Pathology Flashcards
Are fungi eukaryotic or prokaryotic?
Eukaryotic
Do fungi plasma membranes contain ergosterol?
Yes
What is the commonest cause of fungal infections in humans?
Candida spp.
What do we use to treat oral thrush?
Nystatin
What do we use to treat vulvovaginitis?
Co-trimazole (topical)
fluconazole (oral)
What is fluconazole used to treat?
Vulvovaginitis and oesophagitis.
Anidulafungin is an example of which drug class?
Echinocandin
C. Neoformans and C. Gatti are examples of organisms which cause which fungi?
Cryptococcus (a type of yeast).
Which animal is cryptococcus associated with?
Pigeons
Which variant of cryptococcus can cause Meningitis?
C. Gatti
What type of ink is used for a cryptococcal stain?
India = stains the CSF.
Which microorganism causes mycotoxicosis?
Aspergillosis (mould)
Name one fungi which actually lacks ergosterol in the cell wall.
Pneumocystis Jiroveci
What is a main risk factor for any fungi infection?
Immunosuppressed.
What is a dermatophyte?
A group of fungi characterised by the site they invade. e.g. tinea capitis. Invade the dead keratin of skin, nails, hair. LOVE DEAD KERATIN.
Tinea cruris’ target site is:
Groin
Tinea capitis target site is:
Scalp (cap)
Tinea corporis target site is:
Abdomen
Tinea pedis target site is:
Foot
Tinea pedis, capitis, corporis, crusis are examples of what?
Dermatophytes = examples of mould.
Pityriasis versicolor is caused by which fungi?
Malassezia furfur
What is the mechanism of azoles?
Inhibits the conversion of lanosterol - ergosterol by inhibiting cytochrome P450 enzyme: 14a demethylase.
SOB, cough in the history should point toward which fungal diagnosis?
Cryptococcus (associated with pigeons)
Which fungal infection can cause meningitis?
Cryptococcus
Give 5 risk factors for fungal disease:
Immunosuppressed Inhaled steroids malignancy Moisture (dermatophytes) Long lines (candida)
What does immunophenotype refer to?
Flow cytometry, immunohistochemistry
What does cytogenetics refer to?
FISH
Which is more common - Hodgkin’s lymphoma or non-hodgkin’s lymphoma?
Non Hodgkin’s Lymphoma.
Which is the characteristic cell on blood film in Hodgkin’s lymphoma?
Reed Sternberg cells
How do you diagnose Hodgkin’s lymphoma?
CT, PET, Blood tests, LDH, lumbar puncture
Name the 3 B symptoms
Fever, night sweats, weight loss.
Which is the most common type of Hodgkin’s lymphoma?
Nodular Sclerosing.
What does the cancer stage II describe?
> 1 group of nodes above the same side of the diaphragm.
What does the cancer stage I describe?
Only one group of nodes involved
What does the cancer stage III describe?
Nodes above and below the diaphragm involved
What does the cancer stage IV describe?
Extra nodal spread.
How do we treat Hodgkin’s lymphoma?
ABVD - Adriamycin Bleomycin Vinblastine Dacarbazine
+chemotherapy!
Which is the fastest growing type of Non-Hodgkin’s lymphoma?
Burkitt’s lymphoma
What does indolent mean?
Long term survival
i.e. less aggressive.
(paradoxically, more aggressive respond better to treatment).
Which is the lowest grade form of Non-Hodgkin’s lymphoma?
Follicular lymphoma
MZL - marginal zone lymphoma.
What is characteristic to see on blood film of chronic lymphocytic leukaemia?
Lymphocytosis
Smear cells
Which markers are seen in a normal B cell?
CD3-
CD5-
CD19+
Which markers are seen in a normal T cell?
CD3+
CD5+
CD19-
Which markers are seen in a malignant B cell?
CD3-
CD5+
CD19+
Where is Venetoclax used and how does it work?
Used in CLL - chronic lymphocytic leukaemia
Blocks the BCL2 protein.
Which is the most common malignant type of cancer?
Invasive ductal carcinoma
Which is the single most important prognostic factor for cancer?
Status of the axillary nodes i.e. is there metastasis?
Why are basal-like carcinomas so hard to treat with medication?
They are oestrogen/progesterone and HER2 negative.
Which are the three factors we look at in histological grading?
- Tubule formation
- Nuclear pleomorphism
- Mitotic activity
What is the purpose of NHS Breast screening programmes?
To screen for DCIS (ductal carcinoma in situ).
What would DCIS grade on a biopsy grade?
B5a
B5b = invasive carcinoma Grading = B1-B5. B1 = normal breast tissue, B2 = benign.
Which grade is benign tissue on biopsy?
