Q-1

A 15-year-old girl is suspected of having infectious mononucleosis. Which of the following is NOT a recognised complication ofthis condition?(Please select 1 option)Splenic rupture during convalescenceEncephalitisRespiratory obstructionThrombocytopeniaErythematous rash if exposed to flucloxacillin

A-1 ESplenomegaly occurs in around 40% of cases and splenic rupture may occur. Respiratory obstruction may develop due to exudative pharngitis . Thrombocytopenia is frequently observed. The common presentations are with fever, rash, lymphadenopathy and pharyngitis but encephalitis is a rare sequelae. The rash develops on exposure to Ampicillin rather than to Flucloxacillin

Q-2A false negative Mantoux test may be present in the following conditions:True / FalseMiliary tuberculosis Previous Mantoux test Hypothyroidism Prednisolone therapy Sarcoidosis

A-2 TFFTTA false-negative Mantoux test may reflect suppression of the immune system as is the case in any immunosuppressive therapy such as high-dose steroid therapy, azathioprine, cyclosporin. Miliary TB is associated with an overwhelming infection causing a relative immunosuppression and hence mantoux negative. Classically in Sarcoidosis, aetiology, there is a suppression of cell-mediated immunity leading to false-negative testing.

Q-3Epstein-Barr virus is associated with:True / FalseBurkitt's lymphoma cervical neoplasia nasopharyngeal carcinoma pharyngitis autoimminue haemolytic anaemia

A-3 TFTTTb-No association with cervical neoplasia unlike human papilloma virus c-Anaplastic nasopharyngeal carcinoma, common in SE China, virtually all cases have evidence of EB in the tumour tissue. D Infectious mononucleosis. Usually severe pharyngitis. e-Usually resolves after 1-2 months.

Q-4Chickenpox is associated with the following:-True / FalsePneumonitis pancreatitis subacute sclerosing panencephalitis erythema marginatum cerebellar encephalopathy

A-4 TTFFTa-Commoner in adults, resolves with a rash however impaired pulmonary function may last months. b-typically Mumps but is associated with chicken pox. c-Measles. d-Rheumatic fever. e-acute cerebellar ataxia commonest extracutaneous site in children. Appears 21 days after rash.

Q-5Some of the features of infectious mononucleosis are:True / FalseVesicular rash on the neck and body Haemorrhagic spots on the palate Increased levels of AST (aspartate aminotransferase) Arthritis Aseptic meningitis

A-5 FTTTTThe rash is typically maculo-papular, with a petechial rash on the palate found in 30%. Arthritis, aseptic meningitis and raised aspartate aminotransferase are noted.

Q-6Meningitis in infancy:True / FalseMay result in a conductive hearing defect Has a poorer prognosis than in older children Microscopy of the CSF will always enable differentiation between the bacterial and viral aetiologyMay cause hyponatraemia May be associated with urinary tract infection in mother

A-6 FTFTTThe hearing defect associated is sensory neural and can be caused by any of the bacterial strains but in particular Haemophilus. Meningitis in infancy carries a worse prognosis than in older children. CSF microscopy may be altered by antibiotic treatment and hence may not reliably distinguish bacterial from viral. SIADH and adrenal failure can lead to hyponatraemia. Urinary tract infection in the mother with group B streptococcus is a source of infection for neonates who can then develop meningitis.

Q-7Mouth ulceration occurs commonly in:True / FalsePrimary herpes simplex infection Acute leukaemia Rickets Agranulocytosis Juvenile thyrotoxicosis

A-7 TTFTFMouth ulceration may be a feature of underlying systemic disease such as inflammatory bowel disease due to drugs such as steroids or NSAIDs a consequence of an underlying haematological disorder (neutropaenia/ALL). Infections such as rubella, chicken pox, measles and HSV may all cause mouth ulceration.

Q-8Clinical manifestations of mumps include:True / FalseBacterial skin sepsis Pancreatitis Nephritis Deafness Orchitis

A-8 FTTTTPancreatitis, deafness and orchitis are commonly observed complications. Orchitis occurs in 25% of cases and may later result in infertilty. Nephritis and arthropathy can occur. Skin infections are not observed with the condition. Nelson lists the following complications: menigoencephalomyelitis, orchitis and epididymitis, oophoritis, pancreatitis, myocarditis, arthritis, thyroiditis, deafness, dacroadenitis and papillitis.

Q-9Which of the following are causes of generalised lymphadenopathy?True / FalseEpstein-Barr virus Syphilis HIV seroconversion Toxoplasma gondii Q fever

A-9 All are trueGenerally, glandular fever causes cervical lymphadenopathy although generalised LAP is recognised. Other causes of generalised LAP include syphilis, HIV, lymphomas and Q fever.Toxplasmosis is commonly an acquired infection which is characterised by mild chronic febrile illness and a localized group of enlarged lymph nodes. But, in congential disease and the immunocompromised generalised lymphadenopathy occurs and is associated with splenomegaly.

