Q-1

A 46-year-old woman presents 3 days after returning from a

safari holiday in Tanzania. She complains of fever, chills,
myalgia and malaise which started 2 days ago and now
complains of daytime somnolence and night time insomnia.
Her husband also reports she has been acting strangely. She
says she took malarone as antimalarial prophylaxis and had
all the recommended vaccines before travelling. A HIV test
was negative.
On examination her temperature is 38.5ºC, heart rate
90/min, blood pressure 118/90 mmHg, respiratory rate
18/min.
What is the most likely diagnosis?
A. Cerebral malaria
B. Human African Trypanosomiasis
C. Yellow fever
D. Tuberculosis meningitis
E. Bacterial meningitis
ANSWER:
B. Human African Trypanosomiasis
EXPLANATION:
The reversal of the sleep wake cycle is typical of
trypanosomiasis (African sleeping sickness) and can be
accompanied by behavioural changes. Cerebral malaria
would be unlikely given that she took malarone and reversal
of the sleep-wake cycle would not be a feature. TB
meningitis is also very unlikely in this lady, especially in the
absence of HIV or other immunosuppressive illness. Bacterial
meningitis again does not cause reversal of the sleep-wake
cycle and the onset is quite long for bacterial meningitis.
Yellow fever is found in Tanzania (although the risk is low)
and the initial symptoms may be similar but the later stages
involve jaundice, abdominal pain and bleeding not
behavioural and sleep disturbances.
TRYPANOSOMIASIS
Two main form of this protozoal disease are recognised -
African trypanosomiasis (sleeping sickness) and American
trypanosomiasis (Chagas' disease)
Two forms of African trypanosomiasis, or sleeping sickness,
are seen - Trypanosoma gambiense in West Africa and
Trypanosoma rhodesiense in East Africa. Both types are
spread by the tsetse fly. Trypanosoma rhodesiense tends to
follow a more acute course. Clinical features include:
• Trypanosoma chancre - painless subcutaneous nodule at
site of infection
• intermittent fever
• enlargement of posterior cervical lymph nodes
• later: central nervous system involvement e.g.
somnolence, headaches, mood changes,
meningoencephalitis
Management
• early disease: IV pentamidine or suramin
• later disease or central nervous system involvement: IV
melarsoprol
American trypanosomiasis, or Chagas' disease, is caused by
the protozoan Trypanosoma cruzi. The vast majority of
patients (95%) are asymptomatic in the acute phase although
a chagoma (an erythematous nodule at site of infection) and
periorbital oedema are sometimes seen. Chronic Chagas'
disease mainly affects the heart and gastrointestinal tract
• myocarditis may lead to dilated cardiomyopathy (with
apical atophy) and arrhythmias
• gastrointestinal features includes megaoesophagus and
megacolon causing dysphagia and constipation
Management
• treatment is most effective in the acute phase using azole
or nitroderivatives such as benznidazole or nifurtimox
• chronic disease management involves treating the
complications e.g., heart failure

Q-2
A 43-year-old Asian man presents with headache and neck
stiffness. CT brain is normal and a lumbar puncture is
performed with the following results
Serum glucose 4.7 mmol/l
Lumbar puncture reveals:
Opening pressure 15 cmCSF
Appearance Cloudy
Glucose 3.3 mmol/l
Protein 0.7 g/l
White cells 100 / mm³ (70% lymphocytes)
What is the most likely diagnosis?
A. Bacterial meningitis
B. Viral meningitis
C. Tuberculous meningitis
D. Normal CSF result
E. Cryptococcal meningitis
The CSF lymphocytosis combined with a glucose greater than
half the serum level points towards a viral meningitis. TB
meningitis is associated with a low CSF glucose
ANSWER:
B. Viral meningitis
EXPLANATION:
MENINGITIS: CSF ANALYSIS
The table below summarises the characteristic cerebrospinal
fluid (CSF) findings in meningitis:
Bacterial Viral Tuberculous
Appearance Cloudy Clear/cloudy Slight cloudy, fibrin
web
Glucose Low (< 1/2 plasma) 60-80% of plasma
glucose*
Low (< 1/2 plasma)
Protein High (> 1 g/l) Normal/raised High (> 1 g/l)
White cells 10 - 5,000
polymorphs/mm³
15 - 1,000
lymphocytes/mm³
10 - 1,000
lymphocytes/mm³
The Ziehl-Neelsen stain is only 20% sensitive in the detection
of tuberculous meningitis and therefore PCR is sometimes
used (sensitivity = 75%)
*mumps is unusual in being associated with a low glucose
level in a proportion of cases. A low glucose may also be seen
in herpes encephalitis

Q-3
Which one of the following organisms causes
lymphogranuloma venereum?
A. Haemophilus ducreyi
B. Klebsiella granulomatis
C. Herpes simplex virus
D. Chlamydia
E. Treponema pallidum
ANSWER:
D. Chlamydia
EXPLANATION:
STI: ULCERS
Genital herpes is most often caused by the herpes simplex
virus (HSV) type 2 (cold sores are usually due to HSV type 1).
Primary attacks are often severe and associated with fever
whilst subsequent attacks are generally less severe and
localised to one site
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. A painless ulcer
(chancre) is seen in the primary stage. The incubation period=
9-90 days
Chancroid is a tropical disease caused by Haemophilus
ducreyi. It causes painful genital ulcers associated with
unilateral, painful inguinal lymph node enlargement. The
ulcers typically have a sharply defined, ragged, undermined
border.
Lymphogranuloma venereum (LGV) is caused by Chlamydia
trachomatis. Typically infection comprises of three stages
stage 1: small painless pustule which later forms an ulcer
stage 2: painful inguinal lymphadenopathy
stage 3: proctocolitis
LGV is treated using doxycycline.
Other causes of genital ulcers
• Behcet's disease
• carcinoma
• granuloma inguinale: Klebsiella granulomatis*
*previously called Calymmatobacterium granulomatis

Q-4
A 39-year-old female who has recently emigrated from subSaharan Africa is screened
for tuberculosis. She reports being
fit and well with no past medical history and has never had a
BCG vaccination. Her chest x-ray is normal so she has a
Mantoux test which is positive. An interferon gamma test is
also performed which is positive. A HIV test is requested
which is negative. What treatment would you recommend?
A. 3 months of isoniazid (with pyridoxine) and rifampicin
OR 6 months of isoniazid (with pyridoxine)
B. Rifampicin, isoniazid, pyrazinamide and ethambutol for
6 months
C. Observe
D. Rifampicin, isoniazid, pyrazinamide and ethambutol for
2 months then step down to rifampicin and isoniazid for
4 months
E. 3 months of pyrazinamide and isoniazid OR 6 months of pyrazinamide
ANSWER:
E. 3 months of pyrazinamide and isoniazid OR 6 months of pyrazinamide
EXPLANATION:
This patient has latent tuberculosis
TUBERCULOSIS: DRUG THERAPY
The standard therapy for treating active tuberculosis is:
Initial phase - first 2 months (RIPE)
• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol (the 2006 NICE guidelines now recommend
giving a 'fourth drug' such as ethambutol routinely -
previously this was only added if drug-resistant
tuberculosis was suspected)Continuation phase - next 4 months
Rifampicin
Isoniazid
The treatment for latent tuberculosis is 3 months of isoniazid
(with pyridoxine) and rifampicin OR 6 months of isoniazid
(with pyridoxine)
Patients with meningeal tuberculosis are treated for a
prolonged period (at least 12 months) with the addition of
steroids
Directly observed therapy with a three times a week dosing
regimen may be
• indicated in certain groups, including:
• homeless people with active tuberculosis
• patients who are likely to have poor concordance
• all prisoners with active or latent tuberculosis

Q-5
A 28-year-old medical student presents to the infectious
diseases ward with fevers, lethargy and a productive cough
that has been ongoing for two weeks. He has recently
returned to the UK following an elective period spent
volunteering in refugee camps overseas. He has no
significant past medical history. Prior to his travel, the
patient received all appropriate vaccinations and received
the BCG vaccine prior to starting his studies 4 years ago.
White Cell Count 13 x10^9/l
C-reactive Protein 240 mg/L
Na+ 137 mmol/L
Chest X-ray Left upper zone consolidation
Sputum appearances Mucopurulent with streaks of
blood
Sputum cultures Awaited
What is the most likely causative organism for the patient's
pneumonia?
A. Staphylococcus aureus
B. Mycoplasma pneumoniae
C. Mycobacterium tuberculosis
D. Klebsiella pneumoniae
E. Legionella pneumophila
ANSWER:
C. Mycobacterium tuberculosis
EXPLANATION:
The BCG vaccine is unreliable in protecting against
pulmonary tuberculosis
Although the BCG is routinely given to people at high risk of
exposure through occupation, it's strengths lie in preventing
extrapulmonary manifestations of tuberculosis, rather than
the more common, pulmonary form. This patient has spent a
prolonged period of time working in refugee camps, which
tend to be overcrowded, creating an environment in which
TB can spread rapidly amongst inhabitants.
Pneumonia caused Staphylococcus aureus often is preceded
by a viral illness such as influenza.
Mycoplasma pneumoniae frequently causes mild cases of
pneumonia, otherwise referred to 'Walking pneumonia'.
Systemic symptoms are less common, and it usually presents
with a non-productive cough.
Klebsiella pneumoniae often causes cavitating lung lesions
and is most commonly associated with pneumonia in
patients with a history of alcohol excess.
Legionella pneumophila is often accompanied by more
generalised symptoms, such as diarrhoea and myalgia. It is
also associated with hyponatraemia, however the
mechanism through which this occurs is unclear.
BCG VACCINE
The Bacille Calmette-Guérin (BCG) vaccine offers limited
protection against tuberculosis (TB). In the UK it is given to
high-risk infants. Until 2005 it was also routinely given to
children at the age of 13 years.
The Greenbook currently advises that the vaccine is
administered to the following groups (below is summary,
please see the link for more details):
• all infants (aged 0 to 12 months) living in areas of the UK
where the annual incidence of TB is 40/100,000 or
greater
• all infants (aged 0 to 12 months) with a parent or
grandparent who was born in a country where the annual
incidence of TB is 40/100,000 or greater. The same
applies to older children but if they are 6 years old or
older they require a tuberculin skin test first
• previously unvaccinated tuberculin-negative contacts of
cases of respiratory TB
• previously unvaccinated, tuberculin-negative new
entrants under 16 years of age who were born in or who
have lived for a prolonged period (at least three months)
in a country with an annual TB incidence of 40/100,000 or
greater
• healthcare workers
• prison staff
• staff of care home for the elderly
• those who work with homeless people
The vaccine contains live attenuated Mycobacterium bovis. It
also offers limited protection against leprosy.
Administration
• any person being considered for the BCG vaccine must
first be given a tuberculin skin test. The only exceptions
are children < 6 years old who have had no contact with
tuberculosis• 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
Contraindications
• previous BCG vaccination
• a past history of tuberculosis
• HIV
• pregnancy
• positive tuberculin test (Heaf or Mantoux)
The BCG vaccine is not given to anyone over the age of 35, as
there is no evidence that it works for people of this age group.
Q-6
A 42-year-old dentist is reviewed in the medical clinic
complaining of persistent lethargy. Routine bloods show
abnormal liver function tests so a hepatitis screen is sent.
The results are shown below:
Anti-HAV IgG negative
HBsAg negative
Anti-HBs positive
Anti-HBc negative
Anti-HCV positive
What do these results most likely demonstrate?
A. Hepatitis B infection
B. Hepatitis C infection
C. Previous vaccination to hepatitis B and C
D. Hepatitis C infection with previous hepatitis B vaccination
E. Hepatitis B and C infection
ANSWER:
B. Hepatitis C infection
EXPLANATION:
Given the deranged liver function tests these results most
likely indicate previous hepatitis B vaccination with active
hepatitis C infection. However, around 15% of patients
exposed to the hepatitis C virus clear the infection. It would
therefore be necessary to perform a HCV PCR to see if the
virus is still present
There is currently no vaccination for hepatitis C
HEPATITIS C
Hepatitis C is likely to become a significant public health
problem in the UK in the next decade. It is thought around
200,000 people are chronically infected with the virus. At risk
groups include intravenous drug users and patients who
received a blood transfusion prior to 1991 (e.g.
haemophiliacs).
Pathophysiology
• hepatitis C is a RNA flavivirus
• incubation period: 6-9 weeks
Transmission
• the risk of transmission during a needle stick injury is
about 2%
• the vertical transmission rate from mother to child 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%
• there is no vaccine for hepatitis C
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 antiHCV antibodies
Outcome
• around 15-45% of patients will clear the virus after an
acute infection (depending on their age and underlying
health) and hence the majority (55-85%) will develop
chronic hepatitis C
Chronic hepatitis C
Chronic hepatitis C may be defined as the persistence of HCV
RNA in the blood for 6 months.
Potential complications of chronic hepatitis C
• rheumatological problems: arthralgia, arthritis
• eye problems: Sjogren's syndrome
• cirrhosis (5-20% of those with chronic disease)
• hepatocellular cancer
• cryoglobulinaemia: typically type II (mixed monoclonal
and polyclonal)
• porphyria cutanea tarda (PCT): it is increasingly
recognised that PCT may develop in patients with
hepatitis C, especially if there are other factors such as
alcohol abuse
• membranoproliferative glomerulonephritis
Management of chronic infection
• treatment depends on the viral genotype - this should be
tested prior to treatment• the management of hepatitis C has advanced rapidly in
recent years resulting in clearance rates of around 95%.
Interferon based treatments are no longer recommended
• the aim of treatment is sustained virological response
(SVR), defined as undetectable serum HCV RNA six
months after the end of therapy
• currently a combination of protease inhibitors (e.g.
daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with
or without ribavirin are used
Complications of treatment
• ribavirin - side-effects: haemolytic anaemia, cough.
Women should not become pregnant within 6 months of
stopping ribavirin as it is teratogenic
• interferon alpha - side-effects: flu-like symptoms,
depression, fatigue, leukopenia, thrombocytopenia

Q-7
Infection with Schistosoma haematobium is most strongly
associated with:
A. Transitional cell bladder cancer
B. Lung cancer
C. Hepatoma
D. Vulval carcinoma
E. Squamous cell bladder cancer
ANSWER:
E. Squamous cell bladder cancer
EXPLANATION:
Schistosomiasis is a risk factor for Squamous cell bladder
cancer
SCHISTOSOMIASIS
Schistosomiasis, or bilharzia, is a parasitic flatworm infection.
The three main species of schistosome are S. mansoni, S.
japonicum and S. haematobium.
Schistosoma haematobium
These worms deposit egg clusters (pseudopapillomas) in the
bladder, causing inflammation. The calcification seen on x-ray
is actually calcification of the egg clusters, not the bladder
itself.
Depending on the site of these pseudopapillomas in the
bladder, they can cause an obstructive uropathy and kidney
damage.
This typically presents as a 'swimmer's itch' in patients who
have recently returned from Africa. Schistosoma
haematobium is a risk factor for squamous cell bladder cancer
Features
• frequency
• haematuria
• bladder calcification
Management
• single oral dose of praziquantel
Schistosoma mansoni and Schistosoma japonicum
These worms mature in the liver and then travel through the
portal system to inhabit the distal colon. Their presence in the
portal system can lead to progressive hepatomegaly and
splenomegaly due to portal vein congestion.
These species can also lead to complications of liver cirrhosis,
variceal disease and cor pulmonale.
Schistosoma intercalatum and Schistosoma mekongi
These are less prevalent than the other three forms, but are
both attributed to intestinal schistosomiasis.

Q-8
What is the mechanism of action of the antiviral agent
amantadine?
A. Inhibits DNA polymerase
B. Protease inhibitor
C. Nucleoside analogue reverse transcriptase inhibitor
D. Inhibits uncoating of virus in the cell
E. Interferes with the capping of viral mRNA
ANSWER:
D. Inhibits uncoating of virus in the cell
EXPLANATION:
ANTIVIRAL AGENTS
Drug Mechanism of action Indications
Adverse
effects/toxicity
Aciclovir Guanosine analog,
phosphorylated by
thymidine kinase which in
turn inhibits the viral DNA
polymerase
HSV, VZV Crystalline nephropathy
Ganciclovir Guanosine analog,
phosphorylated by
thymidine kinase which in
turn inhibits the viral DNA
polymerase
CMV Myelosuppression/agran
ulocytosis
Ribavirin Guanosine analog which
inhibits inosine
monophosphate (IMP)
dehydrogenase, interferes
with the capping of viral
mRNA
Chronic
hepatitis C,
RSV
Haemolytic anaemia
Amantadine Inhibits uncoating (M2
protein) of virus in cell.
Also releases dopamine
from nerve endings
Influenza,
Parkinson's
disease
Confusion, ataxia, slurred
speech
Oseltamivir Inhibits neuraminidase Influenza
Foscarnet Pyrophosphate analog
which inhibits viiral DNA
polymerase
CMV, HSV if
not
Nephrotoxicity,
hypocalcaemia,Drug Mechanism of action Indications
Adverse
effects/toxicity
responding
to aciclovir
hypomagnasaemia,
seizures
Interferon-
α
Human glycoproteins
which inhibit synthesis of
mRNA
Chronic
hepatitis B &
C, hairy cell
leukaemia
Flu-like symptoms,
anorexia,
myelosuppression
Cidofovir Acyclic nucleoside
phosphonate, and is
therefore independent of
phosphorylation by viral
enzymes (compare and
contrast with
aciclovir/ganciclovir)
CMV retinitis
in HIV
Nephrotoxicity
Anti-retroviral agent used in HIV
Nucleoside analogue reverse transcriptase inhibitors (NRTI)
• examples: zidovudine (AZT), didanosine, lamivudine,
stavudine, zalcitabine
Protease inhibitors (PI)
• inhibits a protease needed to make the virus able to
survive outside the cell
• examples: indinavir, nelfinavir, ritonavir, saquinavir
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
• examples: nevirapine, efavirenz

Q-9
A 23-year-old medical student is seen in a genitourinary
medicine clinic for a painless lesion on the glans of his penis.
He describes a 2-week history of the lesion that started as a
small erythematous papule and has now progressed to
ulceration. This was associated with fevers, sweats and
general malaise. He has returned from his elective in the
Caribbean and admits to an episode of unprotected sex with
a local resident.
On examination there was a 1x2cm painless ulcer on the
glans of his penis. You note groove sign with
lymphadenopathy above and below the left inguinal
ligament only.
What organism is cause of the patients presentation?
A. Treponema pallidum
B. Chlamydia trachomatis
C. Haemophilus ducreyi
D. Klebsiella
E. Gonorrhoea
ANSWER:
B. Chlamydia trachomatis
EXPLANATION:
This patient is presenting with the classic features of
Lymphogranuloma venereum (LGV). This tropical sexually
transmitted disease can be caused by multiple serovars of
Chlamydia Trachomatis. The bacterium gains entry through
breaches in the epithelial/mucous membranes, travelling
through the lymphatics via macrophages to local nodes. It is
endemic to Africa, India, Caribbean, central America and
southeast Asia.
The disease presents in two stages:
Primary stage: Self-limiting painless genital ulcer at the site
of inoculation 3-12 days later.
Secondary stage: Presents 1-6 months later with unilateral
painful lymphadenitis/lymphangitis. The site of inoculation
dictates symptomatology, if rectally, then tenesmus,
proctocolitis, strictures and fistulas can ensue. Cervicitis and
urethritis are also common features. Enlarged lymph nodes
are known as buboes, they are often painful and can lead to
thinning of the overlying skin causing abscesses. Groove sign
is separation inguinal nodes by the inguinal ligament and is
characteristic of the disease.
Diagnosis is achieved by enzyme linked immunoassays or
polymerase chain reaction of infected sample areas/pus.
Acute and convalescent sera can be used, but requires two
samples 2 weeks apart.
Treatment involves antibiotics, either doxycycline or
macrolides (azithromycin or erythromycin) and potential
surgical drainage/aspiration of the buboes or abscesses.
Complications of the disease include: genital elephantiasis,
hepatitis, infertility, pelvic inflammatory disease, arthritis
and fitz hugh curtis syndrome.
Please see Q-3 for STI: Ulcers

Q-10
Which of the following anti-retroviral drugs is a known
inducer of cytochrome P450?
A. Nevirapine
B. Ritonavir
C. Saquinavir
D. Nelfinavir
E. Zidovudine
ANSWER:
A. Nevirapine
EXPLANATION:
HIV: anti-retrovirals - P450 interaction
• nevirapine (a NNRTI): induces P450
• protease inhibitors: inhibits P450
Like other protease inhibitors, ritonavir is a potent inhibitor
of the P450 systemHIV: ANTI-RETROVIRALS
Highly active anti-retroviral therapy (HAART) involves a
combination of at least three drugs, typically two nucleoside
reverse transcriptase inhibitors (NRTI) and either a protease
inhibitor (PI) or a non-nucleoside reverse transcriptase
inhibitor (NNRTI). This combination both decreases viral
replication but also reduces the risk of viral resistance
emerging
Following the 2015 BHIVA guidelines it is now recommended
that patients start HAART as soon as they have been
diagnosed with HIV, rather than waiting until a particular CD4
count, as was previously advocated.
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
Integrase inhibitors
• examples: raltegravir, elvitegravir, dolutegravir

Q-11
A 43-year-old sheep farmer presents with a lesion on his
right hand. It initially started as a small, raised, red papule
but has now become larger. On examination a 2cm, flattopped haemorrhagic lesion is
seen. What is the most likely
diagnosis?
A. Orf
B. Staphylococcal furuncle
C. Hand, foot and mouth disease
D. Paronychia
E. Anthrax
ANSWER:
A. Orf
EXPLANATION:
ORF
Orf is generally a condition found in sheep and goats although
it can be transmitted to humans. It is caused by the parapox
virus.
In animals
• 'scabby' lesions around the mouth and nose
In humans
• generally affects the hands and arms
• initially small, raised, red-blue papules
• later may increase in size to 2-3 cm and become flattopped and haemorrhagic

Q-12
A 29-year-old Russian man who has recently arrived into the
country presents with fever and feeling generally unwell. His
temperature is 38.2ºC and pulse 96/min. On examination a
grey coating is seen surrounding the tonsils and there is
extensive cervical lymphadenopathy. What is the most likely
diagnosis?
A. Dengue fever
B. Typhoid
C. Paratyphoid
D. Actinomycosis
E. Diphtheria
ANSWER:
E. Diphtheria
EXPLANATION:
DIPHTHERIA
Diphtheria is caused by the Gram positive bacterium
Corynebacterium diphtheriae
Pathophysiology
• releases an exotoxin encoded by a β-prophage
• exotoxin inhibits protein synthesis by catalyzing ADPribosylation of elongation
factor EF-2
Diphtheria toxin commonly causes a 'diphtheric membrane'
on tonsils caused by necrotic mucosal cells. Systemic
distribution may produce necrosis of myocardial, neural and
renal tissue
Possible presentations
• recent visitors to Eastern Europe/Russia/Asia
• sore throat with a 'diphtheric membrane' - see above
• bulky cervical lymphadenopathy
• neuritis e.g. cranial nerves
• heart block

Q-13
A 54 year old female is admitted with a severe pneumonia
following a holiday in Turkey. Bloods reveal both
hyponatraemia and deranged liver function tests. A chest xray shows patchy alveolar
infiltrates with consolidation in
the right lower lobe. Which one of the following
investigations is most likely to confirm the probable
diagnosis?
A. Sputum culture
B. Urinary antigen
C. Blood cultures
D. Bone marrow aspirate
E. Lumbar puncture
ANSWER:
B. Urinary antigen
EXPLANATION:
Legionella pneumophilia is best diagnosed by the urinary
antigen test
LEGIONELLA
Legionnaire's disease is caused by the intracellular bacterium
Legionella pneumophilia. It is typically colonizes water tanks
and hence questions may hint at air-conditioning systems or
foreign holidays. Person-to-person transmission is not seen
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
Comparison of Legionella and Mycoplasma pneumonia
Chest x-ray features of legionella pnuemonia are non-specific but includes a midto-
lower zone predominance of patchy consolidation. Pleural effusions are seen in
around 30%.

Q-14
You are speaking to the partner of a 28-year-old man who
has recently been admitted with pyrexia and neck stiffness.
The results of initial investigations are shown below:
Serum glucose 5.0 mmol/l
Lumbar puncture:
Appearance Cloudy
Glucose 1.2 mmol/l
Protein 1.8 g/l
White cells 450 / mm³ (85% polymorphs)
Microscopy Gram-negative diplococci
No other results concerning the serotype of the organism are
available.
The partner is 27-years-old and has no past medical history
of note other than depression for which she takes fluoxetine.
She has had a full course of immunisations including a course
of MenC vaccines whilst at university 8 years ago. What is
the most appropriate next step to reduce her chance of
developing meningitis?
A. No further action is required
B. MenC booster dose
C. Oral ciprofloxacin + MenC booster dose
D. Oral ciprofloxacin
E. Oral rifampicin
ANSWER:
D. Oral ciprofloxacin
EXPLANATION:
Tough question. Clearly the patient has meningitis which the
CSF microscopy confirms as being due to meningococcal
[Link] there is the choice between ciprofloxacin and
rifampicin. Rifampicin has being historically used for this
purpose but the most recent guidance from the Health
Protection Agency and the Greenbook supports the use of
ciprofloxacin.
Secondly there is the question as to whether a booster dose
of vaccine is needed. The guidelines regarding this are
worded vaguely but imply that most close contacts should
receive a booster dose/complete course of vaccine
depending on the serotype of the organism. As this is not
known, only oral chemoprophylaxis should be given for now,
with the vaccine given once this is ascertained. Please see
the HPA link for more details.
MENINGITIS: MANAGEMENT
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
Management
All patients should be transferred to hospital urgently. If
patients are in a pre-hospital setting (for example a GP
surgery) and meningococcal disease is suspected then
intramuscular benzylpenicillin may be given, as long as this
doesn't delay transit to hospital.
BNF recommendations on antibiotics
Scenario BNF recommendation
Initial empirical therapy aged < 3
months
Intravenous cefotaxime +
amoxicillin
Initial empirical therapy aged 3 months
- 50 years
Intravenous cefotaxime*
Initial empirical therapy aged > 50
years
Intravenous cefotaxime +
amoxicillin
Meningococcal meningitis Intravenous benzylpenicillin or
cefotaxime
Pneuomococcal meningitis Intravenous cefotaxime
Meningitis caused by Haemophilus
influenzae
Intravenous cefotaxime
Meningitis caused by Listeria Intravenous amoxicillin +
gentamicin
If the patient has a history of immediate hypersensitivity
reaction to penicillin or to cephalosporins the BNF
recommends using chloramphenicol.
Management of contacts
• prophylaxis needs to be offered to household and close
contacts of patients affected with meningococcal
meningitis
• oral ciprofloxacin or rifampicin or may be used. The
Health Protection Agency (HPA) guidelines now state that
whilst either may be used ciprofloxacin is the drug of
choice as it is widely available and only requires one dose
• the risk is highest in the first 7 days but persists for at
least 4 weeks
• meningococcal vaccination should be offered to close
contacts when serotype results are available, including
booster doses to those who had the vaccine in infancy
• for pneumococcal meninigitis no prophylaxis is generally
needed. There are however exceptions to this. If a cluster
of cases of pneumococcal meninigitis occur the HPA have
a protocol for offering close contacts antibiotic
prophylaxis. Please see the link for more details
*in the 2015 update of the NICE Meningitis (bacterial) and
meningococcal septicaemia in under 16s: recognition,
diagnosis and management the recommendation for initial
empiracally therapy for children > than 3 months is
intravenous ceftriaxone

Q-15
A 35-year-old man is reviewed in clinic having been
diagnosed with HIV two years ago and is stable on antiretroviral therapy. He has a
new regular partner and is
concerned about transmitting the disease to him. What
factor is most likely to increase the risk of transmission?
A. Circumcision
B. Low CD4 count
C. Co-infection with genital warts
D. Diabetes
E. Mucosal ulceration
ANSWER:
E. Mucosal ulceration
EXPLANATION:
The correct answer is mucosal ulceration. Ulceration limits
barrier protection to HIV infection. A low CD4 count is not
associated with increased transmission rate, but an
increased HIV viral load. Genito-urinary infection can
increase transmission rates but genital warts has not been
shown to do so. Diabetes would increase the rates of
bacterial and fungal infections but not viral ones.
Circumcision is protective to HIV transmission.
HIV: OPPORTUNISTIC INFECTIONS AND OTHER DISORDERS
The table below shows the infections and other disorders that
may be encountered by patients with HIV according to the
CD4 count.CD4 count 200 - 500 cells/mm³
Disorder Notes
Oral thrush Secondary to Candida albicans
Shingles Secondary to herpes zoster
Hairy leukoplakia Secondary to EBV
Kaposi sarcoma Secondary to HHV-8
CD4 count 100 - 200 cells/mm³
Disorder Notes
Cryptosporidiosis Whilst patients with a CD4 count of 200-500 may
develop cryptosporidiosis the disease is usually self-limiting
and similar to that in immunocompetent hosts
Cerebral toxoplasmosis
Progressive multifocal
leukoencephalopathy
Secondary to the JC virus
Pneumocystis
jiroveciipneumonia
HIV dementia
CD4 count 50 - 100 cells/mm³
Disorder Notes
Aspergillosis Secondary to Aspergillus fumigatus
Oesophageal candidiasis Secondary to Candida albicans
Cryptococcal meningitis
Primary CNS lymphoma Secondary to EBV
CD4 count < 50 cells/mm³
Disorder Notes
Cytomegalovirus retinitis Affects around 30-40% of patients
with CD4 < 50 cells/mm³
Mycobacterium avium-intracellulare
infection

Q-16
A 48 year old farmer attends the emergency department 7
days after cutting his arm from falling on barbed wire in his
field. He complaints of fever, headache and painful spasms
in his neck and back which last several minutes.
You suspect tetanus and he tells you he has completed a
course of tetanus vaccination previously.
What is the most appropriate treatment?
A. Tetanus booster
B. IM tetanus immunoglobulin
C. Tetanus antitoxin
D. Flucloxacillin
E. Ciprofloxacin
ANSWER:
B. IM tetanus immunoglobulin
EXPLANATION:
In this case there is a high risk wound and symptoms so
tetanus immunuglobulin would be advised alongside a
muscle relaxant such as diazepam, and ventilatory support if
needed. A tetanus booster is not recommended in the UK if
the patient is already immunized. Tetanus antitoxin may be
used in developing countries as it is cheaper but it has a
higher rate of anaphylaxis and a shorter half life so is not
recommended in the UK.
High risk wounds
• Wounds burns needing surgery delayed more than 6
hours
• Wounds contaminated with soil
• Compound fractures
• Wounds containing foreign bodies
• Wounds/burns in people with systemic sepsis
TETANUS
Tetanus is caused by the tetanospasmin exotoxin released
from Clostridium tetani. Tetanus spores are present in soil and
may be introduced into the body from a wound, which is
often unnoticed. Tetanospasmin prevents release of GABA
Features
• prodrome fever, lethargy, headache
• trismus (lockjaw)
• risus sardonicus
• opisthotonus (arched back, hyperextended neck)
• spasms (e.g. dysphagia)
Management
• supportive therapy including ventilatory support and
muscle relaxants
• intramuscular human tetanus immunoglobulin for highrisk wounds (e.g. compound
fractures, delayed surgical
intervention, significant degree of devitalised tissue)
• metronidazole is now preferred to benzylpenicillin as the
antibiotic of choice

Q-17
A 25-year-old woman is admitted to a local hospital whilst
travelling in north India. She is 26 weeks pregnant with her
first child and the pregnancy has been uneventful to date.
For the past 3-4 days she has been feeling generally unwell
with fever, lethargy and vomiting. She takes no regular
medication other than malaria prophylaxis (chloroquine).
On examination her pulse is 96/min, blood pressure 102/66
mmHg. Jaundiced sclera, along with some bruising on her
arms is noted. Her partner states that she also seems
confused.
Bloods show the following:
Bilirubin102 µmol/lALP 256 u/l
ALT 1024 u/l
γGT 563 u/l
Albumin35 g/l
INR 2.4
What is the most likely cause of her deterioration?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis E
D. Malaria
E. Amoebiasis
ANSWER:
C. Hepatitis E
EXPLANATION:
Severe hepatitis in a pregnant woman - think hepatitis E
This lady has developed fulminant hepatitis, or acute liver
failure. This is uncommon with the hepatitis viruses but
pregnant women are at particular risk from hepatitis E
infection. As women approach their third trimester (slightly
later than the scenario here) the mortality rate approaches
20%.
HEPATITIS E
Overview
• RNA hepevirus
• spread by the faecal-oral route
• incubation period: 3-8 weeks
• common in Central and South-East Asia, North and West
Africa, and in Mexico
• causes a similar disease to hepatitis A, but carries a
significant mortality (about 20%) during pregnancy
• does not cause chronic disease or an increased risk of
hepatocellular cancer
• a vaccine is currently in development*, but is not yet in
widespread use

Q-18
A 23-year-old solider who returned from a tour of
Afghanistan 2 months ago presents with a large painless
ulcer on the back of his hand. He reports that it started as a
small papule and gradually enlarged. On examination he has
a 3cm ulcer with a central depression and a raised indurated
border. He is otherwise well in himself and has no other
medical problems.
What is the likely diagnosis?
A. Cutaneous leishmaniasis
B. Sarcoidosis
C. Primary syphilis
D. Pyoderma gangrenosum
E. Buruli ulcer
ANSWER:
A. Cutaneous leishmaniasis
EXPLANATION:
Given the travel history to Afghanistan and the painless
single lesion the most likely explanation is cutaneous
leishmaniasis. Primary syphilis may present with a single
painless lesion but the large size and location on the back of
the hand is unusual. Pyoderma gangrenosum you would
expect to be painful and present more acutely. A buruli ulcer
is an ulcer caused by mycobacterium ulcerans and can
present like this but is rare, usually found in children and has
not been reported in the Middle East.
Source: WHO fact sheets on leishmaniasis
Cutaneous leishmaniasis is transmitted by sandflies and
usually presents as an erythematous patch or papule which
gradually enlarges and becomes an ulcer with a raised
indurated border. In 'dry' forms the lesion is crusted with a
raised edge. It is usually painless unless a secondary
bacterial infection is present. Afghanistan has particularly
high levels of cutaneous leishmaniasis.
LEISHMANIASIS
Leishmaniasis is caused by the intracellular protozoa
Leishmania, usually being spread by sand flies. Cutaneous,
mucocutaneous leishmaniasis and visceral forms are seen
Cutaneous leishmaniasis
• caused by Leishmania tropica or Leishmania mexicana
• crusted lesion at site of bite
• may be underlying ulcer
Mucocutaneous leishmaniasis
• caused by Leishmania braziliensis
• skin lesions may spread to involve mucosae of nose,
pharynx etc
Visceral leishmaniasis (kala-azar)
• mostly caused by Leishmania donovani
• occurs in the Mediterranean, Asia, South America, Africa
• fever, sweats, rigors
• massive splenomegaly. hepatomegaly
• poor appetite*, weight loss
• grey skin - 'kala-azar' means black sickness
• pancytopaenia secondary to hypersplenism
*occasionally patients may report increased appetite with
paradoxical weight loss

Q-19
A 23-year-old man is admitted to the Emergency Department
with an evolving purpuric rash, pyrexia and confusion. His GP
had given him intramuscular benzylpenicillin in the surgery
and dialled 999. Which one of the following investigations is
most likely to reveal the diagnosis?A. Urinary antigen
B. Blood PCR for meningococcus
C. Blood culture
D. CT head
E. Lumbar puncture
ANSWER:
B. Blood PCR for meningococcus
EXPLANATION:
The blood cultures are likely to be negative as antibiotics
have already been given. PCR has a sensitivity of over 90%.
MENINGOCOCCAL SEPTICAEMIA: INVESTIGATIONS
Meningococcal septicaemia is a frightening condition for
patients, parents and doctors. It is associated with a high
morbidity and mortality unless treated early - meningococcal
disease is the leading infectious cause of death in early
childhood. A high index of suspicion is therefore needed.
Much of the following is based on the 2010 NICE guidelines
(please see link).
Presentation of meningococcal disease:
• 15% - meningitis
• 25% - septicaemia
• 60% - a combination of meningitis and septicaemia
Investigations
• blood cultures
• blood PCR
• lumbar puncture is usually contraindicated
• full blood count and clotting to assess for disseminated
intravascular coagulation

Q-20
A 17-year-old girl presents to the emergency department
complaining of a widespread erythematous rash. She has
recently been commenced on amoxicillin for an upper
respiratory tract infection by her general practitioner. Which
of the following is the most appropriate test to provide a
diagnosis?
A. Blood culture
B. Heterophile antibody test
C. Mast cell tryptase
D. Lymph node biopsy
E. Blood film
ANSWER:
B. Heterophile antibody test
EXPLANATION:
Heterophile antibodies - infectious mononucleosis
Infectious mononucleosis is an important differential to
consider in patients presenting with non-specific upper
respiratory tract symptoms, especially in the above
demographic. In patients with infectious mononucleosis,
empirical treatment with amoxicillin often leads to a
morbilliform rash. A heterophile antibody test (Paul-Bunnell)
has high specificity and moderate sensitivity for infectious
mononucleosis.
With the clinical story pointing towards infectious
mononucleosis and with nothing in the story suggesting that
the patient is septic, blood culture would not be appropriate.
Mast cell tryptase is a useful test when investigating an
episode of anaphylaxis. Again the clinical story does not fit
with this and moreover, the mast cell tryptase test would not
provide any useful information in the immediate setting.
Whilst a lymph node biopsy can provide further evidence of
infectious mononucleosis, given its invasive nature and the
rather typical story, it would not be the most appropriate
test.
A blood film may show evidence of atypical lymphocytes, but
would not provide a definitive diagnosis, especially as that
finding is not pathognomonic.
INFECTIOUS MONONUCLEOSIS
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
Other features include:
• malaise, anorexia, headache
• palatal petechiae
• splenomegaly - occurs in around 50% of patients and may
rarely predispose to splenic rupture
• hepatitis, transient rise in ALT
• lymphocytosis: presence of 50% lymphocytes with at
least 10% atypical lymphocytes
• haemolytic anaemia secondary to cold agglutins (IgM)
• a maculopapular, pruritic rash develops in around 99% of
patients who take ampicillin/amoxicillin whilst they have
infectious mononucleosis
Symptoms typically resolve after 2-4 weeks.
Diagnosis
• heterophil antibody test (Monospot test) - NICE
guidelines suggest FBC and Monospot in the 2nd week of
the illness to confirm a diagnosis of glandular [Link] is supportive and
includes:
• rest during the early stages, drink plenty of fluid, avoid
alcohol
• simple analgesia for any aches or pains
• consensus guidance in the UK is to avoid playing contact
sports for 8 weeks after having glandular fever to reduce
the risk of splenic rupture
There is an interesting correlation between EBV and
socioeconomic groups. Lower socioeconomic groups have
high rates of EBV seropositivity, having frequently acquired
EBV in early childhood when the primary infection is often
subclinical. However, higher socioeconomic groups show a
higher incidence of infectious mononucleosis, as acquiring
EBV in adolescence or early adulthood results in symptomatic
disease.

Q-21
You attend a meeting with the hospital management. There
is currently an increased incidence of MRSA septicaemia in
the hospital and a strategy is being drawn up to tackle this.
What is the most effective single step to reduce the
incidence of MRSA?
A. The use of personal protective equipment for staff
including gloves and aprons
B. Hand hygiene
C. Screening patients for MRSA on admission
D. Cohort nursing
E. Limiting the number of visitors
ANSWER:
B. Hand hygiene
EXPLANATION:
Whilst tackling MRSA requires a multi-pronged approach the
evidence base demonstrates that hand hygiene is the single
most important step
MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) was one
of the first organisms which highlighted the dangers of
hospital-acquired infections.
Who should be screened for MRSA?
• all patients awaiting elective admissions (exceptions
include day patients having terminations of pregnancy
and ophthalmic surgery. Patients admitted to mental
health trusts are also excluded)
• from 2011 all emergency admissions will be screened
How should a patient be screened for MRSA?
• nasal swab and skin lesions or wounds
• the swab should be wiped around the inside rim of a
patient's nose for 5 seconds
• the microbiology form must be labelled 'MRSA screen'
Suppression of MRSA from a carrier once identified
• nose: mupirocin 2% in white soft paraffin, tds for 5 days
• skin: chlorhexidine gluconate, od for 5 days. Apply all over
but particularly to the axilla, groin and perineum
The following antibiotics are commonly used in the treatment
of MRSA infections:
• vancomycin
• teicoplanin
• linezolid
Some strains may be sensitive to the antibiotics listed below
but they should not generally be used alone because
resistance may develop:
• rifampicin
• macrolides
• tetracyclines
• aminoglycosides
• clindamycin
Relatively new antibiotics such as linezolid,
quinupristin/dalfopristin combinations and tigecycline have
activity against MRSA but should be reserved for resistant
cases
Interaction of MRSA (green bacteria) with a human white cell. The bacteria shown
is strain MRSA252, a leading cause of hospital-associated infections in the United
States and United Kingdom. Credit: NIAID

Q-22
A patient with a severe headache, nausea and vomiting
comes to the emergency department. Examination reveals
neck stiffness and a positive Kernig's sign. A lumbar puncture
is performed and the CSF is purulent. She is urgently started
on ceftriaxone. Which class of antibiotics does ceftriaxone
belong to?
A. Macrolides
B. Tetracyclines
C. Aminoglycosides
D. Beta-lactams
E. Lincosamides
ANSWER:
D. Beta-lactams
EXPLANATION:
Cephalosporins are a type of beta-lactam
Ceftriaxone is a cephalosporin, which is a subset of betalactams. Beta-lactams also
include penicillins and
carbapenems. Cephalosporins are incredibly potent
antibiotics and are usually reserved for very severe
conditions (e.g. meningitis, as in this scenario).
CEPHALOSPORINS
Cephalosporins are a type of β-lactam antibiotic which are
bactericidal. They are less susceptible to penicillinases than
penicillins.
β-lactam antibiotics work by disrupting the synthesis of
bacterial cell walls, by inhibiting peptidoglycan cross-linking.
Mechanism of resistance
• Changes to penicillin-binding-proteins (PBPs), which are
types of transpeptidases (enzymes produced by bacteria
that cross-links peptidoglycan chains to form rigid cell
walls)

Q-23
A health care assistant 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?
A. HIV test of health care worker in 3 months to determine
treatment
B. Immediate p24 HIV test of health care worker to
determine treatment
C. Oral antiretroviral therapy for 4 weeks
D. Oral antiretroviral therapy for 3 months
E. Intravenous zidovudine
ANSWER:
C. Oral antiretroviral therapy for 4 weeks
EXPLANATION:
Post-exposure prophylaxis for HIV: oral antiretroviral
therapy for 4 weeks
POST-EXPOSURE PROPHYLAXIS
Hepatitis A
• Human Normal Immunoglobulin (HNIG) or hepatitis A
vaccine may be used depending on the clinical situation
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
Hepatitis C
• monthly PCR - if seroconversion then interferon +/-
ribavirin
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%
Varicella zoster
• VZIG for IgG negative pregnant
women/immunosuppressed
Estimates of transmission risk for single needlestick injury
Hepatitis B 20-30%
Hepatitis C 0.5-2%
HIV 0.3%

Q-24
A 44-year-old farmer presents with headache, fever and
muscle aches. He initially thought he had a bad cold but his
symptoms have got progressively worse over the past week.
During the review of systems he reports nausea and a
decreased urine output. On examination his temperature is
38.2ºC, pulse 102 / min and his chest is clear.
Subconjunctival haemorrhages are noted but there is no
evidence of jaundice. What is the most likely diagnosis?
A. Mycoplasma pneumonia
B. Lyme disease
C. Legionella pneumonia
D. Listeria
E. Leptospirosis
ANSWER:
E. Leptospirosis
EXPLANATION:
The main clue in the question is the patients occupation.
Mycoplasma and Legionella are less likely due to the absence
of chest symptoms and signs. Liver failure is seen in only 10%
of patients with leptospirosis..
LEPTOSPIROSIS
Also known as Weil's disease*, leptospirosis is commonly seen
in questions referring to sewage workers, farmers, vets or
people who work in abattoir. It is caused by the spirochaeteLeptospira interrogans
(serogroup L icterohaemorrhagiae),
classically being spread by contact with infected rat urine.
Weil's disease should always be considered in high-risk
patients with hepatorenal failure
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
*the term Weil's disease is sometimes reserved for the most
severe 10% of cases that are associated with jaundice

Q-25
A 29-year-old woman develops severe vomiting four hours
after having lunch at a local restaurant. What is the most
likely causative organism?
A. Escherichia coli
B. Shigella
C. Campylobacter
D. Salmonella
E. Staphylococcus aureus
ANSWER:
E. Staphylococcus aureus
EXPLANATION:
The short incubation period and severe vomiting point to a
diagnosis of Staphylococcus aureus food poisoning.
GASTROENTERITIS: CAUSES
Gastroenteritis may either occur whilst at home or whilst
travelling abroad (travellers' diarrhoea)
Travellers' diarrhoea may be defined as at least 3 loose to
watery stools in 24 hours with or without one of more of
abdominal cramps, fever, nausea, vomiting or blood in the
stool. The most common cause is Escherichia coli.
Another pattern of illness is 'acute food poisoning'. This
describes the sudden onset of nausea, vomiting and diarrhoea
after the ingestion of a toxin. Acute food poisoning is typically
caused by Staphylococcus aureus, Bacillus cereus or
Clostridium perfringens.
Stereotypical histories
Infection Typical presentation
Escherichia coli Common amongst travellers
Watery stools
Abdominal cramps and nausea
Infection Typical presentation
Giardiasis Prolonged, non-bloody diarrhoea
Cholera Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers
Shigella Bloody diarrhoea
Vomiting and abdominal pain
Staphylococcus
aureus
Severe vomiting
Short incubation period
Campylobacter A flu-like prodrome is usually followed by crampy
abdominal pains, fever and diarrhoea which may be
bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome
Bacillus cereus Two types of illness are seen
• vomiting within 6 hours, stereotypically due
to rice
• diarrhoeal illness occurring after 6 hours
Amoebiasis Gradual onset bloody diarrhoea, abdominal pain and
tenderness which may last for several weeks
Incubation period
• 1-6 hrs: Staphylococcus aureus, Bacillus cereus*
• 12-48 hrs: Salmonella, Escherichia coli
• 48-72 hrs: Shigella, Campylobacter
• > 7 days: Giardiasis, Amoebiasis
*vomiting subtype, the diarrhoeal illness has an incubation
period of 6-14 hours

