Pastest: Infectious disease Flashcards
Rash > Diagnosis
Buccal lesion:
Whitish papular (Koplik spot) > Measles
Flat, broad, whitish, wart-like (Condyloma latum) > Secondary syphilis
Rash:
Florid erythematous rash, maculopapular rash (from behind the ear/face to caudally to trunk, arms) > measles
Transitory, erythematous rash (on ear, face, neck) > rubella
Slapped cheeks, erythematous rash over cheeks (spares forhead, nasolabial fold), lace-like reticular rash on trunk > parvovirus B19
Non-blanching petechial/purpuric rash > menongococcaemia
Symmetrical, non-pruritic, purple-pink/reddish-pink rash on trunk extremities, palms, soles > secondary syphilis
Elderly + slowly-growing lesion over that line on face + may ulcerate + no travel history > BCC
Oral mucous/ genital painful ulceration, multiple vesicles with ulceration, shallow ulcers +/- bilateral inguinal lymphadenopathy, shooting pain, urethral discharge > Herpes
Travel history to African countries, middle east, Syria + initial bite/nodule, gradually ulcerates > Leishmaniasis
Children + multiple, vesicular/looking leisons > Molluscum
After starting antibiotic (penicillin, amoxicillin, ampicillin) > itchy, maculopapular rash > Dx: EBV > IOC: Monospot test for heterophile Ab > Tx: supportive; if aplenomegaly > avoid contact sports
After 6weeks to 6months of infection > Rash = scaly of trunk, palms, face, soles + NO h/o penicillin + may H/O primary syphilis/chancre > Dx: Secondary syphilis
- Penicillin causes maculopapular rash, only if patient has underlying EBV = infectious mononeucleosis
After a patch on trunk (= herald patch) > rash on trunk (distinct small oval lesions) > Dx: Ptyriasis rosea
Non-blancing rash + signs of meningism, photophobia > Dx: N. meningitides (meningococcus)
FBC > viral/bacterial disease
Normal WBC, Leukopaenia, Lymphopaenia >>> Viral disease
Leukocytosis >>> Bacterial disease
Clinical features + CSF findings >>> (Diagnosis) >>> Treatment
Confusion >>> meningitis (also), encephalitis
Neck stiffness >>> meningitis, encephalitis (also)
If immunocompromised >>> fungal meningitis
CSF >>> differentiate between 3 types of meningitis +
ZN stain >>> do NOT rely on it, can often be negative in TB (given as a distraction)
Gm stain -ve >>> rules out bacterial; +ve >>> bacterial
- gm -ve diplococci >>> Dx: Neisseria meningitides (Meningococcus)
- gm -ve rods >>> Dx: Haemophilus influenzae, E. Coli, pseudomonas aeruginosa (pseudomonas is hospital acquired)
- gm +ve diplococci >>> Dx: Streptococcus pneumoniae (pneumococcus)
- Rash are present in both meningococcus and pneumococcus >>> so pattern of rash & gram stain in important
- Cold sores, elderly patient may be associated with pneumococcus
CT scan >>> if meningeal enhancemnt >>> go for meningitis
Tx: (1st line)
TB meningitis >>> RIPES + Steroids
Viral meningitis/encephalitis >>> IV acyclovir
Bacterial meningitis >>> IV Cefotaxime (+/- add benzylpenicillin if <3m or >50years)