Q-10Parvovirus B19:True / FalseAplastic anaemia is a recognised complication of first infection Associated with moderate rise in serum transaminases Infection of mother in 3rd trimester of pregnancy causes sensorineural deafness in the newbornThe majority of adults have been infected with parvovirus Causes roseola infantum

A-10 TFFTFParvovirus B19 causes an interruption of erythropoeisis of 5 to 7 days. In patients with a chronic haemolytic anaemia such as hereditary spherocytosis, pyruvate kinase deficiency, sickle cell disease or thalassaemia this can produce an aplastic crisis. Parvovirus B19 exhibits marked tissue specificity only binding to cells bearing P antigen on their surface such as megakaryocytes, endothelial cells, red blood cells and placental cells. Therefore it does not generally cause elevated transaminases. There is no convincing evidence that B19 causes fetal malformation, though infection during pregnancy does confer a 10% risk of second trimester spontaneous abortion and can cause hydrops fetalis. Between 60- 70% of adults have parvovirus antibodies usually due to infection experienced between 4 and 19 years old. Parvovirus B19 causes fifth disease or erythema infectiosum not roseola.

Q-11Clinical features of toxoplasmosis include:True / FalseCervical lymphadenopathy Choroidoretinitis Microcephaly Mouth ulcers Sacroiliitis

A-11 TTTFFCauses for microcephaly include :Down syndromeCongenital rubellaCongenital toxoplasmosisCongenital CMVCri-du-chat syndromeSeckel syndromeRubinstein-Taybi syndromeTrisomy 13Trisomy 18Smith-Lemli-Opitz syndromeCornelia de Lange syndromeUncontrolled maternal phenylketonuriaMethyl mercury poisoning.

Q-12Methicillin-resistant Staphyloccus aureus (MRSA) is:True / Falsean invasive organism when compared to methicillin sensitive strains of Staphyloccus aureus. resistant to methicillin is due to a plasmid a cause of nosocomial pneumonia mostly responds well to vancomycin therapy a cause of toxic shock syndrome.

A-12 FTTTTMRSA usually colonises wounds and venous access sites. Theoretically can cause toxic shock which is often due to MRSA elaborating TSS toxins.

Q-13Chicken Pox:True / Falsehas an incubation period of 5 - 7 days rash occurs in the mouth may develop in non-immune children who have been in contact with an adult with Herpes zoster infection maternal infection during the last 2 weeks of pregnancy is not harmful to the fetus the rash is usually preceeded by 4 - 5 days of prodromal illness

A-13 FTTFFa - 10 - 21 days. b - And also at other mucosal sites such as the genitals. e - The prodrome is usually very short 1 2 days but can be up to 5 days in older children/adults - take your pick!

Q-14Measles vaccine is contraindicated in a child:True / FalseBefore the age of 18 months When there is a history of previous infection with measles If a sibling has epilepsy If there has been a febrile reaction to pertussis vaccine If there is a history of Neomycin allergy

A-14 FFFFTThe timing of the MMR (Mumps, Measles, Rubella vaccine) is around 12-15 months. Contraindications to measles vaccine are life threatening allergic reaction to the vaccine, gelatin or neomycin allergy, pregnancy and acute febrile illness. The vaccine is contraindicated if the patient is immunosuppressed unless the patient is suffering from asymptomatic HIV infection. Family history of epilepsy is irrelevant.

Q-15Which of the following statements is/are true of pertussis (whooping cough)?True / False1- Children under the age of 3 months are not at risk from the disease 2- Erythromycin has been shown to inhibit the growth of the aetiological agent in vitro 3- For well premature infants the immunisation should be carried out 2 months after birth 4- Immunisation is effective in preventing the disease in over 95% of immunised people 5- The incidence of permanent neurological complications from immunisation is less than 1:150,000

A-15 FTTFTPertussis is caused by Bordetella pertussis and young children and infants are particularly susceptible.The vaccination is a suspension of killed organisms and confers immunity in less than 90%.Recommendation for the triple diphtheria, tetanus, and pertussis (DTP) vaccination are for a series of five vaccinations beginning at two months of age.Effective treatment includes macrolides.Neurological complications associated with the vaccine are rare.

Q-16The following are recognised features of Lyme disease:True / FalseRecurrent headache Seventh nerve facial palsy Behavioural change CSF lymphocytosis Neutrophil pleocytois on CSF examination

A-16 All are trueBorrelia Burgdoferi (spirochete). Zoonosis (1xbdes deer tick) - Incubation 3-32 days. Early - Localised: annular rash (erythema migrans), fever, malaise, headache. Disseminated: Haemotogenous spread, multiple small skin lesions, conjunctivitis, nodes, aseptic meningitis, seventh nerve palsy. Late - Arthritis waxing and waning overweeks (knee in 90%) worsens over time. Complications - Dehydrating, encephalitis, polyneuritis, impaired memory.

Q-17Causes of confusion and seizures in patients with AIDS include:True / FalseToxoplasmosis Progressive multifocal leuconencephalopathy Cryptococcal meningitis AIDS-dementia complex CMV

A-17 All are truePML is a progressive infection of oligodendroglial cells by JC papovirus in immune deficiency. Invariably fatal, but uncommon in children with HIV.