Q-26
A patient is prescribed zanamivir (Relenza) for suspected
influenza. Which one of the following underlying problems
may increase the likelihood of side-effects?
A. A history of aspirin sensitivity
B. Epilepsy
C. Asthma
D. Renal impairment
E. Concurrent use with drugs that prolong the QT interval
ANSWER:
C. Asthma
EXPLANATION:
Zanamivir (Relenza) may induce bronchospasm in
asthmatics.
H1N1 INFLUENZA PANDEMIC
The 2009 H1N1 influenza (swine flu) outbreak was first
observed in Mexico in early 2009. In June 2009, the WHO
declared the outbreak to be a pandemic.H1N1
The H1N1 virus is a subtype of the influenza A virus and the
most common cause of flu in humans. The 2009 pandemic
was caused by a new strain of the H1N1 virus.
The following groups are particularly at risk:
• patients with chronic illnesses and those on
immunosuppressants
• pregnant women
• young children under 5 years old
Features
The majority of symptoms are typical of those seen in a flulike illness:
• fever greater than 38ºC
• myalgia
• lethargy
• headache
• rhinitis
• sore throat
• cough
• diarrhoea and vomiting
A minority of patients may go on to develop an acute
respiratory distress syndrome which may require ventilatory
support.
Treatment
There are two main treatments currently available:
Oseltamivir (Tamiflu)
• oral medication
• a neuraminidase inhibitor which prevents new viral
particles from being released by infected cells
• common side-effects include nausea, vomiting, diarrhoea
and headaches
Zanamivir (Relenza)
• inhaled medication*
• also a neuraminidase inhibitor
• may induce bronchospasm in asthmatics
*intravenous preparations are available for patients who are
acutely unwell

Q-27
A 30-year-old man presents to the emergency department 4
weeks after returning from a two-week business trip to
India. For the past week he has felt generally unwell with
fever and lethargy. Last night he started to pass bloody
diarrhoea and have high fevers.
On examination his temperature is 38.2ºC, pulse 102/min,
blood pressure 104/68 mmHg. Tender hepatomegaly is
noted on examination.
Bloods show the following:
Hb 116 g/l
Platelets 269 * 109/l
WBC 13.6 * 109/l
CRP 156 mg/l
Bilirubin 43 µmol/l
ALP 168 u/l
ALT 68 u/l
γGT 205 u/l
Albumin 37 g/l
What is the most likely causative organism/virus?
A. Hepatitis A virus
B. Plasmodium falciparum
C. Entamoeba histolytica
D. Giardia lamblia
E. Campylobacter jejuni
ANSWER:
C. Entamoeba histolytica
EXPLANATION:
This patient presents with dysentery and hepatomegaly. The
unifying diagnosis is amoebiasis with an amoebic liver
abscess. A differential diagnosis here would be Escherichia
coli which can cause both dysentery as well as a pyogenic
liver abscess.
Giardia lamblia does not typically cause bloody diarhoea.
Campylobacter jejuni is not a cause of hepatomegaly.
AMOEBIASIS
Amoebiasis is caused by Entamoeba histolytica (an amoeboid
protozoan) and spread by the faecal-oral route. It is estimated
that 10% of the world's population is chronically infected.
Infection can be asymptomatic, cause mild diarrhoea or
severe amoebic dysentery. Amoebiasis also causes liver and
colonic abscesses
Amoebic dysentery
• profuse, bloody diarrhoea
• stool microscopy may show trophozoites
• treatment is with metronidazole
Amoebic liver abscess
• usually a single mass in the right lobe (may be multiple)
• features: fever, RUQ pain
• serology is positive in > 90%

Q-28
A 29-year-old man with HIV is admitted with shortness of
breath. He has recently emigrated from South Africa and has
only just started taking anti-retroviral medication.
Auscultation of his chest is unremarkable although chest x-ray shows bilateral
pulmonary interstitial shadowing. What
is the investigation of choice?
A. Bronchoalveolar lavage
B. CT thorax
C. Transbronchial biopsy
D. Sputum culture
E. Blood culture
ANSWER:
A. Bronchoalveolar lavage
EXPLANATION:
This man likely has Pneumocystis carinii pneumonia.
Definitive diagnosis is by bronchial alveolar lavage with
silver staining
HIV: PNEUMOCYSTIS JIROVECI PNEUMONIA
Whilst the organism Pneumocystis carinii is now referred to as
Pneumocystis jiroveci, the term Pneumocystis carinii
pneumonia (PCP) is still in common use
• Pneumocystis jiroveci is an unicellular eukaryote,
generally classified as a fungus but some authorities
consider it a protozoa
• PCP is the most common opportunistic infection in AIDS
• all patients with a CD4 count < 200/mm³ should receive
PCP prophylaxis
Features
• dyspnoea
• dry cough
• fever
• very few chest signs
Pneumothorax is a common complication of PCP.
Extrapulmonary manifestations are rare (1-2% of cases), may
cause
• hepatosplenomegaly
• lymphadenopathy
• choroid lesions
Investigation
• CXR: typically shows bilateral interstitial pulmonary
infiltrates but can present with other x-ray findings e.g.
lobar consolidation. May be normal
• exercise-induced desaturation
• sputum often fails to show PCP, bronchoalveolar lavage
(BAL) often needed to demonstrate PCP (silver stain
shows characteristic cysts)
Management
• co-trimoxazole
• IV pentamidine in severe cases
• steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce
risk of respiratory failure by 50% and death by a third)
CT scan showing a large pneumothorax developing in a patient
with Pneumocystis jiroveci pneumonia

Q-29
A 12-year-old boy who had a splenectomy following a road
traffic accident is reviewed in clinic. He had his full
immunisation course as a child and was given a repeat
pneumococcal vaccination 5 days following surgery. What is
the most appropriate ongoing management?
A. Booster dose of Hib and MenC vaccine + lifelong
penicillin V
B. Booster dose of Hib and MenC vaccine + penicillin V for
2 years
C. Lifelong penicillin V
D. Booster dose of Hib and MenC vaccine + annual influenza vaccination + penicillin
V for 2 years
E. Booster dose of Hib and MenC vaccine + annual
influenza vaccination + lifelong penicillin V
ANSWER:
D. Booster dose of Hib and MenC vaccine + annual influenza vaccination + penicillin
V for 2 years
EXPLANATION:
Debate still exists regarding how long a patient should take
penicillin prophylaxis for. The majority of doctors advocate
lifelong penicillin. Consensus guidelines agree however that
In this case prophylaxis should be continued until the patient
is at least 16 years old, so of the available options E is the
correct answer
SPLENECTOMY
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 yearsAntibiotic 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
Surgical aspects
Indications
• Trauma: 1/4 are iatrogenic
• Spontaneous rupture: EBV
• Hypersplenism: hereditary spherocytosis or elliptocytosis
etc
• Malignancy: lymphoma or leukaemia
• Splenic cysts, hydatid cysts, splenic abscesses
Splenectomy following trauma
• GA
• Long midline incision
• If time permits insert a self retaining retractor (e.g.
Balfour/ omnitract)
• Large amount of free blood is usually present. Pack all 4
quadrants of the abdomen. Allow the anaesthetist to
'catch up'
• Remove the packs and assess the viability of the spleen.
Hilar injuries and extensive parenchymal lacerations will
usually require splenectomy.
• Divide the short gastric vessels and ligate them.
• Clamp the splenic artery and vein. Two clamps on the
patient side are better and allow for double ligation and
serve as a safety net if your assistant does not release the
clamp smoothly.
• Be careful not to damage the tail of the pancreas, if you
do then this will need to be formally removed and the
pancreatic duct closed.
• Wash out the abdomen and place a tube drain to the
splenic bed.
• Some surgeons implant a portion of spleen into the
omentum, whether you decide to do this is a matter of
personal choice.
• Postoperatively the patient will require prophylactic
penicillin V and pneumococcal vaccine.
Elective splenectomy
• Elective splenectomy is a very different operation from
that performed in the emergency setting. The spleen is
often large (sometimes massive)
• Most cases can be performed laparoscopically. The spleen
will often be macerated inside a specimen bag to
facilitate extraction.
Complications
• Haemorrhage (may be early and either from short gastrics
or splenic hilar vessels
• Pancreatic fistula (from iatrogenic damage to pancreatic
tail)
• Thrombocytosis: prophylactic aspirin
• Encapsulated bacteria infection e.g. Strep. pneumoniae,
Haemophilus influenzae and Neisseria meningitidis
Post-splenectomy changes
• Platelets will rise first (therefore in ITP should be given
after splenic artery clamped)
• Blood film will change over following weeks, Howell-Jolly
bodies will appear
• Other blood film changes include target cells and
Pappenheimer bodies
• Increased risk of post-splenectomy sepsis, therefore
prophylactic antibiotics and pneumococcal vaccine should
be given.
Post-splenectomy sepsis
• Typically occurs with encapsulated organisms
• Opsonisation occurs but then not recognised
*usually from dog bites

Q-30
What is the mechanism of action of the antiviral agent
amantadine?
A. Inhibits DNA polymerase
B. Protease inhibitor
C. Nucleoside analogue reverse transcriptase inhibitor
D. Inhibits uncoating of virus in the cell
E. Interferes with the capping of viral mRNA
ANSWER:
D. Inhibits uncoating of virus in the cell
EXPLANATION:
Please see Q-8 for Antiviral Agents

Q-31
What is the first line antibiotic in the treatment of Shigella
dysentery?
A. Flucloxacillin
B. Vancomycin
C. Ciprofloxacin
D. Metronidazole
E. Ampicillin
ANSWER:
C. Ciprofloxacin
EXPLANATION:
SHIGELLA
Overview
• causes diarrhoea (may be bloody), abdominal pain
• severity depends on type: S sonnei (e.g. from UK) may be
mild, S. flexneri or S. dysenteriae from abroad may cause
severe disease• Shigella infection is usually self-limiting and does not
require antibiotic treatment
• antibiotics (e.g. ciprofloxacin) are indicated for people
with severe disease, who are immunocompromised or
with bloody diarrhoea

Q-32
A tearful 35-year-old pregnant lady reports that her husband
has recently told her he has chlamydia. She is currently at 36
weeks gestation and is requesting treatment for chlamydia.
What (if anything) should you give her?
A. Azithromycin 1 g single dose
B. Reassure her that if her results come back negative then
she does not need treatment
C. Doxycycline 100mg BD for 7 days
D. Ceftriaxone 500 mg intramuscular (IM) injection
E. Gentamicin 3mg/kg
ANSWER:
A. Azithromycin 1 g single dose
EXPLANATION:
All chlamydia contacts are offered treatment. Prompt
treatment in this patient is essential as she is due to give
birth soon and if the chlamydia is untreated she risks passing
it on to her baby.
CHLAMYDIA
Chlamydia is the most prevalent sexually transmitted infection
in the UK and is caused by Chlamydia trachomatis, an obligate
intracellular pathogen. Approximately 1 in 10 young women in
the UK have Chlamydia. The incubation period is around 7-21
days, although it should be remembered a large percentage of
cases are asymptomatic
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
Pap smear demonstrating infected endocervical cells. Red inclusion bodies
are typical
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)
Another Pap smear demonstrating infected endocervical cells. Stained with H&E

Q-33
Which one of the following is true regarding linezolid?
A. Active against both MRSA and VRE (VancomycinResistant Enterococcus)
B. Bactericidal in action
C. No activity against GISA (Glycopeptide Intermediate
Staphylococcus aureus
D. Adverse effects include raised platelet count
E. Inhibits RNA synthesis
ANSWER:
A. Active against both MRSA and VRE (VancomycinResistant Enterococcus)
EXPLANATION:
LINEZOLID
Linezolid is a type of oxazolidonone antibiotic which has been
introduced in recent years. It inhibits bacterial protein
synthesis by stopping formation of the 70s initiation complex
and is bacteriostatic nature
Spectrum, highly active against Gram positive organisms
including:
MRSA (Methicillin-resistant Staphylococcus aureus)
VRE (Vancomycin-resistant enterococcus)
GISA (Glycopeptide Intermediate Staphylococcus aureus)
Adverse effects
• thrombocytopenia (reversible on stopping)
• monoamine oxidase inhibitor: avoid tyramine containing
foods

Q-34
A 40-year-old woman who is known to be HIV positive is
admitted to the Emergency Department following a seizure.
Her partner reports that she has been having headaches,
night sweats and a poor appetite for the past four weeks.
Blood tests and a CT head are arranged:
CD4 89 u/l
CT head Single homogenously-enhancing lesion in
the right parietal lobe
What is the most likely diagnosis?
A. Primary CNS lymphoma
B. Tuberculosis
C. Progressive multifocal leukoencephalopathy
D. Cryptococcus
E. Toxoplasmosis
ANSWER:
A. Primary CNS lymphoma
EXPLANATION:
This is a difficult question. Toxoplasmosis is the most
common cause of brain lesions in HIV patients. However,
around 80% of toxoplasmosis cases involve multiple lesions
and the history is suggestive of lymphoma. Cerebral
tuberculosis is much less common than lymphoma in HIV.
HIV: NEUROCOMPLICATIONS
Focal neurological lesions
Toxoplasmosis
• accounts for around 50% of cerebral lesions in patients
with HIV
• constitutional symptoms, headache, confusion,
drowsiness
• CT: usually single or multiple ring enhancing lesions, mass
effect may be seen
• management: sulfadiazine and pyrimethamine
Cerebral toxoplasmosis: CT scan with contrast showing multiple ring
enhancing lesions
Cerebral toxoplasmosis: MRI (T1 C+) demonstrates multiple small
peripherally enhancing nodules located predominantly in the basal ganglia
as well as the central portions of the cerebellar hemispheres. Only a small
amount of surrounding oedema is present.
Primary CNS lymphoma
• accounts for around 30% of cerebral lesions
• associated with the Epstein-Barr virus
• CT: single or multiple homogenous enhancing lesions
• treatment generally involves steroids (may significantly
reduce tumour size), chemotherapy (e.g. methotrexate) +with or without whole brain
irradiation. Surgical may be
considered for lower grade tumours
Primary CNS lymphoma: Non-contrast CT demonstrates a hyper-attenuating
mass adjacent to the left lateral ventricle, with no calcification or
haemorrhage.
Primary CNS lymphoma: MRI (T1 C+) demonstrates a large multilobulated
mass in the right frontal lobe. It homogeneously enhances and extends to
involve the caudate and the periventricular area. There is significant mass
effect.
Differentiating between toxoplasmosis and lymphoma is a
common clinical scenario in HIV patients. It is clearly
important given the vastly different treatment strategies. The
table below gives some general differences. Please see the
Radiopaedia link for more details.
Toxoplasmosis Lymphoma
Multiple lesions
Ring or nodular enhancement
Thallium SPECT negative
Single lesion
Solid (homogenous) enhancement
Thallium SPECT positive
Tuberculosis
• much less common than toxoplasmosis or primary CNS
lymphoma
• CT: single enhancing lesion
Generalised neurological disease
Encephalitis
• may be due to CMV or HIV itself
• HSV encephalitis but is relatively rare in the context of
HIV
• CT: oedematous brain
Cryptococcus
• most common fungal infection of CNS
• headache, fever, malaise, nausea/vomiting, seizures,
focal neurological deficit
• CSF: high opening pressure, India ink test positive
• CT: meningeal enhancement, cerebral oedema
• meningitis is typical presentation but may occasionally
cause a space occupying lesion
Progressive multifocal leukoencephalopathy (PML)
• widespread demyelination
• due to infection of oligodendrocytes by JC virus (a
polyoma DNA virus)
• symptoms, subacute onset : behavioural changes, speech,
motor, visual impairment
• CT: single or multiple lesions, no mass effect, don't
usually enhance. MRI is better - high-signal demyelinating
white matter lesions are seen
AIDS dementia complex
• caused by HIV virus itself
• symptoms: behavioural changes, motor impairment
• CT: cortical and subcortical atrophy

Q-35
A 31-year-old woman who is 26 weeks pregnant presents
with a rash. The rash is located just under her axilla and has
been getting progressively larger since it first appeared five
days. She also reports feeling 'flu-like' and having some joint
pains. She has recently returned from a weekend away in
Hampshire. Her pregnancy is uncomplicated to date and
there is no other significant medical history of note. On
examination a large erythematous rash is noted as above. In
the middle a central punctum is seen. Given the likely
diagnosis, what is the most appropriate treatment?
A. Topical miconazole
B. Oral doxycycline
C. Oral amoxicillin
D. Oral fluconazole
E. Oral erythromycin
ANSWER:
C. Oral amoxicillin
EXPLANATION:
This lady has Lyme disease. Doxycycline is therefore
contraindicated and amoxicillin should be given instead. A
fungal rash would not cause the systemic symptoms.
LYME DISEASE
Lyme disease is caused by the spirochaete Borrelia burgdorferi
and is spread by ticks
Features• early: erythema chronicum migrans + systemic features
(fever, arthralgia)
• CVS: heart block, myocarditis
• neuro: cranial nerve palsies, meningitis
Investigation
• NICE recommend that Lyme disease can be diagnosed
clinically if erythema migrans is present
• enzyme-linked immunosorbent assay (ELISA) antibodies
to Borrelia burgdorferi are the first-line test
• if this test is positive or equivocal then an immunoblot
test for Lyme disease should be done
Management of asymptomatic tick bites
• tick bites can be a relatively common presentation to GP
practices, and can cause significant anxiety
• NICE guidance does not recommend routine antibiotic
treatment to patients who've suffered a tick bite
Management of suspected/confirmed Lyme disease
• doxycycline if early disease. Amoxicillin is an alternative if
doxycycline is contraindicated (e.g. pregnancy)
• ceftriaxone if disseminated disease
• Jarisch-Herxheimer reaction is sometimes seen after
initiating therapy: fever, rash, tachycardia after first dose
of antibiotic (more commonly seen in syphilis, another
spirochaetal disease)

Q-36
A 28-year-old student is admitted out of hours to the
infectious diseases ward with suspected malaria following a
backpacking trip around South East Asia. Malarial films are
as follows:
Thick film Parasite burden of 1.5%
Thin film Non-falciparum malaria - Looks like
Plasmodium knowlesi
On admission, the patient is systemically well with
observations at follows:
HR 90bpm
BP 123/75 mmHg
RR 16 breaths per minute
Oxygen Sats 97% on air
Temp 36.4º
Although being relatively well on first admission, you are
called to review her overnight a few hours later, due to her
condition worsening. You arrive to find her observations as
follows:
HR 110bpm
BP 105/65 mmHg
RR 25 breaths per minute
Oxygen Sats 93% on air
Temp 38.4º
Which of the following attributes make Plasmodium
knowlesi infections particularly dangerous?
A. Cytoadherence
B. Hypnozoite formation
C. Short erythrocytic replication stage
D. Resistance to treatment
E. Slow growth leading to late presentation
ANSWER:
C. Short erythrocytic replication stage
EXPLANATION:
P. knowlesi has the shortest erythrocytic replication cycle,
leading to high parasite counts in short periods of time
Plasmodium sp. have two reproductive cycles; an exoerythrocytic cycle which occurs
in hepatocytes, and an
erythrocytic cycle which occurs in the red blood cells. The
length of the erythrocytic cycle varies from species to species,
with P. knowlesi having the fastest cycle at around 24 hours.
The end stage in the cycle involves lysis of the red cells and
release of additional parasites, meaning that P. knowlesi is
capable of producing very high parasite counts in a short
space of time.
For this reason, in Plasmodium knowlesi infection, severe
parasitaemia should be defined as >1%, whereas in other
species, >2% is a marker of severe parasitaemia.
In regards to other options, Plasmodium ovale and
Plasmodium vivax can form hypnozoites, causing clinical
infection long after patients leave malarial areas.
Cytoadherence is an attribute displayed by red cells infected
by Plasmodium falciparum parasites.
MALARIA: NON-FALCIPARUM
The most common cause of non-falciparum malaria is
Plasmodium vivax, with Plasmodium ovale and Plasmodium
malariae accounting for the other cases. Plasmodium vivax is
often found in Central America and the Indian Subcontinent
whilst Plasmodium ovale typically comes from Africa.
Plasmodium knowlesi is another non-falciparum species which
causes clinical pathology, found predominantly in South East
Asia.
Features
• general features of malaria: fever, headache,
splenomegaly
• Plasmodium vivax/ovale: cyclical fever every 48 hours.
Plasmodium malariae: cyclical fever every 72 hours
• Plasmodium malariae: is associated with nephrotic
syndrome
Ovale and vivax malaria have a hypnozoite stage and may
therefore relapse following [Link]
• in areas which are known to be chloroquine-sensitive
then WHO recommend either an artemisinin-based
combination therapy (ACT) or chloroquine
• in areas which are known to be chloroquine-resistant an
ACT should be used
• ACTs should be avoided in pregnant women
• patients with ovale or vivax malaria should be given
primaquine following acute treatment with chloroquine
to destroy liver hypnozoites and prevent relapse

Q-37
A 23-year-old male presents with a purulent urethral
discharge. A sample of the discharge is shown to be a Gram
negative diplococcus. What is the most appropriate
antimicrobial therapy?
A. Oral ciprofloxacin for 7 days
B. Oral penicillin V for 7 days
C. Oral doxycycline for 7 days
D. Oral azithromycin stat dose
E. Intramuscular ceftriaxone stat dose + oral azithromycin stat dose
ANSWER:
D. Oral azithromycin stat dose
EXPLANATION:
Intramuscular ceftriaxone + oral azithromycin is the
treatment of choice for Gonorrhoea
Ciprofloxacin should only be used if the organism is known to
be sensitive due to increasing resistance. Penicillin,
previously first-line treatment, is rarely used now due to
widespread resistance.
GONORRHOEA
Gonorrhoea is caused by the Gram negative diplococcus
Neisseria gonorrhoeae. Acute infection can occur on any
mucous membrane surface, typically genitourinary but also
rectum and pharynx. The incubation period of gonorrhoea is
2-5 days
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)
Local complications that may develop include urethral
strictures, epididymitis and salpingitis (hence may lead to
infertility). Disseminated infection may occur - see below
Management
• ciprofloxacin used to be the treatment of choice.
However, there is increased resistance to ciprofloxacin
and therefore cephalosporins are now used
• the 2011 British Society for Sexual Health and HIV
(BASHH) guidelines recommend ceftriaxone 500 mg
intramuscularly as a single dose with azithromycin 1 g oral
as a single dose. The azithromycin is thought to act
synergistically with ceftriaxone and is also useful for
eradicating any co-existent Chlamydia infections. This
combination can be used in pregnant women as well
• if ceftriaxone is refused or contraindicated other options
include cefixime 400mg PO (single dose)
Colorized scanning electron micrograph of Neisseria gonorrhoeae. Credit:
NIAID
Disseminated gonococcal infection (DGI) and gonococcal
arthritis may also occur, with gonococcal infection being the
most common cause of septic arthritis in young adults. The
pathophysiology of DGI is not fully understood but is thought
to be due to haematogenous spread from mucosal infection
(e.g. Asymptomatic genital infection). Initially there may be a
classic triad of symptoms: tenosynovitis, migratory
polyarthritis and dermatitis. Later complications include septic
arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis
syndrome)
Key features of disseminated gonococcal infection
• tenosynovitis
• migratory polyarthritis
• dermatitis (lesions can be maculopapular or vesicular)

Q-38
Which one of the following statements regarding
toxoplasmosis is true?
A. It is a type of flagellate
B. Congenital toxoplasmosis results in optic nerve atrophy
C. Ceftriaxone should be used initially in patients with HIVassociated
toxoplasmosis
D. The cat is the only known animal reservoir
E. Infection is usually self-limiting
ANSWER:
E. Infection is usually self-limiting
EXPLANATION:
TOXOPLASMOSIS
Toxoplasma gondii is a protozoa which infects the body via
the GI tract, lung or broken skin. It's oocysts release
trophozoites which migrate widely around the body including
to the eye, brain and muscle. The usual animal reservoir is the
cat, although other animals such as rats carry the disease.
Most infections are asymptomatic. Symptomatic patients
usually have a self-limiting infection, often having clinical
features resembling infectious mononucleosis (fever, malaise,
lymphadenopathy). Other less common manifestations
include meningioencephalitis and myocarditis.
Investigation
• antibody test
• Sabin-Feldman dye test
Treatment is usually reserved for those with severe infections
or patients who are immunosuppressed
• pyrimethamine plus sulphadiazine for at least 6 weeks
Congenital toxoplasmosis is due to transplacental spread from
the mother. It causes a variety of effects to the unborn child
including microcephaly, hydrocephalus, cerebral calcification
and choroidoretinitis.
EXPLANATION:
TOXOPLASMOSIS
Toxoplasma gondii is a protozoa which infects the body via
the GI tract, lung or broken skin. It's oocysts release
trophozoites which migrate widely around the body including
to the eye, brain and muscle. The usual animal reservoir is the
cat, although other animals such as rats carry the disease.
Most infections are asymptomatic. Symptomatic patients
usually have a self-limiting infection, often having clinical
features resembling infectious mononucleosis (fever, malaise,
lymphadenopathy). Other less common manifestations
include meningioencephalitis and myocarditis.
Investigation
• antibody test
• Sabin-Feldman dye test
Treatment is usually reserved for those with severe infections
or patients who are immunosuppressed
• pyrimethamine plus sulphadiazine for at least 6 weeks
Congenital toxoplasmosis is due to transplacental spread from
the mother. It causes a variety of effects to the unborn child
including microcephaly, hydrocephalus, cerebral calcification
and choroidoretinitis.

Q-39
A 72-year-old woman who is known to have type 2 diabetes
mellitus and heart failure is reviewed. One week ago she was
treated with oral flucloxacillin and penicillin V for a right
lower limb cellulitis. Unfortunately there has been no
response to treatment. What is the most appropriate next
line antibiotic?
A. Co-amoxiclav
B. Erythromycin
C. Clindamycin
D. Vancomycin
E. Gentamicin
ANSWER:
C. Clindamycin
EXPLANATION:
CELLULITIS
Cellulitis is a term used to describe an inflammation of the
skin and subcutaneous tissues, typically due to infection by
Streptococcus pyogenes or Staphylcoccus aureus.
Features
• commonly occurs on the shins
• erythema, pain, swelling
• there may be some associated systemic upset such as
fever
Criteria for admission
NICE Clinical Knowledge Summaries recommend we use the
Eron classification to guide how we manage patients with
cellulitis:
Class Features
I There are no signs of systemic toxicity and the person has no
uncontrolled co-morbidities
II The person is either systemically unwell or systemically well but with
a co-morbidity (for example peripheral arterial disease, chronic
venous insufficiency, or morbid obesity) which may complicate or
delay resolution of infection
III The person has significant systemic upset such as acute confusion,
tachycardia, tachypnoea, hypotension, or unstable co-morbidities
that may interfere with a response to treatment, or a limbthreatening infection due
to vascular compromize
IV The person has sepsis syndrome or a severe life-threatening
infection such as necrotizing fasciitis
They recommend the following that we admit for intravenous
antibiotics the following patients:
• Has Eron Class III or Class IV cellulitis.
• Has severe or rapidly deteriorating cellulitis (for example
extensive areas of skin).
• Is very young (under 1 year of age) or frail.
• Is immunocompromized.
• Has significant lymphoedema.
• Has facial cellulitis (unless very mild) or periorbital
cellulitis.
The following is recommend regarding Eron Class II cellulitis:
Admission may not be necessary if the facilities and expertise
are available in the community to give intravenous antibiotics
and monitor the person - check local guidelines.
Other patients can be treated with oral antibiotics.
Management
The BNF recommends flucloxacillin as first-line treatment for
mild/moderate cellulitis. Clarithromycin or clindamycin is
recommended in patients allergic to penicillin.
Many local protocols now suggest the use of oral clindamycin
in patients who have failed to respond to flucloxacillin.
Severe cellulitis should be treated with intravenous
benzylpenicillin + flucloxacillin.

Q-40
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?
A. Streptococcus pneumoniae
B. Legionella pneumophilia
C. Staphylococcus aureus
D. Klebsiella pneumoniae
E. Mycoplasma pneumoniae
ANSWER:
D. Klebsiella pneumoniae
EXPLANATION:
Pneumonia in an alcoholic - Klebsiella
PNEUMONIA: CAUSES
Community acquired pneumonia (CAP) may be caused by the
following infectious agents:
• Streptococcus pneumoniae (accounts for around 80% of
cases)
• Haemophilus influenzae
• Staphylococcus aureus: commonly after the 'flu
• atypical pneumonias (e.g. Due to Mycoplasma
pneumoniae)
• viruses
Klebsiella pneumoniae is classically in alcoholics
Streptococcus pneumoniae (pneumococcus) is the most
common cause of community-acquired pneumonia
Characteristic features of pneumococcal pneumonia
• rapid onset
• high fever
• pleuritic chest pain
• herpes labialis

Q-41
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?
A. IV cefotaxime
B. Arrange a CT head
C. Perform a lumbar puncture
D. IV dexamethasone
E. Intramuscular benzypenicillin
ANSWER:
A. IV cefotaxime
EXPLANATION:
This patient has meningococcal meningitis. They need
appropriate intravenous antibiotics immediately. With the
advent of modern PCR diagnostic techniques there is no
justification for delaying potentially lifesaving treatment by
performing a lumbar puncture in patients with suspected
meningococcal meningitis.
Please see Q-14 for Meningitis: Management

Q-42
A 30-year-old man returns from a cheese and wine tasting
holiday in Portugal. On questioning, he tells you about all the
unpasteurised cheese he tried. He comes to the GP
complaining of feeling very unwell. On questioning, he
reports having fluctuating temperatures, he has pain in his
joints and muscles that is transient and has noticed a
peculiar 'wet hay' smell when he sweats, which is a lot. What
is the most likely causative organism?
A. Yersinia pestis
B. Brucella melitensis
C. Wuchereria bancrofti
D. Bartonella henselae
E. Plasmodium falciparum
ANSWER:
B. Brucella melitensis
EXPLANATION:
This patient is presenting with symptoms typical of
Brucellosis; Fluctuating temperatures, transient arthralgia
and myalgia, hyperhidrosis with a 'wet hay' smell. The clue in
the history is his exposure to unpasteurised [Link] melitensis is the
bacteria found in contaminated
unpasteurised milk that causes brucellosis.
Bartonella henselae, the causative agent of cat scratch
disease, would present with a history of exposure to cat
scratches.
Yersinia pestis, the causative agent of bubonic plague, would
present with a history of exposure to flea bites in a plague
endemic area. The patient would also present with a fixed
rather than fluctuating temperature.
Plasmodium falciparum, the causative agent of malaria,
would similarly present with fluctuating temperatures and
excessive sweating, though the history would show exposure
to mosquito bite in a malaria endemic area
BRUCELLOSIS
Brucellosis is a zoonosis more common in the Middle East and
in farmers. Four major species cause infection in humans: B
melitensis (sheep), B abortus (cattle), B canis and B suis (pigs).
Brucellosis has an incubation period 2 - 6 weeks
Features
• non-specific: fever, malaise
• hepatosplenomegaly
• sacroilitis: spinal tenderness may be seen
• complications: osteomyelitis, infective endocarditis,
meningoencephalitis, orchitis
• leukopenia often seen
Diagnosis
• the Rose Bengal plate test can be used for screening but
other tests are required to confirm the diagnosis
• Brucella serology is the best test for diagnosis
• blood and bone marrow cultures may be suitable in
certain patients, but these tests are often negative
Management
• doxycycline and streptomycin

Q-43
A 32-year-old HIV positive man presents to the emergency
department with a painful, swollen leg. He has a history of
poor adherence with his medication and is currently not
taking antiretrovirals; his most recent blood tests from a
year previously show a detectable viral load. On
examination, there are multiple purplish nodules in the skin
overlying the popliteal fossa.
What is the most likely underlying viral cause for his
pathology?
A. Ebstein Barr Virus
B. Human Herpes Virus 8
C. Human Papilloma Virus
D. Hepatitis B
E. Human T-Lymphotrophic Virus
ANSWER:
B. Human Herpes Virus 8
EXPLANATION:
Kaposi's sarcoma is caused by HHV-8 infection in HIV positive
individuals
This is a classical presentation of Kaposi's sarcoma, which is
caused by HHV8 virus individuals with HIV. It is an example
of an AIDS-defining illness.
All of the other options are viral precipitants for other
cancers that do not fit the stem.
Ebstein Barr Virus is associated with Hodgkin's lymphoma
Human Papilloma Virus is associated with cervical cancer in
women and throat and anal cancer in men
Hepatitis B is associated with Hepatocellular carcinoma
Human T-Lymphotrophic Virus is associated with adult T-cell
lymphoma
People with poorly controlled HIV are more likely to develop
the viral-related cancers listed above; this is partly related to
the increased rates of these viral infections in people living
with HIV and also relates to the impaired immune function.
The development of anti-retroviral drugs has significantly
reduced the rates of virus-related cancers in people living
with HIV.
Please see Q-15 for HIV: Opportunistic Infections and Other
Disorders

Q-44
A 26-year-old man returns to the genito-urinary medicine
clinic. He is a known intravenous drug user. Five days ago he
was seen with a urethral discharge. A swab taken in the
clinic showed a Gram-negative diplococcus and treatment
with IM ceftriaxone was given. Unfortunately his symptoms
have not resolved. What is the most likely explanation?
A. Gonorrhoea-resistant to ceftriaxone
B. Co-existent Candida infection
C. HIV infection
D. Co-existent syphilis infection
E. Co-existent Chlamydia infection
ANSWER:
B. Co-existent Candida infection
EXPLANATION:
Co-existent infection with Chlamydia is extremely common in
patients with gonorrhoea.
Please see Q-32 for Chlamydia

Q-45
A 58-year-old caucasian male originally from the United
Kingdom (UK) now living in East Africa has returned to the
UK on holiday. He has become unwell in the last two days,
complaining of a headache, rigors, vomiting, fever,abdominal pain and passing
little amounts of dark red urine.
On examination, there is hepatosplenomegaly, jaundice and
anaemia. Urinalysis reveals blood only and microscopy
showed no red cells. Of the following options, what is the
most likely diagnosis?
A. Leptospirosis
B. Acute viral hepatitis
C. Pyelonephritis
D. Schistosomiasis
E. Blackwater fever
ANSWER:
E. Blackwater fever
EXPLANATION:
Blackwater fever is a rare complication of malaria which can
be fatal. It is caused by large intravascular haemolysis
resulting in haemoglobinuria, anaemia, jaundice and acute
kidney injury. Urine is classically black or dark red in
[Link] cause of the massive haemolysis is unknown. The
treatment is with antimalarials, intravenous fluids and in
some cases dialysis. Urinalysis reveals blood which is not
seen on microscopy as it is haemoglobinuria.
Schistosomiasis has an acute onset which includes symptoms
of fever, chills, headache and fatigue but symptoms of
haematuria do not come till the chronic phase as a result of
bladder fibrosis and calcification, this presents more
insidiously. In addition, in schistosomiasis, urine microscopy
would show red cell casts. Acute hepatitis is a consideration
but normally results in a prodromal phase of flu-like
symptoms lasting 1-6 weeks before jaundice appears and
would not usually cause oliguria. Severe leptospirosis, known
as Weil's disease, can result in renal failure and jaundice but
also tends to cause pulmonary haemorrhage and shows
signs of bleeding. Furthermore, there is usually a relevant
occupational history resulting in exposure to infected rat
urine. Pyelonephritis would cause leucocytes and nitrates to
be positive on urinalysis and would not cause
hepatosplenomegaly.
MALARIA: FALCIPARUM
Feature of severe malaria
• schizonts on a blood film
• parasitaemia > 2%
• hypoglycaemia
• acidosis
• temperature > 39 °C
• severe anaemia
• complications as below
Complications
• cerebral malaria: seizures, coma
• acute renal failure: blackwater fever, secondary to
intravascular haemolysis, mechanism unknown
• acute respiratory distress syndrome (ARDS)
• hypoglycaemia
• disseminated intravascular coagulation (DIC)
Uncomplicated falciparum malaria
• strains resistant to chloroquine are prevalent in certain
areas of Asia and Africa
• the 2010 WHO guidelines recommend artemisinin-based
combination therapies (ACTs) as first-line therapy
• examples include artemether plus lumefantrine,
artesunate plus amodiaquine, artesunate plus
mefloquine, artesunate plus sulfadoxine-pyrimethamine,
dihydroartemisinin plus piperaquine
Severe falciparum malaria
• a parasite counts of more than 2% will usually need
parenteral treatment irrespective of clinical state
• intravenous artesunate is now recommended by WHO in
preference to intravenous quinine
• if parasite count > 10% then exchange transfusion should
be considered
• shock may indicate coexistent bacterial septicaemia -
malaria rarely causes haemodynamic collapse

Q-46
A 22-year-old female presents with an offensive vaginal
discharge. History and examination findings are consistent
with a diagnosis of bacterial vaginosis. What is the most
appropriate initial management?
A. Oral azithromycin
B. Topical hydrocortisone
C. Oral metronidazole
D. Clotrimazole pessary
E. Advice regarding hygiene and cotton underwear
ANSWER:
C. Oral metronidazole
EXPLANATION:
Bacterial vaginosis: oral metronidazole
BACTERIAL VAGINOSIS
Bacterial vaginosis (BV) describes an overgrowth of
predominately anaerobic organisms such as Gardnerella
vaginalis. This leads to a consequent fall in lactic acid
producing aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen
almost exclusively in sexually active women.
Features
• vaginal discharge: 'fishy', offensive
• asymptomatic in 50%Amsel's criteria for diagnosis of BV - 3 of the following 4
points
should be present
• thin, white homogenous discharge
• clue cells on microscopy: stippled vaginal epithelial cells
• vaginal pH > 4.5
• positive whiff test (addition of potassium hydroxide
results in fishy odour)
Management
• oral metronidazole for 5-7 days
• 70-80% initial cure rate
• relapse rate > 50% within 3 months
• the BNF suggests topical metronidazole or topical
clindamycin as alternatives
Comparison of bacterial vaginosis and Trichomonas vaginalis
Clue cells - epithelial cells develop a stippled appearance due to being
covered with bacteria

Q-47
Which one of the following is the most common cause of
visceral larva migrans?
A. Cryptococcus neoformans
B. Strongyloides stercoralis
C. Visceral leishmaniasis
D. Toxocara canis
E. Giardiasis
ANSWER:
D. Toxocara canis
EXPLANATION:
NEMATODES
Ancylostoma braziliense
• most common cause of cutaneous larva migrans
• common in Central and Southern America
Strongyloides stercoralis
• acquired percutaneously (e.g. walking barefoot)
• causes pruritus and larva currens - this has a similar
appearance to cutaneous larva migrans but moves through
the skin at a far greater rate
• abdo pain, diarrhoea, pneumonitis
• may cause Gram negative septicaemia due carrying of
bacteria into bloodstream
• eosinophilia sometimes seen
• management: thiabendazole, albendazole. Ivermectin also
used, particularly in chronic infections
Toxocara canis
• commonly acquired by ingesting eggs from soil
contaminated by dog faeces
• commonest cause of visceral larva migrans
• other features: eye granulomas, liver/lung involvement

Q-48
A 34-year-old postman attends the Emergency Department
following a dog bite to his right hand. What is the most
appropriate antibiotic therapy?
A. Metronidazole + amoxicillin
B. Erythromycin
C. Co-amoxiclav
D. Metronidazole
E. Flucloxacillin + penicillin
ANSWER:
C. Co-amoxiclav
EXPLANATION:
Animal bite - co-amoxiclav
A combination of doxycycline and metronidazole is
recommended in the BNF if the patient is penicillin allergic
ANIMAL BITES
The majority of bites seen in everyday practice involve dogs
and cats. These are generally polymicrobial but the most
common isolated organism is Pasteurella multocida.
Management
• cleanse wound
• current BNF recommendation is co-amoxiclav
• if penicillin-allergic then doxycycline + metronidazole is
recommended

Q-49
A 35-year-old homosexual man is referred to the local
genitourinary clinic following the development of a solitary
painless penile ulcer associated with painful inguinal
lymphadenopathy. He has recently developed rectal pain
and tenesmus. What is the most likely diagnosis?A. Herpes simplex infection
B. Syphilis
C. Granuloma inguinale
D. Chancroid
E. Lymphogranuloma venereum
ANSWER:
E. Lymphogranuloma venereum
EXPLANATION:
Genital ulcers
painful: herpes much more common than chancroid
painless: syphilis more common than lymphogranuloma
venereum
Lymphogranuloma venereum usually involves three stages:
1 - small painless pustule which later forms an ulcer
2 - painful inguinal lymphadenopathy
3 - proctocolitis
Please see Q-3 for STI: Ulcers

Q-50
An 18-year-old male who has recently undergone
chemotherapy for leukaemia presents with fever, cough,
haemoptysis and shortness of breath not responsive to
antibiotics. He underwent a chest CT which revealed a 'halo'
sign suggestive of invasive aspergillosis. What immune
response component is the first line of action against
aspergillosis?
A. Cytokines
B. Neutrophils
C. Eosinophils
D. Basophils
E. Macrophages
ANSWER:
E. Macrophages
EXPLANATION:
Macrophages are the first line immune response, they help
to recruit neutrophils which are also crucial components in
fighting aspergillosis. This knowledge is relevant as it allows
us to understand that patients with deficiencies in
macrophages and neutrophils are prone to aspergillosis. In
healthy individuals when aspergillosis spores are inhaled,
mucociliary clearance is initiated and spores are
phagocytosed, clearing the infection.
A raised level of eosinophils are found in allergic
bronchopulmonary aspergillosis but their role is later in the
process after deposition of the immune complexes. Cytokines
are important in cell signalling but do not directly fight the
disease process, they are released by macrophages,
lymphocytes, mast cells and other immune components.
Basophils are involved in response to allergic diseases like
asthma and anaphylaxis but are not the first line in
aspergillosis.
Invasive Aspergillosis
Seen in the immunocompromised host to include patients
with a chronic granulomatous disease, patients undergoing
chemotherapy and patients receiving a bone marrow
transplant.
Presentation - Pulmonary symptoms are most common,
presenting with a cough, fever, haemoptysis (which can be
severe), dyspnoea and pleuritic chest pain but may be
atypical. There is haematogenous spread to other organs,
most commonly bone resulting in osteomyelitis.
Investigations - can be hard to diagnose. Chest X-ray may
show consolidation, nodules, infiltrates, or cavitating lesions.
Chest CT may show the 'halo' sign (however aspergillosis in
patients with chronic granulomatous disease typically does
not produce this sign). Cultures can be obtained from
sputum, broncho-alveolar lavage, lung tissue via transthoracic percutaneous biopsy.
In addition, there is an assay
to detect Galactomannan which a component aspergillosis
cell wall.
Treatment - is with antifungals. The first line is voriconazole
ASPERGILLOMA
An aspergilloma is a mycetoma (mass-like fungus ball) which
often colonises an existing lung cavity (e.g. secondary to
tuberculosis, lung cancer or cystic fibrosis)
Usually asymptomatic but features may include
• cough
• haemoptysis (may be severe)
Investigations
chest x-ray containing a rounded opacity
high titres Aspergillus precipitins
Aspergilloma in a patient with cavities secondary to previous tuberculosis
infection. The close-up CXR and CT scan from the same patient demonstrate
a rounded soft tissue attenuating masses located in a surrounding cavity.

