Year 3 Infectious Diseases

For a patient undergoing an elective splenectomy, when is the optimal time to give the pneumococcal vaccine?

2 weeks before surgery Following a splenectomy patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus* infections Vaccination if elective, should be done 2 weeks prior to operation Hib, meningitis A & C annual influenza vaccination pneumococcal vaccine every 5 years Antibiotic prophylaxis penicillin V: unfortunately clear guidelines do not exist of how long antibiotic prophylaxis should be continued. It is generally accepted though that penicillin should be continued for at least 2 years and at least until the patient is 16 years of age, although the majority of patients are usually put on antibiotic prophylaxis for life

Patient has cyclical fever and headache, splenomegaly. Diagnosed as Plasmodium vivid malaria. Given chloroquine and primaquine. Why primaquine given?

Destroys liver hypnozoites and prevents relapse Generatly occurs in vivax and oval

A 5-year-old male presents to your GP clinic with mumps. You inform the father that mumps is a notifiable disease and requires you to contact the Local Health Protection Team. He asks why this is and which diseases this applies to. Which of the following can you tell him is an example of a notifiable disease?

Acute meningitis NOT HIV Basically anything infectious

Plasmodium ovale generally found in?

Africa

The Bangladeshi parents of a 12-year-old boy come for advice. They have recently emigrated to the UK and have been advised that he should have the BCG vaccine for tuberculosis by immigration officials. He is well and asymptomatic. What is the most appropriate next step?

Arrange for him to have a tuberculin skin test (to exclude past exposure to tuberculosis) prior to giving the vaccine. Vaccine administration - given intradermally, normally to the lateral aspect of the left upper arm - BCG can be given at the same time as other live vaccines, but if not administered simultaneously there should be a 4 week interval

A 32-year-old woman presents to the GP 4 days after returning from Haiti, she has had a fever and chills on and off for the last day. She is admitted to the hospital and diagnosed with falciparum malaria Given her specific diagnosis, which of the following is the most appropriate treatment for her condition?

Artemether used for tx of falciparum malaria Chloroquine is used as a first-line treatment for non-falciparum malaria and not falciparum malaria. Plasmodium falciparum causes nearly all episodes of severe malaria. The other three types, of which Plasmodium vivax is the most common, cause 'benign' malaria The protection from malaria that sickle-cell trait offers is well documented. Other protective factors include G6PD deficiency HLA-B53 absence of Duffy antigens

Non- falciparum malaria treatment?

Artmisinin-Based combination therapy or chloroquine If chloroquine resistance then ACT Avoid ACT in pregnancy

A 34-year-old man is diagnosed as being HIV positive. He was born and brought up in the United Kingdom and is currently fit and well with no past medical history. At what point should anti-retroviral therapy be started?

At the time of diagnosis Do not wait for the CD4 count to drop Entry inhibitors (CCR5 receptor antagonists) maraviroc, enfuvirtide prevent HIV-1 from entering and infecting immune cells by blocking CCR5 cell-surface receptor Nucleoside analogue reverse transcriptase inhibitors (NRTI) examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir general NRTI side-effects: peripheral neuropathy zidovudine: anaemia, myopathy, black nails didanosine: pancreatitis Non-nucleoside reverse transcriptase inhibitors (NNRTI) examples: nevirapine, efavirenz side-effects: P450 enzyme interaction (nevirapine induces), rashes Protease inhibitors (PI) examples: indinavir, nelfinavir, ritonavir, saquinavir side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition indinavir: renal stones, asymptomatic hyperbilirubinaemia ritonavir: a potent inhibitor of the P450 system

A 15-year-old boy is diagnosed with glandular fever. What is the most appropriate advice to give regarding playing sports?

Avoid contact sports for 8 week after having glandular fever

A 23-year-old man gets crampy abdominal pain with vomiting and diarrhoea overnight. The previous evening he had a takeaway curry with rice. What is the likely causative agent of his gastroenteritis?

