148. Disseminated Viral Infections

Herpesvirus

HSV1: 85% of world considered to be seropositive. HSV1: trigeminal ganglia; HSV2: sacral ganglia. HSV1 tx: penciclovir 1% cream 2g, apply every 2 hours for 4 days. Or acyclovir 400mg TID x 5 days.

Spread by either mucosal contact with ulcerative lesion or by those shedding virus without overt disease. Primary infection usually more extensive lesions with some systemic signs/symptoms. HSV1 initially can be gingiostomatitis/pharyngitis, then recurrence usually herpes labialis. Can also be cause of Bells palsy, herpetic keratitis. Can also cause genital lesions, though primarily HSV2. Recurrence can occur due to exposure to sunlight, fever, menstruation, emotional stress.

Herpetic whitlow is HSV infection of the finger (HSV1 or 2) – left untreated, improves in 2-3 weeks. Herpes Gladiatorum are nongenital skin infection that appear identical to HSV. 20-40% of NCAA wrestlers have occurence of it. Transmission skin to skin; usually in areas of contact during wrestling: face, head, neck, ears, upper extremities. Tx: valacyclovir 1g PO BID x 7.

HSV encephalitis: most common virus is HSV1. Left untreated can be 70% mortality. Usually acute onset of fever and neurologic symptoms (stroke-like, CN abnormalities, focal seizures, ataxia, AMS). MRI (w/ DW very sensitive)/CT showed temporal lobe involvement – can get hypomania initially or KBS (Kluver-Bucy syndrome: loss of anger/fear responses, hypersexual).  CSF: lymphatic pleocytosis, PCR very sensitive for HSV – remains positive > 1 week.

Immunocompromised (chemo, organ transplant, HIV, burns): can have widespread dissemination (esophagitis, hepatitis, colitis, pneumonia).

Culture: fluid from unroofed vesicle. PCR preferred. Tzanck test not useful anymore.

Tx: Encephalitis or Disseminated: IV acyclovir (usually for 3-4 weeks). Poor outcome if treated late so start early. Simple HSV1/2: Acyclovir, valacyclovir (higher bioavailability, fewer doses), famciclovir (fewer doses) x 7-10 days. Recurrent herpes labials does not require tx, though if severe/frequent, can do daily suppressive tx. Subclinical shedding common.

Varicella and Herpes Zoster

Higher incidence in winter/spring. Herpes zoster occurs in 10-20% of population with prior VZV infection. Varicella vaccine has virtually eliminated chickenpox in children. VZV originally spread by respiratory secretions. Herpes zoster can be spread with direct contact with vesicle fluid, though not as contagious as chickenpox. Contagious until lesions have crusted over.

Varicella usually febrile illness with vesicular rash. Lesions are at varying stages including papules, vesicles, crusted lesions. Immunized patients can occasionally develop mild chickenpox. Bacterial superinfection with GAS can occur. Usually only lasts 1-2 weeks. Pneumonitis can occur, more common in pregnant women. Tx: usually supportive, though acyclovir decreases number of lesions and shortens course if started within 24 hrs of rash, though impact modest. Varicella less sensitive than herpesvirus and usually requires higher/longer treatment. Famciclovir and Valacyclovir don’t approved for varicella.

Zoster (Shingles) begins as malaise, headache, and photophobia. Initially have pain/itching/paresthesia which then develop into maculopapular rash in dermatome distribution. Does not cross midline. Can get herpes zoster ophthalmicus (optic branch of trigeminal nerve) which can lead to blindness; tx: valacyclovir and be evaluated by opthalmologist. Postherpetic neuralgia (pain > 30 days) can be a complication. Tx: Start antivirals within 72 hrs of onset of rash and consider tx > 72 hrs if new vesicles still present or developing. Disseminated should get IV acyclovir. Steroids don’t help prevent post neuralgia or outcome (NEJM, 1994). Recommend tx with immunocompromised, eye involvement, disseminated. Valacylovir better bioavaliability, less frequent dosing. 1000mg PO TID x 7-14 days. Famciclovir can be 500mg TID as well.