Q-51
A 24-year-old patient presents to the Emergency
Department with watery diarrhoea. He returned from
holiday in Tanzania yesterday. Which of the following
pathogens is the most likely to be responsible for this
presentation?
A. Enterotoxigenic E. coli
B. Non-typhoidal Salmonella
C. Campylobacter spp
D. Vibrio cholerae
E. Giardia lamblia
ANSWER:
A. Enterotoxigenic E. coli
EXPLANATION:
All the listed options are potential causative organisms of an
acute watery diarrhoeal illness.
Worldwide, enterotoxigenic E. coli (ETEC) is the most
common cause of diarrhoea in travellers. There is, however,
geographical variation - Campylobacter is more common in
travellers in South East Asia.
Diarrhoea in cholera is classically painless, 'rice-water', stool.
While cholera is seen worldwide, it is less common as a cause
of diarrhoea in travellers.
Diarrhoea in acute giardiasis is classically foul-smelling and
fatty, and associated with abdominal cramps and bloating.
The incubation period for acute infection is one to two
weeks.
Non-typhoidal Salmonellae are another common cause of
diarrhoea worldwide. They are the most common cause of
food-borne disease in the United States. The incubation
period is up to three days.
Please see Q-25 for Gastroenteritis: Causes

Q-52
A 24-year-old heterosexual man presents to GUM with a
history of dysuria, urethral irritation and milky discharge
from the urethra. Urethral microscopy reveals >10
polynuclear lymphocytes per field but no gonorrhoea is seen
and urine dip is normal. He did a home test 3 days ago when
his symptoms started and Chlamydia and Gonorrhoea NAATs
were negative. His urine dipstick is normal. His last sexual
encounter was 3 weeks ago. You make a clinical diagnosis of
non specific urethritis (NSU).
What is the most appropriate action to take?
A. Start oral doxycycline for 1 week
B. Reassure the patient; his symptoms will resolve
spontaneously
C. Tell the patient to repeat his Chlamydia and Gonorrhoea
tests in 2 weeks' time.
D. Start oral aciclovir
E. Refer to urology for their assessment and opinion
ANSWER:
A. Start oral doxycycline for 1 week
EXPLANATION:
Non specific (non gonococcal) urethritis is a common
presentation where inflammatory cells but no gonococcal
bacteria are seen on swab; it requires treatment with
doxycycline or azithromycin
The presence of pus cells on urethral swab suggests a
diagnosis of non-specific urethritis, which commonly
presents with symptoms similar to these. BASHH recommend
treating with oral doxycycline. The window period for
Chlamydia and Gonorrhoea tests is generally 2 weeks so the
home test he did is likely to be accurate; while retesting may
be appropriate it should not delay treatment, and should not
be delayed further.
As there is no evidence of gonococcal bacteria on microscopy
there is no indication to treat as Gonorrhoea. There is no
current indication to refer to Urology and no current reason
to treat the patient for HSV.
NON-GONOCOCCAL URETHRITIS
Non-gonococcal urethritis (NGU, sometimes referred to as
non-specific urethritis) is a term used to describe the presence
of urethritis when a gonococcal bacteria are not identifiable
or the initial swab. A typical case would be a male who
presented to a GUM clinic with a purulent urethral discharge
and dysuria. A swab would be taken in clinic, microscopy
performed which showed neutrophils but no Gram negative
diplococci (i.e. no evidence of gonorrhoea). Clearly this
patient requires immediate treatment prior to waiting for the
Chlamydia test to come back and hence an initial diagnosis of
NGU is made.
Causative organisms include:
• Chlamydia trachomatis - most common cause
• Mycoplasma genitalium - thought to cause more
symptoms than Chlamydia
Management
• contact tracing
• the BNF and British Association for Sexual Health and HIV
(BASHH) both recommend either oral azithromycin or
doxycycline

Q-53
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?
A. Escherichia coli
B. Campylobacter
C. Salmonella
D. Shigella
E. Bacillus cereus
ANSWER:
E. Bacillus cereus
EXPLANATION:
Bacillus cereus characteristically occurs after eating rice that
has been reheated
Bacillus cereus infection most commonly results from
reheated rice.
Please see Q-25 for Gastroenteritis: Causes

Q-54
A 24-year-old man is admitted to the Emergency Department
with breathing difficulties and confusion three weeks after
returning from a holiday in Cambodia. His partner says he
has had 'the flu' for the past two weeks. A blood film is
positive for malarial parasites and a chest x-ray and arterial
blood gases suggest acute respiratory distress syndrome. A
diagnosis of severe falciparum malaria is suspected. What is
the treatment of choice?
A. Intravenous artesunate
B. Intravenous clindamycin + oral artemether-lumefantrine
C. Intravenous artemether-lumefantrine
D. Oral atovaquone-proguanil
E. Intravenous quinine
ANSWER:
A. Intravenous artesunate
EXPLANATION:
Severe falciparum malaria - intravenous artesunate
Please see Q-45 for Malaria: Faciparum

Q-55
A 23-year-old man develops watery diarrhoea 5 days after
arriving in Mexico. Which one of the following is the most
likely responsible organism?
A. Salmonella
B. Shigella
C. Campylobacter
D. Escherichia coli
E. Bacillus cereus
ANSWER:
D. Escherichia coli
EXPLANATION:
E. coli is the most common cause of travellers' diarrhoea
Please see Q-25 for Gastroenteritis: Causes

Q-56
A 42-year-old female presents to the Emergency
Department. She is known to be an intravenous drug user
and sometimes practices skin popping. She has multiple
sores and wounds. She is complaining of double vision,
difficulty swallowing, slurred speech and weakness of the
arm muscles. Her arms are weak and floppy. You suspect
that a bacterial toxin is causing her symptoms. What is the
mechanism of action of the most likely toxin?
A. Chloride channel blocker
B. Inhibition of the release of acetylcholine at synapses
C. Inhibition of the release of glycine and gamma-amino
butyric acid at synapses
D. Sodium channel blocker
E. Nicotinic acetylcholine receptor blocker
ANSWER:
B. Inhibition of the release of acetylcholine at synapses
EXPLANATION:
Botulinum toxin inhibits the release of acetylcholine at
synapses
The patient has wound botulism, as characterised by
descending flaccid paralysis and cranial nerve signs.
Intravenous drug users are at higher risk of botulism,
particularly if they engage in skin popping or muscle
popping. A patient with tetanus from a wound would
present with spasms and stiffness of the muscles rather than
flaccid weakness.
Botulinum toxin works by inhibiting the release of
acetylcholine at synapses of the nervous system, both
peripherally and centrally. Tetanus toxin inhibits the release
of inhibitory neurotransmitters (glycine and GABA at
synapses). Tetrodotoxin, produced by several fish species
including pufferfish, is a sodium channel blocker. Curare, the
poison used to tip arrows by the native people of Central and
South America, is a nicotinic acetylcholine receptor blocker.
Chlorotoxin, from the deathstalker scorpion, is a chloride
channel blocker.
BOTULISM
Clostridium botulinum
• gram positive anaerobic bacillus
• 7 serotypes A-G
• produces botulinum toxin, a neurotoxin which irreversibly
blocks the release of acetylcholine
• may result from eating contaminated food (e.g. tinned)
• neurotoxin often affects bulbar muscles and autonomic
nervous system
Features
• patient usually fully conscious with no sensory
disturbance
• flaccid paralysis
• diplopia
• ataxia
• bulbar palsyTreatment with antitoxin is only effective if given early - once
toxin has bound its actions cannot be reversed
Therapeutic uses of botulinum toxin
• strabismus
• dystonias: torticollis, blepharospasm
• hyperhidrosis
• cosmetic: Botox: serotype A of botulinum toxin used

Q-57
A 19-year-old man presents asking for advice. His girlfriend
has recently been diagnosed with meningococcal meningitis.
He is worried he may have 'caught it'. What is the
recommended antibiotic prophylaxis for close contacts such
as this man?
A. Oral co-amoxiclav
B. Oral phenoxymethylpenicillin
C. Oral rifampicin
D. Oral erythromycin
E. Intramuscular cefotaxime
ANSWER:
C. Oral rifampicin
EXPLANATION:
The BNF recommends a twice a day dose of rifampicin for
two days, based on the patients weight. Please note that if
ciprofloxacin is given as a choice this should be picked due to
recent changes in HPA guidelines - see below.
Please see Q-14 for Meningitis: Management

Q-58
A 34-year-old lady presents to the GP with worsening nausea
and fatigue over a 2 week period. On examination, there is a
yellow tinge to the sclera of her eyes. She lives in a remote
fishing village and consumes a diet high in seafood. She does
not smoke or consume alcohol. She does not report any
weight loss or other constitutional features. Her LFTs are as
follows:
Bilirubin 20 µmol/l
ALP 160 u/l
ALT 550 u/l
γGT 30 u/l
Albumin 35 g/l
Other routine blood results are within normal limits.
What is the most likely cause of her symptoms?
A. Gilbert's syndrome
B. Pancreatic adenocarcinoma
C. Hepatitis B
D. Hepatitis C
E. Hepatitis E
ANSWER:
C. Hepatitis B
EXPLANATION:
Hepatitis E is associated with faecal-oral spread, commonly
affecting shellfish and pork products. Blood results show
elevated bilirubin and significant transaminitis.
This lady has no constitutional symptoms, making a
pancreatic adenocarcinoma less likely. As well, pancreatic
cancer rarely occurs before age 40.
Hepatitis B and C are blood-borne viruses and there is no
relevant history in this lady's case.
Please see Q-17 for Hepatitis E

Q-59
You review a 14-year-old boy who has recently emigrated
from Russia. He was involved in car accident two years ago
and underwent an emergency splenectomy. Following this
he takes penicillin V on a daily basis. He is unsure of his
vaccination history. Which organism is he particularly
suscepitble to?
A. Staphylococcus aureus
B. HIV
C. Haemophilus influenzae
D. Streptococcus pneumoniae
E. Mycobacterium tuberculosis
ANSWER:
C. Haemophilus influenzae
EXPLANATION:
Penicillin V would protect him against Streptococcus
pneumoniae but not Haemophilus influenzae due to the
production of beta-lactamases by the organism.
Please see Q-29 for Splenectomy

Q-60
A 34-year-old man from Swaziland presents the the
emergency department with a 3 day history of fever,
shortness of breath and a dry cough. His past medical history
includes tuberculosis and HIV and his most recent CD4 count
is 150.
On examination: heart rate 100/min, blood pressure
110/80mmHg, respiratory rate 28/min, oxygen saturation
98% on air at rest, dropping to 80% on walking. His
temperature is 38.5ºC. On auscultation, his chest is clear.
How would you treat this man?
A. IV cefotaxime
B. Oral ciprofloxacin
C. IV tazocin
D. Oral rifampicin, isoniazid, pyrazinamide and ethambutol
E. Oral co-trimoxazole
ANSWER:
E. Oral co-trimoxazole
EXPLANATION:
This man has pneumocystis jirovecii pneumonia (PCP) which
is occurs in HIV positive patients with a low CD4 count. It
classically presents with a fever, dyspnoea, dry cough,
exercise induced desaturation and very few chest signs. It is
treated with oral co-trimoxazole or IV pentamidine in severe
cases.
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-61
A 27-year-old bisexual man presents to your GUM clinic with
a 7-day history of rectal discharge, pain on passing stools and
tenesmus. On examination, he has tender inguinal
lymphadenopathy and proctoscopy reveals red mucosa with
yellow discharge and some shallow ulcers.
Which one of the following organisms is most likely to be
causative?
A. Enterococcus coli
B. Treponema pallidum
C. Haemophilus ducreyi
D. Neisseria gonorrhoea
E. Chlamydia trachomatis
ANSWER:
E. Chlamydia trachomatis
EXPLANATION:
If a sexually active patient presents with genital chlamydia
and bowel symptoms, LGV proctocolitis should be considered
The presence of ulcers and significant rectal symptoms in a
sexually active man raises the question of lymphogranuloma
venereum, which is caused by a type of Chlamydia
trachomatis. Rectal infection with gonorrhoea could cause
similar symptoms but would not be expected to cause ulcers.
Please see Q-3 for STI: Ulcers
Q-62
A 56-year-old diabetic man was admitted with pyrexia and
rigors secondary to an infected diabetic foot ulcer and
commenced on IV Flucloxacillin. The wound swab grew
methicillin resistant Staphylococcus Aureus (MRSA) and he
was commenced on an alternative IV antibiotic. Within an
hour of administration the patient developed an itchy,
erythematous maculopapular rash, which became diffuse
covering >80% of his body surface area. He also began to
complain of hearing loss in his right ear.
What antibiotic is likely to have been prescribed?
A. Teicoplanin
B. Co-Amoxiclav
C. Clindamycin
D. Vancomycin
E. Cefuroxime
ANSWER:
D. Vancomycin
EXPLANATION:
Vancomycin is a glycopeptide antibiotic, which works by
blocking cell wall subunit assembly (separate from beta
lactams).The antibiotic has extensive gram positive cover
and is commonly used to treat MRSA and Clostridium
difficile.
The characteristic side effects include: Ototoxicity,
nephrotoxicity and red man syndrome. Red man syndrome is
associated with flushing or a maculopapular rash. The
proposed mechanism is non IgE mediated mast cell
degranulation. Red man syndrome is more common with
higher flow rates of infusion. Treatment includes
antihistamines.
VANCOMYCIN
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

Q-63
A 44-year-old homosexual man presents to your GUM clinic
with a 3-day history of diarrhoea, He has no history of recent
foreign travel and is normally fit and well. His abdomen is
soft, non tender and he has normal observations. His last
sexual encounter was 2 weeks ago. Tests for Chlamydia
trachomatis,Neisseria gonorrhoea, HIV and Syphilis are
negative. A stool sample is sent for culture and grows
Shigella.
What is the most suitable management plan?A. Start loperamide and review in 48
hours
B. Admit to the local infectious diseases unit for IV
Metronidazole
C. Reassure the patient this is a commensal bacteria
unlikely to be the cause of their symptoms
D. Advise the patient to increase their fluid intake and seek medical attention if
they become unwell, or develop bloody diarrhoea.
E. Inform Public Health England
ANSWER:
D. Advise the patient to increase their fluid intake and seek medical attention if
they become unwell, or develop bloody diarrhoea.
EXPLANATION:
Shigella infection is usually self limiting and does not require
antibiotic treatment; antibiotics are indicated for people
with severe disease, who are immunocompromised or with
bloody diarrhoea
Shigella infection is usually self-limiting and does not require
antibiotic treatment; antibiotics are indicated for people
with severe disease, who are immunocompromised or with
bloody diarrhoea. This patient sounds fairly well; hospital
admission would be inappropriate and Shigella is only
notifiable if food poisoning is suspected. Antimotility drugs
are not recommended in infective diarrhoea
Please see Q-31 for Shigella

Q-64
You are working in the Emergency Department and you see a
22-year-old man with an itchy erythematous rash across his
back, shoulders and backs of his arms. The rash appeared
yesterday after he started taking an antibiotic, having been
unwell for 10 days with general malaise and a sore throat.
Which antibiotic is most likely to be the cause?
A. Flucloxacillin
B. Phenoxymethylpenicillin
C. Amoxicillin
D. Ciprofloxacin
E. Co-amoxiclav
ANSWER:
C. Amoxicillin
EXPLANATION:
URTI symptoms + amoxicillin → rash ?glandular fever
The correct answer is 3. The patient is likely to have
underlying infectious mononucleosis due to Ebstein-Barr
virus. Amoxicillin is known to commonly produce a
widespread erythematous rash in patients with infectious
mononucleosis. For this reason, it should not be prescribed to
patients with sore throats. Phenoxymethylpenicillin (or
penicillin V) is the first line choice for bacterial tonsillitis
instead. The patient's rash could also be an urticarial rash
due to an allergy to an antibiotic, but there is nothing to
guide you as to which antibiotic he is most likely to be
allergic to.
Please see Q-20 for Infectious Mononucleosis

Q-65
A previously well 68-year-old woman is reviewed on the
acute medical ward. She has recently been commenced on
methotrexate for newly diagnosed rheumatoid arthritis.
During your review, she complains of dysuria and urinary
frequency. She is otherwise systemically well, with no fever
or loin tenderness.
Urinalysis results show:
Leucocytes +++
Nitrites Positive
Blood Trace
Which antibiotics should be used to treat this patient's
urinary tract infection?
A. Amoxicillin + Gentamicin
B. Trimethoprim
C. Ciprofloxacin
D. Co-trimoxazole
E. Nitrofurantoin
ANSWER:
B. Trimethoprim
EXPLANATION:
Trimethoprim and Co-trimoxazole should be avoided in
patients on Methotrexate
Both trimethoprim and methotrexate work by inhibiting the
enzyme dihydrofolate reductase. When given alongside one
another, patients can develop life-threatening
myelosuppression due to the cumulative effect of the folic
acid antagonism that occurs.
Since co-trimoxazole is a combination of trimethoprim and
sulfamethoxazole, this effect occurs with the co-prescription
of co-trimoxazole and methotrexate also.
Amoxicillin and gentamicin is usually given in the treatment
of pyelonephritis/urosepsis, and would be inappropriate in
this patient. Ciprofloxacin is also more commonly used in
complicated urinary tract infections and would not
commonly be first line.
TRIMETHOPRIM
Trimethoprim is an antibiotic, mainly used in the management
of urinary tract infections.
Mechanism of action
• interferes with DNA synthesis by inhibiting dihydrofolate
reductaseAdverse 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

Q-66
A 33-year-old man who is HIV positive is admitted to the
Emergency Department with confusion and drowsiness. He
has been complaining of headaches for a number of days. On
examination heart rate is 90/min, blood pressure 104/78
mmHg and temperature is 37.2ºC. He is confused giving a
Glasgow Coma Scale (GCS) score of 14. There is no
photophobia or neck stiffness.
His infectious diseases consultant reports that he is
prescribed highly active antiretroviral treatment (HAART)
but his compliance is poor and he often misses clinic
appointments.
A CT brain is requested:
CT brain (with contrast): Multiple hypodense regions
predominantly in the basal ganglia which show ring
enhancement. Minimal surrounding oedema. No mass
effect.
What is the most likely diagnosis?
A. Progressive multifocal leukoencephalopathy
B. Cryptococcal infection
C. Cerebral toxoplasmosis
D. CMV encephalitis
E. Tuberculosis
ANSWER:
C. He is confused giving a
Glasgow Coma Scale (GCS) score of 14. There is no
photophobia or neck stiffness.
His infectious diseases consultant reports that he is
prescribed highly active antiretroviral treatment (HAART)
but his compliance is poor and he often misses clinic
appointments.
A CT brain is requested:
CT brain (with contrast): Multiple hypodense regions
predominantly in the basal ganglia which show ring
enhancement. Minimal surrounding oedema. No mass
effect.
What is the most likely diagnosis?
EXPLANATION:
HIV - multiple ring enhancing lesions = toxoplasmosis
Cerebral toxoplasmosis is the most common neurological
infection seen in HIV, occurring in up to 10% of patients
Please see Q-34 for HIV: neurocomplications

Q-67
A patient with HIV is reviewed. Which one of the following is
an example of a nucleoside analogue reverse transcriptase
inhibitors?
A. Zidovudine
B. Indinavir
C. Ritonavir
D. Ribavirin
E. Efavirenz
ANSWER:
A. Zidovudine
EXPLANATION:
HIV drugs, rule of thumb:
NRTIs end in 'ine'
Pis: end in 'vir'
NNRTIs: nevirapine, efavirenz
Zidovudine (AZT) was one of the first HIV drugs and remains
important today.
Please see Q-10 for HIV: Anti-Retrovirals

Q-68
A 43-year-old woman who is a recent immigrant from
Mozambique is referred to the dermatology outpatient
clinic. She has developed a number of hypopigmented, oval
shaped lesions on her body which are associated with
reduced sensation. These are mainly located on the extensor
surfaces of her limbs. She has no past medical history of note
other than suffering from malaria as a child. What is the
most likely diagnosis?
A. HIV
B. Chagas disease
C. Pityriasis versicolor
D. Tuberculosis
E. Leprosy
ANSWER:
E. Leprosy
EXPLANATION:
LEPROSY
Leprosy is a granulomatous disease primarily affecting the
peripheral nerves and skin. It is caused by Mycobacterium
leprae.
Features
• patches of hypopigmented skin typically affecting the
buttocks, face, and extensor surfaces of limbs
• sensory loss
The degree of cell mediated immunity determines the type of
leprosy a patient will develop.
Low degree of cell mediated immunity → lepromatous leprosy
('multibacillary')
• extensive skin involvement
• symmetrical nerve involvement
High degree of cell mediated immunity → tuberculoid leprosy
('paucibacillary')
• limited skin disease
• asymmetric nerve involvement
Management
• WHO-recommended triple therapy: rifampicin, dapsone
and clofazimine

Q-69
A 37-year-old woman who is being treated as an inpatient
for Mycoplasma pneumonia is reviewed. Unfortunately she
is unable to tolerate clarithromycin due to severe nausea.
What is the most suitable alternative antibiotic?A. Linezolid
B. Cefaclor
C. Ciprofloxacin
D. Co-amoxiclav
E. Doxycycline
ANSWER:
E. Doxycycline
EXPLANATION:
Mycoplasma pneumonia if allergic/intolerant to macrolides -
doxycycline
MYCOPLASMA PNEUMONIAE
Mycoplasma pneumoniae is a cause of atypical pneumonia
which often affects younger patients. It is associated with a
number of characteristic complications such as erythema
multiforme and cold autoimmune haemolytic anaemia.
Epidemics of Mycoplasma pneumoniae classically occur every
4 years. It is important to recognise atypical pneumonias as
they may not respond to penicillins or cephalosporins due to it
lacking a peptidoglycan cell wall.
Features
• the disease typically has a prolonged and gradual onset
• flu-like symptoms classically precede a dry cough
• bilateral consolidation on x-ray
• complications may occur as below
Complications
• cold agglutins (IgM) may cause an haemolytic anaemia,
thrombocytopenia
• erythema multiforme, erythema nodosum
• meningoencephalitis, Guillain-Barre syndrome
• bullous myringitis: painful vesicles on the tympanic
membrane
• pericarditis/myocarditis
• gastrointestinal: hepatitis, pancreatitis
• renal: acute glomerulonephritis
Investigations
• diagnosis is generally by Mycoplasma serology
• positive cold agglutination test
Management
• erythromycin/clarithromycin
• tetracyclines such as doxycycline are an alternative
Comparison of Legionella and Mycoplasma pneumonia

Q-70
A nurse in a GUM clinic asks you to look at a rectal gramstained slide for a
symptomatic patient she has just seen. It
shows pinkish/red stained intracellular diplococci.
What is the most likely organism?
A. Neisseria Meningitidis
B. Probable contaminant/commensal organism
C. Chlamydia trachomatis
D. Escherichia coli
E. Neisseria gonorrhoea
ANSWER:
E. Neisseria gonorrhoea
EXPLANATION:
Gonorrhoea is a gram-negative diplococci that can be
identified on gram staining
The stem describes a gram negative stain. Neisseria
gonorrhoeais a gram-negative intracellular diplococcus.
Chlamydia trachomatis cannot be diagnosed on gram
staining. Neisseria meningitidis is another gram-negative
diplococcus but this would not be classed as a commensal
and is much less likely in this scenario. E Coli is a gramnegative diplococcus.
While mixed organisms are often seen
on rectal slides, this particular pattern would raise suspicion
of Neisseria gonorrhoea.
IDENTIFYING GRAM-POSITIVE BACTERIA
Gram positive bacteria will turn purple/blue following the
gram staining. Microscopy will then reveal the shape, either
cocci or rods.
Rods (bacilli)
• Actinomyces
• Bacillus antracis• Clostridium
• Corynebacterium diphtheriae
• Listeria monocytogenes
Cocci
• makes catalase: Staphylococci
• does not make catalase: Streptococci
Staphylococci
• makes coagulase: S. aureus
• does not make coagulase: S. epidermidis (novobiocin
sensitive), S. saprophyticus (novobiocin resistant)
Streptococci
• partial haemolysis (green colour on blood agar): α-
haemolytic
• complete haemolysis (clear): β-haemolytic
• no haemolysis: γ-haemolytic
α-haemolytic streptococci
• optochin sensitive: S. pneumoniae
• optochin resistant: Viridans streptococci
β-haemolytic streptococci
• bacitracin sensitive: Group A: S. pyogenes
• bacitracin resistant: Group B: S. agalactiae

Q-71
A 77-year-old female presents with a non-healing ulcer on
her right foot. Blood cultures grow MRSA. Which antibiotic
would you consider in addition to vancomycin?
A. Flucloxacillin
B. Ceftazidime
C. Ciprofloxacin
D. Metronidazole
E. Rifampicin
ANSWER:
E. Rifampicin
EXPLANATION:
Please see Q-21 for MRSA

Q-72
A 34-year-old man from Zimbabwe is admitted with
abdominal pain to the Emergency Department. An
abdominal x-ray reveals urinary bladder calcification. What
is the most likely cause?
A. Schistosoma mansoni
B. Sarcoidosis
C. Leishmaniasis
D. Tuberculosis
E. Schistosoma haematobium
ANSWER:
A. Schistosoma mansoni
EXPLANATION:
Schistosoma haematobium causes haematuria
Schistosomiasis is the most common cause of bladder
calcification worldwide
Please see Q-7 for Schistosomiasis

Q-73
A 34-year-old man with a past history of HIV infection
presents to the Emergency Department with watery
diarrhoea. Cryptosporidium infection is confirmed on ZN
staining. What is the most suitable management?
A. Metronidazole
B. Sulfadiazine + pyrimethamine
C. Supportive therapy
D. Rifampicin + ethambutol + clarithromycin
E. Co-trimoxazole
Supportive therapy is the mainstay of treatment in
Cryptosporidium diarrhoea
ANSWER:
C. Supportive therapy
EXPLANATION:
HIV: DIARRHOEA
Diarrhoea is common in patients with HIV. This may be due to
the effects of the virus itself (HIV enteritis) or opportunistic
infections
Possible causes
• Cryptosporidium + other protozoa (most common)
• Cytomegalovirus
• Mycobacterium avium intracellulare
• Giardia
Cryptosporidium is the most common infective cause of
diarrhoea in HIV patients. It is an intracellular protozoa and
has an incubation period of 7 days. Presentation is very
variable, ranging from mild to severe diarrhoea. A modified
Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the
characteristic red cysts of Cryptosporidium. Treatment is
difficult, with the mainstay of management being supportive
therapy*
Mycobacterium avium intracellulare is an atypical
mycobacteria seen with the CD4 count is below 50. Typical
features include fever, sweats, abdominal pain and diarrhoea.
There may be hepatomegaly and deranged LFTs. Diagnosis is
made by blood cultures and bone marrow examination.
Management is with rifabutin, ethambutol and clarithromycin
*nitazoxanide is licensed in the US for immunocompetent
patients

Q-74
You are phoned for advice. The parents of a 19-year-old man
have just been messaged by their son who is currently
backpacking in Thailand. Earlier in the day he was bitten by a
dog whilst staying in a rural community. Prior to travelling,
he received vaccination against rabies as he was going to be
visiting many rural areas. What is the most appropriate
advice?
A. He should increase his fluid intake by around 1L a day as
a precaution
B. He should be protected given the previous vaccination
but should monitor for any changes in salivation over
the next 72 hours
C. He should see a local doctor to request antibiotic
therapy
D. He should urgently seek local medical attention for consideration of booster
vaccination + antibiotic therapy
E. He should take the next flight home so he can be
observed for any symptoms of rabies
ANSWER:
D. He should urgently seek local medical attention for consideration of booster
vaccination + antibiotic therapy
EXPLANATION:
Rabies is nearly always fatal if untreated. Whilst you are not
expected to remember all the countries where there is a high
risk of rabies it is clear that being bitten by a dog in a rural
area represents a risk. He needs to urgently see a local
doctor as booster vaccination is indicated to minimise his risk
of developing rabies. Flying home simply delays the most
important intervention.
RABIES
Rabies is a viral disease that causes an acute encephalitis. The
rabies virus is classed as a RNA rhabdovirus (specifically a
lyssavirus) and has a bullet-shaped capsid. The vast majority
of cases are caused by dog bites but it may also be
transmitted by bat, raccoon and skunk bites. Following a bite
the virus travels up the nerve axons towards the central
nervous system in a retrograde fashion.
Rabies is estimated to still kill around 25,000-50,000 people
across the world each year. The vast majority of the disease
burden falls on people in poor rural areas of Africa and Asia.
Children are particularly at risk.
Features
• prodrome: headache, fever, agitation
• hydrophobia: water-provoking muscle spasms
• hypersalivation
• Negri bodies: cytoplasmic inclusion bodies found in
infected neurons
There is now considered to be 'no risk' of developing rabies
following an animal bite in the UK and the majority of
developed countries. Following an animal bite in at-risk
countries:
• the wound should be washed
• if an individual is already immunised then 2 further doses
of vaccine should be given
• if not previously immunised then human rabies
immunoglobulin (HRIG) should be given along with a full
course of vaccination. If possible, the dose should be
administered locally around the wound
If untreated the disease is nearly always fatal.

Q-75
A 32-year-old oil worker presents by ambulance to the
Emergency Department following his return from Angola. His
wife reports that over the past 24 hours, the patient has
become progressively more drowsy with fevers ongoing for
the past 5 days. On examination, the patient is unresponsive
to voice and is visibly clammy. His observations are as
follows:
Heart rate 120 beats per minute
Blood pressure 100/60 mmHg
Respiratory rate 32 breaths per minute
SpO2 96% on 15L O2
Initial investigations are as follows:
Hb 78 g/l
Platelets 90 * 109/l
WBC 20 * 109/l
Na+ 140 mmol/l
K+ 5.6 mmol/l
Urea 15 mmol/l
Creatinine 190 µmol/l
Bilirubin 70 µmol/l
Malarial Films P. falciparum species seen, 12%
parasitaemia
Given this patient's condition, what treatment(s) should be
commenced?
A. Chloroquine
B. Artesunate and exchange transfusion
C. Artesunate
D. Doxycycline
E. Quinine + Doxycycline
ANSWER:
B. Artesunate and exchange transfusion
EXPLANATION:
Exchange transfusion should be considered in cases of severe
parasitaemia (>10%)
This patient has presented with features suggestive of severe
malaria, which is confirmed by his blood results and clinical
[Link] malaria warrants aggressive treatment given its
potential complications. These occur due to the parasites
ability to sequester blood cells in capillary beds, causing
ischaemia.
Patients with severe malaria should be treated with IV
artesunate, and in cases where parasitaemia >10% is seen,
consideration should be given to the performance of
exchange transfusions.
Most falciparum malaria is now resistant to chloroquine
medications, so this option is incorrect. Quinine and
doxycycline may be used for some cases of falciparum
malaria, however, this practice is no longer first-line.
Please see Q-45 for Malaria: Falciparum

Q-76
A 39-year-old man returns from a two week business trip to
Kenya. Four weeks after his return he presents complaining
of malaise, headaches and night sweats. On examination
there is a symmetrical erythematous macular rash over his
trunk and limbs associated with cervical and inguinal
lymphadenopathy. What is the most likely diagnosis?
A. Typhoid fever
B. Tuberculosis
C. Dengue fever
D. Schistosomiasis
E. Acute HIV infection
ANSWER:
E. Acute HIV infection
EXPLANATION:
Man returns from trip abroad with maculopapular rash and
flu-like illness - think HIV seroconversion
Stereotypes are alive and well in the MRCP exam. For
questions involving businessmen always consider sexually
transmitted infections. The HIV prevalence rate in Kenya is
currently around 8%.
HIV: SEROCONVERSION
HIV seroconversion is symptomatic in 60-80% of patients and
typically presents as a glandular fever type illness. Increased
symptomatic severity is associated with poorer long term
prognosis. It typically occurs 3-12 weeks after infection
Features
• sore throat
• lymphadenopathy
• malaise, myalgia, arthralgia
• diarrhoea
• maculopapular rash
• mouth ulcers
• rarely meningoencephalitis
Diagnosis
• antibodies to HIV may not be present
• HIV PCR and p24 antigen tests can confirm diagnosis
An illustration model of the HIV Replication Cycle. Each step of the cycle is
numbered and concisely described. Credit: NIAID

Q-77
A 20-year-old woman was admitted overnight with
suspected meningitis. You are asked to review the initial
microscopy results from the lumbar puncture. The lab tells
you the culture is growing gram negative diplococci.
What is the most likely organism?
A. Streptococcus pneumoniae
B. Listeria monocytogenes
C. Escherichia coli
D. Haemophilus influenzae
E. Neisseria meningitidis
ANSWER:
E. Neisseria meningitidis
EXPLANATION:
Neisseria meningitis and Streptococcus pneumoniae would
be most common in this age group but it is [Link] that
is a gram negative diplococci.
S. pneumoniae is a gram positive diplococci/chain
E. coli is a gram negative bacilli
H. influenzae is a gram negative coccobacilli
L. monocytogenes is a gram positive rodMENINGITIS: CAUSES
0 - 3 months
• Group B Streptococcus (most common cause in neonates)
• coli
• Listeria monocytogenes
3 months - 6 years
• Neisseria meningitidis
• Streptococcus pneumoniae
• Haemophilus influenzae
6 years - 60 years
• Neisseria meningitidis
• Streptococcus pneumoniae
> 60 years
• Streptococcus pneumoniae
• Neisseria meningitidis
• Listeria monocytogenes
Immunosuppressed
• Listeria monocytogenes

Q-78
A 19-year-old man presents with dysuria associated with a
watery discharge from his urethral meatus. A urethral swab
shows non-specific urethritis and urine is sent for
Chlamydia/gonococcus. What is the most appropriate
antibiotic to use?
A. Erythromycin
B. Ciprofloxacin
C. Metronidazole
D. Cefixime
E. Azithromycin
ANSWER:
E. Azithromycin
EXPLANATION:
Chlamydia - treat with azithromycin or doxycycline
Gonorrhoea would be demonstrated by the presence of
Gram negative diplococci on the swab. As the swab showed
non-specific urethritis a diagnosis of Chlamydia is most likely.
The 2009 SIGN guidelines suggest azithromycin should be
used first-line due to potentially poor compliance with a 7
day course of doxycycline.
Please see Q-32 for Chlamydia

Q-79
Which of the following anti-retroviral drugs is most
characteristically associated with nephrolithiasis?
A. Zidovudine
B. Didanosine
C. Indinavir
D. Ritonavir
E. Nevirapine
ANSWER:
C. Indinavir
EXPLANATION:
Please see Q-10 for HIV: Anti-Retrovirals

Q-80
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. Given the likely organism, what is the most
appropriate treatment?
A. Hydroxychloroquine
B. Aciclovir
C. Benzylpenicillin
D. Ciprofloxacin
E. Metronidazole
ANSWER:
E. Metronidazole
EXPLANATION:
Although Escherichia coli is the most common cause of
travellers' diarrhoea, in this particular case the length of
illness and nature of symptoms (bloating, watery diarrhoea)
points to a diagnosis of Giardiasis.
GIARDIASIS
Giardiasis is caused by the flagellate protozoan Giardia
lamblia. It is spread by the faeco-oral route
Features
• often asymptomatic
• lethargy, bloating, abdominal pain
• flatulence
• 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

Q-81
A 12-year-old girl is prescribed oseltamivir for suspected
influenza. What is the mechanism of action of oseltamivir?
A. Inhibits RNA polymerase
B. Interferes with the capping of viral mRNA
C. Neuraminidase inhibitor
D. Inhibits DNA polymerase
E. Protease inhibitor
ANSWER:
C. Neuraminidase inhibitor
EXPLANATION:
Please see Q-26 for H1N1 Influenza Pandemic

Q-82
You are an F2 working in general practice. Last week you saw
a 17-year-old female with acne vulgaris which is causing her
significant distress and started her on tetracycline. She has
come back to see you today complaining about a side effect.
Which side effect is she most likely to be experiencing?
A. Headache
B. Red rash on her face and neck
C. Dizziness
D. Dry lips and tongue
E. Ringing in her ears
ANSWER:
B. Red rash on her face and neck
EXPLANATION:
Tetracyclines can cause a photosensitive skin rash
The correct answer is 2. Tetracyclines are often prescribed for
acne and can cause a photosensitive skin rash. This appears
as a red rash on areas of skin exposed to the sun. Other skin
reactions to tetracyclines include exfoliative dermatitis and
Stevens-Johnson syndrome.
Nausea and headaches a common side effect of many
medications but are not usually a significant problem with
tetracyclines. Tetracyclines can cause grey discolouration of
the teeth in neonates if they are given to pregnant women in
the second or third trimester but not if given to children or
adults. Dry lips and tongue are a side effect of vitamin A
derivatives, including retinoin and isotretinoin, which might
be prescribed further down the line in severe acne.
Tetracyclines are not known to cause damage to the hearing,
unlike gentamicin, furosemide and cisplatin.
TETRACYCLINES
Tetracyclines are a class of antibiotics which are commonly
used in clinical practice.
Examples
• doxycycline
• tetracycline
Mechanism of action
• protein synthesis inhibitors
• binds to 30S subunit blocking binding of aminoacyl-tRNA
Mechanism of resistance
• increased efflux of the bacteria by plasmid-encoded
transport pumps, ribosomal protection
Indications
• acne vulgaris
• Lyme disease
• Chlamydia
• -Mycoplasma pneumoniae
Adverse effects
• discolouration of teeth
• photosensitivity
Tetracyclines should not be given to women who are pregnant
or breastfeeding due to the risk of discolouration of the
infant's teeth.

Q-83
A 23-year-old student returns from India and develops a
febrile illness. Following investigation he is diagnosed as
having Plasmodium vivax malaria. This area is known to
harbour chloroquine-resistant strains of Plasmodium vivax.
What is the most appropriate initial management to treat
the acute infection?
A. Primaquine
B. Atovaquone-proguanil
C. Quinine
D. Doxycycline
E. Artemether-lumefantrine
ANSWER:
E. Artemether-lumefantrine
EXPLANATION:
For non-falciparum malaria:
in areas which are known to be chloroquine-sensitive then
WHO recommend either an artemisinin-based combination
therapy (ACT) or chloroquine
in areas which are known to be chloroquine-resistant an ACT
should be
Please see Q-36 for Malaria: Non-Falciparum

Q-84
A 24-year-old woman who is 18 weeks pregnant presents to
the Emergency Department. Earlier on in the morning she
came into contact with a child who has chickenpox. She is
unsure if she had the condition herself as a child. What is the
most appropriate action?A. Advise her to present within 24 hours of the rash
developing for consideration of IV aciclovir
B. Reassure her that there is no risk of fetal complications
at this point in pregnancy
C. Give varicella immunoglobulin
D. Check varicella antibodies
E. Prescribe oral aciclovir
ANSWER:
D. Check varicella antibodies
EXPLANATION:
Chickenpox exposure in pregnancy - first step is to check
antibodies
If there is any doubt about the mother previously having
chickenpox maternal blood should be checked for varicella
antibodies
CHICKENPOX EXPOSURE IN PREGNANCY
Chickenpox is caused by primary infection with varicella zoster
virus. Shingles is reactivation of dormant virus in dorsal root
ganglion. In pregnancy there is a risk to both the mother and
also the fetus, a syndrome now termed fetal varicella
syndrome
Risks to the mother
5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)
• risk of FVS following maternal varicella exposure is
around 1% if occurs before 20 weeks gestation
• studies have shown a very small number of cases
occurring between 20-28 weeks gestation and none
following 28 weeks
• features of FVS include skin scarring, eye defects
(microphthalmia), limb hypoplasia, microcephaly and
learning disabilities
Other risks to the fetus
• shingles in infancy: 1-2% risk if maternal exposure in the
second or third trimester
• severe neonatal varicella: if mother develops rash
between 5 days before and 2 days after birth there is a
risk of neonatal varicella, which may be fatal to the
newborn child in around 20% of cases
Management of chickenpox exposure
• if there is any doubt about the mother previously having
chickenpox maternal blood should be urgently checked
for varicella antibodies
• if the pregnant women is not immune to varicella she
should be given varicella zoster immunoglobulin (VZIG) as
soon as possible. RCOG and Greenbook guidelines
suggest VZIG is effective up to 10 days post exposure
• consensus guidelines suggest oral aciclovir should be
given if pregnant women with chickenpox present within
24 hours of onset of the rash

Q-85
A 31-year-old woman who is known to be HIV positive
presents following a positive pregnancy test. Her last
menstrual period was 6 weeks ago. The last CD4 count was
420 * 106/l and she does not take any antiretroviral therapy.
What is the most appropriate management with regards to
antiretroviral therapy?
A. Check CD4 at 12 weeks and initiate antiretroviral
therapy if CD4 count is less than 350 * 106/l
B. Do not give antiretroviral therapy
C. Start antiretroviral therapy at 20-32 weeks
D. Start antiretroviral therapy at 10-12 weeks
E. Start antiretroviral therapy immediately
ANSWER:
E. Start antiretroviral therapy immediately
EXPLANATION:
Following the 2015 BHIVA guidelines, it is now recommended
that patients start HAART as soon as they have been
diagnosed with HIV, regardless of whether they are pregnant
or not, rather than waiting until a particular CD4 count, as
was previously advocated.
HIV AND PREGNANCY
With the increased incidence of HIV infection amongst the
heterosexual population there are an increasing number of
HIV positive women giving birth in the UK. In London the
incidence may be as high as 0.4% of pregnant women. The
aim of treating HIV positive women during pregnancy is to
minimise harm to both the mother and fetus, and to reduce
the chance of vertical transmission.
Guidelines regularly change on this subject and most recent
guidelines can be found using the links provided.
Factors which reduce vertical transmission (from 25-30% to
2%)
• maternal antiretroviral therapy
• mode of delivery (caesarean section)
• neonatal antiretroviral therapy
• infant feeding (bottle feeding)
Screening
• NICE guidelines recommend offering HIV screening to all
pregnant women
Antiretroviral therapy
• all pregnant women should be offered antiretroviral
therapy regardless of whether they were taking it
previously
Mode of delivery
• vaginal delivery is recommended if viral load is less than
50 copies/ml at 36 weeks, otherwise caesarian section is
recommended
• a zidovudine infusion should be started four hours before
beginning the caesarean sectionNeonatal antiretroviral therapy
• zidovudine is usually administered orally to the neonate if
maternal viral load is <50 copies/ml. Otherwise triple ART
should be used. Therapy should be continued for 4-6
weeks.
Infant feeding
• in the UK all women should be advised not to breast feed

Q-86
A 30-year-old man comes for review. He lives with a woman
who has recently been diagnosed with having tuberculosis.
The man was born in the UK, has no past medical history of
note and is currently asymptomatic. What is the most
appropriate test to check for latent tuberculosis?
A. Heaf test
B. Mantoux test
C. Sputum culture
D. Chest x-ray
E. Interferon-gamma blood test
ANSWER:
B. Mantoux test
EXPLANATION:
The two main tests used for screening in the UK are the
Mantoux (skin) test and the interferon-gamma (blood) test.
Whilst the use of the interferon-gamma test is increasing it is
still reserved for specific situations, none of which apply in
this case. Please see the NICE guidelines for more details.
The Heaf test is no longer used in the UK.
TUBERCULOSIS: SCREENING
The Mantoux test is the main technique used to screen for
latent tuberculosis. In recent years the interferon-gamma
blood test has also been introduced. It is used in a number of
specific situations such as:
• the Mantoux test is positive or equivocal
• people where a tuberculin test may be falsely negative
(see below)
Mantoux test
• 0 ml of 1:1,000 purified protein derivative (PPD) injected
intradermally
• result read 2-3 days later
Diameter of
induration Positivity Interpretation
< 6mm Negative - no significant
hypersensitivity to tuberculin
protein
Previously
unvaccinated
individuals may be
given the BCG
6 - 15mm Positive - hypersensitive to
tuberculin protein
Should not be given
BCG. May be due to
Diameter of
induration Positivity Interpretation
previous TB infection
or BCG
> 15mm Strongly positive - strongly
hypersensitive to tuberculin
protein
Suggests tuberculosis
infection.
False negative tests may be caused by:
• miliary TB
• sarcoidosis
• HIV
• lymphoma
• very young age (e.g. < 6 months)
Heaf test
The Heaf test was previously used in the UK but has been
since been discontinued. It involved injection of PPD
equivalent to 100,000 units per ml to the skin over the flexor
surface of the left forearm. It was then read 3-10 days later.
Scanning electron micrograph of Mycobacterium tuberculosis bacteria,
which cause TB. Credit: NIAID

Q-87
A 19-year-old man presents with an annular rash, pyrexia
and polyarthralgia to the Emergency Department. He has
just returned from the New Forest and remembers being
bitten by a tick. Given the likely diagnosis, what is the most
appropriate antibiotic therapy?
A. Ciprofloxacin
B. Amoxicillin
C. Metronidazole
D. Doxycycline
E. Ceftriaxone
ANSWER:
D. Doxycycline
EXPLANATION:
As he only has features of early disease, doxycycline is
sufficient.
Please see Q-35 for Lyme Disease

Q-88
Following a recent holiday to South America, a 19-year-old
woman returned home and within a month developed a
swelling around the right cheek with increased fatigue and
diarrhoea. Diagnostic thick and thin blood films identified
the parasite Trypanosoma cruzi. Which medication can be
used to treat her condition during the acute phase of the
disease?
A. Riluzole
B. Benznidazole
C. Praziquantel
D. Miltefosine
E. Chloroquine
ANSWER:
B. Benznidazole
EXPLANATION:
Benznidazole is used in the acute phase of Chagas' disease to
manage the illness
Azoles such as benznidazole are antifungal medications
which target the p450 cytochrome enzyme system to inhibit
the growth of a wide range of organisms.
Riluzole - used to manage motor neurone disease
Praziquantel - used in patients with schistosomiasis
Miltefosine - Used in patients with Leishmaniasis
Chloroquine - Used in the treatment of Malaria
Please see Q-1 for Trypanosomiasis

Q-89
A prison GP is bitten by a patient who is known to have
hepatitis B. The GP has a documented full history of hepatitis
B vaccination and was known to be a responder. What is the
most appropriate action to reduce the chance of contracting
hepatitis B?
A. Admit for intravenous interferon
B. Give hepatitis B immune globulin
C. Give hepatitis B immune globulin + hepatitis B vaccine
booster
D. Give hepatitis B vaccine booster
E. Give oral ribavirin for 4 weeks
ANSWER:
D. Give hepatitis B vaccine booster
EXPLANATION:
Please see Q-23 for Post-Exposure Prophylaxis

Q-90
A 30-year-old HIV positive man attends your travel clinic
asking for your advice on holiday vaccinations. His is taking
anti-retroviral therapy and his most recent CD4 count is 200
cells/mm³. He is otherwise well and has no other medical
conditions.
Which of the following vaccines are contraindicated in this
man?
A. Rabies
B. Meningitis ACWY
C. Japanese encephalitis
D. Tuberculosis (BCG)
E. Hepatitis B
ANSWER:
D. Tuberculosis (BCG)
EXPLANATION:
Live attenuated vaccines such as BCG are contraindicated in
all HIV positive patients.
Other live attenuated vaccines which should not be given in
immunocompromised patients are:
• Yellow fever
• Oral polio
• Intranasal influenza
• Varicella
• Measles, mumps and rubella (MMR)
VACCINATIONS
It is important to be aware of vaccines which are of the liveattenuated type as
these may pose a risk to
immunocompromised patients. The main types of vaccine are
as follows:
Live attenuated
• BCG
• measles, mumps, rubella (MMR)
• influenza (intranasal)
• oral rotavirus
• oral polio
• yellow fever
• oral typhoid
Inactivated preparations
• rabies
• hepatitis A
• influenza (intramuscular)
Toxoid (inactivated toxin)
• tetanus
• diphtheria
• pertussisSubunit and conjugate vaccines are often grouped together.
Subunit means that only part of the pathogen is used to
generate an immunogenic response. A conjugate vaccine is a
particular type that links the poorly immunogenic bacterial
polysaccharide outer coats to proteins to make them more
immunogenic
• pneumococcus (conjugate)
• haemophilus (conjugate)
• meningococcus (conjugate)
• hepatitis B
• human papillomavirus
Notes
• influenza: different types are available, including whole
inactivated virus, split virion (virus particles disrupted by
detergent treatment) and sub-unit (mainly
haemagglutinin and neuraminidase)
• cholera: contains inactivated Inaba and Ogawa strains of
Vibrio cholerae together with recombinant B-subunit of
the cholera toxin
• hepatitis B: contains HBsAg adsorbed onto aluminium
hydroxide adjuvant and is prepared from yeast cells using
recombinant DNA technology

Q-91
A 31-year-old female presents to the genitourinary medicine
clinic due to four fleshy, protuberant lesions on her vulva
which are slightly pigmented. She has recently started a
relationship with a new partner. What is the most
appropriate initial management?
A. Oral aciclovir
B. Topical podophyllum
C. Topical salicylic acid
D. Topical aciclovir
E. Electrocautery
ANSWER:
B. Topical podophyllum
EXPLANATION:
Genital wart treatment
• multiple, non-keratinised warts: topical podophyllum
• solitary, keratinised warts: cryotherapy
Cryotherapy is also acceptable as an initial treatment for
genital warts
GENITAL WARTS
Genital warts (also known as condylomata accuminata) are a
common cause of attendance at genitourinary clinics. They
are caused by the many varieties of the human papilloma
virus HPV, especially types 6 & 11. It is now well established
that HPV (primarily types 16,18 & 33) predisposes to cervical
cancer.
Features
• small (2 - 5 mm) fleshy protuberances which are slightly
pigmented
• may bleed or itch
Management
• topical podophyllum or cryotherapy are commonly used
as first-line treatments depending on the location and
type of lesion. Multiple, non-keratinised warts are
generally best treated with topical agents whereas
solitary, keratinised warts respond better to cryotherapy
• imiquimod is a topical cream which is generally used
second line
• genital warts are often resistant to treatment and
recurrence is common although the majority of
anogenital infections with HPV clear without intervention
within 1-2 years

Q-92
A 26-year-old man presents to your sexual health clinic with
a history of swollen inguinal lymph nodes and fever 1 month
after he had receptive anal intercourse with a casual male
partner. He tells you his last HIV test was 2 months
previously and this is the only sexual contact he has had in
the last 6 months.
What is the most appropriate course of action to determine
his HIV status?
A. Advise the patient it is too early to test for HIV; ask him
to return in 2 weeks and then at 3 months
B. Request a combined antigen (P24) and antibody test
C. Ask the patient to return in 2 months for an RNA PCR
test
D. Perform a bedside 'Point of Care' antibody only test and
reassure the patient if this is normal
E. Take a full blood count for CD4 count
ANSWER:
B. Request a combined antigen (P24) and antibody test
EXPLANATION:
p24 testing can be used 4 week after an exposure and is
often used in combination with the HIV antibody test in
clinical practice
A combined p24/Antibody test is the most appropriate test
used in clinical practice as this has a 4 week window period.
Bedside antibody only test may not be accurate for a recent
risk less than 6 weeks ago. RNA PCR is sometimes used as a
screening test but there is no reason to delay testing. CD4
count needs to be checked should the patient be HIV positive
but will not give you any information about his HIV status
HIV: TESTING
HIV antibody test
• most common and accurate test
• usually consists of both a screening ELISA (Enzyme Linked
Immuno-Sorbent Assay) test and a confirmatory Western
Blot Assay
• most people develop antibodies to HIV at 4-6 weeks but
99% do by 3 monthsp24 antigen test
• usually positive from about 1 week to 3 - 4 weeks after
infection with HIV
• sometimes used as an additional screening test in blood
banks

Q-93
A 25-year-old man returns from a gap-year in Central and
South America and presents with a 2 month history of an
ulcerating lesion on his lower lip. Examination of his nasal
and oral mucosae reveals widespread involvement. What is
the likely cause?
A. Leishmania brasiliensis
B. Leishmania mexicana
C. Trypanosoma cruzi
D. Basal cell carcinoma
E. Leishmania donovani
ANSWER:
A. Leishmania brasiliensis
EXPLANATION:
Mucocutaneous ulceration following travel? - Leishmania
brasiliensis
This patient most likely has leishmaniasis. The pattern of a
primary skin lesion with mucosal involvement is
characteristic of Leishmania brasiliensis
Please see Q-18 for Leishmaniasis

Q-94
A 45-year-old man is diagnosed as having primary syphilis.
Six hours after receiving his first injection of benzylpenicillin
he complains of feeling generally unwell. On examination he
appears flushed. His blood pressure is 94/62 mmHg, pulse
96/min and temperature 37.9º. These symptoms settle after
around four hours. Which one of the following is most likely
to explain this finding.
A. Arunan-Leadbetter reaction
B. Jarisch-Herxheimer reaction
C. Concurrent infectious mononucleosis infection
D. Allergic reaction to benzylpenicillin
E. Undiagnosed tertiary syphilis
ANSWER:
B. Jarisch-Herxheimer reaction
EXPLANATION:
SYPHILIS: MANAGEMENT
Management
• intramuscular benzathine penicillin is the first-line
management
• alternatives: doxycycline
• the Jarisch-Herxheimer reaction is sometimes seen
following treatment. Fever, rash, tachycardia after first
dose of antibiotic. It is thought to be due to the release of
endotoxins following bacterial death and typically occurs
within a few hours of treatment.

