Infectious Diseases Flashcards

1
Q

You are the F1 in AMU and are phoned by a GP about a 23 year old lady with the a twelve hour
history with rapid onset of severe headache, vomiting, neck stiffness, photophobia and fever
She took paracetamol with no effect and the family are concerned as she is becoming drowsy. On
examination the GP reports a GCS of 13/15 and Mrs. Ill has a rash developing on her abdomen.
1. What is the likely diagnosis?
2. What is your immediate advice to the GP?
3. If the patient has a penicillin allergy what further advice would you give?

A

1 - Menigococcal septicaemia (Sepsis as has a rash)

2 - IM benPen 1.2g
-Send to A&E blue light

3 - meropenem IV (borad spec abx) 2g tds,

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2
Q

You are the F1 in AMU and are phoned by a GP about a 23 year old lady with the a twelve hour
history with rapid onset of severe headache, vomiting, neck stiffness, photophobia and fever
She took paracetamol with no effect and the family are concerned as she is becoming drowsy. On
examination the GP reports a GCS of 13/15 and Mrs. Ill has a rash developing on her abdomen.

On arrival the patient is localising to pain, is opening her eyes in response to speech and has
confused conversation. She is pyrexial at 38.7, HR is 98 and BP is 100/60. There is an obvious
rash on her abdomen, arms and legs.
4. What immediate investigations and treatment are necessary? Why are you doing these investigations?
5. Describe the rash you would expect to see?
6. What was the patient’s GCS on admission? If the patient had been alert and orientated on
admission, with a headache, fever and neck stiffness but no rash, what other investigation
would you do?
7. How can you determine if it is safe to do this procedure?
8. Which investigations should be performed on specimens collected during this procedure?
9. Describe the results you would expect from the procedure carried out in question 8 for A.
a viral cause and B. a bacterial cause?
10. Name two organisms likely to cause this disease in adults?
11. What is the treatment if the cause is viral?
12. Which institution needs to be informed of anyone diagnosed with a bacterial form of this
infection and what treatment may be advised for close contacts of the patient?

A

4- ABCDE, BUFALO
Ix - FBC (WCC, platelets / clotting (DIC), U+E (Pre-renal renal failure) / Lactate, LFT, ABG (Acidosis), Glucose (hypo common in sepsis)
- Peripheral blood for meningococcal / pneumococcal PCR
- throat swab for neisseria, blood cultures
- urinary culture - pneumococcal

IV dexamethasone before the first dose of IV Ceftriaxone 2g

5 - Non blanching purpuric

6 - 12. LP (delay it if you have signs of septicaemia - because you can get the result from blood if they have bacteraemia - don’t need to put them at risk of LP complications)

7 - MUST DO FUNDOSCOPY AND MAYBE CT Signs of ICP (Fundoscopy - Papilloedema, Cushing’s reflex (Bradycardia + hypertension), CT head

8 - Protein, glucose, PCR, culture and sensitivities, neutrophils (viral -> lymphocytes), lactate, gram stain, colour

9 - bacterial = turgid, low glucose, raise protein, neutrophils
viral = clear, normal glucose, slightly raised protein, lymphocytes

10 -

VIRUSES = HSV (high dose IV acyclovir 10mg/kg but think about kidneys before), enterovirus

BACTERIA = Strep. P, N. Meningitides, group B strep (babies)

11 - Supportive if purely meningitis, when it becomes encephalitis they need to treat it with acyclovir (VZV, HSV)

12 - Public health England - proper officer, Rifampicin or ciprofloxacin

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3
Q

A 24 year-old medical student presents with a febrile illness one day after returning from her
elective period in Kenya. She complains of fevers, headaches and myalgia. She was “fully
vaccinated” prior to her trip and took Chloroquine and Proguanil anti-malaria prophylaxis.
Medical examination is unremarkable except for a fever of 39.5
1. What is your differential diagnosis?
2. What investigations do you wish to perform?
3. The haematologists report she has Plasmodium falciparum with a parasitaemia of 3%.

