Infections Key Flashcards
1
Q
CAP
rx for mild moderate and severe?
A
Community Acquired Pneumonia
Amoxicillin
(Mild)
Community Acquired Pneumonia
(Moderate)
Amoxicillin + Clarithromycin
Community Acquired Pneumonia
Co-amoxiclav + Clarithromycin
(Severe)
Co-amoxiclav = Amoxicillin + clavulanic
acid
e.g. Augmentin®
2
Q
Staph pneumonia
A
Pneumonia caused by
staphylococcus aureus
Flucloxacillin
3
Q
Pneumocystis Jirovecii “P. Carinii”
Rx
A
Pneumocystis Jirovecii “P. Carinii”
Co-Trimoxazole
(Seen in HIV patients when CD4
count is < 200 cells/microL).
4
Q
Aspiration pneumonia RX?
A
Aspiration Pneumonia
Amoxicillin + Metronidazole
5
Q
CNS (Meningitis)
A
Out-of-hospital Meningitis (GP clinic) IV or IM Benzylpenicillin
In-hospital meningitis (most types) Ceftriaxone
If > 60 YO: IV ceftriaxone + amoxicillin
Listeria Meningitis -Ceftriaxone + Ampicillin +
Gentamicin
CryptococcalMeningitis -Amphotericin B
Meningitis Prophylaxis “for
contacts”
√ Ciprofloxacin “preferred” or:
√ Rifampicin
6
Q
Genitourinary Conditions
A
Lower uncomplicated UTI
Trimethoprim or Nitrofurantoin
(in a non-pregnant ♀)
Candida albicans (Vulvovaginal
Candidiasis)
Clotrimazole or Fluconazole
Trichomonas Vaginalis -Metronidazole
• Bacterial Vaginosis
= (Gardnerella Vaginalis)
Metronidazole
7
Q
Cervicitis treatment
Clamydia and gonorrhoea
A
Cervicitis (Chlamydia) Recent Guidelines for the management
of Cervicitis (September 2019)
Chlamydia
◙ 1st line → Doxycycline 100 mg BID for 7
Days.
◙ Another line:
Azithromycin 1-gram PO
Followed by 500 mg PO OD for 2 days.
Cervicitis (N. Gonorrhea) Neisseria gonorrhoea
◙ Ceftriaxone 1 gm IM (single dose). Or:
◙ Ciprofloxacin 500 mg PO (Single dose).
8
Q
PID
Syphilis
Herpes Rx??
A
PID “Pelvic Inflammatory Disease”
Differs based on hospital guidelines,
one example: (CDM)
Ceftriaxone + Doxycycline +
Metronidazole
Syphilis- Penicillin G
Genital Herpes “HSV” -Aciclovir
9
Q
GIT Conditions
A
Salmonella/ Shigella/ Campylobacter -
Erythromycin or Azithromycin or
Clarithromycin
Or Ciprofloxacin
Clostridium Difficile
√ Oral Vancomycin “first line”
“Pseudomembranous colitis”
√ Metronidazole “second line”
H. Pylori OAC Regimen (Triple):
√ Omeprazole (PPI)
√ Amoxicillin
√ Clarithromycin
10
Q
ENT Conditions
A
Acute “bacterial” Otitis Media Amoxicillin
URTI “Pharyngitis/ Tonsillitis/
Laryngitis”
Phenoxymethylpenicillin
11
Q
Cellulitis
Mastitis
Diabetic Foot
A
√ 1st line: Flucloxacillin
√ If penicillin allergic: Clarithromycin
or Erythromycin (if pregnant) or
Clindamycin.
√ If MRSA: Vancomycin
12
Q
Septic arthritis
Osteomyelitis
A
Flucloxacillin + Sodium Fusidate
13
Q
Scabies
Toxoplasmosis Rx
A
Scabies -5% Permethrin
Toxoplasmosis- Pyrimethamine + Sulfadiazine
14
Q
Brucellosis
A
◙ Infectious → Bacteria Brucella.
◙ Common in some areas especially those who have high exposure to
animals (
e.g. goats, sheep,
camels, cattle,
buffalos,
pigs, dogs).
◙ Examples of Areas →
Nigeria,
South America,
Middle East,
Central and
South-east Asia,
Africa
15
Q
Brucellosis
IP
Locations?
A
◙ Inhalation: the most common mode of transmission in endemic areas,
affecting
farmers, herdsmen “the owner or keeper of a herd of domesticated
animals.” (
and particularly families where the animals share the same
accommodation),
laboratory technicians
and abattoir workers
“slaughterhouses”
.
◙ Other modes of transmission include:
√ Skin (intact or broken) or mucous membrane (conjunctival) contact.
√ Consumption of infected/contaminated food: untreated milk/dairy
products (particularly unpasteurised cheeses), raw meat or liver.
◙ The key point is to think of the diagnosis and then take a travel and
occupational history.
◙ Most cases involve exposure to an infected animal e.g. working in a farm in
an endemic area.
◙ The incubation period is typically 5-30 days but can be up to six months or
possibly longer.
16
Q
Clinical manifestations of brucellosis
A
Brucellosis may be asymptomatic. Symptoms are generally nonspecific.
Symptoms
may appear suddenly over 1-2 days
or gradually over seven days
or more.
In a study of 84 patients:
√ Fever was observed in 73% of patients. It is a differential in pyrexia of
unknown origin (PUO). Classically undulant but other patterns occur.
√ Arthritis/arthralgia (in 64%).
√ Other symptoms can include
malaise, back pain, headaches,
loss of
appetite, weight loss (in chronic infection),
constipation, abdominal pain,
sleep disturbances,
cough, testicular pain, and skin rash (less common).
√ In around a quarter of patients: looks ill, pallor,
lymphadenopathy,
splenomegaly,
hepatomegaly,
epididymo-orchitis,
skin rash.
17
Q
A 30 YO man who went to work in a farm in South America
returned to the UK. He Developed 8 weeks history of night sweat,
fever, arthralgia, weight loss and splenomegaly. Temp: 38°c
Dx
INV
Rx?
A
Brucellosis
Dx:
√ Initial → Rose Bengal test OR Serum agglutination test.
√ Gold standard → Isolation of Brucella spp from a specimen.
◙ Rx → Doxycycline + Rifampicin for 6 weeks
18
Q
• Usually in a patient with influenza infection
(Initially flu-like symptoms then pneumonia).
• Also common in IV drug abusers and elderly.
◙ Chest X-ray: Cavitation.
A
Staphylococcal pneumonia
19
Q
Pneumocystis jirovecii
(or: Pneumocystis Carinii)
“a yeast-like fungus”
• Immunocompromised (HIV with CD4 < 200)
• Exertional Dyspnea.
• Dry Cough.
• Bilateral consolidation.
A
Pneumocystis jirovecii
(or: Pneumocystis Carinii)
“a yeast-like fungus”
20
Q
• Flu-like symptoms
• Erythema Multiforme.
◙ Patchy consolidation often of 1 lower lobe.
Dx?
A
Mycoplasma
Pneumonia
• Flu-like symptoms
• Erythema Multiforme.
(Mycoplasma → Erythema multiforme)
◙ Patchy consolidation often of 1 lower lobe.
21
Q
• Hx of contamination with water.
◙ Bi-basal Consolidation
A
Legionella • Hx of contamination with water.
22
Q
(The commonest cause of
pneumonia)
• TypicaL features of community acquired
pneumonia; (productive cough/ fever/ unilateral
basal crackles and consolidation)
• Association with Herpes Labialis.
◙ Lobar Consolidation.
A
StreptococcaL
(Pneumococcal)
(The commonest cause of
pneumonia)
• TypicaL features of community acquired
pneumonia; (productive cough/ fever/ unilateral
basal crackles and consolidation)
• Association with Herpes Labialis.
◙ Lobar Consolidation.
23
Q
Alcoholic pneumonia
Upper lobes
Cavitations
A
Klebsiella → Cavitating pneumonia particularly of upper lobes.
24
Q
Different types of pneumonia and clinchers
A
• Herpes Labialis → Streptococcal (Pneumococcal).
• Erythema Multiforme → Mycoplasma
• HIV with CD4 < 200 → Pneumocystis Jirovecii (Carinii)
• Pneumonia developed after influenza (Flu) → Staph. Aureus.
• Pneumonia after Hx of Exposure to Water → Legionella.
25
Sometimes a question may try to trick you into choosing (P. jirovecii) by
giving a Hx of HIV-Positive patient, be careful!
HIV is a risk factor for both P.
jirovecii and Streptococcal Pneumonia.
How to differentiate?
(Simple Rule)
√ If the CD 4 < 200 (±) bilateral consolidation → P. jirovecii.
√ If CD4 > 200 (±) Lobar pneumonia → Streptococcal Pneumonia the commonest cause of pneumonia).
26
◙ The causative organism → Epstein-Barr Virus (EBV), also called (Human
Herpesvirus 4; HHV-4).
◙ Presents with → Sore throat, Exudative tonsillar enlargement, Tonsillar
membranes, fever, malaise, lymphadenopathy “especially cervical”
±
Splenomegaly ±
Palatal petechiae ±
Jaundice
◙ Important Hint → Receiving Ampicillin/ Amoxicillin leads to a
development of → Pruritic maculopapular rash.
◙ Another hint → having sore throat and fever a few days ago.
You might even get asked about the drug that has led to rash development!
The answer would be either Ampicillin or Amoxicillin
Infectious Mononucleosis (IMN)
◙ The other name for (IMN) → Glandular Fever. “important √”
27
Imn
Findings in investigation and treatment?
