Path Flashcards
Diagnostic criteria of SIADH
Low plasma sodium (< 135)
* Low plasma osmolality (< 270)
* High urinary sodium (> 20)
* High urinary osmolality (> 100)
* No adrenal/thyroid/renal dysfunction
Sodium in DI?
High
Treatment for high potassium?
- IV calcium gluconate
- IV insulin with dextrose
If potassium is low, remember to check what?
Magnesium level
What to do if high potassium level?
Check again before treating
A patient has had hypertension at a young age and the following blood test results on his U&Es: Na 147, K 3.2, urea 5.0, Cr 70.
What is the next best investigation to confirm the likely diagnosis?
Aldosterone renin ration
Effect of calcitonin?
Less bone reabsorption by osteoclasts
Decreased Ca reabsorption at
DCT
Severe low calcium treatment
IV calcium gluconate
What has lowest calcium: osteomalacia or secondary hyperparathyroidism?
Osteomalacia
Management of hypercalcaemia in the acute setting is?
Fluids, fluids, fluids
Commonest cancers that can metastasise to the bone are?
Prostate, breast, lung
Normal anion gap level?
14-18
Normal plasma osmolality?
275-295
Marker of acute liver dysfunction?
INR/PT
Should urobilinogen be in urine?
YES
Raised AST:ALT > 2:1?
Alcoholic hepatitis
Raised AST:ALT < 1:1
Viral hepatitis
ALT/AST in the 1000s
Acute viral hepatitis, ischaemic hit, toxins
Antibodies in Hashimoto’s disease
Anti-thyroid peroxidase, anti thyroglobulin
Primary atrophic - goitre or no goitre?
No goitre
Treatment for myxoedema coma
I.V Liothyronine
Subclinical hypothyroidism results?
Pre-hypothyroid
Pituitary gland can compensate
High TSH, normal T3/4
If positive anti TPO Ig then higher risk of hypothyroidism later
Radiolabelled iodine uptake scan.
Multiple nodules?
Toxic goitre
Radiolabelled iodine uptake scan.
Generalised increase
Grave’s disease
Radiolabelled iodine uptake scan.
De Quervain’s sign?
Cold thyroid
Radiolabelled iodine uptake scan. What is seen with adenomas??
Focal lesions
Graves’ specific signs and symptoms?
Pretibial myxoedema (soft tissue growth at the shins and skin changes), graves’ orbitopathy is also another specific sign (caused by retrobulbar soft tissue growth), and is characterised by lid lag, exopthalmos and opthalmoplegia.
Medical management of hyperthyroidism
include carbimazole and propylthiouracil.
There are five indications for a thyroidectomy (either full or partial) - name them
)Treatment resistant graves, suspicion of malignancy, cosmetic, or co-existing hyper-parathyroidism.
It is important to ensure patients are euthyroid before radio-iodine or surgery because the treatment / operation can both induce thyroid storm.
Acromegaly Ix
Oral glucose tolerance test
Measurement of GH
Plasma IGF-1
Hashimoto’s can cause which thyroid tumour?
Lymphoma
Psammoma bodies in which thyroid cancer?
Papillary
What stimulates prolactin?
TRH
CPFT: combined pituitary function test - what is given?
GnRH, TRH and insulin
Which blood marker is monitored to check for recurrence of papillary thyroid carcinoma post resection?
Thyroglobulin
Which medication is used for hyperthyroidism?
Carbimazole
Commonest cause of hypothyroidism in the UK?
Hashimoto’s
Reticularis secretes what?
Sex hormones
What does the adrenal medulla produce?
Catecholamines
What does the adrenal medulla produce?
Catecholamines
Purpose of high dose dexamethasone test?
Helps to determine Cushing’s syndrome from disease
What is Cushing’s disease?
Cushing disease occurs when Cushing syndrome is caused by an ACTH-producing pituitary tumour, whereas Cushing syndrome is the set of symptoms that results when there is a surplus of cortisol in the body.
Treatment of Conn’s syndrome?
Spironolactone
Sulphonylurea
gliclazide
DPP-4 agonists
Sitagliptin
SGLT-2 inhibitors
Empagliflozin.
Add GLP-1 antagonist
Liraglutide
DKA criteria:
Ketones >3
pH <7.3
BM >15
A patient presents with new-onset type 2 diabetes, an enlarged jaw and forehead and carpal-tunnel syndrome. Which investigation would be most useful to diagnose the likely cause?
Short SynACTHen test
Combined pituitary function test
Measurement of plasma [growth hormone]
Low-dose dexamethasone suppression test
Oral glucose tolerance test
c)
Sign of AML?
