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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > STIs, stings, malnutrition, altitude > Flashcards

STIs, stings, malnutrition, altitude Flashcards

1
Q

2 key issues with altitude mountain sickness

A

High altitude pulmonary oedema (HAPE)
High altitude cerebral oedema (HACE)

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2
Q

Score system for AMS

A

Lake Louise score
3–5 = mild, 6–9 = moderate, and 10–12 = severe

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3
Q

Define HACE

A

High-altitude cerebral oedema

AMS
+ Altered mental status OR ataxia

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4
Q

Prevent HACE. Name 2 things

A

Acetazolamide [dex works too]
Ascend slowly
Minimal physical activity
Hydration

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5
Q

Name 3 things that affect validity

A
  1. Selection bias
  2. Information bias
  3. Confounding
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6
Q

What is PPV? What does it depend on?

A

The probability that a person with a positive test truly has the disease

Depends on sensitivity but also on
* the prevalence of the disease in the population tested OR
* in the pre test probability in the individual tested

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7
Q

How can you summarize test performance by combining sensitivity and specificity

A

Likelihood ratio

How many times more a positive (or negative) test is likely to occur in a diseased (or non diseased) person
* LHR + = Se / (1-Sp)
* LHR - = (1-Se) / Sp

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8
Q

Gene Xpert has Sensitivity 95%, specificity: 99% what is the likelihood ratio of an infected person?

A

LHR + = 0.95 / (1-0.99)
= 95
A positive test is 95 times more likely to occur in a person with TB

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9
Q

Tropical sprue biopsy? rx?

A

Partial vilous atrophy
increased villous crypts and mononuclear cellular infiltrates, enlarged epithelial cells,

Prolonged erythromycin + folic acid

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10
Q

Which vaccines for respiratory global priorities for kids

A

Pneumococcal
H influenza

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11
Q

Malnourished children with eye disease need what? Key diseases this is ++ relevant in

A

Vitamin A

Measles / diarrhoea

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12
Q

Guinea worm infection called? Seen on ulcer? Dx?

A
  • Dracunculus medinensis
  • Pearly uterus seen poking out
  • Identify worm/larvae after exposure to water
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13
Q

Most common cause of anaemia worldwide

A

Hookworm

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14
Q

Key drug causing macrocytosis

A

Hydroxycarbamide

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15
Q

Why testing for STIs important for HIV

A

facilitates transmission of HIV - much more likely if eg ulcerated skin

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16
Q

Hb make up in sickle cell? carrier?

A

95% HbS, 5% HbF
30%HbS, 70%HbA

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17
Q

Sickle cell parts of chronic Rx

A

Folic acid
Penicillin prophylaxis
hydroxycarbamide to increase HbF

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18
Q

B thalassaemia blood film

A

Hypochromic microcytic anaemia

[would expect to have raised MCV due to anaemia but the low MCV is due to ineffective erythropoesis]

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19
Q

G6PD inheritance ? key drugs causing reactions?

A

X linked

PANDS
Primaquine, Aspirin (acetylsalicylic acid), nitrofurantoin, dapsone, sulfonamides

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20
Q

screening test for G6PD in poor places?

A

Methemoglobin reduction test

[enzyme assays / genetic analysis if rich]

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21
Q

what does it mean if RBCs are hypochromic eg in iron deficiency

A

> 50% of cell is pale in colour on blood film

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22
Q

blood film b12 / folate deficiency

A

Macrocytic anaemia with hypersegmented neutrophils

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23
Q

Most common issue following viper venom? Cheap test?

A

Lack of clotting

WBCT20 (whole blood clotting test 20)
take 20ml blood and put in clean tube
-Leave it undisturbed for 20min and see if it can still be poured
-If still liquid = hypofibrinogenaemia

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24
Q

When antivenom in snake bites

A

swelling >50% affected limb or clinically unwell

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25
Q

Scorpion sting key cause of morbitiy ? rx?

A

Autonomic nervous system
-Hypertension
-CV failire
-Pulm oedema

Antivenom
Prazosin for HTN / cardiac failure
Diruetics / vasodilators for pulm oedema

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26
Q

The characteristic sign of severe envenoming from widow spider? real name?

A

HTN (similar to scorpion)
[abdo pain, autonomic, pain at bite]

Latrodectus

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27
Q

Bite which pain develops over hours, initially white ischemic area which breaks down into a eschlar over a week = ?

A

Loxosceles ssp
(Recluse spider bite)

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28
Q

Bite -> priapism, HTN, sweating tachy?