◙ Dx → Heterophil antibody test = Monospot test = Paul Bunnel
◙ FBC → ↑ WBCs, ↑ ESR, Lymphocytosis, Atypical Lymphocytes > 20%
◙ Rx → Supportive “simple analgesics for any pain and fever
28
√ Cancer of Connective Tissue (Blood vessels ↑ in size resulting
AIDS patients / Homosexual or Bisexual / Jewish or
Mediterranean
→ red, purple, brown or black nodules or papules that are usually non-
painful).
√ RFs (Hints) → Mediterranean.
√ The commonest sites → mouth, nose and throat.
√They can also grow internally (e.g. lungs, GIT).
Kaposi sarcoma
29
Scenario (3):
A pregnant in the 2nd trimester was in significant contact with a child with
chickenpox 7 days ago.
The child developed chicken pox rash the following
day after he met her. She has never had Varicella zoster infection.
A stored
blood sample is tested negative (not detected antibodies) for varicella zoster
virus IgG. Now, she has no rash
. What is the most appropriate management?
The best management → Oral Acyclovir.
• Was the exposure within the infectious period?
Yes, he developed the rash the following day after meeting her, this means
he was infectious (2 days before rash until 5 days after rash).
• Is she immune to VZ?
No, she has no history of chicken pox + Her serology for VZ is negative
→ Give oral aciclovir.
30
A 15-year-old boy has macules, papules and vesicles mainly on his trunk for 3
days now. There is erythema (redness) and tenderness surrounding these
lesions.
Some of the vesicles are secreting pinkish fluids.
His body
temperature is 39.3. What medication class is important in this case?
Give → Antibiotics.
• This is a case of chicken pox which is usually self-limiting and requires only
supportive management (eg, paracetamol, antihistamine for itching).
• However, there is superadded bacterial infection here (erythema and
tenderness surrounding the lesions + pinkish fluid secreted from some
vesicles + high fever).
◘ These signs indicate superadded infection and thus give → Antibiotics.
31
An elderly ♀ on chemotherapy for breast cancer and on steroids for RA
presents to inquire about the management for her condition. She says that
her grandson has chickenpox, and she is in contact with him. What should be
done?
Give → Aciclovir.
She is immunocompromised (Chemotherapy + Steroids) with exposure (She did
not develop the disease).
32
• When to give Varicella-Zoster Immunoglobulin (VZIG)?
VZIG is almost never used now (not recommended since the latest update)
unless for neonates exposed to chickenpox 7 days before or after delivery.
33
Acyclovir? In the following cases:
1 ◙ 2 ◙ aciclovir).
• 1.When to give oral Immunocompromised patients who develop Chickenpox rash.
2.Pregnant ♀ who develop Chicken Pox rash. (If severe rash → IV
3.Immunocompromised patients who are exposed (get in contact with) a
person with chicken pox but in 2 conditions:
—-If the exposure happened within the infectivity period (ie, 2 days before
the appearance of the rash on the person up until 5 days after rash
appearance).
—-If their immunity to varicella is unknown or negative. Ie, if their serology
for varicella zoster immunity is negative. (If it is negative, this means they are
not immune to chicken pox).
4. Pregnant ♀ who get in contact with (ie, exposed to) a person with
chicken pox but in 2 conditions:
——If the contact happened within the infectivity period (ie, 2 days before the
appearance of the rash on the person up until 5 days after rash appearance).
—- If their immunity to varicella is unknown or negative. Ie, if they have not
had varicella (chicken pox) before, or their serology for varicella zoster is
negative. (If it is negative, this means they are not immune to chicken pox).
34
Oral acyclovir effective upto??
IP of chicken pox?
Infection period?
◘ Oral Aciclovir is effective if given up to 14 days after contact.
◘ The infectious period of Varicella Zoster is 2 days before rash appearance
till 5 days after rash or when vesicles dried out and crusted.
◘ Incubation period of VZ can be up to 21 days after exposure.
35
Based on the New 2022 guidelines:
• Instead of Varicella-zoster Immunoglobulins (VZIG),
Now, Oral Aciclovir is given to Immunocompromised individuals
who have significant exposure to chicken pox or shingles
and their VZ
serology for immunity is negative (regardless of the chicken pox Hx).
36
Oral acyclovir
Immunocompromised patients Examples:
Heavy smokers, DM, Cancer, Chemotherapy, Corticosteroids users.
• Oral aciclovir is also given to pregnant women who came in contact
with chicken pox patients if they are not immune (ie, no history of
getting chicken pox and the serology for VZV IgG is negative ie, not
37
Scenario (4):
What if she was in contact with someone 8 days ago. And after
these 8 days have passed, he developed chickenpox rash?
→ Reassure
(The infective period of chickenpox is 2 days before the appearance of the
rash up until 5 days after rash appearance. Here, 8 days have passed and
then he developed the rash. So, when she was in contact with him, he wasn’t
infectious).
38
◙ Hx of travel to/from North Africa (e.g., Egypt) +
Fever + Anemia + Tender Enlarged Liver + Deranged liver enzymes + Jaundice.
(No reason for dark urine)
→ Amoebiasis (Liver amoebic disease).
Amoebiasis (caused by Entamoeba histolytica) is endemic in North Africa.
It
presents with anemia,
fever secondary to intestinal hemorrhage and
tender
enlarged liver with deranged liver function
due to hepatic abscess.
39
◙ Hx of travel to/from North Africa (e.g., Egypt) +
Fever + Tender Enlarged Liver + Deranged liver enzymes
+ Urinary symptoms (Dark urine, Hematuria, Dysuria ± ↑creatinine, urea).
± Thrombocytopenia
.
→ Schistosomiasis (Schistosoma Haematobium).
40
Differentiate species of schistosome and symptoms
It is good to know that an infection with Schistosoma does not present with
both (Hepatomegaly) and (Hematuria) at the same time. This is because the
Schistosoma organisms responsible for these 2 features are different.
√ Schistosoma Mansoni → Affects intestines and liver → Hepatomegaly.
√ Schistosoma Hematobium → Affect the Urinary Bladder → Hematuria, UB
calcification and obstructive uropathy.
“These 2 features are caused by 2 different species”
41
◙ North Africa + Malaria-like symptoms +
√ Diarrhea, abdominal pain, liver involvement:
2. Urinary (hematuria- dysuria), thrombocytopenia, liver involvement:
3. ◙ Hx of travel to/from Africa (e.g., Sudan) (usually the stem doesn’t say
NORTH Africa. If North, think more about Schistosoma, Amoeba)
+ Fever, Chills, Rigors ± Hepatomegaly, Hematuria (dark/red urine)
1.Amoebiasis
2.schistosomiasis
3.malaria
42
Differentiate
Schistosomiasis, malaria and amoebiasis
In Short:
Fever, chills and rigors, liver involvement
↓
Are there urinary symptoms?
↓
Yes → Malaria or Schistosoma Hematobium
- Malaria → Africa (Sub-Saharan Africa, not north Africa), south east Asia.
- S. Hematobium (endemic on NORTH Africa, the Middle east).
No urinary symptoms
→ Amoebiasis (+ GIT symptoms, dysentery, diarrhea), (Worldwide).
43
Clinical features of amoebiasis
Schistosomiasis
Malaria
• All three (Malaria, Schistosomiasis Hematobium, Amoebiasis can present
with:
Fever, Chills, Rigors,
Enlarged tender Liver, Deranged Liver functions.
• Both Malaria and Schistosomiasis can have Thrombocytopenia.
• Both Malaria and Schistosomiasis can have dark urine (haemoglobinuria).
- Malaria → Africa.
- Schistosomiasis → North Africa.
• Amoebiasis is unlikely to have thrombocytopenia, and no dark urine. The
prominent is Dysentery, bloody diarrhea, worldwide (anywhere).
44
◙ Hx of travel to/from India + Fever, Cough, Cervical Lymphadenopathy,
Caseating Granuloma in the LNs
→ TB “Tuberculous Lymphadenitis”
45
Needle Stick Injuries
◙ Basic 1st Aid → Washing with soap under running water + Encouraging
bleeding in the affected area.
◙ Request for the patient’s permission to investigate him for blood-borne
infections (HIV, HCV, HBV).
◙ As for the affected “Pricked” healthcare professional:
√ If the patient is a low-risk (e.g. safe sexual intercourse, does not use IV
drugs)
→ Test the affected healthcare professional for Hepatitis B surface antibody.
√ If the patient is a high-risk (e.g. drug addict, IV drug user)
→ Start Post-Exposure Prophylaxis (PEP) for the affected healthcare
professional.
√ Offer Hepatitis B Booster “if booster doses are not received previously or if
the healthcare professional cannot remember when was the last time he
received a booster dose”.
46
Why do we care about Hepatitis B the most?
• This is because the chance for post-needle prick transmission of HIV is only
0.3%, risk for transmission of HCV is 3%, whereas transmission of HBV is as
high as 30%!
• More importantly, the surgeon should return in 6 weeks to be tested for
HIV and HCV as these need some time to appear in serum if he gets
infected.
47
Needle prick summary
Summary:
• The patient should always be tested for all the following:
HIV, Hepatitis C and Hepatitis B “after his consent”.
• The affected “pricked” doctor should always be tested for Hepatitis B and
hepatitis B booster should be offered if he cannot remember when the last
time he received a booster or if he has not received a booster dose before.
• If the patient was a high risk e.g., IV drug user, then the “pricked” doctor
needs to be started on PEP “Post-Exposure Prophylaxis”.
