Infection and Rheum Flashcards
1
Q
How does lupus present?
A
Skin: - Butterfly, malar rash with naso-labial fold sparing - Discoid scaly rash on sun exposed areas - Livedo reticularis - Raynauds - Alopecia Renal: - Proteinuria - Glomerulonephritis Chest: - Pleurisy, pneumonitis - Pericarditis, myocarditis, endocarditis MSK: - Arthralgia General: - Fever - Fatigue Neuro: - anxiety/depression - seizures - psychosis
2
Q
What would you find on investigation with lupus?
A
Raised ANA (highly sensitive but less specific)
Raised dsDNA (highly specific, less sensitive)
Raised anti-Smith
Raised ESR
CRP may be normal in active disease
Complement C3/C4 low
3
Q
How is lupus monitored?
A
Anti-dsDNA titre
4
Q
Describe the epidemiology of lupus
A
Females (9:1)
Afro-Caribbeans
20-40yo
Increasing incidence
5
Q
How is lupus managed?
A
- hydroxychloroquine
- steroids
+/- methotrexate, mycophenolate mofetil, cyclophosphamide and many others
+ NSAIDS for stiffness
6
Q
What is ankylosing spondylitis?
A
Degenerative spondylarthopathy associated with HLAB27
7
Q
How does ankylosing spondylitis present?
A
<30yo and typically male
Sacroiliitis
Stiffness and low back pain worse at rest - improve with exercise
Kyphosis of the spine
Apical lung fibrosis Anterior Uveitis Aortic regurgitation AV node block Amyloidosis Cauda equina Achilles tendonitis
8
Q
How does ankylosing spondylitis appear on clinical examination?
A
Reduced lateral flexion
Reduced forward flexion - positive Schober’s test
Reduced chest expansion
9
Q
How is ankylosing spondylitis investigated?
A
Inflammatory markers are typically raised X-Ray of sacroiliac joints: - subchondral erosions and sclerosis - bamboo spine (fusion of bones) - squaring of lumbar vertebrae - syndesmophytes CXR - apical fibrosis Spirometry may show restrictive defect
10
Q
How is ankylosing spondylitis managed?
A
NSAID’s for pain
Encourage regular exercise
Physiotherapy
Sulfasalazine for peripheral joint involvement
Anti-TNF if persistently high disease activity (etanercept)
11
Q
What antibody is drug induced lupus associated with?
A
Anti-histone
12
Q
How does polymyositis present?
A
Symmetrical proximal muscle weakness Raynaud's Respiratory muscle weakness Interstitial lung disease Dysphagia and dysphonia
If associated skin manifestation –> dermatomyositis
Typically Middle Aged
More females
13
Q
What investigations would you request if you suspect polymyositis and what would you expect to find?
A
- CK - elevated
- Lactate dehydrogenase, AST and ALT also elevated
- EMG - spontaneous bursts of low amplitude
- Muscle biopsy
- Anti Jo antibody –> if lung involvement, fever and Raynaud’s
- ANA often also high - esp dermatomyositis
14
Q
What skin manifestations are seen in dermatomyositis?
A
Heliotrope purple discolouration around orbit with oedema
Raised purple red scaly patches over extensors
Macular rash over back and shoulders
Gottron’s papules - rough red papule on extensors of hands
Mechanic’s hands - extremely dry scaly hands with cracks
15
Q
What is antiphospholipid syndrome?
A
Acquired predisposition to arterial and venous thromboses
Associated with Lupus
16
Q
What are the features of antiphospholipid syndrome?
A
Thrombus Recurrent miscarriage Livedo reticularis Thrombocytopaenia Prolonged APTT
Pre-eclampsia and pulmonary hypertension
17
Q
What antibodies is antiphospholipid syndrome associated with?
A
Lupus anticoagulant
Anticardiolipin
18
Q
How is antiphospholipid syndrome managed?
A
Primary thrombophylaxis - low dose aspirin
Secondary thrombophylaxis:
- Initial venous/arterial event –> lifelong warfarin INR 2-3
- Recurrent - lifelong warfarin (+aspirin) INR 3-4
19
Q
What is Behcet’s syndrome?
A
Triad
- oral ulcers
- genital ulcers
- anterior uveitis
20
Q
What are the features of behcet’s syndrome?
A
Classic triad Thrombus Arthritis Neurological - aseptic meningitis GI - abdo pain, diarrhoea, colitis Erythema nodosum
21
Q
What blood results are seen in osteomalacia?
A
Low calcium
Low phosphate
High ALP
High PTH
22
Q
What blood results are seen in primary hyperparathyroidism?
A
High Ca
Low PO4
High ALP
High PTH
23
Q
What blood results are seen in chronic kidney disease (–> secondary hyperparathyroidism)?
A
Low Ca
High PO4
High ALP
High PTH
24
Q
What blood results are seen in Paget’s disease of the bone?
A
Normal Ca, PO4 and PTH
High ALP
25
What blood results are seen in osteopetrosis?
