Infection & Immunology Flashcards

Question

Define Behcet's disease.

Answer 1

A systemic vasculitis. Can cause skin and mucosal lesions, uveitis, major arterial and venous vessel disease, and gastrointestinal and neurological manifestations.

Answer 2

1st Line: - Pathergy testing - induration with or without formation of a pustule within 48 hours - Rheumatoid factor - negative - Anti-nuclear antibodies - negative - Anti-neutrophil cytoplasmic antibodies - negative - HLA-B51 - present - Lumbar puncture - hypercellularity, lymphocytosis, polymorphonuclear cells or pleocytosis - MRI - white matter changes involving midbrain, brainstem and basal ganglia - Colonoscopy - inflammation and apthous-type ulcers, vasculitis on biopsy - Upper GI endoscopy - inflammation and apthous-type ulcers, vasculitis on biopsy - CT chest - haemorrhage, pulmonary aneurysm - CT chest angiography - haemorrhage, pulmonary aneurysm - CTPA - pulmonary aneurysm Emerging: - Anti-Saccharomyces cervisiae antibodies - may be elevated when GI symptoms are present

Answer 3

Common: - Increased predisposition in certain ethnic / geographic groups - Oral ulcers - Genital ulcers - Uveitis - Acne lesions - Erythema nodosum - Limitated duration of symptoms - Superficial thrombophlebitis - Hypopyon - inflammatory cells in the anterior chamber of eye Uncommon: - Stroke - Eye pain, blurry vision, photophobia or photosensitivity - Memory loss - Headache, confusion or fever - Haemoptysis, cough, shortness of breath or chest pain - Eye redness or tearing - Impaired speech, balance or movement - Cramping abdominal pain, diarrhoea or GI ulceration

Answer 4

Common: - Increased predisposition in certain ethnic / geographic groups - Oral ulcers - Genital ulcers - Uveitis - Acne lesions - Erythema nodosum - Limitated duration of symptoms - Superficial thrombophlebitis - Hypopyon - inflammatory cells in the anterior chamber of eye Uncommon: - Stroke - Eye pain, blurry vision, photophobia or photosensitivity - Memory loss - Headache, confusion or fever - Haemoptysis, cough, shortness of breath or chest pain - Eye redness or tearing - Impaired speech, balance or movement - Cramping abdominal pain, diarrhoea or GI ulceration

Answer 5

Most commonly seen in Turkey, Israel, the Mediterranean basin and eastern Asia - where Japan and South Korea report the most cases. Most commonly seen in young people aged 20-30 years. More active and severe in males.

Answer 6

In many patients, disease activity decreases with time and this natural course can affect treatment decisions about the type and duration of medical therapy. Presents in various combinations and sequences in patients over time. Risk factors: - Age 20-40 years - Family history - Genetic predisposition - evidence for genetic anticipation

Answer 7

A severe, generalized or systemic hypersensitivity reaction, characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes.

Answer 8

A systemic response is caused by the release of immune and inflammatory mediators from basophils and mast cells. Most frequently caused by allergies to food, medication and venoms. Non-immunological anaphylaxis - similar symptoms (anaphylactoid reaction). Risk factors: - <30 years old - food associated, exercise induced - Atopy / asthma - History of anaphylaxis - Exposure to a common sensitiser - e.g. latex - Adult age - food, insect venom, medicine related - Female sex

Answer 9

The lifetime prevalence of anaphylaxis is currently estimated at 0.05-2 % in the USA and ~3 % in Europe. Several population-specific studies have noted a rise in the incidence, particularly in the hospitalizations and ER visits due to anaphylaxis.

Answer 10

- Acute onset - Shortness of breath - Confusion or disorientation - Hives (urticaria) - Nausea - Vomiting - Diarrhoea - Incontinence - Abdominal cramps and pain - Agitation - Anxiety - Sense of impending doom = angor animi

Answer 11

- Airway swelling - angio-oedema - Inspiratory stridor - Hoarse voice - Chest hyperinflation - Wheezing - Accessory muscle use - Cyanosis - Respiratory arrest - Pale clammy skin - Hypotension - Tachycardia or bradycardia - Cardiac arrest - Erythema - Pruritus - Rhinits - Bilateral conjunctivitis

Answer 12

1st Line: - Mast cell tryptase - may be elevated, normally undetectable - 12-lead ECG - myocardial ischaemia, non-specific ST ECG changes post-adrenaline and with anaphylaxis - U&E - normal in initial phase of anaphylaxis unless comorbidity present - ABG - elevated lactate, metabolic acidosis Consider: - CXR - may show hyperinflation if bronchoconstriction, interstitial fluid (After time-critical interventions have been administered)

Answer 13

IN CARDIORESPIRATORY ARREST - CPR and ALS - Do not give IM adrenaline after cardiac arrest has occurred as circulation to the muscle is inadequate NOT IN CARDIORESPIRATORY ARREST - ABCDE - Position patient and remove trigger - Adrenaline - IM 150ug adrenaline into anterolateral aspect of middle third of thigh, repeat if no improvement after 5 minutes - Establish airway plus high-flow oxygen - 94-96% target sats - IV fluids - rapid IV fluid challenge (500-1000mL, kids 20mL/kg) over <15 mins with crystalloid that has sodium concentration 130-154 mmol/L to counteract fluid shifts associated with vasodilation and/or capillaries - Serial CR assessments - pulse oximeter, ECG monitor, non-invasive blood pressure monitor - Nebulised adrenaline - Nebulised short-acting beta-2-agonist - e.g. salbutamol 5mg every 20-30 mins (adult) - IV atropine - IV glucagon AFTER TREATMENT - Antihistamine - e.g. chlorphenamine - 10mg IM/IV single dose, may be repeated up to 4 doses per day - Corticosteroid - e.g. hydrocortisone sodium succinate 200mg IM/IV - Monitor for biphasic reactions (incidence 1-20%) - Review by a senior clinician and observation POST-ANAPHYLAXIS - Adrenaline autoinjector - Antihistamine - e.g. chlorphenamine 4mg orally every 4-6 hours, max 24mg / day - Corticosteroid - e.g. prednisolone NB: Length of needle - 25 mm (blue 23G or orange 25G) needle is best and suitable for all ages - 16 mm (orange 25G) needle is appropriate for preterm or small infants - 38 mm (green 21G) needle may be needed in some adults. Injection technique - Stretch the skin and give the injection with the needle at a 90° angle to the skin.

Answer 14

- Brain damage - Kidney failure - Cardiogenic shock - Arrhythmias - Heart attacks - Death

Answer 15

With prompt treatment, the overall prognosis of anaphylaxis is good, with a case fatality ratio of less than 1% reported in most population-based studies [Resuscitation Council (UK), 2012].

Answer 16

Infection of intracardiac endocardial structures - mainly heart valves.

Answer 17

Vegetations form as a result of lodging of the organisms on the heart valves during a period of bacteraemia. - Made of platelets, fibrin, infective organisms - Poorly penetrated by immune system - Destroy valve leaflets - Invade myocardium - Invade aortic wall - Abscess cavities form - Activation of immune system also causes formation of immune complexes --> cutaneous vasculitis, glomerulonephritis, arthritis Endocardium can be colonized by virtually any organism, but most common are: 1) Streptococci (40%) - mainly alpha-haemolytic Streptococcus viridans or bovis 2) Staphylococci (35%) - aureus or epidermidis (IVDU) 3) Enterococci (20%) - faecalis 4) Others - e.g. Coxiella burnetti, histoplasma, HACEK - Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella Risk Factors: - Abnormal valves - e.g. congenital, post-rheumatic, calcification, degeneration - Prosthetic heart valves - Turbulant flow - e.g. patent ductus arteriosus or VSD - Recent dental work - Bacteraemia - S.bovis --> GI Malignancy

Answer 18

16-22 per million per year (UK)

Answer 19

- Fever - Sweats - Chills - Malaise - Arthralgia - Myalgia - Confusion - Skin lesions - Ask about recent dental surgery or IV drug use

Answer 20

- Pyrexia - Tachycardia - Signs of anaemia - Clubbing - if long-standing - New regurgitant murmur - Muffled heart sounds - Splenomegay NB: Right-sided lesions may imply IV drug use. Frequency: Mitral > Aortic > Tricuspid > Pulmonary Vasculitic Lesions: - Roth's spots - petechiae on retina - Petechiae (especially on pharyngeal and conjunctival mucosa) - Janeway lesions - painless palmar macules that blanch on pressure - Osler's nodes - tender nodules on finger / toe pads - Splinter haemorrhages - nail-bed haemorrhage

Answer 21

1) Bloods 2) Urinalysis 3) Blood culture 4) Echocardiography 5) Others Bloods - FBC - high neutrophils, normocytic anaemia - High ESR and CRP - U&E - Rheumatoid factor positive Urinalysis - Microscopic haematuria - Proteinuria Blood Culture - 3 sets 1 hour apart - Culture and sensitivity vital but start empirical treatment first - Culture negative 2-5% Echocardiography (Transthoracic) - Transoesophageal echocardiography more sensitive for endocarditis - Useful for detection of vegetations, valve abscess, diagnosis of prosthetic valve endocarditis, assessment of embolic risk Others: - ECG - conduction changes - CXR - septic pulmonary emboli : focal lung infiltrates, central cavitation - e.g. tricuspid valve endocarditis Duke's Classification (2 major, 1 major + 3 minor, all minor): - MAJOR - positive blood culture in 2 separate samples, positive echocardiogram - MINOR - high grade pyrexia >38 degrees, risk factors, positive blood culture (no major criteria), positive echocardiogram (not major), vascular signs +ve echocardiogram = vegetation, abscess, prosthetic valve dehiscence, new valve regurgitation Risk factors: - Abnormal valves - IV drug use - Dental surgery

Answer 22

Antibiotics for 4-6 weeks (at least 6 weeks for prosthetic valve endocarditis). On clinical suspicion: - Benzylpenicillin + Gentamycin - Gentamycin - dose adjusted for peak serum level of 3-4ug/ml, trough <1ug/ml STREPTOCOCCI - Continue Benzylpenicillin + Gentamycin - Alt - Ceftriaxone, Vancomycin STAPHYLOCOCCI - Flucloxacillin / Vancomycin + Gentamycin - Prosthetic - Vancomycin + Gentamicin + Rifampin ENTEROCOCCI - Ampicillin + Gentamycin HACEK - Ampicillin or Ceftriaxone + Gentamycin Culture Negative - Vancomycin + Gentamycin Surgery - If poor response or deterioration = urgent valve replacement - Replacement of prosthees - Kissing mitral valve vegetations - may be able to salvage Prophylaxis - If history of infective endocarditis + undergoing high risk procedures - High risk procedures - e.g. dental, incision or biopsy of respiratory mucosa, procedures in patients with GI/GU tract infection, procedures on infected skin or musculoskeletal tissue, prosthetic heart valve placement - Dental - 2g oral amoxicillin 30-60 mins before procedure

Answer 23

- Valve incompetence - Intracardiac fistulae or abscesses - Aneurysm formation - Heart failure - Renal failure - Glomerulonephritis - Arterial emboli from vegetations (brain, kidney, lungs, spleen)

Answer 24

Fatal if untreated. | When treated, 15-30% mortality.

Answer 25

A clinical syndrome most commonly caused by Epstein-Barr virus (EBV) infection in 80-90% of cases. Mononucleosis syndrome used when the syndrome is caused by a non-EBV aetiology.

Answer 26

Risk factors: - Kissing - Sexual behaviour

Answer 27

More than 90 percent of adults worldwide show serologic evidence of Epstein Barr virus infection. Most common time to develop clinical infectious mononucleosis: Freshman year in college. Incubation period: 4-8 weeks.

Answer 28

- Adolescents and young adults - Febrile illness - Sore throat - Enlarged lymph nodes - Malaise

Answer 29

TRIAD: Fever, Pharyngitis & Lymphadenopathy + atypical lymphocytosis + positive heterophile antibodies test + positive serological test for antibodies against EBV Other Rarer Signs: - Splenomegaly - Rash - Signs of hepatitis - hepatomegaly, jaundice - Myalgia

Answer 30

TRIAD: Fever, Pharyngitis & Lymphadenopathy + atypical lymphocytosis + positive heterophile antibodies test + positive serological test for antibodies against EBV 1st Line: - FBC - lymphocytosis, atypical lymphocytosis - Heterophile antibodies - positive - EBV-specific antibodies - positive for VCA-IgM, VCA-IgG, EA, EBV, EBNA - LFTs - elevated transaminases (transient, mild) 2nd Line: - Real-time PCR - EBV DNA detection - Abdominal US Scan - Splenomegaly - CT Abdo - Splenic rupture (haemodynamically stable patient when rupture is suspected)

Answer 31

- Supportive care - paracetamol, ibuprofen, hydration, anti-pyretics, analgesics - Add Corticosteroid if upper airway obstruction or haemolytic anaemia - Prednisolone

Answer 32

- Upper airway obstruction - Splenic rupture - Fulminant hepatitis - Encephalitis - Severe thrombocytopaenia - Haemolytic anaemia - Long-term fatigue & lethargy

Answer 33

Most people with mono recover completely with no long-term problems. The fatigue associated with the condition may persist for a few months after the fever and other symptoms have resolved. Severe complications as described above are very rare.

Answer 34

Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdominal discomfort.