Bacillus cereus Overview vomiting prominent occurs c. 1-6 hours after eating often due to rice

A man presents with severe vomiting. He reports not being able to keep fluids down for the past 12 hours. You suspect a diagnosis of gastroenteritis and on discussing possible causes he mentions reheating curry with rice the night before. What is the most likely causative organism?

Bacillus cereus = reheated rice Two types of illness are seen vomiting within 6 hours, stereotypically due to rice diarrhoeal illness occurring after 6 hours

A 27-year-old woman presents with painful genital and oral ulceration. Her past medical history includes treatment for a deep vein thrombosis three years ago.

Beech's disease Oral ulcer, genital ulcer, uveitis

An 18-year-old university student has come to see you about the results of triple swabs that she had done for a yellow vaginal discharge. Microscopy has shown 'intracellular Gram-negative diplococci'. She is fit and well otherwise with a negative pregnancy test. What treatment regime would you initiate?

Ceftriaxone 500mg IM + azithromycin 1g oral Gonorrhea Features males: urethral discharge, dysuria females: cervicitis e.g. leading to vaginal discharge rectal and pharyngeal infection is usually asymptomatic Microbiology immunisation is not possible and reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

Plasmodium vivax generally found in?

Central America and Inda

A 40-year-old man is admitted to the intensive care unit following a severe episode of acute pancreatitis. On the third day of his admission he becomes pyrexial. A septic screen is ordered including cultures taken from both peripheral blood and the internal jugular line. There is no signs of infection on the chest x-ray or urine sample. The microbiology laboratory phone to report signs of bacterial infection in the sample from the central line. What is the most likely organism to be isolated?

Central lines = Staphylococcus epidermis Staphylococcus aureus • Coagulase-positive • Causes skin infections (e.g. cellulitis), abscesses, osteomyelitis, toxic shock syndrome Staphylococcus epidermidis • Coagulase-negative • Cause of central line infections and infective endocarditis

An 18-year-old male started university 2-weeks ago. This is the first time he has been away from home. He presents to his GP due to an abnormal penile discharge and pain during urination. These symptoms began 1-week ago. On inspection, there is abnormal discharge around the urethral meatus. Which organism is most likely responsible for causing the patient's symptoms?

Chlamydia trachomatis - commonest bacterial sexually transmitted in the UK Features asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria Potential complications epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome) Investigation traditional cell culture is no longer widely used nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique Screening in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years relies heavily on opportunistic testing Management doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice 'following discussion of the balance of benefits and risks with the patient' patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

A 19-year-old woman is found collapsed during her gap year in Bangladesh. She has had a 2-day history of profuse watery diarrhoea and is now severely dehydrated, the doctors consider if she has cholera. Which of the following features could also be associated with this diagnosis?

Cholera - vibrio cholerae, Gram -ve bacteria - diarrhea - hypoglycemia Cholera is an infection most commonly associated with foreign travel, specifically to areas in Africa, Asia, the Middle East and South America. It can also be associated with shellfish in these areas. Cholera can cause many metabolic abnormalities including hypokalaemia, hypoglycaemia, and metabolic acidosis. Features profuse 'rice water' diarrhoea dehydration hypoglycaemia Management oral rehydration therapy antibiotics: doxycycline, ciprofloxacin

A 36-year-old male comes into your clinic with an 8-hour history of a red painful leg. He was jogging in the park when he cut himself on a branch. On examination, his left leg is tender and warm. You diagnose cellulitis and ask the patient if he has any allergies. He responds that he developed a widespread rash to amoxicillin when younger. What antibiotic do you prescribe?

Clarithromycin

A 45-year-old female presents to the Emergency Department three days after returning from Thailand complaining of severe muscle ache, fever and headache. On examination she has a widespread maculopapular rash. Results show: Malaria film: negative Hb 16.2 *109 g/dl Plt 96 *109/l WBC 2.4 *109/l ALT 146 iu/l What is the most likely diagnosis?

