Presentation
The patient has some combination of urinary frequency, urgency, dysuria, flank pain, nausea, fever, and chills. On physical examination, there is tenderness elicited by percussing the costovertebral angle over the kidneys. The urinalysis may help establish the diagnosis with tubular casts of white cells.
What to do:
Examine urine for presence of gram-positive cocci (presumptively enterococci) or the more usual gram- negative rods, and send for culture and sensitivity.
If the patient appears toxic, with a high fever or white count, nausea or vomiting to prevent adequate oral medicatication and hydration, or if the patient is pregnant or there is any sign of urinary obstruction or developing sepsis, he or she should be admitted to the hospital for intravenous antibiotics.
For stable, otherwise healthy patients, start with a first dose of intravenous antibiotics in the ED (ampicillin 1000mg plus gentamicin 80mg, ceftriaxone 1000-2000mg, ofloxacin 200-400mg or ciprofloxacin 200-400mg), then discharge home on oral hydration and two weeks of oral antibiotics (trimethoprim 160mg plus sulfamethoxazole 800mg bid, ciprofloxacin 500mg bid, norfloxacin 400mg bid or ofloxacin 400mg bid x 14d).
Instruct the patient to return to the ED for re-evaluation in 24-48 hours, and sooner if symptoms worsen. Most patients improve on this regimen, but the others will require hospital admission if they are not improving in two days.
What not to do:
Do not lose the patient to followup. Although lower UTIs often resolve without treatment, upper UTIs inadequately treated can lead to renal damage or sepsis.
Do not miss an infection above a ureteral stone or obstruction. Crampy, colicky pain or hematuria with the symptoms above calls for an excretory urogram (IVP). Antibiotics and hydration alone may not cure an infected obstruction.
Discussion
Although oral antibiotics are usually sufficient treatment for upper UTIs, there is a significant incidence of renal damage and sepsis as sequelae, mandating good followup or admission when necessary. By the same token, lower UTIs can ascend into upper UTIs, or it can be difficult to decide the level of a given UTI, in which case it should be treated as an upper UTI.
Studies have shown tat a 14 day course of oral therapy is highly effective for the woman with clinical evidence of pyelonephritis without sepsis, nausea or vomiting. Quinolones such as ofloxacin (Floxin), ciprofloxacin (Cipro) and norfloxacin (Noroxin) are highly effective and probably the drugs of choice in this setting, except for pregnant women, for whom they are contraindicated. Trimethoprim-sulfamethoxazole (Bactrim, Septra) could also be used, although resistance of 5% to 15% of pathogens may be a more important factor in the selection of therapy for pyelonephritis than for cyctitis.
Sunday, October 31, 2010
Lower urinary tract infection
Presentation
The patient (usually female) complains of urinary frequency and urgency, internal dysuria, and suprapubic pain. There may have been some antecedent trauma (sexual intercourse) to inoculate the bladder, and there may be blood in the urine (hemorrhagic cystitis). Usually, there is no labial irritation, external dysuria or vaginal discharge (which would suggest vaginitis); and no fever, chills, nausea, flank pain, or costovertebral angle tenderness (which would suggest an upper urinary tract infection.)
What to do:
If available in the ED, dip stick for white cells or obtain a urinalysis or Gram stain a sample of urine. The presence of any white cells or bacteria in a clean specimen on microscopic examination confirms the infection. A positive nitrite on dip stick is helpful, but a negative does not rule out infection because many bacteria do not produce nitrites.
If the clinical picture is clearly that of an uncomplicated lower UTI, give trimethoprim 160mg plus sulfamethoxazole 800mg (Bactrim DS or Septra DS) one tablet bid for three days or a 3 day regimen of a quinolone such as ciprofloxacin (Cipro) 250mg bid, norfloxacin (Noroxin) 400mg bid or ofloxacin (Floxin) 200mg bid. Single dose treatment with two TMP/SMX DS tablets is also effective in the young healthy female, but does have a higher early recurrence rate. Instruct the patient to drink plenty of liquids (such as cranberry juice) but do not push fluids when treating children or males.
Extend therapy to 7 days and obtain cultures when treating a patient who is unreliable, pregnant, diabetic, symptomatic more than 5 days, older than 50 or younger than 16. Also extend treatment and obtain cultures on all male patients and those with an indwelling urinary catheter, renal disease, obstructive urinary tract lesions, recurrent infection or other significant medical problems.
