In this fourth edition of Anatomy, Histology, and Cell Biology: PreTest® Pediatrics: PreTest™ Self-Assessment and Review, Twelfth Edition, Atlas of Emergency. Pediatric Neuro – Imaging Sixth Edition 6e eBook PDF Free Download · CLINICAL SUBJECTS. First Aid for the Pediatrics Clerkship. Pediatrics: PreTest™ Self-Assessment and Review, Twelfth Edition, provides .. An 8-month-old infant arrives to the emergency department (ED) with a 2-day.
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Choose an Option Add to Cart. Format eBook e-Books A growing number of textbooks…. Print Printed books Traditional printed books available in…. Description Details Publisher's Note: Prep for the Shelf Exam, Ace the Clerkship! Contents 1. General Pediatrics 2. A year-old female presents to her internist with a 2-day history of low-grade fever and lower abdominal pain.
She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of Bowel sounds are normal.
Pediatrics PreTest Self-Assessment And Review, 14th Edition
On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Which of the following is the best next step in management? Treatment with ceftriaxone and doxycycline Endometrial biopsy Surgical exploration Dilation and curettage Aztreonam A year-old male 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. Examination of the heart, chest, abdomen, and skin show no additional abnormalities. There is no lymphadenopathy. The patient lives in upstate New York and returned from a camping trip a few weeks before noting the rash.
A 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.
A 3-day regimen of trimethoprim-sulfamethoxazole is adequate therapy. Quantitative urine culture with antimicrobial sensitivity testing is mandatory. Obstruction resulting from renal stone should be ruled out by ultrasound.
Low-dose antibiotic therapy should be prescribed while the patient remains sexually active. The etiologic agent is more likely to be sensitive to trimethoprim-sulfamethoxazole than to fluoroquinolones.
A year-old woman is admitted with fever and hypotension. She has a 3-day history of feeling feverish. She has no history of chronic disease, but she uses tampons for heavy menses. She is acutely ill and, on physical examination, found to have a diffuse erythematous rash extending to palms and soles.
She is confused. Acute bacteremia Toxin-mediated inflammatory response syndrome Exacerbation of connective tissue disease Tick-borne rickettsial disease Allergic reaction Infectious Disease 7 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? Give the influenza vaccine to all residents who do not have a contraindication to the vaccine ie, allergy to eggs. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give oseltamivir for 2 weeks to all residents. Give amantadine alone to all residents.
Give azithromycin to all residents to prevent influenza-associated pneumonia. Do not give any prophylactic regimen. A year-old male 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 L vertebra and paraspinal muscle spasm. Hematogenous osteomyelitis rarely involves the vertebra in adults.
The most likely initial focus of infection was soft tissue. Blood cultures will be positive in most patients with this process. An MRI scan is both sensitive and specific in defining the process. Surgery will be necessary if the patient has osteomyelitis. A year-old male with sickle cell anemia is admitted with cough, rusty sputum, and a single shaking chill. Physical examination reveals increased tactile fremitus and bronchial breath sounds in the left posterior chest.
The patient is able to expectorate a purulent sample. Which of the following best describes the role of sputum Gram stain and culture? Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae.
Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary. There is no characteristic Gram stain in a patient with pneumococcal pneumonia. Gram-positive cocci in clusters suggest pneumococcal infection. A recent outbreak of severe diarrhea is currently being investigated.
Several adolescents developed bloody diarrhea, and one remains hospitalized with acute renal failure. A preliminary investigation has determined that all the affected ate at the same restaurant.
The food they consumed was most likely to be which of the following? Pork chops Hamburger Gefilte fish Sushi Soft-boiled eggs A year-old female nurse was admitted to the hospital because of fever to Despite a thorough workup in the hospital for over 3 weeks, no etiology has been found, and she continues to have temperature spikes greater than Which of the following statements about diagnosis is correct?
Chronic infection, malignancy, and collagen vascular disease are the most common explanations for this presentation. Influenza may also present in this manner. Lymphoma can be ruled out in the absence of palpable lymphadenopathy. SLE is an increasing cause for this syndrome.
Factitious fever should be considered only in the patient with known psychopathology. A year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products.
Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. What further diagnostic test is most likely to be helpful? A previously healthy year-old music teacher develops fever and a rash over her face and chest. The rash is itchy and, on examination, involves multiple papules and vesicles in varying stages of development. One week later, she complains of cough and is found to have an infiltrate on x-ray.
Which of the following is the most likely etiology of the infection? Streptococcus pneumoniae Mycoplasma pneumoniae Histoplasma capsulatum Varicella-zoster virus Chlamydia psittaci A year-old male complains of fever and shortness of breath.
There is no pleuritic chest pain or rigors and no sputum production. A chest x-ray shows diffuse perihilar infiltrates. The patient worsens while on erythromycin. A methenamine silver stain shows cystlike structures. Which of the following is correct? Definitive diagnosis can be made by serology.
The organism will grow after 48 h. History will likely provide important clues to the diagnosis. Cavitary disease is likely to develop.
The infection will not recur. A year-old woman cut her finger while cooking in her kitchen. Two days later she became rapidly ill with fever and shaking chills. Her hand became painful and mildly erythematous. Later that evening her condition deteriorated as the erythema progressed and the hand became a dusky red. Bullae and decreased sensation to touch developed over the involved hand.
What is the most important next step in the management of this patient? Surgical consultation and exploration of the wound Treatment with clindamycin for mixed aerobic-anaerobic infection Treatment with penicillin for clostridia infection Vancomycin to cover community-acquired methicillin-resistant Staphylococcus Evaluation for acute osteomyelitis 10 Medicine A year-old male from East Tennessee had been ill for 5 days with fever, chills, and headache when he noted a rash that developed on his palms and soles.
In addition to macular lesions, petechiae are noted on the wrists and ankles. The patient has spent the summer camping. Which of the following is the most important fact to be determined in the history?
Exposure to contaminated springwater Exposure to raw pork Exposure to ticks Exposure to prostitutes Exposure to mosquitos On physical examination, the foot and leg are fiery red with a welldefined indurated margin that appears to be rapidly advancing.
There is tender inguinal lymphadenopathy. The most likely organism to cause this infection is which of the following? Staphylococcus epidermidis Tinea pedis Streptococcus pyogenes Mixed anaerobic infection Alpha-hemolytic streptococci An year-old male has been seen in the clinic for urethral discharge.
He is treated with ceftriaxone, but the discharge has not resolved and the culture has returned as no growth. Which of the following is the most likely etiologic agent to cause this infection? Ceftriaxone-resistant gonococci Chlamydia psittaci Chlamydia trachomatis Herpes simplex Chlamydia pneumoniae Infectious Disease 11 A year-old nursing home resident was admitted to the hospital for pneumonia and treated for 10 days with levofloxacin.
On discharge she was improved but developed diarrhea one week later. She had low-grade fever and mild abdominal pain with 2 to 3 watery, nonbloody stools per day. A cell culture cytotoxicity test for Clostridium difficile—associated disease was positive. The patient was treated with oral metronidazole, but did not improve, even after 10 days.
Diarrhea has increased and fever and abdominal pain continue. What is the best next step in the management of this patient? Obtain C difficile enzyme immunoassay. Continue metronidazole for at least two more weeks. Switch treatment to oral vancomycin. Hospitalize patient for fulminant C difficile—associated disease. Use synthetic fecal bacterial enema. A college wrestler develops cellulitis after abrading his skin during a match.
He is afebrile and appears well but his arm is red and swollen with several draining pustules. Gram stain of the pus shows gram-positive cocci in clusters. The patient will require hospital admission and treatment with vancomycin. The organism will almost always be sensitive to oxacillin. The organism is likely to be sensitive to trimethoprim-sulfamethoxazole. Community-acquired methicillin-resistant staphylococci have the same sensitivity pattern as hospital-acquired methicillin-resistant staphylococci.
The infection is likely caused by streptococci. A year-old male with documented HIV disease has completed his initial evaluation. His physical examination has shown no evidence of opportunistic infection. Which of the following is best advice? The patient should begin treatment with either two nucleoside analogues and nonnucleoside reverse transcriptase inhibitor or two nucleoside analogues and a protease inhibitor.
