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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:


Nader Guma
Manar  Ismail

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.

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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…


Mazen Kherallah
Nader Guma
Mizba Baksh

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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


Nader Guma
Amna Khan

A 59-year-old male is being treated for MSSA sternal osteomyelitis after undergoing coronary artery bypass grafting. He has been home receiving outpatient parenteral antimicrobial therapy (OPAT) with IV oxacillin.

Two weeks after discharge, fever develops. On OPAT laboratory surveillance, the following results are noted:

  • WBC: 18.4

  • Neutrophils: 32%

  • Eosinophils: 18%

  • HCT: 31.3


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


Harsh Sura

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.  

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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


Nader Guma
Harsh Sura

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.

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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


Nader Guma

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 followed influenza immunization for swine flu in 1976-77. Subsequent studies have not confirmed an association between influenza vaccine and Guillain-Barre syndrome. Quinolones may produce a variety of neuropsychiatric side effects, but not Guillain-Barré.

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A 65-year-old man is seen for pneumonia. He has had a non-productive cough, fever, headache, and anorexia for five days.

He says two friends currently are hospitalized for pneumonia at another institution. The last time he saw his hospitalized friends was three weeks ago when they gathered with two other friends to have dinner at a friend’s rural home. Now three of 6 individuals at that gathering have acute, febrile pneumonias.

He remembers the evening well because the family cat gave birth to a litter in the same room during the dinner.

  • T 102.2°F; P 70; BP128/88; RR 28.

  • Chest clear.

  • WBC 6,200 with normal differential.


Nader Guma
Mazen Kherallah

The incubation period for Q Fever (Coxiella burnettii) is usually 14-22 days (range 9-39 days) while Legionella is shorter (2-10 days). Listeria and Brucella don’t cause pneumonia typically, so they don’t fit although Brucella has an incubation period similar to Q fever. The cluster and incubation period do not fit pneumococcal disease.

Humans acquire Q Fever pneumonia due to Coxiella burnetii by inhaling infected aerosols from animals, particularly cattle, goats and sheep, but also cats, dogs, and rabbits. In infected animals, high concentrations of Coxiella are found in the placenta, so aerosols at the time of parturition are often the source of human infection. The incubation period is about 3 weeks. Simultaneous pneumonia and hepatitis should always raise the possibility of Q fever. Thrombocytopenia and a temperature-pulse disparity are common.

The above scenario is based on a well-known outbreak published many years ago that question writers might remember!

Common source outbreaks of pneumococcal pneumonia are rare and usually seen with severe crowding as in jail settings.

Legionella can cause pneumonia, hepatitis, and a temperature-pulse disparity, but the incubation period here is too long and most patients with Legionnaire’s have leukocytosis.

@Everyone

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A 43-year-old male teacher, previously in good health, presents with 4 days of fever and a sudden onset of headache, altered consciousness, and hemiparesis. There is no obvious source of the fever, and the patient has no known risk factors such as HIV infection or intravenous drug abuse.

In the Emergency Room a CT scan and then a CT angiogram is ordered and a ruptured middle cerebral aneurysm is found which is described by the radiologist as “mycotic” based on its location and the characteristics of its wall.


Pending neurosurgical intervention and cultures, the antibiotic(s) most likely to be active against the causative organism is/are:

  • Fluconazole

  • Liposomal Amphotericin B

  • Vancomycin

  • Ciprofloxacin plus gentamicin


Harsh Sura
Mazen Kherallah
Nader Guma

Which of the following is the most likely indication of extension of a mycotic aneurysm of the sinus of Valsava (i.e., interventricular septal abscess development) in a patient with native valve S. aureus aortic valve endocarditis?



Harsh Sura
Nader Guma
Mazen Kherallah

@Everyone

These EKGs show the following patterns:

A) A-V Block

B) Atrial Fibrillation

C) Ventricular Fibrillation

D) Sinus tachycardia

When the infectious process of endocarditis spreads beyond the valve leaflets, mycotic aneurysm of the sinus of Valsalva may form, which can rupture into the interventricular septum and injure the AV node, leading to complete heart block.

Although mycotic aneurysms of the sinus of Valsalva can involve other coronary cusps, rupture into the septum most often results from aneurysms in the noncoronary cusp.

Transesophageal echocardiogram is the most reliable imaging technique to detect aneurysms of the sinus of Valsalva. Surgical repair of a ruptured mycotic aneurysm, usually with aortic valve replacement, can be lifesaving.

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Nader Guma