Morning Report

1. Morning Report 7/6/10 Resident: Bijan Ghassemieh Discussant: Dr. Brukner

2. MKSAP • A 45-year-old man is evaluated because of the acute onset of right ear pain. The patient was well until 10 days ago, when he developed symptoms of an upper respiratory tract infection, including nasal congestion and a nonproductive cough. Although these symptoms are resolving, pain and some loss of hearing in the right ear first occurred last night. He does not have fever, sore throat, or drainage from the ear. Medical history is unremarkable. The patient has no allergies and takes no medications.

3. On physical examination, vital signs, including temperature, are normal. The right tympanic membrane is erythematous, opacified, and immobile, but the external auditory canal is normal. The left ear and posterior pharynx are normal. Examination of the chest is unremarkable.

4. Which of the following is the best initial antibiotic choice in this patient? A. Amoxicillin B. Amoxicillin-clavulanate C. Azithromycin D. Ceftriaxone

5. The best initial antibiotic for this patient is amoxicillin because of its proven efficacy, safety, relatively low cost, and narrow spectrum of activity. • microbiology of otitis media in adults is similar to that of children: Strep pneumoniae, 21% to 63%; H.influenzae, 11% to 26%; Staph aureus, 3% to 12%; and Moraxella, 3%. • Antibiotic therapy reserved for patients in whom evidence of purulent otitis exists. • If symptoms do not improve after 48 to 72 hours initiation of amoxicillin-clavulanate, cefuroxime, or ceftriaxone is recommended. • Alternative agents for patients with penicillin allergy are oral macrolides (azithromycin, clarithromycin).

6. 3 days of pain, swelling, and redness over L knee extending down to just above the ankle There is tenderness over entire lower leg No recent trauma Pain is worsened with ROM 66 yo F with L leg pain and swelling

7. Patient denies: Fevers/chills Tinea, ulcers Hx joint procedures Personal/family hx clots Cardiopulmonary symptoms Not sedentary No hx malignancy No other joints involved No foreign travel

8. PMH Medications Allergies: NKDA Social: neg x3, not sexually active Family Hx: “Lots DM”, no MI, no malignancy • HTN • DM II X 30 years • A1C 13%, Multiple recent episodes of DKA despite reported med compliance • Retinopathy • neuropathy Lantus 50 u SC q am Novolog 10 u TID Novolog SSI 6-8 units Enalapril 20 mg PO daily ASA 81 mg PO daily

9. Differential for unilateral leg swelling • “Leaky” capillaries • Cellulitis (pain, red) • Arthritis (pain, red) • Venous obstruction • DVT (pain, red) • Venous insufficiency • Extrinsic compression (pelvic tumor, lymphoma, May-Thurner syndrome) • Lymphatic obstruction • Tumor • Hx radiation • Surg (especially node dissection) • Filariasis • Other • Baker’s cyst (either via rupture or venous obstruction) • Reflex sympathetic dystrophy (pain, red) • Compartment syndrome (pain) • Diabetic muscle infarction (pain)

10. Exam Vitals: T 37 HR 80 BP 140/76 RR 12 Sat 100% RA GEN: AA female in NAD, except with L leg movement HEENT: Sclerae anicteric. EOMI. PERRL. Pale conjunctivae. Oropharynx clear CV: RRR. Nl S1 and S2. No m/r/g. No JVD PULM: Breathing comfortably .CTA bilaterally ABD: +BS. Soft. Non-tender. No distension. No organomegaly. Rectal: Nl tone. Stools brown, guiac neg. Back: No spine or CVA tenderness EXT: RLE wnl. LLE warm, tender, edematous, red over lateral L knee extending down to just above maleolus. + effusion L knee, moderate pain with ROM of knee. Dec’d ROM. Foot without evidence of tinea or ulceration. 2+ DP pulses bilaterally Lymphatic: No cervical, supraclavicular, axillary, inguinal LAD

11. Important Conditions to Be Considered in the Differential Diagnosis of Acute Monoarthritis Baker D and Schumacher H. N Engl J Med 1993;329:1013-1020

12. Bursitis • consider overlying bursitis/septic bursitis • Can have pain with ROM, jt effusion • may have focal areas of tenderness • Septic from direct inoculation, hematog. spread, spread from adj cellulitis • If unsure bursitis vs. arthritis, need to tap joint

13. Initial Labs/Studies 8.7 136 100 13 2.3 103 4.3 26 1.1 4.1 UA: unremarkable LFTs: unremarkable CK: wnl ESR: > 120 CRP: 357 Blood cx X2: Pending 5.8 20.1 550 MCV 81 56% PMNs, 31% bands Hgb: 8.4 one mo ago

14. Further imaging Plain film L knee: Unremarkable LE dopplers: No DVT. LLE with superficial tissue edema

15. Joint tap

16. Categories of synovial fluid

17. Course • Pt given vancomycin and ertapenem in ER. • Admitted to Gens. Switched to vancomycin and zosyn. Due to concern of superimposed cellulitis • Transfused 2 units PRBCs, with appropriate bump.

