How does the immunology relate to clinical medicine?How does the immunology relate to clinical medicine?

A 66 year old gentleman is admitted to UHCW suffering with a suspected bout of pneumonia. He has a productive cough, is tachypnoeic with a respiratory rate of 32, hypotensive (BP 85/50) and appears quite confused and disorientated

What is the most likely causative organism?a

2

What are the factors that constitute the CURB-65 scoring system and what is the score in this instance?

4

b

c

2

Your consultant orders you to send some samples to the laboratory, (i) what are you going to sample? (ii) what are you going to ask the lab to do with the samples?

The microbiologists are on strike and you have to sort through the samples of your patient and another elderly gentleman with pneumonia. From the gram stains above; (i) which sample is the S.pneumoniae culture? (ii) indicate the features that lead you to this conclusion? (iii) what is the likely organism grown in the other specimen, justify your answer?

6

d

1. 2.

Impressed with your identification of the streptococcal gram stain the consultant ask how you can ensure that this is a Strep. Pneumoniae strain compared to the strep. Pyogenes strain that closed ward 30 last week. Suggest a immunological culture that can be performed to distinguish the 2 bacterial strains

3

e

Mr A is a 33 year old Zimbabwain nationally recently arrived in the UK, he attends A&E with a 2/52 hx of fever, productive cough, & general malaise?

On examination there is marked posterior cervical chain and bilateral inguinal lymph node enlargement. Give 2 pathological scenarios that can give rise to lymphadenopathy.

2

Based on your above answer, list 4 other important pieces of information you would elicit in your clinical history.

2

1

From the history given what diagnosis needs to be considered?

A chest x-ray is taken. Describe the main clinical findings in the above radiograph.

1

You send bloods off to the lab for analysis. The results indicate elevated CRP & ESR levels. (i) what is CRP and what briefly outline the immunological process that gives rise to its elevated levels?(3 marks) (ii) what is ESR and why is it raised? (2 marks)

5

As part of your immunological work-up you send a sample of the patients sputum for analysis. What other sample is important in determining the definitive diagnosis?

1

The above histological sample is taken from patient A. Name the structure shown in the above figure (1 mark). What are the principle cells comprising this structure?(1 mark)

2

A mother brings her 4 year old child to your GP surgery because the health visitor was concerned they were not in the correct percentile for their age group. Mum reports that the infant has had a white discharge on its tongue (figure 1) for a couple of days now and has always been prone to the ‘snivells’. You consult your records & see that the child is a frequent attender to the surgery & has been diagnosed with a

number of viral and bacterial infections in the past.

Q3

Figure 1

What is the condition shown in figure 1 called and what is the most likely causative organism?

1

According to the health visitors notes the child is ‘failing to thrive’. What information would you draw on in order to assist your assessment of the growth of a 4year old child? Give 4 examples

2

As the GP you are concerned that this is quite an extensive medical history for one so young. You order some blood tests to investigate the infections further. Indicate below whether you would expect the levels of the individual blood constituents to be high, low or normal.

Neutrophils :

Eosinophils:

Basophils:

T cells:

Antibody:

Macrophages:3

Justify your answer?

5

4

What caused the infection this patient has suffered?(1 mark) Explain your answer (3 marks)

The next patient at the surgery has come to collect their blood results after having suffered a viral infection 3 weeks ago. Being the good GP you are you took a blood sample in the acute phase of the infection and another 1 week ago upon recovery. The results of the serology results are shown below:

ELISA for RSV acute sample IgM titre 1:64 IgG titre 1:32

convalescent IgM titre <1:8 IgG titre 1:128

ELISA for corona-virus

acute sample IgM titre <1:8 IgG titre 1:256

convalescent IgM titre <1:8 IgG titre 1:256

Q4

The same patient returns a month later with a 3/7 hx of nausea & vomiting and general malaise. He is concerned he may have another viral infection.

The blood results are as follows

Hb 15g/dl CRP 30mg/l (H)

Platelets 330 x 109/l Lymphocytes 3.5 x 109/l

Neutrophils 7.5 x 109/l Eosinophils 0.7 x 109/l (H)

Does he have a viral infection?

1

What is the likely infective organism?

1

During your thorough social history you find that this patient is surviving only on microwave meals. Now why do you think he is prone to these infections?

1