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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
How may a HSV1 infection present?
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
26
How may a HSV2 infection present in a male?
``` Vesicles on shaft or glands Proctitis with discharge Rectal pain Tenesmus Constipation Impotence ```
27
How may a HSV2 infection present in a female?
``` Genital herpes (Chronic-life long) flu-like prodrome vesicles/papules around genitals, anus Shallow ulcers Urethral discharge Dysuria Fever and malaise ```
28
What are the investigations for HSV infections?
Usually clinical diagnosis Viral culture HSV PCR
29
What type of virus is HIV caused by and what cells does it infect?
Retrovirus | Human lymphocytes/macrophages
30
What are the routes of HIV transmission?
``` Sexual contact Before birth During delivery Breast feeding IVDU Blood transfusion (rare) ```
31
What are the 3 stages of HIV infection?
1. Primary- seroconversion (4-8 weeks) 2. Asymptomatic (18 months --> 15yrs) 3. AIDS-related complex ( Think 4 Fs- Flu --> Fine --> falling CD4 --> final crisis
32
What is the primary HIV stage?
Seroconversion: 4-8 weeks post infection self-limiting – fever, night sweats, generalized lymphadenopathy, sore throat, oral ulcers, rash, myalgia, headache, encephalitis, diarrhoea
33
What is the asymptomatic HIV stage?
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
34
What is the AIDS-related complex HIV stage?
Syndrome of secondary diseases reflecting severe immunodeficiency ...or direct effect of HIV infection CD4 <200x10^6
35
What is the cause of oral candidiasis?
Fungal candida infection | Due to immunosuppression
36
What is the cause of hairy leukoplakia?
Triggered by EBV | Occurs in HIV-positive patients, organ transplant recipients.
37
What is the cause of Kaposi's sarcoma?
HHV-8 | AIDS-defining condition (opportunistic infections and cancers that are life-threatening in a person with HIV.)
38
What are the investigations for HIV?
``` ELISA Serum HIV rapid test Sample buccal saliva HIV PCR CD4 count ```
39
What are some common pathogens that cause tonsillitis?
``` Rhinovirus Coronavirus Adenovirus Beta-haemolytic Strep (pyogenes) Mycoplasma pneumoniae Neisseria gonorrhoea ```
40
What are the features of tonsillitis?
``` Pain on swallowing Fever Tonsillar exudate Sudden onset sore throat Tonsillar erythema Tonsillar enlargement Anterior cervical lymphadenopathy ```
41
What are the investigations for tonsillitis?
Throat culture | Rapid streptococcal antigen test
42
What are the common locations of candidiasis?
Mouth | Genitals
43
What is systemic candidiasis?
Acute disseminated candidiasis to blood, pleura and peritoneal fluid Associated with fever, hypotension and leukocytosis
44
What are the risk factors for candidiasis?
``` HIV Malnutrition Diabetes Malignancy Chemotherapy/radiotherapy Other forms of immunosuppression ```
45
What are the investigations for candidiasis?
Superficial smear for microscopy Urinalysis Random/fasting glucose
46
What are the pathogens that cause the common cold?
``` Rhinoviruses (50%) Coronavirus (10-15%) Influenza (5-15%) Parainfluenza (5%) Respiratory syncytial virus (5%) ``` Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis
47
What is an abscess?
Collection of pus that has built up within a tissue, organ or confined space walled off by fibrosis.
48
What are the features of an abscess?
``` Erythema Hot Oedema Pain Loss of function Fever Systemically unwell ```
49
What is the investigation for an abscess?
Clinical diagnosis
50
What is the management for an abscess?
Incision and drainage Only give antibiotics if severe eg: Sepsis, cellulitis, multiple sites of infection
51
What is Bartholin's abscess?
A build up of pus in one of Bartholin's glands, found on each side of the vaginal opening
52
What is Quinsy's abscess?
A build up of pus between one of the tonsils and the wall of the throat
53
What is a pilonidal abscess?
A build up of pus in the skin of the cleft of the buttock
54
What are the common causes of meningitis?
Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenza type B
55
What is a common cause of encephalitis?
HSV-1
56
What are the features of meningitis?
Stiff neck Photophobia Non-blanching rash
57
What are the features of encephalitis?
``` Altered state of consciousness Seizures Personality change Cranial nerve palsies Speech problems Motor and sensory deficit ```
58
What are the investigations of meningitis?
