SAEM Clinical Images Series: Not Your Usual Irritated Eye

eye irritation

In July 2022, a 32-year-old male with a past medical history of HIV (on antiretroviral therapy, CD4 390, viral load undetectable) presented to the emergency department with constitutional symptoms and a rash for 4-5 days. His symptoms included malaise, body aches, subjective fevers, a sore throat, tender, swollen neck glands, body rash, and irritation of his left eye. He also noticed fluid-filled vesicles on his face, neck, trunk, and extremities. He denied travel outside the U.S. but reported a recent trip to New Orleans. He denied any new sexual partners or known exposure to individuals with similar symptoms.

Vitals: BP 135/83; Pulse 104; Temp 100.2 °F (37.9 °C); Resp 22; SpO2 99%

Constitutional: Alert, no acute distress

HEENT: 1×1 mm raised lesion to the left medial canthus/caruncle. No appreciated LAD. Oropharynx is clear and moist, and mucous membranes are normal.

Cardiovascular: Tachycardia, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, unlabored respirations.

Abdominal: Soft. Non-tender.

Skin: Numerous 5-6 mm erythematous macules, bland fluid-filled vesicles, and umbilicated lesions throughout the face, neck, trunk, and extremities.

Complete Blood Count (CBC): WBC: 19.5 10^3/mcL, Hemoglobin: 15.2 gm/dL, Hematocrit: 43.6%, Platelet count: 325 10^3/mcL

Comprehensive Metabolic Panel (CMP): Within normal limits

RPR titer: Reactive, 1:4

Syphilis antibody IgG and IgM: Positive

Orthopoxvirus DNA: Pending

HIV RNA: Pending

The patient has Monkeypox with involvement of the caruncle of the left eye. The patient tested positive for non-variola orthopoxvirus DNA. Ophthalmology was consulted and did not find any other signs of compromise to the eye and recommended treatment with artificial tears. The patient received 14 days of Tpoxx. The patient’s eye lesion and symptoms resolved and he was discharged on hospital day eight.

Ocular lesions are a rare presentation of the monkeypox virus. There is limited literature documenting eye involvement and pictographic examples of its presentation. During the current outbreak, ocular involvement has been used as a criteria for hospital admission. The most commonly seen ophthalmologic lesions include a vesicular rash of the orbital and periorbital skin (25%), focal conjunctiva lesions, blepharitis, and conjunctivitis. Rarely, lesions can process to corneal ulcerations, keratitis, and vision loss. Given the late risk of vision loss in cases of ocular manifestations, clinicians should be aware of the varied presentation of ocular lesions associated with the monkeypox virus.

Take-Home Points

  • While rare, ocular involvement of Monkeypox is associated with vision loss, and should be promptly identified and addressed by a clinician.
  • If there is ocular involvement of primarily cutaneous pathology, a thorough eye exam is indicated in the initial assessment of the patient.
  • Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. Ophthalmic manifestations of monkeypox virus. Eye (Lond). 2023 Feb;37(3):383-385. doi: 10.1038/s41433-022-02195-z. Epub 2022 Jul 27. PMID: 35896700; PMCID: PMC9905463.
  • Kumar N, Acharya A, Gendelman HE, Byrareddy SN. The 2022 outbreak and the pathobiology of the monkeypox virus. J Autoimmun. 2022 Jul;131:102855. doi: 10.1016/j.jaut.2022.102855. Epub 2022 Jun 25. PMID: 35760647; PMCID: PMC9534147.
  • Thornhill, John P., et al. “Monkeypox virus infection in humans across 16 countries—April–June 2022.” N Engl J Med. 2022 Aug 25;387(8):679-691. doi: 10.1056/NEJMoa2207323. Epub 2022 Jul 21. PMID: 35866746.

SAEM Clinical Images Series: Fever with Rash

eschar

A 40-year-old male, tailor by occupation, was brought to the Emergency Department with complaints of high-grade fever for the past 11 days. Fever was documented to be 102°F and was not associated with any chills or rigors. The patient also complained of shortness of breath for one week associated with a dry cough, as well as an altered sensorium for one day. The patient during his hospital stay developed ARDS and was on mechanical ventilation for 20 days. He was then extubated and discharged after 27 days.

Skin: Multiple eschars on knee, foot, and lower chest.

Complete Blood Count: WBC 31,000; Plt 12,000

BUN: 215 mmol/L

Creatinine: 2.5 mmol/L

Liver Function Tests: AST 192 IU/L; ALP 591 IU/L

Blood PCR for Scrub Typhus was found to be positive.

