A 26-year-old woman presents to her physician with multiple complaints. Two days ago, she noticed fevers, chills, and malaise. One day ago, she developed pain in her left knee, left ankle, and right elbow; in addition, there is pain and swelling over her hands. She denies any other medical problems, recent upper respiratory tract infections or diarrheal illnesses, and does not smoke or use illicit drugs. She is sexually active and has had several new partners in the last few months. She is examined, which is significant for pain to palpation over the tendons in her hand and wrist, multiple scattered hemorrhagic vesicles and pustules over the dorsal aspects of both forearms, and erythema and swelling of her left knee, left ankle, and right elbow with decreased range of motion at these joints.
Which of the following is the most likely diagnosis?
Disseminated Neisseria gonorrhoeae. This young, sexually active patient is presenting with systemic symptoms, tenosynovitis, pustular skin lesions, and polyarthritis, which suggests the diagnosis of disseminated gonococcal infection. This infection can present with the symptoms seen in this vignette, or with purulent arthritis without cutaneous manifestations.
Diagnosis can be confirmed with blood cultures, cervical cultures, or synovial fluid analysis, and treatment is with ceftriaxone.
(A) Reactive arthritis may develop in response to a diarrheal illness or a Chlamydia trachomatis infection; it can also present with oligoarthritis but also commonly presents with uveitis and urethritis. Reactive arthritis is less likely to have cutaneous manifestations. (B) There is no mention of a cardiac murmur, and this patient does not meet the modified Duke criteria for the diagnosis of infective endocarditis. (D) N. meningitidis infection can present similarly, but typically has more severe systemic symptoms (with or without meningitis).
A 47-year-old man with no significant medical history presents to the Emergency Department after suffering his first seizure. He says that he has had headaches for the past week and has not felt himself. He lives with his family in California, and his mother recently moved in with him after immigrating to the United States from El Salvador. He is afebrile with normal vital signs, and a brief screening physical examination is normal. He is currently alert and oriented to person, place, and time. An MRI of the brain is shown in Figure below.
What is the most appropriate treatment for this patient?
Albendazole, dexamethasone, and levetiracetam. The brain imaging above shows a scolex (first two images) and many nonenhancing cysts with surrounding edema (third image). A scolex within the cyst cavity is pathognomonic for neurocysticercosis, one of the manifestations of infection by the pork tapeworm Taenia solium. Neurocysticercosis is the most common cause of seizure in Central America, and this patient’s mother recently immigrated from El Salvador. Neurocysticercosis is not caused by ingesting infected pork; those who eat infected pork become carriers of cysticercosis, but do not develop disseminated cysticercosis (e.g., neurocysticercosis). It is only by ingesting eggs shed in the carrier’s feces (e.g., fecal contamination of food) that one develops neurocysticercosis, since it is the embryos that hatch from the eggs that disseminate hematogenously. Treatment is with an antiparasitic agent (e.g., albendazole or praziquantel), and a corticosteroid should be added to reduce inflammation in response to the dying pathogens. (B) Because the patient presented with a seizure, an antiepileptic medication should be started in addition to an antiparasitic medication and a corticosteroid. (Of note, antiparasitic medications are not necessary if there are calcified cysts with no viable parasites.)
(C) Pyrimethamine-sulfadiazine is the treatment for toxoplasmosis, which presents with ring-enhancing lesions on brain imaging. (D, E) Vancomycin and amphotericin B are typically used for MRSA and serious fungal infections, respectively, and are not used for neurocysticercosis.
A 29-year-old woman who is 18 weeks pregnant presents to her physician complaining of fever, cough, myalgias, and a skin rash (Figure below). She has no other medical problems and has had regular prenatal care. Her only medication is a prenatal vitamin. She lives in a rural area of Minnesota and has not traveled recently or had any sick contacts.
What is the best treatment option for this patient?
: Amoxicillin. Lyme disease is caused by the spirochete Borrelia burgdorferi, which is carried by the Ixodes tick. Lyme disease is effectively prevented with removal of the tick within 24 hours. Clinical manifestations of the disease are based on the stage of disease. In the early stage, which occurs a few weeks after infection, there are nonspecific flu-like symptoms and an expanding erythematous rash with a central clearing called erythema migrans (Figure 6-10). After weeks to months, the disease can disseminate and cause migratory arthralgias, cutaneous annular lesions, cranial neuropathies, aseptic meningitis, cardiac conduction blocks, and other serious complications. The late stage of the disease, which occurs months to years after infection, manifests as arthritis and acrodermatitis chronica atrophicans (widespread skin atrophy with polyneuropathy).
(B) Treatment of Lyme disease is with doxycycline; however, this patient is pregnant and so doxycycline is contraindicated. Amoxicillin is the best alternative treatment in pregnant patients or those allergic to doxycycline. (C) Erythromycin is also teratogenic. A useful mnemonic for remembering teratogenic antibiotics is “SAFE Moms Take Really Good Care”: Sulfonamides, Aminoglycosides, Fluoroquinolones, Erythromycin, Metronidazole, Tetracyclines, Ribavirin, Griseofulvin, and Chloramphenicol. (D) Penicillin G is the treatment of Treponema pallidum (syphilis), another spirochete. A third medically important spirochete is Leptospira, which can cause a spectrum of disease ranging from a mild subclinical infection to life-threatening renal failure, ARDS, jaundice, and pulmonary hemorrhage (Weil disease).
