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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > Clincial Rounds > Flashcards

Clincial Rounds Flashcards

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1
Q

Swelling + discharging sinus =

A

Myecetoma foot
[Despite name can be bacterial]

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2
Q

Acinomyecetoma usual cause? Characterised by?

A

Nocardia
Streptomyces

White/yellow soft grains

[White grains can be either bacteria or fungus]

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3
Q

(Fungal) eumycetoma usual cause? Characteristic?

A

Madurella mycetomatis

Pigmented - black grains
[Only from Fungal and almost always mardurella mycetomatis]

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4
Q

What is Botryomycosis

A

Bacteria (despite name) part of staph A
Also has white/yellow granules

[Technically not mycetoma as a staph despite having all features (swelling , sinus, granule]

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5
Q

66F born in Highlands. PMH cervical Ca,
Several years progressive weakness in lower limbs with urinary incontinence and constipation with back pain
No fevers or weight loss
Normal CSF / MRI brain/spine
Hiv negative
Increased reflexes and clonus on exam
Dx? Key Ix? Most common mode of acquisition?

A

Tropical spastic paraperesis
HTLV-1 serology
Breastfeeding [then sexual / blood transfusion]

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6
Q

Chronic cough + haemoptysis with negative TB
CXR clear
=?
On CT?

A

Nodules on CT and peribronchial mass common

Paragonimus

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7
Q

56 M previously healthy comes to donate blood. Positive on screening

What diseases are tested for at screening?
What is romanas sign?
Key rx in chagas?

A

HLTV-1, HIV, HepB/C, Chagas, syphilis

Romanas - orbital oedema in acute chagas inoculation

Beznidazole OR nifurtimox 90 days

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8
Q

Brazilian who is exercising then suddenly dies likely pathology

A

Arrhythmia secondary to chagas

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9
Q

How is blood bank screening of chagas done

A

ELISA

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10
Q

right sided back pain.
Issues with bloating when eating and biliary colic for several months. US shows biliary sludge. Likely Dx?
When do they lay eggs?
Key food to eat and get infected?
Seen on CT?
Dx acute?
Rx?

A

Liver fluke- fasicuola hepetica or fasicuola gigantia

Begin egg laying after 3 months

Water cress

CT may look like liver abscesses / mets or cause liver haematoma

Antigen in faeces- only eggs on microscopy sometimes / more likely in chronic

Triclabendazole

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11
Q

HIV poor controlled

Months of diarrhoea with blood

Then developed focal right arm weakness. Went on to reduced GCS and right sided spastic Paralysis and hypereflexia. Cd4 120
CSF normal
Mri - white matter L sided lesion - no midline shift not SOL
dx? rx?
Key DDx before imaging?

A

JC virus causing PML - treatment with ARV

CMV usually basal ganglia
HIV encephalopathy - more like a dementia picture

Mass
-Lymphoma
-Tuberculoma
-Toxoplasmosis

Bacteria
Eg pneumococcal / n meningitis…
TB or tuburculoma
Syphilis

Viral
-JC virus -> PML
-CMV
-EBV - Lymphoma

Fungal
-Cryptococcal

Toxoplasmosis
Neurocysticercosis
Non hiv releated eg stroke / tumour

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12
Q

74 M no PMH
Lived in andes until 40s growing coffee
Moved to amazon growing banana sugarcane…
6m hx of small papule on L chin which began to ulcerate and was painful
Given abx no improvement
Went on to cover all face including mucosa and had smaller lesions on rest of body
Initially ddx?
Cxr demonstrates fluffy infiltrates bilaterally - what’s most likely?

A

paracoccidioidomycosis

Ddx
Disseminated Leishmaniasis

Leprosy - occationaly painful

Cutaneous TB (lupus vulgaris)

Other atypical mycobacteria

Syphilis

Histoplasmosis

HIV with skin infection eg HTLV-1

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13
Q

Differentiate mucosal Leishmaniasis and paracoccidioidomycosis of face and oral mucosa?

A

paracoccidioidomycosis painful and often come with a cough as infects lungs
Tooth loss common
Haemorrhagic dots

Leishmaniasis tends to start in month and works Down
Nasal septum collapse

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14
Q

Which stain for paracoccidioidomycosis

A

KOH

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15
Q

10% of paracoccidioidomycosis also have?

A

TB

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16
Q

paracoccidioidomycosis rx if severe? Moderate?

