Pathology Flashcards
(884 cards)
1
Q
Are fungi eukaryotic or prokaryotic?
A
Eukaryotic
2
Q
Do fungi plasma membranes contain ergosterol?
A
Yes
3
Q
What is the commonest cause of fungal infections in humans?
A
Candida spp.
4
Q
What do we use to treat oral thrush?
A
Nystatin
5
Q
What do we use to treat vulvovaginitis?
A
Co-trimazole (topical)
fluconazole (oral)
6
Q
What is fluconazole used to treat?
A
Vulvovaginitis and oesophagitis.
7
Q
Anidulafungin is an example of which drug class?
A
Echinocandin
8
Q
C. Neoformans and C. Gatti are examples of organisms which cause which fungi?
A
Cryptococcus (a type of yeast).
9
Q
Which animal is cryptococcus associated with?
A
Pigeons
10
Q
Which variant of cryptococcus can cause Meningitis?
A
C. Gatti
11
Q
What type of ink is used for a cryptococcal stain?
A
India = stains the CSF.
12
Q
Which microorganism causes mycotoxicosis?
A
Aspergillosis (mould)
13
Q
Name one fungi which actually lacks ergosterol in the cell wall.
A
Pneumocystis Jiroveci
14
Q
What is a main risk factor for any fungi infection?
A
Immunosuppressed.
15
Q
What is a dermatophyte?
A
A group of fungi characterised by the site they invade. e.g. tinea capitis. Invade the dead keratin of skin, nails, hair. LOVE DEAD KERATIN.
16
Q
Tinea cruris’ target site is:
A
Groin
17
Q
Tinea capitis target site is:
A
Scalp (cap)
18
Q
Tinea corporis target site is:
A
Abdomen
19
Q
Tinea pedis target site is:
A
Foot
20
Q
Tinea pedis, capitis, corporis, crusis are examples of what?
A
Dermatophytes = examples of mould.
21
Q
Pityriasis versicolor is caused by which fungi?
A
Malassezia furfur
22
Q
What is the mechanism of azoles?
A
Inhibits the conversion of lanosterol - ergosterol by inhibiting cytochrome P450 enzyme: 14a demethylase.
23
Q
SOB, cough in the history should point toward which fungal diagnosis?
A
Cryptococcus (associated with pigeons)
24
Q
Which fungal infection can cause meningitis?
A
Cryptococcus
25
Give 5 risk factors for fungal disease:
```
Immunosuppressed
Inhaled steroids
malignancy
Moisture (dermatophytes)
Long lines (candida)
```
26
What does immunophenotype refer to?
Flow cytometry, immunohistochemistry
27
What does cytogenetics refer to?
FISH
28
Which is more common - Hodgkin's lymphoma or non-hodgkin's lymphoma?
Non Hodgkin's Lymphoma.
29
Which is the characteristic cell on blood film in Hodgkin's lymphoma?
Reed Sternberg cells
30
How do you diagnose Hodgkin's lymphoma?
CT, PET, Blood tests, LDH, lumbar puncture
31
Name the 3 B symptoms
Fever, night sweats, weight loss.
32
Which is the most common type of Hodgkin's lymphoma?
Nodular Sclerosing.
33
What does the cancer stage II describe?
>1 group of nodes above the same side of the diaphragm.
34
What does the cancer stage I describe?
Only one group of nodes involved
35
What does the cancer stage III describe?
Nodes above and below the diaphragm involved
36
What does the cancer stage IV describe?
Extra nodal spread.
37
How do we treat Hodgkin's lymphoma?
```
ABVD -
Adriamycin
Bleomycin
Vinblastine
Dacarbazine
```
+chemotherapy!
38
Which is the fastest growing type of Non-Hodgkin's lymphoma?
Burkitt's lymphoma
39
What does indolent mean?
Long term survival
i.e. less aggressive.
(paradoxically, more aggressive respond better to treatment).
40
Which is the lowest grade form of Non-Hodgkin's lymphoma?
Follicular lymphoma
| MZL - marginal zone lymphoma.
41
What is characteristic to see on blood film of chronic lymphocytic leukaemia?
Lymphocytosis
| Smear cells
42
Which markers are seen in a normal B cell?
CD3-
CD5-
CD19+
43
Which markers are seen in a normal T cell?
CD3+
CD5+
CD19-
44
Which markers are seen in a malignant B cell?
CD3-
CD5+
CD19+
45
Where is Venetoclax used and how does it work?
Used in CLL - chronic lymphocytic leukaemia
| Blocks the BCL2 protein.
46
Which is the most common malignant type of cancer?
Invasive ductal carcinoma
47
Which is the single most important prognostic factor for cancer?
Status of the axillary nodes i.e. is there metastasis?
48
Why are basal-like carcinomas so hard to treat with medication?
They are oestrogen/progesterone and HER2 negative.
49
Which are the three factors we look at in histological grading?
1. Tubule formation
2. Nuclear pleomorphism
3. Mitotic activity
50
What is the purpose of NHS Breast screening programmes?
To screen for DCIS (ductal carcinoma in situ).
51
What would DCIS grade on a biopsy grade?
B5a
```
B5b = invasive carcinoma
Grading = B1-B5. B1 = normal breast tissue, B2 = benign.
```
52
Which grade is benign tissue on biopsy?
B2! B1 = normal tissue.
53
How do we investigate breast disease?
Examination
Investigation: mammography, sonography
Pathology: cytopathology, histopathology
54
How are aspirates coded? What do these codes mean?
C1-C5
C1 = inadequate
C2 = benign
C5 = malignant
55
How is 'benign' coded on the cytology grading?
C2! C1 = normal tissue (inadequate) .
56
Define menarche
First occurrence of menstruation
57
Define fibroadenoma.
Benign fibroepithelial neoplasm of the breast.
58
Name x3 benign breast conditions.
Duct ectasia, mastitis, fat necrosis, papilloma
59
How would duct ectasia present in a patient?
| And on microscopy?
Nipple discharge, breast tenderness.
| Dilated ducts on microscopy
60
'Painful, red breast' points toward which diagnosis?
Acute mastitis.
61
Presentation with breast mass and can be confused for cancer. What is the diagnosis?
Fat necrosis
62
What is a papilloma?
Benign outward growth.
63
'Benign neoplasm of the breast' defines what?
Fibroadenoma
64
What is a Phyllodes tumour?
Benign but more aggressive fibroepithelial neoplasms.
65
Which are the receptors we assess when querying breast cancer?
Oestrogen receptor, progesterone receptor, HER2 receptor.
66
How will low grade tumours present receptor wise?
Oestrogen and progesterone receptor positive, HER2 receptor negative.
67
How will high grade tumours present receptor wise?
Oestrogen and progesterone receptor negative, HER2 receptor positive.
68
Tamoxifen targets which receptors?
oestrogen receptor.
69
Herceptin targets which receptor?
HER2 receptor.
70
Which are the vaccinations required at 8 weeks of age.
```
Diptheria
Tetanus
Pertussis
Polio
HiB (haemophilus influenzae) type B
Hepatitis B
```
71
Name the three major pathogens at surgical site infections
Staphylococcus aureus
Pseudomonas aeruginosa
E.Coli
72
Give three things which increase an individual's risk of surgical site infection.
- ASA score>3
- Diabetes - associated with post operative hyperglycaemia
- Malnutrition
- Low Albumin
- Rheumatoid arthritis
73
Why does obesity place someone at risk of surgical site infection?
Adipose tissue is poorly vascularised = poor oxygenation of tissues.
74
How does smoking increase risk of surgical site infection?
Nicotine prevents wound healing
| Nicotine has vasoconstrictive effects.
75
Name the disinfectant/ antiseptic used on a patient's skin pre-operatively.
Chlorhexidine.
76
What is the most powerful independent risk factor for SSI following cardiothoracic surgery?
Staphylococcus aureus
77
How does hypothermia cause increased risk of surgical site infection?
Hypothermia causes vasoconstriction = reduces oxygen and blood supply to wound.
78
Organisms adhering to the synovial membrane and bacteria growing in the synovial fluid causing inflammation. What is the diagnosis?
Septic arthritis
79
Name the three most important investigations for septic arthritis.
```
Blood cultures
Synovial fluid aspiration
ESR, CRP
X ray; soft tissue damage
US confirms effusion
CT for erosive bone change
```
synovial count > 50, 000 cells/mm suggests septic arthritis. but negative does not exclude.
80
How do we manage septic arthritis?
Antibiotics e.g. cephalosporin, flucloxacillin.
81
Name three components of blood
Red cells
Platelets
FFP (fresh frozen plasma)
Cryoprecipitate
82
Which blood group do we give in an emergency?
Blood Group O negative
83
How are red cells stored compared with platelets?
Red cells = 4 degrees
| Platelets = 20 degrees
84
Name a procedure which will most likely require a large amount of blood transfusion.
Aortic aneurysm repair
85
What is the difference between O positive and O negative blood?
O positive has RhD antigens
| O negative does not have RhD antigens
86
Which are the two blood systems we are most concerned with with blood donation?
ABO and Rh.
87
If you are RhD negative and given RhD positive blood what is likely to happen?
You will make anti-D antibodies.
88
Do anti-D antibodies cross the placenta?
Yes because they are IgG antibodies.
89
Which blood group do we give in an emergency?
O negative
90
Where is giving platelets contraindicated?
TTP - thrombotic thrombocytopenic purpura.
91
How much FFP do we give?
15-20ml/kg.
92
Approximately how many ml makes up a unit?
450mL. (will vary between red cells, fresh frozen plasma and cryoprecipitate for example).
93
What is cryoprecipitate made up of?
Fibrinogen, fibronectin and factor VIII and vWF.
94
Which blood component mainly raises the levels of fibrinogen?
Cryoprecipitate.
95
Name the four main components of blood.
Red cells
Cryoprecipitate
Platetlets
Fresh frozen plasma
96
Name the two types of donor.
Allogeneic
| Autologous
97
If someone is immunocompromised/ at risk of graft vs. host disease, which specific requirement of blood may they need?
Irradiated blood.
98
Which is actually the most frequency blood donor group?
O positive
99
Which blood groups are cross matched?
Red cells (not platelets/ FFP).
100
What do we worry about in RhD negative women?
HDFN - haemolytic disease of the foetus newborn.
101
Is haemolytic disease an acute or delayed reaction?
Delayed (i.e. >24 hours).
102
What is TACO?
Transfusion associated circulatory overload.
103
Name x3 'SHOTs'
Serious hazards of transfusion:
- Anti-D Immunoglobulin errors
- Delayed transfuion
- Avoidable transfusion
104
With which blood component transfusion are allergic reactions most common?
With plasma.
105
With which blood component transfusion are allergic reactions most common?
With plasma.
106
What is IgA deficiency?
A very severe allergic reaction; in 25% of patients, the person develops IgA antibodies in response to exposure to IgA e.g. in a transfusion.
107
Which is the most common pulmonary complication in blood transfusions?
TACO - Transfusion associated circulatory overload.
108
When may a delayed haemolytic transfusion reaction occur?
If blood transfused has the same antigens on the patient's RBCs, the antibodies can cause RBC destruction.
after 3-10 days; delayed.
109
When may a delayed haemolytic transfusion reaction occur?
If blood transfused has the same antigens on the RBCs, the antibodies can cause RBC destruction.
110
How do we test for delayed haemolytic disease?
High bilirubin, high LDH
| Low Hb.
111
How does GvHD occur?
Lymphocytes from the donor's blood are not destroyed in the patient (e.g. in very immunocompromised patients) and so, the donor's lymphocytes see HLA in the patient and attack them.
112
Name the top 3 symptoms in GvHD.
Diarrhoea
Liver failure
(always fatal).
113
Would purpura occur due to low or high platelet count?
Low platelet count = insufficient clotting = bleeding to surface of skin.
114
Why may iron overload occur and at what levels?
After multiple transfusions of blood = iron build up if not excreted. Prevent by iron chelation once ferritin > 1000. = chelating agents to remove iron. 'Deferasirox'
115
Which antibodies can cross the placenta?
Only IgG.
116
How can haemolytic disease of the newborn occur?
Maternal antibodies cross the placenta and destroys fetal red cells.
117
How does giving anti-D immunoglobulin prophylactically work?
72 hours within an event e.g. bleed, give red cells coated in anti-D Ig (immunoglobulin) = mother's spleen will remove them before body has time to develop antibodies to anti-D (sensitisation will not occur).
- does not work if mother already has anti-D antibodies
- we give anti-D antibodies at delivery if feotus is already known to be RhD Positive.
