Pseudomonas aeruginosa, Burkholderia cepacia (v. high mortality) Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia\ Aspergillus

Microbiology Flashcards by Aleksandra Kotwica

The antiviral which is given to untreated pregnant women with HIV to prevent vertical transmission of the virus during childbirth.

Nevirapine/Zidovudine

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An immunomodulatory therapy used in the treatment of hepatitis B.

Preffered Treatment of Hep B

Immunonodulator: interferon alpha Nucleos(t)ide analogues

Inhibitors of viral polymerase – Entecavir (no resistance),Lamivudine, Adefovir dipivoxil, Telbivudine

Inhibitor of reverse transcriptase – Tenofovir

Preferred 1st line treatment choice: o Entecavir, PegINF alpha 2a, and tenofovir

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An antiviral currently used to prevent and treat Influenza in the elderly and which has the potential to be used to prevent Avian influenza.

Neuraminidase inhibitors: Oseltamivir (Tamiflu)

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The final metabolite of the antiviral used to treat Herpes Simplex

Aciclovir triphosphate Aciclovir diphosphate and triphosphate are the product of cellular tyrosine kinase

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An antiviral which can be used in aerosol form to prevent respiratory syncytial virus (broncholitis) in children with heart and lung disease

Ribivarin

Ribavirin is a prodrug, which when metabolized resembles purine RNA nucleotides.

It is a guanosine (ribonucleic) analog used to stop viral RNA synthesis and viral mRNA capping, thus, it is a nucleoside inhibitor.

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Drug used to treat CMV infections.

CMV (and EBV, HHV-6). Nucleoside analogue.

Treat CMV – Congenital, immunocompromised, pregnancy, HIV Remember what CMV does? – RCHEAP (Retinitis/colitis/hepatitis/encephalitis/pneumonits.

Sight-threatening CMV retinitis in severely immunocompromised people

CMV pneumonitis in bone marrow transplant recipients

Prevention of CMV disease in bone marrow and solid organ transplant recipients

Confirmed CMV retinitis in people with AIDS (intravitreal implant)

Ganciclovir -guanosine analgue

SE: BM suppression

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If CMV resistant to ganciclovir (or severe side effects), then use:

Pyrophosphate analogue, inhibits nucleic acid synthesis without requiring activation. Also used as propylaxis post organ transplant.

Foscarnet

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blocks viral DNA extension through activation by viral thymidine kinase (TK) present in HSV

aciclyovir

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An antiviral which can be used in aerosol form to prevent respiratory syncytial virus in children with heart and lung disease

Ribivarin

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Direct antiviral effect + upregulates expression of MHC on cell surfaces

Interferon alpha - Hep B

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Nucleoside phosphonate, it is mainly used for Rx in CMV retinitis.

Often used in treatment of non-herpes viral infections in the opportunistic post-transplant setting: Eg: BK virus for BK nephropathy/BK cystitis/Adenovirus/PML (JC virus)

Cidofovir

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Which option is the product of the action of viral tyrosine kinase on aciclovir?

Aciclovir monophosphate

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Which option inhibits the action of viral DNA polymerase?

Aciclovir triphosphate

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The synthetic nucleoside analogue ganciclovir is the drug of choice against which infective virus?

Cytomegalovirus

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Ribavirin, a synthetic nucleoside that acts as an RNA polymerase inhibitor, is similar in structure to which of the options given above

Guanosine analogue

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Valaciclovir, a prodrug of aciclovir, is used to treat patients with which viral disease in the list, above?

Varicella-zoster virus

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HSV – genital, oral, encephalitis, disseminated If you get herpes you need to.

Act Acyclovir

Very Valaciclovir

Fast! Famciclovir

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Used for the treatment of severe, resistant herpes infections or CMV secondary treatment

Foscarnet

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The treatment of choice for CMV-induced hepatitis

gancyclovir

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A drug that is effective against influenza A but not influenza B

Amantadine

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A purine nucleoside analogue that selects specifically for thymidine kinase

Aciclovir

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A nucleoside analogue which is NRTI inhibitor

Part of HAART

(NRTI, PI, NNRI)

What is it used for?

zidovudine:

Neonatal antiretroviral therapy

zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.

general NRTI side-effects: peripheral neuropathy

zidovudine: anaemia, myopathy, black nail

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The drug mechanisms which acts by stopping post-translational cleaving of polyproteins by inhibiting proteases= protease inhibitor, used in HIV

What are its side effects?

Indinavir

indinavir: renal stones, asymptomatic hyperbilirubinaemia

side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition

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The drug which can be delivered by inhalation to treat both influenza A and B.

Zanamivir ZA i ZB

Zanamivir (Relenza)

inhaled medication*

also a neuraminidase inhibitor

may induce bronchospasm in asthmatics

The following groups are particularly at risk of influenza:

patients with chronic illnesses and those on immunosuppressants

pregnant women

young children under 5 years old

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The drug which works by attenuating or preventing **rabies** or **hepatitis**, following a known exposure but before the onset of signs and symptoms.

**Human Specific Immunoglobulin**

Targets M2 ion channel. BUT single **AA mutation (S**31N) in M2 = resistance

**A**mantadine (Influenza A only) –

A 37yr old American business man staying in a hotel presents with a headache, myalgia and a dry cough. He is also suffering with nausea, diarrhoea and abdominal pain. On examination he is tachypnoeic and has a pyrexia of 39ºC. Blood tests reveal **lymphopenia** and **hyponatraemia**.

L. pneumophila

A 19yr old medical student who lives in residential halls presents with a one week history of **headache, malaise, shortness of breath** and **a cough.** Her WBC is not raised but tests reveal the presence **of cold agglutinins.** ## Footnote **Dry cough, new infiltrates on CXR, dyspnoea and target shaped lesions on the palms. No recent history of herpes.**

M. pneumoniae systemic symptoms, joint pain, **cold agglutinin test**, erythema multiforme. Risk SJS, AIHA

A 30yr old lady presents with a three week **history of tiredness, malaise, cough and weight loss**. She feels her condition has worsened in the past week and she now also suffers from **a fever** and **haemoptysis**. In addition she complains of a “**tender lump”** in her supraclavicular region. Chest x-ray demonstrates nodular shadowing of the right upper zone.

M. tuberculosis

A forty year old ornithologist presents with malaise, muscular pains and a cough. On examination he has a fever and several distinctive rose spots on his abdomen. Chest x-ray reveals **a diffuse pneumonia.**

**C.pistacii**

**Cystic Fibrosis**

Pseudomonas aeruginosa, Burkholderia cepacia (v. high mortality) ## Footnote Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia\* Aspergillus

HIV associated infections

P. Jiroveci (PCP), TB, Cryptococcus neoformans

An 80 year old clown appears at the GP having been discharged from hospital for a complicated bowel resection with a stint in the **ITU.** He has a cough and fever and is prescribed a **macrolide antibiotic** because he is penicillin allergic. What is macrolide mechanism of action:

**MSSA** **Macrolides (see Table: Macrolides**) are antibiotics that are primarily bacteriostatic; by binding to the **50S subunit** of **the ribosome,** they inhibit bacterial protein synthesis

A 55 year old **female clown**, recovering from a cold, is found t**o have a CAVITITING** lesion on **CXR** and a **productive cough.**

MSSA or MRSA

An **18 year old trainee** clown is being seen in **the cystic fibrosis** clinic and is found to be colonised with a particularly persistent organism.

