Random Flashcards
(311 cards)
1
Q
Three lactose fermenting bacteria
A
EEK!! E Coli Enterobacter Klebsiella Lactose fermenting organisms turn Mackonkey Agar Pink
2
Q
First Line Treatment for Giardia Lamblia?
A
Metronidazole
3
Q
Parasitic microorganism transmitted by sandflies responsible for: Fever Splenomegaly Less commonly for: Hepatomegaly Skin hyperpgimentation and dry warty skin Pancytopenia
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Leishmaniasis Forms include: Cutaneous (Itchy scaly papule with associated local lymphadenopathy leaving a depigmented scar behind). Caused by: L. Major and L. Tropica Mucocutaneous Visceral Organisms within the family include: L. Donovani L. Infantum L. Chagasi Culture medium: Novy-Macneal-Nicolle Medium
4
Q
Three Stages of Lyme Disease Management of Lyme Disease Organism
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- Erythema Migrans 2. PEACH: Peripheral Neuropathy, Erythema Migrans, Arthritis, Craniel Nerve Palsies and Heart Block 3. Persistent Arthritis and chronic encephalitis! Treated with doxycycline Borrelia Burgdorferi
5
Q
BCG Vaccine constituent? Efficacy?
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Live attenuated form of mycobacterium bovis Thought to be very effective at preventing severe childhood tb but there is little evidence for its efficacy in adulthood.
6
Q
Risk factors for pulmonary TB re-activation
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Malnutrition Immunocompromise (in particular biologics interfering with macrophage function) Alcohol Excess Aging
7
Q
Gold standard for diagnosing TB
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Lowenstein Jensen Medium (Takes 6 weeks to culture though so clinicians have begun using PCR due to its more rapid turn around time)
8
Q
How many weeks after initiating anti-TB therapy should culture positive sputum samples be concerning and why?
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8-10 weeks MDR-TB (Resistance to Rifampicin and Isoniazid) XDR-TB (Resistance to Rif and INA alongside, moxifloxacin and injectables (kanamycin and amikacin)
9
Q
Top cause of adult bacterial meningitis in the UK Points about the organisim
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Neisseria Meningitidis Gram Negative Cocci IV Ceftriaxone in hospital/ Oral Benzylpenicillin immediately if in GP Encapsulated organism so those with hyposplenism are more at risk
10
Q
Which serotypes of haemophilus influenzae are vaccinated against?
A
Type B The clinical relevance are that despite this vaccine people will still become sick with meningitis etc. from other serotypes.
11
Q
Pregnancy associated meningitis in neonates. Two causes
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E. Coli Listeria Monocytogenes
12
Q
Fungal causes of meningitis
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Cryptococcus Neoformans Candida Sps. Coccidoides Immitis Histoplasma Capsulatum Blastomyces Dermatidis
13
Q
Which Neisseria Meningitidis Strains can be vaccinated against?
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A B C Y W135
14
Q
Most common cause of viral (aseptic) meningitis?
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Enterovirus (Coxsackie) Echovirus
15
Q
Most common cause of viral encephalitis?
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Coxsackie-2 But we are worried about Herpes Simplex Virus - this cuases long term neurological sequalae in 1/4
16
Q
Causes of viral encephalitis?
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Coxsackie HSV Togavirus Flavivirus Bunyavirus
17
Q
Causes of bacterial encephalitis?
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Listeria Monocytogenes
18
Q
Causes of amoebic encephalitis?
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Naegleria Fowleri Acanthamoeba Species Balamuthi Mandrillaris
19
Q
Imaging modality of choice for suspected brain abscess/
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MRI (best) Contrast CT Scan Imagining in suspected brain infections is to rule out anatomical problems i.e. Raised ICP
20
Q
What would point you towards a HSV encephalitis on an MRI scan?
A
Temporal lobe inflammation Enteroviruses hone towards different and more widely distributed brain regions
21
Q
India Ink Stain?
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Cryptococcus Neoformans
22
Q
CSF Analysis: Low Glucose High WCC (polymorphic) Organisms? Treatment?
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Bacterial Meningitis: Neisseria Meningitidis Streptococcus Pneumonia Haemophilus Influenza Listeria Monocytogenes (Immunocompromised) Ceftriaxone Corticosteroids Ampicillin - If >50 for Listeria
23
Q
CSF Analysis: Normal GLucose High WCC (mononuclear) Organisms? Treatment?
A
Viral/ Aseptic Meningitis: Coxsackie Virus Echovirus Herpes Simplex virus Supportive but if HSV is suspected then Acyclovir
24
Q
CSF Analysis: Low/Normal Glucose High Protein High WCC (Mononuclear)
A
TB / Cryptococcus TB: 12 months of anti-TB therapy Cryptococcus: Amphotericin B + Flucytosine, followed by Fluconazole
25
Asides from imaging, CSF sample and tissue sample: What three tests would you order if worried about CNS infection?
Blood Cultures Throat Swab Blood PCR
26
If presentation is meningoecephalitic, suggest immediate management plan (Drugs)?
Ceftriaxone 2g iv BD Ampicillin (If over 50 for listeria) Acyclovir
27
Which viral hepatitis uses reverse transcriptase enzyme?
Hepatitis B Virus Is a DNA virus but uses reverse transcriptase which makes some HIV drugs effective against it. Serotypes A-G 30% chance of infection following needle stick in adults
28
HBV treatment modalities AND side effects/caveats
Short Term therapy: Interferon (Anti viral effect and pro inflammatory effect) - Used in patients who are successfully clearing the virus but just need help to clear - Doesn't work in birth acquired infections - Host of side effects resembling flu like infection - Risk of precipitating autoimmune conditions Long term suppressive therapy: (Indicated in people with large viral load) Lamivudine - Not very potent/ effective - Good side effect profile Tenofovir Entecavir Emtricitabine Used in combination with Tenofovir in patients with HIV co-infection Other therapies Hepatitis B Ig - taken from people with high levels of anti-hepatitis antibodies - Useful in transplant
29
Lamivudine Entecavir Emtricitabine
Nucleoside Reverse Transcriptase Inhibitor NRTI Lamivudine - Low potency - Good side effect profile - Hep B Entecavir - Higher potency - Hep B Emtricitabine - Used in HIV Hep B co-morbid alongside tenofovir (NtRTI)
30
Tenofivir
Nucleotide Reverse Transcriptase Inhibitor (NtRTI) Hep B
31
Telaprevir Boceprevir Asunaprevir Drug Class? Condition? Treatment monitoring?
Serine Protease Inhibitors Hepatitis C SVR12 - 12 weeks after treatment if negative serology considered cured
32
HCV genomic drug targets and examples
NS5A - Ledipasvir, Daclatasvir NS5B - Sofosbuvir, Dasabuvir - not very effective in genotype 3
33
UK recommendation for HCV genotype 3?
Interferon
34
Ribavarin MOA Indications
Guanasine Analogue (Pro-Drug) - prevents RNA synthesis HCV! RSV and Viral haemorrhagic fever
35
What virus does a person need to be infected with to contract a Hepatitis D infection?
Hepatitis B
36
Hepatitis E: Genotype 1 and 2: ?? Genotype 3 and 4: ??
1 and 2: Human epidemic 3 and 4: swine amongst their animals and can become zoonotic (not person to person)
37
Which population have a higher mortality rate from Hep E?
Pregnant Women
38
Hepatitis E: Incubation period : ?? Complications :?? Treatment: ? Moa? Transmission: ?
Incubation: 3-8 weeks Complications: CNS disease, Chronicity Pregnant women!!! - High mortality Treatment: Usually conservative but sometimes ribavarin (Guanosine analogue) - Vaccine is effective Transmission: - Faeco Oral - Pork
39
Why do certain serotypes of E. coli have such high success with regards to causing UTIs?
Virulence Factors facilitate adherence to the urinary epithelium, in particular fimbrae Certain serotypes cause cystitis whereas others cause pyelonephritis
40
6 Organisms Associated with causing UTI
E. Coli Proteus Mirabli Klebsiella Aerogenes Enterococcus Faecalis Staphylococcus Saphrolyticus Saphylococcus Epidermis
41
Second Commonest UTI infection microorganism in young women?
Staph. Saphrolyticus Coagulase Negative
42
Causes of obstruction in the urinary tract
Mechanical Extrarenal - Valves, narrowings, external compression Intrarenal - calcinosis, uric acid/analgesic/hypokalemjx nephropathy, cystic kidney disease, other renal pathology Neurogenic - Polio, Tabes Dorsalis, Diabetic Neuropathy, SCI
43
What causes haematogenous UTIs? Do gram negative or gram positive organisms tend not to cause haematogenous UTI?
S. Aureus abscess due to bacteremia / endocarditis Gram Negatives tend not to
44
UTI Sx Lower Upper
Lower Polyuria, Dysuria, Suprapubic Heaviness, Haematuria, Apyrexial Upper Fever, Rigor (Cytokine Release due to gram negative infection), flank pain, Lower UTI Sx
45
When should you choose to further investigate male/female patients for complicated UTIs? What investigations ?
