Infectious Disease

Emergencies
Internal Medicine Residency
Pranay Sinha
Congratulations!
Must-not-miss diagnoses
Case #1
• 21 yo college student at Northeastern without PMH comes in with
severe fevers, nausea, neck pain progressive over the past 36hrs
• FH, SH negative
• Allergies: Penicillin (twin brother had a rash to it as a baby)
• WBC 13k, BMP wnl, LFTs wnl
• T 102.3 degrees F, P 110, RR 25, SpO2 99% on RA BP: 150/80
• Exam with man in moderate distress, neck stiffness, normal
cardiopulmonary, musculoskeletal, gastrointestinal, and
neurological exam
Case #1
• T 102.3 degrees F, P 110, RR 25, SpO2 99% on RA BP: 150/80
• Exam with man in moderate distress, neck stiffness, normal
cardiopulmonary, musculoskeletal, gastrointestinal, and
neurological exam
Must-not-miss diagnoses
Case #1
• CSF: 130 WBC (90% Neutrophils); Glucose 36 (serum 120);
Protein 70
• Meningitis/Encephalitis panel: pending
Case #1: Bacterial Meningitis
• Dexamethasone (10mg prior to/same time as abx and then 6h)
• Vancomycin and Ceftriaxone (2g q12h) Meningitis dose!
• Would have added ampicillin if immunocompromised,
pregnant, or >55 for Listeria
• If altered, could have considered Acylovir 10mg/kg q8h
Case #2
• 27 years old woman with PMH of OUD and schizoaffective
disorder with hx of MSSA endocarditis presents with
worsening back pain over the last two weeks
• SH notable for IVDU as recently as this afternoon, reuses
needles but doesn’t share, uses sterile water normally, but
injected puddle water two days ago. Injects in arms and legs,
but not in neck
• Meds: On Methadone maintenance therapy
• NKDA
Case #2
• T 101.3 degrees F, P 108, RR 20, SpO2 98% on RA BP: 130/70
• Exam with woman in moderate distress
• Normal HEENT, cardiopulmonary, musculoskeletal,
gastrointestinal
• Point tenderness over L4-L5
• You ask the patient to stand up to check their gait. She reports
weakness in moving her legs (L>R) and is unable to stand up.
She had walked into the ER. Patellar and Achilles reflexes are
brisk (4+). Babinski positive in left foot.
Must-not-miss diagnoses
 Case #2
• You order an MRI with
IV contrast which
shows a lumbar spinal
epidural abscess with
cord compression.
What do you do?
Case #2 Spinal epidural abscess
• Call Neurosurgery for cord
decompression STAT
• Collect 2x sets of blood cx
• Initiate Vancomycin/Cefipime 2g q8h
(renally dosed)
Case #3
• 35 year-old man with hx of previous MVA with traumatic left
knee injury three years ago presents to the ER with acute onset
pain in his left knee. Knee swelled up and became hot and
painful yesterday. Now, he cannot walk and has severe pain
with even mild flexion and extension of the knee.
• No significant FH or SH
• CBC with 12K WBCs
 Case #3
• Man in moderate
distress. Severe pain
with palpation.
Effusion evident
around left knee. Pain
with minimal
manipulation. Right
knee wnl.
Must-not-miss diagnoses
 Case #3
• Synovial fluid
aspirated: 30cc cloudy
fluid evacuated, No
crystals seen, Smear
with GPCs in clusters,
WBC: 60,000 (93%
PMNs)
 Case #3 Septic Arthritis
• Initiative IV antibiotics
(Vancomycin/CTX 2g
q24h)
• Request orthopedic
evaluation for joint
washout
Case #4
• 21 years-old woman with severe PSUD not on treatment. Come
in with severe neck pain after she missed the vein in her left
neck and injected into the surrounding tissue. She had
attempted the injection last night. Pain has progressed and
become excruciating over 24h. Aside from the neck pain, she
reports fevers and nausea.
• SH: Clean needles, clean water, no sharing. Does reuse needles
after cleaning under tap.
Case #4
T 103 degrees F, P: 130, RR: 30, SpO2 100% on RA, BP: 90/50

Severe distress, diffusely hyperemic including in oral mucosa, cellulitis noted at

site of attempted injection with induration and tenderness, but no fluctuance.

