Infectious Disease AS Flashcards
1
Q
What are the different stages of TB?
A
Primary TB
Primary Progressive TB
Latent TB
Secondary TB
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).
3
Q
Primary Progressive TB?
A
- Resembles acute bacterial pneumonia
- Mid and lower zone consolidation, effusions, hilar LNs.
- Lymphohaematogenous spread –> extrapulmonary
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
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.
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
7
Q
Features of meningitis TB?
A
Headache, drowsiness Fever Vomiting Meningism Worsening over 1-3 weeks CNS - Papilloedema - CN palsies
8
Q
What are the lymph- node features of TB?
A
- Cervical lymphadenitis: scrofula
- Painless neck mass: no signs of infection (cold).
9
Q
What are the genito-urinary features of TB?
A
Frequency, dysuria, loin/back- pain, haematuria, sterile pyuria.
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
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.
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. ,
13
Q
What would give a false positive in the Mantoux test?
A
BCG, other mycobacteria, previous exposure.
14
Q
What would give a false negative in the Mantoux test?
A
Immunosuppression.
Miliary TB Sarcoidosis HIV Lymphoma Very young age (< 6 months)
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.
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
17
Q
What is used in the continuation phase in TB?
A
4 months
- Rifampicin and Isoniazid
18
Q
Management of TB Meningitis?
A
RIPE: 2 months
RI: 10 months
± dexamethasone
19
Q
What is the management of latent TB?
A
RI For 3 months
or
Iso (+ pyridoxine) for 6 months.
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.
21
Q
What are the other TB disease?
A
Leprosy
MAI (Mycobacterium avium-intracellulare infection)
Buruli Ulcer
Fish Tank Granuloma
22
Q
What is Leprosy/Hansen’s disease?
A
Pathogenesis
- Transmitted via nasal secretions (not very infectious)
- M.leprae
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
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
25
What is the management of Leprosy?
Tuberculoid: 6 month
- Rifampicin monthly
- Clofazamine daily
Lepromatous: 2 yrs
- Rifampicin months
- Clofazamine + dapsone daily.
26
What is MAI?
MAI (Mycobacterium avium-intracellulare infection)
- Complicates HIV infection
- Widely disseminated: Mainly in the lungs/GIt
- Fever, night sweats, weight loss
- Diarrhoea
- Hepatomegaly
27
What is a Buruli Ulcer? + what is it caused by
M.ulcerans
Australia and the Tropics
Transmitted by insects
Nodule --> ulcer
28
What is fish tank granuloma + what is it caused by?
M.marinum
| Skin lesion appearing ~3 weeks after exposure
29
What is the pathophysiology of influenza?
Spread: droplet
Incubation: 1-4 days
Infectivity: 1d before symptoms start to 7d after
Immunity: only strains which have already attacked pt.
30
What is the presentation of influenza?
```
Fever
Headache
Malaise
Myalgia
N/V
Conjunctivitis
```
31
Complications of Influenza?
```
Bronchitis
Pneumonia: esp Staph
Sinusitis
Encephalitis
Pericarditis
```
Reyes; Rash, vomiting, Increased LFTs in children given aspirin.
32
What investigations do you do for influenza?
Bloods: Paired sera (takes 14 days), lymphopenia, thrombocytopenia
Culture: 1 week from nasal swab
PCR: takes 36hrs
DNA: Up to 15-20mins
33
Management of influenza?
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
34
Prevention of influenza?
```
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.
35
What is the immunology of HIV? what is the structure of the virus?
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.
36
What is the natural history of HIV?
- 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
37
What are the other effects of AIDS?
Complications?
Osteoporosis
Dementia
Neuropathy
Nephropathy
38
How do you diagnose HIV?
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.
39
Other investigations for HIV?
- HIV diagnostic tests
-Drug resistance studies
E.g genotyping
- Mantoux test
- Toxo, CMV, HBV, HCV, Syphilis test
40
What is used to monitor HIV?
- CD4 count
- Viral load (HIV RNA)
- FBC, U+E, LFTs, Lipids, glucose.
41
Indications for HAART?
Highly active anti-retroviral therapy - at least 3 drugs.
For a newly confirmed infection - ART is strongly recommended, regardless of CD4 count.
42
What are the regimens for HAART?