Answer 35

Caused by viruses, bacteria, protozoa or toxins in contaminated food or water. Virus - e.g. rotavirus, adenovirus, astrovirus, calcivirus, Norwalk virus, small round structured viruses Bacteria - e.g. Campylobacter jejuni, E.coli 0157, Salmonella, Shigella, Vibrio cholerae, Listeria, Yersinia enterocolitica Protozoal - e.g. Entamoeba histolytica, Cryptosporidium parvum, Giardia lamblia Toxins - e.g. from Staphylococcus aureus, Cryptosporidium parvum, Giardia lamblia ``` Commonly contaminated foods - Improperly cooked meat - e.g. S.aureus, C.perfringens - Old rice - e.g. B.cereus, S.aureus - Eggs & poultry - e.g. Salmonella - Milk and cheeses - e.g. Listeria, Campylobacter - Canned food - e.g. botulism ``` Non-inflammatory mechanisms - e.g. V. cholerae, enterotoxigenic E.coli (enterotoxins causing enterocytes to release water and electrolytes) Inflammatory mechanisms - e.g. Shigella, enteroinvasive E.coli (release cytokines, invade, damage epithelium), Salmonella typhi (greater invasion and bacteraemia)

Answer 36

Common Under-reported Morbidity & mortality in developing world

Answer 37

- Sudden onset nausea - Vomiting - Anorexia - Diarrhoea - bloody or watery - Abdominal pain / discomfort - Fever - Malaise NB: Enquire about recent travel, antibiotic use and recent food intake - how cooked, source, anyone else ill. Time of onset: - Toxins - early, 1-24h - Bacterial/Viral/Protozoal - 12h or later Effect of toxin: - Botulinum - paralysis - Mushrooms - fits, renal or liver failure

Answer 38

- Diffuse abdominal tenderness - Abdominal distension - Increased bowel sounds Severe: - Pyrexia - Dehydration - Hypotension - Peripheral shutdown

Answer 39

1. Blood 2. Stool 3. AXR or US 4. Sigmoidoscopy Blood - FBC, blood culture (bacteraemia), U&Es (dehydration) Stool - Faecal microscopy for polymorphs, parasites, oocytes, culture, EM (viraL) - Analyse for toxins, pseudomembranous colitis - e.g. Clostridium difficile toxin AXR or US - Exclude other causes of abdominal pain Sigmoidoscopy - IBD exclusion

Answer 40

- Bed rest - Fluids - Electrolyte replacement - Oral rehydration solution - glucose, salt - IV rehydration if severe vomiting - Antibiotic treatment if severe or infective agent identified - e.g. ciprofloxacin against Salmonella, Shigella, Campylobacter - Educate on basic hygiene and cooking NB: Botulism - Botulinum anti-toxin IM and manage in ITU

Answer 41

- Dehydration - Electrolyte imbalance - Pre-renal failure - Secondary lactose intolerance (infants) - Sepsis & shock (Salmonella, Shigella) - Haemolytic uraemic syndrome (E.coli 0157) - Guillian-Barré syndrome in weeks after Campylobacter gastroenteritis Botulism - respiratory muscle weakness, paralysis

Answer 42

Majority of cases self-limiting

Answer 43

The inflammation of the lining of the eyelids and eyeball caused by bacteria, viruses, allergic or immunological reactins, mechanical irritation, or medicines.

Answer 44

Risk Factors: - Exposure to infected person - Infection in one eye - Environmental irritants - Allergen exposure - Camps, swimming pools, military bases - Asian or Mediterranean young male - Atopy - Contact lens use - Ocular prosthesis - Mechanical irritation

Answer 45

The incidence of bacterial conjunctivitis was estimated to be 135 in 10 000 in one study.

Answer 46

- Watery discharge - Ropy, mucoid discharge - Purulent discharge - Itching predominant symptom - Eyelids stuck together in morning - Tender, pre-auricular lymphadenopathy - Conjunctival follicles - Superficial punctate keratopathy - Unilateral disease - Corneal subepithelial infiltrates - Corneal pannus - Vesicular skin rash

Answer 47

- Rapid adenovirus immunoassay - Cell culture - Gram stain - Polymerase chain reaction - Ocular pH

Answer 48

Inflammation of the brain parenchyma.

Answer 49

Causes: - VIRAL - e.g. HSV, herpes zoster, mumps, adenovirus, coxsackie, echovirus, enteroviruses, measles, EBV, HIV, rabies (Asia), Nipah (Malasia), arboviruses transmitted by mosquitos (Jap B encephalitis - Asia, St Louis and West Nile encephalitis - USA) - NON-VIRAL - e.g. syphillis, Staphylococcus aureus - IMMUNOCOMPROMISED - e.g. CMV, toxoplasmosis, Listeria - AUTOIMMUNE OR PARANEOPLASTIC - associated with antibodies - e.g. anti-NMDA or anti-VGKC

Answer 50

7.4 in 100,000 in UK

Answer 51

- Can be mild and self-limiting - Subacute onset (hours to days) - Headache - Fever - Vomiting - Neck stiffness - Photophobia - i.e. symptoms of meningism (meningoencephalitis) - Behavioural changes - Drowsiness - Confusion - History of seizures - Focal neurological symptoms - e.g. dysphagia, hemiplegia - DETAILED TRAVEL HISTORY

Answer 52

- Reduced level of consciousness with deteriorating GCS - Seizures - Pyrexia - Neck stiffness - Photophobia - Kernig's test positive - Hypertension - Bradycardia - Papilloedema - Focal neurological signs - e.g. dysphagia, hemiplegia - Minimental examination may reveal cognitive or psychiatric disturbances NB: Raised intracranial signs and meningism signs.

Answer 53

1. Bloods 2. MRI / CT 3. Lumbar Puncture 4. EEG 5. Brain Biopsy Bloods - FBC - high lymphocytes - U&E - SIADH may occur - Glucose - compare with CSF glucose - Viral serology - ABG MRI / CT - Excludes mass lesion - HSV produces characteristic oedema of the temporal lobe on MRI Lumbar Puncture - High lymphocytes - High monocytes - High protein - Glucose usually normal - CSF culture difficult - Viral PCR now first line EEG - Epileptiform activity - E.g. spiking activity in temporal lobes Brain Biopsy - Rarely performed

Answer 54

Includes HSV1 and HSV2.

Answer 55

Alpha-herpes virus with double-stranded deoxyribonucleic acid (dsDNA). Transmitted via close contact with an individual shedding the virus (e.g. kissing, sexual intercourse). Multiply in epithelial cells of mucosal surface. Produces vesicles or ulcers. Lifelong latent infection when virus enters sensory neurons at infection site. Can then reactivate, replicate and infect surrounding tissue - occurs in response to physical, emotional stresses or immunosuppression.

Answer 56

HSV1 - infection in 2/3 of world's population (approx 3.7 billion <50 years) HSV2 - infection in 11% of world's population ( approx 400 million) 90% adults seropositive for HSV1 by 30 years. 35% adults >60 years seropositive for HSV2. 1/3rd population recurrent HSV infections.

Answer 57

HSV1 Primary Infection: - Asymptomatic - Pharyngitis - Gingivostomatitis - may make eating very painful - Herpetic whitlow - inoculation of virus into a finger Recurrent infection / reactivation: - Prodrome (6h) peri-oral tingling and burning - Vesicles appear (48h), ulcerate and crust over - Complete healing 8-10 days HSV2 - Very painful blisters and rash in genital, perigenital and anal area - Dysuria - Fever - Malaise HSV Keratoconjunctivitis: - Epiphoria - watering eyes - Photophobia

Answer 58

Primary Infection: - Subclinical or sensory nerve prodrome (tingling) - Vesicles - Shallow ulcers Systemic Symptoms: - Fever - Malaise - Tender cervical lymphadenopathy - Heals 8-12 days Reactivation: - Usually less severe unless immunosuppressed Herpes Labialis: - Cold sore lesion at lip border, predominantly HSV1 Genital Herpes: - Predominantly HSV2 Gingivostomatitis: - Fever - Sore throat - Tender oropharyngeal vesicles - Yellow slough filled ulcers Keratoconjunctivitis: - Corneal dendritic ulcers - Avoid steroids Herpetic Whitlow: - Painful vesicles on distal phalanx due to inoculation through a break in the skin Herpes Encephalitis: - Most common treatable viral encephalitis - Transfer of virus from peripheral site to brain via neuronal transmission - Prodrome - fever, malaise, headache, nausea - Encephalopathy - general/ focal signs of cerebral dysfunction including psychiatric symptoms, seizure, focal neurology (temporal involvement in 60%), memory loss (HSV1 in immunocompetent patients)

Answer 59

- Clinical diagnosis - Confirmation required in encephalitis, keratoconjunctivitis or immunosuppression - Viral PCR of CSF, swab or vesicle scraping - Culture - Immunofluorescence - Serology

Answer 60

A time-honored method of draining abscesses to relieve pain and speed healing. Routine cultures and antibiotics are usually unnecessary if an abscess is properly drained.

Answer 61

- Palpable fluctuant abscess - An abscess that does not resolve despite conservative measures - Large abscess >5mm

Answer 62

- Inadequate anaesthesia - Pain during and after the procedure - Bleeding - Reoccurrence of abscess formation - Septic thrombophlebitis - Necrotizing fasciitis - Fistula formation - Damage to nerves and vessels - Scarring

Answer 63

Epididymitis - inflammation of the epididymis Orchitis - inflammation of one or both testicles Acute epididymitis - inflammation of the epididymis characterized by scrotal pain and swelling of less than 6 weeks' duration. Acute Epididymo-orchitis - if concurrent inflammation of the testis is present.

Answer 64

Sexually active men - most commonly caused by: - Chlamydia trachomatis - Neisseria gonorrhoea - Mycoplasma genitalium Older men - most commonly caused by enteric pathogens: - Bladder outlet obstruction - Recent instrumentation of the urinary tract - Systemic illness RISK FACTORS: - Unprotected sexual intercourse - Bladder outflow obstruction - Instrumentation of urinary tract - Immunosuppression - Vasculitis - Amiodarone - Mumps - Exposure to TB

Answer 65

Usually unilateral.

Answer 66

- Irritative lower urinary tract symptoms - Urethral discharge (purulent) - Fever Common - Presence of risk factors - Age >19 years - Gradual onset - Symptoms <6 weeks' duration - Frequent and painful micturition

Answer 67

Common - Unilateral scrotal pain - Tenderness - Hot - Erythematous - Swollen hemiscrotum Uncommon - Pyrexia - Fluctuant swelling or induration of scrotal tissue - Enlarged or tender prostate

Answer 68

1st line: - Gram stain of urethral secretions - >5 WBC per oil immersion field, intracellular gram-negative diplococci - Urine dipstick test - positive leukocyte esterase tests shown as colour change on the reagent strip - Urine microscopy - >10 WBC per high-power field - Urine culture - Isolate of causative organism - NAAT (nucleic acid amplification test) of urethral secretions or first-void urine - Chalmydia trachomatis, Neisseria gonorrhoea, Mycoplasma genitalium DNA / RNA detected - Culture of urethral secretions - positive culture for N.gonorrhoea Consider: - Colour duplex US - epididymis is enlarged, hyperaemic, low-resistance monophasic arterial waveform pattern, good for localising areas of inflammation - Surgical exploration - oedematous epididymis with vascular congestion and evidence of surrounding inflammatory reaction, with no evidence of testicular torsion - 3 early morning urine samples for acid-fast bacilli staining, culture and NAAT - may be positive - HIV test - may be positive - Syphilis test - may be positive

Answer 69

BACTERIAL INFECTION - Abx - Supportive measures - paracetamol or naproxen or ibuprofen NB: Abx Gonorrhoea / Chlamydia suspected - ceftriaxone and doxycycline Gonorrhoea / Chlamydia suspected, Gonorrhoea likely - ceftriaxone, doxycycline and azithromycin Gonorrhoea / Chlamydia / Enteric organisms suspected - ceftriaxone, ofloxacin / levofloxacin Enteric organisms suspected - ofloxacin or levofloxacin M Genitalium suspected - moxifloxacin AMIODARONE-INDUCED - Discontinuation or dose reduction - Supportive measures - paracetamol or naproxen or ibuprofen UNDERLYING VASCULITIS - Specialist referral to rheumatologist - can be due to Behcet's Syndrome or Henoch-Schonlein purpura - Supportive measures - paracetamol or naproxen or ibuprofen IDIOPATHIC OR VIRAL - Supportive measures - paracetamol or naproxen or ibuprofen TB - Anti-TB antibiotics - guidelines! - Specialist referral - Supportive measures - paracetamol or naproxen or ibuprofen

Answer 70

- Scrotal abscess and pyocele - Testicular infarction - Fertility problems - Testicular atrophy - Cutaneous fistulization from rupture of abscess through tunica vaginalis - Recurrence, chronic epididymitis and orchialgia

Answer 71

Most epididymitis cases clear up within 3 months. However, more invasive treatment may be needed in some cases. If an abscess has formed on the testicles, your doctor can drain the pus using a needle or with surgery. Surgery is another option if no other treatments have been successful.

Answer 72

A pandemic infectious disease whose impact on societies is without precedent. AIDS - develops over 10-15 years.

Answer 73

Caused by a retrovirus that infects and replicates in human lymphocytes and macrophages, eroding the integrity of the human immune system over a number of years, culminating in immune deficiency and a susceptibility to a series of opportunistic and other infections as well as the development of malignancies. Most people are infected through sexual contact, before birth or during delivery, during breastfeeding, or when sharing contaminated needles and syringes. Risk Factors: - Needle sharing with IV drug use - Unprotected receptive anal intercourse - Unprotected receptive penile-vaginal sexual intercourse - Percutaneous needle stick injury - High maternal viral load - mother to child transmission - Use of progestin-only injectable contraceptives - HSV-2 infection

Answer 74

1.7 million people were newly infected in 2018.

Answer 75

- Presence of risk factors - Fevers - Night sweats - Weight loss - Skin rashes - Post-inflammatory scars - Oral ulcers - Angular cheilitis - Oral thrush - Oral hairy leukoplakia - Diarrhoea - Wasting syndrome - Changes in mental status or neuropsychiatric function - Recent hospital admissions - TB - Medical comorbidities - Sexual activity - Generalised lymphadenopathy - Kaposi's sarcoma - Genital STIs - Chronic vaginal candidiasis - Shingles - Headaches - Periodontal disease - Retinal lesions on fundoscopy - SOB - Cyanosis - Dry cough - Silent chest - Peripheral neuropathy - Hepatomegaly or splenomegaly - Meningeal signs (bacterial or viral meningitis)

Answer 76

- Presence of risk factors - Fevers - Night sweats - Weight loss - Skin rashes - Post-inflammatory scars - Oral ulcers - Angular cheilitis - Oral thrush - Oral hairy leukoplakia - Diarrhoea - Wasting syndrome - Changes in mental status or neuropsychiatric function - Recent hospital admissions - TB - Medical comorbidities - Sexual activity - Generalised lymphadenopathy - Kaposi's sarcoma - Genital STIs - Chronic vaginal candidiasis - Shingles - Headaches - Periodontal disease - Retinal lesions on fundoscopy - SOB - Cyanosis - Dry cough - Silent chest - Peripheral neuropathy - Hepatomegaly or splenomegaly - Meningeal signs (bacterial or viral meningitis)

Answer 77

1st Line: - Serum HIV ELISA - Serum HIV rapid test - HIV non-invasive tests - Serum Western blot - Serum p24 antigen - Serum HIV DNA PCR - CD4 count - CD4 count of >500 cells/mL: patients are usually asymptomatic; CD4 count of <350 cells/mL: implies substantial immune suppression; CD4 count <200 cells/microlitre: defines AIDS and places the patient at high risk of most opportunistic infections - Serum viral load (HIV RNA) - Drug resistance testing - Pregnancy test - Serum hep B serology - Serum hep C serology - Serum venereal disease research lab test - positive if syphilis infection - Treponema pallidum haemagglutination test - positive if syphilis infection - Rapid plasma reagin - positive if syphilis infection - Tuberculin skin test - FBC with differential - anaemia, thrombocytopenia - Serum electrolytes - Serum creatinine - Urinalysis - proteinuria (renal disease), leukocytes and nitriles (UTI) Consider: - CXR - Pneumocystis jirovecii pneumonia: interstitial to extensive alveolar shadowing; TB: many abnormalities possible including apical fibrosis/scarring, pleural effusion, hilar adenopathy, miliary pattern, lobar or patchy opacification; bacterial pneumonia: lobar or patchy opacification - LFTs - Random of fasting lipid profile - ART high levels - Random or fasting plasma glucose - ART high levels - Hep A serology (IgG) - Toxoplasma serology (IgG) - Gonorrhoea and Chalmydia testing - HLA-B*5701 testing

Answer 78

Localised infection with pus collection in breast tissue. 2 main forms - puerperal (lactational) and non-puerperal.

