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Finals > Infection and Rheum > Flashcards

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
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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

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3
Q

How is lupus monitored?

A

Anti-dsDNA titre

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4
Q

Describe the epidemiology of lupus

A

Females (9:1)
Afro-Caribbeans
20-40yo
Increasing incidence

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5
Q

How is lupus managed?

A
  1. hydroxychloroquine
  2. steroids

+/- methotrexate, mycophenolate mofetil, cyclophosphamide and many others

+ NSAIDS for stiffness

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6
Q

What is ankylosing spondylitis?

A

Degenerative spondylarthopathy associated with HLAB27

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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
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8
Q

How does ankylosing spondylitis appear on clinical examination?

A

Reduced lateral flexion
Reduced forward flexion - positive Schober’s test
Reduced chest expansion

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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
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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)

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11
Q

What antibody is drug induced lupus associated with?

A

Anti-histone

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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

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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
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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

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15
Q

What is antiphospholipid syndrome?

A

Acquired predisposition to arterial and venous thromboses

Associated with Lupus

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16
Q

What are the features of antiphospholipid syndrome?

A 
Thrombus
Recurrent miscarriage 
Livedo reticularis
Thrombocytopaenia
Prolonged APTT

Pre-eclampsia and pulmonary hypertension

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17
Q

What antibodies is antiphospholipid syndrome associated with?

A

Lupus anticoagulant

Anticardiolipin

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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
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19
Q

What is Behcet’s syndrome?

A

Triad

  • oral ulcers
  • genital ulcers
  • anterior uveitis
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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
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21
Q

What blood results are seen in osteomalacia?

A

Low calcium
Low phosphate
High ALP
High PTH

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22
Q

What blood results are seen in primary hyperparathyroidism?

A

High Ca
Low PO4
High ALP
High PTH

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23
Q

What blood results are seen in chronic kidney disease (–> secondary hyperparathyroidism)?

A

Low Ca
High PO4
High ALP
High PTH

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24
Q

What blood results are seen in Paget’s disease of the bone?

A

Normal Ca, PO4 and PTH

High ALP

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25
Q

What blood results are seen in osteopetrosis?

A

Normal Ca, PO4, ALP and PTH

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26
Q

What are the types of bone tumour?

A

Benign = osteoma, osteochondroma, giant cell tumour

Malignant - Osteosarcoma, Ewing’s, Chondrosarcoma

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27
Q

What is important to know about osteoma’s?

A

Overgrowth

Associated with Gardner’s syndrome - FAP

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28
Q

What is important to know about osteochondroma?

A

Most common benign tumour
More in males, <20yo
Cartilage capped bony projections on extensors

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29
Q

What is important to know about giant cell tumours?

A

Epiphyses of long bones

Xray show double bubble or soap bubble appearance

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30
Q

What is important to know about osteosarcomas?

A

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

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31
Q

What is important to know about Ewing’s sarcoma?

A 
Mainly children and adolescents
Small round blue cell tumour
Pelvis and long bone
Severe pain!
Onion skin on xray
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32
Q

What is important to know about chondrosarcoma?

A

Malignant tumour of cartilage
Most commonly affects axial skeleton
Middle age

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33
Q

Which antibody is associated with rheumatoid arthritis?

A

Anti-CCP

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34
Q

Which antibody is associated with Sjogren’s?

How else would you diagnose it?

A

Anti-Ro and Anti-La
ANA+ - 70%
RF - 50%

Schirmer’s test
Hypergammaglobulinaemia and low C4

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35
Q

What does a raised ANCA antibody indicate?

A

Vasculitis

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36
Q

What does CREST syndrome stand for and which antibody is raised?

A 
Calcinosis
Raynaud's
oEsophageal dysmotility
Sclerydactyl
Telangiectasia

Anti-centromere

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37
Q

What is Rheumatoid Arthritis?

A

autoimmune symmetrical destruction of the joint leading to persistent synovitis and systemic inflammation

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38
Q

What antibody tests would you do for suspected Rheumatoid Arthritis? In which order would you do these tests?

A

RF first

if this is negative do anti-CCP

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39
Q

Although Rheumatoid Arthritis is a clinical diagnosis, what diagnostic criteria define Rheumatoid Arthritis?

