Infectious Diseases Flashcards
A 42-year-old man presents to your clinic with history of a slowly-enlarging painless scrotal mass over the past months. He has previous history of unilateral cryptorchidism which required orchiopexy. On examination, a solid scrotal lump is palpated. Which one of the following would be the next best step in management?
A. Measuring serum alpha fetoprotein.
B. Measuring serum human beta chorionic gonadotropin (βHCG).
C. CT scan of the abdomen and pelvis.
D. Ultrasonography of the scrotum.
E. Scrotal needle biopsy.
D. Ultrasonography of the scrotum.
All solid scrotal lumps should be considered malignant until proven otherwise. In approach to scrotal masses the most appropriate next step is to request an ultrasound to further evaluate the scrotal mass.
Ultrasound of the testes can reliably diagnose the testicular tumor with considerable precision and can also detect any invasion of the tunica albuginea.
This man also has undergone orchipexy that is a risk factor for development of testicular cancer.
Risk factors of development of testicular cancer include personal or family history of any of the following:
* Cryptorchidism (undescended testes)
* Orchiopexy
* Testicular atrophy
* Previous testicular cancer
Option A and B: Tumor markers (alpha fetoprotein and beta HCG) are not requested unless ultrasound suggests cancer.
Option C: CT scan of the abdomen, pelvis and chest is done for staging purposes and only considered after confirmed diagnosis of testicular malignancy.
Option E: Needle scrotal biopsy should be avoided because of potential risk of tumor implanting malignant cells in the scrotal wall.
A 20-year-old man presents to the Emergency Department with acutely painful scrotal swelling for the past 12 hours. Evaluation establishes the diagnosis of epidiymoorchitis. Which one of the following is the most likely causative organism?
A. E.coli.
B. Staphylococcus aureus.
C. Chlamydia.
D. Neisseria gonorrhea.
E. Treponema pallidum.
C. Chlamydia
Causative organism in epididymo-orchitis varies based on the age of the patient:
Children and men older than 35 years:
Urinary coliforms (e.g., E coli, Pseudomonas species, Proteus species, Klebsiella species) are the most common causes. Less frequently, pathogens such as Ureaplasma urealyticum, Corynebacterium species, Mycoplasma species, and Mima polymorpha have also been isolated. Systemic Hemophilus influenzae and Neisseria meningitides infections are rare yet possible causes.
Sexually active men younger than 35 years:
Chlamydia is the most common cause in sexually active men younger than 35 years (accounting for up to 50% of cases, although laboratory evidence of Chlamydia may be absent in up to 90% of cases). Infections with Neisseria gonorrhea, Treponema pallidum, Trichomonas species, and Gardnerella vaginalis also occur in this population.
In this sexually active man, who is younger than 35 years.
* RACGP - AFP - Acute scrotal pain
* Medscape - Epididymitis
A 25-year-old Asian woman with no known tuberculosis contact has a positive Tuberculin skin test (TST) in a workup for immigration. A chest X-ray is performed and is completely normal. She has no cough, fever or sputum. Physical examination is unremarkable. Which one of the following is the next best step in management?
A. BCG vaccination.
B. Isoniazid for 9months.
C. Repeat the chest X-ray in 6months.
D. Repeat the TST in 2 weeks.
E. Isoniazid for 2 months.
B. Isoniazid 9 months
Every person with a positive tuberculin skin test (TST), also known as Mantoux test, or interferon gamma release assay (IGRA), should undergo a full investigation for active TB infection, including chest X-ray and sputum smear for acid-fast bacilli (AFB) and culture. If the diagnosis of active disease is established, the patient should receive full four-drug therapy with isoniazid, ethambutole, pyrizinamide, and rifampicin.
LTBI denotes infection with mycobacterium tuberculosis without any active disease. This is why monotherapy with isoniazid for 6 to 9 months is required for such patients.
A positive chest X-ray indicates either healed TB with residual traction scars or active TB infection. For this reason, if an abnormal chest X-ray is the only finding in addition to a positive TST or IGRA, three sputum samples should be obtained for acid fast bacilli (AFB) stain and culture.
If all three samples are negative, active TB infection is excluded, and the patient should be treated for LTBI. With even one positive sample in the presence of chest X-ray abnormalities, active TB infection is the definite diagnosis. Any positive result needs to be discussed with a clinician experienced in TB management before starting any treatment.
Treatment of LTBI requires at least 6 months of isoniazid.
- RACGP - Tuberculosis testing
- Australian Prescriber - Testing for tuberculosis
- Therapeutic Guidelines – Antibiotics: available on: http://tg.org.au
Which one of the following is not a feature of mycoplasma pneumonia?
A. Headache.
B. High fever.
C. Pleuretic chest pain.
D. Cough.
E. Myalgia.
B. High fever
The prodromal phase is characterized by headache, malaise, myalgia and mild fever. Fever more than 39°C is rare in mycoplasma infection and should raise suspicion against another cause.
Cough in mycoplasma is usually incessant and often non-productive (dry) to mildly productive.
Sputum discoloration may be seen late in the course of the disease.
http://emedicine.medscape.com/article/1941994-clin
A 27-year-old man is seen in the emergency department with complaints of dry cough, fever, dyspnea, and diarrhea, which began 4 days after an upper respiratory tract infection. On physical examination, he has a respiratory rate of 22 breaths per minute and temperature of 41°C. On auscultation, bilateral basal crackles are noted. Chest X-ray is remarkable for bilateral interstitial infiltrates. Which one of the following is the most appropriate initial therapy for this patient?
