Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Thanks for coming. Um We're just going to wait a few more minutes and that more people join and then we'll start then. Okay. I'll start now. So, thanks everyone for coming today. I'm going to be covering infection um the acute and chronic infections and I'm Spreen. I'm one of the final year medical students. Um I hope you guys can all see my slides if I'm talking and you guys can't hear or see anything. Please drop me a message. So, starting off with infective endocarditis. So this is infection of the endocardial surface of the heart and the endocardium is the thin smooth inner lining of the heart which covers your heart valves. It's mainly caused by bacterial infections. So the bacteria enters your bloodstream and it gets deposited on the endocardial surface of your heart. And the most common bacteria to be aware of is staph aureus. Um infective endocarditis has different disease courses. So it can be an acute presentation. So it's rapidly progressive. And on the other hand, it can be more subacute or chronic. So you just have a low grade infection. So um it's characterized by the formation of vegetations on your cardiac valves and the most common valve affected is the mitral valve. Um It doesn't only affect just people's normal heart valves. It can also affect prosthetic valves and by vegetations. Um what that is is essentially just a collection of fiber in platelets, different blood cells like your white and red blood cells all clustered together with the bacteria. And it's the vegetations on these cardiac valves which causes the clinical manifestations of infective endocarditis. So it affects it by having locally affecting your heart. So the vegetations will go on to cause regurgitate murmurs and then eventually that can go on and cause congestive cardiac failure. When it's more of an acute presentation, you can get acute heart failure, you can get cardiogenic shock. The vegetations don't just affect the heart alone, you can get embolic event. So what this is is the vegetation will break off and it can get deposited in other organ systems. The mbali can then also go on to form abscesses. So for example, you can get cerebral abscesses and you can get pulmonary abscesses. And finally, the vegetations can also then go on to activate the immune system. Um So what this means is you get immune complexes within the vegetations itself. Um and that can cause vasculitis. So for example, you can get glomerulonephritis. So we've got a question here. So a 35 year old man presents to a and e with fever palpitations and malaise after taking the social history. You find out he's an IV drug user on examination. You hear a murmur, what murmur you most likely to here so you can go ahead and pop it in the chat. Or if you just want to think to yourself what it could be, anyone want to pop an answer in. Yeah, we've got an A, yep. Ok. We've got to ease. Hopefully guys also at home, we're also thinking e that's the correct answer. So here you basically need to know that the Tricuspid valve is the valve most commonly affected in IV drug users. So if you know it's the tricuspid valve affected, um then you need to think what kind of murmur comes along with that. So the tricuspid regurgitation, the answers eager to pansystolic murmur heard loudest at the left lower sternal border and just to quickly recap the other murmurs. So for a the ejection systolic murmur that's able to explain osis, a pansystolic murmur heard over the mitral valve. That's mitral regurgitation and see is talking about aortic regurgitation and D is talking about mitral stenosis and he is the tricuspid regurge. Sorry guys, I've got a bit of a cold. So I might be blowing my nose a bit. So presentation wise for infective endocarditis. So, if someone has a fever and a cardiac murmur, you're gonna think infective endocarditis. Um Those are the two main ones to be thinking about other non specific features. You can get malaise, you can get weight loss, thinking about what the vegetations did. So I've talked about abscesses. If someone has a splenic abscess, they might present with abdominal pain. Um, in the kind of embolic phenomenon in case you might then also get the most important risk factor to be aware of is um, someone had previous infective endocarditis. That's the strongest risk factor for then developing it again. Other risk factors are either drug users, people have poor dentition or any kind of valvular or congenital heart disease. Those are all other types of risk factors. So, I've included a few pictures about kind of the clinical manifestations that you can get with infective endocarditis. Um So if you guys want to go ahead and name what you think this is either in your head or pop it in the chat. Yep. So we've got to people. So they, yeah, correctly. It's a splint, a hemorrhage. So, um what you can see is it's just these thin red brownish lines that can develop under your nails. And this is a sign that's caused by micro emboli. And then can you guys name this sign? Yes. So this one is a bit trickier. So these are your Oslo nodes. Um So what these are, it's caused by immune complex deposition and you tend to get them on the pads of your fingers or your toes, Oslo nodes are really painful to get um kind of subcutaneous nodules. Um And the thing to remember as well about these. Other than that, it's painful is that you get it, it's more common with the sub acute presentation rather than the acute. So people that have that more low grade chronic infection, they're more likely develop to develop Osler's nodes. And then this is quite a difficult um image is not too clear, but you can kind of see the red, the red bits on the palm of their hands. Yeah, that's correct. So these are Janeway lesion's. So they're kind of opposite to the austin nodes in the fact that they are, they're not painful. Um And you get them more in the acute presentation rather than the sub acute rather than being immune complex deposition. There, these ones are formed by micro abscesses and then more of like the more kind of macula's a bit more flatter. And then finally, can you name this sign? Yeah, that's correct. So these are rough spots. So this is an image of your retina and you can kind of see it's pointing at these red, red, circular red circles. So those are the hemorrhagic lesion's. Um And that's also immune complex