Warm*autoimmune*haemolytic*anaemia*

• IgG*causes*haemolysis*at*body*temperature*and*tends*to*affect*extravascular*sites*(eg.*spleen).*
• Causes:*autoimmune*disease,*neoplasia*(eg.*lymphoma),*drugs*(eg.*methyldopa).*
• Management:*steroids,*immunosuppression,*splenectomy.*
Cold*autoimmune*haemolytic*anaemia*
• IgM*causes*haemolysis*at*cold*temperatures*and*tends*to*affect*intravascular*sites*to*cause*symptoms*similar*
to*Raynaud’s*and*acrocyanosis.*
• Causes:*neoplasia*(eg.*lymphoma),*infections*(eg.*mycoplasma,*EBV).*
• Macrocytic*anaemia*may*be*present*due*to*deticulocytosis*to*compensate*for*the*haemolysis.*
Aplastic*anaemia*
• Characterised*by*pancytopaenia*and*a*hypolastic*bone*marrow.*
• Causes:*idiopathic,*drugs*(cytotoxics,*chloramphenicol,*sulphonamides,*phenytoin),*infections*(parvovirus,*
hepatitis),*radiation.*
• Features:*normochromic*normocytic*anaemia,*leukopaenia*(with*lymphocytes*relatively*spared),*
thrombocytopaenia.*
Beta*thalassaemia*
• Autosomal*recessive*condition*that*is*usually*asymptomatic.*
• Features:*mild*hypochromic*microcytic*anaemia;*microcytosis*is*typically*disproportionate*to*degree*of*
anaemia.*
• Investigations:*haemoglobin*A2*is*raised*(>*3.5%).*
• Beta*thalassaemia*major:*symptomatic*beta*thalassaemia*is*due*to*a*chromosome*11*abnormality*and*
requires*lifelong*blood*transfusions.*
• Beta*thalassemia*major:*presenst*in*first*year*of*life*with*failure*to*thrive,*microcytic*anaemia*and*
hepatosplenomegaly.*
Myelodysplasia*
• Acquired*neoplastic*disorder*of*haematopoietic*stem*cells.*
• 1/3*of*cases*may*progress*to*acute*myeloid*leukaemia.*
• Features:*bone*marrow*failure*(anaemia,*neutropaenia,*thrombocytopaenia).*
Waldenstrom’s*macroglobulinaemia*
• Malignancy*characterised*by*secretion*of*monoclonal*IgM*paraproteinaemia.*
• Rare*condition*seen*in*older*men.*
• Features:*monoclonal*IgM*paraproteinaemia,*systemic*upset*(weight*loss,*lethargy),*hepatosplenomegaly,*
hyperviscosity*syndrome*(visual*disturbance),*lymphadenopathy,*cryoglobulinaemia*(eg.*Raynaud’s).*
Polycythaemia*
• Increased*haematocrit*(volume*percentage*of*RBC*in*blood).*
• Primary*cause*is*polycythaemia*vera.*
• Secondary*causes:*COPD,*altitude,*obstructive*sleep*apnea,*excessive*erythropoeitin.*
Polycythaemia*vera**
• Myeloproliferative*disorder*caused*by*clonal*proliferation*of*marrow*stem*cells*leading*to*increase*in*red*cell*
volume.*

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• Often*accompanied*by*overproduction*of*neutrophils*and*platelets.*
• JAK2*mutation*is*present*in*95%*of*patients*and*is*the*firstUline*investigation.*
• Features:*hyperviscosity,*pruritus*(especially*after*hot*bath),*splenomegaly,*haemorrhage*(secondary*to*
abnormal*platelet*function),*plethoric*appearance,*hypertension.*
• Investigations:*FBC*may*show*a*raised*haematocrit,*raised*neutrophils*and*platelets*in*half*of*patients.*
• Diagnostic*criteria:*mutation*of*JAK2;*high*haematocrit*or*raised*red*cell*mass.*
Myelofibrosis*
• Myeloproliferative*disorder*caused*by*hyperplasia*of*abnormal*megakaryocytes.*
• Features:*anaemia*(fatigue*is*most*common*symptom),*massive*splenomegaly,*hypermetabolic*symptoms*
(weight*loss,*night*sweats).*
• Blood*results:*anaemia,*high*WBC,*high*platelet,*increased*cell*turnover*(high*urate*and*LDH).*
• Blood*film:*tearUdrop*poikilocytes.*
G6PD*deficiency*
• Most*common*RBC*enzyme*defect*leading*to*shorter*life*span*of*RBC*and*increased*haemolysis.*
• XUlinked*recessive.*
• Features:*neonatal*jaundice,*intravascular*haemolysis,*gallstones,*splenomegaly.*
• Investiagtions:*G6PD*enzyme*assay*is*diagnostic.*
• Blood*films:*red*cell*fragments*and*Heinz*bodies.*
• Complications:*haemolytic*crisis*due*to*ciprofloxacin,*sulphonamides,*sulphonylureas,*sulphasalazine.*
Thrombocytopaenia*
• Causes*of*severe*disease:*ITP,*DIC,*TTP,*haematological*malignancy.*
• Causes*of*moderate*disease:*heparinUinduced*thrombocytopaenia,*drugUinduced*(quinine,*diuretics,*
sulphonamides,*aspirin,*thiazides),*alcohol,*liver*disease,*hypersplenism,*viral*infection,*pregnancy,*SLE,*
antiphospholipid*syndrome,*vitamin*B*12*deficiency.*
HeparinUinduced*thrombocytopaenia*
• Prothrombin*condition*that*causes*reduction*in*platelets,*thrombosis*and*skin*allergy.*
• Develops*after*5U10*days*of*treatment*of*heparin.*
Thrombocytosis*
• Abnormally*high*platelet*count*(>*400*×*109*/l).*
• Causes:*inflammation,*surgery*(acute*phase*reaction),*malignancy,*essential*thrombocytosis,*hyposplenism.*
Essential*thrombocytosis*
• Caused*by*proliferation*of*megakaryocytes,*resulting*in*an*overproduction*of*platelets.*
• Defined*by*platelet*count*>*600*×*109/l.*
• Features:*burning*sensation*in*hands,*venous*and*arterial*thrombosis,*haemorrhage.*
• Management:*hydroxyurea*is*used*to*reduce*platelet*count;*interferonUalpha*is*used*in*younger*patients.*
• Management:*low*dose*aspirin*may*be*used*to*reduce*thrombotic*risk.*
Lead*poisoning*
• Features:*abdominal*pain,*peripheral*neuropathy*(mainly*motor),*fatigue,*constipation,*blue*lines*on*gum*
margin.*
• Investigations:*raised*blood*serum*lead;*microcytic*anaemia.*

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• Blood*film:*red*cell*abnormalities*(basophilic*stippling,*clover*lead*morphology).*
• Management:*use*chelating*agents*(dimercaptosuccinic*acid,*DUpenicillamine,*EDTA,*dimercaprol).*
Blood*transfusion*
• Universal*donor*of*blood*is*O;*universal*donor*of*plasma*is*AB*RhD*negative.*
• Offer*packed*red*cells*if*haemoglobin*is*<*70*g/l*to*patients*without*ACS*(target*70U90*g/l).*
• Offer*packed*red*cells*if*haemoglobin*is*<*80*g/l*to*patients*with*ACS*(target*80U100*g/l).*
• Acute*transfusion*reaction:*presents*in*first*24*hours*and*usually*resolves*without*complications.*
• Acute*transfusion*reaction:*features*include*fever,*chills,*pruritus,*urticaria;*signs*such*as*dyspnoea,*pyrexia*
and*loss*of*consciousness*indicates*a*more*severe*reaction.*
• NonUimmune*mediated*reactions:*hypocalcaemia,*hyperkalaemia.*
• Anaphylaxis:*features*include*urticaria,*hypotension,*dyspnoea,*wheezing,*stridor,*angioedema.*
• Anaphylaxis:*urticaria*can*be*treated*with*termination*of*transfusion*and*antihistamines;*severe*anaphylaxis*
should*be*treated*with*IM*adrenaline,*antihistamines,*corticosteroids,*bronchodilators*and*supportive*care.*
• Complications:*hypothermia,*hypocalcaemia,*hyperkalaemia,*delayed*type*transfusion*reactions,*transfusion*
related*lung*injury,*coagulopathy.*
Acute*haemolytic*transfusion*reaction*
• Caused*by*ABO*mismatch*and*results*in*massive*intravascular*haemolysis.**
• Confirm*haemolysis*with*Coomb’s*test.*
• Features:*fever,*abdominal*pain,*chest*pain,*agitation,*hypotension.*
• Management:*immediate*transfusion*termination*and*generous*fluid*resuscitation*with*saline.*
Platelet*transfusion*
• Offer*to*patients*with*a*platelet*count*of*<*10*×*109*if*there*is*no*active*bleeding.*
• Offer*to*patients*with*a*platelet*count*of*<*30*×*109*with*clinically*significant*bleeding.*
• Offer*to*patients*with*a*platelet*count*of*<*100*×*109*for*patients*with*severe*bleeding*(eg.*CNS*bleeding).*
• Aim*for*a*platelet*count*of*50*×*109*if*a*patient*requires*surgery*and*is*thrombocytopaenic.*
Other*
• Any*of*following*features*in*a*person*aged*0U24*years*should*prompt*an*urgent*FBC*to*investigate*for*
leukaemia*–*pallor,*persistent*fatigue,*unexplained*fever,*unexplained*persistent*infection,*generalised*
lymphadenopathy,*unexplained*bone*pain,*unexplained*bruising,*unexplained*bleeding.*
• Any*unexplained*hepatosplenomegaly*or*petichiae*in*a*person*0U24*years*should*prompt*an*urgent*referral*
to*specialist*for*investigations.*
Lymphatic*drainage*
• Superficial*inguinal*lymph*nodes:*anal*canal*below*pectinate*line,*perineum,*penis,*scrotum,*vagina.*
• Deep*inguinal*lymph*nodes:*glans*penis.*
• ParaUaortic*lymph*nodes:*testes,*ovaries,*kidney,*adrenal*gland.*
• Axillary*lymph*nodes:*breast,*upper*limb.*
• Internal*iliac*lymph*nodes:*anal*canal*above*pectinate*line,*lower*part*of*rectum,*uterus.*
• Superior*mesenteric*lymph*nodes:*duodenum,*jejunum.*
• Inferior*mesenteric*lymph*nodes:*descending*colon,*sigmoid*colon,*upper*part*of*rectum.*
• Coeliac*lymph*nodes:*stomach.*

