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Infection/Immunology Flashcards

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1
Q

What proportion of cases of meningitis are viral?

What is the incidence of meningococcaemia?

A

2/3rds

Incidence meningococcaemia 0.7-1.4 in 100,000

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2
Q

How is meningococcus transmitted?

A

Large % have nasal/resp tract carriage

Transmitted via aerosol / nasopharyngeal secretion

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3
Q

What are the main virulence factors of meningococcus?

A

Polysaccharide capsule
Lipo-oligosachharide endotoxin (mediates invasion)
Immunoglobulin A1 protease (help org survive intracell)

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4
Q

At what ages are the Men C vaccine given?

A

3m, 4m + 1yr

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5
Q

Describe the physiology behind meningococcus effect on meninges/brain

A

Inflamm mediators + leucocytes → endothelial damage

→ Cerebral oedema
→ Raised ICP
→ Reduced cerebral blood flow

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6
Q

What are the main causative organisms of meningitis in:
Neonates (3)
1m-6yrs (3)
6yrs+ (2)

A

Neonates: GrpB Strep, E.Coli, Listeria

1m-6yrs: N.Meningitidis, S.pneumoniae, H.influenzae

6yrs+: N.Meningitidis, S.Pneumoniae

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7
Q

List some possible symptoms of bacterial meningitis in neonates (8)

A

NB more non-specific

Hyperthermia
Vomiting
Seizures
Bulging fontanelle

Irritability
Altered sleeping/eating
High pitched cry
Quiet child at rest but cries when moved/comforted

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8
Q

List some possible symptoms of meningitis in 3m-2yrs (5)

+ in >2-3yrs

A

NB more bact-associated

Vomiting
Fever

Irritability
Lethargy
Change in behaviour

In >2-3y/o: above + meningism (headache, stiff neck, photophobia)

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9
Q

What % of meningococcal meningitis get the rash?

Describe the rash (site + form)

A

Common: 50-80%

Axilla/flank/wrists/ankles
Non-blanching petechial rash (due to vasculitis)
Irregular in size
Necrotic centre

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10
Q

What other conditions to meningitis may exhibit neck stiffness? (2)

A

Tonsillitis

Cervical lymphadenopathy

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11
Q

What viruses may cause meningitis? (4)

A

Enteroviruses
Adenoviruses
Mumps
Epstein-Barr

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12
Q

What signs may be seen O/E in meningitis? (4)

A

Petechial rash (meningococcal)
Opisthotonus (arched back: raised ICP)
+ve Brudzinski (neck flexion supine → knee/hip flexion)
+ve Kernig (hip flex /knee extension supine → back pain)

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13
Q

What are the 4 element features of septicaemia?

A

Capillary leak: severe hypovol

Coagulopathy: bleed tendency + thrombosis in microvasc

Metabolic derangement: acidosis + hypokal/cal/mag/phos

Myocardial failure: direct damage from inflamm meds (func impaired even after circ vol/metab abns restored)

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14
Q

What signs may be seen on cardiac examination with septicaemia? (3)

A

Raised CVP
Hepatomegaly
Gallop rhythm

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15
Q

What are the features of meningococcal septicaemia? (10)

A

Fever
Vomiting
Headache
Rash (erythematous → petech/purpuric)

Hypotension
Tachycardia/pnoea
Cool extremities
Initially normal consciousness level

Myalgia
Abdo pain

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16
Q

What is the difference b/wn meningococcal septicaemia + meningococcal meningitis?

A

Septicaemia: pts present with shock
Meningitis: pts mainly present with raised ICP

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17
Q

List some DDx for meningococcal septicaemia (6)

A 
Sepsis
Febrile convulsions
Measles/mumps
ITP
HSP
Reye's syndrome (rapid encephalopathy from aspirin)
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18
Q

What is the immediate management of any child with a fever + purpuric rash?

A

Immediate IM benzylpenicillin + urgent transfer to hospital

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19
Q

What is the commonest pathogenic cause of sepsis in children?

