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A 78-year-old woman is hospitalized with a 2-day history of lethargy, headache, and confusion in September. She is an avid gardener living in Connecticut. Medical history is unremarkable, and she takes no medications.

On physical examination, temperature is 38.9 °C (102 °F) and pulse rate is 110/min. She is lethargic and ori-ented only to name. She resists passive flexion of the neck and the ocular examination. No rash is present, and the remainder of the examination is normal.

Laboratory studies show a normal complete blood count and liver chemistry tests. Cerebrospinal fluid shows a leukocyte count of 94/uL (94 x 10%/L), with 88% lymphocytes, 11% monocytes, and 1% polymorphonuclear cells.

Serology for Borrelia burgdorferi is negative.

Which of the following is the most likely diagnosis?

(A) Anaplasmosis

Nader Guma
Sep 01, 2024

Given the patient's presentation with lethargy, headache, confusion, fever, and neck stiffness, along with cerebrospinal fluid (CSF) analysis showing a lymphocytic pleocytosis, a viral encephalitis is strongly suggested. Additionally, the patient lives in Connecticut and is an avid gardener, which increases her exposure to tick-borne diseases.


Powassan virus is a tick-borne flavivirus that can cause encephalitis and is transmitted by the same ticks that spread Lyme disease (Ixodes scapularis). This is particularly relevant given her geographic location in Connecticut, where Powassan virus is endemic.


**Anaplasmosis (A) ** and **Babesiosis

(B) ** are also tick-borne diseases, but they typically present with different symptoms and blood abnormalities, such as leukopenia and thrombocytopenia (anaplasmosis) or hemolytic anemia (babesiosis), neither of which are described in this patient.


**Lyme disease (C) ** can cause neuroborreliosis, but it is less likely given the negative serology for Borrelia burgdorferi.

Thus, the most likely diagnosis is:

**D. Powassan virus infection**

A 34-year-old woman with a history of three weeks of swelling and tenderness over the dorsum of the left hand, pain, redness, and swelling in her right ankle, intermittent pain in shoulder and knee joints, and a rash on her lower extremities. Here are the key points and findings:

Patient History:

  • Unhoused: Staying in shelters and homes of acquaintances in downtown Los Angeles.

  • Substance Use: Smokes one pack of cigarettes daily, consumes four to six alcoholic beverages daily, occasionally smokes marijuana, and occasionally smokes methamphetamine. No injection drug use.

  • Sexual History: Several intimate partners in the past year.

Physical Examination:


Mazen Kherallah
Mazen Kherallah
Jun 15, 2024

Key Points:

  • Clinical Presentation: Swelling and tenderness in multiple joints, rash on lower extremities, and elevated inflammatory markers.

  • Risk Factors: Multiple sexual partners and substance use.

  • Laboratory Findings: Elevated leukocyte count, neutrophilia, elevated ESR, and CRP.

Neisseria gonorrhoeae is known to cause disseminated infections, presenting with symptoms such as tenosynovitis, dermatitis, and polyarthralgia, which matches the patient's symptoms.

Edited

A 28-year-old woman is hospitalized with a 5-day history of chest pain, fever, and cough with green sputum. Two weeks ago, she developed an influenza-like illness and seemed to improve before the onset of the most recent symptoms. She has no other medical conditions and takes no medications.

On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 150/90 mm Hg, pulse rate is 112/min, and respiration rate is 28/min. Oxygen saturation is 96% breathing ambient air. Crackles are heard at the right lower lung base on pulmonary auscultation. The remainder of the physical examination is normal.

Blood and sputum cultures are obtained. COVID-19 testing is negative.

Chest radiograph shows a right lower lobe infiltrate.

Empiric therapy for community-acquired pneumonia is initiated with ceftriaxone, azithromycin, and vancomycin.

Ceftriaxone and azithromycin are discontinued on hospital day 2 when blood and sputum cultures return positive for methicillin-resistant Staphylococcus aureus with…


Harsh Sura
Jun 02, 2024

4

In February, 27-year-old man is seen for fever, myalgias, arthralgias, and headache of one-day duration. Two days before he became ill, he returned from a skiing vacation with friends in California.

They stayed in a cabin in the woods that had been uninhabited for many months. Rodent droppings were evident in the cabin when they arrived. He has been taking NSAIDS for muscle pain precipitated by skiing.

Exam is notable for fever and meningismus.

A CSF exam shows 400 white blood cells, 97% lymphocytes. The CSF protein is 98, and the glucose is 30 with simultaneous blood glucose of 88; Gram stain is negative.


Which one of the following is the most likely cause of his illness?

  • NSAID-induced aseptic meningitis

  • Lymphocytic choriomeningitis virus

  • Enterovirus

  • Hantavirus


A 25-year-old patient in excellent health was in a rural area five days ago when he developed right lower quadrant pain. A local emergency room diagnosed acute appendicitis by abdominal CT scan (appendiceal dilation and edema but no perforation) but elected to treat him with a 10-day course of amoxicillin-clavulanic acid since no surgeon was available.

The patient comes to you for advice since the Emergency Room team told him that follow up was mandatory.