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)
43
Typical regimen (1 NNRTI + 2 NRTI)
```
NNRTI = Efavirenz
NRTI = emtricitabine + tenofovir (Truvada)
Atripla = efavirenz + emtricitabine + tenofovir.
```
44
Typical regimen (PI + 2 NRTI)
PI = Lopinavir (+lose dose ritonavir + Kaletra)
NEver tea
45
Examples of NRTI?
```
Zidovudine
Tenofovir
Stavudine
Abacavir
Lamivudine
```
General NRTI side-effects = peripheral neuropathy
46
Examples of NNRTI?
Nevirapine, efavirenz
Side effects: P450 enzyme interaction (nevirapine induces), rashes.
47
Examples of protease inhibitors?
Navir tease a pro.
Indinavir
Nelfinavir
Ritonavir
Side effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inducer.
48
Examples of integrase inhibitors?
It's grave/great you integrate.
Raltegravir
Elvitegravir
Dolutegravir
49
What prophylaxis do you give at CD4 count 200 and for what?
CD4 count of less than <200 - give co-trimoxazole. PCP.
This is for prophylaxis.
50
What prophylaxis do you give at CD4 count 100 and for what?
Give co-trimoxazole for Toxo
51
What prophylaxis do you give at CD4 count 50 and for what?
MAC Mycobacterium Avium Complex- azithromycin
52
What is HIV exposure management?
- 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).
53
When to use PEP?
- 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.
54
What are the major AIDS-defining illness? Between 500-200? (4)
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)
55
What are the major AIDS-defining illness? Between 200-100? (5)
- Cryptosporidiosis (most common cause of diarrhoea)
- Cerebral Toxoplasmosis
- Progressive Multifocal leukoencephalopathy - JC virus
- Pneumocystis jirovecii pneumonia
- HIV dementia
56
What are the major AIDS-defining illness? Between 100-50? (4)
Aspergillosis
Oesophageal candidiasis (manage with fluconazole, itraconazole)
Cryptococcal meningitis
Primary CNS lymphoma (EBV)
57
What are the major AIDS-defining illness? Between <50?
CMV retinitis - 30-40% of patients
| Mycobacterium avium-intracellulare infection
58
TB and HIV?
- 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.
59
What is PCP?
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.
60
What can CMV cause in HIV?
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.
61
Toxoplasmosis and HIV?
- 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.
62
Candidiasis + HIV?
Features and management
```
Oral: nystatin syspension
Oesophageal
- Dysphagia
- Retrosternal pain
- Manage: itraconazole PO.
```
63
Cryptococcal Meningitis HIV?
Ix?
Treatment?
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.
64
PML and HIV?
- 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.
65
Kaposi' Sarcoma
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
66
What are the different types of Herpes infections?
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.
67
How do you treat all Herpes infections?
Aciclovir (PO, IV, or topical)
68
Varicella Zoster types?
CP?
S?
Ramsay hunt?
- 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.
69
EBV types of disease?
Glandular fever/Infectious mononucleosis.
Burkitt's Lymphoma
Post transplant lymphoproliferative disease
Oral hairy leukoplakia (non-malignant)
Primary brain lymphoma
Nasopharyngeal Ca
70
What is Infectious mononucleosis?
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.
71
Burkitt's Lymphoma
Jaw or abdo mass. Endemic in africa/malaria. Can occur in immunodeficiency.
Starry sky appearance. t98:14).
72
What is oral hairy leukoplakia?
Painless shaggy white plaque along lateral tongue border.
HIV 500-200 cd4 cells
73
What are the false +ve for heterophile abs
Hepatitis, parvovirus, leukaemia, lymphoma, SLE, pancreatic Ca.
74
What is CMV?
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.
75
How to prevent BMT CMV reactivation?
- 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
76
What are the 5 types of Hepatitis?
ABCDE
77
What is the spread of Hepatitis A
FAeco-oral. Caused by Seafood (abroad)
78
What is the spread of Hep B
IV - Blood, body fluids, babies.
79
What is the spread of Hep C
Mainly blood. Less vertical can HCV
80
What is the spread of Hep D
Dependent on prior HBV infection
81
What is the spread of Hep E?
FAEco-oral - developing world.
82
What is the presentation of Hep 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.
83
What are the investigations for Hep A?
Increased ALT, increased AST (AST:ALT <2)
IgM + ~25 days after exposure = recent infection
IgG +ve for life
84
Management of Hep A?
