Infective disease Flashcards

Question

Management Tetanus

Answer 1

Supportive therapy including ventilatory support and muscle relaxants * Intramuscular human tetanus immunoglobulin for high-risk wounds (e.g. Compound fractures, delayed surgical intervention, significant degree of devitalised tissue) * Metronidazole is now preferred to benzylpenicillin as the antibiotic of choice

Answer 2

symptomatic in 60-80% of patients and typically presents as a glandular fever type illness. ↑ symptomatic severity is associated with poorer long term prognosis. It typically occurs 3-12 weeks after infection

Answer 3

- think HIV seroconversion

Answer 4

Features * Sore throat * Lymphadenopathy * Malaise, myalgia, arthralgia * Diarrhoea * Maculopapular rash * Mouth ulcers * Rarely meningoencephalitis

Answer 5

Diagnosis * Antibodies to HIV may not be present * HIV PCR and p24 antigen tests can confirm diagnosis

Answer 6

Reduction in CD4 count * Increase B2-Microglobulin (IBM) * Decrease IL-2 production (DIL=DELL) * Polyclonal B-cell activation * ↓ NK cell function * ↓ delayed hypersensitivity responses

Answer 7

Measles, Mumps, Rubella (MMR) ● V aricella● Yellow Fever●

Answer 8

Cholera* CVD103-HgR● Influenza-intranasal● Poliomyelitis-oral (OPV) ● Tuberculosis (BCG) ●

Answer 9

Hepatitis A ▲ Hepatitis B ■ Hemophilua ■ influenzae B,HiB Influenza-parenteral▲ Japanese encephalitis▲ Meningococcus■-MenC Meningococcus■-ACWY I Pneumococcus■-PPV23 Poliomyelitis-parenteral (IPV)▲ Rabies ▲ Tetanus-Diphtheria (TD)

Answer 10

ossible causes * Cryptosporidium + other protozoa (most common) * Cytomegalovirus * Mycobacterium avium intracellulare * Giardia

Answer 11

Cryptosporidium

Answer 12

ntracellular protozoon and has an incubation period of 7 days.

Answer 13

modified Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the characteristic red cysts of Cryptosporidium. Molecular methods are currently used mainly as a research tool. Treatment is difficult, with the mainstay of management being supportive therapy. (nitazoxanide is licensed in the US for immunocompetent patients)

Answer 14

atypical mycobacteria seen with the CD4 count is below 50. Typical features include fever, sweats, abdominal pain and diarrhoea. hepatomegaly and deranged LFTs. Diagnosis is made by blood cultures and bone marrow examination. Management is with rifampicin, ethambutol and clarithromycin

Answer 15

* Maternal antiretroviral therapy * Mode of delivery (caesarean section) * Neonatal antiretroviral therapy * Infant feeding (bottle feeding)

Answer 16

All pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously * If women are not currently taking antiretroviral therapy it is usually commenced between 28 and 32 weeks of gestation and should be continued intrapartum

Answer 17

* Elective caesarean section* * A zidovudine infusion should be started four hours before beginning the caesarean section

Answer 18

Neonatal antiretroviral therapy * Zidovudine is usually administered orally to the neonate for four to six weeks

Answer 19

fant feeding * In the UK all women should be advised not to breast feed *the 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen

Answer 20

* Caused by HHV-8 (Human Herpes Virus 8) * Presents as purple papules or plaques on the skin or mucosa (e.g. Gastrointestinal and respiratory tract) * Skin lesions may later ulcerate * Respiratory involvement may cause massive hemoptysis and pleural effusion * Radiotherapy + resection

Answer 21

hilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use * Pneumocystis jiroveci is an 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

Answer 22

Features * Dyspnea * Dry cough * Fever * Very few chest signs Extrapulmonary manifestations are rare (1-2% of cases), may cause * Hepatosplenomegaly * Lymphadenopathy

Answer 23

: occurs in AIDS in response to immune system recovery, there is granulamtous uveitis that leads to reduced vision and eye discoloration

Answer 24

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)

Answer 25

Management * Co-trimoxazole * IV pentamidine in severe cases * Steroids if hypoxic (if pO2 < 9.3kpa then steroids ↓ risk of respiratory failure by 50% and death by a third)

Answer 26

sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia

Answer 27

may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV

Answer 28

Management Meningococcus * If penicillin allergic then give chloramphenicol * If there is NO A HISTORY OF ANAPHYLAXIS then cefotaxime may be considered for penicillin allergic patients

