Author: Don Stader, MD
- Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection.
- Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%).
- Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms.
- Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well.
Editor’s note: In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia
Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.
Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.
Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Nick Tsipis, MD
- Persistent fever or positive blood cultures should raise suspicion for endocarditis
- Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk
- Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages
Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813.
Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603
Author: Gretchen Hinson, MD
- Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age
- Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present
- Hyponatremia is a common laboratory finding
- Legionella urinary antigen can be a convenient test to identify the infection
- Treatment is with fluoroquinolones, macrolides and/or tetracyclines
Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires’ disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6.
Cunha BA, Cunha CB. Legionnaire’s Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.
Author: Dylan Luyten, MD.
- Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
- Young person with back pain needs to be evaluated for injection drug use (major risk factor).
- Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
- Treatment is IV antibiotics and surgical debridement.
Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.
Author: Aaron Lessen, MD
- Progresses through distinct phases if untreated:
- Primary syphilis: frequently overlooked because initial chancre is painless.
- Secondary syphilis: viral syndrome, rash on trunk, palms, and soles.
- Latent syphilis: asymptomatic period, lasting 5-20 years.
- Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc).
- Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary.
Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.
Author: Sam Killian, MD
- Japan recently approved baloxavir marboxil (Xofluza), which may potentially “kill” Flu A/B within 24 hours
- Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours)
- Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7 hours)
- Administered as single dose
- Yet to be considered for FDA approval
Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonuclease Inhibitor S-033188 for the Treatment of Influenza: Results from a Phase 3, Randomized, Double-Blind, Placebo- and Active-Controlled Study in Otherwise Healthy Adolescents and Adults with Seasonal Influenza. Open Forum Infectious Diseases. 2017;4(Suppl 1):S734. doi:10.1093/ofid/ofx180.001.
Author: Sue Chilton, MD
- IV drug use and spinal procedures are major risk factors.
- Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
- MRSA is most common organism, but GNR and MSSA are also possible.
Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.
Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.
Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.
Author: Michael Hunt, MD
- Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias.
- A thorough history is critical to the diagnosis. Disease is localized to the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America.
- Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy.
Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis–United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217.
Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26.
Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.
Author: Peter Bakes, M.D.
- High risk patients: underlying lung disease, immunocompromised, extremes of age (<2 or >65), underlying cardiac/renal/neurologic disease, and pregnant women.
- Testing: RT-PCR (RNA based test that is both sensitive and specific)
- Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms.
- Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock.
- Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease).
- High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness.
Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4.
Longo, Dan L. (2012). “187: Influenza”. Harrison’s principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.