Normal Ca, PO4, ALP and PTH
26
What are the types of bone tumour?
Benign = osteoma, osteochondroma, giant cell tumour
Malignant - Osteosarcoma, Ewing's, Chondrosarcoma
27
What is important to know about osteoma's?
Overgrowth
| Associated with Gardner's syndrome - FAP
28
What is important to know about osteochondroma?
Most common benign tumour
More in males, <20yo
Cartilage capped bony projections on extensors
29
What is important to know about giant cell tumours?
Epiphyses of long bones
Xray show double bubble or soap bubble appearance
30
What is important to know about osteosarcomas?
Most common primary malignant bone tumour
Mostly children and adolescents
Metaphyseal region of long bones
X-ray --> codman triangle and sunburst pattern
Due to mutation of Rb gene
Other predisposing factors are Paget's disease and radiotherapy
31
What is important to know about Ewing's sarcoma?
```
Mainly children and adolescents
Small round blue cell tumour
Pelvis and long bone
Severe pain!
Onion skin on xray
```
32
What is important to know about chondrosarcoma?
Malignant tumour of cartilage
Most commonly affects axial skeleton
Middle age
33
Which antibody is associated with rheumatoid arthritis?
Anti-CCP
34
Which antibody is associated with Sjogren's?
How else would you diagnose it?
Anti-Ro and Anti-La
ANA+ - 70%
RF - 50%
Schirmer's test
Hypergammaglobulinaemia and low C4
35
What does a raised ANCA antibody indicate?
Vasculitis
36
What does CREST syndrome stand for and which antibody is raised?
```
Calcinosis
Raynaud's
oEsophageal dysmotility
Sclerydactyl
Telangiectasia
```
Anti-centromere
37
What is Rheumatoid Arthritis?
autoimmune symmetrical destruction of the joint leading to persistent synovitis and systemic inflammation
38
What antibody tests would you do for suspected Rheumatoid Arthritis? In which order would you do these tests?
RF first
| if this is negative do anti-CCP
39
Although Rheumatoid Arthritis is a clinical diagnosis, what diagnostic criteria define Rheumatoid Arthritis?
- Joint involvement (more likely if multiple joints, more likely if small joints)
- RF and anti-CCP
- ESR and CRP
- Symptoms >6 weeks
40
How does Rheumatoid Arthritis present?
Joint pain
Swelling
Morning stiffness
Progressively gets worse with involvement of large joints
41
What are some late deformities seen in the hands in Rheumatoid Arthritis?
```
Swan neck (PIP extension and DIP flexion)
Boutonnieres (PIP flexion and DIP extension)
```
42
What is palindromic rheumatism?
relapsing and remitting monoarthritis of differing large joints
43
How is the response to treatment monitored in Rheumatoid Arthritis?
CRP
| Questionnaires (DAS28 score)
44
How are Rheumatoid Arthritis flares managed?
Steroids - can be oral or IM
45
What is the stepwise management of Rheumatoid Arthritis?
1) methotrexate +/- bridging prednisolone
2) switch to another DMARD such as sulphasalazine, hydroxychloroquine or leflunomide
3) TNF-inhibitors (Etanercept or infliximab)
46
What is an important ADR of TNF inhibitors?
Reactivation of TB
47
What are some respiratory manifestations of Rheumatoid Arthritis?
Pulmonary fibrosis
Pleural effusions
Methotrexate associated pneumonitis
48
What are some ocular manifestations of Rheumatoid Arthritis?
Keratoconjunctivitis sicca (dry)
Episcleritis
Scleritis
49
Name some side effects of the DMARDs
```
METHOTREXATE
- pneumonitis, myelosupression, liver cirrhosis
SULPHASALAZINE
- ILD, rash, oligospermia, heinz body anaemia
HYDROXYCHLOROQUINE
- retinopathy
LEFLUNOMIDE
- ILD, HTN, liver impairment
```
50
What is Feltys syndrome?
RA + low WCC + splenomegaly
51
What are some x-ray findings of Rheumatoid Arthritis?
reduced joint space
juxta-articular osteoporosis
soft tissue swelling
Late: periarticular erosions
52
What is chronic fatigue syndrome?
>4 months disabling fatigue affecting physical and mental function and more than >50% of time
Diagnosis of exclusion
Sleep disturbance, muscle pains, headaches, sort throat, cognitive dysfunction etc.
53
How is chronic fatigue managed?
CBT - very effective
Graded exercise therapy - formally supervised program
'Pacing' - organise activities to avoid tiring
Low dose amitriptyline
Pain management
54
What can cause dactylics?
Spondyloarthritis - psoriatic or reactive
Sickle cell disease
Rare - TB, sarcoid, syphilis
55
How is osteoporosis managed?
Bisphosphonates first line - alendronate
Alternatives after: strontium ranelate and denosumab
56
What is an important thing to be aware of with denosumab?
Atypical femoral fractures
57
What commonly causes drug induced lupus and how does it vary from SLE?