If there are no bacteria or few white cells, no hematuria or suprapubic pain, gradual onset over 7-10 days, and a new sexual partner, the dysuria may be caused by a chlamydia or ureaplasma urethritis. Perform a pelvic exam and obtain samples for culture and microscopic examination. Ask the patient about the use of spermicides or douches, which may irritate the periurethral tissue and cause dysuria.
If there is external dysuria, vaginal discharge, odor, itching and no frequency or urgency, then evaluate for vaginitis with a pelvic examination.
If the dysuria is severe, you may also prescribe phenazopyradine (Pyridium) 200mg tid for 2 days only, to act as a surface anesthetic in the bladder. Warn the patient that it will stain her urine (and perhaps clothes) orange.
Arrange for followup in 2 days if the symptoms have not completely resolved. If necessary, urine culture and a longer course of antibiotics can be undertaken then.
What not to do:
Do not undertake expensive urine cultures for every lower urinary tract infection of recent onset in nonpregnant, normally health women with no history of recent UTI or antibiotic use.
Do not follow the single-dose or 3 day regimens for a possible upper urinary tract infection.
Do not rely on gross inspection of the urine sample. Cloudiness is usually caused by crystals and odors result from diet or medication.
Do not require a follow up visit or culture after therapy unless symptoms persist or recur.
Discussion
Lower UTI or cystitis is a superficial bacterial infection of the bladder or urethra. The majority of these infections involve Escherichia coli, Staphylococcus saprophyticus or enterococci. The urine dip stick is a reasonable screening measure that can direct therapy if results are positive. Under the microscope, in a clean sediment (free of epithelial cells) one white cell per 400x field suggests a significant pyuria, although clinicians accustomed to imperfect samples usually set a threshold of 3-5 WBCs per field. In addition, Trichomonas may be appreciated swimming in the urinary sediment, indicating a different etiology for urinary symptoms or associated vaginitis. In a straightforward lower UTI, urine culture may be reserved for cases which fail to resolve with single-dose or 3 day therapy. In complicated or doubtful cases, however, or with recurrences, a urine culture before initial treatment may be helpful.
Risk factors for UTI in women include pregnancy, sexual activity, use of diaphragms or spermicides, failure to void post coitally, and history of prior UTI. Healthy women may be expected to suffer a few episodes of lower urinary tract infection in a lifetime without indicating any major structural problem, but recurrences at short intervals suggest inadequate treatment or underlying abnormalities. Young men, however, have longer urethras and far fewer lower UTIs, and probably should be evaluated urologically after just one episode unless they have a risk factor such as an uncircumcised foreskin, HIV infection or homosexual activity and respond to initial treatment. In sexually active men, consider urethritis or prostatitis as the etiology. In men over 50 years old, there is a rapid increase in UTI due to prostate hypertrophy, obstruction and instrumentation.
References:
Valenstein PN, Koepke JA: Unnecessary microscopy in routine urinalysis. Am J Clin Pathol 1984;82:444-448.
Stamm WE, Hooton TM: Management of urinary tract infections in adults. N Eng J Med 1993;329:1328-1334.
The patient (usually female) complains of urinary frequency and urgency, internal dysuria, and suprapubic pain. There may have been some antecedent trauma (sexual intercourse) to inoculate the bladder, and there may be blood in the urine (hemorrhagic cystitis). Usually, there is no labial irritation, external dysuria or vaginal discharge (which would suggest vaginitis); and no fever, chills, nausea, flank pain, or costovertebral angle tenderness (which would suggest an upper urinary tract infection.)
What to do:
If available in the ED, dip stick for white cells or obtain a urinalysis or Gram stain a sample of urine. The presence of any white cells or bacteria in a clean specimen on microscopic examination confirms the infection. A positive nitrite on dip stick is helpful, but a negative does not rule out infection because many bacteria do not produce nitrites.
