Questions from S 11 Flashcards
Actual exam question
19 year old male. MSM
Complaining of pruritic perianal rash.
O/E - multiple indurated ulcers, inguinal lymphadenopathy, and widespread buttock oedema.
Treated with Abx for perianal abscess.
Presents two days later with headache, fever, myalgia, bilateral cervical lymphadenopathy and new vesicular lesions on his lips and hands
Patient travelled to London and had unprotected sexual intercourse 18 days prior
What is the differential diagnosis? 8 answers
What is the most likely diagnosis?
Mpox
HSV 1/2
VZV in immunocompromised
Enterovirus
Chancroid
Syphilis
Lymphogranuloma Venereum
Acute HIV syndrome
Most likely:
Mpox
Actual exam question
19 year old male. MSM
Complaining of pruritic perianal rash.
O/E - multiple indurated ulcers, inguinal lymphadenopathy, and widespread buttock oedema.
Treated with Abx for perianal abscess.
Presents two days later with headache, fever, myalgia, bilateral cervical lymphadenopathy and new vesicular lesions on his lips and hands
Patient travelled to London and had unprotected sexual intercourse 18 days prior
What microbiology and virology tests would you order to exclude or confirm causative pathogens? 4 answers
Swab in VTM, for Mpox PCR. From perianal region, lips, hands
Swab in VTM for HSV/ VZV/ Entero PCR. From perianal region, lips, hands
Clotted blood for syphilis EIA/ RPR
Clotted blood for HIV 1/2 Ag/Ab
Swab for Chlamydia Trachomatis (LVG) DNA PCR
First catch urine sample for Neisseria Gonorrhoea PCR
Actual exam question
19 year old male. MSM
Complaining of pruritic perianal rash.
O/E - multiple indurated ulcers, inguinal lymphadenopathy, and widespread buttock oedema.
Treated with Abx for perianal abscess.
Presents two days later with headache, fever, myalgia, bilateral cervical lymphadenopathy and new vesicular lesions on his lips and hands
Patient travelled to London and had unprotected sexual intercourse 18 days prior
What types of samples would you refer for Mpox PCR testing? 5 answeres
Swab in VTM from perianal rash
Swab in VTM from Lips/ hands
Swab in VTM from throat
EDTA + serum
Urine
Actual exam question
Why is travel history important when discussing Mpox cases?
A travel history within the past 21 days to Central Africa who raised suspicion of Clade I infection. This is a HCID, and would therefore need discussed with the Imported Fever Service. This carries a 10% mortality
As our patient acquired it in London, likely Clade 2b, which is responsible for the global outbreaks
Clade 1 is Central African - approx 10% mortality
Clade 2a is West African clade - approx 1-5% mortality
Clade 2b is epidemic strain - approx 1-5% mortality
Travel to Africa
Which countries make you concerned about a Clade 1 infection?
Clade 1 - Central Africa - DR Congo, Central African Republic
Clade 2a - West Africa
Clade 2b - worldwide
Actual exam question
What is the definition of:
Possible Mpox case
A possible case is defined as anyone who fits one or more of the following criteria:
- a febrile prodrome compatible with mpox infection where there is known prior contact with a confirmed case in the 21 days before symptom onset
Febrile prodrome consists of fever ≥ 38°C, chills, headache, exhaustion, muscle aches (myalgia), joint pain (arthralgia), backache, and swollen lymph nodes (lymphadenopathy)
- an illness where the clinician has a suspicion of mpox, such as unexplained lesions, including but not limited to:
genital, ano-genital or oral lesion(s) – for example, ulcers, nodules
proctitis – for example anorectal pain, bleeding
Actual exam question
What is the definition of:
Probable Mpox case
A probable case is defined as anyone with an unexplained rash or lesion(s) on any part of their body (including genital/perianal, oral), or proctitis (for example anorectal pain, bleeding) and who:
- has an epidemiological link to a confirmed, probable or highly probable case of mpox in the 21 days before symptom onset
- identifies as a gay, bisexual or other man who has sex with men (GBMSM)
- has had one or more new sexual partners in the 21 days before symptom onset
Actual exam question
Actual exam question
Describe HSID risk stratification and assessment of new Mpox cases prior to making decisions on who should be admitted to hospital
HSID? may be spelling error
Group A -
- patients with severe disease or immunosuppression - transfer to HCID centre.
- all those with suspected Clade 1 infection - transfer to HCID centre
Group B - patients presenting a risk to others, or requiring hospitalisation for other reasons - admit to specialist regional ID centre
Group C - low risk, advise to isolate at home
Mpox case asked to isolate at home
What criteria is used to step-down isolation precautions?
Clinical criteria - parent team decide patient is well/ no fever
Laboratory criteria - PCR negative throat swab, urine and blood*
May not need to test blood, if blood not tested initially because patient well
Lesion criteria -
no new lesions 48 hours
no mucus membrane lesions
all lesions crusted over, all scabs dropped off, intact skin remains underneath
Actual exam question
Hospital IPC calls you and asks for advice on infection precautions as the patient is being admitted to hospital.
What advice would you give?
If Clade 1 or severely unwell - treat as HCID and transfer to Royal Free
If Clade 2 or stable -
Admit to negative pressure side room
Gloves/ Apron/ Visor/ droplet mask
Keep list of contacts in case contact tracing required
Actual exam question
Describe the vaccine used for Mpox
Describe the route of administration
Describe the frequency of dosing
Imvanex
Modified Vaccinia (Ankara) vaccine. Based on smallpox vaccine. 3rd generation. Live attenuated vaccine - this modern vaccine cannot replicate
Subcutaneous/ IM administration
2x doses 4 weeks apart
Actual exam question
Describe the use of Mpox vaccine as a post-exposure prophylaxis
Within 4 days of exposure
Up to 14 days after exposure
2nd dose 4 weeks after
Only 1 dose required if previously immunised against smallpox
Actual exam question
Describe the use of Mpox vaccine as a pre-exposure prophylaxis
High risk patients in outbreak setting - e.g MSM
Occupational - lab staff, iCaSH staff
Actual exam question
Which antivirals are used against Mpox and what is the mechanism of action?
Tecovirimat - P37 major envelope protein fusion inhibitor. Prevents virus leaving infected cell
Cidofovir - nuceloside analogue inhibits DNA polymerase
Brincidofovir - nucleoside analogue inhibits DNA polymerase. Prodrug of cidofovir. Reduced side effects, oral administration
