Question book 6

Question 1

What type of vaccine is hepB vaccine

killed virus
live attenuated
subunit
toxoid
conjugate

Answer 1

subunit

contains HBV surface angien epitopes, yeast, and two adjuvants - aluminium and thimerosal

A conjugate vaccine is a type of subunit vaccine which combines a weak antigen with a strong antigen as a carrier so that the immune system has a stronger response to the weak antigen.
eg pneumococcal of haemophilus B

toxoid - tetanus, diptheria

Question 2

65 year old male with renal transplant 18 months ago presents to pre-travel clinic for vaccinations.
Which is safe to administer in this patient

influenza A
measles
rubella
yellow fever
varicella

Answer 2

influenza A

other vaccines are all live vaccines

Question 3

68 year old with pulmonary fibrosis attends for annual influenza vaccine

why do vaccines need to be given annually

antigenic shift
antigenic drift
suboptimal B-cell response
suboptimal T-cell reponse
recipient relative immune paresis

Answer 3

antigenic drift?

anitgenic shift happens more rarely
antigenic drift means vaccine may not match circulating strain each year

Question 4

54 year old NHS worked found to be non-immune to VZV

Which of the following is contraindication to receiving vaccination

HIV with CD4 550
radiotherapy 12 months ago
1 week 40mg prednisolone 1 month ago
azathioprine 12 months ago
Weber-Christian disease

Answer 4

1 week 40mg prednisolone 1 month ago

contraindications to live vaccines:

• severe immunodeficiencies
• chemotherapy or radiotherapy in past 6 months
• solid organ transplant on continual immunosuppression
• bone marrow transplant until 12 months after
• high dose steroids - 40mg for 1 week - wait until 3 months after treatment
• HIV CD4 <200

Weber-Christian is cutaneous panniculitis - no immunosuppression

Azathioprine not contraindicated. Stronger drugs such as methotrexate are

Question 5

Which of the following conditions would you recommend to receive pneumococcal vaccine

HCV liver cirrhosis
beta-thalassaemia minor
asthma
recurrent otitis media
those recovered from acute malaria

Answer 5

HCV liver cirrhosis

23 valent polysaccharide vaccine
13 valent conjugate vaccine

children <2 do not demonstrate good response to 23 valent vaccine, so not given at this age

vaccination indicated for:

• all aged 65 or over
• chronic lung/ liver/ renal/ heart disease

Question 6

Which vaccine given at 12-15 months of age to avoid inhibition by maternal antibodies

Haemophilus influenzae B
MMR
BCG
Diptheria, pertussis, tetanus
Meningococcus C

Answer 6

MMR

Question 7

Which of the following food-borne pathogens can be prevented by vaccination

Campylobacter jejuni
Giardia
Shigella
Vibrio cholerae
Salmonella enteriditis

Answer 7

Vibrio cholerae

Question 8

20 week pregnant female travelling to Nigeria for 1 month. Asking for advice regarding Yellow Fever vaccination

vaccination contraindicated, should not be given
vaccine should be given - confers protections for 35 years
vaccine should be given - confers protection lifelong
vaccine should be given, and early re-vaccination considered
vaccination contraindicated, antivirals should be given as chemoprophylaxis

Answer 8

vaccine should be given, and early re-vaccination considered

benefits of vaccination far outweigh risks in pregnancy
vaccination confers protection for at least 35 years - probably life long

pregnant patients should be offered early re-vaccination as may not develop as strong an antibody response

Question 9

47 year old going on cruise in South America. Lost his yellow fever certificate.
What action should be taken

YF is contraindicated and should not be given
He is protected from YF, and replacement certificate should be issued
He is not protected from YF and should be re-vaccinated
He is not protected from YF and should have medical exemption issued
He is at risk of YF, and neither vaccination or certificate is required

Answer 9

He is not protected from YF and should be re-vaccinated

Question 10

24 year old with fever arthralgia rash
multiple unprotected sexual exposures a few months ago

lymph count 2.6
POC HIV test: reactive
CD4 950

which of the following is most correct

this represents seroconversion illness
he is manifesting an AIDS-defining illness
this is a false positive
he is not infectious for HIV
treatment with antiretrovirals should commence when CD4 count is <350

