Infections and Immunity Flashcards
(193 cards)
1
Q
In paediatrics, what is pyrexia?
A
A temperature of 38 degrees celsius
2
Q
In infants of under 3 months, a fever of what is a red flag feature?
A
38 degrees
3
Q
In children 3-6 months old, a fever of over what is an amber flag feature?
A
39 degrees
4
Q
What is the recommended method of taking a temperature in babies/children?
A
A thermometer probe in the axilla/tympanic
severe hypothermia need to know a core temperature - indicates for a rectal thermometer
5
Q
Why does fever matter? (5)
A
- May indicate a severe infective cause
- Fever is the body’s way of trying to reduce pathogens
- Febrile convulsions
- Dehydration
- Rigors
6
Q
What % of children attending hospital have a fever?
A
20% - very few have sepsis
7
Q
What is a febrile convulsion?
A
- A febrile convulsion is caused by a rapid rise in temperature, usually at the beginning of an infection
- Unconscious
- Generalised tonic clonic seizure
- In children 6 months to 6 years
- beyond 6 years this is not often seen - Sleepy afterwards (post-ictal)
- Typical or atypical
8
Q
What % of children have febrile convulsions?
A
2-5%
9
Q
What is a rigor?
A
- Conscious levels are not affected with rigors - they should remain alert
- Shivering vigorously due to hot core temperature
- Any age
- Not usually sleepy afterwards
- May go blue around lips, hands, legs
10
Q
What duration of febrile convulsion is classed as typical as opposed to atypical?
A
Up to 15 minutes is typical
11
Q
What other features of febrile convulsions are classed as atypical? (3)
A
- Duration >15 minutes
- More than one in the same illness
- Focal signs or symptoms (e.g. right sided fit, or abnormal neurology on examination - residual weakness, Todd’s paralysis)
12
Q
Why is it important to determine in febrile convulsions are typical or atypical?
A
Atypical febrile convulsions indicate a higher risk of epilepsy
13
Q
What is the risk for developing epilepsy in the normal population?
A
1%
14
Q
What are the risk factors for developing epilepsy? (3)
A
- Atypical febrile seizures
- Abnormal neurology/neurodevelopment prior to event
- Family history of 1st degree relative with epilepsy
15
Q
What is the % risk of epilepsy in someone with two or more risk factors?
A
10%
16
Q
What is the % risk of having another simple febrile convulsion after experiencing one?
A
30%
17
Q
What/which antipyretics work?
A
Stay hydrated, paracetamol/ibuprofen, cool room
Sponge/cool cloth, wrapping up warm, ice baths do not work
18
Q
What are the NICE guidelines for children with pyrexia with no symptoms?
A
They do not need paracetamol/ibuprofen
19
Q
If the child has a fever with symptoms, what can be given?
A
Calpol/nurofen
20
Q
Do paracetamol/ibuprofen work in children with febrile convulsions?
A
There is no evidence to suggest they work in febrile convulsions
21
Q
What are the causes of fever in children? (13 - think systems)
A
- Viral URTI
- LRTI/pneumonia (viral or bacterial)
- Otitis media
- Viral gastroenteritis
- Tonsilitis
- Chicken pox
- Appendicitis
- UTIs
- Osteomyelitis
- Unknown - PUO
- Meningitis
- Kawasaki’s
- Others - malignancy, rheumatological
22
Q
What signs/symptoms/observations are worrying in a child with fever? How may they look unwell? (15)
A
- Pale/mottled/ashen/blue
- No response to social cues
- Appears ill
- Does not wake
- Weak, high-pitched or continuous cry
- Grunting
- Recessions
- Reduced skin turgor
- Temp >38 if 0-2 months
- Non-blanching rash
- Neck stiffness
- Bonding fontanelle (up until 12 months)
- Focal seizures
- Status epilepticus
- Tachypnoea
23
Q
What is Kawasaki’s disease/how is it diagnosed?
A
Fever - at least 5 days in duration
In the presence of 4 of:
1. Changes in extremities (desquamation (peeling of the skin), erythema, oedema)
2. Bilateral conjunctivitis (non purulent)
3. Rash
4. Cervical lympadenopathy
5. Changes in lips/oropharynx/cracked lips/strawberry tongue
24
Q
Why is it important not to miss Kawasaki’s?
A
It causes a vasculitis, with a risk of cardiac aneurysms
25
What is a differential diagnosis for Kawasaki's?
Scarlett fever
26
What is the treatment for Kawasaki's?
