Infectious

Question 1

What is condyloma acuminatum

Answer 1

Genital warts(HPV 6 and 11 )

Question 2

Infection of skin upper medial scrotum?

Answer 2

Tinea cruris - jock itch

Moisture, warm weather, wet clothes, tight clothes

Question 3

Name 7 causes urethritis and urethral discharge

Answer 3

• Most commonly STI: neisseria gonorrhoea or chlamydia trachomatis. May rarely be ureaplasma urealyticum, trichomonas vaginalis, mycoplasma genitalium.
• urethral catheter
• urethral instrumentation
• urethral calculus
• urethral tumour
• chemical irritation
• systemic illness: Reiter’s syndrome (reactive arthritis)

Question 4

Classification of urethritis and major differences (5) organism, complications, incubation, discharge, symptoms

Answer 4

Gonococcal vs non-gonococcal
• neisseria gonorrhoea vs chlamydia trachomatis, rarely ureaplasma urealyticum and trichomonas vaginalis
• complications urethral stricture 20 years later,epidydimitis, infertility vs epidydimitis (commonest cause heterosexual men), urethral stricture
• incubation 1-7 days us 1-5 weeks
• urethral discharge thick, purulent, yellow-brown vs scanty and watery
. Both dysuria and urethral itching

Question 5

Diagnosis gonococcal urethritis?

Answer 5

Gram stain from urethral swab show gram-negative intracellular diplococci on microscopy

Question 6

Diagnosis non- gonococcal urethritis?

Answer 6

• Gram stain difficult but show >4 PMN /oil immersion field with no evidence N gonorrhoea
• best to do chlamydia monoclonal antibody test from serum sample

Question 7

Treatment gonococcal urethritis?

Answer 7

Ceftriaxone 250 mg IM stat or ofloxacin

And treat for chlamydia (30% with gu also have chlamydia): azithromycin 1 g po or doxycycline 100 mg po bd x 7 days

Question 8

Treatment non-gonococcal urethritis?

Answer 8

Doxycycline 100 mg po bd X 7 days

Or azithromycin 1 mg oral stat

Question 9

How confirm diagnosis urethritis?

Answer 9

Urine microscopy show >4 WBC / HPF of urethral secretion or >15 WBCs / HPF of first voided 10-15 ml urine (centrifuged)

Question 10

Define Fournier’s gangrene

Answer 10

Necrotising fasciitis of perineum
Fulminating infective process spreading rapidly along fascial planes, causing thrombosis of subcutaneous blood vessels and gangrenes of overlying skin

Question 11

Name 6 risk factors necrotising fasciitis of perineum

Answer 11

• Chronic alcoholism
• diabetes!
• immunosuppression: hiv/aids, steroid treatment
• chemo for malignant disease
• transplant patients
• malnutrition

Question 12

Where can sources of infection for Fournier’s gangrene be? (6)

Answer 12

Urogenital
• urethral stricture
• indwelling urethral catheter
• urethral injury

Anorectal
• perianal/ ischiorectal abscess
• routine anorectal procedures

Cutaneous infection/ trauma

Question 13

Name the bacteriology of Fournier’s gangrene (6)

Answer 13

Polymicrobial infection with aerobes and anaerobes. Commonly isolated species:
• enterobacteria esp e coli,
. Bacteroides
• streptococci
• staphylococci
• peptostreptococci
• clostridia
(Normal flora)

Question 14

Cause of tissue destruction in necrotising fasciitis of the perineum?

Answer 14

• Ischaemia
• synergistic action of various bacteria
• production of proteins and enzymes by organisms:
-Hyaluronidase → tissue destruction
-Coagulase → interference with phagocytosis

Question 15

Clinical features Fournier’s gangrene? (8)

Answer 15

Early
• pain, erythema, swelling of scrotum
• pyrexia

Late
• cyanosis/blistering of skin (bullae)
• crepitus
• obvious cutaneous necrosis
• extension to ant abdominal wall and thighs
• septicaemia
Mortality 20%

Question 16

Name 5 factors associated with increased mortality in necrotising fasciitis of perineum

Answer 16

• Increased age
• anorectal infections
• delay in diagnosis and treatment
• debility
• diabetes!