A

Amphortericin B
Itraconazole 12m
[Occationaly co-trimox which would be 24m if itra not available]

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17
Q

Extensive painful facial ulceration with chest signs most likely? Transmission? What country would you be most suspicious from? Need to test for?

A

paracoccidioidomycosis
Inhaled
About 80% of recorded cases have occurred in Brazil
TB

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18
Q

41M
Lima whole life but visted wildlife park . 2m hx of skin lesion on distal part of R lower limb. Initially painless small papule which slowly broke down into an ulcer key ddx, stain?

A

Leishmaniasis
Giemsa

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19
Q

When is treatment failure cutaneous Leishmaniasis? Rx if this?

A

<50% improvement in size or ulcer after course complete

Amphotericin B

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20
Q

Oral option for Leishmaniasis. Spell it

A

Mil ter fosine

[More expensive than liposomal amphotericin B]

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21
Q

Treatment failure in Leishmaniasis risk factors

A

Children <5
Small ulcer <3cm
Lower limbs - especially if oedema in area
Immunosupressed

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22
Q

Which confection more likely to respond to Leishmaniasis rx

A

Stronglyotides

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23
Q

What class of drug is sodium stibogluconate,

A

Pentavalent antimonials

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24
Q

20F born in jungle but lived in lima for 10 years on farm
No PMH
2/12 hx of high fever, malaise, painless lesions on forehead erythematous papules -> ulcers/umbilicated/crusting
White Discharge from L lacrimal eye duct
Jaundice, lymphadenopathy
Diffuse tender hepatomegally with abdo mass
Presented in shock unwell
CT multiple pleural nodules and cavities + massive hepatosplenomegaly