  1. What action is required now? Prescribe any treatment on the drug chart.
  2. How would you monitor her response to treatment?
    -Why is monitoring LFTs important?
  3. What are the complications of severe malaria?
  4. What anti-malarial drugs can be used for a) prophylaxis b) treatment?
A

1- Malaria / dengue / hepatitis / meningitis

2- Blood + films,
FBC (Anaemia, thrombocytopenia, platelets - low in active malaria)
HIV test
Blood cultures
PCR for dengue, yellow fever, zika
CXR
Xray of liver and spleen

Thick = screening film so can if see the plasmodium species are there (sensitivity)
Thin = find the species (identification)

3- 2-5% is parasitaemia severe.

4- ABCDE, IV Artesunate

5- Obs (HR, BP, Temp, Urine)
- glucose (if on quinine), platelets, HB, LFTs (haemolysis in malaria can cause Increased bilirubin and pre-hepatic jaundice)
- daily blood films - parasite count
- IV monitoring

6- parasite >2%, hypoglycaemia (quinine rather than malaria), DIC, haematuria, renal impairment, ARDS, normocytic anaemia, liver dysfunction, cerebral malaria –> Reduced GCS + seizures.

7- Propylaxis - Cloraquine, doxycycline, Malarone
Treat - Artesunate, quinine, Malarone

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4
Q

It is your first day on call as a house officer in AMU and you are called to see Mr Smith, a 35
year old male who gives the following history;
Increasing SOB over 10/7
Fever, rigors, headache and myalgia for 7/7
Cough with dirty green sputum 7/7
Saw GP 2/7 ago, who gave a course of amoxicillin with no improvement
Patient returned from a holiday in Tenerife 10/7 ago where he stayed in a hotel
PMH Asthma since childhood
SH Lifelong smoker 15 pack years
O/E Pt appears unwell- SOB with minimal exertion
HR 110, BP 110/80, RR 30, SpO2 92% on air, Temp 38.5
Signs of left lower lobe consolidation
Labs WCC 12.2, Hb 13.1, Na 128, K 4.1, Urea 7.8, Creatinine 110, AST 84, ALT 66, Bil 12

[Think of this in terms of CAP as well]

  1. What is your most likely clinical diagnosis?
  2. What investigations would you like to do?
  3. Name 5 markers of clinical severity associated with an increased risk of death
  4. Which organism is the commonest cause of this disease? Which organism would you
    suspect in this patient and why?
  5. What are the potential complications of this disease?
  6. What is your management plan for this patient?
A

1- Community aquired pneumonia
- Leigonnaires disease (Holiday, timeline 10days, fever, headache, myalgia)

2- Antigen test for legionella in urine
->Sputum culture (to genotype it)

3- CURB65
-confusion, urea >7, RR>25, BP<90, >65
(She scores 3)

4- CAP - strep. pneumonia, h. Influenza, staph aureus
Atypical types - Chlamydia pneumonia, mycoplasma, legionella

Investigations - CXR, sputum culture

5- Respiratory failure, AKI, septic shock, encepalopathy, pericarditis, abscess, Pleural effusion / empyema (Differentiating these 2 important)

6- CAP +CURB65 >3 -> Amox and clarynthromycin until you know that it is legionella!
Legionella -> IV Chlarythromycin for severe disease or a quinolone

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5
Q

A 50-year-old man, who works as a fishmonger, presents with a 3-day history of diarrhoea and
vomiting. Diarrhoea approx. 10x per day no blood no mucous, vomiting approx every hour.
Ate “shellfish for starters followed by turkey” the day before he became unwell. Rest of family
all well. Patient has never travelled outside of Yorkshire.
On questioning, he reports feeling dizzy on standing, weak and thirsty.
PMH gastritis diagnosed approx 2 years – refused endoscopy, Type II diabetic
DH Lansoprazole, Metformin
SH Non-smoker, drinks “social amounts” alcohol, no pets

What in this Hx increases risk of gastroenteritis?
1. What is the differential diagnosis?
2. What organisms are likely pathogens in this case?
3. What investigations would you do?
4. Outline your treatment plan. Prescribe appropriate treatment on the drug chart. In
what circumstances would you give antibiotic therapy?
5. What are the Public Health issues relating to this case?

