Infectious Diseases Flashcards
1
Q
Mycoplasma pneumoniae features?
A
- Prolonged and gradual onset
- Flu like symptoms precede a dry cough
- Bilateral consolidation on XR
- Often affects younger pts, epidemics every 4 years
- Atypical –> lacks peptidoglycan cell wall –> may not respond to penicillins or cephalosporins
2
Q
Mycoplasma complications?
A
- Cold Agglutins (IgM) –> haemolytic anaemia, thrombocytopenia
- Erythema multiforme, erythema nodosum
- Heart = peri/myocarditis
- GI = hepatitis, pancreatitis
- Renal = acute glomerulonephritis
- Neuro = Meningoencephalitis, GBS
3
Q
Mycoplasma Dx?
A
- Serology
- Positive cold agglutination test
4
Q
Mycoplasma Rx?
A
Doxycycline or macrolide
5
Q
Is HIV a notifiable disease?
A
No
6
Q
Sepsis definition?
A
Life-threatening organ dysfunction caused by a dysregulated host response to infection
7
Q
Septic shock definition?
A
A more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’
8
Q
qSOFA score?
A
Adult patients outside of ICU with suspected infection are identified as being at heightened risk of mortality if score >=2 of:
1. RR > 22/min
2. SBP < 100
3. Altered mentation
9
Q
Sepsis 6?
A
- IVF
- IV Abx
- O2
- UO
- Lactate
- Cultures
10
Q
Giardiasis risk factors?
A
- Foreign travel
- Swimming/drinking water from river or lake
- Male-male sexual contact
11
Q
Giardiasis features?
A
- Non-bloody diarrhoea = steatorrhoea
- Bloating, abdominal pain
- Lethargy, weight loss
- Flatulence
- Malabsorption and lactose intolerance can occur
12
Q
Giardiasis Ix?
A
- Stool microscopy for trophozoite and cysts: sensitivity of around 65%
- Stool antigen detection assay: greater sensitivity and faster turn-around time than conventional stool microscopy methods
- PCR assays being developed
13
Q
Giardiasis Rx?
A
Metronidazole
14
Q
Parvovirus B19 infection causes?
A
- Erythema infectiosum
- Fifth disease
- Slapped cheek syndrome
15
Q
Parvovirus exposure in early pregnancy?
A
If before 20 weeks, she should seek prompt advice from whoever is giving her antenatal care as maternal IgM and IgG will need to be checked.
16
Q
Parvovirus B19 presentation?
A
- Slapped cheek in children
- Pancytopenia in immunosuppressed
- Aplastic crises in SCD
- Hydrops fetalis
17
Q
Necrotising fasciitis causative organism
A
- Type 1 = Most common, mixed anaerobes and aerobes (often occurs post-surgery in diabetics)
- Type 2 = S. pyogenes
18
Q
Necrotising fasciitis RFs?
A
- Skin factors = trauma, burns, soft tissue infections
- DM esp. SGLT2
- IVDU
- Immunosuppression
19
Q
Necrotising fasciitis most common site?
A
Perineum (Fournier’s gangrene)
20
Q
Necrotising fasciitis features?
A
- Acute onset
- Worsening cellulitis with pain out of keeping with physical features
- Extremely tender over infected tissue with hypoaesthesia to light touch
- Skin necrosis and crepitus/gas gangrene are late signs
- Fever and tachycardia may be absent or occur late in the presentation
21
Q
Necrotising fasciitis Rx?
A
- Urgent surgical debridement
- IV Abx
22
Q
Necrotising fasciitis prognosis?
A
Average mortality 20%
23
Q
Cellulitis organisms?
A
S. aureus or S. pyogenes
24
Q
Cellulitis diagnosis?
A
Clinical, no further Ix required in primary care
25
Cellulitis admission criteria classification system?
Eron classification (I-IV)
1. Ok and no comorbidities
2. Well/unwell and 1 comorbidity
3. Very unwell or limb threatening
4. Sepsis or Necrotising fasciitis
26
What cellulitis pts should be admitted for IV Abx?
1. Eron Class III/IV
2. Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin)
3. Is very young (under 1 year of age) or frail
4. Immunocompromised
5. Significant lymphoedema
6. Facial cellulitis (unless very mild) or periorbital cellulitis
27
Cellulitis Rx?
1. Flucloxacillin 1st line
2. Clarithromycin/doxycycline/erythromycin (pregnancy) if pen allergic
3. Severe --> Co-amoxiclav/cefuroxime/clindamycin/ceftriaxone
28
Traveller's diarrhoea definition?
At least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common cause is Escherichia coli.
29
Acute food poisoning definition?
Sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin. Typically caused by Staphylococcus aureus, Bacillus cereus or Clostridium perfringens
30
E.coli diarrhoea history?
Traveller, watery stool, abdominal cramps and nausea
31
Giardia diarrhoea history?
Prolonged, non-bloody diarrhoea
32
Cholera diarrhoea history?
1. Profuse, watery diarrhoea
2. Severe dehydration resulting in weight loss
3. Not common amongst travellers
33
Shigella diarrhoea history?
Bloody diarrhoea, vomiting, abdominal pain
34
S. aureus diarrhoea history?
Severe vomiting, short incubation period
35
Campylobacter diarrhoea history?
1. Flu-like prodrome --> crampy abdominal pain, fever, diarrhoea
2. May mimic appendicitis
3. Complications incl. GBS
36
Bacillus cereus diarrhoea history?
1. Vomiting within 6 hours stereotypically due to rice
2. Diarrhoeal illness occurring after 6 hours
37
Amoebiasis diarrhoea history?
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
38
Diarrhoea 1-6 hour incubation period?
S. aures, B. cereus
39
Diarrhoea 12-48 hours incubation period?
Salmonella, E. coli
40
Diarrhoea 48-72 hours incubation period?
Shigella, campylobacter
41
Diarrhoea >7 day incubation period?
Giardia, Amoeba
42
Genital wart aka?
