Question 12

Which of the following are true regarding tuberculosis?

Incidence is decreasing

True False

It is more common in Asian families

True False

BCG immunisation is indicated in individuals with a positive tuberculin test

True False

Primary infection is often asymptomatic

True False

Tuberculin testing involves intramuscular injection of antigen

True False

The Answer
Comment on this Question

The positive intradermal tuberculin test is indicative of infection, unless the person has received
BCG. It does not mean that an individual should be immunised. The majority of children infected by
Mycobacterium tuberculosis are asymptomatic. The incidence of TB is in fact increasing and is more
common in Asian families.

Question 13

In chickenpox (varicella) infection:

There is an association with cerebellar ataxia

True False
 In the early stages, low PaO2 is an ind icat ion for immed iate treatment w ith ant iv iral
drugs

True False

Incubation period is typically 5-10 days

True False

In the 3rd trimester maternal infection should be managed with anti-viral treatment if
possible within 24 hours

True False

It is a cause of mucosal ulceration

True False

The Answer
Comment on this Question

Diffuse encephalitis may occur in the first week and cerebellar ataxia may occur in the second week.
Pneumonitis, myocarditis, transverse myelitis, glomerulonephritis are all recognised complications.
Varicella embryopathy is seen with some first trimester infections. There are two problems in late
pregnancy - the risk of severe disease in non-immune mothers and in their newborn infants,
particularly if the baby is born within 7 days of the appearance of the rash in the mother or if the
mother develops disease within 48 hrs of delivery. Deaths in pregnant women with varicella are
approximately 5 times more likely than in non-pregnant adults and the risk for mothers appears to be
the highest around the beginning of the third trimester. The incubation period for Varicella is typically
10-21 days.

Question 14

Which of the following are live vaccines?

Oral Polio

True False

Diphtheria
 True False

Tetanus

True False

BCG

True False

Hepatitis B

True False

The Answer
Comment on this Question

Live vaccines include BCG, MMR, oral polio, yellow fever and typhoid.

Question 15

Recognised features of measles include?

Diarrhoea

True False

Febrile convulsion

True False

Generalised punctate erythema

True False

Hypothermia

True False
 Skin staining when the rash has faded

True False

The Answer
Comment on this Question

The classical three Cs of measles include cough, coryza and conjunctivitis. The child may have very
high fevers and consequently febrile convulsions. Koplik spots are seen inside the mouth and are
pathgnomonic for measles. The classic rash is described as a generalised erythematous
maculopapular rash that begins after the fever does. It starts on the head before spreading to cover
most of the body, often causing itching. The rash is said to "stain", changing colour from red to dark
brown, before disappearing. Complications with measles are relatively common, ranging from
relatively mild and less serious diarrhoea, to pneumonia and encephalitis (subacute sclerosing
panencephalitis) and corneal ulceration leading to corneal scarring.

Next question

Question 16

Ophthalmology:

Ophthalmia neonatorum is most commonly caused by Neisseria gonorrhoeae

True False

StevensJohnson syndrome is associated with iritis

True False

Orbital cellulitis is commonly secondary to adjacent sinusitis

True False

Glaucoma may be associated with aniridia

True False

Intrauterine toxoplasmosis infection results in an increased incidence of cataracts

True False
 The Answer
Comment on this Question

Neisseria gonorrhoeae may cause ophthalmia neonatorum, however Chlamydia is more frequently
responsible. StevensJohnson syndrome is a systemic disorder associated with erythema
multiforme (target lesions), fever, mouth, genital, eye ulcers and iritis (a form of anterior uveitis).
Orbital cellulitis presents with significant orbital oedema, limitation of ocular movements, fever, and
altered colour vision as a late feature. Causes include adjacent sinusitis, bacteraemia and other local
infection. Intrauterine infections which predispose to neonatal cataracts include toxoplasmosis,
rubella, cytomegalovirus (CMV), herpes simplex and varicella. Other causes include autosomal
inheritance and chromosomal disorders (e.g. Down syndrome), metabolic disorders (e.g. diabetes
mellitus), trauma and the use of systemic steroids. Glaucoma is rare in childhood and results from
defective drainage of aqueous humour from the anterior chamber. It may be due to primary causes
such as aniridia or secondary causes such as iritis, trauma or intraocular tumour.

