Forwarded from Medical Ethiopia
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Forwarded from Medical collection (Dr. Abdulrhman Faisal)
Question of the week:
A 32-year-old woman with no notable medical history presents to the emergency department with pain in her back, left knee, and right ankle. She reports that the back pain began 3 weeks ago, frequently wakes her from sleep, is associated with stiffness in the morning, and improves with activity.
Her left knee and right ankle have become warm, swollen, and painful during the past week, impairing her ability to work. Naproxen at therapeutic levels provides only mild relief.
The patient also reports conjunctivitis and dysuria. She has multiple sexual partners who use condoms intermittently. She states that she does not experience fevers or rash.
Physical examination reveals moderate swelling in the left knee, warmth and redness of the right ankle, and tenderness at the right upper buttock.
Arthrocentesis of the knee effusion reveals cloudy synovial fluid containing 15,400 leukocytes per high-power field, with 85% neutrophils. Cultures of synovial fluid are negative.
Urine polymerase-chain-reaction testing is positive for Chlamydia trachomatis but negative for Neisseria gonorrhoeae.
A 32-year-old woman with no notable medical history presents to the emergency department with pain in her back, left knee, and right ankle. She reports that the back pain began 3 weeks ago, frequently wakes her from sleep, is associated with stiffness in the morning, and improves with activity.
Her left knee and right ankle have become warm, swollen, and painful during the past week, impairing her ability to work. Naproxen at therapeutic levels provides only mild relief.
The patient also reports conjunctivitis and dysuria. She has multiple sexual partners who use condoms intermittently. She states that she does not experience fevers or rash.
Physical examination reveals moderate swelling in the left knee, warmth and redness of the right ankle, and tenderness at the right upper buttock.
Arthrocentesis of the knee effusion reveals cloudy synovial fluid containing 15,400 leukocytes per high-power field, with 85% neutrophils. Cultures of synovial fluid are negative.
Urine polymerase-chain-reaction testing is positive for Chlamydia trachomatis but negative for Neisseria gonorrhoeae.
Which one of the following treatments is most appropriate for this patient?
Anonymous Poll
28%
Azithromycin
15%
Ceftriaxone
9%
Prednisone
37%
Azithromycin and indomethacin
11%
Methotrexate and prednisone
Answer for the 👆🏻: Azithromycin + Indomethacin
Reactive arthritis (formerly known as Reiter syndrome) is a spondyloarthritis, which classically manifests as arthritis, urethritis, and conjunctivitis. Uveitis, fever, and other constitutional symptoms are also common features, as are acute pustular skin lesions known as keratoderma blennorrhagica.
However, in more than 50% of affected patients, extra-articular manifestations are absent. Joint involvement, typically oligoarticular and asymmetric, may involve the spine (most frequently the sacroiliac joints).
Causative pathogens include Chlamydia trachomatis and enteric bacteria, such as Salmonella, Shigella, Yersinia, Campylobacter, and Clostridioides difficile. Treatment involves eradicating the pathogen if there is evidence of ongoing infection, but in many cases, the precipitating infection has resolved before arthritis develops. In this patient, azithromycin treats the active chlamydial infection.
Nonsteroidal antiinflammatory drug (NSAID) therapy is the first choice for control of arthritis, and it is not uncommon for more than one NSAID to be tried in an attempt to find an effective agent.
Systemic or intra-articular glucocorticoids are indicated if NSAIDs are ineffective. Average disease duration is 3 to 6 months.
In the up to 20% of patients with reactive arthritis who have arthritis that persists beyond several months, disease-modifying antirheumatic drugs, such as methotrexate, can be considered.
Prolonged antibiotic treatment (with rifampin plus azithromycin or doxycycline) may benefit patients who have refractory, Chlamydia-induced reactive arthritis, particularly if there is evidence for persistence of bacteria in an attenuated form.
However, testing for such persistent infection by polymerase chain reaction of synovial tissue is not generally available.
Source: NEJM
Last reviewed Sep 2019. Last modified Jul 2019.
Reactive arthritis (formerly known as Reiter syndrome) is a spondyloarthritis, which classically manifests as arthritis, urethritis, and conjunctivitis. Uveitis, fever, and other constitutional symptoms are also common features, as are acute pustular skin lesions known as keratoderma blennorrhagica.
However, in more than 50% of affected patients, extra-articular manifestations are absent. Joint involvement, typically oligoarticular and asymmetric, may involve the spine (most frequently the sacroiliac joints).
Causative pathogens include Chlamydia trachomatis and enteric bacteria, such as Salmonella, Shigella, Yersinia, Campylobacter, and Clostridioides difficile. Treatment involves eradicating the pathogen if there is evidence of ongoing infection, but in many cases, the precipitating infection has resolved before arthritis develops. In this patient, azithromycin treats the active chlamydial infection.
Nonsteroidal antiinflammatory drug (NSAID) therapy is the first choice for control of arthritis, and it is not uncommon for more than one NSAID to be tried in an attempt to find an effective agent.
