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Imperial Medicine Year 3 > Infectious Disease AS > Flashcards

Infectious Disease AS Flashcards

1
Q

What are the different stages of TB?

A

Primary TB
Primary Progressive TB
Latent TB
Secondary TB

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2
Q

What is Primary TB

A

Childhood or naive TB infection.
- Organisms multiples @ pleural surface (Ghon focus)

  • Macros take TB to LNs ( Nodes + lung lesion = Ghon complex).
  • Mostly asymptomatic: may –> fever + effusion
  • Cell mediated immunity/ DTH control infection in 95%.
    (Fibrosis of Ghon complex –> calcified nodule (Ranke complex).
  • Rarely may –> primary progressive TB (immunocompromised).
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3
Q

Primary Progressive TB?

A
  • Resembles acute bacterial pneumonia
  • Mid and lower zone consolidation, effusions, hilar LNs.
  • Lymphohaematogenous spread –> extrapulmonary
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4
Q

Latent TB?

A

Infected but no clinical or x-ray signs of active TB
Non-infectious
May persist for years
Weakened host resistance –> Reactivation

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5
Q

Secondary TB?

A
  • Usually reactivation of latent TB due to decreased host immunity.
  • May be due to reinfection
  • Typically develops in the upper lobes
  • Hypersensitivity –> tissue destruction –> cavitation and formation of caseating granuloma.
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6
Q

What are the pulmonary features of TB?

A 
Cough, sputum
Malaise
Fever, night sweats, weight loss
Haemoptysis
Pleurisy
Pleural effusion 
Aspergilloma/mycetoma may form in TB cavities
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7
Q

Features of meningitis TB?

A 
Headache, drowsiness
Fever
Vomiting 
Meningism
Worsening over 1-3 weeks
 CNS 
- Papilloedema 
- CN palsies
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8
Q

What are the lymph- node features of TB?

A
  • Cervical lymphadenitis: scrofula

- Painless neck mass: no signs of infection (cold).

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9
Q

What are the genito-urinary features of TB?

A

Frequency, dysuria, loin/back- pain, haematuria, sterile pyuria.

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10
Q

What are the other involved systems in TB?

A

Bone TB: vertebral collapse and Pott’s vertebra
Skin: Lupus vulgaris (jelly-like nodules)
Peritoneal TB: abdominal pain, GI upset, ascites
Adrenal: Addison’s disease

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11
Q

What is the diagnosis of latent TB?
Explain the investigation results and interpretation

A
  • Tuberculin Skin Test/Mantoux test
    <6mm = negative - no significant hypersensitivity (previously unvaccinated individuals may be given BCG).

6-15 mm = Positive - hypersensitive to tuberculin. Should not be given BCG. May be due to previous TB infection.

> 10mm = positive result = implies previous exposure. Need erythema and induration.

> 15mm - Strongly positive - suggests TB infection.

  • If +ve –> IGRA (for prior exposure)
    Interferon Gamma Release Assay
  • Pt lymphocytes incubated with M.tb specific antigens. IFN-y production if previous exposure.
  • Either active or latent TB.
  • Will not be positive if just BCG (uses M.bovis)
    e.g Quantiferon Gold.

Used when mantoux is positive, people where a tuberculin test may be falsely negative.

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12
Q

Tests for Active TB

A

All patients with suspected TB require a HIV test. Often pushed into active disease by immunosuppression.

  • CXR
  • Upper lobe cavitation

Active TB
* Sputum samples (Acid fast bacilli will be seen)
* Culture (GOLD STANDARD TEST)
* sputum smear and stain : Stain Ziehl Neelson

Latent TB
* Tuberculin tests (Montoux test) -> Shows active/latent/BCG vaccinated
If the patient has not had the BCG vaccine then this test can be used.
* Inteferongamma release assay (IGRA) -> Shows active/latent
This is used if the patient has had the BCG vaccine. The titre levels of this tells us if the TV has been treated. ,

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13
Q

What would give a false positive in the Mantoux test?

A

BCG, other mycobacteria, previous exposure.

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14
Q

What would give a false negative in the Mantoux test?

A

Immunosuppression.

Miliary TB
Sarcoidosis
HIV
Lymphoma 
Very young age (< 6 months)
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15
Q

What is the pre-assessment investigations of TB?

A

NB: manage without culture if clinical picture is consistent with TB.

  • Continue even if culture results are negative.
  • Stress importance of compliance
  • Check FBC, liver, renal function
  • Creatine Clearanc 10-50ml/min –> decreased R dose by 50% ,avoid E.
  • Test visual acuity and colour vision
  • Give pyridoxine throughout management.-> This is because Isonazid has a chance to cause peripheral neuropathy

Therefore check LFTs cos all are hepatotoxic, test U+E for electrolyte disturbance + elevation of creatinine.

Baseline visual assessment for ethambutol for vision.

FBC baseline - assess for platelets.

Do not need URine dip.

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16
Q

What is the initial phase of management (RIPE)

A

Last 2 months

  • Rifampicin: hepatitis, orange urine, enzyme induction.
  • Isoniazid (nerves = ice for ice): hepatitis, peripheral sensory neuropathy, decrease PMN. (+ pyridoxine). Due to Vit B6 deficiency.
  • Pyrazinamide: arthralgia (CI: gout, porphyria)
  • Ethambutol: Optic neuritis.

All are hepatotoxic

don’t forget Pyridoxine

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17
Q

What is used in the continuation phase in TB?

A

4 months

- Rifampicin and Isoniazid

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18
Q

Management of TB Meningitis?

A

RIPE: 2 months
RI: 10 months
± dexamethasone

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19
Q

What is the management of latent TB?

A

RI For 3 months
or
Iso (+ pyridoxine) for 6 months.

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20
Q

What is directly observed therapy in TB?

A
  • 3x a week dosing regimen may be indicated in certain groups
  • Homeless people with active TB
  • patients who are likely to have poor concordance
  • all prisoners with active or latent TB.
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21
Q

What are the other TB disease?

A

Leprosy
MAI (Mycobacterium avium-intracellulare infection)
Buruli Ulcer
Fish Tank Granuloma

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22
Q

What is Leprosy/Hansen’s disease?

A

Pathogenesis

  • Transmitted via nasal secretions (not very infectious)
  • M.leprae
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23
Q

What are the classifications of leprosy? 2

A

Tuberculoid

  • Less severe (paucibacillary)
  • Th1 mediated control of bacteria
  • Anaesthetic hypopigmented macules
  • Symmetrical nerve involvement

Lepromatous

  • Weak Th1/2 –> Multibacillary
  • Skin nodules
  • Nerve damage (esp ulnar and peroneal)
  • Asymmetrical nerve involvement
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24
Q

What are the clinical features of Leprosy?

A
  • Hypopigmented, insensate plaques (slow over 5 years).
  • Trophic ulcers
  • Thickened nerves (nerve damage + reduced sweating). Neuropathy + disfigurement.
  • Keratitis
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25
Q

What is the management of Leprosy?

A

Tuberculoid: 6 month

  • Rifampicin monthly
  • Clofazamine daily

Lepromatous: 2 yrs

  • Rifampicin months
  • Clofazamine + dapsone daily.
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26
Q

What is MAI?

A

MAI (Mycobacterium avium-intracellulare infection)

  • Complicates HIV infection
  • Widely disseminated: Mainly in the lungs/GIt
  • Fever, night sweats, weight loss
  • Diarrhoea
  • Hepatomegaly
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27
Q

What is a Buruli Ulcer? + what is it caused by

A

M.ulcerans
Australia and the Tropics
Transmitted by insects
Nodule –> ulcer

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28
Q

What is fish tank granuloma + what is it caused by?

A

M.marinum

Skin lesion appearing ~3 weeks after exposure

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29
Q

What is the pathophysiology of influenza?

A

Spread: droplet

Incubation: 1-4 days

Infectivity: 1d before symptoms start to 7d after

Immunity: only strains which have already attacked pt.

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30
Q

What is the presentation of influenza?

A 
Fever 
Headache 
Malaise 
Myalgia
 N/V
Conjunctivitis
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31
Q

Complications of Influenza?