Question 17

In Haemophilus influenzae type b (Hib) disease:

Sixty per cent of invasive Hib disease presents as meningitis

True False

The mortality rate for Hib meningitis is approximately 20%

True False

Hib infection is rare before 2 years of age

True False

Hib immunization is contraindicated in HIV-positive individuals

True False

All infants in the absence of genuine contraindications should be immunised at 2, 3 and

4 months of age and again between 12 - 13 months

True False
 The Answer
Comment on this Question

Hib infection is rare following the widespread uptake of the immunisation. However, for the at risk
population, it is rare before age 3 months; the incidence then steadily rises, peaking at
approximately 1011 months and then declining to the age of 4 years. All children younger than 13
months should therefore receive the full immunisation course. From 12 - 13 months non-immunised
children should receive a single Hib dose with their MMR (children are less at risk in this age group
and therefore a single dose is effective) and those already immunised should have a booster. The
Hib vaccine is not live and is therefore safe in immunocompromised patients. Of invasive Hib
disease, 60% presents as meningitis, 15% as epiglottitis, 10% as septicaemia alone and the
remaining 15% includes septic arthritis, osteomyelitis, cellulitis, pneumonia and pericarditis. Hib
meningitis has a mortality rate of about 4 - 5%.

Next question

Question 18

Which of the following are recognised associations with congenital rubella syndrome?

Increased risk of spina bifida

True False

Chorioretinitis

True False

Blueberry muffin rash

True False

Patent ductus arteriosus (PDA)

True False

Deafness

True False

The Answer
Comment on this Question
 Congenital rubella causes sensorineural hearing loss, microcephaly, cataracts, chorioretinitis,
hepatosplenomegaly, blueberry muffin rash and PDA.

Question 19

Epiglottitis:

Is usually due to haemophilus influenza type B

True False

Is diagnosed by examination of the throat

True False

The inspiratory stridor is associated with hoarseness

True False

Is commonly associated with septicaemia

True False

Treatment is with IV ceftriaxone/cefotaxime

True False

The Answer
Comment on this Question

Haemophilus influenza is usually the cause of epiglottitis and it is not advised to inspect the throat as
this can distress the child and cause airway compromise and deterioration. Usually the diagnosis is
obvious because the child appears toxic, drooling, pyrexial and unwell. There is not much
hoarseness unlike, for example, in comparison to croup. Treatment is indeed with IV cephalosporins.
Epiglottitis is rare since the introduction of the Hib vaccine.

Question 20

Influenza vaccine is recommended in:

Congenital heart disease

 True False

A patient in complete remission from ALL

True False

Child with cystic fibrosis

True False

HIV positive patient

True False

Diplegic cerebral palsy

True False

The Answer
Comment on this Question

Indications for influenza vaccination in the UK are: chronic respiratory disease, chronic heart
disease, chronic renal disease, diabetes, immunosuppression and HIV.

Question 21

In cholera infection:

Vibrio cholerae serotype 05 is the cause

True False

May be associated with mild diarrhoea in the first week

True False

Chronic carriage is rare

True False Is best treated with metronidazole

 True False

The organism survives up to 8 weeks in water

True False

The Answer
Comment on this Question

Cholera usually presents with severe diarrhoea (rice water stools), but may start with mild symptoms
in the first week and is caused by serotype 01 or 0139. Chronic carriage is rare but it is endemic in
most of South America, Africa and Bangladesh. The organism survives up to 8 weeks in salt water.
Treatment is with fluid and electrolyte rehydration. 3 days of treatment with tetracycline or co-
trimoxazole reduces symptoms.

Question 22

Theme: Common infections

A Adenovirus

B -Haemolytic streptococcus

C Coxsackie virus A16

D EpsteinBarr virus (EBV)

E Human herpesvirus 6

F Mycoplasma pneumoniae

G Parvovirus B19

H Poxvirus

I Rhinovirus

J Varicella-zoster virus

For each of the following scenarios, choose the most likely underlying causative organism from the
above list. Each item may be used once, more than once or not at all.

