Fever Flashcards
A 23-year-old previously healthy man presents to your office for evaluation of fever, cough, sore throat, muscle aches, and headache for the past 4 days. His vital signs include a blood pressure of 122/80 mm Hg, heart rate of 90 bpm, respiratory rate of 22/min, oxygen saturation of 99% on room air, and temperature of 101.4°F. He appears mildly ill but is well hydrated and tolerating oral intake. Rapid influenza diagnostic testing reveals a positive result for influenza B virus. Which of the following is the most appropriate next step in management?
A Initiate course of azithromycin
B Initiate course of oseltamivir
C Initiate course of prednisone
D Refer to the emergency department for evaluation
E Treat with supportive care
E
fever in adults
-38.0˚C (100.4˚F)
-Differential is broad
-Elderly:
-May not present with fever, just decline in mentation or functional status
-Lower baseline body temperatures
-Delayed febrile response
-WBC counts are neither sensitive nor specific for infection
A 24-year-old woman with no significant medical history presents with sore throat, runny nose, and cough for the past 2 days.
An 85-year-old man who has a significant medical history of leukemia and is undergoing chemotherapy presents with one-sided leg swelling, low-grade fevers, and shortness of breath.
A 74-year-old woman who is confused and combative presents from independent living with fever, increased work of breathing, and cough.
- cold
-2. DVT/PE
-3. PNA -> sepsis?
history
-Timing of fever can be helpful to narrow down the source of fever.
-Ex: Recurrent, self-resolving fevers over the course of weeks to months could indicate autoimmune, malignancy, or medication-induced response.
-Ex: Sudden-onset fever and worsening is more likely an infectious source.
-Comorbidities and associated medications
-May assist in identification of risks for infection (eg, recent chemotherapy and possibility of neutropenic fever)
-May explain a blunted physiologic response to fever (eg, beta blocker)
-Events surrounding the start of a fever may assist in determining the etiology.
-Travel hx
-Hx of institutionalization, hospitalization, immobilization, prosthetic indwelling device, recent procedures
-Sick contacts
-Occupational hazards
-Recreational activities
Physical exam
-Vitals: Evaluate for sepsis
-Head: tympanic/mucous membranes, lymphadenopathy, voice changes, posterior oropharynx abnormalities such as erythema, exudates, tonsillar swelling, erythema of tympanic membrane
-Neck: lymphadenopathy, enlarged thyroid or masses, nuchal rigidity
-Lungs: absence or presence of abnormal lungs sounds and/or increased work of breathing
-Cardiac: absence or presence of abnormal cardiac sounds, heart rate, capillary refill time, temperature, and coloring of extremities
-Abdomen: localized tenderness, peritoneal signs, bowel sound dysfunction
-Rectal: consider if concern for source (ie, perirectal abscess or prostatitis)
-Genitourinary (GU): should be considered if concern for pelvic inflammatory disease, epididymitis, tubo-ovarian abscess, Fournier’s gangrene, or sexually transmitted diseases based on history and physical assessment
-Skin and extremities: rash or erythema, capillary refill, swelling of joints, swelling along posterior calf, tenderness along long bones, evaluation of back for decubitus ulcers, abscesses, symmetric joint swelling
-Neurologic: mental status changes, evaluate GCS, focal neurologic findings
investigations into fever
-What to order depends entirely upon clinical picture, some examples:
-Body aches, fevers, chills, cough, rhinorrhea in December. Otherwise, healthy , NAD, clear lung -> viral panel, tylenol, ibuprofen
-Diarrhea and no other source of fever with significant comorbidities -> stool culture, o&p, norovirus, cdiff
-Enlarged thyroid, tachycardia, and fever -> thyroid panel
-Cough, fever, chest pain, rales -> CXR, crackles, viral panel
-RUQ abdominal pain, fever, vomiting -> US
-Hx of cirrhosis, now with fever and generalized abd pain, confusion -> Spontaneous Bacterial Peritonitis (SBP) -> thoracentesis, hepatitis, serum ammonia
-Fever, joint edema, erythema, warmth, pain, limited ROM -> septic arthritis -> arthrocentesis
-Fever, confusion, neck pain and stiffness -> meningitis -> LP
-Fever and focal neuro signs -> brain abscess -> CT
-Dysuria, flank pain, fever -> UTI, UA/Cx, pyelonephritis,
fever differentials
-Viral infections as cause of fever is very common
-MC bacterial infections: Urine, Respiratory tract, Skin/Soft tissue
-Neurologic (Meningitis, encephalitis, brain abscess, malignancy)
-Fungal (Rare, severe immunocompromise)
-Autoimmune (Prolonged fever without source)
-Thromboembolism
-Malignancy
-Thyroid storm
-Toxicologic
-Fever and rash- Meningococcal, Lyme, RMSF, necrotizing fasciitis, toxic shock syndrome, endocarditis .. And more!