Supportive
Avoid Alcohol
IFN-a for fulminant hepatitis (rare)
No risk of hepatocellular carcinoma!
85
Vaccination for Hep A?
- People travelling or going to reside in areas of high or intermediate prevalence -
- People with chronic liver disease
- MSM
- Injecting drug users.
86
Hep B presentation?
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
```
87
Investigations for Hep B?
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.
88
How to interpret Anti-HBs post vaccination?
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
Management of Hep B?
- Pegylated interferon-alpha.
- Anti-virals = Tenofovir, entecavir, telbivudine.
For HC workers - give an accelerated course of hep B vaccine + hepatitis B immune globulin.
90
What are the complications of Hep B?
Fulminant Hepatic failure
Chronic hepatitis (5-10%) --> cirrhosis in 5%
HCC - Typically deterioration of patient with Hep B.
91
What is the presentation of Hep C?
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
Investigations for Hep C?
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
Complications of Chronic Hep C?
- Rheumatological problems: arthralgia, arthritis
- Eye problems: Sjogren's syndrome
Cirrhosis
HCC
Cryoglobulinaemia
Porphyia cutanea tarda
Glomerulonephritis
94
Management of Hep C?
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
What are the side-effects of ribavarin?
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
What is Hepatitis D?
Incomplete RNA virus that can only exist with HBV.
Increased risk of acute hepatic failure and cirrhosis .
Invx: anti-HDV Ab.
97
What is Hep E?
Similar to HAV
| Common in Indochina.
98
What are the differentials for an Acute Hepatitis?
Infection: CMV, EBV, Leptospirosis
Toxin: ETOH, paracetamol, isoniazid, halothane
Vasc: Budd-Chiari
Obs: eclampsia, acute fatty liver of pregnancy
Other: Wilson's AIH
99
What are the differentials for cirrhosis?
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
GI infection - Staph Aureus aetiology, and clinical features?
Meat - 1-6hrs
Diarrhoea, vomiting, abdo pain, decreased BP.
Rapid resolution.
101
GI infection - Bacilius cereus aetiology, clinical features?
- Reheated rice (1-6 hrs)
Water diarrhoea and vomiting.
102
GI infection - E.coli ETEH aetiology, clinical features and management?
E.coi is an anerobic gram negative rod.
Most common cause of travellers diarrhoea.
- Travelling
- Watery Diarrhoea
- Management: Cipro
103
GI infection - E.coli ETEH (O157:H7) aetiology, clinical features and management?
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
GI infection - Campylobacter Jejuni aetiology, clinical features and management?
- Unpasteurised milk
- Animal faeces (cats,dogs).
- 2-5d
- Commonest bacterial diarrhoea
Bloody diarrhoea, fever
Guillain-Barre
Reactive arthritis
- Stool MC+S.
- Management: Clarithromycin
105
GI infection - Shigella aetiology, clinical features and management?
- 1-7 days
- BLoody diarrhoea, abdo pain, fever, reactive arthritis
Stool MC+S
Cipro
106
GI infection - Salmonella enteritidis aetiology, clinical features and management?
Poultry, eggs and meat.
12-48hrs.
Diarrhoea, vomiting, fever, abdo pain.
Manage: Cipro and ceftriaxone.
107
GI infection - Listeria moncytogenes aetiology, clinical features and management?
Refrigerated food - cold enhancement. Pates, soft cheese.
- Watery diarrhoea, cramps, flu-like.
- Pneumonia
- Meningoencephalitis
- Miscarriage
Blood culture
Treat with Ampicillin
108
GI infection - Clostridium difficile aetiology, clinical features and management?
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
Clostridium botulinum aetiology, clinical features and management?
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
Clostridium perfringes aetiology, clinical features and management?
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
Vibrio Cholera aetiology, clinical features and management?
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
Vibrio parahaemolyticus aetiology, clinical features and management?
Raw/undercooked seafood (Japan).
- profuse diarrhoea, abdo pain, vomiting.
Doxycycline 100-200mg/d PO.
113
Norovirus aetiology, clinical features and management?
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
Rotavirus aetiology, clinical features and management?
1-7 days.
Commonest cause in children.
Secretory diarrhoea and vomiting.
115
Salmonella typhi/paratyphi (Typhoid) aetiology, clinical features and management?
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
Yersinia enterocolitica aetiology, clinical features and management?
