Infectious Disease Answer

Diagnosis: Acute rheumatic fever

Criteria: Jones criteria

Acute rheumatic fever (ARF) is a sequella of symptoms that typically occur 2-4 weeks after an untreated bout of group A Streptoccocal (GAS) pharyngitis. Symptoms include arthritis, carditis, erythema marginatum, CNS symptoms, and subcutaneous nodules.

Jones criteria is constellation of symptoms of ARF and are subdivided into major and minor manifestations.

Major

Carditis

Arthritis

CNS involvement

Subcutaneous nodules

Erythema marginatum

Minor

Arthralgia

Fever

Elevated acute phase reactants

Prolonged PR interval

The diagnosis of ARF is made using the Jones criteria and is positive if the patient has evidence of a preceding GAS infection and:

Two major manifestations

One major and two minor manifestations

http://www.medcomic.com

How To Write A Personal Statement

Posted by Kristopher Maday PA-C

This is a lecture I gave to a group of biomedical science students on how to write a personal statement for graduate professional programs. It is directed towards medical professions (PA, MD, DO, DMD, etc.), but the basic tenets are the same. By following a few basic rules and sprinkling in your unique experiences, your narrative will win over the selection committee.

To watch the video, click here

Infectious Disease Question

Posted by Kristopher Maday PA-C

You are participating in a medical mission in South America and are seeing a 11yo boy who is brought in by his mother. He has been complaining of joint pain and fever for the past 2 weeks. She tells you that it seems to “move” from joint to joint over this time and nothing seems to help. She does report that he has seemed to be sick for 4-6 weeks with various “cold” symptoms, but they didn’t seem too severe. On examination, he has temperature of 101.2^oF and the below rash.

What should be your concern and what criteria can help make the diagnosis?

Update to Pneumonia Podcast

Posted by Kristopher Maday PA-C

It figures.

As with any educational or academic en devour, as soon as you finish a paper/poster/presentation, a new publication comes out that would have been awesome to include. I finished and published the Pneumonia podcast on July 12th and on July 14th, the IDSA/ATS released their updated guidelines on managing healthcare-associated (HAP) and ventilator-associated (VAP) pneumonia. Luckily, they didn’t change anything earth-shattering, just tightened them up a bit. Antibiotic regimens are below and they recommend 7-days total of therapy.

2016 IDSA/ATS Guidelines

2016 IDSA/ATS Guidelines

References

IDSA GUIDELINE: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society Clin Infect Dis. first published online July 14, 2016 doi:10.1093/cid/ciw353

#16 – Pneumonia

Posted by Kristopher Maday PA-C

LISTEN TO THE PODCAST HERE

Classifications of Pneumonia

Community-Acquired (CAP)
Healthcare-Associated (HAP)
- Any IV therapy, wound care, or chemotherapy within 20 days
- Resident of nursing home or other long term care facility
- Hospitalization for ≥ 2 days within 90 days
- Visit to outpatient clinic or hemodialysis within 30 days
Ventilator-Associated (VAP)
- Currently or previously intubated during current hospitalization

Epidemiology

6 cases per 1000 persons per year (~ 5 million cases per year)
Top 10 in mortality in US (~60,000 deaths/year)
12% 30-day mortality in patients requiring admission
28% all-cause mortality within one year

Pathogenesis

4 phases of development

Edema
- Proteinaceous exudate in the alveoli
- Bacteria accumulation
Red hepatization
- Erythrocyte extravasation
Grey hepatization
- Neutrophil extravasation with bacterial clearance
Resolution
- Macrophage proliferation with inflammatory response

Murthy SV. Pathology of Pneumonia. SlideShare.

Risk Factors

Age
Winter months
Increased risk of aspiration (AMS, CVA, intoxication, seizures)
Smoking
Underlying pulmonary disease (Asthma, COPD, cancer)
Immunosupression
Viral URI
Decreased host defenses (impaired ciliary clearance)
Acid-reducing medications
Malnutrition
Inhalation exposures

Pathogens

Viral (most common)
- Rhinovirus (most common)
- Influenza
- Adenovirus
- Respiratory Syncytial Virus (RSV)
Bacterial
- S. pneumoniae (most common CAP)
- H. influenza
- M. pneumoniae (most common atypical)
- K. pneumoniae (tends to be more severe)
- Legionella
- ESKAPE bugs (>80% of VAP)
  - Enterococcus
  - Staphylococcus
  - Klebsiella
  - Acinetobacter
  - Pseudomonas
  - Enterobacter
Fungal (immunocompromised)
- Histoplasmosis
- Cryptococcus
- Coccidioides
- Blastomycosis
- Aspergillus

Signs and Symptoms

Productive cough
Fever
Chills and/or rigors
Dyspnea
Pleuritic chest pain
Nausea/vomiting
Altered mental status

Physical Exam Findings

Vital signs
- Febrile (elderly may not mount a response)
- Tachycardic
- Tachypnic
Pulmonary
- Rales and/or rhonchi
- Signs of consolidation
  - Decreased breath sounds
  - Dullness to percussion
  - Increased tactile fremitus
  - Egophany
  - Whispered pectoriliquoy

Radiographic Evaluation

Bacterial
- Unilateral, lobar, air bronchograms

Viral
- Diffuse or perihilar, bilateral

Laboratory Evaluation

CBC with differential
Blood cultures
Sputum culture and gram stain
- Good sample = PMNs with < 10 squamous cells per LPF
Urine antigen (pneumococcal and Legionella)
Multiplex PCR

Should They Stay or Should They Go Now????