Burkholderia cepacia

Assoc. w/ smoking The most common bacterial organisms that cause infective exacerbations of COPD are

Haemophilus influenzae (most common cause) Streptococcus pneumoniae M. Catarrhalis

The previous day he had a **fever, headache and malaise** but has now subsided. 5 year old boy comes to the GP and shows you small **pustules over his fac**e, scalp and t**runk, which have progressed from small macules in a matter of hours.**

***_chicken pox_*** Virology showed the presence of ***_Varicella Zoster Virus._***

A 21 year old man came to hospital complaining of **severe headache, fever, malaise** and **a Sore Throat.** On examination he showed **cervical Lymphadenopathy,** especially the posterior cervical nodes, **and Splenomegaly.** Peripheral blood tests showed the presence of lymphocytosis with atypical mononuclear cells. haemolytic anaemia secondary to cold agglutins (IgM)

Glandulaer Fever HSV4Diagnosis ## Footnote heterophil antibody test **(Monospot test) -** NICE guidelines suggest FBC and **Monospot in the second week of the illnes**s to confirm a diagnosis of glandular fever. 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 o**f splenic rupture**

On your elective in central Africa a 7 year old child comes to your clinic with a large mass on his jaw. You take a biopsy of the lump, which shows **EBV positive large cell lymphoma B cells.** Histology shows **a starry sky appearance (isolated histiocytes on a background of abnormal lymphoblasts).** Genetic testing shows the presence of a 14q/8q translocation. The consultant suggests treating with **cyclophosphamide** and a single dose leads to a spectacular remission.

. ## Footnote **Burkitt's lymphoma**

Shingles

varicela zoster chiken pox in children

3/7 fever, then transient rash. Abx often prescribed for fever then rash is often blamed on pencillin and child branded penicillin allergic. **Most common cause of febrile convulsions.** Latent in monocytes/lymphocytes. **Can cause pneumonitis, hepatitis, encephalitis in BMT** ## Footnote **Diagnosis** **Treatment**

**Causes roseola infantum (**=exanthum subitum, Sixth disease). Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the **human herpes virus 6 (HHV6)**. It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years. **Features** 1. high fever: lasting a few days, followed by a 2. maculopapular rash 3. febrile convulsions occur in around 10-15% 4. diarrhoea and cough are also commonly seen Diagnosis – Blood PCR Rx – Ganciclovir, foscarnet or cidofovir **Other possible consequences of HHV6 infection** aseptic meningitis hepatitis

**Herpetic keratitis —** unilateral/bilateral conjunctivitis + pre-auricular LNs Acute retinal necrosis if immunocompotent, if immunosuppressed: **Progressive Outer Retinal Necrosis (PORN)** (also caused by VZV, EBV, CMV) **Keratitis**: Keratitis describes *inflammation* of the *cornea.* There are a variety of causes: Features red eye: pain and erythema photophobia foreign body, gritty sensation hypopyon may be seen

HSV1 and HSV2

**Herpes Simplex Type 1 complication**

Primary stomatitis

Cytomegalovirus Complication

Pneumotitis

Herpes Simplex Type 2 Complication

Neonatal Infection Associated with Vaginal Delivery

Infection associated with **Kaposi’s sarcoma**

**Human Herpes Virus 8** **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 haemoptysis* and *pleural effusion* radiotherapy + resection

**Human Herpes virus 6**

Exanthem Subitum Roseola Infantum The 6th disease Prodorome of fever **Tratment:** gancyclovir It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years. Features high fever: lasting a few days, followed by a maculopapular rash f**ebrile convulsions** occur in around **10-15%** diarrhoea and cough are also commonly seen **Other possible consequences of HHV6 infection:** aseptic meningitis hepatitis

Fever + submandibular lymphadenopathy. + vesicles Symptoms include **sudden fever with sore throat,** headache, loss of appetite, and often neck pain. Within two days of onset an average of four or five (but sometimes up to twenty) 1 to 2 mm diameter ***grayish lumps form and develop into vesicles with*** red surrounds, and over 24 hours these become shallow ulcers, rarely larger than 5 mm diameter, that heal in one to seven days Most commonly affects infants and young children Typically occurs during the summer

Herpangina (Coxsackie A)

Although it has been known to occur in eighteen-year-olds, whose manifestations are usually limited to **a transient rash ("exanthem")** that occurs following a fever of about **three days' duration.**

**Human herpesvirus 6 (**HHV-6) and **human herpesvirus 7** (HHV-7), ## Footnote **Roseola** is a disease of children, generally *under two years old.*

**Pneumonitis** after a bone marrow transplant

**CMV**

Acute necrotising encephalitis

HSV1

Blistering rash in dermatomal distribution

shingels

Alpha herpes viruses: neurotropic Beta herpes viruses: epitheliotropic Gamma herpes viruses: Lymphotropic what does it mean

). Alpha herpes viruses: neurotropic Beta herpes viruses: epitheliotropic Gamma herpes viruses: Lymphotropic

Candida infection

A 37-year-old woman with a past history of intravenous drug use presents to her GP for her methadone prescription. On examination they **note pale rigid lesions on the** side **of her tongue.** Alongside her methadone the GP prescribes aciclovir. ## Footnote **which virus causes it?**

**hairy leukoplakia** **EBV** causes post-transplant lymphoproliferative disease where control of proliferation of latently infected B cells is lost. In HIV patients; oral hairy leukoplakia and lymphomas. Tx: Reduce immunosuppression + Rituximab (anti-CD20 mAb

In addition to ***CD4+ T-lymphocyte*** counts, HIV monitoring is typically assessed through which measurement?

**Viral load** HIV seroconversion is symptomatic in 60-80% of patients and typically presents as a glandular fever type illness. Increased symptomatic severity is associated with poorer long term prognosis. It typically occurs **3-12** weeks after infection **Features:** sore throat lymphadenopathy malaise, myalgia, arthralgia diarrhoea maculopapular rash mouth ulcers rarely meningoencephalitis **Diagnosis:** * antibodies to HIV may not be present * *HIV PCR* and *p24 antigen* tests can confirm diagnosis **HIV antibody test** * most common and accurate test * usually consists of both a screening ELISA (Enzyme Linked Immuno-Sorbent Assay) test and a confirmatory Western Blot Assay * most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months **p24 antigen test** * usually positive from about 1 week to 3 - 4 weeks after infection with HIV * sometimes used as an additional screening test in blood banks

Which of the above is a naturally occurring cytokine that is able to inhibit **HIV fusion** to **CD4+ T-lymphocytes?**

***MIP-1alpha***

Which viral protein is responsible for the binding or fusion of HIV to human CD4+ T-lymphocytes?

**gp120** **CD4 molecule is receptor for HIV.** **The virus binds via gp120 (initial binding)** **and gp41 (conformational change) – *on CD4+ T cells*** Most strains use **CCR5** and **CXCR4** chemokine co-receptors (on macrophages)

Vaccine given at 12 – 18 months to prevent **otitis media, parotitis, and cataracts** in patients.

MMR

An **immunocompromised HIV** positive patient should not receive this vaccine.

BCG

**Haemophiliacs** and patients in receipt of **regular blood transfusions** should be vaccinated against this virus.

**Hep B**

Toxoid given as part of ‘triple’ vaccine during first year of life to prevent cardinal features of the disease: **muscle spasms and rigidity.**

**Tetanus**

**Vaccine recommended** for high risk patients with **chronic respiratory diseases**, but contraindicated i**n patients hypersensitive to eggs.**

**Influenza**

**MRSA, C.Diff**

**Glycopeptides -** Vancomycin, Teicoplanin

**35 year old household wife** presents with **an infected insect bite**. In the past she has been treated with **_Penicillin_** and responded with **_facial swelling_** and acute shortness of breath.