Herpes Zoster Opthalmicus: ophthalmic branch (v1) of trigeminal nerve (supraorbital, lacrimal, nasociliary). Hutchinson’s sign (1/3 of pts): tip of nose involved – 2x more likely to have keratitis (dendrite on fluorecein). If dendrites seen, needs urgent optho evaluation. Tx with acyclovir, famciclovir, or valacyclovir. Get optho consult. Can tx with oral if immunocompetent (Gnann, 2002).

Ramsey Hunt Syndrome (Herpes Zoster Oticus): unilateral facial paralysis, herpetiform rash, hearing loss/dizziness. Can see rash in ear drum and decreased taste, though usually around auricle. Facial nerve involved. Can go as far down as the shoulder. Severe pain and outcomes worse than Bells palsy. Tx: antiviral x 7-10 days w/ steroid taper prednisone 60mg over 3 weeks. (5 minute video on Ramsey Hunt Syndrome)

Post-herpetic Neuralgia: Can try TCAs for pain relief: Amitriptyline 10-25mg PO daily. Gabapentin: Day 1: 300mg, Day 2: 300mg BID, Day 3: 300mg TID; dose may be titrated as needed for pain relief (range 1800-3600mg/day, though doses > 1800 do not show much more benefit).

Smallpox: always board bioterrorism question – lesions larger, distributed more on extremities, lesions in same stage of development.

Epstein-Barr Virus

Infectious mononucleosis, EBV associated with B-cell lymphoma, Hodgkin disease, Burkitt lymphoma, and nasopharyngeal carcinoma.

Transmitted via salivary secretions. Two age peaks: early childhood and early adulthood. Fever (can persist for > 7days), lymphadenopathy (more posterior than anterior), pharyngitis. Tonsillar exudates common, sometimes necrotic. Splenomegaly in > 1/2 of patients. Resolve over 2-3 weeks. Severe fatigue can be prominent for several months. If mistaken for strep and tx with amoxicllin/ampicillin, will develop morbilliform rash. Rare causes of other organ involvement: encephalitis, meningitis, GBS, hepatitis, myocarditis. In young children, more prolonged fever and adenopathy, less likely to have pharyngitis. Can get mild anemia. Also get mildly elevated LFTs.

Monospot: identifies heterophile antibodies. Poor sensitivity in the first week, better sensitivity in older children/adults. High sensitivity/specificity. Recommend avoiding all contact sports for minimum 4 weeks to avoid splenic injury (rupture 1:1000, usually in first 3 weeks). Consider giving steroids 40mg PO x 5 days, though Cochrane review showed no benefit. Can be contagious for several months (even years) after infection. Serology testing available, though rare to use in the ED. Can also diagnose with > 10% atypical lymphocytes on CBC.

Cytomegalovirus

Similar to herpesviruses that it causes primary infection and then goes into latent state. Transmitted by sex, saliva, breastfeeding, transplant, transplacent, blood transfusion. Fetal CMV infection risk highest in first trimester – is a teratogen. Transplant patients can get infected usually in the first and fourth months post-transplant.

Primary infection presents usually either asymptomatic or mild infectious mononucleosis syndrome. No exudative pharyngitis though. Histologic culture: large cell containing basophilic intrnuclear ‘owl’s eyes.’ Can get mildly elevated LFTs. Can also diagnose with > 10% atypical lymphocytes on CBC.

HIV patients (CD4 < 50): retinitis is the most common manifestation of CMV. Also can get encephalopathy, colitis, peripheral polyradiculopathy.

Tx: Bone Marrow Transplant (pneumonia, GI, graft-vs-host): IV ganciclovir + IVIG; AIDS patient (retinitis, GI, neurologic): IV ganciclovir, valganciclovir; Organ Transplant (pneumonia, GI, infection of transplanted organ, nonspecific febrile illness): IV ganciclovir.

For the immunocompetent patient, supportive care only.

Arbovirus

Caused by mosquito, tick, flies bite. Typically seasonal. Major hosts are mammals/birds. Immune system usually creates IgM and kills virus. If unable to, get hemorrhagic fever or encephalitis.

4 syndromes: fever and myalgias, arthritis and rash, encephalitis (fever, headache, AMS), and hemorrhagic fever (gums, petechiae, and GI bleeding). Can overlap as well.

