Symptoms

 

 

Signs

 

 

 

 

 

 

 

 

 

Septic shock with no positive blood cultures. The characteristic diffuse rash, as well as the lack of a primary infected site, make Staphylococcus the more likely inciting agent.

Streptococcal toxic shock usually has a prominent primary site of infection, but the diffuse rash is usually much more subtle than in this case. Staphylococcal toxic shock can be associated with immunosuppression, surgical wounds, or retained tampons. Mere Staphylococcus aureus colonization (with an appropriate toxigenic strain) can incite toxic shock; overt infection is not necessary. Centers for Disease Control and Prevention guidelines state that measles, Rocky Mountain spotted fever, and leptospirosis need to be ruled out serologically to confirm the diagnosis. However, this patient is at very low risk for these diagnoses based on vaccination and travel history. Juvenile rheumatoid arthritis would be a consideration only if the fevers were more prolonged and there was documented evidence of organomegaly and enlarged lymph nodes.

 

 

 

 

Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.

In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure. These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.

Infection in the kidneys may spread to the bloodstream—a serious condition called sepsis—though this is also uncommon.

 

 

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Content 11

 

A 23-year-old woman with a chronic lower extremity ulcer related to prior trauma presents with rash, hypotension, and fever. She has had no recent travel or outdoor exposure and is up to date on all of her vaccinations. She does not use intravenous (IV) drugs. On examination, the ulcer looks clean with a well-granulated base and no erythema, warmth, or pustular discharge. However, the patient does have diffuse erythema that is most prominent on her palms, conjunctiva, and oral mucosa. Other than profound hypotension and tachycardia, the remainder of the examination is nonfocal. Laboratory results are notable for a creatinine of 2.8 mg/dL, aspartate aminotransferase of 250 U/L, alanine aminotransferase of 328 U/L, total bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, international normalized ratio (INR) of 1.5, activated partial thromboplastin time of 1.6× control, and platelet level of 94,000/μL. Ferritin is 1300 μg/mL. The patient is started on broad-spectrum antibiotics after appropriate blood cultures are drawn and is resuscitated with IV fluid and vasopressors. Her blood cultures are negative at 72 hours; at this point, her fingertips start to desquamate. What is the most likely diagnosis?

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The correct answer is C. You answered C.

The answer is C. (Chap. 24) This patient likely has toxic shock syndrome, given the clinical appearance of septic shock with no positive blood cultures. The characteristic diffuse rash, as well as the lack of a primary infected site, make Staphylococcus the more likely inciting agent.

Streptococcal toxic shock usually has a prominent primary site of infection, but the diffuse rash is usually much more subtle than in this case. Staphylococcal toxic shock can be associated with immunosuppression, surgical wounds, or retained tampons. Mere Staphylococcus aureus colonization (with an appropriate toxigenic strain) can incite toxic shock; overt infection is not necessary. Centers for Disease Control and Prevention guidelines state that measles, Rocky Mountain spotted fever, and leptospirosis need to be ruled out serologically to confirm the diagnosis. However, this patient is at very low risk for these diagnoses based on vaccination and travel history. Juvenile rheumatoid arthritis would be a consideration only if the fevers were more prolonged and there was documented evidence of organomegaly and enlarged lymph nodes.

 

 

A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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The correct answer is A. You answered A.

Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.

 

Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The correct answer is A. You answered A.

The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.

 


 

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