A 
Bronchitis
Pneumonia: esp Staph 
Sinusitis 
Encephalitis 
Pericarditis

Reyes; Rash, vomiting, Increased LFTs in children given aspirin.

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32
Q

What investigations do you do for influenza?

A

Bloods: Paired sera (takes 14 days), lymphopenia, thrombocytopenia

Culture: 1 week from nasal swab

PCR: takes 36hrs

DNA: Up to 15-20mins

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33
Q

Management of influenza?

A

Bed rest and paracetamol
If severe
- Manage in ITU
- Cipro and co-amoxiclav: prevent Staph and Strep

Oseltamivir

  • Neuraminidase inhibitor active vs flu A and B.
  • May be indicated if >1yr with symptoms of >48hrs

Zanamivir
- Inhaled NA inhibitor vs influenza A and B

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34
Q

Prevention of influenza?

A 
Good hygiene 
Trivalent vaccine 
- >65 yrs old 
- DM, COPD, Heart, renal, liver failure 
- Immunosuppression: Splenectomy, steroids 
- Medical staff

Oseltamivir
- Prophylactic use if influenza A/B is circulating and >1 yr old and <48hr since exposure.

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35
Q

What is the immunology of HIV? what is the structure of the virus?

A

HIV binds to gp120 to CD4 - Th cells, monocytes, macrophages, neural cells.

  • CD4 + cells migrate to lymphoid tissue where virus replicates –> infection of new CD4 cells.
  • Deplection + impaired function of CD4+ cells –> immune dysfunction

RNA retrovirus

  • After entry - viral reverse transcriptase makes DNA copy of viral RNA genome.
  • Viral integrase enzyme integrates this with host DNA
  • Core viral proteins synthesised by host and then cleaved by viral protease into mature subunits.
  • Completed virions released by budding.
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36
Q

What is the natural history of HIV?

A
  • Acute infection (asymptomatic)
    Then
  • Seroconversion (transient illness 2-6 weeks after

exposure, fever, malaise, myalgia, pharynitis, macpap rash (symmetrical maculopapular rash) , rarely meningoencephalitis).
then
asymptomatic infection (but 30% will have PGL (persistent generalised lymphadenopathy) - Nodes >1cm in diameter, >2 extra-inguinal sites, >3 months.

then
AIDS-related complex - prodrome with constitutional symptoms + minor opportunistic infections (oral candida, oral hairy leukoplakia, recurrent HSV, seborrheic dermatitis).

Then AIDS.
- CD4 usually <200

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37
Q

What are the other effects of AIDS?
Complications?

A

Osteoporosis
Dementia
Neuropathy
Nephropathy

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38
Q

How do you diagnose HIV?

A

HIV antibody test
- ELISA: detect serum (salivary) anti-HIV Abs
- Western Blot: for confirmation
Most develop antibodies 4-6 weeks but 90% do by 3 months)

Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure.

If recent exposure, may be window period (usually 1-3 weeks. Can be 3-6 months)
- therefore must to HIV infection test** at 12 weeks**.

Test requested = antibodies and p24 antigen. (HIV-1 and HIV-2).

  • PCR: Can detect HIV virions in the window period
  • Rapid Antibody Test: false positives are a problem and results should be confirmed by Western Blot.
  • p24 antigen test - usually positive by 1 week to 3-4 weeks.
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39
Q

Other investigations for HIV?

A
  • HIV diagnostic tests
    -Drug resistance studies
    E.g genotyping
  • Mantoux test
  • Toxo, CMV, HBV, HCV, Syphilis test
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40
Q

What is used to monitor HIV?

A
  • CD4 count
  • Viral load (HIV RNA)
  • FBC, U+E, LFTs, Lipids, glucose.
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41
Q

Indications for HAART?

A

Highly active anti-retroviral therapy - at least 3 drugs.

For a newly confirmed infection - ART is strongly recommended, regardless of CD4 count.

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42
Q

What are the regimens for HAART?

A

At least 3 drugs -
1) typically two nucleoside reverse transcriptase inhibitors (NRTI) + either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI)

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43
Q

Typical regimen (1 NNRTI + 2 NRTI)

A 
NNRTI = Efavirenz
NRTI = emtricitabine + tenofovir (Truvada) 
Atripla = efavirenz + emtricitabine + tenofovir.
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44
Q

Typical regimen (PI + 2 NRTI)

A

PI = Lopinavir (+lose dose ritonavir + Kaletra)

NEver tea

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45
Q

Examples of NRTI?

A 
Zidovudine 
Tenofovir
Stavudine
Abacavir
Lamivudine

General NRTI side-effects = peripheral neuropathy

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46
Q

Examples of NNRTI?

A

Nevirapine, efavirenz

Side effects: P450 enzyme interaction (nevirapine induces), rashes.

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47
Q

Examples of protease inhibitors?

A

Navir tease a pro.

Indinavir
Nelfinavir
Ritonavir

Side effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inducer.

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48
Q

Examples of integrase inhibitors?

A

It’s grave/great you integrate.

Raltegravir
Elvitegravir
Dolutegravir

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49
Q

What prophylaxis do you give at CD4 count 200 and for what?

A

CD4 count of less than <200 - give co-trimoxazole. PCP.

This is for prophylaxis.

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50
Q

What prophylaxis do you give at CD4 count 100 and for what?

A

Give co-trimoxazole for Toxo

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51
Q

What prophylaxis do you give at CD4 count 50 and for what?

A

MAC Mycobacterium Avium Complex- azithromycin

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52
Q

What is HIV exposure management?

A
  • Seroconversion post-needle-stick = ~0.3%
  • Report to Occupational health
  • Immunise against Hep B (active + passive)
  • Test blood from both parties: HIV, HBC, HCV
  • Repeat recipient testing @ 3 and 6 months).
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53
Q

When to use PEP?

A
  • Post-exposure prophylaxis.
  • Start PEP in high-risk exposure from HIV or unknown source
  • Start ASAP as possible
    Continue for at least 28 days. Can be started within 1-2 hrs, but may be started up to 72hrs following exposure.
  • Serological testing at 12 weeks.
  • E.g Truvada + Kaletra.
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54
Q

What are the major AIDS-defining illness? Between 500-200? (4)

A

Between 500-200 CD4 Count

  • Oral thrust (Candida)
  • Shingles (HSV)
  • Hairy Leukoplakia (EBV) - white streaky plaque that is present only on the side of the tongue.
  • Kaposi sarcoma (HHV-8)
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55
Q

What are the major AIDS-defining illness? Between 200-100? (5)

A
  • Cryptosporidiosis (most common cause of diarrhoea)
  • Cerebral Toxoplasmosis
  • Progressive Multifocal leukoencephalopathy - JC virus
  • Pneumocystis jirovecii pneumonia
  • HIV dementia
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56
Q

What are the major AIDS-defining illness? Between 100-50? (4)

A

Aspergillosis
Oesophageal candidiasis (manage with fluconazole, itraconazole)
Cryptococcal meningitis
Primary CNS lymphoma (EBV)

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57
Q

What are the major AIDS-defining illness? Between <50?

A

CMV retinitis - 30-40% of patients

Mycobacterium avium-intracellulare infection

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58
Q

TB and HIV?

A
  • Increased risk of latent TB, and increased risk of disseminated TB.
  • Higher bacterial loads but increased false -ve smears.
  • False -ve skin test (T cell anergy)
  • Absence of characteristic granulomas
  • Increased toxicity combining anti-TB and anti-HIV drugs.
  • IRIS: HAART –> increased CD4 –> paradoxical worsening of TB symptoms.
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59
Q

What is PCP?

A

P.Jiroveci: fungus

Presentation

  • Dry cough
  • Exertional dyspnoea
  • Fever

Extrapulmonary manifestations

  • Hepatosplenomegaly
  • Lymphadenopathy
  • Choroid lesions

CXR: bilateral perihilar interstitial shadowing
Exercise-induced desaturation

DX: visualisation from sputum, BAL or lung biopsy

Rx: High-dose co-trimoxazole IV or pentamidine (severe)

Prophylaxis if CD4 <200.

