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Quiz March 2013

29 yofor male history signicant type plaining of a Fever sore throat, to 103 F (39.4 C) for two Dyspnea was able to tolerate only nicant neck swelling or secretions. He had immixico as a teenager, and his 1. positive nding well-developed,

t was a o appeared slightly dehye distress. 2.Proper

management

9.4 C) s/minute mmHg hs/minute n room air

HISTORY OF PRESENT ILLNESS

ng condipraglottic ease, the o 2 cases idence in en in the es that do e B. Curinfection, also been zae (Hib),

Figure 1.2 Soft-tissue lateral radiograph of the neck from a I diabetes presented to the ED complaining of 29-yeara sore throat, inability to swallow solids and fevers to 103 F (39.4 C) for two old male with epiglottitis, demonstrating thumbprint sign (arrow). days. He noted a hoarse voice and was able to tolerate only

A 29-year-old male with a medical history signicant for type

Cefotaxime Ceftriaxone , Ampi -Sulbactam acute epiglottitis, ,although no randomized trials to date support this practice.6
KEY TEACHING POINTS
PHYSICAL EXAM
GENERAL APPEARANCE: The patient was a well-developed, nontoxic, moderately obese male who appeared slightly dehydrated, sitting upright and in no acute distress.

small sips of liquids. He denied signicant neck swelling or stiffness, and was able to tolerate his secretions. He had immigrated to the United States from Mexico as a teenager, and his immunization status was unknown.

differ sigated in a dults are throat is dynophaThe presemergent tis, where cases of ntion due

VITAL SIGNS 1. Acute epiglottitis is a potentially life-threatening condition Temperature 103 F (39.4 C) Pulse 100 beats/minute resulting from inammation of the supraglottic structures, Blood pressure 145/85 mmHg 22 breaths/minute with a current incidence ofRespirations 1 to 2 cases per 100,000 adults Oxygen saturation 100% on room air in the United States. HEENT: Oropharynx was pink and moist, no erythema, exu2. Sore throat is the chief complaint in 7594% dates, tonsillar or uvular swelling noted. of cases of adult epiglottitis, whereas odynophagia may be present NECK: Supple, anterior cervical lymphadenopathy noted, in tenderness to palpation over cricoid cartilage noted. as many as 94% of cases. LUNGS: Clear to auscultation bilaterally. 3. Soft-tissue lateral neck radiography, which may show an CARDIOVASCULAR: Regular rate and rhythm without rubs, enlarged, misshapen epiglottis (thumbprint sign), has a murmurs or gallops. sensitivity of 88% in establishing the diagnosis. ABDOMEN: Soft, nontender, nondistended. 4. The denitive diagnosis EXTREMITIES: is madeNothrough direct laryngoclubbing, cyanosis or edema. scopic visualization of an enlarged, inamed epiglottis. A peripheral intravenous line was placed and blood was and sent for laboratory testing. Laboratory tests were 5. Treatment of epiglottitisdrawn includes intravenous antibiotics signicant for a leukocyte count of 24 K/L (normal 3.5 and close airway monitoring setting. Most clini12.5 K/in L) an with ICU 92% neutrophils (normal 5070%). A softtissue lateral neck radiograph was obtained (Figure 1.1). cians treat acute cases with intravenous steroids.

Figure 1.1 Soft-tissue lateral radiograph of the neck from a 29-yearold male with sore throat and inability to swallow solids.

What is your diagnosis?

REFERENCES

89 yo female Glaucoma S/p trabeculectomy progressive worsen VA drop , eye pain , photophobia No contact lens , denied trauma VA ngercount

-srow ylevissergorp htiw elamef dlo-raey-98 na fo eye tfeL 1.5 erugiF .aibohpotohp dna niap ,ssender ,noisiv gnine

