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No, it's so windy here. Mhm. So I think we're live now. So, yeah, I think we are alive. All right. So let's just give a few minutes for everyone to join. Ok, we start at 32. Yeah. Sure. Ok. All right. So shall begin and hi everyone. My name is a Sohan. I'm 1/4 year medical student and the lead for this teaching series of be today, we have Doctor Jack Wellington with us and he is going to talk about high yield infectious diseases. So for many students myself included micro and infectious diseases have not been our slowest suit. Uh So I'm hoping that this session will help us a lot to understand infectious disease much better. I'm sure this session will be incredibly valuable for everyone. Just to note, uh Doctor Wellington has an extensive background in academia and research and has published around 100 articles in different fields of medicine and surgery and he is run also running a general club. Um So thank you for anyone who is uh who is interested. You could also attend those as well. Uh Thanks. Thank you very much, Doctor Wellington. Feel free to take the lead and yes, we're very eager to learn of your knowledge about infectious diseases. No problem at all. Thank you for inviting me. So, I'm Doctor Wellington. I am a current academic F one up in York and Humber. I'm currently doing the academic neurosurgery track up there. And I mean, the reason why I've been given this talk a couple of times is I did a Masters in the London School of High and Tropical Medicine in Medical Microbiology. And what I found in medical school, specifically um infectious diseases and medical microbiology is not really a good and not really good. Um Topic taught very well. Um And I basically want to give an overview of the high yield things which you'll see in exams, especially progress tests and UK MLA which is the exam you have to sit before graduating in the um in UK medical schools. So a little bit about me. Um I recently graduated with honest. Um I've had a plethora of national and international leadership roles including neurosurgical and neuropsychiatric roles. Um On my research, G there is 100 articles but for pub, it's um above 60 publications, I've had 10 oral presentations and quite a few posted presentations to national international conferences. I'm currently a review editor for a journal and I hold two International Fellowships in music and the arts. So it's quite difficult to put learning objectives within medical microvirus infectious diseases. Because if you can imagine, you you can split pathology into communicable and non communicable disease where communicable basically means infectious disease. So anything which you see which is contagious from one person to other could be down to an infectious disease. So it's quite difficult to just put one learn objective um one system. So the way I would approach it is not via a systems approach because infectious diseases can be systematic and systemic. So when someone goes septic, that bug can go anywhere. So it's quite difficult really to elude the systems. But for high yield things, I'll be going through certain particular pathologies which are related to specific systems. But just don't categorize a bug into one specific system because it can travel around. Ok. So believe it or not infectious diseases and medical microbiology is actually quite logical. Ok. There is one bug which causes one particular condition, but it has a plethora of characteristics and clinical syndromic features. That's why it's difficult to sometimes allude to a particular bug. And you can imagine there is many, many, many different pathogens out there. So it's difficult to pinpoint but it is quite large log. So think about it, if a pathogen produces a toxin, then it's gonna cause a toxic syndrome. Classic cases would be staphylococcal toxic shock syndrome, which is from Staphylococcus aureus. Um and you get other toxic syndromes from streptococcus pyogenes, et cetera. So just think if it produces a toxin makes a toxic syndrome, infectious diseases is really down to five pathogens in cholesterol minus prions. But I'm not gonna go into prions. Ok. You've got your bacteria, which I'll refer to as bugs, viruses, protozoans, parasites and fungi. So, what I would like to say is you can use Ham's razor and Ham's razor. If you don't know what it means, it means the most logical pathology is probably the most common thing which is affecting it. So, for example, if it's things like a canary, it looks like a canary, it looks, it's going to be a canary. It's not going to be a zebra. Ok? But with infectious diseases, you have the hiccups dicta, meaning that it could be anything, it could be the anti razor to Ockham's razor. So think about your weird and wonderful COVID-19 was a perfect example. Everyone thought it was flu or um or R SV or something, but it turned out to be COVID. So always keep those weird and wonderful things in the back of your mind. F if you think of bacteria, most of the time, it's gonna be antibiotics but do not get into the habit of just prescribing antibiotics at everything. Ok? It's not going to treat everything cos most things are resistant or it could be a virus and ex and in exams, stains such as gram, gram stain, acid fast stain, et cetera. They are your main stain. Hint of what bug could be causing something. So they will give you a hint in a question, for example, er, allusion to this particular stain and it'll give you a clue on what bacteria or fungus or something will be. Ok. So it is impossible to cover a lot of things. But I'm gonna be covering the most common and most high yield things in a space of an hour and a half. So high, all things. I like to talk about chest CN SSE STD S HIV, complications, a bit of gut and a bit of antibiotics. So that's why I'll be covering today. So I do the sessions through questions. So if you can put your answers within the chat, that'll be great. Ok. So first question, a 45 year old male presents to his local GP with new onset fever cough and lethargy. He's now a smoker of 30 cigarettes daily and has a past medical history of chronic bronchitis. His sputum is purulent and his O2 sats are 91%. You send him for hospital admission. So, in a chat, what do you think is the most likely etiology? What's the most likely bug? Oh Wicked. There's a pole. Ok. So we've got some A s, we've got some BS, we've got some DS, anybody else. Ok. Cos in contras of time, I'm going to answer this for you. So the correct answer is haemophilus influenzae. So, and B and the reason being is because this presentation is typical of an acute exacerbation of CO PD chronic bronchitis is a type of CO PD alongside emphysema and the bug which is most commonly um associated with CO PD is haemophilus influenza. Now, you can have strep pneumonia and Moraxella castalis, which do cause these as. So um these presentations, but the most common will be haemophilus influenzae. Now don't neglect the viral causes. So specifically rhinoviruses such is a common cold R SV and influenza, but COVID-19 is one to also be aware of. So next question, a chest X ray shows consolidation consistent with a right middle lobe pneumonia. The patient is allergic to flucloxacillin. What would comprise the management plan for this patient with acute exacerbation of CO PD and associated pneumonia? Please answer the poll. Ooh, we've got a bit of a split here. Let's go up to about 10 responses and then I'll, then I'll answer anybody else before I answer. Ok. So the majority have gone for D so the answer would be d ok. So this person's allergic to flucloxacillin, meaning they can't have amoxicillin. Ok. So the only other alternative would from this set would be Clarithromycin and you need to give a five day course of pred at 30 mg OD because this is an exacerbation of CO PD, they're gonna be inflammatory, meaning you need to cover them with pred alongside the antibiotics. So with nice guidelines, antibiotics are only considered if there is signs of clinical pneumonia or purulent sputum. So if you don't have purulent Sputum and there's no clinical symptoms of pneumonia or no radiological evidence. Then you actually don't give antibiotics. But most of the time with this presentation, you'd blast them with antibiotics and give them a course of pred. And this is what a mid, a mid, a right middle lobe of pneumonia looks like it can be a bit nasty and sputum. Really. If it's a tiny bit yellow or green, then you're treating it as an infection. Ok. Right. Next question, 56 year old female presents to a local A&E department complaining of progressively worsening, chest pain and fever shows you her most recent sputum sample which appears red and jam like she has a past medical history of liver cirrhosis and consumes 