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  • Question 1 - A 75-year-old woman arrives at the Emergency Department feeling fatigued and short of...

    Incorrect

    • A 75-year-old woman arrives at the Emergency Department feeling fatigued and short of breath. During the examination, her haemoglobin level is measured at 70 g/l (normal range: 115–155 g/l), and her serum vitamin B12 level is found to be 95 ng/l (normal range: 130–700 ng/l). Which of the following positive tests would suggest that pernicious anaemia is the likely cause of her vitamin B12 deficiency?

      Your Answer: Gastric anti-parietal cell (GPC) antibody

      Correct Answer: Intrinsic factor (IF) antibody

      Explanation:

      Autoantibodies in the Diagnosis of Pernicious Anaemia

      Pernicious anaemia is a type of megaloblastic anaemia caused by impaired absorption of vitamin B12 due to autoimmune destruction of gastric glands and loss of intrinsic factor (IF). IF antibodies, specifically type I and type II, are present in 50% of patients with pernicious anaemia and are specific to this disorder. Therefore, they can be used to confirm the diagnosis.

      Other autoantibodies, such as antinuclear antibodies (ANA) and gastric anti-parietal cell (GPC) antibodies, are not specific to pernicious anaemia but may be present in some patients. ANA is used in the diagnosis of systemic lupus erythematosus and other autoimmune diseases, while GPC antibodies occur in 90% of patients with pernicious anaemia but are also positive in 10% of normal individuals.

      Tests such as the Coombs test, which detect antibodies that attack red blood cells, are not used in the investigation of pernicious anaemia. Similarly, the immunoglobulin A tissue transglutaminase measurement is not diagnostic of pernicious anaemia but is used as the first-choice test for suspected coeliac disease in young people and adults.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 2 - A 30-year-old patient presents to your GP clinic with a spider bite that...

    Incorrect

    • A 30-year-old patient presents to your GP clinic with a spider bite that occurred 7 days ago. The patient reports experiencing pruritus, urticarial rash, erythema, lip swelling, abdominal pain, and vomiting shortly after being bitten. The patient has been taking cetirizine daily from a home supply for the past week, which has resolved all symptoms.

      What is the recommended follow-up plan for this patient?

      Your Answer: Re-assess after a further week in case of a late-onset reaction

      Correct Answer: Referral to an allergy specialist

      Explanation:

      If someone experiences a systemic reaction to an insect bite, it is important to refer them to an allergy specialist. In this case, the patient’s moderate reaction suggests the need for further evaluation by a specialist who can determine if an adrenaline auto-injector and medical identification bracelet are necessary. However, since the bite occurred 7 days ago and the patient is currently stable, there is no need to refer them to the emergency department or medical team at this time. Additionally, late-onset reactions typically occur within a few hours of the bite, so a follow-up appointment at the 2-week mark is not necessary.

      Venom allergy can cause local or systemic reactions, including anaphylaxis. Acute management is supportive, with anaphylaxis treated with adrenaline, steroids, and antihistamines. Referral to an allergy specialist is recommended for those with systemic reactions or suspected venom allergy. Venom immunotherapy may be recommended for those with a history of systemic reactions and raised levels of venom-specific IgE, but should not be performed in those without demonstrable venom-specific IgE or recent anaphylaxis. VIT has a high success rate in preventing systemic reactions and improving quality of life.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 3 - A 35-year-old teacher with a history of eczema, seasonal allergies and high blood...

    Correct

    • A 35-year-old teacher with a history of eczema, seasonal allergies and high blood pressure visits her doctor complaining of itchy hives on her arms after wearing latex gloves for 30 minutes. She reports no difficulty breathing or facial swelling. Her vital signs are within normal range.
      What is the probable mechanism involved in this case?

      Your Answer: Immunoglobulin E (IgE)-mediated hypersensitivity

      Explanation:

      Types of Hypersensitivity Reactions and Their Characteristics

      Hypersensitivity reactions are immune responses that can cause damage to the body. There are different types of hypersensitivity reactions, each with their own characteristics.

      Immunoglobulin E (IgE)-mediated hypersensitivity is a type of reaction that involves the release of antibodies against an antigen, resulting in mast cell degranulation and the release of inflammatory mediators. This type of reaction is characterized by the presence of weals and occurs within one hour of contact with the allergen. Atopic individuals, such as those with asthma and hay fever, are more susceptible to this type of reaction.