A

Banana (brazilian wandering) spider
-Phoneutria

Only in South America

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29
Q

Trick for Rx of venomous fish sting?

A

Immerse in hot water
-the venom usually heat labile

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30
Q

Key issue with any antivenom?

A

Anaphylaxis common

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31
Q

2 diabetic syndromes more or less only seen in tropics:
present young and hyperglycaemic with pancreatic fibrosis/calcification?
West African young with DKA which remits after acute Rx? Assoc with?
HIV?

A

Malnutrition-related diabetes

DKA that resolved - Atypical ketosis prone type 2 diabetes
HHV8

ART- related diabetes

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32
Q

Key issues for diabetic management in rural places

A

Late presentations
Irregular food supply / western diet adopted
Cultural benefit of being overweight / obese
Lack of insulin / drugs
Lack of dietcians / podiatrists
Poor health education
Lack of labs / monitoring equipment

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33
Q

which 2 infections should you screen for before giving someone with asthma a course of pred in the tropics?

A

Entamoeba histolytica - amoebic dysentery
Stronglioglaisis - hyperinfection syndrome

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34
Q

Name 3 causes of epilepsy in developing countries

A

Hypoxia at birth
head injury
Previous cerbral malaria
HIV + secondary infections eg cryptococcus / toxoplasmosis
Hydatid cytsts
Neurocystercosis (T Solium)

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35
Q

Common antiepileptic available in resource poor places

A

Phenobarbital
start at 30mg daily and increase up to 90mg

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36
Q

What is often used as an indicator of the severity of a humanitarian emergency?

A

Crude mortality rate Eg >1/10,000/day
or under 5 mortality rate

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37
Q

MSF 10 parts of emergency response?

A

1 - initial assessment
2 - measles immunisation
3 - water and sanitation
4 - Food and nutrition
5 - Shelter and infrastructure
6 - Health care in the emergency phase
7 - control of communicable disease epidemics (Eg cholera, shigella, malaria, other respiratory )
8 - Public health surveillance
9 - human resources and training
10 - Coordination

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38
Q

Initial assessment of humanitarian emergency aspects

A
  • Geopolitical context
    -Demographics of the population
    -Map of the site with characteristics of the environment
  • Food/water / shelter availability
  • major health/diseases
  • Human / materials required
  • Which local / national organisations can help
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39
Q

Which easy vaccine should be distributed in a humanitarian emergency? +supplement?

A

Measles + vit A (and zinc)

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40
Q

Minimum water required in a humanitarian emergency? How to test / clean?

A

5L/person/day
ideally 20L to minimise risk of water bourne illness

Test for coliforms with test kit eg del agua / oxfam kit

chlorination

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41
Q

Latrine requirements in humanitarian emergency

A

minimum 1/100 persons initially -> aiming for 1/20 or one per household

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42
Q

in humanitarian emergency which disease needs to be often neglected until health system better established

A

TB

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43
Q

What percentage of <5 deaths are related to malnutrition

A

50% of the 10M deaths a year

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44
Q

Moderate vs severe malnutrition definitions? weight-for-height Z score? height for age? Extra?

A

Moderate
Weight for height - 2-3 SD below normal (70-79%)
MUAC <12.5cm

Severe
Weight for height - >3 SD below normal (<70%)
MUAC < 11.5cm
[Weight for age (<60%)
Height for age - >3 SD below normal (<85%)
Presence of symmetrical oedema (kwashiorkor)]

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45
Q

Symmetrical oedema due to malnutrition is called

A

kwashiorkor

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46
Q

Oedematous malnutrition key features

A

Hair which is easily pluckable
Eye changes from vit A defieicny
Anaemia - Mixed deficiency
Mental - apathy and irritable -> coma
Liver - enlarged and fatty
Anorexia
Skin - hyperpigmented and dry / flaky

Enlarged fatty liver

Ascities is rare

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47
Q

Oedematous malnutrition key features

A

Hair which is easily pluckable
Eye changes from vit A defieicny
Anaemia - Mixed deficiency
Mental - apathy and irritable -> coma
Liver - enlarged and fatty
Anorexia
Skin - hyperpigmented and dry / flaky

Ascities is rare

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48
Q

Electrolytes malnourishment

A

Hypo Ca/K/Mg
HypoNa in blood but raised total body Na

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49
Q

Initial stabilisation of malnourshment rx?

