Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

June 20th Day 77: clinicalproblemsolving.com/morning-report…

w/ Andrew Jenzer, @DxRxEdu, @rabihmgeha

Teaching points by @sukritibanthiya: clinicalproblemsolving.com/wp-content/upl…

Let's start with an initial problem representation:

A 43 y/o M w/ a PMH of type II DM presents w/ a 5-day history of fevers, malaise, left-sided auricular pain and was found to be febrile on exam w/ hypoxia, poor dention, left sided neck swelling & trismus

Another case to deploy the I-Made pneumonic, don't forget DVT

Just a side note, diabetes would be a risk factor for Melioidosis.

What is Melioidosis?👇👇

https://twitter.com/k_vaishnani/status/1266807733237493765

He is a former IV drug user but quit.

Remember to Trust but verify. Maybe he slipped up and is embarrassed to admit. it happens.

Endocarditis can be acute or subacute

What if auricular pain is referred temporal pain from vascular cause like Takayasu causing aortitis

A smoldering fungemia given his occupation as a rancher

Lets not forget about Syphilis too

Could be some malignancy near esophagus/larynx causing referred otalgia

Here is a tweetorial on otalgia,

https://twitter.com/MinaLeENT/status/1211787360486281217

Pseudomonas, Aeromonas can also be administered via IVDU if the patient used tap water, ncbi.nlm.nih.gov/pmc/articles/P… (this was from Turkey but still)

Just important bc Aeromonas spp. can cause septicaemia, wound infections and diarrhoeal illness

Another case of Faget's but not on beta-blocker, pedemmorsels.com/relative-brady…

The throat and neck pain and fever leads a few things on the ddx

Retrophargnygeal access (RPA)
Peritonsillar Abcess (PTA)
Lemierres
Vincent’s
Ludwigs Angina
Epiglottitis
Parotiditis (more facial pain

Lemierre’s could have emboli to the lungs

poor oral hygiene — CIA strep (constellatus, intermedius, anginosus), fusobacterium, peptostreptococcus, anerobes

Given his trismus and vital signs, I would want airway equipment and a CT if he remains stable

Vincent’s — usually gingivitis/peridontitis but can be fulminant, Acute necrotizing ulcerative gingivitis aka trench mouth or ANUG ncbi.nlm.nih.gov/pmc/articles/P…

Ludwig angina is a bilateral, aggressive, and rapidly spreading cellulitis of the sublingual and submaxillary spaces.

Known by various names, including acute necrotizing ulcerative gingivitis and trench mouth, it is an acute bacterial infection of the gingiva caused by spirochetes, such as Borrelia vincentii, fusiform bacteria, or an overgrowth of normal oral flora.

wikem.org/wiki/Vincent%2…

lower molars are usually source and track down potential space, radiopaedia.org/articles/ludwi…

We discussed abx for this patient and Clinda was chosen.
Remember Clindamycin for necrotizing fasciitis and its mechanism

Clindamycin is a macrolide w/ activity against gram+ & anaerobic organisms.

It is useful in the suppression of endotoxin & superantigen production by S aureus hemolytic streptococci & clostridia

Enhances phagocytosis, limiting toxin-mediated destruction, & inhibiting cytokines

Clindamycin has the most reliable coverage for oral bugs including anaerobes like fusobacter, uspharmacist.com/article/necrot…

Clindamycin can be bacteriostatic or cidal depending on the dose

safe to use aztreo for penicillin allergy purposes

Lots of different microbes in the mouth, including Peptostrepto.

Need a review? Antimicrobial Susceptibilities of Peptostreptococcus , aac.asm.org/content/51/6/2…

Need a refresher on a retropharyngeal abscess. ncbi.nlm.nih.gov/books/NBK44187…

MC in children <5 but also occurs in adults.

In pts <5 there is an antecedent URI leading to suppurative cervical lymphadenitis and eventually retropharyngeal abscess.
pedclerk.bsd.uchicago.edu/page/retrophar…

In older children and adults, a retropharyngeal abscess is caused by trauma to the posterior pharynx

This leads to inoculation of the retropharyngeal space and results in abscess formation

If there is any delay in treatment, complications are common, mortality rate can be > 40%

Final dx following his Ct scan showing a 2 cm abscess of the left lateral pharyngeal space with involvement of the left IJ and PE.

Fusobacterium necrophorum

This is a UB (@medrants) favorite dx

It is a rare causative agent of otitis & sinusitis.

Most commonly known is the classic Lemièrre's syndrome of postanginal sepsis w/ suppurative thrombophlebitis of the IJ

The first description of infection with it was made by Veillon and Zuber in 1898 ncbi.nlm.nih.gov/pmc/articles/P…

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Correction. Teaching points today were from @SmithaGaneshan my apologies

Correction. Teaching points today were from @SmithaGaneshan my apologies