Answer 29

* Prophylaxis needs to be offered to household and close contacts of patients affected with meningococcal meningitis * Rifampicin or ciprofloxacin may be used * The risk is highest in the first 7 days but persists for at least 4 weeks * Meningococcal vaccination should be offered when serotype results are available, for close contacts who have not previously been vaccinated*

Answer 30

nvestigations * Blood cultures * Blood PCR, if antibiotic was already started. * Lumbar puncture is usually contraindicated * Full blood count and clotting to assess for disseminated intravascular coagulation

Answer 31

The most important α hemolytic Streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans

Answer 32

Most important organism is Streptococcus pyogenes * Responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis & pharyngitis/tonsillitis * Immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis * Erythrogenic toxins cause scarlet fever * Penicillin is the antibiotic of choice for group A streptococcal infections

Answer 33

Streptococcus agalactiae may lead to neonatal meningitis and septicemia

Answer 34

penicillin + flucloxacillin as first-line treatment for cellulitis. Erythromycin is recommended in patients allergic to penicillin. Treatment failure is now commonly treated with oral clindamycin.

Answer 35

describes a severe systemic reaction to staphylococcal exotoxins. It came to prominence in the early 1980's following a series of cases related to infected tampons

Answer 36

* Encephalitis: typically occurs 1-2 weeks after the onset of the illness. * Subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness * Febrile convulsions * Pneumonia, tracheitis * Keratoconjunctivitis, corneal ulceration * Diarrhoea * ↑ incidence of appendicitis * Myocarditis

Answer 37

* Caused by HHV-8 (Human Herpes Virus 8) * Presents as purple papules or plaques on the skin or mucosa (e.g. Gastrointestinal and respiratory tract) * Skin lesions may later ulcerate * Respiratory involvement may cause massive hemoptysis and pleural effusion * Radiotherapy + resection

Answer 38

occurs in AIDS in response to immune system recovery, there is granulamtous uveitis that leads to reduced vision and eye discoloration

Answer 39

Management * Co-trimoxazole * IV pentamidine in severe cases * Steroids if hypoxic (if pO2 < 9.3kpa then steroids ↓ risk of respiratory failure by 50% and death by a third)

Answer 40

sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia

Answer 41

secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV

Answer 42

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 Features - can present in a variety of ways * Diarrhoea, flu-like illness * Pneumonia , meningoencephalitis * Ataxia and seizures Suspected Listeria infection should be investigated by taking blood cultures. CSF may reveal a pleocytosis, with 'tumbling motility' on wet mounts

Answer 43

Listeria is sensitive to amoxicillin/ampicillin (cephalosporins usually inadequate) * Listeria meningitis should be treated with IV amoxicillin/ampicillin and gentamicin

Answer 44

Anthrax is caused by Bacillus anthracis, a Gram positive rod. It is spread by infected carcasses

Answer 45

Features * Causes painless black eschar (cutaneous 'malignant pustule', but no pus) * Typically painless and non-tender * May cause marked edema * Anthrax can cause gastrointestinal bleeding

Answer 46

Management * The current Health Protection Agency advice for the initial management of cutaneous anthrax is ciprofloxacin * Further treatment is based on microbiological investigations and expert advice

Answer 47

* All patients awaiting elective admissions (exceptions include day patients having terminations of pregnancy and ophthalmic surgery. Patients admitted to mental health trusts are also excluded) * From 2011 all emergency admissions will be screened

Answer 48

* Vancomycin * Teicoplanin

Answer 49

ome strains may be sensitive to the antibiotics listed below but they should not generally be used alone because resistance may develop: * Rifampicin * Macrolides * Tetracyclines * Aminoglycosides * Clindamycin

Answer 50

intracellular bacterium Legionella pneumophilia. It is typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen

Answer 51

* Flu-like symptoms * Dry cough * Lymphopenia * Hyponatremia * Deranged LFTs

Answer 52

Urinary antigen * Treat with erythromycin

Answer 53

leptospirosis is commonly seen in questions referring to sewage workers, farmers, vets or people who work in abattoir. It is caused by the spirochaete Leptospira interrogans (serogroup L icterohemorrhagiae), classically being spread by contact with infected rat urine. Weil's disease should always be considered in high-risk patients with hepatorenal failure. The term Weil's disease referrs for the most severe 10% of cases of leptospirosis associated with jaundice

