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What's the diagnosis, investigations and management? (84 cards)

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1
Q

Travel to Milawi, freshwater exposure with positive Schistosoma serology

A

Lab: Stool/urine O&P negative
Rx: Praziquantel.
Sequelae: If untreated, ectopic CNS lesions, pulmonary haemorrhage.

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2
Q

Born in Malawi. Insidious onset of lethargy, mild mucohemorrhagic diarrhea, cramping, abdominal pain. Diffuse abdominal tenderness, minimal hepatomegaly, mild malnutrition. Mild eosinophilia.

A

Diagnosis: Schistosomiasis
Lab: S. mansoni ova in stool, mild eosinophilia, periportal fibrosis on U/S.
Rx: Praziquantel.
Sequelae: Associated with SCC bladder cancer.

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3
Q

Chronic cough with blood-streaked sputum, progressive chest discomfort, breathlessness on exertion following ingestion of freshwater crab in China/Japan/Korea/Taiwan

A

Paragonimus
Lab: CXR: patchy cystic infiltrate but can have nodule only
Eosinophilia; Paragonimus IgG positive
Eggs in sputum/BAL or stools
Mx: Praziquantel for 3 days.

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4
Q

Transient lymphedema, from DRC

A
  1. Lymphatic filariasis
    - Wuchereria bancrofti
    - Brugia malayi

Nocturnal microfilaria.
Symptomatic treatment
Consider annual MDA with DEC + albendazole

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5
Q

Expat from West Africa with an evanescent pruritus, maculopapular rash, often on the trunk with some subcutaenous nodules - diagnosis, diagnostics and management

A

Onchocerciasis

Other features including eye features, epilepsy.

Microfilariae in skin snips; eosinophilia, serology.

Ivermectin single dose. Doxycycline (target Wolbachia)

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6
Q

Expat from Central/West Africa (e.g. Gabon, Cameroon) with transient Calabar swellings, arthralgia, occasional pruritus and a visible eye worm - diagnosis, diagnostics,

A

Loa Loa (deerflies)
Eosinophilia; antifilarial IgG positive
DEC for 3 weeks

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7
Q

Had a recent barbeque with pork sausages. Initial diarrhea and non-specific abdominal complaints followed by fever, facial edema, painful swollen muscles, including respiratory and mastication muscles - diagnosis, diagnostics and management

A

Trichinosis
Eosinophilia, elevated IgE and CPK, positive T. spiralis IgG, larvae seen on muscle biopsy.
Rx: Albendazole with steroids

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8
Q

Patient with CD4 count 50, recently started ART presenting with an intensely itchy bumps over their head and trunk

A

Eosinophilic folliculitis

Skin biopsy reveals eosinophils under the skin surface and around the hair follicles and sebaceous glands
Treat with itraconazole, permetrhin
Or watch and wait for IRIS to settle

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9
Q

Fever, malaise, RUQ discomfort, wheezing in a 2-year-old who lives with dogs

A

Visceral Larva Migrans

Baylisascaris procyonis, Toxocara canis, Toxocara cati and Ascaris suum

Massive eosinophilia, elevated IgG, T. canis IgG positive; biopsy rarely needed

Treat with Albendazole; steroids may be considered

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10
Q

Severe headache, nausea, neck stiffness, paresthesias after eating some snails in Hawaii

A

Angiostrongylus cantonensis (Rat Lungworm)

CSF shows eosinophilia, elevated pressure, normal glucose, and high protein

Repeated lumbar puncture, analgesics, steroids. Avoid anthelmintics unless heavy steroids are used

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11
Q

Migratory subcutaneous swelling in a returning traveller who walked on the beach barefoot with lots of dog poo

A

Cutaneous larva migrans (CLM) is a self-limiting dermatosis caused by the migration of animal hookworm larvae (most commonly the dog hookworm Ancylostoma caninum and the cat hookworm Ancylostoma braziliense) in the skin.