High dose aspirin
| IV immunoglobulins
27
What are the causes of a non-blanching rash?
1. Meningitis
| 2. Meningococcal septicaemia
28
What are the signs/symptoms of meningitis? (2)
1. Photophobia
2. Neck stiffness
(unlikely to have a rash)
29
What is the specific sign/symptoms that distinguishes meningitis from meningococcal septicaemia?
A rapidly spreading purpuric rash
| may or may not also have meningitis
30
What is the treatment for meningitis/meningococcal septicaemia?
IM penicillin V
31
What causes a non-blanching rash? - what is it?
Blood under the skin - does not disappear when pressed and looks dark red/purple
32
What is the difference between a petechial spot and purpura?
The size is the difference; purpura is larger (2mm - 10mm) in size whereas petechiae is a pin prick size (up to 2mm)
33
What is ecchymosis?
Greater than 10mm in size
34
What are the other causes of purpura?
1. Bleeding/clotting disorders -
TTP/ITP (thrombocytopenic purpura)
2. Henoch-Schönlein purpura (these children will otherwise be completely well, compared to meningococcal septicaemia)
35
A 3 week old baby girl with a temperature of 39 degrees, crying and irritable and feels hot. What is the immediate assessment?
The baby has a bulging fontanelle, a cap refill of 4 seconds, a heart rate of 180/min, a low blood pressure and is mottled. What are the differentials?
ABCDE
- Meningitis (infants are believed to have a less effective blood brain barrier, therefore infections are more likely to cause meningitis)
36
What septic screen should be done in a child with suspected meningitis?
1. Clean catch urine sample
2. CXR
3. Blood cultures
4. LP - if well enough to tolerate (contraindicated if multiple signs of raised ICP)
5. Viral nose swabs
6. Clotting - fear of sepsis/DIC
37
What is Kernig's sign?
Flexion of the knee and then start extending - if it causes pain in the hamstring
38
What can a raised red cell count in CSF indicate?
A sub-arachnoid haemorrhage
39
What is brudinski's sign?
Flex the neck and there will be flexion of the hip/knee
40
How do causes of meningitis differ between neonates and children?
```
The causes of meningitis in neonates are most commonly:
1. E.coli
2. Group B strep
3. Listeria
The causes of meningitis in children are:
1. Viral
2. Meningococcal
3. Pneumococcal
4. TB (very rare)
```
41
What is the difference in treatment of bacterial meningitis between neonates and children in terms of NICE recommendations?
In older children with steroids - dexamethasone
42
What are the normal findings of neutrophils and lymphocytes in CSF results of neonates and babies >1 month old?
0 neutrophils for both
<5 in greater than 1 month old
<11 in neonates
43
What are the complications of untreated meningitis? (4)
1. Cerebral palsy in <2 years
2. Deafness
3. Epilepsy
4. Coning and death
44
What are the risk factors for sepsis in a birth history?
Prolonged labour
Prolonged pre-rupture of membranes
Maternal pyrexia
Group B strep
45
Who receives prophylaxis for a baby with meningitis/meningococcal septicaemia?
Any one who has kissed the baby / close contact
46
What are the differentials for a child with a fever and a rash? (9)
1. Measles
2. Rubella
3. Scarlet fever
4. Hand, foot and mouth disease
5. Chicken pox
6. Meningococcaemia
7. Kawasaki's
8. Fifth disease
9. Roseola
47
What are the differentials for a child with an acute fever? (9)
1. URTI
2. Tonsilitis
3. Otitis media
4. Nonspecific viral infections
5. Pneumonia
6. Meningitis
7. UTIs
8. Septic arthritis
9. Non-infectious causes
48
What are the differentials for a fever with a swelling in the neck?
1. Cervical adenitis
2. Infectious mononucleosis
3. Mumps
4. Thyroiditis (often no fever)
5. Mastoiditis
49
What are the three 'C's (symptoms) associated with measles?
Coryza
Conjunctivitis
Cough
50
What is the differential diagnosis with suspected tonsillitis?
Infectious mononucleosis (glandular fever)
51
How does glandular fever present?
1. Marked cervical lymphadenopathy
2. Fever
3. Sore throat
4. Enlarged purulent tonsils
5. Macular rash in 10-20% of cases
6. Splenomegaly can be commonly found
52
How is glandular fever investigated?
1. FBC with differential white cell count - if the FBC has more than 20% atypical or reactive lymphocytes
2. Monospot test (in the second week of the illness)
53
How is glandular fever different to tonsillitis in terms of the sore throat?
