Infectious disease , HIV, STD FCPS exam with Dr Sohrab

An 18-year-old medical student is brought into the Emergency Department by her flatmate. She has been generally unwell for the last week with a fever, headache and some swelling under her ears, which she thought was caused by enlarged lymph nodes. Today, however, her headache is much worse and she has started to vomit. On examination she is febrile at 37.9oC and slightly drowsy, although she is rousable and can answer questions coherently; she has some neck stiffness and is complaining of slight photophobia. There is no focal neurology, no rash and she is haemodynamically stable. A lumbar puncture is carried out, the interpretation of which is below: Appearance: clear White cells: lymphocyte predominant Glucose: normal Protein: normal No organisms seen on microscopy Which one of the following is the most likely causative organism in this case?

A 24-year-old man comes to the Emergency Department with concerns about his recent sexual intercourse. He thinks that his partner is HIV-positive. They have engaged in unprotected receptive and insertive anal intercourse in the past 24 hours. The patient himself has no past medical history and is not taking any medication. BP is 122/78 mmHg, heart rate is 88 bpm and physical examination is unremarkable. Which one of the following is the most appropriate next step?

Hepatitis serology
HIV antibody/antigen testing and if negative reassure
HIV testing and if negative give post-exposure prophylaxis (PEP)
Rectal and urethral swabs
Safe sex advice and provide condoms

A 38-year-old man presents to his GP with a week’s history of watery diarrhoea, nausea, vomiting and fever. He is known to be HIV-positive and has been on antiretroviral therapy (ART) for around 6 weeks; his CD4 count before starting ART was 152 cells/µl. On examination he has a low-grade pyrexia (38.1 °C), dry mucous membranes and generalised moderate abdominal tenderness, though his abdomen is soft. Which one of the following is the most likely diagnosis?

A 25-year-old PhD student is brought to A+E by her boyfriend. He tells you that she complained of a fever and headache last night, and this morning is very drowsy. On examination she looks unwell with a temperature of 38.5 °C, neck stiffness and photophobia. She has no rash and no focal neurology. You perform a lumbar puncture (LP) and start her on ceftriaxone to cover bacterial meningitis. Later that day you receive a call from the microbiology lab to say that Gram staining of the cerebrospinal fluid (CSF) has shown Gram-negative cocci. Which one of the following is the most likely causative organism?

A 30-year-old woman, who enjoys hiking in the New Forest, presents to her GP concerned that she may have contracted Lyme disease. Which one of the following is not typically associated with Lyme disease?

A 17-year-old boy, who has moved to the UK from India, presents with a mild fever (37.5 °C), a maculopapular rash and pharyngitis; he has severe difficulty swallowing, even his own saliva. On examination there is a greyish membrane surrounding the tonsils; there is also submandibular and cervical lymphadenopathy and oedema of the neck. Which one of the following is the most likely diagnosis?

A 29-year-old woman with no past medical history presents as a blue-light call to the Emergency Department. On initial review she is febrile at 39.3 °C, with a blood pressure of 60/40 mmHg, a heart rate of 140 bpm, a GCS of 12 and a widespread rash. Her blood pressure is unresponsive to fluids, and she is rapidly transferred to the intensive care unit for ionotropic support. You see her when she is stepped down onto the ward 2 weeks later. Now able to give a history, she tells you that she became unwell very quickly, and initially thought she had flu. She had an insect bite before this that she thought might have been slightly infected. She is feeling much better, but has noticed that the skin on her hands and feet is peeling off. Which one of the following organisms is most likely to be responsible for her presentation?

A 23-year-old woman with no past medical history presents to the Emergency Department feeling generally unwell with a non-itchy rash. She has also noticed some genital lesions that have appeared over the last few days. She takes the oral contraceptive pill, but no other medications. On direct questioning she admits to having unprotected sexual intercourse on two occasions during a holiday a few months ago, following which she had a painless spot in her vulval region that took some time to heal. On examination she has a temperature of 37.8oC, blood pressure of 110/75 mmHg and heart rate of 90 bpm. She has a widespread maculopapular rash, which includes the palms and soles, with generalised lymphadenopathy and some scattered plaquelike lesions around the vulva. Which one of the following would be the most useful next investigation in this situation?

An intravenous drug user sees his doctor with a history of lethargy. LFTs demonstrate an ALT of 80 IU/l and a bilirubin of 18 μmol/l. Serological tests for hepatitis viruses show HepB surface Ag-positive and anti-HepB core IgG Abpositive, IgM Ab was absent. Which one of the following options is the most appropriate interpretation of the serological studies?

A 31-year-old man presents to the Emergency Department with fatigue and worsening shortness of breath on exertion, a few weeks after the death of his partner. He reports a dry cough and occasional night sweats for the preceding 6 weeks; he has lost 6–10 kg over the last 6 months. On examination he is tachypnoeic (RR 28/min), but on auscultation his lung fields are clear. His oxygen saturation at rest is around 90%, but that drops quickly on even minimal exertion; he requires oxygen via nasal cannulae to maintain a saturation of ≥ 95%. A full blood count reveals a mild anaemia (Hb 103 g/l), thrombocytopenia (55 x 109/l) and relative lymphopaenia (0.2 x 109/l); his lactate dehydrogenase is raised (340 U/l). He consents to an HIV test, which is positive; his CD4 count is 85 cells/µL. A chest X-ray (CXR) reveals diffuse bilateral pulmonary infiltrates. Which of the following diagnoses fits best with this clinical picture?

