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Conference October 2020 (ID)

Welcome back! It is october and the weather is starting to cool off from the 90’s and 100’s of summer. It has been absolutely perfect weather here for the past couple of weeks! Hopefully you are getting some time to head outside for some activities. This month has been a busy one. We had some interesting in depth discussions on sepsis comparing qSOFA scoring to traditional SIRS/Severe sepsis annotations, a visit from Texas College of Emergency Physicians regarding EM advocacy and Health Policy (https://www.texacep.org/) Legal series updates on AMA’s, and lastly featuring a guest lecture later this month from James Webley MD, an EM Physician from Mclaren Oakland, MI, who has a strong interest in emergency orthopedics. https://sites.google.com/mclarenmeded.org/mclaren-oakland/faculty

From left to right – Dr Heidi Knowles (Core faculty), Dr Meredith Brim (PGY1), Dr Rebecca Smiley (PGY2)
From left to right- Dr Yousef Abdel-Raziq (PGY3), Dr Joshua Reichers (PGY1), Dr Seth Klein, (PGY2), Dr Steven Horton (Clinical faculty)

But First

Our hospital named #1 in the nation for teaching hospitals!

Our own Dr Patel was selected to fly with the Thunderbirds after being selected as a hometown hero! The video is pretty epic!

Dr Chad Holmes represented JPS EM and Street Medicine at the International Street Medicine Symposium!

Next

left to right: Dr Rachel Antol (PGY1), Dr Ferran Ros (Clinical faculty)

Onto Business

Infectious Disease in Emergency Medicine has quite a few core board topics that are must know.

HIV/AIDS

CD4 >500
– Oral hairy leukoplakia, lymphomas, Kaposi sarcoma, candidiasis, psoriasis. These can occur at any CD4 count.
– Candidasis Tx: Nystatin, fluconazole.
– Kaposi’s and HOL need biopsies for confirmation.

CD4 200-500
– Oral thrush: dysphagia/odynophagia with white scrapable exudates/plaques, Tx: nystatin or clotrimazole, if not improving then consider esophagitis (Candida, HSV, CMV)
– HSV infections Tx: Acyclovir, famcyclovir, valacyclovir
– Condyloma Acuminatum Tx: Derm referral, cryotherapy, excision, imiquimod
– Pneumonia: S. pneumoniae, HSV pneumonitis. Tx: 3rd gen cephalosporin + Macrolid. HSV Tx: as above.
– Tuberculosis: 50-200x incidence in AIDS. false neg PPD common d/t immunosuppression. Tx: RIPE therapy (rifampin, isoniazin, pyrazinamide, ethambutol)
– Diarrheal infections: Normal bacterial organisms, Giardia, Cryptosporidium, Isospora belli, CMV, M. avium intracellulare, antibiotic/HAART adverse reaction

CD4 100-200
– PCP/PJP Pneumonia: Elevated LDH – typically >350. “batwing” xray findings. Tx: TMP-SMX. Give steroids (prednisone) if Pa02 <70mmHg or A/a gradient >35mmHg.

– Toxoplasmosis: CT with ring-enhancing lesions (more common in basal ganglia). Tx: Pyrimethamine + sulfadiazine (+ folinic acid)

CD4 50-100
– MAI /MAC (mycobacterium avium complex): Pulmonary infection similar to TB, nodular bronchiectatic disease. Tx: Azithromycin/clarithromycin + Rifampin + ethambutol
– Cryptococcus meningitis: Elevated opening pressure, +CSF cryptococcal antigen, + india ink stain, +fungal culture, + serum Crypt antigen. Tx: PO fluconazole (normal mental status), if AMS IV amphotericin B+flucytosine.
-CNS lymphoma more frequent with CD4 <100
– Disseminated hisoplasmosis
– Salmonella spp. septicemia

CD4 <50
– CMV retinitis/disseminated CMV; Tx: ganciclovir
– CMV retinitis –> Visual acuity changes, photophobia, floaters, scotoma, redness and/or pain. Retina: Fluffy white perivascular lesions

Other
– Med reactions: indinavir – kidney stones. Pentamidine -hypo/hyperglycemia. Didanosine – pancreatitis. Ritonavir – parethesias. Foscarnet – nephrotoxic/seizures.
– PrEP: Pre-exposure prophylaxis – high risk patients. Truvada or Descovy (brand names).
– PEP: post-exposure prophylaxis: initiate within 72 hrs of exposure: 28 day course Raltegravir+ Tenofovir-emtiracitabine.
– HAART therapy: Somewhat controversial which CD4 count to initate tx, however most sources say <350.
– (1-7)

Next

Bacterial Zoonotic Infections

Remember that Coxiella, Bartonella quintana, and Brucella are important causes of culture-negative endocarditis. ( Non HACEK).