LP if there are no clinical features of raised ICP
59
What is the management for meningitis?
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
60
What is Brudzinski's sign?
Neck flexion causes hip and knee to flex
61
What is Kernig's sign?
Cannot straighten leg when hip is at 90 degrees
62
What does the following CSF sample show? ``` Appearance- clear WCC- low Protein- normal Glucose- normal Gram stain- NA ```
Normal CSF
63
What does the following CSF sample show? ``` Appearance- turbid WCC- high neutrophil Protein- high Glucose- low Gram stain- positive ```
Gram positive bacterial meningitis | eg. Streptococcus pneumoniae
64
What does the following CSF sample show? ``` Appearance- turbid WCC- high neutrophil Protein- high Glucose- low Gram stain- negative ```
Gram negative bacterial meningitis | eg. Neisseria meningitidis
65
What does the following CSF sample show? ``` Appearance- clear/cloudy WCC- high lymphocyte Protein- raised Glucose- normal Gram stain- NA ```
Viral meningitis
66
What does the following CSF sample show? ``` Appearance- clear/cloudy WCC- high lymphocytes Protein- raised Glucose- low Gram stain- NA ```
TB/Fungal meningitis
67
What further investigation could be done to differentiate between a TB and fungal meningitis?
Ziehl-Neeslon stain- TB | India ink stain- fungal
68
What are the risk factors for infective endocarditis?
``` Rheumatic heart disease Hx Age-related valvular degeneration Prosthetic valve (S. epidermidis) IVDU (Staph. aureus) Dental procedures (S. viridans) ```
69
What are the investigations and management for infective endocarditis?
3 blood cultures at least 1hr apart within 24hrs Urgent echo Broad spec antibiotics
70
Which infections can cause gastroenteritis with diarrhoea?
Campylobacter/C difficile Bacillus cereus E. coli Vibrio cholera Staph aureus
71
Which infections can cause gastroenteritis with dysentery?
CHESS ``` Campylobacter/C difficile Haemorrhagic E. coli Entamoeba histolytica Shigella Salmonella ```
72
What are the investigations for gasteroenteritis?
FBC | Stool MC+S
73
How is Hep A and E transmitted?
Faecal-oral route
74
What is the management for Hep A and E?
Supportive care
75
What are the clinical features of Hep B?
``` Flu-like prodrome Rash Lymphadenopathy RUQ pain Jaundice ```
76
What are the risk factors for Hep B?
Unprotected sex MSM IVDU Blood transfusion
77
What is the management for Hep B?
Acute- supportive | Chronic- peginterferon alpha, Tenofovir
78
Can you get Hep D without Hep B?
No
79
What is the main worry for Hep B/C?
Risk of HCC
80
What are the common pathogens of UTIs?
Proteus mirabilis (complicated UTI) Escherichia coli Enterococcus faecalis Staphylococcus saprophyticus (young, sexually active) Klebsiella pneumoniae
81
What are the investigations for a UTI?
Dipstick urinalysis- positive nitrates +/- leukocytes Urine microscopy- leukocytes Urine MC&S Abdo USS- exclude urinary tract obstruction or renal stones
82
What is the management for a UTI?
Trimethoprim
83
What are the five types of malaria?
``` Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium knowlesi ```
84
What are the characteristics of Plasmodium flaciparum?
``` Most threatening Common in tropical regions: Sub-Saharan Africa South east Asia Oceania Amazon basis of South America ```
85
What are the features of malaria?
``` Headache Weakness Myalgia Arthralgia Anorexia Diarrhoea Fever - Characteristic paroxysms of chills and rigors followed by fever and sweats may be described ```
86
What are the investigations for malaria?
Giemsa-stained thick and thin stains Thick- detects parasites Thin- identifies species FBC, Clotting profile, U+E, LFTs, blood glucose, Urinalysis, ABG
87
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. Candida albicans
88
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 ```
E. HHV-8
89
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 ```
C. Herpes Simplex Virus 1
90
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 ```
B. Epstein-Barr Virus
91
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. Rest at home, paracetamol
92
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 ```
D. Bacterial tonsillitis
93
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
B. Bacterial meningitis due to Neisseria meningitides
94
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 ```
E. Viral meningitis
95
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. Hepatitis A
96
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 ```
B. Hepatitis B
97
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 ```
B. C. Difficile
98
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 ```
E. Vibrio cholera
99
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. Campylobacter
100
For Human Herpes Viruses (HHV) 1-8, state the name of the virus and the clinical presentation
``` 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 ```
101
Define HSV
Disease resulting from HSV1 (mouth) or HSV2 (genitals) infection.