Answer 54

eatures * Fever * Flu-like symptoms → WITHOU PRODUCTIVE COUGH * Renal failure (seen in 50% of patients) * Jaundice * Subconjunctival hemorrhage * Headache, may herald the onset of meningitis Management * A lumbar puncture should ideally be done first to confirm meningeal involvement, if there are meningeal symptoms. * High-dose benzylpenicillin or doxycycline

Answer 55

is rare but serious infection caused by Hemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has ↓ since the introduction of the Hib vaccine Features * Rapid onset * Unwell, toxic child * Stridor * Drooling of saliva

Answer 56

Borrelia burgdorferi sensu stricto is the main cause of Lyme disease in the United States, whereas Borrelia afzelii and Borrelia garinii cause most European cases.

Answer 57

Early features * Erythema chronicum migrans (small papule often at site of the tick bite which develops into a larger annular lesion with central clearing, occurs in 70% of patients) * Systemic symptoms: malaise, fever, arthralgia Later features * CVS: heart block, myocarditis * Neurological: cranial nerve palsies, meningitis

Answer 58

* Immune mediated type IV hypersensitivity reaction * Ml of 1:1,000 purified protein derivative (PPD) injected intradermally * Result read 2-3 days later * Erythema & induration > 10mm = positive result - this implies previous exposure including BCG

Answer 59

classically involves injection of PPD equivalent to 100,000 units per ml to the skin over the flexor surface of the left forearm. It is then read 3-10 days later Grades 1 and 2 may be the result of previous BCG or avian tuberculosis whilst grades 3 or 4 require a CXR and follow-up

Answer 60

* Miliary TB * Sarcoidosis * HIV * Lymphoma * Very young age (e.g. < 6 months)

Answer 61

* Rifampicin * Isoniazid * Pyrazinamide * Ethambutol (in 2006 NICE recommend giving a 'fourth drug' such as ethambutol routinely - previously this was only added if drug-resistant tuberculosis was suspected) Continuation phase - next 4 months * Rifampicin * Isoniazid

Answer 62

isoniazid alone for 6 months

Answer 63

* Potent liver enzyme inducer * Hepatitis Orange secretions * Flu-like symptoms

Answer 64

Streptomycin

Answer 65

* Homeless people with active tuberculosis * Patients who are likely to have poor concordance * All prisoners with active or latent tuberculosis

Answer 66

* Hyperuricemia causing gout

Answer 67

Peripheral neuropathy: prevent with pyridoxine (Vitamin B6) * May also cause optic neuritis but it is not as common a cause as ethambutol. * Hepatitis, agranulocytosis * Liver enzyme inhibitor

Answer 68

vestibular damage → Vertigo and Vomiting * Angioedema or angioneuritic edema * Cochlear damage → deafness * Nephrotoxicosis

Answer 69

Hansen's disease (HD) is a chronic disease caused by Mycobacterium leprae and Mycobacterium lepromatosis. Features: * Nodular skiManagement: * Skin biopsy and needle test in cold area (ear lobuleand elbow) * Pauci-bacillary leprosy (<5 lesions) Treat with rifampicin and dapsone for 6 months * Multi-bacillary leprosy (>5 lesions) → rifampicin, clofazimine and dapsone for 12 monthsn lesions * Erythremaous raised plaque like lesions in arms and legs Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs, and eyes.

Answer 70

Management: * Skin biopsy and needle test in cold area (ear lobuleand elbow) * Pauci-bacillary leprosy (<5 lesions) Treat with rifampicin and dapsone for 6 months * Multi-bacillary leprosy (>5 lesions) → rifampicin, clofazimine and dapsone for 12 months

Answer 71

* Schizonts on a blood film * Parasitemia > 2% * Hypoglycemia * Temperature > 39 °c * Severe anemia * Complications as below

Answer 72

* Cerebral malaria: seizures, coma * ARF: blackwater fever, secondary to intravascular hemolysis, mechanism unknown * Acute respiratory distress syndrome (ARDS) * Hypoglycemia * Disseminated intravascular coagulation (DIC)

Answer 73

* Strains resistant to chloroquine are prevalent in certain areas of Asia and Africa * WHO 2010 guidelines: artemisinin-based combination therapies (ACTs) as first-line therapy * Examples include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine

Answer 74

* A parasite counts >2% will usually need parenteral treatment irrespective of clinical state * IV artesunate is now recommended by WHO in preference to intravenous quinine (2010 guidelines) * If parasite count > 10% then exchange transfusion should be considered * Shock may indicate coexistent bacterial septicemia - malaria rarely causes hemodynamic collapse

Answer 75

most common cause is Plasmodium vivax, with Plasmodium ovale and Plasmodium malariae accounting for the other cases. Plasmodium vivax is often found in Central America and the Indian Subcontinent whilst Plasmodium ovale typically comes from Africa Benign malarias have a hypnozoite stage and may therefore relapse following treatment

Answer 76

Treatment * Non-falciparum malarias are almost always chloroquine sensitive * Primaquine should be used in Plasmodium vivax and Plasmodium ovale infection to destroy liver hypnozoites

Answer 77

intracellular protozoa Leishmania, usually being spread by sand flies. The organism multiply in monocytes and macrophages, its incubation period may extend upto 10 years. 3 forms are seen as following:

Answer 78

* Caused by Leishmania tropica or Leishmania mexicana * Crusted lesion at site of bite * May be underlying ulcer

Answer 79

* Caused by Leishmania brasiliensis * Skin lesions may spread to involve mucosae of nose, pharynx...

Answer 80

* Mostly caused by Leishmania donovani * Occurs in Mediterranean, Asia, South America, Africa * Fever (typically ↑ twice in 24hours), sweats, rigors * Massive splenomegaly, hepatomegaly * Pancytopenia secondary to hypersplenism * Poor appetite*, weight loss * Grey skin - 'kala-azar' means black sickness or black fever

Answer 81

Two main form of this protozoal disease are recognised - African trypanosomiasis (sleeping sickness) and American trypanosomiasis (Chagas' disease)

Answer 82

tends to follow a more acute course. Clinical features include: * Trypanosoma chancre - tender subcutaneous nodule at site of infection * Enlargement of posterior cervical lymph nodes * Later: central nervous system involvement e.g. Meningoencephalitis

Answer 83

Management * Early disease: IV pentamidine or suramin * Later disease or central nervous system involvement: IV melarsoprol

Answer 84

American trypanosomiasis, or Chagas' disease, is caused by the protozoan Trypanosoma cruzi. (95%) of patients are asymptomatic in the acute phase although a chagoma (an erythematous nodule at site of infection) and periorbital edema are sometimes seen. Chronic Chagas' disease mainly affects the heart and gastrointestinal tract

Answer 85

* 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

Answer 86

r Bilharzia, is a parasitic flatworm infection. The following types of schistosomiasis are recognised: * Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis * Schistosoma Hematobium: urinary schistosomiasis

Answer 87

Schistosomiasis is a risk factor for Squamous cell bladder cance

Answer 88

Management Single oral dose of praziquantel

Answer 89

Prodrome: headache, fever, agitation * Hydrophobia: water-provoking muscle spasms * Hypersalivation

Answer 90

If an individual is already immunised then 2 further doses of vaccine should be given * If not previously immunised then human rabies immunoglobulin (HRIG) should be given along with a full course of vaccination

Answer 91

* Cleanse wound * Current BNF recommendation is co-amoxiclav * If penicillin-allergic then doxycycline + metronidazole is recommended

Answer 92

* Spread via the respiratory route * Can be caught from someone with shingles * Infectivity = 4 days before rash, until 5 days after the rash first appeared (traditionally taught patients were infective until all lesions had scabbed over) * Incubation period = 11-21 days

Answer 93

s generally caused by the Gram negative rod Bartonella henselae Features * fever * history of a cat scratch * regional lymphadenopathy * headache, malaise

Answer 94

cClinical features (tend to be more severe in older children/adults) * Fever initially * Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular * Systemic upset is usually mild

Answer 95

* Keep cool, trim nails * Calamine lotion * School exclusion: current HPA advice is 5 days from start of skin eruption. They also state 'Traditionally children have been excluded until all lesions are crusted. However, transmission has never been reported beyond the fifth day of the rash.' * Immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered

Answer 96

A common complication is secondary bacterial infection of the lesions. Rare complications include: * Pneumonia: varicella pneumonia is the most common and serious complication of chickenpox infection in adults. Auscultation of the chest is often unremarkable → IV acyclovir * Encephalitis (cerebellar involvement may be seen) * Disseminated hemorrhagic chickenpox * Arthritis, nephritis and pancreatitis may very rarely be seen