Cat scratch disease (Bartonella henslae): Transmission: Cat scratch, fleas. Symptoms: Fever, LAD 1-3 wks, neuro, ocular. Abnl Labs: ↑ESR/CRP, ↑AST/ALT. Tx: Azithromycin, Ciprofloxacin, TMP-SMX.

Leptospirosis (Leptospira spp.): Transmission: Water contaminated by rat or cattle urine. Symptoms: Fever, HA, myalgia, jaundice, nonspecific rash. Abnl Labs: ↑Bili, ↑AST/ALT, anemia, AKI, hypoNa, ↑CK. Tx: doxycycline 100 bid x7d or IV penicillin if hospitalized.

Q fever (Coxiella burnetii): Transmission: inhalation of dust contaminated by fecers/urine of infected animal. Symptoms: Fever, HA, myalgia, PNA, endocarditis. Abnl Labs: ↑AST/ALT, ↑Bili, ↓Plt, ↑CK.   Tx: Doxyclycine 100 bid x14d.

Tularemia (Francisella tularensis): Transmission: Arthropod bite, rabbits, food/water. Symptoms: Pneumonia, lymphadenopathy. Abnl Labs: ↑ESR/CRP; normal WBC, LFTs, Cr; ↓Plt. Tx: Streptomycin 7-10d; ciprofloxacin or doxycycline 10-21d.

Next

STD Review

Sexually Transmitted Infections (STIs) / Sexually Transmitted Diseases  (STDs) - Summary Table STI
Courtesy of the MGH white book

Next

Tetanus– Spore-forming, anaerobic, Gram-positive rod Clostridium tetani. Produces tetanospasmin –> Neurotoxin blocks inhibitory nerves . Causes overstimulation of Skeletal muscle motor endplates and Autonomic nervous system: “lockjaw” and muscle spasms with diaphoresis and tachycardia. Tx: Tetanus immune globulin (TIG) 3000–5000 units IM. Tetanus immunization (give opposite site of TIG). Tx wound with Abx: Metronidazole +/- Gram negative/positive coverage. Benzos +/- magnesium for spasms. Intubation if resp failure.

Rabies – Incubation period: 30–90 days. Prodrome (days 1–4): flulike symptoms + pain/paresthesia at bite site (80%). CNS involvement: Agitation, hydrophobia (violent inability to swallow), muscular spasms →paresis of mouth/periphery, opisthotonos, altered mental status. Tx: Human rabies immune globulin (H-RIG) 20 IU/kg dose at initial treatment . Can be given up to 7 days after the first vaccine in the series. As much of the immunoglobulin as possible should be infiltrated around the wound site. Human diploid cell vaccine (HDCV). IM in deltoid (1-mL doses) on days 0, 3, 7, 14, and 28. (9)

Lyme disease – The spirochete Borrelia burgdorfei. Transmission: Ticks Ixodes scapularis (deer ticks) and Ixodes pacificus. Symptoms: Rash (90%) Erythema migrans (migrans, because it grows) – Spreading redness with central clearing (“target lesion”). Disseminated infection –> Large joint arthritis, radiculopathy, meningitis, cardiditis (AV blocks). DDx: Enteroviral diseases, aseptic meningitis, acute rheumatic fever, encephalitis, multiple sclerosis, rheumatoid arthritis, Reiter syndrome. Dx: Serum/CSF serology. Tx: Doxycycline 21 days, IV ceftriaxone (meningitis or >AV block 1st degree), Prophylaxis: If tick attached >24-48 hrs. (8)


Malaria

Plasmodium falciparum (most deadly), P. vivax, P. ovale, and P. malariae
– Transmitted by Anopheles mosquito bite
– Incubation period: 1–4 weeks –>Longer with partial immunity or antimalarial use
– Begins with flulike prodrome: Frequently presents with misleading symptoms (eg, chest pain, abdominal pain, vomiting, diarrhea, arthralgias, etc.) –>Progresses to high fever, chills, and rigor.
– Physical exam: Splenomegaly, jaundice, seizures ( if cerebral malaria or febrile pediatrics)
– Always test for concurrent HIV if malaria suspected.

