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Year 3 > Infections > Flashcards

Infections Flashcards

Infections

1
Q

What is glandular fever also known as?

A

Infective mononucleosis

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2
Q

What is the most common cause of infective mononucleosis?

A

EBV

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3
Q

What proportion of people have had infective mononucleosis?

A

90-95% of world population

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4
Q

What is the classic triad of infective mononucleosis?

A

Lymphadenopathy
Pharyngitis
Fever

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5
Q

How is infective mononucleosis transmitted?

A 
EBV most commonly spread by saliva/ respiratory droplets. 
other bodily fluids:
Sexual transmission
Blood products 
 organ transplant
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6
Q

How may infective mononucleosis present?

A 
Fever 1-2 weeks
Hepatosplenomegaly (jaundice)
Pharyngitis (Tonsillar Exudates)
Lymphadenopathy (Posterior Cervical Nodes)
Photophobia, cough, fatigue, headache
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7
Q

What are the investigations for infective mononucleosis? What would you see?

A

FBC - Lymphocytosis (highest in week 2-3)
Blood film - Atypical lymphocytosis
Heterophile antibodies- Monospot test
EBV specific antibodies (high sensitivity)
Real time PCR - EBV DNA detection
Throat swab to exclude Group A Strep (Streptococcus pyogenes)

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8
Q

What are the three EBV specific antibodies measured?

A

EBV Viral capsid antigen (VCA) IgM
EBV VCA IgG
Epstein-Barr nuclear antigen (EBNA) appears 6-12 weeks after onset of symptoms

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9
Q

What EBV specific receptors will be seen in a healthy Pt without EBV?

A
  • ve VCA IgM
  • ve VCA IgG
  • ve EBNA IgG
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10
Q

What EBV specific receptors will be seen a Pt with early infective mononucleosis?

A

+ve VCA IgM

  • ve VCA IgG
  • ve EBNA IgG
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11
Q

What EBV specific receptors will be seen a Pt with acute infective mononucleosis?

A

+ve VCA IgM
+ve VCA IgG
-ve EBNA IgG

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12
Q

What EBV specific receptors will be seen a Pt with a history of infective mononucleosis?

A

-ve VCA IgM
+ve VCA IgG
+ve EBNA IgG

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13
Q

What is the management for a Pt with infective mononucleosis?

A

Supportive care - Paracetamol or Ibuprofen (anti inflammatory + analgesics)
Corticosteroids may be indicated for severe cases (e.g. haemolytic anaemia, severe tonsillar swelling, obstructive pharyngitis).

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14
Q

Why should you not give aspirin to children?

A

Risk of developing Reye’s syndrome

Causes swelling in the liver and brain

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15
Q

What are the two conditions caused by varicella zoster infections?

A 
Chicken pox (aka varicella)
Shingles (aka herpes zoster)
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16
Q

What are the characteristics of varicella?

A

Fever
Malaise
Generalised pruritic vesicular rash

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17
Q

What are the characteristics of herpes zoster?

A

Reactivation of VZV

Dermatomal distribution of rash

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18
Q

What are the risk factors for a VZV infection?

A

> 50 yrs or child
HIV +ve
Chronic corticosteroid use
aka any form of immunosuppression

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19
Q

What are the investigations for a VZV infection?

A

Clincial diagnosis

Can consider PCR, viral culture, ELISA

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20
Q

What is the management for varicella?

A

Supportive care
Paracetamol
Diphenhydramine (antihistamine)

Avoid aspirin and NSAIDs

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21
Q

What is the management for HSV ?

A

Antiviral therapy:
1st line- famciclovir/valaciclovir
2nd line- acyclovir

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22
Q

What are the complications of VZV? (MOPS)

A

Meningoencephalitis
Ocular complications
Peripheral nerve palsy
Spinal cord myelitis

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23
Q

What can a HSV1 infection cause?

A

Herpes labialis (cold sores)
Genital herpes
HSV encephalitis

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24
Q

What can a HSV2 infection cause?

A

Genital herpes

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25
Q

How may a HSV1 infection present?

A

Gingivostomatitis, cold sores – ulcers filled with yellow slough near the mouth
Herpetic whitlow – vesicle in finger
Eczema herpeticum – HSV infection on eczematous skin
Herpes simplex meningitis – rare, self-limiting
Systemic infection – fever, sore throat, lymphadenopathy, pneumonitis, and hepatitis
Herpes simplex encephalitis - fever, fits, headaches, odd behaviour, dysphasia, hemiparesis
keratoconjunctivitis: Epiphoria (watering eyes), photophobia

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26
Q

How may a HSV2 infection present in a male?

A 
Vesicles on shaft or glands
Proctitis with discharge
Rectal pain
Tenesmus
Constipation
Impotence
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27
Q

How may a HSV2 infection present in a female?

A 
Genital herpes (Chronic-life long) 
 flu-like prodrome
vesicles/papules around genitals, anus
Shallow ulcers
Urethral discharge
Dysuria 
Fever and malaise
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28
Q

What are the investigations for HSV infections?

A

Usually clinical diagnosis
Viral culture
HSV PCR

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29
Q

What type of virus is HIV caused by and what cells does it infect?

A

Retrovirus

Human lymphocytes/macrophages

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30
Q

What are the routes of HIV transmission?

A 
Sexual contact
Before birth
During delivery
Breast feeding
IVDU
Blood transfusion (rare)
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31
Q

What are the 3 stages of HIV infection?

A
  1. Primary- seroconversion (4-8 weeks)
  2. Asymptomatic (18 months –> 15yrs)
  3. AIDS-related complex (

Think 4 Fs- Flu –> Fine –> falling CD4 –> final crisis

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32
Q

What is the primary HIV stage?

A

Seroconversion:
4-8 weeks post infection
self-limiting – fever, night sweats, generalized lymphadenopathy, sore throat, oral ulcers, rash, myalgia, headache, encephalitis, diarrhoea

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33
Q

What is the asymptomatic HIV stage?

A

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

CD4 <400x10^6

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34
Q

What is the AIDS-related complex HIV stage?

A

Syndrome of secondary diseases reflecting severe immunodeficiency

…or direct effect of HIV infection

CD4 <200x10^6

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35
Q

What is the cause of oral candidiasis?

