Past Papers 8 Flashcards
For the following five hepatitis E virus laboratory scenarios, please state the most likely interpretation of the laboratory results:
HEV IgM pos
HEV IgG neg
HEV RNA blood - 100000000 iu/ml
HEV RNA faeces - neg
recent acute HEV infection
For the following five hepatitis E virus laboratory scenarios, please state the most likely interpretation of the laboratory results:
HEV IgM neg
HEV IgG neg
HEV RNA blood - 100000000 iu/ml
HEV RNA faeces - neg
compatible with early acute HEV infection
no development of antibodies yet
either patient is immunosuppressed, or very recent infection
For the following five hepatitis E virus laboratory scenarios, please state the most likely interpretation of the laboratory results:
HEV IgM neg
HEV IgG pos
HEV RNA blood 100000000 iu/ml
HEV RNA faeces pos
Evidence of current HEV infection
depending on time of onset, this may be a recent late-primary infection, or a chronic infection
For the following five hepatitis E virus laboratory scenarios, please state the most likely interpretation of the laboratory results:
HEV IgM neg
HEV IgG neg
HEV RNA blood - 100000000 iu/ml for 4 months
HEV RNA faeces
Chronic HEV infection
chronic after 3 months
patient may be immunosuppressed
Detectable for ≥3 consecutive months: Persisting HEV RNA in blood
for three or more consecutive months indicated establishment
of persistent HEV infection. Monitor HEV RNA in blood every three-six months. Consider therapeutic intervention.
For the following five hepatitis E virus laboratory scenarios, please state the most likely interpretation of the laboratory results:
HEV IgM neg
HEV IgG pos
HEV RNA blood 100 iu/ml
HEV RNA faeces neg
resolving HEV infection
For the following four clinical hepatitis E virus infection scenarios, please state your management options:
An uncomplicated acute HEV infection in the immunocompetent
No specific management for patient
Pregnancy test is female - high risk liver failure if genotypes 1/2 acquired abroad
IPC - check if food handler. May need tested for clearance
monitor for extra-hepatic manifestations
screen for HBV/ HCV ensure not at high risk of liver failure due to pre-existing liver disease
For the following four clinical hepatitis E virus infection scenarios, please state your management options:
First therapeutic step in management of chronic HEV infection in liver transplant recipient
reduction of immunosuppression
For the following four clinical hepatitis E virus infection scenarios, please state your management options:
Specific antiviral treatment following unsuccessful Scenario 7 option
3 month course of ribavirin
600mg-1000mg per day depending on weight/ renal function
For the following four clinical hepatitis E virus infection scenarios, please state your management options:
What other therapeutic options are there if the treatment in scenario 8 fails?
6 month course ribavirin
Pegylated interferon for 3 months in liver-transplant patients. Contra-indicated in other organ transplants
liver transplant
What are common extra-hepatic manifestations of HEV?
The commonest neurological manifestations reported are
Guillain-Barré syndrome (GBS), neuralgic amyotrophy and encephalitis/myelitis.
A distinctive bilateral form of neuralgic amyotrophy is suggested to be a specific clinical phenotype associated with HEV infection
HEV infection in a food handler
What IPC recommendations would you make?
Not much evidence for this.
14 days after onset of jaundice for HEV
7 days after onset of jaundice for HAV
For hepatitis E, the incubation period following exposure to the hepatitis E virus ranges from 3 – 8 weeks, with a mean of 40 days. The period of communicability is unknown but virus excretion in stools has been demonstrated up to 14 days after the onset of jaundice. Transmission of the virus via blood is extremely unlikely.
9a Name the virus family shown in 9A [1 mark]
Candidates will see a black and white electron micrograph with scale
9b Name 6 body organs or systems that typically could be infected with virus 9A and
name one illness for that organ or system [3 marks]
9c Describe the morphology of the virus shown here [1 mark]
Candidates will see a black and white electron micrograph with scale
9d Which human virus typically shows this morphology in electron micrograph? [1 mark]
9e Which virus family typically shows this morphology? [1 mark]
Candidates will see a black and white electron micrograph with scale
9f What type of nucleic acid genome does this virus possess? [1 mark]
9g Which virus family typically shows this morphology? [1 mark]
Candidates will see a black and white electron micrograph with scale
9h Describe the morphology of virus here [1 mark]
9a to 9c - Adenovirus questions?
adenovirus -
icosaehdral structure
fiber projections
non-enveloped
Others unknown - practice EM
Adenoviridae
Morphology types -
spherical - HIV, influenza, covid
icosahedral - adenovirus,HSV, parvoviridae
complex - bacteriophage
What are risk factors for severe congenital CMV?
primary CMV infection in pregnancy
infection occurring earlier in pregnancy - <20 weeks
When is symptomatic congenital CMV likely to present clinically?
