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Jack Wellington MSc (LSHTM) FGMS / wellingtonj1@cardiff.ac.uk Learning Objectives: Systems-Approach Respiratory GIT may encompasssease Cardiovascular Ocular ALL systems!!!! CNS Urinary Tract GUM MSK + Soft Tissues… Learning Objectives: Think LOGICALL Y! • Infectious Diseases and Medical Microbiology is LOGICAL! • Sx often relate to the pathogen in question ➢I.e., if a pathogen produces a TOthink TOXIC Syndrome • Infectious Diseases = Bacteria, Virus, Protozoan, Parasite, Fungi • Use OCCAM’S RAZOR if typical presentation (however, do NOT forget about the WEIRD + WONDERFUL i.e., topical disease) • Abx make up most management if BACTERIAL aetiology ➢Thus, do NOT get into habit of treating EVERY suspected prodromal Sx with Abx • In exams, remember your STAINS! Infectious Diseases: Disclaimer It is IMPOSSIBLE to cover everything in such a short amount of time! Infectious Diseases is a huge component of medical practice Infectious Diseases: High Yield I will be covering the following in detail: 1. Chest Infections: ▪ Typical Pneumonia ▪ Clinical Presentations, Diagnostics, and Management 2. CNS infections: ▪ Meningitis aetiology ▪ Encephalitis aetiology ▪ Clinical Presentations, Diagnostics, and Management 3. Sexually-Transmitted Diseases: ▪ Common to less common aetiologies ▪ Clinical Presentations, Diagnostics, and Management 4. HIV Complications 5. GIT infections A 45 year old male presents to his local GP surgery with new-onset fever, cough, and lethargy. He is a known smoker of 30 cigarettes a day and has a PMH of Chronic Bronchitis. His sputum is purulent and Sa02 91%. You send him for hospital admission. Which of the following is the most likely cause of his symptoms? A) Streptococcus pneumoniae B) Haemophilus influenzae C) Moraxella catarrhalis D) Klebsiella pneumoniae E) Mycobacterium avium-intracellulare Acute Exacerbation of COPD: Aetiology • Very common reason for inpatient admission in the developed world • Most common bacterial organism = Haemophilus influenzae • Others include: ➢Streptococcus pneumoniae ➢Moraxella catarrhalis • Don’t forget that VIRAL causes can be alternative Dx! ➢Especially Rhinoviruses, RSV, + Influenza ➢COVID-19 is another important NOVEL cause!A CXR shows consolidation consistent with a right middle lobe pneumonia. The patient if allergic to Flucloxacillin. What would comprise the management plan for this patient with acute exacerbation of COPD and associated pneumonia? A) Antimicrobial chemotherapy using Amoxicillin for 5 days B) Antimicrobial chemotherapy using Doxycycline for 5 days C) Prednisolone + Amoxicillin for 5 days D) Prednisolone + Clarithromycin for 5 days E) No antibiotics + Prednisolone for 5 daysAcute Exacerbation of COPD: Management •NICE guidelines (2010) detail the following: ➢↑bronchodilator frequency + query warranting a nebuliser ➢Administer 5-day course of oral steroids (i.e., Prednisolone 30mg OD) ➢Abx ONLY CONSIDERED if ‘purulent sputum’ +/- ‘clinical Sx of pneumonia’ ➢If Abx are warranted = Amoxicillin OR Clarithromycin OR Doxycycline (+ 5-day course of PO Steroids) Right Middle Lobe Pneumonia Condition Specific Radiology: Pneumonia. (n.d.). Stepwards.Retrieved October 27, 2021,from https://www.stepwards.com/?page_id=10460 Murray, M. P., & Hill, A. T. (2009). Non-cystic fibrosis bronchiectasis. Clinical Medicine, 9(2), 164–169. https://doi.org/10.7861/clinmedicine.9-2-164A 56 year old female presents to her local A&E department complaining of progressively-worsening chest pain, lethargy, and fever. She also shows you her most recent sputum sample which appears ‘red’ and ‘jam-like’. She has a PMH of Liver Cirrhosis and consumes 30 units of alcohol every 2 days. CXR is completed and you observe a cavitating consolidation in the right upper lobe. What organism is most likely to be the aetiology for this patient? A) Moraxella catarrhalis B) Streptococcus pneumoniae C) Klebsiella pneumoniae D) Mycoplasma tuberculosis E) Aspergillus fumigatusPneumonia by Organism: Klebsiella pneumoniae •Morphology = Gram –ve bacillus •Pathophysiology = encapsulated, endotoxin, mucoid •Transmission = most commonly hospital- acquired •Clinical (Unique) Features: ➢Common in alcoholics, DM + Brochiectasis ➢May follow ASPIRATION ➢‘Red-Currant Jelly’ sputum ➢Predominantly upper lobes Verywell Health. https://www.verywellhealth.com/a-.la ➢Cavitating abscess formation look-at-klebsiella-pneumoniae-1124149 ➢↑mortality (approx. 