A

Fungal candida infection

Due to immunosuppression

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36
Q

What is the cause of hairy leukoplakia?

A

Triggered by EBV

Occurs in HIV-positive patients, organ transplant recipients.

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37
Q

What is the cause of Kaposi’s sarcoma?

A

HHV-8

AIDS-defining condition (opportunistic infections and cancers that are life-threatening in a person with HIV.)

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38
Q

What are the investigations for HIV?

A 
ELISA
Serum HIV rapid test
Sample buccal saliva
HIV PCR
CD4 count
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39
Q

What are some common pathogens that cause tonsillitis?

A 
Rhinovirus
Coronavirus
Adenovirus
Beta-haemolytic Strep (pyogenes)
Mycoplasma pneumoniae
Neisseria gonorrhoea
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40
Q

What are the features of tonsillitis?

A 
Pain on swallowing
Fever
Tonsillar exudate
Sudden onset sore throat
Tonsillar erythema
Tonsillar enlargement
Anterior cervical lymphadenopathy
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41
Q

What are the investigations for tonsillitis?

A

Throat culture

Rapid streptococcal antigen test

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42
Q

What are the common locations of candidiasis?

A

Mouth

Genitals

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43
Q

What is systemic candidiasis?

A

Acute disseminated candidiasis to blood, pleura and peritoneal fluid
Associated with fever, hypotension and leukocytosis

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44
Q

What are the risk factors for candidiasis?

A 
HIV
Malnutrition
Diabetes
Malignancy
Chemotherapy/radiotherapy
Other forms of immunosuppression
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45
Q

What are the investigations for candidiasis?

A

Superficial smear for microscopy
Urinalysis
Random/fasting glucose

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46
Q

What are the pathogens that cause the common cold?

A 
Rhinoviruses (50%) 
Coronavirus (10-15%)
Influenza (5-15%) 
Parainfluenza (5%) 
Respiratory syncytial virus (5%)

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

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47
Q

What is an abscess?

A

Collection of pus that has built up within a tissue, organ or confined space walled off by fibrosis.

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48
Q

What are the features of an abscess?

A 
Erythema
Hot
Oedema
Pain
Loss of function
Fever
Systemically unwell
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49
Q

What is the investigation for an abscess?

A

Clinical diagnosis

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50
Q

What is the management for an abscess?

A

Incision and drainage
Only give antibiotics if severe eg:
Sepsis, cellulitis, multiple sites of infection

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51
Q

What is Bartholin’s abscess?

A

A build up of pus in one of Bartholin’s glands, found on each side of the vaginal opening

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52
Q

What is Quinsy’s abscess?

A

A build up of pus between one of the tonsils and the wall of the throat

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53
Q

What is a pilonidal abscess?

A

A build up of pus in the skin of the cleft of the buttock

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54
Q

What are the common causes of meningitis?

A

Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenza type B

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55
Q

What is a common cause of encephalitis?

A

HSV-1

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56
Q

What are the features of meningitis?

A

Stiff neck
Photophobia
Non-blanching rash

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57
Q

What are the features of encephalitis?

A 
Altered state of consciousness
Seizures
Personality change
Cranial nerve palsies
Speech problems
Motor and sensory deficit
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58
Q

What are the investigations of meningitis?

A

LP if there are no clinical features of raised ICP

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59
Q

What is the management for meningitis?

A

SECONDARY CARE
- Empirical IV Abx within 1 hour of presentation (immediately after blood cultures + LP)
- ceftriaxone/cefotaxime +/- vancomycin
(if >60/immunocompromised also add amoxicillin)

PRIMARY CARE
- Urgent hospital transfer
- IM/IV benzylpenicillin
or - ceftriaxone/cefotaxime

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60
Q

What is Brudzinski’s sign?

A

Neck flexion causes hip and knee to flex

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61
Q

What is Kernig’s sign?

A

Cannot straighten leg when hip is at 90 degrees

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62
Q

What does the following CSF sample show?

Appearance- clear
WCC- low
Protein- normal
Glucose- normal
Gram stain- NA
A

Normal CSF

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63
Q

What does the following CSF sample show?

Appearance- turbid
WCC- high neutrophil
Protein- high
Glucose- low
Gram stain- positive
A

Gram positive bacterial meningitis

eg. Streptococcus pneumoniae

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64
Q

What does the following CSF sample show?

Appearance- turbid
WCC- high neutrophil
Protein- high
Glucose- low
Gram stain- negative
A

Gram negative bacterial meningitis

eg. Neisseria meningitidis

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65
Q

What does the following CSF sample show?

Appearance- clear/cloudy
WCC- high lymphocyte
Protein- raised
Glucose- normal
Gram stain- NA
A

Viral meningitis

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66
Q

What does the following CSF sample show?

Appearance- clear/cloudy
WCC- high lymphocytes
Protein- raised
Glucose- low
Gram stain- NA
A

TB/Fungal meningitis

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67
Q

What further investigation could be done to differentiate between a TB and fungal meningitis?

A

Ziehl-Neeslon stain- TB

India ink stain- fungal

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68
Q

What are the risk factors for infective endocarditis?

A 
Rheumatic heart disease Hx
Age-related valvular degeneration
Prosthetic valve (S. epidermidis)
IVDU (Staph. aureus)
Dental procedures (S. viridans)
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69
Q

What are the investigations and management for infective endocarditis?

A

3 blood cultures at least 1hr apart within 24hrs
Urgent echo
Broad spec antibiotics

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70
Q

Which infections can cause gastroenteritis with diarrhoea?

A

Campylobacter/C difficile

Bacillus cereus
E. coli
Vibrio cholera
Staph aureus

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71
Q

Which infections can cause gastroenteritis with dysentery?

A

CHESS

Campylobacter/C difficile
Haemorrhagic E. coli
Entamoeba histolytica
Shigella
Salmonella
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72
Q

What are the investigations for gasteroenteritis?

A

FBC

Stool MC+S

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73
Q

How is Hep A and E transmitted?

A

Faecal-oral route

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74
Q

What is the management for Hep A and E?

A

Supportive care

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75
Q

What are the clinical features of Hep B?