Auer rods
Acute Promyelocytic Leukaemia
T(15;17)
Presents with DIC. Good prognosis
All-Trans Retinoic Acid (ATRA)
Forces cells to differentiate, stops proliferation
Ruloxitnib is what?
- JAK inhibitor
CML association?
Philadelphia chromosome - treat with imatinib
How is 9:22 dected?
FISH
Blast phase of CML?
> 20% blasts in bone marrow
Behaves like an acute leukaemia
Accelerated of CML?
> 10% blasts in bone marrow
Sign of CLL?
Smudge cells
Richters syndrome:
Transformation of CLL to aggressive disease (ALL / high grade lymphoma)
Staging of CLL?
A – no cytopenia, <3 areas of lymphoid involvement
B – no cytopenia, 3+ areas of lymphoid involvement
C – cytopenias
A – watch and wait
B – consider treatment
C – treat
Treatment for CLL?
Venetoclax (BCL2)
Obinutuzumab (CD20)
Ibrutinib (Brutons TK inhibitor)
FCR (fludarabine, cyclophosphamide, rituximab)
> 20% blasts = What?
AML
Most common Hodgkin lymphoma?
Nodular sclerosing is the most common type
MGUS
Serum monoclonal protein <30g/l
Plasma cells <10% on Bone Marrow
Smouldering myeloma
Serum monoclonal protein (IgG / IgA) >30g/l or Bence Jones Protein
And/or
Clonal bone marrow plasma cells 10%-60% in the marrow
waldenstrom’s
lymphadenopathy, weight loss, splenomegaly
IgM paraproteins
55 year old man presents to his GP with lethargy, fatigue and lymphadenopathy. Blood results show: WCC 7 Hb 90 MCV 80 Na 140 K 4.0 Creatinine 90 Calcium 2.5
Serum electrophoresis shows an IgM paraprotein of 37 g/l
What is the most likely diagnosis?
Acute leukaemia
Multiple Myeloma
Smouldering Myeloma
MGUS
Waldenstrom’s Macroglobulinaemia
E)
55 year old man presents to his GP after a 2 week history of fatigue and easy bruising. Blood results show:
WCC 27 Hb 90 Plt 30
Na 140 K 4.0 Creatinine 90 Calcium 2.5
Blood film shows presence of blasts (see below) with 55% blasts in marrow. Flow cytometry shows a clonal population of cells expressing CD34, MPO, CD13, CD33.
AML
ALL has which cells?
Hand-mirror cells
Do flow cytometry
TREMATODA- flukes?
Schistosoma spp.
Fasciola hepatica
CESTODA- tapeworms
Taenia solium
APICOMPLEXA
Toxoplasma gondii
Plasmodia spp
Complication of taenia solim?
Cysterciocisis (in the brain)
Treatment of neurocysticercosis
Steroids
Anti-convulsants
Anti-parasitics
Surgery
How does hookworm infect?
Penetrates skin
Schistoma affects what organ?
Liver
Treatment for schistomiasis?
Praziquantel
Name the process by which a strain of influenza may rapidly modify whole segments of its genome?
Antigenic shift
What step in the influenza replication cycle does tamiflu inhibit?
Cell exit
Which Plasmodium species causes cerebral malaria?
Plasmodium ovale
Plasmodium knowlesi
Plasmodium falciparum
Plasmodium vivax
Plasmodium malariae
Plasmodium falciparum
What is Toxoplasma gondii’s definitive host?
Domestic cat
Which organism is the leading cause of adult onset seizures in the developing world?
Taenia solim?
Gram positive bacteria stain what colour?
Purple
Gram negative stain what colour?
Red/pink
8-16hrs after reheated meat, watery diarrhoea lasts 24hrs
Gas gangrene
Clostridium perfringens
Descending paralysis after canned foods/honey
Clostridium botulinum
Treatment of typhoid?
IV ceftriaxone
Treatment for mild malaria?
Mild: artemisin combination therapy (Riamet – artemether + lumefantrine)
What are Negri bodies associated with?
Rabies
Treatment - Rabies IgG post-exposure (passive vaccination)
Cause of Q fever?
Coxiella burnetii, from cattle/sheep
Signs of Q fever?
Atypical pneumonia symptoms: fever, dry cough, pleural effusion
Mixed growth, squamous epithelium - MC&S?
Contaminated sample
Upper UTI management?
Upper: admit, IV co-amox + gent
Chlamydia Serovars L1, L2, L3 cause what?
lympho-granuloma venereum (LGV)
Serovars A, B, C: trachoma can cause what?
