2- Pg.1-50

INTERNAL MEDICINE INTERNAL MEDICINE NTERNAL MEDICINE INTERNAL MEDICINE INTERNAL MEDICINE NTERNAL MEDICINE INTERNAL MEDICINE INTERI{AL MEDICINE INTERNAL MEDICINE INTERNAL MEDICINE NTERNAL MEDICINE INTERNAL MEDICINE INTERI{AL MEDICINE I N T E R N A L\ 4 E D I C I \ [ I \ TER.I\]Ai- T4EDi Ci\F IiiTER]{Ai \4EDiCI}TF JXTERNAL]\4ED]CI\F iNTER.NALh4EDJCI\F i\ Ttr FlIljAi_ 5rrEDiC ilr r I};TERI-AL T4EDICi\F

DERMATOLOGY l

$qL!4yEBS

A

Epidermis l. SlrarurnComeum:horn1,keratinlayer 2. StraturnGranulosurn:granularlaver 3. Srarum Lucidum:seen$'irh thick hom1.layer(palms& soles) 4. SlratumSpinosum:pnckte,spinl'layer La.userhansCells; function as maoophage of the epidernis and processconbct anug€ns 5. SrratumGerminadvum:basalcell l4vcr Basal Cell Keratinocvte: onll' cell of the eprderrniscapble of divisron. Thq, dr.r,ide and rnigrate upNard To13lrurnovertime is 28 dals (14 dalr of migration and 14 davs10be discarded). Melanoctle: producesmelanin which is tranderred to keratinocltes. Melanitr prolecls the skin from W radiation- ln u.hires.foutrd mostly in basalcell layer. ln bbcls. foutrd throughout lhe epidermis.

Stralum corneum Granular layer L a n g e r h acnesl l

Stratum malpighii

Keratinocyte Melanocyte

Basal layer

Layers oftheEpidermis

B. Dermal-EpidermalJuncdon(BasemeplMembraneZope) 1- LaminaLucida 2. I-amina Densa 3- SublaminaDensa C. Dermis L Paoillan Derrnis: immediateh beneatl epidermis. Thin haphazardll arrangedcollagenfibers, abu.ndartgrouad substance.and delicate elastic fbers. 2. ReticularDermis:exends lo lhe subcuuneous fat. Coarseelanic fibersandthick collagen bundlesar|angedmostl] Frallel to ski-nsurface.

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SKIN STRUCTURES Halr-Iglllele: hair grour.bpoceeds titougb distinct Phases Anaeen:Prolongedgro*lh Cataeen:shon fived inlerPbase Teloeen:fnal resting Pbase

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Phasesofthe gtowlhcycleofa hair

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CATAGEN

C-ells of hair bulb produce hair shafl I\ hich i s compl erel]' keratinized ard has no liYing cells- llair color is due to &e amoult and t-v?eof melann B. Eccrine Glands: found ir: highes concenu'ationon palrns. soles.and a;iillae. Secretory coil located in dermis ran-grua sq'ear drecd] to skin surface for cmting of bo4"

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C. Amcrine GlanG: found prirnarilf in aiillae and anogenitalrcgioDsand se^'es as a scenl gand Derived frorn hair germ and opensdirectl)' into pilosebaceousfollicle rather than skin surface. Secomezctireatpubem:Glands:found on all boq paru exceplpalmsandsoles. Prodrcesoil (sebum)lbat is D. Sebaceous empnedirto &e hair follicle. This lubrimtesandprolectsLhehair and skin. E. ArrectoresPilorum:smootbmuscleanachedto tle baseof tbe bair follicle. Conuzctin responseto cold or friehr "Gmse Bumns".

ApocrirE |'{

Sraigft

Coled gland

swEld unli

$traled $rqrgn Coiledduct qtanq OernglYasqddure

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Superficial

I dexus De4 Frexus

Diagramatrc crosssectionofthe skinandpanniculus

M. SKIN LES]ONS A. Prirpan,Lesiotrs l. Macule: circunscribed changein color of norrnal sl{in $'ithout elel?tion or dgpression< lcm in diameter.(Freckle) 2. Palch:similarro nacule tut > I cm. solid ele\ation, I cm in diamaer. 3. Papule:circumscribed 4. !&94!: an edemalousFpule. 5. Nodrle: similar to papulebut > I cD6. Tumor: similar to nodule but > 2 cln7. Plaoue:an elevationabovettre skin with a plateau-like surface. 8. Vesicle:eleratedlesion< I crq containingclearfluid 9. Bulla: similarlo vesiclebu1> I cm. 10. Pusn e: similarto vesiclebut filled uith neuuophilsanddeadbacteria.Ruid is \r'hiteor-vellorr' (Pus).

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Macula

Nodule

Papule

Pusnrle

::1"',.,'/nj 'Wheal

Vesicle

B . Secondan,Irsions l. 2. 3. .1. 5. 1.

Scale:al excessof hom]'marerialon the ski.n Crust: scabconsisting of dried bloo4 serum-or trrs. Erosion:scoopedout and shallor,break. No danageto lhe derrus. Fissure:linear form ofar erosion. tllcer: deeplesion involviag tbe dermis. Eschar: dark colord bard lo remsve crust on uicer.

Secondarv Lesroas

Fissure

Ulc er

A

C , @ l. ---------2.-

Affiular: round lesion, ring-like. The rim is differenl fiom the cent'er. :1ong-riinlesionlrsmalHesionriralong-thm 3. Tarp.elor Irisi concenu-icrings like an archerslaryel. 4. Imbricated:targetlesions$ilh nonnrl skin benveenthe abnormalzones. Veq'rare. 5. Seroisinous:makelike. Panialll circularald undulating. 5. Geosaohic:oudineofa continenton a map. 7. Vesetaline:Iesionhasa surfacelhat growsoun{ardin ureven flesh1'rufisthatfe€l sof1. 8. Vem:cous:r*an-like. Tufu of proruding lesionareh)?erkeratotic-not sofi. 9. Ztrsrer.forlx,:conforming ro tle disu-ibutionof a nen'e rmt. 10. Polvn'clic or Circinate;annulal'lesionsgro$ togetler.paflsof theu circlesform largerlesion. I l. Grouped:severalsimilarlesionslocatedin closeproximiN surroundedI a largeareaof normal sktn'

D. Morottolosvof Lesions The follou'ing aspeccshouldbe includedin eve4 description: 1 Size 2. Color 3. ConsistencJ': soft, mediuq firm4. Configurarion: shapeor outline of lesioa. 5. Margination: slurp or diftrse. 6. Surface Characteristics:smootlror roughIV. BACTERIAL INTECTTONSOF TED SKIN A. lmpetieo l. A superficial skin inlection due to S. pyogenes& S. aureus-alone or logether. Especially corDmonin chil&en in hol humid climates. 2. Small, thin-qzlled vesiclesor pusntes on an erytherErous bas€rupture 1oform cbaracteri$ic -vellow-brown(honey-colored)cru$s. Removal of the crustsreveal a superficial, moisl base. Lcsions do nor ulcerate. 3. CommonJyfound on the face and exremities. 4. lnvolved are€srnay b€ prudtic. Reg|onal lymph nodeirvolveE€nt is commoDbul other sjstemic manifesgti oDsarEnue. 5. Treatmenl: Topical antrbiotics(Mupirocir. Baciuacin- Nmmycil) Systemicarribiotics @icloxicillin, Clindamycin) B. EctblEa 1. A supericial sliil infectioncausedt!'Group A Su€p.And or S. aweus. 2- Begins asvesiclesor bullae tlal ruFure to form cmsts. Remowl of crust rweals an ulceration. Heals witb scarring 3. LesionsareD?ically endremalous,circular,andrnultiple. Most commonl]'involvel}Ie lower e\tremi6es. 4. Treahent: Oral antibiotics (DicloxacilLiD) C. Ervsirlas andCelluiitis l. Wben a Strep.infecrion spreadsinro Oe dermal llmpbrtics, erysipelasoccursand n'hen it involves fte deepetdermisand subcuuneousfal celluliris occurs. enzwes lo faciliure rapid spreadof rhe hfection tluoughtissueplanesand 2. S. $ogenes rele.ases prwent abscessforrnation Edema,erytbema,and heardevelc'p. Tbe enzlnes also produce q'stemic manife$ations (fever, tacbl'cardi4 confirsio_nand h]?otension). 3. Predisposingfaaors: edema tinea pedis,previous traum.afo ski.n-bums. swgerr'. or ndiation. 4. Most conmon sitesare thefaceandlower extemities. 5. E1'sipelasunlike ceuulitis has a sbarp\' demarcatedand eleyatedborder. 6. Both needleaspirationands].inbiopq of t}Ie lesionusualll fail to lield organisrns.

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Caustive agents:Usuall)'Sfep. S. aureus-aroundabecessor oDenqound !-in8ueruae--facial-ceuuljt$-rn1€ue6 €Hldrca+636 so1}s|-____-P. mulrocida- cal anddog biles. P. aeruginoss& o&er gnm (, organisms-cornmonin irnmunocomDromis€d hosts. 8, Treatrue : Mild- Oral a.ntibiorics Severe-lnravenousandbiotics Sigls ard q'nrptoltrs [u1\'\'orsen ai.er therapyis iniriated becausethe antimicrobial rapidll kills tie bacteriacausingthe releas€of porent eDzlnes. D.

Furuncles and Carbuncles .1. A irruncle is an infectionof the hair follicle thatproducesan idlem'nelorv nodulewith a frmrle center througbwhich &e bair emerges. 2. A srbuncle afects severaladjacenthairfollicles andbegrnsas a nodule*hich eDlarges to seale an injlamrlvltot-\' masstlal disctuugespx fiom multiple follicular orifices. The_voccur predorninantlyon the back of the neck and is more cosrmonin diabetics3. S. aureusis the mostcommonciuse ofbofh. 4. Treatrnent:Smallfuruncles.moisthe3tlo prcmotedrairage. Carbuncles& L:rge firuncles- I&D

E. Folliculitis I . bllamrnation at the openi.ugof the hair foliicle. Pathogenesisirvolves occlusion of rhe follicular ostium. 2. Skin lesionsare er-1'lherEtousFapulesor pusnrlessurroundingfhe indiYidual haLs most commonlv on $e scalp and exaEmities. 3. hedisposingfactors:chernicals, trauma-tight clothing excessivesweadlg occlusivedressings, prolonged immersion in szler. 4. S. aur€usis lhe most common cause. P. aeruginosa is common rri& ttadequale disinfedion of sudmmingpools. hol tub6.and whirlpools. 5. Tre.atne : Sysernic artibiotics. F.

Enrhasrna 1- A superficial hfection, usually a$mptomatic involving intertriginous areas(goin, a,rillae, roe webs)- Scaling.fissuring andmaceratjonof toe webe (panicularl,vtbe founh). 2- CausaliYeorganismis Co4nebacterium mir:urissimum (gram positive bacilli). This organism producesporphyirs so all lesionsfluoresceuith a red or pink "coral" color with a wood's lamp. 3 . ln other areasthe lesiors are scaly, bro$n or red, sbarpb'demarcaledFgtcbes. Treatnenl: Wash with soapand I}ater Whideld's oinEnenlor toDicalmicoDazole Topica.lantibiotics Eryrluoml'cin

G. NecrotizineFasciitisfHemolltic Sueotococcus Gargene) l - A nnrniudrg ideaion of tbe supnrficia.land deepfascia- Thrombosis of subcubneousvessels occur *ith galgrene of underl]'ing tissues. 2. Disorderusuallvfollot-s a cuaneousinjun (puncorre$ound or lac€ralion)and mos commonlr' involvesthe extrem.ities. 3. Earlf in course,affecredaleabecomesred. boL a_!dedemslous. BeNl,eendatr 2 and 4- skin assumesa blue, drsh' tinge. Blisen ma1.be present. hoc€ss ad\.anceslo areasof fi-ank culaneousgangr€nen'ilh eyentualsloughirg 4. R-adiographsusually reveal gasin t-hesofl tissues. 5. S. plogenesalonema1'be the cause.but more commonll.amixture of aerobicandanaerobic bacleriais responsible. 6, Tre€trent: Im.ur€diateI&D htrar enousanlibrorics

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V- CUTANEOUS SIGNS OF BACTERIAL INFECTTON .---A . BacterialEndocardrns 1. A-ninfectionof nativeor prosfiedccardiacyaivesmosl conmonl\,duelo variousStrep.& Sraph. 2. lnfection causesvegeurtionsof fibnl\ pialeleG-blmd cells.andorganims to form on lhe yalve. Thesevegeutionscanbrealiofland obflruct small andmediumsizedvessels. 3. Mosl p:rienr bavea fever anda hean mumur. 4. Four skin sips can ocalrr: a. Petechjae:snutllreddish-brosn,nonbajancingmaculesor slighth'raisedpapuJes most commonll' found on lbe er:tremiriesand mucousmembranes.Developsin I G.20pl"of tbe qrses. Hemorrluges:I -3rurnbrorrrLred or blacklineardiscolorations b. Spli-nter beneaththe nail plare. Occrrrence is 20olo. c. Osler'sNodes:red or purplepeinfir.lnoduleson padsof fingersandtoes. hesenl in lO7o. d Jaleuar"s ksjoru: nontender,enfiematous maculeson Flms andsoles. Occurrcnctis tsyo. B. Di sseminaledGonococcallnfection L N. gonorhea is D-ansmifledb) sel-ualactjrit]. Diss€miraled diseaseoccursu'hen gonococci enterthe bloodstreanr usualll'from an as.mptomaticlocation(urethra.phawnx-rcctun). 2. Clinical fearures: a. Anhralglas: usuall-f invoh.ing severaljoifls (lrrists hands.lolees). Septicanhdds can occur. b. Tenoqnoritis: pairl suelling and eryt}lemaalong tendoDshealhs. pain on molemenls. c. Skin Lesions:begi:: as rin;- red papulesor perechiaeand becomevesicu.larand pumrtar with a gra)' necrolic cenler on an en'themalousbase. Usually localed on e$emilies. Oc-currcncers 50-707c Will usually clear in 4 days but new lesionsmay appsr. 3. Tre3tnent: Ceffriaxone C. SuohvlococcalScaldedSljn Svndrome 1. lnfecdon or mucousDrembrarecoloDi"ation u'ittr toxin pnodrcing S. aureusl}'hich causeslhe skin to cleaveat tbe granular cell la!'er. 2. Fe!'er ard irribbiliq' precedea generalizedrnaculareruptionwhicb progressesto diffirse ery'lherna. Vesiclesard bullae then developfollou,ed by skin separarion. Skin sloughsleaving a moisl" red baselhat quickly ddes. 3. Vesicular lluid is usually serile. Nikols\ts sign- shearingof normal epidermis in responseto lstera.lpressureis preseft. 4. Occurs mostly in children < 5 1,earsold 5. Trezunenl: Systemicano-biotics Possibledrainageof abscesses Possibleinu'avenouslluids VI. \'IRAL VESICTILAN DISEASES A Herrs Simolex l. Characterized $' small, groupedvesicleson a red base. 2. lrsiom are paini.rl, self-limite{ and usua.llvrecurrent Recurencesaverage2 a yan. 3. Altbougbthe lesjonsca:l occuranvn'bere,HSV-l is mostoflenassociatduith orallabial lesions and HSV-2 with genitallesions. 4. Fevetbli$ers andcold soresaret})emost commonpresenbtionof reactiraredHSV infection. l-€sioDsocclr at tbe oral mucoculaneousborder ard outerpoflion of the lip6. Tle vesicles progresslo ulc€ratedareas$at heal s'ithoul scars. 5. Lesions usually crust $irhin 4-5 days and completel)' disappsr $ithin l0 days. \'rral shedding endswbel lesionsbave crusled 6. Prinarf idection results most oflen fiom direct contactrrilb alotler idected person 7. FactorsO|atinitiarc rezctivation: IIV radiatio4 fever. emodonalstress.fatigue, EaurnameDsrualion-and pregDanq'. E. HSV's conrail a lineardouble$randedDNA molecule.

9.

Treauned: Acvclorir Pa.llisoveCare: aralgesics.antipn:ntics

Varicella(Chickenpox) 1. Highl:' conugous diseas€caus.-d bv prirnaryinfectionlith varicella-zostervirus, a memberof the herpesfamily. 2 . Er:periencedb1 most cbildeD- usualh i-othe spring. Characterized cropnofuidespreadpruritic, small,cle:r vesicleswith pink [' 2 or 3 successive ha.loson lbe scalp,face, mout\ and trunli 4. Lesionsbegrnas rnacuJes andprogressthroughpapujes.vesicles,andpusn est|at crustand hea.l usuallv u'itltout scarring Distinctive fearur€is that in onearea of the body all of the $aees of a iesloncanbe seen. 5 . incubationis aboutl4 &ys. CoDstiuionalsigns(fever-chiils, mya.lgaqand artlrralgas)ma-v precedethe rash [' l-3 da-ys.Crusting of fie lesion usually occurs ['day 6 *ir]r complerc heafilg in l-3 weels. 6 . Disase is acquiredbl directconuct \ith lesionsor ir*nlation of infectedairbomedroples. 7 . TreaEnent:Isoiation Antipruriticsandantip\Tetics(Nonsa[cYlateaspirincancauseReye's S]Tdrome) ToDicalantibiotic ointm€nt

B.

