ID Miscellany|physical Exam|Signs|Humanities #idmesh
๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง
1/11
Is an important clue for leptospirosis that may often be overlooked on exam.
Pic from: link.springer.com/chapter/10.100โฆ
2/11
What is it?
Simply put, it is a form of non-exudative conjunctivitis
1โฃ Non-exudative:
โช๏ธ No purulent discharge
โช๏ธ No matting of eyes in the morning
3/11
2โฃ Conjunctivitis: means that,
โช๏ธ Pattern of eye redness ๐ red, dilated vessels maximal at the periphery (from the palpebral to the bulbar conjunctivae)
4/11
It is NOT ๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง if w/:
โช๏ธ Ciliary flush (redness maximal in the limbus๐) (1)
โช๏ธ Eye pain (2)
โช๏ธ Reduced visual acuity (3)
โช๏ธ Pupillary abnormalities (4)
5/11
Presence of above, ๐ช๐ฏ๐ด๐ต๐ฆ๐ข๐ฅ, would suggest (#'s refer to designation from above list):
โช๏ธ Iritis (1, 2, 3, 4-constricted pupil/poor response)
โช๏ธ Keratitis (1, 2, 3, hazy cornea)
โช๏ธ Scleritis (2 โ deep pain, ocular tenderness)
Lots of ID & non-ID DDX for above.
6/11
๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง is โone of the most reliable and distinguishing features of leptospirosisโ (UpToDate).
When you do an online search for "๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง", 99% of the time, you will get โleptospirosisโ.
7/11
But when you look for DDX of non-exudative conjunctivitis (especially bilateral), youโll see that it can also be seen in a variety of conditions.
8/11
Differential diagnoses of B/L non-exudative conjunctivitis:
โช๏ธ Viral, esp adenovirus & measles
โช๏ธ RMSF (rarely) cdc.gov/mmwr/volumes/6โฆ
โช๏ธ Kawasaki๐ link.springer.com/article/10.100โฆ
โช๏ธ Toxic shock syndrome๐ jamanetwork.com/journals/jama/โฆ
9/11
But (+) ๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง in a patient w/ ๐ฏ๐ฐ๐ฏ๐ด๐ฑ๐ฆ๐ค๐ช๐ง๐ช๐ค fever, in the right epidemiologic setting, should raise suspicion for leptospirosis.
๐ Especially during the septicemic phase where SSX can be ๐ฏ๐ฐ๐ฏ๐ด๐ฑ๐ฆ๐ค๐ช๐ง๐ช๐ค
10/11
"Red eye" in ID is a helpful clue to a variety of conditions (ID & non-ID). At the ๐ฎ๐ช๐ฏ๐ช๐ฎ๐ถ๐ฎ, should examine:
โช๏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 ๐๐จ๐ง๐ฃ๐ฎ๐ง๐๐ญ๐ข๐ฏ๐๐ฅ ๐ฌ๐ฎ๐๐๐ฎ๐ฌ๐ข๐จ๐ง? @DocWoc71 @CarlosdelRio7 @FungalDoc
@TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana
@DocWoc71 @CarlosdelRio7 @FungalDoc @TxID_Edu @GermHunterMD @FranciscoMarty_ @cmejiachew @Vaccinologist @EdselSalvana 11/11 extra 1โฃ
Thank you for all your responses. About 40% has not seen conjunctival suffusion.
How common is it? As high as 99%!! See Table ๐ from cmr.asm.org/content/14/2/2โฆ
What other SSX are common? Myalgia, as high as 100%! Headache, as high as 90%.
11/11 extra 2โฃ
In 1982, WHO introduced a criteria for leptospirosis dx in resource-limited settings (known as the ๐๐๐๐ฃ๐'๐จ ๐๐ง๐๐ฉ๐๐ง๐๐).
This has since been modified in 2013 (Sn 95%). ๐ apps.who.int/iris/bitstreamโฆ
ncbi.nlm.nih.gov/pmc/articles/Pโฆ
11/11 extra 3โฃ
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 4โฃ
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
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