-Any many more!!
pediatric fever: presentation, hx, exam
-often acute fever
-± assoc sx: runny nose, cough, rash, vomiting, diarrhea or other
-If young, ask about feeding!!!, arousability, wet diapers since onset of illness
-Other pertinent history includes medical conditions, birth hx and prematurity (if young), sick contacts, vaccination status, timeline of sx, and potential sick contacts/exposures.
-Exam:
-General appearance!! -> if well appearing -> most likely okay
-Fontanelles (normal: flat and soft) (sunken: dehydrated, third spacing sepsis) (bulging: meningitis)
-undress completely
-Skin: look for rash, vesicles, scalp, joints
-Hearts, lungs, tone, ENT
pediatric fevers: key concepts
-Neonate 0-28 days old -> ER
-Young infant 29 - 90 days
-!!Rectal temp is most accurate -> everyone
->105 -> treat aggressive
-Fever is not dangerous
-Mounting a fever may be protective
-Response to antipyretics (or lack of response) does not correlate with severity of illness
-Non-infectious etiologies may be less responsive than bacterial and viral infections
-Most fevers are viral in nature
-Most bacterial infections are UTI
-Most uncomplicated febrile illnesses last a median of 3-4 days.
pediatric fevers: dx, workup
-0-21 days: Sepsis work up!
-Blood cultures and labs (WBC, CRP, and procalcitonin if available)
-UA and urine culture via catheterization
-LP with CSF analysis (WBC, protein, glucose, Gram stain, culture, and available PCR)
-Herpes simplex virus is a significant concern in this age group
-CXR
-Antibiotics
-Hospital admission recommended
-dont need to know details:
-Well-appearing infants aged 22-28 days:
-Obtain blood culture, labs for inflammatory markers (as above), and UA.
-CSF may not be required if all inflammatory markers are neg
-if not undergoing LP -> inpatient observation w/o antibiotics
-However, a strong argument can be made for holding antibiotics initially with a plan to discharge if improvement and perform a LP and start antibiotics if the patient does not improve.
-Antibiotics may be administered even if labs are normal (1%-2% bacteremia risk).
-Home discharge with a 24-hour follow-up and excellent return instructions may be a reasonable management plan for patients with unremarkable inflammatory markers, urine and CSF (or CSF with enterovirus).
-Return for change in appearance/behavior/color, lethargy, inconsolable crying, difficulty feeding, or evidence of distress.
-Well-appearing infants aged 29-60 days:
-Obtain a UA (any method is acceptable). If positive, then send a culture from a suprapubic aspiration or catheterized specimen.
-Circumcised boys have a UTI incidence of <1% and are exempt from this recommendation.
-Obtain a blood culture and labs for inflammatory markers (as above).
-CSF is not required unless the child is ill appearing or inflammatory markers are elevated
kawasaki disease
-ALWAYS consider in child with prolonged fever and rash
-VASCULITIS
-MC in ages 6mo–5yo
-high risk for aneurysm
-Dx criteria:
-5 days of fever (can be shorter if high suspicion) PLUS
-B/L conjunctivitis
-Cervical lymph node >1.5CM
-Polymorphous exanthem
-Cracked lips or strawberry tongue
-Erythema, edema, cracking or peeling of the hands/feet
-NONBLANCHING rash
-Echo- in all pts who meet KD criteria -> inflammation of coronary arteries
-Pediatric rheumatology and infectious disease consults
-Tx- high dose ASA, IVIG, PPI
pediatric fever tx
-Most are self-limited viral infections
-Antipyretics -> pain and discomfort of fever
-Broad spectrum, empiric antibiotics should be given immediately if the child appears ill
-In well appearing children with suspected bacterial infection, antibiotic therapy should be tailored to suspected source
-ALL FEBRILE NEONATES should be admitted for IV antibiotics until cultures are negative
-majority of children can be discharged immediately if H&P do not reveal red flags for a bacterial infection.
