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Y3 med old > INFECTIOUS DISEASE > Flashcards

INFECTIOUS DISEASE Flashcards

1
Q

Name Gram +ve cocci

A

SSE
S Staphylococcus
S Streptococcus
E Enterococcus

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2
Q

Name Gram +ve bacilli/rods

A

Corny Mike’s List of Basic Cars
Corneybacteria
Mycobacteria
Listeria
Bacillus
Nocardia

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3
Q

Name Gram +ve anaerobes

A

CLAP
Clostridium
Lactobacillus
Actinomyces
Propionibacterium

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4
Q

Name Gram -ve cocci

A

NNM
Neisseria Meningitis
Neisseria gonorrhoea
Moraxella catarrhalis

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5
Q

Name Gram -ve bacilli/rods

A

Escherichia coli
Klebsiella pnuemoniae
Pseudomonas aeruginosa

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6
Q

Name Gram -ve coccobacilli

A

Haemophillus influenza

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7
Q

Antibiotics that inhibit bacterial cell wall synthesis?

A

Penicillin
Carbapenems
Cephalosporin
Vancomycin
Teicoplanin

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8
Q

Antibiotics that inhibit bacterial folic acid synthesis?

A

Trimethoprim
Sulfamethoxazole

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9
Q

Abx that stops bacterial nucleic acid synthesis ?

A

Metronidazole (v good for anaerobes)

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10
Q

Abx that inhibit bacterial protein synthesis ?

A

Macrolides
Clindamycin
Tetracyclines e.g. Doxyclycline
Gentamicin

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11
Q

Define sepsis

A

Life threatening organ dysfunction caused by a dysregulated host response to an infection

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12
Q

Define septic shock

A

Subset of sepsis with profound circulatory, cellular and metabolic abnormalities. Associated with greater risk of mortality than sepsis alone

Z2F: this is when arterial BP drops resulting in organ hypo-perfusion

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13
Q

How can septic shock be measured?

A

Systolic BP less than 90 despite fluid resuscitation
HYPERlactaemia - where lactate is >4 mmol/l

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14
Q

Pathophysiology of sepsis?

A

3 main parts: Cytokine - Coag - Lactate

Cytokines:

1) Pathogens recognised by macrophages, lymphocytes and mast cells
2) Cells release cytokines - cytokines activates other parts of immune system.
3) activation causes vasodilation
4) cytokines make endothelial lining of BV more permeable = so fluid leaks out —> get oedema and reduced intravascular vol.
5) oedema around BV means less O2 can reach tissues

COag:

6) Coag system is activated too!
7) fibrin deposits throughout circulation = also reducing tissue perfusion.
8) Platelets and clotting factors are used up to make clots —> causes thrombocytopenia, haemorrhages (so can’t make any other clots or stop bleeding). = DIC.

Lactate:
9) Get anaerobic resp as no O2 reaching tissues = so blood lactate rises. (as lactate is waste prod of anaerobic resp).

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15
Q

SEPSIS mnemonic

A

Slurred speech or confusion
Extreme shivering or muscle pain
Passing no urine (in 24hrs)
Severe breathlessness
I feel like I’m going to die
Skin mottled or discoloured

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16
Q

RF for developing sepsis?

A

V young or old - under 1, over 75
Chronic conditions e.g. COPD, DM
Immunosuppressed - chemo, immunosuppressants, steroids
Surgery, trauma, burns
Pregnancy, permpartum (just before or after birth)
Indwelling medical devices - catheter, cannula

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17
Q

Presentation of sepsis?

A

Scoring on NEWS.
What is involved?:
Temp, HR, RR, O2 sats, BP, consciousness level (AVPU)

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18
Q

Signs of sepsis on examination?

A
  • Sources of infection - cellulitis, wound discharge, cough, dysuria
  • Non blanching rash
  • Mottled skin
  • Cyanosis
  • Arrythmia - new onset AF
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19
Q

Investigations for sepsis?

A

FBC - Wcc, neutrophils
U&Es - renal function, AKI
LFTs - liver function, liver is potential source of infection
CRP - assess inflammation
Coag screen/clotting - DIC
Blood cultures - bacteraemia
Blood gas - lactate, pH, glucose

Also could do:

  • Urine dip and culture
  • CXR
  • CT scan abdo - suspect infection or abscess
  • Lumbar puncture - suspect meningism
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20
Q

Management for sepsis

A

1) Assessed and treated within 1 hour of presentation
2) Perform sepsis 6:
Take blood lactate, take urine output, take blood cultures.
Give oxygen, broad spec abx, IV fluids
3) escalate - senior, HDU, ICU

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21
Q

Define neutropenic sepsis

A

Sepsis in pt with low neutrophil count of less than 1 x10(9) L

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22
Q

Causes of neutropenia in pts?

A

Anti- cancer chemo
Immunosupressants for RA - Hydroxychloroquine, Methotrexate, Sulfasalazine
Other immunosuppressants - Infliximab, Rituximab
Malaria treatment - Quinine
HyperThyroid treatment - Carbimazole

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23
Q

Why is neutropenic sepsis so urgent to manage?

A

Pts do not have immune system to fight infection - so are at high risk of death. Need emergency admission and management

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24
Q

Specific treatment for neutropenic sepsis

A

Immediate broad spec abx:
Piperacillin with tazobactam (tazocin)

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25
Q

What is osteomyelitis?

A

Inflammation of bone and bone marrow, usually caused by bacterial infections

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26
Q

Most common bacteria causing osteomyelitis?

A

Staphylococcus aureus

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27
Q

Risk factors for developing osteomyelitis?

A

Open fractures
Orthopaedic operations - esp w prosthetic joints
DM - esp w diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression

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28
Q

Presentation of osteomyelitis?