failed hearing test
can present at birth with sepsis like picture, jaundice, rash, pneumonia, seizures
Name 6 common manifestations of symptomatic congenital CMV
Symmetrical IUGR (birth weight <-2SD for gestational age)
Microcephaly (head circumference <-2SD for gestational age)
Blueberry muffin rash
Petechiae or purpura
Hepato or splenomegaly
Prolonged jaundice or conjugated hyperbilirubinaemia
Chorioretinitis
Congenital cataracts
Colitis or atypical necrotising enterocolitis
Pneumonitis
Sepsis like syndrome, especially if non-responsive to antibiotics
ventriculomegaly/intracranial calcification
Seizures
What are antiviral options for congenital CMV?
Ganciclovir/ valganciclovir first line, and only ones with evidence
Cidofovir/ Foscarnet have evidence in drug resistant CMV, but not cCMV
CMV immunoglobulin has shown no benefit in reducing cCMV in mothers who are shown to have primary CMV infection
What are side effects of ganciclovir treatment for cCMV?
Ganciclovir (GCV), and less frequently Valganciclovir,is associated with bone marrow suppression. Side effects
include; neutropenia, anaemia, thrombocytopenia and less commonly raised liver enzymes, urea and
creatinine. Reported symptoms in adults include mood changes, confusion, rash, tiredness, tremor, abdominal
pain, diarrhoea and vomiting. These appear very uncommon in infants
Started ganciclovir for cCMV. Concerns of blood counts
When do you stop treatment?
If the neutrophil count drops to less than 0.2 cease until count recovers to more than 0. 5
If the neutrophil count drops to between 0.2 and 0.5 then recheck weekly and consider stopping if persistent.
If the platelet count drops to less than 50 then stop until the platelet count returns to more than 50
Changes in renal function with rising creatinine should be discussed with Pharmacy/Paediatric IMPS team
and consideration given to changing to once daily dosing.
Started ganciclovir for cCMV. Concerns of blood counts
How often should FBC/UE/LFTs be checked?
FBC, UEs, LFTs
weekly for 6 weeks
then at 8 weeks
then monthly
do more frequently if concerns
Started ganciclovir for cCMV.
Baby otherwise well
When should a CMV blood viral load be checked?
at diagnosis
2 weeks after treatment
Started ganciclovir for cCMV.
when should drug levels be checked?
one test at end of first week of treatment
further testing only if indicated as advised by Paediatric ID.
IV ganciclovir - peak 1 hour after infusion, trough 30mins before infusion
oral ganciclovir - peak 2 hours after administration, trough 30 mins before administration
If patient is receiving IV Ganciclovir, peak level should be taken one (1) hour after end of infusion in
clotted serum bottles. (levels 7 to 9 mg/L) and a trough level taken 30 minutes pre-morning dose
(trough level less than 2 mg/L).
o If patient is receiving oral Valganciclovir, peak level should be taken two (2) hours after administration
in clotted serum bottles. (peak level 5 to 7 mg/L). and trough level taken 30 minutes pre-morning dose
(trough level less than 2 mg/L).
What are appropriate drug levels for ganciclovir and valganciclovir?
Ganciclovir
peak 7 to 9 mg/L
trough less than 2 mg/L
Valganciclovir
peak 5 to 7 mg/L
trough less than 2 mg/L
You have been called by one of the infection control nurses regarding a perceived
increase in incidence of diarrhoea on the paediatric primary immunodeficiency and bone
marrow transplant ward.
The ward consists of 8 positive pressure cubicles with airlocks.
All patients are significantly immunosuppressed.
Five of the patients and 1 staff member are currently reported to have diarrhoea.
Faeces samples are received and tested using a multiplex PCR covering norovirus,
sapovirus, astrovirus, rotavirus and adenovirus
You will see images of viruses either RNA or DNA
Make sure to know what viruses look like under EM
You have been called by one of the infection control nurses regarding a perceived
increase in incidence of diarrhoea on the paediatric primary immunodeficiency and bone
marrow transplant ward.
The ward consists of 8 positive pressure cubicles with airlocks.
All patients are significantly immunosuppressed.
Five of the patients and 1 staff member are currently reported to have diarrhoea.
Faeces samples are received and tested using a multiplex PCR covering norovirus,
sapovirus, astrovirus, rotavirus and adenovirus
Patient has no diarrhoea, but has RNA virus present in stool sample
What further tests would you consider?
3 month old - could be rotavirus vaccine at 8 and 12 weeks.
Check history
Rotavirus VP4/ VP7 typing
make sure no contamination from other viruses - unclear why patient tested if no diarrhoea
enterovirus/ parechovirus?
Maybe patient has pneumonia/ URTI/ meningitis from viral infection