deposition on the retina. You can also get a pale center retina with it. And this one is more common with the sub acute rather than the acute presentation. So when you're doing your cardiovascular exam, and if you see any kind of signs, then you could be thinking about infective endocarditis. So I'm sure we've all seen this image before. Um It really nicely lays out diagnosing infective endocarditis. So you use the modified Jeep criteria. You've got the major and you've got the minor and kind of in the box below. It goes into more detail about the minor criteria. And then from this, you look at the number you have between the majors and the miners to give you ever, you have a definite diagnosis or if you just have a possible diagnosis, but I'm sure you've all seen this before before. I just include it because it's very useful when diagnosing infective endocarditis. So for investigations, the big one to remember is that you need to do your three blood cultures done at three different sites and they have to be a minimum of 30 minutes apart. So this is your main big one to remember. Um And then for your imaging modalities. So you start off with your trans thoracic echo and then once you've done that, if it's positive, so if it's got signs of like vegetations, um then you can move on to do a transesophageal echo or if it was unclear, then you would also want to do a transesophageal echo. So those are your main ones to remember other investigations you can do. Um So doing your urine dip. So looking out for hematuria. So if you've got the emboli in your kidneys, you can also get aortic abscesses forming and this will show on an E C G by having a prolonged pr segment, you want to do your bloods just to get your general baselines. Also looking for raised white cell cancer CRP to show that there's infection. And then other types of imaging, you can do CT scans. So this is looking for any kind of complications like the abscesses forming. So in your thorax, looking for pulmonary abscesses, your abdomen, looking for splenic and your head, looking for cerebral abscesses. And another cause of infective endocarditis. One of the other bacteria's is strep politicus. Um this is associated with colon cancer. So you would be considering doing a colonoscopy for someone has strep politicus, infective endocarditis just to rule out colon cancer in terms of management. So it's all to do based off blood cultures because that will tell you which specific antibiotics is required. So it's all guided by microbiology. Um But if someone is hemodynamically unstable, you do your blood culture, but then you can start them on some broad spectrum antibiotics. Um apart from antibiotics, you can then also think about maybe if they require surgery. Um three kind of main indications, remembers if they've got severe valvular incompetence. There developed chaotic abscesses or the antibiotics aren't working and they're resistant to it, right. So, moving on now. So case to a 26 year old woman presents to a and e with a fever and a terrible headache that came on suddenly, she says she feels nauseous and when you're clerking her, you know, she's confused and irritable. What are your differentials? Yeah. So we've got a few encephalitis meningitis. I'll stop there because Sarah's done exactly what I said. So, yeah. So it's a very um just a general description. So it could be loads of things but just broadly could be thinking about meningitis, encephalitis and also the subarachnoid hemorrhage just because it was a very sudden onset of a headache and then to kind of differentiate a bit between these three um differentials. How would you then go on to investigate her just broadly? Yeah. So those are all really good. So you can start off maybe by just doing your neurological examination. Um and there's the two specific signs that you look out for, for meningitis. So the Kernig's sign is when um if they have a flexed hip and then you start to extend their knee and that's causing a lot of pain, that's a positive Kernig's sign. And then your Brzezinski sign is when you get them to flex their neck and then at the same time, their hip and knee will also involuntary flex. So if they, these two are positive that could point you towards meningitis. Um then yet as you mentioned, your sepsis six, if they're really ill, you'll be thinking about blood cultures, getting those done just doing your baseline bloods to look for any inflammation markers being raised. And then you kind of your main big one would be doing a lumber puncture to help send off the sea analysis to get a bit more detail. Of course, you're not going to do a lumber puncture if it's contraindicated, um in that case, you would go on and do a CT scan. So if you like your subarachnoid hemorrhage looking for any kind of bleeds, um and the kind of main contra indications to remember would be if they had a low G C S, if they had signs of papilledema, when you did fundoscopy or if they were constantly seizing, so then you would do your CT scan instead. So, question to you perform a lumber puncture on the 26 year old woman and find the following results, low glucose, raised protein and they have a raised white cell count and the predominant cell is lymphocytes. What would this point you towards? Yeah. Anyone want to make a guess. Hey, yes, it's a bit trickier, haven't given you much information. Um But this one is pointing towards see um fungal joy itis. So this um table kind of nicely gives a bit of a summary for all the different CSF analysis. Um So you've got your normal on the far left and then if we look at viral. So the predominant cell here is lymphocytes, but often your glucose is going to be normal and your protein would be normal or slightly raised. Um The bacterial, the predominant cell would be neutrophils. Um And the kind of difference between bacterial and fungal because they're quite similar is that in fungal, you get lymphocytes route of bacterial, you get neutrophils. Also, the color is slightly different as well, the appearance. And then finally, between fungal and TB, these are basically exactly the same. The only difference is that the white cell count is higher with TB rather than fungal. That I found this table really nicely summarizes it all. Okay when we're thinking about clinical features between meningitis and encephalitis. So, with meningitis, um we're thinking about the main one being