48
Hep b transmission route?
◙ Side Note:
Hepatitis B (HBV) is 50 to 100 times easier to transmit sexually than HIV (the
virus that causes AIDS).
HBV has been found in vaginal secretions, saliva, and
semen.
Oral sex and especially anal sex, whether it occurs
in a heterosexual
or homosexual context, are possible ways of transmitting the virus
49
Important Notes on Meningitis Treatment “MUST memorise”:
Meningitis above 60 years!!
Important Notes on Meningitis Treatment “MUST memorise”:
Imp. NOTE: If the patient is > 60 YO, we add IV ampicillin/ amoxicillin to
ceftriaxone for fear of Listeria Monocytogenes.
Therefore:
√ An over 60 YO patient presents to a hospital with a suspected meningitis
→ IV Ceftriaxone + Amoxicillin
50
√ If a patient with suspected meningitis has hypersensitivity to penicillin or
cephalosporins → give_____
√ when to Notify the Health Protection Team ?
√ If a patient with suspected meningitis has hypersensitivity to penicillin or
cephalosporins → Chloramphenicol
√ Notify the Health Protection Team immediately as soon as there is clinical
suspicion. (Meningitis is a notifiable Disease)
51
√ In Listeria Meningitis →____
Cryptocococcal meningitis?
Meningitis prophylaxis??
√ In Listeria Meningitis → Ceftriaxone (+) Ampicillin (+) Gentamicin
√ In Cryptococcal Meningitis → Amphotericin B
Meningitis prophylaxis → Ciprofloxacin (for contacts)
“Preferred” or Rifampicin.
52
◙ HIV positive patients should NOT be given the following vaccines:
√ BCG vaccine. (X)
√ Yellow Fever Vaccine. (X)
53
◙ If CD4 < 200 cells/ ml → Also AVOID ____ Vaccines. (X)
◙ If CD4 < 750 cells/ ml in children → Also AVOID. ____Vaccines. (X)
MMR
54
If a child is due for MMR vaccination and he has HIV with CD4 >750
→ ______
If a child is due for MMR vaccination and he has HIV with CD4 >750
→ administer MMR vaccine as usual
(paracetamol is given if there is fever after receiving the vaccine).
55
Tetanus Prophylaxis
Updated based on the recent UK guidelines.
1 ♦ Is the wound high risk; dirty/ contaminated/ compound fracture?
2 ♦ What is the person’s immunisation status?
√ If Fully immunised/up-to-date (completed 5 doses of tetanus vaccine)
1 ♦ Is the wound high risk; dirty/ contaminated/ compound fracture?
Yes [i.e. high-risk wound]:
◙ If √ If the victim is not fully immunised → give tetanus immunoglobulin.
√ If he/ she is fully immunised → no need for tetanus immunoglobulin.
◙ If status.
No [i.e. low-risk wound]
→ no need for Tetanus Immunoglobulin regardless of the immunisation
56
2 ♦ What is the person’s immunisation status?
√ If Fully immunised/up-to-date (completed 5 doses of tetanus vaccine) →______
Do not give tetanus vaccine.
An exception here is if the last booster dose was received more than 10
years ago and the wound is tetanus-prone, we give additional booster
vaccine.
√ If Unknown or Incomplete Complete course of tetanus vaccine →
Give (5
doses) Or Full course of DTP if never been immunised (Diphtheria, Tetanus,
Pertussis)
57
♦ Important, sometimes we also give ______ as prophylaxis for wound
infection if the wound is high risk and there is fever.
Antibiotics
58
Immunisation status?
Contaminated wound?
New guidelines for vaccine administration for wound
The new update, in short →
People who have completed the full course of the tetanus vaccine
(including the booster doses) if injured with a deep or contaminated
wound will no longer receive Tetanus Immunoglobulin. Instead,
cleaning the Wound, reassurance & maybe an Antibiotic as
prophylaxis.
In the past, people with contaminated wounds would receive
tetanus immunoglobulin whether they had completed the doses or
not. Now, if they had been given the full course, they won’t be given
tetanus immunoglobulin (the Hx of immunisation makes a
difference now).
Important:
If the last booster dose had been received more than 10 years ago, we give a
tetanus booster vaccine.
59
CI of lumbar puncture
◙ For your knowledge, LP Contraindications:
• ↑ Intracranial pressure.
• Bulging, tense fontanelle.
• Ongoing seizure.
• GCS < 9 or a drop of ≥ 3. • Unequal, dilated, unresponsive pupils.
• Papilledema.
60
Septicaemia and meningitis
Points in favour of Septicaemia → Arthralgia and muscle aches, Cold periphery, Pale or mottled skin, SOB,
Rash.
Meningitis:
• Points in favour of meningitis → Photophobia, Severe headache, Nick stiffness.
61
In one of the exams, a scenario of a child who has never received vaccines
presents with a cut on his finger from a broken glass.
The answer was:
→ Give DTP “Diphtheria, Tetanus, Pertussis” vaccine the in the A&E room
and advise to complete the course of DTP vaccine.
62
◙ Vaccination status is unknown (treated as unvaccinated):
√ Clean wound → tetanus vaccine.
√ Tetanus-prone wound → tetanus vaccine + tetanus immunoglobulin.
√ High-risk tetanus-prone wound → tetanus vaccine + tetanus
immunoglobulin.
Note that rabies vaccine is not indicated in the UK unless in bats bites. (Not
in dogs bites).
63
◙ An adult who has had the last booster dose more than 10 years ago:
√ Clean wound → Nothing needed.
√ Tetanus-prone wound → tetanus booster vaccine.
√ High-risk tetanus-prone wound → tetanus booster vaccine + tetanus
immunoglobulin.
64
◙ An adult who has had the last booster dose within the last 10 years:
√ Clean wound → Nothing needed.
√ Tetanus-prone wound → Nothing needed.
√ High-risk tetanus-prone wound → Nothing needed.
65
◙ A child who has had the 1ry course (the first 3 doses) but delayed the
booster doses:
√ Clean wound → tetanus booster dose (to continue with the schedule).
√ Tetanus-prone wound → tetanus booster vaccine.
√ High-risk tetanus-prone wound → tetanus booster vaccine + tetanus
immunoglobulin.
66
◙ A child who is up-to-date with his vaccination schedule:
√ Clean wound → Nothing needed.
√ Tetanus-prone wound → Nothing needed.
√ High-risk tetanus-prone wound → Nothing needed.
67
Tetanus-prone wound:____
High risk tetanus-prone wound:___
◘ Tetanus-prone wound:
√ Certain animal bites (e.g. stray animals that dig into soil).
√ Puncture injuries in a contaminated area (e.g. while gardening).
√ Compound fractures.
√ Wounds that contain foreign bodies.
◘ High risk tetanus-prone wound:
√ Wounds heavily contaminated with soil.
√ Extensive wounds/ burns.
68
1 ♦ If clean wound in a child who has never been immunised?
→ Full course of DTP “Diphtheria, Tetanus, Pertussis”,
No need for
Immunoglobulins as the wound is clean.
69
2 ♦ If contaminated wound in an adult who does not remember his last
booster dose date?
→ Tetanus immunoglobulin
(+)
Full course of tetanus vaccine (as the
immunisation status is unknown).
70
♦ If a child deep penetrating wound + full course of tetanus vaccine (Up-
to-date)?
→ According to the Sept 2019 update, nothing is needed as he has
completed the full course of tetanus vaccine.
→ Clean the wound + Reassure ± Give prophylactic is contaminated.
71
4 ♦ If an adult with tetanus-prone wound + last booster vaccine was within
the last 10 years
→ Reassure
72
5 ♦ If an adult with tetanus-prone wound (e.g., puncture wound) +
completed his immunisation but the last booster vaccine was given more
than 10 years ago.
→ Give tetanus booster vaccine ONLY. (Recently asked).
73
6 ♦ If an adult with a high-risk tetanus-prone wound (e.g., wound
contaminated with soil) + last booster vaccine was given more than 10
years ago
→ Give tetanus booster vaccine + Tetanus immunoglobulin.
(Recently asked).
74
√ A contagious and infectious viral disease, causing swelling of the parotid
salivary glands in the face, and a risk of sterility in adult males.
√ It affects most commonly the Salivary Glands, mostly the parotid glands.
• Bilateral Parotitis → painful and tender swelling at the angles of jaw
(peri-auricular) bilaterally “usually”.
• Fever, Dry mouth (due to blockage of salivary glands), difficult to open
mouth or talk (due to swelling).
• Orchitis (4 or 5 days post-parotitis) (NOT ALWAYS) →
local severe
testicular pain and tenderness,
Swollen oedematous scrotum, impalpable
Mumps: (Paramyxovirus) Transmitted via saliva droplets “close contact
75
RX of mumps
◙ IMPORTANT
There is no specific treatment for Mumps (neither antibiotics nor
corticosteroids). All that is needed is paracetamol/ ibuprofen for fever
and pain + Reassurance.
A Question:
If on paracetamol but still symptomatic → Give NSAIDs (eg, Ibuprofen).
(There is no specific management for mumps
76
Hepatitis B Serology (important points to memorise)
• HBsAg (+ve) → during acute and chronic infection “The first marker that
becomes abnormal after acquiring Hepatitis B infection”.
• HBsAg (+ve) and HbeAg (+ve) → Highly infectious “Active viral replication”
(eAger to spread)
√ What if antibodies against this I develop?
→ Indicates response to treatment.
→ Anti-Hbe
• Anti-HBs (+ve) → post vaccination (there is immunity).