1. positive nding

2.Proper management

Treatment with empiric antibiotics must be prompt because endophthalmitis can result in a poor visual outcome agnosis is endophthalmitis with hypopyon. Figure 5.1 if not treated aggressively.4 Emergent consultation with an nstrates several of the ndings of this condition: a red ophthalmologist is necessary once this diagnosis is enterFindings : Endophthalmitis th circumlimbal ush, hypopyon (inammatory cells tained. Endophthalmitis is an ophthalmologic emergency, as - red a eye with cicumlimbal ush 5 2 udates [pus] layered in the anterior chamber of the eye), Emergency the patient is in danger of losing his or her vision. -hypopyon urulent discharge on the lid margin and eyelashes. The treatment purulent discharge from lid margin and lashesshould begin with a dose of broad-spectrum intrat received gatioxacin 0.3% eye drops eye, Intravitreal therapy elato mthe ef left dlo -raeyvenous -98 nantibiotics. a ni noi siv derrantimicrobial ulb dna n iap eremains yE 3 er eye was subsequently dilated with tropicamide 1% the mainstay of treatment. The majority of patients require henylephrine 2.5% drops.Mx The:patient was taken to the intravitreal injections, vitreous tap, subconjunctival steroids or gatioxacin 0.3% eye drop mergently by the ophthalmologist, where a vitrectomy vitrectomy to prevent loss of the eye.4 of ATB consult ophthalmologist for vitrectomy / intravitreal injection ntravitreal injection of antibiotics was performed. The t was discharged that same day to continue gatioxacin ednisolone eye drops every hour while awake, with a KEY TEACHING POINTS SSENLLI TNESERP FO YROTSIH -up appointment with the ophthalmologist the follow1. Endophthalmitis is an ophthalmologic emergency fingis yrotsih cigolomlahthpo na htiw elamef dlo-raey-98 requirnA y. ing a index and prompt with d elia f high dah o hw ,seof ye suspicion htob ni am ocua lg elgna consultation nepo rof tnaci h tiw ymotcelucebart enogrednu dah dna tnemeganam lacidem an ophthalmologist. erp ,reisymptoms lrae shtnomof xis eye tfel eht ot tnem taert C pain, nicymredness, otim hthalmitis 2. Initial endophthalmitis include g ninesro w ylevisserand gorpblurring fo syad laof rev es htiw DE eht ot detnes ocular discharge vision. hthalmitis is an infection involving the deep strucfel reh morf egrahcsid dna aibohpotohp ,niap ,ssender ,noisiv 3. t Common signs include decreased visual acuity, lid swelling, of the eye, namely the anterior, posterior and vitreraew ton did dna spord eye wen ro amuart deined ehS .eye conjunctival and corneal edema, anterior chamber cells .sesnel tcatnoc ambers.1 Noninfectious (sterile) endophthalmitis may and brin, hypopyon, vitreous inammation, retinitis, and from various causes, such as retained native lens mateblunting of the red reex. NOITANIMAXE LACISYHP er an operation or from toxic agents.2 The two classi4. n Intravitreal antimicrobial remains the i elamef ylre dle na saw tneitherapy tap ehT : ECNARAEP PA mainstay LARENEG of ns of endophthalmitis are endogenous and exogenous. .trofmothe csid e tuca on of treatment for infectious endophthalmitis; majority enous endophthalmitis results from the hematogenous patients require intravitreal injections, vitreous tap, subSNGIS LATIV of organisms from a distant source of infection (e.g., conjunctival steroids vitrectomy to prevent )C 7or 3( F 6.89 erutareploss meT of the 2 ylevissergorp htiw elamef dlo-raey-98 na fo eye tfeL 1.5 erugiF -srow Exogenous endophthalmitis results from direct arditis). eye. etunim/staeb 88 esluP .aibohpotohp dna niap ,ssender ,noisiv gnine ation of the eye as a complication of ocular surgery, forgHmm 09/051 erusserp doolB odies, or blunt or penetrating trauma.1,2
etunim/shtaerb 81 snoitaripseR

WER

13 yo male bicycle collision tender at Lt side abdomen

1. positive nding

Figure 53.1 CT of the abdomen and pelvis from a 13-year-old male with left upper quadrant abdominal pain after a bicycle collision.

2.Grade/Classication by CT?

Findings : Grade IV splenic laceration. Extensive splenic laceration to hilum Management : conservative / or Sx

The diagnosis is grade 4 splenic laceration. The CT scan of the abdomen and pelvis demonstrated an extensive splenic laceration extending into the splenic hilum (arrow, Figure 53.2), associated with a large amount of intraperitoneal hemorrhage in both the abdomen and pelvis. The patient was admitted to the surgical service and serial hematocrits were followed, with the hematocrit dropping to 28% on hospital day #2 before stabilizing. The patient was managed conservatively without operative intervention and was discharged on hospital day #5. He was given strict precautions to avoid sports or any strenuous physical activity.
Pediatric intra-abdominal injury and splenic trauma

The American Association for the Surgery of Trauma (AAST) splenic injury grading system is as follows

grade I subcapsular haematoma < 10% of surface area capsular laceration < 1 cm depth grade II subcapsular haematoma 10 - 50% of surface area intraparenchymal haematoma < 5 cm in diameter laceration 1 - 3 cm depth not involving trabecular vessels grade III subcapsular haematoma > 50% of surface area or expanding intraparenchymal haematoma > 5 cm or expanding laceration > 3 cm depth or involving trabecular vessels ruptured subcapsular or parenchymal haematoma grade IV 53.2 CT of the abdomen and pelvis from a 13-year-old male laceration involving segmental or hilar vessels with major Figure with left upper quadrant abdominal pain after a bicycle collision demonstrating splenic laceration (arrow). devascularization (> 25% of spleen) grade V shattered spleen hilar vascular injury with devascularised spleen

