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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Negative
Negative
Treatment Plan
CCS NOTE
Therapy for urethritis has to be ordered before the results of the tests are known.
Discussion
Gonorrhea is one of the most common reportable bacterial infections in the United States. Only
50% of all cases are reported. Gonorrhea can cause a wide variety of infections, ranging from
an asymptomatic carrier to urethritis, pharyngitis, cervicitis, pelvic inflammatory disease,
conjunctivitis, proctitis, and disseminated disease. Some untreated cases (1–2%) will
eventually disseminate. The most common site of infection in men is the urethra.
VDRL test3.
HIV test4.
Ceftriaxone 125 mg intramuscularly once and single-dose azithromycin1.
Doxycycline (orally for a week) or azithromycin (1 dose)2.
Oral cefixime can be substituted for ceftriaxone to treat gonorrhea. Fluoroquinolones are
NO longer recommended for the treatment of gonococcal infections in the United States
because fluroquinolone-resistant N. gonorrhoeae are now widespread throughout the
country.
91
An increasing amount of gonorrhea is resistant to penicillin; thus, ceftriaxone is now the
treatment of choice. A single dose is effective. Azithromycin or doxycycline is used to treat C.
trachomatis. Because Chlamydia is an intracellular organism, it is not seen on a Gram stain of
the urethral swab. Immunofluorescence staining can be done if required to diagnose chlamydiae
because they do not culture easily. Ligase chain reaction (a nucleic acid amplification test) is a
test done on urine with a very high sensitivity and specificity. Doxycycline or azithromycin is
added to the treatment of all patients with gonorrhea because of the very high rates of co-
infection and because confirming a diagnosis of chlamydia requires a relatively expensive test
and follow-up in several days.
Other effective regimens for gonorrhea are spectinomycin, and third-generation cephalosporins
such as cefotaxime, ceftizoxime, and cefixime.
Neisseria bacteria, including Neisseria gonorrhoeae and Neisseria meningitidis, will grow
on a Thayer-Martin agar, which is 5% chocolate sheep blood and antibiotics.
CLINICAL PEARL
Classic findings of DGI are:
It contains vancomycin, which is able to kill most Gram-positive organisms
Colistin, which is added to kill most gram-negative organisms except Neisseria
Nystatin, which can kill most fungi
Trimethoprim, which inhibits gram-negative organisms, especially swarming Proteus
Migratory polyarthralgia evolving into frank arthritis. N. gonorrhoeae infection
should be considered in the differential diagnosis of monoarticular septic arthritis in
a sexually active patient.
Tenosynovitis involving ≥1 joints.
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Remember, blood and synovial fluid cultures are often negative. A high index of
clinical suspicion for DGI should prompt the collection of specimens from the cervix
or urethra, pharynx, and rectum for culture to make a presumptive diagnosis.
Treatment
Ceftriaxone plus doxycycline
CLINICAL PEARL
Terminal complement deficiency (C5 to C9) can cause recurrent Neisseria infection.
Final Diagnosis
Gonococcal urethritis
Skin lesions in 75% of patients. The classic lesion is characterized by a small
number of necrotic vesicopustules on an erythematous base.
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Case 12
Chief Complaint
“I’ve got some blisters on my penis.”
History and Physical Examination
A 37-year-old ambitious executive for a local health maintenance organization comes to
your office because he developed multiple blister-like lesions on his penis over the last
1–2 days. They are somewhat painful, and he is worried that he has AIDS. He denies
unprotected sex and IV drug abuse and had an HIV test before his marriage 3 years ago.
He reports several similar episodes several years ago when he worked as a photographer
in Nepal. He was never told what they were, and they resolved over several days without
any treatment.
He is afebrile, is pleasant, and does not appear to be in distress. Heart, lung, and abdomen
are normal. Examination of genitals shows 6–8 vesicular lesions 3–4 mm in diameter on
the glans of the penis. There is no crusting, drainage, or bleeding. They are moderately
tender. There is also mild inguinal adenopathy bilaterally.
Differential Diagnosis
Initial Management
Herpes simplex type 1
1.
Herpes simplex type 2
2.
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Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
Assessment
Multiple small, tender vesicular lesions of the genitals or mouth are very characteristic of
herpes simplex, and the differential diagnosis is small. Occasionally, if the lesions have
unroofed or become confluent, they may be confused with chancroid, which is also painful.
Most often herpetic lesions have such a characteristic appearance that no further diagnostic
tests are required. If there is any doubt of the diagnosis, however, perform an HSV PCR, as that
is the most sensitive and specific test.
The Tzanck prep has low sensitivity and specificity and would not be the correct test. Viral
culture may also be used. Serology on blood testing is not useful in confirming the diagnosis
because 85–90% of the population is positive. Herpes simplex 1 is found in 70% of the
population, and herpes simplex 2 in 20%.
Further Management Plan/Results
Treatment Plan
Acyclovir; famciclovir and valacyclovir are also acceptable alternatives.