A

Lansoprazole - Alters pH -> increased risk gastroenteritis

1- Viral hepatitis
-campylobacter, salmonella, shigella, E. coli (0157, 0404)
Rotavirus, norovirus

3- 3x Stool MC+S + Norovirus PCR (can also do on vom), Hep A serology, U+E as dehydrated, LFT, Clotting (as ?hepatitis)

4- ABCDE
Fluid resus if needed

If severe = erythromycin for campylobacter
If severe = cipro for salmonella/shigella

5- notifiable, works in food handling - if you work in the food industry can’t go back to work for a week after the last vomit/shit

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6
Q

A 20-year-old plumber was admitted with a three day history of painful swelling of his left leg
and groin and feeling generally unwell with episodes of fever with rigors. He was a known
insulin-dependent diabetic and his diabetes was normally well controlled although his blood
sugar had been quite erratic over the last 48 hours.
On examination he had a temperature of 38oC, pulse was 108/min and his blood pressure
was120/80. He had a marked area of swelling and erythema over his left shin spreading towards
the ankle and knee. This area was warm and tender to touch. He also had tender lymph nodes,
which were palpable in his groin. There were no obvious breaks in the skin of his leg or his feet.
Investigations showed a WCC of 26x10 /l with a neutrophilia of 23x10/l. His blood sugar was
22mmol/l and his CRP was 259mg/l.
1. What is the diagnosis?
2. What predisposing factor has he to this type of infection?
3. What further investigations are needed?
4. What are the most likely pathogens?
5. How would you manage this patient? Prescribe any treatment on the drug chart.
6. What other potentially dangerous condition should be considered in your differential
diagnosis?

A

1 - Cellulitis

2- Diabetic

3- Swabs between the toes, blood cultures, Sepsis 6
-Temp, U+E, LFT, FBC

4- Staph aureus, Group A strep

5-ABCDE sepsis 6
IV Abx (as systemically unwell, diabetic, WCC 26)
Fluclox (staph) and BenPen (strep)

6- Necrotising fasciitis (diabetes + unwell + if BP drops)
-this until proven otherwise

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7
Q

A 24-year HIV positive man presents with a 12 day history of increasing shortness of breath and
a non-productive cough. He was diagnosed with HIV 3 years ago but had not been started on
anti-retroviral therapy because of his chaotic lifestyle and failure to attend clinics. His CD4
count on diagnosis was 300.
On examination, he is febrile, his oxygen saturations at rest on air are 87% falling to 72% with
exertion. Chest examination is unremarkable. A CXR reveals bilateral fine peri-hilar infiltrates
1. What is the most likely diagnosis in this case? why?
2. What do you think his CD4 count is now?
3. List another important HIV associated lung conditions?
4. 3 investigations would you do?
5. Prescribe the treatment for his lung condition ?
6. What prophylaxis is used to prevent which infections in HIV infected patients?

A

PCP (pneumocystitis pneumonia) Caused by Pneumocystis jiroveci - no treatment, dry cough (other pneumonias normally productive), reduced sats on exertion, cxr findings (bat wing)

2- probably decreased to below 200 as infection / no treatment. Don’t usually get PCP unless CD4 >200

3- AIDS defining - PCP, bacterial pneumonia (pneumococcal), TB
-Lung Ca, Pulm artery HTN, COPD, MAI

4- PaO2 to assess severity, ABG, LDH
- Viral load, CD4 count
- PCR of induced sputum for PCP (deep sputum)
- you would do a sputum culture to check for spree. pneumoniae

5-Co-trimoxazole IV for PCP +HIV treatment

6- Co-trimoxazole oral - PCP
Azithromycin - MAI if CD4<50
Isosanazid + rifimpamycin - TB

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8
Q

What is issue with co-trimoxazole

A

Bone marrow suppression
Nephrotoxic

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9
Q

Target CD4 / vial load in hiv

A

CD4 > 400 cells/mm3

Viral load - <40 (Want 0)

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10
Q

What does HIV do

A

destroys CD4 cells - these are T helper lymphocytes which carry CD4 on their surfaces

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11
Q

What is reverse transcription

A

viral RNA -> DNA

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12
Q

How does HIV enter cell?