A
  • Joint involvement (more likely if multiple joints, more likely if small joints)
  • RF and anti-CCP
  • ESR and CRP
  • Symptoms >6 weeks
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40
Q

How does Rheumatoid Arthritis present?

A

Joint pain
Swelling
Morning stiffness
Progressively gets worse with involvement of large joints

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41
Q

What are some late deformities seen in the hands in Rheumatoid Arthritis?

A 
Swan neck (PIP extension and DIP flexion)
Boutonnieres (PIP flexion and DIP extension)
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42
Q

What is palindromic rheumatism?

A

relapsing and remitting monoarthritis of differing large joints

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43
Q

How is the response to treatment monitored in Rheumatoid Arthritis?

A

CRP

Questionnaires (DAS28 score)

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44
Q

How are Rheumatoid Arthritis flares managed?

A

Steroids - can be oral or IM

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45
Q

What is the stepwise management of Rheumatoid Arthritis?

A

1) methotrexate +/- bridging prednisolone
2) switch to another DMARD such as sulphasalazine, hydroxychloroquine or leflunomide
3) TNF-inhibitors (Etanercept or infliximab)

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46
Q

What is an important ADR of TNF inhibitors?

A

Reactivation of TB

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47
Q

What are some respiratory manifestations of Rheumatoid Arthritis?

A

Pulmonary fibrosis
Pleural effusions
Methotrexate associated pneumonitis

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48
Q

What are some ocular manifestations of Rheumatoid Arthritis?

A

Keratoconjunctivitis sicca (dry)
Episcleritis
Scleritis

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49
Q

Name some side effects of the DMARDs

A 
METHOTREXATE
- pneumonitis, myelosupression, liver cirrhosis
SULPHASALAZINE
- ILD, rash, oligospermia, heinz body anaemia
HYDROXYCHLOROQUINE
- retinopathy
LEFLUNOMIDE
- ILD, HTN, liver impairment
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50
Q

What is Feltys syndrome?

A

RA + low WCC + splenomegaly

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51
Q

What are some x-ray findings of Rheumatoid Arthritis?

A

reduced joint space
juxta-articular osteoporosis
soft tissue swelling

Late: periarticular erosions

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52
Q

What is chronic fatigue syndrome?

A

> 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.

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53
Q

How is chronic fatigue managed?

A

CBT - very effective
Graded exercise therapy - formally supervised program
‘Pacing’ - organise activities to avoid tiring
Low dose amitriptyline
Pain management

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54
Q

What can cause dactylics?

A

Spondyloarthritis - psoriatic or reactive
Sickle cell disease
Rare - TB, sarcoid, syphilis

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55
Q

How is osteoporosis managed?

A

Bisphosphonates first line - alendronate

Alternatives after: strontium ranelate and denosumab

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56
Q

What is an important thing to be aware of with denosumab?

A

Atypical femoral fractures

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57
Q

What commonly causes drug induced lupus and how does it vary from SLE?

A

Procainamide and hydralazine

No renal or nervous system involvement normally

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58
Q

What is Ehler-Danlos syndrome?

A 
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
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59
Q

What is fibromyalgia? What is the epidemiology?

A

Syndrome of wisespread pain throughout body with specific tender points

No known aetiology

More common in women 30-50yo

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60
Q

What are the features of fibromyalgia?

A 
Chronic pain at multiple sites - sometimes all over
Lethargy
Cognitive impairment
Sleep disturbance
Headache
Dizziness
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61
Q

How is fibromyalgia managed?

A

Biopsychosocial approach

Explanation
Aerobic exercise
CBT
Medication - pregablin, duloxetine, amitriptyline

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62
Q

What is gout?

A

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

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63
Q

What joints are commonly affected in gout?

A

1st metatarsophalangeal

Others - ankle, wrist, knee

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64
Q

What happens if gout is untreated?

A

Damage joints leading to chronic joint problems

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65
Q

What are the radiological features of gout?

A
  • 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
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66
Q

What can predispose someone to gout?

A

Decreased uric acid excretion - diuretics, CKD, lead toxicity

Increased uric acid - myeloproliferative disorder, cytotoxic drugs, severe psoriasis

Lesch-nyhan syndrome

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67
Q

How is gout managed?

A

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
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68
Q

What lifestyle modifications should be considered for gout?

A
  • 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
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69
Q

What is the main side effect of colchicine?

A

Diarrhoea

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70
Q

How is gout investigated and what is seen?