30 units of alcohol every two days. Chest X ray is completed and you observe a cavitating consolidation in the right upper lobe. What organism do you think is most? Um, what is the course? Ok. So we've got quite a few of gone for sea. Any other takers? Ok. I think we have a clear winner here. So the answer is Klebsiella pneumonia. So Klebsiella is probably one of the most disgusting and resistant bugs ever to live in hospitals and it's most commonly associated with alcoholics and pneumonia. So if the question has um, s er, hemoptysis and alcoholic, then with a pneumonia, consider klebsiella because that is most commonly associated. Um, Klebsiella is quite difficult to treat and has got a very high mortality and what it tends to do is it cavitate, it causes abscesses within the lung. Um, and, and also it's found a lot in your urinary system. It can follow aspiration and it's classically associated with red currant jelly. Sputum not to be mixed with red currant jelly stools, which is associated with interception red currant. Jerry sputum is classically associated with klebsiella and it's a gram negative bacilli, meaning it's a collar form. So it's a mucoid, er, a mucoidy encapsulated endotoxin forming bug, which is commonly found in the gut. Ok. So if you've got klebsiella, then you really need to blast someone with antibiotics and this is what a lung abscess looks like. So if you look on the um on the chest X ray, which has little arrows, um it's showing this sort of rim of air around and it's called like it looks like a cavitating, um looks like a circle that is an abscess forming. So if you have fluid around and you've got a um an air fluid level, then that shows that there's a um an abscess there. Ok. And that will need draining. So, next question, a 75 year old male presents to local A&E department complaining of a cough, lethargy and fever. So, the symptoms followed a flu like illness. Now complains that his hands get very pale and cold when walking his dog, which is important on examination, he looks unwell and he's got conjunctivi conjunctivi pallor. You observed target like lesions which is really important on his legs with associated breathing, er bruising on his torso. He explains these lesions have been there for a while but thought nothing of it. You order a chest X ray and observed bilateral consolidation. So what instead of what bug, what investigation would you do? So there's a couple of hints in this question alluding to the bug which is causing it. So think about what bacteria and then think about the test you would do for said bacteria. OK. So we've got some A's some Ds, some es anybody else. OK. We've got now ac OK. So we've got a bit of a mixed bag here. So what gives it away is the two things? Number one target like lesions, which is a dermatological inflammatory condition associated with this bug. And we've got the very pale and cold hands when walking his dog. So both of these are se clearly of having the bacteria and the bacteria in question is mycoplasma pneumonia and you classically do serology testing for this bug and it's the reason why. So the morphology of this bug is really complicated. OK. Mycoplasma, it says it in the name. So Myco meaning is called like a fungi sort of wa um er cell wall, meaning it doesn't have a classic peptide to Glycon cell wall and that then allows it to mediate immune responses and evade innate immunity. So, and actually act quite parasitic a bit like mycobacterium, which is in the TB family. Ok. And this has clinic clinical features which are considered unique. So it's incredibly c resistant because it lacks our walls. It causes epidemics every four years in textbooks, it's got a longer duration of disease. And you get this flu like prodrome before you get a cough. And classically, it causes bilateral consolidation. So it's not just loc localized to, to one lobe. And the the complications you get are called agglutinin autoimmune hemolytic anemia. So basically, when this patient's hands were cold, you get a Raynaud's phenomenon, meaning you, you actually get an autoimmune reaction to the red blood cells which allow it to hemolyze. So that's why it goes red pale and it's classically associated with an autoimmune response from mycoplasma pneumonia due to type two hypersensitivity. And the only way to test for this is by doing a direct Coombs test. The Coombs test is looking for hemolysis or hemolytic anemia. Ok. And you'd also do a cold agglutinin test. So when um so when it's at cold temperatures, classically, four °C hemolysis occurs. So that's when agglutination occurs as well. Ok. And the target like lesions is known as erythema multiform and there's a difference between multiform and nodosum multiform is superficial whilst nodosum is to do with the fat inflammation inside. So, multiform is on the l on the surface. Um and nodosum is further down and erythema nodosum is classically associated with autoimmune conditions such as Crohn's, it's associated with TB pregnancy. Whilst erythema multiform is associated with mycoplasma and pneumonia and sensitivity reactions. Ok. So those were the two complications seen in the question and they're the most common. You get a rather rare things like bullous me meringis. Um You can also get Guillain Barre syndrome with this er bug meningoencephalitis, er, cardiac involvement, it causes a whole load of things due to it not having a cell wall mediating autoimmune responses. Hence why you'd have to do serology for this. Um For this meaning you just take a blood sample and send it off for mycoplasma called um serology. Ok. They usually respond to macrolides or clarithromycin. Uh um and this is what multiform looks like and this is what hallucination happens. So at four °C, the red blood cells basically clump together cos they're hemolyzed right. Next question. So, slightly different. A 25 year old male has just come back from holiday in Spain, feeling miserable. That is a really big sign, by the way. So if you've read this question, you should n sort of know what bug it is already. He has developed a new dry cough. His vitals are about 8 8% heart rate is 55 and he's got a temperature of 39 °C. Ok. Think about that relation be between the heart rate and the temperature you omit for bloods, which reveals a lymphopenia, lft derangement and really importantly, hyponatremia patient is confused. Er, you order a chest X ray which shows a pleural fusion. What um what investigation are you gonna do? So, I'll give you a clue. We've already done serology. So it's not gonna be that. Ok. So we have, we have quite a few A S. You got some BS, got some C's got some A S. Ok? So you got to split between A&E. Ok. So the big hint here is this heart rate and the temperature. Now, do you think a heart rate would be low if their temperature is sky high, it probably wouldn't be, they'd be tachycardic. So it's a bit weird that his heart rate's a bit low and some bacterial or syndromes actually have this relationship. It's called relative bradycardia, ok? And there are a couple of bugs which do it and this bug definitely does it alongside another one which will come on to later. Um And the other thing which is really important is this low sodium. So this here is legionnaires's disease. So the test for legionella pneumophila is urinary antigen. So, well, to everyone who got a. So legionella pneumophila classically causes legionnaires's disease. That is your full blown pneumonia and clinical syndrome. There is a milder version called Pontiac fever and this bug is classically associated with relative bradycardia, meaning you've got a low heart rate in the presence of a very high temperature, your lymphocytes are depleted. So you got lymphopenia therefore, your adaptive immune system is basically slowed and you also get a low sodium, OK? Which causes confusion and that's really important because people with low sodium can get very poorly and very confused. So you need to treat that and transmission is usually via water. So ac water tanks, if someone's been on holiday and it stays in a hotel with dodgy ac or water from elsewhere, then this is where it can colonize. Ok. Um, so always think of legionnaires' disease if it's got a weird lab results and derangement in their LFT S it and using these. Ok. And they've been abroad and this is what it looks like. So it's a bit patchy around the right sort of sort of upper middle lobes. There is an ever so slight, um, pleural effusion on the left, there's a meniscus sign there ever so slight. It's very patchy though. And there's some, um, there's some fluffiness around the cardiac border. So this would be, um, this would be consistent with legionella and you treat it with macroides such as Clarithromycin, other pneumonias to be aware of pneumococcal pneumonia is