Question book 7 Flashcards
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
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
32 year old from rural West Africa. Which virus has no known animal reservoir
Rabies Coronavirus CMV Hantavirus Lassa fever
CMV
Other animals such as monkeys have CMV, but it is uniquely different in genomic structure
No evidence of human-human transmission
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
do not perform any tests, and give treatment with doxycycline
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
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
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
babesiosis
parasites infect red blood cells
risk factors include asplenia
presents similar to malaria
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
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
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
zika
transmitted by aedes mosquito
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
send malaria blood film
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
isolate patient with respiratory precautions
likely avian influenza - outbreaks previously related in Vietnam to drinking duck blood pudding
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
co-amoxiclav and clarithromycin
probably legionella, but need to cover common CAP pathogens
Spain has penicillin resistance, so need co-amoxiclav
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
brucellosis
brucella abortus - cattle
brucella meiltensis - goats and sheep
leishmaniasis would cause splenomegaly, but not spinal tenderness
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
Schistosoma haematobium - has a “t” in the name for terminal spine
it is a urine sample, so should expect haematobium
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
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
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
Enterotoxigenic E. coli - most common cause of traveller’s diarrhoea
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
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
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
Cryptosporidium parvum
can occasionally last up to a month in immunocompetent patients
Necator/ ancylostoma cause no diarrhoea - usually just anaemia
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
Salmonella paratyphi
Paratyphi or Typhi cause enteric fever
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
ceftriaxone
Enteric fever - widespread resistance in SEA to ciprofloxacin, penicillin, and often co-trimoxazole
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
chancroid
biopsy shows shoals of fish
treatment with single dose azithromycin or ceftriaxone
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
Vibrio cholerae
TCBS plate - yellow growth, oxidase pos
if taken straight from TCBS plate, may be oxidase neg
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
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
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
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
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
Haemophilus ducreyi
may appear as shoals of fish
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
Burkholderia pseudomallei
Treatment is with ceftazidime or meropenem for at least two weeks
will require 8 weeks erradication therapy with oral co-trimoxazole
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
Malassezia furfur - pityriasis versicolor
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
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 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
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
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
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
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
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
22 year old returns from Tanzania with haematuria. Schistosomal serology is positive
What is treatment of choice
Albendazole Ivermectin Mebendazole Praziquantel Suramin
Praziquantel
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
IV quinine
Hb <80 is severe marker
parasitaemia >10% is severe marker
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
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
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
MERS
camels are source - slaughterhouse?
Saudi Arabia has highest rate of MERS
Could be avian influenza - unclear why not
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
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
What are treatment options for babesia
atovaquone and azithromycin
clindamicin and quinine
treatment for 7-10 days
Travellers diarrhoea lasting >14 days
What are possible causes
Giardia
Entamoeba histolytica
Cyclospora
Cryptosporidium
How to diagnose bacilus cereus infection
Clinical diagnosis usualy
Because it is toxin mediated, cannot culture stool for diagnosis
Need to grow bacteria from suspected food source
What is most common cause of tinea capitis
Malassezia furfur Candida tropicalis Microsporum spp Trichophyton rubrum Trichophyton tonsurans Trichophyton mentagrophytes
Trichophyton tonsurans
Patient with epilepsy travelling to malaria area.
What is appropriate prophylaxis
mefloquine
chloroquine
doxycycline
atovaquone-proguanil
atovaquone-proguanil
mefloquine/ chloroquine contraindicated epilepsy
doxycycline half-life may be reduced by phenytoin, barbiturates, carbamazepine
Suspected lympatic filariasis
Suspected loa loa
when should blood films be taken
Lymphatic filariasis - Brugia malayi, W bancrofti - blood film at night
Loa loa - take at midday
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
oral chloroquine
non-severe malaria
needs primaquine to clear hypnozoites if vivax or ovale
What are uses for triclabendazole?
Fasciola
Paragonimus