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
Entamaeoba histolytica aetiology, clinical features and management?
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
Giardia lambila aetiology, clinical features and management?
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
Strongyloides aetiology, clinical features and management?
Endemic in sub-tropics.
Migrating urticarial rash on trunk and legs.
Pneumonitis, enteritis
Malabsoption --> chronic diarrhoea
Stool MC+S
Serology
Manage with Ivermectin
120
What is a secretory diarrhoea?
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
What is an inflammatory diarrhoea?
- Bacteria invading lamina propria: activate innate immunity
- Fever
- PMN in stool
- Campylobacter, Shigella, non-typhoidal salmonella, EIEC
122
What is enteric fever?
- Abdo pain, fever, mononuclear cells in stool
| - Typhoid salmonella, Yersinia enterocolitiica, Brucella.
123
STI - Gonorrhoea presentation?
Gram-negative diplococci.
Young Black Males
Men: purulent urethral d/c, dysuria, prostatitis
Women
- usually asymptomatic, dysuria, d/c.
124
Diagnosis of gonorrhoea ?
Urine NAATs
-
Culture is gold standard
- Intracellular Gm-diplococi
125
Management of gonorrhoea?
Cefixime/Ceftriazone IM
+ Azithro for C
126
Complications of gonorrhoea?
```
Prostatitis
Epididymitis
Salpingitis/PID
(urethral strictures, epididymitis, salpingitis)
Reactive Arthritis
Ophthalmia Neonatorum
```
127
What is Chlamydia?
10% <25
Asympto in 50% men an 80% women.
Men
- Urethritis/ discharge
Women
- Cervicitis, urethritis, salpingitis
128
Diagnosis of chlamydia
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
Management of chlamydia?
doxycycline.
TReatment is given on the basis of exposure to infection rather than proven infection. Treat then test.
If pregnancy then azithromycin
130
Complications of chlamydia?
```
Prostatitis
epidiymitis
salpingitis/PID
Reactive arthritis
Opthalmia neonatorum
Increased incidence of ectopic pregnancies
Perihepatitis.
```
131
HPV 6, 11?
Asymptomatic
Cauliflower warts
Fleshy protuberances
Manage with Podophyllotoxin
Cryotherapy
Imiquimod topical cream.
132
Herpes 2
- 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
Syphillis presentation, diagnosis and management?
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
Chancroid (different to a chancre that is a single, painless lesion with bilateral lymphadenopathy and can heal spontaneously without treatment).
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
Stages of Syphillis?
Primary
Secondary
Tertiary
Quaternary
136
What is primary syphilis?
Mac--> Pap--> Indurated, painless ulcer = Chancre.
- Regional LN
- Heals in 1-3 weeks.
137
What is secondary syphilis?
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
What is tertiary syphilis?
2-20yrs latency
Gummas
- Granulomas in skin, mucosa, bones, joints
139
What is Quaternary syphilis?
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
What is the diagnosis of Syphilis?
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
Culture for Treponemes?
- Seen by dark ground microscopy of chancre fluid
- Seen in lesions of 2ndry syphilis
- May not been seen in late syphilis?
142
Management of syphillis?
2-3 dose of benzyl penicillin
| Or doxycycline for 28 days.
143
What is a Jarisch-Herxheimer Reaction
Fever, Increased HR, vasodilatation after first management
- ?sudden release of endotoxin in syphilis
No wheeze or hypotension
Manage: Steroids or antipyretics
144
What is leptospirosis?
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
What is Brucellosis?
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
What is Lyme disease
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
What is Cat-scratch disease?
Bartonella Henselae - Hx of cat scratch.
Tender regional LNs.
+ve cat scratch skin Ag test.
manage with azithromycin.
148
Rabies what is it?
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
What are the four species of Malaria?
Falciparum
Vivax
Ovale
Malariae
150
What is the biology of malaria?
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
What is Falciparium Malaria presentation?
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
What are the complications of Falciparum Malaria
Cerebral malaria: confusion, coma, fits
Lactic acidosis --> Kussmaul respiration
hypoglycaemia
Acute renal failure: secondary to ATN
ARDS
153
Diagnosis of Malaria Falciparium
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
Management of uncomplicated Falciparum?
Artemisinin combination therapies - first line.
Artemether plus lumefantrine etc, artesunate plus amodiaquine.