A 
Flu-like prodrome
Rash
Lymphadenopathy
RUQ pain
Jaundice
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76
Q

What are the risk factors for Hep B?

A

Unprotected sex
MSM
IVDU
Blood transfusion

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77
Q

What is the management for Hep B?

A

Acute- supportive

Chronic- peginterferon alpha, Tenofovir

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78
Q

Can you get Hep D without Hep B?

A

No

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79
Q

What is the main worry for Hep B/C?

A

Risk of HCC

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80
Q

What are the common pathogens of UTIs?

A

Proteus mirabilis (complicated UTI)
Escherichia coli
Enterococcus faecalis
Staphylococcus saprophyticus (young, sexually active)

Klebsiella pneumoniae

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81
Q

What are the investigations for a UTI?

A

Dipstick urinalysis- positive nitrates +/- leukocytes
Urine microscopy- leukocytes
Urine MC&S
Abdo USS- exclude urinary tract obstruction or renal stones

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82
Q

What is the management for a UTI?

A

Trimethoprim

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83
Q

What are the five types of malaria?

A 
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Plasmodium knowlesi
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84
Q

What are the characteristics of Plasmodium flaciparum?

A 
Most threatening
Common in tropical regions:
Sub-Saharan Africa
South east Asia
Oceania
Amazon basis of South America
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85
Q

What are the features of malaria?

A 
Headache
Weakness
Myalgia
Arthralgia
Anorexia
Diarrhoea
Fever - Characteristic paroxysms of chills and rigors followed by fever and sweats may be described
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86
Q

What are the investigations for malaria?

A

Giemsa-stained thick and thin stains
Thick- detects parasites
Thin- identifies species

FBC, Clotting profile, U+E, LFTs, blood glucose, Urinalysis, ABG

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87
Q

A 30 yo lady on the HIV ward has white plaques all over her tongue that extend into her throat. She says it’s very painful to swallow.
What is the most likely causative organism?

A. Candida albicans
B. Epstein-Barr virus
C. Herpes Simplex Virus
D. Streptococcal throat infection
E. Human Herpes Virus 8
A

A. Candida albicans

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88
Q

A 50 year old homeless man presents to A&E with purple purpural lesions on his back and on his gums.
What is the most likely causative organism?

A. HHV-2
B. HHV-4
C. HHV-5
D. HHV-7
E. HHV-8
A

E. HHV-8

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89
Q

A 26 year old architect presents to GP with a history of sharp tingling around his lips followed by a painful ulcer on the side of his mouth. O/E he has cervical lymphadenopathy and a blister on his finger.
What is the pathogen?

A. Varicella Zoster Virus
B. Epstein-Barr Virus
C. Herpes Simplex Virus 1
D. Herpes Simplex Virus 2
E. Cytomegalovirus
A

C. Herpes Simplex Virus 1

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90
Q

A 20 year old medical student presents with sore throat, headache, myalgia and coryzal symptoms. O/E she has cervical lymphadenopathy, enlarged exudative tonsils and splenomegaly.
What is the most likely diagnosis?

A. Varicella Zoster Virus
B. Epstein-Barr Virus
C. Herpes Simplex Virus 1
D. Herpes Simplex Virus 2
E. Cytomegalovirus
A

B. Epstein-Barr Virus

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91
Q

A 20 year old medical student presents with sore throat, headache, myalgia and coryzal symptoms. O/E he has cervical lymphadenopathy, enlarged exudative tonsils and splenomegaly.
What is the most appropriate management?

A. Rest at home, paracetamol
B. Amoxicillin
C. Acyclovir
D. Ceftriaxone
E. Vancomycin
A

A. Rest at home, paracetamol

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92
Q

A 15 year old female patient presents to A&E with difficulty speaking. 4 days ago she experienced a sore throat, which progressively got worse. It’s now difficult for her to speak or swallow. She has not had a cough or cold recently.
O/E there is bilateral tonsillar exudate and the oropharynx is not erythematous. There are 3 tender swellings on the anterior border of the sternocleidomastoid muscle.
Her observations are: T 39.1, HR 90, BP 113/68, SpO2 97%
What is the most likely diagnosis?

A. Infectious mononucleosis
B. Viral tonsillitis
C. Common cold
D. Bacterial tonsillitis 
E. Chickenpox
A

D. Bacterial tonsillitis

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93
Q

A 22 year old university student is seen in the GP with a fever, headache, neck stiffness and photophobia. Which is the most likely causative organism in this patient?

A. Bacterial meningitis due to Haemophilus influenzae
B. Bacterial meningitis due to Neisseria meningitides
C. Bacterial meningitis due to Streptococcus pneumoniae
D. Fungal meningitis

A

B. Bacterial meningitis due to Neisseria meningitides

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94
Q

A 22 year old university student is seen in the A&E with a fever, headache, neck stiffness and photophobia. A lumbar puncture was performed. The appearance of the fluid is clear, there are raised proteins and normal glucose. Lymphocyte count is raised. What is the most likely cause of this?

A. Bacterial meningitis
B. Drug induced meningitis
C. Fungal meningitis
D. TB meningitis 
E. Viral meningitis
A

E. Viral meningitis

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95
Q

40 year old woman returns from holiday in Vietnam. She started getting diarrhoea after eating some local food on her last day in Vietnam. She presents with fever, nausea and is sore all over. The white of her eyes are yellow.
What is the most likely causative organism?

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
A

A. Hepatitis A

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96
Q

A 29 yo male comes to the GP with fever, fatigue, joint pain and urticaria-like skin rash. He had unprotected anal sex a month ago. He comes back a week later for a blood test, which shows raised ALT and AST. He now complains of feeling sick, RUQ pain and looks a bit yellow.
What is the most likely causative organism?

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
A

B. Hepatitis B

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97
Q

A 70 yo M has been in hospital for the past two weeks for severe pneumonia. He develops bloody diarrhoea, colitis and reduced urine output. He has raised CRP, WCC and low albumin.
What is the most likely causative organism?

A. Campylobacter
B. C. Difficile 
C. Bacillus cereus
D. E. Coli
E. Vibrio cholera
A

B. C. Difficile

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98
Q

A 20 year old medical student comes back from their holiday and presents to A&E with profuse diarrhoea of rice water appearance. There is no blood.
What is the most likely cause?