C. Herres Zoser (Shineles) l. Characterizedby pa:nftI, srnall groupedvesiclesoccurring on an hJlamed bas€and usuallv localized to I or 2 derrnalomeswithout crossiagthe midline. 2. Vesiclestend to enlargeandbecomepEstularin 3-4 daysthen erodeand crus!iD 7-10 da's. Patient is contagiousrmtil vesjclesform crusl Scarringis cornmon. 3. Rash is usrully precededby a prodrome offever. nalaise, headache,and localized Fain and para*hesias lasting 14 days. Llmphadenopathyis also commo& 4. Varicella results fiom pnmary infeaion and herpes-zosterreprese s reactivatjon of lhe latent virus. 5. Treabem: Usualll' self-lirniting and u-e.amentis unnecessarv Ac-vclovir Topic:l Zostrix (Capsa.icin)to reducr pain D. Hand-Fml-And-Moulh Dis€as€ l. A relatively benig4 highly conagious, self-limiting disorderusuallv secn in infan$ aJd ]-oung childten. 2 . Acquired by direct contad and caused Dost comDonlv b_ycoxsackie virus -A16 or entercvirus 71. 3 . After an incubation of l-3 da-ys,2-8mm brigb! red macdes appear on the tongue, hard Flale, and buccal mucosa. Ttese lesioDs develop inro lhi!-r .alled gray vesicles surrormded by a red balo. Healing takes 7-t0 da1s.

4.

5. 6,

lesionson the sidesanddorsumof the banG, feet,fingers,and toesoccuraf,erthe oral Curaneous lesions. Idtially- theselesionsappearas red papujeswitlr snnl! thirl gral' .r,esicles appeanngin dre center- Tbel' are usua.lll oval or linear and run parallel to skir: Iines and usualll'resolve in l0l4 days. Sorethroaland mouth,arorexi4 nalaise,andfsver arealsocommon. TreauDe : Slrnpomaric rhenp-v-diseaseis usually selfJimiting

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7 VT- \'IRAT WAXTS O'ERRUCAE) Wans are benign gro\rdts caused b] papillomariruses of t]re paporavirus group. The-r-are slo*. gro$ ing DNA-conlainhg Yiruses tlat replicale ir the uucleus of cells- Thev can occur on all areas of the bodl and are ven mmmon on lbe foot. Wans are boused in the epidermis. Upon debidemeD! pitrpoinl bleeding occurs because the 1'essels in 1be dsrmal papilae are sut. Remember. rhe dermal papillae have finger-like projecrions that irterlock rirh $e €pidermis.

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Vemrca Vu] earis l. Most commonform of qar! 2, Seenon firgers. hands.-andlmeesmosl comrnonlrin cbil&en-3. Firm noduleexhibidngvegeEdons$lth thrombosedcapillaq lmps. Theseare fte $"ns blood suppll and arepathognomonic for n,ans(lookslike black dorson the skin).

B.

Verruca Plantaris l. Traumaat pressuresileson planErsurfaceofthe foot aliowspenerationbl'\\"n virus. 2_ Hl?erkeraroticplaqueuro thrombosed capillariesform (m4'not be noticeableuntil debridement). 3. Tenderon lateralcompression.

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C. Mosaic wans L Ver-r'large.diffrse groupof s'afis uith ill-definedboundaries.Mar' lmk similarro a callous. 2. No pinpoint bleedingupondebridement becausethe dermalppillae are not pusbedsu;rrfictallr'. l-€sion has a more horizontalthal venica.larranpement. D. Histolosv of \\rans l. l-argevacuolated"suiss cheeseeffecl" ofrrarg plug?. $lcrotic nuclei: srnall shrunkencells. 3. Basoph.ilici.nclusionbodiessurrounded [.a peri-nuclearhalo. E , TreaEne of Wans t . Acid TherapJ' a. Best consenztive approac,bb. 807"Monoclrloracetic acid (N4onoc€te) is be$ for sharph,circumscribed$ais. c. 60% Saliq'lic acid canaisobe usedaioneor in combinauonwirh the monochloracetic acid. d Fot the mosaicRzrls, it is betrerto usel}te monochloracericacid becauseil doesn'l sDreadoul ugno *'eightbearing aud destrol.surroundinggood skin, Iike &e salicllic acid pase joes. e. Trealment lakesabout6 *eeks. hasa successrate of 75-g0yo-and is oflen paiDftl. 2 . Surgical Excision: mus be down lo rhe level of tlre superficial fascia. 3 . Cryotlerapy' (Freezing):very painirl and nol very effecti!'€. l,aser Sureerr' F. MolluscumContaeiosurn l. An epiderrnalDNA pnxvirus n hich residesin tbe keratiroc]le. The virus muJtipliesand forms globulesof vira.lproteins (molluscumor Henderson-panersonbodies)2. Hisorically, the diseaseuzs recognizedas a higbly conugious childhood condition More recently. il hasbecomea sel.uall-l'b-ansnineddisease. 3. lncubadonperiodaverages 4-8 weeks. 4. Indiridual lr?ns occur as as\lnpomatic smootb-surfaced,flesh-colored-bemi-sphericalpapules severalrnillimeters ir diameter. h 257o.theselesions are surrouDdedby a flaq elrthematous halo. This centralumbilication is pathognomonic. 5. ln children- face. extemities. and sometirnes trunk are ilvoived. lrsions spontaneously involute 6.

over several monrhs. Total course is abod 2 years. Ir adults, irner thighs, pubis, and genetalia are usual.lf involved. Resolutionis quickerthanin chil&en.

\/NI. DER]TIATOPII}TES AIYD SUPERFICIAL TUNGI Dernatophlres are capableof colonizing or infectiag keratinizedrissuesuchas bair, nails. and stralun comeum- l-ofecriorxare causedbv membersof tbe generaMicrosporurn Trichophyton-and Epidermopbyres. A KOH fneparationca-obc pcrformed in order ro identif,' tbe specresb]' culture. A i.

Tilea Pedis(Arblete'sFool) T. D€nlaErophltes.T- rubru.El-andE. foccosum are tle main causadyeagents.

ltching andfoul odor arethe mostconmon s\lnploms. Fourclassifications: b], mac€ratiolanddernatitisjr: theroe webs. Skirjs----a. ChronicInterdisilal:characterized _ *'hite witb a foul odot. b. ChronichpulosouarnousHroerkerarotic:chracterizedb'fine, dr1',$'hite scalestult rna) be patchl or coverthe foot in a moccasir-liliedisrribution.Usualll occun bilateralll andrs assocraleds'iti T. rubrun b) tensevesiclesand bullaecontaininga serousfluid c. Vesjcularor Subacule:chamcierized menugrophlles and is the form mon responsiblefor an id reacEon $.ith T. associaled Usualll' on other Pansof tlle bodl'. d. AcuteLllceralive:a rapid sprerdof an eczemaloidvesiculopustuliuFrocess.Secondan' bacteriai infection car occur and t}revesicular flujd tums purulent. Can involve latge areasof tbe foot ard en appearu'ith cellulitis llmphangitis,andllmphadenitls. 4. Trcatrnent:Appropriate hygrene-avoid going barefoot,nash and {'feel dai\'. Topiel rmrdazoleagenls(usuall]'fot 2-4 weeks) -Clotrinaz ole O-otrimin) -Miconazole(Mcatin) -Econazole(Spectazole) -Ketrcornzole (Nizoral) - Sulconazole(Exelderm) O)iiconazole (O)iisla0 B. Tinea Caoitis t, Scalp ringworm caused['T. lonsurarls. 2, Non-inJlammator-1 $'multiple scal)'lesionsandareasofbroken hair. $?e is characterized C. Tinea Barbae 1. Commonll' referred to as barber's itch and is most oft€n seenin farm workers in co act \vith anirnals. 2, The superfcial form appears\r'ith scalin& er--\4iemaand broken hair associated$'ith T. rubrum aad T. violaceum. 3- In deeperforms perifollicular pustules-cnrsting and exudalesare seenassociated$'itb T. vemrcosumand T. menngrophytes. D. Tine3 Faci2le l. Presera as eD'tlernatous,scaling pruritic lesions on lhe face and nedr 2. Causativeorganisrnsare T. rubrurq T. menlagopbles, andM. canis. E. Tinea CorFris dry, scaly l. Characterizedby I or more circu.lar.slurply circumscribed,slightll' er-rr-hematous, parchesu'itr progessive central clearing on the runk aad linbs. 2. T. rubtur\ and T. menbgtophltes are most commonly involved 3. Majocchi's gtanulomaconsistsof perifonicular and granulornatous,slightly elevated nodules occurring on lhe lower leg. F. Tinea Cruds l. Commodl'bronn as'Jock irch". 2. Appearsasvell demarcated,scaling circirate lesions$ilh el-rlhelnatousraisedborden invohing the groin and intertriginous areas. 3. T. rubrun- T. me agrophles, and E. floccosum are most common G. Tins Versicolot J. Cbanderized b finell scaling gutule or nummular prches occurrhg on the upper Eunk and enending onlo lhe neck and arms. 2. Causedb1'dimorphic I'eas, Pitlrospotum orticulare. H. Tinea Marum l. Cli.ncal presenEtioorangesfiom mild, aqmptomatic scalmglo discrete\€siculopusnrlar plaques and parches. 2. lnvolvementof onehandandboth feel is commonandunexplairlable. 3- T. rubrumis mostcorrmorr l. Tinea Nisa 2. 3.

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l. -2.

A supcrficial infeoJon of the so-arumcorneumcausedbl Exophialauemecki, Usuallv found ir fopical and subtropicalaras. An a$mptomatic.nonscalingdarkbrourrro black-lesiononlhe1nlmsJoles.andfilgers

IX, SIIBCUTANEOUS AND DEEP FTINGAL INTECT]ONS A- Mvcetoma0\4aduraFoot) l. An hfection causedo,'\'a wide varien'of agents(bacteriaandfungi found in soil and plants) resuJti.ngin an indolent mndition consistingofa triad of rumefaction,&aining sinuses-and grains (mi croc-olonies of oreanisms). 2. lnfeadonbcginsas an initial implanbtionlhat formsa localll inrasiveindolenl tumor-likemass. Tbc rlass sloutY enlatgesand sinusrractsform- and edemaald induration lead to scarring ilto a $,oodenfirmnessin pansoflhe tissue.Ne$ nodulesform andmoresinusFaclsdeveloDand desruction of the tissuea.ndbone occru_ 3. Treiunent: I&D of abscessand surgicaldebridement Antimicrobial thenpv dependingon tle causativeorganisu X, PAPULOSOUAMOUSDISEASES A Psoriasis l. A chronic, in{lamm:lon ras}rqith increasedand rapid epidermalpnoliferationresulting in accumulationof stranrmcomeult 2. Classiclesionis nell-circumscribed,entterDalousplaqueu'itb a dry, silve4'scaleappearingon exlensor surfaccsof the limb6. ksions ar€ bilaleral ard slmmetrical in dism-bution 3 . lrsion exhibirs rhe Koebnerphenomenonu'hich meansreplication of skin in an area of pressure due ro scr-alching 4. Remo\"I of lhe scalesrcsultsin piryoint bleeding hloqr as lhe Auspitz' sign_ 5. Nails are irvolved in 50oloof the casesand presenl$it}r lued depessions and onl,chollsis6- Different twes include: plaque-gunare.erltuodennic, pustular-and anhritic. 7. Histopathologr:Eoidermis-hlperkeralosisand ac2nlhosis \r'itr elongatedrete ridges. A.lsosee Murro€'s (a collection of neutrophils in the matum corneum). absc€sses Dermis- capiltan, prolileratjon with psivascular inllammatron. 8. Tre3tmenl: Lubricarts Tan Arthralfu (bydrocarbonoinEnent) To,picalconicosteroids Phorotberapy-Ultraviolet B (J\lB) radiation Oral psoralenplus ultraviolet A (PUVA) Roralen is a drug derivedfrom plar6 R'hichl'h€n actiuted by' long save UV lighl is phololoxic and melanogenic. The W lighr causesbinding of the PsoraleDto DNA lbus inhibiting DNA productio4 therefore, inhibiting cellular producuon. Sl,semicthenpv-.merholrexare. retinoids-cvclosporin,hy&o4urea- r,itaminD3 B. Reir€r's l. A seronegativeaqmmetric arthopathy. Slndrome consistsof conjunctivitig uretbritis, and arthdtis. (9:l) andmoslFriena bavean HLA-827 hadob?e. 2. Diseasehasa srong malepreponderance 3. Classiclesionis rermedkeraroderma bleDorrhagicltrtr. Very sirnilarto pum:lar psori:sison the palmerandplaaur skin but lesionsofReirer's bavea thick laverof keradnoverll-i-ng the pusn es. .1. Penisms) also be rnvolved n'it! moisl. red plaques. 5. Treatrnent:NSAID's lmmunosuppressive agenc

11

C. Lichen Planus 1. An idlarnmatory dermatitis of unknown etiolog' tlnt is primarill' papular in origln --J-Violaceous, tolygonal llar-lop@. pruritic-papules displayinga lace-likeFn€m-ofwhite lines (Wickhm's striae). on tbeir surfaces 3. Lesionsappearon flexor surfacesofthe \rrists andforearms,Iumbararea,penis,ankles,anterior aspeosof the legs.anddorsumof the hanG. Lesionsdispl4' tbe Koebnerphenomenon. 4. Mucous membranesare aflected in over 507o 5. Nails are involvedin abour107o.Mosr clmmon chrngesare thinningand longirudinalridgtng of tbe naiJ plare and or,vcholYsis. 6. Variarts include: anaular, lile3r, hlperrophic, atropbic,bullous, ulc€ra ve or etosive, Iupus ery$ematous overlap- pemphigoides-and planopilaris or follicular. of *re basalc€ll layer. Damaged Eoidermis-hperkeratosis$'i1hdegenerarion 7. Histoparholog_v: 'sawtmtlr" appearanc€. Clusers of eosinophilic cells releasemelanin Acantbosisresulring in a bodies resull from keratinoc]'le degencrationand are seenalong fle epiderDajdermal junction. Dermis- bandlike lmphoci'tic infiltare in uper dermis. 8. Tre:rment:Oral, intralesionaland topicalcortico$eroids Andhistamines Pbototlleran' Slstemic rednoid rheraB' Daosone D. Pitwiasis Rosea I- Acute- self-limiting inllanmalory diseaseof ur oo\r'n but suspectedyiral etiologr- affecting chitdrcn and )'oung adulrss'ith the highest incidencein tbe n'ilter. 2. Lesions are found ro oval, eqthenutous ppules and plaguesuith an innef, collareue of scale The c€nler usuallv sbows someclearing . "herald ptch" usually on t}re trurk rhal begins as a slnall 3. Firsr cutaneousmanifesution is a er]'thematousFpule and rapidl-va round ro oval palch 2-10 cm in diametcr. l-esions are distn-buledalong lines of clearzge on $e EuDk aDdproximal extemities ro producea'Christm:ts re€" panern4. Trcaturcnt: Topical conicoseroids Ulu-avioler lielt E. Pitwiasis RubraPilaris 1- Chancterizedb'hlperkeralodc follicular Fpules. salmoncoloredscall'plaques,andpalmerpladar k€ratoalerma. "island spari:rgl- normal appearingskin widrin sheds of eryLhema. 2. Sriking featue is 3. Lesions usualll appearfim on the upper half of &e bodl', ofien in tbe scalp, and spreadcaudally. 'keralodermic 4. PlanrarlesioDsca! extendup &e sidesof t}le feel lo producea sharp\' demarcaled sandal". Fissuring is common 5. Tre.atment:Topical stroids- emollienls, and keralol)'tics Sysemic rerinoids Metlotrexate Oral vilamin A

X- ECZEMATOUS DISEASES *boiling over". We useI as a generalterm. The hallmark of all of Eczlma is a Greek u'ord meaning the egzenrasis the presenceof itciring. All conditiorx car appearin lhe acule, subacute.or chtonic phases- Trgrmenr of egzemaof ulho$'n etiologi is usuall]'lopical cordcosteroiG.

A

Alopic Derrnatitis n'ith as.hn4 alergic rhinitis, or ha1'fever. 1. A geneticdisordersometimesassociated 2. Frequentlf immruogJobulh E is ircreasedin tbe serum 3. Skin diseaseusualll' srars in i:rfanq and marl' chil&eo exTeri€nc€resolution afler 2'6 -vears.

12

4. 5.

-

6.

3 phasesare: infantile, childhood and adolescentor adull Sites commonll' aflected are: face, scalp,diaper areasandbunoclcs,bands.antecubitaland poplrcai rossae.Aggrarzting faclors: e):tremelemperarurechanges,s\yeadng bacteria. soap6,and delergenrs.