A

Fever

Gangrene
Pain and tenderness
Erythema
Swelling

Non-specific - w fever, lethargy, nausea and muscle aches

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29
Q

Investigations to do for suspected osteomyelitis?

A

MRI - best for establishing dx

XR - not good in early disease. Signs on XR = periosteal reaction, localised osteopenia, destruction of bone

FBC - raised WCC,
CRP, ESR

Blood cultures - causative organism and find abx sensitivity.

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30
Q

Management for osteomyelitis?

A

Surgical debridement of infected bone and tissues
ABx therapy- 4-6 weeks or 3-6 months in chronic osteomyselitis
If in prosthetic joint = prosthetic replacement surgery.

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31
Q

BNF recommendation for abx therapy of acute osteomyelitis?

A

6 weeks flucloxacillin +/- Rifampicin or fusidic acid for first 2 weeks

Alternative of flucloxacillin = Clindamycin. If MRSA related = vancomycin or teicoplanin

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32
Q

Name atypical bacteria that cause atypical pneumonia

A

Legions of Psittaci MCQs
Legionella pneumophila
Chlamydia psittacosis
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Q fever - coxiella burneti

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33
Q

Abx options for MRSA?

A

Doxycycline
Clindamycin
Vancomycin
Teicoplanin
Linezolid

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34
Q

Cause of malaria?

A

Blood protozoan (single celled organism) parasite - Plasmodium species. Spread via bites from female Anopheles mosquito carrying the disease.

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35
Q

Types of Plasmodium species causing malaria?

A

Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae

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36
Q

Presentation of malaria - symptoms?

A

NON SPECIFIC

Abrupt onset rigors
High fever
Sweats
Severe headache
Myalgia
Malaise
Nausea
Vomiting

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37
Q

Common bacteria that cause chest infections/pneumonia ( spell them too!)

A

Streptococcus pneumoniae
Haemophilus influenzae

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38
Q

Less common/opportunistic bacteria that cause chest infections/pneumonia and when?

A

Moraxella catarrhalis- in immunocompromised patients and those with chronic pulmonary disease
Pseudomonas aeruginosa- patients with CF or bronchiectasis
Staphylococcus aureus- In patients with CF

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39
Q

Main investigation for malaria?

A

Malaria blood film - need 3 to diagnose malaria

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40
Q

What do blood results for malaria show?

A

Anaemia
Thrombocytopenia
Leukopenia
Abnormal Liver enzymes

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41
Q

Chest infection presentation?

A

Cough
Sputum production
Fever
Lethargy
Crackles on the chest

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42
Q

Common bacteria that cause chest infections ( spell them too!)

A

Streptococcus pneumoniae
Haemophilus influenzae

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43
Q

Management for complicated or severe malaria?

(Dr Tom said this is more likely to come up in exam)

A

Has to be IV:

  1. Artesunate (most effective, but not licensed)
  2. Quinine dihydrochloride
  • a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state
  • intravenous artesunate is now recommended by WHO in preference to intravenous quinine
  • if parasite count > 10% then exchange transfusion should be considered
  • shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse
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44
Q

Antibiotic for chest infection in community?

A

Amoxicillin or erythromycin or doxycycline

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45
Q

Complications from malaria by Plasmodium falciparum?

A

Cerebral malaria
Seizures
Reduced consciousness
AKI —> renal failure
Pulm oedema
DIC - disseminated intravascular coagulopathy
Severe haemolytic anaemia
Death

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46
Q

Blood film for malaria has been done. What other investigations to order?

A

Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS

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47
Q

Management for uncomplicated malaria?

A

Admit P falciparum pts for treatment
Discuss with local ID unit

Oral options as follows:
1 Artemether with lumefantrine (called Riamet)
2 Proguanil and atovaquone (Malarone)
3 Quinine sulphate
4 Doxycycline

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48
Q

Management for complicated or severe malaria?

(Dr Tom said this is more likely to come up in exam)

A

Has to be IV:

  1. Artesunate (most effective, but not licensed)
  2. Quinine dihydrochloride
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49
Q

Main management for malaria with Plasmodium falciparum?

A

Admit
IV artesunate treatment
Monitor for complications.

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50
Q

Blood film for malaria has been done. What other investigations to order?

A

Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS

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51
Q

Malaria prophylaxis advice to give pts?

A

Know where is high risk
Mosquito spray
Mosquito nets and barriers when sleeping
Antimalarial medication.

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52
Q

Exam patient with Chlamydophila pneumoniae?

A

School aged child with mild- moderate chronic pneumoniae and wheeze

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53
Q

Q fever exam patient?

A

Farmer with flu like symptoms
Q-fever linked to animal exposure and their bodily fluids

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54
Q

Chlamydia psittaci exam pt?

A

Parrot owner- contracted from infected birds

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55
Q

Define meningitis

A

Inflammation of the meninges

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56
Q

Gram stain of Neisseria meningitidis?

A

Gram negative diplococci

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57
Q

Symptoms of meningitis?

Signs of meningitis?

A

Symptoms: fever, headaches, photophobia, nausea and vomiting, seizures, drowsiness,

Signs: purpuric rash (non-blanching), neck stiffness

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58
Q

Common bacterial causes of meningitis in 6 years - 60 years?

A

Neisseria meningitidis
Streptococcus pneumoniae

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59
Q

Causes of meningitis? (i.e which pathogen groups?)

A

Viral
Bacterial
Fungal
Parasitic (v rare)

Bacterial meningitis is most clinically significant form because of its high mortality and morbidity

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60
Q

Most common bacterial cause of meningitis in neonates (0-3m)?

A

Group B Streptococcus (usually contracted during birth Group B strep that live harmlessly in the vagina).

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61
Q

Name of special tests to look for meningeal irritation?