The patient should make his own decision on beginning therapy since time of initiation does not affect mortality in an asymptomatic patient. The patient should consider beginning new antiviral agents such as raltegravir or maraviroc. Any new regimen should avoid abacavir because of its high incidence of hypersensitivity reactions.
A businessman traveling around the world asks about prevention of malaria. He will travel to India and the Middle East and plans to visit several small towns.
What is the most appropriate advice for the traveler? Common sense measures to avoid malaria such as use of insect repellants, bed nets, and suitable clothing have not really worked in preventing malaria.
Prophylaxis should be started the day of travel. Chemoprophylaxis has been proven to be entirely reliable. Questions 30 to 33 Match the clinical description with the most likely organism. Each lettered option may be used once, more than once, or not at all. Streptococcus pneumoniae Staphylococcus aureus Viridans streptococci Providencia stuartii Actinomyces israelii Haemophilus ducreyi Neisseria meningitidis Listeria monocytogenes A year-old female with mitral valve prolapse and mitral regurgitant murmur develops fever, weight loss, and anorexia after undergoing a dental procedure.
An year-old male, hospitalized for hip fracture, has a Foley catheter in place when he develops shaking chills, fever, and hypotension. A young man develops a painless, fluctuant purplish lesion over the mandible. A cutaneous fistula is noted after several weeks. A year-old man who had a splenectomy after a childhood accident develops shaking chills and dies within 8 hours from refractory hypotension and respiratory failure.
Infectious Disease 13 Questions 34 to 36 Select the fungal agent most likely responsible for the disease process described. Histoplasma capsulatum Blastomyces dermatitidis Coccidioides immitis Cryptococcus neoformans Candida albicans Aspergillus fumigatus Zygomycosis A young, previously healthy male presents with verrucous skin lesions, bone pain, fever, cough, and weight loss.
Chest x-ray shows nodular infiltrates. A diabetic patient is admitted with elevated blood sugar and acidosis. The patient complains of headache and sinus tenderness and has black, necrotic material draining from the nares.
A young woman presents with asthma and eosinophilia. Fleeting pulmonary infiltrates occur with bronchial plugging. Herpes simplex virus Epstein-Barr virus Parvovirus B19 Staphylococcus aureus Neisseria meningitidis Listeria monocytogenes Streptococcus viridans Haemophilus influenzae Mother of a 5-year-old with sore throat and slapped-cheek rash also develops rash and arthralgia of small joints of the hand.
A year-old menstruating female has multisystem disease with hypotension, diffuse erythematous rash with desquamation of skin on hands and feet.
An year-old college student presents with fever, neck stiffness, and petechiae on his trunk. A year-old has a sore throat and develops a diffuse rash after administration of ampicillin. Infectious Disease 15 Questions 41 to 45 Match the clinical description with the most likely etiologic agent. Candida albicans Aspergillus flavus Coccidioides immitis Herpes simplex type 1 Herpes simplex type 2 Hantavirus Tropheryma whippelii Coxsackievirus B Histoplasma capsulatum Human parvovirus Cryptococcus neoformans An HIV-positive patient develops fever and dysphagia; endoscopic biopsy shows yeast and hyphae.
A year-old develops sudden onset of bizarre behavior. CSF shows 80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities. A patient with a previous history of tuberculosis now complains of hemoptysis. There is an upper lobe mass with a cavity and a crescent-shaped air-fluid level. A Filipino patient develops a pulmonary nodule after travel through the American Southwest.
A year-old male who had a fever, cough, and sore throat develops chest pain after several days, with diffuse ST-segment elevations on ECG. Infectious Disease Answers 1. The answer is c. Fauci, pp This 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. The 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. The most likely organism causing this infection is H influenzae. 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.
The answer is a. 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. This 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. The answer is b. 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 condylomata lata, are specific for secondary syphilis.
The VDRL slide test will be positive in all patients with secondary syphilis. The Weil-Felix titer has been used as a screening test for rickettsial infection. In this patient, who has condylomata and no systemic symptoms, Rocky Mountain spotted fever would be unlikely. No chlamydial infection would present in this way. Blood cultures might be 16 Infectious Disease Answers 17 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. Fauci, pp , 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, and the CSF Gram stain confirms S pneumoniae as the etiologic agent. 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 is a common problem 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 monocytogenes 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. Gram stain of meningococci would show gram-negative diplococci. Because the patient has no papilledema and no focal neurologic findings, treatment should not be delayed to obtain an MRI scan. This young woman presents with symptoms of both upper and lower respiratory infection.