      Delayed-type hypersensitivity reactions produce symptoms 48-72 hours after contact with an allergen. Allergic contact dermatitis is an example of this type of reaction, which causes redness, itching, swelling, blistering, or bumps on the skin.

      Antibody-mediated cytotoxic reactions occur when antibodies bind to antigens on the cell surface, interfering with cell function and marking the cells for destruction. This type of reaction is the basis for autoimmune diseases and haemolytic diseases in newborns.

      Contact irritant dermatitis occurs when irritants remove oils and natural moisturizing factors from the skin, allowing chemical irritants to penetrate the skin barrier and trigger inflammation. This type of reaction presents acutely with redness, papules, swelling, and blistering, and progresses to redness, dryness, and cracking in the chronic stage.

      Immune complex-mediated hypersensitivity occurs when antibodies bind to free-floating antigens, forming antigen-antibody complexes that can deposit in susceptible tissue and cause inflammation and damage. Henoch-Schönlein purpura is an example of a disease caused by this mechanism.

      Understanding the Different Types of Hypersensitivity Reactions

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 4 - A 25-year-old woman comes to her General Practitioner complaining of bilateral erythematous palms....

    Correct

    • A 25-year-old woman comes to her General Practitioner complaining of bilateral erythematous palms. She reports itching and the presence of some vesicles. She has observed this developing quickly at work, where she has just begun a new job as a hairdresser.
      What is the most probable diagnosis?

      Your Answer: Allergic contact dermatitis

      Explanation:

      Skin Conditions: Allergic Contact Dermatitis, Atopic Eczema, Scabies, Hand, Foot and Mouth Disease, and Ringworm

      Skin conditions can vary in their causes and symptoms. Allergic contact dermatitis is a delayed hypersensitivity reaction that occurs upon contact with an allergen, such as nickel, hair dyes, bleaches, perfumes, fragrances, and rubber antioxidants in gloves. Atopic eczema is a chronic skin condition that presents with red, itchy skin localized to the flexor surfaces and doesn’t normally develop vesicles. Scabies is a contagious skin condition caused by exposure to mites, which is very itchy and often starts between the fingers, but it would not normally flare up while at work. Hand, foot and mouth disease is a common childhood condition caused by the Coxsackievirus, characterized by a vesicular rash on the hands, feet, and mouth. Ringworm is a fungal skin infection that is usually circular with a silver scale and can be itchy, but it would be unlikely to cause bilateral hand symptoms and doesn’t cause the vesicular rash described here.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 5 - A 45-year-old man visits his GP for a medication review after undergoing a...

    Incorrect

    • A 45-year-old man visits his GP for a medication review after undergoing a renal transplant three months ago. The GP notes that the patient's medication was changed following the transplant, with the addition of immunosuppressant medication. What is the most probable immunosuppressive drug regimen for this patient?

      Your Answer: Ciclosporin, prednisolone

      Correct Answer: Mycophenolatemofetil (MMF), prednisolone, tacrolimus

      Explanation:

      After a renal transplant, patients require immunosuppressive drugs to prevent rejection. There are four classes of maintenance drugs: calcineurin inhibitors, antiproliferative agents, mammalian target of rapamycin inhibitors, and steroids. Mycophenolate mofetil is a cost-efficient antiproliferative agent that reduces the risk of acute rejection by 50%. Prednisolone is a steroid that is typically used in low doses and gradually reduced over several months. Azathioprine may also be used in initial therapy, but a calcineurin inhibitor is necessary. Basiliximab may be used for induction therapy within four days of the transplant. Ciclosporin and prednisolone are both used for maintenance immunosuppression, but require an antiproliferative agent to complete the regimen. Sirolimus may be used with a corticosteroid in patients intolerant of calcineurin inhibitors, according to National Institute for Health and Care Excellence guidelines.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 6 - Liam is a 6-year-old boy who has been brought to the emergency department...

    Correct

    • Liam is a 6-year-old boy who has been brought to the emergency department by his father. He experienced swelling of his lips and an itchy mouth after eating a peach. Liam is generally healthy, with only mild allergies to pollen and occasional skin irritation.

      During the examination, you observe that Liam's lips are swollen, and there are a few red bumps around his mouth. His chest sounds clear, and his vital signs are normal.

      What is the probable diagnosis?