A

Kernigs test
Brudzinki’s test

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62
Q

Describe Kernig’s test

A

Lying pt on back
Flex one hip and knee to 90deg
Slowly straighten knee while keeping hip flexed at 90deg
This creates stretch in meninges. If meningitis is present = spinal pain, or resistance to movement

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63
Q

Describe Brudzinki’s test

A

Pt lays flat on back
Examiner lifts pt’s head and neck off the bed and flex pt’s chin to chest
If meningitis is present = cause involuntary flex of hips and knees.

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64
Q

Most common cause of meningitis in older people ?

A

Listeria monocytogenes

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65
Q

Viral causes of meningitis?

A

Herpes simplex virus
Enterovirus
Varicella zoster virus

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66
Q

Causes of non-infective meningitis?

A

Malignancy (leukaemia, lymphoma and other tumours)
Chemical meningitis
Drugs (NSAIDs, trimethoprim)
Sarcoidosis
Systemic Lupus Erythematosus
Behcet’s disease

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67
Q

Investigations for meningitis?

A

Nice guidelines:

FBC
CRP
Coag screen
Blood culture
Whole-blood PCR
Blood glucose
ABG/VBG
Lumbar puncture - CSF analysis (if no signs of raised ICP)

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68
Q

Initial management of bacterial meningitis?

A

2g of IV ceftriaxone (or cefotaxime) twice daily.
Add IV amoxicillin if neonate or older person

Also require dexamethasone with 1st dose

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69
Q

Management of meningococcal meningitis?

Management of pneumococcal meningitis?

A

MM: Intravenous benzylpenicillin or ceftriaxone (or cefotaxime)

PM: IV ceftriaxone

If penicillin allergic = chloramphenicol IV

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70
Q

Management of meningitis with non-blanching rash in community setting before hospital transfer?

A

IM benzylpenicillin

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71
Q

Complications of meningitis?

A

Septic shock
DIC
Coma
Subdural effusions
SIADH
Seizures

Delayed complications : Sensorineural Hearing loss (most common), cranial nerve dysfunction, hydrocephalus, intellectual deficits, ataxia, blindness
Death

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72
Q

Patient with TB has insidious onset of personality change and headache. Also has N&V. What is top differential?

A

TB meningitis

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73
Q

Why does pt with miliary TB need lumbar puncture?

A

Exclude TB meningitis

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74
Q

Characteristics of CSF with bacterial meningitis:
Appearance?
Protein level?
Glucose level?
WCC?
Culture?

A

Appearance - cloudy
Protein level - high >1g
Glucose level - low; less than half of plasma.
WCC - neutrophils, 1000+
Culture - bacteria - diplococci, Gram -ve

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75
Q

Characteristics of CSF with viral meningitis:
Appearance?
Protein level?
Glucose level?
WCC?
Culture?

A

Appearance - clear (sometimes cloudy)
Protein level - normal/slightly raised
Glucose level - 60-80% of plasma
WCC - lymphocytes, 1000+
Culture - no bacteria culture

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76
Q

Characteristics of CSF with TB meningitis:
Appearance?
Protein level?
Glucose level?
WCC?

A

Appearance - clear, slightly cloudy. Fibrin web may develop.
Protein level - high >1g
Glucose level - low
WCC - lymphocytes, 1000+

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77
Q

Encephalitis features?

A

Fever, headache, psychiatric symptoms, seizures, vomiting

Focal features e.g. aphasia

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78
Q

Causes of encephalitis?

A

HSV-1 responsible for 95% of cases in adults

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79
Q

Where does encephalitis typically affect?

A

Temporal and inferior frontal lobes

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80
Q

Investigations + results for encephalitis?

A

CSF: lymphocytosis, elevated protein

PCR for HSV

Imaging: MRI is best- medial temporal and inferior frontal changes

Imaging normal in 1/3 of pts

ECG pattern: lateralised periodic discharges at 2Hz

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81
Q

Managment of encephalitis?

A

IV aciclovir should be started in all cases of suspected encephalitis

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82
Q

Prognosis of encephalitis?

A

Prompt treatment: 10-20% mortality

Untreated: 80% mortality

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83
Q

Aciclovir side effects?

A

Generalised fatigue/malaise (common)

Gastrointestinal disturbance (common)

Photosensitivity and urticarial rash (common)

Acute renal failure

Haematological abnormalities

Hepatitis

Neurological reactions

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84
Q

When should you suspect encephalitis?

A

Sudden onset behaviour changes, new seizures and unexplained acute headache with meningism

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85
Q

TB drug most likely to hepatotoxicity

A

Pyrazinamide

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86
Q

When is staph aureus likely to cause pneumonia?

A

After influenza

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87
Q

What causes diabetic foot disease?

A

secondary to neuropathy and peripheral artery disease

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88
Q

Why is diabetes a RF for peripheal arterial disease?

A

diabetes is RF for both microvascular and macrovascular ischaemia

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89
Q

Presentation of diabetic foot infection?

A

Neuropathy: loss of sensation

Ischaemia: lack of foot pulses, reduced ABPI, intermittent claudication

Complications: calluses, ulceration, cellulits, gangrene, osteomyelitis

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90
Q

What is low risk for diabetic foot disease?

A

No deformity, just calluses alone

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91
Q

What is moderate risk for diabetic foot disease?

A

deformity or
• neuropathy or
• non-critical limb ischaemia

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92
Q

What is high risk for diabetic foot disease?

A

Previous ulceration, previous amputation, on RRT, neuropathy + non-critical limb ischaemia, neuropathy + callus AND/OR defomity, non-critical limb ischaemia + callus AND/OR deformity

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93
Q

What is ankle brachial pressure index?

A

ratio of systolic BP in the lower legs to arms

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94
Q

What are the interpretations of ABPI?

A

> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD

  1. 0 - 1.2: normal
  2. 9 - 1.0: acceptable

< 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently

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95
Q

What is charcots arthropathy?