Females : 2 or more episodes of pyelonephritis Males: 1 Episode of pyelonephritis Investigations : Renal USS, IV urography
46
22 Year old woman presents with dysuria, urinary frequency and haematuria. There is no evidence of thrush or other STI. a) Urine Sample and Dipstick b) Blood Tests c) Empiral Antibiotic Treatment for UTI d) MSU and wait for cultures
c) 3 or more typical UTI symptoms and no evidence of thrush or STI has a 90% rate of being culture positive ---\> start treatment In hospital cultures are usually sent due to higher tendency of resistant organisms
47
22 Year old woman presents with urinary frequency and haematuria. There is no evidence of thrush or other STI. a) Urine Sample and Dipstick b) Blood Tests c) Empiral Antibiotic Treatment for UTI d) MSU and wait for cultures
a) If 2 or less symptoms you should collect a sample and examine/ dipstick. If not cloudy do not treat If only lecucoytes positive then wait for sample and only commence empirical treatment if symptoms are severe
48
What does nitrite testing on urine dipstick look for?
Coliform Bacteria Coliforms have an enzyme that convert nitrates to nitrites
49
2 Complications of UTI in pregnancy
Early labour Pyelonephritis
50
Culture and Sensitivity Testing for UTIs should be performed in: List of 9
Positive Leucocyte + Negative Nitrites Pregnancy Catheterised Patients (only if symptomatic with systemic infection) Failed antibiotic treatment Man with suspected UTI Abnormalities of urinary tract Children with suspected UTI suspected pyelonephritis Renal Impairment Sexually active young men and women with symptoms
51
Causes of sterile pyuria
Chlamydia Trachomatis Mycobacterium Tuberculosis Calculus Catheter Bladder Cancer Previously treated infection
52
What implies a poorly taken sample?
Mixed Bacterial Growth Lots of Squamous Epithelial Cells ( Indicates a lot of distal urethral cells so likely to be perineal contamination)
53
Three methods of obtaining urine sample and indications
MSU - most common Cather - if already catherised Suprapubic aspiration - in children
54
Excretion method of clindamycin and clarithromycin
Hepatic Excretion hence poor efficacy in treatment of UTIs
55
Which of these antibiotics is most likely to contribute to c diff: a) Cefalexin b) amikacin c) azithromycin d) chloramphenicol
a) cefalexin Remember the three c's: - clindamycin - cephalosporins - ciprofloxacin
56
UTI treatment courses are usually 3 or 7 days: What are the indications for either?
3 Days: Uncomplicated UTI in a woman 7 days: Recurrent UTIs / UTI In a man
57
Complications of pyelonephritis 4
Perinephric Abscess Sepsis / Septic Shock Acute papillary necrosis Chronic pyelonephritis
58
Clinical Suspicion of HSV encephalitis you should ...
Start empirical treatment immediately with IV aciclovir 10 mg/kg TDS for 21 days Stop treatment if found to not be HSV
59
Which HERPEVIRUS antivirals require activation and which don't
Require activation: Aciclovir Ganciclovir Don't require activation: Foscarnet Cidofovir
60
CMV management in the SCT placement?
Pre- emptive Weekly blood tests looking at viral PCR and when reaches threshold commence treatment with Foscarnet/ Cidofovir (consider GCV or vGCV but bear in mind they cause BM suppression)
61
Post transplant proliferative disease Virus Responsible? What family of viruses is it from? Diagnosis? Management?
EBV herpeviruses Diagnosis: Viral load of \> 10^5 c/ml Management: i) stop immunosuppression ii) Rituximab (anti - CD20 MAB)
62
Haemorrhagic Cystitis following Bone Marrow Transplant. Organism? Treatment:
BK virus i) Bladder Washouts ii) Reduce immunosuppression where possible iii)Cidofovir - if severe
63
When would you test for drug resistance in HIV?
Baseline resistance testing is undertaken in HIV patients Furthermore upon treatment failure as with other viruses
64
What usually causes ACV resistant HSV strains?
Viral Thymidine Kinase mutations responsible for about 95% of resistance and the other 5% due to viral DNA polymerase Can also be associated with Ganciclovir cross resistance Diagnosis - Plaque reduction assay (phenotypic testing) Treatment - Foscarnet or Cidofovir
65
Which atypical Respiratory tract infection is particularly associated with ground glass shadowing on CT?
Pneumocystis Jerovoci BAL - Looking for cysts PCR Test - very sensitive and may lead to a lot false positives because Pneumocystis is present asymptomatically in lots of people Rx: Co- Trimoxaxole 960 mg BD Clindamycin + Primiquine
66
AIDS defining illnesses: What CD4 counts are associated with which types of illnesses
500 - HSV and bacterial skin infections. Also fungal infections 400 - Kaposi's Sarcoma HHV8 300 - Hairy leukoplakia. Tuberculosis 200 - PCP, Cryptococcus, Toxoplasmosis 100 - CMV, Lymphoma
67
Bacterial Causes of brain and lung abscesses/infection in immunocompromised patients? A fungal?
Actinomyces - Gram Positive Facultative Anaerobes. associated with basopholic granules (sulphur granules). Grocott Stain Nocardia - Aerobic Fungal: Cryptococcus : India ink staining/ Antigen testing. Is a capsulated yeast.
68
Which antimocrobial agents have activity against biofilms i.e. on metalwork?
Rifampicin (RNA synthesis inhibitor) Ciprofloxacin (Fluoroquinolone)
69
What is the most important treatment principle for prosthetic joint infection?
Debridement and removal of prosthesis. Although antibiotics are important they will not work until the infective source is removed
70
What prevents clearance of prosthetic joint infections?
i) Biofilm formation - cells are quiescent so antibitoics have limited effect ii) fibrous capsule formation can prevent drug from entering into deeper infections
71
Markers of severity of c diff? a) diarrhoea \>5 times a day b) temperature \>38.5 c) HR \>90 d) creatinine e) antibiotic response failure after 72 hours f) deranged LFTs g) clinical or radiological signs of colitis h) obstructive jaundice
b, c, d, e, g b) temperature \>38.5 c) HR \>90 d) creatinine e) antibiotic response failure after 72 hours g) clinical or radiological signs of colitis
72
Ribotype 027. C Diff is associated with: a) Vancomycin resistant c diff b) metronidazole resistant c diff c) high mortality c diff d) oesophageal infection
c) high mortality c diff 16 times more toxin A AND 23 times more toxin B than control strains
73
c diff histopathology
Pseudomembranous Colitis A disruption of the tight junctions accompanied by neutrophil infiltration
74
Parvovirus B19 (DNA Virus) i) Risk of transplacental transmission ii) High risk \>20 weeks or \<20 weeks? iii) Risk of hydrops fettles iv) Risk of miscarriage
i) 25-30% ii) Risk is associated with infection \<20 weeks gestation iii) 3% \<20 weeks iv) 9% \<20 weeks
75
Rubella (RNA Virus) i) Features of congenital Rubella Syndrome ii) Below what week of gestation do foetuses get CRS iii) What symptoms are associated with Rubella infection between 13- 18 weeks?
i) Glaucoma, Cardiac defects, loss of hearing, retinopathy, splenomegaly, meningeoencephalitis, blueberry muffin rash ii) \<10 weeks iii) Hearing defects and retinopathy. Risk of disease from Rubella decreases after 20 weeks gestation.
76
Should the MMR vaccine be offered to a pregnant woman who is seronegative for rubella antibodies?
NO MMR is a live vaccine! Live vaccines are contraindicated in pregnant women due to theoretical risk to the foetus.
77
You are suspicious of foetal CMV infection in a neonate \<3 weeks of age due to hepatosplenomegaly and prematurity. What type of screening test is undertaken? What are the preferred screening tests? i) blood and skin ii) blood and urine iii) urine and saliva iv) saliva alone v) blood alone
CMV PCR iii) Urine and saliva
78
When is treatment recommended for congenital CMV infection? Detail first and second line treatments and highlight side effects/ differences in MOAs.
Treatment is recommended when there is any significant organ involvement. Treatment: 1st Line - Ganciclovir - guanosine analogue much like acyclovir. Requires activation through viral thymidine kinase enzyme. Associated with Bone marrow suppression so consideration should be given. (valganciclovir - oral prodrug) 2nd Line - Foscarnet/ Cidofovir. These don't require enzyme activation.
79
What trimester of pregnancy is greatest associated with Primary HSV Type 1/Type 2 Infection being transmitted to to foetus?
Third trimester infections
80
Three types of clinical presentation for neonatal herpes?
i) SEM: Skin eyes and mouth - 7-12 days postpartum. - Ocular and neural sequelae ii) CNS Disease - 17-18 days post-partum - Encephalopathy - 50% mortality rate iii) Disseminated Disease - 4-11 days post-partum - vesicular rash and a sepsis-like presentation - 80% mortality rate
81
What predisposes neonates to contracting severe disseminated haemorrhagic neonatal chickenpox?
Maternal chickenpox being contracted 1 week before through to 1 week after delivery
82
Three significant complications from measles infection?
i) Opportunistic Bacterial infections - OM, Pneumonia, Bronchitis ii) Encephalitis iii) Subacute Sclerosing Pan-Encephalitis
83
Which of the following will receiving Human IG prevent in a susceptible pregnant women who has come into contact with suspected measles? i) Foetal Loss ii) Preterm Delivery iii) Congenital Abnormalities to Fetus iv) Maternal Morbidity
iv) Maternal Morbidity. Measles does not cause congenital abnormalities. Measles is associated with foetal loss and prematurity but receiving human IG has not been shown to influence this.