Your radiologist reviews the film and confirms the diagnosis was in fact a non-perforated appendicitis.

WBC has fallen from 18000/mm3 with a neutrophilic predominance when the patient was first seen in the rural ER to 6000/mm3 with a normal differential in your office.

He is no longer symptomatic on day 5 of antibiotics.


Which of the following is the most appropriate management at this time?

  • Change therapy to ampicillin-sulbactam intravenously

  • Refer to surgery for emergent appendectomy

  • Complete the course of amoxicillin-clavulanic acid

  • Repeat CT scan


Mazen Kherallah
Mazen Kherallah
May 15, 2024

The gold standard therapy for non-perforated appendicitis is surgical excision, which can be done laparoscopically or by open procedure. (Nonperforated appendicitis is defined as acute appendicitis that presents without clinical or radiographic signs of perforation, specifically inflammatory mass or abscess). The surgical approach has many advantages e.g., confirms the diagnosis, identifies any perforation or peritonitis that was missed on imaging, and avoids the possibility of recurrent appendicitis.

The attitude towards medical management is changing for children, and this is affecting management of adults.

There is extensive literature on the use of medical therapy after CT confirmed appendicitis. 90% respond to medical management and 10% require rescue surgery, often due to persistent pain. However, 10-30% of patients have recurrent appendicitis, sometimes within two weeks of stopping antibiotics, but sometimes occurring as long as a year later. Thus, medical therapy can be an effective measure for non-perforated appendicitis in low risk patients.

High risk patients would include the elderly, the immunosuppressed, or patients with substantial comorbidities, although the exact definition of these groups in this context can be vague.

A perforated appendix always requires antibiotics and drainage. There are multiple factors that determine whether drainage should be surgical or by interventional radiology, and whether the surgery should be immediate, should follow a period of IV antimicrobial therapy or whether non-operative management (i.e., no removal of the appendix following the initial drainage) is appropriate.

You should know that medical therapy is a reasonable option for non-perforated appendicitis, understanding that CT with contrast often fails to recognize perforations, and that recurrent appendicitis is common following medical management.  

A 22-year-old sexually active woman who came to New York City two days ago from Puerto Rico is seen for bilateral ankle arthritis and nodules on the legs.

Her illness began two weeks ago with migratory pain involving both knees symmetrically which spontaneously resolved. She then developed bilateral ankle pain and swelling, which has persisted.

On exam, she has tender reddish-purple nodules over the anterior lower legs and clear evidence of bilateral ankle arthritis with effusions. Her CBC is normal. Chest x-ray shows hilar adenopathy.


Which one of the following is the most likely diagnosis?

  • Rheumatic fever

  • Dengue

  • Gonococcemia

  • Sarcoidosis


Mazen Kherallah
Mazen Kherallah
May 15, 2024

This patient has migratory arthritis which might make one think of disseminated gonorrhea since you are given gratuitous information about her sexual history. The key to this question is the hilar adenopathy and the skin lesions which are nodules rather than the petechial or pustular lesions typical of disseminated gonorrhea. Gonococcemia may be accompanied by arthritis which is not symmetrical and not associated with hilar adenopathy or erythema nodosum.

Lofgren’s Syndrome, a form of sarcoidosis, is characterized by the triad of hilar adenopathy, erythema nodosum and arthritis, typically of the lower extremities.

Rheumatic fever causes a migratory polyarthritis following streptococcal pharyngitis but is not associated with hilar adenopathy.

Dengue viral infection causes joint pain (and is sometimes called “break-bone fever” for that reason) and is endemic to Puerto Rico but does not cause erythema nodosum or hilar adenopathy.

Primary tuberculosis can cause hilar adenopathy without pulmonary infiltrate and erythema nodosum but not the bilateral arthritis seen here.

A 29-year-old woman has the rapid onset of ascending paralysis. Her CSF exam is normal except for an elevated protein (90 mg/dl). Two weeks before her weakness began, she had an influenza immunization. Ten days prior to the onset of weakness, she had a febrile gastroenteritis for which she received a fluoroquinolone. Her fever and diarrhea resolved after three days.


Which one of the following is the most likely related to her paralytic illness?

  • Influenza vaccine

  • Cytomegalovirus

  • Campylobacter

  • Mycoplasma


Mazen Kherallah
Mazen Kherallah
May 10, 2024

The most common cause of acute ascending neuromuscular paralysis is Guillain-Barré. The disease is symmetrical and slowly progressive from most distal to proximal. Lack of reflexes and dysautonomia are characteristic. There is no specific diagnostic test although the CSF often shows an elevated protein but normal cell counts (albuminocytologic dissociation).

Campylobacter is the most common and well-established infection associated with subsequent development of Guillain-Barré syndrome. Other infections that have been linked with this disease include HIV, CMV, and influenza. Zika virus infection has also been reported to cause Guillain-Barré syndrome. The presumptive mechanism of infection-related Guillain Barre syndrome is production of an antibody that cross-reacts with host peripheral nerve components because of shared epitopes (i.e., molecular mimicry).

An increased incidence of Guillain-Barré