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Rocky Mountain spotted fever
- a flu-like illness during the summer
- RMSF should be strongly considered in patients such as this one with a nonspecific febrile illness within 3 weeks of potential tick exposure, and immediate treatment with doxycycline should be given pending results of diagnostic studies. Many people with tick-borne infection do not recall a specific tick bite. Up to 90% of patients eventually develop the characteristic blanching erythematous macules located around the wrists and ankles that spread centripetally. The most commonly available diagnostic test for RMSF is a convalescent serology.
- Babesia microti, an intracellular protozoan parasite. Babesiosis is transmitted to humans by ticks and occurs primarily in the northeastern United States with an epicenter in Cape Cod, Massachusetts, and the associated islands. Most infections are subclinical, but a nonspecific febrile illness can occur. Babesiosis should be considered in patients who have traveled to endemic areas and now have a nonfocal febrile illness with chills, sweats, myalgia, arthralgia, nausea, vomiting, or fatigue. On physical examination, fever, splenomegaly, hepatomegaly, and jaundice may be present.
- Most cases of babesiosis resolve without any specific treatment. For ill patients, treatment is usually a two-drug regimen, quinine and clindamycin. As these drugs are often poorly tolerated, recent evidence suggests a regimen of atovaquone andazithromycin can be equally effective. In life-threatening cases, exchange transfusion is performed. In this procedure, the infected red blood cells are removed and replaced with uninfected ones. Imizol is a drug used for treated of Babesiosis in dogs.
usually is diagnosed in young women, generally shows unusual fever patterns such as very high or brief spikes and rapid defervescence without chills, and diaphoresis. A fever diary will typically demonstrate a lack of normal diurnal temperature variation. Like this patient, physical and laboratory findings of infection or inflammation are lacking during the febrile illness.
Familial Mediterranean fever
an autosomal recessive disorder prevalent in people of Jewish, Turkish, Arabic, and Armenian heritage. Most patients have the onset of illness before age 10 years, 95% before the age of 20 years. The key feature is short periods of fever (1-3 days) associated with serositis; 90% of patients have abdominal pain, and pleuritis and synovitis are also common. Episodes of fever are accompanied by elevated markers of inflammation such as leukocytosis and erythrocyte sedimentation rate.
SIRS Systemic inflammatory response syndrome
at least two of the following conditions: temperature greater than 38.0°C (100.4°F) or less than 36.0°C (96.8°F), heart rate greater than 90/min, respiration rate greater than 20/min or arterial blood Pco2 less than 32 mm Hg (4.3 kPa), leukocyte count greater than 12,000/µL (12 × 109/L) or less than 4000/µL (4 × 109/L) or with greater than 10% immature band forms
Sepsis: The systemic inflammatory response to a documented infection. In association with infection, manifestations of sepsis are the same as those described for SIRS.
Peritonsillar abscess (Quinsy)
Complications of untreated group A β-hemolytic streptococcal (GABHS) infection include peritonsillar abscess (“quinsy”), poststreptococcal glomerulonephritis, and rheumatic fever. About half of patients with peritonsillar abscess present first with this complication rather than with pharyngitis. Among those who present first with sore throat and then develop peritonsillar abscess, only one quarter have GABHS pharyngitis. Patients who present first with sore throat, such as this patient, are distinguished by worsening sore throat despite antibiotic therapy, fever dysphagia, pooling of saliva, possible drooling, and muffled voice. On physical examination, the patient is ill-appearing and often has enlarged tonsils with deviation of the uvula to the unaffected side. The more serous complications include airway obstruction, dissection of the infection to the parapharyngeal space, spontaneous abscess drainage and aspiration of pus (usually while sleeping) and sepsis. Treatment consists of needle drainage or surgical incision and drainage of the abscess.
- Treat with Amoxicillin
- The microbiology of otitis media in adults is similar to that of children: Streptococcus pneumoniae, 21% to 63%; Haemophilus influenzae, 11% to 26%; Staphylococcus aureus, 3% to 12%; and Moraxella catarrhalis, 3%. Thirty percent of bacterial cultures of the middle ear show no growth.
- Antibiotic therapy should be reserved for patients in whom evidence of purulent otitis exists. Guidelines for antibiotic use are the same in children and adults. Amoxicillin is the recommended initial antibiotic because of its proven efficacy, safety, relatively low cost, and narrow spectrum of activity. If symptoms do not improve after 48 to 72 hours of amoxicillin therapy, initiation of amoxicillin-clavulanate, cefuroxime, or ceftriaxone is recommended. Alternative agents for patients with penicillin allergy are oral macrolides (azithromycin, clarithromycin).