Fungal meningitis >>> anti-fungal (e.g. amphotericin B)
Dog bite >>> organisms
- Pasteurella maltocida (most common)
- S. pyogens
- Capnocytophaga
Animal bite > 1st line TOC
Co-amoxiclav
Travel history >>> diagnosis
West Africa & those countries (e.g. Gambia) >>>
1st to think: Malaria
High fever, rigors, diarrhoea, vomiting, hypotension >>> Malaria
Fever, headache, loose stools, +/- leukocytosis, thrombocytopaenia >>> Malaria >>> IOC: Thick blood film
- Thick blood film shows: type of malaria + stages of parasite in RBC
- (thin film to show a geater detail)
Fever, constipation >>> Typhoid
Fever, cough, sputum >>> Atypical pneumonia
*** Malaria prophylaxis do NOT exclude malaria (given as a distraction)
Businessman travelling to South Africa >>> fever, malase, LNpathy, acute nephritis + urine protein ++, blood ++ >>> Dx: Secondary syphilis (>nephrotic syndrome)
- D/D: HBV, HCV
- Plasmodium malariae causes nephrotic syndrome + membranous GN (but not acute nephritis)
RMSF >>> TOC
Oral doxycycline
If the patient is pregnant >>> TOC: Chloramphenicol
HBV serology to diagnosis
In questions about HBV >>>
Step-1: Look for any,
+ve s Ag / +ve e Ag / +ve HBV DNA >>> Active infection (whatever other findings are)
- Anti-HBc IgM +ve > Acute active hepatitis
- Anti-HBc IgM -ve + Anti-HBc IgG +ve > Chronic active hepatitis/ Carrier active hepatitis
- Hepatitis B vaccine is ineffective in acute/chronic active hepatitis
- +ve e Ag indicates high infectivity
+ve s Ag + -ve e Ag >>> Pre-core mutant HBV >>> do HBV DNA
Step-2: If not such > now look for any evidence of immunity,
both core Ab (IgG) + surface Ab >>> prior infection/latent infec.
surface Ab alone >>> Vaccinated
both core Ab + anti-HBe Ab >>> chronic carrier + low infectivity
***
Surface Ab = Anti-HBs Ab
Core Ab = Anti-HBc Ab
Prior infection = now cleared
Latent infection = any immunosupression can reactivate
Pre-core mutant = Active disease + but due to genetic mutation > produce only s antigen, doesn’t produce e antigen
***
HBsAg & HBeAg is used to define phase of HBV
HBsAg is +ve in acute & chronic active cases > So, can’t differentiate between these two > one isolated test that’s only +ve in acute active disease > Anti-HBc IgM
PEP TOC for HIV
Tenofovir disoproxil + Emtricitabine + Raltegravir
Jarisch- Herxcheimer reaction occurs in - ?
- Spirochete infection: Syphilis (Treponema pallidum), Lyme disease (Borrelia burgdorferi)
- Relapsing fever (other borrelia species)
- Leptospirosis
- Q fever (Coxiella burnetii)
Neck stiffness + photophobia + multisystem failture (liver failure = high ALT/AST, high bilirubin; renal failure = high urea, high creatinine) ->>> D/D ?
+ Conjunctivitis > Leptospirosis (hepato-renal syndrome)
+ dry cough, pneumonia > mycoplasma pneumonia + multi-organ failure
+ low consciousness + very low/significant hypotension > meningococcal sepsis + multi-organ failure
IOC for suspected legionella ?