      Your Answer: Oral allergy syndrome

      Explanation:

      The most common symptoms of oral allergy syndrome are itching and tingling of the lips, tongue, and mouth. This condition occurs when the body reacts to proteins in certain foods as if they were pollen due to cross-reacting allergens. While the reaction is localized, it can cause an itchy mouth or throat and sometimes hives. However, there is no evidence of anaphylaxis as there is no wheezing or hypotension.

      While contact dermatitis is a possibility, it typically presents with a rash rather than swelling of the lips and an itchy mouth. The presence of hay fever also makes a diagnosis of oral allergy syndrome more likely. Eczema, on the other hand, presents as dry and red skin rather than swelling and itching of the lips.

      Lastly, hand, foot, and mouth is a viral infection that causes a sore throat and high temperature. It can also cause ulcers in the mouth and blisters on the hands and feet.

      Understanding Oral Allergy Syndrome

      Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.

      It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.

      OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.

      In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.

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      • Allergy And Immunology
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  • Question 7 - Individuals with primary antibody deficiencies often experience repeated infections. What is the most...

    Correct

    • Individuals with primary antibody deficiencies often experience repeated infections. What is the most common symptom observed in these individuals?

      Your Answer: Respiratory infection

      Explanation:

      Understanding Primary Antibody Deficiencies: Causes, Symptoms, and Diagnosis

      Primary antibody deficiencies refer to a group of rare disorders that affect the body’s ability to produce effective antibodies against pathogens. These disorders may be caused by a mutation in a single gene or by multiple genetic factors, similar to diabetes. While primary antibody deficiencies are the most common forms of primary immune deficiency, other primary immune deficiencies involve defects in cellular immunity, phagocyte defects, and complement defects. It is important to distinguish primary antibody deficiencies from secondary immune deficiencies caused by factors such as malignancy, malnutrition, or immunosuppressive therapy.

      Clinical history is crucial in identifying primary antibody deficiencies. Patients of any age who experience recurrent infections, particularly in the respiratory tract, should be investigated if the frequency or severity of infection is unusual or out of context. While most patients are under 20 years old, common variable immunodeficiency typically peaks in the second or third decade of life. A systematic review has found that respiratory and sinus infections are the most common presenting symptoms, followed by gastrointestinal and cutaneous infections. Meningitis, septic arthritis/osteomyelitis, and ophthalmic infections are much less common.

      In summary, understanding primary antibody deficiencies is essential in diagnosing and managing patients with recurrent infections. Clinical history plays a crucial role in identifying these disorders, which can be caused by genetic factors and affect the body’s ability to produce effective antibodies against pathogens.

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      • Allergy And Immunology
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  • Question 8 - A 50-year-old woman had a renal transplant three months ago. She presents with...

    Correct

    • A 50-year-old woman had a renal transplant three months ago. She presents with fatigue, fever, sweating (especially at night), aching joints and headaches. On examination, there are no focal signs.
      Which is the MOST LIKELY diagnosis?

      Your Answer: Cytomegalovirus (CMV) infection

      Explanation:

      Common Infections in Kidney Transplant Patients

      Kidney transplant patients are at a higher risk of infections due to immunosuppression. In the first month post-transplant, infections are similar to those in non-immunosuppressed individuals. However, in the one-month to six-month period, immunomodulating viruses like Cytomegalovirus (CMV), herpes simplex viruses, Epstein–Barr virus, and human herpesvirus-6, hepatitis A, B and C viruses, and human immunodeficiency virus (HIV) are most problematic. influenza can also cause respiratory symptoms, but routine annual administration of the injectable inactivated vaccine is recommended. Herpes simplex virus can cause severe lesions and even disseminated or visceral disease. Pneumonia and urinary infections are also common, and patients should receive appropriate immunisation and prophylactic antibiotics and antiviral drugs for a few months after transplantation. A small group of patients may experience persistence of viral infections and are at risk of opportunistic infections like cryptococcus, pneumocystis, listeria, and nocardia.

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      • Allergy And Immunology
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  • Question 9 - A 47-year-old woman with rheumatoid arthritis is being evaluated in the clinic as...

    Incorrect

    • A 47-year-old woman with rheumatoid arthritis is being evaluated in the clinic as she has not responded well to methotrexate. The possibility of starting sulfasalazine is being considered. However, if she has an allergy to which of the following drugs, it may not be advisable to prescribe sulfasalazine?