Answer 10

this represents seroconversion illness

History of exposure, and positive test. with high CD4 count suggests recent infection

Question 11

51 year old HIV positive attends for review. Now has undetectable viral load, and CD4 615

What end organ disease does HIV directly cause

nephropathy
enteritis
hepatitis
retinitis
arthropathy

Answer 11

nephropathy

Form of FSGS - caused by direct invasion of HIV into renal epithelial cells

Other renal disease such as membranous nephropathy can occur due to HIV immune complex deposition

Enteritis and retinitis usually caused by opportunistic infections
Arthropathy due to reactive arthritis

HIV end organ disease:
HIV associated neurocognitive disorders (HAND)
nephropathy
AIDS

Question 12

32 year old presents with SOB - diagnosed with PCP pneumonia
HIV test turns positive
Which test is most useful for prognostic purposes in new diagnoses of HIV

HIV envelope antibody
HIV p24 antigen
HIV viral load
CD4 count
HIV plasma RNA

Answer 12

CD4 count is strongest prognosticator for those not presenting with an OI

HIV viral load influences which drug therapy to start, but does not predict future disease. HIV viral load is same as HIV plasma RNA

HIV p24 antigen is used for early diagnosis of infection

Question 13

55 year old with HIV presents with weakness and numbness of his left arm and leg. CD4 count 60
MRI shows focal mass lesion in right hemisphere

What is most likely cause of this presentation

Toxoplasma gondii
Progressive multifocal leukoencephalopathy
Primary CNS lymphoma
Cryptococcus neoformans
Mycobacterium tuberculosis

Answer 13

Toxoplasma gondii

Toxoplasma abscesses are the most common mass lesion in immunocompromised individuals worldwide

Any patient with CD4 <200 and CNS signs should be treated with anti-toxoplasma therapy until alternative diagnosis has been made

History does not suggest PML - as has discrete hemiparesis

CNS lymphoma is reasonable alterantive

Question 14

40 year old with HIV presents with confusion, seizures, and altered GCS
Originally from France, and known Toxoplasma gondii IgG pos
MRI did not sow any focal lesions
LP did not show any raised ICP
Previous CD4 count <200 8 months ago
Started on co-trimoxazole for PCP prophylaxis, but developed a rash, so changed to dapsone

What treatment regime would be recommended

liposomal amphotericin
sulphadiazine with pyrimethamine
clindamicin with pyrimethamine
atovaquone with pyrimethamine
azithromycin with pyrimethamine

Answer 14

clindamicin with pyrimethamine

First line toxo therapy is sulphadiazine with pyrimethamine
Should be screened for G6PD deficiency due to risk of haemolysis with sulphur-containing drugs

Second line therapy if cannot take sulphur containing drugs is clindamicin with pyrimethamine

Folinic acid needs to be given with pyrimethamine

Question 15

35 HIV positive patient presents with fever weight loss, and decreased appetite. On examination has widespread lymphadenopathy
CD4 114
HIV VL 65000
HHV8 viral load 10,000 copies

Lymph node biopsy shows onion-skin appearance on histopathology with interfollicular plasmablasts expressing HHV8 latent nuclear antigen

What is the most likely diagnosis

Primary effusion lymphoma
Kaposi sarcoma
Multicentric Castleman disease
Hodgkin's lymphoma
Non-Hodgkin's lymphoma

Answer 15

Multicentric Castleman disease

Castlemans’ disease has localised and multicentric forms.
Castlemans disease is a HHV8 driven disease similar to Kaposi Sarcoma

Histological confirmation should be made by IHC for HHV8

Rituximab is therapy option

Question 16

35 year old presents with multiple purple raised lesions on trunk and arms. Had been seen by GP for his dry skin over face last year, when he was prescribed emollients. Diagnosed with HIV, and you suspect Kaposi Sarcoma

Which of the following are not treatments of Kaposi Sarcoma

introduction of antiretroviral therapy
intralesional vinblastine
liposomal anthracycline
ganciclovir
paclitaxel chemotherapy

