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Sthanu

@Sthanu5

Jul 18

Which of the following is the most likely diagnosis?

A. Erythema multiforme

B. Annular urticaria

C. Secondary syphilis

D. Fixed drug eruption

E. Polymorphous light eruption

A. Erythema multiforme.

Presents with target lesions favoring the extensor extremities.

Without a hx, one must discover distinguishing features in the clinical photo to arrive at the correct diagnosis.

On the dorsal hand, there are variable edematous urticarial papules, some of which feature three zones:

*a dusky center surrounded by two concentric rings of different colors

Although not all of the lesions are fully developed, based on the presence of typical targets, EM is the best answer

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Sthanu

@Sthanu5

Apr 20

A 20-wks pregnant patient is admitted to ICU with septic shock.

Culture reveals listeria.

The patient is known to have had severe anaphylactic reactions to penicillin

What is the drug of choice for this patient?

A) TMP-SMX

B) Clindamycin

C) Vancomycin

D) Ciprofloxacin

Answer:

A) TMP-SMX

In immunocompromised patients, including pregnant women, listeriosis can present as life-threatening sepsis and/or central nervous system (CNS) infection (invasive infection).

In this clinical setting, the mean incubation period is 11 days.

The manifestations of CNS infection include

meningoencephalitis,

cerebritis,

rhombencephalitis (infection and inflammation of the brain stem),

brain abscess, and

spinal cord abscess

●The first line of drugs in severe Listeriosis is ampicillin (or penicillin).

●Some experts add gentamicin, it is not advisable due to its potential toxicity.

●Trimethoprim/sulfamethoxazole (TMP-SMX), is the drug of choice if a pati
nt is PCN allergic.

●Unfortunately, this should be avoided in the first trimester and the last month of pregnancy.

●In the first trimester, this affects folic acid metabolism, and in the last month, it may cause kernicterus in the fetus.

●In those periods, meropenem can be used.

●This patient is way out of those risk periods for the drug, so the answer is A.

●Vancomycin has been proposed, but the failure rate is very high.

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Sthanu

@Sthanu5

Apr 20

65 year old female on day 7 post colectomy with primary anastomosis.

Dysponea ?infective changes.

Decreased breath sounds at both bases.

Findings?

Cause?

Answer

Subdiaphragmatic free gas secondary to anastomotic leak

🔴

Radiograph

Large volume of free subdiaphragmatic gas with air-fluid levels under both hemidiaphragms.

Bil pleural effusions and bibasal collapse/consolidation.

Cardiomediastinal contour is within normal limits.

Surgical clips project over the LUQ.

CT Abdomen/Pelvis performed approximately 4 hours after the x-ray

●Marked amounts of free fluid and gas within the abdomen.

●Surgical sutures in keeping with a recent subtotal colectomy are noted

●The rectal contrast falls short of the site of anastomosis.

●Free gas locules are predominantly centered within the left upper quadrant corresponding to the region of anastomosis suggesting this is likely the site of perforation.

●The segment of bowel opacified by the rectal contrast demonstrates no extraluminal extravasation.

●The small and large bowel loops are dilated without evidence of mechanical obstruction in keeping with an ileus.

●Bil pleural effusions are associated with almost complete bibasal collapse.

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Sthanu

@Sthanu5

Apr 16

Which of these patterns of treatment of MRSA bloodstream infections significantly decreased odds of all-cause mortality?

Early use (within 3 days) of daptomycin

Early use (within 3 days) of vancomycin

Any use of daptomycin

Any use of vancomycin

Answer

Early use (within 3 days) of daptomycin

●A meta-analysis aimed to compare the effectiveness of vancomycin vs daptomycin for the prevention of mortality among adult patients with MRSA bloodstream infections.

●The researchers found that daptomycin treatment was associated with nonsignificant odds of all-cause mortality compared with vancomycin treatment;

*subanalyses revealed that switching to daptomycin from vancomycin within 3 or 5 days made the association significant, decreasing the odds of all-cause mortality by 55% and 45%, respectively.

●However, switching to daptomycin from vancomycin after 5 days of treatment was not significantly associated with reduced odds of mortality.

●An additional meta-analysis indicated that daptomycin should particularly be considered in patients with intermediate- and high-risk sources of bacteremia.

Daptomycin

●Staphylococcus Aureus Bacteremia

<1 year: Safety and efficacy not established

≥1 year

12-17 years: 7 mg/kg IV q24hr infused over 30 minutes

7-11 years: 9 mg/kg IV q24hr infused over 30 minutes

1-6 years: 12 mg/kg IV q24hr infused over 60 minutes

Duration of therapy: Up to 42 days

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Sthanu

@Sthanu5

Apr 14

Early (IV) administration of dexamethasone in bacterial meningitis particularly decreases the risk of?

A) hearing loss

B) vision loss

Answer:

A) hearing loss

●The use of corticosteroids (typically, dexamethasone, 0.15 mg/kg every 6 hours for 2-4 days) as adjunctive treatment for bacterial meningitis improves outcome by attenuating the detrimental effects of host defenses (eg, inflammatory response to the bacterial products and the products of neutrophil activation).

●Corticosteroids for acute bacterial meningitis. showed that adjunctive corticosteroids were effective in reducing hearing loss and neurological sequelae in patients with bacterial meningitis caused by all pathogens particularly H.influenza.

Administration of IV glucocorticoids has now become the standard of care in the early management of community-acquired bacterial meningitis.

Dexamethasone is considered as the drug of choice.

The dose is 10 mg administered 15 to 20 minutes prior or with the first dose of antibiotic every 6 hours for 96 hours.

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Sthanu

@Sthanu5

Mar 15

Interesting case!

10 years old male with 4 days of worsening of long-standing intermittent abdominal distension and diffuse abdominal pain.

Thoughts?

Sigmoid volvulus

Radiograph

Grossly dilated large bowel loops.

Dilated bowel with fecal material, predominantly on the right.

A kidney/coffee bean sign with a thick inner wall of opposed bowel loops compared single layered outer walls is identified.

Additionally, the Frimann-Dahl sign with three dense lines of sigmoid walls converging towards the right pelvis.

Bilateral psoas shadows are obscured.

No pneumoperitoneum or air-fluid levels.

No abnormal soft tissue densities or calcifications.

The chest X-ray shows no sub-diaphragmatic free air and is generally unremarkable.

On single contrast enema

👉 bird beak-like projection on AP imaging, a bird beak sign, outlining the site of obstruction.

Minimal contrast is observed traversing past the "beak" towards the right of the abdomen.

No opacification of the remainder of the large bowel to cecum or reflux into the small bowel.

Contrast flow abruptly cuts off within the sigmoid colon.

No extravasation of contrast.

Free flow of water-soluble (Gastrograffin) contrast through the rectum.

Normal recto-sigmoid ratio.

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