      Your Answer: Leflunomide

      Correct Answer: Aspirin

      Explanation:

      Sulfasalazine may cause a reaction in patients who are allergic to aspirin.

      Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease

      Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.

      However, caution should be taken when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.

      Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 10 - A 67-year-old man presents for his first seasonal influenza vaccination. He reports a...

    Correct

    • A 67-year-old man presents for his first seasonal influenza vaccination. He reports a history of anaphylaxis and carries an epipen. What would be a contraindication to administering the vaccine?

      Your Answer: Food allergy to egg

      Explanation:

      Being mindful of contraindications for the influenza vaccine is crucial. The presence of ovalbumin, an egg protein, in the regular influenza vaccine may lead to anaphylaxis in individuals with a severe egg allergy. To address this concern, egg protein-free vaccines such as Optaflu are accessible for these patients.

      influenza vaccination is recommended in the UK between September and early November, as the influenza season typically starts in the middle of November. There are three types of influenza virus, with types A and B accounting for the majority of clinical disease. Prior to 2013, flu vaccination was only offered to the elderly and at-risk groups. However, a new NHS influenza vaccination programme for children was announced in 2013, with the children’s vaccine given intranasally and annually after the first dose at 2-3 years. It is important to note that the type of vaccine given to children and the one given to the elderly and at-risk groups is different, which explains the different contraindications.

      For adults and at-risk groups, current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B. The Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months with chronic respiratory, heart, kidney, liver, neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, or a body mass index >= 40 kg/m². Other at-risk individuals include health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill.

      The influenza vaccine is an inactivated vaccine that cannot cause influenza, but a minority of patients may develop fever and malaise that lasts 1-2 days. It should be stored between +2 and +8ºC and shielded from light, and contraindications include hypersensitivity to egg protein. In adults, the vaccination is around 75% effective, although this figure decreases in the elderly. It takes around 10-14 days after immunisation before antibody levels are at protective levels.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 11 - You have a female patient aged 30 who works in a factory producing...

    Incorrect

    • You have a female patient aged 30 who works in a factory producing latex products. She has developed asthma and you have referred her to the respiratory unit for further investigation into the possibility of occupational asthma. She wants to know what tests she may need.

      Which test is of proven value in diagnosing occupational asthma?

      Your Answer: Chest x ray

      Correct Answer: Serial peak flow measurements

      Explanation:

      Diagnosis of Occupational Asthma

      Investigations that have been proven valuable in diagnosing occupational asthma include serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. To accurately measure peak flow, it should be measured more than four times a day at and away from work for three weeks. Results should be plotted as daily minimum, mean, and maximum values, and intraday variability should be calculated as a percentage of either the mean or highest value (normal upper value is 20%).

      Occupational asthma can be confirmed if there is a consistent fall in peak flow values with increased intraday variability on working days, and improvement on days away from work. Computer-based analysis may be necessary. It is important to note that these investigations are only useful when the patient is still in the job with exposure to the suspected agent.

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      • Allergy And Immunology
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  • Question 12 - As part of a tutorial on pruritus, you plan to use cases from...

    Incorrect

    • As part of a tutorial on pruritus, you plan to use cases from both yourself and GP registrars who frequently prescribe antihistamines for itchy conditions. Your goal is to determine the scenario in which a non-sedating antihistamine would be most effective. Please select the ONE option that best fits this scenario.

      Your Answer: A 65-year-old man with generalised pruritus but no rash

      Correct Answer: A 15-year-old girl with acute urticaria

      Explanation:

      Antihistamines: Uses and Limitations in Various Skin Conditions

      Urticaria, Chickenpox, atopic eczema, local reactions to insect stings, and general pruritus are common skin conditions that may benefit from antihistamines. However, the effectiveness of antihistamines varies depending on the underlying cause and the individual’s response.

      For a 15-year-old girl with acute urticaria, non-sedating H1 antihistamines are the first-line treatment. If the first antihistamine is not effective, a second one may be tried.

      A 4-year-old girl with Chickenpox may benefit from emollients and sedating antihistamines to relieve pruritus. Calamine lotion may also be used, but its effectiveness decreases as it dries.

      Antihistamines are not routinely recommended for atopic eczema, but a non-sedating antihistamine may be tried for a month in severe cases or when there is severe itching or urticaria. Sedating antihistamines may be used for sleep disturbance.