If the clinical picture is clearly that of an uncomplicated lower UTI, give trimethoprim 160mg plus sulfamethoxazole 800mg (Bactrim DS or Septra DS) one tablet bid for three days or a 3 day regimen of a quinolone such as ciprofloxacin (Cipro) 250mg bid, norfloxacin (Noroxin) 400mg bid or ofloxacin (Floxin) 200mg bid. Single dose treatment with two TMP/SMX DS tablets is also effective in the young healthy female, but does have a higher early recurrence rate. Instruct the patient to drink plenty of liquids (such as cranberry juice) but do not push fluids when treating children or males.
Extend therapy to 7 days and obtain cultures when treating a patient who is unreliable, pregnant, diabetic, symptomatic more than 5 days, older than 50 or younger than 16. Also extend treatment and obtain cultures on all male patients and those with an indwelling urinary catheter, renal disease, obstructive urinary tract lesions, recurrent infection or other significant medical problems.
If there are no bacteria or few white cells, no hematuria or suprapubic pain, gradual onset over 7-10 days, and a new sexual partner, the dysuria may be caused by a chlamydia or ureaplasma urethritis. Perform a pelvic exam and obtain samples for culture and microscopic examination. Ask the patient about the use of spermicides or douches, which may irritate the periurethral tissue and cause dysuria.
If there is external dysuria, vaginal discharge, odor, itching and no frequency or urgency, then evaluate for vaginitis with a pelvic examination.
If the dysuria is severe, you may also prescribe phenazopyradine (Pyridium) 200mg tid for 2 days only, to act as a surface anesthetic in the bladder. Warn the patient that it will stain her urine (and perhaps clothes) orange.
Arrange for followup in 2 days if the symptoms have not completely resolved. If necessary, urine culture and a longer course of antibiotics can be undertaken then.
What not to do:
Do not undertake expensive urine cultures for every lower urinary tract infection of recent onset in nonpregnant, normally health women with no history of recent UTI or antibiotic use.
Do not follow the single-dose or 3 day regimens for a possible upper urinary tract infection.
Do not rely on gross inspection of the urine sample. Cloudiness is usually caused by crystals and odors result from diet or medication.
Do not require a follow up visit or culture after therapy unless symptoms persist or recur.
Discussion
Lower UTI or cystitis is a superficial bacterial infection of the bladder or urethra. The majority of these infections involve Escherichia coli, Staphylococcus saprophyticus or enterococci. The urine dip stick is a reasonable screening measure that can direct therapy if results are positive. Under the microscope, in a clean sediment (free of epithelial cells) one white cell per 400x field suggests a significant pyuria, although clinicians accustomed to imperfect samples usually set a threshold of 3-5 WBCs per field. In addition, Trichomonas may be appreciated swimming in the urinary sediment, indicating a different etiology for urinary symptoms or associated vaginitis. In a straightforward lower UTI, urine culture may be reserved for cases which fail to resolve with single-dose or 3 day therapy. In complicated or doubtful cases, however, or with recurrences, a urine culture before initial treatment may be helpful.
Risk factors for UTI in women include pregnancy, sexual activity, use of diaphragms or spermicides, failure to void post coitally, and history of prior UTI. Healthy women may be expected to suffer a few episodes of lower urinary tract infection in a lifetime without indicating any major structural problem, but recurrences at short intervals suggest inadequate treatment or underlying abnormalities. Young men, however, have longer urethras and far fewer lower UTIs, and probably should be evaluated urologically after just one episode unless they have a risk factor such as an uncircumcised foreskin, HIV infection or homosexual activity and respond to initial treatment. In sexually active men, consider urethritis or prostatitis as the etiology. In men over 50 years old, there is a rapid increase in UTI due to prostate hypertrophy, obstruction and instrumentation.
References:
Valenstein PN, Koepke JA: Unnecessary microscopy in routine urinalysis. Am J Clin Pathol 1984;82:444-448.
Stamm WE, Hooton TM: Management of urinary tract infections in adults. N Eng J Med 1993;329:1328-1334.
Candidiasis
CAUSATIVE AGENT:-
Small, oval, thin-walled, budding cells with or without the presence of pseudohyphae
Stains gram-positive
C. albicans is identified by the ability to produce germ tubes and/or chlamydospores in cornmeal agar
All Candida species may be distinguished by sugar fermentation tests.