A

Juvenile paracoccidioidomycosis

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25
Ddx of massive splenomegaly? Key
HSVB [Hyper shits visit bruh] Hypereactice Malarial spenomegaly Schistosomiasis (periportal fibrosis) Visceral Leishmaniasis Brucellosis
26
Paracoccidioidomycosis rx
Amphotericin B followed by itraconazole for 24 months
27
46F PMH mother TB 8/12 painful right paravertebal mass in lumbar region Night sweats, weight loss Worsened pain 1/12 Comsume unpasteurised dairy Otherwise mosty unremarkable exam 2 key Ddx and differentiate
TB - younger, more likely thoracic, paravertebral abscess common Lytic lesions (with NO remodelling) Gibbus deformity common Brucellosis - >40, Lumbar, abscess only in 10%, lytic and blastic lesions
28
60M no PMH 90 days ago went to highlands 2/52 fever, neck pain, jaundice amd confusion Significant jaundice, hepatomegally and palor on exam Rods seen infecting RBCs Which infections do you see actual RBC invasion by pathogens?
Bartonella Malaria Babesia
29
17tr old peru HIV/HTLV-1 negative Vomiting after meals for 2 months Headaches Developed jaundice / fever / night sweats predominant. Weight loss Significant cervical lymphadenopathy Papular skin lesions in inguinal and body Living in jungle - visited caves 9m before sx US - acute hepato splenomegaly and diffuse liver disease Micronodules in lungs TB positive Key DDx
Juvenile subacute paracoccidioidomycosis Usually pulmonary compromise -> peri oral ulcers Ddx Histoplasmosis Disseminated TB Dengue Visceral Leishmaniasis Schistosomiasis
30
Why always males in paracoccidioidomycosis
Oestrogen inhibits
31
Features of dimorphic fungi? Pathology?
Need to culture in 25 degrees and 37 degrees - mold spores, which are the infectious particles, are inhaled into the lung - undergo a morphological change into a pathogenic yeast form. [Mould in the cold Yeast in the heat]
32
Name 3 Examples of dimorphic fungi
Histoplasma capsulatum Blastomyces dermatitidis Talaromyces marneffei Coccidioides immitis, Paracoccidioides brasiliensis Sporothrix schenckii
33
Typical of yeast under microscope? Key stain?
Has double wall KOH
34
What triggers morphological change in dimorphic fungi
Temperature -> when increases from 25 to 37 degrees
35
What are we considering if Rx for tb meningitis then returns with worsening symptoms and new neutrophilic csf tap (2 key ddx)? Rx?
Secondary bacterial infection - need to cover with cef TB Paradoxical reactive meningitis - High dose steroids - as it is due to an immune response - [Due to dying TB and immune response]
36
Why does cryptococcal not stain with India ink?
Has a capsule
37
Name 10 causes of meningoencephalitis
Bacterial - listeria, pneumococcal, HIB, meningococcal, neurosyphilis Mycobacteria- TB Viral - CMV, HSV, JCV, VZV, HIV (more cognitive), EBV, enterovirus (acute) Fungal Yeast - Cryptococcal, , candida (very rare primary CNS) Filamentous - Aspergillus, Dimorphic (Histoplasmosis, paracoccidioidomycosis, Talaromyces marneffei, Coccidioides immitis) Parasites -Protozoa - Toxoplasmosis, malariae, -flagellate - Trypanosomiasis esp chagaoma, Leishmaniasis - Free living amoeba -helminth - angiostrongyloides, racoon ascaris, stronglyotides (hyperinflection), Neuro Shisto, Neurocysticercosis Hydatid
38
Key thing to monitor with amphotericin b
Renal / Liver toxicity - [much less with liposomal version]
39
Key thing to monitor with flucytosine
Levels as risk of bone marrow suppression
40
How long for induction/consolidation/ maintenance phase in cryptococcal
2 weeks 8 weeks 1 year minimum
41
Key monitoring in cryptococcal meningitis after 2 weeks
Repeat culture -> if positive need resistance testing
42
Disseminated cryptococcal skin lesions look like?
Umbilicated papules (bit like moluscum)
43
Which stain AFB positive stool culture not Mycobacterial
Cryptosporidiosis, cystospora, cyclospora
44
travel 5 weeks ago Itchy, serpiginous rash tracking over the course of several days, then disappeared and then he noted the mass reappearing elsewhere On exam - firm mass with clear margins 3×8 cm in size Classic of? Acquired by? Rx? How to rule out differentials?
gnathostomiasis eating raw fish albendazole 400 mg BD for 21 days or ivermectin 200 μg/kg on two consecutive days. CNS - add steroids -Loa presents similar but incubation longer (5months) -Strongyloides more likely fine, serpiginous tracks and not with a large mobile mass