meninges. Um so they present with a stiff neck, photophobia, headache, um fevers, nausea and vomiting. And then the other big one is if they have a non blanching particular rash. So if they had that, you'd straightaway be thinking it could be meningococcal septicemia and that's caused by your Neisseria meningitidis. Um For encephalitis, you get symptoms like focal seizures, focal neurology's kind of any changes to their strength or sensation, fever and just general unusual alter behavior. So a bit more like non specific for encephalitis in terms of causes. So, viral meningitis is less severe than bacterial meningitis and the most common virus, just to remember is the Coxsackie B virus in terms of bacterial meningitis. So it's broken down by age group if you remember Neisseria um and strep pneumonia because obviously those rum infants, adults and the older adults. So I'd say those are the main two to really remember. But then for neonatal, if you just remember group B strep because um that's often the mum can develop that when she's pregnant. So then pass it on to the baby. So group B strep and then finally is listeria on the site of your knees as well. But if you can only remember to, I would just say remember Neisseria and strep pneumoniae. I so encephalitis can be caused by loads of different things. It can be infective or non infective, but it's most commonly caused by viruses. Um And HSV is the most common cause in adults. Um and then other viruses are like the varicella zoster EBV and C M V can also cause encephalitis for management. So with meningitis, if they're in the community, you can give them benzylpenicilloyl in. However, if they might have an allergic reaction to Benzel penicillin, don't spend time flapping around trying to find an alternative because the most important thing is to transfer them to hospital. So if it's by giving them Ben Pen and you're going to delay it, then you shouldn't do it because the most important thing is getting them there. When you're in hospital, you can give them kept attacks seem or kept trying Axon and um patient's are older than 50 years old. You can add amoxicillin because that also covers for listeria with meningitis. You can also consider giving dexamethasone. Um This dexamethasone is given for meningitis caused by strep pneumoniae. I and you want to give dexamethasone either before they have their antibiotics or within 12 hours of giving them the antibiotics. And for encephalitis, you can give them IV, a sick liver is the main one. And if it's caused by CMG, you can give them ganciclovir um for viral meningitis because it's less severe. It's often just kind of a supportive management. So giving them analgesia fluids. Um, and it's just more of supportive rather than giving them antibiotics. Okay. So case three, it's infective diarrhea. Suddenly we're just going to talk a bit about this. So there's loads of different causes for it. You can get bacterial causes, which we'll talk a bit about later viruses are what most common cause of infected diarrhea. So your rotavirus norovirus, um and then you can also get protas over that causes infective diarrhea as well. So I've got a couple of questions now. So a 35 year old man returned from visiting family in Pakistan three days ago, he has developed bloody diarrhea and described the sensation of needing to open his bowels even when he has just had a bowel movement, which organism is most likely to be responsible. Yep. So the answer is b um shigella and the reason for this is because he's presented with bloody diarrhea. So that's more common with shigella compared to having like a watery presentation. Um And it's also more common in South Asian countries as well. So another one, an 18 year old student develop severe vomiting two hours after eating a Chocolate Eclair, she found in the shared kitchen in her halls of residents. She has also had two episodes of loose stools, which organism is most likely to be responsible. Yep, that's correct. The answer is c um and the reason for this is because she's presented with severe vomiting and also the incubation periods being really short of just two hours. So that would point you towards Staph aureus. So it's a very busy slide this but it's mainly when you get the slides back, you can then have a look at it in more detail. Um It's just broken down really like the different bacterias that can cause infected diarrhea as well as a few of the protozoa. Um And it's to do with whether they can have bloody diarrhea with it and also in terms of the incubating period. Um So Staph aureus, which we mentioned, you get the severe vomiting. Another important one remembers echo like because that's the number one cause of travelers diarrhea, that's more typical of like a watery stools. Um And then we mentioned shigella already and then the other really easy one to remember is just particular serious, mainly because if someone has had some dodgy rice, then it will probably be that. Um But yeah, the slides mainly just for when you get the, when you get the sides, you can have a good, good look at this in terms of management of infective diarrhea. So you want to try and prevent it as much as possible. So, maintaining good hygiene um and also meal prep, maintaining good hygiene standards. There, soon as someone starts getting symptoms and isolations really important, um you can send off fecal testing, so doing microscopy culture and sensitivity. Um and then also just thinking about their fluid status because obviously they can become dehydrated very quickly. Um So doing fluid challenges, um they could just require oral fluids or they might need IV fluids. And then when they start getting better, just doing a slow um introduction, just a very simple diet. And then in terms of antibiotics, so you don't really tend to give antibiotics. You'd only really think about doing this if someone has loads of co morbidity, so they're at risk of complications. And if you definitely know what the causative organism was, then you would start thinking about putting them on some antibiotics. Okay. Next case, 19 year old Anna is brought to a and E by her housemate because she has become increasingly drowsy. The housemate tells you that Anna has been vomiting, complaining of achy muscles and has a fever. She mentions that and has just come back from holiday, but she can't remember which country. What are your