B2! B1 = normal tissue.
How do we investigate breast disease?
Examination
Investigation: mammography, sonography
Pathology: cytopathology, histopathology
How are aspirates coded? What do these codes mean?
C1-C5
C1 = inadequate
C2 = benign
C5 = malignant
How is ‘benign’ coded on the cytology grading?
C2! C1 = normal tissue (inadequate) .
Define menarche
First occurrence of menstruation
Define fibroadenoma.
Benign fibroepithelial neoplasm of the breast.
Name x3 benign breast conditions.
Duct ectasia, mastitis, fat necrosis, papilloma
How would duct ectasia present in a patient?
And on microscopy?
Nipple discharge, breast tenderness.
Dilated ducts on microscopy
‘Painful, red breast’ points toward which diagnosis?
Acute mastitis.
Presentation with breast mass and can be confused for cancer. What is the diagnosis?
Fat necrosis
What is a papilloma?
Benign outward growth.
‘Benign neoplasm of the breast’ defines what?
Fibroadenoma
What is a Phyllodes tumour?
Benign but more aggressive fibroepithelial neoplasms.
Which are the receptors we assess when querying breast cancer?
Oestrogen receptor, progesterone receptor, HER2 receptor.
How will low grade tumours present receptor wise?
Oestrogen and progesterone receptor positive, HER2 receptor negative.
How will high grade tumours present receptor wise?
Oestrogen and progesterone receptor negative, HER2 receptor positive.
Tamoxifen targets which receptors?
oestrogen receptor.
Herceptin targets which receptor?
HER2 receptor.
Which are the vaccinations required at 8 weeks of age.
Diptheria Tetanus Pertussis Polio HiB (haemophilus influenzae) type B Hepatitis B
Name the three major pathogens at surgical site infections
Staphylococcus aureus
Pseudomonas aeruginosa
E.Coli
Give three things which increase an individual’s risk of surgical site infection.
- ASA score>3
- Diabetes - associated with post operative hyperglycaemia
- Malnutrition
- Low Albumin
- Rheumatoid arthritis
Why does obesity place someone at risk of surgical site infection?
Adipose tissue is poorly vascularised = poor oxygenation of tissues.
How does smoking increase risk of surgical site infection?
Nicotine prevents wound healing
Nicotine has vasoconstrictive effects.
Name the disinfectant/ antiseptic used on a patient’s skin pre-operatively.
Chlorhexidine.
What is the most powerful independent risk factor for SSI following cardiothoracic surgery?
Staphylococcus aureus
How does hypothermia cause increased risk of surgical site infection?
Hypothermia causes vasoconstriction = reduces oxygen and blood supply to wound.
Organisms adhering to the synovial membrane and bacteria growing in the synovial fluid causing inflammation. What is the diagnosis?
Septic arthritis
Name the three most important investigations for septic arthritis.
Blood cultures Synovial fluid aspiration ESR, CRP X ray; soft tissue damage US confirms effusion CT for erosive bone change
synovial count > 50, 000 cells/mm suggests septic arthritis. but negative does not exclude.
How do we manage septic arthritis?
Antibiotics e.g. cephalosporin, flucloxacillin.
Name three components of blood
Red cells
Platelets
FFP (fresh frozen plasma)
Cryoprecipitate
Which blood group do we give in an emergency?
Blood Group O negative
How are red cells stored compared with platelets?
Red cells = 4 degrees
Platelets = 20 degrees
Name a procedure which will most likely require a large amount of blood transfusion.
Aortic aneurysm repair
What is the difference between O positive and O negative blood?
O positive has RhD antigens
O negative does not have RhD antigens
Which are the two blood systems we are most concerned with with blood donation?
ABO and Rh.
If you are RhD negative and given RhD positive blood what is likely to happen?
You will make anti-D antibodies.
Do anti-D antibodies cross the placenta?
Yes because they are IgG antibodies.
Which blood group do we give in an emergency?
O negative
Where is giving platelets contraindicated?
TTP - thrombotic thrombocytopenic purpura.
How much FFP do we give?
15-20ml/kg.
Approximately how many ml makes up a unit?
450mL. (will vary between red cells, fresh frozen plasma and cryoprecipitate for example).
What is cryoprecipitate made up of?
Fibrinogen, fibronectin and factor VIII and vWF.
Which blood component mainly raises the levels of fibrinogen?
Cryoprecipitate.
Name the four main components of blood.
Red cells
Cryoprecipitate
Platetlets
Fresh frozen plasma
Name the two types of donor.
Allogeneic
Autologous
If someone is immunocompromised/ at risk of graft vs. host disease, which specific requirement of blood may they need?
Irradiated blood.
Which is actually the most frequency blood donor group?
