A 30-year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarseness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor. Which of the following is the best course of action?
T his patient, with the development of hoarseness, breathing difficulty, and stridor, is likely to have acute epiglottitis. Because of the possibility of impending airway obstruction, the patient should be admitted to an intensive care unit for close monitoring. T he diagnosis can be confirmed by indirect laryngoscopy or soft tissue x-rays of the neck, which may show an enlarged epiglottis. Otolaryngology consult should be obtained. T he most likely organism causing this infection is H influenzae. Many of these organisms are β-lactamase producing and would be resistant to ampicillin. Streptococcal pharyngitis can cause severe pain on swallowing, but the infection does not descend to the hypopharynx and larynx. Lateral neck films would be more useful than a chest x-ray. Classic finding on lateral neck films would be the thumbprint sign. Infectious mononucleosis often causes exudative pharyngitis and cervical lymphadenopathy but not stridor.
A 70-year-old patient with long-standing type 2 diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. Which of the following organisms is most likely to grow from the purulent drainage?
Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. T his infection usually occurs in older, poorly controlled diabetics and is almost always caused by P aeruginosa. It can invade contiguous structures including facial nerve or temporal bone and can even progress to meningitis. S pneumoniae, H influenzae and M catarrhalis frequently cause otitis media, but not external otitis. Candida albicans almost never affects the external ear.
A 25-year-old male student presents with the chief complaint of rash. He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following:
Which of the following is the most useful laboratory test in this patient?
The diffuse rash involving palms and soles would in itself suggest the possibility of secondary syphilis. The hypertrophic, wartlike lesions around the anal area, called condyloma lata, are specific for secondary syphilis. The VDRL slide test will be positive in all patients with secondary syphilis. Rash and lymphadenopathy would not be found if the perianal lesions were due to HPV. Chlamydia infections cause urethritis with mucopurulent discharge from the penile meatus but not the systemic symptoms or hypertrophic skin changes. Blood cultures might be drawn to rule out bacterial infection such as chronic meningococcemia; however, the clinical picture is not consistent with a systemic bacterial infection. Biopsy of the condyloma is not necessary in this setting, as regression of the lesion with treatment will distinguish it from genital wart (condyloma acuminatum) or squamous cell carcinoma.
A 35-year-old previously healthy man develops cough with purulent sputum over several days. On presentation to the emergency room, he is lethargic. Temperature is 39°C, pulse 110, and blood pressure 100/70. He has rales and dullness to percussion at the left base. There is no rash. Flexion of the patient’s neck when supine results in spontaneous flexion of hip and knee. Neurologic examination is otherwise normal. There is no papilledema. A lumbar puncture is performed in the emergency room. The cerebrospinal fluid (CSF) shows 8000 leukocytes/µL, 90% of which are polys. Glucose is 30 mg/dL with a peripheral glucose of 80 mg/dL. CSF protein is elevated to 200 mg/dL. CSF Gram stain is pending. Which of the following is the correct treatment option?
This previously healthy male has developed acute bacterial meningitis as evident by meningeal irritation with a positive Brudzinski sign, and a CSF profile typical for bacterial meningitis (elevated white blood cell count, high percentage of polymorphonuclear leukocytes, elevated protein, and low glucose). The patient likely has concomitant pneumonia. This combination suggests pneumococcal infection. Because of the potential for beta-lactam resistance, the recommendation for therapy prior to availability of susceptibility data is ceftriaxone and vancomycin. Though herpes simplex can be seen in young healthy patients, the clinical picture and CSF profile are not consistent with this infection. The CSF in herpes simplex encephalitis shows a lymphocytic predominance and normal glucose. Listeria monocyto-genes meningitis is a concern in immunocompromised and elderly patients. Gram stain would show gram-positive rods. Neisseria meningitidis is the second commonest cause of bacterial meningitis but rarely causes pneumonia (the portal of entry is the nasopharynx). Although penicillin G still kills the meningococcus, empiric therapy should cover all likely pathogens until Gram stain and culture results are available. Because the patient has no papilledema and no focal neurologic findings, treatment should not be delayed to obtain an MRI scan.
. A 29-year-old man presents with a 4-day history of fever, headache with retro-orbital pain, severe musculoskeletal and lumbar back pain and rash. The symptoms began 3 days after he returned from a 2-week vacation to the Caribbean islands. The rash developed on his face before spreading over his trunk and extremities. The patient reports receiving appropriate vaccination, including hepatitis A virus vaccine, hepatitis B virus vaccine, and typhoid vaccine. Laboratory tests reveal normal kidney and liver function tests but leukopenia and thrombocytopenia. Which of the following organisms is the most likely cause of this infection?
All the listed diseases can be acquired during travel, but the severe myalgias, skin rash, and thrombocytopenia are most consistent with dengue. Dengue fever is characterized by fever, severe frontal headache, retro-orbital pain, and severe musculo-skeletal and lumbar back pain. A macular or scarlatiniform rash develops within 3 to 4 days of the illness. Virtually all cases respond to conservative measures with bleeding, hepatitis, and myositis reported as potential rare complications. Dengue hemorrhagic fever is a more severe form of the disease. It is more common among infants and elderly people. It is characterized by increased vascular permeability with hypovolemic shock and thrombocytopenia with spontaneous ecchymoses and mucosal bleeding. Dengue is a mosquito-borne illness. Leptospirosis is a spirochetal disease that has two phases. The bacteremic phase is characterized by sudden onset fevers, rigors, headache, photophobia, and severe myalgias. Four to 30 days later, the immunologic phase ensues and is characterized by conjunctivitis, photophobia, retrobulbar pain, neck stiffness, diffuse lymphadenopathy, hepatosplenomegaly, and aseptic meningitis. The most severe form is called Weil disease; it is associated with up to 40% mortality and is characterized by high direct bilirubin and mild elevation in alkaline phosphatase and transaminase values, combined with a high creatine phosphokinase. Malaria is a parasitic disease usually caused by P falciparum. Patients present with influenza-like symptoms, jaundice, and in its most severe forms with obtundation and confusion. Hepatitis A causes markedly elevated transaminase values and jaundice. S typhi causes typhoid fever. Patients present with influenza-like illness with abdominal discomfort and constipation. Mild, bloody diarrhea could develop in some cases. The patient might develop small rose-colored macules called “rose spots” on the trunk, but thrombocytopenia is not a common feature of typhoid fever.
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