The combination of sore throat, bullous myringitis, and infiltrates on chest x-ray is consistent with infection caused by M pneumoniae. This minute organism is not seen on Gram stain. Neither S pneumoniae nor H influenzae would produce this combination of upper and lower respiratory tract symptoms.
The patient is likely to have high titers of IgM cold agglutinins and a positive complement fixation test for mycoplasma.
The low hematocrit and elevated reticulocyte count reflect a hemolytic anemia that can occur from Mycoplasma infection. These IgM-class antibodies are directed to the I antigen on the erythrocyte membrane.
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Adenovirus can cause upper respiratory symptoms, but pneumonia and bullous myringitis would be unusual with a viral infection. The methenamine silver stain is used for fungi and pneumocystis; these organisms 18 Medicine do not cause bullous myringitis. Mycoplasma does not grow on blood or routine sputum cultures. The patient is high risk for tuberculosis due to his history of incarceration and homelessness.
The location of the infiltrate in the upper lobe, as well as the formation of a cavity, further suggests reactivation tuberculosis. Sputum smear and culture for AFB are mandatory. The patient requires respiratory isolation precautions in a negative pressure room, not contact precautions.
Anaerobic infection would be in the differential diagnosis of upper lobe infiltrate with cavity formation, but evaluation for tuberculosis is critical because of the risk of person-to-person spread.
Single drug therapy with INH is a good prophylactic regimen but is inappropriate until active TB is excluded. Monotherapy for active TB leads to the rapid development of drug resistance. The pneumococcus rarely causes cavitary pneumonia. This young man presents with classic signs and symptoms of infectious mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed.
The symptoms described in association with atypical lymphocytes and a positive heterophile test are virtually always caused by Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients. Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. The history and physical examination suggest amebic liver abscess.
Symptoms usually occur 2 to 5 months after travel to an endemic area. Diarrhea usually occurs first but has usually resolved before the hepatic symptoms develop. The most common presentation for an amebic liver abscess is abdominal pain, usually RUQ.
Stool will not show the trophozoite at this stage of the disease process. Aspiration is not necessary unless rupture of abscess is imminent. Metronidazole remains the drug of choice for amebic liver abscess. A painful vesicular rash in a dermatomal distribution strongly suggests herpes zoster, although other viral pathogens may also cause vesicles. Herpes zoster may involve the eyelid when the first or second branch of the fifth cranial nerve is affected. It often involves the face and can occur after an abrasion of the skin.
Its distribution is not dermatomal, and while it may cause vesicles, they are usually small and are not weeping fluid. Chickenpox produces vesicles in various stages of development that are diffuse and produce more pruritus than pain.
Coxsackievirus can produce a morbilliform vesiculopustular rash, often with a hemorrhagic component and with lesions of the throat, palms, and soles. Herpes simplex virus causes lesions of the lip herpes labialis and also does not spread in a dermatomal pattern. This patient presents with the clinical picture of pelvic inflammatory disease PID , including lower quadrant tenderness, cervical motion tenderness, and adnexal tenderness.
Fever and mucopurulent discharge are additional evidence for the diagnosis. Treatment requires antibiotic therapy. Ceftriaxone and doxycycline are one recommended regimen that would cover both Neisseria gonorrhoeae and C trachomatis.
Endometrial biopsy can provide definitive diagnosis, but it is unnecessary except when patients do not respond to therapy or have atypical presentations. Dilation and curettage, a more invasive procedure, would rarely be necessary.
At times, surgical emergencies may mimic PID and even require hospitalization for further observation. The specific findings of cervical motion tenderness, discharge, and bilateral tenderness all distinguish PID from appendicitis in this patient.