O positive
Which blood groups are cross matched?
Red cells (not platelets/ FFP).
What do we worry about in RhD negative women?
HDFN - haemolytic disease of the foetus newborn.
Is haemolytic disease an acute or delayed reaction?
Delayed (i.e. >24 hours).
What is TACO?
Transfusion associated circulatory overload.
Name x3 ‘SHOTs’
Serious hazards of transfusion:
- Anti-D Immunoglobulin errors
- Delayed transfuion
- Avoidable transfusion
With which blood component transfusion are allergic reactions most common?
With plasma.
With which blood component transfusion are allergic reactions most common?
With plasma.
What is IgA deficiency?
A very severe allergic reaction; in 25% of patients, the person develops IgA antibodies in response to exposure to IgA e.g. in a transfusion.
Which is the most common pulmonary complication in blood transfusions?
TACO - Transfusion associated circulatory overload.
When may a delayed haemolytic transfusion reaction occur?
If blood transfused has the same antigens on the patient’s RBCs, the antibodies can cause RBC destruction.
after 3-10 days; delayed.
When may a delayed haemolytic transfusion reaction occur?
If blood transfused has the same antigens on the RBCs, the antibodies can cause RBC destruction.
How do we test for delayed haemolytic disease?
High bilirubin, high LDH
Low Hb.
How does GvHD occur?
Lymphocytes from the donor’s blood are not destroyed in the patient (e.g. in very immunocompromised patients) and so, the donor’s lymphocytes see HLA in the patient and attack them.
Name the top 3 symptoms in GvHD.
Diarrhoea
Liver failure
(always fatal).
Would purpura occur due to low or high platelet count?
Low platelet count = insufficient clotting = bleeding to surface of skin.
Why may iron overload occur and at what levels?
After multiple transfusions of blood = iron build up if not excreted. Prevent by iron chelation once ferritin > 1000. = chelating agents to remove iron. ‘Deferasirox’
Which antibodies can cross the placenta?
Only IgG.
How can haemolytic disease of the newborn occur?
Maternal antibodies cross the placenta and destroys fetal red cells.
How does giving anti-D immunoglobulin prophylactically work?
72 hours within an event e.g. bleed, give red cells coated in anti-D Ig (immunoglobulin) = mother’s spleen will remove them before body has time to develop antibodies to anti-D (sensitisation will not occur).
- does not work if mother already has anti-D antibodies
- we give anti-D antibodies at delivery if feotus is already known to be RhD Positive.
How does giving anti-D immunoglobulin prophylactically work?
72 hours within an event e.g. bleed, give red cells coated in anti-D Ig (immunoglobulin) = mother’s spleen will remove them before body has time to develop antibodies to anti-D.
What are the doses of anti-D that we give before and after 20 weeks of pregnancy?
Before 20 weeks = 250 iu
After 20 weeks = 500 iu
What is sensitisation?
In effect to produce an allergic response - to cause antigens to bind to antibodies.
What is HLA?
a complex of genes (MHC) on chromosome 6 - proteins found on cells e.g. MHC class II found on CD8+ T cells.
What is HLA?
a MHC on chromosome 6 - proteins found on cells e.g. MHC class II found on CD8+ T cells.
Which chromosome is HLA found on?
Chromosome 6.
Which HLA Class is expressed on all cells?
HLA Class I (A, B, C)
HLA Class III is DQ, DR, DP.
HLA is found on which cells?
The APC (HLA is a MHC found on the APC to present to the T cell).
How can HLA be a problem in transplantation?
HLA genes are so variable between human beings = creates mismatches in transplantation due to immune reactions as ‘foreign material’.
e.g. = donor is HLA-A1 when recipient has a mix of HLA-A 1 and HLA-A2
Are anti-HLA antibodies naturally occuring?
No; they are formed later in life e.g. during pregnancy or transplantation (after a stimulation).
Not like anti-A or anti-B.
Are anti-A and anti-B antibodies naturally occuring?
Yes.
Name two ways in which we can prevent graft rejection?
ABO/ HLA tissue matching
Anti-HLA antibody screening
Name two ways in which we can prevent graft rejection?
ABO/ HLA tissue matching
HLA screening
Which are the three infections currently screened for during pregnancy?
HIV
Hepatitis B
Syphilis
What is the TORCH screen?
Used for screening congenital infections; Toxiplasmosis Other (HIV, hepatitis B syphilis) Rubella Cytomegalovirus HSV.
Name 3 typical signs in congenital infection.
Rashes
Jaundice
Hepatosplenomegaly
Name three clinical features of congenital rubella syndrome?
Eyes - cataracts, glaucoma
Ears - deafness
Heart - PDA, ASD/VSD.