155
Management of severe falciparum
Parasite count of more than 2% will usually need parental treatment irrespective of clinical state.
IV artesunate.
If parasite count >10% exchange transfusion.
156
Presentation and management of uncomplicated ovale, vivax, malariae?
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
Malaria prophylaxis?
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
Antimalarial SEs?
Chloroquine: retinopathy
Fansidar: SJS, LFTS increase, blood
159
What is sleeping sickness?
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
American Trypanosomiasis - Chagas Disease?
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
What are the types of leishmaniasis?
CUtaneous
| Visercal
162
What is cutaneous leishaminiasis?
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
What is visceral leishmainiasis?
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
What is Filariasis
From asia, africa, south america.
Lymphatic Filariasis
- Wuchereria bancrofti
- Elephantiais
Lok for microfilariae in the blood
Eosinophilia.
165
Dengue Fever
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
Schistosomiasis
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
Tetanus pathophysiology?
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
Presentation of tetanus?
```
Prodrome: Fever, malaise, headache.
Trismus
Risus sardonicus - grinning
Opisthotonus - back arching
Spasms: may lead to respiratory arrest
AUtonomic dysfunction: arrythmias, fluctuating BP.
```
169
Management of tetanus?
Mx on ITU: may need intubation
Human tetanus Ig
Metronidazole, benpen.
170
Prevention of tetanus
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
What is ferritin?
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
Animal bites management
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
Aspergilloma
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
Post exposure prophylaxis
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
Acute Cystitis?
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
Management of UTIs
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
Metronidazole
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
Streptococci classes?
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
Tetanus management?
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
Parvovirus B19
Erythema infectiosum
Rose-red rash the cheeks appear bright red, hence the slapped cheek syndrome. q
181
Black hairy tongue
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
Hookworm?
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
Live vaccines?
```
BCG
MMR
Influenza (intranasal)
Yellow fever
Oral typhoid
Oral rotavirus
Oral polio
```
184
Inactivated preparations
Rabies
Hepatitis A
Influenza (intramuscular)
185
Toxoid
Tetanus
Diphtheria
Pertussis
186
Bacterial Vaginosis?
Manage with Metronidazole 400mg BD for 5 days.
Gardnerella vaginalis
If pregnant still use metronidazole.
187
Diphtheria?
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
Pearly penile papules?
Normal variant of the glans
Approximately 1-2mm in size.
189
Splenectomy vaccines and management
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
Notifiable diseases?
```
Acute meningitis
Poliomyelitis
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever
HUS
Rabies
Rubella
Scarlet Fever
SARDS
Smallpox
Whooping cough
```
191
Trichomonas
Strawberry cervix
192
Bacterial vaginosis?
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
Ebola?
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
Lyme's disease?
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)
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Post-splenectomy changes?
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.
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UTI leading to delirium
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.
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Pseudomonas
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.
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Malaria prophylaxis?
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.
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Yellow Fever
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.
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Scarlet Fever
Caused by Strep Pyogenes
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Parvovirus B19
Erythema infectiosum
Rose-red rash called slap cheek.
Can present with pancytopenia.
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Cellulitic, extremely tender and haemorrhagic bullae?
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.
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Trichomonas vaginalis
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.
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Gram positive cocci?
Staph and strep
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Gram negative cocci?
Neisseria meningitis
Neisseria gonorrhoea
Moraxella catarrhalis
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Gram positive rods
ABCD L
```
Actinomyces
Bacillus anthracis (anthrax)
Clostridium
Diphtheria: Corynebacterium diphtheriae
Listeria monocytogenes
```
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Gram negative rods
```
Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni
```
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Red man syndrome
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.
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Most common STI?
Chlamydia
Then Genital warts
Then Gonorrhea
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Surgical microbiology?
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.
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Management of genital warts?
Multiple, non-keratinised warts: topical podophyllum
Solitary, keratinised warts: cryotherapy.
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Surgical site infection
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
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Pyrexia of Unknown Origin
Prolonged fever >3 weeks resisting diagnosis after a week in hospital
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Jaundice + minimal systemic upset after eating pork?
Faecal-oral route spread by undercooked pork.
Hep E
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Genital ulcer?
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.
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MRSA topical management?
Nasal mupirocin and chlorhexidine.
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Cellulitis
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.
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Terbinafine
Check Liver function tests