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12
Q

Returning traveller, went on a fishing trip to Vietnam, presenting with migratory subcutaneous swelling

A

Gnathostomiasis
SE Asia, Latin America, rarely Africa
Eosinophilia; G. spinigerum ELISA positive.
Rarely an ectopic infection: eosinophilic meningoencephalitis or spinal cord involvement
Rx: Albendazole for 3 weeks or ivermectin for refractory cases.

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13
Q

4-week history of diffuse abdominal pain, diarrhoea, nausea and weakness and pneumonia. Background of liver transplant on immunosuppression. Bowel obstruction and gram negative sepsis. Longstanding eosinophilia. From SE Asia.

A

Strongyloides hyperinfection

Larvae in stool, eosinophilia, Strongyloides IgG positive

Treat: Ivermectin and antibiotics for superinfection

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14
Q

Returning traveller from India with diarrhoea with some cramping, progressed over weeks to having blood/mucous in the stool Now presenting with RUQ pain and some weight loss

A

Amoebiasis (Entamoeba histolytica)

Stool microscopy (hot) or PCR
Serology
Imaging for liver abscess
Rx Metronidazole with a luminal agent (iodoquinol or paromycin), large abscesses need draining

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15
Q

Fever, chills, headache. RCT positive. 15 weeks pregnant.

A

Malaria

Severity signs: High parasitemia, thrombocytopenia, elevated CK, lactic acidosis, hypoglycemia

Treat with IV artesunate in severe cases, ACT in non-severe

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16
Q

Travel to India, treated for malaria but within 2 weeks presenting with a fever again

A

Plasmodium vivax Relapse

Ring forms, schizonts in peripheral smear

Chloroquine for acute phase, primaquine 14 days for hypnozoite eradication following G6PD deficiency

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17
Q

30 year old from Bolivian with syncope and dilated cardiomyopathy with dysphagia

A

Chagas disease (Trypanosoma cruzi)

Chagoma may occur at entry site, acute chagas may present with fever, malaise, lymphadenopathy,

Diagnosis:
Serology
PCR (most helpful in newborns)
Microscopy of blood or heart muscle

Rx: Benznidazole 60 days (associated with lots of toxicity) for immunosuppressed or to prevent vertical transmission

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18
Q

Seen in DRC with acute febrile illness and lymphadenopathy following a painful bite with a visible chancre

A

African trypanosomiasis - T brucei rhodesiense (more acute form)

Dx
Microscopy
Molecular approaches

Rx
Suramin (early), melarsoprol (late)

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19
Q

Seen in DRC with enlarged lymph nodes, mild fever, general malaise followed by personality changes and sleepiness

A

African sleeping sickness - T brucei gambiense (west african)

Dx
Microscopy
Molecular approaches

Rx
Pentamidine (early) +/- nifurtimox (late).

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20
Q

Grew up in India presenting with 3 weeks of fever, massive splenomegaly, hepatomegaly, pallor and weight loss

A

Visceral leishmaniasis (sandfly)
L. infantum, L donovani

Dx: Pancytopenia, hypergammaglobulinemia, hypoalbuminemia, microscopy of amastigotes in marrow, lymph or spleen aspirate
Serology in East Asia, not so helpful in Africa

Rx: Liposomal amphotericin B, miltefosine alternative

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21
Q

Nodules appearing following visceral leishmaniasis diagnosis

A

Post-Kala Azar Dermal Leishmaniasis (PKDL)

Dx Slit skin smeal

Mx Miltefosine monotherapy 12 weeks (teratogenic)

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22
Q

Chronic ulcerative skin lesion; painless, no systemic symptoms following sandfly bite

A

Cutaneous Leishmaniasis

Dx
Look for amastigotes on smears or tissue sections
No role for serology here (unlike visceral)
Can grow on culture

Mx - approach
American vs Non-American? If American are they Viannia? (i.e. are they at risk of mucosal involvement)
Immunosuppressed?