Trauma remains the leading cause of death and disability in children, with blunt trauma accounting for more than 90% of all pediatric injuries.1 Although falls are the most common single mechanism of injury in children, injuries involving bicycles, all-terrain vehicles, motorcycles and sports occur frequently. Abdominal injuries occur in isolation or as a part of multisystem trauma. Bicycle handlebar and lap belt injuries are particularly common mechanisms that should raise the level of suspicion for a signicant intra-abdominal injury (IAI), with high likelihood of requiring operative intervention.1,2 The spleen is the most commonly injured intra-abdominal organ in children following blunt trauma.1,3 Traumatic splenic injury may result in hematoma, laceration, fragmentation or complete devascularization. The trauma resulting in these injuries may be relatively minor and may not be recalled by

colliding into a strong ocean wave are mechanisms of injury that have resulted in splenic rupture.3 The classic physical ndings of splenic rupture are left upper quadrant pain and tenderness and left shoulder pain. Kehrs sign (left shoulder pain from irritation of the inferior border of the left diaphragm by hematoma) may be elicited by placing patients in the Trendelenburg position.3 Associated comorbid ndings or injuries can help predict which children have IAI, particularly the presence of a femur fracture or a low systolic blood pressure, which itself carries an odds ratio for IAI of 4.8.4,5 Although any abdominal examination abnormality should be considered an indicator of IAI, a negative examination and absence of comorbid injuries do not rule out an IAI.4 After the history and physical examination, the next step in evaluating pediatric patients with potential IAI is considering which laboratory tests are necessary. In hypotension unresponsive to isotonic uid boluses, the type and crossmatch for blood is the most important test to order.4 In the stable child, laboratory tests can be used to help predict which children may have IAI. The most useful laboratory tests for this purpose include the complete blood count (CBC), liver function tests (LFT) and urinalysis (UA).4,5 The greatest use for the hemoglobin and hematocrit is to follow serial values in known solid organ injuries. An initial hemoglobin and hematocrit are recommended in the evaluation of patients with pediatric abdominal trauma, but should not be used to decide whether to perform an additional imaging study.4 Focused Assessment with Sonography for Trauma (FAST) is used to detect free intraperitoneal uid (i.e., blood) and has identied abdominal injuries in adults with a sensitivity ranging from 6399% in published series. Several reports have shown that FAST can reliably detect intraperitoneal uid in children with a sensitivity of 5693% and a specicity of 7997%.1 However, a positive FAST in a hemodynamically stable child is of limited use because stable children with solid organ injury will likely be managed nonoperatively and will require an abdominal CT scan for diagnosis of and staging the injury. FAST may be most useful in children in two circumstances. First, in the hemodynamically unstable child with multiple injuries and several potential causes of hypotension, FAST may indicate whether intra-abdominal bleeding is the source of hypotension, therefore guiding immediate operative management. Second, FAST may serve as a screening tool, along with physical examination and laboratory evaluation, to help identify children who will benet from abdominal CT scanning.1 In the hemodynamically stable patient, CT scan remains the study of choice for identication of IAI.6 CT has become the gold standard for the diagnosis of splenic injuries after trauma.7 As an initial diagnostic test, CT is particularly useful in diagnosing solid organ injuries, particularly to the liver, spleen and kidneys. CT allows accurate grading of these solid organ injuries, which helps guide nonoperative therapy. However, CT is less reliable for the diagnosis of intestinal and

HISTORY OF PRESENT ILLNESS

26 yo male felt pop in lower neck while practicing golf. no weakness PHYSICAL EXAMINATION
GENERAL APPEARANCE: VITAL SIGNS

A 26-year-old male was practicing his golf swing in his back yard when he felt a pop in his lower neck and the sudden onset of pain. In the ED, he denied focal weakness, numbness or tingling to his extremities. He reported his pain was worse with movement of his neck, particularly with exion.

The patient was a well-developed male sitting upright on the gurney in no acute discomfort. Temperature Pulse Blood pressure Respirations Oxygen saturation
HEENT: NECK:

98.1 F (36.7 C) 80 beats/minute 126/88 mmHg 22 breaths/minute 100% on room air

Unremarkable.

Midline tenderness to palpation over the lower neck, no swelling or masses. Pain with active exion of the neck.
CARDIOVASCULAR:

Regular rate and rhythm without rubs, murmurs or gallops. Clear to auscultation bilaterally. Soft, nontender, nondistended.

LUNGS:

ABDOMEN:

EXTREMITIES: NEUROLOGIC:

1. positive 2.Proper No clubbing, cyanosis or edema. nding management Alert and oriented to person, place and time;

cranial nerves IIXII grossly intact; upper extremity and lower

terior view, as a vertically-slit appearance of the spinous prorives its ustralia cess in the lower vertebrae (the double spinous process sign).5 HISTORY OF PRESENT ILLNESS for the Because injury involves only the spinous process, this fracA 26-year-old male was practicing his golf swing in his back orceful ture is considered stable and-is not associated neurologic Findings : Clay Shovelers Fxwith of C7 yard when he felt a pop in his lower neck and the sudden of the impairment. Management of ( this fracturefx involves consultaspinous process Oblique of base of onset of pain. In the ED, he denied focal weakness, numbness is more tion with the neurosurgeon or spine surgeon, pain control and spinous process ) or tingling to his extremities. He reported his device pain was followcervical immobilization with an orthotic forworse comfort. m blows with movement of his neck, particularly with exion. Close follow up is warranted. n motor Management : conservative / or results PHYSICAL EXAMINATION type GENERAL of APPEARANCE: The patient was a well-developed