Blindness
Treatment for chlamydia infection
Treatment:
Azithromycin 1g stat, or
Doxycycline 100mg BD 7d
Male urethral discharge?
Gonorrhoea
Treatment for gonorrhoea?
Treatment:
Ceftriaxone 250mg IM STAT
Secondary syphilis?
Bacteraemia after 1-6 months fever, lymphadenopathy
Rash on palms and soles
Condyloma acuminate (genital warts)
Signs of tertiary syphilis:
30yrs later 3 different syndromes:
Gummatous: skin/bone/mucosal granulomas
Cardiovascular: mimics any cardiac disease; aortic root dilatation
Neurosyphilis: dementia, tabes dorsalis, Argyll-Robertson pupil
Treatment for syphillis
Treatment: IM benzathine penicillin STAT
TB meningitis findings on LP?
Clear / turbid
Low
High - mononuclear
Bacterial meningitis findings on LP?
Bacterial
Turbid
Low
High - polymorphs
Hospital acquired pneumonia?
S. aureus, Klebsiella, Pseudomonas, Haemophilus
ABx cause of pseudomembranous colitis
3Cs (clindamycin, cephalosporins, ciprofloxacin)
Small non-tender nodules in IE?
Janeway lesions
Painful nodules in IE?
Osler’s nodes
Example of glycopeptide?
Vancomycin
Example of aminoglycoside?
Gentamicin
Example of macrolide?
Erythromycin
Example of fluoroquinolone?
Ciproflaxin
Which antibiotic inhibits DNA synthesis?
Fluoroquinolones - Ciprofloaxin
Treatment for pharyngitis?
Benzylpenicillin
MRSA resistance mechanism?
Bypass antibiotic-sensitive step in the pathway
Beta-lactam resistance mechanism?
Enzyme-mediated drug inactivation
Tetracycline resistance mechanism?
Impairment of accumulation of the drug
Modification of the drug target is the mechanism for which resistance?
Quinolone
Signs of late LGV?
Inguinal lymphadenopathy, genital elephantiasis
Treatment for syphillis?
Single dose IM benzathine penicillin
Jarisch-herxheimer reaction is seen with which disease?
Syphilis
Donovanosis associated with what?
Large, beefy red ulcers. Donovan bodies.
Duke’s criteria for IE?
2 major, 1 major + 3 minor, 5 minor
What organism causes the plague?
Yersinia pestis
What organism causes the plague?
Yersinia pestis
What causes anthrax?
Bacillus anthracis
Signs of anthrax?
Painless round black lesions + rim of oedema
Massive lymphadenopathy + mediastinal haemorrhage
Visceral leishmania is also known as what?
Kala Azar
Treatment for aspergillus?
voriconazole
What does terbinafine target?
Mould cell membrane
Echinocandin eg. caspfungin inhibits what?
Cell wall yeast (less toxic SEs)
How can varian CJD be diagnosed?
Tonsillar biopsy
Protein in sporadic CJD?
14-3-3
Most cases of CJD affect which codon?
129 codon MM
Which CJD has an earlier age of onset?
Variant
First symptom of variant cJD?
Dementia
First symptoms of sporadic cJD?
Rapid, progressive dementia with myoclonus
What is the fontana stain for?
melanin
Cytokeratin is a marker of what?
Epithelial cells
Unstable occlusion is what level of sclerosis?
> 90%
Arrythmia after MI?
Ventricular fibrillation - occurs in the first 24 hours
Common causes of heart failure?
Ischaemic heart disease, myocarditis, hypertension, cardiomyopathy
Mutation in Kostmann syndrome?
Mutation in HAX1 protein
Treatment of Kostmann syndrome?
G-CSF
What has absent pus formation?
Leucocyte adhesion deficiency. High neutrophil count
What is deficient in leukocyte adhesion deficiency?
Deficient CD11a/18
What is the deficiency in chronic granulomatous disease?
Deficiency of NADPH oxidase complex
Nitroblue tetrazolium test negative?
Yellow
Cytokine deficiency
Mycobacterial infection
Salmonella infection
Membrane attack complex deficiency - what organisms at risk of?
NHS
N. meningitidis
S. pneumoniae
H. influenzae
Alternative complement deficiencies - at risk of what?
Infections with encapsulated bacteria
Ix classical pathway activity?
CH50
Ix alternative pathway activity?
AP50
A 5 month old baby girl presents with recurrent fungal infections and diarrhoea, with failure to thrive. There is a family history of early infant death. Blood tests show:
Absent B cells
Absent T cells
Absent NK cells
What is the diagnosis?
ADA deficiency
Reticular dysgenesis mutation?