Epidemiology
Normal host saprophyte yeasts found commonly in the gastrointestinal tract, genitourinary tract and oropharynx
Worldwide distribution
70% of nosocomial candidal infections are due to C. albicans with the rest due to C. glabrata, C. guilliermondii, C. krusei, C. pseudotropicalis, C. stellatoidea and C. tropicalis
Fifth most common blood pathogen isolated from hospitalized patients and the fourth most common in ICU patients
Risk factors for candidiasis:
age extremes
central venous catheters
TPN
burns
exogenous hormone therapy
prosthetic devices
malnourishment
metabolic disease
concurrent infections with other pathogens
antibiotic therapy
uncontrolled diabetes mellitus
GI surgery
AIDS
mechanical disruption of epithelial surfaces
physiological impairment of epithelial barrier function
Clinical syndromes
Candiduria
Cutaneous
Disseminated
Oral candidiasis
Vulvovaginitis
Diagnosis
Diagnosis is dependent on visualization of budding yeast (with or without pseudohypha) and the presence of clinical symptoms
culture
KOH preparation
Gram's stain
Comments on treatment
Cutaneous
Requires drying
Nystatin powder or imidazole (Butoconazole, Clotrimazole, Miconazole , Tioconazole ) powder
Topical steroids initially
Paronychia may require topical imidazole up to 3 months
Oral candidiasis:
Nystatin, Fluconazole, Itraconazole, Clotrimazole.
Candiduria:
Remove predisposing factors, (ie, Foley catheter)
Recommended: Amphotericin B (conventional)
Alternative: Fluconazole
Disseminated:
Drainage or debridement
Recommended: Amphotericin B (conventional)
Alternative: Fluconazole (not effective against C. krusei or C. glabrata)
Endophthalmitis may require subtenonian or intracameral injection of Amphotericin B (conventional)
Vulvovaginitis:
Imidazole derivatives (Butoconazole, Clotrimazole, Miconazole , Tioconazole ) and triazole derivative (Terconazole) (85% to 90%) are more effective than Nystatin
Extensive vulvar inflammation usually requires topical cream
Resistant or recurrent infections: oral agents (Ketoconazole, Fluconazole or Itraconazole)
Prophylaxis: Ketoconazole and Fluconazole
Small, oval, thin-walled, budding cells with or without the presence of pseudohyphae
Stains gram-positive
C. albicans is identified by the ability to produce germ tubes and/or chlamydospores in cornmeal agar
All Candida species may be distinguished by sugar fermentation tests.
Epidemiology
Normal host saprophyte yeasts found commonly in the gastrointestinal tract, genitourinary tract and oropharynx
Worldwide distribution
70% of nosocomial candidal infections are due to C. albicans with the rest due to C. glabrata, C. guilliermondii, C. krusei, C. pseudotropicalis, C. stellatoidea and C. tropicalis
Fifth most common blood pathogen isolated from hospitalized patients and the fourth most common in ICU patients
Risk factors for candidiasis:
age extremes
central venous catheters
TPN
burns
exogenous hormone therapy
prosthetic devices
malnourishment
metabolic disease
concurrent infections with other pathogens
antibiotic therapy
uncontrolled diabetes mellitus
GI surgery
AIDS
mechanical disruption of epithelial surfaces
physiological impairment of epithelial barrier function
Clinical syndromes
Candiduria
Cutaneous
Disseminated
Oral candidiasis
Vulvovaginitis
Diagnosis
Diagnosis is dependent on visualization of budding yeast (with or without pseudohypha) and the presence of clinical symptoms
culture
KOH preparation
Gram's stain
Comments on treatment
Cutaneous
Requires drying
Nystatin powder or imidazole (Butoconazole, Clotrimazole, Miconazole , Tioconazole ) powder
Topical steroids initially
Paronychia may require topical imidazole up to 3 months
Oral candidiasis:
Nystatin, Fluconazole, Itraconazole, Clotrimazole.