A

Arthrocentesis with synovial fluid analysis

Negatively birefringent needle shaped crystals

Also - serum uric acid, Xray, ultrasound, DECT

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71
Q

How do pseudogout crystals appear?

A

Positively birefringent rhomboid shaped crystals

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72
Q

What causes pseudo gout?

A

Calcium pyrophosphate deposition in synovium

Increased age
Haemochromatosis
Hyperparathyroidism
Low magnesium, low phosphate
Acromegaly
Wilson's disease
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73
Q

What are the features of pseudo gout?

A

Knee, wrist and shoulders affected

Chondrocalcinosis on Xray - linear calcifications of the meniscus and articular cartilage

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74
Q

How is pseudogout managed?

A

Aspirate joint fluid - exclude septic arthritis

NSAID’s or steroids (IA/IM/oral)

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75
Q

What is Marfan’s disease?

A

Autosomal dominant disorder.

Defect in fibrillin 1

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76
Q

What are the features of Marfan’s disease?

A
  • 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
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77
Q

How are patients with Marfan’s managed?

A

Regular echo monitoring

beta blocker/ACEi therapy

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78
Q

What is the prognosis for Marfan’s?

A

40-50 yo

Mostly due to aortic dissection and other cvs problems

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79
Q

What is McArdle’s disease and how does it present?

A

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
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80
Q

What is polyarteritis nodosa?

A

Vasculitis affecting medium sized arteries

Necrotising inflammation –> aneurysm formation

More common in middle aged men and Hep B

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81
Q

What are the features of polyarteritis nodosa?

A 
Fever, malaise, anaemia
Weight loss
HTN
Sensorimotor polyneuropathy
Testicular pain
Livedo reticular
Haematuria and renal failure
ANCA in 20%
HepB in 30%
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82
Q

What are the features of polymyagia rheumatica?

A
  • > 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
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83
Q

How do you investigate polymyalgia rheumatica?

A

Inflammatory markers - ESR - raised (>40mm/hr)

CK and EMG normal

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84
Q

How is polymyalgia rheumatica managed?

A

Prednisolone
Regular review

If it doesn’t respond to steroids, its not PMR

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85
Q

What is Raynaud’s phenomenon?

A

Exaggerated vasoconstrictive response to digital arteries and cutaneous arterioles to the cold or emotional stress

Primary - raynaud’s disease
Secondary - raynaud’s phenomenon

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86
Q

What are some secondary causes of Raynaud’s?

A 
Connective tissue disorders - scleroderma, RA, SLE
Leukaemia
T1 cryoglobulinaemia
Use of vibrating tools
COCP
Cervical rib
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87
Q

How is Raynaud’s managed?

A

Refer to secondary care if suspect secondary
First line - Ca2+ blocker like nifedipine
IV prostacyclin infusion - last several weeks/months

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88
Q

What are the features of Sjogren’s?

A 
Dry eyes
Dry mouth
Vaginal dryness
Arthralgia
Raynaud's
Sensory polyneuropathy
Recurrent episodes of parotitis
Renal tubular acidosis

++ risk of Lymphoma (often NH)

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89
Q

How is sjogrens managed?

A

Artificial tears and saliva

Pilocarpine - stimulate saliva production

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90
Q

What is Sjogrens?

A

Autoimmune disorder affecting exocrine glands leading to dry mucosal surfaces

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91
Q

What is Still’s disease?

A 
Arthralgia
Raised serum ferritin
Salmon pink maculopapular rash
Pyrexia in early afternoon
Lymphadenopathy

Negative for RF and ANA

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92
Q

How is still’s disease managed?

A

NSAIDs - fever, joint pain, serositis
Steroids - symptoms

If remain - methotrexate, IL1 or anti-TNF

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93
Q

What is systemic sclerosis? Which antibodies are they associated with?

A

3 patterns of disease:

  • Limited cutaneous - CREST is a subtype
  • Diffuse
  • Scleroderma

ANA 90%
RF 30%
anti-scl70 - diffuse
anti-centromere - limited

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94
Q

What are the symptoms of limited cutaneous systemic sclerosis?

A

Raynaud’s first sign
Scleroderma - face and distal limbs
Anti centromere

CREST

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95
Q

What are the features of diffuse systemic sclerosis?

A
  • 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
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96
Q

What is scleroderma?