A 38-year-old woman with no previous medical history presents to the Emergency Department with a fever and severe headache. She is not taking any medications and denies recent travel, sick contacts, or recent illnesses. She lives in California and works as a secretary. She does not have any pets and has been sexually active exclusively with her husband for the past 18 years. Other than a temperature of 39.3°C, her vitals are within normal limits. She has some nuchal rigidity and her hips flex when her neck is flexed. There are no signs of papilledema on funduscopic examination. A lumbar puncture is performed, and the results are shown below.
A screening HIV test and blood cultures are negative, and Gram stain and cultures of the CSF are also negative.
What is the most likely cause of this patient’s condition?
Echovirus. Aseptic meningitis is diagnosed by CSF studies that show meningeal inflammation (elevated leukocytes) with negative blood and CSF culture results. The most common cause of aseptic meningitis is a viral infection, and enteroviruses (echovirus, coxsackievirus, etc.) are the most common type. The CSF in viral meningitis will show elevated leukocytes (with a lymphocyte predominance), elevated total protein, and normal glucose and opening pressure. Other potential viruses include herpesviruses, adenovirus, HIV, mumps, and many more. West Nile virus is a possibility, but is a less common cause of aseptic meningitis. In addition, this patient does not have any obvious mosquito exposures (recent hiking, outdoor activity, etc.), making the diagnosis less likely. Treatment of viral meningitis is supportive (unless it is caused by HSV, in which acyclovir should be given).
S. pneumoniae is the most common cause of bacterial meningitis, which would typically present with a higher CSF leukocyte count with a neutrophil predominance, a higher total protein, and a low glucose; CSF Gram stain and culture should also be positive. Other important bacterial pathogens include rickettsial infections, Borrelia burgdorferi, Coxiella, and Ehrlichia. TB and syphilis can both produce aseptic meningitis, and both commonly have a low CSF glucose. There are no TB risk factors or sexual risk factors presented in the vignette, making these etiologies unlikely. Cryptococcus is a common cause of meningitis in HIV patients; however, this patient’s screening HIV test was negative. Coccidioides is another fungal organism that can cause aseptic meningitis and typically presents with a low CSF glucose like other fungal infections. Autoimmune conditions such as rheumatoid arthritis, SLE, sarcoidosis, and others can cause aseptic meningitis, but other historical clues and physical examination findings would likely be present to suggest this as the diagnosis. Other important causes of aseptic meningitis include neoplasms, medications (including NSAIDs, intravenous immunoglobulins, and trimethoprim-sulfamethoxazole), brain abscesses or partially treated bacterial meningitis, and parasites (e.g., toxoplasmosis).
A 62-year-old man is hospitalized for severe fatigue, fevers, and weight loss. He has no past medical history and takes no medications. His family history is negative for cardiac disease or cancer, and he does not smoke or drink alcohol. On examination, his temperature is 38.5°C with a normal blood pressure and heart rate. There is no scleral icterus, and he has good dentition. Cardiac auscultation reveals an early diastolic decrescendo murmur at the left upper sternal border. The pulmonary and abdominal examinations are normal. His laboratory values show a creatinine of 1.8 mg/dL (baseline 1.0 mg/dL), and his urinalysis shows WBCs and dysmorphic RBCs. His urine cultures are negative, but his blood cultures are positive for group D Streptococcus, specifically Streptococcus gallolyticus. The patient undergoes transthoracic echocardiography (TTE), which shows a vegetation on the aortic valve, and he begins treatment with penicillin G.
What should be done next in the management of this patient?
Colonoscopy. This patient meets the modified Duke criteria (Table below) for infective endocarditis, since he has a new regurgitant murmur and positive blood cultures for an organism known to cause endocarditis. Both the viridans group of Streptococcus species as well as the S. bovis biotypes (note that nomenclature has changed; species include S. gallolyticus and S. infantarius) are common organisms that cause native valve endocarditis, even in patients without risk factors. The S. bovis biotypes are normal GI tract inhabitants and have been associated with colorectal cancer (especially S. gallolyticus). Patients who have positive blood cultures for this organism should also undergo colonoscopy given the association with colon cancer.
Modified Duke Criteria:
(A) TEE would be appropriate if the TTE was nondiagnostic, or if it was negative and there was a high clinical suspicion for infective endocarditis. (C) CT scan of the chest is not part of the workup for infective endocarditis. (D) The indications for surgery to treat serious cases of infective endocarditis include CHF and cardiogenic shock, extension of the primary infection (e.g., periannular abscess), persistent embolic events despite treatment, difficult to treat organism, and prosthetic valve endocarditis (especially if there is valvular dysfunction). (E) Penicillin G is an appropriate treatment for group D strep infections. Antibiotic selection should be based on culture and sensitivity data, and most group D strep species are not sensitive to doxycycline.
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