4. Because the injury involves only the spinous process, this fracture is considered stable and is not associated with neurologic impairment. 5. Management involves neurosurgical or orthopedic consultation, pain control and cervical immobilization.
REFERENCES

lateral 1. A clay-shovelers fracture refers to an oblique fracture of dily eviVITAL SIGNS the base of the spinous process, most commonly occurring s in the Temperature F (36.7 C) at one of the lower 98.1 cervical segments. unction Pulse 2. The fracture is believed to occur as a result of forceful 80 beats/minute he fracof the cervical spine, or forceful contraction of the Blood exion pressure 126/88 mmHg ng midtrapezius and rhomboid muscles. Respirations 22 breaths/minute nolamiFigure 56.2 Lateral radiograph of the cervical spine from a 26-year3. The injury is most commonly visualized on the lateral Oxygen saturation 100% on room air old male demonstrating clay-shovelers fracture of the C7 spinous prough the cess cervical (arrow). spine radiograph, which should include the entire eroposHEENT: Unremarkable. cervical spine and the C7-T1 junction. us pro4. Because the injury involves only the spinous process, this 5 NECK: Midline tenderness to palpation over the lower neck, s sign). fracture is considered stable and is not associated with is fracno swelling or masses. Pain with active exion of the neck. neurologic impairment. urologic 5. Management involves neurosurgical or orthopedic CARDIOVASCULAR: Regular rate and rhythm without consulrubs, onsultapain control and cervical immobilization. murmurstation, or gallops. rol and omfort.
LUNGS:

male sitting upright on the gurney in no acute discomfort.

KEY TEACHING POINTS

[1] Hockberger RS, Kaji AH, Newton EJ. Spinal injuries. In: Marx JA, Hockberger RS, Walls RM, et al. (eds.). Emergency Medicine Concepts and Clinical Practice, 6th ed. Philadelphia: Mosby, 2006:398439. [2] Boden BP, Jarvis CG. Spinal injuries in sports. Neurol Clin 2008;26:6378. [3] Mueller J.B. Fractures, cervical spine. eMedicine Website. Available at http://www.emedicine.com/emerg/topic189.htm. Accessed June 30, 2008. [4] Feldman VB, Astri F. An atypical clay shovelers fracture: a case report. J Can Chiropr Assoc 2001;45:21320. [5] Cancelmo JJ. Clay shovelers fracture a helpful diagnostic sign. Amer J Roengenol 1972;115:5403.

Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender, nondistended. [1] Hockberger RS, Kaji AH, Newton EJ. Spinal injuries. In: Marx JA, Hockberger RS, Walls RM, et al. (eds.). EmerEXTREMITIES: No clubbing, cyanosis or edema. gency Medicine Concepts and Clinical Practice, 6th ed. Philadelphia: Mosby, 2006:398439. Alert and oriented to person, place and time; cture NEUROLOGIC: of Boden BP, Jarvis CG. Spinal injuries in sports. and Neurol Clin cranial[2] nerves IIXII grossly intact; upper extremity lower curring 2008;26:6378.

REFERENCES

12 yo boy

e 63.1 Anteroposterior (panel A) and lateral (panel B) radiographs of the right foot from a 12-year-old with right foot trauma.

1. positive nding

2.Proper management

motor vehicle collision in one. All patients had swelling and pain with passive motion but none had neurovascular decits. Only the two oldest children had an osseous injury that necessitated open reduction and internal xation, but all had elevated compartment pressures ranging from 3855 mmHg. All Findings : had fasciotomies of the nine compartments of seven patients the foot, and the skin was primarily within ve days folfx displace base 1st closed MTB Foot trauma in a 12-year-old male lowing the operation. fx MTB 2-4th No patients had complications or required skin grafting. All patients had a good or excellent result after A 2353 B an average duration of follow up of 41 months (range Management : Figure 63.1 Anteroposterior (panel A) and lateral (panel B) radiographs of the right foot from a 12-year-old months).

- compartment syndrome
KEY TEACHING POINTS

male with right foot trauma.

26

ymptoms s and detoms that ures and t reliable

into four the four rsals; the r hallucis partment, quadratus comparts and the

1. Lisfranc fracture-dislocations of the foot generally result from high-energy forces, such as crushing trauma to the foot (often in exion or rotation). 2. Patients with Lisfranc fracture-dislocations commonly present with midfoot pain, swelling and decreased ability to bear weight. 3. The most consistent radiographic nding in Lisfranc joint dislocations is loss of the usual alignment between the medial borders of the second metatarsal and second cuneiform. 4. Patients with Lisfranc injuries require urgent consultation with an orthopedic or podiatric specialist. 5. In compartment syndrome of the foot, ndings on examination include increased pain on passive dorsiexion of the metatarsophalangeal joints, poor capillary rell and absent pulses (late ndings). 6. Appropriate treatment for suspected compartment syndrome of the foot is urgent and complete fasciotomy.
REFERENCES

ment syn-

Figure 63.3 Lisfranc joint.