differentials? Yeah, those are all good suggestions. That's what I put as well. So if you're thinking about your vector borne diseases, so malaria, Dengue, Ricketts seal disease. Um and then it might not have anything to do with the fact that she was abroad and it could just be like meningitis or encephalitis as well. So, in terms of Ricketts Seal disease, I'm not going to talk about it now because I don't think it's less likely that this will, this one will come up. But I remember when we got taught, it was a bit confusing. So, what I've done is I've just included my notes that I made in for fear of really simple breakdown of Ricketts Seal disease with the three different types um with a bit of information. So you guys can have a read about it. But I think it's probably less likely to come up than the other one. So we're not going to go through it now. So, malaria, this is caused by protozoan parasites um by the Plasmodium family and it's transmitted by the anopheles mosquito when you want to think a bit about the life cycle. So I know the CDC image is a bit confusing and there's lots of information on. So and as for fear, I kind of made this very simple image um of a breakdown of the life cycle. So what happens is a mosquito will bite a human and it injects parasites, the spar a sites then go on to the liver and it can then develop to ski isn't and these will rupture and then you get um something called marrow sites. So that's all happened in the liver. But then now we moved on to the red blood cell. So the marrow sites go into your red blood cell and they then become immature trophies sites. Um At this point, they can either go on to gamma two sites or they go into the cycle called like the orifice itics cycle, which you can see it goes to mature trover sites, citizens and then it ruptures to marrow sites. So that's kind of just a very simple version of the life cycle of malaria features. So all the clinical features really not that specific. Um So you just get fever, generally feeling unwell, different gi symptoms or upper respiratory tract symptoms. So I think it's just really important when you're doing your history to make sure you include travel history because if they've gone abroad, that's probably what will then make you think. Oh, this could be malaria because the symptoms are all just quite generic, some signs you can look out for. So they can have pallor due to anemia, they can have hepatosplenomegaly. Um and they might have jaundice and that's because bilirubin is being produced when the red blood cells are rupturing. Um malaria can also then go on to be quite severe and you can get widespread organ dysfunctions. So it's important to be aware of that. So kind of clinical features of severe malaria. I've mentioned a few. So if you've got respiratory distress, they can get kidney problems can affect their brain. Um So it can be a severe disease investigation. So the gold standard, one to remember is to do a blood film with the GM sustain um when you're doing the blood film, so you need to make sure you get three samples sent over the three consecutive days. And the reason why you do three rather than just doing one is because of the kind of the life cycle that I just spoke about because there's not going to be malaria released all the time from the red blood cells cause it's all to do it. Like the rupture time it takes for the red blood cells. So you want to do three and the blood film, you have a thick and you have a thin film, the thick film is better at getting the parasitemia level and the thin film, the getting the causative organism. So by that like which type of plasmodium it is that's caused it. Um other than the blood film, you can do rapid diagnostic tests which will give you a quick result. So on another question, on a malaria blood film, you see the following. Which type of plasmodium is this? Yeah, we've got a couple of answers for a. So the answer's plasmodium falciparum, I'd say this is probably the only one you really need to know on blood film just because plasmodium fast part is the most common cause of malaria and it's also the most severe and dangerous form. And the thing to be looking out for um that point you towards it is having the double chromatin dots also known as the headphone sign, which I don't think it's that easy to see, but you can kind of see a little headphone sign on, on the blood film and then managing malaria. So it depends on which type of Plasmodium it is that's causing the malaria. And then also whether it's complicated or uncomplicated. I think if you need to remember any of them, just remember the management for Plasmodium falciparum. Um since that is the most common one. So if it's uncomplicated, um you give them Malarone or Ryan Met and those are the generic brand names because they're just easier to remember. And if it's complicated, then you give them IV are twos Nate and by complicated. So there's three things to be looking out for. So if you can see schizont on the blood film, if the parasitemia level is over 2% or if they're showing any of the severe signs that I previously talked about, that's then considered complicated, which is when you would then want to give them the IVR to using it rather than just the Malarone Rima at. And if it's not sure if you're not sure what the cause is, um or if it's like a mixed type, then you just treat it as if it was Plasmodium falciparum. So prophylaxis wise um simply just mosquito spray, mosquito nets, and then you can also take anti malarial drugs um as prophylaxis before going to a country which has malaria in. Um so Malarone is like is the most expensive one cause it's got the best side effect profile and this is a causal antimalarials. So in terms of your life cycle, it's directing against the hepatic stage and then doxycycline, the meth mcquinn are a lot cheaper, but that's because you can get loads of different side effects with them. Um And these work by being suppressive antimalarials. So they're directed against the urethra citic stage. Okay, we're now going to move on to dengue fever. Um So this is very common disease in countries where dengue is rife. Um It's caused by aids aegypti mosquitoes and it's a virus. So it's caused by the flabby virus. So there's four different serotypes, dengue, 123 and four. Um If you get one type of the stereotype, you'll then have immunity to that one that you only