TMIH exam focused revision Flashcards
Sudanese refugee presenting with fever, abdominal pain, diarrhoea and bleeding gums
Viral haemorrhagic fever
Typhoid
Complicated malaria
Bacterial gastroenteritis
Leptospirosis
Malaria film or RDT
Blood culture
Stool culture and OCP
ELISA antigen and PCR tests
A girl from Peru presenting with a 4 month history of a lesion on her nose which started as a nodule and turned into an ulcer
Leishmaniasis
Sporotrichosis
Cutaneous TB/other mycobacteria
Balamuthia mandrillaris
Cutaneous anthax
Scrape with lancet around edge of lesion
Giemsa staining (leishmania amastigotes)
Culture/PCR of FNA or biopsy
Smear microscopy and culture for sporotrichosis
Purified protein derivative (PPD) for TB
Histopathological examination
Woman from Malawi presenting with insidious headache coming on over 1 week, fever, confusion and third CN palsy. LP shows raised opening pressure, high protein, low glucose
Meningitis including:
Cryptococcal
TB
Bacterial
Cerebral malaria
CSF - gram stain, culture, PCR for MTB
CrAG serum + CSF
India ink stain + fungal culture
HIV test
Mx
Ceftriaxone
Amphotericin B + flucystosin
TB treatment
A 4 year old from Uganda presenting with seizure and reduced consciousness. Fundoscopy shows retinal whitening
- Cerebral malaria
- Meningitis
- Encephalitis
- Poisoning (e.g. organophosphate)
- Hypoglycaemia
- Renal/liver failure
- Status epilepticus
LP, EEG, bloods (glucose, ammonia), blood cultures, malaria film
26 year old german student returning from Botswana with a migratory rash after being on a fishing trip
Gnathostomiasis
Strongyloides
Loa loa
Cat/dog hookworm
Sparganosis (canine/feline tapeworms)
Student returning from 6 week trip to Ghana, presenting with localised swelling (treated as a boil with antibiotics) with a black scab
Myiasis
Rickettsial disease
Staph/strep infection
Cutaneous anthrax
Spider bite
45 year old Malawian man presenting with several week history of back pain and spastic paraparesis
Spinal TB
Cord compression from metastases or disc prolapse
Transverse myelitis
HIV associated myelopathy
Schistosomiasis
45 year old man man in the Gambia who has multiple painful genital ulcers
Chancroid - haemophilus ducreyi
Syphilis - usually painless
Herpes simplex
An 8 year old boy from Lao with unilateral parotid swelling
Bacterial:
Staph aureus
Strep pyogenes
H influenzae (unvaccinated)
Bukholderia pseudomallei
TB
Actinomycosis
Cat scratch disease bartonella henselae
Viral:
Mumps (unvaccinated)
CMV
Influenza/parainfluenza
Rare: Malignancy, salivary stone
A 34F with meningitis (predominantly neutrophils) and HIV in Malawi
Bacterial:
Strep pneumo
Neisseria meningitidis (dry season)
Staph aureus
H influenzae
TB
Cryptococcal meningitis
Traveller returning from Thailand with eosinophilia
Helminths
Ectoparasites - scabies + myiasis
Coccidiomycosis
Paracoccidiomycosis
CTD
Asthma
Allergy
Drug induced
Leukaemias
Paraneoplastic
43 year old presenting with fever, urticaria, splenomegaly following travel to Mozambique. Eosinophilia and derranged LFTs present.
Katayama syndrome (acute schistosomiasis)
DDx (though would not explain the eosinophilia:
EBV/CMV
Leptospirosis
Rickettsial disease
Typhoid fever
Malaria
Amoebic liver abscess
35M in US presents with a cutaneous ulcer with surrounding neck swelling after cutting himself shaving. It is not responding to ceftriaxone.