Wright’s or Giemsa stain of an unroofed lesion
Stain: multinucleated giant cells visible lesion (Tzanck prep)
Viral culture or HSV PCR: herpes simplex grows after 72 hours
95
Discussion
This patient should be reassured that a recurrent episode of genital herpes is not indicative of
AIDS. A confirmatory clue that this patient’s infection is a recurrence and not a primary
infection is the absence of systemic symptoms. Initial infections of both oral and genital herpes
are often associated with fever, headache, malaise, and adenopathy. These symptoms are
generally absent from recurrences. Recurrent herpetic lesions only need 5 days of treatment,
though primary lesions may need 10 days.
Topical acyclovir is worthless for oral lesions and of very limited use in genital lesions. As
with this man’s original episodes several yrs ago, most episodes resolve spontaneously
anyway, and the acyclovir treatment is solely to shorten the duration of the outbreak. Although
oral lesions are more often caused by type 1 virus and genital lesions by type 2 virus, either
one may cause oral or genital lesions. There is a clinical benefit of distinguishing between the
two because viral shedding and recurrent ulcers are less likely with HSV-1 than HSV-2.
Herpes encephalitis is the most common cause of viral encephalitis.
Herpetic infections can recur at any time and with any frequency after the original infection
from as infrequent as several yrs apart to as short as several wks apart. Any form of physical
or emotional stress, intercurrent infection, or immunosuppression (such as with AIDS or
steroid use) can cause recurrences.
Frequent recurrences of genital herpes can be suppressed with a regular dose of acyclovir 400
mg 2x/day, valacyclovir 1x/day, or famciclovir 2x/day on a chronic basis.
CCS NOTE
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The options to move the clock forward also include an “as needed” option. This is for
patients like this one, in which there is a brief, self-inflicted problem. See them once
after the initial visit to make sure the lesions have resolved. Then click on “RETURN
AS NEEDED.” This is done for patients in whom the problem has resolved.
Final Diagnosis
Herpes simplex of the genitals
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Case 13
Chief Complaint
Diarrhea for the past 2 days
History and Physical Examination
Eighteen fellows and attending doctors from the department of medicine have come
unexpectedly to the employee health service over the past 36 hours with a history of 1–2
days of diarrhea. All of them were present at a large dinner party given by one of the
hospital’s gastroenterologists several days ago. They all complain of multiple episodes of
watery diarrhea. Some have blood visible in their stool, and some have profound
abdominal cramping and fever. They all ate multiple dishes at the party including chicken,
lamb, beef, salads, sauces, and an excellent tiramisu (sponge cake with eggs, espresso,
wine, sugar, melted chocolate, and cheese).
Their temperatures range from 37.6 to 38.6 C (99.6 to 101.4 F). Chest, heart, head, eyes,
ears, nose, and throat are all normal. Abdominal examination shows some distention with
generalized, mild tenderness.
Differential Diagnosis
Salmonella
1.
Campylobacter
2.
Shigella
3.
Norwalk virus
4.
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Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
Assessment
Salmonella, Shigella, Campylobacter, Yersinia, and E. coli can all present with a dysentery
syndrome of multiple watery bowel movements, fever, abdominal pain, and blood in the stool.
It is generally not possible to distinguish the causative agents on the basis of the history alone.
S. aureus and Bacillus cereus tend to present with a more acute onset of 2–6 hours after
ingestion of the contaminated food with more upper GI symptoms. Viral diarrhea is seldom
accompanied by blood or WBCs in the stool. Almost all of them are benign and self-limited.
The definitive diagnosis of bacteria-related food poisoning depends upon stool culture.
Campylobacter and Salmonella are the most common causes of bacterial food poisoning.
Yersinia5.
Enteroinvasive E. coli6.
Stool examination for blood and leukocytes
Blood culture
Stool culture
Stool exam: positive blood in the stool; positive leukocytes with methylene blue staining of
the stool
Blood culture: positive for Campylobacter
Stool culture: positive for Campylobacter
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Giardia and cryptosporidiosis are uncommon in this setting in which the water supply is
presumably safe. In addition, Giardia and cryptosporidiosis do not give red or white cells in
the stool. Giardia is treated with metronidazole.
Treatment Plan
Discussion
Gastrointestinal infections are an enormous source of illness worldwide and rank second only
to respiratory infections as a cause of death. They are the number-one cause of death in
children worldwide, with >12,000 deaths per day.
The vast majority of cases of food poisoning resolve spontaneously without antibiotics and
with the use of hydration alone. The rehydration solutions are a combination of water, salt,
potassium, and sugar. Antimotility agents are avoided because they may lead to toxic
megacolon and buildup of the infectious agent. For instance, when diphenoxylate is used in
Shigella, there can be prolonged fever and shedding of the organism. In Salmonella, they can
increase the risk of bacteremia. If a patient is extremely ill or if the diarrhea is not resolving,
antibiotics may be used. In the absence of a specific etiology, ciprofloxacin is a good choice.
Trimethoprim/sulfa may also be adequate.
Although almost all food poisoning in the United States is self-limited, there are some
occasional complications. In cases where the diarrhea is <24 hrs, there is no need to send stool
studies.
Supportive with hydration alone in the majority of cases
1.
Spontaneous resolution expected in 3–7 days
2.
Avoidance of antimotility agents such as diphenoxylate and loperamide
3.
Severe cases of infectious diarrhea with signs of sepsis, such as hypotension, fever, and
tachycardia, are treated empirically with ciprofloxacin.
4.
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