A

Bones in the foot become weak–> dislocations and fractures–> changes shape of foot/ ankle

Presents with 6Ds- destruction, deformity, degeneration, dislocation, dense bones and debris)

96
Q

Define Cellulitis

A

Infection of subcutaeneous tissues and dermis

97
Q

If cellulitis extends over a joint worry there might be___1____

___2____( ortho infection) may present as cellulitis

A

If cellulitis extends over a joint worry there might be___septic arthritis____

__Osteomyelitis___(ortho infection) may present as cellulitis

98
Q

Key in cellulitis is a __1___ in the skins barrier for pathogens to enter.

A

1 Breakdown

bacteria need a point of entry

99
Q

Give examples of how skin barrier may be broken to allow bacteria to enter and cause cellulitis

A

IV drug ucer infection around venepuncture

skin trauma

eczematous skin

fungal nail infections / athletes foot (cracks between toes)

ulcers

100
Q

Who is susceptible to get cellulitis?

A
  • DM - hyperglyacemia
  • DM with Peripheral neuropathy - cant feel trauma
  • Obesity - pressure sores/immobility
  • IV drug users - infection / abscess around point of injection
  • PAD - poor blood flow for healing and tendancy to ulcerate
101
Q

What systemic features might point to bacteraemia rather than local infection in cellulitis?

A

fevers

sweats

rigors

102
Q

How does cellulitis present ? (to look at)

A

Erythema (red discolouration)

Warm or hot to touch

Tense

Thickened

Oedematous

Bullae (fluid-filled blisters)

A golden-yellow crust can be present and indicate a staphylococcus aureus infection

103
Q

Who is susceptible to MRSA cellulitis infection?

A

Recent hopsital admission and length of their stay

Ask: has MRSA screening been done? results please

104
Q

What are the bacteria causes of cellulitis ?

A

Staphylococcus aureus

Group A Streptococcus (mainly streptococcus pyogenes)

Group C Streptococcus (mainly Streptococcus dysgalactiae)

MRSA

105
Q

Compare the gram stain morphology of Staphylococcus and Streptococcus

A

Staph - clusters of gram +ve cocci

Strep - chains of gram +ve cocci

106
Q

Cellulitis - if there is a hx of trauma with skin penetratio what immunisation status must be checked?

A

Tetanus

consider immunisation

107
Q

If cellulitis errythema extends over a joint what do you need to assess?

A
  • Range of movement of joint
    • Septic Arthritis -pain restricts
    • Osteomyelitis LL - weight bearing reduced
  • Time course
    • start on joint or spread to joint?
  • Prosthics
    • metalwork / recent arthroscopy
108
Q
  1. What is a lifethreatening complication of cellulitis?
  2. What would you seen on plain Xray for the above?
A
  1. Necrotising fascitis
  2. Xray - may see gas bubbles within tissues
109
Q
  1. What are two differencials for an errythematous, swollen LL?
  2. Can they co-exist?
A
  1. Cellulitis / DVT
  2. Yes - think elderly immobile woman with infected venous ulcers
110
Q

What bedside investigation would you do for pt with suspected cellulitis and why?

A

Diabetic: BM - hyperglycaemia

Non Diabetics: fasting glucose

ASK : Is sliding scale of insulin needed for better glycaemic control?

111
Q

Cellulitis - how should you examine the skin?

A

Note distribution and extent of errythema

Draw around at admission - judge extent

Broken skin? check between toes

Temperature difference

palpate local lymphadenopathy

112
Q

If cellulitis includes joint - how examine?

A

Palpate for bony tenderness

Feel for effusioon

Assess passive and active range of movement

113
Q

Cellulitis - if ulcers present how to examine?

A

Is any bone visible ?

Describe ulcer (slough, exudate, necrotic tissue, margins, depth)

Metal probe to see if can reach bone - indication of bony involvement

114
Q

What lab investigations for suspected cellulitis and why?

A

Blood

  • FBC - raised WCC (neutrophilia in bacterial)
  • CRP
  • Blood cultures - organism and sensitivities

Other

  • Abscess I&D aspiration - bacterial cause
  • Joint fluid aspiration - microscopy and culture - organism
  • Deep bone biopsy - debridement see if osteomyelitis
115
Q

What imaging for suspected cellulitis?

A

Plain Xray / MRI - look for joint destruction in septic arthritis and changes associated with osteomyelitis

116
Q

Treatment for cellulitis?

A

1st line - IV / oral flucloxacillin

Allergy: IV clarithromycin or erythromycin if pregnant

117
Q

What is the classification for severity of cellulitis?

A

Eron Classification

118
Q

Outline Eron classification for cellulitis

A

Class 1 – no systemic toxicity or comorbidity

Class 2 – systemic toxicity or comorbidity

Class 3 – significant systemic toxicity or significant comorbidity

Class 4 – sepsis or life-threatening

119
Q

What are some differencials for cellulitis ( BMJ best practice)

A

Necrotising fascitis - pain ++ / necrotic bulous changes/ crepitus

Thrombophlebitis (superficial) - tender palpable cord along vein (recent catheter)

DVT- previous DVT/ hypercoag/immobile

Gout - urate, knee, 1st metatarsopharangeal

Lyme disease - ticks

Dermamtitis - demarcated/pruritis/ Hx

Fixed drug eruption - Hx rxn, well demarcated, itching burning, lips/genitals involved

120
Q

At which stages of Eron classification would you admit for IV AB?

A
  1. If Eron stage 3 or 4 (toxic, co-morbidities ++, septic)
  2. frail, very young or immunocompromised patients.
121
Q

Causative organism(s) in Type 1 necrotising fasciitis?

A

Mixed organisms - aerobes and anaerobes.

122
Q

Pts with _______ what condition? _____ most commonly get type 1 necrotising fasciitis post surgery?

A

Pts with diabetes most commonly get type 1 necrotising fasciitis post surgery

123
Q

Difference between Cellulitis and Erysepilas in terms of where it affects the body?

