Infectious disease Flashcards by Grace Hardy

what disease are sewage workers at risk of?

leptospirosis

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what diseases are IVDU at risk of?

endocarditis
hep B/C, HIV
soft tissue infection

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bugs most likely caught from restaurant

salmonella

campylobacter

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unusual organism infections in HIv

TB
PCP
toxoplasma
MAI [Mycobacterium avium complex]
cryptococcus
candidiasis

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23 yr old female, 12 hr Hx of rapid onset severe headache, vomiting, neck stiffness, photophobia, fever,. Now drowsy, GCS 13/15, rash developing on abdo.
Likely diagnosis?

MENINGITIS WITH meningococcal septicemia

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GP phones you in AMU about 23 yr old female, 12 hr Hx of rapid onset severe headache, vomiting, neck stiffness, photophobia, fever,. Now drowsy, GCS 13/15, rash developing on abdo.
Advice to GP?

give IM benzyl pneicillin

admit immediatelty

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GP phones you in AMU about 23 yr old female, 12 hr Hx of rapid onset severe headache, vomiting, neck stiffness, photophobia, fever,. Now drowsy, GCS 13/15, rash developing on abdo.
Advice to GP if patient has penicillin allergy?

NO ben pen

admit

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what is the triad of meningism?

headache, neck stiffness, photophobia

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23 yr old female, 12 hr Hx of rapid onset severe headache, vomiting, neck stiffness, photophobia, fever,. Now drowsy, GCS 13/15, rash on abdo + limbs.

Temp 38.7, HR 98, BP 100/60.

Immediate Ix and Tx?

ABCDE!

cultures, ABG, CRP, FBC, clotting, U+E, UO [catheter]

cefotax/ceftriax

fluid resus [/inotropes/vasopressors]

O2 if sats require

[dex]

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what rash would you expect to see in meningococcal septicaemia?

non-blanching petechial/purpuric rash

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23 yr old female, 12 hr Hx of rapid onset severe headache, vomiting, neck stiffness, photophobia, fever,. Now drowsy, GCS 13/15, rash on abdo + limbs.

if the patient has been alert and orientated, with headache/fever/neck stiffness + NO RASH. what other Ix would you want to do?

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contraindications for LP

bleeding disorder
cardioresp compromise
local infection
^ICP [severe headache, reduced LOC, falling pulse, rising BP, vomiting, focal neurology, papilloedema

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during or after an LP, what do you test the CSF for

pressure, appearance

glucose, protein, gram stain

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2 organisms likely to cause meningitis in adults

neiss meningitidis

strep pneum

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treatment of viral meningitis

self-limiting

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what institution need to be informed of anyone diagnosed with a bacterial meningitis + what treatment might be advised for close contacts?

proper officer / consultant for communicable disease control [works for public health england]

ciprofloxacin [or rifampicin]

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Ix in suspected malaria? What would you specifically do out of hours?

FBC [anaemia, thrombocytopenic]
thick and thin films
U+E, urine output [AKI]
clotting [DIC]
glucose [hypo]
ABG [acidosis]
urinalysis [haemoglobinuria]
LFT, cultures

OOH: rapid diagnostic test

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24 yr old, 1 day after returning from Kenya. Fever, headache, myalgia. Was “fully vaccinated” and took proguanil + chloroquine. Temp 39.5.

differentials

MALARIA
typhoid
dengue
viral haemorrhagic fever
diptheria
yellow fever
ebola 
etc!

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24 yr old, 1 day after returning from Kenya. Fever, headache, myalgia. Was “fully vaccinated” and took proguanil + chloroquine. Temp 39.5.
Haematologist reports she has plasmodium falciparum with a parasitaemia of 3%.
What do you do now?

artesunate IV then artemether-lumefantrine PO

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daily parasite count

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what are the complications of severe malaria

pulm oedema/ARDS
AKI
impaired conscious/seizure
shock
hypoglycaemia
anaemia
spontaneous bleed/ DIC
acidosis
haemoglobinuria`

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how many negative films do you need to exclude malaria?

