud's, myalgia 6. Sensory polyneuropathy 7. Recurrent episodes of parotitis

Answer 107

1. An exaggerated vasoconstrictive response of the digital arteries and cutaneous arteriole to the cold or emotional stress 2. Primary: Raynaud's disease, young women, bilateral 3. Secondary: Raynaud's phenomenon, e.g.: a. Scleroderma (most common) b. RA c. SLE

Answer 108

Calcium channel blockers: nifedipine

Answer 109

1. Bloods, Antibodies: a. Rheumatoid factor (RF) positive in nearly 50% of patients b. ANA positive in 70% c. anti-Ro (SSA) antibodies in 70% of patients with PSS d. anti-La (SSB) antibodies in 30% of patients with PSS 2. Schirmer's test: filter paper near conjunctival sac to measure tear formation 3. Histology: focal lymphocytic infiltration

Answer 110

1. Artificial saliva and tears 2. Pilocarpine may stimulate saliva production

Answer 111

Inflammation and infection of the vertebra

Answer 112

Pain (progressive history) and stiffness

Answer 113

1. Bloods: inflammatory markers 2. Imaging: radiographs, MRI ± radionuclide scanning 3. Blood cultures and aspiration of the infected intervertebral disc space

Answer 114

1. Antibiotics specific to cultured organism 2. Might consider steroids (a complex condition that needs MDT approach)

Answer 115

A chronic multi-system inflammatory autoimmune disorder that most commonly affects women during their reproductive years

Answer 116

1. Autoimmune: Type 3 hypersensitivity reaction 2. Associated with HLA B8, DR2, DR3 3. Thought to be caused by immune system dysregulation leading to immune complex formation 4. Immune complex deposition can affect any organ including the skin, joints, kidneys and brain

Answer 117

1. Much more common in females (F:M = 9:1) 2. More common in Afro-Caribbeans and Asian communities 3. Onset is usually 20-40 years 4. Incidence has risen substantially during the past 50 years (3 fold)

Answer 118

1. By system affected by immune complex deposition 2. General 3. Skin 4. MSK 5. Cardiovascular 6. Respiratory 7. Renal 8. Neuropsychiatry

Answer 119

1. Fatigue 2. Fever 3. Mouth ulcers 4. Lymphadenopathy

Answer 120

1. Malar (butterfly) rash: spares nasolabial folds 2. Discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas, lesions may progress to become pigmented and hyperkeratotic before becoming atrophic 3. Photosensitivity 4. Raynaud's phenomenon 5. Livedo reticularis 6. Non-scarring alopecia: hair thinning

Answer 121

1. Arthralgia 2. Non-erosive arthritis

Answer 122

1. Cardiovascular: a. Pericarditis: the most common cardiac manifestation b. Myocarditis 2. Respiratory: a. Pleurisy b. Fibrosing alveolitis

Answer 123

1. Proteinuria 2. Glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)

Answer 124

1. Anxiety and depression 2. Psychosis 3. Seizures

Answer 125

1. Bloods: a. inflammatory markers b. Complement levels: are low during active disease (formation of complexes leads to consumption of complement) 2. Antibodies: diagnostic a. ANA positive (99%) b. anti-dsNSA: highly specific (> 99%), but less sensitive (70%) c. anti-Smith: highly specific (> 99%), sensitivity (30%) d. Rheumatoid factor (20%)

Answer 126

1. ANA 2. Anti-dsDNA 3. Anti-Smith 4. Rheumatoid factor (20%)

Answer 127

1. NSAIDs 2. Suncream for photosensitivity 3. Hydroxychloroquine: the treatment of choice for SLE 4. If internal organ involvement e.g. renal, neuro, eye then consider: prednisolone, cyclophosphamide

Answer 128

Hydroxychloroquine

Answer 129

A condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues

Answer 130

1. Limited cutaneous systemic sclerosis 2. Diffuse cutaneous systemic sclerosis 3. Scleroderma: without organ involvement