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60
Q

What can CMV cause in HIV?

A

Retinitis

  • Decreased acuity
  • Eye pain, photophobia
  • Pizza sign on fundoscopy
  • Manage with ganciclovir eye implant.

Cotton-wool spots, infiltrates and haemorrhages - pizza pie appearance on fundoscopy.

Remember central retinal vein occlusion = stormy sunset.

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61
Q

Toxoplasmosis and HIV?

A
  • Posterior uveitis
  • Encephalitis
  • Focal neurology

Diagnosis with toxoplasma serology + LN or CNS biopsy.
Gondii parasite.
Antibody test or Sabin-Feldman dye test.

CT/MRI: Ring-shaped contrast enhancing lesion.

Differentiating between toxo and lymphoma is hard.
Toxo = multiple lesions, ring or nodular enhancing. Thallium SPECT negative.
Lymphoma = Single lesion, solid enhancement, Thallium SPECT positive.

Rx: pyrimethamine + sulphadiazine + folate for at least 6 weeks.

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62
Q

Candidiasis + HIV?

Features and management

A 
Oral: nystatin syspension 
Oesophageal 
- Dysphagia 
- Retrosternal pain 
- Manage: itraconazole PO.
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63
Q

Cryptococcal Meningitis HIV?
Ix?
Treatment?

A

Presentation

  • Chronic history
  • Headache
  • confusion
  • Papilloedema
  • CN lesions

Ix

  • India ink CSF stain
  • Increased CSF pressure
  • CrAg in blood and CSF.

Management
- Amphotericin B + flucystosine for 2 weeks then fluconazole for 6 months/until CD4 >200.

Affects HIV positive patints.

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64
Q

PML and HIV?

A
  • Progressive mutlifocal leukoencephalopathy
  • Demyelinating inflammation of brain white matter caused by JC virus.
  • Presentation
    Weakness
    Paralysis
    Visual loss
    Cognitive decline

Ix: JC viral PCR
Manage: HAART, mefloquine may halt progression.

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65
Q

Kaposi’ Sarcoma

A

Neoplasm derived from capillary endothelial cells or fibrous tissue

Caused by HHV8 infection.

Presentation

  • Purple papules
  • May have visceral involvement

Children present with generalised lymphadenopathy

Management

  • HAART
  • Radiotherapy or Chemo
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66
Q

What are the different types of Herpes infections?

A

Persist in DRG with mucocutaneous spread.

  • HSV 1 - Oropharyngeal/primary stomatitis. Severe painful ulceration + submandibular lymphadenopathy. Severe and painful.

Gingivostomatitis = oral aciclovir, chlorhexidine.
Cold sores: topcial aciclovir.

  • HSV2 - Meningitis/Encephalitis. Flu-like prodrome, headache, focal neuro, fits, odd behaviour.
    CSF: increased lympho, normal gluc, CSF PCR, MRI.

Genitals Herpes
- HSV-2. Flu like prodrome, Dysuria, inguinal LNs, painful ulcers, sacral radiculomyelitis –> urinary retention + sacral sensory loss (elsbry syndrome).

Manage with oral aciclovir.

Herpes Gladiatorum

Herpetic Whitlow - Painful red fingers.

Eczema Herpeticum - Herpes infection at the site of skin damage.

Herpetic Keratitis - Unilateral//bilateral conjunctivitis + pre-auricular LNs (may make a corneal ulcer - dendritic ulcer

Remember, syphilis, lymphogranuloma venereum (caused by chlaymdia) (doxycycline) and granuloma ingiunal (caused by Klebsiella granulomatis) all cause painless genital ulcers.
Behcets causes painful genital ulcers but herpes simplex is more likely.

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67
Q

How do you treat all Herpes infections?

A

Aciclovir (PO, IV, or topical)

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68
Q

Varicella Zoster types?
CP?
S?
Ramsay hunt?

A
  • Spread by Droplet or contact
    replication in LN, then liver and spleen.

Chickenpox = varicella zoster = Flu-like prodrome. Non contagious after lesion scab. Droplet spread. May lead to pneumonitis, haemorrhage, encephalitis. Treat with calamine lotion (sometimes aciclovir).

Shingles (herpes zoster). Zoster reactivation due to decreased immunity/stress. Painful vesicular rash in dermatomal distribution. Thoracic and ophthalmic most commonly. Multidermatomal in immunocompromised. May progress to post-herpetic neuralgia (severe dermatomal pain) . Manage with aciclovir PO/IV, Famciclovir and Valciclovir.

Ramsay Hunt = ear zoster, facial palsy, decreased taste and hearing.

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69
Q

EBV types of disease?

A

Glandular fever/Infectious mononucleosis.

Burkitt’s Lymphoma

Post transplant lymphoproliferative disease

Oral hairy leukoplakia (non-malignant)

Primary brain lymphoma

Nasopharyngeal Ca

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70
Q

What is Infectious mononucleosis?

A

Fever, malaise, sore throat, cervical LN+++. Splenomegaly, hepatitis (–> hepatomegaly, jaundice).

Present with malaise, palatal petechiae, splenomegaly, hepatitis, transient rise in ALT, lymphocytosis.

Maculopapular, pruritic rash develops in 99% of patients who take amipillin/amoxicillin.

Complications: splenic rupture, CN lesion, ataxia, GBS, pancytopenia.

Diagnosis: lymphocytosis, atypical lymphocytes.

+ve heterophiles Abs (Monospot).

Increased LTFs.

Management

  • Rest during early stages, drink plenty of fluid, avoid alcohol.
  • Simple analgesia
  • Avoid contact sports for 8 weeks after glandular fever.
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71
Q

Burkitt’s Lymphoma

A

Jaw or abdo mass. Endemic in africa/malaria. Can occur in immunodeficiency.

Starry sky appearance. t98:14).

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72
Q

What is oral hairy leukoplakia?

A

Painless shaggy white plaque along lateral tongue border.

HIV 500-200 cd4 cells

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73
Q

What are the false +ve for heterophile abs

A

Hepatitis, parvovirus, leukaemia, lymphoma, SLE, pancreatic Ca.

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74
Q

What is CMV?

A

Mucocutaneous spread
Infected cells become swollen
B-epitheliotropic.

Primary infection - 80% asymptomatic. Flu-like illness

Reactivation: Immunocompromised.
HIV: retinitis > colitis > CNS disease
Renal transplant: pneumonitis > colitis > hepatitis > retinitis.

Pneumonitis = bilateral interstitial infiltrates.

Diagnosis: owl’s eye intranuclear inclusions, atypical lymphocytes.

manage with ganciclovir, foscarnet, cidofovir.

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75
Q

How to prevent BMT CMV reactivation?

A
  • Do weekly PCR for first 100d
  • If viraemia +ve –> ganciclovir IV
  • Use CMV -ve irradiated blood products.

Solid organ transplant

  • seroneg recipient + seropos donor
  • Renal tx prophylaxis = valganciclovir
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76
Q

What are the 5 types of Hepatitis?

A

ABCDE

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77
Q

What is the spread of Hepatitis A

A

FAeco-oral. Caused by Seafood (abroad)

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78
Q

What is the spread of Hep B

A

IV - Blood, body fluids, babies.

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79
Q

What is the spread of Hep C

A

Mainly blood. Less vertical can HCV

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80
Q

What is the spread of Hep D

A

Dependent on prior HBV infection

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81
Q

What is the spread of Hep E?

A

FAEco-oral - developing world.

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82
Q

What is the presentation of Hep A?

A

Presentation - incubation 2-4 weeks. Not associated with chronic liver disease.

  • Prodromal Phase (fever, malaise, arthralgia, nausea, anorexia.
  • Distaste for cigarettes.

Icterical phase
- Jaundice, HSM, Lymphadenopathy, cholestatis.

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83
Q

What are the investigations for Hep A?

A

Increased ALT, increased AST (AST:ALT <2)

IgM + ~25 days after exposure = recent infection

IgG +ve for life

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84
Q

Management of Hep A?