118
How does giving anti-D immunoglobulin prophylactically work?
72 hours within an event e.g. bleed, give red cells coated in anti-D Ig (immunoglobulin) = mother's spleen will remove them before body has time to develop antibodies to anti-D.
119
What are the doses of anti-D that we give before and after 20 weeks of pregnancy?
Before 20 weeks = 250 iu
| After 20 weeks = 500 iu
120
What is sensitisation?
In effect to produce an allergic response - to cause antigens to bind to antibodies.
121
What is HLA?
a complex of genes (MHC) on chromosome 6 - proteins found on cells e.g. MHC class II found on CD8+ T cells.
122
What is HLA?
a MHC on chromosome 6 - proteins found on cells e.g. MHC class II found on CD8+ T cells.
123
Which chromosome is HLA found on?
Chromosome 6.
124
Which HLA Class is expressed on all cells?
HLA Class I (A, B, C)
HLA Class III is DQ, DR, DP.
125
HLA is found on which cells?
The APC (HLA is a MHC found on the APC to present to the T cell).
126
How can HLA be a problem in transplantation?
HLA genes are so variable between human beings = creates mismatches in transplantation due to immune reactions as 'foreign material'.
e.g. = donor is HLA-A1 when recipient has a mix of HLA-A 1 and HLA-A2
127
Are anti-HLA antibodies naturally occuring?
No; they are formed later in life e.g. during pregnancy or transplantation (after a stimulation).
Not like anti-A or anti-B.
128
Are anti-A and anti-B antibodies naturally occuring?
Yes.
129
Name two ways in which we can prevent graft rejection?
ABO/ HLA tissue matching
| Anti-HLA antibody screening
130
Name two ways in which we can prevent graft rejection?
ABO/ HLA tissue matching
| HLA screening
131
Which are the three infections currently screened for during pregnancy?
HIV
Hepatitis B
Syphilis
132
What is the TORCH screen?
```
Used for screening congenital infections;
Toxiplasmosis
Other (HIV, hepatitis B syphilis)
Rubella
Cytomegalovirus
HSV.
```
133
Name 3 typical signs in congenital infection.
Rashes
Jaundice
Hepatosplenomegaly
134
Name three clinical features of congenital rubella syndrome?
Eyes - cataracts, glaucoma
Ears - deafness
Heart - PDA, ASD/VSD.
135
Name three clinical features of congenital rubella syndrome?
Eyes - cataracts, glaucoma
Ears - deafness
Heart - PDA, VSD.
136
How does the treatment differ in early onset sepsis Vs. late onset sepsis?
Early onset antibiotics: Benzylpenicillin +gentamycin
| Late onset antibiotics = cefotaxime + vancomycin.
137
Which is the most important bacterial cause of paediatric mortality and morbidity?
Meningitis
138
Name 3 investigations for meningitis
Lumbar puncture for CSF.
Throat swabs
Blood cultures
139
How does viral fluid appear on CSF?
```
Clear
Normal glucose (bacterial = low glucose).
```
140
How does viral fluid appear on CSF?
Clear
141
Which is the most important microorganism cause of paediatric mortality and morbidity?
Streptococcus pneumoniae.
142
Which are the two main species responsible for Meningitis?
Neisseria Meningitidis
| Streptococcus pneumoniae.
143
Are most respiratory infections in children bacterial or viral?
Viral
144
What is the most bacterial cause of respiratory tract infections in children?
Streptococcus pneumoniae.
145
Which treatments are commonly the treatment of choice in children with bacterial respiratory tract infections?
Macrolides e.g. azithromycin; many strains are resistant to penicillin or amoxicillin.
146
Bordetella pertussis is responsible for which condition?
Whooping cough.
147
Which is the biggest culprit for Urinary tract infections?
E.Coli
148
What is the relationship between GFR and clearance?
GFR and clearance should equal one another if markers are not reabsorbed/ filtered or bound to serum proteins.
149
Which is the gold standard marker to measure GFR?
Inulin (collected from urine)
150
What is inulin?
The perfect Gold standard marker to measure GFR.
However, not suitable to adminster
so use Cr-EDTA.
151
Name three characteristics of the ideal marker to measure GFR.
Not reabsorbed
Freely filtered at glomerulus!
Not plasma protein bound.
152
What is the disadvantage of using urea as a marker for GFR?
Urea is reabsorbed by the tubular cells.
153
What is the disadvantage of using creatinine as a marker for GFR?
Actively secreted into the urine by tubular cells.
| Related to muscle mass.
154
Is Creatinine the ideal marker for measuring GFR?
No. can be used but actively secreted by the tubular cells into the urine.
155
Is the issue with creatinine that it is reabsorbed by the tubular cells?
No; it is actively secreted by tubular cells.
| Urea is reabsorbed by tubular cells.
156
The Cockcroft Gault equation can be used to measure what more accurately?
Creatinine clearance.
| Incorporates weight and gender
157
What is Cystatin?
A marker of GFR (again, not the best as reabsorbed. Inulin = ideal).
158
For creatinine clearance, can we take a single urine sample?
No; needs a 24hour collection sample.
159
The Bence Jones protein in urine is diagnostic for which condition?
Multiple myeloma (blood cancer affecting plasma cells).
160
Does the urine dipstick test sensitively detect bence jones proteins?
No. Usual urine dipstick testing is not sensitive to BJPs.
161
You can reliably exclude bacteriuria if the urine
| dipstick is negative for nitrites. True or false.
True.
162
What does urine microscopy examine for?
Crystals, red blood cells, white blood cells.
| Centrifuge at 3000rpm.
163
Calcium oxalate crystals and alcoholic poisoning. What is the likely diagnosis?
Ethylene glycol poisoning.
164
Which white blood cell is bilobar?
Eosinophil
165
What is the best way to measure kidney function?
GFR not creatinine.
| best way to measure GFR is through inulin (but not always realistic).
166
How many stages in acute kidney injury?
3 stages.
AKI Stage 1 (more than x1.5-1.9 fold creatinine)
AKI Stage 2
AKI Stage 3 (more than 3 fold baseline creatinine)
167
Pre renal kidney injury is associated with structural abnormalities. True or false?
False = why pre renal injury responds to restoration of volume.
168
What is the difference between pre-renal acute kidney injury and acute tubular necrosis?
Pre renal AKI responses to restoring circulatory volume (i.e. fluids) due to there not being structural damage whereas acute tubular necrosis does not.
169
A 68 year old man with previously normal renal function is found to have a creatinine of 624μmol/l. What is the likely cause of his AKI?
Benign prostatic hyperplasia.
170
Acute blood loss is likely to cause which kind of kidney injury?
Pre-renal acute kidney injury
171
Obstructive uropathy is likely to cause which kind of AKI?
Post-renal acute kidney injury.
172
Vasculitis and glomerulonephritis are likely to cause which kind of acute kidney injury?
Intrinsic AKI.
173
What is rhabdomyolysis?
Breakdown of muscle releasing leaked muscle content into the circulation.
174
What are the four stages of wound healing?
Haemostasis
Inflammation
Proliferation
Remodelling
175
How many stages of chronic kidney disease are there compared with acute kidney disease?
```
Acute = 3 stages
Chronic = 5 stages
```
176
What is the main marker for chronic kidney disease?
ACR - albumin: creatinine ratio.
177
Name three consequences of Chronic kidney disease.
```
Hyperkalaemia
Acidosis
Anaemia
Renal bone disease
Hyperparathyroidism
Uraemia
```
178
Acidosis and hyperkalaemia are main causes of which kidney disease?
Chronic kidney disease.
179
Does kidney failure result in acidosis or alkalosis?
Acidosis; failure of kidney to excrete protons.
180
How do we treat acidosis?
Sodium bicarbonate.
181
What two measures do
| we use to define acute kidney injury?
Creatinine and urine output.
182
Which medications can cause hyperkalaemia?
potassium sparing diuretics e.g. spironolactone
| ACE Inhibitors
183
How does chronic renal disease cause anaemia?
Decline in erythropoietin producing cells.
Usually normocytic, normochromic.
184
What is an ESA?
Erythropoietin stimulating agent.
185
How can chronic kidney disease (CKD) cause hyperparathyroidism?
High PTH causes low Vitamin D and high phosphate = resistance to PTH = hypocalcaemia = high PTH
186
What is 1-alpha calcidol
Vitamin D receptor activator.
187
What cardiovascular impact can chronic kidney disease have?
Uraemia
= uraemic cardiomyopathy.
188
BMI >30 is a contraindication to transplantation. True or false?
False.
189
What is the difference between haemodialysis and peritoneal dialysis?
Haemodialysis = Artery to machine outside of the body which acts as a filter.
Peritoneal dialysis = Lining of the belly acts as a natural filter.
190
What is usually the route of administration for adrenaline in anaphylaxis?
Intramuscular; intravenous is used rarely e.g. in cardiac arrest.
191
What is the typical dose of adrenaline for children aged 6-11 years in anaphylaxis?
300 micrograms of 1:1000 adrenaline IM. Repeat every 5 minutes if necessary.
192
How often is adrenaline repeated in anaphylaxis?
Every 5 minutes.
193
Which is the most appropriate test for food allergies?
Skin prick test.
194
What is the amount of adrenaline injection in children Vs adults?
```
Children = 300mcg
Adults = 500mcg.
```
195
Give three signs of anaphylaxis.
Urticarial rash
Stridor
Acute onset hypotension
Respiratory distress
196
What is chlorphenamine?
An antihistamine
197
Which is the test we use most commonly to test for contact dermatitis?
Skin patch test.
198
What is the best enzyme to confirm anaphylaxis?
Tryptase levels (remains elevated for 12 hours following episode).
199
On examination a patient has gross facial and tongue oedema - should they be treated for anaphylaxis IM or IV?
IM still. IV for severe reactions e.g. shock
200
What is the typical dose of adrenaline for children aged 6 months - 5 years in anaphylaxis?
150 micrograms (1 in 1000)
201
What is refractory anaphylaxis?
Respiratory and cardiovascular problems.
202
What does HAI stand for?
Healthcare associated infection. (not hospital acquired!)
203
Antibiotic associated diarrhoea is most likely caused by which organism?
Clostridium difficile.
204
Give two examples of E.Coli associated infection
```
Urinary catheter (UTI)s
Ventilator associated (pneumonia)
```
205
How prevalent are HAI in the UK?
300 000 a year -
206
Which is the most common HCAI?
Clostridium difficile
207
What kind of bacteria is Clostridium difficile?
Gram positive spore forming anaerobe.
208
What kind of bacteria is Clostridium difficile?
Gram positive spore forming anaerobe.
| Produces toxins A and B.
209
Name one key risk factor Clostridium difficile infection.
Antibiotic use.
210
Which is the first line treatment for Clostridium difficile?
Vancomycin/ Fidaxomicin
211
Which is the main bacteria associated with catheter infection?
E.Coli
212
Name some commonly resistant gram negative bacteria.
E. Coli, klebsiella, enterobacter
213
Which bacteria has high resistance to antibiotics?
Enterobacter
214
Which is the go to antibiotic for cellulitis?
Cefuroxime and Vancomycin
215
For MRSA, which is the go to antibiotic?
Meropenem and Vancomycin
216
For MRSA, which is the go to antibiotic?
Meropenem and vancomycin
217
Name three places where MRSA may be found in HAI?
Catheters, UTI associated catheters, SSI.
218
Give some examples of how we can class immune deficiencies.
```
Metabolic
Infection
Age
Malnutrition
Environmental
Drug
```
219
What is the commonest cause of secondary immune deficiencies?
Malnutrition.
220
How would you classify methotrexate?
Cytotoxic agent
221
What type of drug if phenytoin?
Anti epileptic
222
Which biological agent is associated with reactivation of TB?
Anti-TNF agents.
223
Name three haematological cancers (blood cancers)
Multiple Myeloma
Non Hodgkin's lymphoma
CLL - Chronic lymphocytic leukaemia
224
What is FISH?
FBC
Immunoglobulins (IgG, IgA, IgM, IgE).
Serum complement (C3, C4)
HIV test
225
What is the main method by which serum protein electrophoresis works?
SPE separation through charge.
226
Where can SPE be helpful?
Serum protein electrophoresis: can detect monoclonal bands seen in blood cancers e.g. multiple myeloma, NHL.
SPE can miss 20% light chains.
227
What can SPE miss?
Identifying light chains.
228
What type of vaccine is the Tetanus vaccine?
Protein antigen.