A. Entamoeba histolytica
B. Staph aureus
C. Bacillus cereus
D. E. Coli
E. Vibrio cholera
A

E. Vibrio cholera

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99
Q

A 40 yo woman presents to A&E with bloody, foul smelling diarrhoea. She went to a barbeque yesterday where she suspects she ate undercooked chicken. She has a fever and severe abdominal pain.
What is the most likely cause?

A. Campylobacter
B. Shigella
C. Bacillus cereus
D. E. coli 
E. Salmonella
A

A. Campylobacter

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100
Q

For Human Herpes Viruses (HHV) 1-8, state the name of the virus and the clinical presentation

A 
HHV-1 = HSV-1 (multiple presentations including temporal lobe encephalitis)
HHV-2 = HSV-2 (genital herpes)
HHV-3 = VZV (chicken pox, shingles)
HHV-4 = EBV (mononucleosis)
HHV-5 = CMV (mononucleosis in immunocompromised)
HHV-6+7 = roseola infantum
HHV-8 = Kaposi's sarcoma
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101
Q

Define HSV

A

Disease resulting from HSV1 (mouth) or HSV2 (genitals) infection.

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102
Q

Summarise the epidemiology of HSV

A

VERY COMMON – 90% adults seropositive for HSV1 by 30 years (can be asymptomatic)

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103
Q

What are the two phases of HSV infection?

A

Virus becomes dormant following primary infection – trigeminal/sacral root ganglia.

Reactivation may occur in response to stress or immunosuppression (HIV)

Latent phase: Chronic infection where infectious virions are not produced –> Asymptomatic

Lytic phase: Viral replication and transport of virus to skin –> Active infection

104
Q

Define VZV

A

HHV-3
Primary infection is called varicella (chickenpox).

Reactivation of the dormant virus in the dorsal root ganglia, causes zoster (shingles).

105
Q

epidemiology of VZV

A

Chickenpox peak incidence: 4–10 years
Shingles peak incidence: >50 years.

About 90% of adults are VZV IgG positive.

106
Q

VZV presentation- chicken pox

A

Prodromal malaise
Mild pyrexia
Generalised pruritic, vesicular rash - face and trunk predominantly
Contagious from 48 h before the rash and until all the vesicles have crusted over (within 7–10 days).

107
Q

VZV presentation- shingles

A

May occur due to stress
Tingling in a dermatomal distribution- unilateral
Followed by painful skin lesions.
The skin remains painful until after the rash has gone
Recovery in 10–14 days.

108
Q

How is VZV chickenpox managed?

A

Treat symptoms:
Calamine lotion- for itching
Analgesia- paracetamol
Antihistamines- diphenhydramine

109
Q

How is VZV chickenpox in ADULTS managed?

A

Consider Aciclovir, valaciclovir or famciclovir if within 24 h of rash onset

otherwise treat symptoms

110
Q

How is shingles managed?

A

1st line: Valaciclovir or famciclovir
2nd line: Aciclovir
… if within 72 h of appearance of the rash for 7 days

111
Q

When is the VZV vaccine considered?

A

VZIG may be indicated:
immunosuppressed
Pregnant women exposed to varicella zoster
…if not previously immune

112
Q

complication of shingles

A

Postherpetic neuralgia

113
Q

Which drug is contraindicated in infectious mononucleosis?

A

Amoxicillin or ampicillin is CONTRAINDICATED due to widespread maculopapular rash

114
Q

Prognosis of mononucleosis

A

Most make an uncomplicated recovery in 3–21 days.

115
Q

How does hairy leukoplakia present?

A

Irregular, white, PAINLESS plaques on lateral tongue that cannot be scraped off.
ONLY in immunocompromised

116
Q

Define candidiasis

A

Fungal infection caused by Candida species (Candida albicans) = thrush
dimorphic fungus

117
Q

RFs for different types of candidiasis

A

Oral Candidiasis and Oesophageal thrush (Immunocompromised- neonates, steroids, diabetes, AIDS)
Vulvovaginitis (diabetes, use of antibiotics)
Diaper rash
Infective Endocarditis (IV drug users)
Disseminated candidiasis (especially in neutropenic patients

118
Q

Signs and symptoms of oral /vaginal candidiasis

A

Oral Candidiasis and Oesophageal thrush =
Dysphagia

Vulvovaginitis/ Balanitis =
thick discharge, itching, soreness, redness
Diaper rash

119
Q

Signs and symptoms of disseminated/systemic candidiasis

A

Endocarditis (IV drug users)

Disseminated candidiasis (in neutropenia)
fever, hypotension +/- leucocytosis
120
Q

Investigations for candidiasis

A

CLINICAL

Swabs no routinely recommended

Exclude DDx:

  • Urinalysis (UTI)
  • Random or fasting blood glucose (Diabetes)
  • Glucose tolerance test (Diabetes)
  • HIV antibody test
  • Vaginal pH test (to exclude STIs)
121
Q

Management of oral candidiasis

A

Miconazole oral gelandNystatin suspension

122
Q

Management of vaginal candidiasis

A

intravaginal antifungal cream or pessary (clotrimazole, miconazole) or an oral antifungal (fluconazole or itraconazole).

123
Q

Treatment of systemic candidiasis

A

Amphotericin B

124
Q

State 3 HIV-associated tumours

A
  1. Kaposi’s sarcoma
    Caused by HHV8
  2. Squamous cell carcinoma (particularly cervical or anal due to HPV)
  3. Lymphoma.
125
Q

How does kaposi’s sarcoma present?

A

pink or violaceous (purple) patch on the skin or in the mouth.