have immunity to that specific one. And if you then get a subsequent infection with a different type of stereotype, your then more likely to get a more serious disease and you can get severe dengue in terms of the clinical features. So the main one is you can get a fever and this happens in a biphasic pattern. So what this means is you can get a fever for three or four days and then the fever will subside for a couple of days and then it will come back again. Um And that's what biphasic pattern means. And then you can get malaise headaches, achy muscles, you can develop rashes, um and you can get eye pain. So when thinking about dengue, you can get Dengue with or without warning signs. And then this can also then go onto progress into severe dengue. So the probable dengue, this is when you've gone to a country where there is Dengue. Um, and you have a fever and then you also have to, with the other follow features that you can see listed, um, just to clarify people if they don't know. So the tourniquet test. So what you do is you inflate a BP cuff for five minutes and after that, if they have 20 patiki eye in one inch squared, then that's a positive tourniquet sign. Um And then you can also get warning signs of these are a bit more severe. Um So getting like persistent vomiting, abdominal pain, doing the blood tests and seeing some changes, um, like increased hematocrit and then severe dengue. Um is when you can get organ impairment, you can get shock. So having your low BP and high heart rate and also getting hemorrhage, having hemorrhages Denny for investigations. So you start off by just doing some bloods. So on your full blood count, you can be looking for any raised hematocrit or low platelets. Um And that suggests kind of dengue with warning signs. Um For your LFTs, you might have raised A L T A S T and that suggests that you're going getting organ involvement. So that's severe Denny. Um You want to do, you're using these because they might have electrolyte imbalance if they're vomiting loads and then your coag screen, you'll have a ray, a prolonged APTT and A PT due to the low platelets. You can also do your Eliza test and specifically look for Dengue doing PCR serology for management. There's not too much that can be done. Um So really, you just want to monitor them and do supportive treatment, but if they're having hemorrhages, then you may, they may need a blood transfusion for prevention. They don't have any specific drugs to take like the malaria. So you kind of just need to use insecticides and try and prevent it by just covering water storage and containers. Okay. So next case. So you take a very brief history from a 24 year old man who presents to the G P with a two week long history of fever, difficulty concentrating, generalize muscle aches and fatigue. He also tells you he has a rash. So if you look at all the different rashes on the side, um and then apply that to kind of the other symptoms that I've mentioned. What would your differentials be for each one? Um Okay. Yep. So for a, we've got syphilis and be, we've got Lyme disease and then cease quite difficult. Um But we've got um HIV. So if I go through each one, so for syphilis, um often you can get kind of enduring the secondary syphilis stage, you can get a characteristic rash. Um and these are kind of rough red brown spots that develop on your palms and the soles of your feet. For Lyme disease. I mean, this is the easiest one to remember because you got your classic um Lyme disease rash called erythema migrants. So you have that circular red rash and then you have the clearing around it and then see for HIV. So you can get a macular popular rash um that can occur after recent HIV infection, usually around 2 to 6 weeks after exposure, they can then develop this rash. So Lyme disease, this is caused by the spirochete bacteria called Borrelia burgdorferi differ. Hurry. Um It's transmitted to humans by the like cd's tick. So the clinical features kind of depends on the stage of the Lyme disease. So, early localized disease. So this is 7 to 14 days after the bite, you then get the erythema migrants rash. You can get headaches, you can get fatigue. Um you can get a fever are frau Jer um kind of the symptoms you can get and then when you progress a little bit further. So it's called early disseminated disease. Um So 3 to 10 weeks after the bite, you can then get a flu like illness, developed facial nerve palsies. Um you can get back pain, you can develop meningitis and you can also get cardiac involvement. So you can get heart blocks or you can get myopericarditis notice and then finally, in late disseminated disease. So months, two years after you've had the bite, you can get chronic lyme arthritis. Um and you can get neurological impairments, you can get cognitive dysfunction, bladder dysfunction. Um and you can get some skin skin conditions called aqua dermatitis chronic, a trophy cans, which is a very long word to remember. So, to investigate, if someone comes in with the erythema migrants, then you can just make a clinical diagnosis. Um Otherwise, if the erythema migrants isn't there, but you suspect it. Um then you can do an Eliza test. Um And if the Eliza test is positive, then you move on and do an immuno block test. Because if the immuno block test is also positive, then you give them treatment if the Eliza test is negative. But you think that they do still have Lyme Disease, then you can repeat the test four weeks later. Um And then if at 12 weeks, if someone still has symptoms, you and it's negative, you can just do the immune a block test. So another question, a 30 year old woman who's 28 weeks pregnant presents the GP because she was bitten by a tick a week ago when she was walking her dog, she says she has no symptoms but has noticed a rash. You examine her and see a bull's eye rash. How would you manage this patient? Yeah. So the answer is D um, and the thing to be aware of was because she's 28 weeks pregnant. So that's why it's d with amoxicillin rather than Doxycycline. Um, because she's got that bull's eye rash, you're going to go ahead and give her treatment. You're not just going to reassure her or you don't need to perform any other tests. So, as we said, so the management, you give them 21 days of oral doctor cycling. But then if there's any contraindications such as being pregnant, you give them amoxicillin instead