A

Erysipelas - more superfical - epidermis and dermis

Cellulitis - dermis and subcut tissue

124
Q

Necrotising fasciitis can be classified according to the causative organism:

Type 1 is caused by ____________ (often occurs post-surgery in diabetics). This is the most common type

Type 2 is caused by __________

A

Type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type

Type 2 is caused by Streptococcus pyogenes

125
Q

Which organism most commonly causes erysipelas ? compare to celluitis

A

Erysipelas - Streptoccous pyogenes (group A beta -haemolytic)

Cellulitis - Staphloccoccus aureus is most common

126
Q

What is Waterhouse-Friderichsen syndrome?

A

Complication of meningoccoal meningitis- it is adrenal insufficiency secondary to adrenal haemorrhage

127
Q

Risk factors for necrotising fasciitis?

A

IV drug use

Immunosupression

Diabetes mellitus - especially if being treated with SGLT-2 inhbitors

Skin factors: recent trauma, burns or soft tissue infections

128
Q

Where does Erysipelas commonly occur and who does it usually affect ?

A

Where? Most commonly on face - cheeks and periorbitally

Who? often children / elderly / immunocompromised

129
Q

When do you withhold dexamethasone in meningitis?

A

Septic shock

Meningococcal septicaemia

Immunocompromised

Meningitis following surgery

130
Q

Presentation of necrotizing fasciitis?

A

Acute onset

Pain at affected site on skin - pain out of proportion to physical features

Swelling at affected site

Erythema at afected site

Rapidly worsening cellulitis

Tenderness over infected tissue - even with light touch

Skin necrosis, gas gangreen, dusky - late signs

Fever and tachycardia - late signs or absent

131
Q

Management of necrotising fasciitis?

A

Urgent surgial referral debridement

IV abx (broad spec e.g meropenem).

132
Q

What is discitis?

A
133
Q

Define necrotising fasciitis

A

Necrotizing fasciitis — a destructive and rapidly progressive soft tissue infection that involves the deep subcutaneous tissues and fascia (and occasionally muscles), which is characterized by extensive necrosis and gangrene of the skin and underlying structures (from NICE)

134
Q

Features of discitis?

A

Back pain

Pyrexia

Rigors

Sepsis

Neurological features: e.g. changing lower limb neurology

135
Q

Causes of discitis?

A

Bacterial- staphyloccocus aureus

Viral

TB

Aseptic

136
Q

Diagnosis of discitis?

A

MRI- highest sensitivity

CT guided biopsy may be required for

137
Q

Treatment of discitis?

A

6-8 weeks of IV antibiotics (flucloxacillin for staph aureus )

Choose antibiotic based on cultures

138
Q

Complications of discitis?

A
139
Q

What else do you need to be aware of for discitis?

A

Usually due to haematogenous spread implying bacteriaemia and seeding has occured.

Consider doing an transthoracic echo as pt may have endocarditis

140
Q

Presentation of infective endocarditis?

A

Main symptom and sign = fever and murmer (aortic valve regurgitation)

Symptoms: Headache, myalgia, weight loss, abdominal pain, night sweats, pleuritic chest pain, cough

Signs: Janeway lesions, osler nodes, non-blanching petechiae. murmer.

141
Q

Investigations for suspected infective endocarditis?

A

ECG

FBC, U+Es, LFTs, CRP

3 blood culture samples (from different sites) - check have not missed infection

1st line imaging = transthoracic echo

Most sensitve imaging modality = transoesophageal echo

CXR

142
Q

RF for infective endocarditis?

A

Valvular damage

  • prosthetic valve
  • age related valvular damage
  • previous rheumatic heart disease

IV drug use

Male

Age 60 +

Poor dentition

Previous endocarditis

143
Q

Initial management of endocarditis (called Blind therapy)?

A

Benzylpenicillin and gentamicin

144
Q

Management of native valve (i.e. not prosthetic valve) infective endocarditis caused by Staphylococcus aureus?

A
  • Flucloxacillin 4 weeks
  • Penicillin allergy = Vancomycin + rifampicin 4 weeks
145
Q

Management of prosthetic valve infective endocarditis caused by Staphylococcus aureus?

A

Flucloxacillin + gentamicin + rifampicin for 4-6 weeks

146
Q

Management of infective endocarditis caused by Steptococci sp?

A

Benzylpenicillin 4-6 weeks

147
Q

Complications of infective endocarditis?

A

Heart failure - from acute valvular insufficiency

Stroke, haemorrhages

Renal failure

Osteomyelitis

Septic arthritis

148
Q

Common valve affected in IV drug users with infective endocarditis?

A

Tricuspid valve on R side of the heart

149
Q

Entry mechanism of Strep viridans causing infective endocarditis?

A

Poor dental hygiene

150
Q

Entry mechanism for Staph epidermidis which causes infective endocarditis?

A

Indwelling devices - cannulas.

151
Q

Major clinical criteria of Modified Dukes criteria for infective endocarditis?

A
  1. Blood culture positive
  2. Echo positive or PET CT +ve or CardioCT +ve
152
Q

Minor clinical criteria of Modified Dukes criteria for infective endocarditis?

A
  1. Predisposition present - IVDU, Heart condition
  2. Fever of 38C<
  3. Vascular phenomena present - arterial emboli, infarcts, conjunctival haemorrages
  4. Immunological phenomena present - glomerulonephritis, osler nodes, Rheumatoid factor
  5. Serology evidence of infective endocarditis
153
Q

How is definitive infective endocarditis calculated using Dukes Modified criteria?

A

2 major criteria + 3 minor criteria

OR

All 5 minor criteria present

154
Q

What should a travel Hx include about a persons acivity when they return unwell from abroad?