102
Summarise the epidemiology of HSV
VERY COMMON – 90% adults seropositive for HSV1 by 30 years (can be asymptomatic)
103
What are the two phases of HSV infection?
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
Define VZV
HHV-3 Primary infection is called varicella (chickenpox). Reactivation of the dormant virus in the dorsal root ganglia, causes zoster (shingles).
105
epidemiology of VZV
Chickenpox peak incidence: 4–10 years Shingles peak incidence: >50 years. About 90% of adults are VZV IgG positive.
106
VZV presentation- chicken pox
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
VZV presentation- shingles
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
How is VZV chickenpox managed?
Treat symptoms: Calamine lotion- for itching Analgesia- paracetamol Antihistamines- diphenhydramine
109
How is VZV chickenpox in ADULTS managed?
Consider Aciclovir, valaciclovir or famciclovir if within 24 h of rash onset otherwise treat symptoms
110
How is shingles managed?
1st line: Valaciclovir or famciclovir 2nd line: Aciclovir ... if within 72 h of appearance of the rash for 7 days
111
When is the VZV vaccine considered?
VZIG may be indicated: immunosuppressed Pregnant women exposed to varicella zoster ...if not previously immune
112
complication of shingles
Postherpetic neuralgia
113
Which drug is contraindicated in infectious mononucleosis?
Amoxicillin or ampicillin is CONTRAINDICATED due to widespread maculopapular rash
114
Prognosis of mononucleosis
Most make an uncomplicated recovery in 3–21 days.
115
How does hairy leukoplakia present?
Irregular, white, PAINLESS plaques on lateral tongue that cannot be scraped off. ONLY in immunocompromised
116
Define candidiasis
Fungal infection caused by Candida species (Candida albicans) = thrush dimorphic fungus
117
RFs for different types of candidiasis
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
Signs and symptoms of oral /vaginal candidiasis
Oral Candidiasis and Oesophageal thrush = Dysphagia Vulvovaginitis/ Balanitis = thick discharge, itching, soreness, redness  Diaper rash
119
Signs and symptoms of disseminated/systemic candidiasis
Endocarditis (IV drug users) ``` Disseminated candidiasis (in neutropenia) fever, hypotension +/- leucocytosis ```
120
Investigations for candidiasis
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
Management of oral candidiasis
Miconazole oral gel and Nystatin suspension 
122
Management of vaginal candidiasis
intravaginal antifungal cream or pessary (clotrimazole, miconazole) or an oral antifungal (fluconazole or itraconazole).
123
Treatment of systemic candidiasis
Amphotericin B
124
State 3 HIV-associated tumours
1. Kaposi’s sarcoma Caused by HHV8 2. Squamous cell carcinoma (particularly cervical or anal due to HPV) 3. Lymphoma.
125
How does kaposi's sarcoma present?
pink or violaceous (purple) patch on the skin or in the mouth.
126
Investigations for HIV
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
Other tests for patients recently diagnosed with HIV
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
Define tonsilitis
Acute infection of parenchyma of palatine tonsils. May occur in isolation or as part of generalised pharyngitis
129
Most common viral causes of tonsilitis
rhinovirus, coronavirus, adenovirus | Associated with IM infection
130
Most common bacterial causes of tonsilitis
Mycoplasma pneumoniae Neisseria gonorrhoea Group A streptococci (sore throat after Big MNG)
131
Signs and symptoms of tonsilitis
``` Pain on swallowing Fever >38 Tonsillar exudate Sudden onset sore throat Tonsillar erythema and enlargement Anterior cervical lymphadenopathy ```
132
What type of tonsilitis is most common?
viral (90% adults, 70% children)
133
Summarise the epidemiology of tonsilitis
VERY common | especially children 5-15yrs
134
What score is used to diagnose group A strep (bacterial) tonsilitis?
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
How does lymphadenopathy differ between EBV and tonsilitis?
``` EBV = posterial cervical Tonsilitis = anterior cervical ```
136
What criteria, other than FeverPAIN, is used to diagnose strep (bacterial) tonsilitis?
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
define common cold
mild, self-limiting, viral, upper respiratory tract infection characterized by nasal stuffiness and discharge, sneezing, sore throat, and cough
138
What are the most common pathogens causing common cold?