Contaq Dermatitis Allereic ContactD€rrnadus a. A cell-medialedgpe IV, delayedimmunologicreaoion. b. 2 phases:Firn is sensitization in lhich the patienlbecomesallergicto tbe chemical-The secondoccurs uitt comilued or repealexposureto &e allergen. c. Eruptionsusualll appearasitchl'feet- generallvofa chronicnaturesecondal to shoegear breaking doun and p:tting the feet into contact$'ilh various componentsof the shoes. Dors.rm of the foot is the mos conunonarea. d 2 common a.llergensin shoesare merepobenzotiiazole and tetramelh]'lftiuran s'hich are usedin rubber adhesives.Phenolic resiru. lea*rer tanning agenrs.and formaldehl'de have also been identi.fiedas allergers. e. A diagnosiscan be confrmed l'ith a patch test by cutting out a snull sampleof the shoeand placing il on the patienrsback. A sho€contacr dennatitis kil is also auilable. 2. Irritanl ContactDerrnatitis a. Represenls8070of conlact dermalosesand resultsfrom non-immrmologic physical or chemical &mage ro the skin. b. Skin reacdonsm4v be acute.as e'ilh ex?osu.reto acidr or chronic. due lo repeateddamage fiom a weaker agent.

B.

l.

C. SeborrieicDermatitis i . Usuall]' occurs ar 20-40 yearsof ageand persistsfor life. 2. Occun i.Dhairj'areas and clinically consins of mitd erythenu coveredu'il}l a greaq'scale. 3. Most commonforms: a. Scalp seborrhs can mirnic psoriasisbut is less scaly, more diffi,rse,and more ssil),managed b. Facial seborrheaappearsu'ith a mild enrhema and gres-r' scale in the paranasalarea. c. Truncal seborrheuoccursas small circinare or peuloid pardres in the cenfal chesl. d Flereral seborrbeaocqrrs in rb€ axilae, groirl ard infamaaunary areasand is similar ro the scalp lesions. 4. Patientscan bav-eI or sev-eralforms simultareouslr'. 5. Etiolos' is udsto$.n but e\ad€nce favon Pit-wosporum orzle. 6. Treatrnen:Kerarol'rticshzmpoosZinc pFithione (Sebulon,Danex,HeadandShoulders) Seleniumsultrde suspension(SelsunBIue) Salc_vlicacid and sulfur (Sebulex) Topical $ercids Tar preparations Antiirngals (KebcoDazole)

D. StasisDermatitis l. Characterized b'en'thema- dependenledem4and hemosiderinpigmentationof the distalloper legs. panicularly medially. 2. Most mmrnonly occun asa consequenceof phlebitis or raricose veirs. *'hicb lead to venous insuff ciencl', r'enous hlT,enensioD,and eventua$' stasisdermalitis. 3 . Srasisu.lc€rsare a cornpllcationof unconfolled disease. 4. Trealment:Control tre venousinsu.fficienq- suppon $ockiDgs eler.ation diurebcs E. Dvshvdrosis(Pompholrx) l. A non-inoemmero4,idiopathic-recurredvesicularenption on tbe palmsandsoles.

13

prudlic.buming vesicles.I-5 mm in diameter. Charaderizedt!'s\mmetrical, rensc,deeFFseale4 palmsand solcs. Vesiciesma) coalesc€lo the volar aspects of the on the sidesof tie digl6 and -form bullae or evolveimo sterilepusnrlesrlurd5-andshrhliorruFure bass is a -i. The caus€is unlmo*Tlbut the patientis usual]'a Bpe A personrlitJ"thus a ps1'cbogenic uilh sress is exacerbaled Disorder possibilil . 4. Treaunent:Usualll' reqrondsr.eD'poorl},lo all $eraF. otherttan s]'stemicsteroids Toprcal corucoseroids and antihi $amines Cool qzrer soaks 2.

--

}f I. CUTANEOUS DRUG REACTIONS A Enrhema Muitiforme I - l"ndtoore chu*cterizedclinicall)'b)' acute.selflimiled but ofien recurrentepisodesand by q'urmetricalJl distribuled toun-d fxed skin lesions svoh'ein se1'eral papule. Overhoursto dalr lhe papu.les 2. frrna4'lesion is a roun4 erl'themalous differentPuerns. 3. Lcsionsma1.cn]argeald codesceto produce.snnll plaquesor ma) e\olve $'idl concent'iczones andcenFalponion is u'hire. lo reyealtargetlesions.Outerzoneof rargetlesionis eryrhemalous yeuow, or graY. 4. ln 25o%,the lesions arc limiled to lhe oral cavitv. 5. Treame : ToPicaJconicosteroids Antihislamtnes B.

Srndrome) Enllrema lr4uitiformeN4aior(Stevers-Johnson I . Usualll follots a l -14 day prodromeof fever, nalais€, cougb- sorethroal. aflhralgia, and nryalgra. q'hich are 2. lnllammarory bullous lesions suddenlyappezt on lhe mucolls membrares crusls. characteristicalll' coveredby hemorrhagc plraryrui, IaSru;- and lo\r'er resplrarory trdct can 3. Bilareral pumlcnt conjrmctiritis a!pe2rs. r.Nares, be ir:volvcd 4. Skin involvernenlraries fiom unicarialro urget or bullouslesions. 5- Complications include: blindness,renal failure, pneumoni4 scarring of the skirl and nail loss. 6. Treaunenl: I:rge dosesof q'stemic steroids Moa2litv of patie s not treztedis 5-15%

C- Enthema Nodosum l.-Most oflen presentsnith the suddenonselof ill defined- tender,e4tlernatousnoduJesot plagues distribured slT1merricall.vover the anterior lo*er legs. 2. Initialll lesionsare rcd- ;Ug.htly€levate4ard l-5 cm in diameterwith difitse borders. Nodules evoh,ethrough color changesofa bruise fiom red ro blue 10)'ello$' $'i1h a IteeD tml 3. Nodules-a)i las benueetrl-2 rveeksand usualll resolve$'ithout scarring.EntiJeepisode subsidesover a 3{ week Period 4. Fever,malaise,and artbalgiasnral'precedelesions. 5. Femal€sareafleded more thanntales(9:l).

67.

Etiologjc facrors include: intectious ageds, sarcoidosis.inJlatnnarory bol{el disease.a::d drugs suchas sulfonamidesand otal contt:lcgptrves Trsrment: NSAID'S Oral Poussium iodide Steroidsare nol lhal eflective

XfI]. GRAIYULOMATOUS DISEASES A. NecrobiosisLjpoidicaDiabeticorum i. cuu-.r.-.t [' se\led shzrply bu1irreguJarll dernarcatedp:.tches.usuall]' on the shins.

T4

2. 3.

5

B. l. 2. 3.

lndrraed prches ap;rar vellouish in centerandviolac€ousal lhe DeriDhen.. About 759'oarefenalesandaboul2/3 havediaberesmellitus stoPa&01ogl--De8€neration-orrecrobiosisofcoliagenrvithpoilrnorphic cellularjnfrlu3les-.----------composed of llmphoid cells,fibroblasts.andhistiomes. Treatrnent:TopicalconicoseroiG Intralesional sleroid injectioD

GranuJomaAnnulare A benign usualll selflimiring disorderof unloo$T etiologr. Occurspredominantllin childrenandvoungadults. Aflects \r'omenmore commonlvlhan mer:4 clinical q'pes:localized genenJizd perforaringand subcuuneous(deep).

4.

l-ocalized is tle mosl corrunonard presentsu.irb a limited nunber of a-qrnptomatic,fleshcolored to red-purple. I -5 nrn dermarpapules,often arrangedin an arciform or amular panem. 5. ksions fourd mos{comntonlJon $e lunds artdfe€t. lnYolvementof &e arrns.legs-trunk and fact nuy also occrrr. 6. Hislopathologl':Focal degeneration of collagenwith ar inJlarnrnalorj' infiltrale andfbrosis $'ithin lhe dermis. 7. Trstme : Sponuneousresolutionoccun in 507owithin 2 .r.ears. >3V. NAIL DISORDERS A. Psoriasis:subungualkeratosis.nail pining onvcholvsis.discoloration(oil spols). B. Lichen Planus:longirudfuElgroo'ing andridg:ing sheddingof nail plareani arophy of nail be4 Preryglum formation subungualhlpe.rpigrnenaion. c. Darier's Disers€: longiDldirurlsubungualred and *.hire sr'e:ks. distal u.edge-shapedsubungual k€ratoses. D. Ajorcia Areata:pined (stripped)n,ril<. E. onvcholvsis: separationof nail plarefrom mil bed- psoriasis,hl.porhlroidisrq hlpenhlroidism, pregDarc]'. moniliasis, teuacyclhes, aftitrcial nails. F Clutrbins:bilia{ ciriosis, chtonicrespir-atoN illnesses,congenihlheaadefec6,familial. 6lcrease in I-ofiboDd'sangle>180degrecsl G. SDoonNails (Kojlonvchia):faulryiron meubolisrr, familial, inllammaron'skin diseases, idioparhlc. H. OnYchog-\phosis:b)?erfoph) and cu.n?ture-t-auma or circulalory disorder. L Anonvchia:Steveru-Johnson svndrome,epidernolysisbulJosa,absenceof nails. J. Beau's Lires: transversefillroqs- s-vstemicillness. faurn:t K. Onvchoschizia:spliningof distalnail plateinro laven, dehvdrationofnail plate. L. Ilalf and HalfNails: proximal u'hjre, disral red- renal disease. M. Muebcke's Lines: rurron. u'hite, n'arxlerse balds occurriag in pam- hlpoarbuminemia. N. Mee'sLines:q hireEansverselines.singleor multiple- arsenicpoisoning O. Onychorrhexis:ta-ightnesswith breakageof nail. P. Tern's Srndrome:disal t -2 mm norrualpinli color, proxirnalend hasq'hite ap1earance-cirrbosis. Q. RacouetNails: hherited disorder. R Median Nail Dvstroobv: invened fir tree- trauma. S. Leukonvchia:shire discolorationof nail plate,bed, or matrix. T. YeUowNail Srndrome:pulmonaD.diseaseandllmphedema.

15

s t

DIABETES I\IELLITUS Pat bogenesis Group of disorderscbanoerized$ gJucoseintolerarce.hsllin producedb]'beta cells ir tle paacreas decre:sesblood glucosebf inlu-bitinggj)-cogenbrealidormandfacilitateseffi\' of glucoseino the tissues. h1'pergl,'"cemia \Vhen rissuesfail to usegJucose. resulls.Dabelesatrects2-596of the populadonin the U.S. Tlpes

Tlpe I (IDDI\O lnsuhndependentdiabetesqas formerll calledjrn'enile-onserdiabelesbut nou is referredto as q?e I becaus€it is not re$rjctedto lhe jureuile agegroup.lt is charaderized b)' abrupl onset,pol$ri4 poll'dipsia. pollphag4 and oflen rapid weighr loss. b. T)?e I I (NIDDM) Non-ilstrlin de;rndent diabetesnas referred to asaduh onset Slmploms are oflen lesspronounced$an t)?e l. Patienls\rith NIDDM present\ith ihixt, pruntus and fatigue. ftiesit)' is presentin 60-90% of thesepatients. c. Secondary pancrea$c l. FaDcreaticdisease:hemochromalosis, defcienc], pancretectomy 2. Hormonal: Cushing's srndrome, aoomegall,, pheochromocl'torna 3. Drug-irduced:thiazides.diuretics,seroids.phen-.r'toin 4. Genetic *'n&omes: lipodystropby- myoronic d_vsrophy.aUxia- relangiectasia d impatredglucoselolerilce (iGT), alsolsro$'nas chemicallarenLborderline.orsubclinical e. Gesational: glucoseiDtolerance$ilb onsel drri.ng pregnancl a.

Distinguishhg Featuresof DM Featu res a8e onsel prerzlence Kerosis weight complicadon genetics:HLA monozlSotic trl'irx lOOo/o islel cell anlibodJ' insulin secretion h1,perinsulinisn insulin uearment reqrured insu-linresisla.Dc€ defecl

IDDM <30 -2-.3Yo colrrmon nornral freguenl yes 4O-50o/o

NIDDM >30 240/o I:IIE obese (80%o)

usualh not

occasional:poorconu-olexcessantibody

usual: receplor

Diagomis a. b. c.

d.

Classic qmptorns: polydipsia, polrplega polyrria Hlpergl'lcenia: fasring plasma glucose level greater than l4Omgdl on more than one occasion OraJ glucose tolerance test: 75g glucose dose dissolved il 300n1 $ater a.fierovernight fast: plasna glucose above 200mg/dl al both 2 hrs aDd al least one ol}ter time between zero and 2 hls. Henroglobin Alc: (gdcoqlaled hemoglobir) Concerurationin nomoal indiyiduals 3{o/o; padents R'ith DM haye trvo-lo lbreefold elsYation. ls a rough reflection ofthe mean leYel of circulating glucose for the pevious 2 lo 3 moDrhs oife of RBC-120 days). / ,

- -

)

(r{,'Al. x35.i)'bA

I I I I I I I I I I I

no moderalelo

always

r

1,

freguetrl no Concord near

)'es sereredefcienq,

t

I

- - : b1 r c " ' l ) * 1 + r

l6

I I

Trr|tmeDl

a.

of reaEnent.Objectivesincludeproriding nuEiuontr'ift a balanc€of Diel : is lie cornerstone

- . protein fat and cadohydrates a.trd10 norn allzg lvqt€lf!

Ord H)'pog.tlcemics:Sulfonl'lueas are recommendedfor palieDtsnith s,rmptomaticNIDDM s'bo cannolbe controUed b dretaloneandin \\'homan addiEonof i:rsr:lir is impracticalor a detaileddiscussionseepharmacologls€ction.) unzcceptrble.(For c. I-rxulin : Usedprimariil'for the I?e I (IDDM diabetic uho is h1'poinsulinernicard prone to kerosis.Also canbe providedfor 5'pe I I diabeticwho is nol compliantq'i& diet.(see pbarmacolog,"-secbonfor deuils) CoDplicetions A. Acule: l.Ketoacidosis:precipitatingfacton- infection-omissionof insulin-new ons€tdiabetes a. cbarac.b) pH 600mg/dr*ithoutketosis-see b. Siens: lethargr .confixiorr seizures.coma dehl'dration ht'penension polytna. poll'{psia K+ and phosphale) c. Tx: fluid replacemenl insulin. electrol)'1es(esp. 3.lnfecrion: al increasedrisk dre 10triopalhy A) neuropatby,B) \'ascular insuffciencl.and C) irrmuropathy a. inrmunesutusdecreased dueto granulocrtedepletionanddefectivephagocvteingeston b. nephropathycan compromiseantibiosis c- lnfections car include epidermopbYlosis,ascendirg UTI. pvelonephritis.sepocemiaand gasinfections d (seeseaion on diabeticfoot idecdors for details) glucose<50mg/dl l.Hl.poglycemia-plasrna a. due10 I )IDDM -imbalancebfir'-iEsuiinandgJucose,2)reactiYe-insulin secretionvs. absorpdonof food 3)irsulir overproduoion-pancreatictumor or alcohol ingestion 4Omg/dlor less3)immediate b. Dx.: WhipCe's triad-I )riskof b1'pogJlremia,2)BS rccurence following adnin. of glucose adjusrmentof dosageatrdpatienteducation c. Tx.: relatedro cause(ieirsulinoma-surgerj,) ir reboundblpergl]'cemia-ma)be duero b1'pogll,cenia resuJrs d somog]'ipheDomeDon: excesssecredonof cou.Dte rregdatorJ bormones(gucagonand epi-nephrine) B. Chronic: I .Alherosclerosls a. Possiblydre lo oxidationofLDL plagueoccludirglargervesselsM, HTN, CVA) b. maooalgiopath-v-iDcre2se basemenlmembranelhickening(neuropatht, nepluopathy, microangioapati] c. rerinoPthY) tib. Post.libandperonaelaneriesusualll' d. higlr incidenceof los'er exremit) disease-anr afleded(seeP\D secrion) 2.Reriropatbv a. increasedcapillary permeabili5' b. microaneul'sms c. bemorrbages d rerinal detachnent b.

t7

3.Nephtopathl a-Diffi,rse: 1. n'ideningof4:lomerularbasenlentmembrane 2. mesangialcell thickenilg

I I

b.Nodu]ar: I. accumulalionof PAs-positivematerialat the glomerularrufuOiimmelsteil-Wiison lesion) of aflerentgJomerularanerioles 2. h1'lanization c.Tx: l. srrict control of blood sugat 2. conrol HTN 3. decresseFrotein in diel 4.Neuropa$J.4natomic Clasif cation slructure signs/s!'mDloms

2.

disordcr

eliologr'

nePe rool pd4 dermaromesensoq'Ioss

radiculopa$l'

probabb'\'ascular

mired ncne vascular pain, weahress-setr.loss. reflex change

moDoneuoFatb)'

probably

nene &rmind sen loss(stockfug-glove) absentreflex mild weal ess,

polyeuropa&1-

meEbolic

I I I I

nen'e lermiDal(muscl€) anterior thigh pain \r,ilh wealoess

aml-.otrophY

uahrown

sl mpalbctic garglior pomrral byootension, imporence,gastrophy. a ydrosis-aduopaty

autonollllc

unlrrosr

Derrotxlliv

I I\

a. Palhogenicmechanisrns dueto sorbilol excess.swellingand ceUh1'perosmolaliq' l. sorbilolpathlrzy-schs'aan denruction 2. occlusionofrasa nervorum 3. decreasednerve myoinositol 4. decreas€dnerve conduclion 5. alteredm1'elinslnrhesisanddeficientreFir 6. molor atrd sensoryneuroPathY 7. autonomicdisorden 8. neurotophicfadors:nenegrou1bfactors Treamenl: L antideFnessarrs-amitritr)'liDel0-25m9 qd . noru-ipt1'lbe 300mg tid 2. anticon\dsant'carbamaz:Pine 3. topical-capsacm 4. analgesicVsedadves

I I

I

18

t t

Dirtretic Charcor Foot: a. pathophl'siologt-: I neuropalh]'-lossof+ai1r-percepion proprioception+ndsvmpo.theticactir.ittjoinl degeneration 2-t?uma:incre:sedweighlbearbgpnomotes and subhlxadon b. stages: phase,joinl laxit\ - subluxatiorlo$eochondnlfragrnenution l.developmenl:destructive 2.colescenc€: absorpdonof debrisandfusionof largerfi-agmenrs to adjacentbone revascularizanon 3.recon-struaion: andremodelhgof boneand fragments c. clinical features: yascular neuropathic boundng p se erytlrerna $lelling u,armfr d.

absenl,/diminished parn proprioception rr-bration deeptendonrellexes

skelelsl rocker bonorn ddormiry' medial ursal subhuarion digiul subhDiarion crepirus h_\?ermobility

culen€ous ulcer hlperkeratoss infecdon hvperhydrosis

treatmedt: l. casting/immobilization 2- accommodatjl€ foot ge2t 3. reconstructivesurgcr''

Diabetic Fmt Ulcers: 1. abnormalpressuredisFr'butionsecondaq'to neuropath,v -acc€ntuatedby faulty biomechanicsibonedigonion -poorly fned shoes 2. secondarj'lo cuts or Frncnne woundsfiom foreign bodies 3. higb infe.tion ralc often u'irh multiple organisru 4. prcrEntion is corlcfstore of Da -adeguateshoeg€ar -proper bygiene -control of blood sugar -fieguent inspecdon Diaberesrrd Surger-T: !.