A
  • Countries - stop overs / time
  • Activities - lakes (water contact ) / rural backpacking
  • water supply - bruhsing teeth / drinking
  • Types of Food
  • Insect bites - repellent / nets at night
  • Accomodation
  • Vaccination status / Prophylaxis for malaria taken
  • Any symptoms? then or anyone travelling with
  • Sexual Hx - condom use/ sex worker/ MSM
  • Medical conditons - predispose to infection e.g. diabetes / immunosuppressive therapy
155
Q

What DDx could a patient traveller coming form aboard have if they describe insect bites?

A
  • Malaria
  • Dengue fever
  • Leishmaniasis
156
Q

What DDx could a patient traveller coming form aboard have if they describe Diarrhoea?

A
  • Giardia
  • Ameobiasis
  • typhoid / para typhoid
  • schistomiasis
  • tapeworm
157
Q

What DDx could a patient traveller coming form aboard have if they describe abdominal pain?

A
  • Typhoid / para typhoid
  • schistomiasis
  • giardia
  • amoedbiais
  • tapeworm / hookworm / roundworm
158
Q

What DDx could a patient traveller coming form aboard have if they describe haematemesis?

A
  • Dengue fever
  • viral haemorrhagic fever
159
Q

What DDx could a patient traveller coming form aboard have if they describe urinary symptoms?

A
  • Schistomiasis - urinary freq / dysuria / haematuria
160
Q

What DDx could a patient traveller coming form aboard have if they describe rigors / high fevers?

A
  • classic for malaria
161
Q

What DDx could a patient traveller coming form aboard have if they describe night sweats?

A
  • malaria
  • TB
  • Brucellosis
  • Visceral leishmaniasis
162
Q

What DDx could a patient traveller coming form aboard have if they describe cough?

A
  • Typhoid / paratyphoid
  • schistomiasis
  • visceral leishmaniasis
163
Q

What DDx could a patient traveller coming form aboard have if they describe chest pain?

A
  • Typhoid / paratyphoid
164
Q

Unwell traveller from abroad - what are some differencials if 0-10 days?

A
  • Dengue
  • Rickettsia
  • Viral (including mononucleosis)
  • GI ( bacterial / amoeba)
165
Q

Unwell traveller from abroad - what are some differencials if 10-21 days?

A
  • Malaria
  • Typhoid
  • Primary HIV infection
166
Q

Examinatioin of pt returned from abroad what should you examine the eyes for?

A

Conjunctival pallor - Anameia:

  • Malaria - haemolysis
  • Typhoid / paratyphoid
  • typhus

Conjunctival Suffusion

  • Leptospirosis
167
Q

Examinatioin of pt returned from abroad and see: jaunice …..what DDx you thinking?

A
  • Malaria
  • Hep A - viral hepatitis from food poisoning breakout
168
Q

Examinatioin of pt returned from abroad and see: ROSE SPOTS (pink macules 2 -3 mm on chest / abdomen) …..what Diagnosis you thinking?

A
  • Typhoid / paratyphoid
169
Q

Examinatioin of pt returned from abroad and see: crusted ulcer healing by scarring …..what Diagnosis you thinking?

A

Hallmark of cutaeneous Leishmaniasis

170
Q

Investigations for pt returned from abroad: what abnormalities are you looking for in a FBC and why might this be?

A

Haemolytic anaemia :

  • Malaria
  • Typhoid / paratyphoid
  • typhus

Eoisinophilia:

  • worm infections
171
Q

Investigations for pt returned from abroad: what abnormalities are you looking for in a Renal Function U&E and why might this be?

A

Impaired in:

  • Malaria
  • Typhus
172
Q

Investigations for pt returned from abroad: what abnormalities are you looking for in a LFTs and why might this be?

A

Derranged in:

  • Typhoid / paratyphoid
  • ameobic abscesses
  • schistomiasis
173
Q

Investigations for pt returned from abroad: what abnormalities are you looking for in a thick and thin blood film ?

A

3 sets required separate in time

  • detect malaria parasite and species
  • ring form in Plasmodium falciparum
  • Crenulated edge
174
Q

Investigations for pt returned from abroad: why would you do blood cultures and blood glucose?

A
  • cultures - look for organism
  • Glucose - critical in treatment of falciparium as treatment with quinine can cause hypoglycaemia
175
Q

Investigations for pt returned from abroad: bedside tests might you do?

A
  • urine dip - haemoglobinuria in falciparum malaria
  • commericial malaria antigen test kit
176
Q

What lab required tests might you send off for when investigation a patient returned from abroad ?

A
  • Stool culutes - inclide test for Ova, Cysts and Parasites
  • urine specimens for M&S
  • Skin lesion biopsy
  • Liver biopsy - inflamm response schistomiasis
  • lymph node biopsy - leishmaniasis
  • Bone marrow cultues -typhoid / paratyphoid / leishmania
177
Q

Unwell traveller from abroad :

>21 days what are your differencials

A
  • Malaria
  • Chronic bacterial (brucella. coxiella, endocarditis, bone and hoint infections)
  • TB
  • Parasitic infection (helminths / protozoa
178
Q

Examination of a unwell returned traveller from abroad - black necrotic ulcer with erythematous margins what are you thinking?

A

Rickettsia (tick exposure)

179
Q

Examination of unwell returned traveller - what could a maculopapular rash indicate?

A

Dengue fever

Leptospiroiss

Rickettsia

Infection mononucleosis (EBV, CMV)

childhood : rubella, parovirus B19

primary HIV infection

180
Q

Examination of unwell returned traveller - what could splenomegaly indicate?

A

Mononucleosis

Malaria

visceral leishmaniasis

typhoid fecer

brucellosis

181
Q

What neurological symptoms can you get in a returned traveller who is unwell? How serious is this?