Answer 79

Lactational: - Milk stasis associated with infection - Most commonly with Staphylococcus aureus, coagulase-negative staphylococci Non-Puerperal: - Staphylococcus aureus and anaerobes - Enterococci or Bacteroides spp. - TB and actinomycosis - more rare - Smoking, mammary duct ectasia / periductal mastitis, associated inflammatory breast cancer excluded - Associated with wound infections after breast surgery, diabetes and steroid therapy

Answer 80

Lactational breast abscesses are common and tend to occur soon after starting breast-feeding and on weaning, when incomplete emptying of the breast results in stasis and engorgement. Non-lactational abscesses are more common in those aged 30-60 years and in smokers.

Answer 81

The patient complains of discomfort and development of a painful swelling in an area of the breast. She may complain of feeling unwell and feverish. Women with a non-puerperal abscess often have a history of previous infections, systemic upset is often less pronounced.

Answer 82

Local - Area of breast is swollen, warm and tender - Overlying skin inflammation - Cracks or fissures in nipple - Non-puerperal cases - evidence of scars or tissue distortion, or signs of duct ectasia (e.g. nipple retraction) Systemic - Pyrexia - Tachycardia

Answer 83

- USS | - Aspiration for microscopy, culture and sensitivity of pus samples

Answer 84

Medical - Early, cellulitic phase treated with antibiotics - flucloxacillin for lactational, +metronidazole in non-puerperal - Breast drainage regularly to prevent milk stasis Surgical Lactational - Daily needle aspiration with antibiotic cover - Formal incision and drainage for >5cm - Cosmetically acceptable and ensures full drainage - Loculi explored and broken down - Wound may be packed lightly and left open, with daily packing, or primary closure performed - Breastfeeding should continue from the non-affected breast and the affected side emptied either manually or with a breast pump - Advice on avoided cracked nipples Non-puerperal - Open drainage should be avoided - Carried out through small incision - Definitive treatment carried out once infection has settles by the excision of the involved duct system

Answer 85

- Slow wound healing - Difficulties in breastfeeding - Poor cosmetic outcome - Mammary fistula formation - Overlying skin undergoes necrosis

Answer 86

- Untreated, it will eventually point and spontaneously discharge onto the skin surface - Non-puerperal abscesses tend to recur

Answer 87

It is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 10^9/L or lower.

Answer 88

Causes: - Cytotoxic chemotherapy - temporary reduction in production of blood cells (5-10 days after chemotherapy neutrophils are at their lowest, recover 5 days later) - Drugs - azathioprine, methotrexate, sulfasalazine, adalimumab, infliximab - Stem cell transplantation - Infections - Bone marrow disorders such as aplastic anaemia and myelodysplastic syndromes - Nutritional deficiencies - Autoimmune Risk factors: - People receiving high-intensity chemotherapy regimens - People undergoing haematopoietic stem cell transplantations - Age - >60yrs - Chemotherapy - Corticosteroids - Antibiotics - Advanced maliganncy - History of previous febrile neutropenia - Prolonged hospital admission - Previous surgery - DM - Liver disease - Renal disease - Poor nutritional status - CV access device - TPN - risk of invasive fungal infection

Answer 89

Rate of increase of deaths is higher for 15-24 year old age group, lower for >80 age group.

Answer 90

- Neutrophil count <0.5 x 10^9/L - Temperature >38 degrees - Chills and shvering - Tachycardia - Tachypnoea - Clammy - Cold - Pale or mottled skin - Dizziness - Confusion - Disorientation - Slurred speech - Diarrhoea - N&V

Answer 91

- Neutrophil count <0.5 x 10^9/L - Temperature >38 degrees - Chills and shvering - Tachycardia - Tachypnoea - Clammy - Cold - Pale or mottled skin - Dizziness - Confusion - Disorientation - Slurred speech - Diarrhoea - N&V

Answer 92

Take blood tests and microbiology samples including: - Blood gas including glucose and lactate measurement — hypoglycaemia may result from depleted glycogen stores; hyperglycaemia may result from the stress response to sepsis; hyperlactataemia is a non-specific indicator of cellular or metabolic stress and is a marker of illness severity, with a higher level predictive of higher mortality rates. - Blood culture — ideally done before antibiotic administration. - Full blood count — white cell count may be high or low; thrombocytopenia may indicate disseminated intravascular coagulation (DIC), but may also be chemotherapy- or tumour-related. - C-reactive protein (CRP) — may indicate infection and/or inflammation. - Creatinine, urea and electrolytes — may indicate dehydration and/or acute kidney injury. - Liver function tests — increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction, and may be chemotherapy-induced. - Clotting screen — if abnormal may indicate coagulopathy/DIC. - Urine analysis and culture, sputum microscopy and culture, chest X-ray, and additional investigations such as chest CT or bronchoalveolar lavage may be indicated if there is severe or prolonged neutropenia. This may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.

Answer 93

Inflammation of the leptomeningeal (pia mater and arachnoid) coverings of the brain, most commonly caused by infection. Aseptic meningitis - characterised by clinical and laboratory evidence for meningeal inflammation and negative routine bacterial culture Mollaret's meningitis - recurrent benign lymphocytic meningitis

Answer 94

Bacterial - Neonates - Group B streptococci, Escherichia coli, Listeria monocytogenes - Children - Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae - Adults - Neisseria meningitidis (meningococcus), Streptococcus pneumonia, tuberculosis - Elderly - Streptococcus pneumoniae, Listeria monocytogenes Viral - Enteroviruses - Mumps - HSV - VZV - HIV Fungal - Cryptococcus - associated with HIV infection Aseptic Meningitis - Enterovirus, mycobacteria, fungi, spirochetes - Autoimmune - e.g. Sarcoidosis, Behcet's disease, Systemic lupus erythematosus - Malignancy - lymphoma, leukaemia, metastatic carcinomas - Medication - NSAIDs, trimethoprim, azathioprine Mollaret's Meningitis - 50% exhibit transient neurological manifestations - HSV-2 - Large granular plasma cells on Papnicolaou's stain, PCR for HSV DNA - Treat with acyclovir Risk Factors: - Close communities - e.g. dormitories - Basal skull fractures - Mastoiditis - Sinusitis - Inner ear infections - Alcoholism - Immunodeficiency - Splenectomy - Sickle cell anaemia - CSF shunts - Intracranial surgery

Answer 95

Variation according to geography, age, social conditions. UK Public Health Laboratory Service receives approx 2500 notifications / year. Recent visitors to Haj (meningococcal serogroup W135). Epidemics occur in the meningitis belt of Africa (meningococcal serogroup A).

Answer 96

- Severe headache - Photophobia - Neck or backache - Irritability - Drowsiness - Vomiting - High-pitched crying or fits (common in children) - Clouding of consciousness - Fever Check travel and exposure history: - Rodents - lymphocytic choriomeningitis virus - Ticks - Lyme borrelia, Rocky Mountain spotted fever - Mosquitoes - West Nile virus, St. Louis encephalitis virus - Sexual activity - HSV-2, HIV, syphilis - Travel - C.immitis, A.cantonensis - Contact with other individuals with vrial exanthems - enteroviruses

Answer 97

Signs of Meningism: - Photophobia - Neck stiffness - Kernig's sign - with hips flexed, pain / resistance on passive knee extension - Brudzinski's sign - flexion of hips on neck flexion Signs of Infection - Fever - Tachycardia - Hypotension - Skin rash - petechiae with meningococcal septicaemia - Altered mental state

Answer 98

1. Bloods 2. Imaging 3. Lumbar Punctre 4. viral 5. TB Bloods - 2 sets of blood cultures - do not delay antibiotics Imaging - CT scan to exclude a mass lesion or raised intracranial pressure before LP - LP may lead to cerebral herniation due to subsequent CSF removal - CT head before LP in patents with immunodeficiency, history of CNS disease, reduced consciousness, fit, focal nerologic deficit, papilloedema LP - Note opening CSF pressure - Send for microscopy with culture, sensitivity, Gram staining, biochemistry, cytology - Streptococcus pneumoniae - Gram-positive diplococcic - Neisseria Meningitidis - gram-negative diplococcic Bacterial - Cloudy CSF - Increased neutrophils - Increased protein - Reduced glucose - CSF serum glucose ratio of <0.5 Virus - Increased lymphocytes - Increased protein - Normal glucose TB - Fibrinous CSF - Increased lymphocytes - Increased protein - Reduced glucose Staining of petechiae scrapings may detect meningococcus in 70%. Additional studies - e.g. viral PCR, staining / culture for mycobacteria and fungi, HIV test depending on the clinical presentation / CSF findings.

Answer 99

1. IMMEDIATE ANTIBIOTICS IV or IM - If meningitis suspected before lumbar puncture or CT - 3rd generation cephalosporin - cefotaxime 2g QDS or ceftriaxone 2g BD - Benzylpenicillin - initial blind therapy, sensitive meningococci and pneumococci - Listeria = amoxicillin + gentamicin - Penicillin & Cephalosporin resistant pneumococci = + vancomycin + rifampicin - History of anaphylaxis to penicillin or cephalosporins = chloramphenicol - Patients treated with benzylpenicillin or chloramphenicol = 2 days rifampicin (eliminate nasopharyngeal carriage) 2. DEXAMETHASONE IV - 10mg QDS for 4 days - Given shortly before or with first dose of antibiotics - Continue in pneumococcal or H. influenzae meningitis - reduce complications of death (pneumococcal) and hearing loss (H.influenzae) - Avoid dexamethasone if HIV suspected 3. RESUSCITATION - ITU 4. PREVENTION - Notify public health services - Consult a consultant in communicable disease control for advice regarding chemoprophylaxis - e.g. rifampicin for 2 days - Vaccination for close contacts - Vaccination against meningococcal serogroups A and C (none for B)

Answer 100

- Septicaemia - Shock - DIC - Renal failure - Fits - Peripheral gangrene - Cerebral oedema - Cranial nerve lesions - Cerebral venous thrombosis - Hydrocephalus - Water house - Friderichsen Syndrome - bilateral adrenal haemorrhage

Answer 101

Bacterial meningitis mortality at 10-40% with meningococcal sepsis. In developing countries - higher mortality rate Viral meningitis - self-limiting

Answer 102

Acute inflammation and necrosis of cardiac muscle = myocardium.

Answer 103

Infection: - Viruses - e.g. Coxackie B, echovirus, EBV, CMV, adenovirus, influenza - Bacterial - e.g. post-streptococcal, tuberculosis, diptheria, Lyme disease - Fungal - e.g. candidiasis - Protozoal - e.g. trypanosomiasis (Chagas disease) - Helminths - e.g. thrichinosis Non-infective: - Systemic disorders - e.g. SLE, sarcoidosis, polymyositis - Hypersensitivity myocarditis - e.g. sulphonamides Drugs: - Chemotherapy agents - e.g. doxorubicin, streptomyocin - Cocaine abuse - Heavy metals - Radiation

Answer 104

Unknown. Many cases not detected at time of acute illness. Europe & USA - Coxsackie B virus SA - Chagas disease.

Answer 105

- Prodromal 'flu-like' illness - Fever - Malaise - Fatigue - Lethargy - Breathlessness - pericardial effusion, myocardial dysfunction - Sharp chest pain - suggesting associated pericarditis

Answer 106

Signs of concurrent pericarditis or complications - e.g. heart failure, arrhythmia.

Answer 107

1) Blood 2) ECG 3) CXR 4) Pericardial fluid drainage 5) Echocardiography 6) Myocardial biopsy Bloods - FBC - high WCC in infective causes - U&E - High ESR or CRP - Cardiac enzymes high - Antistreptolysin O titre, ANA, serum ACE, TFT - viral or bacterial serology ECG - Non-specific T wave and ST changes - Widespread saddle-shaped ST elevation in pericarditis CXR - Normal - Cardiomegaly - Pulmonary oedema Pericardial fluid drainage - Glucose - Protein - Cytology - Culture - Sensitivity Echocardiography - Systolic / diastolic function - Wall motion abnormalities - Pericardial effusion Myocardial Biopsy - Rarely required - Result does not influence management

Answer 108

A parasitic infection caused by protozoa of the genus Plasmodium.

Answer 109

5 species infect humans. - Plasmodium falciparum (or P. falciparum) - Plasmodium malariae (or P. malariae) - Plasmodium vivax (or P. vivax) - Plasmodium ovale (or P. ovale) - Plasmodium knowlesi (or P. knowlesi) Naturally transmitted to humans through a bite by an infected female Anopheles mosquito, potentially transmitted by blood transfusion or organ transplantation. Widely distributed throughout tropical and subtropical regions. Travellers account for the majority of disease in Western countries. Risk factors: - Travel to endemic area - Inadequate or absent chemoprophylaxis - Insecticide-treated bed net not used in endemic area - Settled migrants returning from travel to endemic area of origin - Iron administration (children) Risk factors for SEVERE DISEASE: - Low host immunity - Pregnancy - Age < 5 years - Immunocompromise - Older age

Answer 110

Malaria is a major health problem in Africa, Asia, Central America, Oceania, and South America. About 40% of the world's population lives in areas where malaria is common. Approximately 300-500 million cases of malaria occur every year, and 1-2 million deaths occur, most of them in young children.