A

Supportive
Avoid Alcohol
IFN-a for fulminant hepatitis (rare)

No risk of hepatocellular carcinoma!

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85
Q

Vaccination for Hep A?

A
  • People travelling or going to reside in areas of high or intermediate prevalence -
  • People with chronic liver disease
  • MSM
  • Injecting drug users.
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86
Q

Hep B presentation?

A

Incubation: 1-6 months

Presentation 
- Prodromal phase and icteric phase as for Hep A
- Extra-hepatic features due to immune complexes. 
Urticaria or Vasculitic rash
Cryoglobulinaemia
PAN
GN 
Arthritis
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87
Q

Investigations for Hep B?

A

HBsAg +ve = current infection (+ve >6 months = chronic disease). Normally implies acute disease or chronic.

Anti-HBs = cleared infection or vaccinated. NEGATIVE in immunity.

Anti-HBc IgM = recent infection
Anti-HBc IgG = past infection

Anti-HBc = caught - negative if immunised.

HBeAg +ve = high infectivity

HBV PCR: monitoring response to Rx.

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88
Q

How to interpret Anti-HBs post vaccination?

A

Anti-HBs level from immunisation
- >100 indicates adequate response, no further testing required. Show still receive booster at 5yrs.

  • 10-100 - Suboptimal response - one additional vaccine dose should be given.
  • <10: Non-responder. Test for current or past infection. Give further vaccine course with test following. IF still fails to respond then give HBIG would be required for protection to virus.
89
Q

Management of Hep B?

A
  • Pegylated interferon-alpha.
  • Anti-virals = Tenofovir, entecavir, telbivudine.

For HC workers - give an accelerated course of hep B vaccine + hepatitis B immune globulin.

90
Q

What are the complications of Hep B?

A

Fulminant Hepatic failure
Chronic hepatitis (5-10%) –> cirrhosis in 5%
HCC - Typically deterioration of patient with Hep B.

91
Q

What is the presentation of Hep C?

A

Blood - thousands of UK cases due to transfusion.

  • Presentation - initial infection is usually asymptomatic
  • 25% have acute icteric phase
  • 85% –> chronic infection
  • 20-30% –> cirrhosis within 20yrs.
  • Very increased risk of HCC.
92
Q

Investigations for Hep C?

A

No vaccine for Hep C.

  • Anti-HCV Abs
  • HCV-PCR (HCV RNA) for acute infection.

Viral load is the best way to monitor.

  • Liver biopsy if PCR +ve to assess liver damage
  • HCV genotype.
93
Q

Complications of Chronic Hep C?

A
  • Rheumatological problems: arthralgia, arthritis
  • Eye problems: Sjogren’s syndrome
    Cirrhosis
    HCC
    Cryoglobulinaemia
    Porphyia cutanea tarda
    Glomerulonephritis
94
Q

Management of Hep C?

A

Management depends on viral genotype. (worse efficacy if 1,4,5 or 6.

Aim is to reach an undetectable serum HCV RNA six months after end of therapy.

Currently a combination of protease inhibitors (daclatasvir + sofosbuvir) with or without ribavirin.

Ribavarin = haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic.

Interferon alpha - side -effects: Flu-like symptoms, depression, fatigue, leukopenia.

95
Q

What are the side-effects of ribavarin?

A

Haemolytic anaemia
Cough
Can be teratogenic so should not become pregnant within 6 months of stopping ribavirin.

Interferon alpha - side-effect: flu-like symptoms. depression, fatigue, leukopenia.

96
Q

What is Hepatitis D?

A

Incomplete RNA virus that can only exist with HBV.

Increased risk of acute hepatic failure and cirrhosis .

Invx: anti-HDV Ab.

97
Q

What is Hep E?

A

Similar to HAV

Common in Indochina.

98
Q

What are the differentials for an Acute Hepatitis?

A

Infection: CMV, EBV, Leptospirosis
Toxin: ETOH, paracetamol, isoniazid, halothane
Vasc: Budd-Chiari
Obs: eclampsia, acute fatty liver of pregnancy
Other: Wilson’s AIH

99
Q

What are the differentials for cirrhosis?

A

Common

  • Chronic ETOH
  • NAFLD/NASH

Others

  • Genetic: wilsons, A1ATD, HH, CF
  • AI: AH, PBC, PSC
  • Drugs: Methotrexate, amiodarone, isoniazid
  • Neoplasm: HCC, mets
  • Vasc: Budd-Chiari, RHF, constrict, pericarditis.
100
Q

GI infection - Staph Aureus aetiology, and clinical features?

A

Meat - 1-6hrs

Diarrhoea, vomiting, abdo pain, decreased BP.

Rapid resolution.

101
Q

GI infection - Bacilius cereus aetiology, clinical features?

A
  • Reheated rice (1-6 hrs)

Water diarrhoea and vomiting.

102
Q

GI infection - E.coli ETEH aetiology, clinical features and management?

A

E.coi is an anerobic gram negative rod.

Most common cause of travellers diarrhoea.

  • Travelling
  • Watery Diarrhoea
  • Management: Cipro
103
Q

GI infection - E.coli ETEH (O157:H7) aetiology, clinical features and management?

A

Undercooked minced beef (12-72hrs)

Dysentery
HUS - Renal failure and haemolytic anaemia. Can also include thrombocytopenia.

Diagnosis: Stool MC+S

Management : Dialysis if necessary

104
Q

GI infection - Campylobacter Jejuni aetiology, clinical features and management?

A
  • Unpasteurised milk
  • Animal faeces (cats,dogs).
  • 2-5d
  • Commonest bacterial diarrhoea
    Bloody diarrhoea, fever
    Guillain-Barre
    Reactive arthritis
  • Stool MC+S.
  • Management: Clarithromycin
105
Q

GI infection - Shigella aetiology, clinical features and management?

A
  • 1-7 days
  • BLoody diarrhoea, abdo pain, fever, reactive arthritis

Stool MC+S

Cipro

106
Q

GI infection - Salmonella enteritidis aetiology, clinical features and management?

A

Poultry, eggs and meat.

12-48hrs.

Diarrhoea, vomiting, fever, abdo pain.

Manage: Cipro and ceftriaxone.

107
Q

GI infection - Listeria moncytogenes aetiology, clinical features and management?

A

Refrigerated food - cold enhancement. Pates, soft cheese.

  • Watery diarrhoea, cramps, flu-like.
  • Pneumonia
  • Meningoencephalitis
  • Miscarriage

Blood culture

Treat with Ampicillin

108
Q

GI infection - Clostridium difficile aetiology, clinical features and management?

A

Antibiotic use

  • ceph, cipro, clinda
  • FO spread via spores.

1-7 days.

Bloody diarrhoea, abdo pain, fever - foul smelling.
Pseudomembranous colitis
Toxic megacolon
GI perforation.

Stool MC+S. CDT ELISA

Stop causative Abx

  • 1st lin: metronidazole 400mg TDS PO for 10 days
  • 2nd line: Vanc 125mg QDS PO.

Colectomy may be needed.

109
Q

Clostridium botulinum aetiology, clinical features and management?

A

Canned/Vac-packed food.
Kids = honey
Students = beans

12-36hrs 
Afebrile 
Descending symmetric flaccid paralysis 
No sensory sign 
Autonomic: Dry mouth, fixed dilated pupils.

Toxin in blood samples

  • Antitoxin, Benpen + metro.
110
Q

Clostridium perfringes aetiology, clinical features and management?

A

Reheated meat
- 8-24hrs.
Watery diarrhoea + cramps
Stool MC+S

  • can cause gas gangrene and haemolysis.
  • Features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation

Gas gangrene can occur in traumic or surgical inoculation or spontaneous in immunocompromised patients.

Benpen + metro.

111
Q

Vibrio Cholera aetiology, clinical features and management?

A

FO Spread
Dirty Water

Hrs-5d.
Rice-water stools
Shock, acidosis, renal failure.

Hypoglycaemia

Stool MC+S.