Dengue fever Viral infection progress to viral haemorrhagic fever (also yellow fever, Lassa fever, Ebola) Basics transmitted by the Aedes aegyti mosquito incubation period of 7 days a form of disseminated intravascular coagulation (DIC) known as dengue haemorrhagic fever (DHF) may develop. Around 20-30% of these patients go on to develop dengue shock syndrome (DSS) Features causes headache (often retro-orbital) fever myalgia pleuritic pain facial flushing (dengue) maculopapular rash Treatment is entirely symptomatic e.g. fluid resuscitation, blood transfusion etc

Which one of the following viruses is associated with nasopharyngeal carcinoma?

EBV: associated malignancies: Burkitt's lymphoma Hodgkin's lymphoma nasopharyngeal carcinoma HIV-associated CNS lymphomas

Which one of the following causes of gastroenteritis has the longest incubation period?

Giardiasis

A 55-year-old business man presents with a 15 day history of watery, non-bloody diarrhoea associated with anorexia and abdominal bloating. His symptoms started 4 days after returning from a trip to Pakistan. On examination he is apyrexial with dry mucous membranes but normal skin turgor. What is the most likely causative organism?

Giardiasis is caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route Features often asymptomatic lethargy, bloating, abdominal pain non-bloody diarrhoea chronic diarrhoea, malabsorption and lactose intolerance can occur stool microscopy for trophozoite and cysts are classically negative, therefore duodenal fluid aspirates or 'string tests' (fluid absorbed onto swallowed string) are sometimes needed Treatment is with metronidazole

A phlebotomist gives herself a needlestick injury whilst taking blood from a patient who is known to be hepatitis B positive. The phlebotomist has just started her job and is in the process of being immunised for hepatitis B but has only had one dose to date. What is the most appropriate action to minimise her risk of contracting hepatitis B from the needle?

Give an accelerated course of hepatitis B vaccine and hepatitis B immune globulin Hepatitis B HBsAg positive source: if the person exposed is a known responder to HBV vaccine then a booster dose should be given. If they are in the process of being vaccinated or are a non-responder they need to have hepatitis B immune globulin (HBIG) and the vaccine unknown source: for known responders the green book advises considering a booster dose of HBV vaccine. For known non-responders HBIG + vaccine should be given whilst those in the process of being vaccinated should have an accelerated course of HBV vaccine

A newly qualified staff nurse at the local hospital undergoes vaccination against hepatitis B. The following results are obtained three months after completion of the primary course: Result Anti-HBs: 10 - 100 mIU/ml Reference An antibody level of >100 mIU/ml indicates a good immune response with protective immunity What is the most appropriate course of action?

Give one further dose of hepatitis B vaccine The features of hepatitis B include fever, jaundice and elevated liver transaminases. Complications of hepatitis B infection chronic hepatitis (5-10%) fulminant liver failure (1%) hepatocellular carcinoma glomerulonephritis polyarteritis nodosa cryoglobulinaemia Anti-HBs level (mIU/ml) Response > 100 Indicates adequate response, no further testing required. Should still receive booster at 5 years 10 - 100 Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required < 10 Non-responder. Test for current or past infection. Give further vaccine course (i.e. 3 doses again) with testing following. If still fails to respond then HBIG would be required for protection if exposed to the virus

A 31-year-old man from Russia who is known to be HIV positive presents with purple plaques on his skin. Which of the following viruses is thought to be the cause of Kaposi's sarcoma?

HHV-8 Kaposi sarcoma Kaposi's sarcoma caused by HHV-8 (human herpes virus 8) presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract) skin lesions may later ulcerate respiratory involvement may cause massive haemoptysis and pleural effusion radiotherapy + resection

A 24-year-old patient has had a sexual encounter and is concerned about his risk of acquiring a sexually transmitted Infection (STI). He has had one incidence of unprotected sex in the last 3 months - a homosexual encounter with a new, asymptomatic male partner, during which they both engaged in anilingus (oro-anal sex). They did not have penetrative sex.