Answer 131

1. Four times more common in females 2. Age of onset 30–60 years

Answer 132

1. Raynaud's may be the first sign 2. Affects face and distal limbs predominately 3. Associated with anti-centromere antibodies 4. A subtype of limited systemic sclerosis is CREST syndrome: a. Calcinosis b. Raynaud's phenomenon c. oEsophageal dysmotility d. Sclerodactyly e. Telangiectasia

Answer 133

1. Affects trunk and proximal limbs predominately 2. Associated with anti scl-70 antibodies 3. Most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) 4. Other complications include renal disease and hypertension 5. Patients with renal disease should be started on an ACE inhibitor 6. Poor prognosis

Answer 134

1. Without organ involvement 2. Tightening and fibrosis of skin 3. May be manifest as plaques (morphoea) or linea

Answer 135

Anti-centromere

Answer 136

Anti-Scl-70

Answer 137

ANA and Rheumatoid factor

Answer 138

1. Pain management through NSAIDs or corticosteroids 2. Calcium channel blockers for Raynaud's (limited): nifedipine 3. ACEi for renal involvement (diffuse)

Answer 139

1. Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms) is extremely common amongst children in the UK 2. Infestation occurs after swallowing eggs that are present in the environment

Answer 140

1. Asymptomatic in around 90% of cases 2. Possible features include: a. Perianal itching, particularly at night b. Girls may have vulval symptoms

Answer 141

1. Most patients are treated empirically based on clinical diagnosis 2. Can also be diagnosed by the applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs

Answer 142

1. Combination of anthelmintic with hygiene measures for all members of the household 2. Mebendazole is used first-line for children > 6 months old 3. A single dose is given unless infestation persists

Answer 143

A local or generalised superficial swelling of the skin

Answer 144

1. Most commonly caused by allergy: drugs e.g. penicillins, and food

Answer 145

1. While the majority of these cases are acute and self-limiting events, roughly 30% of people will go on to experience prolonged symptoms 2. Acute urticaria is more common in children and adolescents than in adults 2. Chronic urticaria more typically affects adults, women are affected more often than men

Answer 146

1. Pale, pink raised skin 2. Variously described as 'hives', 'wheals', 'nettle rash' 3. Pruritic 4. Generally resolves within 24h 5. Up to 40% of cases have associated: angio-oedema: swelling of the face, tongue or lips

Answer 147

1. Acutely often diagnosed clinically 2. Chronic urticaria: a. FBC: may provide evidence of occult infection, anaemia, or findings suggestive of chronic illness b. Ig-E antibodies c. Inflammatory markers d. Antithyroid/antinuclear antibodies: exclude thyroid/rheumatic causes of chronic illness

Answer 148

1. Non-sedating antihistamines are first-line 2. Prednisolone is used for severe or resistant episodes

Answer 149

1. BCG 2. measles, mumps, rubella (MMR) 3. Influenza (intranasal) 4. Oral rotavirus 5. Oral polio 6. Yellow fever 7. Oral typhoid

Answer 150

1. Rabies 2. Hepatitis A 3. Influenza (intramuscular)

Answer 151

1. Tetanus 2. Diphtheria 3. Pertussis

Answer 152

1. Pneumococcus (conjugate) 2. Haemophilus (conjugate) 3. Meningococcus (conjugate) 4. Hepatitis B 5. Human papillomavirus

Answer 153

1. Varicella-zoster is the herpes virus that causes chickenpox 2. Shingles is an acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV)

Answer 154

1. VZV is an herpes ds-DNA virus 2. Highly contagious, transmission is by aerosol inhalation or direct contact with the vesicular secretions

Answer 155

1. Chickenpox peak incidence occurs at 4–10 years 2. Shingles peak incidence occurs at >50 years 3. About 90% of adults are VZV IgG positive (previously infected)