Scrub typhus is often diagnosed clinically based on exposure to endemic regions and its characteristic eschar, which usually appears on the lower extremities, axillae, or genital region. [1,2] Still, diagnosis can be tricky, and similar eschars can be caused by spider bites, Mediterranean spotted fever, Queensland tick typhus, African tick-bite fever, and anthrax. [3] Scrub typhus is a potentially fatal mite-borne rickettsial infection caused by Orientia tsutsugamushi. It is endemic to the Asia–Pacific region, which has an estimated 1 million instances per year. Those affected may have headaches, myalgias, hearing loss, and rash, in addition to fever. Encephalitis, hepatitis, and pulmonary and cardiac involvement can occur. [1,2]

Early empiric treatment with Doxycycline is life-saving.

Take-Home Points

  • Consider Scrub Typhus in a patient presenting with eschars.
  • Early empiric treatment with Doxycycline is life-saving.
  • Botelho-Nevers E, Raoult D. Fever of unknown origin due to rickettsioses. Infect Dis Clin North Am. 2007 Dec;21(4):997-1011, ix. doi: 10.1016/j.idc.2007.08.002. PMID: 18061086.
  • Hendershot EF, Sexton DJ. Scrub typhus and rickettsial diseases in international travelers: a review. Curr Infect Dis Rep. 2009 Jan;11(1):66-72. doi: 10.1007/s11908-009-0010-x. PMID: 19094827.
  • Shiao CC, Lin SY. Eschar: a clue to scrub typhus. CMAJ. 2011 Oct 18;183(15):E1152. doi: 10.1503/cmaj.101929. Epub 2011 Sep 12. PMID: 21911554; PMCID: PMC3193135.

SAEM Clinical Images Series: Face and Chest Rash

chicken pox

A 23-year-old female with a past medical history of asthma presented with a rash that began five days ago on her face and spread to her chest. The lesions are painful and pruritic, spreading slightly to her extremities. She noted a slight sore throat and nasal congestion. She denied any known fever and had no known vaginal or oral lesions. She has a 5-year-old daughter at home with no known symptoms. She is sexually active with one male partner who has no rash or illness. She is vaccinated for COVID-19. She is unsure of childhood illnesses and believes she was never properly immunized as a child in Central America.

Vitals: BP 110/55; Temperature 37°C; pulse ox 97%

Skin: Face, thorax, and extremity papules are noted with an erythematous base, some vesicular, others with occasional crust or scabs. No dermatomal distribution. There is relative sparing of extremities with more lesions noted on the trunk and face. Negative Nikolsky sign. Otherwise, no other findings on physical examination.

Non-contributory

Herpes varicella-zoster, or chickenpox, is a viral infection transmitted by airborne droplets and direct contact. Before immunization, 90% of cases occurred in children. While primary infection in children is generally benign, adult and infant infections can have severe complications including encephalitis and pneumonia. Erythematous vesicular lesions appear in successive crops typically starting on the face and spreading to the trunk. Extremities usually have more minor involvement with sparing of palms and soles. Vesicles progress quickly to crusted erosions in 8-to-12-hour periods. Treatment should focus on symptomatic care.

Antivirals can slow the severity of the course if given within 24 hours of the onset. Severely immunocompromised patients should receive acyclovir 10 mg/kg IV every 8 hours for 7 to 10 days.

Take-Home Points

  • Chickenpox presents with several “crops” of lesions: papules, vesicles, and scabs.
  • Adult primary disease is not common and is more severe than pediatric illness.
  • Antivirals are not indicated after the first day of illness in immunocompetent adults with mild to moderate disease.

  • Gomez-Gutierrez AK, Flores-Camargo AA, Casillas Fikentscher A, et al. Primary varicella or herpes zoster? An educational case report from the primary care clinic. Cureus Apr 2022;14(4):e23732.
  • Hughes CM, Liu L, Davidson WB, et al. A Tale of Two Viruses: Coinfections of Monkeypox and Varicella Zoster Virus in the Democratic Republic of Congo. Am J Trop Med Hyg. 2020 Dec 7;104(2):604-611. doi: 10.4269/ajtmh.20-0589. PMID: 33289470
  • Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses. 2018 Nov 2;10(11):609. doi: 10.3390/v10110609. PMID: 30400213
  • Wolff K, Johnson RA Saavedra AP. Fitzpatrick’s Color Atlas of Clinical Dermatology. 7th ed. McGraw Hill. 2013:673-675.

SAEM Clinical Images Series: A Serious Pain in the Neck

lemierre

An otherwise healthy 34-year-old male presented to the Emergency Department with two weeks of anterior neck pain. Symptoms began with several days of pain in his mandibular molars, progressing to pain and swelling in the neck. In the last several days, the patient developed warmth and redness in the chest wall associated with subjective fever and chills. Additionally, the patient reports difficulty swallowing solid foods secondary to odynophagia associated with intermittent globus sensation. He has no history of immunocompromise and denies any drug or alcohol use. Of note, he has not seen a dentist in many years.