Q-95
A 34-year-old man presents with a widespread
maculopapular rash and mouth ulcers. Two months ago he
presented to the local GUM clinic after developing a painless
penile ulcer. At the time he was noted to have inguinal
lymphadenopathy. Which one of the following organisms is
most likely to be responsible?
A. Lymphogranuloma venereum
B. Herpes simplex virus type 2
C. Mycoplasma genitalium
D. Haemophilus ducreyi
E. Treponema pallidum
ANSWER:
E. Treponema pallidum
EXPLANATION:
This patient has symptoms of secondary syphilis.
SYPHILIS
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. The incubation period
is between 9-90 days
Primary features
• chancre - painless ulcer at the site of sexual contact
• local non-tender lymphadenopathy
• often not seen in women (the lesion may be on the
cervix)
Secondary features - occurs 6-10 weeks after primary
infection
• systemic symptoms: fevers, lymphadenopathy
• rash on trunk, palms and soles
• buccal 'snail track' ulcers (30%)
• condylomata lata (painless, warty lesions on the genitalia
Classical palm lesions of secondary syphilisMore generalised rash of secondary
syphilis
Tertiary features
• gummas (granulomatous lesions of the skin and bones)
• ascending aortic aneurysms
• general paralysis of the insane
• tabes dorsalis
• Argyll-Robertson pupil
Features of congenital syphilis
• blunted upper incisor teeth (Hutchinson's teeth),
'mulberry' molars
• rhagades (linear scars at the angle of the mouth)
• keratitis
• saber shins
• saddle nose
• deafness

Q-96
Which one of the following statements best describes the
prevention and treatment of hepatitis C?
A. No vaccine is available and treatment is only successful
in around 10-15% of patients
B. No vaccine and no treatment is available
C. A vaccine is available and treatment is successful in
around 50% of patients
D. A vaccine is available but no treatment has been shown
to be effective
E. No vaccine is available but treatment is successful in the majority of patients
ANSWER:
E. No vaccine is available but treatment is successful in the majority of patients
EXPLANATION:
Please see Q-6 for Hepatitis C

Q-97
A 31-year-old female with no past medical history of note is
admitted to hospital with dyspnoea and fever. She has
recently returned from holiday in Turkey. A clinical diagnosis
of pneumonia is made. On examination she is noted to have
an ulcerated lesion on her upper lip consistent with
reactivation of herpes simplex. Which organism is most
associated with this examination finding?
A. Legionella pneumophilia
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Pneumocystis carinii
E. Mycoplasma pneumoniae
ANSWER:
C. Streptococcus pneumoniae
EXPLANATION:
Streptococcus pneumoniae is associated with cold sores
Streptococcus pneumoniae commonly causes reactivation of
the herpes simplex virus resulting in 'cold sores'
Please see Q-40 for Pneumonia: Causes

Q-98
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?
A. No action needed, complete hepatitis B vaccination
course as normal
B. Give oral ribavirin for 4 weeks
C. Give an accelerated course of the hepatitis B vaccine + hepatitis B immune
globulin
D. Give hepatitis B immune globulin + oral ribavirin for 4
weeks
E. Give hepatitis B immune globulin
ANSWER:
C. Give an accelerated course of the hepatitis B vaccine + hepatitis B immune
globulin
EXPLANATION:
Please see Q-23 for Post-Exposure Prophylaxis

Q-99
A 25-year-old student with an anaphylactic allergy to egg
protein is planning to travel in South East Asia. Which of the
following vaccinations is contraindicated in egg allergy?
A. Yellow fever vaccine
B. Typhoid vaccine
C. Inactivated polio vaccine
D. Japanese encephalitis vaccine
E. Rabies vaccine
ANSWER:
A. Yellow fever vaccine
EXPLANATION:
Egg protein is present in clinically significant quantities in the
yellow fever [Link] embryos are also used in the production of the MMR and
some rabies vaccines. The egg protein content is not clinically
significant, however, as it is in the range of picograms to
nanograms per dose.
Egg protein is present in potentially significant amounts in
killed injected and live attenuated influenza vaccines. It is
not present in recombinant influenza vaccine.
Anaphylaxis to egg protein is also a contraindication to the
use of propofol.
Please see Q-90 for Vaccinations

Q-100
A 35-year-old male presents with a facial droop. On
neurological examination, a lower motor neuron facial nerve
lesion is localised. He describes a rash over his forearm 3
weeks ago which settled. What is the most like diagnosis?
A. Lyme disease
B. Stroke
C. Motor neuron disease
D. Multiple sclerosis
E. Ramsay Hunt syndrome
ANSWER:
A. Lyme disease
EXPLANATION:
This patient has a lower motor facial nerve lesion. One must
next consider all the causes of a facial nerve palsy.
Considering the history of a rash (erythema migrans), Lyme
disease is the most likely answer. The symptoms of Lyme
disease most often occurs 3 days to 1 month after the initial
tick bite. A stroke and multiple sclerosis affects the central
nervous system and present with a upper motor neuron
lesion as opposed to a lower motor neuron lesion. Motor
neuron disease doesn't normally affect the facial nerve and
never presents with a rash. Ramsay Hunt syndrome typically
presents with a triad of ipsilateral facial paralysis (lower
motor neuron facial palsy), ear pain, and a vesicular rash on
the face or in the ear. The rash doesn't appear on the
forearm.
Please see Q-35 for Lyme Disease

Q-101
A 23-year-old man has a Mantoux test prior to receiving the
BCG vaccine. He develops a 12 mm indurated lesion on his
forearm. Which one of the following cytokines is most
involved in this response?
A. Interleukin-8
B. Interferon-γ
C. Interferon-β
D. Interferon-α
E. Interleukin-10
ANSWER:
B. Interferon-γ
EXPLANATION:
Tuberculin skin tests are an example of type IV (delayed)
hypersensitivity reactions. These are largely mediated by
interferon-γ secreted by Th1 cells which in turn stimulates
macrophage activity.
Please see Q-86 for Tuberculosis: Screening

Q-102
A 24-year-old woman presents due to an itchy vulva and
pain during sex. She also mentions a green, offensive vaginal
discharge for the past 2 weeks. What is the most likely
diagnosis?
A. Candida
B. Bacterial vaginosis
C. Gonorrhoea
D. Trichomonas vaginalis
E. Chlamydia
ANSWER:
D. Trichomonas vaginalis
EXPLANATION:
TRICHOMONAS VAGINALIS
Trichomonas vaginalis is a highly motile, flagellated protozoan
parasite. Trichomoniasis is a sexually transmitted infection
(STI).
Features
• vaginal discharge: offensive, yellow/green, frothy
• vulvovaginitis
• strawberry cervix
• pH > 4.5
• in men is usually asymptomatic but may cause urethritis
Investigation
• microscopy of a wet mount shows motile trophozoites
Management
• oral metronidazole for 5-7 days, although the BNF also
supports the use of a one-off dose of 2g metronidazole
Comparison of bacterial vaginosis and Trichomonas vaginalisTrichomonas vaginalis -
largely transparent core with finely granular
eosinophilic cytoplasm. Surrounded by neutrophils with segmented nuclei
Image sourced from Wikipedia© Image used on license from PathoPic

Q-103
You are counselling a 26-year-old man who has recently had
a positive HIV test. His most recent CD4 count is 650
cells/mm^3. Which one of the following vaccinations is
contraindicated?
A. Oral poliomyelitis
B. Yellow fever
C. Pneumococcus
D. Parenteral poliomyelitis
E. Measles, Mumps, Rubella
ANSWER:
A. Oral poliomyelitis
EXPLANATION:
HIV: IMMUNISATION
The Department of Health 'Greenbook' on immunisation
defers to the British HIV Association for guidelines relating to
immunisation of HIV-infected adults
Vaccines that can be
used in all HIV-infected
adults
Vaccines that can
be used if CD4 >
200
Contraindicated in
HIV-infected
adults
Hepatitis A
Hepatitis B
Haemophilus influenzae B
(Hib)
Influenza-parenteral
Japanese encephalitis
Measles, Mumps,
Rubella (MMR)
Varicella
Yellow Fever
Cholera CVD103-
HgR
Influenza-intranasal
Poliomyelitis-oral
(OPV)
Tuberculosis (BCG)
Vaccines that can be
used in all HIV-infected
adults
Vaccines that can
be used if CD4 >
200
Contraindicated in
HIV-infected
adults
Meningococcus-MenC
Meningococcus-ACWY I
Pneumococcus-PPV23
Poliomyelitis-parenteral
(IPV)
Rabies
Tetanus-Diphtheria (Td)

Q-104
A 64-year-old woman presents to the Emergency
Department with a cough, fever, diarrhoea and myalgia. The
cough is non-productive and and has been getting gradually
worse since she returned from holiday in Spain one week
ago. Her husband is concerned because over the past 24
hours she has become more drowsy and febrile. He initially
thought she had the 'flu but her symptoms have got
progressively worse. She is normally fit and well but drinks
around 20 units of alcohol per week.
On examination pulse is 76/min, blood pressure 104/62
mmHg, oxygen saturations are 94% on room air and
temperature is 38.4ºC. Bilateral coarse crackles are heard in
the chest.
Initial blood tests show the following:
Hb 13.6 g/dl
Platelets 311 * 109/l
WBC 14.2 * 109/l
Na+ 131 mmol/l
K+ 4.3 mmol/l
Urea 9.2 mmol/l
Creatinine 91 µmol/l
Bilirubin 12 µmol/l
ALP 31 u/l
ALT 64 u/l
A chest x-ray shows patchy consolidation in the left lower
zone with an associated pleural effusion.
What is the most likely causative organism?
A. Streptococcus pneumoniae
B. Mycoplasma pneumoniae
C. Legionella pneumophila
D. Klebsiella pneumoniae
E. Staphylococcus aureus
ANSWER:
C. Bilateral coarse crackles are heard in
the chest.
Initial blood tests show the following:
Hb 13.6 g/dl
Platelets 311 * 109/l
WBC 14.2 * 109/l
Na+ 131 mmol/l
K+ 4.3 mmol/l
Urea 9.2 mmol/l
Creatinine 91 µmol/l
Bilirubin 12 µmol/l
ALP 31 u/l
ALT 64 u/l
A chest x-ray shows patchy consolidation in the left lower
zone with an associated pleural effusion.
What is the most likely causative organism?
EXPLANATION:There are a number of features here which strongly suggest
Legionella:
• recent foreign travel
• flu-like symptoms
• hyponatraemia
• pleural effusion
Please see Q-13 for Legionella

Q-105
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?
A. Alanine transaminase level
B. Anti-HCV antibodies
C. Viral load
D. Prothrombin time
E. Hepatitis C genotype
ANSWER:
C. What is the best
way to assess his response to treatment?
EXPLANATION:
Please see Q-6 for Hepatitis C

Q-106
A 74-year-old woman has a chest x-ray organised by her GP
due to a chronic cough. The chest x-ray shows a cavity in the
left upper zone inside of which there is a solid mass. An
aspergilloma is suspected. What is the most appropriate
next test?
A. Sputum culture
B. Serology for Aspergillus precipitins
C. Blood culture
D. Bronchoscopy with biopsy
E. Transthoracic fine needle biopsy
ANSWER:
B. Serology for Aspergillus precipitins
EXPLANATION:
Please see Q-50 for Aspergilloma
Q-107
Which one of the following is least likely to result from
Streptococcus pyogenes infection?
A. Rheumatic fever
B. Scarlet fever
C. Cellulitis
D. Type 2 necrotizing fasciitis
E. Pneumonia
ANSWER:
E. Pneumonia
EXPLANATION:
Streptococcus pyogenes rarely causes pneumonia.
STREPTOCOCCI
Streptococci are gram-positive cocci. They may be divided into
alpha and beta haemolytic types
Alpha haemolytic streptococci (partial haemolysis)
The most important alpha haemolytic Streptococcus is
Streptococcus pneumoniae (pneumococcus). Pneumococcus
is a common cause of pneumonia, meningitis and otitis media.
Another clinical example is Streptococcus viridans
Beta haemolytic streptococci (complete haemolysis)
These can be subdivided into groups A-H. Only groups A, B &
D are important in humans.
Group A
• most important organism is Streptococcus pyogenes
• responsible for erysipelas, impetigo, cellulitis, type 2
necrotizing fasciitis and pharyngitis/tonsillitis
• immunological reactions can cause rheumatic fever or
post-streptococcal glomerulonephritis
• erythrogenic toxins cause scarlet fever
Group B
• Streptococcus agalactiae may lead to neonatal meningitis
and septicaemia
Group D
• Enterococcus

Q-108
A 34-year-old HIV positive man is being treated for
Pneumocystis carinii pneumonia with co-trimoxazole.
Arterial blood gases show a pO2 of 8.2 kPa. What drug
should be added to treatment?
A. Meropenem
B. Chloramphenicol
C. Steroids
D. Nebulised fluconazole
E. Magnesium sulphate
ANSWER:
C. Steroids
EXPLANATION:
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-109
A 24-year-old man attends your GUM clinic for results of his
recent tests. He frequently engages in unprotected sex with
multiple partners. You note he had a mildly raised Venereal
Disease Research Laboratory (VDRL) test at 1:8. He did
however have a negative EIA and TPPA test. You suspect it
could be a false positive test [Link] of the following would be useful at
determining a
cause?
A. HIV test
B. Rheumatoid factor
C. Serum electrophoresis
D. Varicella serology
E. Mycoplasma serology
ANSWER:
A. HIV test
EXPLANATION:
False positive VDRL/RPR: 'SomeTimes Mistakes Happen' (SLE,
TB, malaria, HIV)
The answer is HIV test. The VDRL test is very sensitive for
syphilis infections and titres can be used to track treatment
and progression. It is, however, prone to many false
positives. This is defined by a positive VDRL in the absence of
a positive EIA/TPPA (which, in contrast, stay positive lifelong
after infection).
False positives are usually due to a reaction of antibodies to
the cardiolipin-lecithin-cholesterol reagent in the RPR/VDRL
tests.
Systemic lupus erythematous, HIV, antiphospholipid
syndrome and TB infection are classic causes of this. Other
Treponemal infections like yaws and pinta can also cause
false positives, but this would not occur with atypical
bacteria such as Mycoplasma.
SYPHILIS: INVESTIGATION
Treponema pallidum is a very sensitive organism and cannot
be grown on artificial media. The diagnosis is therefore usually
based on clinical features, serology and microscopic
examination of infected tissue
Serological tests can be divided into
• cardiolipin tests (not treponeme specific)
• treponemal specific antibody tests
Cardiolipin tests
• syphilis infection leads to the production of non-specific
antibodies that react to cardiolipin
• examples include VDRL (Venereal Disease Research
Laboratory) & RPR (rapid plasma reagin)
• insensitive in late syphilis
• becomes negative after treatment
Treponemal specific antibody tests
• example: TPHA (Treponema pallidum HaemAgglutination
test)
• remains positive after treatment
Causes of false positive cardiolipin tests
• pregnancy
• SLE, anti-phospholipid syndrome
• TB
• leprosy
• malaria
• HIV
Treponema pallidum, the bacteria that cause syphilis. Note the spiral shape
of the organism. Credit: NIAID

Q-110
Which one of the following is least associated with a false
negative tuberculin skin test?
A. Lymphoma
B. Miliary tuberculosis
C. Sarcoidosis
D. Chronic kidney disease stage 3
E. HIV
ANSWER:
D. Chronic kidney disease stage 3
EXPLANATION:
Severe renal failure may cause a false negative test but CKD
stage 3 would not.
Please see Q-86 for Tuberculosis: Screening

Q-111
A 87 year old lady presents to the Emergency Department
with a two day history of new confusion. Her heart rate is
120 beats per minute, blood pressure 95/45 mmHg and
temperature 38.4ºC. You suspect urinary sepsis and after
taking urine and blood cultures you start appropriate
treatment with intravenous fluids and broad spectrum
antibiotics. Later that day the microbiology lab phones to
inform you the microscopy of the urine sample shows Gram
positive cocci in clusters. What is the likely organism in this
case?
A. Escherichia coli
B. Klebsiella pneumoniaeC. Staphlococcus saprophyticus
D. Enterococcus faecalis
E. Staphlococcus aureus
ANSWER:
B. Klebsiella pneumoniaeC. Staphlococcus saprophyticus
EXPLANATION:
Prompt treatment of sepsis is essential to improve patient
outcomes. Broad spectrum antibiotics should be given
promptly after microbiological specimens are taken.
Antibiotic therapy should be altered when the causative
organism is known. In this case a Gram positive cocci in
clusters grown from the urine is most likely to be S.
saprophyticus. S. aureus is a common pathogen but is
unusual in urinary infections. Although E. coli and K.
pneumoniae are common urinary pathogens they are both
Gram negative bacilli. Enterococcus commonly forms chains
on microscopy.
Please see Q-70 for Identifying Gram-Positive Bacteria

Q-112
A 17-year-old man attends the local sexual health clinic. He
has developed a large, keratinised genital wart on the shaft
of his penis. This has been present for around three months
but he has been too embarrassed to present before now.
What is the most appropriate initial management?
A. Topical aciclovir
B. Cryotherapy
C. Topical salicylic acid
D. Electrocautery
E. Topical podophyllum
ANSWER:
B. Cryotherapy
EXPLANATION:
Genital wart treatment
• multiple, non-keratinised warts: topical podophyllum
• solitary, keratinised warts: cryotherapy
As the wart is keratinised cryotherapy should be used
initially
Please see Q-91 for Genital Warts

Q-113
The most appropriate treatment for cutaneous larva migrans
is:
A. Thiabendazole
B. Sulfadoxine
C. Pyrimethamine
D. Metronidazole
E. Dapsone
ANSWER:
A. Thiabendazole
EXPLANATION:
Please see Q-47 for Nematodes

Q-114
Which one of the following features is least likely to occur in
a patient with visceral leishmaniasis?
A. Massive splenomegaly
B. Diarrhoea
C. Pyrexia
D. Pancytopaenia
E. Grey skin
ANSWER:
B. Diarrhoea
EXPLANATION:
The most common symptoms seen in patients with visceral
leishmaniasis are pyrexia, splenomegaly (which is often
massive), weight loss and night sweats. Pancytopaenia
occurs secondary to hypersplenism. Diarrhoea is not a typical
feature
Please see Q-18 for Leishmaniasis

Q-115
Which one of the following organisms causes erysipelas?
A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Staphylococcus epidermidis
D. Streptococcus pyogenes
E. Streptococcus viridans
ANSWER:
D. Streptococcus pyogenes
EXPLANATION:
Please see Q-107 for Streptococci

Q-116
A 24-year-old student returns from a gap year in Malawi
complaining of visible haematuria, dysuria and urinary
frequency. She says she felt well throughout her trip but
experienced an itchy rash on her legs a few hours after
swimming in Lake Malawi which has now resolved.
Her blood results show:
Hb 98 g/l
Platelets 150 * 109/l
WBC 9.0 * 109/l
Neutrophils 4.0 * 109/l
Lymphocytes 2.5 * 109/l
Eosinophils 0.5 * 109/lHow would you treat her?
A. Albendazole
B. Trimethoprim
C. Prednisolone
D. Doxycycline
E. Praziquantel
ANSWER:
E. Praziquantel
EXPLANATION:
This woman is likely to have schistosoma haematobium
(schistosomiasis/bilharzia) from the symptoms and raised
eosinophils. She has also swam in Lake Malawi which is a big
risk factor for getting schistosomiasis. The schistosoma
parasite enters the skin from the water which can cause an
initial itch as in the case followed by symptoms above. It is
treated with praziquantel. Albendazole is another antiparasitic drug but is not
used in schistosomiasis. Doxycycline
may be used to treat chlamydia but this is unlikely,
Trimethoprim would be used to treat a UTI but this is unlikely
due to the presentation and raised eosinophils.
Glomerulonephritis may present in a similar way to this and
is treated with prednisolone is some cases but again the
initial itch and raised eosinophils point more toward
schistosomiasis.
Source: WHO
Please see Q-7 for Schistosomiasis

Q-117
Which one of the following vaccines uses a protein that
attaches to the polysaccharide outer coat to make the
pathogen more immunogenic?
A. Rabies
B. Yellow fever
C. Oral polio
D. Measles
E. Meningococcus
ANSWER:
E. Meningococcus
EXPLANATION:
Please see Q-90 for Vaccinations

Q-118
A 50-year-old man is admitted with sepsis of unknown
origin. He has had three sets of blood cultures taken. The
microbiology laboratory phone the ward with some
preliminary results about a bacterium growing from the first
set of cultures. Which of the following findings would make
you concerned that the bacterium isolated is Staph aureus?
A. Bacteria seen in diplococci pairs
B. Poor uptake of gram stain
C. Coagulase test positive
D. Rapid growth on MacConkey agar
E. Haemolysis on blood agar
ANSWER:
C. Coagulase test positive
EXPLANATION:
Staph aureus is a coagulase positive Staph
The coagulase test is used to differentiate between different
Staphylococcus species and often returns from the lab before
determination of the exact species. Staph aureus is the most
important of the coagulase positive Staphylococcus species
and is highly pathogenic. Coagulase-negative Staph species
are most likely to be skin commensal organisms of relatively
low pathogenicity, such as Staph epidermidis or Staph
saprophyticus, although some may still cause deeper
infection or sepsis.
CLASSIFICATION OF BACTERIA
Remember:
• Gram-positive cocci = staphylococci + streptococci
(including enterococci)
• Gram-negative cocci = Neisseria meningitidis + Neisseria
gonorrhoeae, also Moraxella catarrhalis
Therefore, only a small list of Gram-positive rods (bacilli) need
to be memorised to categorise all bacteria - mnemonic =
ABCD L
• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenes
Remaining organisms are Gram-negative rods, e.g.:
• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Q-119
A 31-year-old man who is known to be HIV positive presents
with dyspnoea and a dry cough. He is currently homeless and
has not been attending his outpatient appointments or
taking antiretroviral medication.
Clinical examination reveals a respiratory rate of 24 / min.
Chest auscultation is unremarkable with only scattered
crackles. His oxygen saturation is 96% on room air but this
falls rapidly after walking the length of the ward. Given the
likely diagnosis, what is the most appropriate first-line
treatment?
A. Fluconazole
B. Co-trimoxazoleC. Erythromycin
D. Ganciclovir
E. Sulfadiazine and pyrimethamine
ANSWER:
B. Co-trimoxazoleC. Erythromycin
EXPLANATION:
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-120
A 33-year-old man is admitted due to profuse diarrhoea. He
has a history of HIV infection and Cryptosporidium diarrhoea
is suspected. What investigation is most likely to confirm the
diagnosis?
A. Blood cultures
B. Sigmoidoscopy with biopsy
C. Abdominal x-ray
D. Acid-fast staining of stool sample
E. Cryptosporidium PCR of stool sample
ANSWER:
D. Acid-fast staining of stool sample
EXPLANATION:
Cryptosporidium cysts turn red following acid-fast staining.
Molecular methods are currently used mainly as a research
tool
HIV: diarrhoea
Diarrhoea is common in patients with HIV. This may be due to
the effects of the virus itself (HIV enteritis) or opportunistic
infections
Possible causes
• Cryptosporidium + other protozoa (most common)
• Cytomegalovirus
• Mycobacterium avium intracellulare
• Giardia
Cryptosporidium is the most common infective cause of
diarrhoea in HIV patients. It is an intracellular protozoa and
has an incubation period of 7 days. Presentation is very
variable, ranging from mild to severe diarrhoea. A modified
Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the
characteristic red cysts of Cryptosporidium. Treatment is
difficult, with the mainstay of management being supportive
therapy*
Mycobacterium avium intracellulare is an atypical
mycobacteria seen with the CD4 count is below 50. Typical
features include fever, sweats, abdominal pain and diarrhoea.
There may be hepatomegaly and deranged LFTs. Diagnosis is
made by blood cultures and bone marrow examination.
Management is with rifabutin, ethambutol and clarithromycin
*nitazoxanide is licensed in the US for immunocompetent
patients

Q-121
What percentage of patients who contract the hepatitis C
virus will become chronically infected?
A. 30-35%
B. 55-85%
C. 90-95%
D. 5-10%
E. 15-20%
ANSWER:
B. 55-85%
EXPLANATION:
Hepatitis C - 55-85% become chronically infected
Hepatitis C
Hepatitis C is likely to become a significant public health
problem in the UK in the next decade. It is thought around
200,000 people are chronically infected with the virus. At risk
groups include intravenous drug users and patients who
received a blood transfusion prior to 1991 (e.g.
haemophiliacs).
Pathophysiology
• hepatitis C is a RNA flavivirus
• incubation period: 6-9 weeks
Transmission
• the risk of transmission during a needle stick injury is
about 2%
• the vertical transmission rate from mother to child 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%
• there is no vaccine for hepatitis C
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
Outcome
• around 15-45% of patients will clear the virus after an
acute infection (depending on their age and
underlying health) and hence the majority (55-85%)
will develop chronic hepatitis C
Chronic hepatitis C
Chronic hepatitis C may be defined as the persistence of HCV
RNA in the blood for 6 months.
Potential complications of chronic hepatitis C
• rheumatological problems: arthralgia, arthritis
• eye problems: Sjogren's syndrome
• cirrhosis (5-20% of those with chronic disease)
• hepatocellular cancer
• cryoglobulinaemia: typically type II (mixed
monoclonal and polyclonal)
• porphyria cutanea tarda (PCT): it is increasingly
recognised that PCT may develop in patients with
hepatitis C, especially if there are other factors such
as alcohol abuse
• membranoproliferative glomerulonephritis
Management of chronic infection
• treatment depends on the viral genotype - this
should be tested prior to treatment
• the management of hepatitis C has advanced rapidly
in recent years resulting in clearance rates of around
95%. Interferon based treatments are no longer
recommended
• the aim of treatment is sustained virological response
(SVR), defined as undetectable serum HCV RNA six
months after the end of therapy
• currently a combination of protease inhibitors (e.g.
daclatasvir + sofosbuvir or sofosbuvir + simeprevir)
with or without ribavirin are used
Complications of treatment
• ribavirin - side-effects: haemolytic anaemia, cough.
Women should not become pregnant within 6
months of stopping ribavirin as it is teratogenic
• interferon alpha - side-effects: flu-like symptoms,
depression, fatigue, leukopenia, thrombocytopenia

Q-122
A 31-year-old woman with a three year history of ulcerative
colitis is started on azathioprine to help prevent relapses.
Which one of the following vaccines must be avoided whilst
she is on this treatment?
A. Yellow fever
B. Rabies
C. Pertussis
D. Diphtheria
E. Tetanus
ANSWER:
A. Yellow fever
EXPLANATION:
Live attenuated vaccines
• BCG
• MMR
• oral polio
• yellow fever
• oral typhoid
Live vaccines should not be given to patients who are
immunosuppressed, such as those taking azathioprine.
Vaccinations
It is important to be aware of vaccines which are of the liveattenuated type as
these may pose a risk to
immunocompromised patients. The main types of vaccine are
as follows:
Live attenuated
• BCG
• measles, mumps, rubella (MMR)
• influenza (intranasal)
• oral rotavirus
• oral polio
• yellow fever
• oral typhoid
Inactivated preparations
• rabies
• hepatitis A
• influenza (intramuscular)Toxoid (inactivated toxin)
• tetanus
• diphtheria
• pertussis
Subunit and conjugate vaccines are often grouped together.
Subunit means that only part of the pathogen is used to
generate an immunogenic response. A conjugate vaccine is a
particular type that links the poorly immunogenic bacterial
polysaccharide outer coats to proteins to make them more
immunogenic
• pneumococcus (conjugate)
• haemophilus (conjugate)
• meningococcus (conjugate)
• hepatitis B
• human papillomavirus
,
Notes
• influenza: different types are available, including
whole inactivated virus, split virion (virus particles
disrupted by detergent treatment) and sub-unit
(mainly haemagglutinin and neuraminidase)
• cholera: contains inactivated Inaba and Ogawa
strains of Vibrio cholerae together with recombinant
B-subunit of the cholera toxin
• hepatitis B: contains HBsAg adsorbed onto
aluminium hydroxide adjuvant and is prepared from
yeast cells using recombinant DNA technology

Q-123
A 42-year-old businessman presents to General Practice
after returning from a trip to Thailand, 4 weeks ago, with an
ulcer on his penis. He has a prior history of treated syphilis.
On examination, you note a non-painful chancre on the shaft
of the penis. There is no penile discharge and no
lymphadenopathy is noted.
Which of the following tests are more likely to reflect a
repeat infection with treponema pallidum?
A. Enzyme immunoassay
B. Treponema pallidum haemagglutination assay
C. Rapid plasma reagin
D. Chemiluminescence immunoassay
E. Treponema pallidum particle agglutination assay
ANSWER:
C. Rapid plasma reagin
EXPLANATION:
The answer is the rapid plasma reagin test which is a
cardiolipin test which becomes negative after treatment.
The enzyme immunoassay, treponemal pallidum
haemagglutination assay, chemiluminescence immunoassay
and treponema pallidum particle agglutination assay are all
treponemal-specific antibody tests which remain positive
after the first infection and would not provide evidence for a
repeat infection.
Syphilis: investigation
Treponema pallidum is a very sensitive organism and cannot
be grown on artificial media. The diagnosis is therefore usually
based on clinical features, serology and microscopic
examination of infected tissue
Serological tests can be divided into
• cardiolipin tests (not treponeme specific)
• treponemal specific antibody tests
Cardiolipin tests
• syphilis infection leads to the production of nonspecific antibodies that react
to cardiolipin
• examples include VDRL (Venereal Disease Research
Laboratory) & RPR (rapid plasma reagin)
• insensitive in late syphilis
• becomes negative after treatment
Treponemal specific antibody tests
• example: TPHA (Treponema
pallidum HaemAgglutination test)
• remains positive after treatment
Causes of false positive cardiolipin tests
• pregnancy
• SLE, anti-phospholipid syndrome
• TB
• leprosy
• malaria
• HIVTreponema pallidum, the bacteria that cause syphilis.
Note the spiral shape of the organism. Credit: NIAID

Q-124
A 57-year-old female presents with headache and fever to
the Emergency Department. On examination neck stiffness is
noted along with a positive Kernig's sign. A lumbar puncture
is performed and reported as follows:
CSF culture Gram positive bacilli
What is the most likely causative organism?
A. Cryptococcus
B. Haemophilus influenzae
C. Streptococcus pneumoniae
D. coli
E. Listeria monocytogenes
ANSWER:
E. Listeria monocytogenes
EXPLANATION:
Listeria monocytogenes - Gram-positive rod
Classification of bacteria
Remember:
• Gram-positive cocci
= staphylococci + streptococci (including enteroc
occi)
• Gram-negative cocci = Neisseria
meningitidis + Neisseria gonorrhoeae,
also Moraxella catarrhalis
Therefore, only a small list of Gram-positive rods (bacilli)
need to be memorised to categorise all bacteria -
mnemonic = ABCD L
• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenes
Remaining organisms are Gram-negative rods, e.g.:
• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Q-125
A 27-year-old woman develops fever and lymph node
swelling after being scratched by her cat. Which one of the
organisms is responsible for cat scratch disease?
A. Bordetella pertussis
B. Moraxella catarrhalis
C. Bartonella henselae
D. Francisella tularensis
E. Yersinia enterocolitica
ANSWER:
C. Bartonella henselae
EXPLANATION:
Cat scratch disease - caused by Bartonella
henselae
Cat scratch disease
Cat scratch disease is generally caused by the Gram
negative rod Bartonella henselae
Features• fever
• history of a cat scratch
• regional lymphadenopathy
• headache, malaise
Q-126
A 20-year-old student presents to the Emergency
Department three weeks after being scratched by their pet
kitten on their left arm. There is a crusted papule at the site
of the scratch and painful left axillary lymphadenopathy.
Which is the most likely causative organism?
A. Bartonella
B. Coxiella
C. Brucella
D. Mycoplasma
E. Yersinia
ANSWER:
A. Bartonella
EXPLANATION:
The correct answer is Bartonella, the causative agent of cat
scratch disease.
Coxiella burnetii is a gram-negative rod and the causative
agent of Q fever, a zoonosis. The history usually includes
exposure to farm animals. The clinical presentation is varied
and acute infection may result in flu-like symptoms,
pneumonia, hepatitis and a potentially fatal endocarditis.
Brucella spp. are gram-negative rods and the causative
agent of brucellosis, a zoonosis. The history usually includes
exposure to animal fluids (e.g. unpasteurised milk).
Yersinia spp. are gram-negative rods and the causative
agents of yersiniosis, a diarrhoeal illness, and plague (Y.
pestis).
Mycoplasma spp. are gram-indeterminate bacteria, the
genus includes over 100 species. They most commonly cause
pneumonia (M. pneumoniae) and genital tract infections (M.
genitalium).

Q-127
A 34-year-old female with a background of HIV present with
progressive weakness in her lower limbs. She also states that
she is finding it difficult to walk up the stairs and is becoming
generally clumsy. She is known to be non compliant with her
anti-retroviral therapy. She had no other systemic symptoms
such as weight loss and no other past medical history. On
examination, one notes power is normal in both upper and
lower limbs. However, one notes bilateral dysmetria in the
upper limbs and lower limbs. She had an MRI which showed
some white matter lesions bilaterally in the parietal lobes.
What is the most likely diagnosis?
A. Cerebral vasculitis
B. Cerebral metastasis
C. Multiple sclerosis
D. Progressive multifocal leukoencephalopathy
E. Toxoplasmosis
ANSWER:
C. Multiple sclerosis
EXPLANATION:
Multiple sclerosis and progressive multifocal
leukoencephalopathy lead to white matter lesions on MRI.
However, with her background of HIV and being noncompliant with her medication, she
is at risk of neurocomplications from being immunocompromised. Therefore
progressive multifocal leukoencephalopathy is the more
likely diagnosis.
Cerebral metastasis typically presents as ring enhancing
lesions on the MRI and one would expect for there to be
some other systemic symptoms to suggest malignancy from
an unknown primary.
Cerebral vasculitis is a possible diagnosis, however one
would expect other symptoms such as a vasculitis rash. One
would also expect a past medical history other than HIV
which could lead to vasculitis, such as a systemic disease like
rheumatoid arthritis or Behcet's disease. MRI normally
shows multiple bilateral infarctions, affecting different
vascular territories, in various stages of healing,
Toxoplasmosis is a diagnosis to consider in a patient with
HIV non-compliant with her medication and presenting with
neurological symptoms. However, one would expect ring
enhancing lesions on MRI. One would not expect white
matter lesions bilaterally in toxoplasmosis.
HIV: neurocomplications
Focal neurological lesions
Toxoplasmosis
• accounts for around 50% of cerebral lesions in
patients with HIV
• constitutional symptoms, headache, confusion,
drowsiness
• CT: usually single or multiple ring enhancing lesions,
mass effect may be seen
• management: sulfadiazine and pyrimethamineCerebral toxoplasmosis: CT scan with
contrast showing
multiple ring enhancing lesions
Cerebral toxoplasmosis: MRI (T1 C+) demonstrates
multiple small peripherally enhancing nodules located
predominantly in the basal ganglia as well as the central
portions of the cerebellar hemispheres. Only a small
amount of surrounding oedema is present.
Primary CNS lymphoma
• accounts for around 30% of cerebral lesions
• associated with the Epstein-Barr virus
• CT: single or multiple homogenous enhancing
lesions
• treatment generally involves steroids (may
significantly reduce tumour size), chemotherapy
(e.g. methotrexate) + with or without whole brain
irradiation. Surgical may be considered for lower
grade tumours
Primary CNS lymphoma: Non-contrast CT demonstrates a
hyper-attenuating mass adjacent to the left lateral
ventricle, with no calcification or [Link] CNS lymphoma: MRI (T1 C+)
demonstrates a
large multilobulated mass in the right frontal lobe. It
homogeneously enhances and extends to involve the
caudate and the periventricular area. There is significant
mass effect.
Differentiating between toxoplasmosis and lymphoma is
a common clinical scenario in HIV patients. It is clearly
important given the vastly different treatment strategies.
The table below gives some general differences. Please
see the Radiopaedia link for more details.
Toxoplasmosis Lymphoma
Multiple lesions
Ring or nodular enhancement
Thallium SPECT negative
Single lesion
Solid (homogenous)
enhancement
Thallium SPECT positive
Tuberculosis
• much less common than toxoplasmosis or primary
CNS lymphoma
• CT: single enhancing lesion
Generalised neurological disease
Encephalitis
• may be due to CMV or HIV itself
• HSV encephalitis but is relatively rare in the context
of HIV
• CT: oedematous brain
Cryptococcus
• most common fungal infection of CNS
• headache, fever, malaise, nausea/vomiting, seizures,
focal neurological deficit
• CSF: high opening pressure, India ink test positive
• CT: meningeal enhancement, cerebral oedema
• meningitis is typical presentation but may
occasionally cause a space occupying lesion
Progressive multifocal leukoencephalopathy (PML)
• widespread demyelination
• due to infection of oligodendrocytes by JC virus (a
polyoma DNA virus)
• symptoms, subacute onset : behavioural changes,
speech, motor, visual impairment
• CT: single or multiple lesions, no mass effect, don't
usually enhance. MRI is better - high-signal
demyelinating white matter lesions are seen
AIDS dementia complex
• caused by HIV virus itself
• symptoms: behavioural changes, motor impairment
• CT: cortical and subcortical atrophy

Q-128
A 74-year-old female presents with headache and neck
stiffness to the Emergency Department. Following a lumbar
puncture the patient was started on IV ceftriaxone. CSF
culture grows Listeria monocytogenes. What is the most
appropriate treatment?
A. Add IV amoxicillin
B. Change to IV amoxicillin + gentamicin
C. Add IV ciprofloxacin
D. Add IV co-amoxiclav
E. Continue IV ceftriaxone as monotherapy
ANSWER:
B. Change to IV amoxicillin + gentamicin
EXPLANATION:
The current BNF suggests treatment with
amoxicillin/ampicillin + gentamicin. Treatment should be for
at least 10-14 days
Listeria
Listeria monocytogenes is a Gram positive bacillus which has
the unusual ability to multiply at low temperatures. It is
typically spread via contaminated food, typicallyunpasteurised dairy products.
Infection is particularly
dangerous to the unborn child where it can lead to
miscarriage.
Features - can present in a variety of ways
• diarrhoea, flu-like illness
• pneumonia , meningoencephalitis
• ataxia and seizures
Suspected Listeria infection should be investigated by taking
blood cultures. CSF may reveal a pleocytosis, with 'tumbling
motility' on wet mounts
Management
• Listeria is sensitive to amoxicillin/ampicillin
(cephalosporins usually inadequate)
• Listeria meningitis should be treated with IV
amoxicillin/ampicillin and gentamicin
In pregnant women
• pregnant women are almost 20 times more likely to
develop listeriosis compared with the rest of the
population due to changes in the immune system
• fetal/neonatal infection can occur both
transplacentally and vertically during child birth
• complications include miscarriage, premature labour,
stillbirth and chorioamnionitis
• diagnosis can only be made from blood cultures
• treatment is with amoxicillin

Q-129
A 31-year-old woman presents as she has noted an
offensive, fishy vaginal discharge. She describes a grey,
watery discharge. What is the most likely diagnosis?
A. Trichomonas vaginalis
B. Candida
C. Chlamydia
D. Bacterial vaginosis
E. Physiological discharge
ANSWER:
D. Bacterial vaginosis
EXPLANATION:
Bacterial vaginosis
Bacterial vaginosis (BV) describes an overgrowth of
predominately anaerobic organisms such as Gardnerella
vaginalis. This leads to a consequent fall in lactic acid
producing aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen
almost exclusively in sexually active women.
Features
• vaginal discharge: 'fishy', offensive
• asymptomatic in 50%
Amsel's criteria for diagnosis of BV - 3 of the following 4 points
should be present
• thin, white homogenous discharge
• clue cells on microscopy: stippled vaginal epithelial
cells
• vaginal pH > 4.5
• positive whiff test (addition of potassium hydroxide
results in fishy odour)
Management
• oral metronidazole for 5-7 days
• 70-80% initial cure rate
• relapse rate > 50% within 3 months
• the BNF suggests topical metronidazole or topical
clindamycin as alternatives
Comparison of bacterial vaginosis and Trichomonas
vaginalis.
Bacterial vaginosis in pregnancy
• results in an increased risk of preterm labour, low
birth weight and chorioamnionitis, late miscarriage
• it was previously taught that oral metronidazole
should be avoided in the first trimester and topical
clindamycin used instead. Recent guidelines however
recommend that oral metronidazole is used
throughout pregnancy. The BNF still advises against
the use of high dose metronidazole regimesClue cells - epithelial cells develop a
stippled appearance
due to being covered with bacteria

Q-130
An 18-year-old man is bitten by a frantic dog whilst taking a
gap year in Ecuador. He is worried about rabies and phones
for advice. He was not immunised against prior to travelling
to Ecuador. What is the most appropriate advice after
thorough cleansing of the wound?
A. Give human rabies immunoglobulin + full course of vaccination
B. Give human rabies immunoglobulin + oral penicillin for
the next 2 weeks
C. Advise low risk but take oral co-amoxiclav for the dog
bite
D. Give human rabies immunoglobulin
E. Give full course of vaccination
ANSWER:
A. Give human rabies immunoglobulin + full course of vaccination
EXPLANATION:
Rabies - following possible exposure give
immunglobulin + vaccination
Rabies
Rabies is a viral disease that causes an acute encephalitis. The
rabies virus is classed as a RNA rhabdovirus (specifically a
lyssavirus) and has a bullet-shaped capsid. The vast majority
of cases are caused by dog bites but it may also be
transmitted by bat, raccoon and skunk bites. Following a bite
the virus travels up the nerve axons towards the central
nervous system in a retrograde fashion.
Rabies is estimated to still kill around 25,000-50,000 people
across the world each year. The vast majority of the disease
burden falls on people in poor rural areas of Africa and Asia.
Children are particularly at risk.
Features
• prodrome: headache, fever, agitation
• hydrophobia: water-provoking muscle spasms
• hypersalivation
• Negri bodies: cytoplasmic inclusion bodies found in
infected neurons
There is now considered to be 'no risk' of developing rabies
following an animal bite in the UK and the majority of
developed countries. Following an animal bite in at-risk
countries:
• the wound should be washed
• if an individual is already immunised then 2 further
doses of vaccine should be given
• if not previously immunised then human rabies
immunoglobulin (HRIG) should be given along with a
full course of vaccination. If possible, the dose should
be administered locally around the wound
If untreated the disease is nearly always fatal.