Japanese encephalitis: one of the most common viral encephalitis in the world; prominent in Asia, usually affects children. Adults have been exposed/immune.

West Nile Virus encephalitis: US/Canada/Mexico; usually elderly. 38% in Texas. 80% are asymptomatic. Only 1/150 who are bit develop symptoms. No human transmission. Caused by asian tiger mosquito (also vector for dengue and chikungunya, day feeders). Main vector birds (american crow and bluebird – leave the dead birds alone). Only need 30% DEET for any mosquito repellant. Usually present with fever/headache/myalgias. Can get low WBC, low platelets. WNV RNA PCR has cross reactivity, lots of early negatives as well. Also can get poliomyelitis (spinal cord involvement).

Hemorrhagic fever: usually caused by Dengue, yellow fever (Africa/South America), Rift Valley fever, or chikungunya. Aedes aerqupti is the mosquito vector for yellow fever.

St. Louis encephalitis: US/Canada/Mexico; elderly at risk

CSF showed lymphatic pleocytosis, elevated protein. Serologic testing for IgM antibodies preferred, can be false negative early in course. Usually review titers over time. Supportive care is the treatment.

Clinical Cases

Herpes Zoster opththalmicus, UMEM Education Pearls

References / Resources

Tintinalli, Seventh Edition, Chapter 148: Disseminated Viral Infections

Crashing Patient, Scott Weingart, Viruses and Influenza

AAEM Scientific Assembly 2011, Mononucleosis: New Look at an Old Problem – Andrea Marmor

USC EM Grand Rounds, September, 2012, West Nile Virus Update – William Mallon

UptoDate, Clinical Manifestations and Diagnosis of HSV1 Infection, Reviewed 3/3/14

UptoDate, HSV1 encephalitis, Reviewed 3/3/14

UptoDate, Epidemiology, clinical manifestations, and treatment of CMV infection in immunocompetent hosts, Reviewed 3/3/14

EM in 5, Anna Bargren, Ramsay Hunt Syndrome Video

UMED Educational Pearls, Brian Corwell, Herpes Gladiatorum

148. Disseminated Viral Infections

147. Soft Tissue Infections

Definitions

Cellulitis: deep dermis and subq fat infection

Erysipelas: more superficial infection with lymphatic involvement.

Folliculitis: hair follicle infection

Furuncles: single, deep nodules involving hair follicle

Carbuncles: multiple interconnecting furuncles that drain thru several openings in the skin.

MRSA

59% purulent skin and soft tissue infections in patients > 18yo and 75% purulent skin abscesses in children are MRSA. They basically had to have something to culture though. If they had underlying disease, lower probability of MRSA since they are more likely to get other things. We cannot predict who should be treated for MRSA since almost half of all MRSA infections had no RFs.

MRSA should be considered in any dx likely to be staph/strep as well as sepsis/fulminant pneumonia.

Treatment: MRSA resistant to cephalexin and dicloxacillin and Tintinalli stated one study showed 48% resistance to clindamycin. Group A strep are resistant to Bactrim and doxycycline. Its reasonable to not do abx with simple MRSA abscess if < 5cm, no immunocompromise, and no overlying cellulitis. MRSA tx with clindamycin (check local susceptibilities), Bactrim (nearly 100% susceptible),or doxycycline (82-85% susceptible, though Greg Moran states 100%). For life threatening infection, give vancomycin. Rifampin not recommended as mono therapy. IV medication: Vancomycin, linezolid, daptomycin, clindamycin.

Carrier State Eradication: oral antibiotics vs intranasal mupirocin, or chlorhexidine skin scrubs. One regiment: nasal mupirocin x 5 days monthly for a year decreased carrier state and recurrent infection.

Cellulitis and Erysipelas

Erysipelas is onset of symptoms of abrupt fever/chills/malaise/nausea as the prodromal phase. Skin discolorizations occur over next few days. The ear cannot have cellulitis; can only have erysipelas due to no deeper dermis tissue (milian ear sign).

Streaking due to lymphagitis. Typically with strep or staph when associated with abscess.