18. Septic arthritis microbiology • Gram positive aerobes (80%) • Staph aureus (60%) • Streptococci • Non-group A beta hemolytic (18%) • Strep pneumo (3%) • Gram negatives (18%) • N. Gonorrheae • Others usually in setting of trauma, IVDU, elderly, or immunosupressed • Anaerobes • Risk groups above, and extremity wounds or GI cancers

19. Septic Arthritis Treatment • Normal hosts empirically treated for GP organisms (Staph & Strep) • Vancomycin +/- • Gram negative coverage if risk factors or gram stain findings (immunocompromised pts) • Ceftriaxone for gonococcal infxn • Duration: one month (duration of IV vs PO dependent on bug and bioavailability of susceptible Abx)

20. Joint Drainage? • Not a lot of data: • drainage vs no drainage • Best method of drainage (needle aspirate, arthroscopic, or arthrotomy) • In general, all septic arthritis gets drained, and the bigger the joint the more aggressive the method • Monitor with serial synovial fluid analysis • Open drainage recommended for knee joint if infection not clearing with closed drainage and abx

21. Differential for culture negative septic arthritis • Already received Abx • Not septic arthritis • GP bacteria seen on gram stain or culture approx 80% of cases • GN bacteria seen less frequently • Gonococcal (culture positive in less than 50% of cases) • Sexually active, fevers/chills, rash, polyarthralgias, tenosynovitis evolving to persistent oligoarthritis • Inoculate plates of chocolate agar or Thayer-Martin medium at bedside, culture other sites (pharynx, urethra, cervix, rectum, skin lesions), send fluid for PCR • Tuberculosis • Hx TB risk factors, insidious onset, failure to respond to tx • Fungal • Insidious onset, trauma with inocculation, travel to SW US (cocci), immunodeficiency (candida) • Lyme • Hx tick bite, erythema migrans

22. Arthritis/cellulitis course • Treated with Vancomycin and Zosyn (zosyn later d/c’ed) • Serial exams by primary team and ortho • No trip to OR • Continued improvement • Blood and synovial cultures negative • Cellulitis and arthritis resolved • No residual symptoms

23. What about the anemia? No bleeding (vaginal, GI, or GU) Had c-scope 10 yrs ago nml per report No icterus or dark urine No new meds MCV 81 56% PMNs, 31% bands Hgb: 8.4 one mo ago 5.8 20.1 550

24. Further heme labs DAT: neg LDH: 385 (116-245) Haptoglobin: 304 (57-192) % retic: 1.3% RPI: 0.2 Fe: 18 (40-160) TIBC: 177 (230-430) % sat: 10.2% (14-50%) Ferritin: 535 (10-220) TSH: wnl Hgb electrophoresis: wnl Smear: microcytosis, thrombocytosis, toxic granulations

25. Serum Levels That Differentiate Anemia of Chronic Disease from Iron-Deficiency Anemia Weiss G and Goodnough L. N Engl J Med 2005;352:1011-1023

26. Further heme workup Abd US: Hepatomegaly. Normal spleen. Gallbladder sludge. In the R retroperitoneum there is an amorphous mass which displaces the kidney, suspicious for abscess vs. hematoma Marrow bx: Iron stores adequate. No evidence of dysplasia. The etiology remained unclear, but 2 possibilities : 1.) autoimmune process 2.) early primary myelofibrosis

27. Further imaging CT chest/abd/pelvis w/o: Abnormal R perinephric, pararenal, peripsoas space 9 X 6 cm soft tissue collection with associated gas foci. Differential dx includes hematoma (with or without associated secondary infection), perinephric abscess, and less likely neoplasm. L knee effusion. No evidence of communication between retroperitoneal collection and L knee effusion.

28. IR US guided procedure 18 gauge needle advanced into collection, with copious purulent fluid returning on aspiration. Drain left in place. Cx: MRSA

29. What’s in the retroperitoneum again? • GU: Adrenals, kidneys, ureters, bladder • Circulatory: Aorta, IVC • GI: Esophagus (part), duodenum (most), ascending and descending colon, rectum (part), pancreas (head,neck, body) • Not clear where the abscess came from, as no evidence of pathology in any of above • Patient had been admitted several times for DKA and likely had a foley catheter

30. Evaluting for endocarditis in setting of staph aureusbacteremia • Endocarditis incidence 10-15% in prospective observational studies in pts with staph aureus bacteremia • TTE vs TEE? • In a series of 103 pts with SAB, diagnostic echo findings identified in 25% by TEE vs. 7% with TTE • start with TTE, then TEE if non-diagnostic • Pt underwent TEE: no signs of endocarditis Fowler et al. Role of echocardiography in evaluation of pts with SAB: experience in 103 pts. JACC 1997

31. Additional Points • Elderly are less likely to be febrile with septic arthritis • Perinephric abscesses may be insidious in elderly or in pts with autonomic neuropathy from DM • Endocarditis should be suspected in patients with septic arthritis from Staph aureus, strep or enterococcus without other cause • Abscesses and septic arthritis can be from transient or self-limited bacteremia especially due to Staph Aureus

32. Follow up • Pt d/c’ed on vancomycin with drain in place. Repeat imaging 1 month later showed resolution of abscess. Drain pulled, switched to course of PO bactrim. • With treatment of underlying infection, anemia completely resolved and Hb was 13 • Pt improved blood sugar control • Pt still needs colonoscopy to r/o ascending or descending colon pathology as cause for abscess