2. 3.

good mebbolic balanceprior ro surgerl' -nonnal vital signtelectrol!'tes -blood glucosettn,. 100and 200 mg/dl -renal and hepalc staD$ -preopEKG preferableto admil parienl lo bospiral&e &l' before sugeD' lo adjust insulin dose glucosemeasuremenBse!'eralhn before and after surgery

Managemenrdring Minor hoctdures l. tbosepatienrsrmdergoinglocal ane$Iesia 2. rill be given oral nurition inmedjarcl]' posto'p. 3- no changeb diet oral hy'pogvcemicor insulin regimen 4. monitor glucise I hour before ard I bour afier surgerS' N{alagementduring Ir4ajorhocedures I -heop. eval -!Pe I \.s O?e II -qpe of tbemp'r (diel oral ' insuln)

r9

-diabetic control {valuate for anr sr-stemicmmplications -admit to lrospital a dr] pnorlo surgery,orZ-3da.vsif-poor control -preoplabs(ECG. UA Chemist'', CBC, gycol$taled hemogjobin) -scheduleearlYin dal-b€nerequilibriumbt$'insulin doseand caloric inake -if diet controlled and s.able, fasthg blood glucoseon t}e morning of surgery -rf oral hlpogl cemics. discnntirue tre morning before tbe dal' of surgery -if on insulinand mnirolled (<250mgdl), glve % the usualdoseon moming of surserv ?.

Inraopentive and Posoperative Maragemenl a. InDona consideratioDs -bloodglucose slrouldbe between 100-200mg/dl -fiequenl intraop gucose lestiDglo avoid ianogenic h1'pogJycemia b. : -

Mahods of maragemenr prEop$an IV $'iO l000ml 5yodextrose@5\1) $'ith 40mEg4- of KCL run at l00mlftr (needto dec.rale in pts. witl CIIF or rena.lfailure) adminisler% of usual moming insuhn glucosetesl inmediarely after 9rlgg-'1'

-

mnlinuery fluids al 80nJ u. monjlor blood every 4 to6 hr wilb aFropriare rcgularinsulin coverage {rloE dosecontinuousregular insulil IV solutionconsistof 100U of rcguiarinsulinaddedto 500 ml of .5% normalsaline solution Clucoselevel: follou'ing surgery,b\.dration slatus atrd glucose mos important info. diet controlle{ glucose<300m9/dl can manageon dier alone l2 ro 24 hrs afler surgery oral h1'pogvcemics,if glucoseurlder conEol, caDlafl ordl agenttre day follos'ing surgery uking insufin reguircsfi€quenl (er.ery4 hrs for tre fug l2 posrophrs) glucose lesring-insulin givenor y if patientsglucosevalues>3oorDgdl{njy reeular insulin is lo be usedat intervals of4 to 6 hrs.

Pharmacologr': lns,tlin. a. source-beef, podq hunan admin.- is a prolein structur€usuall-rgiven subcuuneousll adverserx. - mainly sx. of hypoglycemia -tachycatdia -confixion -venigo .diaohoresis b. prePaEhons:L RaPidacri"g <nstalline zinc or regular.can give su\ or r\/ -semilenle-onll given subq 2.lnrermediale -isophrne or NPH(neutral proramine hagedom){dl

subq

20

3.

holonged Protamine zinc-ma)i effect in 2.{hr -tfalente-gven+'ith-5€milenle{o form lenternintermediateafllng form 4.Humalog 70130

Oral Hl.pogl-vcemics:usedin palients $'ith NIDDM mechanism:-srmulate insull releasefrom beu cells -reduc€s€rumglucagol levels -rncreasebinding of insulin to brget tjssues adversent-: -GI disnlbances -hy'pogl1'cemia -prudtus _nausea -anemia drug interactions:l. Dsplacefiom plasmaproteils -clofibrate -phenvlbutazone -salic,vlales -sulfonamides 2. reducehepatic metabolism dicusarol {hloramphenicol .monoarnineoxidaseinhibitor .pben1'lbutazone

"*'$ffi":"**

Biguanide: (medormin) classificarion: antih)?errylcemic NOT hlDoglvcemic mechanisnr:decrease inestinat glucoseabsorption -increasedperiphexalglucoseupuke -incr. Iruulin -medialedglucoseugake {ecreased bepaticglucoseproducrion advanbge: -gylcemic con8ol u.jtlout weight gain (nhich occursu,ith insulinandhFogylcemic agenrs) -reducestotal serumchole$erol -rncreasesHDL decreas€s trigllcerides adverseni: mosts€riousis lacdc acidosis risk facrors (conu-aildicatioDs) -renal hsufrciencl -hepafic disease -seyerecardiovasculardisease -se1'erepulmonaD' dissse temporan' dircontinue; -fV contrasl mediun -hfection -sugeD. tr;runa -acuteMl angila

21

a a I -stroke dehldration -severe-Gljllness Drug ni: oral sulfonylur€avinsulin alcohol-ircrlacticacidosis crmetrdi-ne-incr medorminlevels nifedipine cationicdrugs(Tanilidine.riamlenne, tnmethoprim) nepbrotoxic &ugs aggressiveuseof diuretics Dose:500m9rabletsBID Rezulin (Irog.l i tazone) -TrogljbzoDeis a thiazoUdiredione altidiabericagenttnt lo*'ers bloodgucose b)' impro\ing targel cell respons€to insulin -TrogJiuzone decreasesheparicgJucoseourput and inoeases insulindependent glucosedisposa.l in skeleul muscle.Ils mecb:rnism ofaction is thoughtto invoh,ebindinglo nuclearreceplorsPerodsomeholiferator AcdvaredReceptor (PPAR) Oratregul.atethe ransrip.ion of a number of insulin resporsive genes cridcal for the controlof glucoseand [pid metabolism. -Rezulin is indicaled to improve glycemic control in patientsu'irh D?e 2 diaberesmellitus as an adjund ro dier and exercisein combination $ilh (not substitutedfor) : . A sultonl'lurea &ug for patientsu'ho are nol adegualeh.controlled wi& a suJfonvlureaalone or, . A sulfonYlureadrug togetbcrnith metrormin for ptients wlro ar€ not adegualeiyconEoUeduith Oe combin:don ofa sulfonylurea ard metformin or, . lnsulin in patientsq'bo are nol adegualelyconEolled qith irsulin alone. -Contraindications -Seyertidiosl'ocratic hepatocellularinjulT has beetrr€ported duriDg Darkeled use, Rezulir therapyshouldnot be iniriaed if the patient exhibits clinical evidenceof aaive liver diseaseor increascd s€ntmtr'ansamjras€levels (ALT>l_5 times the upper limit of normal) -Thus, doseadju$nenl in padenrswitl renal d_vsfiEctionis not necessary -Rezulin is nor indicaled as ilidal $erapv in ptients with t]T)€2 diabetes. -Rezulinis arailablein 200, 300and400 mg ublets as follows -Rezulin sbouldbe uken uith a meal.

I I

CombinationTberap . . .

Su.lfool-lureas Metformin Insulin

22

I

lnfection Work-Uo Definition: lnrasion ofthe bod) bl harrnfuiorganismsq: $tth an rnidatioDofan inllarnmatonresDonse bVthe bost.

asbaderia.fi.rngi.and\druses

lnfeclious Dose:Minimal numberofviral Fnicles necessan' to esuablish a diseasesule: I x 106.Tlus betwe€Dcolonizationand infecrion. allo\rEfor diff€renuarioD xer': Diagnoscan infectiousprocessquickll ard accuratelr'.Dagnosisis madeI ancillan rests.Nlaliediaglrosistlrenirnplementa proadjveReattr)ent Dlan" @4!g

L

clinica.lexa4 Nor I

To establisba treatmenlplan, work to alswer 2 questions: A Is hosPir"li"ationrequired? OuFatientversusir-patienttherapn'.Oral antibioticsversusfV antibiorjcs B. is srgical intervention qarranted? Bedsidedebridementverss OR I&D Bisron (Subiective): A Chief Complainl B. Hi$ory of heserl lllness C. NLDOCAT l. Ar1' previous ulcerationor infeaion? 2. An]' rec€nl antibiotic usage? 3. Traurna? 4. La$ meal? 5. Cbeck sboegearfor forcigr bod1.or signs of irriution 6. Constitutional signs& qmproms: fe'er (highesrterrp & when?),chills, nighl s*,.,rs, rigors (\iolenl shaking).n uses-vorniring loss of appelite, dirrh€a, weight ioss, general m2laisefatigue. myaldas. Histoq' of... -(begirto think empirica.lly): Posr-op IV line sepss Implant Scrarchiag negaEve Puncure Wound Pseudomonas Diabetic Infe.tion Mrug Abuse WalerRelated volnificans, Dog/Cat Biles Hurnan Bites

Sraph-aureus Suph epidemridis Suph. epidermidis Tirea inf. uitb seconda4'bacrerial bf. = gram Cellulitis = Staph& Srep Osteomyelitis= Polynicrobial MRSA MRSE, Pseudomonas Pseudonrorns. Aeromonashydrophilia. Vibrio Mycobaoerium marinum Pasteurellamr:lticida Eikenella mrrodens

Fever BodJ lemperature is regulaled b't}te h1'porhalamic tbermoregulaton' center in respons€ to rarious srimuli. Th€ stimuli a-ffecting the h)'pothalamus are endogenous p\Togens s€creted bv leulocltes and Kupfer cells. Other sdmuli are bacterial endoroxins, phagoc_r'rosis,and cenain immure reactions. The endogenous progen then insEases tle set poinl and rem;rrature is raised T*o signs of i-screasedsel poin are chills and shiverbg. Gram neFtive baderia tend to carrse more of an intense fever. Gram positive bacteria lend lo er,oke a profourd inllamrnatoD' rEsponse, qhicb releases endogenous prrogens. It is believed that a cenain tueshold of endogenous progens is necessarJ' for feYer to occur. It is for this reason we mal no! see fevers n'ift earlv loc"t;-.6 ;.r1'..,ro*.

/,)

-- Ccrc"d

C"iOc tt

107 106 105 104 103

HFerthermia r Anesthet-rc

102

Blood Tran$:sion Reacdons ClosedAb6cesses Reactiors,ll'iyerDsease Ateledasis,PneumonitisrDrue Wound Infection

l0l

Drainine Ab6cess

100 99 98

Overshoot BerugnPost-opFever,Posl-arestresa Usual Raneeof Normal

97 96

t

Post-opHlpothermia

u. E4!-U4!s4L-gjg.E

Diabetes: w}lat $?e and for ho$ long? Las BC? Classicriad (neuropathy,nephropalhy, rerinopthy). and u'hen?), HTN, Murmus, MVP. MI Qasrone). B. C-ardiovascr:lar:CABG (hou mar,r'b1'passes pNebitis. C. Lung/Liver/Renal discase. III. Medications: Nore dosagesandfiequencies.Uon anu'biotics:hou'longand n'hy? IV. Allersies: Penicillin,Local ane$hetics,Iodine/Shellfish.NoteD?e of reaction. dates,& ph)'siciansand/orhosprtal.Get medicalrecords V. Pa$ Sursical Ejson': Lin aI surSeries. on r€cenl lower extremiry surgeries. A

I

I I

r'L b!el_Elgs4;

I

A Cigaretes.Alcohol, I!'Drugs (how long & horr much?). B. Occupadon: Is Ftiert on feer al work C. HIV risk faaors. VII Ea!q!!LEiS9.!ti A. Are parents still alive? UnoL $'hat s'as causeof dealh B. Persotrlo contact in caseof emergenq'. WIl. Reyieq of Srstems: A HEENT: hea&ches, glaucoma.retir:opahy. q'e or ear infections- sinusitii sorethroal, stifl neck B. CVS: HTN, MI, CHF, MVP- murmur, angina,dlspnea, ph.l&itis, claudication C. Resp: COPD, asthma,bronchitis, recentcougb or col4 TB, pneumonia D. Gl: ulcen, GERD'S. drarrhea constiparionoast bowel mov€menl). hepatitis E. GU: urgencl, fitguenq, nocturia hernaturia.retenrio4 incontinence,Lrfl, renal stones,STD'S F. MS: Muscle orjoint patr arthritis(q?e & ho$'long?). Is palientambulalor)'?Any assistive dsvices? G. Neuro: CVA/TIA seizures.vertigo. qncope- paralysis-NM disorder. peripheral neuopathy

t

IX. Ph vsical Eramioalion (Obiectiv€): A GeneralaFpearanc€of paded: DoesparieDllook sick? Are thel' diaphoretjc-flushed disheveledpoor anilude? B. Vital Signs:heliminaD $ a1'lo dercrrninetle amourl of stresstre infection hasplaced upon pauem. l. Temperature: Note Tmai i! Past24 hours & Tpres 2. Blood Pressure:Ma1'decreaseduring infection. 3- Pulse: May insease duing bfection. 4. Relpiralory R31e:may incre$e during ir:fection. 5. Firger Stick Blood Glucos€in Diaberics:Usualll' elevaredduring infecrion.

z.+

I

Scptic Paticnt: Eleyarcd tempcrature, h\ToteDsivc, tacbycardic, racbypnic. C. Brcre rcnia: . kfinition:Timple?resencesftacxeriain-rhealdfil$1rffi1tutl-liTteTlma-riffisunons 2. Significance: method [r. l'hich infecdorx can be spr€rd to di$ant foci. D.

E.

Septicemia: l. Deflnition: cliniel sare ia s'hich ir addition to bacreremia rere are fever. chills. & other clinicai qmproms. 2. Significa-uce:representsfajlure ofthe bodl,ro jocalize infecdon.

Don't limit exam lo lhe lower extremit\': L Look for orher sourcesof infecion: a. Eyes. ears nose. throal

b. c. d e. f. g.

RespiraroryTracr SBE Phlebitis,IV line sepsis GastrointestimlTract GenirouriruryTrao Skin:decubsor ulcerationson otier pansof body.