Glandular fever is usually more severe, lasting longer and up to 60% will have palatal petechiae, with a 'whitewash' exudate on the tonsils
54
How are children under the age of 12 investigated for glandular fever?
Instead of the FBC look at the white cell count, arrange blood tests for Epstein-Barr viral serology after the child has been ill for at least 7 days
55
In addition to a FBC, serology and Monospot test, what other blood test can be performed in suspected glandular fever and will show elevations 2-3 times the upper limit of normal?
LFTs - aspartate aminotransferase (AST) and alanine aminotransferase (ALT) will be elevated
56
What type of lymphadenopathy is most common in glandular fever?
Posterior cervical lymphadenopathy
57
What is the management for glandular fever?
- Paracetamol and ibuprofen
- Limit spread of the disease: avoid kissing, sharing eating or drinking utensils
- Avoid contact sports/heavy lifting to reduce the risk of splenic rupture
58
Which immunisations are given at 8 weeks old? (4 - but 1 of those covers 6 infections)
1. Diphtheria, tetanus, pertussis, polio, haemophilus influenzae type B (Hib) and hep B
2. Pneumococcal
3. Meningococcal group B
4. Rotavirus gastroenteritis
59
What is the name of the vaccines given at 8 weeks old? (4)
1. Infranix hexa (6 infections covered - DTaP/IPV/Hib/HepB
2. Prevenar 13 (Pneumococcal)
3. Bexsero (MenB)
4. Rotarix (Rotavirus)
60
Where are the 8 week old immunisations given- which site? (4)
1. Diphtheria, tetanus, polio etc - thigh
2. Pneumococcal - thigh
3. MenB - left thigh
4. Rotavirus - by mouth
61
At 12 weeks old, which two immunisations are given?
1. Diphtheria, tetanus, pertussis, polio, Hib, hep B
2. Rotavirus
(both same name, same site)
62
At 16 weeks old, which three immunisations are given?
1. Diphtheria, polio, tetanus, pertissus, Hib, hep B
2. Pneumococcal
3. MenB
63
Which immunisation is given in the left thigh (trade name too)?
Meningococcal group B - Bexsero
64
At 12 months old or just after their first birthday, which immunisations are given? (4)
1. Hib and MenC
2. Pneumococcal
3. MMR
4. Men B
65
What is the trade name for MMR and where is the site of administration?
Priorix - upper arm or thigh
66
At three years, four months old, which immunisations are given? (2)
1. Diphtheria, tetanus, pertussis and polio
| 2. MMR
67
In girls aged 12 to 13 years, which immunisation is given?
HPV vaccine known as Gardasil
68
At 14 years old, which immunisations are given? (2)
1. Diphtheria, tetanus and polio
| 2. Meningococcal disease
69
In babies born with parents or grandparents from a country of high incidence of TB, which immunisation is given?
BCG
70
What is meningitis?
A condition caused by inflammation of the meninges (the outer membranes covering the brain and spinal cord)
71
How is meningitis different to encephalitis?
Encephalitis is the inflammation of the brain tissues itself
72
What does meningococcal disease refer to?
This term refers to either meningococcal meningitis or meningococcal septicaemia
73
What are the top 3 common causes of bacterial meningitis in children aged 3 months and over, and adults too?
1. Neisseria meningitidis
2. Streptococcus pneumoniae
3. Haemophilus influenzae type B (HiB)
(NHS)
74
In neonates, what are the most common causative organisms of meningitis? (4)
1. Streptococcus agalactiae
2. E.coli
3. Strep. pneumoniae
4. Listeria monocytogenes
75
What are the clinical features of meningococcal septicaemia?
There is often a short coryza prodrome, followed by fever, malaise, and the development of a purpuric rash/petechial lesions.
76
What are the signs that are specific to meningitis but not meningococcal septicaemia? (6)
1. Photophobia
2. Kernig's sign
3. Brudzinski's sign
4. Paresis
5. Seizures
6. Focal neurological deficit including cranial nerve involvement and abnormal pupils
77
What is Kernig's sign?
Severe stiffness of the hamstrings - when the hip is flexed at 90 degrees, the leg cannot straight
78
What is Brudzinski's sign?
When lying supine, flexion of the neck consequently causes hip and knee flexion
79
What are the classical signs of meningitis that are often absent in infants with bacterial meningitis? (3)
1. Neck stiffness
2. Bulging fontanelle
3. High-pitched cry
80
What are the non-specific symptoms that children with meningitis commonly present with?
