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Question 1
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A 68-year-old man presents for follow-up after being hospitalized for erysipelas of his leg. He was feeling ill and needed intravenous antibiotics. He is now finishing his course of oral antibiotics. He has no reported allergies to medications.
What medication is expected to be prescribed?Your Answer: Flucloxacillin
Explanation:For individuals with cellulitis or erysipelas, an antibiotic is necessary. These conditions are characterized by acute inflammation and swelling, with erysipelas having more superficial lesions with a distinct raised margin.
When selecting an antibiotic, consider the severity of symptoms, the location of the infection, the risk of complications, and previous antibiotic use. If the individual was admitted to the hospital due to systemic illness, oral flucloxacillin is the preferred treatment for erysipelas. However, co-amoxiclav should be used for cellulitis near the eyes or nose.
Ciprofloxacin should only be used for specific indications due to its association with Clostridium difficile infection. Doxycycline is not the first choice, and if there is a penicillin allergy, clarithromycin or erythromycin should be used instead of flucloxacillin for erysipelas or cellulitis.
Erythromycin is not the first-line choice, but it may be appropriate if there is a history of penicillin allergy.
Antibiotic Guidelines for Common Infections
Respiratory infections such as chronic bronchitis and community-acquired pneumonia are typically treated with amoxicillin, tetracycline, or clarithromycin. In cases where atypical pathogens may be the cause of pneumonia, clarithromycin is recommended. Hospital-acquired pneumonia within five days of admission is treated with co-amoxiclav or cefuroxime, while infections occurring more than five days after admission are treated with piperacillin with tazobactam, a broad-spectrum cephalosporin, or a quinolone.
For urinary tract infections, lower UTIs are treated with trimethoprim or nitrofurantoin, while acute pyelonephritis is treated with a broad-spectrum cephalosporin or quinolone. Acute prostatitis is treated with a quinolone or trimethoprim.
Skin infections such as impetigo, cellulitis, and erysipelas are treated with topical hydrogen peroxide, oral flucloxacillin, or erythromycin if the infection is widespread. Animal or human bites are treated with co-amoxiclav, while mastitis during breastfeeding is treated with flucloxacillin.
Ear, nose, and throat infections such as throat infections, sinusitis, and otitis media are treated with phenoxymethylpenicillin or amoxicillin. Otitis externa is treated with flucloxacillin or erythromycin, while periapical or periodontal abscesses are treated with amoxicillin.
Genital infections such as gonorrhoea, chlamydia, and bacterial vaginosis are treated with intramuscular ceftriaxone, doxycycline or azithromycin, and oral or topical metronidazole or topical clindamycin, respectively. Pelvic inflammatory disease is treated with oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.
Gastrointestinal infections such as Clostridioides difficile, Campylobacter enteritis, Salmonella (non-typhoid), and Shigellosis are treated with oral vancomycin, clarithromycin, ciprofloxacin, and ciprofloxacin, respectively.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 2
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A 15-year-old boy has coryzal symptoms, conjunctivitis and a rash suggestive of measles.
Select the single correct statement regarding notification of this disease to the relevant public health authorities.Your Answer: Notification can be made on clinical suspicion
Explanation:The Importance of Speed and Accuracy in Notifying Infectious Diseases
Infectious disease control relies on the prompt identification and containment of outbreaks. To achieve this, doctors are required to provide identifying information to the Proper Office of the Local Authority for patients with notifiable infectious diseases. However, laboratory staff are not currently obligated to do so. The notifications system prioritizes speed in detecting outbreaks, with accuracy of diagnosis being secondary. Salivary surveillance schemes exist for measles, mumps, and rubella, but recent data shows low incidence compared to the number of notifications submitted. Prompt and accurate notification is crucial in preventing the spread of infectious diseases.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 3
Incorrect
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A 50-year-old nun returns from a trip to Nigeria with fever and deranged LFTs. She has an ALT of 2500 U/l and bilirubin of 75 μ mol/l. She was fully vaccinated before travel. She also took mefloquine malaria prophylaxis.