X. I-,owerErtrtmin. Eramination: A Vssculer Ststus: l. Pulses: a If non-plpable then check l,ith Doppler. Unon_audibleor u,esk$,ift DoFpler, get noD_ rn\ash'e aflerial sndies (PVR,s). b ABI < 0-45 is ila@uate for beating in di;betics. Al leas 3onmHg neededro hcal digiral wounds. c. May need-aneriogramand rzsorlar surgeD,consullfo, possibleb1gass. d Questionfor irchernic res poiry'reliefofpain qilh d€penOencvotiimb 2. Capiliaw Refill: Also check color and temperarureofdigrts. B. Neurologicd Ststus: i. Cbeck all sensory,motor, & refex functions. 2. Detennine level & duration ofneuropaLbyif Fesenl a- UseSemmes-Weinslein monofilaments.Comesin 3 sizes. lf patientcannolfeel Oe 5.07 size, protective lhreshold is lost. C. Orthopedic Slatus: l. Noreall boneypromineDces2. Nole fool type and deformities. 3. PEVious amlxlatioDs? 4. Pain lrirh range of motion of affecledjoint \€rsus lendernessupon palpation. D. Demarologic Sktus: l. Assessfor rbe 5 CARDINAL STGNSOF INFLAMMATION: a. Dolor - Pain This is tre mo$ indicadvesign. Eren neuropathic fntienls lrill havepain, b. Rubor - Redress c. Calor - Heal d. Tumor - Swelling e. Fuoctio I-asea- loss of Funaion At the sire of inllammation- blood lessels dilate and tbere is an itcrease in blood flow lo tbe area causi-ttg RIIBOR & CALOR Then thereis extravasation of phagocyesand fluid into lhe penyascuiatspoc€resulting in TUMOR. This ed€macausessfelching of the cutaneousnerve 6bersandrbeparienrer?eriencesDOLOR n,bjchcausesFIJNCTIO I_ASEA Al$ aYsDolel-olensit'r'of lb€ sigrs of inflammation & compar€lo the contralal€ral limb.

25

I 2. --

--

--

Wound Erzluation: a. ].ocation - digits. inrerspaces,boneyprominences,planlar space. - Sizs=?lwaysmeasurafierdebridern c. Base- granulaJ,fibrotic, fat5', necrotic, rnaceraled d. Depth - Doeswoundprobelo boneor trackup tendonsheathsor fascialplanes?Is bone or rendonex:posed?

\\/agncr Classificationof Diabctic.Ncuronalhic. & \/ascular Fool Lesions 0 - No open lesion! ma]' ha!€ kemlosis. I - Full lhiclmessulcerationthal doesnoi go bevond slcil 2 - Beyond full thichress of skil Tendonor joint c?psulemay be exposed3 - Ulceration open10bone. Osteomyelitisis present. 4 - Wel or drJ gangcDeqith or $ithout cellulitis localized 1othe forefoot. 5 - Gangreneto exerxive portion offoot or q'hole foot. Foot sahage is not possible. hemorrhagrc, e. Drairuge- serous,serosanguinous. liquefactive,Frrulence. i Odor - foul odor indicative of anaerobes,fruiq' odor bdicative of pseudomonas. g. Margins of Wound - r'iable. nonriable, necrotjc, undermined irregular border. punched-oul" keralotic. hFerpi8Dented bdurated rnacerated h. Surour.ting Tissue l. E4thema versrs Celluliris (outline borden with nart<er to monilor regressionor progesslon). !.41[ggg - abnormaire&ressof lhe skin due to capillary congesdonsuch as inflamrnation. egUgIli! - al acutespeading infedion of the skin and corurectivetissue. More *ide-spread lhan er-'\'therna and boundariesare not clearly demarcated (Mos common organims associared$it}r cellulitis are Group A Stre;l & Suph aueus.) 2. Edema - as edemadecreases,you sill seean increasein skin lines. 3. Llnphadenopatby - check for lump6 in groin & behind hee. 4. Llmphangiitis - 'blood poisoning'. Red su-ealaup legs along llmphatic chanlels. lnfection is drainedfrom the body via llmphatics. Llmph nodescan become swollen during this processdue ro exc€ssbaderia & increasein pressurefiom tbe ed€ma. If \mph nodes becomeol'enlhelmed, llmph dainage can be blocked and red srreakscan occur (#l org is gp. A Strep) Bacteria can also seedthe blood r.ia h phatics and causea baaeremia which can lesd lo a seFicemia.

-r

I

t

I

)

,

, I

,

I

)fl. Medical Imaeins: A Conventional Radiogrqhs: l. Alwavs order even*ilh soft tissueinfections. Need bas€lineradiograpis. 2- Examine for: a. Soft tissuesu'eUing. b. Gas in sofi tissues. (Mrl also b€ able lo feel creDilation in sl{in clinicallv.) c. ForeignBody. d Traunu e. Osteom)'elitis: o Periogealreacdon . L\dc chsrgessith scleroticborder. . Conical beaking. . de$ruction. Osseous . Seguesmrn involucmo, cloaca,Brodie's abscess (chronic changes). 3. l-as time canbe l0-14 dalr.

,

26

The folloring medicalirnagirg modelitiesshouldonlYbe usedasan adjunctlo lheraF. Thq' shouldonJr. be used if the results would aher a reaEnent plan or benef t fte patjenl. Ths!- shodd iever be reljed upon lnfection for completediscussionof each. B. Nuclear Scinirigmpbl(Seeradiolog' secrion). C. CT Scan (Seeradiologvsection). D. MRI. (Sce radiolog/ seslion). )O1. l-aboraron' Eyaluation: CBC wilh diff

l.

2 . Chemistn,Panel

I. ESR,/CRP 2. Blmd Culrues 3. Urinrlfsis 4. Urine Culture

I

PT

DTT

2. LFT's. TFT's 3. C)(R 4. EKG

BLIN Crearinine c. Glucose Finr Iine resrsshould be pedo4red upon l4irial presgnratiql otpqqe!! 19aid in d4gnosis esrablish 4 appropriate Festment Protocol. Secondlbe tesr can be performedaniiiniriaf priiintation ffre1, ma1. help monitor Patienls progressor help rule-out other sourc€sof infection. Teststor surg€D,shouti Ueinirirlly only if psde needsrogoroLbeoR immedialely.(Do Dolorderif ibq.are nol FJcrformed medicallyindic€rcd) Pleasese€seclion on 'he & PostopMaruBemcnt: Hospibr ciraning" for normal lab ralues. A ComplereBlood Counr(CBC): l. Hemoglobin(Hgb). 2. Hernarocril (Hcr). 3. Plaleler (Plrs). 4. While Blood Cells (W,BC): Usuall-v>t0.0O0for infecrion0-eukoclrosi s) a. Differtnlid: Granuloa"es (Contdin eran!les in cttosol ) Aoranulocvtes Neutrophils: Monoct'les Polrmorphonuclear (PM]..) cells Llmpboc,vres Band cells Basophils Eosinoohils a. b.

'

PMN'S: Mature Deutrophil. Initiaj k rer celr, activeryphagocltic- contairu llsozlmes & lactoferrin. Half-life is 6 hours but irnctions last for I -2 dals. Mat'radon tirne is i e dars. ' l'matur€ neutropbil. Nucleus is elongared& twisred lr is lessdeformabl; & &-d-gg!\: less motile; tberefore, lesseffecdve in phagoc-\aosis & killing- h."eases during acute infection O-efi Sbifi). . Basophils: contain heparin,histarnine.& otlrer subsancesro contact snool}r muscle & increasepermeability of blood vessels. . Eosinoobils: Fuaion unlsrorlIncreasedin (NAACP): Neoplasmg Arergens, Addisons, colragen 'arc.,.rar diseases,parasites . Monocr'tes: Secondlire of phagocyic rcgonse (replacesneuuophil within 24 hour). Acti\"ted r o macroplEgeal idlanroalory sife. A llocrophage is an aggressi\€ phagoqtic, badericidal, & long-tived cell. lt process€sanugen & delilers trem to hlrpboc-rres for specitrcantibodr. production. . Lrmohocrles: Possesscellular mediarorsfor irununitv-prodrce B cells ate prodlued Aom bone marroq,& speciic anu-bodr,. I cel/s are prod.rcedfiom thlrnus & produce specific sensidzedllnphocltes.

27

Laboraro4' diaglosis of infecrion: I-eukocgosis(increasel*TC's) Filh a shifalo tbe l€ft (incr€es€band cells). Durir:g-aeureinfeedon:-tiebodlties lo{rg"htrlerniecrionlli'ircreasingthe-numberiof'WBes. spccificallv neurrophils. Unfonunalelr'. tle neuuophils do nol hrve time lo mature before lbev are neededro n1 ro "kill" the infecrion andband cells are produced.

-

B.

Chemisul'Panel: 1. BIIN: Measureshvdrationsule. Lessspecificfor renalfunction. BUN/Cr ma1'be elevatedin dehYdrared $are. Follo! let'elsclosell 2. Crearinine:Be$ hernatologicindexofrenal function Useto measurecreatinineclearancefor proper altibiotic dosages. 3. Glucose:Sressof infeaion mav causean increase& may complicatewound healing. 4- Elecdolyes: Na K C! CQ.

t t l

t I

t

Blood Culrues: a. Usedlo diagnosebacteremia;however,mostbacteremias are intermittent& a (+) anlturE can be diffrcult to obtail b. Take as soonas possibleaier the onsetofa fever (usuallJ,lol)_ c. Need 2-3 crrlturesat l€$ 20 minrles apan & fom different sites. This increasesthe chatrccsof catching tre organisr. d Must utilize aspetictechniqueto avoid skio conlamilants.

t

t

DECISION MAKING #l Docs the pstie Deedto be gdmitred? . Outpatient versusInpatiert ltrerapy, r Oral antibiotics versu fV ano-biotics. l. Outptient Therap5': a. l,ocalized signs of infection qith no sy$emic manifegations. b. Benign medjcalbistory(patientis not immunocompromised). c. Can be setrl bome on oral antibiotics. 2. lnpntientTher4y: a. Extensionof infection b. Sysemicmanifesariors. c. N€edry antibiodcs. d ReCuLesurgical i-nrewendon. e. lmmunocompromisedhost. . Diabetes . Peripheral Vasculal Dissse (vascularsurger]' consull)

I

t I I I

.Hry

. . . .

I

I

C. SecondLin€ Tests: l. Erytroc-!'te Sedimentation Rate(ESR): a. Dererrniled b1'measuringthe distancein rnm a column of er'lhrocltes falls in I hourb. NON-SPECIRC: lnllammation, infection, malignanq', renal disease,connedi\€ rissue disease,age. c. Use as a baseLneto monilor effecdleness.Drau'eveq'5-7 dal,s. 2. C-ReactiveProlein: Similarto ESRbut moredithcult to perform& more expensil.e. 3. Urimlysis: (+) leukoc]'tes& nitrztes (probableUTI). If there are an increase ir the sguamous epithelialceus.the samplesas probabl)'coDtaminaled (Deedto rep€alle$). Checkurile culture to deterrnine specific organism(s). 4.

t

Cancer RheuDaroid .Afl-hdris Steroid TheraDlElderly

I 28

I I

lnmunocomprornisedFlients rru]'nol be able to elcit an inllamrnaton response& the infection mal look benign- The rJ?icalredness.srelling. & h€almal'not be pres€ntbut lhis doesnol meanthat the iffectioD is locafizel-Thetinntune-svstent cannorfightthe ilfectiorraseffecrivell'zsziealrhl. pati therefore,wbat ma\' look benigncantum into a rapidlyprogressrng & faul hfecrion. Caudonshouldbe usedurth thesepatjentsandhospitalization eyenfor localizedinfedions shouldbe considered #2 ls surEicrl iolervenliotr necessary? . BedsidedebridemenlversusOR l&D l. BedsideDebridemert: a. Local.izedinfection. b. Neirropathicpatients_ c Bener evaluadonof lie wound 2- OperaringRoom lncision & Drainage: a. Untrown exent of infection. b. Wound probesto bone or boneis ex:posed c. Woundracks up fascialplanesor rendonshealhs. d Abscess. e. Gasil sofi dssues:Needsirffnediatel&D.

XIII. Treatmenl: A. Sysemic Theraqv(Antrbiodcs): l. Oral versusry. 2. Chooseaccordingro ciinical scenario: a. Diaberes:polFucrobial b. Cellulitis: Group A Strep,Sraphaureus c. Gas:clostridiurn d. Foul odor: anaerobes e. FruiN odor: pseudomonas f. lnersFces: gram (-) g. Goldenpunlence: Staphaureus 3- sun broad& na.'o* specl','n pcnding culture resula & sensitivities. Good options for i-urialtberap'are Ancef/Flagvlor Bacr-in/Fragrlor Unasrr (will lary depedrngof hospital micro. rcsistanceprofile) 4. ObaiD sulruresbefore naning antibiorics. Ma-vg€l negauvecultures if patient is alread.r.on anu-biotics. 5- CalculateCreatinineclearanceprior to dosiag Abx B. Local Therapy-(Wound Care): l. lncision& Drain"age: a. Use generalaresthesiaor spinal if enenl of iDfection is unlsnrrn. Infection ma-vtrack up leg bevond t-heboundariesof a Iocal block b. Don'tusea tourniquel.Needto differentiatehealthl, bleedingtissuefrom necrotic ussue. lf a rourniguel is used dop it before final debrideme ro eDsureadeouate debridement. c. Plan all incisions. Fina.lgoal is wourd closure. d Debridemenr(Rememberthe 3 D's: debridemen! drai::age,decompression): . Do not scpararctssue planes.lnirial ircision shouldbe down ro bone. . Rcsea all bfeced- necrotic soft tissue ald bone. r Carefirl Ssarttingof sldr edges.especialll.in patienrsnith pVD. e. Cultures: . Soff tissue srabs: gram stain aerobic,araerobic, illgal. acid-fast. . Bone: obtai! piec€sfor cultue & biops-l'. . Requestsensiti\"ideson all cu]rures

29

i

g.

2.

lrrieaion: Need.hig}r.powerIorlavage.Pulselavageapparatusor.60ccqringeuithan faciliures debridemenr gaugeblunt dp needle. The high powerandPressure . lrrieant solution is irrelevan-Lusualll us€ aorrnal sallne . Addirg a:ttibioticsto itriSantsolutionoflersno benefit. Woundshouldbe packedopen: . Useplain Nu Gauzepacki.ngon srnallern'ounds& 4X4 gauzesor Kerlix on larger *ounds. . Performdaill'dressingchangeson wound& monitorfor signsof healtlg. o Wlen all signs of infecrion bavebeenirradicate! l'ound can be close4 usualll 3-a daJsafier initial I&D.

Daijy Wound Care (Bedside): a. lrrigttion. b. Local debridemsnt. c. Fackirg. d. Wet ro Dry Dressings: l. Absorbsfluid exudates. 2. Facilitates debridemenl upon remoral. 3. Solutions: . Saline:isoronic,dr-ving. . Beudine: drf ir:g antimicrobial.canbe cau$ic ro ds$res. . Dilute Betadine:less@ng & Iesscausticto ussues. . Dakirs (hf'pochlorale. usually %o/o):antimicrobial, promoles granulation DSSUe.

. Ac€tic Acid (usualy %%):antimictobial Soodfor pseudomonas. e . Monitor for heallhl'lissue. Firal goalis woundclosut€. t Biologic & Slnthetic MembraneDressing: l. Not used oflen- but if desirc to use.granulationtissue must be present. 2- Mat€rials: . Porci.neskil grafi. o Amniotic membrane. . Epigutd A syrthetic nembrar:e v'i& 2 layers. The inner layer is madeof poll'urethane. GranuJationtissuegro$'s into & anachesro this layer. The ouler layeris composedofleflon. This layeris breathableandbacteria impermeable. g. Elevale limb. This encouragesvenous& llmpbatic daiJrage to reduceedema& improve local blood florl. Patienls$'ith compromisedcircu.Iationshould have legs level in be{ nol eleYated.

t

Wound Closure: a. Primarl' Closure:nev€tuseudess all necrotictissueis excised& no signsof infecdon exrst. b. Delayed Prirnary Closure: o Usrull-v 3-4 daysa.fterinirial l&D. . Excise all necrotic. non-r'iable lssue. . Obtain bleeding skin edges. . Irriealion. . Culture. . Suture: Avoid closure of deeptissues. Utilze non-reacdvematerials Q'J)'lorl Pmleue). c. Secondar-r'Intentjon: for large wounds Oratc€rnol be teapproximated. d Skin Gratu (Apligrafi)

t

30

I

*PaiieDts rvith severe P\/D require lower extremitv blpass surgerv or angioplasty prior to clcure

Osteomvelitis

I. Psfid!.esri

Osteotm'elitis: A. Hematopenous Usuallvoccursil chil&el & is primarily a medicalJytreareddisease. \f,rhenit occursin adults,it is usuallya surgicallytreateddisease.Now increasinginci&rct in the elderly>50 yrs -Primarily long bonesLE andthehumerus -Venebreain tbe eldcrly Le*,and Waldvogel,NLIM: 336: 1997 -S. Aureus,Sr? in neoneales -GNRs in elderiy,immunocompromised patielts -Pseudomonas b l\fDAs andlong termindwellingurinar,vcatherers B. ContiguousOsteornvelitis(direct extensiod:Dired infectionofbone fiom andexoqeloussourceor spreadof infeaion from a nearby infectedfocus. -Prothesis, implantg openFacnres primary concernscon c. osteomvelitisin a oatientu,ithvascularimpairment:Thesepatimts havedifficulty mormtingan inflarnmatoryresponse.Theyalsohavepoordeliveryofantibiotic to the infectionsite. -vascularityneedsto bead&essedto insue adequethealing D. Acue osteomvelitis:suppurativeinfeaion ac-companied by edema,vascularcongestiur,& small vesseltrombosis. E- Chronic Osteomvelitis:Nidus ofinfecled deadboneor scartissue,an ischernicsofl tissueenveloDe. & a refraaory clinical cowse. F. seouesmtm:Pieceofnecrotictissue,us'ally bone,thathasbecomes?arated fiom su-ro'nding healtbytissue. G- Irrolutrum: The sheathof new bonethat formsarowrda sequestrurn. H. Brodie'sAbscess:A chronicabscess ofbone surrormded by iense fibroustissueand scleroticbone.