(Vaccine comes from Harvard Business School “HBs”)
• Which Antibodies will be +ve at the onset of symptoms and will remain +ve
even after treatment “Indicates Past or ongoing infection”?
→ The core antibody “Anti-HBc”
Note → s=surface ▐ e=envelope ▐ c=core ▐ Ag=Antigen ▐ Anti=Antibodies
77
Important hep b markers
The first marker to become abnormal -
HBsAg. (Acute/Chronic infection)
→ Indicates high infectivity → HbeAg.
Indicates recent vaccination → Anti-HBs
Indicates past infection → Anti-HBc
Anti-HBc
78
Other important markers in hep b
Additional:
IgM anti-HBc → Recent acute infection.
HBV DNA → Infectivity (Active viral replication)
79
Other important markers hep b
Important:
If Anti-HBs is positive, then there is immunity against Hepatitis B
√ If Anti-HBc is also positive → the immunity is due to natural infection.
√ If Anti-HBc is negative → the immunity is due to vaccination.
80
◙ Single, Not-painful ulcer
→ Syphilis.
“Syphilis painless, chancre”
81
◙ Multiple, Painful ulcers (usually start as vesicles) ± Dysuria ± flu-like
symptoms
Herpes genital HSV→ → give Acyclovir
82
Genital ulcers types
So, in Genital herpes (HSV) → multiple painful ulcers (started off as vesicles).
± usually have malaise, fever, myalgia
± painful micturition (dysuria).
In Hemophilus Ducreyi →
single or multiple painful ulcers (
started off as an
erythematous papular lesion (an inflamed patch)
later turn into painful ulcers
± This chancre is usually sexually acquired from abroad:
outside the UK,
usually developing countries).
83
◙ Single, Painful ulcer - genital
→ Hemophilus Ducreyi
(Chancroid). (“I Do cry from
Pain and being Single)
“Important: it can be multiple painful ulcers but they should have been
started as single chancer i.e., single erythematous inflamed papule or patch,
not vesicles like in HSV”.
84
Multiple painless growths (could be cauliflower shaped)
Human papilloma virus 6,11 (genital warts)
85
◙ Hx of travel, WATERY Diarrhea (Not-bloody), Weight Loss, abdominal pain,
foul-smelling flatulence, bloating
-giardiasis
-First line investigation → stool microscopy “for ova, parasite”
- First line Rx → Metronidazole + Hygiene.
86
◙ Traveller’s diarrhea that is usually of a short period and
self-limited in 72
hours (especially Hx of a travel to Africa) without bloody diarrhea
→ E. coli.
87
Hx of Travel to certain areas especially those who have high exposure to
animals (e.g. goats, sheep, camels, cattle, buffalos, pigs, dogs).
e.g. → Nigeria,
South America,
Middle East,
Central and South-east Asia,
Africa.
+ Hx of exposure to animals (e.g. working in a farm).
+ night sweat, fever, arthralgia, weight loss, splenomegaly.
→ Brucellosis.
88
◙ Hx of travel + Diarrhea →
Bloody Diarrhea, Fever, abdominal pain
→ Think of Traveller’s diarrhea that causes bloody diarrhea
→ e.g. “Gram -ve Bacilli”
Campylobacter jejuni
89
◙ Hx of travel to Africa + Meningitis-like symptoms ± fever, Anemia
Test for def diagnosis?
→ Cerebral malaria.
√ Test for definitive diagnosis → Note: prophylaxis against Malaria does not exclude the possibility of an
infection!
90
◙ Hx of Travelling + Water exposure (Swimming/ Fishing/ Rowing) ± Contact
with Animals.
√ Presents with → Red eyes (Subconjunctival Hemorrhage), Followed by
Yellow eyes (Jaundice) + Rash
√ + Others (Fever, rigors, malaise, Arthralgia, Myalgia)
→ Leptospirosis.
√ To confirm Dx → Serology
√ If not in the options → PCR of blood and urine.
√ If not in the options → Blood and urine culture and sensitivity.
91
◙ Hx of travel, Prodrome (Initially): HIGH Fever (40 C), Watery Diarrhea,
Headache, Myalgia → Followed by BLOODY Diarrhea
Rx?
Dx?
→ Campylobacter jejuni. [G-ve bacilli]
→ Give erythromycin or azithromycin or clarithromycin.
Or if not in the options → ciprofloxacin.
92
◙ Hx of travel to/from South America, Africa + Farmer
“contact with animals”
+ fever + night sweat + arthralgia + weight
loss ± splenomegaly
→ Brucellosis
93
◙ Hx of travel to/from South America + Severe headache + Patient
adopts a crouching position
→ Typhoid
94
◙ Hx of travel to/from India + Flu-like symptoms +
Enlarged Anterior
Cervical LNs ±
grey membranes on tonsils/ uvula.
→ Diphtheria
india = Diphtheria
95
◙ Fever, Cough, Cervical Lymphadenopathy,
Hoarseness, Dysphagia,
Weight loss, IV drug user, low socioeconomic
→ TB “Laryngeal TB”
96
◙ Chronic Productive Cough / Hemoptysis / Weight loss (Cachexia,
malnurished) / Fatigue / Night sweats / RFs “Homeless / Drug Abuser /
Smoker” → ??
INV?
→ Sputum for Acid Fast Bacilli
~If no sputum in the cough → BAL
~If patient refuses → Gastric lavage.
97
◙ Hx of travel to/from India +
Fever, Cough, Cervical Lymphadenopathy,
Caseating Granuloma in the LNs
→ TB “Tuberculous Lymphadenitis”.
98
◙ Hx of travel to/from Africa (e.g., Sudan)
+ Fever, Chills, Rigors ± Hepatomegaly, Hematuria (dark/red urine
→ Malaria.
99
◙ Hx of travel to/from North Africa (e.g., Egypt) +
Fever + Anemia + Tender Enlarged Liver + Deranged liver enzymes + Jaundice.
→ Amoebiasis (Liver amoebic disease).
Amoebiasis (caused by Entamoeba histolytica) is endemic in North Africa
presents with anemia,
fever secondary to intestinal hemorrhage
and tender
enlarged liver with
deranged liver function
due to hepatic abscess.
100
A 24-year-old man presents to the clinic with a three-day history of painful
swelling in his right testicle.
He had parotid gland swelling and fever that
started one week ago, diagnosed as mumps by his GP.
He has been taking
paracetamol for fever and discomfort. On examination, his right testicle is
swollen, tender, and slightly red.
His temperature is 37.8°C, and his vital signs
are normal.
Current medications include only paracetamol.
This patient is presenting with mumps orchitis, a known complication of
mumps.
Mumps is caused by a paramyxovirus, and orchitis occurs in about 20-
30% of post-pubertal males with mumps.
The virus itself has no specific
antiviral treatment, and management is supportive.
• Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), is the correct
answer as it helps to reduce both pain and inflammation.
This is the
cornerstone of treating mumps orchitis, along with rest, supportive care,
and scrotal elevation.
101
1. Varicella-Zoster Immunoglobulin (VZIG):
▪ VZIG is no longer the first-line prophylaxis for pregnant women exposed to
chickenpox.
Instead, oral Aciclovir is recommended for non-immune
pregnant women (VZV IgG negative) following exposure.
▪ VZIG is mainly reserved for
neonates exposed within 7 days before or after
delivery,
or when antivirals are contraindicated (e.g., due to absorption
issues or renal toxicity)
102
Aciclovir Rx
2. Aciclovir:
▪ Oral Aciclovir is the preferred treatment for pregnant women and
immunocompromised individuals exposed to chickenpox or shingles,
administered 7–14 days after exposure. Also, for those who develop
chickenpox.
▪ IV Aciclovir may be used in severe cases or when complications, such as
pneumonia, arise.
In milder cases, oral Aciclovir is started within 24 hours of
rash onset to reduce severity.
103
Aciclovir in children and pregnancy
This reflects the most recent updates, with Aciclovir replacing VZIG in many
cases and the use of oral or IV forms depending on the severity of the case.
But
most cases receive aciclovir orally unless severe or complicated.
√ Remember that in children, non-complicated chickenpox
→ Reassure + Supportive treatment (self-limiting).
However, if 2ry bacterial infection develops on top of chickenpox vesicles (eg,
high fever, sick child,
erythema, tenderness around the lesions, pinkish-
yellowish pus or discharge) → Antibiotics
104
A 45-year-old man comes to the clinic with a three-day history of a sore
throat, fever, and difficulty swallowing.
Physical examination reveals swollen,
red tonsils with white patches and exudates, and tender anterior cervical
lymphadenopathy.
His temperature is 38.5°C. What is the most likely
causative agent?
Answer →
Explanation:
• The patient's symptoms of a sore throat, fever, difficulty swallowing, and
physical findings of swollen red tonsils with white patches (tonsillar
exudates) and
tender cervical lymph nodes are highly indicative of
streptococcal pharyngitis caused by Group A Streptococcus (GAS).
• The absence of symptoms such as hepatosplenomegaly or pronounced
fatigue makes Epstein-Barr virus less likely, and
the typical presentation for
Mycoplasma pneumoniae or Candida albicans does not fit this clinical
picture.
• Group B Streptococcus is not a common cause of pharyngitis in adults.
105
Group A Strep (GAS)
o GASP or GAS Pyro
▪ GASP stands for Group A Strep (Pyogenes):
1. GASP for breath when you have a severe sore throat due to difficulty
swallowing.