Q-18When immunising a child in the United Kingdom:True / FalseThe first diphtheria, pertussis and tetanus inoculation should be given at two months BCG is never performed in the neonatal period Immunity to polio after the three initial doses is lifelong Polio vaccine is given orally as part of primary immunisation HIV positive children should receive the measles/mumps/rubella and IM polio vaccines

A-18 TFFFTFrom cBNF "For primary immunisation of children aged between 2 months and 10 years vaccination is recommended usually in the form of 3 doses (separated by 1-month intervals) of diphtheria, tetanus, pertussis (acellular, component), poliomyelitis (inactivated) and haemophilus type b conjugate vaccine (adsorbed) (see schedule, section 14.1). In unimmunised children aged over 10 years the primary course comprises of 3 doses of adsorbed diphtheria [low dose], tetanus and inactivated poliomyelitis vaccine. A booster dose should be given 3 years after the primary course. Children under 10 years should receive either adsorbed diphtheria, tetanus, pertussis (acellular, component) and inactivated poliomyelitis vaccine or adsorbed diphtheria [lowdose], tetanus, pertussis (acellular, component) and inactivated poliomyelitis vaccine. Children aged over 10 years should receive adsorbed diphtheria [low dose], tetanus, and inactivated poliomyelitis vaccine. A second booster dose of adsorbed diphtheria [low dose], tetanus and inactivated poliomyelitis vaccine should be given 10 years after the previous booster dose." and "VACCINES AND HIV INFECTION HIV-positive children with or without symptoms can receive the following live vaccines: MMR (but not whilst severely immunosuppressed), varicella-zoster (but avoid if immunity significantly impaired - consult product literature);(2)(3) and the following inactivated vaccines: cholera (oral), diphtheria, Haemophilus influenzae type b, hepatitis A, hepatitis B, influenza, meningococcal, pertussis, pneumococcal, poliomyelitis(4), rabies, tetanus, typhoid (injection). HIVpositive individuals should not receive: BCG, yellow fever(5) Note The above advice differs from that for other immunocompromised patients."

Q-19A 15 month old girl presents with small lumps on the back of the head. She was well upto 2 weeks before, whenshe developed a fever and generalised erythematous rash. This has resolved, but mother noted these lumpswhile brushing her hair. Full term normal delivery, no neonatal problems. Immunisations up to date. No family orsocial history of note.On examination the temperature is 36.7C, respiratory rate 25/min and pulse of 100/min. Well and well grown.0.25-0.5 cm rubbery non-tender lumps in the occipital region around the nuchal area. Otherwise noabnormalities to find.What is the most likely diagnosis?(Please select 1 option)Exanthem subitumInfectious mononucleosisMeaslesParvovirus infectionRubella

A-19 AThe history suggests occipital gland enlargement following a viral exanthema. At this age the most likely culprit is Human Herpes Virus 6 (HHV6), which accounts for 20% of febrile illness in emergency rooms between 12 and 18 months of age. 90% of children have seroconvert by 2 years of age. Mother should be reassured.

Q-20The following statements are true:True / FalseBrucellosis is characterised by neutrophil leucocytosis. Brucellosis is a recognised cause of spondylitis. Toxoplasmosis causes visceral larva migrans. Toxoplasmosis causes posterior uveitis. Serological evidence of toxoplasmosis is rare in adults.

A-20 FTFTFBrucellosis is a zoonosis, spreading from infected animals particularly cattle. There are 4 species, melitensis, abortus, suis, and canis. Pasteurisation of milk has decreased the incidence in the UK dramatically. Brucella are gram negative bacilli which are fastidious. There is usually a history of exposure, and the symptoms are rather non-specific with fever, malaise, arthralgia and depression.35% have hepatosplenomegaly. Leukopaenia is common, and 75% have a positive blood culture (90% of bone marrow cultures will be positive). Toxoplasma is most frequent in farming communities where contact occurs with cats, and patients eat raw meat. Clinical manifestations include: focal choroidoretinitis or posterior uveitis, optic atrophy, retinal detachment, cataract and glaucoma.

Q-21The following mechanisms of microbial resistance are correctly ascribed:True / FalseEnterococcus faecalis by beta-lactamase production Herpes simplex by mutations of viral thymidine kinase Pseudomonas aeruginosa by mutation of specific binding proteins Staphylococcus aureus by slime production Staphylococcus epidermidis by slime production

A-21 TTFFTPseudomonas produce inducible beta-lactamases and slime. Staphylococcus aureus produces betalactamases.Q-22In cases of non-gonococcal urethritis:True / FalseChlamydia trachomatis is the commonest organism Association with septic arthritis is common It is usually treated with Septrin Cystitis is typical Chronic conjunctivitis is a recognised sequela.

A-22 TFFFTMost non-gonococcal urethritis is due to chlamydia, and more rarely due to mycoplasma, ureaplasma, trichomonas or meningococcal disease. These may occur together. Non-gonococcal urethritis is also part of Reiter's Syndrome (arthritis, conjunctivitis, urethritis). This can be caused by gonococcus and campylobacter.Complications of NGU: Salpingitis, perihepatitis, conjunctivitis, sterility. Treatment of NGU: Doxycyclin or Erythromycin.