22 yo m. foot pain during soccer

complaining of left foot while playing evere pain followed his right foot imme1. positive mbness or tingling to

nding

a right foot raised, in

2.Proper management well-developed please specify

ute air

Figure 65.1 Anteroposterior (panel A) and oblique (panel B) radio-

immobi-

acture of dened al at the xtension and fth he more rsely or the fth he injury applied oting or l heads). etatarsal es at the s.1 l to the be conthe fth

sclerosis.2 Emergency treatment of Jones fractures involves ice, elevation, splinting of the injured foot and pain control.3 The denitive treatment of Jones fractures may be nonoperative or operative. Nonoperative treatment varies from functional bracing to casting, but typically involves the application of a Findings non-weight-bearing short-leg cast for six weeks for best : 1,4 results. The time needed to achieve union is a minimum of fx base of the 5th MTB =Jones fractrure two months, with delayed union or nonunion reported in up to 50% of cases. Operative treatment involves intramedullary screw xation or bone Management : grafting. These allow earlier weightbearing and generally result in union in less than three months. - compartment syndrome As many as 50% of patients with this fracture develop persistent nonunions, requiring bone grafting and internal xation.3
KEY TEACHING POINTS

tuberosity of the fth metatarsal, and should not be confused with the more common avulsion fracture of the fth

2.

3.

4.

RE

[1

1. A Jones fracture is a transverse fracture of the proximal fth metatarsal at the junction of the diaphysis and metaphysis without extension distal to the intermetatarsal articulation of the fourth and fth metatarsals. 2. The mechanism of injury in a Jones fracture involves a large adduction force applied to the forefoot with the ankle A B plantar exed, causing the fth metatarsal to fracture. 3. Emergent treatment of Jones fractures involves ice, elevaFigure 65.2 Anteroposterior (panel A) and oblique (panel B) radiotion, splinting of the injured foot and pain control. 4. The denitive treatment of Jones fractures may be non- graphs of a 22-year-old male with a Jones fracture (arrows). operative (bracing or casting and non-weight-bearing for six weeks) or operative (intramedullary screw xation or bone grafting).
REFERENCES

[2

[3

[4

[1] Fetzer GB, Wright RW. Metatarsal fractures and fractures of the proximal fth metatarsal. Clin Sports Med 2006;25:139 50.

97

Headache and rash in a 21-year-old male

21 yomale. headache / facial ushing / palpitation not itching just got back from dinner party at restaurant. T 36.1 P121 BP112/66

1. positive nding
HISTORY OF PRESENT ILLNESS

3. cause by? 2.Proper management

A 21-year-old male presented to the ED with the chief complaint of a throbbing bilateral headache. He also complained of facial ushing, palpitations, transient severe shortness of breath, a rash over his arms and trunk, and red eyes. He had just eaten dinner at a local seafood restaurant. He denied any previous similar symptoms or ingestion of new or different foods or medications.
PHYSICAL EXAMINATION
GENERAL APPEARANCE:

The patient was awake and alert in no

acute discomfort.
VITAL SIGNS

Temperature Pulse

97 F (36.1 C) 121 beats/minute

with the sociated ackerel); evention ombroid gic data g is the e found 97 iguatera

treatment necessary.1 Although bronchospasm is rare, bronchodilators or other adrenergic agents are recommended if it Findings occurs. Patients receiving antihistamine therapy (particu: Scombroid sh poisoning larly diphenhydramine) in the ED should not be allowed to Erythematous macular rash on the extremities drive at discharge. Scombroid sh poisoning is an immeditrunk/ Warm. ately reportable disease to the local public health department, requiring a completed Condential Morbidity Report form to be faxed to the health department, as well as timely Management : Anti histamine notication of the public health department by phone.

