Infection and Immunology Flashcards

Question

What is candidiasis?

Answer 1

A fungal infection due to any type of Candida (type of yeast)

Answer 2

Candida normally lives on the skin and inside the body, in places such as the mouth, throat, gut, and vagina, without causing any problems. Candida can cause infections if it grows out of control or if it enters deep into the body (bloodstream or internal organs) Although mucosal disease is common, invasive disease is not, and the primary reason is that Candida species in general are unable to enter intact epithelium

Answer 3

Immunosuppressive agents e.g. systemic corticoid steroid use Current or recent past use of brand spectrum antibiotics Malabsorption/ malnutrition HIV infection Poor oral hygiene (oral candidiasis) Endocrine disturbances (DM, pregnancy, hypoadrenalism) - reduce effectiveness of immune system

Answer 4

``` Oral: -creamy white/ yellow plaques adherent to oral mucosa -Cracks/ ulcers around the mouth -spotty red areas on the buccal mucosa -burning oral pain -loss of taste -pain while eating or swallowing Vaginal: -vaginal itching or soreness -pain during sexual intercourse -pain/ discomfort when urinating -abnormal vaginal discharge ```

Answer 5

Rash Erythema Visible plaques/ulcers

Answer 6

Superficial smear of the lesion for microscopy: test for candida Biopsy Blood culture FBC: WCC elevated indicates infection

Answer 7

An acute spreading infection of the skin with visually indistinct borders that principally involves the dermis and subcutaneous tissue

Answer 8

``` Erythema Oedema Warmth Tenderness Commonly occurs in an extremity ```

Answer 9

A distinct form of superficial cellulitis with notable lymphatic involvement and is raised, sharply demarcating it from uninvolved skin

Answer 10

Cellulitis develops when micro-organisms gain entry to the dermal and subcutaneous tissues via disruptions in the cutaneous barrier The most common causative agents are: -Beta-haemolytic streptococci -Staphylococcus aureus

Answer 11

``` Cellulitis is a common condition Main risk factors are: -skin break -poor hygiene -poor vascularization of tissue (e.g. diabetes mellitus) ```

Answer 12

There may be history of a cut, scratch or injury Skin discomfort Periorbital: Painful swollen red skin around eye Orbital cellulitis: Painful or limited eye movements, visual impairment

Answer 13

``` Lesion: -Erythema -Oedema -Warm tender indistinct margins *Pyrexia may signify systemic spread Exclude abscess: Test for fluid thrill or fluctuation- aspirate if pus suspected Periorbital: -Swollen eyelids -Conjunctival injection Orbital cellulitis: -Proptosis (protrusion of the eyeball) -Impaired acuity and eye movement Test for relative afferent pupillary defect, visual acuity and colour vision ```

Answer 14

Bloods: WCC, blood culture Discharge: Culture and sensitivity Aspiration: As it is often non-purulent, it is not usually necessary CT/MRI scan: When orbital cellulitis is suspected (to assess the posterior spread of infection)

Answer 15

Medical: -Oral penicillins (e.g. flucloxacillin, benzylpenicillin, coamoxiclav) -Tetracyclines are effective in most community acquired cases -In the hospital- intravenous use may be necessary Surgical: -Orbital decompression may be necessary in orbital cellulitis(emergency) Abscess: Abscesses can be aspirated, incised and drained or excised completely

Answer 16

``` Sloughing (shedding) of overlying skin Localized tissue damage In orbital cellulitis, there may be permanent vision loss and spread to brain Abscess formation Meningitis Cavernous sinus thrombosis ```

Answer 17

Good with treatment

Answer 18

Inflammation of the lining of the eyelids and eyeball

Answer 19

``` Caused by: Bacteria Viruses Allergic or immunological reactions Mechanical irritation Medicines ``` Bacterial and viral conjunctivitis is highly contagious

Answer 20

``` Exposure to infected person Infection in one eye Environmental irritants Allergen exposure Mechanical irritation Chronic contact lens useful Camps/ swimming pools ```

Answer 21

``` Watery discharge (viral) Ropy/ mucoid discharge, itching (allergic) Purulent discharge (bacterial) Eyelids stuck together in the morning (bacterial and viral) ```

Answer 22

Tender pre-auricular lymphadenopathy (more common in viral than bacterial infection) Conjunctival follicles- round collections of lymphocytes

Answer 23

1st line: Rapid adenovirus immunoassay- 2 visible lines equal positive Others: Cell culture/ Gram stain/ PCR- isolate viral or bacterial strains, amplify DNA

Answer 24

Inflammation of the brain parenchyma

Answer 25

In the majority of cases encephalitis is the result of a viral infection. Most common in the UK is HSV. Other: bacteria (syphilis, staph A), immunocompromised (Cytomegalovirus, toxoplasmosis, Listeria)

Answer 26

Annual UK incidence is 7.4 in 100,000

Answer 27

Usually encephalitis is a mild self-limiting illness. Subacute onset (hours to days) headache Fever Vomiting Neck stiffness, photophobia, i.e. symptoms of meningism (meningoencephalitis) with behavioural changes Drowsiness and confusion There is often a history of seizures Focal neurological symptoms (e.g. dysphasia and hemiplegia) may be present It is important to obtain a detailed travel history

Answer 28

Reduced level of consciousness with deteriorating GCS, seizures, pyrexia. Signs of meningism: Neck stiffness, photophobia, Kernigs test positive. Signs of raised intracranial pressure: hypertension, bradycardia, papilloedema. Focal neurological signs. Minimental examination may reveal cognitive or psychiatric disturbances.

Answer 29

Positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance)- indicating the presence of meningitis or subarachnoid haemorrhage

Answer 30

Blood: FBC (raised lymphocytes), U&E (SIADH may occur), glucose (compare with CSF glucose), viral serology, ABG. MRI/CT: Excludes mass lesion. HSV produces characteristic oedema of the temporal lobe on MRI. Lumbar puncture: raised Lymphocytes,monocyte and protein, glucose usually normal. Viral PCR is first line. EEG: May show epileptiform activity, e.g. spiking activity in temporal lobes

Answer 31

Epididymitis is characterized by acute unilateral scrotal pain and swelling of less than 6 weeks' duration. The pain usually begins at the epididymis and can spread to the entire testicle (epididymo-orchitis)

Answer 32

- Among sexually active men of all ages, STI pathogens including Chlamydia trachomatis and Neisseria gonorrhoeaeare common causes of epididymitis - In older men (>35 years), infection may be due to non-sexually transmitted infection with common uropathogens, such as Escherichia coli and Enterococcus faecalis

Answer 33

Epididymitis is the most common cause of scrotal pain in adults with an incidence of 25–65 cases per 10,000 adult males per year Over half of men and boys with epididymitis also have orchitis. -Isolated orchitis is rare: the commonest cause is mumps infection, although it can also be caused by other viral infections

Answer 34

Gradual onset (unlike testicular torsion) Unilateral scrotal pain and swelling Other symptoms: fever, dysuria

Answer 35

Diffuse enlargement of the testis Erythema of the scrotal skin Swelling for < 6 weeks: otherwise indicates chronic inflammation

Answer 36

*first catch urine sample Urethral swab: highly sensitive and specific for documenting urethritis and the presence or absence of gonococcal infection (look for urethral discharge) Urine dipstick test: positive leukocyte esterase test (urethritis and lower urinary tract infection) Urine microscopy: WBC Urine culture: isolate causative organism Colour duplex ultrasound: done in patients with signs suggestive of abscess formation or possible testicular torsion and infarction; epididymis is enlarged and hyperaemic (increased blood flow) Consider STI screen

Answer 37

If <35yrs; -Doxycycline 100mg/12h (covers chlamydia; treat sexual partners) -If gonorrhoea suspected add ceftriaxone 500mg IM stat. If >35yrs (mostly non-STI) associated UTI is common: -Ciprofloxacin 500mg/12h or ofloxacin 200mg/12h *Antibiotics should be used for 2–4wks Also: analgesia, scrotal support, drainage of any abscess.

Answer 38

``` (usually of chronic disease, more commonly associated with uropathogen enteric organisms than sexually transmitted organisms) include: Chronic pain Reactive hydrocele Abscess formation Infarction of the testicle Testicular atrophy Reduced fertility ```

Answer 39

In men with infectious acute epididymitis, symptoms usually resolve rapidly following the initiation of appropriate antibiotic therapy RARE CASES: particularly in STIs-epididymal obstruction/testicular atrophy and subsequent infertility problems

Answer 40

Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdominal discomfort

Answer 41

Inflammation of the colon due to a virus or bacteria

Answer 42

Can be caused by viruses, bacteria, protozoa or toxins contained in contaminated food or water

Answer 43

Viral: Rotavirus, adenovirus, astrovirus Bacterial: Campylobacter jejuni, Escherichia coli, Salmonella, Shigella, Vibrio cholerae, Listeria, Yersinia enterocolitica Protozoal: Entamoeba histolytica Toxins: From Staphylococcus aureus, Clostridium botulinum, Bacillus cereus, mushrooms, heavy metals, seafood Commonly contaminated foods: Improperly cooked meat (S. aureus, C. perfringens), old rice (B. cereus, S. aureus), eggs and poultry (Salmonella), milk and cheeses (Listeria, Campylobacter), canned food (botulism)

Answer 44

Common, and often under-reported, a serious cause of morbidity and mortality in the developing world

Answer 45

Sudden onset nausea, vomiting, anorexia Diarrhoea (bloody or watery) Abdominal pain or discomfort Fever and malaise *Enquire about recent travel, antibiotic use and recent food intake (how cooked, source andwhether anyone else ill) Time of onset: -Toxins (early; 1–24 h) -Bacterial/viral/protozoal (12 h or later) Effect of toxin: -Botulinum causes paralysis -Mushrooms can cause fits, renal or liver failure

Answer 46

``` Diffuse abdominal tenderness Abdominal distension Bowel sounds are often increased If severe: -Pyrexia -Dehydration -Hypotension -Peripheral shutdown ```