Answer 111

- Presence of risk factors for acquiring malaria - Presence of risk factors for severe disease - Fever or history of fever - Headache - Weakness - Myalgia - Arthalgia - Anorexia - Diarrhoea - Seizures - N&V - Abdominal pain - Pallor - Hepatosplenomegaly - Jaundice - Altered level of consciousness - Hypotension - Anuria / oliguria - Influenza-like respiratory symptoms

Answer 112

- Presence of risk factors for acquiring malaria - Presence of risk factors for severe disease - Fever or history of fever - Headache - Weakness - Myalgia - Arthalgia - Anorexia - Diarrhoea - Seizures - N&V - Abdominal pain - Pallor - Hepatosplenomegaly - Jaundice - Altered level of consciousness - Hypotension - Anuria / oliguria - Influenza-like respiratory symptoms

Answer 113

1st Line: - Giemsa-stained thick and thin blood smears - detection of asexual or sexual forms of parasites inside erythrocytes - Rapid diagnostic tests (RDTs) - detection of parasite antigen or enzymes - FBC - thrombocytopenia, anaemia, variable WCC - Clotting profile - PT prolonged - Serum electrolytes, urea and creatinine - normal or mildly impaired, renal failure in severe infection - Serum LFTs - elevated bilirubin, elevated aminotransferases - Serum blood glucose - hypoglycaemia, hyperglycaemia - Urinalysis - moderate protein, urobilinogen, conjugated bilirubin - ABG - metabolic acidosis or lactic acidosis (severe) Consider: - PCR blood for malaria - detection of parasites at very low levels - CXR - pneumonia, pulmonary oedema, ARDS - Blood culture - no abnormal growth (search for other causes) - Urine culture - no abnormal growth (search for other causes) - Sputum culture - no abnormal growth (search for other causes ) - Lumbar puncture - exclude bacterial meningitis, sometimes CSF lactate elevated - HIV test - may be positive (more severe malaria in presence of HIV) - PCRT nasopharyngeal swabs for influenza - negative in malaria - CT head - usually normal - Loop-mediated isothermal amplification - detection of parasites at very low levels

Answer 114

A life-threatening subcutaneous soft-tissue infection that may extend to the deep fascia, but not into the underlying muscle.

Answer 115

Can be aerobic, anaerobic or mixed flora. TYPE 1 - Polymicrobial infection - Anaerobe - e.g. Bacteroides or Peptostreptococcus - Facultative anaerobe - e.g. Enterobacterales, non-group A streptococcus TYPE 2 - Monomicrobial infection - E.g. Streptococcus pyogenes (group A strep) Specific Risk Factors: - Freshwater exposure - Aeromonas hydrophila - Saltwater exposure or consumption of raw oysters - Vibrio vilnificus General Risk Factors: - Inpatient contact with index case - Varicella zoster infection - Cutaneous injury - Surgery - Trauma - Non-traumatic skin lesions - IV drug use - Chronic illness - Immunosuppression - NSAIDs

Answer 116

The number of cases reported for necrotizing fasciitis in adults is 0.40 cases per 100,000 people/year while the incidence in children is reportably higher at 0.08 cases per 100,000 people/year. Necrotizing fasciitis is considered a rare condition, however, the mortality rate remains high.

Answer 117

- Presence of risk factors - Anaesthesia or severe pain over site of cellulitis - Fever - Palpitations - Tachycardia - Tachynpnoea - Hypotension - Lightheadedness - N&V - Delirium - Crepitus - Vesicles or bullae - Grey discolouration of skin - Oedema or induration - Location of lesion

Answer 118

- Presence of risk factors - Anaesthesia or severe pain over site of cellulitis - Fever - Palpitations - Tachycardia - Tachynpnoea - Hypotension - Lightheadedness - N&V - Delirium - Crepitus - Vesicles or bullae - Grey discolouration of skin - Oedema or induration - Location of lesion

Answer 119

1st Line: - FBC and differential - abnormally high or low WBC count with or without a left shift, high % of polymorphonuclear leukocytes - Serum electrolytes - LOW sodium - Serum urea and creatinine - HIGH - Serum CRP - HIGH - Serum creatinine kinase - HIGH - Serum lactate - HIGH - Blood and tissue cultures - indicates polymicrobial or monomicrobial aetiology - Gram stain - ABG - hypoxaemia, acidosis - Radiography, CT/ MRI, US Scan - oedema extending along fascial plan and/or soft tissue gas - Surgical exploration - necrotising soft-tissue infection

Answer 120

An inflammatory condition of bone caused by an infecting organism, most commonly Staphylococcus aureus.

Answer 121

Usually involves single bone, but rarely affects multiple sites. Occurs in peripheral or axial skeleton. Stage on the aetiology of infection, pathogenesis, extent of bone involvement, duration and host factors particular to the individual patients. Either haematogenous or contigous-focus. Risk factors: - Previous osteomyelitis - Penetrating injury - IV drug misuse - Diabetes - HIV infection - Recent surgery - Distant or local infections - Sickle cell anaemia - RA - CKD - Immunocompromising conditions - URTI - Varicella infection

Answer 122

The annual incidence of osteomyelitis was less than eleven cases per 100,000 person-years until the sixth decade of life. Thereafter, incidence rates increased steeply with age, corresponding to a roughly 50% increase in incidence per decade of life.

Answer 123

- Risk factors - Limp or reluctance to weight-bear - Non-specific pain at site of infection - Malaise and fatigue - Local back pain associated with systemic symptoms - Paravertebral muscle tenderness and spasm - Local inflammation, tenderness, erythema or swelling - Fever - Spinal cord or nerve root compression - Wound drainage, acute or old healed sinuses - Scars, previous flaps, fracture fixation - Reduced range of movement - Reduced sensation in diabetic foot infection - UTI symptoms - Torticollis - Skin or other infections, recent episodes of Staphylococcus aureus bloodstream infection, indwelling catheter - Limb deformity - Tenderness to percussion - Meningitis

Answer 124

- Risk factors - Limp or reluctance to weight-bear - Non-specific pain at site of infection - Malaise and fatigue - Local back pain associated with systemic symptoms - Paravertebral muscle tenderness and spasm - Local inflammation, tenderness, erythema or swelling - Fever - Spinal cord or nerve root compression - Wound drainage, acute or old healed sinuses - Scars, previous flaps, fracture fixation - Reduced range of movement - Reduced sensation in diabetic foot infection - UTI symptoms - Torticollis - Skin or other infections, recent episodes of Staphylococcus aureus bloodstream infection, indwelling catheter - Limb deformity - Tenderness to percussion - Meningitis

Answer 125

1st Line: - FBC - HIGH WCC - ESR - HIGH - CRP - HIGH - Blood culture - may be positive, indicating infecting organism and microbial sensitivities - Plain XR of affected area Results of XR - ACUTE DISEASE - Initially normal - Osteopenia 6-7 days after infection onset - Evidence of bone destruction, cortical breaches and periosteal reaction - Involucra and sequestra sometimes seen - Diffuse osteopenia developing later due to disuse of affected limb - Joint effusion in local joints Results of XR - DISCITIS - Lacteral spin radiographs show late changes at 2-3 weeks into illness - Decreased intervertebral space - Erosion of vertebral plate Results of XR - VERTEBRAL OSTEOMYELITIS: - Localised rarefication (thinning) of vertebral body - Anterior bone destruction later on Results of XR - CHRONIC DISEASE - Intramedullary scalloping - Cavities - Cloacae seen - Fallen leaf sign when a piece of endosteal sequestrum detached and fallen into medullary canal Consider: - Bone samples and bone biopsy - positive, other pathology shown - PCR - MALDI-TOF mass spectrometry - match reference strains - Swabs - Urine microscopy, culture and sensitivities - Histology 0 infecting organisms, acute or chronic inflammatory cells, dead bone, active bone resorption, small sequestra, malignancy - Probe-to-bone test - may reach bone, rule in osteomyelitis in high-risk patient with diabetes - Bone MRI - high signal on T2 images, fat suppression sequences, changes in children within 3-5 days of onset, vertebral bone changes - US - collections, subperiosteal abscesses, adjacent joint infusions - CT scan - bone destruction, sequestra, abscess - Radionuclide scan - increased uptake of radioactive injectate in infected sites - Bone scintigraphy - hot spots of infection, positive 24hrs after onset - Echocardiogram - valvular vegetations - CXR - show primary or reatcive TB - Mantoux test - positive for Mycobacteruim TB

Answer 126

Inflammation of the pericardium, may be acute, subacute or chronic.

Answer 127

- Idiopathic - Infective - commonly Coxsackie B, echovirus, mumps virus, streptococci, fungi, staphylococci, TB - Connective tissue disease - e.g. sarcoid, SLE, scleroderma - Post-myocardial infarction (24-72h) in up to 20% of patients - Dressler's Syndrome (weeks to months after acute MI) - Malignancy ( lung, breast, lymphoma, leukaemia, melanoma) - Metabolic (myxoedema, uraemia) - Radiotherapy - Thoracic surgery - Drugs - e.g. hydralazine, isoniazid

Answer 128

Uncommon Clinical incidence <1 in 100 hospital admissions. More common in males.

Answer 129

Chest pain: - Sharp - Central - Radiates to neck and shoulders - Aggravated by coughing, deep inspiration, lying flat - Relieved by sitting forward - Dyspnoea - Nausea

Answer 130

- Fever - Pericardial friction rub - best heard lower left sternal edge, with patient leaning forward in expiration - Heart sounds may be faint in the presence of an effusion Cardiac tamponade: - High JVP (Bell's Triad) - Low BP (^^) - Muffled heart sounds (^^) - Tachycardia - Pulsus paradoxus - Reduced SBP by >10mmHg on inspiration Constrictive Pericarditis (Chronic): - High JVP with inspiration - Kussmaul's sign - Pulsus paradoxus - Hepatomegaly - Ascites - Oedema - Pericardial knock - rapid ventricular filing - AF

Answer 131

1) ECG 2) Echocardiogram 3) Bloods 4) CXR ECG - Widespread ST elevation that is saddle shaped Echocardiogram - Assess pericardial effusion and cardiac function Bloods - FBC - U&E - ESR - CRP - Cardiac enzymes - normal - Blood cultures - ASO titres - ANA - Rheumatoid factor - TFT - Mantoux test - Viral serology CXR - Normal - globular heart shadow if 250mL effusion - Pericardial calcification can be seen in constrictive pericarditis - best seen on lateral CXR or CT

Answer 132

- Acute - cardiac tamponade treated by emergency pericardiocentesis - Medical - treat underlying cause, NSAIDs for relief of pain and fever - Recurrent - low-dose steroids, immunosuppressants or colchicine - Surgical - excision of pericardium in constrictive pericarditis

Answer 133

- Pericardial effusion - Cardiac tamponade - Cardiac arrhythmia

Answer 134

Depends on underlying cause Good prognosis in viral cases - recovery within 2 weeks Poor in malignant pericarditis Recurrent - particularly in those caused by thoracic surgery

Answer 135

An inflammatory multisystem disorder, occurring following group A B-haemolytic streptococci (GAS) infection.

Answer 136

Unknown. Streptococcal pharyngeal infection required. Genetic susceptibility. Molecular mimicry - role in the initiation of tissue injury - e.g. antibodies directed against GAS antigens cross-react with host antigens

Answer 137

5-15 years - peak incidence Far East, Middle East, Easter Europe, South America Mean incidence 19/100,000 . Reduction in incidence in West, non-Western countries incidence is relatively high.

Answer 138

- 2-5 weeks after GAS infection - Fever - Malaise - Anorexia - Painful, swollen joints - Reduced movement and function - Breathlessness - Chest pain - Palpitations

Answer 139

- Duckett Jones Criteria - positive diagnosis if at least 2 major criteria, or one major plus 2 minor criteria Major Criteria: - Arthritis - migratory or fleeting polyarthritis with swelling, redness, tenderness of large joints - Carditis - new murmur (Carey Coombs murmur - mid-diastolic murmur due to mitral valvulitis), pericarditis, pericardial effusion or rub, cardiomegaly, cardiac failure, ECG changes - Chorea - rapid, involuntary, irregular movements with flowing or dancing quality, slurred speech (more common in females) - Nodules - small, firm, painless, subcutaneous nodules on extensor surfaces, joints and tendons - Erythema Marginatum (20%) - transient erythematous rash with raised edges, seen on trunk and proximal limbs (cresent or ring-shaped patches) Minor Criteria - Pyrexia - Previous rheumatic fever - Arthralgia - only if arthritis is not present as major criteria - Recent streptococcal infection - supported by positive throat cultures or high antitreptolysin O titre - High ESR, CRP orWCC - High PR and QT intervals on ECG - if carditis not present as major criteria

Answer 140

1. Bloods 2. Throat swab 3. ECG 4. Echocardiogram Bloods - FBC - raised WCC - ESR/CRP - raised ESR, CRP - Raised antitreptolysin O titre Throat Swab - Culture for GAS - Rapid streptococcal antigen test ECG - Saddle shaped ST elevation - PR segment depression - Arrhythmias (signs of pericarditis) Echocardiogram - Pericardial effusion - Myocardial thickening or dysfunction - Valvular dysfunction

Answer 141

Inflammation of the peritoneum, caused by bacterial infection either via the blood or after rupture of an abdominal organ. E.g. Perforation of peptic ulcer, duodenal ulcer, diverticulum, appendix, bowel, gallbladder Spontaneous bacterial peritonitis - seen in patients with cirrhosis, and is an infection of ascitic fluid that can't be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition

Answer 142

Due to bacterial infection Risk factors: - Decompensated hepatic state - Low ascitic protein / complement - GI bleeding - Endoscopic sclerotherapy for oesophageal varices

Answer 143

The prevalence of SBP in patients with cirrhosis and ascitis at the time of hospital admission ranges from 10-27%.

Answer 144

- Prostration - the action of lying stretched out on the ground - Ascites - Fever - Shock - Lying still - +ve cough test - Tenderness- with/without rebound / percussion pain - Board-like abdominal rigidity - Guarding - No bowel sounds - Erect CXR may show gas under the diaphragm - Hypothermia - Hypotension - Tachycardia

Answer 145

NB: Always check serum amylase as acute pancreatitis also shows these symptoms!