II.

Classification: r*,aldvo{el Hsm atogenous Osteomyelitis Contiguous Focus Oseomyelitis Osteomyelitis associatedwith Vascular Disease Chronic Osteomyelitis

III. Clinical Evsluation:

Clerov-Mader AnaromicSrage L MedullaryOseomyelitis 2. Supo-ficialOsteomyelitis 3. LocalizedOsreomyelitis 4. Difrse Osteomplitis Phpiologic Stage A. NormalHost B. SysremicallyCompromised Hos @S) Locally CompromisedHosr@L) C, Trqtrn€nt is worsethan the Disease

@leasesee infection work-up.)

IV. lmasinp Modalities: A. Radiographs: l. Need 30-5002resorptioDto detect osseouschangeson x-ray. This can take lG14 davs. 2. Always ule x-rays for an infection. Can act as a baseline& monitor the regessjon c progression of the infeclious process. 3. Signs (ln orda by *trich appearsfirs): o Sofl tissue swelling. . Periostealreaction (thickening or elevatim). . Focal osteopenia. B. Pleaserefer to Radiology of l-nfectionfor bone scars, MRI, & CT.

J I

V. II4!.Ssts: A. Bone biopsy: I. Definitivediamosis. 2. Bone culture& microscopicexaminationofbone. 3- Urilize imagingmodalitiesto determinebes areato takebiopsy. Osteomyelitismaybe diagnosedwith positivebiood cultrres wilh a positivebone B. Hematogenous s@n,

I I I

\4. Treatmept: A. PrirnaryGoals: l. Adequatedrainage. 2. Thoroughdebridement 3. Oblileratim of deadspace. 4. Antimicrobialcoverage. B. PrimarySurgical: l. DebridemeDt ofall nonviable& marginallyviabletissue2. Antibjotic PollrDelhylrnethacrylate lrnpregnated Beads(PMMA): a.

)

)

tnorcllrons lor use:

. . . .

Deadspace rnaintenance followedby bonegrafling,bonefusion,or primary closure. Debridemenl& closure. CombineddebridemeDt & internalfixation procedure. S)slemicdisease*fiich conraindicatesadequalesystemicIevelsof organloxic antibiotics,suchasamhroglycosides. b. Genramycinis the t'aditionalantibjoticusedwjth PMMA beadsbecauseit is not h€atlabile andthe curingprocessoflhe PMMA is an exolhermicprocess.Otherantibioticsmay be used;however,the antibioticmustbe addedin rhe doughphaseofrhe PMMA This preventstheheatdegradaticlofthe antibiotic. Antibjoticsrhathavebeertusedinclude: . Genlam)ain . CephalosporiDsCefazolin,Moxalaclam,Cefotaxime . Tobramycin o Vancornycin . Ticarcillb c. hocedure: . Mix & consfucl the be3dson a wire and place in the wound. . Closethe wound overthe beads. . Leave tbe beadsin for about2-4 weeks. d.

Mechanis . Irnmediateanssusainedreleaseofantibiotic in the local area r Releaseofantibiolic declincsexoon€ntiallvwith time

3. lneress-Egress Slstems: a. C)osedsuctionirrigation. A closedsysem in whicb continualflushing ofthe wormdis accomplisbed throughinflow rubing(ingress)& outflowtubing (egress).Therearemany problemsr,riththis qrsiem,sudr as contaminatimof the oul0ow tubjrg (usually pseudomonas). 4. B;passSurgery:(Consuh vascularsurgeryfor options.)

I

I

I I

r )

I I l ,}

C. SecondarySurgical- Reconstrucnve: l. Papireaubonegraft: Tbis technigueis for filling bonedefects. Small cancellouschipsare packedinto bonedeficits*terr tbe woundis granr:Jar.This grafl is given time to takethen various closurc canbe used 2. BoneFusion: Usedafter resectionwhe! infectionsareneararticular swfac€s. 3. Delayedprimaryclosure. 4. Tissuet-ansfer/Skinprafting. 5. Be:d therapy,bonegrafling, & closu'e.

)z

t \

Wi-Follow-Uo:A. Goal is to preventrecu'rence. B. Antibiotics: l. customarily6-8 weeksfolJowinglas surgerl,or sinceinitial clinicalresolurionof infeaion when no slngery has beenperformed. 2' The word "cure" is inappropriate.rr is possibrefor an arealo adivate for up to 20 vears. 3. Follow-upinrs-vals: . Firs 6 months:everymonth. o 6 mcnths-l year: every3 months. . I year-2years:every'5months. I-ocal An ti bi otics/Anti biotic Beads The implanrableadmirtr.reofantibioticto any ofsevsral carriersfor the purposeoflocalizing increased anribiolicconc€ntratioos st specificlargettissuesiles. Selededant;bioticsbouldmeetthe following criteria: A. ll2O soluble B. nontoxicto tissue C. baaericidal(preferably) D. available in powder form E. heal stable if usedwirb PMMA Carriers may be: A. biological l. cancellousboncgrafl 2. demineralzedbsre mat-ix J. L_a hydroxyapatlte B. biologicallyinar l. polloetbyl m ethacrylate(PMMA) 2. plaser of pa-is . commerciallypreparedaDlibiolic carriss areavailablein Europe,andare expectedto be _ availablein the UnitedSatesafter furtherinvestigaticnofpossibletoxiciries Miclau et al comparedthe elutionoftobramycintom variouscarricrs,and formd: A. cancellousbonesraff elded ?0% of its artibiolic within tbe first 24 hoursof implantatiorg and hadnon-measu'eable levelsat l4 da)rs B dernineralized bonemat-ix relased 45%o of its antibioticwirhin the firs 24 hoursof implantation,andbadnan-measurable levelsal l4 days c. olaser of pariserued rz% of its antibioticin rhe firs 24 ho'rs afler imprantalim,with measurablelevelsofaDfbiotic up to 2l da)6post-implanbtion D PMMA eluted77oof its antibiolicudrhinthe fust 24 hoursof implanration,with t-ace amoms measurable up to l4 dap pos-implantation PMMA rbe mostcommonlyusedcarrierfor implanrableantibiosis,lsually comesin balf-packs(20 g) or tull-packs(4G60 g); consisrsof A. mcnomer(liquid) B. pollder (powder) + the monomerandpolyrnerare mixed together(an exoth€rmicreaction)witr tbe antibiotic powderuntiJa doughyconsisenryis adrieved,ar Phich rime smali beadsare fashionedandplal on 26 or 28 gaugewire like pearlson a necklace.The barde',edbeadsaretho implanredinro a deid qp; h utich bigb local levelsof antibioticaredesiredgpielly within an areaof deb,rided os"o111y"tit-i. Uor,"the spacepreviouslyoccupiedby osteomyeliticboneafferresection.(N.B. no onewearingconraas Jould be in the surgicalsuitedr.ningpreparationof the beads,as oflersive vaporsbaveUecrti*-ea ro morUiOity witb thoseindividuals)

33

Suggesred R:tio of A-otibiotic:PMMA Anlibiotic Cefazolin

Amountof Antibioric 4-8 E

Ceforaxime Nafcillin Tob'ramycin Vancomycin Ticarcillin Clin&myctn

4-l

o

4-6s 5- 10e

.Am ounr of PMMA 40-60 p

40-60s 40-60s 40-60 p

4-Ep

40-60e

4-8 o

40-60s 40-609

I

Diffusioo (Ehtion) of Antibiotic fiom PMMA dqends or: A. D?e of cemerl used(Palacosvs- Simplexvs. CMW) B. coefficientofdiffirsion for eachantibiotic C. conc€ntrdtionofantibiotic within tlrebead D. size/s,sfae aralroughness of the bead of fluid thal movesDasttbe bead E. amor-nrt Be-adProperties A. smalla beads= moresurfaceareato total volume,leadingto inoeasedelutiqr rates ofantib;otic within a beadleadsto increasedpore sizeandroughncss, B. higher conceno-ations ofelution eachleadingto increasedrates C. Ciemy proposeda ratio of I :5 u,henaddingantibioticpowderto the PMMA powder;e.g.for every l0 g ofpowderedPMMA polymer,add2 g powderedantibiotic,stalingthat any hi8herratio would preventproperhatdcningofihe PMMA D. mos studiesconductedwith l-2 g antibioticto 40-60g PMMA in literatu'e PMMA Beads: very few Complietions wjth Anlibiotic-lmptegnated A. if the cerncntis usedfor fixation,mechanicalstrengthis compromisedwith preatertban l0plo antibiotic conicnl (not an issuewith beads) B. caresbouldbe usedin patiantswith rerraldisease,thoughlocal antibioticconc.eflfaticnsl0-50 greal€r lhan t}e toxic serumlevelscanbe adrievedwithoutthe serumever absorbingenouptrto times achievethosetoxic levels C. no allergicreaaionshavebeenreportedto datein the lite-ature DisadvaDtages A. second procedure required for bead removal, tlpically

T

I

I

T

after l0-14 days

SEPTIC ARTHRITIS Infedious arthritis sands apart ficrn other rheurnaticdissdas becausecure rather than mse contol is possible.Whaher or not this gcl canbe adrieveddepandsupan the type of cganisn, pronptress in initialing therapy,medicalsratusofthe individual, and pnic sratusofrhe involvedjoinl ALnog any palhogenmay aflbcl artiorlar canilageand psianiorlar tissues.A multinrdeof baoa-i4 viruses,mycobaoeria and fingi have besr asociated with artritis. MECSANISMS OF SEPTIC ARTIIRITIS

r I

I

may inade rhe joinl dir€dly and produce l. DIRECT JOINT INVASION BY THE MICROBE : pathogens cn-gobg inflammatim and dest-uctim. Examples include direct joinl innoorlaticn (pmcure wound) or hernarogenouspread 2. ]OINTS MAY BE A]TFECTEDINDTRFCILY AS A REST]LTOF:

I \

) 51

A. rhe resulting immue resPonseoftle afl'ededhos1.Fcr exarnple,in Hepatitis-Barthritis cirorlating immrmecomplexesappearlo m€dialethe pollarthritis thal acconpaniesthe prodromalsage of thi! B. rnicrobial debrisrhatmay pasisr in t)e joint andperyetuatean iniammatdy response,evenafler $e cnganismis no longerin fie joint. This appeanfue in sornecasesofgorurococcalanhritis in *hich an qrgoingsvnovitisis associated with serilejoint fluidthatis non-inflamrnatcry, so called,' pos-infectious srile arthritis." C

rmkrownmechaa.isms. This appliesto alrnosall ofthe reactiveartn itides,suchasthoseassociated with gastrointesinalinfectislswith someof the entericgra:mnegativeorganisms (Shigellasp.,y€rsiniasp.).

A CUTE BACTERJAL ART}IRITIS PREDISPOSING FACTORSAND ASSOCIATEDCON'DITIONS l. Rheumatoidarthritis possiblemedranisn fc associatiGl damagedjoint is a goodnidus fcr infectim mmprcrniseddefenscsfirn medicatisrs defectivephagocytcis (?) importanl clinical featurc usuallydueto Staph.aurans ncatnenl resultsoflen Poor 2. Crysal-induced arthritis possiblemeclranisnfor associatiqr synovial fluid acidosismay prqnote cD/gal depositicn enzymatic' st-ienining " of cartilage impdanr clin;calfeatur€s identifcatioDof cnslals ill tbejfir

dcs Dotrule out septicartbritb

3. Severeosemnhritis, Cbtrcci jointf Hernartlrces possiblernedranisn for associaticn o joint disoFnizatim, d'oric synovitis!aDdbroody effusiurs alr provide nidus fs baaeria impqtanl clinical feanrc . alwals sendbloodyjointfluid for culture 4. Clronic s.vstemic (SLE,sickJecell anerni4canca, ac.) disease possiblemedranismfa associaticr . imPairedSensalizeddefenses dueto cbo:ic illness,phagocyticdeficimciel andmedicatims impcnznt clinical featu'€s o oflsr dueto Stapbaure$ or gram negativebacilli . coruider Salromellasp. in padals with sicklecell

35

r \

f

I

A CUTE BACIERIAL_ARTERIIIS PREDI SPOSINGFACTORS AND ASSOCLATEDCONDMONS

I

L Rbeurnatoidanhritis

t

possiblemechanismfor association darnagedjoin B a good nidx for infection conpromised defensesfi om medications defectivepbagoqrosis (?)

(

imponafl clirncalfeatur€s usuall]' dre to Staph.aueus uEalmentlesrrllsoflen Dor

,

2. Cr1'sral-fud:ced arthritis

t

possiblemechanisrnfor association sporia.l fluid acidosismry F omde crlstal deposition enzrmatic " sriprnrning ' of carilage

T

ltnponant clinical fealres identificatiooof c4'sta1sin tbe joinr doesnot rule oul septicarthritis

r

3. SevereosteoanhritA Charcotjoints HemanhGcs poss-blemechanisrnfor association . joifl disorgarizatton,chronic spovitis, and bloodJ'efirsions all Fro\ide ni.r"< for basl€ria

t

inporan clinical feaores . al*ays sendbloodyjoint fluid for o nue 4. Chronic q'semic dis€ase(SLE, sickle cell an€xn4 cancEr, etc.) possiblemechani-snr for associatim r impairedSeneralizeddefensesdue lo chmnic illness.phagoqtic deficiarcier and medicatiors

I I

t

imFnnanl clilJcal feamrEs o oflen dre to Staphaurers or gra[| negatile bacilli . considerSalmonellasp. in patientswith si*le cell

t

PATEOGENESIS Acure bad€rial ar0vitis occun mos ofien bt' hematogenous disseminarionAom a primar.r'sourceof infection Ho\r'ever, join sepsismay also tesult fom the enension of an aqtacsntson tissue infection or aQiornrng osreom)'elitis.

Ttuee sages of canilage destructioD b'r'e beeo descnbed

I I I

36

I I

2. 3

lnitial e'ens includ€ uberadonof l'sosomal enzrrnes fiom pMNs and qno'ial lining celts resulringin lhe loss of proreogrl'canfiom cafi age. u the infecdousptocesi i. resolvedeirry- a -: resoration of proreogll'camatrirm4-be achievedand chondroc-we daruge avoided During l}e second sage. increased nrecbadcal su€ss ald inadeguare nutrDon rcsull rn chondmc\le danuse. In the las sage. enzrmes releasedfrom PMNs and snorial lining cells Eilll rh€ altercdjoid rnecirznicsgradrallr. deoov tbecollagennerwork

CLINICAL fEATURES Sepncartlritis usualll afeas onejotrr but ma)' involve t$ o or morejoims. Tbe L|\ oh,edjoint is generaUl,red, hol s$ollen and acutell parnflrl. There is also exlremepain and limilation uith range of moton The lsree folloued b1'the hip and anldeare tbe mostcommonjvinvolvedjoints in non-gonococcdsepDcan-hritis. Svsemic ferrues inclu& fever ( m:1'be los grade), chills and rigors. A carefirlph1'sicalexamrnav reyeal an hfectious focus involving an1'site, but fie usualsourcesinclu& tle skin nasopharlrui sinus€s,lungr ce^Di andth€ redum JOINT DISTRIBUTI ON

loee

55

hih

l l

ankle shoulder $Ttg

8 E 7

elbo*' otlrcrs

5

40 28

3 ll 3

I-ABORAMRYTESTS Peripheral leukocl'losis occurs i! $e majorit)' ofpatients E'ith aore baaerial aribritis. An ele\ated ESR t also generally found hrients suspeoed of having septic anlfitis shor:ld have blood altures and c:t]ltlres of rcgions thal mal, be tle prinur)'sourc€ of infection ( phl'sical exrmination !'ill help lo determine areas tur ma5'neeO ro te cu!1,;ed ). Blood culrures ma)' be positive in up 10 75% of Ftients. A diagnosis of septic art-britis is datlish€d b gram sain and a positire slnovial flujd cultue. A D?ical joml infeclon demonstrates a rrrulent efiirsion with a s\no\ial fluid \r'hil€ count grcarcr tIan 50,000 ceficmmand more tl,an 90"/. PMNs Gram srain and culturr an obligarol'v if septic anhrfis is suspecred" INCIDENCE

OF ORGANTS]\IS IN ACUTE BACTERIAL

Granr-posiri ve clcci

15o/o

Gram-negatvecocci ( N. gonorrtneae)

sE/o

Gram-negadvebacilli

5Y"

ARTHRITIS

IN ADULTS

TREATMEIiT l. Treatrtrentshouldbegrnimnediatell' aner the suspicionand/orconfrmation ofthe diagnosis.