Hepatitis A - associated with sexual transmission during anal-oral sex

A 19-year-old woman presents with multiple painful blisters and ulcers around her labia. She has been feeling like she has the flu for the past five days. It is extremely painful when she urinates.

Herpes simplex

A 32-year-old man is brought in to the emergency department by his girlfriend. She describes him as behaving very unusually towards her over the past two days, being increasingly confused and disorientated. His girlfriend also noticed some jerking movements which she believes were seizures. He has no past medical history of note and is not taking any medications. His observations are as follows: Temperature: 39ºC Blood pressure 124/76mmHg Heart rate 103/min Respiratory rate 13/min There is no rash, neck stiffness or focal neurology present. He has not had any foreign travel recently. CSF analysis reveals a high protein, normal glucose, and a predominance of mononuclear cells. Which of the following is the most likely causative organism for this presentation?

Herpes simplex virus Most common cause of viral encephalitis Sudden change in behavior and fever, and seizure. No neck stiffness, or headaches, or CSF results.

A 31-year-old woman presents to the Emergency Department complaining of a headache. She has had 'flu' like symptoms for the past three days with the headache developing gradually yesterday. The headache is described as being 'all over' and is worse on looking at bright light or when bending her neck. On examination her temperature is 38.2º, pulse 96 / min and blood pressure 116/78 mmHg. There is neck stiffness present but no focal neurological signs. On close inspection you notice a number of petechiae on her torso. She has been cannulated and bloods (including cultures) have been taken. What is the most appropriate next step?

IV cefotaxime Meningococcal meningitis Investigations suggested by NICE full blood count CRP coagulation screen blood culture whole-blood PCR blood glucose blood gas Lumbar puncture if no signs of raised intracranial pressure

A 53-year-old lady comes in to the Emergency Department with a cough productive of green sputum and palpitations. She feels very unwell, feverish and lethargic. On examination she has bronchial breathing at her right base with respiratory rate 25/min, sats 95% on room air. Her heart sounds are normal with an irregularily irregular heartbeat. Her heart rate was 120/min and blood pressure 90/40 mmHg. An ECG shows atrial fibrillation with a fast ventricular rate. She has no history of atrial fibrillation. What is the first treatment that should be given?

IV fluids - septic from a pneumonia - AF - no previous history - IV antibiotics 'sepsis six' should be started straight away: 1. Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD) 2. Take blood cultures 3. Give broad spectrum antibiotics 4. Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes 5. Measure serum lactate 6. Measure accurate hourly urine output

Which one of the following is true regarding Escherichia coli infection?

Important cause of neonatal meningitis Escherichia coli is a facultative anaerobic, lactose-fermenting, Gram negative rod which is a normal gut commensal. E. coli infections lead to a variety of diseases in humans including: diarrhoeal illnesses UTIs neonatal meningitis

A 20-year-old male presents to the GP with a 10-day history of a sore throat and fever. He explains that he feels tired all the time where he is taking naps more frequently during the week. On examination, the patient has cervical lymphadenopathy. On palpation, the abdomen is non-tender and there is splenomegaly. What is the next course of action?

Infectious mononucleosis - self limiting Infectious mononucleosis (glandular fever) is caused by the Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases. Less frequent causes include cytomegalovirus and HHV-6. It is most common in adolescents and young adults. The classic triad of sore throat, pyrexia and lymphadenopathy is seen in around 98% of patients: sore throat lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged pyrexia

A 24-year-old woman is reviewed in the genitourinary medicine clinic. She presented with vaginal discharge and dysuria. Microscopy of an endocervical swab showed a Gram-negative coccus that was later identified as Neisseria gonorrhoea. This is her third episode of gonorrhoea in the past two years. What is the most likely complication from repeated infection?

Infertility Infertility secondary to pelvic inflammatory disease (PID) is the most common complication of gonorrhoea. It is the second most common cause of PID after Chlamydia.