84
Women with chickenpox at 28 weeks gestation. Treatment?
Give Acyclovir- thought to be safe during pregnancy . Not VZIG which is only indicated as post exposure prophylaxis.
85
Antibiotic prophylaxis is proposed to majorly reduce the occurrence of SSIs. This is usually administered at the time of anaesthesia induction. When might further intraoperative doses be recommended? (2)
i) Significant Blood Loss ii) Prolonged operation
86
What are the recommendations for ventilation in theatre? Anything different for orthopaedic theatre?
20 air changes per hour (3 fresh air) Laminar air flow is suggested for orthopaedic theatre
87
Which of the following constitutes good homeostatic preventative mechanisms for reducing SSI risk? i) hyperthermia + hypoxia ii) normothermia + hypoxia iii) no measurement of oxygen saturations or temperature iv) normothermia + 95% oxygen saturations v) hypothermia + 95% oxygen saturations
iv) normothermia +95% oxygen saturations Both are important for ensuring good blood flow through the patient's tissues and thus the prevention of any SSI.
88
Why do damaged joints pose a greater risk to the development of septic arthritis?
Joint damage leads to exposure of host proteins such as fibronectin to the bacteria, which find it easier to adhere to these proteins than to synovial membranes etc. Organisms such as staph aureus even have virulence factors such as fibronectin binding protein which utilise the defect in the joint.
89
Organisms commonly associated with septic arthritis?
Gram Positives make up the majority of septic arthritis. Staph Aureus (46)% - Fibronectin Binding Protein Panton Valentine Leukocidin Streptococci (22%) (pyogenes, pneumoniae, agalactiae) Gram Negative organisms are less common (E.Coli, Haemophilus Inf., Neisseria Gonorrhoea, Salmonella) Kingella Kingae (Gram Negative Coccobacilli) - adhere to synovium thorugh bacterial pilli. Rare causes of septic arthritis are: Lyme Disease, Brucellosis, Mycobacteria and some Fungi
90
How would you investigate suspected vertebral osteomyelitis?
First - MRI (90% Sensitive) THEN Blood Cultures/ CT guided biopsy or open biopsy
91
What are features of chronic Osteomyelitis? i) Pain, Brodie's Abscess and and Bone erosions ii) Pain, Bone erosions and multi-drug resistant organisms on culture ii) Pain, Brodie's Abscess and Sinus Tract
ii) Brodie's Abscess and Sinus Tract Brodie's Abscess are usually discharging abscesses found in the tibia Bone biopsy are required to diagnosed. Treament is through extensive been debridement and removal of effected soft tissue.
92
Describe specific surgical techniques for treatment of chronic osteomyelitis?
Lautenbach Technique - Double lumen suction mechanism. ANtibiotic is delivered through the device and every week a litre of hartman is administered through the devices and then cultures are taken. Discharge is still accompanied by oral Abx Papineau Technique - Infected tissue and bone is completely excised and cancellous bone is grafted onto the defect caused by infection and debridement.
93
Most common bacterial cause of prosthetic joint infection? a) Gram Positive, Coagulase Positive Staphylococci (Aureus) b) Gram Positive, Coagulase Negative Staphylococci (Epidermidis) c) Gram Negative Cocci (Neisseria Meningitidis) d) Brucellosis
b) Gram +ve, Coagulase Negative Staphylocci Staph aureus and gram negative organisms can cause PJIs but they're less common
94
Suspected prosthetic joint infection. You organise a CRP and Joint aspiration. Which results would confirm a PJI in the prosthetic hip joint: a) CRP \>5 WCC \<1700/ml of WCC b) CRP \>5 WCC \<3000/ml of WCC c) CRP \>13.5 WCC \>4200/ ml of WCC d) CRP \>13.5 WCC \<1700/ml of WCC e) CRP \>5 WCC \>4200/ml of WCC
e) CRP \>5 WCC \>4200/ml of WCC PJI in the hip and knee have different requirements for diagnosis. Knee: CRP \>13.5 WCC for joint aspirate \>1700/ml Hip: CRP \>5 WCC for joint aspirate \>4200/ml
95
In which technique for surgical management of prosthetic joint infection is a spacer loaded with antibiotic containing cement used?
Two stage revision! - In this method a period of antibiotics (IV) is administered followed by re-debridal and re-sampling to test for cure from infection BEFORE the new joint is put in. Six weeks with IV antibiotics before the joint is put in. In single stage revision - excision is performed and the the bone cement is loaded with antibiotics based on the sample. The new joint is implanted at the first surgery.
96
What are the live attenuated vaccines?
PYT BIRM polio yellow fever typhoid BCG Influenza (Intranasal) Rotavirus (oral) MMR
97
Most common cause of bacterial meningitis in neonates?
Group B Streptococcus
98
Most common cause of osteomyelitis in patients with sickle cell anaemia?
Salmonella It's normally staphylococcus Aureus
99
What are the sepsis 6?
Sepsis trust have recommended the commencement of the sepsis 6 if ANY red flag sign is present: - SBP \<90 mmHg or \>40 mmHg fall - MAP \<65 mmHg - HR \>132 BPM - RR \> 25 BPM - AVPU = V, P OR U the sepsis 6 are - high flow oxygen - blood cultures - broad spectrum antibiotics - IV fluid challenges - serum lactate and haemoglobin - hourly urine output
100
Which organisms cause: Type 1 necrotizing fascitis type 2 necrotising fascitis How is it best managed?
Should suspect NF when there is acute onset, extremely tender erythematous lesion development . Type 1: Anaerobes and aerobes (associated with diabetics post- operatively) Type 2: Strep Pyogenes
101
Low glucose on CSF Analysis?
Bacterial and Tuberculosis are expected to be lower Unexpectedly Measles and herpes encephalitis may have a low glucose
102
Pregnant woman is going to malaria endemic region Which of the following prophylactic regimes is contraindicated? a) Atovaquone + Proguanil (Malarone) b) Chloroquine c) Doxycycline d) Mefloquine (Lariam) e) Proguanil (Paludrine) f) Proguanil + Chloroquine
c) Doxycycline Proguanil - requires folate supplementation. As does proguanil + atovaquone For children prophylaxis recommended is : Diethyltoluamide (DEET) over 2 months of age Doxycycline over age of 12
103
What microorganisms are responsible for hand, foot and mouth disease?
Picornoviridae - intestinal viruses Coxsackie A16 and Enterovirus 71 - Non specific symptoms - oral ulcers - vesicles in palmar and plantar surfaces
104
Most common infective exacerbation of COPD
Haemophilus Influenza - Needs Amoxicillin (or s tetracycline) + prednisolone
105
HAART Nucleoside Analogue Reverse Transcriptase Inhibitors
All NRTIs are associated with peripheral neuropathy Zidovudine - anaemia, myopathy, black nails Lamivudine Didanosine - pancreatitis Usually two of these + PI/ NNRTI
106
HAART Non Nucleoside Reverse Transcriptase Inhibitors
Efavirenz Nevirapine Both interact with P450 enzyme and induce rashes
107
HAART Proteosome Inhibitors
Indinavir - stones, hyperbilirubinaemia Nelfinavir Ritonavir - potent p450 inhibitors Saquinavit SEs: Diabetes, hyperlipidaemia, buffalo jump, p450 interaction, obesity
108
Which anti-malarial is given in addition to chloroquine for plasmodium ovale or vivax?
Primaquine - Used to destroy liver hypnozoites and prevent relapse Vivax/Ovale : Cyclical 48 hour fever Malariae: Cyclical fever for ever 72 hours
109
What does Anti- HBS Level of 10-100 mIU/ml represent following three courses of hepatitis b vaccine?
