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QUESTION 3 Infectious Diseases
With which of the following viruses is cancer of the cervix most strongly associated?
A. Epstein-Barr virus (EBV).
B. Cytomegalovirus (CMV).
C. Human papilloma virus (HPV).
D. Human immunodeficiency virus (HIV).
E. Herpes simplex virus (HSV).
Associated with condyloma acuminatum (genital warts), squamous intraepithelial lesions and anogential malignancy including cervial, vaginal, vulval and anal carcinoma
High risk HPV types 16 (70%) & 18 associated with cervial cancer
Not all infections with HPV type 16 & 18 progress to Ca
HPV-16 is the most commonly detected HPV type ass with anal cancer as well
HPV is also a risk factor for carcinoma of penis. 70% were type 16.
HPV 6 & 11 cause genital warts
Viral oncogenes E6 & 7 – interact with growth-regulating host cell proteins
Latest development is the HPV vaccine
Gardasil – administered IM , series of 3 injections over period of 6 months
Prevent infection with HPV types 16, 18, 6 & 11
Women who are already infected with one of the 4 HPV types targeted by vaccine were protected from clinical disease
Also prevent HPV 16/18 caused anal Ca
We all know the answer is C. HPV
Infectious diseases STD's anogential warts
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Diabetic neuropathic arthropathy is most likely to affect which of the following areas?
C. 1st metatarsophalangeal joint.
Diabetes is the most common cause of neuropathic (charcot) arthropathy
Diabetic neuropathic arthropathy most commonly affects the joints of the foot and ankle
Most frequent joints are
3) metatarsophalangeal jts
We know diabetes often affects the feet so we battle between the answers B and C. But the Charcot's joint is common amongst diabetic foots where there is collapse of the foot arch. Therefore it would be Answer B.
- combination of mechanical and vascular factors
- lack of proprioception,
- sudden onset of unilateral warth, redness and edema
- history of minor trauma
- slowly progressive arthropathy
- collapse of arch of midfoot and bony prominences
- presence of peripheral neuropathy
- portals of entry of infection
- jts with effusion aspiration - ? organisms, ? crystals
Radiological findings (depends on stage)
- early soft tissue swelling, loss of jt space, osteopenia
- osteolysis of phalanges
- stress #
Acute: NWB till resolution of swelling and redness
Well fitting shoes
Oral bisphosphonates à better pain control and increase bone mineralization
Late : irreversible, surgery avoided, good foot wear to even pressure areas out.
Endocrinology: Diabetic complications neurologic
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In a patient with IgA nephropathy who has a serum creatinine in the normal range, which of the following is the best predictor of developing end-stage renal failure?
A. Urine red cell count.
B. Serum IgA level.
C. Creatinine clearance.
D. Level of proteinuria.
E. Blood pressure.
Ig A nephropathy (Berger’s disease)
- Most common glomerulopathy worldwide
- Progression to ESRD – 50%
- Dx: presence of mesangial IgA deposition on immunofluorescence microscopy
- Bx of involved skin revelas dermal IgA deposition and leukocytoclastic vasculitis
Liver Chronic liver disease
Gastro Celiac disease, Crohn’s disease, adenocarcinoma
Resp Idiopathic interstitial pneumonitis, obstructive bronchiolitis, adenocarcinoma
Skin Dermatitis herpetiformis, mycosisfungoides, leprosy
Eyes Episcleritis, anterior uvevitis
Misc Ankylosing spondylitis, relapsing polychondritis, Sjogren’s syndrome,
Gross hematuria (24 -48hr) after a pharyngeal or gastrointestinal infection, vaccination or strenuous exercise
Diagnostic: mesangial deposition of IgA detected by immunofluorescence microscopy
mesangial expansion by increased matrix and cells
Diffuse proliferation, cellular crescents, interstitial inflammation and areas of glomerulosclerosis
Optimum treatment is subject of ongoing debate and controversy
Non immunosuppressive therapies
1) ACE inhibitors
- blood pressure control- minimize secondary glomerula injury
- slow progression of renal disease
- should be started if there is evidence of progressive disease and protein excretion above 500mg/day
2) ACEi + ARB
- COOPERATE trial – combination therapy was associated with significant reduction in doubling of the serum concentration or progression to ESRD and greater antiproteinuric effect
3) Statin therapy
- lower cardiovascular risk
- associated with slower rate of loss of glomerular filtration rate
Immunosuppressive agents- cyclophosphomide and mycophenolate mofetil is unproven
- Pts with acute onset of nephritic syndrome & minimal change disease as well as mesangial IgA deposits on renal biopsy
- Pts with progressive active disease despite ACE and/or ARB
- Pts with severe disease at baseline (serum Cr 133) or progressive disease with corticosteroids
Clinical predictors of poor prognosis
- Pt with little or no proteinuria have a low risk of progression in the short term
- Most will have stable or slowly progressive disease
- Older age
- Nephrotic range proteinuria
- Renal insufficiency at presentation
Monitoring disease activity
- Urine sediment
- Protein excretion- Pr/Cr ratio
- Serum creatinine concentration
Answer D Level of proteinuria
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QUESTION 8 Giant cell arteritis
Headache, blindness and jaw claudication secondary to end-organ ischaemia are common clinical manifestations of temporal arteritis (giant cell arteritis). Which of the following most accurately describes the common pathophysiologic mechanism of end-organ ischaemia in this condition?
A. Luminal occlusion secondary to concentric intimal hyperplasia.
B. Thrombotic occlusion of medium arteries.
C. Spasm of medium and large arteries.
D. Aneurysm formation, haemorrhage and rupture.
E. Arterial dissection, haemorrhage and rupture.
Giant cell arteritis
- Inflammation of medium and larged sized arteries
- Involves one or more branches of carotid artery
Incidence and prevalence
- Exclusive in >50years
- Women more common than men
- Disease associated with polymyalgia rheumatica
Pathology and Pathogenesis
- panarteritis with inflammatory mononuclear cell infiltrates within the vessel wall with frequent giant cell formation
- Proliferation of intima and fragmentation of internal elastic lamina
- T lymphocyte produce IL-2 and IFN - g
- IL-6, IL-1Beta expression detected in circulating monocytes
- Fever, anemia, high EST & headaches
- Other manisfestations: malaise, fatigue, anorexia, wt loss, sweats and arthralgias
- Polymyalgia rheumatica synfrome is characterized by stiffness, aching and pain in the muscles of the neck, shoulders, lower back, hips and thighs
- Involvement of temporal artery à headache. Scalp pain and claudication of jaw and tongue
- Complication: ischemic optic neuropathy à sudden blindness
- Increased risk of aortic aneurysm – dissection
- Elevated ESR
- Normochromic / hypochromic anemia
- CK are not elevated
Biopsy of temporal artery
Dramatic clinical response to a trial of glucocorticoid therapy
Prevent visual loss
Prednisolone 40 -60mg/d for 1 month à gradual tampering.
ESR can serve as useful indicator of inflammatory disease activity in monitoring and tapering therapy
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