A

Prevent:
-Hypoglycaemia - frequent small feeds
-Hypothermia - keep warm
-Treat dehydration and shock - ReSoMal (rehydration solution for the malnorished) - type of ORS
-Correct electrolytes
-Rx infection
-Mutrients - all should get folic acid / zinc / copper / vit A

[Should always aim to keep fluids ORAL as high risk of fluid overload / cardiac failure]

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50
Q

Which feed is often used in acute severe malnutrition

A

F75 used for first 2-7 days
- Has less protein/calories/fat as not intended for weight gain
- Avoids refeeding syndrome

F100 - used for rehab phase

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51
Q

Unconcious shocked malnourished child rx

A

5mg/kg 10% IV dextrose
Warm
15mg/kg over 1 hr [Eg Darrows with 5% glucose]

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52
Q

what is malnutrition wasting called

A

Marasmus

53
Q

Vit A found in? initial Sx? seen on exam in deficiency? what happens eventually? Retinol?

A

Green leafy veg
Dry / gritty eyes with worsened night vision

On exam - Bitot’s spots (grey or white plaques on lateral aspect of conjunctiva)

Keratomalacia eventually - whole eye breaks down -> irreversible blindness

Retinol often normal even in deficiency - only reduces once very severe

54
Q

What is gritty eyes from vit A deficiency termed?

A

Xerophthalmia

55
Q

Vit B1 called? syndrome when deficient?

A

Thiamine
beriberi

[Also causes wernicke-korsakoff]

56
Q

Beriberi (thiamine b1) deficiency 2 forms?

A

Wet - cardiomyopathy -> peripheral oedema

Dry - painful polyneuropathy

57
Q

Diagnosis of b1 deficiency can use what test?

A

red blood cell transketolase enzyme reduction

58
Q

B3 is called? Syndrome when deficient?

A

Niacin / nicotinic acid

Pellagra
-Diarrhoea
-Dermatitis
-Dementia

59
Q

Key rash in pellagra?

A

Hyperpigmented affecting neck
‘cascals necklace’

60
Q

Which deficiency -> gingivitis? Leads to?

A

Vit C (ascorbic acid)
Bleeding - from gums and base of hair follicles

61
Q

Main risk factors for diarrhoea name 3

A

Malnutrition
Low birth weight
Lack of breastfeeding
No measles vaccination
Crowding
Indoor pollution eg open fires

62
Q

Which cells kill virus-infected cells in innate immune response

A

NK cells
CD-8 cells

63
Q

Which IL key for TB

A

IL-12

64
Q

Why HTLV-1 leads to bad stronglyoglotides

A

Blocks IL-5 which would usually stimulate eosinophil production

65
Q

Which Ig looks like a pretty snowflake (looks like 5 groups of normal ig_

A

IgM

66
Q

Which Ig on mucosal surfaces

A

IgA

67
Q

Which Ig is not secreted and remains as a cell receptor

A

IgD

68
Q

Define MDR TB

A

Resistant to Rifampicin and Isoniazid

69
Q

how much of daily energy should come from protein? fat?

A

Protein - 10%
Fat - 20%

70
Q

Name a screening tool for malnutrition

A
  • Nutritional Risk Screening 2002
  • Malnutrition Universal Screening Tool
  • Mini‐Nutritional Assessment – Short Form
71
Q

Moderate/severe malnutrition.
Weight loss?
BMI?

A
72
Q

Normal vaginal pH? Why is it this?

A

<4.7
Lactic acid production by Lactobacillus
(L. crispatus and L. jensenii)

73
Q

Which vaginitis is discharge yellow/green? white? odours? strawberry cervix? ‘clue cells’? Usual pH for 3 key conditions?

A
74
Q

Which bacteria are commonly implicated in BV? Rx?

A

Loss of lactobacilli -> growth of commensal
Gardnerella vaginalis
[Vaginal Garden]

Metronidazole or tinidazole or clinda

75
Q

homogeneous, grey-white discharge , uniformly adherent to vaginal epithelium? Name a score system for Dx? Rx if preg?

A

BV

Amsel criteria = 3 of:
– homogeneous discharge
– pH >4.5
– clue cells (>20%)
– amine odor on addition of KOH (+whiff test)

Nugent score (gram stain findings)

Intravaginal Metronidazole or clinda

76
Q

Trichomonas vaginalis rx?

A

Metronidazole / tinidazole

77
Q

Which candida in thrush? Rx? If Preg?

A

C. albicans
Flucondazole

Preg - vaginal clotrimazole

78
Q

Diptheria rx

A

Antitoxin + penicillin/erythromycin

79
Q

Calais Camp and see refugee patient who presents with a rash. It started in his groin 3 weeks ago and has since spread. It is pruritic and keeps him up at night. He came now as he has an open wound in his inner right thigh that is painful with some purulent discharge.