Mutation of adenylate kinase 2 (AK2)
Mutation in X-linked SCID?
γ-chain of IL-2 receptor
ADA deficiency
Adenosine deaminase deficiency
Required for lymphocyte metabolism
Low B, T, and NK cells
Treatment of Bruton’s X-linked a-gammaglobulinaemia?
IVIG
Bruton’s X-linked a-gammaglobulinaemia
X-linked
Defective B cell tyrosine kinase gene
Pre B cells cannot develop into mature B cells
No circulating Ig after 3 months
Absent lymph nodes and tonsils
What cells does SCID have?
B cells
2 year old girl
Recent episode of severe staph aureus sepsis
Background: delayed separation of umbilical cord and severe skin infections
WCC normal, lymphocytes normal
Neutrophils high
Ig normal
NBT normal
Diagnosis?
Leucocyte adhesion deficiency
HLA association Goodpasture’s
HLA -DR15
HLA association SLE?
HLA-DR3
HLA association Grave’s disease?
HLA-DR3
What is libman-Sacks endocarditis associated with?
associated with SLE andanti-phospholipid syndrome
Central tolerance breakdown: APECED
Mutation of transcription factor AIRE: responsible for expression of self antigens in thymus to enable –ve selection of autoreactive T cells
ALPS
Mutation in Fas pathway
T cells NOT killed in thymus enter periphery untolerised
Autoimmune
Lymphoproliferative
Syndrome
Large spleen and lymph nodes
Autoimmune cytopenia
Lymphoma
IPEX signs?
Immune dysregulation
Polyendocinopathy
Enteropathy
X-linked syndrome
Diarrhoea, diabetes and dermatitis
15 year old with recurrent candidiasis, nail pitting and hypoparathyroidism. Name the causative mutation.
Mutation in TF AIRE
10 year old with abdominal fullness and splenomegaly. FBC reveals high lymphocytes. History of autoimmune thrombocytopenia. Diagnosis?
ALPS
Gel and coombs classification of T1DM?
Type 4
Patient develops skin rash, joint aches and fever after being given penicillin for a chest infection - gel coombs classification?
Type 3
A 12 year old boy presents with haematuria and proteinuria. He has recently been discharged following severe meningococcal septicaemia. There is abnormal fat distribution.
C3 levels are low, and C4 levels are normal.
What is the underlying diagnosis?
Nephritic factor deficiency
Examples of conjugate vaccines?
NHS
Adjuvant
= a substance which enhances the body’s immune response to an antigen
brown fluid aspirated from a lump, which then resolved spontaneously
Benign cyst
Stellate mass with fibrosis
Radial scar – benign sclerosing lesion, glandular tissue
Biopsy of a lump showing epithelial cells
Phyllodes (fibroepithelial and stromal) >50y
-Man with AF who presented with loin pain and fevers
Renal infarct
smoker with raised parathyroid-related polypeptide
Squamous cell carcinoma
-Decreased Na+ in newborn
(CAH 17-OH progesterone)
Swelling of lower limbs with cANCA positive
Wegener’s (against proteinase-3)
-Oedema + have to look at picture provided which shows a red cell cast
Guy with IHD placed on an ACE inhibitor and develops renal failure
Renal artery stenosis
Guy post prostatectomy with normal urine osmolality and hyponatraemia
TURP syndrome
Deficiency in beri beri syndrome?
B1
Causes PML
JC virus
Cellular mediated rejection
T cells
Body cavity lymphoma
HHV8
Blast cells are seen in AML?
Yes
Normal skin pathogen with low pathogenicity
Staph epidermidis
Pneumonia in smoker
Moraxella catarrhalis
● Enzyme raised in rhabdomyolysis
Creatinine kinase
- Chronic liver failure sign?
Low albumin
Enzyme in mumps
> Amylase
- High TSH, low T3 and 4
myxoedema
- Impaired glucose tolerance
7.8-11.0?
Impaired fasting glucose?
6.1-6.9
- High TSH, high T4, low t3
TSH producing pituitary adenoma
– hashimoto’s
(anti-Thyroid peroxidase), anti-thyroblobulin
- Rate limiting haem synthesis
ALA synthase
MI markers
Troponin, CK(MB), LDH, AST
Types of renal stone
● Renal stones: Calcium oxalate (radiopaque, struvit) mg ammonium phosphate (Proteus, Staghorn), Uric acid (radiolucent)
● Patient with IgM paraprotein
Waldenstrom’s Macroglobulinaemia
- Greek, anaemic, frontal bossing, HSM, hair on end appearance
Thalassaemia
Woman who received a transfusion before her hysterectomy who presented with bleeding gums and rash on her shins on discharge
Post transfusion purpura
c) Transfusion in past, allergy plasma proteins
Washed red cells
- Acute SOB, dry cough, and Hypoxia >
Transfusion associated lung injury
Coeliac disease cancer?
