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extra 1 (e) > Infections and Immunity > Flashcards

Infections and Immunity Flashcards

1
Q

What immunisations are given <1yr? (8)

A

8 weeks (2 months):

1) 6-in-1 vaccine
2) Pneumococcal (PCV) vaccine
3) Rotavirus vaccine
4) MenB

12 weeks (3 months):

5) 6-in-1 vaccine - 2nd dose
6) Rotavirus vaccine - 2nd dose

16 weeks (4 months):

7) 6-in-1 vaccine - 3rd dose
8) PCV - 2nd dose
9) MenB - 2nd dose

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2
Q

What immunisations are given aged 1-15yr? (10)

A

1 year:

1) Hib/MenC - 1st dose
2) MMR - 1st dose
3) PCV - 3rd dose
4) MenB - 3rd dose

2-10yrs:
5) Flu vaccine - every year

3yrs and 4 months:

6) MMR - 2nd dose
7) 4-in-1 pre-school booster

12-13yr:
8) HPV vaccine

14yr:

9) 3-in-1 teenage booster
10) MenACWY

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3
Q

What immunisations are given to adults? (3)

A

65yr:

1) Pneumococcal (PPV) vaccine
2) Flu vaccine (and every year after)

70yr:
3) Shingles vaccine

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4
Q

What immunisations are offered to pregnant women? (2)

A 
Flu vaccine - during flu season
Whooping cough (pertussis) vaccine - from 16 wks
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5
Q

What is in the 6-in-1 vaccine?

A

DHHPTW

1) Diptheria
2) Hep B
3) Hib - Haemophilus influenza type b
4) Polio
5) Tetanus
6) Whooping cough - pertussis

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6
Q

What is in the 4-in-1 pre-school booster?

A

DTPP

1) Diphtheria
2) Tetanus
3) Whooping cough - pertussis
4) Polio

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7
Q

What is in the 3-in-1 teenage booster?

A

DTP

1) Diphtheria
2) Tetanus
3) Polio

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8
Q

Which vaccines are live? (3)

A

1) Influenza
2) MMR
3) Rotavirus (oral)

+ BCG

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9
Q

When does meningitis mostly occur in children?

A

Mostly in first 5 years of life

75% of cases are <15yrs

Younger children are at greater risk of brain damage and are more difficult to diagnose

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10
Q

What proportion of meningitis cases are bacterial vs viral?

A

1/3rd bacterial

2/3rd viral

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11
Q

What is the pathophysiology of bacterial meningitis?

A

Colonisation of nasopharyngeal epithelium

Invasion of blood then meninges

Cerebral oedema caused by inflammation + leaky vessels

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12
Q

What is the pathophysiology of viral meningitis?

A

Infection of a mucus membrane followed by LN involvement

Primary viraemia = causes viral illness

Secondary viraemia = inolved organs such as liver

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13
Q

List some risk factors for meningitis (5)

A

1) Young age = most significant
2) Immune suppression
3) CSF shunt / dural defects
4) Spinal procedures eg spinal anaesthetics (Pseudomonas may be cause)
5) Crowding eg uni halls inc risk of meningococcal meningitides

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14
Q

What are some risk factors for neonatal meningitis? (6)

A

1) Low birth weight (<2500g)
2) Prematurity
3) Premature rupture of membranes
4) Traumatic delivery
5) Fetal hypoxia
6) Maternal peripartum infection

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15
Q

What are the most common bacterial causative organisms of meningitis in neonates? (3)

A

1) Group B strep
2) Listeria monocytogenes
3) E coli

+ other coliforms

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16
Q

What are the most common bacterial causative organisms of meningitis in infants / children? (4)

A

1) Haemophilus influenzae
2) Neisseria meningitidus
3) Streptococcus pneumoiae
4) Mycoplasma tuberculosis

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17
Q

What are the most common causative organisms of meningitis in adolescents / adults? (2)

A

1) Neisseria meningitidis

2) Streptococcus pneumoniae

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18
Q

What are the most common viral causative organisms of meningitis across all ages? (3)

A

1) Enterovirus
2) Adenovirus
3) Epstein-Barr

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19
Q

What symptoms may meningitis present with? (13)

A

Infant:

1) Fretfulness
2) High-pitched cry
3) Bulging fontanelle
4) Poor feeding
5) Respiratory distress

Child:

6) Headache
7) Photophobia
8) Neck stiffness

All ages:

9) Fever
10) Irritable
11) Vomitting
12) Drowsiness
13) Seizures

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20
Q

What are some signs of raised ICP? (6)

A

1) Papilloedema
2) Altered / LOC
3) Full fontanelle
4) Inc BP
5) Dec HR
6) Focal neuro signs

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21
Q

What is meningitis vs meningococcal septicaemia?