Question 17

Management Fournier’s gangrene? (5)

Answer 17

• Aggressive haemodynamic stabilisation
• iv broad spec antibiotics triple therapy (PAM)
- penicillin for gram positive
-Aminoglycoside eg amikacin for gram negative, or cephalosporin third generation
- metronidazole for anaerobes
• urgent surgical debridement of areas of overt subcutaneous necrosis, may need multiple
- testes may need to be put in subcutaneous “pockets” in thighs
- split skin grafts for large defects later
• May need suprapubic cystostomy or colostomy diversion
• Treat underlying cause
• adequate nutrition

Question 18

How does Fournier’s gangrene spread? (7)

Answer 18

Via fascia. Along fascia plane
• Infection Colles superficial perineal fascia → Buck deep. and Dartos superficial fascia → penis and scrotum
• Colles → Scarpa fascia (Anterosuperior to Colles , cover abdominal and thoracic muscles, extend to clavicles) And campers (Loose areolar fascial layer deep to skin abdominal wall but superficial to scarpa, continuation colles superolateral ) → abdominal wall
• Colles fascia attached to perineal body and urogenital diaphragm posterior , pubic rami and fascia lata laterally, limiting progression in these directions.
• Testicular involvement rare: testicular arteries originate directly from aorta thus have separate blood supply.

Question 19

Differential diagnosis Fournier’s gangrene presentation? (6)

Answer 19

• Scrotal cellulitis
• scrotal abscess
• Strangulated inguinal hernia
• penile gangrene rare
• scrotal gangrene- complication of vasculitis
• pyoderma gangrenosum- rare skin condition

Question 20

Treatment bilharzia?

Answer 20

• Praziquantel 4o mg per kg, repeat urine microscopy 1 month later to confirm ova eradication
. Surgery for complications
-Cystectomy for bladder carcinoma
- ureteric reimplant for ureteric stricture

Question 21

Define UTI

Answer 21

Infection above internal sphincter of bladder

Below that called prostatitis, urethritis etc

Question 22

Treatment UTI? (7)

Answer 22

• General measures: admit if toxic, complicated, vomiting; iv fluids if inadequate hydration; blood culture if high temperature
• simple, uncomplicated:
• tmp-smx (bactrim) (sulfonamides) 160/800mg po bid for 3 days or
• nitrofurantoin 100 mg po bid for 5 days or
• Fosfomycin

• complicated

• Fluroquinolones: ciprofloxacin! (ciprobay!) 1g po daily 2-3 weeks; ofloxacin, or
• Aminoglycosides: gentamicin (garamycin!) with ampicillin ; amikacin
• cephalosporins: ceftriaxone 1-2g iv q24h for 2-3 weeks; cefotaxime (claforan!)
• co-amoxiclavalanic acid (augmentin) - not for empirical, E. coli resistant!

Question 23

Treatment syphilis?

Answer 23

Benzathine penicillin 2.4 million units IM stat

Or doxycyclycline if allergic

Question 24

Treatment chancroid?

Answer 24

Erythromycin or
Co-trimoxazole or
Ceftriaxone 250 mg IM stat

Question 25

Treatment granuloma inguinale?

Answer 25

Doxycyclicine 100mg 2x/day or
Co-trimoxazole 2 tabs 2x/day
Until lesions resolved (at least 3 weeks)

Question 26

Treatment hsv?

Answer 26

Acyclovir 200-400 mg 5x/day for 7-10 days, or until clinical resolution
Must start within 2-3 days appearance of lesions

Question 27

Treatment condyloma acuminata? (8)

Answer 27

Medical
• salicylic acid
• podophyllin (protect normal skin with Vaseline) (chemical cauterization)
• trichloroacetic acid
• imiquimod! (Aldara)
• interferon
• 5 fluorouracil ! - contraindicated on mucosa, too toxic

Surgical
• cautery: electro-coagulation
• surgical excision eg circumcision
• cryotherapy: liquid nitrogen, histofreezer
• laser

Question 28

Which other conditions are associated with condyloma acuminata?

Answer 28

Peri -anal warts
Cervical cancer
( hpv )

Question 29

Clinical presentation bilharzia? (5)

Answer 29

• Cercarial dermatitis (“swimmers itch”) at site of cercariae penetration:pruritic maculopapular eruption 3-8 hours after exposure, last hours to days.
• katayama fever: in populations not previously exposed, not endemic. Allergic reaction to schistosomes in liver laying eggs. Present with fever, jaundice, hepatosplenomegaly 3-4 weeks after infection
• urinary schistosomiasis
- terminal haematuria! Classic
- frequency and dysuria
- may present with complications, like squamous cell carcinoma of bladder

Question 30

Diagnosis schistosome haematobium? (4)

Answer 30

• Terminal urine! Most ova excreted middle of day and after exercise:microscopy for ova with terminal spike
. FBC: eosinophilia in acute phase
• IVP /eug:
-Calcifications bladder wall, distal ureters, seminal vesicles
- dilated ureters
-Filling defect bladder due to bilharzia papule, blood clot, carcinoma
- small bladder capacity
• serology ELISA to screen, cystoscope if unsure or complications

Question 31

Where does schistosome mansoni live?

Answer 31

Intestinal schistosomiasis