Suboptimal response - further dose is required
110
5 Significant complications of hepatitis C virus
Chronic Infection 80-85% Cirrhosis - 20-30% Hepatocellular Cancer Cryoglobulinaemia Porphyria Cutanea Tards CCCHOP
111
Two respiratory infections associated with cystic fibrosis (specifically)
Brukholderia Cepacia Pseudomonas Auregenosa
112
Congenital condition associated with linear scars at the angle of the mouth
Congenital Syphilis - Blunted upper incisor teeth - Rhagades (linear scars at the angle of the mouth) - keratitis - saber shins - saddle nose - deafness
113
Empirical treatment for neisseria gonorrhoea
IM Ceftriagone + 1g oral azithromycin
114
Systemic complications of mycoplasma pneumonia: Derm Harm
Erythema Multiforme Cold AIHA Management: Macrolides - Erythromycin or clarithromycin Tetracyclines - Doxycycline is second line
115
When would you perform stool microbiology in a child? 3 Situstions
Suspected septicaemia Blood/ Mucus in stool Child is immunocompromised
116
Viral Prophylaxis: Hep a Hep b Hep C HIV VZC
Hep A - Human Normal Ig/ Hep A Vaccine Hep B - Booster vaccine if known responder. If not - HBIG + vaccine/ Accelerated vaccine if already started Hep C - Monitor PCR and if seroconversion - Interferon +\- Ribavarin HIV - Anti retroviral combination for 4 weeks. Test at 12 weeks VZV - VZIG for IgG negative women and IgG negative immunosuppressive people
117
BNF recommended treatment: Chronic Bronchitis Exacerbation CAP Atypical Pneumonia HAP
Chronic Bronchitis Exacerbation - Amoxicillin/Doxycycline/Clarithromycin CAP - Amoxicillin. Pen Allergy - Doxy/ Clarithroy. Add flucloxacillin if concerned about staph aureus. Atypical Pneumonia - Clarithromycin HAP - \<5 Days : Co-amoxiclav / Cefuroxime - \>5 days : Tazocin / Broad spec cephalosporin (ceftazidime)/ Ciprofloxazin
118
Pneumonia Associated with alcoholism and DM
Klebsiella Pneumonia (Gram negative rod) - Red currant jelly sputum - Upper lobe pneumonia - Lung abscess and empyema
119
HBs antigen on viral serology screening is indicative of: a) Highly infectious disease b) chronic infection c) previous infection - now carrier d) acute infection e) acute highly infectious
HBs antigen indicates current acute infection - is the surface antigen of the virus particle itself
120
Organism responsible for Acute epiglottitis
Haemophilus Influenzae
121
Investigation of choice for Chlamydia
Nucleic Acid Amplification Technique
122
Management of STIs: Chlamydia Gonorrhoea
Chlamydia : Azithromycin - single dose or Doxycycline - 7 days Gonorrhoea : IM Ceftriazone + Oral Azithromycin
123
Predisposing conditions for osteomyelitis: 5
DM SICKLE CELL IVDU IMMUNOSUPPRESSION ALCOHOL
124
What is a chancroid?
Haemophilus Ducreyi Painful necrotising genital ulcers accompanied by inguinal lymphadenopathy
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Site of latency: HSV1
Sensory Nerve Ganglia
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Site of latency: HSV2
Sensory nerve ganglia
127
Site of latency: VZV
Sensory nerve ganglia
128
Site of latency: EBV
Leukocytes and epithelial Cells
129
Site of latency: CMV
B Lymphocytes
130
Site of latency: HHV6A and HHV6B
T lymphocytes and epithelial Cells
131
Site of latency: HHV8
Epithelial Cells
132
Some complications of VZV in immunocompromised patients What are the three patterns of involvement in immunocompromised patients
Bacterial superinfection Haemorrhaging skin lesions (purpura fulminans) Pneumonitis hepatitis These occur in the immunocompromised and tend to be a late complication in SCT (100 days) 3 patterns of involvement: Dermatomal skin lesions Skin lesions without dermatomal distribution (associated with visceral involvement) VZV reactivation with no skin involvement
133
EBV complications in immunosuppressed List 2
Oral hairy leukoplakia post-transplant lymphoproliferative disease (lymphoma precursor) Lymphoma
134
CMV retinitis and pneumonitis are well characterised in patients who are immunocompromised What specific causes of immunosuppresion cause which conditions
HIV CMV Retinitis post transplant CMV pneumonitis
135
Which viruses are weekly titers performed of in post transplant patients?
CMV EBV Adenovirus
136
Mouth ulcers in a stem cell transplant patient Which 2 viruses do you request PCR of when you take a swab
Enterovirus HSV
137
Many viruses in the immunocompromised come accompanied with an increased risk of pneumonitis: What are they: I P R A N
Influenza A and B (Oseltamivir or Zanamivir) Parainfluenza 1,2,3 and 4 RSV (Ribavarin) Adenovirus Novel coronavirus To diagnose: specimen from respiratory tract and then PCR Can try immunoglobulin in any
138
What parasite is hyperinfection syndrome associated with
Strongyloidiasis Responsible causes of immunosuppression - HTLV1, steroids and biological therapies (NOT HIV) allow the parasites to cause more severe symptoms and complications such as : Bowel breakdown Meningitis Death
139
Which two of these parasites have autoinfection as part of lifecycle A) ascaris lumbricoides B) ancylostoma duodenale (hookworm) C) necator Americanus (hookworm) D) enterobius vermicularis (threadworm) E) toxocara canis F) strongyloides
D) enterobius vermicularis F) strongyloides
140
What is the most worrying symptom associated with bacteremia i.e low chance of self resolution
Hypotension - These patients are more liable to doing badly
141
Principles of antimicrobial drug choice
Narrow Spectrum is preferred over broad spectrum Bactericidal is preferred to bacteriostatic Local Sensitivities Host characteristics - site of infection, age, pregnancy, allergies, polypharmacy
142
What is the MIC (Minimum Inhibitory a Concentration)
The least amount of drug required to inhibit the growth of an organism in culture If the MIC is greater than or equal to predefined breakpoints set by governing microbiology bodies the organism is said to be resistant
143
When stabilised patient with an infection mostly antibiotics are switched to oral. When would you not do this?
Particularly deep seated infections / hard to reach places: Osteomyelitis CNS infections
144
Considering pharmacokinetic/pharmacodynamic predictors of efficacy: How do you adjust the peak concentration? How do you adjust the trough concentration?
Peak - by altering the dose Trough - by altering the frequency
145
Considering pharmacokinetic/pharmacodynamic predictors of efficacy: When dosing penicillins is the a) dose or the b) frequency more important?
Penicillins due to their MOA to exhibit their bacteriocidal properties rely on having a prolonged period of time over the MIC. To achieve this frequent dosing is important i.e. TDS and QDS. The answer is therefore b) frequency
146
Considering pharmacokinetic/pharmacodynamic predictors of efficacy: Vancomycin is a glycopeptide antibiotic. Is the peak concentration or the duration of time over the MIC more important?
For vancomycin it is actually the space underneath the curve that is important so both the concentration and the time over the MIC.
147
Considering pharmacokinetic/pharmacodynamic predictors of efficacy: For macrolides what is the important consideration: peak concentration time duration over the MIC
Peak concentration With macrolides one large dose is important!
148
Why is ceftriaxone not used in neonates?
Displaced bilirubin from albumin and causes biliary sludging Use cefotaxime instead
149
Gram Positive Cocci 8
Staphylococcus - Aureus (Coagulase +) Epidermidis (Novobiocin Sensitive) Saphrolyticus (Novoviocin Resistant) Streptococcus b Hemolytic (Clear) Pyogenes (group a, bacitracin sensitive) Agalactiae (group b, bacitracin resistant) y hemolytic enterococcus faecalis, faecium a hemolytic (green) pneumoniae - optochin sensitive but has capsule viridans - optochin resistant but non capsulated
150
Gram Positive Bacilli 5 (ABCD L)
Actinomycetes Bacillus Anthracis Clostridium Diptheria Listeria
151
What paraprotein is secreted in Waldenstroms Macroglobulinaemia?
IgM Very rare to have IgM myeloma so where there is raised serum IgM think about waldenstroms The syndrome exists with bone marrow infiltration, splenomegaly and lymphadenopathy but NO skeletal lesions
152
Cutaneous Leishmaniasis: Is caused by L. ______ and L.\_\_\_\_ Mucocutaneous Leishmaniasis: Is caused by L. _______ Visceral Leishmaniasis: Is caused by L. \_\_\_\_\_\_\_\_\_\_\_
Cutaneous : Leishmania Tropica and Mexicans Mucocutaneous: Leishmania Braziliensis Visceral: Leishmania Donovani - non specific symptoms with massive splenomegaly (panyctopenia) and hepatomegaly. Grey Skin.
153
Complicated Malaria occurs due to which organism? What features can you expect to see?
P. Falciparum Features: Large parasitarmia (\>5%) Confusion/ Coma Oligoanuric AKI Jaundice Anaemia ARDS Hypoglycaemia Acidosis Shock
154
a)Two treatments for severe falciparum malaria b) complications for both
Iv Artesunate - BM monitoring due to hypoglycaemia - WHO 1st line and is rapid clearing IV quinine - Cardiac monitoring for arrhythmias and BM monitoring for hypoglycaemia
155
What diseases does Rickettsia cause? - 3 What treatment? What are the vectors
Rocky Mountain Spotted Fever African Tick Bite Fever Chiggers (more severe) Doxycycline Arthropods: ticks, lice, mites
156
What organism causes neurocystercicosis? What is the treatment and the rationale?
Taenia Solium (faeco oral ingestion of eggs or consumption of pork) Albendazole/Praziquantel + Steroid - steroid to prevent an immunological response to the dying eggs which would lead to inflammation in the brain (high mortality if no steroids)
157
Gram Negative Cocci 3
Neisseria Meningitidis Neisseria Gonorrhoea Morexella Catarhalis
158
What causes genital warts?
HPV 6 and 11 Solitary warts - cryotherapy Multiple warts - topical podophyllum
159
What constitutes centor criteria? What organisms are suspected with high scorers?
History of fever Tonsillar Exudates Tender anterior cervical adenopathy Absence of cough Modified score includes: - age under 15 add a point - age over 44 subtract a point Streptococcus pharyngitis
160
When should receive immediate antibiotic prescribing?