2. GASP also stands for Group A Strep causing Pharyngitis.
3. GAS starts as a Pyro (from Greek "Pyr" meaning fire): think of fire in
the throat (tonsillitis) or skin (scarlet fever).
106
3. Epstein-Barr Virus (EBV)
o Less common cause of sore throat.
o Associated symptoms:
▪ Lymphadenopathy.
▪ Pronounced fatigue.
▪ Possible hepatosplenomegaly.
107
GBS
2. Group B Streptococcus (GBS)
o Also known as Group B beta-haemolytic streptococcus or Streptococcus
agalactiae.
o Rarely causes pharyngitis and tonsillitis.
o More commonly associated with:
▪ Neonatal infections (sepsis, pneumonia, meningitis).
▪ Infections in pregnant women.
108
o Symptoms include:
▪ Sore throat with fever.
▪ Difficulty swallowing.
▪ Tonsillar exudates.
1. Group A Streptococcus (GAS)
o Also known as Group A beta-haemolytic streptococcus or Streptococcus
pyogenes.
o Commonly causes:
▪ Strep throat.
▪ Scarlet fever.
▪ Impetigo.
▪ Rheumatic fever.
o Symptoms include:
▪ Sore throat with fever.
▪ Difficulty swallowing.
▪ Tonsillar exudates.
109
RX TB
• DOT strategy is endorsed by the (WHO) to help underserved groups adhere
to the TB treatment.
It requires volunteers, healthcare workers or family
members to observe and record patients taking TB medications doses
Notes on Tuberculosis (TB) Management
• For patients with known or suspected TB
→ They need to be isolated in a negative pressure room.
→ Admit to hospital in respiratory isolation and initiate contact tracing.
The full TB treatment is 6 months. After 2 weeks of isolation and TB
antibiotics treatment, the patient becomes no longer infectious. Thus, he can
be discharged with directly observed therapy (DOT) in place.
• After discharge, the patients “especially those who are considered
underserved groups such as homeless, imprisoned, drug or alcohol misusers,
too ill to adhere to treatment, History of non-adherence to therapy” these
people would follow a strategy called Directly Observed Therapy (DOT).
110
Staph infection RX
For infections caused by staphylococcus aureus (even if pneumonia), a
suitable treatment option is → Flucloxacillin
.
What if MRSA? → Vancomycin.
111
Important Notes on Infectious gastroenteritis
• Most cases in children are caused by a virus called ____
• Cases in adults are usually caused by _____ (the 'winter vomiting bug').
•
Important Notes on Infectious gastroenteritis
• Most cases in children are caused by a virus called rotavirus.
• Cases in adults are usually caused by norovirus (the 'winter vomiting bug').
• It can sometimes be bacterial (bacterial food poisoning) eg, history of
eating in a street market
112
Cf of gastroenteritis
.
• It presents with some or all of the following:
Abdominal pain – Diarrhea (watery and or bloody) – Nausea – Vomiting –
Mild Fever
• These symptoms can lead to → Dehydration (due to diarrhea, vomiting).
• If untreated, dehydration can lead to → acute kidney injury (Thus, high
serum urea and creatinine). (Due to repeated diarrhea episodes).
113
Bacterial poisoning may cause a bloody diarrhea (based on the causative
organism).
• The important investigation here
______
• The important investigation here
→ Stool microscopy, culture and sensitivity. √
• The management in general is supportive (with fluids ie, good hydration,
paracetamol, antiemetics…).
• However, if stool culture shows -for example- gram -ve bacilli indicating
(Campylobacter Jejuni):
√ Most cases of gastroenteritis due to campylobacter jejuni are self-limiting
with good hydration.
√ However, if severe disease → Erythromycin (first) or Azithromycin or Clarithromycin or
Ciprofloxacin.
114
A 71-year-old man presents to the GP with intense pain and weakness of the
right side of his face for the past 4 days.
He has been taking oral aciclovir for
the past 4 days but there is still pain that makes him unable to sleep.
There
are blisters on his right ear canal. What is the most appropriate medication
to add on?
→ Prednisolone.
• This is most likely a case of Ramsay Hunt Syndrome (Herpes Zoster Oticus).
• Rx → Oral antiviral (eg, aciclovir) [+] Corticosteroids (eg, prednisolone).
√ If lasted for > 3 months, it is called (post-herpetic neuralgia). If this occurs
Give → Amitriptyline or Pregabalin or gabapentin or duloxetine.
Also, if pain persists for > 2 weeks of the infection onset, a neuropathic agent
(eg, amitriptyline) is more beneficial than prednisolone.
115
Example (2):
A 56-year-old man presents to the GP with intense pain and weakness of the
right side of his face for the past 4 weeks. He has been taking oral aciclovir
for the past 4 weeks but there is still pain that makes him unable to sleep.
Additional paracetamol and NSAIDs were not beneficial. There are blisters on
his right ear canal. What is the most appropriate medication to add on?
→ Amitriptyline or gabapentin or pregabalin or duloxetine (neuropathic agent).
• This is most likely a case of Ramsay Hunt Syndrome (Herpes Zoster Oticus).
• Rx → Oral antiviral (eg, aciclovir) [+] Corticosteroids (eg, prednisolone).
Since the pain is persistent for > 2 weeks (4 weeks here)
→ a neuropathic
agent is more beneficial than steroids.
Steroids are preferred to be given within the first 2 weeks on infection onset
116
Ramsay hunt syndrome RX
Important Note:
Start with oral aciclovir. Prednisolone should be started within 2 weeks of
symptoms.
If The rash and pain persist for more than 2 weeks, it is better to
add on a neuropathic agent eg, amitriptyline, or gabapentin or pregabalin or
duloxetine. (
They would be more beneficial than prednisolone after 2 weeks
of the onset of symptoms).
So:
Aciclovir → up to 2 weeks, add prednisolone → > 2 weeks and still pain →
one of the following:
Amitriptyline or Pregabalin or gabapentin or duloxetine.
“Generally, amitriptyline is preferred over other neuropathic agents”
117
Which antibody will indicate a previous infection (eg, one year ago)? For
example: A man had infection with cytomegalovirus a year ago. which
antibody will be positive (elevated) now?
→ IgG.
Remember:
• IgM → indicates recent or still active (acute) infection.
It rises in the first 10 days of the infection and remains for up to 4 months.
• IgG → Indicates a previous infection.
IgG rises 2-3 weeks after the clinical symptoms and remains for life.
118
Hep C
Hepatitis C workup
√ For HCV, initially we
do
HCV antibody: this indicates if the patient has ever been exposed to HCV”.
√ If HCV antibody is positive, to confirm that he is “currently and actively”
having hepatitis C, we do PCR: for HCV RNA detection”.
√ If HCV RNA test is negative, we redo it again after 6 months.
√ After hepatitis C is being confirmed, to pick the best antiviral regimen, we
do → HCV genotype test
119
A 26 YO man has recently come back from Africa and now is having
multiple painful ulcers on his penile shaft and prepuce.
He informed that he
was active sexually when he was in Africa.
He describes that these painful
ulcers had started off as an erythematous papular lesion and later on
turned into painful ulcers.
He is otherwise well. What is the likely Dx
→ Hemophilus Ducreyi
120
A 57 YO man complains of white-yellowish coats and patches on his
tongue, palate and buccal mucosa, and a mild burning sensation of his oral
cavity.
He smokes 5-10 cigarettes a day for the past 10 years.
He has COPD
for which he takes salbutamol and inhaled corticosteroids everyday.
The likely Dx →
inhaled corticosteroids cause
Oral thrush “candidiasis” (due to the prolonged use )
√ The most appropriate management → Fluconazole orally.
121
A 42 YO woman has been having rash on her arm for 3 weeks. It is
expanding. She also has low-grade fever, fatigue and joint pain. A picture of
the rash is shown: erythema migrans
The likely Dx → See the erythema migrans (migrating, expanding rash ± flue like symptoms,
joint pain → Think Lyme disease).
◙ The appropriate investigation
→ Lyme serology
(Antibodies to Borrelia Burgdorferi).
122
◙ Scenario (2):
A 12 YO boy has recently returned to the UK 2 months ago. He was in a
vacation with his family visiting West Africa.
He started to have headache,
general muscle aches and stiff nick yesterday.
Also, over the past 5 days, he
has been having profuse sweating, diarrhea, muscle aches and malaise. His
temperature is 38.1.
He has completed 6-week prophylaxis against malaria
and has been vaccinated against yellow fever before his travels.
The best investigation for definitive diagnosis
→ Thin and thick blood film for microscopy.
√ He is likely having cerebral malaria.
√ He was in Africa (more towards malaria).
√ He has jaundice (more towards malaria).
√ FBC of this patient may also show anemia and thrombocytopenia but it was
not mentioned here.
123
124
√ In the scenario (1), the patient was in the UK, has no jaundice, was living in
a dorm with other people “outbreaks of meningococcal meningitis is
common in young adults who live in crowded environments”.
√ Suspect malaria in any patient who presents with a fever after a history of
travel to a Malaria-endemic area (e.g. many parts of Africa) in the last year,
particularly the last 3 months.
Many cases may have non-specific symptoms
and are thus misdiagnosed until late.
☼ Neck stiffness, fever, and Impaired consciousness can be seen in both
meningitis and cerebral malaria.
However, the presence of jaundice here
points more towards cerebral malaria + the Hx of travel to Africa makes
Malaria more suspicious.
√ Meningitis is an important differential here however, the exam writer
would make some points towards meningitis like photophobia, living in a
dorm with other people “outbreaks of meningococcal meningitis
◙ Scenario (2):
A 12 YO boy has recently returned to the UK 2 months ago. He was in a
vacation with his family visiting West Africa.