WBC 17k
Plt: 110 (baseline: 180)
Cr: 1.4 (b/l 0.8)
AST/ALT: 60/55
CRP 278
Must-not-miss diagnoses
Case #4
Blood cultures collected turned positive in 3hrs with smear
positive for these bacteria
Case #4 Streptococcal toxic shock
syndrome
Penicillin IV 2million units q4h
Clindamycin IV 900mg q8h
Case #4 Streptococcal toxic shock
syndrome
Multisystem disease
GI- vomiting or diarrhea
Muscular – myalgias, elevated CPK
Mucous membrane - hyperemia
Renal
Pulmonary – infiltrates, ARDS
Hepatic – bili and aminotransferase increases
Hematologic – decreased platelets
CNS – disorientation, altered MSE
Slide credit: Dr. Tamar Barlam
Case #5
• 45 year-old man with PMH of OUD presents with severe pain over
his left leg. He first noticed it two days ago and thought that he was
having a cramp, but the pain continued to get worse and he noticed a
new rash over his right leg today. He is asking for antibiotics because
he thinks he has cellulitis which he has had in the same leg before.
• PMH: OUD on MMT
• No significant FH
• SH notable for recent relapse into OUD. He has been injecting in his
legs because his arm veins are “shot.” Clean needles, clean water, no
sharing
Case #5
WBC: 12.3K
Hb: 12.9
Na 135
Cr 1.3
Glucose 150
CRP: 450
Case #5
• T 97.3 degrees F P: 130 RR: 30 BP: 150/90 SpO2: 99% on RA
• Severe distress. Pain out of proportion in left leg. He won’t let
you touch it.
Must-not-miss diagnoses
Case #5
WBC: 12.3K
CRP: 450
Hb: 12.9
Na 135
Cr 1.3
Glucose 150
Case #5 Necrotizing fasciitis
1. Call surgery
2. Call surgery AGAIN
3. Make sure surgery sees the patient
4. Vanc/Pip-Tazo/Clinda
5. Consider ID consult

With toxic shock syndrome,

mortality >70%, approaches 100%
if not taken to OR
Case #5 Necrotizing fascitis
1. Call surgery
2. Call surgery AGAIN
3. Make sure surgery sees the patient
4. Vanc/Pip-Tazo/Clinda
5. Consider ID consult

With toxic shock syndrome,

mortality >70%, approaches 100%
if not taken to OR
Case #5 Necrotizing fasciitis
Case#6
Case#6 Echthyma gangrenosum

Photo credit: Dr. Tamar Barlam

Echthyma gangrenosum

Photo credit: Dr. Tamar Barlam

Case 7

Photo credit: Dr. Tamar Barlam

Case #7 Vibrio vulnificus cellulitis

Photo credit: Dr. Tamar Barlam

Case #8
Case #8 Meningococcemia with purura
fulminans in asplenic patient
Purpura fulminans evolution
Purpura fulminans evolution
Sepsis without an obvious primary focus
• Elderly patient with multiple comorbidities, pacemaker
• Staph septicemia
• Patient s/p splenectomy six months ago after skiing accident
• S. pneumoniae sepsis
• Elderly patient s/p travel to Martha's Vineyard with renal failure, ARDS, DIC
• Babesiosis
• From Arkansas, likes to trap rabbits
• Tularemia, typhoidal form
• From New Mexico, lots of prairie dogs near home
• Plague
Must-not-miss diagnoses
• Fever- Gram negative sepsis
• Neckache- Bacterial meningitis
• Rash and hypotension- Toxic-shock syndrome
• Altered mental status in a traveler- Cerebral Malaria
• Pain out of proportion in a normal looking leg – Nec. Fascitis
Thank you