Answer 156

1. Highly infectious 2. Spread via the respiratory route 3. Can be caught from someone with shingles (reactivation) 4. Infectivity = 4 days before rash, until 5 days after the rash first appeared 5. Incubation period = 10-21 days

Answer 157

1. Tends to be more severe in older children/adults 2. Fever initially 3. Itchy, rash starting on head/trunk before spreading. 4. Initially macular then papular then vesicular 5. Systemic upset is usually mild

Answer 158

1. Supportive: keep cool, trim nails, calamine lotion 2. Infectious until all lesions are dry and have crusted over (usually about 5 days after the onset of the rash): school exclusion 3. IVIG for immunocompromised or pregnant women

Answer 159

1. Secondary bacterial infection of the lesions 2. NSAIDs may increase this risk 3. Whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis

Answer 160

1. Pneumonia 2. Encephalitis (cerebellar involvement may be seen) 3. Disseminated haemorrhagic chickenpox 4. Arthritis, nephritis and pancreatitis may very rarely be seen

Answer 161

1. An acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV) 2. Following primary infection with VZV (chickenpox), the virus lies dormant in the dorsal root or cranial nerve ganglia

Answer 162

1. Increasing age 2. HIV: strong risk factor, 15 times more common 3. Other immunosuppressive conditions (e.g. steroids, chemotherapy)

Answer 163

1. Prodromal period: a. Burning pain over the affected dermatome for 2-3 days b. Pain may be severe and interfere with sleep c. Around 20% of patients will experience fever, headache, lethargy 2. Rash: a. Initially erythematous, macular rash over the affected dermatome b. Quickly becomes vesicular c. Characteristically is well demarcated by the dermatome and does not cross the midline: however, some 'bleeding' into adjacent areas may be seen

Answer 164

1. Analgesia: a. Paracetamol and NSAIDs are first-line b. If not responding: neuropathic agents (e.g. amitriptyline) c. Oral corticosteroids may be considered in the first 2 weeks in immunocompetent adults 2. Antivirals: a. NICE recommendations: antivirals within 72 hours for the majority of patients, unless the patient is < 50 years and has a 'mild' truncal rash associated with mild pain and no underlying risk factors b. One of the benefits of prescribing antivirals is a reduced incidence of post-herpetic neuralgia, particularly in older people c. Aciclovir, famciclovir, or valaciclovir are recommended

Answer 165

1. They are potentially infectious 2. May need to avoid pregnant women and the immunosuppressed 3. Should be advised that they are infectious until the vesicles have crusted over, usually 5-7 days following onset 4. Covering lesions reduces the risk

Answer 166

1. most common complication of Shingles 2. More common in older patients 3. Affects between 5%-30% of patients depending on age 4. Most commonly resolves with 6 months but may last longer

Answer 167

1. Post-herpetic neuralgia 2. Herpes zoster ophthalmicus: shingles affecting affecting the ocular division of the trigeminal nerve, is associated with a variety of ocular complications 3. Herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis

Answer 168

1. Temporal arteritis 2. Takayasu's arteritis

Answer 169

1. Polyarteritis nodosa 2. Kawasaki disease

Answer 170

1. ANCA-associated: a. granulomatosis with polyangiitis (Wegener's granulomatosis) b. eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) c. microscopic polyangiitis 2. Immune complex: a. Henoch-Schonlein purpura b. Goodpasture's syndrome (anti-glomerular basement membrane disease) c. cryoglobulinaemic vasculitis hypocomplementemic d. urticarial vasculitis (anti-C1q vasculitis)

Answer 171

1. Granulomatosis with polyangiitis: Wegener's granulomatosis 2. Eosinophilic granulomatosis with polyangiitis: Churg-Strauss syndrome 3. Microscopic polyangiitis

Answer 172

1. Renal impairment: caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria 2. Respiratory symptoms: a. Dyspnoea b. haemoptysis 3. Systemic symptoms: a. Fatigue b. Weight loss c. Fever 3. Vasculitic rash: present only in a minority of patients 4. ENT symptoms: sinusitis