Answer 146

NB: Always check serum amylase as acute pancreatitis also shows these symptoms! - Ascitic fluid lab tests - cell count, culture - Urine - look at leukocyte esterase - Defined by ascitic fluid absolute neutrophil count >250cells/mm^3 - Ascitic fluid pH and asterial blood PH - Ascitic fluid protein, glucose, lactate dehydrogenase - Bloos - FBC, creatinine

Answer 147

- Antibiotics - beware of local resistance patterns - If sepsis, history of fluoroquinolone prophylaxis, nosocomial-acquired SBP, history of previous infections with resistant organisms --> broader initial empirical coverage - Albumin indicated in renal dysfunction patients - Continuous antibiotic prophylaxis if ascitic fluid protein concentration <15g/L or previous episode of SBP

Answer 148

- Dehydration - Sepsis - Multiple organ infection / failure - Hepatic encephalopathy - Hepatorenal syndrome - liver disease leading to increasing renal failure - Shock - Death

Answer 149

Depends on underlying cause or how rapidly the patient is effectively treated, especially for infectious bacteria. Ranges from good (appendicitis) to poor (hepatorenal syndrome).

Answer 150

Infection of the distal lung parenchyma. Categories: - Community-acquired, hospital-acquired or nosocomial - Aspiration pneumonia, pneumonia in the immunocompromised - Typical and atypical - e.g. Mycoplasma, Chlamydia, Legionella

Answer 151

Community-Acquired: - Streptococcus pneumonia (70%) - COPD = Haemophilus influenzae & Morazella catarrhalis - Contract with Birds/Parrots = Chlamydia pneumonia & Chlamydia psittaci - Periodic epidemics = Mycoplasms pneumonia - Anywhere with air con = Legionella - Recent influenza infection, IV drug users = Staphylococcus aureus - Q Fever, rare = Coxiella burnett - TB = may present as pneumonia Hospital-Acquired: - Gram-negative enterobacteria = Pseudomonas, Klebsiella - Anaerobes = aspiration pneumonia Risk Factors: - Age - Smoking - Alcohol - Pre-existing lung disease - Immunodeficiency - Contact with pneumonia

Answer 152

Incidence 5-11 in 1000 (25-44 in 1000 in elderly) | Community-acquired causes >60,000 deaths/year in UK

Answer 153

- Fever - Rigors - Sweating - Malaise - Cough - Sputum (yellow, green or rusty in S pneumoniae) - Breathlessness - Pleuritic chest pain - Confusion - severe cases,elderly, Legionella Atypical Pneumonia: - Headache - Myalgia - Diarrhoea - Abdominal Pain

Answer 154

- Pyrexia - Respiratory distress - Tachypnoea - Tachycardia - Hypotension - Cyanosis - Reduced chest expansion - Dullness to percussion - Increased tactile vocal fremitus - Bronchial breathing - inspiration phase lasts as long as the expiration phase - Coarse crepitations on the affected side - Chronic suppurative lung disease (e.g. empyema, abscess): Clubbing

Answer 155

1. Bloods 2. CXR 3. Sputum 4. Urine 5. Atypical Viral Serology 6. Bronchoscopy & Bronchoalveolar Lavage Bloods - FBC - abnormal WCC - U&E - low Na+, especially with Legionella - LFT - Blood cultures - sensitivity 10-20% - ABG - to assess pulmonary function - Blood film - RBC agglutination by Mycoplasma caused by cold agglutinins CXR - Lobar or patchy shadowing - Pleural effusion - Klebsiella - often seen in upper lobes - Repeat 6-8 weeks - if abnormal suspect underlying pathology Sputum/Pleural Fluid - Microscopy - Culture & sensitivity - Acid-fast bacilli Urine - Pneumococcus antigens - Legionella antigens Atypical Viral Serology - Increased antibody titres between acute and convalescent samples - greater than 2 weeks post onset Bronchoscopy - If Pneumocystis carinii pneumonia is suspected - When pneumonia fails to resolve - When there is clinical progression

Answer 156

1. Assess Severity - see prognosis, if >1 feature presents the manage in hospital 2. Start Empirical Antibiotics - Oral amoxicillin (0 markers) - Oral or IV amoxicillin and erythromycin (1 marker) - IV cefuroxime / cefotaxime / co-amoxiclav and erythromycin (>1 marker) - Add metronidazole, if aspiration, lung abscess or empyema suspected - Switch to the appropriate antibiotic as per sensitivity NB: Levofloxacin and moxifloxacin can provide useful alternatives in selected hospitalized patients with community-acquired pneumonia. 3. Supportive Treatment - Oxygen - maintain PO2 > 8kPa, start with 28% O2 in COPD to avoid hypercapnia - Parenteral fluids for dehydration or shock - Analgesia - Chest physiotherapy - CPAP, BiPAP or ITU care for respiratory failure - Surgical drainage may be needed for empyema / abscess 4. Discharge Planning - Presence of two or more features of clinical instability predict a significant chance of re-admission or mortality - Raised temperature, heart rate, respiratory rate - Low BP, oxygen saturation, mental status and oral intake 5. Non-Resolving Pneumonia - Consider other causes Causes of Non-Resolving Pneumonia - Unusual pathogens - e.g. Chlamydia psittaci, C.burnetti, Mycobacterium tuberculosis, Nocardia, Actinomyces israeli, fungi (Aspergillus, histoplasmosis, coccidioidomycosis, blastomycosis) - PE - Malignancy - e.g. bronchogenic carcinoma, bronchoalveolar cell carcinoma, lymphoma - Inflammatory - e.g. vasculitis, Wegener's granulomatosis, sarcoidosis, systemic lupus erythematosus - Congestive heart failure - Drug toxicity - Diffuse alveolar hemorrhage - Bronchiolitis obliterans-organizing pneumonia - Eosinophilic pneumonia - Acute interstital pneumonia - Pulmonary alveolar proteinosis 6. Prevention - Pneumococcal & H.influenzae type B vaccination in vulnerable groups - E.g. elderly, splenectomized

Answer 157

- Pleural effusion - Empyema (pus in the pleural cavity) - Localized superation leading to lung abscess - seen by Staphyloccoal, Klebsiella pneumonia, presenting with swinging fever, persistent pneumonia, copious / foul-smelling sputum - Septic shock - ARDS - Acute renal failure M.Pneumonia - Erythema multiforme - Myocarditis - Haemolytic anaemia - Meningoencephalitis - Transverse myelitis - Guillian-Barre Syndrome

Answer 158

Most resolve with treatment (1-3 weeks). High mortality of severe pneumonia - Community-acquired - 5-10% - Hospital-acquired - 30% - 50% of those in ITU Markers of Severe Pneumonia (CURB-65 Score) C = Confusion U = Urea >7mmol/L R = RR >30/min B = BP - Systolic <90mmHg, Diastolic <60mmHg Age >65 years. Other markers are: - Hypoxia <8kPa - ECC <4 or >20 x 10^9 /mm^3 - Age >50 years

Answer 159

The infection of 1 or more joints caused by pathogenic inoculation of microbes. Occurs either by direct inoculation or haematogenous spread.

Answer 160

Regard a hot, swollen, acutely painful joint with restriction of movement as septic arthritis until proven otherwise, even in the absence of fever and irrespective of microbiology and blood test results. Risk factors: - Underlying joint disease - Prosthetic joint - Age - Immunosuppression - Contiguous spread - Exposure to ticks - Previous intra-articular corticosteroid injection - Recent joint surgery - Low socioeconomic status

Answer 161

The estimated incidence of septic arthritis in developed countries is 6 cases per 100,000 population per year. In patients with underlying joint disease or with prosthetic joints the incidence increases approximately 10-fold, to 70 cases per 100,000 of the population.

Answer 162

- Hot - Swollen - Painful - Restricted - Acute presentation - Fever - Large joint - Prosthetic joint - Single joint affected - Symptoms are out of proportion to elsewhere disease activitiy - Sexual activity - gonoccocal septic arthritis may present with polyarthralgia localising over one joint, fever, chills and skin lesions - Erythema migrans - Risk factors present

Answer 163

- Hot - Swollen - Painful - Restricted - Acute presentation - Fever - Large joint - Prosthetic joint - Single joint affected - Symptoms are out of proportion to elsewhere disease activitiy - Sexual activity - gonoccocal septic arthritis may present with polyarthralgia localising over one joint, fever, chills and skin lesions - Erythema migrans - Risk factors present

Answer 164

1st Line: - Synovial fluid microscopy, Gram stain and polarising microscopy - ?micro-organisms, urate or pyrophosphate crystals - Synovial fluid culture and sensitivities - Synovial fluid WCC - Blood culture and sensitivities - WCC - elevated - ESR - elevated - CRP - elevated - U&E - assess for sepsis and end-organ damage - LFTs - assess for sepsis and end-organ damage - Plain X-Ray - reveals degenerative changes or chondrocalcinosis (not diagnostic for septic arthritis) - USS - presence of effusion to guide aspiration Consider: - Procalcitonin (PCT) - raised >0.5ng/mL more specific marker for bacterial infection than CRP, ESR or WCC - MRI - ?associated osteomyelitis - PCR - Swabs for microscopy, culture and sensitivity - Urine dipstick - organisms on microscopy, WCC, blood - ELISA - Synovial biopsy - ? myobacterium tuberculosis, fungi - Calprotectin - high

Answer 165

An acute infection of the parenchyma of the palatine tonsils. DOES NOT INCLUDE TONSILLITIS AS PART OF INFECTIOUS MONONUCLEOSIS.

Answer 166

Difficult to distinguish clinically from viral pharyngitis. The most common bacterium causing tonsillitis is Streptococcus pyogenes (group A streptococcus), the bacterium that causes strep throat. Other strains of strep and other bacteria also may cause tonsillitis. Risk factors: - Age between 5-15 years - Contact with infected people in enclosed spaces - e.g. child care centres, schools, prison

Answer 167

The incidence of tonsillitis is not completely known, research indicates that 15-30% of sore throats in children and 5-10% sore throats in adults are bacterial tonsillitis.

Answer 168

- Presence of risk factors - Pain on swallowing - Sudden onset of sore throat - Headache - Abdominal pain - Nausea & vomiting

Answer 169

- Fever - >38 degrees - Tonsillar exudate (purulent), especially in Group A B-haemolytic streptococci - Abdominal pain - may lead to false diagnosis of gastroenteritis - Presence of cough or runny nose - Tonsillar erythema - Tonsillar enlargement - Enlarged anterior cervical lymph nodes especially in Group A B-haemolytic streptococci

Answer 170

CENTOR CRITERIA Centor criteria (fever >38.5°C, swollen, tender anterior cervical lymph nodes, tonsillar exudate and absence of cough) are an algorithm to assess the probability of group A β haemolytic Streptococcus (GABHS) as the origin of sore throat, developed for adults. 1st line: - Throat culture (48hr delay) - Rapid streptococcal antigen test - identifies Group A Beta-haemolytic streptococci (GABHS) 2nd line: - Serological testing for streptococci - x4 increase in Anti-streptolysin O (ASO), anti-deoxyribonuclease B or other antibody titres (hyaluronidase, streptokinase, nicotinic acid dehydrogenase) - WBC count and differential - raised neutrophil (bacterial infection) / lymphocytes count (infectious mononucleosis) - Heterophile antibodies - Vaginal and cervical, or penile and rectal cultures - positive culture (Thayer-Martin medium) for Neisseria gonorrhoea - HIV viral load assay - in high-risk patients with persistent infection and severe constitutional symptoms (malaise, tiredness, weight loss, generalised lymphadenopathy) - Lateral cervical view X-ray, exposed for soft tissue - enlarged retropharyngeal and posterior oropharyngeal soft tissue

Answer 171

Granulomatous disease caused by Mycobacterium tuberculosis. Primary - Initial infection may be pulmonary (acquired by inhalation from cough of the infected patient) or occasionally, gastrointestinal Miliary TB - Results when there is hematogenous dissemination Post-Primary - Caused by re-infection or reactivation

Answer 172

M.tuberculosis is an intracellular organism - AKA acid-fast bacilli Survives after being phagocytosed by macrophages.

Answer 173

Annual mortality of 3 million. 95% in developing countries UK incidence annually 6000 Asian immigrants >30 times native UK white population incidence

Answer 174

Primary TB - Asymptomatic - Fever - Malaise - Cough - Wheeze - Erythema nodosum - Phlyctenular conjunctivitis (allergic manifestations) Miliary TB - Fever - Weight loss - Meningitis - Yellow caseous tubercles spread to other organs - e.g. bone and kidney may remain dormant for years Post-Primary TB - Fever - Night sweats - Malaise - Weight loss - Breathlessness - Cough - Sputum - Haemoptysis - Pleuritic pain - Signs of pleural effusion - Collapse - Consolidation - Fibrosis Non-Pulmonary TB - Particularly in immunocompromised Lymph Nodes - Suppuration of cervical lymph nodes leading to abscesses or sinuses, which discharge pus and spread to skin = scrofuloderma CNS - Meningitis - Tuberculoma Skin - Lupus vulgaris - jellylike reddish-brown glistening plaques Heart - Percardial effusion - Constrictive pericarditis Gastrointestinal - Subacute obstruction - Change in bowel habit - Weight loss - Peritonitis - Ascites Adrenal - Insufficiency Bone/Joints - Osteomyelitis - Arthritis - Paravertebral Abscesses - Vertebral collapse - Pott's disease - Spinal cord compression from abscesses

Answer 175

Primary TB - Asymptomatic - Fever - Malaise - Cough - Wheeze - Erythema nodosum - Phlyctenular conjunctivitis (allergic manifestations) Miliary TB - Fever - Weight loss - Meningitis - Yellow caseous tubercles spread to other organs - e.g. bone and kidney may remain dormant for years Post-Primary TB - Fever - Night sweats - Malaise - Weight loss - Breathlessness - Cough - Sputum - Haemoptysis - Pleuritic pain - Signs of pleural effusion - Collapse - Consolidation - Fibrosis Non-Pulmonary TB - Particularly in immunocompromised Lymph Nodes - Suppuration of cervical lymph nodes leading to abscesses or sinuses, which discharge pus and spread to skin = scrofuloderma CNS - Meningitis - Tuberculoma Skin - Lupus vulgaris - jellylike reddish-brown glistening plaques Heart - Percardial effusion - Constrictive pericarditis Gastrointestinal - Subacute obstruction - Change in bowel habit - Weight loss - Peritonitis - Ascites Adrenal - Insufficiency Bone/Joints - Osteomyelitis - Arthritis - Paravertebral Abscesses - Vertebral collapse - Pott's disease - Spinal cord compression from abscesses

Answer 176

1. Sputum / Pleural Fluid /Bronchial Washings - microscopy, culture (6 weeks), low sensitivity 2. Tuberculin Tests - positive in previous exposure, strongly positive = infection (and not BCG) 3. Mantoux Test - intradermal injection of PPD, induration and erythema after 72h 4. Heaf Test - place drop of PPD on forearm, fire spring-loaded needled gun, read after 3-7 days, graded according to papule size and vesiculation 5. Interferon-Gamma Tests - latent TB, esposure of host T-cells to TB antigens causes release of interferon (negative with BCG vaccination) 6. CXR - Primary infection - peripheral consolidation, hilar lymphadenopathy - Miliary - fine shadowing - Post-primary - upper lobe shadowing, streaky fibrosis, cavitation, calcification, pleural effusion, hilar lymphadenopathy 7. HIV Testing - to co-incident disease (2% may be HIV positive) 8. CT, Lymph Nodes, Pleural Biopsy, Sampling of Other Affected Systems

Answer 177

A skin condition consisting of erythematous, blanching, oedematous, non-painful, pruritic lesions that develop rapidly, usually over minutes. Typically lasts less than 24hours and leaves no residual skin markings upon resolutions. Acute episodes - period of less than 6 weeks, caused by specific stimulus and are self-limiting. Chronic episodes - period of over 6 weeks, not attributable to a specific stimulus.