Urinary antigen test
Fever + SOB + dry cough >>> Dx
Fever + SOB + dry cough > Atypical pneumonia
If lymphopaenia, hyponatraemia, deranged LFTs >> Dx: Legionella
If diarrhoea, air-conditioning >> Dx: Legionella
- Temp for colonisation and multiplication: 20- 45 C
- Droplet diameter for infection: <5 micrometer
If target lesions on skin (erythema multiforme) >> Dx: Mycoplasma
If CXR shows patchy (reticulo-nodular) shadow >> Dx: Mycoplasma
If h/o bird exposure >>> Dx: Chlamydia psittaci
Fever + SOB + h/o influenzae >> Dx: Staphylococcal pneumonia
Fever + SOB + cavitary lesion >> Dx: Klebsiella pneumonia, Staphylococcal pneumonia
Neurological infective diseases: D/D to Dx
Trismus (1st), then rigidity & spasm + trismus (lockjaw), risus sardonicus, opisthotonus (arched back, hyperextended neck), spasms (e.g. dysphagia) >>> Dx: Tetanus
Descending flaccid paralysis of autonomic & motor system (e.g. speaking: dysarthria, swallowing:dysphagia, visual: ptosis, neck: difficulty lifting head- neck etc.) + NO sessory change + NO LOC + h/o IV drug use >>> Dx: Botulism [from visual, speech, swallowing> neck, arms (before going into) > respiratory system
Risk factors of btulism: canned food, improperly preserved food, open wound, IV drug use; Cause: bacterial neurotoxin by ‘clostridium botulinum’
Ascending paralysis + reduced power in limbs + NO sensory change >>> Dx: GBS
IV drugs user + destruction around injection site + severe sepsis >>> Dx: Injection anthrax
Many weeks/months after dog bite > encephalomyelitis, confusion, hallucination, hydrophobia, hypersalivation >>> Dx: Rabies (also prodrome: headache, fever, agitation)
List of notifiable diseases to CCDC (consultant in communicable disease control)/ UK Gov/ public health england
Diseases notifiable to local authority proper officers under the Health Protection (Notification) Regulations 2010: (A to Z)
- Acute encephalitis
- Acute infectious hepatitis
- Acute meningitis
- Acute poliomyelitis
- Anthrax
- Botulism
- Brucellosis
- Cholera
- Diphtheria
- Enteric fever (typhoid or paratyphoid fever)
- Food poisoning
- Haemolytic uraemic syndrome (HUS)
- Infectious bloody diarrhoea
- Invasive group A streptococcal disease
- Legionnaires’ disease
- Leprosy
- Malaria
- Measles
- Meningococcal septicaemia
- Mumps
- Plague
- Rabies
- Rubella
- Severe Acute Respiratory Syndrome (SARS)
- Scarlet fever
- Smallpox
- Tetanus
- Tuberculosis
- Typhus
- Viral haemorrhagic fever (VHF)
- Whooping cough
- Yellow fever
Report other diseases that may present significant risk to human health under the category ‘other significant disease’.
*** HIV is not a notifiable disease: Newly diagnosed HIV cases are indcluded in national resgister.
Fever + sore throat > Diagnosis
EBV vs CMV:
Both > marked lymphocytosis, hepatosplenomegaly, anaemia
If an immunocompromised patient > Dx: CMV
If renal transplant patient > Dx: CMV
If negative IgG for EBV > Dx: EBV (A distractor)
- IgG can be regularly negetive for EBV; Since, IOC is IgM to EBV (by heterophile antibody test or Monospot test)
EBV vs Streptococcal pneumoniae (group A)
Both: palatal petechiae (absent in other viral diseases)
If uvular oedema and/or raised ESR > Dx: EBV
If hepatosplenomegaly > Dx: EBV
If rash after antibiotics > Dx: EBV
If no uvular oedema + normal ESR + no rash after antibiotics > Dx: Streptococcal pneumoniae
- In a patient with uvular oedema and/or raised ESR or any way with confirmed case of EBV > if streptococcal pneumoniae is found in throat culture > it is not infection, that is bacterial colonisation (so, do NOT treat that)
EBV vs HIV seroconversion illness:
Lymphopaenia > Dx: HIV seroconversion illness
Marked relative lymphocytosis >/= 60%, atypical lymphocytes >/= 10%, leukocytosis, atypical monocytes > Dx: EBV
EBV vs HAV:
If flu-like illness + gastroentritis + NO bone marrow supression, pharyngitis, splenomegaly > Dx: HAV
NO gastroenteritis + possible bone marrow supression (anaemia), pharyngitis, splenomegaly > Dx: EBV
EBV > drug-induced rash vs viral rash of EBV/infectious mononucleosis:
Both: maculopapuar
Pruritic + prolonged > Dx: Drug-induced (due to amoxicillin/ampicillin/penicillin in EBV patient)
Non-pruritic + rapidly disappears > Dx: Early viral rash of EBV
Clinical triad for EBV: fever + pharyngitis + lymphadenopathy
Specifics for EBV:
Bilateral posterior cervical LNpathy > Dx: EBV
Criteria to rule out EBV: Normal leukocyte count or lymphonaemia/leukopaenia
Other important features of EBV:
*hepatitis, abdominal pain, jaundice, deranged LFTs (high ALT, AST, bilirubin etc.)