A

Tightening and fibrosis of skin

May manifest as plaques or linear

97
Q

What is temporal arteritis?

A

Large vessel vasculitis which overlap with PMR

Skip lesions histologically

98
Q

What are the features of temporal arteritis?

A 
Rapid onset 
>60yo
Headache
Jaw claudication
Visual disturbance
Scalp tenderness
Tender/palpable temporal artery
PMR association
99
Q

How is temporal arteritis investigated?

A

Raised inflammatory markers - ESR, CRP may also be elevated

Temporal artery biopsy - skip lesions

CK and EMG normal

100
Q

How is temporal arteritis managed?

A

High dose pred - should be dramatic review

Urgent ophthalmology review

101
Q

What are the x-ray findings seen in rheumatoid arthritis?

A

Early:

  • Loss of joint space
  • Juxta-articular osteoporosis
  • Soft tissue swelling

Late:

  • Periarticular erosions
  • Subluxation
102
Q

What is reactive arthritis?

A

Arthritis which develops following infection

Reiter’s syndrome

Conjunctivitis, urethritis, arthritis
“Can’t see, can’t pee, can’t climb a tree”

103
Q

What commonly causes reactive arthritis?

A

Post STI - chlamydia

Post dysentry - shigella, salmonella, campylobacter

104
Q

How is reactive arthritis managed?

A

Analgesia, NSAIDs, IA steroids

Can use sulfasalazine and methotrexate if persistent

Rarely last >12 months

105
Q

What do you need to find out from a returning traveller in the history?

A 
Exactly where they went
Where did they stay?
Activities/events
Bites
Diet
Fresh water? 
Sexual activity
Unwell contacts
106
Q

Which areas in the world may someone return from that would raise suspicion that they may have malaria?

A

Tropics

  • Amazon region of south america
  • Mid Africa/madagascar
  • Middle East
  • India, China, Philipines etc.
107
Q

What happens in malaria?

A

Mosquite bite and malaria sporozytes enter blood –> liver.

Rupture to release merozites

Merozites infect RBC. Some do not mature but differentiate into gametozytes

108
Q

How does non-falciparum malaria present?

A

Fever - cyclical (48hr vivax/ovale, 72hr malariae)
Headache
Splenomegaly
Malariae - nephrotic syndrome

Ovale and vivax have hypnozoite phase so may relapse after treatment

109
Q

How long does malaria incubate for?

A

10-30 days

110
Q

How is malaria diagnosed?

A

3x blood films

111
Q

What are the types of malaria?

A

Falciparum - most common cause of severe malaria
Ovale
Malariae
Vivax

112
Q

What factors are protective against malaria?

A

Sickle cell trait
G6PD deficiency
HLA-B23
Absence of Duffy antigens

113
Q

How is non falciparum malaria managed?

A

ACT (artemisinin based combination therapy) or chloroquine

Avoid ACT in pregnancy

Ovale/vivax - give primaquine after chloroquine for hynozoites

114
Q

What are the features of falciparum malaria?

A
  • Schizonts on blood film
  • Parasitaemia >2%
  • Hypoglycaemia
  • Acidosis
  • Fever >39
  • Severe anaemia
  • Complications
115
Q

What complications are associated with falciparum malaria?

A 
Cerebral Malaria
Acute renal failure
Hypoglycaemia
ARDS
DIC
116
Q

If a patient is in shock with malaria, what does this indicate?

A

Patient has co-existent bacterial septicaemia

Malaria rarely causes haemodynamic collapse

117
Q

What is enteric fever? What causes it and how is it transmitted?

A

Typhoid/paratyphoid fever - similar regions to malaria

Caused by salmonella typhi/paratyphi - gram - rods

Faecal oral transmission

118
Q

What are the features of enteric fever?

A

Headache, Fever, Arthralgia

Relative bradycardia
Normal WCC
Abdo pain and distension
Constipation
Rose spots - more in paratyphoid
119
Q

How is enteric fever diagnosed?

A

Salmonella on blood culture, stool sample or bone marrow

120
Q

How is enteric fever managed?

A

Suspected - IV Ceftriaxone + azithromycin

Modify once know what susceptible

121
Q

Where is enteric fever especially prevalent?

A

Indian subcontinent

122
Q

How useful is the vaccine for enteric fever?