Select the single most likely diagnosis.Your Answer: Hepatitis A
Correct Answer: Hepatitis E
Explanation:Hepatitis E: A Likely Diagnosis for Abnormal Liver Function Tests
Abnormal liver function tests can be caused by various factors, but in this case, hepatitis E is the most likely diagnosis. While hepatitis A vaccine is effective in preventing hepatitis A, it is not the cause of the patient’s symptoms. Acute hepatitis B is less likely as it is transmitted through blood or sexual contact. Malaria and dengue fever may also cause abnormal liver function tests, but not to the extent seen in this patient.
Hepatitis E is a viral infection that is acquired through the faeco-oral route. Unlike hepatitis A, it has no chronic form but has a higher mortality rate of 1-2%. Pregnant women in their last trimester are at a higher risk of death from hepatitis E. Outbreaks of hepatitis E are more common in developing countries.
It is important to note that both hepatitis A and E can cause fulminant liver failure in patients with underlying liver disease. Therefore, prompt diagnosis and treatment are crucial in managing these conditions.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 4
Incorrect
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influenza is a viral respiratory illness that can cause mild to severe symptoms and can lead to complications such as pneumonia.
Your Answer: Vaccine must be repeated yearly because the immune response is short-lived
Correct Answer: Aerosol transmission can occur before the onset of symptoms
Explanation:Understanding influenza: From Epidemics to Pandemics
influenza, commonly known as the flu, is a highly contagious respiratory illness caused by influenza viruses. The incubation period of influenza is typically two days, but can range from one to four days. Aerosol transmission may occur one day before the onset of symptoms, making it easy for the virus to spread.
Up to 15% of the population can develop influenza in any given year, with an average of 50-200 GP consultations for influenza or flu-like illnesses per 100,000 of the population per week. An epidemic is declared when the GP consultation rate for new cases of influenza or flu-like illness exceeds 400 per 100,000 population per week.
Clinicians usually diagnose influenza based on clinical criteria alone when the virus is circulating in the community. Investigations are typically reserved for community surveillance purposes.
The influenza virus undergoes minor mutations to one or both of its surface antigens, known as antigenic drift. This causes seasonal epidemics, where people have only partial immunity from previous infection or vaccination. As a result, the vaccine requires annual changes.
An influenza pandemic is an epidemic of an influenza virus that spreads on a worldwide scale and infects a large proportion of the human population. This occurs due to the emergence of influenza A virus that is genetically significantly different from the circulating human influenza A viruses, known as antigenic shift. These pandemics occur irregularly, with the 1918 Spanish flu being the most serious pandemic in history with a high mortality.
Understanding the nature of influenza, from its epidemics to pandemics, is crucial in developing effective prevention and control strategies.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 5
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A 28-year-old man presents to his GP with complaints of joint pain and swelling, feeling generally unwell. He recently returned from a hiking trip in Thailand, and one day after his return, he experienced severe watery diarrhoea and abdominal cramps that lasted for a week.
During the examination, the patient appears unwell and fatigued. He has large effusions of the left knee and right ankle, along with tender plantar fascia bilaterally. Additionally, he has tender metatarsophalangeal joints on both feet, and a papular rash on the soles of his feet.
Despite taking regular paracetamol and ibuprofen for the past week, the patient's symptoms have only minimally improved. What is the most appropriate next step in managing this patient, given the most likely diagnosis?Your Answer: Oral prednisolone
Explanation:Reactive arthritis doesn’t usually have an acute onset and can develop up to four weeks after the initial infection. It may have a relapsing-remitting course over several months.
The correct treatment for this patient’s severe polyarthritis would be oral prednisolone, a systemic corticosteroid. The dosing should be based on the severity of the arthritis, with tapering to the lowest effective dose. Typical starting doses are 20-40 mg/day.
TNF inhibitor therapy would not be appropriate in this case. However, it may be effective and safe for patients with reactive arthritis who are unresponsive to NSAID or non-biologic DMARD therapy.
Celecoxib is not the correct choice for this patient. Since regular ibuprofen did not provide relief for a week, the next step would be oral corticosteroids. Although patients may require high doses of NSAIDs with a long half-life, such as Naproxen 500mg BD, systemic corticosteroids are more appropriate for this patient with multiple joints involved and systemic illness.