He started to have headache,
general muscle aches and stiff nick yesterday.
Also, over the past 5 days, he
has been having profuse sweating, diarrhea, muscle aches and malaise. His
temperature is 38.1.
He has completed 6-week prophylaxis against malaria
and has been vaccinated against yellow fever before his travels.
125
126
Meningitis VS Cerebral Malaria
◙ Scenario (1):
A 23 YO man has recently returned from the UK where he was living with
other students in a dorm. He started to have headache, stiff nick and
photophobia yesterday.
Also, over the past 2 days, he has been having
profuse sweating, muscle aches and malaise. His temperature is 38.9.
He
has completed 6-week prophylaxis against malaria and has been vaccinated
against yellow fever before his travels.
The best investigation for definitive diagnosis → Lumbar puncture.
√ He is likely having meningitis (headache, stiff neck, photophobia, fever).
√ The most common type of meningitis in this age is meningococcal
meningitis (caused by Neisseria meningitidis).
√ Outbreaks of meningitis is common in young adults living in crowded
places.
√ Remember, Malaria is not common in the UK.
√ However, if the question gives additional clues towards malaria such as
having jaundice, anemia, thrombocytopenia, then cerebral malaria would be
a more suspicious diagnosis and for which, the gold standard test would be
→ Thin and thick blood film for microscopy.
127
Needlestick injury while extracting a blood sample from a high-risk patient
(e.g., IV drug user)
→ Start post-exposure prophylaxis as soon as possible.
128
Scenario
A patient with Cellulitis admitted for 3 days and treated with clindamycin.
Soon after,
he develops bloody diarrhea, abdominal pain and high fever.
WBCs and CRP are high.
• The diagnosis? → C. Difficile (Pseudomembranous Colitis).
• The treatment → Vancomycin.
• If not on the options? →pick metronidazole.
Note: clostridium difficile can easily spread to others. √
129
• Manifestations:
• Hx of recent treatment with antibiotics (e.g. Amoxicillin, clindamycin) for
4-9 days or more.
• Diarrhea (might be bloody but not always bloody √).
• Abdominal pain (might be very severe).
• Fever.
• High WBCs and CRP.
Clostridium difficile [Pseudomembranous Colitis]
• Receiving certain Antibiotics can suppress the normal flora that inhabits
the GIT. Therefore, C. Difficile becomes free to infect the GIT causing
“Pseudomembranous Colitis”.
• Examples of the antibiotics that can cause C. Difficile:
Clindamycin,
Amoxicillin, Ampicillin,
Co-Amoxiclav,
Broad spectrum
cephalosporin,
Quinolones (e.g. Ciprofloxacin).
130
Investigation → Clostridium Difficile Toxin (CDT) in the stools.
Investigation → Clostridium Difficile Toxin (CDT) in the stools.
• Treatment:
√ 1st Line → Oral Vancomycin.
√ 2nd line → Oral Metronidazole.
(Recently, vancomycin has become the first line. However, if it is not in the
options, pick the second line which is metronidazole
131
Osteomyelitis
Osteomyelitis describes an infection of the bone. It may be subclassified into:
Haematogenous osteomyelitis
• results from bacteraemia
• is usually monomicrobial
• most common form in children
• vertebral osteomyelitis is the most common form of haematogenous
osteomyelitis in adults.
• Risk factors include:
sickle cell anaemia,
intravenous drug user,
immunosuppression due to either medication or HIV,
infective endocarditis
132
Non heamatogenous osteomyelitis
Non-haematogenous osteomyelitis:
• results from the contiguous spread of infection from adjacent soft tissues
to the bone or from direct injury/trauma to bone
• is often polymicrobial
• most common form in adults
• risk factors include: diabetic foot ulcers/pressure sores,
diabetes mellitus,
peripheral arterial disease
133
Investigation and management of osteomyelitis
◙ Microbiology
Staph. Aureus is the most common cause except in patients with sickle-cell
anaemia where Salmonella species predominate.
◙ Investigations
MRI is the imaging modality of choice, with a sensitivity of 90-100% (imp √).
◙ Management
√ flucloxacillin for 6 weeks
√ clindamycin if penicillin-allergic
134
Meningitis types how to differentiate
Important:
In suspected meningitis (fever, neck rigidity, photophobia…etc) +
♦ Turbid/ purulent/ or cloudy CSF + (No rash)
→ Think: Streptococcus pneumoniae.
♦ Turbid/ purulent/ or cloudy CSF + (There is non-blanching Rash)
→ Think: Neisseria Meningitidis.
√ Turbid/ purulent/ or cloudy CSF = Bacterial meningitis.
√ The presence of rash goes more with Neisseria rather than Strept. Pneumoniae.
135
Examples of Bacterial Meningitis organisms:
Streptococcus pneumonia
◘ Streptococcus pneumoniae (pneumococcus).
This bacterium is the most
common cause of bacterial meningitis in infants, young children and adults.
It
more commonly causes pneumonia or ear or sinus infections.
A vaccine can help
prevent this infection.
136
Examples of Bacterial Meningitis organisms:
Meningococcus
◘ Neisseria meningitidis (meningococcus). This bacterium is another leading
cause of bacterial meningitis.
These bacteria commonly cause an upper
respiratory infection but can cause meningococcal meningitis when they enter the
bloodstream.
This is a highly contagious infection that affects mainly teenagers
and young adults.
It may cause local epidemics in college dormitories, boarding
schools and military bases.
A vaccine can help prevent infection.
137
Examples of Bacterial Meningitis organisms:
Haemophiilus influenzae
◘ Haemophilus influenzae (haemophilus).
Haemophilus influenzae type b (Hib)
bacterium was once the leading cause of bacterial meningitis in children.
But new
Hib vaccines have greatly reduced the number of cases of this type of meningiti
138
Examples of Bacterial Meningitis organisms:
Listeria
◘ Listeria monocytogenes (listeria). These bacteria can be found in unpasteurized
cheeses,
hot dogs and lunchmeats.
Pregnant women,
newborns,
older adults and
people with weakened immune systems are most susceptible.
Listeria can cross
the placental barrier, and
infections in late pregnancy may be fatal to the baby.
139
140
Regarding meningitis, CSF sample can give a clue about
the causative organism as follows:
√ Viral meningitis CSF → Clear
√ TB meningitis CSF → Fibrin web
√ Bacterial meningitis CSF → Purulent (or: turbid, or cloudy).
141
◙ ↑ Intracranial Pressure (brain mass lesion effect) →
Headache, Eye pain,
Seizures,
Focal Neurologic Deficits, Confusion.
◙ Others →
Visual Hallucination,
Facial weakness
.
◙ The causative organism → Toxoplasma Gondii.
It lives and reproduces in Cats’ Guts!
◙ It is reactivated especially in patients with HIV-positive infection when the
CD4 is very low (<100). (Hint √)
◙ Brain MRI with Contrast → Ring enhancing lesion/s. (Hint! √)
◙ Treatment of toxoplasmosis in general → Pyrimethamine + Sulfadiazine.
142
You need to remember 2 things when suspecting meningitis
√ Immediately commence IV antibiotics “IV Ceftriaxone even before Investigations results.
or Cefotaxime”
√ Notify the Health Protection Team immediately as soon as there is clinical
suspicion. (Meningitis is a notifiable Disease)
143
◙ Hx of travel, Prodrome (Initially): HIGH Fever (40C), Watery Diarrhea,
Headache, Myalgia → Followed by BLOODY Diarrhea
→ Campylobacter jejuni.
√ Most cases of gastroenteritis due to campylobacter jejuni are self-limiting
with good hydration.
√ However, if severe disease → Erythromycin (first) or Azithromycin or Clarithromycin or
Ciprofloxacin
144
Types of bacteria and shape
.
• Notes:
√ Campylobacter means Curved Bacilli “rods”. It is Gram -ve on stool culture
and sensitivity.
√ So, Campylobacter → Gram -ve Bacilli “rods”.
√ V. Cholera → Gram -ve comma-shaped.
√ Streptococcus pneumonia → Gram +ve Diplococci.
√ Staphylococcal Aureus → Gram +ve and Coagulase +ve cocci “round”
145
◙ Herpes Zoster Ophthalmicus. √
√ Reactivation of Varicella Zoster Virus (VZV) in the Ophthalmic branch of the
Trigeminal nerve (5th CN).
√ Conjunctivitis, Keratitis, Painful Vesicles around the eye …etc.
√ Rx → Oral Aciclovir (antiviral) + Corticosteroids (eg, prednisolone)
146
Febrile Neutropenia (Neutropenic Sepsis)
Patient is unwell + Recent chemotherapy → Start IV Antibiotics IMMEDIATELY
Still unwell after 4-5 days?
→ fungal infection investigation + Add IV Antifungals
Febrile Neutropenia “Neutropenic Sepsis”
From its name: Febrile → Fever ▐
Neutropenia → Low Neutrophils.
≤ 0.5 x 109/L (Normal: 2-7.5 X 109/L) √ Absolute Neutrophil count
Fever (≥ 38.5°C)
or 2 consecutive temperature of (≥ 38.0°C)
√ Fever • It occurs mainly after initiating chemotherapy in malignancy patients.
(Chemotherapy → BM suppression → ↓ Blood Cells Production).
• Another cause → within 1-year of Bone Marrow transplantation.
◙ How to manage? “Important”
• Start empirical IV antibiotics IMMEDIATELY!
• Start empirical → IV Tazocin (Tazobactam + Piperacillin).