37

2. Ano-bioticsare chosenpri.rnariJl'on the basisof the snorial fluid gram stain and are aduged basedon lbe cr tur€ resulls. 3. Closed needleagiradon shouJdbe performed.atleastoncedai]lao dlain lhe affectedjoirL4. Open surgcal drainageis indicated if there is a lack of responselo t}rerag' ( joint fluid a nrr'esrernain pe6isrend)' positive or potienls rcnain febrile after 3-4 dal's of antibiotic rherap\' ); Some srudies espouse irnmediac open sugtcal drainage. 5. The infectedjoilt sbouldbe keFr ar rest lo prc\'eDtnrechanicalstress:generallv using a splitrt u'ill provide adegu.ateimmobilization and reducepin andu?unra. 6. As joint qEtroms resolve,p.ssire rangeof motion exercisesshouldbe safled lo avoidjoint contracrues. 7. Weighrb€aringshouldbe deferreduntil irdlarnmationhascompletell resolved S}?{O\'IAL

FLUID EXAMINAT]ON ( IMPORTANT FOINTS )

l

Culu:resare nearll' l00olopositive in non-gonococcalbacterialart}u.itiq,h.1 onl; 25-50elopositire in gonococcal anbdtis. , Gram stain smearsate app Dximalely7570positive uilh gnm postive cocci, str/o wtth gram negativeba.illi, and less than 25% in gonococcalanhritis.

l

TIre leukoc]le and differcntial leukc\t countsare generalll gealer t|an 50-0O0cells/cmnraDdgrEatert|an 8fflo PMNs. hrt tl}eseresits can also occuru'ith noninfectjousinllammalory anhritis.

)

Srnorial iluid glucos€is lesslhan 50oZfasting simultaneousserumglucosebut rnav nol be prese and ma1'be seenwith Rheumatoidartlritis.

RAD]OGRAPMC

l

TESTING

Radiographic examinationof aflectedjoinls lnay rcveal onll- sofl tissue swelling earlv in tlre course of the disease. irl)flz-articr ar osleopeda appearsabour 7-10 dals aier th€ onsel of jofut inibction- If the joinr hfecdon is not eradicatedprogressivejoint spcc narro$'iagrnay develop.I "te radiographictrn.}i"es indude join subl&rationand e!€nhraljoint &stuction-

)

Radioisotopescanningma1'be helpfitl in localizirg sitesof idection, bou'et'ertbe fin.ri.gs are non-specifc and radionuclideimagilg Benerall)hasliule rcl€ in the inidal e\."luationofacde setrticaflhritis. RADIOGRAPMC.PATB OLOGIC CORRELATTON PATHOI,/OGIC ABNORMALITY

RADIOCNAPH-IC ABNORJT'ALITY

) -

edemaand \peruophy of sofl tissre

joht eftrsio4

-

qnovial membrarewith fluid prod:ction

sweUing

-

hlperernia

oslcopoross

-

inflrmrnurnry Fa]lnrts nith chondraldestruction

Jolrl sFce loss

-

pannusdestructioDofbone fibrous or bonl anhlosis

t

marginal andcenu-alerosions bory anlq'losis

CHILDFOOD SEPTIC ARTHRITTS BACTERIA

(# OF CA.SES)< 2 Y?S

2{ \T.S

>6YlS

TOTAL

J6

S, aursx ll idl[enzr Suetrococci Gramneg" bacillr S pneumoniae

-154

8l

-

9'

27 24

23

23

4

I

- "'--

16 (34yo) -r71(36{/0)

6

.14(15yo) 39 (8yo)

3

30 (6yo)

482 From seriesbl Fid; and Nelsor Speiseret a.l.-Pelrol2and \/ahEveL Borella el el., and Samilsonet al.

39

t

t

INCIDENCE OF ORGANIS]VISIN CHITDEOOD SEPTICdRTERITIS Granr-positivecocci

1V/o

Gram-negatire cocci

5o/o

Gnrn-negarive bacilli


H. inlluenza

tv/o

I

GONOCOCCAL ARTERITIS (DISSE]\{INATED GONOCOCCAL INTTCT]ON ) Gonococcal anhitis ts lhe mosl corunon form of acue bacterial anhritis. Joi infecton Aom a pnma4' sourceofinfection disseminationofthe gonococca.l

involvemenl occun drrinq

CLIM CAL MANIFESTATIONS The organimr lrinally infecrsmucosalcell surfacrs-Tlprcally the primary infection involves the reprodrctve orCarts,but nq' irvolve the pharynxor recam. Dsseminabd gonococcalinfections occur in apFoxtnarely l-3% of all primar]' infectioDs.Dssemilaoon seemslo occur more conmonlv b females,generallvaroundthe time of menscuatiotr *** An imponad nore is tlat patienS n'ith complemelltdeficienciesareat an increasedrisk of gonocacal baoeremia. Mosl patienB with di(<eminaledgonococcalinfectionsare lessl}|an 40 veals of age and relate a hisory of prornisoi-v ard mproleded serual inercouse. Agab the primary sites of infection are the uretbra in rnales. cen{r il femaleEanflhe rccllm andpbr}a\ in both serres. Patientsdissemi.nated diseasernal'hare qstemic firdings thal bclude fever. .hill(, and rDalaise.A migrarorl poll-antrritis is tte most comrnonidtial joint nunifesation and subsequenlfndings ma1'localize to one or morcjoints. Aly joint nuy be irwolved

t l

t

kri-articrnar pir and su'elling arc conmol! and lcommoritis is formd ir a significant numbcr of ptienrs. Tlpical skin lesioosare a freguentmanifesration,generallybegirming as srnall erylherMlous ma-.ulei l}'hicb maYdevelq into prstular lesionscharacterizrdby a grq'. necroticcener with a hernhorragicbase. I.ABORATORY TESTS Peripheral leukoqle counts nuy be normal or moderalely elevated Synovial lluid analysis rweals aa fuilammatory fluid s'ith a rariable nurnberof strite cells ruging from a few lhousand lo sereral hrmdred rhousandper cr.rbicmillimaer. Joinl fluid culuuc aJepositive in lessrhan hatr of all patiens evenunder ideal conditions.

I

DIAGNOSIS active [patiens *to developan acrie migralory Disseminatedinfection shouldbe su$eoed ir young sex-uall,y polranhriG, renos\To\itis, ar:d/ora charaqerisic rash PnmzrJ soure andjoinr o]ltures along sith qlovial Iluid au\'sis shouldbe performed

40

i

TREATMENT 1. Arnbiotics :

Cefoiarone( Roceph.in) Ilr4iTVor Ceftizoxime( C.firox ) fV or Cclotatime ( Claforan) IV tben, Cefiuoximeaxetil ( Ceftin ) po or Amoxicillir/clav!.lanaE ( Augnrendn) po or ( Cipro ) po Ciproflo>cacin

Parenreralanriobiotics are generalll' continued for 2148 houn until s\?nForns begin lo rcsolye, ard tlen pauenu are suitched lo enteralaDubioticsto conlrlete a 7-10 dav courseof tlrcrap.. 2. Joint alpiradon 3. Joint irnmobiliztrion I'IMLARTHRINS ! :

.

.

I

; -

Virat anlnilis oflen beglm with non4ecific s-rmtromssuch as ma.laiseand farigue, headache-nec* srifrress sote t|IEL and nauseaand vomiti'g Joinl iwoh'emenl is genenliy pol]"nifltar, md the anhriris is usually shon-liltd and rateb'Esuls in joint damage.kboralory lesls are non-speciic. The follos'ilg arc someoflhe mos cornmoncausesofviral aflhritis: l. Hepatitis-B- joilt Enifeslztions ma1'be seenin l0-30e/oof ptients . The anhritis is generallyself-limiting 2. Rubella- rnay occur in nanrralrubellainfection or afler irnmunizationwi& the [ar anenuatedlirus. 3. ParvovirusB t9 a. HIv rcIacrt anhropany

FTTNGALARTHRTTIS A $ide \ari$' of fimgi m4'cause joint infettio4 ntricb rna;'arise eitherfiom direct encndon fom a focus of o$eom-Y-elitis or bl bemaogenousdisserninationThe anhdtis is usualJymonoy'paucianiorlar:, most oflen in l"rg. weigblbearingjoinr a:rd generally follors a chronic or indolent cor.use-Synoviat fluid anal5is and culore arerariable, oflenproviding liule lo no diagDostic\alue. Fungi ihit may be associaredwilh infectious arthritis nal'be groupedas superficialor de€porganstm. Although normal hostsnu1' developfirngal arrlritis. tlterEis usuall)' somePrEdisposingboor that increasessuscepn-bili$'to infection The diagrrosiscan be made $' qnoYial fluid cultureor s_rnovialtissre tiopqy. ST'PERFICTAL Spomthrixschenckii Candidaalticans Actinomycesisraelii " Maduomycoses*

DEEP AryergiDLsfirmigals Hisroda$ta capsnatun Crypococcusneoformas Coccrdioidesirnmu:rSBlasoml'ces dermatitidis

Nf}'COBACTERIAL BONE AND JOINT INFECT]ONS Extr-aplmona4' trberculosisoccursin qroxjnately

1-2.67oof Ftients q'ith urberculosis.

11is g,enerallybel.ievedlbar sleleul TB is caused[r' diss€minationof bacilli [' hemarogenousspr€ad or ]lmpbanc &airugs from anotberareaof TB. TB anldtis most Aequentlf irwolves weightbearingloints and is usualll monoanicllar. A positive tuberculinskin testis otnined ia mos parientg and in about50oloa pre\ious personalor famil)' historyis presem Syorial Frtrolop' ter'€alsa chrcnjc granulotr|arousreaction qift gianl. bngban-r)"e cellular:iafilu-ation Acid-bs saiaing of the qrorium or sunoundingtissuema.vrevealthe orgarusnu.

41

Radiographicalll' the afleoed joint ma1'reral onll sofl tissue sn'elling or morc ad\"nced chalges rritb Xrq- abnormalitiesof Fs destruaion of peri-anicdar bone, nanol'hg of the space;and osteoporosis-Chest or presenl TB rDal' be presentrn 5ff26ofpatrents.

ARTITNOCENTESIS AND SYNO\TIALFLUID ANALySIS Slnoviai fluid is ar inziuable sourceof dagnostic information. Oneof tlre rnos irnponant rca-sons lo psrform qnorial fluid enqlvsisis to rule out baoerial hfection in severell.iniamed joints. There is no other slfficientJl' reliable R"] to differentiate seFtrc aflhritis fiom acde cl1'stal-indrced anhritis. Anhrrcentesis nul' b€ therapeuricas rveUas diagnostic.For reru;eeffrsions in which the inua-anicllar pessr-ueis higb- remora.lof the lluid will relieve qTnFoms and at leas rheoreticallydeoeasejoinl darDage. TECENIQUE 1. The joinl should be movedt-bmughits rangeof motion to resxsFnd ils co ents. 2. Analomic landmark defining the joint surface shou]dbe identified and rurv be outlned qith a pen or matker. 3. The speci.ficareaof tbejoint 10b€ aspiratedis identifed and ma)'be marked]vi& the redaded ponion ofa ball pou pen 4. The skil sbould be cleansedof obv'iousdLt with soapard s"tcr. 5- The skin can be infiluared with a Iml a-uest-bctic. protecdorl 6. A bridscrub u,rlh a beudhe solutionfolJowedb1'an alcohols*zb shouldprovide ad€qu.ale 7. Do nol louch lbe skin al lbe sspiratioosifeafier cleansing! 8. It is a misake to selerra srlall needleuiLb lhe inGntion of sparingthe patienl pain. Vrscousmalerial flo*.s l\'ifi great diffrculn. if al all tuough needlessmall€rtnn 20 gauge. 9. Srrerch the skin sligh0y, peneEateUrc skir! alpirate gendy, and ad\ace $e neede slowly rmtil fluid appearsin the syrmge. 10. Afler rcmoral of the needle.appll gen0ecompressional the Frncture sirefor se!'eralminutes.Tb€n apll a bandid or ljgbt dessing. C. COMPLI CATIONS OF' ART}IROCENTESIS l. Iatrogenic fufection ofa preriorsll' serile joint (il basbe€n estinaled tut infeoion occursin lqss than I in 10.000i-nstarlces of rliegnonic arthrocenlesis). 2. Bleeding al tbe puncnue site and presumablvoithin thejoint; in atticoagulatedFtients uto develop acute anhritis, anticoa8ulationits€lf is not a conn-aindication o arth,rocentesis 3. Possibleinjury ro canilageb)' tlre needle. ,1.Occasionatl)patientsnul experiencea rasoragal ( qrcoFl

) episodeduring or afler l}re procedrre.

S}?{O\4AL TLUID ANALYSE I. GROSSEXAMINANON 1. VOLLII\4E : can sene as one measrl'Eof th€ se\€ritl' of a process b-i loq voh:me dms Dol mean the imponant inra-afiicular foc€ss. absenceof an 2. \4SCOSITY : flurd of norrnal Yiscosit_vholds together and srerches approxirllatel,v.'one inch befor€ seporatiag.L,os, r,iscosiq' Auid drop6 from a qrbge like $aler. \rrscosiq' is geDera]' decEised in hflamroatory joiat fl uids.

I \

l ^,\

3 coloR AND hllammarory fluid-in a gtass ]'ello$ color

GLARITY: if neqspaperprinl canror be read through rhe fluid, ir generall), suggesrsan process.The plastic of somes-\Tingesmakesfluids arpear falsely cloudy. so examine te contai,'er(ie-res tube ). Nonnal and noninllam.uraron joim-fluidsar? transE ents[:rw sr @nding on theamoult of alhr:mil or biliruhn presen

II. MCROSCOPIC EXAMINATION l. WET MOI'INT : Usefirlfor identjf cation of cells,cartilagefragmenrs,fipid doplds, q'roplasnic ilciusiors. and somecl8tals. Sickledred cdls mai'be seenin eftrsions ofpadentswith sickleceu disease. 2. CRYSTAL ANALYSIS : A polarizing light miroscope providesthe gold sandard for o1'stal i&ntif cauon MonosodiumuElle cn'suls otgoul ale ne€dlesbapedor long n'ith bluntendr and.ri
I]I. SPECIAL LABORATORY TESTS l. CULTIJRES : if joint infection is suspc'ctedthe truid should be se for c-ultureand sensitivity. The follo$ing r}?e of cullues canbe seDt:aerobc.anaembc,gonococcalfi:nga! ard Nberculosis. 2. MUCIN O-OT TEST: seleral &oF of slTorial fluid are addedto about 20 ml. of 57oaceic acid in a srnll be-aker alloEing onemiautefor a dot to foml A " good clot " from norrnal or oseoanhritis fluid forrnsa frrm mass thal dtrs not fragnent on shaking.A " poor clot " like ftat fiom marq inflammatoD'fluids fi,agments eas l' and forms fl2kef shrEds ald cloudinessin the surroundingIluid ' Good mucin clot " generallv reflectstle nornd inegrit_vof b1zJuronare.

13

COUNT AND DIFFERENTIAL: u'ilJ pror.ide idormation abor.u lbe level of ioint

3. LEUKOCyIE infltntrradon.

4. CLUCOSE: qrovial lluid glucoseconcenradonis normatv slig}tJ1'lessthan tbat of blood gluc!6e. A ver]' of glucosein the qnovral lluid sugge$sjoint infecrion.Ocsrcionaleffi:sions in Rheumatoid los ler'el qnovia.l fluid leuel ofless t|an half thar ofblood anlritis havea RHEIJMATIC DISEASES CEARACTERIZED BY S}?{O\'IAL FLI]ID ANALYSIS

I

INFLAMMATORY Rheumatoiddisease Reitels qrldmme honatic anlritis Ankylosing spon{'litis Ulcerativecolitis Acurecq,sai qnovitis S!,semiclt4us e^lhematosus \tral or fungal urfections

NONINFLAMMA'TOR}' Osteoarthrbis Traurns Oseochondritis dessicars Neumpathicarthropathl' Sicldecell dis€ase Osteochon&omaross H1'peru'opbicoseoantuopatbl' Ochronosis Hemochrornatcis Acromegaly Am)'loidosis

I I

)

SEPTIC Baclerialinfections

]

HEMORRHAGIC Trauma uith or without fracnne Postsurgical Pignrentedvillonodrlar Snovitis Slnovioraa Neuroparldcanlroparh-lHemangiorna Coagulationdisor&s Hemophilia von WilletnaDd'sdisease Tlrerapanic anticoagulation Sickle cell disease Tirornboc,vtop€ru ENels-Danlosqrdrome Scurvv

L

/ 1

I

CLASSIFjCATTON OF SYNOVIAL ETTUSIONS

EXAM

NORMAL

NONINFLAMIVI

INFLAMM.

