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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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Final Diagnosis
Infectious diarrhea secondary to Campylobacter
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Case 14
Chief Complaint
Dyspnea and dizziness
History and Physical Examination
A 45-year-old man presents to the emergency department with 3 days of dizziness and
dyspnea. He denies chest pain or palpitations. He has no cough or fever. His past medical
history is unremarkable. He lives in Massachusetts and works as a lawyer. He goes
camping on the weekends with his children, but has not noticed any tick bites or rashes.
On physical examination he appears well. Temperature is normal, BP is 100/60 mm Hg,
and pulse 35/min. Other than bradycardia, the remaining physical examination findings are
unremarkable. Results of initial lab studies show a normal CBC, metabolic panel, and
cardiac enzyme measurements.
EKG is shown. Relevant findings are complete heart block.
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Differential Diagnosis
Bradycardia with heart block can be due to:
CLINICAL PEARL
With patients from the northeast United States, camping/tick exposure, and bradycardia,
always consider Lyme disease.
Initial Management
Hypothyroidism1.
Lyme disease2.
Beta-blocker or calcium channel blocker use3.
Ischemic heart disease4.
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Setting: emergency department
Diagnostic/Therapeutic Plan
Discussion
Lyme disease is the most common arthropod-borne infection in the United States, with around
26,000 confirmed cases reported in 2014. The incidence varies geographically, and
hyperendemic areas in the northeast and north central United States reflect the geographic
density of the vector deer tick, Ixodes scapularis, in these areas. The causative spirochete is
Borrelia burgdorferi sensu stricto, which is transmitted to humans following vector tick
attachment and feeding. Deer ticks may also serve as vectors for other tick-borne infection, and
coinfection may occur.
The clinical manifestations of Lyme disease depend on the stage of infection.
If erythema migrans is seen, there is no need to send serology because a measurable antibody
response may not have had time to develop and will be negative. If you're given erythema
migrans on the exam, the answer is to treat with doxycycline.
Immediate treatment with IV ceftriaxone
Serologic testing for Borrelia burgdorferi; enzyme-linked immunosorbent assay is the initial
test and a Western blot assay is used for confirmation
Early localized Lyme disease typically occurs 1–2 wks following infection.
The initial clinical manifestation is erythema migrans, an erythematous skin lesion at the site
of tick attachment (noted in 70–80% of patients with confirmed infection).
Classically, the border of erythema migrans expands over several days, and the lesion
develops central clearing, leading to the description of a “target” or “bull’s-eye”
appearance.
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Neurologic manifestations of early disseminated Lyme disease include cranial nerve palsy
(unilateral or bilateral), aseptic meningitis, and radiculopathy.
Late-stage Lyme occurs in as many as 60% of untreated patients. Lyme arthritis is characterized
by migratory monoarticular or oligoarticular inflammation, which often improves
spontaneously and then recurs in the same joint or another joint months to year later. The knee
is involved in 85% of patients.
The finding of B. burgdorferi antibodies in patients who have nonspecific symptoms of fatigue
or myalgia or who are unlikely to have been exposed to a vector tick likely represents a false-
positive test result for Lyme disease.
Therefore, serologic testing for Lyme disease should be restricted to patients with clinically
suggestive signs or symptoms who either reside in or have traveled to an endemic area.
Patients who have nonspecific symptoms such as fatigue, myalgia, or arthralgia but a low
pretest probability for Lyme disease should not be tested for this disease.
Patients with erythema migrans, Bell’s palsy, or joint involvement should be treated with
doxycycline or amoxicillin. Although amoxicillin covers Lyme disease, doxycycline is also
active against Anaplasma phagocytophilum and is the preferred agent for patients age ≥8 who
are not pregnant or breast-feeding. Anaplasma phagocytophilum is also transmitted via the
Ixodes scapularis and there is commonly co-infection.
IV ceftriaxone is the recommended therapy for patients with Lyme myocarditis associated with
second- or third-degree heart block or Lyme meningitis or encephalitis.