Q-131
A middle-aged man is diagnosed with nasopharyngeal
carcinoma. What type of virus family is associated with this
malignancy?
A. Reovirus
B. Herpesvirus
C. Parvovirus
D. Adenovirus
E. Hepadnaviridae
ANSWER:
B. Herpesvirus
EXPLANATION:
The Epstein-Barr virus is one of the herpes viruses
Epstein-Barr virus: associated conditions
Malignancies associated with EBV infection
• Burkitt's lymphoma*
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
• HIV-associated central nervous system lymphomas
The non-malignant condition hairy leukoplakia is also
associated with EBV infection.
*EBV is currently thought to be associated with both African
and sporadic Burkitt's

Q-132
A 28-year-old man who has recently emigrated from Nigeria
presents with a penile ulcer. It initially started as a papule
which later progressed to become a painful ulcer with an
undermined ragged edge. Examination of the testes was
unremarkable but tender inguinal lymphadenopathy was
noted. What is the most likely diagnosis?
A. Chancroid
B. Lymphogranuloma venereum
C. Syphilis
D. Herpes simplex infection
E. Granuloma inguinale
ANSWER:
A. Chancroid
EXPLANATION:
Genital ulcers
• painful: herpes much more common than
chancroid
• painless: syphilis more common than
lymphogranuloma venereum + granuloma
inguinale
A diagnosis of chancroid is more likely than
lymphogranuloma venereum as the ulcer is painful.
Whilst herpes simplex is obviously more common the
description of the ulcer is very characteristic of chancroid.
Painful inguinal lymphadenopathy is present in around
50% of patients.
STI: ulcers
Genital herpes is most often caused by the herpes simplex
virus (HSV) type 2 (cold sores are usually due to HSV type 1).
Primary attacks are often severe and associated with fever
whilst subsequent attacks are generally less severe and
localised to one site
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. A painless ulcer
(chancre) is seen in the primary stage. The incubation period=
9-90 days
Chancroid is a tropical disease caused by Haemophilus
ducreyi. It causes painful genital ulcers associated with
unilateral, painful inguinal lymph node enlargement. The
ulcers typically have a sharply defined, ragged, undermined
border.
Lymphogranuloma venereum (LGV) is caused by Chlamydia
trachomatis. Typically infection comprises of three stages
• stage 1: small painless pustule which later forms an
ulcer
• stage 2: painful inguinal lymphadenopathy
• stage 3: proctocolitis
LGV is treated using doxycycline.
Other causes of genital ulcers
• Behcet's disease
• carcinoma
• granuloma inguinale: Klebsiella granulomatis*
*previously called Calymmatobacterium granulomatis

Q-133
A 29-year-old man presents with a nine day history of watery
diarrhoea that developed one week after returning from
India. He had travelled around northern India for two
months. On examination he is apyrexial and his abdomen is
soft and non-tender. What is the most likely causative
organism?
A. Amoebiasis
B. Giardiasis
C. Campylobacter
D. Shigella
E. Salmonella
ANSWER:
B. Giardiasis
EXPLANATION:
The incubation period and prolonged, non-bloody diarrhoea
point towards giardiasis
Giardiasis
Giardiasis is caused by the flagellate protozoan Giardia
lamblia. It is spread by the faeco-oral route
Features
• often asymptomatic
• lethargy, bloating, abdominal pain
• flatulence
• 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 neededTreatment is with metronidazole

Q-134
A 63-year-old man presents to the acute receiving ward with
a two-week history of a cough, fever, night sweats, weight
loss and diarrhoea. He has tender hepatomegaly on
examination. His past medical history includes HIV and his
recent CD4 count is less than 50. A blood culture reveals
mycobacterium avium complex. What is the treatment for
this condition?
A. Rifampicin + Ethambutol
B. Pentamidine
C. Rifampicin + Isoniazid + Pyrazinamide
D. Rifampicin + Ethambutol + Clarithromycin
E. Rifampicin + Isoniazid + Pyrazinamide + Ethambutol
ANSWER:
A. Rifampicin + Ethambutol
EXPLANATION:
A minimum of two drugs should be given: clarithromycin plus
ethambutol. In severe disease, rifabutin can be added. This is
recommended due to fewer side-effects than rifampicin
however rifampicin is still widely used as the third drug in
severe disease due to its cheaper cost. Azithromycin can be
also substituted for clarithromycin in severe disease. ref:
oxford handbook of tropical medicine.
Mycobacterium avium complex and mycobacterium
tuberculosis can present similarly, however mycobacterium
avium complex can result in marked hepatomegaly, whereas
mycobacterium tuberculosis usually results in focal lesions in
the liver. ref: Radin DR. Intraabdominal Mycobacterium
tuberculosis vs Mycobacterium avium-intracellulare
infections in patients with AIDS: distinction based on CT
findings. AJR Am J Roentgenol. 1991 Mar;156(3):487-91.
HIV: Mycobacterium avium complex
Mycobacterium avium complex (MAC) is an atypical
mycobacterial infection seen in HIV patients. It is caused by
both Mycobacterium avium and Mycobacterium
intracellulare, and is often referred to as Mycobacterium
avium-intracellulare (MAI). Over 95% of MAC infections in
patients with HIV are caused by Mycobacterium avium. MAC
is generally seen when the CD4 count is less than 50
cells/mm³
Features
• fever, sweats
• abdominal: pain, diarrhoea
• lung: dyspnoea, cough
• anaemia
• lymphadenopathy
• hepatomegaly/deranged LFTs
Diagnosis
• blood cultures
• bone marrow aspirate
Prophylaxis
• clarithromycin or azithromycin when CD4 is less than
100 cells/mm³
Management
• rifampicin + ethambutol + clarithromycin

Q-135
A 28-year-old student is admitted out of hours to the
infectious diseases ward with suspected malaria following a
backpacking trip around South East Asia. Malarial films are
as follows:
Thick
film Parasite burden of 1.5%
Thin film Non-falciparum malaria - Looks like Plasmodium
knowlesi
On admission, the patient is systemically well with
observations at follows:
HR 90bpm
BP 123/75 mmHg
RR 16 breaths per minute
Oxygen Sats 97% on air
Temp 36.4º
Although being relatively well on first admission, you are
called to review her overnight a few hours later, due to her
condition worsening. You arrive to find her observations as
follows:
HR 110bpm
BP 105/65 mmHg
RR 25 breaths per minute
Oxygen Sats 93% on air
Temp 38.4º
Which of the following attributes make Plasmodium
knowlesi infections particularly dangerous?A. Cytoadherence
B. Hypnozoite formation
C. Short erythrocytic replication stage
D. Resistance to treatment
E. Slow growth leading to late presentation
ANSWER:
C. Short erythrocytic replication stage
EXPLANATION:
P. knowlesi has the shortest erythrocytic replication
cycle, leading to high parasite counts in short periods
of time
Plasmodium sp. have two reproductive cycles; an
exo-erythrocytic cycle which occurs in hepatocytes,
and an erythrocytic cycle which occurs in the red
blood cells. The length of the erythrocytic cycle varies
from species to species, with P. knowlesi having the
fastest cycle at around 24 hours. The end stage in the
cycle involves lysis of the red cells and release of
additional parasites, meaning that P. knowlesi is
capable of producing very high parasite counts in a
short space of time.
For this reason, in Plasmodium knowlesi infection,
severe parasitaemia should be defined as >1%,
whereas in other species, >2% is a marker of severe
parasitaemia.
In regards to other options, Plasmodium
ovale and Plasmodium vivax can form hypnozoites,
causing clinical infection long after patients leave
malarial areas. Cytoadherence is an attribute
displayed by red cells infected by Plasmodium
falciparumparasites.
Malaria: non-falciparum
The most common cause of non-falciparum malaria
is Plasmodium vivax, with Plasmodium
ovale and Plasmodium malariae accounting for the other
cases. Plasmodium vivax is often found in Central America
and the Indian Subcontinent
whilst Plasmodiumovale typically comes from Africa.
Plasmodium knowlesi is another non-falciparum species
which causes clinical pathology, found predominantly in
South East Asia.
Features
• general features of malaria: fever, headache,
splenomegaly
• Plasmodium vivax/ovale: cyclical fever every 48
hours. Plasmodium malariae: cyclical fever every 72
hours
• Plasmodium malariae: is associated with nephrotic
syndrome
Ovale and vivax malaria have a hypnozoite stage and may
therefore relapse following treatment.
Treatment
• in areas which are known to be chloroquinesensitive then WHO recommend either an
artemisinin-based combination therapy (ACT) or
chloroquine
• in areas which are known to be chloroquineresistant an ACT should be used
• ACTs should be avoided in pregnant women
• patients with ovale or vivax malaria should be given
primaquine following acute treatment with
chloroquine to destroy liver hypnozoites and
prevent relapse

Q-136
What is the first line treatment in hydatid disease?
A. Metronidazole
B. Ciprofloxacin
C. Itraconazole
D. Albendazole
E. Sodium stibogluconate
ANSWER:
D. Albendazole
EXPLANATION:
Tape worms
Tape worms are made up of repeated segments called
proglottids. These are often present in faeces and are useful
diagnostically
Cysticercosis
• caused by Taenia solium (from pork) and Taenia
saginata (from beef)
• management: niclosamide
Hydatid disease
• caused by the dog tapeworm Echinococcus
granulosus
• life-cycle involves dogs ingesting hydatid cysts from
sheep liver• often seen in farmers
• may cause liver cysts
• management: albendazole

Q-137
A 30-year-old man has just returned to the UK after visiting
Kenya. He did not take any anti-malarials during his visit and
received multiple mosquito bites. He is pyrexial but stable at
present. Malaria is confirmed with a rapid antigen test. You
are waiting for the rest of his test results. Which of the
following findings would suggest that he should be treated
as having severe malaria?
A. Temperature > 38ºC after paracetamol
B. Plasmodium vivax species on blood film
C. CRP > 300 mg/L
D. Blood sugar 18 mmol/L
E. Parasitaemia of 6%
ANSWER:
E. Parasitaemia of 6%
EXPLANATION:
Parasitaemia > 2% is a feature of severe malaria
A parasite level of > 2% is diagnostic of severe malaria on
UK guidelines. Other criteria include clinical findings
(impaired consciousness, respiratory distress, multiple
convulsions, shock, jaundice) and laboratory findings
(hypoglycaemia, acidosis, raised lactate, acute kidney
injury and severe anaemia). The other options are not
included in the criteria. The majority of severe forms of
malaria are due to Plasmodium falciparum but other
species can also cause serious complications.
Patients with severe malaria should be treated with IV
anti-malarials and HDU or ICU should be considered.
UK malaria treatment guidelines 2016
Malaria: Falciparum
Feature of severe malaria
• schizonts on a blood film
• parasitaemia > 2%
• hypoglycaemia
• acidosis
• temperature > 39 °C
• severe anaemia
• complications as below
Complications
• cerebral malaria: seizures, coma
• acute renal failure: blackwater fever, secondary to
intravascular haemolysis, mechanism unknown
• acute respiratory distress syndrome (ARDS)
• hypoglycaemia
• disseminated intravascular coagulation (DIC)
Uncomplicated falciparum malaria
• strains resistant to chloroquine are prevalent in
certain areas of Asia and Africa
• the 2010 WHO guidelines recommend artemisininbased combination therapies (ACTs)
as first-line
therapy
• examples include artemether plus lumefantrine,
artesunate plus amodiaquine, artesunate plus
mefloquine, artesunate plus sulfadoxinepyrimethamine, dihydroartemisinin plus
piperaquine
Severe falciparum malaria
• a parasite counts of more than 2% will usually need
parenteral treatment irrespective of clinical state
• intravenous artesunate is now recommended by
WHO in preference to intravenous quinine
• if parasite count > 10% then exchange transfusion
should be considered
• shock may indicate coexistent bacterial septicaemia -
malaria rarely causes haemodynamic collapse

Q-138
A 30-year-old man comes for review. He returned from a
holiday in Egypt yesterday. For the past two days he has
been passing frequent bloody diarrhoea associated with
crampy abdominal pain. Abdominal examination
demonstrates diffuse lower abdominal tenderness but there
is no guarding or rigidity. His temperature is 37.5ºC. What is
the most likely causative organism?
A. Giardiasis
B. Enterotoxigenic Escherichia coli
C. Staphylococcus aureus
D. Salmonella
E. Shigella
ANSWER:
B. Enterotoxigenic Escherichia coli
EXPLANATION:
Enterotoxigenic Escherichia coli infections do not usually
cause bloody diarrhoea. A differential diagnosis would be
amoebic dysentery, enterohemorrhagic Escherichia coli and
possibly [Link]: causes
Gastroenteritis may either occur whilst at home or whilst travelling abroad
(travellers' diarrhoea)
Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24
hours with or without one of more of
abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common
cause is Escherichia coli.
Another pattern of illness is 'acute food poisoning'. This describes the sudden
onset of nausea, vomiting and diarrhoea
after the ingestion of a toxin. Acute food poisoning is typically caused by
Staphylococcus aureus, Bacillus
cereus or Clostridium perfringens.
Stereotypical histories
Infection Typical presentation
Escherichia coli Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis Prolonged, non-bloody diarrhoea
Cholera Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers
Shigella Bloody diarrhoea
Vomiting and abdominal pain
Staphylococcus
aureus
Severe vomiting
Short incubation period
Campylobacter A flu-like prodrome is usually followed by crampy abdominal pains,
fever and
diarrhoea which may be bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome
Bacillus cereus Two types of illness are seen
• vomiting within 6 hours, stereotypically due to rice
• diarrhoeal illness occurring after 6 hours
Amoebiasis Gradual onset bloody diarrhoea, abdominal pain and tenderness which may
last for
several weeks
Incubation period
• 1-6 hrs: Staphylococcus aureus, Bacillus cereus*
• 12-48 hrs: Salmonella, Escherichia coli
• 48-72 hrs: Shigella, Campylobacter
• > 7 days: Giardiasis, Amoebiasis
*vomiting subtype, the diarrhoeal illness has an incubation
period of 6-14 hours

Q-139
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?A. Giardia lamblia
B. Salmonella typhi
C. Treponema pallidum
D. Staphylococcus aureus
E. Streptococcus pneumoniae
ANSWER:
B. Salmonella typhi
EXPLANATION:
Salmonella typhi infection can cause rose spots on
the abdomen
Rose spots appear in Salmonella typhi infections. They
also appear in [Link] infections although it is more
associated with typhoid than psittacosis.
Giardiasis would not present this severely and acutely.
Syphilis would present with painless chancre.
Staphylococcus aureus would present within hours
following ingestion and it is associated with violent
vomiting.
Streptococcus pneumoniae does not usually cause
gastroenteritis.
Enteric fever (typhoid/paratyphoid)
The Salmonella group contains many members, most of which
cause diarrhoeal diseases. They are aerobic, Gram negative
rods which are not normally present as commensals in the
gut.
Typhoid and paratyphoid are caused by Salmonella
typhi and Salmonella paratyphi (types A, B & C) respectively.
They are often termed enteric fevers, producing systemic
symptoms such as headache, fever, arthralgia
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)

Q-140
A 19-year-old man presents 3 days after returning from a
backpacking trip across Brazil. He complains of a sudden
onset fever, headache, joint pains and rash all over his body.
He has no existing health conditions and is not on any
medication.
On examination he has a petechial rash on his limbs. He has
no focal neurology and no signs of meningism.
Hb 100 g/l
Platelets 80 * 109/l
WBC 4.0 * 109/l
Eosinophils 0.4 * 109/l
What is the most likely diagnosis?
A. Viral hepatitis
B. Chagas disease
C. Dengue fever
D. Malaria
E. Bacterial meningitis
ANSWER:
C. Dengue fever
EXPLANATION:
Dengue fever is found in South America (as well as South
East Asia) and presents like this with sudden onset fever and
arthralgia combined with low platelets and haemorrhage in
the case of Dengue haemorrhagic fever. Chagas disease
(American trypanosomiasis) is also found in this area but
would usually present with mild features and you would
expect to see raised eosinophils. Viral hepatitis and malaria
are less likely to present with a petechial rash. Bacterial
meningitis is unlikely as there are no signs of meningism.
Dengue fever
Dengue fever is a viral infection which can 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

Q-141
Which one of the following features is not associated with
Lyme disease?
A. Jarisch-Herxheimer reaction
B. Meningitis
C. Prolonged PR interval on ECG
D. Erythema marginatum
E. Arthralgia
ANSWER:
D. Erythema marginatum
EXPLANATION:
Lyme disease is associated with erythema chronicum
migrans
Lyme disease: features
Early features
• erythema chronicum migrans (small papule often at
site of the tick bite which develops into a larger
annular lesion with central clearing, 'bulls-eye'.
Occurs in 70% of patients)
• systemic symptoms: malaise, fever, arthralgia
Later features
• CVS: heart block, myocarditis
• neurological: cranial nerve palsies, meningitis
• polyarthritis

Q-142
A 25-year-old man with a history of epilepsy presents for
advice regarding malarial prophylaxis. Next month he plans
to travel to Vietnam. His trip will take him to some of the
costal tourist destinations but he also plans to travel inland.
What is the most appropriate medication to prevent him
developing malaria?
A. Quinine
B. Atovaquone + proguanil
C. Mefloquine
D. Primaquine
E. Pyrimethamine + sulfadoxine
ANSWER:
B. Atovaquone + proguanil
EXPLANATION:
In certain parts of South-East Asia there is widespread
chloroquine resistance. Chemoprophylaxis using atovaquone
+ proguanil (Malarone), mefloquine (Lariam) or doxycycline
is therefore recommended. Mefloquine should be avoided in
this patient due to his history of epilepsy
Malaria: prophylaxis
There are around 1,500-2,000 cases each year of malaria in
patients returning from endemic countries. The majority of
these cases (around 75%) are caused by the potentially
fatal Plasmodium falciparum protozoa. The majority of
patients who develop malaria did not take prophylaxis. It
should also be remembered that UK citizens who originate
from malaria endemic areas quickly lose their innate
immunity.
Up-to-date charts with recommended regimes for malarial zones should be consulted
prior to prescribing
Drug Side-effects + notes
Time to begin before
travel
Time to end after
travel
Atovaquone + proguanil
(Malarone)
GI upset 1 - 2 days 7 days
Chloroquine Headache
Contraindicated in
epilepsy
Taken weekly
1 week 4 weeksDrug Side-effects + notes
Time to begin before
travel
Time to end after
travel
Doxycycline Photosensitivity
Oesophagitis
1 - 2 days 4 weeks
Mefloquine (Lariam) Dizziness
Neuropsychiatric
disturbance
Contraindicated in
epilepsy
Taken weekly
2 - 3 weeks 4 weeks
Proguanil (Paludrine) 1 week 4 weeks
Proguanil + chloroquine See above 1 week 4 weeks
Pregnant women should be advised to avoid travelling to
regions where malaria is endemic. Diagnosis can also be
difficult as parasites may not be detectable in the blood film
due to placental sequestration. However, if travel cannot be
avoided:
• chloroquine can be taken
• proguanil: folate supplementation (5mg od) should
be given
• Malarone (atovaquone + proguanil): the BNF
advises to avoid these drugs unless essential. If
taken then folate supplementation should be given
• mefloquine: caution advised
• doxycycline is contraindicated
It is again advisable to avoid travel to malaria endemic
regions with children if avoidable. However, if travel is
essential then children should take malarial prophylaxis as
they are more at risk of serious complications.
• diethyltoluamide (DEET) 20-50% has been shown to
repel up to 100% of mosquitoes if used correctly. It
can be used in children over 2 months of age*
• doxycycline is only licensed in the UK for children
over the age of 12 years
*A BMJ review (BMJ 2015; 350:h99) suggest DEET could also
be used in breastfeeding women and pregnant women in
their 2nd or 3rd trimester

Q-143
A 33-year-old primigravida woman presents to her GP at 22
weeks gestation with a 2-day history of painful shallow
ulcers on the labia and vagina; she has had one prior
outbreak of herpes 2 years previously with a viral swab
performed at that time positive for HSV2. She is otherwise
well and her 20-week scan was normal. She is concerned
about how HSV may affect her pregnancy and whether it will
be safe for her to deliver vaginally.
What should you advise her?
A. There is high risk of blood borne neonatal transmission
of HSV regardless of treatment
B. All antiviral medications normally used in herpes are
teratogenic and should be avoided
C. Ibuprofen and salt water bathing are recommended for
analgesia
D. Most women with outbreaks of recurrent HSV during
pregnancy are recommended to deliver by elective
caesarean section
E. Suppressive treatment with aciclovir from 36 weeks
gestation may be considered
ANSWER:
E. Suppressive treatment with aciclovir from 36 weeks
gestation may be considered
EXPLANATION:
Recurrent herpes outbreaks in pregnancy should be
treated with suppressive therapy; risk of transmission
to the baby is low and aciclovir is safe to use in
pregnant women
Aciclovir, while not licensed for use in pregnancy, is
commonly used in pregnancy and is thought to be
safe; valaciclovir and famciclovir should be avoided.
Suppressive treatment is often considered from 36
weeks to reduce asymptomatic shedding and risk of
transmission during delivery. Vaginal delivery is
usually anticipated in recurrent genital herpes.
Ibuprofen is contraindicated in pregnancy

Q-144
A 39-year-old man with HIV is admitted due to shortness of
breath. Chest x-ray shows bilateral pulmonary infiltrates and
Pneumocystis carinii pneumonia is suspected. What type of
staining should be applied to the bronchoalveolar lavage to
demonstrate the organism?A. Rubeanic acid
B. Silver stain
C. Pearl's stain
D. Rose Bengal
E. Congo red
ANSWER:
B. Silver stain
EXPLANATION:
HIV: Pneumocystis jiroveci pneumonia
Whilst the organism Pneumocystis carinii is now referred to
as Pneumocystis jiroveci, the term Pneumocystis
carinii pneumonia (PCP) is still in common use
• Pneumocystis jiroveci is an unicellular eukaryote,
generally classified as a fungus but some authorities
consider it a protozoa
• PCP is the most common opportunistic infection in
AIDS
• all patients with a CD4 count < 200/mm³ should
receive PCP prophylaxis
Features
• dyspnoea
• dry cough
• fever
• very few chest signs
Pneumothorax is a common complication of PCP.
Extrapulmonary manifestations are rare (1-2% of cases), may
cause
• hepatosplenomegaly
• lymphadenopathy
• choroid lesions
Investigation
• CXR: typically shows bilateral interstitial pulmonary
infiltrates but can present with other x-ray findings
e.g. lobar consolidation. May be normal
• exercise-induced desaturation
• sputum often fails to show PCP, bronchoalveolar
lavage (BAL) often needed to demonstrate PCP (silver
stain shows characteristic cysts)
Management
• co-trimoxazole
• IV pentamidine in severe cases
• steroids if hypoxic (if pO2 < 9.3kPa then steroids
reduce risk of respiratory failure by 50% and death by
a third)
CT scan showing a large pneumothorax developing in a
patient with Pneumocystis jiroveci pneumonia

Q-145
A 67-year-old man is referred to the respiratory clinic. He has
a past history of tuberculosis as a child but is otherwise
normally fit and well. Over the past two months he has had a
cough, lost one stone in weight and had four episodes of
haemoptysis. A chest x-ray shows a solid mass occupying the
right upper zone. Investigation results include the following:
Aspergillus precipitin antibody Positive
What is the most likely diagnosis?
A. Lung abscess
B. Invasive aspergillosis
C. Aspergilloma
D. Reactivation of primary tuberculosis
E. Allergic bronchopulmonary aspergillosis
ANSWER:
C. Aspergilloma
EXPLANATION:
Aspergilloma
An aspergilloma is a mycetoma (mass-like fungus ball) whichoften colonises an
existing lung cavity (e.g. secondary to
tuberculosis, lung cancer or cystic fibrosis)
Usually asymptomatic but features may include
• cough
• haemoptysis (may be severe)
Investigations
• chest x-ray containing a rounded opacity
• high titres Aspergillus precipitins
Aspergilloma in a patient with cavities secondary to
previous tuberculosis infection. The close-up CXR and CT
scan from the same patient demonstrate a rounded soft
tissue attenuating masses located in a surrounding cavity.

Q-146
A 47-year-old lady is referred by her GP with a two day
history of fever and headache. She is normally fit and well
and has no past medical history of note. On examination you
note nuchal rigidity. Investigations show the following:
Serum glucose 4.9 mmol/l
Lumbar puncture reveals:
Opening pressure 14 cmCSF
Appearance Cloudy
Glucose 1.7 mmol/l
Protein 1.9 g/l
White cells 900 / mm³ (90% polymorphs)
What is the most likely infective agent?
A. Streptococcus pneumoniae
B. coli
C. Listeria monocytogenes
D. Enterovirus
E. Streptococcus pyogenes
ANSWER:
A. Streptococcus pneumoniae
EXPLANATION:
6 years - 60 years age group are at risk from
meninigitis caused by Streptococcus pneumoniae
The CSF results are consistent with bacterial
meningitis (low glucose, high protein, high
polymorphs). In this age group Streptococcus
pneumoniae and Neisseria meningitidis are the most
common causes of bacterial meningitis.
Meningitis: causes please see

Q-77

Q-147
For a patient undergoing an elective splenectomy, when is
the optimal time to give the pneumococcal vaccine?
A. Four weeks before surgery
B. One week before surgery
C. Immediately following surgery
D. Two weeks after surgery
E. At least one month after surgery
ANSWER:
A. Four weeks before surgery
EXPLANATION:
The current British National Formulary recommends giving
the vaccine at least 2 weeks before elective splenectomy.
Therefore 4 weeks is the best response from the given
options.
Splenectomy
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
Surgical aspects
Indications
• Trauma: 1/4 are iatrogenic
• Spontaneous rupture: EBV
• Hypersplenism: hereditary spherocytosis or
elliptocytosis etc
• Malignancy: lymphoma or leukaemia
• Splenic cysts, hydatid cysts, splenic abscesses
Splenectomy following trauma
• GA
• Long midline incision
• If time permits insert a self retaining retractor (e.g.
Balfour/ omnitract)
• Large amount of free blood is usually present. Pack
all 4 quadrants of the abdomen. Allow the
anaesthetist to 'catch up'
• Remove the packs and assess the viability of the
spleen. Hilar injuries and extensive parenchymal
lacerations will usually require splenectomy.
• Divide the short gastric vessels and ligate them.
• Clamp the splenic artery and vein. Two clamps on the
patient side are better and allow for double ligation
and serve as a safety net if your assistant does not
release the clamp smoothly.
• Be careful not to damage the tail of the pancreas, if
you do then this will need to be formally removed
and the pancreatic duct closed.
• Wash out the abdomen and place a tube drain to the
splenic bed.
• Some surgeons implant a portion of spleen into the
omentum, whether you decide to do this is a matter
of personal choice.
• Postoperatively the patient will require prophylactic
penicillin V and pneumococcal vaccine.
Elective splenectomy
• Elective splenectomy is a very different operation
from that performed in the emergency setting. The
spleen is often large (sometimes massive)
• Most cases can be performed laparoscopically. The
spleen will often be macerated inside a specimen bag
to facilitate extraction.
Complications
• Haemorrhage (may be early and either from short
gastrics or splenic hilar vessels
• Pancreatic fistula (from iatrogenic damage to
pancreatic tail)
• Thrombocytosis: prophylactic aspirin
• Encapsulated bacteria infection e.g. Strep.
pneumoniae, Haemophilus
influenzae and Neisseria meningitidis
Post-splenectomy changes
• Platelets will rise first (therefore in ITP should be
given after splenic artery clamped)
• Blood film will change over following weeks, HowellJolly bodies will appear
• Other blood film changes include target cells and
Pappenheimer bodies
• Increased risk of post-splenectomy sepsis, therefore
prophylactic antibiotics and pneumococcal vaccine
should be given.
Post-splenectomy sepsis
• Typically occurs with encapsulated organisms
• Opsonisation occurs but then not recognised
*usually from dog bites

Q-148
Which one of the following is a Gram positive coccus?A. Enterococcus faecalis
B. Moraxella catarrhalis
C. Haemophilus influenzae
D. Neisseria meningitidis
E. Bacillus anthracis
ANSWER:
A. Enterococcus faecalis
EXPLANATION:
Enterococci - Gram-positive cocci
Classification of bacteria see

Q-118

Q-149
A 41-year-old female presents with 3 day history of a dry
cough and shortness of breath. This was preceded by flu-like
symptoms. On examination there is a symmetrical,
erythematous rash with 'target' lesions over the whole body.
What is the likely organism causing the symptoms?
A. Pseudomonas
B. Staphylococcus aureus
C. Mycoplasma pneumoniae
D. Chlamydia pneumoniae
E. Legionella pneumophilia
ANSWER:
C. Mycoplasma pneumoniae
EXPLANATION:
Pneumococcus may also cause erythema multiforme
Mycoplasma pneumoniae please see

Q-69

Q-150
Which one of the following tests is most likely to remain
positive in a patient with syphilis despite treatment?
A. Wassermann reaction
B. Rapid plasma reagin (RPR)
C. Venereal disease research laboratory (VDRL)
D. Blood culture
E. Treponema pallidum haemagglutination test (TPHA)
ANSWER:
E. Treponema pallidum haemagglutination test (TPHA)
EXPLANATION:
Syphilis: investigation please see

Q-109

Q-151
Which of the following is true regarding the Salmonella
species?
A. Rose spots appear in all patients with typhoid
B. They are normally present in the gut as commensals
C. They are anaerobic organisms
D. A relative bradycardia is often seen in typhoid fever
E. Salmonella typhi can be categorised into type A, B and C
ANSWER:
D. A relative bradycardia is often seen in typhoid fever
EXPLANATION:
Enteric fever (typhoid/paratyphoid)see

Q-139
Q-152
A 28-year-old female returns from a country that is known to
have Zika virus transmission. She presents with fever,
headache and myalgia following a mosquito bite. She
expresses the wish to have children in the near future.
In view of the possibility of Zika virus, how long should she
wait before attempting conception?
A. 2 months
B. 4 months
C. 6 months
D. 8 months
E. 10 months
ANSWER:
C. 6 months
EXPLANATION:
The answer according to the World Health Organisation is to
use barrier methods for 6 months after returning from a
category 1 or 2 area
Zika virus
Zika is a mosquito-borne infection caused by Zika virus, a
member of the genus flavivirus and family Flaviviridae. It was
first isolated from a monkey in the Zika forest in Uganda in
1947.
Transmission is usually via the bite of an infected Aedes
mosquito, although a small number of cases of sexual
transmission have been reported. There is increasing evidence
of transmission via the placenta from mother to fetus.
The majority of people infected with Zika virus have no
symptoms. For those with symptoms, Zika virus tends to cause
a mild, short-lived (2 to 7 days) febrile disease. Signs and
symptoms suggestive of Zika virus infection may include a
combination of the following:
• fever
• rash
• arthralgia/arthritis
• conjunctivitis
• myalgia
• headache• retro-orbital pain
• pruritus
Serious complications in adults are not common, although the
virus has been associated with Guillain-Barre syndrome.
Scientific consensus however has linked Zika with
microcephaly and other congenital abnormalities, which has
led the World Health Organisation (WHO) to declare a Public
Health Emergency of International Concern (PHEIC).
Advice for travellers
There is currently no vaccine or drug to prevent Zika infection.
Prevention revolves around avoiding mosquito bites (Aedes
mosquitoes usually bite during the day) by using mosquito
repellent and cover up clothing. Pregnant women are advised
to avoid non-essential travel to Zika prevalent areas until after
pregnancy.

Q-153
Which one of the following best describes the action of
aciclovir?
A. Inhibits uncoating of virus in the cell
B. Inhibits DNA polymerase
C. Interferes with the capping of viral mRNA
D. Inhibits RNA polymerase
E. Protease inhibitor
ANSWER:
B. Inhibits DNA polymerase
EXPLANATION:
Antiviral agents
Drug Mechanism of action Indications Adverse effects/toxicity
Aciclovir Guanosine analog, phosphorylated
by thymidine kinase which in turn
inhibits the viral DNA polymerase
HSV, VZV Crystalline nephropathy
Ganciclovir Guanosine analog, phosphorylated
by thymidine kinase which in turn
inhibits the viral DNA polymerase
CMV Myelosuppression/agranulocytosis
Ribavirin Guanosine analog which inhibits
inosine monophosphate (IMP)
dehydrogenase, interferes with the
capping of viral mRNA
Chronic
hepatitis C,
RSV
Haemolytic anaemia
Amantadine Inhibits uncoating (M2 protein) of
virus in cell. Also releases dopamine
from nerve endings
Influenza,
Parkinson's
disease
Confusion, ataxia, slurred speech
Oseltamivir Inhibits neuraminidase Influenza
Foscarnet Pyrophosphate analog which
inhibits viiral DNA polymerase
CMV, HSV if
not responding
to aciclovir
Nephrotoxicity, hypocalcaemia,
hypomagnasaemia, seizures
Interferon-
α
Human glycoproteins which inhibit
synthesis of mRNA
Chronic
hepatitis B & C,
hairy cell
leukaemia
Flu-like symptoms, anorexia,
myelosuppression
Cidofovir Acyclic nucleoside phosphonate,
and is therefore independent of
phosphorylation by viral enzymes
(compare and contrast with
aciclovir/ganciclovir)
CMV retinitis in
HIV
NephrotoxicityAnti-retroviral agent used in HIV
Nucleoside analogue reverse transcriptase inhibitors (NRTI)
• examples: zidovudine (AZT), didanosine, lamivudine,
stavudine, zalcitabine
Protease inhibitors (PI)
• inhibits a protease needed to make the virus able to
survive outside the cell
• examples: indinavir, nelfinavir, ritonavir, saquinavir
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
• examples: nevirapine, efavirenz

Q-154
A 45-year-old male presents with yellow discolouration of
his nails. On examination he has thickened yellow toe nails.
You decide to treat him with terbinafine.
What is the mechanism of action of terbinafine?
A. Interacts with microtubules to disrupt mitotic spindle
B. Inhibits the fungal enzyme squalene epoxidase
C. Binds with ergosterol
D. Converted to 5-fluorouracil
E. Inhibits synthesis of beta-glucan
ANSWER:
B. Inhibits the fungal enzyme squalene epoxidase
EXPLANATION:
Terbinafine inhibits the fungal enzyme squalene
epoxidase, causing cellular death
Terbinafine inhibits the fungal enzyme squalene
epoxidase, causing cellular death. It is an antifungal
medication used to treat ringworm, pityriasis versicolor,
and fungal nail infections.
Griseofulvin interacts with microtubules to disrupt mitotic
spindle.
Amphotericin B binds with ergosterol forming a
transmembrane channel.
Flucytosine is converted by cytosine deaminase to 5-
fluorouracil, which inhibits thymidylate synthase and
disrupts fungal protein synthesis.
Caspofungin inhibits synthesis of beta-glucan, a major
fungal cell wall component
Antifungal agents
Drug Mechanism of action Adverse effects Notes
Azoles Inhibits 14α-demethylase which
produces ergosterol
P450 inhibition
Liver toxicity
Amphotericin
B
Binds with ergosterol forming a
transmembrane channel that leads
to monovalent ion (K+, Na+, H+
and Cl) leakage
Nephrotoxicity, flu-like
symptoms, hypokalaemia,
hypomagnaseamia
Used for systemic
fungal infections
Terbinafine Inhibits squalene epoxidase Commonly used in
oral form to treat
fungal nail
infections
Griseofulvin Interacts with microtubules to
disrupt mitotic spindle
Induces P450 system,
teratogenic
Flucytosine Converted by cytosine deaminase
to 5-fluorouracil, which inhibits
thymidylate synthase and disrupts
fungal protein synthesis
VomitingDrug Mechanism of action Adverse effects Notes
Caspofungin Inhibits synthesis of beta-glucan, a
major fungal cell wall component
Flushing
Nystatin Binds with ergosterol forming a
transmembrane channel that leads
to monovalent ion (K+, Na+, H+
and Cl) leakage
As very toxic can
only be used
topically (e.g. for
oral thrush)

Q-155
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?
A. Repeat course (i.e. 3 doses) of hepatitis B vaccine
B. Repeat anti-HBs level in three months time
C. Give a course of hepatitis B immune globulin (HBIG) +
one further dose of hepatitis B vaccine
D. Give one further dose of hepatitis B vaccine
E. Do a HIV test
ANSWER:
D. Give one further dose of hepatitis B vaccine
EXPLANATION:
Hepatitis B
Hepatitis B is a double-stranded DNA hepadnavirus and is
spread through exposure to infected blood or body fluids,
including vertical transmission from mother to child. The
incubation period is 6-20 weeks.
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
Immunisation against hepatitis B (please see the Greenbook
link for more details)
• children born in the UK are now vaccinated as part of
the routine immunisation schedule. This is given at 2,
3 and 4 months of age
• at risk groups who should be vaccinated include:
healthcare workers, intravenous drug users, sex
workers, close family contacts of an individual with
hepatitis B, individuals receiving blood transfusions
regularly, chronic kidney disease patients who may
soon require renal replacement therapy, prisoners,
chronic liver disease patients
• contains HBsAg adsorbed onto aluminium hydroxide
adjuvant and is prepared from yeast cells using
recombinant DNA technology
• around 10-15% of adults fail to respond or respond
poorly to 3 doses of the vaccine. Risk factors include
age over 40 years, obesity, smoking, alcohol excess
and immunosuppression
• testing for anti-HBs is only recommended for those at
risk of occupational exposure (i.e. Healthcare
workers) and patients with chronic kidney disease. In
these patients anti-HBs levels should be checked 1-4
months after primary immunisation
• the table below shows how to interpret anti-HBs levels:
Anti-HBs
level
(mIU/ml) Response
> 100 Indicates adequate response, no further testing required. Should still
receive booster at 5 yearsAnti-HBs
level
(mIU/ml) Response
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
Management of hepatitis B
• pegylated interferon-alpha used to be the only treatment available. It reduces
viral replication in up to
30% of chronic carriers. A better response is predicted by being female, < 50 years
old, low HBV DNA
levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy
• whilst NICE still advocate the use of pegylated interferon firstl-line other
antiviral medications are
increasingly used with an aim to suppress viral replication (not in a dissimilar
way to treating HIV
patients)
• examples include tenofovir and entecav

Q-156
A 35-year-old man who has recently immigrated from
Zimbabwe to the UK presents to the emergency department
with fever, myalgia and headaches. He is suspected to have
malaria.
Which test is most likely to allow for accurate speciation of
the malarial pathogen?
A. Thick blood film
B. Thin blood film
C. Quantitative buffy coat analysis
D. Blood cultures
E. Point of care malaria test
ANSWER:
A. Thick blood film
EXPLANATION:
Thick blood films check for parasite burden, thin films
allow for speciation
1) Parasite burden is evaluated from thick blood films,
while thin films allow for speciation.
2) Thin peripheral blood films allow for better
visualisation of the parasites and therefore speciation
3) Quantitative buffy coat analysis is performed by
centrifuging the blood sample, and examining the
interface between the buffy coat (layer of platelets and
white cells) and the red cells for parasites. This test is
more sensitive than thick smears at diagnosis of
parasitaemia, however isn't as good as thin smears for
speciation.
4) Blood cultures allow for bacterial growth and
speciation however have no role in the diagnosis of
parasitic diseases
5) These allow for rapid diagnosis and diagnosis-led
treatment in resource limited areas, rather than blind
treatment which may promote the development of
resistance. They are not able to differentiate between the
various species of non-falciparum malaria.
Malaria: investigation
The gold standard for diagnosis of malaria remains the blood
film. Rapid diagnostic tests (detecting plasmodial histidinerich protein 2) are
currently being trialled and have shown
sensitivities from 77-99% and specificities from 83-98% for
falciparum malariaBlood film - if doubt about diagnosis should be repeated
• thick: more sensitive
• thin: determine species
Other tests
• thrombocythaemia is characteristic
• normochromic normocytic anaemia
• normal white cell count
• reticulocytosis

Q-157
A 27-year-old woman who is 10 weeks pregnant presents
with 'cystitis'. She describes a two day history of dysuria,
suprapubic pains and frequency. There has been no vaginal
bleeding. Urine dipstick is positive for leucocytes and
nitrites. Her temperature is 37.6ºC. What is the most
appropriate management?
A. Oral nitrofurantoin
B. Await the midstream specimen of urine (MSU) result
C. Oral trimethoprim
D. Oral ciprofloxacin
E. Topical clotrimazole
ANSWER:
A. Oral nitrofurantoin
EXPLANATION:
This pregnant lady has symptoms consistent with a urinary
tract infection. The BNF recommend that trimethoprim is
avoided in the first trimester as it is a folate antagonist.
Ciprofloxacin is contraindicated throughout pregnancy. As this
patient clearly has a UTI and is pyrexial should be treated
straightaway, rather than waiting for the MSU,
Urinary tract infection in adults: management
Lower urinary tract infections
Non-pregnant women
• local antibiotic guidelines should be followed if
available
• CKS/2012 SIGN guidelines recommend trimethoprim
or nitrofurantoin for 3 days
Pregnant women with symptomatic bacteriuria should be
treated with an antibiotic for 7 days. A urine culture should be
sent. For asymptomatic pregnant women:
• a urine culture should be performed routinely at the
first antenatal visit
• if positive, a second urine culture should be sent to
confirm the presence of bacteriuria
• SIGN recommend to treat asymptomatic bacteriuria
detected during pregnancy with an antibiotic
• a 7 day course of antibiotics should be given
• a further urine culture should be sent following
completion of treatment as a test of cure
Acute pyelonephritis
For patients with sign of acute pyelonephritis hospital
admission should be considered
• local antibiotic guidelines should be followed if
available
• the BNF currently recommends a broad-spectrum
cephalosporin or a quinolone (for non-pregnant
women) for 10-14 days

Q-158
A 45-year-old man presents to the Emergency Department
due to severe pain in the perineal area over the past 6 hours.
On examination the skin is cellulitic, extremely tender and
haemorrhagic bullae are seen. What is the most appropriate
management?
A. IV antibiotics + surgical debridement
B. IV antibiotics
C. IV corticosteroids
D. Plasma exchange
E. Urgent microscopy of wound swab
ANSWER:
A. IV antibiotics + surgical debridement
EXPLANATION:
Surgical referral is the single most important step in the
management of necrotising fasciitis. There has been little
change in the mortality of necrotising fasciitis since the
introduction of antibiotics
Necrotising fasciitis
Necrotising fasciitis is a medical emergency that is difficult to
recognise in the early stages
It can be classified according to the causative organism:
• type 1 is caused by mixed anaerobes and aerobes
(often occurs post-surgery in diabetics)
• type 2 is caused by Streptococcus pyogenes
Features
• acute onset
• painful, erythematous lesion develops
• extremely tender over infected tissueManagement
• urgent surgical referral debridement
• intravenous antibiotics

Q-159
An 82-year-old gentleman admitted with back pain to a
medical ward for a magnetic resonance imaging of his spine
has a background of prostate cancer under surveillance and
a long-term catheter inserted a few weeks ago by urology. A
midstream specimen of urine was positive for extended
spectrum beta-lactamases (ESBL) (>100.000 colonies). He
claims he has no dysuria and urine in catheter bag looks
clear and there are no signs of hematuria. He is also afebrile
and hemodynamically stable.
Hb 111 g/l
Platelets 236 * 109/l
WBC 6.8 * 109/l
Na+ 143 mmol/l
K+ 5.1 mmol/l
Urea 6.2 mmol/l
Creatinine 102 µmol/l
CRP 7.8 mg/l
What would be the next step to manage his bacteriuria?
A. This bacteriuria should not be treated. Ensure good hydration and monitor any
urinary symptoms or pyrexia
B. Commence nitrofurantoin 100 mg four times a day for 3
days
C. Commence one stat dose of gentamicin intravenously
and if no response contact microbiology
D. Check sensitivities first and commence antibiotics
regardless of clinic
E. Remove catheter immediately and contact urology
ANSWER:
A. This bacteriuria should not be treated. Ensure good hydration and monitor any
urinary symptoms or pyrexia
EXPLANATION:
Asymptomatic bacteriuria should not be treated
except in pregnancy, children younger than 5 years or
immunosuppressed patients due to the risk of
complications
This is a case of a elderly patient with a long-term
catheter. Bacteriuria is likely to be contamination and
does not require any treatment if patient
asymptomatic to prevent increase in antimicrobial
resistance. Asymptomatic bacteriuria should not be
treated except in pregnancy, children younger than 5
years or immunosuppressed patients due to the risk of
complications.
Urinary tract infection in adults: management see

Q-157

Q-160
A 20-year-old man who presented with persistent diarrhoea
and abdominal bloating after returning from a gap year in
Africa is diagnosed as having strongyloidiasis. How would
the Strongyloides stercoralis organism initially entered his
body?
A. Sexual transmission
B. Faecal-oral route
C. Penetrated the skin
D. Respiratory droplet route
E. Mosquito vector
ANSWER:
C. Penetrated the skin
EXPLANATION:
Strongyloides stercoralis gains access to the body by
penetrating the skin
This typically occurs via the soles of the feet but
autoinfection in the perianal area may also occur.
Strongyloides stercoralis
Strongyloides stercoralis is a human parasitic nematode
worm. The larvae are present in soil and gain access to the
body by penetrating the skin. Infection with Strongyloides
stercoralis causes strongyloidiasis.
Features
diarrhoea
abdominal pain/bloating
papulovesicular lesions where the skin has been penetrated
by infective larvae e.g. soles of feet and buttocks
larva currens: pruritic, linear, urticarial rash
if the larvae migrate to the lungs a pneumonitis similar to
Loeffler's syndrome may be triggered
Treatment
ivermectin and albendazole are usedDiagram showing the lifecycle of Strongyloides
stercoralis

Q-161
A 62-year-old man presents to the emergency department
with a productive cough of green sputum and occasional
bloody specks. On examination his temperature is 38.3ºC,
respiratory rate 23/min, heart rate 100/min and there is left
basal coarse crackles with a small cold sore above his lips.
What is the most likely diagnosis?
A. Streptococcal pneumonia
B. Viral pneumonia
C. Mycoplasma pneumonia
D. Klebsiella pneumonia
E. Legionella pneumonia
ANSWER:
A. Streptococcal pneumonia
EXPLANATION:
This patient is most likely to be suffering from pneumonia
secondary to streptococcal pneumoniae. It is the most
common cause of community acquired pneumonia and
further clues to this being the diagnosis is the evidence of a
cold sore and the blood stained sputum.
For exam purposes, particular diagnosis of community
acquired pneumonia have clues in the questions. Klebsiella is
associated with cardiomyopathies and alcoholics, with upper
lobar involvement, whereas Mycoplasma occurs in
epidemics with skin changes and some haematological
involvement. Legionella typically is a water borne infection
with hyponatraemia and gastroenterological symptoms
Pneumonia: causes see