Procainamide and hydralazine
No renal or nervous system involvement normally
58
What is Ehler-Danlos syndrome?
```
Autosomal dominant condition affecting type III collagen
Features:
- joint hypermobility
- elastic, fragile skin
- easy bruising
- aortic regurgitation, mitral valve prolapse, aortic dissection
- subarachnoid haemorrhage
- angioid retinal streaks
```
59
What is fibromyalgia? What is the epidemiology?
Syndrome of wisespread pain throughout body with specific tender points
No known aetiology
More common in women 30-50yo
60
What are the features of fibromyalgia?
```
Chronic pain at multiple sites - sometimes all over
Lethargy
Cognitive impairment
Sleep disturbance
Headache
Dizziness
```
61
How is fibromyalgia managed?
Biopsychosocial approach
Explanation
Aerobic exercise
CBT
Medication - pregablin, duloxetine, amitriptyline
62
What is gout?
Inflammatory arthritis with flares and symptom free intervals
Monocrystal synovitis due to deposited of urate monohydrate secondary to chronic hyperuricaemia
Acute episodes of intense pain, swelling and erythema for around 12 hours
63
What joints are commonly affected in gout?
1st metatarsophalangeal
Others - ankle, wrist, knee
64
What happens if gout is untreated?
Damage joints leading to chronic joint problems
65
What are the radiological features of gout?
- Joint effusion - early
- Well-defined punched out erosions with sclerotic margins in a junta-articular distribution
- Preservation of joint space until late
- Eccentric erosions
- No periarticular osteopenia (RA does)
- Soft tissue tophi
66
What can predispose someone to gout?
Decreased uric acid excretion - diuretics, CKD, lead toxicity
Increased uric acid - myeloproliferative disorder, cytotoxic drugs, severe psoriasis
Lesch-nyhan syndrome
67
How is gout managed?
Acute attack:
- NSAID or Colchicine in acute attacks
- Oral/IA steroids if both CI for acute attack
- Continue allopurinol if on it in acute attack, don't start it
Urate lowering therapy:
- After first attack
- Esp. if >=2 attacks, top, renal disease, uric acid renal stones, or on cytotoxics/diuretics
- Offer allopurinol first line and titrate, colchicine cover
- Febuxostat if allopurinol ineffective/not tolerated
68
What lifestyle modifications should be considered for gout?
- Reduced alcohol intake and avoid in acute attack
- Lose weight if obese
- Avoid purine high food: liver, kidneys, seafood, oily fish, yeast products
- Consider Vit C supplementation
- Avoid precipitating drugs. Losartan okay in gout
69
What is the main side effect of colchicine?
Diarrhoea
70
How is gout investigated and what is seen?
Arthrocentesis with synovial fluid analysis
Negatively birefringent needle shaped crystals
Also - serum uric acid, Xray, ultrasound, DECT
71
How do pseudogout crystals appear?
Positively birefringent rhomboid shaped crystals
72
What causes pseudo gout?
Calcium pyrophosphate deposition in synovium
```
Increased age
Haemochromatosis
Hyperparathyroidism
Low magnesium, low phosphate
Acromegaly
Wilson's disease
```
73
What are the features of pseudo gout?
Knee, wrist and shoulders affected
Chondrocalcinosis on Xray - linear calcifications of the meniscus and articular cartilage
74
How is pseudogout managed?
Aspirate joint fluid - exclude septic arthritis
NSAID's or steroids (IA/IM/oral)
75
What is Marfan's disease?
Autosomal dominant disorder.
Defect in fibrillin 1
76
What are the features of Marfan's disease?
- Tall with large arm span>height ratio
- High arched palate
- Arachnodactyly
- Pectus excavatum
- Pes planus
- Scoliosis >20 degrees
- Dilation of aortic sinuses in heart --> aneurysm/dissection/regurg/mitral valve prolapse
- Lungs - repeated pneumothoraces
- Upward lens dislocation in eye, blue sclera
- Ductal ectasia
77
How are patients with Marfan's managed?
Regular echo monitoring
beta blocker/ACEi therapy
78
What is the prognosis for Marfan's?
40-50 yo
Mostly due to aortic dissection and other cvs problems
79
What is McArdle's disease and how does it present?
Autosomal recessive type V glycogen storage disease leading to reduced muscle glycogenolysis
- Muscle pain and stiffness following exercise
- Muscle cramps
- Myoglobinuria
- Low lactate during exercise
80
What is polyarteritis nodosa?
Vasculitis affecting medium sized arteries
Necrotising inflammation --> aneurysm formation
More common in middle aged men and Hep B
81
What are the features of polyarteritis nodosa?
```
Fever, malaise, anaemia
Weight loss
HTN
Sensorimotor polyneuropathy
Testicular pain
Livedo reticular
Haematuria and renal failure
ANCA in 20%
HepB in 30%
```
82
What are the features of polymyagia rheumatica?