Answer 47

Blood: -FBC -Blood culture (helps identification if bacteriaemia present) -U&Es: dehydration Stool: -Faecal microscopy for polymorphs, parasites, oocysts, culture, electron microscopy (used to diagnose viral infections) -Analysis for toxins, particularly for pseudomembranous colitis (Clostridium difficile toxin) AXR or ultrasound: -To exclude other causes of abdominal pain Sigmoidoscopy: -Often unnecessary unless inflammatory bowel disease needs to be excluded

Answer 48

Bed rest Fluid and electrolyte replacement with oral rehydration solution (containing glucose and salt) IV rehydration may be necessary in those with severe vomiting *Most infections are self-limiting -Antibiotic treatment is only warranted if severe or the infective agent has been identified (e.g. ciprofloxacin against Salmonella, Shigella, Campylobacter) Botulism: Botulinum antitoxin IM and manage in ITU. Public health: -Often a notifiable disease -Educate on basic hygiene and cooking

Answer 49

Dehydration Electrolyte imbalance Pre-renal failure Secondary lactose intolerance (particularly in infants) Sepsis and shock (particularly Salmonella and Shigella) Haemolytic uraemic syndrome is associated with toxins from E. coli Guillian–Barre syndrome may occur weeks after recovery from Campylobacter gastroenteritis *Botulism: Respiratory muscle weakness or paralysis

Answer 50

Generally good, as the majority of cases are self-limiting

Answer 51

Disease resulting from HSV1 or HSV2 infection

Answer 52

HSV is an alpha-herpes virus with double-stranded deoxyribonucleic acid (dsDNA) Transmitted via close contact with an individual shedding the virus (e.g. kissing, sexual intercourse)

Answer 53

90% adults seropositive for HSV1 by 30 years 35% adults >60 years seropositive for HSV2 Over 1/3 world population has recurrent HSV infections Most common cause of encephalitis

Answer 54

HSV1: Primary infection often asymptomatic Usual symptoms: -Pharyngitis; -Gingivostomatis, may make eating very painful -Herpetic whitlow, inoculation of virus into a finger Recurrent infection/reactivation (herpes labialis/cold sore): - Prodrome (6 h) peri-oral tingling and burning - Vesicles appear (48 h duration), ulcerate and crust over -Complete healing 8–10 days HSV2: Very painful blisters and rash in genital, perigenital and anal area Dysuria Fever and malaise

Answer 55

HSV1: Primary infection: -Tender cervical lymphadenopathy -Erythematous, oedematous pharynx -Oral ulcers filled with yellow slough (gingivostomatitis) -Digital blisters/pustules (herpetic whitlow) Herpes labialis: Perioral vesicles/ulcers/crusting HSV2: - Maculopapular rash - Vesicles and ulcers (external genitalia, anal margin, upper thighs) - Inguinal lymphadenopathy - Pyrexia

Answer 56

Usually a clinical diagnosis | Vesicle fluid: Electron microscopy, PCR, direct immunofluorescence, growth of virus in tissue culture

Answer 57

A pandemic infectious disease whose impact on societies is without precedent It is caused by a retrovirus that infects and replicates in human lymphocytes and macrophages, eroding the integrity of the human immune system over a number of years This results in immune deficiency and a susceptibility to a series of opportunistic and other infections as well as the development of certain malignancies

Answer 58

HIV is retrovirus that infects and replicates primarily in human CD4+ T cells and macrophages It can be transmitted via blood, blood products, sexual fluids, other fluids containing blood, and breast milk Most individuals are infected with HIV through: - Sexual contact (most common) - Before birth or during delivery - During breastfeeding - When sharing contaminated needles and syringes (intravenous drug users)

Answer 59

Globally, the HIV incidence rate is believed to have peaked in the late 1990s and to have stabilised subsequently Transmission among heterosexuals was the largest single route of infection >40,000,000 adults affected worldwide

Answer 60

Three phases: 1. Seroconversion: (4–8 weeks post-infection) Self-limiting Fever, night sweats Generalized lymphadenopathy Sore throat Oral ulcers Rash Myalgia Headache Encephalitis Diarrhoea 2. Early/asymptomatic: (18 months to 15 +years) Apparently well -some patients may have persistent lymphadenopathy (>1 cm nodes, at 2 + extrainguinal sites for >3 months) Progressive minor symptoms, e.g. rash, oral thrush, weight loss, malaise 3. AIDS: Syndrome of secondary diseases reflecting severe immuno deficiency or direct effect of HIV infection (CD4 cell count <200/mm3)

Answer 61

Neurological: Polyneuropathy, myelopathy, dementia Lung: Lymphocytic interstitial pneumonitis Heart: Cardiomyopathy, myocarditis Haematological: Anaemia, thrombocytopenia GI: Anorexia, HIV enteropathy (malabsorption and diarrhoea), severe wasting Eyes: Cotton wool spots

Answer 62

Bacterial: Mycobacteria (lungs, GI, skin), e.g. Mycobacterium tuberculosis, staphylococci (skin), Salmonella, capsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae) Viral: CMV (retinitis, oesophagitis, colitis, pneumonitis, adrenalitis, encephalitis), HSV (encephalitis), varicella zoster virus (VZV) (recurrent shingles), human papillomavirus (HPV) (warts), Epstein–Barr virus (EBV) Fungal: Pneumocystis pneumonia (PCP), Cryptococcus (meningitis), Candida (oral, airway, genital, oesophageal), invasive aspergillosis Protozoal: Toxoplasmosis (cerebral abscess, chorioretinitis, encephalitis)

Answer 63

Kaposis sarcoma (cutaneous or conjunctival vascular tumour caused by human herpesvirus) Squamous cell carcinoma (particularly cervical or anal) Non- Hodgkins B-cell lymphoma (brain, GI) Hodgkins lymphoma

Answer 64

HIV testing (after discussion and consent): -e.g. Serum HIV enzyme linked immunosorbent assay: positive/Serum HIV rapid test -HIV antibodies (usually positive by 12 weeks after exposure) -PCR for viral RNA or incorporated proviral DNA Monitor CD4+ count and viral load Others: (as appropriate) -For PCP (Pneumocystis pneumonia):CXR bilateral perihilar/ground glass shadowing, bronchoalveolar lavage -Cryptococcal meningitis: Brain CT or MRI, lumbar puncture – cerebrospinal fluid (CSF) microscopy (India ink staining), culture, ELISA for antigen CMV (colitis): Colonoscopy and biopsy (cytomegalic cells with inclusions) Toxoplasmosis: Brain CT or MRI shows ring-enhancing lesions Cryptosporidia/microsporidia: Stool microscopy

Answer 65

A treatment for abscesses to relieve pain and speed healing

Answer 66

The treatment typically used to clear an abscess of pus and start the healing process Smaller abscesses may not need to be drained to disappear

Answer 67

Damage to adjacent structures Bacteremic complications Spread of infection owing to inadequate drainage (dissemination)

Answer 68

A clinical syndrome most commonly caused by Epstein Barr virus (EBV) infection, also known as glandular fever

Answer 69

Epstein Barr virus (EBV), also known as human herpes virus 4, is the aetiological agent in approximately 80% to 90% of cases Other causes: Herpes virus 6, cytomegalovirus and HSV-1

Answer 70

Close contact e.g. kissing, sharing eating utensils, sexual behaviour

Answer 71

Common (UK annual incidence 1 in 1000) Has two peaks: 1. 1–6 years (usually asymptomatic) 2. 14–20 years

Answer 72

Incubation period: 4–8 weeks | May have abrupt onset: sore throat, fever, fatigue, headache, malaise, anorexia, sweating, abdominal pain

Answer 73

Pyrexia Oedema and erythema of pharynx, fauces and soft palate, with white/creamy exudate on the tonsils which becomes confluent within 1–2 days, palatal petechiae. Cervical/generalized lymphadenopathy Splenomegaly (50–60%), hepatomegaly (10–20%). Jaundice (5–10%)

Answer 74

1st line: - Bloods: FBC (leukocytosis), LFT (raised aminotransferases) - Blood film: Lymphocytosis (>20% atypical lymphocytes) - Heterophile antibodies: produced in response to EBV infection - EBV specific antibodies * Throat swab: exclude streptococcal tonsilitis Consider: CT of abdomen (splenic rupture)

Answer 75

Infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendineae, sites of septal defects, or the mural endocardium

Answer 76

The endocardium can be colonized by virtually any organism, but the most common are: 1. Streptococci (40%): Mainly a-haemolytic 2. Staphylococci(35%):Staphylococcusaureus 3. Enterococci (20%) Historical sources of bacteraemia should be considered, such as indwelling vascular catheters, recent dental work, and intravenous drug use RF: prosthetic heart valves, congenial heart disease, valvular disease, IV drug use

Answer 77

Incidence 16–22 per million per year, around 50% are over 60 years old Incidence increases with age