229
What type of vaccine is the Pneumovax?
Carbohydrate antigen
230
What is key diagnostic aspect for primary antibody syndromes?
Failure to respond to vaccination.
231
Flow cytometry is mainly used to assess which cell type?
The lymphocyte
232
Name the three tests we should do for immune deficiencies.
FISH, renal and liver profile, calcium and bone profile, SPE (serum protein electrophoresis) and flow cytometry, assessment of IgG classes.
233
Which are the four incurable sexually transmitted diseases?
HIV
Hepatitis B
Herpes
HPV
234
What is the pathogenesis of HIV?
HIV virus binds to CD4 then CCR5 and CXCR4
| Replicates via a DNA intermediate
235
Which is the bacterium associated with reheated cooked rice?
Bacillus cereus.
236
How would campylobacter jejuni present in a patient?
BLOODY diarrhoea and vomiting.
237
Which is the first line medication of choice for a patient presentation of bloody diarrhoea and vomiting?
Ciprofloxacin.
238
Which medication is usually used for traveller's diarrhoea?
Clarithromycin.
239
Which is the most common cause of Traveller's diarrhoea?
E. Coli.
240
Which is the most common cause of Traveller's diarrhoea with a 15 day long history?
Giardiasis.
241
Low Hb and low reticulocyte count is likely to point toward which diagnosis?
Parvovirus B19 infection due to aplasia in this infection.
242
Vaginal WHITE discharge with fishy smell points toward which diagnosis?
Bacterial vaginosis.
243
What is the key organism causing bacterial vaginosis?
Gardnerella vaginalis.
244
How does bacterial vaginosis compare with trichomonas?
Bacterial vaginosis = white discharge
| Trichomonas = green, frothy discharge.
245
What is the medical term for the bull's eye rash and in which condition is it seen?
Erythema Migrans - seen in Lyme's disease.
246
Which test should be offered to all those with TB?
A HIV test; TB is an 'AIDS defining' illness.
247
Which is the most common cause of pyelonephritis?
E.Coli
248
Which bacteria is typically due to the cause of diarrhoea following rice?
Bacillus cereus.
249
What is an aspergilloma?
A mass caused by the fungus aspergillus which is associated with TB.
250
What happens to CD4+ T cells in chronic HIV?
CD4+ T cell depletion
Impaired CD4+ and CD8+ T cells
In acute HIV, some increase in CD8+
251
How do we diagnose HIV infection?
'4th Generation testing'
HIV antigen and antibody testing.
Assays detect specific antigens.
252
Name three comorbidities of HIV.
```
TB
Diabetes Mellitus
GORD
Hepatitis B and C
Depression and anxiety
```
253
Name three baseline investigations for HIV.
Full Blood count
Renal, liver and bone profile
Sexual health screen
Baseline chest x ray and ECG.
254
Name three things which determine the magnitude of the HIV viral load on a graph.
CD8+ count
Immune activation
Genetics
Viral genetics
255
Name one key virus where CD4+ is the lowest.
CMV
| Cytomegalovirus.
256
Which is the most important prognostic indicator in HIV patients?
CD4+ T cell count
257
Ritonavir works through which mechanism and for which condition?
Protease inhibitor
| In HIV.
258
What is Maraviroc?
A CCR5 antagonist used in treatment of HIV.
259
Which medication types are currently Golden practice for treating HIV?
x2 NRTI and x1 integrase inhibitor.
260
ART can eliminate infection once HIV-1 has integrated into host DNA - true or false.
False.
261
Which part of the adrenal gland makes cortisol?
Zona fasciculata.
262
What does the zona reticularis make?
Androgens.
263
What may a patient presenting with low blood sugar and low thyroxine have as a condition?
low blood sugar = low cortisol = addison's
low thyroxine = hypothyroidism
Addison's + hypothyroidism = Schmidt's syndrome.
264
Which is the test for Addison's?
```
Short SynACTHen test.
= give patient ACTH and cortisol.
Adminster 250mcg of ACTH
Check cortisol at 30 and 60 minutes.
In Addison's, cortisol will stay low despite ACTH injection.
```
265
Name three possible adrenal masses.
Phaeochromocytoma
Conn's syndrome (aldosterone secreting tumour)
Cushing's syndrome = (cortisol secreting mass)
266
How do we treat phaeochromocytomas?
Alpha blocker
THEN
beta blocker:
267
Which is the alpha blocker we use in phaeochromocytoma?
phenoxybenzamine.
268
In which condition do we use the Dexamethasone suppression test?
Cushing's syndrome.
269
What is a normal cortisol level?
<50nM
270
In a set of results, how can we differentiate between Cushing's syndrome and Cushing's disease (pituitary dependent cause)?
Cushing's syndrome = levels still stay very high
| Cushing's disease = levels decrease but still above range.
271
Which is the number one cause for Cushing's syndrome?
Being on oral steroids for something else i.e. another condition.
272
```
9am cortisol (Wednesday): 500 nM
Given high dose dex suppression
9am cortisol (Friday) 170nM
What is the diagnosis?
```
Cushing's disease (pituitary dependent).
273
Name two neoplastic lung diseases
Lung cancer
| Mesothelioma (asbestos = main culprit).
274
Which are the two ways in which we can divide non neoplastic lung disease?
Airway (Asthma, COPD, bronchitis)
| Parenchymal (Fibrosing interstitial disease, infection, pulmonary oedema, emphysema).
275
Define Chronic bronchitis.
Productive cough for most days for at least 3 months over 2 consecutive years.
276
Define bronchiectasis
Permanent abnormal dilatation of bronchi
Bronchiectasis is not reversible.
277
Which patients are most at risk of bronchiectasis?
Post infection e.g. cystic fibrosis.
| Obstruction in lobe.
278
What is the main aspect of cystic fibrosis contributing to respiratory disease?
Mucus production.
279
Name a main cause of pulmonary oedema from the cardiovascular system.
Left ventricular failure.
280
What is hyaline membrane disease of the newborn?
Lack of surfactant production in neonates = stiff lung.
281
'White out' of lungs on x ray is most commonly due to what?
```
Alveolar damage (= white infiltrates).
'DAD - diffuse alveolar damage.
```
282
Which are the two types of bacterial pneumonia we often refer to? (clue is location).
Lobar pneumonia and Bronchopneumonia.
283
What is a key difference between bronchopneumonia and lobar pneumonia?
Bronchopneumonia is due to low virulence organisms e.g staphylococcus, streptococcus.
Lobar pneumonia is due to high virulence organisms e.g. pneumococci.
284
Describe the four stages of lobar pneumonia.
```
CRGR
Congestion; hyperaemia.
Red hepatisation (RBCs, fibrin)
Grey hepatisation (RBCs break down = exudate)
Resolution .
```
285
Define emphysema
Permanent loss of the alveolar parenchyma to the terminal bronchiole.
286
Is Emphysema an airway or parenchymal disease?
Parenchymal disease.
287
Which protein predisposes one to emphysema?
Deficiency in alpha 1 anti-trypsin.
288
What is the relationship between smoking and emphysema?
Smoking reduces alpha 1 antitrypsin = an antiprotease = tissue damage (tissues need proteases).
289
Give 3 causes of granulomatous disease.
Sarcoidosis
IVDU
Infection
290
What are we talking about when we refer to 'farmer's lung'?
Extrinsic allergic alveolitis.
291
Name the three non-small cell carcinomas
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
292
What type of cancer is an adenocarcinoma?
Non small cell carcinoma
293
Are all non small cell carcinomas malignant?
Yes
294
Which comes first - metaplasia or dysplasia?
Hyperplasia to metaplasia to dysplasia.
295
What is the main precursor to a adenocarcinoma?
AAH - atypical adenomatous hyperplasia (a lesion).
296
Are adenocarcinomas mainly central or peripheral compared to squamous cell carcinoma?
Peripheral
297
Which type of cancer can be targeted more easily with specific drug therapies?
Adenocarcinoma (in contrast, squamous cell carcinomas can get worse with some drug therapies e.g. can haemorrhage).
298
Generally, which cancer types are more chemosensitive (sensitive to chemotherapy)?
Small cell cancers respond better to chemotherapy than non small cell cancers.
299
Cetuximab is a cancer therapy targeting which pathway?
EGFR pathway.
300
An EGFR mutation is most likely to cause which cancer?
Adenocarcinoma
301
PDL1 expression is commonly seen in which cancer?
Squamous cell carcinoma
302
What are anal genital warts?
Benign epithelial tumours
303
Which virus causes anogenital warts?
HPV.
304
In which part of the skin does most cell replication occur?
Stratum spinosum
305
HPV codes for how many proteins?
6-8 proteins
306
Which is the main type of HPV to cause genital warts?
Type 6.
307
What is the maximum incubation time for HPV?
2 years.
308
Which is the initial test for female patients presenting with warts?
Speculum examination
309
Name some causes of a low lymphocyte count
HIV infection
Renal failure
Steroid therapy
310
Why would you perform an MRI before a lumbar puncture?
Need to exclude a mass lesion if for example the patient is drowsy so do not do LP first = to avoid coning.
311
Which test is certainly NOT recommended in suspected brain mass lesions?
Lumbar puncture;coning
312
Which test is certainly NOT recommended in suspected brain mass lesions?
Lumbar puncture; coning
313
What is coning?
Risk of compression of the lower brain stem as cerebellar tonsils move down through the foramen magnum
314
Which is the main CNS culprit microorganism for AIDS?
Toxoplasma gondii
315
What are amphotericin/ fluconazole used to treat?
Fungal infections e.g. cryptococcus.
316
Give 3 common causes of fever in the traveller -
x1 bacterial
x1 viral
x1 parasitic
```
Bacterial = Typhoid
Viral = Arbovirus (dengue)
Parasitic = Malaria
```
317
Which virus causes Dengue fever?
Arbovirus
318
Name two common acute viruses that can present with fever.
```
Dengue fever
HIV seroconversion (when antibodies become detectable)
```
319
Give 2 causes of Jaundice in a traveller with fever
Malaria
Leptosporosis
Cholangitis
320
25 year old female returning from Uganda.
History of fever, mouth sores and rash.
Lymphadenopathy
Fever with rash: think viruses
?EBV
?HIV Seroconversion
321
What is herpes zoster?
Shingles - cannot become infected if not for having previously had Chickenpox.
322
What is the main difference between viral meningitis and viral encephalitis?
In viral meningitis, there will be a complete absence of brain function.
323
What is the normal level for CSF protein?
0. 15-0.45g/L
i. e. 150-450mg/L.
>450mg/L = high protein i.e. viral
324
Which is the most common cause of viral meningitis vs. viral encephalitis?
Viral meningitis = enteroviruses
| Viral encephalitis = Herpes simplex viruses
325
What is the name of the equation to determine creatinine clearance and which 3 factors are required to calculate these?
Cockcroft-Gault equation
Age
Weight
Serum creatinine
326
Is bacterial or viral meningitis more common?
Bacterial meningitis.
327
Is a petechial or purpuric rash common in meningitis?
No; but when it is seen, it is common for meningococcal septicaemia.
328
When is an EDTA PCR sample performed?
For pneumococcal and meningococcal infection.
329
What is the first line management for bacterial meningitis?
Broad spectrum antibiotics and steroids.
330
Which is the most common cause microorganism wise in young adults in bacterial meningitis?
Neisseria Meningitidis.
331
What caution must we take with sickle cell disease patients?
They are hyposplenic so therefore they are at risk of pneumococcus, meningococcus and haemophilus influenzae B.
332
When a rash DOES present in Meningitis, what is the likely microorganism?
Meningococcus
333
Itchy skin, jaundice, aches, fatigue and returned from Egypt having had local food. Not sexually active for past 3 months. What is the diagnosis?
Hepatitis A.
334
Which is the most common route of transmission for hepatitis A?
Faeco-oral route.
335
Which is the main test we use to test for hepatitis A?
Serology IgG/ IgM. (but this does not distinguish between new and chronic illness).
336
How long must a patient be on HIV treatment for before returning to unprotected sex?
6 months
337
Which is the most common cause of tonsillitis?
Group A Streptococcus.
338
Which condition is known as the 'kissing disease'?
infective mononucleosis/ glandular fever (same name both caused by EBV).
339
Which is the specific test for HIV?
4th generation antibody antigen HIV test
340
Name three tests we request in querying an STI.
HIV 4th generation test
Hepatitis screen
Syphilis serology
341
How do we confirm a diagnosis of hepatitis B?
We require a surface antigen rather than just surface and core antibodies; can have Hepatitis B antibody just from begin vaccinated.