A

Meningitis = inflammation of the leptomeninges that surround the brain and spinal cord

  • Various causative organisms
  • May have neck stiffness / photophobia
  • Unlikely to have a rash

Meningococcal septicaemia = systemic infection

  • CAUSED BY NEISSERIA MENINGITIDIS
  • Rapidly spreading purpuric rash
  • May or may not also have meningitis
  • Often fatal
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22
Q

List 3 signs of meningism

A

1) Nuchal rigidity - unable to flex neck
2) Kernig’s sign - unable to extend knee when thigh flexed to 90 degrees
3) Brudunski’s sign - involuntary lifting of leg when lying supine and head is raised

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23
Q

List some ddx of meningitis

A

Drugs / toxicity
Migraine
Encephalitis
SAH

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24
Q

What investigations are done in meningitis? (6)

A

Do not delay abx by more than 30 mins

1) LP - unless suspected raised ICP
2) CT head
3) Bloods - FBC, U&Es, CRIP, glucose, blood cultures, gases
4) Urine for MCC
5) Nasal / throat swabs
6) CXR - lung abscess

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25
Q

What would the LP results be in bacterial vs viral meningitis?

A

Viral:

  • Clear / hazy appearance
  • Lymphocytes +
  • Protein +
  • Glucose = Normal

Bacterial:

  • Cloudy / purprulent
  • Neutrophils ++
  • Protein ++
  • Glucose = Low
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26
Q

List some contraindications to LP (7)

A

1) Raised ICP = stabilise first
2) Shock = stabilise first
3) After convulsions = stabilise first
4) Respiratory insufficiency = stabilise frist

5) Abnormal clotting
6) Infection at LP site
7) Extensive purpura

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27
Q

What is a pyrexia?

What is a red flag?

What is an amber flag?

A

Temp of 38 degrees celsius or more

<3 months, fever of more than 38 = red flag

3-6 months, fever of over 39 = amber flag

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28
Q

What is the treatment of suspected meningococcal meningitis in the community?

A

If in doubt - treat as bacterial

IM benzylpenicillin single dose

<10yr = 1g
1-9yr = 600mg
<1yr = 300mg
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29
Q

What is the treatment of suspected bacterial meningitis in hospital?

A

<3 months = IV cefotaxime
>3 months = IV ceftriaxone

Symptomatic treatment - antipyretics, analgesics, IV fluids (viral meningitis is treated only symptomatically)

Dexamethasone

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30
Q

What is the prognosis of bacterial and viral meningitis?

A

Bacterial: 5-10% die, 10% experience brain damage
- Pneumococcal has the highest morbidity/mortality

Viral: complete recovery usually
- Except HSV (morbidity/mortality 50%)

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31
Q

What are some complications of meningitis?

A

Immediate:

  • Septic shock
  • Seizures
  • DIC
  • Cerebral oedema
  • Hydrocephalus (blockage of ventricular outlet)

Delayed:

  • Hearing loss (follow up includes hearing test)
  • Focal paralysis
  • Seizures
  • Cerebral palsy (if <2yr)
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32
Q

List preventative measures for meningitis

A

Prophylactic abx in labour if known Group B strep colonisation
- Or neonatal abx if not completely treated in labour

Vaccinations:

  • Childhood vaccination against Him, Menc/B, strep pneumonia
  • Quadrivalent (meningococcus groups A,C,W,Y) for teenagers

Chemoprohpylaxis for those living in same house / spending more than 5 hours a day with child
- Ciprofloxacin or rifampicin

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33
Q

What is meningococcal septicaemia?

A

Acute infection of the bloodstream and subsequent vasculitis with bacteria Neisseria meningitides

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34
Q

What type of bacteria is Neisseria meningitides?

A

Gram -ve diplococci

35
Q

What groups are there of Neisseria meningitides?

A

A, B, C, W, Y

36
Q

What is the epidemiology of meningococcal septicaemia?