SEPTTC

color

straq'

strauy')'ellow

yellou

rariable

$tsC (mm3)

<200

[email protected]

2.mG75.O()0

> t 00.000

PMN (oz)

45

45

>50

>75

culture

t-,

(-)

muci.n clot

firm

fum

l

ofren(+) fiiable

Aiable

A A

Tuberculosisof Bonesand Joints

Amer ThoracicAsw.Anter J Respand Clin CareMed. 149.1994

INTRODUCTION The prevalenceoftuberculosisbasbeenrising sincr 19E6.$ith morbidrl-1' rncreasingl4yo from t. 2. 1

,{. 5. 6. 7.

1 9 8 5t o 1 9 9 3 . Urbal areasofdevelopedcountriesare morelilell to encounterpatents u'ho haveNb€rculosis Faclorslbat contributeto i-nsssed rareilclude; of lhe imrnuneq'stem a. suppression b. de\€lopmenrof drug-resist3nlstrainsof M]'cobacl.erium c. aging population d increasednumber of health-careworh.en who are ex?osedto the disease HfV renrairx the leading lcro*n risk for the reactivadonof lalent tuberculosisinfection Spinal tubercuiosishas exised for at least 5000 years Pott notedtheassociationbenveentubcrculosisinvolvementof *re thoracicspineand praplegia Tlre saniurium setting ir the en before anirubercular drugs-eas consideredto be successirl

THREE RELATED ORGANISMS Mycobaaeriumruberculosis- mo$ common L M1'cobacreriumaficanum - found outside Northwestem Africa 2. 3. M!'cobacterium bovis - found in areasnot utilizing milk paseurizauon MYCOBACTERIUM TTJBERCLILOS]S -thir rod uitb round ends.norunolile, \ralbout cap6ule,resistsdecolorizationwith strong mineral acids and alcoho.l:hence,is coruideredan acid-alcohol-fastor acid-fast bacillus. -gro$s cnll, on enrichedmedium contaidng €g,gand polrto bas€or serun (albumin) base -\'isible coloniesaFpcatal around2lo 4 q'eeks.seconda4'loox-\'gentension lncreasedorfgen tensiorqas in $e lung allowsthe organismto gron'freely. INCIDENCE -one-third of tbe globel popuiation is infected $ith Mycobacrerium nrberculosis -M. ruberculosisis the causeof 3 rnillion deat}s per year -ren million pcnons are presently iDfected.and 9076of neq' activated casescome fiom tis infecredpool of indivjdl|qh

-in non-Hispanic$'hitepeople,t}e medianageat diagnosisis 6l years -among tbe American miroritj', the medianage ofdiagnosis is 39 years -one-third of parcnrswilh hrberculosisq'ho are also infected$'ith HIV will haveextrapulmona4'disease$ith or nithout a pulmonaD/compone SITE OF INFECNON -Tuberculosis hasbeenreponed h all bonesof tbe bo$ -ln the U.S..r}le soineis involved50o of lhe time 5Oo/o Tboracic spine 25o/o Cenical spme Pon's Dise€s€-TB of tre venebra 25o/o Lumbar spine ^o$er reponed areasare less coEmonpelvis l2Yo hip & femur l00h too ioee & tbia 70/o n-b6 ankle or shoulder27o 2r'o elboq'or sTist 3Yo muhide sires --€$apulmoDa4' tuberculosisis more common i.n chil&en than in adulB -mosl corrynone^lrilpulrnonaS inYolvemenl in childen is $c superficial l\mph nod€s(soofula)

I I

DIAG@CLILOSIS _-IIM=-AL l. Localized paia 2. Associaledfever 3. $'eight loss 4 funcal rigidiq. 5. musclespasrr 6. neurologjcalsigns T cold abscess(sn'er.ring nithoutinnamrnation)- sfongh, suggesuve of rB osreomveliris @Tubercular sketeul

t

I )

lesions demands tuntereraluation ;;,h*;;d;;;;;;;.:.i.i,,;ri:il",Jr*n

uacl and kidnevs. one-third ofpatientsuirh boneorjoinr rg

hare-l ,usron.of pulmonan.invorvemenr :

PLAIN RADIOGRAPHS r. NO SPECIFICRADIOGRAPHICRNDINGS 2. osteopenia 3. sofi-tissuesu,elling a. mtnimal p€riostealreaction 5. narros'ing ofjoinl spac€ 6. cystsin boneadjacentrojoirl 7. enlargementofthe epiphisis in childrcn 8. subchondralerosions 9. new-boneformation

7 )

)

!

BONE SCANS- nol lerjbl).belpful SKIN TESTS -Koch disco'ered rhe ruleriai Nberculin thal s"s lhe antigenic componenl 'fMycobaderium ruberculosis. This $,aslaer precipibred our lo re'eal rfr. !.in.A pior.i', d"".r;;i;?6;'. -rnterpreution of the ppD tes depcnn.,on "^po.-" to ur llrcrtosrs, immunosup'resion of lhe hosr and prer.iousexposurero baiile Caf_enecuerl" (UiG). -ar lea'' 200% ofdebiritaredor malnourished parientsu'ho iJJ. "nenrr.,r. oseasehave a falsenegauve skil lesL -HIV infecred patienrs$'itb concomitan TB are prone to be anergrca'd silr &erefore prodde a negadve skin-te$ing OTHER TESTS l. ESR - neitler slEcific nor completelyreliable 2- ELISA (ename-tinlied.imrn'nlsorbent-assay) - reponedsensitrl'rtrof60 - 80%o. bul tiese testsmay be negativefor pad€ntswbo have'advanc_ed ^ disease. 3. Cbomarography-nolwid€lyavajlable 4. Nucleic Acid hobes-nol n,idelYavailable 5. Pol\meraseCbai-nReacdons_not uidell. arailable CULT1IRE

*HT:$ffiTi.j:trnds

onrecognition ofM).cobacrerium tubercuJosis oneirher hisrologic

BIOPSY -Biops-"r and possibleoperative treztrnenl are reservedfor parients*.ho fair to respondto ad€quate chemorherag., $ ho ha'e sufr11tial imparrmenr(asin TB infeded venebrae),or ,neur.glogjca] in \r'hom eit-berrcststantstrains or other diseaseentitiaa "ra *rpact"a

r+o

)

)

,

I

-

-_--.---ll

TREATMENT padenaissuspecled ofh-aringtuberculosis. thatpatientrnustte?lacedrn an.isolationtoom 2. operarivehten'ention shouldbc deiaveduntil tbepaUentis !o longeridecrious -:. Medical featlnent a. conuct Centerfor DiscascConBolfor mostrccenlsuidelines b. consulran infectiousdiseasespecialist 4. Anribiosls a. ruJumum of tlree drugs to rlhich tlre organismis susceptible b. at lea$ oDeof Oesedrugsmustbe bactericidal c. PossibleantibioticselecUon includes.but is nol limited to. Isoniazid 3-5 mgkE/&y t0 mg QD hridoxine Rifarnpin 10 mgkeld4' hrazinarnide 20-25 ngkg/dat Elhamburol 15-25mgkg/da1'. StreptomycinI 5-20 me&Lg/ &y 5. Oprimumduntion of lrezrme , 6-9 montbsfor patientsu'ith pulrnona4'involrementaloneParen$ uith e)ib-dpuhnonarJ. tuberculosisreguire l2-lg montE of lratrnent

MANAGEMENT ofH]\/ L Definirion: a human retrovirus thal infects j\Trphocytes and other cells bearing the cDt surface marker. LnfeoionIeaG to lyrnphopeniacDl llmphoc.rnedeficienc'and dvsfunnion.impired cellmediatedimmune response,and poll,clonal B+11 actiYadonrvith impaired B-c€ll rcsponseto new anDgens. 1. AIDS: characterizedby oppomrnistic infeaions and unusualmaligDancies IL Srandard of Carr l. Document cDrl coufi every 3-4 monlhs aslong as cDl>50. Do not needto follo$ cDl counr<50 Viral load lesting every 3-4 months. 2. A.l1 V-infected Fdents shodd h3vettre following regardtessof CD.l count: A PPDianergi panel l. U PPD is (+) give INH for I year. 2. Arerg- panel{becks rhe abilil_tto hos;tan immune svsenl response. Watrl il ,ed ard raised. B . RPR/FTA: lf RPR is reactive, ger an LP. C. hreumococcal racci.ne: Get every 3-5 years. D. h{luenzal shot: Gel every year. This is controversial. E. Hepatitis screenald hepurax seriesifHBV serology is negative. F. Cen'ial pap smearfor all women evelr 6-12montls. G. Toxoplasnu rirer3. CD.l of 500 begil combiration andretroviral therapv using: A. AZT 2OomgTlD + a s€condrevelse tra.Dscriptase inhibitor +,/- a proreasejrtribilor. l. AZT: can causenegaloblastic anenia, neufopenia GI efleds, a!xie$, dzrk blue nails. B. Or}ler nucleosidereversetr:urscripus€inhibirors include: L DDI: can causepancreatitis,peripheral neuropathl'. 2. DDC: catrcausemouth ulcerg peripheral neuropathl. 3. D4T 4. 3TC: hasthe le-astarnourt of side effects. C. Proteaseinlu-biloIs: (saquina\ir, indenorir. naltrle\t, riloDavir. am;nenorir.l l. Decreaseriral load markedly and prolong life. 2. Be selecdveqith pa ent: llave tobe compliafl \'itr medication.If dosesare missed resistanc€can form

47

D.

rsversera:rscri6aseinhibilon: Nomucleosideribonuclease 1. \'lrarune

3. efaf irenz carinii pneun:onia)prophvlaxis. 4. CD;1.200begin PCP (Pneurnoc]'stis candidiass A. pCp prophvlaris shouldbc suned regradlessof CDI countif patientbasoroPharyngeal qn&ome (tlrusb). fevers-weight losv\rEsting B. PCP propbl'laxis dng lberaPi': l. nr"tri. I DS on Mon, Wed, ald Fri. This is the drugof choice. Can causerash fever. neuaop€ni4GI effecE.liver d-vsfunciton. 2. Dapsone:Second&ug of choice. Mus checkfor G6PD{an causehemol}lic anemu. Ma1'also use dapsoneplus pgimethamine. 3. Aerosolized pcntamidine: Third drug ofchoice. Can still get PCP rn uPperlobes. Can dzmageto rctma. Canalsogive montbll IV pentamidtne. causecardiomyopath)'. PCP: C. To diagrrose l. LDH wil be increased 2. If galliun scanis (=) possiblePCP,iI:(:) definite\' NOI PCP--3. Gel ABG, f P2<15. $art upering dosesof steroids(ie. prednisone40mgBID x 5 daYs. 40 mg QD x 5 days,20 mg QD x 5 dalE). 4. Bronchoscop)-. D. PG ttetmetrt: l. Bacu-itt 2. Pentamidbe: Seconddrug of choice. Must correcl for Enat insufrciencl'- Can cause pancreatitii life-lhtealeninghJpoglycemiaandh)?enension. 5. CDII<75 begi! MAC (M1'cobaaeriu$ a\ium mmplex) Proph]'laxis: A Rifaburin: Drug of choice for prophl'laxis. Can causeGl effects and hepatotoxicilv. Secondline choicesincludeclariuuomycinor azithromycil B- Ca:: causebone ruuro$' suFPressionand panq'ropenia. Need lo cbeck AFB itt blood May also be found in rcspiraroryor Gl tract. C. Tre-annentfor MAC is for life. Usualll' clarirhromlcin + one other drug (ethambutol,clofazimine, ciprofl oxac-n rifabutin). 6. CMV (c-flomegalourus): A Retinits: Mon cornrnonplace il presents. UsualJl'patient is ar end $age disease. Trerl for life. B. Ma1'be found i.nbone marron', liver, urine, blood C. Tre.lment Cfhereis no proPh)'laxisavailable): l. Ganciclovir. Can causebone marrow suppressionand neuropenia. Oral form canbe used for CMV colitis. 2. Foscamet: Assocaited$ith renal failure and eledrollte abnorrnalities. MaY have some anti-regoriral FoPenies. D. Recurrencesoccur freguent\'and reguire reinstitmion of hiSh dosehduction therapl. E. +Nole-CMv, MAC, \mPhorna all can Pres€ntwi& fever, bone marrow supPrcssto!' panc-noPerx4 and an increasein LFT's. 7 . Kaposis A C:r be found in skin, rnout\ GI facq li\€r (can caus€biliatl' obatruction), lung (lhesebl€€d easily- prognosisvery Poor). B. Treatmeol is chemotierap'. lntralesion interferon qm be injected fot skin lesion 8 . TB A. Rise \ith increasein Hry. Wift this see3n increasein extra-pulmonal-'\'TB B. U prdeDl basbeen ircarcerated,homeless,or ljYed in a shellet shouldbe restedfor TB C- Treatmentfor patientsq'ith HfV and TB shou.ldbe for one 1'er. 9 . Periptreral neuroPath]': A About 50% of Hry patienls qill bave lhis. B. Treamrent: l. Elayil: asmuch astheir blood pressurecanlolerale

48

t

)

l

)

2- Morphi:re. 3. Me:.ilitine. 10. Otlir possibleidedions:$a)'a*"1'from A. Toxoplasmicencepailitis: hevendon{o nol eal rl$ mell. Nashall vegetables. plus grimethzmine. cats- hoph)'la)osis Bactrlmor dapsone B. Cr-rl:tosporidosis: Found in contamimted dinking q"ter. No availableprophl'laris. C. Cryptococcus:Avoid sirescontamilated$'itb pigeoDdroppins. Treahent is fluconazole. D. Coccidioml'cosis:Foundin soil. farms. heferred rstment is flucoruzole. AJrernatednrgs amphotericrn includ€ rraconazole,ketaconazole, B. E. Hiioplasmosis: Foundin chickencoopc,caves.bird rooning sites. Treaurentis fluconazole. and skin Treahenl is an oral azole(fluconazole). F. Candidiasis: Foundon mucosalsurfaces Can also usetopical nlsLatinor cloairuzole. Herpes Sinrplex: Treaunentis aclrcloyir until lesionsbaveresolve4 Can use ry foscarnetfor st'ainsresisantto acyclovir. of acvclorir is guesrionable. H. \'aric€lla-Zoner: Effectiveness l. Hurnan Papillomavirus: May needbiops.vof cervix. J. Bacillary an€lometosis: l,ooks similar lo Kaposis. Treaunentis erytlrom_vcin. K. SeborrheicDemnrids

NEUROLOGY Neuologic disodels [ra)' lead ro \€rious los€r exmmit_r' manifesutiorx including carus defornitie<. eguinrs, pes planus spasticrt)', paralysis, gail ab'norrnalities and diminished sensado!-

I. DIAGNOSTTC WORKUP: illsorv

ofillness - Shonldbe otuined Aom all arailable sources. - Utilize a problem orientedfonnat i.e-NLDOCAT. a. Patied b. Farily/Guardian if patient is a child asceflab tregnancl' course delivol', APGAR score, dfl,'eloprnentalmilegones. c. Oth€rbeal0careDrofessioDals 2.hs medicalhisory 3.Pasrswgical hisory 4.C\rrenl rEdications 5famill'hisorl' 6.Social history- occupation,EIOE iuicit ftlgs, STD''HV T. P}rySICAL EXAM -a conplete neurologicexamshouldbe performed Neurolos'

consultationis highl-r'rccommended

l- Mental satuscheck- otnined $' obeenationand duing hisory uking - Assessgeneralapearance,le\€l of conscjousness, orienution affect,cogrritiorr

49

2. Creial n6\€s

L Olfadory- senseof smell a-anrFsia-lossin I eye b. bi-tempomlhemisnopsia-tosslemporalfields losscomplaefield'L or R (seeFig 1) c.bomonjmowhemianopsia-

C,O

'x-' "L

(|,:-.

c.c C O O C

IIL Occdomotor >>> i v*. Trochleaf >>>>>> extraoQrlar eye motlol'ls

M. Abfucens V. Trigemiml - Motot- musclesof rDa$icauon - Sersory-entirefacevia 3 di\isions W. Facial- Motor- musclesof facial ex?ression - Sensory-anerior 2/3 tongue V[. Vst-bulocochlear- h€aring - senso4'po$erior l/3 tongue D(. Glmsophar-vngcal -unrJa midli.ne,nomral voict, gagEsponse X Vagus )C. Spinalaccessory- Motor iernocleidonastoid andtraPezius ) I. Hlpoglossal - motor tongue

3. Molor e)am - e\€luale qmmetr)'. fimction and rnusclelone a Lowet extEmilv T12-L3 - IlicFsoas IJ-4 - Addrcrorg Quadticep6 I..4- Tibialis anterior lJ - AbdrcloE EHI- mL EDB SI - Glure s rraximus' PL, PB, TP, Casuosoleus S2-3- lrrsrinsics b. Upperodlemig C5 - Deltoid C55 -BiceP6 C6 - Wris enenson C7 - Tdc+, Wrist flo(oF, Finget exlensors C8 - Finger flexors CE-TI - Iland inrinsics c. ]r4anualnuscle res grading 5 - Normal - Comple€ ROM a€ainstgEviq'$iti full resisance 4 - Good - Conplete RoM 'g:in
50