- >60 yo
- Rapid onset
- Aching and morning stiffness in proximal limbs
- NO WEAKNESS
- Mild polyarthralgia, lethargy, depression, low grade fever, anorexia and night sweats
- Associated with giant cell arteritis
83
How do you investigate polymyalgia rheumatica?
Inflammatory markers - ESR - raised (>40mm/hr)
| CK and EMG normal
84
How is polymyalgia rheumatica managed?
Prednisolone
Regular review
If it doesn't respond to steroids, its not PMR
85
What is Raynaud's phenomenon?
Exaggerated vasoconstrictive response to digital arteries and cutaneous arterioles to the cold or emotional stress
Primary - raynaud's disease
Secondary - raynaud's phenomenon
86
What are some secondary causes of Raynaud's?
```
Connective tissue disorders - scleroderma, RA, SLE
Leukaemia
T1 cryoglobulinaemia
Use of vibrating tools
COCP
Cervical rib
```
87
How is Raynaud's managed?
Refer to secondary care if suspect secondary
First line - Ca2+ blocker like nifedipine
IV prostacyclin infusion - last several weeks/months
88
What are the features of Sjogren's?
```
Dry eyes
Dry mouth
Vaginal dryness
Arthralgia
Raynaud's
Sensory polyneuropathy
Recurrent episodes of parotitis
Renal tubular acidosis
```
++ risk of Lymphoma (often NH)
89
How is sjogrens managed?
Artificial tears and saliva
| Pilocarpine - stimulate saliva production
90
What is Sjogrens?
Autoimmune disorder affecting exocrine glands leading to dry mucosal surfaces
91
What is Still's disease?
```
Arthralgia
Raised serum ferritin
Salmon pink maculopapular rash
Pyrexia in early afternoon
Lymphadenopathy
```
Negative for RF and ANA
92
How is still's disease managed?
NSAIDs - fever, joint pain, serositis
Steroids - symptoms
If remain - methotrexate, IL1 or anti-TNF
93
What is systemic sclerosis? Which antibodies are they associated with?
3 patterns of disease:
- Limited cutaneous - CREST is a subtype
- Diffuse
- Scleroderma
ANA 90%
RF 30%
anti-scl70 - diffuse
anti-centromere - limited
94
What are the symptoms of limited cutaneous systemic sclerosis?
Raynaud's first sign
Scleroderma - face and distal limbs
Anti centromere
CREST
95
What are the features of diffuse systemic sclerosis?
- Scleroderma on trunk and proximal limbs
- scl-70 antibody
- Common cause of death due to resp involvement - ILD/pulmonary artery hypertension
- Renal disease
- HTN
- Poor prognosis
96
What is scleroderma?
Tightening and fibrosis of skin
May manifest as plaques or linear
97
What is temporal arteritis?
Large vessel vasculitis which overlap with PMR
Skip lesions histologically
98
What are the features of temporal arteritis?
```
Rapid onset
>60yo
Headache
Jaw claudication
Visual disturbance
Scalp tenderness
Tender/palpable temporal artery
PMR association
```
99
How is temporal arteritis investigated?
Raised inflammatory markers - ESR, CRP may also be elevated
Temporal artery biopsy - skip lesions
CK and EMG normal
100
How is temporal arteritis managed?
High dose pred - should be dramatic review
| Urgent ophthalmology review
101
What are the x-ray findings seen in rheumatoid arthritis?
Early:
- Loss of joint space
- Juxta-articular osteoporosis
- Soft tissue swelling
Late:
- Periarticular erosions
- Subluxation
102
What is reactive arthritis?
Arthritis which develops following infection
Reiter's syndrome
Conjunctivitis, urethritis, arthritis
"Can't see, can't pee, can't climb a tree"
103
What commonly causes reactive arthritis?
Post STI - chlamydia
| Post dysentry - shigella, salmonella, campylobacter
104
How is reactive arthritis managed?
Analgesia, NSAIDs, IA steroids
Can use sulfasalazine and methotrexate if persistent
Rarely last >12 months
105
What do you need to find out from a returning traveller in the history?
```
Exactly where they went
Where did they stay?
Activities/events
Bites
Diet
Fresh water?
Sexual activity
Unwell contacts
```
106
Which areas in the world may someone return from that would raise suspicion that they may have malaria?
Tropics
- Amazon region of south america
- Mid Africa/madagascar
- Middle East
- India, China, Philipines etc.
107
What happens in malaria?
Mosquite bite and malaria sporozytes enter blood --> liver.
Rupture to release merozites
Merozites infect RBC. Some do not mature but differentiate into gametozytes
108
How does non-falciparum malaria present?
Fever - cyclical (48hr vivax/ovale, 72hr malariae)
Headache
Splenomegaly
Malariae - nephrotic syndrome
Ovale and vivax have hypnozoite phase so may relapse after treatment
109
How long does malaria incubate for?
10-30 days
110
How is malaria diagnosed?
3x blood films
111
What are the types of malaria?