-Young infants >1mo may be discharged if deemed low risk by criteria including eval of blood and urine with or w/o CSF -> Close f/u (~24 hours) must be ensured
An 84-year-old African American man presents to the local emergency department (ED) from a skilled nursing facility for fever, generalized malaise, and altered mentation for the past 12 hours.
On arrival, the patient is answering questions appropriately but does appear increasingly somnolent.
Pt has a history of hypertension, coronary artery disease and past CVA.
Vital signs: Temp 39.4 C (103° F), HR 125 bpm, BP 92/55 mmHg, RR 22 per min, SpO2 99% on RA.
Physical exam is significant for dry mucous membranes, tachycardic regular rhythm, tachypnea but otherwise clear breath sounds.
Pt has mild lower abdominal tenderness to palpation with an indwelling Foley catheter in place. Pt has brisk lower extremity pulses.
The nurses ask “What are your initial orders doc?”
-UA and Urine cx, blood culture
-fluids
-prob infection from folley cath
-empiric antibiotics
-take out the catheter
-CXR
-can be multiple sources
-viral panel
-sputum if there is a cough
-CBC, CMP, lactate, LFTs
SIRS
-SIRS criteria:
-temp >38 (100.4) or <36 (96.8)
-HR > 90
-RR > 20 or CO2 < 32
-WBC > 12,000 or < 4,000 or >10% bands
-qSOFA score:
-systolic BP <= 100
-RR >= 22
-GCS <15
-scores >= 2 have increased risk of mortality
sepsis presentation
-Classic: Fever, tachycardia, tachypnea, ± hypotension, with delirium
-Variability in presentation
-Factors that increase risk of sepsis
-Age >65
-Social: Nursing home or LTC, prisoners, homeless, alcoholism
-Co-morbidities: Diabetes, CHF, COPD, Liver disease, Cancer, CKD
-Immunosuppression: Chemotherapy, daily steroid use, immune modulating drugs or immune blocking drugs
approach to critical pt in sepsis (hour 1)
-Recognize S&S of sepsis (also, core temperature)
-ABCs
-Vascular access
-Peripheral IV or IO access
-Central (Line) venous catheters
-Arterial line- check MAP
-Empiric antibiotic therapy*
-Attempt collection of cultures before antibiotics, within first hour
-Lactated ringers at 30mL/kg (less if heart or oliguric renal failure)
-Vasopressors to maintain goal MAP >65mmHg!!:
-Norepinephrine 0.01-3.0 μg/kg/min (generally first line)- through central line
-Vasopressin 0.03 units/min
-Addition of vasopressin generally utilized once norepinephrine dose is ≥15 μg/min.
-Use caution or avoid vasopressin use in cases of mesenteric or cardiac ischemia.
-Epinephrine 0.01-2 μg/kg/min
-find and control source of infection:
-remove indwelling foley catheters if possible
-full PE
-CXR
-ECG if tachy
-labs:
-CBC, CMP, UA, VBG (for lactate), cultures (blood + urine), other as indicated -> CT, CSF, SSTI wound cultures, joint cx
-serial exams:
-repeat vitals and PE
-urine output
-trend lactate
-Dispo:
-admit, usually ICU
hospital measures and sepsis bundles (dont memorize)
-Center for Medicaid and Medicare services (CMS)
-Surviving sepsis campaign 2018
-1 hour bundle (SEP-1)
-Hour-1 Bundle
-Measure lactate level* remeasure if >2mmol/L
-Obtain blood cultures before administering antibiotics
-Administer broad-spectrum antibiotics
-Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L
-Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg
-3 hour bundle (SEP-3)
-Lactate measurement
-Blood cultures done before antimicrobial initiation
-Broad spectrum antibiotics
-Administration of 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
-6 hour bundle
-Administration of vasopressors for hypotension that does not respond to fluids to achieve a MAP ≥ 65 mm Hg
-Reassess and document volume status after fluid administration for patients with hypotension that does not respond to fluids or lactate ≥ 4 mmol/L
-Repeat lactate measurement for patients with initial lactate ≥ 4 mmol/L
cellulitis
-Infection of skin (dermis + subcutaneous tissue)
-MCC- group A beta-hemolytic strep (Strep pyogenes) or Staph aureus (rising rates of MRSA)
