Infective disease Flashcards
Gram Positive cocc
staPhylococci + strePtococci (including enterococci)
Gram Negative cocci
Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella
Gram positive rods (bacilli)
- Actinomyces
- Bacillus antracis (anthrax)
- Clostridium
- Diphtheria: Corynebacterium diphtheriae
- Listeria monocytogenes
Antibiotics with anti-anaerobic activity
Penicillins
* Cephalosporins (except ceftazidime)
* Erythromycin
* Metronidazole
* Tetracycline
Antibiotics with NO anti-anaerobic activity
- Gentamicin
- Ciprofloxacin
- Ceftazidime
Incubation Periods - Less than 1 week
Scarlet fever
* Influenza
* Diphtheria
* Meningococcus
Incubation Periods 1 - 2 weeks
Malaria
* Measles
* Dengue fever
* T yphoid
Incubation Periods 3 weeks
- Mumps
- Rubella
- Chickenpox
Incubation Periods Longer than 3 weeks
Infectious mononucleosis
* Cytomegalovirus
* Viral hepatitis
* HIV
Live attenuated vaccines
- BCG
- measles, mumps, rubella (MMR)
- oral polio
- oral typhoid*
- yellow fever
Whole killed organism/inactivated (injectable killed typhoid is no longer used in the UK)
rabies
* influenza
Detoxified exotoxins vaccines
- tetanus
Fragment/Extracts of the organism or virus (may also be produced using recombinant DNA technology)vaccines
diphtheria
* pertussis (‘acellular’ vaccine)
* heptitis B
* meningococcus, pneumococcus, hemophilus
cholera vaccine
contains inactivated Inaba and Ogawa strains of Vibrio cholerae together with recombinant B-subunit of the cholera toxin
hep vaccine
contains HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology
Post-Exposure Prophylaxis Hepatitis A
- Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation
ppost-Exposure Prophylaxis Hepatitis b
HBsAg positive source: if the person exposed is a known responder to HBV vaccine then a booster dose should be given. If they are in the process of being vaccinated or are a non- responder they need to have hepatitis B immune globulin (HBIG) and the vaccine
* Unknown source: for known responders the green book advises considering a booster dose of HBV vaccine. For known non-responders HBIG + vaccine should be given whilst those in the process of being vaccinated you have an accelerated course of HBV vaccine
post-Exposure Prophylaxis Hepatitis c
- Monthly PCR - if seroconversion then interferon +/- ribavirin
HIV post-Exposure Prophylaxis
- A combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) as soon as possible (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) for 4 weeks
- Serological testing at 12 weeks following completion of post-exposure prophylaxis
- ↓ risk of transmission by 80%
Varicella zoster post-Exposure Prophylaxis
VZIG for IgG negative pregnant women/immunosuppressed
Tetanus vaccine
cell-free purified toxin that is given as part of a combined vaccine (e.g. combined with diphtheria and inactivated polio vaccine)
Tetanus vaccine is currently given in the UK as part of the routine immunisation schedule at:
* 2 months
* 3 months
* 4 months
* 3-5 years
* 13-18 years
Intramuscular human tetanus immunoglobuli
should be given to patients with high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue) irrespective of whether 5 doses of tetanus vaccine have previously been given
If vaccination history is incomplete or unknown then a dose of tetanus vaccine should be given combined with intramuscular human tetanus immunoglobulin for high-risk wounds
Tetanus is caused by
tetanospasmin exotoxin released from Clostridium tetani. Tetanus spores are present in soil and may be introduced into the body from a wound, which is often unnoticed. Tetanospasmin prevents release of GABA
Tetanus features
- Prodrome fever, lethargy, headache
- Trismus (lockjaw)
- Risus sardonicus
- Opisthotonus (arched back, hyperextended neck)
- Spasms (e.g. Dysphagia)
Management Tetanus
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
HIV seroconversio
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
Man returns from trip abroad with maculopapular rash and flu-like illness
- think HIV seroconversion
HIV features
Features
* Sore throat
* Lymphadenopathy
* Malaise, myalgia, arthralgia
* Diarrhoea
* Maculopapular rash
* Mouth ulcers
* Rarely meningoencephalitis
HIV diagnosis
Diagnosis
* Antibodies to HIV may not be present
* HIV PCR and p24 antigen tests can confirm
diagnosis
HIV immunology: The following immunological changes are seen in progressive HIV:
Reduction in CD4 count
* Increase B2-Microglobulin (IBM)
* Decrease IL-2 production (DIL=DELL)
* Polyclonal B-cell activation
* ↓ NK cell function
* ↓ delayed hypersensitivity responses
Vaccines that can be used if CD4 > 200
Measles, Mumps, Rubella (MMR) ● V aricella●
Yellow Fever●
Contraindicated in HIV- infected adults
Cholera* CVD103-HgR● Influenza-intranasal● Poliomyelitis-oral (OPV) ● Tuberculosis (BCG) ●
Vaccines that can be used in all HIV-infected adults
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)
Diarrhea is common in patients with HIV. This may be due to the effects of the virus itself (HIV enteritis) or opportunistic infections causes
ossible causes
* Cryptosporidium + other protozoa (most
common)
* Cytomegalovirus
* Mycobacterium avium intracellulare * Giardia
common infective cause of diarrhoea in HIV patients.