Falciparum - most common cause of severe malaria
Ovale
Malariae
Vivax
112
What factors are protective against malaria?
Sickle cell trait
G6PD deficiency
HLA-B23
Absence of Duffy antigens
113
How is non falciparum malaria managed?
ACT (artemisinin based combination therapy) or chloroquine
Avoid ACT in pregnancy
Ovale/vivax - give primaquine after chloroquine for hynozoites
114
What are the features of falciparum malaria?
- Schizonts on blood film
- Parasitaemia >2%
- Hypoglycaemia
- Acidosis
- Fever >39
- Severe anaemia
- Complications
115
What complications are associated with falciparum malaria?
```
Cerebral Malaria
Acute renal failure
Hypoglycaemia
ARDS
DIC
```
116
If a patient is in shock with malaria, what does this indicate?
Patient has co-existent bacterial septicaemia
Malaria rarely causes haemodynamic collapse
117
What is enteric fever? What causes it and how is it transmitted?
Typhoid/paratyphoid fever - similar regions to malaria
Caused by salmonella typhi/paratyphi - gram - rods
Faecal oral transmission
118
What are the features of enteric fever?
Headache, Fever, Arthralgia
```
Relative bradycardia
Normal WCC
Abdo pain and distension
Constipation
Rose spots - more in paratyphoid
```
119
How is enteric fever diagnosed?
Salmonella on blood culture, stool sample or bone marrow
120
How is enteric fever managed?
Suspected - IV Ceftriaxone + azithromycin
Modify once know what susceptible
121
Where is enteric fever especially prevalent?
Indian subcontinent
122
How useful is the vaccine for enteric fever?
Moderate protection against typhoid
Almost no protection against paratyphoid
123
What history would raise suspicion of enteric fever?
Prolonged fever
No rise in WCC
Recent travel to endemic area
124
What is dengue fever?
Viral infection transmitted by Aedes mosquito
125
How is dengue fever managed?
NOTIFIABLE DISEASE
| Symptomatic - fluids, transfusion if low haematocrit
126
What is Kaposis sarcoma?
HHV8 infection leading to purple papule/plaques on the skin and mucosa
Skin lesions may ulcerate
May get massive haemoptysis and pleural effusions
127
What neurocomplications are associated with HIV?
Toxoplasmosis
Primary CNS lymphoma
Encephalitis
Cryptococcus
Progressive multifocal Leukoencephalopathy
AIDS dementia
128
Describe oesophageal candidiasis and how is it managed?
Most common cause of oesophagitis in those with HIV
Odynophagia and dysphagia
Fluconazole and itraconazole 1st line
129
What is pneumocystis jiroveci pneumonia?
Unicellular eukaryote - classified as fungus
Most common opportunistic infection in HIV
130
Who should receive pneumocystis jiroveci prophylaxis and what is it?
CD4 <200
TMP/SMX - trimethoprim/sulphamethoxazole (Co-trimoxazole)
131
What are the features of pneumocystis pneumonia?
Dyspnoea
Dry cough
Fever
Few chest signs
Commonly get pneumothorax
Extrapulmonary - hepatosplenomegaly, lymphadenopathy, choroid lesions
132
How is pneumocystis pneumonia investigated?
CXR - bilateral interstitial infiltrates (can be normal)
Exercise induced desaturation
Sputum often fail to show PCP - need bronchoalveolar lavage
133
How is pneumocystis pneumonia managed?
Co-trimoxazole
IV pentamidine
Steroids if hypoxic
134
What is amoebiasis?
Entamoeba histolytica spread by faecal oral route
10% of worlds population chronically infected
135
How does amoebiasis present?
Can be asymptomatic or cause mild diarrhoea
```
Dysentry:
- Profuse bloody diarrhoea
- Long incubation
- Stool - trophozoites if examined within 15 mins or kept warm
Liver and colon abscess:
- Liver abscess usually single mass in right lobe
- Contents described as "anchovy sauce"
- Fever, RUQ
- Serology + in >90%
```
136
How is amoebiasis managed?
Dysentry - metronidazole
Follow with amoebicide
137
What is the most common organism in animal bites? (typically cats and dogs)
Mostly polymicrobial but most commonly:
| Pasteurella multocida
138
How are animal bites managed?
Cleanse wound - punctures should not be sutured closed unless cosmesis at risk
Co-Amox
Doxy+metronidazole if pen allergic
139
What organisms are common in human bites?
Multimicrobial
- strep saprophyticus
- staph aureus
- Eikenella
- Fusobacterium
- Prevotella
140
How are human bites managed?