Candiduria:
Remove predisposing factors, (ie, Foley catheter)
Recommended: Amphotericin B (conventional)
Alternative: Fluconazole
Disseminated:
Drainage or debridement
Recommended: Amphotericin B (conventional)
Alternative: Fluconazole (not effective against C. krusei or C. glabrata)
Endophthalmitis may require subtenonian or intracameral injection of Amphotericin B (conventional)
Vulvovaginitis:
Imidazole derivatives (Butoconazole, Clotrimazole, Miconazole , Tioconazole ) and triazole derivative (Terconazole) (85% to 90%) are more effective than Nystatin
Extensive vulvar inflammation usually requires topical cream
Resistant or recurrent infections: oral agents (Ketoconazole, Fluconazole or Itraconazole)
Prophylaxis: Ketoconazole and Fluconazole
Malaria
Organism-
Obligate intracellular parasite
Sexual reproduction in mosquitoes, asexual in humans
Only 4 species are infective to humans: P. falciparum, P. vivax, P. ovale and P. malariae
Epidemiology
Only endemic in tropical areas of the developing world
Vector (Anopheline mosquito) present worldwide
In North America, transmission occurs after the influx of many infected persons (ex: refuges from endemic areas)
Transmission can also occur by blood products, among IV drug users (IVDU) who shares needles and congenitally
Clinical syndromes
Initial infection is very non-specific, "flu-like"
P. falciparum infection in more fulminant than the other and is often resistant to chloroquine and is a medical emergency
Diagnosis
Blood smear
Comments on treatment
Prevention
screen, nets and DEET
Chloroquine sensitive (Haiti/Dominical Republic, Central America West and North of the Panama canal and parts of the Middle East): chloroquine phosphate
Chloroquine resistant: mefloquine, doxycycline, atovaquone
Treatment
P. vivax or P. ovale
chloroquine phosphate
chloroquine-resistant P. vivax: halofantrine
P. falciparum (chloroquine sensitive) or P. malaria: chloroquine phosphate
P. falciparum (chloroquine resistant): PO treatment
quinine + doxycycline
atovaquone + provaquine
P. falciparum (chloroquine resistant): IV treatment: quinidine
Obligate intracellular parasite
Sexual reproduction in mosquitoes, asexual in humans
Only 4 species are infective to humans: P. falciparum, P. vivax, P. ovale and P. malariae
Epidemiology
Only endemic in tropical areas of the developing world
Vector (Anopheline mosquito) present worldwide
In North America, transmission occurs after the influx of many infected persons (ex: refuges from endemic areas)
Transmission can also occur by blood products, among IV drug users (IVDU) who shares needles and congenitally
Clinical syndromes
Initial infection is very non-specific, "flu-like"
P. falciparum infection in more fulminant than the other and is often resistant to chloroquine and is a medical emergency
Diagnosis
Blood smear
Comments on treatment
Prevention
screen, nets and DEET
Chloroquine sensitive (Haiti/Dominical Republic, Central America West and North of the Panama canal and parts of the Middle East): chloroquine phosphate
Chloroquine resistant: mefloquine, doxycycline, atovaquone
Treatment
P. vivax or P. ovale
chloroquine phosphate
chloroquine-resistant P. vivax: halofantrine
P. falciparum (chloroquine sensitive) or P. malaria: chloroquine phosphate
P. falciparum (chloroquine resistant): PO treatment
quinine + doxycycline
atovaquone + provaquine
P. falciparum (chloroquine resistant): IV treatment: quinidine
Conjunctivitis
Presentation
The patient complains of a red eye, a sensation of fullness, burning, itching, or scratching, and perhaps a gritty or foreign body sensat ion and tearing or purulent discharge and crusting or mattering. Examination discloses generalized injection of the conjunctiva, thinning out towards the cornea (localized inflammation suggests some other diagnosis such as a foreign body, episcleritis, or a viral or bacterial ulcer). Vision and pupillary reactions should be normal and the cornea and anterior chamber should be clear. Any discomfort should be temporarily relieved by instilling topical anesthetic solution. Deep pain, photophobia, decreased vision and injection more pronnounced around the limbus (ciliary flush) suggest more serious involvement of the cornea and iris.
Different symptoms suggest different etiologies. Tearing, preauricular lymphadenopathy and upper respiratory symptoms suggest a viral conjunctivitis. Pain upon awakening with lid crusting and a copious purulent exudate suggests a bacterial conjunctivitis. Few symptoms upon awakening but discomfort worsening during the day suggests a dry eye. Little conjunctival injection with a seasonal recurrence of chemosis and itching, and cobblestone hypertrophy of the tarsal conjunctiva suggests allergic (vernal) conjunctivitis. Physical and chemical conjunctivitis, caused by particles, solutions, vapors, natural or occupational irritants that inflame the conjunctiva, should be evident from the history.