1. Fever
2. Vomiting
3. Irritability
4. Upper respiratory tract symptoms
81
As well as presenting symptoms, what are factors are important to take into consideration when querying meningitis?
1. Level of parental/carer concern
2. How quickly the illness is progressing
3. Clinical judgement of the overall severity of the illness
82
What is classed as meningococcal disease?
Either meningitis with a non-blanching rash OR meningococcal septicaemia
83
In primary care, which drug can be given to someone with suspected meningococcal disease?
IM or IV benzylpenicillin (the only contraindication to this is a clear history of anaphylaxis after a previous dose; a history of rash following penicillin is not a contraindication)
84
In secondary care, what is the treatment for a child with a petechial rash with symptoms/signs of meningococcal disease?
IV ceftriaxone
85
If a child has a petechial rash with fever, but the diagnosis of meningococcal disease is questionable, which investigations should be carried out? (8)
1. FBC
2. CRP
3. Coagulation screen
4. Blood culture
5. PCR for N meningitidis
6. Blood glucose
7. Blood gas
8. Lumbar puncture
86
What are the early signs/symptoms of meningococcal septicaemia? (4)
1. Leg pain
2. Skin mottling
3. Cold peripheries
4. Breathing difficulties
87
When does the haemorrhagic rash characteristic with septicaemia tend to appear?
Tends to present later in the illness, >12 hours
88
What are the late presentations of septicaemia? (3)
1. Confusion
2. Seizures
3. Coma
89
What are the early complications of meningococcal septicaemia?
1. DIC
2. AKI
3. Adrenal haemorrhage
4. Circulatory collapse
90
What are the late complications of meningococcal septicaemia?
1. Deafness
2. Renal failure
3. Scarring
4. Limb amputations (10%)
(mortality is highest in neonates - they don't have any reserves)
91
What is the other name for infectious mononucleosis and what causes it?
Glandular fever, it is caused b the Epstein-Barr virus (a member of the herpes virus family)
92
How is glandular fever spread?
Through contact with saliva, so via kissing, sharing food or drink utensils and children chewing on toys that have been contaminated
93
At what age range do people typically present with acute glandular fever?
15 - 24 years
94
What % of children with have detectable EBV antibodies by age 5?
50%
95
What % of people with have EBV antibodies by 25 years old?
90%
| most these people with have had asymptomatic or subclinical infection
96
Although rare, what are the respiratory complications of glandular fever (infective mononucleosis)?
Upper airway obstruction - due to gross enlargement of tonsils or a peritonsilar abscess (quinsy)
97
What are the neurological complications of glandular fever? (5)
1. Encephalitis/aseptic meningitis
2. Facial nerve palsy
3. Guillain-Barre syndrome
4. Brachial plexus neuropathy
5. Hemiplegia
98
What are the haematological complications of glandular fever? (3)
1. Mild thrombocytopenia (25-50%)
2. Mild neutropenia (common and self-limiting, however if it is severe neutropenia this can lead to neutropenic sepsis, pneumonia and death)
3. Autoimmune haemolytic anaemia
99
In 90% of people with glandular fever, what will the LFTs be like?
Abnormal - with AST (aspartate aminotransferase) and ALT (alanine aminotransferase) elevated to 2-3 times the upper limit of normal (typically this abnormality peaks at 2 weeks of the illness and normalises by 3-4 weeks)
100
What are the 3 main features of glandular fever?
1. Fever (90% of people)
2. Lymphadenopathy (100%) - typically posterior cervical lymphadenopathy (however can be anywhere including inguinal and axillary)
3. Sore throat (90%) - this is usually severe
101
What are the features of the sore throat in glandular fever? (3)
1. Tonsillar enlargement (91%) - the tonsils may meet in the midline
2. Whitewash exudate on the tonsils
3. Palatal petechiae (60%) (1-2mm diameter, crops lasting 3-4 days)
102
In addition to the three common presenting features, what are clinical features may support a diagnosis of glandular fever?
1. Prodromal symptoms such as general malaise, fatigue, myalgia, chills, sweats, anorexia, retro-orbital headache
2. Splenomegaly (up to 50%)
3. Hepatomegaly
4. Non-specific widespread rash that presents after being treated with amoxicillin
5. Jaundice
103
In children younger than 12, what is the investigation for suspected glandular fever?
Arrange blood tests for EBV viral serology after the person has been ill for 7 days
104
If the EBV viral serology comes back as negative, what other tests should be considered? (2)
1. Cytomegalovirus
| 2. Toxoplasmosis
105
In children over the age of 12, what are the investigations that should be carried out?