Name three clinical features of congenital rubella syndrome?
Eyes - cataracts, glaucoma
Ears - deafness
Heart - PDA, VSD.
How does the treatment differ in early onset sepsis Vs. late onset sepsis?
Early onset antibiotics: Benzylpenicillin +gentamycin
Late onset antibiotics = cefotaxime + vancomycin.
Which is the most important bacterial cause of paediatric mortality and morbidity?
Meningitis
Name 3 investigations for meningitis
Lumbar puncture for CSF.
Throat swabs
Blood cultures
How does viral fluid appear on CSF?
Clear Normal glucose (bacterial = low glucose).
How does viral fluid appear on CSF?
Clear
Which is the most important microorganism cause of paediatric mortality and morbidity?
Streptococcus pneumoniae.
Which are the two main species responsible for Meningitis?
Neisseria Meningitidis
Streptococcus pneumoniae.
Are most respiratory infections in children bacterial or viral?
Viral
What is the most bacterial cause of respiratory tract infections in children?
Streptococcus pneumoniae.
Which treatments are commonly the treatment of choice in children with bacterial respiratory tract infections?
Macrolides e.g. azithromycin; many strains are resistant to penicillin or amoxicillin.
Bordetella pertussis is responsible for which condition?
Whooping cough.
Which is the biggest culprit for Urinary tract infections?
E.Coli
What is the relationship between GFR and clearance?
GFR and clearance should equal one another if markers are not reabsorbed/ filtered or bound to serum proteins.
Which is the gold standard marker to measure GFR?
Inulin (collected from urine)
What is inulin?
The perfect Gold standard marker to measure GFR.
However, not suitable to adminster
so use Cr-EDTA.
Name three characteristics of the ideal marker to measure GFR.
Not reabsorbed
Freely filtered at glomerulus!
Not plasma protein bound.
What is the disadvantage of using urea as a marker for GFR?
Urea is reabsorbed by the tubular cells.
What is the disadvantage of using creatinine as a marker for GFR?
Actively secreted into the urine by tubular cells.
Related to muscle mass.
Is Creatinine the ideal marker for measuring GFR?
No. can be used but actively secreted by the tubular cells into the urine.
Is the issue with creatinine that it is reabsorbed by the tubular cells?
No; it is actively secreted by tubular cells.
Urea is reabsorbed by tubular cells.
The Cockcroft Gault equation can be used to measure what more accurately?
Creatinine clearance.
Incorporates weight and gender
What is Cystatin?
A marker of GFR (again, not the best as reabsorbed. Inulin = ideal).
For creatinine clearance, can we take a single urine sample?
No; needs a 24hour collection sample.
The Bence Jones protein in urine is diagnostic for which condition?
Multiple myeloma (blood cancer affecting plasma cells).
Does the urine dipstick test sensitively detect bence jones proteins?
No. Usual urine dipstick testing is not sensitive to BJPs.
You can reliably exclude bacteriuria if the urine
dipstick is negative for nitrites. True or false.
True.
What does urine microscopy examine for?
Crystals, red blood cells, white blood cells.
Centrifuge at 3000rpm.
Calcium oxalate crystals and alcoholic poisoning. What is the likely diagnosis?
Ethylene glycol poisoning.
Which white blood cell is bilobar?
Eosinophil
What is the best way to measure kidney function?
GFR not creatinine.
best way to measure GFR is through inulin (but not always realistic).
How many stages in acute kidney injury?
3 stages.
AKI Stage 1 (more than x1.5-1.9 fold creatinine)
AKI Stage 2
AKI Stage 3 (more than 3 fold baseline creatinine)
Pre renal kidney injury is associated with structural abnormalities. True or false?
False = why pre renal injury responds to restoration of volume.
What is the difference between pre-renal acute kidney injury and acute tubular necrosis?
Pre renal AKI responses to restoring circulatory volume (i.e. fluids) due to there not being structural damage whereas acute tubular necrosis does not.
A 68 year old man with previously normal renal function is found to have a creatinine of 624μmol/l. What is the likely cause of his AKI?
Benign prostatic hyperplasia.
Acute blood loss is likely to cause which kind of kidney injury?
Pre-renal acute kidney injury
Obstructive uropathy is likely to cause which kind of AKI?
Post-renal acute kidney injury.
Vasculitis and glomerulonephritis are likely to cause which kind of acute kidney injury?
Intrinsic AKI.
What is rhabdomyolysis?
Breakdown of muscle releasing leaked muscle content into the circulation.
What are the four stages of wound healing?
Haemostasis
Inflammation
Proliferation
Remodelling
How many stages of chronic kidney disease are there compared with acute kidney disease?
Acute = 3 stages Chronic = 5 stages
What is the main marker for chronic kidney disease?