and

1. Symptoms of scombroid sh poisoning are related to the ingestion of biogenic amines, especially histamine. The onset of symptoms of scombroid sh poisoning usually occurs 1030 minutes after ingestion of the implicated sh, which sometimes has a characteristic peppery and bitter taste. 2. The symptoms of scombroid sh poisoning are nonspecic, and may include ushing, palpitations, headache, nauHISTORY OF PRESENT ILLNESS hough it sea, diarrhea, sense of anxiety, prostration or loss of vision A 21-year-old male presented to the ED with the chief comof food(rare). plaint a throbbing bilateral headache. He also a complained illness is of3. Findings on physical examination can include diffuse, macort. The of facial ushing, palpitations, transient severe shortness of ular, blanching erythematous rash (most common), tachyng ingesbreath, a rash over his arms and trunk, and eyes. He had cardia, wheezing (generally only in red histamine-sensitive n of the asthmatics), hypotension orrestaurant. hypertension, and conjunctijust eaten dinner at a local seafood He denied any racterisvitis. symptoms or ingestion of new or different previous similar nspecic 4. Treat acute illness with antihistamines as needed; H1foods or medications. diarrhea, blockers (e.g., diphenhydramine 2550 mg PO/IV/IM q4 3,4 Find6h) and H2-blockers (e.g., ranitidine 150 mg PO q12h or blanchPHYSICAL EXAMINATION 50 mg IV q812h, or cimetidine 300 mg PO/IV q68h). wheezing GENERAL5. APPEARANCE: The patient was and alert in no Scombroid sh poisoning must beawake immediately reported to hypotenthe local public health department. acute discomfort. itude of itivity to SIGNS VITAL REFERENCES portion

d to the The hishistidine, m of sh. contain h. Serum elevated and H2abating

KEY TEACHING POINTS Headache and rash in a 21-year-old male

mackerel -tuna Sashimi


Scombrotoxism Scombroid ichthyotoxicosis Heat tolerance

amberjack Sashimi Kampachi

mahimahi

sizzler

22 yo m. HIV malaise,fever, dysphagia, generalized mouth pain CT, computed tomography; ESR, erythrocyte sedimentation rate; WBC, white cervical lymphadenopathy blood (cell) count.

Laboratory and Radiographic Tests

May have an elevated WBC and ESR G Bite-wing radiographs or facial CT H may help delineate the degree of alveolar bone destruction
G

1. positive nding 2.Proper management

b p c p t l

w c t c o i i

Figure 3.2 Acute necrotizing ulcerative gingivitis in an HIV patient. Courtesy of Dr. Sol Silverman.

w ( u

G G

JZP/XXX P2: RPV/XXX QC: RPV/XXX T1: RPV Necrotizing Ulcerative Gingivostomatitis 0521871761c03Acute CUFX252/Chin 0 521 86017 2 April 17, 2008 23:29 Signs and Symptoms

Fusobacterium Spirochetes (Treponema vincenti and Borrelia species)

- HIV -LN positive with generalized mouth pain - hyperemic painful gingiva with erosion of interdental papilla and pseudomembrane over gingival ulceration.
Table 3.5 Clinical Features: Acute Necrotizing Ulcerative Gingivostomatitis Organisms Streptococcus mutans Actinomyces species G Bacteroides fragilis G Fusobacterium G Spirochetes (Treponema vincenti and Borrelia species)
G G

Fever and cervical lymphadenopathy G Fetid breath G Diffusely erythematous and edematous gingiva G Necrosis and ulceration of the have light grey interdental gingival papilla G Gray pseudomembrane may overlie the interdental papilla
G

Si

G May have an elevated WBC and ESR Laboratory and Treatment Table Tests 3.6 Clinical Features: Deep Mandibular Space G Bite-wing radiographs or facial CT Infections Radiographic - Penicillin VK or Erythromycin may help delineate the degree of alveolar bone destruction

La Ra

CT, computed tomography; ESR, erythrocyte sedimentation rate; WBC, white G Actinomyces species blood (cell) count. G

-mouthwash Organisms

Streptococcus mutans

CT bl

Bacteroides fragilis and Pre intermedia G Other gram-negative anaero belo

Signs and Symptoms

Fever and cervical lymphadenopathy Fetid breath G Diffusely erythematous and edematous gingiva G Necrosis and ulceration of the interdental gingival papilla G Gray pseudomembrane may overlie the interdental papilla
G G G G

Signs and Symptoms

pat G Fever and cervical lymphad chin G Swelling over the chin exten pla posteriorly to the level of th the G Carious anterior mandibular lar
G

No difculty breathing G No elevation of tongue with wh of the mouth cle Laboratory and Radiographic Findings
G

Laboratory and Radiographic Tests

May have an elevated WBC and ESR Bite-wing radiographs or facial CT may help delineate the degree of alveolar bone destruction
Figure 3.2

Elevated WBC and ESR cal G Soft-tissue neck CT require ont delineate position and exten in t abscess into

the

CT, computed tomography; ESR, erythrocyte sedimentation rate; WBC, white Dr. Sol Silverman. blood (cell) count.