Erthyromycin

Patient with an abdominal collection that contains **gram –ve anaerobes, what david is saying ....**

Metronidazole

56 year old male with **endocarditis** caused by **VRE.** Gram +ve, MRSA **+ VRE** **Vancomycin**-resistant enterococci **(VRE)**

**Linezolid** Oxazolidinones

**Gram negative sepsis**

Inhibit protein synthesis Aminoglycosides Gentamicin

C.difficile colitis where **metronidazole** has failed

Vancomycin

**Severe systemic infection** before cause has been identified

**CeFURoxime**

**Atypical pneumonia** caused by Legionella in individuals **with penicillin allergy**

Erythromycin

Long-term prophylactic treatment for post-splenectomy patients

**Penicillin V**

A 75 yr old lady develops severe wound infection following hip replacement. MRSA is isolated from the wound.

vancomycin The following antibiotics are commonly used in the treatment of MRSA infections: vancomycin + teicoplanin linezolid

An 82 yr old gentleman, living at home, develops severe dyspnoea with a productive cough and fever. His PaO2 has fallen below 8kPa, and he is becoming confused.

B. cefuroxime & clarithromycin

A 6 month old child whose father has just been diagnosed with tuberculosis.

isoniazid

A 12 yr old boy requests treatment for widespread impetigo. He developed an urticarial rash 3 yrs ago when he was given penicillin V.

Erythromycin

Eye drops Bacterial conjuctivitis

Chloramphenicol

Gram-negative curved rod, whose toxin affects adenyl cyclase. Its major cause of death is shock, metabolic acidosis and renal failure.

D. Vibrio cholera

This microbes affects mainly the distal colon, producing acute mucosal inflammation and erosion. It is spread by person-to-person contact, and its clinical features include fever, pain, diarrhoea and dysentery.

Shigella

This microbe affects the ileum, appendix and colon. Its peyer patch invasion leads to mesenteric lymph node enlargement with necrotising granulomas. Complication can include peritonitis, pharyngitis and pericarditis.

Yersinia

undergoes multiplication in Peyer's patches following invasion of human epithelial cells and penetration of the mucosa which occurs in the ileum. Complications include diarrhoea, mesenteric adenitis, mesenteric ileitis, or acute pseudoappendicitis, reactive arthritis and erythema nodosum

Yersinia enterocolitica

Ingestion of ............ cysts is followed by excystation in the small bowel and trophozite colonisation of the small colon. ## Footnote The trophozyte may then encyst and be excreted in faeces or it may invade the intestinal mucosal barrier, thereby gaining access to the circulation. Complications include amoebic colitis, liver abscesses, pleuropulmonary amoebiasis and cerebral amoebiasis.

Entamoeba histiolytica

A 40 year old female, who is a ex-smoker, who has recently returned from a holiday in India, comes to A+E complaining of severe abdominal cramps and bloody diarrhoea. **She mentions that her mother suffered from similar symptoms in the past.**

Ulcerative Collitis

A 34 year old female returned from Indonesia two weeks ago. She complains of diarrhoea, abdominal pain, weight loss, nausea and vomiting for the past few days. She has no fever. Investigation reveals **steatorrhoea** and stools appear to contain numerous cysts. * *Giardiasis is** caused by the flagellate protozoan **Giardia lamblia.** * *Features** **often asymptomatic:** lethargy, bloating, abdominal pain non-bloody diarrhoea chronic 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** ## Footnote **Giardasis**

Drinking unpastuerised milk, food eg: poultry Prodrome of headache and fever, abdo cramps, **bloody (foulsmelling)** diarrhoea **Curved, S-shaped,** Microaerophilic, Oxidase +ve, motile, sensitive to nalidixic acid (first quinolone). Assoc with Guillain-Barre, reactive arthritis (Reiter’s) TreatmenT:

C.Jejuni Erythromycin or Cirp

Following a trip to Brazil **MSM**, a patient develops **bloody diarrhoea**, with a high fever, sweating and on examination the patient is found to **have RUQ pain** **_(RUQ pain due to liver abscess)_** **_Chronic weight loss +_**

Entamoeba Histolytica

Following a barbeque, a 41 year old develops **watery diarrhoea and vomiting.** On retrospect, he wondered whether he should have had that dodgy looking shish kebab... Multiplies in Peyers patches, 3% carriers (in gallbladder) Slow onset fever + **CONSTIPATION,** relative bradycardia **Splenomegaly** and **rose spots,** anaemia and leukopaenia

**Salmonella**

A 40 yea**r old homosexual man** develops **severe flatulence, accompanied by bloating** and **explosive diarrhoea.**

**Giardia Lamblia**

Mrs A became ill at about midnight after eating chicken wings for lunch at a summer BBQ. Mrs A complained of nausea, vomiting and non-bloody diarrhoea. Her symptoms resolved 3 days later.

Salmonella

Mr S became ill with nausea, vomiting and watery diarrhoea about 4 hours after eating some ham at a conference buffet lunch. Mr B’s illness was attributed to a heat stable, preformed toxin in the ham. His symptoms resolved within 24hours.

S.aureus

Mr C complained of **fever** and **severe** (\>10 bowel movements/day) **diarrhoea** after looking after his neighbours dogs for a few days. Laboratory analysis of Mr C’s stools found the causative organism to be ***a S-shaped microaerophillic bacteria.***

**Campylobacter**

Miss D initially complained of a dry mouth and visual disturbance a few days after ingesting some home canned produce. She sought medical attention after she began to experience bilateral descending paralysis. Miss A later died from respiratory failure.

**Clostridium botulinum**

Different geographical populations of this organism often give rise to traveller’s diarrhoea

E. coli

A toxin-mediated organism that does not damage or invade the gastrointestinal epithelium

Cholera

An organism that gives rise to ‘rice water stools’ upon infection

Cholera

Bubonic plague

yeresnia petris ## Footnote Yersinia pestis, gram-ve lactose fermenter. In rats, transmitted by fleas. Still seen in some American National Parks such as Yosemite. Dx: PCR Bubonic plague – flea bites human – Swollen LN (Bubo) – dry gangrene

A student who presented with two day history of **bloody diarrhoea**, vomiting, fever, headache and myalgia. He has just returned from camping in the country side near a farm where he had fresh **cow’s milk for breakfast everyday.**

Campylobacter Jejuni **Drinking unpastuerised milk, food eg: p**oultry Prodrome of **headache** and **fever**, abdo cramps, bloody (foulsmelling) diarrhoea **Curved**, **S-shaped,** Microaerophilic, Oxidase +ve, motile, sensitive to nalidixic acid (first quinolone). Assoc with **Guillain-Barre**, reactive arthritis (Reiter’s) Erythromycin or Cipro if first 4-5/7

A 2 year old boy living in the slums who has a one day history of **profuse watery diarrhoea, fever and abdominal cramps.** His family’s main source of water is the river near their squatters.

**Cryptosporidium parvum** Infects the **jejunum**. Severe **diarrhoea** in immunocompromised. Oocysts seen in stool by modified Kinyoun acid fast stain **Tx** Paromomycin Nitazoxanide in kids

A man was bitten by a rat in Asia. Ten days later he complains of fever, malaise, headache and myalgia.