*Anaemia
*Splenomegaly in 50% > splenic rupture
* enlarged tonsils
*Haemolytic anaemia, secondary to cold aglutinin
IOC for group A streptococcal infection >>> ASO titre
Rapid screening test for EBV >>> Serological test:
- Monospot test > to detect heterophile antibodies in serum , against viral coded proteins: 85% sensitivity
- False -ve (monspot -ve glandular fever) > outside of classic 15-25years range
- False +ve in pregnancy, autoimmune disease
Definitive test for EBV >>> serum IgM antibodies to EBV capsid antigen (VCA)
Mycobacterium or Acid-alcohol-fast bacilli or AFB (Acid-fast bacilli): D/D to Dx
Skin biopsy:
Multiple acid-alcohol fast bacilli > multibacillary: lepromatous leprosy
Limited one/few AFB > paucibacillary: tuberculoid leprosy
Features:
Extensive/multiple skin plaque + symmetrical nerve involvement > lepromatous leprosy
Limited skin plaque + asymmetrical nerve involvement > tuberculoid leprosy
Fish trunk granuloma in hand + handling of aquarium, fresh water, salt water, swimming > Mycobacterium marinum
Travel history:
D/D to Dx
Travel to to india, south asia, east asia:
- Fever, night sweat, weight loss, raised inflammatory markers >>>
- Neutrophilia, deranged LFTs, non-caseating granuloma >>> Brucellosis (gram -ve bacillus)
- Lymphocytosis, caseating granuloma, other classical features of TB >>> TB (blood culture is not usually +ve, culture of respiratory secretion takes weeks to yeild bacteria)
- Ingestion of unpasteurised milk, exposure to infected cattles >>> Brucellosis (More common in middle east, north europe, north america)
- hepatosplenomegaly
- sacroilitis: spinal tenderness
- spondylitis > associated rheumatic features (about 50% of cases)
- complications: osteomyelitis, infective endocarditis, meningoencephalitis, orchitis, leukopenia is common
- Screening: Rose bengal plate test
- Confirmatory: Brucella serology
Travel to tropics, india & return:
- Fever, headache >>>
- Constipation, sparse generalised rash, small papules >>> Dx: Typhoid
- though relative tachycardia in other sepsis condition, here it has relative bradycardia (even around 70 is relative bradycardia for sepsis patient)
- early disease may have diarrhoea for a short period; later may develop hepatosplenomegaly
- Dry cough, couple episodes of slighly loose stools, haemodynamically stable, relative bradycardia, palpable spleen, Gm -ve bacilli > Dx: Enteric fever
- Abdominal pain, rose spots may also be found
- Enteric fever is caused bby S. typhi and S. paratyphi
- Loose stools/diarrhoea, haemodynamically unstable. Gm -ve bacilli, +/- urinary S/S, renal angle tenderness > Dx: E. Coli
- Intermittent abdominal bloating + irritable bowel syndrome (diarrhoea and constipation) + NO rash >>> Dx: Giardiasis by Giardia lamblia
- Catholic priest + Trip to india + flu-like illness + fever, myalgia, RUQ pain, deranged LFTs: high bilirubin, high ALP, very high ALT + took all recommended vaccines and malaria prophylaxis +/- low platelets > HEV
- Catholic priest > excludes sexually or blood-related transmitted infections (HBV, HCV)
- taken all vaccines > would prevent against HAV (not full protection against HEV)
- periodic fever + bone pains + aches + low platelets > would Dx: Dengue
- HEV is an RNA herpes virus with 4 genotypes: Mainly occurs in South Asia, Central Asia, Middle east, North Africa
- It is acquired faeco-ral route, NO chronic form, high mortality in endemic areas; Most deaths occurs in pregnant female in their last trimester of pregnancy
