Inflammation and infection

Question 1

Guillian Barre syndrome

- Definition

Answer 1

Primary caused by an autoimmune demyelinating mechanism

Question 2

Most common Guillian Barre type

Answer 2

Autoimmune inflammatory demyelinating polyneuropathy (AIDP)

Question 3

Miller Fisher syndrome is…

Answer 3

Type of Guillain Barre syndrome that primary presents with

• Cranial nerve palsy (3, 4, 6)
• Ophthalmoplegia
• Areflexia
• Ataxia
• Distal paraesthesia

Question 4

Associations with Guillain Barre syndrome

Answer 4

URTI or GI infection

GI infection
- Campylobacter jejuni

URTI

• EBV
• CMV
• HIV

Question 5

Acute presentation of Guillain Barre syndrome (first 12 hours)

Answer 5

Symmetrical, ascending weakness and paraesthesia

Question 6

Subacute presentation of Guillian Barre syndrome (1-2 weeks)

Answer 6

Cranial nerve palsy

Sensory deficit

Question 7

Later presentations of Guillain Barre syndrome

Answer 7

Autonomic dysfunction

• Orthostasis
• Syncope
• Urinary retention

Respiratory muscle weakness

Question 8

What investigation is used to assess respiratory compromise in GBS?

Answer 8

Spirometry

- Reduced FVC is major determinant for ICU/ intubation

Question 9

Investigations for GBS

Answer 9

Bloods tests
- FBC, U+Es, lipids, LFTs, ESR

Lumbar puncture
- Normal white cells and raised proteins is indicative but if absent, does not rule out disease

Respiratory assessment

• Spirometry
• ABG

Nerve conduction

ECG
- rhythm disturbances

Question 10

Management of GBS

Answer 10

1. Respiratory support if respiratory compromise is indicated
2. IV immunoglobulins
3. Plasma exchange in severe disease

Question 11

Prognosis of GBS:

• Most patients recover within ______
• Prognosis is worse for which patients?

Answer 11

Most patients have complete recovering within a year

Worse prognosis in:

• Older patients
• Longer respiratory support required
• Advanced co-morbidities
• Axonal changes in nerve studies

Question 12

Differentials for GBS

• Brain
• Spinal cord
• Peripheral nerve
• NMJ
• Muscle

Answer 12

Brain

• Stroke
• Brainstem compression
• Encephalitis

Spinal cord

• Cord compression
• Polio
• Transverse myelitis

Peripheral nerve

• Vascuilits
• Lead poisoning
• Porphyria

NMJ

• MG
• Botulism

Muscle
- Hypokalaemia

Question 13

Complications of shingles

Answer 13

Persistent pain= postherptic neuralgia

Eyes= Herpes zoster ophthalmicus

Ears= Herpes zoster oticus (Ramsay Hunt syndrome)

Acute retinal necrosis

Question 14

The pathological agent of shingles is…

Answer 14

Varicella-zoster virus

Question 15

Presentation of shingles

Answer 15

Unilateral eruption of a vesicular rash in a dermatomal pattern.
- Most commonly the lumbar and thoracic dermatomes

Severe, pain (burning)

Question 16

Management of shingles

Answer 16

1. Oral antiviral
   - Acilovir
   - Famciclovir
   - Valaciclovir
2. Analgesia
   - Paracetamol, oxycodone

Question 17

Myasthenia gravis is associated with which tumour

Answer 17

Thymoma

Question 18

Age distribution of MG

- Men, women

Answer 18

Men = 60-70

Women = 30s

Question 19

The most common autoantibody associated with MG is…

Answer 19

Acetylcholine receptor antibodies

Question 20

Less common autoantibodies associated with MG

Answer 20

Muscle-specific receptor tyrosine kinase (MuSK)

Low density lipoprotein receptor-related protein 4 (LRP4)

Question 21

Group of muscles most commonly affected in MG are…

Answer 21

Proximal muscles

Muscles in head and neck

Question 22

Occular symptoms of OG

Answer 22

Diplopia

Ptosis

Question 23

Facial + neck features of MG

Answer 23

Facial muscle weakness

Shaky voice/ voice fatigue

Swallowing difficulty + Jaw fatigue

Slurred speech

Question 24

Examination findings in MG

Answer 24

Fatigue after blinking repeatedly

Repeated shoulder abduction (20x) will trigger weakness

Normal muscle bulk, tone, sensation and reflexes.

Question 25

Management of acute MG

Answer 25

IV IgG

Question 26

MG crises occurs when…

It is managed by giving…

Answer 26

There is respiratory failure due to respiratory muscle weakness

Management

1. IV immunoglobulins
2. Plasma exchange
3. Steroids

Question 27

Serological diagnosis for MG

Answer 27

Anti acetylcholine receptor antibodies (ACh-R)

Muscle-specific receptor kinase antibodies (MuSK)

Low density lipoprotein receptor related protein 4 (LRP4) antibodies

Question 28

Long term treatment options for MG [4]

Answer 28

Acetylcholinesterase inhibitors = increase ACh availability
- Neostigmine etc

Immunosuppression

• Prednisolone
• Aziathioprine

Thymectomy

Monoclonal antibodies (if resistant to above)

• Rituximab= decreases autoantibody production
• Eculizumab = suppresses complement activation

Question 29

What autoimmune diseases are associated with MG

Answer 29

Thyroid diseases

SLE

Addison’s disease

Juvenile RA

Question 30

Patients with MG will show resistance to which anaesthetic agent?

Answer 30

Suxamethonium

Question 31

Herpes Zoster Ophthalmicus is treated with…

Answer 31

IV aciclovir

Question 32

Postherpetic pain in shingles is treated with

Answer 32

Anticonvulsants/ amitriptyline via anagesia ladder

Question 33

Post-herpetic neuralgia is the most common in what age group?

Answer 33

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