Which of the following types of viral meningitis may be characteristically associated with a low cerebrospinal fluid glucose level?
Correct Answer A: Mumps meningitis is associated with a low CSF glucose.
Mumps meningitis is associated with a low glucose in up to a third of patients.
Meningitis: CSF analysis: The table below summarizes the characteristic cerebrospinal fluid (CSF) findings in meningitis:
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.
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?
Correct Answer E: 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:
Diagnosis:
A 62-year-old woman who has recently been treated for ascending cholangitis is referred to hospital due to persistent fever and anorexia. An ultrasound scan reveals the presence of a liver abscess.
What is the most appropriate antibiotic therapy to accompany drainage of the abscess?
Correct Answer C:
Pyogenic liver abscess: Management:
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?
Correct Answer D:
Post-exposure prophylaxis:
Hepatitis A:
Hepatitis B:
Hepatitis C:
HIV:
Varicella zoster:
Estimates of transmission risk for single needlestick injury:
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?
Correct Answer C: Whilst the RCOG guidelines recommend 28-32 weeks the BHIVA suggest a slightly earlier gestation may be suitable depending on individual circumstances. The most suitable answer is therefore 20-32 weeks.
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 minimize harm to both the mother and fetus, and to reduce the chance of vertical transmission.
Factors which reduce vertical transmission (from 25-30% to 2%):
Screening:
Antiretroviral therapy:
Mode of delivery:
Neonatal antiretroviral therapy:
*The 2008 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.
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