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Infectious*disease*
Sepsis*
• Red*flags:*systolic*BP*<*90*mmHg;*HR*>*130;*RR*>*25;*lactate*>*2*mmol/l.*
• Other*features:*urinary*retention,*nonUblanching*rash,*reduced*alertness,*confusion,*cyanosis.*
• Management:*1)*give*oxygen*(sat*>*94%);*2)*give*broad*spectrum*antibiotics;*3)*give*IV*fluid*(500*ml*bolus);*
4)*measure*serum*lactate*(venous*blood*gas);*5)*measure*urine*output;*6)*take*blood*cultures.*
Respiratory*tract*infection*
• Includes*acute*otitis*media,*acute*sore*throat,*common*cold,*acute*sinusitis,*acute*bronchitis.*
• Management:*antibiotics*for*children*<*2*years*with*bilateral*acute*otitis*media,*children*with*otorrhoea*with*
acute*otitis*media,*patients*with*3*or*more*Centor*criteria,*comorbidity*(diabetes,*glucocorticoid*use,*elderly).*
Viral*URTI*
• Features:*sore*throat,*cough,*otalgia,*blocked*nose,*rhinorrhoea,*mild*fever.*
• Signs:*chest*is*clear*on*auscultation,*vital*signs*are*normal.*
• Management:*conservative.*
Influenza*(Flu)*
• Type*A*and*B*viruses*cause*the*majority*of*clinical*disease.*
• Features:*headache,*myalgia,*fever,*cough;*clear*chest*on*auscultation.*
• Vaccination:*intranasal*for*children;*first*dose*is*given*at*2U3*years,*then*annually*after*that.*
Live*vaccine,*so*is*contraindicated*in*immunocompromised,*aged*<*2*years*and*children*with*current*illness.*
• Vaccination:*inactivated*vaccine*for*adults;*contraindicated*with*egg*allergy.*
• Vaccination:*recommended*and*safe*to*use*at*all*stages*of*pregnancy.*
Malaria*
• Caused*by*Plasmodium&protozoa.*Spread*by*female*mosquito.*
• Features:*fever,*myalgia,*fatigue;*jaundice,*splenomegaly.*
• Features*(severe):*temperature*>*39,*severe*anaemia,*acidosis,*hypoglycaemia;*schizonts*(sporozoan*cells)*on*
blood*film,*high*parasitaemia*(>*2%).*
• Management:*prophylaxis*should*be*taken*before*entering*countries*with*an*endemic;*
chloroquine*is*preferred*agent*(take*1*week*before*travel*and*continue*until*4*weeks*after*travel).*
• Management:*pregnant*women*should*avoid*going*to*countries*with*malaria*endemic,*but*if*unavoidable*
chloroquine*may*be*used.*
• Management:*firstUline*treatment*is*artemisininUbased*combination*therapy*such*as*artemether*plus*
artesunateUbased*drugs.*
• Management:*severe*malaria*(parasite*count*>2%)*is*treated*with*IV*artesunate;*if*parasite*count*>10%*
exchange*transfusion*should*be*considered.*
• Complications:*cerebral*malaria,*acute*renal*failure,*acute*respiratory*distress*syndrome,*hypoglycaemia,*
DIC.*
Mumps*
• Caused*by*RNA*paramyxovirus;*spreads*by*droplets.**
• Infectious*7*days*before*and*9*days*after*parotid*swelling*starts.*

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• Features:*fever,*malaise,*muscular*pain,*initially*unilateral*parotitis*(pain*on*eating)*which*progresses*to*
bilateral*pain.*
• Management:*rest;*paracetamol*for*fever*and*discomfort.*MMR*vaccine*is*available.*
• Complications:*orchitis*(inflammation*of*testes),*hearing*loss,*meningoencephalitis,*pancreatitis.*
Typhoid*
• Caused*by*gram*negative*Salmonella&typhi;*parathyphoid*is*caused*by*Salmonella&paratyphi.*
• Initial*features:*systemic*symptoms*(headache,*fever,*arthralgia).*
• Other*features:*abdominal*pain,*distension,*diarrhea/constipation,*rose*spots*(irregular*small*rashes*on*
trunk,*more*common*in*paratyphoid),*bradycardia,*splenomegaly.*
• Complications:*osteomyelitis,*GI*bleed,*meningitis,*cholecystitis.*
Dengue*fever*
• Viral*infection*transmitted*by*mosquitos.*
• Features:*headache,*fever,*myalgia,*pleuritic*pain,*facial*flush,*maculopapular*rash.*
• Investigations:*low*platelet*count*and*raised*ALT*is*typical.*
• Management:*symptomatic*–*fluid*resuscitation,*blood*transfusion.*
• Complication:*dengue*haemorrhagic*fever*(type*of*DIC).*
Yellow*fever*
• Viral*haeomrrhagic*fever*that*is*spread*by*mosquitos.*Incubation*period*of*2U14*days.*
• Featuers:*suddenUonset*fever,*rigors,*nausea*and*vomiting*that*lasts*less*than*one*week*followed*by*a*brief*
period*of*remission*followed*by*jaundice,*haematemesis*and*oliguria.*
Toxoplasmosis*
• Caused*by*protozoa*Toxoplasma&gondii.*
• Classically*found*in*cat*faeces*or*food.*
• Features:*most*cases*are*asymptomatic;*fever,*malaise,*lymphadenopathy.*Less*common*symptoms*include*
meningioencephalitis,*eye*problems,*myocarditis.*
• Investigations:*antibody*test,*SabibUFeldman*dye*test.*
• Investigations:*MRI*may*reveal*ringUshaped*contrast*enhancing*lesions.*
• Management:*pyrimethamine*+*sulphadiazine*for*6*weeks;*treat*only*those*with*severe*infection*or*
immunosuppressed*patients.*
Lyme*disease*
• Caused*by*Borrelia&burgdorferi*and*is*spread*by*ticks.*
• Associated*with*heart*block,*myocarditis,*cranial*nerve*palsy*and*meningitis.*
• Features:*erythema*chronicum*migrans*(bullseye*distinctive*rash)*and*systemic*features*(fever,*arthralgia,*
tiredness).*
• Investigations:*serology*testing*for*antibodies*to*Borrelia&burgdorferi*is*diagnostic*–*takes*3U8*weeks*before*
they*are*detectable.*
• Management:*treated*with*doxycycline*(amoxicillin*if*contraindicated);*ceftriaxone*if*there*are*systemic*
symptoms.*
• Complications:*JarischUHerxheimer*reaction*may*be*seen*following*treatment.*
Ebola*