-Infection begins at a site of trauma: cut, puncture, surgical wound, bites, shaving
-unilateral normally
-!!Pain, redness, swelling, warmth, tenderness in the affected area
-firm
-May have associated fevers, chills, sweats, swollen lymph nodes, streaking (ascending lymphangitis)
-Prognosis: Good w/ outpatient treatment
-Dx: CLINICAL
-US- adjunct -> cobble stoning and edematous fluid
-Tx for non-purulent cellulitis: -Antibiotics
-!!Cephalexin 500 mg PO Q6 hours X 5-7 days or
-!Doxycycline 100 mg PO BID X 5-7 days if true PCN allergy
-High risk for MRSA: Empiric addition of trimethoprim-sulfamethoxazole (TMP-SMX)- bactrim
cellulitis considerations
-in in dirty water -> vibrio- will blister too -> doxy
-cats, dogs -> Augmentin
-fight bite (punch face and tooth gets you) -> augmentin
cellulitis mimics
-Stasis dermatitis: MC misdiagnosis as cellulitis! Often !bilateral and chronic! Presence of telangiectasia, varicose veins, hyperpigmentation, edema subsides with recumbency
-send to wound clinic, elevate, NO antibiotics
-Contact dermatitis – itchy!
-Allergic reactions – itchy!
-Peripheral arterial disease
-DVT: venous cord, can check Homan’s sign (discomfort behind the knee on forced dorsiflexion of foot), duplex ultrasound
-Mono-arthritis (septic/gout): suspect when cellulitis overlies a joint
abscesses
-Localized infection causing !pocket of pus within the dermis!
-can be complication of cellulitis -> warm, firm, with fluctuant center
-Painful, tender, !fluctuant, surrounding induration! ± erythema
-DX- clinical
-US- swish sign
-CT- for perianal abscess -> surgeon bc can cause fistula
-pilonidal abscess -> surgeon bc reoccur usually
-psoas- common
-bartholin cyst - word catheter
-breast- needle aspiration by surgeon
-Tx: Simple linear !I&D! with #11 blade
-ED performs at uncomplicated sites (limbs, back, axilla)
-Must break loculations! through probing
-But Sarah.. Are the following needed?
-Wound culture swabs?
-Packing?
-Antibiotics? -> abscess + cellulitis =I&D + antibiotics
-just abscess = I&D
abscess discharge instructions- dont memorize
-Apply warm and dry compresses, a heating pad set on low, or a hot water bottle 3 or 4 times a day for pain. Keep a cloth between the heat source and your skin.
-Keep your bandage clean and dry. Change the bandage whenever it gets wet or dirty, or at least one time a day.
-If the abscess was packed with gauze:
-Keep follow-up appointments to have the gauze changed or removed. If the doctor instructed you to remove the gauze, follow the instructions you were given for how to remove it.
-After the gauze is removed, soak the area in warm water for 15 to 20 minutes 2 times a day, until the wound closes.
-Take prescribed antibiotics as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
-Take pain medicines exactly as directed.
skin and soft tissue summary
-Abscess and cellulitis are 2 MC soft tissue infections in the ER
-They can occur together requiring different treatments
-Cellulitis requires antibiotics alone
-Abscessesrequire tx with I&D
-May also require antibiotics if surrounding cellulitis
-Caveat: If US shows a very small abscess <1cm diameter, may choose tx with antibiotics and warm compresses instead, with 2 day f/u for reassessment
necrotizing soft tissue infection (NSTI)
-Rapidly progressive infection of the deep fascia causing necrosis of the subcutaneous tissue
-“Flesh eating disease”
-Early signs and symptoms like cellulitis
-Swelling and severe pain
-Can also have:
-Margins are poorly defined (tenderness extends beyond apparent area of involvement)
-Edema extending beyond margin of erythema
-!!Bullae
-!!Gangrenous skin
-Crepitus (13-31%)
-Wooden feel to the subq tissue
-!!Severe pain out of proportion to exam
-Dx: clincial
-X-ray- NF showing ectopic air in the subcutaneous tissue
-Do not rely on imaging
-Tx:
-Broad spectrum antibiotics
-Prompt surgical debridement
What is the most common isolated organism from dog and cat bites?