40%) ➢May cause UTIs Klebsiella pneumoniae: CXR ON - RADIOLOGY: How Klebsiella infection appears on chest X-ray. (n.d.). ON - RADIOLOGY. Retrieved October 27, 2021, from http://onradiology.blogspot.com/2010/07/how-klebsiella-infection-appears-on.htmlA 75 year old male presents to the local A&E department complaining of a cough, lethargy, and fever. The Sx followed from a previous ‘flu- like illness’ and he now complains that his hands get very pale and cold when walking his dog. On examination, he looks unwell and pale with conjuncbeen there for a while but thought nothing of it. You order a CXR and observe bilateral consolidation.plains these lesions have What investigation would confirm the aetiology of this patient’s clinical presentation? A) Urinary antigen B) FBC C) Serology D) Indirect Coombs Test E) Sputum Culture Pneumonia by Organism: Mycoplasma pneumoniae •Morphology = complicated •Pathophysiology = parasitic bacterium, lacks cell wall, mediates immune responses •Transmission = droplet •Clinical (Unique) Features: ➢Epidemics = every 4 years Mycoplasma Pneumonia Increases Risk for Rheumatoid Arthritis. (2019, February 15). Rheumatology ➢↑resistance (lacks cell wall) pneumonia-increases-risk-for-rheumatoid-arthritis/rheumatoid-arthritis-advisor/mycoplasma- ➢Longer duration of disease ➢1 Flu-like prodrome 2 cough ➢CXR = bilateral consolidation Mycoplasma pneumoniae: Complications • IgM-mediated ‘cold-agglutin’ autoimmune haemolytic anaemia: ➢Cold = haemolysis occurs at approx. 4°C ➢Intravascular + complement-predominant ➢Clinical Features = Raynaud’s Phenomenon + Acrocyanosis (↓circulation) ➢Direct Coomb’s Test (+ve) + Cold Agglutination Test (+ve) Investigation ➢Type 2 Hypersensitivity = SEROLOGY! • Erythema Multiforme vs. Erythema Nodosum ➢Multiforme + Nodosum = hypersensitivity reaction (Type 4) ➢Multiforme = superficial microvasculature inflammation ❖Minor (non-mucosal) + Major (mucosal) ➢Nodosum = subcutaneous fat inflammation • CNS disease = GBS, Meningoencephalitis • Bullous Myringitis • Liver dysfunction = often LFT derangement due to Hepatitis / Pancreatitis • Associated Nephritis + HUS • Cardiac involvement = Pericarditis / Myocarditis Mycoplasma pneumoniae: Complications Management = Doxycycline or Macrolide Trayes, K. P., Love, G., & StuddiforCold agglutinin disease - 2. (n.d.). Imagebank.hematology.org.Retrieved October 27, Physician, 100(2), 82–88.nd Manageme2021, from http://imagebank.hematology.org/image/1053/cold-agglutinin-disease-- https://www.aafp.org/afp/2019/0715/p82.htmlupload A 25 year old male has just arrived back from a holiday in Spain feeling ‘miserable’. He has developed a new dry cough and flu-like Sx. His vitals are Sa02 88%, HR 55 BPM, tympanic temperature reading of 39°C, and blood pressure of 100/60 mmHg. You admit this patient and order bloods which reva CXR which reveals patchy consolidation bilaterally with a pleural effusion. confused and unwell, so you order What investigation would confirm the aetiology of this patient’s clinical presentation? A) Urinary antigen B) FBC C) Serology D) Indirect Coombs Test E) Sputum CulturePneumonia by Organism: Legionella pneumophila •Morphology = gram –ve coccobacillus •Pathophysiology = intracellular bacterium, B-lactamase •Transmission = colonises water (i.e., water-tanks, AC) •Clinical (Unique) Features: ➢Relative bradycardia ➢Lymphopenia https://www.stepwards.com/?page_id=3794ds. ➢↓Na+ ➢Pleural Effusion (approx. 30%) ➢LFT derangment Legionella pneumophila - CXR Investigation = urinary Legionella antigen Management = MACROLIDE Eurorad.org. (n.d.). Eurorad - Brought to You by the ESR. https://www.eurorad.org/case/10665 Pneumonia: Other Causes • Pneumococcal Pneumonia: ➢Aetiology = Streptococcus pneumonia ➢Morphology = Gram +ve cocci (chains) ➢Clinical Features: ❖Most common cause of CAP ❖Sudden ‘rapid’ onset ❖↑fever + chest pain (pleuritiworse on inspiration ❖Herpes Labialis • Staphylococcal Pneumonia: ➢Aetiology = Staphylococcus aureus ➢Morphology = Gram +ve cocci (clusters) ➢For exams = common post-Influenza A 21 year old female presents for annual review at her local hospital. Her PMH is consistent with CF and she is currently under the paediatric respiratory specialist for the management of her CF. Recently, she has had increasingly-more frequent admissions to hospital concerning exacerbations of her Bronchiectafeelings for.rms you that she has been visiting another patient on the CF ward who she has What organism(s) are you most concerned