A

Scabies
Ivermectin / permethin cream

80
Q
  • Cambodian refugee 20 yrs prior
  • Presents with acute LLQ pain Intermittent loose stool, perianal pruritis
  • PMHx- SLE with ESRD on dialysis
A

Strongy hyperinfection

81
Q

Syphilis, herpes, chancroid, LGV, donovanosis.
Organism?
Number of lesions? appearance?
Characteristics?
Lymphadenopathy?

A
82
Q

=? rx?

A

Herpes simplex (probable HSV2)
Acyclovir - no cure

83
Q

Painful and has lymphadenopathy? rx?

A

Chancroid (haemophilus ducreyi) - painful / purulent
ceftriaxone
[Cipro/azithro options]

84
Q

=? rx?

A

Syphilis (Treponema pallidum)- often painless and clean

benzylpenicillin

85
Q

=? rx?

A

LGV - chlamydia trachomatis (often rapid healing of ulcer then affects lymph nodes)

Doxy

86
Q

=? rx?

A

Granuloma inguinale (klebsiella granulomatis) - especially if ‘beefy’ red lesions
Azithro / doxy

87
Q

Genital disease with vesicles =

A

Herpes

88
Q

How to diagnose herpes? aciclovir resistant?

A

PCR - Sensitive and specific

Viral culture - not sensitive
-Only way to determine aciclovir resistance

89
Q

Name 3 herpes prevention strategies

A

Avoid sex with lesions
Condoms
Suppressive antiviral therapy
Disclosure of serostatus

90
Q

HSV 1 vs 2 locations

A

1 - oral and genital
2 - only genital

91
Q

Prodrome then Firm, deep-seated, well-circumscribed, sometimes umbilicated lesions
– Starts on face and spreads to extremities, including palms & soles

A

Mpox

92
Q

Name 3 Ddx of disseminated rash

A

Hairless Sexy Men Get Very Fucking Hard Muscles

HIV
Syphilis
Mpox / Other pox viruses
Gonococcal (Disseminated ) infection - especially if pustulating
Varicella/VZV
Herpes (Disseminated )
Fungal infections (disseminated)
Molluscum contagiosum

93
Q

Name 2 causes of proctitis

A

Gonorrhea
Chlamydia (including LGV)
HSV

94
Q
A

Groove sign - LGV

95
Q

Rx?

A

Donovanosis (Granuloma Inguinale) (bright red beefy)
Klebsiella granulomatis

Azithro

96
Q

Infectious cause of stroke in a young person

A

Neurosyphilis
(Cryptococcus + HIV rare)

97
Q

Partner is known to have syphilis what should you do

A

Treat empirically - Benpen

98
Q

On TB/HIV rx present with shortness of breath, irritable (per cousin), minor muscle wasting with possible wt. loss. Diarrhoea and this rash in sun-exposed areas
=?
Key drug implicated?

A

Niacin deficiency (B3) - pellegra
Diarrhoea, dementia, dermatitis
(often round neck)

Isoniazid - interferes with niacin metabolism

99
Q

“Walking in water”, swollen feet - which vitamin deficiency most likely

A

B1 - thiamine (wet beri beri)

100
Q

Isoniazid leads to which vitamin deficiency?

A

B3 (naicin) -> pellegra

101
Q

10F Gradual weight loss, fatigue, brought in because “everything hurts
Physical exam: normal height/weight for age
* Mouth ulcers
* Spots in eye

A

Vit A deficiency

102
Q

Arrested growth
* Vitamin A deficiency symptoms
* Altered taste
* Impaired immunity
* Hair loss, poor skin integrity
=which deficiency?

A

Zinc deficiency

103
Q

18M taking TDF/FTC for PrEP presents to urgent care with a rash 0 diffuse, non pruritic, non painful and made up of erythematous macules on his chest, back, palms, and soles
Labs with normal BMP, CBC, but elevated
AST (350) and ALT (450)
–4 th generation HIV and Monospot negative
Dx most likely? Ix?

A

Syphilis
o Rapid plasma reagin (RPR)
o Treponemal antibody:

104
Q

Which stages of syphilis might you get neurosyphilis

A
105
Q

Syphilis Rx, Primary / secondary / latent / neuro?