Answer 16

ganciclovir

ganciclovir/ aciclovir have minimal effect on HHV8 activity, so not used for treatment

Question 17

60 year old from Cambodia felt unwell with fever, weight loss, cough. Cervical and inguinal lymphadenopathy, and hepatosplenomegaly. Had papular skin lesions, with central necrotic umbilication mainly on trunk and upper limbs

HIV test pos
Bloods show anaemia and milt thrombocytopenia

What would be the initial treatment regime

commence antiretroviral therapy
liposomal amphotericin B
antituberculous therapy
itraconazole
paclitaxel chemotherapy

Answer 17

liposomal amphotericin B

Talaromyces (penicilliosis) is likely diagnosis
Umbilicated lesions is either Talaromyces or Molloscum Contagiosum

Question 18

24 HIV positive patient denies problems with adherence to his medication. He was diagnosed after his partner notification and has not suffered from opportunistic infection.
He has maintained a reasonable CD4 count, but last viral load was 354 copies/ml 6 months ago, and current VL is 460.
Never reached an undetectable viral load <59

What is definition of his current viral response to treatment

virological failure
incomplete virological response
virological rebound
low-level viraemia
virological blip

Answer 18

incomplete virological response - 2 consecutive VL >200 after 24 weeks, without achieving <50 copies

Virological rebound - failure to maintain VL below 50 copies

Low level viraemia - persistent VL between 50-200 copies

virological blip - a single result between 50-200 copies, but returns to <50 copies whilst on therapy. Not usually a clinical concern - check adherence. But single result >200 suggests virological failure, and needs genotypic resistance testing

Question 19

23 year old recently diagnosed with HIV. Has oesophageal candidiasis, Mycobacterium tuberculosis and PCP during recent admission to hospital. Commenced on antiretroviral therapy

Pregnancy test positive - suspect she is in first trimester

Which one of the following would be safe to continue

co-trimoxazole
efavirenz
moxifloxacin
itraconazole
none of the above

Answer 19

efavirenz

No ARV license for first trimester
Zidovudine licensed for third trimester

But data has shown efavirenz and most common ones are safe in pregnancy. So if patient is on them, it is safe to continue

co-trimox/ moxiflox/ itraconazole are all contra-indicated

Question 20

HIV patients on tenofovir, emtricitabine and efavirenz
HIV VL was undetectable
Complaining of nightmares

Based on the likely drug to be switched, which of the following medications will need a dose increase in the first week

raltegravir
maraviroc
dolutegravir
rilpivirine
elvitegravir/ cobicistat

Answer 20

maraviroc

efavirenz is drug which causes nightmares. But after stopping it can still effect drug metabolism for some time after

Use double dose maraviroc for 1 week until efavirenz leaves system

Question 21

HIV2 shows innate resistance to which class of antivirals

Non-nucleoside reverse transcriptase inhibitor NNRTI
Nucleoside reverse transcriptase inhibitor NRTI
Protease inhibitors
Integrase inhibitors
Chemokine CCR5 antagonists

Answer 21

Non-nucleoside reverse transcriptase inhibitor NNRTI

First line for HIV 2 is tenofovir, emtricitabine and lopinavir/ ritonavir

Question 22

22 year old man has recent unprotected intercourse 48 hours earlier. Sexual partner is known to clinic and known to be HIV pos.
Viral load 350 4 months ago
Viral load undetectable 1 month ago
No significant resistance on genotypic testing

How would you treat the recipient

reassure that transmission is low risk and no treatment needed
offer post-exposure prophylaxis with truvada and raltegravir for 14 days
offer post-exposure prophylaxis with truvada and raltegravir 28 days
offer post-exposure prophylaxis with truvada and efavirenz for 14 days
offer post-exposure prophylaxis with truvada and efavirenz for 28 days

Answer 22

offer post-exposure prophylaxis with truvada and raltegravir 28 days

PEP is for 28 days
Truvada and raltegravir is choice of treatment
Needs to be commenced within list 72 hours of exposure

Question 23

Patient with HIV has SOB, diagnosed with PCP
Treated with co-trimoxazole and made full recovery
CD4 count 230 6 months later in clinic