A

Moderate protection against typhoid

Almost no protection against paratyphoid

123
Q

What history would raise suspicion of enteric fever?

A

Prolonged fever
No rise in WCC
Recent travel to endemic area

124
Q

What is dengue fever?

A

Viral infection transmitted by Aedes mosquito

125
Q

How is dengue fever managed?

A

NOTIFIABLE DISEASE

Symptomatic - fluids, transfusion if low haematocrit

126
Q

What is Kaposis sarcoma?

A

HHV8 infection leading to purple papule/plaques on the skin and mucosa

Skin lesions may ulcerate
May get massive haemoptysis and pleural effusions

127
Q

What neurocomplications are associated with HIV?

A

Toxoplasmosis
Primary CNS lymphoma

Encephalitis
Cryptococcus
Progressive multifocal Leukoencephalopathy
AIDS dementia

128
Q

Describe oesophageal candidiasis and how is it managed?

A

Most common cause of oesophagitis in those with HIV

Odynophagia and dysphagia

Fluconazole and itraconazole 1st line

129
Q

What is pneumocystis jiroveci pneumonia?

A

Unicellular eukaryote - classified as fungus

Most common opportunistic infection in HIV

130
Q

Who should receive pneumocystis jiroveci prophylaxis and what is it?

A

CD4 <200

TMP/SMX - trimethoprim/sulphamethoxazole (Co-trimoxazole)

131
Q

What are the features of pneumocystis pneumonia?

A

Dyspnoea
Dry cough
Fever
Few chest signs

Commonly get pneumothorax
Extrapulmonary - hepatosplenomegaly, lymphadenopathy, choroid lesions

132
Q

How is pneumocystis pneumonia investigated?

A

CXR - bilateral interstitial infiltrates (can be normal)
Exercise induced desaturation
Sputum often fail to show PCP - need bronchoalveolar lavage

133
Q

How is pneumocystis pneumonia managed?

A

Co-trimoxazole
IV pentamidine
Steroids if hypoxic

134
Q

What is amoebiasis?

A

Entamoeba histolytica spread by faecal oral route

10% of worlds population chronically infected

135
Q

How does amoebiasis present?

A

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
Q

How is amoebiasis managed?

A

Dysentry - metronidazole

Follow with amoebicide

137
Q

What is the most common organism in animal bites? (typically cats and dogs)

A

Mostly polymicrobial but most commonly:

Pasteurella multocida

138
Q

How are animal bites managed?

A

Cleanse wound - punctures should not be sutured closed unless cosmesis at risk

Co-Amox
Doxy+metronidazole if pen allergic

139
Q

What organisms are common in human bites?

A

Multimicrobial

  • strep saprophyticus
  • staph aureus
  • Eikenella
  • Fusobacterium
  • Prevotella
140
Q

How are human bites managed?

A

Co-amox

Consider risk of HIV and hep C

141
Q

Antibiotic for chronic bronchitis exacerbation

A

Amox or tetracycline or clarithromycin

142
Q

Antibiotic for pneumonia

A

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
Q

Antibiotics for UTI’s

A

Lower - trimethoprim or nitrofurantoin. Amox alternative

Pyelonephritis - Cefalexin or ciprofloxacin

144
Q

Antibiotics for prostatitis

A

Ciprofloxacin or Trimethoprim

145
Q

Antibiotic for impetigo

A

Topical hydrogen peroxide

Oral fluclox

146
Q

Antibiotics for skin infections

A

Cellulitis/Erysipelas/Mastitis - fluclox

Cellulitis near eyes or nose/bites - co-amox

147
Q

Antibiotics for ENT infections

A

Throat - phenoxymethylpenicillin (PenV)
Sinusitis - penV
Otitis media - amox
Otitis externa - fluclox - delayed prescription
Periapical/periodontal abscess - amoxicillin
Gingivitis - Metronidazole

148
Q

Antibiotics for STI’s

A

Gonorrhoea - IM ceftriaxone
Chlamydia - doxycycline or 1 off azithromycin
PID - Oral metronidazole + oral doxy + IM ceftriaxone
Syphilis - Benzathine benzylpenicillin
Bacterial vaginosis - Metronidazole

149
Q

Antibiotics for GI infections

A

C diff - metronidazole or vanc for 2nd episode
Campylobacter - clarithromycin
Salmonella - Ciprofloxacin
Shigellosis - Ciprofloxacin

150
Q

What is an aspergilloma?