126
Q

Investigations for HIV

A

GOLD STANDARD: ELISA, confirmed with Western blot

  1. Serum HIV rapid test
  2. Serum HIV DNA PCR - infants
  3. CD4 count – indicates immune status, assists staging process
  4. Serum viral load (HIV RNA) - millions of copies/mL
127
Q

Other tests for patients recently diagnosed with HIV

A

Drug resistance test – to determine therapy
Serum hepatitis B and C serology
Treponema pallidum haemagglutination test – screening for symphilis
Tuberculin skin test – TB
FBC, U+E, LFTs

128
Q

Define tonsilitis

A

Acute infection of parenchyma of palatine tonsils. May occur in isolation or as part of generalised pharyngitis

129
Q

Most common viral causes of tonsilitis

A

rhinovirus, coronavirus, adenovirus

Associated with IM infection

130
Q

Most common bacterial causes of tonsilitis

A

Mycoplasma pneumoniae
Neisseria gonorrhoea
Group A streptococci

(sore throat after Big MNG)

131
Q

Signs and symptoms of tonsilitis

A 
Pain on swallowing 
Fever >38
Tonsillar exudate
Sudden onset sore throat
Tonsillar erythema and enlargement
Anterior cervical lymphadenopathy
132
Q

What type of tonsilitis is most common?

A

viral (90% adults, 70% children)

133
Q

Summarise the epidemiology of tonsilitis

A

VERY common

especially children 5-15yrs

134
Q

What score is used to diagnose group A strep (bacterial) tonsilitis?

A

FeverPAIN:
Fever (>38) during previous 24h
Purulence (pharyngeal, tonsillar exudate)
Attend rapidly (3 days or less after symptom onset)
Severely inflamed tonsils
No cough or coryza
(lymphadenopathy)

135
Q

How does lymphadenopathy differ between EBV and tonsilitis?

A 
EBV = posterial cervical
Tonsilitis = anterior cervical
136
Q

What criteria, other than FeverPAIN, is used to diagnose strep (bacterial) tonsilitis?

A

Centor criteria:
>=3 of following –> rapid strep antigen test
1. Tonsillar exudate
2. Tender anterior cervical lymphadenopathy or lymphadenitis
3.History of fever over 38
4. Absence of cough

137
Q

define common cold

A

mild, self-limiting, viral, upper respiratory tract infection characterized by nasal stuffiness and discharge, sneezing, sore throat, and cough

138
Q

What are the most common pathogens causing common cold?

A 
Rhinoviruses (50%) 
Coronavirus (10-15%)
Influenza (5-15%) 
Parainfluenza (5%) 
Respiratory syncytial virus (5%)- bronchiolitis in children
139
Q

Investigations for common cold

A

Clinical diagnosis

Consider: FBC, Throat swab, Sputum culture, CRP, CXR

140
Q

Signs and symptoms of common cold

A 
Runny/blocked nose
SNEEZING
Sore throat
Cough
Headache
Malaise and Fever.
Usually clear within 7 to 10 days
141
Q

Management of common cold

A

Supportive care – hydration, analgesic, antipyretic, decongestant (oxymetazozline nasal, ipratropium nasal) +/- antihistamine, antitussive

142
Q

Most common cause of external (cutaneous + subcutaneous) abscess

A

Staph aureus

143
Q

Common sites of internal abscesses

A 
Lungs
Brain
Teeth
Kidneys
Tonsils
Perianal abscesses – common in IBD and diabetes
Incisional abscess
144
Q

How is abscess diagnosed?

A

clinical, Ultrasound can help diagnosis

145
Q

How is abscess managed?

A

small- aspiration
otherwise- incision + drainage
severe cases(cellulitis, sepsis)- excision + antibiotics

146
Q

What is the name for a peritonsillar abscess?

A

quinsy

build-up of pus between one of your tonsils and the wall of your throat

147
Q

Toxoplasma is associated with which animals?

A

cat faeces, undercooked pork

148
Q

What pathology can toxoplasma cause in immunocompromised patients?

A

myocarditis, encephalitis, focal CNS signs, stroke, seizures

149
Q

What is the classic head CT finding of someone with toxoplasma infection?

A

multiple, ring enhancing lesions

150
Q 
A 13-year-old female patient presents to A&E with difficulty speaking. 4 days ago she experienced a sore, painful throat, which progressively got worse. She has difficulty swallowing. 
On examination there is bilateral tonsillar exudate. There are 3 tender swellings on the anterior border of the sternocleidomastoid muscle and her observations are: T 39.1, HR 90, BP 113/68, SpO2 97% .
What is the most likely diagnosis?
Infectious mononucleosis
Viral tonsillitis
Common cold
Bacterial tonsillitis 
Chickenpox
A

bacterial tonsilitis

> 3 on centor criteria
viral is posterior cervical + EBV has splenomegaly

151
Q

A baby girl born 1 day ago born after a long vaginal labour, becomes drowsy. On examination, T: 38.9, HR: 170bpm, RR: 30. Which is the most likely causative agent?

Neisseria meningitis
Streptococcus pneumonia
Listeria monocytogenes
Group B streptococcus 
E. Coli
A

Group B streptococcus

commonest cause of fever and drowsiness in neonates is meningitis

Prolonged rupture of membranes is more associated with Group B strep

152
Q

15-year-old boy with DiGeorge syndrome had a dental tooth extraction 2 weeks ago, visits his GP who on auscultation finds a new onset murmur on the left sternal edge. Basic observations: BP 110/80, HR: 95, Temperature: 38.5, SaO2 98% on air. What is the most likely causative agent?

Staph aureus
Staph epidermis
Streptococcus viridian
Streptococcus bovis
Enterococci
A

Streptococcus viridian

DiGeorge patients have congenital heart defects.
Dental procedures may result in introduction of infection.

153
Q

24 year old medical student comes back from their holiday and presents to A&E with profuse diarrhoea of rice water appearance. There is no blood. What is the most likely causative agent?

Entamoeba histolytica
Staph aureus
Bacillus cereus
E. Coli
Vibrio cholera
A

Vibrio cholera

154
Q

40 year old woman presents to A&E with bloody, foul smelling diarrhoea. She went to a barbeque yesterday where she suspects she ate undercooked chicken. She has a fever and severe abdominal pain. What is the most likely causative agent?

A

Campylobacter – undercooked poultry

Salmonella is more associated with raw eggs

155
Q

67 year old male has been in hospital for the past two weeks for severe pneumonia. He develops bloody diarrhoea, colitis and reduced urine output. He has raised CRP, WCC and low albumin. What is the most likely causative organism?

A

C. difficile

association with antibiotics suggested by the severe pneumonia and hospitalisation

156
Q

Define meningitis

A

Inflammation of leptomeningeal (pia mater and arachnoid) coverings of the brain

157
Q

Define encephalitis

A

Inflammation of brain parenchyma

158
Q

Who does meningitis most commonly affect?