CT, computed tomography; ESR, erythrocyte sedimentation rate; W wh blood (cell) count. (Ta
Acute necrotizing ulcerative gingivitis in an HIV patient. Courtesy of

und

normal oral ora and develop a fulminant form in the stressed

Tabl

oth with /or der. 40 ore nto ble-

systemic) treatment. If inammation seems to have spread beyond the localized area of the hordeolum or eyelid margin, topical antibiotics can I be prescribed (see Table 29.2). For recurrent infection, severe Clinical Features secondary infection, or local cellulitis, systemic antibiotics are indicated. External hordeola are often self-limited but can be Table 29.1 summarizes the clinical features that distinguish drained by lancing the lesion if necessary. these two disorders from each other. P1: JZP/XXX P2: RPV/XXX QC: RPV/XXX T1: RPV 9780521871761c29 CUFX252/Chin 0 521 86017 2 April 2, 2008 15:38
necessary in these diagnoses.

derom ous cus ten nes, t of

Differential Diagnosis

Table 29.2 Treatment of Blepharitis and Hordeolum Patient Category Adults: Preferred Choices

Blepharitis and hordeola are usually fairly straightforward to diagnose. However, a broad initial differential can avoid misdiagnosis:

name it .
G G

Therapy Recommendations Eyelid hygiene Cleanse eyelids bid with cloth soaked in warm water for 510 minutes G Wash eyelid margins with diluted baby shampoo, eyelid cleanser, or a teaspoon of sodium bicarbonate in cup of boiled water G Articial tears (e.g., Hypromellose 0.3%) for those with dry eyes G Topical antibiotics for mild cases of blepharitis and hordeola (e.g., erythromycin ointment 1.25 cm to lid margin qid or eye drops such as chloramphenicol (AK-Clor, Chloroptic, 5 mg/mL) q4h) G Systemic antibiotics (e.g., erythromycin 250 mg PO qid 7 days, azithromycin 500 mg PO day 1, then 250 mg PO daily on days 25) for hordeolum, recurrent staphylococcal blepharitis, severe secondary infection of the meibomian glands, or local cellulitis G External hordeola are often self-limited but can be drained by lancing the lesion if necessary

Figure 29.2

Blepharitis. Courtesy of Atlas of Ophthalmology online.

Ta

151

B
Figure 29.3 Hordeolum. Courtesy of Atlas of Ophthalmology online.

Figure 29.4 Dacryocystitis. Courtesy of Atlas of Ophthalmology online.

152

Systems

DACRYOCYSTITIS

Figure 29.1

Eyelid anatomy. Adapted from drawing by Felipe Micaroni Lalli.

especially on awakening G With or without conjunctival injection

igure 29.3), both ten confused with he eyelids and/or n ocular disorder. pproximately 40 men, and is more y categorized into act dermatitis ble-

Laboratory and Radiographic Findings

There are no specic laboratory tests or radiographic ndings for these diagnoses. It is possible to do a microbial culture of the eyelid by swabbing the eyelashes but usually not necessary in these diagnoses.

and contact dering skin cells from sitivity to various ill not be the focus Table 29.1 summarizes the clinical features itis is most often these two disorders from each other. nibacterium acnes, Figure 29.2 Blepharitis. Courtesy of Atlas of Ophthalmology online. ther as a result of

Clinical Features

that distinguish

Eyelid hygiene is extremely important (e.g., washing eyelids and eyelashes with diluted baby shampoo, eyelid cleanser) (Table 29.2). Clean, warm compresses at the onset of sympOrganisms Blepharitis: toms may limit severity. Those with dry eyes can be given artiG Staphylococcus epidermidis cial tears (e.g., Hypromellose 0.3%). Many G Propionibacterium cases acnes of blepharitis and hordeolum will resolve without antibiotic G Corynebacterium species (topical or systemic) treatment. Hordeolum: If inammation seems to haveoften spread beyond the localized G Most Staphylococcus aureus, but can be area of the hordeolum or eyelid margin, topical antibiotics infected with organisms similar tocan those be prescribed (see Table 29.2). For recurrent causing blepharitis infection, severe secondary infection, or local cellulitis, systemic antibiotics are indicated. Period External hordeola often self-limited Incubation 17are days (up to 12 days) but can be drained by lancing the lesion if necessary.

iocular Infections

G G

Signs and Symptoms


151

Differential Diagnosis

Blebphitis Blepharitis and hordeola are usually fairly straightforward


to diagnose. However, a broad initial differential can avoid misdiagnosis:

Blepharitis: G Usually bilateral and intermittent symptoms G Inamed Table 29.2 Treatment of Blepharitis and Hordeolum eyelid margins G Eyelid itching, burning, or soreness G Mild foreign-body sensation Patient Category Therapy Recommendations G Crusting and debris of eyelid margins, G Eyelid hygiene Adults: especially on awakening G Cleanse eyelids bid with cloth soaked in warm Preferred G With or without misdirection or loss of Choices water for 510 minutes eyelashes G Wash eyelid margins with diluted baby shampoo, G cleanser, With or or without conjunctival eyelid a teaspoon of sodium injection bicarbonate in cup of boiled water G With or without swollen eyelids G Articial tears (e.g., Hypromellose 0.3%) for those G With or without light sensitivity with dry eyes Hordeolum: G Topical antibiotics for mild cases of blepharitis and G Usually unilateral ointment hordeola (e.g., erythromycin 1.25G cm to lid margin qid or or eyepimple-like drops such as lesion on Pointing eruption chloramphenicol (AK-Clor, Chloroptic, mg/mL) either internal or external 5 side of eyelid q4h) G Inamed eyelid margin G Systemic antibiotics (e.g., erythromycin 250 mg G Eyelid itching, burning, or soreness PO qid 7 days, azithromycin 500 mg PO day 1, Crusting andon debris of eyelid margins, then G 250 mg PO daily days 25) for hordeolum, recurrent staphylococcal blepharitis, severe especially on awakening secondary infection of the conjunctival meibomian glands, or G With or without injection
G

Tr

Figure 29.3

Hordeolum. Courtesy of Atlas of Ophthalmology online.