Which one of the following vaccinations should be avoided in patients who are HIV positive?

Live attenuated vaccines BCG MMR oral polio yellow fever oral typhoid

A 52-year-old man with a history of alcohol dependence is admitted with fever and feeling generally unwell. An admission chest x-ray shows consolidation in the right upper lobe with early cavitation. What is the most likely causative organism?

Klebsiella pneumoniae Common in alcoholics

A 44 year old woman has presents with increasing lethargy and cough. She puts it down to the stress she was under at a recent conference in Spain. Since then she has felt feverish and lethargic with a cough starting two days ago. She has no past medical history but admits to recent unprotected sexual intercourse. Chest x-ray shows bi-basal consolidation. Blood tests are as follows: White cell count 12 * 10^9/l Haemoglobin 135 g/l CRP 145 mg/l Sodium 125 mmol/l Potassium 4.7 mmol/l Alanine Transaminase 87 IU/l What organism is responsible?

Legionella pnuemophilia Legionella pneumonia often occurs in outbreaks centred around a communial water supply. This is alluded to in this question by the recent conference in Spain. It also frequently leads to a bi-basal pneumonia as demonstrated in the question. In addition, Legionella often causes a hyponatraemia and deranged liver function tests. This are shown in this question. Hyponatraemia can often lead to the patients presenting confused but this is not mentioned in this particular question. Features flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients Diagnosis urinary antigen Management treat with erythromycin

A 34-year-old sewage worker presents with a 3 days history of lower back pain, fever, myalgia, fatigue, jaundice and a subconjunctival haemorrhage. He has no past medical history and has not been abroad in the last 6 months. Na+ 135 mmol/l K+ 5.2 mmol/l Urea 10 mmol/l Creatinine 180 µmol/l What is the most likely diagnosis?

Leptospirosis Sewage workers at risk Features fever flu-like symptoms renal failure (seen in 50% of patients) jaundice subconjunctival haemorrhage headache, may herald the onset of meningitis Management high-dose benzylpenicillin or doxycycline

A 45-year-old woman presents with a 3 day history of fever, myalgia and fatigue 1 week after returning from Kenya where she was visiting relatives. On examination she has mild jaundice and splenomegaly of 4cm. What is the most likely diagnosis?

Malaria Splenomegaly and jaundice are commonly seen in malaria and people travelling to malaria areas to visit friends and relative are often the most at risk as if they were born in a country with high levels of malaria they may believe they still have immunity and so don't take antimalarials.

A 13-year-old boy is admitted to the orthopaedic ward following an operation to internally fixate his fractured femur. It is day 6 post-op and the nurse has called the Foundation Year 1 doctor as the patient has spiked a temperature overnight at 38.9ºC. On assessment the patient's respiratory rate is 30/minute, heart rate 135 bpm, blood pressure is 126/76 mmHg and the patient has a productive cough. What is the most appropriate management option?

Piperacillin with tazobactam Late onset hospital acquired pneumonia. Should be treated with antipseudomonal beta-lactam penicillin

A 29-year-old woman is admitted with to the Emergency Department. She has a one week history of cough and has become increasingly short of breath over the past two days. This has been accompanied by fever, headache, anorexia and 'cold chills'. On examination she is slightly pale and slightly confused. Her pulse is 134/min, blood pressure 94/62 mmHg, respiratory rate 30/min and oxygen saturations are 90% on room air. There are reduced breath sounds in the right lower lung was some coarse crackles. You cannulate her and take blood cultures. A nurse has applied high flow oxygen and is setting up the fluid challenge you have prescribed. What is the most appropriate next step?

Pneumonia = septic Prescribe broad spectrum IV antibiotics This patient is likely to have pneumonia and has become septic as a consequence. She has a number of signs of 'red flag' sepsis including her heart rate, confusion and respiratory rate. She should therefore have the 'sepsis six', including intravenous antibiotics, as soon as possible. For every hour that intravenous antibiotics are delayed there is an 8% increase in mortality.