A. Amoxicillin/clavulanate.
B. Penicillin.
C. Azithromycin.
D. Ciprofloxacin.
E. Trimethoprim-sulfamethoxazole.
C. Azithromycin
This man has the characteristic features of an atypical pneumonia. The most common causative organism in atypical pneumoniae is mycoplasma pneumoniae, but in infections with this organism the fever is unlikely to exceed 39°C.
Signs and symptoms of atypical pneumonia in addition to high fever and gastrointestinal problems make infection with legionella pneumophila pneumonia (legionnaires’ disease) the most likely diagnosis. Macrolides (e.g. azithromycin) are antibiotics of choice for all atypical pneumonias, including legionnaires disease. They also may cover streptococcus pneumonia.
http://emedicine.medscape.com/article/220163-clini * http://emedicine.medscape.com/article/220163-overv
A 24-year-old pregnant woman, who is 19 weeks pregnant, presents to your office complaining of frequency, urgency and dysuria. Further investigations establish the diagnosis of urinary tract infection. The culture results are still pending. The patient has history of allergic reaction to penicillin manifesting as a rash. Which one of the following would be the antibiotic of choice for treating this patient?
A. Amoxicillin.
B. Clarithromycin.
C. Aminoglycosides.
D. Tetracyclines.
E. Cephalexin.
E. Cephalaxin
The antibiotic of choice for empirical treatment of urinary tract infection (UTI) in pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second- and third-line medications, respectively. Patients allergic to penicillin manifested as a rash can be still rather safely treated with cephalexin. If the presentation of allergy to penicillin was anaphylaxis, cephalosporins were not recommended, and the patient should be treated with nitrofurantoin.
Asymptomatic bacteriuria (>105 colony count in urine culture of an asymptomatic woman) in pregnancy should also be treated with a one week course of antibiotics. Urine culture should be repeated 48 hours after completion of treatment to confirm resolution of the infection.
Macrolides e.g. clarithromycin are *not recommended *for treatment of UTI.
Aminoglycosides are category D and should not be used during pregnancy, unless there is severe gram negative sepsis.
Tetracyclins are contraindicated in pregnancy due to their potential teratogenic effects.
A 6-year-old boy is brought to your practice with fever and cough for 7 days. On examination, he has a blood pressure of 100/70 mmHg, pulse rate of 110 bpm, respiratory rate of 22 breaths per minute and a temperature of 37.7°C. There is no respiratory distress. Lung auscultation reveals bilateral crackles at lung bases. Chest X-ray is performed that is remarkable for bilateral patchy infiltrates more prominent in the left upper lobe.
Blood test is :
HB 130g/L (120-150)
WCC 14x109/L (4-11)
Neutrophils 6.5x 109/L (2.0-7.5)
Lymphocytes 3.7x109/L (1.5-4.0)
Platelets 180x109/L (150-400)
Which one of the following is the most likely diagnosis?
A. Streptococcus viridians.
B. Mycoplasma pneumoniae.
C. Adenovirus.
D. Respiratory syncytial virus.
E. Hemophilus influenza.
B. Mycoplasma pneumoniae
The clinical findings and radiological findings of diffuse patchy infiltrates are highly suggestive of atypical pneumonia.
Viral pneumonia is the most common cause of atypical pneumonia in children younger than 2 years.
Mycoplasma pneumoniae is the most common causative organism in this age group (school-aged children).
Patients with mycoplasma pneumoniae usually experiences a prodromal phase characterized by headache, malaise, myalgia and mild fever. Fever more than 39°C is rare in mycoplasma infection and should always raise suspicion against another cause.
Usually the patient is not very ill
Mycoplasma pneumonia has a more prolonged course, compared to viral pneumonia.
Like other pulmonary diseases, chest X-ray is the best initial diagnostic test.
*http://emedicine.medscape.com/article/1941994-over
* Therapeutic Guidelines - Respiratory; available on: http://tg.org.au * AMC Handbook of Multiple Choice Questions – page 543
A 57-year-old man presents to your GP practice with progressive cough, fever and malaise for the past 3 months. His background history includes smoking for 20 years and working in pottery industry for 30 years. Five years ago, he developed shortness of breath, for which he sought medical care and was diagnosed with silicosis. Which one of the following can be the cause for his recent condition?
A. Bronchogenic carcinoma.
B. Tuberculosis.
C. Chronic obstructive pulmonary disease.
D. Mesothelioma.
E. Pneumonia.
B. Tuberculosis
People who have chronic exposure to silica (miners, quarry workers, potters, etc.) may develop silicosis, which is an occupational interstitial lung disease. Pulmonary silicosis presents with exertional dyspnea due to progressive fibrosis of the lung parenchyma. Typical radiologic findings vary based on the severity and course of the disease and may include small nodular opacities (< 1 cm) in the upper lung zones and reticular changes and honey-combing (a late finding).
Although bronchogenic carcinoma is another possibility in heavy smokers with exposure to silica, it is not usually associated with fever and malaise. With fever and malaise and the history of silicosis, TB is more likely than bronchogenic carcinoma.