Condylomata accuminata
43
HPV types causing genital warts?
6 and 11
44
HPV types predisposing to cervical cancer?
16, 18, 33
45
Genital wart features?
1. Small 2-5mm fleshy protuberances which are slightly pigmented
2. May bleed or itch
46
Genital wart management?
1. Topical podophyllum/cryotherapy 1st line
a. Multiple, non-keratinised warts --> topical podophyllum
b. Solitary, keratinised warts --> cryotherapy
2. Imiquimod 2nd line
47
Most common organism from animal bite?
Pasteurella multocida
48
Animal bite Rx?
1. Cleanse wound. Don't suture puncture wound unless cosmesis is at risk
2. Co-amoxiclav
3. If pen allergic then doxycycline + metronidazole
49
Human bite Rx?
Co-amoxiclav
50
Exacerbation of chronic bronchitis Rx?
Amoxicillin or tetracycline or clarithromycin
51
Uncomplicated CAP Rx?
Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)
52
Possible atypical pneumonia Rx?
Clarithromycin
53
HAP Rx?
1. Within 5d = Co-amoxiclav or cefuroxime
2. >5d = Tazocin or Quinolone (ciprofloxacin) or Broad-Spectrum Cephalosporin (Ceftazidime)
54
UTI Rx?
1. Trimethoprim or nitrofurantoin
2. Alternative = Amoxicillin or cephalosporin
55
Acute pyelonephritis Rx?
Broad-spectrum cephalosporin or quinolone
56
Acute prostatitis Rx?
Quinolone or trimethoprim
57
Impetigo Rx?
1. Topical hydrogen peroxide
2. Oral flucloxacillin or erythromycin if widespread
58
Cellulitis Rx?
Flucloxacillin
59
Cellulitis near eyes or nose Rx?
Co-amoxiclav
60
Erysipelas Rx?
Flucloxacillin
61
Mastitis during breast feeding Rx?
Flucloxacillin
62
Throat infection Rx?
1. Phenoxymethylpenicillin
2. Erythromycin alone if penicillin-allergic
63
Sinusitis Rx?
Phenoxymethylpenicillin
64
Otitis media Rx?
Amoxicillin (erythromycin if penicillin-allergic)
65
Otitis externa Rx?
Flucloxacillin (erythromycin if penicillin-allergic)
66
Periapical or periodontal abscess Rx?
Amoxicillin
67
Gingivitis: acute necrotising ulcerative Rx?
Metronidazole
68
Gonorrhoea Rx?
IM Ceftriaxone
69
Chlamydia Rx?
Doxycyline or Azithromycin
70
PID Rx?
1. Oral ofloxacin + Oral metronidazole OR
2. IM Ceftriaxone + Oral Doxycycline + Oral metronidazole
71
Syphilis Rx?
Benzathine benzylpenicillin or doxycycline or erythromycin
72
Bacterial Vaginosis Rx?
Oral/topical metronidazole or topical clindamycin
73
C. diff Rx?
1. 1st episode = oral vancomycin
2. 2nd episode = Oral fidoxamicin
74
Campylobacter enteritis Rx?
Clarithromycin
75
Salmonella (non-typhoid) Rx?
Ciprofloxacin
76
Shigella Rx?
Ciprofloxacin
77
Gonorrhoea features?
1. Male = urethral discharge, dysuria
2. Female = cervicitis e.g. leading to vaginal discharge
3. Rectal and pharyngeal infection usually asymptomatic
78
Gonorrhoea local complications?
1. Urethral strictures and epididymitis
2. Salpingitis --> may lead to infertility
79
Gonorrhoea systemic complications?
1. DGI = Disseminated gonococcal infection
2. Gonococcal arthritis
80
Tenosynovitis, migratory polyarthritis and dermatitis (lesions can be maculopapular or vesicular)?
Disseminated gonococcal infection
81
Aspergilloma definition?
A mycetoma (mass-like fungus ball) which often colonises an existing lung cavity (e.g. secondary to tuberculosis, lung cancer or cystic fibrosis).
82
Aspergilloma features?
Cough and haemoptysis
83
Aspergilloma Ix?
1. CXR containing a rounded opacity, crescent sign may be present
2. High titres of Aspergillus precipitins
84
Spinal epidural abscess definition?
A collection of pus that is superficial to the dura mater (of the meninges) that covers the spinal cord
85
Spinal epidural abscess most common organism?
S. Aureus
86
Spinal epidural abscess pathophysiology?
1. Contiguous spread = discitis
2. Haematogenous spread = IVDU
3. Direct infection = spinal surgery
87
Spinal epidural abscess presentation?
1. Fever
2. Back pain
3. Focal neurological deficit
88
Spinal epidural abscess Ix?
1. Bloods = incl. HIV, Hep B, Hep C
2. Blood cultures
3. MRI whole spine (since skip lesions may be present)
89
Lyme disease cause?
Borrelia burgdorferi
90
Lyme disease feature classification?
1. Early (within 30 days) = erythema migrans, systemic features
2. Late (after 30 days) = cardio, neuro
91
Lyme disease early features?
1. Erythema migrans = bulls eye rash, 1-4 weeks after bite, painless, >5cm in diameter and slowly increases in size, present in 80% pts
2. Systemic features = headache, lethargy, fever, arthralgia
92
Lyme disease later features?
1. Cardio = heart block, peri/myocarditis
2. Neuro = facial nerve palsy, radicular pain, meningitis
93
Lyme disease Ix?
1. Clinically if erythema migrans is present --> Abx can be started
2. 1st line = ELISA to borrelia burgdorferi = if negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA 4-6 weeks after the first ELISA test. If still suspected in people who have had symptoms for 12 weeks or more then an immunoblot test should be done, if positive or equivocal then an immunoblot test for Lyme disease should be done
94
Rx of asymptomatic tick bites?
Remove tick with fine tipped tweezers, wash area, routine Abx not recommended
95
Suspected/confirmed Lyme disease Rx?