Scenario 1
A 12-year-old boy has a painful erythematous throat for which he is prescribed a broad-
spectrum antibiotic. He represents the following day with a florid maculopapular rash all
over his trunk.

EpsteinBarr virus (EBV) CORRECT ANSWER

Glandular fever should always be considered in older children with sore throats. If
amoxicillin is given when a child has EBV infection, it will cause a florid maculopapular
rash. This is one way of making the diagnosis!

Scenario 2

A 3-year-old is at nursery and her mother notices that she is unwell, refusing foods, and
has some vesicles on her palms and toes.

Coxsackie virus A16 CORRECT ANSWER

Vesicles on the hands and feet, and probably in the mouth if refusing food, are the
reason why hand, foot and mouth disease has that name. It is caused by Coxsackie
virus A16 and is very contagious. Nurseries often close during an outbreak.

Scenario 3

A 7-year-old boy presents with feeling unwell and has a macular rash all over his body.
There are some target lesions visible.

Mycoplasma pneumoniae CORRECT ANSWER

Target lesions are seen in erythema multiforme (EM). In an unwell child with arythema
multiforme mycoplasma infection should always be considered, as must herpes simplex
infection. StevensJohnson syndrome is an important complication.

Question 23

Which of the following pairs are appropriate?

Streptococcus B - neonatal meningitis

True False

Haemophilus - epiglottis

True False
 Pertussis - croup

True False

Toxocara canis - diarrhoea

True False

Strep viridans type 12 - acute nephritis

True False

The Answer
Comment on this Question

Neonatal meningitis is usually caused by group B streptococcus, E. coli and less commonly by
listeria. Between 3 months and 6 years most cases of bacterial meningitis are caused by
meningococcus, pneumococcus and H. influenzae. Above this age H. influenzae is rare. Treatment
of an 18 month old must cover H. influenzae and should therefore be treated with either a second or
third generation cephalosporin or chloramphenicol. Although treatment will prevent the in vitro
growth of the causative organism, biochemical and cytochemical analysis of CSF should still allow a
diagnosis of bacterial meningitis to be made. In the UK 60% of meningococcal infections are caused
by the serotype group B for which there is as yet no effective vaccine.

Haemophilus does cause epiglottitis, pertussis causes whopping cough, and strep viridans is
associated with bacterial endocarditis. Toxocara canis infects dogs.

Question 24

The following is true of threadworm:

The eggs survive for two to three weeks at room temperature

True False

If treatment is required, the whole family must be treated

True False

Re-infection is common

True False
 It is a common cause of recurrent abdo pain

True False

It is most common in pre-school children

True False

The Answer
Comment on this Question

Threadworm is a common parasite throughout the world. The incidence is highest in school children
from 5 to 9 years.

Hands are contaminated by scratching the perianal area where eggs are deposited, and by contact
with soiled underclothing, nightclothing or bedding. Infection is also acquired by inhalation of egg-
containing dust, which may be disseminated from bedclothing by shaking, or movements of the
sleeper. At room temperature eggs survive for 2-3 weeks.

Threadworm infection generally causes no symptoms whatsoever. The most

common manifestation is pruritus of the perineal areas especially at night due to
migration of the worms and the presence of eggs. Threadworms are no commoner in
children with recurrent abdominal pain than in those without pain. Very heavy
infections can, however, result in catarrhal inflammation of the bowel from the
attachment and irritation of worms, resulting in gastrointestinal disturbance.
Intestinal obstruction has even been reported.

Treatment for most cases of threadworm is often unnecessary, especially as reinfection of children is
almost inevitable. However, if for clinical reasons treatment is deemed necessary, then the whole
family must be treated and a second course can be given after 3 weeks.

Question 24

Which of the following is the most appropriate treatment for the contacts of a child who is
admitted with meningococcal sepsis?