Pneumonia Severity Index (PSI)
- Step 1
  - If none of the following, then Class I and outpatient treatment
    - Age > 50 years
    - Neoplastic disease
    - Heart failure
    - Cerebrovascular disease
    - Renal disease
    - Liver disease
    - Altered mental status
    - HR ≥ 125/min
    - RR ≥ 30/min
    - SBP ≤ 90 mmHg
    - Temperature ≤ 35^oC or ≥ 40^oC
- Step II

Screen Shot 2016-07-12 at 7.45.22 AM — Step II of PSI/PORT Score for Risk Stratification

CURB-65 Score
- 5 variables
  - Confusion
  - Urea (BUN ≥ 20 mg/dL)
  - Respiratory rate ≥ 30/min
  - Blood pressure (SBP < 90 mmHg or DBP < 60 mmHg)
  - Age ≥ 65 years
- Interpretation
  - Score 0-1 = Outpatient management
  - Score 2-3 = Inpatient management
  - Score 4-5 = ICU management
SMART-COP Score
- Used to predict need for respiratory or vasopressor support

Treatment

Care should be taken to think about patients with risk factors for drug-resistant S. pneumoniae:
- Age > 65 years
- Beta-lactam, macrolide, or fluouroquinolone in the past 3-6 months
- Alcoholism
- Medical comorbidities
- Immunosuppression
- Exposure to child in daycare
Community-Acquired

Healthcare-Associated

Treatment of Healthcare-Associated Pneumonia. IDSA/ATS 2007 Guidelines.

Cottage Physician

References

Mandell LA, Wunderink RG. Pneumonia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid=79733578. Accessed July 11, 2016.
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American journal of respiratory and critical care medicine. 171(4):388-416. 2005. [pubmed]
File TM, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgraduate medicine. 122(2):130-41. 2010. [pubmed]
Murthy SV. Pathology of Pneumonia. http://www.slideshare.net/vmshashi/pathology-of-pneumonia. Accessed on July 11, 2016.
Almirall J, Bolíbar I, Balanzó X, González CA. Risk factors for community-acquired pneumonia in adults: a population-based case-control study. The European respiratory journal. 13(2):349-55. 1999. [pubmed]
Mandell LA, Wunderink RG, Anzueto A. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 44 Suppl 2:S27-72. 2007. [pubmed]
Musher DM, Thorner AR. Community-acquired pneumonia. The New England journal of medicine. 371(17):1619-28. 2014. [pubmed]
Jain S, Self WH, Wunderink RG. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. The New England journal of medicine. 373(5):415-27. 2015. [pubmed]
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 278(17):1440-5. 1997. [pubmed]
Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine. 336(4):243-50. 1997. [pubmed]
Lim WS, van der Eerden MM, Laing R. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 58(5):377-82. 2003. [pubmed]
Charles PG, Wolfe R, Whitby M. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 47(3):375-84. 2008. [pubmed]
Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. The Cochrane database of systematic reviews. 2015. [pubmed]

Answer to Pulmonary Question

Posted by Kristopher Maday PA-C

The diagnostic criteria for acute respiratory distress syndrome (ARDS) are the Berlin Criteria.

Timing – within 7 days of a known clinical insult or worsening respiratory symptoms
Imaging – Bilateral opacities not fully explained by effusions, atelectasis, or masses/nodules
Absence of cardiac failure or fluid overload
Hypoxemia – PaO2/FiO2 ≤ 300 mmHg with PEEP/CPAP ≥ 5 cmH2O

Reference

Pulmonary Question

Posted by Kristopher Maday PA-C

What are the criteria for diagnosing acute respiratory distress syndrome?

Look at the above picture for a hint 🙂

Answer to Surgery Question

Posted by Kristopher Maday PA-C

Surgery Question

Posted by Kristopher Maday PA-C

What is a quick way to remember the 4 main causes of acute onset of abdominal pain?