\<2 years old and bilateral acute otitis media child with otorrhea and acute otitis media acute sore throat/pharyngitis/tonsillitis and 3 or more centor criteria systemically unwell presentation suggestive of severe bacterial illness high risk of complications due to pre existing morbidity history of cough, over the age of 65(+2 of the below criteria) or over the age of 80 (+1 of the below criteria) - hospitalization in previous year - diabetes - CHF - on steroids
161
Which 2 organisms are usually suspected in osteomyelitis?
S Aureus Non Typhi Salmonella - malaria and sickle cell Treatment - Flucloxacillin for 6 weeks - Clindamycin if pen allergic
162
What organisms are commonly responsible for Hand foot and mouth disease?
Coxsackie A16 Enterovirus 71 Fever, ulcers and vesicles and palmar and plantar surfaces Unwell children kept off school
163
Causes of erythema multiforme Viruses: Bacteria: Drugs: Other:
Viruses: HSV, Orf Bacteria: Mycoplasma, Strep Pneum Drugs: Penicillin, Sulphonamides, Carbamezapine, Allopurinol, NSAIDs, OCP, Nevirapine Other: Connective tissue diseases (SLE), Sarcoidosis, Malignancy
164
Most common cause of erythema multiforme:
HSV
165
Hepatitis B Vertical Transmission Rate: a) 10% b)15% c) 20% d) 25%
c) 20% but increases to 90% if woman is positive for HBeAg
166
First line treatment for amoebiasis
Metronidazole Causes liver and colonic abscesses. Sx - profuse bloody diarrhoea Dx- stool microscopy looking for trophozoites
167
Which pneumonia would likely exhibit a positive walk test?
PCP The patient would desaturate when asked to walk
168
Mechanism of spread for legionella pneumonia
Infected water droplets Widely accepted to not spread from person to person
169
Which serotypes is routinely tested for in the urinary antigen test for legionella pneumophillia?
Serotypes 1 This is the predominant cause of legionella pneumonia
170
Commonest cause of HAP?
Enterbacyeriaciae (31%) S Aureus Pseudomonas
171
Owl Eye Inclusions
CMV
172
which three of the following bacteria are well characterized causes of early onset sepsis in the neonate? a) neisseria meningitidis b) cryptococcus neoformans c) streptococcus agalactiae d) leptospirosis e) listeria sp f) haemophilus influenza g) e. coli
Early onset: \<48 hours c) strep. agalactiae e) listeria sp. g) e. coli
173
Management for early onset neonatal sepsis
ABCDE approach Ventilation, fluids and nutrition Abx: Benzylpenicillin and Gentamicin. Amoxicillin/ampicillin if concerns about listeria Organisms : E. coli, GBS And listeria
174
Late onset sepsis in neonate: What's the time frame? Which organism would you suspect in patients with a long line in situ?
Time frame : 48 hours - 6 weeks Organism: Coagulase negative staphylococcus
175
Late onset neonatal sepsis: Which organism would you suspect in a patient with a confirmed cerebral abscess? a) streptococcus agalactiae b) listeria monocytogenes c) citrobacter koseri d) coagulase negative staph aureus e) vibrio cholera
c) citrobacter koseri
176
Late onset neonatal sepsis: Management of hospital acquired Management of community acquired
hospital : 1: BenPen + gent 2: Taz + vanc - if very ill community: amox + cefotaxime
177
Definition of pyrexia of unknown origin
\>38.3 degrees for a period of \>3/52 despite \>1/52 investigation
178
What group of organisms cause RMSF, ATBF How do you treat?
Rickettsia - small gram negative pleomorphic bacteria. Vector transmission. Dx: Serology Treatment : Doxycycline
179
Neutropenic Sepsis/Fever Criteria
\<0.5 x10^9 neutrophil count OR \<1.0 x 10^9 neutrophil count and falling Clinically significant fever: 38.5\< now?
180
Features of HIV seroconversion illness
Rash Lymphadenopathy Malaise/ non specific symptoms
181
What is procalcitonin a marker for?
Inflammation and in particular indicates a bacterial infection
182
Dimorphism fungus associated with temperate climates. Cause fevers and can lead to disseminated disease.
Histoplasmosis
183
Microorganisms causing IE: Prosthetic valve endocarditis?
Usually coagulase negative staphylococci , staph epidermiditis, staph aureus, gram negatives Vanc + Gent + Rifampicin
184
Microorganisms causing IE: Acute bacterial endocarditis of native valve Days- Weeks
Staph Aureus/ Coagulase negative staph (particularly if prosthetic) Treat with Flucloxacillin
185
Microorganisms causing IE: Subacute bacteria endocarditis Weeks- Months
GAS - usually viridans (optichin insensitive)
186
Microorganisms causing IE: MSSA endocarditis
Flucloxacillin - 4/52
187
Microorganisms causing IE: MRSA endocarditis
Vanc + gent/rifa/fucidin
188
Microorganisms causing IE: Enterococcus
Ampicillin + Gentamicin
189
Microorganisms causing IE: Culture Negative Endocarditis
Uncommon/ Atypical bacteria: - Brucella, Chalmydia, mycoplasma, coxiella burnetti, rothia - streptococcus bovis - think malignancy HACEK organisms: Haemophilus Parainfluenza Aggregatibacter/Actinobacillus Cardiobacterium Hominis Eikenella Corrodens Kingella Kingae
190
Indications for surgical intervention for infective endocarditis
-\>1 serious emboli event - uncontrolled infection - unresponsive to ab - suppurative complication - CHF - Prosthetic valve endocarditis
191
Codon 129 polymorphisms on chromosome 20 associated with which disease?
Prion Disease Polymorphisms include MM, MV and VV MM has the highest association
192
Most common form of prion disease?
Sporadic CJD - either PRNP mutation or PrPc conversion to PRPsc
193
What form of prion disease are tonsillar biopsies useful in the diagnosis of?
Variant CJD
194
EEG with periodic triphasic changes. Which type of prion disease
Sporadic CJD present in about 66% of cases
195
Non specific slow waves on EEG, which type of prion disease?
vCJD
196
What prion disease are you likely to see pulvinar sign in?
Variant CJD Posterior thalamus high signal on T2 MRI
197
What is the inheritance pattern for familial prion disease
Autosomal dominant GSS syndrome - gerrsmann-straussler, scheinker syndrome. ataxia, dementia Fatal familial insomnia
198
Molluscum Contagiosum on the face of an infant: a) Normal finding in infants b) suggestive of HIV c) needs to be treated immediately as an inpatient d) uncommon illness and should be reported to the local health authoroties
b) suggestive of HIV Caused by the poxvirus - molluscum contagiosum virus Solitary lesions are not worrisome but disseminated lesions or lesions on the face perhaps represent immunosuppression
199
Shingles in the trigeminal distribution/ multidermatomal shingles warrants testing for? a) mutated VZV b) developmental abnormalities c) thymic aplasia d) HIV
d) HIV you could argue thymic abnormalities seeing as the thymus is responsible for t cell development
200
HIV RNA Load: a) is associated with circulating albumin b) is associated to vertical transmission rates in pregnant mothers to their children c) is reduced in winter months d) can not be reduced with HAART
b) Higher the viral load in mum - the higher the risk of transmission This is why it is so important to reduce maternal load during pregnancy and around time of delivery Initially after infection there is a high load of viraemia and then this reduces as host defences tackle the virus. following this the viral load will increase later in life once cd4 count has been sufficiently depleted
201
What is the effect of prolonged rupture of membranes on HIV transmission?
Increases risk linearly with the length of prolonged rupture
202
Formula feeding vs breast feeding to reduce HIV transmission risk on a populAtion wide basis in africa: Is it safer than breast feeding? Any specific considerations?
If infant mortality rate in a country is high than breast feeding is recommended alongside maternal ARV therapy (tenofovir + 3TC+efavirenz) if AFASS (acceptable, feasible, affordable, sustainable, safe) criteria are satisfied then formula fed rearing is an option
203
An african teenager is diagnosed with HIV and initiates treatment. Subsequently develops a cough in the upcoming weeks with haemoptysis and respiratory distress. M Tuberclosis was cultured on what medium? Why has this happened?
Lowenstein Jensen Medium Immune Reconsititution Inflammattory Syndrlme
204
Hospital acquired pneumonia treatment Within 5 days After 5 days
\< 5: Co-Amoxiclav or cefuroxime \> 5: Tazocin or ceftazidine (other broad spec cephalosporin) or quinolone
205
What organism causes erysipelas What treatment do you give
Erysipelas: infection of upper dermis caused by beta haem group a strep (strep pyog) Treat: phenoxymethylpenicillin or erythromycin if pen allergy
206
Genitourinal infection: State management for all Syphyllis Chlamydia Gonorrhoea PID BACTERIAL VAGINOSIS
Gonorrhoea - IM ceftriaxone + oral azithromycin Syphyllis - BenPen / Doxycycline / Erythromycin Chlamydia - doxycycline or azithromycin (single dose azithro is preferred due to adherence ) PID - oflaxacin + metro/ IM cef + met + doxy bacterial vaginosis - metronidazole (oral or topical) / clindamycin (topical)
207
Live attenuated vaccines: 7
BCG MMR Intranasal influenza Oral rotavirus Oral polio Yellow Fever Oral Typhoid
208
What does the sabin-feldman dye test stain?