Smoking history makes chronic obstructive pulmonary disease (COPD) another possibility, but it does not cause fever and malaise unless an infection superimposes the condition. It is unlikely for a COPD patient to have lung infection as the first presentation of the disease.
Mesothelioma is a very rare malignancy of the pleura and is associated with asbestosis. It presents with pleuretic chest pain, pleural effusion and pleural thickening and calcification on imaging.
With symptoms persisting for three months, pneumonia is unlikely.
Which one of the following conditions is likely to cause the oral lesions shown in the accompanying photograph in a 67-year-old man?
A. HIV.
B. Use of systemic corticosteroids.
C. Diabetes mellitus.
D. Chronic xerostomia.
E. All of the above.
E. All of the above
The photograph shows the oral Candidiasis (thrush) it colonizes the oral cavity in 60-75% of population, but the infection often occurs in those with immunodeficiency. These patches are easily scraped off, leaving only an underlying red patch.
Risk factors to development of oral Candidiasis include :
* Immunodeficiency
* Cytotoxic therapy
* Broad spectrum antibiotics
* Corticosteroids including inhaled corticosteroids
* Diabetes mellitus
* HIV
* Debility
* Anemia (iron, folic acid, or B12 deficiency)
* Dentures
* Chronic xerostomia
A 69-year-old woman presents to your clinic with complaint of vaginal discharge. As a part of workup you perform a urine PCR test for gonorrhea and Chlamydia. The result is positive for gonorrhea. You tell her about the results and that gonorrhea is a sexually transmissible disease. She mentions that she has not had any sexual relationship with anyone whatsoever. Which one of the following will be the next best step in management?
A. Repeat the PCR test.
B. Give a single dose of ceftriaxone.
C. Give a single dose of azithromycin.
D. Arrange for hysteroscopy.
E. Counsel her about treatment.
E. Counsel her about treatment
Currently, a nucleic acid amplification test (NAAT) such as PCR is recommended as the optimal method for the diagnosis of genital tract infections caused by Neisseria gonorrhea and Chlamydia trachomatis in men and women with or without symptoms. Samples for NAATs can be collected from vagina or endocervix, urine (male and female) or urethra (only men).
Compared with culture, commercially available NAATs offer rapid results (within hours) and are generally more sensitive than culture. Cultures are only recommended when drug resistance is suspected.
In situations where positive test results are not supported by sexual history or clinical findings (such as in this scenario), retesting the patient with a different NAAT or culture is recommended. A decision to delay treatment until retesting confirms the diagnosis should be made in consultation with the patient. Patients should be counselled about prompt treatment after a positive screening test because an additional test might be falsely negative. Since the treatment of Chlamydia trachomatis and Neisseria gonorrhea is safe and relatively inexpensive, the patient might choose to be treated empirically without further testing or wait for the repeated test result.
A 31-year-old woman presents with painful genital wart over the labia majora and minora. She is 38-week pregnant. Which one of the following is the next best step in management?
A. Take a piece of wart for PCR.
B. Obtain blood for culture.
C. Observer until after delivery.
D. Cryotherapy.
E. Excision of the lesion.
D. Cryotherapy
Higher human papilloma virus (HPV) infection rates have been reported in pregnant women. If condyloma develops, rapid growth can be observed. Contributing factors include immune system suppression during pregnancy and hormonal changes.
Small asymptomatic lesions do not require treatment as most of them resolve after delivery. Large lesions can be treated with cryotherapy or keratolytics such as trichloracetic acid (TCA) or bichloracetic acid (BCA) as the preferred methods during pregnancy. Recurrences should be treated with same methods if complete response had occurred.
Interferon, podophyllin, podophyllotoxin, imiquimod and 5-fluorouracil are topical agents that chemically ablate warts. Except imiquimod, these agents are contraindicated throughout pregnancy. Although imiquimod is category B1, there is not enough evidence regarding the safety of imiquimod during pregnancy, and it can be used after the pregnant woman is fully informed.
A 56-year-old Victorian farmer presents to your GP clinic with chest tightness and coughing for the past 2 months. He also mentions vague right upper quadrant abdominal pain. On examination, no remarkable findings are noted except for mildly jaundiced sclera. Which one of the following could be the most likely diagnosis?
A. Hydatid cyst.
B. Q fever.
C. Ross River fever.
D. Brucellosis.
E. Dengue fever.
A. Hydatid cyst
The clinical picture, suggestive of lung and hepatic involvement, and the occupation of the patient make echinococcus infection (hydatid cyst) the most likely diagnosis.
In Australia, most hydatid infections are passed between sheep ad dogs, although other animals including horses, kangaroos, dingoes and foxes may be involved.
People become infected by ingesting eggs of the parasite, usually while there is a hand-to-mouth transfer of eggs in dog feces. This can occur when handling dogs or objects (including food and water) soiled with dog feces. Person-to-person or sheep-to-person transmission does not occur.
The pressure effect of the cyst on the liver can produce symptoms of obstructive jaundice and abdominal pain. With biliary rupture, the classic triad of biliary colic, jaundice and urticaria is observed. Passage of hydatid membranes in vomit (hydatid emesia) and passage of membrane in the stool (hydatid enterica) may rarely occur.