Q-40

Q-162
A 35-year-old man returns from a two week holiday in Italy.
He has a 10 day history of rectal bleeding associated with
lower back pain. On examination there is a painful swelling
of his right knee. What is the most likely diagnosis?
A. Gonococcal septicaemia
B. Amoebiasis
C. Crohn's disease
D. Tuberculosis
E. Ulcerative colitis
ANSWER:
A. Gonococcal septicaemia
EXPLANATION:
Gonococcus contracted via anal sex may cause proctitis. The
knee swelling seen in this patient is septic arthritis, which is
characteristic of the second stage of disseminated
gonococcal infection. Proctitis may present with either lower
back or rectal pain
Gonorrhoea
Gonorrhoea is caused by the Gram negative
diplococcus Neisseria gonorrhoeae. Acute infection can occur
on any mucous membrane surface, typically genitourinary but
also rectum and pharynx. The incubation period of
gonorrhoea is 2-5 days
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)
Local complications that may develop include urethral
strictures, epididymitis and salpingitis (hence may lead to
infertility). Disseminated infection may occur - see below
Management
• ciprofloxacin used to be the treatment of choice.
However, there is increased resistance to
ciprofloxacin and therefore cephalosporins are now
used• the 2011 British Society for Sexual Health and HIV
(BASHH) guidelines recommend ceftriaxone 500 mg
intramuscularly as a single dose with azithromycin 1 g
oral as a single dose. The azithromycin is thought to
act synergistically with ceftriaxone and is also useful
for eradicating any co-existent Chlamydia infections.
This combination can be used in pregnant women as
well
• if ceftriaxone is refused or contraindicated other
options include cefixime 400mg PO (single dose)
Colorized scanning electron micrograph of Neisseria
gonorrhoeae. Credit: NIAID
Disseminated gonococcal infection (DGI) and gonococcal
arthritis may also occur, with gonococcal infection being the
most common cause of septic arthritis in young adults. The
pathophysiology of DGI is not fully understood but is thought
to be due to haematogenous spread from mucosal infection
(e.g. Asymptomatic genital infection). Initially there may be a
classic triad of symptoms: tenosynovitis, migratory
polyarthritis and dermatitis. Later complications include septic
arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis
syndrome)
Key features of disseminated gonococcal infection
• tenosynovitis
• migratory polyarthritis
• dermatitis (lesions can be maculopapular or
vesicular)

Q-163
What is the mechanism of action of the antiviral agent
ribavirin?
A. Inhibits DNA polymerase
B. Inhibits uncoating of virus in the cell
C. Protease inhibitor
D. Nucleoside analogue reverse transcriptase inhibitor
E. Interferes with the capping of viral mRNA
ANSWER:
E. Interferes with the capping of viral mRNA
EXPLANATION:
Antiviral agents

Q-153

Q-164
A 33-year-old woman who was diagnosed as having HIV-1
two years ago is reviewed in clinic. She is fit and well
currently and has no symptoms of note. The only medication
she takes is the occasional paracetamol for tension
headaches. Her latest blood tests are as follows:
CD4 325 * 106/l
What is the most appropriate action with regard with to
anti-retroviral therapy?
A. Wait until the CD4 count is below 200 * 106/l
B. Wait until the CD4 count is above 350 * 106/l
C. Wait until the CD4 count is below 250 * 106/l
D. Start antiretroviral therapy now
E. Wait until the CD4 count is below 300 * 106/l
ANSWER:
D. Start antiretroviral therapy now
EXPLANATION:
HIV: anti-retrovirals
Highly active anti-retroviral therapy (HAART) involves a
combination of at least three drugs, typically two nucleoside
reverse transcriptase inhibitors (NRTI) and either a protease
inhibitor (PI) or a non-nucleoside reverse transcriptase
inhibitor (NNRTI). This combination both decreases viral
replication but also reduces the risk of viral resistance
emerging
Following the 2015 BHIVA guidelines it is now recommended
that patients start HAART as soon as they have been
diagnosed with HIV, rather than waiting until a particular CD4
count, as was previously advocated.
Entry inhibitors (CCR5 receptor antagonists)
• maraviroc, enfuvirtide
• prevent HIV-1 from entering and infecting immune
cells by blocking CCR5 cell-surface receptorNucleoside 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
Integrase inhibitors
• examples: raltegravir, elvitegravir, dolutegravir

Q-165
A 56-year-old farmer presents with a painless black eschar
on his cheek with surrounding swelling and mild fever. The
eschar started initially as an itchy boil-like lesion which
became enlarged. In the last week, he had been visiting rural
farms in the Turkey to help with agriculture work. What
diagnosis would need to be considered first?
A. Necrotic ulcer
B. Anthrax
C. Cellulitis
D. Necrotising spider bite
E. Scrub typhus
ANSWER:
B. Anthrax
EXPLANATION:
A black eschar with oedema is characteristic of anthrax.
There are occasional outbreaks in central Asia and Africa
(ref: WHO). The cutaneous form is the most common, caused
by handling infected animals resulting in farmers being at
risk. In this case, anthrax would need to be considered and
ruled out first. Scrub typhus would also give an eschar but
would be accompanied by other symptoms such as muscle
pain, cough, and GI upset. A necrotic ulcer is unlikely as it
does not usually present on the face. There is no history of
spider bite making necrotizing spider bite less likely.
Anthrax
Anthrax is caused by Bacillus anthracis, a Gram positive rod. It
is spread by infected carcasses. It is also known as
Woolsorters' disease. Bacillus anthracis produces a tripartite
protein toxin
• protective antigen
• oedema factor: a bacterial adenylate cyclase which
increases cAMP
• lethal factor: toxic to macrophages
Features
• causes painless black eschar (cutaneous 'malignant
pustule', but no pus)
• typically painless and non-tender
• may cause marked oedema
• anthrax can cause gastrointestinal bleeding
Management
• the current Health Protection Agency advice for the
initial management of cutaneous anthrax is
ciprofloxacin
• further treatment is based on microbiological
investigations and expert advice

Q-166
You review a 45-year-old woman who has been admitted
feeling generally unwell. Four months ago she had a renal
transplant and has since been taking a combination of
ciclosporin and mycophenolate for immunosuppression. For
the past three days she has had fever, dyspnoea and a dry
cough. A chest x-ray shows bilateral interstitial infiltrates.
What is the most likely diagnosis?
A. Graft-versus host disease
B. Cytomegalovirus pneumonitis
C. Cell mediated acute transplant rejection
D. Mycophenolate pneumonitis
E. Cryptococcus neoformans pneumonia
ANSWER:
B. Cytomegalovirus pneumonitis
EXPLANATION:
Renal transplant + infection ?CMV
Over 50% of renal transplant patients have a significant
infection within the first 12 months of having a renal
transplant.
At the time of transplant the CMV-serological status of the
donor and recipient are noted. The highest risk is seen in
CMV-seronegative recipients who receive a kidney from a
CMV-seropositive donor. These patients are usually given
antiviral [Link] tend to be seen after four weeks as before
this time the immune system has not been fully affected by
the immunosuppressants.
Cytomegalovirus
Cytomegalovirus (CMV) is one of the herpes viruses. It is
thought that around 50% of people have been exposed to the
CMV virus although it only usually causes disease in the
immunocompromised, for example people with HIV or those
on immunosuppressants following organ transplantation.
Pathophysiology
• infected cells have a 'Owl's eye' appearance due to
intranuclear inclusion bodies
Patterns of disease
Congenital CMV infection
• features include growth retardation, pinpoint
petechial 'blueberry muffin' skin lesions,
microcephaly, sensorineural deafness, encephalitiis
(seizures) and hepatosplenomegaly
CMV mononucleosis
• infectious mononucelosis-like illness
• may develop in immunocompetent individuals
CMV retinitis
• common in HIV patients with a low CD4 count (< 50)
• presents with visual impairment e.g. 'blurred vision'.
Fundoscopy shows retinal haemorrhages and
necrosis, often called 'pizza' retina
• IV ganciclovir is the treatment of choice
Fundus photograph showing CMV retinitis. Credit: National
Eye Institute, National Institutes of Health
CMV encephalopathy
• seen in patients with HIV who have low CD4 counts
CMV pneumonitis
CMV colitis
Q-167
A 17-year-old girl presents with a sore throat. On
examination she has inflamed tonsils covered in white
patches. Tender cervical lymphadenopathy and a low grade
pyrexia are also present. Which one of the following
organisms is most likely to be responsible?
A. Streptococcus viridans
B. Streptococcus agalactiae
C. Streptococcus pneumoniae
D. Staphylococcus aureus
E. Streptococcus pyogenes
ANSWER:
E. Streptococcus pyogenes
EXPLANATION:
Streptococci
Streptococci are gram-positive cocci. They may be divided into
alpha and beta haemolytic types
Alpha haemolytic streptococci (partial haemolysis)
The most important alpha
haemolytic Streptococcus is Streptococcus
pneumoniae(pneumococcus). Pneumococcus is a common
cause of pneumonia, meningitis and otitis media. Another
clinical example is Streptococcus viridans
Beta haemolytic streptococci (complete haemolysis)
These can be subdivided into groups A-H. Only groups A, B &
D are important in humans.
Group A
• most important organism is Streptococcus pyogenes
• responsible for erysipelas, impetigo, cellulitis, type 2
necrotizing fasciitis and pharyngitis/tonsillitis
• immunological reactions can cause rheumatic fever
or post-streptococcal glomerulonephritis
• erythrogenic toxins cause scarlet fever
Group B
• Streptococcus agalactiae may lead to neonatal
meningitis and septicaemiaGroup D
• Enterococcus
Group B streptococcus bacteria. Credit: NIAID

Q-168
A 27-year-old man who has recently moved to the UK from
Uganda presents complaining of fatigue and purple skin
lesions all over his body. On examination he has multiple
raised purple lesions on his trunk and arms. You also notice
some smaller purple lesions in his mouth. He has recently
started taking acyclovir for herpes zoster infection.
What is the most likely diagnosis?
A. Dermatofibroma
B. Kaposi's sarcoma
C. Drug reaction to acyclovir
D. Psoriasis
E. Haemangioma
ANSWER:
B. Kaposi's sarcoma
EXPLANATION:
Raised purple lesions is a classic description of Kaposi's
sarcoma suggesting he has underlying HIV infection. HIV has
a high prevalence in Uganda and the recent herpes zoster
infection suggests he may have underlying
immunocompromise.
Dermatofibromas are usually small pink/red nodules that
are characteristically very firm and would not be found in the
mouth. Psoriasis presents with red, scaly lesions and again is
not seen on mucosal surfaces. A drug reaction is unlikely to
present like this. A haemangioma can present with a purple
raised lesion but again it would be unusual to see them in
the mouth and Kaposi's sarcoma is much more likely in this
case.
HIV: Kaposi's 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
Kaposi's sarcoma in a patient with HIV

Q-169
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/lUrea 10 mmol/l
Creatinine 180 µmol/l
What is the most likely diagnosis?
A. Leptospirosis
B. Cysticercosis
C. Glomerulonephritis
D. Hepatitis A
E. Hepatitis E
ANSWER:
A. Leptospirosis
EXPLANATION:
Sewage workers are at risk of leptospirosis which is
transmitted through rat urine. It typically presents as above
and can progress to renal failure. Cysticercosis would not
cause jaundice or renal failure. Glomerulonephritis should
not cause jaundice or subconjunctival haemorrhage and
acute viral hepatitis would not normally cause renal failure
and would be unlikely without any travel history.
Leptospirosis
Also known as Weil's disease*, leptospirosis is commonly seen
in questions referring to sewage workers, farmers, vets or
people who work in abattoir. It is caused by the spirochaete
Leptospira interrogans (serogroup L icterohaemorrhagiae),
classically being spread by contact with infected rat urine.
Weil's disease should always be considered in high-risk
patients with hepatorenal failure
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
*the term Weil's disease is sometimes reserved for the most
severe 10% of cases that are associated with jaundice

Q-170
A 34-year-old male returns from india and upon arriving
home is diagnosed with pneumonia that is resistant to
multiple antibiotics, in particular to imipenem. What is the
likely virulence factor which caused the pneumonia?
A. D-alanyl-D-lactate variation leading to loss of affinity
B. New Delhi metallo-beta-lactamase 1
C. Presence of MexAB-OprM efflux pumps
D. Alteration to the penicillin binding protein 2
E. Reduced permeability & ribosomal modification
ANSWER:
B. New Delhi metallo-beta-lactamase 1
EXPLANATION:
New Delhi metallo-beta-lactamase 1 is the mutation that
leads to carbapenem resistance. Typically found in Klebsiella
pneumoniae, Escherichia Coli (E. Coli), Enterobacter cloacae
and others. First line of management is the old antibiotic
colistin and second line may be tigecycline.
D-alanyl-D-lactate variation leading to loss of affinity to
antibiotics is the mechanism of VRE (vancomycin resistant
enterococci). Vancomycin binds to D-ala-D-ala.
The presence of MexAB-OprM efflux pumps is one of the
mechanisms by which pseudomonas aeruginosa is resistant
to -lactams, chloramphenicol, fluoroquinolones, macrolides,
novobiocin, sulfonamides, tetracycline, and trimethoprim.
Alteration to the penicillin binding protein 2 is the
mechanism behind methicillin-resistant staphylococcus
aureus. Mutations in the MEC gene which codes the penicillin
binding proteins give staphylococcus aureus its resistance.
Virulence factors
Bacteria employ a large number of virulence factors which enable them to colonize
the host and evade/suppress the
immune response. The table below shows a select number of virulence factors which
are important for the exam.
Virulence factor Example organisms
IgA protease Streptococcus pneumoniae
Haemophilus influenzae
Neisseria gonorrhoeae
M Protein Streptococcus pyogenes
Polyribosyl ribitol phosphate capsule Haemophilus influenzaeVirulence factor
Example organisms
Bacteriophage Corynebacterium diphtheriae
Spore formation Bacillus anthracis
Clostridium perfringens
Clostridium tetani
Lecithinase alpha toxin Clostridium perfringens
D-glutamate polypeptide capsule Bacillus anthracis
Actin rockets Listeria monocytogenes

Q-171
A 34-year-old man presents with a widespread
maculopapular rash and mouth ulcers. Two months ago he
presented to the local GUM clinic after developing a painless
penile ulcer. At the time he was noted to have inguinal
lymphadenopathy. Which one of the following organisms is
most likely to be responsible?
A. Lymphogranuloma venereum
B. Herpes simplex virus type 2
C. Mycoplasma genitalium
D. Haemophilus ducreyi
E. Treponema pallidum
ANSWER:
E. Treponema pallidum
EXPLANATION:
This patient has symptoms of secondary syphilis.
Syphilis
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. The incubation period
is between 9-90 days
Primary features
• chancre - painless ulcer at the site of sexual contact
• local non-tender lymphadenopathy
• often not seen in women (the lesion may be on the
cervix)
Secondary features - occurs 6-10 weeks after primary
infection
• systemic symptoms: fevers, lymphadenopathy
• rash on trunk, palms and soles
• buccal 'snail track' ulcers (30%)
• condylomata lata (painless, warty lesions on the
genitalia )
lassical palm lesions of secondary syphilisMore generalised rash of secondary
syphilis
Tertiary features
• gummas (granulomatous lesions of the skin and
bones)
• ascending aortic aneurysms
• general paralysis of the insane
• tabes dorsalis
• Argyll-Robertson pupil
Features of congenital syphilis
• blunted upper incisor teeth (Hutchinson's
teeth), 'mulberry' molars
• rhagades (linear scars at the angle of the mouth)
• keratitis
• saber shins
• saddle nose
• deafness

Q-172
A 32-year-old woman attends the emergency department 8
days after returning from a Safari holiday in Uganda with
headache, fever, muscle pains and malaise. She admits she
did not have any vaccinations before she went and did not
take antimalarial prophylaxis. She has no past medical
history and is not taking any other medications.
Her temperature is 39.5ºC, blood pressure 100/70 mmHg,
heart rate 110/min, respiratory rate 20 breaths/min, oxygen
saturations 98% on air. Her blood sugar is 2.8 mmol/L.
Her blood film shows P. falciparum with 5% parasitaemia
How would you treat her?
A. Oral artesunate combination therapy
B. Oral chloroquine
C. IV artesunate
D. IV mefloquine
E. IV quinine
ANSWER:
C. IV artesunate
EXPLANATION:
This lady has severe falciparum malaria as she has a high
parasitaemia (>2%), hypoglycaemia and a high temperature.
The latest WHO guidelines recommend IV artesunate as 1st
line treatment for severe falciparum malaria. IV quinine can
be used if artesunate is not available but is inferior to
artesunate. Chloroquine should be used with caution as
there is high level of chloroquine resistance in some areas of
the world. If she had non-severe falciparum malaria then
artesunate combination therapy should be used.
Criteria for severe falciparum malaria
• High parasitaemia (>2%)
• Hypoglycaemia
• Severe anaemia
• Renal failure
• Pulmonary oedema
• Metabolic acidosis
• Abnormal bleeding
• Multiple convulsions
• Seizures
• Shock
Management
• Severe falciparum, malaria IV artesunate
• Non-severe falciparum malaria oral artesunate
combination therapy (ACT)
• Non-falciparum malaria oral ACT or chloroquine if
not resistant
Sources: WHO management of severe malaria
[Link]
[Link]?ua=1
Malaria: Falciparum
Feature of severe malaria
• schizonts on a blood film
• parasitaemia > 2%
• hypoglycaemia
• acidosis
• temperature > 39 °C
• severe anaemia
• complications as below
Complications
• cerebral malaria: seizures, coma
• acute renal failure: blackwater fever, secondary to
intravascular haemolysis, mechanism unknown
• acute respiratory distress syndrome (ARDS)
• hypoglycaemia
• disseminated intravascular coagulation (DIC)
Uncomplicated falciparum malaria
• strains resistant to chloroquine are prevalent in
certain areas of Asia and Africa
• the 2010 WHO guidelines recommend artemisininbased combination therapies (ACTs)
as first-line
therapy• examples include artemether plus lumefantrine,
artesunate plus amodiaquine, artesunate plus
mefloquine, artesunate plus sulfadoxinepyrimethamine, dihydroartemisinin plus
piperaquine
Severe falciparum malaria
• a parasite counts of more than 2% will usually need
parenteral treatment irrespective of clinical state
• intravenous artesunate is now recommended by
WHO in preference to intravenous quinine
• if parasite count > 10% then exchange transfusion
should be considered
• shock may indicate coexistent bacterial septicaemia -
malaria rarely causes haemodynamic collapse

Q-173
Which one of the following statements is true regarding
Listeria monocytogenes?
A. Multiplies rapidly at high temperatures
B. The organism is resistant to ampicillin
C. It is a Gram negative bacillus
D. It is diagnosed by the presence of urinary antigen
E. May cause ataxia
ANSWER:
E. May cause ataxia
EXPLANATION:
Listeria
Listeria monocytogenes is a Gram positive bacillus which has
the unusual ability to multiply at low temperatures. It is
typically spread via contaminated food, typically
unpasteurised dairy products. Infection is particularly
dangerous to the unborn child where it can lead to
miscarriage.
Features - can present in a variety of ways
• diarrhoea, flu-like illness
• pneumonia , meningoencephalitis
• ataxia and seizures
Suspected Listeria infection should be investigated by taking
blood cultures. CSF may reveal a pleocytosis, with 'tumbling
motility' on wet mounts
Management
• Listeria is sensitive to amoxicillin/ampicillin
(cephalosporins usually inadequate)
• Listeria meningitis should be treated with IV
amoxicillin/ampicillin and gentamicin
In pregnant women
• pregnant women are almost 20 times more likely to
develop listeriosis compared with the rest of the
population due to changes in the immune system
• fetal/neonatal infection can occur both
transplacentally and vertically during child birth
• complications include miscarriage, premature labour,
stillbirth and chorioamnionitis
• diagnosis can only be made from blood cultures
• treatment is with amoxicillin

Q-174
Which one of the following statements regarding hepatitis B
is correct?
A. Ribavirin is the treatment of choice for chronic hepatitis
B
B. All patient immunised against hepatitis B require an
anti-HBs check to assess their response to the vaccine
C. 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine
D. The vaccine is of the live-attenuated type
E. An anti-HBs level of 20 mIU/ml indicates an adequate
response to the vaccine
ANSWER:
C. 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine
EXPLANATION:
Only those at risk of occupational exposure (i.e. Healthcare
workers) and patients with chronic kidney disease require an
anti-HBs check.
Hepatitis B
Hepatitis B is a double-stranded DNA hepadnavirus and is
spread through exposure to infected blood or body fluids,
including vertical transmission from mother to child. The
incubation period is 6-20 weeks.
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
Immunisation against hepatitis B (please see the Greenbooklink for more details)
• children born in the UK are now vaccinated as part of
the routine immunisation schedule. This is given at 2,
3 and 4 months of age
• at risk groups who should be vaccinated include:
healthcare workers, intravenous drug users, sex
workers, close family contacts of an individual with
hepatitis B, individuals receiving blood transfusions
regularly, chronic kidney disease patients who may
soon require renal replacement therapy, prisoners,
chronic liver disease patients
• contains HBsAg adsorbed onto aluminium hydroxide
adjuvant and is prepared from yeast cells using
recombinant DNA technology
• around 10-15% of adults fail to respond or respond
poorly to 3 doses of the vaccine. Risk factors include
age over 40 years, obesity, smoking, alcohol excess
and immunosuppression
• testing for anti-HBs is only recommended for those at
risk of occupational exposure (i.e. Healthcare
workers) and patients with chronic kidney disease. In
these patients anti-HBs levels should be checked 1-4
months after primary immunisation
• the table below shows how to interpret anti-HBs
levels:
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
Management of hepatitis B
• pegylated interferon-alpha used to be the only
treatment available. It reduces viral replication in up
to 30% of chronic carriers. A better response is
predicted by being female, < 50 years old, low HBV
DNA levels, non-Asian, HIV negative, high degree of
inflammation on liver biopsy
• whilst NICE still advocate the use of pegylated
interferon firstl-line other antiviral medications are
increasingly used with an aim to suppress viral
replication (not in a dissimilar way to treating HIV
patients)
• examples include tenofovir and entecavir

Q-175
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?
A. Hepatitis A
B. Japanese encephalitis
C. Rheumatic fever
D. Malaria
E. Dengue fever
ANSWER:
E. Dengue fever
EXPLANATION:
The low platelet count and raised transaminase level is
typical of dengue fever
Dengue fever
Dengue fever is a viral infection which can 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
Q-176
Which one of the following is the most likely presentation of
Staphylococcus aureus food poisoning?A. Tenesmus
B. Watery diarrhoea
C. Dysentery
D. Severe vomiting
E. Presentation 24-48 hours after eating affected food
ANSWER:
D. Severe vomiting
EXPLANATION:
Severe nausea and vomiting are caused by enterotoxins A-E
Gastroenteritis: causes
Gastroenteritis may either occur whilst at home or whilst
travelling abroad (travellers' diarrhoea)
Travellers' diarrhoea may be defined as at least 3 loose to
watery stools in 24 hours with or without one of more of
abdominal cramps, fever, nausea, vomiting or blood in the
stool. The most common cause is Escherichia coli.
Another pattern of illness is 'acute food poisoning'. This
describes the sudden onset of nausea, vomiting and diarrhoea
after the ingestion of a toxin. Acute food poisoning is typically
caused by Staphylococcus aureus, Bacillus
cereus or Clostridium perfringens.
Stereotypical histories:
Infection Typical presentation
Escherichia coli Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis Prolonged, non-bloody diarrhoea
Cholera Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers
Shigella Bloody diarrhoea
Vomiting and abdominal pain
Staphylococcus
aureus
Severe vomiting
Short incubation period
Campylobacter A flu-like prodrome is usually followed by crampy
abdominal pains, fever and diarrhoea which may be
bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome
Bacillus cereus Two types of illness are seen
• vomiting within 6 hours, stereotypically due to
rice
• diarrhoeal illness occurring after 6 hours
Amoebiasis Gradual onset bloody diarrhoea, abdominal pain and
tenderness which may last for several weeks

Q-177
Following a diagnosis of tetanus, what is the most
appropriate antibiotic therapy to give with human tetanus
immunoglobulin?
A. IV clarithromycin
B. IV benzylpenicillin
C. IV gentamicin
D. IV metronidazole
E. IV ciprofloxacin
ANSWER:
D. IV metronidazole
EXPLANATION:
Tetanus
Tetanus is caused by the tetanospasmin exotoxin released
from Clostridium tetani. Tetanus spores are present in soil and
may be introduced into the body from a wound, which is
often unnoticed. Tetanospasmin prevents release of GABA
Features
• prodrome fever, lethargy, headache
• trismus (lockjaw)
• risus sardonicus
• opisthotonus (arched back, hyperextended neck)
• spasms (e.g. dysphagia)
Management
• supportive therapy including ventilatory support and
muscle relaxants
• intramuscular human tetanus immunoglobulin for
high-risk wounds (e.g. compound fractures, delayed
surgical intervention, significant degree of devitalised
tissue)
• metronidazole is now preferred to benzylpenicillin as
the antibiotic of choice

Q-178
A 37-year-old sewer worker presents to the Emergency
Department with flu-like symptoms and pyrexia for the past
3 days. Since this morning he has started to develop a
headache and signs of meningism are found on examination.
Blood tests show:
Sodium 145 mmol/l
Potassium 4.7 mmol/l
Urea 10.3 mmol/l
Creatinine 133 µmol/l
What is the antibiotic treatment of choice?
A. Co-trimoxazole
B. CiprofloxacinC. Metronidazole
D. Benzylpenicillin
E. Erythromycin
ANSWER:
D. Benzylpenicillin
EXPLANATION:
Leptospirosis - give penicillin or doxycycline
This patient has leptospirosis. The treatment of choice
is benzylpenicillin. A lumbar puncture should ideally
be done first to confirm meningeal involvement.
Leptospirosis
Also known as Weil's disease*, leptospirosis is commonly seen
in questions referring to sewage workers, farmers, vets or
people who work in abattoir. It is caused by the spirochaete
Leptospira interrogans (serogroup L icterohaemorrhagiae),
classically being spread by contact with infected rat urine.
Weil's disease should always be considered in high-risk
patients with hepatorenal failure
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
*the term Weil's disease is sometimes reserved for the most
severe 10% of cases that are associated with jaundice

Q-179
A 30-year-old woman presents with a white, malodorous
vaginal discharge. There is no associated itch or dyspareunia.
A diagnosis of bacterial vaginosis is suspected.
Overgrowth of which one of the following organisms is most
likely to cause this presentation?
A. Lactobacilli
B. Trichomonas
C. Candida
D. Mycoplasma hominis
E. Gardnerella
ANSWER:
E. Gardnerella
EXPLANATION:
Bacterial vaginosis - overgrowth of
predominately Gardnerella vaginalis
Bacterial vaginosis please see

Q-46

Q-180
A 7-year-old boy is admitted to hospital after presenting
with fever, headache and neck stiffness. A diagnosis of
pneumococcal meningitis is made. There are no other
reports of meningitis in the local area over the past 4 weeks.
How should the close contacts of this boy be managed?
A. No action is needed
B. Pneumococcal vaccine booster
C. Oral amoxicillin
D. Oral amoxicillin + pneumococcal vaccine booster
E. Oral ciprofloxacin
ANSWER:
A. No action is needed
EXPLANATION:
Carriage of pneumococcus is extremely common and no
antibiotic prophylaxis is generally required in this situation.
There are however exceptions to this if a 'cluster' of cases
develop - please the HPA link for more details.
Meningitis: management please see

Q-14

Q-181
A 62-year-old patient with type 2 diabetes mellitus presents
with a 'rash' on his left shin. This has grown in size over the
past two days and is now a painful, hot, erythematous area
on his anterior left shin spreading around to the back of the
leg. He is systemically well and a decision is made to give
oral treatment. He has a past history of penicillin allergy.
What is the most appropriate antibiotic to give?
A. Ciprofloxacin
B. Cefaclor
C. Flucloxacillin
D. Vancomycin
E. Clarithromycin
ANSWER:
E. Clarithromycin
EXPLANATION:
Cellulitis please see

Q-39

Q-182
A 25-year-old intravenous drug user with chronic hepatitis C
becomes pregnant. Approximately what is the chance of the
virus being transmitted to her child?A. <10%
B. 10-20%
C. 20-30%
D. 30-40%
E. 40-50%
ANSWER:
A. <10%
EXPLANATION:
Hepatitis C see

Q-6

Q-183
A 22-year-old woman who is an immigrant from Malawi
presents for review as she thinks she is pregnant. This is
confirmed with a positive pregnancy test. She is known to be
HIV positive. Which one of the following should NOT be part
of the management plan to ensure an optimal outcome?
A. Oral zidovudine for the newborn until 6 weeks of age
B. Maternal antiretroviral therapy
C. Encourage breast feeding
D. Intrapartum zidovudine infusion
E. Elective caesarean section
ANSWER:
C. Encourage breast feeding
EXPLANATION:
The BHIVA guidelines suggest vaginal delivery may be an
option for women on HAART who have an undetectable viral
load but whether this will translate into clinical practice
remains to be seen
In terms of breastfeeding the BHIVA guidelines state the
following:
All mothers known to be HIV positive, regardless of
antiretroviral therapy, and infant PEP,
should be advised to exclusively formula feed from birth.
HIV and pregnancy see

Q-85

Q-184
An 18-year-old male is admitted with fever, headache and
neck stiffness. He receives IV ceftriaxone. A lumbar puncture
and culture of his cerebrospinal fluid reveal that the
pathogenic organism is Neisseria meningitides. What is the
appearance of this bacterium on gram staining?
A. Gram-positive cocci
B. Gram-negative cocci
C. Gram-positive rod
D. Gram-negative rod
E. Poorly staining organism
ANSWER:
B. Gram-negative cocci
EXPLANATION:
Neisseria gonorrhoeae - Gram-negative cocci
Neisseria species are gram-negative cocci. The bacteria
cluster together in pairs to form diplococci. Other important
gram-negative cocci include Moraxella catarrhalis and
Haemophilus influenza.
Interpretation of gram stains for the non-microbiologist
Barenfanger and Drake. Laboratory medicine. 2001, number
7, vol 3
Classification of bacteria see

Q-118

Q-185
A 30-year-old man presents for review two weeks after
returning from a camping holiday in the New Forest. For the
past few days he has felt general unwell with lethargy and
arthralgia. On examination he has a rash consistent with
erythema chronicum migrans. What is the most appropriate
test to perform given the likely diagnosis?
A. ELISA test for antibodies to Borrelia burgdorferi
B. Polymerase chain reaction for Borrelia DNA
C. Blood cultures
D. Blood film
E. Bone marrow biopsy
ANSWER:
A. ELISA test for antibodies to Borrelia burgdorferi
EXPLANATION:
Serological tests are the most appropriate first line
investigation for diagnosing Lyme disease. ELISA tests are
preferred to Western blots as they are more sensitive.
Lyme disease see

Q-35Lyme disease

Q-186
Which of the following types of viral meningitis may be
characteristically associated with a low cerebrospinal fluid
glucose level?
A. Mumps
B. Cytomegalovirus
C. Measles
D. HIV
E. Echovirus
ANSWER:
A. Mumps
EXPLANATION:
Mumps meningitis is associated with a low CSF glucoseMumps meningitis is associated
with a low glucose in up to a
third of patients
Meningitis: CSF analysis see

Q-2
Q-187
A 19-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?
A. Fitz-Hugh-Curtis syndrome
B. Cervical cancer
C. Arthropathy
D. Infertility
E. Uterine abscess
ANSWER:
D. Infertility
EXPLANATION:
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. FitzHughCurtis syndrome (a
complication of PID) and
arthropathy may occur but are far less common.
Lymphogranuloma venereum is caused by Chlamydia
trachomatis.
Gonorrhoea please see

Q-37

Q-188
A 44-year-old man who is known to have HIV is admitted to
the Emergency Department following a seizure. He has been
taking antiretroviral therapy for the past two years. A CT
scan (without contrast) shows a solitary lesion in the basal
ganglia. What is the most effective method to help
differentiate between lymphoma and toxoplasmosis?
A. MR spectroscopy
B. CT with contrast
C. Thallium SPECT
D. Peripheral blood film
E. Lumbar puncture
ANSWER:
C. Thallium SPECT
EXPLANATION:
Differentiating between toxoplasmosis and lymphoma is an
important aspect of managing neurocomplications relating
to HIV. Given the more limited availablity of SPECT compared
to CT many patients are treated empirically on the basis of
scoring systems, for example there is a 90% likelihood of
toxoplasmosis if all of the following criteria are met:
• toxoplasmosis IgG in the serum
• CD4 < 100 and not receiving prophylaxis for
toxoplasmosis
• multiple ring enhancing lesions on CT or MRI
HIV: neurocomplications see

Q-34

Q-189
A 33-year-old is investigated for lethargy. The full blood
count is reported as follows:
Hb 10.1 g/dl
Plt 156 * 109/l
WBC 3.7 * 109/l
His daughter was unwell one week previously with a pyrexial
illness associated with a red rash on her cheeks. What is the
most likely cause?
A. Measles
B. Coxsackie a16
C. Group A haemolytic streptococci
D. Parvovirus B19
E. HHV-6 (Human Herpesvirus-6)
ANSWER:
D. Parvovirus B19
EXPLANATION:
Parvovirus B19
Parvovirus B19 is a DNA virus which causes a variety of clinical
presentations. It was identified in the 1980's as the cause of
erythema infectiosum
Erythema infectiosum (also known as fifth disease or
'slapped-cheek syndrome')
The illness may consist of a mild feverish illness which is
hardly noticeable. However, in others there is a noticeable
rash which appears after a few days. The rose-red rash makes
the cheeks appear bright red, hence the name ‘slapped cheek
syndrome’. The rash may spread to the rest of the body but
unlike many other rashes, it only rarely involves the palms and
soles.
The child begins to feel better as the rash appears and the
rash usually peaks after a week and then fades. The rash is
unusual in that for some months afterwards, a warm bath,
sunlight, heat or fever will trigger a recurrence of the bright
red cheeks and the rash itself. Most children recover and need
no specific treatment. In adults, the virus may cause acute
[Link] aware that the virus can affect an unborn baby in the first
20 weeks of pregnancy. If a woman is exposed early in
pregnancy (before 20 weeks) she should seek prompt advice
from whoever is giving her antenatal care.
It is spread by the respiratory route and a person is infectious
3 to 5 days before the appearance of the rash. Children are no
longer infectious once the rash appears and there is no
specific treatment.
The child need not be excluded from school as they are no
longer infectious by the time the rash occurs.
Other presentations
Other presentations include:
• asymptomatic
• pancytopaenia in immunosuppressed patients
• aplastic crises e.g. in sickle-cell disease (parvovirus
B19 suppresses erythropoiesis for about a week so
aplastic anaemia is rare unless there is a chronic
haemolytic anaemia)

Q-190
A 34-year-old female is admitted to hospital with fever,
rigors and myalgia. She reports being bitten by her rabbit 4
days prior.
On examination, you notice an ulcer around the site of the
bite with tender regional lymphadenopathy. On closer
inspection of the lymph nodes, you notice pus coming out
from them.
Blood tests reveal:
Hb 119 g/l
Platelets 153 * 109/l
WBC 12.4 * 109/l
Na+ 128 mmol/l
K+ 3.7 mmol/l
Urea 11.3 mmol/l
Creatinine 187 mol/l
Bilirubin30 mol/l
ALP 85 u/l
ALT 111 u/l
Albumin37 g/l
Creatine kinase 831 iu/L
What is the most likely diagnosis?
A. Legionella
B. Mycoplasma pneumonia
C. Tularaemia
D. Psittacosis
E. Leptospirosis
ANSWER:
C. Tularaemia
EXPLANATION:
Tularaemia is a zoonotic infection involving the
microorganism F. tularensis commonly transmitted through
lagomorphs such as rabbits, hares and pikas but also in
aquatic rodents - beavers and muskrat - and ticks. It can
present in a variety of forms. Commonly, it produces an
erythematous papulo-ulcerative lesion at the site of the bite
with reactive and ulcerating regional lymphadenopathy. It is
treated with antibiotics such as doxycycline.
Psittacosis, legionella and mycoplasma tend to present with
an atypical pneumonic pattern. Leptospirosis is associated
with contact with vermin and can present with liver
involvement associated with thrombocytopaenia and an
acute kidney injury which is not mentioned here.
Animal bites
The majority of bites seen in everyday practice involve dogs
and cats. These are generally polymicrobial but the most
common isolated organism is Pasteurella multocida.
Management
• cleanse wound
• current BNF recommendation is co-amoxiclav
• if penicillin-allergic then doxycycline + metronidazole
is recommended

Q-191
A 48-year-old man with a past medical history of poorly
controlled HIV is admitted with shortness of breath. He also
complains of haemoptysis. Imaging and blood tests confirm a
diagnosis of invasive aspergillosis. He is treated with
amphotericin B.
What is the mechanism of action of amphotericin B?
A. Inhibits DNA polymerase
B. Converted to to 5-fluorouracil
C. Binds with ergosterol
D. Inhibits synthesis of beta-glucan
E. Interacts with microtubules to disrupt mitotic spindle
ANSWER:
C. Binds with ergosterol
EXPLANATION:
Amphotericin B binds with ergosterol, a component of fungal
cell membranes, forming pores that cause lysis of the cell
wall and subsequent fungal cell death
Amphotericin B binds with ergosterol, a component of fungal
cell membranes, forming pores that cause lysis of the cell
wall and subsequent fungal cell death.
Flucytosine is converted by cytosine deaminase to 5-
fluorouracil, which inhibits thymidylate synthase anddisrupts fungal protein
synthesis.
Caspofungin inhibits synthesis of beta-glucan, a major fungal
cell wall component.
Griseofulvin interacts with microtubules to disrupt mitotic
spindle.
Anti viral agents such as aciclovir inhibit viral DNA
polymerase
Antifungal agents see

Q-154

Q-192
A 20-year-old student presents complaining of multiple
painful ulcers on the shaft of his penis. He tells you he has
had a new sexual partner recently but she has not reported
any symptoms. He feels generally unwell and had tender
enlarged inguinal lymph nodes bilaterally. He denies urethral
discharge or dysuria.
What is the most likely diagnosis?
A. Behcets syndrome
B. Herpes simplex
C. Syphilis
D. Lymphogranuloma venereum
E. Donovanosis
ANSWER:
B. Herpes simplex
EXPLANATION:
Syphilis, Lymphogranuloma venereum (LGV) and
donovanosis (granuloma inguinal) all cause painless genital
ulcers. Behcets may cause painful genital ulcers but herpes
simplex is more likely given the recent change in sexual
partner and the lack of other symptoms.
STI: ulcers
Genital herpes is most often caused by the herpes simplex
virus (HSV) type 2 (cold sores are usually due to HSV type 1).
Primary attacks are often severe and associated with fever
whilst subsequent attacks are generally less severe and
localised to one site. There is typically multiple painful ulcers.
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. A painless
ulcer(chancre) is seen in the primary stage. The incubation
period= 9-90 days.
Chancroid is a tropical disease caused by Haemophilus
ducreyi. It causes painful genital ulcers associated with
unilateral, painful inguinal lymph node enlargement. The
ulcers typically have a sharply defined, ragged, undermined
border.
Lymphogranuloma venereum (LGV) is caused by Chlamydia
trachomatis. Typically infection comprises of three stages
• stage 1: small painless pustule which later forms an
ulcer
• stage 2: painful inguinal lymphadenopathy
• stage 3: proctocolitis
LGV is treated using doxycycline.
Other causes of genital ulcers
• Behcet's disease
• carcinoma
• granuloma inguinale: Klebsiella granulomatis*
*previously called Calymmatobacterium granulomatis

Q-193
A 29-year-old HIV positive man is admitted with right-sided
hemiplegia. For the past four days he has been complaining
of headache and flu-like symptoms. CT scan shows multiple
ring enhancing lesions. A diagnosis of cerebral toxoplasmosis
is suspected. What is the most suitable management?
A. Artemether and lumefantrine
B. Co-trimoxazole
C. Supportive treatment
D. Pyrimethamine and sulphadiazine
E. Metronidazole and gentamicin
ANSWER:
D. Pyrimethamine and sulphadiazine
EXPLANATION:
Toxoplasmosis
Toxoplasma gondii is a protozoa which infects the body via
the GI tract, lung or broken skin. It's oocysts release
trophozoites which migrate widely around the body including
to the eye, brain and muscle. The usual animal reservoir is the
cat, although other animals such as rats carry the disease.
Most infections are asymptomatic. Symptomatic patients
usually have a self-limiting infection, often having clinical
features resembling infectious mononucleosis (fever, malaise,
lymphadenopathy). Other less common manifestations
include meningioencephalitis and myocarditis.
Investigation
• antibody test
• Sabin-Feldman dye test
Treatment is usually reserved for those with severe infectionsor patients who are
immunosuppressed
• pyrimethamine plus sulphadiazine for at least 6
weeks
Congenital toxoplasmosis is due to transplacental spread from
the mother. It causes a variety of effects to the unborn child
including microcephaly, hydrocephalus, cerebral calcification
and choroidoretinitis.

Q-194
A 19-year-old student is brought to the Emergency
Department by friends due to a severe headache and
drowsiness. On examination he has a widespread purpuric
rash. Meningococcal infection is strongly suspected but he is
known to be penicillin allergic (previous anaphylaxis). What
is the antibiotic of choice?
A. Chloramphenicol
B. Meropenem
C. Teicoplanin
D. Erythromycin
E. Ciprofloxacin
ANSWER:
A. Chloramphenicol
EXPLANATION:
Meningitis: management see

Q-14

Q-195
A 54-year-old homosexual man presents to the emergency
department with fever and malaise 24 hours after being
treated for syphilis with intramuscular benzathine penicillin
in his local GUM clinic. He has a florid maculopapular rash
over his arms, legs and torso which he tells you has been
present for the last 2 weeks. The patient informs you he has
no sexual contacts for the last 2 months and his last HIV test
was performed 3 days ago when he tested positive for
syphilis and was negative. Observations are normal and
there are no other findings on systemic examination.
What would be the most appropriate response to this
presentation?
A. Repeat HIV test, viral load and CD4 count
B. Admit for CT head, lumbar puncture and observation
C. Reassure the patient and discharge him
D. Repeat syphilis serology and repeat treatment if this is
positive
E. Refer to dermatology for outpatient biopsy
ANSWER:
C. Reassure the patient and discharge him
EXPLANATION:
The Jarisch-Herxheimer reaction is a known
phenomenon following syphilis treatment that does
not require any specific treatment or investigations
A flu-like reaction, known as the Jarisch-Herxheimer
reaction, is a known phenomenon following syphilis
treatment with Benzathine penicillin that is usually self
limiting to 24-48 hours that it is important to inform
patients about prior to treatment. As examination was
normal and there is no history of neurological symptoms
there is no need to investigate for neurosyphilis. Syphilis
serology will very likely still be positive 1 day after
treatment and there is no indication to repeat this.
Syphilis: management
Management
• intramuscular benzathine penicillin is the firstline management
• alternatives: doxycycline
• the Jarisch-Herxheimer reaction is sometimes
seen following treatment. Fever, rash, tachycardia
after first dose of antibiotic. It is thought to be
due to the release of endotoxins following
bacterial death and typically occurs within a few
hours of treatment.