      For a 50-year-old woman with a local reaction to a wasp sting, antihistamines are most effective when used immediately after the sting. After 48 hours, they are unlikely to have a significant impact on the local reaction.

      Finally, for a 65-year-old man with general pruritus but no rash, antihistamines may be prescribed, but their effectiveness is limited as histamine may not be the main cause of the pruritus.

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      • Allergy And Immunology
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  • Question 13 - A 55-year-old woman complains of light-headedness, weakness, nausea and difficulty breathing within minutes...

    Correct

    • A 55-year-old woman complains of light-headedness, weakness, nausea and difficulty breathing within minutes of a wasp sting. A neighbour brings her into the surgery. She is hypotensive and wheezy. You decide to administer adrenaline.
      Select from the list the single correct option.

      Your Answer: Adrenaline 0.5 mg (0.5 ml 1 : 1000) intramuscular injection

      Explanation:

      Administering Adrenaline: Dosage and Site of Injection

      When administering adrenaline, it is recommended to inject it intramuscularly in the anterolateral aspect of the middle third of the thigh. This site is considered safe, easy, and effective. The standard adult dose is 0.5 ml 1:1000, while children aged 6-12 years should receive 0.3 ml. For younger children, the dose varies from 0.15 ml for those aged 6 months to 6 years, and 0.1-0.15 ml for infants younger than 6 months. If there is no improvement after 5 minutes, a repeat dose of intramuscular adrenaline may be necessary. In some cases, patients may require intravenous adrenaline, which should only be administered by trained and experienced medical professionals such as anaesthetists and A&E consultants.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 14 - A 26-year-old woman is 18 weeks pregnant. She works as a kindergarten teacher,...

    Correct

    • A 26-year-old woman is 18 weeks pregnant. She works as a kindergarten teacher, and two children in the kindergarten have developed Chickenpox. Her own mother is certain that she had Chickenpox as a child.
      What is the most appropriate piece of advice to give in order to reassure this woman that her baby is not at risk from this Chickenpox contact?

      Your Answer: The patient is at low risk of developing an infection as she is sure she had a previous Chickenpox infection

      Explanation:

      Understanding Chickenpox Serology Results in Pregnancy

      Chickenpox infection during pregnancy can have serious consequences for both the mother and the fetus. Therefore, it is important to determine a woman’s immunity status before she is exposed to the virus. Serology testing can help determine if a woman has been previously infected or vaccinated against Chickenpox. Here are the possible results and their implications:

      – Negative IgG and negative IgM serology: This indicates that the woman has not been previously exposed to the virus and is not immune. She should avoid exposure and receive immunoglobulin if she has significant exposure. She should also be vaccinated postpartum.
      – Positive IgG and negative IgM serology: This indicates that the woman has been previously infected or vaccinated and has protective immunity against re-infection. This is the desired result if the woman has no history of Chickenpox.
      – Positive IgG and positive IgM serology: This suggests recent infection, but should not be used alone to diagnose infection. Clinical presentation should also be considered. If the woman develops Chickenpox, she should receive acyclovir.
      – No serology testing needed: If the woman has a definite history of Chickenpox, she is considered immune and doesn’t need serology testing.

      It is important to note that a history of Chickenpox may not be a reliable predictor of immunity in women from overseas, and serology testing may be necessary. The NICE guidance on Chickenpox infection in pregnancy provides further recommendations.

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      • Allergy And Immunology
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  • Question 15 - A 35-year-old woman has recently developed symmetrical polyarthritis affecting the small joints of...

    Correct

    • A 35-year-old woman has recently developed symmetrical polyarthritis affecting the small joints of the hands and feet.
      Which of the following tests is most likely to contribute to a definitive diagnosis in this patient?

      Your Answer: Rheumatoid factor

      Explanation:

      Autoantibodies and their Association with Autoimmune Diseases

      Autoantibodies are antibodies that target the body’s own tissues and cells. They are often associated with autoimmune diseases, which occur when the immune system mistakenly attacks healthy cells and tissues. Here are some common autoantibodies and their association with autoimmune diseases:

      1. Rheumatoid factor: This autoantibody is found in 60-70% of patients with rheumatoid arthritis (RA) and in 5% of the general population. It may also be elevated in other autoimmune diseases. Testing for rheumatoid factor is recommended in people with suspected RA who have synovitis on clinical examination.

