Case presentation: A 48 year-old male cyclist travels to new england for a race. Afterwards he is sore, tired and fatigued, but 1 week later back in Colorado he is still sore, tired, and fatigued, and he also noticed a rash that started after a few days. The patient presents to the ED after a syncope with HR in the low 40s.
This patient has Lyme Disease. Hallmarked by the rash that he has, known as erythema migrans – a migrating red rash.
Symptoms usually present 1-2 weeks after a tick bite, and generally start as nonspecific – fever, myalgias, headache, arthralgias, malaise. 80% of patients present with the rash that starts as a small red lesion that enlarges with a bright red border.
A smaller percentage of patient get early disseminated disease. The most concerning complications are cardiac – Atrioventricular Block, bradycardia, and syncope – or a meningitis presentation.
Late disseminated findings include chronic joint and muscle arthralgias, seizures, paresthesias, memory and cognitive changes. Amy Tan – author of The Joy Luck Club – has chronic lyme and she loses memory if she is off her antibiotics for any period of time.
Lyme Disease is increasing by more than 10% per year for several years due to the destruction of habitat of predators, leading to mice population explosion, and global warming.
Each stage of the tick life cycle require a blood meal – larva to nymph to adult. Normally larva find it hard to get a blood meal in the fall after they hatch in the late summer. The larva go dormant until spring when they are able to find a blood meal and eventually become adults so the life cycle can start over on an annual basis.
As the climate has warmed a higher percentage of larvae are feeding earlier in the year, with a greater frequency in the New England area.
The bacteria that causes Lyme Disease needs time to replicate in the host, but due to asynchronous feeding between the mice and ticks there is a higher concentration of the bacteria in both the mice and the ticks.
Presentation: A fever and nasal congestion that began in an infant one week ago but has resolved. A rash that was predominantly over the cheeks but has spread to the rest of the body. No pain with the rash, just blistering.
Diagnosis: Fifth disease or erythema infectiosum, which it is caused by parovirus B19. This disease’s first phase starts with “slap-cheek” rash that lasts 1-4 days, which moves to the extremities and then to the trunk. The second phase consists of the formation of a reticular rash. In the third phase, the rash comes and goes depending on whether and activity.
Around 75% of people have parovirus B19 in their body, although it is almost always benign.
The virus can cross both the brain-barrier and the placental-barrier, causing complications in people with thalassemia and women who are pregnant.
1 to 9 of all miscarriages are believed to be caused by this parovirus.
When a patient comes in with purpura the way to think is outside in, because there is a long list of things that can cause purpura.
The most common cause of purpura is trauma.
The next level is a blood vessel problem; Ehler’s-Danlos Syndrome, Vitamin C deficiency.
Coagulation disorders is the 3rd level; hemophilia, coagulopathy (drugs are a big cause), low platelet counts (such as ITP)
The most serious problems are often acquired and purpura could be a potentially deadly manifestation – such as HUS (caused by E. coli O157:H7), bacterial meningitis (meningococcus), leukemia/lymphoma, HSP.
Often children are more seriously affected when they have purpura – importnant to check CBC, PT INR, and a BMP to evaluate for kidney function.
Pityriasis rosea is a papulosquamous rash believed to be caused by a virus (although no one has identified the agent) presenting with a salmon-colored patch followed by the presentation of lesions that follow the cleavage lines forming a “christmas tree” pattern.
Treatment is supportive with antihistamines and topical steroids.
Syphillis is a very important historical and current disease. The study of Syhpillis or “Syphilology” evolved into the field of dermatology.
Syphilis, an is caused by the spirochete bacteria, Treponema pallidum.
Syphilis comes in three stages: primary, secondary, and tertiary stages.
In the primary stage, they develop a canker that is a painless ulcerative lesion on the genitals, mouth or anus and resolves over time.
In the next few weeks you begin the secondary stage of syphilis marked by the development of a rash – that can mimic any rash except those with vesicles – classically it involves the hands and soles of the feet.
The tertiary stage occurs over many years, it has many manifestations including neurosyphilis – which can cause psychosis, dementia or even stroke symptoms. People with tertiary stage syphilis also develop a proximal aortic aneurysm, called a “leutic aneurysm” causing aortic regurgitation. This has a ton of clinical signs and can manifest in the bouncing of someones head, pulsating hands, and blushing of nail beds with each beat of the heart. Tertiary stage syphilis can also cause hepatitis and even give people “gummas”, which are rubbery lesions to peoples skin. Bottom line – Syphillis causes a ton of symptoms and has been called the “Great Imitator” as a result.
Treatment of syphilis is penicillin, which is the best antibiotic to treat the infection. Depending on the stage and length of time the person has had syphilis dictates how long of a treatment regimen they will be placed on.
For those allergic to penicillin with neurosyphilis, people can undergo a process of developing anergy to be able to tolerate penicillin. This is usually done in conjunction with an immunologist.
In the United States, Baltimore and Louisiana have higher rates of syphilis than the rest of the country.
Link to Podcast: http://medicalminute.madewithopinion.com/syphillis-the-great-imitator/
Betadine and hydrogen peroxide are toxic to the cells that are attempting to help heal the wound. Pouring these on wounds can paradoxically increase infection risk! DON’T DO IT.
A Cochran review was done recently that compared saline, boiled-steralized water, and potable tap water. It was determined there was no significant difference between the three for wound irrigation success.
A study in 1982, showed that there was no significant difference between using no gloves, sterile gloves, or gloves out of the box for wound management.