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what anti-malaria drugs can be used for prophylaxis?

chloroquine, proguanil, doxycycline, mefloquine, atorvaquone. e.g. malarone = atorvaquone-proguanil

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AMU - 35 yr old male. Increasing SOB 10/7.
fevers, rigors, headache, myalgia 7/7.
Cough, dirty green sputum 7/7.
GP gave amoxi, no effect.
Pt returned from holiday in tenerife 10/7 ago.

HR 110, BP 110/80, RR 30, SpO2 92% OA, temp 38.5, signs of left lower lobe consolidation.

Diagnoiss~?

pneumonia

e.g. legionella

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AMU - 35 yr old male. Increasing SOB 10/7. fevers, rigors, headache, myalgia 7/7. Cough, dirty green sputum 7/7. GP gave amoxi, no effect. Pt returned from holiday in tenerife 10/7 ago. HR 110, BP 110/80, RR 30, SpO2 92% OA, temp 38.5, signs of left lower lobe consolidation. Ix?

``` CXR FBC U+E LFT cultures sputum culture CRP atypical serology [legionella, mycoplasma, chlamydia] ```

name 5 markers of clinical severity ass. w/ increased risk of death in CAP

CURB-65 ``` confusion urea >7 RR>30 BP <90/60 >65 ```

commonest cause of CAP

strep pneum

main complicaitons of pneumonia

abscess | empyema

complications of legionaires

multiorgan failure needing ITU, e.g. AKI

ABx for legionellla pneumonia

IV clarith [+ rifampicin if ^severity]

whats the risk of using non-prokinetic antiemetics in D+V

toxic megacolon/ perf

50 yr old fishmonger, 3 day Hx of ^^^D+V, no blood or mucous. Ate shellfish + turkey day before, no travel Hx. differentials including likely palthogens

bacterial/ viral [norovirus] gastroenteritis [IBD/IBS] campylobacter, salmonella [mild can present without blood], noro

50 yr old fishmonger, 3 day Hx of ^^^D+V, no blood or mucous. Ate shellfish + turkey day before, no travel Hx. Investigations?

stool culture blood culture FBC U+E

50 yr old fishmonger, 3 day Hx of ^^^D+V, no blood or mucous. Ate shellfish + turkey at restaurant day before, no travel Hx. Mx?

oral rehydration salts encourage oral fluids, may need IV [prokinetic antiemetics - metoclop, domperidone]

50 yr old fishmonger, 3 day Hx of ^^^D+V, no blood or mucous. Ate shellfish + turkey at restaurant day before, no travel Hx. public heath issues?

tell CCDC stop work as fishmonger to prevent spread CCDC will investigate restaurant

which bugs cause inflammation of the termninal large bowel, causing bloody mucous-y diarrhoea [dysentery], tenesmus.

shigella | salmonella

20 yr old plumber admitted with 3 day history of painful swelling of left leg and groin. Generally unwell, fever, rigors. Insulin-dependent DM. Temp 38, pulse 108, BP 120/80. Marked area of swelling and erythema over left shin spreading twards ankle + knee - warm/tender. Also tender palpable lymph nodes in groin. No breaks in skin. high WCC, CRP and BM. Differntials?

cellulitis DVT charcot joint

rule out DVT: doppler US cultures D-dimer would be high in either cellulitis or DVT due to inflamm

most likely pathogens for cellulitis

staph aureus | strep pyogenes [gram +ve group A beta haemolytic]

Mx of cellultitis

IV fluclox

20 yr old, 3 day history of painful swelling of left leg and groin. Unwell, fever, rigors. Insulin-dependent DM. Temp 38, pulse 108, BP 120/80. Marked area of swelling and erythema over left shin spreading twards ankle + knee - warm/tender. Also tender palpable lymph nodes in groin. No breaks in skin. high WCC, CRP and BM. You diagnose cellulitis. What other potentially dangerous condition should be considered?

