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TMIH exam focused revision Flashcards

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1
Q

Sudanese refugee presenting with fever, abdominal pain, diarrhoea and bleeding gums

A

Viral haemorrhagic fever
Typhoid
Complicated malaria
Bacterial gastroenteritis
Leptospirosis

Malaria film or RDT
Blood culture
Stool culture and OCP
ELISA antigen and PCR tests

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2
Q

A girl from Peru presenting with a 4 month history of a lesion on her nose which started as a nodule and turned into an ulcer

A

Leishmaniasis
Sporotrichosis
Cutaneous TB/other mycobacteria
Balamuthia mandrillaris
Cutaneous anthax

Scrape with lancet around edge of lesion
Giemsa staining (leishmania amastigotes)
Culture/PCR of FNA or biopsy
Smear microscopy and culture for sporotrichosis
Purified protein derivative (PPD) for TB
Histopathological examination

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3
Q

Woman from Malawi presenting with insidious headache coming on over 1 week, fever, confusion and third CN palsy. LP shows raised opening pressure, high protein, low glucose

A

Meningitis including:
Cryptococcal
TB
Bacterial

Cerebral malaria

CSF - gram stain, culture, PCR for MTB
CrAG serum + CSF
India ink stain + fungal culture
HIV test

Mx
Ceftriaxone
Amphotericin B + flucystosin
TB treatment

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4
Q

A 4 year old from Uganda presenting with seizure and reduced consciousness. Fundoscopy shows retinal whitening

A
  1. Cerebral malaria
  • Meningitis
  • Encephalitis
  • Poisoning (e.g. organophosphate)
  • Hypoglycaemia
  • Renal/liver failure
  • Status epilepticus

LP, EEG, bloods (glucose, ammonia), blood cultures, malaria film

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5
Q

26 year old german student returning from Botswana with a migratory rash after being on a fishing trip

A

Gnathostomiasis
Strongyloides
Loa loa
Cat/dog hookworm
Sparganosis (canine/feline tapeworms)

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6
Q

Student returning from 6 week trip to Ghana, presenting with localised swelling (treated as a boil with antibiotics) with a black scab

A

Myiasis
Rickettsial disease
Staph/strep infection
Cutaneous anthrax
Spider bite

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7
Q

45 year old Malawian man presenting with several week history of back pain and spastic paraparesis

A

Spinal TB
Cord compression from metastases or disc prolapse
Transverse myelitis
HIV associated myelopathy
Schistosomiasis

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8
Q

45 year old man man in the Gambia who has multiple painful genital ulcers

A

Chancroid - haemophilus ducreyi
Syphilis - usually painless
Herpes simplex

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9
Q

An 8 year old boy from Lao with unilateral parotid swelling

A

Bacterial:
Staph aureus
Strep pyogenes
H influenzae (unvaccinated)
Bukholderia pseudomallei
TB
Actinomycosis
Cat scratch disease bartonella henselae

Viral:
Mumps (unvaccinated)
CMV
Influenza/parainfluenza

Rare: Malignancy, salivary stone

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10
Q

A 34F with meningitis (predominantly neutrophils) and HIV in Malawi

A

Bacterial:
Strep pneumo
Neisseria meningitidis (dry season)
Staph aureus
H influenzae
TB

Cryptococcal meningitis

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11
Q

Traveller returning from Thailand with eosinophilia

A

Helminths
Ectoparasites - scabies + myiasis
Coccidiomycosis
Paracoccidiomycosis

CTD
Asthma
Allergy
Drug induced
Leukaemias
Paraneoplastic

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12
Q

43 year old presenting with fever, urticaria, splenomegaly following travel to Mozambique. Eosinophilia and derranged LFTs present.

A

Katayama syndrome (acute schistosomiasis)

DDx (though would not explain the eosinophilia:
EBV/CMV
Leptospirosis
Rickettsial disease
Typhoid fever
Malaria

Amoebic liver abscess

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13
Q

35M in US presents with a cutaneous ulcer with surrounding neck swelling after cutting himself shaving. It is not responding to ceftriaxone.