What to do:
Instill proparcaine anesthetic drops (Alcaine, Ophthaine) to allow for a more comfortable exam and to help determine if the patient's discomfort is limited to the conjunctiva and cornea or, if there is no pain relief, that the pain comes from deeper eye structures.
Examine the eye, including visual acuity, inspection for foreign bodies, pupillary reaction fundoscopy, estimation of intraocular pressure by palpation of the globe above the tarsal plate, slit lamp examination (when available), and fluorescein and ultraviolet or cobalt blue light to assess the corneal epithelium.
Ask about and look for any rash, arthritis, or mucous membrane involvement which could point to Stevens-Johnson syndrome, Kawasaki's, Reiter's, or some other syndrome that can present with conjunctivitis.
For bacterial conjunctivitis, start the patient on warm compresses and seven days of topical antibiotics such as erythromycin, sulfacetamide, tobramycin or gentamycin ointment (which transiently blurs vision) every 4 hours, or solutions such as sulfacetamide 10%, tobramycin 0.3% or ciprofloxacin every 2 hours, with oral analgesics as needed. If it is unclear whether the problem is viral or bacterial, it is safest to treat it as bacterial.
For viral and chemical conjunctivitis, use cold compresses and weak topical vasoconstrictors such as naphazoline 0.1% (Naphcon) every 3-4 hours, unless the patient has a shallow anterior chamber that would be prone to acute angle- closure glaucoma with mydriatics.
For allergic conjunctivitis, use cold compresses and topical decongestant- antihistamine combinations such as drops of naphazoline with pheniramine (Naphcon A) or naphazoline with antazoline (Vasocon A) every 3-4 hours. Topical corticosteroid drops provide dramatic relief, but prolonged use increases the risk of opportunistic viral, fungal and bacterial corneal ulceration, cataract formation and glaucoma. If a severe contact dermatitis is suspected, then a short course of oral prednisone would be indicated.
If the problem is dry eyes (keratoconjunctivitis sicca) use methylcellulose (Dacriose) artificial tear drops.
Have the patient follow up with the ophthalmologist if the infection does not clearly resolve in 2 days. Obtain early consultation there is any involvement of cornea or iris.
What not to do:
Do not forget to wash your hands and equipment after examining the patient, or you may spread herpes simplex or epidemic keratoconjunctivitis to yourself and other patients. Also, do not forget to instruct the patient on the importance of hand washing and separation of towels and pillows for ten days after the onset of symptoms.
Do not patch an affected eye, as this interferes with the cleansing function of tear flow.
Do not give steroids without arranging for ophthalmologic consultation, and never give steroids if a herpes simplex infection is suspected.
Discussion
Warm compresses are soothing for all types of conjunctivitis, but antibiotic drops and ointments should be reserved for when bacterial infection is likely. Neomycin-containing ointments and drops should probably be avoided, because allergic sensitization to this antibiotic is common. Any corneal ulceration requires ophthalmological consultation. Most viral and bacterial conjunctivitis will resolve spontaneously, with the possible exception of staphylococcus, meningiococcus, and gonococcus infections, which can produce destructive sequelae without treatment.
Most bacterial conjunctivitis is caused by Streptococcus pneumoniae, Haemophilus aegyptus and Staphylococcus aureus. Routine conjunctival cultures are seldom of value, but you should Gram stain and culture a copious purulent exudate. Neisseria gonorrhoeae infection confirmed by Gram-negative intracellular diplococci on Gram stain requires immediate ophthalmologic consultation. Corneal ulceration, scarring and blindness can occur in a matter of hours. Chlamydial conjunctivitis will usually present with l
The patient complains of a red eye, a sensation of fullness, burning, itching, or scratching, and perhaps a gritty or foreign body sensat ion and tearing or purulent discharge and crusting or mattering. Examination discloses generalized injection of the conjunctiva, thinning out towards the cornea (localized inflammation suggests some other diagnosis such as a foreign body, episcleritis, or a viral or bacterial ulcer). Vision and pupillary reactions should be normal and the cornea and anterior chamber should be clear. Any discomfort should be temporarily relieved by instilling topical anesthetic solution. Deep pain, photophobia, decreased vision and injection more pronnounced around the limbus (ciliary flush) suggest more serious involvement of the cornea and iris.
