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?
Correct Answer E:
Cellulitis: management:
The BNF recommends flucloxacillin as first-line treatment for mild/moderate cellulitis. Clarithromycin or clindamycin is recommend 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.
A 72-year-old woman is reviewed following a course of oral flucloxacillin for right lower limb cellulitis. The local protocol suggest oral clindamycin should be used next-line.
Which one of the following side-effects is it most important to warn her about?
Clostridium difficile: Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.
Features:
Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool.
Management:
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?
Correct Answer B: Cardiac involvement is the leading cause of death in patients with Chagas' disease.
Trypanosomiasis: Two main form of this protozoal disease are recognized:
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:
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:
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?
Correct Answer D:
Vaginal discharge: Vaginal discharge is a common presenting symptom and is not always pathological.
Common causes:
Less common causes:
Key features of the common causes are listed below:
Which one of the following statements regarding scabies is false?
Correct Answer D: It is normal for pruritus to persist for up to 4-6 weeks post eradication.
Scabies: Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults.
The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.
Patient guidance on treatment (from Clinical Knowledge Summaries):
The BNF advises to apply the insecticide to all areas, including the face and scalp, contrary to the manufacturer's recommendation. Patients should be given the following instructions:
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