Rehydrate

  • Cooked rice powder solution
  • Hartmann’s with K+ supplements
  • Cipro
  • Zn Supplement
112
Q

Vibrio parahaemolyticus aetiology, clinical features and management?

A

Raw/undercooked seafood (Japan).

  • profuse diarrhoea, abdo pain, vomiting.

Doxycycline 100-200mg/d PO.

113
Q

Norovirus aetiology, clinical features and management?

A

12-48hrs.

Commonest cause in adults 50% of all gastroenteritis worldwide.

Fever, diarrhoea, projectile vomiting.

Acute food poisoning.
Assess for features of dehydration and shock. Check temp, bp, Hr and RR.

Assess for abdo tenderness.

114
Q

Rotavirus aetiology, clinical features and management?

A

1-7 days.

Commonest cause in children.
Secretory diarrhoea and vomiting.

115
Q

Salmonella typhi/paratyphi (Typhoid) aetiology, clinical features and management?

A

Enteric fever - gram negative rods

FO spread, Tropics.

3-21 days.

Malaise, headache, cough, constipation. 
High fever with relative bradycardia. 
Rose spots: patchy red macules
Epistaxis, splenomegaly 
Diarrhoea after 1 weeks. that is pea green.

Diagnose

  • Leukopenia
  • Blood culture
  • urine or stool culture

Management
- Cefotaxime or cipro

Complications

  • Osteomyelitis
  • GI bleed/perforation
  • meningitis
  • Cholecystitis
  • Chronic carriage
116
Q

Yersinia enterocolitica aetiology, clinical features and management?

A

24-36hrs

Food contaminated by domestic animal faeces

Abdo pain, fever, diarrhoea.
Mesenteric adenitis
reactive arthritis, pharyngitis, pericarditis.
Erythema nodosum.

Diagnosis: Serology.

Manage with cipro

117
Q

Entamaeoba histolytica aetiology, clinical features and management?

A

1-4weeks

MSM
travelling.

Dysentery, wind, tenesmus. 
Weight loss if chronic 
Liver abscess 
- RUQ pain, swinging fever, sweats
- Mass in R lobe

Flashed-shaped ulcer on histo.

Stool micro- Motile trophozoite with 4 nuclei.

Amoebic liver abscess - ususally a single mass in the right lobe. The contents are often described as anchovy sauce.

Management: Metronidazole, Tinidazole if severe or abscess.

118
Q

Giardia lambila aetiology, clinical features and management?

A

MSM
Hikers
Travellers

1-4 weeks. - Really late. Therefore 15 days is more likely giardia.

Bloating, explosive diarrhoea, offensive gas. Non-bloody.

Malabsorption –> steatorrhoea and weight loss. -
DX- Direct fluorescent Ab Assay. Stool micro. String test.

  • Pear shaped trophozoites with 2 nuclei.

Duodenal fluid analysis on swallowed string.

Management: Tinidazole/metronidazole

119
Q

Strongyloides aetiology, clinical features and management?

A

Endemic in sub-tropics.

Migrating urticarial rash on trunk and legs.

Pneumonitis, enteritis
Malabsoption –> chronic diarrhoea

Stool MC+S
Serology

Manage with Ivermectin

120
Q

What is a secretory diarrhoea?

A

Bacteria only found in lumen: don’t activate innate immunity.
No/low fever.

No faecal leukocytes.

Caused by bacterial toxins: Cholera, E.coli, s.aureus.

Channels open –> Water loss.

121
Q

What is an inflammatory diarrhoea?

A
  • Bacteria invading lamina propria: activate innate immunity
  • Fever
  • PMN in stool
  • Campylobacter, Shigella, non-typhoidal salmonella, EIEC
122
Q

What is enteric fever?

A
  • Abdo pain, fever, mononuclear cells in stool

- Typhoid salmonella, Yersinia enterocolitiica, Brucella.

123
Q

STI - Gonorrhoea presentation?

A

Gram-negative diplococci.

Young Black Males

Men: purulent urethral d/c, dysuria, prostatitis

Women
- usually asymptomatic, dysuria, d/c.

124
Q

Diagnosis of gonorrhoea ?

A

Culture is gold standard
- Intracellular Gm-diplococi

125
Q

Management of gonorrhoea?

A

Cefixime/Ceftriazone IM

+ Azithro for C

126
Q

Complications of gonorrhoea?

A 
Prostatitis 
Epididymitis
Salpingitis/PID 
(urethral strictures, epididymitis, salpingitis)
Reactive Arthritis
Ophthalmia Neonatorum
127
Q

What is Chlamydia?

A

10% <25

Asympto in 50% men an 80% women.

Men
- Urethritis/ discharge

Women
- Cervicitis, urethritis, salpingitis

128
Q

Diagnosis of chlamydia

A

NAATs - urine = Investigation of choice

Culture - endocervical swab/discharge.

Women = vulvovaginal swab is first line.
Men is urine test.

Should be carried out 2 weeks after possible exposure

129
Q

Management of chlamydia?

A

doxycycline.

TReatment is given on the basis of exposure to infection rather than proven infection. Treat then test.

If pregnancy then azithromycin

130
Q

Complications of chlamydia?

A 
Prostatitis 
epidiymitis 
salpingitis/PID
Reactive arthritis
Opthalmia neonatorum
Increased incidence of ectopic pregnancies
Perihepatitis.
131
Q

HPV 6, 11?

A

Asymptomatic
Cauliflower warts

Fleshy protuberances

Manage with Podophyllotoxin
Cryotherapy

Imiquimod topical cream.

132
Q

Herpes 2

A
  • Flu-like prodrome
  • Inguinal LNs
  • Painful groups vesicles –>Ulcers
  • Dysuria

Diagnosis
- PCR/Serology

Management is

  • Analgesia/
  • Oral Aciclovir

Complications
- Meningitis
- Elsbergy Syndrome
(sacral radiculomyelitis - retention + saddle paraesthesia)

133
Q

Syphillis presentation, diagnosis and management?

A

PAINLESS - Indurating ulcers. Mac pap rash: soles, palms. Aortic aneurysm. Tabes dorsalis.

Cardiolipin

Diagnosis

  • VDRL/RPR: cardiolipin Abs
  • not treponeme specific
  • indicates active disease.

Used to differentiate this from a syphilitic chancre.

False positive cardiolipin

  • Pregnancy
  • SLE, anti-phospholipid
  • TB
  • Leprosy
  • Malaria
  • HIV

TPHA/FTA
- treponeme-specific.
Treponema pallidum HaemAgglutination test.
remains positive after treatment.

RPR
- Rapid plasma reagin is used to monitor disease activity. The higher it is the more solution is needed to dilute it.

If it is higher then treat with Benzathine Penicillin G>

Management with Bezathine Penicillin is 1st line IM. Could also use doxycycline.

134
Q

Chancroid (different to a chancre that is a single, painless lesion with bilateral lymphadenopathy and can heal spontaneously without treatment).

A

Mainly africa
- Papule –> painful soft genital ulcer. Base convered in yellow/grey. Progressing to inguinal buboes.

Caused by Haemophilus ducreyi

Culture/PCR.

Management: Azithromycin.

135
Q

Stages of Syphillis?

A

Primary
Secondary
Tertiary
Quaternary

136
Q

What is primary syphilis?

A

Mac–> Pap–> Indurated, painless ulcer = Chancre.

  • Regional LN
  • Heals in 1-3 weeks.
137
Q

What is secondary syphilis?

A

6 weeks-6 month after chancre.
Systemic bacteraemia –> fever, malaise

Skin rash 
- Symmetrical, non-itchy, mac pap/pustular. 
- Palms, soles, face, trunk. 
Buccal snail-track ulcers. 
Warty lesions: condylomata lata.
138
Q

What is tertiary syphilis?

A

2-20yrs latency
Gummas
- Granulomas in skin, mucosa, bones, joints

139
Q

What is Quaternary syphilis?