Co-amox
Consider risk of HIV and hep C
141
Antibiotic for chronic bronchitis exacerbation
Amox or tetracycline or clarithromycin
142
Antibiotic for pneumonia
Uncomplicated CAP - amoxicillin (doxy/clarith if pen allergic, fluclox if staph)
Atypical - clarithromycin
Hospital acquired - co-amox within 5 days, >5 days then tazocin
143
Antibiotics for UTI's
Lower - trimethoprim or nitrofurantoin. Amox alternative
Pyelonephritis - Cefalexin or ciprofloxacin
144
Antibiotics for prostatitis
Ciprofloxacin or Trimethoprim
145
Antibiotic for impetigo
Topical hydrogen peroxide
Oral fluclox
146
Antibiotics for skin infections
Cellulitis/Erysipelas/Mastitis - fluclox
Cellulitis near eyes or nose/bites - co-amox
147
Antibiotics for ENT infections
Throat - phenoxymethylpenicillin (PenV)
Sinusitis - penV
Otitis media - amox
Otitis externa - fluclox - delayed prescription
Periapical/periodontal abscess - amoxicillin
Gingivitis - Metronidazole
148
Antibiotics for STI's
Gonorrhoea - IM ceftriaxone
Chlamydia - doxycycline or 1 off azithromycin
PID - Oral metronidazole + oral doxy + IM ceftriaxone
Syphilis - Benzathine benzylpenicillin
Bacterial vaginosis - Metronidazole
149
Antibiotics for GI infections
C diff - metronidazole or vanc for 2nd episode
Campylobacter - clarithromycin
Salmonella - Ciprofloxacin
Shigellosis - Ciprofloxacin
150
What is an aspergilloma?
Mycetoma (mass like fungus ball) which colonises an existing lung cavity - secondary to TB, lung cancer or CF
151
How do aspergilloma's present and how are they investigated?
Asymptomatic usually
Cough and haemoptysis
CXR - rounded opacity and crescent sign
High titres of aspergillus precipitins
152
What type of microbe is bacillus cereus?
Gram positive rod
153
Key things about bacillus cereus infection
Highly adaptable to extremes of pH and oxygen
Food poisoning mostly
Undercooked/reheated rice
Can cause infections in IVDU/immunocompromised too
2 types of food poisoning - emetic and diarrhoea
154
How us a bacillus cereus infection treated?
Rarely required
Can use vancomycin
155
What type of vaccine is BCG?
Live attenuated vaccine containing mycobacterium bovis
Protect against TB and limited protection against leprosy
156
Who should receive the BCG vaccine?
Infants living in high risk areas or with parents/grandparents born in high risk area
Previously unvaccinated tuberculin negative contacts of TB
Healthcare workers
Prison staff
Care home staff
People working with homeless people
Not given to anyone over age of 35
157
What are the contraindications for the BCG vaccine
```
Previous BCG
Hx of TB
HIV
Pregnancy
Positive tuberculin test
```
158
What are the features of botulism?
```
Fully conscious with no sensory disturbance
Flaccid paralysis
Diplopia
Ataxia
Bulbar palsy
```
159
How is botulism managed?
Botulism antitoxin - if given early enough
Supportive care
160
What is campylobacter jejuni?
Commonest cause of infectious intestinal disease
Spread by faecal oral route
Gram negative bacillus
161
What are the features of campylobacter?
Prodrome - headache and malaise
Bloody diarrhoea
Abdo pain - mimic appendicitis
162
How is campylobacter managed?
Usually self limiting
Clarithromycin if severe or immunocompromised
Cipro is alternative
163
What classifies campylobacter as severe?
High fever
Bloody diarrhoea
More than 8 stools per day
Sx > 1 week
164
What are the complications associated with campylobacter?
Guillian Barre syndrome
Reactive arthritis
Septicaemia, endocarditis, arthritis
165
What causes cholera?
Vibro cholerae - gram negative bacteria
166
What are the features of cholera?
Profuce, rice water diarrhoea
Dehydrated
Hypoglycaemia
167
How is cholera managed?
Oral rehydration therapy
| Doxy/ciprofloxacin
168
Give examples of gram positive organisms
Cocci - staph, strep, entero
Rods - clostridium, bacillus anthraces, corynebacterium (diptheria), listeria
169
Give examples of gram negative organisms
Cocci - Neisseria meningitidis/gonorrhoea, moraxella catarrhalis
Rods (rest) - E coli, H influenza, Pseudomonas, Salmonella, Shigella, Campylobacter
170
What are the different clostridium strains and what do they cause?
Perfringens - gas gangrene
Botulinum - botulism
Difficile - pseudomembranous colitis
Tetani - spastic paralysis
171
What is CMV?
Human herpes virus commonly in immunocompromised
Infected cells have Owl's eye appearance - intranuclear inclusion bodies
172
What are the types of CMV?
```
Congenital
Mononucleosis
Retinitis
Encephalopathy
Pneumonitis
Colitis
```
173
How does congenital CMV present?
```
Growth retardation
Pinpoint petechial skin lesions - blueberry muffin
Microcephaly
Sensorineural deafness
Encephalitis
Hepatosplenomegaly
```
174
What is diptheria caused by?
Gram positive rod - corynebacterium diphtheriae
175
How does diptheria present?