Q-196
A 27-year-old male presents with malaise, pyrexia,
lymphadenopathy and a maculopapular rash. The Monospot
test is negative. Given a history of high-risk sexual behaviour
you are asked to exclude a HIV seroconversion illness. What
is the most appropriate investigation?
A. Antibodies to HIV-2
B. gp120 polymerase chain reaction
C. p24 antigen test
D. CCR5 polymerase chain reaction
E. Antibodies to HIV-1
ANSWER:
C. p24 antigen test
EXPLANATION:
HIV: seroconversion see

Q-76

Q-197
A 93-year-old woman is seen on the acute ward round with
refractory Clostridium difficile infection. She has already
received 2 weeks of oral metronidazole, oral vancomycin
and intravenous [Link] of the following may be implemented as the next
line
of management?
A. Probiotics
B. IV Vancomycin
C. Fidaxomicin
D. Meropenem
E. IV Immunoglobulins (IVIg)
ANSWER:
C. Fidaxomicin
EXPLANATION:
Fidaxomicin is used for Clostridium
difficile infections that don't respond to
metronidazole/vancomycin
Fidaxomicin is a new antibiotic that is useful
for Clostridium difficileinfections. It has a relatively narrow
spectrum and may even reduce likelihood of recurrence,
compared to oral vancomycin alone.
IV vancomycin has no role in Clostridium
difficile infections. Probiotics have no valuable evidence
at present and IVIg has some evidence and can be used
as a very last line. Meropenem may, if anything, worsen
the situation.
Clostridium difficile
Clostridium difficile is a Gram positive rod often encountered
in hospital practice. In the UK it can be found in 3% of normal
adults and up to 66% of babies. It produces an exotoxin which
causes intestinal damage leading to a syndrome called
pseudomembranous colitis.
Risk factors
• Broad spectrum antibiotics
• Use of PPI and H2 receptor antagonists
• Contacted with persons infected with [Link]
Features
• Diarrhoea
• Abdominal pain
• A raised white blood cell count is characteristic
• If severe, toxic megacolon may develop
Diagnosis is made by detecting Clostridium difficile toxin (CDT)
in the stool
Management
• First-line therapy is oral metronidazole for 10-14 days
• If severe, or not responding to metronidazole, then
oral vancomycin may be used
• Patients who do not respond to vancomycin may
respond to oral fidaxomicin
• Patients with severe and unremitting colitis should
be considered for colectomy

Q-198
A 63-year-old man who migrated from India 7 months ago is
referred to the acute medical unit with a history of headache
and pyrexia. A lumbar puncture suggests a diagnosis of
meningeal tuberculosis. What treatment should he be
started on?
A. Rifampicin, isoniazid, pyrazinamide and ethambutol
B. Rifampicin and streptomycin
C. Rifampicin, isoniazid, pyrazinamide, ethambutol and
streptomycin
D. Rifampicin and isoniazid with prednisolone
E. Rifampicin, isoniazid, pyrazinamide and ethambutol with prednisolone
ANSWER:
A. Rifampicin, isoniazid, pyrazinamide and ethambutol
EXPLANATION:
The use of steroids in patients with tuberculous meningitis is
supported by a Cochrane review in 2008
Tuberculosis: drug therapy
The standard therapy for treating active tuberculosis is:
Initial phase - first 2 months (RIPE)
• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol (the 2006 NICE guidelines now
recommend giving a 'fourth drug' such as ethambutol
routinely - previously this was only added if drugresistant tuberculosis was
suspected)
Continuation phase - next 4 months
• Rifampicin
• Isoniazid
The treatment for latent tuberculosis is 3 months of isoniazid
(with pyridoxine) and rifampicin OR 6 months of isoniazid
(with pyridoxine)
Patients with meningeal tuberculosis are treated for a
prolonged period (at least 12 months) with the addition of
steroidsDirectly observed therapy with a three times a week dosing
regimen may be
indicated in certain groups, including:
• homeless people with active tuberculosis
• patients who are likely to have poor concordance
• all prisoners with active or latent tuberculosis

Q-199
A 38-year-old man who has recently emigrated from eastern
Europe presents to Emergency Department one hour after
sustaining a 4 cm laceration to the dorsum of his left hand.
He works as a builder and sustained the laceration after
cutting into a cardboard box using a Stanley knife.
On examining the wound there is no sign of a foreign body
or neurovascular deficit. He is referred to Plastics for
apposition of the wound.
You ask him about his tetanus vaccination status. He has 'no
idea' but can remember getting some vaccinations as a child.
What is the most appropriate action with respect to tetanus?
A. Requires human tetanus immunoglobulin + tetanus
vaccine + complete vaccine course at a later date
B. Requires tetanus vaccine + complete vaccine course at a later date
C. Requires human tetanus immunoglobulin
D. No action required
E. Requires tetanus vaccine + oral penicillin V prophylaxis
for one week
ANSWER:
B. Requires tetanus vaccine + complete vaccine course at a later date
EXPLANATION:
This wound is not high risk for tetanus. The Greenbook would
however recommend that we vaccinate against tetanus in
this situation. His immunisation status is unknown and it is
therefore prudent to reduce his risk of developing tetanus in
future by ensuring he has a complete course of tetanus
vaccination.
Tetanus: vaccination
The tetanus vaccine is a cell-free purified toxin that is
normally given as part of a combined vaccine.
Tetanus vaccine is currently given in the UK as part of the
routine immunisation schedule at:
• 2 months
• 3 months
• 4 months
• 3-5 years
• 13-18 years
This therefore provides 5 doses of tetanus-containing
vaccine. Five doses is now considered to provide adequate
long-term protection against tetanus.
Intramuscular human tetanus immunoglobulin should be
given to patients with high-risk wounds (e.g. Compound
fractures, delayed surgical intervention, significant degree of
devitalised tissue) irrespective of whether 5 doses of tetanus
vaccine have previously been given
If vaccination history is incomplete or unknown then a dose
of tetanus vaccine should be given combined with
intramuscular human tetanus immunoglobulin for high-risk
wounds

Q-200
A 37-year-old immigrant from Bolivia is admitted to the
Emergency Department following a collapse. He is known to
have a history of Chagas' disease. Which one of the following
complications of Chagas' disease accounts for the majority of
mortality in affected patients?
A. Large bowel perforation secondary to megacolon
B. Myocarditis
C. Perinephric abscess
D. Meningoencephalitis
E. Pulmonary haemorrhage
ANSWER:
B. Myocarditis
EXPLANATION:
Cardiac involvement is the leading cause of death in patients
with Chagas' disease
Trypanosomiasis see
Q-1

Q-201
A 58-year-old man presents with fever, chills and back pain
for the past four weeks. A chest x-ray and urine culture are
unremarkable. Around two months ago he went to stay with
family on a Cypriot sheep farm. A chest x-ray and urine
culture are unremarkable. A diagnosis of Brucellosis is
suspected. Which one of the following tests is most likely to
confirm the diagnosis?
A. Stool culture
B. Blood cultures
C. Brucella serology
D. Liver biopsy
E. Urinary antigen
ANSWER:
C. Brucella serology
EXPLANATION:
Brucellosis
Brucellosis is a zoonosis more common in the Middle East and
in farmers. Four major species cause infection in humans: B
melitensis (sheep), B abortus (cattle), B canis and B suis (pigs).
Brucellosis has an incubation period 2 - 6 weeks
Features
• non-specific: fever, malaise
• hepatosplenomegaly
• sacroilitis: spinal tenderness may be seen
• complications: osteomyelitis, infective endocarditis,
meningoencephalitis, orchitis
• leukopenia often seen
Diagnosis
• the Rose Bengal plate test can be used for screening
but other tests are required to confirm the diagnosis
• Brucella serology is the best test for diagnosis
• blood and bone marrow cultures may be suitable in
certain patients, but these tests are often negative
Management
• doxycycline and streptomycin

Q-202
A 30-year-old man presents to the acute medical receiving
ward, one week after returning from Tanzania. He has
developed a high fever, 38.9, which started abruptly,
headache and generalised severe joint pain preventing him
from walking. You note his finger looks swollen. There is no
rash. He has been taking his anti-malarial pills. His blood
results are as follows:
Hb 160 g/l
Platelets 300 * 109/l
WBC 6 * 109/l
A. Septic arthritis
B. Malaria
C. Chikungunya
D. Zika
E. Dengue
ANSWER:
C. Chikungunya
EXPLANATION:
Severe joint pain and high fever point to chikungunya after
return from Africa. The absence of a rash makes chikungunya
more likely than dengue. In addition, a feature which points
to chikungunya is the severe joint pain which is often
debilitating and normal blood results (with dengue in some
cases there are low platelets). Zika is not as common in
Africa and tends to produce milder symptoms including lowgrade fever (most cases
are in South America). Malaria is
less likely as he was taking his anti-malarial pills, in addition,
joint swelling is not a feature of malaria. Septic arthritis
more commonly affects one joint at a time were as this man
has generalised severe joint pain.
Chikungunya
Alphavirus disease caused by infected mosquitoes. Areas
affected are Africa, Asia and Indian subcontinent but in recent
years there has been seen in a few cases in Southern Europe.
Tanzania had the first reported case.
Symptoms: Prominent symptoms are severe joint pain and
abrupt onset of high fever. Other symptoms include general
flu-like illness of muscle ache, headache, and fatigue. The
disease shares its symptoms with dengue but tends to have
more joint pain which can be debilitating. A rash may develop
as with other viral illness and swelling of the joints in not
uncommon.
Treatment: Relief of symptoms. No specific treatment.

Q-203
A 19-year-old man presents with a 12-hour history of a
headache and fever. On examination, you elicit neck
stiffness, photophobia and a positive Kernig's sign. He scores
15 on the Glasgow Coma Scale (GCS) and there has been no
change in behaviour and there is no evidence of raised
intracranial pressure. He is haemodynamically stable and
there is no rash.
Blood cultures are taken and a lumbar puncture is
performed. You decide to treat empirically for bacterial
meningitis and prescribe intravenous cefotaxime every 6
hours.
Which of the following is most appropriate in addition to
intravenous cefotaxime?
A. Give intravenous aciclovir
B. Give intravenous dexamethasone with the first
antibiotic dose and continue every 6 hours
C. Give intravenous dexamethasone with the first antibiotic dose only
D. Await the cerebrospinal fluid results and prescribe
intravenous dexamethasone only if Streptococcus
pneumoniae is isolated
E. Give intravenous amoxicillin
ANSWER:
C. Give intravenous dexamethasone with the first antibiotic dose only
EXPLANATION: Corticosteroids (dexamethasone) should be given as an adjunct to
prevent neurological sequelae
1: Aciclovir should be given if herpes simplex encephalitis is
suspected, based on reduced consciousness or change in
behaviour or cognition. These features are not present and
so aciclovir is not indicated.
2: This is the correct answer. Intravenous dexamethasone
should be given prior to or with the first dose of antibiotic to
reduce the risk of neurological sequelae by reducing
cerebrospinal inflammation. If pneumococcal meningitis is
suspected or confirmed from clinical features, cerebrospinal
fluid parameters or culture results, then dexamethasone
should be continued for 4 days. It should be stopped if
another causative organism is strongly suspected or
confirmed.
3: Dexamethasone should be continued until investigation
results suggest an alternative organism to Streptococcus
pneumoniae .
4: Dexamethasone should be given with the first dose of
antibiotic to reduce the risk of neurological sequelae.
5: Amoxicillin is recommended in addition to cefotaxime in
the empirical treatment of patients <3 months old or >50
years old.
Meningitis:
management
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
Management
All patients should be transferred to hospital urgently. If
patients are in a pre-hospital setting (for example a GP
surgery) and meningococcal disease is suspected then
intramuscular benzylpenicillin may be given, as long as this
doesn't delay transit to hospital.
BNF recommendations on antibiotics
Scenario BNF recommendation
Initial empirical therapy aged < 3
months
Intravenous cefotaxime +
amoxicillin
Initial empirical therapy aged 3 months
- 50 years
Intravenous cefotaxime*
Initial empirical therapy aged > 50 years Intravenous cefotaxime +
amoxicillin
Meningococcal meningitis Intravenous benzylpenicillin or
cefotaxime
Pneuomococcal meningitis Intravenous cefotaxime
Meningitis caused by Haemophilus
influenzae
Intravenous cefotaxime
Meningitis caused by Listeria Intravenous amoxicillin +
gentamicin
If the patient has a history of immediate hypersensitivity
reaction to penicillin or to cephalosporins the BNF
recommends using chloramphenicol.
Management of contacts
• prophylaxis needs to be offered to household and
close contacts of patients affected with
meningococcal meningitis
• oral ciprofloxacin or rifampicin or may be used. The
Health Protection Agency (HPA) guidelines now state
that whilst either may be used ciprofloxacin is the
drug of choice as it is widely available and only
requires one dose
• the risk is highest in the first 7 days but persists for at
least 4 weeks
• meningococcal vaccination should be offered to close
contacts when serotype results are available,
including booster doses to those who had the vaccine
in infancy
• for pneumococcal meninigitis no prophylaxis is
generally needed. There are however exceptions to
this. If a cluster of cases of pneumococcal meninigitis
occur the HPA have a protocol for offering close
contacts antibiotic prophylaxis. Please see the link for
more details
*in the 2015 update of the NICE Meningitis (bacterial) and
meningococcal septicaemia in under 16s: recognition,
diagnosis and management the recommendation for initial
empiracally therapy for children > than 3 months is
intravenous ceftriaxone

Q-204
A 22-year-old woman presents with lethargy, pyrexia and
headaches. She is a student and returned from a holiday in
Ibiza ten days ago. These symptoms have been present for
the past six days and she is wondering whether she may
need an antibiotic. She also has a history of menorrhagia andis concerned that she
may be anaemic. Clinical examination
reveals a temperature of 37.9ºC and marked cervical
lymphadenopathy. You order a full blood count which is
reported as follows:
Hb 12.1 g/dl
Platelets 189 * 109/l
WCC 13.1 * 109/l
Neutrophils 5.2 * 109/l
Lymphocytes 6.2 * 109/l
Film Atypical lymphocytes seen
What is the most likely diagnosis?
A. Acute lymphoblastic leukaemia
B. Hashimoto's thyroiditis
C. Infectious mononucleosis
D. HIV seroconversion
E. Septicaemia secondary to streptococcal throat infection
ANSWER:
C. Infectious mononucleosis
EXPLANATION:
Atypical lymphocytes - ?glandular fever
Infectious mononucleosis
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
Other features include:
• malaise, anorexia, headache
• palatal petechiae
• splenomegaly - occurs in around 50% of patients and
may rarely predispose to splenic rupture
• hepatitis, transient rise in ALT
• lymphocytosis: presence of 50% lymphocytes with at
least 10% atypical lymphocytes
• haemolytic anaemia secondary to cold agglutins
(IgM)
• a maculopapular, pruritic rash develops in around
99% of patients who take ampicillin/amoxicillin whilst
they have infectious mononucleosis
Symptoms typically resolve after 2-4 weeks.
Diagnosis
• heterophil antibody test (Monospot test) - NICE
guidelines suggest FBC and Monospot in the 2nd
week of the illness to confirm a diagnosis of glandular
fever.
Management is supportive and includes:
• rest during the early stages, drink plenty of fluid,
avoid alcohol
• simple analgesia for any aches or pains
• consensus guidance in the UK is to avoid playing
contact sports for 8 weeks after having glandular
fever to reduce the risk of splenic rupture
There is an interesting correlation between EBV and
socioeconomic groups. Lower socioeconomic groups have
high rates of EBV seropositivity, having frequently acquired
EBV in early childhood when the primary infection is often
subclinical. However, higher socioeconomic groups show a
higher incidence of infectious mononucleosis, as acquiring
EBV in adolescence or early adulthood results in symptomatic
disease.

Q-205
A 43-year-old man from Sierra Leone presents with a flu-like
illness. On examination he has very large posterior cervical
lymph nodes. A diagnosis of African trypanosomiasis is
confirmed on blood smear. What is the most appropriate
treatment?
A. Atovaquone-proguanil
B. Sodium stibogluconate
C. Benznidazole
D. Metronidazole
E. Pentamidine
ANSWER:
E. Pentamidine
EXPLANATION:
Trypanosomiasis
Two main form of this protozoal disease are recognised -
African trypanosomiasis (sleeping sickness) and American
trypanosomiasis (Chagas' disease)
Two forms of African trypanosomiasis, or sleeping sickness,
are seen - Trypanosoma gambiense in West Africa
and Trypanosoma rhodesiense in East Africa. Both types arespread by the tsetse fly.
Trypanosoma rhodesiense tends to
follow a more acute course. Clinical features include:
• Trypanosoma chancre - painless subcutaneous
nodule at site of infection
• intermittent fever
• enlargement of posterior cervical lymph nodes
• later: central nervous system involvement e.g.
somnolence, headaches, mood changes,
meningoencephalitis
Management
• early disease: IV pentamidine or suramin
• later disease or central nervous system involvement:
IV melarsoprol
American trypanosomiasis, or Chagas' disease, is caused by
the protozoan Trypanosoma cruzi. The vast majority of
patients (95%) are asymptomatic in the acute phase although
a chagoma (an erythematous nodule at site of infection) and
periorbital oedema are sometimes seen. Chronic Chagas'
disease mainly affects the heart and gastrointestinal tract
• myocarditis may lead to dilated cardiomyopathy
(with apical atophy) and arrhythmias
• gastrointestinal features includes megaoesophagus
and megacolon causing dysphagia and constipation
Management
• treatment is most effective in the acute phase using
azole or nitroderivatives such as benznidazole or
nifurtimox
• chronic disease management involves treating the
complications e.g., heart failure

Q-206
Which one of the following is a Gram negative coccus?
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Enterococcus faecalis
D. Listeria monocytogenes
E. Campylobacter jejuni
ANSWER:
B. Moraxella catarrhalis
EXPLANATION:
Moraxella catarrhalis - Gram-negative cocci
Classification of bacteria
Remember:
• Gram-positive cocci
= staphylococci + streptococci (including enterococci)
• Gram-negative cocci = Neisseria
meningitidis + Neisseria gonorrhoeae, also Moraxella
catarrhalis
Therefore, only a small list of Gram-positive rods (bacilli) need
to be memorised to categorise all bacteria - mnemonic =
ABCD L
• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenes
Remaining organisms are Gram-negative rods, e.g.:
• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Q-207
A 38-year-old man presents to the genitourinary clinic with
multiple, painless genital ulcers. A diagnosis of granuloma
inguinale is made. What is the causative organism?
A. Klebsiella granulomatis
B. Chlamydia
C. Herpes simplex virus
D. Treponema pallidum
E. Haemophilus ducreyi
ANSWER:
A. Klebsiella granulomatis
EXPLANATION:
Granuloma inguinale - Klebsiella granulomatis
STI: ulcers
Genital herpes is most often caused by the herpes simplex
virus (HSV) type 2 (cold sores are usually due to HSV type 1).
Primary attacks are often severe and associated with fever
whilst subsequent attacks are generally less severe and
localised to one site. There is typically multiple painful ulcers.
Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by
primary, secondary and tertiary stages. A painless
ulcer (chancre) is seen in the primary stage. The incubation
period= 9-90 days.
Chancroid is a tropical disease caused by Haemophilusducreyi. It causes painful
genital ulcers associated with
unilateral, painful inguinal lymph node enlargement. The
ulcers typically have a sharply defined, ragged, undermined
border.
Lymphogranuloma venereum (LGV) is caused by Chlamydia
trachomatis. Typically infection comprises of three stages
• stage 1: small painless pustule which later forms an
ulcer
• stage 2: painful inguinal lymphadenopathy
• stage 3: proctocolitis
LGV is treated using doxycycline.
Other causes of genital ulcers
• Behcet's disease
• carcinoma
• granuloma inguinale: Klebsiella granulomatis*
*previously called Calymmatobacterium granulomatis

Q-208
Which of the following antibiotics is predominately
bactericidal?
A. Trimethoprim
B. Erythromycin
C. Ciprofloxacin
D. Chloramphenicol
E. Minocycline
ANSWER:
C. Ciprofloxacin
EXPLANATION:
Antibiotics: bactericidal vs. bacteriostatic
Bactericidal antibiotics
• penicillins
• cephalosporins
• aminoglycosides
• nitrofurantoin
• metronidazole
• quinolones
• rifampicin
• isoniazid
Bacteriostatic antibiotics
• chloramphenicol
• macrolides
• tetracyclines
• sulphonamides
• trimethoprim

Q-209
A 53-year-old woman is diagnosed with left leg cellulitis. A
swab is taken and oral flucloxacillin is started. The following
result is obtained:
Skin swab: Group A Streptococcus
How should the antibiotic therapy be changed?
A. No change
B. Add topical fusidic acid
C. Add clindamycin
D. Switch to phenoxymethylpenicillin
E. Add erythromycin
ANSWER:
D. Switch to phenoxymethylpenicillin
EXPLANATION:
Penicillin is the antibiotic of choice for group A streptococcal
infections. The BNF suggests stopping flucloxacillin if
streptococcal infection is confirmed in patients with cellulitis,
due to the high sensitivity. This should be balanced however
with the variable absorption of phenoxymethylpenicillin.
Streptococci
Streptococci are gram-positive cocci. They may be divided into
alpha and beta haemolytic types
Alpha haemolytic streptococci (partial haemolysis)
The most important alpha
haemolytic Streptococcus is Streptococcus
pneumoniae (pneumococcus). Pneumococcus is a common
cause of pneumonia, meningitis and otitis media. Another
clinical example is Streptococcus viridans
Beta haemolytic streptococci (complete haemolysis)
These can be subdivided into groups A-H. Only groups A, B &
D are important in humans.
Group A
• most important organism is Streptococcus pyogenes
• responsible for erysipelas, impetigo, cellulitis, type 2
necrotizing fasciitis and pharyngitis/tonsillitis
• immunological reactions can cause rheumatic fever
or post-streptococcal glomerulonephritis
• erythrogenic toxins cause scarlet fever
Group B• Streptococcus agalactiae may lead to neonatal
meningitis and septicaemia
Group D
• Enterococcus
Group B streptococcus bacteria. Credit: NIAID
Q-210
Which of the following is least recognised as a cause of a
false positive VDRL test?
A. Pregnancy
B. SLE
C. Oral contraceptive pill
D. Tuberculosis
E. HIV
ANSWER:
C. Oral contraceptive pill
EXPLANATION:
Syphilis: investigation
Treponema pallidum is a very sensitive organism and cannot
be grown on artificial media. The diagnosis is therefore usually
based on clinical features, serology and microscopic
examination of infected tissue
Serological tests can be divided into
• cardiolipin tests (not treponeme specific)
• treponemal specific antibody tests
Cardiolipin tests
• syphilis infection leads to the production of nonspecific antibodies that react
to cardiolipin
• examples include VDRL (Venereal Disease Research
Laboratory) & RPR (rapid plasma reagin)
• insensitive in late syphilis
• becomes negative after treatment
Treponemal specific antibody tests
• example: TPHA (Treponema
pallidum HaemAgglutination test)
• remains positive after treatment
Causes of false positive cardiolipin tests
• pregnancy
• SLE, anti-phospholipid syndrome
• TB
• leprosy
• malaria
• HIVTreponema pallidum, the bacteria that cause syphilis. Note
the spiral shape of the organism. Credit: NIAID

Q-211
Which one of the following viruses is associated with
nasopharyngeal carcinoma?
A. Adenovirus
B. Rhinovirus
C. Herpes simplex virus
D. Epstein-Barr virus
E. Picornavirus
ANSWER:
D. Epstein-Barr virus
EXPLANATION:
EBV: associated malignancies:
• Burkitt's lymphoma
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
Epstein-Barr virus: associated conditions
Malignancies associated with EBV infection
• Burkitt's lymphoma*
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
• HIV-associated central nervous system lymphomas
The non-malignant condition hairy leukoplakia is also
associated with EBV infection.
*EBV is currently thought to be associated with both African
and sporadic Burkitt's

Q-212
A 38-year-old HIV-positive woman who is 38 weeks into her
first pregnancy comes to the obstetric clinic for review. She
has been compliant with medication and her viral load has
been consistently <50 copies. She would like to have a
vaginal delivery and is keen to breastfeed after the birth.
What would you advise her regarding breastfeeding?
A. She can breastfeed regardless of the viral load
B. Breastfeeding is not recommended
C. She can breastfeed as long as the baby is on the
neonatal antiretroviral therapy
D. She can breastfeed to a maximum of approximately
100ml a day
E. She can breastfeed as long as the viral load remains at
<50 copies
ANSWER:
B. Breastfeeding is not recommended
EXPLANATION:
In the UK all HIV positive women should be advised not to
breastfeed
In the UK all HIV positive women should be advised not to
breastfeed, hence only option 2 is correct. It is not advisable
to breastfeed regardless of the viral load, the amount of
breastfeeding or whether she or the baby is on the
antiretroviral therapy.
HIV and pregnancy
With the increased incidence of HIV infection amongst the
heterosexual population there are an increasing number of
HIV positive women giving birth in the UK. In London the
incidence may be as high as 0.4% of pregnant women. The
aim of treating HIV positive women during pregnancy is to
minimise harm to both the mother and fetus, and to reduce
the chance of vertical transmission.
Guidelines regularly change on this subject and most recent
guidelines can be found using the links [Link] which reduce vertical
transmission (from 25-30% to
2%)
• maternal antiretroviral therapy
• mode of delivery (caesarean section)
• neonatal antiretroviral therapy
• infant feeding (bottle feeding)
Screening
• NICE guidelines recommend offering HIV screening to
all pregnant women
Antiretroviral therapy
• all pregnant women should be offered antiretroviral
therapy regardless of whether they were taking it
previously
Mode of delivery
• vaginal delivery is recommended if viral load is less
than 50 copies/ml at 36 weeks, otherwise caesarian
section is recommended
• a zidovudine infusion should be started four hours
before beginning the caesarean section
Neonatal antiretroviral therapy
• zidovudine is usually administered orally to the
neonate if maternal viral load is <50 copies/ml.
Otherwise triple ART should be used. Therapy should
be continued for 4-6 weeks.
Infant feeding
• in the UK all women should be advised not to breast
feed

Q-213
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?
A. HTLV-1
B. HIV-2
C. HHV-8
D. CMV
E. HPV-8
ANSWER:
C. HHV-8
EXPLANATION:
Kaposi's sarcoma - caused by HHV-8 (human herpes virus 8)
HIV: Kaposi's 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
Kaposi's sarcoma in a patient with HIV

Q-214
A 67 year patient with known emphysema presents to the
Emergency Department with a two week history of cough
productive of blood stained sputum. Chest X-Ray shows a
circular area of dense right upper lobe consolidation. Despite
seven days of intravenous antibiotics (piperacillin and
tazobactam) his condition has not improved. An urgent
inpatient bronchoscopy reveals no endobronchial lesion but
broncho-alveolar lavage reveals an underlying pathogenic
organism. Ziehl-Nielson staining is negative. What organism
would you suspect?
A. Moraxella catarrhalis
B. Aspergillus fumigatus
C. Pseudomonas aeruginosa
D. Mycobacterium tuberculosis
E. Burkholderia cepacia
ANSWER:
B. Aspergillus fumigatus
EXPLANATION:
This patient is likely to have developed an aspergilloma in an
emphysematous cavity, which explains the lack of
improvement with broad spectrum intravenous antibiotics,haemoptysis and chest X-Ray
findings. Moraxella and
pseudomonas are usually sensitive to piperacillin +
tazobactam and do not classically cause clinical haemoptysis.
M. tuberculosis is unlikely given the negative Ziehl-Nielson
staining. Burkholderia is typically an infective organism in
cystic fibrosis patients, not those with emphysema.
Please see Q-50 for Aspergilloma

Q-215
Which one of the following is least associated with rabies?
A. Hydrophobia
B. Opisthotonus
C. Pyrexia
D. Headache
E. Hypersalivation
ANSWER:
B. Opisthotonus
EXPLANATION:
Opisthotonus is associated more with tetanus. It describes a
state of a hyperextension and spasticity in which a patient's
neck and spinal column enter into an arching position. It is
an extrapyramidal effect and is caused by spasm of the axial
muscles
Rabies
Rabies is a viral disease that causes an acute encephalitis. The
rabies virus is classed as a RNA rhabdovirus (specifically a
lyssavirus) and has a bullet-shaped capsid. The vast majority
of cases are caused by dog bites but it may also be
transmitted by bat, raccoon and skunk bites. Following a bite
the virus travels up the nerve axons towards the central
nervous system in a retrograde fashion.
Rabies is estimated to still kill around 25,000-50,000 people
across the world each year. The vast majority of the disease
burden falls on people in poor rural areas of Africa and Asia.
Children are particularly at risk.
Features
• prodrome: headache, fever, agitation
• hydrophobia: water-provoking muscle spasms
• hypersalivation
• Negri bodies: cytoplasmic inclusion bodies found in
infected neurons
There is now considered to be 'no risk' of developing rabies
following an animal bite in the UK and the majority of
developed countries. Following an animal bite in at-risk
countries:
• the wound should be washed
• if an individual is already immunised then 2 further
doses of vaccine should be given
• if not previously immunised then human rabies
immunoglobulin (HRIG) should be given along with a
full course of vaccination. If possible, the dose should
be administered locally around the wound
If untreated the disease is nearly always fatal.

Q-216
A 64-year-old man is admitted to the emergency department
as his wife is concerned that he is becoming confused
following a recent bad chest infection. She reports that he
has not improved after a course of amoxicillin.
On examination, his respiratory rate is 30/min, blood
pressure 88/60 mmHg, heart rate 120/min. Crackles are
noted on the right side of his chest.
What is the most appropriate fluid therapy to give?
A. 20 ml/kg stat
B. 30 ml/kg stat
C. 500ml stat
D. 20 ml/kg over 1 hour
E. 10 ml/kg over 1 hour
ANSWER:
C. 500ml stat
EXPLANATION:
This patient has a number of features of red flag sepsis,
including the confusion, low blood pressure and raised
respiratory rate. The sepsis 6 should be started.
In the NICE guidelines on sepsis the following
recommendations are made with regards to fluid
resuscitation:
If patients over 16 years need intravenous fluid resuscitation,
use crystalloids that contain sodium in the range 130–154
mmol/litre with a bolus of 500 ml over less than 15 minutes.
Sepsis
Sepsis is defined as life-threatening organ dysfunction caused
by a dysregulated host response to an infection. Sepsis is
increasingly recognised as an important cause of mortality in
the UK and there has been increasing efforts recently to
improve the care of patients who present with sepsis.
How sepsis is classified has changed in recent years - the
Surviving Sepsis Guidelines were updated in 2017.
The new guidelines recognise the following terms:
• sepsis: life-threatening organ dysfunction caused by
a dysregulated host response to infection• septic shock: a more severe form sepsis,
technically
defined as 'in which circulatory, cellular, and
metabolic abnormalities are associated with a
greater risk of mortality than with sepsis alone'*
The old category of severe sepsis is no longer used.
The term 'systemic inflammatory response syndrome (SIRS)'
has also fallen out of favour. Adult patients outside of ICU
with suspected infection are identified as being at heightened
risk of mortality if they have quickSOFA (qSOFA) score
meeting >= 2 of the following criteria: respiratory rate of
22/min or greater, altered mentation, or systolic blood
pressure of 100mmHg or less
Management
NICE released their own guidelines in 2016. These focussed on
the risk stratification and management of patients with
suspected.
For risk stratification NICE recommend using the following
criteria:
Red flag criteria Amber flag criteria
• Responds only to voice or pain/
unresponsive
• Acute confusional state
• Systolic B.P <= 90 mmHg (or drop
>40 from normal)
• Heart rate > 130 per minute
• Respiratory rate >= 25 per minute
• Needs oxygen to keep SpO2
>=92%
• Non-blanching rash, mottled/
ashen/ cyanotic
• Not passed urine in last 18 h/ UO <
0.5 ml/kg/hr
• Lactate >=2 mmol/l
• Recent chemotherapy
 Relatives concerned about
mental status
 Acute deterioration in
functional ability
 Immunosuppressed
 Trauma/ surgery/
procedure in last 6 weeks
 Respiratory rate 21-24
 Systolic B.P 91-100 mmHg
 Heart rate 91-130 OR new
dysrhythmia
 Not passed urine in last
12-18 hours
 Temperature < 36ºC
 Clinical signs of wound,
device or skin infection
Clearly the underlying cause of the patients sepsis needs to be
identified and treated and the patient supported regardless of
the cause or severity. If however any of the red flags are
present the '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
*these patients can be clinically identified by a vasopressor
requirement to maintain a MAP ≥ 65mmHg and serum lactate
>2mmol/L in the absence of hypovolemia

Q-217
A 25-year-old woman has recently moved to the United
Kingdom from sub-Saharan Africa to attend University. She
comes from an area where there is a high prevalence of
tuberculosis (TB). The patient is not pregnant and is currently
asymptomatic. She thinks she may have had a BCG
vaccination in the past but is not sure. She has no other
medical history and is a non-smoker.
Which test should initially be used to screen this lady for TB?
A. Mantoux test
B. Interferon gamma blood test
C. Early morning urine sample
D. Chest x-ray
E. Send three sputum samples
ANSWER:
A. Mantoux test
EXPLANATION:
The patient is asymptomatic so we can say she does not have
active TB. However, she may have latent TB. TB is not easily
caught and requires prolonged close contact. The recent NICE
guidelines state that the initial screening test is the Mantoux
test. The interpretation has also changed in the recent
guidelines. A diameter of 5 mm is considered positive
regardless of BCG history.
Changes on the chest x-ray cannot always differentiate
between active and latent TB.
Interferon gamma blood test is recommended if the
Mantoux test is positive.
An early morning urine sample is no longer recommended.
The patient is currently asymptomatic and therefore we
cannot collect sputum.
Tuberculosis: screening
The Mantoux test is the main technique used to screen for
latent tuberculosis. In recent years the interferon-gamma
blood test has also been introduced. It is used in a number of
specific situations such as:
• the Mantoux test is positive or equivocal
• people where a tuberculin test may be falsely
negative (see below)
Mantoux test• 0.1 ml of 1:1,000 purified protein derivative (PPD)
injected intradermally
• result read 2-3 days later
Diameter of
induration Positivity Interpretation
< 6mm Negative - no significant
hypersensitivity to
tuberculin protein
Previously unvaccinated
individuals may be given
the BCG
6 - 15mm Positive - hypersensitive to
tuberculin protein
Should not be given BCG.
May be due to previous TB
infection or BCG
> 15mm Strongly positive - strongly
hypersensitive to
tuberculin protein
Suggests tuberculosis
infection.
False negative tests may be caused by:
• miliary TB
• sarcoidosis
• HIV
• lymphoma
• very young age (e.g. < 6 months)
Heaf test
The Heaf test was previously used in the UK but has been
since been discontinued. It involved injection of PPD
equivalent to 100,000 units per ml to the skin over the flexor
surface of the left forearm. It was then read 3-10 days later.
Scanning electron micrograph of Mycobacterium tuberculosis
bacteria, which cause TB. Credit: NIAID

Q-218
Which one of the following conditions is not associated with
prior Epstein-Barr virus infection?
A. Hodgkin's lymphoma
B. Adult T-cell leukaemia
C. Burkitt's lymphoma
D. Nasopharyngeal carcinoma
E. Hairy leukoplakia
ANSWER:
B. Adult T-cell leukaemia
EXPLANATION:
EBV: associated malignancies:
• Burkitt's lymphoma
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
Adult T-cell leukaemia is associated with HTLV-1 infection
Epstein-Barr virus: associated conditions
Malignancies associated with EBV infection
• Burkitt's lymphoma*
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
• HIV-associated central nervous system lymphomas
The non-malignant condition hairy leukoplakia is also
associated with EBV infection.
*EBV is currently thought to be associated with both African
and sporadic Burkitt's

Q-219
A 75-year-old woman is admitted with confusion to the
Emergency Department. Her urine dipstick is positive for
nitrites and leucocytes and a diagnosis of urinary tract
infection is suspected. She is therefore prescribed a 7 day
course of trimethoprim. Bloods taken in the Emergency
Department are as follows:
Na+ 141 mmol/l
K+ 3.7 mmol/l
Urea 4.3 mmol/l
Creatinine 78 µmol/l
CRP 21 mg/l
Five days later on the ward her bloods are repeated:
Na+ 140 mmol/l
K+ 3.9 mmol/l
Urea 5.3 mmol/l
Creatinine 125 µmol/l
CRP 6 mg/lWhat is the most likely explanation for the change in renal
function?
A. Impaired renal function secondary to acute
pyelonephritis
B. Crystal-induced nephropathy secondary to trimethoprim
C. Trimethoprim competitively inhibiting the tubular secretion of creatinine
D. Interstitial nephritis secondary to trimethoprim
E. Spurious result due to plasma-bound trimethoprim
being confused with creatinine
ANSWER:
C. Trimethoprim competitively inhibiting the tubular secretion of creatinine
EXPLANATION:
The fall in CRP is not consistent with the development of
acute pyelonephritis
Trimethoprim
Trimethoprim is an antibiotic, mainly used in the management
of urinary tract infections.
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

Q-220
A 64-year-old gentleman with chronic obstructive pulmonary
disease presents to the GP with increasing dyspnoea. He is
febrile and gives a history of a cough productive of green
sputum over the last few days. You diagnose an infective
exacerbation of his underlying lung disease. After sending a
sputum sample you make the decision to start oral steroids
and appropriate antibiotics. On reviewing the results of the
sputum sample the lab has reported an initial culture of a
Gram-negative cocci. What is the most likely organism?
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Neisseria meningitidis
D. Pseudomonas aeruginosa
E. Streptococcus pneumoniae
ANSWER:
B. Moraxella catarrhalis
EXPLANATION:
Moraxella catarrhalis - Gram-negative cocci
Of all the available organisms
only Neisseria and Moraxella are Gram-negative
cocci. Neisseria meningitidis is not a common respiratory
pathogen and therefore the likely organism in this case
is Moraxella.
Moraxella catarrhalis is a Gram-negative coccus that is a
common cause of respiratory infections in patients with
underlying lung disease. It also commonly causes sinusitis
and middle ear infections.
Classification of bacteria
Remember:
• Gram-positive cocci
= staphylococci + streptococci (including enterococci)
• Gram-negative cocci = Neisseria
meningitidis + Neisseria gonorrhoeae, also Moraxella
catarrhalis
Therefore, only a small list of Gram-positive rods (bacilli) need
to be memorised to categorise all bacteria - mnemonic =
ABCD L
• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenes
Remaining organisms are Gram-negative rods, e.g.:
• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Q-221
A 31-year-old man is admitted to hospital with a 4 day
history of fever and dyspnoea. He is known to be HIV
positive but poorly compliant with his antiretroviral therapy
(ART). Bloods taken during a clinic visit two weeks ago show
the following:
CD4 180 cells/µl
On examination today his pulse is 102/min, oxygen
saturations 97% on room air with a temperature of 38.1ºC.
He has coarse crackles on the right side of his chest. A chest
x-ray shows consolidation of the right mid zone.
What is the most likely causative organism?A. Mycobacterium tuberculosis
B. Cryptococcus neoformans
C. Streptococcus pneumoniae
D. Pneumocystis jirovecii
E. Histoplasma capsulatum
ANSWER:
C. He has coarse crackles on the right side of his chest. A chest
x-ray shows consolidation of the right mid zone.
What is the most likely causative organism?A. Mycobacterium tuberculosis
EXPLANATION:
Whilst Pneumocystis jirovecii is of course associated with
HIV, patients who are immunocompromised are more likely
to develop infections due to the common pathogens which
affect immunocompetent individuals. Streptococcus
pneumoniae is therefore the most likely cause of communityacquired pneumonia in
this patient. Remember also
that Pneumocystis jirovecii tends to present in a different
way, with very few chest signs and bilateral interstitial
pulmonary infiltrates on chest x-ray.
Pneumonia: causes
Community acquired pneumonia (CAP) may be caused by the
following infectious agents:
• Streptococcus pneumoniae (accounts for around 80%
of cases)
• Haemophilus influenzae
• Staphylococcus aureus: commonly after the 'flu
• atypical pneumonias (e.g. Due to Mycoplasma
pneumoniae)
• viruses
Klebsiella pneumoniae is classically in alcoholics
Streptococcus pneumoniae (pneumococcus) is the most
common cause of community-acquired pneumonia
Characteristic features of pneumococcal pneumonia
• rapid onset
• high fever
• pleuritic chest pain
• herpes labialis

Q-222
A 24-year-old male attends the clinic for a yellow fever
vaccine before travelling to South America. He has no past
medical history and takes no regular medicines. He states
that he also had a varicella zoster vaccination a few weeks
ago.
What is the minimum interval required between the last
vaccination?
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks
E. 1 year
ANSWER:
D. 4 weeks
EXPLANATION:
Live vaccines given by injection may be either given
concomitantly or a minimum interval of 4 weeks apart to
prevent risk of immunological interference
Live vaccines can be given on the same day. If not given on
the same day, then there must be a 4 week interval between
further live vaccinations to prevent the risk of immunological
interference.
Vaccinations
It is important to be aware of vaccines which are of the liveattenuated type as
these may pose a risk to
immunocompromised patients. The main types of vaccine are
as follows:
Live attenuated
• BCG
• measles, mumps, rubella (MMR)
• influenza (intranasal)
• oral rotavirus
• oral polio
• yellow fever
• oral typhoid
Inactivated preparations
• rabies
• hepatitis A
• influenza (intramuscular)
Toxoid (inactivated toxin)
• tetanus
• diphtheria
• pertussis
Subunit and conjugate vaccines are often grouped together.
Subunit means that only part of the pathogen is used to
generate an immunogenic response. A conjugate vaccine is a
particular type that links the poorly immunogenic bacterial
polysaccharide outer coats to proteins to make them more
immunogenic
• pneumococcus (conjugate)
• haemophilus (conjugate)
• meningococcus (conjugate)• hepatitis B
• human papillomavirus
,
Notes
• influenza: different types are available, including
whole inactivated virus, split virion (virus particles
disrupted by detergent treatment) and sub-unit
(mainly haemagglutinin and neuraminidase)
• cholera: contains inactivated Inaba and Ogawa
strains of Vibrio cholerae together with recombinant
B-subunit of the cholera toxin
• hepatitis B: contains HBsAg adsorbed onto
aluminium hydroxide adjuvant and is prepared from
yeast cells using recombinant DNA technology

Q-223
A 50-year-old sewage worker presents with a one week
history of fever and feeling generally unwell. Which one of
the following features would be least consistent with a
diagnosis of leptospirosis?
A. Meningism
B. Conjunctival erythema
C. Productive cough
D. Decreased urine output
E. Severe myalgia
ANSWER:
C. Productive cough
EXPLANATION:
Pulmonary complications can occur in leptospirosis but
generally happen in severe and late-stage disease. Severe
disease may result in acute respiratory distress syndrome or
pulmonary haemorrhage.
Leptospirosis
Also known as Weil's disease*, leptospirosis is commonly seen
in questions referring to sewage workers, farmers, vets or
people who work in abattoir. It is caused by the spirochaete
Leptospira interrogans (serogroup L icterohaemorrhagiae),
classically being spread by contact with infected rat urine.
Weil's disease should always be considered in high-risk
patients with hepatorenal failure
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
*the term Weil's disease is sometimes reserved for the most
severe 10% of cases that are associated with jaundice

Q-224
A 78-year-old woman is admitted to the general medical
ward with lobar pneumonia and is commenced on Coamoxiclav. A few days later, she
reports having some loose
stool and abdominal pain. Microbiology reports come back
positive for Clostridium difficile.
Which classification of bacteria do Clostridium species
belong to?
A. Gram positive cocci
B. Gram negative cocci
C. Gram positive bacilli
D. Gram negative bacilli
E. Intracellular bacteria
ANSWER:
C. Gram positive bacilli
EXPLANATION:
Clostridium - Gram-positive rod
Clostridium species are classified as gram positive bacilli.
Other gram positive bacilli include:
• Actinomyces sp.
• Bacillus anthracis
• Corynebacterium diphtheriae
• Listeria monocytogenes
Classification of bacteria
Remember:
• Gram-positive cocci
= staphylococci + streptococci (including enterococci)
• Gram-negative cocci = Neisseria
meningitidis + Neisseria gonorrhoeae, also Moraxella
catarrhalis
Therefore, only a small list of Gram-positive rods (bacilli) need
to be memorised to categorise all bacteria - mnemonic =
ABCD L
• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenesRemaining organisms are Gram-negative rods, e.g.:
• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Q-225
A 52-year-old male is admitted to hospital with a
temperature of 38.2 C and a 3 days history of a productive
cough. He has been generally unwell for the past 10 days
with flu-like symptoms. On examination blood pressure is
96/60 mmHg and the heart rate is 102 / min. Chest x-ray
shows bilateral lower zone consolidation. What is the most
likely causative organism?
A. Moraxella catarrhalis
B. Mycoplasma pneumoniae
C. Klebsiella
D. Staphylococcus aureus
E. Chlamydia pneumoniae
ANSWER:
D. Staphylococcus aureus
EXPLANATION:
Preceding influenza predisposes
to Staphylococcus aureuspneumonia
Pneumonia: causes
Community acquired pneumonia (CAP) may be caused by the
following infectious agents:
• Streptococcus pneumoniae (accounts for around 80%
of cases)
• Haemophilus influenzae
• Staphylococcus aureus: commonly after the 'flu
• atypical pneumonias (e.g. Due to Mycoplasma
pneumoniae)
• viruses
Klebsiella pneumoniae is classically in alcoholics
Streptococcus pneumoniae (pneumococcus) is the most
common cause of community-acquired pneumonia
Characteristic features of pneumococcal pneumonia
• rapid onset
• high fever
• pleuritic chest pain
• herpes labialis

Q-226
A 25-year-old woman has recently moved to the United
Kingdom from sub-Saharan Africa to attend University. She
comes from an area where there is a high prevalence of
tuberculosis (TB). The patient is not pregnant and is currently
asymptomatic. She thinks she may have had a BCG
vaccination in the past but is not sure. She has no other
medical history and is a non-smoker. A chest x-ray is normal.
She has a Mantoux test which is positive and subsequently
an interferon-gamma release assay which is also positive.
What is the best management option for this patient?
A. Isoniazid and pyridoxine for 6 months
B. No treatment indicated at present
C. Rifampicin and isoniazid with pyridoxine for 6 months
D. Arrange a bronchoscopy and lavage
E. Rifampicin, isoniazid, pyrazinamide and ethambutol for
6 months
ANSWER:
A. Isoniazid and pyridoxine for 6 months
EXPLANATION:
The 2016 NICE guidelines on Tuberculosis (TB) advice that if a
Mantoux test is positive (>5mm) then the patient should be
screened for active TB. If there is no evidence of active TB
and an interferon-gamma release assay is positive then you
should consider treatment for latent TB. The two options are:
• 3 months of isoniazid with pyridoxine and rifampicin
• 6 months of isoniazid with pyridoxine
The other drug combinations are incorrect and not
recommended by NICE. We have been given the diagnosis of
latent TB with the Mantoux test and interferon-gamma
release assay and therefore a bronchoscopy and lavage are
not required.
Tuberculosis: drug therapy
The standard therapy for treating active tuberculosis is:
Initial phase - first 2 months (RIPE)
• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol (the 2006 NICE guidelines now
recommend giving a 'fourth drug' such as ethambutol
routinely - previously this was only added if drugresistant tuberculosis was
suspected)
Continuation phase - next 4 months
• Rifampicin
• IsoniazidThe treatment for latent tuberculosis is 3 months of isoniazid
(with pyridoxine) and rifampicin OR 6 months of isoniazid
(with pyridoxine)
Patients with meningeal tuberculosis are treated for a
prolonged period (at least 12 months) with the addition of
steroids
Directly observed therapy with a three times a week dosing
regimen may be
indicated in certain groups, including:
• homeless people with active tuberculosis
• patients who are likely to have poor concordance
• all prisoners with active or latent tuberculosis

Q-227
A 72-year-old woman who is known to have type 2 diabetes
mellitus and heart failure is reviewed. One week ago she was
treated with oral flucloxacillin and penicillin V for a right
lower limb cellulitis. Unfortunately there has been no
response to treatment. What is the most appropriate next
line antibiotic?
A. Co-amoxiclav
B. Erythromycin
C. Clindamycin
D. Vancomycin
E. Gentamicin
ANSWER:
C. Clindamycin
EXPLANATION:
Cellulitis please see