342
What will be positive in a hepatitis B vaccination?
Surface antibody (not antigen). - antigen is if someone actually has hepatitis B.
343
Lymphocytes in the CSF should make one consider which two conditions?
Encephalitis
| Meningitis
344
Lymphadenopathy, fever, splenomegaly and lymphocytosis should make one consider which diagnosis?
Glandular fever is the same thing as infective mononucleosis (caused by EBV).
345
Fever, symmetrical facial swelling, headache, neck stiffness. What is the likely diagnosis?
Mumps virus; symmetrical facial swelling. Mumps is a notifiable disease BTW.
346
In Hepatitis serology, how would we gauge that the patient currently has active disease?
A positive HBV sAg (surface antigen) - confirmed by body antigen.
347
Which is the most likely route of transmission for Hepatitis B?
Sexual contact
348
Give 3 facts about Hepatitis B including incubation period.
```
8 genotypes
DNA virus
Sexual contact
Incubation period - 1-6 months.
Treat with nucleoside analogue: Tenofovir
```
349
From hepatitis serology, how can we tell if a patient is non infectious?
Surface antigen negative: HBV sAg -ve
350
What do we use to treat Hepatitis B?
Tenofovir.
351
When is HBV (hepatitis B) infection classed as chronic?
When longer than 6 months.
352
Hepatitis B Infected mothers can continue to breast feed as there is no additional risk of transmission. True or false.
True.
(Vertical transmission is 90% common from mother to baby when mother is eAg positive). - 10% common when mother is surface antigen positive.
353
With which hepatitis can you get hepatitis D?
Hepatitis B.
354
Give 3 typical ways a patient with Malaria can present.
Cerebral involvement (dizzy, drowsy)
Anaemia
Renal failure
Hypoglycaemia
355
Which is the preferred treatment for malaria?
IV artesunate
356
What is the most common cause of a purpuric rash? - Purpura Fulminans?
Meningococcal sepsis
| secondly pneumococcal sepsis and staphylococcus sepsis
357
What is the first line of treatment for Meningococcal sepsis?
Ceftriaxone for N. Meningitidis
| - if N. Meningitidis is the KNOWN cause, treat with benzylpenicillin.
358
Which class of drugs is Ceftriaxone?
Cephalosporin
359
Why would we not use clarithromycin in cholecystitis?
Does not cover gut bacteria.
360
Which bacteria would we use to cover most gram negative bacteria and anaerobes?
Co-amoxiclav
361
Gentamicin is in which class of antibiotics?
Aminoglycoside
362
Which causes a rash - Mumps or measles?
Measles. Mumps does not cause a rash.
363
Name three conditions which could present with a maculopapular rash.
Measles
HIV
Rubella
Hand foot and mouth disease.
364
Give 3 causes of granulomatous inflammation in the liver.
Sarcoidosis
Tuberculosis
Schistomiasis
Drug-induced
365
What type of amyloid is associated with multiple myeloma?
AL - light chain amyloid.
366
Give 3 different causes of liver damage due to alcohol.
Steatosis
Steatohepatitis (more ballooning and fibrosis associated compared with steatosis).
Cirrhosis
367
Give an example of a monogenic autoinflammatory disease.
Familial Mediterranean fever
368
Give an example of a monogenic autoimmune disease.
FOX P3 IPEX (immune regulation, polyendocrinopathy, enteropathy, X-linked syndrome).
369
Which type of condition is Crohn's disease?
Polygenic inflammatory.
370
In which conditions (generally) are HLA associated?
Autoimmune
371
What is Hashimoto's disease?
The most common form of hypothyroidism.
372
Which is the best marker for rheumatoid arthritis?
Anti CCP (rather than rheumatoid factor).
373
What is MC&S?
Microscopy, culture and sensitivity.
374
What is the difference between colonisation and infection?
```
Colonisation = bacteria multiply with no host response
Infection = bacteria multiply WITH host response.
```
375
What is the difference between culture and sensitivity?
```
Culture = identification of a bacteria
Sensitivity = identifying which antibiotics are most suitable.
```
376
In gram stain, what are purple cells?
Gram positive.
377
Name a yeast which causes Meningitis.
Cryptococcus meningitis. (cryptococcal neoformans = encapsulated yeast i.e.fungus).
378
Which microorganism causes slapped cheek syndrome?
Parvovirus B19. - erythema infectiosum.
379
How would you differentiate between Malaria and Hepatitis A presentation. Also consider what are their typical presentations.
Typically both = fever, malaise, jaundice. splenomegaly.
Malaria = shorter, maybe 3 days.
Hepatitis A = longer incubation period, few weeks.
Hepatitis A = severe jaundice.
380
What is the normal range for CD4+ cell count?
500 - 1500 cell/mm^3
381
A patient with a CD4+ count of <200cell/mm^3 will require what for their treatment?
HAART and co-trimoxazole to cover against pneumocystis jiroveci pneumonia.
382
Name the medication we use to treat Pneumocystis Jiroveci?
Co-Trimoxazole.
383
Name the medication used to treat Meningococcal meningitis prophylactically.
Ciprofloxacin.
384
Which medication should not be taken during breastfeeding?
Codeine.
385
Name the emergency contraception medication.
Levonorgestrel
386
Which is the medication of choice if a patient is allergic to penicillin?
Doxycycline, clarithromycin.
387
What type of bacteria is Neisseria Gonorrhoea?
Gram negative coccus
388
What are the signs of Gonorrhoea in men?
Urethral discharge and dysuria.
389
Which drug class does Ciprofloxacin belong to?
Fluoroquinolone
390
With regards to Glandular fever, what is the main advice we would give patients playing sports?
Do not play contact sports for 4 weeks.
391
Name the largest risk factor for colonic carcinoma
Ulcerative Colitis
392
Describe Ulcerative Colitis' inflammation.
Inflammation confined to the mucosa.
393
Describe Crohn's inflammation.
Transmural inflammation
394
In a patient with diarrhoea with C. difficile as the likely cause, how do we treat?
Oral vancomycin
395
What is the relationship between cortisol and potassium?
Cortisol causes hypokalaemia
| High cortisol = low potassium
396
Does alkalosis cause hyper or hypokalaemia?
Hypokalaemia
397
How would we differentiate between ATN and glomerula disease?
Renal biopsy.
398
Name the 3 causes of Cushing's disease
Pituitary
Ectopic ACTH
Adrenal tumour
399
Which cause of Cushing's disease is associated with hypokalaemia?
Ectopic ACTH; Cortisol is very high
| High Cortisol = low potassium
400
What is the most frequent brain tumour in adults?
Metastatic deposit
401
What is the most frequent brain tumour in children?
Pilocytic astrocytoma
402
What does the tumour grade tell us?:
Therapy response
Disease Spread
Survival
Cell of origin
Survival
403
Which mutation identifies astrocytic tumours with a better prognosis?
IDH mutation
404
5 year old headache, vomiting and papilloedema with cystic lesion. Diagnosis?
Pilocytic astrocytoma (common in children. Meningiomas uncommon in children).
405
70 year old with left arm and leg weakness and then seizure. MRI shows heterogeneous enhancing right frontal lesion. Diagnosis?
Glioblastoma grade 4.
406
What will 'compensated' mean in arterial blood gases
The pH is normally improved whereas the PC02 then has to increase
407
Which are the two types of oedema?
Vasogenic (damages BBB) and Cytotoxic (cellular injury)
408
Which are the two types of hydrocephalus?
```
Non-communicating = obstruction of CSF flow
Communicating = no obstruction. Problem is with reabsorption of CSF into venous sinuses.
```
409
What are the consequences of raised ICP on the brain?
Forces brain against the skull and inflexible dural folds = results in herniation of brain where there is space available.
410
Which are the two kinds of stroke?
haemorrhagic and infarct
411
Is subdural haemorrhage classified as a stroke?
No. Only subarachnoid haemorrhage (SAH)
412
What is the average duration of a TIA?
1 minute. Most TIAs last less than five minutes.
413
There is permanent damage to the brain when a TIA is over. True or false?
False; this is the case with stroke, not TIA.
414
Most strokes are due to infarct or haemorrhage?
Infarct
415
What is a contusion?
Brain in collision with the skull
416
What is the commonest cause of a coma?
Diffuse axonal injury
417
In which condition do we see heinz bodies?
Glucose-6-phosphate dehydrogenase deficiency
418
In which conditions do we see Howell-Jolly bodies? What do they look like?
Sickle cell disease
Hyposplenism
Megaloblastic anaemia
Basophilic (purple spot) nuclear remnants in RBCs.
419
What are reticulocytes?
Immature RBCs.
420
What does right shift mean?
Hypermature white cells
421
What is rouleaux formation? Where may we see it?
Stacked RBCs - myeloma
422
What is the name of the fragmented parts of RBCs - irregularly shaped with sharp edges? In which condition are these soon?
Schistocytes seen in DIC, HUS (haemolytic uraemic syndrome), TTP.
423
What is the name of the cell bull's eye appearance with central pallor? Where may these be seen?
Target cell - seen in Liver disease, hyposplenism.
424
What is often the cause of high MCV?
Decreased production of RBCs. This is why folate/B12 deficiency result in macrocytic anaemias - B12 and folate are required for RBC production.
425
Give two conditions which result in low MCV.
Iron deficiency, thalassaemia.
| ACD - Anaemia of chronic disease
426
Which condition would show normal MCV?
Acute blood loss.
427
Give 3 ways Iron deficiency anaemia may present on the blood film.
Poikilocytosis
Anisocytosis
Microcytosis
Hypochromic cells
428
Which are the first investigations to assess iron deficiency anaemia
OGD, colonoscopy, urine dip, coeliac investigation.
429
What is ACD? What is Anaemia of Chronic disease?
Inhibition of RBCs driven by cytokines e.g. TNF-alpha (reduces EPO synthesis).
430
Give 2 causes of anaemia of chronic disease.
Chronic infection e.g. TB
Rheumatoid arthritis
Malignancy.
431
Is ferritin high or low in ACD?
High.
432
What is the difference between iron deficiency and anaemia of chronic disease in terms of iron and ferritin?
Iron deficiency; Low iron, low ferritin, high TIBC.
| Anaemia of chronic disease; Low iron, high ferritin, low TIBC.
433
What are iron levels usually like in pregnancy?
High.
434
Which cell is characteristically low in aplastic anaemia?
Reticulocyte count
435
How will MCV look in Alcohol?
High MCV.
436
Which is the most common cause of macrocytosis without anaemia?
Alcohol
437
What does a megaloblastic blood film look like?
Hypersegmented polymorphs, leucopenia, macrocytosis.
438
What is the name of the condition in which there is B12 deficiency? What can we give to treat?
Pernicious anaemia. Give vitamin B12 in form of hydroxocobalamin.
439
Which is the test we use to diagnose Pernicious anaemia.
Parietal cell antibodies.
440
How do haemolytic anaemias present in terms of markers?
Raised unconjugated bilirubin, LDH, Hb (; increased breakdown of RBCs).
441
Which marker is raised in haemolytic anaemia?
Raised unconjugated bilirubin
442
Parvovirus B19 can cause what?
Aplastic crisis
443
Sickle cell disease and thalassaemia are examples of which type of condition?
Haemoglobinopathies
444
Hereditary spherocytosis is what kind of defect?
Membrane defect
445
What is the main cause of hereditary spherocytosis?
Spectrin/ ankyrin deficiency.
446
How can we treat spherocytosis?
Splenectomy, folic acid.
447
Name three causes of haemolytic anaemias
Membrane defects e.g. Hereditary spherocytosis, elliptocytosis
Enzyme defects e.g. G6PD deficiency, pyruvate deficiency
Haemoglobinopathies e.g. sickle cell disease, beta thalassaemia
Non inherited causes include drugs, alloimmune e.g. haemolytic transfusion reactions.
448
How do we treat hereditary spherocytosis?
Splenectomy and Folic acid.
449
Which is the commonest RBC enzyme defect?
Glucose-6-phosphate dehydrogenase deficiency.
450
What is Glucose-6-phosphate dehydrogenase deficiency? G6PD. Which cell is associated with it?
X linked RBC enzyme defect.
Rapid anaemia and jaundice
Heinz bodies
Dark urine; intravascular haemolysis
451
What is the cause of dark urine in Glucose-6-phosphate dehydrogenase deficiency?
Intravascular haemolysis
452
Which foods can precipitate Glucose-6-phosphate dehydrogenase deficiency?