A

Fever and altered mental state - meningo-encephalitis (EMERGENCY)

e.g. cerebral malaria, Japanese encephalitis, West Nile virus

(also common causes N. meningitis, Strep. pmeumonia, Herpes Simplex virus)

182
Q

What vaccinications should you ask about in returning traveller who is unwell?

A

Hep A / B

Typhoid

Tetanus

Childhood vaccines (MMR, yellow fever, rabies)

183
Q

Baseline investigations for patients newly diagnosed with HIV

A

Confirmatory HIV test

CD4 count

HIV viral load

HIV resistance profile

HLA B5701 status

Serology for syphilis, hep B (sAg, cAb,sAb), hep c,hep A

Toxoplasma IgG, measles IgG, varicella IgG, rubella IgG

FBC, U&Es, LFTs, bone profile, lipid profile

Schistosoma serology (if spent >1mnth in sub-Saharan Africa)

Wome should have annual cervical cytology

184
Q

Where is support provided for patient with HIV?

A

HIV clinical nurse, community support groups, psych support if needed

185
Q

What is post-exposure prophylaxis in HIV

A

Depends on the type of incidents- low risk may not need PEP

Combination of oral anti-reterovirals as soon as possible for 4 weeks

Serological testing at 12 weeks following completion of PEP

Reduces risk of transmission by 80%

186
Q

What is the HIV seroconversion reaction?

A

Symptomatic in 60-80% of patients

3-12 weeks after infection

The HIV has entered the body is now rapidly multiplying

187
Q

Features of seroconversion reaction?

A

Sore throat, lymphadenopathy, malaise, mylagia, arthralgia, diarrhoea, maculopapular rash, mouth ulcers

188
Q

Diagnosis of HIV?

A

Combination tests of HIV antibodies and P24 antigen

If positive, repeat to confirm the diagnosis

Viral load may also be measured- HIV RNA level

Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, if negative, offer a repeat test at 12 weeks

189
Q

What is anti-retroviral therapy?

A

Involves a combination of at least 3 drugs, usually 2 nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitors (NNRTI)

190
Q

As well as their normal ART treatment what else should patients with HIV and a low CD4+ count be on?

A

CD4< 200–> co-trimoxazole 480mg PO OD as primary prophylaxis against PCP

CD4<50 –> Azithromycin 1250mg PO once weekly protect against MAI, also be assessed by opthalmology with dilated fundoscopy to look for intra-ocular infections

191
Q

Nucleoside analogue reverse transcriptase inhibtors side effects?

A

Periperheral neuropathy

Tenofovir: renal impairment and osteroporosis

Zidovudine: anaemia, myopathy, black nails

Didanosine: pancreatitis

192
Q

non- Nucleoside analogue reverse transcriptase inhibtors side effects

A

P450 enzyme interactions

rashes

193
Q

Protease inhibtors side effects

A

Diabetes, hyperlipdaemia, buffalo hump, central obsesity, p450 enzyme inhibition

194
Q

What is Septic Arthritis ?

A

Infection of the joint and synovial fluid

195
Q

What organsims cause septic arthritis?

A

Staphloccus aureus (most common cellulitis)

Strep pyogenes

Haemophilus influenzae type B (<5yrs / non working spleen)

Strep pneumoniae (no spleen / hyposplensim)

Mycobaterium tuberculosis (immunosuppressed TB in body)

196
Q

Briefly outline the pathophsyiology of septic arthritis

A

Results from either direct bacterial invasion from overlying cellutlis or osteomyelitis. Can also result from haemotoligcal spread from bacteraemia. Cabn occur following surgery e..g total hip replacement

197
Q

What are the clincial features of septic arthritis?

A

Hot

Swollen

Tender joint

Reduced rang of movement (active and passive) due to pain

Fever (more likely with haematological spread)

(NOTE: TB septic arthtirits can get COLD joint!)

198
Q

What are some RF for septic arthritis (BMJ BP)

A

OA / RA

low socioeconomic status

Prosthetic Joint

>80 yrs

Immunosuppressed (HIV/diabetes/ alcohol misuse)

concurrent infection

ulcers

recent joint surgery

interarticular injections

199
Q

What investigations would you do for septic arthritis?

A

Joint aspiration microscopy, sensitivity and culutre

WCC count of aspirate

Blood cultures

CRP / ESR / WCC

U&Es

LFTs

200
Q

How treat septic arthritis

A

THINK SEPSIS - start sepsis 6

Flucloxacillin

Penicillin allergic - Clindamycin

refer to Ortho for surgical washout if severe/ prosthetic joint removal

201
Q

What are some complications of septic arthritis

A

Damange to synovium and cartilage - osteomyelitis and arthritis

sepsis

death

202
Q

Xray features of Mycoplasma pneumoniae?

A

Bilateral consolidation

203
Q

You suspect malaria in a pt. After thick and thin blood film the parasite count was 5%. In the last six hours, she had become progressively drowsy. What intravenous treatment is most appropriate?

A

IV artesunate

This is SEVERE malaria

Or IV quinine until artesunate is available. quinine ( cardiac monitoring + regular BMs - risks of arrhythmias + hypoglycemia)

204
Q

Definition of cystitis?

A

UTI that affects the bladder

205
Q

Cause of cystitis?

A

Eschericha coli - from colon –> transurethral movement into the bladder.

206
Q

Clinical features of cystitis?

A

Urinary frequency

Dysuria

Urgency

Foul smelling urine

Suprapubic pain

Suprapubic tenderness on palpation of region

207
Q

Ddx to cystitis?

A

Pyelonephritis

208
Q

Investigations for cystitis?

A

Urine dipstick - positive for leucocytes and nitrites

MSSU (especially in men, children and pregnant women) - to culture and treat accordingly

209
Q

Management of cystitis?

A

Oral nitrofurantoin or trimethoprim

Conservative measures to reduce risk of further infections - regular fluid intake, post-coital voiding.

210
Q

Definition of pyelonephritis?