Answer 78

``` Fever with sweats/chills/rigors (may be relapsing and remitting) Malaise Fatigue Weight loss Headache Arthralgia Myalgia Dyspnoea Confusion (particularly in elderly) Skin lesions ```

Answer 79

Pyrexia, tachycardia, signs of anaemia Clubbing (if long-standing) New regurgitant murmur or muffled heart sounds: Frequency: Mitral > aortic > tricuspid > pulmonary Splenomegaly Vasculitic lesions: -Petechiae particularly on retinae (Roths spots) -Pharyngeal and conjunctival mucosa -Janeway lesions (painless palmar macules, which blanch on pressure) -Oslers nodes (tender nodules on finger/toe pads) -Splinter haemorrhages (nail-bed haemorrhages)

Answer 80

Bloods: -FBC (leukocytosis, normocytic anaemia) -Raised ESR and CRP -U&Es: mildly elevated urea -Rheumatoid factors: may be positive (minor criteria for diagnosis) -Complement levels: decreased Blood culture: At least three sets 1h apart: bacteraemia or fungaemia ECG: progression of the infection may lead to conduction system disease Imaging: Echocardiography: Should be performed in all cases of suspected IE, detection of vegetations and valve abscess, diagnosis of prosthetic valve endocarditis and assessment of embolic risk CT/CXR: valvular abnormalities and vegetations, septic pul- monary emboli: focal lung infiltrates

Answer 81

Major criteria: Positive blood culture in two separate sample -Positive echocardiogram (vegetation, abscess, prosthetic valve dehiscence, new valve regurgitation) Minor criteria: - High-grade pyrexia (temperature >38􏰂C) - Risk factors (abnormal valves, IV drug use, dental surgery) - Positive blood culture, but not major criteria - Positive echocardiogram, but not major criteria - Vascular signs

Answer 82

ABC approach 1. Broad-spectrum antimicrobial therapy is required empirically on clinical suspicion: -Benzylpenicillin + gentamicin (empirical treatment) 2. Streptococci: Continue as above (alternatives – ceftriaxone, vancomycin) 3. Staphylococci: Flucloxacillin/vancomycin + gentamicin (for prosthetic valves: vancomycin + gentamicin + rifampin) Enterococci: Ampicillin + gentamicin Surgery: If poor response or deterioration, urgent valve replacement is indicated. *Antibiotic prophylaxis for patients with a PMH of infective endocarditis undergoing high risk procedures

Answer 83

``` Valve incompetence Intracardiac fistulae or abscesses Aneurysm formation Heart failure Renal failure Glomerulonephritis Arterial emboli from the vegetations (brain, kidneys, lungs, spleen) ```

Answer 84

Fatal if untreated | Even when treated, 15–30% mortality (mortality is greater in older patients)

Answer 85

A parasitic infection caused by protozoa of the genus Plasmodium. Five species are known to infect humans; Plasmodium falciparum is the most life-threatening

Answer 86

It is naturally transmitted to humans through a bite by an infected female Anopheles mosquito but may potentially be transmitted by blood transfusion or organ transplantation

Answer 87

It is widely distributed throughout tropical and subtropical regions, and the main burden of disease falls on these areas (93% of all malaria deaths occurred in the African region) Travellers account for the majority of disease in Western countries *Pregnant women and children aged under 5 years remain the most susceptible to disease in endemic areas

Answer 88

*High degree of clinical suspicion in any feverish traveller (incubation up to 1 year, but usually 1–2 weeks) *Cyclical symptoms of high fever, flulike symptoms, severe sweating and shivering cold/rigors Peak temperature may coincide with rupture of the intra-erythrocytic schizonts: -every 48 h for P. falciprum (malignant tertian) -every 72 h for P. malariae (benign quartan) -every 48 h for P. vivax and P. ovale (benign tertian)

Answer 89

Pyrexia/rigors Anaemia Hepatosplenomegaly

Answer 90

Thick/thin blood film (using Fields or Giemsas stain): * -Test of choice to identify parasite - Detection of asexual or sexual forms of the parasites inside erythrocytes - Measure daily for detection and quantitative count of level of intracellular ring forms. - Has to be negative for 3 days to exclude malaria - >2% in P. falciparum malaria is severe Rapid diagnostic test: immunochromatographic tests detect the presence of malaria antigen or enzyme and typically give a visible band after 15 minutes if positive Bloods: - FBC (anaemia, prothrombin time may be moderately prolonged) - U&Es: usually normal or mildly impaired; renal failure may be present in severe infection - LFTs: may show elevated bilirubin or elevated aminotransferases - ABG: In severe malaria, tissue hypoxia due to microvascular obstruction, impaired red cell deformability, anaemia, hypovolaemia, and hypotension can lead to lactic acidosis, which may contribute to impaired level of consciousness Urinalysis: In severe Plasmodium falciparum infections, massive haemolysis combined with acute tubular necrosis produce acute renal failure with haemoglobinuria and proteinuria

Answer 91

Inflammation of the breast with or without infection

Answer 92

A breast abscess is a localised area of infection with a walled-off collection of pus It may or may not be associated with mastitis (as a complication)

Answer 93

Lactational | Non-lactational

Answer 94

Infectious mastitis and breast abscesses are usually caused by bacteria colonising the skin. Cases due to Staphylococcus aureus are by far the most common. Non-infectious mastitis may result from underlying duct ectasia and infrequently foreign material (e.g. nipple piercing, breast implant)

Answer 95

The global prevalence of mastitis in lactating women is approximately 1% to 10% but may be higher Breast abscess develops in 3% to 11% of women with mastitis

Answer 96

Fever Decreased milk outflow (if lactational) Breast warmth/ tenderness/ swelling/ redness (erythema) Flu like symptoms- malaise and myalgia

Answer 97

Breast erythema | UNCOMMON: Breast mass, fistula, nipple inversion/retraction, nipple discharge, lymphadenopathy, extra-mammary lesions

Answer 98

1st line: -Breast ultrasound-hypoechoic lesion (abscess), may be well circumscribed, irregular, or ill defined -Diagnostic needle aspiration- purulent fluid indicates a breast abscess -CMS of nipple discharge or needle aspirate- indicate infection/malignancy (CMS- cytology, microscopy and sensitivity) Others: pregnancy test, mammogram, blood culture

Answer 99

``` The goal of treatment for mastitis is to provide prompt and appropriate management to prevent complications such as a breast abscess. Lactational: -Effective milk removal -Antibiotic therapy -Warm compresses -Symptomatic relief ``` Non-lactational: - Antimicrobial therapy (observational period) - Supportive measures should include analgesia, if necessary. - For granulomatous mastitis (idiopathic granulomatous inflammation)- glucocorticosteroids

Answer 100

Breast abscesses (less than 10% of patients with mastitis) Cessation of breastfeeding (most patients can continue to breastfeed) Sepsis Scarring (recurrent infections) Functional mastectomy (breast that is unable to effectively lactate as a complication of prior tissue destruction from infection or treatment)

Answer 101

When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications. Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients. Lactational abscesses tend to be easier to treat than non-lactational abscesses- these are multi-factorial and have a greater risk of becoming chronic

Answer 102

Inflammation of the meninges (pia mater and arachnoid) (coverings of the brain) most commonly caused by infection

Answer 103

Infection: Bacterial: -Neonates: Group B streptococci, Escherichia coli, Listeria monocytogenes -Children: Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae -Adults: *Neisseria meningitidis (meningococcus), Streptococcus pneumoniae, TB -Elderly: Streptococcus pneumoniae, Listeria monocytogenes Viral: Enteroviruses, mumps, Herpes simplex V, HIV Fungal: Cryptococcus (associated with HIV infection)

Answer 104

``` Close communities (e.g. dormitories) Basal skull fractures Mastoiditis Sinusitis Inner ear infections Alcoholism Immunodeficiency Splenectomy Sickle cell anaemia CSF shunts Intracranial surgery ```

Answer 105

Variation according to geography, age, social conditions | Viral meningitis is one of the most common infections of the CNS

Answer 106

``` ASK ABOUT TRAVEL HISTORY *Severe headache *Photophobia *Neck stiffness or backache Irritability Drowsiness Vomiting Fever Clouding of consciousness High-pitched crying or fits (common in children) ```

Answer 107

``` Signs of meningism: -Photophobia -Neck stiffness Signs of infection: -Fever -Tachycardia -Hypotension -Skin rash (petechiae with meningococcal septicaemia) -Altered mental state ```

Answer 108

Blood: Two sets of blood cultures (do not delay antibiotics) Imaging: -CT scan to exclude a mass lesion or increased intracranial pressure before LP, (may lead to cerebral herniation during subsequent CSF removal) *A CT scan of the head must be done before LP in patients with: -Immunodeficiency -History of CNS disease -Reduced consciousness -Fit -Focal neurologic deficit -Papilloedema Lumbar puncture: Send CSF for MCS and Gram staining (Streptococcus pneumoniae: Gram-positive diplococcic, Neisseria Meningitidis: gram-negative diplococcic) Bacterial: Cloudy CSF, raised neutrophils, raised protein, reduced glucose (CSF: serum glucose ratio of <0.5) Viral: raised Lymphocytes, raised protein BUT normal glucose *TB: Fibrinous CSF, raised lymphocytes, raised protein, reduced glucose

Answer 109

Immediate IV/IM antibiotics if meningitis suspected (before lumbar puncture or CT) Antibiotics: Benzylpenicillin may be given as initial blind therapy Amoxicillin + gentamicin Add vancomycin and if necessary rifampicin If anaphylaxis to penicillin or cephalosporins- use chloramphenicol Steroids: IV (10 mg for 4 days) given shortly before or with first dose of antibiotics to reduce complications Avoid dexamethasone in patients with HIV Resuscitation: Patient is best managed in ITU Prevention (only applicable to meningococcal meningitis): Notify public health services and consult a consultant in communicable disease control, vaccination for meningococcal serogroups A and C

Answer 110

``` Septicaemia Shock DIC-disseminated intravascular coagulation, which is the inappropriate clotting of blood within the vessels Renal failure Fits Peripheral gangrene Cerebral oedema Cranial nerve lesions Cerebral venous thrombosis Hydrocephalus Water- house–Friderichsen syndrome (bilateral adrenal haemorrhage) ```

Answer 111

Mortality rate from bacterial meningitis is high (10–40% with meningococcal sepsis) In developing countries mortality rate often higher Viral meningitis self-limiting

Answer 112

Acute inflammation and necrosis of cardiac muscle (myocardium) in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease

Answer 113

Usually unknown (idiopathic) Infection: -Viruses: e.g. Coxsackie B, echovirus, EBV, CMV -Bacterial: e.g. post-streptococcal, tuberculosis, -diphtheria, Lyme disease -Fungal: e.g. candidiasis. -Protozoal: e.g. trypanosomiasis (Chagas disease) Non-infective: -Systemic disorders (e.g. SLE, sarcoidosis, polymyositis) -Hypersensitivity myocarditis (e.g. sulphonamides) Drugs: -Chemotherapy agents (e.g. doxorubicin, streptomycin) Others: Cocaine abuse, heavy metals, radiation

Answer 114

True incidence is unknown, as many cases are not detected at the time of acute illness Coxsackie B virus is a common cause in Europe and the USA but in South America Chagas disease is the common cause *Patients with myocarditis tend to be younger (<50 years) than those presenting with more common cardiac conditions such as acute coronary syndrome

Answer 115