Abscess - staph/strep
Cutaneous anthrax
Bubonic plaque
Spider bite
Rickettsial disease
Glandular tularaemia
6 year old boy from Malawi presenting with dry cough, fever, and conjunctivitis
Measles
Malaria
Rubella
Scarlet fever
Typhoid fever
Rickettsial infections
Atypical pneumonia - bacterial or viral
Meningococcal disease
Complication of measles
- Encephalitis
- Dehydration
- Severe diarrhoea
- Septicaemia
- Otitis media
- Giant cell or superimposed pneumonia
- Corneal ulceration
What is the incubation period and infectivity period for measles?
8-12 days
4 days before rash and 4 days after rash
What is a late complication of measles?
Subacute severe sclerosing panencephalitis
Management of measles
Paramyxovirus
Vitamin A supplementation (two doses 24 hours apart at least)
Consider antibiotics for superadded bacterial pneumonia, corneal ulcers or otitis media
Nutritional support and hydration
Immunoglobulin to contacts
Can vaccinate at 9 months, delay until after ART initiated in HIV
Unmasking IRIS
An opportunistic disease, which was not present at the time of ART initiation, becomes clinically
manifest because of ART-induced immune recovery
Paradoxical IRIS
Immune recovery after initiation of ART triggers the clinical
deterioration of the disease (e.g. pulmonary TB) during the initial months of treatment.
What is the anthrax
Gram positive rod
Bacillus anthracis
GI, cutaneous or inhalational forms
Cutaenous is characterised by a painless lesion with surrounding vesicles and odoema
Treatment: doxycycline
What is the upper limit of incubation period for viral haemorrhagic fever?
21 days
32 year old british woman visiting family and relatives in rural Nigeria presenting with 3 day history of jaundice and fever
Malaria
VHF (although no injected sclerae or rash)1
Leptospirosis
Typhoid fever
Hepatitis (although usually slower onset)
Ascending cholangitis
31 year old man with HIV and CD4 count of 150 presenting with 3 week history of cough, shortness of breath and 10kg weight loss
Pneumocystis pneumonia
TB
Cryptococcosis
Histoplasmosis
Atypical bacterial pneumonia
PCP - investigations and management
Induced sputum or preferably bronchoscopy to obtain bronchoalveolar lavage specimens
- Visualisation of pneumocystis jirovecii on immunofluorescence and/or PCR
Imaging
- Perihilar infiltrates on CXR
- Ground glass changes on CT
Co-trimoxazole 14-21 days
Steroids in severe cases
2nd line treatment:
Primaquine + clindamycin
72 year old male farmer from Laos presenting with verroucous fungating lesions around the left foot which have been present for years
Eumycetoma and actinomycetoma
- Chromoblastomycosis
- Sporotrichosis
- Mycobacterium including leprae TB
- Kaposi’s sarcoma
- SCC
- Psoriasis
- Sarcoid
- Not leish (not in Laos)
Ix
Skin scrapings (direct microscopy, culture for sporo)
Mx
Chromoblastomycosis - Itraconazole + surgical debridement + treatment of bacterial superadded infection
Where is visceral leishmaniasis found?
Brazil
East Africa
India
Where is cutaneous leishmaniasis found?
Americas
Mediterranean basin
Middle East
Central Asia
Africa
What is chromoblastomycosis caused by?
Chronic fungal infection of the skin and SC tissue
Fonsecaea, Phialophora, Cladophialophora
Verrucous nodules or plaques
Skin scrapings under direct microscopy show brown, round, thick-walled structures “medlar bodies”
Snake bite first aid measures
Reassurance
Pain relief
Remove jewellry/clothes
Pressure immobilisation
Tetanus
Antibiotics
Wound management
IV antivenom (immunoglobulin)
What do elapid snake bites lead to?
Neurotoxic effects
Mamba, cobra, rinkhals
Puff adder effects
V pattern on back
Cardiotoxic
Cytotoxic
Haemotoxic
Myotoxic effects from what kind of snake?
