Question book 6 Flashcards
What type of vaccine is hepB vaccine
killed virus live attenuated subunit toxoid conjugate
subunit
contains HBV surface angien epitopes, yeast, and two adjuvants - aluminium and thimerosal
A conjugate vaccine is a type of subunit vaccine which combines a weak antigen with a strong antigen as a carrier so that the immune system has a stronger response to the weak antigen.
eg pneumococcal of haemophilus B
toxoid - tetanus, diptheria
65 year old male with renal transplant 18 months ago presents to pre-travel clinic for vaccinations.
Which is safe to administer in this patient
influenza A measles rubella yellow fever varicella
influenza A
other vaccines are all live vaccines
68 year old with pulmonary fibrosis attends for annual influenza vaccine
why do vaccines need to be given annually
antigenic shift antigenic drift suboptimal B-cell response suboptimal T-cell reponse recipient relative immune paresis
antigenic drift?
anitgenic shift happens more rarely
antigenic drift means vaccine may not match circulating strain each year
54 year old NHS worked found to be non-immune to VZV
Which of the following is contraindication to receiving vaccination
HIV with CD4 550 radiotherapy 12 months ago 1 week 40mg prednisolone 1 month ago azathioprine 12 months ago Weber-Christian disease
1 week 40mg prednisolone 1 month ago
contraindications to live vaccines:
- severe immunodeficiencies
- chemotherapy or radiotherapy in past 6 months
- solid organ transplant on continual immunosuppression
- bone marrow transplant until 12 months after
- high dose steroids - 40mg for 1 week - wait until 3 months after treatment
- HIV CD4 <200
Weber-Christian is cutaneous panniculitis - no immunosuppression
Azathioprine not contraindicated. Stronger drugs such as methotrexate are
Which of the following conditions would you recommend to receive pneumococcal vaccine
HCV liver cirrhosis beta-thalassaemia minor asthma recurrent otitis media those recovered from acute malaria
HCV liver cirrhosis
23 valent polysaccharide vaccine
13 valent conjugate vaccine
children <2 do not demonstrate good response to 23 valent vaccine, so not given at this age
vaccination indicated for:
- all aged 65 or over
- chronic lung/ liver/ renal/ heart disease
Which vaccine given at 12-15 months of age to avoid inhibition by maternal antibodies
Haemophilus influenzae B MMR BCG Diptheria, pertussis, tetanus Meningococcus C
MMR
Which of the following food-borne pathogens can be prevented by vaccination
Campylobacter jejuni Giardia Shigella Vibrio cholerae Salmonella enteriditis
Vibrio cholerae
20 week pregnant female travelling to Nigeria for 1 month. Asking for advice regarding Yellow Fever vaccination
vaccination contraindicated, should not be given
vaccine should be given - confers protections for 35 years
vaccine should be given - confers protection lifelong
vaccine should be given, and early re-vaccination considered
vaccination contraindicated, antivirals should be given as chemoprophylaxis
vaccine should be given, and early re-vaccination considered
benefits of vaccination far outweigh risks in pregnancy
vaccination confers protection for at least 35 years - probably life long
pregnant patients should be offered early re-vaccination as may not develop as strong an antibody response
47 year old going on cruise in South America. Lost his yellow fever certificate.
What action should be taken
YF is contraindicated and should not be given
He is protected from YF, and replacement certificate should be issued
He is not protected from YF and should be re-vaccinated
He is not protected from YF and should have medical exemption issued
He is at risk of YF, and neither vaccination or certificate is required
He is not protected from YF and should be re-vaccinated
24 year old with fever arthralgia rash
multiple unprotected sexual exposures a few months ago
lymph count 2.6
POC HIV test: reactive
CD4 950
which of the following is most correct
this represents seroconversion illness
he is manifesting an AIDS-defining illness
this is a false positive
he is not infectious for HIV
treatment with antiretrovirals should commence when CD4 count is <350
this represents seroconversion illness
History of exposure, and positive test. with high CD4 count suggests recent infection
51 year old HIV positive attends for review. Now has undetectable viral load, and CD4 615
What end organ disease does HIV directly cause
nephropathy enteritis hepatitis retinitis arthropathy