A

Mycetoma (mass like fungus ball) which colonises an existing lung cavity - secondary to TB, lung cancer or CF

151
Q

How do aspergilloma’s present and how are they investigated?

A

Asymptomatic usually
Cough and haemoptysis

CXR - rounded opacity and crescent sign
High titres of aspergillus precipitins

152
Q

What type of microbe is bacillus cereus?

A

Gram positive rod

153
Q

Key things about bacillus cereus infection

A

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
Q

How us a bacillus cereus infection treated?

A

Rarely required

Can use vancomycin

155
Q

What type of vaccine is BCG?

A

Live attenuated vaccine containing mycobacterium bovis

Protect against TB and limited protection against leprosy

156
Q

Who should receive the BCG vaccine?

A

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
Q

What are the contraindications for the BCG vaccine

A 
Previous BCG
Hx of TB
HIV
Pregnancy
Positive tuberculin test
158
Q

What are the features of botulism?

A 
Fully conscious with no sensory disturbance
Flaccid paralysis
Diplopia
Ataxia
Bulbar palsy
159
Q

How is botulism managed?

A

Botulism antitoxin - if given early enough

Supportive care

160
Q

What is campylobacter jejuni?

A

Commonest cause of infectious intestinal disease

Spread by faecal oral route

Gram negative bacillus

161
Q

What are the features of campylobacter?

A

Prodrome - headache and malaise
Bloody diarrhoea
Abdo pain - mimic appendicitis

162
Q

How is campylobacter managed?

A

Usually self limiting

Clarithromycin if severe or immunocompromised
Cipro is alternative

163
Q

What classifies campylobacter as severe?

A

High fever
Bloody diarrhoea
More than 8 stools per day

Sx > 1 week

164
Q

What are the complications associated with campylobacter?

A

Guillian Barre syndrome
Reactive arthritis
Septicaemia, endocarditis, arthritis

165
Q

What causes cholera?

A

Vibro cholerae - gram negative bacteria

166
Q

What are the features of cholera?

A

Profuce, rice water diarrhoea
Dehydrated
Hypoglycaemia

167
Q

How is cholera managed?

A

Oral rehydration therapy

Doxy/ciprofloxacin

168
Q

Give examples of gram positive organisms

A

Cocci - staph, strep, entero

Rods - clostridium, bacillus anthraces, corynebacterium (diptheria), listeria

169
Q

Give examples of gram negative organisms

A

Cocci - Neisseria meningitidis/gonorrhoea, moraxella catarrhalis

Rods (rest) - E coli, H influenza, Pseudomonas, Salmonella, Shigella, Campylobacter

170
Q

What are the different clostridium strains and what do they cause?

A

Perfringens - gas gangrene
Botulinum - botulism
Difficile - pseudomembranous colitis
Tetani - spastic paralysis

171
Q

What is CMV?

A

Human herpes virus commonly in immunocompromised

Infected cells have Owl’s eye appearance - intranuclear inclusion bodies

172
Q

What are the types of CMV?

A 
Congenital 
Mononucleosis
Retinitis
Encephalopathy
Pneumonitis
Colitis
173
Q

How does congenital CMV present?

A 
Growth retardation
Pinpoint petechial skin lesions - blueberry muffin
Microcephaly
Sensorineural deafness
Encephalitis
Hepatosplenomegaly
174
Q

What is diptheria caused by?

A

Gram positive rod - corynebacterium diphtheriae

175
Q

How does diptheria present?

A

Recent visitor to Eastern Europe/russia/asia
Sore throat with grey pseudomembrane on pharynx
Bulky cervical lymphadenopathy - bull neck
Neuritis
Heart block

176
Q

How is diptheria investigated and managed?

A

Culture throat

IM penicillin and diphtheria antitoxin

177
Q

How does ebola spread and what are the symptoms?

A

Human to human contact

Early: Fever, Fatigue, Muscle pain, Headache, Sore throat
Late: Diarrhoea, vomit, rash, impaired renal/liver function, bleeding

178
Q

What is Epstein Barr virus associated with?

A

Burkitt’s Lymphoma
Hodgkins lymphoma
Nasopharyngeal carcinoma
HIV associated CNS lymphoma

Hairy leukoplakia

179
Q

What does E coli commonly cause?