Answer 173

1. Urinalysis for haematuria and proteinuria 2. Bloods: a. urea and creatinine for renal impairment b. FBC: normocytic anaemia and thrombocytosis may be seen c. CRP: raised d. ANCA testing: antibodies 3. Chest x-ray: nodular, fibrotic or infiltrative lesions may be seen

Answer 174

1. Cytoplasmic (cANCA): Granulomatosis with polyangiitis: Wegener's granulomatosis 2. Perinuclear (pANCA): Eosinophilic granulomatosis with polyangiitis: Churg-Strauss syndrome

Answer 175

1. Churg-Strauss syndrome 2. Ulcerative colitis (70%) 3. Primary sclerosing cholangitis (70%) 4. Anti-GBM disease (25%) 5. Crohn's disease (20%)

Answer 176

1. Managed by specialist teams (e.g. renal, rheumatology, respiratory) to allow an exact diagnosis to be made 2. Kidney or lung biopsies may be taken to aid the diagnosis 3. The mainstay of management is immunosuppressive therapy

Answer 177

1. Also known as giant cell arteritis: GCA 2. A vasculitis of unknown cause that affects medium and large-sized vessels arteries

Answer 178

Polymyalgia rheumatica (PMR): around 50% of patients will have features of PMR

Answer 179

1. Typically patient > 60 years old 2. Usually rapid onset (e.g. < 1 month) 3. Headache (found in 85%) 4. Jaw claudication (65%) 5. Tender, palpable temporal artery 6. Around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness) 7. Also lethargy, depression, low-grade fever, anorexia, night sweats

Answer 180

High-dose glucocorticoids (40-60mg prednisolone) should be given as soon as the diagnosis is suspected and before the temporal artery biopsy

Answer 181

Permanent vision loss: anterior ischemic optic neuropathy

Answer 182

1. Raised inflammatory markers: a. ESR > 50 mm/hr (note ESR < 30 in 10% of patients) b. CRP may also be elevated 2. Temporal artery biopsy: skip lesions may be present 3. Creatine kinase and EMG may be normal

Answer 183

1. Urgent high-dose glucocorticoids: a. Should be given as soon as the diagnosis is suspected b. If there is no visual loss: high-dose prednisolone (40-60mg) c. If there is evolving visual loss: IV methylprednisolone is usually given prior to starting high-dose prednisolone d. There should be a dramatic response, if not the diagnosis should be reconsidered 2. Urgent ophthalmology review: a. Patients with visual symptoms should be seen the same-day by an ophthalmologist d. Visual damage is often irreversible

Answer 184

Bone protection with bisphosphonates is required as long, tapering course of steroids is required

Answer 185

1. A type of vasculitis which is predominately seen in children 2. Important to recognise as it may cause potentially serious complications, including coronary artery aneurysms

Answer 186

1. High-grade fever which lasts for > 5 days (characteristically resistant to antipyretics) 2. Conjunctivitis 3. Bright red, cracked lips 4. Strawberry tongue 5. Cervical lymphadenopathy 6. Red palms of the hands and the soles of the feet which later peel

Answer 187

1. High-dose aspirin 2. Intravenous immunoglobulin

Answer 188

Echocardiogram

Answer 189

1. A large vessel vasculitis 2. It typically causes occlusion of the aorta 3. Can lead to absent or weak limb pulses

Answer 190

More common in younger females (e.g. 10-40 years) and Asian people

Answer 191

1. Systemic features of a vasculitis e.g. malaise, headache 2. Unequal blood pressure in the upper limbs 3. Carotid bruit and tenderness 4. Absent or weak peripheral pulses 5. Upper and lower limb claudication on exertion 6. Aortic regurgitation (around 20%)

Answer 192

Renal artery stenosis

Answer 193

1. Vascular imaging of the arterial tree: either magnetic resonance angiography (MRA) or CT angiography (CTA)