Arrange a FBC with differential WCC and a Monospot test in the second week of the illness
106
If there are clinical features of glandular fever but what EBV serology comes back as negative, what may be important to do?
Repeat the test 7 days later
107
What in the full blood count will indicate it is glandular fever?
If the FBC has more than 20% atypical or 'reactive' lymphocytes OR more than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total WCC
108
What are the differential diagnoses for glandular fever? (9)
1. Streptococcal sore throat
2. Leukaemia
3. CMV
4. Acute toxoplasmosis
5. Acute viral hepatitis
6. Primary HIV infection
7. Rubella
8. Roseola
9. Mumps
109
What are the differences in presenting features between glandular fever and strep. throat?
In streptococcal throat, lymphadenopathy is usually anterior as opposed to posterior.
Splenomegaly is not typical and fatigue is less prominent.
110
What is the management for glandular fever? (5)
1. Paracetamol/ibuprofen
2. Explain expected course of illness - 2-3 weeks, tiredness is common and lasts longer than other symptoms
3. Return to normal school/work and avoid kissing etc.
4. Avoid heavy contact sports or lifting due to risk of splenic rupture
5. Safety netting - seek urgent medical attention if develop stridor, have difficulty swallowing, become systemically unwell or have severe abdominal pain
111
What causes scarlet fever?
Streptococcus pyogenes (also known as group A streptococcus)
112
What age range is most common time for scarlet fever to occur?
2-8 years, with peak being 4 years of age
113
Scarlet fever is seasonal, when are most cases likely to occur?
In the winter and spring months
114
What are the characteristic clinical features of scarlet fever? (3)
1. Sore throat
2. Fever
3. Extensive, red, sandpaper-like rash
115
Although rare, what are the suppurative complications of scarlet fever? (7)
1. Otitis media
2. Throat infection
3. Acute sinusitis/mastoiditis
4. Streptococcal pneumonia
5. Meningitis cerebral abscess
6. Endocarditis, osteomyelitis, liver abscess
7. Necrotising fasciitis and streptococcal toxic shock syndrome
116
When are the suppurative complications of scarlet fever most likely to occur?
In the beginning of the illness
117
What is a food allergy?
A food allergy describes an adverse immune-mediated response, which occurs when a person is exposed to specific food allergens.
118
What are the different classes of food allergy?
1. IgE-mediated
2. Non-IgE-mediated
3. Mixed IgE and non-IgE-mediated
119
What happens with an IgE-mediated food allergy?
This follows exposure and sensitization to trigger food allergens with the development of serum-specific IgE antibody. It produces immediate and consistently reproducible symptoms which may affect multiple organs including the skin, GI tract, respiratory, CV and neurological systems.
120
What is a non-IgE-mediated food allergy?
Involves a cell-mediated mechanism, such as food protein-induced enterocolitis syndrome which tends to occur in young children and presents with GI symptoms such as vomiting with or without diarrhoea, abdominal cramps, colic and sometimes faltering growth
121
What is cows' milk protein allergy?
It is an immune-mediated allergic response to proteins in milk - milk contains casein and whey fractions, each of which have five protein components, and a person can be sensitized to one or more of these components.
122
What are the different classifications of cows' milk protein allergy?
1. IgE-mediated reactions
2. Non-IgE-mediated reactions
3. Mixed
123
How does an IgE-mediated cows' milk protein allergy present?
Reactions are acute and frequently have a rapid onset. They occur up to 2 hours after ingestion of cows' milk and most commonly within 20-30 minutes
124
How does a non-IgE-mediated cows' milk protein allergy present?
The reaction is generally delayed and non-acute. They manifest up to 48 hours or even 1 week after ingestion of cows' milk protein
125
What does food sensitization mean?
It describes the production of serum-specific IgE antibodies to food allergens, without the clinical symptoms of an allergic reaction on food exposure
126
What is a food intolerance?
It is a non-immune adverse reaction to food and/or food additives which are distinct from food allergy. They often present non-specifically with GI upset, headache, fatigue, and MSK symptoms. Typically there is a delay in symptom onset and a prolonged symptomatic phase. The cause is unknown but they may be due to enzyme deficiencies or pharmacological reactions to chemicals such as caffeine or tyramine.
127
What are the most common food allergens? (7)
1. Cows' milk
2. Hens' eggs
3. Peanuts and other legumes (soybean, pea and chickpea)
4. Tree nuts (walnuts, almonds, hazelnuts, pecan, cashews, pistachio, brazil nuts)
5. Crustacean shellfish and fish
6. Wheat
7. Celery, mustard, sesame, lupine, molluscan shellfish
128
What are the common raw food allergens for oral allergy syndrome?