1. Doxycycline if early disease (amoxicillin in pregnancy)
2. Ceftriaxone if disseminated disease
3. 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
96
URTI symptoms + amoxicillin --> rash?
Likely glandular fever
97
Glandular fever causes?
EBV, CMV, HHV6
98
Glandular fever presentation?
1. Sore throat
2. Pyrexia
3. Lymphadenopathy
99
Glandular fever features?
1. Malaise, anorexia, headache
2. Palatal petehiae
3. Splenomegaly (50%)
4. Hepatitis, transient rise in ALT
5. Lymphocytosis = presence of 50% lymphocytes and at least 10% atypical lymphocytes
6. Haemolytic anaemia secondary to cold agglutins (IgM)
7. A maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
100
Glandular fever Dx?
Heterophil antibody test (Monospot test) - NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
101
Glandular fever Rx?
1. Supportive, avoid alcohol
2. Avoid contact spots for 4 weeks to reduce risk of splenic rupture
102
Leptospirosis aetiology?
The spirochaete Leptospira interrogans (serogroup L. icterohaemorrhagiae), classically being spread by contact with infected rat urine.
103
Leptospirosis epidemiology?
1. Sewage workers, farmers, vets, abattoir
2. Returning traveller
104
Weil's disease?
Hepatorenal failure associated with Leptospirosis
105
Leptospirosis features?
1. Early = fever, flu-like symptoms, subconjunctival haemorrhage
2. Late = AKI, Hepatitis, aseptic meningitis
106
Leptospirosis Ix?
1. Serology = Abs to leptospira develop after about 7 days
2. PCR
3. Culture = may take several weeks so limits usefulness in Dx, blood and CSF samples are generally positive for the first 10 days, urine cultures become positive during the second week of illness
107
Leptospirosis Rx?
High dose benzylpenicillin or doxycycline
108
Differentiating erysipelas from other skin infections?
Lack of involvement of subcutaneous tissue
109
Main cause of erysipelas?
Streptococcus pyogenes, a beta-haemolytic group A streptococci and the rash is caused by an endotoxin rather than the bacteria itself
110
Most common STI in UK?
Chlamydia, around 1 in 10 young women have it
111
Chlamydia features?
Asymptomatic in 70% women and 50% men
1. Women = cervicitis (discharge, bleeding), dysuria
2. Men = urethral discharge, dysuria
112
Chlamydia Ix?
NAAT = vulvovaginal swab in women, urine test in men (should be carried out 2 weeks after a possible exposure)
113
Chlamydia screening?
Open to all 15-24 years
114
Chlamydia Rx?
1. Doxycycline 7d 1st line
2. If doxy C/I then Azithromycin 1g OD one day then 500mg OD two days
3. If pregnancy = azithromycin/erythromycin/amoxicillin
115
Chlamydia contact tracing?
1. Men with urethral symptoms = all contact since, and in the four weeks prior to, the onset of symptoms
2. Women and asymptomatic men = all partners from the last six months or the most recent sexual partner should be contacted
3. Contacts should have treat then test
116
When is test of cure for chlamydia in pregnant women?
6 weeks post infection
117
Is Test of Cure required in uncomplicated chlamydia infection in men and non- pregnant women?
No
118
Clue cells?
Bacterial vaginosis
119
BV definition?
Describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
120
BV features?
1. Vaginal discharge = fishy, offensive
2. Asymptomatic in 50%
121
Amsel's criteria for BV?
3 out of 4 should be present
1. Thin, white homogeneous discharge
2. Clue cells on microscopy: stippled vaginal epithelial cells
3. Vaginal pH > 4.5
4. Positive whiff test (addition of KOH results in fish odour)
122
BV Rx?
1. Oral metronidazole 5-7 days
2. 70-80% initial cure rate
3. Relapse rate > 50% within 3m
4. Topical metronidazole/topical clindamycin are alternatives
123
Strawberry cervix?
Trichomonas vaginalis
124
BV in pregnancy mushkies?
1. Results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
2. Treat with oral metronidazole as normal
125
Hep B needlestick transmission risk?
20-30%
126
Hep C needlestick transmission risk?
0.5-2%
127
HIV needlestick transmission risk?
0.3%
128
Hepatitis A PEP?
Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation
129
Hepatitis B PEP HBsAg positive source?
1. If the person exposed is a known responder to the HBV vaccine then a booster dose should be given
2. If they are a non-responder (anti-HBs < 10mIU/ml 1-2 months post-immunisation) they need to have hepatitis B immune globulin (HBIG) and a booster vaccine
130
Hepatitis B PEP unknown source?
1. For known responders the HBV vaccine the Green Book advises considering a booster dose of HBV vaccine
2. For known non-responders HBIG + vaccine should be given whilst those in the process of being vaccinated should have an accelerated course of HBV vaccine
131
Hepatitis C PEP?
1. Monthly PCR - if seroconversion then interferon +/- ribavarin
132
HIV PEP?
1. The risk of HIV transmission depends heavily on the incident (e.g. needle stick, type of sexual intercourse, human bite etc) and the current viral load of the patient
2. A combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) as soon as possible (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) for 4 weeks
3. Serological testing at 12 weeks following completion of post-exposure prophylaxis
4. Reduces risk of transmission by 80%
133
Varicella zoster PEP?
VZIG for IgG negative pregnant women/immunosuppressed
134
Listeria monocytogenes mushkies?
A Gram-positive bacillus which has the unusual ability to multiply at low temperatures. It is typically spread via contaminated food, typically unpasteurised dairy products. Infection is particularly dangerous to the unborn child where it can lead to miscarriage
135
Listeria features?
1. Diarrhoea, flu-like illness
2. Pneumonia, meningoencephalitis
3. Ataxia and seizures
136
Listeria Ix?
1. Blood cultures
2. CSF may reveal a pleocytosis with 'tumbling motility' on wet mounts
137
Listeria Rx?