the, the most common cause of community acquired pneumonia and it is caused by streptococcus pneumonia. Ok. Um, classically, it's um associated with something called herpes labialis, which is basically cold sores. So, if you've got cold sores and pneumonia, think strep pneumo, you also get this really rusty co um sputum, which is associated with pneumo. Um strep. Ok. And staphylococcal pneumonia, the only thing to remember for exams is if they had flu and then they get pneumonia, then it's staphylococcal pneumonia. Just remember that. Ok. So a 21 year old female presents an, an animal review at a local hospital. She's got CF and she's currently being treated on a pediatric respiratory specialist unit for the management of CF. Um, recently she has been having, um, exacerbations of a bronchiectasis which has led her to be having more admissions. But she also informed you that she's been visiting another patient on a CFCF ward who she has had feelings for. So, what organism are you most cons or organisms are you most concerned about regarding a recent inpatient admissions? And I kid you not this, this is a, this can be a real scenario. OK. So we've got one person with fatigue, OK? Now we got half, half a b anybody else before I answer. OK. So we've got the majority come for a, the way I remember this is the most resistant bacteria which we probably have in hospitals and one of them is pseudomonas. OK? And then the other is Burkholderia, which some people have not heard of. But Burkholderia is a very resistant organism which is found um in hospitals and respiratory wards. So basically pseudomonas and bronch um and Burkholderia, they are really resistant bacteria which colonized in people of the lungs of people who got CF and bronchiectasis. OK. And the reason why this is very high yield is you have to counsel patients, uh CF patients um regarding cross infection. So if two patients have got CF, you actually can't have them socializing around each other because they're commonly colonized with these two organisms. There was a film which was like a love romance thing between two CF patients. I can't remember the name of the film but that this is sort of alluding to that. And the reason why it's really important is that these two organisms, if you're colonized with these is a contraindication to lung transplant. So they can't have a lung transplant. So it's very important that these people are not colonized with them because they probably won't ever get rid of them. You can give nebulized tobramycin, which is for pseudomonas. But again, they are gonna be colonized with these because they're resistant to every bug. Ok. Now, for bronchiectasis, the most common bacteria is hemo hem hemohim a bit like CO PD. So if you have a question where someone's got bronchiectasis and you've got a flare up or something, then think Hemophilus influenza. If you've got CF think pseudomonas and this is what pseudomonas genoa. Um, chest infection looks like it's nasty, it's cavitating. So you've got another abscess right here, which is in the right upper lobe, you can see the difference between the air and the fluid and the consolidation. It's just really, really nasty and people just don't people just die from it and this is Burkholderia. So Burkholderia causes an upper lobe pneumonia. And again, people just really can't get rid of it because it's so resistant. Now, Curb 65 you need to know this inside out because Curb 65 is basically um you need to know the values because it'll come up in questions. Ok. So in the community, you take the U away because you can't do point of care testing for urea. So it's just C RB 65. So confusion you can um would be rated less than eight on the A MT S scale. So basically, if they look a bit confused and delirious, you can just score them for that respiratory rate above 30 BP 9060 then above 65. OK? And if, and, and depending on what score they do, um they, what score they score um then they, it warrants whether they need hospital admission. Some places also have point of care. C RP testing and if it's above 100 they all need antibiotics, but it's not routine in the U. So most GP practices don't have this in hospitals, you just add the urea. So the urea cut off is seven to score. And if they're low risk, you give one antibiotic. If it's high risk or sub risk moderate, then you'd wanna give a combined therapy. So usually an amoxicillin or a betalactam is stable antibiotic such as piperacillin and tazobactam which is Tazo and you add on Clarithromycin, right? So a 35 year old male presents to his local GP with worsening exertional dyspnea. Very important and a persistent dry cough, not wet. Um, he's also been experiencing night sweats, weight loss and fluctuation fever. He's got H I HIV, which is not well controlled with heart. Heart is highly, um, uh, highly active antiretroviral therapy, which is basically antivirals and his CD four count is less than 200. You send him to a hospital for a chest X ray which shows a pneumothorax. Otherwise, it looks pretty much normal. What is the most likely cause of his symptoms? The most important thing here is the exertional dyspnea HIV and CD four C less than 200. Ok. So I think we've got a unanimous. See. Yeah. So PCP, Pneumocystis pneumonia. It used to be known as Pneumocystis Carini. Hence why it was called PCP. But everyone knows it is Pneumocystis and it is basically a yeast like fungus and it's most common and is most common opportunistic infection in HIV slash AIDS or any immunocompromised. So, if someone's got a CD four count, which is less than 200 that technically means they are going into the AIDS criteria. Um So therefore, they will need um antibiotic prophylaxis because they're more likely to acquire um infections such as fungi, parasites and um yeasts and protozoan, et cetera because your CD 4h um T helper cells allow your adaptive immune system to work. Ok. And PCP classically is associated with exertional dyspnea. In other words, as soon as they start walking around, they drop their SATS, a dry cough TB is always wet. Whilst PCP is always dry, um they usually have a normal chest X ray but sometimes you'll get a pneumothorax, sputum culture. You never do because it's futile. The cla the gold standard is a bronchoalveolar lavage. Ok? But that's quite invasive and you, the stain for this is silver. So you use a silver stain and you'll look for little cysts which are present as a yeast. And the management for any exams is cotrimoxazole, which is trimethoprim and sulfADIAZINE. Ok? If they are allergic to trimethoprim have got a problem with folate, then you can give pentamidin if severe. And basically this is what a silver stain looked like. Uh looks like. So you've got these little cysts which are all blue little cysts and they're all yeasts and this chest X ray actually looks pretty normal. So don't be fooled. Ok. Next a bit different. Now, a four year old boy has come to see au with his parents for s same day referral from his GP in the morning and he's already received um Im Benzyl penicillin at the GP. So that should give you a massive clue of how sick this patient is. The patient does not look warm and well perfused and is irritable in pediatrics, pediatricians, class kids as irritable or miserable, miserable is good, irritable bad. Ok. Kids are miserable when they're ill, but if they're irritable, that means they're not Rous. Ok. And that means they're very unwell on examination. The boy has a disseminated nonblanching rash. Huge clue. And, um, does not, er, cooperate when examining papillary reflexes, um, positive chronic sign and you start antibiotics. What is most likely cause for his symptoms? I'll split between A and B como sieve. Ok. So we've got a majority of these and that would be correct. So this here is meningococcal septicemia. The big um clue is the tech rash, the non blanching disseminated rash. So meningitis is really important. If you don't know how to recognize meningitis, then please go away and find out because this pote this will kill. Ok. So early features very, you know, very vague prodrome, headache, fever, abnormal skin color, ok? Meaning they're going slightly septic or going a bit gray. Uh late features, meningism. So it's a triad of three things, nuchal rigidity, which is neck stiffness, photophobia can't see lights and these um and they get quite um hurt or scared of lights and headache. Ok. If you have those three things, think meningitis or um irritation of the meninges. So Koenigs sign. So a Kernig sign is when it's basically a straight leg raise and when you stretch, do a straight leg raise and push, then it's actually stretching the meninges, meaning they're going to be irritated So if you've got meningeal irritation and you do a Koenig sign, they will jump up because