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• Transmitted*by*direct*contact*with*humans;*incubation*period*of*2U21*days.*
• Features:*sudden*onset*fever,*fatigue,*muscle*pain,*headache,*sore*throat;*followed*by*vomiting,*diarrhoea,*
rash,*impaired*renal*function,*impaired*liver*function.*
• Management:*isolation*of*anyone*who*has*a*fever*and*has*recently*travelled*to*West*Africa.*
Pyrexia*of*unknown*origin*
• Prolonged*fever*that*lasts*>*3*weeks*which*resists*diagnosis*and*treatment*after*a*week*in*hospital.*
• Causes:*lymphoma,*hypernephroma,*preleukaemia,*atrial*myxoma,*abscess*infection,*tuberculosis.*
• Exam*hint:*pyrexia*of*unknown*origin*accompanied*by*weight*loss,*lymphadenopathy*and*high*WBC*is*
lymphoma.*
Meningitis*
• Causes:*0*to*3*months*–*Group*B*Streptococcus*(most*common),*E.coli,*Listeria&monocytogenes;*
3*months*to*6*years*–*Neisseria&meningitidis,*Streptococcus&pneumoniae,&Haemophilus&influenzae;*
6*to*60*years*–*Neisseria&meningitidis,&Sterptococcus&pneumoniae;**
>*60*years*–*Streptococcus&pneumoniae,&Neisseria&meningitidis,&Listeria&monocytogenes.*
• Causes:*most*common*bacteria*in*immunosuppressed*patients*is*Listeria&monocytogenes.*
• Causes:*HIV*positive*patients*may*be*infected*with*Cryptococcus*neoformans*if*CSF*reveals*yeast.*
• Features:*fever,*headache,*stiff*neck,*photophobia,*phonophobia,*rash;*presents*as*irritability*in*children.*
• Investigations:*blood*culture,*FBC,*CRP,*coagulation*screen,*blood*glucose,*blood*gas.*
• Investigations:*lumbar*puncture*is*diagnostic;*contraindicated*with*raised*intracranial*pressure.*
• Investigations:*in*patients*with*meningococcal*septicaemia*do*not*perform*lumbar*puncture;*take*blood*
cultures*and*PCR*for*meningococcus*instead.*
• CSF*(normal*ranges):*glucose*(50U80*mg/dl);*protein*(15U40*mg/dl);*RBC*(nil);*WBC*(0U3*cells/mm3).*
• CSF*(interpretation):*bacterial*cause*–*cloudy*appearance,*low*glucose,*high*protein,*polymorph*WBC;**
viral*cause*–*clear/cloudy,*glucose*greater*than*half*of*serum*level,*normal/raised*protein,*lymphocyte*WBC;**
tuberculous*cause*–*slightly*cloudy*+*fibrin*web,*low*glucose,*high*protein,*lymphocyte*WBC.*
• Management:*urgent*admission*is*required;*if*suspected*in*a*rural*setting*then*give*IM*benzylpenicillin*on*the*
way*to*hospital.*
• Management:*initial*empirical*therapy*for*>*50*years*is*IV*cefotaxime*+*amoxicillin;**
if*<*50*years*empirical*therapy*is*IV*cefotaxime*(3rd*generation*cephalosporin).*
• Management:*Meningitis:*meningococcal*meningitis*is*treated*with*IV*benzylpenicillin*or*cefotaxime;**
Listeria*meningitis*is*treated*with*IV*amoxicillin*+*gentamicin;*all*others*are*treated*with*IV*cefotaxime.*
• Management:*if*patient*is*allergic*to*penicillin*or*cephalosporins,*use*chloramphenicol.*
• Management:*prophylaxis*oral*ciprofloxacin*needs*to*be*given*to*close*contacts*of*patients*affected*with*
meningococcal*meningitis;*risk*is*highest*in*first*7*days*postUexposure.*
Viral*encephalitis*
• Most*common*cause*in*adults*is*Herpes*simplex*virus.*
• Features:*sudden*change*in*behaviour,*confusion,*fever,*seizures.*
• CSF:*high*protein,*normal*glucose,*predominance*of*mononuclear*cells.*
Infectious*mononucleosis*(Glandular*fever)*
• Caused*by*EpsteinUBarr*virus.*

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• Features:*sore*throat,*pyrexia,*lymphadenopathy*(cervical*lymphadenopathy)*is*present*in*98%*of*patients;*
malaise,*anorexia,*headache,*palatal*petechiae,*splenomegaly,*hepatitis,*lymphocytosis*with*atypical*
lymphocytes.*
• A*maculopapular,*pruritic*rash*develops*in*99%*of*patients*who*take*amoxicillin*whilst*they*have*glandular*
fever.*
• Investigations:*FBC,*Monospot*test*(heterophil*antibody*test)*during*second*week*of*illness.*
• Management:*symptoms*typically*disappear*after*2U4*weeks.*
• Management:*supportive*and*includes*rest,*fluid*intake,*simple*analgesia*and*avoiding*contact*sports*for*8*
weeks*after*infection*resolves*due*to*risk*of*spleen*rupture.*
Diphtheria*
• Caused*by*gram*positive*Corynebacterium&diphtheriae.*
• History*of*recent*travel*to*Asia.*
• Diphtheria*toxin*commonly*causes*a*diphtheric*membrane*to*form*on*tonsils*caused*by*necrotic*mucosal*
cells;*systemic*distribution*may*lead*to*necrosis*of*myocardial,*neural*and*renal*tissue.*
• Features:*sore*throat*with*grey*coated*tonsils,*cervical*lymphadenopathy,*neuritis*(CN*dysfunction),*heart*
block.*
Tuberculosis*
• Caused*by*Mycobaterium&tuberculosis.*
• Features:*bloody*sputum,*breathlessness,*malaise,*fever,*weight*loss,*night*sweats;*high*risk*geography.*
• Investigations:*Mycobacterium*can*be*cultured*and*detected*with*ZiehlUNeelsen*staining.*
• Investigations:*Mantoux*test*is*the*main*technique*used*to*screen*for*latent*tuberculosis;*interferonUgamma*
blood*test*is*used*to*confirm*this*if*Mantoux*test*is*positive*or*may*be*fasely*negative.*
• Mantoux*test:*<*6*mm*=*result*is*negative,*unexposed*to*TB*so*consider*giving*BCG;**
6U15*mm*=*result*is*positive,*should*not*be*given*BCG*as*already*hypersensitive*or*may*have*had*previous*TB;*
>*15*mm*=*result*is*strongly*positive,*currently*infected*with*TB.*
• Mantoux*test:*false*negative*may*be*caused*by*miliary*TB,*sarcoidosis,*HIV,*lymphoma,*<*6*months*of*age.*
• Histology:*characterised*by*formation*of*granuloma*with*caseous*necrosis*in*centre*(caseating*granuloma).*
• Management:*firstUline*therapy*for*active*disease*is*rifampicin,*isoniazid,*pyrazinamide*and*ethambutol*for*2*
months;*next*is*rifampicin*and*isoniazid*for*4*months.*
• Management:*treatment*fot*latent*tuberculosis*is*is*3*months*of*isoniazid*and*rifampicin*with*pyridoxine*or*6*
months*of*isoniazid*with*pyridoxine.*
• Management:*meningeal*tuberculosis*is*treated*for*at*least*12*months*with*standard*therapy*with*the*
addition*of*steroids.*
• BCG*vaccine:*contains*live*attenuated*Mycobacterium&bovis*and*requires*a*tuberculin*skin*test*first*to*exclude*
past*exposure*to*TB;*given*intradermally.**
• BCG*vaccine:*contraindications*include*previous*BCG*vaccines,*past*history*of*tuberculosis,*HIV,*pregnancy,*
positive*tuberculin*test.*
• BCG*vaccine:*given*to*all*infants*living*in*areas*of*incidence,*infants*with*a*parent*who*was*born*in*a*country*
where*TB*is*common,*people*with*previous*exposure*to*respiratory*TB,*healthcare*workers,*prison*staff,*
homeless*people*contact.*It*is*not*given*to*>35*y.o*as*there*is*no*evidence*that*it*works*in*this*age*group.*
Types*of*TB*

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• Primary*TB:*a*small*lung*lesion*called*Ghon*focus*may*develop*(tubercleUladen*macrophages);*lesion*usually*
heals*by*fibrosis*but*immunocompromised*people*may*develop*miliary*(disseminated)*tuberculosis.*
• Miliary*TB:*spread*of*bacteria*in*lungs*through*pulmonary*venous*system.*
• Secondary*TB:*immunocompromised*patients*may*reactivate*initial*TB*infection*–*generally*occurs*at*apex*of*
lungs*and*spread.**
• Secondary*TB:*causes*include*HIV,*steroids,*malnutrition.*
• Secondary*TB:*sites*of*spread*include*lungs*(most*common),*CNS*(tuberculous*meningitis),*vertebral*bodies*
(Pott’s*disease),*cervical*lymph*nodes,*GI*tract,*kidneys.*
• Latent*TB:*CXR*may*show*a*calcified*Ghon*complex*(previous*primary*TB*that*has*calcified).*
• Latent*TB:*treatment*is*3*months*of*isoniazid*(with*pyridoxine)*and*rifampicin;*or*6*months*of*isoniazid*
(with*pyridoxine).*
Legionella*
• Caused*by*Legionella&pneumophilia.*
• Transmitted*by*water*source*and*airUconditioning*systems*during*overseas*travel.*
• Features:*fluUlike*symptoms*+*fever,*dry*cough,*confusion,*lymphopaenia;*hyponatraemia,*deranged*LFTs.*
• Investigations:*urinary*antigen*is*diagnostic.*
• CXR:*pleural*effusion,*bibasal*consolidation.*
• Management:*erythromycin.*
Aspergilloma*
• MassUlike*fungal*ball*that*colonises*an*existing*lung*cavity;*usually*asymptomatic.*
• Features:*cough,*haemoptysis.*
• Investigations:*high*titre*of*Aspergillus*precipitins.*
• CXR:*rounded*opacity.*
Invasive*aspergillosis*
• Systemic*Aspergillus*infection*that*is*the*leading*cause*of*death*in*immunocompromised*patients.*
• Risk*factors:*HIV,*leukaemia,*broadUspectrum*antibiotics*use,*TNFUa*inhibitor*use.*
Leptospirosis*
• Caused*by*Leptospira&interrogans.*
• Classically*spread*by*infected*rat*urine.*
• Weil’s*disease*is*leptospirosis*that*is*associated*with*jaundice.*
• Features:*fever,*fluUlike*symptoms,*headache,*uscle*ache,*renal*failure,*subconjunctival*haemorrhage,*jaundice*
(if*severe).*
• Management:*high*dose*benzylpenicillin*or*doxycycline.*
Gastroenteritis*
• Features:*loose*bowel*motion*accompanied*by*abdominal*cramps,*fever,*nausea*and*vomiting,*blood*in*stool.*
• May*also*present*as*acute*food*poisoning*(sudden*onset*nausea,*vomiting,*diarrhoea*after*ingestion*of*toxin).*
• E.coli:*most*common;*causes*diarrhoea*with*abdominal*cramps*and*nausea*(12U48*hours*incubation).*
• Shigella:*causes*bloody*diarrhoea*with*vomiting*and*abdominal*pain*(48U72*hours*incubation).*
• Campylobacter&jejuni:*causes*fluUlike*symptoms*with*bloody*diarrhoea,*fever*and*crampy*abdominal*pain**
(48U72*hours*incubation).*