45
Dengue diagnosis
NS1 antigen or PCR IgM/IgG
46
What happens in severe dengue
Capillary leakage and bleeding
47
hyperkeratotic skin crusts that may be loose and flaky or thick and adherent. covering lots of areas with fissures rx?
Crusted scabies Rx ivermectin Will likely have secondary bacterial infection of fissures too
48
All patients with spinal cord symtoms should be tested for?
-HIV -Schistosoma spp. in urine and stool -evidence of tuberculosis or neoplasia on chest and spinal radiography. -LP
49
Gold standard Ix for Potts
CT-guided percutaneous vertebral or paravertebral biopsy and aspiration
50
Multiple painful genital ulcers 2 key Differentials and rx
Herpes simplex - may need acyclovir if HIV / pronounced Chancroid with a single dose of azithromycin 1 g PO or ciprofloxacin 500 mg bid forthree days or erythromycin 500 mg qds for seven days. [syphilis with a single dose of IM benzathine penicillin 2.4 million units. USUALLY PAINLESS And single]
51
H durecyi grows best at what temp
33 degrees -Notoriously difficult to culture
52
S. typhi seems to favour chronic carriage if co infection with what?
Schisto - Should give praziquantel if endemic place
53
Salmonella actually reduced rate with what infection
HIV
54
Watery stool sample shows shows small slender curved bacilli with darting motility? how to confirm?
Cholera - by using Vibrio cholerae antiserum O1 which will completely inhibit motility
55
unilateral parotitis in children is usually? What about in SE Asia - key bug?
Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae Burkholderia pseudomallei = melioidosis, the commonest cause of suppurative parotitis in children in SE asia.
56
Top 3 most common cause of death in Thailand
HIV TB Melioidosis (Burkholderia pseudomallei) Causes abscesses [Be aware this is actually quite common]
57
Where does Melioidosis (Burkholderia pseudomallei) usually affect
Parotid gland in 40% (kids) Lungs
58
Melioidosis rx
May need surgical drainage -ceftazidime, meropenem or imipemem for 14 days -co-trimoxazole monotherapy for 3-5 months
59
Raw fish in history Then erythema rash looks like cellulitis But then migrates?
Gnathostoma spinigerum - Fresh water fish consumption
60
Raised crusted lesion verrucous arm Looks similar to Leishmaniasis / cutaneous TB Small black dots on dermatoscope?Ix? Rx?
Chromoblastomycosis- small black dots typical Usually just 1 lesion which expands Use tape on lesion then place on slide Itraconazole- for years
61
66M Dactylitis with Papules and nodules / cold abscesses + arthralgia Xray shows osteolytic lesions in fingers Biopsy - tuberculoid granulomas (granulomas with necrosis) Tuberculoid granulomas - central necrosis seen in which conditions?
Sporothrix, TB, Nocardia, atypical mycobacteria, paracoccidioidomycosis, sarcoid
62
15M now 22 Works in agriculture Small injury to foot which went on to swell and have lots of discharging sinuses, with grape like lesions No bone involvement Dx?
Botryomycosis- [botryo = grapes] Ddx mycetoma
63
35F no PMH 3m Cough dyspnoea Vomiting weight loss, no haemoptysis 1m fevers CT - pneumonia with cavitation given abx Continues to deteriorate 3x sputum negative, HIV negative GeneXpert positive Rif resistant Rx options?
Short option BPaLM 6m 18m regime of 4 drugs. Ideally 4 that they've never been exposed to eg levo, moxi, amikasin, mero (+co-amox)
64
If treat TB with Meropenem what other drug do you need to use?
clavulanic acid - Eg in Co-amox
65
Before discharge home with MDR-TB what needs to happen?
Clear sputum. DSTs have a suitable TB regime for OP
66
Derranged LFTs >5x normal on TB rx. Plan?
Stop all meds Re challenge 1 at a time
67
If need a 3 drug TB regime how long is Rx?
Eg. Levo amikacin and ethambutol Continue for 12 months
68
Anterior superior lyric lesion of vertebrae typical of?
Brucellosis
69
Acute histoplasmosis why retrosternal pain?
Rapid enlargement of lymphnodes
70
Erythematous lesions on legs and body Not itchy or painful Given prednisolone and had resolution of sx Year later re appeared and worse on limbs Bloods - mild raised ESR, otherwise unremarkable. ANA / RF negative Notice evidence of burn injuries yo arms and hands
Leprosy Burns and other injuries are due to Anaesthetic lesions
71
In what circumstances would a Anaesthetic lesion not be leprosy
If there is hyperkeratosis
72
Key thing when examining leprosy