EATL
● Fibroepithelial tumour with abundant stromal elements
Phyllodes tumour
Patient with a cancer in their bladder following chronic schistosomiasis
Squamous cell carcinoma
loss of E-cadherin in breast cancer?
Lobular carcinoma in situ
- PTH secreting lung tumour?
Squamous cell carcinoma
GORD cell changes
Metaplasia squamous to columnar
- Polyps not associated with cancer risk
Hamartomatous
- Raised amylase and abdo pain
Acute pancreatitis
Patient with a mass following acute pancreatitis
Pseudocyst
- Mass under dura mater compressing parietal lobe
Meningioma
- Tumour which secretes oestrogen
Theca or Granulosa tumour
- Most common malighant gynae cancer
Endometrial carcinoma
Man has an MI 3 years ago. Now he comes into hospital and very unwell. Blood is aspirated from the pericardium
Myocardial rupture
Cell of the immune system that makes pus when it dies
Neutrophils
● Cell whose activity is inhibited by MHC Class 1
NK cells
● When they eat cherries, apples, pears and hazelnuts, they get itchy mouths but are fine when they eat apple pie
Oral allergy syndrome
lammatory syndrome which is 90% inheritable and associated with sacroilitis
Ankylosing spondylitis???
Used to treat osteoporosis, when the patient cannot tolerate bisphosphonates
Denosumab, RANKL inhibitor
Causes progressive multifocal leukoencephalopathy
John Cunningham Virus
- Chemokine promoting eosinophil growth
IL-5
- Recurrent meningitis
C7 deficiency
Monocytes resident in peripheral skin cells
Langerhans?
Mentioned FAS pathway
- ALPS (Auto-immune Lymphoproliferative Syndrome)
- TPMT levels should be checked before giving what?
Azathioprine
- In RA high anti CCP levels due to what?
PADI enzymes
- TH1 cells
subset of cells that express CD4 and secrete IFN gamma and IL2
- CTLA4 receptor for CD80/CD86 on t cells
asx with autoimmune conditions like diabetes and thyroid disease
- Anti Jo association?
dermatomyositis and polymyositis
- ANti scl-70
diffuse systemic sclerosis
hep C treatment?
IFN alpha
x linker hyper IgM syndrome tx?
- Human normal immunoglobulin
- Basiliximab (anti il2 receptor)
antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection
IMMUNE modulation SEs
a. Cyclophosphamide - infertility
b. Prednisolne - osteoporosis
c. Azathioprine neutropenia particulary if TPMT is low
d. Cyclosporin - hypertension
e. Mycophenoloate mofetil - progressive multifocal leakuencephalopathy
Man goes to wedding in Devon, comes back with pneumonia + confusion
Legionella
- Urethritis, arthritis, eye problems
Reiter’s syndrome (can’t see, pee climb a tree)
- MSM, severe flatulence, steatorrhoea, Cysts
Giardia lamblia
- Haemorrhagic cystitis in kids
Adenovirus?
- Molluscum contagiosum cause?
Pox virus
ring enhancing lesion
● HIV Tuberculoma
mass under dura mater compressing frontal lobe (usually)
Meningioma
Interferon beta treats what?
Behcet’s
Relapsing Multiple Sclerosis
Pembrolizumab (PD1)
Metastatic Melanoma
Ipilimumab (CTLA4)
advanced melanoma
Nivolumab (PD1)
Hodgkin’s Lymphoma
Atezolizumab (PDL1)
Metastatic Bladder Cancer
A 35-year-old man develops diarrhoea with fever and malaise 24 hours after eating a take-away meal. Stool cultures reveal the source of the infection is Salmonella spp. Which antibody is responsible for protecting against gastrointestinal infections?
IgA
Conjugate vaccine?
Pneumococcus
Which of the following is not safe in patients with HIV?
Yellow fever
Mycophenolate
Infection, particular risk of HSV reactivation and
progressive multifocal leukoencephalopathy (PML) (reactivated JC virus)
Progressive neural demyelination condition
Replace what with methotrexate?
Folate
mTor inhibitor MOA?
Inhibits IL2 signaling pathways
TTP
ADAMST13 enzyme
pentad of symptoms including confusino
How do you manage TTP?
Plasma exchange
Serum methylmalonic acid
Elevated in vitamin B12 deficiency
