Case 8: Jordu Flaisek

Question 1

What is cellulitis?
Common pathogens?
S/Sx?
Treatment?
Complications?

Answer 1

• Spread of acute inflammation of dermis/subcutaneous tissue
• GAS, S. aureus, H. influenzae, P. aeruginosa
• Fever, chills, malaise, headache, tenderness, pain, erythema over affected area
• Oral/IV antibiotics (S. aureus-Cephalexin, S. pyogenes-Penicillin), high MRSA risk: Bactrim
• Sepsis, Post-strep glomerulonephritis, necrotizing fasciitis, meningitis

Question 2

What is the role of Chuukese in Hawaii’s homeless population?

Answer 2

COFA (Compact of Free Association) allows Micronesians visa-free entry to US. Many migrate to escape Micronesia’s poor health & economic conditions, but they experience racism here. Unable to find jobs, so end up homeless. Majority of Micronesians are Chuukese

Question 3

Tinea Pedis
Pathogens
S/Sx
Treatment

Answer 3

“Athlete’s foot”

• Dermatophyte (fungal) foot infection of feet that survives off keratin
• Trichopyton (rubrum, interdigitale), Microsporum, Epidermophyton (floccosum)
• White/green fungal growth btwn toes; fissuring/maceration; often seen with thickening/discoloration of toe nails, peeling/cracking/scale feet; itching/burning, foul odor
• Anti-fungal cream (Miconazole) or oral anti-fungals

Question 4

Pharmacology of Cephalexin

Answer 4

• 1st generation cephalosporin with Beta-lactam microbial effects (like penicillin)
• Binds to PBP (transpeptidase)
• Inhibit final step in peptidoglycan synthesis on bacterial cell wall
• Cell wall weakened
• Bacterial cell lysis
• May also interfere with autolysin inhibitor to cause autolysis

Question 5

Pharmacology of Trimethoprim-Sulfamethoxazole

Answer 5

“Bactrim” “TMP-SMX)
Poor GAS coverage
Contains trimethoprim & sulfamethoxazole
Sulfamethoxazole (sulfonamide, structural analog of PABA) competitively inhibits dihydropteroate synthase (humans have NO de novo folate synthesis)
-Decrease DHF synthesis
-Decrease purine and thymidine syn
Trimethoprim (structural analog of folic acid) inhibits DHF reductase (50k x more sensitive to bacteria than human)
-Decrease DHF to THF
-Decrease recycling of folic acid in bacteria
-Decrease thymidylate, purine nucleotide, amino acid synthesis
-Decrease nucleic acid/protein metabolism

Question 6

Pharmacology Miconazole

Answer 6

Imidazole, antifungal

• Inhibits 14alpha demethylase of fungal cell
• No conversion of lanosterol to ergosterol
• Faulty membrane synthesis (destabilized)
• Leakage of cellular contents
• Cell lysis

Question 7

Layers of skin

Answer 7

Epidermis (Stratum corneum, lucidum, granulosu, spinosum, basale)
Basement membrane (lamina lucida, densa)
Dermis
Subcutaneous tissue

Question 8

Functions of skin

Answer 8

• Barrier to protect from environment, pathogens, injury
• Thermoregulation
• Neural sensation (pain, touch, temp)
• Immunologic function
• Endocrine organ (hormones, vitamin D, secretion of sweat/sebum)

Question 9

Macule vs. Patch

Answer 9

Freckle

Circumscribed change in skin color that is flush with surrounding skin 1cm

Question 10

Papule vs. Nodule vs. Tumor

Answer 10

Solid cystic elevations

Papule: 2cm

Question 11

Plaque

Answer 11

Elevated lesion > 1 cm

Question 12

Scale

Answer 12

Desiccated thin plates of cornified epidermal cells

Question 13

Wheal

Answer 13

Circumscribed flat topped firm elevation of skin with well-demarcated and palpable margin

Question 14

Vesicle vs. Bulla

Answer 14

Circumscribed elevated lesion with clear serous or hemorrhagic fluid < 1cm (vesicle) or >2cm (bulla)

Question 15

Pustule

Answer 15

Vesicle containing purulent exudate

Question 16

Staphylococcus aureus
ID
Virulence Factors

Answer 16

Gram +, Cocci, clusters, Catalase +, Coagulase +, B-hemolytic with golden hue

• Protein A: Attaches to Fc portion of IgG
• Coagulase: forms fibrin coat around organism
• Hemolysin/leukocydin: destroy RBC and WBC
• Hyaluronidase: breakdown CT
• Staphylokinase: lyse clots
• Lipase: breakdown fats

Question 17

Trichuris Trichuria

Lifecycle

Answer 17

Whipworm
Ingest embryonated eggs
Eggs hatch into larval worms in small intestines
Larvae migrate to cecum/large intestines
Penetrate mucosa & develop into adults
Females lay eggs after 3 months
(3-10,000 eggs)
Defecate on soil (feces containing eggs)
Eggs mature (two cell stage, advanced cleavage) and become infectious over 3 weeks

Question 18

Clinical presentation of Whipworm

Treatment

Answer 18

Mostly asymptomatic
Heavy infections include: abdominal pain/distention
Bloody diarrhea
Acrid smelling stool
Weakness
Weight loss
Anemia
Treatment: Albendazole/mebendazole to inhibit microtubule synthesis, dysfunction of absorptive/secretory fx of nematode gut leads to death.

Question 19

What are common health problems of homeless in Hawaii?

Answer 19

Approximately 5,000 in HI most of which are sheltered and on Oahu

• Exposure to communicable disease
• Malnutrition
• Respiratory infections
• STIs
• Trauma
• Substance Abuse
• Mental illness
• Chronic disease: HTN, diabetes, asthma

Question 20

Waikiki Health Care-A-Van

Answer 20

2 vans that travel to 30 locations
Medical care, counseling, housing assistance, referrals, application help
Emergency food, hygiene, clothes

Question 21

Next Step Shelter

Answer 21

Shelter, but also provides referrals, behavioral health, tobacco cessation, job training, housing placement assistance

Question 22

HOME project

Answer 22

Hawaii Homeless Outreach Medical Education Project
-Student run clinic established in 2006
-Free, quality healthcare for homeless while increasing student/physician awareness
Medical (BP, sugar, eye/ear, labs,shots), Social/Dental referral

Question 23

McGuire Fund

Answer 23

Est. 1988
Funds community projects, student research, and funds for patient (one time events)
Must have exhausted all attempts to find patient care funds elsewhere

Question 24

Classic steps of wound healing

Answer 24

Blood clot
Regeneration of tissue via proliferation of residual cells & maturation of stem cells
If can’t be accomplished by regen
-Angiogenesis
-Form granulation tissue
Macrophages secrete cytokines (primarily TGF-b) which stimulates fibroblast migration/proliferation
Fibroblast deposition of ECM (CT)
Scar formation
Connective tissue remodeling (via MMPs that degrade ECM)