``` Prodromal ‘flu-like’ illness Fever Malaise Fatigue Lethargy Breathlessness (pericardial effusion/myocardial dysfunction) and orthopnoea Palpitations Sharp chest pain (suggesting associated pericarditis) ```

Answer 116

Atrial and ventricular arrhythmias Sinus tachycardia S3 gallop Signs of concurrent pericarditis: -Pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration) -Heart sounds may be faint in the presence of an effusion

Answer 117

12 lead ECG: anyone who resents with chest pain, Non-specific T wave and ST changes, widespread saddle-shaped ST elevation in pericarditis Bloods: - FBC (raised WCC in infective causes) - U&Es, BNP, raised ESR or CRP, cardiac enzymes e.g. creatinine kinase, troponin (may be elevated) - To identify the cause (viral or bacterial serology, antistreptolysin O titre, ANA, serum ACE, TFT) CXR: May be normal or show cardiomegaly with or without pulmonary oedema (frequently reveals bilateral pulmonary infiltrates in the setting of myocarditis-induced CHF) Echocardiography: Assesses systolic/diastolic function, wall motion abnormalities, pericardial effusion: global and regional left ventricular motion abnormalities and dilatation Myocardial biopsy: Rarely required, show histological findings of myocardial cellular infiltrates ± myocardial necrosis

Answer 118

A life-threatening subcutaneous soft-tissue infection that may extend to the deep fascia, but not into the underlying muscle

Answer 119

Type I necrotising fasciitis is a polymicrobial infection of subcutaneous tissue (such as Bacteroides plus Escherichia coli or non-group A streptococcus with or without Staphylococcus aureus) Type II necrotising fasciitis is a monomicrobial infection of subcutaneous tissue most commonly caused by Streptococcus pyogenes (group A streptococci)

Answer 120

``` Diabetes mellitus Peripheral vascular disease Immunocompromising conditions or immunosuppression (corticosteroids) Chronic renal or hepatic insufficiency Chickenpox or herpes zoster Intravenous drug use ```

Answer 121

Type I (due to mixed anaerobic-facultative anaerobic infections) is more common than type II necrotising fasciitis

Answer 122

``` Anaesthesia or severe pain over the site of cellulitis indicates necrotising fasciitis Examination of the skin overlying the area of cellulitis may reveal vesicles or bullae Grey discolouration of skin Oedema Location: about half of cases occur in the extremities, with the remainder concentrated in the perineum, trunk, and head and neck areas Systemic signs of infection: -Fever -Nausea and vomiting -Palpitations -Tachycardia -Tachypnoea -Hypotension -Light headedness ```

Answer 123

Bloods: - FBC: abnormally high or low WCC - U&Es: hyponatraemia is a non-specific finding - Urea and Creatinine: may be elevated - CRP: elevation (non-specific) - Creatinine kinase: elevated - Serum lactate: elevated Blood and tissue cultures: positive; may indicate polymicrobial or monomicrobial aetiology ABG: hypoxaemia, acidosis CT/MRI: oedema extending along fascial plane and/or soft tissue gas Surgical exploration: surgical consultation for inspection, exploration, and drainage of infected tissue should be obtained in every case of suspected necrotising fasciitis

Answer 124

A potentially life-threatening complication of anti-cancer and other immunosuppressive drug treatment It is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower

Answer 125

A syndrome defined as life-threatening organ dysfunction due to a dysregulated host response to infection

Answer 126

The risk of clinically significant infection and sepsis increases as the neutrophil count decreases to less than 0.5 x 109/L

Answer 127

It is a common complication of chemotherapy- often more common in patients with haematological malignancies than in patients with solid tumours Risk: greatest with the first treatment, also cumulative with ongoing cycles of therapy

Answer 128

Infants and people over 60 years of age are at higher risk Corticosteroids (additional immunosuppression) Co-morbidities: diabetes mellitus, liver disease, renal disease; poor nutritional status Full dose intensity chemotherapy Concurrent radiotherapy Prior episodes of neutropenia following chemotherapy

Answer 129

The most common life-threatening complication of cancer therapy Higher incidence in patients with heamatological malignancy

Answer 130

Symptoms or signs indicating possible infection: Dysuria Dyspnoea Diarrhoea Cough Nausea or vomiting Chills, shivers and/or a temperature greater than 38°C

Answer 131

``` Clinical features of possible sepsis: -Fever -Rigors -Tachycardia -Hypotension *people with sepsis may present with non-specific, non-localized clinical features: -general malaise -agitation -behavioural change In addition, neutropenia may cause changes in behaviour, mental state, or cognition which is independent from the onset of sepsis ```

Answer 132

Bloods: -FBC: absolute neutrophil count (ANC) <500 -U&Es: normal or elevated, indicator of renal dysfunction -LFTs: albumin <35 g/L (also a RF for neutropenic sepsis), total bilirubin and aminotransferases elevated Blood cultures: positive for pathogen CXR: infiltrates in pneumonia Others: -Stool and urine culture -Lumbar puncture: for patients with suspected CNS infection -Viral assay -CT of chest, abdomen and pelvis: infiltrates of pneumonia

Answer 133

An inflammatory condition of bone caused by an infecting organism, most commonly Staphylococcus aureus

Answer 134

May be caused from haematogenous spread, direct inoculation of micro-organisms into bone, or from a contiguous (touching) focus of infection

Answer 135

Staphylococcus aureus

Answer 136

``` Penetrating injuries e.g. open fractures Surgical site infections Intravenous drug misuse Diabetes Mellitus- diabetic foot Periodontal abscess of the mandible ```

Answer 137

Greater incidence in men than women | Risk increased with age particularly over 50

Answer 138

Malaise Fatigue Vague symptoms: non-specific pain at site of infection, low grade fever Local inflammation, erythema or swelling

Answer 139

``` Local inflammation, erythema or swelling Reduced range of movement Reduced sensation (particularly in diabetic foot) ```

Answer 140

Bloods: -Raised WCC -Raised ESR/CRP Plain x-rays of affected areas: osteopenia, bone destruction (lytic lesions)- 'fallen leaf' sign Ultrasound: look for signs of associated septic arthritis and infection (collections, subperiosteal abscesses) CT: bone destruction Radionuclide scan: increased uptake at infected sites Histology: organisms or inflammatory cells, dead cells

Answer 141

Inflammation of the pericardium, may be acute, subacute or chronic

Answer 142

New-onset inflammation lasting <4-6 weeks

Answer 143

Can be idiopathic or due to an underlying systemic condition (e.g., systemic lupus erythematosus) As many as 90% of cases are either idiopathic or due to viral infections or systemic autoimmune conditions

Answer 144

Viral or bacterial infection (viral is most common): -Commonly coxsackie B, echovirus, mumps virus, streptococci, fungi, staphylococci, TB Systemic autoimmune conditions e.g. rheumatoid arthritis and SLE Malignancy Metabolic disorders Cardiac surgery (4 weeks after coronary artery bypass graft) Transmural MI: -post-myocardial infarction (24–72 h) -Dresslers syndrome (weeks to months after acute MI)

Answer 145

Acute pericarditis is more common in adults (typically between 20 to 50 years old) and in men Uncommon- the clinical incidence is <1 in 100 hospital admissions

Answer 146

Chest pain (most common- 85% of cases) -Sharp, stabbing, pleuritic, or aching, and can mimic the pain of myocardial ischaemia or infarction **Almost all patients report relief of pain with sitting up or leaning forward -Pain radiates to neck or shoulders -Aggravated by coughing, deep inspiration and lying flat Others: Dyspnoea, nausea

Answer 147

Fever Pericardial friction rub (best heard lower left sternal edge, with patient leaning forward in expiration) Heart sounds may be faint in the presence of an effusion

Answer 148

Raised JVP with inspiration (Kussmauls sign) Pulsus paradoxus: an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration (<10 mmHg) Hepatomegaly Ascites Oedema Pericardial knock (rapid ventricular filling) AF

Answer 149

Impedes (delays) normal diastolic filling and can be a medium to late complication of acute pericarditis

Answer 150

*ECG: Widespread ST elevation that is saddle-shaped (most useful diagnostic test) Bloods: -Troponin: elevated -ESR and CRP: elevated consistent with inflammation -Urea: elevated suggest a urea cause -FBC: elevated leukocytes Pericardial fluid/blood culture: positive if infectious cause (and viral serology, ANA, rheumatoid factor) CXR: Usually normal unless a large pericardial effusion is present >300 mL effusion: water-bottle-shaped enlarged cardiac silhouette Chest CT: Pericardial calcification can be seen in constrictive pericarditis: -pericardial thickness, calcification -deformed ventricular contours -dilatation of the inferior vena cava -angulation of the ventricular septum (lateral CXR or CT)

Answer 151

Inflammation of the peritoneum usually caused by infection from bacteria or fungi Left untreated, peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple organ failure and death

Answer 152

The two main types: - Primary spontaneous peritonitis, an infection that develops in the peritoneum - Secondary peritonitis, which usually develops when an injury or infection in the abdominal cavity allows infectious organisms into the peritoneum

Answer 153

Both types of peritonitis are life-threatening The death rate from peritonitis depends on many factors, but can be as high as 40% in those who also have cirrhosis As many as 10% may die from secondary peritonitis

Answer 154

The most common risk factors for primary spontaneous peritonitis include: - Liver disease with cirrhosis: buildup of abdominal fluid (ascites) that can become infected - Kidney failure getting peritoneal dialysis Common causes of secondary peritonitis include: - A ruptured appendix, diverticulum, or stomach ulcer - Digestive diseases such as Crohn's disease and diverticulitis - Pancreatitis - Pelvic inflammatory disease - Perforations of the bowel, stomach, intestine, gallbladder, or appendix - Surgery - Trauma to the abdomen

Answer 155

Abdominal pain or tenderness Rigors Fever Not passing any urine (or passing less volume than usual) Difficulty passing gas or having a bowel movement Vomiting *may have fluid in the abdominal cavity= ascites

Answer 156

An infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition It is one of the most frequently encountered bacterial infections in patients with cirrhosis

Answer 157