Answer 178

Acute: - Lasts less than 6 weeks - Hypersensitivity reaction to a specific trigger - Viral infections Chronic : - Daily or near-daily episodes of hives occuring for 6 weeks or more - Complex aetiology Risk Factors: - Positive family history - Female sex - Exposure to drug or food trigger - Recent viral infection - Recent insect bite or sting

Answer 179

A recent studies reported that the lifetime prevalence of all types of urticaria was 8.8% to 10.8%, with a female predominance and a mean age of 35 to 39 years. Angio-oedema - swelling involving the deeper layers of the subdermis and occurs in association with urticaria in 40% of cases. Involves face and neck, potentially compromise airway.

Answer 180

- Pruritus - unpleasant sensation of the skin that provokes the urge to scratch - Resolution in 24 hours - Swelling of face, tongue or lips - Erythematous oedematous lesions - Blanching lesions - Stridor

Answer 181

- Pruritus - unpleasant sensation of the skin that provokes the urge to scratch - Resolution in 24 hours - Swelling of face, tongue or lips - Erythematous oedematous lesions - Blanching lesions - Stridor

Answer 182

- FBC - normal, eosinophilia, neutrophilia - ESR - elevated or normal - CRP - elevated or normal - C4 - decreased in hereditary and acquired angio-oedema - TSH - elevated or normal - ANA - anti-nuclear antibodies - positive in rheumatological disease - Skin prick testing - may be positive - Allergen avoidance diet - Serum tryptase - Skin biopsy - C1 esterase inhibitor level and function, C1q levels - Specific IgE to suspected allergen

Answer 183

Primary infection is called vaircella (chicken pox). Reactivation of the dormant virus in the dorsal root ganglia, causes zoster (shingles).

Answer 184

- Herpes ds-DNA virus - Highly contagious - Transmission by aerosol inhalation or direct contact with vesicular secretions Viral inhalation and infection of the URT. Replication in regional lymph nodes, liver and spleen. Week 2-3 - spreads to skin, producing rash and then leading to clinical resolution. Remains latent in dorsal root ganglia. Reactivation causes virus to travel down sensory axon to produce dermatomal shingles rash.

Answer 185

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

Answer 186

- Incubation period 14-21 says Chicken Pox: - Prodromal malaise - Mild pyrexia - Sudden appearance of an intensely itchy spreading rash - Affecting the face and trunk more than the extremities, the oropharynx, conjunctivae, genitourinary tract - Vesicles weep and crust over, forming new vesicles - Contagious from 48h before the rash and until all the vesicles have crusted over - within 7-10 days Shingles: - May occur after a period of stress - Tingling / hyperaesthesia in a dermatomal distribution - Painful skin lesions - Recovering in 10-14 days

Answer 187

Chicken Pox: - Macular papular rash - Evolves into crops of vesicles - Areas of weeping and crusting - Skin excoriation - from scratching - Mild pyrexia Shingles: - Vesicular macular papular rash - Dermatomal distribution - Skin excoriation

Answer 188

Both chickenpox and shingles usually clinical diagnosis. Vesicle Fluid - Electron microscopy - Direct immunofluorescence - Cell culture - Viral PCR - all rarely necessary Chicken Pox - Consider HIV testing - Especially in adults with prior history of varicella infection

Answer 189

Chicken Pox: - Children - treat symptoms with calamine lotion, analgesia, antihistamines - Adults - consider aciclovir, valaciclovir, famciclovir if within 24h of rash onset especially if elderly, smoker, immunocompromised or pregnant Shingles: - Aciclovir, valaciclovir, famciclovir if within 72h of rash onset if elderly, immunocompromised or ophthalmic involvement - Low-dose amitriptyline if in moderate / severe discomfort - Simple analgesia (paracetamol) Prevention: - VZIG may be indicated in immunosuppressed and pregnant women exposed to varicella zoster - Chickenpox vaccine licensed in the UK, but no guidelines avaliable for appropriate use

Answer 190

Chicken Pox: - Secondary infection - Scarring - Pneumonia - Encephalitis - Cerebellar syndrome - Congenital varicella syndrome Shingles: - Postherpetic neuralgia - Zoster opthalmicus - rash involves ophthalmic division of Trigeminal Nerve (CN V) - Ramsay Hunt's Syndrome - reactivation in geniculate ganglion causing zoster of the ear and facial nerve palsy (vesicles behind pinna of ear or in canal) - Sacral zoster may lead to urinary retention - Motor zoster - muscle weakness of myotome at the similar level as involved dematome

Answer 191

Depends on complications. Worse in pregnancy, elderly and immunocompromised.

Answer 192

Hepatitis caused by infection with the RNA viruses, hepatitis A (HAV) and hepatitis E virus (HEV), that follow an acute course without progression to chronic carriage.