nephropathy
Form of FSGS - caused by direct invasion of HIV into renal epithelial cells
Other renal disease such as membranous nephropathy can occur due to HIV immune complex deposition
Enteritis and retinitis usually caused by opportunistic infections
Arthropathy due to reactive arthritis
HIV end organ disease:
HIV associated neurocognitive disorders (HAND)
nephropathy
AIDS
32 year old presents with SOB - diagnosed with PCP pneumonia
HIV test turns positive
Which test is most useful for prognostic purposes in new diagnoses of HIV
HIV envelope antibody HIV p24 antigen HIV viral load CD4 count HIV plasma RNA
CD4 count is strongest prognosticator for those not presenting with an OI
HIV viral load influences which drug therapy to start, but does not predict future disease. HIV viral load is same as HIV plasma RNA
HIV p24 antigen is used for early diagnosis of infection
55 year old with HIV presents with weakness and numbness of his left arm and leg. CD4 count 60
MRI shows focal mass lesion in right hemisphere
What is most likely cause of this presentation
Toxoplasma gondii Progressive multifocal leukoencephalopathy Primary CNS lymphoma Cryptococcus neoformans Mycobacterium tuberculosis
Toxoplasma gondii
Toxoplasma abscesses are the most common mass lesion in immunocompromised individuals worldwide
Any patient with CD4 <200 and CNS signs should be treated with anti-toxoplasma therapy until alternative diagnosis has been made
History does not suggest PML - as has discrete hemiparesis
CNS lymphoma is reasonable alterantive
40 year old with HIV presents with confusion, seizures, and altered GCS
Originally from France, and known Toxoplasma gondii IgG pos
MRI did not sow any focal lesions
LP did not show any raised ICP
Previous CD4 count <200 8 months ago
Started on co-trimoxazole for PCP prophylaxis, but developed a rash, so changed to dapsone
What treatment regime would be recommended
liposomal amphotericin sulphadiazine with pyrimethamine clindamicin with pyrimethamine atovaquone with pyrimethamine azithromycin with pyrimethamine
clindamicin with pyrimethamine
First line toxo therapy is sulphadiazine with pyrimethamine
Should be screened for G6PD deficiency due to risk of haemolysis with sulphur-containing drugs
Second line therapy if cannot take sulphur containing drugs is clindamicin with pyrimethamine
Folinic acid needs to be given with pyrimethamine
35 HIV positive patient presents with fever weight loss, and decreased appetite. On examination has widespread lymphadenopathy
CD4 114
HIV VL 65000
HHV8 viral load 10,000 copies
Lymph node biopsy shows onion-skin appearance on histopathology with interfollicular plasmablasts expressing HHV8 latent nuclear antigen
What is the most likely diagnosis
Primary effusion lymphoma Kaposi sarcoma Multicentric Castleman disease Hodgkin's lymphoma Non-Hodgkin's lymphoma
Multicentric Castleman disease
Castlemans’ disease has localised and multicentric forms.
Castlemans disease is a HHV8 driven disease similar to Kaposi Sarcoma
Histological confirmation should be made by IHC for HHV8
Rituximab is therapy option
35 year old presents with multiple purple raised lesions on trunk and arms. Had been seen by GP for his dry skin over face last year, when he was prescribed emollients. Diagnosed with HIV, and you suspect Kaposi Sarcoma
Which of the following are not treatments of Kaposi Sarcoma
introduction of antiretroviral therapy intralesional vinblastine liposomal anthracycline ganciclovir paclitaxel chemotherapy
ganciclovir
ganciclovir/ aciclovir have minimal effect on HHV8 activity, so not used for treatment
60 year old from Cambodia felt unwell with fever, weight loss, cough. Cervical and inguinal lymphadenopathy, and hepatosplenomegaly. Had papular skin lesions, with central necrotic umbilication mainly on trunk and upper limbs
HIV test pos
Bloods show anaemia and milt thrombocytopenia
What would be the initial treatment regime
commence antiretroviral therapy liposomal amphotericin B antituberculous therapy itraconazole paclitaxel chemotherapy
liposomal amphotericin B
Talaromyces (penicilliosis) is likely diagnosis
Umbilicated lesions is either Talaromyces or Molloscum Contagiosum
24 HIV positive patient denies problems with adherence to his medication. He was diagnosed after his partner notification and has not suffered from opportunistic infection.
He has maintained a reasonable CD4 count, but last viral load was 354 copies/ml 6 months ago, and current VL is 460.