``` Abdominal pain or tenderness Signs of ascites: flank dullness, shifting dullness, fluid wave, and auscultatory percussion Signs of sepsis may be present: -Hypothermia -Hypotension -Tachycardia ```

Answer 158

Bloods: -FBC: leukocytosis, anaemia (if worsens may be a GI bleed) -Creatinine: elevated hepatorenal syndrome may be present -LFTs: May be useful in determining if patient has liver disease: liver enzymes and bilirubin elevated; albumin decreased Blood cultures: growth of causative organism Peritoneal fluid analysis: - culture - pH - WCC CT scan of abdomen: demonstrates diffuse ascites; excludes pneumoperitoneum in patients with secondary peritonitis

Answer 159

Patients who appear otherwise well with no signs of sepsis, encephalopathy, or GI bleeding may be started on oral antibiotics: quinolone or a cephalosporin such as cefixime- continue for 5 to 10 days Patients who have signs of sepsis, encephalopathy, or GI bleeding should be started on empirical broad-spectrum antibiotics active against both gram-negative and gram-positive organisms Typical choice of antibiotic would be: -cephalosporin, ciprofloxacin -or a broad-spectrum penicillin with a beta-lactamase inhibitor, such as ampicillin/sulbactam Surgery: necessary to remove infected tissue, treat the underlying cause of the infection, and prevent the infection from spreading, especially if peritonitis is due to a ruptured appendix, stomach or colon

Answer 160

HIGH RISK: sepsis/septic shock HIGH RISK: renal dysfunction/impairment Medium: worsening ascites Risk of paracentesis: -Bleeding e.g. intraperitoneal haemorrhage -Persistent leak at the site of the paracentesis -Bowel perforation

Answer 161

One year reoccurrence in primary spontaneous peritonitis however the mortality rate has decreased *renal dysfunction was found to be the most important independent predictor of mortality

Answer 162

Infection of distal lung parenchyma

Answer 163

1. Community-acquired, hospital-acquired or nosocomial (originating in hospital) 2. Aspiration pneumonia, pneumonia in the immunocompromised 3. Typical and atypical (Mycoplasma, Chlamydia, Legionella) 4. Location: lobar

Answer 164

Community-acquired: -Streptococcus pneumoniae (70%) -Haemophilus influenzae and Moraxella catarrhalis (COPD) -Chlamydia pneumonia and Chlamydia psittaci (contact with birds/parrots) -Mycoplasma pneumonia (periodic epidemics) -Legionella (anywhere with air conditioning) -Staphylococcus aureus (recent influenza infection, IV drug users) Hospital-acquired: -Gram-negative enterobacteria (Pseudomonas, Klebsiella), anaerobes (aspiration pneumonia)

Answer 165

``` Age (over 65 years) Smoking (or exposure) Alcohol Poor oral hygiene Pre-existing lung disease e.g. COPD Immunodeficiency (chronic renal/liver disease, diabetes mellitus) Contact with pneumonia ```

Answer 166

Incidence 􏰄5–11 in 1000 (25–44 in 1000 in elderly) | Community- acquired causes >60 000 deaths/year in the UK

Answer 167

Streptococcus pneumoniae

Answer 168

Fever Cough with increasing sputum production(yellow, green or rusty in S. pneumoniae) Rigors, sweating (night sweats) Malaise Breathlessness and pleuritic chest pain Confusion (severe cases, elderly, Legionella).

Answer 169

``` Inspection: -Pyrexia -Respiratory distress -Tachypnoea -Tachycardia -Hypotension -Cyanosis Resp examination: -Reduced chest expansion -Dullness to percussion -Increased tactile vocal fremitus -Bronchial breathing (inspiration phase lasts as long as expiration phase) -Coarse crepitations on affected side *Chronic suppurative lung disease (empyema, abscess): Clubbing ```

Answer 170

Headache, myalgia, diarrhoea/abdominal pain

Answer 171

``` CURB-65 mortality risk score C- Confusion U- Urea > 7mmol/L* R- Respiratory rate > 30 B- BP = SBP < 90 mmHg OR DBP < 60 mmHg 65- age >65 years *Urea may not be easily measured in community ```

Answer 172

CXR: new consolidation (repeat 6–8 weeks) Pulse oximetry: low arterial oxygen saturation < 94% ABG: low arterial oxygen saturation Sputum/pleural fluid: Microscopy, culture and sensitivity, acid-fast bacilli Urine: Pneumococcus and Legionella antigens Bloods: -FBC: leukocytosis (abnormal WCC) -CRP: elevated -U&Es: Low sodium -Blood culture: CMS -LFTs: usually normal *When pneumonia fails to resolve or when there is clinical progression: Bronchoscopy (and bronchoalveolar lavage)

Answer 173

A type of bacteria that causes tuberculosis

Answer 174

1. Assess severity 2. Start antibiotics: -Oral amoxicillin -Oral or IV amoxicillin and erythromycin -IV cefuroxime/cefotaxime/co-amoxiclav and erythromycin *switch to appropriate antibiotic as per sensitivity 3. Supportive therapy: -Oxygen (maintain PO2 > 8 kPa, start with 28% O2 in COPD to avoid hypercapnia) -Parenteral fluids for dehydration or shock, analgesia, chest physiotherapy -CPAP, BiPAP or ITU care for respiratory failure -surgical drainage may be needed for empyema/abscesses 4. Discharge planning: Presence of two or more features of clinical instability (pyrexia, heart rate, respiratory rate and low BP, oxygen saturation, mental status and oral intake) predict a significant chance of re-admission or mortality

Answer 175

``` Pleural effusion Empyema (pus in the pleural cavity) Lung abscess (especially staphylococcal, Klebsiella pneumonia- rare) Septic shock ARDS Acute renal failure Septic schock Heart failure ```

Answer 176

For patients admitted to hospital, mortality rate ranges from 5% to 15%, but increases to 20% to 50% in patients requiring admission to the intensive care unit (ICU) Patients treated in the community generally have a good prognosis

Answer 177

An inflammatory (autoimmune) multisystem disorder, occurring following group A b-haemolytic streptococci (GAS) throat infection

Answer 178

Streptococcal pharyngeal infection is required, and genetic susceptibility may be present for the autoimmune response to be triggered

Answer 179

Peak incidence: between 5-15 years. More common in the Far East, Middle East, eastern Europe and South America The mean incidence is 19/100 000. Despite the decline in incidence over time in the West, the incidence rates remain relatively high in non-Western countries

Answer 180

``` 2–5 weeks after GAS infection- recent sore throat General: Fever Malaise Anorexia Joints: Painful, swollen, reduced movement/function Cardiac: Breathlessness, chest pain, palpitations ```

Answer 181

Duckett Jones criteria: Positive diagnosis if at least two major criteria, or one major plus two minor criteria are present Major criteria: - Arthritis: Migratory or fleeting polyarthritis with swelling, redness and tenderness of large joints - Carditis: New murmur, e.g. Carey Coombs murmur (mid-diastolic murmur due to mitral valvulitis), pericarditis, pericardial effusion or rub, cardiomegaly, cardiac failure, ECG changes - Chorea (Sydenhams): Rapid, involuntary, irregular movements with flowing or dancing quality. May be accompanied by slurred speech. More common in females - Nodules: Small firm painless subcutaneous nodules seen on extensor surfaces, joints and tendons. - Erythema marginatum (20% cases): Transient erythematous rash with raised edges, seen on trunk and proximal limbs. They may form crescent- or ring-shaped patches Minor criteria: - Pyrexia - PMH rheumatic fever - Arthralgia (only if arthritis is not present as major criteria) - Recent streptococcal infection (supported by positive throat cultures or raised antistreptolysin O titre) - Elevated inflammatory markers (ESR, CRP or WCC) - Prolonged PR and QT intervals on ECG (only if carditis not present as major criteria)

Answer 182

Bloods: -FBC (elevated WCC) -Elevated ESR/CRP -Elevated or rising antistreptolysin O titre *Throat swab: Culture for GAS, rapid streptococcal antigen test ECG: -Prolonged PR interval is a minor criterion of acute rheumatic fever -Features of pericarditis -Arrhythmias Echocardiogram: -Pericardial effusion -Myocardial thickening or dysfunction -Valvulardysfunction CXR: may demonstrate cardiomegaly and/or congestive cardiac failure

Answer 183

Joint inflammation resulting from intra-articular (occurring within a joint) infection

Answer 184

May be idiopathic, although in most cases, there is systemic infection allowing for haematogenous spread Other causes are orthopaedic procedures, osteomyelitis, diabetes, immunosuppression, alcoholism

Answer 185

Bacteria: -Staphylococcus aureus, Mycobacterium tuberculosis (all ages) -Strepotococcus pneumoniae, Strepotococcus pyogenes, Neisseria meningitidis (<4 years) Mainly Neisseria gonorrhoea (16–40 years) Viruses: -Rubella -Mumps -Hepatitis B Fungi: Candida

Answer 186

``` Underlying joint disease such as rheumatoid arthritis, osteoarthritis Joint prostheses Intravenous drug abuse Diabetes (increased risk of infection) Alcoholism ```

Answer 187

Most common in children and the elderly

Answer 188

Fever Excruciating joint pain, redness, swelling and loss of joint function Usually affecting single large joint- (polyarthritis in the immunosuppressed)

Answer 189

More insidious onset and is chronic

Answer 190

Painful, hot, swollen and immobile joint with overlying erythema Severe pain prevents passive movement Pyrexia Look for signs of aetiology- type of infective organism

Answer 191

**Joint aspiration: Grossly purulent- send synovial fluid for cytology and microscopy Bloods: -FBC (raised WCC and neutrophils) -raised CRP and ESR -blood cultures for CMS Plain joint radiographs: Affected joint may initially be normal- assess joint damage in later films MRI scan: Useful in detecting associated osteomyelitis