ACR - albumin: creatinine ratio.
Name three consequences of Chronic kidney disease.
Hyperkalaemia Acidosis Anaemia Renal bone disease Hyperparathyroidism Uraemia
Acidosis and hyperkalaemia are main causes of which kidney disease?
Chronic kidney disease.
Does kidney failure result in acidosis or alkalosis?
Acidosis; failure of kidney to excrete protons.
How do we treat acidosis?
Sodium bicarbonate.
What two measures do
we use to define acute kidney injury?
Creatinine and urine output.
Which medications can cause hyperkalaemia?
potassium sparing diuretics e.g. spironolactone
ACE Inhibitors
How does chronic renal disease cause anaemia?
Decline in erythropoietin producing cells.
Usually normocytic, normochromic.
What is an ESA?
Erythropoietin stimulating agent.
How can chronic kidney disease (CKD) cause hyperparathyroidism?
High PTH causes low Vitamin D and high phosphate = resistance to PTH = hypocalcaemia = high PTH
What is 1-alpha calcidol
Vitamin D receptor activator.
What cardiovascular impact can chronic kidney disease have?
Uraemia
= uraemic cardiomyopathy.
BMI >30 is a contraindication to transplantation. True or false?
False.
What is the difference between haemodialysis and peritoneal dialysis?
Haemodialysis = Artery to machine outside of the body which acts as a filter.
Peritoneal dialysis = Lining of the belly acts as a natural filter.
What is usually the route of administration for adrenaline in anaphylaxis?
Intramuscular; intravenous is used rarely e.g. in cardiac arrest.
What is the typical dose of adrenaline for children aged 6-11 years in anaphylaxis?
300 micrograms of 1:1000 adrenaline IM. Repeat every 5 minutes if necessary.
How often is adrenaline repeated in anaphylaxis?
Every 5 minutes.
Which is the most appropriate test for food allergies?
Skin prick test.
What is the amount of adrenaline injection in children Vs adults?
Children = 300mcg Adults = 500mcg.
Give three signs of anaphylaxis.
Urticarial rash
Stridor
Acute onset hypotension
Respiratory distress
What is chlorphenamine?
An antihistamine
Which is the test we use most commonly to test for contact dermatitis?
Skin patch test.
What is the best enzyme to confirm anaphylaxis?
Tryptase levels (remains elevated for 12 hours following episode).
On examination a patient has gross facial and tongue oedema - should they be treated for anaphylaxis IM or IV?
IM still. IV for severe reactions e.g. shock
What is the typical dose of adrenaline for children aged 6 months - 5 years in anaphylaxis?
150 micrograms (1 in 1000)
What is refractory anaphylaxis?
Respiratory and cardiovascular problems.
What does HAI stand for?
Healthcare associated infection. (not hospital acquired!)
Antibiotic associated diarrhoea is most likely caused by which organism?
Clostridium difficile.
Give two examples of E.Coli associated infection
Urinary catheter (UTI)s Ventilator associated (pneumonia)
How prevalent are HAI in the UK?
300 000 a year -
Which is the most common HCAI?
Clostridium difficile
What kind of bacteria is Clostridium difficile?
Gram positive spore forming anaerobe.
What kind of bacteria is Clostridium difficile?
Gram positive spore forming anaerobe.
Produces toxins A and B.
Name one key risk factor Clostridium difficile infection.
Antibiotic use.
Which is the first line treatment for Clostridium difficile?
Vancomycin/ Fidaxomicin
Which is the main bacteria associated with catheter infection?
E.Coli
Name some commonly resistant gram negative bacteria.
E. Coli, klebsiella, enterobacter
Which bacteria has high resistance to antibiotics?
Enterobacter
Which is the go to antibiotic for cellulitis?
Cefuroxime and Vancomycin
For MRSA, which is the go to antibiotic?
Meropenem and Vancomycin
For MRSA, which is the go to antibiotic?
Meropenem and vancomycin
Name three places where MRSA may be found in HAI?
Catheters, UTI associated catheters, SSI.
Give some examples of how we can class immune deficiencies.
Metabolic Infection Age Malnutrition Environmental Drug
What is the commonest cause of secondary immune deficiencies?
Malnutrition.
How would you classify methotrexate?
Cytotoxic agent
What type of drug if phenytoin?
Anti epileptic
Which biological agent is associated with reactivation of TB?
Anti-TNF agents.
Name three haematological cancers (blood cancers)
Multiple Myeloma
Non Hodgkin’s lymphoma
CLL - Chronic lymphocytic leukaemia
What is FISH?
FBC
Immunoglobulins (IgG, IgA, IgM, IgE).