Q-23Influenzae vaccine is recommended in the following patients:True / FalseHIV infected child Chronic purulent lung disease Acute lymphoblastic leukaemia patient Chronic heart disease Severe cerebral palsy/mentally retarded

A-23 All are true Frequent genetic reassortments make vaccine production difficult. Currently, a trivalent vaccine is used consisting of 2 types of 2 strains of type A and one strain of type B based on last year's circulating viruses. Usual protection is about 75%, although this will reduce in pandemic years.Recommendations are that the following receive influenza vaccine:1. Diseases: a) Chronic respiratory disease including asthma. b) Chronic heart disease. c) Chronic renal failure. d) Diabetes mellitus. e) Immunosuppression due to disease or treatment including asplenia or splenic dysfunction.2. Those in residential homes.

Q-24Infection with Neisseria gonorrhoea may present with:True / FalseArthritis Phylyctenular conjunctivitis Keratoderma blenorrhagica Proctitis Endocarditis

A-24 TFFTTIncubation is 1-4 days. In most cases it is asymptomatic.Uncomplicated: Urethritis with purulent discharge and local inflammation. Ophthalmitis (child).Disseminated: (1-3%) after 7-30 days. Arthritis, dermatitis, carditis, meningitis, osteomyelitis.Complications: Pelvic inflammatory disease, hepatitis, septic abortion, concurrent STD. Keratoderma is associated with various congenital abnormalities. It consists of psoriasis-like plaques especially on the soles of the feet. Keratoderma blenorrhagica is seen in Reiters, and consists of vesicles filled with caseous material. Phlyctenular conjunctivitis can occur in TB and coccidioidomycosis and consists of small yellow lesions at the corneal

Q-25 Herpes simplex:True / FalseIs a common cause of erythema multiforme. In the newborn is often fatal. Infection of genitalia is always due to type II. Primary infection is commonly followed by latent infection of sensory ganglion cells. May cause damage to the eyes.

A-25 TTFTTHerpes simplex virus is a DNA enveloped virus which is extremely common. It causes infections of skin, mucus membranes, eyes, CNS, genitalia or systemic systems. The severity of disease is proportional to the degree of immuno-incompetence of the host. HSV1 affects the skin and mucus membranes above the waist. HSV2 generally affects the genitalia and the neonate. Incubation period is 2-12 days, and is through close contact or skin breaks.Clinical features:1. 85% are asymptomatic.2. Vesicular lesions causing a scab which heals over 700 days, causing local pain but rarely scarring.3. Primary mucus membrane involvement is manifest as gingivostomatitis, or occasional eczema hepeticum or keratoconjunctivitis. Secondary involvement usually results in cold sores or chronic keratoconjunctivitis. Systemic infection usually occurs in the newborn or in immunocompromised patients such as those with cancer or HIV. CNS infection results in fever, changes in conscious level or personality with focal signs, and a pre- for the temporal lobes.4. Erythema multiforme is caused by hypersensitivity reaction to: Drugs such as Penicillin, Sulphanomide, Isoniazid, Tetracycline, Aspirin or Carbamazepine.Infections such as EBV, herpes simplex virus 1 and 2, mycoplasma, TB, Group A Strep. Other: Sunlight, leukaemia, lymphoma, HSP or Kawasaki Disease.

Q-26The following clinical features suggest that a febrile child of 9 months has a severe infection:True / FalseThe presence of petechiae Rousable only to pain Toe-core temperature difference of 4C Wetting of the nappy once a day Serum fibrinogen of 0.78g/L

A-26 FTTTTOnly 7% of children with fever and petechiae have a serious infection, but petechiae are characteristic of meningococcal disease, so 48 hours of antibiotics is reasonable until cultures are negative. Loss of consciousness is a late sign, suggesting septic shock is affecting brain function. A high toe-core temperature difference suggests poor perfusion. Oliguria suggest renal dysfunction. Normal fibrinogen level is 2-4g/l (1.25-3 in newborn). Low levels are found in disseminated intravascular coagulation.

Q-27The following antimicrobial agents work in the way described:True / FalsePenicillin by binding to specific receptors to increase bacterial cell wall permeability. Acyclovir by specific inhibition of viral thymidine kinase. Erythromycin by inhibiting bacterial folate synthetase. Vancomycin by inhibiting bacterial ribosomes. Ciprofloxacin by inhibition of bacterial DNA gyrase.

A-27 TFFFTAcyclovir is phosphorylated by viral thymidine kinase, which is triphosphorylated by cellular enzymes to inhibit the herpes simplex virus DNA polymerase, thereby acting as a DNA chain terminator.Erythromycin inhibits bacterial ribosomes. Vancomycin inhibits cell wall synthesis by a mechanism that differs from betalactamases (no cross-resistance).

Q-28Regarding the epidemiology of infections, the following statements are true:True / FalseResistant vivax malaria is a major problem in Kenya. Diphtheria has been eradicated in most parts of the world. Polio has been eradicated in most parts of the world. Tetanus has been eradicated in most parts of the world. The AIDS epidemic seems to be declining worldwide.