      2. Antinuclear antibody: This autoantibody binds to the contents of the cell nucleus. It is present in almost all people with systemic lupus erythematosus and is also found in patients with other autoimmune diseases such as rheumatoid arthritis, scleroderma, Sjögren’s syndrome, polymyositis, and certain forms of chronic active hepatitis.

      3. Antimitochondrial antibody: This autoantibody is present in 90-95% of patients with autoimmune liver disease, primary biliary cholangitis, and also in 0.5% of the general population. It is also found in about 35% of patients with primary biliary cirrhosis.

      4. Antiphospholipid antibodies: These autoantibodies are associated with antiphospholipid syndrome, an autoimmune, hypercoagulable state that can cause arterial and venous thrombosis as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.

      5. HLA-B27 antigen: This antigen is strongly associated with ankylosing spondylitis, as well as other diseases such as psoriasis, reactive arthritis, and inflammatory bowel disease. Its prevalence varies in the general population according to racial type.

      In conclusion, autoantibodies can provide important diagnostic and prognostic information in autoimmune diseases. Testing for these antibodies can help healthcare providers make accurate diagnoses and develop effective treatment plans.

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      • Allergy And Immunology
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  • Question 16 - A 32-year-old woman visits her doctor to discuss the results of some recent...

    Incorrect

    • A 32-year-old woman visits her doctor to discuss the results of some recent blood tests she had done due to ongoing symptoms of chronic fatigue. She has a previous diagnosis of irritable bowel syndrome (IBS) from a few years ago, but is otherwise healthy and has never had her blood checked before. She reports experiencing intermittent abdominal bloating, constipation, and abdominal pains. She is not taking any medications, her weight is stable, and her blood tests show microcytic anemia with low ferritin levels. Which of the following tests is most likely to lead to an accurate diagnosis? Choose only ONE option.

      Your Answer: Faecal calprotein

      Correct Answer: Tissue transglutaminase (TTG)

      Explanation:

      Diagnostic Tests for a Patient with Gastrointestinal Symptoms: A Case Study

      A 28-year-old female patient presents with intermittent abdominal bloating, constipation, abdominal pains, and persistent fatigue. She has never had any blood tests before. The following diagnostic tests are available:

      Tissue Transglutaminase (TTG) Test: This test is used to diagnose coeliac disease, an immune-mediated disorder triggered by exposure to dietary gluten. The patient’s symptoms and history suggest coeliac disease, and a TTG test should be requested. If the result suggests possible coeliac disease, the patient should be referred to gastroenterology for endoscopic intestinal biopsy.

      Faecal Immunochemical Testing (FIT): FIT testing can be used to look for occult faecal blood if colorectal cancer is suspected. However, the patient’s young age and stable weight make colorectal cancer less likely.

      Cancer-Antigen 125 (CA-125) Test: This test is used to diagnose ovarian cancer, which is difficult to diagnose due to nonspecific symptoms. However, the patient’s age makes ovarian cancer less likely than other options.

      Faecal Calprotectin Test: This test is used to distinguish between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). However, the patient’s symptoms do not suggest IBD, and faecal calprotectin may not be the most likely test to lead to the correct diagnosis.

      Haemochromatosis Gene (HFE) Testing: This test is used to detect hereditary haemochromatosis, which presents with iron overload rather than deficiency. The patient’s symptoms suggest iron-deficiency anaemia, and HFE testing may not be necessary.

      In conclusion, based on the patient’s symptoms and history, a TTG test for coeliac disease is the most appropriate diagnostic test to request.

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      • Allergy And Immunology
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  • Question 17 - What is the most common identified trigger of anaphylaxis in adolescents? ...

    Correct

    • What is the most common identified trigger of anaphylaxis in adolescents?

      Your Answer: Food

      Explanation:

      Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.

      The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.

      Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12

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      • Allergy And Immunology
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  • Question 18 - A 35-year-old homeless Romanian man presents to his General Practitioner with a persistent...

    Correct

    • A 35-year-old homeless Romanian man presents to his General Practitioner with a persistent cough that has lasted for the last four weeks, with breathlessness at rest. He sometimes does casual work as a labourer, but he is finding that he is unable to keep up with this work due to his breathlessness and generally feels fatigued and 'not well'.
      On further questioning, he reports night sweats and weight loss over the past 4-6 weeks. He is a non-smoker and is not on regular medication. He requests a course of antibiotics to make his cough better so he can get back to work.
      What is the most likely underlying diagnosis?