Answer 192

A systemic autoimmune disorder characterised by the presence of dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) because of lymphocytic infiltration into the lacrimal and salivary glands

Answer 193

``` Pre-existing conditions: -Systemic lupus erythematosus (SLE) -Rheumatoid arthritis -Systemic sclerosis (scleroderma) Family Hx ```

Answer 194

HLA Class 2 markers

Answer 195

The most common of all systemic autoimmune rheumatic diseases. Female-to-male ratio of 9:1 Population prevalence of between 0.5% and 1.56%

Answer 196

Fatigue Dry eyes Dry mouth

Answer 197

``` Vasculitis: skin rash Peripheral neuropathy (1/3rd of patients) Enlarged salivary glands Burning mouth (reduced salivary flow) ```

Answer 198

Schirmer's test: positive Antibodies to the ribonucleoproteins 60 kD Ro and La Sialometry: decreased salivary flow Parotid sialography: (x-ray with radioactive contrast) gross distortion of the normal pattern of parotid ductules Minor salivary gland biopsy: mononuclear cell infiltrates Angiography: for vasculitis (aneurysm, or smooth, tapering vessel stenosis) Urinalysis: may show abnormal levels of phosphate, calcium, potassium, glucose (renal tubular acidosis)

Answer 199

Quantitatively measures tears- filter paper is placed in the lower conjunctival sac The test is positive if less than 5 mm of paper is wetted after 5 minutes

Answer 200

A chronic multi-system inflammatory autoimmune disorder that most commonly affects women during their reproductive years

Answer 201

Combination of hormonal, genetic (HLA clustering) and exogenous factors (drugs)

Answer 202

Common- prevalence is 1–2 in 1000 More common in young people (15–45 years) 9 times more common in females Disease is much more common and severe in those of African and Asian descent

Answer 203

General: Fever, fatigue, weight loss, lymphadenopathy, splenomegaly Oral ulcers Raynaud's phenomenon Alopecia: Hair thinning Skin: -Malar (butterfly) rash- primarily affects the cheeks and the bridge of the nose -Photosensitive rash (appears after sun exposure) -Discoid rash: erythematous raised patches

Answer 204

Arthritis Tendonitis Myopathy Avascular necrosis of femoral head

Answer 205

``` Pericarditis Myocarditis Arrhythmias Libman–Sacks endocarditis (non-infective mitral valve disease) Aortic valve lesions ```

Answer 206

Pleuritis Pleural effusions Basal atelectasis Restrictive lung defects

Answer 207

``` Headache Stroke Cranial nerve palsies Confusion Chorea (abnormal involuntary movement disorder) Fits Peripheral neuropathy ```

Answer 208

Depression | Psychosis

Answer 209

Symptoms of glomerulonephritis: - Hypertension - Proteinuria (<3 g/24 h); - Haematuria (microscopic or macroscopic, especially IgA nephropathy) - Nephrotic syndrome -proteinuria - Nephritic syndrome (haematuria, proteinuria, subcutaneous oedema, oliguria, hypertension, uraemia)

Answer 210

Bloods: - FBC: anaemia, leukopenia, thrombocytopenia - Activated PTT (prolonged) - Elevated urea and creatinine - Elevated ESR and CRP (latter is sometimes normal) - Complement * Antinuclear antibody (ANA) and Antiphospholipid antibodies : positive Urine: Haematuria, proteinuria, microscopy (for casts). Joints: Plain radiographs: inflammation, non-erosive arthritis Heart and lung: CXR (pleural effusion, infiltrates, cardiomegaly), ECG, echocardiogram, CT scan Kidney: Renal biopsy (if glomerulonephritis suspected) CNS: MRI scan, lumbar puncture

Answer 211

A multi-system, autoimmune disease, characterised by functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs, and production of auto-antibodies

Answer 212

Unknown. Genetic and environmental factors (e.g. vinyl chloride, epoxy resins) have been suggested -Endothelial cells: endothelial cell damage, platelet activation, myointimal cell proliferation and narrowing of blood vessels -Fibroblasts: lay down collagen in the dermis

Answer 213

Age of onset 30–60 years Three times more common in females Annual incidence is one in 10 000

Answer 214

``` Fatigue Initially swollen oedematous painful fingers Changes in pigmentation and finger ulcers Dry mouth Nausea, vomiting, anorexia Impotence Dyspnoea Dry cough ```

Answer 215

Raynauds phenomenon Initially swollen oedematous painful fingers Later they become thickened, tight, shiny and bound to underlying structures Changes in pigmentation

Answer 216

Microstomia (puckering and furrowing of perioral skin) | Telangiecstasia (widened venules cause threadlike red lines on the skin)

Answer 217

Pulmonary fibrosis leading to pulmonary hypertension | Dry crackles at lung bases

Answer 218

Pericarditis or pericardial effusion Myocardial fibrosis Heart failure or arrhythmias

Answer 219

``` Oesophageal dysmotility (dysphagia) Reflux oesophagitis Gastric paresis (nausea, vomiting, anorexia) Watermelon stomach Small bowel pseudo-obstruction Colonic hypomotility (constipation) Anal incontinence Angiodysplasia (small vascular malformation of the gut.) ```

Answer 220

Hypertensive renal crisis | Chronic renal failure

Answer 221

Trigeminal neuralgia | Muscular wasting or weakness

Answer 222

*Serum auto-antibodies: positive ANA in more than 90% of patients Bloods: may be normal, occasionally anaemic, elevated ESR and CRP, elevated serum urea and creatinine with scleroderma renal crisis Serum muscle enzymes: elevated in scleroderma myopathy, muscle biopsy Lung: CXR, pulmonary function tests (interstitial lung disease), CT scan Heart: ECG, echocardiography (pulmonary HTN) GI: Endoscopy, barium studies (diminished muscle tone), gastric/oesophageal scintigraphy Kidney: U&E and measurement of creatinine clearance Neuromuscular: Electromyography, nerve conduction studies, biopsy Joints: Radiography (for subcutaneous calcification, flexion deformities)

Answer 223

An autoimmune-mediated lymphocytic inflammation of the thyroid gland resulting in a destructive thyroiditis with release of thyroid hormone and transient thyrotoxicosis (hyperthyroidism) This is frequently followed by a hypothyroid phase and full recovery

Answer 224

Painless (lymphocytic) thyroiditis is part of the spectrum of autoimmune thyroid disease and considered by many to be a variant presentation of Hashimoto's thyroiditis It has been associated with HLA-DR3 and DR5

Answer 225

The condition is twice as likely to occur in women and can occur in all age groups, although the mean age of onset is in the 30s Postnatal thyroiditis occurs after 7% of pregnancies Also seen in patients treated with cytokines or biological agents

Answer 226

``` Postnatal period Receiving immune-modulatory therapy Lithium therapy PMH of Type 1 DM and other autoimmune conditions Weaker RF: -Female sex -FH ```

Answer 227

Features of hyperthyroidism: - Heat intolerance - Nervousness - Palpitations - Weight loss - Excessive fatigue

Answer 228

Small non-tender goitre Features of hyperthyroidism (tachycardia) and then features of hypothyroidism (cold intolerance, poor concentration, weight gain)

Answer 229

Thyroid function tests: - TSH: low TSH suggests thyrotoxicosis; elevated in hypothyroid phase - Serum free T4 and T3: elevated in the thyrotoxic phase; low in the hypothyroid phase - Thyroid Peroxidase antibodies: confirm autoimmune aetiology: frequently positive - TSH-r antibodies: *distinguish between Graves' 4,6 or 24 hour radioiodine uptake: very low, usually <1% (Uptake elevated or within the normal range in Graves' disease and toxic multinodular goitre) Total T3/T4 ratio: when radioiodine uptake is contraindicated: distinguish thyroiditis from Graves' disease and toxic nodular goitre: LOW Others: - Thyroid biopsy: rarely necessary, lymphocytic infiltrate - techniteum 99pertechnetate: uptake scan - serum thyroglobulin: elevated - Colour flow doppler ultrasound: reduced flow (widely available but uncommonly used)

Answer 230

Thyrotoxic phase: - Treatment may not be necessary for asymptomatic patients - In symptomatic thyrotoxicosis: beta-blockers will ameliorate the tachycardia and tremulousness (or calcium-channel blocker) - If not responding to treatment: systemic corticosteroids Hypothyroid phase: - Again may not be needed - In moderate to severe: levothyroxine is given to normalise serum TSH concentrations - In permanent hypothyroidism: levothyroxine should be continued indefinitely Recurrent thyroiditis: Up to 11% of patients with sporadic painless thyroiditis will have recurrent thyroiditis -Although it is rarely done, such patients may elect to have their thyroid gland ablated with radioiodine or surgically removed between episodes when they are euthyroid

Answer 231

Arrhythmias: AF Exacerbation of co-morbidities particularly ismchaemic heart disease and congestive heart failure (lower risk) More likely to develop permanent hypothyroidism Can also develop Graves' disease, recurrent hyperthyroidism

Answer 232

Most patients recover normal thyroid function: - 6% remain permanently hypothyroid - 1/3 have persistent goitre or thyroid peroxidase (TPO) antibodies - Recurrent episodes are common postnatally (69%) but may also occur in up to 11% of patients with sporadic disease

Answer 233

An acute infection of the parenchyma of the palatine tonsils

Answer 234

Tonsillitis is usually viral but the most common bacterial pathogen is Group A beta-haemolytic streptococci. Local inflammatory pathways result in oropharyngeal swelling, oedema, erythema, and pain RF: contact with infected people in enclosed spaces

Answer 235

Acute tonsillitis is more common in children between the ages of 5-15 years. More common in winter and early spring although can occur at any time of the year

Answer 236

``` Sudden onset of sore throat Headache Fever Pain on swallowing Presence of cough or runny nose Tonsillar enlargement Associated nausea and vomiting ```