Spirillum minus

**Cat-scratch disease**

Bartonella henselae

Fever in returning traveller

Ricetssia

Fever in returning traveller plus contact with cattle

Brucella abortus

A 10 year old boy of Middle-Eastern origin presents with general malaise and loss of appetite. He also complains of fever and joint pain. A throat swab is taken, revealing the presence o**f Group A Streptococci.**

rheumatic fever

A zoonosis associated with **_hepatitis, jaundice, conjunctival injection_** and **_renal impairment_**. Transmission normally occurs by direct contact with either the urine or tissues of an infected animal. 􀁸 Excreted in **dog/rat urine**. Penetrates broken skin/swimming in contaminated water - because it is **spirochete** 􀁸 High spiking temp/headache/conjunctival haemorrhages/jaundice, malaise, myalgia, meningism, carditis, renal failure, haemolytic anaemia (incubation 10-14/7) **what is the treatment??**

Leptospiriosis 􀁸 Rx – Amoxicillin, erythromycin, doxycycline or ampicillin

A 22 year old student, who returned from a holiday in the Mediterranean 3 weeks ago, presents with an undulant **fever, malaise, weakness** and generalized bone pain. Upon examination l**ymphadenopathy** and **hepatosplenomegaly** are also noted. 􀁸 From consumption of contaminated food (untreated milk/dairy products), animal contact or environmental contamination. Also includes laboratory acquired. 􀁸 Symptoms – Fever – **Classically undulant fever (peaks in eve. normal by morn),** malaise, rigors, sweating, myalgia/arthralgia, tiredness (incubation 3-4/52) 􀁸 Complications – endocarditis, osteomyelitis (occasionally meningoencephalitis) 􀁸 Signs – **arthritis**, spinal tenderness, **lymphadenopathy, splenomegaly, hepatomegaly,** epididymo-orchitis. **Rarely** – jaundice, CNS abnormalities, cardiac murmur, pneumonia. Treatment and investigation

M 􀁸 Rx – 4-6/52 Tetracycline or Doxycycline combined with Streptomycin. Or PO doxycycline + rifampicin 8/52 Serology - **anti-O-polysaccharide antibody.** (Titres \>1:160). WCC usually normal. Leucocytosis rare, significant number of pts neutropaenic.

A 45 year old male farmer presents **with a raised, erythematous rash,** with c**learing in the centre. He also complains of headache, fever, athralgia and malaise.**

Lyme Borrelia burgdoferi (spirochaete). Arthropod-borne (Ixodes = tick) 􀁸 Early localized – Cyclical fevers, non-specific flu-like symptoms. **Erythema chronicum migrans** **(ECM) – ‘Bullseye Rash’** 􀁸 Early disseminated – Malaise, lymphadenopathy, hepatitis, carditis, arthritis 􀁸 Late persistent – Arthritis, focal neurology, neuropsychiatric disturbance, ACA (acrodermatitis chronic atrophicans) 􀁸 Dx: **Biopsy edge of ECM + ELISA for Lyme Abs** 􀁸 Treatment: Doxycycline 2-3/52,

A 30 year man presented with **jaundice** and **conjunctival haemorrhages**. He had recently been canoeing in the US and had felt **‘run-down’** upon his return to the UK.

Leptospira interrogans

A 25 year old Maltese man presented to his GP with lethargy for a month and headaches and fever. On examination, he had a temperature of 39°C and one fingerbreadth splenomegaly. Small Gram-negative coccobacilli were seen on culture in Casteneda’s medium.

Brucella

**A 22 year** old student presented **to her GP upon** return from a biology field trip, with a lesion on her leg which was **3” in diameter and flat, with a red edge** and **dim centre.** She also mentioned feeling tired and suffering from headaches. On examination, the GP noted a fever of 38.0°C and an irregular heartbeat.

**Borrelia burgdorferi (Lyme disease)**

A 21 year old man presents at his GP complaining of **an itchy, scaly rash on the soles** of **his fee**t. Skin scrapings are taken and sent away for microscopic examination. Which fungi might be identified?

Trichophytum rubrum Trichophyton rubrum as it is the commonest fungus from feet

A 55 year old farmer is seen in the Oncology clinic with a diagnosis o**f hepatocellular carcinoma.** He is a lifelong teetotal and his virology has all been negative. Which fungus may have indirectly been a cause of his cancer?

Aspergillus flavus

A 27 year old lady from Botswana presents at A+E complaining of a dry cough and feeling feverish. A chest x-ray is normal, ***but fine crackles*** were heard on auscultation. Serology shows a CD4+ count of 50 and she is admitted. Later a high resolution CT of the chest shows **a ground glass appearance of the lungs**. What AIDS defining infection does this lady have?

Pneumocystis carinii

A 17 year old Nigerian girl presents at her GP with patches of **hypopigmentation on her trunk.** After an initial trial of steroid cream, the girl returns complaining that the rash is spreading. Woods lamp examination of the rash produces a yellow fluorescence. What is the causative fungus?

**Pityrosporum orbiculare**

. If there was laceration and lots of blisters on the foot

Trichophyton interdigitale.

normally associated with **GROIN** infections,

E floccusum

the old joke with Rugby players' groins.

E floccusum

A 23 year old female on a camping holiday used the local rowing club showers nearby. A few days later she noticed an itchy sensation between some her toes. What is the most likely diagnosis?

Tinea pedis

A homosexual male presented with painful dyspagia and was noted to have whitish velvety plaques on the mucous membranes of the mouth and tongue. When his GP scraped away the whitish material pinpoint bleeding occurred. What is the most likely diagnosis?

Candidiasis

A fertile woman presents to her GP with an itchy vaginal discharge. What is the most likely diagnosis?

candidiasis

**A 47 year old** man is admitted following lung transplantation three months ago with **cough and breathlessness**. He has a cavitating lesion on chest X-ray. At the time of his transplant, building work was being done on the hospital campus in close proximity to the surgical ward.

Aspergillosis

A 45 year old female whose main hobby was pigeon racing was noted by her GP to an enlarged lymph node in her neck. What is the most likely diagnosis? Remember India Ink staining which is often a clue in questions.

Cryptococcis

An 8 year-old boy presents to casualty with a painful and swollen right thigh after being kicked in a football match. On examination a boil is found on the upper part of his right thigh and blood cultures are positive.

staphylococcus aureus

A 19 year-old student presents to her GP with a **macular rash** and **suboccipital lymphadenopathy.** She also complains of pain on moving her hands and wrists.

Rubella Rubella RNA virus. Resp transmission. Incubation 12-21 days Symptoms: 20-50% have subclinical infection Classical: picture of flu like symptoms followed by pinpoint macular-papular rash and lymphadenopathy (in adults.) Diagnosis via serology of saliva swabs : Mark Peterzan The patient is female. Rubella is followed by a reactive polyarthritis in a RA-like distribution (PIP, MCP, wrist) in 50% of women and 6% of men. If she hasn't had MMR, do a pregnancy test!