necrotising fasciitis

what do you feel on examining leg in necrotising fasciitis

crepitus [gas in tissue]

clues + exam/Ix that a cellulitis is nec fasc?

disproportionate pain systemically unwell sweep test by plastic surgeon

bact in nec fasc

group A strep | or polymicrobial

Mx of nec fasc

debridement +/- amputation ABx - eg. clindamycin + benzylpenicillin

24 yr old HIV +ve man. 12 day Hx of ^SOB + non-productive cough. CD4 on diagnosis 3 yrs ago was 300, no ART since. O/E: febrile. sat 87%, falling to 72% on exertion. Examination unremarkable. CXR - bilateral fine peri-hilar infiltrates [bat wings]. What is the likely diagnosis?

PCP [Pneumocystis pneumonia]

what CD4 count is normal? and what count = AIDS? what count do you need to have to get PCP?

>500 is normal <200 = AIDS <200 to get PCP

Pt has PCP. List other important HIV associated lung conditions

strep pneumoniae still most common! cryptococcus, TB, CMV, pseudomonas, lung KS

24 yr old HIV +ve man. 12 day Hx of ^SOB + non-productive cough. CD4 on diagnosis 3 yrs ago was 300, no ART since. O/E: febrile. sats 87%, falling to 72% on exertion. CXR - bilateral fine peri-hilar infiltrates [bat wings]. what Ix would you do to confirm a diagnosis of PCP?

bronchial lavage + PCR [cant get PCP from sputum] re-do CD4

treatment for PCP?

co-trimoxazole [septrin] | +pred

in an HIV +ve patient with PCP and not on ART yet, do you give both ABx and ART together? or which would you start first?

TREAT INFECTIONS 1ST! | otherwise they get IRIS [Immune reconstitution inflammatory syndrome]

What prophylaxis is used to prevent infections in HIV patients?

pneumococcal, HepB + flu vaccines co-trimoxazole [septrin] if CD4 <200 [AIDS] to prevent PCP + toxoplasma azithromycin at CD4<50 for MAI

briefly describe a suitable ART regimen to start a patient on

3 drugs: 2 NRTIs [nucleoside reverse transcriptase] and 1 from either protease inhibitors, integrase inhibitors, or NNRTI [non-nucleoside reverse transciptase]

describe the different incubation times for hepatitis viruses A-E

A + E short | B,C,D long [1-6/12]

given 2 patients, 1 a 30 yr old man born in ethiopia, the other a 30 yr old IVDU born in the UK, who is more likely to have Hep B and which Hep C?

hep B more likely transmitted vertically in an endemic area [or sex] hep C more likely transmitted through injecting drugs [or anal sex]

18 yr old woman presents with fevers + jaundice. Moved to UK aged 4 from pakistan, husband moved to UK 3 months ago just prior to their marriage. Temp 37.8, tender RUQ, deeply jaundiced, no rash or bowel upset. most likely cause?

Hep B

if a 20 yr old contract hep B through sex, what chance do they have of clearing the virus vs chronic? And in a child who contracted it from their mother vertically or in very early childhood?

age 20 - 95% clear the virus baby - 95% go on to have chronic hep B

no indication for treatment for acute infection [unless rarely fulminant - requires transplant]

75 yr old man with know mixed mitral valve disease admitted for urinary retention secondary to BPH. Catheterised for 3 days, removed, then discharged. 2 weeks later: fever, sweats, malaise, ^SOB. O/E: loud, harsh, systolic murmur and palpable thrill. Diagnosis?

infective endocarditis from urosepsis

clinical features of endocarditis.

fever, rigors, malaise murmur roth spots, janeway lesions, splinter haemorrhages, oslers node, clubbing, hepatosplenomegaly, arthralgia microscopic haematuria emboli / abscess

who's at risk of endocarditis?