Answer 97

first step is to check antibodies

Answer 98

* Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation * Studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks * Features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Answer 99

* If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies * If the pregnant woman is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure * Consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

Answer 100

Overview * RNA paramyxovirus * Spread by droplets * Infective from prodrome until 5 days after rash starts * Incubation period = 10-14 days Features Intra oral rash of measles * 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

Answer 101

If a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection) * This should be given within 72 hours The Only MRCP Notes You’ll Ever Need

Answer 102

Gram negative diplococcus Neisseria gonorrhoea. Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx. The incubation period of gonorrhoea is 2-5 days

Answer 103

Features * ♂s: urethral discharge, dysuria * ♀s: cervicitis e.g. Leading to vaginal discharge * Rectal and pharyngeal infection is usually asymptomatic, but may present as rectal bleeding

Answer 104

Ciprofloxacin 500mg PO used to be the treatment of choice * However, there is ↑ resistance to ciprofloxacin and therefore cephalosporins are now used * Options include cefixime 400mg PO (single dose) or ceftriaxone 250mg IM

Answer 105

* Ciprofloxacin 500mg PO used to be the treatment of choice * However, there is ↑ resistance to ciprofloxacin and therefore cephalosporins are now used * Options include cefixime 400mg PO (single dose) or ceftriaxone 250mg IM

Answer 106

gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to Hematogenous spread from mucosal infection (e.g. asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)

Answer 107

* Tenosynovitis * Migratory polyarthritis * Dermatitis (lesions can be maculopapular or vesicular)

Answer 108

(They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16, 18 & 33) predisposes to cervical cancer.

Answer 109

Features * Small (2 - 5 mm) fleshy protuberances which are slightly pigmented * May bleed or itch

Answer 110

Management * Topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy * Imiquimod is a topical cream which is generally used second line * Genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

Answer 111

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

Answer 112

Genital ulcers * Painful: herpes >> chancroid * Painless: syphilis > lymphogranuloma venereum + granuloma inguinale

Answer 113

Treponema pallidum * Chancre - painless ulcer at the site of sexual contact * Often not seen in women Secondary features - occurs 4-10 weeks after primary infection * Systemic symptoms: fevers, lymphadenopathy * Rash on trunk, palms and soles * Buccal 'snail track' ulcers (30%) * Condylomata lata

Answer 114

* Gummas * Aortic aneurysms * General paralysis of the insane * Tabes dorsalis (slow degeneration of the sensory neurons. The degenerating nerves are in the dorsal column; proprioception, vibration, and fine touch).

Answer 115

* Syphilis infection leads to the production of non-specific antibodies that react to cardiolipin * Examples include VDRL (venereal disease research laboratory) & RPR (rapid plasma reagin) * Insensitive in late syphilis * Becomes negative after treatment

Answer 116

* Example: TPHA (Treponema pallidum hemagglutination test) * Remains positive after treatment

Answer 117

* Pregnancy * SLE, anti-phospholipid syndrome * TB * Leprosy * Malaria * HIV

Answer 118

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

Answer 119

(HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap

Answer 120

* Primary infection: may present with a severe gingivostomatitis * Cold sores * Painful genital ulceration

Answer 121

Management: * Gingivostomatitis: oral aciclovir, chlorhexidine mouthwash * Cold sores: topical aciclovir although the evidence base for this is modest * Genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Answer 122

* Behcet's disease * Carcinoma * Granuloma inguinale: Klebsiella granulomatis (previously called Calymmatobacterium granulomatis)

Answer 123

tropical disease caused by Hemophilus ducreyi. It causes painful genital ulcers associated with inguinal lymph node enlargement.

Answer 124

Treponema pallidum Painless Non-exudative Hard (indurated) edge Heal spontaneously within 3 - 6 weeks, even in the absence of treatment Can occur in the pharynx as well as on the genitals

Answer 125

'Cottage cheese' discharge Vulvitis Itch

Answer 126

Trichomonas vaginalis Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix

Answer 127

Offensive, thin, white/grey, 'fishy' discharge

Answer 128

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. Whilst it’s not a sexually transmitted infection it is seen almost exclusively in sexually active women.