a. Pasturella multocida!!!!!!!!!!
b. Streptococcus
c. Fusobacterium
d. Propionibacterium
bites
-DOG:
-more initial trauma
-crush injury
-augmentin
-Cat:
-small and innocuous
-deep puncture
-2x infection rate of dogs
-cellulitis, tenosynovitis, septic arthritis, osteomyelitis
-augmentin
-Human:
-occlusion bites
-closed fist bites
-high infection rates
-staph, strep, Eikenella
-augmentin
-Achieve hemostasis to eval wound
-Examine wounds through a full ROM
-Look for tendon injuries and retained foreign bodies
-Clenched fist injuries have a high rate of serious infections
wound care
-Anesthesia -> Debride -> Remove devitalized tissue -> irrigate copiously
-High pressure irrigation ↓↓ risk of infection
-Cleanse:
-Normal saline = potable tap water
-Soap and water
-Virucidal as needed : Betadine (Iodine-Povidine)
-DO NOT USE ALCOHOL, HYDROGEN PEROXIDE -> DAMAGES AND PREVENTS PROPER HEALING (you can do it one time on a dirty bite)
-Equipment:
-18 gauge catheter with 65mL syringe
-Igloo wound irrigation system or splash guard
management of bites
-Radiography:
-always x-ray to r/o retained FB, look for fractures or pockets of air in joint penetration
-Antibiotics
-!Augmentin is a good first line for dog, cat, human bites -> Alternatives: Doxy, bactrim, cipro
-IV antibiotics if severely infected +/- sepsis
-!Tetanus consideration
-!Rabies consideration
-If human bite -> baseline HIV and hepatitis testing
-If animal bite -> rabies vaccination screening
-If cellulitis -> circle with skin marker, start abx, monitor
-If osteomyelitis suspected -> ESR, CRP
-If severely infected hand bite -> OR for surgical debridement and IV antibiotics
-F/u in 24-48 hours as risk of infection is high
flexor tenosynovitis
-Recent bite or trauma 2-5 days prior
-Usually non febrile
-Kanavel signs:
-Fusiform digit swelling (entire thing)
-Finger held in passive flexion (contracted)
-Pain with extension
-Tender over the flexor tendon sheath
-US may show fluid around a thickened tendon sheath in clinically unclear cases
-gap between tendon and the tissue (fluid)
-Surgical emergency- debridement
-IV antibiotics
All of the following are common vectors for rabies EXCEPT:
Fox
Skunk
Chipmunk!!!!!!!
Raccoon
Bat
rabies
-Fatal viral encephalitis
-Rhaboviridae lyssavirus, Single stranded RNA
-Rabies is present in nearly every country -> 59,000 deaths / year world wide, Most common in india
-Animal vaccinations have largely eliminated cases in domestic animals -> 2-3 cases per year in US
-Reservoir
-Bats*, skunks, raccoons, foxes, mongoose, coyote, wolf, unvaccinated dogs
-Saliva in bite from infected animal
-No documented cases in small rodents
-Post exposure prophylaxis (PEP):
-can be delayed if animal can be captured and observed for 10 days, or autopsied
-If animal develops signs of rabies -> PEP can be initiated
-Bat + person -> assume a small bite and initiate PEP
-Local wound cleaning
-Human rabies immune globulin (HRIG)
-20IU/kg IM
-Administer 1x on first visit after bite
-Infiltrate as much as possible into wound then rest into deltoid or anterolateral thigh
-Provides immediate antibodies
-Rabies vaccine
-1mL IM in deltoid as soon as possible
-Days 0,3,7,14 (+28 if immunocompromised)
-CONTRALATERAL from side of HRIG
5 stages of rabies
-incubation- 10 days-2yrs
-prodrome- 0-10 days -> nonspecific sx
-acute neurologic period- 2-7 days
-encephalitic form (80%)- hyperactivity, AMS, hydrophobia, hypersalivation
-paralytic form (20%)- ascending flaccid paralysis
-coma- periods of rapid, irregular breathing in coma -> apnea and paralysis
-death- 2-14 days after sx onset
-respiratory paralysis, seizures, or cardiac dysrhythmias as cause
rabies management
-Most patients will die
-No effective treatment for rabies
-Prevention is key!