RF: immunocompromise, PVD, lymphedema (OR 71.2), skin breakdown/site of entry (OR 23.8), venous insufficiency (OR 2.9), leg edema (OR 2.5), and obesity (OR 2). Also steroids, alcoholics, DM, splenomegaly.

Cellulitis caused by B-hemolytic strep, staph, and GN aerobic bacilli. Erysipelas caused by B-hemolytic strep. Bullous erysipelas is more severe form and 50% caused by MRSA.

Other bacteria per exposure: saltwater (Vibrio vulnificus and parahaemolyticus – consider doing 3rd generation cephalosporin + amino glycoside) freshwater (aeromonas), meat/fish (erysipelothrix rhusiopathiae).

Cultures: useless. without purulent discharge, low yield. Blood cultures in mild infection are 5%. If systemic symptoms, may be useful.

Treatment: Elevation, prevent skin dryness, tx predisposing conditions. Consider nonMRSA tx first for otherwise healthy pts with no purulence/exudate: cephalaxin (500mg q6) / dicloxacillin (500mg q6)/ clindamycin (150-450mg q6). Erysipelas: If systemic symptoms, needs IV antibiotics. Ceftriaxone covers strep, though does not cover staph. Cefazolin covers both. Extremely mild disease: initial IV dose + PCN or amoxicillin. If PCN allergic, erythromycin / cephalosporins/ macrolides. Don’t give one time dose of IV antibiotics in the ED before discharge. Either IV abx + admission vs PO and discharge (ALiEM). One dose vancomycin hasn’t been shown to be helpful; it kills across multiple doses. Bioavailability 100% with most drugs.

Cellulitis without abscess: 82% cure rate with Keflex alone, 85% with combo of Keflex + Bactrim. No difference. (Pallin DJ, 2013). Make sure theres no purulence though before doing Keflex only.

Weingart recommends admitting all cellulitis over weight bearing joints. More likely to result in longer stay admission if initially: objective fever, elevated lactate, or cellulitis involving hand (Volz, 2013)

Abscesses / Furuncles / Carbuncles

Carbuncles are commonly on the upper back, chest, buttocks, hips, and axilla.

After I&D, recommend warm compresses or soaks three times a day and schedule followup in 2-3 days for recheck and replacement of packing.

Consider loop drainage in larger abscesses to prevent recurrent packing (Tsoraides, 2010). ERcast tutorial video.

Necrotizing Soft Tissue Infections

RF: advanced age, DM, alcoholism, PVD, CAD, renal failure, HIV, cancer, NSAID use (Das DK, 2012), decubitus ulcers, chronic skin infections, IV drug use, immunocompromise, liver disease.

Mortality 25-35%. Bacteremia in 25-30%. Bacteria: Polymicrobial most common. Clostridium are now uncommon. Other mono infections: Group A strep, Staph. Vibrio vulnificus is another cause – usually related to seawater environment, liver disease risk factor. Type I: polymicrobial; Type II: Strep or Staph; Type III: marine vibrio gram-negative rods.

Due to tissue ischemia and destruction, antibiotics alone will not be effective. Usually requires immediate surgical intervention. Pain out of proportion is the single most important feature. Lack of crepitus does not rule out infection. Late in presentation present with bronze/brownish discoloration or bullae. Usually have tachycardia out of proportion to fever. Tense edema outside the involved skin.

CT preferred for diagnosis looking for fascial thickening/edema, deep tissue collections and gas formation. Tintinalli states IV contrast provides no additional benefit. MRI better sensitivity.

Wall, et al, 2000 found WBC > 15900 and serum sodium < 135 differentiated necrotizing vs non-necrotizing. Other clinical features to differentiate: High bandemia, elevated creatinine. LRINEC (scoring system for NF): Elevated CRP, elevated WBC, low Hgb, low Sodium, High Creatinine, High Glucose.

LRINEC Score for Necrotizing Soft Tissue Infection – MDCalc

Antibiotics: GP, GN, and aerobes. Zosyn / Imipenem (Levoquin for PCN allergy)+ Vancomycin / Linezolid / Dapto + Clindamycin (found to suppress GAS toxin production even if bacteria resistance).

IVIG controversial, only a few studies. HBO not slam dunk either.