Sea snake
16 year old boy from Sri Lanka presenting with fever, jaundice, subconjunctival haemorrhage and AKI
Leptospirosis
Dengue
Scrub typhus
Hantavirus
Dengue
Leptospirosis investigations and management
CSF, blood, urine culture of leptospira (8 weeks + dark microscopy)
PCR
Doxycycline/IV benpen
Complications of leptospirosis
Cholestatic jaundice, AKI, bleeding (Weil’s)
Myocarditis
Meningitis (aseptic)
Pulmonary
Treatment of Loa Loa based on microfilaraemia
<2000 - DEC
1000-8000 - Ivermectin
High - Albendazole
Loa loa vector
Chrysops horse fly
Is there any role for doxycycline in Loa Loa?
No ain’t no Wolbachia
Loa Loa diagnosis
Blood film (daytime)
PCR
Serology has lots of cross reactivity with other nematodes and filarial species
What should you be suspicious of when assessing an HIV patient with severe anaemia?
TB hiding away in the bone marrow
What is non-typhoidal salmonella?
Salmonella enteriditis, typhimurium
Enterocolitis in immunocompetent
Sepsis in HIV/malnutrition/malaria
severe anaemia, abdo pain, diarrhoea, splenomegaly, co-infection with strep pneumo, H influenzae or TB
Mx: fluoroquinolone or azithromycin
12 year old boy in rural Kenya presenting with painful eyes including corneal opacification, lid scarring, trichiasis
Trachoma
Vitamin A deficiency
Corneal and conjunctival damage from traditional medicine
Trachoma stages
- Trachomatous inflammation with follicles (TF)
- Trachomatous inflammation intense (TI)
- Trachomatous conjunctival scarring (TS)
- Trachomatous trichiasis (TT)
- Corneal opacity
SAFE - Surgery (TT), Antibiotics (TF/TI), Facial cleanliness, Environmental
Trachoma MDA
Annual azithromycin for 3 years if prevalence >10%
Which season does meliodosis usually present in?
Wet (80%)
What are some risk factors for meliodosis?
South East Asia and Northern Australia
Diabetes
Steroids
Immunosuppression (but not HIV)
Alcoholism
CKD
Treatment of meliodosis
Ceftazidime or meropenem 2 weeks
Co-trimoxazole 3-6 months
Manifestations of Kaposi’s sarcoma
Cutaenous
Lymphadenopathy
Pulmonary
What test can you do to check for disseminated TB in HIV?
Urine LAM (lipoarabinomannan)
Considerations in TB + HIV
Prednisolone can reduce risk of IRIS
Often smear negative
Profound anaemia
More likely to have miliary and extra-pulmonary TB
Peruvian farmer presenting with a chronic ulcer and nodular lymphangitis
Cutaneous leishmaniasis
Sporotrichosis
TB
Mycobacterium marinarum
Nocardiosis
Forms of sporotrichosis
Cutaneous
In immunosuppressed
Pulmonary (inhalation)
Disseminated
Treatment of cryptococcal meningitis
Amphotericin B + flucytosine 2 weeks
Oral fluconazole 8 weeks
Continue prophylactic fluconazole until CD4 improved
N.B no role for steroids
ART 4-10 weeks after treatment of CM
23M farmer from Myanmar presenting with 3 year history of unilateral scrotal swelling
Hydrocele (transillumination)
Lymphatic filariasis
Cyst
Inguinal hernia
Peripheral odoema secondary to heart failure
Urogenital schistosomiasis if endemic region
Lymphatic filariasis diagnosis
Blood film (nocturnal)
PCR assays
Ultrasound
Circulating filarial antigen
Lymphatic filariasis causes and epidemiology
Wuchereria bancrofti
Brugia malayi
South Asia
South East Asia
Sub Saharan Africa
South America
Caribbean
What treatment for LF should be avoided in Loa Loa endemic region?