A

Diarrhoea
UTI
Neonatal meningitis

180
Q

Stereotypical gastroenteritis histories: E Coli

A

traveller
watery
abdo cramps/nausea

181
Q

Stereotypical gastroenteritis histories: Giardiasis

A

prolonged non bloody diarrhoea

Flatulence

182
Q

Stereotypical gastroenteritis histories: Cholera

A

cramps
watery diarrhoea
dehydration

183
Q

Stereotypical gastroenteritis histories: Shigella

A

bloody diarrhoea
vomit
abdo pain

184
Q

Stereotypical gastroenteritis histories: S Aureus

A

Severe vomiting

Short incubation time

185
Q

Stereotypical gastroenteritis histories: Bacillus Cereus

A

Vomiting within 6 hr - uncooked/reheated rice

Diarrhoea after 6 hr

186
Q

Stereotypical gastroenteritis histories: Amoebiasis

A

Gradual onset bloody diarrhoea
Abdo pain
Tenderness
Last weeks

187
Q

Gastroenteritis incubation times

A

1-6hr - S Aureus/bacillus cereus
12-48hr - Salmonella/E Coli
48-72hr - Shigella/Campylobacter
>7 days - Giardiasis/Amoebiasis

188
Q

How is travellers diarrhoea defined?

A 
>=3 watery stools in 24 hrs
With 1+:
- abdo cramps
- fever
- nausea
- vomiting
- blood in stool
189
Q

How is giardiasis investigated and managed?

A

Trophozoite and cysts negative on stool culture - req. duodenal fluid aspirates or string tests

Metronidazole

190
Q

What are the features of hep A?

A 
Flu like prodrome
RUQ pain
Tender hepatomegaly
Jaundice
Cholestatic LFT's
191
Q

How is hep A spread and what is the prognosis?

A

Faecal oral

Doesn’t cause chronic disease - no increased risk of hepatocellular carcinoma

192
Q

Which hepatitis strands have a vaccine available?

A

A and B

E in development

Can’t vaccinate against Hep C!

193
Q

Who should receive a hep A vaccine?

A 
Travel to live in high risk area
Chronic liver disease
Haemophilia
MSM
IVDU
Occupational risk - lab worker, sewage workers, work with primates
194
Q

What are the features of hep B?

A

Jaundice
Fever
Elevated liver transaminases

195
Q

What are the complications of hep b?

A

Chronic hepatitis - ground glass hepatocytes on light microscopy

Fulminant liver failure
Hepatocellular carcinoma
Glomerulonephritis
Polyarteritis nodosa
Cryoglobulinaemia
196
Q

How is hepatitis managed?

A

Vaccine now part of regular program

Pegylated interferon alpha

197
Q

How can hepatitis B anti-HBs levels be interpreted?

A

> 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
Q

Who are the at risk group for hep C?

A

IVDU

Blood transfusion prior to 1991

199
Q

How is hep C transmitted?

A

Needle stick - 2%
Vertical transmission - 6%
Sexual intercourse 5%

Breast feeding not contraindicated

200
Q

What are the features of Hep C?

A 
30% exposed develop:
Transient rise in LFT's
Jaundice
Fatigue
Arthralgia
201
Q

How is Hep C investigated?

A

HCV RnA - acute infection

Anti HCV antibodies - they remain in those who clear the virus

202
Q

What is the prognosis of Hep C?

A

15-45% clear after acute infection

Majority develop chronic hep c

203
Q

How is chronic hep c defined?

A

Persistence of HCV RNA for >6 months

204
Q

What are the complications of chronic hep C?

A 
Rheum - arthralgia/arthritis
Eye - Sjogrens
Cirrhosis
Hepatocellular carcinoma
Cryoglobulinaemia
Glomerulonephritis
205
Q

How is chronic hep c managed?

A

Depend on genotype

Combination of protease inhibitors: daclatasvir + sofosbuvir) ± ribavirin

206
Q

How do patients get hep D?

A

Co-infection with hep B or superinfection from hep B

207
Q

Hep D complications, diagnosis and management

A

Superinfection –> fulminant hepatitis, chronic hepatitis, cirrhosis

Diagnosed via reverse polymerase chair reaction of RNA

Interferon

208
Q

Summary of Hep E - spread and prognosis

A

Faecal oral
3-8 week incubation

Similar to hep A but significant mortality in pregnancy
No chronic disease or increased risk of cancer

209
Q

Which HPV strains cause pathology?