A

Most cases <5yr

Second peak in a adolescence

37
Q

What are the early signs of meningococcal septicaemia? (6)

A

1) Fever
2) Mottling
3) Leg pain
4) Cold peripheries
5) Breathing difficulties
6) Non-blanching rash >12hrs

38
Q

What are some early complications of meningococcal septicaemia? (4)

A

1) DIC
2) AKI
3) Adrenal haemorrhage
4) Circulatory collapse

39
Q

What are some late complications of meningococcal septicaemia? (5)

A

1) Deafness
2) Scarring
3) Renal failure
4) Limb amputations
5) Mortality

40
Q

What are purpura?

A

Non-blanching spots caused by bleeding under the skin

Spots <3mm are called petechiae

Spots >10mm are called ecchymoses

41
Q

What are purpura a sign of?

A

= non-specific sign

However in febrile / unwell child they can indicate serious bacterial infection esp meningococcal disease

42
Q

List some causes of purpura

A

VITAMIN CDE

Vascular
Infective / Inflammatory
Trauma
Autoimmune
Metabolic
Iatrogenic
Neoplastic
Congenital / Coagulopathy 
Developmental / Digestive
Endocrine / Environment
43
Q

What is a vascular condition causing purpura?

A

Henoch-Schonlein purpura

44
Q

What is the distribution of purpura in Henoch-Schonlein purpura?

What is the platelet count?

A

Pupura distributed across extensor surfaces, buttocks and ankles

Normal platelet count

45
Q

What is an infective / inflammatory cause of purpura?

A

Meningococcal disease

46
Q

What is the distribution of purpura in meningococcal disease?

A

Diffuse macular rash - appear before your eyes

Give immediate IM Benzylpenicillin !!!!

47
Q

What coagulopathies can cause purpura?

A

Thrombocytopenia

Also DIC and scurvy (vit C deficiency causes weak capillary walls)

48
Q

What is the course of purpura in thrombocytopenia?

A

Petichial rash followed by a purpuric rash

Usually acute onset in the weeks following a URTI

49
Q

What is Henoch-Schonlein purpura?

A

IgA-mediated, autoimmune hypersensitivity vasculitis of childhood

Main features: purpura, arthritis, abode pain, GI bleeding and nephritis

50
Q

Define:

1) Sepsis
2) Septicaemia
3) Septic shock

A

Sepsis = systemic inflammatory response

Septicaemia = blood borne infection which causes sepsis

Septic shock = severe sepsis causing hypotension and compromised tissue perfusion

51
Q

Describe the process of septic shock

A

Bacterial toxins cause systemic inflammatory response:

1) Vasodilation
2) Increased microvascular permeability
3) Tissue hypoxia
4) Myocardial depression
5) DIC

52
Q

How may early signs of compensated shock present?

A 
Tachycardia
Cool peripheries
Tachypnoea
Decreased UO
Inc cap refill time
O2 sats <95%
Confusion / LOC
Hypotension (later)

NB high fever can also cause tachycardia and peripheral vasoconstriction which may present similarly to early compensated shock

If septicaemia is meningococcal = look for signs of meningitis and non-blanching petechial/purpuric rash as an early sign (not always present) - in 30% rash is blanching and maculopapular

53
Q

What investigations should be performed for septic shock?

A

Septic screen = CRAP blood

Cultures - blood, urine, stool, CSF (if no raised ICP), indwelling catheters
Radiography - CXR, AXR
ABG - metabolic acidosis
Pee (urinalysis)
Bloods - FCB (raised WCC), U&Es, LFTs, CRP, ESR, glucose, calcium, phosphate, clotting

54
Q

List some common possible sauces of septic shock (4), their causative organisms and appropriate abx

A

1) Indwelling catheter - s. aureus (trust guidelines)
2) Intra-abdo - gut anaerobes (metronidazole, gentamicin)
3) Immunosuppressed - pseudomonas (ceftazidime, gentamicin)
4) Cellulitis - group A strep (penicillin)

55
Q

What prophylaxis is given for septic shock?

A

Close contacts (and affected child on discharge) are given 2-day course of rifampicin

NB makes urine pink

56
Q

How us neisseria meningitides divided?

A

Into 13 serogroups

These include A, B, C, W and Y which account for 90% of invasive disease and we are vaccinated against

57
Q

Which vaccine commonly gives a fever in the days following its administration?