147
How to manage neutropenic sepsis
Start empirical IV antibiotics IMMEDIATELY!
• Start empirical → IV Tazocin (Tazobactam + Piperacillin).
After 48 hours, if the patient is still febrile and/or neutropenic
→ Alternative antibiotic: Meropenem ± Vancomycin.
• After 4-6 days, if the patient is still unwell
→ Investigate for fungal infection
(sometimes, the answer would be: Add IV Antifungal).
In Summary:
In a patient with neutropenic sepsis, if 4-6 days have passed and the patient
is still febrile and/or neutropenic despite receiving adequate antibiotics
→ Investigate for fungal infections
Another correct answer
→ Continue the antibiotics and Add IV Antifungals
Important,
Sometimes, the neutrophil count will not be given in a stem.
Regardless of
that, start IV antibiotics in all patients with recent chemotherapy who have
fever and feel unwell (suspected Neutropenic Sepsis).
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Tumor Lysis Syndrome → UK Pc
HyperUricemia (↑ Uric Acid “Also called serum Urate) → Gout.
HyperKalemia (↑ K+ “Potassium”)
HyperPhosphatemia (↑ Phosphate)
Hypocalcemia. (↓ Calcium).
Tumor Lysis Syndrome → UK Pc
HyperUricemia (↑ Uric Acid “Also called serum Urate) → Gout.
HyperKalemia (↑ K+ “Potassium”)
HyperPhosphatemia (↑ Phosphate)
Hypocalcemia. (↓ Calcium).
√ It occurs mainly in Leukemia (Especially ALL) and Lymphoma (Particularly
Burkitt’s Lymphoma) after initiating Chemotherapy.
√ Chemotherapy, Radiotherapy, Surgery → Rapid Lysis of Tumour Cells →
Excessive amounts of Uric acid “Urate”, Potassium and Phosphate are
released into the blood.
149
√ Hx of Travelling + Water exposure (Swimming/ Fishing/ Rowing) ±
Contact with Animals.
√ Presents with → Red eyes (Subconjunctival Hemorrhage), Followed by
Yellow eyes (Jaundice) + Rash
√ + Others (Fever, rigors, malaise, Arthralgia, Myalgia)
√ ALT and AST are usually elevated (but rarely exceeding 200).
Investigation and RX?
◙ Diagnosis (All investigations are important):
• First line → • Second line → • Third line →
Serology
PCR of blood and urine.
Blood and urine culture and sensitivity
.
So, in the exam, pick → Serology.
If not in the options → PCR of blood and urine.
If not in the options → Culture of blood and urine.
√ The organism is detectable in Blood in the first 7-10 days of the disease.
√ The organism is detectable in Urine after 7 days and up 30 days.
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Leptospirosis
Transmission and RX
Important:
In leptospirosis, if you have to options (either serology or blood and urine
culture and sensitivity),
pick (serology) as urine and blood cultures may take
several weeks and are less sensitive.
◙ Treatment:
√ Usually mild and self-limited.
√ Oral Doxycycline (for mild cases).
√ Ampicillin or Benzylpenicillin (for severe cases).
◙ It spreads by contact with the urine of infected animals (Direct), or:
by contact with water that is contaminated with infected animal’s urine (Indirect)
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Doxycycline
Remember:
Doxycycline →
Chlamydial cervicitis,
Lyme disease,
Leptospirosis
Remember, Doxycycline is contraindicated in pregnancy, instead, give
amoxicillin.
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Necrotising Fasciitis (Mainly by Group A beta-hemolytic Streptococci)
Necrotising = Necrosis
Fasciitis = Infection spread deep and involves deep Fascia and muscles.
√ Life-threatening as it spreads rapidly and involves deep layers (dermis,
subcutaneous tissues, fascia, muscles).
RX?
√ RFx → IM or SC Drug injections / DM / Immunosuppression.
it does not respond to flucloxacillin Initially (First 1-2 days), it resembles cellulitis (erythema, swelling, pain over
the affected area).
However, (while
Cellulitis responds).
Then → septic shock.
Bullae → grey/ black skin (Necrosis) → hard subcutaneous tissue →
√ VERY SEVERE PAIN disproportionate to physical signs.
√ Rx → Urgent Surgical Debridement and IV antibiotics (e.g. IV Clindamycin/
Benzylpenicillin).
153
Erysipelas and necrotising fasciitis
Necrotising Fasciitis is diffuse and deep infection
while Erysipelas is well-
demarcated infection.
154
A 5 YO child returned from Ghana with his family 6 weeks ago and
now
presents with fever, neck stiffness, chills, vomiting and impaired
consciousness that have started 2 days ago.
Before he left to Ghana, he was
commenced on malaria prophylaxis. His FBC shows Anemia.
√ The likely Dx → Cerebral Malaria.
Hx of travel to Africa + Meningitis-like features + Anemia → Cerebral malaria.
√ Test for definitive diagnosis → Thin and Thick blood film for microscopy.
◙ Be aware that malaria prophylaxis does not guarantee full protection
against all subtypes of malaria.
◙ Suspect malaria in any patient who presents with a fever after a history of
travel to a Malaria-endemic area (e.g. many parts of Africa) in the last year,
particularly the last 3 months.
Many cases may have non-specific symptoms
and are thus misdiagnosed until late.
◙ Neck stiffness and Impaired consciousness are seen in both meningitis and
cerebral malaria.
However, the presence of Anemia points more towards
cerebral malaria + the Hx of travel to Africa makes Malaria more suspicious.
155
Q) When can a child with chicken pox return to a school?
A) After the rash and vesicles are dried and crusted
(Usually around 5 days after the onset of the rash)
156
In HIV-Positive patients, prophylaxis antibiotics might be needed:
√ If CD4 < 200 → Co-trimoxazole
(Prophylaxis against Pneumocystis jirovecii).
√ If CD4 < 50 → Azithromycin (Prophylaxis against Mycobacterium avium).
157
Be aware that superficial Neck Abscess is not uncommon and
if large
enough, it can cause dysphagia.
Once there is high fever with erythematous skin swelling, think of Abscess.
Rx → IV antibiotics, Incision and Drainage.
• The presence of fever, tachycardia and tachypnea warrants Intravenous
(not-oral) antibiotics as the patient might be septic.
158
Red Flags for Sepsis:
• Responds only to voice or pain/ or unresponsive.
• Acute confusional state
• Systolic B.P ≤ 90 mmHg (or drop >40 from normal)
• Heart rate > 130 per minute
• Respiratory rate ≥ 25 per minute
• Needs oxygen to keep SpO2 >=92%
• Non-blanching rash, mottled/ ashen/ cyanotic
• Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr
• Lactate ≥ 2 mmol/l
• Recent chemotherapy
159
Pep
If a person has been bitten by a high-risk person (e.g. Drug addict)
→ Start Post-Exposure Prophylaxis.
Note, all human bites should be treated with a 7-day course of Co-amoxiclav
(Amoxicillin + clavulanic acid e.g. Augmentin®) PO.
If penicillin allergic → Metronidazole + Doxycycline
160
A patient presents with diarrhea. Blood culture and staining show
gram negative curved rods.
√ Rx → First line (Erythromycin or Azithromycin or Clarithromycin).
√ If these were not in the options, pick the second line, which is
(Ciprofloxacin).
• Notes:
√ Campylobacter means Curved Bacilli “rods”. It is Gram -ve on stool culture
and sensitivity.
√ So, Campylobacter → Gram -ve Bacilli “rods”.
161
◙ In breast Abscess, the commonest causative organism
→ Staphylococcus aureus
162
Positive acid-fast bacilli (AFB) on sputum sample.
→ TB “Tuberculosis”.
163
What if she in contact (got exposed) to a chickenpox patient too long
before this patient developing rash?
→ Reassure.
The infective period is typically 2 days before appearance of the rash until 5
days after rash appearance on the contact.
Example: If a pregnant woman got in contact with a chickenpox 8 days
before his rash appearance? → Reassure.
164
A 54 yr old man with left sided facial pain and painful rash extending to the
midline of his nose.
He had complained of headache 2 weeks prior with no
cause found. What is the affected structure?
◙ Herpes Zoster Ophthalmicus. √
√ Reactivation of Varicella Zoster Virus (VZV) in the Ophthalmic branch of the
Trigeminal nerve (5th CN
√ Conjunctivitis, Keratitis, Painful Vesicles around the eye (unilateral facial
painful rash) …etc.
√ Rx → Aciclovir
165
A 12 YO girl presents with fever, dry cough and hoarseness of voice of a 3-
day duration.
On direct laryngoscopy, there is oedematous vocal cord.
What is the next most appropriate investigation?
→ No further investigations required.
This is likely a case of common cold or a common laryngitis which does not
need any further investigations.
• Laryngitis is a swelling of the vocal cord usually caused by an infection,
commonly viral (common cold). Another reason is the overuse of voice.
• All that is needed is to rest your voice and to drink a plenty of fluid. If
there is fever, take paracetamol.
166
What is the drug of choice in treating MRSA?
√ MRSA (Methicillin-Resistant Staphylococcus Aureus)
√ Vancomycin is a glycopeptide which continues to be the drug of choice
for treating most MRSA infections caused by multi-drug resistant strains.
√ Another good glycopeptide for MRSA is teicoplanin.
167
Lyme disease pregnancy RX?
In a previous key, we mentioned that first line treatment of Lyme disease is
Doxycycline.
However, doxycycline is CONTRAINDICATED in pregnancy.
Thus, we give Amoxicillin instead.