Answer 129

* Thin, white homogenous discharge * Clue cells on microscopy * Vaginal pH > 4.5 * Positive whiff test (addition of potassium hydroxide results in fishy odour)

Answer 130

Results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage * It was previously taught that oral metronidazole should be avoided in the 1st trimester and topical clindamycin used instead. Recent guidelines however recommend: oral metronidazole is used throughout pregnancy. BNF is against the use of high dose metronidazole regimes

Answer 131

Oral metronidazole for 5-7 days * 70-80% initial cure rate * Relapse rate > 50% within 3 month

Answer 132

Features * Asymptomatic in around 70% of women and 50% of ♂s * Women: cervicitis (discharge, bleeding), dysuria * Men: urethral discharge, dysuria

Answer 133

Potential complications * Epididymitis * Pelvic inflammatory disease * Endometritis * ↑ incidence of ectopic pregnancies * Infertility * Reactive arthritis * Perihepatitis (Fitz-Hugh-Curtis syndrome)

Answer 134

Investigation * Traditional cell culture is no longer widely used * Nuclear Acid Amplification Tests (NAATs) are now rapidly emerging as the investigation of choice * Urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

Answer 135

diagnosis of Chlamydia is most likely. Both many times infect together

Answer 136

Doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline * If pregnant then erythromycin or amoxicillin may be used. The SIGN guidelines suggest considering azithromycin 'following discussion of the balance of benefits and risks with the patient'

Answer 137

also known as parrot disease, parrot fever, it is characterized by malaise, fever, myalgias and pneumonia. Exposure to an ill bird and a rash (Horder’s spots) are pathognomonic. Erythromycin or tetracyclines are the drugs of choice.

Answer 138

Local antibiotic guidelines should be followed if available * Clinical knowledge summaries (CKS) recommend trimethoprim or nitrofurantoin for 3 days

Answer 139

* Asymptomatic bacteriuria is screened for on the booking visit and should be treated with an antibiotic for 7 days (sensitivities should already be available) * For acute lower urinary tract infections consider amoxicillin or an oral cephalosporin for 7 days*

Answer 140

* Local antibiotic guidelines should be followed if available * The BNF currently recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days * Clinical knowledge summaries recommend ciprofloxacin for 7 days or co-amoxiclav for 14 days

Answer 141

Sensorineural deafness Congenital cataracts Congenital heart disease (e.g. patent ductus arteriosus) Glaucoma other Growth retardation Hepatosplenomegaly Purpuric skin lesions 'Salt and pepper' chorioretinitis Microphthalmia Cerebral palsy

Answer 142

Cerebral calcification Chorioretinitis Hydrocephalus other Anemia Hepatosplenomegaly Cerebral p

Answer 143

Growth retardation Purpuric skin lesions Sensorineural deafness Encephalitiis Pneumonitis Hepatosplenomegaly Anemia Jaundice Cerebral palsy

Answer 144

protozoa which infects the body via the GI tract, lung or broken skin. Its 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.

Answer 145

investigation for Toxoplasmosis * Antibody test * Sabin-Feldman dye test Treatment is usually reserved for those with severe infections or patients who are immunosuppressed * Pyrimethamine + Sulphadiazine for at least 6 weeks.

Answer 146

infection most commonly results from reheated rice

Answer 147

Staphylococcus aureus, Bacillus cereus or Clostridium perfringens.

Answer 148

Common amongst travellers Watery stools Abdominal cramps and nausea

Answer 149

Prolonged, non-bloody diarrhea

Answer 150

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

Answer 151

Bloody diarrhea Vomiting and abdominal pain

Answer 152

Severe vomiting Short incubation period

Answer 153

A flu-like prodrome Followed by crampy abdominal pains Fever and diarrhoea which may be bloody Complications include Guillain-Barre syndrome

Answer 154

Two types of illness are seen Vomiting within 6 hours, stereotypically due to rice Diarrhoeal illness occurring after 6 hours (6-14hrs)

Answer 155

Profuse 'rice water' diarrhoea * Dehydration * Hypoglycemia

Answer 156

Profuse 'rice water' diarrhoea * Dehydration * Hypoglycemia

Answer 157

* Oral rehydration therapy * Antibiotics: doxycycline, ciprofloxacin

Answer 158

caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route Features * Often asymptomatic * Lethargy, bloating, abdominal pain * Non-bloody diarrhoea * Chronic/prolonged diarrhoea, malabsorption and lactose intolerance can occur * Stool microscopy for trophozoite and cysts are classically negative, therefore duodenal fluid aspirates or 'string tests' (fluid absorbed onto swallowed string) are sometimes needed Treatment is with metronidazole

Answer 159

Treatment is with metronidazole

Answer 160

a facultative anaerobic, lactose-fermenting, Gram negative rod which is a normal gut commensal.