  1. Conservative
  2. Local - intralesional antimonials
  3. Miltefosine (teratogenic)
  4. Pentavalent animonials e.g. meglumine
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23
Q

Gap year student ate lots of raspberries and lettuce in Peru and now has fever, vomiting, watery diarrhoea

A

Cyclospora cayetanensis

Dx
Stool with AFB positive oocytes (variably acid fast - pink on green background)

Mx co-trimoxazole 7-10 days

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24
Q

Patient with HIV with chronic diarrhoea and abdominal pain

A

Cryptosporidium

Stool AFB positive for oocysts (fuscia pink on a green background)

Most often self-limiting in healthy individuals, ARV in HIV

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25
Sheep farmer who spends lots of time with sheepdog, RUQ pain, US shows a large >5cm multilocular cyst and a cough
Cystic echinococcosis (Echinococcus granulosus) Dx: Serology + imaging Primarily in the lungs and liver Simple <5cm cyst treat with albendazole alone Complex (solid components or daughter cysts) and/or >5cm needs PAIR + albendazole
26
Refugee from China, had contact with foxes due to being homeless presenting with RUQ pain, jaundice and weight loss with evidence of calcified lesions on liver US
Alevolar echinococcosis (echinococcus multilocularis) Dx: Imaging Serology Biopsy - if malignancy needs to be excluded Mx Radical surgery of solitary lesions with 2 years of albendazole May require lifelong albendazole
27
Peruvian pig farmer presenting with headaches and new onset of seizures
Neurocysticercosis (Taenia solium) Occurs from ingestion of the eggs and therefore faecal oral contamination (with potential for human to human transmission) - rather than eating pork containing cysts Dx Serology Neuroimaging Mx albendazole to be considered but not without risk
28
Returning traveller from Pakistan with fever, headache, malaise, constipation then diarrhoea with hepatosplenomegaly on exam
Enteric fever (salmonella typhi/paratyphi) Dx: Blood culture (gold standard) Bone marrow (highest yield) Mx Azithromycin or 3rd generation cefalosporins
29
Somalian patient with fever, night sweats, back pain, arthralgia, orchitis and a new murmur. Sister owns camel.
Brucellosis Dx Blood culture (slow growing) +/- PCR Rose bengal test Mx Doxycycline 45 days + IV gentamicin or streptomycin
30
Bartonellosis
Bartonella bacilliformis Vector borne found in the Andean valley in Peru Sandfly vector Haemolytic anaemia, malaise, fever Complications - CNS, pericarditis, myocarditis
31
Plumber presenting with difficulty swallowing, trismus, neck rigidity, spasms triggered by minor stimuli
Tetanus (clostridium tetani) Dx: Clinical diagnosis, cultures rarely helpful Mx: Tetanus immunoglobulin - None required in complete vaccination - Booster + TIG needed in incomplete/unvaccinated Sedation (diazepam), wound debridement, antibiotics (metronidazole) May require mechanical ventilation
32
Recent flooding in India. Initially presenting with fever, headache, conjunctival suffusion, jaundice and hepatomegaly. Followed by meningeal symptoms
High ESR, thrombocytopenia, bilirubin elevation, AKI Urine/blood PCR Serology Rx: Ceftriaxone or penicillin, supportive care (N.B jarisch-herxheimer)
33
Fever, headache and rash following trip to North America, tick bite noted
Rickettsia rickettsii (Rocky mountain spotted fever) Dx: serology Mx: doxycycline
34
Asylum seeker, 7 days ago came to UK having been in a refugee camp. Presenting with persistent fever, rash and eschar
Epidemic typhus (rickettsia prowazekii) Body louse faeces Note sustained fever, vasculitis complications Dx Serology Mx Doxycycline
35
Patient from Uganda presenting with fever, chills, painful unilateral inguinal swelling with a blood smear showing bipolar staining with coccobacilli
Plague (yersinia pestis) Bubonic, pulmonary, septicaemia Dx Blood smear or bubo aspirate culture growing yersinia pestis Mx Streptomycin or gentamicin
36
A farmer from Ethiopia presenting with a painless black eschar