-Vaccinate your cats and dogs
-Identify those who qualify for pre-exposure prophylaxis w/ rabies vaccine
-Travel to endemic areas
-Veterinarians
-Animal handlers
tetanus post exposure prophylaxis (PEP)
-Tetanus prophylaxis should be given even to those that present late as the incubation period can be up to several months
-Wounds at increased risk:
->24 hours old
-Crush injury
-Devitalized tissue
-Burns
-IV drug abusers
-Soil in wounds
-PEP:
-Adults >18 and adolescents 11-18yo who had initial tetanus vaccinations and a booster within 10 years do NOT require prophylaxis
-Within 5 years for bites
-Td or TDAP
-Tetanus immunoglobulin (TIG)
-If HIV + , never received a full vaccination series, or active tetanus infection
A 38-year-old male with a history of injection drug use presents to the emergency department (ED) with one day of progressively worsening, pressure-like chest pain radiating to his back. He appears diaphoretic and in moderate distress. He has had difficulty opening his mouth.
Triage vital signs include BP 143/98, HR 115, T 99.2, RR 20, SpO2 98% on room air.
Tachycardic, diaphoretic, and in acute distress. + Tenderness throughout his thoraco-lumbar spine. Increased tone in all extremities. Two abscesses on his upper extremities. An MRI of the spine is unremarkable.
Reexamination reveals new spasmodic neck stiffening, jaw clenching, and arching of his back.
tetanus
tetanus
-spore producing bacteria- clostridium tetani
-28% mortality rate if contracted
-RF- IVDA, unimmunized, foreign born, elderly
-Tetanus vaccine screening:
-bite wounds
-crush injury
-puncture wounds
-Fever, tachycardia, hypertension
-Muscle rigidity, ↑ tone
-Seizure-like muscle spasm
-Trismus (lock jaw)
-Risus sardonicus (sardonic smile)
-Opisthotonos - hyperextension
-Tx:
-ABCs
-wound debridement
-tetanus immune globulin (TIG) 500U IM into the wound
-tetanus toxoid vaccine
-Antimicrobial therapy- penicilline and !metronidazole!
-muscle spasm control- benzos
bacterial meningitis
-Significant morbidity and mortality
-MCC: S. pneumo (see chart for pathogen by age)
-Classic triad: Fever, neck stiffness, AMS
-Headache (MC)
-Focal neuro deficits (1/3)
-Seizures
-Signs of meningeal irritation:
-!Nuchal rigidity
-!Kernigs: Hip is flexed, but knee cannot be straightened
-!Brudinski’s: Flexion of the neck (by you) leads to flexion of the hip (by the patient)
-Head jolt sign
-Do not delay ANTIBIOTICS for CT/ LP/blood cultures! Goal < 60 mins
-Obtaining a CT head before LP is controversial
-IDSA recommends CT before LP in patients:
->60 years old
-History of CNS disease
-Immunocompromised state
-Seizure <1 week before presentation
-AMS
-Focal neuro deficits
-CSF testing = Gold standard
-CSF opening pressure
-Gram stain
-Cell count
-Glucose level
-Protein level
-Tx:
-Empiric treatment: !Vancomycin + Ceftriaxone!
-!Add ampicillin for listeria if >50yo
-!Add acyclovir IV if HSV
-Neonates: ampicillin + gentamicin
-Consider adding !dexamethasone! to decrease morbidity and morality (controversial)
post exposure prophylaxis: bacterial meningitis
-N. Meningitidis can be spread with !respiratory secretions or saliva!