Aztreonam has good gram-negative coverage but does not adequately cover the sexually transmitted pathogens. 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 20 Medicine be unilateral as in this case or bilateral. Sarcoidosis can cause facial palsy, but there are no other signs or symptoms 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. 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 trimethoprim-sulfamethoxazole is recommended. 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 3 or more per year urinary tract infections. Fluoroquinolones have a better spectrum of activity than trimethoprimsulfamethoxazole but are reserved for more serious or recurrent infections.
The disease process described is most consistent with toxic shock syndrome, an inflammatory response syndrome characterized by hypotension, fever, and multiorgan involvement. It can occur in healthy women who use tampons.
TSST-1 is a toxin produced by S aureus that is responsible for activating superantigens such as tumor necrosis factor and interleukin Symptoms include confusion, as has occurred in this patient, in addition to diarrhea, myalgias, nausea and vomiting, and syncope.
In addition to fever and hypotension there is a diffuse rash initially appearing on the trunk but spreading to palms of the hands and soles of the feet. Desquamation occurs a week after initial appearance of the rash. There are many potential laboratory abnormalities as manifestations of multiorgan involvement. These include azotemia, coagulopathy with abnormal aPTT, and electrolyte abnormalities, including hyponatremia, hypocalcemia, and hypokalemia.
Liver function tests show hyperbilirubinemia and elevated alanine aminotransferase.
Infectious Disease Answers 21 The disease is not a bacteremia, although it is precipitated by localized staphylococcal or sometimes streptococcal infection. Toxic shock syndrome sometimes mimics diseases that cause multiorgan involvement, such as systemic lupus or Rocky Mountain spotted fever.
Serological studies for these diseases were negative in this patient. An allergic reaction would cause urticaria and would not account for the fever and the electrolyte abnormalities.
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 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. The answer is d. The presentation strongly suggests vertebral osteomyelitis. The vertebrae are a common site for hematogenous osteomyelitis.
Prior urinary tract infection is often the primary mechanism for bacteremia and vertebral seeding. MRI is sensitive and specific for the diagnosis of vertebral osteomyelitis and is the diagnostic procedure of choice. Blood cultures at the time of presentation are positive in less than half of all cases. Treatment requires 6 to 8 weeks of antibiotics, but surgery is rarely required for cure.
This is particularly important in the era of multiantibiotic-resistant S pneumoniae. Sputum culture and sensitivity can direct specific antibiotic therapy for the patient as well as provide epidemiologic information for the community as a whole. A good sputum sample showing many polymorphonuclear leukocytes and few squamous epithelial cells can give important clues to etiology.
A Gram stain that shows gram-positive lancet-shaped diplococci intracellularly is good evidence for pneumococcal infection. Gram-positive cocci in clusters would suggest staphylococcal infection, which would be uncommon in this 22 Medicine setting.
Empirical antibiotic therapy becomes more difficult in communityacquired pneumonia as more pathogens are recognized and as the pneumococcus develops resistance to penicillin, macrolides, and even quinolones. The outbreak described is similar to those caused by Escherichia coli H7. Ingestion of and infection with this organism may result in a spectrum of illnesses, including mild diarrhea, hemorrhagic colitis with bloody diarrhea, acute renal failure, and hemolytic uremic syndrome.
Infection has been associated with ingestion of contaminated beef in particular ground beef , ingestion of raw milk, and contamination via the fecal-oral route. Cooking ground beef until it is no longer pink is an effective means of preventing infection, as are hand washing and pasteurization of milk.
Patients may develop fever as a result of infectious or noninfectious diseases. The term fever of unknown origin FUO is applied when significant fever persists without a known cause after an adequate evaluation. Several studies have found the leading causes of FUO to include infections, malignancies, collagen vascular diseases, and granulomatous diseases. As the ability to more rapidly diagnose some of these diseases increases, their likelihood of causing undiagnosed persistent fever lessens.
Infections such as intra-abdominal abscesses, tuberculosis, hepatobiliary disease, endocarditis especially if the patient had previously taken antibiotics , and osteomyelitis may cause FUO.
In immunocompromised patients, such as those infected with HIV, a number of opportunistic infections or lymphomas may cause fever and escape early diagnosis.
Self-limited infections such as influenza should not cause fever that persists for many weeks. Neoplastic diseases such as lymphomas and some solid tumors eg, hypernephroma and primary or metastatic disease of the liver are associated with FUO.