Vitals: BP 115/80; HR 120; T 101°F; RR 16; O2 sat 97%

General: Well appearing in no acute distress

HEENT: Poor dentition, mild trismus. No gingival inflammation or swelling or induration to suggest abscess. The floor of the mouth is unremarkable.

Skin: The neck and upper chest demonstrate erythema and tenderness with an enlarged area of fluctuance on the superior aspect of the left breast (Figure 1).

White blood cell (WBC) count: 6.3 k/uL

Lactate: 1.6 mmol/L

Glucose: 95 mg/dL

Creatinine: 0.72 mg/dL

Lemierre Syndrome, also known as septic thrombophlebitis of the internal jugular vein, is a rare condition with an incidence of 3-15 cases per million people. This condition occurs when an oropharyngeal or odontogenic infection spreads locally from pharyngeal tissue to the internal jugular vein. The pathogens classically arise from normal oral flora, most commonly Fusobacterium necrophorum. The presentation may be associated with trismus and/or dysphagia. Subsequent complications, including localized abscess formation and bacteremia, stem from a combination of surrounding tissue invasion and systemic septic embolization.

Given the potential for regional lymphatic spread and septic embolization, patients may present with both local and systemic findings. Skin exam may reveal regionalized cellulitic or infectious changes overlying the neck or chest (Figure 1).

Respiratory signs and symptoms may suggest the presence of pulmonary septic emboli or mediastinitis.

Constitutional symptoms including fever, chills, and fatigue are common though nonspecific. The differential is broad and includes a number of infectious, lymphatic, endocrine, and neoplastic conditions.

It is essential for the clinician to consider the alternative diagnosis of Ludwig’s Angina through careful evaluation of the oral floor.

Given the potential for oropharyngeal and respiratory compromise, emergency clinicians must maintain a high index of suspicion for this condition. Diagnostics should include laboratory studies with blood cultures, as well as CT imaging of the neck and chest to evaluate for filling defects of the internal jugular vein.

When entertaining the diagnosis, early antibiosis is prudent. Treatment should include both an extended course of antibiotic therapy as well as surgical source control of abscesses. Given the propensity for thrombus development (Figure 2), anticoagulation may be considered, but its indication here remains controversial. Patients with Lemierre Syndrome will require surgical consultation and hospital admission.

Take-Home Points

  • Lemierre Syndrome is a septic thrombophlebitis of the internal jugular vein most commonly occurring via direct spread from the oral cavity. Distinction from Ludwig’s Angina is imperative.
  • Given the proximity to critical structures and the potential for systemic organ dysfunction from septic emboli, emergency physicians need to maintain a high clinical suspicion for this rare diagnosis.
  • Treatment includes parenteral antibiotics and prompt consultation of medical and surgical subspecialists to identify the infectious source as well as mitigate against systemic spread and/or thrombus propagation.
  • Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012 Oct;12(10):808-15. doi: 10.1016/S1473-3099(12)70089-0. Epub 2012 May 25. PMID: 22633566.

SAEM Clinical Images Series: A Painful Swollen Digit

finger

A 50-year-old male with a history of polysubstance use disorder and poorly-controlled type 2 diabetes mellitus presents with left hand pain. One week ago, the patient sustained a macerating injury of the left distal middle digit. Since that time he has experienced worsening pain throughout the digit, now associated with diffuse swelling and discoloration. The patient also reports reduction in range of motion.

Vitals: Temp 97.6°F (36.4°C); BP 134/89; HR 87; Resp 16

General: Uncomfortable appearing male.

Musculoskeletal: Left hand third digit with fusiform edema, diffuse erythema, and warmth. Held in passive flexion at rest. Skin breakdown noted at distal fingertip with scant serous drainage. Tender to palpation, most markedly over the volar surface of the PIP joint. Patient reports severe pain with passive extension at the MCP, PIP, and DIP joints.

Glucose: 296

White Blood Cell (WBC) Count: 8,000/μl

ESR: 54 mm/hr

Infectious flexor tenosynovitis is an infection of the flexor tendon and synovial sheath with a significant risk of complications (e.g., tendon rupture, loss of function, amputation) if not promptly treated. Patients classically present 2-4 days after penetrating trauma to the hand (e.g., bite/scratch, puncture wound, laceration, injection).

This diagnosis is suggested clinically by four cardinal findings, the Kanavel signs:

1) diffuse “fusiform” swelling of the digit (most common)

2) digit held in passive flexion

3) tenderness to percussion over the flexor sheath

4) pain with passive extension

Although fundamentally a clinical diagnosis, the initial evaluation for infectious flexor tenosynovitis should include laboratory studies including complete blood count (CBC) and inflammatory markers (ESR/CRP). Radiographs may be performed to evaluate for occult traumatic injury or foreign body. Treatment includes emergent consultation of orthopedics or hand surgery, initiation of intravenous (IV) antibiotics, and hospital admission. Antibiotics should target gram-positive organisms (Staphylococcus, including MRSA, and Streptococcus). In immunocompromised patients, additional coverage against gram-negative organisms and anaerobes may be needed. Risk factors for poor outcomes include immunocompromise (HIV, diabetes, immunosuppression), intravenous drug use, peripheral vascular disease, and polymicrobial infection.