Never reached an undetectable viral load <59
What is definition of his current viral response to treatment
virological failure incomplete virological response virological rebound low-level viraemia virological blip
incomplete virological response - 2 consecutive VL >200 after 24 weeks, without achieving <50 copies
Virological rebound - failure to maintain VL below 50 copies
Low level viraemia - persistent VL between 50-200 copies
virological blip - a single result between 50-200 copies, but returns to <50 copies whilst on therapy. Not usually a clinical concern - check adherence. But single result >200 suggests virological failure, and needs genotypic resistance testing
23 year old recently diagnosed with HIV. Has oesophageal candidiasis, Mycobacterium tuberculosis and PCP during recent admission to hospital. Commenced on antiretroviral therapy
Pregnancy test positive - suspect she is in first trimester
Which one of the following would be safe to continue
co-trimoxazole efavirenz moxifloxacin itraconazole none of the above
efavirenz
No ARV license for first trimester
Zidovudine licensed for third trimester
But data has shown efavirenz and most common ones are safe in pregnancy. So if patient is on them, it is safe to continue
co-trimox/ moxiflox/ itraconazole are all contra-indicated
HIV patients on tenofovir, emtricitabine and efavirenz
HIV VL was undetectable
Complaining of nightmares
Based on the likely drug to be switched, which of the following medications will need a dose increase in the first week
raltegravir maraviroc dolutegravir rilpivirine elvitegravir/ cobicistat
maraviroc
efavirenz is drug which causes nightmares. But after stopping it can still effect drug metabolism for some time after
Use double dose maraviroc for 1 week until efavirenz leaves system
HIV2 shows innate resistance to which class of antivirals
Non-nucleoside reverse transcriptase inhibitor NNRTI
Nucleoside reverse transcriptase inhibitor NRTI
Protease inhibitors
Integrase inhibitors
Chemokine CCR5 antagonists
Non-nucleoside reverse transcriptase inhibitor NNRTI
First line for HIV 2 is tenofovir, emtricitabine and lopinavir/ ritonavir
22 year old man has recent unprotected intercourse 48 hours earlier. Sexual partner is known to clinic and known to be HIV pos.
Viral load 350 4 months ago
Viral load undetectable 1 month ago
No significant resistance on genotypic testing
How would you treat the recipient
reassure that transmission is low risk and no treatment needed
offer post-exposure prophylaxis with truvada and raltegravir for 14 days
offer post-exposure prophylaxis with truvada and raltegravir 28 days
offer post-exposure prophylaxis with truvada and efavirenz for 14 days
offer post-exposure prophylaxis with truvada and efavirenz for 28 days
offer post-exposure prophylaxis with truvada and raltegravir 28 days
PEP is for 28 days
Truvada and raltegravir is choice of treatment
Needs to be commenced within list 72 hours of exposure
Patient with HIV has SOB, diagnosed with PCP
Treated with co-trimoxazole and made full recovery
CD4 count 230 6 months later in clinic
Which of the following is true regarding PCP prophylaxis
- dapsone is first line therapy in PCP prophylaxis
- Once CD4 drops below 200, PCP prophylaxis should continue for life
- Following treatment of PCP, if CD4 rises above 200 for 3 months, then PCP prophylaxis can be stopped
- Co-trimoxazole is first line prophylaxis for PCP before dapsone because of toxicity issues rather than increased efficacy
- G6PD status needs to be established prior to therapy with pentamidine
- Following treatment of PCP, if CD4 rises above 200 for 3 months, then PCP prophylaxis can be stopped
HIV patient has cryptococcal pneumonitis
Started on casponfungin
Continued to deteriorate and was changed to ambisome and flucytosine
Which of the following would make choosing an echinocandin for this indication inappropriate
- Cryptococcus neoformans is resistant to echinocandins as it does not contain (1,3) beta-glucan synthase
- echinocandins have poor penetration into the CNS
- echinocandins have no in-vitro activity against cryptococcal species
- echinocandins are prohibitively expensive given the prolonged therapy need for Cryptococcal meningitis
- echinocandins have multiple drug interactions with HIV ARVs and may complicate therapy if need to be changed
- echinocandins have poor penetration into the CNS
Echinocandins work by inhibiting (1,3) beta-d-glucan synthase thereby disrupting cell wall.
Has poor penetration into CNS
Amphotericin and fluctyosine is first line treatment , followed by fluconazole maintenance phase
Cryptococcus is intrinsically resistant to echinocandins. But not related to 1,3 beta-glucan synthase
56 year old with AML has had induction phase chemotherapy
CT indicates pneumonitis
BAL performed
microscopy: no organisms seen
bacterial culture: scanty Streptococcus oralis
fungal culture: no growth
viral PCR: adenovirus detected
Which other clinical syndrome does the pathogen in this case commonly cause
genital cancer kerato-conjunctivitis genital ulcers HFNM aseptic meningitis
kerato-conjunctivitis
Adenovirus causes croup, pneumonia, conjunctivitis, gastroenteritis (40 and 41)
Streptococcus oralis is a commensal contaminant
34 year old on tacrolimus following kidney transplant
Presents with fever, fatigue, cervical lymphadenopathy
Blood tests
CMV PCR neg
EBV PCR neg
HHV6 PCR neg
Which disease is HHV6 associated with
Fifth's disease Roseola infantum Kaposi sarcoma Castleman's disease Oral hairy leukoplakia
Roseola infantum
Fifth’s disease - ParvoB19
Kaposi sarcoma - HHV8
Castleman’s disease - HHV8
Oral hairy leukoplakia - EBV
7 year old with ALL treated with methotrexate, cytaribine, cyclophosphamide
Chemotherapy given via Hickman line
Attended A&E with neutropenic fever
No localising signs
Gram stain shows fungal hyphae without chlamydospores
Commenced on ambisome, but remained febrile at day 7
Fever settled on removal of CVC and changing antifungal therapy to voriconazole
What is most likely organism identified
Fusarium solani Malassezi furfur Candida auris Paecilomyces lilacinus Aspergillus fumigatus
Paecilomyces lilacinus
Unclear answer - think other pathogens would be susceptible to ambisome
50 year old undergoing autologous stem cell transplant for AML, but developed febrile illness 10 days after receiving stem cells
Neutropenic. Broad spectrum antimicrobials prescribed
Chest lesions on CXR
CT suggests fungal cause
Blood culture flagged positive with filamentous fungi
What is the most likely fungal pathogen causing the above presentation
Fusarium solani Aspergillus fumigatus Paecilomyces spp Penicillium spp Scopulariopsis spp
Fusarium solani
Aspergillus is most common cause, and would be likely here. However, it rarely grows in blood culture
33 year old undergoing haemopoetic stem cell transplant for AML.