Anaesthetic lesions Clinical assessment of nerves in sequence to determine which are affected
73
When is a lesion mid borderline leprosy?
Lesions with a 'donut' Centre has normal skin
74
mycetoma - grains
75
Chronic cough and then sudden popping sensation and coughs up this salty liquid
Hydatid
76
Hydatid
77
Leishmaniasis amastigotes
78
Paracoccidioidomycosis
79
India ink cryptococcus
80
Histoplasmosis
81
Blood film. Rods and cocci. Intraerythrocytic. Inside red blood cell. Bartonella
82
What is this? Why would the inflammatory infiltrate be linear?
Mycobacterium leprae Linear as follows a nerve / vessle
83
92 Small papule that slowly grew. Minor discharge. Slightly itchy but Not painful. No one in home with same Sx, but some in community. No oral/nasal sx Key contra indication to sodium stibogluconate? Milterfosine key side effect?
Sodium stibogluconate - Long QT/arrhythmias Milterfosine side effects - GI upset
84
Key groups who have failed Leishmaniasis rx?
Children Leg lesions Immunocompromised
85
74M Ulcerating lesion on arm Painless and no other symptoms Tracking lymph nodes Ddx?
Slan Sporotrichosis Leish Atypical mycobacteria Nocardia
86
61M PMH Leishmaniasis lesion but negative smear No access to PCR, what test can you do? Issue with this?
Leishmaniasis antigen skin test - Will be positive for life - low specificity
87
10M - lives in jungle Erythematous papule on face Leishmaniasis confirmed 2 rounds of rx with sodium stibogluconate but relapsed after each 2nd line?
Amphotericin B If limited cutaneous- Thermotherapy/imiquimod etc
88
When would amphotericin B be first line for cutaenous Leishmaniasis?
Diffuse or Disseminated disease
89
59F t2dm, hemicolectomy 2/12 diarrhoea no blood/mucus 5kg weight loss. Afebrile 1/12 nausea + Vomiting + swallowing difficulty + abdo discomfort + reduced appetite Hiv positive Colonoscopy ulcers Biopsy shows .... cells with massive cytoplasm ? And spindle cells ?
Massive cytoplasm - CMV Spindle cells - colonic kaposis sarcoma
90
Ulcers on oesophagus in HIV with reduced cd4 2 key ddx?
CMV HSV
91
Name 3 causes of atypical lymphocytosis
CLL EBV HTLV-1 causes ATLL and lymphocytic 'flower cells'
92
When does HTLV-1 usually get transmitted? When does it cause ATLL? 3 Key complications of HTLV-1?
Vertical not until 6th decade usually Tropical spastic paraperesis Strongy hyperinfection ATLL
93
33F lived in jungle 10 years ago. Pmh strongyloides and htlv-1 positive Watery diarrhoea- takes co trimox and stops Several months intermittent- malnourished No blood or mucus or fevers or rash. Stool shows this Dx? Rx?
Cystoisospora belli Co trimox - often needs higher dose in Immunocompromised
94
21M med student from mountains Fever, headache, myalgia, diffuse macula rash which resolved Then new diffuse erythematous rash Low platelets Ddx of 'white islands in sea of red'
Dengue Zika, chikungunya, HIV seroconversion
95
49M Chef Visited jungle 2 months ago Did not visit caves 3 days after return - fever, myalgia Slowly Worsened generally unwell mild GI sx Became Jaundiced No lymphadenopathy, severe hepatosplenomegaly Resp unremarkable Anaemic, very mild eosinophilia Bilirubin / transaminases very high HIV positive on admission PAS (image) and silver stain positive yeast within histocytes =? Rx disseminated disease?
Histoplasmosis Amphotericin B followed by itraconazole Silver stain below
96
Which cells make granulomas
Histocytes
97
59F no PMH Born in jungle moved to lima as a child. Copper IUD Yellow Vaginal discharge for 1 year No LUTS No TB contact US - thickened cervix, no changes in ovaries CT-AP - Unremarkable Hep/hiv/syphilis/htlv-1 negative Biopsy -> granules surrounded by Splendore–Hoeppli phenomenon Filamentous bacteria on silver stain =? Key risk factor for cervical disease? Rx?
Cervical actinomycosis IUDs IV Penicillin
98
22M no PMH Born in jungle 1m Weakness / SOB / mild abdo pain which slowly Worsened Now headache and 1 episode Vomiting Hb 26 and mild oedema in limbs Liver/renal tests normal Raised eosinophils
Hookworm
99
Which diseases cause hypereosinophilia >1500 [Raised eosinophils are only >500]
Parasite that go through tissues -Fasciola -Paragonimus - lava migrans Toxocariasis/gnathostomiasis / Ancylostoma braziliensis etc -Strongyloides
100
Why HTLV-1 not transmitted intrauterine?
Lives in lymphocytes which do not cross placenta
101
HTLV-1 positive- what should you screen for?