A

Meningococcus

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20
Q

What Ix should be done if suspect meningococcal septicaemia? (11)

A 
FBC
Coag screen
U+Es
LFTs
Blood gases
Blood glucose

LP
Cultures: urine/blood/throat/stool
Rapid antigen test (for meningitis orgs)
CXR (if suspect TB)
Consider CT/MRI + EEG
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21
Q

Describe the management of meningococcal septicaemia (6)

A

Empirical broad spec Abx (depends on likely pathogen - usually 3rd gen cephalo like ceftriaxone/cefotaxime)

CVP
Catheterisation
Mechanical ventilation
Iotropic support (for myocardial contractility)
FFP + Platelets → correct any DIC (widespread microvasc thrombosis)

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22
Q

As well as Abx, what other drug must be given in meningococcal septicaemia for neonates?

A

Abx + Dexamethasone (reduce risk of long-term complications e.g. deafness)

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23
Q

What prophylaxis is given for household contacts of meningococcemia?

A

Rifampicin (eradicate nasopharyngeal carriage)

Men C vaccine

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24
Q

What is the mortality rate of meningococcaemia?

What is the incidence of serious complications?

A

15-20% neonates
5% risk in childen older than this

10-15% will have focal neuro sequelae

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25
What are the possible complications on the nervous system of meningococcaemia? (9)
Hearing loss Visual field defects Facial palsy Local vasculitis → CN palsy/ other focal lesion Hemiparesis ``` Hydrocephalus Subdural effusion (pneumococcal + HiB) ``` Epilepsy (local cerebral infarct → multi/focal seizures) Cerebral abscess
26
What are the other (not CNS) complications of meningococcaemia (6)
Bacterial endocarditis Pericarditis DIC Thrombocytopenia Septic arthritis Gangrene
27
What may be the underlying cause in pts with recurrent meningococcaemia?
Underlying immune deficits | 30% recurrent meningococcaemia have complement defc
28
What are the poss causative organisms for neonatal early onset sepsis (4) + neonatal late onset sepsis (7)
Early (from birth canal): GrpB Strep / E.Coli / Listeria / H.Influenzae ``` Late (from environment): Staph epidermidis Staph aureus E.Coli / Enterococci / Klebsiella / Pseudomonas Candida ```
29
What are the 2 main 'at risk' groups for septicaemia + common associated pathogens?
Immunodeficient: pneumococcus | Chronic resp illness: pseudomonas
30
Describe the physiology behind Shock
= Inadequate substrate/oxygen delivery → anaerobic → lactic acid accum → Cannot maintain homeostasis → disrupt ion pumps → intracellular Na influx / K efflux → Cells swell / memb breakdown / cell death → Multiorgan failure
31
What are the 3 main features in which you should assume shock?
Prolonged CRT Tachycardia Cool extremities
32
What are some early (compensated) features of shock (8)
``` Tachycardia Tachypnoea CRT > 2s Core-peripheral temp gap >4 degrees Pale/cold/mottled skin ``` Sunken eyes/fontanelle Reduced skin turgor Reduced urine output
33
What is the physiological mechanisms behind early/compensated shock
BP maintained by increased HR/RR | Blood diversion from non-essentials e.g. skin
34
What are some late (decompensated) features of shock (6)
Acidotic breathing (Kussmaul) Bradycardia Blue peripheries Hypotensive Confusion/reduced consciousness Anuria
35
What empirical Abx for sepsis are given in neonates? | + in older infants / older children?
Neonates: ampicillin + gentamicin/3rd gen cephalo Older: 3rd gen cephalo
36
Outline the management of shock (9)
BLS Abx High-flow O2 Volume replacement (20ml/kg) Intubation/ventilation (if still shocked after 2x VR - even if still alert) Correction of acidosis Correction of elec abns Correct coagulopathy → FFP Correct anaemia → blood