Ivermectin
DEC
29 year old woman from Malawi presenting with confusion, diarrhoea and a skin rash
Pellagra (B3 deficiency)
HIV
TB
Malignancy
SLE
Diagnostics for neurocysticercosis
Enzyme linked immunoelectrotransfer blot
Neurocysticercosis definition
Occurs from eating Taenia solium eggs from salad etc
A key cause of preventable epilepsy in Africa, Asia, Latin America
Become encysted in either the parenchyma or the subarachnoid space
Principles of neurocysticercosis treatment
Albendazole + steroids - Vesicular
Albendazole + Praziquantel + steroids > 2 cysts and ring enhancing, colloidal
If there is no surrounding odoema to the cyst or it is calcified there is no benefit to using antihelminth treatment
Management of hydrocephalus and raised intracranial pressure - supportive, not for antihelminth treatment
A 62 year old woman from rural Ethiopia presenting with difficulty chewing (stiffness of the mouth)
Tetanus (clostridium tetani)
GCA
Management of tetanus
Diazepam
Antitoxin
Metronidazole
Consider tracheostomy
Complications of tetanus
Pneumonia
Respiratory arrest
Laryngeal spasms
Arrhythmias
Autonomic dysregulation
7 year old girl from West Africa presenting with two skin ulcers and a contracture of the wrist
Buruli ulcer
Yaws
Mycobacterium TB/leprae
Anthrax
Buruli ulcer presentation and epidemiology
Mycobacterium ulcerans
Found in Africa, parts of Australia, Japan and China
May present as a nodule, a plaque, odoema which can progress to an ulcer with undermined edges. It can involve bone. It may be painless and without a fever.
Buruli ulcer investigations and management
PCR, culture, histopathology, direct microscopy of wound swab
Rifampicin + clarithromycin 8 weeks (studies aiming to reduce that) - note may have paradoxically worsening symptoms after or secondary bacterial infection
41 year old traveller returns from Thailand beach holiday with a migratory rash
Cutaneous larva migrans:
Animal hookworm
Gnathostomiasis
Strongy (currens)
Examples of animal hookworm, investigations and management
Ancylostoma caninum
Ancylostoma braziliense
No investigations needed (eosinophilia often not present even)
Treat with a single dose of ivermectin
Ocular surface squamous neoplasia
Associated with HIV, UV light, HPV
Greyish/white elevated mass unilaterally of the eye
Treatment with topical chemotherapy or surgical excision
7 year old girl from South Sudan presenting with 4 week history of undulating fever. Malnourished with widespread lymphadenopathy and splenomegaly
Visceral leishmaniasis
TB
HIV
Kaposi’s sarcoma
Malaria
Brucellosis
Leukaemia and lymphoma
Brucellosis treatment
Doxycycline 100 mg twice a day for 45 days, plus streptomycin 1 g daily for 15 days
Brucellosis presentation
Unpasteurised milk consumption
Fever, wasting, splenomegaly
Visceral leishmaniasis investigations
Rapid antigen test (rK39)
Direct agglutination test (DAT)
Visceral leishmaniasis species
L. donovani, L infantum (often from infected sandfly)
Visceral leishmaniasis epidemiology
Sudan, South Sudan, India, Ethopia, Brazil
Visceral leishmaniasis investigations
Lymph, spleen, bone marrow biopsies to visualise amastigotes
Visceral leishmaniasis treatment
Pentavalent antimonials
Amphotericin B
Miltofesine
Hydatid cyst
Cystic echinococcus - echinococcus granulosus
Ingestion of eggs from dogs (sheep dogs)
Middle East, South America, Africa
Typically large, unilocular, with well-defined walls
Surgical (>5cm, complex) + albendazole
Alveolar echinococcus
Echinococcus multilocularis
Ingestion of eggs from fox or dog faeces
Multilocular, infiltrative growth resembling a malignancy with poorly defined margins and solid appearance
Northern hemisphere - Central Europe, Russia, North America
Surgical +/- albendazole
Amoebic liver cyst
Entamoeba histolytica
Faecal oral route
Thick, liquefied contents, lacks true wall
Metronidazole 7-10 days
Serology - sensitive but not so helpful in endemic settings
Aspiration can be sent for PCR and would be sterile
Initiating 1st line treatment for HIV
Tenofovir
Lamuvidine
Dolutegravir
Tenofovir definitely if Hep B positive
Avoid Bictegravir due to interactions with TB drugs
Prophylactic co-trimoxazole
Risk factors for IRIS
Low Hb
Low CD4 count
Rapid change in CD4
Rapid reduction in viral load
Short period between treatment of infection and initiation of ART
Acute non-compressive flaccid paraparesis
Acute transverse myelitis
Vascular spinal cord ischaemia
Acute transverse myelitis
Lymphocytes and protein in CSF
Steroids/aciclovir
What are common complications associated with cystic echinococcus?