#15 – Appendicitis

Posted by Kristopher Maday PA-C

LISTEN TO THE PODCAST HERE

Epidemiology

1^st described in the late 1400s and 1^st published in 1544 by Jean Fernal
1^st appendectomy was performed in 1736 on an 11yo boy
233/100,000 population
May occur throughout life, but is most common age group is 10-19yo and slightly more common in men
Badass of the Millennium goes to….Leonid Rogozov. He was the only physician on a Soviet team in Antarctica in 1961 and performed an appendectomy…on himself…and survived (Article here)

Leonid Rogozov performing an appendectomy on himself – 1961

Anatomy of the Appendix

Wikipedia

Located where the taenia coli converge at the base of cecum
Average length 6-9cm, outer diameter 3-8mm, and luminal diameter 1-3mm
Arterial supply is from appendicular branch of the ileocolic artery
The attachment of the base of the appendix is constant, but the tip may be positioned:
- Retrocecal (most common)
- Subcecal
- Preileal
- Postileal
- Pelvic

Wikipedia

Pathogenesis

Follows traditional predictable series of events for inflammation of a hollow visceral organ:
- Inflammation
  - Most commonly by an obstruction
    - Fecalith, calculi, lymphoid hyperplasia, infection, mass
    - Causes a closed-loop obstruction
- Distention
  - Normal secretion and bacterial overgrowth
    - Causes visceral nerve pain
  - Luminal pressure > perfusion
    - Involves the serosa
      - Causes parietal pain
- Perforation
  - As areas of ischemia progress and pressures increase, perforation may occur
    - May be contained (localized) or cause peritonitis
  - Although this progression is predictable, the time frame may be variable
    - Perforation may occur anywhere from 24-48 hours after symptom onset

History

Abdominal pain occurs first
- Starts as diffuse, periumbilical
- Appendix position may alter pain location
Nausea and vomiting then follows
Anorexia (Negative Cheeseburger Sign)
Last is migratory pain to RLQ (50-60%)

Physical Examination

Often non-specific as appendix position, time course of illness, and patient anatomy may obscure findings
Classic physical exam findings include:
- McBurney’s Point Tenderness
  - Maximal tenderness 3cm from ASIS, or 1/3^rd the distance from ASIS to umbilicus
- Rovsing’s Sign
  - Palpation or rebound pressure of LLQ causes RLQ pain
- Psoas Sign (retrocecal)
  - Pain in RLQ when ipsilateral hip is extended or flexed against resistance
- Obsturator Sign (pelvic)
  - Pain in RLQ with internal rotation of ipsilateral hip with flexed knee
- Guarding and peritoneal signs may be seen with perforation

Laboratory Studies

CBC with differential and CRP are needed for the scoring systems, but are not very specific

Pretest Probability Scoring Systems

Alvarado Score
- Developed in 1986 and modified in 1994
Appendicitis Inflammatory Response (AIR) Score
- Developed in 2008
Pediatric Appendicitis Score
- Developed in 2002

Interpretation
- Alvarado Score
  - 0-3 – low probability (discharge)
  - 4-6 – indeterminate (image or admit)
  - ≥ 7 – high probability (admit or surgery)
- AIR Score
  - 0-4 – Low probability (discharge)
  - 5-8 – Indeterminate (image or admit)
  - ≥ 9 – high probability (admit or surgery)
- PAS
  - < 3 – low probability (discharge)
  - 3-7 – indeterminate (image or admit)
  - ≥ 8 – high probability (admit and consult)

Radiographic Imaging

Imaging is generally reserved for indeterminate cases or special populations (children, women, elderly) as clinical examination is just as effective as imaging in ruling-out appendicitis
Computed Tomography
- IV contrast
- Findings suggesting appendicitis:
  - ≥ 6mm diameter
  - Appendiceal wall thickening ≥ 2mm
  - Periappendiceal fat stranding
  - Appendicolith

Ultrasound
- Study of choice in children and pregnant women and becoming study of choice in adults
- Findings suggestive of appendicitis:
  - Aperistaltic, noncompressible, dilated (> 6mm) appendix
  - Distinct appendiceal wall layers
  - Echogenic prominent pericecal fat
  - Periappendiceal fluid collection
  - Target appearance on axial section

Metanalyses Comparing CT to US in Appendicitis

Management

Nonoperative Management
- Several studies have looked at antibiotic management of uncomplicated appendicitis and found:
  - Up to 53% of antibiotic-only management still required surgery within 48hr
  - Antibiotic-only patients had lower pain scores and quicker return to work
  - Up to 37% of antibiotic-only patients required surgery for recurrent appendicitis within 2 years
  - Most recent study (APPAC Trial, JAMA, 2015) did meet prespecified criterion for noninferiority
  - May be an options for special populations
    - Poor surgical candidates, patients who refuse surgery
- As for now, there isn’t enough good data to support routine, nonoperative management for uncomplicated appendicitis
Operative Management
- Uncomplicated
  - Urgent (12-24hr) vs Emergent (< 12hr)
    - No difference in outcomes
- Complicated (perforation with abscess)
  - Sick or with generalized peritonitis = emergent surgery
  - Limited peritonitis
    - Antibiotics, bowel rest, percutaneous drainage
    - Interval appendectomy after improvement in clinical course
- Laparoscopic vs Open Appendectomy
  - Laparoscopic > open in regards to patient outcomes
- Complications
  - Wound infections
  - Organ space infections
  - Stump appendicitis