Centor criteria for Strep throat
- fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough
- Patients with two Centor criteria, such as the patient described here, have an intermediate probability for GABHS infection, and rapid streptococcal antigen testing (sensitivity of 88% and specificity of 94%) is a reasonable strategy for these patients. Patients with 0 or 1 criterion have a low (<3%) probability of GABHS, and neither testing nor antibiotic treatment is recommended. Empiric antibiotic therapy is recommended for patients who meet all four Centor criteria because the probability of GABHS is 40% or greater. Opinion differs regarding the management of patients with three criteria, and either empiric antibiotic treatment or testing and then treating only if test results are positive is acceptable. Patients with Centor scores of 3 or 4 who have negative rapid antigen testing should then undergo throat cultures to guide treatment decisions.
Asymptomatic bacteriuria in pregnancy
begin ampicillin. Pregnant women are screened for asymptomatic bacteriuria, which is associated with low birth weight, prematurity, and an increased risk for pyelonephritis. This pregnant woman has asymptomatic bacteriuria that now requires treatment. An appropriate antibiotic for this patient is ampicillin, amoxicillin, or nitrofurantoin. These antibiotics are Food and Drug Administration pregnancy risk category B drugs. Ciprofloxacin and trimethoprim are both pregnancy risk category C drugs and are therefore not indicated.Urine cultures should be obtained after treatment in pregnant women with asymptomatic bacteriuria to confirm eradication of bacteria. Confirming the sterility of the urine can be done by repeating urine cultures at intervals until delivery.
UTI with prostatic abscess
- Start IV antibiotics - ciprofloxacin
- If not improving - transrectal ultrasound if kidneys cannot tolerate CT
- avoid foley, may increase risk of septicemia
Screening for asymptomatic bacteriuria is recommended only for pregnant women and before transurethral resection of the prostate, urinary tract instrumentation involving biopsy, or other tissue trauma resulting in mucosal bleeding. Women with diabetes, premenopausal nonpregnant women, older persons living in the community, elderly institutionalized persons, persons with spinal cord injury, and patients with catheters while the catheter remains in situ should not be screened or treated for asymptomatic bacteriuria.
Treat pyelonephritis with a fluoroquinolone (ciprofloxacin or levofloxacin)
- abrupt onset of fever, chills, sweats, nausea, vomiting, diarrhea, and flank or abdominal pain; hypotension and septic shock may occur in severe cases
- The presence of bacteriuria and pyuria is the gold standard for diagnosing pyelonephritis if these findings are associated with a suggestive history and physical examination findings. Leukocyte casts in the urine are suggestive of pyelonephritis but are uncommonly detected. Blood cultures should be obtained in patients who appear ill. Hypotensive patients with pyelonephritis should receive intravenous fluids.
- Treatment of pyelonephritis consists of antibiotics for 7 to 14 days. Patients who are acutely ill, nauseated, or vomiting should receive parenteral therapy initially and can begin receiving oral therapy once oral intake is tolerated. The standard therapy in nonpregnant women is a fluoroquinolone. Alternatives to fluoroquinolone antibiotics include extended-spectrum cephalosporins or penicillins, but oral options may be more limited for patients with a contraindication to fluoroquinolones. Eradication of bacteriuria in patients treated for pyelonephritis can be confirmed through repeat urinalysis and urine culture. Imaging studies should be used only if an alternative diagnosis or a urologic complication is suspected.
- Until recently, trimethoprim or the combination of trimethoprim-sulfamethoxazole was highly effective for treating acute pyelonephritis. The increased frequency of resistant strains of Escherichia coli and other gram-negative bacteria to these antimicrobial agents has led to a preference for initial therapy with fluoroquinolones except in pregnant women, because fluoroquinolone antibiotics are Food and Drug Administration pregnancy risk category C drugs.
Recurrent cystitis - initiate patient administered septra
- This patient most likely has a recurrent urinary tract infection (UTI). Self-treatment with trimethoprim-sulfamethoxazole on development of symptoms is appropriate. Recurrent UTIs are common in women and are believed to represent new infection rather than a relapse of a previous episode. Although evaluation for subtle predisposing factors such as anatomic urinary tract abnormalities is seldom useful, inquiring about behavioral practices can be helpful. Sexual intercourse is a risk factor for acute and recurrent UTIs, as is the use of spermicides or spermicides plus a diaphragm.
- One study found that women correctly diagnosed more than 90% of recurrent infections, and that self-treatment was effective in more than 95% of patients—numbers that rival those of physician-initiated therapy.