Anthrax (bacillus anthracis) Also pulmonary presentation (inhalational) or GI due to ingestion of bad meat Dx culture Mx: Ciproflox/amox in simple cases or cipro + mero + linezolid + IVIg in severe
37
Patient presenting with an enlarged inguinal lymph node with a previous ulcerative lesion in genital area. HIV positive and previous syphilis
Lymphogranuloma venereum Dx: Chlamydia trachomatis in aspirate Mx Doxycycline or azithromycin
37
Painful genital ulcer with tender regional lymphadenopathy with swab from the ulcer growing Haemophilus ducreyi
Chancroid Dx culture, exclude syphilis and HSV Mx single dose azithromycin
38
Pregnant women has presented with what started as a painless chancre and 6 weeks later develop fever and rash on the palms and soles
Maternal syphilis Dx: Nontreponemal tests e.g. RPR (swirling card test) and VDRL (used to screen for syphilis but not specific to syphilis) Confirmatory treponemal tests TPHA or EIA Mx: IM benzathine penicillin (3 doses often given in pregnancy if late latent or unclear of stage), IV penicillin for neurosyphilis
39
Profuse watery diarrhoea with oliguria in a refugee camp in the context of recent outbreak
Cholera - O1/O139 producint toxin Dx Stool culture vibrio cholerae Mx Aggressive fluid resuscitation (IVF, ORS), zinc PO <5 years, Doxycycline
40
A 10 year old boy in a rural village in Uganda presenting with a single painless nodule ulcerating with a wide undermined edge. No fever or lymphadenopathy.
Buruli ulcer (mycobacterium ulcerans) Dx: PCR gold standard, culture + histology Mx: Rifampicin + streptomycin for 8 weeks, debridement of necrotic tissue
41
A 35 year old man from India presenting with a scaly anaesthetic lesion on his forearm
Paucibacillary leprosy - mycobacterium leprae Dx: slit skin smear, biopsy siehl-nielseon staining Mx: Rif + dapsone 6 months
42
A 26 year old woman presenting with multiple hypopigmented anaethetic patches over the trunk with palpable thickened peripheral nerve
Multibacillary leprosae (mycobacterium leprae) Dx: slit skin smear, biopsy siehl-nielseon staining Mx: Rif + dapsone + clofazimine for 12 months
43
8 year old from Thailand presenting with parotid abscess and culture shows an oxidase positive gram negative bacillus
Meliodosis (burkholderia pseudomallei) Dx: culture blood, sputum, abscesses Mx: IV ceftazidime or meropenem for 10 days --> co-trimoxazole maintenance 20 weeks
44
50 year old man from Japan with a background of spastic paraparesis, chronic dermatitis. Mother died of some form of leukaemia.
HTLV1 --> HAM or spastic parapareis and ATL Dx: Serology/PCR Mx: No treatment or vaccine
45
90 year old patient from a nursing home presenting with intense itch and hyperkeratosis of the hands
Scabies Dx: clinical, scrapings showing mites Mx: Ivermectin or pemethrin
46
65 year old from India presenting with fever, retro-orbital headache and a macular rash. Leukopenia, thrombocytopenis and elevated transaminases. Now presenting with pulmonary odoema
Severe dengue Dx: Serology Mx: Supportive care
47
20 year old returning from Brazil with a history of fever, diffuse rash and polyarthritis with a knee effusion
Chikungunya Dx: Serology Mx:Supportive care
48
27 year old in rural Nigeria presenting with fever, sore throat and hearing loss. It's harvest and he sleeps on the floor
Lassa fever Dx: Serology/PCR Mx: Early ribavirin
49
45 year old VFR in DRC presenting with fever and severe headache and sore throat, 3 days later started to get vomiting, diarrhoea and GI bleed
Ebola Dx: PCR Mx: supportive
50
5 year old child in Bangladesh presenting with fever, hydrophobia, agitation and seizures following a dog bite 3 months ago
Furious rabies Dx: PCR from saliva/CSF Mx: palliation
51
Farmer in rural Uganda presenting with a chronic painless swelling in the foot with sinus tracts and drainage of black grains
Madura foot (eumycetoma fungal more common in Africa) Triad: Grains + painless swelling + sinus tracts Dx: Slow growing culture of madurella mycetomatis Mx: Itraconazole or ketoconazole