A

Syphilitic aortitis

  • Aortic aneurysm
  • Aortic regurg
Neurosyphilis 
- Paralytic dementia 
- Meningovascular: CN palsies, stroke
- Tabes dorsalis 
Degeneration of sensory neurones 
Ataxia + Romberg's( +ve) 
- Areflexia
- Plantars upgoing
  • Argyll- Robertson pupil
    accommodates, doesn’t react
140
Q

What is the diagnosis of Syphilis?

A

Two types
- Cardiolipin antibodies
e.g VDLR, RPR
Not treponeme specific
- False +ve: pregnancy, pneumonia, SLE, malaria, TB.
- Reflects disease activity: -ve after management

Treponeme-specific Ab

  • +ve in primary and secondary syphilis
  • Remains +ve despite management
  • THPA and FTa.
141
Q

Culture for Treponemes?

A
  • Seen by dark ground microscopy of chancre fluid
  • Seen in lesions of 2ndry syphilis
  • May not been seen in late syphilis?
142
Q

Management of syphillis?

A

2-3 dose of benzyl penicillin

Or doxycycline for 28 days.

143
Q

What is a Jarisch-Herxheimer Reaction

A

Fever, Increased HR, vasodilatation after first management
- ?sudden release of endotoxin in syphilis

No wheeze or hypotension

Manage: Steroids or antipyretics

144
Q

What is leptospirosis?

A

Caused by infected rat urine - due to swimming/canoeing.

Sewage worker. Or people who work in an abattoir

Presentation 
- High fever, headache, myalgia/myositis 
- Cough, chest pain ± haemoptysis 
± hepatitis with jaundice ± meningitis. 
- Subconjunctival haemorrhage

Blood culture + give doxycycline. or high-dose benzylpenicillin.

145
Q

What is Brucellosis?

A

Brucella Melitensis - goats

  • Abortus = Cattle
  • Suis: pigs

Due to unpasteurised milk/cheese. Affects vets, farmers and abattoir workers.

Presents with PUO (undulant fever: peak PM, normal AM).

Sweats, malaise, anorexia
Arthritis, spinal tenderness.

LN, HSM
Rash Jaundice.

Diagnosis: Pancytopenia. Positive Rose BEngal Test.

manage: Doxy + rifampicin + gent.

146
Q

What is Lyme disease

A

Ixodes tick bites. Borrelia Burgdorferi.
Walkers, hikers. Adventure holiday in america.

Early localised
- Erythema migrans (target lesions)

Early disseminated
- Malaise, LN, Migratory arthritis, hepatitis

Later persistent

  • arthritis, focal neuro (Bell’s Palsy), heart block, myocarditis.
  • lymphocytoma: blue/red ear lobe.

Diagnosis: Biopsy ECM edge + ab Elisa. This is for elisa. IF they have erythema migrans no need to do investigations and just start on Doxy.

manage with Doxy.

Erythema migrans is sufficent to begin treating a patient without lab investigations. Lyme disease without focal symptoms is with oral doxycycline.

IV ceftriaxone or cefotaxime is recommended for Lyme disease associated with cardiac or neurological complications.

147
Q

What is Cat-scratch disease?

A

Bartonella Henselae - Hx of cat scratch.

Tender regional LNs.

+ve cat scratch skin Ag test.

manage with azithromycin.

148
Q

Rabies what is it?

A

Animal bites
- bats, dogs, foxes

Prodrome
- headache, malaise, bits. Itch odd behavior.

Furious rabies

  • Hydrophobia
  • Muscle spasm

Dumb rabies
- Flaccid limb paralysis

Diagnosis
- Bullet shaped RNA virus
NEgri bodies.

Can give Rabies Ig + vaccine.

149
Q

What are the four species of Malaria?

A

Falciparum
Vivax
Ovale
Malariae

150
Q

What is the biology of malaria?

A

Plasmodium sporozoites injected by female ANopheles mosquito.

Sporozoites migrate to liver, infected hepatocytes and multiply asymptomatically. become Merozoites

These are release from liver and infected RBCs.

Multiple in RBC

  • lead to haemolysis
  • RBC sequestration –> splenomegaly
  • Cytokine release.
151
Q

What is Falciparium Malaria presentation?

A

90% present within 1 month.

Flu-like prodrome
- headache, malaise, myalgia, anorexia

Fever paroxysms

  • Shivering <1hr. Hot stage for 2-6 hrs at 41 C and flushe , dry skin, headache, n/v.
  • Sweating for 2-h4 hrs as temp falls.

Signs

  • Anaemia
  • Jaundice
  • HSM
  • No rash, No LN
152
Q

What are the complications of Falciparum Malaria

A

Cerebral malaria: confusion, coma, fits
Lactic acidosis –> Kussmaul respiration
hypoglycaemia
Acute renal failure: secondary to ATN

ARDS

153
Q

Diagnosis of Malaria Falciparium

A

Present early

Serial thick and thin blood films (thick detect Falciparum) 
Parasitaemia level
FBC: anaemia, thrombocytopenia
Clotting: DIC
GLucose 
ABG: lactic acidosis 
- U+E: renal failure 
Urinalysis: Haemoglobinuria.
154
Q

Management of uncomplicated Falciparum?

A

Artemisinin combination therapies - first line.

Artemether plus lumefantrine etc, artesunate plus amodiaquine.

155
Q

Management of severe falciparum

A

Parasite count of more than 2% will usually need parental treatment irrespective of clinical state.

IV artesunate.

If parasite count >10% exchange transfusion.

156
Q

Presentation and management of uncomplicated ovale, vivax, malariae?

A

PLasmodium vivax/ovale - cyclical fever every 48hrs.

Present much later on

Malariae: every 72hrs + is associated with nephrotic syndrome.

Manage with chloroquine- or artemisinin.

ACTs avoided in pregnant women.

157
Q

Malaria prophylaxis?

A

Malarone (Atovaquone + proguanil) - GI upset. 1-2 days before, 7 days after.

Chlorquine (headache + contraindicated in epilepsy). Taken weekly 1 week before and 4 weeks after.

Doxycycline (photosensitivity/oesophagitis) - 1-2 days before, 4 weeks after.

158
Q

Antimalarial SEs?

A

Chloroquine: retinopathy
Fansidar: SJS, LFTS increase, blood

159
Q

What is sleeping sickness?

A

Afrian Trypanosomiasis - Tsetse fly.

Tender subcut nodule at site of infection.

Haemolyphatic stage

  • Rash, fever, rigors.
  • LNs, HSM.
  • Posterior cervical nodes (Winterbottom’s sign).

Meningoencephaloapthic stage
- Convulsions, apathy, hypersomnolence.

T.gambiense: West Africa
T.rhodesiense: East Africa

Thick and Thin Films - Flagellated protozoa

160
Q

American Trypanosomiasis - Chagas Disease?

A

T.cruzi - due to Reduviids

  • Latin America
  • Erythematous nodule, fever, LN, HSM (called a chagoma)
  • Swelling of eyelid (Romana Sign)
  • Cardiac disease = most worrying. Leads to myocarditis.

Management = azoles or ntriderivaties such as benzidazole.

161
Q

What are the types of leishmaniasis?

A

CUtaneous

Visercal

162
Q

What is cutaneous leishaminiasis?

A

L.major, L.tropica

  • Skin ulcer @ bite –> depigmented scar.
  • In south america. Risk of mucocutaneous leishmaniasis.

Diffuse cutaneous
- Widespread nodules (fail to ulerate)

Mucocutaneous (L.Braziliensis)

  • South america
  • Ulcer in mucous mem of mouth and nose.
163
Q

What is visceral leishmainiasis?

A

Kala Azar (L. donovani)

  • Dry, warty hyperpigmented skin lesions (dark face and hands)
  • Prolonged fever
  • Massive splenomegaly, LNs, abdo pain.
  • Pancytopaenia secondary to hypersplenism
  • Grey skin - kala azar means blackness sickness

Gold standard == Bone marrow or splenic aspiration.

164
Q

What is Filariasis

A

From asia, africa, south america.

Lymphatic Filariasis

  • Wuchereria bancrofti
  • Elephantiais

Lok for microfilariae in the blood
Eosinophilia.