Recent visitor to Eastern Europe/russia/asia
Sore throat with grey pseudomembrane on pharynx
Bulky cervical lymphadenopathy - bull neck
Neuritis
Heart block
176
How is diptheria investigated and managed?
Culture throat
IM penicillin and diphtheria antitoxin
177
How does ebola spread and what are the symptoms?
Human to human contact
Early: Fever, Fatigue, Muscle pain, Headache, Sore throat
Late: Diarrhoea, vomit, rash, impaired renal/liver function, bleeding
178
What is Epstein Barr virus associated with?
Burkitt's Lymphoma
Hodgkins lymphoma
Nasopharyngeal carcinoma
HIV associated CNS lymphoma
Hairy leukoplakia
179
What does E coli commonly cause?
Diarrhoea
UTI
Neonatal meningitis
180
Stereotypical gastroenteritis histories: E Coli
traveller
watery
abdo cramps/nausea
181
Stereotypical gastroenteritis histories: Giardiasis
prolonged non bloody diarrhoea
| Flatulence
182
Stereotypical gastroenteritis histories: Cholera
cramps
watery diarrhoea
dehydration
183
Stereotypical gastroenteritis histories: Shigella
bloody diarrhoea
vomit
abdo pain
184
Stereotypical gastroenteritis histories: S Aureus
Severe vomiting
| Short incubation time
185
Stereotypical gastroenteritis histories: Bacillus Cereus
Vomiting within 6 hr - uncooked/reheated rice
| Diarrhoea after 6 hr
186
Stereotypical gastroenteritis histories: Amoebiasis
Gradual onset bloody diarrhoea
Abdo pain
Tenderness
Last weeks
187
Gastroenteritis incubation times
1-6hr - S Aureus/bacillus cereus
12-48hr - Salmonella/E Coli
48-72hr - Shigella/Campylobacter
>7 days - Giardiasis/Amoebiasis
188
How is travellers diarrhoea defined?
```
>=3 watery stools in 24 hrs
With 1+:
- abdo cramps
- fever
- nausea
- vomiting
- blood in stool
```
189
How is giardiasis investigated and managed?
Trophozoite and cysts negative on stool culture - req. duodenal fluid aspirates or string tests
Metronidazole
190
What are the features of hep A?
```
Flu like prodrome
RUQ pain
Tender hepatomegaly
Jaundice
Cholestatic LFT's
```
191
How is hep A spread and what is the prognosis?
Faecal oral
Doesn't cause chronic disease - no increased risk of hepatocellular carcinoma
192
Which hepatitis strands have a vaccine available?
A and B
E in development
Can't vaccinate against Hep C!
193
Who should receive a hep A vaccine?
```
Travel to live in high risk area
Chronic liver disease
Haemophilia
MSM
IVDU
Occupational risk - lab worker, sewage workers, work with primates
```
194
What are the features of hep B?
Jaundice
Fever
Elevated liver transaminases
195
What are the complications of hep b?
Chronic hepatitis - ground glass hepatocytes on light microscopy
```
Fulminant liver failure
Hepatocellular carcinoma
Glomerulonephritis
Polyarteritis nodosa
Cryoglobulinaemia
```
196
How is hepatitis managed?
Vaccine now part of regular program
Pegylated interferon alpha
197
How can hepatitis B anti-HBs levels be interpreted?
>100 - adequate response - booster in 5 years
10-100 - suboptimal response, 1 more dose
<10 - non responder - test for infection and further 3 dose course. If fail, HBIG if exposed
198
Who are the at risk group for hep C?
IVDU
| Blood transfusion prior to 1991
199
How is hep C transmitted?
Needle stick - 2%
Vertical transmission - 6%
Sexual intercourse 5%
Breast feeding not contraindicated
200
What are the features of Hep C?
```
30% exposed develop:
Transient rise in LFT's
Jaundice
Fatigue
Arthralgia
```
201
How is Hep C investigated?
HCV RnA - acute infection
Anti HCV antibodies - they remain in those who clear the virus
202
What is the prognosis of Hep C?
15-45% clear after acute infection
Majority develop chronic hep c
203
How is chronic hep c defined?
Persistence of HCV RNA for >6 months
204
What are the complications of chronic hep C?
```
Rheum - arthralgia/arthritis
Eye - Sjogrens
Cirrhosis
Hepatocellular carcinoma
Cryoglobulinaemia
Glomerulonephritis
```
205
How is chronic hep c managed?
Depend on genotype
Combination of protease inhibitors: daclatasvir + sofosbuvir) ± ribavirin
206
How do patients get hep D?
Co-infection with hep B or superinfection from hep B
207
Hep D complications, diagnosis and management
Superinfection --> fulminant hepatitis, chronic hepatitis, cirrhosis
Diagnosed via reverse polymerase chair reaction of RNA
Interferon
208
Summary of Hep E - spread and prognosis
Faecal oral
3-8 week incubation
Similar to hep A but significant mortality in pregnancy
No chronic disease or increased risk of cancer
209
Which HPV strains cause pathology?