Involvement of the lungs produces chronic cough, dyspnea, pleuretic chest pain and hemoptysis. Expectoration of cyst membrane and fluid is observed with intrabronchial rupture.
A 65-year-old man presents to your clinic with a painful swelling below his left eye. The lesion is illustrated in the accompanying photograph. Which one of the following would be the most appropriate next step in management?
A. Incision and drainage.
B. Cold compression.
C. Warm compression.
D. Antibiotics.
E. Topical steroids.
D. Antibiotics
Dacryocystitis is an infection of the lacrimal sac often due to nasolacrimal duct obstruction. It presents as a swollen, red, pus-filled sac below the medial aspect of the eye.
- Swelling and redness over the medial canthus
- Possible abscess formation in severe cases
- History of a watery eye
- Hot Compresses: Apply to the affected area to reduce inflammation.
- Massaging: Gently massage the tear sac and nasolacrimal duct.
- Astringent Eye Drops: Use zinc sulfate 0.25% + phenylephrine 0.12%, 1 or 2 drops three times daily.
- Topical Antibiotics: Use chloramphenicol if there is conjunctivitis.
-
Systemic Antibiotics: Start oral antibiotics to prevent the spread of infection. The choice of antibiotics is guided by Gram-stain and culture results.
- Empiric choices: di/flucloxacillin or amoxicillin-clavulanate.
-
Intravenous Antibiotics: Indicated if there is:
- Orbital cellulitis
- Significant periorbital/facial cellulitis
- Marked systemic symptoms (e.g., fever)
- Surgical Intervention: Perform a dacryocystorhinostomy after the infection has subsided with adequate antibiotic therapy.
- Mild Cases: Manage with hot compresses, massaging, astringent eye drops, and topical antibiotics if needed.
- Severe Cases: Start systemic antibiotics immediately, followed by intravenous antibiotics if complications arise.
- Post-Infection: Perform surgical intervention (dacryocystorhinostomy) once the infection is controlled.
The picture shows a swollen, red, puss-filled sac below the medial aspect of the left eye suggestive of dacryocystitis. Dacryocystitis is infection of the lacrimal sac often secondary to obstruction of the nasolacrimal duct. It presents with inflammation localized over the medial canthus. The condition may vary in clinical presentation from mild (such as in infants) to more severe forms with abscess formation such as in this case. There is often a history of watery eye for months beforehand.
Mild cases are managed with hot compresses and massaging the tear sac and nasolacrimal duct (the mainstay of the management) and astringent eye drops (e.g. zinc sulfate 0.25% + phenylephrine 0.12%, 1 or 2 drops 3 times daily). Topical antibiotics such as chloramphenicol are used if there is concomitant conjunctivitis.
More severe cases of dacryocystitis are often caused by Staphylococcus aureus or Streptococcus pyogenes, but occasionally Gram-negative and anaerobes can be the culprits. Systemic antibiotic therapy is always required as the most important initial step to limit the likelihood of infection spreading to adjacent areas such as the orbit, and serious complications such as orbital cellulitis. Although, the most appropriate choice of antibiotics are guided by Gram-stain and culture, di/flucloxacillin or amoxicillin-clavulanate, orally, should be started while the results are pending.
Intravenous route is used if there is orbital celllulitis, significant periorbital/ facial cellulitis, or if the patient has marked systemic symptoms (e.g. fever).
Antibiotic therapy is then followed by surgical treatment after the infection has subsided with adequate antibiotic therapy. For dacryocystitis, an dacryocystorhinostomy is preferred after several days of initiating antibiotic therapy.
Six days ago, a 30-year-old man presented to your practice with complaints of acute sore throat and a fever of 39.2°C. On examination, he had red swollen tonsils with exudate. He was prescribed amoxicillin. Today, he has presented with a non- blanching pruritic rash. Which one of the following options best describes the most likely cause for the rash?
A. Infectious mononucleosis.
B. Allergic drug reaction.
C. Hypersensitivity vasculitis.
D. Varicella zoster infection.
E. Streptococcal pharyngitis.
B. Allergic drug reaction
A patient with suspected bacterial pharyngitis develops a rash after starting on amoxicillin. This often occurs when a patient with infectious mononucleosis (IM) is misdiagnosed and treated with antibiotics.
- Cause: Epstein–Barr virus
- Common Ages: 10-35 years, peak incidence 15-25 years
-
Symptoms:
- Sore throat
- Lymphadenopathy (swollen lymph nodes)
- Fever
- Rash
- Hepatosplenomegaly (enlarged liver and spleen)
- Incubation Period: 4-6 weeks
-
Initial Rash:
- Occurs in ~5% of cases
- Pinkish, maculopapular (similar to rubella)
- Blanching and non-pruritic (not itchy)
-
Rash After Antibiotics:
- 90-100% of patients given ampicillin or amoxicillin develop a rash
- Non-blanching and itchy
- Develops 5-9 days after starting antibiotics
-
Allergic Reaction to Antibiotics:
- Common in IM patients treated with amoxicillin
- Non-blanching, itchy rash
- Appears 5-9 days after starting the antibiotic
-
Other Considerations:
- Varicella Zoster: Vesicular, pruritic rash (no indication in this scenario)
- Streptococcal Pharyngitis: Scarlatiniform rash (blanching, papular, erythematous within 2 days)
- Amoxicillin in IM: High likelihood of rash due to drug reaction.