Toxoplasmosis Gondii
209
Causes of infective endocarditis?
Commonly - Culture negative Subacute- Strep Viridans Acute - Staph Aureus Rare: Aspergillus, Brucella, Coxiella, Chlamydia HACEK: Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella.
210
Orange secretions
Rifampicin
211
Peripheral Neuropathy
Isoniazid
Give Pyrodoxine (B6)
212
Visual Disturbances ( TB Drug)
Ethambutol
213
Fite Stain
Mycobacterium Leprae
214
Treatment for Latent TB
Isoniazid for 6-9 months
215
TB prophyalxis
Isoniazid alone
216
**Rx for Leprosy (Mycobacterium)**
**Rifampicin**
**Dapsone**
**Clofimazine**
217
**Mycobacterium Lepr.**
**Immunology**
Depigmented lesions
Neuropathic Ulcers
Depigmented - Th1 Mediated. Indicates less organisms.
Neuropathic - Th2 mediated. Indicates lots of organisms
218
**Pneumonia**
Positive Diplocicci
Negative Coccobacilli
Negative Coccus
Positive Cocci
Negative Rod
Positive diplococci - Strep Pneumoniae
Negative Coccobacilli - Haemophilus Influenza
Negative Coccus - M. Catarrhalis
Positive Cocci- Staph Aureus
Negative Rod - Klebsiella Pneumonia
219
**Immunosppression + RTI**
HIV
Neutropaenia
Bone Marrow Tx
Splenectomy
Cystic Fibrosis
HIV - PCP, TB, Crytococcus Neoformans
Neutropaenia - Fungi (Asperg.)
Bone Marrow Tx - Asperg. + CMV
Splenectomy - Encapsulated Organisms (**SKHNCP -** Strep, Klebs, Haemoph, Neiss, Crypt, Pseud)
Cystic Fibrosis - Pseud, Burkholderia
220
**Gomori's Methanamine Silver Stain**
**PCP**
Walk Test
Ground Glass Shadowing
Gomori's Methenamine Silver Stain
Protozoa (Apple Green)
221
Boat Shaped Organisms
PCP
222
**HAP**
1st Line
2nd Line
Aspiration
**Special HAP Pneumonias**
Pseudomonas
MRSA
1st line - Cipro +Vanc
2nd Line - Tazocin + Vanc
Aspiration - Cef + Met
Pseudomonas - Tazocin / Gent + Cipro
MRSA - Vancomycin
223
**CAP**
Mild - moderate
Moderate - severe
**Atypical**
**Special CAPs**
Legionella
S Aureus
**CAP**
Mild -moderate: Amox + Macrolide
Mod - Severe: Co-Amox + Macro/ Cefurox
**Atypical** (Chlamydia, Mycoplasma)
Abx - Macro/Tetra i.e. doxycycline (Protein synthesis inhibitors )
**Special**
Legionella - Macrolide + Rifa
S Aureus - Fluclox
224
**Genital Ulcers**
Whats it called and what causes it
Herpes - Painful
Chancroid - Haemophilis Ducreyi ( Painful)
Chancre - Syphillus (Painless
Lymphogranuloma Venereum - Painless. Chlamydia Serovars 1-3
Granuolma Inguinale - dovonasis. Klebsiella Granulomatis (Gram Neg Rod)
225
**Obligate Intracellular Gram Negative Diplococcus**
**-** Non genital disease in adults?
- Non genital disease in neonates?
Complement Deficiency?
**Rx**
Following Rx in men?
Neisseria Gonorrhea - Most common cause of septic arthritis in adults
Opthalmia neonatorium in neonates
DGI - Bacteraemia + Arthritis
**Rx -** Ceftriaxone, cefixime, spectinomycin
Gonococcal disease in men - Give Tetracycline alongside cef to prevent Post gonococcal urethritis
226
**Gram negative non culturable intracellullar pathogen**
Dx?
Which serovars cause genital infection?
Cx?
Rx?
**Chlamydia Trachomatis**
Dx - NAATs - Gold standard
Serovars D-K: Genital Chlamydia Infection/Ophthalmia Neonatorum
Serovars A-C - eyeinfections
Cx - PID, ectopics, urethritis, reiter's syndrome
Rx - Azithromycin 1g, Doxycycline 100mg BD 7/7 (Eryhtomcyin)
227
Initially painless genital uncers that become painful rupturing
Organism?
Dx?
Rx
**LGV**
Chlamydioa Trachomatis - serovar L1-3
Rectal disease in MSM
Form abscesses, elephantitis, and other local destructive effects
**Dx -** NAATs, Real time PCR (central HPA)
**Rx -** Doxy - 1st line, Erythro/Azithro
228
**Gram Neg Spirochete**
Dx
Disease progression
C
Rx
**Treponema Pallidum** - HIV / HCV coinfection
**Dx**
Antibody Detection:
Non Specific: VDRL (cardiolipin, lecithin and cholesterol). RPR - new version, good for monitoring treatment efficacy
Specific: Specific ones are EIA, FTA, TPHA, TPPA. but they remain positive for years so don't indicate new/cleared infection
**Disease**
Primary - Macule/papule/ ulcer painless. regional lymphadenopathy
secondary - bacteraemia, systemic symptoms, mac pac rash everywhere, mucosal inflammation, **genital warts- condyloma acuminate.** Neuro involvement
Tertiary - Gumma - granukomas on skin, bone mucosa. Cardio - aortitis, inflammation, lots of spirochaetes present
Neuro - Tabes dorsalis, GPOTI, Meningovascular, Argyll robertson - accomodates but doesn't react.
**Rx - IM BenPen/ Doxy**
229
Large expanding ulcers that break down
Beefy red
**Rx**
Donovanosis - Kleb Granulomatis
**Rx**
Azithromycin
230
Dx Fungi
## Footnote
**Bedside?**
**Culture, Mannan, Antibodies**
**Elisa, PCR, B Glucan**
**Antigen in Serum CSF**
**Bedside** - Woods Lamp: Tinea, Pityriasis (Malassezie Globosa)
**Culture, Mannan, Antibodies -** Candida Albicans
**ELISA, PCR, B-Glucan Test -** Aspergillus
**Antigen in Serum/CSF -** Cryptococcus
231
**i) Cardiac and Upper GI Disease**
**Flagellated Organism**
**i) Cardiac and GI Disease**
**Flagellated Organism**
CHAGAS- Trpyanosoma Cruzi (Triatome vector)
South America
232
**ii) Acute severe illness causing spreading lymphangitis**
**Flagellated Organism**
**iii) Slow late development of neurological and psychiatric illness/ occipital lymphadenopathy**
**Flagellated organism**
African Sleeping SIckness (Tsetse Fly)
ii) Trympanosoma Brucei Rhodesiense - East africa
Bite - Chancre
iii) Trympanosoma Brucei Gambiense - West Africa
233
**Iv) Rolled edge ulcer taking a long time to heal**
**v) Fever, anaemia, fatigue, massive hepatosplenomegaly**
**Leishmaniasis (Sandfly)**
iv) Cutaneous
v) Kala azar - Visceral
234
**Child Itchy Bum**
Organism
Rx
Enterobium Vermularis
Mebendazole - For family too
235
Eosinophilia, GI, Lung symptoms
## Footnote
**Organism**
**Rx**
Strongyloides - autoinfection
Albendazole ( also used to treat hookworm infections)
236
Rupture can lead to anaphylaxis
Rx
Hydatid Disease 9 Ehinococcus)
- dog tapewarm, sheep cysts
Rx - Albendazole Praziquantel
237
**Bladder Cancer Risk**
Different organisms
Dx, Rx
Schistosomiasis (SCC Bladder)
Mansori, Japonicus, Haematobium (Bladder cancer)
Dx - Eggs, Serology
Rx - Praziquantel
238
Cough, Wheeze, Eosinophilia, Itchy, Fever
**Organism**
Dx? Rx?
**Katayana Fever**
- Schistosomiasis
**Dx** - Eggs, Serology
**Rx - Praziquantel**
239
**Calaber swellings**
Loaisis
240
Dance sign on ultrasound?
Organism?
Cx
**Wurcheria Bacrofti (Filariasis/ Elephantitis)**
Mosquito borne
causes lymphoedema and elephantitis
241
**Adult migrates to feet and comes out**
Dracunaliasis - Guinea workm
242
**Neonatal Disease associated with HSV1/2**
**3 types**
**Time associations**
SEM: Long term ocular/ neural. **7-12/7 post partum**
Disseminated Vesicular: **multiorgan failure and fulminant hepatitis** 4-11/7
Neurological Disease
243
Benign reccurent asceptic meningitis usually HSV 2
**Mollaret's Meningitis**
244
**Cytology: Multi-nucleated giant cells/ Tzanck Cells**
**VZV**
245
Neonate:
Scarring, Hypoplastic Limbs, Choreoretinitis, Cataracts
When is the risk greatest during pregnancy
**Congenital VZV**
\<20 weeks
246
**Neonate**
IUGR, jaundice, hepatosplenomegaly, chorioretanitis, encephalitis, microcephaly, thrombocytopenia
**CMV**
- classicaly late senorineuraly deafness
247
Owl Eye inclusions
CMV
248
**CMV**
**Dx**
Neonate
In utero
Adult
**Rx**
**Dx**
- Neonate: Urine/ Saliva PCR
- In utero - Amnioscentesis PCR ( miscarriage recommended if positive)
Adult - Blood PCR, Owl eye inclusions on cell culture, Serology - IgM more indicative of acute disease
**Rx**
Ganciclovir
249
**Post transplant lymphoproliferative Disease**
Organism?