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• Giardiasis:*causes*prolonged*nonUbloody*diarrhoea*(>*7*hours*incubation).*
• Cholera:*causes*profuse*diarrhoea*leading*to*severe*dehydration.*
• Amoebiasis:*gradual*onset*bloody*diarrhoea,*abdominal*pain*and*tenderness*which*may*last*for*weeks**
(>*7*days*incubation).*
• Staphylococcus&aureus:*causes*severe*vomiting*(<*6*hours*incubation).*
• Bacillus&cereus:*causes*vomiting*(<*6*hours*incubation)*or*diarrhoea*(>*6*hours*incubation);*associated*with*
reheated*rice.*
Cholera*
• Caused*by*gramUnegative*Vibro&cholerae.*
• Highly*associated*with*foreign*travel.*
• Features:*profuse*diarrhoea,*dehydration,*hypoglycaemia.*
• Management:*oral*rehydration*and*doxycycline*or*ciprofloxacin.*
Giardiasis*
• Caused*by*giardia*parasite.*Sources*include*water*source,*airUconditioning*systems.*
• Features:*diarrhoea*with*crampy*abdominal*pain*and*bloating.*
Amoebiasis*
• Caused*by*protozoan*Entamoeba&histolytica.*
• Spread*by*faecalUoral*route.*
• Features:*asymptomatic*or*mild*diarrhoea,*severe*amoebic*dysentery.*
• Amoebic*dysntery:*profuse*bloody*diarrhoea;*stool*microscopy*reveals*trophozoites.*
• Management:*metronidazole.*
Clostridium&difficile*infection*
• GramUpositive*rod*infection*that*develops*when*normal*gut*flora*are*suppressed*by*broadUspectrum*
antibiotics*(especially*cephalosporins*and*clindamycin);*also*associated*with*PPI*use.*
• May*lead*to*pseudomembranous*colitis.*
• Risk*factors:*broadUspectrum*antibiotics*(clarithromycin*is*high*risk),*personUtoUperson*spread.*
• Features:*diffuse*watery*stool*(diarrhoea),*abdominal*pain,*raised*WBC;*toxic*megacolon*if*severe.*
• Investigations:*diagnosis*is&Clostridium&difficile&toxin*in*stool.*
• Management:*firstUline*is*oral*metronidazole*for*10U14*days;*oral*vancomycin*if*severe.*
• Management:*isolate*patients*for*48*hours.*
• Management:*antiUmotility*and*antiUperistaltic*drugs*(including*opioids)*should*be*withheld*as*they*slow*
clearance*of*the*toxin.*
Whipple’s*disease*
• MultiUsystem*disorder*caused*by*Tropheryma&whippelii.*
• Associated*with*HLAUB27.*
• Features:*diarrhoea,*weight*loss,*largeUjoint*arthralgia,*lymphadenopathy,*hyperpigmentation,*
photosensitivity,*pericarditis.*
• Investigations:*jejunal*biopsy*shows*deposition*of*macrophages*containing*PAS*granules.*
• Management:*oral*coUtrimoxazole*for*1*year.*
Hyatid*cyst*

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• Liver*or*lung*cyst*that*forms*due*to*an*intense*fibrotic*reaction*that*occurs*around*site*of*infection*by*
Echinococcus&granulosus*tapeworms.*
• Features:*malaise,*RUQ*pain;*only*symptomati*if*cyst*is*>*5*cm.*
• Investigations:*abnormal*LFTs;*eosinophilia*(33%*of*cases).*
• Investigations:*CT*is*best*investigation.*
• Management:*surgical*resection.*
Lower*urinary*tract*infection*
• Features:*dysuria,*increased*frequency,*hesitancy,*incomplete*voiding.*
• Management:*trimethoprim*or*nitrofurantoin*for*3*days.*
• Management:*pregnant*women*should*be*treated*with*nitrofurantoin*for*7*days*(but*not*during*
breastfeeding).*
Acute*pyelonephritis*
• Management:*broadUspectrum*cephalosporin*or*quinolone*(for*nonUpregnant*women)*for*10U14*days.*
Chlamydia*
• Caused*by*Chlamydia&trachomatis.*Incubation*period*of*7U21*days.*
• Features:*asymptomatic*in*most*cases;*women*present*with*cervicitis*(discharge*+*bleeding)*and*dysuria;*
men*present*with*urethral*discharge*and*dysuria.*
• Investigations:*PCR*is*firstUline*for*diagnosis.*
• Management:*treatment*is*azithromycin*(1*g*stat)*or*doxycycline*(7*days);*if*pregnant,*azithromycin,*
erythromycin*or*penicllin*may*be*used.*
• Management:*give*antibiotics*without*waiting*for*results*if*suspicious.*
• Management:*all*recent*sexual*partners*should*be*contacted*and*offered*empirical*treatment*and*testing.*
• Complications:*epididymitis,*PID,*endometriosis,*ectopic*pregnancy,*infertility.*
FitzUHughUCurtis*syndrome**
• PeriUhepatic*inflammation*secondary*to*chlamydia.**
• Features:*RUQ*discomfort*with*pyrexia;*hepatic*adhesions*(lesions*between*liver*and*abdominal*wall)*are*
specific*to*this*disease.*
Gonorrhoea*
• Caused*by*gramUnegative*Neisseria&gonorrhoeae.*Incubation*period*is*2U5*days.*
• Features:*men*present*with*urethral*discharge,*dysuria;*women*present*with*cervicitis*with*discharge.*
• Management:*ciprofloxacin*or*cephalosporin;*IM*ceftriaxone*(500*mg)*+*oral*azithromycin*(1*g)*is*preferred*
regime.*
• Complication:*PID*that*leads*to*infertility.*
Bacterial*vaginosis*
• Overgrowth*of*predominantly*anaerobic*organisms*such*as*Gardenella&vaginalis.*
• Seen*exclusively*in*sexually*active*women*although*it*is*not*a*STI.*
• Features:*fishy*smelling,*offensive*white/grey*vaginal*discharge;*asymptomatic*in*50%.*
• Investigations:*vaginal*pH*>*4.5;*whiff*test*positive.*
• Diagnostic*criteria:*a)*thin,*white*homogenous*discharge;*b)*clue*cells*(stippled*vaginal*epithelial*cells)*on*
microscopy;*c)*vaginal*pH*>4.5;*d)*positive*whiff*test*(potassium*hydroxide*causes*fishy*odour).*