A

through binding of viral envelope glycoprotein (GP120

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13
Q

What is meant by window period in HIV testing

A

Immediately post infection (2-3 weeks) no antibody response mounted therefore false negative

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14
Q

What Ix for Dx of HIV

A

Serum (or salivary) HIV ELISA

Western blot - expensive tho

serum p24 antigen - detectable <4weeks

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15
Q

What other Ix bar diagnosis in HIV

A

Serum cd4 and viral load - used as markers to assess advance of disease

Hep B /c
Tuberculin skin test - because TB is an AIDs defining condition
CXR - look for PCP, TB, COPD etc
Preg - vertical transmission

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16
Q

Can you disclose a positive HIV result to partner without consent ?

A

Yes

Can be criminally liable if know status and transmit infection

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17
Q

CD4 for AIDS

A

<200

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18
Q

What is being described here?
Short illness soon after infection - highest infectivity. Antibody becomes detectable in blood, antigen becomes undetectable
Fever lasting >4d
Aching limbs
Blotchy red rash
Headache
Diarrhoea
Mouth ulcers

A

Seroconversion / primary HIV

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19
Q

AIDS defining conditions?

A

PCP, CMV, TB, Oral hairy leukoplakia,
sentinel tumours - Kaposi’s sarcoma or lymphoma

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20
Q

Mx of CD4 <200

A

Prophylaxis is recommended until CD4 count increases under HAART to prevent opportunistic infections:

Co-trimoxazole - PCP, toxoplasmosis and bacterial infection. SE: rash and BM suppression

Azithromycin - used to protect against MAI in patients with a CD4 count of <50

Ganciclovir - treatment and secondary prophylaxis for active CMV disease

Isoniazid (6M) +/- rifampicin (3M) for LTB if +ve quantiferon

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21
Q

Name 2 mx of candidiasis

A

Clotrimazole - canestan
Fluconazole
Nystatin

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22
Q

Methods of preventing HIV …NAME 3

A

Circumcision

Microbicidal gel (with tenofovir)

Reduce vertical transmission

Post exposure prophylaxis

Screen blood products, needle exchange

Behavioural - appropriate sex-education, condoms

HAART = highly active anti-retroviral therapy

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23
Q

How many drugs do you use for MX of HIV ?

A

3
2 x NRTI + 1 x NNRTI

or 2 x NRTI + 1 x PI

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24
Q

What are NRTIs ? eg?

A

Nucleoside reverse transcriptase inhibitors

Lamivudine, zidovudine (AZT), tenofovir (TDF), emtricitabine (FTC)

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25
Q

What are NNRTI? EG?

A

Non-nucleoside reverse transcriptase inhibitors

Nevirapine

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26
Q

what are PIs? eg?

A

protease inhibitors

Lopinavir

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27
Q

Name 2 barriers to compliance of HIV meds

A

SE
Social support
Stigma of HIV

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28
Q

Ix in viral haemorrhagic fever?

A

FBC: leukopenia and thrombocytopenia

LFT: elevated transaminases

Coagulation screen: PTT, INR and clotting times prolonged

[DIC
PCR]

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29
Q

Mx of Viral haem fevers

A

Notify public health and proper officer (local communicable disease consultant)

Seek advice on prevention transmission

Barrier nursing and visitor restriction

Supportive management: blood volume, clotting, care of major organs

Antivirals (ribavirin) - no use for Ebola or Marburg

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30
Q

Cause of amoebiasis

A

Ingestion of cysts in faecally contaminated food and water

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31
Q

Main comp with amoebiasis?

A

Amoebic liver abscess

32
Q

Ix for amoebiasis?

A

Stool antigen detection

PCR of stool or liver abscess pus for E histolytica DNA

Serum antibody test

Stool microscopy (x3)

Liver USS

CXR

33
Q

Mx amoebiasis?

A

metronidazole
+aspirate abscess

34
Q

Giardia transmission

A

faeco-oral route mainly swallowing water whilst swimming, drinking tap water, eating lettuce

35
Q

Pres of giardia

A

Diarrhoea (no mucus/blood) - greasy and foul smelling, frequent belching

36
Q

Ix giardia

A

Stool microscopy (x3) - cysts and trophozoites
Stool antigen test (ELISA) - +ve for cell wall
String test (mucus examined for trophozoites)
Baseline FBC

37
Q

Mx giardia

A

metronidazole

38
Q

What causes typhoid

A

salmonella

39
Q

what organs does typhoid go to

A

liver, spleen, bone marrow

40
Q

Whats this
High fever (stepwise for 5-7 days, 0.5 degrees), height in afternoon
Dull frontal headache
Dry cough
Malaise
Prostration = lying flat on the floor
Diarrhoea not prominent
ix?