Cryptosporidium
Cryptosporidium organism
ntracellular protozoon and has an incubation period of 7 days.
Cryptosporidium diagnosis
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)
Mycobacterium avium intracellulare HIV
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
Pregnancy: HIV Factors which ↓ vertical transmission (from 25-30% to 2%)
- Maternal antiretroviral therapy
- Mode of delivery (caesarean section)
- Neonatal antiretroviral therapy
- Infant feeding (bottle feeding)
Antiretroviral therapy HIV pregnancy
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
Mode of delivery HIV delivery
- Elective caesarean section*
- A zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy HIV pregnancy
Neonatal antiretroviral therapy
* Zidovudine is usually administered orally to the neonate for four to six weeks
baby feeding HIV
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
Kaposi’s sarcoma
- 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
Pneumocystis carinii pneumonia
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
PCP features
Features
* Dyspnea
* Dry cough
* Fever
* Very few chest signs
Extrapulmonary manifestations are rare (1-2% of cases), may cause
* Hepatosplenomegaly
* Lymphadenopathy
Immune Reconstitution Uveitis
: occurs in AIDS in response to immune system recovery, there is granulamtous uveitis that leads to reduced vision and eye discoloration
PCP - Investigation
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)
PCP Management
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)
The most common cause of biliary disease in patients with HIV
sclerosing cholangitis due to
infections such as CMV, Cryptosporidium and Microsporidia
Pancreatitis in the context of HIV infection
may be secondary to anti-retroviral treatment
(especially didanosine) or by opportunistic infections e.g. CMV
Meningitis Meningococcus
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
MeningitisManagement of contacts
- 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*
Meningococcal septicemia:
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
α hemolytic streptococci
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
β hemolytic streptococci - group a
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
β hemolytic streptococci - group b
Streptococcus agalactiae may lead to neonatal meningitis and septicemia
Cellulitis: the BNF recommends
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.
Staphylococcal toxic shock syndrome
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
Complications chicken pox
- 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
Kaposi’s sarcoma
- 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
Immune Reconstitution Uveitis:
occurs in AIDS in response to immune system recovery, there is granulamtous uveitis that leads to reduced vision and eye discoloration
PCP management
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)
most common cause of biliary disease in patients with HIV
sclerosing cholangitis due to
infections such as CMV, Cryptosporidium and Microsporidia
Pancreatitis in the context of HIV infection
secondary to anti-retroviral treatment
(especially didanosine) or by opportunistic infections e.g. CMV
Listeria monocytogenes
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
Management Listeria monocytogenes
Listeria is sensitive to amoxicillin/ampicillin (cephalosporins usually inadequate)
* Listeria meningitis should be treated with IV amoxicillin/ampicillin and gentamicin
Anthrax is caused by
Anthrax is caused by Bacillus anthracis, a Gram positive rod. It is spread by infected carcasses
Anthrax features
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
Anthrax management
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
Who should be screened for MRSA?
- 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
The following antibiotics are commonly used in the treatment of MRSA infections:
- Vancomycin
- Teicoplanin
MRSA resistance
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
Legionnaire’s disease
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
Legionnaire’s disease features
- Flu-like symptoms * Dry cough
- Lymphopenia
- Hyponatremia
- Deranged LFTs
Legionnaire’s
Urinary antigen
* Treat with erythromycin
Leptospirosis (Weil’s disease)
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
Leptospirosis (Weil’s disease) features
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
Acute epiglottitis
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
Lyme Disease cause
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.