In Brodie's abscess, the **bone abscess** was surrounded by **fibrosis** and **bone** sclerosis, seen as a **halo** on **MRI.**

Osteomyelitis 􀁸 Ax: Local or haematogenous spread. Brodie abscess (subacute) 􀃆 frank osteomyelitis 􀁸 Bugs: Staphylococcus aureus 􀁸 Px: Pain, fever, local swelling 􀁸 Dx: MRI, bone biopsy for culture/histology

Causes of reactive arthritis post VIRAL post BACTERIAL Ureaplasma other: Group A Strep, Neisseria gonorrhoea, Brucella, TB (Poncet's disease) peri-infectious Borrelia burgdorferi (Lyme arthritis: tertiary Lyme disease - treatment doxy and amoxicillin) Rheumatic fever

rubella hepatitis B parvovirus B19 ## Footnote (includes Reiter's syndrome, which can be post-dysentery or post-urethritis) dysentery: Shigella, Salmonella, Yersinia, Camplyobacter (Camylobacter can also be a precedent of Guillain-Barre urethritis: Chlamydia (note: obligate intracellular),

A 35 year old lady with a history of TB presents with collapsed cervical vertebrae, a marked kyphosis causing difficulty in moving.

pot's disease

Your Consultant spotlights you to expand on the diagnosis of osteomyelitis in a gentleman with a histor**y of sickle cell crises**, presenting with bone pain and excessive sweating. On X-ray he informs you there is **“cortical destruction, involucrum and sequestra”.**

**Salmonella osteomyelitis - in sickle cell patients**

A 10 year old boy presents with moderate pain in his lower leg, little redness and swelling, remitting for 6 months. His mother gives you the X-ray report from the previous episode, which showed “**a well defined ovoid shape *_with a surrounding sclerotic margin_* but little involucrum in his tibia**”.

Brodie's abscess

arthritic manifestations of congenital syphilis at the time of puberty.

Clutton's joints

A 19 year old student presents with a short history **of severe headache** and **photophobia.** O/E he has a **non-blanching rash** over his abdomen. CSF is performed and shows **gram- negative cocci**

Neisseria meningitides

A 30 year old builder develops abdominal pain and diarrhoea 48 hours after having Texa Fried Chicken. Faecal culture shows motile, **oxidase-positive colonies and gram stain shows gram-negative rods.**

Campylobacter jejuni

A 27 year old teacher presents with symptoms of ***dysuria of 3 days*** duration. MSU gram stain shows neutrophils, erythrocytes and ***gram negative bacilli***

Escherichia coli

A 55 year old man comes into A&E complaining of a increasing difficulty in opening is mouth and that the muscles on his face occasionally spasm. On examination you observe that his eyes are partially closed and that the angles of his mouth are stretched outwards and slightly downwards. You also note that he has a very rigid abdomen. Which treatment option should be carried out first for this patient?

V. injection of tetanus antitoxin

A 35 year old HIV positive male presents with fever lasting a few weeks, night sweats and appetite loss.

Mycobacterium tuberculosis

A 15 year old girl consults her GP after experiencing a high temperature and **several headaches** over **the last three weeks.** She has no medical history of note and has recently begun a weekend job helping at a local farm. what would be the investigation and treatment??

Brucelliosis Mode of transmission – Inhalation, Skin or mucus membrane contact. **􀁸 From consumption of contaminated food (untreated milk/dairy products), animals (working in the farm)** contact or environmental contamination. Also includes laboratory acquired. 􀁸 Symptoms – Fever – **Classically undulant fever** (peaks in eve. normal by morn), malaise, rigors, sweating, myalgia/arthralgia, tiredness (incubation 3-4/52) 􀁸 Complications – endocarditis, osteomyelitis (occasionally meningoencephalitis) 􀁸 Signs – arthritis, spinal tenderness, lymphadenopathy, splenomegaly, hepatomegaly, epididymo-orchitis. Rarely – jaundice, CNS abnormalities, cardiac murmur, pneumonia. 􀁸 Ix – Serology - **anti-O-polysaccharide antibody**. (Titres \>1:160). WCC usually normal. Leucocytosis rare, significant number of pts neutropaenic. 􀁸 Rx – 4-6/52 Tetracycline or Doxycycline combined with Streptomycin. Or PO doxycycline + rifampicin 8/52

An 80 year old man returns to his GP two weeks after being prescribed co-trimoxazole for a UTI. His urinary symptoms have now eased, but he is still experiencing a fever. His blood count shows eosinophilia.

**Drug induced fever**

A 40 year old female intravenous drug user presents at A&E with a mild ongoing fever, nausea and vomiting. Her partner mentions that she is a bit yellow.

Hepatitis B

A 45 year old female presents with fever. O/E she is pyrexial, has h**epatosplenomegaly, lymphadenopathy and a severely swollen eyelid.** She returned from Guatemala 2 days ago.

Chagas

A 21 year old male presents with a swinging fever, severe rigors, vomiting and confusion. Travel history reveals that he returned from Kenya 14 days ago. O/E he was pyrexial, had hepatosplenomegaly but no lymphadenopathy and was slightly jaundiced. His GCS was 11.

Plasmodium falciparum

A 45 year old male presents with frequency, dysuria and haematuria. Blood tests reveal a marked eosinophilia. He arrived back to the UK 4 months ago after travelling Africa; his best memory was diving in Lake Malawi.

Schistosomiasis

A 21 year old female presents with **chronic diarrhoea** beginning 2 days before her return to the UK from **India 3 weeks ago.** She has *lost weight, feels bloated* and also complains o**f very offensive burps.**

**Giardia lamblia**

A 35 year old male complains of **a persistent ulcer in the mucosa of the mouth.** When questioned further admits to remembering **a small ulcer** on **his upper arm** which healed without treatment when holidaying in Brazil one year ago.

o **Dermal ulcer** same as **cutaneous leishmaniasis** o Months to yrs later **– ulcers** in **mucous membranes** of nose and mouth

A 45 year-old Egyptian male complains of haematuria. On further investigation, cystoscopy reveals a squamous cell carcinomatous lesion.

Schistosoma haematobium

An African woman and her 33 year-old husband come to their doctor because she is worried that he is not as alert as he used to be. On examination, he has non-tender lymphadenopathy, hepatomegaly and marked CNS abnormalities. He is noted to be quite lethargic.

Trypanosoma brucei gambiense

A thin peripheral blood film from a 59 year-old female demonstrates eosinophilia and microfilariae. On examination, the skin overlying her superficial lymph nodes is streaky red and tender.

C. Wuchereria bancrofti

A 43 year-old Asian male with AIDS presents with a prolonged fever, dizziness and a persistent cough. On examination, he is found to have marked splenomegaly and rough, dry skin. Blood results reveal pancytopenia.

Leishmania donovani

A 20 year-old man presents with a persisting intermittent fever which began whilst he was travelling in South America the previous week. He has a dry cough and a massively enlarged spleen. **Sandfly parasites** are detected in a spleen aspirate. Usually young malnourished child o Abdo discomfort + distension/anorexia/wt. loss o Leishmania donovani: invasion of reticuloendothelial system -\> **hepato-splenomegaly,** BM invasion. Later disfiguring dermal disease (PKDL).

H. Visceral leishmaniasis (kala-azar) **Transmitted through bite of the sandfly** (south & central America+ middle east) o *Skin ulcer at site of bite* – multiply in dermal macrophages Heals after 1yr leaving depigmented scar May be single or multiple painless nodules which grow + ulcerate, Type IV reaction

A **55 year-old Gambian** man presents with **a low-grade fever** which has been **coming** and **going for about 2 months.** He says it started when visiting **his family in Gambia** when he was also feeling weak and sleeping a lot.

**Trypanosomiasis**

A 7 year-old girl presents with a few week’s history of fever, malaise and weight loss. She has **hepatosplenomegaly** and **neck stiffness.** Chest x-ray shows diffuse, small, nodular opacities.