1. Birch pollen - apple, pear, peach, plum, cherry, apricot, carrot, celery, parsley, almond, hazelnut
2. Timothy grass - swiss chard, orange
129
What is oral allergy syndrome?
AKA pollen-food syndrome, describes a localised food allergy which may occur due to cross-reactivity between aeroallergens, such as birch pollen, fresh vegetables, fruits and nuts
130
What are the risk factors for developing a food allergy? (4)
1. Presence of a known food allergy increases the likelihood of additional food allergies
2. Known atopic eczema - severe eczema below the age of one year is associated with the development of egg, milk, and peanut allergy
3. Family history of food allergy
4. Family history of atopy
131
What % of children and adults have a primary nut allergy respectively?
2% of children and 0.5% of adults
132
What % of infants and adults respectively have an egg allergy?
2% infants and 0.1% adults
133
What are the complications of food allergies? (3)
1. Severe and life-threatening reactions (food allergy is the most common trigger of anaphylaxis in community)
2. Stress and anxiety
3. Reduced quality of life (dietary restrictions, impact on social interactions)
134
Many children outgrow their food allergy, however which food allergies are most likely to persist? (4)
1. Peanuts
2. Tree nuts
3. Fish
4. Shellfish
135
Which factors may increase the likelihood of a severe food allergy? (4)
1. History of asthma (especially if it is poorly controlled)
2. A history of atopy
3. History of previous systemic allergic reactions
4. Allergy to the food classes of peanut, tree nuts, fish and shellfish
136
What systemic clinical features would indicate a suspected IgE-mediated food allergy? (8)
Systemic features (life-threatening anaphylaxis) -
1. Respiratory distress
2. Severe wheezing
3. Hypotension
4. Bradycardia
5. Drowsiness
6. Confusion
7. Collapse
8. LOC
137
What clinical features of the skin would suggest an IgE-mediated food allergy? (5)
1. Urticaria
2. Angioedema (lips, face, around the eyes)
3. Erythema
4. Generalised itching
5. Flushing
138
What are the gastrointestinal features that would suggest an IgE-mediated food allergy? (4)
1. Nausea
2. Vomiting
3. Diarrhoea
4. Abdominal pain
139
What are the respiratory features of an IgE-mediated allergic reaction to food? (9)
1. Persistent cough
2. Hoarseness
3. Wheeze
4. Breathlessness
5. Stridor
6. Nasal discharge
7. Congestion
8. Itching
9. Sneezing
140
What are the symptoms of oral allergy syndrome?
Typically mild;
1. Transient localised urticaria
2. Tingling, itching and swelling of the lips, tongue and throat
3. Co-morbid allergic rhinitis symptoms after ingestion of fresh fruit and vegetables
141
What is important to ask in the history of someone with suspected food allergy?
1. Causal food or foods
2. The symptoms, frequency, speed of onset, duration, timing of the reaction in relation to the suspected allergen exposure
3. Form of the food e.g. raw, semi-cooked, baked and quantity of the food
4. Setting of the reactions
5. Age when started
6. Co-morbid atopic conditions
142
When examining someone with a suspected food allergy, what is important to do?
Nutritional status - weight, height and BMI
| and any signs of clinical reaction, co-morbid conditions e.g. eczema, asthma
143
What investigations should be arranged for someone with suspected food allergy? (2)
1. Skin prick testing
| 2. Serum-specific IgE allergy testing
144
What are the differentials for an IgE-mediated food allergy? (4)
1. Acute spontaneous urticaria and angioedema (often a viral infection, no trigger)
2. Carcinoid syndrome
3. Food intolerance (should be suspected if delay in symptom onset and prolonged symptoms
4. Food poisoning
145
In addition to food allergies, what are the other causes of anaphylaxis? (5)
1. Stings (wasp, bee etc)
2. Antibiotics
3. Anaesthetic drugs e.g. suxamethonium, vecuronium, atracurium
4. Contrast media
5. Othes (rarely), hair dye, latex
146
Which allergy causes death most rapidly from contact?
IV/injected drugs
147
How long does it take for a food reaction to cause respiratory arrest?
30-35 minutes
148
What are the ABCDE problems associated with anaphylaxis?