Answer 161

* Diarrhoeal illnesses * UTIs * Neonatal meningitis

Answer 162

E coli O157:H7 is a particular strain associated with severe, hemorrhagic, watery diarrhoea. It has a high mortality rate and can be complicated by hemolytic uremic syndrome. It is often spread by contaminated ground beef. The presentation is usually: * Diahrrea * Renal Failure or Impairment * Thrombocytopenia * ↓ Hb due to hemorrhage

Answer 163

contains many members, most of which cause diarrhoeal diseases. They are aerobic, Gram negative rods which are not normally present as commensals in the gut.

Answer 164

Features * Initially systemic upset as above * Relative bradycardia * Abdominal pain, distension * Constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid * Rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid

Answer 165

Typhoid and paratyphoid are caused by Salmonella typhi and Salmonella paratyphi (types A, B & C) respectively. They are often termed enteric fevers, producing systemic symptoms such as headache, fever, and arthralgia.

Answer 166

Possible complications include * Osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens) * GI bleed/perforation * Meningitis * Cholecystitis * Chronic carriage (1%, more likely if adult ♀s)

Answer 167

* Causes bloody diarrhoea, abdo pain * Severity depends on type: S sonnei (e.g. from UK) may be mild, S flexneri or S dysenteriae from abroad may cause severe disease * Treat with ciprofloxacin

Answer 168

Diagnosis: * Black sopits on thigh * Hx of tick bites * Low grade fever * Faint macular rash

Answer 169

Presentation: * Fever * Rash on hands, feet which later → desequamte (peel) * Tachycardia with no hypotension (unlike Staphylococcal Toxic Shock Syndrome) Management: Doxycycline

Answer 170

Rhipicephalus sanguineus. * Incubation period: 7 days. * The disease manifests abruptly with chills, high fevers, myalgia and joints pain, severe headache, photophobia and diarrhea. * The location of the bite forms a black spots or ulcerous crust (tache noire). Around the fourth day of the illness an exanthem (widespread rash) appears, first macular and then maculopapular and sometimes petechial. * Treated by Doxycycline.

Answer 171

ype of viral hemorrhagic fever (also yellow fever, Lassa fever, Ebola) Low platelet count and raised transaminase level is typical of dengue fever

Answer 172

Basics * Transmitted by the Aedes aegyti mosquito * Incubation period of 7 days * A form of disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever (DHF) may develop. Around 20-30% of these patients go on to develop dengue shock syndrome (DSS) Neoplasia * Lymphoma * Hypernephroma * Preleukemia * Atrial myxoma Infections * Abscess * TB Connective tissue disorders The Only MRCP Notes You’ll Ever Need 420 / 546 www.sudamedica.com Features * Causes headache (often retro-orbital) * Myalgia * Pleuritic pain * Facial flushing (dengue) * Maculopapular rash * Pyrexia

Answer 173

Epstein-Barr virus (also known as human herpesvirus 4, HHV-4). It is most common in adolescents and young adults. Features * Sore throat * Lymphadenopathy * Pyrexia * Malaise, anorexia, headache * Palatal petechiae * Splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture * Hepatitis * Presence of 50% lymphocytes with at least 10% atypical lymphocytes * Hemolytic anaemia

Answer 174

Management is supportive and includes: * 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

Answer 175

* RNA virus * 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 * A vaccine is currently in development, but is not yet in widespread use

Answer 176

* Burkitt's lymphoma* * Hodgkin's lymphoma * Nasopharyngeal carcinoma * HIV-associated central nervous system lymphomas The non-malignant condition hairy leukoplakia is also associated with EBV infection. *EBV is currently thought to be associated with both African and sporadic Burkitt's

Answer 177

The following groups are particularly at risk: * Patients with chronic illnesses and those on immunosuppressants * Pregnant women * Young children under 5 years old

Answer 178

Features: the majority of symptoms are typical of those seen in a flu-like illness: * Fever greater than 38oC * Myalgia * Lethargy * Headache * Rhinitis * Sore throat * Cough * Diarrhoea and vomiting * A minority of patients may go on to develop an acute respiratory distress syndrome which may require ventilatory support.