A

MMR

Parents often bring children to A&E but advise them this is a self-limiting reaction

58
Q

List some ddx for a child presenting with a fever and a rash (7)

A

1) Measles
2) Rubella
3) Roseola
4) Scarlett fever
5) Fifth disease
6) Hand food and mouth disease
7) Chicken pox
8) Meningococcaemia

59
Q

List some ddx for a child presenting with an acute fever (9)

A

1) URTI
2) Tonsillitis
3) OM
4) Nonspecific viral infection
5) Pneumonia
6) Meningitis
7) UTI
8) Septic arthritis
9) Non-infectious causes

60
Q

List some ddx for a febrile child with a swelling in the neck (5)

A

1) Cervical adenitis
2) Infectious mononucleosis
3) Mumps
4) Thyroiditis (often no fever)
5) Mastoiditis

61
Q

List some ddx of a child with pyrexia of unknown origin (6)

A

1) Infective endocarditis
2) Osteomyelitis
3) Collagen vascular disease
4) IBD
5) Neoplastic disease
6) Factitious fever

62
Q

What is causes a factitious fever?

A

Eg taking a temperature after a hot drink, deliberate manipulation of the thermometer

63
Q

List some ddx of a febrile child with recurrent infections (2)

A

1) HIV / AIDS

2) Hyposplenism / splenectomy

64
Q

What virus causes chickenpox?

A

Varicella-Zoster virus

65
Q

What does reactivation of VZV lead to?

A

Shingles

66
Q

What is the incubation period of chicken pox?

A

14-17 days

67
Q

What is the usual duration of the rash in chickenpox?

A

6-10 days

68
Q

What is the recommended isolation period for chicken pox?

A

Until all the lesions are crusted over (usually 5-6 days)

69
Q

Describe the type of rash and distribution in chickenpox

A

Vesicular rash

Occurs in crops on face and trunk

Pass through stages of papule, vesicle, pustule and crust

70
Q

What is the first feature of chickenpox? How long does this last?

A

Fever for up to 4 days

71
Q

How else does chickenpox present?

A 
Headache
Malaise
Abdo Pain
Itchy rash
Shallow ulcers of the mucous membranes
Coryzal
72
Q

What may occur when immunocompromised get chickenpox?

A

Pneumonia
Large and bleeding vesicles
DIC

73
Q

What investigations are done for chickenpox?

A

Diagnosis clinical

Can confirm with scrapings and performing immunohistochemical staining or PCR

Complications require further investigations eg CXR and neurological features eg LP

74
Q

What is the management of chickenpox in an otherwise healthy individual?

A

Rest and fluids
Symptomatic - analgesia and antipyretics
Help pruritus with antihistamines
Keep nails short

Avoid contact with pregnancy women, neonates, immunocompromised

75
Q

Why are NSAIDs not advised. for chickenpox?

A

Possible association with necrotising soft tissue infections

76
Q

What populations require antiviral treatment for chickenpox?

A

IV aciclovir:

  • Immunocompromised
  • Systemic disease
  • Pt on high dose steroids
  • New lesions appearing after 8 days

PO aciclovir:
- >12yr

77
Q

What are some complications of chickenpox?

A

1) Secondary infection of skin lesions (eg if Group A strep can produce necrotising fasciitis and toxic shock syndrome)
2) Viral pneumonia
3) Encephalitis
4) CNS complications eg benign cerebellar ataxia

78
Q

Why is chickenpox late in pregnancy concerning?

A

It can cause premature delivery

If rash appears within a week of delivery or 2 days after, there is a risk of neonatal chickenpox

79
Q

Why is neonatal chickenpox concerning?

A

There is transplacental transmission of virus but not antibody, and there is no time for IgG to develop and the baby is at 30% risk of death from severe pneumonia or fulminant hepatitis

NB IgG can cross the placenta (initial IgM cannot) - so if at least a week passes between rash and delivery is fine as IgG will have developed

80
Q

Why is chickenpox within first 2 weeks of pregnancy concerning?

A

Risk of congenital varicella syndrome

  • IUGR
  • Microcephaly
  • Cortical atrophy
  • Limb hypoplasia
81
Q

What is the treatment of neonatal chickenpox?

A

Immunoglobulin and aciclovir

82
Q

How is chickenpox transmitted?

A

Respiratory droplets or direct contact with vesicular fluid

83
Q

How does encephalitis following chickenpox usually present?

A

Ataxia one week after rash

Good prognosis

84
Q

When should parents be advised they can reenter their children to school with chickenpox?

A

6 days after the last spots appear

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