Serum complement (C3, C4)
HIV test
What is the main method by which serum protein electrophoresis works?
SPE separation through charge.
Where can SPE be helpful?
Serum protein electrophoresis: can detect monoclonal bands seen in blood cancers e.g. multiple myeloma, NHL.
SPE can miss 20% light chains.
What can SPE miss?
Identifying light chains.
What type of vaccine is the Tetanus vaccine?
Protein antigen.
What type of vaccine is the Pneumovax?
Carbohydrate antigen
What is key diagnostic aspect for primary antibody syndromes?
Failure to respond to vaccination.
Flow cytometry is mainly used to assess which cell type?
The lymphocyte
Name the three tests we should do for immune deficiencies.
FISH, renal and liver profile, calcium and bone profile, SPE (serum protein electrophoresis) and flow cytometry, assessment of IgG classes.
Which are the four incurable sexually transmitted diseases?
HIV
Hepatitis B
Herpes
HPV
What is the pathogenesis of HIV?
HIV virus binds to CD4 then CCR5 and CXCR4
Replicates via a DNA intermediate
Which is the bacterium associated with reheated cooked rice?
Bacillus cereus.
How would campylobacter jejuni present in a patient?
BLOODY diarrhoea and vomiting.
Which is the first line medication of choice for a patient presentation of bloody diarrhoea and vomiting?
Ciprofloxacin.
Which medication is usually used for traveller’s diarrhoea?
Clarithromycin.
Which is the most common cause of Traveller’s diarrhoea?
E. Coli.
Which is the most common cause of Traveller’s diarrhoea with a 15 day long history?
Giardiasis.
Low Hb and low reticulocyte count is likely to point toward which diagnosis?
Parvovirus B19 infection due to aplasia in this infection.
Vaginal WHITE discharge with fishy smell points toward which diagnosis?
Bacterial vaginosis.
What is the key organism causing bacterial vaginosis?
Gardnerella vaginalis.
How does bacterial vaginosis compare with trichomonas?
Bacterial vaginosis = white discharge
Trichomonas = green, frothy discharge.
What is the medical term for the bull’s eye rash and in which condition is it seen?
Erythema Migrans - seen in Lyme’s disease.
Which test should be offered to all those with TB?
A HIV test; TB is an ‘AIDS defining’ illness.
Which is the most common cause of pyelonephritis?
E.Coli
Which bacteria is typically due to the cause of diarrhoea following rice?
Bacillus cereus.
What is an aspergilloma?
A mass caused by the fungus aspergillus which is associated with TB.
What happens to CD4+ T cells in chronic HIV?
CD4+ T cell depletion
Impaired CD4+ and CD8+ T cells
In acute HIV, some increase in CD8+
How do we diagnose HIV infection?
‘4th Generation testing’
HIV antigen and antibody testing.
Assays detect specific antigens.
Name three comorbidities of HIV.
TB Diabetes Mellitus GORD Hepatitis B and C Depression and anxiety
Name three baseline investigations for HIV.
Full Blood count
Renal, liver and bone profile
Sexual health screen
Baseline chest x ray and ECG.
Name three things which determine the magnitude of the HIV viral load on a graph.
CD8+ count
Immune activation
Genetics
Viral genetics
Name one key virus where CD4+ is the lowest.
CMV
Cytomegalovirus.
Which is the most important prognostic indicator in HIV patients?
CD4+ T cell count
Ritonavir works through which mechanism and for which condition?
Protease inhibitor
In HIV.
What is Maraviroc?
A CCR5 antagonist used in treatment of HIV.
Which medication types are currently Golden practice for treating HIV?
x2 NRTI and x1 integrase inhibitor.
ART can eliminate infection once HIV-1 has integrated into host DNA - true or false.
False.
Which part of the adrenal gland makes cortisol?
Zona fasciculata.
What does the zona reticularis make?
Androgens.
What may a patient presenting with low blood sugar and low thyroxine have as a condition?
low blood sugar = low cortisol = addison’s
low thyroxine = hypothyroidism
Addison’s + hypothyroidism = Schmidt’s syndrome.
Which is the test for Addison’s?
Short SynACTHen test. = give patient ACTH and cortisol. Adminster 250mcg of ACTH Check cortisol at 30 and 60 minutes. In Addison's, cortisol will stay low despite ACTH injection.
Name three possible adrenal masses.
Phaeochromocytoma
Conn’s syndrome (aldosterone secreting tumour)
Cushing’s syndrome = (cortisol secreting mass)
How do we treat phaeochromocytomas?
Alpha blocker
THEN
beta blocker:
Which is the alpha blocker we use in phaeochromocytoma?
phenoxybenzamine.
In which condition do we use the Dexamethasone suppression test?
Cushing’s syndrome.
