Q-1

A 15-year-old girl is suspected of having infectious mononucleosis. Which of the following is

NOT a recognised complication of
this condition?
(Please select 1 option)
Splenic rupture during convalescence
Encephalitis
Respiratory obstruction
Thrombocytopenia
Erythematous rash if exposed to flucloxacillin

A-1 E
Splenomegaly 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-2
A false negative Mantoux test may be present in the following conditions:
True / False
Miliary tuberculosis
Previous Mantoux test
Hypothyroidism
Prednisolone therapy
Sarcoidosis

A-2 TFFTT
A 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-3
Epstein-Barr virus is associated with:
True / False
Burkitt's lymphoma
cervical neoplasia
nasopharyngeal carcinoma
pharyngitis
autoimminue haemolytic anaemia

A-3 TFTTT
b-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-4
Chickenpox is associated with the following:-
True / False
Pneumonitis
pancreatitis
subacute sclerosing panencephalitis
erythema marginatum
cerebellar encephalopathy

A-4 TTFFT
a-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-5
Some of the features of infectious mononucleosis are:
True / False
Vesicular rash on the neck and body
Haemorrhagic spots on the palate
Increased levels of AST (aspartate aminotransferase)
Arthritis
Aseptic meningitis

A-5 FTTTT
The 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-6
Meningitis in infancy:
True / False
May 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 aetiology
May cause hyponatraemia
May be associated with urinary tract infection in mother

A-6 FTFTT
The 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-7
Mouth ulceration occurs commonly in:
True / False
Primary herpes simplex infection
Acute leukaemia
Rickets
Agranulocytosis
Juvenile thyrotoxicosis

A-7 TTFTF
Mouth 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-8
Clinical manifestations of mumps include:
True / False
Bacterial skin sepsis
Pancreatitis
Nephritis
Deafness
Orchitis

A-8 FTTTT
Pancreatitis, 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-9
Which of the following are causes of generalised lymphadenopathy?
True / False
Epstein-Barr virus
Syphilis
HIV seroconversion
Toxoplasma gondii
Q fever

A-9 All are true
Generally, 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-10
Parvovirus B19:
True / False
Aplastic 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 newborn
The majority of adults have been infected with parvovirus
Causes roseola infantum

A-10 TFFTF
Parvovirus 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-11
Clinical features of toxoplasmosis include:
True / False
Cervical lymphadenopathy
Choroidoretinitis
Microcephaly
Mouth ulcers
Sacroiliitis

A-11 TTTFF
Causes for microcephaly include :
Down syndrome
Congenital rubella
Congenital toxoplasmosis
Congenital CMV
Cri-du-chat syndrome
Seckel syndrome
Rubinstein-Taybi syndrome
Trisomy 13
Trisomy 18
Smith-Lemli-Opitz syndrome
Cornelia de Lange syndrome
Uncontrolled maternal phenylketonuria
Methyl mercury poisoning.

Q-12
Methicillin-resistant Staphyloccus aureus (MRSA) is:
True / False
an 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 FTTTT
MRSA usually colonises wounds and venous access sites. Theoretically can cause toxic shock
which is often due to MRSA elaborating TSS toxins.

Q-13
Chicken Pox:
True / False
has 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 FTTFF
a - 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-14
Measles vaccine is contraindicated in a child:
True / False
Before 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 FFFFT
The 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-15
Which of the following statements is/are true of pertussis (whooping cough)?
True / False
1- 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 FTTFT
Pertussis 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-16
The following are recognised features of Lyme disease:
True / False
Recurrent headache
Seventh nerve facial palsy
Behavioural change
CSF lymphocytosis
Neutrophil pleocytois on CSF examination

A-16 All are true
Borrelia 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 over
weeks (knee in 90%) worsens over time. Complications - Dehydrating, encephalitis,
polyneuritis, impaired memory.