about regarding her recent inpatient admissions? A) Mycoplasma pnuemoniae + Haemophilus influenzae B) Aspergillus fumigatus + Staphylococcus aureus C) Mycoplasma tuberculosis + Pseudomonas aeruginosa D) Pseudomonas aeruginosa + Burkholderia cepacia E) Burkholderia cepacian + Legionella pneumophila Pneumonia + Bronchiectasis • Exacerbations of Bronchiectasis are most commonly associated with the following organisms: ➢Haemophilus influenzae (most common) ➢Klebsiella pneumoniae ➢Pseudomonas aeruginosa ➢Streptococcus pneumoniae • In the context of CF… ➢Cross-infection with other CF patients needs to be counselled. ➢Burkholderia cepacia complex + Pseudomonas aeruginosa ➢Commonly colonised ➢Burkholderia cepacia chronic infection is a contraindication to lung transplantation ➢Very resistant organismsPseudomonas aeruginosa - CXR http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/cxr/atlas/cf2.htmBurkholderia cepacian complex - CXR issues, environmental controversies and ethical dilemmas. European Respiratory clinical Journal, 17(2), 295–301. https://doi.org/10.1183/09031936.01.17202950 Pneumonia: Assessment 1) In community, CRB-65 will suffice: • C = confusion (AMTS ≤8/10) 0 = ↓risk • R = respiratory rate ≥30/min 1-2 = moderate risk • B = BP ≤90mmHg (systolic); BP ≤60mmHg 3-4 = ↑risk (diastolic) • 65 = ≥65 years old If ≥2 = warrants hospital assessment NICE also recommend POC CRP testing (not routinely used): CRP >100mg/L = Abx 2) In hospital, CURB-65 (just add Urea >7mmol/L) 0-1 = ↓risk pneumococcal + legionella Ag testing, CRPultures, 2-3 = moderate risk monitoring >3 = ↑risk 4) Abx: • ↓risk = Amoxicillin OR macrolide OR tetracycline • -/↑risk = Amoxicillin (OR B-lactamase stable Abx) + macrolideA 35 year old male presents to his local GP with worsening exertional dyspnoea and a persistent dry cough. He has also been experiencing night sweats, weight loss, and fluctuating fevers. He has an established history of HIV which is not well-controlled with HAART. His last CD4+ count was <200 cell/mm . You send him to hospital for subsequent CXR which reveals a 1cm pneumothorax, otherwise normal. You treat accordingly. What is the most likely cause of his Sx? A) Aspergillus fumigatus B) Mycoplasma tuberculosis C) Pneumocystis jirovecii D) Legionella pneumophila E) Histoplasma capsulatum Pneumocystis jirovecii Pneumonia (PCP) • Aetiology = Pneumocystis jirovecii • Morphology = unicellular eukaryote (yeast-like fungus) • Clinical Significance = most common opportunistic infection in HIV/AIDS ➢Hence, if CD4+ count <200 cells/mm = Co-Trimoxazole prophylaxis • Clinical Presentation: ➢Exertional dyspnoea ➢Dry cough (TB is wet cough!) ➢↓chest stigmata ➢Hepatosplenomegaly + choroid lesions (rare) ➢CXR = may be normal; bilateral interstitial infiltrates; pneumothorax ➢Sputum culture is FUTILE bronchoalveolar lavage better ➢Silver stain = cysts • Management = Co-Trimoxazole (or IV/aerosolised Pentamidine if severe) PCP: Silver Stain from http://www.medical-labs.net/pneumocystis-carini-in-special-silver-stain-2621/ved October 27, 2021, Gaillard, F. (n.d.). Image | Radiopaedia.org. Radiopaedia. Retrieved October 27, 2021, from https://radiopaedia.org/images/381418A 4 year old boy presents to the Children’s Assessment Unit with his parents as a same-day referral from his GP this morning where he received IM Benzylpenicillin. The patient does not look warm and well-perfused, and is irritable. On examination, the boy is pale with a disseminated non-blanching rash and does not cooperate when examining pupillary reflexes. You elicit a positive Kernig’s Sign and immediately start empirical Abx for this condition. What organism is the most likely cause of his Sx? A) Streptococcus pneumoniae B) Haemophilus influenzae C) Neisseria meningococcus D) Escherichia coli E) Streptococcus agalactiae Meningitis: Clinical Features • Early features: ➢Headache and leg pains. ➢Fever with cold hands and feet. ➢Abnormal skin colour. • Late features: ➢Meningism= Nuchal Rigidity, Photophobia and Headache. ➢Kernig’s Sign= pain and resistance on passive knee extension with hip fully flexed. ➢Brudzinski’s Signs: ❖Cheek Sign= pressure on cheek elicits reflex rise and flexion of forearm (only seen in Meningitis). ❖Symphyseal Sign= pressure on Pubic Symphysis elicits reflex flexion of hip and knee, and abduction of leg (clinically identical sign as Cheek Sign). ➢Decreased GCS (maybe coma). ➢Seizures (20%) and focal CNS signs (20%) and Opisthotonos. ➢Petechial rash (non-blanching)= may be only 1 or 2 spots (or more). ❖GSepticaemia.hen applying pressure to rash, should disappear. If not, think MeningococcalMeningitis: Clinical Features Meningitis: Diagnosis • Investigations suggested by NICE include: ➢Bloods (i.e. FBC, U&E, LFT, CRP and inflammatory markers, Coagulation Screen, BM). ➢Blood Cultures and Whole-Blood PCR. ➢ABG/VBG. ➢Take Throat Swabs (1 for bacteria; 1 for virology). ➢CXR. ➢Consider HIV/TB tests. ➢If stable and no signs of increased I, get senior help and perform LP (within 1 hour). ➢If unstable, septicaemia and signs of increased I, get ICU help and delay L.This 4 year old boy has been started on empirical Abx but is awaiting blood cultures, whole- blood PCR, and relevant bloods. Your senior asks you to perform a Lumbar Puncture in the mean time. Which is NOT an absolute contraindication to performing a LP in this patient? A) Auspitz’s Sign B) Disseminated Intravascular Coagulation C) Meningococcal Septicaemia D) Sixth Nerve Palsy E) Cushing’s Triad Lumbar Puncture: Procedure Posterior 1)Skin 2)Superficial Fascia 3)Supraspinous Ligament Meningococcal Septicaemia is a 4)Interspinous Ligament 5)Ligamentum Flavum CONTRAINDICATION! 6)Epidural Space (contains Thus, use blood internal vertebral venous cultures and PCR plexus) meningococcus 7)Dura Mater 8)Arachnoid Mater surgical-nursing/lumbar-puncture/ember 14). Lumbar Puncture. Nursing Crib. https://nursingcrib.com/nursing-notes-reviewer/medical- Anterior 9)Subarachnoid Space Adverse Effects: (contains CSF) ➢ Post-Spinal Headache and Nausea (most common) Contraindications: ❖ Tx= prolonged bedrest, CSF Leak Repair (via ➢ Raised ICP or Cerebral Herniation/Mass Epidural Blood Patch), analgesia or IV ➢ Bleeding Diathesis (i.e. Thrombocytopaenia, Caffeine injection. Coagulopathy, Cushing’s Syndrome) ➢ Paraesthesia of Legs (usually resolves) ➢ Site Infections ➢ Epidural haemorrhage ➢ Vertebral Deformities (i.e. Kyphosis, Scoliosis) ➢ Adhesive Arachnoiditis (extremely rare!)Achest infection and has been experiencing vertigo alongside diplopia and blurriness. On examination, you elicit an Abducens Nerve deficit and signs of meningism. Her PMH is consistent with HIV/AIDS which is poorly controlled. If a LP was performed, what would be pathognomic for this clinical presentation? A) Clear, non-turbid CSF sample B) Normal lymphocyte count C) ‘Pink’ bacilli on Ziehl-Neelsen Stain D) Encapsulate yeasts on India Ink Stain E) Increased CSF:serum glucose ratio Lumbar Puncture: Interpretation Normal Bacterial Viral Fungal TB Appearance Clear Yellowish, turbid Clear Fibrin Web Fibrin Web (yellowish and (yellowish and viscous) viscous) Polymorphs Normal (<5) Elevated Slightly increased Slightly increased Slightly or normal or normal increased or normal Opening Pressure 5-20 cmH20 High Normal or slightly High or normal High or normal elevated Lymphocytes Normal Slightly increased Markedly Markedly Markedly or normal increased increased increased Glucose Normal Decreased Normal Normal or Decreased (CSF:serum ratio) decreased Protein 0.18-0.45 g/L Markedly Slightly increased Slightly increased Increased increased or normal or normal Cultures N/A Positive Negative Positive (Fungal) Positive (AFB) Bacterial Meningitis: Aetiology 0-3 months: •Group B Streptococcus (most common in neonates). •E. Coli •Listeria Monocytogenes 3 months – 6 years: •Neisseria Meningitidis •Streptococcus Pneumoniae •Haemophilus Influenzae 6 years – 60 years: •Neisseria Meningitidis •Streptococcus Pneumoniae > 60 years: •Neisseria Meningitidis •Streptococcus Pneumoniae •Haemophilus Influenzae If immunocompromised, think Listeria Monocytogenes. A 2 month old infant has just received a diagnosis of Bacterial Meningitis caused by Streptococcus agalactiae (Group B Streptococcus). You want to initiate empirical Abx therapy. Which of the following should you administer? A) IV Ceftriaxone + Gentamicin B) IV Cefotaxime + Ampicillin C) IV Ceftriaxone D) IV Amoxicillin + Gentamicin E) IV Benzylpenicillin Bacterial Meningitis: Management Case BNF Recommendation Prophylaxis for close Initial empirical therapy aged < 3 IV Cefotaxime + Amoxicillin (OR) contacts (7 days before months Ampicillin onset) = Ciprofloxacin (OR) Initial empirical therapy aged 3 IV Cefotaxime (OR) Ceftriaxone Rifampicin months – 50 years IV Dexamethasone Initial empirical therapy aged >50 IV Cefotaxime (OR) Ceftriaxone + administered in years Amoxicillin (OR) Ampicillin conjunction with Abx, Meningococcal