A-28 FFTFFFalciparum is the major resistance problem in sub-Saharan Africa. Most vivax is Chloroquine sensitive, though resistant strains are appearing in New Guinea and Indonesia. Diphtheria is still prevalent in many parts of the world. An upsurge in polio is now nearing eradication. Tetanus is still common. AIDS is increasing inexorably.

Q-29Concerning falciparum malaria:True / FalseThe temperature pattern is quartan. Hypoglycaemia is a recognised consequence. Is likely to recur 5 years after leaving an endemic area. Corticosteroids are of no benefit in treating cerebral malaria. Primaquine is the treatment of choice in chloroquine-resistant areas.

A-29 FTFTFFalciparum produce a variable pattern of fever (subtertian or malignant tertian); Vivax and ovale produce benign tertian and quartan. Hypoglycaemia occurs, especially in infants. Recurrences of Vivax or ovalemay recur weeks after apparently successful treatment (hepatic cycle), but rarely after more than a year. In comatose stage of cerebral malaria, Dextran 70 may prevent intravascular coagulation. Convulsions need anti-convulsants. Quinine may be used in Chloroquine-resistance.

Q-30Which of the following statements are true regarding microbiological specimens?True / False1- Blood cultures should be collected after the sterilisation of the skin with two alcohol wipes2- A bag urine with 100 white cells and >105 Escherichia coli/ml confirms urinary tract infection in an infant 3- Bordetella pertussis can usually be grown from pernasal swabs of children with a classical whoop4- The diagnosis of pulmonary tuberculosis in infants is best made with three successive early morning gastric washings 5- Conjunctival scrapings may be helpful in diagnosing chlamydial eye infection in Infants

A-30 FFFTT For good quality blood cultures, iodine or chlorhexidine should be used.At least two urine samples should be obtained (preferably including a catheter specimen or suprapubic aspirate) prior to commencing antibiotics.Bordetella culture is notoriously difficult, with true cultures 30-40%.Infants cough up and swallow their sputum.Conjunctival scrapings can be used for culture or immunofluorescence and are the diagnosis method of choice. Remember to treat the accompanying (present in >50%) with oral erythromycin.

Q-31The following should be avoided in suspected immunodeficiency:True / FalseMMR DaPT Oral polio Pneumovax II Transfusion of packed cells

A-31 TFTFTLive vaccines: MMR, oral polio, BCG, measles.Inactivated: IM polio.Toxoids: DaPT.Submit: Hib.Packed cells contain a few lymphocytes which can give transfusional graft versus host disease (GVHD) in SCID, which is invariably fatal. Viruses can also be transmitted via blood products.

Q-32A 21 day old boy presents with possible meningitis. If the CSF findings are as follows, the giveninterpretations are reasonable:True / False10 white cells/mm3 - normal Glucose of 0.2mmol/L - TB meningitis 250 lymphocytes - bacterial meningits Protein of 2gm/L - viral meningitis CSF glucose of 67% of blood glucose - viral meningitis

A-32 TTFFTIn the premature neonate, up to 25 mononuclear cells or 10 polymorphs may be seen in the CSF. In term newborns, up to 20 mononuclear cells or 10 polymorphs may be seen. In the neonatal period, up to 5 mononuclear cells or 10 polymorphs may be seen. Thereafter, more than 5 mononuclear cells should be considered abnormal. CSF protein levels are considerably higher in the premature or newborninfant, with levels upto 3g/L in the former and 1.2g/L in the latter. In older children, levels above 0.4g/L should be considered abnormal. CSF glucose levels are normally >50% of those in the blood. They are normal in viral meningitis, reduced in bacterial meningitis, and may be extremely low in TB meningitis.

Q-33Regarding diphtheria:True / False1- It is predominantly spread from cutaneous lesions. 2- It is characterised by an inflammatory exudate forming a greyish membrane on the buccal mucosa. 3- It produces a toxin which affects the myocardium, nervous and adrenal tissues. 4- 3 doses of toxoid provides 75% protection. 5-About 50 cases per year are seen in the UK.

A-33 FFTFFDiphtheria is spread by droplets, through contact with soiled articles (fomites), and, in areas of poor hygiene, from cutaneous spread. The inflammatory exudate forms a greyish membrane on the tonsils and respiratory tract which may cause respiratory obstruction. Incubation is between 2 and 5 days, and patients may be infectious for 4 weeks. The toxin affects the myocardium, nervous and adrenal tissues.The immunisation has been tremendously successful, and most cases seen in the UK are imported from the Indian subcontinent or Africa. Recently, there has been a worrying epidemic of diphtheria in Russia and the newly independent states of the former Soviet Union. In 1995, 52,000 cases and 1,700 deaths were reported.