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

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

Q-18
When immunising a child in the United Kingdom:
True / False
The 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 TFFFT
From 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 [low
dose], 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-19
A 15 month old girl presents with small lumps on the back of the head. She was well
upto 2 weeks before, when
she developed a fever and generalised erythematous rash. This has resolved, but
mother noted these lumps
while brushing her hair. Full term normal delivery, no neonatal problems. Immunisations
up to date. No family or
social 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 no
abnormalities to find.
What is the most likely diagnosis?
(Please select 1 option)
Exanthem subitum
Infectious mononucleosis
Measles
Parvovirus infection
Rubella

A-19 A
The 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-20
The following statements are true:
True / False
Brucellosis 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 FTFTF
Brucellosis 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-21
The following mechanisms of microbial resistance are correctly ascribed:
True / False
Enterococcus 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 TTFFT
Pseudomonas produce inducible beta-lactamases and slime. Staphylococcus
aureus produces betalactamases.
Q-22
In cases of non-gonococcal urethritis:
True / False
Chlamydia 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 TFFFT
Most 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-23
Influenzae vaccine is recommended in the following patients:
True / False
HIV 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-24
Infection with Neisseria gonorrhoea may present with:
True / False
Arthritis
Phylyctenular conjunctivitis
Keratoderma blenorrhagica
Proctitis
Endocarditis

A-24 TFFTT
Incubation 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 / False
Is 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 TTFTT
Herpes 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-26
The following clinical features suggest that a febrile child of 9 months has a
severe infection:
True / False
The 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 FTTTT
Only 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-27
The following antimicrobial agents work in the way described:
True / False
Penicillin 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 TFFFT
Acyclovir 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-28
Regarding the epidemiology of infections, the following statements are true:
True / False
Resistant 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 FFTFF
Falciparum 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-29
Concerning falciparum malaria:
True / False
The 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 FTFTF
Falciparum 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 ovale
may 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-30
Which of the following statements are true regarding microbiological
specimens?
True / False
1- Blood cultures should be collected after the sterilisation of the skin with two alcohol
wipes
2- 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 whoop
4- 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-31
The following should be avoided in suspected immunodeficiency:
True / False
MMR
DaPT
Oral polio
Pneumovax II
Transfusion of packed cells

A-31 TFTFT
Live 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-32
A 21 day old boy presents with possible meningitis. If the CSF findings are as
follows, the given
interpretations are reasonable:
True / False
10 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 TTFFT
In 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 newborn
infant, 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-33
Regarding diphtheria:
True / False
1- 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 FFTFF
Diphtheria 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-34
At 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 syphilis
Congenital toxoplasmosis
Congenital herpes
Congenital rubella
Congenital CMV infection
A-34 E
The 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-35
An 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/min
Heart rate 130/min
White 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 septicaemia
Pneumococcal bacteraemia
Septic arthritis
Urinary tract infection
Viral infection

A-35 B
The 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-36
A 5-year-old female presents with suspected Mumps. Which one of the following
would not be an expected
complication of the condition?
(Please select 1 option)
Deafness
Disseminated intravascular coagulation
Meningoencephalitis
Pancreatitis
Oophoritis
A-36 B
Parotitis, 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-37
A 16-year-old male is admitted with an acute infection. He has had a history of similar
infections in the past, all
attributed to Neisserial organisms. Which of the following immune deficiencies is he likely to
have?
(Please select 1 option)
C1 inhibitor
C3
Lymphocytes
C2
C5

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

Q-38
Possible means of diagnosis of congenital HIV infection in neonate born to an infected
mother is:
True / False
test 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 FTFTF
As 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, as
is 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-39
The following statements are true of pertussis:
True / False
It 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 TFFFF
Pertussis 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-40
Two 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 gyrase
Downregulation of the resistance gene
Loss of a plasmid containing the resistance gene
Mutations in the resistance gene
Transposition of another sequence into the resistance gene

A-40 C
Bacteria 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-41
Which of the following is true of the antibiotic combination quinupristin and
dalfopristin?
(Please select 1 option)
Effective against resistant M. TB
Indicated in subjects with chronic renal impairment
Particularly effective in the treatment of pseudomonas infection in cystic fibrosis
Administered orally
Effective against multi- resistant S. aureus

A-41 E
Quinupristin 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-42
Mycoplasma infection is associated with:
True / False
Erythema multiforme
Erythema nodosum
Myocarditis
Peripheral neuropathy
Severe prolonged headache

A-42 All are true
Mycoplasma usually begins with coryza and slow-onset pneumonia with
systemic upset. Symptoms are
more impressive than signs.
It can precipitate asthma.
Autoimmune complications include
skin
CNS
cardiac
GI
joint
problems.