Different symptoms suggest different etiologies. Tearing, preauricular lymphadenopathy and upper respiratory symptoms suggest a viral conjunctivitis. Pain upon awakening with lid crusting and a copious purulent exudate suggests a bacterial conjunctivitis. Few symptoms upon awakening but discomfort worsening during the day suggests a dry eye. Little conjunctival injection with a seasonal recurrence of chemosis and itching, and cobblestone hypertrophy of the tarsal conjunctiva suggests allergic (vernal) conjunctivitis. Physical and chemical conjunctivitis, caused by particles, solutions, vapors, natural or occupational irritants that inflame the conjunctiva, should be evident from the history.
What to do:
Instill proparcaine anesthetic drops (Alcaine, Ophthaine) to allow for a more comfortable exam and to help determine if the patient's discomfort is limited to the conjunctiva and cornea or, if there is no pain relief, that the pain comes from deeper eye structures.
Examine the eye, including visual acuity, inspection for foreign bodies, pupillary reaction fundoscopy, estimation of intraocular pressure by palpation of the globe above the tarsal plate, slit lamp examination (when available), and fluorescein and ultraviolet or cobalt blue light to assess the corneal epithelium.
Ask about and look for any rash, arthritis, or mucous membrane involvement which could point to Stevens-Johnson syndrome, Kawasaki's, Reiter's, or some other syndrome that can present with conjunctivitis.
For bacterial conjunctivitis, start the patient on warm compresses and seven days of topical antibiotics such as erythromycin, sulfacetamide, tobramycin or gentamycin ointment (which transiently blurs vision) every 4 hours, or solutions such as sulfacetamide 10%, tobramycin 0.3% or ciprofloxacin every 2 hours, with oral analgesics as needed. If it is unclear whether the problem is viral or bacterial, it is safest to treat it as bacterial.
For viral and chemical conjunctivitis, use cold compresses and weak topical vasoconstrictors such as naphazoline 0.1% (Naphcon) every 3-4 hours, unless the patient has a shallow anterior chamber that would be prone to acute angle- closure glaucoma with mydriatics.
For allergic conjunctivitis, use cold compresses and topical decongestant- antihistamine combinations such as drops of naphazoline with pheniramine (Naphcon A) or naphazoline with antazoline (Vasocon A) every 3-4 hours. Topical corticosteroid drops provide dramatic relief, but prolonged use increases the risk of opportunistic viral, fungal and bacterial corneal ulceration, cataract formation and glaucoma. If a severe contact dermatitis is suspected, then a short course of oral prednisone would be indicated.
If the problem is dry eyes (keratoconjunctivitis sicca) use methylcellulose (Dacriose) artificial tear drops.
Have the patient follow up with the ophthalmologist if the infection does not clearly resolve in 2 days. Obtain early consultation there is any involvement of cornea or iris.
What not to do:
Do not forget to wash your hands and equipment after examining the patient, or you may spread herpes simplex or epidemic keratoconjunctivitis to yourself and other patients. Also, do not forget to instruct the patient on the importance of hand washing and separation of towels and pillows for ten days after the onset of symptoms.
Do not patch an affected eye, as this interferes with the cleansing function of tear flow.
Do not give steroids without arranging for ophthalmologic consultation, and never give steroids if a herpes simplex infection is suspected.
Discussion
Warm compresses are soothing for all types of conjunctivitis, but antibiotic drops and ointments should be reserved for when bacterial infection is likely. Neomycin-containing ointments and drops should probably be avoided, because allergic sensitization to this antibiotic is common. Any corneal ulceration requires ophthalmological consultation. Most viral and bacterial conjunctivitis will resolve spontaneously, with the possible exception of staphylococcus, meningiococcus, and gonococcus infections, which can produce destructive sequelae without treatment.