A

UTI affecting kidneys / renal pelvis

211
Q

Cause of pyelonephritis?

A

Escherichia coli - from colon transurethrally to kidney

212
Q

Clincal features of pyelonephritis?

A

Fever/ rigors

Malaise

Loin/flank pain

Vomiting

Clinical exam = fever, loin and or flank tenderness

213
Q

Differentials for pyelonephritis?

A

Cystitis - (but pts rarely have flank/loin tenderness or be pyrexial )

Lower UTI

Men - acute prostatis

Acute abdo condition - if have N&V

Women - PID, gynae conditions

214
Q

Investigations for pyelonephritis?

A

Urine dip - positve for leucocytes and nitrites

FBC - raised WCC

U+Es - renal impairment

Blood cultures

Urine MSSU - for MC&S

Renal USS - for hydronephrosis of kidney with severe infection

215
Q

Management for pyelonephritis?

A

Admit

IV abx - broad spec cephalosporin/quinolone/gentamicin

IV fluids if dehydrated

216
Q

What AB drug is used for chemoprophylaxis for close contacts of a pt with bacterial meningitis?

A

Rifampicin

A commonly used alternative is Ciprofloxacin, although off license.

217
Q

Symptoms of pneumonia

A

Cough Sputum Dyspnea Chest pain - may be pleuritic Fever

218
Q

Signs of pneumonia

A

Fever Tachycardia Reduced oxygen sats On auscultation - reduced breath sounds and bronchial breathing

219
Q

CXR findings for pneumonia ?

A

Consolidation

220
Q

Investigations for pneumonia and corresponding findings ?

A

CXR - consolidation

FBC - neutrophillia I.e. high WCC

U+Es - dehydration - urea in CURB6

CRP - raised as response to infection

ABG - indicated if O2 sats are low

Sputum culture - find sensitivity for abx

221
Q

Classic organism causing pneumonia in alcoholics?

A

Klebsiella pneumoniae

222
Q

Baseline investigations for all new pts diagnosed with HIV?

A
  • Confirmatory HIV test
  • CD4 count
  • HIV viral load
  • HIV resistance profile
  • HLA B*5701 status - as allele can cause hypersensitivity to some drug treatments
  • Serology for other conditions: syphillis, hep B, hep C, hep A
  • Immunoglobulin status for Measles, Rubella, Toxoplasma, Varicella
  • FBC, U+Es, LFTs, bone profile and lipid profile
  • Women - annual cervical cytology
  • If spent 1m< in sub saharan Africa, need a schistosomiasis screen
223
Q

Which vaccinations should pts with HIV get?

A

Hep B

Pneumococcus

Annual influenza vaccine

224
Q

Treatment for typhoid?

A

IV ceftriaxone 2g OD (empirical - before sensitivity known)

Once sensitivities known - switch to PO Ciprofloxacin 500mg BD or Azithromycin 500mg OD

225
Q

C.diff abc?

A

oral Metronidazole or vancomycin

226
Q

what is minimum inhibitory conc?

A

Min conc of an abx required to inhibit bacterial growth

Abx specific

Organism specific

Isolate specific

227
Q

Classical definition of Pt with PUO?

A

Temp 38< (on many occasions)

Illness for 3+ weeks

No diagnosis despite having inpaient investigations for 1+ week

228
Q

Common causes of Pyrexia with unknown origin?

A

Infective - TB, abscess, infective endocarditis, brucellosis

AutoImmune/connective tissue - temporal arteritis, Wegener’s granulomatosis

Neoplastic - leukaemias, lymphomas, renal cell carcinoma

Other - drugs, VTE, hyperthyroidism, adrenal insufficiency

229
Q

What to ask in Hx of Pt with pyrexia of unknown origin?

A

Chrolonolgy of Sx

Pets/animal exposure?

Travel - in last year?

Occupation?

Meds?

FHx?

Vaccination history?

Sexual contacts?

230
Q

What to examine in a patient with Pyrexia of unknown origin?

A

LN? - swollen? where?

Stigmata of endocarditis?

Weight loss/cachexia?

Joint abnormalities?

231
Q

What investiagtions to do in pt with pyrexia of unknown origin?

A

Bloods: FBC, U+Es, LFTs, bone profile CRP, clotting, TFTs, MULTIPLE sets of blood cultures (2-3), LDH, B12, ferritin, folate. If you think is related to AI disease = immunoglobulins, RF, ANA, dsDNA etc

Microbiology/virology: HIV, HEP B+C, syphillis, MSU, sputum cultures, malaria films (x3 from 3 diff sites at diff times, for pts w/ travel Hx). Viral swabs, CMV+EBV serology, Brucella serology, fungal serology

Imaging: CXR, CT TAP, MR head, MR spine, PET scan (if relevant)

Biopsies: MC+S, TB culture, histology done on all samples. Need biopsy from bone marrow, LN, abscess, liver

232
Q

What needs to be monitered when pt is on TB treatment?

A

LFTs

Visual aquity tests

233
Q

How to prescibe abx?

Mnemonic GRASP

A

G- guidelines
R- renal function/ liver function
A- allergies
S-sentivities
P- previous abx

234
Q

How to look at drug chart?

PRESCRIBER mnemonic

A

P- patient details: name, DOB
Re- allergic reactions- check and ask, what happens
S- Signature (prescription not valid otherwise)
C- contraindication- use BNF
R- Route
I- indication + duration
B- blood clots- VTE risk assessment
E- anti-Emetics
R- pain Relief

FYI generic name of drug and when to review/ stop- 48 hours if not sure

235
Q

What is Rickettsial disease?

A
  • occur worldwide and are associated with the patient having been bitten by an ectoparasite such as a louse, mite, flea, mosquito, or most commonly, a tick.
  • usually divided into the spotted fever group, where patients present with fever and spots, and the typhus group.

Y3 med old (8 decks)

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