ROBIN HENRY DRETLER MD;FIDSA1/20/2012

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

Cardiac: no murmur Lungs: clear Abd: nl BS, neg Murphy’s 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/

dermatomyositis TTP JRA Wegener’s

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

Recent evidence of Gp A strep

Culture, ASO, streptozyme

Major Manifestations: Carditis 40% Polyarthritis 75% Erythema marginatum

<10% Subcutaneous nodules

<10% Choreaform

movements 15%

Minor Manifestations: Fever Arthralgia Heart block Elevated acute phase

reactants

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

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