``` IVDU heart murmur/ defect prosthetic valve Hx of rheum fever previous IE pacemaker/defib HCM ```

organisms for infective endocarditis

strep viridans staph aureus [normal valve] staph epidermidis [prosthetic valve]

Ix in suspected endocarditis

cultures X3 echo FBC, ESR/CRP, rheumatoid factor, U+E, Mg, LFT. urinalysis CXR [cardiomeg, pulm oedema] ECG [HB] CT [emboli in brain/spleen etc]

how can you prevent endocarditis eg. in a pt with a catheter/ going for dental procedure who has a valve defect/ IDVU

amoxi prophylaxis

which side of the heart/ valves are affected in endocarditis usually? and which in IVDUs?

normally L sided/ mitral IVDU right sided/ tricuspid

Abx of endocarditis of native vs prosthetic valve

4-6 weeks IV Abx based on micro consultation following cultures e. g. native: ampicillin, fluclox, gent prosthetic: vanc + gent + rifampicin

duke criteria for endocarditis - give 2 major and 2 minor criteria

major: cultures +ve echo ``` minor: predisposed - IVDU/valve defect fever emboli/janeway lesion glomeneph/oslers ```

indications for surg in IE

``` HF VALVE OBSTRUCTION repeated emboli fungal persistent bacetraemia myocardial abscess unstable infected prosthetic valve ```

if strep bovis is cultured in an infective endocarditis patient, what ix should you do and why

colonoscopy | colon Ca is likely entry point

complications of infective endocarditis

``` stroke PE kidney infarct abscess HF ```

hep B, C and HIV. Which is most infectious in sexual transmission

what happens if you give amoxi in EBV

rash

transmission from needle stick, which is most likely - Hep B, C or HIV?

Hep B

in hepatitis serology, what does it mean if hepatitis antigens are present? [HBsAg/ HBeAg]

means the virus is there currently

If you've been immunised to hepB, will you have surface antibodies, or core antibodies, or both?

surface only, meaning youve made antibodies against the surface antigen and cleared it. Surface antigen not present as the virus is not present. No core antibodies at the vaccine doesnt contain the core of the virus.

risk factors for developing fulminating hepatitis following viral hepatitis infection

imm.supp. drugs pregnancy HIV

IgG and IgM. Which infers acute and which chronic?

IgM is acute infection | IgG is past/previous infection

Mx of chronic hep B infection

tenofovir

clinical monitoring and Mx of hepC patient

liver US HCC monitoring [alpha fetoprotein] endoscopy screen for varices direct acting antiviral drugs

what condition would you screen for in a TB infected patient?

hiv

how do you diagnose TB

sputum for acid fast bacilli/ microscopy/ culture

what do you do in a patient who you suspect has TB but culture and staining is negative?

not 100%, doesnt rule out TB. clinical/ radiological findings can be sufficient to treat

risk factors for TB

HIV homelessness from endemic area

standard TB Tx

isoniazid [6 months] rifampicin [6 months] ethambutol [1st 2 months- induction] pyrazinamide [1st 2 months -induction]

SEs of TB drugs

N+V [give antiemetics] pyrazinamide -arthralgia isoniazid - peripheral neuropathy [pyridoxine] liver toxicity [Is/Rif/Py] ethambutol - optic neuritis

why viral load would keep going up in HIV despite ART?

wrong drug [mutation/resistance] poor compliance poor absorption [e.g. coeliac]

how is contact screening done in TB?

mantoux test [if +ve, CXR etc.]

pts with HIV at risk of what cancers

cervical [annual smear] lymphoma KS

KS is caused by what virus

human herpesvirus 8

what is meant by the "window period" in HIV

2-3 weeks after exposure, tests are false negative | [before host antibody response has been mounted]

what markers can be used to assess how advanced HIV disease is/ tx monitoring

CD4 count | viral load

you strongly suspect HIV in a patient, but HIV test is -ve. what do you do now?

re-test 12 weeks later [window period] can do viral load/ talk to ID

infective cause of haematuria you should test for in patient recently arrived from africa

schistosomiasis

why can HIV pt get pancytopenia?

marrow suppression

SEs of cotrimoxazole

rash [stevens johnson/TEN] | marrow suppression

what advice do you give HIV positive new mum w/ regards feeding

exclusively bottle feeding