A

Abscess - staph/strep
Cutaneous anthrax
Bubonic plaque
Spider bite
Rickettsial disease
Glandular tularaemia

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14
Q

6 year old boy from Malawi presenting with dry cough, fever, and conjunctivitis

A

Measles

Malaria
Rubella
Scarlet fever
Typhoid fever
Rickettsial infections
Atypical pneumonia - bacterial or viral
Meningococcal disease

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15
Q

Complication of measles

A
  • Encephalitis
  • Dehydration
  • Severe diarrhoea
  • Septicaemia
  • Otitis media
  • Giant cell or superimposed pneumonia
  • Corneal ulceration
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16
Q

What is the incubation period and infectivity period for measles?

A

8-12 days
4 days before rash and 4 days after rash

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17
Q

What is a late complication of measles?

A

Subacute severe sclerosing panencephalitis

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18
Q

Management of measles

A

Paramyxovirus

Vitamin A supplementation (two doses 24 hours apart at least)
Consider antibiotics for superadded bacterial pneumonia, corneal ulcers or otitis media
Nutritional support and hydration

Immunoglobulin to contacts

Can vaccinate at 9 months, delay until after ART initiated in HIV

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19
Q

Unmasking IRIS

A

An opportunistic disease, which was not present at the time of ART initiation, becomes clinically
manifest because of ART-induced immune recovery

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20
Q

Paradoxical IRIS

A

Immune recovery after initiation of ART triggers the clinical
deterioration of the disease (e.g. pulmonary TB) during the initial months of treatment.

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21
Q

What is the anthrax

A

Gram positive rod
Bacillus anthracis
GI, cutaneous or inhalational forms
Cutaenous is characterised by a painless lesion with surrounding vesicles and odoema

Treatment: doxycycline

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22
Q

What is the upper limit of incubation period for viral haemorrhagic fever?

A

21 days

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23
Q

32 year old british woman visiting family and relatives in rural Nigeria presenting with 3 day history of jaundice and fever

A

Malaria
VHF (although no injected sclerae or rash)1
Leptospirosis
Typhoid fever
Hepatitis (although usually slower onset)
Ascending cholangitis

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24
Q

31 year old man with HIV and CD4 count of 150 presenting with 3 week history of cough, shortness of breath and 10kg weight loss

A

Pneumocystis pneumonia
TB
Cryptococcosis
Histoplasmosis
Atypical bacterial pneumonia