they're in so much pain. Ok. B Brizin signs. That's more textbook quite. I've never seen it in real life. I've seen a Koenig, but I've never seen BRZ Insys just learn it for exams. Ok. Um, they will be coming in and out of consciousness. So, have a decreased G CS. Some of them will have focal C NS signs. So such as a um a third nerve palsy or an eye palsy, some of them will be seizuring like febrile convulsions and then some will be an Opisthotonos. Opisthotonos is meningeal irritation. It basically is arching of the back. You usually see it in um, in Tetanus. Ok? Er Tech rash. This is the thing which um all mothers will know of and you can ask this over the phone. It's called the glass test. So basically put a glass over the rash and if it's, if it disappears, it's not tei so it's fine. If it does not disappear, then it's probably blood, meaning you have to rule out meningococcal septicemia. And this. Ok. So I thought the most co most common cause is in kids is um ha frenzy. How do I differentiate the cause? Right. Ok. So in kids for meningitis it's the most because people are vaccinated against Neer meningitis and also um streptococcus pneumonia. Um haemophilus influenza is seen. It's not the most common though. Um I, it's, it's just, it's, it's an incidental but, ok, so three bugs can cause meningitis commonly. And that's h influenza strep, pneumo and, er, nice meningitis. So, if, if you suspect any, if you suspect this syndrome, think always rule out nice meningococcus first because that's the one which is gonna kill, um, because it causes septicemia, the others are not going to kill us rapidly. Ok. So on the left this is Opisthotonos and then on the right, this is Koenig's and Brisen Skis. Ok. So meningitis, if you have a patient with suspected meningitis, you have to pretty much do all the tests into the sun. You do af you do a full septic screen, meaning you do all of their bloods in so normal bloods, but also do a coag because coagulation screen will see if they've got any bleeding di fes because um a sepsis will cause deranged clotting. So, and these people will need a lumbar puncture at some point. So it's really good to get a coag, ok? Blood cultures and whole blood PCR. So if you've got someone with suspected meningococcal septicemia, you don't straight away lumbar puncture them because it's actually contraindicated because they're septic. So if you went to bleed, if you went to lumbar puncture them, they could actually bleed into the spinal cord cos they're septic and therefore cause paralysis and compression. So the first thing you do is you take blood cultures and you do a whole blood PCR for Neera meningococcus and that will be quicker. You do an ABG or VBG to see lactase and oxygenation. You take throat swabs. So you do one for bacteria. One for virology, cos there are viruses which cause meningo um encephalitis. You do a chest X ray. Not first though, you consider HIV and TB test for immunosuppression and if stable and no signs of increased ICP or intracranial pressure, you do a lumbar puncture within one hour. But if there is any signs of ICP or um septicemia, you don't, you don't um do lumbar puncture, you just basically pump them full of antibiotics and I'll get onto the antibiotics in a minute. I'm gonna ask the next question. This four year old boy has been started on empirical antibiotics but is awaiting blood cultures and whole blood PCR relevant bloods. Your senior asked you to perform a lumbar puncture in the meantime. So which is not an absolute contraindication to perform a lumbar puncture in this patient. So, thinking about what I've said when you don't do a lumbar puncture, try and rule it out C for Paul, please. Ok. You've got a mixed bag at the moment. Ok. So you're a split between A and C. So let's go through them. So B is disseminated intravascular coagulation. So this is basically a bleeding disorder where you clot and bleed at the same time. Therefore, you, you wouldn't wanna lumbar puncture someone for this? Ok. Um sixth nerve palsy is a sign of increased ICP. It's actually one of the first signs of raised ICP. And um um it's actually prior to third nerve palsy cos the sixth nerve runs. Um It's one of the longest. So therefore, it's gonna be more affected by ACP. So that's, that would be um an absolute contraindication. Cushing's triad is a mixture of bradycardia hypertension and basically erratic breathing, um or er respiratory dysregulation. So that is a sign of raised ICP. Um So we're really stuck between A and C. So A or spit sign, if you don't know what that is, is actually bleeding when you take um A S um psoriasis plaque off. So it's nothing to do with the brain or anything. So, Auspitz sign is actually the answer. Meningococcal septicemia, you wouldn't do a lumbar puncture straight away. You'd actually just start them on empirical antibiotics and do a whole blood PCR first. So a bit about lumbar puncture as juniors and as you're doing a neurosurgery um rotation or anesthetics, you won't be doing lumbar puncture, but it's really important to know. So this is what the anesthetists do contraindications. Ok. According to nice Meningococcal septicemia is a contraindication that use blood cultures and PCR meningococcus burst be. And then senior decision. Ok. So if you've got any raised ICP, any bleeding disorders site infections or if you've got significant kyphosis or scoliosis, most common side effects of a um of a lumbar puncture is classically a postspinal headache and nausea. So people, because you've basically drained CSF, they get a low pressure headache, meaning that the ventricles within your brain are just not filled to capacity with CSF. Therefore, you get just this horrible, um, colicky sort of headache and it just continues. So the way to treat it is actually laying flat. Um So your, so your, um, CSF doesn't drain too quickly. CSF, leak repair if it's still, um if it's still leaking analgesia and actually coffee, caffeine is really good at this. It's, I don't know, don't ask me why, but caffeine is a really good er solution. Um If you've got any issues with like paraia of the legs, um epidural hemorrhage and very, very rare is something called a des arachnoiditis where the dura mater and the arachnoid mater basically stick to each other. Ok. Next. So a 55 year old female presents the a and with a progressively worsening headache, fever, and neck stiffness. So that should give you a clue that this is meningism. She has recently um had a chest infection has been experiencing vertigo alongside diplopia and blurriness on examination, you elicit an abducens nerve deficit and signs of meningism. The past medical history is consistent with HIV, which is poorly controlled. So what would be pathognomic for this? So, what would you see on a lumbar puncture? So, think about what is the most common cause of meningoencephalitis in HIV and When's the polls up? You can answer. Ok. So we've got 50% DS. Maybe you go half, half DNE. Ok. So we're pretty much, half, half the DNA. So if you think HIV and meningitis, you have to think of all the immunocompromised uh pathogens out there and the most common cause of meningitis in someone who's immunocompromised is a lovely little fungus, um which is known as Cryptococcus Neoformans. Ok. So you get to see classically on India ink in capsule yeasts. Ok. So, cryptococcus Neoformans is a fungus. You need to just if you have HIV and and a headache and meningitis, think cryptococcus, it causes um abducens nerve deficit and it's usually um got a prom of flu like symptoms, et cetera. So India ink which is like purple. If you put that on a slide and you see a little yeast, then it's um you know, it's cryptococcus. Ok. Lumbar puncture interpretation. So basically, um if you have a look at this, I'm not gonna explain all of it, but this is just a really good table which summarizes what you're looking for. Um The important things I'm gonna note is look at the polymorph and lymphocytes opening pressure and glucose. Ok. So, viral is pretty much going to be normal for most things, but the protein is gonna be elevated and the lymphocytes which are adaptive to immunity is gonna be markedly increased. Ok. Fungal is very similar to TB, it comes out with this fibrin web, which is very, very rare by the way. But the difference being TB is a glutton for glucose. It will decrease it a lot in your CSF. There cos it's, it's mighty chunky, it wants to eat everything. So the glucose is very, um very low and the cultures for TB is different to a fungus. Ok. So this is a nice little table show in the most common bugs which cause bacterial meningitis according to age group. So, neonates, the most common is group B streptococcus or strep um agalactiae um alongside listeria which is found in milk. Um And then