Lyme Disease features
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
TB & Anti-TB theMantoux test
- 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
TB Heaf test
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
Head test - false negative
- Miliary TB
- Sarcoidosis
- HIV
- Lymphoma
- Very young age (e.g. < 6 months)
The standard therapy for treating active tuberculosis is:
- 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
Latent tuberculosis: treatment
isoniazid alone for 6 months
SE Rifampicin
- Potent liver enzyme inducer
- Hepatitis
Orange secretions * Flu-like symptoms
used in resistant TB
Streptomycin
Directly observed therapy 3 per week dosing regimen may be indicated in certain groups, including:
- Homeless people with active tuberculosis
- Patients who are likely to have poor concordance
- All prisoners with active or latent tuberculosis
Pyrazinamide SE
- Hyperuricemia causing gout
Isoniazid SE
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
Streptomycin SE
vestibular damage → Vertigo and Vomiting * Angioedema or angioneuritic edema * Cochlear damage → deafness * Nephrotoxicosis
Leprosy
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.
Leptosy management
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
Feature of severe malaria
- Schizonts on a blood film
- Parasitemia > 2%
- Hypoglycemia
- Temperature > 39 °c
- Severe anemia
- Complications as below
Complications of malaria
- Cerebral malaria: seizures, coma
- ARF: blackwater fever, secondary to intravascular
hemolysis, mechanism unknown - Acute respiratory distress syndrome (ARDS)
- Hypoglycemia
- Disseminated intravascular coagulation (DIC)
Uncomplicated falciparum malaria
- 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
Severe falciparum malaria
- 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
Non-falciparum malaria
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
Non-falciparum malaria treatment
Treatment
* Non-falciparum malarias are almost always chloroquine sensitive
* Primaquine should be used in Plasmodium vivax and Plasmodium ovale infection to destroy
liver hypnozoites
Leishmaniasis
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:
Cutaneous leishmaniasis
- Caused by Leishmania tropica or Leishmania mexicana * Crusted lesion at site of bite
- May be underlying ulcer
Mucocutaneous leishmaniasis
- Caused by Leishmania brasiliensis
- Skin lesions may spread to involve mucosae of nose, pharynx…
Visceral leishmaniasis (kala-azar)
- 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
Trypanosomiasis:
Two main form of this protozoal disease are recognised - African
trypanosomiasis (sleeping sickness) and American trypanosomiasis (Chagas’ disease)
Trypanosoma rhodesiense
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
Trypanosoma rhodesiense treatment
Management
* Early disease: IV pentamidine or suramin
* Later disease or central nervous system involvement: IV melarsoprol
Chagas’ cause
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
Chagas’ treatment
- 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
Schistosomiasis,
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
Schistosoma hematobium causes
hematuria
Schistosoma Hematobium is a risk factor for
Schistosomiasis is a risk factor for Squamous cell bladder cance
Schistosoma management
Management
Single oral dose of praziquantel
Rabies:
Prodrome: headache, fever, agitation
* Hydrophobia: water-provoking muscle spasms
* Hypersalivation
Following an animal bite in at risk countries:
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
Animal Bites: Management
- Cleanse wound
- Current BNF recommendation is co-amoxiclav
- If penicillin-allergic then doxycycline + metronidazole is recommended
Chickenpox is highly infectious
- 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
Cat scratch disease
s generally caused by the Gram negative rod Bartonella henselae Features
* fever
* history of a cat scratch
* regional lymphadenopathy
* headache, malaise
chicken pox features
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
management
- 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
chicken pox rare complications
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
Chickenpox exposure in pregnancy
first step is to check antibodies
Fetal varicella syndrome (FVS)
- 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
Management of chickenpox exposure
- 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
Measles
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
chicken pox -Management of contacts
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
Gonorrhoea
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
Gonorrhoea features
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
Gonorrhoea Management
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
Gonorrhoea Management
- 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
Disseminated gonococcal infection (DGI)
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)
Key features of disseminated gonococcal infection
- Tenosynovitis
- Migratory polyarthritis
- Dermatitis (lesions can be maculopapular or vesicular)
Genital warts causes by
(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.
genital warts features
Features
* Small (2 - 5 mm) fleshy protuberances which are slightly pigmented
* May bleed or itch
genital warts management
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
Genital Ulcers:
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
Genital ulcers painful vs painless
Genital ulcers
* Painful: herpes»_space; chancroid
* Painless: syphilis > lymphogranuloma venereum + granuloma inguinale
Syphilis
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
Tertiary features Syphilis
- 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).