- IOC: IgM anti-HEV in serum ; NO treatment & NO vaccine
- After 4-7days (tropical Queensland, india) > headache, flu-like symptoms + generalised rash + leukopaenia, lymphopaenia >>> Dx: Dengue
- After 4-6weeks + fever, anorexia, malaise, splenomegaly, LNpathy, fatigue +/- thrombocytopaenia >>> Dx: EBV
- Normal WBC/Low WBC rules out EBV
- Acute onset rules out EBV
- Fever > headache. malasie, myalgia +/- jaundice, hepatosplenomegaly + No rash >>> Dx: Malaria falciparum
- Fever, headache, malaise, myalgia, nausea, vomiting, photophobia + NO generalised rash + NO abdominal pain > D/D: Influenzae
- Sickle cell anaemia patients + pancytopaenia + rash in cheeks >> Dx: Parvovirus
- Generalised rash rules out parvovirus
- Mild-self limiting disease in children
- Constipation, sparse generalised rash, small papules >>> Dx: Typhoid
Travel to African countries:
- non-specific: lathergy, night sweats, anorexia, gradual weight loss; + pancytopenia + hepatosplenomegaly + raised ALT + raised ALP + erythematous plaque on buttock >>> Dx: Visceral leishmaniasis > TOC: Na stibogluconate IV
- S/E of Na stibogluconate: ECG changes of arrythmia, acute (chemical) pancreatitis,; (nausea, fatigue, abdominal pain)
- Alternative therapy: Pentamidine
- “Amastigote” from lymph node, bone marrow, spleen >>> Dx: Leishmaniasis
- Travelling to ‘Sierra Leone’ rural > high fever, diarrhoea, vomiting > D/D: Ebola >> Send the patient direct to an isolation unit
- Sierra leone is ond of the “prevalent regions” for Ebola virus >>> send the patient to an isolation unit (as s protocol for escorting suspected patients)
Travel to East-Asia, Thiland, Africa:
- h/o eating local food >>> watery diarrhoea + eosinophilia + larvae in stool of strongyloides >>> Dx: S. stercoralis
- From Uganda + high eosinophil + urticarial rash over buttock, waist, diarrhoea, abdominal pain >>> Dx: S. stercolaris
- From Thiland, elephant Safari > denies other sexual contacts + generalised itch, dry cough, diarrhoea + high eosinophil count >>> Dx: S. Stercoralis >>> Tx: Ivermectin
- Gradual weight loss + intermittent IBS + chronic dry cough + significant gradual weight loss + high eosinophil >>> Dx: S. stercoralis
- It is more common in tropics, subtropics, far-east
- The most likely risk factor of S. stercoralis is >>> walking barefoot
- Chronic S. stercoralis infection >>> vague symptoms of abdominal pain, features of malabsorption, eosinophilia, diarrhoea, urticaria
- It causes marked eosinophilia > hallmark of tissue invasive helminth infection
- Diagnosed by:
- Stool/duodenal fluid > larvae
- Antibodies (mainly in chronic infections)
- TOC: Ivermectin (highest rate of eradication = 97%) and Alternative: Albendazole (only if ivermectin is unavailable)
Travelling to certain tropicals, Guatemala:
- Fully vaccinated prior travel + malaria prophylaxis >>> Vegetraian & ate salads-fruits + Chronic severe diarrhoea + no response to ciprofloxacin & metronidazole (=not bacterial) >>> Dx: Ciclospora Cayetanesis >>> TOC: Co-trimoxazole
- Immunocompromised are particularly affected
- Varied presentation depending upon person’s immune system
- Flu-like illness >>> incubation around a week
- NO alternatives to Co-trimoxazole yet
- Co-trimoxazole is used in typically in PCP pneumonia
* Swiming in fresh water >>> Dx: Schistosomiasis