everything pretty much from there on is IVE for the big three. So nice meningitits, streptococcus, pneumoniae and homophile influenza. If they're immunocompromised, think listeria, everyone forgets listeria, but listeria can be a pretty nasty bug if left. So just think um if you're concerned. So now we're going on to empirical antibiotics. So someone's got bacterial meningitis with uh caused by group B strep. Which of the following should you administer? Now, think of the age range of this patient? Ok. That should be a clue. All right. Ok. So we've got some Benzyl pen. Ok. We got quite a few Benzyl pen for quite a few A as well. Some bees. Ok. So this question can be quite confusing. Cos some people will think it's the treatment for basically um uh group B strep in pregnant women, which is actually different to a meningitis caused by group B strep. So for group B strep which is colonized and causing like um peri partum sepsis or anything like that or pupal fever, you would give Benzyl pen, but this is a meningitis in a neonate. So, the classic meningitis antibiotics is cefotaxime or Kef trioxone. So if this patient was three months old and above, then it would just be cefotaxime or cefTRIAXone on its own. But because of the risk of listeria, you need to cover them with ampicillin or amoxicillin. So the right answer is B so you use cefotaxim and ampicillin gentamicin is an awful antibiotic. It's using gram negatives for like urosepsis, usually urine. Um and like endocarditis. I hate it. It's a horrible um um antibody cos you have to monitor it because it ba basically packs your kidneys in and causes deafness. So the correct answer would be B and this here is a nice little B NF recommendation. OK. So I'm not gonna explain all that. Um But class um classically in exams, um A question regarding prophylaxis for contacts will be um will maybe an a a question. So historically, Rifampicin which is atb drug was used for people were just not tolerating it. So it's actually ciprofloxacin now and that would be for contact. So, read the question, um read the question carefully. If it says prophylaxis, then it'd be ciprofloxacin. Um You can use dexamethasone, dexamethasone is a steroid, a strong potent corticosteroids which basically would um it reduces cerebral edema and it reduces the rate of neurological, securely, post meningitis. So, the most common being sentine neural deafness. So it just reduces the risk of that. But you do not use this in meningococcal septicemia, sepsis, decreased immunity or anything like that because it'll just destroy your immune system. It suppresses your immune system. Ok. So you wouldn't do that. You'd give dexamethasone say in a strep pneumo meningitis or a haemophilus influenza meningitis, but not meningococcal. Or if they're overly septic. If the patient is penicillin allergic, um or cephalosporin allergic, then you'd use chloramphenicol. Ok. Right. 35 year old male recently been working in Sub Saharan Africa presents with a worsening headache and fever. He's got meningism, no indications of raised ICP. You conduct a lumbar puncture and this is what you see. Can anybody tell me what the correct answer is according to this lumbar puncture, I'll give you clearly opening pressure is high. So, ok, so we've got a split between B and D. Ok. Anything else? Ok. So, pretty much we've got mostly DS and that would be correct. So TB is um endemic in regions of the sub Saharan Africa. And if you look at the lumbar puncture, number one, it's yellow, it's a bit mucky. Um There is a predominance for lymphocytes over polymorph. So, polymorph such as neutrophils are common in neonates. Lymphocytes are more neuro adaptive. So TB evades the innate system because it's got, it basically got a very weird cell wall. So therefore, lymphocytes have to play in. So therefore, there's more, it's got a majority for lymphocytes, opening pressure. TB is a big bacteria. So therefore, it's gonna increase the opening pressure. Um As I said, TB is a glutton for glucose. So it's got very, very low glucose here. And if you look at the cultures, AZN stain is basically the same as an acid fast bacilli stain. So ZN stands for Zeel Nielsen stain. And that's a stain you use for TB and my um and mycobacteria. So this is tuberculosis meningitis. Now TB is a very fascinating bacteria. It's one of my favorites actually. And it basically is elusive and it's a killer. OK? It's been here since the, the ancient Egyptians and they used to call it consumption because it basically consumes you. So you lose weight, you, you basically are all the cancer signs plus hemoptysis. So it basically consumes you and it just eats you away and it's a vile bacteria, but it's very interesting how it works. OK? Most people have actually got latent TB. So if you do a chest X ray and sometimes you can find something called a G complex, that means they've just got latent TB. Um And then which means it's not active. So it's just sitting there. OK? But when it gets activated, when you're immunocompromised, for example, then it caused it causes havoc, it goes everywhere So, um TB can be disseminated to your lungs. So, hemoptysis, classically, you get something called a rasmin aneurysm, which is on which is pathognomic for TB. You only see it in TB and that's the type of aneurysm in the pulmonary artery. And you get upper lobe sclerosis. Classically, it can spread away from your lungs, it can go elsewhere, so you can go to your brain, it can go to your spine, which is pots disease. It can go to your cervical lympho, er um your lymph nodes here which causes a condition called scrofula. It looks vile. Um it can go everywhere called milly and it can also even go to your bladder and your genitals, ok. It goes everywhere. Um and it's classically got those b symptoms such as fatigue, night sweats, fever, weight loss diagnosis is if you have um latent, the test is a mon too tubercular skin test and this is the one you have before the BCG vaccine. It's basically puts in a bit of the protein of the cell wall underneath your skin. And if you react to it, then you have the BCG. OK? And if you're sensitive to it, IG ra S are basically assays, you can use them for TB. But really the gold standard is a sputum culture. You actually need to grow it OK. Management TB. Drugs come up all the time and the management really is two months of all four and then followed by four months of two of them. Ok. I'll go onto the TB drugs in a minute. The BCG vaccine is about 70% accurate. Um and it's sorry, 70% effective. Um And interestingly, you can still get TB with the BCG vaccine. Ok. But the BCG vaccine is also used in bladder cancers. So do read up on that cos it's quite interesting how it works. So this here, OK. If you have a look, this is bilateral hilar lymphadenopathy and it's only seen in either TB or sarcoidosis. Ok? And this is what it looks like and it's causing little GME complexes which is basically little pockets um of um of tuberculosis. Now, as you can see in the spine, this is go where the um if you've got the spine, um the vertebrae there, it's a different color on MRI, that's all TB infection. So that's called Pott's disease. These little balloon things is called a ramus and's aneurysm. And then the on the Far right. Um the child here is called Scrofula. So this is sural lymphadenitis and then this is really important. So, wipes is how you remember the acronym for TB um for TB drugs. So, Rifampicin really strong antibiotic. It's nephrotoxic um and it classically causes red, orange bodily secretions. So your tears, your sweats, other bodily fluids go orange, isoniazid, isoniazid, um depletes your vitamin B6 and it will basically causes peripheral neuropathy as a side effect. So, if you want to re treat that you can give B vitamin B6 which is perox er pyridoxine pyrizinamide. It causes gout ethamp butal it causes optic neuritis. So every single person will have to have eye tests, visual acuity tests, et cetera. Right. Next one, a 27 year old female has got HIV presents with uh to A&E with confusion and headache. Her most recent CD four count is 100 and 50. That means she's in the eight criteria and she is not compliant with her therapy. CT scan reveals a ring enhancing, sorry, ring enhancing lesion. What do we think it is? Clue B in the ring and hand ciliation and you take it at all? Ok. So we've got a mixture between D and E. Mhm Me. Oh, we can do better than full responses. I'll give you that is a difficult question. Definitely. OK. So most people have gone for e which is actually the correct answer. So basically this person's in the age criteria. Ok. And now they've had a CT scan which shows that they've got CT contrast which is going in rings in your brain. I mean, I'll show you what that looks like in a minute. And out