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25
PCP - investigations and management
Induced sputum or preferably bronchoscopy to obtain bronchoalveolar lavage specimens - Visualisation of pneumocystis jirovecii on immunofluorescence and/or PCR Imaging - Perihilar infiltrates on CXR - Ground glass changes on CT Co-trimoxazole 14-21 days Steroids in severe cases 2nd line treatment: Primaquine + clindamycin
26
72 year old male farmer from Laos presenting with verroucous fungating lesions around the left foot which have been present for years
Eumycetoma and actinomycetoma - Chromoblastomycosis - Sporotrichosis - Mycobacterium including leprae TB - Kaposi's sarcoma - SCC - Psoriasis - Sarcoid - Not leish (not in Laos) Ix Skin scrapings (direct microscopy, culture for sporo) Mx Chromoblastomycosis - Itraconazole + surgical debridement + treatment of bacterial superadded infection
27
Where is visceral leishmaniasis found?
Brazil East Africa India
28
Where is cutaneous leishmaniasis found?
Americas Mediterranean basin Middle East Central Asia Africa
29
What is chromoblastomycosis caused by?
Chronic fungal infection of the skin and SC tissue Fonsecaea, Phialophora, Cladophialophora Verrucous nodules or plaques Skin scrapings under direct microscopy show brown, round, thick-walled structures "medlar bodies"
30
Snake bite first aid measures
Reassurance Pain relief Remove jewellry/clothes Pressure immobilisation Tetanus Antibiotics Wound management IV antivenom (immunoglobulin)
31
What do elapid snake bites lead to?
Neurotoxic effects Mamba, cobra, rinkhals
32
Puff adder effects
V pattern on back Cardiotoxic Cytotoxic Haemotoxic
33
Myotoxic effects from what kind of snake?
Sea snake
34
16 year old boy from Sri Lanka presenting with fever, jaundice, subconjunctival haemorrhage and AKI
Leptospirosis Dengue Scrub typhus Hantavirus Dengue
35
Leptospirosis investigations and management
CSF, blood, urine culture of leptospira (8 weeks + dark microscopy) PCR Doxycycline/IV benpen
36
Complications of leptospirosis
Cholestatic jaundice, AKI, bleeding (Weil's) Myocarditis Meningitis (aseptic) Pulmonary
37
Treatment of Loa Loa based on microfilaraemia
<2000 - DEC 1000-8000 - Ivermectin High - Albendazole
38
Loa loa vector
Chrysops horse fly
39
Is there any role for doxycycline in Loa Loa?
No ain't no Wolbachia
40
Loa Loa diagnosis
Blood film (daytime) PCR Serology has lots of cross reactivity with other nematodes and filarial species
41
What should you be suspicious of when assessing an HIV patient with severe anaemia?
TB hiding away in the bone marrow
42
What is non-typhoidal salmonella?
Salmonella enteriditis, typhimurium Enterocolitis in immunocompetent Sepsis in HIV/malnutrition/malaria severe anaemia, abdo pain, diarrhoea, splenomegaly, co-infection with strep pneumo, H influenzae or TB Mx: fluoroquinolone or azithromycin
43
12 year old boy in rural Kenya presenting with painful eyes including corneal opacification, lid scarring, trichiasis
Trachoma Vitamin A deficiency Corneal and conjunctival damage from traditional medicine
44
Trachoma stages
1. Trachomatous inflammation with follicles (TF) 2. Trachomatous inflammation intense (TI) 3. Trachomatous conjunctival scarring (TS) 4. Trachomatous trichiasis (TT) 5. Corneal opacity SAFE - Surgery (TT), Antibiotics (TF/TI), Facial cleanliness, Environmental
45
Trachoma MDA
Annual azithromycin for 3 years if prevalence >10%
46
Which season does meliodosis usually present in?
Wet (80%)
47
What are some risk factors for meliodosis?
South East Asia and Northern Australia Diabetes Steroids Immunosuppression (but not HIV) Alcoholism CKD
48
Treatment of meliodosis
Ceftazidime or meropenem 2 weeks Co-trimoxazole 3-6 months
49
Manifestations of Kaposi's sarcoma
Cutaenous Lymphadenopathy Pulmonary
50
What test can you do to check for disseminated TB in HIV?
Urine LAM (lipoarabinomannan)
51
Considerations in TB + HIV
Prednisolone can reduce risk of IRIS Often smear negative Profound anaemia More likely to have miliary and extra-pulmonary TB
52
Peruvian farmer presenting with a chronic ulcer and nodular lymphangitis
Cutaneous leishmaniasis Sporotrichosis TB Mycobacterium marinarum Nocardiosis
53
Forms of sporotrichosis
Cutaneous In immunosuppressed Pulmonary (inhalation) Disseminated
54
Treatment of cryptococcal meningitis