**Miliary tuberculosis**

**A 25 yr** old femal**e humanitarian volunteer** complaining of swinging fever, profound abdominal pain with **severe malaise**. On further questioning she reveals a history of **self limiting diarrhoeal** illness 3/52 ago during which she passed mucus and some blood. You are also informed she recently returned from a humanitarian mission to Ghana 6/52 ago. O/E she is unwell with exquisitely **tender hepatomegaly.** You also find increased breath sounds and **a dull percussion note** in **the lower region** of the right lung.

**Entamoeba histolytica** **disease - Ameobiasis (also comes up in questions)** ***Motile trophozoite in diarrhoea* Non-motile cyst in non-diarrhoeal illness** 4 nuclei and no animal reservoir. Colonize colon Makes a flask-shaped ulcer on histology Symptoms: dysentery, wind, tenesmus. Chronic weight **loss + RUQ pain due to liver abscess** Stool microscopy **Metronidazole** + Paromomycin if luminal disease

A 24 yr old male complaining of 3/52 history of fever/chills with muscular aches and spasms. On further questioning he reveals the he also an episode of diarrhoea/vomiting with a headache lasting 48hrs. This followed his participation in an amateur eating competition 1/12 ago, during which he may have eaten some improperly cooked pork. O/E he has marked periorbital oedema with conjunctivitis. Blood tests reveal a marked eosinophillia, while gastrocnemius biopsy demonstrates the presence of encysted larvae.

Trichinella spiralis

A 32 yr old female complaining of the presence of small pale bodies in her stools on a number of occasions. On further questioning she admits some occasional mild epigastric pain over the past 4/12. O/E she appears clinically well. There is no significant travel history.

Taenia saginata

A 25yr old man who had recently returned from travel in Afrcia presented with ***fever***, ***diarrhoea*** and ***hepatoslenomegaly.*** He also ***noted skin changes*** which had developed over the past month.

**Visceral Leishmania** protozoa 􀁸 Cutaneous, eg: L. major, L. tropica o *Transmitted through bite of the sandfly* (south & central America+ middle east) o *Skin ulcer at site of bite –* multiply in dermal macrophages – **Heals after 1yr leaving depigmented scar** – May be single or multiple painless nodules which grow + ulcerate, Type IV reaction **􀁸 Diffuse cutaneous** o Pts with immunodeficiency, Nodular skin lesions arise but do NOT ulcerate – Lots of nodules, esp nose, Skin test–ve as immunodeficient 􀁸 Muco-cutaneous, eg: L. braziliensis o Dermal ulcer same as cutaneous leishmaniasis o Months to yrs later – ulcers in mucous membranes of nose and mouth 􀁸 Visceral = Kala Azar, eg: L. donovani, L. infantum (L. chagasi in S. America) o Usually young malnourished child o Abdo discomfort + distension/anorexia/wt. loss o Leishmania donovani: invasion of reticuloendothelial system -\> hepato-splenomegaly, BM invasion. Later disfiguring dermal disease (PKDL).

An 18 yr old boy presented with **diarrhoea, anorexia abdominal discomfort** and **distension**. He noted that he had been passing pale, fatty stools. He had been back-packing in North America. Both **cysts** and **trophozoites** were present on stool examination.

**_Giardiasis_: Pear shaped trophozoite** 2 uclei **Trophozoites/cysts** found in stool Get it by ingesting cysts from faecally contaminated H2O Malabsorption of protein + fat - foul smelling non-bloody diarrhoea Dx = ELISA string test **Metronidazole** **EMQ: Travellers/hikers/MSM/ mental hospitals**

The **CT scan of a neonate show**s diffuse **intracranial calcification** and **hydrocephalus**. On questioning, his mother tells you that she used to work in a **slaughterhouse** and **has five cats.**

Toxoplasma gondii

A 10 year old girl presents with *fever, hepatomegaly, splenomegaly and anaemia.* She recently emigrated from the Sudan. Her mother tells you that 6 months ago the girl **developed dark patches on her hands and forehead.**

**Leishmania donovani**

An 18 month old girl from Brazil sees you whilst on a short holiday in Britain. Her parents are worried because she appears to have had fever for the last few weeks, seems more tired and out of spirits than usual, has loss of appetite, vomiting and diarrhoea and complains of pains in her legs. On examination she has general lymphadenitis and non-pitting oedema in her legs and feet. Her Machado-Guerreiro test is positive.

Trypanosoma cruzi

At birth, a neonate is diagnosed with sensorineural deafness, retinopathy and cardiovascular abnormalities. The mother suffered from German measles during the 1st trimester of Pregnancy, which was treated with Paracetamol. The mother had not been vaccinated before pregnancy.

Congenital Rubella Syndrome

An infant is diagnosed with pneumonia in her 5th day of life. Vaginal swabs from the mother as well as umbilical and oral swabs from the neonate showed a Gram positive coccus. The infant is given antibiotics and is monitored in hospital for a period of time until respiration and appetite improve.

**Group B Streptococci Syndrome**

A 2 week old infant develops swollen red eyelids. The mother explains that the initial ocular discharge seen at 10 days was watery, but has become copious, thick and purulent. Mother, father and infant are shown to all be infected with the same bacterium and are treated with penicillin.

Chlamydial conjunctivitis in the newborn

**A French mother** brings her **2 month old daughter** with fever to hospital. The infant is shown to have elevated **hepatic enzymes** and is treated **with pyrimethamine, sulphadiazine** and **folic acid** for a year after appropriate investigations are performed.

**Congenital Toxoplasmosis**

An infant is born prematurely and subsequently has low birth weight. In addition, he has encephalitis and vesicular skin lesions. Despite being recommended to have a caesarean due to active viral lesions, the mother refuses and the neonate was delivered vaginally. Emperic Acyclovir is given to the neonate.

Neonatal Herpes Simplex Infection ## Footnote the important point is that you know that you need to use this drug at all in such a patient around the time of delivery to prevent certain death of the child. he says that **VZV Ig** should be given if a mother develops **vesicles a week antepartum** and **29 days post-partum.** There are some who have no idea that any treatment is needed for such children!

A 2 week old female had an **enlarged liver** and **spleen** and her skin was tinged yellow. She was not eating much nor was she vomiting. She also suffered from regular seizures. Investigation revealed **intra-cranial calcification.**

Congenital toxoplasmosis

A newly born male presented with **microphthalmia, deafness and hepatosplenomegaly**. His platelet count was **50 x 10^9/L.** In addition, rashes were noticed on his body. He suffers from SOB and is unable to finish feeding.

**Congenital Rubella Syndrome**

**The CSF** in a neonate showed **a raised WCC,** consisting mainl**y of polymorphs.** Culture **showed pneumococcus.**

**Bacterial meningitis**

A prematurely born 1 week old infant presented with **microcephaly, chorioretinitis and vesicular skin lesions.** v He also had non-specific features of fever, irritability and failure to feed.

Neonatal HSV infection

A 6 day old baby presented with eyelid oedema and conjunctivitis with micropurulent discharge. Cultures obtained using Dracon swabs were positive for C. trachomatis.

Chlamydial ophthalmia

A 31 year old man presents to a GUM clinic complaining o**f pain** o**n passing urine** (post-gonnococcal urethritis) and **a penile discharge.** His history reveals that he had travelled to Bangkok 10 days earlier “on a business trip”. On examination he had a purulent urethral discharge and **a swollen tender prostate (rectal procatitis).** **Gram negative diplococci** were found in smears of the discharge and culture of the causative agent confirmed the presumed diagnosis.