Rx?
Organism - **EBV (HHV7)**
**Rx -** Rituximab (Anti- CD20 )
250
**PUO criteria**
**Healthcare associated**
Fever \>38.8
Persisting for 3/52
Despite intensive Ix for 1/52
**Healthcare Associated:**
Following 24 hours in hospital
251
**Dimporphic Fungus in a returning traveller with fever**
Histoplasma Capsulatum
Histoplasmo Duboisii
252
**Findings in malaria**
What enters from bite?
What is in liver?
Schuffner's dots associated with?
Ring on blood film?
What invades erythrocytes?
Maurer's Clefts?
Severe parasitemia?
**Length of rhythm for the malarias**
From bite - Sporozoite
Liver - Hypnozoite
Schuffner's dots - Vivax and Ovale
Ring on blood film - Trophozoite (young in P falciparum, can be gametocytes in falciparum)
Erythrocyte invaders - Merozites (escape from liver)
Maurer's Clefts - P Falciparum
Severe parasitaemia- \>2% associated with falciparum
**Rhythm Length**
Tertian (48 hours) - Falciparum, Vivax, and ovale
Quartan (72 hours) - Malariae
253
**Malaria Rx**
Falciparum
Mild + Severe
Ovale/ Vivax
**Falciparum**
Mild - Quinine + Doxy/Clinda or Malarone (Atovo/Prog) or Riamet (arthem and lumef)
Severe - Atermisin/ Artesenate (IV) / or Quinine + doxy
Quinine can cause arrhythmias and glucose disturbance
254
Return from: i) Africa / ii) America
with
fever, headache, myalgia, **scab**
**Rx?**
**Rickettsia Spp.** (scab is known as an eschar)
I) African tick bite fever
ii) Rocky Mountain Spotted Fever
**Rx:** Doxy
255
Subcut, Muscular and brain cysts
**Rx?**
**Taenia Solium**
**Rx -** Albendazole/Praziquantel ( give steroids to prevent response to dying parasite)
256
TSST - 1 Toxin
Any other toxin producing bacterial gastroentritis?
**Staph Aureus**
- Causes release of IL1 and IL2
**B Cereus**
**Shigella** (avoid antiboitics in general but Cipro if needed)
257
Canned/vacuum packed foods
Honey
Beans
**Organism**
**Rx**
Botulinum - Gram positive Bacillus
Toxin mediated - descending paralysis
Rx - Antitoxin
258
Reheated meats
Watery Diarrhoea
**organism**
**What else does the organism cause?**
Perfringens
Gas Gangrene
259
Reheated rice
Vomiting and watery diarrhoea
**B Cereus**
- 18 hour incubation period
260
**Rx for E. Coli**
Usually self limiting but if rx required then ciprofloxacin
261
**i )Slow** onset fever and constipation
ii) poultry egg and meat. non bloody diarrhoea
**Rx**
i) Typhi / Paratyphi
ii) Entreritides
**Rx - Ceftriaxone or Cipro**
NB -multiply in peyer's patches
262
Painful bloody diarrhoea
Rx?
Shigella
**Enterotoxin mediated**
**Rx** Can give cipro if indicated but usually self limited
263
Cold enrichment
Enterocolitis/ Mesenteric Adenitis w/ necrotising granulomas
**Other Sx**
Yersinia Enterocolitis
**Other sx -** reactive arthritis, EN, reiter's
Lots of things cause mesenteric adenitits
Most common currently is yersnia but can be viral, or due to beta haemolytic streps
264
Bloody foul smelling diarrhoea
**Exam tips?**
**Rx**
**C Jejuni**
- curve or comma shaped
Due to - unpasteurised milk, poultry
**Rx -** eryhtromycin/ciprofloxacin
265
Unpasteurised dairy
Tumbling motility
**Rx**
**Listeria Monocytogenes**
- watery diarrhoea, no vomiting
**Rx -** Ampicillin, Ceftriaxone, Cotrimoxazole
266
Mobile trophozoite/ Flask shaped ulcer/ 4 nuclei
Pear shaped trophozoite / 2 nuclei
**Rx**
Entamoebia Histolytica
Giardia Lamblia
**Metronidazole**
267
What works on pseudomonas
Tazocin
FQs: Cipro
CPs: Mero
268
What works on CRE
Colistin
269
Posterior thalamus highlighted
CSF Analysis?
Genetics?
Dx
vCJD - BSE associated
**May or may not be 14-3-3 positive,** PrPsc4t
**All cases have 129 Codon MM**
**Tonsillar Biopsy - 4t** 100% Sens and spec
270
**MM or VV Codon Homyzogousity**
**Iatrogenic CJD -** Surgery
- progressive ataxia then dementia and myoclonus
271
**PRNP Mutations**
Gertsmann Straussler Scheinker - AD
Fatal Familial Insomnia - AD
272
**Cat Scratch**
Bartonellosis
273
**Gram -ve aerobic bacilli**
Untreated milk and dairy
**Dx**
**Rx**
Brucellosis - facultative intracellular
**Undulant fever -** peaks in evening and normal by morning + other systemic features
**Dx**
Anti - O polysaccharide antibody
Normally have normal WCC
**Rx -** Doxy
274
**Negri Bodies**
**Dx**
**Rx**
Rabies - rhabdovirus
**Dx -** ELISA, immunofluorescence in brain tissue, PCR,
**Rx -** IgG post exposure.
275
**High spiking temps, headache, conjuntival haemorrhages**
associated with swimming in contaminated water
**Cx**
**Rx**
**leptospirosis interrogans (**Obligate aerobic motile spirochaete) - dog or rat urine into swimming pool
Cx - Meningism, Carditis, HA, RF
Rs - Amox, Macro, Doxy
276
Painless round black lesion with rim of oedema
Rx?
**Bacillus Anthracis**
**Rx - Cipro or Doxy**
277
**i) Sandfly bite causing skin ulcer**
Organisms
**ii) Sandfly bite causing skin ulcer which progresses to involve mucous membranes**
Organism
**iii)** Hepatosplenomegaly (massive), abdo discomfort
i) Cutaneous Leishmaniasis
- L. Major, Tropica
- **diffuse** disease is associated with immunyodeficiency and is characteristically nodular in appearance
ii) Mucocutaneous
- L. Braziliensis
iii) Kala Azar (Viscleral)
L. Donovani, Infantum, Chagasi (Oesophogeal dysmotility)
278
**Duke's Criteria**
Infective Endocarditis
2 Major / 1 Major + 3 minor / 5 minor
**Major**
- \>2 +ve blood cultures 12 hours apart
- Echo positive
- +ve serology for - bartonella, coxiella, Brucella
**Minor**
- Underlying RFs - Murmur, IVDU
- Fever/ High CRP
- Immune- splinter haem, haematuria
- Vascular - emboli
- Positive echo (no vegetation)
- Positive blood culture (not 2 / not 12 hours apart)
279
**Rx for IE**
Prosthetic Valve
Native Valve - Acute
Native valve - subacute
Strep Viridans
MSSA
MRSA
Enterococcal
Prosthetic - Vanc + Gent + Rifampicin
Native Acute - Fluclox
Native Subacute - Pen + Gent
Strep Viridans - Benpen + gent
MSSA- Fluclox
MRSA - Vanc + gent/rifa
Enterococcal - Ampicillin + Gent
280
**Culture -ve IE**
Usually because of early Abx treatment ( before three sets of BCs were taken)
BUT
Aspergillosis, Brucella, Coxiella, Chalmydia, mycoplasma
**HACEK -** Haemophilus Parainfluenzae, Aggratibacter, Cardiobacterium, Eikinella, Kingella
281
**3 Common Flu Types and their seasonal Peaks**
**Influenza A**
H1 - End of January
H1N1 - End of december
**Influenza B** - March
282
**Cleaves host sialic acid residues**
**Binds sialic acid receptors**
**IFITM3**
NEuraminidase
Haemogglutinin
IFITM3 - Prevents uncoating of viruses and stops antigenic shifts.
283
**M2 Ion Channel target.** What mutation confers resistance?
**Neruaminidase Inhibitors**
Amantadine - S31N in M2
Oseltamivir, Zanamavir. = only effective within 48 hours of infection
284
**Describe the contribution of NA and HA to influenza virulence**
**NA** - Cleaves host sialic acid exposing receptor binding site (a2 3SA) for binding by. (Oseltamivir, Zanamavir inhibit)
**HA** - which is cleaved by host clara trpytase to activate it.
285
**Antivirals**
**Require activation (and their prodrugs) -2 (SEs + MOAs) what viruses**
**Not requiring activation - 2 (SEs + MOAs) what viruses**
**Require activation by viral thymidine kinase**
Aciclovir (Valaciclovir) - Guanosine analogue). HSV and VZV
Gancicloir (Valganciclovir prodrug) - Nucleoside analogue. 2nd line HSV. CMV, EBV, HHV-6. BM Suppression
**Don't require activation (both nephrotoxic and given alongside probenecid to reduce the nephrotoxicity)**
Foscarnet - Pyrophosphate analogue inhibits NA synthesis. 2nd line CMV, 3rd line HSV and first line for **BM transplant prophylaxis** (Ganciclovir would be inappropriate due to BM suppression)
Cidofovir - Nucleoside phosphonate. 3rd line HSV. CMV retinitis, opportunistic viral infections i.e. BK, adenovirus, PML.