- Immediate Action: Stop the antibiotic.
- Evaluation: Check for IM and avoid using similar antibiotics in the future.
By understanding the typical presentations and timing of rashes associated with IM and antibiotic use, you can better identify and manage allergic drug reactions.
The scenario describes a rather common clinical situation: a patient with suspected bacterial pharyngitis develops rash after being started on amoxicillin. This occurs when a patient with infectious mononucleosis is misdiagnosed as bacterial pharyngitis and started on antibiotics.
Infectious mononucleosis (IM) is a febrile illness caused by Epstein–Barr virus from herpes family. It can mimic diseases such as primay HIV infection, streptococcal tonsillitis, viral hepatitis and acute lymphatic leukemia. It may occur at any age but is more common between10 and 35 years with the peak incidence among those ages 15-25 years.
IM has an incubation period of 4-6 weeks. The disease may initially present with sore throat (the cardinal finding), lymphadenopathy, fever, rash, and hepatosplenomegaly.
The rash of IM is almost always related to antibiotics given for tonsillitis. The primary rash, most often non-specific, pinkish and maculopapular (similar to that of rubella), occurs in only about 5% of cases. It is usually blanching and non-pruritic.
About 90–100% of patients prescribed ampicillin or amoxycillin will be affected. This rash is non-blanching and itchy, and develops 5-9 days after antibiotics are started.
The rash of this patient is most likely to be an allergic reaction to the antibiotic. The exact mechanism of rash following administration of antibiotics in IM is not fully understood.
As mentioned earlier, the rash of IM presents early in the course of the disease. It has a faint color, and is non-pruritic and non-blanching in contrast to the rash here which is non-blanching and itchy.
Neither the initial rash of IM nor the drug-related rash developing after antibiotics are given are not caused by hypersensitivity vasculitis.
Varicella zoster infection presents with vesicular rash that is pruritic. There is no hint regarding varicella zoster as a cause in the scenario.
Streptococcal pharyngitis can be associted with scarlatiniform form rash (similar to the rash in scarlet fever) which might resemble the rash of this patiet. In a suspetible patient, this rash manifests within the first 2 days of symptoms and cause a papular, blanching and erythematous rash. This patient has developed an itchy, non-blanching rash 6 days after the onset of symptoms that makes such diagnosis less likely.
A 16-year-old boy presents with a rash shown in the following photograph. The rash developed few days after he was started on amoxicillin-clavulanate and paracetamol because of sore throat, fever and cervical lymphadenopathy. He mentions no improvement despite being on antibiotic. Which one of the following is the most appropriate next step in management?
A. Add gentamicin.
B. Add erythromycin.
C. Stop the antibiotic.
D. Wait and watch.
E. Give systemic corticosteroids.
C. Stop the antibiotic
This occurs when a patient with Ebstein-Barr infectious mononucleosis is misdiagnosed as having bacterial pharyngitis and started on antibiotics accordingly in the majority of patients.
Infectious mononucleosis (IM) is a febrile illness caused by the herpes (Epstein–Barr) virus. It can mimic diseases such as HIV primary infection, streptococcal tonsillitis, viral hepatitis and acute lymphatic leukaemia. It may occur at any age but usually between 10 and 35 years; it is commonest in 15–25 years age group.
It has a incubation period of 4-6 weeks. The disease may present initially with sore throat (the cardinal finding), lymphadenopathy, fever, rash, hepatosplenomegaly, etc. There might be exudative tonsillitis resembling that of streptococcal pharyngitis. The rash of IM is almost always related to antibiotics given for tonsillitis when it is mistakenly considered bacterial.
The rash develops 5-9 days after antibiotics are started.
There could be another possible cause to the rash: a genuine delayed hypersensitivity reaction to amoxicillin-clavulanate, meaning that the patient has developed a genuine allergy to the antibiotic rather than an interaction with the underlying infection.
No matter if the rash is a result of interaction between the antibiotic and IM or a drug eruption caused by a genuine drug allergy, the next step in management is cessation of the culprit antibiotic, which is the amoxicillin – clavulanate here. Systemic steroids are the treatment of last resort for bothersome rashes not responding to more conservative treatments such as antihistamines.
C. Stop the antibiotic
The patient likely has infectious mononucleosis (IM) caused by the Epstein-Barr virus, but it was misdiagnosed as bacterial pharyngitis and treated with antibiotics.
-
Infectious Mononucleosis (IM):
- Cause: Epstein-Barr virus.
- Age Group: Common in ages 15-25.
- Incubation Period: 4-6 weeks.
- Symptoms: Sore throat, lymphadenopathy, fever, rash, hepatosplenomegaly.
- Tonsillitis: Often exudative, resembling streptococcal pharyngitis.
-
Rash in IM:
- Timing: Develops 5-9 days after starting antibiotics.
- Cause: Usually due to antibiotics given for mistaken bacterial infection.
-
Possible Causes of Rash:
- Interaction: Between antibiotic and Epstein-Barr virus.
- Drug Allergy: A genuine allergic reaction to the antibiotic.
-
Management:
- Stop the antibiotic: Regardless of the cause, stopping amoxicillin-clavulanate is essential.
- Alternative Treatments: If the rash is severe and not responding to conservative treatments like antihistamines, systemic steroids may be considered.