Q-34At birth a 37+3/40 infant is noted to have purple spots and is admitted to the neonatal unit. Pregnancy had been complicated by a mild febrile illness at 9 weeks. Serial ultrasounds had shown growth retardation. Delivery was uncomplicated, and Apgars were 8 at 1 minute and 9 at 5 minutes.On examination the weight was 2.2kg and OFC 31cm. Temperature was 36.8C, RR 40/min, HR 120/min. No murmur. O2 saturations were 94- 96% in air. There were profuse non-blanching purple spots over the trunk and limbs. The liver was 4 cm and spleen 3 cm.What is the most likely diagnosis?(Please select 1 option)Congenital syphilisCongenital toxoplasmosisCongenital herpesCongenital rubellaCongenital CMV infectionA-34 EThe history of maternal illness in pregnancy, and clinical features of IUGR, microcephaly, purpura and hepatosplenomegaly strongly point to a congenital infection. Although all the TORCH organisms (toxoplasma, other [syphilis, hepatitis B, HIV], rubella, CMV, Herpes) can cause similar pictures, CMV is by far the commonest in the developed world. Intracranial calcification, chorioretinitis, deafness, heart disease are additional common features.

Q-35An 11 month old girl presents with fever for 3 days. She has no localizing symptoms for infection. She was born at 38/40 gestation weighing 2.98kg and there were no neonatal problems. She is fully immunised and there is no FH/SH of note.On examination:There is no increased work of breathing, and chest and ENT examination are normal. She is well perfused and capillary refill time is 1 second. She is alert and fontanelle is normal. Urine dipstix is negative for protein, blood, leukocytes and nitrites.Fever to 39.8C (tympanic)Respiratory rate 30/minHeart rate 130/minWhite cell count 28.2 x 109/l (NR 3-10)Neutrophils 93%CRP 149 mg/l (NR less than 5)What is the most likely diagnosis?(Please select 1 option) Meningococcal septicaemiaPneumococcal bacteraemiaSeptic arthritisUrinary tract infectionViral infection

A-35 BThe history is of high fever without localising signs in a child of 3-36 months. The neutrophilia and very high CRP make a bacteraemia likely. The commonest organism is pneumococcus (85%), with H. influenzae, meningococcus and salmonella accounting for most of the rest.Q-36A 5-year-old female presents with suspected Mumps. Which one of the following would not be an expectedcomplication of the condition?(Please select 1 option)DeafnessDisseminated intravascular coagulationMeningoencephalitisPancreatitisOophoritisA-36 BParotitis, oophoritis and orchitis occur frequently in the condition. Meningo-encephalitis, arthritis , transverse myelitis , cerebellar ataxia and deafness may also be sequelae. DIC is not an expected feature of the condition.

Q-37A 16-year-old male is admitted with an acute infection. He has had a history of similar infections in the past, allattributed to Neisserial organisms. Which of the following immune deficiencies is he likely to have?(Please select 1 option)C1 inhibitorC3LymphocytesC2C5

A-37 E Defiencies of late complement 5-9 are associated with recurrent neisserial or capsulated bacterial infections

Q-38Possible means of diagnosis of congenital HIV infection in neonate born to an infected mother is:True / Falsetest for anti-p24 antibody in infant blood attempt virus isolation from infant's peripheral blood leukocytes test for delayed hypersensitivity reactions attempt detection of viral genome by polymerase chain reactions test infant's serum by Western Blot

A-38 FTFTFAs with all IgG antibodies, anti-HIV will cross the placenta and therefore all infants of infected mothers will have HIV antibodies in the blood at birth. In this situation therefore, anti-HIV antibody is not a reliable marker of active infection, and i n uninfected babies it will gradually be lost over the first 18 months of life. However virus isolation itself from the infants blood is a possible means of diagnosis, asis the detection of viral genome by PCR techniques.IgG antibody to the viral capsid p24 protein (anti-p24) can be detected in the mother from the earliest weeks of infection and through the asymptomatic phase. It is frequently lost as disease progresses and therefore will not be detected in the child. A lthough not a means of diagnosis of congenital HIV infection, recent studies have shown that cutaneous delayed-type hypersensitivity skin testing response, a functional measure of cellular immunity, is an independent predictor of progression to AIDS in persons with HIV.

Q-39The following statements are true of pertussis:True / FalseIt can occur in the first three months of life Absence of a whoop rules out the diagnosis in a child with a cough A lymphocytic leucocytosis should be demonstrated to confirm the diagnosis Bronchiolitis obliterans is a recognised later complication Ampicillin is the drug of choice to eradicate the infection

A-39 TFFFFPertussis can occur at any time in a child without immunity to the condition who is exposed. The whoop may not be seen and apnoeic episodes can occur as a feature. Although a lymphocytosis is observed the diagnosis is confirmed by culture of the organism in nasal secretions. There is no reported association between bronchiolitis obliterans. Erythromycin may assist in eliminating the organism from nasal secretions.