of these really the only two which cause these sort of lesions ringing Hansen lesions is either a lymphoma which is more prevalent in HIV and AIDS and toxoplasmosis and toxoplasma. Gondi is a protozoan which is seen um in cat feces actually. Um so, and I'll show you. Yeah. So toxoplasmosis is a prosome parasite. Ok. And it's in normal uh I immunocompetent people. It causes a mild flu like illness. But in people who have got risk factors such as immunosuppression or pregnancy, it actually can cause havoc. So it's one of the torch organisms in pregnancy, torch being um bacteria and viruses, et cetera which cause congenital defects. Toxoplasmosis causes um congenital birth defects such as sentinel hearing loss, cataracts, et cetera. So that's why pregnant women cannot go near cat ps um or undercooked food or anything like that. Ok. So it can either be congenital. So, um it basically, um it causes um hydrocephalus damage to the eye, et cetera or it can be immunosuppressant and it's actually one of the major causes of HIV er er of um, of mortality in, in, in HIV populations. Um, and it basically causes abscesses in the brain, which is those ring enhancing lesions. Ok. Uh The diagnosis really is serology. Um and the CT and management is dependent on whether you're pregnant or not. So, if you're pregnant, you can't take sulfADIAZINE and pme um pyrimethamine because it depletes your folate. So you take spiramycin instead, but for everyone else, um, it's usually pyrimethamine with Falon acid to cover for folate and this is what it looks like. So see where the contrast is basically enhanced around as a ring around the abscess and that darkness around the ring is basically cy um is um edema. So it's cytotoxic edema from the abscess. Ok. Now you may ask how do you distinguish between toxoplasmosis and say um lymphoma because this here is ACN S lymphoma. Ok. It looks very, very similar. It's got that ring and C NS lymphoma is very common. Uh well, not very common. It's common in HIV AIDS populations. So there is this particular scan you can do. OK. And this scan here is this blue, this blue and orange um looking scan, which is a type of pet scan and it's known as SPECT OK, spect thallium scan. And it's positive. If you've got increased uptake of say a fluoroglucose marker, then it will be positive within C NS lymphoma. The lymphoma actually takes it up whilst um the toxo doesn't. So if you are confused between Toxo and lymphoma, the correct scan to get would be a spect that's quite high yield. Next 28 year old female presents A&E with increasing confusion and headache. Um had an remark uh basically unremarkable. Apart from a recent chest infection three months ago, she had a flare up of a fascicular oral rash. MRI shows temporal lobe enhancement. So what do you think is causing this? The clue really is the um physical oral rash and temporal lobe enhancement. Can I have the pole, please? Ok. You gotta make sure between B and Z OK. We've got all the bees. OK. So we've got a majority of bees which is the correct answer. So HSV one and two. So herpes simplex virus, herpes simplex causes classically fascicular sores. OK? And these can either be orally which is HSV, one or gentle, which is HSV two. OK. HSV. One. The reason why it causes a fascicular oral rash is because the virus hides within the dorsal of the trigeminal nerve. OK. That's why you get the distribution according to the nerve. So um either V 1 B2 or V three. So when people have got like herpes do ophthalmicus, that means they've got chicken pox, which is um only in, within the dorsal ganglion of, of, of, of the ophthalmic. Whilst here you get this rash because the herpes simplex resides within the dorsal ganglion of the trigeminal nerve and it's only reactivated when you're ill or you're stressed or you immunocompromised and this is basically what's happened. Ok. So this HSV one has basically flared up and because it's in such close proximity with the meninges in the brain, it it's gone and traveled up because this person's been immunocompromised. Cos they've had a chest infection, it's crossed the blood brain barrier and it's gone into the brain which is causing encephalitis. So the difference between meningitis and encephalitis is meningitis doesn't really cause confusion and confabulation. Ok. And meningoencephalitis are usually caused by viruses. Ok. Most common being HSE. So this would be a HSV one encephalitis on MRI, just to note, classically, you will see temporal lobe enhancement. So because the trigeminal nerve is situated near to the temporal lobe, that is where it goes to first. OK. And that's where you get the enhancement. I'll show you an MRI in a minute. So the most common etiology of cephalitis is HSV, cephalitis in neonates, it's HSV two because usually it's vaginal delivery. So it's close to the genitals in Children and adults, it's HSP one. Um and you can get that from say, um, kissing or, um, even just sharing drinks from people who've had cold sores. Um, it's consistent with an aseptic meningitis, aseptic, meaning there's no, it's not purulent, there's no bacteria but may come with herpetic skin. So herpes sores or mucosal lesions such as cold sores. Um, the diagnosis is really if you PCR lumbar P to the CSF and you get an MRI CT is not great because it doesn't show soft tissue as well. It's gonna be MRI and the treatment is a 21 day course of I va cyclovir. Cyclovir is an antiviral. Ok. Occasionally you'll get chicken pox or c uh cyclovirus or H HV six, which is um, roseola infantum, but these are usually associated with immuno expression HIV AIDS. Just don't worry about the whole monkey thing. It's just a, it's just a general yield thing. It's um, a bee virus which was based off the rest and Evil series is where they got the idea. So, um, it causes fatal, um, encephalitis in monkeys and this is what MRI MRI temporal lobe enhancement looks like. So you can see on the left here there is, is quite a debit which would be associated with this, right? A bit different. Now, 18 year old female presents a name of a joint pain. Just started. University. Been drinking heavily complains of dysuria, urethral discharge, offensive pus like. What do you think is the bug? OK. So you got a bit of C LD A the clue really is joint pain, offensive puss, like um urethral discharge. Ok. So surprisingly, this is actually gonorrhea. So I can see why people have put chlamydia is number one, but gonorrhea usually causes more symptoms. It's more symptomatic especially within the discharge. Ok. So if you, if you've ever seen gonorrhea, it basically causes this classic green like offensive smelly discharge. Um More symptomatic than chlamydia. Cos chlamydia is often asymptomatic and with gonorrhea, you can get a joint infection. So it disseminates. It's called um gonococcal disseminated gonococcal infection. Ok. And it goes to, it causes an arthritis. It can cause a dermatitis. Um And I'll get onto that in a minute. So, yeah, so basically, gonorrhea is a gram negative diplococci. It's the same family as Neisseria meningitidis. Ok. So that's why it's got the same gram morph morph morphology and really, it depends on males and females. So, diphtheria discharge in females, it causes inflammation of the cervix in males, inflammation of the prostate. It can also cause inflammation of the back passage and in the throat as well. Complications of gonorrhea stricture in males, it can cause a urethral stricture which can be permanent and it can cause a reactive arthritis. Meaning that you get arthritis from um like an autoimmune response and you get inflammation of the epididymis or the um all the testicles or the ovarian tubes, the fallopian tubes and diagnostics really is swab. So you need to do a swab. Um The the management of gonorrhea is actually changing. So, gonorrhea has become very resistant and it depends on where you are what trust. But if empirically, it would be one dose of im cefTRIAXone where people describe it as quite a hefty antibiotic dose. It does hurt and it's put, it's put in the bottom. Um or you can have an, a week's worth of fi and um an a um azithromycin. So gonorrhea. So this is disseminated gonococcal infection which is a classic triad of fascicular dermatitis, migratory arthritis and tinus synovitis. Basically, it causes tendon inflammation, arthritis within the joints and the skin changes. Ok, an 18 year old female presents to a local genital unary medicine clinic with dysuria increasingly with abdominal pain, denies vaginal discharge feels unwell though. She also notes that she is worried there is something um that there could be something up as she has had multiple sexual partners on speculum examination. Cervical excitation is noted and pregnancy test is negative. So the cervical excitation should