Strongy TB ATLL / T cell lymphoma Evidence of tropical spastic paraperesis
102
HTLV-1 causes which cancer? Rx of limited cutaneous
T-cell leukaemia/lymphoma zidovudine
103
24F born in southern Highlands. PMH nil 1 day right sided abdo pain sudden onset Vomiting No fever, no other sx Raised eosinophils Tender Hepatomegaly on exam Why eosinophilia?
Ruptured hydatid cyst
104
19M no pmh 2-3days headache over eye The developed painful lymph nodes in neck No fever Bloods unremarkable New pain + swelling in elbow with high fever Has a new cat ix? Rx?
Bartonella IgM - weak positive = recent infection Azithromycin Needs follow up as lots of long term eg neuroretinitis , hepatitis
105
Name 2 diseases from cats
Bartonella henselae Toxoplasmosis Sporothrix braziliensis
106
46F noticed plaque on finger slowly increasing in size Began to notice a some new proximal nodules Dx? Gold standard ix? Rx?
Sporothrix schenckii Gold standard - culture (white then turns grey/dark) then microscopy -> grows quick over 3 days Itraconazole
107
70M itchy painful red lesion on finger and wrist of same hand which rapidly Worsened with oedema and ulceration =? Rx?
Loxosceles laeta (recluse spider) bite with superinfection Usually only oedematous on face Antiserum only works if in <24hrs Loxosceles ssp. Fine for exam
108
Key difference snake vs spider bite
YOU PROBABLY JUST SEE IT Snake = oedema
109
Ocular lesions of toxoplasmosis looks like Salt and pepper
110
Key cause of deviation of eye with retinitis and granulomas
Toxocara (ocular lava migrans)
111
Hypereosinophilia, persistent eczema, visual problems
Toxoxcara
112
Infective dermatitis HTLV-1
113
10months RUQ pain and annorexia + diarrhoea some fevers 7kg weight loss raised WCC + eosinophilia and negative stool O&P CT -? =? ix? rx?
Fasciola ssp. CT - Hypodense lesions in right love Serology - Fas2 ELISA [make sure you know Fas2*] Triclabendazole 2 days (taken with fatty food eg yogurt)
114
Fasiola eggs look like which other worm?
Faciola looks like diphillobotrium but 3x bigger (and usually open)
115
45M HIV 8 years on ARV intermittent. Prev TB and syphilis. MSM Cusco and had 2 weeks intermittent fevers which progressed to constant associated with diarrhoea + mucus Returned to lima and had worsening headaches with neck stiffness followed by a seizure Visual issues LP- Raised opening pressure, lymphocytes predominant, Glucose low India ink positive Colonoscopy - ulceration and nodules (dark red) Ophthalmoscope- pizza pie appearance Dx? Rx?
Cryptococcal meningitis - Ampho / flucytosine / fluconazole Visceral kaposis sarcoma - rx chemo eg paclitaxel Cmv retinitis - gancyclovir ART - After 4 weeks
116
When would you use steroids with hiv and cryptococcal infection?
Only in IRIS [Mortality worse in acute cryptomeningitis ]
117
15M PMH HIV/TB diagnosed 1 year ago 3/52 intermittent abdo pain , 2/52 diarrhoea no blood or mucus , 1/52 nausea and Vomiting On exam very malnourished. Mild tachy. Multiple hypopigmented lesions Poor AE to bases and tender hepatomegaly. Loss of vili with PAS/AFB positive elongated bacilli How to exclude ddx of these stains? Rx? [PAS stain]
Mycobacterium avium complex - or other atypical mycobacteria - Rifampin, ethambutol, azithromycin -Tb AFB positive, PAS negative -Whipple PAS-positive, AFB negative
118
38M 7 days dysphagia dry cough and nausea and left elbow swelling Xr diffuse nodular bilat infiltrates and osteomyelitis on elbow xr Biopsy demonstrates - Pt develops significant transaminitis in first 2 weeks likely culprit? What it was after 6 weeks?
Which for lfts in first 2 weeks - isoniazid Most Lfts deranged after 6 weeks likely - pyrazinamide
119
19M fever headache confusion over 4 days. Recent return from Vietnam CSF raised white cells - neutrophilic, mildly raised glucose, normal protein. Ix? Why CSF neutrophilic?
Positive IgM Japanese encephalitis [More sensitive than PCR as often CSF viral load has come down by time of presentation] -Early in viral meningitis you can get neutrophils -> later turns to lymphocytes
120
25F 3 weeks illness, headache constipation and fatigue raw fish in Hx -> red sub cut nodules which turned to plaques on her RUQ ->moved to R iliac crest Eosinophilia Fas2 -ve, Stool O&P -ve =? Rx?
Gnathostoma spinigerum (most common) Ivermectin (or albendazole)
121
6M 1 week of fever and irritability. Pallor blood film=? Phases? Geography? Transmission? Rx?