1. Amoxicillin/ampicillin
2. Listeria meningitis should be treated with IV amoxicillin/ampicillin and gentamicin
138
Listeria in pregnant women mushkies?
1. 20 times more likely to develop listeriosis compared with the rest of the population due to changes in the immune system
2. Fetal/neonatal infection can occur both transplacentally and vertically during child birth
3. Complications include miscarriage, premature labour, stillbirth and chorioamnionitis
4. Diagnosis can only be made from blood cultures
5. Rx = amoxicillin
139
Enteric fever (typhoid/paratyphoid) organism?
Salmonella typhi and Salmonella paratyphi (types A, B & C) respectively. They are often termed enteric fevers, producing systemic symptoms such as headache, fever, arthralgia.
140
Salmonella gram stain?
Gram negative rod
141
Enteric fever transmission?
Faeco-oral route
142
Enteric fever features?
1. Relative bradycardia
2. Constipation more common in typhoid
3. Rose spots in 40%, more common in paratyphoid
143
Enteric fever complications?
1. Osteomyelitis (esp. in sickle cell)
2. GI bleed/perforation
3. Meningitis
4. Cholecystitis
5. Chronic carriage (1%, more likely if adult females)
144
Pre-hospital setting Meningitis Rx?
IM Benzylpenicillin
145
Meningitis < 3m Rx?
IV Cefotaxime + amoxicililn/ampicillin
146
Meningitis 3m - 50 y/o Rx?
1. IV Cefotaxime/Ceftriaxone
147
Meningitis > 50 y/o Rx?
IV Cefotaxime/Ceftriaxone + Amoxicillin/Ampicillin
148
Meningococcal meningitis Rx?
IV Benzylpenicillin or Cefotaxime/Ceftriaxone
149
Pneumococcal meningitis Rx?
IV Cefotaxime/Ceftriaxone
150
H. influenzae meningitis Rx?
IV Cefotaxime/Ceftriaxone
151
Listeria Meningitis Rx?
IV Amoxicillin/Ampicillin + Gentamicin
152
Steroids for meningitis?
IV Dexamethasone unless:
1. Septic shock
2. Meningococcal septicaemia
3. Immunocompromised
4. Meningitis following surgery
153
Meningitis Rx if pt has history of immediate hypersensitivity reaction to penicillin or to cephalosporins?
Chloramphenicol
154
Meningitis Rx of contacts?
1. Prophylaxis to household and close contacts within 7d before onset
2. Oral ciprofloxacin/rifampicin
3. Vaccination should be offered to close contacts when serotype results are available
4. Pneumococcal meningitis = no prophylaxis is generally needed
155
Syphilis Abx?
1. IM Benzathine penicillin
2. Alternatives = doxycycline
156
Jarisch-Herxheimer reaction?
1. Fever, rash, tachycardia after the first dose of antibiotic
2. In contrast to anaphylaxis, there is no wheeze or hypotension
3. Thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
4. No Rx other than antipyretics if required
157
Trichomonas vaginalis features?
1. Frothy yellow/green offensive vaginal discharge
2. Vulvovaginitis
3. Strawberry cervix
4. pH > 7.5
5. Usually asymptomatic in men, can cause urethritis
158
Trichomonas Ix?
Microscopy of a wet mount shows motile trophozoites
159
Trichomonas Rx?
Oral metronidazole for 5-7 days (although BNF also supports one-off dose of 2g metronidazole)
160
Two conditions that cause offensive vaginal discharge with vaginal pH > 4.5?
BV and Trichomonas --> treat both with metronidazole
161
Bronchiolitis?
RSV
162
Croup?
Parainfluenza virus
163
Common cold?
Rhinovirus
164
Flu?
Influenza virus
165
Most common cause of CAP?
S. pneumoniae
166
Most common cause of bronchiectasis exacerbations?
Haemophilus influenzae
167
Pneumonia following influenza?
Staphylococcus aureus
168
Flu like symptoms preceding a dry cough?
Mycoplasma pneumoniae
169
Legionella features?
1. Air conditioning, dry cough
2. Lymphopenia
3. Deranged LFTs
4. Hyponatraemia
170
Few chest signs, exertional dyspnoea, HIV?
Pneumocystis Jirovecii
171
Lower UTI in non-pregnancy women Rx?
1. Trimethoprim or nitrofurantoin for 3 days
2. Send urine culture if: > 65 y/o, or visible/non-visible haematuria
172
Lower UTI in pregnancy women Rx?
1. Symptomatic = culture, nitrofurantoin 1st line, amoxicillin/cefalexin 2nd line
2. Asymptomatic = culture at first antinatal visit, 7 days course of nitro/amox/cefalexin, needs further culture for TOC
173
What UTI Abx is teratogenic in first trimeter?
Trimethoprim
174
Men lower UTI Rx?
Trimethoprim or Nitrofurantoin 7 days unless prostatitis suspected
175
Catheterised pt Lower UTI Rx?
1. Do not treat if asymptomatic
2. Symptomatic = 7d course, consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
176
Types of Influenza?
A, B and C.
A and B account for majority of clinical cases.
177
Influenze vaccine type?
1. Child = live
2. Regular = inactivated
178
NHS influenza vaccination for children?
1. Given intranasally
2. 1st dose at 2-3 years, then annualy after that
3. Live vaccine
179
NHS influenza vaccination mushkies?
1. If immunosuppressed should receive inactivated, injectable vaccine
2. Only children aged 2-9 years who have not received an influenza vaccine before need 2 doses
3. More effective than the injectable vaccine
180
Children influenza vaccine contraindications?
1. Immunocompromised
2. < 2 y/o
3. Current febrile illness/blocked nose
4. Current wheeze or history of severe asthma
5. Egg allergy
6. Pregnancy/breastfeeding
7. If child is taking aspirin
181
Child influenza vaccine s/e?
1. Blocked nose/rhinorrhoea
2. Headache
3. Anorexia
182
Adult influenza vaccine mushkies?