Amphotericin B + flucytosine 2 weeks Oral fluconazole 8 weeks Continue prophylactic fluconazole until CD4 improved N.B no role for steroids ART 4-10 weeks after treatment of CM
55
23M farmer from Myanmar presenting with 3 year history of unilateral scrotal swelling
Hydrocele (transillumination) Lymphatic filariasis Cyst Inguinal hernia Peripheral odoema secondary to heart failure Urogenital schistosomiasis if endemic region
56
Lymphatic filariasis diagnosis
Blood film (nocturnal) PCR assays Ultrasound Circulating filarial antigen
57
Lymphatic filariasis causes and epidemiology
Wuchereria bancrofti Brugia malayi South Asia South East Asia Sub Saharan Africa South America Caribbean
58
What treatment for LF should be avoided in Loa Loa endemic region?
Ivermectin DEC
59
29 year old woman from Malawi presenting with confusion, diarrhoea and a skin rash
Pellagra (B3 deficiency) HIV TB Malignancy SLE
60
Diagnostics for neurocysticercosis
Enzyme linked immunoelectrotransfer blot
61
Neurocysticercosis definition
Occurs from eating Taenia solium eggs from salad etc A key cause of preventable epilepsy in Africa, Asia, Latin America Become encysted in either the parenchyma or the subarachnoid space
62
Principles of neurocysticercosis treatment
Albendazole + steroids - Vesicular Albendazole + Praziquantel + steroids > 2 cysts and ring enhancing, colloidal If there is no surrounding odoema to the cyst or it is calcified there is no benefit to using antihelminth treatment Management of hydrocephalus and raised intracranial pressure - supportive, not for antihelminth treatment
63
A 62 year old woman from rural Ethiopia presenting with difficulty chewing (stiffness of the mouth)
Tetanus (clostridium tetani) GCA
64
Management of tetanus
Diazepam Antitoxin Metronidazole Consider tracheostomy
65
Complications of tetanus
Pneumonia Respiratory arrest Laryngeal spasms Arrhythmias Autonomic dysregulation
66
7 year old girl from West Africa presenting with two skin ulcers and a contracture of the wrist
Buruli ulcer Yaws Mycobacterium TB/leprae Anthrax
67
Buruli ulcer presentation and epidemiology
Mycobacterium ulcerans Found in Africa, parts of Australia, Japan and China May present as a nodule, a plaque, odoema which can progress to an ulcer with undermined edges. It can involve bone. It may be painless and without a fever.
68
Buruli ulcer investigations and management
PCR, culture, histopathology, direct microscopy of wound swab Rifampicin + clarithromycin 8 weeks (studies aiming to reduce that) - note may have paradoxically worsening symptoms after or secondary bacterial infection
69
41 year old traveller returns from Thailand beach holiday with a migratory rash
Cutaneous larva migrans: Animal hookworm Gnathostomiasis Strongy (currens)
70
Examples of animal hookworm, investigations and management
Ancylostoma caninum Ancylostoma braziliense No investigations needed (eosinophilia often not present even) Treat with a single dose of ivermectin
71
Ocular surface squamous neoplasia
Associated with HIV, UV light, HPV Greyish/white elevated mass unilaterally of the eye Treatment with topical chemotherapy or surgical excision
72
7 year old girl from South Sudan presenting with 4 week history of undulating fever. Malnourished with widespread lymphadenopathy and splenomegaly
Visceral leishmaniasis TB HIV Kaposi's sarcoma Malaria Brucellosis Leukaemia and lymphoma
73
Brucellosis treatment
Doxycycline 100 mg twice a day for 45 days, plus streptomycin 1 g daily for 15 days
74
Brucellosis presentation
Unpasteurised milk consumption Fever, wasting, splenomegaly
75
Visceral leishmaniasis investigations
Rapid antigen test (rK39) Direct agglutination test (DAT)
76
Visceral leishmaniasis species
L. donovani, L infantum (often from infected sandfly)
77
Visceral leishmaniasis epidemiology
Sudan, South Sudan, India, Ethopia, Brazil
78
Visceral leishmaniasis investigations
Lymph, spleen, bone marrow biopsies to visualise amastigotes
79
Visceral leishmaniasis treatment
Pentavalent antimonials Amphotericin B Miltofesine
80
Hydatid cyst
Cystic echinococcus - echinococcus granulosus Ingestion of eggs from dogs (sheep dogs) Middle East, South America, Africa Typically large, unilocular, with well-defined walls Surgical (>5cm, complex) + albendazole
81
Alveolar echinococcus