286
**HBV Treatment**
**What type of virus is it**
When to treat ? (3)
First Line treatment choice?
Drug classes and examples (3)
**DS DNA Virus**
**When to treat?**
Viral load \>2000
ALT upper limit of normal
Evidence of moderate-severe liver dimage histologically
**First line treatments:** Entecavir, PegINF alpha 2, tenofovir
**Classes**
**Nucleo s/t ide analogues**
Viral polymerase inhibitors- Lamivudine, **Entecavir**, Telbivudine
Reverse transcriptase inhibitors - **tenofovir**
**Directly antiviral**
Pegylated Interferon Alpha 2 (Directly antiviral and upregulates MHC on cell surfaces aiding immunological clearance)
287
**Hepatitis C Virus - Type**
**Treatment outcome**
**Genotypes?**
**Drugs? - what else do they treat**
Single Stranded RNA Virus
**outcome:** SVR - \>6/12
**Genotypes- 1,4,5,6 (treatment resistant) 2 and 3 ( treatment successful)**
**Drugs -** Combo of
PegINFa2b/2a
ribavarin (nucleoside analogue) - RSV, PIV, HBV, HEV, Lassa
288
What organism is common in the aetiology of PTLD, oral hairy leukoplakia (HIV) and HIV lymphomas?
How do you treat\>
**EBV**
Treat with rituximab
289
Paediatric post-BMT patient virus risk?
Adenovirus
- Weekly PCR usrveillance
**Rx - Ribaviron or IV cidfovir**
290
**Likely bug causes and Rx for the following:**
SSI
Septic Arthritis
Osteomyelitis
PJI - Also what are the CRP/ WCC for the knee and the hip
SSI - Staph Aur, e coli, pseudomon, haem strep. **Fluclox**
Septic Arthritis - Staph aur, strep, e coli. **IV ceph or fluclox**
Osteomyelitis - Staph, salmonella if SCD. **Debridement + IV Abx for 6 weeks**
PJI - Staph, enterobactericiea. **Single stage or Two stage revision. Knee has a a higher CRP (rhymes)**
**Knee: CRP\> 13.5 WCC \>1700**
**Hip: CRP \>5 WCC \>4200**
**out of 5 seperate samples of the joint, more than three have to be positive for same organism**
291
blood β-D-glucan positive
Rx?
**Candida Albicans**
Rx - Azole antifungals. Clotrimazole
292
**Antibiotics - what are they active against**
Cell Wall Synthesis Inhibitors (4 groups)
Protein synthesis inhibitors (5 groups)
DNA synthesis inhibitors (2 groups)
RNA synthesis inhibitors (1 group)
Cell membrane toxins (2 groups)
Folate inhibitors (2 groups)
**Cell Wall (mainly gram positive)**
Penicillins -Amox, Augm (gram +/- and anaerobes) Amp, Fluclos, Benpen, Pen V
Cephalosporins - Ceftriaxone, Cefataxime(3rd gen have gram negative activity)
Carbapenems (Gram negs as well) - Meropenem, Carbopenin
Glycopeptides - Vancomicin, Teicoplanin
**Protein synthesis inhibitors**
Macrolides - erythro, clarithro ( Gram positives)
Oxalizodines - Linezolid ( Gram positives /MRSA)
Aminoglycosides - Gentamicin (Gram neg sepsis)
Tetracyclines - Doxy (intracellular pathogens)
Chloramphenicol - eye drops and meningitis (in pen and cephalosporin allergy)
**DNA synthesis inhibitors**
Fluoroquinolones (Cipro, moxi) -Gram negatives
Nitroimidazoles - Metronidazole ( Anaeobes + protozoa i.e. giardia and entomaeba)
**RNA synthesis**
Rifampicin - TB
**Cell Membrane toxins**
Polymxin - colistin (gram negs)
Cyclic lipopeptide - daptomycin ( gram +ves and MRSA)
**Folate inhibitors**
Sulfonamides- Sulphamethoxazole (PCP)
Diaminoprimidines - Trimethoprin (UTIs and PCP)
293
**ABx resistance Mechanisms (BEAT)**
Bypass antibiotic sensitive step in pathway - MRSA
Enzyme mediated inactivation - beta lactamases
Impaired accumulation - tetracycline
Target modification - quinolone
294
UK Immunisation schedule
* Two months: Hib/IPV/DTaP/PCV
* Three months: Hib/IPV/DTaP/Men C
* Four months: Hib/IPV/DTaP/PCV/Men C
* Twelve months: Hib/Men C
* Thirteen months: MMR/PCV
* Three years four months old or soon after: MMR/DTaP/IPV
* 13–18 years: Booster Diptheria and tetanus/IPV, HPV
Pre Uni: Men ACWY
295
**When would you give vancomycin to treat antibiotic associated colitis? what is this colitis caused by?**
C Diff (Gram positive spore forming anaerobe)
* **Third** or subsequent episodes
* Severe infection
* Infection not responding to metronidazole
* patients who cannot tolerate metronidazole
296
297
What don't cephalosporins cover very well (even the third generations)
Anaerobes
-Hence you give metronidazole
298
**Pseudomonas cover**
Abx and their class
Piperacillin (Tazocin. Penicillin B lactam - cell membrane inhibitor)
Ceftazidine (B lactam - cell membrane inhibitor)
Ciprofloxacin (Fluoroquinalone - Protein inhibitor)
Gentamicin +Tubramycin (Aminoglycoside - Protein inhibitor)
299
**Protein Synthesis Inhibitors**
30S ribosomal subunit (2)
50S ribosomal subunit (3)
Tend to be bacteriostatic
**30S**
Aminoglycoside - Gentamicin, Tubramycin, Amikacin
Tetracycline - Doxycycline
**50S**
Macrolides (Good against gram positives)
Oxalezidiones (Gram positives)
Chloramphenicol (Eye drops and meningitis due to good CSF penetration)
300
**Which antibiotic class is good against protozoa**
Mechanism?
What other drug class acts via same mechanism?
**Nitroimidazoles - Metronidazole**
**DNA Synthesis Inhibitor**
Used in the bowel specifically against anaerobes
Fluroquinolones - Cipro (Gram neg and Gram positive) (bad against anaerobes)
301
mecA gene
MRSA
-Changes penicillin binding protein
**BEAT**
**Bypasses antibiotic sensitive step - MRSA**
Enzyme inactivation - Staph aureus
Accumulation impairment - Tetracyclines
Target modification - macrolides/quinolones
302
Which organisms have developed resistance to carbapenem ?
Klebsiella and E Coli
303
**TORCH Infections**
Limb hypoplasia
skin lesions, encephalitis, conjunctivitis
rhinitis skin and teeth
deafness, cataracts, cardiac malformations, micropthalmia
retinitis, intracranial calcifications, mental retardation, jaundice
deafness, micropthalmia, cerebral calcifications, mental retardation, stillbirth
**VZV -** Limb hypoplasia
**HSV -** skin, encephalitis, conjunctivitis (early SEM, late severe disseminated, later SEM + neurological)
**Syphyllis -** Rhinitis, skin and teeth
**Rubella -** deafness, **cataracts**, **cardiac malformations**, micropthalmia (cataracts, cardiac differentiate it from CMV)
**Toxoplasmosis -** retinitis, intracranial calcifications, mental retardation, jaundice
**CMV -** deafness, micropthalmia, cerebral calcifications, mental retardation, stillbirth
304
**Neonatal sepsis:**
**Rx, organisms**
\<48 hours after birth
\>48 hour after birth
**\<48 hours**
GBS, E Coli, Listeria
BenPen, Gent (+ amox/amp for listeria)
**\>48 hours**
Staph, GBS, E Coli, Listeria
BenPen + Gent / Taz + Vanc
305
What percentage of Hep C patients progress to chronic
80%
306
**Spirochaetes (3)**
Treponema Pallidum
Leptospirosis
Borrelia
**All Gram negative**
307
**Needlestick injury risk**
Hep B
Hep C
HIV
B - 30%
C- 3%
HIV - 0.3%
308
**Hep B Treatment**
**vs**
**Hep C Treatment**
Hep B - Peg IFN 2a
+ **2** of (lamivudine, tenofavir, entecavir, emtricitabine)
Hep C - Peg IFN 2b
+ Ribovarin (guanosine analogue )
**New** Hep C therpaies - NSSA 1 (lediprast Daclatasvir) NSSB 1 ( sofusbuvir)
Protease inhibitor - Teleprevir, bocepravir
309
310
**Obligate intracellular bacteria**
**Stay in side when it's REALLY COLD**
Rickketsia
Chlamydia
311