1. Trivalent: 2 subtypes of A, 1 subtype of B
2. An inactivated vaccine, so cannot cause influenza. A minority of patients however develop fever and malaise which may last 1-2 days
3. Should be stored between +2 and +8ºC and shielded from light
4. C/I = hypersensitivity to egg protein
5. 75% effective in adults, less in elderly
6. 10-14 days before Ab at protective levels
183
Adult influenza vaccination indication?
> 65 y/o and at-risk groups:
1. Chronic resp/heart/liver/kidney/neurological disease
2. DM
3. Immunosuppression
4. Asplenia or splenic dysfunction
5. Pregnant women
6. BMI > 40
7. Health and social care staff, those living in long-stay residential care homes, carers of the elderly/disabled person
184
Metronidazole and alcohol?
Disulfiram-like reaction with alcohol
185
Commonest bacterial cause of infectious intestinal disease in UK?
Campylobacter (gram negative bacillus)
186
Campylobacter features?
1. Prodrome = headache and malaise
2. Diarrhoea = often bloody
3. Abdominal pain = may mimic appendicitis
187
Campylobacter Rx?
1. Usually self limiting
2. If severe, clarithromycin
3. Ciprofloxacin is alternative
188
Campylobacter complications?
1. GBS
2. Reactive arthritis
3. Septicaemia, endocarditis
189
HIV seroconversion features?
Symptomatic in 60-80% and typically presents as a landular fever type illness. Increased symptomatic severity is associated with poorer long term prognosis. It typically occurs 3-12 weeks after infection
1. Sore throat, lymphadenopathy
2. Malaise, myalgia, arthralgia
3. Diarrhoea
4. Maculopapular rash
5. Mouth ulcers
6. Rarely meningoencephalitis
190
HIV Dx?
1. HIV antibodies
2. p24 antigen
3. If combined test of above is positive, should be repeated to confirm diagnosis, some centres may also test viral load
191
Testing for HIV in asymptomatic patient timing?
1. 4 weeks after possible exposure
2. Offer repeat test at 12 weeks
192
HIV antibodies mushkies?
1. May not be present in early infection, but most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months
2. Usually consists of both a screening ELISA and a confirmatory Western Blot Assay
193
p24 antigen mushkies?
1. A viral core protein that appears early in the blood as the viral RNA levels rise
2. Usually positive from about 1 week to 3-4 weeks after infection with HIV
194
Winter vomiting bug?
Norovirus
195
Norovirus symptoms?
1. Within 15-50 hours of infection
2. Most have both vomiting and diarrhoea
196
Is norovirus notifiable?
No
197
Norovirus Dx?
Clinical history and stool culture viral PCR
198
Norovirus-like picture further differentials?
1. Salmonella
2. E. coli
3. Rotavirus
199
Salmonella > Norovirus differentiation?
Bloody diarrhoea, high fever, animal products
200
Rotavirus > Norovirus differentiation?
Children < 5 y/o
201
E. coli > Norovirus differentiation?
Longer incubation (up to 10 days), severe abdominal cramping, bloody diarrhoea
202
Herpes simplex virus infection features?
1. Primary infection = severe gingivostomatitis
2. Cold sores
3. Painful genital ulceration
203
HSV gingivostomatitis Rx?
Oral aciclovir, chlorhexidine mouthwash
204
HSV cold sore Rx?
Topical aciclovir
205
Genital herpes Rx?
Oral aciclovir
206
HSV Pregnancy Rx?
1. Elective C-section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
2. Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
207
3Ms of HSV?
1. Multinucleation
2. Margination of Chromatin
3. Molding of the nuclei
208
Hepatitis C pathophysiology?
RNA flavivirus, incubation period 6-9 weels
209
Hepatitis C transmission mushkies?
1. Needlestick = 2%
2. Mother to child = 6% (higher ith HIV)
3. Breastfeeding is not C/I
4. Sex = <5%
5. No vaccine
210
After exposure to Hepatitis C virus?
30% will develop:
1. Transient rise in serum aminotransferase
2. Fatigue
3. Arthralgia
211
Hepatitis C Ix?
HCV RNA for acute infection
212
Hepatitis C prognosis?
Around 15-45% of patients will clear the virus after an acute infection (depending on their age and underlying health) and hence the majority (55-85%) will develop chronic hepatitis C
213
Chronic hepatitis C definition?
Persistence of HCV RNA in the blood for 6 months
214
Hepatitis C complications?
1. Rheumatological = arthralgia, arthritis
2. Eye = Sjogrens
3. Cirrhosis (5-20%), HCC
4. Cryoglobulinaemia (Type II, mixed monoclonal and polyclonal)
5. Porphyria Cutanea Tarda
6. Membranoproliferative Glomerulonephritis
215
Chronic Hepatitis C Rx?
1. Depends on virus genotype
2. Clearance rates of 95%, aim is sustained virological response (SVR) = undetectable serum HCV RNA six months after the end of therapy
3. Combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) +/- Ribavarin
216
Ribavarin s/e?
1. Haemolytic anaemia, cough
2. Women should not become pregnant within 6m as is teratogenic
217
IFN-a s/e?
1. Flu-like symptoms
2. Depression, fatigue
3. Leukopenia, thrombocytopenia
218
Live attenuated vaccines?
BOOOM YI
1. BCG
2. Oral rotavirus, typhoid, polio
3. MMR
4. Yellow Virus
5. Influenze (intranasal)
219
Inactivated vaccines?
HIR
1. Hepatitis A
2. Influenza (IM)
3. Rabies
220
Toxoid (inactivated toxin) vaccines?
DTP
221
Conjugate vaccines?
1. Pneumococcus, meningococcus, haemophilus
2. HPV, HBV
222
Lyme disease Rx?
14-21 day course
223
Chancroid organism?
Haemophilus Ducreyi
224
Chancroid features?
1. Painful genital ulcers
2. Unilateral, painful inguinal lymph node enlargement
3. Ulcers typically have a sharply defined, ragged, undermined border
225
Painful genital ulcers?