A

Affects extremes of age (impaired immunity)

159
Q

What is the most common cause of encephalitis?

A

Virus- main = HHV

Can be infective or non-infective cause

160
Q

Most common causative agents for meningitis

A

Most commonly bacterial:

  • Streptococcus pneumoniae,
  • Neisseria meningitidis
  • Haemophilus influenzae type B
161
Q

State some causes of aseptic meningitis

A

Characterised by clinical and laboratory evidence for meningeal inflammation and
negative routine bacterial cultures:
- enteroviruses (commonest)
- mycobacteria, fungi
- autoimmune (sarcoidosis, Bechet’s, SLE)
- malignancy (lymphoma, leukaemia, mets)
- iatrogenic (trimethoprim, NSAIDs, azathioprine)

162
Q

symptoms of meningitis

A

MENINGISM:
Photophobia
Neck stiffness
Fever

Headache

163
Q

symptoms of encephalitis

A 
Altered state of consciousness
seizures
personality change
cranial nerve palsies
speech problems
motor and sensory deficit

CONFUSION IS LESS COMMON IN MENINGITIS

164
Q

Investigations for meningitis

A

Blood: Two sets of blood cultures
Imaging: CT scan to exclude intracranial pressure.
Lumbar puncture: Send CSF for MC&S and Gram staining

165
Q

Investigations for encephalitis

A

Blood cultures
neuroimaging (MRI)
CSF analysis

166
Q

immediate management of meningitis

A

Empirical antimicrobial therapy should be started promptly:

Ceftriaxone + Vancomycin

Consider corticosteroids –
Dexamethasone for bacterial meningitis

(unless meningococcal septicaemia is suspected)

167
Q

What meningitis infection would you expect in neonates after an extended labour (+infection in previous infection)?

A

Group B streptococcus

168
Q

What meningitis infection would you expect in late neonates? (few weeks post birth)

A

E. coli

169
Q

What are the 3 common meningitis bacterial pathogens in neonates?

A

Group B strep
E. coli
Listeria monocytogenes

170
Q

Most common bacterial causes of meningitis in children + teenagers

A 
Neisseria meningitides (if vaccinated)
Haemophilus influenzae (if unvaccinated)
171
Q

What type of bacteria is Neisseria meningitides?

A

gram negative diplococci

172
Q

What are the 2 commonest causes of meningitis in adults/elderly and what are they associated with?

A

most common = streptococcus pneumoniae

elderly, cheese/unpasteurised milk. alcoholics = Listeria monocytogenes

173
Q

2 signs of meningism

A

Brudzinksi’s sign- severe neck stiffness causes a patients hips and knees to flex when neck is flexed
Kernig’s sign- severe stiffness of hamstrings causes inability to straighten leg when the hip is flexed to 90 degrees

174
Q

signs of meningitis

A 
Brudinski's and Kernig's signs
fever
tachycardia
hypotension
petechial rash- non-blanching = meningococcal septicaemia
altered mental state
175
Q

contraindications for lumbar puncture

A

Neurological signs suggesting raised ICP (CT head first)
Superficial infection over LP site
Coagulopathy

176
Q

How would CSF results differ in appearance between different infectious causes of meningitis?

A 
NORMAL = clear
BACTERIAL = turbid
VIRAL/TB/FUNGAL = clear/cloudy
177
Q

Compare CSF results between different infectious causes of meningitis

A 
WCC
- normal = low
- bacterial = neutrophils (aka granulocytes)
- viral/TB/fungal = lymphocytes
PROTEIN
- bacterial = very high +++
- viral/TB/fungal = high +
GLUCOSE
- bacterial = very low ---
- viral = normal
- TB/fungal = low -

Bacterial will also have gram stain positive

178
Q

If a patient presents with a non-blanching rash/meningococcal septicaemia + meningism how would you manage them?

A

This is NEISSERIA MENINGITIDES
Admit
give single IV dose of benzylpenicillin

179
Q

What antibiotic would you give for suspected Lisseria meningitis?

A

ampicillin

180
Q

If a meningitic patient presents with impaired consciousness, what drug would consider giving and why?

A

suspect meningo-encephalitis
IV acyclovir
most common cause of encephalitis is HHV

181
Q

What prophylactic drugs would you give to people exposed to meningitis?

A

Rifampicin

182
Q

Fungal causes of encephalitis

A

Cryptococcus, candida

183
Q

Parasitic causes of encephalitis

A

Toxoplasma gondii, malaria

184
Q

Define infective endocarditis

A

Infection of endocardial structures (mainly heart valves)

185
Q

Most common causes of infective endocarditis? For each pathogen, state the associated RF

A

Streptococci (40%)- abnormal heart valves- congenital, post rheumatic, degenerative/calcification (viridans/bovis)
Staphylococci (35%)- prosthetic heart valves (S.aureus), IV drug users (S.epidermis)
Enterococci(20%)- E. faecalis.

186
Q

Which organisms may test negative on culture in infective endocarditis?

A

HACEK
(Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella),
Coxiella burnetii, histoplasma

187
Q

RF for infective endocarditis

A 
Abnormal valves (e.g. congenital, post-rheumatic, calcification/ degeneration)
Prosthetic heart valves
IV drug use
Turbulent flow (e.g. PDA or VSD), 
Recent dental work
188
Q

which valve is most likely to be affected in IVDU associated endocarditis?

A

first valve in contact with venous system- tricuspid

189
Q

Which infective endocarditis causative organism is associated with GI malignancy?

A

Streptococcus Bovis

190
Q

symptoms of infective endocarditis

A

Fever with sweats/chills/rigors (may be relapsing and remitting).
Malaise, arthralgia, myalgia, confusion (particularly in elderly).
Skin lesions- Osler’s nodes (tip of the finger/toes, painful) + Janeway lesions (palm and soles, non-painful.)
Inquire about recent dental surgery or IV drug abuse.