A - airway swelling, hoarse voice, stridor
B - SOB, wheeze, exhaustion due to tachypnoea, confusion due to hypoxia, cyanosis, respiratory arrest
C - shock (pale and clammy), tachycardia, hypotension, LOC, cardiac arrest
D - neurological status change due to decreased brain perfusion
E - urticaria, erythema, mucosal changes - angioedema
149
What are the differentials for anaphylaxis?
1. Faint
2. Panic attack
3. Breath-holding episode in children
4. Idiopathic urticaria
150
What is the management of someone in anaphylactic shock?
1. Recognise patient is seriously unwell
2. Call for help immediately
3. ACBDE assessment (give high-flow oxygen!)
4. Adrenaline IM 1:1000 (repeat after 5 minutes if no better)
5. IV fluid challenge
6. Chlorphenamine (antihistamine)
7. Hydrocortisone
151
What is the dose for adrenaline in anaphylaxis based on ages?
Adult = 500mcgs IM (0.5mls)
Child >12 = 500 mcgs IM
Child 6-12 = 300mcgs IM (0.3mls)
Child <6 = 150mcgs IM (0.15mls)
152
What is the appropriate IV fluid challenge for a child with anaphylaxis?
Crystalloid 20ml/kg
153
How does adrenaline work to treat anaphylaxis? (its effects on alpha and beta receptors?)
1. Adrenaline eases breathing difficulties and restores adequate cardiac output.
2. It is an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema.
3. Its beta-receptor activity dilates the bronchial airways, increases the force of myocardial contraction and suppresses histamine and leukotriene release
154
Where does an IM adrenaline injection need to be given in anaphylaxis?
The anterolateral aspect of the middle third of the thigh - needle must be long enough to access the muscle
155
In addition to the drugs in the anaphylaxis pathway (adrenaline, antihistamine, steroid) what else can be considered? (by a specialist) (2)
1. Bronchodilators
| 2. Cardiac drugs e.g. vasopressin, glucagon, atropine
156
If someone has a suspected food allergy but not anaphylaxis, what is the management for them?
Refer to an allergy specialist for further assessment and management. The urgency of this depends on the clinical features/judgement
157
If food allergy tests do not correspond with the clinical history, what is the gold standard test for diagnosis of a food allergy?
Oral food challenge - performed under medical supervision. It involves increasing quantities of the food allergen, starting with direct mucosal exposure (allergen contact with the lips) and then titrated oral ingestion as tolerated. If symptoms are not provoked, the test is negative and clinical allergy can be excluded
158
At eight weeks old, which immunisations are given/recommended to be given to all babies in the UK? (9)
1. Diphtheria
2. Tetanus
3. Pertussis
4. Polio
5. Haemophilus influenzae type b
6. Hepatitis B
7. Pneumococcal
8. Meningococcal group B
9. Rotavirus gastroenteritis
159
At 12 weeks old, which vaccinations are recommended in the UK? (7)
1. Diphtheria
2. Tetanus
3. Pertussis
4. Polio
5. Hib
6. Hepatitis B
7. Rotavirus
160
At 16 weeks old, which vaccinations are recommended to be given in the UK? (8)
1. Diphtheria
2. Tetanus
3. Pertussis
4. Polio
5. Hib
6. Hep B
7. Pneumococcal
8. Men B
161
At one year old, which vaccinations are recommended to given in the UK? (5)
1. Hib
2. MenC
3. Pneumococcal
4. MMR
5. MenB
162
Which vaccination is given seasonally in children aged 2 - 8 years old?
Live attenuated influenza vaccine
163
Which two vaccinations are given at 3 years, 4 months old?
1. Diphtheria
2. Polio
3. Tetanus
4. Pertussis
5. MMR
164
Which vaccination is given to girls aged 12-13 years old?
HPV (two doses, 6-24 months apart) - protecting against cervical cancer, and genital warts)
165
Which vaccinations are given to children aged 14 (school year 9)? (4)
1. Tetanus
2. Diphtheria
3. Polio
4. Meningococcal groups A, C, W, and Y
166
Why is it important to receive the haemophilus influenzae type B (Hib) vaccine?
It is responsible for causing meningitis, epiglotitis and bacteraemia
167
What advice is important to give to parents/carers of children younger than 1 receiving vaccinations? (5)
1. Explain the benefits of vaccination - prevents serious illness in children, e.g. meningitis, whooping cough, tetanus
2. Reassure vaccinations are safe - pain, reddening at site of injection are common and systemic effects are usually limited to mild fever
3. Infranix vaccine contraindicated in children with hypersensitivity to neomycin, polymyxin and polysorbate 80
4. If the MenB vaccine is given advise calpol as soon as possible after the vaccination, then 4-6 hours after the first dose
5. Offer written information - public health england leaflets, or NHS choices website
168
Which vaccinations are associated with egg proteins and therefore what is the advise for those with egg allergies?