and if they're no longer in the early stages and they have disseminated disease, then you give them IV kept try oxen for 21 days. Okay. So, syphilis, um this is another disease caused by a spirochete bacteria. This was caused by Treppe Noma pallidum. Um It can be transmitted in loads of different ways, mainly sexually or vertical transmission in IV. Drug use, blood transfusions is less common these days just because the blood products are screened in terms of the stages. So you, you get exposed to it, you then develop the primary stage, um that can go on to the secondary and then move onto latent. When you're at the latent stage, you can either go back to secondary or it can progress to tertiary and at any point, you can get neuro syphilis. Um and what neuro syphilis is is you can get loads of different symptoms such as headaches, older behavior. Um If you're thinking about spinal column injury, wanting that syphilis can cause is your Tardis disor lis, which is when you're dorsal columns affected, um you can get ocular problems. So such as your Argha Robertson pupil, um on the way to remember our goal, Robertson is when you do the um pupil reflexes by shining the light, it accommodates but doesn't react. Um They can also just get painful red eyes. So your ocular neuro syphilis can occur any time because just the bacteria can get into your central nervous system or into your eyes. So if we think about the clinical features that come with each one, so with primary syphilis, you get the Chiang cra which is a painless ulcer. Um and that tends to resolve after 3 to 8 weeks. Um And you can also get lymphadenopathy with it. For secondary syphilis, you get that rash, which is the image we had earlier on. So you can get a maculopapular rash, you can get condyloma, marta, lotta, um alopecia, fevers, fatigue, and oral ulcers. Um And then if it goes into the latent phase, that's when it's a symptomatic. So they won't have any symptoms. And then finally, with tertiary syphilis, the main ones, remember as you get these go Mattis lesion's um and you can then also get problems with your heart and you can get aortic, um, aneurysms, so, investigations for syphilis. So if someone's in the primary stage and they still have the Chiang cra, then you can do dark field microscopy or you can just swab it. Um, but if they no longer have the Chiang cra, then you're going to move on and you would do something called a Treppe normal test and the Treppe normal tests are your enzyme immuno essays or your T P P A. Um What this does is it determines whether you've been exposed to syphilis. So it's really important to remember that this is going to be positive life long. So it's not enough just doing a trip, a normal test um because it doesn't show if they have active infection or not. So if that is positive, then you need to check if they do have active infection. So you do your non Treppe normal tests also called cardiolipin tests. And these are your RPR or your V DRLS. Um And what these do is it determines the disease activity and it can also measure response to treatment. So when you're looking at response to treatment, um you can look at like their previous results and if the title is increased by fourfold, then you know that the treatment's not worked um or their reinfected. So you go ahead and give them more treatment for it. So those are kind of all the different investigations that you can do for syphilis. So a 38 year old man presents the G P with fatigue lymphadenopathy and tells you he's had a painless Pienaar also three weeks ago. But this has now gone. The G P decides to investigate him for syphilis. A few days later you received the following results. So the enzyme immunity essays positive and the VDRL is also positive. How would you treat him? Yep. So the answer here is see you want to give him a stack dose because you can see that the RPR which is showing the current disease activity is positive. So you'd want to go and give him um some treatment and then following on from this. So he doesn't return for his repeat blood test to see if the antibiotics treated the syphilis. Five years later, he returns to the G P with a soft granuloma to the forehead. How would you treat him now? Yeah. Yeah, we've got a couple of des that's correct. So this time you're going to give it once weekly for three weeks. Um And the reason for this is because he's got that soft granuloma, you know, he's got tertiary syphilis because he's got the um Goumas as they're called. So this time you're not just going to give him a stat dose and he, he needs a bit more. So, yeah, for the management you want to give them I am Benzo Benzoyl penicillin and as I've said the length of it just depends on the stage that they're at. Um, for all S T I S U. Um, they need to go get screened for other sexually transmitted infections. Um, you need to avoid them to abstain from sexual activities until they're treated. Um, think about contact tracing and also just give them a bit of education about preventing any future infections. Also, another thing to remember is when someone gets the treatment, one kind of side effect that comes along with it is something called the Joy Irish Hex Heimer reaction. Um and this is triggered by the penicillin treatment. So they can get muscle aches, fevers, um flushing palpitations. Um but this isn't, it's different to anaphylaxis. So they don't need to be treated as if it was anaphylaxis. It's just managed conservatively. Okay. So now HIV. So this is a viral infection. It's caused by the lenti virus. Um It's a type of retrovirus works by attacking people's CD four cells. It's transmitted in the same way as syphilis. And there's two different subtypes you have HIV, one which is the more predominant one which um most people know about and then HIV too, which is just mainly found in West Africa. So talking about the different stages now of HIV. So stage one of HIV, which is also called um kind of this zero conversion period. So what happens is you get exposed to HIV. Um and kind of in this 2 to 4 weeks after that, you have the cereal conversion. So what's happening is you're getting a high viral load. Um and it means you're really highly infectious at this stage. Um And the cereal conversion can last up to 12 weeks and the person is making HIV antibodies. So when you're kind of checking for HIV, that's when it becomes detectable during