A

typhoid

FBC - mild anaemia
LFT - transaminase x 2/3
Blood culture - pos
Stool culture - pos
Bone marrow culture - pos

41
Q

Comps of typhoid name 2

A

Chronic biliary carriage
Typhoid hepatitis
Bowel perforation

42
Q

Mx typhoid

A

ABX - ceftriaxone
fluids
antipyretics

43
Q

what is
Flu-like, fever (very high spikes > 40 degrees), arthralgia, rash (maculopapular on D4), flushing (diffuse on face, neck + chest), retro orbital pain

A

dengue

44
Q

Ix dengue

A

FBC (elevated HCT, leukopenia, thrombocytopenia)
LFT (high), albumin (low)
serology: +ve IgM and IgM

45
Q

Mx dengue

A

Oral/IV fluids +
supportive care +
antipyretics +
NOTIFICATION

46
Q

What is
Prolonged fever
Wt loss + nt sweats
Ulcerative lesions/skin nodules/mucosal infiltration
Hyperpigmentation
Pancytopenia

2 main syndromes

A

leishmaniasis

Cutaneous: skin ulcers
Visceral: involving RE system: liver, spleen, BM

47
Q

Leishmaniasis ix

A

FBC - pancytopenia

LFT - high AST/ALT/bili

U + Cr - high

Microscopy of biopsy/aspirate - amastigote form in macrophage

Leishmanin skin test (5mm or greater)

rK39 dipstick - antibodies against rK39

48
Q

Mx leish

A

Cutaneous - sodium stibogluconate

Visceral - amphotericin B

49
Q

Mx sleeping sickness

A

Sleeping sickness (early)
IV suramin

Sleeping sickness (late)
Melarsopol

50
Q

Cause of sleeping sickness

A

tse-tse fly

51
Q

schistosomiasis from?

A

skin contact - contaminated freshwater in rural areas of sub-saharan Africa

52
Q

Dx of schisto ?
mx?

A

Microscopic visualisation of eggs in stools or urine

Praziquantel (anti-helminthic)

53
Q

schitso ix

A

Stool or urine microscopy: visualisation of eggs
Tissue biopsy (rectal, liver, bladder, cervical): granulomas surr eggs
Urinalysis: haematuria
FBC: eosinophilia (90% of acute), normocytic normochromic anaemia
AUSS: wall thickening of bladder

54
Q

main comp to think about in schisto

A

bladder ca - due to chronic inflammation

55
Q

3 preventitive measures for malaria

A

Avoid outdoor after sunset
Insect repellent
Long sleeves
Insecticide treated bed nets
Antimalarial chemoprophylaxis

56
Q

Ix of malria

A

Giemsa stained thick and thin blood films

Rapid diagnostic test

FBC

57
Q

Mx malaria

A

chloroquine

or Artesunate

58
Q

Name 3 comps of malaria

A

Acute renal failure due to dehydration and hypovolaemia

Hypoglycaemia may be worsened by quinine therapy, use 10% dextrose

Metabolic acidosis due to tissue hypoxia from hypovolaemia, hypotension, anaemia (deep breathing is 91% sensitive)

Seizure due to acidosis, hypoglycaemia

Acute respiratory distress syndrome due to pulmonary oedema

59
Q

If the q has caves or bats what 4

A

Histoplasmosis
Leptospirosis
VHF
Rabies

60
Q

What is MRSA resistant to? what to give?

A

beta-lactams
Penicillins
Carbapenems
Cephalosporins

Give vancomycin

61
Q

Abx which -> C diff

mx?

A

Caused by the majority of C antibiotics

Ciprofloxacin
Co-amoxiclav
Carbapenems
*Clindamycin (the worst)
Cephalosporin

Mx - metronidazole / vancomycin

62
Q

What is a viral haemorrhage fever?