MMR - the BNF says it is safe to given to a child with egg allergy, even if they have had anaphylaxis, as it contains minimal egg protein (if any)
Influenza vaccine - if a person has had an anaphylactic reaction to egg before, then avoid, but if only minor, then should be safe, as it contains very small amounts of egg protein
169
What are the rare complications of chickenpox? (4)
1. Pneumonia
2. Encephalitis
3. Disseminated haemorrhagic chickenpox
4. Arthritis, nephritis, and pancreatitis
170
What is another term used to described molluscum contangoisum?
Pox disease
171
What type of arthritis often follows a bacterial infection - commonly of GI or GU origin?
Reactive arthritis - common organisms include shigella, salmonella
172
What is the name of the syndrome when children with sickle cell disease can present with tender swelling of the hand, wrists and feet. With such episodes being precipitated by stress of cold.
Hand-foot-syndrome
173
What are the three types of juvenile idiopathic arthritis?
1. Monoarticular- single joint
2. Pauciarticular - <4 joints (aka oligoarticular)
3. Polyarticular - >4 joints
174
How long does a joint have to be swollen for in a child, before it is classed as JIA?
6 weeks or more
175
What are the complications of JIA?
1. Chronic anterior uveitis
2. Flexion contraction of the joints
3. Amyloidosis
176
What is Still's disease?
A systemic form of juvenile arthritis, that is though to be an autoimmune disorder.
177
When does Still's disease normally begin?
At 3-4 years of age and is more common in girls
178
What are the features of Still's disease?
Intermittent high pyrexia, salmon-pink rash with aches and pains of the joints and muscles. Other features include hepatosplenomegaly, lymphadenopathy and pericarditis.
179
What infection can cause acute rheumatic fever?
Group A beta-haemolytic streptococcal pharyngitis
180
What is the process of molecular mimicry which is seen in rheumatic fever?
In susceptive individuals exposed to group A beta-haemolytic strep pharyngitis, the antibodies formed against the bacterial carbohydrate cell wall cross-react with antigens in the heart, joints and skin.
181
In developing acute rheumatic fever, what is the consequence of the immune response on the heart?
In the heart it leads to myocarditis, pericarditis, and endocarditis, resulting in valve destruction, conduction defects and arrhythmia, and congestive heart failure.
182
What diagnostic tool is used to help diagnose rheumatic fever?
Duckett Jones criteria - requires evidence of streptococcal infection - serial anti-streptolysin O titres
183
What are the major criteria of the Duckett Jones diagnostic tool? (5)
Major:
1. Pancarditis
2. Polyarthritis
3. Sydenham's chorea (St Vitus' dance)
4. Erythema marginatum
5. Subcutaneous nodules
184
What are the minor criteria of the Duckett Jones diagnostic tool?
1. Fever
2. Arthralgia
3. High erythrocyte sedimentation rate or WCC
4. Heart block
185
What is enteropathic arthritis?
It is an asymmetrical pauciarticular arthritis predominately affecting the larger joints of the lower limb. It occurs with underlying IBD.
186
What test is important to do in a baby presenting with jaundice and seizures?
A TORCH screen
187
What is involved in the TORCH screen?
```
Testing for :
Toxoplasmosis
Other e.g. syphilis
Rubella
Cytomegalovirus
Herpes simplex
```
188
What features are common to all TORCH infections? (8)
1. Low birth weight
2. Prematurity
3. Jaundice
4. Microcephaly
5. Seizures
6. Anaemia
7. Failure to thrive
8. Encephalitis
189
Name 4 gram-positive cocci?
1. Staph. aurerus
2. Staph. epidermis
3. Strep. pneumoniae
4. Strep. pyogenes
190
Name some gram-positive bacilli? (4)
1. C. diff
2. C. perfringens
3. C. diphtheria
4. Listeria monocytogenes
191
Name some gram-negative bacilli? (8)
1. E.coli
2. Klebsiella pneumoniae
3. Salmonella
4. Shigella
5. Haemophilus influenzae
6. Legionella pneumophilia
7. B. Pertussis
8. Proteus Mirabilis
192
Name 2 gram-negative diploccoci?
Neisseria meningitidis
| Neisseria gonorrhoea
193
Name the spiral shaped bacteria that causes syphilis?
Treponema pallidum