165
Q

Dengue Fever

A

Aedes mosquito

Flushes :Face, neck, chest
Central macpap rash
Headache, arthralgia
HSM
Jaundice 
Haemorrhage: petechial, GI, gums or nose, GU.

Shows up with low platelets, raised transaminases.

Do tourniquet test - petechiae over cuff area.

Manage symptomatically

166
Q

Schistosomiasis

A

Tremotode
Snail vector

Itchy papular rash at site of penetration
- Swimmer’s itch.

Mansoni

  • abdo pain D+V
  • later hepatic fibrosis and portal HTN
  • HSM

Haematobium
- frequency, dysuria, haematuria
- May –> Hydroneprhosis and renal failure.
Increased risk of bladder SCC.

167
Q

Tetanus pathophysiology?

A

Clostridium tetani spores live in faces, dust, soil.

  • Mucosal breach admits spores
  • Spores germinate and produce exotoxin

Exotoxin prevents the release of inhibitory transmitters
- GABA and glycine.

Generalised muscle over-activity.

168
Q

Presentation of tetanus?

A 
Prodrome: Fever, malaise, headache. 
Trismus 
Risus sardonicus - grinning
Opisthotonus - back arching 
Spasms: may lead to respiratory arrest
AUtonomic dysfunction: arrythmias, fluctuating BP.
169
Q

Management of tetanus?

A

Mx on ITU: may need intubation
Human tetanus Ig
Metronidazole, benpen.

170
Q

Prevention of tetanus

A

Acitve immunisation with tetanus toxoid.
Clean minor wounds
- Uncertain Hx <3 doses: give vaccine.
- >3 doses: only vaccinate if >10yrs since last dose.

If heavily contaminated
- <3 doses: vaccine + TIg

171
Q

What is ferritin?

A

Intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is required.

  • Increased ferritin without iron overload
    Inflammation (due to ferritin being an acute phase reactant)
    Alcohol excess
    Liver disease
    Chronic kidney disease
    Malignancy
  • With iron overload (around 10% of patients)
    Primary iron overload (hereditary haemochromatosis)
    Secondary iron overload (e.g. following repeated transfusions)

Reduced ferritin
- Decreased in cases of iron deficiency anaemia

172
Q

Animal bites management

A

Co-amoxiclav

if patient is allergic = doxycycline and metronidazole.

Generally polymicrobial but most common isolated organism is Pasteurella mutlocida.

Management

  • Cleanse wound.
  • Give co-amoxiclav

Human bites
- Co-amoxiclav

173
Q

Aspergilloma

A

This patient is likely to have developed an aspergilloma in an emphysematous cavity, which explains the lack of improvement with broad spectrum intravenous antibiotics, haemoptysis and chest X-Ray findings.

174
Q

Post exposure prophylaxis

A

Hep B - 20-30%
Hep C - 0.5-2%
HIV - 0.3%

Hep A - hep A vaccine or human normal immunoglobulin

Hep B - HBsAg positive source: if known responder give HB vaccine

If they are in the process of being vaccinated or are a non-responder they need to have Hep B IG.
For known non-responders HBIG + vaccine should be given.

Hep C
- Monthly PCR - if seroconversion then interferon +/- ribavirin.

HIV
- combo of antiretrovirals (Tenofovir, entricitabine, lopinavir, ritonavir). Within 1-2 hr but up to 72hrs following exposure. for 4 weeks.

VZ - Give VZIG for IgG negative pregnant women.

175
Q

Acute Cystitis?

A

UTIs in men are considered “complicated” by definition and warrant at least 7 days of antibiotic therapy*.

Offer an immediate antibiotic prescription to pregnant women and men with lower UTI. Take account of:
previous urine culture and susceptibility results
previous antibiotic use, which may have led to resistant bacteria [NICE 2018].

The choice of antibiotic should be reviewed when microbiological results are available.

176
Q

Management of UTIs

A

Non-pregnant women
local antibiotic guidelines should be followed if available
CKS/2012 SIGN guidelines recommend trimethoprim or nitrofurantoin for 3 days
send a urine culture if:
visible or non-visible haematuria

Pregnant women
if the pregnant woman is symptomatic:
a urine culture should be sent in all cases
should be treated with an antibiotic for 7 days
nitrofurantoin (should be avoided near term), amoxicillin or cefalexin
asymptomatic bacteriuria in pregnant women:
a urine culture should be performed routinely at the first antenatal visit
Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course
the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
a further urine culture should be sent following completion of treatment as a test of cure

Men
an immediate antibiotic prescription should be offered. Normally 7 days .

Catherised patients
do not treat asymptomatic bacteria in catheterised patients
if the patient is symptomatic they should be treated with an antibiotic
a 7-day, rather than a 3-day course should be given

Acute pyelonephritis

For patients with sign of acute pyelonephritis hospital admission should be considered
local antibiotic guidelines should be followed if available
the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

In women most likely organisms is E.coli.

177
Q

Metronidazole

A

Metronidazole is a type of antibiotic that works by forming reactive cytotoxic metabolites inside the bacteria.

Adverse effects
disulfiram-like reaction with alcohol (also caused by cefoperazone). - headache, flushing, nausea, vomiting, sweatiness, headache, palpitations.

178
Q

Streptococci classes?

A

alpha haemolytic
- Strep pneumoniae or viridans

beta haemolytic
- A-H. A, B and D.

A = pyogenes (erysipelas, impetigo, cellulitis, T2 necroziting fasciitis)

B = Agalactiae –> neonatal meningitis

179
Q

Tetanus management?

A

Given as part of routine immunisation.

5 doses of tetanus-containing vaccine.

IM human tetanus IG should be given to patients with high-risk wounds regardless of whether 5 doses have been previously given.

If vaccine history is incomplete or unknown then a dose of tetanus vaccine should be given.

180
Q

Parvovirus B19

A

Erythema infectiosum

Rose-red rash the cheeks appear bright red, hence the slapped cheek syndrome. q

181
Q

Black hairy tongue

A

Temporary harmless oral condition relatively common. Defective desquamation of the filiform papillae. May be brown, green, pink.

Poor oral hygiene, tobacco.

Mainly due to tetracycline -
Doxycycline
Tetracycline

Used to treat acne, lyme disease, chlamydia, mycoplasma pneumonia.

SE

  • discolouration of teeth: therefore should not be used in children < 12 years of age
  • photosensitivity
  • angioedema
  • black hairy tongue
182
Q

Hookworm?

A

Anaemia
Eosinophilia
Rash

Occurs from walking barefoot in an affected area.

Strongyloides (round worm)

  • Pruritus, abdo pain, diarrhoea, pneumonitis,
  • Gram negative septicaemia
  • Eosinophilia
  • Thiabendazole, albendazole. Ivermectin alos used, particularly in chronic infections.
183
Q

Live vaccines?

A 
BCG
MMR 
Influenza (intranasal) 
Yellow fever
Oral typhoid
Oral rotavirus
Oral polio
184
Q

Inactivated preparations

A

Rabies
Hepatitis A
Influenza (intramuscular)

185
Q

Toxoid

A

Tetanus
Diphtheria
Pertussis

186
Q

Bacterial Vaginosis?

A

Manage with Metronidazole 400mg BD for 5 days.

Gardnerella vaginalis

If pregnant still use metronidazole.

187
Q

Diphtheria?

A

Gram Positive Bacterium

  • release an exotoxin encoded by B-prophage

Diphtheric membrane - on tonsils caused by necrotic mucosal cells.

Presents with recent visit to eastern europe, russia, asia. 
Sore throat with diphtheric membrane 
Bulkly cervical lymphadenopathy 
Neuritis 
Heart block
188
Q

Pearly penile papules?

A

Normal variant of the glans

Approximately 1-2mm in size.

189
Q

Splenectomy vaccines and management

A

Give Hib, meningitis A +C
Influenza vaccine annually
Pneumococcal vaccine every 5 yrs.

For strep pneumonia. Give vaccine 2 weeks before elective splenectomy.

Haemophilus influenzae
Meningococci

Some killers have pretty nice cars.

190
Q

Notifiable diseases?