Necrotizing Sweet Syndrome: dermatologic disease that mimics necrotizing disease, though an inflammatory response, not infection. Steroids will treat. Obviously this is something we won’t consider.

Folliculitis

Clusters of pruritic erythematous lesions usually < 5mm in diameter with pustules occasionally in the centers. Treatment: remove exposure, soap cleansing BID. Usually resolve spontaneously. Also warm compresses may be applied. topical antibiotics such as bacitracin or polymyxin B can be used. Avoid shaving. More extensive cases can use oral abx.

Pilonidal Abscess

Along superior gluteal folds – blockage of sinus tract leads to infection. Causes are normal flora, likely Staph. Tx: I&D, recurrences need surgery outpatient for extensive excision.

Bartholin Gland Abscess

Usually at 4 and 8oclock on labia minora. Usually polymicrobial. GC/C can be causes too. Definitive tx with marsupialization to prevent recurrence. With I&D, needs placement of Word catheter. Only needs 2-4mL of sterile saline. They recommend elliptical incision along vaginal mucosal surface. Left in place for 4 weeks. If abx needed, recommend cephalaxin + metronidazole.

Sporotrichosis

Most commonly in tropical/subtropical regions. Most commonly in soil and decaying vegetables. Usually inoculation with thorn or splinter. Can also occur with infected animals, usually cats.

3 weeks incubation period. 3 types of local infection occur: fixed cutaneous type which appears as a nodule with erythema; lymphocutaneous type – most common type which occurs with painless nodule at site of inoculation with later subcutaneous nodules with clear skin lesions along local lymphatic channels.

Diagnosis made from clinical suspicion, but culture of the pus, tissue biopsy will identify the fungus. Tx: itraconazole 100-200mg daily x 3-6months. Fluconazole not as effective, but reserved for pts not tolerating itraconazole. IV amphotericin effective, but side effects large.

References / Resources

Tintinalli, Seventh Edition, Chapter 147: Soft Tissue Infections

Essentials of EM 2013, Cellulitis: Do I Treat for MRSA? – Greg Moran

Crashing Patient, Weingart, Soft Tissue Infections

ercast.org, Rob Orman, Loop Abscess Drainage technique

ALiEM, Zlatan Coralic, One-dose vancomycin for SSTIs: Just don’t do it

Clinical Infectious Diseases, Clinical Practice Guidelines for Treatment of MRSA, 2011

AAEM 2013, Cellulitis Gone Bad: Flesh-Eating Bacteria, Jason Knight

Essentials of EM 2011, Nec Fasc Literature – William Mallon

147. Soft Tissue Infections

146. Septic Shock

Definitions

SIRS, Sepsis, and Septic Shock Criteria – MDCalc

SIRS: Must meet at least 2 of the 4 criteria:

    1. Temperature > 38.3 (100.9), 38.5 (101.3 in kids), or < 36 (96.8)
    2. Tachycardia > 90
    3. RR > 20 or PaCo2 < 32
    4. Leukocyte count > 12 or < 4 or > 10% bands

Sepsis: SIRS + source of infection (look primarily in CNS, pulmonary, intraabdominal, urinary tract, skin, and soft tissue)

Severe Sepsis: Sepsis + CV organ dysfunction or acute respiratory distress syndrome or two or more other organs affected

Septic Shock: Hypotension < 90mmHg without other explained cause, MAP < 60mmHg or a reduction in BP > 40mmHg from baseline despite adequate volume resuscitation.

Other causes of SIRS: Trauma, Burns, Pancreatitis, etc.

ARDS: lung edema caused by microcirculatory injury.  Acute lung injury is Arterial hypoxemia (PaO2 / FiO2) is < 300 and bilateral pulmonary infiltrates on CXR in absence of pneumonia or heart failure. ARDS is PaO2/FiO2 < 200.

DIC: frequently found in septic shock. Thrombocytopenia, prolonged PT and aPTT, decreased fibrinogen and antithrombin III levels, increased fibrin monomer, fibrin split products and D-dimer levels.

Lab Markers

Serum lactic acid: help with sepsis prognosis. Early clearance correlates with decreased mortality.

CRP: elevated in sepsis (go figure)

Procalcitonin: greater sensitivity, specificity and overall accuracy than CRP, though not generally clinically available yet.