Treat all family members with rifampicin

Treat close contacts with rifampicin

 Treat those contacts as advised by the Consultant for Communicable Disease
Control (CCDC)

Treat close contacts: children with penicillin and adults with rifampicin

Leave the contact tracing and treatment to CCDC

The Answer
Answer: Treat those contacts as advised by the Consultant for Communicable Disease
Control (CCDC)
Comment on this Question

Although it is within the remit of the CCDC part of the public health department to contact, trace
and treat the necessary family members, it is good practice to liaise with them and treat the contacts
at risk. This is easier for the acute clinicians to do because the contacts (usually family members)
are often with the unwell child.

Question 25

The following are true in Clostridium difficile diarrhoea:

50% of the infant population carry the organism

True False

More likely to occur with antibiotic treatment using third generation cephalosporins than
with using benzylpenicillin

True False

Diagnosis is by the culture of C. difficile from stool samples only

True False

Is best treated with oral metronidazole

True False

Can be transm itted from person to person

 True False

The Answer
Comment on this Question

5% of the adult population and 20% of the elderly are carriers of C. Difficile. Asymptomatic carriage
is more common still in infants and with reported rates of carriage of 30-70% in otherwise healthy
infants. Cephalosporins, ampicillin, amoxicillin and clindamycin are the most likely to cause C.
difficile diarrhoea. Since many people carry the organism, the presence of toxin alone is not enough
for diagnosis, but culture has to be positive and is found in 30% of antibiotic associated diarrhoea. If
antibiotic associated C. difficile diarrhoea is suspected, the most important intervention is to stop the
antibiotic thought to be associated with its development. Oral metronidazole is used as first-line
therapy to suppress growth and toxin production by C. difficile. Oral vancomycin is usually reserved
for persistent treatment failure. More important is source-isolation of the patient with strict
handwashing and hygienic measures to reduce the risks of cross infection.

Next question

Difficult

Question 26

The risk of septicaemia in a pyrexial child is more likely if which of the following are present:

Generalised convulsions for 5 minutes

True False

Sickle cell trait

True False

Purpura

True False

Floppiness

True False

White cell count < 3 x 109/l

 True False

The Answer
Comment on this Question

There are many ways children may respond in septicaemia. High or low fever, convulsions, irritability
or floppiness, high or low white count, purpura (especially in meningococcal disease) may all be
present. Sickle cell crisis presents with pain and sometimes fever and will require treatment with pain
relief, antibiotics and fluids and just because a child has sickle cell trait does not necessarily mean
that septicaemia is more likely.

Question 27

The following are true of toxoplasmosis:

It is mostly transmitted through respiratory route

True False

It is a cause of convulsions in the neonatal period

True False

If a mother is infected in the 1st trimester it seldom causes foetal abnormalities

True False

If a mother has toxoplasma IgM antibodies then she should have plasmapheresis

True False

Undercooked meat is a common source

True FalseThe Answer

Comment on this Question

Infection is either congenital or as a result of eating undercooked beef or lamb. It may cause
cerebral necrosis and patchy calcification. If a mother is infected in early pregnancy, teratogenic
damage is maximum, and maternal IgM has little effect on the foetus.
 Question 28

With regard to molluscum contagiosum:

It is a pox RNA virus infection

True False

It typically presents with small, pearly, umbilicated lesions anywhere on the body

True False

It has low infectivity

True False

Lesions generally take 69 months to resolve

True False

The treatment of choice is removal by piercing the lesion with a sharpened orange stick
dipped in phenol or liquid nitrogen

True False

The Answer
Comment on this Question

Molluscum contagiosum is a pox DNA virus infection that typically presents as small pearly
umbilicated lesions almost anywhere on the body, commonly, face, neck, axillae and thighs with
characteristic satellite spread around the original lesion. The incubation period is 27 weeks and it
spreads easily to siblings (e.g. via bath water) and the child remains infectious as long as the lesions
are present. Atopic and immunocompromised children are particularly susceptible. The treatment of
choice is patience as spontaneous resolution is the rule, typically after several months. Removal with
phenol or liquid nitrogen is generally reserved for cosmetic reasons only