Echinococcus multilocularis Ingestion of eggs from fox or dog faeces Multilocular, infiltrative growth resembling a malignancy with poorly defined margins and solid appearance Northern hemisphere - Central Europe, Russia, North America Surgical +/- albendazole
82
Amoebic liver cyst
Entamoeba histolytica Faecal oral route Thick, liquefied contents, lacks true wall Metronidazole 7-10 days Serology - sensitive but not so helpful in endemic settings Aspiration can be sent for PCR and would be sterile
83
Initiating 1st line treatment for HIV
Tenofovir Lamuvidine Dolutegravir Tenofovir definitely if Hep B positive Avoid Bictegravir due to interactions with TB drugs Prophylactic co-trimoxazole
84
Risk factors for IRIS
Low Hb Low CD4 count Rapid change in CD4 Rapid reduction in viral load Short period between treatment of infection and initiation of ART
85
Acute non-compressive flaccid paraparesis
Acute transverse myelitis Vascular spinal cord ischaemia
86
Acute transverse myelitis
Lymphocytes and protein in CSF Steroids/aciclovir
87
What are common complications associated with cystic echinococcus?
Cystobiliary fistula with biliary obstruction Secondary bacterial infection Cyst rupture leading to anaphylaxis Emobilsm of cyst content Compression syndromes
88
Focal brain lesions in HIV
Toxoplasmosis PML Lymphoma Cryptococcoma or tuberculoma Brain tumour/metastasis Abscess Neurocysticercosis
89
PML
Reactivation of JC virus muscle weakness, cognitive dysfunction, hemianopia, gait difficulties Note there is no odoema or mass effect unlike other lesions PML IRIS - steroids, continue ART
90
Bartonellosis - Oroya fever
Vector borne - Bartonella bacilliformis Andean valleys in Peru, Colombia, Ecuador Most asymptomatic but some after 3-8 weeks develop haemolytic anaemia with jaundice and high fevers Angioproliferative phase with small painless violaceous papules Heart failure CNS complications Coccobacillary structures inside red blood cells AKA Carrion's disease - remember the mad Peruvian medical student who injected himself with a patient's wart but died from the systemic disease (proving its the same thing)
91
What test can you use to check for TB in a patient coinfected with HIV?
Urinary LAM (mycobacterial lipoarabinomannan)
92
40 year old farmer from Peru presenting with 4 month history of cough and chest pain and weight loss 20kg
TB Histoplasmosis Paracoccidiomycosis
93
Paracoccidiomycosis
Latin America Typically rural, farmers due to soil exposure - Fever * Lymphadenopathy * Hepatosplenomegaly * Skin and oral mucosal lesions Complications * Respiratory * Adrenal * Neurological
94
Coccidiomycosis
Valley fever - north america Can mimic TB
95
Chromoblastomycosis
Subcutaneous mycoses secondary to inoculation injury - see also sporotrichosis and mycetoma
96
Mycetoma (Madura foot)
Caused by either * Bacteria (actinomycetes) or * Fungi, eg. Madurella mycetomatis Starts as a painless subcutaneous nodule Progresses to multiple discharging sinuses Black grains in the pus suggest fungal infection Red grains suggest actinomycetes Diagnosis confirmed by microscopy or culture
97
Complications of leptospirosis
Hepatic failure Renal failure Haemorrhage Myocarditis Conjunctivitis Pneumonitis
98
Diagnosis and treatment of leptospirosis
Spirochaetes seen in urine on dark field microscopy Serology: MAT PCR of blood or urie Penicillin, cephalopsporins, macrolides, tetracyclines
99
Yaws summary
Skin to skin contact Affecting skin and bones Caused by Treponema pallidum
100
Differentials for splenomegaly in a 40 year old woman in the Gambia
Lymphoproliferative disorder Hyper reactive malarial splenomegaly Visceral leishmaniasis Portal HTN due to schistosomiasis or cirrhosis secondary to chronic Hep B TB Brucellosis
101
Signs of mycetoma
Tumour Tracts Grains
102
Differentials of mycetoma
Actinomycosis Podoconiosis TB Bacterial OM Cuatenous leish Non TB mycobacteria
103
Arthemeter-Lumefantrine
Artemeinin containing therapy
104
At what cut off of G6PD deficiency is it safe to give primaquine?
>30%
105
Intestinal capillariasis
Zoonotic nematode
106
Best test for histoplasmosis
Urinary antigen
107
Risk factors for mucosal involvement in cutaneous leish
Male, immunosuppressed, above waist lesion, previous MCL
108
Treatment for diptheria
Erythromycin Benzathine penicillin

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