the cereal conversion. Um clinical features that you get with primary HIV. So you get rash, you can get a fever, fatigue, lymphadenopathy, sore throats, um kind of just general kind of symptoms. Stage two of HIV, which is your chronic HIV can be a symptomatic, also kind of known as the clinical latency period. Um and it can last for several years. So during this stage, your immune response is trying to control the virus. So it's trying to limit the symptoms. Um but you still get viral replication. So you're still infectious even if you don't have any symptoms. Um and then when your CD four count starts to lower. So when you get below 500 that's when you start to get things called non aids. Defining illness is um and some examples of this is oral candid ASIS, um oral Harry leukoplakia and to differentiate between the two, um the oral Harry leukoplakia, that's when the white plaques don't get, can't be scraped off and you're also more prone to kind of yeast infections and you just get generalized lymphadenopathy. So, stage three of HIV. This is called um more commonly just known as AIDS. So you get AIDS defining illness is at this point. Um, annual. See your immune systems can no longer cope. So your CD four cells are falling below 200. So when we talk about AIDS, defining illness is kind of broken up here depending on your level of your CD four count. So when the CD four count is between 200 to 501 AIDS, defining illness they can get is a car posey sarcoma. This is caused by the human herpes virus eight. And it's usually self limiting, but sometimes it can um developing like the gr respiratory tract. Um and then it might require chemotherapy at this point when it gets to between 102 100. The main one, I'm sure you guys all know about is P J P also used to be called PCP. Um This is caused by a fungus that affects your lungs. Um And the kind of main symptom to remember here is that when they are exercising, their oxygen saturations will lower. You can also do chest x rays and uh bronchioalveolar lavage barge um to diagnose P J P and it's treated the with co-trimoxazole. And it's quite important that anyone that's below 200 they get started on the co-trimoxazole prophylactically just because it's such a common complication of AIDS. Um You can also get cryptosporidium that causes the chronic diarrhea that's a protozoa. And then it can also cause cerebral toxoplasmosis iss which is a protozoa. Um and they can present with headaches and confusion. You want to do a CT scan and then if it drops even further to between 50 to 100 you can then get cryptococcal meningitis, um which is a fungal infection. Um and you can also get a softer gel candidate basis, which is caused by candidate alba cans and they can get painful, swallowing and painful when they're talking. And then the other thing that can affect your brain is primary cns lymphoma. Um And you, that's associated with E B V and you do a CT scam. And then lastly, when you're on your CD, four count of less than 50 you can get my bacterium, avium and intracellular. And these are bacteria that can cause symptoms like fevers and night sweats and weight loss and you can get CMB retinitis or colitis. So those are all the main aids, defining illness is to be aware of. Um And I've included the information I've just said on, on the slides when you get them sent out. So you can read over them again. So question nine, a 66 year old woman who is known to be HIV positive presents to E D with a headache, confusion and drowsiness. You request a CT head for the lady which shows this image. How would you manage her? Mhm. Okay. So it's a bit of a tricky question. The answer here is be um And the reason for this is because if you look at the CT scan, so it's showing that it's a primary CNS lymphoma. Um And the reason why, you know, it's a primary cns lymphoma rather than toxo plasmosis is because with CNS lymphoma, you get this single lesion, which you can see on the scan. Whereas with toxoplasmosis, you get multiple lesion's. So, so once you've identified that it's a primary cns lymphoma, you then need to think what the management is. Um And that's be if it was toxoplasmosis. So if it had multiple lesions, then the management for that is a, you give themselves a dire seen and I've seen. So investigations wise, the kind of main one to remember just your fourth generation blood test and it's very good at detecting the antibodies. But if they want just a quicker test, then you do a third generation test. Um But if those are positive, then they go on and get a confirmatory blood test done. And if a patient is a symptomatic and they, you think they could have HIV, then you would repeat the blood test again after 12 weeks just to make sure that it is negative and to confirm it. So management wise, um there's no cure but what there's loads of different antiretroviral therapies now, which are really effective. And the main thing for doing that is you're trying to lower the viral load of HIV and keep the CD four count as high as possible. So, the main one to remember is Truvada. This is made up of two N R T I s and then on top of Truvada, you give them one more antiretroviral therapy. So you give them three in total. And that's just to help target all the different parts of the HIV life cycle. In terms of prophylaxis, you can give them Truvada as well along with the raltegravir. And that's given 72 hours before the pre exposure prophylaxis. You can give them Truvada and to monitor HIV, you measure the CD four count and the viral load. I've also included the kind of endings of the different drugs just to help you guys. Remember. So for the N N R T I S, it often ends in fear for Integrys inhibitors that ends in gravity and the protease ends in Nevada. Okay. So the last case, now a 35 year old man presents two G P of the seven week history of a cough. He also has a poor appetite and noticed his clothes are loose fitting. He has also been having fevers. What are your differentials? Yep. So you mentioned, so thinking about TB, it could be lung cancer, uh maybe COPD or community acquired pneumonia. So when we're thinking about TB, this is caused by the bacteria, my bacterium tuberculosis. Um this is an acid fast factors. That's really important to remember. So it's really difficult to stain. So you need to use the special stain called the zeal Nielsen stain and that will stain read. Uh and most