When a rash develops in a patient with infectious mononucleosis after starting antibiotics, the primary management step is to stop the antibiotic. This helps address whether the rash is due to the interaction with the Epstein-Barr virus or a genuine drug allergy.
A 30-year-old man presented to your GP office with complaints of acute sore throat and a fever of 39.2°C which developed 48 hours prior to his visit. On examination, he had red swollen tonsils with exudate. He was prescribed amoxicillin. After 5 days, he presents with a non-blanching pruritic rash all over body. The rash is shown in the following photograph. Which one of the following tests could be most diagnostic at this stage?
A. Penicillin allergy test.
B. Blood culture.
C. Full blood count.
D. Throat swabs and cultures.
E. Serologic tests for EBV.
C. Full blood count
Epstein-Barr Infectious Mononucleosis (IM)
Scenario:
This scenario often occurs when Epstein-Barr Infectious Mononucleosis (IM) is misdiagnosed as streptococcal pharyngitis and the patient is given aminopenicillins (e.g., amoxicillin, ampicillin).
Key Points:
- Cause: Epstein-Barr virus (herpes family).
- Common Age: 10-35 years (most common between 15-25 years).
- Incubation Period: 4-6 weeks.
- Symptoms: Sore throat (cardinal finding), lymphadenopathy, fever, rash (especially after starting antibiotics), and hepatosplenomegaly. The exudative tonsillitis may resemble streptococcal pharyngitis.
Diagnosis:
- Full Blood Count (FBC):
- Most Appropriate Initial Test: Invariably shows lymphocytosis (>50% lymphocytes).
- Blood Film: Shows atypical lymphocytes (>10% lymphocytes).
-
Diagnostic Tests for IM:
- Monospot® Test: Detects heterophile antibodies (reaction with horse red blood cells). More commonly used and preferred over serologic tests.
- Paul-Bunnell Test: Traditional test (reaction with sheep red blood cells).
-
Additional Information:
- Serologic Tests (IgG and IgM against Epstein-Barr): Rarely needed unless Monospot® test is negative but clinical suspicion remains high. Performed weekly for six weeks if necessary.
- Blood Cultures and Throat Swabs: Not useful for diagnosing IM as they are typically negative in this condition.
Clinical Application:
- Patient with Rash After Antibiotics: Consider IM if there is unresponsiveness to antibiotics and rash development. Perform an FBC to check for lymphocytosis.
- Further Management: Confirm diagnosis with Monospot® test if needed.
Conclusion:
The most appropriate initial test for a patient suspected of having Epstein-Barr Infectious Mononucleosis, especially after the development of a rash post-antibiotics, is a full blood count (FBC).
The scenario can be frequently encountered when Epstein-Barr infectious mononucleosis is misdiagnosed as streptococcal pharyngitis and the patient is started on aminopenicillins i.e. amoxicillin and ampicillin.
Epstein-Barr Infectious mononucleosis (IM) is a febrile illness caused by Epstein–Barr virus from herpes family. It can mimic diseases such as primary HIV infection, streptococcal tonsillitis, viral hepatitis and acute lymphocytic leukemia. It may occur at any age but usually between 10 and 35 years (most common between 15 and 25 years).
After an incubation period of 4-6 weeks, IM may present with sore throat (the cardinal finding), lymphadenopathy, fever, rash, and hepatosplenomegaly. There might be exudative tonsillitis resembling streptococcal pharyngitis. The rash develops 5-9 days after antibiotics are started.
With the rash and unresponsiveness to antibiotics, Epstein-Barr IM should be considered and investigated as the most likely cause.
Of the options, a full blood count, is the most appropriate test; however, not the most diagnostic one. In IM, the FBC will invariably demonstrate lymphocytosis (>50% lymphocytes). Lymphocytosis is a rule in IM. With normal or decreased lymphocyte count, a different diagnosis should be considered. Blood film will show atypical lymphocytes (>10% lymphocytes).
Diagnostic tests for Epstein-Barr IM are traditional Paul-Bunnell test (reaction of heterophile antibodies with sheep red blood cells) or the newer Monospot®® test (reaction of heterophile antibodies with horse red blood cells).
With Monospot® test available, serological studies (IgG and IgM titres against Epstein-Barr) are rarely indicated and only reserved for patients with signs and symptoms suggestive of the infection but with negative Monospot test results performed weekly for six weeks. Blood cultures and cultures of throat swabs are very unlikely to be positive if the cause is IM. They are not useful or indicated in this situation. Blood cultures are negative in IM and have no diagnostic value.
Throat swabs and cultures are negative in IM. They are not appropriate diagnostic tests to consider for patients with IM.
Serologic tests, so early in the course of the disease, are less likely to be diagnostic.Moreover, they are not clinically indicated because Monospot® test is more available and diagnostic.
A 47-year-old man presents with complaints of swinging fevers, productive cough with a fetid odor and right-sided chest pain that worsens with respiration. These have occurred and progressed over a course of few days. A chest X-ray is obtained that shows a round opacity in the right middle lobe. There is air-fluid level within the opacity. Expectorated sputum is sent for gram stain and culture. The initial result of the Gram stain test reveals Staphylococcus aureus in the sputum. You start the patient on intravenous flucloxacillin. Which one of the following is could be the most appropriate next step in management?
