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MRCP part 1 > Infectious diseases and STIs > Flashcards

Infectious diseases and STIs Flashcards

1
Q

Causes of non-falciparum malaria

A

Most common: Plasmodium vivax- Central America, indian subcontinent

Plasmodium ovale - Africaand Plasmodium malariae

Plasmodium knowlesi is another non-falciparum species which causes clinical pathology, found predominantly in South East Asia.

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2
Q

Features of non-falciparum malaria

A

general features of malaria: fever, headache, splenomegaly
Plasmodium vivax/ovale: cyclical fever every 48 hours. Plasmodium malariae: cyclical fever every 72 hours
Plasmodium malariae: is associated with nephrotic syndrome.

Ovale and vivax malaria have a hypnozoite stage and may therefore relapse following treatment.

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3
Q

Treatment of non-falciparum malaria

A

in areas which are known to be chloroquine-sensitive then WHO recommend either an artemisinin-based combination therapy (ACT) or chloroquine
in areas which are known to be chloroquine-resistant an ACT should be used
ACTs should be avoided in pregnant women
patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy liver hypnozoites and prevent relapse

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4
Q

Features of infectious mononucleosis

Triad

A

The classic triad of sore throat, pyrexia and lymphadenopathy is seen in around 98% of patients:
sore throat
lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged
pyrexia

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5
Q

Other features of infectious mononucleosis

A

malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

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6
Q

Diagnosing infectious mononucleosis

A

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.

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7
Q

Management of infectious mononucleosis

A

rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
consensus guidance in the UK is to avoid playing contact sports for 8 weeks after having glandular fever to reduce the risk of splenic rupture

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8
Q

Overview of Hep E

A

RNA hepevirus
spread by the faecal-oral route
incubation period: 3-8 weeks
common in Central and South-East Asia, North and West Africa, and in Mexico
causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy
does not cause chronic disease or an increased risk of hepatocellular cancer
a vaccine is currently in development, but is not yet in widespread us

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9
Q

Difference between falciparum and non-falciparum malaria

A

plasmodium falciparum is more deadly

Plasmodium vivax is more easily transmissable

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10
Q

What is mycoplasma pneumoniae?

A

Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae classically occur every 4 years. It is important to recognise atypical pneumonia as it may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall.

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11
Q

Features of mycopplasma pneumoniae

A

the disease typically has a prolonged and gradual onset
flu-like symptoms classically precede a dry cough
bilateral consolidation on x-ray
complications may occur as below

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12
Q

Complications of mycoplasma pneumoniae

A

cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia
erythema multiforme, erythema nodosum
meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
bullous myringitis: painful vesicles on the tympanic membrane
pericarditis/myocarditis
gastrointestinal: hepatitis, pancreatitis
renal: acute glomerulonephritis

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13
Q

Diagnosis of mycoplasma pneumoniae

A

mycoplasma serology

positive cold agglutinins

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14
Q

Management of mycoplasma pneumoniae

A

doxycycline or a macrolide (e.g. erythromycin/clarithromycin)

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15
Q

Common features of legionella and mycoplasma pneumoniae

A

atypical pneumonia
flu like symptoms
derranged LFTs
Treat with macrolide

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16
Q

GI Abx

Salmonella (non-typhoid)

A

Ciprofloxacin

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17
Q

GI abx

Shigella

A

Ciprofloxacin

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18
Q

GI Abx

Campylobacter

A

Clarithromycin

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19
Q

What is cytomegalovirus

A

Cytomegalovirus (CMV) is one of the herpes viruses. It is thought that around 50% of people have been exposed to the CMV virus although it only usually causes disease in the immunocompromised, for example people with HIV or those on immunosuppressants following organ transplantation.

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20
Q

Histological features of cytomegalovirus

A

infected cells have a ‘Owl’s eye’ appearance due to intranuclear inclusion bodies

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21
Q

Congenital cytomegalovirus

A

features include growth retardation, pinpoint petechial ‘blueberry muffin’ skin lesions, microcephaly, sensorineural deafness, encephalitiis (seizures) and hepatosplenomegaly

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22
Q

Cytomegalovirus infectious mononucleosis

A

infectious mononucelosis-like illness

may develop in immunocompetent individuals

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23
Q

CMV retinitis

A

common in HIV patients with a low CD4 count (< 50)
presents with visual impairment e.g. ‘blurred vision’. Fundoscopy shows retinal haemorrhages and necrosis, often called ‘pizza’ retina
IV ganciclovir is the treatment of choice

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24
Q

HIV neurocomplications

Focal Lesions

Toxoplasmosis

A

accounts for around 50% of cerebral lesions in patients with HIV
constitutional symptoms, headache, confusion, drowsiness
CT: usually single or multiple ring enhancing lesions, mass effect may be seen
management: sulfadiazine and pyrimethamine