Gonorrhoea Gonorrhoea 􀁸 Neisseria gonorrhoeae: obligate intracellular **Gram –ve diplococcus.** 􀁸 Opthalmia neonatorum (neonatal conjunctivitis) develops if left untreated when transfer to child from birth canal. 􀁸 Pts with complement deficiencies: they get disseminated gonococcal infection -\> **Septicaemia, rash and/or arthritis** Diagnosis: urethral (sensitivity 95%) / rectal (sensitivity 20%) smears – producing a culture from these is Gold Standard. Treatment: Ceftriaxone IM – 250mg single dose OR Cefixime PO – 400mg single dose o If resistant Spectinomycin IM – 2g single dose

19 year old woman presents with cervicitis, erythema and oedema. Cultures were unable to be grown with agar but were subsequently grown using tissue medium.

Chlamydia trachomatis

29 year old male presents with **a painless ulcer on the penis**. The lesion organism was identified using dark ground microscopy ***to show treponemes.***

**Syphilis**

Presents as a shallow painful ulcer, sometimes progressing to a lymphadenopathy.

chancroid Genital ulcers: If - Painful = herpes \> chancroid Chancroid occurs when **Haemophilus ducreyi** penetrates the skin through an injury, like a scratch or cut. Once past the skin surface, the warmth, moisture, and nutrients allow bacteria to grow rapidly. The first sign of chancroid is a small, red papule that occurs within three to seven days following exposure to the bacteria, but may take up to one month. Usually within one day, the papule becomes an genital ulcer. The chancroid ulcer is painful, bleeds easily, drains a grey or yellowish pus, and has sharply defined, ragged edges. Swollen, painful lymph node is called a "bubo." The bubo, which appears as a red, spherical lump, may burst through the skin, releasing a thick pus and forming another ulcer. Additionally patients with chancroid ulcers are more likely to acquire HIV. It is endemic in Africa, Asia and South America, and is more common in men, particularly uncircumcised men. HIV is a very important cofactor, with a 60% association in Africa.

What treatment should be prescribed for a 25-year old lady complaining of pruritus and a creamy vaginal discharge?

Oral fluconazole

A neonate is referred and presents **with skin lesions**, **lymphadenopathy a**nd failure to thrive.

Syphilis

40 yr old male presents with jaundice, fever, hepatomegaly, and a positive past history of HBV. Most likely cause?

Hepatitis Delta virus Hepatitis D RNA virus can only infect Hepatitis B patients.

A 49 year old male presents with fever, vomiting and seizures. His WCC is increased. He recently had a dental infection. The MRI of his brain shows a ring-enhancing lesion.

Cerebral Abscess cerebral abscess, tuberculoma, toxoplasmosis and sometimes CNS lymphoma. The ring usually represents vasogenic oedema.

A 40 year old man presents with haemoptysis, neck stiffness and photophobia. He has been feeling unwell for the past week. CSF was turbid with a high level of protein.

Mycobacterium Tuberculosis

A 3 year old girl with incomplete vaccinations presents with insidious symptoms of meningism over the course of a couple of days. Blood culture revealed presence of Gram negative coccibacilli.

*Haemophilus influenzae* *Haemophilus influenzae in \<3 month olds and unvaccinated children GBS, E.Coli, Listeria common 1-3months so empirical Abx at this age incl Amox*

A 73 year old gentleman presents with high fever and neck stiffness of acute onset. A complete history reveals that he is recovering from a recurrent pneumonia.

Streptococcus pneumoniae

A 56 yr old male presents with fever, vomiting and seizures. Examination reveals a well established ear infection and there is a ‘ring-enhancing’ lesion on the MRI of his brain.

Cerebral abscess

A 1 yr old child is brought into A&E by his mother. She has noticed he has a fever and is now becoming increasingly restless and will not stop screaming. He has a non-blanching rash on his thigh.

Acute bacterial meningitis

An 18 yr old student comes in feeling ‘pretty lousy and aching all over’. She is wearing dark glasses and complains of a stiff neck. CSF examination reveals a normal CSF/blood glucose ratio and 0.7 g/L protein with a lymphocyte count of 15

Acute viral meningitis

A 70 yr old man presents with his wife. She complains that he has become increasingly forgetful and now she is unable to understand what he says. On examination you notice some ataxia and sudden spasms of his muscles. An EEG shows periodic sharp waves.

Prion disease (CJD)

The cause of infections which are particularly common in sexually active, young females

Candida

Used as antimicrobial treatment of UTIs during the initial stages of pregnancy. Concentrated in the urine.

Nitrofurantoin

These infections are almost invariably associated with functional or anatomical **abnormalities** of **the renal tract.** Tip: also causes cavitating pneumonia.

**Klebsiella**

Broad spectrum penicillin traditionally used in the treatment of UTIs.

ampicyllin

One of the 1st line drugs for UTIs in non pregnant women but contra-indicated in pregnant women

Trimethoprim

The most common cause of UTI in catheterized men

E.Coli

The 2nd commonest cause of uncomplicated UTI in young women

Staph saprophyticus

Can be used as monotherapy for acute pyelonephritis and should always be prescribed orally because its bioavailability is near 100% and iv dosing is 30 times more expensive.

Ciprofloxacin

Causes haemorrhagic cystitis in children.

Adenovirus

A cephalosporin used for treating pseudomonal infections in cystic fibrosis

ceftazidine

In combination those drugs are used for very sick patients with obstructed infected upper UTIs and gram negative septicaemia.

iv ampicillin, Gentamicin

Given IM as a single shot for gonococcal urethritis

Ceftriaxone

A similar trick question is to ask what is the commonest cause of **vomiting blood** in an **alcoholic** on a **Friday night binge.**

The ans would be **duodenal ulcer**, NOT variceal bleed. For separate notes, see attached file.

A 40-year-old Indian male presents to **A&E** with **dysuria** and **back pain.** He has recently noticed **blood in his urine** and his past medical history reveals that he has had hypertension for 5 years. After some initial reluctance, he admits to **having HIV,** which was diagnosed on his arrival in the UK 7 years previously.

Renal TB

A 27-year-old Caucasian female, who is 7 months pregnant, presents to A&E with a 2 day history of vomiting, rigors and loin pain. On examination, she is found to be pyrexic (39oC). Urine dipstick indicates the presence of leucocytes, nitrite, proteinuria and haematuria.

Acute Pyelonephritis

A 23-year-old Caucasian women presents to her GP with urinary frequency, urgency and burning. She also complained of slow stream as well as suprapubic pain. She has had several UTIs in the past and analysis of her urine showed no significant bacteruria.

urethral syndrome

A 63 year old gentleman has a two day history of **fever** and **rigors** with l**ower back pain** and **discomfort on passing urine.** Urine microscopy and culture revealed 2 x 104 Escherichia Coli per ml urine.

**Bacterial prostatitis**

**A 40 year old lady** was previously diagnosed with **acute UTI** and treated with **trimethoprim**. Ten days later she returns to her GP with the same symptoms of **dysuria** and **frequency**, and **urine microscopy r**eveals a positive culture of the same bacteria.

recurrent uti relapse of a UTI implies re-infection with the SAME organism. Recurrent UTIs imply infection with DIFFERENT organisms.