Meningitis IV Benzylpenicillin (OR) excluding: Cefotaxime (OR) Ceftriaxone • Meningococcal Septicaemia Pneumococcal Meningitis IV Cefotaxime (OR) Ceftriaxone Meningitis caused by IV Cefotaxime (OR) Ceftriaxone • Sepsis • ↓immunity Haemophilus Influenzae • Postoperative Meningitis Meningitis caused by Listeria IV Gentamicin and Amoxicillin Monocytogenes (OR) Ampicillin If Penicillin / Cephalosporin allergic = Chloramphenicol! A 35 year old male who has recently been working in sub-Saharan Africa presents to A&E with a worsening headache and fever. He elicits signs of meningism and has no indications of raised ICP. You conduct a LP which shows the following: CSF Sample Appearance Yellow + viscous Which of the following is the correct diagnosis? A) Viral Meningitis Polymorphs 30% PMNshocytes; B) Bacterial Meningitis Opening 25 cmH20 Pressure C) Cryptococcal Meningitis Glucose Very low (CSF:serum ratio) D) Tuberculous Meningitis Protein 1.2 g/L (normal E) Subarachnoid Haemorrhage <1 g/L) Cultures Positive on ZN Stain Mycobacterium tuberculosis: Summary Acid-fast (Ziehl–Neelsen Staining) bacilli; either latent (90%) or active (10%) Signs and symptoms: ➢Pulmonary = haemoptysis, Rasmussen’s Aneurysm (Pulmonary Artery Aneurysm), Upper Lobe sclerosis. ➢Lymphadenitis (‘Scrofula’), Miliary TB (disseminated), Urogenital TB.l Cervical ➢General = fatigue, night sweats, fever, weight loss. Diagnosis: ➢Latent = Mantoux Tuberculin Skin Test (not accurate); Interferon Gamma Release Assays ➢Active = Culture (i.e. blood, sputum, urine) Management: ➢2 months of Rifampicin, Isoniazid, Ethambutol and Pyrazinamide ➢Followed by 4 months of Rifampicin and Isoniazid only. Prevention = BCG vaccine TB: CXR Team, H. J. (2020, September 27). Ghon complex, ghon focus, definition, chest x-ray & causes. Health Jade. https://healthjade.net/ghon-complex/ TB: Extrapulmonary Castañer, E., Gallardo, X., Rimola, J., Pallardó, Y., Mata, J. M., Perendreu, J., Martin, C., & Gil, D. (2006). ElBeialy, M. A. (n.d.). Image | Radiopaedia.org. Radiopaedia. Retrieved October 31, 2021,Pulmonary Artery Anomalies in the Adult: Radiologic Overview. RadioGraphics, 26(2), from https://radiopaedia.org/images/4293445 349–371. https://doi.org/10.1148/rg.262055092 Gaillard, F. (n.d.). Image | Radiopaedia.org. Radiopaedia. Retrieved October 31, 2021, from https://radiopaedia.org/images/155Mycobacterium tuberculosis: Management Rifampicin: • Adverse Effects = Red-orange bodily secretions Isoniazid: • Adverse Effects = Peripheral Neuropathy (treat with TB management: Pyridoxine) • 2 months intensive = Rifampicin + Isoniazid + Pyrazinamide: Pyrazinamide + • Adverse Effects = Hyperuricaemia + Gouty Arthritis Ethambutol • 4 months continuation = Ethambutol: Rifampicin + • Adverse Effects = Retrobulbar Neuritis (i.e. Optic Isoniazid Neuritis) Streptomycin: • Adverse Effects = ototoxicity + nephrotoxicity A 27 year old female with a known PMH of HIV/AIDS presents to A&E with increasing confusion and headache. Most recent CD4+ cell count is 150 cells/mm and she is not compliant with her HAART. CT scan reveals ring-enhancing lesions. Which of the following is the correct diagnosis? A) CNS Lymphoma B) Cerebral Malaria C) Cryptococcal Meningitis D) Progressive Multifocal Leukoencephalopathy E) CNS Toxoplasmosis CNS T oxoplasmosis: Summary • Aetiology = Toxoplasmosis gondii (parasitic) • Clinical Presentation: ➢Usually mild, flu-like illness ➢Bimmunosuppressionnclude pregnant women (causes congenital defects) and ➢Commonly acquired congenitally or via immunosuppression: ❖Congenital – systemic illness then CNS localisation, causing damage to the eye, hydrocephalus and intracerebral calcification ❖Immunosuppression – was a major cause of death in HIV/AIDS patients, resulting in encephalitis and Toxoplasma necrosed abscesses; HAART has reduced no. of cases • Transmission = cat faeces, undercooked food • Diagnosis = serology; amniotic fluid analysis; MRI/CT (head) • Management = Spiramycin, or Pyrimethamine/Sulfadiazine and Folinic Acid CNS T oxoplasmosis: Diagnostics October 31, 2021, from http://neuroradiologyteachingfiles.com/bfa.html CNS T oxoplasmosis: Diagnostics Kessler LS, Ruiz A, Donovan Post MJ, Ganz WI, Brandon AH, Foss JN. Thallium-201 brain SPECT of lymphoma in AIDS patients: pitfalls and technique optimization. AJNR Am J Neuroradiol. 