Q-39

Q-228
A 57-year-old businessman presents to the emergency
department with fevers, myalgia and headache which have
been ongoing for the past 10 days. He also reports that he
has noticed the beginnings of a rash on his face and trunk,
which you would describe as maculopapular. He has no
significant past medical history, and recently returned from a
trip to Bangkok three weeks ago, where he admits to having
intercourse with a local sex worker. He cannot remember if
he used protection. Otherwise he made sure to take
appropriate precautions with malarial prophylaxis and pretravel vaccines.
Which of the following tests would be most likely to give a
diagnosis in this history?
A. Malarial films
B. HIV antibody test
C. CD4 count
D. P24 antigen
E. Dengue serology
ANSWER:
B. HIV antibody test
EXPLANATION:
HIV antibody testing is most reliable 3 months post exposure
This patient's symptoms are most likely secondary to an
acute HIV seroconversion syndrome. This occurs most
commonly 1-4 weeks from time of infection with the virus
and in the majority of patients, is accompanied by a flu-like
illness with a maculopapular rash. This illness marks the
beginning of HIV antibody production, but this test is still
often negative during the process. p24 antigen however is
most often positive for the first 3-4 weeks following
exposure, while the antibodies can take up to 3 months to be
detected.
Malaria is unlikely given this patient's use of prophylaxis and
that Bangkok has a relatively low risk of malaria
transmission. Dengue fever, although capable producing
similar symptoms, often causes fever for a shorter duration.
HIV: testing
HIV antibody test
• most common and accurate test
• usually consists of both a screening ELISA (Enzyme
Linked Immuno-Sorbent Assay) test and a
confirmatory Western Blot Assay
• most people develop antibodies to HIV at 4-6 weeks
but 99% do by 3 months
p24 antigen test
• usually positive from about 1 week to 3 - 4 weeks
after infection with HIV
• sometimes used as an additional screening test in
blood banks

Q-229
You are counselling a 26-year-old man who has recently had
a positive HIV test. His most recent CD4 count is 650
cells/mm^3. Which one of the following vaccinations is
contraindicated?
A. Oral poliomyelitis
B. Yellow fever
C. Pneumococcus
D. Parenteral poliomyelitis
E. Measles, Mumps, Rubella
ANSWER:
A. Oral poliomyelitis
EXPLANATION:
HIV: immunisationThe Department of Health 'Greenbook' on immunisation
defers to the British HIV Association for guidelines relating to
immunisation of HIV-infected adults
Vaccines that can be used in
all HIV-infected adults
Vaccines that can
be used if CD4 >
200
Contraindicated in HIVinfected adults
Hepatitis A
Hepatitis B
Haemophilus influenzae B
(Hib)
Influenza-parenteral
Japanese encephalitis
Meningococcus-MenC
Meningococcus-ACWY I
Pneumococcus-PPV23
Poliomyelitis-parenteral
(IPV)
Rabies
Tetanus-Diphtheria (Td)
Measles, Mumps,
Rubella (MMR)
Varicella
Yellow Fever
Cholera CVD103-HgR
Influenza-intranasal
Poliomyelitis-oral (OPV)
Tuberculosis (BCG)

Q-230
A 28-year-old man from Zimbabwe presents to the
emergency department with a 2 week history of fever,
cough, headache, vomiting and neck stiffness. He is known
to be HIV positive and is on treatment. His most recent CD4
count was 450 cells/mm³
On examination he has no focal neurological signs but
appears drowsy and confused. You suspect meningitis and
perform and lumbar puncture
The results show:
Opening pressure 25mm H2O
Appearance cloudy
White cells 200 cells/mm³
Cells 90% lymphocytes
CSF protein 3 g/L
CSF glucose 1.1 mmol/L
Blood glucose 6.8 mm/L
What is the most likely diagnosis?
A. Meningococcal meningitis
B. TB meningitis
C. Cryptococcal meningitis
D. Partially treated bacterial meningitis
E. Herpes simplex meningitis
ANSWER:
B. TB meningitis
EXPLANATION:
The lymphocytic CSF with high protein and low glucose in
this case could be due to both cryptococcal and TB
meningitis, however the insidious onset of symptoms, very
high protein and low glucose compared to the plasma
glucose (<1/3 of plasma) points more towards TB meningitis.
Also this man has a relatively high CD4 count and only a
mildly raised opening pressure which makes cryptococcal
meningitis more unlikely. TB and HIV co-infection are
common, especially in sub-Saharan Africa and should always
be considere
Meningitis: CSF analysis
The table below summarises the characteristic cerebrospinal
fluid (CSF) findings in meningitis:
Bacterial Viral Tuberculous
Appearance Cloudy Clear/cloudy Slight cloudy, fibrin
web
Glucose Low (< 1/2
plasma)
60-80% of plasma
glucose*
Low (< 1/2 plasma)
Protein High (> 1 g/l) Normal/raised High (> 1 g/l)
White cells 10 - 5,000
polymorphs/mm³
15 - 1,000
lymphocytes/mm³
10 - 1,000
lymphocytes/mm³
The Ziehl-Neelsen stain is only 20% sensitive in the detection
of tuberculous meningitis and therefore PCR is sometimes
used (sensitivity = 75%)
*mumps is unusual in being associated with a low glucose
level in a proportion of cases. A low glucose may also be seen
in herpes encephalitis

Q-231
A 23-year-old woman comes for review. She has had
recurrent genital warts for the past 4 years which have failed
to respond to topical podophyllum. On one occasion she had
cryotherapy but will not have it again due to local
discomfort. On examination she has a large number of fleshy
genital warts around her introitus. What is the most
appropriate next step in treatment?
A. Topical glutaraldehyde
B. Oral podophyllum
C. Topical imiquimod
D. Oral aciclovir
E. Topical salicylic acid
ANSWER:
C. Topical imiquimod
EXPLANATION:
Genital warts
Genital warts (also known as condylomata accuminata) are a
common cause of attendance at genitourinary clinics. They
are caused by the many varieties of the human papilloma
virus HPV, especially types 6 & 11. It is now well establishedthat HPV (primarily
types 16,18 & 33) predisposes to cervical
cancer.
Features
• small (2 - 5 mm) fleshy protuberances which are
slightly pigmented
• may bleed or itch
Management
• topical podophyllum or cryotherapy are commonly
used as first-line treatments depending on the
location and type of lesion. Multiple, non-keratinised
warts are generally best treated with topical agents
whereas solitary, keratinised warts respond better to
cryotherapy
• imiquimod is a topical cream which is generally used
second line
• genital warts are often resistant to treatment and
recurrence is common although the majority of
anogenital infections with HPV clear without
intervention within 1-2 years

Q-232
A 30-year-old man has returned from South America after
one week. He has developed a mild fever, muscle pain,
headache and conjunctivitis. He has been taking his antimalarial tablets. What is
the most likely diagnosis?
A. Dengue
B. Chikungunya
C. Malaria
D. Influenza
E. Zika
ANSWER:
E. Zika
EXPLANATION:
Zika, Chikungunya and Dengue can produce similar
symptoms. Zika is prevalent in South America. It tends to
cause mild fever whereas dengue and chikungunya tend to
cause abrupt onset of high fever. Chikungunya and dengue
would cause more joint pain and conjunctivitis is less
common with these conditions. He has been taking his
antimalarials making malaria less likely. Influenza could be a
consideration but because of the recent travel history zika
should be considered first.
Zika virus
Zika is a mosquito-borne infection caused by Zika virus, a
member of the genus flavivirus and family Flaviviridae. It was
first isolated from a monkey in the Zika forest in Uganda in
1947.
Transmission is usually via the bite of an infected Aedes
mosquito, although a small number of cases of sexual
transmission have been reported. There is increasing evidence
of transmission via the placenta from mother to fetus.
The majority of people infected with Zika virus have no
symptoms. For those with symptoms, Zika virus tends to cause
a mild, short-lived (2 to 7 days) febrile disease. Signs and
symptoms suggestive of Zika virus infection may include a
combination of the following:
• fever
• rash
• arthralgia/arthritis
• conjunctivitis
• myalgia
• headache
• retro-orbital pain
• pruritus
Serious complications in adults are not common, although the
virus has been associated with Guillain-Barre syndrome.
Scientific consensus however has linked Zika with
microcephaly and other congenital abnormalities, which has
led the World Health Organisation (WHO) to declare a Public
Health Emergency of International Concern (PHEIC).
Advice for travellers
There is currently no vaccine or drug to prevent Zika infection.
Prevention revolves around avoiding mosquito bites (Aedes
mosquitoes usually bite during the day) by using mosquito
repellent and cover up clothing. Pregnant women are advised
to avoid non-essential travel to Zika prevalent areas until after
pregnancy.

Q-233
A 25-year-old man who is taking immunosuppressive
therapy for Adult onset Still's disease, and has come into
contact with a child who has chicken pox. He is varicella
zoster IgG antibody negative. He has a small number of early
chicken pox blisters and you decide to start aciclovir therapy.
Which of the following fits best with the mode of action of
aciclovir?
A. DNA polymerase inhibitor
B. DNA gyrase inhibitor
C. Reverse transcriptase inhibitor
D. NS3/4A inhibitor
E. NS5A inhibitor
ANSWER:
A. DNA polymerase inhibitor
EXPLANATION:
Aciclovir is much more specific for viral than mammalian
DNA polymerase
Aciclovir is phosphorylated after entry into herpes infected
cells to form aciclovir triphosphate. The first step in this
process is dependant on the presence of HSV-coded
thymidine kinase. Aciclovir triphosphate acts as an inhibitor
of, and substrate for, the herpes-specific DNA polymerase,
preventing further viral DNA synthesis without affecting
normal cellular processes. It is 10-30 times more specific for
viral DNA polymerase versus the human enzyme.
Bacterial DNA gyrase is the target of quinolone antibiotics.
Reverse transcriptase is an enzyme target for the treatment
of RNA viruses such as HIV. NS3/4A and NS5A are both
targets in the treatment of hepatitis C. Modern antivirals
which target NS3/4A and NS5A have revolutionised the
treatment of hepatitis C, bringing cure into focus for the first
time.
Please see Q-8 for Antiviral Agents

Q-234
A 55-year-old man who was admitted following a stroke two
weeks ago is reviewed. Yesterday he started to have a
temperature and become more confused. A septic screen
has shown radiological evidence of pneumonia. On
examination his respiratory rate is 36/min, pulse 112/min,
oxygen saturations of 95% on room air and blood pressure of
102/66 mmHg. What is the most appropriate antibiotic to
use?
A. Teicoplanin
B. Cefuroxime
C. Amoxicillin
D. Imipenem with cilastatin
E. Piperacillin with tazobactam
ANSWER:
B. Cefuroxime
EXPLANATION:
Cefuroxime is a second generation cephalosporin and is
therefore a poor choice as it has limited action against Gramnegative bacteria.
Antibiotic guidelines
The following is based on current BNF guidelines:
Respiratory system
Condition Recommended treatment
Exacerbations of
chronic bronchitis
Amoxicillin or tetracycline or clarithromycin
Uncomplicated
community-acquired
pneumonia
Amoxicillin (Doxycycline or clarithromycin in
penicillin allergic, add flucloxacillin if
staphylococci suspected e.g. In influenza)
Pneumonia possibly
caused by atypical
pathogens
Clarithromycin
Hospital-acquired
pneumonia
Within 5 days of admission: co-amoxiclav or
cefuroxime
More than 5 days after admission: piperacillin
with tazobactam OR a broad-spectrum
cephalosporin (e.g. ceftazidime) OR a quinolone
(e.g. ciprofloxacin)
Urinary tract
Condition Recommended treatment
Lower urinary tract
infection
Trimethoprim or nitrofurantoin. Alternative:
amoxicillin or cephalosporin
Acute pyelonephritis Broad-spectrum cephalosporin or quinolone
Acute prostatitis Quinolone or trimethoprim
Skin
Condition Recommended treatment
Impetigo Topical fusidic acid, oral flucloxacillin or
erythromycin if widespread
Cellulitis Flucloxacillin (clarithromycin or clindomycin if
penicillin-allergic)
Erysipelas Phenoxymethylpenicillin (erythromycin if penicillinallergic)
Animal or human
bite
Co-amoxiclav (doxycycline + metronidazole if
penicillin-allergic)
Mastitis during
breast-feeding
Flucloxacillin
Ear, nose & throat
Condition Recommended treatment
Throat infections Phenoxymethylpenicillin (erythromycin alone if
penicillin-allergic)
Sinusitis Amoxicillin or doxycycline or erythromycin
Otitis media Amoxicillin (erythromycin if penicillin-allergic)
Otitis externa* Flucloxacillin (erythromycin if penicillin-allergic)
Periapical or
periodontal abscess
Amoxicillin
Gingivitis: acute
necrotising ulcerative
MetronidazoleGenital system
Condition Recommended treatment
Gonorrhoea Intramuscular ceftriaxone + oral azithromycin
Chlamydia Doxycycline or azithromycin
Pelvic
inflammatory
disease
Oral ofloxacin + oral metronidazole or
intramuscular ceftriaxone + oral doxycycline
+ oral metronidazole
Syphilis Benzathine benzylpenicillin or doxycycline or
erythromycin
Bacterial vaginosis Oral or topical metronidazole or topical
clindamycin
Gastrointestinal
Condition Recommended treatment
Clostridium difficile First episode: metronidazole
Second or subsequent episode of
infection: vancomycin
Campylobacter
enteritis
Clarithromycin
Salmonella (nontyphoid)
Ciprofloxacin
Shigellosis Ciprofloxacin
*a combined topical antibiotic and corticosteroid is generally
used for mild/moderate cases of otitis externa

Q-235
A 55-year-old man is referred to the medical admissions
unit. He recently returned from a holiday in Italy and has
failed to respond to a course of co-amoxiclav for a
suspected lower respiratory tract infection. Chest x-ray
shows bilateral infiltrates. Bloods are as follows:
Na+ 122 mmol/l
K+ 4.3 mmol/l
Urea 8.4 mmol/l
Creatinine 130 µmol/l
What is the likely diagnosis?
A. Goodpasture's syndrome
B. Legionella pneumonia
C. Pneumocystis carinii pneumonia
D. Pulmonary eosinophilia
E. Mycoplasma pneumonia
ANSWER:
B. Legionella pneumonia
EXPLANATION:
Legionella
Legionnaire's disease is caused by the intracellular
bacterium Legionella pneumophilia. It is typically colonizes
water tanks and hence questions may hint at air-conditioning
systems or foreign holidays. Person-to-person transmission is
not seen
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
Comparison of Legionella and Mycoplasma pneumoniaChest x-ray features of legionella
pnuemonia are non-specific
but includes a mid-to-lower zone predominance of patchy
consolidation. Pleural effusions are seen in around 30%.

Q-236
A 65-year-old man who has recently move to the UK from
India presents with multiple pale patches on his skin. He has
no previous medical problems and is not taking any
medications. On examination he has 10 hypopigmented
patches with reduced sensation. You suspect lepromatous
leprosy.
What is the most appropriate treatment?
A. Rifampicin, dapsone and clofazimine for 12 months
B. Dapsone, ethambutol and pyrazinamide for 12 months
C. Dapsone and ethambutol for 6 months
D. Rifampicin and isoniazid for 6 month
E. Rifampicin and dapsone for 6 months
ANSWER:
A. Rifampicin, dapsone and clofazimine for 12 months
EXPLANATION:
This man has multibacillary leprosy (>6 lesions) so should
have triple therapy with rifampicin, dapsone and clofazimine
for 12 months. For paucibacillary leprosy (5 or less lesions)
you should give rifampicin and dapsone for 6 months.
Leprosy
Leprosy is a granulomatous disease primarily affecting the
peripheral nerves and skin. It is caused by Mycobacterium
leprae.
Features
• patches of hypopigmented skin typically affecting the
buttocks, face, and extensor surfaces of limbs
• sensory loss
The degree of cell mediated immunity determines the type of
leprosy a patient will develop.
Low degree of cell mediated immunity → lepromatous leprosy
('multibacillary')
• extensive skin involvement
• symmetrical nerve involvement
High degree of cell mediated immunity → tuberculoid leprosy
('paucibacillary')
• limited skin disease
• asymmetric nerve involvement
Management
• WHO-recommended triple therapy: rifampicin,
dapsone and clofazimine

Q-237
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?
A. IV cefotaxime
B. Arrange a CT head
C. Perform a lumbar puncture
D. IV dexamethasone
E. Intramuscular benzypenicillin
ANSWER:
A. IV cefotaxime
EXPLANATION:
This patient has meningococcal meningitis. They need
appropriate intravenous antibiotics immediately. With the
advent of modern PCR diagnostic techniques there is no
justification for delaying potentially lifesaving treatment by
performing a lumbar puncture in patients with suspected
meningococcal meningitis.
Please see Q-14 for Meningitis: Management

Q-238
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?
A. At the time of diagnosis
B. CD4 < 200 * 106/l
C. CD4 < 250 * 106/l
D. CD4 < 300 * 106/l
E. CD4 < 350 * 106/l
ANSWER:
A. At the time of diagnosis
EXPLANATION:
Anti-retroviral therapy for HIV is now started at the time of
diagnosis, rather than waiting for the CD4 count to drop to a
particular level
HIV: anti-retrovirals
Highly active anti-retroviral therapy (HAART) involves a
combination of at least three drugs, typically two nucleoside
reverse transcriptase inhibitors (NRTI) and either a protease
inhibitor (PI) or a non-nucleoside reverse transcriptase
inhibitor (NNRTI). This combination both decreases viral
replication but also reduces the risk of viral resistance
emerging
Following the 2015 BHIVA guidelines it is now recommended
that patients start HAART as soon as they have been
diagnosed with HIV, rather than waiting until a particular CD4
count, as was previously advocated.
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
Integrase inhibitors
• examples: raltegravir, elvitegravir, dolutegravir

Q-239
A 17-year-old male presents with a severe sore throat, fever
and lethargy. On examination he is noted to have cervical
lymphadenopathy. He has now been unwell for 6 days. A
blood test is taken the next day:
Hb 15.5 g/L Male: (135-180)
Female: (115 - 160)
Platelets 300 * 109/L (150 - 400)
WBC 9 * 109/L (4.0 - 11.0)
Neuts 3 * 109/L (2.0 - 7.0)
Lymphs 5.5 * 109/L (1.0 - 3.5)
Mono 0.5 * 109/L (0.2 - 0.8)
Eosin 0.1 * 109/L (0.0 - 0.4)
Heterophil antibody test POSITIVE
What is the most appropriate next step in management?
A. Ultrasound of spleen
B. Amoxicillin
C. Observation
D. Oseltamivir
E. Zanamivir
ANSWER:
C. Observation
EXPLANATION:
Infectious mononucleosis is generally a self-limiting
condition
This patient has infectious mononucleosis. No active
treatment is required although patients should be counselled
regarding the need to avoid contact sports for 8 weeks given
the risk of splenic [Link] see Q-20 for Infectious Mononucleosis

Q-240
A 28-year-old nurse on your ward receives a needle stick
injury after taking blood from a known HIV positive patient.
You give her first aid treatment and send bloods for an initial
HIV test. She asks you about post exposure prophylaxis.
What would you advise?
A. Tenofovir, repeat HIV test in 12 weeks
B. Combination antiretrovirals (Tenofovir, emtricitabine
and lopinavir/ritonavir) repeat HIV test in 4 weeks
C. Nevirapine, repeat HIV test in 4 weeks
D. Combination antiretrovirals (Tenofovir, emtricitabine
and lopinavr/ritonavir), repeat HIV test in 12 week
E. Tenofovir, repeat HIV test in 4 weeks
ANSWER:
B. Combination antiretrovirals (Tenofovir, emtricitabine
and lopinavir/ritonavir) repeat HIV test in 4 weeks
EXPLANATION:
Combination antiretrovirals should be given rather than
single therapy as it is more effective and it helps prevent
development of resistance. Nevirapine can be used in post
exposure prophylaxis in new born babies born to HIV positive
mothers.
Repeat testing for HIV antibody/antigen should be done at
12 weeks as this is how long it can take to develop
antibodies.
Source: British HIV association - UK guideline for the use of
post-exposure prophylaxis for
HIV following sexual exposure (2011)
Post-exposure prophylaxis
Hepatitis A
• Human Normal Immunoglobulin (HNIG) or hepatitis A
vaccine may be used depending on the clinical
situation
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
Hepatitis C
• monthly PCR - if seroconversion then interferon +/-
ribavirin
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%
Varicella zoster
• VZIG for IgG negative pregnant
women/immunosuppressed
Estimates of transmission risk for single needlestick injury
Hepatitis B 20-30%
Hepatitis C 0.5-2%
HIV

Q-241
A 34-year-old man from Venezuela presents with a flu-like
illness and periorbital oedema. Generalised
lymphadenopathy is noted. A diagnosis of Chagas' disease is
confirmed on blood smear. What is the most appropriate
treatment?
A. Benznidazole
B. Sodium stibogluconate
C. Metronidazole
D. Pentamidine
E. Atovaquone-proguanil
ANSWER:
A. Benznidazole
EXPLANATION:
Trypanosomiasis see

Q-1

Q-242
A 69-year-old man is brought into the emergency
department by ambulance, with a few days history of
increasing shortness of breath, fever and a productive cough.
On review, you find:
HR 105 bpm
Oxygen saturation 90 % on airBP 100/65 mmHg
Temp 38.9ºC
Respiratory Rate 32 breaths per minute
Chest X-ray Right mid-zone cavity with surrounding
consolidation
The patient is started on oxygen, antibiotics and IV fluids and
his observations improve to the point where taking a history
is easier. He reports that he normally keeps fit and has no
other long-term health conditions, but that he has been
more tired for the past few weeks. He explains further that
he and his wife both caught a 'bad cold' from their
grandchildren about a month ago.
What is the most likely cause for this gentleman's
symptoms?
A. Lung cancer
B. Klebsiella pneumoniae infection
C. Staphylococcus aureus infection
D. Pulmonary tuberculosis
E. Streptococcus pneumoniae infection
ANSWER:
C. Staphylococcus aureus infection
EXPLANATION:
Staphylococcus aureus is associated with cavitating lesions
when it causes pneumonia
This gentleman likely developed influenza a few weeks prior
to his presentation at the emergency department, which is
associated with the development of S. aureus pneumonia
following resolution.
S. aureus is associated with the development of cavitating
lung lesions in the context of pneumonia, especially when
caused by strains capable of producing a cytotoxin known as
Panton-Valentine Leukocidin. This cytotoxin can often lead
necrotic, hemorrhagic pneumonia and length stays in
intensive care units for the patients affected.
Although lung cancer, Klebsiella pneumoniae, and
pulmonary tuberculosis are all associated with cavitating
lung lesions, these causes are less likely for the following
reasons:
• Squamous cell carcinoma is the most common
oncological cause of cavitating lung lesions, which is
often linked to a history of smoking. The question
gives us no information to suggest the patient is a
smoker.
• Klebsiella pneumoniae is often associated a
causative pathogen of pneumonia in patients with a
history of alcoholism
• Pulmonary tuberculosis often causes a more drawn
out, subacute presentation and is often associated
with immunosuppression and other comorbidities
Streptococcus pneumoniae is not associated with cavitating
lung lesions.
Pneumonia: causes
Community acquired pneumonia (CAP) may be caused by the
following infectious agents:
• Streptococcus pneumoniae (accounts for around 80%
of cases)
• Haemophilus influenzae
• Staphylococcus aureus: commonly after the 'flu
• atypical pneumonias (e.g. Due to Mycoplasma
pneumoniae)
• viruses
Klebsiella pneumoniae is classically in alcoholics
Streptococcus pneumoniae (pneumococcus) is the most
common cause of community-acquired pneumonia
Characteristic features of pneumococcal pneumonia
• rapid onset
• high fever
• pleuritic chest pain
• herpes labialis

Q-243
A 19-year-old man presents with a two-day history of a
diffuse headache and sore throat. He is pyrexial at 37.8ºC
and is reluctant to have a fundoscopy due to photophobia. A
lumbar puncture is performed:
Serum glucose 5.9 mmol/l
Lumbar puncture reveals:
Appearance Clear
Glucose 4.1 mmol/l
Protein 0.3 g/l
White cells lymphocytes 2 /mm³
polymorphs 0 /mm³
What is the most likely diagnosis?
A. Guillain-Barre syndrome
B. Viral meningitis
C. Bacterial meningitis
D. Cerebral malaria
E. Normal CSF result
ANSWER:
E. Normal CSF result
EXPLANATION:
There results are consistent with normal CSF - an alternative
diagnosis should be considered
Meningitis: CSF analysis see

Q-2

Q-244
A 44-year-old farmer presents to the Emergency Department
due to a high temperature and confusion. On examination
his pulse is 124 bpm, blood pressure 84/56 mmHg and
temperature 39.8ºC. He has a generalised erythematous rash
which is starting to desquamate on his palms and is also
noted to have a paronychial infection of a fingernail on the
left hand. What is the most likely diagnosis?
A. Paraquat overdose
B. Leptospirosis
C. Staphylococcal toxic shock syndrome
D. Disseminated herpes simplex infection
E. Organophosphate poisoning
ANSWER:
C. He has a generalised erythematous rash
which is starting to desquamate on his palms and is also
noted to have a paronychial infection of a fingernail on the
left hand. What is the most likely diagnosis?
EXPLANATION:
Staphylococcal toxic shock syndrome
Staphylococcal toxic shock syndrome describes a severe
systemic reaction to staphylococcal exotoxins. It came to
prominence in the early 1980's following a series of cases
related to infected tampons
Centers for Disease Control and Prevention diagnostic criteria
• fever: temperature > 38.9ºC
• hypotension: systolic blood pressure < 90 mmHg
• diffuse erythematous rash
• desquamation of rash, especially of the palms and
soles
• involvement of three or more organ systems: e.g.
gastrointestinal (diarrhoea and vomiting), mucous
membrane erythema, renal failure, hepatitis,
thrombocytopenia, CNS involvement (e.g. confusion)
© Image used on license from DermNet NZ

Q-245
A 17-year-old female presents for review. Four days ago she
presented to her doctor with a severe sore throat, lethargy
and headache. Her doctor prescribed a course of amoxicillin
to treat an upper respiratory tract infection. Two days ago
she developed a widespread, pruritic maculopapular rash.
Her original symptoms have also not improved. What is the
most likely diagnosis?
A. Infectious mononucleosis
B. Kawasaki disease
C. Penicillin allergy
D. HIV seroconversion
E. Beta-lactamase producing streptococcal sore throat
ANSWER:
A. Infectious mononucleosis
EXPLANATION:
URTI symptoms + amoxicillin → rash ?glandular fever
A rash develops in around 99% of patients who take
amoxicillin whilst they have infectious mononucleosis. Her
treatment should be supportive as detailed below.
Please see Q-20 for Infectious Mononucleosis

Q-246
A 27-year-old pregnant woman is found to have Chlamydia.
She reports being allergic to penicillin. What is the most
appropriate treatment?
A. No antibiotic therapy is indicated
B. Cefixime
C. Erythromycin
D. Doxycycline
E. Ciprofloxacin
ANSWER:
C. Erythromycin
EXPLANATION:
NICE Clinical Knowledge Summaries recommends
azithromycin, erythromycin or amoxicillin for pregnant
women who have Chlamydia.
The efficacy of amoxicillin, often assumed to be ineffective
against Chlamydia, was supported in a recent Cochrane
review. A test of cure should be carried out following
treatment.
Please see Q-32 for Chlamydia

Q-247
A 25-year-old man is bitten by his assailant during a fight
outside a nightclub. Alongside Streptococci spp. and
Staphylococcus aureus, which of the following organisms is
most likely to be isolated?
A. Pseudomonas aeruginosa
B. Eikonella corrodens
C. Neisseria gonorrhoeae
D. Acinetobacter baumannii
E. Enterococcus faecalis
ANSWER:
B. Eikonella corrodens
EXPLANATION:
Eikenella is notable as a cause of infections following human
bites
Eikonella corrodens is found in around 10-30% of human bite
wounds.
Animal and human bites
Animal bites
The majority of bites seen in everyday practice involve dogs
and cats. These are generally polymicrobial but the most
common isolated organism is Pasteurella multocida.
Management
• cleanse wound
• current BNF recommendation is co-amoxiclav
• if penicillin-allergic then doxycycline + metronidazole
is recommended
Human bites
Human bites commonly cause multimicrobial infection,
including both aerobic and anaerobic bacteria.
Common organisms include:
• Streptococci spp.
• Staphylococcus aureus
• Eikenella
• Fusobacterium
• Prevotella
Co-amoxiclav is recommended, as for animal bites.
The risk of viral infections such as HIV and hepatitis C should
also be considered.

Q-248
A 21-year-old female comes to see her GP complaining of a
three day history of dysuria, frequency and a mild fever. She
has no abdominal or loin pain and a urine dipstick done at
the practice shows 2+ leucocytes but negative for blood,
protein and nitrites.
Which of the following organisms is the most likely cause of
the infection?
A. Escherichia Coli
B. Staphylococcus saprophyticus
C. Proteus mirabilisD. Pseudomonas aeruginosa
E. Klebsiella pneumoniae
ANSWER:
B. Staphylococcus saprophyticus
EXPLANATION:
This patient has symptoms of a lower urinary tract infection
which should be treated with antibiotics. The clue to finding
the correct answer is the fact that despite being leucocyte
positive, the urine dipstick is nitrite negative. Gram negative
organisms test positive on the nitrite test as they convert
nitrates to nitrites for energy. Gram positive organisms are
unable to reduce nitrate to nitrite and therefore, test
negative. As staphylococcus species are the only gram
positive organisms of the answers given, this is the correct
answer.
Please see Q-157

Q-249
A 19-year-old man presents with a compound fracture of his
leg following a fall from scaffolding. Examination reveals
soiling of the wound with mud. He is sure he has had five
previous tetanus vaccinations. What is the most appropriate
course of action to prevent the development of tetanus?
A. Clean wound + intramuscular human tetanus immunoglobulin
B. Clean wound + tetanus vaccine
C. Clean wound + tetanus vaccine + intramuscular human
tetanus immunoglobulin
D. Clean wound + tetanus vaccine + benzylpenicillin
E. Clean wound
ANSWER:
A. Clean wound + intramuscular human tetanus immunoglobulin
EXPLANATION:
A soiled, compound fracture is regarded as high-risk for
tetanus and intramuscular human tetanus immunoglobulin
should be given. There is a role for antibiotics given the
soiled wound although benzylpenicillin would not be the
drug of choice.
See

Q-199

Q-250
A 19-year-old medical student undergoes primary
immunisation against hepatitis B. His post immunisation
bloods are reported as follows:
Anti-HBs < 10 mIU/ml
What is the most appropriate course of action?
A. Give one further dose of hepatitis B vaccine
B. Do a HIV test
C. Test for current or past hepatitis B + repeat course (i.e. 3 doses) of vaccine
D. Give two further doses of hepatitis B vaccine
E. Give a course of hepatitis B immune globulin (HBIG) +
one further dose of hepatitis B vaccine
ANSWER:
C. Test for current or past hepatitis B + repeat course (i.e. 3 doses) of vaccine
EXPLANATION: Please see Q-174

Q-251
A 25-year-old sexually active woman presents with dysuria
and urgency. A urine dipstick is positive for leukocytes and
nitrites. Urine culture and gram staining reveal a grampositive organism in
clusters that is coagulase-negative.
What is the most likely causative organism?
A. Escherichia coli
B. Staphylococcus aureus
C. Staphylococcus saprophyticus
D. Proteus mirabilis
E. Klebsiella
ANSWER:
B. Staphylococcus aureus
EXPLANATION:
Staphylococcus saprophyticus can commonly cause UTI in
sexually active young women
Staphylococcus saprophyticus is the second most common
cause of UTIs in sexually active young women (E. coli is most
common). It is a gram-positive coccus that grows in clusters
and is coagulase-negative.
Escherichia coli is a gram-negative bacteria.
Staphylococcus aureus is gram-positive that grows in clusters
but is coagulase-positive.
Proteus mirabilis is gram-negative bacilli and is ureasepositive.
Klebsiella is a gram-negative bacilli.
All of these bacteria can cause UTIs.
Urinary tract infection in adults: management
Lower urinary tract infectionsNon-pregnant women
• local antibiotic guidelines should be followed if
available
• CKS/2012 SIGN guidelines recommend trimethoprim
or nitrofurantoin for 3 days
Pregnant women with symptomatic bacteriuria should be
treated with an antibiotic for 7 days. A urine culture should be
sent. For asymptomatic pregnant women:
• a urine culture should be performed routinely at the
first antenatal visit
• if positive, a second urine culture should be sent to
confirm the presence of bacteriuria
• SIGN recommend to treat asymptomatic bacteriuria
detected during pregnancy with an antibiotic
• a 7 day course of antibiotics should be given
• a further urine culture should be sent following
completion of treatment as a test of cure
Acute pyelonephritis
For patients with sign of acute pyelonephritis hospital
admission should be considered
• local antibiotic guidelines should be followed if
available
• the BNF currently recommends a broad-spectrum
cephalosporin or a quinolone (for non-pregnant
women) for 10-14 day

Q-252
A 28-year-old male presents with shortness of breath, dry
cough and fever for one week. Prior to this, he had been
generally unwell for several months complaining of weight
loss, fatigue, generalised lymphadenopathy and myalgia. He
admits to using intravenous drugs in the past.
Observations reveal O2 sats 88% on air, heart rate 112 bpm,
blood pressure 124/85mmHg, respiratory rate 24/min and
temperature 37.8ºC. His chest is clear and heart sounds are
normal. On mobilising his O2 sats drop to 75% on air and he
is acutely short of breath.
Chest x-ray shows bilateral perihilar shadowing.
Arterial blood gas on 5 litres of oxygen shows:
pH 7.41
PaO2 8.9 kPa
PaCO2 3.6 kPa
What is the most appropriate treatment for this patient?
A. Amoxicillin and clarithromycin
B. Co-trimoxazole
C. Co-trimoxazole and prednisolone
D. Doxycycline
E. Oseltamivir
ANSWER:
B. Co-trimoxazole
EXPLANATION:
This patient has Pneumocystis jirovecii pneumonia most
likely on a background of undiagnosed HIV infection.
Treatment for pneumocystis pneumonia is with oral cotrimoxazole or IV pentamidine
if oral antibiotics or not
tolerated. Steroids are also given if there is severe
hypoxaemia, as in this case.
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-253
A woman who is 14 weeks pregnant presents as she came
into contact with a child who has chickenpox around 4 days
ago. She is unsure if she had the condition herself as a child.
Blood tests show the following:
Varicella IgM Negative
Varicella IgG Negative
What is the most appropriate management?
A. Varicella zoster immunoglobulin
B. No action required
C. IV aciclovir
D. Varicella zoster vaccination
E. Varicella zoster vaccination + varicella zoster
immunoglobulin
ANSWER:
A. Varicella zoster immunoglobulin
EXPLANATION:
Chickenpox exposure in pregnancy - if not immune give VZIG
The negative IgG indicates no previous exposure to
chickenpox
Chickenpox exposure in pregnancy see

Q-84

Q-254
A 24-year-old gentleman presents with a worsening
headache to the emergency department. He emigrated from
Sudan two weeks ago. He has had a cough for six weeks. His
GP did a tuberculin skin test which was found to be negative
and has not responded to oral antibiotics. He has no medical
history and takes no regular medications. Blood tests
demonstrate positive HIV serology but cryptococcal antigen
is negative and other tests are normal. Toxoplasmosis
serology is negative. CT demonstrates a single 3cm lesionand meningeal enhancement
but no other abnormalities.
What is the most likely organism that is responsible for his
headache?
A. Toxoplasma gondii
B. Cryptococcus neoformans
C. Cytomegalovirus
D. Mycobacterium tuberculosis
E. JC virus
ANSWER:
D. Mycobacterium tuberculosis
EXPLANATION:
The correct answer is Mycobacterium tuberculosis. This
young patient has a headache in the context of untreated
HIV and therefore likely has a low CD4 count making him
vulnerable to HIV neurological complications. He also has a
chronic cough with a significant history of time in Sudan,
making him at high risk of TB. Meningeal enhancement on
the CT also increases the suspicion of TB. In
immunosuppression, the tuberculin skin test is unreliable and
therefore does not exclude TB. Cryptococcal infection is
unlikely with a negative antigen test. Toxoplasmosis is
possible but the lack of confusion and drowsiness and the
lack of any neurological deficit makes it less likely, especially
when considering the negative serology. The absence of
fever and confusion makes CMV encephalitis unlikely.
Progressive multifocal leukoencephalopathy shows
widespread demyelination.
Please see Q-34 for HIV: neurocomplications

Q-255
A 28-year-old man who is immunosuppressed secondary to
HIV infection is admitted to hospital with dyspnoea and a
dry cough. His chest x-ray shows bilateral interstitial
pulmonary infiltrates and he is started on co-trimoxazole
empirically. The following morning he complains of a sudden
worsening of his dyspnoea associated with left-sided chest
pain. Which complication is most likely to have developed?
A. Empyema
B. Pulmonary embolism
C. Acute respiratory distress syndrome
D. Pericarditis
E. Pneumothorax
ANSWER:
E. Pneumothorax
EXPLANATION:
Pneumocystis jiroveci pneumonia - pneumothorax is
a common complication
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-256
A patient who has recently returned from the Ivory Coast
presents with cyclical fever and headache. He is found to
have splenomegaly on examination. Following a blood film
he is diagnosed as having Plasmodium vivax malaria. He is
treated initially with chloroquine then later given
primaquine. What is the benefit of the primaquine?
A. Destroy liver hypnozoites and prevent relapse
B. Reduce the risk of chloroquine-related retinopathy
C. Reduce the incidence of chloroquine resistance
D. Cover Plasmodium ovale in case of co-infection
E. Prevent immature trophozoites forming gamatocytes
ANSWER:
A. Destroy liver hypnozoites and prevent relapse
EXPLANATION:
Please see Q-36 for Malaria: Non-Falciparum

Q-257
A 39-year-old man presents with shortness of breath
following one week of flu-like symptoms. He also has a nonproductive cough but no
chest pain. A chest x-ray shows
bilateral consolidation and examination reveals
erythematous lesions on his limbs and trunk. Which one of
the following investigations is most likely to be diagnostic?
A. Cold agglutins
B. Sputum culture
C. Urinary antigen for Legionella
D. Serology for Mycoplasma
E. Blood culture
ANSWER:
D. Serology for Mycoplasma
EXPLANATION:
Mycoplasma? - serology is diagnostic
The flu-like symptoms, bilateral consolidation and erythema
multiforme point to a diagnosis of Mycoplasma. The most
appropriate diagnostic test is Mycoplasma serology
Please see Q-69

Q-258
A 27-year-old student presents to the GP with a 24-hour
history of explosive diarrhoea and vomiting. On further
questioning, he has not noticed any blood in his stool, has no
history of foreign travel. He tells you he has been eating rice
kept warm in a rice cooker for several days.
What is the likely pathogenic organism underlying his
symptoms?
A. Bacillus cereus
B. Campylobacter jejuni
C. Shigella flexneriD. Norwalk virus
E. Staphylococcus aureus
ANSWER:
A. Bacillus cereus
EXPLANATION:
Bacillus cereus characteristically occurs after eating rice that
has been reheated
This young gentleman is likely to have toxigenic food
poisoning from Bacillus cereus. Bacillus cereus spores
germinate in cooked rice and produce toxin if the cooked
product is kept insufficiently chilled. S. aureus will also cause
a toxigenic food poisoning but the specific history in this case
makes this a less likely underlying organism. Equally Norwalk
virus can cause explosive diarrhoea and vomiting but is not
associated with any specific food stuffs.
Campylobacter and Shigella cause bacterial food poisoning
and would likely have a longer history with bloody
diarrhoea.
Please see Q-25 for Gastroenteritis: Causes

Q-259
A 29-year-old woman presents to the genitourinary medicine
clinic for treatment of recurrent genital warts. Which one
the following viruses are most likely to be responsible?
A. Human papilloma virus 16 & 18
B. Human papilloma virus 13 & 17
C. Human papilloma virus 6 & 11
D. Human papilloma virus 12 & 14
E. Human papilloma virus 15 & 21
ANSWER:
C. Human papilloma virus 6 & 11
EXPLANATION:
Genital warts - 90% are caused by HPV 6 & 11
Types 6 and 11 are responsible for 90% of genital warts
cases
Genital warts
Genital warts (also known as condylomata accuminata) are a
common cause of attendance at genitourinary clinics. They
are caused by the many varieties of the human papilloma
virus HPV, especially types 6 & 11. It is now well established
that HPV (primarily types 16,18 & 33) predisposes to cervical
cancer.
Features
• small (2 - 5 mm) fleshy protuberances which are
slightly pigmented
• may bleed or itch
Management
• topical podophyllum or cryotherapy are commonly
used as first-line treatments depending on the
location and type of lesion. Multiple, non-keratinised
warts are generally best treated with topical agents
whereas solitary, keratinised warts respond better to
cryotherapy
• imiquimod is a topical cream which is generally used
second line
• genital warts are often resistant to treatment and
recurrence is common although the majority of
anogenital infections with HPV clear without
intervention within 1-2 years

Q-260
A 54-year-old man presents to a sexual health clinic with
positive serology for syphilis, which was found during
routine work up for an insurance medical. He travels a great
deal for work and states he has on occasion paid for sex with
male sex workers in Thailand. He has never had a syphilis
test before and is very shocked as he feels well and is
completely asymptomatic. He is reluctant to have treatment
for his syphilis as he feels very well and asks you how he can
have syphilis if he doesn't have symptoms.
Which of the following should you advise him?
A. Asymptomatic (latent) infection implies late disease
B. Symptomatic syphilis requires repeated antibiotic
treatments; latent disease requires a one off treatment
only
C. Spontaneous clearance of Treponema pallidum does not occur
D. Only symptomatic patients need treatment for syphilis
E. Almost all patients with syphilis will describe a chancre
as their first symptom
ANSWER:
C. Spontaneous clearance of Treponema pallidum does not occur
EXPLANATION:
Latent syphilis (i.e asymptomatic syphilis) can occur
at an early and a late stage and requires the same
antibiotic treatment
Syphilis can be present without any symptoms at
either an early or a late stage; these are called 'early
latent' (less than 2 years since last negative syphilis
test) and 'late latent' (more than 2 years since last
negative test). Whether the syphilis is latent or
causing symptoms does not alter the treatment; this is
only affected by whether syphilis has not been tested
for in the last 2 years, in which case further doses arerequired, or if
neurosyphilis is suspected. Many
patients with syphilis are unaware of having had a
chancre and this is sometimes picked up incidentally
on clinical examination. There is no known clearance
of Treponema pallidum without antibiotic treatment
Please see Q-171

Q-261
A 30-year-old man presents to the genito-urinary medicine
clinic. He has been handed a slip from an ex-girlfriend stating
she has tested positive for Chlamydia. He last slept with her
2 months ago. He has no symptoms of note, in particular no
dysuria or discharge. What is the most appropriate
management?
A. Reassure symptoms would have presented by now
B. Offer antibiotic therapy
C. Offer Chlamydia testing and antibiotic treatment immediately without waiting for
the results
D. Offer Chlamydia testing and antibiotic treatment if
positive
E. Notify public health
ANSWER:
C. Offer Chlamydia testing and antibiotic treatment immediately without waiting for
the results
EXPLANATION:
Please see Q-32 for Chlamydia

Q-262
A 46-year-old woman presents 3 days after returning from a
safari holiday in Tanzania. She complains of fever, chills,
myalgia and malaise which started 2 days ago and now
complains of daytime somnolence and night time insomnia.
Her husband also reports she has been acting strangely. She
says she took malarone as antimalarial prophylaxis and had
all the recommended vaccines before travelling. A HIV test
was negative.
On examination her temperature is 38.5ºC, heart rate
90/min, blood pressure 118/90 mmHg, respiratory rate
18/min.
What is the most likely diagnosis?
A. Cerebral malaria
B. Human African Trypanosomiasis
C. Yellow fever
D. Tuberculosis meningitis
E. Bacterial meningitis
ANSWER:
B. Human African Trypanosomiasis
EXPLANATION:
The reversal of the sleep wake cycle is typical of
trypanosomiasis (African sleeping sickness) and can be
accompanied by behavioural changes. Cerebral malaria
would be unlikely given that she took malarone and reversal
of the sleep-wake cycle would not be a feature. TB
meningitis is also very unlikely in this lady, especially in the
absence of HIV or other immunosuppressive illness. Bacterial
meningitis again does not cause reversal of the sleep-wake
cycle and the onset is quite long for bacterial meningitis.
Yellow fever is found in Tanzania (although the risk is low)
and the initial symptoms may be similar but the later stages
involve jaundice, abdominal pain and bleeding not
behavioural and sleep disturbances.
Please see Q-1 for Trypanosomiasis

Q-263
A 44-year-old man who is known to be HIV positive presents
with shortness-of-breath. Which one of the following
features is most characteristic of Pneumocystis carinii
pneumonia?
A. Usually occurs when the CD4 count is 200-300/mm³
B. Absence of fever
C. Productive cough
D. Oxygen saturations usually improve after short period of
exertion
E. Normal chest auscultation
ANSWER:
E. Normal chest auscultation
EXPLANATION:
Please see Q-28 for HIV: Pneumocystis Jiroveci Pneumonia

Q-264
A 34-year-old man from West Africa is admitted due to
confusion associated with left-sided weakness and ataxia. He
is known to be HIV positive but is not on anti-retroviral
treatment. The following results are obtained:
CD4 43 u/l
CT head Low attenuation diffusely.
No mass effect or enhancement
What is the most likely diagnosis?
A. Toxoplasmosis
B. Tuberculosis
C. Progressive multifocal leukoencephalopathy
D. Cryptococcus
E. Cerebral lymphoma
ANSWER:
C. Progressive multifocal leukoencephalopathy
EXPLANATION:
Please see Q-34 for HIV: neurocomplications
Q-265
A patient who was an intravenous drug user in the 1990s
asks for a hepatitis C test. What is the most appropriate
action?
A. Refer him for pre-test counselling to discuss the pros
and cons of testing
B. Advise him that no accurate test is currently available
but that he should undertake normal precautions
C. Arrange an anti-HCV antibody test
D. Arrange a HCV RNA test
E. Refer him to gastroenterology for a liver biopsy
ANSWER:
C. Arrange an anti-HCV antibody test
EXPLANATION:
HCV RNA tests are normally only ordered following a positive
antibody test.
Please see Q-6 for Hepatitis C

Q-266
What is the most appropriate antibiotic to use in cholera?
A. Erythromycin
B. Metronidazole
C. Doxycycline
D. Penicillin V
E. Trimethoprim
ANSWER:
C. Doxycycline
EXPLANATION:
Cholera
Overview
• caused by Vibro cholerae - Gram negative bacteria
Features
• profuse 'rice water' diarrhoea
• dehydration
• hypoglycaemia
Management
• oral rehydration therapy
• antibiotics: doxycycline, ciprofloxacin