Necla Tulek

Question 1

What is the the basis of the initial evaluation of the patient with
fever with altered liver parameters ?

Answer 1

A thorough history, physical examination, and standard laboratory
testing

Question 2

Acute hepatitis

Answer 2

Acute hepatitis is a term used to describe a wide variety of conditions
characterized by acute inflammation of the hepatic parenchyma or injury
to hepatocytes resulting in elevated liver function indices.
If the period of inflammation or hepatocellular injury lasts for less than six
months, characterized by normalization of the liver function tests, it is
called acute hepatitis.

Question 3

Chronic hepatitis

Answer 3

if the inflammation or hepatocellular injury persists beyond six
months, it is termed chronic hepatitis.

Question 4

The most common infectious cause of acute hepatitis is?

Answer 4

secondary to a viral
infection(acute viral hepatitis).

Question 5

What are the infectious causes of acute hepatitis?

Answer 5

Viral infections • Bacterial infections • Fungal infections • Parasitic infections

Question 6

What are the nonhepatotropic viruses of hepatitis?

Answer 6

• Epstein-Barr virus (EBV) • Cytomegalovirus (CMV) • Herpes simplex virus (HSV) • Coxsackievirus • Adenovirus • Dengue virus • Coronavirus-19(COVID-19) • Others (measles, varicella…)

Question 7

The clinical course of hepatitis varies widely from an asymptomatic
phase recognized only by?

Answer 7

elevation in aminotransferase levels to
fulminant hepatitis with frank jaundice and hepatic coma

Question 8

Which viral hepatitis transfer with stool?

Answer 8

A,E

Question 9

Which viral hepatitis is epidemic?

Answer 9

A,E,B,C,D

Question 10

Which viral hepatitis causes fulminant hepatitis?

Answer 10

A,E,B,C,D

Question 11

Which viral hepatitis cannot cause chronicity ?

Answer 11

A and in immunocompromised patients of E

Question 12

Which viral hepatitis cannot cause HCC?

Answer 12

A,E

Question 13

Which exotic viruses cause clinical liver involvement and how they transfer ?

Answer 13

• Transmission routes typically involve arthropods
• Crimean Congo haemorrhagic fever, • Dengue, • Rift Valley fever, • Yellow fever.
• Transmitted by the aerosolised excreta of rodents
• Hantavirus, • Lassa fever,
• Direct contact or contact with bodily fluids
viruses is very important.
• Ebola.

Question 14

What is the most sensitive diagnostic method for exotics viruses?

Answer 14

PCR

Question 15

Which vaccines is available for exotic viruses that cause liver inv?

Answer 15

yellow fever and Ebola, Dengue.

Question 16

Bacterial Infection Involving the Liver

Answer 16

• Staphylococcus aureus
• Group A Streptococcus pyogenes
• Enterobacteriaceae • Clostridium perfringens • Listeria monocytogenes : • Salmonella and Shigella • Salmonella Typhi:

Yersinia enterocolitica :,actinomyces,legionella pneumophila

Question 17

Fitz-Hugh-Curtis syndrome

Answer 17

is inflammation of the liver capsule with adhesion formation resulting in right upper quadrant pain. • Chlamydia trachomatis, and Neisseria gonorrhoeae, • Present with perihepatitis and the associated right upper quadrant pain and fever. • Patients frequently have a history of pelvic inflammatory disease

Question 18

Coxiella burnetti?

Answer 18

Infections with the organism lead to Q fever, which is characterized by relapsing fevers,
pneumonitis, endocarditis, and hepatitis. Characteristically, the serum alkaline phosphatase is
elevated disproportionately to the mild rise in serum bilirubin and transaminases. Fibrin ring
granulomas are seen on liver biopsy and treatment is with doxycycline .

Question 19

Bartonella henselae?

Answer 19

.Cat scratch disease
is associated with hepatosplenic necrotizing granulomas. Peliosis hepatis or blood-filled cysts are seen in infections in patients with concomitant AIDS. A papular dermatitis and pulmonary and neurological symptoms may also occur. The bacillary angiomatosis is treated with erythromycin, while doxycycline may be considered for treatment of visceral disease

Question 20

Tuberculosis of the liver

Answer 20

.fever
.jaundice
.serum globulin -> inc
.the A/G ratio -> dec
.

Question 21

Lyme infection

Answer 21

.borrelia burgdorferi
.hep dx with:anorexia,nauseating,vomiting,weight loss,R up pain
.liver enzymes:inc
.rash(erythema migraine)
.tx:oral doxycycline,azithromycin,ceftriaxone

Question 22

Syphilis

Answer 22

.hepatic inv occurs in secondary syphilis
.anorexia,weight loss
.maculopapular rash (palms ,soles)
.jaundice
.hepatomegaly
.R up Q pain
.silver stain
.tx: penicillin

Question 23

Anicteric leptospirosis

Answer 23

There is usually a biphasic
illness, with the first phase characterized
by fever and conjunctival injection. The
second phase is associated with myalgias,
nausea, vomiting, and abdominal pain. It is
at this time that aseptic meningitis may
occur and an increase in serum liver
enzymes and jaundice is seen.

Question 24

Weil disease

Answer 24

Weil disease is the icteric form of the
infection and occurs in 5–10 % of
patients. It too has a biphasic illness
with an earlier phase that is marked by
jaundice. High fever and renal
manifestations with acute tubular
necrosis develop in the second phase
and often lead to renal failure. There is
a high mortality.

Question 25

Weils dx and viral hepatitis

Answer 25

.conjunctival inj : + - .bronchitis: + - .albuminuria : + -

Question 26

What are the parasitic infections of liver:

Answer 26

Malaria,babesiosis,leishmaniasis,toxoplasmosis,amoebic liver abscess ,fascioliasis,trichinosis,schistosomiasis

Question 27

(A)Liver abscess formation usually follows an underlying problem such as immunocompromise, diabetes mellitus, surgery, or malignancy. (B)Pyogenic abscesses may follow an episode of appendicitis, perforated bowel, or inflammatory bowel disease. A pyogenic liver abscess may also be the initial manifestation of hepatic malignancy.

Answer 27

A B . <50yr >50yr .m>F. M=f .solitary. Multiple .serological tests: +. - .blood cultures: - +

Question 28

Fungal Infections of the Liver

Answer 28

Candida albicans

Question 29

Candida albicans

Answer 29

.in severely imm compromised .lead to hepatic abscess and multiorgan dx .CT scan the most useful test .clinical features:fever, abdominal discomfort, and tender hepatomegaly. The serum aminotransferases, bilirubin, and alkaline phosphatase levels are elevated. There is a very high mortality rate.

Question 30

Symptoms of acute viral hepatitis:

Answer 30

fever, malaise, fatigue, loss of appetite, vomiting, diarrhea, and abdominal pain. Patients may also report yellowish discoloration of their sclera (icterus) and /or skin (jaundice), dark-colored urine, and light- colored stools. Physical ex:icterus ,jaundice to signs of acute encephalopathy, seizures, bleeding diathesis, hypotension, and other manifestations related to multiple organ failure.

Question 31

Symptoms of chronic liver dx:

Answer 31

caput medusae, spider nevi, palmar erythema, ascites, Dupuytren contracture, gynecomastia, and hepatic encephalopathy

Question 32

Markers suggestive hepatocellular injury

Answer 32

.Elevation of serum transaminases .Marked elevations greater than five times the upper limit of normal or greater than 500 IU/L is suggestive of extensive hepatocellular injury. It is commonly encountered in acute hepatitis, drug-induced liver injury such as acetaminophen overdose, profound ischemia to the liver, hepatic necrosis, or cases of severe autoimmune hepatitis. .

Question 33

Markers of liver injury secondary to cholestasis

Answer 33

.AP : inc .GGT : inc

Question 34

**in viral hepatitis ALT is typically higher than AST**

Answer 34

Elevation of AST and ALT typically > 400IU/L .hyperbilirubinemia .alkaline phosphate moderately elevated

Question 35

In patients with findings suggesting acute viral hepatitis, the following studies are done to screen for hepatitis viruses A, B, and C

Answer 35

IgM antibody to HAV (IgM anti-HAV) •Hepatitis B surface antigen (HBsAg) •IgM antibody to hepatitis B core (IgM anti-HBc) •Antibody to HCV (anti-HCV) •Hepatitis C RNA (HCV-RNA) polymerase chain reaction **If serologically confirmed HBV infection is severe, anti- HDV is measured. *If the patient has recently traveled to an endemic area or is immunosuppressed, IgM antibody to HEV (IgM anti- HEV) should be measured if the test is available.

Question 36

For patients with acute hepatitis:

Answer 36

outpatient with close follow-up. Liver enzymes and PT should be monitored every 5 to 7 days for the first two weeks, then, if convalescence is satisfactory, at 14-day intervals until function test results have returned to normal. • Bed rest is not indicated, but the patient should avoid strenuous activity. • She should eat a well-balanced diet and abstain from alcohol for the duration of the illness. Because acetaminophen can be toxic to the liver, ibuprofen would be a better alternative for controlling fever. • If nausea precludes the patient from ingesting food and fluids, IV replacement of fluids and electrolytes may be necessary. • In the event the patient develops bleeding tendencies or signs of encephalopathy, she should immediately be taken to the hospital or her physician's office. • Hepatitis A virus is a reportable disease. The health department should be informed of the case immediately.

Question 37

What Are Possible Treatments of Hepatitis B?

Answer 37

-only supportive treatment -should be treated with interferons and antivirals -bed rest and avoidance of alcohol

Question 38

What are the examples of non-infectious dx that can cause fever and rash

Answer 38

• deep venous thrombosis, • superficial thrombophlebitis, • Erythromelalgia( is a rare clinical syndrome characterized by a triad of redness, warmth, and burning pain, most notably affecting the extremities. It usually affects the lower extremities (most commonly feet) or may involve upper extremities (hands) in few cases) • relapsing polychondritis, • foreign body reactions, • drug reactions, • cutaneous lupus erythematosus, • cutaneous vasculitis, and erythema nodosum……………

Question 39

Measles (rubeola):

Answer 39

-"brick-red" maculopapular rash -fever, cough, coryza, conjunctivitis, and Koplik's spots.

Question 40

Chickenpox (varicella)

Answer 40

• Centrifugal distribution:lesions concentrated on the face and distal extremities; fewer lesions on the trunk. • Centripetal distribution: lesions concentrated on the trunk with fewer lesions on the extremities.

Question 41

Rubella

Answer 41

-rash that resembles measles -Forchheimer spots, or punctate soft palate macules -Prominent postauricular, posterior cervical, and/or suboccipital adenopathy may also assists in the diagnosis

Question 42

Erythema infectiosum(fifth disease)

Answer 42

-due to human parvovirus B19 -"slapped cheeks" -erythematous maculopapular rash that spreads from arms to trunk and rash in a reticular pattern *(affect the face)

Question 43

Roseola infantum(exanthem subitum; sixth disease)

Answer 43

-by human herpesvirus 6 -high fever for three to four days, -followed by seizures -generalized maculopapular rash that starts on the neck and trunk and spreads to the face and extremities. (Nit affect the face)

Question 44

Scarlet fever

Answer 44

-exotoxin (erythrogenic toxin)-mediated diffuse erythematous -rash occurring most commonly in the setting of pharyngitis -group A Streptococcus (GAS) infection -manifested by a coarse, sandpaper-like, erythematous, blanching rash,which ultimately desquamates

Question 45

Kawasaki syndrome

Answer 45

-seen in children less than four years of age. -fever lasting >5 days -bilateral conjunctival injection -erythematous fissured lips -injected oropharynx or "**strawberry tongue" ** -edema and erythema of the hands or feet -subsequent periungual desquamation; rash ; and cervical lymphadenopathy

Question 46

Acute rheumatic fever

Answer 46

-erythema marginatum -(transient macular lesions with central clearing found on the extensor surfaces of the proximal extremities and trunk) and subcutaneous nodules often located over bony prominences

Question 47

Arcanobacterium haemolyticum

Answer 47

-Adolescents and young adults with pharyngitis -fever -lymphadenopathy -maculopapular/scarlatiniform rash whose work-up is negative for group A Streptococcus -viral-associated mononucleosis may be infected with A. haemolyticum -The rash, can be pruritic, is typically seen first over the extensor surfaces before spreading centrally . The rash usually spares the face.

Question 48

Mycoplasma pneumoniae

Answer 48

mild erythematous maculopapular or vesicular rash, erythema multiforme, or the Stevens-Johnson syndrome

Question 49

Diseases that present in childhood:

Answer 49

-measles (rubeola) -chicken pox (varicella) -Rubella -erythema infectiosum -Roseola infantum -scarlet fever -kawaski syndrome -acute rheumatic fever -enteroviruses -mononucleosis -arcanobacterium haemolyticum -mycoplasma pneumoniae

Question 50

Diseases in adults

Answer 50

-Measles -mononucleosis -cytomegalovirus -the acute retroviral synd -erythema infectiosum -Herpes zoster (shingles) -mycoplasma pneumoniae -covid-19

Question 51

Cytomegalovirus

Answer 51

Cytomegalovirus should be considered in the heterophileantibody-negative patient with infectious mononucleosis, although lymphadenopathy and pharyngitis may not be as prominent.

Question 52

Lymphadenopathy,arthritis,and fever:

Answer 52

****Erythema infectiosum in adults

Question 53

Herpes zoster (shingles)

Answer 53

-Individuals who did not have chickenpox during childhood may develop it later in life. -a dermatome and ending at the midline

Question 54

multisystem inflammatory syndrome

Answer 54

A diffuse polymorphic erythematous rash, nonexudativeconjunctivitis, oral mucositis, and/or indurated edematous feet and hands have been described in children and adults

Question 55

Nonpolio enteroviralinfections occur in which season:

Answer 55

Summer and fall

Question 56

Kawasaki syndrome, meningococcal infection, and parvoviralinfections present most commonly in which season:

Answer 56

Winter and early spring

Question 57

Measlesand rubella are more frequent in the

Answer 57

Spring

Question 58

tickbornediseases such as Lyme disease, ehrlichiosis/anaplasmosis, Tularemia are usually seen in the

Answer 58

Summer

Question 59

Vibrio vulnificusinfections occur between the months of

Answer 59

April and October (when warmer ocean waters facilitate propagation of this organism) (Raw seafood)

Question 60

Herpetic whitlow

Answer 60

when warmer ocean waters facilitate propagation of this organism

Question 61

Toxoplasmosis and cat scratch disease (bartonella hensele) From

Answer 61

Cats and kittens

Question 62

Psittacosis from

Answer 62

poultry, finches, or parrots

Question 63

Cryptococcosis from

Answer 63

pigeon, dog, or cat feces

Question 64

Rat bite fever or leptospirosis from

Answer 64

Rats

Question 65

**Mos quito bites:

Answer 65

• West Nile fever, • Zikafever, • Chikungunya

Question 66

Sandfly:

Answer 66

• Leishmania • Sandflyfever

Question 67

FEVER AND RASH EMERGENCIES

Answer 67

-Meningococcal infection -Bacterial endocarditis -Toxic shock syndrome -Miliary tuberculosis

Question 68

Meningococcal infection

Answer 68

-meningococcemia and/or meningitis are the most common. -r, myalgia, somnolence, headache, and nausea, rash occurs in most patients with meningococcemia. Early lesions may be macular, but rapidly increasing numbers of petechial or purpuric lesions can develop on the distal extremities and trunk, **usually sparing the palms and soles .

Question 69

**Bacterial endocarditis (Skin manifestations,S.aureus most common causes)

Answer 69

Associated peripheral cutaneous or mucocutaneous lesions include petechiae(most common), splinter hemorrhages(nonblanching,linear reddish-brown lesions under the nail bed), (((Janeway lesions(, macular, nonblanching, nonpainful, and erythematous lesions on the palms and soles),Osler's nodes(, Osler's nodes are painful, violaceous nodules found in the pulp of fingers and toes and are seen more often in subacute than acute cases of IE),and Roth spots(exudative,edematous hemorrhagic lesions of retina). )))theses three are more specific for IE

Question 70

**Criteria for the diagnosis of TSS :

Answer 70

• a temperature above 38.9ºC, hypotension, • a desquamating rash, • involvement of at least three organ systems, • exclusion of clinical mimics such as RMSF, leptospirosis, and measles .

Question 71

The rash in TSS:

Answer 71

The rash seen in TSS is diffuse and erythematous and can resemble a sunburn

Question 72

the most common cutaneous manifestation (TB cutis miliaris disseminata);

Answer 72

consists of small, erythematous to violaceous, macular, papular, purpuric, or vesicular lesions that can break down and become umbilicated with crust formation. These lesions subsequently heal with resultant hypopigmented depressed scars .