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• Management:*oral*metronidazole*(5U7*days);*topical*metronidazole*or*topical*clindamycin*are*alternatives.*
• Complications:*increased*risk*of*preterm*labour,*low*birth*weight,*chorioamnionitis,*late*miscarriage.*
Vaginal*candidiasis*(Thrush)*
• Caused*by&Candida*(fungal*infection),*often*after*recent*antibiotic*exposure.*
• Risk*factors:*diabetes,*antibiotics,*steroids,*immunosuppression.*
• Features:*‘cottage*cheese’*nonUsmelly*discharge;*vulvitis*(dyspareunia,*dysuria),*itch,*vulval*erythema.*
• Management:*oral*fluconazole*150*mg*PO*stat;*if*pregnant*use*a*clotrimazole*pessary*as*oral*antifungals*are*
contraindicated.*
Trichomoniasis*
• Caused*by*Trichomonas*vaginalis*(protozoa).*
• Features:*yellow/green,*offensive,*frothy*discharge;*vulvovaginitis,*strawberry*cervix.*
• Management:*oral*metronidazole.*
Herpes*simplex*
• Primary*infection*may*present*with*gingivostomatitis,*cold*sores*and*painful*genital*ulceration.*
• Genital*infection:*herpes*lesions,*irritating*rash*on*vulva,*dysuria.*
• Investigations:*urine*dipstick*shows*blood*and*WBC.*
• Management:*genital*herpes*is*treated*with*oral*aciclovir;*cold*sore*is*treated*with*topical*aciclovir.*
• Management:*during*pregnancy,*elective*caesarean*section*at*term*is*advised*if*primary*attack*of*herpes*
occurs*at*>*28*weeks*gestation;*recurrent*herpes*should*be*treated*with*drug*therapy*until*delivery*to*reduce*
transmission*to*baby*(oral*aciclovir*400*mg*TDS).*
Genital*warts*
• Causes:*HPV*(especially*6*and*11).*
• Features:*small*fleshy*protuberances*on*genitalia*that*may*bleed*or*itch;*may*be*keratinised.*
• Management:*nonUkeratinised*warts*are*treated*with*topical*podophyllum;**
keratinised*warts*are*treated*with*cryotherapy*(imiquimoid*is*secondUline).*
• Pearly*penile*papules*are*a*normal*variant*of*the*glans*penis*and*is*not*a*cause*for*concern.*
Chancroid*
• Tropical*disease*caused*by*Haemophilus&ducreyi.*
• Features:*painful*genital*ulcers*that*are*sharply*defined*and*ragged*with*undermined*borders;*associated*
with*unilateral,*painful*inguinal*lymphadenopathy.*
Syphilis*
• STI*caused*by*Treponema&pallidum.*Incubation*period*is*9U90*days.*
• Often*not*seen*in*women.*
• Primary*features:*chancre*(pailness*ulcer*at*site*of*sexual*contact),*local*nonUtender*lymphadenopathy.**
• Secondary*features:*occurs*after*6U10*weeks.*Systemic*symptoms*(fever,*lymphadenopathy),*maculopapular*
rashes*on*trunk/palms/soles,*condylomata*lata,*buccal*ulcers.*
• Management:*benzylpenicillin*with*doxycycline*as*an*alternative*(but*not*during*pregnancy).*
• Complications:*JarischUHerxheimer*reaction*is*sometimes*seen*following*treatment*–*fever,*rash,*tachycardia*
within*a*few*hours*after*first*dose*of*antibiotic.*

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• Congenital*syphilis:*features*include*blunted*upper*incisor*teeth*(Hutchinson’s*teeth),*‘mulberry’*molars,*
keratitis,*saber*shins,*saddle*nose,*deafness,*rhagades*(linear*scars*at*angle*of*mouth).*
Erythema*infectiosum*(Slapped*cheek*syndrome)*
• Caused*by*parvovirus*B19.*
• Features:*rosy*red*rash*on*cheek*that*appears*after*a*few*days*after*onset*of*mild*pyrexia*and*disappears*
after*1U2*weeks.*Exposure*to*heat*source*(eg.*sunlight,*fever)*will*trigger*recurrence*of*rash*for*a*few*months.*
• Management:*most*children*recover*and*need*no*specific*treatment;*children*are*no*longer*infectious*once*
the*rash*appears.*
• Management:*may*trigger*acute*arthritis*in*adults;*adults*are*infectious*3U5*days*before*the*rash*appears.*
• Pregnancy:*mothers*who*have*had*contact*with*suspected*parvovirus*require*immediate*serological*testing*
for*parvovirus*B19*IgM*and*IgG.*If*IgG*positive*and*IgM*negative*the*mother*is*immune*to*parvovirus;*if*IgG*
negative*and*IgM*positive*the*mother*is*nonUimmune*and*has*contracted*the*infection*(requires*treatment).*
Lymphogranuloma*venerum*
• Caused*by*Chlamydia&trachomatis.*
• Features:*small*painless*pustule*which*later*forms*a*painless*ulcer,*followed*by*painful*inguinal*
lymphadenopathy*and*proctocolitis*(inflammation*of*rectum*and*colon).*
• Management:*doxycycline.*
Cellulitis*
• Inflammation*of*skin*typically*due*to*Strep&pyogenes&or*Staph&aureus.*
• Features:*erythema,*pain,*swelling;*systemic*symptoms*(fever).*
• Patients*with*systemic*upset*such*as*acute*confusion,*haemodynamic*instability,*limbUthreatening*infection,*
sepsis,*rapidly*deteriorating*cellulitis,*immunocompromised,*lymphedema,*or*is*very*young*(<*1*years)*
should*receive*IV*antibiotics;*others*should*be*treated*with*oral*antibiotics.*
• Management:*flucloxacillin*is*firstUline*treatment*for*mild/moderate*cellulitis*(clarithromycin*or*clindamycin*
if*penicillinUallergic);*clindamycin*is*secondUline.*Severe*cellulitis*requires*IV*benzylpenicillin*+*flucloxacillin.*
• Management:*failure*to*resolve*with*correct*antibiotics*may*require*surgical*drainage*to*remove*collection*of*
pus.*
Necrotising*fasciitis*
• Type*1*is*caused*by*mixed*anaerobes/aerobes*(often*postUsurgery*in*diabetics);*type*2*is*caused*by*
Streptococcus&pyogenes.*
• Features:*acute*onset,*cellulitis,*painful*and*erythematous*lesions,*extreme*tenderness*over*infected*tissue.*
• Management:*urgent*surgical*referral*for*debridement*and*IV*antibiotics.*
Gas*gangrene*
• Clostridium&perfringens:*cause*of*gas*gangrene*(production*of*gas*in*gangrenous*tissue)*and*haemolysis.*
• Features:*muscle*necrosis,*sepsis,*gas*production;*black*blisters*which*produce*foul*smelling*discharge.*
Tetanus*
• Caused*by*Clostridium&tetani*which*releases*tetanospasmin*exotoxins*that*prevent*release*of*GABA;**
tetanus*spores*are*found*in*soil*and*mostly*infect*through*wounds.*
• Features:*fever,*lethargy,*headache,*trismus*(lockjaw),*risus*sardonicus,*spasms,*opisthotonus.*
• Management:*supportive*therapy*including*ventilatory*support*and*muscle*relaxant;*metronidazole*is*
antibiotic*of*choice.*

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• Management:*IM*tetanus*immunoglobulin*for*high*risk*wounds*(with*tetanus*vaccine*booster*if*patient*is*not*
vaccinated).*
• Management:*5*doses*of*vaccination*generally*provide*lifeUlong*protection.*
Animal*bite*
• Most*common*organism*found*is*Pasteurella&multocida.*
• Management:*sterilisation*of*wound*and*coUamoxiclav;*if*penicillinUallergic*then*doxycycline*+*metronidazole*
is*recommended.*
Rabies*
• Caused*by*rabies*virus*(dog*bites).*
• Features:*headache,*fever,*agitation,*hydrophobia*(waterUprovoking*muscle*spasms),*hypersalivation.*
• Management:*sterilise*wound*first;*dog*bites*in*poor*countries*require*drug*treatment.*
• Management:*if*patient*is*already*immunised*then*2*further*doses*of*vaccine*should*be*given;*
if*not*immunised*then*human*rabies*immunoglobulin*(HRIG)*and*full*course*of*vaccination*should*be*given.*
• Management:*unclean*wounds*also*require*tetanus*treatment.*
Leishmaniasis*
• Caused*by*protozoa*Leishmania;*spread*by*sandflies.*
• Cutaneous*leishmaniasis:*crusted*lesion*at*site*of*bite,*may*be*underlying*ulcer.*
• Mucocutaneous*leishmaniasis:*primary*skin*lesion*may*spread*to*involve*mucosae*of*nose,*pharynx,*etc.*
• Visceral*leishmaniasis:*fevers,*sweats,*rigors,*massive*splenomegaly*and*hepatomegaly,*poor*appetite,*weight*
loss,*grey*skin,*pancytopaenia*secondary*to*hypersplenism.*
HIV*
• Seroconversion:*period*of*time*during*which*antibodies*develop*and*become*detectable.*
• Seroconversion:*symptomatic*in*60U80%*and*presents*as*a*glandular*feverUlike*illness*3U12*weeks*after*
infection.*
• Seroconversion:*features*includes*sore*throat,*lymphadenopathy,*malaise,*myalgia,*arthralgia,*diarrhoea,*
maculopapular*rash,*mouth*ulcers.*
• Investigations:*antibodies*to*HIV*may*not*be*detectable*in*the*first*few*weeks*of*infection*(99%*by*3*months).*
• Investigations:*HIV*PCR*or*p24*antigen*tests*can*confirm*diagnosis;*HIV*antibody*testing*is*most*accurate*and*
includes*both*ELISA*and*Western*Blot*Assay.*
• Investigations:*negative*result*of*ELISA*is*recommended*to*be*repeated*at*3*months*from*date*of*suspected*
infection*to*reUconfirm*the*result.*
• Management:*highly*active*antiUretroviral*therapy*(HAART)*is*firstUline*immediately*after*diagnosis.*
• Management:*postUexposure*prophylaxis*involves*a*combination*of*oral*antiretrovirals*immediately**
(<*72*hours*following*exposure)*for*4*weeks;*perform*serological*testing*at*3*months*afterwards.*
Conditions*associated*with*HIV*
• Kaposi’s*sarcoma:*caused*by*HHVU8*and*seen*commonly*in*HIV.*
• Kaposi’s*sarcoma:*presents*as*purple*papules*or*plaques*on*skin*or*mucosa*–*skin*lesions*may*ulcerate;*
lesions*on*respiratory*tract*mucosa*may*cause*massive*haemoptysis*and*pleural*effusion.*
• Kaposi’s*sarcoma:*treated*with*radiotherapy*and*resection.*
• Oesophageal*candidiasis:*presents*with*dyaphagia*and*oodynophagia*(with*a*history*of*HIV).*