6 and 11 - genital warts
16 and 18 - cancer
210
Which HPV strains are vaccinated against? Who is vaccinated?
6, 11, 16 and 18
All 12 and 13 yo girls and boys (from Sept 19)
2 doses, 2nd is 6-24 months after first
211
What is infectious mononucleosis?
Glandular fever - caused by Ebstein Barr virus 90% of cases (HHV4)
212
What is the classic triad of symptoms in glandular fever?
Sore throat
Lymphadenopathy - anterior and posterior triangles
Pyrexia
213
How is glandular fever differentiated from tonsillitis?
Tonsilitis only affect upper anterior cervical chain
214
What are the other features of glandular fever?
```
Malaise, anorexia, headache
Palatal petechiae
Splenomegaly - can rupture!
Hepatitis - transient ALT rise
Lymphocytosis
Haemolytic anaemia
Maculopapulor pruritic rash if take amoxicillin
```
215
How is glandular fever diagnosed?
Monospot
Repeat with FBC 2 wk into illness
216
How is glandular fever managed?
Resolve after 2-4 weeks
Conservative
Avoid contact sports
217
what is important about the influenza vaccine given to children?
Intranasal
1st dose 2-3yo then annually
Live vaccine
218
What is important to know about the influenza vaccine in adults?
2 subtypes
All people over 65 or those at risk
Inactivated virus
CI if hypersensitivity to egg protein
219
Summary of legionella
Intracellular bacterium
Colonise water tanks - air con units
Flu like symptoms, dry cough, lymphopaenia, hyponatraemia
Diagnosed by urinary antigen
Managed with erythromycin/clarithromycin
220
What causes mumps?
RNA paramyxovirus
221
How does mumps spread?
Droplets
Infective for 7 days before and 9 days after parotid swelling
222
How does mumps present?
Fever
Malaise
Muscular pain
Parotitis - ear ache, pain on eating - often bilateral
223
How is mumps managed?
Rest
Paracetamol
Notifiable disease
224
What are the complications of mumps?
Orchitis
Heating loss - transient and unilateral
Meningoencephalitis
Pancreatitis
225
What is characteristic about mycoplasma pneumoniae?
Erythema multiforme
| Cold autoimmune haemolytic anaemia
226
How is mycoplasma pneumonia managed?
Doxycycline or erythro/clarith
227
Quick summary of norovirus
Nausea, vomit diarrhoea
Faecal oral spread
15-50 hour incubation
Supportive care
228
What is the post exposure prophylaxis for Hep A, B and C?
Hep A - HNIG or vaccine
Hep B
- HBsAg positive source - if respond to vaccine then that or HBIG
- Unknown source - Booster or vaccine
Hep C - monthly PCR, if seroconversion - interferon ± ribovarin
229
What is post exposure prophylaxis for HIV?
Depend on mode of transmission and patient viral load
Antiretrovirals and serological testing
230
What is post exposure prophylaxis for varicella zoster?
VZIG if IgG negative pregnant/immunocompromised woman
231
How are hyposplenic patients managed in terms of vaccinations and likely causative organisms?
Need pneumococcal, haemophilia type B and meningococcal type c vaccines
Annual influenza for all
Abx prophylaxis offered to all - penicillin V or amoxicillin
Particular risk of encapsulated organisms - step, haemophilus, meningococcus
232
What is pseudomonas aeruginosa?
Gram negative rod
233
What can pseudomonas cause?
Chest infections - esp CF
Skin - burns, wound infections, hot tub folliculitis
Otitis externa - diabetics
UTIs
234
What is pyrexia of unknown origin and what can cause it?
Prolonged fever for >3 weeks
Neoplasia - lymphoma, hypernephroma, preleukaemia, atrial myxoma
Infections - abscess, TB
Connective tissue disorders
235
What is staphylococcal toxic shock syndrome?
Severe systemic reaction to staph exotoxins:
- Fever >38.9
- Hypotension
- Diffuse erythematous rash
- Desquamation of rash
- Multi organ
Managed by removing infection focus, giving IV fluids and IV Abx
236
What are the features of tetanus?
```
Prodrome of fever, lethargy headache
Trismus - lock jaw
Risus sardonicus - facial muscle spasm
Opisthotonus - arched back, hyperextended neck
Spasms
```
237
How is tetanus managed?
Supportive care
IM human tetanus IG if high risk
Metronidazole
238
What is toxoplasmosis?
Intracellular protozoan that infects via GI tract, lung or broken skin
LINKED WITH CATS
Asymptomatic normally in immunocompetent but can resemble glandular fever - no treatment
Immunosuppressed - cerebral toxoplasmosis
Can be congenital - neurological/ophthalmic
239
What are the features of cerebral toxoplasmosis? How is it managed?
Headache, confusion, drowsiness
CT - single or multiple ring enhancing lesions
Pyrimethamine + sulphadiazine for >6wks