- Trimethoprim-sulfamethoxazole, 160 mg/800 mg twice daily for 3 days, is effective for treating uncomplicated cystitis. In addition, the reported 12% resistance of Escherichia coli to this agent is low enough that other antibiotics do not need to be considered.
Routinely screen sexually active women <25 for chlamydia, gonorrhea, HIV
- United States Preventative Services Task Force recommends screening for gonorrhea in high-risk persons, including women who have a history of sexually transmitted disease (STD) infection, have multiple sexual partners, are pregnant, or are under the age of 25 years, because this is the population with the highest prevalence
- American College of Physicians and the CDC recommend HIV screening for patients in all health care settings. They recommend “opt-out screening,” in which the patient is notified that testing will be performed unless the patient declines.
- Persons at risk and all pregnant women should be screened for syphilis. Pregnant women are screened during the first prenatal visit and during the third trimester and, for women at high risk, at the time of delivery. Other high-risk persons include commercial sex workers, prisoners, any person diagnosed with another STD, men who have sex with men, and those who engage in other high-risk behaviors. Screening is not recommended in the general population because a positive test result will most likely be a false-positive test result.
Empirically treat cervicitis for chlamydia and gonorrhea
- Cervicitis is the presence of a mucopurulent cervical discharge or endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is commonly caused by either gonorrhea or chlamydial infection, and although gonorrhea infection is often symptomatic, either may be asymptomatic or only mildly symptomatic.
- intermenstrual bleeding is not uncommon. The absence of gram-negative intracellular diplococci on Gram stain does not rule out gonorrhea, because it is observed in only 50% of women with this infection.
- Cefuroxime and azithromycin
not a sexually transmitted disease and does not cause cervicitis. On vaginal examination, inflammation is not evident, but a homogeneous, white, noninflammatory discharge coats the vaginal walls. The vaginal pH is higher than 4.5, the “whiff test” is positive (a fishy odor is present when potassium hydroxide is added to vaginal secretions), and “clue cells” (squamous epithelial cells covered with bacteria obscuring the edges of the epithelial cells) are found on wet mount.
Treat disseminated gonococcal infection with ceftriaxone
- DGI may cause septic or sterile immune-mediated arthritis and tenosynovitis and frequently involves the knees, hips, and wrists but not the spine. Dermatitis associated with sparse peripheral necrotic pustules also is common. A characteristic prodrome of migratory arthralgia and tenosynovitis may precede the settling of the synovitis in one or several joints.
- Genitourinary symptoms associated with DGI usually are absent in women, and genital infection in women may have occurred long before systemic dissemination. Patients with rectal and pharyngeal colonization of Neisseria gonorrhoeae in the setting of DGI are commonly asymptomatic. In all patients in whom DGI is clinically suspected, routine culture of the rectum and pharynx, as well as the blood and the joints, is indicated.
- On diagnosis of DGI, prompt evaluation for additional sexually transmitted diseases, including syphilis and HIV, is indicated. Empiric treatment forChlamydia trachomatis infection with doxycycline also should be considered, because coinfection with N. gonorrhoeae and C. trachomatis is common. Patients with DGI are frequently asymptomatic, and this condition can cause infertility if untreated. Sexual partners of patients with DGI also should be treated.
3-day history of fever, headache, and painful sores in the genital area. Tender ulcerative lesions with a yellow crusted roof cover the labia bilaterally and the vaginal introitus.
HSV-1 or HSV-2 may cause the infection, but HSV-2 is the more common pathogen. Genital herpes lesions typically begin as vesicles that ulcerate and are quite painful. The initial infection is often the most severe and can be accompanied by local lymphadenopathy and systemic symptoms. Recurrences vary in frequency and are typically less severe than the initial episode. Many recurrences are subclinical but are nonetheless contagious. The diagnosis of genital herpes is often suspected on clinical grounds but may be confirmed by viral culture or serologic testing if the diagnosis is in doubt. Viral culture for HSV-1 and HSV-2 is a rapid test, with results often available by the next day. The specificity of viral culture approaches 100%, but the sensitivity varies with the quality of specimen handling and the age of the lesion (older, crusted lesions have lower yield).
uncommon sexually transmitted disease caused byHaemophilus ducreyi. Infection is characterized by the presences of ragged, purulent, painful ulcers associated with tender lymph nodes that may suppurate. The superficial vesicles and erosions of herpes simplex virus infection are not easily mistaken for the deep, ragged ulcers of chancroid.
primary ulcerative lesion (chancre) in patients with syphilis develops approximately 3 weeks after infection occurs, has a clean appearance with heaped-up borders, and is usually painless and often unrecognized, particularly in women. Multiple small painful vesicles and erosions argue strongly against this diagnosis.