Chancroid
226
Pneumonia in alcoholic?
Klebsiella
227
What UTI Abx avoided near term?
Nitrofurantoin as may cause neonatal haemolysis
228
Treatment for active TB?
1. RIPE 2m
2. RI 4m
229
Latent TB Rx?
1. 3m RI OR
2. 6m I
230
Meningeal YB Rx?
12m with addition of steroids
231
Directly observed TB therapy?
3 times a week dosing regimen for:
1. Homeless with active TB
2. Pts more likely to have poor concordance
3. All prisoners with active or latent TB
232
TB treatment complications?
1. Immune reconstitution disease = 3-6 weeks after starting Rx, often presents with enlarging lymph nodes
2. Drug s/e
233
Rifampicin s/e?
1. Potent enzyme inducer
2. Hepatitis, orange secretions
3. Flu-like symptoms
234
Isoniazid s/e?
1. Peripheral neuropathy
2. Hepatitis, agranulocytosis
3. Liver enzyme inhibitor
235
Pyrazinamide s/e?
1. Hyperuricaemia causing gout
2. Arthralgia, myalgia
3. Hepatitis
236
Ethambutol s/e?
Optic neuritis: check visual acuity before and during treatment
237
Prodrome, abdominal pain, bloody diarrhoea?
Campylobacter
238
Common trigger for cold sores?
Sunlight
239
Toxoplasmosis mushkies?
Toxoplasma gondii is an obligate intracellular protozoan that infects the body via the gastrointestinal tract, lung or broken skin. It's oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease.
240
Toxoplasmosis treatment in immunocompetent pts?
Not needed
241
Toxoplasmosis Ix?
Serology
242
Toxoplasmosis in HIV presentation?
Cerebral toxoplasmosis accounts for around 50% of cerebral lesions in patients with HIV = single or multiple ring-enhancing lesions, mass effect may be seen
243
Cerebral toxoplasmosis Rx?
Pyrimethamine plus sulphadiazine for at least 6 weeks
244
Congenital toxoplasmosis features?
1. Neurological = cerebral calcification, hydrocephalus, chorioretinitis
2. Ophthalmic = retinopathy, cataracts
245
Rusty sputum?
S. aureus
246
COPD chest infection organism?
H. influenzae
247
Behcet's triad?
1. Oral ulcers
2. genital ulcers
3. Uveitis
248
HSV1 typically?
Cold sores
249
HSV2 typically?
Genital herpes
250
Lymphogranuloma venereum mushkies?
Caused by Chlamydia trachomatis, infection has 3 stages:
1. Small painful pustule which later causes an ulcer
2. Painful inguinal lymphadenopathy
3. Proctocolitis
251
LGV Rx?
Doxycycline
252
Granuloma inguinale bacteria?
Klebsiella granulomatis
253
Uncomplicated CAP and staphylococci suspected e.g. influenze Rx?
Amoxicillin AND flucloxacillin
254
Hepatitis B mushkies?
A double-stranded DNA hepadnavirus and is spread through exposure to infected blood or body fluids, including vertical transmission from mother to child. The incubation period is 6-20 weeks.
255
Hepatitis B features?
1. Fever
2. Jaundice
3. Elevated transaminases
256
Hepatitis B complications?
1. Chronic hepatitis (5-10%) = ground glass hepatocytes --> fulminant liver failure
2. HCC
3. Glomerulonephritis
4. PAN
5. Cryoglobulinaemia
257
Testing for anti-HBs in which groups?
Should be checked 1-4 months after primary immunisation
1. Healthcare workers
2. CKD
258
Anti-HBs < 10?
Non-responder. Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus
259
Anti-HBs 10-100?
Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required
260
Anti-HBs > 100?
Indicates adequate response, no further testing required. Should still receive booster at 5 years
261
Hepatitis B Rx?
1. Pegylated IFN-a
2. Others = tenofovir, entecavir, telbivudine
262
PEP HIV duration?
4 weeks
263
What improves neurological outcomes in the treatmetn of bacterial meningitis?
Dexamethasone
264
LGV genital ulcer painful or painless?
Painless
265
How many doses of tetanus confers lifelong protection?
5
266
Tetanus immunisation timings?
1. 2m, 3m, 4m
2. 3-5 years
3. 13-18 years
267
Tetanus prone wound?
1. Puncture injury in contaminated environment
2. Wounds with foreign bodies
3. Compound fractures
4. Wounds/burns with systemic sepsis
5. Certain animal bites and scratches
268
High-risk tetanus prone wounds?
1. Heavy contamination with material likely to contain tetanus spores e.g. soil, manure
2. Wounds or burns that show extensive devitalised tissue
3. WOunds or burns that require surgical intervention
269
Wound and Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago?
No vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
270
Wound and Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago?
1. Tetanus prone wound = reinforcing dose of vaccine
2. High risk wound = Reinforcing dose of vaccine + tetanus immunoglobulin
271
Wound and tetanus vaccination history is incomplete or unknown?
1. Reinforcing dose of vaccine, regardless of the wound severity
2. For tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin
272
Kaposi's sarcoma mushkies?
1. HHV8
2. Purple papules/plaques on the skin or mucosa (e.g. GI and respiratory tract) --> may later ulcerate
3. Respiratory involvement may cause haemoptysis and pleural effusion
4. Rx = Radiotherapy + resection
273
Most common cause of COPD exacerbations?
Haemophilus influenzae
274
Salmonella Rx?
Ciprofloxacin
275
Clostridia gram stain?
Gram +ve, obligate anaerobic bacilli
276
Clostridia types x 4?
1. Botulinum
2. Difficile
3. Tetani
4. Perfringens
277
Clostridium botulinum mushkies?
1. Typically seen in canned foods and honey
2. Prevents ACh release leading to flaccid paralysis
278
Clostridium perfringens mushkies?
1. Produces α-toxin, a lecithinase, which causes gas gangrene (myonecrosis) and haemolysis
2. Features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation
279
Clostridium tetani features?