52
Returning traveller who visited a bat cave in Ohio and now presents cough, shortness of breath and fever
Histoplasmosis May also have hepatosplenomegaly, diffuse rash, pancytopenia, elevated LDH Dx: Yeast form in the peripheral blood (like mickey mouse) Mx: Amphotericin B 1-2 weeks followed by chronic supporession with itraconazole 12 months in severe disease
53
A patient with HIV CD4 <200 presenting with headache, fever, neck stiffness and low GCS. CRAG positive on CSF
Cryptococcosis Serum/CSF cryptococcal antigen, CSF may be india ink or culture positive Mx: Amphotericin B + flucytosine, followed by fluconazole
54
Single papular lesion following a scratch whilst gardening followed by more diffuse nodular lesions in lymphatic distribution
Sporotrichosis Dx: sporothrix schenckii on culture Mx: itraconazole for 3 months
55
A 27 year old with a background of HIV visiting from California with flu-like symptoms, cough, weight loss, verrucous skin lesions
Coccidiomycosis Dx: culture, serology, PCR, histopathology Mx: Fluconazole 3-6 months
56
A 37 year old alcoholic returning from a walking/camping holiday in Brazil with longstanding mucocutaenous lesions, oral ulcers and exertional dyspnoea.
Paracoccidiomycosis Dx: Bilateral fibronodular disease on CXR and serology Mx: Itraconazole 1 year
57
Snake bite - intense pain and swelling at the site of the bite with systemic bleeding, shock and blistering. Saw the snake and it had a short, thick body and some zigzags on its back
Viper bite Dx: Coagulopathy, elevated CK and myoglobulinuria Mx: Antivenom, supportive care
58
Snake bite - no local swelling or pain, ptosis, descending flaccid paraparesis and progressive respiratory distress. Caught sight of the snake which had a long thin body and a long tail
Snake bite - Elapid e.g. krate Dx: Usually normal labs Mx: Ventilatory support
59
A patient presenting with swelling of the leg but ruled out causes of lymphatic filariasis
Podoconiosis
60
Get a wriggly rash on the tummy after going for a walk on the beach barefoot in Brazil
Ancylostoma braziliense
61
A 5 year old child presenting with unilateral flaccid paralysis
Polio - enterovirus Faecal oral transmission Dx: Stool samples, throat swabs, or cerebrospinal fluid (CSF) within 14 days of symptom onset for PCR Mx: supportive
62
A 27 year old man who works as a farmer in Uganda presenting with headache, nausea, excessive salivation, muscle twitching and seizure
Organophosphate poisoning Inhibits acetylcholinesterase Mx: Atropine
63
A 26 year old backpacker has returned from Ghana with some localised swelling on the back and a black scab. She is otherwise systemically well. On examination there is a white pulsating mass underneath the scab of the lesion. She didn't iron a single t shirt whilst she was away!!
Myiasis Sub-Saharan Africa - Mango/Tumbu fly South America - human botfly Mx: cover with petroleum jelly and then pull it out
64
Differentials for a 45 year old male in malawi presenting with back pain and difficulty walking. On examination he has a spastic paraparesis and sensory level between T9-11.
Spinal TB Spinal metastases Disc prolapse Transverse myelitis Schistosomiasis
65
Differentials for parotitis in a 6 year old in Loas
Staph aureus Strep pyogenes Haemophilus influenzae Burkholderia pseudomallei Bartonella henselae TB Parainfluenza Enterovirus Flu Mumps (although normally bilateral) CMV/EBV
66
A 35 year old man from Thailand who presents with fever, widespread lymphadenopathy and a widespread papular rash with umbilicated centre - differentials
Differentials: HIV + molluscum + talaromycosis + histoplasmosis + penicilliosis + cryptococcosis CMV/EBV Bartonella - bacillary angiomatosis Meliodosis
67
A 35 year old farmer in the US presenting with a painless central ulcer with surrounding odoema ++ - 5 differentials
Bacillus anthrax (cutaneous) - Tx docycycline Bubonic plaque Rickettsia Bacterial acthyma Necrotic spider bite
68
