Question book 7 Flashcards

1
Q

34 year male presents with 6 months tiredness. Extensive travel to South Asia and South East Asia

Anaemia, eosinophilia, low folate/ B12

Which enteric pathogen is most likely to be associated with this presentation

Schistosomiasis mekongi
Taenia solium
Strongyloides stercoralis
Taenia saginata
Diphyllobothrium latum
A

Diphyllobothrium latum - associated with B12 deficiency as it directly utilises B12

Hookworm - Ancylostoma/ necator can cause anaemia. But not usually enough to make symptomatic

Other answers present in different ways

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2
Q

32 year old from rural West Africa. Which virus has no known animal reservoir

Rabies
Coronavirus
CMV
Hantavirus
Lassa fever
A

CMV

Other animals such as monkeys have CMV, but it is uniquely different in genomic structure
No evidence of human-human transmission

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3
Q

40 year old returns from holiday in New England. Been bitten by insects
Annular lesion on lower left limb
Complains of headache and rash. No meningism or focal neurological signs

What is next management step

perform EIA test and treat with doxycycline immediately
commence IV ceftriaxone
perform two-tiered testing, and wait results before giving treatment
do not perform any tests, and give treatment with doxycycline
perform two-tiered testing, and treat with doxycycline

A

do not perform any tests, and give treatment with doxycycline

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4
Q

45 year old with fever, headache and myalgia with diarrhoea.
Returned from 2 week holiday in USA 10 days ago. Visited rural area near Lake Michigan
Describes having multiple insect bites

Anaemia, thrombocytopenia, lymphopenia
Blood film - morulae in cytoplasm of granulocytes

What is most likely vector

Black legged tick - Ixodes scapularis
Lone star tick - Ambylomma americanum
American dog tick - Dermacentor variabilis
Rocky mountain wood tick - Dermacentor andersoni
Soft tick - Ornithodoros spp

A

Black legged tick - Ixodes scapularis

Most likely diagnosis is anaplasma - as suggested by morulae in cytoplasm of granulocytes
Geographical distribution similar to Lyme disease, as black-legged tick transmits both lyme and anaplasma

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5
Q

20 year old with fever, arthralgia, headache, dark urine
Travelled to Midwestern USA and performed rural activities and water sports
Had splenectomy 2 years ago due to motorcycle accident, and takes prophylactic penicillin

anaemia, thrombocytopenia, raised creatinine, transaminitis
blood film - intra-erythrocytic parasites

what is most likely diagnosis

ehrlichiosis
lyme disease
babesiosis
RMSF
Tularaemia
A

babesiosis

parasites infect red blood cells
risk factors include asplenia
presents similar to malaria

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6
Q

Three days after returning from USA, 24 year old presents to local A&E with fever, headache, anorexia, sore throat and abdominal pain
Had been walking and camping
On examination meningitis and photophobia
Excessively lacrimating and crying in pain
bilateral conjunctivitis and peri-auricular lymphadenopathy noted

Bloods - anaemia, thrombocytopenia, raised creatinine, transaminitis, raised CK

What is best treatment option

meropenem
ceftriaxone
streptomycin + chloramphenicol
doxycycline and gentamicin
ciprofloxacin and doxycycline
A

streptomycin + chloramphenicol

likely cause is tularaemia meningitis
dog tick/ wood tick/ lone star tick or via inhalation of dead animals

cipro/ doxy/ gent/ strep are all treatment options. But streptomycin and chloramphenicol are recommended for meningitis

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7
Q

Antenatal ultrasound notes reduced foetal head circumference. After birth microcephaly confirmed
Mother had visited Brazil at week 12 of pregnancy
Describes short illness with headache, myalgia and arthralgia, which self resolved

what is most likely cause

zika
chikungunya
malaria
dengue
CMV
A

zika

transmitted by aedes mosquito

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8
Q

32 year old with fever, cough and flu like symptoms from Sierra Leone

What is next essential management step with this patient

isolate in containment level 4 facility
send malaria blood film
start on chloroquine
wait for blood culture results
send stool for MC&S for ova, cysts and parasites
A

send malaria blood film

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9
Q

37 year old returns from Hanoi where he drank duck blood. Presents with cough, malaise, and flu like illness
What management step should be taken next

admit to ward and start oral amantadine
isolate patient with respiratory precautions
discharge with oral erythromcyin
admit to ward and commence ceftriaxone
admit and start IV aciclovir
A

isolate patient with respiratory precautions

likely avian influenza - outbreaks previously related in Vietnam to drinking duck blood pudding