Cardiolipin tests Syphilis
- 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
Treponemal specific antibody tests Syphilis
- Example: TPHA (Treponema pallidum hemagglutination test)
- Remains positive after treatment
Causes of false positive cardiolipin tests
- Pregnancy
- SLE, anti-phospholipid syndrome
- TB
- Leprosy
- Malaria
- HIV
Lymphogranuloma venereum
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
Herpes Simplex Virus:
(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
Herpes Simplex Virus features
- Primary infection: may present with a severe gingivostomatitis
- Cold sores
- Painful genital ulceration
Herpes Simplex Virus management
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
Other causes of genital ulcers
- Behcet’s disease
- Carcinoma
- Granuloma inguinale: Klebsiella granulomatis (previously called Calymmatobacterium granulomatis)
Chancroid
tropical disease caused by Hemophilus ducreyi. It causes painful genital ulcers associated with inguinal lymph node enlargement.
Chancre
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
Candida
‘Cottage cheese’ discharge Vulvitis
Itch
Trichomonas vaginalis
Trichomonas vaginalis
Offensive, yellow/green, frothy discharge Vulvovaginitis
Strawberry cervix
Bacterial vaginosis
Offensive, thin, white/grey, ‘fishy’ discharge
Bacterial vaginosis (BV
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.
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
- Thin, white homogenous discharge
- Clue cells on microscopy
- Vaginal pH > 4.5
- Positive whiff test (addition of potassium hydroxide results
in fishy odour)
Bacterial vaginosis in pregnancy
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
BV Management
Oral metronidazole for 5-7 days
* 70-80% initial cure rate
* Relapse rate > 50% within 3 month
Chlamydia
Features
* Asymptomatic in around 70% of women and 50% of ♂s
* Women: cervicitis (discharge, bleeding), dysuria
* Men: urethral discharge, dysuria
Chlamydia complications
Potential complications
* Epididymitis
* Pelvic inflammatory disease
* Endometritis
* ↑ incidence of ectopic pregnancies
* Infertility
* Reactive arthritis
* Perihepatitis (Fitz-Hugh-Curtis syndrome)
Chlamydia investigation
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
the swab showed non-specific urethritis
diagnosis of Chlamydia is most likely. Both many times
infect together
clamydia Management
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’
Chlamydia psittaci (psittacosis)
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.
Lower urinary tract infections in women (cystitis)
Local antibiotic guidelines should be followed if available
* Clinical knowledge summaries (CKS) recommend trimethoprim or nitrofurantoin for 3 days
Lower urinary tract infections in pregnancy
- 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*
For patients with sign of acute pyelonephritis hospital admission should be considered
- Local antibiotic guidelines should be followed if available
- The BNF currently recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days
- Clinical knowledge summaries recommend ciprofloxacin for 7 days or co-amoxiclav for 14
days
Rubella Congenital infection
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
Congenital infection Toxoplasmosis
Cerebral calcification Chorioretinitis Hydrocephalus
other
Anemia
Hepatosplenomegaly Cerebral p
Congenital infection CMV
Growth retardation
Purpuric skin lesions
Sensorineural deafness
Encephalitiis Pneumonitis Hepatosplenomegaly Anemia
Jaundice
Cerebral palsy
Toxoplasma Gondii
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.
Toxoplasma Gondii treatment
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.
Bacillus cereus
infection most commonly results from reheated rice
. Acute food poisoning is typically caused by
Staphylococcus aureus, Bacillus cereus or Clostridium perfringens.