7 days after tranplant he was febrile and neutropenic. Oral and abdominal pain, with diarrhoea. Temp 38.5degC. Hickman line looks clean. Mild abdominal tenderness
Commenced on Tazocin and amikacin
Blood culture no growth at 48 hours
He is reviewed at 72 hours, afebrile - what would be your next step regarding the antimicrobials
- no bacterial cause found so add antifungal
- continue tazocin and gentamicin until neutrophils >0.5
- stop gentamicin and continue tazocin until neutrophil count >0.5
- stop all antimicrobials at 72 hours
- change to second line antibiotic therapy with meropenem
- stop all antimicrobials at 72 hours
European guidelines suggest stopping if no localising signs, and clinical improvement. Do not need to wait for neutrophils to recover
44 year old admitted with persistent cough. Had renal transplant 5 years ago.
Lives in house, recently renovated. No beds or foreign travel.
Pyrexial and tachypnoeic
CT shows small nodular changes with ground glass changes
Bronchoscopy performed which reported growth of a mould
What is appropriate first line therapy
ambisome micafungin and amphotericin voriconazole and amphotericin voriconazole caspofungin
voriconazole - first line treatment for probable aspergillus infection
If patient had been on an azole suppressive therapy, and became unwell, then switch to a different class - amphotericin
dual therapy is not required unless shown to be resistant
35 year old with SOB and dry cough. Works as a scaffolder.
CXR shows bilateral haziness
CT shows widespread ground glass changes
HIV test positive
What is the most likely pathogen CMV Mycobacteria tuberculosis PCP Mycobacterium avium complex Streptococcus pneumoniae
PCP
diagnosis usually via BAL PCR, or staining with silver stain/ PAS
b-d-glucan will be raised
Male with recurrent staphylococcal infections is investigated for a possible immune system disorder. Note that his neutrophils fail to stain with nitroblue-tetrazolium dye. What is the most likely cause of the immunodeficiency
myeloperoxidase deficiency chronic granulomatous disease IgA deficiency Familial Mediterranean fever Alpha-1-antitrypsin deficiency
chronic granulomatous disease
nitroblue-tetazolium test - positive is normal. Covnerts colours NBT into purple stain
In CGD - negative test means neutrophils fail to stain (remains colourless), and indicates impaired phagocyte function
myeloperoxidase deficiency is a inherited deficiency, suspected when patient has candida infection
55 renal transplant patient attended a summer wedding, where reception held in couples home. They have two snakes and a lizard. Buffet dinner
Which scenarios is least likely to be a risk to the individual
Pet reptiles in the home Eating sprouts in a sandwich Eating raw oysters Drinking pasteurised juices Eating from a buffet at a summer wedding
Drinking pasteurised juices
14 year old with hypogammaglobulinaemia develops persistent diarrhoea. Previously treated for Campylobacter infection. He was clinically well, with non-bloody diarrhoea. Stool culture isolates Campylobacter jejuni in stool culture. Blood culture no growth
What is therapy of choice
fosfomycin colistin erythromycin ciprofloxacin amoxicillin
erythromycin
may also need FFP or HNIG
55 year old with bowel cancer is receiving chemotherapy via CVC. Presents hypotensive, tachycardic, febrile. Examination does not show obvious source of infection
Given tazocin and gentamicin for neutropenic sepsis
Blood culture grows an organism, and gram stain demonstrates a gram negative rod
What is the likely organism E.coli Citrobacter freundii Salmonella enteritidis Pseudomonas aeruginosa Proteus mirabilis
Pseudomonas aeruginosa
What are the two species of Histoplasma, and where are they located geographically?
Histoplasma capsulatum var. Capsulatum, an agent of the so-called American histoplasmosis (wrongly, because of global distribution),
Histoplasma capsulatum var. duboisii, an agent of African histoplasmosis - clinically predominantly causes cutaneous and subcutaneous disease compared to capsulatum