``` Rhinoviruses (50%) Coronavirus (10-15%) Influenza (5-15%) Parainfluenza (5%) Respiratory syncytial virus (5%)- bronchiolitis in children ```
139
Investigations for common cold
Clinical diagnosis | Consider: FBC, Throat swab, Sputum culture, CRP, CXR
140
Signs and symptoms of common cold
``` Runny/blocked nose SNEEZING Sore throat Cough Headache Malaise and Fever. Usually clear within 7 to 10 days ```
141
Management of common cold
Supportive care – hydration, analgesic, antipyretic, decongestant (oxymetazozline nasal, ipratropium nasal) +/- antihistamine, antitussive
142
Most common cause of external (cutaneous + subcutaneous) abscess
Staph aureus
143
Common sites of internal abscesses
``` Lungs Brain Teeth Kidneys Tonsils Perianal abscesses – common in IBD and diabetes Incisional abscess ```
144
How is abscess diagnosed?
clinical, Ultrasound can help diagnosis
145
How is abscess managed?
small- aspiration otherwise- incision + drainage severe cases(cellulitis, sepsis)- excision + antibiotics
146
What is the name for a peritonsillar abscess?
quinsy | build-up of pus between one of your tonsils and the wall of your throat
147
Toxoplasma is associated with which animals?
cat faeces, undercooked pork
148
What pathology can toxoplasma cause in immunocompromised patients?
myocarditis, encephalitis, focal CNS signs, stroke, seizures
149
What is the classic head CT finding of someone with toxoplasma infection?
multiple, ring enhancing lesions
150
``` 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 ```
bacterial tonsilitis >3 on centor criteria viral is posterior cervical + EBV has splenomegaly
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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 ```
Group B streptococcus commonest cause of fever and drowsiness in neonates is meningitis Prolonged rupture of membranes is more associated with Group B strep
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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 ```
Streptococcus viridian DiGeorge patients have congenital heart defects. Dental procedures may result in introduction of infection.
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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 ```
Vibrio cholera
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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?
Campylobacter – undercooked poultry Salmonella is more associated with raw eggs
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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?
C. difficile association with antibiotics suggested by the severe pneumonia and hospitalisation
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Define meningitis
Inflammation of leptomeningeal (pia mater and arachnoid) coverings of the brain
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Define encephalitis
Inflammation of brain parenchyma
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Who does meningitis most commonly affect?
Affects extremes of age (impaired immunity)
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What is the most common cause of encephalitis?
Virus- main = HHV | Can be infective or non-infective cause
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Most common causative agents for meningitis
Most commonly bacterial: - Streptococcus pneumoniae, - Neisseria meningitidis - Haemophilus influenzae type B
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State some causes of aseptic meningitis
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)
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symptoms of meningitis
MENINGISM: Photophobia Neck stiffness Fever Headache
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symptoms of encephalitis
``` Altered state of consciousness seizures personality change cranial nerve palsies speech problems motor and sensory deficit ``` CONFUSION IS LESS COMMON IN MENINGITIS
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Investigations for meningitis
Blood: Two sets of blood cultures Imaging: CT scan to exclude intracranial pressure. Lumbar puncture: Send CSF for MC&S and Gram staining
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Investigations for encephalitis
Blood cultures neuroimaging (MRI) CSF analysis
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immediate management of meningitis
Empirical antimicrobial therapy should be started promptly: Ceftriaxone + Vancomycin Consider corticosteroids – Dexamethasone for bacterial meningitis (unless meningococcal septicaemia is suspected)
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What meningitis infection would you expect in neonates after an extended labour (+infection in previous infection)?
Group B streptococcus
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What meningitis infection would you expect in late neonates? (few weeks post birth)
E. coli
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What are the 3 common meningitis bacterial pathogens in neonates?
Group B strep E. coli Listeria monocytogenes
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Most common bacterial causes of meningitis in children + teenagers
``` Neisseria meningitides (if vaccinated) Haemophilus influenzae (if unvaccinated) ```
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What type of bacteria is Neisseria meningitides?
gram negative diplococci
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What are the 2 commonest causes of meningitis in adults/elderly and what are they associated with?
most common = streptococcus pneumoniae | elderly, cheese/unpasteurised milk. alcoholics = Listeria monocytogenes
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2 signs of meningism
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
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signs of meningitis
``` Brudinski's and Kernig's signs fever tachycardia hypotension petechial rash- non-blanching = meningococcal septicaemia altered mental state ```
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contraindications for lumbar puncture
Neurological signs suggesting raised ICP (CT head first) Superficial infection over LP site Coagulopathy
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How would CSF results differ in appearance between different infectious causes of meningitis?