Escherichia coli
Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis
Prolonged, non-bloody diarrhea
Cholera
Profuse, watery diarrhea
Severe dehydration resulting in weight loss Not common amongst travellers
Shigella
Bloody diarrhea
Vomiting and abdominal pain
Staphylococcus aureus
Severe vomiting
Short incubation period
Campylobacter
A flu-like prodrome
Followed by crampy abdominal pains
Fever and diarrhoea which may be bloody Complications include Guillain-Barre syndrome
Bacillus cereus
Two types of illness are seen
Vomiting within 6 hours, stereotypically due to rice Diarrhoeal illness occurring after 6 hours (6-14hrs)
Cholera: is caused by Vibro cholerae - Gram negative bacteria
Features
Profuse ‘rice water’ diarrhoea * Dehydration
* Hypoglycemia
Cholera features
Profuse ‘rice water’ diarrhoea * Dehydration
* Hypoglycemia
Cholera management
- Oral rehydration therapy
- Antibiotics: doxycycline, ciprofloxacin
Giardiasis
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
Giardiasis treatment
Treatment is with metronidazole
Escherichia coli:
a facultative anaerobic, lactose-fermenting, Gram negative rod which is a normal gut commensal.
E coli infections lead to a variety of diseases in humans including:
- Diarrhoeal illnesses
- UTIs
- Neonatal meningitis
E coli O157:H7
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
Salmonella g
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.
Typhoid Features
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
Typhoid
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.
Typhoid ossible complications include
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)
Shigella:
- 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
African Tick Typhus: caused by Rickettsiae
Diagnosis:
* Black sopits on thigh
* Hx of tick bites
* Low grade fever
* Faint macular rash
Rocky Mountain Spotted Fever: is the most lethal and most frequently reported rickettsial infection, spreads by ticks, common in USA.
Presentation:
* Fever
* Rash on hands, feet which later → desequamte (peel)
* Tachycardia with no hypotension (unlike Staphylococcal Toxic Shock Syndrome)
Management: Doxycycline
Mediterranean Spotted Fever:
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.
Dengue fever
ype of viral hemorrhagic fever (also yellow fever, Lassa fever, Ebola) Low platelet count and raised transaminase level is typical of dengue fever
Dengue fever features
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
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Features
* Causes headache (often retro-orbital)
* Myalgia
* Pleuritic pain
* Facial flushing (dengue)
* Maculopapular rash
* Pyrexia
Infectious mononucleosis (glandular fever)
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
Infectious mononucleosis (glandular fever) management
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
Hepatitis E
- 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
Malignancies associated with EBV infection:
- 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
H1N1 influenza (Swine Flu): risk groups
The following groups are particularly at risk:
* Patients with chronic illnesses and those on immunosuppressants
* Pregnant women
* Young children under 5 years old
H1N1 influenza (Swine Flu): features
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.
Swine flu treatment
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
Parvovirus B19 is a
DNA virus which causes a variety of clinical presentations. It was identified in the 1980’s as the cause of erythema infectiosum
Erythema infectiosum (also known as fifth disease or ‘slapped-cheek syndrome’) features
- Most common presenting illness
- Systemic symptoms: lethargy, fever, headache
- ‘slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Orf
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
Ancylostoma braziliense
Most common cause of cutaneous larva migrans
* Common in Central and Southern America
Strongyloides stercoralis
- 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
Toxocara canis
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
Cysticercosis
Cysticercosis
* Caused by Taenia solium (from pork) and Taenia saginata (from beef)
* Management: niclosamide
Hydatid disease
- 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
causes ovulation
LH surge
Causes of primary amenorrhoea
- Turner’s syndrome
- Testicular feminisation
- Congenital adrenal hyperplasia
- Congenital malformations of the genital tract
Initial investigations primary amenorrhoea
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
Hypertension in pregnancy - preexisting
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
Pregnancy-induced hypertension
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
Pre-eclampsia is a
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
Pre-eclampsia is important as it predisposes to the following problems (complications)
- Fetal: prematurity, intrauterine growth retardation
- Eclampsia
- Hemorrhage: placental abruption, intra-abdominal, intra-cerebral
- Cardiac failure
- Multi-organ failure
Pre-eclampsia - risk factors
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
Features of severe pre-eclampsia
- 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
pre-eclampsia Management
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
Eclampsia may be defined as the development of seizures in association pre-eclampsia.
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)
Magnesium sulphate monitor
Magnesium sulphate monitor reflexes + respiratory rate
HELLP is an abbreviation of the main findings:
Hemolytic anemia
* Elevated Liver enzymes and
* Low Platelet count