37
How is management of fluid resuscitation different depending on whether responsive to initial volume replacement
Responsive: monitor/reassess for further shock/pulm oedema Unresponsive: further VR (may have 2x bolus) + poss ionotropic support + poss adrenaline
38
Describe Type 1 Hypersensitivity reaction: initial + subsequent
Initial: allergen → antigen-presenting cell → Thelper → B cells (with IgE-bound) Thelper cells produce cytokines → B cells prolif → plasma cells (IgE producing) IgE → mast cells (now sensitised) Subsequent: allergen → mast cell IgE → Inflamm mediator release (preformed e.g. histamine + arachidonic acid derived) → Vasodilation / SM contraction → Small vessel permeability → Mucus secretion
39
What Ix may be done into allergies? (4)
Detailed clinical Hx Hypersensitivity marker bloods Patch testing (cutaneous allergens) Stimulus introduced in controlled conditions
40
What other condition is assoc w. eczema in young infants? | What conditions assoc w. allergic rhino-conjunctivitis? (4)
Link b/wn eczema + food allergy (esp egg) Eczema, sinusitis, adenoidal hypertrophy, asthma
41
Define effects of mild/moderate/severe insect sting hypersensitivity
Mild → local swelling Moderate → generalised urticaria Severe → systemic symps with wheeze/shock
42
What types/drugs are commoner for allergic reaction? (6)
``` Antibiotics (penicillins/cephalosporins) Anaesthetics (lidocaine) Analgesics (aspirin, NSAIDs) Dextran (anticoag) Opiates Radiocontrast media ```
43
What are the short-term risks in HIV infection (2) | What are the long-term risks (6)
Opportunistic infections Pancytopenia (thrombi/anaemia/neutropenia) ``` Non-compliance Transmission Failure to thrive Cancers (Kaposi's sarcoma, Non-Hodgkins) Neuropathy/myelopathy HIV encephalopathy ```
44
What is EBV infection characterised by? (4)
1-2wks H/o malaise/fatigue (persisting fatigue) Pharyngitis Generalised lymphadenopathy Hepatosplenomegaly
45
List the possible symptoms that may be seen in EBV/Glandular fever (6)
``` Fever (>90%) Sore throat Headache Nausea Myalgia Abdo pain ```
46
List some possible complications of EBV infection (10) | Harry Tries Justifying His Stupid 'Necessities' + Unrealistic Costly Recreational Plans
``` Hepatitis (90%) Thrombocytopenia (mild) (50%) Jaundice (5%) Haemolytic anaemia Splenic rupture (req splenectomy) Neuro complications (coma/meningitis/enceph/CN palsy) Upper airway obstrn Chronic fatigue syndrome Reye syndrome Peri/myocarditis ```
47
What is Kawasaki disease | What age group does it affect?
Rare type vasculitis of medium-sized blood vessels | Affects <5yrs
48
How may Kawasaki disease present? | What are the Dx criteria? (6)
Severe fever unresponsive to meds + viral-like symps Temp ≥38 for >5d plus at least 2 of: Rash Cervical lymphadenopathy Conjunctivitis (bilateral) Oral/throat changes (cracked lips/strawberry tongue) Arm/leg skin changes (swelling/red/peeling)
49
How long spent in acute/sub-acute/convalescent phase of Kawasaki disease?
Acute (Weeks 1-2) Sub-acute (Weeks 3-4) (less severe symps) Convalascent (weeks 4-6) (lethargy persists)
50
List the symptoms that may be seen in the sub-acute phase of Kawasaki disease (8)
``` Lethargy Headache Joint pain Peeling skin Abdo pain Jaundice D+V Pyuria ```
51
In what phase of Kawasaki disease are complications most likely to happen? What is the main concerning complication involved with mortality? What is the mortality rate of Kawasaki disease?
Sub-acute phase: Coronary aneurysms likely to develop (in 1/3rd pts) → MI / Sudden death Mortality 1-2%
52
What Ix can be done into Kawasaki disease? (4) | How is it Dx?
CRP/ESR (raised) WCC (raised) Platelets (raised - in 2nd wk) ECHO (for aneurysm) Clinical Dx
53
Describe the management of Kawasaki disease (4)