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25
Q

HIV neurocomplications

Focal Lesions

Primary CNS lesions

A

accounts for around 30% of cerebral lesions
associated with the Epstein-Barr virus
CT: single or multiple homogenous enhancing lesions
treatment generally involves steroids (may significantly reduce tumour size), chemotherapy (e.g. methotrexate) + with or without whole brain irradiation. Surgical may be considered for lower grade tumours

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26
Q

HIV neurocomplications

Focal Lesions

TB

A

much less common than toxoplasmosis or primary CNS lymphoma

CT: single enhancing lesion

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27
Q

HIV neurocomplications

General neurological disease

Encephalitis

A

may be due to CMV or HIV itself
HSV encephalitis but is relatively rare in the context of HIV
CT: oedematous brain

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28
Q

HIV neurocomplications

General neurological disease

Cryptococcus

A

most common fungal infection of CNS
headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit
CSF: high opening pressure, India ink test positive
CT: meningeal enhancement, cerebral oedema
meningitis is typical presentation but may occasionally cause a space occupying lesion

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29
Q

HIV neurocomplications

General neurological disease

Progressive multifocal leukoencephalopathy (PML)

A

widespread demyelination
due to infection of oligodendrocytes by JC virus (a polyoma DNA virus)
symptoms, subacute onset : behavioural changes, speech, motor, visual impairment
CT: single or multiple lesions, no mass effect, don’t usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen

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30
Q

HIV neurocomplications

General neurological disease

AIDs Dementia Complex

A

caused by HIV virus itself
symptoms: behavioural changes, motor impairment
CT: cortical and subcortical atrophy§

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31
Q

Management of Gonorrhoea

A

IM ceftriaxone - first line

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32
Q

Typical presentation of E Coli

A

Common amongst travellers
Watery stools
Abdominal cramps and nausea

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33
Q

Typical presentation of Giardia

A

Prolonged, non-bloody diarrhoea

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34
Q

Typical presentation of cholera

A

Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers

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35
Q

Typical presentation of shigella

A

Bloody diarrhoea

Vomiting and abdominal pain

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36
Q

Typical presentation of staph aureus

A

Severe vomiting

Short incubation period

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37
Q

Typical presentation of campylobacter

A

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome

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38
Q

Typical presentation of bacillus cereus

A

Two types of illness are seen
vomiting within 6 hours, stereotypically due to rice
diarrhoeal illness occurring after 6 hours

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39
Q

Typical presentation of amoebiasis

A

Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

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40
Q

What is rubella

A

Rubella, also known as German measles, is a viral infection caused by the togavirus. Following the introduction of the MMR vaccine it is now rare. If contracted during pregnancy there is a risk of congenital rubella syndrome. Remember that the incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

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41
Q

Risk of Rubella in Pregnancy

A

in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks

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42
Q

Features of congenital rubella

A 
sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
'salt and pepper' chorioretinitis
microphthalmia
cerebral palsy
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43
Q

Diagnosis of rubella in pregnancy

A

suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss

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44
Q

Management of rubella in pregnancy

A

suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
since 2016, rubella immunity is no longer routinely checked at the booking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

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45
Q

Treatment of chlamydia

A

doxycyline or azithromycin

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46
Q

Treatment of syphilis

A

Benzathine benzylpenicillin or doxycycline or erythromycin

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47
Q

Treatment of bacterial vaginosis

A

Oral or topical metronidazole or topical clindamycin

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48
Q

Treatment of pelvic inflammatory disease

A

Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

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49
Q

Anti-fungals

Azoles

A

Inhibits 14α-demethylase which produces ergosterol Adverse effects:
P450 inhibition
Liver toxicity

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50
Q

Anti-fungals

Amphotericin B - used for systemic infections

A

Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage

Adverse effects- nephrotoxicity, flu-like symptoms, hypokalaemia, hypomagnaseamia

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51
Q

Anti-fungals

Terbinafine

A

Inhibits squalene epoxidase

Commonly used in oral form to treat fungal nail infections

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52
Q

Anti-fungals

Griseofulvin

A

Interacts with microtubules to disrupt mitotic spindle Induces P450 system, teratogenic

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53
Q

Anti-fungals

Flucytosine

A

Converted by cytosine deaminase to 5-fluorouracil, which inhibits thymidylate synthase and disrupts fungal protein synthesis
S/E: Vomiting

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54
Q

Anti-Fungals

Caspofungin

A

Inhibits synthesis of beta-glucan, a major fungal cell wall component

S/e: Flushing

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55
Q

Anti-fungals

Nystatin

A

Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage

As very toxic can only be used topically (e.g. for oral thrush)

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56
Q

Cause of Lyme Disease

A

spirochaete Borrelia burgdorferi and is spread by ticks

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57
Q

Early features of Lyme Disease

A

Erythema migrans
‘bulls-eye’ rash is typically at the site of the tick bite
typically develops 1-4 weeks after the initial bite but may present sooner
usually painless, more than 5 cm in diameter and slowlly increases in size
present in around 80% of patients.
systemic features
headache
lethargy
fever
arthralgia