      Your Answer: Tuberculosis (TB)

      Explanation:

      Diagnosing Respiratory Conditions: Differential Diagnosis of a Persistent Cough

      A persistent cough can be a symptom of various respiratory conditions, making it important to consider a differential diagnosis. In the case of a homeless patient from Romania, the most likely diagnosis is pulmonary tuberculosis (TB), given the patient’s risk factors and symptoms of weight loss, night sweats, malaise, and breathlessness. To investigate this, three sputum samples and a chest X-ray should be arranged.

      While lung cancer can also present with similar symptoms, the patient’s young age and non-smoking status make this less likely. Asthma is unlikely given the absence of environmental triggers and the presence of additional symptoms. Bronchiectasis is also an unlikely diagnosis, as it is characterized by copious mucopurulent sputum production, which is not described in this case. Pulmonary fibrosis is rare in patients under 50 years old and doesn’t typically present with night sweats.

      In summary, a persistent cough can be indicative of various respiratory conditions, and a thorough differential diagnosis is necessary to determine the most likely diagnosis and appropriate treatment plan.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 19 - Immunodeficiency is most likely to result from which of the following conditions? Please...

    Incorrect

    • Immunodeficiency is most likely to result from which of the following conditions? Please select one option.

      Your Answer: Sarcoidosis

      Correct Answer: Nephrotic syndrome

      Explanation:

      Causes of Secondary Immunodeficiency

      Secondary immunodeficiency can be caused by various factors such as lymphoreticular malignancy, drugs, viruses, malnutrition, metabolic disorders, trauma or major surgery, and protein loss. Lymphoma, myeloma, cytotoxic drugs, and immunosuppressants like corticosteroids are some of the common causes of secondary immunodeficiency. HIV is also a significant cause of secondary immunodeficiency. Malnutrition, particularly protein calorie deficiency, is the most common cause of secondary immunodeficiency worldwide. Metabolic disorders like renal disease requiring peritoneal dialysis can also lead to secondary immunodeficiency. Trauma or major surgery and protein loss due to nephrotic syndrome or ulcerative or erosive gastrointestinal disease can also cause secondary immunodeficiency. While heart failure, lung cancer, and polycythemia are consequences of HIV infection, sarcoidosis has been reported to occur in patients with common variable immunodeficiency.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 20 - You see a 6-month-old boy who you suspect has non-IgE-mediated cow's' milk protein...

    Incorrect

    • You see a 6-month-old boy who you suspect has non-IgE-mediated cow's' milk protein allergy. He is exclusively breastfed. You would like to do a trial elimination of cows' milk from his diet.

      What would you advise the mother to achieve this trial elimination?

      Your Answer: Stop breastfeeding and switch to an amino acid formula

      Correct Answer: Exclude cows' milk protein from her diet for 4 weeks

      Explanation:

      Managing Non-IgE-Mediated Cow’s’ Milk Protein Allergy in Infants

      When dealing with a breastfed infant suspected of having non-IgE-mediated cows’ milk protein allergy, it is recommended to advise the mother to exclude cows’ milk from her diet for 2-6 weeks. During this period, calcium and vitamin D supplements may be prescribed to ensure the infant’s nutritional needs are met. After the exclusion period, reintroducing cows’ milk is advised to determine if it is the cause of the infant’s symptoms. If there is no improvement or the symptoms worsen, a referral to secondary care may be necessary.

      For formula-fed or mixed-fed infants, replacing cow’s milk-based formula with hypoallergenic infant formulas is recommended. Extensively hydrolysed formulas (eHF) are typically the first option, and amino acid formulas are an alternative if the infant cannot tolerate eHFs or has severe symptoms. It is important to note that parents should not switch to soy-based formulas without consulting a healthcare professional, as some infants with cow’s’ milk protein allergy may also be allergic to soy.

      In cases where there is faltering growth, acute systemic reactions, severe delayed reactions, significant atopic eczema with multiple food allergies suspected, or persistent parental concern, a referral to secondary care should be considered. With proper management and guidance, infants with non-IgE-mediated cow’s’ milk protein allergy can still receive adequate nutrition and thrive.

    • This question is part of the following fields:

      • Allergy And Immunology
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