``` NORMAL = clear BACTERIAL = turbid VIRAL/TB/FUNGAL = clear/cloudy ```
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Compare CSF results between different infectious causes of meningitis
``` 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
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If a patient presents with a non-blanching rash/meningococcal septicaemia + meningism how would you manage them?
This is NEISSERIA MENINGITIDES Admit give single IV dose of benzylpenicillin
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What antibiotic would you give for suspected Lisseria meningitis?
ampicillin
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If a meningitic patient presents with impaired consciousness, what drug would consider giving and why?
suspect meningo-encephalitis IV acyclovir most common cause of encephalitis is HHV
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What prophylactic drugs would you give to people exposed to meningitis?
Rifampicin
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Fungal causes of encephalitis
Cryptococcus, candida
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Parasitic causes of encephalitis
Toxoplasma gondii, malaria
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Define infective endocarditis
Infection of endocardial structures (mainly heart valves)
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Most common causes of infective endocarditis? For each pathogen, state the associated RF
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.
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Which organisms may test negative on culture in infective endocarditis?
HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), Coxiella burnetii, histoplasma
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RF for infective endocarditis
``` 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 ```
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which valve is most likely to be affected in IVDU associated endocarditis?
first valve in contact with venous system- tricuspid
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Which infective endocarditis causative organism is associated with GI malignancy?
Streptococcus Bovis
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symptoms of infective endocarditis
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.
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signs of infective endocarditis
- 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).
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What mnemonic can be used to remember the signs of infective endocarditis?
FROM JANE with ♥: ``` Fever Roth spots Osler nodes Murmur Janeway lesions Anaemia Nail-bed haemorrhage Emboli ```
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What hand sings may you see of infective endocarditis?
JANEWAY LESIONS- painless, blanching palmar macules OSLER'S NODES- painful, tender nodules on finger/toe pads SPLINTER HAEMORRHAGE
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Buzzwords for infective endocarditis
- prosthetic valve - dental procedures (strep) - new onset murmur - vegetation on echo - right heart (IVDU) - indwelling catheter
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Investigations for infective endocarditis
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
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What classification is used to diagnose infective endocarditis?
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.
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complications of infective endocarditis
``` Congestive heart failure Valve incompetence Aneurysm formation Systemic embolization Renal failure Glomerulonephritis. ```
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Management of infective endocarditis?
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
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Define gastroenteritis
Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdominal discomfort.
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Most common causes of viral gastroenteritis
Rotavirus (children, decreasing due to vaccine) adenovirus astrovirus calcivirus
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Most common causes of bacterial gastroenteritis
``` Campylobacter jejuni E.coli Salmonella Shigella Vibrio cholerae Listeria Yersinia enterocolitica. ```
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Most common causes of protozoal gastroenteritis
Entamoeba histolytica Cryptosporidium parvum Giardia lamblia
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What pathogens might be present in undercooked meat?
S. aureus, C. perfringens
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What pathogens might be present in old rice?
B. cereus, S. aureus
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What pathogens might be present in milk + cheese?
Listeria, Campylobacter
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What pathogens might be present in canned food?
botulism
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Diarrhoea versus dysentry
dysentry = bloody diarrhoea
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Which pathogens can cause dysentry? (CHESS)
``` CHESS: Campylobacter / Clostridium difficile Haemorrhagic E. coli Entamoeba histolytica Shigella Salmonella ```
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What 2 categories of toxin can be produced to create inflammatory/non-inflammatory diarrhoea?
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)
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Which bacteria is responsible for diarrhoea after antibiotic use?
C. difficile
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Which bacteria is responsible for short-lived diarrhoea 1-6 hours after eating?
Staph aureus
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Which bacteria is responsible for rice-water diarrhoea with poor sanitisation + shock?
Vibrio cholera
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Which bacteria is responsible for diarrhoea after eating leafy vegetables?
E. Coli | also haemorrhagic E.coli = dysentry followed by HUS
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Which bacteria is responsible for diarrhoea after eating reheated rice? What else can it cause?
Bacillus cereus | can cause cerebral abscess
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Which bacteria responsible for diarrhoea is found in eggs?
Salmonella | multiplies in Payer’s patches of the intestine
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Which bacteria responsible for diarrhoea is found in poultry?
Campylobacter
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Shigella is associated with what?
person-person contact | MSM
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Gastroenteritis symptoms
``` Sudden onset nausea Vomiting Anorexia. Diarrhoea (+/- blood) Abdominal pain Fever and malaise. ```
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Investigations for gastroenteritis
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
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Management of gastroenteritis with no systemic illness (fever, shock, dysentry, >2 weeks)
Supportive therapy Bed rest, fluids and electrolyte replacement with oral rehydration solution No stool culture needed
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Management of gastroenteritis with systemic illness (fever, shock, dysentry, >2 weeks)
Admit and give oral fluids (IV rehydration for severe vomiting) Antibiotics if infective organism identified Direct faecal smear, then culture
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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 ```
Hepatitis A Jaundice, RUQ pain & raised ALT & AST is suggestive of Hepatitis. Jamaica is an endemic country and Hepatitis A is faeco-orally transmitted
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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 ```
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
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?
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
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  ```
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
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Define hepatitis
Inflammatory liver injury
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Signs and symptoms of hepatitis
Fever Jaundice Raised ALT, raised AST
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common causes of hepatitis
Viral A, B, C, D, E Alcoholic Autoimmune
229
Investigations for viral hepatitis
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
Which hepatitis are faeco oral?
A+E | Faeco-oral hepatitis = The vowels hit your bowels
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Hep A common history features
Acute- Travel history (contaminated water is a major source) | Asymptomatic (usually)
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Hep A symptoms
``` Nausea Vomiting (+ Diarrhoea) Fever Jaundice Abdominal pain (particularly RUQ) ```
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Hep A treatment
supportive, and alcohol should be avoided. | There is a small risk of acute liver failure, which necessitates the need for liver transplantation
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risks of chronic HEV infection are high for which group?
``` HEV infection is usually acute and self-limiting. immunocompromised patients (including organ transplant recipients on immunosuppressants) are at risk of chronic infection. ```
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HAV is common in which areas/foods?
Outbreaks are more common in Asia and Africa improperly cleaned shellfish from contaminated water can be source of HAV MSM
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Acute HBV symptoms
Nausea, Anorexia, RUQ pain, Jaundice
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How is HBV spread?
vertical mother-child transmission, contaminated blood products and sexually.
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HBV vs HCV
``` 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 ```
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which hepatitis is RF for HCC?
HCV
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Treatment of HCV
Antiretrovirals are now curative e.g. Sofosbuvir (NS5B inhibitors) Ledipasvir (NS5A inhibitors) Grazoprevir (NS3/4 protease
241
Define UTI
Characterized by presence of>100,000 of colony-forming units per millilitre of urine. UTI may affect bladder (cystitis), kidney (pyelonephritis) or prostate (prostatitis).
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cystitis signs
Frequency, Urgency, Dysuria Haematuria. Foul-smelling ± cloudy urine. Suprapubic or loin pain.
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pyelonephritis signs
Rigors. Pyrexia. Nausea ± vomiting. Acute confusional state  elderly.
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Common pathogens causing UTI
Escherichia coli = most common Proteus mirabilis Klebsiella Enterococci
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Investigations for UTI
Assess RF Dipstick urinalysis: positive nitrites (E.coli specific) +/- leukocytes Urine MC&S (Abdo USS – exclude urinary tract obstruction or renal stones)
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RF UTI
female, recent instrumentation, abnormality, incomplete bladder emptying, sexual activity, new sexual partner, diabetes, catheter, pregnancy
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management of UTI
Trimethoprim/ Nitrofurantoin
248
E.coli UTI causes what positive dipstick result?
nitrites
249
Define malaria
Infection with protozoan Plasmodium
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Causative organisms for malaria
Plasmodium spp P. vivax/ovale P. falciparum P. malaria
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Incubation period of malaria
Incubation usually 1-2 weeks but up to a year
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organisms responsible for transmission of malaria
female Anopheles mosquito
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Symptoms of malaria
``` Headache Weakness Myalgia/ Arthralgia Anorexia Fever - Characteristic paroxysms of severe cold / rigors followed by severing sweating ```
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Signs of malaria
Pyrexia Anaemia Splenomegaly
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Investigations for malaria
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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