Final Diagnosis
Lyme disease
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Case 15
Chief Complaint
Fever, urgency, and dysuria
History and Physical Examination
A 25-year-old woman comes to the office with a 3-day history of lower abdominal pain
that is beginning to radiate to her right flank. She denies nausea or vomiting, but states she
feels feverish and is worried that she may have the flu. She denies diarrhea; her last
bowel movement was this morning, and she has been drinking a lot of fluids. She has
noticed an increase in her urinary frequency.
Vital signs are T 39.2 C (102.5 F), BP 120/70 mm Hg, pulse 95/min, and respirations
16/min. Physical examination shows tenderness in the suprapubic region, hyperactive
bowel sounds, and no peritoneal signs or masses. Her right flank is tender to light
percussion. The remainder of the physical examination is within normal limits.
Differential Diagnosis
Initial Management
Pyelonephritis1.
Cystitis2.
Pelvic inflammatory disease3.
Perinephric abscess4.
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Setting: outpatient or emergency department
Initial Diagnostic Plan
Test Results
Assessment
A febrile person with complaints of fever and dysuria clearly has an infection of the urinary
system. The high fever and flank pain point to an upper urinary site. Pyelonephritis and
perinephric abscess are most likely. Perinephric abscess is less common with such a short
duration of illness of only 3 days. Perinephric abscess most often arises from a preexisting
pyelonephritis that has been present for several wks, particularly in association with stones.
Further Diagnostic Plan Results
Urine culture >100,000 colonies of Escherichia coli
Blood culture negative
Treatment Plan
IV antibiotics active against gram-negative bacilli (fluoroquinolones or cephalosporins)
Discussion
Numerous medications are effective treatments in a generally healthy person with an
uncomplicated UTI or mild pyelonephritis. High fever, shaking chills, or other evidence of
Urinalysis
50–100 WBC per high-power field; trace proteinuria; many bacteria; nitrate-positive
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bacteremia are indications for IV antibiotics.
Significant nausea and vomiting or any other inability to take oral antibiotics are indications for
hospital admission and the use of IV antibiotics. As empiric treatment prior to knowing the
susceptibility data on an individual organism, antibiotics that are effective against the gram-
negative bacilli would be effective. Trimethoprim-sulfamethoxazole (TMP/SMZ) has been
traditionally used to treat uncomplicated UTI. TMP/SMZ or ciprofloxacin for 3 days are
standard for cystitis.
Because of an increasing amount of resistance amongst the gram-negative bacilli, TMP/SMZ is
becoming less useful as empiric treatment for UTI. For pyelonephritis, TMP/SMZ should not
be used as empiric therapy. All quinolones are very effective, though they can be quite
expensive.
If IV medication were required, the medications of choice would be the drugs just described
(in IV form):
Do not use aminoglycosides alone for the treatment of any serious infection. In addition, use the
culture and sensitivity to guide modification of antibiotic therapy. IV ceftriaxone has become
the first-line agent for empiric treatment of pyelonephritis.
It is very important to narrow the coverage as soon a culture results have returned.
Third-generation cephalosporins
Aztreonam
Ticarcillin-clavulanic acid
Piperacillin (possibly in combination with an aminoglycoside, depending upon severity of
infection)
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No predetermined length of treatment can be given for pyelonephritis. Treatment is usually
continued for 7–14 days; however, it may need to be continued longer, depending upon the
severity of the illness and how long it takes for the person to become afebrile.
Additional testing such as renal U/S or IV pyelography is indicated only if a complication such
as a stone, stricture, or tumor is suspected to be ausing the pyelonephritis. Otherwise, those
tests are not part of routine management of a simple, uncomplicated pyelonephritis. If
symptoms persist beyond 3–5 days of effective treatment, obtain U/S or CT scan of the kidney
to exclude a perinephric abscess or other drainable collection of fluid.
Final Diagnosis
Pyelonephritis
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