Take-Home Points

  • Infectious flexor tenosynovitis is a surgical emergency that is diagnosed clinically by the presence of one or more of the four Kanavel signs on physical exam.
  • History of trauma or penetrating injury and immunocompromised status should raise suspicion for infectious flexor tenosynovitis; common pathogens include Staphylococcus and Streptococcus species.
  • Treatment includes emergent consultation with orthopedics or hand surgery as well as early initiation of IV antibiotics.

  • Ritter K, Fitch R. Tenosynovitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. Accessed November 30, 2022. https://accessmedicine-mhmedical-com.ezproxy.bu.edu/content.aspx?bookid=2969&sectionid=250459435.
  • Hyatt MT, Bagg MR. Flexor Tenosynovitis. OrthopClin N Am 2017;48:217-27.
  • Pang HN, Teoh LC, Yam AKT, Lee JYL, Puhaindran ME, Tan ABH. Factors affecting the prognosis of pyogenic flexor tenosynovitis. Journal of Bone and Joint Surgery. 2007;89(8):1742-1748.

SAEM Clinical Images Series: The Color Purple

purple urine

A 64-year-old female with a history of quadriplegia and bladder rupture secondary to a motor vehicle accident two years ago, complicated by chronic indwelling suprapubic foley, presents from her skilled nursing facility with fever, oliguria, tachycardia, low blood pressure, and a change in the color of her urine.

Vitals: T 100.4°F; HR 126; BP 105/74; RR 24

General: Pleasant but mildly confused morbidly obese female smelling strongly of urine

Genitourinary: Poorly maintained indwelling suprapubic catheter with purulence noted around the ostomy and purple urine in her foley tubing and bag

Urinalysis (UA): 168 WBC, >182 RBC, Large leukocyte esterase, Positive nitrite

This is a case of Purple Urine Bag syndrome (PUBS), an uncommon subset of CAUTI that generally occurs in female patients with constipation and an indwelling foley. Although not fully understood, it is thought that the long stool transit time of constipation allows GI flora to break tryptophan down into indoles which travel to the liver via the portal system where they become indoxyl sulfate, which is excreted into the urine. Bacterial enzymes there catalyze this to indoxyl which oxidizes in alkaline urine to both indigo (blue) and indirubin (red), the combination of which, plus interaction with the plastic catheter tubing, causes the vivid purple discoloration. Risk factors include women, chronically catheterized, elderly, recurrent UTI, institutionalization, and chronic constipation.

Causative organisms are primarily gram-negative and include Proteus mirabilis, Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa, Morganella morganii, and Enterococcus species.

Take-Home Points

  • PUBS is a rare subset of CAUTI primarily caused by gram-negative bacteria.
  • It is predominantly found in women, chronically catheterized, institutionalized, and constipated patients.
  • Treatment is appropriate antibiotics and improved foley hygiene, foley exchange as well as improved bowel regimen to increase stool transit time.
  • Meekins Pauline, Ramsay Amy, Ramsay Michael. Purple Urine Bag Syndrome. West J Emerg Med. 2012 Dec;13(6):499-500. 2. Scleszka Laura, Swan Tricia. October 9, 2020. Can Urine Color Guide Management? [online] EMRA. Available at: https://www.emra.org/emresident/article/purple-urine-bag-syndrome/ [Accessed 19 Dec. 2022]

By |2023-08-14T09:14:36-07:00Aug 14, 2023|Infectious Disease, SAEM Clinical Images|

ALiEM AIR Series | Infectious Disease 2023 Module

ALiEMU AIR Series infectious disease 2023

Welcome to the AIR Infectious Disease Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to infectious diseases in the Emergency Department. 6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 5 Honorable Mentions. We recommend programs give 3 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Infectious Disease Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Infectious Disease

SiteArticleAuthorDateLabel
SGEMLumbar punctures in febrile infants with positive urinalysis – it’s just overkillDennis Ren, MDDecember 31, 2022AIR
EMDocsBacterial MeningitisMounir Contreras Cejin, MD January 28, 2023HM
ALiEMThe Febrile InfantCorey Ziemba, MD, Justin Hacnik, MD and J.D. Cambron, DOMarch 29, 2023HM
EMCritApproach to CNS infectionJosh Farkas, MDAugust 15, 2022HM
Core EMUpdates in STI CareDaniel Imas, MDMarch 17, 2022HM
REBEL EMShort course antibiotics for Peds CAPMarco Propersi, DODec 5, 2022HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

 

Reference

  1. Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275
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