Most bacterial conjunctivitis is caused by Streptococcus pneumoniae, Haemophilus aegyptus and Staphylococcus aureus. Routine conjunctival cultures are seldom of value, but you should Gram stain and culture a copious purulent exudate. Neisseria gonorrhoeae infection confirmed by Gram-negative intracellular diplococci on Gram stain requires immediate ophthalmologic consultation. Corneal ulceration, scarring and blindness can occur in a matter of hours. Chlamydial conjunctivitis will usually present with l
Sunburn
Presentaion: Patients generally seek help only if their sunburn is severe. There will be a history of extended exposure to sunlight or to an artificial source of ultraviolet radiation, such as a sunlamp. The burns will be accompanied by intense pain and the patient will not be able to tolerate anything touching the skin. There may be systemic complaints that include nausea, chills, and fever. The affected areas are erythematous and are accompanied by mild edema. The more severe the burn, the earlier it will appear and the more likely it will progress to edema and blistering.
What to do:
Inquire as to whether or not the patient is using a photosensitizing drug (e.g., tetracyclines, thiazides, sulfonamides, phenothiazines) and have the patient discontinue its use.
Have the patient apply cool compresses of water or Burow's solution (Domeboro Powder Packets-1 pkt in 1 pint of water) as often as desired to relieve pain. This is the most comforting therapy.
The patient may be helped by applying a topical steroid spray such as dexamethasone (Decaspray) and using an emollient such as Lubriderm.
With a more severe burn prescribe a short course of systemic steroids (40-60mg of Prednisone qd x 3d). This will reduce inflammation, swelling, pain, and itching.
What not to do:
Do not allow the patient to use OTC sunburn medications that contain local anesthetics (benzocaine, dibucaine or lidocaine). They are usually ineffective or only provide very transient relief. In addition there is the potential hazard of sensitizing the patient to these ingredients.
Do not trouble the patient with unnecessary burn dressings. These wounds have a very low probability of becoming infected. Treatment should be directed at making the patient as comfortable as possible.
Discussion
With sunburn, the onset of symptoms is usually delayed for 2-4 hours. Maximum discomfort usually occurs after 14-20 hours, and symptoms last between 24 and 72 hours. Patients should be instructed on the future use of sunscreens containing para-aminobenzoic acid (PABA) (e.g., Pabanol and PreSun). Prophylactic use of aspirin prior to sun exposure has also been recommended.
What to do:
Inquire as to whether or not the patient is using a photosensitizing drug (e.g., tetracyclines, thiazides, sulfonamides, phenothiazines) and have the patient discontinue its use.
Have the patient apply cool compresses of water or Burow's solution (Domeboro Powder Packets-1 pkt in 1 pint of water) as often as desired to relieve pain. This is the most comforting therapy.
The patient may be helped by applying a topical steroid spray such as dexamethasone (Decaspray) and using an emollient such as Lubriderm.
With a more severe burn prescribe a short course of systemic steroids (40-60mg of Prednisone qd x 3d). This will reduce inflammation, swelling, pain, and itching.
What not to do:
Do not allow the patient to use OTC sunburn medications that contain local anesthetics (benzocaine, dibucaine or lidocaine). They are usually ineffective or only provide very transient relief. In addition there is the potential hazard of sensitizing the patient to these ingredients.
Do not trouble the patient with unnecessary burn dressings. These wounds have a very low probability of becoming infected. Treatment should be directed at making the patient as comfortable as possible.
Discussion
With sunburn, the onset of symptoms is usually delayed for 2-4 hours. Maximum discomfort usually occurs after 14-20 hours, and symptoms last between 24 and 72 hours. Patients should be instructed on the future use of sunscreens containing para-aminobenzoic acid (PABA) (e.g., Pabanol and PreSun). Prophylactic use of aspirin prior to sun exposure has also been recommended.
Dengue
Microbiology
Member of the arbovirus
heterogeneous group of RNA virus
usually transmitted by hematogenous arthropods
spherical, non-enveloped
Family flavivirideae
4 types
Epidemiology
Natural virus: humans
Distribution similar to malaria: warm, humid (tropical) countries
Clinical syndromes
Dengue fever
Dengue hemorrhagic fever
Diagnosis
Serology
Comments on treatment
Supportive
No antimicrobial agents shown effective
Member of the arbovirus
heterogeneous group of RNA virus
usually transmitted by hematogenous arthropods
spherical, non-enveloped
Family flavivirideae
4 types
Epidemiology
Natural virus: humans
Distribution similar to malaria: warm, humid (tropical) countries
Clinical syndromes
Dengue fever
Dengue hemorrhagic fever
Diagnosis
Serology
Comments on treatment
Supportive
No antimicrobial agents shown effective
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