Hordeolum

Laboratory and Radiographic Findings

local cellulitis External hordeola are often self-limited but can be There are no specic drained by lancing the lesion if laboratory necessary tests or

152

radiographic ndings for these diagnoses. It is possible to do a microbial culture of the eyelid by swabbing the eyelashes but usually not Systems necessary in these diagnoses.

Ey an (Ta to c iti sy

P1: JZP/XXX P2: RPV/XXX QC: RPV/XXX T1: RPV 9780521871761c29 CUFX252/Chin 0 521 86017 2 April 2, 2008

these two disorders from each other.

15:38

Differential Diagnosis
Blepharitis and hordeola are usually fairly straightforward to diagnose. However, a broad initial differential can avoid misdiagnosis:

Table 29.2 Treatment of Blepharitis and Hordeolum Patient Category Therapy Recommendations

Dacryocystitis

15:38

Figure Dacryocystitis. Courtesy of Atlas of Ophthalmology online. Table 29.4 Treatment of Dacryocystitis

Patient Category

Therapy Recommendations

DACRYOCYSTITIS Figure 29.3 Hordeolum. Courtesy of Atlas of Ophthalmology online. Adults: Irrigation of the lacrimal sac Preferred Choices Warm compresses Epidemiology

G Eyelid hygiene Adults: G Cleanse eyelids bid with cloth soaked in warm Preferred Table 29.4 Choices Treatment of Dacryocystitis water for 510 minutes G Wash eyelid margins with diluted baby shampoo, eyelid cleanser, or a teaspoon of sodium Patient Category Therapy Recommendations bicarbonate in cup of boiled water G the Articial tears Adults: Irrigation of lacrimal sac(e.g., Hypromellose 0.3%) for those Preferred Choices Warm compresses with dry eyes G Topical antibiotics for mild cases of blepharitis and Topical antibiotics: G Erythromycin ointment 1.25 cm to lid margin qid hordeola (e.g., erythromycin ointment G Eye drops such as trimethoprim sulfate and 1.25 cm to lid margin qid or eye drops such as Polymyxin chloramphenicol B sulfate ophthalmic solution 1 drop (AK-Clor, Chloroptic, 5 mg/mL) q3h q4h) Oral antibiotics: G Systemic antibiotics (e.g., erythromycin 250 mg G Pediatric: oral antibiotics: amoxicillin-clavulanate PO qid 7 days, azithromycin 500 mg PO day 1, 2040 mg/kg/day divided tid; cefaclor 2040 250 mg PO daily on days 25) for hordeolum, mg/kg/daythen divided tid recurrent staphylococcal blepharitis, severe G Adult: cephalexin 500 mg qid or amoxicillin/ secondary infection of the meibomian glands, or clavulanate 500 mg bid local cellulitis G Surgical treatment for dacryoliths, obstruction, G External hordeola are often self-limited but can be or congenital causes drained by lancing the lesion if necessary

Periocular Infections

Topical antibiotics: 152 Dacryocystitis (Figure G 29.4) can be either congenital or qid Erythromycin ointment 1.25 cm to lid margin

Other diagnoses to consider are:

e.

acquired; in the acquired it can present either acutely or G form, Eye drops such as trimethoprim sulfate and G blepharitis chronically. Congenital dacryocystitis is related to the embryoPolymyxin B sulfate ophthalmic solution 1 drop G orbital or preseptal cellulitis q3h genesis of the lacrimal excretory system. Dacryocystitis is preG chalazion Oral antibiotics: sumed by some to occur more often on the left rather than the G conjunctivitis G Pediatric: oral antibiotics: amoxicillin-clavulanate right because of a narrower angle between the nasolacrimal G canalicular laceration 2040 mg/kg/day divided tid; cefaclor 2040 duct and lacrimal fossa on the left. Those at higher risk for mg/kg/day divided tid acquired dacryocystitis Ginclude females, atter Adult: cephalexin 500those mg qid with or amoxicillin/ noses and narrower faces, and age500 greater clavulanate mg bidthan 40. African Americans seem to haveGa lower risk of dacryocystitis. Surgical treatment for dacryoliths, obstruction, Treatment and Prophylaxis or congenital causes For mild cases of dacryocystitis without fever, outpatient therapy is the standard of care. This includes irriga-

Periocular Infections

Systems

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