- eosinophilia (maybe) + haematuria (due to colonisation around venous plexus in urinary bladder) >>> Dx: S. haematobium
- Africa + malaise + abdominal pain + frequent blood-stained stool >>> Dx: S. mansoni
* Marked lymphoedema >>> Dx: Wucheria bancrofti
Cerebral abscess > initial IV antibiotics > oral antibiotic during discharge = antibiotic with best or broadest cover for anaroebic organism of this condition
(Antibiotics with anti-anarobic activity, with no anti-anarobic activity)
Co-amoxiclav (Amoxicillin + Clavulanic acid) >>> covers against:
- Beta lactamase producing gram +ve organism + anarobes
- Adequate brain penetration
- Amoxicillin alone do NOT cover enough against anarobes
Antibiotic with anti-anarobic activity:
- Penicillins
- Cephalosporins (except Ceftazidime)
- Erythromycin
- Metronidazole
- Tetracycline
Antibiotic with no anti-anarobic activity:
- Gentamicin
- Ciprofloxacin
- Ceftazidime
Paragonimiasis vs TB vs Sarcoidosis
Granuloma: D/D:
- Sarcoidosis
- TB
- Paragonimiasis
Haemoptysis, cavitating lesion, productive cough: D/D: (absent in sarcoidosis)
- TB: culture for AFB +ve, NO urticaria, NO eosinophilia
- Paragonimiasis: culture for AFB -ve. urticaria, eosinophilia
Time course of HIV after initial infection
- After infected with HIV >>> 2-12 weeks (mainly 2 to 4 weeks, rarely up to 10months) >>> HIV seroconversion >>> Latent / Asymptomatic period of 5-10years (even physical examination is normal, 1/3rd can be generalised LNpathy)
- After 18 months of infection >>> CD4 count goes below 500
- At average 5-10years (if kept untreated) >>> CD4 count goes below 200 = develops AIDS = AIDS defining illness
Abnormal prion protein in brain is related to > ?
CJD (Cruetzfeldt-Jacob disease)
Diarrhoea/Vomiting >>> Dx
Without given history of food/travel:
- Watery diarrhoea (frequently) + fever + history of antibiotics treatment (due to any cause) >>> Dx: Pseudomembranous colitis = Clostridium defficile infection/enterocolitis
- initial: mild self-limiting diarrhoea >>> to fulminating toxic megacolon
- tend to have week or more before seeking medical attention
- Due to diarrhoea > may have changes in electrolytes, high urea, creatinine, CRP
- TOC: Oral metronidazole or vancomycin + re-hydration
- Bloody diarrhoea + abdominal pain + diabetic patient + high serum lactate >>> Dx: Acute mesenteric ischaemia
With given history of food/travel:
- Contaminated food > bloody diarrhoea >>> Dx: EHEC (Enterohaemorrhagic E. Coli)
- Contaminated meat, egg, poultry, dairy products > acutely > abdominal pain, diarrhoea +/- headache >>> Dx: Salmonella gastroenteritis (may have septicaemia); no person-to-person spread, but many people may/may not expose to one site
- Contaminated food or dairy products > within 6 hours > severe vomiting (only) >>> Dx: Staphylococcus aureus toxin (contaminated from small abscess, whitlow, discharging lesion > food > warm + not fully cooked); may also have nausea, abdominal cramps, followed by diarrhoea; short-lived > resolved by 24hours)
- Acute presentation > abdominal pain, diarrhoea, blood, mucous >>> Dx: Shigella (bloody diarrhoea) +/- copious amount (electrolyte abnormalities due to diarrhoea & tender RUQ may follow)
- Children nursuries, toddler day-care >>> Dx: Shigella
- Children of nurseries + wrokers (multiple cases at a time); (human to human transmission is possible) >>> Dx: Shigella
- Contaminated fruits >>> Dx: Shigella
- H/o travel to Nile cruise >>> Dx: Shigella