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58
Q

Later features of Lyme Disease

A 
cardiovascular
heart block
peri/myocarditis
neurological
facial nerve palsy
radicular pain
meningitis
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59
Q

Investigation of Lyme Disease

A

enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test
Clinica diagnosis is erythema migrans

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60
Q

Management of Lyme Disease

A

Doxycyline (1st Line)
Amoxicillin (2nd line when Doxy contra-indicated)
IV ceftriaxone if disseminated disease
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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61
Q

Pott’s disease

A

Vertebral TB

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62
Q

Extra pulmonary TB

A 
central nervous system (tuberculous meningitis - the most serious complication)
vertebral bodies (Pott's disease)
cervical lymph nodes (scrofuloderma)
renal
gastrointestinal tract
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63
Q

Strongyloides stercoralis - what is it

Nematodes (roundworms)

A

Strongyloides stercoralis is a human parasitic nematode worm. The larvae are present in soil and gain access to the body by penetrating the skin. Infection with Strongyloides stercoralis causes strongyloidiasis.

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64
Q

Features of strongyloides stercoralis

Nematodes (roundworms)

A

diarrhoea
abdominal pain/bloating
papulovesicular lesions where the skin has been penetrated by infective larvae e.g. soles of feet and buttocks
larva currens: pruritic, linear, urticarial rash
if the larvae migrate to the lungs a pneumonitis similar to Loeffler’s syndrome may be triggered

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65
Q

Management of strongyloides sterocoralis

A

ivermectin and albendazole are used

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66
Q 
Enterobius vermicularis (pinworm)
Nematodes (roundworms)
A

Threadworm infestation is asymptomatic in around 90% of cases, possible features include perianal itching, particularly at night; girls may have vulval symptoms

Diagnosis may be made by the applying sticky plastic tape to the perianal area and sending it to the laboratory for microscopy to see the eggs

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67
Q

Treatment for enterobius vermicularis

Nematodes (roundworms)

A

-bendazoles

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68
Q

Ancylostoma duodenale, Necator americanus (hookworms)

Nematodes (roundworms)

A

Larvae penetrate skin of feet; gastrointestinal infection → anaemia
Thin-shelled ova

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69
Q

Ancylostoma duodenale, Necator americanus (hookworms) Treatment

A

-bendazoles

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70
Q

Loa loa- what are they

Nematodes (roundworms)

A

Transmission by deer fly and mango fly

Causes red itchy swellings below the skin called ‘Calabar swellings’, may be observed when crossing conjunctivae

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71
Q

Loa loa treatment

A

Diethylcarbamazine

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72
Q

Trichinella spiralis

Nematodes (roundworms)

A

Typically develops after eating raw pork

Features include fever, periorbital oedema and myositis (larvae encyst in muscle)

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73
Q

Treatment for trichinella spiralis

A

-bendazoles

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74
Q

Onchocerca volvulus

Nematodes (roundworms)

A

Causes ‘river blindness’. Spread by female blackflies

Features include blindness, hyperpigmented skin and possible allergic reaction to microfilaria

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75
Q

Onchocerca volvulus- treatment

A

Ivermetcin - ‘river blindness= ivermetcin’

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76
Q

Wuchereria bancrofti

Nematodes (roundworms)

A

Transmission by female mosquito

Causes blockage of lymphatics → elephantiasis

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77
Q

Wuchereria bancrofti- treatment

A

Diethylcarbamazine

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78
Q 
Toxocara canis (dog roundworm)
Nematodes (roundworms)
A

Transmitted through ingestion of infective eggs.

Features include visceral larva migrans and retinal granulomas
VISCious dogs → blindness

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79
Q

Toxocara canis (dog roundworm) - treatment

A

Diethylcarbamazine

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80
Q 
Ascaris lumbricoides (giant roundworm)
Nematodes (roundworms)
A

Eggs are visible in faeces

May cause intestinal obstruction and occasional migrate to lung (Loffler’s syndrome)

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81
Q

Ascaris lumbricoides (giant roundworm) - treatment

A

-bendazoles

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82
Q

Cestodes (tapeworms)

Echinococcus granulosus

A

Transmission through ingestion of eggs in dog faeces. Definite host is dog, which ingests hydatid cysts from sheep, who act as an intermediate host. Often seen in farmers.

Features include liver cysts and anaphylaxis if cyst ruptures (e.g. during surgical removal)

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83
Q

Cestodes (tapeworms)
Echinococcus granulosus
Treatment

A

-bendazoles

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84
Q

Cestodes (tapeworms)

Taenia solium

A

Often transmitted after eating undercooked pork. Causes cysticercosis and neurocysticercosis, mass lesions in the brain ‘swiss cheese appearance’

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85
Q

Cestodes (tapeworms)
Taenia solium
Treatment

A

-bendazoles

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86
Q

Trematodes (flukes)

Schistosoma haematobium

A

Hosted by snails, which release cercariae that penetrate skin.
Causes ‘swimmer’s itch’ - frequency, haematuria. Risk factor for squamous cell bladder cancer