191
Q

signs of infective endocarditis

A
  • Pyrexia, tachycardia, signs of anaemia.
  • New regurgitant murmur or muffled heart sounds (right-sided lesions may imply IV drug use).
  • Splenomegaly.
  • Vasculitic lesions: Petechiae particularly on retinae (Roth’s spots), pharyngeal and conjunctival mucosa

HANDS
- Janeway lesions (painless palmar macules, which blanch on pressure);
- Osler’s nodes (tender nodules on finger/toe pads)
- Splinter haemorrhages (nail-bed
haemorrhages)
- Clubbing (if long-standing).

192
Q

What mnemonic can be used to remember the signs of infective endocarditis?

A

FROM JANE with ♥:

Fever
Roth spots
Osler nodes
Murmur
Janeway lesions
Anaemia
Nail-bed haemorrhage
Emboli
193
Q

What hand sings may you see of infective endocarditis?

A

JANEWAY LESIONS- painless, blanching palmar macules
OSLER’S NODES- painful, tender nodules on finger/toe pads
SPLINTER HAEMORRHAGE

194
Q

Buzzwords for infective endocarditis

A
  • prosthetic valve
  • dental procedures (strep)
  • new onset murmur
  • vegetation on echo
  • right heart (IVDU)
  • indwelling catheter
195
Q

Investigations for infective endocarditis

A

Bloods: FBC (high neutrophils, normocytic anaemia), ESR and CRP, U&Es, RF (RA can cause)

3 blood cultures, 1 h apart, within 24 hs
Urgent echo
Dukes classification
Broad spectrum antibiotics until sensitivity reported

196
Q

What classification is used to diagnose infective endocarditis?

A

Duke’s classification: (2 major, 1 major + 3 minor, all minor).
Major criteria:
Positive blood culture in two separate samples.
Positive echocardiogram
(vegetation, abscess, prosthetic valve dehiscence, new valve regurgitation).

Minor criteria:
High-grade pyrexia (temperature >38$C)
Risk factors (abnormal valves, IV drug use, dental surgery).
Vascular signs.

197
Q

complications of infective endocarditis

A 
Congestive heart failure
Valve incompetence
Aneurysm formation
Systemic embolization 
Renal failure
Glomerulonephritis.
198
Q

Management of infective endocarditis?

A

Antibiotics for 4-6 weeks
NATIVE VALVES
Penicillin-sensitive Streptococcus viridans = Benzylpenicillin + gentamicin
S. aureus = Flucloxacillin

PROSTHETIC VALVES
Staphylococci = Flucloxacillin + rifampicin + gentamicin (stronger set because prosthetic bacteria stronger)

if penicillin allergic- replace with vancomycin

199
Q

Define gastroenteritis

A

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

200
Q

Most common causes of viral gastroenteritis

A

Rotavirus (children, decreasing due to vaccine)
adenovirus
astrovirus
calcivirus

201
Q

Most common causes of bacterial gastroenteritis

A 
Campylobacter jejuni 
E.coli
Salmonella
Shigella
Vibrio cholerae
Listeria
Yersinia enterocolitica.
202
Q

Most common causes of protozoal gastroenteritis

A

Entamoeba histolytica
Cryptosporidium parvum
Giardia lamblia

203
Q

What pathogens might be present in undercooked meat?

A

S. aureus, C. perfringens

204
Q

What pathogens might be present in old rice?

A

B. cereus, S. aureus

205
Q

What pathogens might be present in milk + cheese?

A

Listeria, Campylobacter

206
Q

What pathogens might be present in canned food?

A

botulism

207
Q

Diarrhoea versus dysentry

A

dysentry = bloody diarrhoea

208
Q

Which pathogens can cause dysentry? (CHESS)

A 
CHESS:
Campylobacter / Clostridium difficile 
Haemorrhagic E. coli 
Entamoeba histolytica
Shigella
Salmonella
209
Q

What 2 categories of toxin can be produced to create inflammatory/non-inflammatory diarrhoea?

A

ENTEROTOXINS- non-inflammatory- cause enterocytes to secrete water and electrolytes (V. cholerae, enterotoxigenic E. coli)

CYTOTOXINS- inflammatory- invade and damage epithelium (Shigella, enteroinvasive E. coli), can cause bacteraemia (salmonella)

210
Q

Which bacteria is responsible for diarrhoea after antibiotic use?

A

C. difficile

211
Q

Which bacteria is responsible for short-lived diarrhoea 1-6 hours after eating?

A

Staph aureus

212
Q

Which bacteria is responsible for rice-water diarrhoea with poor sanitisation + shock?

A

Vibrio cholera

213
Q

Which bacteria is responsible for diarrhoea after eating leafy vegetables?

A

E. Coli

also haemorrhagic E.coli = dysentry followed by HUS

214
Q

Which bacteria is responsible for diarrhoea after eating reheated rice? What else can it cause?

A

Bacillus cereus

can cause cerebral abscess

215
Q

Which bacteria responsible for diarrhoea is found in eggs?

A

Salmonella

multiplies in Payer’s patches of the intestine

216
Q

Which bacteria responsible for diarrhoea is found in poultry?

A

Campylobacter

217
Q

Shigella is associated with what?

A

person-person contact

MSM

218
Q

Gastroenteritis symptoms

A 
Sudden onset nausea
Vomiting
Anorexia.
Diarrhoea (+/- blood) 
Abdominal pain 
Fever and malaise.
219
Q

Investigations for gastroenteritis

A

Examination:
Mucous membranes, skin turgor, cap refill –>dehydration?
HR, BP –> shock?
Temperature

Bloods: FBC, ESR/CRP, U&Es - deranged (low K in severe D&V)
Stool MC&S: Bacterial pathogens, Ova cysts (eggs), Parasites

220
Q

Management of gastroenteritis with no systemic illness (fever, shock, dysentry, >2 weeks)

A

Supportive therapy
Bed rest, fluids and electrolyte replacement with oral rehydration solution
No stool culture needed

221
Q

Management of gastroenteritis with systemic illness (fever, shock, dysentry, >2 weeks)

A

Admit and give oral fluids
(IV rehydration for severe vomiting)
Antibiotics if infective organism identified
Direct faecal smear, then culture

222
Q

37-year-old bride-to-be returned from Jamaica 3 days ago, where she partied and explored the local cuisine with her best friends. She presents to her GP complaining of being jaundiced with right upper quadrant pain and fever. She has raised ALT and AST. What is the most likely cause of her symptoms?