A 17-year-old female presents to the GP with a 3-day history of fever, low-grade back pain and rigors. Additionally, she has noticed that she has to go to the toilet more frequently. She has a past medical history of asthma and type 1 diabetes mellitus (T1DM) which are both well controlled. With her likely diagnosis, what is the most common causative agent of this condition?

Pyelonephritis Most commonly caused by E coli Young females have the highest incidence of pyelonephritis. As well as this her symptoms and previous diagnosis of T1DM point towards this diagnosis. E coli is by far the most common organism that causes pyelonephritis. Any organism that can ascend up the genitourinary tract can cause pyelonephritis, the other answers are all causes but not the most frequent.

The phlebotomist in a GP surgery sustains a needlestick injury whilst taking blood from a patient who is known to be HIV positive. Following thorough washing of the wound what is the most appropriate management?

Refer to Emergency Department and oral antiretroviral therapy for 4 weeks HIV a combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) as soon as possible (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) for 4 weeks serological testing at 12 weeks following completion of post-exposure prophylaxis reduces risk of transmission by 80%

A 19-year-old female returns from Ghana. She presents with pyrexia (40°C). She complains of bloody stools preceding this. On examination, she has abdominal distension, hepatosplenomegaly and rose spots on her abdomen. Before empirical treatment has started she passes away due to bowel perforation, resulting in overwhelming sepsis. Which organism is responsible for this type of pathology?

Salmonella typhi Features initially systemic upset as above relative bradycardia abdominal pain, distension constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid Possible complications include osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens) GI bleed/perforation meningitis cholecystitis chronic carriage (1%, more likely if adult females)

A 42-year-old woman is admitted to hospital with pyrexia and a productive cough. Around 10 days ago she developed symptoms consistent with a flu-like illness. For around 4-5 days she was in bed with myalgia, fever and lethargy. Initially there was an improvement in her condition but over the past three days she has developed a cough productive of thick pink-yellow sputum. On examination there are scattered crackles in the right base. A chest x-ray confirms pneumonia. Which one of the following organisms is more common in patients who have recently had influenza?

Staphylococcus aureus Co-prescription of flucloxacillin to the standard antibiotic (amoxicillin)

Which organism is most likely to cause osteomyelitis in children with sickle cell disease?

Staph aureus most common cause overall - diabetes - IVDU - immunosuppression due to meds or HIV - alcohol excess Salmonella - most common cause in sickle cell patients Ix: MRI Tx: flucloxacillin for 6 weeks Clindamycin if penicillin allergic

A 29-year-old woman develops severe vomiting four hours after having lunch at a local restaurant. What is the most likely causative organism?

Staphylococcus aureus food poisoning

A 75-year-old male with a long history of intravenous drug use is admitted with fevers, rigors and back pain. Three sets of blood cultures taken at admission grow positive for gram positive cocci in clusters. He is suspected of having Staphylococcus aureus bacteraemia and is commenced on intravenous vancomycin. Half an hour after the infusion is commenced, he is noted by the nurse to be flushed. On examination, he is noted to have erythema over his neck, face and trunk but denies any significant distress or discomfort. His observations are as follow: blood pressure 125/70 mmHg, heart rate 85/min, temperature of 36.8ºC, respiratory rate of 18/min and oxygen saturation of 98% on room air. Which of the following is the most appropriate management?

Stopping the vancomycin infusion until symptoms resolve and then re-starting at a slower rate. Vancomycin is a glycopeptide antibiotic used in the treatment of Gram positive infections, particularly methicillin-resistant Staphylococcus aureus (MRSA). Mechanism of action inhibits cell wall formation by binding to D-Ala-D-Ala moieties, preventing polymerization of peptidoglycans Mechanism of resistance alteration to the terminal amino acid residues of the NAM/NAG-peptide subunits (normally D-alanyl-D-alanine) to which the antibiotic binds Adverse effects nephrotoxicity ototoxicity thrombophlebitis red man syndrome; occurs on rapid infusion of vancomycin

A 23-year-old man presents with an ulcer on the coronal sulcus of the penis. The ulcer is not causing him any discomfort. On examination an ulcer with an erythematous border and a clean base is found.