A. Transpleural drainage.
B. Lobectomy.
C. Transcutaneous aspiration.
D. Water-sealed chest drain.
E. CT scan of the chest.
E. CT scan of the chest
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Clinical Presentation:
- Right middle lobe opacity with air-fluid level suggests lung cavitation.
- Symptoms: fever, productive cough (often foul-smelling), night sweats, weight loss, and malaise.
- Often seen in an indolent course over days to weeks or months.
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Possible Causes:
- Microbial infections (e.g., Staphylococcus aureus, Klebsiella pneumoniae, etc.).
- Non-microbial causes like pulmonary infarction, bronchiectasis, necrotizing carcinoma, etc.
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Characteristics:
- Lung abscess appears as a cavity in the lung, often visible on chest X-ray or CT scan.
- Staphylococcus aureus can cause severe pneumonia, especially after influenza infection, presenting with shock and lung necrosis.
- Chest X-Ray: Initial imaging to identify the presence of a lung abscess.
- CT Scan of the Chest: Provides better anatomical detail and helps in differentiating between lung abscess and empyema.
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Uncomplicated Lung Abscess:
- Antibiotics (often intravenously) are the main treatment, especially if the abscess communicates with the airway and drains spontaneously.
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Complicated Lung Abscess:
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Criteria for Complication:
- Failure to respond to medical management.
- Suspected neoplasm.
- Associated with an obstructed bronchus.
- Extremely large abscess (>6 cm).
- Involvement of resistant organisms like Pseudomonas aeruginosa.
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Management Options:
- Lobectomy or Pneumonectomy: Surgical removal of the affected lung lobe or entire lung.
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Endoscopic or Percutaneous Drainage: Alternative for those who are poor surgical candidates.
- Requires careful handling to avoid contamination of the pleural space.
- Bronchoscopy can be used for diagnosis but is less effective for drainage.
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Criteria for Complication:
- Aspiration for Sample: Not needed as the etiologic agent is already identified.
- Water-Sealed Chest Drain: Used for empyema, not for lung abscess without complications.
- Immediate Step: Perform a CT scan of the chest to confirm the diagnosis and assess the extent of the lung abscess.
- Follow-Up: Begin appropriate antibiotic treatment and consider surgical options if the abscess is complicated.
The clinical presentation as well as the radiographic finding of right middle lobe opacity with an air-fluid level is highly suggestive of lung cavitation. Lung abscess is a common cause of cavitation in lung parenchyma. Other pulmonary lesions that are not caused by microbes may resemble lung abscess. These include:
-Lesions of pulmonary infarction
-Bronchiectasis
-Necrotizing carcinoma
-Pulmonary sequestration
-Vasculitides e.g. polyarteritis nodosa, granulomatosis with polyangiitis (Wegener’s), Goodpasture syndrome –Cysts or bullae with fluid collections
The following organisms are capable of producing monomicrobial lung abscess:
-Staphylococcus aureus
-Klebsiella pneumoniae
-Gram negative bacilli
-Hemophilus influenza type B
-Legionella
-Nocardia Actinomycosis
Lung abscess can present with the following features:
An indolent course over days to weeks (or months in specific situations)
-Fever (rigors or chills are often absent)
-Productive cough that can be foul-smelling
-Night sweats
-Weight loss
-Malaise
The most characteristic form of pneumonia caused by Staphylococcus aureus is fulminant disease in young adults or adolescents with underlying influenza infection. The patient often has a fulminant course with shock, neutropenia, lung necrosis and high mortality rate despite antibiotic treatment.
Antibiotics (often intravenously) are mainstay of therapy for uncomplicated lung abscess, especially for those with air-fluid level that indicates communication of the abscess with airway and spontaneous abscess drainage. Surgical intervention is reserved for patients with complicated lung abscess. The following are considered as complicated lung abscess:
Failure to respond to medical management
Suspected neoplasm
Abscesses associated with an obstructed bronchus
An extremely large abscess (>6 cm in diameter)
Abscesses involving relatively resistant organisms such as Pseudomonas aeruginosa
The usual procedure in such cases is a lobectomy or pneumonectomy. For those who are poor candidates for surgery alternative methods such as endoscopic drainage or percutaneous drainage may be considered. Percutaneous procedures require special care to prevent contamination of the pleural space. Bronchoscopy may be done as a diagnostic procedure, especially to detect an underlying lesion, but this procedure is of relatively little use to facilitate drainage and can result in spillage of abscess contents into the airways. Endoscopic drainage, which requires an experienced operator, is performed by placing a pigtail catheter into the abscess cavity under bronchoscopic visualization and leaving the catheter in place until the cavity has drained.
Radiographic evaluation for differentia diagnoses or associated conditions
A chest X-ray generally demonstrates the pulmonary lesion to the extent necessary for diagnosis and management; however, better anatomic definition can be achieved with CT scanning. CT is particularly helpful if the diagnosis and delineation of the cavity is in doubt or in distinguishing between lung abscess and empyema despite looking similar on X-ray sometimes, require completely different managements.
However, if CT scan found the cause to be an empyema and not an abscess, transpleural drainage will be indicated.
Lobectomy (preferred) and transpleural drainage can be considered if the abscess is complicated, evident by the size, poor response to treatment, obstruction, etc. There is no clue in the scenario pointing towards complications; therefore, these measures are not appropriate for now.
The etiologic agent in this patient has already been determined by sputum exam so aspiration to obtain a sample is not appropriate or useful.
Water-sealed chest drain is a treatment option for empyema either in isolation or as a complication of lung abscess. There is no indication for that at present.
Rob is a 30-year-old patient of yours, who was found to be HIV positive a while back. He was started on antiretroviral therapy after a consultation with an infectious disease specialist. Today, he is in your office for a follow-up visit. He looks quite calm and avoiding. After breaking the ice, you realize that he has been feeling down and has not taken his medications for the past 6 months. You arrange for laboratory tests, the results of which shows a decreased CD4 count of 46/mm3. You talk him into restarting his anti HIV medications. He is convinced to follow your instructions. In addition to the anti HIV medications, which one of the drug(s) he should receive?
A. Fluconazole.
B. Azithromycin and trimethoprim-sulfamethoxazole.
C. Dapsone.
D. Azithromycin and fluconazole.
E. Azithromycin, dapsone, and fluconazole.
B. Azithromycin and trimethoprim-sulfamethoxazole
HIV and CD4 Cells:
- HIV primarily infects CD4 T lymphocytes.
- A healthy person has a CD4 count around 700/mm³.
- HIV reduces CD4 count by 50-100/mm³ per year.
- Opportunistic infections typically occur when CD4 count drops below 200/mm³.
Common Opportunistic Infections:
- Pneumocystis jiroveci pneumonia (PCP)
- Toxoplasmosis
- Mycobacterium avium complex (MAC)
Prophylaxis Based on CD4 Count:
1. Pneumocystis jiroveci (CD4 < 200/mm³)
- Prophylactic Treatment: Trimethoprim-sulfamethoxazole (double-strength tablet daily)
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Toxoplasmosis (CD4 < 100/mm³)
- Prophylactic Treatment: Trimethoprim-sulfamethoxazole (double-strength tablet daily)
-
Mycobacterium avium complex (MAC) (CD4 < 50/mm³)
- Prophylactic Treatment: Azithromycin (1200 mg weekly)
Example Scenario:
- Patient CD4 Count: 46/mm³
- Prophylactic Regimen Needed:
- Trimethoprim-sulfamethoxazole for PCP and Toxoplasmosis.
- Azithromycin for MAC.
- PCP and Toxoplasmosis: Trimethoprim-sulfamethoxazole
- MAC: Azithromycin
- Dapsone: Alternative to trimethoprim-sulfamethoxazole if intolerant.
- Fluconazole: Used for treating candidiasis, not for routine prophylaxis.
Given the patient’s CD4 count of 46/mm³, they should start prophylaxis with both trimethoprim-sulfamethoxazole (for PCP and Toxoplasmosis) and azithromycin (for MAC) along with their antiretroviral therapy.
The primary mechanism of HIV is infecting a particular subset of T lymphocytes known as CD4. Decreased amount of CD4 cells results in development opportunistic infections that define AIDS.
CD4 count in a non-infected person is approximately 700/mm3. HIV infection causes this number to drop at a rate of 50-100/mm3/year; therefore, without treatment, it would take 5-10 years for CD4 count to drop to around 200/mm3 when the first AIDS-defining syndrome develops.
An HIV infected person does not develop opportunistic infection unless CD4 decrease below a certain level; therefore, prophylactic treatment against such infections is not indicated as long as the CD4 count is above the predicted CD4 count for that infection.
The most common opportunistic infections associated with HIV infection include:
-Pneumocystis jiroveci (formerly carini)
-Mycobacterium avium complex (MAC)
-Toxoplasmosis
-Candidiasis
-Cryptococcosis Coccidioidomycosis
-CMV
-Tuberculosis
-Histoplasmosis
-Cryptosporidium
Of these infections, routine prophylactic is indicated for pneumocystis jiroveci, toxoplasmosis, and mycobacterium avium complex once CD4 count drops below 200/mm3, 100/mm3, and 50/mm3, respectively.
The following table summarizes the opportunistic infections in HIV infected patients and the CD4 count below which prophylaxis is commenced as well as the appropriate prophylactic regimen:
Routine prophylaxis for the following infections is not routinely indicated, unless there are indications other than CD4 count:
Candidiasis Cryptococcosis Coccidioidomycosis CMV
Tuberculosis Histoplasmosis Cryptosporidium
With a CD4 count of 46/mm3, this patient should be started on routine prophylaxis against pneumocystis jiroveci, toxoplasmosis, and mycobacterium avium complex. For this purpose, combination of trimethoprim-sulfamethoxazole and azithromycin should be considered in addition to antiretroviral therapy.
Pneumocystis jiroveci (formerly carini) - CD4 : 200 - Prophylactic recommendation: Trimethoprim-sulfamethoxazole (double-strength tablet daily)
Toxoplasmosis - CD4: 100 - Recommendation : Trimethoprim-sulfamethoxazole (double-strength tablet daily)
Mycobacterium avium complex - CD4 : 50 - Recommendation: Azithromycin (1200 mg weekly)
Dapsone can be replaced with trimethoprim-sulfamethoxazole as second-line medication, where the former cannot be tolerated or is contraindicated. Fluconazole is used for treatment of Candidiasis (oropharyngeal, vaginal, esophageal) and has no role in routine prophylaxis.