WuidQ: Washington University ID Questions Profile picture
Learning infectious disease via board-style MCQs & case discussions. Gerome Escota @mddreamchaser, Ige George @IgeGeorgeMD, & Nico Cabrera @ncabrera @WashUID.

Dec 18, 2019, 15 tweets

ID Miscellany|physical Exam|Signs|Humanities #idmesh

๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง

1/11
Is an important clue for leptospirosis that may often be overlooked on exam.

Pic from: link.springer.com/chapter/10.100โ€ฆ

2/11
What is it?

Simply put, it is a form of non-exudative conjunctivitis

1โƒฃ Non-exudative:

โ–ช๏ธ No purulent discharge
โ–ช๏ธ No matting of eyes in the morning

3/11
2โƒฃ Conjunctivitis: means that,

โ–ช๏ธ Pattern of eye redness ๐Ÿ‘‰ red, dilated vessels maximal at the periphery (from the palpebral to the bulbar conjunctivae)

4/11
It is NOT ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง if w/:

โ–ช๏ธ Ciliary flush (redness maximal in the limbus๐Ÿ‘‡) (1)
โ–ช๏ธ Eye pain (2)
โ–ช๏ธ Reduced visual acuity (3)
โ–ช๏ธ Pupillary abnormalities (4)

5/11
Presence of above, ๐˜ช๐˜ฏ๐˜ด๐˜ต๐˜ฆ๐˜ข๐˜ฅ, would suggest (#'s refer to designation from above list):

โ–ช๏ธ Iritis (1, 2, 3, 4-constricted pupil/poor response)
โ–ช๏ธ Keratitis (1, 2, 3, hazy cornea)
โ–ช๏ธ Scleritis (2 โ€“ deep pain, ocular tenderness)

Lots of ID & non-ID DDX for above.

6/11
๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง is โ€œone of the most reliable and distinguishing features of leptospirosisโ€ (UpToDate).

When you do an online search for "๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง", 99% of the time, you will get โ€œleptospirosisโ€.

7/11
But when you look for DDX of non-exudative conjunctivitis (especially bilateral), youโ€™ll see that it can also be seen in a variety of conditions.

8/11
Differential diagnoses of B/L non-exudative conjunctivitis:

โ–ช๏ธ Viral, esp adenovirus & measles

โ–ช๏ธ RMSF (rarely) cdc.gov/mmwr/volumes/6โ€ฆ

โ–ช๏ธ Kawasaki๐Ÿ‘‡ link.springer.com/article/10.100โ€ฆ

โ–ช๏ธ Toxic shock syndrome๐Ÿ‘‡ jamanetwork.com/journals/jama/โ€ฆ

9/11
But (+) ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง in a patient w/ ๐˜ฏ๐˜ฐ๐˜ฏ๐˜ด๐˜ฑ๐˜ฆ๐˜ค๐˜ช๐˜ง๐˜ช๐˜ค fever, in the right epidemiologic setting, should raise suspicion for leptospirosis.

๐Ÿ‘‰ Especially during the septicemic phase where SSX can be ๐˜ฏ๐˜ฐ๐˜ฏ๐˜ด๐˜ฑ๐˜ฆ๐˜ค๐˜ช๐˜ง๐˜ช๐˜ค

10/11
"Red eye" in ID is a helpful clue to a variety of conditions (ID & non-ID). At the ๐˜ฎ๐˜ช๐˜ฏ๐˜ช๐˜ฎ๐˜ถ๐˜ฎ, should examine:

โ–ช๏ธ Pattern of redness, vision, cornea, pain, pupils (direct/indirect, convergence)

As detailed above, can enrich clinical reasoning & form illness scripts!

11/11
In your practice, how often have you seen ๐‚๐จ๐ง๐ฃ๐ฎ๐ง๐œ๐ญ๐ข๐ฏ๐š๐ฅ ๐ฌ๐ฎ๐Ÿ๐Ÿ๐ฎ๐ฌ๐ข๐จ๐ง? @DocWoc71 @CarlosdelRio7 @FungalDoc
@TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana

@DocWoc71 @CarlosdelRio7 @FungalDoc @TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana 11/11 extra 1โƒฃ
Thank you for all your responses. About 40% has not seen conjunctival suffusion.

How common is it? As high as 99%!! See Table ๐Ÿ‘‡ from cmr.asm.org/content/14/2/2โ€ฆ

What other SSX are common? Myalgia, as high as 100%! Headache, as high as 90%.

11/11 extra 2โƒฃ
In 1982, WHO introduced a criteria for leptospirosis dx in resource-limited settings (known as the ๐™๐™–๐™ž๐™ฃ๐™š'๐™จ ๐™˜๐™ง๐™ž๐™ฉ๐™š๐™ง๐™ž๐™–).
This has since been modified in 2013 (Sn 95%). ๐Ÿ‘‡ apps.who.int/iris/bitstreamโ€ฆ
ncbi.nlm.nih.gov/pmc/articles/Pโ€ฆ

11/11 extra 3โƒฃ
When I was training in the Philippines, where frequent outbreaks of leptospirosis occurs especially after a flood, we used the Faine's criteria.

It demonstrates the value of conjunctival suffusion & myalgia (esp of the calves) in suspecting leptospirosis.

11/11 extra 4โƒฃ
Look what Osler has to say about leptospirosis, in his first edition of Principles and Practice of Medicine (1st edition, 1892)!

At that time, it was a diagnosis of uncertain etiology, as originally described by Weil in 1886. @AdamRodmanMD @BedsideRounds

Share this Scrolly Tale with your friends.

A Scrolly Tale is a new way to read Twitter threads with a more visually immersive experience.
Discover more beautiful Scrolly Tales like this.

Keep scrolling