Prompt IVIG (+ infliximab/steroids/ciclosporin if persistent) Aspirin: high dose until fever/inflamm markers normal + low-dose until normal ECHO Antiplatelets (if platelets high) Long term warfarin (if large aneurysm)
54
List some possible non-deliberate causes of immunosuppression (5)
Malnutrition Ageing Certain cancers (leukaemia/lymphoma/multi-myeloma) AIDS Drug side effect (treating other condition)
55
List/catagorise the different causes of immunodeficiency (1+7)
Primary (uncommon): inherited / autosomal recessive ``` Secondary: Intercurrent viral/bacterial HIV Malignancy Malnutrition Immunosuppressants Splenectomy Nephrotic syndrome ```
56
What is immunodeficiency characterised by?
SPUR infections: | Serious / Persistent / Unusual / Recurrent
57
List some diff T cell defect conditions (6)
``` Severe Combined Immunodefc (SCID) (inheritable) HIV (progressive defc) DiGeorge syndrome (absent thymus) Duncan syndrome (abnormal EBV response) Wiskott-Aldrich (triad w. thrombocytopenia/eczema) Ataxia Telangiectasia (DNA repair defect) ```
58
List some diff B cell defect conditions (4)
Selective IgA defc (commonest) X-linked agammglobulinaemia (abnorm tyrosine kinase - for B cell maturation) Common Variable Immunodefc (CVID) - B cell defc (high risk autoimmune + malignancy) Hyper IgM syndrome (B cells make IgM but cannot switch it →IgG/A)
59
How do T cell defects present? (5)
``` In 1st 3m Severe/unusual viral/fungals Failure to thrive Severe bronch/diarrhoea/oral thrush PCP ```
60
How do B cell defects present? (4)
In 1st 2yrs (beyond infancy due to passive immunity) Failure to thrive Severe bacterial infections (ear/sinus/skin/pulm) Complications of recur rents (bronchiectasis/hearing loss)
61
How do neutrophil defects present (5)
``` Recurrent bacterial infections Abscesses Poor wound healing Invasive fungals e.g. aspergilliosis Granulomas (from chronic inflamm) ```
62
Give an example of neutrophil defect
Chronic granulomatous disease | X-linked recessive phagocytosis defect
63
How do leucocyte function defects present? (4)
Delayed umbilical cord separation Delayed wound healing Chronic skin ulcers Deep seating infections
64
Give an example of leucocyte function defect
Leucocyte Adhesion Defect (LAD) | Inability for neutrophils to migrate to inf/inflamm site
65
How do complement defects present? (2)
Recurrent bacterial + meningococcal infections | SLE-like illness
66
Give 3 examples of complement defect conditions
Early complement component defc Terminal complement component defc Mannose-binding lectin (MBL) defc
67
What are the 5 options for prevention/treating infections in immunodefc? (PIGS in Bs)
Antimicrobial prophylaxis: T-cell/neutrophil → co-trimox (PCP) / antifungals B-cell → Abx (azithromycin) Ig replacement Gene therapy (certain types SCID) Screen for end-organ disease Bone marrow transplant
68
What pathogens may cause typhoid fever? (2) | What is the route of transmission
Salmonella thyphi Parathyphi infection Via contaminated food/water
69
What are the clinical features of typhoid fever? (10)
``` Worsening fever Malaise/myalgia Headache Cough Bradycardia ``` Abdo pain GI symps (2nd wk) Anorexia Splenomegaly Rose spots**
70
What are the poss complications of typhoid fever? (4)
GI perforation Myocarditis Nephritis Hepatitis
71
What age children are affected worse by malaria? | What % of child deaths?
6m-5yrs | Where endemic = 10% all child deaths
72
What are the clinical features of malaria
``` Fever Thrombocytopenia Anaemia Jaundice D+V Flu-like symptoms ```
73
What happens in cerebral malaria? | What are the main features (2)
``` Rapid encephalopathy (occurs in 20-50% pts) from parasites adhering to cerebral microvasc (→ ischaemia/blockage) ``` Raised ICP Seizures

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