Bartonella bacilliformis Acute - fever and haemolysis Eruptive - nodular eruptions Transmitted by sandflies bite - Lutzomia Peru, Ecuador, Colombia - Andean valleys Cipro (add ceftriaxone in complicated disease) Kids - Co-amox if mild [cipro+cef in severe] Only warts - Azithromycin
122
6M USA headache and vomiting, mild fever and slightly stiff neck otherwise unremarkable exam LP - raised wcc + eosinophils MRI - meningeal enhancement Most likely? DDx?
-Angiostrongylus cantonensis - (snail eating/contaminated food) is the most common infective Drug allergy - most common in wealthy countries -Baylisascaris procyonis -Angiostrongylus cantonensis -Toxocara -Gnathostoma -Cysticercosis [Fungal rarely] [BATGC]
123
Angiostrongylus cantonensis key Ix? rx?
PCR (Serology not great) -LP - eosinophilic Steroids + albendazole
124
15M from el salvador admitted with seizure Bitemporal headache and nausea Intermittent haemoptysis CT: Lung and CNS nodular lesions Lung biopsy -> this
Paragonimus mexicana (as in latin america) praziquantel
125
43M Croatian in Thailand with fever (2 week holiday) Headaches sweat chills Malaria/urine negative Given azithromycin -> 1/12 non-productive cough and ongoing fever Developed '1inch red nodular lesion below knee biopsy->? Rx?
‘Safety pin’ appearance of Burkholderia pseudomallei [Meliodosis] -Forms abscesses in many organs -May cause a pneumonia Ceftazidime OR Meropenem then Co-trimoxazole
126
Child with 3/12 fever visited costarica 10 months ago , splenomegaly and mild pancytopenia Bone marrow - no malignancy but this: PE: mild hepatosplenomegaly, pallor Dx? Rx?
Visceral leishmaniasis Liposomal amphotericin B
127
Cruz ship worker from India (US/Mexico/Jamacia) with 5/7 fever, abdo pain, myalgia Worsened with RUQ pain, nausea + vomiting + chest pain CT - hypodense How to differentiate echinococcus cysts, amoebic and pyogenic abscesses in a liver?
Echinococcus - NEVER fever unless superinfection Aspirate [Give metronidazole - > amoebic recovers quickly]
128
'Welts all over' just returned from Africa fever, athralgias Numerous lesions with eschar and diffuse rash
African tick bite fever Rickettsia Africae Doxy
129
50M in Kenya Failed malaria Rx with Developed RUQ pain + conjunctival erythema + scleral jaundice Recent flooding and Lots of sick livestock around....
Rift valley fever
130
Verrucous lesion ? DDx without microscope?
Sporothrix schneckii [Chromo, verrucous leish, TB]
131
Which leprosy
Lepromatous
132
30F HIV positive. Diagnosed pulm TB 1/12 ago 2 weeks into RIPE -> Headache and blurred vision. Fundoscopy ...
Note clear margins of nerve = not optic neuritis Vessles normal Large white lesion = choroid TB
133
40MSM Chronic headache, weight loss and diarrhoea LP OP 27cm, India ink positive HIV positive Given ampho b and fluconazole -> focal signs. Why?
DDx TB granuloma co-infection [this is what happened] Toxoplasmosis co-infection Infarct Vasculitis
134
30F HIV positive. Diagnosed pulm TB 1/12 ago 2 weeks into RIPE -> Headache and blurred vision. Fundoscopy ...
Note clear margins of nerve = not optic neuritis Vessels normal Large white lesion = choroidal TB
135
62M pmh completed RX TB. NHL 2022 on chemo. On co-trimox, fluconazole and acyclovir Weeks of diarrhoea no blood no mucus Progressed to fever headache and weakness No rash. Works in fields without shoes Wheeze, hepatomegaly with cervical lymph nodes Hb 8.5 Mild thrombocytopenia and neutropenia with a few eosinophils =?
Stronglyloides stercolis hyperinfection
136
Why mild/no eosinophilia in strongy hyperinfection?
Stongy itself has anti-inflammatory properties -> inhibits IL-5 -> reduced eosinophils
137
8M 1 day hx Headache and fever, swimming recently. CT cerebral oedema CSF raised protein, 500 white cells 80% neut
Naegleria fowleri Amphotericin B ± intrathecal + Rifampin + Fluconazole + Miltefosine + azithromycin
138
20F abdo lumbar pain Chronic abdo pain and symptoms with pain 3 weeks ago that has settled Large cystic mass in spleen on CT key ix for dx? Benefit of albendazole and prazi?
Western blot - E Granulosus Albendazole - better penetration into cyst Praziquantel - better killing eg of rupture
139
When is adult diarrhoea classed as chronic?
2 weeks or more
140
Wasting syndrome in HIV is? Top 3?
Weight loss, Chronic diarrhoea, hepatomegaly, Anaemia/neutropenia Histoplasmosis TB MAC
141
Differentiate leish and histo by stain used?
Histo = PAS positive stain Leish = giemsa