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87
Q

Trematodes (flukes)
Schistosoma haematobium
Treatment

A

Praziquantel

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88
Q

Trematodes (flukes)

Paragonimus westermani

A

Caused by undercooked crabmeat, results in secondary bacterial infection of lungs

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89
Q

Trematodes (flukes)
Paragonimus westermani
Treatment

A

Praziquantel

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90
Q

Trematodes (flukes)

Clonorchis sinensis

A

Caused by undercooked fish

Features include biliary tract inflammation. Known risk factor for cholangiocarcinoma

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91
Q

Trematodes (flukes)
Clonorchis sinensis
Treatment

A

Praziquantel

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92
Q 
Trematodes (flukes)
Fasciola hepatica (the liver fluke)
A

May cause biliary obstruction

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93
Q

Trematodes (flukes)
Fasciola hepatica (the liver fluke)
Treatment

A

Triclabendazole

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94
Q

Gram negative cocci

A

Neisseria gonorrhoeae
Moraxella catarrhalis
Neisseria meningitidis

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95
Q

gram positive rods

mnemonic = ABCD L

A 
Actinomyces
Clostridium
Listeria monocytogenes
Bacillus anthracis
Corynebacterium diphtheriae
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96
Q

Live attenuated vaccines

A 
BCG
measles, mumps, rubella (MMR)
influenza (intranasal)
oral rotavirus
oral polio
yellow fever
oral typhoid
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97
Q

Inactivated vaccine preparations

A

rabies
hepatitis A
influenza (intramuscular)

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98
Q

Toxoid (inactivated toxin) vaccines

A

tetanus
diphtheria
pertussis

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99
Q

Conjugate/ sub unit vaccines

A 
pneumococcus (conjugate)
haemophilus (conjugate)
meningococcus (conjugate)
hepatitis B
human papillomavirus
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100
Q

Plasmodium malariae

A

associated with nephrotic syndrome

cyclical fever every 72 hours

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101
Q

Rickettsiae

A

Rickettsiae are Gram-negative obligate intracellular parasites. Types of rickettsiae cause a variety of diseases that are typically characterised by fever, headache and rash.

The Weil-Felix reaction is positive except in Q fever. Rickettsial diseases are all treated with tetracyclines.

102
Q

Rocky Mountain spotted fever

Rickettsia ricketsii

A

Headache and fever are common

Rash starts on the peripheries (wrist, ankles) before spreading centrally. It is initially maculopapular before becoming vasculitic

Endemic to east coast of US

103
Q

Q fever

Coxiella burnetti

A

No rash but causes pneumonia

104
Q

Endemic typhus
Rickettsia typhi
Flea

A

Rash starts centrally then spreads to the peripheries

105
Q

Complications of chronic Hep C

A

rheumatological problems: arthralgia, arthritis
eye problems: Sjogren’s syndrome
cirrhosis (5-20% of those with chronic disease)
hepatocellular cancer
cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)
porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse
membranoproliferative glomerulonephritis

106
Q

Management of chronic Hep C

A

currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

107
Q

Complications of chronic Hep C Treatment

A

ribavirin - side-effects: 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, thrombocytopenia

108
Q

History of Toxocara canis

A

a man develops visceral larva migrans. During the work-up he is noted to have developed some retinal granulomas

109
Q

History of loa loa

A

a man develops episodic angioedema whilst in west Africa. On one occasion he noticed a ‘worm moving across the left eye’

110
Q

What is polyarteritis nodosa

A

Polyarteritis nodosa (PAN) is a vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation. PAN is more common in middle-aged men and is associated with hepatitis B infection.

111
Q

Features of polyarteritis nodosa

A

fever, malaise, arthralgia
weight loss
hypertension
mononeuritis multiplex, sensorimotor polyneuropathy
testicular pain
livedo reticularis
haematuria, renal failure
perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with ‘classic’ PAN
hepatitis B serology positive in 30% of patients

112
Q

stereotypical history of Taenia solium (helminth)

A

a recent immigrant from Latin America presents to the Emergency Department following a seizure. A CT head shows multiple cystic lesions

113
Q

Stereotypical history of Schistosoma haematobium

A

a man develops haematuria and frequency after visiting Malawi

114
Q

Causes of genital herpes

A

Genital herpes is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1). Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers.

115
Q

STI: Ulcers - syphilis

A

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days.

116
Q

what is chancroid

A

a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

117
Q

what is Lymphogranuloma venereum (LGV)

A

caused by Chlamydia trachomatis. Typically infection comprises of three stages
stage 1: small painless pustule which later forms an ulcer
stage 2: painful inguinal lymphadenopathy
stage 3: proctocolitis

LGV is treated using doxycycline.