1998 Jun-Jul;19(6):1105-9. PMID: 9672019; PMCID: PMC8338647. A 28 year old female presents to A&E with increasing confusion and headache. PMH is unremarkable apart from a recent chest infection 3 weeks ago for which she also had a flare of a vesicular oral rash. MRI shows temporal lobe enhancement. Which of the following is the correct diagnosis? A) Mumps Encephalitis B) HSV-1 Encephalitis C) HSV-2 Encephalitis D) Cerebral Abscess E) Neurocysticercosis HSV Encephalitis: Summary • Most common aetiology of Encephalitis = HSV Encephalitis (HSE) caused by HSV-1/2 ➢Neonates = HSV-2 (acquired via vaginal delivery) ➢Older children and adults = HSV-1 ➢Signs and symptoms = consistent with Aseptic Meningitis, however may additionally present with herpetic skin or mucosal lesions ➢Diagnosis = Temporal Lobe Enhancement via CT/MRI; CSF PCR ➢Management = IV Acyclovir for 21 days (relapse may occur) • Occasionally VZV, CMV or HHV-6 Encephalitis (usually associated with immunosuppression and HIV/AIDS) • Rare = zoonotic ‘B-Virus’ from Cercopithecine Herpesvirus of Macaque Monkeys causes sever, fatal encephalitis of transmitted via bite or scratch HSV Encephalitis: Diagnostics Gaillard, F. (n.d.). Image | Radiopaedia.org. Radiopaedia. Retrieved October 31, 2021, from https://radiopaedia.org/images/381390 An 18 year old male presents to A&E with joint pain. He has just started university and has been recently drinking heavily. He also complains of dysuria and urethral discharge for which he states is ‘offensive and pus-like’. Which of the following is the most likely aetiology? A) Chlamydia trachomatis B) Klebsiella donovani C) Neisseria gonorrhoeae D) Trichomonas vaginalis E) Treponema pallidum STD: Gonorrhoea • Aetiology = Neisseria gonorrhoeae • Morphology = gram –ve diplococci • Clinical Presentation: ➢Dysuria (M+F) ➢Discharge (M+F) ➢Females = cervicitis ➢Males = prostatitis ➢May cause proctitis + throat infection • Complications: https://www.wikidoc.org/index.php/Neisseria_gonorrhoeaeg. Retrieved October 31,2021,from ➢Urethral stricture ➢Reactive arthritis ➢Epididymitis / Salpingitis • Diagnostics = swabs + MC&S (vulvovaginal, oral, rectal, urethral) • Management = currently IM Ceftriaxone (or) PO Cefixime + AZISTD: Disseminated Gonococcal Infection Tenosynovitis DGI Migratory Arthritis Vesicular DermatitisAn 18 year old female presents to her local GUM clinic with dysuria. She also complains of increasingly-worsening lower abdominal pain. She denies any vaginal discharge but feels unwell. She also notes that she is worried that she has ‘picked something up’ as she has multiple sexual partners. On speculum examination, cervical excitation is noted and pregnancy test is negative. Which of the following is the most likely aetiology? A) Chlamydia trachomatis B) Klebsiella donovani C) Gardnerella vaginalis D) Trichomonas vaginalis E) Treponema pallidum STD: Chlamydia • Aetiology = Chlamydia trachomatis (serovars D-K) ➢Most common STD in UK • Morphology = intracellular eubacteria (parasitic) • Clinical Presentation: ➢Asymptomatic (more so in women) ➢Discharge (M+F) ➢Dysuria ➢Cervicitis / Prostatitis • Diagnostics = NAAT ➢Males = urine culture ➢Females = vulvovaginal swab ➢2 weeks post-exposure (if applicable) • Management = Doxycycline (7 days) (or) AZI STD: Chlamydia Heaton, R. L., & Walid, M. S. (2011). Intra-ligamentous fibroid removed laparoscopically. Open Journal of Obstetrics and Gynecology, 01(03), 136–138. https://doi.org/10.4236/ojog.2011.13025An 45 year old female presents with offensive-smelling vaginal discharge for which she is very self-conscious about. The odour is so awful that she is worried that others will judge her whilst catching her local bus to work. She is in a long-term relationship with her husband and denies being unfaithful. Which of the following is the most likely aetiology? A) Trichomonas vaginalis B) Treponema pallidum C) Gardnerella vaginalis D) HSV-2 E) Peptostreptococci spp. Bacterial V aginosis •Aetiology = Gardnerella vaginalis, peptostreptococci, Bacteroides, Mobiluncus spp. •Morphology = gram-variable •Clinical Presentation: ➢Vaginal discharge (‘fishy’ + offensive) – thin-white ➢Maybe asymptomatic ➢Not distressing •Management = PO Metronidazole (7 days) (or) topical Clindamycin BV: Diagnostics Health Cop. https://healthcop.org/gardnerella/es & Prevention. (2018,June 10). HealthCop.com - Your BV: Amsel’s Criteria 1.