An Indian man is referred with peripheral oedema of the arms and recurrent rhinitis. On examination there is deformity of the nose with collapse of the nasal bridge and multiple skin plaques. A skin biopsy reveals multiple acid– alcohol-fast bacilli. Which one of the following options is the most likely diagnosis?

A 23-year-old man presents to his GP complaining of fevers, headache, malaise and muscle pain. He returned to the UK a week previously after a walking trip in the South-Eastern USA; he reports using a cigarette to burn a tick off his leg soon after his return. On examination he has a maculopapular, erythematous rash on the palms and soles of his feet; a few petechiae can also be seen on closer inspection. Which one of the following fits best with this clinical picture?

A 52-year-old man has asked the practice nurse about the applicability of vaccines before taking a holiday abroad. He has a history of asthma and has required 20 mg of daily prednisolone for the previous 2 months; this was recently increased to 40 mg during an exacerbation. Which one of following vaccinations would be contraindicated in this man?

A 23-year-old man from the Gambia presents to the General Practioner with a 4-day history of intermittent fevers, headache and loose stools. He now reports feeling very fatigued and struggles to get out of bed. There is no past medical history of note. On examination, his temperature is 38.9 °C. He has a heart rate of 117 bpm and a blood pressure of 134/80 mmHg. There are no signs of meningism and fundoscopy is normal. His abdomen is diffusely tender. Which of the following is the most appropriate investigation to establish a diagnosis?

A 47-year-old woman undergoing chemotherapy for breast cancer has a neutrophil count of 0.2 × 109/l. She presents with an acute deterioration in conscious level associated with headache, photophobia and neck stiffness. Following CT and CSF examination, a provisional diagnosis of bacterial meningitis is made. Which one of the following organisms is most likely to be responsible for this patient’s condition?

An 18-year-old man presents to the Emergency Department with a short history of urethral discharge and dysuria. He has just returned from a holiday in Magaluf with friends, during which he had unprotected sexual intercourse on more than one occasion. Gram-staining of the discharge reveals Gram-negative diplococci. The patient refuses to have any intramuscular injection. Which one of the following options would be the most appropriate therapy in this case?

A 29-year-old woman returns from a trip to the jungles of Northern Thailand with body ache, severe myalgia of her back, arms and legs, and a maculopapular rash that began on her limbs and has now spread to involve the trunk. She had fevers of up to 40 °C for the first few days, but these have now subsided. Three sets of malaria films are negative. Which one of the following fits best with this clinical picture?

A 19-year-old student visits you complaining of fevers and headaches for the past 2 weeks. She has just started university after travelling extensively during her gap year. She also reports a sore throat, general malaise and muscle ache, loss of appetite and vague abdominal pain. She remembers a short period of diarrhoea 10 days ago; this has since resolved. On examination there are a few faint maculopapular blanching lesions on her chest. Routine blood tests reveal a thrombocytopenia (95 x 109/l) with a raised ESR (68 mm/h). Which one of the following fits best with this clinical picture?

A 26-year-old man presents with two to three erythematous nodules on his arms; 3 weeks ago he returned from a month travelling in South America. They have been increasing in size and in the last few days have started to develop a golden crust. Which of the following options is the most likely diagnosis?

A 40-year-old businessman is admitted with a 5-day history of fevers, cough and diarrhoea, 1 week after returning from a business trip to Rome. He is a smoker, but has no past medical history and is taking no regular medications. On examination he is pyrexial at 38.1 °C, with a heart rate of 95 bpm, a blood pressure of 120/80 mmHg and oxygen saturations of 93% on air. He has bibasal crackles on chest auscultation, with scattered wheeze, and an unremarkable abdominal examination. Blood tests show a lymphopenia with a sodium level of 130 mmol/l, a mild acute kidney injury and slightly deranged liver function. You are concerned that he may have Legionnaire’s disease. Which one of the following tests would be first choice to confirm this diagnosis?

A 30-year-old patient with hereditary elliptocytosis is booked to undergo an elective splenectomy. Which one of the following best describes the vaccines this patient should receive?

Annual influenza vaccination only
BCG vaccine ideally 4–6 weeks before surgery
Measles/mumps/rubella (MMR) vaccine ideally 4–6 weeks before surgery
No further live vaccines at any point
Pneumococcal vaccination ideally 4–6 weeks before surgery

A 22-year-old man returns from 3 months travelling around Central and southern Africa, including Malawi, Tanzania and Uganda. He presents to his GP complaining of painless haematuria, and perineal itching and inflammation. Which one of the following diagnoses fits best with this clinical picture?

Gonorrhoea
Infection with Schistosoma haematobium
Infection with Schistosoma japonicum
Infection with Schistosoma mansoni
Bladder squamous cell carcinoma (SCC)

A 23-year-old woman comes to the clinic complaining of an offensive-smelling vaginal discharge – she has tried washing with soap two to three times a day without success. She tells you that she has had the same regular sexual partner for the last 2 years. On examination she looks well. Vaginal examination reveals a fishy odour and a greyish adherent vaginal discharge. Which one of the following options is the most likely infectious agent?

A 19-year-old woman presents to the General Practitioner with a 4-week history of excessive greenish vaginal discharge. On direct questioning, she also describes pelvic pain on sexual intercourse, with occasional post-coital bleeding. She has had three casual sexual partners without contraception in the last six months. On examination, she is clinically well, but her cervix is tender on bimanual palpation. Which of the following is the most likely diagnosis?

A 30-year-old man presents with an acute onset of pain and blurred vision of his right eye. He has no history of recent travel. On examination he is mildly photophobic and there is conjunctival injection. Closer examination reveals multiple, small, branching erosions on the surface of his cornea; several of the branches have bulbous ends. Which one of the following is the most likely diagnosis?