- NO vomiting in shigella
- Shigella is highly infectious, passed via feco-oral route, aerobic, non-motile, gram -ve bacilli; > Mainstay of Tx: ORT, AB of choice: 3rd gen. Cephalosporin
- Shigella is widespreadly resistant against penicillin, and ciprofloxacin
- Self limiting in majority; indication of antibiotics:
- elderly, the infirm, and who work in childcare settings
- They improve symptoms, shorten duration, and reduce spread
- Contaminated water, milk, poutry > abdominal pain, fever, diarrhoea (bloody) >>> D/D: Campylobacter (no human to human transmission, all exposed to one source)
-
Chronic watery diarrhoea/explosive diarrhoea + flatulence + weight loss (due to malabsorption) +/- abdominal pain >>> Dx: Giardiasis
- Giardia is flagellated protozoa > > foecal-oral spread > infection of duodenum and jejunum
- Diarrhoea (NOT bloody), vomiting, malaise, same group of people of same place >>> Dx: Rota virus
- Non-bloody diarrhoea + vomiting (usually in group of people) >>> Dx: Norovirus (winter vomiting virus)
- Watery Diarrhoea in HIV-immunosupressed patients >>> Dx: Cryptosporidium (less commonly blood, self limiting, but can be very dangerous)
- CD4 count: 100 to 300 > think Cryptosporidium (profuse watery diarrhoea)
- CD4 count: <100 > think CMV (bloody diarrhoea)
- CD4 count <50 > think Micropolyspora (profuse watery diarrhoea)
- Some text says: CMV has CD4 <100, but it is the most common when CD4 <50 …… So, consider it when HIV + bloody diarrhoea + CD4 <100
Time period between food intake & symptoms:
- 12-48hours >>> diarrhoea + vomiting >>> Dx: Salmonella typhi/paratyphi
- 12-36hours >>> diarrhoea + vomiting + muscle weakness >>> Dx: Clostridium botulinum
- 1-5days >>> profuse watery diarrhoea >>> Dx: Vibrio cholerae
- 2-3days (48-72hours) >>> bloody diarrhoea, mucous-rich >>> Dx: Shigella
HIV patient + very recent history (days) of anal inter-course >> bloody diarrhoea with mucous >>> Dx: Shigella
- Cryptosporidium has profuse watery diarrhoea
- Microsporidum has large volume watery diarrhoea
- CMV has bloody diarrhoea but + need more long time to develop + CD4 <100
West African + chronic diarrhoea & weight loss for 10 weeks > episode of shingles 5weeks back + (headache, neck stiffness, increasing confusion) for few days + no mass lesion + 7th nerve palsy + CD4 <100 + raised ICP (= bilateral papilloedema) >>> Dx: Cryptococcus neoformans >>> TOC: Amphotericin B + Fluocytosine
Features of Viral infection of eye:
to Dx
-
Keratitis + dendritic ulceration of cornea >>> Dx: Herpes Simplex Virus (HSV)
- Acute pain, conjunctival injection, blurring of vision
- Risk of corneal blindness >> so, urgent treatment
- TOC: Topical Acyclovir
- C.I: Topical steroids
- D/D of keratitis: reduced tear formation >>> dry eyes + keratitis + NO corneal ulcer
- Conjunctivits + Gastroenteritis >>> Dx: Adenovirus
- Conjunctivits + Developing countries with poor hygiene + >>> (Trachoma, comes from flies) >>> Dx: Chlamydia trachomitis
- HIV patient or immunocompromised patient >>> D/D: CMV or HSV
- CMV retinitis is more common
- HSV can cause acute ncrotising retinitis in them
Jaundice >>> Dx
- Hepatosplenomegaly + _mild high AST/ALT, very high bilirubin, very high creatinin_e >>> Dx: Leptospirosis (Weil’s disease) > TOC: IV Penicillin
- Sewage worker >>> Dx: Leptospirosis
- Fishing trip, arthralgia, myalgia, dry cough, jaundiced sclera >>> Dx: Leptospirosis