give you a clue which of the following is most likely ati OK. So we got a of D anybody else. OK. So to move it on. So this, so to work this out. So vital excitation is only seen and present in two conditions, either an ectopic pregnancy or pelvic inflammatory disease. And as this person's got a negative pregnancy test, then you know, this is pelvic inflammatory disease and most commonly associated with an STD such as chlamydia. So chlamydia trachomatis, the ones which cause the STD is C um serovars D. There are other versions of chlamydia out there um such as L GV and trachoma which is in um which is seen in Africa um which causes blindness. Um but basically, it's a very weird bacteria which is intracellular and is parasitic in nature. Most often it's asymptomatic but it can cause problems. Diagnostics is um basically a nucleic acid amplification amplification test, which is basically a swab. Ok. So management is really doxycycline for seven days or one dose of azithromycin. And this here is basically perihepatitis. So if you've got basically lesions and adhesions attached to the abdominal wall, the anterior abdominal wall with the liver and this is seen in pelvic inflammatory stores with chlamydia. It is also known as Fitz Hugh Curtis, er Fitzhugh um Curtis syndrome. So not Fitzhugh Patrick syndrome, Fitz Hugh Curtis syndrome, right. 45 year old female presents with offensive smelling vaginal discharge, very selfish self conscious about it. Um She is worried that other people will judge her whilst catching her local bus. Um, she is in lo long term relationship with her husband and denies being unfaithful. Does anybody know what could be happening here? Very common. Ok. Someone's giving the answer in the chat. But what, what bacteria causes it? Ok. We got quite a few people going for aim. We got, I think one person with AC OK. So bacterial vaginosis as someone's um noted here, it is um it's actually not an STD. It's um it's sometimes associated with ST but it's actually not, it's actually to do with um vaginal ph and um local colonization of bacteria. So, the correct answer is Gardnerella vaginalis. It's C and there's a couple of other bacteria which causes it like pep pepto streptococci, but it's not as common. So, Gardnerella is the most common here. OK. And bacterial vaginosis um really is, it causes officially offensive vaginal discharge. It can be quite smelly, it's thin white, it's homogenous. You may be as asymptomatic, it's not distressing and typically you manage it with metroNIDAZOLE or topical clindamycin. Um but you have to use AMLS criteria which is basically four things to diagnose BV. Um And it does anybody know what this histology is showing, which is show as seen in BV. So this here is known as a clue cell. So a clue cell is basically, it's a cervical cell here and all the bacteria clump around it. That is classic for bacterial vaginosis. Um So it's, it's called a clue cell. And you have to follow AM sl's criteria, which is four things. So the PH has to be above 4.5. So it's not acidic. They have to have a positive whiff test which is potassium hydroxide. They have to also have the presence of clue cells and they also um have to have a thin white homogenous discharge, which is offensive. OK. And that is AMLS criteria, right? 24 year old male presents with very painful lesions on his foreskin and scrotum. They, they are very painful and they're fascicular in nature. You suspect HSV two and want to initiate management. What is the most, what is the most likely management plan? So, remember what is HSV and what can you use for it? Ok. So we've got a mixture of C and D. Now we've got A B just to speed things on cos I'm conscious of time. I'm going to get on with the answer. OK. So we mix two C and DS. So the correct answer here. So you can avoid the antibiotic, Clindamycin. OK. Conservative. No, you're not gonna do that cos you wanna treat it because this person's in a lot of pain. So topical people get usually mixed up with topical oral because this needs to get into your system. Do oral. OK? Because the HSV will be in your system. So oral acyclovir, you don't use steroids, steroids will dampen the immune system. Ok. So, oral acyclovir and this is what it looks like. Not very pleasant, but it's very, very painful. Ok? You've also get diphtheria, it's very itchy. You get lymph nodes which are raised and you could get systemic syndrome. So people feel poorly like flu, like symptoms and um and this, this rash. So diagnostics is the same as chlamydia. It was in that and management is po acyclovir. So, oral acyclovir, people tend to get relapses. So you just give a course of acyclovir. You get conservative management. Sometimes people get topical, local anesthetic which is put over it. Um and saline bath and et cetera and some opiates. Um if you're pregnant though and you've got genital herpes, you need to have an elective C section cos you don't want that baby to basically be um exposed to it through the vaginal canal. Ok. 35 year old male presents with generalized rash trunk, palms, salts began and um basically had a painless lesion on his glands. Penis. He's also describes an ongoing fever and widespread lymphadenopathy. What is the most likely diagnosis? Ok. So we've got a lot of bees A B else. Ok. We've got, we've got an E we've got ad fine. So here, the clue really is it started as a painless lesion. Now in STD, um er sort of er history taking if it's painful, think herpes is most common if it's painless, think syphilis is most common first. Ok. That's the difference. So painless, you can think syphilis. Number one, painless syphilis, it rhymes. Ok. So primary syphilis would just be the Canasa. Ok? And that's in that area. Secondary is when it actually spreads. You get a basically a maculopapular rash which goes um to your, to um to your trunk, palms and soles. Ok? And then you get systemically and well tertiary is when you get all the other sequelae such as gumma, um neurological cardiac dementia, et cetera. So that would be severe. So, this is secondary syphilis. Ok. Hand foot and mouth is more of a vesicular um rash which is caused by Coxsackie virus. And then chancroid is a painful lesion and it's a tropical lesion caused by haemophilus dre. Ok. So it's, it's quite rare here. So, syphilis, sy syphilis is known as treponema pallidum. It's a spirochaete, meaning that it's spiral. So it does, it doesn't really stain very well on gram stain. So you have to use specific um stains which, which are used, I think silver stain is one of them. Ok. So, um and they classically have this spiro spiral um form because the morphology is Spiros, it's usually not resistant. So the the classic treatment has been around for years and that is im benzathine penicillin. G so, Benzathine is a type of um additive they use with penicillin which works to get rid of syphilis. So that is the answer is penicillin G and it's just one off dose and primary syphilis is just as shaka. Then you get the secondary syphilis and then you get the tertiary, so tertiary has got all the other neurological cardiac issue. Ok. Um Be warned of something called a Yari Herx reaction. That basically means if you've had the penicillin, it breaks away the bacteria, the bacteria then release inflammatory and release antigens which then cause your system to go into a sort of a semi allergic anaphylactoid reaction. It's not anaphylaxis. You just have to be reassured by that. This, I wouldn't really worry about. This is more for like um microbiologists, other STD S so trichomoniasis. So this is trichomonas, vaginalis. It's a flagellated protozoan. It's classically, it's associated with strawberry Cervix. Ok. Um And it's, and it's seen it's a, it's an STD and it's on the rise actually in the UK, but the diagnosis really is getting it under a slide and you see the trophocyte is actually moving and the management's metroNIDAZOLE, lymphogranuloma venereum. This is a type of chlamydia. Um but it's seen a lot with HIV and er men who have sex with men and it causes basically a proctitis. Um and an er Bubo's which is really inflamed lymph glands. Ok. And management is doxycycline. So this is what it looks like. So on the left is the Bubo which is seen in L GV. And then this is strawberry Cervix, which is seen in trichomoniasis. Ok. Um A bit of gutt stuff now. Alright. So a 40 year old male who's turned from a vacation in Vietnam with crampy, ongoing abdominal pain associated water, watery, non bloody diarrhea. This has been a effect in his work life as he is opening his spouse 5 to 7 times daily for the last three months. What do you think could be the cause? The big clue here is nonbloody diarrhea and it's prolonged. So he's had it for the last three months, mixture between A and C. OK. Now we're gonna