168
Diagnosis and clinical features of Lyme disease
◙ Hx of Camping or Walking in gardens/ Jungles.
◙ Erythema Migrans (erythematous, painless, non or mildly itchy)
± (fever, headache, myalgia, general aches and pains)
◙ Later On (Possible) →
Facial Paralysis,
Meningitis,
AV-heart block,
Myocarditis,
Arthritis.
It might present as annular rash with scaly edges (e.g. on the thigh) that’s
slowly growing with associated general pains and aches.
◙ Diagnosis → Antibodies to Borrelia Burgdorferi.
169
RX Lyme disease
Treatment:
√ Early disease → Doxycycline (First-line but Contraindicated in Pregnancy
→
Amoxicillin is given instead).
√ Disseminated Disease → Ceftriaxone.
√ Pregnant woman → Amoxicillin.
170
◙ Syphilis Investigations in Short (Commonly Asked)
√ If the penile ulcer is still present
→ Swab the penile ulcer for Dark field microscopy (if in Genitourinary clinic)
or
swab the penile ulcer for PCR (if the patient is in a GP clinic).
√ If the penile ulcer has healed but the mouth ulcers are present
→ Swab of the mouth ulcers for PCR.
171
√ Other tests → for hsv
Viral culture + DNA detection using PCR (Polymerase Chain
Reaction):
• Viral culture is less sensitive than NAAT/PCR but may still be used where
NAAT is unavailable.
The sample collection method for both is a viral
swab from the lesion.
So, in the exam: NAAT → PCR → Culture (Method of collection: Swab).
√ If Negative and the ulcers are recurrent/atypical? →
Anti-HSV antibody:
• Serology can detect past exposure to HSV (types 1 and 2) but is not useful
for diagnosing acute infections. It may help in cases of atypical or
recurrent presentations when swabs are negative.
172
Other tests → Viral culture + DNA detection using PCR (Polymerase Chain
Reaction):
• Viral culture is less sensitive than NAAT/PCR but may still be used where
NAAT is unavailable. The sample collection method for both is a viral
swab from the lesion.
So, in the exam: NAAT → PCR → Culture (Method of collection: Swab).
173
Stohilis serology when to do?
Bear in in mind that swabs of oral lesion cannot be tested under dark field
microscopy.
If there no (swab of oral ulcers for PCR) in the options,
pick
syphilis serology.
√ If both penile and mouth ulcers have healed
→ Serology for syphilis.
174
◙ HSV Investigations in Short (Commonly Asked)
√ First Line → NAAT testing (including PCR):
• NAAT,
which includes PCR, is the gold standard for detecting HSV.
It is
superior to viral culture for sensitivity and accuracy.
Other tests → Viral culture + DNA detection using PCR (Polymerase Chain
Reaction):
• Viral culture is less sensitive than NAAT/PCR but may still be used where
NAAT is unavailable. The sample collection method for both is a viral
swab from the lesion.
So, in the exam: NAAT → PCR → Culture (Method of collection: Swab).
175
Young, fever, cough with sputum
→ suspect bacterial pneumonia
√ Cough, sputum, fever in (very old or very young) → think of pneumonia.
176
An old immunocompromised patient presents with painful dysphagia
(Odynophagia) + Redness, Fissuring and Soreness at the mouth angles.
→ Candida albicans (Oral thrush)
Painful dysphagia = odynophagia = candida “fungal
Candida Albicans can cause Oesophageal Candidiasis
which presents with
Dysphagia and Odynophagia (pain and burning sensation on swallowing food
or fluid).
Another Differential Dx → Bacterial (Staph. Aureus)
177
Candidiasis vs leukoplakia
√ Oral Candidiasis → Thick white marks + Can be rubbed out ± Inflamed
mouth.
√ Leukoplakia → White marks, cannot be rubbed out, sharply defined.
178
A pregnant lady presents with thick white marks in her mouth for 3 weeks.
O/E, her mouth and tongue appear inflamed. She smokes 20 Cigarettes a
day.
The likely Dx → Oral Thrush (Candidiasis).
Rx → Oral Fluconazole “or fluconazole oral suspension”.
- If the infection is mild and localized → Miconazole gel “first line”.
√ Pregnancy → weak immunity → Candida albicans can grow.
√ Smoking is a precipitating factor in both Oral Candidiasis and Leukoplakia.
179
Oral Thrush (Oral Candidiasis
Risk factors?
Features?
RFx →Hx of immunosuppression
(e.g. DM,
recent Hx of treatment using
antibiotics,
taking steroids),
smoking,
elderly
- Thick white marks ± Inflamed mouth/ tongue.
- Note that Plaques might enlarge and become painful and cause
discomfort while eating and swallowing.
- Can be rubbed out (removed).
- It might also present with red inflamed painful sore mouth angles.
180
RX of oral thrush
Treatment:
- Stop Smoking.
- Good inhaler techniques, spacer device, rinse mouth with water after use.
- Oral Fluconazole 50 mg OD for 7 days or Fluconazole oral suspension.
- If the infection is mild and localized → Miconazole gel “first line”.
181
◙ The four Anti-TB drugs are the same in pregnancy.
◙ The four Anti-TB drugs are the same in pregnancy.
√ (RIPE) → Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
√ These are not-contraindicated during pregnancy.
◙ Streptomycin should be avoided during pregnancy (Harmful to fetus)
182
When can a cook “Food handler” “Chef” return to work
after an attack of gastroenteritis?
→ 48 hours after all symptoms
(eg, Diarrhea, Vomiting) have cleared
In the UK,
Gastroenteritis patients can return to work after 2 days (48 hours)
of the last episode of symptoms (Diarrhea or Vomiting
183
Meningitis vs OM
◙ Remember that otitis media can complicate into Meningitis!
◙ Remember that Meningitis can cause hearing loss
and thus hearing test
should be arranged after treating meningitis
(Vice versa relation) :D
184
What is the diagnosis of the next serology results?
• HBsAg -ve
• Anti-HBs -ve
• Anti-HBc +ve
• HCV antibody reactive
• HCV RNA detected
Let’s analyse it:
For Hepatitis B:
• HBsAg -ve → No Acute or Chronic Hepatitis B.
• Anti-HBs -ve → No vaccination or immunity.
• Anti-HBc +ve → Possible recovered hepatitis B.
185
HCV current infection
How to detect?
Initial test ?
For hepatitis C, the presence of HCV RNA → Current Hepatitis C Infection
√ For HCV, initially we do been exposed to HCV”.
√ If HCV antibody is positive, to confirm that he is “currently and actively”
having hepatitis C,
we do PCR for HCV RNA detection”.
186
Breastfeeding Notes
√ If the mother has HIV → AVOID breastfeeding!
√ If the mother has Breast Abscess → Continue Breastfeeding “usually”.
√ If the mother has Mastitis → Continue Breastfeeding. (One of the causes of
Mastitis is a failure to fully empty the breast during breastfeeding.
Failure to
empty the breast causes breastmilk stasis, which is associated with an
increased risk for abscess formation.
Treatment for mastitis involves
encouraging mothers to breastfeed)
√ If the mother has Nipple Candidiasis → Continue Breastfeeding.
√ If the mother has Hepatitis B → Continue Breastfeeding (provided that the
baby has received hepatitis B immunoprophylaxis).
√ If the mother has Hepatitis C → Continue Breastfeeding (unless the
mother’s nipple is cracked or bleeding).
√ If the mother has TB → Continue Breastfeeding. (babies need to be
immunised with BCG as soon as possible),
Anti-TB drugs “RIPE” are not
harmful to the baby).
√ If a breastfeeding ♀ has depression, what is the safe SSRI in Breastfeeding?
(Safe in breaStfeeding).
→ Sertraline √ Also, Sertraline (followed by Citalopram) is the SSRI of choice in patients
with Hx of MI. (Psychiatry chapter).
187
Whipple disease and coeliac disease findings
Jejunal biopsy shows deposition of macrophages containing Periodic acid-
Schiff (PAS) granules → Whipple’s Disease.
◙ Duodenal/Jejunal biopsy shows Villous atrophy “Shortening”, Crypt
hyperplasia, lymphocytosis. → Celiac Disease
.
◙ A patient with known celiac disease underwent duodenal biopsy that shows
lymphomatous infiltrates → Lymphoma.
“Remember, T-cell lymphoma is a rare complication of celiac disease”.
188
◙ A rare multi-system disorder caused by Tropheryma whippelii infection. It
is more common in those who are HLA-B27 positive and in middle-aged men
Whipple’s disease
Clinical features
◙ Features
malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia,
dementia,
seizures,
ataxia,
myoclonus.
189
Whipple disease inv
Ming and dds
◙ Investigation
Jejunal biopsy shows Stunted Villi and deposition of macrophages containing
Periodic acid-Schiff (PAS) granules. [Diagnostic and Important for exam √]
◙ Management
guidelines vary: oral co-trimoxazole for a year is thought to have the lowest
relapse rate,
sometimes preceded by a course of IV penicillin
The most important point to remember is that in a patient with indigestion and
Jejunal biopsy reveals Macrophages with PAS Granules → Whipple’s disease.
DDx:
• Jejunal or Duodenal Biopsy in Celiac Disease:
- Villous Atrophy.
- Crypt hyperplasia.
- ↑ inter-epithelial lymphocytes.
190
Human bites
Note, all human bites should be treated with a 7-day course of Co-amoxiclav
(Amoxicillin + clavulanic acid e.g. Augmentin®) PO.
If penicillin allergic → Metronidazole + Doxycycline
191