Q-40Two strains of Escherichia coli are isolated and both are resistant to ampicillin. Strain A retains its resistance to amplicillin when grown form multiple generations in the absence of ampicillin. However strain B loses its resistance when grown in the absence of ampicillin. Which of the following best explains the loss of antibiotic resistance in strain B?(Please select 1 option)Changes in the bacterial DNA gyraseDownregulation of the resistance geneLoss of a plasmid containing the resistance geneMutations in the resistance geneTransposition of another sequence into the resistance gene

A-40 CBacteria develop resistance to antibiotics by gaining genes that encode for particular proteins that offer protection to the organism. Sometimes this is by mutation and other times the gene may be acquired from another bacterial species. The genes are usually found in plasmids - circular segments of DNA separate from the bacterial chromosome. Plasmids can easily spread from one bacteria to another - a sort of resistance package that bacteria can share.

Q-41Which of the following is true of the antibiotic combination quinupristin and dalfopristin?(Please select 1 option)Effective against resistant M. TBIndicated in subjects with chronic renal impairmentParticularly effective in the treatment of pseudomonas infection in cystic fibrosisAdministered orallyEffective against multi- resistant S. aureus

A-41 EQuinupristin and dalfopristin are a synergistic combination of a Streptogramin A and B respectively.They are effective against Gram positive aerobes and are particularly useful against resistant Strep. pneumoniae and S. aureus.They can only be administered via a central line.

Q-42Mycoplasma infection is associated with:True / FalseErythema multiforme Erythema nodosum Myocarditis Peripheral neuropathy Severe prolonged headache

A-42 All are trueMycoplasma usually begins with coryza and slow-onset pneumonia with systemic upset. Symptoms aremore impressive than signs.It can precipitate asthma.Autoimmune complications includeskinCNScardiacGIjointproblems.

Q-43A 16-year-old boy presented with fever, headache and neck stiffness for 24 hours. He had an identical illness requiring admission to hospital for one year previously.Cerebrospinal fluid analysis shows white cells of 400/ml with a 90% neutrophilia and Gram stain revealed scanty Gram negative diplococci.Which component of the immune system is likely to be defective?(Please select 1 option)B lymphocytesComplement pathwayImmunoglobulinNeutrophilsT lymphocytes

A-43 BThis young man has a recurrent meningococcal meningitis, and deficiencies of complement C5-9 predispose to Neisseria infections(complement deficiencies) One must recognise that the diplococci seen on microscopy are those of Neisseria meningitides.

Q-44Whooping cough (pertussis) in children:True / FalseWas responsible for over 300 deaths in children in 1986 Is infectious for at least two months after the termination of the coughing Is associated with an increase in the total lymphocyte count Is usually diagnosed by growing the organism from a cough plate Is invariably associated with an inspiratory whoop

A-44 TFTFFA relatively high number of deaths occurred in 1986 , possibly due to falling vaccination rates following concerns regarding safety. The annual death rate is around 30 per year. The disease is often not associated with an inspiratory whoop after coughing but apnoeic episodes can occur. The disease is most infectious inthe first 7-14 days of the illness termed the catarrhal phase. The disease is characterised by lymphocytosis. The organism is examined in nasal secretions.

Q-45An 8 month old child presents with spots on the legs. He is well and feeding well. 39+6/40 3.5kg, no neonatal problems. No drugs nor medications, fully immunised. No FH/SH of note.On examination temperature 37.4C (tympanic), RR 30/min, HR 110/min. Well perfused, capillary refill time of 1 second. 20- 30 1-2mm non-blanching purpuric spots over the shins.What is the most likely diagnosis?(Please select 1 option)Child physical abuseCough petechiaeEnteroviral infectionHenoch Schoenlein purpura (HSP)Idiopathic Thrombocytopaenic purpura (ITP)

Q-45 cThis child is well, and presents with purpuric spots and a low-grade fever. Although about 20% of such children have serious bacterial infection and 7-10% have meningitis/ septicaemia, this still leaves 70% who have some sort of viral infection. A large number of viruses (eg Varicella and EBV) can present in this way, although in clinical practice the specific cause is rarely found. There are not enough clinical details to lead you towards a diagnosis of ITP and the rash is in the wrong distribution for the diagnosis to be HSP.

Q-46A 7 month old girl presents with fever and a rash. She was completely well till 5 days ago, when she developed a slight cold. The next day she developed fever to 39.7C, which has persisted despite antipyretics. Despite this she has remained relatively well and continues to drink, though her appetite is poor. Today she has developed a rash over the face and trunk. She was born at term weighing 3.8kg and there were no neonatal problems. She is fully immunised to date and there is no family history orsocial history of note.On examination she has a temperature of 36.8C, respiratory rate 25/min and heart rate 100/min. The rash is macular, profuse, pink and blanching. It is most prominent over the face and trunk. She has shotty cervical lymphadenopathy.What is the most likely diagnosis?(Please select 1 option)CMV infectionInfectious mononucleosisMeaslesParvovirus infectionRoseola infantum

A-46 EThe history of a well child with high fever for a few days followed by resolution of fever at around the time of appearance of a rose-coloured rash is characteristic of roseola infantum. Since the introduction of MMR, this is by far the commonest cause of a measles-like rash. The peak incidence is 6-18 months. 5% develop febrile seizures. It is caused by Human herpes virus 6 and 7.