- intramuscularly delivered ceftriaxone and oral doxycycline
- polymicrobial infection of the endometrium, fallopian tubes, and ovaries; diagnosis is based on the presence of abdominal discomfort, uterine or adnexal tenderness, or cervical motion tenderness. Other diagnostic criteria include temperature higher than 38.3°C (101.0°F), cervical or vaginal mucopurulent discharge, leukocytes in vaginal secretions, and documentation of gonorrheal or chlamydial infection. PID is most likely to occur within 7 days of the onset of menses. All women with suspected PID should be tested for gonorrhea, chlamydia, and HIV infection, and undergo pregnancy testing. In severe cases, imaging should be performed to exclude a tubo-ovarian abscess. Ambulatory patients are treated with ceftriaxone and doxycycline with or without metronidazole. Duration of treatment is 14 days. Patients with PID should be hospitalized if there is (1) no clinical improvement after 48 to 72 hours of antibiotics; (2) an inability to tolerate oral antibiotics; (3) severe illness with nausea, vomiting, or high fever; (4) suspected intra-abdominal abscess; (5) pregnancy; or (6) noncompliance with outpatient therapy.
Treat Pneumocystis jirovecii with septra and steroids
- The diagnosis should be considered in any patient with a CD4 cell count of less than 200/µL who presents with fever, dry cough, and dyspnea developing over several days or weeks. The chest radiograph typically shows bilateral interstitial infiltrates, but findings can vary from a normal film to consolidation or a pneumothorax. The diagnosis is established by silver stain examination of induced sputum or a bronchoscopic sample showing characteristic cysts. A 3-week course of trimethoprim-sulfamethoxazole is the standard treatment. Corticosteroids are required for patients with evidence of hypoxia (arterial Po2 <70 mm Hg [9.3 kPa] or an alveolar-arterial gradient >35 mm Hg [4.7 kPa]) and should be continued for the entire course of treatment.
- Dapsone can be an adjunctive treatment to trimethoprim in acute Pneumocystis jirovecii and can be used alone as a prophylactic agent for patients with a CD4 count less than 200/µL in patients who are intolerant of trimethoprim-sulfamethoxazole, but it is not recommended as single drug therapy forPneumocystis jirovecii pneumonia.
Prophylatic pneumocystis, toxoplasmosis, mycobacterium avium management with septra
- Several drugs have been shown to provide effective prophylaxis against opportunistic infections in patients with HIV infection and to prolong life in some patients. The CD4 cell count is an indicator of immune competence. Recommendations regarding when to initiate prophylaxis are based on CD4 cell count levels. The threshold forPneumocystis and toxoplasmosis prophylaxis is 200/µL and 100/µL, respectively. The patient's CD4 cell count is 77/µL, and she should receive prophylaxis for Pneumocystis and for toxoplasmosis if her antibody titer is positive (demonstrating previous infection but not immunity). Trimethoprim-sulfamethoxazole is the first-line agent for both.
- Azithromycin is used for prophylaxis against Mycobacterium avium complex in patients with a CD4 cell count less than 50/µL.
- Isoniazid would be indicated if the patient were found to have a positive tuberculin skin test greater than 5 mm and a negative chest x-ray excluding active tuberculosis.
Treat recurrent herpes zoster & hiv
All patients with HIV infection and herpes zoster infection are treated with antiviral therapy regardless of the age of the zoster lesions. Most patients with HIV infection can be treated with an oral antiviral drug with good bioavailability, such as valacyclovir or famciclovir, but patients with severe disease, evidence of dissemination, or ophthalmologic involvement may have better outcomes if treated with intravenous acyclovir.
Diagnose acute HIV infection with RNA viral load and antibodies
- Detection of HIV RNA is the most sensitive test for detecting HIV infection during the acute symptomatic phase. Tests for HIV-specific antigens, such as p24, can also detect the presence of virus in the acute setting. Antibodies to HIV do not commonly occur until about 6 weeks after infection and may therefore be negative during the acute symptomatic phase. Patients diagnosed with acute HIV infection on the basis of an HIV viral load measurement should have confirmatory serologic antibody testing performed at a subsequent point in time.
- In addition to the acute retroviral syndrome, this patient must be evaluated for secondary syphilis using the rapid plasma reagin test. Secondary syphilis and acute retroviral syndrome should always be considered in sexually active patients with rash, fever, and generalized lymphadenopathy. Other causes of a mononucleosis syndrome (for example, Ebstein-Barr virus and cytomegalovirus infections) should also be considered if these tests are inconclusive.
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