Treatment

Rivers, 2001: started the idea of ‘early goal directed therapy.’ Optimization of oxygenation, ventilation, and circulation; initiation of drug therapy including abc; control of source of sepsis. Mortality rate from intervention group was lower than group receiving usual care (30% vs 46%).

Surviving Sepsis Campaign Guidelines 2012

A. Initial Resuscitation: First 6 hours, CVP 8-12, MAP > 65, UO 0.5ml/kg/hr, mixed venous oxygen saturation > 65-70%. Weingart doesn’t believe in CVP; not accurate. Weingart’s CVP: ultrasound IVC and doesn’t require dangers of central line. Patients that don’t require central line: serial lactates are Weingart’s preference over mixed venous oxygen saturation levels. Shoot for lactate less than 2 in any patient.

B. Screening for Sepsis: Have hospital protocols in place for screening.

C. Diagnosis: Get cultures. Get at least 2 sets of blood cultures. Don’t delay abx too much. One from each central line and one from ‘clean stick.’ Do imaging studies to confirm source of infection.

D. Antimicrobial Therapy: Get abx within first hour from within time of recognition. Use empiric antibiotic regiments. Use low procalcitonin or similar biomarkers to assist when discontinuing empiric abx. Duration typically 7-10 days. Don’t use abx in patients with only SIRS response with no infectious cause.

E. Source Control: Take out catheters. Consider percutaneous drainage from intraabdominal processes such as cholecystitis instead of taking them to the OR.

F. Infection Prevention: Oral decontamination and selective digestive decontamination.

G. Fluid Therapy: Crystalloids first fluid of choice. Against use of hydroxyethyl starches. Albumin when patients require substantial amounts of crystalloids. Initial bolus for fluid challenge: 30cc/kg. Fluid challenge until hemodynamic improvement either based on dynamic or static.

H. Vasopressors:  MAP > 65. Norepinephrine first choice of vasopressor. Add on epi when additional agent (second choice). Vasopressin can be added (fixed dose 0.03 units/minute). Dopamine not recommended unless bradyarrythmias (basically never). Phenylephrine not recommended. Maybe considered in crappy peripheral IV. Low dose dopamine does not help for renal protection. Vasopressor use should have arterial line.

I. Inotropic Therapy: Dobutamine in presence of myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output or ongoing signs of hypo perfusion. Infusion up to 20 mcg/kg/min. Dobutamine can go through peripheral line as well.

J. Corticosteroids: If BP not achieved with fluids and vasopressors, add on steroids. Hydrocortisone 200mg/daily (give 50mg q6hr or 100mg q8,though they recommend continuous drip to prevent hyperglycemia). Don’t use ACTH stimulation test.

K. Blood Product Administration: Only transfuse if Hgb < 7. Don’t use FFP to correct elevated INR/PT. Don’t use antithrombin. Don’t give platelets until less than 10,000.

L. Immoglobulins: Not recommended.

M. Selenium: Not recommended.

N. Activated Protein C: Not recommended.

O. Mechanical Ventilation of ARDS:  Tidal volume 6mL/kg of predicted body weight. Use plateau pressures and keep below 30. Use PEEP to avoid alveolar collapse at end of expiration. Recruitment maneuvers. Prone positioning. Head of the bed up. Don’t use beta-agonist with sepsis induced ARDS unless they have bronchospasm.

P. Sedation, Analgesia: NMS should be avoided if possible. Minimum sedation.

Q. Glucose Contro: Maintain glucose < 180.

R. Renal Replacement: Use it if needed.

S. Bicarbonate Therapy: Not recommended until pH < 7.15.

T. DVT Prophylaxis: Use subc lovenox.

U. Stress Ulcer Prophylaxis:  PPI or H2 blocker.

V. Nutrition: Oral or enteric feeding within 48 hours. Low dose feeding in first week. Use IV glucose and enteral nutrition over TPN alone.

W. Setting Goals of Care: Discuss goals and prognosis with family.

ProCESS trial (NEJM, 2014): Basically found no difference in mortality if early detection of sepsis, early antibiotics and aggressive fluid resuscitation were done. No need for central venous monitoring or central venous oxygenation levels.