- Travel by river side, Very high bilirubin, mild high creatinine, very high ALT, very high ALP >>> Dx: Leptospirosis
- may also have purpuric rash, scattered coarse crackles on auscultation, RUQ pain
- Possibility of exposure to ‘rat urine’ near the river bank
- Course of leptospisosis: After 2 to 30days of incubation period >>> abrupt onset of ‘flu-like symptoms’ >>> After 5-days of that illness >>> jaundice, coagulopathy
- Tx: Doxycycline, Penicillin, Cephalosporin & measures to reduce the rodent population
- Incubation 2-6 weeks >>> Flu-like illness (fever, malaise, anorexia, nausea. myalgia) > then, more prominent rise of AST/ALT, high bilirubin, normal creatinine >>> Dx: HAV
- Africa, South america emdemic region
- high AST/ALT, high bilirubin, fever, pharyngitis, lymphocytosis, anaemia +/- hepatosplenomegaly + immunocompromised/HIV/renal transplant >>> Dx: CMV
- high AST/ALT, high bilirubin, fever, pharyngitis, LNpathy, lymphocytosis, +/- hepatosplenomegaly >>> Dx: EBV
- Hepatomegaly + Ascites + Abdominal pain + NO fever >>> Dx: Budd-Chiari syndrome (occlusion of draining hepatic veins)
- Bloody diarrhoea + anaemia + Low platelets + deranged LFTs (= hepatic injury) >>> Enterotoxigenic E. coli O157 (= Haemolytic uraemic syndrome = HUS)
- Microangiopathic intravascular haemolytic anaemia
S/E of internferon-alpha (IFN-alpha) + Ribavirin therapy for HCV
Interferon-alpha (IFN-alpha) [S/C] >>>
- Flu
- Depression, emotional lability, mood changes
- Fatigue
- Thyroiditis
- Low WBC (Leukopaenia)
- Low platelet (Thrombocytopaenia)
Ribavirin PO >>>
- Haemolytic anaemia (most common S/E), cough
- reduces Hb up to 20g/L > so, it is avoided in >
- Previous h/o blood disorder
- Elderly
- Heart disease
- reduces Hb up to 20g/L > so, it is avoided in >
- Teratogenic (prevent pg during & up to 1 year from Tx; some say 6months, whatever sex is being treated)
* Viral genotype 2, 3, 3a (chronic infection) are more likely to respond to Rx
* genotype 4 has less responsiveness
* Telepravir for HCV can cause hypocalcaemia
* Rx response is checked by ALT level and viral load
* HCV can raise AST/ALT transaminases & creatinine (by GN); these are not by drugs
Vaccination in a COPD patient
- Annual influenzae vaccine (yearly basis- against influenzae virus (not against haemophilus influenzae type B = Hib)
- 5-yearly pneumococcal vaccine (Against streptococcus pneumoniae)
*** influenzae vaccine needed in annually post-splenectomy patient is also against influenzae virus (not against Hib; Hib vaccine against type haemophilus influenzae B is given 14days after emergency splenectomy or 14days = 2weeks before elective splenectomy)
Sickle cell anaemia patient >>> Associated virus-related illness
- Sickle cell anaemia patient >>> infected with parvovirus B19 >>> aplastic crisis
- Erythematous rash all over body
- Painful swollen joints
- Absent reticulocytes
Osteomyelitis >>> Management
Specific site identified (by MRI or other way)
- IV Flucloxacillin
- It will cover the S. aureus, the most common cause of osteomyelitis
- If doesn’t work > test for MRSA > if +ve, only then offer: Vancomycin + ciprofloxacin
- Other options like Co-amoxiclav, Meropenem, Cefotaxime + Metronidazole these can work against S. aureus… can be given if do NOT know the exact site of osteomyelitis
- They have S/E of Pseudomonas colitis risk
- But when we exact site is known > Prefer IV flucloxacillin over others (benefit outweigh the risk)
