ROBIN HENRY DRETLER MD;FIDSA 1/20/2012

HPI: 67 yom rigor followed by fever, severe diarrhea. Saw PCP and given Cipro. After 1 dose developed severe joint pains and came to EW. Fever, hypotension, rash, bandemia and toxicity. Admitted on vanco, zosyn, cipro, doxycycline. ID consulted. No resp or urinary sxs, no HA or stiff neck, no skin wounds, no IVDA, less diarrhea more painful joints.

SH: married, monogamous, no tob, min alcohol FH: HTN PE: Toxic, hypotensive, tachcardia Skin: diffuse erythema back of wrist and forearm, both ankles, red palms, medial thighs, right knee red and hot

Diffuse erythema

Erythema marginatum

HEENT: normal MM, but injected conjunctivae

Cardiac: no murmur Lungs: clear Abd: nl BS, neg Murphys Ext: L knee, R knee, R wrist all swollen, hot, tender but moble Neuro: wnl

Wbc: 3.8 with 30% bands Hct: 43 Plts:129 Bili: 3.6 AST: 370 ALT: 251 Alk Phos: wnl Creat 1.8 INR: 2.2 FDP 5<20

Vasculitis Lupus Polymyositis/dermato myositis TTP JRA Wegeners

Atypical rash Hot joints Non-tender muscles No lung involvement Clear CXR No pupura Positive FDP, INR

Sepsis ABE HIV seroconversion TSS Staph TSS Gp A Strep

No conj hemorrhages, murmur, splinter hemorrhages No risk factors

Rheumatic Fever overlap TSS Usually 4-6 weeks post GAS sore throat Rare USA, but kills millions annually in 3rd world Associated with a specific M protein type

Major Manifestations: Carditis 40% Polyarthritis 75% Erythema marginatum <10% Subcutaneous nodules <10% Choreaform movements 15% Recent evidence of Gp A strep

Minor Manifestations: Fever Arthralgia Heart block Elevated acute phase reactants

Culture, ASO, streptozyme

Joint Involvement: Arthralgia to arthritis Inverse relationship between severity of joints and severity of carditis Usually knees, elbows, ankles, wrists
Subcutaneous nodules: Firm, painless over tendos Associated with carditis and occur weeks later

Erythema marginatum
Painless, mobile, macular erythema on trunk and extremities

Fever Lightheadedness/Hypotension GI distress Hematologic ABNL Rash No other cause identified Hepatitis OK, but Arthropathy unusual Moving rash is not typical

May occur 6 months later Emotional lability Generalized weakness Rapid uncoordinated purposeless movements Self limited

Penicillin Salicylates Steroids

High Risk Recurrence IM PCN monthly Oral PCN 250 mg BID or Sulfadiazine 1 Gm Tx 5 years or until age 18: whichever is LONGER Check household contacts