Fava broad beans; an oxidant
453
What are the clinical features of pyruvate kinase deficiency?
Neonatal Jaundice
Splenomegaly
Haemolytic anaemia
454
Describe the difference in structure between HbA, HbA2 and HbF.
HbA - 2 alpha, 2 beta
HbA2 = 2 alpha, 2 gamma
HbF = 2 alpha, 2 delta
455
Which globin chain is affected in sickle cell disease and beta thalassaemia?
Beta globin chain.
456
Are haemoglobinopathies autosomal dominant or recessive?
Autosomal recessive.
457
What is the cause of sickle cell disease?
GAG-GTG mutation.
Glu - Val mutation at 6th amino acid on beta chain.
HbS instead of HbA.
458
What is HbAS compared with HbSS?
```
HbAS = sickle cell trait
HbSS = Sickle cell anaemia
```
459
When does sickle cell disease manifest?
3-6 months; reduction in foetal HbF.
460
Name three features of sickle cell disease.
Anaemia
Splenomegaly
Folate deficiency
461
How do we diagnose sickle cell anaemia?
Blood film
Hb electrophoresis
Guthrie test (at birth)
462
How do we treat sickle cell anaemia?
Analgesia
Blood transfusion in severe crises
All chronic patients should be on penicillin.
Folic acid and hydroxycarbamide (which will increase HbF).
463
How do we diagnose Beta thalassaemia?
Hb electrophoresis and Guthrie test.
464
What is the presentation of beta thalassaemia?
Skull bossing, maxillary hyptertrophy, hepatosplenomegaly.
465
How do we treat beta thalassaemia?
Blood transfusions with iron chelation.
| Folic acid.
466
What is the difference between alpha and beta thalassaemia?
Alpha thalassaemia = excess beta chains
| Beta thalassaemia = excess alpha chains.
467
What is the Coombs test?
Coombs/ antiglobulin test (AGT)/ DAT (direct antiglobulin test).
Coombs test checks for antibodies against RBCs.
```
DAT = identifies haemolytic anaemia. Positive = agglutination.
Indirect = only in prenatal testing (more prevention).
```
468
What is MAHA? Which is the key cell?
Microangiopathic haemolytic anaemia = Mechanical RBC destruction.
Key cell = schistocytes.
469
What is HUS? Which organism causes it? Give a patient's presentation.
Haemolytic uraemic syndrome. Caused by E.Coli
E.Coli toxin damages endothelial cells and RBCs.
MAHA, DIARRHOEA, RENAL FAILURE.
470
Which factor do we need to trigger the coagulation cascade?
Tissue factor.
471
Which factors convert prothrombin to thrombin?
Va (5a), Calcium and platelet factor.
472
Which factor converts Fibrinogen to fibrin?
Thrombin.
473
APTT Vs. PT Vs TT measure which part of the coagulation cascade? What do these stand for?
APTT (activated partial thromboplastin time) = intrinsic pathway
PT (prothrombin time) = extrinsic pathway
TT (thrombin time) = common pathway
474
Which factor does the intrinsic pathway start off with compared with the extrinsic pathway?
Intrinsic pathway starts with factor 12
| Extrinsic pathway starts with factor 7
475
APTT measures which part of the coagulation cascade?
The intrinsic pathway.
476
Name three causes of thrombocytopenia.
Bone marrow failure
AITP - autoimmune thrombocytopenia purpura
Drugs e.g. heparin.
477
What is the cause of Haemophilia A?
```
Factor 8 (VIII) deficiency
X linked (affects mainly males)
```
478
Why is the APTT prolonged but the PT is normal in Haemophilia A?
Haemophilia A = F8 deficiency. F8 is in the intrinsic pathway. APTT relates to intrinsic pathway only.
479
Which pathway does PT measure?
The extrinsic pathway.
480
What will blood tests look like in Haemophilia A?
Prolonged APTT
Normal PT
Low Factor VIII assay.
481
What is Haemophilia B?
Factor 9 deficiency.
482
What will APTT and PT look like in Haemophilia B?
Prolonged APTT ; Factor 9 is in the intrinsic pathway.
| Normal PT.
483
Which are the main factors in the extrinsic factor?
Factors 5 and 7. (Haemophilia is affected by factors 8/9 in the intrinsic pathway).
484
Which factor is affected in Von Willebrand's disease?
Factor 8 (VIII). Reduced F8 as F8 carries vwf.
485
Which is prolonged in vWF - APTT or PT?
Prolonged APTT; Factor 8 (in the intrinsic pathway) carries vWF.
486
What is DIC?
Widespread coagulation. Can be caused by malignancy, sepsis, trauma.
Hyperclotting.
487
Vitamin K is needed for the synthesis of which factors?
2, 7,9,10.
488
Give 2 causes of Vitamin K deficiency
1. Warfarin
| 2. Malabsorption, malnutrition of Vitamin K.
489
Despite using mainly APTT for much of the clotting disorders, when would we need PT?
Disseminated intravascular coagulation.
490
Which are the three factors of Virchow's triad?
Hyper coagulability
Endothelial stability (vessel wall)
Stasis (flow)
491
What is the Wells score used to measure?
Pulmonary embolism and DVT..
492
After a high Well's score, which tests should be performed? What does the Well's score assess?
Assessing an individual's risk for DVT, PE.
| High Well's: Ultrasound for DVT risk in limb. CTPA for PE.
493
Which treatment is involved in DVT prophylaxis?
Low molecular weight heparin, TED stockings.
494
How does heparin work?
Inactivating thrombin. Side effect = bleeding, thrombocytopenia.
495
What is the target INR?
2. 5 for first episode of DVT
| 3. 5 for recurrent DVT/ PE.
496
Name four haematological changes in pregnancy.
Reduced Hb, platelets, Protein S.
| Increased red cell mass, plasma volume.
497
How does haemolytic disease of the newborn occur?
antibodies from mother - often Anti-D cross the placenta and correspond to foetus' red cells which have the antigen = destroys the red blood cells. Causes anaemia and jaundice.
Always transfuse RhD negative blood.
498
Which pathway will affected in Haemophilia A and which will be normal?
```
apTT; F8/F9 deficiency in the intrinsic pathway
Normal PT (extrinsic pathway)
```
499
Spherocytosis and a positive Coomb's test is indicative of what?
Haemolytic anaemia.
500
How can AML be classified?
Myeloid or lymphoid.
| Acute or chronic.
501
Name 3 ways in which acute leukaemia is characterised?
Immature blast cells
| Bone marrow failure
502
Name three ways in which bone marrow failure can present in a patient.
```
Anaemia = pallor
Thrombocytopenia = bleeding
Neutropenia = infection
```
503
On a blood film, what do we typically see in AML?
Auer Rods, granules; myeloid and blast cells.
504
Which two investigations do we use to investigate AML?
Cytogenetics and FISH.
505
What is involved in a coagulation screen?
PT and thrombin time (does not include platelets)
506
Auer rods can be definitive of myeloid. True or false?
True.
507
Name two clinical features of AML.
Splenomegaly
| Hepatomegaly.
508
Which cell typically shows granules - lymphoblastic or myeloid?
Myeloid.
509
Name two causes of high MCV.
B12, folate deficiency.
510
Which marker will be definitively low in DIC?
Fibrinogen.
511
How do we treat polycythaemia vera?
Venesection and hydroxycarbamide
512
What is Polycythaemia vera caused by?
JAK2 mutation.
513
What does bone marrow aspirate look at?
Blast cells
| Erythroblasts
514
What is the main issue in AML in terms of mechanism?
Dysfunction in transcription factors during leukaemogenesis - but requires 2 hits.
515
Which test would you do to differentiate between AML and ALL?
Immunophenotyping
516
Give x3 features of AML
Bone marrow failure i.e. bleeding, anaemia, infection.
| DIC
517
When would you require a bone marrow aspirate?
When there is aleukaemic picture
518
How do we treat AML?
Red cells, platelets, fresh frozen plasma, allopurinol, chemotherapy.
519
Why does cytogenetic/molecular genetic category matter in treating AML vs ALL?
Ph-positive need imatinib
520
What is Imatinib?
A tyrosine kinase inhibitor
521
Name two consequences of Salpingitis.
Infertility
| Ectopic pregnancy
522
What is a polyp?
Benign hyperplastic growth - can lead to bleeding, discharge.
523
Name the risk factors for cervical cancer
HPV
Many sexual partners
smoking
524
What is CIN?
Cervical intraepithelial neoplasia
| Dysplasia in the Squamous epithelium
525
Which is the most common cervical carcinoma type?
Squamous > adenocarcinoma
526
What is latent HPV infection?
HPV stays in the basal cells where infection is not produced. HPV effects are not seen.
527
How does HPV transform the normal cell?
2 proteins are encoded by the virus - E6 and E7.
| They bind to tumour suppressor genes (P53 and Rb) and inactivate them = inhibits apoptosis.
528
How does HPV appear in patients?
Often body eliminates infection within 2 years.
Few symptoms, body eliminates HPV by itself.
However when persistent - can cause cancer.
529
How often does cervical screening occur?
25-49 - 3 yearly
50+ = 5 yearly.
sample from cervix.
530
What is the HPV DNA test?
Uses RNA probes to look between low risk and high risk HPV.
531
When is the HPV vaccine offered?
1st dose in year 8
| 2nd dose 6-24 months after first.
532
Give 2 indications for a uterine biopsy.
Infertility
| Uterine bleeding.
533
Which is the most common gynaecological cancer in women?
Gynaecological cancer
534
Give two risk factors for gynaecological cancer
Nulliparity
| Obesity
535
What is a leiomyoma?
Tumour of the smooth muscle.
536
Which is the medical term for fibroid?
Mesenchymal tumours leiomyoma
537
How do we define the malignant tumours of the smooth muscle?
Leiomyosarcoma
538
What actually is endometriosis?
Endometrial glands and stroma outside of the uterus
539
How do we classify ovarian tumours?
```
Primary
-epithelial (different types e.g. serous, mucinous).
-germ cell
-sex cord
Secondary
```
540
Which are the commonest ovarian tumour?
Epithelial tumours.
541
Name two risk factors for ovarian cancers.
Nulliparity and infertility
542
What is Lynch syndrome?
HNPCC syndrome
543
BRCA mutations are usually associated with low or high grade tumours?
High grade tumours. Low grade are more associated with KRAS, BRAF.
544
When will a tumour be classified as mucinous?
Displays morphology similar to cells of the GI tract.
545
Which part of the female genital tract is the commonest to receive metastatic tumours?
Ovaries
546
Pelger-Huet cells and ringed sideroblasts on blood film are characteristic of which condition?
Myelodysplastic syndrome
547
Auer rods are characteristic of what?
Acute myeloid leukaemia
548
Give some characteristics of MDS (myelodysplastic syndrome).
Number of cytopenias (Hb, neutrophils, monocytes, platelets all <<<
549
What is the main cause of MDS?
Mutations in TP53 and other tumour suppressor genes.
550
How do we treat MDS?
1. Product support to replace platelets, Hb. - Blood product support.
Antimicrobial therapy.
Growth factors
Stem cell transplantation
Chemotherapy
(not widely treated with either however).
551
Which oral chemotherapy may we use in the treatment of MDS?
Hydroxyurea
552
The primary treatment of MDS is intensive chemotherapy. True or false?
False.
553
What is aplastic anaemia?
Stem cell problem where the bone marrow cannot produce blood cells.
554
Name the triad of aplastic anaemia.
Anaemia (pallor), leucopenia (infections) and platelets (bleeding)
555
Give 3 differentials of pancytopenia
Aplastic anaemia
AML
Idiopathic thrombocytopenic purpura
556
How do we diagnose aplastic anaemia?
Camitta criteria
| Reticulocytes, neutrophils, platelets <<
557
Name one key pancytopenia.
Fanconi anaemia
558
What is fanconi anaemia?
The most common form of inherited aplastic anaemia.
559
Which is the most common aspect of dyskarytosis congenita?
Telomere shortening
560
What is the incubation period for
- bacteria
- viruses
- parasites?
561
Define Gastroenteritis.
Rapid onset, diarrhoea less than 2 weeks.
| Loose stool >3 times a day.
562
How will a patient present differently if their diarrhoea is caused by Vibrio cholerae vs. salmonella/campylobacter jejuni?
Vibrio cholerae = no fever
| Salmonella = fever
563
In a patient who has had watery diarrhoea with fever for 1-6 hours, which bacterium is the likely culprit?
Staphylococcus aureus.
564
Which pathogenic virus has the longest incubation period?