A 
Acute meningitis 
Poliomyelitis
Anthrax
Botulism 
Brucellosis
Cholera
Diphtheria
Enteric fever
HUS
Rabies
Rubella
Scarlet Fever
SARDS
Smallpox
Whooping cough
191
Q

Trichomonas

A

Strawberry cervix

192
Q

Bacterial vaginosis?

A

Anaerobic organisms = Gardnerella vaginalis.

Fall in lactic acid - raised vaginal pH.

Fishy, offensive odour.

Amsel criteria

  • Thin, white homogenous discharge.
  • Clue cells on microscopy
  • Vaginal pH >4.5
  • positive whiff test.

Manage with oral metronidazole

193
Q

Ebola?

A

Incubation is 2-21 days.

however all patients returning from Africa with an unexplained fever should be referred to secondary care to rule out other differentials, including malaria.

Ebola spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding.

Ebola should be suspected in patients presenting to primary care services who have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have recently visited any of the affected areas (see maps) within the previous 21 days
OR
Have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF.

194
Q

Lyme’s disease?

A

Lyme Disease is caused by bacteria transmitted via the bite of an infected tick. High risk areas for infected ticks in the UK include the South of England and Scottish Highlands. Lyme disease can be diagnosed in patients with the erythema migrans rash.

Red rash which grows in size and sometimes has a central clearing like a bull’s eye. Not usually itchy or painful.

1-4 weeks after the tick bite and lasts several weeks. Patients may also have fever, sweats, malaise, lymphadenopathy, myalgia, cognitive impairments, headache, neck pain, stiffness.

Caused by Borrelia burgdorferi.

Can use ELISA to Borrelia burgdorferi.

Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

195
Q

Post-splenectomy changes?

A

Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell-Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post-splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given.

196
Q

UTI leading to delirium

A

Manage with Nitrofurantoin for 3 days.

If a patient is on methotrexate do not give trimethoprim.

Do not give trimethoprim to pregnant women.

Trimethoprim can cause tubular dysfunction leading to hyperkalaemia and increased serum creatinine. SHould be avoided in patients taking renin angiotensin antagonist.

Causes myelosuppression, transient rise in creatinine.

Do not give nitrofurantoin during breastfeeding.

197
Q

Pseudomonas

A

Commonlly infects patient with any degree of immunosuppression.

Chronicity of ulcer is long.

Produces a chronic sloughy ulcer.

Green colour is characteristic and produces a classically offensive smell.

198
Q

Malaria prophylaxis?

A

Atovaquone + proguanil (Malarone) = GI upset, 1-2 days before. 7 days after.

Chloroquine = Headache, contraindicated in epilepsy. Taken Weekly. 4 week.

Doxycycline - Photosensitivity and oesophagitis. 1-2 days till 4 weeks after.

Mefloquine - Dizziness neuropsych disturbance, contraindicated in epilepsy.

Proguanil

Proguanil and chloroquine.

199
Q

Yellow Fever

A

Pattern of disease is most consistent with yellow fever.

Classically it will present in two phases. Where patient experiences a brief remission in between.

Viral haemorrhagic fever (Dengue and Yellow Fever)

Feature may cause flu-like lasting less than one week.
Classic description involves sudden onset high fevers, rigors, nausea, vomiting.

If severe, jaundice and haematemesis.

Incubation of 2-14 days.

Dengue has incubation of 4-10 days.

Hepatitis 40-160 days.

Leptospirosis = 7-21 days.

200
Q

Scarlet Fever

A

Caused by Strep Pyogenes

201
Q

Parvovirus B19

A

Erythema infectiosum
Rose-red rash called slap cheek.

Can present with pancytopenia.

202
Q

Cellulitic, extremely tender and haemorrhagic bullae?

A

IV antibiotics and surgical debridement for necrotising fasciitis.

Type 1 = Mixed anaerobes and aerobes. Most common type.

Type 2 = Streptococcus pyogenes.

Acute onset, painful, erythematous lesions. Rapidly worsening cellulitis with pain out of keeping with physical features.

Extremely tender over infected tissue.

Urgent surgical referral debridement. Requires immediate surgical debridement.

IV antibiotics.

203
Q

Trichomonas vaginalis

A

Highly motile, flagellated protozoan parasite.

Frothy, yellow/green offensive discharge.

Vulvovaginitis
Strawberry cervix
pH >4.5
In men is usually asymptomatic but may cause urethritis.

Management = oral metronidazole for 5-7 days.

204
Q

Gram positive cocci?

A

Staph and strep

205
Q

Gram negative cocci?

A

Neisseria meningitis
Neisseria gonorrhoea
Moraxella catarrhalis

206
Q

Gram positive rods

A

ABCD L

Actinomyces
Bacillus anthracis (anthrax)
Clostridium
Diphtheria: Corynebacterium diphtheriae
Listeria monocytogenes
207
Q

Gram negative rods

A 
Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni
208
Q

Red man syndrome

A

Rapid intravenous infusion of vancomycin.

Common adverse reaction of IV vancomycin.
Distinct entity from anaphylaxis.

Redness, pruritus and burning sensation.

Vancomycin related activation of mast cells and release of histamine.

Management - Stop infusion, when symptoms have resolved, recommencement ot a slower rate.

209
Q

Most common STI?

A

Chlamydia

Then Genital warts

Then Gonorrhea

210
Q

Surgical microbiology?

A

Staph A

  • Most common
  • Gram-positive
  • Exo + entero toxin
  • treat with penicillin
  • common cause of cutanoeous infection + abscess

Strep Pyogenes

  • Chain like colonies - Group A strep

E.coli

  • gram negative rod
  • Enterotoxigenic E.coli. Large volume fluid secretion.
  • Enteropathogenic E.coli. Large volume diarrhoea + fever.

Campylobacter jejuni

  • Curved gram negative, non-sporulating bacteria.
  • One of the most common causes if diarrhoea worldwide.
  • Right iliac fossa + diarrhoea.
211
Q

Management of genital warts?

A

Multiple, non-keratinised warts: topical podophyllum

Solitary, keratinised warts: cryotherapy.

212
Q

Surgical site infection

A

Shaving wound INCREASES risk.
Hypoxia increases risk
Delayed admin of antibiotics

Preoperatively

  • Do not remove body hair
  • Use electrical clippers.
  • Antibiotic prophylaxis
  • Placement of prosthesis or valve
  • Clean-contaminated surgery
  • contaminated surgery (opening bowel)

Intraoperatively

  • Prep skin with chlorhexidine
  • cover surgical site
213
Q

Pyrexia of Unknown Origin

A

Prolonged fever >3 weeks resisting diagnosis after a week in hospital

214
Q

Jaundice + minimal systemic upset after eating pork?

A

Faecal-oral route spread by undercooked pork.

Hep E

215
Q

Genital ulcer?

A

Painful: herpes much more common than chancroid
Painless: syphilis more common than lymphogranuloma venereum

Chancroid - painful genital ulcer associated with unilateral, painful inguinal lymph node enlargement. Ulcer have a sharply defined, ragged undermined border.

216
Q

MRSA topical management?

A

Nasal mupirocin and chlorhexidine.

217
Q

Cellulitis

A

Inflammation of the skin and subcut tissues, typically due to infection by Strep Pyogenes. But also due to Staph A.

Staph is gram +ve, Catalase +ve, coagulase +ve.

Staph epidermidis = catalase positive but coagulase negative.

Strep pyogenes + strep viridans = catalase negative.

Commonly occurs on the shins,
Erythema, pain, swelling.

There may be some associated systemic upset such as fever.

Class 1 = No signs of systmic toxicity and person has no uncontrolled co-morbidities

Class 2 = Systemically well with comorbidity or unwel.

Class 3 = Person has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension.

Class 4 = Person is septic

Class I = Oral antibiotics.

3 or 4 need IV antibiotics.
Severe or rapidly deteriorating cellulitis.

Class II = May not be necessary for admission if IV antibiotics in community.

Others can be managed with oral antibiotics.

218
Q

Terbinafine

A

Check Liver function tests

Imperial Medicine Year 3 (35 decks)

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