Alcoholic hepatitis
Gall stones
Cholecystitis 
Hepatitis A
Hepatitis C
A

Hepatitis A

Jaundice, RUQ pain & raised ALT & AST is suggestive of Hepatitis.
Jamaica is an endemic country and Hepatitis A is faeco-orally transmitted

223
Q

A 64-year-old male with thalassaemia is investigated under the two-week wait for jaundice, hepatomegaly and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E
A

Hepatitis C

The combination of jaundice, hepatomegaly and weight loss, when combined with a raised aFP, points to a diagnosis of hepatocellular carcinoma.
HBV and HCV can cause chronic infection, but HCV is more likely

224
Q

35-year-old woman presenting to her GP with increased urinary frequency and lower back pain. On examination her BP is 130/90, HR: 83bpm, RR: 17bpm and T: 38.3. Which is the most likely finding on her urine dip stick and MC&S?

A

This is the clinical picture of UTI. Urine dipstick will show positive nitrites and leukocytes.
E.Coli is the most common cause and it is a gram negative bacilli

225
Q

A 45-year old man presented to his GP with cyclical fevers. He returned from Ethiopia 10 days ago. What is the most likely causative agent?

Salmonella typhi
Yersinia pestis
Leptospirosis
Plasmodium falciparum
Coxiella burnetii
A

Malaria is associated with endemic areas and cyclical fevers
Causative organism is Plasmodium falciparum.
Salmonella causes dysentery
Y. Pestis causes plaque
Leptospira is due to water contaminated with animal urine
Coxiella burnetti causes Q fever

226
Q

Define hepatitis

A

Inflammatory liver injury

227
Q

Signs and symptoms of hepatitis

A

Fever
Jaundice
Raised ALT, raised AST

228
Q

common causes of hepatitis

A

Viral A, B, C, D, E
Alcoholic
Autoimmune

229
Q

Investigations for viral hepatitis

A

Blood:
FBC
LFTs (bilirubin, albumin, AlkPhos, GGT).
U&E
Clotting: Prolonged PT is a sensitive marker of significant liver damage.
Ultrasound scan: For other causes of liver impairment (e.g. malignancies).
Viral serology
Viral PCR
Liver biopsy: To assess degree of inflammation and liver damage (useful in diagnosing cirrhosis as patients)

230
Q

Which hepatitis are faeco oral?

A

A+E

Faeco-oral hepatitis = The vowels hit your bowels

231
Q

Hep A common history features

A

Acute- Travel history (contaminated water is a major source)

Asymptomatic (usually)

232
Q

Hep A symptoms

A 
Nausea
Vomiting (+ Diarrhoea)
Fever
Jaundice
Abdominal pain (particularly RUQ)
233
Q

Hep A treatment

A

supportive, and alcohol should be avoided.

There is a small risk of acute liver failure, which necessitates the need for liver transplantation

234
Q

risks of chronic HEV infection are high for which group?

A 
HEV infection is usually acute and self-limiting. 
immunocompromised patients (including organ transplant recipients on immunosuppressants) are at risk of chronic infection.
235
Q

HAV is common in which areas/foods?

A

Outbreaks are more common in Asia and Africa

improperly cleaned shellfish from contaminated water can be source of HAV

MSM

236
Q

Acute HBV symptoms

A

Nausea, Anorexia, RUQ pain, Jaundice

237
Q

How is HBV spread?

A

vertical mother-child transmission, contaminated blood products and sexually.

238
Q

HBV vs HCV

A 
HBV and HCV present similarly. however:
HBV = only 10% chronic
HCV = chronic, increased HCC risk
HBV = DNA, HCV = RNA
HCV = blood transmitted, HBV = more commonly sexually transmitted
239
Q

which hepatitis is RF for HCC?

A

HCV

240
Q

Treatment of HCV

A

Antiretrovirals are now curative e.g.
Sofosbuvir (NS5B inhibitors)
Ledipasvir (NS5A inhibitors)
Grazoprevir (NS3/4 protease

241
Q

Define UTI

A

Characterized by presence of>100,000 of colony-forming units per millilitre of urine. UTI may affect bladder (cystitis), kidney (pyelonephritis) or prostate (prostatitis).

242
Q

cystitis signs

A

Frequency, Urgency, Dysuria
Haematuria.
Foul-smelling ± cloudy urine.
Suprapubic or loin pain.

243
Q

pyelonephritis signs

A

Rigors.
Pyrexia.
Nausea ± vomiting.
Acute confusional state  elderly.

244
Q

Common pathogens causing UTI

A

Escherichia coli = most common
Proteus mirabilis
Klebsiella
Enterococci

245
Q

Investigations for UTI

A

Assess RF
Dipstick urinalysis: positive nitrites (E.coli specific) +/- leukocytes
Urine MC&S
(Abdo USS – exclude urinary tract obstruction or renal stones)

246
Q

RF UTI

A

female, recent instrumentation, abnormality, incomplete bladder emptying, sexual activity, new sexual partner, diabetes, catheter, pregnancy

247
Q

management of UTI

A

Trimethoprim/ Nitrofurantoin

248
Q

E.coli UTI causes what positive dipstick result?

A

nitrites

249
Q

Define malaria

A

Infection with protozoan Plasmodium

250
Q

Causative organisms for malaria

A

Plasmodium spp
P. vivax/ovale
P. falciparum
P. malaria

251
Q

Incubation period of malaria

A

Incubation usually 1-2 weeks but up to a year

252
Q

organisms responsible for transmission of malaria

A

female Anopheles mosquito

253
Q

Symptoms of malaria

A 
Headache
Weakness
Myalgia/ Arthralgia
Anorexia
Fever - Characteristic paroxysms of severe cold / rigors followed by severing sweating
254
Q

Signs of malaria

A

Pyrexia
Anaemia
Splenomegaly

255
Q

Investigations for malaria

A

Giemsa-stained thick and thin blood smears
Thick – detects parasites present
Thin – identifies species

Other: FBC (Hb, platelets), Clotting profile, U+E, LFTs, blood glucose, Urinalysis, ABG

Year 3 (38 decks)

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