-Indications for PEP:
-Household members
-Healthcare workers with intimate exposure to respiratory secretions < 25 hours after antibiotic therapy was initiated in patient
-When to start PEP:
-Within 24 hours of finding out about exposure
-Most effective within 14 days of being exposed
-PEP therapy:
-Rifampin PO BID for 2 days
-!!Ceftriaxone IM injection single dose
aseptic meningitis
-Viral meningitis and non-infective meningitis (autoimmune, drug induced, malignancy, SAH)
-Similar appearing, but generally less ill
-CSF PCR testing:
-Enteroviruses
-HSV 1 and 2
-Varicella zoster virus
-Treatment
-Most supportive
-IDSA: Consider starting acyclovir for suspected HSV/Varicella-zoster
fungal meningitis
-Immunocompromised patients
-Immunocompetent with recent neurosurgical intervention or IVDU
-Typical pathogens:
-Immunosuppressed (esp neutropenia, transplant) -> Aspergillus and candida
-HIV -> Cryptococcal
-Diabetic, recent sinus infection -> Mucormycosis
-Presents as subacute or chronic meningitis over the hours of weeks to years
-CSF testing:
-!India ink staining for cryptococcus
-Fungal culture
-Tx:
-Cryptococcus: Amphotyericin B and flucytosine
-Aspergillosis, candida, coccidiodomycosis: Voriconazole or fluconazole
A 42-year-old male presents with confusion, headache, and fever. The patient is unable to answer questions. A head CT is negative for a space-occupying lesion or hemorrhage. A lumbar puncture is performed, with cerebral spinal fluid (CSF) analysis showing a lymphocytic pleocytosis and normal glucose. MRI is obtained. PCR of the CSF is positive for HSV-1.
encephalitis
-Infection of the brain parenchyma
-Think viruses: HSV, HZV, EBV, CMV, rabies, West nile virus, enteroviruses, influenza, mumps
-Can be amebic, tick borne, Hashimotos encephalopathy
-!!!!Fever + behavioral/neuro changes! + seizure
-Often have meningeal signs = meningoencephalitis = HA, photophobia, altered
-LP with elevated opening pressure, protein, lymphocytes, normal glucose
-CSF PCR: CMV, HSV, VZV
-Imaging can show:
-CT head = edema
-MRI = increased intensity T2
-Serologic testing: West nile, mumps, EBV
-Tx is limited, mostly supportive:
-HSV: Acyclovir
-CMV: Ganciclovir
encephalitis diff dx
DDX:
SAH
Lyme
Abscess of brain
Encephalopathy (toxic v metabolic)
Sepsis
Meningitis
NMS/SS
Sympathomimetic toxicity
Malignant hyperthermia
Anticholinergic toxicity
Heart stroke
DTs
Thyroid storm
what is this…what else should we check
-brain abscess
-can be complication of meningitis, encephalitis, toxoplasmosis
-this is toxoplasmosis- bc ring enhancing -> HIV?
3 main stages of HIV
-1. initial HIV reaction = acute retroviral syndrome
-non specific fever, fatigue, pharyngitis, rash, NVD, HA 2-4wks post exposure
-2. HIV- CD4 >500; CD4 200-499
-3. AIDS- CD4 <200 and/or h/o opportunistic infection
HIV emergencies
-MC and life-threatening infections in pts with HIV/AIDS at any stage are = in pts with normal immune systems!
-!!!!!IF CD4<200 or AIDS and FEVER = SEPSIS work up + EMPIRIC ANTIBIOTICS
-PULMONARY:
-MC PNA: Strep Pneumo
-If CD4<200 or AIDs, strongly consider imaging, sputum / viral panels, legionella/strep urine testing, TB testing
-TB CD4<500
-Place in negative pressure room while evaluating for TB
-PCP
-CD4<200
-Fever, cough, SOB
-Bilateral perihilar infiltrates or normal CXR
-Bactrim
-NEURO:
-AMS, HA, Focal neuro deficits
-CD4<200 or AIDS, CTH and LP
-!Meningitis – TB, syphilis
-!CMV encephalitis
-!Toxoplasmosis (CD4<100)
-Mass lesions, encephalitis
-Ring enhancing lesions on CT
-Pyrimethamine, sulfadiazine, and leucovorin
-Cryptococcus (CD4<100)
-Meningoencephalitis
-India ink, CSF antigen
-IV amphotericin, PO Flucytosine
PML
-Progressive neuro deficits
-Other DDX: Aids dementia, primary CNS lymphoma, neurosyphilis, CNS TB, HSV encephalitis
-
upper lobe PNA
-aspiration- always laying down
-or TB is the risk factors align
Adverse reactions to HAART
-HAART have lots of side effects
-Dx of exclusion
-Lactic acidosis - Abdominal pain
-Steven Johnson Syndrome- Cutaneous and mucous membrane ulcerations
-Pancreatitis- Severe, sometimes life threatening