+ve Whiff Test (KOH + discharge = fishy odour) 2.Vaginal discharge >4.5 pH 3.Thin, white homogenous discharge 4.Clue Cells on microscopyA 24 year old male presents with very painful lesions on his foreskin and scrotum. These are very painful and vesicular in nature. You suspect HSV-2 infection and want to initiate management. Which of the following is the most likely management plan? A) Topical Clindamycin B) Topical Acyclovir C) Oral Acyclovir D) Oral Acyclovir + Topical Steroids E) Conservative measures STD: Genital Herpes • Aetiology = HSV-1 / HSV-2 (OVERLAP!) • Clinical Presentation: ➢Painful sores! – Vesicular ➢Dysuria ➢Pruritus ➢Tender inguinal lymphadenitis Herpes genital: Sintomas, causas e tratamentos. (n.d.). Inspire Saúde. Retrieved October 31, 2021, from ➢Systemic syndrome (fever, headache, malaise) https://www.inspiresaude.pt/geral/herpes-genital-sintomas-causas-e-tratamentos/ • Diagnostics = NAAT + Serology (if applicable) • Management = PO Acyclovir (may need long-term) ➢Relapses may occur ➢Conservative measures – analgesia, saline bathing, topical LA ➢If pregnant (>28 weeks) – elective C/SA 35 year old male presents with a generalised rash across his trunk, palms, and soles. This began 6 months post the development of a painless lesion on his glans penis. He also describes an ongoing fever and widespread lymphadenopathy. Which of the following is the most likely diagnosis? A) Primary Syphilis B) Secondary Syphilis C) Tertiary Syphilis D) Hand, Foot, and Mouth Disease E) Chancroid STD: Syphilis • Aetiology = Treponema pallidum (spirochaete) • Clinical Presentation: ➢Primary Syphilis – chancre (painless!), non-tender local lymphadenopathy ➢Secondary Syphilis: 6-10 weeks post-primary syndrome ❖Generalised rash affecting palms, soles, and trunk ❖‘Snail-track’ buccal lesions ❖Condylomata lata ➢Tertiary Syphilis: many years after initial infection ❖Tabes dorsalis ❖Argyll-Robertson Pupil ❖Gummatous lesions STOCK IMAGE - by www.MEDICALIMAGES.com. (2021). Medical Images. ❖General paralysis of the insane (Paralytic Dementia) https://www.medicalimages.com/stock-photo-image-image9929548.html ❖Ascending aortic aneurysm formation • Management = IM Benzathine Penicillin G ➢Penicillin-allergic = Doxycycline ➢Be warned of Jarisch-Herxheimer Reaction! STD: Syphilis Diagnostics Disease Staging VDRL / RPR TPHA FTA-ABS Primary (early) - - + (Active) Primary (late) + + / - + (Active) Secondary + Tertiary + + + (Active) Latent + / - + + Treated - + + STD: Others • Trichomoniasis: ➢Aetiology = Trichomonas vaginalis (flagellated protozoan) ➢Clinical Presentation: ❖Green, offensive discharge ❖Associated with vaginal >4.5 pH ❖Vulvovaginitis / Urethritis (M) ❖‘Strawberry Cervix’ ➢Diagnosis = ‘wet prep’ for motile trophozoites ➢Management = PO Metronidazole • Lymphogranuloma Venereum (LGV) ➢Aetiology = Chlamydia trachomatis (serovars L1-3) ➢Clinical Presentation = stages (painless pustule/ulcfistulising buboes proctocolitis) ➢Risk Factors: ❖HIV co-infection ❖Tropical countries (↑occurrence) ➢Management = Doxycycline STD: Others LGV and T richomoniasis groove sign - pictures, photos. (2017, April 13). Disease Pictures. https://diseaeseshows.com/groove_sign/ 13 [cited 2021 Oct 30]. Available from: https://epomedicine.com/blog/strawberry-in-medicine/. A 40 year old male has returned from a vacation in Vietnam with ongoing crampy abdominal pain with associated watery non-bloody diarrhoea. This has been affecting his work-life as he is opening his bowel 5-7 times daily for the last 3 months. Which of the following is the most likely diagnosis? A) Escherichia coli B) Giardia lamblia C) Salmonella typhi D) Shigella flexneri E) Campylobacter coli GIT : Giardiasis • Aetiology = Giardia lamblia (flagellated protozoan) • Transmission = FO route • Clinical Presentation: ➢Chronic non-bloody diarrhoeal disease ➢↑flatulence + bloating ➢Crampy abdominal pain ➢May be asymptomatic ➢Malabsorption + Lactose intolerance (may be seen) • Diagnostics: ➢Stool sampling ‘classically’ shows nothing (absent cysts + trophozoite) ➢Hence, duodenal aspirates (‘string tests’) • Management = Metronidazole https://criticalcaredvm.com/giardiasis-dogs-cats-diarrhea/Diarrhea. (2018, January 1). CriticalCareDVM.A 23 year old female has returned from a vacation in Egypt with crampy abdominal pain and nausea with associated watery non-bloody diarrhoea. She has had more than 3 loose stools in the last 24 hours. Which of the following is the most likely diagnosis? A) Escherichia coli B) Entamoeba histolytica C) Salmonella typhi D) Shigella flexneri E) Campylobacter coli GIT : T raveller's Diarrhoea • Aetiology = Escherichia coli (gram –ve bacillus) • Transmission = FO route • Clinical Presentation: ➢Non-bloody, watery diarrhoea ➢Crampy abdominal pain ➢Nausea + vomiting (may be seen) • Most common cause of Traveller’s Diarrhoea ➢Defined as >3 watery stools in 24hrs +/- associated Sx • Management = Conservative + ORT https://fineartamerica.com/featured/lm-of-the-gram-negative-bacteria-e-coli-drrosalind-kingscience-photo-library.htmlmber2, 2021, from A 35 year old male has returned from travelling around South-East Asia with abdominal pain, nausea, and constipation. He also complains of a new-onset rash covering his torso. Basic observations show a fever of 39°C alongside a HR of 55BPM. Which of the following is the most likely diagnosis? A) Yersinia enterocolitica B) Entamoeba histolytica C) Salmonella typhi D) Shigella flexneri E) Campylobacter coli GIT : Typhoid/Paratyphoid Fever • Aetiology = Salmonella typhi / paratyphi (A-C) (gram –ve bacillus) • Transmission = FO + water routes • Clinical Presentation: ➢Constipation (also bloody diarrhoea) ➢Abdominal pain + distension ➢Relative bradycardia ➢‘Rose Spots’ – more common in Paratyphoid • Complications: ➢GIT perforation + haemorrhage ➢Osteomyelitis (Sickle Cell) ➢Chronic carriage of Salmonella ➢Biliary + meningeal inflammation • Management = ↑resistance; classically fluoroquinolones but AZI + 2, 2021,from https://fineartamerica.com/featured/false-colour-tem-of-salmonella-typhi-ions cnri.html GIT: Food Poisoning Identification of causative organism dependent on the incubation period! <6hrs = Staphylococcus aureus, Bacillus cereus 12-48hrs = Salmonella spp., Escherichia coli 48-72hrs = Shigella spp., Campylobacter spp. >1 week = Giardia lamblia, Entamoeba spp. A 47 year-old male who is a known IVDU has presented to the surgical assessment unit with suspected cellulitis. However, on examination, you notice retinal haemorrhage with a white, pale centre on fundoscopy, and a murmur on chest auscultation. Given the most likely diagnosis, which of the following is the most likely aetiology? A) Staphylococcus epidermidis B) Coxiella burnetii C) Staphylococcus aureus D) Streptococcus bovis E) Bartonella henselae Infective Endocarditis: Aetiology •Aetiology = most common cause is S. aureus ➢S. epidermidis (+ other coagulase –ve staphylocci) ❖Most common following prosthetic valve surgery (<2months) ➢Streptococcus bovis = associated with CRC ➢Viridans streptococci = dental plaque + poor oral hygiene ➢HACEK (culture –ve) = Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella) IE: Clinical Presentation https://www.roshreview.com/blog/ep-9-pneumonia-endocarditis-colchicine-toxicity-herpes-zoster-lung-ultrasound/ IE: Modified Duke Criteria osh Review | Emergencymedicine, Medical education, Cardiovascular system. (n.d.). Pinterest. Retrieved November 2, 2021, from https://www.pinterest.co.uk/pin/707909635149234086/ IE: Management Case Presentation Recommended Antimicrobial Chemotherapy Initial therapy Native valve = Amoxicillin (+/- Gentamicin) If penicillin allergic, MRSA Dx, or sepsis = Vancomycin + Gentamicin If prosthetic valve = Vancomycin + Rifampicin + Gentamicin Native valve staphylococcal IE Flucloxacillin If penicillin allergic, or MRSA Dx = Vancomycin + Rifampicin Prosthetic valve staphylococcal IE Flucloxacillin + Rifampicin + Gentamicin If penicillin allergic, or MRSA Dx = Vancomycin + Rifampicin + Gentamicin ↑Sensitive streptococcal IE Benzylpenicillin If penicillin allergic = Vancomycin + Gentamicin ↓Sensitive streptococcal IE Benzylpenicillin + Gentamicin If penicillin allergic = Vancomycin + GentamicinA 76 year old female has been admitted due to MRSA +ve Cellulitis. You administer antibiotics. You are bleeped shortly after as the patient has been turning progressively ‘red’. Given the most likely diagnosis, which of the following is the most likely aetiology? A) Teicoplanin B) Tazocin C) Vancomycin D) Ceftriaxone E) Linezolid Abx: Important ADRs Antibiotic ADR Amoxicillin / Ampicillin EBV-related rash; anaphylaxis Co-amoxiclav (Augmentin) Cholestasis; anaphylaxis Flucloxacillin ↑risk of superinfection with Candida; cholestasis (several weeks post-use); anaphylaxis Erythromycin / Clarithromycin GIT disturbance; QT interval prolongation; CYP450 inhibition; acute cholestatic hepatitis; interactions with Statins Ciprofloxacin ↓ seizure threshold; Achilles tendinopathy; GIT disturbance; CYP450 inhibition Metronidazole ‘Disulfiram Effect’ Doxycycline Photosensitivity; growth stunting; ‘black hairy tongue’ Trimethoprim Pruritus + rashes; haematopoiesis suppression