A

6 and 11 - genital warts

16 and 18 - cancer

210
Q

Which HPV strains are vaccinated against? Who is vaccinated?

A

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
Q

What is infectious mononucleosis?

A

Glandular fever - caused by Ebstein Barr virus 90% of cases (HHV4)

212
Q

What is the classic triad of symptoms in glandular fever?

A

Sore throat
Lymphadenopathy - anterior and posterior triangles
Pyrexia

213
Q

How is glandular fever differentiated from tonsillitis?

A

Tonsilitis only affect upper anterior cervical chain

214
Q

What are the other features of glandular fever?

A 
Malaise, anorexia, headache
Palatal petechiae
Splenomegaly - can rupture! 
Hepatitis - transient ALT rise
Lymphocytosis
Haemolytic anaemia
Maculopapulor pruritic rash if take amoxicillin
215
Q

How is glandular fever diagnosed?

A

Monospot

Repeat with FBC 2 wk into illness

216
Q

How is glandular fever managed?

A

Resolve after 2-4 weeks
Conservative
Avoid contact sports

217
Q

what is important about the influenza vaccine given to children?

A

Intranasal
1st dose 2-3yo then annually
Live vaccine

218
Q

What is important to know about the influenza vaccine in adults?

A

2 subtypes
All people over 65 or those at risk
Inactivated virus
CI if hypersensitivity to egg protein

219
Q

Summary of legionella

A

Intracellular bacterium

Colonise water tanks - air con units

Flu like symptoms, dry cough, lymphopaenia, hyponatraemia

Diagnosed by urinary antigen

Managed with erythromycin/clarithromycin

220
Q

What causes mumps?

A

RNA paramyxovirus

221
Q

How does mumps spread?

A

Droplets

Infective for 7 days before and 9 days after parotid swelling

222
Q

How does mumps present?

A

Fever
Malaise
Muscular pain
Parotitis - ear ache, pain on eating - often bilateral

223
Q

How is mumps managed?

A

Rest
Paracetamol
Notifiable disease

224
Q

What are the complications of mumps?

A

Orchitis
Heating loss - transient and unilateral
Meningoencephalitis
Pancreatitis

225
Q

What is characteristic about mycoplasma pneumoniae?

A

Erythema multiforme

Cold autoimmune haemolytic anaemia

226
Q

How is mycoplasma pneumonia managed?

A

Doxycycline or erythro/clarith

227
Q

Quick summary of norovirus

A

Nausea, vomit diarrhoea
Faecal oral spread
15-50 hour incubation
Supportive care

228
Q

What is the post exposure prophylaxis for Hep A, B and C?

A

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
Q

What is post exposure prophylaxis for HIV?

A

Depend on mode of transmission and patient viral load

Antiretrovirals and serological testing

230
Q

What is post exposure prophylaxis for varicella zoster?

A

VZIG if IgG negative pregnant/immunocompromised woman

231
Q

How are hyposplenic patients managed in terms of vaccinations and likely causative organisms?

A

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
Q

What is pseudomonas aeruginosa?

A

Gram negative rod

233
Q

What can pseudomonas cause?

A

Chest infections - esp CF
Skin - burns, wound infections, hot tub folliculitis
Otitis externa - diabetics
UTIs

234
Q

What is pyrexia of unknown origin and what can cause it?

A

Prolonged fever for >3 weeks

Neoplasia - lymphoma, hypernephroma, preleukaemia, atrial myxoma

Infections - abscess, TB

Connective tissue disorders

235
Q

What is staphylococcal toxic shock syndrome?

A

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
Q

What are the features of tetanus?

A 
Prodrome of fever, lethargy headache
Trismus - lock jaw
Risus sardonicus - facial muscle spasm
Opisthotonus - arched back, hyperextended neck
Spasms
237
Q

How is tetanus managed?

A

Supportive care
IM human tetanus IG if high risk
Metronidazole

238
Q

What is toxoplasmosis?

A

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
Q

What are the features of cerebral toxoplasmosis? How is it managed?

A

Headache, confusion, drowsiness

CT - single or multiple ring enhancing lesions

Pyrimethamine + sulphadiazine for >6wks

Finals (16 decks)

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