AN HIV positive man presenting with shortness of breath on exertion, fevers and weightloss with bilateral infiltrates on CXR
PCP Dx: BAL/grocott methenamine staining Mx: High dose co-trimoxazole 21 days
69
Over the course of 1 week, spastic paraparesis in a 14 year old boy from Tanzania, recent famine
Konzo Symmetrical spastic paraparesis No sensory or GU involvement Abrupt onset <1 week Cassava growing area
70
14 year old in Malawi bitten by a snake, did not move out of the way but puffed up and bit him
African puff-adder Viperidae family More localised systemic swelling and necrosis with systemic shock and bleeding Mx: Anti-venom IV if systemic symptoms Abx Tetanus Debridement Pressure pad
71
A 14 year old Sri Lankan boy presenting with fever, hepatomegaly, subconjunctival haemorrhage and muscle pain after a fishing trip
Leptospirosis Dx PCR urine/blood Serology Mx Doxycycline Ceftriaxone to cover typhoid as well
72
12 year old boy from a village in rural Western Kenya presenting with 9 month history of eye pain and visual loss. The upper lids are swollen and turned inwards. There is corneal scarring with whitening/opacification. He has been to see a traditional healer. What are the main differentials?
Vitamin A deficiency Corneal ulcer Chemical trauma as a result of traditional medicine Trachoma - chlamydia trachomatis
73
Peruvian farmer presenting with what started as a painless nodule but now has underlying abscess and multiple neighbouring subcutaneous nodules. He has failed treatment with antibiotics and cutaenous leishmaniasis treatment
Sporotrichosis (rose gardners) Mx: itraconazole/Amphotericin B if systemic involvement (lung or bony)
74
A monk from myanmar presenting with a 3 month history of unilateral scrotal swelling. It is a very common presentation in his local region. Differentials.
DDx: lymphatic filariasis, testicular tumour, hydrocele, inguinal hernia, testicular TB, urogenital schisto Lymphatic filariaris Dx: blood smear (nocturnal), Circulating filarial antigen (CFA), PCR if available, US Mx: Albendazole or DEC (not in oncho/loa loa areas) Doxycycline
75
A 35 year old lady from Malawi presenting with diarrhoea and a photosensitive rash. More recently she is becoming confused. It is the rainy season. They eat two meals a day which is mainly maize porridge.
Pellagra - vitamin B3 deficiency Maize does not have much trytophoran which is needed for niacin synthesis. Mx niacin (PO) or IV in severe cases
76
A 28 year old woman presenting with a 1 year history of focal seizures with evidence of cysts on MRI. She previously went backpacking across South America and South East Asia. She is vegan.
Neurocysticercosis T solium egg ingestion (i.e. NOT from pork meat) but from salad leaves Mx: Albendazole, steroids, antiepileptics
77
Lady from Malawi living with HIV presenting with a greyish/white raised gelatinous lesion on the conjunctiva
Ocular surface squamous neoplasia
78
Differentials for a child presenting with a 4 week history of fever, splenomegaly and wasting
1. TB 2. HIV 3. Visceral leishmaniasis 4. Malaria 5. Brucellosis 6. Malignancy (leukaemia/lymphoma)
79
A 56 year old woman who has been travelling in Laos and ate lots of raw fish presents with explosive diarrhoea, colicky pain and anaemia. A stool sample shows eggs which look like peanuts
Capillaria philippensis Can lead to auto-infections Mx abendazole
80
27 year old lady living with HIV in Sub Saharan Africa presenting with a maculopapular rash including haemorrhagic crusts on the eyelids and lips. She started co-trimoxazole and ART 1 month ago.
Stevens Johnson Syndrome
81
19 year old presenting with subacute spastic paraparesis with no back pain and bladder/bowel involvement after a period of famine. He ate mostly lathyrus grasspea plant
Neurolathyrism
82
Recent travel to Vietnam working in a dog rescue centre has tried eating some frog presenting with migratory subcutaneous swelling
Spargnanosis Canine/feline tapeworm infection
83

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