-Nephrolithiasis- May not show on imaging if indinavir
fever in recently returned traveler: Risk of infectious exposure
-High risk (1 in 10 travelers): diarrhea, upper respiratory illness, and noninfectious illnesses such as injuries and exacerbation of preexisting chronic diseases
-Moderate risk (1 in 200 travelers): dengue fever, chikungunya, enteroviral infection, gastroenteritis, giardiasis, hepatitis A, malaria, salmonellosis, sexually transmitted diseases, shigellosis
-Low risk (1 in 1000 travelers): amebiasis, ascariasis, measles, mumps, enterobiasis, scabies, tuberculosis, typhoid, hepatitis B
-Very low risk (1 in >1000 travelers): HIV, anthrax, Chagas’ disease, hemorrhagic fevers, pertussis, plague, typhus, hookworm
fever in travelers: dx
-Isolation and PPE early on
-Minimum work up for international travelers with fever: CBC, BMP, UA/Ucx
-Add CXR for respiratory symptoms
-Add viral swab for viral syndromes
-Add stool sample with ova and parasites if diarrhea
-Add blood culture if fever remains undifferentiated or if appears systemic
-Add blood smear if travel to areas with malaria
-Consider specific serologic testing for whichever diseases you are concerned about (wont usually be back by end of ED visit)
-If still undifferentiated, consider consulting ID
malaria
-Common in Sub-Saharan Africa, southeast Asia, central and south America, Caribbean
-Pathogens:
-Most malaria is Malaria falciparum!
-Deadly and common
-Does not reside in liver, does not cause recurrent disease
-Malaria ovale and vivax reside in liver, cause recurrent disease, but are less common
-Develops in 12-14 days, up to 30 days
-Symptoms:
-Asymptomatic
-!!Cyclical low grade fevers, rigors, diaphoresis, headaches, myalgias
-25% with GI symptoms: vague abd pain, n/v/d, jaundice
-Fever
-Jaundice
-Hepatomegaly, Splenomegaly
-Severe malaria:
-Significant anemia
-Metabolic acidosis
-Cerebral malaria
-Multi-organ failure
-Treat pts with UNDIFFERENTIATED fever after tropical travel as if they have malaria until proven otherwise
malaria dx and tx
-Lab tests:
-Thrombocytopenia
-Blood cultures
-Must sent !serial blood smears!
-Thick smear – identifies parasites
-Thin smear – identifies species and burden
-Repeat the smear q8-12h x 3 times to definitively rule out malaria
-(dont need to know) Tx is variable by resistance patterns and species
-Severe anemia: ARTESUNATE! (investigational drug)
-ACT is oral artemisinin combination therapy and was recently FDA approved
-IV artesunate for sick and shocked patient unable to tolerate PO (stocked by CDC only)
-Uncomplicated malaria: Atovaquone or Chloroquine
-Must add primaquine if species is vivax or oval
fever and myalgias differentials
-!!Do not forget mundane common illnesses: viral URI, PNA, UTI and meningitis
-Dengue fever (viral)
-MCC of fever in returning travelers from Caribbean, South America, Southeast asia, and less commonly sub-Saharan Africa
-Suspect if fever developed within 2 weeks of travel
-Sx: Most are asymptomatic, repeated infections tend to get more severe
-Fever, Retro-orbital headache, muscle pains (bone break), nausea, vomiting , maculopapular rash
-<1% develop hemorrhagic symptoms: thrombocytopenia, hypotension, tachycardia, inability to tolerate PO raise suspicion
-PCR, IgG/IgM, Blood culture
-Supportive care
-Zika (viral)
-Common in Caribbean, central Africa, southeast asia
-Usually asymptomatic. Can have conjunctivitis, joint pain, headache, fever
-Worth testing if pregnant
-Chikungunya (viral)
-MC in Carribeans and South America
-Presents with: Fever, Severe joint pains and muscle aches, morbilliform rash
-supportive
-Other considerations: leptospirosis, typhoid fever, trypanosomiasis and schistosomiasis
enteric fever (dont need to know)
-Salmonella typhi or salmonella paratyphi
-Contamination of food or water
-Common in developing nations
-Incubation 5-21 days
-Begins with diarrhea which may resolve by the ER visit
-Sustained fever, anorexia, malaise, vague abd pain, constipation after diarrhea
-Relative bradycardia for the fever
-Rose spots
-Hepatosplenomegaly