Cystobiliary fistula with biliary obstruction
Secondary bacterial infection
Cyst rupture leading to anaphylaxis
Emobilsm of cyst content
Compression syndromes
Focal brain lesions in HIV
Toxoplasmosis
PML
Lymphoma
Cryptococcoma or tuberculoma
Brain tumour/metastasis
Abscess
Neurocysticercosis
PML
Reactivation of JC virus
muscle weakness, cognitive dysfunction, hemianopia, gait difficulties
Note there is no odoema or mass effect unlike other lesions
PML IRIS - steroids, continue ART
Bartonellosis - Oroya fever
Vector borne - Bartonella bacilliformis
Andean valleys in Peru, Colombia, Ecuador
Most asymptomatic but some after 3-8 weeks develop haemolytic anaemia with jaundice and high fevers
Angioproliferative phase with small painless violaceous papules
Heart failure
CNS complications
Coccobacillary structures inside red blood cells
AKA Carrion’s disease - remember the mad Peruvian medical student who injected himself with a patient’s wart but died from the systemic disease (proving its the same thing)
What test can you use to check for TB in a patient coinfected with HIV?
Urinary LAM (mycobacterial lipoarabinomannan)
40 year old farmer from Peru presenting with 4 month history of cough and chest pain and weight loss 20kg
TB
Histoplasmosis
Paracoccidiomycosis
Paracoccidiomycosis
Latin America
Typically rural, farmers due to soil exposure
- Fever
* Lymphadenopathy
* Hepatosplenomegaly
* Skin and oral mucosal lesions
Complications
* Respiratory
* Adrenal
* Neurological
Coccidiomycosis
Valley fever - north america
Can mimic TB
Chromoblastomycosis
Subcutaneous mycoses secondary to inoculation injury - see also sporotrichosis and mycetoma
Mycetoma (Madura foot)
Caused by either
* Bacteria (actinomycetes) or
* Fungi, eg. Madurella mycetomatis
Starts as a painless subcutaneous nodule
Progresses to multiple discharging sinuses
Black grains in the pus suggest fungal infection
Red grains suggest actinomycetes
Diagnosis confirmed by microscopy or culture
Complications of leptospirosis
Hepatic failure
Renal failure
Haemorrhage
Myocarditis
Conjunctivitis
Pneumonitis
Diagnosis and treatment of leptospirosis
Spirochaetes seen in urine on dark field microscopy
Serology: MAT
PCR of blood or urie
Penicillin, cephalopsporins, macrolides, tetracyclines
Yaws summary
Skin to skin contact
Affecting skin and bones
Caused by Treponema pallidum
Differentials for splenomegaly in a 40 year old woman in the Gambia
Lymphoproliferative disorder
Hyper reactive malarial splenomegaly
Visceral leishmaniasis
Portal HTN due to schistosomiasis or cirrhosis secondary to chronic Hep B
TB
Brucellosis
Signs of mycetoma
Tumour
Tracts
Grains
Differentials of mycetoma
Actinomycosis
Podoconiosis
TB
Bacterial OM
Cuatenous leish
Non TB mycobacteria
Arthemeter-Lumefantrine
Artemeinin containing therapy
At what cut off of G6PD deficiency is it safe to give primaquine?
> 30%
Intestinal capillariasis
Zoonotic nematode
Best test for histoplasmosis
Urinary antigen
Risk factors for mucosal involvement in cutaneous leish
Male, immunosuppressed, above waist lesion, previous MCL
Treatment for diptheria
Erythromycin
Benzathine penicillin