Q-43
A 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 lymphocytes
Complement pathway
Immunoglobulin
Neutrophils
T lymphocytes

A-43 B
This 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-44
Whooping cough (pertussis) in children:
True / False
Was 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 TFTFF
A 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 in
the 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-45
An 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 abuse
Cough petechiae
Enteroviral infection
Henoch Schoenlein purpura (HSP)
Idiopathic Thrombocytopaenic purpura (ITP)

Q-45 c
This 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-46
A 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 or
social 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 infection
Infectious mononucleosis
Measles
Parvovirus infection
Roseola infantum

A-46 E
The 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-47
The following statements concerning infections in childhood are correct:
True / False
Herpangina 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 FTTFT
Herpangina 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 / False
It 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. Orchitis
occurs in around`25% of cases.

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

A-49 TFFTT
A 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-50
The medical officer for enviromental health should be informed following the
diagnosis of:
True / False
Meningococcal meningitis
Rubella
Measles
Chicken Pox
Food poisoning
A-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-51
Escherichia coli 0157 / H7:
True / False
is 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-52
The following are characteristic of acute hepatitis B:
True / False
Most 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 FFFTF
Clinical 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-53
Giardia lamblia:
True / False
Is widespread in Europe.
Is waterborne.
Is a recognised cause of steatorrhoea.
Is often asymptomatic.
Is eradicated by Mebendazole.

A-53 TTTTF
Giardia 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-54
The following are specific conditions with increased susceptibility to
infection:
True / False
Noonan's Syndrome
Right atrial isomerism
Down's Syndrome
Zinc deficiency
Copper deficiency

A-54 FTTTF
Right 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-55
A 3-year-old boy presents with fever and headache. He has received oral
Amoxicillin for 3 days. The
following CSF findings exclude a partially treated meningitis:
True / False
Negative 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 false
The 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 <60%, and it also
reduces the ability to grow the bacteria, particularly meningococcus. CSF
glucose, protein, neutrophils and bacterial antigen testing or PCR should be
completely unaffected.

Q-56
Theme: Presentation of infectious disease in childhood

A Chicken Pox
B Herpes simplex
C Infectious mononucleosis
D Measles
E Mumps
F Mycoplasma
G Pertussis
H Rubella
I Tuberculosis

For each presentation of infectious disease choose the single most likely diagnosis
from the list of options.
1- Commonly causes an acute gingivostomatitis.

2- Causing an acute parotitis

3- Causing an exudative tonsillitis.

4-May be complicated by cerebellar ataxia.

5- May typically present with apnoeas during infancy.

6- Associated with a mild fever, and maculopapular rash that typically starts on
face and extends to rest of body.

A-56 B E C A G H
Herpes simplex - the majority of children have benign manifestations of primary
infection with Herpes simplex, for example a gingival stomatitis. The virus is readily
spread by direct contact especially to damaged skin e.g. eczema.

Mumps infection is now uncommon due to the vaccination. It is caused by a
paramyxovirus and usually causes minimal symptoms. The most common
manifestation being an acute parotitis although severe infection with mumps may
result in meningoencephalitis plus deafness.

Glandular fever is also called infectious mononucleosis. It is caused by Epstein-Barr
virus and usually presents with an exudative pharyngitis or tonsillitis and cervical
lymphadenopathy. It may cause a transient impairment of cellular and humeral
immunity, which is usually self limiting.

Chicken pox is a common childhood illness caused by Varicella. Vesicles usually
appear as crops over the trunk. Viral cerebellitis is a complication.

Pertussis is caused by Bordetella pertussis. In infancy it can be dangerous, often
presenting with apnoeas. Signs of an upper respiratory tract infection are also
common with a paroxysmal cough (whoop). Babies may also present with vomiting
and cyanosis. A blood count will reveal a lymphocytosis. Complications include
broncho-pneumonia and bronchiectasis as a sequelae is also associated though
uncommon.

Rubella infection is uncommon now due to widespread MMR vaccination. Typically
causes a mild illness which may go undetected in 25-50% of cases. Typical
symptoms are transient macular papular rash that starts on the face and extends to
body and a low grade fever. Complications include arthritis, encephalitis and
thrombocytopaenia.
Q-57
Theme: Treatment of infectious disease

A Acyclovir
B Acyclovir plus cefotaxime
C Ampicillin plus gentamicin
D Benzylpenicillin
E Ceftriaxone
F Ciprofloxacin
G Flucloxacillin
H Netilmicin
I Symptomatic treatment
J Teicoplanin
For each case of infectious disease described below choose the single best
treatment option from the list.
1- A 7-year-old child develops an exudative tonsillitis and lethargy, monospot is
positive.