Answer 179

Treatment: there are two main treatments currently available: 1. Oseltamivir (Tamiflu) 􏱎 Oral medication 􏱎 A neuraminidase inhibitor which prevents new viral particles from being released by infected cells 􏱎 Common side-effects include nausea, vomiting, diarrhoea and headaches 2. Zanamivir (Relenza) 􏱎 Inhaled medication* 􏱎 Also a neuraminidase inhibitor 􏱎 May induce bronchospasm in asthmatics *intravenous preparations are available for patients who are acutely unwell

Answer 180

DNA virus which causes a variety of clinical presentations. It was identified in the 1980's as the cause of erythema infectiosum

Answer 181

* Most common presenting illness * Systemic symptoms: lethargy, fever, headache * 'slapped-cheek' rash spreading to proximal arms and extensor surfaces

Answer 182

f is generally a condition found in sheep and goats although it can be transmitted to humans. It is caused by the parapox virus.In animals * 'scabby' lesions around the mouth and nose In humans * Generally affects the hands and arms * Initially small, raised, red-blue papules * Later may ↑ in size to 2-3 cm and become flat-topped and hemorrhagic

Answer 183

Most common cause of cutaneous larva migrans * Common in Central and Southern America

Answer 184

* Acquired percutaneously (e.g. Walking barefoot) * Causes pruritus and larva currens - this has a similar appearance to cutaneous larva migrans but moves through the skin at a far greater rate * Abdo pain, diarrhoea, pneumonitis * May cause gram negative septicemia due to carrying of bacteria into bloodstream * Eosinophilia sometimes seen * Management: thiabendazole, albendazole. Ivermectin also used, particularly in chronic infections

Answer 185

Toxocara canis * Commonly acquired by ingesting eggs from soil contaminated by dog faeces * Commonest cause of visceral larva migrans * Other features: eye granulomas, liver/lung involvement

Answer 186

Cysticercosis * Caused by Taenia solium (from pork) and Taenia saginata (from beef) * Management: niclosamide

Answer 187

* Caused by the dog tapeworm Echinococcus granulosus * Life-cycle involves dogs ingesting hydatid cysts from sheep liver * Often seen in farmers * May cause liver cysts * Management: albendazole

Answer 188

* Turner's syndrome * Testicular feminisation * Congenital adrenal hyperplasia * Congenital malformations of the genital tract

Answer 189

Exclude pregnancy with urinary or serum bHCG * Gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) * Prolactin * Androgen levels: raised levels may be seen in PCOS * Oestradiol * Thyroid function tests

Answer 190

Pre-existing hypertension A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no edema Occurs in 3-5% of pregnancies and is more common in older women

Answer 191

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no edema Occurs in around 5-7% of pregnancies Resolves following birth (typically after 1 month). Women with PIH are at ↑ risk of future pre-eclampsia or HTN later in life

Answer 192

condition seen after 20 weeks gestation characterized by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Edema used to be third element of the classic triad but is now often not included in the definition as it is not specific

Answer 193

* Fetal: prematurity, intrauterine growth retardation * Eclampsia * Hemorrhage: placental abruption, intra-abdominal, intra-cerebral * Cardiac failure * Multi-organ failure

Answer 194

Risk factors * > 40 years old * Nulliparity (or new partner) * Multiple pregnancy * Body mass index > 30 kg/m^2 * Diabetes mellitus * Pregnancy interval of more than 10 years * Family history of pre-eclampsia * Previous history of pre-eclampsia * Pre-existing vascular disease such as hypertension or renal disease

Answer 195

* Hypertension: typically > 170/110 mmHg and proteinuria as above * Proteinuria: dipstick ++/+++ * Headache * Visual disturbance * Papilledema * RUQ/epigastric pain * Hyperreflexia * Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome Management

Answer 196

Consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold * Oral methyldopa is often used first-line with oral labetalol, nifedipine and hydralazine also being used * For severe hypertension IV labetalol and IV hydralazine are used in addition to the above * ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic. * Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 197

Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following: * Should be given once a decision to deliver has been made * In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g/hour * Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment * Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 198

Magnesium sulphate monitor reflexes + respiratory rate

Answer 199

Hemolytic anemia * Elevated Liver enzymes and * Low Platelet count