Produces an exotoxin (tetanospasmin) that prevents the release of glycine from Renshaw cells in the spinal cord causing a spastic paralysis
280
EBV associated malignancies?
1. Burkitt's
2. Hodgkin's
3. Nasopharyngeal
4. HIV-associated CNS lymphomas
281
BCG vaccine type?
Live attenuated Mycobacterium bovis. It also offers limited protection against leprosy
282
Who receives BCG vaccine?
1. All infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater
2. All infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. The same applies to older children but if they are 6 years old or older they require a tuberculin skin test first
3. Previously unvaccinated tuberculin-negative contacts of cases of respiratory TB
4. Previously unvaccinated, tuberculin-negative new entrants under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater
5. Healthcare workers, prison staff, care home staff, those who work with the homeless
283
What must be done before BCG vaccination?
Tuberculin skin test (only exception is children < 6 y/o who have had no contact with TB)
284
BCG administration mushkies?
1. Given intradermally, normally to the lateral aspect of the left upper arm
2. BCG can be given at the same time as other live vaccines, but if not administered simultaneously there should be a 4 week interval
285
BCG contraindications?
1. Previous BCG
2. Previous TB
3. HIV
4. Pregnancy
5. Positive Tuberculin test (Heaf or Mantoux)
286
Is BCG vaccine given to > 35 y/o?
No
287
Diphtheria cause?
Gram positive bacterium Corynebacterium diphtheriae
288
Diphtheria features?
1. Recent visitor to Eastern Europe/Russia/Asia
2. Sore throat with a 'diphtheric membrane' - grey, pseudomembrane on the posterior pharyngeal wall
3. Bulky cervical lymphadenopathy (bull's neck appearance)
4. Neuritis e.g. cranial nerves
5. Heart block
289
Diphtheria Ix?
Culture of throat swab = uses tellurite agar or Loeffler's media
290
Diphtheria Rx?
1. IM penicillin
2. Diphtheria antitoxin
291
Malaria prophylaxis?
1. Atovaquone + Proguanil (Malorone)
2. Chloroquine
3. Doxycycline
4. Mefloquine (Lariam)
5. Proguanil (Paludrine)
5. Proguanil + Chloroquine
292
Malorone mushkies?
1. GI upset
2. 1-2 days before travel
3. 1 week after travel
293
Chloroquine mushkies?
1. Headache, C/I in epilepsy, taken weekly
2. 1 week before travel
3. 4 weeks after travel
294
Doxycycline mushkies?
1. Photosensitivity, oesophagitis
2. 1-2 days before travel
3. 4 weeks after travel
295
Mefloquine (Lariam) mushkies?
1. Dizziness, neuropsychiatric disturbance, C/I in epilepsy, taken weekly
2. 2-3 weeks before travel
3. 4 weeks after travel
296
Proguanil (Paludrine) mushkies?
1. 1 week before travel
2. 4 weeks after travel
297
What Malaria drugs are C/I in epilepsy?
Chloroquine and Mefloquine (they are also both taken weekly)
298
Pregnancy malaria prophylaxis?
1. Chloroquine can be taken
2. Proguanil = folate supplementation needed
3. Malorone = try to avoid, if taken then take folate
4. Mefloquine = caution advised
5. Doxycycline contraindicated
299
Children malaria prophylaxis?
1. DEET 20-50% has been shown to repel up to 100% of mosquitoes if used correctly. It can be used in children over 2 months of age
2. >12 y/o = Doxycycline
300
Legionella mushkies?
1. Air conditioning or foreign holidays
2. Flu-like symptoms incl. fever (>95%)
3. Dry cough, relative bradycardia, confusion
4. Lymphopenia, hypontraemia, deranged LFTs
5. Pleural effusion: seen in 30% pts
301
Legionella Dx?
Urinary antigen
302
Legionella Rx?
Erythromycin/Clarithromycin
303
Rabies definition?
A viral disease that causes an acute encephalitis. The rabies virus is classed as a RNA rhabdovirus (specifically a lyssavirus) and has a bullet-shaped capsid. The vast majority of cases are caused by dog bites but it may also be transmitted by bat, raccoon and skunk bites. Following a bite the virus travels up the nerve axons towards the central nervous system in a retrograde fashion.
304
Rabies features?
1. Prodrome = headache, fever, agitation
2. Hydrophobia = water-provoking muscle spasms
3. Hypersalivation
4. Negri bodies = cytoplasmic inclusion bodies found in infected neurons
305
Negri bodies?
Rabies
306
Risk of rabies following an animal bite in the UK?
No risk
307
Animal bite Rx in foreign countries?
1. Wash wound
2. If immunised = 2 further doses of vaccine should be given
3. Not immunised = HRIG + full course of vaccination, if possible give dose locally around the wound
308
BV in pregnancy?
Still use oral metronidazole
309
PCP mushkies?
1. Pneumocystis jiroveci is an unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa
2. Most common opportunistic infection in AIDS
3. All pts with CD4 < 200 should receive PCP prophylaxis
310
PCP features?
1. Dyspnoea, dry cough, fever, very few chest signs
2. Pneumothorax is a common complication
3. Extrapulmonary manifestations (1-2%) are rare = hepatosplenomegaly, lymphadenopathy, choroid lesions
311
PCP Ix?
1. CXR
2. Exercise-induced saturation
3. Sputum often fails to show PCP, BAL often needed
312
PCP on BAL?
Silver stain shows chaarcetristic cysts
313
PCP Rx?
1. Co-trimoxazole
2. IV Pentamidine in severe cases
3. Aerosolized pentamidine is an alternative
4. Steroids if hypoxic
314
Syphilis definition?
STI caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. The incubation period is between 9-90 days
315
Primary syphilis features?
1. Chancre = painless ulcer at the sit of sexual contact
2. Local non-tender lymphadenopathy
3. Often not seen in women (lesion may be on the cervix)
316
Secondary syphilis features?