142
Cheap way of determining Disseminated histo
Histo buffy coat -Take blood in EDTA -Centrifuge -> layer on top of RBCs -Microscopy - if histo = Disseminated
143
Itraconazole particularly reduces which ART med
Efavirenz
144
Venezuelan with purpuric nodular painful lesions involving all 4 limbs which drain pus and inguinal lymphadenopathy ANCA/ANA negative, given pred and hydroxychloroquine-> improvement Mild reduced sensatio =? Rx?
Erythema nodosum leprosum -painful erythematous lesions Steroids (Thalidomide held as child baring age) [This case was given 100mg minocycline] Type 2 erythema nodosum are immune complex deposition Get reactions for years after rx as have a lack of cell-mediated immunity - dead mycobacteria and their antigen load will persist for a long time.
145
WHO criteria for severe Malaria
146
19F highlands 35/40 pregnant occipital headache and dypnea Calf pain -> difficulty walking. Septic shock on admission Fetus dead and pt jaundiced with haematuria Tender hepatomegaly, GCS 14 AKI, with ++direct bilirubin =? Rx? Co-infection common with?
Bartonella bacilliformis Cipro + ceftriaxone Salmonella bacteraemia
147
77M highlands no PMH 3m diarrhoea + mucus which progressed to include pus With pain and Vomiting. 20kg weight loss Low albumin, mild raised bili / ALP Colonic perf - biopsy =? Rx?
Balantioides coli (old name Balantidium coli) Rx Tetracycline Or metronidazole
148
21F - 4 years ago fell and cut knee and has papular painless lesions on knee Developed new lesion on thigh Biopsy shows Dx? Essential extra Ix? Rx?
Balamuthia mandrillaris MRI brain Fluconazole (or Itraconazole) + Albendazole +Miltefosine [FAM this disease is rough]
149
42M septic shock 4 days fever, lymphnodes in cervical axilla and groin. Groin lymph node ++ pain . Mild dyspnoea Today reduced GCS, conjunctival suffusion Hepatosplenomegaly Hepatorenal insult ARDS on CXR. Lepto and Dengue negative. dx? rx?
Yersina pestis Gent + cipro
150
Name 2 fungi causing eosinophilia
Aspergillus Coccidioides immitis
151
Cold abscess 3 ddx
ANT no Fever here Actinomycosis Nocardia Tb [Fungi]
152
'Tripple' species to cause rapid liver/lung/renal failure over a short period
Leptospira interrograns Hanta virus Yellow fever
153
malaria assoc + EBV in first 5 years of life -> high risk of?
burkits lymphoma
154
found in stool
schistosoma intercalatum
155
39/40 neonate. 4th pregnancy Mum positive RPR. Treated with Penicillin G No issues at birth and normal physical exam. When treat as congenital syphilis if no findings on neonate exam ?
Inadequate treatment - Mum must complete therapy at least 4 weeks before delivery + no abnormalities on Neonate workup Eg LP
156
35M Cd4 250 . Recent rx cutaneous TB -> had other umbilicated papules on face which improved. Finished Rx and now: 14 days papular lesions on face and pain in hands. Some are umbilicated Osteolytic lesions in bones of hands on Xray. Dx? Explain the partial improvement of the lesions
Disseminated histoplasmosis Lesions improved with RIPE as histo sensitive to rifampicin
157
24 new diagnosis of HIV on admission 1 Month papules and fever. 2 key ddx?
Treponema pallidum Mpox
158
33F PMH diabetes 1 week history of cough, rhinorrhoea and vesicular lesion on nose -> given acyclovir 3 day hx of jaw pain Pain developed in ear and facial asymmetry Found confused next morning R hemiparesis and left eye proptosis CT carotid stenosis left eye proptosis Dx? Rx?
Mucor ssp - rhinocerebralorbital surgical debridement Control of immunocompromising features Ampho B (posiconazole / isavuconazole
159
Extrapulmonary TB bedside test?
FASH Focused assessment sonography in HIV
160
Itraconazole administration tips
With food With acid eg coke and stop PPIs if possible
161
28M prev pulm TB completed rx Unwell for 3 weeks with diarrhoea and abdo pain. No blood 4 days of confusion O/E Reduced GCS, hr 78, hypotensive, no fever Pale, HIV, HTLV negative Csf mild raised protein and lymphocytes CT chest - multiple cavities and inflam infiltrate Given TB meningitis rx -> eosinophollia and worsening abdo sx What happened?
Chronic strongy + TB -> steroids for TB meningitis precipitated strongy hyperinfection
162
What type of meningitis do you get in strongy hyperinfection?
Bacterial eg e coli / salmonella -Translocation

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

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