A number of collagen vascular diseases may cause FUO. Since conditions such as systemic lupus erythematosus are more easily diagnosed today, they are less frequent causes of this syndrome.
Adult Still disease, however, is often difficult to diagnose. Other causes of FUO include granulomatous diseases ie, giant cell arteritis, regional enteritis, sarcoidosis, and granulomatous hepatitis , drug fever, and peripheral pulmonary emboli. Factitious fever is most common among young adults employed in healthrelated positions.
A prior psychiatric history or multiple hospitalizations at other institutions may be clues to this condition.
Such patients may induce infections Infectious Disease Answers 23 by self-injection of nonsterile material, with resultant multiple abscesses or polymicrobial infections. Alternatively, some patients may manipulate their thermometers.
In these cases, a discrepancy between temperature and pulse or between oral temperature and witnessed rectal temperature will be observed. This patient has evidence for acute hepatitis as is suggested by the history, physical examination and laboratory data showing hepatocellular injury. The incubation period of about one month is also typical.
Hepatitis B and C are less likely without evidence for drug abuse or blood transfusion. Antibody to hepatitis B surface antigen would not be evidence for acute hepatitis B. HCV RNA is the appropriate test for acute hepatitis C infection, but this disease typically causes mild transaminase elevation and rarely presents with icterus.. Liver biopsy is not indicated in acute hepatitis as the diagnosis is usually apparent from the examination, liver enzymes, and serological evidence of recent viral infection.
Abdominal ultrasound would not be helpful as liver enzymes suggest hepatocellular damage, not biliary obstruction. It occurs 3 to 7 days after the onset of the rash. The hallmarks of the chickenpox rash are papules, vesicles, and scabs in various stages of development. Fever, malaise, and itching are usually part of the clinical picture. The differential can include some coxsackievirus and echovirus infections, which might present with pneumonia and vesicular rash.
Rickettsialpox, a rickettsial infection, has also been mistaken for chickenpox. Although the pneumococcus, Mycoplasma, and Chlamydia are common causes of community-acquired pneumonia in young adults, they would not account for the preceding vesicular rash. Histoplasmosis can cause acute pneumonitis after a large exposure but would not account for the rash. Patients with Pneumocystis jiroveci formerly carinii frequently present with shortness of breath and no sputum production.
The interstitial pattern of infiltrates on chest x-ray distinguishes the pneumonia from most bacterial infections. Diagnosis is made by review of methenamine silver stain. Serology is not sensitive or specific enough for routine use. The organism does not grow on any media. Cavitation can occur particularly in those who have received aerosolized pentamidine but 24 Medicine is quite unusual.
The history is likely to suggest a risk factor for HIV disease. Fauci p. The striking features of this infection are its rapid onset and progression to a cellulitis characterized by dusky dark red erythema, bullae formation, and anesthesia over the area. These are clues to necrotizing fasciitis, a rapidly spreading deep soft tissue infection.
The organism, usually S pyogenes, reaches the deep fascia from the site of penetrating trauma. Prompt surgical exploration down to fascia or muscle may be lifesaving.
Necrotic tissue is Gram stained and cultured—streptococci, staphylococci, mixed anaerobic infection, or clostridia are all possible pathogens. Antibiotics to cover these organisms are important but not as important as prompt surgical debridement.
Acute osteomyelitis is considered when cellulitis does not respond to antibiotic therapy, but would not present with this rapidity. The rash of Rocky Mountain spotted fever RMSF occurs about 5 days into an illness characterized by fever, malaise, and headache.
The rash may be macular or petechial, but almost always spreads from the ankles and wrists to the trunk. The disease is most common in spring and summer. North Carolina and East Tennessee have a relatively high incidence of disease. RMSF is a rickettsial disease with the tick as the vector.The patient has anaerobic infection and needs outpatient clindamycin therapy.
Doxycycline is considered the drug of choice, but chloramphenicol is preferred in pregnancy because of the effects of tetracycline on fetal bones and teeth.
Ceftriaxone and doxycycline are one recommended regimen that would cover both Neisseria gonorrhoeae and C trachomatis.
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