References/Resources

Tintinalli, Seventh Edition, Chapter 146: Septic Shock

EMCrit Podcast, Surviving Sepsis Campaign Guidelines 2012

Surviving Sepsis Campaign Guidelines 2012

EM Basic Podcast, Sepsis

146. Septic Shock

145. Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome

Toxic Shock Syndrome

Definition: Fever > 38.9, Rash (diffuse macular erythroderma), Desquamation (1-2 weeks after onset, usually on palms/soles, Hypotension, Multisystem involvement (GI, muscular, mucous membrane, renal, hepatic, hematologic), Laboratory (neg UA/throat/CSF/blood except for staph aureus). Probable if 5 of 6 positive. Confirmed if all 6 positive.

RF: menstruation (tampons), skin cuts/burns, recent surgery, postpartum/abortion; lesser risks: sinusitis, IUDs, pharyngitis.

Caused by Staph Aureus toxin-1. Headache most common initial complaint in severe TSS.

Rash: diffuse, blanching erythroderma. “painless sunburn.” Desquamation or peeling occurs 6-14 days after onset.

Tx: Treat like burn patient. Admit to ICU, Lots of NS boluses. Remove any FB or packing. Abx (really don’t help with syndrome, are more from preventing recurrence): Nafcillin or Oxacillin or Linezolid. Also can use Vancomycin or Clindamycin. IVIG has been shown some benefit in refractory cases. UtD recommends clindamycin first line + nafcillin or vancomycin. Steroids have been shown probable better outcomes, though still not mainstream yet.

Patients have numerous sequaelae: rash, decreased renal fxn, hair/nail loss, cyanotic extremities, neuro deficits. Pts not txed with B-lactamase abx will have recurrence.

Streptococcal Toxic Shock Syndrome

Infx with Group A Streptococci (GAS). Similar to TSS, but develops with associated severe soft tissue infx. Cultures positive for GAS. Higher mortality than staph.

RF: extremes of age, DM, alcoholism, drug abuse, tx with NSAIDs, immunodeficiency. Rarely develops from pharyngitis.

Toxin mediated as well. Scarlet fever toxin is most severe.

Can turn into necrotizing fasciitis or myositis.

Tx: Same as TSS with slightly different abx. PCN G 24million units/dose or ampicillin, clindamycin or linezolid. IVIG also has been shown to work. Debridement is mandatory.

References

Tintialli, Seventh Edition, Chapter 145: TSS and STSS

Crashing Patient: Toxic Shock Syndrome, reviewed on 2/19/14

UptoDate, Staphylococcal toxic shock syndrome, reviewed on 2/191/4

145. Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome

144. Sexually Transmitted Diseases

STI Algorithm 

If discharge or dysuria with no ulcer, tx as gonorrhea/chlamydia.

If ulcer lesion and painful, think ‘shingles of the privates’ – HSV. MCC genital ulcers.

If painless and Single lesion, think Syphilis.

If looks like HSV but has bubo and from African country (rare in US), think chancroid (H. ducreyi).

If they had painless ulcer in the past, but now have ‘groove sign’ and from developed country (rare), think LGV.

Condylomata lata: secondary syphilis. Condylomata acuminata: HPV.

If in doubt, give the dirty bird cocktail: Ceftriaxone 250mg IM (GC/chancroid) + doxycycline 100mg BID x 2 weeks (chlamydia/LGV/syphilis) + acyclovir (HSV). (Doesn’t treat HIV obviously.)

Urethritis

Diagnosed clinically. Dysuria, penile discharge.

NAAT (Nucleic Acid Amplification Testing) done on endocervical swabs which are more sensitive than urine, though urine still pretty good. Urine on men is fine.

Chlamydia MCC, most reported STI. Tx for both it and gonorrhea.

Tx: Rocephin 250mg IM x 1 + doxycycline 100mg BID x 1 week. Can give azithromycin 1g x 1 instead of doxycycline. 2g x 1 can be substituted in the cephalosporin allergy patient, though not recommended. Dont give cipro anymore (resistance). Also amoxicillin can be given for chlamydia in pregnancy.