What is a normal cortisol level?
<50nM
In a set of results, how can we differentiate between Cushing’s syndrome and Cushing’s disease (pituitary dependent cause)?
Cushing’s syndrome = levels still stay very high
Cushing’s disease = levels decrease but still above range.
Which is the number one cause for Cushing’s syndrome?
Being on oral steroids for something else i.e. another condition.
9am cortisol (Wednesday): 500 nM Given high dose dex suppression 9am cortisol (Friday) 170nM What is the diagnosis?
Cushing’s disease (pituitary dependent).
Name two neoplastic lung diseases
Lung cancer
Mesothelioma (asbestos = main culprit).
Which are the two ways in which we can divide non neoplastic lung disease?
Airway (Asthma, COPD, bronchitis)
Parenchymal (Fibrosing interstitial disease, infection, pulmonary oedema, emphysema).
Define Chronic bronchitis.
Productive cough for most days for at least 3 months over 2 consecutive years.
Define bronchiectasis
Permanent abnormal dilatation of bronchi
Bronchiectasis is not reversible.
Which patients are most at risk of bronchiectasis?
Post infection e.g. cystic fibrosis.
Obstruction in lobe.
What is the main aspect of cystic fibrosis contributing to respiratory disease?
Mucus production.
Name a main cause of pulmonary oedema from the cardiovascular system.
Left ventricular failure.
What is hyaline membrane disease of the newborn?
Lack of surfactant production in neonates = stiff lung.
‘White out’ of lungs on x ray is most commonly due to what?
Alveolar damage (= white infiltrates). 'DAD - diffuse alveolar damage.
Which are the two types of bacterial pneumonia we often refer to? (clue is location).
Lobar pneumonia and Bronchopneumonia.
What is a key difference between bronchopneumonia and lobar pneumonia?
Bronchopneumonia is due to low virulence organisms e.g staphylococcus, streptococcus.
Lobar pneumonia is due to high virulence organisms e.g. pneumococci.
Describe the four stages of lobar pneumonia.
CRGR Congestion; hyperaemia. Red hepatisation (RBCs, fibrin) Grey hepatisation (RBCs break down = exudate) Resolution .
Define emphysema
Permanent loss of the alveolar parenchyma to the terminal bronchiole.
Is Emphysema an airway or parenchymal disease?
Parenchymal disease.
Which protein predisposes one to emphysema?
Deficiency in alpha 1 anti-trypsin.
What is the relationship between smoking and emphysema?
Smoking reduces alpha 1 antitrypsin = an antiprotease = tissue damage (tissues need proteases).
Give 3 causes of granulomatous disease.
Sarcoidosis
IVDU
Infection
What are we talking about when we refer to ‘farmer’s lung’?
Extrinsic allergic alveolitis.
Name the three non-small cell carcinomas
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
What type of cancer is an adenocarcinoma?
Non small cell carcinoma
Are all non small cell carcinomas malignant?
Yes
Which comes first - metaplasia or dysplasia?
Hyperplasia to metaplasia to dysplasia.
What is the main precursor to a adenocarcinoma?
AAH - atypical adenomatous hyperplasia (a lesion).
Are adenocarcinomas mainly central or peripheral compared to squamous cell carcinoma?
Peripheral
Which type of cancer can be targeted more easily with specific drug therapies?
Adenocarcinoma (in contrast, squamous cell carcinomas can get worse with some drug therapies e.g. can haemorrhage).
Generally, which cancer types are more chemosensitive (sensitive to chemotherapy)?
Small cell cancers respond better to chemotherapy than non small cell cancers.
Cetuximab is a cancer therapy targeting which pathway?
EGFR pathway.
An EGFR mutation is most likely to cause which cancer?
Adenocarcinoma
PDL1 expression is commonly seen in which cancer?
Squamous cell carcinoma
What are anal genital warts?
Benign epithelial tumours
Which virus causes anogenital warts?
HPV.
In which part of the skin does most cell replication occur?
Stratum spinosum
HPV codes for how many proteins?
6-8 proteins
Which is the main type of HPV to cause genital warts?
Type 6.
What is the maximum incubation time for HPV?
2 years.
Which is the initial test for female patients presenting with warts?
Speculum examination
Name some causes of a low lymphocyte count
HIV infection
Renal failure
Steroid therapy
Why would you perform an MRI before a lumbar puncture?
Need to exclude a mass lesion if for example the patient is drowsy so do not do LP first = to avoid coning.
Which test is certainly NOT recommended in suspected brain mass lesions?
Lumbar puncture;coning
Which test is certainly NOT recommended in suspected brain mass lesions?
Lumbar puncture; coning
What is coning?