Labs: ↑AST/ALT, ↑Bili, ↓Plt, ↑CK, ↑haptoglobin/LDH, hypoglycemia. Parasitemia (parasites/microL of blood), 4-10% diagnostic, anemia, mild coagulopathy/abnl PT/aPTT, ↑BUN/creatinine.

Clinical course: Above progresses to ARDS, seizures, circulatory collapse, renal failure, hepatic failure without intervention.

Tx: Atovaquone-proguanil. Adult tab = 250 mg atovaquone/100 mg proguanil. Pediatric tab = 62.5 mg atovaquone/25 mg proguanil. OR Quinine PLUS one of the following: doxycycline, tetracycline, or clindamycin. Alternate options: Mefloquine, chloroquine, hydroxychloroquine. (10,11)

Thats all for now, see you at conference!

From left to right – Dr Addie Boone (PGY4 FM-EM), Dr Chukwuagozie Iloma (PGY2), Dr Alexandra Bulga (PGY1), Dr James Howard (PGY1).
From left to right – Dr Amy Ho (Core faculty), Dr Matthew Fillingame (PGY1), Dr Hunter Scarborough (PGY3 Chief)

References

  1. Kelley CF, Barbour JD, Hecht FM. The relation between symptoms, viral load, and viral load set point in primary HIV infection. J Acquir Immune Defic Syndr 2007; 45:445.
  2. Hayashi M, Takayanagi N, Kanauchi T, et al. Prognostic factors of 634 HIV-negative patients with Mycobacterium avium complex lung disease. Am J Respir Crit Care Med 2012; 185:575.
  3. Mocroft A, Ledergerber B, Katlama C, et al. Decline in the AIDS and death rates in the EuroSIDA study: an observational study. Lancet 2003; 362:22-29. [Context Link]
  4. Palella FJ, Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era. Changing causes of death and disease in the HIV Outpatient Study. J Acquir Immune Defic Syndr 2006;
  5. Hammer SM, Eron JJ, Reiss P, et al. Antiretroviral treatment of adult HIV infection. 2008 recommendations of the International AIDS Society- USA Panel. J Am Med Assoc 2008; 300:555-570.
  6. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 29, 2008; 1-128.
  7. European AIDS Clinical Society (EACS) Guidelines for the Clinical management and treatment of HIV infected adults in Europe. Available at http://www.eacs.eu/guide/1_Treatment_of_HIV_Infected_Adults.pdf .
  8. Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: A Review. JAMA 2016; 315:1767.
  9. Centers for Disease Control and Prevention. Tetanus. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html (Accessed on February 24, 2020).
  10. Svenson JE, MacLean JD, Gyorkos TW, Keystone J. Imported malaria. Clinical presentation and examination of symptomatic travelers. Arch Intern Med 1995; 155:861.
  11. Ashley EA, White NJ. Harrison’s Principles of Internal Medicine, 20th ed, Jameson JL, Fauci AS, Kasper DL et al (Eds), McGraw Hill, New York 2018.

Image references

  1. Courtesy of – National Cancer Institute, AV-8500-3620, Public Domain, https://commons.wikimedia.org/w/index.php?curid=859393
  2. ENT surgeons Blog (http://www.drajayjain.com/2011/12/leukoplakia-of-tongue.html
  3. Rads Wiki. https://radiopaedia.org/radswikinet-1
  4. MGH “Whitebook” pocket reference
  5. Devide Menidrey@Unsplash.com
  6. K. Homles DO FACEP
  7. https://www.bmj.com/content/370/bmj.m3029

Stefan Meyering DO, FAAEM, FACEP

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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