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10
Q

45 year old with recent travel to Spain presents with confusion, severe pneumonia, and diarrhoea.
What antibiotic should be initiated for this patient

ciprofloxacin and metronidazole
amoxicillin and clarithromycin
levofloxacin
co-amoxiclav and clarithromycin
ciprofloxacin and clarithromycin
A

co-amoxiclav and clarithromycin

probably legionella, but need to cover common CAP pathogens
Spain has penicillin resistance, so need co-amoxiclav

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11
Q

28 year old with recent travel to Africa and Middle East present with 3 week history of fever, night sweats and splenomegaly, and tender spine
blood culture becomes positive

what is most likely diagnosis in this patient

TB
visceral leishmaniasis
hydatid disease
brucellosis
malaria
A

brucellosis

brucella abortus - cattle
brucella meiltensis - goats and sheep

leishmaniasis would cause splenomegaly, but not spinal tenderness

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12
Q

32 year old with haematuria
Has been to East Africa, South Asia and South East age

microscopy shows urine sample with egg with terminal spine

what is most likely organism

Schistosoma mekongi
Schistosoma japonicum
Schistosoma intercalatum
Schistosoma haematobium
Schistosoma mansoni
A

Schistosoma haematobium - has a “t” in the name for terminal spine

it is a urine sample, so should expect haematobium

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13
Q

24 year old presents with acute abdominal pain and vomiting. She is flushed and hypotensive, and urticarial wheals are noted. She reports eating raw fish

what is likely diagnosis

chlonorchiasis
diphyllobothrium
anisakiasis
gnathostomiasis
strongylodiasis
A

anisakiasis

caused by infection with Anisakis simplex - nematode which normally infects crustaceans and fish
human disease during ingestion of raw fish

common in Scandinavia, Japan, pacific coast South America
treatment is largely supportive, worms die in 1-2 weeks

chlonorchiasis - presents with liver obstruction picture
diphyllobothrium - presents with fatigue, anaemia, B12 deficiency
gnathostomiasis - intestinal symptoms, or creeping skin rash
strongylodiasis - intestinal symptoms, loeffler syndrome, or hyperinfection

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14
Q

26 year old presents with abdominal pain and diarrhoea immediately on return from India. Reported eating street food on his way to the airport
What is the most common cause of traveller’s diarrhoea

Campylobacter jejuni
Enterotoxigenic E. coli
Salmonella spp
Shigella spp
Astrovirus
A

Enterotoxigenic E. coli - most common cause of traveller’s diarrhoea

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15
Q

54 year old female with diarrhoeal illness 24 hours after consumption of seafood from a street vender in Caribbean
Which investigation is needed

Stool culture for vibrio spp
Stool microscopy for Cyclospora cayetanensis
Stool culture for E.coli O015 H:7
Stool culture for Campylobacter jejuni
Stool culture for Bacillus cereus
A

Stool culture for vibrio spp

possible causes are Vibrio cholera, Vibrio parahaemolyticus, and Vibrio vulnifucus
Vibrio parahaemolyticus, and Vibrio vulnifucus are acquired by eating contaminated seafood
Vibrio vulnifucus can also be acquired by water touching open wounds

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16
Q

28 year old backpacker returns from 1 month trip to Peru. Has 3 week history of diarrhoea with is voluminous and watery
Stool culture negative
viral PCR neg

What is most likely

Giardia intestinalis
Cryptosporidium parvum
Necator americanus
Cyclospora cayetanensis
Shigella sonnei
A

Cryptosporidium parvum

can occasionally last up to a month in immunocompetent patients

Necator/ ancylostoma cause no diarrhoea - usually just anaemia

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17
Q

25 year old with previous gastrectomy visits family in Bangladesh
Two weeks after his return he develops fever without diarrhoea
Which pathogen is likely cause

Campylobacter jejuni
Salmonella paratyphi
Vibrio cholerae
Citrobacter freundii
Shigella sonnei
A

Salmonella paratyphi

Paratyphi or Typhi cause enteric fever

18
Q

25 year old with previous gastrectomy visits family in Bangladesh
Two weeks after his return he develops fever without diarrhoea

What is best empirical therapy

ampicillin
co-trimoxazole
chloramphenicol
ceftriaxone
nalidixic acid
A

ceftriaxone

Enteric fever - widespread resistance in SEA to ciprofloxacin, penicillin, and often co-trimoxazole

19
Q

22 year old presents to GP with groin pain
Had unprotected sex with a sex worker whilst on business trip in Nigeria
Has painful ulcer on glans of penis, which bleeds easily on light touch
Painful inguinal lymphadenopathy

What is most likely cause of his symptoms

chancroid
syphilis
HSV
HIV
gonorrhoea
A

chancroid

biopsy shows shoals of fish

treatment with single dose azithromycin or ceftriaxone

20
Q

50 year old presents with watery diarrhoea and dehydration. Lives in Delhi. Arrived in UK 6 hours prior to onset of watery diarrhoea, vomiting, abdominal cramps, fever