Which of the following is true regarding PCP prophylaxis

• dapsone is first line therapy in PCP prophylaxis
• Once CD4 drops below 200, PCP prophylaxis should continue for life
• Following treatment of PCP, if CD4 rises above 200 for 3 months, then PCP prophylaxis can be stopped
• Co-trimoxazole is first line prophylaxis for PCP before dapsone because of toxicity issues rather than increased efficacy
• G6PD status needs to be established prior to therapy with pentamidine

Answer 23

• Following treatment of PCP, if CD4 rises above 200 for 3 months, then PCP prophylaxis can be stopped

Question 24

HIV patient has cryptococcal pneumonitis
Started on casponfungin
Continued to deteriorate and was changed to ambisome and flucytosine

Which of the following would make choosing an echinocandin for this indication inappropriate

• Cryptococcus neoformans is resistant to echinocandins as it does not contain (1,3) beta-glucan synthase
• echinocandins have poor penetration into the CNS
• echinocandins have no in-vitro activity against cryptococcal species
• echinocandins are prohibitively expensive given the prolonged therapy need for Cryptococcal meningitis
• echinocandins have multiple drug interactions with HIV ARVs and may complicate therapy if need to be changed

Answer 24

• echinocandins have poor penetration into the CNS

Echinocandins work by inhibiting (1,3) beta-d-glucan synthase thereby disrupting cell wall.
Has poor penetration into CNS

Amphotericin and fluctyosine is first line treatment , followed by fluconazole maintenance phase

Cryptococcus is intrinsically resistant to echinocandins. But not related to 1,3 beta-glucan synthase

Question 25

56 year old with AML has had induction phase chemotherapy
CT indicates pneumonitis
BAL performed

microscopy: no organisms seen
bacterial culture: scanty Streptococcus oralis
fungal culture: no growth
viral PCR: adenovirus detected

Which other clinical syndrome does the pathogen in this case commonly cause

genital cancer
kerato-conjunctivitis
genital ulcers
HFNM
aseptic meningitis

Answer 25

kerato-conjunctivitis

Adenovirus causes croup, pneumonia, conjunctivitis, gastroenteritis (40 and 41)

Streptococcus oralis is a commensal contaminant

Question 26

34 year old on tacrolimus following kidney transplant
Presents with fever, fatigue, cervical lymphadenopathy

Blood tests
CMV PCR neg
EBV PCR neg
HHV6 PCR neg

Which disease is HHV6 associated with

Fifth's disease
Roseola infantum
Kaposi sarcoma
Castleman's disease
Oral hairy leukoplakia

Answer 26

Roseola infantum

Fifth’s disease - ParvoB19
Kaposi sarcoma - HHV8
Castleman’s disease - HHV8
Oral hairy leukoplakia - EBV

Question 27

7 year old with ALL treated with methotrexate, cytaribine, cyclophosphamide
Chemotherapy given via Hickman line
Attended A&E with neutropenic fever
No localising signs

Gram stain shows fungal hyphae without chlamydospores
Commenced on ambisome, but remained febrile at day 7
Fever settled on removal of CVC and changing antifungal therapy to voriconazole

What is most likely organism identified

Fusarium solani
Malassezi furfur
Candida auris
Paecilomyces lilacinus
Aspergillus fumigatus

Answer 27

Paecilomyces lilacinus

Unclear answer - think other pathogens would be susceptible to ambisome

Question 28

50 year old undergoing autologous stem cell transplant for AML, but developed febrile illness 10 days after receiving stem cells

Neutropenic. Broad spectrum antimicrobials prescribed

Chest lesions on CXR
CT suggests fungal cause

Blood culture flagged positive with filamentous fungi

What is the most likely fungal pathogen causing the above presentation

Fusarium solani 
Aspergillus fumigatus
Paecilomyces spp
Penicillium spp
Scopulariopsis spp

Answer 28

Fusarium solani

Aspergillus is most common cause, and would be likely here. However, it rarely grows in blood culture