Risk of compression of the lower brain stem as cerebellar tonsils move down through the foramen magnum
Which is the main CNS culprit microorganism for AIDS?
Toxoplasma gondii
What are amphotericin/ fluconazole used to treat?
Fungal infections e.g. cryptococcus.
Give 3 common causes of fever in the traveller -
x1 bacterial
x1 viral
x1 parasitic
Bacterial = Typhoid Viral = Arbovirus (dengue) Parasitic = Malaria
Which virus causes Dengue fever?
Arbovirus
Name two common acute viruses that can present with fever.
Dengue fever HIV seroconversion (when antibodies become detectable)
Give 2 causes of Jaundice in a traveller with fever
Malaria
Leptosporosis
Cholangitis
25 year old female returning from Uganda.
History of fever, mouth sores and rash.
Lymphadenopathy
Fever with rash: think viruses
?EBV
?HIV Seroconversion
What is herpes zoster?
Shingles - cannot become infected if not for having previously had Chickenpox.
What is the main difference between viral meningitis and viral encephalitis?
In viral meningitis, there will be a complete absence of brain function.
What is the normal level for CSF protein?
- 15-0.45g/L
i. e. 150-450mg/L.
> 450mg/L = high protein i.e. viral
Which is the most common cause of viral meningitis vs. viral encephalitis?
Viral meningitis = enteroviruses
Viral encephalitis = Herpes simplex viruses
What is the name of the equation to determine creatinine clearance and which 3 factors are required to calculate these?
Cockcroft-Gault equation
Age
Weight
Serum creatinine
Is bacterial or viral meningitis more common?
Bacterial meningitis.
Is a petechial or purpuric rash common in meningitis?
No; but when it is seen, it is common for meningococcal septicaemia.
When is an EDTA PCR sample performed?
For pneumococcal and meningococcal infection.
What is the first line management for bacterial meningitis?
Broad spectrum antibiotics and steroids.
Which is the most common cause microorganism wise in young adults in bacterial meningitis?
Neisseria Meningitidis.
What caution must we take with sickle cell disease patients?
They are hyposplenic so therefore they are at risk of pneumococcus, meningococcus and haemophilus influenzae B.
When a rash DOES present in Meningitis, what is the likely microorganism?
Meningococcus
Itchy skin, jaundice, aches, fatigue and returned from Egypt having had local food. Not sexually active for past 3 months. What is the diagnosis?
Hepatitis A.
Which is the most common route of transmission for hepatitis A?
Faeco-oral route.
Which is the main test we use to test for hepatitis A?
Serology IgG/ IgM. (but this does not distinguish between new and chronic illness).
How long must a patient be on HIV treatment for before returning to unprotected sex?
6 months
Which is the most common cause of tonsillitis?
Group A Streptococcus.
Which condition is known as the ‘kissing disease’?
infective mononucleosis/ glandular fever (same name both caused by EBV).
Which is the specific test for HIV?
4th generation antibody antigen HIV test
Name three tests we request in querying an STI.
HIV 4th generation test
Hepatitis screen
Syphilis serology
How do we confirm a diagnosis of hepatitis B?
We require a surface antigen rather than just surface and core antibodies; can have Hepatitis B antibody just from begin vaccinated.
What will be positive in a hepatitis B vaccination?
Surface antibody (not antigen). - antigen is if someone actually has hepatitis B.
Lymphocytes in the CSF should make one consider which two conditions?
Encephalitis
Meningitis
Lymphadenopathy, fever, splenomegaly and lymphocytosis should make one consider which diagnosis?
Glandular fever is the same thing as infective mononucleosis (caused by EBV).
Fever, symmetrical facial swelling, headache, neck stiffness. What is the likely diagnosis?
Mumps virus; symmetrical facial swelling. Mumps is a notifiable disease BTW.
In Hepatitis serology, how would we gauge that the patient currently has active disease?
A positive HBV sAg (surface antigen) - confirmed by body antigen.
Which is the most likely route of transmission for Hepatitis B?
Sexual contact
Give 3 facts about Hepatitis B including incubation period.
8 genotypes DNA virus Sexual contact Incubation period - 1-6 months. Treat with nucleoside analogue: Tenofovir
From hepatitis serology, how can we tell if a patient is non infectious?
Surface antigen negative: HBV sAg -ve
What do we use to treat Hepatitis B?
Tenofovir.
When is HBV (hepatitis B) infection classed as chronic?
When longer than 6 months.
Hepatitis B Infected mothers can continue to breast feed as there is no additional risk of transmission. True or false.
True.
(Vertical transmission is 90% common from mother to baby when mother is eAg positive). - 10% common when mother is surface antigen positive.
With which hepatitis can you get hepatitis D?
Hepatitis B.