What is most likely cause

Plesiomonas shigelloides
Vibrio cholerae
Campylobacter jejuni
Shigella spp

A

Vibrio cholerae

TCBS plate - yellow growth, oxidase pos
if taken straight from TCBS plate, may be oxidase neg

21
Q

55 year old returns from Kenya. Had visited game reserves
Presents with abdominal pain, fever and constipation 5 days after returning from UK
Mild abdominal tenderness
Pyrexial and tachycardic
Blood cultures grow Salonella Typhi
She completely recovers

1 year later S.typphi is isolated from stool

What is the most likely condition

Dumper's illness
Presumptive carriage
Chronic carriage
Anascara
Cary-blair syndrome
A

Chronic carriage - defined as shedding 12 months after initial infection

Cary-Blair is type of transport medium for enteric pathogens

Anascara is fluid accumulation in multiple body compartments. Can be due to nephrotic syndrome or severe malnutrition in children

22
Q

37 year old returns from Philippines with dysuria and epididymitis with rash on his body and hands, and is investigated for STI
Prior to going to Philippines, 6 months earlier tested for syphilis

EIA: pos
TPPA: pos
VDRL: neg

What is most likely diagnosis

primary syphilis
secondary syphilis
symptomatic tertiary syphilis
past treated disease
HIV co-infection
A

HIV co-infection

rash suggestive of secondary syphilis, however the serology does not quite fit that picture
Serology may be false negative due to prozone phenomenon. This is more likely in patients with HIV infection

23
Q

22 year old has painful penile ulcer on return from trip to Thailand
Ulcer on glans with ragged edge, grey base, which bleeds easily on palpation

Sample shows gram neg coccobacilli

Haemophilus paraphrophilus
Burkholderia pseudomallei
Haemophilus ducreyi
Haemophilus influenzae
Treponema pallidum
A

Haemophilus ducreyi

may appear as shoals of fish

24
Q

32 year old in Vietnam has severe pneumonia and fever. Had been trekking for 2 months.
CT chest shows bilateral pneumonia, and liver abscess
BAL - gram neg bacilli
Culture - oxidase pos, resistant to gentamicin and colistin

What is most likely organism

Haemophilus influenzae
Burkholderia pseudomallei
Chlamydophila psittaci
Pseudomonas aeruginosa
Stenotrophomonas maltophilia
A

Burkholderia pseudomallei

Treatment is with ceftazidime or meropenem for at least two weeks
will require 8 weeks erradication therapy with oral co-trimoxazole

25
Q

20 year old from Africa has scaly lesion on scalp with loss of hair. Other lesions on ipper arms and hypopigmented, scaly and macular

Microscopy demonstrates yeasts with short hyphae
What is most likely cause

Malassezia furfur
Candida tropicalis
Microsporum spp
Trichophyton rubrum
Trichophyton mentagrophytes
A

Malassezia furfur - pityriasis versicolor

26
Q

29 year old female returns for pre-travel advice. Travelling to Kenya including safari park
Past history of depression. Taking OCP

Which malaria prophylaxis is best choice

Mefloquine
Atovaquone-proguanil
Chloroquine
Artemisinin
Doxycyline
A

Atovaquone-proguanil

mefloquine/ chloroquine avoid as psychiatric history
chloroquine avoid due to drug resistance
artemisinin is treatment, not prophylaxis

doxycycline is fine alternative, but atovaquone-proguanil is first line

27
Q

27 year old travelling to Gambia, including trekking.
She is 16 weeks pregnant

Which anti-malarials would be best choice

Mefloquine
Atovaquone-proguanil
Chloroquine
Artemisinin
Doxycycline
A

Mefloquine

Caution in first trimester - but benefits outweigh risks

chloroquine avoid due to drug resistance
artemisinin is treatment, not prophylaxis
doxycyline is teratogenic
atovaquone-proguanil lack of evidence of safety in pregnancy

28
Q

64 year old has IHD and AF. On bisoprolol, atorvastatin and warfarin

Which malaria prophylaxis is most appropriate

  • mefloquine starting 2 weeks prior to entering malaria area
  • atovaquone-proguanil starting 2 days prior to entering malaria area
  • mefloquine starting 2 days prior to entering malaria area
  • atovaquone-proguanil starting 2 weeks prior to entering malaria area
  • doxycycline starting 2 days prior to entering malaria area
A

mefloquine starting 2 weeks prior to entering malaria area

mefloquine can rarely increase INR, so take two weeks before travel and monitor INR

doxycycline can increase INR levels
atovaquone-proguanil can increase INR levels

29
Q

18 year old returns from extended trip to rural Nigeria.
3 week history of being intensely itchy, affecting whole body
Examination shows faint papular rash on some extensor surfaces, and numerous excoriations over entire body