6-10 weeks after primary infection
1. Systemic = fevers, lymphadenopathy
2. Rash on trunk, palms and soles
3. Buccal 'snail track' ulcers (30%)
4. Condylomata lata (painless, warty lesions on the genitalia)
317
Tertiary syphilis features?
1. Gummas = granulomatous lesions of the skin and bones
2. Ascending aortic aneurysms
3. General paralysis of the insane
4. Tabes dorsalis
5. Argyll-Robertson pupil
318
Congenital syphilis features?
1. Blunted upper incisor teeth (Hutchinson's teeth), mulberry molars
2. Rhegades (linear scars at the angle of the mouth)
3. Keratitis
4. Saber shins
5. Saddle nose
6. Deafness
319
HIV and meningitis organism?
Cryptococcus neoformans
320
Cryptococcus neoformans stain?
India ink
321
Antiretroviral therapy broad strokes?
Antiretroviral therapy (ART) involves a combination of at least three drugs, typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). This combination both decreases viral replication but also reduces the risk of viral resistance emerging
322
When should ART be started?
As soon as they have been diagnosed with HIV
323
NRTI examples?
Nucleoside analogue reverse transcriptase inhibitors (NRTI)
1. Zidovudine
2. Abacavir
3. Emtricitabine
4. Didanosine
5. Lamivudine
6. Stavudine
7. Zalcitabine
8. Tenofovir
324
ART entry inhibitors?
Prevent HIV-1 from entering and infecting immune cells
1. Maraviroc = binds CCR5, preventing interaction with gp41
2. Enfuvirtide = binds to gp41, aka fusion inhibitor
325
NRTI s/e?
Peripheral neuropathy
326
Tenofovir s/e?
Renal impairment and osteoporosis
327
Didanosine s/e?
Pancreatitis
328
Zidovudine s/e?
Anaemia, myopathy, black nails
329
NNRTI examples?
Nevirapine and efavirenz
330
NNRTI s/e?
P450 enzyme inducer, rashes
331
Protease inhibitor examples?
1. Ritonavir
2. Indinavir
3. Nelfinavir
4. Saquinavir
332
Protease inhibitor s/e?
1. DM, hyperlipidaemia, buffalo hump, central obesity
2. P450 enzyme inhibition
333
Indinavir s/e?
Renal stones, asymptomatic hyperbilirubinaemia
334
Ritonavir s/e?
Potent P450 inhibitor
335
Integrase inhibitor example?
1. Raltegravir, Dolutegravir, Elvitegravir
2. Blocks the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
336
Trimethoprim s/e?
1. Myelosupprssion
2. Transient rise in creatinine
337
Methorexate which Abx should be avoided?
Trimethoprim and co-trimoxazole
338
Pneumonia in CF?
Psuedomonas Aeruginosa
339
Psuedomonas Aeruginosa gram stain?
Aerobic gram negative rod
340
Hot tub folliculitis?
Pseudomonas aeruginosa
341
DM with malignant otitis externa organism?
Pseudomonas aeruginosa
342
Psuedomonas Aeruginosa pathophysiology?
Produces both an endotoxin (causes fever and shock) and exotoxin A (inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2)
343
Lyme disease in pregnancy Rx?
Amoxicillin
344
Painful genital ulcer with a ragged border associated with tender inguinal lymphadenopathy?
Chancroid
345
Painless genital ulcer causes?
1. Chlamydia trachomatis = lymphogranuloma venereum
2. Treponema pallidum = syphilis
3. Klebsiella granulomatis = granuloma inguinale
346
Genital warts cause?
HPV 6 and 11
347
Cervical cancer HPV?
16 and 18
348
HPV associations?
1. >99% Cervical cancers
2. 85% anal cancers
3. 50% vulval and vaginal cancers
4. 20-30% mouth and throat cancers
349
HPV vaccine protect against?
HPV 6, 11, 16, 18
350
HPV vaccination mushkies?
1. All 12 and 13 year olds, normally given in school
2. Daughter may receive vaccine against parental wishes
3. Given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
351
HPV for MSM?
MSM < 45 y/o to protect against anal, throat and penile cancers
352
All sexually active men with dysuria test?
STI
353
Campylobacter Rx?
Clarithromycin, but usually self limiting
354
Dental abscess Rx?
Amoxicillin
355
Acute prostatitis Rx?
Ciprofloxacin or trimethoprim
356
Who should be screened for MRSA?
All elective admissions and emergency admissions
357
How should a pt be screened for MRSA?
1. Nasal swab and skin lesions or wounds
2. Swab should be wiped around the inside rim of a patient's nose for 5 seconds
3. The microbiology form must be labelled 'MRSA screen'
358
MRSA suppression from a carrier?
1. Nose = mupirocin 2% in white soft paraffin 5d TDS
2. Skin = Chlorhexidine gluconate 5d OD, particularly to axilla, groin and perineum
359
MRSA infection Rx?
Vancomycin, Teicoplanin, Linezolid
360
Wound with unclear tetanus vaccination history?
Booster vaccine + immunoglobulin, unless the wound is very minor and < 6 hours old
361
VZV PEP criteria?
1. Significant exposure to chickenpox or herpes zoster
2. Clinical condition that increases the risk of severe varicella; this includes immunosuppressed patients, neonates and pregnant women
3. No antibodies to the varicella virus
362
Diarrhoea in HIV most likely cause?
Cryptosporidium
363
Diarrhoea in HIV causes?
1. HIV Enteritis
2. Cryptosporidium + other protozoa (mmost common)
3. CMV
4. MAI
5. Giardia
364
Mycobacterium Avium intracellulare features?
1. Seen with the CD4 count is below 50
2. Fever, sweats, abdominal pain, diarrhoea, hepatomegaly, deranged LFTs
3. Dx = blood cultures and bone marrow examination
4. Rx = Rifabutin, ethambutol, clarithromycin
365
Most common complication of gonorrhoea?
Infertility secondary to PID