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• Oesophageal*candidiasis:*treated*with*fluconazole*and*itraconazole.*
• Diarrhoea:*causes*in*patients*with*HIV*include*cryptosporidium*(most*common),*CMV,*Mycobacterium&avium&
intracellulare,*Giardia.*
• Diarrhoea:*perform*stool*microbiological*investigations*if*you*suspect*septicemia,*there*is*blood*or*mucus*in*
stool,*or*person*is*immunocompromised.*
• Cerebral*toxoplasmosis:*features*include*headache,*confusion,*drowsiness.*
• Cerebral*toxoplasmosis:*CT*shows*multiple*ringUenhancing*lesions,*midline*shift.*
• Cerebral*toxoplasmosis:*treatment*is*sulfadiazine*and*pyrimethamine.*
• CNS*lymphoma:*associated*with*EBV.*
• CNS*lymphoma:*CT*shows*a*single*homogenous*(solid)*enhancing*lesion.*
• CNS*lymphoma:*treatment*involves*steroids*(reduce*tumour*size),*chemotherapy*(eg.*methotrexate),**
surgery*may*be*considered*for*small*tumours.*
Bacteria*
• GramUpositive*cocci*include*staphylococci*and*streptococci.*
• GramUpositive*bacteria:*catalase*+ve*is*Staphylococcus*and*catalase*–ve*is*Streptococcus.*
• GramUnegative*cocci*include*Neisseria&meningitidis,*Nesseria&gonorrhea*and*Moraxella.*
• GramUpositive*rods*include*Clostridium,&Listeria&monocytogenes,&actinomyces,&Bacillus&anthracis,&
Corynebacterium&diphtheriae.*
• Most*other*bacterial*organisms*are*gramUnegative*rods*(refer*to*above*points).*
• Staphylococcus&aureus:*gramUpositive*bacteria*that*causes*skin*infections;*coagulaseUpositive.*
• Staphylococcus&aureus:&exotoxin*may*result*in*toxic*shock*syndrome*and*endotoxin*may*cause*gastroenteritis.*
• Staphylococcus&aureus:*many*strains*are*resistant*to*penicillin*via*betaUlactamase*production;*resistance*to*
methicillin*is*via*mec*operon*(altered*penicillin*binding*protein).*
• Staphylococcus&epidermidis:*coagulaseUnegative,*gramUpositive;*common*cause*of*central*line*infections*and*
infective*endocarditis.*
• Streptococcus&pneumoniae:*common*cause*of*pneumonia,*meningitis,*otitis*media.*
• Streptococcus&pyogenes:*gramUpositive*chain;*produces*beta*haemolysis*on*blood*agar;*catalase*negative.*
• Streptococcus&pyogenes:*causes*impetigo,*cellulitis,*erysipelas,*type*2*necrotising*fasciitis,*tonsilitis,*scarlet*
fever.*
• Streptococcus&pyogenes:*can*cause*sore*throat*–*inflamed*tonsils*covered*in*white*patches*with*cervical*
lymphadenopathy*and*a*lowUgrade*fever*may*be*present.*
• Streptococcus&pyogenes:*sensitive*to*penicillin,*macrolides.*
• Streptococcus&agalactiae:*may*lead*to*neonatal*meningitis*and*septicaemia.*
• Pseudomonas&aeruginosa:*gramUnegative*rod;*oxidase*positive.*
• Pseudomonas&auruginosa:*common*cause*of*chronic*wound*infections;*also*causes*chest*infections*(especially*
cystic*fibrosis),*wound*infections,*otitis*externa,*UTIs,*neuropathic*ulcers*in*diabetics.*
• Klebsiella&pneumoniae:*gramUnegative*rod;*part*of*normal*gut*flora*but*more*common*in*alcoholics*and*
diabetics.*
• Klebsiella&pneumoniae:*commonly*causes*pneumonia,*UTIs,*lung*abscess*formation*and*empyema;*produces*
redUcurrant*jelly*sputum*and*often*affects*upper*lobes.*

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• E.coli:*gramUnegative*rod;*strain*0517*may*cause*haemolyticUuraemic*syndrome.*
• E.coli:*leads*to*a*variety*of*diseases*including*diarrhea,*UTIs,*neonatal*meningitis.*
Cytomegalovirus*
• Herpes*virus*that*usually*only*causes*disease*in*immunocompromised*people.*
• CMV*(congenital):*presents*with*growth*retardation,*petechial*‘blueberry*muffin’*skin*lesions,*microcephaly,*
sensorinueral*deafness,*encephalitis,*hepatosplenomegaly,*pneumonitis,*seizures,*jaundice.*
• CMV*mononucleosis:*infectious*mononucleosisUlike*illness*that*develops*in*immunocompetent*people.*
• CMV*retinitis:*common*in*HIV*patients*or*immunocompromised*people.*
• CMV*retinitis:*presents*with*visual*impairment*(eg.*blurred*vision);*fundoscopy*shows*retinal*haemorrhage*
and*necrosis.*
• CMV*retinitis:*treatment*is*IV*ganciclovir.*
• CMV*pneumonitis:*pneumoniaUlike*symptoms*(fever,*dyspnea,*dry*cough)*in*someone*with*a*recent*renal*
transplant*is*likely*to*be*a*CMV*infection.*
MRSA*
• Suppression*of*MRSA*in*carriers*is*achieved*with*mupirocin*for*nose*carriers;*chlorhexidine*gluconate*for*
skin*carriers.*
• Active*MRSA*infections*can*be*treated*with*vancomycin*(firstUline),*teicoplanin,*linezolid.*
Antibiotic*guidelines*
• Exacerbation*of*COPD:*amoxicillin*or*tetracycline*or*clarithromycin.*
• CommunityUacquired*pneumonia:*amoxicillin*(doxycycline*or*clarithromycin*if*penicillinUallergic).*
• Pneumonia*secondary*to*influenza:*amoxicillin*+*flucloxacillin*(staphylococci*suspected).*
• Atypical*pneumonia:*clarithromycin.*
• HospitalUacquired*pneumonia:*coUamoxiclav*or*cefuroxime*if*within*5*days*of*admission;*if*>5*days*after*
admission*use*piperacillin*with*tazobactam*or*broadUspectrum*cephalosporin*(ceftazidime)*or*quinolone*
(ciprofloxacin).*
• Lower*UTI:*trimethoprim*or*nitrofurantoin;*alternative*is*amoxicillin*or*cephalosporin.*
• Acute*pyelonephritis:*broadUspectrum*cephalosporin*or*quinolone.*
• Acute*prostatitis:*quinolone*or*trimethoprim.*
• Impetigo:*topical*fusidic*acid*or*oral*flucloxacillin*or*erythromycin*if*widespread.*
• Cellulitis:*flucloxacillin*(clarithromycin*or*clindomycin*if*penicillinUallergic).*
• Erysipelas:*phenoxymethylpenicillin*(erythromycin*if*penicillinUallergic).*
• Animal*bite:*coUamoxiclav*(doxycycline*+*metronidazole*if*penicillinUallergic).*
• Mastitis:*flucoxacillin.*
• Throat*infections:*amoxicillin*(erythromycin*if*penicillinUallergic).*
• Sinusitis:*amoxicillin*or*doxycycline*or*erythromycin.*
• Otitis*media:*amoxicillin*(erythromycin*if*penicillinUallergic).*
• Otitis*externa:*flucloxacillin*(erythromycin*if*penicillinUallergic).*
• Gingivitis:*metronidazole.*
• Gonorrhoea:*IM*ceftriaxone*+*oral*azithromycin.*
• Chlamydia:*doxycycline*or*azithromycin.*