Question 29

33 year old undergoing haemopoetic stem cell transplant for AML.
7 days after tranplant he was febrile and neutropenic. Oral and abdominal pain, with diarrhoea. Temp 38.5degC. Hickman line looks clean. Mild abdominal tenderness
Commenced on Tazocin and amikacin

Blood culture no growth at 48 hours

He is reviewed at 72 hours, afebrile - what would be your next step regarding the antimicrobials

• no bacterial cause found so add antifungal
• continue tazocin and gentamicin until neutrophils >0.5
• stop gentamicin and continue tazocin until neutrophil count >0.5
• stop all antimicrobials at 72 hours
• change to second line antibiotic therapy with meropenem

Answer 29

• stop all antimicrobials at 72 hours

European guidelines suggest stopping if no localising signs, and clinical improvement. Do not need to wait for neutrophils to recover

Question 30

44 year old admitted with persistent cough. Had renal transplant 5 years ago.
Lives in house, recently renovated. No beds or foreign travel.
Pyrexial and tachypnoeic
CT shows small nodular changes with ground glass changes
Bronchoscopy performed which reported growth of a mould

What is appropriate first line therapy

ambisome 
micafungin and amphotericin
voriconazole and amphotericin
voriconazole
caspofungin

Answer 30

voriconazole - first line treatment for probable aspergillus infection

If patient had been on an azole suppressive therapy, and became unwell, then switch to a different class - amphotericin

dual therapy is not required unless shown to be resistant

Question 31

35 year old with SOB and dry cough. Works as a scaffolder.
CXR shows bilateral haziness
CT shows widespread ground glass changes
HIV test positive

What is the most likely pathogen
CMV
Mycobacteria tuberculosis
PCP
Mycobacterium avium complex
Streptococcus pneumoniae

Answer 31

PCP

diagnosis usually via BAL PCR, or staining with silver stain/ PAS
b-d-glucan will be raised

Question 32

Male with recurrent staphylococcal infections is investigated for a possible immune system disorder. Note that his neutrophils fail to stain with nitroblue-tetrazolium dye. What is the most likely cause of the immunodeficiency

myeloperoxidase deficiency
chronic granulomatous disease
IgA deficiency
Familial Mediterranean fever
Alpha-1-antitrypsin deficiency

Answer 32

chronic granulomatous disease

nitroblue-tetazolium test - positive is normal. Covnerts colours NBT into purple stain
In CGD - negative test means neutrophils fail to stain (remains colourless), and indicates impaired phagocyte function

myeloperoxidase deficiency is a inherited deficiency, suspected when patient has candida infection

Question 33

55 renal transplant patient attended a summer wedding, where reception held in couples home. They have two snakes and a lizard. Buffet dinner

Which scenarios is least likely to be a risk to the individual

Pet reptiles in the home
Eating sprouts in a sandwich
Eating raw oysters
Drinking pasteurised juices
Eating from a buffet at a summer wedding

Answer 33

Drinking pasteurised juices

Question 34

14 year old with hypogammaglobulinaemia develops persistent diarrhoea. Previously treated for Campylobacter infection. He was clinically well, with non-bloody diarrhoea. Stool culture isolates Campylobacter jejuni in stool culture. Blood culture no growth

What is therapy of choice

fosfomycin
colistin
erythromycin
ciprofloxacin
amoxicillin

Answer 34

erythromycin

may also need FFP or HNIG

Question 35

55 year old with bowel cancer is receiving chemotherapy via CVC. Presents hypotensive, tachycardic, febrile. Examination does not show obvious source of infection
Given tazocin and gentamicin for neutropenic sepsis

Blood culture grows an organism, and gram stain demonstrates a gram negative rod

What is the likely organism
E.coli
Citrobacter freundii
Salmonella enteritidis
Pseudomonas aeruginosa
Proteus mirabilis

Answer 35

Pseudomonas aeruginosa

Question 36

What are the two species of Histoplasma, and where are they located geographically?

Answer 36

Histoplasma capsulatum var. Capsulatum, an agent of the so-called American histoplasmosis (wrongly, because of global distribution),

Histoplasma capsulatum var. duboisii, an agent of African histoplasmosis - clinically predominantly causes cutaneous and subcutaneous disease compared to capsulatum