If you need to call in prescription for gonorrhea treatment, give Cefixime 400mg PO x 1.

Fitz Hugh Curtis Syndrome: chlamydia perihepatitis.

No sex for 1 week after treatment complete. Partners need to be treated or tested.

Trichomonis Vaginalis: protozoan infix usually in women. Thin watery discharge. Tx: Flagyl 2g PO x 1 or 500mg BID x 7 days. Avoid alcohol with flagyl (disulfram rxn). Safe in pregnancy.

Herpes Simplex Virus

MC reported ulcerative STI. If in doubt, likely HSV.

PAINFUL, grouped vesicles/ulcers. Think ‘shingles of the privates.’ (recurrent as well)

Viral shedding can still occur with asymptomatic – sucks for their partners.

Need to culture everyone. Tzanck smear is insensitive. Viral culture still the preferred test. Antigen blood testing insensitive, can take 6 weeks to become positive.

Tx: Acyclovir 400mg TID x 10 days, 800mg TID x 5 days for recurrence. Valacyclovir 1g is BID, though more expensive. Suppressive therapy for pt with > 6 episodes/yr.

Syphilis

PAINLESS, SINGLE LESION (chancre). Think that people get secondary syphilis because the ulcer is painless and goes away on its own.

Treponema pallidum – spirochete. See corkscrew-like bug on darkfield microscopy.

Darkfield only test during active primary disease. For secondary, latent, and tertiary, check indirect tests first: VDRL or RPR (either one is fine). If it is positive, need to do direct testing.

Secondary syphilis: maculopapular rash, classically involves palms/soles as well. Usually has flu-like symptoms.

Condylomata lata: secondary syphilis – flat wart. Highly contagious.

Latent period, then tertiary syphilis: thoracic aneurysms, meningitis, peripheral neuropathy (tabes dorsalis).

Tx: 2.4 million units benzocaine PCN G IM x 1 (has to be this due to long-acting; can’t substitute other PCN). Can substitute doxycycline or azithromycin if PCN allergy. Have to use PCN in pregnancy. If allergic, need to desensitize.

Jarisch Herxheimer reaction: Flu-like syndrome with fever after big dose of PCN. Due to large viral load death.

Chancroid

Painful, deep ulcer. Rare in the US, though can have outbreaks. Sub-saharan Africa.

Haemophilus ducreyi (gram negative bacterium).

Looks like HSV, though will have painful pus-filled unilateral lymph nodes (bubos). 1/2 of men will get it.

Tx: the same as gonorrhea (Ceftriaxone or azithromycin). Bubo can be I&D or aspirated for pain relief.

LGV

Chancroid is to HSV as LGV is to syphilis. Painless ulcer and also is very rare in the US.

Chlamydia trachomatis. Get ‘groove sign:’ lymph node involvement of both femoral and inguinal nodes.

Tx: same as chlamydia (surprise surprise): doxycycline x 21d.

Granuloma Inguinale

Donovanosis. Caused by Klebsiella granulomatis. Rare in US. Endemic in India, Africa, Pacific nations.

Nodule that progresses to painless, ulcer. Beefy red and bleed easily. Not highly contagious.

Tx with doxycycline x 21d. Erythomycin base for pregnancy.

Genital Warts

Painless raised warts. Cauliflower-like.

HPV: types 6 and 11 are the most common, though benign. 16 and 18 are the cancer causing ones.

Diagnose; can consider prescribing gels (podofilox 0.5% BID); likely just referral.

3-shot vaccine available for 4 types of HPV.

Pediculosis

Body / crab louse. Pruritic.

Tx: lindane / permethrim x 10 minutes. Repeat in 1 week.

Other Considerations

CDC recommends considering testing for HBV, HCV, and HIV. At least refer them to a clinic to have it done.

References

UpToDate: Approach to the patient with genital ulcers

UpToDate: Pathogenesis, clinical manifestations, and treatment of early syphilis

UpToDate: Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection

Rosen’s Emergency Medicine: Chapter 96: Sexually Transmitted Diseases

Crashing Patient: Genital Infections and STDs

Tintinalli, Seventh Edition, Chapter 144: Sexually Transmitted Diseases

144. Sexually Transmitted Diseases