Answer 193

``` HAV = picornavirus HEV = calcivirus ``` - Small - Non-enveloped - Single-stranded - Linear - RNA viruses - Transmission by faecal-oral route - Replicate in hepatocytes - Secreted into bile - Immune responses causes liver inflammation and hepatocyte necrosis = CD8+ T-cells, NK cells - Inflammatory cell infiltration of poral tracts = neutrophils, macrophages, eosinophils, lymphocytes - Zone 3 necrosis - Bile duct proliferation

Answer 194

HAV - Endemic in developing world, infection occurs sub-clinically - Better sanitation in developed world - age of exposure increases = more likely to be symptomatic 5000 cases (5% seroprevalence). HEV - Endemic in Asia, Africa and Central America

Answer 195

Incubation period of 3-6 weeks. Prodromal Period - Malaise - Anorexia - distate for cigarettes in smokers - Fever - Nausea - Vomiting Hepatitis - Dark urine - Pale stools - Jaundice lasting 3 weeks - Itching & prolonged jaundice in HAV - due to cholestatic hepatitis

Answer 196

- Pyrexia - Jaundice - Tender hepatomegaly - Palpable spleen in 20% - Absence of stigmata of chronic liver disease - Few spider naevi transiently

Answer 197

1. Bloods 2. Viral Serology 3. Urinalysis Bloods - LFT - High AST and ALT, High bilirubin, High AlkPhos - High ESR - Low albumin - High platelets Viral Serology - Hep A - anti-HAV IgM (during acute illness, disappears after 3-5 months), anti-HAV IgG (recovery phase, lifelong persistence) - Hep E - anti-HEV IgM (high 1-4 weeks after onset), anti-HEV IgG - Hep B & C - rule out Urinalysis - +ve for bilirubin - High urobilinogen

Answer 198

- No specific management - Bed rest and symptomatic treatment - e.g. antipyretic, antiemetics - Colestyramine for severe pruritis Prevention: - Public health - e.g. safe water, sanitation, food hygiene, notifiable disease, personal hygiene, sensible dietary precautions when travelling - Immunization (HAV) - passive IM human immunoglobulin effective for short period, active attenuated HAV vaccine for travellers, high-risk individuals

Answer 199

- Fulminant hepatic failure - 0.1% HAV cases, 1-2% HEV cases, 20% if pregnant - Cholestatic hepatitis with prolonged jaundice and pruritis after HAV infection - Post-hepatitis syndrome - continued malaise for weeks-months

Answer 200

3-6 weeks recovery Relapse during recovery occasionally No chronic sequelae Fulminant hepatic failure has 80% mortality

Answer 201

Hepatitis caused by infection with hepatitis B virus (HBV), which may follow an acute or chronic (defined as viraemia and hepatic inflammation continuing >6 months) course. Hepatitis D virus (HDV), a defective virus, may only co-infect with HBV or superinfect persons who are already carriers of HBV.

Answer 202

HBV - Enveloped - Partially double-stranded DNA virus - Sexual contact, blood and vertical transmission - Viral proteins produced - e.g. HBcAg, HBsAg, HBeAG = core, surface and e antigens HDV - Single-stranded RNA virus - Coated with HBsAG = surface antigen Antibody and cell-mediated immune responses to viral replication lead to liver inflammation and heptocyte necrosis. Mild-severe inflammation. Changes of cirrhosis. Risk Factors: - IV drug abuse - Unscreened blood and blood products - Infants of HBeAg-positive mothers - Sexual contact with HBV carrier - Younger individuals more likely to develop chronic carriage - Genetic factors - higher rates of viral clearance

Answer 203

Common 350 million worldwide infected with HBV 1-2million deaths annually Common in SE Asia, Africa, Mediterranean countries HDV found worldwide HBV uncommon in UK

Answer 204

- Incubation period of 3-6 months - 1-2 week prodrome - malaise, headache, anorexia, N&V, diarrhoea, RUQ pain - Serum-sickness-type illness - e.g. fever, arthralgia, polyarthritis, urticaria, maculopapular rash - Jaundice - Dark urine - Pale stools Recovery usually within 4-8 weeks - 1% may develop fulminant liver failure Chronic carriage diagnosed after routine LFT testing or if cirrhosis or decompensation develops.

Answer 205

Acute - Jaundice - Pyrexia - Tender hepatomegaly - Splenomegaly - Cervical lymphadenopathy (10-20%) - Urticaria - Maculopapular rash Chronic - No findings - Signs of chronic liver disease or decompensation

Answer 206

1. Viral Serology 2. PCR 3. LFT 4. Clotting 5. Liver biopsy Viral Serology - Acute - HBsAg positive, IgM anti-HBcAg - Chronic - HBsAg positive, igG anti-HBcAg, HBeAg positive or negative - HBV cleared or immunity - anti-HBsAg positive, IgG anti-HBcAg - HDV infection - detected by IgM or IgG against HDV PCR - Detection of HBV DNA - most sensitive measure LFT - High AST, ALT - High bilirubin - High AlkPhos Clotting - High PT in severe disease Liver Biopsy - Percutaneous - Transjugular if clotting is deranged or ascites present

Answer 207

Prevention: - Passive immunization - HepB immunoglobulin (HBIG) - if acute exposure, neonates born to HBeAg-positive mothers - Active immunization - recombinant HBsAg vaccine - individuals at risk, neonates born to HBV-positive mothers, also protects against HDV Acute HBV Hepatitis: - Symptomatic treatment - e.g. bed rest, antiemetics, antipyretics, cholestyramine for pruritis - Notification of communicable disease Chronic HBV Heptaitis: - Indications for treatments with anti-virals = HBeAg-positive, HBeAg negative chornic hepatitis (dependents on ALT, HBV DNA), compensated cirrhosis and HBV DNA >2,000 IU/mL, decompensated cirrhosis and detectable HBV DNA by PCR - Interferon alpha - high half life - Nucleoside/nucleotide analogues - watch out for drug resistance - e.g. adefovir, entecavir, telbivudine, tenofovir, lamivudine Interferon Alpha - Cytokine - Augments natural antiviral mechanisms - SE: flu-like symptoms, fevers, chills,myalgia, headaches, bone marrow suppression, bone marrow depression

Answer 208

- Fulminant hepatic failure - 1% - Chronic HBV infection (10% adults, higher in neonates) - Cirrhosis - Hepatocellular carcinoma - Extrahepatic immune complex disorders- e.g. glomerulonephritis, polyarteritis nodosa - Superinfection with DHV --> acute liver failure

Answer 209

10% of infections become chronic 20-30% of those will develop cirrhosis Factors of good response to inferferon: - High serum transaminases - Low HBV DNA - Active histological changes - Absence of complicating disease

Answer 210

Hepatitis caused by infection with Hepatitis C (HCV), often following a chronic course. (80% cases).

Answer 211

HCV - Small - Eneveloped - Single-stranded RNA virus - Flavivirus family Poor fidelity of replication High mutation rates Different HCV genotypes - quasi-species Transmission: - Parenteral route - Recipients of blood and blood products prior to blood screening - IV drug users - Non-sterile acupuncture - Tattooing - Haemodialysis - Health care workers - Sexual and vertical transmission uncommon - 1-5%, increased risk in those co-infected with HIV Pathology - Hepatotropic - Not directly hepatotoxic - Humoural and cell-mediated response leads to hepatic inflammation and necrosis - Liver biopsy - chronic hepatitis - Lymphoid follicles in portal tracts - Fatty changes - Features of cirrhosis Common 0.5-2% in developed countries. Higher in certain areas due to poor sterilisation practices. Different HCV genotypes have different geographical prevalence.

Answer 212

99% of acute infections = asymptomatic <10% jaundiced with flu-like illness Diagnosed after incidental abnormal LFT or in older individuals with complications of cirrhosis

Answer 213

No signs of chronic liver disease in long-standing infection Les common: - Skin rash - due to mixed cryoglobulinaemia causing a small-vessel vasculitis - Renal dysfunction - due to glomerulonephritis

Answer 214

1. Bloods 2. Liver Biopsy Bloods - HCV serology - anti-HCV antibodies (IgM acute, IgG past or chronic) - Reverse transcriptase PCR - detection of HCV RNA, confirm antibody testing - LFT - acute = high AST, ALT, chronic = 2-8x elevation of AST and ALT Liver biopsy - Assess degree of inflammation and liver damage as transaminase levels bear little correlation to histological changes - Diagnose cirrhosis - monitoring for hepatocellular carcinoma

Answer 215

Prevention - Screening of blood, blood products and organ donors - Needly exchange schemes for IV drug abusers - Instrument sterilization - No vaccine avaliable at present Medical Acute - No specific management and mainly supportive - e.g. anti-pyretics, anti-emetics, cholestyramine - Specific antiviral treatment delayed for 3-6 months Chronic - Combined treatment with pegylated interferon-alpha and ribavirin - Interferon-alpha = cytokine which auments natural antiviral mechanisms - Ribavirin = guanosine nucleotide analogue - HCV 1 or 4 = 24-48 weeks - HCV 2 or 3 = 12-24 weeks Monitoring of HCV load recommended after 12 weeks of treatment to determine efficacy of treatment. Regular ultrasound of liver may be necessary if the patient has cirrhosis.

Answer 216

- Fulminant hepatic failure in acute phase (0.5%) - Chronic HCV carriage - Cirrhosis - Hepatocellular carcinoma - Porphyria cuteanea tarda - Cryoglobulinaemia - Glomerulonephritis

Answer 217

80% of exposed progress to HCV chronic. | 20-30% of these develop cirrhosis over 10-20 years.

Answer 218

A systemic auto-immune disorder, characterised by keratoconjunctivitis sicca and xerostomia as a consequences of lymphocytic infiltration into the lacrimal salivary glands.

Answer 219

Primary - occurs alone Secondary - occurs along with another auto-immune disease - e.g. lupus, RA, systemic sclerosis Risk factors: - Female - SLE - RA - Systemic sclerosis (scleroderma) - HLA Class I markers - Age peaks in 20-30s and after menopause - Genetic inheritance

Answer 220

Sjogren syndrome is far from a rare disorder with an incidence approaching approximately one-half of that of rheumatoid arthritis (RA) or affecting 0.5% to 1.0% of the population. Between 400,000 and 3.1 million adults have Sjögren's syndrome.

Answer 221

- Dry eyes - keratoconjunctivitis sicca - Dry mount - xerostomia - Dryness of skin, nose, throat, vagina - Arthralgias - Myalgias - Peripheral neuropathies - Lymphoma - Fatigue - Vasculitis - Dental caries - Increased oral fungal and bacterial infections - Arthritis - Kidney disease - Corneal ulceration - No salvia pool - Enlarged salivary glands - Facial pain - Burning mouth syndrome - History of VTE - History of AA or dissection

Answer 222

- Dry eyes - keratoconjunctivitis sicca - Dry mount - xerostomia - Dryness of skin, nose, throat, vagina - Arthralgias - Myalgias - Peripheral neuropathies - Lymphoma - Fatigue - Vasculitis - Dental caries - Increased oral fungal and bacterial infections - Arthritis - Kidney disease - Corneal ulceration - No salvia pool - Enlarged salivary glands - Facial pain - Burning mouth syndrome - History of VTE - History of AA or dissection

Answer 223

1st Line: - Schirmer's test - positive (filter paper placed in lower conjunctival sac, less than 5mm of paper is wetted after 5 mins) - Anti-60 kD (SS-A) Ro and anti-La (SS-B) - positive Consider: - Sialometry - decreased - Minor salivary gland biopsy - focus score 1 or greater - Lissamine green test - score of 3 or more - Fluorescein corneal staining test - score of 3 or more - Parotid sialography - gross distortion of the normal pattern of parotid ductules coupled with significant retention of contrast material - Salivary gland Technetium-99m pertechnetate scintigraphy - decreased uptake and secretion - Skin biopsy - focal and segmental transmural necrotising inflammation in a medium-sized vessel (i.e., a small or medium-sized artery) - Angiography - beading, aneurysm, or smooth, tapering vessel stenosi - Urinalysis - may show abnormal levels of phosphate, calcium, potassium, glucose due to renal tubular acidosis - Serum electrolytes - may show hypokalaemia with a normal anion gap; hyperchloraemic metabolic acidosis - MRI salivary glands - inflammation of salivary glands - US salivary glands - high salivary gland ultrasonography score

Answer 224

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

Answer 225

- Anti-nuclear antibodies + constitutional symptoms - Involves skin and joints - Serositis, nephritis, haematological cytopenias and neurological manifestations Risk factors: - Female sex - Age 15-45 years - African / Asian descent in Europe and US - Drugs - Sun exposure - Family history of SLE - Tobacco smoking

Answer 226

The reported prevalence of systemic lupus erythematosus (SLE) in the United States is 20 to 150 cases per 100,000 [1-3]. In women, prevalence rates vary from 164 (white) to 406 (African American) per 100,000 [2].

Answer 227

- Malar (butterfly) rash - Photosensitive rash - Discoid rash - Fatigue - Weight loss - Fever - Oral ulcers - Alopecia - Arthralgia / artritis - Fibromyalgia - Raynaud's phenomenon - Chest pain and SOB - Venous or arterial thrombosis - Hypertension - Signs of nephrosis (e.g. oedema) - Lymphadenopathy - Abdominal pain, vomiting or diarrhoea - Nose ulcers - Poorly localised proximal limb inflammatory pain with weakness - Dysrhythmias - e.g. tachycardia - Conduction defects or unexplained cardiomegaly - CNS signs - seizures, CNS abnormalities, cognitive defects, psychosis - Dysphagia

Answer 228

- Malar (butterfly) rash - Photosensitive rash - Discoid rash - Fatigue - Weight loss - Fever - Oral ulcers - Alopecia - Arthralgia / artritis - Fibromyalgia - Raynaud's phenomenon - Chest pain and SOB - Venous or arterial thrombosis - Hypertension - Signs of nephrosis (e.g. oedema) - Lymphadenopathy - Abdominal pain, vomiting or diarrhoea - Nose ulcers - Poorly localised proximal limb inflammatory pain with weakness - Dysrhythmias - e.g. tachycardia - Conduction defects or unexplained cardiomegaly - CNS signs - seizures, CNS abnormalities, cognitive defects, psychosis - Dysphagia

Answer 229

1st Line: - FBC and differential - anaemia, leukopenia, thrombocytopenia, pancytopenia - Activated PTT - anti-phospholipid antibody patients have prolonged PTT - U&E - high urea, high creatinine - ESR and CRP - high - Anti-nuclear antibodies, dsDNA, Smith antigen - positive - Urinalysis - haematuria, casts (red cell, granular, tubular or mixed), proteinuria - CXR - pleural effusion, infiltrates, cardiomegaly - ECG - exclude other causes Consider: - Blood and urine cultures - exclude infection - Antiphospholipid antibodies - positive - Coombs test - positive - 24-hour urine collection for protein or spot urine for protein/creatinine ratio - proteinuria - Complement levels - complement consumption - Creatinine phosphokinase - elevated - Plain XR of affected joints - inflammation, non-erosive arthritis - Renal USS - exclusion - Chest CT - lung fibrosis, effusions - PFT - restrictive pattern - Pleural aspiration - exudate - Brain MRI - white matter changes - Echocardiography - pericarditis, pericardial effusion, pulmonary hypertension - Skin biopsy - immune deposits at the dermal-epidermal junction on immunofluorescence or non-specific inflammation - Renal biopsy - immune deposits, mesangial hypercellularity, focal, segmental or global glomerulonephritis - TSH - exclusion

Answer 230

A multi-system, autoimmune disease, characterised by functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs, production of autoantibodies.

Answer 231

Unknown. 2 TYPES: - Limited cutaneous SSc - Diffuse cutaneous SSc Limit - less severe internal organ involvement, better prognosis Risk factors: - Family history - Immune dysregulation - e.g. positive ANA - Exposure to environmental substances and toxins - e.g. silica dust, solvents

Answer 232

Scholarly articles for epidemiology of systemic sclerosis Epidemiology of systemic sclerosis - ‎Nikpour - Cited by 114 Epidemiology of systemic sclerosis: incidence, … - ‎Barnes - Cited by 310 Epidemiology of systemic sclerosis (scleroderma) - ‎MEDSGER JR - Cited by 343 A 2019 epidemiology study reported that based on 39 publications, the prevalence of systemic sclerosis in Europe and North America was 7.2-33.9 cases per 100,000 individuals, with an annual incidence rate of 0.6-2.3 cases per 100,000 individuals. Systemic sclerosis is rare in the resident population of Japan and China.

Answer 233

- Raynaud;'s phenomenon - Digital pits or ulcers - Swelling of the hands and feet - Skin thickening - Loss of function of hands - Sclerodactyly - Heartburn reflux and dysphagia - Bloating - Faecal incontinence - Athralgias and myalgias - Abnormal nail-fold capillaroscopy - Telangiectasia - Subcutaneous calcinosis - Dyspnoea - Dry crackles at lung bases - Tendon friction rub - Abrupt onset moderate / marked hypertension - Fatigue - Dry cough - Decreased exercise tolerance - Weight loss - Inflammatory arthritis - Proximal muscular weakness (inflammatory myositis) - Synovitis - Increased accentuation of the pulmonic component of S2 heart sound - Signs of anaemia

Answer 234

- Raynaud;'s phenomenon - Digital pits or ulcers - Swelling of the hands and feet - Skin thickening - Loss of function of hands - Sclerodactyly - Heartburn reflux and dysphagia - Bloating - Faecal incontinence - Athralgias and myalgias - Abnormal nail-fold capillaroscopy - Telangiectasia - Subcutaneous calcinosis - Dyspnoea - Dry crackles at lung bases - Tendon friction rub - Abrupt onset moderate / marked hypertension - Fatigue - Dry cough - Decreased exercise tolerance - Weight loss - Inflammatory arthritis - Proximal muscular weakness (inflammatory myositis) - Synovitis - Increased accentuation of the pulmonic component of S2 heart sound - Signs of anaemia

Answer 235