Intra-articular injections are useful for large joint effusions, but in this case, systemic corticosteroids are more appropriate due to the patient’s multiple joint involvement and systemic illness.
Understanding Reactive Arthritis: Symptoms and Features
Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).
This condition is defined as an arthritis that develops after an infection where the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease.
The arthritis associated with reactive arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis. Other symptoms include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles).
To remember the symptoms associated with reactive arthritis, the phrase can’t see, pee, or climb a tree is often used. It is important to note that the term Reiter’s syndrome is no longer used due to the fact that the eponym was named after a member of the Nazi party. Understanding the symptoms and features of reactive arthritis can aid in prompt diagnosis and treatment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 6
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A new case of Chickenpox has been reported at the daycare yesterday. A mother attends with her 4-year-old son and is anxious because she is going away for a week’s holiday on the next day. She wonders how soon her son will develop symptoms.
Select from the list the option within which the incubation period for Chickenpox lies.Your Answer: Medium (7-21 days)
Explanation:Understanding Incubation Periods and Latent Periods in Diseases
Incubation period refers to the time between exposure to a pathogenic organism and the onset of symptoms. This period can range from minutes to even 30 years, depending on the disease. Latent period, on the other hand, is the time from infection to infectiousness. While the two terms may be synonymous, a distinction is sometimes made between them.
Examples of diseases with short incubation periods include norovirus, influenza, and scarlet fever. Diseases with medium incubation periods include roseola, measles, and pertussis. Mumps, erythema infectiosum, and rubella have long incubation periods, while infectious mononucleosis and hepatitis A have extra-long incubation periods. Hepatitis B has an incubation period greater than six weeks.
Clinical latency occurs in diseases like AIDS, where people infected with HIV may not show any symptoms or signs of AIDS despite having a large viral load. It is important to understand incubation and latent periods in diseases to prevent their spread and manage their symptoms effectively.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 7
Incorrect
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Sarah is a 28-year-old woman who comes to the emergency department after being bitten on the hand by a dog while walking in the park. She has a laceration on her left index finger which is bleeding. There is no visible foreign object and the wound appears clean. She is stable and has no other medical issues. Her last tetanus shot was 2 years ago.
What is the most probable treatment that Sarah will receive?Your Answer: A rabies vaccine
Correct Answer: Broad spectrum antibiotics
Explanation:It is not advisable to administer post-exposure prophylaxis for HIV after being bitten by a human. Since the wound is free from contamination and the individual received a tetanus shot 4 years ago, there is no need for a tetanus booster.
Post-Exposure Prophylaxis for Viral Infections
Post-exposure prophylaxis (PEP) is a preventive treatment given to individuals who have been exposed to a viral infection. The type of PEP given depends on the virus and the clinical situation. For hepatitis A, either human normal immunoglobulin or the hepatitis A vaccine may be used. For hepatitis B, the PEP given depends on whether the source is known to be positive for HBsAg or not. If the person exposed is a known responder to the HBV vaccine, then a booster dose should be given. If they are a non-responder, they need to have hepatitis B immune globulin and a booster vaccine. For hepatitis C, monthly PCR is recommended, and if seroconversion occurs, interferon +/- ribavirin may be given. For HIV, a combination of oral antiretrovirals should be given as soon as possible for four weeks. The risk of HIV transmission depends on the incident and the current viral load of the patient. For varicella zoster, VZIG is recommended for IgG negative pregnant women or immunosuppressed individuals. The risk of transmission for single needlestick injuries varies depending on the virus, with hepatitis B having a higher risk than hepatitis C and HIV.
Overall, PEP is an important preventive measure for individuals who have been exposed to viral infections. It is crucial to determine the appropriate PEP based on the virus and the clinical situation to ensure the best possible outcome.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 8
Incorrect
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A 30-year-old woman with a history of epilepsy and currently taking sodium valproate is found to have a urinary tract infection. Which antibiotic should be avoided if possible?
Your Answer: Nitrofurantoin
Correct Answer: Ciprofloxacin
Explanation:Understanding Quinolones: Antibiotics that Inhibit DNA Synthesis
Quinolones are a type of antibiotics that are known for their bactericidal properties. They work by inhibiting DNA synthesis, which makes them effective in treating bacterial infections. Some examples of quinolones include ciprofloxacin and levofloxacin.