118
Q

Gram +ve rods

A 
Actinomyces
Bacillus anthracis (anthrax)
Clostridium
Diphtheria: Corynebacterium diphtheriae
Listeria monocytogenes
119
Q

Gram -ve rods

A 
Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni
120
Q

Gram-positive cocci

A

staphylococci + streptococci (including enterococci)

121
Q

Gram negative cocci

A

Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis

122
Q

HIV Management: Protease Inhibitor side effects

A

diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition

indinavir: renal stones, asymptomatic hyperbilirubinaemia
ritonavir: a potent inhibitor of the P450 system

123
Q

HIV management: Integrase Inhibitors

A

block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
examples: raltegravir, elvitegravir, dolutegravir

124
Q

HIV Management: Non-nucleoside reverse transcriptase inhibitors (NNRTI)

A

examples: nevirapine, efavirenz

side-effects: P450 enzyme interaction (nevirapine induces), rashes

125
Q

HIV Management: Nucleoside analogue reverse transcriptase inhibitors (NRTI)

A

examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir
general NRTI side-effects: peripheral neuropathy
tenofovir: used in BHIVAs two recommended regime NRTI. Adverse effects include renal impairment and ostesoporosis
zidovudine: anaemia, myopathy, black nails
didanosine: pancreatitis

126
Q

HIV Management: Entry Inhibitors

A

maraviroc (binds to CCR5, preventing an interaction with gp41), enfuvirtide (binds to gp41, also known as a ‘fusion inhibitor’)
prevent HIV-1 from entering and infecting immune cells

127
Q

HIV Management: Basics

A

ART = 3 drugs:
2x nucleoside reverse transcriptase inhibitors (NRTI)
+
1 x Protease inhibitor OR 1 x non-nucleoside reverse transcriptase inhibitor (NNRTI)

127
Q

HIV Management: Basics

A

ART = 3 drugs:
2x nucleoside reverse transcriptase inhibitors (NRTI)
+
1 x Protease inhibitor OR 1 x non-nucleoside reverse transcriptase inhibitor (NNRTI)

128
Q

First line treatment for acute prostatitis

A

Quinolone or trimethoprim

129
Q

Examples of quinolone antibiotics

A

Ciprofloxacin, levofloxacin

130
Q

First line treatment for dental abcess

A

Amoxicillin

131
Q

What is trichomonas vaginalis

A

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

132
Q

Features of trichomonas vaginalis

A

vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis

133
Q

Investigations of trichomonas vaginalis

A

microscopy of a wet mount shows motile trophozoites

134
Q

Management of trichomonas vaginalis

A

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

135
Q

Treatment of severe falciparum malaria

A

Parasite count > 2% IV artesunate

Parasite count >10% plasma exchange

136
Q

Features of severe falciparum malaria

A 
schizonts on a blood film
parasitaemia > 2%
hypoglycaemia
acidosis
temperature > 39 °C
severe anaemia
complications as below
137
Q

Complications of severe malaria

A

cerebral malaria: seizures, coma
acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown
acute respiratory distress syndrome (ARDS)
hypoglycaemia
disseminated intravascular coagulation (DIC)

138
Q

Management of uncomplicated malaria falciparum

A

Asia/Africa- strains resistant to chloroquinolone - artemisinin-based combination therapies
e.g artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine

139
Q

Non-gonococcal uretheritis - causes

A

Chlamydia trachomatis - most common cause

Mycoplasma genitalium - thought to cause more symptoms than Chlamydia

140
Q

Stereotypical history of non-gonococcal urethritis

A

male who presented to a GUM clinic with a purulent urethral discharge and dysuria. A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram negative diplococci (i.e. no evidence of gonorrhoea)

141
Q

Management of non-gonococcal urethritis

A

contact tracing

the BNF and British Association for Sexual Health and HIV (BASHH) both recommend either oral azithromycin or doxycycline

142
Q

amphotericin B mechanism of action

A

Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage

143
Q

Terbinafine mechanism of action

A

Inhibits squalene epoxidase

144
Q

CD 4 200-500 -opportunistic infections

A

oral thrush, hairy leukoplakia, shingles, karposi’s sarcoma (HHV 8)

145
Q

CD 4 count 100-200 opportunistic infections

A

Cryptosporidiosis- usually self limiting
Cerebral toxoplasmosis
Progressive multifocal leukoencephalopathy- 2 to JC virus
Pneumocystis jirovecii pneumonia
HIV dementia

146
Q

CD 4 count 50-100 opportunistic infections

A

Aspergillosis
Oesophageal candidiasis
Cryptococcal meningitis
Primary CNS lymphoma

147
Q

CD 4 count <50 opportunistic infections

A

cytomegalovirus retinitis

Mycobacterium avium-intracellulare infection

148
Q

Gardnerella vaginalis

A

cause of bacterial vaginitis

clue cells found on microscopy

149
Q

Features of tertiary syphilis

A 
granulomatous lesions of the skin and bones
tabes dorsalis
Argyll-Robertson pupil
gummas
ascending aortic aneurysm
150
Q

Features of congenital syphilis

A

Hutchinson’s teeth
saddle nose
linear scars at the angle of the mouth
mulberry molars

151
Q

Aciclovir - mechanism of action

A

Guanosine analog, phosphorylated by thymidine kinase which in turn inhibits the viral DNA polymerase

152
Q

Aciclovir adverse effects

A

Crystalline nephropathy

153
Q

Live attenuated vaccines

A 
oral typhoid
MMR
influenza (intranasal)
oral polio
oral rotavirus
yellow fever
BCG
154
Q

ganciclovir mechanism of action

A

Guanosine analog, phosphorylated by thymidine kinase which in turn inhibits the viral DNA polymerase

155
Q

Ganciclovir side effects

A

Myelosuppression/agranulocytosis

156
Q

First line treatment for animal/human bite

A

Co-amoxiclav

157
Q

Foscarnet mechanism of action

A

Pyrophosphate analog which inhibits viiral DNA polymerase

158
Q

Foscarnet adverse effects

A

Nephrotoxicity, hypocalcaemia, hypomagnasaemia, seizures

159
Q

Initial empirical therapy aged < 3 months

A

Intravenous cefotaxime + amoxicillin (or ampicillin)

160
Q

Pneumocystis jiroveci- what is it

A

unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa
PCP is the most common opportunistic infection in AIDS
all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis

161
Q

Features of pneumocystis jiroveci

A 
dyspnoea
dry cough
fever
very few chest signs
Extrapulmonary manifestations are rare (1-2% of cases), may cause
hepatosplenomegaly
lymphadenopathy
choroid lesions
162
Q

Investigations for pneumocystis jiroveci

A

CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal
exercise-induced desaturation
sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts)

163
Q

Management of pneumocystis jiroveci

A

co-trimoxazole
IV pentamidine in severe cases
aerosolized pentamidine is an alternative treatment for Pneumocystis jiroveci pneumonia but is less effective with a risk of pneumothorax
steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

164
Q

Stereotypical history of strep pyogenes

A

a 10-year-old presents with fever and a sore throat. Today they have a developed a fine, erythematous, ‘sand-paper’ rash which is more prominent in flexural areas.

165
Q

Erythema infectiosum

A

Associated with slapped cheek syndrome
Parvovirus B19
Barely noticeable mild feverish illness
Teratogenic in first 20 weeks of pregnancy

166
Q

Clostridia

A

Clostridia are gram-positive, obligate anaerobic bacilli

167
Q

Clostridium perfringens

A

produces α-toxin, a lecithinase, which causes gas gangrene (myonecrosis) and haemolysis
features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation

168
Q

Clostridium botulinum

A 
typically seen in canned foods and honey
prevents acetylcholine (ACh) release leading to flaccid paralysis
169
Q

Clostridium difficile

A

causes pseudomembranous colitis, typically seen after the use of broad-spectrum antibiotics
produces both an exotoxin and a cytotoxin

170
Q

Clostridium tetani

A

produces an exotoxin (tetanospasmin) that prevents the release of glycine from Renshaw cells in the spinal cord causing a spastic paralysis

171
Q

Cause of syphilis

A

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. The incubation period is between 9-90 days

172
Q

Primary features of syphilis

A

chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)

173
Q

Secondary features of syphilis - usually 6-10 weeks post infection

A

systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia)

174
Q

Tertiary features of syphilis

A 
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
175
Q

Overview of Measles

A

RNA paramyxovirus
spread by droplets
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days

176
Q

Features of measles

A

prodrome: irritable, conjunctivitis, fever
Koplik spots (before rash): white spots (‘grain of salt’) on buccal mucosa
rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
diarrhoea occurs in around 10% of patients

177
Q

Complications of measles

A

otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis

178
Q

Sub-unit/congugate vaccines

A 
meningococcus
hepatitis B
haemophilus
pneumococcus
human papillomavirus
179
Q

Toxoid vaccines

A

pertussis
diphtheria
tetanus

180
Q

Management of malaria:non-falciparum malaria (preventing relapse)

A

Primaquine

181
Q

CSF: tuberculos menigitis

A

slightly cloudy appearance with fibrin web, glucose 25% of plasma, protein 4 g/l, WCC 500 per mm^3 (lymphs)

182
Q

CSF: bacterial meningitis

A

cloudy appearance, glucose 25% of plasma, protein 1.5 g/l, WCC 2,000 per mm^3 (neuts)

183
Q

Presentation of diptheria

A

recent visitors to Eastern Europe/Russia/Asia
sore throat with a ‘diphtheric membrane’ - grey, pseudomembrane on the posterior pharyngeal wall
bulky cervical lymphadenopathy
may result in a ‘bull neck’ appearanace
neuritis e.g. cranial nerves
heart block

184
Q

Pathophysiology of diptheria

A

Gram positive bacterium Corynebacterium diphtheriae

releases an exotoxin encoded by a β-prophage
exotoxin inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2

185
Q

Management of diptheria

A

intramuscular penicillin

diphtheria antitoxin

186
Q

Stereotypical history of rubella

A

a child develops a pink maculopapular rash, initially on the face before spreading to the whole body. Suboccipital and postauricular lymphadenopathy is present

187
Q

Stereotypical history of measles

A

a child presents with fever, conjunctivitis and being irritable. He has also developed a maculopapular rash which started behind ears before spreading and becoming blotchy & confluent

188
Q

Cat scratch disease

A 
fever
history of a cat scratch
regional lymphadenopathy
headache, malaise
Gram negative rod Bartonella henselae
189
Q

erysipelas

A

infection of the upper layers of the skin (superficial). The most common cause is group A streptococcal bacteria, especially Streptococcus pyogenes
Rx: Flucloxacillin

190
Q

Stereotypical history of Onchocerca volvulus

A

a man develops hyperpigmented skin and blindness after being bitten by a fly

191
Q

Stereotypical history of Ancylostoma duodenale

A

a man develops abdominal pain after a holiday where he was walking barefoot in northern Africa. Bloods show an iron deficiency anaemia

192
Q

Mechanism of action: amantidine

A 
Inhibits uncoating (M2 protein) of virus in cell. Also releases dopamine from nerve endings
Used in influenza (rarely due to resistance) and parkinsonism
193
Q

Chancroid

A

caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border

194
Q

Stereotypical history of Loa loa

A

a man develops episodic angioedema whilst in west Africa. On one occasion he noticed a ‘worm moving across the left eye’

195
Q

Conditions that can be caused by Hep B

A
  • erythema nodosum
  • cryoglobulinaemia
  • hepatic cirrhosis
196
Q

American trypanosomiasis, or Chagas’ disease

A

caused by the protozoan Trypanosoma cruzi
chagoma (an erythematous nodule at site of infection) and periorbital oedema are sometimes seen.
Chronic Chagas’ disease mainly affects the heart and gastrointestinal tract-
myocarditis may lead to dilated cardiomyopathy (with apical atophy) and arrhythmias
gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation

197
Q

Management of Chagas disease

A

treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox
chronic disease management involves treating the complications e.g., heart failure

198
Q

mechanism of action: terbinafine

A

inhibits squalene epoxidase

199
Q

melioidosis

A

Severe, bacterial infection caused by Burkholderia pseudomallei and is common in East Asia and Northern Australia
Risk factor: diabetes
Rx - IV ceftazidime

200
Q

Sub-unit and conjugate vaccines

A 
use polysaccarides to make them more immunogenic pneumococcus (conjugate)
haemophilus (conjugate)
meningococcus (conjugate)
hepatitis B
human papillomavirus
201
Q

Management of PCP

A

Oral co-trimoxazole

202
Q

Management of Schistosomiasis

A

Praziquantel

203
Q

Cat scratch disease

A

Bartonella henselae

204
Q

Q fever causative organism

A

Coxiella burnetii

205
Q

Carbapenem resistance

A

New Delhi metallo-beta-lactamase 1
typically found in klebsiella, e coli, Enterobacter cloacae
Treat with tigercycline or colistin

206
Q

Vancomycin resistance

A

D-alanyl-D-lactate variation leading to loss of affinity to antibiotics is the mechanism of VRE (vancomycin resistant enterococci). Vancomycin binds to D-ala-D-ala.

207
Q

Pseudomonas resistance

A

MexAB-OprM efflux pumps is one of the mechanisms by which pseudomonas aeruginosa is resistant to -lactams, chloramphenicol, fluoroquinolones, macrolides, novobiocin, sulfonamides, tetracycline, and trimethoprim.

208
Q

Diagnosis of intestinal ameobias

A

‘hot’ stool sample - microscopy within 15 mins

209
Q

Animal bites (dogs)

A

Pasteurella multocida

210
Q

C.diff

A

gram positive bacilli

211
Q

gram negative cocci

A

Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis

212
Q

Cryptosporidium staining

A

Modified Ziehl-Neilson

213
Q

Features of Zika virus

A 
fever
rash
arthralgia/arthritis
conjunctivitis
myalgia
headache
retro-orbital pain
pruritus
214
Q

tuberculoid leprosy

A

recent onset of hypopigmented skin lesions, sensory peripheral neuropathy and thickened peripheral nerves having come from an endemic region.

215
Q

Aspergilloma in previous TB

A

Occupies previous cavitating lesion

chest x-ray containing a rounded opacity. A crescent sign may be present- air around the lesions

216
Q

Brucellosis

A

luctuating temperatures, transient arthralgia and myalgia, hyperhidrosis with a ‘wet hay’ smell. unpasteurised cheese.
Brucella melitensis is the bacteria found in contaminated unpasteurised milk

217
Q

Lemierre’s syndrome

A

Lemierre’s syndrome is an infectious thrombophlebitis of the internal jugular vein.

It most often occurs secondary to a bacterial sore throat caused by Fusobacterium necrophorum leading to a peritonsillar abscess. A combination of spread of the infection laterally from the abscess and compression lead to thrombosis of the IJV.

Patients will present with a history of bacterial sore throat followed by neck pain, stiffness and tenderness (may be mistaken for meningitis) and systemic involvement (fevers, rigors, etc). Septic pulmonary emboli may also occur.