1st Line: - Serum auto-antibodies - positive ANA - FBC - microcytic anaemia (GI bleed), microangiopathic haemolytic anaemia (MAHA) in scleroderma renal crisis - Urea and serum creatinine - high in scleroderma renal crisis - ESR and CRP - high - Urine microscopy - proteinuria, cells or casts in scleroderma renal crisis - Complete PFTs - spirometry, lung volumes and diffusing capacity measurement - interstitial lung disease = low FVC, low DLCO plus restrictive pattern , pulmonary hypertension, disproportionate drop in DLCO compared with FVC - ECG - cardiac involvement - Echocardiogram - pulmonary hypertension, rise in RVSP, pericardial effusion, RV or LV diastolic dysfunction present - CXR- interstitial lung disease (bi-basilar interstitial infiltrates), cardiomegaly, RHF - Barium swallow - diminished oesophageal peristalsis and gastroparesis, diminished muscle tone in lower oesophagus, reflux of barium, strictures Consider: - CT chest - interstitial lung disease (ground glass opacities, thickened interstitium, interstitial fibrosis), traction bronchiectasis, honey-combing - OGD + biopsy - oesophageal inflammation, ulceration, strictures, gastric antral vascular ectasia, Barrett's metaplasia, adenocarcinoma may be present - Serum muscle enzymes - elevated in scleroderma myopathy - Electromyogram /nerve conduction studies - inflammatory myositis - Muscle biopsy - inflammatory myositis

Answer 236

Inflammation of the thyroid gland, which can lead to over or under-production of thyroid hormones.

Answer 237

3 PHASES: - Thyrotoxic phase - inflamed, hyperthyroid - Hypothyroid phase - due to excessive previous release - Euthyroid phase - resumes normal hormone levels TYPES: - Hashimoto's Thyroiditis - anti-thyroid peroxidase antibodies, hypothyroid - Silent thyroiditis or painless thyroiditis - autoimmune, female - Post-partum thyroiditis - - Radiation induced thyroiditis - Subacute granulomatous thyroiditis (de Quervain's) - caused by viral infection, painful, 20-50yrs, high temperature, pain in neck, jaw or ear - Acute thyroiditis or suppurative thyroiditis - Drug-induced thyroiditis - e.g. amiodarone, interferons, lithium, cytokines Risk factors: - >60 years - Family history - Autoimmune disease - e.g. T1DM, coeliac - Treated previously with radioactive iodine or anti-thyroid medications

Answer 238

Studies in the United States and Western Europe report a prevalence of 1.2% in individuals aged 11-18 years. Approximately 25% of adults with type 1 diabetes have thyroiditis, about one half of whom have hypothyroidism. Approximately 10% of children with type 1 diabetes have antithyroid antibodies.

Answer 239

Hyperthyroidism: - Exopthalamos - Opthalmoplegia - Goitre - with bruit in Graves' - Tachycardia - Angina - AF - Systolic hypertension - Oligomenorrhoea - Diarrhoea - Sweaty, tremulous, warm hands - Proximal myopathy - Pretibial myxoedema (Graves') - Ankle swelling (heart failure) - Weight loss - Increased appetite - Heart intolerance - Anxiety - Irritability - Fast, fine tremor Hypothyroidism: - Periorbital oedema - Husky voice - Bradycardia - Carpal tunnel syndrome - Menorrhagia - Constipation - Low metabolic rate, weight gain - Sensitivity to cold - Lethargy - Mental impairment - Depression

Answer 240

Hyperthyroidism: - Exopthalamos - Opthalmoplegia - Goitre - with bruit in Graves' - Tachycardia - Angina - AF - Systolic hypertension - Oligomenorrhoea - Diarrhoea - Sweaty, tremulous, warm hands - Proximal myopathy - Pretibial myxoedema (Graves') - Ankle swelling (heart failure) - Weight loss - Increased appetite - Heart intolerance - Anxiety - Irritability - Fast, fine tremor Hypothyroidism: - Periorbital oedema - Husky voice - Bradycardia - Carpal tunnel syndrome - Menorrhagia - Constipation - Low metabolic rate, weight gain - Sensitivity to cold - Lethargy - Mental impairment - Depression

Answer 241

- TFTs - Antibodies - TPO (thyroid peroxidase antibodies) or TRAb (thyroid receptor stimulating antibodies) - ESR, CRP - USS - evaluate anatomy of thyroid gland, see if there's any nodules, change in blood flow or echotexture (intensity and density) - Radioactive iodine uptake (RAIU) - low in thyrotoxic phase

Answer 242

- Depends on the type, symptoms and phase of thyroiditis - Thyrotoxic phases may recover, go to euthyroid or hypothyroid - May be temporary of permenant - May not be necessary to treat symptoms in subacute, painless or post-partum - Thyroidal pain - NSAIDs, steroids - Anxiety symptoms - beta-blockers - Stop drugs inducing thyroiditis - Treat infection - Thyroid hormone replacement therapy for 6-12 months, or permenantly for Hashimoto's thyroiditis

Answer 243

- Goitre - Heart problems - Mental health issues - Myxoedema - Birth defects

Answer 244

In the case of Hashimoto's thyroiditis, the resulting hypothyroidism is generally permanent. People who develop subacute thyroiditis usually have symptoms for 1 to 3 months, but complete recovery of thyroid function can take up to 12 to 18 months. These people have about a 5 percent chance of developing a permanent condition of hypothyroidism. The time frame for recovery to a thyroid that functions normally for post-partum, silent or painless thyroiditis is also about 12 to 18 months. People with these conditions have about a 20 percent chance of developing permanent hypothyroidism.

Answer 245

Characterised by presence of >100,000 of colony-forming units per milllitre of urine. May affect bladder (cystitis), kidney (pyelonephritis) or prostate (prostatitis).

Answer 246

Transurethral ascent of normal colonic organisms. Escherichia coli Proteus mirabilis Klebsiella Enterococci (hospitals)

Answer 247

30% of women experience UTI at some point in their lives. 5% of pregnant women, 2% of non-pregnant women, 20% elderly living at home, 50% institutionalized elderly. Rare in children and young men (if present, suspect an underlying cause).

Answer 248

- Silent - asymptomatic bacteruria Cystitis: - Frequency - Urgency - Dysuria - pain on micturition - Haematuria - Suprapubic pain - Smelly urine Pyelonephritis (acute): - Feber - Malaise - Rigors - Loin / flank pain Prostatitis: - Fever - Low back / perineal pain - Irritative and obstructive symptoms - e.g. hesitancy, urgency, intermittency, poor stream, dribbling Elderly: - Malaise - Nocturia - Incontinence - Confusion Up to 30% of women with UTI symptoms may not have bacteruria.

Answer 249

May be asymptomatic. Cystitis: - Fever - Abdominal / suprapubic / loin tenderness - Bladder distension Pyelonephritis - Fever - Loin / flank tenderness Prostatitis: - Tender - Swollen prostate

Answer 250

MSU - Dipstick test - blood, protein, leucocytes, nitrites - Microscopy, culture and sensitivity - >10^5 colonies/mL indicates significant bacteriuria, but with UTI symptoms threshold becomes lower = women (>10^2/mL), men (>10^5/mL) - If there is sterile pyuria (pus cells with no organisms), consider if this may be partially treated UTI, tuberculosis stones, tumour, interstitial nephritis, renal papillary necrosis Imaging - Renal USS or IV urogram if women with frequent UTI and children/men

Answer 251

Cystitis: - Local microbiological polices - Commonly used: oral co-trimoxazole, trimethoprim, nitrofurantoin, amoxicilliin, ciprofloxacin (males) Pyelonephritis: - IV gentamicin, cefuroxime, ciprofloxacin Catheterized patients: - Obtain culture - Change catheter - Do not treat unless patient is symptomatic Prophylaxis: - High fluid intake - Regular micturation to keep bladder empty - Cranberry-based products reduced frequency of recurrence - Low-dose long-term (6-12 months) antibiotics if frequently having UTIs Surgical: - Rarely necessary - May be necessary for relief of any obstruction and removal of any renal calculi

Answer 252

- Renal papillary necrosis - in those with underlying renal disease - e.g. DM, stones - Renal / perinephric abscess - seen on renal USS - Pyonephritis - pus in palvicalyceal system - Gram-negative septicaemia

Answer 253

Mostly resolve with treatment. Among pregnant women, 20% develop acute pyelonephritis if not treated, however there is a high relapse rate.

Answer 254

Vasculitis - the inflammation and necrosis of blood vessels. Classification according to vessel size: - LARGE = Giant cell arteritis, Takayasu's aortitis - MEDIUM = Polyarteritis nodosa, Kawasaki's disease - SMALL = Churg-Strauss Syndrome, microscopic polyangiitis, Henoch-Schonlein purpura, Wegener's granulomatosis, mixed essential cryoglobinaemia, relapsing polychondritis Summary: Large = GCA, TA Medium - PN, KD Small = CSS, MP, HSP, WG, MEC, RP EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - Triad of tissue eosinophilia, granulomatous inflammation + vasculitis GRANULOMATOSIS WITH POLYANGIITIS (WG) - Triad of upper and lower respiratory tract involvement and pauci-immune glomerulonephritis MICROSCOPIC POLYANGIITIS - Ill-defined - Characterised by systemic, pauci-immune, necrotizing, small vessel vasculitis without evidence of necrotizing granulomatous inflammation POLYARTERITIS NODOSA - Necrotising inflammation of medium-sized or small arteries - Without glomerulonephritis or vasculitis in arterioles, capillaries or venules TAKAYASU'S ARTERITIS - Affects aorta and main branches - Can cause stenosis, occlusion and aneurysm formation GIANT CELL ARTERITIS / TEMPORAL ARTERITIS - Granulomatous inflammation of large arteries - Branches of external carotid artery - temporal artery most common

Answer 255

Unknown aetiology. ?Autoimmune origin. Immune complex deposition in vessel walls triggers classical complement activation and inflammation. EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - May have perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) directed against myeloperoxidase (MPO) - Risk factors - history of asthma, allergic rhinitis, sinusitis GRANULOMATOSIS WITH POLYANGIITIS (WG) - Anti-neutrophil cytoplasmic antibody (ANCA) - Common involvement of cutaneous, ocular, MSK and peripheral nervous system tissue - Small and medium vessels - Risk factors - genetic (HLA-DP, alpha-1-antitrypsin, proteinase 3, ANCA), infection with Staph aureus, environmental triggers (silica) MICROSCOPIC POLYANGIITIS - p-ANCA triggering neutrophil degranulation and endothelial injury - anti-MPO antibodies can cause necrotizing and crescentic glomerulonephritis POLYARTERITIS NODOSA - Only medium sized vessels - Risk factors - HBV, 40-60 yrs, hairy cell leukaemia, blood transfusion pre-HBV screening, HCV, male TAKAYASU'S ARTERITIS - Symptoms due to claudication and stroke - Diminished or absent pulses and hypertension is common - Risk factors - genetic predisposition, female, <40, Asian GIANT CELL ARTERITIS / TEMPORAL ARTERITIS - Unknown - Increasing age, genetic and ethnic background, infection - Associated with HLA-DR4 and HLA-DRB1

Answer 256

EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - 10.7-14 per million adults. No gender difference. GRANULOMATOSIS WITH POLYANGIITIS (WG) - Descriptive epidemiological studies carried out primarily in European countries estimate a prevalence of WG ranging from 24 to 157 per million and annual incidence rates from 3 to 14 per million MICROSCOPIC POLYANGIITIS Annual incidence of 3.6 cases per million persons. The prevalence is one to three cases per 100,000 population. POLYARTERITIS NODOSA Rare disease, with an incidence of about 3-4.5 cases per 100,000 population annually TAKAYASU'S ARTERITIS - Women - <40 yrs GIANT CELL ARTERITIS - 18 in 100,000 - M:F = 2-4:1 - 65-70 yrs

Answer 257

Features of All Disease: - General - fever, night sweats, malaise, weight loss - Skin - rash (vasculitic, purpuric, maculopapular, livedo reticularis) - Joint - arthralgia, arthritis - GI - abdominal pain, haemorrhage from mucosal ulceration, diarrhoea - Kidney - glomerulonephritis, renal failure - Lung - dyspnoea, cough, chest pain, haemoptysis, lung haemorrhage - CVS - pericarditis, coronary arteritis, myocarditis, heart failure, arrhythmias - CNS - mononeuritis multiplex, infarctions, meningeal involvement - Eyes - retinal haemorrhage, cotton wool spots EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - Asthma - Allergic rhinitis - Sinusitis - Eosinophilia GRANULOMATOSIS WITH POLYANGIITIS (WG) - Granulomatous vasculitis of upper and lower respiratory tract - Nasal discharge - Ulceration - Deformity - Haemoptysis - Sinusitis - Corneal thinning - Glomerulonephritis MICROSCOPIC POLYANGIITIS - Non-specific with multiple organs affected - Glomerulonephritis with no glomerular Ig deposits POLYARTERITIS NODOSA - Microaneurysms - Thrombosis - Infarctions (causing GI perforation) - Hypertension - Testicular pain TAKAYASU'S ARTERITIS - Constitutional upset - Head or neck pain - Tenderness over affected arteries - aorta and major branches - Dizziness - Fainting - Low peripheral pulses - Hypertension GIANT CELL ARTERITIS - Subacute onset, usually over a few weeks - Scalp and temporal tenderness - pain on combing hair - Jaw and tongue claudication - Blurred vision - Sudden blindness in one eye - amaurosis fugax - Malaise, low-grade fever, lethargy, weight loss, depression - Early morning pain and stiffness of the muscles of the shoulder and pelvic girdle - 40-60% of cases associated with PMR

Answer 258

Features of All Disease: - General - fever, night sweats, malaise, weight loss - Skin - rash (vasculitic, purpuric, maculopapular, livedo reticularis) - Joint - arthralgia, arthritis - GI - abdominal pain, haemorrhage from mucosal ulceration, diarrhoea - Kidney - glomerulonephritis, renal failure - Lung - dyspnoea, cough, chest pain, haemoptysis, lung haemorrhage - CVS - pericarditis, coronary arteritis, myocarditis, heart failure, arrhythmias - CNS - mononeuritis multiplex, infarctions, meningeal involvement - Eyes - retinal haemorrhage, cotton wool spots EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - Asthma - Allergic rhinitis - Sinusitis - Eosinophilia GRANULOMATOSIS WITH POLYANGIITIS (WG) - Granulomatous vasculitis of upper and lower respiratory tract - Nasal discharge - Ulceration - Deformity - Haemoptysis - Sinusitis - Corneal thinning - Glomerulonephritis MICROSCOPIC POLYANGIITIS - Non-specific with multiple organs affected - Glomerulonephritis with no glomerular Ig deposits POLYARTERITIS NODOSA - Microaneurysms - Thrombosis - Infarctions (causing GI perforation) - Hypertension - Testicular pain TAKAYASU'S ARTERITIS - Constitutional upset - Head or neck pain - Tenderness over affected arteries - aorta and major branches - Dizziness - Fainting - Low peripheral pulses - Hypertension GIANT CELL ARTERITIS - Swelling and erythema overlying the temporal artery - Scalp and temporal tenderness - Thickened non-pulsatile temporal artery - Low visual acuity

Answer 259

EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CSS) - FBC with differential - eosinophilia - ANCA - positive - CRP - high - ESR- high - Urea & creatinine - normal or high - Urinalysis - normal or abnormal (may show glomerulonephritis - haematuria, proteinuria, RBC casts) - PFT - reversible airway obstruction - CXR- interstitial infiltrates or nodules - Echo - left ventricular regional wall motion abnormlaities, intracardiac thrombus, pericardial effusion GRANULOMATOSIS WITH POLYANGIITIS (WG) - Urinalysis and microscopy - haematuria, proteinuria, dysmorphic RBC, RBC casts - CT chest - lung nodules, infiltrates - ANCA - cANCA, pANCA - FBC and differential - anaemia - Creatinine - high - ESR - high MICROSCOPIC POLYANGIITIS - ESR - high - CRP - high - FBC - anaemia - Creatinine - high - pANCA with MPO specificity - positive - Urinalysis - haematuria, proteinuria, RBC casts - If neuropathy, EMG may reveal sensorimotor peripheral neuropathy POLYARTERITIS NODOSA - CRP - high - ESR - high - FBC - normocytic anaemia, high WBC, high platelet - Complement - low - Creatinine - high or normal - Midstream urine - proteinuria (mild) or normal - LFTs - high liver enzymes - HBV - HbsAg positive and/or HbeAg positive - HCV - positive anti-HCV antibodies - Cryoglobulins - none - Blood culture - no growth - CK - normal or mildly elevated - ANCA - negative - ANA - negative - Anti-dsDNA - negative - RF - negative - Anti-CCP - negative - Lupus anticoagulant - negative - IgG antiphospholipid antibodies - negative - B2 glycoprotein - negative - Fibrinogen - normal or high - Conventional digital subtraction angiography - microaneurysms, vessel actasia, focal occlusive lesions in medium sized vessels - Echo - normal TAKAYASU'S ARTERITIS - ESR- >50mm/hr with active disease - CRP - high - CTA - segmental narrowing or occlusion, dilation of affected vessels, aortic aneurysms seen, thickening of vessel walls seen - MRA - segmental narrowing, occlusion or dilation of involved arteries, vessel wall inflammation GIANT CELL ARTERITIS - ESR - >50mm/hr - CRP - high - FBC - normochromic, normocytic anaemia, normal WBC, high platelet, mild leukocytosis - LFTs - AST, ALT, ALP mildly high - Temporal artery USS - wall thickening (halo sign), stenosis or occlusion - Temporal artery biopsy - granulomatous inflammation in 50% of cases, multinucleated giant cells present, inflammatory infiltrate focal and segmental - Aortic arch angiography - stenosis or occlusion of SC, axillary or proximal brachial arteries

Answer 260

SUSPECTED - No visual neurological symptoms - Prednisolone 4 weeks, taper over 6-12 months - Visual or neurological symptoms - Methylprednisolone pulse therapy 1g IV for 3 days CONFIRMED - Prednisolone - 4 weeks, taper over 6-12 months - Aspirin - 75mg OD oral - Osteoporosis prevention - Calcium Carbonate + Ergocalciferol + Alendronic Acid / Risedronate Sodium - Tocilizumab or Methotrexate

Answer 261

- Carotid artery or aortic aneurysms - Thrombosis - Recanalization or embolism to opthalamic artery - Visual disturbances - Amaurosis fugax - cannot see out of one or both eyes due to lack of blood flow to eyes - Sudden monoocular blindness

Answer 262

For most condition lasts for 2 years before complete remission.