commonly TB affects your lungs, you get pulmonary TB, but it can also then go on and affect other parts of your body. So you can get um CNS TB and you can get meningitis with that. It can affect your spine. You can get Pott's disease. It can also affect your heart and you can get pericardial TB and TB is more common and lower socioeconomic countries. So, the different stages. So once you are exposed to TB, you can just clear the infection away or some people might progress and get primary TB. Um you can then from the primary TB, it can progress and you can get progressive primary TB, it can go onto the latent phase. Um and from the latent phase, it can then get reactivated, which is called post primary TB. And it often tends to reactivate in people that are immunocompromised. If they have HIV, then it can get reactivated. So, clinical features because it often affects your lungs. So they can present with like a chronic cough. They may or may not have hemoptysis iss, they get weight loss, they can have fever. Um and you can also get lymphadenopathy. Um and so you kind of get this painless um like cold abscess that develops on your neck. Um And rather than it's seeming to be like acutely infected. It's often, um, not really kind of this known abscess. So it's just called the cold abscess. Um, and you can also get erythema nodosa. Um, so when you're thinking about investigations as two different types, so you can look for previous immune response to TB or you're active TB. So when you're looking at previous immune response, you do a Montu test and if it's more than five centimeters, then it's considered positive. So you then go on and do an inter Ferral released essay. So what this is is you take a blood sample and you mix it with a bit of TB bacteria and if the person has previously had TB, um then it be sensitized to that bacteria and it releases the interferon gamma. So if both of these tests are negative, it means they're not have been previously exposed to TB. So you can give them the B C G vaccine and as I'm sure you'll know B C G vaccines are offered to healthcare workers. And it also is given to me in eights who are from higher areas of um where TB is more common or if their relatives are from TV, prevalent countries. But if someone is presenting with active TB, um the gold standard is to do a sputum culture, you can also do a spewed and smear chest X rays, look for any complications and also think about maybe doing an HIV test. So I know Charlie did some risky, um, prep in his last session. Um, but I thought be quite nice for you guys to just have a bit of a practice about doing a chest X ray interpretation. So I'll just give you maybe about four minutes just to really quickly, um, think how you would interpret this chest X ray kind of using a format. So I'll go ahead and just give you kind of four minutes roughly. Okay. So you've had a bit of time to think about how you interpret it. So I filled out the stationary that you would get given and you're risky. Um So always important to remember to do your patient identifies because often they kind of fill out a few of them and they might just sneakily miss one off. So just always double check that it's always filled out. Um And then when you start, it always include who you are and your position. And then thinking about chest X ray interpretations, you always start off with your pneumonic ripe. So rotation for this, it was just normal inspiration. I wrote that it was adequate and you could see eight ribs visible, the projection. So it was a pa chest X ray and the exposure was fine. So I just wrote adequate exposure. And then after that, you move on and you think about your A B C D E. So A for airway, the trachea was central, I couldn't see any higher a lymphadenopathy then moving on to breathing. So I wrote that the lung fields were all clear except for cavitary lesion in the right mid zone for cardiac. Um I wrote know cardiomegaly and all cardiac borders visible. And for diaphragm, always talk about the cost a phrenic angles and if there was any pneumoperitoneum. So for this X ray, those were both normal and then e for everything else, always check for any fractures because they might just throw one in, hoping people don't realize. So I wrote no bony abnormalities, know pacing wires or pacemaker, seen and then you finish off by giving your impression. So the impression here is pulmonary tuberculosis and then I did a bit of a plan. So I don't think you necessarily need to do, but I just wrote, you could investigate the Pommery TB. Um So I'd request dispute and culture and then always remember to sign off at the end. So management wise for TB, if they have active TB, you give them six months of revamps in and Eisen eyes side and then two months of prison um I'd and FM Butul, if they're in the latent TB stage and they're at risk of reactivation, you can give them six months of Eisen I'd or just three months of revamps in and Eisen I Zaid, sorry, Frances was so badly. And then the it's important to just remember this side effects that you can get for each TB drug So for revamps in, you can get orange or red secretions. Um for eyes, own eyes, did you can get peripheral neuropathy? And for pyrazinamide, you get hyper senior. So that results in gout and um f in Butul for color blindness and reduce visual acuity. So those are the main side effects to remember also for eyes, own eyes to help stop peripheral neuropathy. You co prescribe pyridoxine at the same time because that will help prevent it. And all of these drugs are hepatotoxic. So you need to make sure you get LFTs done and on top of that, you just want to get baseline blood. So doing your full blood count using knees and doing a vision test because of the side effect of f and beautiful. So that's the end. Thanks for coming. I hope it was useful. Um If you fill out the feedback form, um I'll send those slides across to you. So you can have a read about that if anyone has any questions about what I've spoken today or I know you've got your exams coming up really soon. So you just have any general questions about the risky or the Muslim. I literally just sat my exams like a month ago less than that. So if you have any questions, um just pop them in the chat um or you can just say your questions. Um and good luck guys because I know your exams are really soon after you've done your risk is, and Moses.