Individuals who walk or swim in the river Nile put themselves at risk of developing this condition.

Schistosomiasis of the bladder

**A 35 year** old Asian gentleman has recently migrated to **the United Kingdom.** He presents with **urinary frequency, dysuria and loin tenderness**. Urine culture is **negative, however he has pyuria.**

**Renal tuberculosis** A sterile pyuria occurs in renal tuberculosis.

A 32 year old male recently underwent a **kidney transplant procedure**. During his time in hospital he was continually disturbed by the noise of building work. He started to develop **fever, dyspnoea an dslight confusion.**

Aspergillus Fumigatis

A 12 year old boy develops wound infection after a right hemicolectomy for Crohn’s disease. Gram stain of exuded pus shows clusters of **Gram-positive cocci**. Culture shows coagulase-positive yellow colonies.

Staphylococcus aureus

A 74 year old male is soon to undergo colorectal surgery and hospital procedures of antibiotic prophylaxis is followed.

Cef. & Met. 0-2hrs before incision & no longer than 24 hrs post-surgery

A 35 year old woman **receiving chemotherapy** for **high grade lymphoma** develps **SOB** and **dry cough**. CXR shows **bilateral reticulonodular shadowing.** A transbronchial biopsy shows alveoli filled with foamy eosinophilic material and numerous boat-shaped organisms staining positively with silver stain. Sputum culture is negative.

. ## Footnote **Pneumocystis pneumonia**

is used in the treatment of cryptococcal meningitis + invasive fungal infection

Amphotericin B

An 18 year old boy with cystic fibrosis recently underwent a knee operation. After a couple of days recovering in the ward he starts to wheeze, becomes breathless and coughs up sputum. He has a fever and blood cultures indicate the presence of **gram-negative bacteria.**

**Burkholderia cepacia** **Cystic Fibrosis Pseudomonas aeruginosa, Burkholderia cepacia (v. high mortality)** **both are gream (\_)**

A 68 year old woman who has undergone colorectal surgery **develops boils** on her legs **and impetigo.** She has a fever and culture of her skin lesions indicates the presence of Staph. Aureus. Treatment with methicillin and flucoxacillin shows no improvement in her condition.

MRSA

A 50-year-old man was admitted with **acute pancreatitis** and underwent emergency pancreatectomy. He was in ITU for four weeks for respiratory support where he remained febrile and septic. Blood cultures and wound swabs grew **gram-positive cocci** in chains, which grew on **MacConkey plate** and ***was aesculin-positiv***e. This isolate was also resistant to the conventional anti-streptococcal antibiotics.

Vancomycin-resistant enterococcus(VRE)

A patient with 20% burns with open wounds is awaiting skin grafting. The wound swab grew **gram-negative bacilli** that produced a green pigment and w**as oxidase-positive**. A similar organism was isolated from other patients on the same unit. Bacteriological typing subsequently proved all the isolates were of the same type.

Pseudomonas auroginosa

Following Christmas dinner in hospital, eight out of the junior doctors came down with fever and diarrhoea 18 hours later. On interrogation some patients in different wards were found to be similarly affected. The common food history of all those suffers was the Christmas turkey. Stool cultures grew gram-negative bacilli that were oxidase-negative and urease-negative and gave positive agglutination test for an enteric pathogen.

Salmonella enteridis

Three patients on the same ward/medical firm came down with diarrhoea and vomiting within 24 hours. The attention is drawn to the ward sister that many patients started their symptoms at the same time. Stool samples were sent for bacterial cultures and viral studies. Subsequently, the diagnosis was obtained by electron microscopy, which showed the same pathogen for all patients. Notice no food is involved here

**Rotavirus**

Donovanosis = Granuloma inguinale 􀁸 􀁸 Africa, India, PNG, Australian aboriginal communities 􀁸 Large, expanding ulcers starting as papule or nodule that breaks down. Beefy red appearance 􀁸 Diagnosis – Giemsa stain of biopsy or tissue crush. Donovan bodies 􀁸 Treated with azithromycin

Klebsiella granulomatis. Gram negative bacillus

A 45 year old man was admitted for a perforated gastric ulcer for which he had emergency surgery. He was maintained in ITU for the following 2 weeks. His wound culture grew **gram positive cocci in chains,** which was **aesculin-positive** and resistant to the conventional **anti-streptococcal antibiotics.**

**Vancomycin resistant enterococcus**

## Footnote **A 25% burns patient with significant wounds** grew **gram-negative bacilli t**hat produced a **green pigment and was oxidase positive.** Three other patients in the same ward were found to isolate the same organism.

## Footnote **Pseudomonas aeruginosa**

A 85-year-old man admitted for "off-legs" who was catheterised developed a fever. He complained of mild suprapubic pain.

Escherichia coli

A 65 year old lady was admitted for **CABG.** Blood cultures went on to grow **coagulase-positive staphylococcus sp.,** which was resistant to flucloxacillin. Her wound swab also grew the same organism.

**MRSA** **flucloxacillin**

Sitting in on your consultant’s GUM clinic, you see a shy 30-year-old woman who admits to losing her virginity a week ago and now is worried about the appearance of insect bite-like marks in her genital region and a concurrent fever. On intense questioning, she reveals that her partner seemed to have a painful sore on his penis.

HSV type 2

On Tuesday, a confident African friend comes to you for advice. He has noticed a **painful ulcer on his penis,** from which he has helpfully collected exudate. Sneaking into the labs at Chelsea & Westminster late one evening, you culture this. Later, you note the presence of **Haemophilus ducreyi.**

Chancroid

a 25-year-old homosexual man who presented with **purplish lesions on** his skin and **pneumonia.** A stunningly swift culture from the labs determines the organism is **Pneumocystis carinii.** Before reporting your registrar to the GMC, you fill in the diagnosis on the patient’s notes.

HIV

remember that microscopy showed a gram negative diplococcus. has been feeling feverish, has a rash and painful joints.

Disseminated gonococcal infection

Before copulating, you notice Helga has some muco-purulent discharge from her vagina. Upon questioning, she admits to a history of pelvic pain. You abandon your amorous advances and accompany Helga to A&E, where you impress the doctors on call with your spot diagnosis.

Chlamydiae Trachomatis

Lymphatic infection with Chlamydia trachomatis: serovars L1, L2 and L3 􀁸 Endemic in parts of developing world. More recently MSM in developed world treatment

doxycycline

also known as parrot fever, and ornithosis — is a zoonotic infectious disease caused by a bacterium called Chlamydophila psittaci and contracted from infected parrots, such as macaws, cockatiels and budgerigars, and pigeons, sparrows, ducks, hens, gulls and many other species of bird.

Psittacosis —

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

Cryptococcus

## Footnote the most common opportunistic infection in AIDS

Whilst the organism **Pneumocystis carinii** is now referred to as **Pneumocystis jiroveci,** the term **Pneumocystis carinii pneumonia (PCP)** is still in common use ## Footnote ***Pneumocystis jiroveci*** is an unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa all patients with a CD4 count \< 200/mm³ should receive PCP prophylaxis **Management** co-trimoxazole IV pentamidine in severe cases

**The Paul Bunnell reaction** was positive for **heterophilic antibiodies.a maculopapular,** pruritic rash develops in around **99% of patients who take ampicillin/amoxicillin** ## Footnote **what is the disease ?**

Infectious mononucleosis (glandular fever) i s caused by the Epstein-Barr virus (also known as human herpesvirus 4, HHV-4).