Answer 237

Tonsillar exudate (purulent "discharge/pus milky looking") -particularly when caused by Group A beta-haemolytic streptococci Tonsillar erythema Tonsillar enlargement Enlarged anterior cervical lymph nodes

Answer 238

Throat culture Rapid streptococcal antigen test Bloods: WCC, CRP, ESR *Important to establish whether the patient has acute tonsillitis and not another cause of sore throat (retropharyngeal abscess or infectious mononucleosis)

Answer 239

Analgesia Antibiotics- penicillin is still first choice Corticosteroids (dexamethasone) Tonsillectomy may be considered for patients who have recurrent symptoms of tonsillitis and no other explanation for recurrent symptoms

Answer 240

Scarlet fever (diffuse erythematous rash from delayed skin reactivity produced by Streptococcus species) Acute sinusitis Acute Otitis media

Answer 241

The rash blanches with pressure and has multiple small papules. It generally starts on the head and neck, and is associated with circumoral (around mouth) pallor and a strawberry tongue. It subsequently spreads to the trunk, sparing the palms and soles, and is more marked over the skin folds

Answer 242

Acute tonsillitis is an acute, self-limiting infective condition that normally resolves completely within 1 week. In vulnerable people tonsillitis may run a more severe course. Antibiotics and/or admission to hospital for a limited period of time may be advisable Some patients may also develop recurrent tonsillitis; tonsillectomy may be considered in these cases

Answer 243

An infectious granulomatous disease caused by Mycobacterium tuberculosis *notifiable disease

Answer 244

M. tuberculosis is an intracellular organism (also known as acid-fast bacilli, AFB) which survives after being phagocytosed by macrophages *predominantly in the upper lobes

Answer 245

According to WHO, TB is the 9th leading cause of death worldwide, and is the leading cause of death from a single infectious agent Both the very young (age <5 years) and older people are at increased risk for progression to disease *Incidence in Asian immigrants >30 times native UK white population

Answer 246

``` Exposure to infection Birth in a high rid country e.g. Asia, Latin America, and Africa HIV Immunosuppressive medication IV drug use Malnutrition ```

Answer 247

``` *TB is a multi-system disease- but can be LATENT Primary TB: -Mostly asymptomatic* -May have fever -Malaise -Cough -Wheeze Miliary TB: -Fever -Weight loss -Meningitis -Yellow caseous tubercles spread to other organs (e.g. in bone and kidney may remain dormant for years) Post-primary TB: -Fever/night sweats -Malaise -Weight loss -Breathlessness -Cough, sputum, haemoptysis -Pleuritic pain ```

Answer 248

Signs of pleural effusion, collapse, consolidation, fibrosis (abnormal chest auscultation and percussion) Wheeze Erythema nodosum and phlyctenular conjunctivitis (allergic manifestations)

Answer 249

Lymph nodes: Suppuration (acute onset of tender) cervical lymph nodes leading to abscesses or sinuses, which discharge pus and spread to skin (scrofuloderma). CNS: Meningitis, tuberculoma Skin: Lupus vulgaris (jellylike reddish-brown glistening plaques) Heart: Pericardial effusion, constrictive pericarditis Gastrointestinal: Subacute obstruction, change in bowel habit, weight loss, peritonitis, ascites Genitourinary: UTI symptoms, renal failure, epididymitis, endometrial or tubal involvement, infertility Adrenal: Insufficiency Bone/joints: Osteomyelitis, arthritis, paravertebral abscesses and vertebral collapse (Potts disease), spinal cord compression from abscesses.

Answer 250

*CXR: fibronodular opacities in upper lobes with or without cavitation (hilar lymphadenopathy) Sputum smear: positive for acid-fast bacilli (AFB) Sputum culture: positive for Mycobacterium tuberculosis DNA or RNA amplification tests for rapid diagnosis: +ve Bloods: -Latent: exposure of host T cells to TB antigens causes release of interferon -Active: Raised WCC, low Hb Bronchoscopy and bronchoalveolar lavage: positive for AFB *Gastric aspirate if unable to produce sputum

Answer 251

An inflammatory reaction of the urinary tract epithelium in response to pathogenic micro-organisms, most commonly bacteria

Answer 252

UTIs result from pathogenic organisms gaining access to the urinary tract and not being effectively eliminated The bacteria ascend the urethra and generally have an intestinal origin; therefore, Escherichia coli causes most UTIs in men and women

Answer 253

Uncomplicated: normal renal tract structure and function Complicated: structural/functional abnormality of genitourinary tract, eg obstruction, catheter, stones, neurogenic bladder, renal transplant

Answer 254

1. Increased bacterial inoculation: - Sexual activity - Urinary incontinence - Faecal incontinence - Constipation 2. Increased binding of uropathogenic bacteria: - Spermicide use - Reduced oestrogen - Menopause 3. Reduced urine flow: - Dehydration - Obstructed urinary tract 4. Increased bacterial growth: - Diabetes Mellitus - Immunosuppression - Obstruction - Stones - Catheter - Renal tract malformation - Pregnancy

Answer 255

All patient-care settings identify UTI as the most common infection The ratio of UTI occurrence between institutionalised women and men is almost equal (2 to 3:1), unlike the ratio for younger women and men (25:1)

Answer 256

Cystitis: Frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria. Acute pyelonephritis: Fever, rigor, vomiting, loin pain/tenderness, costovertebral pain, associated cystitis symptoms, septic shock Prostatitis: -Pain: perineum, rectum, scrotum, penis, bladder, lower back. Fever, malaise, nausea, urinary symptoms, swollen or tender prostate on PR*

Answer 257

Bladder (cystitis) | Prostate (prostatitis)

Answer 258

Pyelonephritis = infection of kidney/renal pelvis

Answer 259

Fever Abdominal or loin tenderness Check for a distended bladder, enlarged (tender) prostate *If vaginal discharge, consider Pelvic inflammatory disease

Answer 260

Dipstick urinalysis: positive leukocyte esterase and/or nitrite (avoid using in pregnant women) *(MSU) Urine culture and microscopy: leukocytes and/or bacteria (≥10^2 CFU/mL)- Use in pregnant women, men, children Bloods: (if systemically unwell) FBC, U&E, CRP, and blood culture (positive in only 10–25% of pyelonephritis) Imaging: -Consider USS (rules out obstruction) and referral to urology for assessment in men with upper UTI; failure to respond to treatment; recurrent UTI (>2/year); pyelonephritis; persistent haematuria -CT renal tract: perirenal abscess, urinary calculi, or tumours -CT Kidneys, Ureter and Bladder: urinary tract stone, abscess *consider urogram for those who have voiding dysfunction without a clearly identifiable cause such as BPH or failure to treatment

Answer 261

The goal of treatment: eradication of bacteria through antibiotics There are different guidelines for the different populations that can be affected by UTIs

Answer 262

If 3 or more symptoms (or 1 severe) of cystitis, and no vaginal discharge: treat empirically with 3-day course of trimethoprim, or nitrofurantoin (if eGFR >30) - If first-line empirical treatment fails, culture urine and treat according to antibiotic sensitivity. * In upper UTI, take a urine culture and treat initially with a broad-spectrum antibiotic according to local guidelines/sensitivities, eg co-amoxiclav.

Answer 263

*Get expert help UTI in pregnancy is associated with preterm delivery and intrauterine growth restriction Asymptomatic bacteriuria should be confirmed on a second sample Treat with an antibiotic- local guidance advice for antibiotic choice (avoid ciprofloxacin, trimethoprim in 1st trimester, nitrofurantoin in 3rd trimester) Confirm eradication.

Answer 264

Treat lower UTI with a 7-day course of trimethoprim or nitrofurantoin (if eGFR >30) - If symptoms suggest prostatitis (pain in pelvis, genitals, lower back, buttocks) consider a longer (4-week) course of a fluoroquinolone (eg ciprofloxacin) due to ability to penetrate prostatic fluid - If upper or recurrent UTI, refer for urological investigation

Answer 265

All catheterized patients are bacteriuric Send MSU only if symptomatic (symptoms of UTI may be non-specific/atypical) Possible symptoms: Fever, flank/ suprapubic pain, change in voiding pattern, vomiting, confusion, sepsis -Change long-term catheter before starting an antibiotic. -Where possible use a narrow-spectrum antibiotic according to culture sensitivity.

Answer 266

Prostatitis Pyelonephritis *Renal function impairment: RF include prostatitis, obstruction, the presence of stones, and the presence of indwelling catheters *Sepsis

Answer 267

In the absence of a complicated UTI, antibiotic therapy is more effective and results in fewer failures Younger patients have a better prognosis Older patients often have a complicated UTI

Answer 268

A skin condition characterised by erythematous, blanching, oedematous, non-painful, pruritic lesions that typically resolve within 24 hours and leave no residual markings

Answer 269

Many cases of acute urticaria are allergic in nature and caused by an IgE-mediated reaction The most common agents involved are drugs (e.g., penicillins, sulfonamides, muscle relaxants, diuretics, NSAIDs) and foods (e.g., milk, eggs, peanuts, tree nuts, finfish, shellfish). Insect bites can also lead to acute urticaria Non-IgE-mediated mechanisms can also be responsible and these cases tend to involve certain drugs (e.g., NSAIDs, opioids, vancomycin), radiocontrast dye, or acute viral infections (especially in children)

Answer 270

Approximately 40% of cases are thought to be autoimmune in nature, while many cases are idiopathic individuals with acute or chronic urticaria experience spontaneous and unpredictable lesions

Answer 271

The life-time prevalence for acute urticaria is approximately 20%. While the majority of these cases are acute and self-limiting events, roughly 30% of people will go on to experience prolonged symptoms Acute urticaria is more common in children and adolescents than in adults, while chronic urticaria more typically affects adults In chronic urticaria, women are affected more often than men

Answer 272

Erythematous oedematous lesions that may be distributed on any part of the body Typically pruritic, although occasionally patients may report a painful or burning sensation Generally resolve within 24h Swelling of the face, tongue or lips (up to 40% of cases of urticaria have associated angio-oedema) *Urticarial lesions blanch when palpated: Non-blanching lesions should raise suspicion for vasculitis