What is most likely cause

Malassezia furfur
Onchocerca volvulus
Coccidioides immitis
Brugia Malayi 
Wucheria bancrofti
A

Onchocerca volvulus - transmitted by Simuliam black fly

onchodermatitis - itchy pruritis, papules
1-2 years later presents with subcutaneous nodules
can also presents as ocular onchocerciasis with itchy eyes

less common manifestation is nodding disease, which can presents as seizures

diagnosis by skin snip and microscopy or PCR

treatment with invermectin

30
Q

22 year old returns from Tanzania with haematuria. Schistosomal serology is positive

What is treatment of choice

Albendazole
Ivermectin
Mebendazole
Praziquantel
Suramin
A

Praziquantel

31
Q

27 year old presents with fever following climbing Mount Kilimanjaro

Bloods - Hb 79, PLT 29
2.5% parasitaemia

What is treatment

oral chloroquine
IV quinine
oral atovaquone-proguanil
oral mefloquine
IV chloroquine
A

IV quinine

Hb <80 is severe marker

parasitaemia >10% is severe marker

32
Q

19 year old returns from gap year trip to Egypt, Gambia, Uganda, Tanzania, Brazil

Asymptomatic. But stool shows a parasite

which drug is most efficacious

mebendazole
ivermectin
praziquantel
albendazole
suramin
A

ivermectin treatment of choice for strongyloides

albendazole/ mebendazole have some effect against strongyloides, but not as effective
praziquantel is for schistosomiasis
suramin is for trypanosomiasis

33
Q

22 year old from Saudi Arabia 10 days ago presents with fever, cough, SOB.
Uncle works in local slaughterhouse

Looks unwell with RR 30, bilateral crepitations
CXR shows widespread infiltrates
requires intubation

What is most likely diagnosis

MERS
Avian influenza
Influenza A
SARS
Human metapneumovirus
A

MERS

camels are source - slaughterhouse?
Saudi Arabia has highest rate of MERS

Could be avian influenza - unclear why not

34
Q

Which diseases do these ticks transmit

Black legged tick - Ixodes scapularis
Lone star tick - Ambylomma americanum
American dog tick - Dermacentor variabilis
Rocky mountain wood tick - Dermacentor andersoni
Soft tick - Ornithodoros spp

anaplasma
babesia
ehrilicia
lyme
relapsing fever
RMSF
tularaemia
A

Black legged tick - Ixodes scapularis - anaplasma/ babesia/ lyme

Lone star tick - Ambylomma americanum - Ehrlichia

American dog tick - Dermacentor variabilis - tularaemia/ RMSF

Rocky mountain wood tick - Dermacentor andersoni - tularaemia/ RMSF

Soft tick - Ornithodoros spp - relpasing fever

35
Q

What are treatment options for babesia

A

atovaquone and azithromycin
clindamicin and quinine

treatment for 7-10 days

36
Q

Travellers diarrhoea lasting >14 days

What are possible causes

A

Giardia
Entamoeba histolytica
Cyclospora
Cryptosporidium

37
Q

How to diagnose bacilus cereus infection

A

Clinical diagnosis usualy

Because it is toxin mediated, cannot culture stool for diagnosis
Need to grow bacteria from suspected food source

38
Q

What is most common cause of tinea capitis

Malassezia furfur
Candida tropicalis
Microsporum spp
Trichophyton rubrum
Trichophyton tonsurans
Trichophyton mentagrophytes
A

Trichophyton tonsurans

39
Q

Patient with epilepsy travelling to malaria area.

What is appropriate prophylaxis

mefloquine
chloroquine
doxycycline
atovaquone-proguanil

A

atovaquone-proguanil

mefloquine/ chloroquine contraindicated epilepsy

doxycycline half-life may be reduced by phenytoin, barbiturates, carbamazepine

40
Q

Suspected lympatic filariasis
Suspected loa loa

when should blood films be taken

A

Lymphatic filariasis - Brugia malayi, W bancrofti - blood film at night

Loa loa - take at midday

41
Q

Patient with confirmed non-falciparum malaria

Hb 81, PLT 74
Cr 104
6% parasitaemia

What is treatment of choice

oral chloroquine
IV quinine
oral atovaquone-proguanil
oral mefloquine
IV chloroquine
IV artemesinin
A

oral chloroquine

non-severe malaria

needs primaquine to clear hypnozoites if vivax or ovale

42
Q

What are uses for triclabendazole?

A

Fasciola

Paragonimus