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• PID:*oral*ofloxacin*+*oral*metronidazole*or*IM*ceftriaxone*+*oral*doxycycline*+*oral*metronidazole.*
• Syphilis:*benzathine*benzylpenicillin*or*doxycycline*or*erythromycin.*
• Bacterial*vaginosis:*oral/topical*metronidazole*or*topical*clindamycin.*
• Clostridium*difficile:*first*episode*with*metronidazole;*subsequent*infections*with*vancomycin.*
• Campylobacter*gastroenteritis:*clarithromycin.*
• Salmonella:*ciprofloxacin.*
• Shigellosis:*ciprofloxacin.*
Vaccines*
• Live*attenuated*vaccines:*are*a*risk*to*immunocompromised*patients*(contraindicated*with*HIV).*
• Live*attenuated*vaccines:*BCG,*MMR,*influenza,*yellow*fever,*oral*polio,*oral*rotavirus,*oral*typhoid.*
• Toxoid*(inactivated*toxin)*vaccines:*tetanus,*diphtheria,*pertussis.*
*
Metabolic*medicine*
Hypernatraemia*
• Causes:*dehydration,*osmotic*diuresis,*diabetes*insipidus,*excess*IV*saline.*
• Management:*correct*chronic*hypernatraemia*at*a*rate*no*greater*than*0.5*mmol/hr*using*IV*fluid.*
• Rapid*correction*of*chronic*hypernatraemia*can*cause*cerebral*oedema*that*leads*to*seizure,*coma*or*death.*
Hyponatraemia*
• Causes:*sodium*depletion,*excess*water.*
• Assess*fluid*status*(hyperU,*hypoU,*euvolaemic)*gives*information*about*cause.*
• Repeat*abnormal*measurement*and*exclude*pseudohyponatraemia*(hyperlipidaemia,*sample*from*IV*access).*
• Interpretation:*urinary*sodium*>*20*mmol/l*and*urine*osmolarity*>*500*mmol/kg*suggests*SIADH.*
• Interpretation:*urinary*sodium*>*20*mmol/l*suggests*diuretics,*Addison’s*disease,*AKI,*hypothyroidism.*
• Interpretation:*urinary*sodium*<*20*mmol/l*and*hypervolaemia*suggests*water*excess*due*to*heart*failure,*
liver*cirrhosis,*renal*failure,*excess*IV*dextrose.*
• Interpretation:*urinary*sodium*<*20*mmol/l*suggests*sodium*depletion*due*to*diarrhoea,*vomiting,*burns.*
• Osmotic*demyelination*syndrome:*caused*by*rapid*correction*of*severe*hyponatraemia.*
• Osmotic*demyelination*syndrome:*presents*as*speech*disturbance,*swallowing*dysfunction,*limb*paralysis,*
movement*disorder,*psychatric*disturbance.*
Hyperkalaemia*
• Causes:*haemolysis*of*blood*sample,*AKI,*drugs*(spironolactone,*ACE*inhibitors,*ARBs),*metabolic*acidosis,*
Addison’s*disease,*rhabdomyolysis,*massive*blood*transfusion.*
• Associated*with*metabolic*acidosis*because*potassium*ions*compete*with*hydrogen*ions*for*exchange*with*
sodium*ions*into*the*distal*tubule*for*excretion.*
• Investigations:*firstUline*is*ECG*urgently.*
• ECG:*peaked*T*waves,*small*P*waves,*widened*QRS*complex*(sinusoidal*pattern),*ventricular*fibrillation.*
• Management:*firstUline*is*IV*calcium*gluconate*to*stabilise*the*myocardium*cardiac*membrane*and*prevent*
arrhythmias.*

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• Management:*combined*insulin*and*dextrose*infusion*can*be*used*to*temporarilty*shift*potassium*from*the*
extracellular*to*intracellular*fluid*compartment;*potassium*can*be*removed*from*body*using*loop*diuretics*or*
dialysis.*
• Management:*sodium*bicarbonate*infusion*can*help*correct*metabolic*acidosis.*
Hypokalaemia*
• Causes:*potassium*excretion*(thiazides,*loop*diuretics,*diarrhoea,*vomiting,*ileostomy,*dialysis),*magnesium*
depletion*(increases*potassium*loss),*transcellular*shift*(insulin,*metabolic*alkalosis),*decreased*potassium*
intake.*
• Features:*muscle*weakness,*hypotonia.*
• ECG:*U*waves,*small*or*absent*T*waves,*prolonged*PR*interval,*ST*depression,*long*QT*syndrome.*
• Management:*mild*to*moderate*(2.5U3.4*mmol/l)*can*be*treated*with*oral*potassium*if*asymptomatic.*
• Management:*severe*(<*2.5*mmol/l)*or*symptomatic*can*be*treated*with*IV*potassium*with*cardiac*
monitoring*at*a*rate*of*no*more*than*20*mmol/hr.*
Hypercalcaemia*
• Causes:*primary*hyperparathyroidism*(most*common),*malignancy,*renal*calculi,*sarcoidosis,*acromegaly,*
hyperthyroidism,*dehydration,*Addison’s*disease,*thiazides.*
• Most*common*metabolic*complication*in*patients*with*cancer.*
• Investigations:*firstUline*is*PTH*level.*A*normal*or*raised*PTH*suggests*primary*hyperparathyroidism;*low*
PTH*suggests*secondary*hyperparathyroidism.*
• ECG:*shortened*QT*interval.*
• Management:*rehydration*with*IV*saline*(3U4*l/day)*followed*by*biphosphonates*and*takes*2U3*days*to*work*
with*a*maximal*effect*at*day*7.*
Hypocalcaemia*
• Causes:*vitamin*D*deficiency,*hypoparathyroidism,*CKD,*rhabdoyolysis,*magnesium*deficiency,*massive*blood*
transfusion.*
• Features:*tetanus*(twitching,*cramping,*spasm),*perioral*paraesthesia;*Trousseau’s*positive*(95%*of*cases).*
• Trousseau’s*sign:*carpal*spasm*when*brachial*artery*is*occluded*by*an*inflated*BP*cuff*above*sytolic*pressure.*
• Investigations:*firstUline*is*PTH*level.*
• ECG:*prolonged*QT*interval.*
• Management:*treat*severe*hypocalcaemia*with*IV*calcium*gluconate*(10*ml*of*10%*solution*over*10*minutes).*
• Management:*ECG*monitoring.*
Hypomagnesaemia*
• Causes:*diuretics,*total*parenteral*nutrition,*diarrhoea,*alcohol,*hypokalaemia,*hypocalcaemia.*
• Features:*paraesthesia,*tetany,*seizures,*arrhythmias,*hypocalcaemia*(magnesium*is*required*for*PTH).*
• Patients*may*be*unresponsive*to*treatment*with*calcium*and*vitamin*D*because*magnesium*is*required*for*
both*PTH*secretion*and*its*action*on*tissues.*
• Exacerbates*digoxin*toxicity.*
• ECG:*similar*to*hypokalaemia.*
• Management:*oral*magnesium*salt*if*>*0.4*mmol/l;*IV*magnesium*sulphate*if*<*0.4*mmol/l.*
Hypoglycaemia*

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• Most*common*cause*is*insulin*or*sulphonylurea*overdose*in*diabetics.*
• Causes*in*nonUdiabetics:*drugs,*pituitary*insufficiency,*liver*failure,*Addison’s*disease,*neuropathy*of*
autonomic*nervous*system.*
• Features:*sweating,*anxiety,*blurred*vision,*confusion,*tremor,*dizziness,*seizures,*aggression.*
• Commonly*mistaken*for*being*drunk.*
• Management:*short*acting*carbohydrate*or*emergency*glucagon*injection.*
Hyperuricaemia*
• Causes*of*increased*synthesis*of*uric*acid*include*diet*rich*in*purines,*exercise,*psoriasis,*cytotoxics,*
myeloproliferative*disorders,*LeschUNyhan*disease.*
• Causes*of*decreased*synthesis*of*uric*acid*include*drugs*(aspirin,*diuretics,*pyrazinamide),*preUeclampsia,*
alcohol,*renal*failure,*lead.*
• Patients*may*be*asymptomatic*with*high*uric*acid*levels.*
Hyperlipidaemia*
• Lifestyle*modifications:*less*fat*in*diet,*exercise,*weight*loss,*alcohol*reduction,*smoking*cessation.*
• Give*atorvastatin*20*mg*to*patients*with*type*1*diabetes,*CKD,*or*a*10*year*cardiovascular*risk*>*10%.*
• Give*atorvastatin*80*mg*to*all*patients*who*require*secondary*cardiovascular*prevention.*
• FolowUup*patients*on*statin*therapy*at*3*months*for*a*full*lipid*profile.*
• Treatment*goal*is*to*reduce*nonUHDL*cholesterol*by*at*least*40%*–*if*not,*increase*dose*to*80*mg.*
Hypertriglyceridaemia*
• Causes:*diabetes,*obesity,*alcohol,*chronic*renal*failure,*liver*disease,*drugs*(thiazides,*unopposed*estrogen,*
nonUselective*beta*blockers).*
Hypercholesterolaemia*
• Causes:*nephrotic*syndrome,*cholestasis,*hypothyroidism.*
Familial*hypercholesterolaemia*
• Autosomal*dominant*condition*that*results*in*high*levels*of*LDL.*
• Diagnostic*indicators*include*high*LDL*levels,*gene*testing*and*tendon*xanthoma.*
• Management:*80*mg*atorvastatin.*Screen*firstUdegree*relatives*and*refer*to*specialist.*
Syndrome*inappropriate*ADH*secretion*(SIADH)*
• Causes:*small*lung*cancer*(most*common),*infection,*neurological*injury,*drugs*(SSRIs,*carbamazepine,*
cyclophosphamide,*sulphonylureas,*vincristine).*
• Management:*slow*correction*via*fluid*restriction*and*ADH*receptor*antagonist.*
Abetalipoproteinaemia*
• Autosomal*recessive*disorder*characterised*by*deficiency*of*fat*soluble*vitamins*including*A,*D,*E*and*K.*
• Features:*failure*to*thrive,*developmental*delay,*steatorrhoea,*retinitis*pigmentosa,*cerebellar*signs,*
acanthocytosis,*absent*reflexes,*hypocholesterolaemia.*
• Features:*signs*of*vitamin*deficiency*may*also*be*seen.*
Vitamin*deficiency*
• Vitamin*B1*(thiamine):*beriberi;*polyneuropathy,*WernickeUKorsakoff*syndrome,*heart*failure.*
• Vitamin*B3*(niacin):*pellagra;*dermatitis,*diarrhoea,*dementia.*
• Vitamin*B6*(pyridoxine):*anaemia,*irritability,*seizures,*peripheral*neuropathy.*