A

Primary / secondary / early latent
-Ben pen single dose [half of dose into each butt cheek]

Late latent / unknown latent
-IM ben pen for 3 weeks

Neuro
-IV Benpen

106
Q

Non gonococcal urethritis in men top 3 causes

A

Chlamydia trachomatis (15-40%)
Mycoplasma. genitalium (15-25%)
Trichomonas vaginalis (1-8%)

107
Q

Most common presentation vit A toxicity

A

Headache

108
Q

WHO guideline for Abx in acute severe malnutrition

A

Amox empiric treatment

109
Q

Mycoplasma genitalium rx

A

Doxycycline
followed by Moxifloxacin

110
Q

Specific serovar of Lymphogranuloma venereum

A

Caused by L1-L3 serovars of C. trachomatis

111
Q

16F No PMH
facial rash for past 2 months, which started on her arm and spread to her axilla, chest and face
On biopsy (Warthin Starry silver stain)

A

Treponema pallidum

112
Q

2 key predictors of neonatal mortality

A

Low birth weight
Preterm

[IgG mostly passed from mother through placenta towards end of pregnancy]

113
Q

Neonatal sepsis top bugs ? How do these change depending on income ?

A

Gram-positive
-Coag-negative staph (neonates = essential immunocompromised)
-S aureus
-Group B strep

Gram Negative - Higher risk of death
-Klebsiella
-E coli
-Pseudomonas

Resource-rich = gram positive
Resource-poor = gram negative

114
Q

Main causes of neonatal pneumonia

A

Gram positives - GBS and S. aureus

115
Q

Top 2 causes neonatal meningitis

A

GBS
E. col

Vag and anus
[2/3rds of cases between them]

116
Q

Rx first line neonatal sepsis? What Ix should be done on all neonates with unknown sepsis

A

Ampicillin + gentamicin
LP

117
Q

Key protein in breast milk that is very protective

A

lactoferrin

118
Q

Scorpion sting local effects usually?

A

immediate agonising local pain with minimal swelling

[Exception - Hemiscorpius lepturus (Iran, Iraq, Pakistan)
* painless sting, followed by swelling blistering, necrosis]

119
Q

What are the systemic effects of scorpion stings

A

Ion channel toxins
1 - Autonomic storm [ think pheochromocytoma]
-Parasympathetic (cholinergic) - vomiting, sweating, hypersecretion, pancreatitis, priapism
-Sympathetic (adrenergic) - “goose bumps/flesh”, tachycardia, cardiovascular, myocarditis pulmonary oedema, hyperglycaemia

2-Neurotoxic effects:
fasciculations, tonic-clonic spasms “pseudo-convulsions”,
nystagmus, opsoclonus, irritability, paralysis, ptosis

120
Q

Rx scorpion skin local?

A

Local anaesthetic - eg ring block of the affected finger

121
Q

Scorpion sting systemic Rx?

A

Keep calm
Antivenom

ICU - may need dobutamine for LVF
-Prazosin for HTN

122
Q

Sx?

A

Widdow - lactrodectus

Profuse sweating
-> Muscle Eg Abdomonal rigidity

123
Q

What happens when I bite you?
Key complication?

A

‘Recluse’ loxosceles - Necrotic araneism (arachnidism)

Initially painless
- Develop slow burning / stinging etc
->12-72hrs ‘red white and blue sign’
-+ systemic symptoms eg headache, fever, scarlet rash
(see below)

After 3-7 days black necrotic eschar

Key comp = Haemolytic syndrome
-> fever, jaundice, haemoglobinuria with AKI
-> respiratory distress

124
Q

Local sx? Systemic?

A

Latin American wandering/armed/banana spiders (Phoneutria

Local sx of goosebumps/sweating
-note wide bite marks

Hypertension -> stroke
Priaprism
[rapidly-evolving headache, nausea, vomiting]

125
Q

Key issue when kept as pets

A

Tarantula
Fire hairs -> local issues

Bite is mostly just trauma related
-> mild local swelling / muscle spasms

126
Q

what happens if you touch me?
rx?

A

possibly fatal bleeding and kidney failure

Rx - Antivenom

127
Q

Which scorpions cause Cardiorespiratory effects
Eg hypertension, shock, tachy- and brady- arrhythmias, ECG
changes, pulmonary oedema

A

Leiurus, Androctonus, Hottentotta, Tityus

[Left atrial heart tachy]

128
Q

Which scoprions cause neurotoxic effects?
erratic eye movements, fasciculation, muscle spasms (pseudo-convulsions) causing respiratory distress

A

Centruroides, Parabuthus
[Cerebral Paralysis]

129
Q
A

Box jellyfish sting
Chironex fleckeri

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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