Answer 273

*Mainly for chronic urticaria* Bloods: -FBC: may provide evidence of occult infection, anaemia, or findings suggestive of chronic illness -Metabolic profile: May provide evidence of chronic illness, such as hepatitis or nephritis -ESR and CRP: non-specific elevation -anti-Ig E antibodies: reassures both the patient and the physician that there are no exogenous factors causing the condition -Antithyroid/antinuclear antibodies: exclude thyroid/rheumatic causes of chronic illness Skin biopsy: may show urticarial vasculitis in setting of atypical urticarial lesions

Answer 274

Primary infection is called varicella (chickenpox) | Reactivation of the dormant virus in the dorsal root ganglia, causes zoster (shingles)

Answer 275

VZV is an herpes ds-DNA virus Highly contagious, transmission is by aerosol inhalation or direct contact with the vesicular secretions

Answer 276

Chickenpox peak incidence occurs at 4–10 years Shingles peak incidence occurs at >50 years About 90% of adults are VZV IgG positive (previously infected)

Answer 277

*Incubation period 14–21 days Chickenpox: -Prodromal malaise -Mild pyrexia -Sudden appearance of intensely itchy spreading rash affecting the face and trunk more than the extremities, the oropharynx, conjunctivae and genitourinary tract -As vesicles weep and crust over, new vesicles appear -Contagious from 48 h before the rash and until all the vesicles have crusted over (within 7–10 days) Shingles: -May occur after a period of stress -Tingling/hyperaesthesia in a dermatomal distribution, followed by painful skin lesions Recovery in 10–14 days

Answer 278

Chickenpox (disseminated varicella): -Macular papular rash evolving into crops of vesicles with areas of weeping (exudate) and crusting (vesicles, macules, papules and crusts may all be present at one time) -Skin excoriation (from scratching) -Mild pyrexia Shingles: -Vesicular macular papular rash, in a dermatomal distribution -Skin excoriation

Answer 279

*Clinical diagnosis: typical vesicular rash at different stages, with pruritus, fever, malaise Others: -Vesicle fluid: Electron microscopy, direct immunofluorescence, cell culture, viral PCR (all rarely necessary) -Chickenpox: Consider HIV testing especially in adults with prior history of varicella infection

Answer 280

Vasculitis is the inflammation and necrosis of blood vessels (autoimmune disorders)

Answer 281

Large: Giant cell arteritis (GCA), Takayasus aortitis (TA). Medium: Polyarteritis nodosa (PAN), Kawasakis disease (KD) Small: Churg–Strauss syndrome (CSS), microscopic polyangiitis (MP), Wegeners granulomatosis (WG)

Answer 282

A rare autoimmune condition that causes inflammation of small and medium-sized blood vessels in persons with a history of airway allergic hypersensitivity (atopy). Also called Churg–Strauss syndrome (small)

Answer 283

Inflammation of the blood vessels in your nose, sinuses, throat, lungs and kidneys. Formerly called Wegener's granulomatosis (small)

Answer 284

Unknown- thought to be of autoimmune origin | Immune complex deposition in vessel walls triggers classical complement activation and inflammation

Answer 285

Hepatitis B infection

Answer 286

Annual incidence of small vessel vasculitis is 􏰄1 in 10000 | TA is more common in Japanese young females, PAN may affect any age (M:F is 2 : 1)

Answer 287

Constitutional symptoms (whole body): malaise, fever, arthralgia, myalgia- may develop these months before specific signs - The large vessel vasculitides have classical clinical patterns resulting from the vessels affected - Medium and small vessel vasculitides are characterized by multiorgan involvement with less specific clinical features

Answer 288

Headache and tenderness (GCA) Visual changes Upper extremity or jaw claudication Asymmetric brachial pulses

Answer 289

General: Fever, night sweats, malaise, weight loss Skin: Rash (vasculitic, purpuric, maculopapular) Joint: Arthralgia or arthritis GI: Abdominal pain, haemorrhage from mucosal ulceration, diarrhoea Kidney: Glomerulonephritis, renal failure Lung: Dyspnoea, cough, chest pain, haemoptysis, lung haemorrhage CVS: Pericarditis, coronary arteritis, myocarditis, heart failure, arrhythmias CNS: Mononeuritis multiplex, infarctions, meningeal involvement Eyes: Retinal haemorrhage, cotton wool spots

Answer 290

``` Constitutional upset Head or neck pain Tenderness over affected arteries (aorta and the major branches) Dizziness and fainting Reduced peripheral pulses Hypertension ```

Answer 291

``` Microaneurysms Thrombosis Infarctions (e.g. causing GI perforations) Hypertension Testicular pain ```

Answer 292

``` Granulomatous vasculitis of upper and lower respiratory tract Nasal discharge Ulceration and deformity Haemoptysis Sinusitis Corneal thinning Glomerulonephritis ```

Answer 293

Asthma | Eosinophilia

Answer 294

Non-specific with multiple organs affected | Glomerulonephritis with no glomerular Ig deposits

Answer 295

Bloods: FBC (normocytic anaemia, raised platelets, raised neutrophils), raised ESR/CRP, elevated urea and creatinine (glomerulonephritis) Autoantibodies: *anti-neutrophil cytoplasmic autoantibodies (ANCA) Urine: Haematuria, proteinuria. Red cell casts CXR: Diffuse, nodular or flitting shadows. Atelectasia (collapse of lung tissue with loss of volume) Biopsy: Renal, lung (transbronchial), temporal artery (in GCA) Angiography: To identify aneurysms (in PAN)

Answer 296

Chickenpox (primary infection): - Children: Treat symptoms (calamine lotion, analgesia, antihistamines) - Adults: Consider acyclovir if within 24 h of rash onset especially if elderly, smoker, immunocompromised or pregnant (especially second or third trimester) Shingles (reactivation): - Aciclovir, valaciclovir or famciclovir if within 72 h of appearance of the rash if elderly, immunocompromised or ophthalmic involvement. - Low-dose amitriptyline may benefit those with moderate/severe discomfort - Simple analgesia (paracetamol) Prevention: - VZIG(immunoglobulin blood product that is offered to individuals at high risk of severe chickenpox) may be indicated in the immunosuppressed and in pregnant women exposed to varicella zoster - Chickenpox vaccine is licensed in the United Kingdom, but no guidelines available for appropriate use

Answer 297

Chickenpox: - Secondary infection e.g. Pneumonia, encephalitis, cerebellar syndrome, congenital varicella syndrome - Scarring Shingles: - Postherpetic neuralgia - Zoster opthalmicus (rash involves opthalmic division of trigeminal nerve) - Ramsay Hunts syndrome (bilateral facial weakness) - Sacral zoster may lead to urinary retention - Motor zoster (muscle weakness of myotome at similar level as involved dermatome)

Answer 298

Depends on the complications | Worse in pregnancy, the elderly and immunocompromised

Answer 299

An infection with the RNA viruses, hepatitis A (HAV) or hepatitis E virus (HEV), that is not associated with chronic liver disease

Answer 300

Both are small non-enveloped single-stranded linear RNA viruses of 􏰀7500 nucleotides, with transmission by the faecal–oral route Both viruses replicate in hepatocytes and are secreted into bile (resistant to bile lysis due to lack of a lipid envelope) Liver inflammation and hepatocyte necrosis is caused by the immune response, with targeting of infected cells by CD8+ T cells and natural killer cells Transmitted via close contact with an infected person or by contact with contaminated food or water products

Answer 301

HAV is endemic in Asia, Africa and Central America, infection often occurs sub-clinically In the developed world, better sanitation means that seroprevalence is lower, age of exposure is older and hence is more likely to be symptomatic

Answer 302

Incubation period for HAV or HEV is 3–6 weeks Prodromal period: -Malaise, anorexia (distaste for cigarettes in smokers), fever, nausea and vomiting Hepatitis: -Prodrome followed by dark urine, pale stools and jaundice lasting 􏰀3 weeks -Occasionally, itching and jaundice last several weeks in HAV infection (owing to cholestatic hepatitis)

Answer 303

Pyrexia Jaundice Tender hepatomegaly- spleen may be palpable (20%) *Absence of stigmata of chronic liver disease, although a few spider naevi may appear, transiently

Answer 304

Bloods: -LFTs: SIGNIFCANTLY ELEVATED AST and ALT, raised bilirubin, raised AlkPhos) -Elevated ESR -In severe cases, reduced albumin and elevated platelets Viral serology: -Hepatitis A: Anti-HAV IgM (during acute illness, disappearing after 3–5 months) -Anti-HAV IgG (recovery phase and lifelong persistence) -Hepatitis E: Anti-HEV IgM (" 1–4 weeks after onset of illness) -Anti-HEV IgG. Hepatitis B and C viral serology is also necessary to rule out these infections Urinalysis: Positive for bilirubin, raised urobilinogen

Answer 305

No specific management but there is post prophylactic exposure: -Active or passive immunisation is available for protection following exposure to hepatitis A virus Bed rest and symptomatic treatment (e.g. antipyretics, antiemetics) Colestyramine for severe pruritus

Answer 306

Public health: -Safe water -Sanitation -Food hygiene standards *Both are notifiable diseases -Personal hygiene and sensible dietary precautions when travelling Immunization (HAV only): -Passive immunization with IM human immunoglobulin is only effective for a short period -Active immunization with attenuated HAV vaccine offers safe and effective immunity for those travelling to endemic areas, high-risk individuals (e.g. residents of institutions)

Answer 307

Fulminant hepatic failure develops in 0.1% cases of HAV, 1 or 2% of HEV but up to 20% in pregnant women Cholestatic hepatitis with prolonged jaundice and pruritus may develop after HAV infection Post-hepatitis syndrome: Continued malaise for weeks to months

Answer 308

Recovery is usual within 3–6 weeks Occasionally, a relapse during recovery There are no chronic sequelae *Fulminant hepatic failure carries an 80% mortality (greater risk in pregnant women)

Infection and Immunology Flashcards

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