The mechanism of action of quinolones involves inhibiting topoisomerase II (DNA gyrase) and topoisomerase IV. However, bacteria can develop resistance to quinolones through mutations to DNA gyrase or by using efflux pumps that reduce the concentration of quinolones inside the cell.
While quinolones are generally safe, they can have adverse effects. For instance, they can lower the seizure threshold in patients with epilepsy and cause tendon damage, including rupture, especially in patients taking steroids. Additionally, animal models have shown that quinolones can damage cartilage, which is why they are generally avoided in children. Quinolones can also lengthen the QT interval, which can be dangerous for some patients.
Quinolones should be avoided in pregnant or breastfeeding women and in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Overall, understanding the mechanism of action, mechanism of resistance, adverse effects, and contraindications of quinolones is important for their safe and effective use in treating bacterial infections.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 9
Incorrect
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A 30-year-old office worker has come to the clinic with a painful swollen face that has developed over 24 hours. He is particularly swollen in the parotid area on the left. He has a fever of 38.2oC. He also has malaise, headache and has lost his appetite.
What is the most probable diagnosis?Your Answer: Parvovirus infection
Correct Answer: Mumps
Explanation:Mumps: Symptoms, Complications, and Differential Diagnosis
Mumps is a viral infection that is rare in vaccinated individuals but can affect those who have not been vaccinated or exposed to the virus. The onset of mumps can be sudden, and one-third of cases present with unilateral parotitis. Unlike parotid adenomas, which develop slowly, mumps is characterized by acute inflammation of the parotid gland. Glandular fever, on the other hand, typically affects the neck glands and is often accompanied by a sore throat. In children, parvovirus can cause slapped cheek syndrome, which is characterized by nonspecific viral symptoms followed by the appearance of firm red cheeks a few days later. Sialadenosis, a generalized swelling of the glands, is associated with hypertrophy of the acinar component of the gland and is commonly seen in individuals with systemic diseases such as Sjogren syndrome. Complications of mumps can include epididymo-orchitis, viral meningitis, pancreatitis, and, in rare cases, myocarditis. It is important to differentiate mumps from other conditions with similar symptoms to ensure proper diagnosis and treatment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 10
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A 23-year-old woman with stable sickle cell anaemia presents with an erythematous rash all over her body, which is associated with painful swollen joints. On examination she has clinical signs of anaemia. The full blood count shows absent reticulocytes in the peripheral blood.
Which pathogen is most likely to have caused her symptoms?Your Answer: Parvovirus B19
Explanation:Parvovirus B19 Infection: Symptoms, Transmission, and Complications
Parvovirus B19 infection is a common viral illness that is primarily spread through respiratory droplets, but can also be transmitted through contaminated surfaces. Children between the ages of 6 and 10 are most commonly affected, with up to 70% of the population having been infected by the age of 20. Susceptible adults can also become infected, often through exposure to the virus from their own children. Epidemics tend to occur every 4-5 years, with peak infection rates in the winter and spring.
The most common symptom of parvovirus B19 infection is erythema infectiosum, a rash illness characterized by a red rash on the face and extremities. The rash typically appears 17-22 days after exposure to the virus and is preceded by mild fever and fatigue. In addition to the rash, more than 80% of adults with parvovirus B19 infection experience joint pain and swelling, particularly in the small joints of the hands and feet. A positive test for parvovirus B19-specific IgM indicates current or recent infection.
While parvovirus B19 infection typically doesn’t cause significant anemia in individuals with normal red-cell lifespan and function, it can lead to a more severe form of anemia called aplastic crisis in individuals with shortened red-cell lifespan, such as those with sickle-cell anemia. During the acute phase of aplastic crisis, there is a lack of reticulocytes in the blood and erythroid aplasia in the bone marrow. However, recovery is typically marked by the presence of reticulocytosis and giant pronormoblasts in the bone marrow.
In summary, parvovirus B19 infection is a common viral illness that can cause a range of symptoms, including rash and joint pain. While typically not severe, it can lead to complications in individuals with certain medical conditions.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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