Norovirus; 24-48 hours.
565
Which pathogen is associated with molluscs and shellfish?
Norovirus
566
Which pathogen is associated with meats, hot dogs and soft cheese?
Listeria monocytogenes.
567
Which pathogen is associated with faecally contaminated food or water?
E.Coli.
568
Which pathogen is associated with poultry, eggs, and unpasteurised milk?
Salmonella
569
How does the mechanism of cholera work?
Adenylate cyclase becomes activated which opens Cl- channel at the apical membrane of enterocytes. Efflux of Cl into the lumen = loss of H20 and electrolytes.
570
How do superantigens work?
They bind directly to T-cell receptors and MHC molecules. This produces a massive cytokine response IL-1 and IL-2, CD4+ cells.
571
What is the difference between inflammatory diarrhoea and enteric fever?
```
Inflammatory diarrhoea (exudate) = septic shock, neutrophilia
Enteric fever = no septic shock, no neutrophilia
```
572
Which bacteria causes enteric fever?
S. Typhi
573
In a patient vomiting with diarrhoea lasting 2-3 days, which is the most suspected pathogen?
Norovirus.
574
Haemolytic anaemia is an extra-intestinal manifestation of which pathogen?
Campylobacter Jejuni.
575
Meningitis is an extra-intestinal manifestation of which pathogens?
Listeria, salmonella.
576
Reheated fried rice, which is the pathogen responsible?
Bacillus cereus. (gram positive rods).
577
Food is not cooked to a high enough temperature - which is the microorganism responsible? What can the bacteria cause as a complication?
Bacillus cereus - not destroyed by reheating. Cerebral abscesses as a complication.
578
Which bacteria causes food poisoning from reheating food - but specifically reheating meat?
Clostridium pefringens.
579
Which microorganism is actually inactivated by cooking?
Clostridium botulinum.
580
Pseudomembranous colitis is caused by which pathogen? Which toxins does this pathogen cause?
```
Clostridium difficile.
Toxin A (enterotoxin)
Toxin B (cytotoxin)
```
581
How do we best manage colitis?
Vancomycin - stop antibiotics.
582
Which pathogen typically grows on refrigerated food? How do we treat?
Listeria monocytogenes.
| Treat with Amoxicillin
583
Which bacteria is responsible for Traveller's diarrhoea?
E. Coli.
584
Which is the main type of E. Coli to cause traveller's diarrhoea?
Enterotoxigenic E. Coli (ETEC).
585
Which antibiotic is used for the vibrio pathogens?
Doxycycline
586
How does Campylobacter present?
Watery, foul smelling diarrhoea, bloody stool, fever, abdominal pain.
587
Giardia lamblia is what type of microorganism? How do we treat it?
Protozoa. Treat with Metronidazole.
588
The rotavirus presents for approximately how long? Who does the virus typically effect?
3-8 days. Typically affecting children aged 6 months - 2 years.
589
Which condition between osteomalacia, paget's disease, sarcoidosis and osteoporosis causes hypercalcaemia?
Sarcoidosis.
590
Which antibiotic is used to treat pseudomonas auerginosa?
Gentamicin (an aminoglycoside) and Ciprofloxacin (broad spectrum antibiotic).
591
Which inflammatory disease affects the large bowel and duodenum?
Crohn's disease
592
The Breslow score is used to measure which condition?
Melanoma
593
Where is the enzyme 25-hydroxylase found?
Liver
594
Which is the antibiotic of choice in Diabetes with cellulitis?
Flucloxacillin - to cover staphylococcus and streptococcus.
595
Which is the best marker of liver damage following paracetamol overdose?
Prothrombin time
596
During pregnancy, what happens to the platelet count?
Platelet = reduces
597
What are the normal changes to full blood count in pregnancy?
Mild anaemia, macrocytosis (increase in red cell mass) and neutrophilia
598
what is the normal range for platelet count?
Between 150-400x10^9/L
599
Give 3 causes of thrombocytopenia in pregnancy.
Pre-eclampsia
ITP - Immune thrombocytopenic purpura
DIC
600
How do we treat ITP
IV immunoglobulin
Steroids
for bleeding
601
What is MAHA?
Red cell destruction due to platelets building up in blood vessels.
microangiopathic haemolytic anaemia.
602
What are the coagulation changes during pregnancy?
Rise in vWF and factor VII, VIII = increased rate of thrombosis.
Fall in protein S.
603
Which tests would we request to look at thromboembolic disease in pregnancy?
Doppler and VQ scan
604
How do we define post-partum haemorrhage?
>500mL blood loss
605
What is the main purpose of haemoglobinopathy screening?
To avoid birth of children with a0 thalassaemia *not compatible with life).
To avoid sickle cell disease
606
What is the difference between iron deficiency and thalassaemia trait?
RBCs are raised in thalassaemia trait whereas low or normal in iron deficiency anaemia.
607
In gestational thrombocytopenia, the baby's platelets can be affected. True or false?
False.
608
When do you restart LWMH after delivery?
609
Name one common cause of post partum haemorrhage.
Uterine atony
610
What are myeloblasts?
Precursors of myeloid cells (immature myeloid cells) - often seen in acute infection.
611
What is a normal percentage of myeloblasts?
What is the next stage of abnormal myeloid cells?
What about when there are too many myeloblasts?
Normal percentage = <5%
5-20% = Myelodysplasia
>20% = AML
612
What is the name of the stage in between a normal percentage of myeloblasts up to AML?
Myelodysplasia
613
What is the percentage of lymphoblasts in ALL
>20%
614
Which are the B cell markers?
CD19+, CD20+
615
Which cell is in excess in the bone marrow in myeloma?
Plasma cells
616
Are Bence Jones Proteins usually seen in urine?
No; in multiple myeloma we we will see them as free chains in the urine.
617
How will ITP (Immune thrombocytopenia purpura present on blood tests?
Low platelets = easy bleeding, easy bruising.
618
How will ALL present on blood tests?
Low neutrophils, low white cell count, high MCV.
619
How may ITP differ from ALL in the patient's blood test markers?
ALL = low white cell count and low neutrophils whereas ITP shows normal white cell count.
620
Where reticulocytes are raised, what should the key diagnosis in your head be?
Haemolytic anaemia - inherited or acquired.
621
Which haemolytic anaemia is caused by a defect in the RBC membrane?
Hereditary Spherocytosis.
622
Which haemolytic anaemia is caused by a defect in the RBC enzyme?
Glucose-6-phosphate deficiency (G6PD).
623
How do we diagnose Hereditary spherocytosis?
DAT -ve (the guthrie test) and blood film to check for spherocytes.
624
How do we diagnose Sickle cell anaemia?
Electrophoresis.
625
How may one acquire a haemolytic anaemia?
Auto or allo
Auto - being linked to immune disease
Allo - linked to blood transfusion
626
When would a DAT test be positive vs. negative?
```
DAT positive (DAT +ve) = acquired haemolytic anaemia
DAT negative (DAT -ve) = inherited haemolytic anaemia e.g. hereditary spherocytosis
```
627
How do we differentiate between iron deficiency and anaemia of chronic disease (ACD)?
Iron deficiency = Normal/ low ferritin. High transferrin
ACD = Normal/ high ferritin. Low transferrin.
Transferrin is the differentiator.
628
Which is the one marker which is high in iron deficiency?
Transferrin. (This is different to transferrin saturation which will still be low in iron deficiency). Transferrin = HIGH in Fe2+ deficiency.
629
What is anaemic of chronic disease (ACD)?
Iron stores are normal but sequestered and unavailable for erythropoeisis.
Hence, high hepcidin; hepcidin sequesters iron.
630
Which are the haematinics?
Iron, B12, folate.
631
Patient presents with pancytopaenia. Give 3 differentials.
Bone marrow failure
Non malignant: DNA synthesis failure, aplastic anaemia
Malignant: cancers spreading to the bone marrow
*non haematological = breast/ prostate
*haematological = leukaemia, myeloma, lymphoma.
632
Give two causes of pancytopaenia
Aplastic anaemia
| Haematological cancers: leukaemia, myeloma, lymphoma
633
How can CML present in patients? And on examination?
Lethargy and bleeding. On examination, hepatosplenomegaly.
634
What are blood cell markers like in CML?
Leukocytes
Neutrophils
Myelocytes (myeloblasts if not chronic)
635
Which translocation produces the Philadelphia chromosome? And which gene is produced as a result? How does this relate to cancer?
9:22 = produces the ABL-BCR fusion gene. Encodes the 210 kDA protein which increases TK (tyrosine kinase) activity = cancerous.
636
Which is the best prognostic factor as a marker to look for in CLL?
The TP53 mutation.
637
Name two targeted therapies for CLL?
```
BCR-ABL Kinase inhibitors (Ibrutinib)
BLL2 Inhibitor (Venetoclax)
```
638
Venetoclax is what type of cancer class therapy and is used to treat which cancer?
BLL2 inhibitor - used in CLL.
639
The BCR-ABL fusion gene causes which cancer?
CML - Chronic lymphocytic leukaemia.
640
What is involved in a myeloma screen?
IgA, IgM, IgG, Calcium.
641
Give an example of a phosphodiesterase inhibitor
Sildenafil.
642
Listeria monocytogenes is what kind of bacteria?
Gram positive
643
Allopurinol is contraindicated with which drug and why?
Allopurinol is contraindicated with azathioprine; allopurinol interferes with the metabolism of azathioprine and increases mercaptopurine levels.
Allopurinol inhibits xanthine oxidase.
Xanthine oxidase is responsible for inactivating mercaptopurine.
= Risks bone marrow suppression.
644
How does the treatment of acute gout compare with chronic gout?
Acute gout = Colchicine
| Chronic gout = Allopurinol
645
Liver damage following paracetamol overdose is best diagnosed by which marker?
Prothrombin time.
646
CD20+, EBV+, 'starry sky' appearance is indicative of which cancer?
Burkitt's lymphoma.
647
What is the difference between sensitivity and specificity?
Sensitivity - Correctly identifying patients with a disease
| Specificity - Correctly identifying people without a disease
648
Starry sky appearance on blood film is diagnostic of what condition?
Burkitt's lymphoma.
649
Which infection is most common amongst IV drug users?
Hepatitis C
650
Which factor is deficient in Haemophilia A and Haemophilia B?
Haemophilia A = Factor VIII deficiency (8)
| Haemophilia B = Factor IX deficiency (9)
651
What is Disseminated intravascular coagulation (DIC)?
Give x2 causes of DIC.
Widespread activation of coagulation but clotting factors and platelets are consumed so there is increased risk of bleeding.
Causes: Malignancy, sepsis, trauma, toxins.
652
Vitamin K is needed for synthesis of which factors?
Factors 2, 7, 9, 10.
653
What do we use to treat DVT/ PE?
1. LMWH and warfarin
or 2. DOAC e.g. Apixaban
LMWH will be stopped once INR is in the therapeutic range (2-3).
Treatment for 3 months minimum.
654
What is the mechanism by which heparin works?
Activates antithrombin = inhibits thrombin and factors 9,10,11.
655
What is haemolytic disease of the newborn?
Where maternal antibody (most typically anti D antibody) is high it can destroy foetal red cells if they have the corresponding antigen.
656
What are the main clinical features of acute leukaemia?
Bone marrow failure = always comes with:
1. Anaemia
2. Infection (neutropenia)
3. Bleeding (thrombocytopenia)
657
What exactly is immunophenotyping?
Looking at the different markers cells express. This is really useful in AML vs ALL. myeloid vs lymphocyte.
658
In flow cytometry, how will ALL vs AML present?
Different markers. ALL = lymphocytes so B and T cell markers (CD19, CD3, CD4, CD8)
AML = myeloid markers - CD33+
659
How is chronic myeloid leukaemia often diagnosed?
Large number of differentiated neutrophils.
660
What is the main treatment for CML?
Imatinib - 95% remission rate!!!
661
On examination what is the main finding of CML?
Splenomegaly - often massive.
662
The Philadelphia chromosome (9;22) caused by the fusion gene BCR-ABL is often diagnostic for which condition?
CML - Chronic myeloid leukaemia.
663
Which are the three phases of CML?
Chronic (<5% blasts)
Accelerated (>10% blasts)
Blast (>20%)
664
Which phase of CML is most receptive to Imatinib as a therapy?
Chronic phase
665
Smear cells are seen in which diagnosis?
CLL - Chronic lymphocytic leukaemia.
666
Which marker is a key prognostic factor for Chronic lymphocytic leukaemia? (CLL)
LDH
667
The chronic, accelerated and blast phases describe which cancer?
Chronic myeloid leukaemia (CML)
668
What is a lymphoma?
A neoplastic tumour of lymphoid tumour.
669
Which is more common - Hodgkin's or non-hodgkin's lymphoma?
Non-hodgkin's lymphoma.
670
How does Hodgkin's lymphoma present?
```
Asymmetrical lymphadenopathy
B symptoms:
- weight loss <10% unintentional in 6 months
- Fever
- Night sweats
```
671
Which lymphoma is EBV related?
Hodgkin's lymphoma
672
The Reed Sternberg cell is seen in which cancer?
Hodgkin's lymphoma - a binucleate cell
673
What is the name of the staging system which describes stages 1-4 for cancer?
Ann-Arbor system
674
Patient involvement with 3 Lymph node regions above the diaphragm but no weight loss or night sweats would be which staging on Ann Arbor?
2A (A because no constitutional symptoms otherwise would be B)
675
What is the treatment for Hodgkin's lymphoma?
```
ABVD
Adriamycin
Bleomycin
Vinblastine
Dacarbazine
```
(2-4 cycles in stage 1/2, 6-8 cycles in stage 3/4).
676
What is the difference between autologous and allogeneic SCT?
```
Autologous = patient's own stem cells
Allogeneic = HLA-matches stem cells
```
677
Name the 3 HIGH GRADE types of Non-hodgkin's lymphoma.
Burkitt's
Diffuse large B cell
Mantle cell
Low grade = marginal zone
678
Is Marginal zone high or low grade and which type of lymphoma?
Low grade non-hodgkin's lymphoma
679
What is Burkitt's characterised by on histology?
Starry sky appearance
680
How do we treat Burkitt's lymphoma?
Chemotherapy - rituximab = anti CD20+
681
Which is the chemotherapy treatment of choice for most non hodgkin's lymphomas?
Rituximab
682
Which are the three types of Burkitt's lymphoma?
Endemic: EBV associated, Africa
Sporadic: EBV associated, outside of africa
Immunodeficiency: Not EBV associated
683
How do we treat MALT?
Remove antigenic stimulus - often due to H pylori. So H. Pylori triple therapy.
684
Rituximab is anti which marker?
CD20+
685
Which medication is used against T cell lymphomas?
Alemtuzumab (anti CD 52).
686
Define multiple myeloma. Production of antibodies - IgG being the most common
Neoplasm of plasma cells
687
What are the clinical features of multiple myeloma?
```
CRAB
Calcium
Renal failure
Anaemia
Bone pain, osteoporosis, osteolytic lesions, fractures.
```
688
How does multiple myeloma typically present on blood film?
Rouleaux formation (RBC stacking)
BJPs in urine
High ESR
main treatment = bisphosphanates for CRAB symptoms.
689
Where are CRAB symptoms seen and which treatment can we use for them?
Multiple myeloma.
| Bisphosphanates.
690
What is amyloidosis?
Misfold of proteins - kappa: lambda light chain ratio affected.
691
How do we differentiate between myelodysplastic syndromes and acute myeloid leukaemia?
Blast number.
Myelodysplastic = <20% blasts
Acute leukaemia = >20% blasts
692
What are ring sideroblasts and where can they be seen?
Ring around the nucleus of the cell
| MDS (myelodysplastic syndrome)
693
Name 3 forms of treatment that could be used for myelodysplastic syndromes.
EPO transfusion, antibiotics
Chemotherapy
Allogenic transplant
694
What is aplastic anaemia?
Inability of bone marrow to produce blood cells. 70% idiopathic.
Symptoms will depend on type of cytopaenia accompanied.
695
How do we treat aplastic anaemia?
Transfusion, antibiotics, iron chelation.
696
Which is the most common inherited aplastic anaemia?
Fanconi anaemia (fanconi syndrome is different - a renal problem).
697
Give an example of a myeloproliferative disorder.
Chronic myeloid leukaemia (CML)
698
Give one philadelphia chromosome positive and one philadelphia chromosome negative myeloproliferative disorder.
One proliferative chromosome +ve = CML
| One proliferative chromosome -ve = Polycythaemia vera
699
Which condition is philadelphia chromosome negative and associated with JAK2 mutations
Polycythaemia vera.
700
What is the difference between polycythaemia vera and pseudo polycythaemia vera?
Polycythaemia vera = high red cell mass, high plasma volume.
Pseudo polycythaemia vera = NORMAL RED CELL MASS, high plasma volume.
701
Which mutation is most associated with polycythaemia rubra vera?
JAK2 mutation.
702
After venesection, which medication is usually used for maintenance?
Hydroxycarbamide.
703
What is the name of the myeloproliferative disorder where megakaryocytes dominate the bone marrow?
Essential thrombocythaemia - 50% associated with JAK2 mutation.
704
How do we treat essential thrombocythaemia?
Aspirin and hydroxycarbamide.
705
What is the opposite to cytopenia?
Cytosis.
706
When do we use red cells vs. platelets vs. FFP for transfusion?
Red cells = iron deficiency/ B12/ folate deficiency
Platlets = TTP, DIC
FFP = often when a patient undergoes surgery
For all, do not transfuse unless actively bleeding.
707
Name one immune and one non immune immediate adverse affect to blood transfusion.
Immune = TRALI
Non immune = TACO.
delayed is more graft vs. host disease, viral infections, iron overload.
708
Anaphylaxis is more common in patients with what?
IgA deficiency.
709
Which antibodies mediate intravascular haemolysis compared with extravascular?
Intravascular haemolysis = IgM related
| Extravascular haemolysis = IgG related.
710
Give 3 main presentations of graft Vs host disease
Skin desquamation
Diarrhoea
Liver failure
711
How do we differentiate between TACO and TRALI?
TACO = raised JVP (; cardiac overload).
712
Caseating granulomas are common of which condition?
TB
713
Name the main investigations in TB and what we would see.
CXR (upper lobe cavitation)
Sputum samples (microscopy on Ziehl-Neeson stain), acid fast bacilli seen
Tuberculin skin prick test
714
How do we treat TB? and for what time period?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
All 4 for x2 months, then continue R+I for 4 more months.
715
Which medication gives orange secretions as a side effect?
Rifampicin
716
Which medication used to treat TB can cause optic neuritis as a side effect?
Ethambutol
717
Which condition is CURB 65 used for?
Pneumonia
718
Which are the three main pathogens which can cause pneumonia?
Streptococcus, klebsiella, pseudomonas, haemophilus.
719
What is the difference between typical and atypical pneumonia?
Atypical is not in keeping with CXR, does not common signs and does not respond to penicillin.
720
Which is the gram negative enterobacter rod which can cause pneumonia?
Klebsiella pneumonia.
721
Which is the most common bacteria to cause pneumonia?
Streptococcus pneumoniae.
722
Travel, air conditioning and pneumonia symptoms. Which bacteria is the cause?
Legionella.
723
Which pneumonia is associated with birds?
Chlamydia Psittaci.
724
Which are the three main investigations to diagnose pneumonia.
1. CXR
2. Sputum MC&S
3. Atypical screen: Legionella, Chlamydia
725
Which are the bacteria to cause atypical pneumonia?
Legionella and mycoplasma.
726
Why do penicillins not work against atypical bacteria for TB?
No cell wall in atypical bacteria.
727
Which is the first line medication treatment for Hospital acquired pneumonia?
Ciprofloxacin and Vancomycin.
728
Where someone is allergic to penicillin, what is the first line medication?
A macrolide e.g. Clarithromycin.
| or a quinolone e.g. Ciprofloxacin.
729
Ciprofloxacin is what kind of medication?
Quinolone
730
How will a moderate CURB score compare with a severe CURB score for treatment?
Moderate CURB = amoxicillin and clarithromycin
| Severe CURB = Co-amoxiclav and clarithromycin
731
Which is the most common pathogen for infective endocarditis in IVDU?
Staphylococcus aureus.
732
Which is the most common pathogen for infective endocarditis prosthetic valve patients?
CoNS (coagulase negative staphylococci).
733
Duke's criteria is used to diagnose which condition?
Infective Endocarditis.
734
Which are the 3 types of GI infections?
Secretory diarrhoea - no fever e.g. Cholera
Inflammatory diarrhoea - fever e.g. Campylobacter, Shigella
Enteric fever e.g. Yersinia
735
What do we treat IE with? acutely vs. subacutely?
Acutely - Flucloxacillin
Subacutely - Benzylpenicillin and gentamycin
Prosthetic valve - vancomycin and gentamycin
736
Which bacterium causes Pseudomembranous colitis and how do we treat it?
Clostridium difficile.
First line = Metronidazole
Second line = Vancomycin.
737
Which bacterium can cause sudden vomiting and non-bloody diarrhoea from reheated rice?
Bacillus Cereus (self limiting).
738
Traveller's diarrhoea is caused by which bacteria and how is it treated?
E. Coli. Usually self limiting but can be treated with Ciprofloxacin.
739
Which is the culprit for non bloody diarrhoea after eating poultry?
Salmonella
740
Which is the culprit for bloody diarrhoea after eating poultry?
Campylobacter Jejuni.
741
Rice water stool is caused by which bacteria?
Vibrio Cholera
742
Which bacteria is the culprit for having had unpasteurised dairy? What is the treatment?
Listeria Monocytogenes.
| Treatment: Ampicillin.
743
Differentiate between Norovirus, adenovirus and rotavirus.
```
Norovirus = Adult outbreaks
Adenovirus = Secretory diarrhoea <2 years
Rotavirus = Secretory diarrhoea < 6 years
```
744
Which marker is almost always indicative of a uti?
Nitrites
745
What is the difference between a lower and upper UTI?
Lower UTI = only bladder.
| Upper UTI = Kidney infection (pyelonephritis).
746
Which is the most common pathogen for UTIs?
E. Coli
747
Which are the two positive markers in UTI?
Nitrites and leukocytes (less specific).
748
How do we treat UTIs?
```
Lower UTI = Nitrofurantoin/ Trimethoprim
Upper UTI (pyelonephritis) = admit, coamoxicillin, gentamicin.
```
749
Which is the antibiotic of choice for Staphylococcus aureus at wound sites?
Flucloxacillin.
750
Which are the investigations of choice for septic arthritis?
Joint aspirate, MC&S, Blood cultures.
751
Which is the most common bacteria at prosthetic valves?
CoNS - coagulase negative staphylococci.
752
What does a prosthetic joint make someone at risk for?
Septic arthritis.
753
Clostridium difficile can cause what and is treated with which medication?
Pseudomembranous Colitis
| Treated with Metronidazole.
754
What is a risk factor for E.Coli?
Catheters
755
Which are the main bacteria found at wound sites/ surgical site infection?
MRSA, CoNS (coagulase negative staphylococcus)
756
Which is the most common cause of meningitis?
Neisseria Meningitidis.
| Streptococcus pneumoniae.
757
In neonates, which is the most common microorganism to cause meningitis?
Group B Streptococcus
758
Which bacteria is encephalitis most commonly caused by?
HSV1
759
Which medication do we use to cover for Listeria?
Ampicillin
760
How do we treat bacterial meningitis?
Resuscitate, IV ceftriaxone, corticosteroids.
761
How will bacteria compare with virus in terms of CSF?
```
Bacteria = turbid, cloudy, low glucose, polymorph cells
Virus = Clear, normal glucose, mononuclear cells
```
762
What are the differentials for a painful lump vs. painless lump?
Painful lump = Syphilis
| Painless lump = HSV.
763
What type of bacteria is Neisseria gonorrhoea?
Gram negative diplococcus.
764
How do we treat gonorrhoea?
Ceftriaxone IM - 250mg single dose.
765
Obligate intracellular gram negative pathogen. Which condition?
Chlamydia Trachomatis
766
How do we diagnose Chlamydia?
| How do we treat Chlamydia?
NAAT - nucleic acid amplification tests.
| Azithromycin 1g stat, doxycycline 100mg BD for 7 days.
767
What is a main complication of chlamydia?
PID.
768
Which bacteria causes syphilis?
Treponema pallidum
769
What are the signs of syphilis?
3 stages
1st stage = painless genital ulcer, 6 weeks
2nd stage = rash on palms and soles, lymphadenopathy
3rd stage = 20-30 years later: gummatous syndrome = granulomas, cardiovascular, neurological
770
What is gummatous disease?
Third stage syphilis i.e. tertiary syphilis where you see granulomatous lesions.
771
Treponema - which disease?
Syphilis.
772
How do we treat syphilis?
Single dose IM penicillin - doxycycline if allergic.
773
What is Chancroid?
A tropical ulcer disease in Africa. Diagnosed by chocolate agar.
774
'Strawberry cervix' is a cause of which bacteria and therefore which condition?
T. vaginalis protozoa
Trichomoniasis
Treat with metronidazole
775
What are 3 characteristics of bacterial vaginosis?
| Which is the characteristic cell on microscopy?
Abnormal vaginal flora, low lactobacill, discharge, odour.
| Clue cells.
776
Thick white cottage cheese discharge. What is the diagnosis?
Candidiasis.
777
Small papules as a dsDNA virus. What is the diagnosis?
Molluscum contagiosum
778
Genital warts are what kind of virus? Which virus subtypes are specifically common causes?
dsDNA human papillomavirus. HPV6 or HPV 11.
779
Name 3 viral STIs
Hepatitis
Herpes
HIV
780
How does Rifampicin work - what is it used to treat?
Inhibits RNA synthesis - treats TB mycobacteria
781
How do tetracyclines work. Give one example.
Inhibit protein synthesis. Doxycycline
782
Name the three beta lactam types?
Penicillins
Cephalosporins
Carbapenems
783
Which are the broad spectrum antibiotics?
Co-amoxiclav, ciprofloxacin.
784
Which are the narrow spectrum antibiotics?
Flucloxacillin, gentamicin, metronidazole.
785
What type of virus if influenza?
8 segments RNA genome.
| Natural reservoir is ducks
786
Give 2 hepatic causes of pale stool colour.
Hepatic/ post hepatic causes:
- gallstones
- hepatitis
- gallstones
787
Why do we have no bilirubin in the urine in pre-hepatic disorders?
Bilirubin conjugation has not happened. Only conjugated bilirubin can pass into the urine. Unconjugated is bound to albumin which cannot pass through the glomerulus.
788
Which molecule is unconjugated bilirubin bound to?
Albumin.
789
What is a marker for increased haemolysis?
Raised LDH.
790
Give a cause of hepatomegaly with a smooth border compared to with a craggy border.
Smooth border = Viral hepatitis, biliary tract obstruction
| Craggy border = PCOS, Cirrhosis
791
Urine colour change and abdominal pain. What enzyme deficiency could this be?
AIP - acute intermittent porphyria. (build up of porphyrins due to disruption in Hb synthesis).
792
In which porphyria are skin lesions seen?
HCP and VP
| not AIP
793
Why can't we use urine to measure protoporphyrin levels?
Protoporphyrin is lipophilic - use RBC protoporphyrin levels instead.
794
Which hypothalamic hormones stimulates ACTH from the pituitary?
CRH
795
Name one key side effect of a TRH injection.
Metallic taste in mouth.
796
How do we do the CPFT? Combined pituitary function test.
Fast patient overnight
Administer the hypothalamic hormones i.e. GnRH, TRH and insulin.
Measure pituitary hormones (GH, TSH, LH, FSH, prolactin) at 0,30,60,90,120 minute intervals.
797
Is dopamine a hypothalamic or pituitary hormone?
Hypothalamic hormone.
798
Differentiate between mild, moderate and extreme elevation in high prolactin levels.
```
Mild = <1000miu/l (stress, recent breast exam, PCOS)
Moderate = 1000-5000 miu/l (hypothalamic tumour, drugs)
Extreme = >5000 miu/l (macroprolactinoma)
```
799
What is the figure for high prolactin?
>5000 miu/l
800
How do we treat prolactinoma?
1. Dopamine agonist = cabergoline, bromocriptine
| 2. transphenoidal excision
801
What is the gold standard for acromegaly?
OGTT
802
Is Hashimoto's hyperthyroidism or hypothyroidism?
Hypothyroidism
803
Give 3 differentials for high thyroxine.
Grave's disease
Plummer's (toxic multinodular goitre)
Drugs e.g. amiodarone.
804
Are Grave's and plummer's painful or painless goitres?
Painless
805
What is MEN?
Multiple endocrine neoplasia = gives a predisposition to developing endocrine cancers
MEN1
MEN2a
MEN2b
806
Calcium is bound to which molecule?
50% bound to albumin - so calcium is affected by albumin level.
45% ionised (free)
807
What do Vitamin D levels look like in primary, secondary and tertiary hyperparathyroidism?
Normal
808
Calcium is bound to which molecule when not ionised?
Albumin
809
Which is the main marker of dehydration?
urea
810
Trousseau's and Chvostek's sign are seen in which condition?
Hypocalcaemia
811
Give one cause of low calcium with high phosphate vs. low calcium with low phosphate.
Low calcium, high phosphate: hypoparathyroidism
Low calcium, low phosphate:
osteomalacia.
812
How do we differentiate between liver and bone ALP?
Liver ALP will also show a rise in gamma-GT.
813
Write down the order of lipoproteins in order of density.
Chylomicron < FFA < VLDL < IDL < LDL < HDL
814
What is the mechanism of statins?
HMG-CoA reductase inhibitor
815
Which is the receptor for LDLs?
PCSK9
816
How does Orlistat work?
Gut lipase inhibitor
817
The Guthrie blood test is done at which age and for which condition?
6 days old for Cystic Fibrosis
818
What is MELAS?
Mitochondrial encephalopathy lactic acidosis stroke like episodes.
819
What is a fasting glucose value diagnostic for Diabetes Mellitus for?
>7mmol/L
820
What will we see in Diabetic ketoacidosis?
Confusion
Kussmaul breathing
Abdominal pain, N+V.
821
In fluid replacement, how much saline do we usually give?
0.9% saline over 1hr.
822
What is HHS?
Hyperosmolar hyperglycaemic state
pH >7.3
High blood glucose, high osmolarity.
823
When may we see low glucose and low insulin?
Non-islet tumour hyperglycaemia
| Tumours which secrete IGF2 = binds to IGF1 and insulin receptor
824
Which is the marker of insulin?
C Peptide
825
What is the more common type of hyperbilirubinaemia in infancy?
High Conjugated bilirubin
826
What are the different causes of neonatal jaundice and at which stages?
Jaundice within the 1st 24 hours of life = acute haemolysis/ sepsis
Jaundice after 2 weeks = hepatobiliary failure
827
Which is the gold standard to measure GFR?
Inulin
828
When will we see casts in urine microscopy?
Glomerulonephritis
829
How do we define Acute kidney injury?
Serum creatine > 26 within 48 hours.
| >50% rise in serum creatine over 7 da7s
830
Give 5 indications for dialysis.
```
Acidosis
Electrolyte disturbance
Intoxication e.g. lithium, aspirin
Overload fluid e.g. pulmonary oedema
Uraemic encephalopathy
```
AEIOU
831
What is the GFR for end-stage kidney failure?
<15
832
Which is the biggest cause of mortality in CKD?
Vascular calcification
833
What is the difference between haemodialysis and peritoneal dialysis?
Haemodialysis = insert arteriovenous fistula
| Peritoneal dialysis = Uses peritoneum as dialysis membrane
834
Rutherford Morrison (hockey stick scar) is for which condition and in which location?
Kidney transplant in right iliac fossa
835
The mesangial cell is the macrophage of which organ?
Kidney
836
Give an example of a PAMP
Bacterial sugar, DNA, RNA
837
Which cells express inhibitory receptors to prevent inappropriate activation against self molecules?
Natural killer cells.
838
What will define an altered self cell? i.e. potential pathogen?
Those which lack inhibitory signals.
839
Name the 3 secondary lymphoid organs.
Lymph nodes
Spleen
MALT - mucosal associated lymphoid tissue.
840
Describe the process of T cell maturation
T cells exported from haematopoetic stem cells to the thymus to undergo positive and negative selection. Mature T cells move to secondary lymphoid organs e.g. spleen
841
Which receptor do all T cells express?
CD3+
842
Which are the cytotoxic T cells?
CD8+ T cells
843
What is central tolerance?
No recognition of self antigens = cell can survive.
844
The classical pathway involves which complements?
C1, C2, C4
845
The MBL pathway involves which complements?
C2, C4.
846
What is the difference between cytokines and chemokines?
Cytokines e.g. IL-2, IL-6 etc.
| Chemokines = CCL19, CCL21
847
Which antibody is found in respiratory and GI secretions?
IgA.
848
What is Kostmann syndrome?
Failure of neutrophil maturation
849
Which is the mutation for neutropenia?
ELA-2 - neutrophil elastase.
850
What is NBT? Where can we use it?
Nitro-blue tetrazolium
A dye which changes colour from yellow to blue when there is H202 free radical interaction.
Chronic granulomatous disease.
851
Which complements are involved in the mannose binding lectin pathway?
C2 and C4, not C1.
852
The classical, alternate and MBL pathway all converge onto which complement?
C3
853
Which mutation causes x-linked SCID?
Mutation of gamma chain of IL-2 receptor on chromosome 13.
854
Which mutation causes x-linked SCID?
Mutation of gamma chain of IL-2 receptor on chromosome 13.
855
Which disease is caused by 22q11.2 deletion?
DiGeorge syndrome. Reduced T cell number, normal B cell number.
856
Give the factors of DiGeorge syndrome.
```
CATCH 22
Cardiac abnormalities
Abnormal faces (high forehead, low ears)
Thymic aplasia
Cleft palate
Hypocalcaemia
```
chromosome 22
857
What is NBT? When may we use it?
A dye which changes from colour to yellow to blue following interaction with hydrogen peroxide.
Chronic granulomatous disease.
858
How do we differentiate between the complement deficiencies?
CH50 and AP50 tests.
e.g. SLE has low CH50, low C3 and C4.
C1q deficiency has low CH50, C3 and C4.
859
Give 3 tests to investigate lymphocyte deficiencies.
1. White cell count
2. Lymphocyte subsets
3. IGs
860
Which type of immunity is involved in autoinflammatory responses?
Innate - adaptive is autoimmune
861
How can we class autoinflammatory or autoimmune diseases?
Monogenic or polygenic.
| Autoinflammatory or autoimmune.
862
What type of disease are Crohn's and UC?
Polygenic autoinflammatory.
863
What type of disease is rheumatoid arthritis?
Polygenic autoimmune disease
864
Give an example of a mixed pattern disease
Ankylosing spondylitis
865
How would you classify pernicious anaemia as a disease?
Polygenic autoimmune disease.
866
Monogenic autoinflammatory diseases have an issue which type of immunity?
Innate immunity
867
What is familial mediterranean fever? mutation, recessive or dominant? which cell type affected?
Autosomal recessive
Mutation in MEFV
Gene encodes pyrin-marenostrin - expressed by neutrophils.
So, in familial mediterranean fever = neutrophil issue
Can
868
Colchicine is associated with treating what type of conditions? Give 2 examples.
Inflammatory conditions. e.g. gout, familial mediterranean fever.
869
What will a mutation in the FAS pathway cause?
Failure of lymphocyte apoptosis.
870
What is tolerance?
Control of not producing an immune response to an antigen.
'i can be tolerant, i can have them around and do nothing'.
871
Where is a FAS pathway mutation seen?
ALPS - autoimmune lymphoproliferative syndrome.
872
What is APS1?
Autoimmune polyendocrine syndrome type 1
= abnormality in tolerance.
Defect in AIRE. - autoimmune regulator gene. AIRE is involved in T cell tolerance.
873
Addisons and Vitiligo are seen in which monogenic autoimmune disease?
APS1 - autoimmune polyendocrine syndrome 1.
874
Where are HLA associations more common - autoimmune or autoinflammatory conditions?
Autoimmune
875
HLA-DR4 is associated with which condition?
Rheumatoid arthritis.
876
HLA B27 is associated with which diseases?
Ankylosing spondylitis, reactive arthritis, IBD.
877
Type I hypersensitive disorders are which Ig related?
IgE
878
Give 2 examples of IgE mediated allergies vs. Non-IgE mediated.
IgE = Peanuts, penicillin, latex
| Non IgE = Exercise, NSAIDS, Opioids.
879
How do we manage anaphylaxis?
elevate legs, 100% oxygen, IV adrenaline 500mcg, hydrocortisone 200mg IV.
880
bowed legs. specifically which diagnosis?
Paget's disease
881
High paraprotein. specifically which diagnosis?
Multiple myeloma
882
Is Rheumatoid arthritis symmetrical or asymmetrical?
Symmetrical
883
Petechical rash after a URTI. What is the diagnosis?
ITP.
884
Which virus increases the risk of nasopharyngeal cancer?
EBV