Syphilis

A 39-year-old woman initially presented with a chest infection but deteriorated despite antibiotics and is now in ITU. She has had a bronchoscopy and bronchio-alveolar lavage which confirmed a diagnosis of invasive aspergillosis. Which of the following is the strongest risk factor for this condition?

TNF alpha inhibitor use Immunocompromised patient Invasive aspergillosis is a systemic Aspergillus infection (Aspergillus fumigatus, Aspergillus flavus, and Aspergillus terreus) that is a leading cause of death in immunocompromised patients. Risk factors include: HIV Leukaemia Following broad-spectrum antibiotics

A patient presents to their GP 2-days following a 1-month volunteering trip to sub-Saharan Africa. They have been feeling very feverish recently and have recorded their temperature to be above 38.0ºC on several occasions. They report feeling very tried recently. They appear jaundiced. On examination they have a tender abdomen. On performing a blood test you discover the patient is hypoglycaemic and has a low platelet count. The diagnosis is confirmed on performing a blood-film. What is the most likely cause of the underlying diagnosis?

The most likely underlying diagnosis is malaria. This is most commonly associated with Sub-Saharan Africa (about 85% of all cases). It cause symptoms such as fever, hepatosplenomegaly, diarrhoea and jaundice. It is also associated with anaemia, thrombocytopaenia rosetting of red blood cells and auto-agglutination of RBCs. Severe signs of malaria include acidosis and a parasitaemia >2%. The commonest cause of malaria is Plasmodium falciparum. P. ovale and P. malariae are less common causes of malaria.

You are asked to see a 31-year-old woman on the labour ward who has developed a high fever (39.1ºC) 2 days post-partum. She complains of dysuria, and frequency, you suspect a urinary tract infection. She is choosing to breast feed, has severe anaphylactic reactions to penicillins. Which antibiotic would be appropriate?

Trimethoprim - present in milk but no known to be harmful Mechanism of action interferes with DNA synthesis by inhibiting dihydrofolate reductase Adverse effects myelosuppression transient rise in creatinine: trimethoprim competitively inhibits the tubular secretion of creatinine resulting in a temporary increase which reverses upon stopping the drug

Ezal is a 54-year-old Syrian refugee who has recently been diagnosed with tuberculosis (TB) after experiencing fevers and haemoptysis. The consultant informs him he will have to start on a regime of 4 medications to treat his TB. She tells him he must first do a few tests, prior to starting treatment. Which set of investigations below are most appropriate for this patient?

Urea and electrolytes, LFT, vision testing, FBC The medication regime is Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol. We need to have baseline LFTs as all drugs in the regimen are hepatotoxic. We test Us and Es to monitor electrolyte disturbances and any elevation in Creatinine as a result of treatment. We need a baseline visual assessment as Ethambutol can cause loss of vision. We need an FBC as a baseline, and to assess for platelet count which can be important in the context of hepatotoxicity. We do not need a Urine dip. Rifampicin does turn urine and tears orange-red but should not cause derangement of urine tests.

You are reviewing a 31-year-old man in the liver clinic. He is currently on triple therapy for hepatitis C. What is the best way to assess his response to treatment?

VIral load Pathophysiology hepatitis C is a RNA flavivirus incubation period: 6-9 weeks Transmission the transmission risk needle stick injury is about 2% the vertical transmission is about 6%. The risk is higher if there is coexistent HIV breast feeding is not contraindicated in mothers with hepatitis C the risk of transmitting the virus during sexual intercourse is probably less than 5% After exposure to the hepatitis C virus only around 30% of patients will develop features such as: a transient rise in serum aminotransferases / jaundice fatigue arthralgia Investigations HCV RNA is the investigation of choice to diagnose acute infection whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies