A 35-year-old man complains of inability to close his right eye. Examination shows facial nerve weakness of the upper and lower halves of the face. There are no other cranial nerve abnormalities, and the rest of the neurological examination is normal. The patient is afebrile. Examinations of the heart, chest, abdomen, and skin show no additional abnormalities. There is no lymphadenopathy. About 1 month ago the patient was seen by a dermatologist for a bull’s-eye skin rash 2 weeks after returning from a camping trip in upstate New York. Which of the following is the most likely diagnosis?
This patient’s symptoms and time course are consistent with stage 2 Lyme disease. A few weeks after a camping trip and presumptive exposure to the Ixodes tick, the patient developed a rash consistent with erythema chronicum migrans (stage 1). Secondary neurologic, cardiac, or arthritic symptoms occur weeks to months after the rash. Facial nerve palsy is one of the more common signs of stage 2 Lyme disease; it may be unilateral (as in this case) or bilateral. Stage 3 Lyme disease occurs months to years later and is characterized by recurrent and sometimes destructive oligoarticular arthritis. Sarcoidosis can cause facial palsy, but there are no other signs or symptoms (such as lymphadenopathy) to suggest this disease. Idiopathic Bell palsy would not account for the previous rash or the exposure history. Syphilis always needs to be considered in the same differential with Lyme disease, but the rash described would be atypical, and the neurologic findings of secondary syphilis are usually associated with mild meningeal inflammation. The upper motor neuron involvement of lacunar infarct would spare the upper forehead.
A 25-year-old woman complains of dysuria, frequency, and suprapubic pain. She has not had previous symptoms of dysuria and is not on antibiotics. She is sexually active and on birth control pills. She has no fever, vaginal discharge, or history of herpes infection. She denies back pain, nausea, or vomiting. On physical examination she appears well and has no costovertebral angle tenderness. A urinalysis shows 20 white blood cells per high power field. Which of the following statements is correct?
The patient’s presentation strongly suggests acute uncomplicated cystitis. Although some physicians still perform urine culture and sensitivity on all such patients, it is generally considered practical and appropriate to treat with empiric antibiotic therapy. A 3-day regimen of trimethoprimsulfamethoxazole or fluoroquinolone, or a 5-day course of nitrofurantoin are the recommended regimens. Knowledge of local antibiotic resistance patterns can help choose among these three regimens. Workup for obstruction or kidney stone is not indicated in cystitis but may be necessary in the evaluation of pyelonephritis (especially recurrent disease). Low-dose antibiotic therapy has been used successfully in women with frequent (three or more per year) urinary tract infections. Although 10% to 20% of community-acquired UTIs may be resistant to one of the recommended oral regimens, patients may respond to the high antibiotic levels achieved in the urine. If this woman’s symptoms do not respond to oral antibiotics after a few days, culture-directed treatment would be recommended. Parenteral antibiotics are not recommended for uncomplicated cystitis.
A 59-year-old man undergoes coronary bypass surgery. He receives cefazolin prophylactically for 24 hours. On the ninth postoperative day, he develops a fever of 39.8°C with a heart rate of 115 beats/minute and a blood pressure of 105/65 mm Hg. The surgical site is healing well with no redness or discharge. His white blood cell count is 14,000/mm3 and urinalysis reveals many white blood cells per high power field. Blood and urine cultures grow a non-lactose fermenting oxidase-positive gram-negative rod. Which of the following antibiotics is most appropriate to treat this infection?
The patient has a healthcare–associated urinary tract infection complicated by gram-negative bacteremia. The complete identification of gram-negative rods might take 48 hours. Knowing the ability of the growing bacteria to ferment lactose might help in the early prediction of the likely pathogen at hand. Among lactose fermenting gram-negative rods, enterobacteriaceae like E coli are most common. Among non-lactose fermenting oxidase-positive gramnegative bacteria, P aeruginosa is most common. Ceftriaxone, doripenem, and trimethoprim-sulfamethoxazole can be used to treat urinary tract infections while moxifloxacin and tigecycline do not achieve high enough concentration in urine to be used for this indication. Of the listed antibiotics, doripenem, which is a carbapenem beta-lactam antibiotic, is the only one with anti-pseudomonal activity. Antibiotics with anti-pseudomonal activity include certain penicillins (piperacillin/tazobactam and ticarcillin/clavulanate), cephalosporins (ceftazidime and cefepime), carbapenems (imipenem, meropenem, and doripenem), fluoroquinolones (ciprofloxacin and levofloxacin), and aminoglycosides (gentamicin, tobramycin, and amikacin).
You are a physician in charge of patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of influenza A outbreak. None of the nursing home residents have received the influenza vaccine. Which course of action is most appropriate?
Influenza A is a potentially lethal disease in the elderly and chronically debilitated patient. In institutional settings such as nursing homes, outbreaks are likely to be particularly severe. Thus, prophylaxis is extremely important in this setting. All residents should receive the influenza vaccine unless they have known egg allergy (patients can choose to decline the vaccine). Since protective antibodies to the vaccine will not develop for 2 weeks, oseltamivir can be used for protection against influenza A during the interim 2-week period. Because of increasing resistance, amantadine is no longer recommended for prophylaxis. The best way to prevent influenza-associated pneumonia is to prevent the outbreak in the first place.
A 60-year-old male patient complains of low back pain, which has intensified over the past 3 months. He had experienced some fever at the onset of the pain. He was treated for acute pyelonephritis about 4 months ago. Physical examination shows tenderness over the L2-3 vertebra and paraspinal muscle spasm. Laboratory data show an erythrocyte sedimentation rate of 80 mm/h and elevated C-reactive protein. Which of the following statements is correct?
The presentation strongly suggests vertebral osteomyelitis. MRI is sensitive and specific for the diagnosis of vertebral osteomyelitis and is the diagnostic procedure of choice. MRI will reveal the extent of contiguous disc and soft tissue involvement and will help assess for pending neurological compromise. The vertebrae are a common site for hematogenous osteomyelitis. Prior urinary tract infection is often the primary mechanism for bacteremia and vertebral seeding. Blood cultures at the time of presentation are positive in fewer than half of all cases. Treatment requires 6 to 8 weeks of antibiotics, but surgery is rarely required for cure.
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