2- A 1-year-old child presents to the Emergency Department with neck stiffness
and a purpuric rash.

3- A 4-year-old child presents with encephalopathy. The EEG shows high
amplitude, abnormal waveforms. The MRI scan is also abnormal. A diagnosis
of encephalitis is made.
A-57 I E B

Glandular fever where the treatment is symptomatic/conservative only.

A child with meningococcaemia presented to the surgery and benzylpenicillin needs
to be given urgently prior to transfer to hospital. Thereafter, first line therapy is
with a third generation cephalosporin.

A child with encephalitis. The majority of cases are secondary to viruses although
toxic and metabolic causes need to be considered. Of the viruses herpes simplex is
the most common agent causing encephalitis. When encephalitis is suspected both
antibiotics and acyclovir must be commenced immediately.

Q-58
Theme: Cutaneous manifestations of infectious disease

A Rheumatic fever
B TB
C Lyme disease
D Chicken pox
E Histoplasmosis
F Cat scratch disease
G Measles
H Parvovirus
I Hepatitis B
J Herpes simplex


For each cutaneous manifestation described below choose the single most
likely associated infectious disease.
1- Erythema nodosum in presence of abnormal chest x ray.

2- Erythema marginatum.

3- Erythema chronicum migrans.

4- Erythema infectiosum.

5- Gianotti-Crosti.

6- Koplik spots.
A-58 B A C H F G
Erythema nodosum may be associated with streptococcal reactions, rheumatic fever
and tuberculosis. In the presence of an abnormal chest x ray TB is the most likely
answer.

Erythema marginatum is one of the five major criteria to make a diagnosis of
rheumatic fever. It is a pink rash with pale centres and a serpiginous margin, found
on the trunk and proximal limbs.

Erythema chronicum migrans found in Lyme disease. A febrile illness caused by
Borrelia burgdorferi transmitted by bites of animal tick. The rash is characterised by
red margins and central clearing.

Erythema infectiosum also known as Fifths disease caused by human parvovirus,
often results in a low grade temperature, slapped cheek appearance to the face and
a reticular lacy rash to the arms.

Gianotti-Crosti is a syndrome of non-pruritic erythematous papules on the face,
buttocks and extremities. Characteristically related to Hepatitis B infection although
other viruses for example EBV may be associated.

Koplik spots are white coarse granules found on the buccal mucosa opposite the
back molars and is pathognomonic for measles.

Q-59
Theme: Infections

A Measles
B Rubella
C Chicken pox
D Herpes simplex
E Mumps
F Glandular fever
G Pertussis
H Polio myelitis
I Hepatitis A

For each description below choose the single most likely infection from the
list of options.
1- Caused by a gram negative pleomorphic bacillus.

2- Is caused by a paramyxovirus which can cause orchitis.

3- . This infection is most often associated with post-viral fatigue.

A-59 G E F
Whooping cough is not uncommon in infancy. It typically presents with apnoeic
episodes or cyanotic episodes during infancy. In the older child upper respiratory
tract infections and a paroxysmal cough with a whoop is characteristic.

Mumps and measles are caused by a paramyxoviruses, but only mumps causes
orchitis

Glandular fever virus infects the B lymphocytes which results in an immuno-
deficiency which is usually self limiting.

Q-60
Theme: Viral infections

A Measles
B Rubella
C Chicken Pox
D Herpes Simplex
E Mumps
F Glandular fever
G Pertussis
H Polio myelitis
I Hepatitis A
For each description below choose the single most likely viral infection from the list
of options.
1- May result in Giant cell pneumonia.

2- May result in a Keratoconjunctivitis.

3- Caused by an RNA virus with no known carrier state.

Q-60 A D I

Measles infection is uncommon due to world-wide immunisation. A child with
measles usually has a fever, upper respiratory tract symptoms and a morbilliform
rash. Serious complications include a giant cell pneumonia and encephalitis (SSPE).

Herpes simplex infection may be transmitted verdantly to an infant from their
mother's genital tract. It may cause isolated skin lesions, a Keratoconjunctivitis or a
paronychia. More seriously it is also responsible for encephalitis.

Hepatitis A, which is caused by an RNA virus is usually transmitted by the oral
route. It has an incubation period of between 15-50 days and treatment is usually
symptomatic only.
Thank you