A

VHF = general term for illness sometimes associated with bleeding, which is caused by a virus.

63
Q

What are the DD of a viral haemorrhage fever?

A

Lassa fever, Ebola, yellow fever, dengue

64
Q

Where is TB most common?

A

South-east Asia
Africa

65
Q

What should TB patients be screened for?

A

TB! strong association

66
Q

What is multi-drug resistant TB and how does it come about?

A

TB resistant to isoniazid and rifampicin (possibly more)

Can occur when poor compliance to TB medication

67
Q

What is the treatment of multi-drug resistant TB?

A

5-8 different drugs for up to 2 years

68
Q

How do you diagnose TB?

A

Clinical features+

Sputum culture - can take up to 2 weeks!

Sputum needs to be analysed for acid-fast bacilli, this used to be done with the Zheil-Neelson stain but is now done with auramine-phenol stain with fluorescent microscopy. However, this staining only shows the presence of the bacteria not that it is alive - culture is more important.

PCR is also now available to see if it rifampicin resistant.

69
Q

What is the classical treatment for TB?

A

RIPE

Rifampicin - 6 months
Isoniaid - 6 months
Pyrazinamide - 8 weeks
Ethambutol - 8 weeks

TB NURSES ARE KEY!!!!!!!!!!

70
Q

What are the side effects of RIPE?

A

Rifampicin - Red tears
Isoniazid - peripheral neuropathy
Pyrazinamide - hepatotoxicity, arthralgia
Ethambutol - optic neuritis

71
Q

What to do if LFTs become off with TB meds

A

if >5x normal stop meds and only start again when they are normal

72
Q

Who is key in TB management

A

NURSES!

73
Q

Vertical transmission of HIV? How can this be prevented?

A

25-40% though birth or breast milk.

Prevention - HAART after 1st trimester. Viral load measured every 2 weeks and Caesarian only considered if viral load is undetectable. AZT mono therapy given to baby for 1 month

74
Q

75 year old man known mixed mitral valve disease.

Admitted to Hosp with urinary retention secondary to large prostate. Catheterised for 3 days after which time the catheter is removed and he is discharged.

Two weeks later - A&E 5 days fever, sweat, malaise, increase SOB.

O/E = loud harsh systolic murmur

  1. diagnosis?
  2. signs?
  3. Investigations?
  4. Cause?
  5. Prevention in this case?
  6. Differences?
  7. Treatment and complications of this condition?
  8. Prevention?
A

1 - infective endocarditis

2 -

F - fever
R - roth spots
O - oslers nodes
M - murmur
J - janeway lesion
A - anaemia
N - nail haemorrhages
E - emboli

3 - ECHO, 3x blood cultures, DUKES criteria, U&E, LFT, FBC, urinalysis (can cause glomerulonephritis)

4 - enterococcus - only thing that could cause a UTI then cause endocarditis (can also come from GUT), otherwise in absence of UTI is strep. viridans

5 - look after catheter

6 - clinical differences =
microbiological differences = skin organism (s. aureus, s.epidermidis - on tricuspid valve)

7 - IV 4-6 weeks amoxicillin and gentamicin for enterococci, different for different drugs

Stroke (clots), glomerulonephritis (from immune deposits), death, valve replacement, limb ischaemia (clots)

8 - good oral hygiene

75
Q

18 year old woman with fevers and jaundice. Moved to UK from Pakistan when she was 4 and has not been abroad since. Her husband moved to the UJ just prior to their marriage 3 months ago and speaks no English. O/E deeply jaundiced with temp 37.8 and tender RUQ. No rash or bowel upset.

1 - Main infective causes in UK?

2 - which does this woman have?

3 - how has she caught it?

4 - investigations?

5 - treatment?

6 - natural history of this condition?

7 - anyone else at risk?

A

1 - hepatitis B and C

2 - hep B

3 - caught off husband - sexually transmitted

4 - hep B serology, surface antigen first then go onto do other tests such as core IgM, E antigen and E antibody, viral load

5 - tenofovir or entecavir

6 - typically can be asymptomatic for years and can have flares - can lead to fibrosis and cirrhosis

7 - recommend family tested.