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• Vitamin*B9*(folic*acid):*megaloblastic*anaemia,*neural*tube*defects.*
• Vitamin*A:*poor*night*vision.*
• Vitamin*C:*scurvy;*gingivitis,*bleeding,*poor*wound*healing,*general*malaise.*
• Vitamin*D:*rickets,*osteomalacia.*
• Vitamin*E:*mild*haemolytic*anaemia*in*newborn*infants,*ataxia,*peripheral*neuropathy.*
• Vitamin*K:*haemorrhagic*disease*of*newborn,*bleeding.*
Pellagra*
• Caused*by*niacin*(nicotinic*acid)*deficiency.*
• May*be*caused*by*isoniazid.*
• Features:*dermatitis,*diarrhoea,*dementia.*
Refeeding*syndrome*
• Metabolic*abnormalities*that*occur*on*feeding*a*person*following*a*period*of*starvation.*
• Features:*hypophosphataemia,*hypokalaemia,*hypomagnesaemia,*abnormal*fluid*balance.*
• May*lead*to*organ*failure.*
• Management:*if*patient*has*not*eaten*for*>*5*days,*aim*to*reUfeed*at*a*rate*no*more*than*50%*of*daily*
requirement*for*the*first*2*days.*
Dehydration*
• Features:*dry*mucous*membranes,*loss*of*skin*turgor,*sunken*eyes;*severe*dehydration*can*present*with*
tachycardia,*hypotension,*delirium.*
• Investigations:*disproportionate*rise*of*urea*to*creatinine;*because*urea*is*reabsorbed*along*with*increased*
water*reabsorption*in*response*to*dehydration.*
• Investigations:*may*lead*to*increase*in*concentration*of*electrolytes*and*serum*proteins*due*to*reduced*
intravascular*fluid*volume.*
Alcoholic*ketoacidosis*
• NonUdiabetic*euglycaemic*form*of*ketoacidosis*that*occurs*in*alcoholics,*who*often*starve*and*become*
malnourished*leading*to*break*down*of*fat,*producing*ketones.*
• Features:*metabolic*acidosis,*elevated*anion*gap,*elevated*serum*ketone*levels,*normal*or*low*glucose*level.*
• Management:*best*treatment*is*infusion*of*saline*and*thiamine*(to*avoid*Wernicke*encephalopathy).*
Metabolic*disturbances*
• Metabolic*acidosis:*causes*are*classified*according*to*the*anion*gap.*
• Anion*gap:*calculated*by*(sodium*+*potassium)*–*(bicarbonate*+*chloride);*normal*range*is*8U14*mmol/l.*
• Anion*gap:*normal*anion*gap*suggests*it*is*due*to*hydrogen*ion*and*bicarbonate*imbalance.*
• Anion*gap:*raised*anion*gap*suggests*it*is*due*to*increased*production*or*reduced*excretion*of*organic*acids.*
• Anion*gap:*causes*of*metabolic*acidosis*+*normal*anion*gap*include*GI*bicarbonate*loss*(diarrhoea),*renal*
tubular*acidosis,*ammonium*chloride,*Addison’s*disease.**
• Anion*gap:*causes*of*metabolic*acidosis*+*raised*anion*gap*include*lactate*(shock,*hypoxia),*ketones*(DKA,*
alcohol),*urate*(renal*failure),*acid*poisoning*(salicylates,*methanol).**
• Metabolic*alkalosis:*may*be*caused*by*a*loss*of*hydrogen*ions*or*gain*of*bicarbonate.*
• Metabolic*alkalosis:*causes*include*vomiting,*aspiration,*diuretics,*hypokalaemia,*primary*
hyperaldosteronism,*Cushing’s*syndrome,*congenital*adrenal*hyperplasia.*

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• Respiratory*acidosis:*causes*include*COPD,*decompensation*in*other*respiratory*conditions,*sedative*drugs*
(benzodiazepines,*opiates).*
• Respiratory*alkalosis:*causes*include*anxietyUcaused*hyperventilation,*pulmonary*embolism,*salicylate*
poisoning,*CNS*disorders*(stroke,*SAH,*encephalitis),*altitude,*pregnancy.*
Iron*studies*
• Ferritin:*intracellular*protein*that*binds*iron*for*storage.*
• Ferritin:*increases*during*inflammation,*liver*disease,*CKD,*alcohol*excess,*malignancy,*haemochromatosis.*
• Ferritin:*normal*transferrin*saturation*excludes*haemochromatosis*(<45%*in*females,*<50%*in*males).*
• Ferritin:*decreased*in*iron*deficiency*anaemia.*
• Transferrin:*protein*that*iron*binds*to*for*transport.*
• Total*iron*binding*capacity:*measure*of*available*binding*sites*on*transferrin*for*iron.*
Alkaline*phosphatase*
• Causes*of*raised*ALP:*cholestasis,*hepatitis,*fatty*liver,*Paget’s*disease,*pregnancy,*healing*fractures.*
• Raised*ALP*and*raised*calcium*is*either*bone*metastases*or*hyperparathyroidism.*
• Raised*ALP*and*low*calcium*is*either*osteomalacia*or*renal*failure.*
• May*be*elevated*significantly*during*pregnancy.*
*
Nephrology*
Acute*kidney*injury*
• Risk*factors:*CKD,*history*of*AKI,*nephrotoxic*drugs*within*the*past*week,*age*>*65*years,*other*organ*disease.*
• Prerenal*causes:*hypovolaemia,*renal*artery*stenosis.*
• Intrinsic*causes:*acute*tubular*necrosis*(most*common),*glomerulonephritis,*acute*interstitial*nephritis,*
rhabdomyolysis,*tumour*lysis*syndrome,*nephrotoxic*drugs.*
• Postrenal*causes:*renal*calculi,*benign*prostatic*hyperplasia,*external*compression*of*ureter.*
• Features:*reduced*urine*output*(<*0.5*ml/kg/hour),*pulmonary*and*peripheral*oedema,*abnormal*U&Es,*
arrythmias*(due*to*electrolyte*imbalance),*features*of*uraemia*(pericarditis,*encephalopathy).*
• Investigations:*firstUline*is*to*measure*urinary*and*serum*sodium*and*creatinine*levels*and*osmolality.*
• Investigations:*secondUline*is*to*perform*renal*ultrasonography*if*no*prerenal*cause*is*found.*
• Investigations:*thirdUline*is*to*perform*urinalysis*if*kidneys*are*normalUsized.*
• Diagnostic*criteria:*rise*in*creatinine*>*26*umol/l*in*past*48*hours;*or*>*50%*in*past*7*days;*or*fall*in*urine*
output*to*less*than*0.5*ml/kg/hour*for*more*than*6*hours.*
• Management:*hypovolaemia*is*treated*with*IV*fluids*(firstUline)*to*ensure*kidneys*are*properly*perfused,*but*
not*excessively*(fluid*overload).**
• Management:*nephrotoxic*drugs*(NSAIDs,*aminoglycosides,*ACE*inhibitors,*diuretics,*ARBs)*should*be*
stopped*as*it*may*worsen*renal*function.*
• Management:*some*drugs*(metformin,*lithium,*digoxin)*may*need*to*be*stopped*because*of*their*risk*of*
toxicity.*Aspirin*at*a*dose*of*75*mg*od*is*safe.*
• Management:*dialysis*is*reserved*for*patients*that*do*not*respond*to*medical*treatment*for*complications.*
Prerenal*AKI*
• Kidneys*reabsorb*sodium*to*preserve*volume*in*response*to*hypovolaemia,*resulting*in*concentrated*urine.*

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