218
Q

Campylobacter

A

Unpasteurised milk, bloody diarrhoea and fevers

Clarithromycin

219
Q

mycoplasma and skin

A

associated with erythema multiforme

220
Q

Linezolid- mechanism of action

A

type of oxazolidinone antibiotic
It inhibits bacterial protein synthesis by stopping the formation of the 50s initiation complex and is bacteriostatic in nature.

221
Q

Linezolid- used to treat?

A

Spectrum, highly active against Gram positive organisms including:
MRSA (Methicillin-resistant Staphylococcus aureus)
VRE (Vancomycin-resistant enterococcus)
GISA (Glycopeptide Intermediate Staphylococcus aureus)

222
Q

Linezolid adverse effects

A

thrombocytopenia (reversible on stopping)

monoamine oxidase inhibitor: avoid tyramine containing foods

223
Q

Features of anthrax

A

causes painless black eschar (cutaneous ‘malignant pustule’, but no pus)
typically painless and non-tender
may cause marked oedema
anthrax can cause gastrointestinal bleeding

224
Q

Management of anthrax

A

Ciprofloxacin

225
Q

HIV: Mycobacterium avium complex features

A 
fever, sweats
abdominal: pain, diarrhoea
lung: dyspnoea, cough
anaemia
lymphadenopathy
hepatomegaly/deranged LFTs
226
Q

HIV: Mycobacterium avium complex management

A

rifampicin + ethambutol + clarithromycin

226
Q

HIV: Mycobacterium avium complex management

A

rifampicin + ethambutol + clarithromycin

227
Q

Leptospirosis

A

Spirochete infected rat urine
sewage workers, farmers, vets or people who work in an abattoir
Treat with ben pen or doxycyline

228
Q

VDRL (Venereal Disease Research Laboratory) & RPR (rapid plasma reagin)

A

Used to investigate syphyllis, can be falsely positive in antiphospholipid syndrome, pregnancy, SLE, TB, leprosy, malaria, HIV.

229
Q

Dengue

A

Retro-orbital headache, fever, facial flushing, rash, thrombocytopenia in returning travelle

230
Q

Basics of Dengue

A

transmitted by the Aedes aegypti mosquito
incubation period of 7 days
a form of disseminated intravascular coagulation (DIC) known as dengue haemorrhagic fever (DHF) may develop. Around 20-30% of these patients go on to develop dengue shock syndrome (DSS)

231
Q

Treatment of Dengue

A

entirely symptomatic e.g. fluid resuscitation, blood transfusion etc
no antivirals are currently available

232
Q

Low glucose CSF- viral

A

Mumps

herpes encephalitis

233
Q

indinavir

A

protease inhibitor associated with renal stones

234
Q

Tetracyclines (doxycycline)

A

Inhibit 30s sub-units of ribosomes

235
Q

CNS toxoplasma

A

ring enhancing lesion

pyrimethamine plus sulphadiazine

236
Q

Leprosy

A

Hypopigmentation

Sensation loss

237
Q

Staph aureus

A

Gram +ve
Coagulase +ve
Catalase +ve

238
Q

Mechanism of action of Amphotericin B

A

binds to ergosterol, a component of fungal cell membranes, forming pores that cause lysis of the cell wall and subsequent fungal cell death

239
Q

Sequelae of corynebacterum (diptheria)

A

Heart block
neuritis
Bulky lymphadenopathy
sore throat with diptheric (grey) membrane

240
Q

IVDU with descending paralysis

A

Clostridium botulinum

241
Q

Most common causes of viral meningitis (Adults)

A

Enterovirus e.g. Coxsackie B

242
Q

African trypanosomiasis treatment

A

early disease: IV pentamidine or suramin

later disease or central nervous system involvement: IV melarsoprol

243
Q

Chagas disease

A

protozoan Trypanosoma cruzi. (95%) are asymptomatic in the acute phase although a chagoma (an erythematous nodule at site of infection) and periorbital oedema are sometimes seen. Chronic Chagas’ disease mainly affects the heart and gastrointestinal tract
myocarditis may lead to dilated cardiomyopathy (with apical atophy) and arrhythmias
gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation

244
Q

Management of chagas disease

A

treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox
chronic disease management involves treating the complications e.g., heart failure

245
Q

Urine dip - +ve for leucocytes, -ve for nitrates

A

Gram +Ve bacteria e.g. staph saprophyticus

246
Q

Jarisch-Herxheimer reaction

A

Seen in management of syphillis - release of endotoxins
Flushing, rash and fever
No wheeze or hypotension - differentiates from anaphylaxis

247
Q

URTI + amoxicillin –> rash

A

?Glandular fever

248
Q

Chikungunya

A

alphavirus spread by infected bacteria

Debilitating arthralgia, flu like illness

249
Q

Second line management of genital warts (herpes simplex)

A

imiquimod

250
Q

Amantadine

A

inhibits uncoating of viral M2

increases dopamine release from neuronal synapses

MRCP part 1 (15 decks)

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