Q-47The following statements concerning infections in childhood are correct:True / FalseHerpangina is caused by herpes simplex virus type I Hand-foot-and-mouth disease is caused by Coxsackie A Peri-orbital oedema is one of the clinical features of glandular fever Patients with typhoid fever typically present with diarrhoea The skin rash of measles appears 4 days after the onset of fever

A-47 FTTFTHerpangina is caused by a Coxsackie virus. Hand, foot and mouth disease is caused by coxsackie A. The initial presentation of typhoid is with a febrile illness. The rash of measles occurs 4-7 days after the prodromal illness which includes fever and upper respiratory tract symptoms.

Q-48 Which of the following statements is/are true of mumps:True / FalseIt has a short incubation of 2-4 days It can cause meningo-encephalitis It always causes bilateral parotid swellings Sterility rarely follows orchitis It always causes orchitis in post-pubertal male

A-48 FTFTF Mumps has an incubation period of 14-21 days and may rarely cause meningoencephalitis. Any of the salivary glands may be afffected or only one. Sterility is a relatively uncommon complication following orchitis. Orchitisoccurs in around`25% of cases.

Q-49A false negative Mantoux test may be present in the following conditions:True / FalseMiliary tuberculosis Previous Mantoux test Hypothyroidism Prednisolone therapy Sarcoidosis

A-49 TFFTTA false-negative Mantoux test may reflect suppression of the immune system as is the case in any immunosuppressive therapy such as high-dose steroid therapy, azathioprine, cyclosporin. Miliary TB is associated with an overwhelming infection causing a relative immunosuppression and hence mantoux negative.Classically in Sarcoidosis, aetiology, there is a suppression of cell-mediated immunity leading to false-negative testing.

Q-50The medical officer for enviromental health should be informed following the diagnosis of:True / FalseMeningococcal meningitis Rubella Measles Chicken Pox Food poisoningA-50 TTTFT

Notification of infectious disease is obligatory under the 1968 Public Health Act. Notifiable diseases include food poisoning, meningitis, rubella, mumps, measles. Chicken pox is not notifiable.

Q-51Escherichia coli 0157 / H7:True / Falseis a bowel commensal causes haemorrhagic colitis is an important cause of cholera-like illness is a recognised cause of the haemolytic uraemic syndrome can be prevented from causing clinical illness by vaccination

A-51 FTFTF Escherichia coli 0157 / H7 characteristically causes a haemorrhagic colitis with abdominal pain but little or no fever. An outbreak of 500 cases in the USA was described in 1993. This outbreak was associated with the consumption of hamburgers. There were over 50 cases of haemolytic uraemic syndrome and 4 fatalities. The source of an outbreak in Wishaw, Scotland in 1996 was a butcher's. There were over 500 cases and 18 fatalities.

Q-52The following are characteristic of acute hepatitis B:True / FalseMost patients present with splenomegaly. It confers immunity to hepatitis A. It commonly presents with distal joint arthritis. There is increased infectivity in the presence of the e antigen. Pruritis is an important early symptom.

A-52 FFFTFClinical features of hepatitis B are as follows:1. Most are asymptomatic.2. Symptoms: Lethargy, anorexia, arthralgia, rash (any type), papular acrodermatitis (Gianotti Crosti), polyarthritis,glomerulonephritis, aplastic anaemia. 25 % have jaundice.3. Complications: Acute fulminent hepatitis. Chronic hepatitis. Membranous glomerulonephritis. Hepatitis E antigen is present in the acute phase and indicates a highly infectious state. Pruritis is characteristic of chronic hepatitis.

Q-53Giardia lamblia:True / FalseIs widespread in Europe. Is waterborne. Is a recognised cause of steatorrhoea. Is often asymptomatic. Is eradicated by Mebendazole.

A-53 TTTTFGiardia is a worldwide protozoa. It causes variable villus flattening on jejunal biopsy. The majority of cases are asymptomatic, though they may cause acute or chronic diarrhoea and a malabsorption syndrome. Symptoms are considerably worse in the immunosuppressed or immunodeficient.Metronidazole should be given if the patients are symptomatic.

Q-54The following are specific conditions with increased susceptibility to infection:True / FalseNoonan's Syndrome Right atrial isomerism Down's Syndrome Zinc deficiency Copper deficiency

A-54 FTTTFRight atrial isomerism is associated with asplenia. There is a high risk of infection with encapsulated bacteria. Howell Jolly bodies may be seen on blood film. Down's Syndrome has a variety of immune defects and a high incidence of otitis media due to eustachian tube structure. With zinc deficiency there is a low lymphocyte function.

Q-55A 3-year-old boy presents with fever and headache. He has received oral Amoxicillin for 3 days. Thefollowing CSF findings exclude a partially treated meningitis:True / FalseNegative gram stain A CSF glucose of 45% of blood glucose A white cell count of 50 A negative CSF culture Negative Kernig's Sign

A-55 All are falseThe assessment of children with suspected bacterial meningitis who have already received antibiotic therapy is a diagnostic conundrum. This applies to about 25-50% of children, so it is an important problem. Partial treatment may reduce the incidence of positive CSF gram stains to