Systemic or intra-articular glucocorticoids are indicated if NSAIDs are ineffective. Average disease duration is 3 to 6 months.
In the up to 20% of patients with reactive arthritis who have arthritis that persists beyond several months, disease-modifying antirheumatic drugs, such as methotrexate, can be considered.
Prolonged antibiotic treatment (with rifampin plus azithromycin or doxycycline) may benefit patients who have refractory, Chlamydia-induced reactive arthritis, particularly if there is evidence for persistence of bacteria in an attenuated form.
However, testing for such persistent infection by polymerase chain reaction of synovial tissue is not generally available.
Source: NEJM
Last reviewed Sep 2019. Last modified Jul 2019.
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Question of the week.
A 73-year-old woman with a history of hypertension and chronic obstructive pulmonary disease presents to the emergency department with red streaking on her right arm.
She grazed the arm 2 days ago and stopped minimal bleeding from the wound by applying local pressure. She reports a fever of 38.7°C.
She has a platelet count of 243,000 per mm³ (reference range, 150,000–350,000). She is started on intravenous vancomycin and ceftriaxone. She is then hospitalized, improves quickly, and is discharged on day 3.
Five days after discharge, the patient notices a petechial rash on her legs and presents again for evaluation.
A complete blood count reveals these results: hemoglobin 11.4 g/dL (reference range, 12.0–16.0), leukocytes 4200 per mm³ (4500–11,000), platelets 18,000 per mm³ (150,000–350,000), and a normal fibrinogen level.
Review of the peripheral-blood smear reveals marked reduction of the platelet count, but normal platelet morphology. No schistocytes are present.
A 73-year-old woman with a history of hypertension and chronic obstructive pulmonary disease presents to the emergency department with red streaking on her right arm.
She grazed the arm 2 days ago and stopped minimal bleeding from the wound by applying local pressure. She reports a fever of 38.7°C.
She has a platelet count of 243,000 per mm³ (reference range, 150,000–350,000). She is started on intravenous vancomycin and ceftriaxone. She is then hospitalized, improves quickly, and is discharged on day 3.
Five days after discharge, the patient notices a petechial rash on her legs and presents again for evaluation.
A complete blood count reveals these results: hemoglobin 11.4 g/dL (reference range, 12.0–16.0), leukocytes 4200 per mm³ (4500–11,000), platelets 18,000 per mm³ (150,000–350,000), and a normal fibrinogen level.
Review of the peripheral-blood smear reveals marked reduction of the platelet count, but normal platelet morphology. No schistocytes are present.
Which one of the following conditions is the most likely cause of this patient's thrombocytopenia?
Anonymous Quiz
43%
Drug-induced thrombocytopenia
20%
Thrombotic thrombocytopenic purpura
16%
Disseminated intravascular coagulation
10%
Immune thrombocytopenia
11%
Folate deficiency
Key Learning Point
In an inpatient who has received vancomycin and ceftriaxone, the most likely cause of a new thrombocytopenia that develops during or shortly after hospitalization is drug-induced thrombocytopenia.
Detailed Feedback
Thrombocytopenia is a common laboratory abnormality in hospitalized patients. Perhaps the most common etiology is drug-induced thrombocytopenia.
More than 100 agents have been implicated in drug-induced thrombocytopenia; among those most frequently cited are heparin, quinine, and some antibiotics.
In a large case series of vancomycin-treated patients who then developed thrombocytopenia, vancomycin-dependent platelet-reactive antibodies were identified.
Immune thrombocytopenia is unlikely to develop this acutely during or shortly after hospitalization in a patient who presents with a normal platelet count.
Disseminated intravascular coagulation is possible but unlikely in a patient who is improving clinically.
Folate deficiency is a cause of thrombocytopenia but would not cause thrombocytopenia that developed acutely.
Thrombotic thrombocytopenic purpura has a classic pentad: fever, acute kidney failure, thrombocytopenia, microangiopathic hemolytic anemia, and altered mental status.
Source: NEJM, Dec 2020.
In an inpatient who has received vancomycin and ceftriaxone, the most likely cause of a new thrombocytopenia that develops during or shortly after hospitalization is drug-induced thrombocytopenia.
Detailed Feedback
Thrombocytopenia is a common laboratory abnormality in hospitalized patients. Perhaps the most common etiology is drug-induced thrombocytopenia.
More than 100 agents have been implicated in drug-induced thrombocytopenia; among those most frequently cited are heparin, quinine, and some antibiotics.
In a large case series of vancomycin-treated patients who then developed thrombocytopenia, vancomycin-dependent platelet-reactive antibodies were identified.
Immune thrombocytopenia is unlikely to develop this acutely during or shortly after hospitalization in a patient who presents with a normal platelet count.
Disseminated intravascular coagulation is possible but unlikely in a patient who is improving clinically.
Folate deficiency is a cause of thrombocytopenia but would not cause thrombocytopenia that developed acutely.
Thrombotic thrombocytopenic purpura has a classic pentad: fever, acute kidney failure, thrombocytopenia, microangiopathic hemolytic anemia, and altered mental status.
Source: NEJM, Dec 2020.