let E and between ABC and E OK, we've got more bees now. OK. So when thinking about gut infections, the way I learn it is either bloody diarrhea or non bloody diarrhea. And then you can work out the bacteria from that. So, out of these, the ones which cause non bloody diarrhea is se so, e coli e coli is a funny one cos it can also cause um hemolytic uremic syndrome cos so it can cause hemorrhage colitis, um Giardia which cause nonbloody um and the others cause bloody. So, as the two, this is Giardia. So Giardia classically causes a chronic diarrhea syndrome. And Giardia looks like this. It's basically a bit like trom trichomoniasis. It's a flagellated proto zone. You get it from fecal oral and um it causes a chronic non bloody diarrheal disease. You get the flatulence and bloating because it's, it basically causes a malabsorption syndrome and it can be, it can make you lactose intolerant, um, for a period of time, it can come back, but sometimes it's permanent. Um, the classic, um, test was actually swallowing a piece of string and letting that go to your duodenum and then taking aspirates from it, but we don't do that anymore. It's just stool sampling and looking for cysts. The management is metroNIDAZOLE. Right. So 23 year old female returned from vacation in Egypt, crampy abdominal pain associated with watery non bloody diarrhea. She's had more than three loose stools in the last 24 hours. What is the most likely diagnosis? Ok. So we've got a one day. Ok. So we've got the majority a which is the correct answer. So E coli is the most common cause of travelers diarrhea. So if you're going away and you've got some diarrhea, it's probably most likely down to E COLI. Ok. Now, to define travelers diarrhea, it has to be more than three watery sos within 24 hours with associated nausea, et cetera and you don't treat it. So it's just conservative oral rehydration therapy, right? So a 35 year old male traveling around Southeast Asia abdominal pain and he's got constipation this time. So not diarrhea, he complains of a new onset rash covering his torso. He's got a fever of 39 but his heart rate's only 55. So he's got that relative. Bradycardia. What is the bug OK. He's got one for tea. Ok. Now we're gonna mix box, we got BC and D. Ok. So we've got a bit of a mixture here. So, out of these. Ok. The ones which there's pretty much only one here which causes constipation and that is salmonella typhi. So this is typhoid fever. Ok. So, eia antico lytica causes Azumi fever which is seen in Japan. Um this is bloody diarrhea, entamoeba, histolytica causes um amoebic um liver disease. Um Ame amoebiasis, um also known as dysentery. Er shigella flex causes a dysentery as well. Campylobacter causes bloody diarrhea. So, typhoid and paratyphoid fever. So, stamina typhi or semi paratyphi, um it's a gram negative bacillus but it classically causes constipation. Um but it can cause bloody diarrhea as well. You get distention, abdominal pain and you get relative bradycardia like legionella. Um and that rash is called rose spots, which is seen really more in paratyphoid and complications because you get constipation, they can perforate. So that's really important in sickle cell. You actually get osteomyelitis with salmonella. Ok. So that's always important to um know about and the treatment really is ciprofloxacin, but there is increasing um resistance to this food poisoning. Um think about the duration. So if it's very quick onset, think staphylococcus aureus because the toxin producing and bacillus cereus. So bacillus is usually associated with rice. Ok. And then your longer ones think Giardia and amoeba. So I promise it's nearly finished. Um a 47 year old male who has known IVD U er intravenous drug user has presented a surgical assessment unit with er cellulitis. However, on examination, you notice retinal hemorrhage with a white pale center, um endoscopy and a murmur on chest auscultation. What do you think is happening? And what bug? Ok. So we got a mixture between the two stuffs. Yeah. So someone's put the answer right in, in the chart. So this is endocarditis. Yeah. So the most common cause of um infective endocarditis is staphylococcus aureus. So, but remember, um epidermidis actually lives on your skin and it's most common if you've had prosthetic valve surgery. So if they've opened you up, so if you had surgery, basically, um there are other bugs which are associated with infective endocarditis. So, streptococcus bovis is associated with um infective endocarditis. If you've got colorectal cancer, viridans is a type of streptococci and it's seen with poor dental hygiene. Ok. So the dental hygiene basically in the bug gets into your blood system which goes down into your heart and has I wouldn't worry about. Ok. And these are the things you're supposed to see on examination. But the way I learn it is if you have any of these or basically fever and a new onset heart murmur, always think endocarditis until proven. Otherwise, the whole white pale center on fundoscopy is known as a Roth spot and that's basically retinal hemorrhage and the way you diagnose endocarditis is used in something called a modified Duke criteria. And this came up in my finals actually. So the major criteria, I just learn it. Ok. But the, the essence really is you have to take three blood cultures, ok. At each temperature spike, that is basically what you're doing and then you treat accordingly. Now, endocarditis is quite complicated and depends on what um if you've got uh a native valve, your own valve or you've got a prosthetic. And then if you're penicillin, allergic et cetera, but initial therapy really is going to be a penicillin or Vancomycin. Ok. So I think this is the last question, 76 year old females been admitted due to M RSA positive cellulitis. So you've administered some antibiotics, but shortly after you've administered them, the patient's going red, what antibiotic has been given. Ok. And we've got Vancomycin. Now, you've got Tyer plan in. Now we've got some others. Tazocin, Linezolid. Ok. So if you are tasked with Red Man Syndrome, the only antibiotic which does this is Vancomycin and that is via an IV route only. So Vancomycin, it basically, if it's given IV, it releases and um, so it basically allows all your basophils to degranulate, causing histamine, systemic histamine release, which basically causes you to go red makes you hypotensive et cetera. So, always look out for it. Um, and stop the Vancomycin when it starts. Ok. But it is a known side effect. And the reason why I'm testing. That is because antibiotics have side effects classically, you know, the amoxicillins and the penicillins, they all cause um diarrhea, anaphylaxis. Um and amoxicillin specifically, if you've got Epstein Barr Epstein Barr virus, which is glandular fever virus. Um if you give amoxicillin, it causes a rash. Um So that is a good one to know um er the macrolides such as Clarithromycin, they all prolong QT interval, pro um inter qt interval. So it, you would have to do an E CG and you never prescribe it with statins because it can cause rhabdomyolysis. Ciprofloxacin, it decreases seizure threshold. So if someone's on an anti epileptic who's got epilepsy, you want to avoid it. It also causes achilles tendinopathy. So people can have an ach achilles tendon rupture with Cipro metroNIDAZOLE. You don't drink on it because it causes disulfiram effect. Disulfiram is um is a perversive um drug which gets people off of alcohol. So if you take, if you take alcohol with disulfiram, you just vomit and it's not very pleasant. So that's what Metrazole does. Doxycycline, it causes growth, stenting photosensitivity and trimethoprim think folate deficiency and that is me. I'm completely finished. So I hope that was very useful. Sorry if I ran over time, but hopefully a lot of the stuff I covered is quite high yield and I'm open to any questions. Thanks very much doctor. Well, for the informative session. Um So if anyone has any questions, please just pop in the chat. Uh I'm just gonna send the feedback link uh in the chat group. You must also have received an email as well, whichever way is easier for you. Well, I appreciate some feedback. Any questions at all? I'm open for it. Um Which question is, is there a particular question, Heather or I can, I mean, the presentation you can have, so they usually have the answers straight after the present uh after the question. So, yeah, you can share the presentations, right? I think that's it. Yes, I will. Thank you very much. Thank you very much. Yes. So we will send that, um, to you if you'd like that or anyone else as well. Just let us know we can send the uh powerpoint. Thank you. Yeah, I think you'll be able to have the presentation and the recording should be available in the middle.